ESBL’s – which ones?

[Michael Wishart]

Hi all

This is a partly microbiology, partly infection control question (like many we are faced with). We are an acute private hospital with a 16 bed ICU and oncology, major orthopaedic and cardiac surgical services. We have changed our main microbiology lab provider in the last few years, so some of the decisions we have made about infection control based on micro reporting now need to be revisited.

The main issue is about what we determine as ‘multi-resistant gram negatives’, and how we then manage those. The lab we used to use only reported certain resistance patterns in certain organisms; the current lab seems to report much more broadly, especially in regard to ESBL-producing organisms. Our ID physician is of the opinion that most ESBL producing organism probably pose very little risk, and we should focus of Klebsiella EBSL producers only from an infection control perspective (ie alerting, additional precautions, etc), but the lab (which also services another major hospital group) reports any gram-negative that is positive for ESBL enzymes they test for (we had our first Aeromonas ESBL-producers reported recently, which kind of kick-started this discussion).

I am of two minds. I appreciate the opportunity to reduce the number of patients we need to place in additional precautions and alert, but I am also concerned we open ourselves up to the potential for spreading ESBL enzymes within our facility. We currently have no evidence that ESBL producing organisms are endemic or established within our facility, and it would be nice to keep it that way. My concern is not so much which gram negatives are more likely to cause actual infection (which is I believe our ID physician’s view), but more the potential for gram negative organisms to share their ESBL enzymes with different gram negative species that ARE more likely to result in actual infection/disease. What I am not clear on is what the risk of this occurring is, and whether alerting and using additional precautions is a useful way to reduce this risk.

I am aware there is a group working on some recommendations for standardisation of reporting gram negative resistance for labs, but I am not sure this will actually address my concerns.

Any thoughts, or processes that your facilities have determined for this issue, would be of value in helping me work through this, and would be gratefully received.

Cheers
Michael

Michael Wishart
CNC Infection Control
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@hsn.org.au
w:www.holyspiritnorthside.org.au
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