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Suriya R V, Kv L, Feliciana J H, R A. Diagnostic Test Precision of Modified Carbapenem Inactivation Method and Carbapenemase Nordmann-Poirel Test for Phenotypic Detection of Carbapenemase Production in Enterobacterales: A Systematic Review. Cureus 2024; 16:e67322. [PMID: 39301399 PMCID: PMC11412648 DOI: 10.7759/cureus.67322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Accepted: 08/20/2024] [Indexed: 09/22/2024] Open
Abstract
Carbapenem-resistant Enterobacterales, particularly those that produce carbapenemases, pose a significant public health concern due to very limited treatment options. The timely identification of carbapenemase-producing Enterobacterales (CPE) is essential for putting in place efficient infection control measures and selecting appropriate antimicrobial therapies, thereby improving the clinical outcome of the patient. The purpose of this systematic review is to compare the diagnostic accuracy and practicality between two phenotypic tests, namely the modified carbapenem inactivation method (mCIM) and carbapenemase Nordmann-Poirel (Carba NP) test, in detecting carbapenemase production by Enterobacterales and thereby aiding the clinician in making a decision to choose an appropriate test for their phenotypic detection. This systematic review involved combining sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, diagnostic odds ratio with 95% confidence interval (CIs), Forest plot for sensitivity and specificity, and plotting suitable summary receiver operating characteristic curve with the area under the curve. Of the 20 studies included in this review, the overall effect sizes of Carba NP and mCIM with 95% CIs were as follows: sensitivity, 91% (86-96%) and 97% (95-99%); specificity, 93% (88-97%) and 97% (93-100%); PPV, 97% and 98%; NPV, 79% and 90%; accuracy, 93% and 97%; diagnostic odds ratio, 1487.8879 and 8527.5541; and AUC, 0.85 and 1, respectively. In conclusion, the mCIM method showed superior sensitivity (97%), specificity (97%), and accuracy compared to the Carba NP test in detecting carbapenemase production, even though both these methods had a few technical limitations. The Carba NP test is rapid, affordable, and dependable, whereas mCIM is more accurate and cost-effective but time-consuming. We propose that both tests can be reliably used for screening of carbapenemase production in Enterobacterales, as endorsed by the Clinical and Laboratory Standards Institute even in resource-limited clinical laboratories, in the order of prioritizing the mCIM method first and then followed by the Carba NP test when situation demands expedited results.
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Affiliation(s)
- Vijay Suriya R
- Microbiology, SRM (Sri Ramaswamy Memorial) Medical College Hospital and Research Centre, SRM Institute of Science and Technology, Kattankulathur, IND
| | - Leela Kv
- Microbiology, SRM (Sri Ramaswamy Memorial) Medical College Hospital and Research Centre, SRM Institute of Science and Technology, Kattankulathur, IND
| | - Han Feliciana J
- Microbiology, SRM (Sri Ramaswamy Memorial) Medical College Hospital and Research Centre, SRM Institute of Science and Technology, Kattankulathur, IND
| | - Aishwarya R
- Microbiology, SRM (Sri Ramaswamy Memorial) Medical College Hospital and Research Centre, SRM Institute of Science and Technology, Kattankulathur, IND
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Smith M, Crnich C, Donskey C, Evans CT, Evans M, Goto M, Guerrero B, Gupta K, Harris A, Hicks N, Khader K, Kralovic S, McKinley L, Rubin M, Safdar N, Schweizer ML, Tovar S, Wilson G, Zabarsky T, Perencevich EN. Research agenda for transmission prevention within the Veterans Health Administration, 2024-2028. Infect Control Hosp Epidemiol 2024:1-10. [PMID: 38600795 DOI: 10.1017/ice.2024.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Matthew Smith
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Chris Crnich
- William. S. Middleton Memorial VA Hospital, Madison, WI, USA
| | - Curtis Donskey
- Geriatric Research, Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL, USA
- Department of Preventive Medicine and Center for Health Services and Outcomes Research, Northwestern University of Feinberg School of Medicine, Chicago, IL, USA
| | - Martin Evans
- MRSA/MDRO Division, VHA National Infectious Diseases Service, Patient Care Services, VA Central Office and the Lexington VA Health Care System, Lexington, KY, USA
| | - Michihiko Goto
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Bernardino Guerrero
- Environmental Programs Service (EPS), Veterans Affairs Central Office, Washington, DC, USA
| | - Kalpana Gupta
- VA Boston Healthcare System and Boston University School of Medicine, Boston, MA, USA
| | - Anthony Harris
- Department of Epidemiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Natalie Hicks
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, USA
| | - Karim Khader
- DEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Stephen Kralovic
- Veterans Health Administration National Infectious Diseases Service, Washington, DC, USA
- Cincinnati VA Medical Center and University of Cincinnati, Cincinnati, OH, USA
| | - Linda McKinley
- William. S. Middleton Memorial VA Hospital, Madison, WI, USA
| | - Michael Rubin
- DEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Nasia Safdar
- William. S. Middleton Memorial VA Hospital, Madison, WI, USA
| | - Marin L Schweizer
- William. S. Middleton Memorial VA Hospital, Madison, WI, USA
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, and William S. Middleton Hospital, Madison, WI, USA
| | - Suzanne Tovar
- National Infectious Diseases Service (NIDS), Veterans Affairs Central Office, Washington, DC, USA
| | - Geneva Wilson
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines Jr. Veterans Affairs Hospital, Hines, IL, USA
- Department of Preventive Medicine, Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Trina Zabarsky
- Environmental Programs Service (EPS), Veterans Affairs Central Office, Washington, DC, USA
| | - Eli N Perencevich
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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3
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Allel K, Hernández-Leal MJ, Naylor NR, Undurraga EA, Abou Jaoude GJ, Bhandari P, Flanagan E, Haghparast-Bidgoli H, Pouwels KB, Yakob L. Costs-effectiveness and cost components of pharmaceutical and non-pharmaceutical interventions affecting antibiotic resistance outcomes in hospital patients: a systematic literature review. BMJ Glob Health 2024; 9:e013205. [PMID: 38423548 PMCID: PMC10910705 DOI: 10.1136/bmjgh-2023-013205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 01/26/2024] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION Limited information on costs and the cost-effectiveness of hospital interventions to reduce antibiotic resistance (ABR) hinder efficient resource allocation. METHODS We conducted a systematic literature review for studies evaluating the costs and cost-effectiveness of pharmaceutical and non-pharmaceutical interventions aimed at reducing, monitoring and controlling ABR in patients. Articles published until 12 December 2023 were explored using EconLit, EMBASE and PubMed. We focused on critical or high-priority bacteria, as defined by the WHO, and intervention costs and incremental cost-effectiveness ratio (ICER). Following Preferred Reporting Items for Systematic review and Meta-Analysis guidelines, we extracted unit costs, ICERs and essential study information including country, intervention, bacteria-drug combination, discount rates, type of model and outcomes. Costs were reported in 2022 US dollars ($), adopting the healthcare system perspective. Country willingness-to-pay (WTP) thresholds from Woods et al 2016 guided cost-effectiveness assessments. We assessed the studies reporting checklist using Drummond's method. RESULTS Among 20 958 articles, 59 (32 pharmaceutical and 27 non-pharmaceutical interventions) met the inclusion criteria. Non-pharmaceutical interventions, such as hygiene measures, had unit costs as low as $1 per patient, contrasting with generally higher pharmaceutical intervention costs. Several studies found that linezolid-based treatments for methicillin-resistant Staphylococcus aureus were cost-effective compared with vancomycin (ICER up to $21 488 per treatment success, all 16 studies' ICERs CONCLUSION Robust information on ABR interventions is critical for efficient resource allocation. We highlight cost-effective strategies for mitigating ABR in hospitals, emphasising substantial knowledge gaps, especially in low-income and middle-income countries. Our study serves as a resource for guiding future cost-effectiveness study design and analyses.PROSPERO registration number CRD42020341827 and CRD42022340064.
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Affiliation(s)
- Kasim Allel
- Disease Control Department, London School of Hygiene & Tropical Medicine, London, UK
- Institute for Global Health, University College London, London, UK
- Department of Health and Community Sciences, University of Exeter, Exeter, UK
| | - María José Hernández-Leal
- Department of Community, Maternity and Paediatric Nursing, University of Navarra, Pamplona, Spain
- Millennium Nucleus on Sociomedicine, Santiago, Chile
| | - Nichola R Naylor
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
- HCAI, Fungal, AMR, AMU & Sepsis Division, UK Health Security Agency, London, UK
| | - Eduardo A Undurraga
- Escuela de Gobierno, Pontificia Universidad Catolica de Chile, Santiago, Chile
- CIFAR Azrieli Global Scholars program, Canadian Institute for Advanced Research, Toronto, Ontario, Canada
| | | | - Priyanka Bhandari
- Disease Control Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Ellen Flanagan
- Disease Control Department, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Koen B Pouwels
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- The National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Laith Yakob
- Disease Control Department, London School of Hygiene & Tropical Medicine, London, UK
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Pople D, Kypraios T, Donker T, Stoesser N, Seale AC, George R, Dodgson A, Freeman R, Hope R, Walker AS, Hopkins S, Robotham J. Model-based evaluation of admission screening strategies for the detection and control of carbapenemase-producing Enterobacterales in the English hospital setting. BMC Med 2023; 21:492. [PMID: 38087343 PMCID: PMC10717398 DOI: 10.1186/s12916-023-03007-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/27/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Globally, detections of carbapenemase-producing Enterobacterales (CPE) colonisations and infections are increasing. The spread of these highly resistant bacteria poses a serious threat to public health. However, understanding of CPE transmission and evidence on effectiveness of control measures is severely lacking. This paper provides evidence to inform effective admission screening protocols, which could be important in controlling nosocomial CPE transmission. METHODS CPE transmission within an English hospital setting was simulated with a data-driven individual-based mathematical model. This model was used to evaluate the ability of the 2016 England CPE screening recommendations, and of potential alternative protocols, to identify patients with CPE-colonisation on admission (including those colonised during previous stays or from elsewhere). The model included nosocomial transmission from colonised and infected patients, as well as environmental contamination. Model parameters were estimated using primary data where possible, including estimation of transmission using detailed epidemiological data within a Bayesian framework. Separate models were parameterised to represent hospitals in English areas with low and high CPE risk (based on prevalence). RESULTS The proportion of truly colonised admissions which met the 2016 screening criteria was 43% in low-prevalence and 54% in high-prevalence areas respectively. Selection of CPE carriers for screening was improved in low-prevalence areas by adding readmission as a screening criterion, which doubled how many colonised admissions were selected. A minority of CPE carriers were confirmed as CPE positive during their hospital stay (10 and 14% in low- and high-prevalence areas); switching to a faster screening test pathway with a single-swab test (rather than three swab regimen) increased the overall positive predictive value with negligible reduction in negative predictive value. CONCLUSIONS Using a novel within-hospital CPE transmission model, this study assesses CPE admission screening protocols, across the range of CPE prevalence observed in England. It identifies protocol changes-adding readmissions to screening criteria and a single-swab test pathway-which could detect similar numbers of CPE carriers (or twice as many in low CPE prevalence areas), but faster, and hence with lower demand on pre-emptive infection-control resources. Study findings can inform interventions to control this emerging threat, although further work is required to understand within-hospital transmission sources.
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Affiliation(s)
- Diane Pople
- HCAI, Fungal, AMR, AMU & Sepsis Division, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK.
| | - Theodore Kypraios
- School of Mathematical Sciences, University Park, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Tjibbe Donker
- University Medical Center Freiburg, Institute for Infection Prevention and Hospital Epidemiology, Breisacher Strasse, 79106, Freiburg im Breisgau, Germany
| | - Nicole Stoesser
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- NIHR Health Protection Research Unit in Antimicrobial Resistance and Healthcare Associated Infections, University of Oxford and UKHSA, Oxford, UK
| | - Anna C Seale
- University of Warwick, Warwick, UK
- London School of Hygiene & Tropical Medicine, London, UK
- UK Health Security Agency, London, UK
| | - Ryan George
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Andrew Dodgson
- UK Health Security Agency, Manchester Public Health Laboratory, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Rachel Freeman
- IQVIA, The Point, 37 North Wharf Road, London, W2 1AF, UK
| | - Russell Hope
- HCAI, Fungal, AMR, AMU & Sepsis Division, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Ann Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Susan Hopkins
- NIHR Health Protection Research Unit in Antimicrobial Resistance and Healthcare Associated Infections, University of Oxford and UKHSA, Oxford, UK
- UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
- Division of Infection and Immunity, UCL, Gower St, London, UK
| | - Julie Robotham
- HCAI, Fungal, AMR, AMU & Sepsis Division, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
- NIHR Health Protection Research Unit in Antimicrobial Resistance and Healthcare Associated Infections, University of Oxford and UKHSA, Oxford, UK
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van der Schoor AS, Severin JA, Klaassen CHW, van den Akker JPC, Bruno MJ, Hendriks JM, Vos MC, Voor in ‘t holt AF. Universal screening or a universal risk assessment combined with risk-based screening for multidrug-resistant microorganisms upon admission: Comparing strategies. PLoS One 2023; 18:e0289163. [PMID: 37490485 PMCID: PMC10368271 DOI: 10.1371/journal.pone.0289163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/12/2023] [Indexed: 07/27/2023] Open
Abstract
OBJECTIVE Timely identification of patients who carry multidrug-resistant microorganisms (MDRO) is needed to prevent nosocomial spread to other patients and to the hospital environment. We aimed to compare the yield of a universal screening strategy upon admission to the currently installed universal risk assessment combined with risk-based screening upon admission. METHODS This observational study was conducted within a prospective cohort study. From January 1, 2018, until September 1, 2019, patients admitted to our hospital were asked to participate. Nasal and perianal samples were taken upon admission and checked for the presence of MDRO. The results of the universal risk assessment and risk-based screening were collected retrospectively from electronic health records. RESULTS In total, 1017 patients with 1069 separate hospital admissions participated in the study. Universal screening identified 38 (3.6%) unknown MDRO carriers upon admission (37 individual patients), all carrying extended-spectrum beta-lactamase-producing Enterobacterales. For 946 of 1069 (88.5%) patients, both the universal risk assessment and universal screening were performed. For 19 (2.0%) admissions, ≥1 risk factor was identified. The universal risk assessment identified one (0.1%) unknown carrier, compared to 37 out of 946 carriers for the universal screening (P<0.001). Of the 37 carriers identified through the universal screening, 35 (94.6%) reported no risk factors. CONCLUSIONS Our results show that in our low endemic setting, a universal screening strategy identified significantly more MDRO carriers than the currently implemented universal risk-assessment. When implementing a universal risk-assessment, risk factors should be carefully selected to be able to identify ESBL-E carriers. While the universal screening identified more MDRO carriers, further research is needed to determine the cost-effectiveness of this strategy.
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Affiliation(s)
- Adriënne S. van der Schoor
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Juliëtte A. Severin
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Corné H. W. Klaassen
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Johanna M. Hendriks
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Margreet C. Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Anne F. Voor in ‘t holt
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Park SH, Yi Y, Suh W, Ji SK, Han E, Shin S. The impact of enhanced screening for carbapenemase-producing Enterobacterales in an acute care hospital in South Korea. Antimicrob Resist Infect Control 2023; 12:62. [PMID: 37400884 DOI: 10.1186/s13756-023-01270-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/23/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Carbapenemase-producing Enterobacterales (CPE) poses a significant challenge to infection control in healthcare settings. Active screening is recommended to prevent intra-hospital CPE transmission. METHODS CPE screening was initiated at a 660-bed hospital in South Korea in September 2018, targeting patients previously colonized/infected or admitted to outside healthcare facilities (HCFs) within 1 month. Universal intensive care unit (ICU) screening was performed at the time of admission. After a hospital-wide CPE outbreak in July-September 2019, the screening program was enhanced by extending the indications (admission to any HCF within 6 months, receipt of hemodialysis) with weekly screening of ICU patients. The initial screening method was changed from screening cultures to the Xpert Carba-R assay. The impact was assessed by comparing the CPE incidence per 1000 admissions before (phase 1, September 2018-August 2019) and after instituting the enhanced screening program (phase 2, September 2019-December 2020). RESULTS A total of 13,962 (2,149 and 11,813 in each phase) were screened as indicated, among 49,490 inpatients, and monthly screening compliance increased from 18.3 to 93.5%. Compared to phase 1, the incidence of screening positive patients increased from 1.2 to 2.3 per 1,000 admissions (P = 0.005) during phase 2. The incidence of newly detected CPE patients was similar (3.1 vs. 3.4, P = 0.613) between two phases, but the incidence of hospital-onset CPE patients decreased (1.9 vs. 1.1, P = 0.018). A significant decrease was observed (0.5 to 0.1, P = 0.014) in the incidence of patients who first confirmed CPE positive through clinical cultures without a preceding positive screening. Compared to phase 1, the median exposure duration and number of CPE contacts were also markedly reduced in phase 2: 10.8 days vs. 1 day (P < 0.001) and 11 contacts vs. 1 contact (P < 0.001), respectively. During phase 2, 42 additional patients were identified by extending the admission screening indications (n = 30) and weekly in-ICU screening (n = 12). CONCLUSIONS The enhanced screening program enabled us to identify previously unrecognized CPE patients in a rapid manner and curtailed a hospital-wide CPE outbreak. As CPE prevalence increases, risk factors for CPE colonization can broaden, and hospital prevention strategies should be tailored to the changing local CPE epidemiology.
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Affiliation(s)
- Sun Hee Park
- Infection Prevention and Control Unit, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daejeon, Republic of Korea.
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
- The Catholic University of Korea, Eunpyeong St. Mary's Hospital, 93-19 Jingwan-dong, Eunpyeong-gu, Seoul, Republic of Korea.
| | - Yunmi Yi
- Infection Prevention and Control Unit, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daejeon, Republic of Korea
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Woosuck Suh
- Infection Prevention and Control Unit, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daejeon, Republic of Korea
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seul Ki Ji
- Infection Prevention and Control Unit, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daejeon, Republic of Korea
| | - Eunhee Han
- Infection Prevention and Control Unit, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daejeon, Republic of Korea
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soyoung Shin
- Infection Prevention and Control Unit, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daejeon, Republic of Korea
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Rice S, Carr K, Sobiesuo P, Shabaninejad H, Orozco-Leal G, Kontogiannis V, Marshall C, Pearson F, Moradi N, O'Connor N, Stoniute A, Richmond C, Craig D, Allegranzi B, Cassini A. Economic evaluations of interventions to prevent and control health-care-associated infections: a systematic review. THE LANCET. INFECTIOUS DISEASES 2023; 23:e228-e239. [PMID: 37001543 DOI: 10.1016/s1473-3099(22)00877-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 11/23/2022] [Accepted: 12/14/2022] [Indexed: 03/30/2023]
Abstract
Almost 9 million health-care-associated infections have been estimated to occur each year in European hospitals and long-term care facilities, and these lead to an increase in morbidity, mortality, bed occupancy, and duration of hospital stay. The aim of this systematic review was to review the cost-effectiveness of interventions to limit the spread of health-care-associated infections), framed by WHO infection prevention and control core components. The Embase, National Health Service Economic Evaluation Database, Database of Abstracts of Reviews of Effects, Health Technology Assessment, Cinahl, Scopus, Pediatric Economic Database Evaluation, and Global Index Medicus databases, plus grey literature were searched for studies between Jan 1, 2009, and Aug 10, 2022. Studies were included if they reported interventions including hand hygiene, personal protective equipment, national-level or facility-level infection prevention and control programmes, education and training programmes, environmental cleaning, and surveillance. The British Medical Journal checklist was used to assess the quality of economic evaluations. 67 studies were included in the review. 25 studies evaluated methicillin-resistant Staphylococcus aureus outcomes. 31 studies evaluated screening strategies. The assessed studies that met the minimum quality criteria consisted of economic models. There was some evidence that hand hygiene, environmental cleaning, surveillance, and multimodal interventions were cost-effective. There were few or no studies investigating education and training, personal protective equipment or monitoring, and evaluation of interventions. This Review provides a map of cost-effectiveness data, so that policy makers and researchers can identify the relevant data and then assess the quality and generalisability for their setting.
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Affiliation(s)
- Stephen Rice
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.
| | - Katherine Carr
- Dental School, Newcastle University, Newcastle upon Tyne, UK
| | - Pauline Sobiesuo
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hosein Shabaninejad
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Giovany Orozco-Leal
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Christopher Marshall
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK; NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona Pearson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK; NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
| | - Najmeh Moradi
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Nicole O'Connor
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK; NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
| | - Akvile Stoniute
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Richmond
- NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
| | - Dawn Craig
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK; NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
| | - Benedetta Allegranzi
- Infection Prevention and Control Technical and Clinical Hub, Department of Integrated Health Services, WHO, Geneva, Switzerland
| | - Alessandro Cassini
- Infection Prevention and Control Technical and Clinical Hub, Department of Integrated Health Services, WHO, Geneva, Switzerland
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8
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Basquiera AL, Aguirre MA, Serra FA, Vaca M, Brulc EB, Perusini MA, Ferini GA, Schutz NP, Otero V, García Corbanini D, Litvack E, Giron J, Garnica G, Martinez B, Michelangelo H, San Román E, Pollán J, Fantl DB, Arbelbide JA, Valledor A, Staneloni MI. Decrease in Mortality from Sepsis: Impact of the Multidisciplinary Program for the Hematologic Patient at Very High Risk. Indian J Hematol Blood Transfus 2023; 39:7-14. [PMID: 36699429 PMCID: PMC9868195 DOI: 10.1007/s12288-021-01497-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 10/05/2021] [Indexed: 01/28/2023] Open
Abstract
A program for the hematologic patient at very high risk of infections (HAR, from its initials in Spanish) was implemented, based on a multidisciplinary team and six measures intended to reduce the colonization and subsequent sepsis by multidrug-resistant organisms (MDRO). We aimed at evaluating the effectiveness of the HAR program in terms of MDRO infections mainly caused by Klebsiella pneumoniae carbapenemase-producing and multidrug-resistant Pseudomona aeruginosa, and sepsis-related mortality. We established retrospective comparisons between the pre-HAR period (2016-2018) and the post-HAR period (2018-2019), in patients who received a hematopoietic stem cell transplant (HSCT) and/or intensive chemotherapy to treat non-M3 acute myeloid leukemia (CH-AML). We included 262 patients: 176 pre-HAR and 86 post-HAR. MDRO infection was 4.6% at 30 days and 6.1% at 90 days (all the cases during the pre-HAR period). Sepsis-related mortality was 6.5%, considering a median follow-up of 608 days: 6.1% in the HSCT group and 12.4% in the CH-AML group (p = 0.306). Sepsis-related mortality was 8.7% in the pre-HAR period and 0% in the post-HAR period (p = 0.014). The implementation of this multidisciplinary program based in preventive measures and the appropriate use of antibiotics enabled a decrease in sepsis-related mortality in very high-risk hematologic patients.
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Affiliation(s)
- Ana L. Basquiera
- Hematology Section, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Buenos Aires, Argentina
- Present Address: Hospital Privado Universitario de Córdoba, Naciones Unidas 346, 5016 Córdoba, Argentina
| | - María A. Aguirre
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Florencia A. Serra
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mayra Vaca
- Hematology Section, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Buenos Aires, Argentina
| | - Erika B. Brulc
- Hematology Section, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Buenos Aires, Argentina
| | - María A. Perusini
- Hematology Section, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Buenos Aires, Argentina
| | - Gonzalo A. Ferini
- Hematology Section, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Buenos Aires, Argentina
| | - Natalia P. Schutz
- Hematology Section, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Buenos Aires, Argentina
| | - Victoria Otero
- Hematology Section, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Buenos Aires, Argentina
| | | | - Edgardo Litvack
- Nursery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Julio Giron
- Nursery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Gastón Garnica
- Nursery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Bernardo Martinez
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Emergency Unit for Adults, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Hernán Michelangelo
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Intermediate Care Unit for Adults, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Eduardo San Román
- Intensive Care Unit for Adults, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Javier Pollán
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Dorotea B. Fantl
- Hematology Section, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Buenos Aires, Argentina
| | - Jorge A. Arbelbide
- Hematology Section, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Buenos Aires, Argentina
| | - Alejandra Valledor
- Infectology Section, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - María I. Staneloni
- Infections Committee, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Kardaś-Słoma L, Fournier S, Dupont JC, Rochaix L, Birgand G, Zahar JR, Lescure FX, Kernéis S, Durand-Zaleski I, Lucet JC. Cost-effectiveness of strategies to control the spread of carbapenemase-producing Enterobacterales in hospitals: a modelling study. Antimicrob Resist Infect Control 2022; 11:117. [PMID: 36117231 PMCID: PMC9484055 DOI: 10.1186/s13756-022-01149-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 08/03/2022] [Indexed: 11/24/2022] Open
Abstract
Background Spread of resistant bacteria causes severe morbidity and mortality. Stringent control measures can be expensive and disrupt hospital organization. In the present study, we assessed the effectiveness and cost-effectiveness of control strategies to prevent the spread of Carbapenemase-producing Enterobacterales (CPE) in a general hospital ward (GW). Methods A dynamic, stochastic model simulated the transmission of CPE by the hands of healthcare workers (HCWs) and the environment in a hypothetical 25-bed GW. Input parameters were based on published data; we assumed the prevalence at admission of 0.1%. 12 strategies were compared to the baseline (no control) and combined different prevention and control interventions: targeted or universal screening at admission (TS or US), contact precautions (CP), isolation in a single room, dedicated nursing staff (DNS) for carriers and weekly screening of contact patients (WSC). Time horizon was one year. Outcomes were the number of CPE acquisitions, costs, and incremental cost-effectiveness ratios (ICER). A hospital perspective was adopted to estimate costs, which included laboratory costs, single room, contact precautions, staff time, i.e. infection control nurse and/or dedicated nursing staff, and lost bed-days due to prolonged hospital stay of identified carriers. The model was calibrated on actual datasets. Sensitivity analyses were performed. Results The baseline scenario resulted in 0.93 CPE acquisitions/1000 admissions and costs 32,050 €/1000 admissions. All control strategies increased costs and improved the outcome. The efficiency frontier was represented by: (1) TS with DNS at a 17,407 €/avoided CPE case, (2) TS + DNS + WSC at a 30,700 €/avoided CPE case and (3) US + DNS + WSC at 181,472 €/avoided CPE case. Other strategies were dominated. Sensitivity analyses showed that TS + CP might be cost-effective if CPE carriers are identified upon admission or if the cases have a short hospital stay. However, CP were effective only when high level of compliance with hand hygiene was obtained. Conclusions Targeted screening at admission combined with DNS for identified CPE carriers with or without weekly screening were the most cost-effective options to limit the spread of CPE. These results support current recommendations from several high-income countries. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-022-01149-0.
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Manoukian S, Stewart S, Dancer SJ, Mason H, Graves N, Robertson C, Leonard A, Kennedy S, Kavanagh K, Parcell B, Reilly J. Probabilistic microsimulation to examine the cost-effectiveness of hospital admission screening strategies for carbapenemase-producing enterobacteriaceae (CPE) in the United Kingdom. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:1173-1185. [PMID: 34932169 PMCID: PMC8689289 DOI: 10.1007/s10198-021-01419-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 11/29/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Antimicrobial resistance has been recognised as a global threat with carbapenemase- producing-Enterobacteriaceae (CPE) as a prime example. CPE has similarities to COVID-19 where asymptomatic patients may be colonised representing a source for onward transmission. There are limited treatment options for CPE infection leading to poor outcomes and increased costs. Admission screening can prevent cross-transmission by pre-emptively isolating colonised patients. OBJECTIVE We assess the relative cost-effectiveness of screening programmes compared with no- screening. METHODS A microsimulation parameterised with NHS Scotland date was used to model scenarios of the prevalence of CPE colonised patients on admission. Screening strategies were (a) two-step screening involving a clinical risk assessment (CRA) checklist followed by microbiological testing of high-risk patients; and (b) universal screening. Strategies were considered with either culture or polymerase chain reaction (PCR) tests. All costs were reported in 2019 UK pounds with a healthcare system perspective. RESULTS In the low prevalence scenario, no screening had the highest probability of cost-effectiveness. Among screening strategies, the two CRA screening options were the most likely to be cost-effective. Screening was more likely to be cost-effective than no screening in the prevalence of 1 CPE colonised in 500 admitted patients or more. There was substantial uncertainty with the probabilities rarely exceeding 40% and similar results between strategies. Screening reduced non-isolated bed-days and CPE colonisation. The cost of screening was low in relation to total costs. CONCLUSION The specificity of the CRA checklist was the parameter with the highest impact on the cost-effectiveness. Further primary data collection is needed to build models with less uncertainty in the parameters.
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Affiliation(s)
- Sarkis Manoukian
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, Scotland, UK.
| | - Sally Stewart
- Safeguarding Health Through Infection Prevention Research Group, Glasgow Caledonian University, Glasgow, Scotland, UK
| | - Stephanie J Dancer
- Department of Microbiology, Hairmyres Hospital, NHS Lanarkshire and School of Applied Sciences, Edinburgh Napier University, Edinburgh, Scotland, UK
| | - Helen Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, Scotland, UK
| | | | - Chris Robertson
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, Scotland, UK
| | | | - Sharon Kennedy
- Information Services Division, Public Health Scotland, Edinburgh, Scotland, UK
| | - Kim Kavanagh
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, Scotland, UK
| | - Benjamin Parcell
- Medical Microbiology, NHS Tayside, Ninewells Hospital and School of Medicine, Dundee, Scotland, UK
| | - Jacqui Reilly
- Safeguarding Health Through Infection Prevention Research Group, Glasgow Caledonian University, Glasgow, Scotland, UK
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Transmission of gram-negative antibiotic-resistant bacteria following differing exposure to antibiotic-resistance reservoirs in a rural community: a modelling study for bloodstream infections. Sci Rep 2022; 12:13488. [PMID: 35931725 PMCID: PMC9356060 DOI: 10.1038/s41598-022-17598-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 07/27/2022] [Indexed: 11/29/2022] Open
Abstract
Exposure to community reservoirs of gram-negative antibiotic-resistant bacteria (GN-ARB) genes poses substantial health risks to individuals, complicating potential infections. Transmission networks and population dynamics remain unclear, particularly in resource-poor communities. We use a dynamic compartment model to assess GN-ARB transmission quantitatively, including the susceptible, colonised, infected, and removed populations at the community-hospital interface. We used two side streams to distinguish between individuals at high- and low-risk exposure to community ARB reservoirs. The model was calibrated using data from a cross-sectional cohort study (N = 357) in Chile and supplemented by existing literature. Most individuals acquired ARB from the community reservoirs (98%) rather than the hospital. High exposure to GN-ARB reservoirs was associated with 17% and 16% greater prevalence for GN-ARB carriage in the hospital and community settings, respectively. The higher exposure has led to 16% more infections and attributed mortality. Our results highlight the need for early-stage identification and testing capability of bloodstream infections caused by GN-ARB through a faster response at the community level, where most GN-ARB are likely to be acquired. Increasing treatment rates for individuals colonised or infected by GN-ARB and controlling the exposure to antibiotic consumption and GN-ARB reservoirs, is crucial to curve GN-ABR transmission.
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12
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Economic Evaluation of Nemonoxacin, Moxifloxacin and Levofloxacin in the Treatment of Early Community-Acquired Pneumonia with Possible Pulmonary Tuberculosis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084816. [PMID: 35457683 PMCID: PMC9028707 DOI: 10.3390/ijerph19084816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/09/2022] [Accepted: 04/14/2022] [Indexed: 11/23/2022]
Abstract
The Chinese community-acquired pneumonia (CAP) Diagnosis and Treatment Guideline 2020 recommends quinolone antibiotics as the initial empirical treatment options for CAP. However, patients with pulmonary tuberculosis (PTB) are often misdiagnosed with CAP because of the similarity of symptoms. Moxifloxacin and levofloxacin have inhibitory effects on mycobacterium tuberculosis as compared with nemonoxacin, resulting in delayed diagnosis of PTB. Hence, the aim of this study is to compare the cost-effectiveness of nemonoxacin, moxifloxacin and levofloxacin in the treatment of CAP and to determine the value of these treatments in the differential diagnosis of PTB. Primary efficacy data were collected from phase II-III randomized, double-blind, multi-center clinical trials comparing nemonoxacin to moxifloxacin (CTR20130195) and nemonoxacin to levofloxacin (CTR20140439) for the treatment of Chinese CAP patients. A decision tree was constructed to compare the cost-utility among three groups under the perspective of healthcare system. The threshold for willingness to pay (WTP) is 1–3 times GDP per capita ($11,174–33,521). Scenarios including efficacy and cost for CAP patients with a total of 6% undifferentiated PTB. Sensitivity and scenario analyses were performed to test the robustness of basic analysis. The costs of nemonoxacin, moxifloxacin, and levofloxacin were $903.72, $1053.59, and $1212.06 and the outcomes were 188.7, 188.8, and 188.5 quality-adjusted life days (QALD), respectively. Nemonoxacin and moxifloxacin were dominant compared with levofloxacin, and the ICER of moxifloxacin compared with nemonoxacin was $551,643, which was much greater than WTP; therefore, nemonoxacin was the most cost-effective option. Regarding patients with PTB who were misdiagnosed with CAP, taking nemonoxacin could save $290.76 and $205.51 when compared with moxifloxacin and levofloxacin and resulted in a gain of 2.83 QALDs. Our findings demonstrate that nemonoxacin is the more economical compared with moxifloxacin and levofloxacin, and non-fluoroquinolone antibiotics are cost-saving and utility-increasing compared to fluoroquinolones in the differential diagnosis of PTB, which can help healthcare system in making optimal policies and help clinicians in the medication of patients.
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Çaǧlayan Ç, Barnes SL, Pineles LL, Harris AD, Klein EY. A Data-Driven Framework for Identifying Intensive Care Unit Admissions Colonized With Multidrug-Resistant Organisms. Front Public Health 2022; 10:853757. [PMID: 35372195 PMCID: PMC8968755 DOI: 10.3389/fpubh.2022.853757] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/14/2022] [Indexed: 12/29/2022] Open
Abstract
Background The rising prevalence of multi-drug resistant organisms (MDROs), such as Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant Enterococci (VRE), and Carbapenem-resistant Enterobacteriaceae (CRE), is an increasing concern in healthcare settings. Materials and Methods Leveraging data from electronic healthcare records and a unique MDRO universal screening program, we developed a data-driven modeling framework to predict MRSA, VRE, and CRE colonization upon intensive care unit (ICU) admission, and identified the associated socio-demographic and clinical factors using logistic regression (LR), random forest (RF), and XGBoost algorithms. We performed threshold optimization for converting predicted probabilities into binary predictions and identified the cut-off maximizing the sum of sensitivity and specificity. Results Four thousand six hundred seventy ICU admissions (3,958 patients) were examined. MDRO colonization rate was 17.59% (13.03% VRE, 1.45% CRE, and 7.47% MRSA). Our study achieved the following sensitivity and specificity values with the best performing models, respectively: 80% and 66% for VRE with LR, 73% and 77% for CRE with XGBoost, 76% and 59% for MRSA with RF, and 82% and 83% for MDRO (i.e., VRE or CRE or MRSA) with RF. Further, we identified several predictors of MDRO colonization, including long-term care facility stay, current diagnosis of skin/subcutaneous tissue or infectious/parasitic disease, and recent isolation precaution procedures before ICU admission. Conclusion Our data-driven modeling framework can be used as a clinical decision support tool for timely predictions, characterization and identification of high-risk patients, and selective and timely use of infection control measures in ICUs.
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Affiliation(s)
- Çaǧlar Çaǧlayan
- Asymmetric Operations Sector, Johns Hopkins University Applied Physics Laboratory, Laurel, MD, United States
| | - Sean L. Barnes
- Department of Decision, Operations and Information Technologies (DO&IT), R.H. Smith School of Business, University of Maryland, College Park, MD, United States
| | - Lisa L. Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Anthony D. Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Eili Y. Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Center for Disease Dynamics, Economics and Policy, Washington, DC, United States
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14
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Jean SS, Harnod D, Hsueh PR. Global Threat of Carbapenem-Resistant Gram-Negative Bacteria. Front Cell Infect Microbiol 2022; 12:823684. [PMID: 35372099 PMCID: PMC8965008 DOI: 10.3389/fcimb.2022.823684] [Citation(s) in RCA: 108] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 02/15/2022] [Indexed: 01/08/2023] Open
Abstract
Infections caused by multidrug-resistant (MDR) and extensively drug-resistant (XDR) Gram-negative bacteria (GNB), including carbapenem-resistant (CR) Enterobacterales (CRE; harboring mainly blaKPC, blaNDM, and blaOXA-48-like genes), CR- or MDR/XDR-Pseudomonas aeruginosa (production of VIM, IMP, or NDM carbapenemases combined with porin alteration), and Acinetobacter baumannii complex (producing mainly OXA-23, OXA-58-like carbapenemases), have gradually worsened and become a major challenge to public health because of limited antibiotic choice and high case-fatality rates. Diverse MDR/XDR-GNB isolates have been predominantly cultured from inpatients and hospital equipment/settings, but CRE has also been identified in community settings and long-term care facilities. Several CRE outbreaks cost hospitals and healthcare institutions huge economic burdens for disinfection and containment of their disseminations. Parenteral polymyxin B/E has been observed to have a poor pharmacokinetic profile for the treatment of CR- and XDR-GNB. It has been determined that tigecycline is suitable for the treatment of bloodstream infections owing to GNB, with a minimum inhibitory concentration of ≤ 0.5 mg/L. Ceftazidime-avibactam is a last-resort antibiotic against GNB of Ambler class A/C/D enzyme-producers and a majority of CR-P. aeruginosa isolates. Furthermore, ceftolozane-tazobactam is shown to exhibit excellent in vitro activity against CR- and XDR-P. aeruginosa isolates. Several pharmaceuticals have devoted to exploring novel antibiotics to combat these troublesome XDR-GNBs. Nevertheless, only few antibiotics are shown to be effective in vitro against CR/XDR-A. baumannii complex isolates. In this era of antibiotic pipelines, strict implementation of antibiotic stewardship is as important as in-time isolation cohorts in limiting the spread of CR/XDR-GNB and alleviating the worsening trends of resistance.
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Affiliation(s)
- Shio-Shin Jean
- Department of Emergency and Critical Care Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
- Department of Pharmacy, College of Pharmacy and Health care, Tajen University, Pingtung, Taiwan
| | - Dorji Harnod
- Division of Critical Care Medicine, Department of Emergency and Critical Care Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Po-Ren Hsueh
- Departments of Laboratory Medicine and Internal Medicine, China Medical University Hospital, School of Medicine, China Medical University, Taichung, Taiwan
- School of Medicine, China Medical University, Taichung, Taiwan
- Ph.D Program for Aging, School of Medicine, China Medical University, Taichung, Taiwan
- Departments of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
- *Correspondence: Po-Ren Hsueh,
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Jamal AJ, Faheem A, Farooqi L, Zhong XZ, Armstrong I, Boyd DA, Borgundvaag E, Coleman BL, Green K, Jayasinghe K, Johnstone J, Katz K, Kohler P, Li AX, Mataseje L, Melano R, Muller MP, Mulvey MR, Nayani S, Patel SN, Paterson A, Poutanen S, Rebbapragada A, Richardson D, Sarabia A, Shafinaz S, Simor AE, Willey BM, Wisely L, McGeer AJ. Household Transmission of Carbapenemase-producing Enterobacterales in Ontario, Canada. Clin Infect Dis 2021; 73:e4607-e4615. [PMID: 32869855 PMCID: PMC8662791 DOI: 10.1093/cid/ciaa1295] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 08/27/2020] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Data on household transmission of carbapenemase-producing Enterobacterales (CPE) remain limited. We studied risk of CPE household co-colonization and transmission in Ontario, Canada. METHODS We enrolled CPE index cases (identified via population-based surveillance from January 2015 to October 2018) and their household contacts. At months 0, 3, 6, 9, and 12, participants provided rectal and groin swabs. Swabs were cultured for CPE until September 2017, when direct polymerase chain reaction (PCR; with culture of specimens if a carbapenemase gene was detected) replaced culture. CPE risk factor data were collected by interview and combined with isolate whole-genome sequencing to determine likelihood of household transmission. Risk factors for household contact colonization were explored using a multivariable logistic regression model with generalized estimating equations. RESULTS Ninety-five households with 177 household contacts participated. Sixteen (9%) household contacts in 16 (17%) households were CPE-colonized. Household transmission was confirmed in 3/177 (2%) cases, probable in 2/177 (1%), possible in 9/177 (5%), and unlikely in 2/177 (1%). Household contacts were more likely to be colonized if they were the index case's spouse (odds ratio [OR], 6.17; 95% confidence interval [CI], 1.05-36.35), if their index case remained CPE-colonized at household enrollment (OR, 7.00; 95% CI, 1.92-25.49), or if they had at least 1 set of specimens processed after direct PCR was introduced (OR, 6.46; 95% CI, 1.52-27.40). CONCLUSIONS Nine percent of household contacts were CPE-colonized; 3% were a result of household transmission. Hospitals may consider admission screening for patients known to have CPE-colonized household contacts.
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Affiliation(s)
- Alainna J Jamal
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Amna Faheem
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Lubna Farooqi
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Xi Zoe Zhong
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Irene Armstrong
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Communicable Disease Control, Toronto Public Health, Toronto, Ontario, Canada
| | - David A Boyd
- Antimicrobial Resistance and Nosocomial Infections, National Microbiology Laboratory, Winnipeg, Manitoba, Canada
| | - Emily Borgundvaag
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Brenda L Coleman
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Karen Green
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | | | - Jennie Johnstone
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Kevin Katz
- Department of Infection Prevention and Control, North York General Hospital, Toronto, Ontario, Canada
| | - Philipp Kohler
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Angel X Li
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Laura Mataseje
- Antimicrobial Resistance and Nosocomial Infections, National Microbiology Laboratory, Winnipeg, Manitoba, Canada
| | - Roberto Melano
- Bacteriology, Public Health Ontario Laboratory, Toronto, Ontario, Canada
| | - Matthew P Muller
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Infection Prevention and Control, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Michael R Mulvey
- Antimicrobial Resistance and Nosocomial Infections, National Microbiology Laboratory, Winnipeg, Manitoba, Canada
| | - Sarah Nayani
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Samir N Patel
- Bacteriology, Public Health Ontario Laboratory, Toronto, Ontario, Canada
| | - Aimee Paterson
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Susan Poutanen
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Anu Rebbapragada
- Scientific Affairs and Market Access, Hologic Inc., Toronto, Ontario, Canada
| | - David Richardson
- Department of Infection Prevention and Control, William Osler Health System, Brampton, Ontario, Canada
| | - Alicia Sarabia
- Department of Infection Prevention and Control, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Shumona Shafinaz
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Andrew E Simor
- Department of Infection Prevention and Control, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Barbara M Willey
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Laura Wisely
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
| | - Allison J McGeer
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada
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Phee L, Paget S, Jacques J, Bharathan B, El-Mugamar H, Sivaramakrishnan A. Carbapenemase-producing organism (CPO) colonisation at a district general hospital: universal screening may help reduce transmission. Infect Prev Pract 2021; 3:100164. [PMID: 34647013 PMCID: PMC8498735 DOI: 10.1016/j.infpip.2021.100164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 07/23/2021] [Indexed: 11/30/2022] Open
Abstract
Objective Assess the potential of hospital-wide routine screening by determining the prevalence and incidence of carbapenemase-producing organisms (CPOs) isolated from rectal screens at Barnet and Chase Farm Hospitals. Methods 3,553 samples were collected between 01/12/2018 and 31/08/2019: from adult critical care wards (universal screening - admission, discharge and weekly), from medical wards with risk-factor based screening according to the prevailing Public Health England (PHE) carbapenemase-producing Enterobacteriaceae (CPE) screening guidelines, or on an ad hoc basis. Prevalence was defined as previously documented positive CPO colonisation, or new positive status, as a proportion of all eligible samples. Incidence was defined as all newly positive patients per 1,000 patient-days. Results Overall CPO prevalence was 2.1% (95% CI: 1.61–2.58%). Inpatient prevalence was significantly higher at 2.6% vs outpatient at 0.5% (p < 0.001). Incidence was 0.44 per 1,000 patient-days (95% CI: 0.33–0.57), with a rate ratio between Barnet and Chase Farm of 4.9 (p = 0.013). Incidence was highest where universal screening strategy was applied (3.9 per 1000 patient-days, 95% CI: 2.4–5.91). This was 2.5 times higher than risk-factor based screening (p = 0.005) and 23.5 times that of wards without routine surveillance implemented (p < 0.001). Conclusion Surveillance remains a cornerstone in controlling CPO transmission. Our local incidence, lacking hospital-wide screening, significantly exceeded the reported UK average. Universal screening could help to uncover the true prevalence and incidence of CPO, thereby providing the necessary information to properly control transmission, reducing nosocomial outbreaks and ultimately reducing the overall cost to healthcare.
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Affiliation(s)
- Lynette Phee
- Department of Microbiology, Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, UK.,Department of Pathology, Singapore Health Services, SKH, Singapore
| | - Stephanie Paget
- Department of Microbiology, Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, UK
| | - Judy Jacques
- Infection Prevention and Control Team, Barnet Hospital, Royal Free London NHS Foundation Trust, UK
| | - Binutha Bharathan
- Department of Microbiology, Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, UK
| | - Husam El-Mugamar
- Department of Microbiology, Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, UK
| | - Anand Sivaramakrishnan
- Department of Microbiology, Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, UK
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17
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Prescott K. Learning from pragmatic local research. Infect Prev Pract 2021; 3:100171. [PMID: 34568806 PMCID: PMC8448619 DOI: 10.1016/j.infpip.2021.100171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Katherine Prescott
- Department of Microbiology, Nottingham University Hospitals NHS Trust, England, UK
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Du X, Han Y, Jian Y, Chen L, Xuan J. Clinical Benefits and Cost-Effectiveness of Moxifloxacin as Initial Treatment for Community-Acquired Pneumonia: A Meta-Analysis and Economic Evaluation. Clin Ther 2021; 43:1894-1909.e1. [PMID: 33814200 DOI: 10.1016/j.clinthera.2021.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/25/2021] [Accepted: 03/05/2021] [Indexed: 01/10/2023]
Abstract
PURPOSE Moxifloxacin and levofloxacin are currently recommended as empirical initial treatment options for community-acquired pneumonia (CAP) in China according to guidelines. Most studies that evaluated the efficacy and safety of moxifloxacin and levofloxacin in treating CAP as initial empirical treatment were single-centered trials assessing different clinical end points. In addition, there is limited research investigating moxifloxacin's clinical benefits in the context of health care resource utilization and reimbursement from the payer's perspective in China. Hence, this study was aimed at comparing the clinical efficacy of moxifloxacin and levofloxacin by conducting a meta-analysis and assessing their economic value from the China payer's perspective through a cost-utility analysis model. METHODS For the meta-analysis, 6 bibliographic databases were searched for relevant publications from January 2000 to August 2020, and studies were assessed for eligibility under predetermined criteria. Meta-analysis was performed by using a random effects model when analyses included >2 trials. For the economic evaluation, a decision-tree model was constructed to investigate the cost-utility of moxifloxacin versus levofloxacin as initial regimens in the treatment of CAP inpatients. Parameter values were derived from meta-analysis, published literature, and clinician survey. The outcome was reported in the form of an incremental cost-effectiveness ratio. One-way sensitivity analysis and probabilistic sensitivity analysis were undertaken to assess the robustness of the model. FINDINGS Twenty-seven randomized controlled trials were included in the meta-analysis. Results indicated that the clinical response rate at the test-of-cure visit with initial treatment of moxifloxacin was significantly higher than that of levofloxacin (3441 patients; random effects model; I2 = 49%; odds ratio, 3.35; 95% CI, 2.35-4.77; P < 0.001). In terms of the safety profile, total adverse events were not significantly different between the 2 groups (2770 patients; random effects model; I2 = 40%; odds ratio, 0.77; 95% CI, 0.56-1.06; P = 0.11). Output of the cost-utility model showed that under the willingness-to-pay threshold of one-time China gross domestic product per capita, moxifloxacin is dominant over levofloxacin, being less costly and more efficacious (0.002 quality-adjusted life year gained, CNY 844 [US$131] saved in total cost, negative incremental cost-effectiveness ratio). Sensitivity analyses indicated the robustness of the model as moxifloxacin remained dominant when model parameter values fluctuated. IMPLICATIONS Moxifloxacin is more efficacious than levofloxacin as the initial empirical treatment for CAP. In addition, treatment of CAP with moxifloxacin instead of levofloxacin is expected to be cost-saving from the perspective of payers in China. However, for the cost-utility analysis, in the absence of a national representative database on costs for hospitalization in China, inputs in the cost-utility model could be underestimated or overestimated due to estimating errors applied to both treatment arms. (Clin Ther. 2021;43:XXX-XXX) © 2021 Elsevier HS Journals, Inc.
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Affiliation(s)
- Xiwen Du
- Shanghai Centennial Scientific Co Ltd, Shanghai, China
| | - Yi Han
- School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, China
| | - Yifei Jian
- School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, China
| | - Liping Chen
- School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, China
| | - Jianwei Xuan
- School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, China.
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Lee BY, Bartsch SM, Ferguson MC, Wedlock PT, O’Shea KJ, Siegmund SS, Cox SN, McKinnell JA. The value of decreasing the duration of the infectious period of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. PLoS Comput Biol 2021; 17:e1008470. [PMID: 33411742 PMCID: PMC7790237 DOI: 10.1371/journal.pcbi.1008470] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 10/27/2020] [Indexed: 01/08/2023] Open
Abstract
Finding medications or vaccines that may decrease the infectious period of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) could potentially reduce transmission in the broader population. We developed a computational model of the U.S. simulating the spread of SARS-CoV-2 and the potential clinical and economic impact of reducing the infectious period duration. Simulation experiments found that reducing the average infectious period duration could avert a median of 442,852 [treating 25% of symptomatic cases, reducing by 0.5 days, reproductive number (R0) 3.5, and starting treatment when 15% of the population has been exposed] to 44.4 million SARS-CoV-2 cases (treating 75% of all infected cases, reducing by 3.5 days, R0 2.0). With R0 2.5, reducing the average infectious period duration by 0.5 days for 25% of symptomatic cases averted 1.4 million cases and 99,398 hospitalizations; increasing to 75% of symptomatic cases averted 2.8 million cases. At $500/person, treating 25% of symptomatic cases saved $209.5 billion (societal perspective). Further reducing the average infectious period duration by 3.5 days averted 7.4 million cases (treating 25% of symptomatic cases). Expanding treatment to 75% of all infected cases, including asymptomatic infections (R0 2.5), averted 35.9 million cases and 4 million hospitalizations, saving $48.8 billion (societal perspective and starting treatment after 5% of the population has been exposed). Our study quantifies the potential effects of reducing the SARS-CoV-2 infectious period duration.
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Affiliation(s)
- Bruce Y. Lee
- Public Health Informatics, Computational, and Operations Research (PHICOR), City University of New York Graduate School of Public Health and Health Policy, New York City, New York, United States of America
| | - Sarah M. Bartsch
- Public Health Informatics, Computational, and Operations Research (PHICOR), City University of New York Graduate School of Public Health and Health Policy, New York City, New York, United States of America
| | - Marie C. Ferguson
- Public Health Informatics, Computational, and Operations Research (PHICOR), City University of New York Graduate School of Public Health and Health Policy, New York City, New York, United States of America
| | - Patrick T. Wedlock
- Public Health Informatics, Computational, and Operations Research (PHICOR), City University of New York Graduate School of Public Health and Health Policy, New York City, New York, United States of America
| | - Kelly J. O’Shea
- Public Health Informatics, Computational, and Operations Research (PHICOR), City University of New York Graduate School of Public Health and Health Policy, New York City, New York, United States of America
| | - Sheryl S. Siegmund
- Public Health Informatics, Computational, and Operations Research (PHICOR), City University of New York Graduate School of Public Health and Health Policy, New York City, New York, United States of America
| | - Sarah N. Cox
- Public Health Informatics, Computational, and Operations Research (PHICOR), City University of New York Graduate School of Public Health and Health Policy, New York City, New York, United States of America
| | - James A. McKinnell
- Infectious Disease Clinical Outcomes Research Unit (ID-CORE), Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California, United States of America
- Torrance Memorial Medical Center, Torrance, California, United States of America
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Fahy S, O'Connor J, O'Brien D, Fitzpatrick L, O'Connor M, Crowley J, Bernard M, Sleator R, Lucey B. Carbapenemase screening in an Irish tertiary referral hospital: Best practice, or can we do better? Infect Prev Pract 2020; 2:100100. [PMID: 34368728 PMCID: PMC8335925 DOI: 10.1016/j.infpip.2020.100100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/26/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Carbapenems are a family of end line antibiotics with increasing levels of resistance that are a cause for concern. AIM To ascertain whether the CPE screening programme employed in an acute tertiary hospital is fit for purpose. METHOD We outlined the current working algorithm employed using a universal screening programme over a 26-month screening period. Rectal swabs are cultured on arrival. Those with suspicious growth are further investigated using NG-Carba 5 lateral flow tests and Vitek 2.0 sensitivity cards. These practices were compared with NHS guidelines. FINDINGS & CONCLUSIONS In all, 53 true positives were detected from 45 patients since the screening was implemented in early 2018 (46 OXA-48, 6 KPC, 1 NDM). As the rate of screening increased, the number of positive screens decreased over time. There were a lot of similarities between the HSE guidelines and the published NHS CPE toolkit. It was evident that there is no standard practice being employed across all hospitals. Comparing the MUH to national guidelines it appears to be quicker and more effective with universal screening in place at reducing the potential contacts and identifying carriers. Cost analysis indicates that the need to confirm all positive strains in a reference lab is costly, unnecessary and time consuming. There are adequate confirmatory tests available in-house for routine positive screens. It was concluded that infection prevention and control are key to identifying and controlling possible outbreaks in a hospital setting.
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Affiliation(s)
- S. Fahy
- Department of Clinical Microbiology, Mercy University Hospital, Cork, Ireland
- Department of Biological Sciences, Cork Institute of Technology, Bishopstown, Cork, Ireland
| | - J.A. O'Connor
- Department of Clinical Microbiology, Mercy University Hospital, Cork, Ireland
| | - D. O'Brien
- Department of Clinical Microbiology, Mercy University Hospital, Cork, Ireland
| | - L. Fitzpatrick
- Department of Clinical Microbiology, Mercy University Hospital, Cork, Ireland
| | - M. O'Connor
- Infection Prevention & Control Department, Mercy University Hospital, Cork, Ireland
| | - J. Crowley
- Infection Prevention & Control Department, Mercy University Hospital, Cork, Ireland
| | - M. Bernard
- Infection Prevention & Control Department, Mercy University Hospital, Cork, Ireland
| | - R.D. Sleator
- Department of Biological Sciences, Cork Institute of Technology, Bishopstown, Cork, Ireland
| | - B. Lucey
- Department of Biological Sciences, Cork Institute of Technology, Bishopstown, Cork, Ireland
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Holma T, Antikainen J, Haiko J. Evaluation of three molecular carbapenemase tests: Eazyplex SuperBug complete B, Novodiag CarbaR+, and Amplidiag CarbaR+MCR. J Microbiol Methods 2020; 180:106105. [PMID: 33217483 DOI: 10.1016/j.mimet.2020.106105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Carbapenemase-producing Gram-negative bacilli, i.e., Enterobacterales, Pseudomonas aeruginosa, and Acinetobacter, are of increased concern for the public health around the world. There is urgent need for rapid and accurate tests in order to provide correct treatment and to prevent bacterial spread in healthcare settings. METHODS The aim of this study was to evaluate three commercial multiplex carbapenemase tests with CE-IVD marking: Eazyplex SuperBug complete B (AmplexDiagnostics), Novodiag CarbaR+ (Mobidiag), and Amplidiag CarbaR+MCR (Mobidiag). All these tests recognize KPC, NDM, OXA-48/181 group, VIM, OXA-23 group, and OXA-24/40 group, and Novodiag CarbaR+ and Amplidiag CarbaR+MCR additionally recognize IMP, OXA-51 group (with promoter located within ISAbaI), OXA-58 group, and MCR, and Amplidiag CarbaR+MCR further recognizes GES (carbapenemase-type only). RESULTS The sensitivities and specificities of these tests with bacterial isolates were 100%. The sensitivity directly from clinical samples was 100%, but the specificity was lower, which is simply explained by the higher sensitivity of the molecular methods compared with culture method. CONCLUSIONS Overall, these CE-IVD marked tests provide a good alternative in the detection of carbapenemase-producing organisms.
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Affiliation(s)
- Tanja Holma
- Helsinki University and Helsinki University Hospital, HUSLAB, Department of Clinical Microbiology, Helsinki, Finland
| | - Jenni Antikainen
- Helsinki University and Helsinki University Hospital, HUSLAB, Department of Clinical Microbiology, Helsinki, Finland
| | - Johanna Haiko
- Helsinki University and Helsinki University Hospital, HUSLAB, Department of Clinical Microbiology, Helsinki, Finland.
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Predic M, Delano JP, Tremblay E, Iovine N, Brown S, Prins C. Evaluation of patient risk factors for infection with carbapenem-resistant Enterobacteriaceae. Am J Infect Control 2020; 48:1028-1031. [PMID: 31924388 DOI: 10.1016/j.ajic.2019.11.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 11/19/2019] [Accepted: 11/20/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND To evaluate risk factors for infection or colonization with carbapenem-resistant Enterobacteriaceae (CRE) to develop an algorithm for targeted CRE screening. METHODS We conducted a case-control study of 50 CRE-positive cases and 100 CRE-negative controls to identify risk factors that were significant for CRE infection or colonization. The setting was at an acute care academic hospital. Patients who tested positive for CRE or other microbiological laboratory tests during the study period were included. We reviewed medical records of 50 patients who were CRE-positive and 100 matched controls who had a non-CRE culture at a similar anatomic site within the closest time period to the case's culture date. Risk factors were assessed using logistic regression with SAS 9.4, observing the 95% confidence interval (CI) to determine significance. RESULTS Significant risk factors for CRE infection or colonization included the use of fluoroquinolones (odds ratio [OR], 3.75; 95% CI, 1.35, 10.38) and cephalosporins (OR, 2.37; 95% CI, 1.17, 4.86). In addition, undergoing an invasive procedure with a scope device was also a significant risk factor for our participants (OR, 4.57; 95% CI, 1.31, 16.02). Significance of these risk factors varied within the community-acquired and hospital-acquired cases. CONCLUSIONS Our results suggest that exposure to certain antimicrobials and invasive procedures with a scope device (endoscopic retrograde cholangiopancreatography, duodenal endoscope) are risk factors for CRE. The findings of significant differences in antimicrobials received highlight the necessity to understand antimicrobial stewardship in the development of CRE colonization and infection. Along with antibiotics, inaccessibility to components within scope devices may be increasing the risk of CRE spread.
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Otter JA, Mookerjee S, Davies F, Bolt F, Dyakova E, Shersing Y, Boonyasiri A, Weiße AY, Gilchrist M, Galletly TJ, Brannigan ET, Holmes AH. Detecting carbapenemase-producing Enterobacterales (CPE): an evaluation of an enhanced CPE infection control and screening programme in acute care. J Antimicrob Chemother 2020; 75:2670-2676. [DOI: 10.1093/jac/dkaa192] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 03/03/2020] [Accepted: 03/05/2020] [Indexed: 12/14/2022] Open
Abstract
Abstract
Objectives
The transmission of carbapenemase-producing Enterobacterales (CPE) poses an increasing healthcare challenge. A range of infection prevention activities, including screening and contact precautions, are recommended by international and national guidelines. We evaluated the introduction of an enhanced screening programme in a multisite London hospital group.
Methods
In June 2015, an enhanced CPE policy was launched in response to a local rise in CPE detection. This increased infection prevention measures beyond the national recommendations, with enhanced admission screening, contact tracing and environmental disinfection, improved laboratory protocols and staff/patient education. We report the CPE incidence and trends of CPE in screening and clinical cultures and the adoption of enhanced CPE screening. All non-duplicate CPE isolates identified between April 2014 and March 2018 were included.
Results
The number of CPE screens increased progressively, from 4530 in July 2015 to 10 589 in March 2018. CPE detection increased from 18 patients in July 2015 (1.0 per 1000 admissions) to 50 patients in March 2018 (2.7 per 1000 admissions). The proportion of CPE-positive screening cultures remained at approximately 0.4% throughout, suggesting that whilst the CPE carriage rate was unchanged, carrier identification increased. Also, 123 patients were identified through positive CPE clinical cultures over the study period; there was no significant change in the rate of CPE from clinical cultures per 1000 admissions (P = 0.07).
Conclusions
Our findings suggest that whilst the enhanced screening programme identified a previously undetected reservoir of CPE colonization in our patient population, the rate of detection of CPE in clinical cultures did not increase.
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Affiliation(s)
- Jonathan A Otter
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London W12 0NN, UK
- Imperial College Healthcare NHS Trust, St Mary’s Hospital, Praed Street, London W2 1NY, UK
| | - Siddharth Mookerjee
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London W12 0NN, UK
- Imperial College Healthcare NHS Trust, St Mary’s Hospital, Praed Street, London W2 1NY, UK
| | - Frances Davies
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London W12 0NN, UK
- Imperial College Healthcare NHS Trust, St Mary’s Hospital, Praed Street, London W2 1NY, UK
| | - Frances Bolt
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London W12 0NN, UK
- Imperial College Healthcare NHS Trust, St Mary’s Hospital, Praed Street, London W2 1NY, UK
| | - Eleonora Dyakova
- Imperial College Healthcare NHS Trust, St Mary’s Hospital, Praed Street, London W2 1NY, UK
| | - Yeeshika Shersing
- Imperial College Healthcare NHS Trust, St Mary’s Hospital, Praed Street, London W2 1NY, UK
| | - Adhiratha Boonyasiri
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London W12 0NN, UK
| | - Andrea Y Weiße
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London W12 0NN, UK
| | - Mark Gilchrist
- Imperial College Healthcare NHS Trust, St Mary’s Hospital, Praed Street, London W2 1NY, UK
| | - Tracey J Galletly
- Imperial College Healthcare NHS Trust, St Mary’s Hospital, Praed Street, London W2 1NY, UK
| | - Eimear T Brannigan
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London W12 0NN, UK
- Imperial College Healthcare NHS Trust, St Mary’s Hospital, Praed Street, London W2 1NY, UK
| | - Alison H Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London W12 0NN, UK
- Imperial College Healthcare NHS Trust, St Mary’s Hospital, Praed Street, London W2 1NY, UK
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Accuracy and applicability of different phenotypic methods for carbapenemase detection in Enterobacteriaceae: A systematic review and meta-analysis. J Glob Antimicrob Resist 2020; 21:138-147. [DOI: 10.1016/j.jgar.2019.10.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/09/2019] [Accepted: 10/10/2019] [Indexed: 11/23/2022] Open
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Bartsch SM, O'Shea KJ, Ferguson MC, Bottazzi ME, Cox SN, Strych U, McKinnell JA, Wedlock PT, Siegmund SS, Hotez PJ, Lee BY. How Efficacious Must a COVID-19 Coronavirus Vaccine be to Prevent or Stop an Epidemic by Itself. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020. [PMID: 32511569 DOI: 10.1101/2020.05.29.20117184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Given the continuing coronavirus disease 2019 (COVID-19) pandemic and much of the U.S. implementing social distancing due to the lack of alternatives, there has been a push to develop a vaccine to eliminate the need for social distancing. METHODS In 2020, we developed a computational model of the U.S. simulating the spread of COVID-19 coronavirus and vaccination. RESULTS Simulation experiments revealed that when vaccine efficacy exceeded 70%, coverage exceeded 60%, and vaccination occurred on day 1, the attack rate dropped to 22% with daily cases not exceeding 3.2 million (reproductive rate, R0, 2.5). When R0 was 3.5, the attack rate dropped to 41% with daily cases not exceeding 14.4 million. Increasing coverage to 75% when vaccination occurred by day 90 resulted in 5% attack rate and daily cases not exceeding 258,029when R0 was 2.5 and a 26% attack rate and maximum daily cases of 22.6 million when R0 was 3.5. When vaccination did not occur until day 180, coverage (i.e., those vaccinated plus those otherwise immune) had to reach 100%. A vaccine with an efficacy between 40% and 70% could still obviate the need for other measures under certain circumstances such as much higher, and in some cases, potentially unachievable, vaccination coverages. CONCLUSION Our study found that to either prevent or largely extinguish an epidemic without any other measures (e.g., social distancing), the vaccine has to have an efficacy of at least 70%.
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Segagni Lusignani L, Presterl E, Zatorska B, Van den Nest M, Diab-Elschahawi M. Infection control and risk factors for acquisition of carbapenemase-producing enterobacteriaceae. A 5 year (2011-2016) case-control study. Antimicrob Resist Infect Control 2020; 9:18. [PMID: 31988746 PMCID: PMC6969403 DOI: 10.1186/s13756-019-0668-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 12/20/2019] [Indexed: 01/01/2023] Open
Abstract
Background Carbapenemase-producing enterobacteriaceae (CPE) are a major threat for severely ill patients. However, only limited data on the epidemiology and on evidence-based infection prevention and control measures are available. The aim of this study was to investigate the epidemiology of patients with CPE, characterizing the CPE isolates by their resistance mechanisms and genetic similarity, to explore risk factors for their acquisition, and to evaluate the effectiveness of the current CPE infection control measures. Methods A retrospective case-control study was performed using data from 2011 to 2016 in a 1800-bed academic hospital in Central Europe, where risk-based screening at patients´ admission is performed. Carbapenem resistance mechanisms of all carbapenem resistant enterobacteriaceae from patients admitted during this period were investigated. Clinical data of the CPE-positive patients were analysed and compared to a matched control group (case-control ratio of 1:3). We performed univariate and multivariate statistical analysis to identify risk factors for CPE acquisition. Results Of 621,623 admitted patients in the study period, 75 patients with carriage of carbapenem resistant enterobacteriaceae were included (0.12/1000 admittances). Carbapenemase-encoding genes were detected in 77.3% (58/75) of patients with carbapenem-resistant enterobacteriaceae. The enzyme blaOXA-48 was found in 34.5% (20/58), blaKPC in 29.3% (17/58), blaNDM enzymes in 20.7% (12/58) and blaVIM in 8.6% (5/58) of the isolates. The overall mortality among CPE patients was 25.9% (15/58) and attributable mortality of CPE was 53.3% (8/15). Multivariate analysis revealed four risk factors to be independent predictors of CPE carriage: the length of hospital admission > 20 days (AOR: 4.9, 95% CI: 1.4–15.5; P < 0.001), hospital admission within the previous year (AOR: 22.3, 95% CI: 3.9–88.4; P < 0.001), exposure to a healthcare facility in a country with high or unknown carbapenem-resistant enterobacteriaceae prevalence 3 months before admission (AOR: 11.8, 95% CI: 2.2–63.2; P < 0.01) and the use of antibiotics longer than 10 days (AOR: 5.2, 95% CI: 1.4–35.9; P < 0.05). The current risk-based screening strategy at hospital admission could not identify 37 (63.8%) of the 58 CPE-positive patients. Epidemiological investigation and genotyping revealed that no outbreaks due to CPE occurred during this period. Conclusion Overall, the CPE carriage rate in patients was very low, the attributable mortality, however, is alarming (53%). BlaOXA-48 and blaKPC were the main cause of carbapenem resistance in enterobacteriaceae. Although the strict application of standard infection control measures was effective for prevention of outbreaks in this setting, an enlarged risk based targeted screening strategy has to be implemented.
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Affiliation(s)
- Luigi Segagni Lusignani
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Elisabeth Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Beata Zatorska
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Miriam Van den Nest
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Magda Diab-Elschahawi
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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Mac S, Fitzpatrick T, Johnstone J, Sander B. Vancomycin-resistant enterococci (VRE) screening and isolation in the general medicine ward: a cost-effectiveness analysis. Antimicrob Resist Infect Control 2019; 8:168. [PMID: 31687132 PMCID: PMC6820905 DOI: 10.1186/s13756-019-0628-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/16/2019] [Indexed: 11/10/2022] Open
Abstract
Background Vancomycin-resistant enterococci (VRE) are a serious antimicrobial resistant threat in the healthcare setting. We assessed the cost-effectiveness of VRE screening and isolation for patients at high-risk for colonisation on a general medicine ward compared to no VRE screening and isolation from the healthcare payer perspective. Methods We developed a microsimulation model using local data and VRE literature, to simulate a 20-bed general medicine ward at a tertiary-care hospital with up to 1000 admissions, approximating 1 year. Primary outcomes were accrued over the patient's lifetime, discounted at 1.5%, and included expected health outcomes (VRE colonisations, VRE infections, VRE-related bacteremia, and deaths subsequent to VRE infection), quality-adjusted life years (QALYs), healthcare costs, and incremental cost-effectiveness ratio (ICER). Probabilistic sensitivity analysis (PSA) and scenario analyses were conducted to assess parameter uncertainty. Results In our base-case analysis, VRE screening and isolation prevented six healthcare-associated VRE colonisations per 1000 admissions (6/1000), 0.6/1000 VRE-related infections, 0.2/1000 VRE-related bacteremia, and 0.1/1000 deaths subsequent to VRE infection. VRE screening and isolation accrued 0.0142 incremental QALYs at an incremental cost of $112, affording an ICER of $7850 per QALY. VRE screening and isolation practice was more likely to be cost-effective (> 50%) at a cost-effectiveness threshold of $50,000/QALY. Stochasticity (randomness) had a significant impact on the cost-effectiveness. Conclusion VRE screening and isolation can be cost-effective in majority of model simulations at commonly used cost-effectiveness thresholds, and is likely economically attractive in general medicine settings. Our findings strengthen the understanding of VRE prevention strategies and are of importance to hospital program planners and infection prevention and control.
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Affiliation(s)
- Stephen Mac
- 1Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3M6 Canada.,2Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, 200 Elizabeth Street, 10th Floor, Room 247, Toronto, ON M5G 2C4 Canada
| | - Tiffany Fitzpatrick
- 3Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, ON M5T 3M7 Canada
| | - Jennie Johnstone
- 3Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, ON M5T 3M7 Canada.,4Department of Laboratory Medicine and Pathobiology, University of Toronto, 1 King's College Circle, Toronto, ON M5S 1A8 Canada.,5Public Health Ontario, 480 University Avenue, Suite 300, Toronto, ON M5G 1V2 Canada
| | - Beate Sander
- 1Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3M6 Canada.,2Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, 200 Elizabeth Street, 10th Floor, Room 247, Toronto, ON M5G 2C4 Canada.,5Public Health Ontario, 480 University Avenue, Suite 300, Toronto, ON M5G 1V2 Canada.,6ICES, G1 06, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
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Infection prevention and control practices related to carbapenemase-producing Enterobacteriaceae (CPE) in acute-care hospitals in Ontario, Canada. Infect Control Hosp Epidemiol 2019; 40:1006-1012. [PMID: 31244458 DOI: 10.1017/ice.2019.173] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine infection prevention and control (IPAC) practices for carbapenemase-producing Enterobacteriaceae (CPE), an emerging threat, at acute-care hospitals in Ontario, Canada. DESIGN A descriptive cross-sectional survey. METHODS We surveyed IPAC directors and managers at all acute-care hospitals in Ontario, Canada, to gather information on IPAC practices related to CPE, including admission screening, other patient screening, environmental testing, use of precautions to prevent transmission, and outbreak management. RESULTS Of 116 acute-care hospitals, 105 (91%) responded. Admission screening included patients previously colonized or infected with CPE (n = 64, 61%), patients recently hospitalized outside of Canada (Indian subcontinent, n = 62, 59%; other countries, n = 56, 53%), and patients recently hospitalized in Canada (n = 22, 21%). Fifty-one hospitals (49%) screened patients for colonization during an outbreak. Almost all hospitals (n = 101, 96%) used precautions to prevent transmission from patients with CPE colonization or infection; most hospitals (n = 54, 53%) continued precautions indefinitely. Few hospitals (n = 19, 18%) performed environmental cultures. Eight hospitals (8%) reported at least 1 outbreak, and 6 hospitals (6%) reported transmission from sink or shower drains to patients. CONCLUSIONS Variability in practices may result from lack of evidence and challenges in updating guidelines as evidence emerges. A coordinated approach to slow the emergence of CPE should be considered in our population.
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Kohler PP, Melano RG, Patel SN, Shafinaz S, Faheem A, Coleman BL, Green K, Armstrong I, Almohri H, Borgia S, Borgundvaag E, Johnstone J, Katz K, Lam F, Muller MP, Powis J, Poutanen SM, Richardson D, Rebbapragada A, Sarabia A, Simor A, McGeer A. Emergence of Carbapenemase-Producing Enterobacteriaceae, South-Central Ontario, Canada 1. Emerg Infect Dis 2019; 24:1674-1682. [PMID: 30124197 PMCID: PMC6106407 DOI: 10.3201/eid2409.180164] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
We analyzed population-based surveillance data from the Toronto Invasive Bacterial Diseases Network to describe carbapenemase-producing Enterobacteriaceae (CPE) infections during 2007–2015 in south-central Ontario, Canada. We reviewed patients’ medical records and travel histories, analyzed microbiologic and clinical characteristics of CPE infections, and calculated incidence. Among 291 cases identified, New Delhi metallo-β-lactamase was the predominant carbapenemase (51%). The proportion of CPE-positive patients with prior admission to a hospital in Canada who had not received healthcare abroad or traveled to high-risk areas was 13% for patients with oxacillinase-48, 24% for patients with New Delhi metallo-β-lactamase, 55% for patients with Klebsiella pneumoniae carbapenemase, and 67% for patients with Verona integron-encoded metallo-β-lactamase. Incidence of CPE infection increased, reaching 0.33 cases/100,000 population in 2015. For a substantial proportion of patients, no healthcare abroad or high-risk travel could be established, suggesting CPE acquisition in Canada. Policy and practice changes are needed to mitigate nosocomial CPE transmission in hospitals in Canada.
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Knight GM, Dyakova E, Mookerjee S, Davies F, Brannigan ET, Otter JA, Holmes AH. Fast and expensive (PCR) or cheap and slow (culture)? A mathematical modelling study to explore screening for carbapenem resistance in UK hospitals. BMC Med 2018; 16:141. [PMID: 30111322 PMCID: PMC6094916 DOI: 10.1186/s12916-018-1117-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 07/04/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Enterobacteriaceae are a common cause of hospital infections. Carbapenems are a clinically effective treatment of such infections. However, resistance is on the rise. In particular, carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-CRE) are increasingly common. In order to limit spread in clinical settings, screening and isolation is being recommended, but many different screening methods are available. We aimed to compare the impact and costs of three algorithms for detecting CP-CRE carriage. METHODS We developed an individual-based simulation model to compare three screening algorithms using data from a UK National Health Service (NHS) trust. The first algorithm, "Direct PCR", was highly sensitive/specific and quick (half a day), but expensive. The second, "Culture + PCR", was relatively sensitive/specific but slower, requiring 2.5 days. A third algorithm, "PHE", repeated the "Culture + PCR" three times with an additional PCR. Scenario analysis was used to compare several levels of CP-CRE prevalence and coverage of screening, different specialities as well as isolation strategies. Our outcomes were (1) days that a patient with CP-CRE was not detected and hence not isolated ("days at risk"), (2) isolation bed days, (3) total costs and (4) mean cost per CP-CRE risk day averted per year. We also explored limited isolation bed day capacity. RESULTS We found that although a Direct PCR algorithm would reduce the number of CP-CRE days at risk, the mean cost per CP-CRE risk day averted per year was substantially higher than for a Culture + PCR algorithm. For example, in our model of an intensive care unit, during a year with a 1.6% CP-CRE prevalence and 63% screening coverage, there were 508 (standard deviation 15), 642 (14) and 655 (14) days at risk under screening algorithms Direct PCR, Culture + PCR and PHE respectively, with mean costs per risk day averted of £192, £61 and £79. These results were robust to sensitivity analyses. CONCLUSIONS Our results indicate that a Culture + PCR algorithm provides the optimal balance of cost and risk days averted, at varying isolation, prevalence and screening coverage scenarios. Findings from this study will help clinical organisations determine the optimal screening approach for CP-CRE, balancing risk and resources.
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Affiliation(s)
- Gwenan M Knight
- National Institute of Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Commonwealth Building, Hammersmith Campus, Imperial College London, Du Cane Road, London, W12 0NN, UK. .,Infectious Diseases and Immunity, Commonwealth Building, Hammersmith Campus, Imperial College London, Du Cane Road, London, W12 0NN, UK.
| | | | | | | | - Eimear T Brannigan
- Infectious Diseases and Immunity, Commonwealth Building, Hammersmith Campus, Imperial College London, Du Cane Road, London, W12 0NN, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Jonathan A Otter
- National Institute of Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Commonwealth Building, Hammersmith Campus, Imperial College London, Du Cane Road, London, W12 0NN, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Alison H Holmes
- National Institute of Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Commonwealth Building, Hammersmith Campus, Imperial College London, Du Cane Road, London, W12 0NN, UK.,Imperial College Healthcare NHS Trust, London, UK
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Tormo N, Albert E, Borrajo E, Bosque M, Camarena JJ, Domínguez V, Fuentes E, Gascón I, Gomila B, Gonzalo N, Jiménez M, Martínez O, Nogueira JM, Orta N, Prat J, Rodríguez JC, Gimeno C, Navarro D. A survey on practices for active surveillance of carriage of multidrug-resistant bacteria in hospitals in the Autonomous Community of Valencia, Spain. Eur J Clin Microbiol Infect Dis 2018; 37:2069-2074. [PMID: 30105621 DOI: 10.1007/s10096-018-3340-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/23/2018] [Indexed: 11/25/2022]
Abstract
A questionnaire-based cross-sectional study was conducted to gather information on current microbiological practices for active surveillance of carriage of multidrug-resistant (MDR) bacteria in hospitals from 14 health departments of the Autonomous Community of Valencia (ACV), Spain, which together provided medical attention to 3,271,077 inhabitants in 2017, approximately 70% of the population of the ACV. The survey consisted of 35 questions on MDR bacteria screening policies, surveillance approach chosen (universal vs. targeted), and microbiological methods and processes in use for routine detection and reporting of colonization by MDR bacteria, including the anatomical sites scheduled to be sampled for each MDR bacterial species, and the methodology employed (culture-based, molecular-based, or both). Our study revealed striking differences across centers, likely attributable to the lack of consensus on optimal protocols for sampling, body sites for screening, and microbiological testing, thus underscoring the need for consensus guidelines on these issues.
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Affiliation(s)
- Nuria Tormo
- Microbiology Service, Consorcio Hospital General Universitario, Valencia, Spain
| | - Eliseo Albert
- Microbiology Service, and Department of Microbiology, School of Medicine, Hospital Clínico Universitario, Av. Blasco Ibáñez 17, 46010, Valencia, Spain
| | | | - Monserrat Bosque
- Microbiology Service, Hospital Arnau de Vilanova, Valencia, Spain
| | | | | | | | | | - Bárbara Gomila
- Microbiology Service, Hospital General Universitario, Castellon, Spain
| | - Nieves Gonzalo
- Microbiology Service, Hospital General Universitario, Elche, Spain
| | | | | | | | - Nieves Orta
- Microbiology Unit, Hospital Francesc de Borja, Gandia, Spain
| | - Josep Prat
- Microbiology Unit, Hospital de Sagunto, Valencia, Spain
| | | | - Concepción Gimeno
- Microbiology Service, Consorcio Hospital General Universitario, Valencia, Spain
| | - David Navarro
- Microbiology Service, and Department of Microbiology, School of Medicine, Hospital Clínico Universitario, Av. Blasco Ibáñez 17, 46010, Valencia, Spain.
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Iragorri N, Spackman E. Assessing the value of screening tools: reviewing the challenges and opportunities of cost-effectiveness analysis. Public Health Rev 2018; 39:17. [PMID: 30009081 PMCID: PMC6043991 DOI: 10.1186/s40985-018-0093-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 04/04/2018] [Indexed: 12/29/2022] Open
Abstract
Background Screening is an important part of preventive medicine. Ideally, screening tools identify patients early enough to provide treatment and avoid or reduce symptoms and other consequences, improving health outcomes of the population at a reasonable cost. Cost-effectiveness analyses combine the expected benefits and costs of interventions and can be used to assess the value of screening tools. Objective This review seeks to evaluate the latest cost-effectiveness analyses on screening tools to identify the current challenges encountered and potential methods to overcome them. Methods A systematic literature search of EMBASE and MEDLINE identified cost-effectiveness analyses of screening tools published in 2017. Data extracted included the population, disease, screening tools, comparators, perspective, time horizon, discounting, and outcomes. Challenges and methodological suggestions were narratively synthesized. Results Four key categories were identified: screening pathways, pre-symptomatic disease, treatment outcomes, and non-health benefits. Not all studies included treatment outcomes; 15 studies (22%) did not include treatment following diagnosis. Quality-adjusted life years were used by 35 (51.4%) as the main outcome. Studies that undertook a societal perspective did not report non-health benefits and costs consistently. Two important challenges identified were (i) estimating the sojourn time, i.e., the time between when a patient can be identified by screening tests and when they would have been identified due to symptoms, and (ii) estimating the treatment effect and progression rates of patients identified early. Conclusions To capture all important costs and outcomes of a screening tool, screening pathways should be modeled including patient treatment. Also, false positive and false negative patients are likely to have important costs and consequences and should be included in the analysis. As these patients are difficult to identify in regular data sources, common treatment patterns should be used to determine how these patients are likely to be treated. It is important that assumptions are clearly indicated and that the consequences of these assumptions are tested in sensitivity analyses, particularly the assumptions of independence of consecutive tests and the level of patient and provider compliance to guidelines and sojourn times. As data is rarely available regarding the progression of undiagnosed patients, extrapolation from diagnosed patients may be necessary.
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Affiliation(s)
- Nicolas Iragorri
- 1Department of Community Health Sciences and O'Brien Institute for Public Health, University of Calgary, Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6 Canada.,2Health Technology Assessment Unit, University of Calgary, Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6 Canada
| | - Eldon Spackman
- 1Department of Community Health Sciences and O'Brien Institute for Public Health, University of Calgary, Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6 Canada.,2Health Technology Assessment Unit, University of Calgary, Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6 Canada
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Rapid detection of carbapenemase-producing Acinetobacter baumannii and carbapenem-resistant Enterobacteriaceae using a bioluminescence-based phenotypic method. J Microbiol Methods 2018; 147:20-25. [DOI: 10.1016/j.mimet.2018.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/05/2018] [Accepted: 02/06/2018] [Indexed: 01/04/2023]
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Contribution and limits of clinical specimens for the screening of intestinal multi-drug-resistant bacteria in view of laboratory automation. J Hosp Infect 2017; 97:59-63. [DOI: 10.1016/j.jhin.2017.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 06/01/2017] [Indexed: 11/20/2022]
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