Implementation of a Clostridioides difficile prevention bundle: Understanding common, unique, and conflicting work system barriers and facilitators for subprocess design

OBJECTIVE

Clostridioides difficile (C. difficile) poses a major challenge to the healthcare system. We assessed factors that should be considered when designing subprocesses of a C. difficile infection (CDI) prevention bundle.

DESIGN

Phenomenological qualitative study.

METHODS

We conducted 3 focus groups of environmental services (EVS) staff, physicians, and nurses to assess their perspectives on a CDI prevention bundle. We used the Systems Engineering Initiative for Patient Safety (SEIPS) model to examine 5 subprocesses of the CDI bundle: diagnostic testing, empiric isolation, contact isolation, hand hygiene, and environmental disinfection. We coded transcripts to the 5 SEIPS elements and ensured scientific rigor. We sought to determine common, unique, and conflicting factors across stakeholder groups and subprocesses of the CDI bundle.

RESULTS

Each focus group lasted 1.5 hours on average. Common work-system barriers included inconsistencies in knowledge and practice of CDI management procedures; increased workload; poor setup of aspects of the physical environment (eg, inconvenient location of sinks); and inconsistencies in CDI documentation. Unique barriers and facilitators were related to specific activities performed by the stakeholder group. For instance, algorithmic approaches used by physicians facilitated timely diagnosis of CDI. Conflicting barriers or facilitators were related to opposing objectives; for example, clinicians needed rapid placement of a patient in a room while EVS staff needed time to disinfect the room.

CONCLUSIONS

A systems engineering approach can help to holistically identify factors that influence successful implementation of subprocesses of infection prevention bundles.

Trends in antimicrobial resistance in Israel, 2014-2017

We analyzed Israeli national data on antimicrobial susceptibility from bloodstream isolates collected between 2014 and 2017 and compared resistance proportions with those of Europe. The incidence of bloodstream infection (BSI) caused by most antibiotic-resistant organisms remained unchanged or decreased. An exception was increased incidence of BSI caused by third-generation cephalosporin-resistant Escherichia coli. Overall, resistance proportions were similar to those observed in southern Europe, with the exception of a lower proportion of carbapenem-resistant Klebsiella pneumoniae in Israel.

Is systematic fecal carriage screening of extended-spectrum beta-lactamase-producing Enterobacteriaceae still useful in intensive care unit: a systematic review

BACKGROUND

Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) are disseminating worldwide leading to increased hospital length of stay and mortality in intensive care units (ICU). ESBL-E dissemination was first due to outbreaks in hospital settings which led to the implementation of systematic fecal carriage screening to improve hygiene procedures by contact precautions. ESBLs have since spread in the community, and the relevance of contact precautions is questioned. ESBL-E dissemination led to an overuse of carbapenems triggering the emergence of carbapenem-resistant Enterobacteriaceae. Empirical antimicrobial therapy based on ESBL-E fecal carriage has been proposed but is debated as it could increase the consumption of carbapenems among ESBL-E carriers without any clinical benefit. Finally, selective decontamination among ESBL-E fecal carriers is evoked to decrease the risk for subsequent ESBL-E infection, but its efficacy remains debated. We propose to systematically review the evidence to recommend or not such systematic ESBL-E fecal carriage screening in adult ICU.

METHODS

Every article focusing on ESBL-E and ICU available on the MEDLINE database was assessed. Articles were included if focusing on cross-transmission, efficacy of hygiene procedures, link between ESBL-E colonization and infection or guidance of empirical therapy or selective decontamination efficacy.

RESULTS

Among 330 articles referenced on PubMed, 39 abstracts were selected for full-text assessment and 25 studies were included. Systematic screening of ESBL-E fecal carriage to guide contact precautions do not seem to decrease the rate of ESBL-E cross-transmission. It has a very good negative predictive value for subsequent ESBL-E infections but a positive predictive value between 40 and 50% and so does not help to spare carbapenems. Cessation of ESBL-E carriage systematic screening could decrease the use of carbapenems in ICU without any clinical harm. Nevertheless, further studies are needed to validate these results from monocentric before-after study. Selective decontamination strategy applied to ESBL-E fecal carriers could be helpful, but available data are conflicting.

CONCLUSION

Current knowledge lacks of high-quality evidence to strongly recommend in favor of or against a systematic ESBL-E fecal carriage screening policy for ICU patients in a non-outbreak situation. Further evaluation of selective decontamination or fecal microbiota transplantation among ESBL-E fecal carriers is needed.

Close proximity interactions support transmission of ESBL-K. pneumoniae but not ESBL-E. coli in healthcare settings

Antibiotic-resistance of hospital-acquired infections is a major public health issue. The worldwide emergence and diffusion of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, including Escherichia coli (ESBL-EC) and Klebsiella pneumoniae (ESBL-KP), is of particular concern. Preventing their nosocomial spread requires understanding their transmission. Using Close Proximity Interactions (CPIs), measured by wearable sensors, and weekly ESBL-EC-and ESBL-KP-carriage data, we traced their possible transmission paths among 329 patients in a 200-bed long-term care facility over 4 months. Based on phenotypically defined resistance profiles to 12 antibiotics only, new bacterial acquisitions were tracked. Extending a previously proposed statistical method, the CPI network's ability to support observed incident-colonization episodes of ESBL-EC and ESBL-KP was tested. Finally, mathematical modeling based on our findings assessed the effect of several infection-control measures. A potential infector was identified in the CPI network for 80% (16/20) of ESBL-KP acquisition episodes. The lengths of CPI paths between ESBL-KP incident cases and their potential infectors were shorter than predicted by chance (P = 0.02), indicating that CPI-network relationships were consistent with dissemination. Potential ESBL-EC infectors were identified for 54% (19/35) of the acquisitions, with longer-than-expected lengths of CPI paths. These contrasting results yielded differing impacts of infection control scenarios, with contact reduction interventions proving less effective for ESBL-EC than for ESBL-KP. These results highlight the widely variable transmission patterns among ESBL-producing Enterobacteriaceae species. CPI networks supported ESBL-KP, but not ESBL-EC spread. These outcomes could help design more specific surveillance and control strategies to prevent in-hospital Enterobacteriaceae dissemination.

Role of place of acquisition and inappropriate empirical antibiotic therapy on the outcome of extended-spectrum β-lactamase-producing Enterobacteriaceae infections

The impact of inappropriate empirical antibiotic therapy (IEAT) on the outcome of severe infections due to extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-Ent) remains unclear. Current evidence is limited by study design and lack of confounder control. The main objective of this study was to define the outcome of severe infections due to ESBL-Ent according to clinical parameters and place of infection acquisition. Adult hospitalised patients with ESBL-Ent infections were included in a 3-year multicentre prospective study. Primary outcomes were IEAT rates and crude mortality of severe infections, adjusted by place of acquisition [community-acquired infection (CAI), healthcare-associated infection (HCAI) and hospital-acquired infection (HAI)]. Among 729 patients, 519 (71.2%) were diagnosed with HAI, 176 (24.1%) with HCAI and 34 (4.7%) with CAI. Moreover, 32.9% of patients received IEAT; higher rates of IEAT were observed in pneumonia (23%) and deep surgical site infections (19%). HCAIs were more frequently associated with IEAT than HAIs (48.3% vs. 27.9%; OR = 1.7, 95% CI 1.2-2.4). The overall mortality rate for severe infections (n = 264) was 12.1% and was significantly higher in HCAIs (20%) than HAIs (10%) (RR = 2.3, 95% CI 1.01-5.3). IEAT significantly increased the risk of mortality in bloodstream infections (RR = 8.3, 95% CI 2-46.3). Rates of IEAT and overall mortality of ESBL-Ent severe infections were higher in HCAIs than HAIs. Prompt diagnosis of patients with severe HCAIs due to ESBL-Ent is essential since these infections receive high rates of IEAT and significantly higher mortality than HAIs [ClinicalTrials.gov Identifier: NCT00404625].

ESBL colonization and acquisition in a hospital population: The molecular epidemiology and transmission of resistance genes

A prospective cohort study (German Clinical Trial Registry, No. 00005273) was performed to determine pre-admission colonization rates, hospital acquisition risk factors, subsequent infection rates and colonization persistence including the respective molecular epidemiology and transmission rates of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae (EPE). A total of 342 EPEs were isolated from rectal swabs of 1,334 patients on admission, at discharge and 6 months after hospitalization. Inclusion criteria were patients’ age > 18 years, expected length of stays > 48 hours, external referral. The EPEs were characterized by routine microbiological methods, a DNA microarray and ERIC-PCR. EPE colonization was found in 12.7 % of admitted patients, with the highest rate (23.8 %) in patients from nursing homes. During hospitalization, 8.1 % of the patients were de novo EPE colonized, and invasive procedures, antibiotic and antacid therapies were independent risk factors. Only 1/169 patients colonized on admission developed a hospital-acquired EPE infection. Escherichia coli was the predominant EPE (88.9 %), and 92.1% of the ESBL phenotypes could be related to CTX-M variants with CTX-M-1/15 group being most frequent (88.9%). A corresponding β-lactamase could not be identified in five isolates. Hospital-acquired EPE infections in patients colonized before or during hospitalization were rare. The diversity of the EPE strains was much higher than that of the underlying plasmids. In seven patients, transmission of the respective plasmid across different species could be observed indicating that the current strain-based surveillance approaches may underestimate the risk of inter-species transmission of resistance genes.

Impact of single-room contact precautions on hospital-acquisition and transmission of multidrug-resistant Escherichia coli: a prospective multicentre cohort study in haematological and oncological wards

OBJECTIVES

Colonization and infection with third-generation cephalosporin-resistant Escherichia coli (3GCR-EC) are frequent in haematological and oncological patients. In this high-risk setting, German guidelines recommend single-room contact precautions (SCP) for patients with 3GCR-EC that are non-susceptible to fluoroquinolones (F3GCR-EC). However, this recommendation is controversial, as evidence is limited.

METHODS

We performed a prospective, multicentre cohort study at four haematology and oncology departments assessing the impact of SCP on hospital-acquired colonization or bloodstream infection (BSI) with F3GCR-EC. Two sites performed SCP for F3GCR-EC patients including single rooms, gloves and gowns (SCP sites), and two did not (NCP sites). Active screening for 3GCR-EC was performed and isolates were characterized with molecular typing methods including whole genome sequencing and core genome multiple locus sequence typing to assess patient-to-patient transmission. Potential confounders were assessed by competing-risk regression analysis.

RESULTS

Within 12 months, 1386 patients at NCP sites and 1582 patients at SCP sites were included. Hospital-acquisition of F3GCR-EC was observed in 22/1386 (1.59%) and 16/1582 (1.01%) patients, respectively (p 0.191). There were 3/1386 (0.22%) patients with BSI caused by F3GCR-EC at NCP sites and 4/1582 (0.25%) at SCP sites (p 1.000). Patient-to-patient transmission occurred in three cases at NCP and SCP sites each (p 1.000). The number of patients needed to screen in order to prevent one patient-to-patient transmission of F3GCR-EC was determined to be 3729.

CONCLUSIONS

Use of SCP had no significant impact on hospital-acquisition or patient-to-patient transmission of F3GCR-EC in this high-risk setting.

Entérobactéries productrices de carbapénémases en médecine intensive : comment maîtriser le risque ?

La diffusion globale des entérobactéries productrices de carbapénémases principalement au niveau de certaines zones géographiques, dont le pourtour méditerranéen, est une situation préoccupante. Elle doit nous inciter à maintenir notre niveau de vigilance. Trois principaux mécanismes de résistance s’exprimant à des degrés variables sont décrits. Plusieurs critères tels que l’identification de la population à risque, la qualité du diagnostic microbiologique, la gestion du risque ainsi que la diffusion intrahospitalière doivent être maîtrisés. Une politique d’amélioration de l’hygiène des mains, le respect des précautions complémentaires d’hygiène ainsi que la maîtrise de la consommation des antibiotiques sont plus que nécessaires.

Carriage of ESBL-producing Enterobacteriaceae in French hospitals: the PORTABLSE study

BACKGROUND

Currently, contact precautions are recommended for patients colonized or infected with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE). Recent studies have challenged this strategy. This study aimed to assess the rate of ESBL-PE faecal carriage among hospitalized patients according to type of hospital ward, and to identify risk factors associated with carriage.

METHODS

A point prevalence study was conducted in five different types of hospital ward [medical, surgical, intensive care unit (ICU), after care and rehabilitation, and geriatric] in eight French hospitals. All patients included in the study provided a fresh stool sample.

RESULTS

In total, 554 patients were included in the study, with a median age of 73 years (range 60-82 years). The overall faecal carriage rate of ESBL-PE was 17.7%. The most frequently encountered species among ESBL-PE was Escherichia coli (71.4%), followed by Klebsiella pneumoniae (14.3%). Risk factors associated with ESBL-PE faecal carriage on univariate analysis were: living in the Paris region (P<0.01) and hospitalization on a geriatric ward (P<0.01). Interestingly, the cumulative duration of hospital stay before screening was not associated with a significantly higher prevalence of ESBL-PE carriage, regardless of ward type. The ESBL-PE colonization rate was much higher for patients hospitalized on geriatric wards (28.1%) and ICUs (21.7%) compared with those for patients hospitalized on surgical wards (14.8%), medical wards (12.8%) or aftercare and rehabilitation (11.2%).

CONCLUSION

The overall prevalence of ESBL-PE faecal carriage was 17.7%, with only 21% of patients identified previously as carriers. The delay between admission and screening was not associated with an increase in ESBL-PE faecal carriage.

Universal or targeted approach to prevent the transmission of extended-spectrum beta-lactamase-producing Enterobacteriaceae in intensive care units: a cost-effectiveness analysis

OBJECTIVE

Several control strategies have been used to limit the transmission of multidrug-resistant organisms in hospitals. However, their implementation is expensive and effectiveness of interventions for the control of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) spread is controversial. Here, we aim to assess the cost-effectiveness of hospital-based strategies to prevent ESBL-PE transmission and infections.

DESIGN

Cost-effectiveness analysis based on dynamic, stochastic transmission model over a 1-year time horizon.

PATIENTS AND SETTING

Patients hospitalised in a hypothetical 10-bed intensive care unit (ICU) in a high-income country.

INTERVENTIONS

Base case scenario compared with (1) universal strategies (eg, improvement of hand hygiene (HH) among healthcare workers, antibiotic stewardship), (2) targeted strategies (eg, screening of patient for ESBL-PE at ICU admission and contact precautions or cohorting of carriers) and (3) mixed strategies (eg, targeted approaches combined with antibiotic stewardship).

MAIN OUTCOMES AND MEASURES

Cases of ESBL-PE transmission, infections, cost of intervention, cost of infections, incremental cost per infection avoided.

RESULTS

In the base case scenario, 15 transmissions and five infections due to ESBL-PE occurred per 100 ICU admissions, representing a mean cost of €94 792. All control strategies improved health outcomes and reduced costs associated with ESBL-PE infections. The overall costs (cost of intervention and infections) were the lowest for HH compliance improvement from 55%/60% before/after contact with a patient to 80%/80%.

CONCLUSIONS

Improved compliance with HH was the most cost-saving strategy to prevent the transmission of ESBL-PE. Antibiotic stewardship was not cost-effective. However, adding antibiotic restriction strategy to HH or screening and cohorting strategies slightly improved their effectiveness and may be worthy of consideration by decision-makers.

Multicenter collaboration study on the β-lactam resistant Enterobacteriaceae in Japan - The 65th anniversary public interest purpose project of the Japanese Society of Chemotherapy

This study was conducted using the same method of the "1-day multicenter collaborative research for Clostridium difficile infectious". This surveillance study was performed by 38 participating medical facilities across Japan. Of the 268 fecal specimens collected in this study, 5 (1.9%) carbapenem-resistant Enterobacteriaceae (CRE) were judged carbapenem resistant by the criteria of the Infectious Disease Act, Japan (2 mg/L or more and 64 mg/L or more MICs for imipenem and cefmetazole, respectively). However, no isolate was shown to have a meropenem MIC of 2 mg/L or more. No carbapenemase encoding genes were detected from the CRE. Extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae were detected from 29 specimens (11%), and the predominant ESBL-encoding gene group was bla_CTX-M-9. The predominant ST-type by multilocus sequence typing of ESBL encoding gene-positive Escherichia coli was ST131.

Rapid identification of ST131 Escherichia coli by a novel multiplex real-time allelic discrimination assay

Escherichia coli sequence type 131 is increasingly described in severe hospital infections. We developed a rapid real-time allelic discrimination assay for the rapid identification of E. coli ST131 isolates. This rapid assay represents an affordable alternative to sequence-based strategies before completing characterization of potentially highly virulent isolates of E. coli.