Extended-spectrum β-Lactamase–Producing Enterobacteriaceae in French Nursing Homes

An Association Between High Carriage Rate Among Residents, Environmental Contamination, Poor Conformity With Good Hygiene Practice, and Putative Resident-to-Resident Transmission

Hélène Cochard, DN; Benjamin Aubier, MB; Roland Quentin, MD; Nathalie van der Mee-Marquet, PhD, PharmD


Infect Control Hosp Epidemiol. 2014;35(4):384-389. 

In This Article

Abstract and Introduction


Objective. We evaluated the spread of multidrug-resistant Enterobacteriaceae in 38 nursing homes (NHs) in the Centre region of France.

Methods. We conducted a multicenter prevalence study and evaluated extended-spectrum β-lactamase– and carbapenemase-producing Enterobacteriaceae (ESBLE and CPE, respectively) colonization of 1,155 residents. The colonizing isolates were studied by randomly amplified polymorphic DNA typing. We observed hygiene practices and studied the contamination of the environment in 8 NHs.

Results. A total of 114 residents were ESBLE carriers (9.9%); none were CPE carriers. A total of 82.6% of the ESBLE were Escherichia coli. ESBLE colonization was associated with poor health status (P = .002), malignancy (P = .006), urinary incontinence (P = .007), fecal incontinence (P = .002), previous hospitalization (P = .033), and carbapenem treatment (P = .040). The clonal relationship between isolates within NHs suggested resident-to-resident ESBLE transmission in 15 NHs. ESBLE isolates were recovered from 6 of 232 bedrooms studied. A total of 1,533 observations revealed low rates of conformity for hand hygiene (25.7%), the use of gloves (45.9%) and protective clothing (13.3%), and waste management (46.7%). Conformity rates correlated inversely with ESBLE carriage rates.

Conclusions. In most of the participating NHs, improved application of standard precautions during incontinence care is needed, and greater efforts to clean the environment of residents are required.


The epidemiological trends for invasive infections associated with extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBLE) are worrying. Following the worldwide spread of CTX-M-15-producing Escherichia coli of the ST131 lineage,[1] the issue is now being exacerbated by the emergence of carbapenemase-producing Enterobacteriaceae (CPE).[2]

A coordinated regional effort involving healthcare institutions (HCIs) and nursing homes (NHs)[3] may help focus the attention of healthcare workers on the increasing spread of these multidrug-resistant (MDR) bacteria and may contribute to monitoring and controlling their spread in these institutions.[4] With this aim, we conducted a multicenter prevalence study of ESBLE carriage among elderly residents in the Centre region of France in 2010 (population, 2.8 million; 340 NHs). This first study revealed low rates of carriage among residents (1.9%), close to that found by nationwide surveillance in France in 2006 in a community setting (1.1%), and was thus reassuring.[5] By contrast, since 2011, there have been several ESBLE outbreaks in NHs in our region, which suggests that the epidemiology of ESBLE in the NHs has changed.[6]

We therefore conducted a second ESBLE carriage point-prevalence study during the first quarter of 2013. First, we evaluated ESBLE and CPE colonization of 1,155 residents of 38 NHs. Second, we used molecular typing to assess clonal relationships between colonizing MDR isolates. We studied 8 of the 38 participating NHs in more detail; we assessed hygiene practices routinely applied during care and resident washing and evaluated contamination of the residents' environment by searching for ESBLE and CPE on inanimate surfaces in the rooms of each resident enrolled into the study.