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Household acquisition and transmission of ESBL-producing Enterobacteriaceae after hospital discharge of ESBL-positive index patients

Riccio, M E; Verschuuren, T; Conzelmann, N; Martak, D; Meunier, A; Salamanca, E; Delgado, M; Guther, J; Peter, S; Paganini, J; Martischang, R; Sauser, J; de Kraker, M E A; Cherkaoui, A; Fluit, A C; Cooper, B S; Hocquet, D; Kluytmans, J A J W; Tacconelli, E; Rodriguez-Baño, J; Harbarth, S; Brossier, Caroline; von Dach, Elodie; Renzi, Gesuele; Schrenzel, Jacques; Bunk, Stefanie; Goepel, Siri; Hölzl, Florian; Eib, Michael; Autenrieth, Ingo B; Pascual, Álvaro; Bertrand, Xavier; Scharringa, Jelle; Musicha, Patrick

Objectives: This study aimed to determine rates and risk factors of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) acquisition and transmission within households after hospital discharge of an ESBL-PE-positive index patient.

Methods: Two-year prospective cohort study in five European cities. Patients colonized with ESBL-producing Escherichia coli (ESBL-Ec) or Klebsiella pneumoniae (ESBL-Kp), and their household contacts were followed up for 4 months after hospital discharge of the index case. At each follow up, participants provided a faecal sample and personal information. ESBL-PE whole-genome sequences were compared using pairwise single nucleotide polymorphism-based analysis.

Results: We enrolled 71 index patients carrying ESBL-Ec (n = 45), ESBL-Kp (n = 20) or both (n = 6), and 102 household contacts. The incidence of any ESBL-PE acquisition among household members initially free of ESBL-PE was 1.9/100 participant-weeks at risk. Nineteen clonally related household transmissions occurred (case to contact: 13; contact to case: 6), with an overall rate of 1.18 transmissions/100 participant-weeks at risk. Most of the acquisition and transmission events occurred within the first 2 months after discharge. The rate of ESBL-Kp household transmission (1.16/100 participant-weeks) was higher than of ESBL-Ec (0.93/100 participant-weeks), whereas more acquisitions were noted for ESBL-Ec (1.06/100 participant-weeks) compared with ESBL-Kp (0.65/100 participant-weeks). Providing assistance for urinary and faecal excretion to the index case by household members increased the risk of ESBL-PE transmission (adjusted prevalence ratio 4.3; 95% CI 1.3-14.1).

Conclusions: ESBL-PE cases discharged from the hospital are an important source of ESBL-PE transmission within households. Most acquisition and transmission events occurred during the first 2 months after hospital discharge and were causally related to care activities at home, highlighting the importance of hygiene measures in community settings.

Clinical study registration: German Clinical Trials Register, DRKS-ID: DRKS00013250.

Keywords: Acquisition; Extended-spectrum β-lactamase; Household; Prospective cohort study; Transmission.

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