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Allel K, Hernández-Leal MJ, Naylor NR, Undurraga EA, Abou Jaoude GJ, Bhandari P, Flanagan E, Haghparast-Bidgoli H, Pouwels KB, Yakob L. Costs-effectiveness and cost components of pharmaceutical and non-pharmaceutical interventions affecting antibiotic resistance outcomes in hospital patients: a systematic literature review. BMJ Glob Health 2024; 9:e013205. [PMID: 38423548 PMCID: PMC10910705 DOI: 10.1136/bmjgh-2023-013205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 01/26/2024] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION Limited information on costs and the cost-effectiveness of hospital interventions to reduce antibiotic resistance (ABR) hinder efficient resource allocation. METHODS We conducted a systematic literature review for studies evaluating the costs and cost-effectiveness of pharmaceutical and non-pharmaceutical interventions aimed at reducing, monitoring and controlling ABR in patients. Articles published until 12 December 2023 were explored using EconLit, EMBASE and PubMed. We focused on critical or high-priority bacteria, as defined by the WHO, and intervention costs and incremental cost-effectiveness ratio (ICER). Following Preferred Reporting Items for Systematic review and Meta-Analysis guidelines, we extracted unit costs, ICERs and essential study information including country, intervention, bacteria-drug combination, discount rates, type of model and outcomes. Costs were reported in 2022 US dollars ($), adopting the healthcare system perspective. Country willingness-to-pay (WTP) thresholds from Woods et al 2016 guided cost-effectiveness assessments. We assessed the studies reporting checklist using Drummond's method. RESULTS Among 20 958 articles, 59 (32 pharmaceutical and 27 non-pharmaceutical interventions) met the inclusion criteria. Non-pharmaceutical interventions, such as hygiene measures, had unit costs as low as $1 per patient, contrasting with generally higher pharmaceutical intervention costs. Several studies found that linezolid-based treatments for methicillin-resistant Staphylococcus aureus were cost-effective compared with vancomycin (ICER up to $21 488 per treatment success, all 16 studies' ICERs CONCLUSION Robust information on ABR interventions is critical for efficient resource allocation. We highlight cost-effective strategies for mitigating ABR in hospitals, emphasising substantial knowledge gaps, especially in low-income and middle-income countries. Our study serves as a resource for guiding future cost-effectiveness study design and analyses.PROSPERO registration number CRD42020341827 and CRD42022340064.
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Affiliation(s)
- Kasim Allel
- Disease Control Department, London School of Hygiene & Tropical Medicine, London, UK
- Institute for Global Health, University College London, London, UK
- Department of Health and Community Sciences, University of Exeter, Exeter, UK
| | - María José Hernández-Leal
- Department of Community, Maternity and Paediatric Nursing, University of Navarra, Pamplona, Spain
- Millennium Nucleus on Sociomedicine, Santiago, Chile
| | - Nichola R Naylor
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
- HCAI, Fungal, AMR, AMU & Sepsis Division, UK Health Security Agency, London, UK
| | - Eduardo A Undurraga
- Escuela de Gobierno, Pontificia Universidad Catolica de Chile, Santiago, Chile
- CIFAR Azrieli Global Scholars program, Canadian Institute for Advanced Research, Toronto, Ontario, Canada
| | | | - Priyanka Bhandari
- Disease Control Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Ellen Flanagan
- Disease Control Department, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Koen B Pouwels
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- The National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Laith Yakob
- Disease Control Department, London School of Hygiene & Tropical Medicine, London, UK
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Popovich KJ, Aureden K, Ham DC, Harris AD, Hessels AJ, Huang SS, Maragakis LL, Milstone AM, Moody J, Yokoe D, Calfee DP. SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2023; 44:1039-1067. [PMID: 37381690 PMCID: PMC10369222 DOI: 10.1017/ice.2023.102] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 05/03/2023] [Indexed: 06/29/2023]
Abstract
Previously published guidelines have provided comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing efforts to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection. This document updates the "Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission and Infection in Acute Care Hospitals" published in 2014.1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Kyle J. Popovich
- Department of Internal Medicine, RUSH Medical College, Chicago, Illinois
| | - Kathy Aureden
- Infection Prevention, Advocate Aurora Health, Downers Grove, Illinois
| | - D. Cal Ham
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anthony D. Harris
- Health Care Outcomes Research, University of Maryland School of Medicine, Baltimore, Maryland
| | - Amanda J. Hessels
- Columbia School of Nursing, New York, New York
- Hackensack Meridian Health, Edison, New Jersey
| | - Susan S. Huang
- Division of Infectious Diseases, University of California Irvine School of Medicine, Irvine, California
| | - Lisa L. Maragakis
- Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Aaron M. Milstone
- Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Julia Moody
- Infection Prevention, HCA Healthcare, Nashville, Tennessee
| | - Deborah Yokoe
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California
- Transplant Infectious Diseases, UCSF Medical Center, San Francisco, California
| | - David P. Calfee
- Department of Medicine, Weill Cornell Medicine, New York, New York
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
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Rice S, Carr K, Sobiesuo P, Shabaninejad H, Orozco-Leal G, Kontogiannis V, Marshall C, Pearson F, Moradi N, O'Connor N, Stoniute A, Richmond C, Craig D, Allegranzi B, Cassini A. Economic evaluations of interventions to prevent and control health-care-associated infections: a systematic review. THE LANCET. INFECTIOUS DISEASES 2023; 23:e228-e239. [PMID: 37001543 DOI: 10.1016/s1473-3099(22)00877-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 11/23/2022] [Accepted: 12/14/2022] [Indexed: 03/30/2023]
Abstract
Almost 9 million health-care-associated infections have been estimated to occur each year in European hospitals and long-term care facilities, and these lead to an increase in morbidity, mortality, bed occupancy, and duration of hospital stay. The aim of this systematic review was to review the cost-effectiveness of interventions to limit the spread of health-care-associated infections), framed by WHO infection prevention and control core components. The Embase, National Health Service Economic Evaluation Database, Database of Abstracts of Reviews of Effects, Health Technology Assessment, Cinahl, Scopus, Pediatric Economic Database Evaluation, and Global Index Medicus databases, plus grey literature were searched for studies between Jan 1, 2009, and Aug 10, 2022. Studies were included if they reported interventions including hand hygiene, personal protective equipment, national-level or facility-level infection prevention and control programmes, education and training programmes, environmental cleaning, and surveillance. The British Medical Journal checklist was used to assess the quality of economic evaluations. 67 studies were included in the review. 25 studies evaluated methicillin-resistant Staphylococcus aureus outcomes. 31 studies evaluated screening strategies. The assessed studies that met the minimum quality criteria consisted of economic models. There was some evidence that hand hygiene, environmental cleaning, surveillance, and multimodal interventions were cost-effective. There were few or no studies investigating education and training, personal protective equipment or monitoring, and evaluation of interventions. This Review provides a map of cost-effectiveness data, so that policy makers and researchers can identify the relevant data and then assess the quality and generalisability for their setting.
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Affiliation(s)
- Stephen Rice
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.
| | - Katherine Carr
- Dental School, Newcastle University, Newcastle upon Tyne, UK
| | - Pauline Sobiesuo
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hosein Shabaninejad
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Giovany Orozco-Leal
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Christopher Marshall
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK; NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona Pearson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK; NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
| | - Najmeh Moradi
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Nicole O'Connor
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK; NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
| | - Akvile Stoniute
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Richmond
- NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
| | - Dawn Craig
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK; NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
| | - Benedetta Allegranzi
- Infection Prevention and Control Technical and Clinical Hub, Department of Integrated Health Services, WHO, Geneva, Switzerland
| | - Alessandro Cassini
- Infection Prevention and Control Technical and Clinical Hub, Department of Integrated Health Services, WHO, Geneva, Switzerland
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Al Musawi S, Alkhaleefa Q, Alnassri S, Alamri A, Alnimr A. Predictive Role of Targeted, Active Surveillance Cultures for Detection of Methicillin-Resistant Staphylococcus aureus. Infect Drug Resist 2021; 14:4757-4764. [PMID: 34795491 PMCID: PMC8594744 DOI: 10.2147/idr.s340871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/04/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Methicillin-resistant Staphylococcus aureus (MRSA) colonisation is an important source of healthcare-acquired infections. Reliable screening strategies for MRSA colonisation are essential for the timely implementation of infection control measures. AIM This study determined reliable MRSA screening sites to predict colonisation in resource-limited settings and estimated the impact of missed MRSA cases when shifting from multi- to single-site screening. METHODOLOGY A cross-sectional study was conducted in patients with positive MRSA surveillance cultures from the routinely screened sites (nasal, axillary, groin, and throat) from January 2009 to December 2019. RESULTS A total of 1906 screening tests were positive for MRSA cultures (n = 1345 patients). As a single site, the nasal cavity showed the highest MRSA detection, with a sensitivity of 66.8% (95% CI = 64-69) with 277.9 missed isolation days. Screening three or more anatomical sites detected 97-100% of MRSA cases, with 0-24.5 missed isolation days. Screening the axilla and groin separately or in combination showed a good clinical utility index (CUI) of >0.6 to <0.8, while an excellent CUI was obtained upon screening other site samples (>0.8). The combined nasal and throat cultures demonstrated a sensitivity of 93.2 (95% CI = 91-94) with 57.2 missed isolation days. CONCLUSION Multi-site screening is the optimal strategy for minimising MRSA exposure within a healthcare facility. For active MRSA surveillance, a combination of nasal and throat cultures can provide a practical approach in low-resource settings compared to nasal sampling alone.
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Affiliation(s)
- Safiya Al Musawi
- Department of Pathology, Salmaniya Medical Complex, Ministry of Health, Manama, Kingdom of Bahrain
| | - Qassim Alkhaleefa
- Department of Microbiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Samia Alnassri
- Department of Infection Control, King Fahad Hospital of the University, Dammam, Kingdom of Saudi Arabia
| | - Aisha Alamri
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Amani Alnimr
- Department of Microbiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
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Abstract
Antibiotic-resistant bacteria are an increasing problem in the NICU. Ineffective empiric antibiotic therapy is associated with increased risk for morbidity and mortality. Organisms that are resistant to multiple antimicrobial agents (multidrug-resistant organisms) are particularly problematic. These organisms may be transmitted to infants if infection control practices are not adhered to, or they may be created by antibiotic exposure. Therefore, meticulous infection prevention-including hand hygiene, surveillance cultures, contact precautions, and selective decolonization-and antibiotic stewardship are important strategies to minimize drug resistance in the NICU.
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Affiliation(s)
| | - Joseph B Cantey
- Division of Neonatology and.,Division of Allergy, Immunology, and Infectious Diseases, Department of Pediatrics, University of Texas Health San Antonio, San Antonio, TX
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Lee Y, Gettman L. Descriptive Analysis of Acceptance by Prescribers and Economic Benefit of Pharmacist Recommended Interventions in a Critical Care Unit. Innov Pharm 2018; 9:1-20. [PMID: 34007688 PMCID: PMC6438544 DOI: 10.24926/iip.v9i2.958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Pharmacist clinical intervention is defined as the action that identifies and prevents medication-related problems and optimizes patient's medication therapy in cooperation with other healthcare professionals. Types of clinical interventions may vary, but each is patient specific. Few studies have focused on clinical pharmacists interventions in a critical care setting at a rural hospital. OBJECTIVES The purpose of this study was to assess physician acceptance rate of pharmacist-recommended interventions in the critical care unit (CCU) at a rural hospital over five years and to evaluate the economic benefit of accepted pharmacist-recommended interventions over a one-year time period. METHODS This study was a retrospective chart review over a five-year time period. Each intervention was categorized and analyzed for acceptance or non-acceptance by the treating physician. Evaluation of economic benefit, cost saving and cost avoidance, for a one-year time period was performed. RESULTS A total of 1275 interventions were documented during study period. The average acceptance rate for documented interventions was 56%. The acceptance rate by physicians increased over the study period; with the acceptance rate in 2013 being statistically significantly higher than any other years. The overall cost saving for selected interventions was $432 for the one year. The overall cost avoidance of all accepted interventions for the one year was $453,339.36-$468,327.62. CONCLUSION Clinical pharmacists provide various types of interventions to improve patient care. The analysis of potential cost saving and cost avoidance of selected interventions illustrated a positive economic outcome.
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Affiliation(s)
- YoonJung Lee
- Texas Tech University Health Sciences Center
- Harding University College of Pharmacy
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Nelwan EJ, Sinto R, Subekti D, Adiwinata R, Waslia L, Loho T, Safari D, Widodo D. Screening of methicillin-resistant Staphylococcus aureus nasal colonization among elective surgery patients in referral hospital in Indonesia. BMC Res Notes 2018; 11:56. [PMID: 29357913 PMCID: PMC5778668 DOI: 10.1186/s13104-018-3150-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: 10/14/2017] [Accepted: 01/09/2018] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Methicillin-resistant Staphylococcus aureus (MRSA) colonization is associated with serious surgical site infection in high-risk patients. High prevalence of MRSA colonization was reported in many settings, nonetheless local data is required. The purpose of this study is to identify the prevalence and risk factor of MRSA nasal carriage in adult patients in National Referral Hospital in Indonesia before underwent elective surgical procedure. RESULTS From 384 patients, 16.9% patients of them had undergone orthopaedic surgery, 51.3% had received antibiotics within the previous 3-month and 41.1% patients had history of hospitalization within the previous 1 year. Total of 21.6% patients were on invasive devices for at least 48 h before the operation; 24.2% had an open wound; 19.3% patients were referred from other hospital/ward. Of these patients, solid tumor without metastasis was the most common factor identified by the Charlson index (38.3%). Nasal colonization of Gram-positive bacteria was detected in 76.8%; S. aureus in 15.6% of patients (n = 60). MRSA was identified in three isolates (0.8%) by both culture and polymerase chain reaction (PCR) tests. Due to low prevalence of MRSA nasal carriage, this finding supports the recommendation to not routinely apply mupirocin for nasal decolonization on patient planned for surgery in Indonesia.
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Affiliation(s)
- Erni J Nelwan
- Division of Tropical and Infectious Diseases, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jl. Salemba Raya 6, Jakarta, 10430, Indonesia.
| | - Robert Sinto
- Division of Tropical and Infectious Diseases, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jl. Salemba Raya 6, Jakarta, 10430, Indonesia
| | - Decy Subekti
- Eijkman Oxford Clinical Reseach Unit, Jl. Diponegoro No. 69, Jakarta, 10430, Indonesia
| | - Randy Adiwinata
- Division of Tropical and Infectious Diseases, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jl. Salemba Raya 6, Jakarta, 10430, Indonesia
| | - Lia Waslia
- Eijkman Oxford Clinical Reseach Unit, Jl. Diponegoro No. 69, Jakarta, 10430, Indonesia
| | - Tonny Loho
- Department of Clinical Pathology, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jl. Salemba Raya 6, Jakarta, 10430, Indonesia
| | - Dodi Safari
- Eijkman Institute for Molecular Biology, Jl. Diponegoro No. 69, Jakarta, 10430, Indonesia
| | - Djoko Widodo
- Division of Tropical and Infectious Diseases, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jl. Salemba Raya 6, Jakarta, 10430, Indonesia
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Spread of Tst-Positive Staphylococcus aureus Strains Belonging to ST30 Clone among Patients and Healthcare Workers in Two Intensive Care Units. Toxins (Basel) 2017; 9:toxins9090270. [PMID: 28869541 PMCID: PMC5618203 DOI: 10.3390/toxins9090270] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 08/24/2017] [Accepted: 08/31/2017] [Indexed: 11/16/2022] Open
Abstract
Staphylococcus aureus is a major cause of infections. Toxic shock syndrome toxin (TSST-1) and Panton–Valentine leukocidin (PVL) are associated with severe clinical syndromes. S. aureus colonizing isolates recovered from healthcare workers and patients in the intensive care unit (ICU) of a university hospital comprising Group A were compared with those from adult non-ICU carriers (Group B). mecA, lukS/lukF-PV (Panton–Valentine leukocidin, PVL), and tst (toxic shock syndrome toxin) gene carriage was detected by PCR. Clones were identified in all methicillin-resistant S. aureus (MRSA) and toxin-positive methicillin-susceptible strains (MSSA) by pulsed-field gel electrophoresis (PFGE), agr groups, and multi locus sequencing typing (MLST). Group A included 90 S. aureus isolates, whereas Group B 53. PVL was more frequently found among MRSA vs. MSSA (p < 0.001) and in strains of Group B as compared to Group A (p < 0.001), consistent with the spread of ST80-IV. Higher incidence of tst gene carriage was identified among MSSA vs. MRSA (P 0.005) belonging mainly to ST30, and Group A vs. Group B (P 0.002). The wide dissemination of ST80-IV mainly in the community is responsible for a high percentage of PVL-positive MRSA, while silent spread of tst-positive S. aureus clones among ICU patients and personnel poses a threat of hospital transmission and possible severe infections.
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Glisovic S, Eintracht S, Longtin Y, Oughton M, Brukner I. Rectal swab screening assays of public health importance in molecular diagnostics: Sample adequacy control. J Infect Public Health 2017; 11:234-237. [PMID: 28801105 DOI: 10.1016/j.jiph.2017.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 06/16/2017] [Accepted: 07/09/2017] [Indexed: 11/30/2022] Open
Abstract
Rectal swabs are routinely used by public health authorities to screen for multi-drug resistant enteric bacteria including vancomycin-resistant enterococci (VRE) and carbapenem-resistant enterobacteriaceae (CRE). Screening sensitivity can be influenced by the quality of the swabbing, whether performed by the patient (self-swabbing) or a healthcare practitioner. One common exclusion criterion for rectal swabs is absence of "visible soiling" from fecal matter. In our institution, this criterion excludes almost 10% of rectal swabs received in the microbiology laboratory. Furthermore, over 30% of patients in whom rectal swabs are cancelled will not be re-screened within the next 48h, resulting in delays in removing infection prevention measures. We describe two quantitative polymerase chain reaction (qPCR)-based assays, human RNAse P and eubacterial 16S rDNA, which might serve as suitable controls for sampling adequacy. However, lower amounts of amplifiable human DNA make the 16s rDNA assay a better candidate for sample adequacy control.
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Affiliation(s)
| | - Shaun Eintracht
- Medical Faculty, McGill University, Montreal, Quebec, Canada; SMBD-Jewish General Hospital, Montreal, Quebec, Canada
| | - Yves Longtin
- Medical Faculty, McGill University, Montreal, Quebec, Canada; SMBD-Jewish General Hospital, Montreal, Quebec, Canada
| | - Matthew Oughton
- Medical Faculty, McGill University, Montreal, Quebec, Canada; SMBD-Jewish General Hospital, Montreal, Quebec, Canada
| | - Ivan Brukner
- Medical Faculty, McGill University, Montreal, Quebec, Canada; SMBD-Jewish General Hospital, Montreal, Quebec, Canada.
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Skally M, Finn C, O'Brien D, Fitzpatrick F, Burns K, McFadden E, Fitzpatrick M, Smyth E, Humphreys H. Invasive MRSA infections in neurosurgical patients - a decade of progress. Br J Neurosurg 2017; 31:374-378. [PMID: 28049348 DOI: 10.1080/02688697.2016.1260688] [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: 10/20/2022]
Abstract
BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) is an important cause of bloodstream infection (BSI), which is declining in many countries, including Ireland. However, it also causes other invasive infections, such as meningitis in neurosurgical patients. It is unclear whether the decline in MRSA BSI is reflected in other invasive infections and in specialist units. AIM To investigate trends in the incidence of MRSA invasive infection in a national neurosurgical centre over a 10-year period. METHODS A retrospective review of neurosurgical patients with MRSA recovered from sterile sites and indicating invasive infection, according to internationally agreed definitions was conducted between January 2006 and December 2015. Rates per 10,000 bed days used (BDU) and neurosurgical bed days used (NBDU) were calculated and trends were analysed. RESULTS Forty-four cases of invasive MRSA infection were identified over the study period. The majority were BSI (26, 59%) followed by ventriculitis (8, 18%). Invasive MRSA infections declined significantly from 0.52 per 10,000 BDU (or 4.65 per 10,000 NBU) in 2006 to 0.22 per 10,000 BDU (or 2.04 per 10,000 NBDU) in 2015, p < .01, despite an increase in neurosurgical clinical activity. Half of the infections occurred in patients with no previous history of MRSA colonisation/infection. The mean length-of-stay for neurosurgical patients with invasive MRSA infections was 67 days (median 32.5 days), significantly greater for other neurosurgical patients (p < .01). CONCLUSION There has been a significant decrease in invasive MRSA infections in neurosurgical patients, reflecting national and international trends for MRSA BSI. This indicates that infection prevention and control measures have been effective in reducing invasive MRSA infections overall, thus contributing to improved patient care.
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Affiliation(s)
- Mairéad Skally
- a Department of Clinical Microbiology , Beaumont Hospital , Dublin , Ireland
| | - Caoimhe Finn
- b Department of Infection Prevention and Control , Beaumont Hospital , Dublin , Ireland
| | - David O'Brien
- c Department of Neurosurgery , Beaumont Hospital , Dublin , Ireland
| | - Fidelma Fitzpatrick
- a Department of Clinical Microbiology , Beaumont Hospital , Dublin , Ireland.,d Department of Clinical Microbiology , The Royal College of Surgeons in Ireland , Dublin , Ireland
| | - Karen Burns
- a Department of Clinical Microbiology , Beaumont Hospital , Dublin , Ireland.,e Healthcare Associated Infections Team, Health Protection Surveillance Centre , Dublin , Ireland
| | - Elaine McFadden
- a Department of Clinical Microbiology , Beaumont Hospital , Dublin , Ireland
| | | | - Edmond Smyth
- a Department of Clinical Microbiology , Beaumont Hospital , Dublin , Ireland.,d Department of Clinical Microbiology , The Royal College of Surgeons in Ireland , Dublin , Ireland
| | - Hilary Humphreys
- a Department of Clinical Microbiology , Beaumont Hospital , Dublin , Ireland.,d Department of Clinical Microbiology , The Royal College of Surgeons in Ireland , Dublin , Ireland
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Roth VR, Longpre T, Coyle D, Suh KN, Taljaard M, Muldoon KA, Ramotar K, Forster A. Cost Analysis of Universal Screening vs. Risk Factor-Based Screening for Methicillin-Resistant Staphylococcus aureus (MRSA). PLoS One 2016; 11:e0159667. [PMID: 27462905 PMCID: PMC4963093 DOI: 10.1371/journal.pone.0159667] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 07/05/2016] [Indexed: 12/03/2022] Open
Abstract
Background The literature remains conflicted regarding the most effective way to screen for MRSA. This study was designed to assess costs associated with universal versus risk factor-based screening for the reduction of nosocomial MRSA transmission. Methods The study was conducted at The Ottawa Hospital, a large multi-centre tertiary care facility with approximately 47,000 admissions annually. From January 2006-December 2007, patients underwent risk factor-based screening for MRSA on admission. From January 2008 to August 2009 universal MRSA screening was implemented. A comparison of costs incurred during risk factor-based screening and universal screening was conducted. The model incorporated probabilities relating to the likelihood of being tested and the results of polymerase chain reaction (PCR) testing with associated effects in terms of MRSA bacteremia and true positive and negative test results. Inputted costs included laboratory testing, contact precautions and infection control, private room costs, housekeeping, and length of hospital stay. Deterministic sensitivity analyses were conducted. Results The risk factor-based MRSA screening program screened approximately 30% of admitted patients and cost the hospital over $780 000 annually. The universal screening program screened approximately 83% of admitted patients and cost over $1.94 million dollars, representing an excess cost of $1.16 million per year. The estimated additional cost per patient screened was $17.76. Conclusion This analysis demonstrated that a universal MRSA screening program was costly from a hospital perspective and was previously known to not be clinically effective at reducing MRSA transmission. These results may be useful to inform future model-based economic analyses of MRSA interventions.
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Affiliation(s)
- Virginia R. Roth
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
- * E-mail:
| | - Tara Longpre
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Doug Coyle
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Health Economics Research Group, Brunel University, Uxbridge, Middlesex, United Kingdom
| | - Kathryn N. Suh
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Katherine A. Muldoon
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Karamchand Ramotar
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Alan Forster
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Strategies to Prevent MRSA Transmission in Community-Based Nursing Homes: A Cost Analysis. Infect Control Hosp Epidemiol 2016; 37:962-966. [PMID: 27174005 DOI: 10.1017/ice.2016.96] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To estimate the costs of 3 MRSA transmission prevention scenarios compared with standard precautions in community-based nursing homes. DESIGN Cost analysis of data collected from a prospective, observational study. SETTING AND PARTICIPANTS Care activity data from 401 residents from 13 nursing homes in 2 states. METHODS Cost components included the quantities of gowns and gloves, time to don and doff gown and gloves, and unit costs. Unit costs were combined with information regarding the type and frequency of care provided over a 28-day observation period. For each scenario, the estimated costs associated with each type of care were summed across all residents to calculate an average cost and standard deviation for the full sample and for subgroups. RESULTS The average cost for standard precautions was $100 (standard deviation [SD], $77) per resident over a 28-day period. If gown and glove use for high-risk care was restricted to those with MRSA colonization or chronic skin breakdown, average costs increased to $137 (SD, $120) and $125 (SD, $109), respectively. If gowns and gloves were used for high-risk care for all residents in addition to standard precautions, the average cost per resident increased substantially to $223 (SD, $127). CONCLUSIONS The use of gowns and gloves for high-risk activities with all residents increased the estimated cost by 123% compared with standard precautions. This increase was ameliorated if specific subsets (eg, those with MRSA colonization or chronic skin breakdown) were targeted for gown and glove use for high-risk activities. Infect Control Hosp Epidemiol 2016;37:962-966.
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Nelson RE, Stevens VW, Khader K, Jones M, Samore MH, Evans ME, Douglas Scott R, Slayton RB, Schweizer ML, Perencevich EL, Rubin MA. Economic Analysis of Veterans Affairs Initiative to Prevent Methicillin-Resistant Staphylococcus aureus Infections. Am J Prev Med 2016; 50:S58-S65. [PMID: 27102860 PMCID: PMC7909478 DOI: 10.1016/j.amepre.2015.10.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 10/12/2015] [Accepted: 10/22/2015] [Indexed: 11/26/2022]
Abstract
INTRODUCTION In an effort to reduce methicillin-resistant Staphylococcus aureus (MRSA) transmission through universal screening and isolation, the Department of Veterans Affairs (VA) launched the National MRSA Prevention Initiative in October 2007. The objective of this analysis was to quantify the budget impact and cost effectiveness of this initiative. METHODS An economic model was developed using published data on MRSA hospital-acquired infection (HAI) rates in the VA from October 2007 to September 2010; estimates of the costs of MRSA HAIs in the VA; and estimates of the intervention costs, including salaries of staff members hired to support the initiative at each VA facility. To estimate the rate of MRSA HAIs that would have occurred if the initiative had not been implemented, two different assumptions were made: no change and a downward temporal trend. Effectiveness was measured in life-years gained. RESULTS The initiative resulted in an estimated 1,466-2,176 fewer MRSA HAIs. The initiative itself was estimated to cost $207 million during this 3-year period, while the cost savings from prevented MRSA HAIs ranged from $27 million to $75 million. The incremental cost-effectiveness ratios ranged from $28,048 to $56,944/life-years. The overall impact on the VA's budget was $131-$179 million. CONCLUSIONS Wide-scale implementation of a national MRSA surveillance and prevention strategy in VA inpatient settings may have prevented a substantial number of MRSA HAIs. Although the savings associated with prevented infections helped offset some but not all of the cost of the initiative, this model indicated that the initiative would be considered cost effective.
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Affiliation(s)
- Richard E Nelson
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah.
| | - Vanessa W Stevens
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah
| | - Karim Khader
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Makoto Jones
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Matthew H Samore
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Martin E Evans
- Veterans Affairs Medical Center, Lexington, Kentucky; MRSA/MDRO Program, National Infectious Disease Service, Veterans Health Administration, Lexington, Kentucky; Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - R Douglas Scott
- Division of Healthcare Quality Promotion, CDC, Atlanta, Georgia
| | | | - Marin L Schweizer
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa; Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Eli L Perencevich
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa; Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Michael A Rubin
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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Edmiston CE, Ledeboer NA, Buchan BW, Spencer M, Seabrook GR, Leaper D. Is Staphylococcal Screening and Suppression an Effective Interventional Strategy for Reduction of Surgical Site Infection? Surg Infect (Larchmt) 2016; 17:158-66. [DOI: 10.1089/sur.2015.257] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Charles E. Edmiston
- Departments of Surgery (Vascular), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nathan A. Ledeboer
- Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Blake W. Buchan
- Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Gary R. Seabrook
- Departments of Surgery (Vascular), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Leaper
- Infection Prevention Consultants, Boston, Massachusetts
- Institute of Skin Integrity and Infection Prevention, University of Huddersfield, Huddersfield, United Kingdom
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The Impact of a Universal Decolonization Protocol on Hospital-Acquired Methicillin-Resistant Staphylococcus aureus in a Burn Population. J Burn Care Res 2016; 37:e525-e530. [DOI: 10.1097/bcr.0000000000000301] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Response to McKinnell et al's original article "cost-benefit analysis from the hospital perspective of universal active screening followed by contact precautions for methicillin-resistant Staphylococcus aureus carriers". Infect Control Hosp Epidemiol 2015; 36:856-7. [PMID: 26081998 DOI: 10.1017/ice.2015.111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Lee AS, Pan A, Harbarth S, Patroni A, Chalfine A, Daikos GL, Garilli S, Martínez JA, Cooper BS. Variable performance of models for predicting methicillin-resistant Staphylococcus aureus carriage in European surgical wards. BMC Infect Dis 2015; 15:105. [PMID: 25880328 PMCID: PMC4347652 DOI: 10.1186/s12879-015-0834-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 02/12/2015] [Indexed: 11/10/2022] Open
Abstract
Background Predictive models to identify unknown methicillin-resistant Staphylococcus aureus (MRSA) carriage on admission may optimise targeted MRSA screening and efficient use of resources. However, common approaches to model selection can result in overconfident estimates and poor predictive performance. We aimed to compare the performance of various models to predict previously unknown MRSA carriage on admission to surgical wards. Methods The study analysed data collected during a prospective cohort study which enrolled consecutive adult patients admitted to 13 surgical wards in 4 European hospitals. The participating hospitals were located in Athens (Greece), Barcelona (Spain), Cremona (Italy) and Paris (France). Universal admission MRSA screening was performed in the surgical wards. Data regarding demographic characteristics and potential risk factors for MRSA carriage were prospectively collected during the study period. Four logistic regression models were used to predict probabilities of unknown MRSA carriage using risk factor data: “Stepwise” (variables selected by backward elimination); “Best BMA” (model with highest posterior probability using Bayesian model averaging which accounts for uncertainty in model choice); “BMA” (average of all models selected with BMA); and “Simple” (model including variables selected >50% of the time by both Stepwise and BMA approaches applied to repeated random sub-samples of 50% of the data). To assess model performance, cross-validation against data not used for model fitting was conducted and net reclassification improvement (NRI) was calculated. Results Of 2,901 patients enrolled, 111 (3.8%) were newly identified MRSA carriers. Recent hospitalisation and presence of a wound/ulcer were significantly associated with MRSA carriage in all models. While all models demonstrated limited predictive ability (mean c-statistics <0.7) the Simple model consistently detected more MRSA-positive individuals despite screening fewer patients than the Stepwise model. Moreover, the Simple model improved reclassification of patients into appropriate risk strata compared with the Stepwise model (NRI 6.6%, P = .07). Conclusions Though commonly used, models developed using stepwise variable selection can have relatively poor predictive value. When developing MRSA risk indices, simpler models, which account for uncertainty in model selection, may better stratify patients’ risk of unknown MRSA carriage.
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Affiliation(s)
- Andie S Lee
- Infection Control Program, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland. .,Departments of Infectious Diseases and Microbiology, Royal Prince Alfred Hospital, Sydney, Australia.
| | - Angelo Pan
- Infectious and Tropical Diseases Unit, Istituti Ospitalieri di Cremona, Cremona, Italy.
| | - Stephan Harbarth
- Infection Control Program, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | | | - Annie Chalfine
- Infection Control Unit, Groupe Hospitalier Paris Saint-Joseph, Paris, France.
| | - George L Daikos
- First Department of Propaedeutic Medicine, Laiko General Hospital, Athens, Greece.
| | - Silvia Garilli
- Infectious and Tropical Diseases Unit, Istituti Ospitalieri di Cremona, Cremona, Italy.
| | | | - Ben S Cooper
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Clinical Vaccinology and Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
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Huang SS, Septimus E, Avery TR, Lee GM, Hickok J, Weinstein RA, Moody J, Hayden MK, Perlin JB, Platt R, Ray GT. Cost savings of universal decolonization to prevent intensive care unit infection: implications of the REDUCE MRSA trial. Infect Control Hosp Epidemiol 2014; 35 Suppl 3:S23-31. [PMID: 25222894 PMCID: PMC10920056 DOI: 10.1086/677819] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To estimate and compare the impact on healthcare costs of 3 alternative strategies for reducing bloodstream infections in the intensive care unit (ICU): methicillin-resistant Staphylococcus aureus (MRSA) nares screening and isolation, targeted decolonization (ie, screening, isolation, and decolonization of MRSA carriers or infections), and universal decolonization (ie, no screening and decolonization of all ICU patients). DESIGN Cost analysis using decision modeling. METHODS We developed a decision-analysis model to estimate the health care costs of targeted decolonization and universal decolonization strategies compared with a strategy of MRSA nares screening and isolation. Effectiveness estimates were derived from a recent randomized trial of the 3 strategies, and cost estimates were derived from the literature. RESULTS In the base case, universal decolonization was the dominant strategy and was estimated to have both lower intervention costs and lower total ICU costs than either screening and isolation or targeted decolonization. Compared with screening and isolation, universal decolonization was estimated to save $171,000 and prevent 9 additional bloodstream infections for every 1,000 ICU admissions. The dominance of universal decolonization persisted under a wide range of cost and effectiveness assumptions. CONCLUSIONS A strategy of universal decolonization for patients admitted to the ICU would both reduce bloodstream infections and likely reduce healthcare costs compared with strategies of MRSA nares screening and isolation or screening and isolation coupled with targeted decolonization.
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Affiliation(s)
- Susan S Huang
- Division of Infectious Diseases and Health Policy Research Institute, University of California Irvine School of Medicine, Orange, California
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May L, McCann C, Brooks G, Rothman R, Miller L, Jordan J. Dual-site sampling improved detection rates for MRSA colonization in patients with cutaneous abscesses. Diagn Microbiol Infect Dis 2014; 80:79-82. [PMID: 24958641 DOI: 10.1016/j.diagmicrobio.2014.05.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 04/29/2014] [Accepted: 05/03/2014] [Indexed: 10/25/2022]
Abstract
Extranasal sites are common reservoirs of Staphylococcus aureus colonization and may be relevant for methicillin-resistant S. aureus (MRSA) screening and infection control strategies. The objective here was to determine whether inguinal specimens could also be screened using Xpert SA Nasal Complete assay for MRSA. Results were compared to broth enrichment culture. Among 162 consented adults seeking care in the emergency department for cutaneous abscesses, inguinal specimens were found positive for MRSA more often than nares specimens, 24% and 26% by PCR or culture, respectively, compared to 19% each by PCR or culture. Overall, 6% of adults colonized with MRSA would have been missed by nares screening alone. Compared to culture, Xpert SA Nasal Complete assay demonstrated sensitivity and specificity of 89% and 97%, respectively, for detecting nares and/or inguinal MRSA colonization. In conclusion, inguinal specimens were a more common reservoir for MRSA than nares specimens in this population of patients.
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Affiliation(s)
- L May
- Department of Emergency Medicine, The George Washington University Medical Faculty Associates, Washington, DC; Department of Epidemiology and Biostatistics, School of Public Health and Health Services, The George Washington University, Washington, DC.
| | - C McCann
- Department of Epidemiology and Biostatistics, School of Public Health and Health Services, The George Washington University, Washington, DC
| | - G Brooks
- Department of Emergency Medicine, The George Washington University Medical Faculty Associates, Washington, DC; Department of Epidemiology and Biostatistics, School of Public Health and Health Services, The George Washington University, Washington, DC
| | - R Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD
| | - L Miller
- Infectious Disease Clinical Outcomes Research Unit, Division of Infectious Disease, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, CA
| | - J Jordan
- Department of Epidemiology and Biostatistics, School of Public Health and Health Services, The George Washington University, Washington, DC
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Shitrit P, Reisfeld S, Paitan Y, Gottesman BS, Katzir M, Paul M, Chowers M. Extended-spectrum beta-lactamase-producing Enterobacteriaceae carriage upon hospital admission: prevalence and risk factors. J Hosp Infect 2013; 85:230-2. [DOI: 10.1016/j.jhin.2013.07.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 07/11/2013] [Indexed: 11/28/2022]
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Gurusamy KS, Koti R, Wilson P, Davidson BR. Antibiotic prophylaxis for the prevention of methicillin-resistant Staphylococcus aureus (MRSA) related complications in surgical patients. Cochrane Database Syst Rev 2013; 2013:CD010268. [PMID: 23959704 PMCID: PMC11299148 DOI: 10.1002/14651858.cd010268.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Risk of methicillin-resistant Staphylococcus aureus (MRSA) infection after surgery is generally low, but affects up to 33% of patients after certain types of surgery. Postoperative MRSA infection can occur as surgical site infections (SSIs), chest infections, or bloodstream infections (bacteraemia). The incidence of MRSA SSIs varies from 1% to 33% depending upon the type of surgery performed and the carrier status of the individuals concerned. The optimal prophylactic antibiotic regimen for the prevention of MRSA after surgery is not known. OBJECTIVES To compare the benefits and harms of all methods of antibiotic prophylaxis in the prevention of postoperative MRSA infection and related complications in people undergoing surgery. SEARCH METHODS In March 2013 we searched the following databases: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library); NHS Economic Evaluation Database (The Cochrane Library); Health Technology Assessment (HTA) Database (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. SELECTION CRITERIA We included only randomised controlled trials (RCTs) that compared one antibiotic regimen used as prophylaxis for SSIs (and other postoperative infections) with another antibiotic regimen or with no antibiotic, and that reported the methicillin resistance status of the cultured organisms. We did not limit our search for RCTs by language, publication status, publication year, or sample size. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion in the review, and extracted data. We calculated the risk ratio (RR) with 95% confidence intervals (CI) for comparing binary outcomes between the groups and planned to calculated the mean difference (MD) with 95% CI for comparing continuous outcomes. We planned to perform meta-analysis using both a fixed-effect model and a random-effects model. We performed intention-to-treat analysis whenever possible. MAIN RESULTS We included 12 RCTs, with 4704 participants, in this review. Eleven trials performed a total of 16 head-to-head comparisons of different prophylactic antibiotic regimens. Antibiotic prophylaxis was compared with no antibiotic prophylaxis in one trial. All the trials were at high risk of bias. With the exception of one trial in which all the participants were positive for nasal carriage of MRSA or had had previous MRSA infections, it does not appear that MRSA was tested or eradicated prior to surgery; nor does it appear that there was high prevalence of MRSA carrier status in the people undergoing surgery.There was no sufficient clinical similarity between the trials to perform a meta-analysis. The overall all-cause mortality in four trials that reported mortality was 14/1401 (1.0%) and there were no significant differences in mortality between the intervention and control groups in each of the individual comparisons. There were no antibiotic-related serious adverse events in any of the 561 people randomised to the seven different antibiotic regimens in four trials (three trials that reported mortality and one other trial). None of the trials reported quality of life, total length of hospital stay or the use of healthcare resources. Overall, 221/4032 (5.5%) people developed SSIs due to all organisms, and 46/4704 (1.0%) people developed SSIs due to MRSA.In the 15 comparisons that compared one antibiotic regimen with another, there were no significant differences in the proportion of people who developed SSIs. In the single trial that compared an antibiotic regimen with placebo, the proportion of people who developed SSIs was significantly lower in the group that received antibiotic prophylaxis with co-amoxiclav (or cefotaxime if allergic to penicillin) compared with placebo (all SSI: RR 0.26; 95% CI 0.11 to 0.65; MRSA SSI RR 0.05; 95% CI 0.00 to 0.83). In two trials that reported MRSA infections other than SSI, 19/478 (4.5%) people developed MRSA infections including SSI, chest infection and bacteraemia. There were no significant differences in the proportion of people who developed MRSA infections at any body site in these two comparisons. AUTHORS' CONCLUSIONS Prophylaxis with co-amoxiclav decreases the proportion of people developing MRSA infections compared with placebo in people without malignant disease undergoing percutaneous endoscopic gastrostomy insertion, although this may be due to decreasing overall infection thereby preventing wounds from becoming secondarily infected with MRSA. There is currently no other evidence to suggest that using a combination of multiple prophylactic antibiotics or administering prophylactic antibiotics for an increased duration is of benefit to people undergoing surgery in terms of reducing MRSA infections. Well designed RCTs assessing the clinical effectiveness of different antibiotic regimens are necessary on this topic.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
| | - Rahul Koti
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
| | - Peter Wilson
- University College London HospitalsDepartment of Microbiology & Virology60 Whitfield StreetLondonUKW1T 4EU
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
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Impact of intensive infection control team activities on the acquisition of methicillin-resistant Staphylococcus aureus, drug-resistant Pseudomonas aeruginosa and the incidence of Clostridium difficile-associated disease. J Infect Chemother 2013; 19:1047-52. [PMID: 23715827 DOI: 10.1007/s10156-013-0621-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 05/11/2013] [Indexed: 12/30/2022]
Abstract
The transmission of multidrug-resistant organisms (MDROs) is an emerging problem in acute healthcare facilities. To reduce this transmission, we introduced intensive infection control team (ICT) activities and investigated the impact of their introduction. This study was conducted at a single teaching hospital from 1 April 2010 to 31 March 2012. During the intervention period, all carbapenem use was monitored by the ICT, and doctors using carbapenems inappropriately were individually instructed. Information related to patients with newly identified MDROs was provided daily to the ICT and instructions on the appropriate infection control measures for MDROs were given immediately with continuous monitoring. The medical records of newly hospitalized patients were reviewed daily to check previous microbiological results and infection control intervention by the ICT was also performed for patients with a previous history of MDROs. Compared with the pre-intervention period, the antimicrobial usage density of carbapenems decreased significantly (28.5 vs. 17.8 defined daily doses/1000 inpatient days; p < 0.001) and the frequency of use of sanitary items, especially the use of aprons, increased significantly (710 vs 1854 pieces/1000 inpatient days; p < 0.001). The number of cases with hospital-acquired MRSA (0.66 vs. 0.29 cases/1000 inpatient days; p < 0.001), hospital-acquired drug-resistant Pseudomonas aeruginosa (0.23 vs. 0.06 cases/1000 inpatient days; p = 0.006) and nosocomial Clostridium difficile-associated disease (0.47 vs. 0.11 cases/1000 inpatient days; p < 0.001) decreased significantly during the intervention period. Our study showed that proactive and continuous ICT interventions were effective for reduction of MDRO transmission.
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Abstract
Recent evidence from publications describing the success of interventions to control hospital meticillin-resistant Staphylococcus aureus (MRSA), often in the endemic setting, is reviewed. Overall, there is cautious ground for optimism that MRSA can be controlled in a cost-effective manner by employing a bundle approach, the mainstay of which is widespread admission screening to inform patient-specific control measures.
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Affiliation(s)
- Ian M Gould
- Department of Medical Microbiology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK.
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Bearman G, Stevens MP. Control of Drug-Resistant Pathogens in Endemic Settings: Contact Precautions, Controversies, and a Proposal for a Less Restrictive Alternative. Curr Infect Dis Rep 2012; 14:620-6. [DOI: 10.1007/s11908-012-0299-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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