Control of emerging extensively drug-resistant organisms (eXDRO) in France: a survey among infection preventionists from 286 healthcare facilities

Limiting the Spread of Multidrug-Resistant Bacteria in Low-to-Middle-Income Countries: One Size Does Not Fit All

The spread of multidrug-resistant organisms (MDRO) is associated with additional costs as well as higher morbidity and mortality rates. Risk factors related to the spread of MDRO can be classified into four categories: bacterial, host-related, organizational, and epidemiological. Faced with the severity of the MDRO predicament and its individual and collective consequences, many scientific societies have developed recommendations to help healthcare teams control the spread of MDROs. These international recommendations include a series of control measures based on surveillance cultures and the application of barrier measures, ranging from patients' being isolated in single rooms, to the reinforcement of hand hygiene and implementation of additional contact precautions, to the cohorting of colonized patients in a dedicated unit with or without a dedicated staff. In addition, most policies include the application of an antimicrobial stewardship program. Applying international policies to control the spread of MDROs presents several challenges, particularly in low-to-middle-income countries (LMICs). Through a review of the literature, this work evaluates the real risks of dissemination linked to MDROs and proposes an alternative policy that caters to the means of LMICs. Indeed, sufficient evidence exists to support the theory that high compliance with hand hygiene and antimicrobial stewardship reduces the risk of MDRO transmission. LMICs would therefore be better off adopting such low-cost policies without necessarily having to implement costly isolation protocols or impose additional contact precautions.

How to improve hospital admission screening for patients at risk of multidrug-resistant organism carriage: a before-and-after interventional study and cost-effectiveness analysis

Background

Infection prevention and control (IPC) is a prioritised task for healthcare workers in emergency department (ED). Here, we examined compliance with admission screening (AS) and additional precautions (AP) measures for patients at risk of infection with multidrug-resistant organisms (MDROs) by using a two-stage, multifaceted educational intervention, also comparing the cost of a developed automated indicator for AS and AP compliance and clinical audits to sustain observed findings.

Methods

In the first stage, staff in the ED of the University Hospitals of Geneva, Switzerland, were briefed on IPC measures (AS and AP). A cross-sectional survey was then conducted to assess barriers to IPC measures. In the second stage, healthcare workers underwent training sessions, and an electronic patient record ‘order-set’ including AS and AP compliance indicators was designed. We compared the cost–benefit of the audits and the automated indicators for AS and AP compliance.

Results

Compliance significantly improved after training, from 36.2% (95% CI 23.6% to 48.8%) to 78.8% (95% CI 67.1% to 90.3%) for AS (n=100, p=0.0050) and from 50.2% (95% CI 45.3% to 55.1%) to 68.5% (95% CI 60.1% to 76.9%) for AP (n=125, p=0.0092). Healthcare workers recognised MDRO screening as an ED task (70.2%), with greater acknowledgment of risk factors at AS considered an ED duty. The monthly cost was higher for clinical audits than the automated indicator, with a reported yearly cost of US$120 203. The initial cost of developing the automated indicator was US$18 290 and its return on investment US$3.44 per US$1 invested.

Conclusion

Training ED staff increased compliance with IPC measures when accompanied by team discussions for optimal effectiveness. An automated indicator of compliance is cheaper and closer to real-time than a clinical audit.

Recommendations for detection and rapid management of carbapenemase-producing Enterobacterales outbreaks

There is large heterogeneity in approaches to tackling nosocomial outbreaks caused by carbapenemase-producing Enterobacterales (CPE), however there is limited guidance on how to approach their management. Rapid and robust infection prevention and control interventions can be effective in preventing and reducing the impact of outbreaks in healthcare environments. We present a stepwise approach to aspects of CPE outbreak management, including the development of an action plan, engagement and communication with key stakeholders, developing a dynamic risk assessment, and staff education. These can provide a blueprint for organisations to create templates and checklists to inform their own outbreak response.

Cohorting for preventing the nosocomial spread of Carbapenemase-Producing Enterobacterales, in non-epidemic settings: is it mandatory?

BACKGROUND

Worldwide dissemination of Carbapenemase-Producing Enterobacterales (CPE) has led to national and international guidance recommending the implementation of cohorting in healthcare settings (HS). However, in view of recent data regarding the spread of Extended-spectrum Beta-lactamase-producing Enterobacterales, we may wonder about the usefulness of this measure in a non-outbreak settings; here, individual contact isolation may be sufficient to control the risk of dissemination.

AIM/METHODS

We conducted a narrative review of the literature and discussed the role of cohorting.

FINDINGS

CPE are responsible for outbreaks in HS, which are considered the epicentre of spread of resistance strains. CPE are responsible for adverse effects such as increases in hospital stay and costs, less therapeutic options and thus higher risk of clinical failures and mortality. Environment and materials have also been described contaminated with CPE and can be the source of outbreak. Even if guidelines and publications have supported implementation of cohorting, there are no randomized studies demonstrating the mandatory nature of this measure. Most studies are descriptive and cohorting is usually one of several other measures to control outbreaks. Cohorting is not adapted to all HS, which requires human and material resources. Other measures must be strengthened such as compliance of hand hygiene, antibiotic stewardship and surveillance of contact patients. Individual risk factors of acquisition should also be evaluated.

CONCLUSION

Local epidemiology and resources must be assessed before implementing cohorting.

Highly drug-resistant bacteria: Is intra- and inter-hospital communication optimal?

OBJECTIVES

Communication represents a key component of the control of highly drug-resistant bacteria (HDRB) in healthcare settings. This survey assessed communication strategies developed and adopted in a large hospital network.

METHODS

An online survey was sent to 83 infection control specialists working in hospitals of the Pays de la Loire region, France, in June 2016. Internal and external systems of identification and communication of HDRB status (colonized and contact patients) were assessed at the following steps of the hospital pathway: patient admission, during the stay, at discharge, and at readmission.

RESULTS

Sixty-one hospitals (73%) participated in the survey: 31 (51%) had recently managed colonized patients and 51 (93%) had recently managed contact patients. At patient admission, 28 (46%) hospitals had an identification system for repatriated patients. During hospital stay, the colonized or contact status was informed in computerized patient records for 47/57 (82%) and 43 (75%) hospitals, respectively. At patient discharge, 56/61 (92%) hospitals declared transmitting the HDRB status to the downstream ward. Twenty-six and 25/60 (43% and 42%) hospitals had an automated alert system at readmission of colonized or contact patients, respectively. This strategy met the expectations of 15/61 (26%) infection control specialists.

CONCLUSION

Efforts are still required in terms of communication for HDRB control. Sharing experiences and tools developed by hospitals may be beneficial for the entire hospital network.

Nation-wide survey of screening practices to detect carriers of multi-drug resistant organisms upon admission to Swiss healthcare institutions

As emergence and spread of multi-drug resistant organisms (MDRO) requires a standardized preventive approach, we aimed to evaluate current MDRO admission screening practices in Swiss hospitals and to identify potential barriers impeding their implementation. In early 2018, all Swiss public and private healthcare institutions providing inpatient care were contacted with a 34-item questionnaire to investigate current MDRO admission screening policies. Among 139 respondents representing 180 institutions (response rate, 79%), 83% (149) of institutions implemented MDRO admission screening, while 28% of private and 9% of public institutions did not perform any screening. Targeted high-risk screening included carbapenemase producers, extended-spectrum beta-lactamase producers and methicillin-resistant Staphylococcus aureus at the institutional level for respectively 78% (115), 81% (118) and 98% (145) of screening institutions. Vancomycin-resistant enterococci (44% of institutions), multi-resistant Acinetobacter baumanii (41%) and Pseudomonas aeruginosa (37%) were systematically searched only by a minority of screening institutions. A large diversity of risk factors for targeted screening and some heterogeneity in body sites screened were also observed. Admission-screening practices were mostly impeded by a difficulty to identify high-risk patients (44%) and non-compliance of healthcare workers (35%). Heterogeneous practices and gaps in small and privately-owned institutions, as well as a mismatch between current epidemiologic MDRO trends and screening practices were noticed. These results highlight the need for uniform national MDRO screening standards.