Increased Risk for Carbapenem-Resistant Enterobacteriaceae Colonization in Intensive Care Units After Hospitalization in Emergency Department

Matias Chiarastelli Salomão; Maristela Pinheiro Freire; Icaro Boszczowski; Sueli F. Raymundo; Ana Rubia Guedes; Anna S. Levin


Emerging Infectious Diseases. 2020;26(6):1156-1163. 

In This Article

Abstract and Introduction


Carbapenem-resistant Enterobacteriaceae (CRE) colonization is common in hospital patients admitted to intensive care units (ICU) from the emergency department. We evaluated the effect of previous hospitalization in the emergency department on CRE colonization at ICU admission. Our case–control study included 103 cases and 201 controls; cases were patients colonized by CRE at admission to ICU and controls were patients admitted to ICU and not colonized. Risk factors were emergency department stay, use of carbapenem, Simplified Acute Physiology Score, upper digestive endoscopy, and transfer from another hospital. We found that ED stay before ICU admission was associated with CRE colonization at admission to the ICU. Our findings indicate that addressing infection control problems in EDs will help to control carbapenem resistance in ICUs.


Klebsiella pneumoniae carbapenemase (KPC), described in 1996, is an enzyme capable of hydrolyzing all β-lactam antimicrobial drugs known at the time.[1] Since then, other carbapenemases have been described in Enterobacteriaceae all over the world, leading to a substantial increase in resistance to antimicrobial drugs.[2,3]

Surveillance data from central line–associated bloodstream infections (CLABSI) in intensive care units (ICUs) in the state of São Paulo, Brazil, demonstrated an increase of carbapenem-resistant K. pneumoniae, from 14% in 2011 to 55% in 2017.[4] In 2017, K. pneumoniae was the most frequent species causing CLABSI (20%) in São Paulo.

Hospital das Clínicas of the University of São Paulo has routinely performed CRE screening for patients admitted to ICU since January 2014. Early identification and isolation of colonized patients was implemented to decrease secondary colonization. Concomitant training sessions for hand hygiene and contact precautions took place during this period. Despite all efforts, ICUs had a high colonization pressure (17% –29%, mean 21%) due to admission of colonized patients, mainly from EDs (I. Boszczowski, unpub. data).

In 2016, we found that 7% of patients admitted to the ED were positive for CRE. However, among those who were negative at admission, 18% became colonized during their stay in the ED. These findings led us to hypothesize that hospitalization in the ED may be a risk factor for CRE colonization in other units of the hospital;[5] ≈60% of the patients admitted to ICUs come from hospitalizations in the ED. We evaluated the effect of hospitalization in the ED on CRE colonization at the time of admission to an ICU.