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Letter
CTX-M β-lactamase–producing
Escherichia coli in Long-term Care Facilities, France
Najiby Kassis-Chikhani,*
Sophie Vimont,† Karine Asselat,* Christophe Trivalle,* Bérédia Minassian,*
Christian Sengelin,* Valérie Gautier,‡ Danièle Mathieu,* Elisabeth Dussaix,*
and Guillaume Arlet†‡
*Hôpital Paul Brousse, Villejuif, France; †Hôpital Tenon, Paris, France;
and ‡Université Paris VI, Paris, France
Suggested
citation for this article
To the Editor: In long-term care facilities, most endemic infections
affect respiratory and urinary tracts, as well as skin and soft tissues
(1–3). Infection and colonization by antimicrobial-resistant
organisms, in particular those producing plasmid-mediated extended-spectrum
β-lactamases (ESBL), are common in long-term care facilities (4).
Since 1984, ESBL-producing Enterobacteriaceae have spread among
French hospitals; within Parisian public hospitals (Assistance Publique,
Hôpitaux de Paris), ESBL-producing Escherichia coli is the most
frequent species found, representing 49.5% of 220 Enterobacteriaceae
isolated in 2002, mostly in urinary tract infections (5).
Among ESBL-producing Enterobacteriaceae, CTX-M–type β-lactamases
confer a higher level of resistance to cefotaxime and ceftriaxone than
to ceftazidime. CTX-M–producing strains are endemic in Latin America,
Japan, and certain parts of Eastern Europe; in contrast, these strains
are emerging in France, Western Europe, and the United States (6).
We report the first documented outbreak of CTX-M–producing E. coli
infection in a long-term care facility in France. Our hospital is an 800-bed
institution with 300 beds for long-term patients distributed among three
units located in two buildings. The outbreak occurred in a 35-bed unit
and involved 26 of 47 hospitalized patients from October 2001 to March
2003. This facility hosts patients for extended periods of time or permanently.
The index case was identified in October 2001; the patient had a urinary
tract infection attributable to an ESBL-producing E. coli, which
showed resistance patterns not previously found in our hospital. Three
new cases were detected within the following 2 months, and all patients
had urinary tract infection with the same pattern of resistance. In January
2002, patients were screened for ESBL-producing strains by rectal swabbing
and urine culture. The results showed E. coli with a high level
of resistance to amoxicillin and ticarcillin (MIC > 128 µg/mL),
partial restoration of susceptibility to these agents by addition of clavulanic
acid (MIC = 16–32 µg/mL), and higher resistance to cefotaxime (MIC
> 128 µg/mL) than to ceftazidime (MIC = 32–64 µg/mL.)
A cephalosporin/co-amoxiclav synergy test was positive, which suggests
a CTX-M ESBL. Strains were also resistant to ciprofloxacin (MIC 64 µg/mL)
and gentamicin (MIC > 64 µg/mL) but remained susceptible to trimethoprim-sulfamethoxazole.
Attempts to transfer resistance to β-lactams by conjugation to E.
coli J53-2 with the 26 strains tested were unsuccessful. In contrast,
transformants were obtained with plasmid DNA of the 19 strains tested
by electroporation. The transformants' susceptibility pattern was similar
to that of the donor strains, except for ciprofloxacin resistance. Analytical
isoelectric focusing showed that all clinical strains and transformants
had bands of β-lactamase activity with an alkaline pI of 7.6 and
5.4. Polymerase chain reaction (PCR) amplification of the 26 clinical
isolates was positive for blaCTX-M and blaTEM (7).
The 26 strains of E. coli had the same profile by repetitive-element
PCR and pulsed-field gel electrophoresis, while unrelated control strains
had very different profiles. Sequencing in strains isolated from four
of the patients identified a CTX-M-15 β-lactamase and a TEM-1 β-lactamase.
The four strains were related to the phylogenetic group B2 and produced
the iutA (ferric aerobactin receptor), YuA (Yersinia siderophore
receptor), and fimH (type I fimbriae) virulence factors (8).
Incidence of colonization or infection by the culprit strain was 34.3%
(12 of 35 patients) within the initial 4-month period and 55.3% (26 of
47 patients) over a 1-year period.
Intensified hygienic procedures implemented in January 2002 contributed
to a decrease in the number of cases in February only; since then, a regular
increase of new cases extended the outbreak and caused problems with controlling
it. All urinary tract infections were successfully treated with a 15-day
course of trimethoprim-sulfamethoxazole; however, reinfection occurred
in some. Neither incontinence (p = 0.35), dementia (p = 0.22), nor previous
antibiotic treatment (amoxicillin, amoxicillin-clavulanic acid, extended-spectrum
cephalosporins, and fluoroquinolones [p = 1.00, 0.30, 0.12, 0.52, respectively])
appeared to be risk factors for infection or colonization in our study,
but the number of patients is too small to reach a conclusion. However,
patients that were infected or colonized had greater functional impairment,
especially incontinence and dementia. Nonambulatory status, decubitus
ulcers, and feeding tubes were not risk factors for acquiring ESBL-producing
E. coli in our study.
The outbreak has not been controlled: 13 patients have persistent digestive-tract
colonization. Difficulties encountered in controlling such outbreaks may
be explained by several factors. Patients cannot be easily isolated in
long-term care facilities. Strict isolation and limitation of activity
and mobility cannot always be applied because of their impact on social
activities.
Acknowledgments
We thank Abel Naas
for helping to collect the clinical information and Claudia Ferreira
for helping to write this letter.
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Suggested citation
for this article:
Kassis-Chikhani N,
Vimont S, Asselat K, Trivalle C, Minassian B, Sengelin C, et al. CTX-M
β–lactamase-producing Escherichia coli in long-term care facilities,
France [letter]. Emerg Infect Dis [serial on the Internet]. 2004 Sep [date
cited]. Available from: http://www.cdc.gov/ncidod/EID/vol10no9/03-0969.htm
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