Drivers of extended-spectrum β-lactamase (ESBL)- producing Enterobacterales colonization among residents of long-term care facilities: a European multicentre prospective cohort study

Background

Extended-spectrum β-lactamase (ESBL)-producing Enterobacterales (ESBL-PE) are highly prevalent in long-term care (LTCF) settings. In order to estimate the acquisition rate of ESBL-producing Escherichia coli and Klebsiella pneumoniae in LTCF settings, and identify clinical and environmental risk factors, a multi-centre, prospective cohort study was conducted in six LTCFs in Germany, France, Spain and the Netherlands.

Methods

Longitudinal screening of residents was performed over 32 weeks, collecting epidemiological and clinical data and environmental samples. The primary outcome was the rate of new acquisition of ESBL-PE among LTCF residents. Molecular epidemiology was studied using whole genome sequencing, and risk factor analysis was undertaken using logistic and Poisson regression models.

Results

In total, 299 residents provided 1958 samples during follow-up. The prevalence of ESBL-PE colonization at baseline was 16.4%, and the incidence of acquisition was 0.79 per 1000 resident-days, both with high variability between LTCFs. Age ≥80 years, vascular disease and antibiotic consumption within the preceding year were risk factors for baseline colonization. Lack of hand sanitizers and a low nurse:resident ratio were associated with colonization. The presence of medical devices was associated with risk of acquisition. Vascular disease, hemiplegia, antibiotic consumption, and non-availability of private bathrooms were associated with carriage of multiple sequence types (STs). The prevalence of ESBL-PE among environmental samples was 2%, exclusively in LTCFs with high prevalence among residents. Genetic analysis showed a high prevalence of ST10 E. coli and ST405 K. pneumoniae at two study sites.

Conclusion

Infection prevention interventions, including availability of hand sanitizers, the number of nurses per resident, and antimicrobial stewardship, constitute important measures to control ESBL-PE in LTCFs. Genome-based surveillance could guide targeted interventions.