Carbapenem-Resistant Gram- Negative Bacilli in Canadian Acute-Care Hospitals: Surveillance Report January 1, 2010 to December 31, 2012

Executive Summary

Gram-negative bacilli (GNB) cause a variety of diseases, ranging from pneumonia to urinary tract infections, to serious bloodstream or wound infections. The symptoms vary depending on the disease. GNB infections and colonization typically occur in ill patients with exposure to acute and long-term care setting. The most common GNB causing infections in the health care setting are Klebsiella pneumonia, Escherichia coli and Acinetobacter. GNB that have acquired resistance to carbapenems are called carbapenem-resistant Gram-negative bacilli (CRGNB).

This report provides a comprehensive look at CRGNB and carbapenemase-producing organisms (CPO) in Canadian acute-care hospitals since 2010 through the Canadian Nosocomial Infection Surveillance Program (CNISP). In Canada, carbapenemase-producing organisms (CPO) remain relatively uncommon in most acute-care hospitals in Canada, especially in the eastern region. CPOs represents a subset of CRGNB that have acquired resistance to carbapenem by the ability to produce carbapenemase; an enzyme that breaks down carbapenem. Carbapenemase producers are mainly identified among Klebsiella pneumoniae and found mostly in hospital settings.

The regional differences in CPO rates are observed across Canada. A major contributor to this variation is an outbreak of the Klebsiella pneumoniae carbapenemase (KPC) subtype reported in the central region. Regional variation of rates has also been reported by the United States and among European countries. Factors which may influence the regional emergence and spread of carbapenemases include local antimicrobial usage patterns, different policies or implementation of infection control measures, the role of interfacility transfers as well as differences in screening practices and detection methods across hospitals and laboratories. Importation of carbapenemases from other countries as a consequence of travel and medical tourism may also play an important role in the regional distribution of cases as hospitals in larger, urban cities may serve patients who are more likely to have travelled internationally.

In conclusion, the burden of CRGNB and CPO among Canadian acute-care hospitals remains low, yet the global dissemination of gram-negative bacilli that have acquired carbapenemase genes is a growing public health concern. Moreover, the significant proportion of non-travel associated CPO positive patients suggests the local establishment and spread of carbapenemase-producing organisms in Canada. Thus, the continued surveillance of carbapenem resistant and carbapenemase-producing organisms will enable the Agency to continue to monitor the spread and burden of these types of antimicrobial resistance in Canadian acute-care hospitals.

The following are highlights of this surveillance report.

  • Rates of CRGNB in hospitals participating in CNISP remain low. In 2012, 0.14 cases per 1,000 patient admissions of carbapenem-resistant Enterobacteriaceae and 0.02 cases per 1,000 patient admissions of carbapenem-resistant Acinetobacter were identified among 38 hospitals.
  • The number of CPO cases (154 cases between January 1, 2010 and December 31, 2012) in Canada remains low and the rates have remained stable over the three years since the Agency began conducting surveillance
  • 44.8% of cases were colonized; 31.8% of cases were infected and status was unknown for 23.4% of cases.
  • The central region of Canada reported the highest number of cases, the majority of which are likely due to an outbreak reporting at one hospital.
  • Only twenty-three cases (14.9%) reported international travel within the 12 months prior to diagnosis and of those 16 cases sought medical care while abroad.
  • No cases were admitted to the intensive care unit due to CPO while three deaths were determined to be attributed to CPO.
  • For all three years, CPO subtype blaKPC-type (Klebsiella pneumonia carbapenemase) were observed in the highest proportion followed by CPO subtype blaNDM-1 (New Delhi Metallo-beta-lactamase).

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