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Long-term care facilities (LTCFs) are an important reservoir of multidrug-resistant organisms (MDROs). Colonization of LTCF residents by MDROs is generally higher in Italy compared to other European countries. The present review by the working group for the study of infections in LTCFs (GLISTer) of the Italian Association of Clinical Microbiologists (AMCLI) aims to propose criteria for a laboratory-based surveillance of MDROs in Italian LTCFs.We recommend the adhesion to three levels of laboratory-based MDROs surveillance in LTCFs: i) mandatory MDRO surveillance by cumulative retrospective analysis of antimicrobial susceptibility data, obtained as part of routine care of clinical specimens. ii) strongly recommended surveillance by active rectal swab cultures or molecular screening to determine colonization with carbapenemase-producing Enterobacterales, should a resident be proven infected. iii) voluntary surveillance by prospective MDRO surveys, mainly based on point prevalence colonization studies, allowing to determine the MDROs baseline prevalence in the facility.Laboratory-based surveillance of MDROs in LTCFs is aimed at providing useful epidemiological information to healthcare providers operating in the facility, but it is only effective if the collected data are used for infection prevention and control purposes, targeting the peculiar aspects of LTCFs.

In 2016, we undertook a point prevalence screening study for Enterobacteriaceae with extended-spectrum β-lactamases (ESBLs), high-level AmpC cephalosporinases and carbapenemases, and also methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin resistant enterococci (VRE) in a long-term care facility (LTCF) and the associated acute care hospital geriatric unit in Bolzano, Northern Italy. Urine samples and rectal, inguinal, oropharyngeal and nasal swabs were plated on selective agars. Demographic data were collected. ESBL and carbapenemase genes were sought by PCR. We found the following colonization percentages with multidrug-resistant (MDR) bacteria in 2016 in LTCF residents: all MDR organisms, 66.1%; ESBL producers, 53.0%; carbapenemase-producers, 1.7%; MRSA, 14.8%; VRE, 0.8%. Colonization by all MDR bacteria was 19.4% for LTCF staff and 26.0% for geriatric unit patients. PCR showed that 80.3% of Escherichia coli isolates from LTCF residents, all E. coli isolates from LTCF staff, 62.5% and 100% of Klebsiella pneumoniae from LTCF residents and geriatric unit patients, respectively, had a blaCTX-M-type gene. All carbapenemase-producing Enterobacteriaceae harboured a blaVIM-type gene. To conclude, the ongoing widespread diffusion of MDR bacteria in the LTCF suggests that efforts should be strengthened on MDR screening, implementation of infection control strategies and antibiotic stewardship programs targeting the unique aspects of LTCFs.

Background: In 2012 we undertook a screening study for Enterobacteriaceae with extended-spectrum β-lactamases (ESBLs), derepressed or acquired high-level AmpC cephalosporinases, and metallo-β-lactamases (MBLs), and also methicillin-resistant Staphylococcus aureus (MRSA), in a long-term care facility (LTCF1) and the associated acute care hospital geriatric ward in Bolzano, northern Italy. The study followed up an initial survey carried out in LTCF1 in 2008. For comparison, screening in 2012 was extended to a second LTCF., Methods: Urine samples and rectal, inguinal, oropharyngeal, and nasal swabs were plated on selective agars. Isolates were typed by pulsed-field gel electrophoresis. Resistance genes and Escherichia coli belonging to ST131 were sought by PCR. Demographic data were collected., Results: Fewer residents of LTCF1 were colonized with multidrug-resistant (MDR) bacteria in 2012: all MDR organisms, 53.8% vs 74.8% in 2008; ESBL producers, 49.0% vs 64.0% in 2008; MRSA, 13.2% vs 38.7% in 2008; only 2 MBL-producers were isolated in 2012 vs 8 in 2008. Colonization of staff in LTCF1 by MDR bacteria had also decreased (overall 10.5% in 2012 vs 27.5% in 2008). Changed case mixes and risk factors, together with strengthened hygiene measures probably underlie the changes. Colonization proportions in 2012 in LTCF2 were similar to those in LTCF1. By contrast there was no significant change in the proportion of patients colonized by MDR bacteria in the geriatric ward (22.2% in 2008 vs 22.7% in 2012)., Conclusions: A significant decrease in the proportions of staff and residents of an LTCF colonized by MDR bacteria was observed over a 4-y interval.

The recent (2011-2012) distribution of carbapenemase determinants in Enterobacteriaceae was studied in the Bolzano area (Northern Italy). Low proportions of carbapenemase producers were found for Escherichia coli (0.2%), Citrobacter freundii (1.1%), Klebsiella pneumoniae (1.3%), Klebsiella oxytoca (1.6%) and Enterobacter spp (1.8%). Although VIM-1 remained the most common carbapenemase, the emergence of K. pneumoniae producing KPC-3 and of E. coli producing OXA-48 was observed. Of concern is the spread of the hyperepidemic strains E. coli ST131 producing VIM-1 and K. pneumoniae ST258 producing KPC-3. Low essential and category agreements between the reference broth microdilution and commercial methods were observed for carbapenems., (© 2013.)

The emergence of metallo-β-lactamase (MBL)-producing Enterobacteriaceae is a serious public health concern. Producers have been repeatedly isolated from patients and long-term care facility (LTCF) residents around Bolzano, and we sought to assess their prevalence and clinical impact. All routine Enterobacteriaceae isolates from a Bolzano tertiary-care hospital and associated long-term care facilities in 2008 (n = 5500) were screened for MBLs, with case details reviewed for the source patients. In total, 36 producers were obtained from 29 patients, comprising 14 Escherichia coli, six Klebsiella pneumoniae, four Klebsiella oxytoca, four Citrobacter freundii, two Enterobacter cloacae and two Morganella morganii, as well as single Citrobacter amalonaticus, Enterobacter aerogenes, Providencia stuartii and Proteus mirabilis isolates. All were PCR-positive for bla(VIM) and 25 were PCR-positive for qnrS; 19 non-K. pneumoniae had bla(SHV) and one had bla(CTX-M-group1); 13 were from 12 LTCF residents and 23 were from 17 acute-care patients. All these patients had serious underlying diseases with prolonged hospitalization or LTCF stay; only seven had infections due to the MBL producers, comprising four urinary tract infections, two catheter-related bloodstream infections and one patient with both a surgical site infection and pneumonia. Five patients had more than one MBL-producing organism. Pulsed-field gel electrophoresis identified a cluster of six related E. coli, whereas pairs of K. pneumoniae and C. freundii isolates had >85% profile similarity. Transformants prepared from two isolates were shown to be PCR-positive for bla(VIM), qnrS and bla(SHV); their plasmids gave similar restriction fragment length polymorphism patterns, and bla(VIM-1), qnrS1 and bla(SHV-12) were detected by sequencing.