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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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Humphreys H, Cormican M, Brennan W, Burns K, O'Donovan D, Dalchan T, Keane S, Sheahan A. Reflections on a national public health emergency response to carbapenemase-producing Enterobacterale s (CPE). Epidemiol Infect 2022; 150:1-19. [PMID: 35300746 PMCID: PMC9006571 DOI: 10.1017/s0950268822000218] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/31/2022] [Accepted: 01/31/2022] [Indexed: 11/20/2022] Open
Abstract
Carbapenemase-producing Enterobacterales (CPE) are important globally. In 2017, Ireland declared a national public health emergency to address CPE in acute hospitals. A National Public Health Emergency Team and an expert advisory group (EAG) were established. The EAG has identified key learnings to inform future strategies. First, there is still an opportunity to prevent CPE becoming endemic. Second, damp environmental reservoirs in hospitals are inadequately controlled. Third, antibiotic stewardship remains important in control. Finally, there is no current requirement to extend screening to detect CPE outside of acute hospitals. These conclusions and their implications may also be relevant in other countries.
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Affiliation(s)
- Hilary Humphreys
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Martin Cormican
- Antimicrobial Resistance and Infection Control Team, Health Service Executive, Dublin, Ireland
- Department of Bacteriology, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Wendy Brennan
- Carbapenemase-producing Enterobacterales Reference Laboratory, Galway University Hospital, Galway, Ireland
| | - Karen Burns
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Diarmuid O'Donovan
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Therese Dalchan
- Antimicrobial Resistance and Infection Control Team, Health Service Executive, Dublin, Ireland
| | - Shirley Keane
- Antimicrobial Resistance and Infection Control Team, Health Service Executive, Dublin, Ireland
| | - Anne Sheahan
- Antimicrobial Resistance and Infection Control Team, Health Service Executive, Dublin, Ireland
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3
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Zhu Y, Xiao T, Wang Y, Yang K, Zhou Y, Luo Q, Shen P, Xiao Y. Socioeconomic Burden of Bloodstream Infections Caused by Carbapenem-Resistant Enterobacteriaceae. Infect Drug Resist 2021; 14:5385-5393. [PMID: 34938086 PMCID: PMC8685763 DOI: 10.2147/idr.s341664] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/25/2021] [Indexed: 01/04/2023] Open
Abstract
Background Although infection with carbapenem-resistant Enterobacteriaceae (CRE) has become an urgent public health threat worldwide, the socioeconomic burden of CRE bloodstream infection (BSI) remains to be clarified. Methods This retrospective study included all patients infected with Escherichia coli or Klebsiella pneumoniae who were hospitalized for BSI from 2013 to 2015. Socioeconomic burden, including direct and indirect economic burden, was compared in patients infected with carbapenem-sensitive Enterobacteriaceae (CSE) and CRE following 1:1 propensity score matching (PSM) to control for confounding variables. Results Data from 879 patients with Enterobacteriaceae BSI were evaluated, including 152 (17.3%) patients infected with CRE and 727 (82.7%) infected with CSE. PSM yielded 112 pairs of 224 patients. Median hospital length of stay did not differ significantly in the CRE and CSE groups (35 vs 29 days, P = 0.089), but in-hospital 28-day mortality rate was significantly higher in patients infected with CRE than with CSE (45.5% vs 32.1%, P = 0.040). Median direct economic burden was significantly greater in patients with CRE-BSI than with CSE-BSI during hospitalization ($24,940.1 vs 16,864.0, P = 0.017) but not during the period after infection ($10,403.4 vs 8498.0, P = 0.178). Drug expenditure accounted for the largest proportion of costs in both groups. The median disability-adjusted life year (DALY) was higher in CRE-BSI than in CSE-BSI patients, but the difference was not statistically significant (7.9 vs 6.7 years, P = 0.190). Median indirect economic burden did not differ significantly in these two groups ($3848.5 vs 1139.9, P = 0.304), although indirect economic burden increased significantly from 2013 to 2015 in patients with CRE-BSI. Conclusion Carbapenem resistance had a major impact on the clinical and socioeconomic burden of patients with Enterobacteriaceae BSI. The higher mortality rate in patients with CRE-BSI was associated with increased direct healthcare burden and indirect socioeconomic loss.
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Affiliation(s)
- Yunying Zhu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, People's Republic of China
| | - Tingting Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, People's Republic of China
| | - Yuan Wang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, People's Republic of China
| | - Kai Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, People's Republic of China
| | - Yanzi Zhou
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, People's Republic of China
| | - Qixia Luo
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, People's Republic of China
| | - Ping Shen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, People's Republic of China
| | - Yonghong Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, People's Republic of China
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4
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Bartsch SM, Wong KF, Mueller LE, Gussin GM, McKinnell JA, Tjoa T, Wedlock PT, He J, Chang J, Gohil SK, Miller LG, Huang SS, Lee BY. Modeling Interventions to Reduce the Spread of Multidrug-Resistant Organisms Between Health Care Facilities in a Region. JAMA Netw Open 2021; 4:e2119212. [PMID: 34347060 PMCID: PMC8339938 DOI: 10.1001/jamanetworkopen.2021.19212] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Multidrug-resistant organisms (MDROs) can spread across health care facilities in a region. Because of limited resources, certain interventions can be implemented in only some facilities; thus, decision-makers need to evaluate which interventions may be best to implement. OBJECTIVE To identify a group of target facilities and assess which MDRO intervention would be best to implement in the Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County, a large regional public health collaborative in Orange County, California. DESIGN, SETTING, AND PARTICIPANTS An agent-based model of health care facilities was developed in 2016 to simulate the spread of methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacteriaceae (CRE) for 10 years starting in 2010 and to simulate the use of various MDRO interventions for 3 years starting in 2017. All health care facilities (23 hospitals, 5 long-term acute care hospitals, and 74 nursing homes) serving adult inpatients in Orange County, California, were included, and 42 target facilities were identified via network analyses. EXPOSURES Increasing contact precaution effectiveness, increasing interfacility communication about patients' MDRO status, and performing decolonization using antiseptic bathing soap and a nasal product in a specific group of target facilities. MAIN OUTCOMES AND MEASURES MRSA and CRE prevalence and number of new carriers (ie, transmission events). RESULTS Compared with continuing infection control measures used in Orange County as of 2017, increasing contact precaution effectiveness from 40% to 64% in 42 target facilities yielded relative reductions of 0.8% (range, 0.5%-1.1%) in MRSA prevalence and 2.4% (range, 0.8%-4.6%) in CRE prevalence in health care facilities countywide after 3 years, averting 761 new MRSA transmission events (95% CI, 756-765 events) and 166 new CRE transmission events (95% CI, 158-174 events). Increasing interfacility communication of patients' MDRO status to 80% in these target facilities produced no changes in the prevalence or transmission of MRDOs. Implementing decolonization procedures (clearance probability: 39% in hospitals, 27% in long-term acute care facilities, and 3% in nursing homes) yielded a relative reduction of 23.7% (range, 23.5%-23.9%) in MRSA prevalence, averting 3515 new transmission events (95% CI, 3509-3521 events). Increasing the effectiveness of antiseptic bathing soap to 48% yielded a relative reduction of 39.9% (range, 38.5%-41.5%) in CRE prevalence, averting 1435 new transmission events (95% CI, 1427-1442 events). CONCLUSIONS AND RELEVANCE The findings of this study highlight the ways in which modeling can inform design of regional interventions and suggested that decolonization would be the best strategy for the Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County.
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Affiliation(s)
- Sarah M. Bartsch
- Public Health Informatics, Computational, and Operations Research, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
| | - Kim F. Wong
- Center for Simulation and Modeling, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Leslie E. Mueller
- Public Health Informatics, Computational, and Operations Research, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
| | - Gabrielle M. Gussin
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - James A. McKinnell
- Infectious Disease Clinical Outcomes Research Unit, Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
- Torrance Memorial Medical Center, Torrance, California
| | - Thomas Tjoa
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - Patrick T. Wedlock
- Public Health Informatics, Computational, and Operations Research, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
| | - Jiayi He
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - Justin Chang
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - Shruti K. Gohil
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | | | - Susan S. Huang
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - Bruce Y. Lee
- Public Health Informatics, Computational, and Operations Research, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
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5
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Foley M, Duffy F, Skally M, McCormack F, Finn C, O'Connor M, Cafferkey J, Thomas T, Burns K, Fitzpatrick F, O'Connell K, Smyth EG, Humphreys H. Evolving epidemiology of carbapenemase-producing Enterobacterales: one hospital's infection prevention and control response over nine years. J Hosp Infect 2021; 112:61-68. [PMID: 33812939 DOI: 10.1016/j.jhin.2021.03.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/28/2021] [Accepted: 03/28/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Preventing carbapenemase-producing Enterobacterales (CPE) transmission is a significant challenge for hospital infection prevention and control teams (IPCTs). Control measures include screening at-risk patients, contact tracing, and the isolation of carriers with contact precautions. AIM The evolution of infection prevention and control measures was assessed in a tertiary acute care hospital with predominately multi-bedded patient accommodation, from 2011 to 2019 as cases of CPE increased. The implications for, and the response and actions of, the IPCT were also reviewed. METHODS CPE data collected prospectively from our laboratory, IPCT, and outbreak meeting records were reviewed to assess how the IPCT adapted to the changing epidemiology, from sporadic cases, to outbreaks and to localized endemic CPE. FINDINGS Of 178 cases, 152 (85%) were healthcare-associated and there was a marked increase in cases from 2017. The number of screening samples tested annually increased from 1190 in 2011 to 16,837 in 2019, and six outbreaks were documented, with larger outbreaks identified in later years. OXA-48 carbapenemase was detected in 88% of isolates and attendance at outbreak meetings alone accounted for 463.5 h of IPCT members, and related staff time. CONCLUSION Despite considerable efforts and time invested by the IPCT, the number of CPE cases is increasing year-on-year, with more outbreaks being reported in later years, albeit partly in response to increased screening requirements. Infrastructural deficits, the changing epidemiology of CPE, and national policy are major factors in the increasing number of cases.
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Affiliation(s)
- M Foley
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland
| | - F Duffy
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland
| | - M Skally
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland
| | - F McCormack
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland
| | - C Finn
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland
| | - M O'Connor
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland
| | - J Cafferkey
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland
| | - T Thomas
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - K Burns
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland; Health Protection Surveillance Centre, Dublin, Ireland
| | - F Fitzpatrick
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - K O'Connell
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - E G Smyth
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - H Humphreys
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland.
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Lee BY, Bartsch SM, Lin MY, Asti L, Welling J, Mueller LE, Leonard J, Brown ST, Doshi K, Kemble SK, Mitgang EA, Weinstein RA, Trick WE, Hayden MK. How Long-Term Acute Care Hospitals Can Play an Important Role in Controlling Carbapenem-Resistant Enterobacteriaceae in a Region: A Simulation Modeling Study. Am J Epidemiol 2021; 190:448-458. [PMID: 33145594 DOI: 10.1093/aje/kwaa247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 11/14/2022] Open
Abstract
Typically, long-term acute care hospitals (LTACHs) have less experience in and incentives to implementing aggressive infection control for drug-resistant organisms such as carbapenem-resistant Enterobacteriaceae (CRE) than acute care hospitals. Decision makers need to understand how implementing control measures in LTACHs can impact CRE spread regionwide. Using our Chicago metropolitan region agent-based model to simulate CRE spread and control, we estimated that a prevention bundle in only LTACHs decreased prevalence by a relative 4.6%-17.1%, averted 1,090-2,795 new carriers, 273-722 infections and 37-87 deaths over 3 years and saved $30.5-$69.1 million, compared with no CRE control measures. When LTACHs and intensive care units intervened, prevalence decreased by a relative 21.2%. Adding LTACHs averted an additional 1,995 carriers, 513 infections, and 62 deaths, and saved $47.6 million beyond implementation in intensive care units alone. Thus, LTACHs may be more important than other acute care settings for controlling CRE, and regional efforts to control drug-resistant organisms should start with LTACHs as a centerpiece.
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7
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McKinnell JA, Singh RD, Miller LG, Kleinman K, Gussin G, He J, Saavedra R, Dutciuc TD, Estevez M, Chang J, Heim L, Yamaguchi S, Custodio H, Gohil SK, Park S, Tam S, Robinson PA, Tjoa T, Nguyen J, Evans KD, Bittencourt CE, Lee BY, Mueller LE, Bartsch SM, Jernigan JA, Slayton RB, Stone ND, Zahn M, Mor V, McConeghy K, Baier RR, Janssen L, O'Donnell K, Weinstein RA, Hayden MK, Coady MH, Bhattarai M, Peterson EM, Huang SS. The SHIELD Orange County Project: Multidrug-resistant Organism Prevalence in 21 Nursing Homes and Long-term Acute Care Facilities in Southern California. Clin Infect Dis 2020; 69:1566-1573. [PMID: 30753383 DOI: 10.1093/cid/ciz119] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 02/05/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Multidrug-resistant organisms (MDROs) spread between hospitals, nursing homes (NHs), and long-term acute care facilities (LTACs) via patient transfers. The Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County is a regional public health collaborative involving decolonization at 38 healthcare facilities selected based on their high degree of patient sharing. We report baseline MDRO prevalence in 21 NHs/LTACs. METHODS A random sample of 50 adults for 21 NHs/LTACs (18 NHs, 3 LTACs) were screened for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum β-lactamase-producing organisms (ESBL), and carbapenem-resistant Enterobacteriaceae (CRE) using nares, skin (axilla/groin), and peri-rectal swabs. Facility and resident characteristics associated with MDRO carriage were assessed using multivariable models clustering by person and facility. RESULTS Prevalence of MDROs was 65% in NHs and 80% in LTACs. The most common MDROs in NHs were MRSA (42%) and ESBL (34%); in LTACs they were VRE (55%) and ESBL (38%). CRE prevalence was higher in facilities that manage ventilated LTAC patients and NH residents (8% vs <1%, P < .001). MDRO status was known for 18% of NH residents and 49% of LTAC patients. MDRO-colonized adults commonly harbored additional MDROs (54% MDRO+ NH residents and 62% MDRO+ LTACs patients). History of MRSA (odds ratio [OR] = 1.7; confidence interval [CI]: 1.2, 2.4; P = .004), VRE (OR = 2.1; CI: 1.2, 3.8; P = .01), ESBL (OR = 1.6; CI: 1.1, 2.3; P = .03), and diabetes (OR = 1.3; CI: 1.0, 1.7; P = .03) were associated with any MDRO carriage. CONCLUSIONS The majority of NH residents and LTAC patients harbor MDROs. MDRO status is frequently unknown to the facility. The high MDRO prevalence highlights the need for prevention efforts in NHs/LTACs as part of regional efforts to control MDRO spread.
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Affiliation(s)
- James A McKinnell
- Infectious Disease Clinical Outcomes Research, LA Biomed at Harbor-University of California Los Angeles Medical Center, Torrance
| | - Raveena D Singh
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Loren G Miller
- Infectious Disease Clinical Outcomes Research, LA Biomed at Harbor-University of California Los Angeles Medical Center, Torrance
| | - Ken Kleinman
- University of Massachusetts Amherst School of Public Health and Health Sciences, Orange
| | - Gabrielle Gussin
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Jiayi He
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Raheeb Saavedra
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Tabitha D Dutciuc
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Marlene Estevez
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Justin Chang
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Lauren Heim
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Stacey Yamaguchi
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Harold Custodio
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Shruti K Gohil
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Steven Park
- University of California Irvine Health, Orange
| | - Steven Tam
- Division of Geriatrics, Department of Medicine, University of California Irvine, Orange
| | | | - Thomas Tjoa
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Jenny Nguyen
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | | | | | - Bruce Y Lee
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Leslie E Mueller
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarah M Bartsch
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - John A Jernigan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rachel B Slayton
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nimalie D Stone
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew Zahn
- Epidemiology and Assessment, Orange County Health Care Agency, Santa Ana, California
| | - Vincent Mor
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Rhode Island.,Center of Innovation in Long-Term Services and Supports, Veterans Affairs Medical Center, Providence VA Medical Center, Rhode Island.,Center for Long-Term Care Quality and Innovation, Brown University School of Public Health, Providence, Rhode Island
| | - Kevin McConeghy
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Rhode Island.,Center of Innovation in Long-Term Services and Supports, Veterans Affairs Medical Center, Providence VA Medical Center, Rhode Island.,Center for Long-Term Care Quality and Innovation, Brown University School of Public Health, Providence, Rhode Island
| | - Rosa R Baier
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Rhode Island.,Center for Long-Term Care Quality and Innovation, Brown University School of Public Health, Providence, Rhode Island
| | - Lynn Janssen
- Healthcare-associated Infections Program, Center for Healthcare Quality, California Department of Public Health, Richmond, California
| | - Kathleen O'Donnell
- Epidemiology and Assessment, Orange County Health Care Agency, Santa Ana, California.,Healthcare-associated Infections Program, Center for Healthcare Quality, California Department of Public Health, Richmond, California
| | - Robert A Weinstein
- Cook County Health and Hospitals System, Chicago, Illinois.,Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Mary K Hayden
- Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Micaela H Coady
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Megha Bhattarai
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Susan S Huang
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange.,Health Policy Research Institute, University of California Irvine School of Medicine
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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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Hilliquin D, Lomont A, Zahar JR. Cohorting for preventing the nosocomial spread of Carbapenemase-Producing Enterobacterales, in non-epidemic settings: is it mandatory? J Hosp Infect 2020; 105:S0195-6701(20)30197-3. [PMID: 32315668 DOI: 10.1016/j.jhin.2020.04.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/14/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Worldwide dissemination of Carbapenemase-Producing Enterobacterales (CPE) has led to national and international guidance recommending the implementation of cohorting in healthcare settings (HS). However, in view of recent data regarding the spread of Extended-spectrum Beta-lactamase-producing Enterobacterales, we may wonder about the usefulness of this measure in a non-outbreak settings; here, individual contact isolation may be sufficient to control the risk of dissemination. AIM/METHODS We conducted a narrative review of the literature and discussed the role of cohorting. FINDINGS CPE are responsible for outbreaks in HS, which are considered the epicentre of spread of resistance strains. CPE are responsible for adverse effects such as increases in hospital stay and costs, less therapeutic options and thus higher risk of clinical failures and mortality. Environment and materials have also been described contaminated with CPE and can be the source of outbreak. Even if guidelines and publications have supported implementation of cohorting, there are no randomized studies demonstrating the mandatory nature of this measure. Most studies are descriptive and cohorting is usually one of several other measures to control outbreaks. Cohorting is not adapted to all HS, which requires human and material resources. Other measures must be strengthened such as compliance of hand hygiene, antibiotic stewardship and surveillance of contact patients. Individual risk factors of acquisition should also be evaluated. CONCLUSION Local epidemiology and resources must be assessed before implementing cohorting.
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Affiliation(s)
- Delphine Hilliquin
- Unité d'hygiène et d'épidémiologie, Hôpital Édouard Herriot, GH Centre, Hospices civils de Lyon, France; Université Lyon 1 Claude Bernard, Lyon, France.
| | - Alexandra Lomont
- Service de Microbiologie Clinique, Unité de contrôle et prévention du risque infectieux, GH Paris Seine Saint-Denis, AP-HP, Bobigny, France; IAME, Inserm 1137, Université Sorbonne Paris Nord - Paris 13, France
| | - Jean-Ralph Zahar
- Service de Microbiologie Clinique, Unité de contrôle et prévention du risque infectieux, GH Paris Seine Saint-Denis, AP-HP, Bobigny, France; IAME, Inserm 1137, Université Sorbonne Paris Nord - Paris 13, France
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Schneider A, Coope C, Michie S, Puleston R, Hopkins S, Oliver I. Implementing a toolkit for the prevention, management and control of carbapenemase-producing Enterobacteriaceae in English acute hospitals trusts: a qualitative evaluation. BMC Health Serv Res 2019; 19:689. [PMID: 31606053 PMCID: PMC6790044 DOI: 10.1186/s12913-019-4492-4] [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: 03/29/2019] [Accepted: 08/29/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antimicrobial resistance is an increasing problem in hospitals world-wide. Following other countries, English hospitals experienced outbreaks of carbapenemase-producing Enterobacteriaceae (CPE), a bacterial infection commonly resistant to last resort antibiotics. One way to improve CPE prevention, management and control is the production of guidelines, such as the CPE toolkit published by Public Health England in December 2013. The aim of this research was to investigate the implementation of the CPE toolkit and to identify barriers and facilitators to inform future policies. METHODS Acute hospital trusts (N = 12) were purposively sampled based on their self-assessed CPE colonisation rates and time point of introducing local CPE action plans. Following maximum variation sampling, 44 interviews with hospital staff were conducted between April and August 2017 using a semi-structured topic guide based on the Capability, Opportunity, Motivation and Behaviour Model and the Theoretical Domains Framework, covering areas of influences on behaviour. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. RESULTS The national CPE toolkit was widely disseminated within infection prevention and control teams (IPCT), but awareness was rare among other hospital staff. Local plans, developed by IPCTs referring to the CPE toolkit while considering local circumstances, were in place in all hospitals. Implementation barriers included: shortage of isolation facilities for CPE patients, time pressures, and competing demands. Facilitators were within hospital and across-hospital collaborations and knowledge sharing, availability of dedicated IPCTs, leadership support and prioritisation of CPE as an important concern. Participants using the CPE toolkit had mixed views, appreciating its readability and clarity about patient management, but voicing concerns about the lack of transparency on the level of evidence and the practicality of implementation. They recommended regular updates, additional clarifications, tailored information and implementation guidance. CONCLUSIONS There were problems with the awareness and implementation of the CPE toolkit and frontline staff saw room for improvement, identifying implementation barriers and facilitators. An updated CPE toolkit version should provide comprehensive and instructive guidance on evidence-based CPE prevention, management and control procedures and their implementation in a modular format with sections tailored to hospitals' CPE status and to different staff groups.
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Affiliation(s)
- Annegret Schneider
- University College London, Gower St, Bloomsbury, London, WC1E 6BT, UK. .,National Institute for Health Research Health Protection Unit in Evaluation of Interventions, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK.
| | - Caroline Coope
- National Institute for Health Research Health Protection Unit in Evaluation of Interventions, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK.,Field Service South West, National Infection Service, Public Health England, 2 Rivergate, Bristol, BS1 6EH, UK
| | - Susan Michie
- University College London, Gower St, Bloomsbury, London, WC1E 6BT, UK.,National Institute for Health Research Health Protection Unit in Evaluation of Interventions, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - Richard Puleston
- Field Service East Midlands, National Infection Service, Public Health England, Nottingham, NG24LA, UK
| | - Susan Hopkins
- Division of Healthcare-Associated Infection and Antimicrobial Resistance, National Infection Service, Public Health England, London, UK
| | - Isabel Oliver
- National Institute for Health Research Health Protection Unit in Evaluation of Interventions, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK.,Field Service South West, National Infection Service, Public Health England, 2 Rivergate, Bristol, BS1 6EH, UK
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