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Janis Wiener, MD; John P. Quinn, MD; Patricia A. Bradford, PhD; Richard V. Goering, PhD; Catherine Nathan, MS; Karen Bush, PhD; Robert A. Weinstein, MD

JAMA. 1999;281:517-523.

Context  Infections caused by ceftazidime sodium–resistant gram-negative bacteria that harbor extended-spectrum -lactamases (ESBLs) are increasing in frequency in hospitals in the United States.

Objectives  To report a citywide nursing home–centered outbreak of infections caused by ESBL-producing gram-negative bacilli and to describe the clinical and molecular epidemiology of the outbreak.

Design  Hospital-based case-control study and a nursing home point-prevalence survey. Molecular epidemiological techniques were applied to resistant strains.

Settings  A 400-bed tertiary care hospital and a community nursing home.

Patients  Patients who were infected and/or colonized with ceftazidime-resistant Escherichia coli, Klebsiella pneumoniae, or both and controls who were admitted from nursing homes between November 1990 and July 1992.

Main Outcome Measures  Clinical and epidemiological factors associated with colonization or infection by ceftazidime-resistant E coli or K pneumoniae; molecular genetic characteristics of plasmid-mediated ceftazidime resistance.

Results  Between November 1990 and October 1992, 55 hospital patients infected or colonized with ceftazidime-resistant E coli, K pneumoniae, or both were identified. Of the 35 admitted from 8 nursing homes, 31 harbored the resistant strain on admission. All strains were resistant to ceftazidime, gentamicin, and tobramycin; 96% were resistant to trimethoprim-sulfamethoxazole and 41% to ciprofloxacin hydrochloride. In a case-control study, 24 nursing home patients colonized with resistant strains on hospital admission were compared with 16 nursing home patients who were not colonized on hospital admission; independent risk factors for colonization included poor functional level, presence of a gastrostomy tube or decubitus ulcers, and prior receipt of ciprofloxacin and/or trimethoprim-sulfamethoxazole. In a nursing home point-prevalence survey, 18 of 39 patients were colonized with ceftazidime-resistant E coli; prior receipt of ciprofloxacin or trimethoprim-sulfamethoxazole and presence of a gastrostomy tube were independent predictors of resistance. Plasmid studies on isolates from 20 hospital and nursing home patients revealed that 17 had a common 54-kilobase plasmid, which conferred ceftazidime resistance via the ESBL TEM-10, and mediated resistance to trimethoprim-sulfamethoxazole, gentamicin, and tobramycin; all 20 isolates harbored this ESBL. Molecular fingerprinting showed 7 different strain types of resistant K pneumoniae and E coli distributed among the nursing homes.

Conclusions  Nursing home patients may be an important reservoir of ESBL-containing multiple antibiotic–resistant E coli and K pneumoniae. Widespread dissemination of a predominant antibiotic resistance plasmid has occurred. Use of broad-spectrum oral antibiotics and probably poor infection control practices may facilitate spread of this plasmid-mediated resistance. Nursing homes should monitor and control antibiotic use and regularly survey antibiotic resistance patterns among pathogens.

Author Affiliations: Michael Reese Hospital and Medical Center, Chicago, Ill (Drs Wiener, Quinn, and Weinstein and Ms Nathan); Wyeth-Ayerst Research, Pearl River, NY (Dr Bradford); Creighton University, Omaha, Neb (Dr Goering); and R. W. Johnson Pharmaceutical Research Institute, Raritan, NJ (Dr Bush). Dr Wiener is now in private practice in Oak Park, Ill; Dr Quinn is now with the Department of Medicine, University of Illinois at Chicago; and Ms Nathan and Dr Weinstein are now with the Division of Infectious Diseases, Cook County Hospital and Rush Medical College, Chicago.

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