1
|
Yetmar ZA, Miller VL, Sampathkumar P, Beam E. Impact of a change in universal gloving protocol on rates of central line-related bloodstream infection, Clostridioides difficile, and vancomycin-resistant Enterococcus. Am J Infect Control 2023; 51:720-722. [PMID: 36244572 PMCID: PMC10097826 DOI: 10.1016/j.ajic.2022.10.001] [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: 07/27/2022] [Revised: 09/30/2022] [Accepted: 10/01/2022] [Indexed: 11/25/2022]
Abstract
In this retrospective cohort of adult hematology-oncology and transplant patients, discontinuation of universal gloving did not result in significant changes in rates of central line-associated bloodstream infection, Clostridioides difficile infection, or vancomycin-resistant Enterococcus colonization. Active surveillance and subsequent isolation may be a viable alternative strategy to universal precautions.
Collapse
Affiliation(s)
- Zachary A Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN.
| | - Vickie L Miller
- Infection Prevention and Control, Mayo Clinic, Rochester, MN
| | - Priya Sampathkumar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN
| | - Elena Beam
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
2
|
Grunnill M, Hall I, Finnie T. Check your assumptions: Further scrutiny of basic model frameworks of antimicrobial resistance. J Theor Biol 2022; 554:111277. [PMID: 36150539 DOI: 10.1016/j.jtbi.2022.111277] [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: 01/24/2022] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 01/14/2023]
Abstract
Since the mid-1990s, growing concerns over antimicrobial resistant (AMR) organisms has led to an increase in the use of mathematical models to explore the inter-host transmission of such infections. Previous work reviewing such models categorised them into generic frameworks based on their underlying assumptions. These assumptions dictated the coexistence between AMR and antimicrobial sensitive strains. We add to this work performing stability analyses of the frameworks, along with simulating them deterministically and stochastically. Stability analyses found that many of these assumptions lead to models having the same equilibria, but showed differences in the equilibria's stability between models. Deterministic simulations reveal that assuming replacement of one infecting strain by another leads to an unusual antimicrobial treatment threshold. Increasing beyond this threshold causes a discontinuous increase in disease burden. The cost of AMR to pathogen fitness (lowered transmission) dictates both the threshold of treatment that causes the discontinuous increase in disease burden and the size of that increase. It was also shown that Superinfection states can be biased against resident strains and so favour coexistence of both strains. Stochastic simulations demonstrated that differing scenario starting conditions can guide models to converge upon equilibria that they may not have under deterministic simulation. These findings highlight the importance of checking assumptions when modelling AMR and strain competition more widely.
Collapse
Affiliation(s)
- Martin Grunnill
- Laboratory of Applied Mathematics (LIAM), York University, North York, M3J 3K1, Ontario, Canada.
| | - Ian Hall
- Department of Mathematics, University of Manchester, Manchester, M13 9PL, Greater Manchester, United Kingdom
| | - Thomas Finnie
- Directorate of Emergency Preparedness, Resilience and Response, UK Health Security Agency, Porton Down, Salisbury, SP4 0JG, Wiltshire, United Kingdom
| |
Collapse
|
3
|
Cruz-López F, Martínez-Meléndez A, Villarreal-Treviño L, Morfín-Otero R, Maldonado-Garza H, Garza-González E. Contamination of healthcare environment by carbapenem-resistant Acinetobacter baumannii. Am J Med Sci 2022; 364:685-694. [PMID: 35853519 DOI: 10.1016/j.amjms.2022.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 06/12/2022] [Accepted: 07/12/2022] [Indexed: 01/25/2023]
Abstract
Acinetobacter baumannii is frequently found on floors, devices, and environmental sites in hospitals and can survive for prolonged periods and accumulate resistance determinants. The infection and presence of carbapenem-resistant A. baumannii (CRAB) in patients is associated with increased mortality, severe clinical outcomes, and longer lengths of stay at hospitals. This review addresses contamination by CRAB in corporal surfaces of patients and healthcare workers and environmental sites at healthcare-related settings. We summarized published data during the last decade on potential reservoirs for CRAB, including contamination frequency and the involved resistance mechanisms, and some measures associated with the elimination of CRAB from hospital surfaces.
Collapse
Affiliation(s)
- Flora Cruz-López
- Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, San Nicolás de los Garza, México
| | - Adrián Martínez-Meléndez
- Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, San Nicolás de los Garza, México
| | - Licet Villarreal-Treviño
- Departamento de Microbiología e Inmunología, Facultad de Ciencias Biológicas, Universidad Autónoma de Nuevo León, San Nicolás de los Garza, México
| | - Rayo Morfín-Otero
- Hospital Civil de Guadalajara 'Fray Antonio Alcalde', e Instituto de Patología Infecciosa y Experimental, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, México
| | - Héctor Maldonado-Garza
- Facultad de Medicina y Hospital Universitario 'Dr. José Eleuterio González', Universidad Autónoma de Nuevo León, Monterrey, México
| | - Elvira Garza-González
- Facultad de Medicina y Hospital Universitario 'Dr. José Eleuterio González', Universidad Autónoma de Nuevo León, Monterrey, México.
| |
Collapse
|
4
|
Godijk NG, Bootsma MCJ, Bonten MJM. Transmission routes of antibiotic resistant bacteria: a systematic review. BMC Infect Dis 2022; 22:482. [PMID: 35596134 PMCID: PMC9123679 DOI: 10.1186/s12879-022-07360-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background Quantification of acquisition routes of antibiotic resistant bacteria (ARB) is pivotal for understanding transmission dynamics and designing cost-effective interventions. Different methods have been used to quantify the importance of transmission routes, such as relative risks, odds ratios (OR), genomic comparisons and basic reproduction numbers. We systematically reviewed reported estimates on acquisition routes’ contributions of ARB in humans, animals, water and the environment and assessed the methods used to quantify the importance of transmission routes. Methods PubMed and EMBASE were searched, resulting in 6054 articles published up until January 1st, 2019. Full text screening was performed on 525 articles and 277 are included. Results We extracted 718 estimates with S. aureus (n = 273), E. coli (n = 157) and Enterobacteriaceae (n = 99) being studied most frequently. Most estimates were derived from statistical methods (n = 560), mainly expressed as risks (n = 246) and ORs (n = 239), followed by genetic comparisons (n = 85), modelling (n = 62) and dosage of ARB ingested (n = 17). Transmission routes analysed most frequently were occupational exposure (n = 157), travelling (n = 110) and contacts with carriers (n = 83). Studies were mostly performed in the United States (n = 142), the Netherlands (n = 87) and Germany (n = 60). Comparison of methods was not possible as studies using different methods to estimate the same route were lacking. Due to study heterogeneity not all estimates by the same method could be pooled. Conclusion Despite an abundance of published data the relative importance of transmission routes of ARB has not been accurately quantified. Links between exposure and acquisition are often present, but the frequency of exposure is missing, which disables estimation of transmission routes’ importance. To create effective policies reducing ARB, estimates of transmission should be weighed by the frequency of exposure occurrence. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07360-z.
Collapse
Affiliation(s)
- Noortje G Godijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Martin C J Bootsma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Mathematics, Faculty of Sciences, Utrecht University, Utrecht, The Netherlands
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
5
|
Gowler CD, Slayton RB, Reddy SC, O’Hagan JJ. Improving mathematical modeling of interventions to prevent healthcare-associated infections by interrupting transmission or pathogens: How common modeling assumptions about colonized individuals impact intervention effectiveness estimates. PLoS One 2022; 17:e0264344. [PMID: 35226689 PMCID: PMC8884501 DOI: 10.1371/journal.pone.0264344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 02/08/2022] [Indexed: 12/03/2022] Open
Abstract
Mathematical models are used to gauge the impact of interventions for healthcare-associated infections. As with any analytic method, such models require many assumptions. Two common assumptions are that asymptomatically colonized individuals are more likely to be hospitalized and that they spend longer in the hospital per admission because of their colonization status. These assumptions have no biological basis and could impact the estimated effects of interventions in unintended ways. Therefore, we developed a model of methicillin-resistant Staphylococcus aureus transmission to explicitly evaluate the impact of these assumptions. We found that assuming that asymptomatically colonized individuals were more likely to be admitted to the hospital or spend longer in the hospital than uncolonized individuals biased results compared to a more realistic model that did not make either assumption. Results were heavily biased when estimating the impact of an intervention that directly reduced transmission in a hospital. In contrast, results were moderately biased when estimating the impact of an intervention that decolonized hospital patients. Our findings can inform choices modelers face when constructing models of healthcare-associated infection interventions and thereby improve their validity.
Collapse
Affiliation(s)
- Camden D. Gowler
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Department of Ecology and Evolutionary Biology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Rachel B. Slayton
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Sujan C. Reddy
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Justin J. O’Hagan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- * E-mail:
| |
Collapse
|
6
|
Expert consensus on perioperative management of liver transplantation in adults with acute-on-chronic liver failure. LIVER RESEARCH 2021. [DOI: 10.1016/j.livres.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
7
|
An agent-based model to simulate the transmission of vancomycin-resistant enterococci according different prevention and control measures. Infect Control Hosp Epidemiol 2020; 42:857-863. [PMID: 33336639 DOI: 10.1017/ice.2020.1308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Despite the existence of various levels of infection prevention and control (IPC) measures aimed at limiting the transmission of vancomycin-resistant enterococci (VRE) in hospitals, these measures are sometimes difficult to implement. Using an agent-based model (ABM), we simulated the transmission of VRE within and between 3 care units according to different IPC measures. METHODS The ABM was modelled on short-stay medical wards, represented by 2 conventional care units and 1 intensive care unit. The scenarios consisted of the simulation of various compliance rates of caregivers with regard to hand hygiene (HH) in different contexts of IPC measures: (1) standard precautions for all patients, (2) additional contact precautions for VRE-carrier patients, (3) geographical cohorting of carrier patients, and (4) creation of an isolation unit with dedicated staff. RESULTS With <50% HH compliance, the dissemination of VRE was not adequately controlled. With 80% compliance for all patients (ie, standard precautions scenario), there were no secondary VRE cases in 50% of the simulations, which represented the best scenario. A more realistic rate, 60% HH compliance for all patients, revealed interesting results. Implementing an isolation unit was effective only if the level of HH compliance was low. Patient cohorting was less effective. CONCLUSIONS The present ABM showed that while contact precautions, geographic cohorting, and an isolation unit may represent good complements to standard precautions, they may theoretically not be necessary if HH is followed at a high level of compliance.
Collapse
|
8
|
Abstract
Hospital-acquired infections are a known menace to the primary disease, for which a patient is admitted. These infections are twenty times more common in developing countries than in the developed ones. Surveillance for colonised patients can be passive or active process. In many hospitals, active surveillance culture for certain sentinel organisms followed by contact precautions for the same is an important part of infection control policy. Specific measures can be taken on early detection of multidrug-resistant organism, allowing prevention of widespread transmission in hospitals. Cultures are the most conventional and economical microbiological method of detection. The cost of active surveillance is a major challenge, especially for developing nations. These nations lack basic infrastructure and have logistic issues. The guidelines regarding this are not very clearly delineated for developing countries. Each hospital has its own challenges and the process is to be tailor-made accordingly. The following review delineates the various aspects of active surveillance for the colonisation of various organisms and the advantages and disadvantages of the same.
Collapse
Affiliation(s)
- Manisha Biswal
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Archana Angrup
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rimjhim Kanaujia
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Establishing a Research Agenda for Preventing Transmission of Multidrug-Resistant Organisms in Acute-Care Settings in the Veterans Health Administration. Infect Control Hosp Epidemiol 2018; 39:189-195. [PMID: 29417927 DOI: 10.1017/ice.2017.309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
11
|
Cheah ALY, Cheng AC, Spelman D, Nation RL, Kong DCM, McBryde ES. Mathematical modelling of vancomycin-resistant enterococci transmission during passive surveillance and active surveillance with contact isolation highlights the need to identify and address the source of acquisition. BMC Infect Dis 2018; 18:511. [PMID: 30309313 PMCID: PMC6182842 DOI: 10.1186/s12879-018-3388-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 09/17/2018] [Indexed: 01/14/2023] Open
Abstract
Background Clinical studies and mathematical simulation suggest that active surveillance with contact isolation is associated with reduced vancomycin-resistant enterococci (VRE) prevalence compared to passive surveillance. Models using pre- and post-intervention data that account for the imperfect observation and serial dependence of VRE transmission events can better estimate the effectiveness of active surveillance and subsequent contact isolation; however, such analyses have not been performed. Methods A mathematical model was fitted to surveillance data collected pre- and post-implementation of active surveillance with contact isolation in the haematology-oncology ward. We developed a Hidden Markov Model to describe undetected and observed VRE colonisation/infection status based on the detection activities in the ward. Bayesian inference was used to estimate transmission rates. The effectiveness of active surveillance was assumed to be via increased detection and subsequent contact isolation of VRE positive patients. Results We estimated that 31% (95% credible interval: 0.33–85%) of the VRE transmissions were due to cross-transmission between patients. The ratio of transmission rates from patients with contact isolation versus those without contact isolation was 0.33 (95% credible interval: 0.050–1.22). Conclusions The majority of the VRE acquisitions in the haematology-oncology ward was estimated to be due to background rates of VRE, rather than within ward patient to patient acquisition. The credible interval for cross-transmission was wide which results in a large degree of uncertainty in the estimates. Factors that could account for background VRE acquisition include endogenous acquisition from antibiotic selection pressure and VRE in the environment. Contact isolation was not significantly associated with reduced VRE transmission in settings where the majority of VRE acquisition was due to background acquisition, emphasising the need to identify and address the source of acquisition. As the credible interval for the ratio of VRE transmission in contact isolated versus non-contact isolated patients crossed 1, there is a probability that the transmission rate in contact isolation was not lower. Our finding highlights the need to optimise infection control measures other than active surveillance for VRE and subsequent contact isolation to reduce VRE transmission. Such measures could include antimicrobial stewardship, environmental cleaning, and hand hygiene. Electronic supplementary material The online version of this article (10.1186/s12879-018-3388-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Agnes Loo Yee Cheah
- Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia.,Department of Infectious Diseases, Alfred Health, Prahran, VIC, Australia
| | - Allen C Cheng
- Department of Infectious Diseases, Alfred Health, Prahran, VIC, Australia.,Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Prahran, VIC, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Denis Spelman
- Department of Infectious Diseases, Alfred Health, Prahran, VIC, Australia.,Microbiology Unit, Alfred Health, Prahran, VIC, Australia.,Department of Infectious Diseases, Monash University, Melbourne, VIC, Australia
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - David C M Kong
- Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia. .,Pharmacy Department, Ballarat Health Services, Ballarat Central, VIC, Australia. .,Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC, Australia.
| | - Emma S McBryde
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC, Australia. .,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia.
| |
Collapse
|
12
|
Practical methods for effective vancomycin-resistant enterococci (VRE) surveillance: experience in a liver transplant surgical intensive care unit. Infect Control Hosp Epidemiol 2018; 39:1178-1182. [PMID: 30178725 DOI: 10.1017/ice.2018.178] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE We evaluated the utility of vancomycin-resistant Enterococcus (VRE) surveillance by varying 2 parameters: admission versus weekly surveillance and perirectal swabbing versus stool sampling. DESIGN Prospective, patient-level surveillance program of incident VRE colonization. SETTING Liver transplant surgical intensive care unit (SICU) of a tertiary-care referral medical center with a high prevalence of VRE.PatientsAll patients admitted to the SICU from June to August 2015. METHODS We conducted a point-prevalence estimate followed by admission and weekly surveillance by perirectal swabbing and/or stool sampling. Incident colonization was defined as a negative screen followed by positive surveillance. VRE was detected by culture on Remel Spectra VRE chromogenic agar. Microbiologically-confirmed VRE bloodstream infections (BSIs) were tracked for 2 months. Statistical analyses were calculated using the McNemar test, the Fisher exact test, the t test, and the χ2 test. RESULTS In total, 91 patients underwent VRE surveillance testing. The point prevalence of VRE colonization was 60.9%; VRE prevalence on admission was 30.1%. Weekly surveillance identified an additional 7 of 28 patients (25.0%) with incident colonization. VRE BSIs were more common in VRE-colonized patients than in noncolonized patients (8 of 43 vs 2 of 48; P=.028). In a direct comparison, perirectal swabs were more sensitive than stool samples in detecting VRE (64 of 67 vs 56 of 67; P=.023). Compliance with perirectal swabbing was 89% (201 of 226) compared to 56% (127 of 226) for stool collection (P≤0.001). CONCLUSIONS We recommend weekly VRE surveillance over admission-only screening in high-burden units such as liver transplant SICUs. Perirectal swabs had greater collection compliance and sensitivity than stool samples, making them the preferred methodology. Further work may have implications for antimicrobial stewardship and infection control.
Collapse
|
13
|
Lee T, Pang S, Abraham S, Coombs GW. Antimicrobial-resistant CC17 Enterococcus faecium: The past, the present and the future. J Glob Antimicrob Resist 2018; 16:36-47. [PMID: 30149193 DOI: 10.1016/j.jgar.2018.08.016] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 08/17/2018] [Accepted: 08/18/2018] [Indexed: 01/23/2023] Open
Abstract
Enterococcus faecium is a robust opportunistic pathogen that is most commonly found as a commensal of the human and animal gut but can also survive in the environment. Since the introduction and use of antimicrobials, E. faecium has been found to rapidly acquire resistance genes that, when expressed, can effectively circumvent the effects of most antimicrobials. The rapid acquisition of multiple antimicrobial resistances has led to the adaptation of specific E. faecium clones in the hospital environment, collectively known as clonal complex 17 (CC17). CC17 E. faecium are responsible for a significant proportion of hospital-associated infections, which can cause severe morbidity and mortality. Here we review the history of E. faecium from commensal to a significant hospital-associated pathogen, its robust phenotypic characteristics, commonly used laboratory typing schemes, and antimicrobial resistances with a focus on vancomycin and its associated mechanism of resistance. Finally, we review the global epidemiology of vancomycin-resistant E. faecium and potential solutions to problems faced in public health.
Collapse
Affiliation(s)
- Terence Lee
- Antimicrobial Resistance and Infectious Diseases Research Laboratory, Murdoch University, Perth, WA, Australia
| | - Stanley Pang
- Antimicrobial Resistance and Infectious Diseases Research Laboratory, Murdoch University, Perth, WA, Australia; PathWest Laboratory Medicine, Nedlands, WA, Australia
| | - Sam Abraham
- Antimicrobial Resistance and Infectious Diseases Research Laboratory, Murdoch University, Perth, WA, Australia
| | - Geoffrey W Coombs
- Antimicrobial Resistance and Infectious Diseases Research Laboratory, Murdoch University, Perth, WA, Australia; PathWest Laboratory Medicine, Nedlands, WA, Australia.
| |
Collapse
|
14
|
Morfin-Otero R, Perez-Gomez HR, Gonzalez-Diaz E, Esparza-Ahumada S, Rodriguez-Noriega E. Enterococci as Increasing Bacteria in Hospitals: Why Are Infection Control Measures Challenging for This Bacteria? CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0166-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
15
|
DalBen MF. Transmission-Based Precautions for Multidrug-Resistant Organisms: What to Prioritize When Resources Are Limited. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0143-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
16
|
Dhar S, Cook E, Oden M, Kaye KS. Building a Successful Infection Prevention Program: Key Components, Processes, and Economics. Infect Dis Clin North Am 2017; 30:567-89. [PMID: 27515138 DOI: 10.1016/j.idc.2016.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Infection control is the discipline responsible for preventing health care-associated infections (HAIs) and has grown from an anonymous field, to a highly visible, multidisciplinary field of incredible importance. There has been increasing focus on prevention rather than control of HAIs. Infection prevention programs (IPPs) have enormous scope that spans multiple disciplines. Infection control and the prevention and elimination of HAIs can no longer be compartmentalized. This article discusses the structure and responsibilities of an IPP, the regulatory pressures and opportunities that these programs face, and how to build and manage a successful program.
Collapse
Affiliation(s)
- Sorabh Dhar
- Department of Hospital Epidemiology and Infection Prevention, Detroit Medical Center, Detroit, MI, USA; Department of Medicine, Wayne State University, Detroit, MI, USA; Department of Hospital Epidemiology and Infection Prevention, John D Dingell VA Medical Center, Detroit, MI, USA; Harper University Hospital, 5 Hudson, 3990 John R, Detroit, MI 48201, USA.
| | - Evelyn Cook
- Duke Infection Control Outreach Network, Duke University Medical Center, 1610 Sycamore Street, Durham, NC 27707, USA
| | - Mary Oden
- Infection Prevention, Clinical Operations, Tenet Health, 1443 Ross Avenue Suite 1400, Dallas, TX 75202, USA
| | - Keith S Kaye
- Department of Hospital Epidemiology and Infection Prevention, Detroit Medical Center, Detroit, MI, USA; Department of Medicine, Wayne State University, Detroit, MI, USA; University Health Center, 4201 Saint Antoine, Suite 2B, Box 331, Detroit, MI 48201, USA
| |
Collapse
|
17
|
Huang TS, Lee SSJ, Lee CC, Chen CY, Chen FC, Chen BC, Sy CL, Wu KS. Evaluation of a matrix-assisted laser desorption ionization-time of flight mass spectrometry assisted, selective broth method to screen for vancomycin-resistant enterococci in patients at high risk. PLoS One 2017; 12:e0179455. [PMID: 28609453 PMCID: PMC5469485 DOI: 10.1371/journal.pone.0179455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 05/29/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Bile esculin azide with vancomycin (BEAV) medium is a sensitive, but slightly less specific method for vancomycin-resistant enterococci (VRE) screening. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) is a rapid method for identification of clinical pathogens. This study aimed to assess the performance of a novel combination screening test for VRE, using BEAV broth combined with MALDI-TOF MS. MATERIALS AND METHODS Clinical specimens were collected from patients at risk of VRE carriage, and tested by the novel combination method, using selective BEAV broth culture method followed by MALDI-TOF MS identification (SBEAVM). The reference method used for comparison was the ChromID VRE agar method. RESULTS A total of 135 specimens were collected from 78 patients, and 63 specimens tested positive for VRE positive using the ChromID VRE method (positive rate 46.7%). The sensitivity, specificity, positive predictive value, and negative predictive value of SBEAVM method after an incubation period of 28 hours were 93.7%, 90.3%, 89.4%, and 94.2%, respectively. The SBEAVM method when compared to the ChromID VRE method had a shorter turnaround time (29 vs. 48-72 hours) and lower laboratory cost ($2.11 vs. $3.23 per test). CONCLUSIONS This study demonstrates that SBEAVM is a rapid, inexpensive, and accurate method for use in VRE screening.
Collapse
Affiliation(s)
- Tsi-Shu Huang
- Division of Microbiology, Department of pathology and laboratory medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Susan Shin-Jung Lee
- Division of Microbiology, Department of pathology and laboratory medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chia-Chien Lee
- Division of Microbiology, Department of pathology and laboratory medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chiu-Yen Chen
- Department of Nursing, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Fang-Chen Chen
- Department of Nursing, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Infection Control Unit, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Bao-Chen Chen
- Division of Microbiology, Department of pathology and laboratory medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Cheng Len Sy
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Kuan-Sheng Wu
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- * E-mail:
| |
Collapse
|
18
|
Faron ML, Buchan BW, Coon C, Liebregts T, van Bree A, Jansz AR, Soucy G, Korver J, Ledeboer NA. Automatic Digital Analysis of Chromogenic Media for Vancomycin-Resistant-Enterococcus Screens Using Copan WASPLab. J Clin Microbiol 2016; 54:2464-9. [PMID: 27413193 PMCID: PMC5035414 DOI: 10.1128/jcm.01040-16] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 07/07/2016] [Indexed: 11/20/2022] Open
Abstract
Vancomycin-resistant enterococci (VRE) are an important cause of health care-acquired infections (HAIs). Studies have shown that active surveillance of high-risk patients for VRE colonization can aid in reducing HAIs; however, these screens generate a significant cost to the laboratory and health care system. Digital imaging capable of differentiating negative and "nonnegative" chromogenic agar can reduce the labor cost of these screens and potentially improve patient care. In this study, we evaluated the performance of the WASPLab Chromogenic Detection Module (CDM) (Copan, Brescia, Italy) software to analyze VRE chromogenic agar and compared the results to technologist plate reading. Specimens collected at 3 laboratories were cultured using the WASPLab CDM and plated to each site's standard-of-care chromogenic media, which included Colorex VRE (BioMed Diagnostics, White City, OR) or Oxoid VRE (Oxoid, Basingstoke, United Kingdom). Digital images were scored using the CDM software after 24 or 40 h of growth, and all manual reading was performed using digital images on a high-definition (HD) monitor. In total, 104,730 specimens were enrolled and automation agreed with manual analysis for 90.1% of all specimens tested, with sensitivity and specificity of 100% and 89.5%, respectively. Automation results were discordant for 10,348 specimens, and all discordant images were reviewed by a laboratory supervisor or director. After a second review, 499 specimens were identified as representing missed positive cultures falsely called negative by the technologist, 1,616 were identified as containing borderline color results (negative result but with no package insert color visible), and 8,234 specimens were identified as containing colorimetric pigmentation due to residual matrix from the specimen or yeast (Candida). Overall, the CDM was accurate at identifying negative VRE plates, which comprised 84% (87,973) of the specimens in this study.
Collapse
Affiliation(s)
| | - Blake W Buchan
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA Wisconsin Diagnostic Laboratories, Milwaukee, Wisconsin, USA
| | | | - Theo Liebregts
- PAMM Laboratory of Medical Microbiology, Veldhoven, Netherlands
| | - Anita van Bree
- PAMM Laboratory of Medical Microbiology, Veldhoven, Netherlands
| | - Arjan R Jansz
- PAMM Laboratory of Medical Microbiology, Veldhoven, Netherlands
| | | | - John Korver
- Hamilton Regional Laboratory Medicine Program, Hamilton Health Sciences, Ontario, Canada
| | - Nathan A Ledeboer
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA Wisconsin Diagnostic Laboratories, Milwaukee, Wisconsin, USA
| |
Collapse
|
19
|
Mather AE, Reeve R, Mellor DJ, Matthews L, Reid-Smith RJ, Dutil L, Haydon DT, Reid SWJ. Detection of Rare Antimicrobial Resistance Profiles by Active and Passive Surveillance Approaches. PLoS One 2016; 11:e0158515. [PMID: 27391966 PMCID: PMC4938605 DOI: 10.1371/journal.pone.0158515] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 06/16/2016] [Indexed: 11/24/2022] Open
Abstract
Antimicrobial resistance (AMR) surveillance systems are generally not specifically designed to detect emerging resistances and usually focus primarily on resistance to individual drugs. Evaluating the diversity of resistance, using ecological metrics, allows the assessment of sampling protocols with regard to the detection of rare phenotypes, comprising combinations of resistances. Surveillance data of phenotypic AMR of Canadian poultry Salmonella Heidelberg and swine Salmonella Typhimurium var. 5- were used to contrast active (representative isolates derived from healthy animals) and passive (diagnostic isolates) surveillance and assess their suitability for detecting emerging resistance patterns. Although in both datasets the prevalences of resistance to individual antimicrobials were not significantly different between the two surveillance systems, analysis of the diversity of entire resistance phenotypes demonstrated that passive surveillance of diagnostic isolates detected more unique phenotypes. Whilst the most appropriate surveillance method will depend on the relevant objectives, under the conditions of this study, passive surveillance of diagnostic isolates was more effective for the detection of rare and therefore potentially emerging resistance phenotypes.
Collapse
Affiliation(s)
- Alison E. Mather
- Boyd Orr Centre for Population and Ecosystem Health, University of Glasgow, Glasgow, United Kingdom
- School of Veterinary Medicine, University of Glasgow, Glasgow, United Kingdom
- * E-mail:
| | - Richard Reeve
- Boyd Orr Centre for Population and Ecosystem Health, University of Glasgow, Glasgow, United Kingdom
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Dominic J. Mellor
- Boyd Orr Centre for Population and Ecosystem Health, University of Glasgow, Glasgow, United Kingdom
- School of Veterinary Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Louise Matthews
- Boyd Orr Centre for Population and Ecosystem Health, University of Glasgow, Glasgow, United Kingdom
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Richard J. Reid-Smith
- Public Health Agency of Canada, Guelph, Ontario, Canada
- Department of Population Medicine, University of Guelph, Guelph, Ontario, Canada
| | - Lucie Dutil
- Public Health Agency of Canada, St. Hyacinthe, Quebec, Canada
| | - Daniel T. Haydon
- Boyd Orr Centre for Population and Ecosystem Health, University of Glasgow, Glasgow, United Kingdom
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Stuart W. J. Reid
- Boyd Orr Centre for Population and Ecosystem Health, University of Glasgow, Glasgow, United Kingdom
- School of Veterinary Medicine, University of Glasgow, Glasgow, United Kingdom
| |
Collapse
|
20
|
Farr BM. What To Think If the Results of the National Institutes of Health Randomized Trial of Methicillin-ResistantStaphylococcus aureusand Vancomycin-ResistantEnterococcusControl Measures Are Negative (and Other Advice to Young Epidemiologists): A Review and an Au Revoir. Infect Control Hosp Epidemiol 2016; 27:1096-106. [PMID: 17006818 DOI: 10.1086/508759] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2006] [Accepted: 08/31/2006] [Indexed: 12/27/2022]
Abstract
The incidence of methicillin-resistantStaphylococcus aureus(MRSA) and vancomycin-resistantEnterococcus(VRE) infections continues to rise in National Nosocomial Infections Surveillance system hospitals, and these pathogens are reportedly causing more than 100,000 infections and many deaths each year in US healthcare facilities. This has led some to insist that control measures are now urgently needed, but several recent articles have suggested that isolation of patients does not work, is not needed, or is unsafe, or that a single cluster-randomized trial could be used to decide such matters. At least 101 studies have reported controlling MRSA infection and 38 have reported controlling VRE infection by means of active detection by surveillance culture and use of isolation for all colonized patients in healthcare settings where the pathogens are epidemic or endemic, in academic and nonacademic hospitals, and in acute care, intensive care, and long-term care settings. MRSA colonization and infection have been controlled to exceedingly low levels in multiple nations and in the state of Western Australia for decades by use of active detection and isolation. Studies suggesting problems with using such data to control MRSA colonization and infection have their own problems, which are discussed. Randomized trials are epidemiologic tools that can sometimes provide erroneous results, and they have not been considered necessary for studying isolation before it is used to control other important infections, such as tuberculosis, smallpox, and severe acute respiratory syndrome. No single epidemiologic study should be considered definitive. One should always weigh all available evidence. Infection with antibiotic-resistant pathogens such as MRSA and VRE is controllable to a low level by active detection and isolation of colonized and infected patients. Effective measures should be used to minimize the morbidity and mortality attributable to these largely preventable infections.
Collapse
Affiliation(s)
- Barry M Farr
- Department of Medicine, University of Virginia Health System, Charlottesville, VA 22908, USA.
| |
Collapse
|
21
|
Singh N, Léger MM, Campbell J, Short B, Campos JM. Control of Vancomycin-Resistant Enterococci in the Neonatal Intensive Care Unit. Infect Control Hosp Epidemiol 2016; 26:646-9. [PMID: 16092746 DOI: 10.1086/502595] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AbstractBackground and Objective:Multidrug-resistant organisms (MDROs), such as vancomycin-resistant enterococci (VRE), cause serious infections, especially among high-risk patients in NICUs. When VRE was introduced and transmitted in our NICU despite recommended infection control practices, we instituted active surveillance cultures to determine their efficacy in detecting and controlling spread of VRE among high-risk infants.Methods:Active surveillance cultures, other infection control measures, and a mandatory in-service education module on preventing MDRO transmission were implemented. Cultures were performed on NICU admission and then weekly during their stay. Molecular DNA fingerprinting of VRE isolates facilitated targeting efforts to eliminate clonal spread of VRE. Repetitive sequence PCR (rep-PCR)-based DNA fingerprinting was used to compare isolates recovered from patients with VRE infection or colonization. Environmental VRE cultures were performed around VRE-colonized or -infected patients. DNA fingerprints were prepared from the products of rep-PCR amplification and analyzed using software to determine strain genetic relatedness.Results:Active surveillance cultures identified 65 patients with VRE colonization or infection among 1,820 admitted to the NICU. Rep-PCR performed on 60 VRE isolates identified 3 clusters. Cluster 1 included isolates from 21 patients and 4 isolates from the environment of the index patient. Clusters 2 and 3 included isolates from 23 and 3 patients, respectively. Similarity coefficients among the members of each cluster were 95% or greater.Conclusions:Control of transmission of multi-clonal VRE strains was achieved. Active surveillance cultures, together with implementation of other infection control measures, combined with rep-PCR DNA fingerprinting were instrumental in controlling VRE transmission in our NICU. (Infect Control Hosp Epidemiol 2005;26:646-649)
Collapse
Affiliation(s)
- Nalini Singh
- Department of Pediatrics, George Washington University School of Medicine, Washington, DC 20010, USA.
| | | | | | | | | |
Collapse
|
22
|
Perencevich EN, Hartley DM. Of Models and Methods: Our Analytic Armamentarium Applied to Methicillin-Resistant Staphylococcus aureus. Infect Control Hosp Epidemiol 2016; 26:594-7. [PMID: 16092738 DOI: 10.1086/502587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
23
|
Popiel KY, Miller MA. Evaluation of Vancomycin-Resistant Enterococci (VRE)–Associated Morbidity Following Relaxation of VRE Screening and Isolation Precautions in a Tertiary Care Hospital. Infect Control Hosp Epidemiol 2016; 35:818-25. [DOI: 10.1086/676860] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
ObjectiveTo determine whether relaxing vancomycin-resistant enterococci (VRE) precautions results in an increase in the incidence of invasive VRE infections over time.DesignRetrospective analysis of a microbiology database before and after relaxation of VRE screening and isolation precautions.SettingUrban tertiary care teaching hospital in Montreal, Canada.Participants.All hospitalized and emergency room patients over a 13-year period from January 1, 2000, to March 31, 2013.MethodsWe assessed the results of all microbiology cultures for the presence of VRE as well as the results of all polymerase chain reaction assays forvanAandvanBduring the study period. Applying criteria for 4 clinical situations (bacteremia, definite infection, possible infection, and colonization with VRE), we analyzed the effects of relaxed VRE screening and isolation precautions on the incidence of each of these outcomes over the time preceding and following this change.ResultsWhen VRE screening and isolation precautions were relaxed, a marked rise in VRE colonization was observed, with a lesser but definite rise in the 3 other outcomes. Despite this initial rise in all measures, all incidences other than colonization plateaued during the 34 months of follow-up.ConclusionsRelaxation of VRE screening and isolation precautions was associated with an immediate increase in colonization and infection incidence. Despite increasing colonization, infection outcomes remained infrequent and stable, suggesting a finite number of susceptible hosts at risk. Relaxation of VRE protocols may not lead to increasing infection incidence in a hospital setting, advocating that cost effectiveness exercises, with targeted screening and isolation precautions, are crucial.
Collapse
|
24
|
Resistance Mechanisms, Epidemiology, and Approaches to Screening for Vancomycin-Resistant Enterococcus in the Health Care Setting. J Clin Microbiol 2016; 54:2436-47. [PMID: 27147728 DOI: 10.1128/jcm.00211-16] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Infections attributable to vancomycin-resistant Enterococcus (VRE) strains have become increasingly prevalent over the past decade. Prompt identification of colonized patients combined with effective multifaceted infection control practices can reduce the transmission of VRE and aid in the prevention of hospital-acquired infections (HAIs). Increasingly, the clinical microbiology laboratory is being asked to support infection control efforts through the early identification of potential patient or environmental reservoirs. This review discusses the factors that contribute to the rise of VRE as an important health care-associated pathogen, the utility of laboratory screening and various infection control strategies, and the available laboratory methods to identify VRE in clinical specimens.
Collapse
|
25
|
Mahabeer Y, Lowman W, Govind CN, Swe-Swe-Han K, Mlisana KP. First outbreak of vancomycin-resistant Enterococcus in a haematology unit in Durban, South Africa. S Afr J Infect Dis 2016. [DOI: 10.1080/23120053.2015.1118819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
|
26
|
Lister DM, Kotsanas D, Ballard SA, Howden BP, Carse E, Tan K, Scott C, Gillespie EE, Mahony AA, Doherty R, Korman TM, Johnson PDR, Stuart RL. Outbreak of vanB vancomycin-resistant Enterococcus faecium colonization in a neonatal service. Am J Infect Control 2015; 43:1061-5. [PMID: 26190380 DOI: 10.1016/j.ajic.2015.05.047] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 05/28/2015] [Accepted: 05/29/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To describe successful termination of an outbreak of vancomycin-resistant Enterococcus faecium (VREfm) colonization within a neonatal service. SETTING Multisite neonatal intensive care unit and special care nurseries within a single health care service. PARTICIPANTS Forty-four cases of VREfm-colonized neonatal inpatients-including 2 clinical isolates (eye swab and catheter-urine specimen) and 42 screening isolates. INTERVENTIONS Active surveillance cultures, patient isolation, contact precautions, enhanced environment cleaning, and staff and parent education. Whole genome sequencing and multilocus sequence typing were used to characterize the outbreak and refine infection control procedures. RESULTS Peak prevalence of VREfm colonization across all sites was 31% upon discovery of the outbreak. Subsequent to the intervention, transmission was halted within 8 weeks and no further isolates of the outbreak strain have been detected as of 12 months following outbreak cessation. Environmental swabs revealed VREfm colonization of baby-weighing scales, a baby bath, and a pharmacy refrigerator within the neonatal intensive care unit. All isolates were of a single multilocus sequence type (sequence type 796) and highly clonal at the core genome level. CONCLUSIONS Bundled infection control interventions were effective in rapidly terminating a clonal outbreak of sequence type 796 VREfm colonization within a neonatal inpatient service. Strain-typing and active surveillance cultures were critical in guiding the management of this outbreak. The closed environment of a neonatal unit likely facilitated eradication of the patient and environment reservoirs of VREfm colonization.
Collapse
Affiliation(s)
- David M Lister
- Monash Infectious Diseases, Monash Health, Clayton, Victoria, Australia.
| | - Despina Kotsanas
- Monash Infectious Diseases, Monash Health, Clayton, Victoria, Australia
| | - Susan A Ballard
- Department of Microbiology, Austin Health, Heidelberg, Victoria, Australia
| | - Benjamin P Howden
- Department of Microbiology, Austin Health, Heidelberg, Victoria, Australia; Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Microbiological Diagnostic Unit Public Health Laboratory, The University of Melbourne, Parkville, Victoria, Australia
| | - Elizabeth Carse
- Monash Childrens Hospital, Monash Health, Clayton, Victoria, Australia
| | - Kenneth Tan
- Monash Childrens Hospital, Monash Health, Clayton, Victoria, Australia
| | - Carmel Scott
- Department of Infection Prevention & Epidemiology, Monash Health, Clayton, Victoria, Australia
| | - Elizabeth E Gillespie
- Department of Infection Prevention & Epidemiology, Monash Health, Clayton, Victoria, Australia
| | - Andrew A Mahony
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Richard Doherty
- Monash Childrens Hospital, Monash Health, Clayton, Victoria, Australia
| | - Tony M Korman
- Monash Infectious Diseases, Monash Health, Clayton, Victoria, Australia
| | - Paul D R Johnson
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Rhonda L Stuart
- Monash Infectious Diseases, Monash Health, Clayton, Victoria, Australia; Department of Infection Prevention & Epidemiology, Monash Health, Clayton, Victoria, Australia
| |
Collapse
|
27
|
|
28
|
Weber SG, Huang SS, Oriola S, Huskins WC, Noskin GA, Harriman K, Olmsted RN, Bonten M, Lundstrom T, Climo MW, Roghmann MC, Murphy CL, Karchmer TB. Legislative Mandates for Use of Active Surveillance Cultures to Screen for Methicillin-ResistantStaphylococcus aureusand Vancomycin-Resistant Enterococci: Position Statement From the Joint SHEA and APIC Task Force. Infect Control Hosp Epidemiol 2015; 28:249-60. [PMID: 17326014 DOI: 10.1086/512261] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Accepted: 01/05/2007] [Indexed: 01/14/2023]
Abstract
Legislation aimed at controlling antimicrobial-resistant pathogens through the use of active surveillance cultures to screen hospitalized patients has been introduced in at least 2 US states. In response to the proposed legislation, the Society for Healthcare Epidemiology of America (SHEA) and the Association of Professionals in Infection Control and Epidemiology (APIC) have developed this joint position statement. Both organizations are dedicated to combating healthcare-associated infections with a wide array of methods, including the use of active surveillance cultures in appropriate circumstances. This position statement reviews the proposed legislation and the rationale for use of active surveillance cultures, examines the scientific evidence supporting the use of this strategy, and discusses a number of unresolved issues surrounding legislation mandating use of active surveillance cultures. The following 5 consensus points are offered. (1) Although reducing the burden of antimicrobial-resistant pathogens, including methicillin-resistantStaphylococcus aureus(MRSA) and vancomycin-resistant enterococci (VRE), is of preeminent importance, APIC and SHEA do not support legislation to mandate use of active surveillance cultures to screen for MRSA, VRE, or other antimicrobial-resistant pathogens. (2) SHEA and APIC support the continued development, validation, and application of efficacious and cost-effective strategies for the prevention of infections caused by MRSA, VRE, and other antimicrobial-resistant and antimicrobial-susceptible pathogens. (3) APIC and SHEA welcome efforts by healthcare consumers, together with private, local, state, and federal policy makers, to focus attention on and formulate solutions for the growing problem of antimicrobial resistance and healthcare-associated infections. (4) SHEA and APIC support ongoing additional research to determine and optimize the appropriateness, utility, feasibility, and cost-effectiveness of using active surveillance cultures to screen both lower-risk and high-risk populations. (5) APIC and SHEA support stronger collaboration between state and local public health authorities and institutional infection prevention and control experts.
Collapse
Affiliation(s)
- Stephen G Weber
- Section of Infectious Diseases, University of Chicago, Chicago, IL 60637, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Calderwood MS, Mauer A, Tolentino J, Flores E, van Besien K, Pursell K, Weber SG. Epidemiology of Vancomycin-Resistant Enterococci Among Patients on an Adult Stem Cell Transplant Unit: Observations From an Active Surveillance Program. Infect Control Hosp Epidemiol 2015; 29:1019-25. [DOI: 10.1086/591454] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective.To use the findings of an active surveillance program to delineate the unique epidemiology of vancomycin-resistant enterococci (VRE) in a mixed population of transplant and nontransplant patients hospitalized on a single patient care unit.Design.Surveillance survey and case-control analysis.Setting.A 19-bed adult bone marrow and stem cell transplant unit at a referral and primary-care center.Patients.The study included patients undergoing transplantation, patients who had previously received bone marrow or stem cell transplants, and patients with other malignancies and hematological disorders who were admitted to the study unit.Methods.Patients not previously identified as colonized with VRE had perirectal swab specimens collected at admission and once weekly while hospitalized on the unit. The prevalence of VRE colonization at admission and the incidence throughout the hospital stay, genotypes of VRE specimens as determined by pulsed field gel electrophoresis, and risk factors related to colonization were analyzed.Results.There was no significant difference in the prevalence or incidence of new colonization between nontransplant patients and prior or current transplant recipients, although overall prevalence at admission was significantly higher in the prior transplant group. Preliminary genotypic analysis of VRE isolates from transplant patients suggests that a proportion of cases of newly detected VRE carriage may represent prior colonization not detected at admission, with different risk factors suggestive of a potential epidemiological distinction.Conclusion.Examination of epidemiological and microbiological data collected by an active surveillance program provides useful information about the epidemiology of VRE that can be applied to inform rational infection control strategies.
Collapse
|
30
|
Doan TN, Kong DCM, Kirkpatrick CMJ, McBryde ES. Optimizing hospital infection control: the role of mathematical modeling. Infect Control Hosp Epidemiol 2014; 35:1521-30. [PMID: 25419775 DOI: 10.1086/678596] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Multidrug-resistant bacteria are major causes of nosocomial infections and are associated with considerable morbidity, mortality, and healthcare costs. Preventive strategies have therefore become increasingly important. Mathematical modeling has been widely used to understand the transmission dynamics of nosocomial infections and the quantitative effects of infection control measures. This review will explore the principles of mathematical modeling used in nosocomial infections and discuss the effectiveness of infection control measures investigated using mathematical modeling.
Collapse
Affiliation(s)
- Tan N Doan
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | | | | | | |
Collapse
|
31
|
Abstract
It is critical for health care personnel to recognize and appreciate the detrimental impact of intensive care unit (ICU)-acquired infections. The economic, clinical, and social expenses to patients and hospitals are overwhelming. To limit the incidence of ICU-acquired infections, aggressive infection control measures must be implemented and enforced. Researchers and national committees have developed and continue to develop evidence-based guidelines to control ICU infections. A multifaceted approach, including infection prevention committees, antimicrobial stewardship programs, daily reassessments-intervention bundles, identifying and minimizing risk factors, and continuing staff education programs, is essential. Infection control in the ICU is an evolving area of critical care research.
Collapse
Affiliation(s)
- Mohamed F Osman
- Division of Trauma/Burns and Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St. Boston, MA 02115, USA
| | - Reza Askari
- Division of Trauma/Burns and Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St. Boston, MA 02115, USA.
| |
Collapse
|
32
|
Goldsack JC, DeRitter C, Power M, Spencer A, Taylor CL, Kim SF, Kirk R, Drees M. Clinical, patient experience and cost impacts of performing active surveillance on known methicillin-resistant Staphylococcus aureus positive patients admitted to medical-surgical units. Am J Infect Control 2014; 42:1039-43. [PMID: 25278390 DOI: 10.1016/j.ajic.2014.07.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 07/03/2014] [Accepted: 07/07/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND There is a large and growing body of evidence that methicillin-resistant Staphylococcus aureus (MRSA) screening programs are cost effective, but such screening represents a significant cost burden for hospitals. This study investigates the clinical, patient experience and cost impacts of performing active surveillance on known methicillin-resistant S aureus positive (MRSA+) patients admitted to 7 medical-surgical units of a large regional hospital, specifically to allow discontinuation of contact isolation. METHODS We conducted mixed-methods retrospective evaluation of a process improvement project that screened admitted patients with known MRSA+ status for continued MRSA colonization. RESULTS Of those eligible patients on our institution's MRSA+ list who did complete testing, 80.2% (130/162) were found to be no longer colonized, and only 19.8% (32/162) were still colonized. Forty-one percent (13/32) of interviewed patients in contact isolation for MRSA reported that isolation had affected their hospital stay, and 28% (9/32) of patients reported emotional distress resulting from their isolation. Total cost savings of the program are estimated at $101,230 per year across the 7 study units. CONCLUSION Our findings provide supporting evidence that a screening program targeting patients with a history of MRSA who would otherwise be placed in isolation has the potential to improve outcomes and patient experience and reduce costs.
Collapse
|
33
|
Humphreys H. Controlling the spread of vancomycin-resistant enterococci. Is active screening worthwhile? J Hosp Infect 2014; 88:191-8. [PMID: 25310998 DOI: 10.1016/j.jhin.2014.09.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 09/10/2014] [Indexed: 11/28/2022]
Abstract
Vancomycin-resistant enterococci (VRE) are significant causes of healthcare-acquired infections. Active screening, i.e. the use of rectal swabs or faeces to detect carriage in at-risk patients, has been described as contributing to prevention by identifying previously unrecognized cases. The aim of this review was to determine the impact of screening for VRE on prevention and control, its cost-effectiveness and recent approaches to laboratory detection. A review of published studies in English from 2000 was undertaken. Whereas various guidelines were accessed and reviewed, the emphasis was on original reports and studies. It was determined that the patient groups who may need screening are those admitted to critical care units, haematology/oncology and transplant wards, patients on chronic dialysis and patients admitted to acute hospitals from long-stay units. Active screening is associated with reduced VRE colonization and infection and cost savings in some studies, even if these fall short of randomized trials. Selective media increase sensitivity and reduce the time to detection but the role of molecular methods remains to be determined. In conclusion, active screening contributes to VRE prevention probably by heightening awareness of control measures, including isolation. However, further studies are required to: better define high-risk groups that warrant screening; quantify the clinical and economic benefit; and determine the optimal laboratory methods in a range of different patient populations.
Collapse
Affiliation(s)
- H Humphreys
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland and Beaumont Hospital, Dublin, Ireland.
| |
Collapse
|
34
|
Abstract
BACKGROUND Vancomycin-resistant Enterococcus (VRE) screening is routine practice in many intensive care units despite the question of its clinical significance. The value of VRE screening at predicting subsequent VRE or other hospital-acquired infection (HAI) is unknown. The purpose of this investigation was to examine the rate of subsequent VRE HAI in patients undergoing VRE screening. METHODS This study was conducted in a 24-bed surgical intensive care unit (SICU) at a Level I trauma center. Patients admitted to the SICU between February and August 2011 who had rectal swab for VRE screening within 72 hours were followed prospectively for the development of VRE and other HAIs. Demographics, clinical characteristics, and infection rates were compared between VRE-positive and VRE-negative patients. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of VRE screening for predicting subsequent VRE HAI were calculated. RESULTS A total of 341 patients had VRE screening within 72 hours of SICU admission, with 32 VRE-positive (9%) and 309 VRE-negative (91%) patients. VRE-positive patients had a higher incidence of any HAI (78% vs. 35%, p < 0.001). Eight VRE-positive patients (25%) developed VRE HAI compared with only 3 VRE-negative patients (1%) (p < 0.001). VRE screening had a 73% sensitivity, 93% specificity, 25% PPV, and 99% NPV for determining subsequent VRE HAI. CONCLUSION VRE colonization was present in 9% of SICU patients at admission. Negative VRE screen result had a high specificity and NPV for the development of subsequent VRE HAI. Empiric treatment of VRE infection may be unnecessary in VRE-negative patients. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III. Therapeutic study, level IV.
Collapse
|
35
|
Abstract
Vancomycin-resistant enterococci (VRE) consist mainly of Enterococcus faecalis and E faecium, the latter mostly hospital-acquired. In addition, E gallinarum and E casseliflavus are intrinsically vancomycin-resistant and are community-acquired. VRE have become common in many hospitals throughout the world and, once established, are very difficult to eradicate. VRE are difficult to treat; therefore, infection control measures in hospitals are of prime importance in preventing the establishment of these pathogens. Most severe VRE infections will need combination therapy because many of the effective antimicrobial agents, when used alone, have only a bacteriostatic effect.
Collapse
Affiliation(s)
- Ethan Rubinstein
- Section of Infectious Diseases, Department of Internal Medicine and Medical Microbiology, University of Manitoba, 543-645 Bannatyne Ave, Basic Medical Building, Winnipeg, Manitoba R3E 0J9, Canada.
| | | |
Collapse
|
36
|
Optimal control of vancomycin-resistant enterococci using preventive care and treatment of infections. Math Biosci 2014; 249:8-17. [PMID: 24480735 DOI: 10.1016/j.mbs.2014.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 12/04/2013] [Accepted: 01/12/2014] [Indexed: 11/21/2022]
Abstract
The rising prevalence of vancomycin-resistant enterococci (VRE) is a major health problem in intensive care units (ICU) because of its association with increased mortality and high health care costs. We present a mathematical framework for determining cost-effective strategies for prevention and treatment of VRE in the ICU. A system of five ordinary differential equations describes the movement of ICU patients in and out of five VRE-related states. Two control variables representing the prevention and treatment of VRE are incorporated into the system. The basic reproductive number is derived and calculated for different levels of the two controls. An optimal control problem is formulated to minimize VRE-related deaths and costs associated with prevention and treatment controls over a finite time period. Numerical solutions illustrate optimal single and dual allocations of the controls for various cost values. Results show that preventive care has the greatest impact in reducing the basic reproductive number, while treatment of VRE infections has the most impact on reducing VRE-related deaths.
Collapse
|
37
|
Iosifidis E, Evdoridou I, Agakidou E, Chochliourou E, Protonotariou E, Karakoula K, Stathis I, Sofianou D, Drossou-Agakidou V, Pournaras S, Roilides E. Vancomycin-resistant Enterococcus outbreak in a neonatal intensive care unit: epidemiology, molecular analysis and risk factors. Am J Infect Control 2013; 41:857-61. [PMID: 23669299 DOI: 10.1016/j.ajic.2013.02.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 02/04/2013] [Accepted: 02/05/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND Vancomycin-resistant Enterococcus faecium (VRE) may cause outbreaks in neonatal intensive care units (NICU). We describe a biphasic VRE outbreak and identify risk factors for VRE acquisition. METHODS After the occurrence of 2 cases of VRE infections in a 44-bed NICU, a bundle of interventions was implemented that included active surveillance cultures for VRE, enhanced infection control measures, and audits on antimicrobial use, from June to December 2008. Analysis was performed using polymerase chain reaction and pulse-field gel electrophoresis techniques. A case-control study was conducted to identify risk factors. RESULTS Among 253 neonates screened, 101 (39.9%) were found to be colonized with VRE. During the first 9 weeks of the study period, 59 new cases were detected. Molecular analysis showed 1 predominant clone. During weeks 10-12, no new cases of VRE colonization were detected; however, at week 13, just when the outbreak appeared to be over, a second wave occurred, with 42 new cases and multiple clones detected. Multivariate analysis identified administration of antimicrobial therapy for late-onset neonatal sepsis and hospitalization during the first month of this outbreak as significant risk factors for VRE colonization. CONCLUSION Both a high prevalence of VRE colonization and antimicrobial use promoted the transmission of VRE during this biphasic outbreak. Adherence to infection control measures and antimicrobial stewardship policies are of utmost importance.
Collapse
Affiliation(s)
- Elias Iosifidis
- Third Department of Pediatrics, Aristotle University School of Medicine, Hippokration General Hospital, Thessaloniki, Greece
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Spicknall IH, Foxman B, Marrs CF, Eisenberg JNS. A modeling framework for the evolution and spread of antibiotic resistance: literature review and model categorization. Am J Epidemiol 2013; 178:508-20. [PMID: 23660797 PMCID: PMC3736756 DOI: 10.1093/aje/kwt017] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Antibiotic-resistant infections complicate treatment and increase morbidity and mortality. Mathematical modeling has played an integral role in improving our understanding of antibiotic resistance. In these models, parameter sensitivity is often assessed, while model structure sensitivity is not. To examine the implications of this, we first reviewed the literature on antibiotic-resistance modeling published between 1993 and 2011. We then classified each article's model structure into one or more of 6 categories based on the assumptions made in those articles regarding within-host and population-level competition between antibiotic-sensitive and antibiotic-resistant strains. Each model category has different dynamic implications with respect to how antibiotic use affects resistance prevalence, and therefore each may produce different conclusions about optimal treatment protocols that minimize resistance. Thus, even if all parameter values are correctly estimated, inferences may be incorrect because of the incorrect selection of model structure. Our framework provides insight into model selection.
Collapse
Affiliation(s)
- Ian H Spicknall
- Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109, USA.
| | | | | | | |
Collapse
|
39
|
van Kleef E, Robotham JV, Jit M, Deeny SR, Edmunds WJ. Modelling the transmission of healthcare associated infections: a systematic review. BMC Infect Dis 2013; 13:294. [PMID: 23809195 PMCID: PMC3701468 DOI: 10.1186/1471-2334-13-294] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 06/21/2013] [Indexed: 11/22/2022] Open
Abstract
Background Dynamic transmission models are increasingly being used to improve our understanding of the epidemiology of healthcare-associated infections (HCAI). However, there has been no recent comprehensive review of this emerging field. This paper summarises how mathematical models have informed the field of HCAI and how methods have developed over time. Methods MEDLINE, EMBASE, Scopus, CINAHL plus and Global Health databases were systematically searched for dynamic mathematical models of HCAI transmission and/or the dynamics of antimicrobial resistance in healthcare settings. Results In total, 96 papers met the eligibility criteria. The main research themes considered were evaluation of infection control effectiveness (64%), variability in transmission routes (7%), the impact of movement patterns between healthcare institutes (5%), the development of antimicrobial resistance (3%), and strain competitiveness or co-colonisation with different strains (3%). Methicillin-resistant Staphylococcus aureus was the most commonly modelled HCAI (34%), followed by vancomycin resistant enterococci (16%). Other common HCAIs, e.g. Clostridum difficile, were rarely investigated (3%). Very few models have been published on HCAI from low or middle-income countries. The first HCAI model has looked at antimicrobial resistance in hospital settings using compartmental deterministic approaches. Stochastic models (which include the role of chance in the transmission process) are becoming increasingly common. Model calibration (inference of unknown parameters by fitting models to data) and sensitivity analysis are comparatively uncommon, occurring in 35% and 36% of studies respectively, but their application is increasing. Only 5% of models compared their predictions to external data. Conclusions Transmission models have been used to understand complex systems and to predict the impact of control policies. Methods have generally improved, with an increased use of stochastic models, and more advanced methods for formal model fitting and sensitivity analyses. Insights gained from these models could be broadened to a wider range of pathogens and settings. Improvements in the availability of data and statistical methods could enhance the predictive ability of models.
Collapse
Affiliation(s)
- Esther van Kleef
- Infectious Disease Epidemiology Department, Faculty of Epidemiology and Population Health, Centre of Mathematical Modelling, London School of Hygiene and Tropical Medicine, London, UK.
| | | | | | | | | |
Collapse
|
40
|
Byun SJ, Kang J. Risk Factors and Clinical Outcomes for Vancomycin-Resistant Enterococcus Colonization on Intensive Care Unit Admission. J Korean Acad Nurs 2013; 43:287-95. [DOI: 10.4040/jkan.2013.43.2.287] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Sook-Jin Byun
- Infection Control Team, Dong-A University Medical Center, Busan, Korea
| | - Jiyeon Kang
- Department of Nursing, Dong-A University, Busan, Korea
| |
Collapse
|
41
|
Polyclonal outbreak of vancomycin-resistant Enterococcus faecium in a pediatric oncology department. J Pediatr Hematol Oncol 2012; 34:511-6. [PMID: 22627577 DOI: 10.1097/mph.0b013e318257a5d3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We present a polyclonal outbreak of vancomycin-resistant enterococci (VRE) colonization in a pediatric oncology department and the role of a bundle of actions. After the occurrence of VRE bloodstream infections in 2 patients, an active surveillance of VRE colonization was started. Enhanced infection control measures and closure of the department to new admissions for the first 3 months were implemented. Among 32 patients screened for VRE, 21 were found colonized. Daily prevalence of VRE colonization among hospitalized patients ranged from 40% to 75%, but no new VRE infections occurred. Monthly incidence of VRE colonization decreased from 2.5 to 0.6 cases per 100 occupied bed-days at the end of this outbreak by the implementation of the above-mentioned measures. All VRE isolates tested were Enterococcus faecium carrying VanA gene. Pulsed field gel electrophoresis showed a polyclonal outbreak. A case-control study did not show any particular risk factors for colonization. High use of glycopeptide was noted before study outbreak that was drastically decreased during the study but only temporarily. Control of VRE in pediatric oncology departments with high colonization rates is challenging and requires a multifaceted strategy. Polyclonal spread of VRE found in this study suggests a possible effect of prior antimicrobial overuse and the critical need for antimicrobial stewardship especially in the era of multidrug-resistant bacteria.
Collapse
|
42
|
Yoon YK, Kim HJ, Lee WJ, Lee SE, Yang KS, Park DW, Sohn JW, Kim MJ. Clinical prediction rule for identifying patients with vancomycin-resistant enterococci (VRE) at the time of admission to the intensive care unit in a low VRE prevalence setting. J Antimicrob Chemother 2012; 67:2963-9. [PMID: 22888271 DOI: 10.1093/jac/dks303] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES The purpose of this study was to develop and validate a clinical prediction rule to screen patients at risk of vancomycin-resistant enterococci (VRE) carriage at intensive care unit (ICU) admission in a hospital setting with low VRE prevalence. METHODS This study was retrospectively conducted in the ICUs of a university-affiliated hospital in Korea, where active surveillance cultures for VRE had been run at ICU admission and weekly thereafter. In the derivation cohort from April 2008 to September 2010, risk factors for VRE carriage at ICU admission were determined and assigned weighted point values using a multivariate logistic regression model. In the validation cohort from October 2010 to March 2011, predictability of the prediction rule was evaluated. RESULTS Of a total of 4445 cultures taken from patients at ICU admission, 153 (3.4%) patients carried VRE. In the derivation cohort, independent risk factors (assigned points) for VRE carriage at ICU admission were ICU readmission during hospitalization (1 point), chronic obstructive lung disease (2 points), recent antibiotic treatment (3 points) and recent vancomycin use (2 points). In the validation cohort, the sensitivity, specificity, and positive and negative predictive values of the prediction rule, on the basis of risk scores ≥3 points, were 84.2%, 82.5%, 15.2% and 99.3%, respectively. CONCLUSIONS This clinical prediction rule for identifying VRE carriage at the time of ICU admission is expected to markedly reduce the screening volume (by 80.1%) in our healthcare facility. For use in clinical practice, the rule needs to be prospectively validated in other settings.
Collapse
Affiliation(s)
- Young Kyung Yoon
- Division of Infectious Diseases, Korea University Medical Center, Seoul, Republic of Korea
| | | | | | | | | | | | | | | |
Collapse
|
43
|
Hall IM, Barrass I, Leach S, Pittet D, Hugonnet S. Transmission dynamics of methicillin-resistant Staphylococcus aureus in a medical intensive care unit. J R Soc Interface 2012; 9:2639-52. [PMID: 22572025 DOI: 10.1098/rsif.2012.0134] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Intensive care units (ICUs) play an important role in the epidemiology of methicillin-resistant Staphyloccocus aureus (MRSA). Although successful interventions are multi-modal, the relative efficacy of single measures remains unknown. We developed a discrete time, individual-based, stochastic mathematical model calibrated on cross-transmission observed through prospective surveillance to explore the transmission dynamics of MRSA in a medical ICU. Most input parameters were derived from locally acquired data. After fitting the model to the 46 observed cross-transmission events and performing sensitivity analysis, several screening and isolation policies were evaluated by simulating the number of cross-transmissions and isolation-days. The number of all cross-transmission events increased from 54 to 72 if only patients with a past history of MRSA colonization are screened and isolated at admission, to 75 if isolation is put in place only after the results of the admission screening become available, to 82 in the absence of admission screening and with a similar reactive isolation policy, and to 95 when no isolation policy is in place. The method used (culture or polymerase chain reaction) for admission screening had no impact on the number of cross-transmissions. Systematic regular screening during ICU stay provides no added-value, but aggressive admission screening and isolation effectively reduce the number of cross-transmissions. Critically, colonized healthcare workers may play an important role in MRSA transmission and their screening should be reinforced.
Collapse
Affiliation(s)
- Ian M Hall
- Microbial Risk Assessment, Emergency Response Department, Health Protection Agency, Porton Down, UK
| | | | | | | | | |
Collapse
|
44
|
Contribution of mathematical modeling to the fight against bacterial antibiotic resistance. Curr Opin Infect Dis 2011; 24:279-87. [PMID: 21467930 DOI: 10.1097/qco.0b013e3283462362] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE OF REVIEW Modeling of antibiotic resistance in pathogenic bacteria responsible for human disease has developed considerably over the last decade. Herein, we summarize the main published studies to illustrate the contribution of models for understanding both within-host and population-based phenomena. We then suggest possible topics for future studies. RECENT FINDINGS Model building of bacterial resistance has involved epidemiologists, biologists and modelers with two different objectives. First, modeling has helped largely in identifying and understanding the factors and biological phenomena responsible for the emergence and spread of resistant strains. Second, these models have become important decision support tools for medicine and public health. SUMMARY Major improvements of models in the coming years should take into account specific pathogen characteristics (resistance mechanisms, multiple colonization phenomena, cooperation and competition among species) and better description of the contacts associated with transmission risk within populations.
Collapse
|
45
|
Marner ES, Wolk DM, Carr J, Hewitt C, Dominguez LL, Kovacs T, Johnson DR, Hayden RT. Diagnostic accuracy of the Cepheid GeneXpert vanA/vanB assay ver. 1.0 to detect the vanA and vanB vancomycin resistance genes in Enterococcus from perianal specimens. Diagn Microbiol Infect Dis 2011; 69:382-9. [PMID: 21396533 DOI: 10.1016/j.diagmicrobio.2010.11.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2010] [Revised: 11/05/2010] [Accepted: 11/07/2010] [Indexed: 11/30/2022]
Abstract
Rapid detection of vancomycin-resistant enterococci (VRE) carriers could be useful to health care facilities to minimize transmission. To that end, we compared the performance of the Cepheid GeneXpert vanA/vanB assay with that of direct and broth-enriched culture methods for detection of VRE from perianal swabs. Enterococci were cultivated on Enterococcosel™ agar with 8 μg/mL vancomycin, Bile Esculin Azide Agar with 6 μg/mL vancomycin, and Bile Esculin Azide Enterococcosel Broth. Compared to the reference standard (combination of direct agar plating, broth-enriched culture, and clinical chart review), the sensitivity, specificity, positive predictive value, and negative predictive value of the vanA/vanB assay were 96.4%, 93.0%, 92.0%, and 96.9%, respectively (n=184). The 95% limit of detection was 100 colony-forming units (CFU)/mL for vanA and 114 CFU/mL for vanB. In summary, the GeneXpert vanA/vanB assay is a rapid and accurate method to identify vanA/vanB-colonized patients for VRE screening programs that use perianal swab specimens.
Collapse
|
46
|
Huskins WC, Huckabee CM, O'Grady NP, Murray P, Kopetskie H, Zimmer L, Walker ME, Sinkowitz-Cochran RL, Jernigan JA, Samore M, Wallace D, Goldmann DA. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med 2011; 364:1407-18. [PMID: 21488763 PMCID: PMC3410743 DOI: 10.1056/nejmoa1000373] [Citation(s) in RCA: 275] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Intensive care units (ICUs) are high-risk settings for the transmission of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE). METHODS In a cluster-randomized trial, we evaluated the effect of surveillance for MRSA and VRE colonization and of the expanded use of barrier precautions (intervention) as compared with existing practice (control) on the incidence of MRSA or VRE colonization or infection in adult ICUs. Surveillance cultures were obtained from patients in all participating ICUs; the results were reported only to ICUs assigned to the intervention. In intervention ICUs, patients who were colonized or infected with MRSA or VRE were assigned to care with contact precautions; all the other patients were assigned to care with universal gloving until their discharge or until surveillance cultures obtained at admission were reported to be negative. RESULTS During a 6-month intervention period, there were 5434 admissions to 10 intervention ICUs, and 3705 admissions to 8 control ICUs. Patients who were colonized or infected with MRSA or VRE were assigned to barrier precautions more frequently in intervention ICUs than in control ICUs (a median of 92% of ICU days with either contact precautions or universal gloving [51% with contact precautions and 43% with universal gloving] in intervention ICUs vs. a median of 38% of ICU days with contact precautions in control ICUs, P<0.001). In intervention ICUs, health care providers used clean gloves, gowns, and hand hygiene less frequently than required for contacts with patients assigned to barrier precautions; when contact precautions were specified, gloves were used for a median of 82% of contacts, gowns for 77% of contacts, and hand hygiene after 69% of contacts, and when universal gloving was specified, gloves were used for a median of 72% of contacts and hand hygiene after 62% of contacts. The mean (±SE) ICU-level incidence of events of colonization or infection with MRSA or VRE per 1000 patient-days at risk, adjusted for baseline incidence, did not differ significantly between the intervention and control ICUs (40.4±3.3 and 35.6±3.7 in the two groups, respectively; P=0.35). CONCLUSIONS The intervention was not effective in reducing the transmission of MRSA or VRE, although the use of barrier precautions by providers was less than what was required. (Funded by the National Institute of Allergy and Infectious Diseases and others; STAR*ICU ClinicalTrials.gov number, NCT00100386.).
Collapse
Affiliation(s)
- W Charles Huskins
- Division of Pediatric Infectious Diseases, Mayo Clinic, Rochester, MN 55905, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Cook E, Marchaim D, Kaye KS. Building a successful infection prevention program: key components, processes, and economics. Infect Dis Clin North Am 2011; 25:1-19. [PMID: 21315992 DOI: 10.1016/j.idc.2010.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Infection control is the discipline responsible for preventing nosocomial infections. There has been an increasing focus on prevention rather than control of hospital-acquired infections. Individuals working in infection control have seen their titles change from infection control practitioner to infection control professional and most recently to infection preventionist (IP), emphasizing their critical role in protecting patients. The responsibilities of IPs span multiple disciplines including medicine, surgery, nursing, occupational health, microbiology, pharmacy, sterilization and disinfection, emergency medicine, and information technology. This article discusses the structure and responsibilities of an infection control program and the regulatory pressures and opportunities the program faces.
Collapse
Affiliation(s)
- Evelyn Cook
- Department of Medicine, Duke Infection Control Outreach Network, Durham, NC, USA.
| | | | | |
Collapse
|
48
|
Controlling a vancomycin-resistant enterococci outbreak in a Brazilian teaching hospital. Eur J Clin Microbiol Infect Dis 2010; 30:369-74. [DOI: 10.1007/s10096-010-1095-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 10/08/2010] [Indexed: 10/18/2022]
|
49
|
Methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus: Recognition and prevention in intensive care units. Crit Care Med 2010; 38:S335-44. [DOI: 10.1097/ccm.0b013e3181e6ab12] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
50
|
Kruse EB, Dettenkofer M. Epidemiologie von und Präventionsmaßnahmen bei multiresistenten Erregern. Ophthalmologe 2010; 107:313-7. [DOI: 10.1007/s00347-009-2074-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|