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Rankin DA, Walters MS, Caicedo L, Gable P, Moulton-Meissner HA, Chan A, Burks A, Edwards K, McAllister G, Kent A, Laufer Halpin A, Moore C, McLemore T, Thomas L, Dotson NQ, Chu AK. Concurrent transmission of multiple carbapenemases in a long-term acute-care hospital. Infect Control Hosp Epidemiol 2024; 45:292-301. [PMID: 38196201 PMCID: PMC10933503 DOI: 10.1017/ice.2023.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/12/2023] [Accepted: 09/21/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVE We investigated concurrent outbreaks of Pseudomonas aeruginosa carrying blaVIM (VIM-CRPA) and Enterobacterales carrying blaKPC (KPC-CRE) at a long-term acute-care hospital (LTACH A). METHODS We defined an incident case as the first detection of blaKPC or blaVIM from a patient's clinical cultures or colonization screening test. We reviewed medical records and performed infection control assessments, colonization screening, environmental sampling, and molecular characterization of carbapenemase-producing organisms from clinical and environmental sources by pulsed-field gel electrophoresis (PFGE) and whole-genome sequencing. RESULTS From July 2017 to December 2018, 76 incident cases were identified from 69 case patients: 51 had blaKPC, 11 had blaVIM, and 7 had blaVIM and blaKPC. Also, blaKPC were identified from 7 Enterobacterales, and all blaVIM were P. aeruginosa. We observed gaps in hand hygiene, and we recovered KPC-CRE and VIM-CRPA from drains and toilets. We identified 4 KPC alleles and 2 VIM alleles; 2 KPC alleles were located on plasmids that were identified across multiple Enterobacterales and in both clinical and environmental isolates. CONCLUSIONS Our response to a single patient colonized with VIM-CRPA and KPC-CRE identified concurrent CPO outbreaks at LTACH A. Epidemiologic and genomic investigations indicated that the observed diversity was due to a combination of multiple introductions of VIM-CRPA and KPC-CRE and to the transfer of carbapenemase genes across different bacteria species and strains. Improved infection control, including interventions that minimized potential spread from wastewater premise plumbing, stopped transmission.
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Affiliation(s)
- Danielle A. Rankin
- Florida Department of Health in Orange County, Orlando, Florida
- Bureau of Epidemiology, Florida Department of Health, Tallahassee, Florida
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Maroya Spalding Walters
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Luz Caicedo
- Florida Department of Health in Orange County, Orlando, Florida
| | - Paige Gable
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Allison Chan
- Division of Laboratory Services, Tennessee Department of Health, Nashville, Tennessee
| | - Albert Burks
- Division of Laboratory Services, Tennessee Department of Health, Nashville, Tennessee
| | - Kendra Edwards
- Bureau of Epidemiology, Florida Department of Health, Tallahassee, Florida
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gillian McAllister
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alyssa Kent
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alison Laufer Halpin
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Christina Moore
- Division of Laboratory Services, Tennessee Department of Health, Nashville, Tennessee
| | - Tracy McLemore
- Division of Laboratory Services, Tennessee Department of Health, Nashville, Tennessee
| | - Linda Thomas
- Division of Laboratory Services, Tennessee Department of Health, Nashville, Tennessee
| | - Nychie Q. Dotson
- Bureau of Epidemiology, Florida Department of Health, Tallahassee, Florida
- HCA Healthcare, Nashville, Tennessee
| | - Alvina K. Chu
- Florida Department of Health in Orange County, Orlando, Florida
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Cincotta SE, Walters MS, Ham DC, Octaria R, Healy JM, Slayton RB, Paul P. Regional impact of multidrug-resistant organism prevention bundles implemented by facility type: A modeling study. Infect Control Hosp Epidemiol 2024:1-8. [PMID: 38415308 DOI: 10.1017/ice.2023.278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
BACKGROUND Emerging multidrug-resistant organisms (MDROs), such as carbapenem-resistant Enterobacterales (CRE), can spread rapidly in a region. Facilities that care for high-acuity patients with longer stays may have a disproportionate impact on this spread. OBJECTIVE We assessed the impact of implementing preventive interventions, directed at a subset of facilities, on regional prevalence. METHODS We developed a deterministic compartmental model, parametrized using CRE and patient transfer data. The model included the community and healthcare facilities within a US state. Individuals may be either susceptible or infectious with CRE. Individuals determined to be infectious through admission screening, periodic prevalence surveys (PPSs), or interfacility communication were placed in a state of lower transmissibility if enhanced infection prevention and control (IPC) practices were in place at a facility. RESULTS Intervention bundles that included PPS and enhanced IPC practices at ventilator-capable skilled nursing facilities (vSNFs) and long-term acute-care hospitals (LTACHs) had the greatest impact on regional prevalence. The benefits of including targeted admission screening in acute-care hospitals, LTACHs, and vSNFs, and improved interfacility communication were more modest. Daily transmissions in each facility type were reduced following the implementation of interventions primarily focused at LTACHs and vSNFs. CONCLUSIONS Our model suggests that interventions that include screening to limit unrecognized MDRO introduction to, or dispersal from, LTACHs and vSNFs slow regional spread. Interventions that pair detection and enhanced IPC practices within LTACHs and vSNFs may substantially reduce the regional burden.
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Affiliation(s)
- Samuel E Cincotta
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Maroya S Walters
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - D Cal Ham
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rany Octaria
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jessica M Healy
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rachel B Slayton
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Prabasaj Paul
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Robin TT, Cascante-Vega J, Shaman J, Pei S. System identifiability in a time-evolving agent-based model. PLoS One 2024; 19:e0290821. [PMID: 38271401 PMCID: PMC10810497 DOI: 10.1371/journal.pone.0290821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 08/16/2023] [Indexed: 01/27/2024] Open
Abstract
Mathematical models are a valuable tool for studying and predicting the spread of infectious agents. The accuracy of model simulations and predictions invariably depends on the specification of model parameters. Estimation of these parameters is therefore extremely important; however, while some parameters can be derived from observational studies, the values of others are difficult to measure. Instead, models can be coupled with inference algorithms (i.e., data assimilation methods, or statistical filters), which fit model simulations to existing observations and estimate unobserved model state variables and parameters. Ideally, these inference algorithms should find the best fitting solution for a given model and set of observations; however, as those estimated quantities are unobserved, it is typically uncertain whether the correct parameters have been identified. Further, it is unclear what 'correct' really means for abstract parameters defined based on specific model forms. In this work, we explored the problem of non-identifiability in a stochastic system which, when overlooked, can significantly impede model prediction. We used a network, agent-based model to simulate the transmission of Methicillin-resistant staphylococcus aureus (MRSA) within hospital settings and attempted to infer key model parameters using the Ensemble Adjustment Kalman Filter, an efficient Bayesian inference algorithm. We show that even though the inference method converged and that simulations using the estimated parameters produced an agreement with observations, the true parameters are not fully identifiable. While the model-inference system can exclude a substantial area of parameter space that is unlikely to contain the true parameters, the estimated parameter range still included multiple parameter combinations that can fit observations equally well. We show that analyzing synthetic trajectories can support or contradict claims of identifiability. While we perform this on a specific model system, this approach can be generalized for a variety of stochastic representations of partially observable systems. We also suggest data manipulations intended to improve identifiability that might be applicable in many systems of interest.
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Affiliation(s)
- Tal T. Robin
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Jaime Cascante-Vega
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Jeffrey Shaman
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY, United States of America
- Columbia Climate School, Columbia University, New York, NY, United States of America
| | - Sen Pei
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY, United States of America
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4
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Pople D, Kypraios T, Donker T, Stoesser N, Seale AC, George R, Dodgson A, Freeman R, Hope R, Walker AS, Hopkins S, Robotham J. Model-based evaluation of admission screening strategies for the detection and control of carbapenemase-producing Enterobacterales in the English hospital setting. BMC Med 2023; 21:492. [PMID: 38087343 PMCID: PMC10717398 DOI: 10.1186/s12916-023-03007-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/27/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Globally, detections of carbapenemase-producing Enterobacterales (CPE) colonisations and infections are increasing. The spread of these highly resistant bacteria poses a serious threat to public health. However, understanding of CPE transmission and evidence on effectiveness of control measures is severely lacking. This paper provides evidence to inform effective admission screening protocols, which could be important in controlling nosocomial CPE transmission. METHODS CPE transmission within an English hospital setting was simulated with a data-driven individual-based mathematical model. This model was used to evaluate the ability of the 2016 England CPE screening recommendations, and of potential alternative protocols, to identify patients with CPE-colonisation on admission (including those colonised during previous stays or from elsewhere). The model included nosocomial transmission from colonised and infected patients, as well as environmental contamination. Model parameters were estimated using primary data where possible, including estimation of transmission using detailed epidemiological data within a Bayesian framework. Separate models were parameterised to represent hospitals in English areas with low and high CPE risk (based on prevalence). RESULTS The proportion of truly colonised admissions which met the 2016 screening criteria was 43% in low-prevalence and 54% in high-prevalence areas respectively. Selection of CPE carriers for screening was improved in low-prevalence areas by adding readmission as a screening criterion, which doubled how many colonised admissions were selected. A minority of CPE carriers were confirmed as CPE positive during their hospital stay (10 and 14% in low- and high-prevalence areas); switching to a faster screening test pathway with a single-swab test (rather than three swab regimen) increased the overall positive predictive value with negligible reduction in negative predictive value. CONCLUSIONS Using a novel within-hospital CPE transmission model, this study assesses CPE admission screening protocols, across the range of CPE prevalence observed in England. It identifies protocol changes-adding readmissions to screening criteria and a single-swab test pathway-which could detect similar numbers of CPE carriers (or twice as many in low CPE prevalence areas), but faster, and hence with lower demand on pre-emptive infection-control resources. Study findings can inform interventions to control this emerging threat, although further work is required to understand within-hospital transmission sources.
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Affiliation(s)
- Diane Pople
- HCAI, Fungal, AMR, AMU & Sepsis Division, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK.
| | - Theodore Kypraios
- School of Mathematical Sciences, University Park, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Tjibbe Donker
- University Medical Center Freiburg, Institute for Infection Prevention and Hospital Epidemiology, Breisacher Strasse, 79106, Freiburg im Breisgau, Germany
| | - Nicole Stoesser
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- NIHR Health Protection Research Unit in Antimicrobial Resistance and Healthcare Associated Infections, University of Oxford and UKHSA, Oxford, UK
| | - Anna C Seale
- University of Warwick, Warwick, UK
- London School of Hygiene & Tropical Medicine, London, UK
- UK Health Security Agency, London, UK
| | - Ryan George
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Andrew Dodgson
- UK Health Security Agency, Manchester Public Health Laboratory, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Rachel Freeman
- IQVIA, The Point, 37 North Wharf Road, London, W2 1AF, UK
| | - Russell Hope
- HCAI, Fungal, AMR, AMU & Sepsis Division, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Ann Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Susan Hopkins
- NIHR Health Protection Research Unit in Antimicrobial Resistance and Healthcare Associated Infections, University of Oxford and UKHSA, Oxford, UK
- UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
- Division of Infection and Immunity, UCL, Gower St, London, UK
| | - Julie Robotham
- HCAI, Fungal, AMR, AMU & Sepsis Division, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
- NIHR Health Protection Research Unit in Antimicrobial Resistance and Healthcare Associated Infections, University of Oxford and UKHSA, Oxford, UK
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Lapp Z, Octaria R, O’Malley SM, Nguyen TN, Wolford H, Crawford R, Moore C, Snippes Vagnone P, Noel D, Duffy N, Pirani A, Thomas LS, Pattee B, Pearson C, Bulens SN, Hoffman S, Kainer M, Anacker M, Meek J, See I, Gontjes KJ, Chan A, Lynfield R, Maloney M, Hayden MK, Snitkin E, Slayton RB. Distinct Origins and Transmission Pathways of blaKPC Enterobacterales across Three U.S. States. J Clin Microbiol 2023; 61:e0025923. [PMID: 37439675 PMCID: PMC10446861 DOI: 10.1128/jcm.00259-23] [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: 03/06/2023] [Accepted: 06/27/2023] [Indexed: 07/14/2023] Open
Abstract
Carbapenem-resistant Enterobacterales (CRE) are among the most concerning antibiotic resistance threats due to high rates of multidrug resistance, transmissibility in health care settings, and high mortality rates. We evaluated the potential for regional genomic surveillance to track the spread of blaKPC-carrying CRE (KPC-CRE) by using isolate collections from health care facilities in three U.S. states. Clinical isolates were collected from Connecticut (2017 to 2018), Minnesota (2012 to 2018), and Tennessee (2016 to 2017) through the U.S. Centers for Disease Control and Prevention's Multi-site Gram-negative Surveillance Initiative (MuGSI) and additional surveillance. KPC-CRE isolates were whole-genome sequenced, yielding 255 isolates from 214 patients across 96 facilities. Case report data on patient comorbidities, facility exposures, and interfacility patient transfer were extracted. We observed that in Connecticut, most KPC-CRE isolates showed evidence of importation from outside the state, with limited local transmission. In Minnesota, cases were mainly from sporadic importation and transmission of blaKPC-carrying Klebsiella pneumoniae ST258, and clonal expansion of blaKPC-carrying Enterobacter hormaechei ST171, primarily at a single focal facility and its satellite facilities. In Tennessee, we observed transmission of diverse strains of blaKPC-carrying Enterobacter and Klesbiella, with evidence that most derived from the local acquisition of blaKPC plasmids circulating in an interconnected regional health care network. Thus, the underlying processes driving KPC-CRE burden can differ substantially across regions and can be discerned through regional genomic surveillance. This study provides proof of concept that integrating genomic data with information on interfacility patient transfers can provide insights into locations and drivers of regional KPC-CRE burden that can enable targeted interventions.
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Affiliation(s)
- Zena Lapp
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA
| | - Rany Octaria
- Department of Medicine, Division of Epidemiology, Vanderbilt University, Nashville, Tennessee, USA
- Tennessee Department of Health, Nashville, Tennessee, USA
| | | | - Tu Ngoc Nguyen
- Connecticut Department of Public Health, Hartford, Connecticut, USA
| | - Hannah Wolford
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ryan Crawford
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA
| | | | | | - Diane Noel
- Connecticut Department of Public Health, Hartford, Connecticut, USA
| | - Nadezhda Duffy
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ali Pirani
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
| | | | | | - Claire Pearson
- Connecticut Department of Public Health, Hartford, Connecticut, USA
| | - Sandra N. Bulens
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sophie Hoffman
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA
| | - Marion Kainer
- Tennessee Department of Health, Nashville, Tennessee, USA
| | | | - James Meek
- Connecticut Emerging Infections Program, Yale School of Public Health, New Haven, Connecticut, USA
| | - Isaac See
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kyle J. Gontjes
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
| | - Allison Chan
- Tennessee Department of Health, Nashville, Tennessee, USA
| | - Ruth Lynfield
- Minnesota Department of Health, Saint Paul, Minnesota, USA
| | - Meghan Maloney
- Connecticut Department of Public Health, Hartford, Connecticut, USA
| | - Mary K. Hayden
- Department of Medicine, Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois, USA
- Department of Pathology, Rush University Medical Center, Chicago, Illinois, USA
| | - Evan Snitkin
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
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Wang F, Zou X, Zhou B, Yin T, Wang P. Clinical characteristics of carbapenem-resistant Klebsiella pneumoniae infection/colonisation in the intensive care unit: a 9-year retrospective study. BMJ Open 2023; 13:e065786. [PMID: 37308270 DOI: 10.1136/bmjopen-2022-065786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Abstract
OBJECTIVES Carbapenem-resistant Klebsiella pneumoniae (CRKP) infection/colonisation has been reported in hospitals. The clinical characteristics of CRKP infection/colonisation in the intensive care unit (ICU) have received little attention. This study aims to investigate the epidemiology and extent of K. pneumoniae (KP) resistance to carbapenems, the sources of CRKP patients and CRKP isolates, and the risk factors for CRKP infection/colonisation. DESIGN Retrospective single-centre study. DATA SOURCE Clinical data were obtained from electronic medical records. PARTICIPANTS Patients isolated with KP in the ICU from January 2012 to December 2020. MAIN OUTCOME MEASURES The prevalence and changing trend of CRKP were determined. The extent of KP isolates resistance to carbapenems, the specimen types of KP isolates, and the sources of CRKP patients and CRKP isolates were all examined. The risk factors for CRKP infection/colonisation were also assessed. RESULTS The rate of CRKP in KP isolates raised from 11.11% in 2012 to 48.92% in 2020. CRKP isolates were detected in one site in 266 patients (70.56%). The percentage of CRKP isolates not susceptible to imipenem increased from 42.86% in 2012 to 98.53% in 2020. The percentage of CRKP patients from general wards in our hospital and other hospitals gradually converged in 2020 (47.06% vs 52.94%). CRKP isolates were mainly acquired in our ICU (59.68%). Younger age (p=0.018), previous admission (p=0.018), previous ICU stay (p=0.008), prior use of surgical drainage (p=0.012) and gastric tube (p=0.001), and use of carbapenems (p=0.000), tigecycline (p=0.005), β-lactams/β-lactamase inhibitors (p=0.000), fluoroquinolones (p=0.033), and antifungal drugs (p=0.011) within the prior 3 months were independent risk factors for CRKP infection/colonisation. CONCLUSIONS Overall, the rate of KP isolates resistance to carbapenems increased, and the severity of this resistance significantly increased. Intensive and local infection/colonisation control measures are necessary for ICU patients, especially those with risk factors for CRKP infection/colonisation.
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Affiliation(s)
- Fei Wang
- Department of Pharmacy, Xiangya Hospital Central South University, Changsha, China
- Department of Pharmacy, Yantai Yuhuangding Hospital, Yantai, China
| | - Xiaocui Zou
- Department of Pharmacy, Xiangya Hospital Central South University, Changsha, China
| | - Boting Zhou
- Department of Pharmacy, Xiangya Hospital Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital Central South University, Changsha, China
| | - Tao Yin
- Department of Pharmacy, Xiangya Hospital Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital Central South University, Changsha, China
| | - Ping Wang
- Department of Pharmacy, Xiangya Hospital Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital Central South University, Changsha, China
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Azzini AM, Be G, Naso L, Lambertenghi L, Salerno ND, Coledan I, Bazaj A, Mirandola M, Miotti J, Mazzaferri F, Accordini S, Lo Cascio G, Tacconelli E. Risk factors for colonization with multidrug-resistant Gram-negative bacteria and Clostridioides difficile in Long Term Care Facilities (LTCFs) residents: the evidence from 27 facilities in a high endemic setting. Front Cell Infect Microbiol 2023; 13:1155320. [PMID: 37377644 PMCID: PMC10292821 DOI: 10.3389/fcimb.2023.1155320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/19/2023] [Indexed: 06/29/2023] Open
Abstract
Introduction Residency in LTCFs increases the likelihood of colonization with multidrug resistant Gram-negative bacteria (MDR-GNB). We assessed the prevalence and risk factors for enteric colonization by III-generation cephalosporins-resistant and carbapenem-resistant (CR) GNB in a large group of LTCFs in a high endemic setting. We also assessed the prevalence and risk factors for C. difficile colonization. Methods A point prevalence survey with rectal screening (RS) was conducted in 27 LTCFs in north Italy. Epidemiological and clinical variables on the survey day, history of hospitalization and surgery within one year, and antibiotics within three months, were collected. The presence of III-generation cephalosporin resistant and CR GNB was assessed using a selective culture on chromogenic medium and PCR for carbapenemase detection. The presence of C. difficile was assessed using ELISA for GDH and RT-PCR to identify toxigenic strains. Multi-variable analyses were performed using two-level logistic regression models. Results In the study period 1947 RSs were performed. The prevalence of colonization by at least one GNB resistant to III-generation cephalosporin was 51% (E. coli 65%, K. pneumoniae 14% of isolates). The prevalence of colonization by CR GNB was 6%. 6% of all isolates (1150 strains) resulted in a carbapenem-resistant K. pneumoniae, and 3% in a carbapenem-resistant E. coli. KPC was the most frequent carbapenemase (73%) identified by PCR, followed by VIM (23%). The prevalence of colonization by C. difficile was 11.7%. The presence of a medical device (OR 2.67) and previous antibiotic use (OR 1.48) were significantly associated with III-generation cephalosporin resistant GNB colonization. The presence of a medical device (OR 2.67) and previous hospitalization (OR 1.80) were significantly associated with CR GNB. The presence of a medical device (OR 2.30) was significantly associated with C. difficile colonization. Main previously used antibiotic classes were fluoroquinolones (32% of previously treated subjects), III-generation cephalosporins (21%), and penicillins (19%). Conclusion Antimicrobial stewardship in LTCFs is a critical issue, being previous antibiotic treatment a risk factor for colonization by MDR-GNB. The prevalence of colonization by III-generation cephalosporin and CR GNB among LTCF residents also underlines the importance to adhere to hand hygiene indications, infection prevention and control measures, and environmental hygiene protocols, more achievable than rigorous contact precautions in this type of social setting.
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Affiliation(s)
- Anna Maria Azzini
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Giorgia Be
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
- Infectious Disease Unit, Mater Salutis Hospital - ULSS 9 Scaligera, Legnago, Italy
| | - Laura Naso
- Microbiology and Virology Unit, AOUI Verona, Verona, Italy
| | - Lorenza Lambertenghi
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Nicola Duccio Salerno
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Ilaria Coledan
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
- SerT Suzzara, SC Ser.D. Mantova, ASST Mantova, Suzzara, Italy
| | - Alda Bazaj
- Microbiology Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Massimo Mirandola
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Jessica Miotti
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Fulvia Mazzaferri
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Simone Accordini
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Giuliana Lo Cascio
- Microbiology and Virology Unit, AOUI Verona, Verona, Italy
- Microbiology Unit, AUSL Piacenza, Piacenza, Italy
| | - Evelina Tacconelli
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
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Pei S, Blumberg S, Vega JC, Robin T, Zhang Y, Medford RJ, Adhikari B, Shaman J. Challenges in Forecasting Antimicrobial Resistance. Emerg Infect Dis 2023; 29:679-685. [PMID: 36958029 PMCID: PMC10045679 DOI: 10.3201/eid2904.221552] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
Antimicrobial resistance is a major threat to human health. Since the 2000s, computational tools for predicting infectious diseases have been greatly advanced; however, efforts to develop real-time forecasting models for antimicrobial-resistant organisms (AMROs) have been absent. In this perspective, we discuss the utility of AMRO forecasting at different scales, highlight the challenges in this field, and suggest future research priorities. We also discuss challenges in scientific understanding, access to high-quality data, model calibration, and implementation and evaluation of forecasting models. We further highlight the need to initiate research on AMRO forecasting using currently available data and resources to galvanize the research community and address initial practical questions.
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Epidemiology and molecular characterization of fecal carriage of third-generation cephalosporin-resistant enterobacterales among elderly residents in Japan. J Infect Chemother 2022; 28:569-575. [PMID: 35039227 DOI: 10.1016/j.jiac.2021.12.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/16/2021] [Accepted: 12/29/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The spread of third-generation cephalosporin-resistant Gram-negative bacteria is a serious concern in acute and post-acute care settings. This study aimed to understand the epidemiology and molecular background of fecal colonization of resistant Enterobacterales in elderly people. METHODS In December 2015-December 2017, stool or rectal swab samples were collected from 101 elderly patients receiving home care, using long-term care facilities (LTCF), and living in nursing homes repeatedly at 3-9-month intervals. Patient clinical background data were collected from medical records. After phenotypic screening for extended-spectrum β-lactamase (ESBL), AmpC-type β-lactamase or carbapenemase production, drug resistance genes of isolates were analyzed using polymerase chain reaction (PCR). ESBL-producing Escherichia coli isolates obtained from the same patients in repetitive screenings were analyzed using PCR-based ORF typing. Risk factors for persistent carriage of resistant Enterobacterales were analyzed using multivariate analysis. RESULTS Resistant Enterobacterales isolates were detected in 37 of 101 (36.6%) and 29 of 80 (36.3%) residents in first and second screenings, respectively. ESBL-producing E. coli accounted for 80% isolates, the most common being CTX-M-9-group β-lactamase producers. Molecular epidemiological analysis revealed probable transmissions of ESBL-producing E. coli; 58% of ESBL-producing E. coli colonizers were persistent colonizers at least after 3 -month intervals. Age > 87 years and LTCF residence were independent risk factors for persistent carriage of ESBL-producing E. coli. CONCLUSIONS We showed, for the first time, high persistent colonization rate of ESBL-producing E. coli among elderly people in post-acute care settings with probable horizontal transmission. We also identified significant risk factors for persistent colonization.
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10
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Pei S, Liljeros F, Shaman J. Identifying asymptomatic spreaders of antimicrobial-resistant pathogens in hospital settings. Proc Natl Acad Sci U S A 2021; 118:e2111190118. [PMID: 34493678 PMCID: PMC8449327 DOI: 10.1073/pnas.2111190118] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/03/2021] [Indexed: 12/14/2022] Open
Abstract
Antimicrobial-resistant organisms (AMROs) can colonize people without symptoms for long periods of time, during which these agents can spread unnoticed to other patients in healthcare systems. The accurate identification of asymptomatic spreaders of AMRO in hospital settings is essential for supporting the design of interventions against healthcare-associated infections (HAIs). However, this task remains challenging because of limited observations of colonization and the complicated transmission dynamics occurring within hospitals and the broader community. Here, we study the transmission of methicillin-resistant Staphylococcus aureus (MRSA), a prevalent AMRO, in 66 Swedish hospitals and healthcare facilities with inpatients using a data-driven, agent-based model informed by deidentified real-world hospitalization records. Combining the transmission model, patient-to-patient contact networks, and sparse observations of colonization, we develop and validate an individual-level inference approach that estimates the colonization probability of individual hospitalized patients. For both model-simulated and historical outbreaks, the proposed method supports the more accurate identification of asymptomatic MRSA carriers than other traditional approaches. In addition, in silica control experiments indicate that interventions targeted to inpatients with a high-colonization probability outperform heuristic strategies informed by hospitalization history and contact tracing.
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Affiliation(s)
- Sen Pei
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY 10027;
| | - Fredrik Liljeros
- Department of Sociology, Stockholm University, 114 19 Stockholm, Sweden
- Department of Public Health Sciences, Karolinska Institutet, 171 77 Solna, Sweden
| | - Jeffrey Shaman
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY 10027;
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11
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Epidemiology and Transmission of Carbapenemase-Producing Enterobacteriaceae in a Health Care Network of an Acute-Care Hospital and Its Affiliated Intermediate- and Long-Term-Care Facilities in Singapore. Antimicrob Agents Chemother 2021; 65:e0258420. [PMID: 34001509 PMCID: PMC8284465 DOI: 10.1128/aac.02584-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Movement of patients in a health care network poses challenges for the control of carbapenemase-producing Enterobacteriaceae (CPE). We aimed to identify intra- and interfacility transmission events and facility type-specific risk factors of CPE in an acute-care hospital (ACH) and its intermediate-term and long-term-care facilities (ILTCFs). Serial cross-sectional studies were conducted in June and July of 2014 to 2016 to screen for CPE. Whole-genome sequencing was done to identify strain relatedness and CPE genes (blaIMI, blaIMP-1, blaKPC-2, blaNDM-1, and blaOXA-48). Multivariable logistic regression models, stratified by facility type, were used to determine independent risk factors. Of 5,357 patients, half (55%) were from the ACH. CPE prevalence was 1.3% in the ACH and 0.7% in ILTCFs (P = 0.029). After adjusting for sociodemographics, screening year, and facility type, the odds of CPE colonization increased significantly with a hospital stay of ≥3 weeks (adjusted odds ratio [aOR], 2.67; 95% confidence interval [CI], 1.17 to 6.05), penicillin use (aOR, 3.00; 95% CI, 1.05 to 8.56), proton pump inhibitor use (aOR, 3.20; 95% CI, 1.05 to 9.80), dementia (aOR, 3.42; 95% CI, 1.38 to 8.49), connective tissue disease (aOR, 5.10; 95% CI, 1.19 to 21.81), and prior carbapenem-resistant Enterobacteriaceae (CRE) carriage (aOR, 109.02; 95% CI, 28.47 to 417.44) in the ACH. For ILTCFs, presence of wounds (aOR, 5.30; 95% CI, 1.01 to 27.72), respiratory procedures (aOR, 4.97; 95% CI, 1.09 to 22.71), vancomycin-resistant enterococcus carriage (aOR, 16.42; 95% CI, 1.52 to 177.48), and CRE carriage (aOR, 758.30; 95% CI, 33.86 to 16,982.52) showed significant association. Genomic analysis revealed only possible intra-ACH transmission and no evidence for ACH-to-ILTCF transmission. Although CPE colonization was predominantly in the ACH, risk factors varied between facilities. Targeted screening and precautionary measures are warranted.
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12
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Dai Y, Meng T, Wang X, Tang B, Wang F, Du Y, Qiu Y, Liu J, Tan R, Qu H. Validation and Extrapolation of a Multimodal Infection Prevention and Control Intervention on Carbapenem-Resistant Klebsiella pneumoniae in an Epidemic Region: A Historical Control Quasi-Experimental Study. Front Med (Lausanne) 2021; 8:692813. [PMID: 34307419 PMCID: PMC8292674 DOI: 10.3389/fmed.2021.692813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/11/2021] [Indexed: 11/25/2022] Open
Abstract
Objective: To verify the effects of comprehensive infection prevention and control (IPC) interventions for the prevention of the cross-transmission of carbapenem-resistant Klebsiella pneumoniae (CRKP) within intensive care units (ICUs) in an epidemic region. Methods: A historical control, quasi-experimental design was performed. The study was conducted between January 2017 and December 2019, following the implementation of a multimodal IPC bundle. The baseline period was established from January 2013 to June 2013, when only basic IPC measures were applied. Results: A total of 748 patients were enrolled during the entire study. The incidence of ICU-acquired CRKP colonization/infection was 1.16 per 1,000 patient-days during the intervention period, compared with 10.19 per 1,000 patient-days during the baseline period (p = 0.002). The slope of the monthly incidence of CRKP at admission showed an increasing trend (p = 0.03). The incidence of ICU-acquired catheter-related bloodstream infections caused by CRKP decreased from 2.54 to 0.96 per 1,000 central-line-days (p = 0.08). Compliance with contact precautions and terminal room disinfection improved during the intervention period. All environmental surface culture samples acquired after terminal room disinfection were negative for CRKP. Conclusion: Our findings suggest that in epidemic settings, multimodal IPC intervention strategies and consistent monitoring of compliance, may limit the spread of CRKP in ICUs.
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Affiliation(s)
- Yunqi Dai
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Tianjiao Meng
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaoli Wang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Bin Tang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Feng Wang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ying Du
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yuzhen Qiu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jialin Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ruoming Tan
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hongping Qu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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13
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Chen HY, Jean SS, Lee YL, Lu MC, Ko WC, Liu PY, Hsueh PR. Carbapenem-Resistant Enterobacterales in Long-Term Care Facilities: A Global and Narrative Review. Front Cell Infect Microbiol 2021; 11:601968. [PMID: 33968793 PMCID: PMC8102866 DOI: 10.3389/fcimb.2021.601968] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 04/06/2021] [Indexed: 01/15/2023] Open
Abstract
The emergence of carbapenem-resistant Enterobacterales (CRE) has become a major public health concern. Moreover, its colonization among residents of long-term care facilities (LTCFs) is associated with subsequent infections and mortality. To further explore the various aspects concerning CRE in LTCFs, we conducted a literature review on CRE colonization and/or infections in long-term care facilities. The prevalence and incidence of CRE acquisition among residents of LTCFs, especially in California, central Italy, Spain, Japan, and Taiwan, were determined. There was a significant predominance of CRE in LTCFs, especially in high-acuity LTCFs with mechanical ventilation, and thus may serve as outbreak centers. The prevalence rate of CRE in LTCFs was significantly higher than that in acute care settings and the community, which indicated that LTCFs are a vital reservoir for CRE. The detailed species and genomic analyses of CRE among LTCFs reported that Klebsiella pneumoniae is the primary species in the LTCFs in the United States, Spain, and Taiwan. KPC-2-containing K. pneumoniae strains with sequence type 258 is the most common sequence type of KPC-producing K. pneumoniae in the LTCFs in the United States. IMP-11- and IMP-6-producing CRE were commonly reported among LTCFs in Japan. OXA-48 was the predominant carbapenemase among LTCFs in Spain. Multiple risk factors associated with the increased risk for CRE acquisition in LTCFs were found, such as comorbidities, immunosuppressive status, dependent functional status, usage of gastrointestinal devices or indwelling catheters, mechanical ventilation, prior antibiotic exposures, and previous culture reports. A high CRE acquisition rate and prolonged CRE carriage duration after colonization were found among residents in LTCFs. Moreover, the patients from LTCFs who were colonized or infected with CRE had poor clinical outcomes, with a mortality rate of up to 75% in infected patients. Infection prevention and control measures to reduce CRE in LTCFs is important, and could possibly be controlled via active surveillance, contact precautions, cohort staffing, daily chlorhexidine bathing, healthcare-worker education, and hand-hygiene adherence.
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Affiliation(s)
- Hsin-Yu Chen
- Division of Infectious Disease, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shio-Shin Jean
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Emergency Medicine, Department of Emergency Medicine and Critical Care Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yu-Lin Lee
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Min-Chi Lu
- Division of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan.,Department of Microbiology and Immunology, School of Medicine, China Medical University, Taichung, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine and Center for Infection Control, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Yu Liu
- Division of Infectious Disease, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan.,Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Po-Ren Hsueh
- Division of Infectious Disease, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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14
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Lee BY, Bartsch SM, Lin MY, Asti L, Welling J, Mueller LE, Leonard J, Brown ST, Doshi K, Kemble SK, Mitgang EA, Weinstein RA, Trick WE, Hayden MK. How Long-Term Acute Care Hospitals Can Play an Important Role in Controlling Carbapenem-Resistant Enterobacteriaceae in a Region: A Simulation Modeling Study. Am J Epidemiol 2021; 190:448-458. [PMID: 33145594 DOI: 10.1093/aje/kwaa247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 11/14/2022] Open
Abstract
Typically, long-term acute care hospitals (LTACHs) have less experience in and incentives to implementing aggressive infection control for drug-resistant organisms such as carbapenem-resistant Enterobacteriaceae (CRE) than acute care hospitals. Decision makers need to understand how implementing control measures in LTACHs can impact CRE spread regionwide. Using our Chicago metropolitan region agent-based model to simulate CRE spread and control, we estimated that a prevention bundle in only LTACHs decreased prevalence by a relative 4.6%-17.1%, averted 1,090-2,795 new carriers, 273-722 infections and 37-87 deaths over 3 years and saved $30.5-$69.1 million, compared with no CRE control measures. When LTACHs and intensive care units intervened, prevalence decreased by a relative 21.2%. Adding LTACHs averted an additional 1,995 carriers, 513 infections, and 62 deaths, and saved $47.6 million beyond implementation in intensive care units alone. Thus, LTACHs may be more important than other acute care settings for controlling CRE, and regional efforts to control drug-resistant organisms should start with LTACHs as a centerpiece.
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15
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Toth DJA, Samore MH, Nelson RE. Economic Evaluations of New Antibiotics: The High Potential Value of Reducing Healthcare Transmission Through Decolonization. Clin Infect Dis 2021; 72:S34-S41. [DOI: 10.1093/cid/ciaa1590] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Antibiotics designed to decolonize carriers of drug-resistant organisms could offer substantial population health benefits, particularly if they can help avert outbreaks by interrupting person-to-person transmission chains. However, cost effectiveness of an antibiotic is typically evaluated only according to its benefits to recipients, which can be difficult to demonstrate for carriers of an organism that may not pose an immediate health threat to the carrier.
Methods
We developed a mathematical transmission model to quantify the effects of 2 hypothetical antibiotics targeting carbapenem-resistant Enterobacteriaceae (CRE) among long-term acute care hospital inpatients: one assumed to decrease the death rate of patients with CRE bloodstream infections (BSIs) and the other assumed to decolonize CRE carriers after clinical detection. We quantified the effect of each antibiotic on the number of BSIs and deaths among patients receiving the drug (direct effect) and among all patients (direct and indirect effect) compared to usual care. We applied these results to a cost-effectiveness analysis with effectiveness outcome of life-years gained and assumed costs for antibiotic doses and for CRE BSI.
Results
The decolonizing antibiotic, once indirect effects were included, produced increased relative effectiveness and decreased relative costs compared to both usual care and the BSI treatment antibiotic. In fact, in most scenarios, the decolonizing drug was the dominant treatment strategy (ie, less costly and more effective).
Conclusions
Antibiotics that decolonize carriers of drug-resistant organisms can be highly cost-effective when considering indirect benefits within populations vulnerable to outbreaks. Public health could benefit from finding ways to incentivize development of decolonizing antibiotics in the US, where drugs with unclear direct benefits to recipients would pose difficulties in achieving FDA approval and financial benefit to the developer.
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Affiliation(s)
- Damon J A Toth
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Mathematics, University of Utah, Salt Lake City, UT, USA
| | - Matthew H Samore
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Richard E Nelson
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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16
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Bower CW, Fridkin DW, Wolford HM, Slayton RB, Kubes JN, Jacob JT, Ray SM, Fridkin SK. Evaluating Movement of Patients With Carbapenem-resistant Enterobacteriaceae Infections in the Greater Atlanta Metropolitan Area Using Social Network Analysis. Clin Infect Dis 2021; 70:75-81. [PMID: 30809636 DOI: 10.1093/cid/ciz154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 02/20/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Carbapenem-resistant Enterobacteriaceae (CRE) are an urgent threat with potential for rapid spread. We evaluated the role of Medicare patient movement between facilities to model the spread of CRE within a region. METHODS Through population-based CRE surveillance in the 8-county Atlanta (GA) metropolitan area, all Escherichia coli, Enterobacter spp., or Klebsiella spp. resistant to ≥1 carbapenem were reported from residents. CRE was attributed to a facility based on timing of culture and facility exposures. Centrality metrics were calculated from 2016 Medicare data and compared to CRE-transfer derived centrality metrics by Spearman correlation. RESULTS During 2016, 283 incident CRE cases with concurrent or prior year facility stays were identified; cases were attributed mostly to acute care hospitals (ACHs; 141, 50%) and skilled nursing facilities (SNFs; 113, 40%), and less frequently to long-term acute care hospitals (LTACHs; 29, 10%). Attribution was widespread, originating at 17 of 20 ACHs (85%), 7 of 8 (88%) LTACHs, but only 35 of 65 (54%) SNFs. Betweenness of Medicare patient transfers strongly correlated with betweenness of CRE case-transfer data in ACHs (r = 0.75; P < .01) and LTACHs (r = 0.77; P = .03), but not in SNFs (r = 0.02; P = 0.85). We noted 6 SNFs with high CRE-derived betweenness but low Medicare-derived betweenness. CONCLUSIONS CRE infections originate from almost all ACHs and half of SNFs. We identified a subset of SNFs central to the CRE transfer network but not the Medicare transfer network; other factors may explain CRE patient movement in these facilities.
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Affiliation(s)
- Chris W Bower
- Georgia Emerging Infections Program, Atlanta, Georgia.,Atlanta Veterans Affairs Medical Center, Decatur, Atlanta, Georgia.,Atlanta Research and Education Foundation, Atlanta, Georgia
| | - Daniel W Fridkin
- Georgia Emerging Infections Program, Atlanta, Georgia.,Atlanta Veterans Affairs Medical Center, Decatur, Atlanta, Georgia.,Atlanta Research and Education Foundation, Atlanta, Georgia
| | - Hannah M Wolford
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rachel B Slayton
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Julianne N Kubes
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jesse T Jacob
- Georgia Emerging Infections Program, Atlanta, Georgia.,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Susan M Ray
- Georgia Emerging Infections Program, Atlanta, Georgia.,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Scott K Fridkin
- Georgia Emerging Infections Program, Atlanta, Georgia.,Atlanta Veterans Affairs Medical Center, Decatur, Atlanta, Georgia.,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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17
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Paul P, Slayton RB, Kallen AJ, Walters MS, Jernigan JA. Modeling Regional Transmission and Containment of a Healthcare-associated Multidrug-resistant Organism. Clin Infect Dis 2021; 70:388-394. [PMID: 30919885 DOI: 10.1093/cid/ciz248] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/20/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The Centers for Disease Control and Prevention (CDC) recently published interim guidance for a public health response to contain novel or targeted multidrug-resistant organisms (MDROs). We assessed the impact of implementing the strategy in a US state using a mathematical model. METHODS We used a deterministic compartmental model, parametrized via a novel analysis of carbapenem-resistant Enterobacteriaceae data reported to the National Healthcare Safety Network and patient transfer data from the Centers for Medicare and Medicaid Services. The simulations assumed that after the importation of the MDRO and its initial detection by clinical culture at an index hospital, fortnightly prevalence surveys for colonization and additional infection control interventions were implemented at the index facility; similar surveys were then also implemented at those facilities known to be connected most strongly to it as measured by patient transfer data; and prevalence surveys were discontinued after 2 consecutive negative surveys. RESULTS If additional infection-control interventions are assumed to lead to a 20% reduction in transmissibility in intervention facilities, prevalent case count in the state 3 years after importation would be reduced by 76% (interquartile range: 73-77%). During the third year, these additional infection-control measures would be applied in facilities accounting for 42% (37-46%) of inpatient days. CONCLUSIONS CDC guidance for containing MDROs, when used in combination with information on transfer of patients among hospitals, is predicted to be effective, enabling targeted and efficient use of prevention resources during an outbreak response. Even modestly effective infection-control measures may lead to a substantial reduction in transmission events.
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Affiliation(s)
- Prabasaj Paul
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rachel B Slayton
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alexander J Kallen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Maroya S Walters
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - John A Jernigan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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18
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Carbapenem-resistant Enterobacterales bacteriuria and subsequent bacteremia: A population-based study. Infect Control Hosp Epidemiol 2020; 42:962-967. [PMID: 33298218 DOI: 10.1017/ice.2020.1325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To describe the epidemiology of carbapenem-resistant Enterobacterales (CRE) bacteriuria and to determine whether urinary catheters increase the risk of subsequent CRE bacteremia. DESIGN Using active population- and laboratory-based surveillance we described a cohort of patients with incident CRE bacteriuria and identified risk factors for developing CRE bacteremia within 1 year. SETTING The study was conducted among the 8 counties of Georgia Health District 3 (HD3) in Atlanta, Georgia. PATIENTS Residents of HD3 with CRE first identified in urine between 2012 and 2017. RESULTS We identified 464 patients with CRE bacteriuria (mean yearly incidence, 1.96 cases per 100,000 population). Of 425 with chart review, most had a urinary catheter (56%), and many resided in long-term care facilities (48%), had a Charlson comorbidity index >3 (38%) or a decubitus ulcer (37%). 21 patients (5%) developed CRE bacteremia with the same organism within 1 year. Risk factors for subsequent bacteremia included presence of a urinary catheter (odds ratio [OR], 8.0; 95% confidence interval [CI], 1.8-34.9), central venous catheter (OR, 4.3; 95% CI, 1.7-10.6) or another indwelling device (OR, 4.3; 95% CI, 1.6-11.4), urine culture obtained as an inpatient (OR, 5.7; 95% CI, 1.3-25.9), and being in the ICU in the week prior to urine culture (OR, 2.9; 95% CI, 1.1-7.8). In a multivariable analysis, urinary catheter increased the risk of CRE bacteremia (OR, 5.3; 95% CI, 1.2-23.6). CONCLUSIONS In patients with CRE bacteriuria, urinary catheters increase the risk of CRE bacteremia. Future interventions should aim to reduce inappropriate insertion and early removal of urinary catheters.
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19
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Toth DJA, Khader K, Beams A, Samore MH. Model-based Assessment of the Effect of Contact Precautions Applied to Surveillance-detected Carriers of Carbapenemase-producing Enterobacteriaceae in Long-term Acute Care Hospitals. Clin Infect Dis 2020; 69:S206-S213. [PMID: 31517974 PMCID: PMC6761367 DOI: 10.1093/cid/ciz557] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND An intervention that successfully reduced colonization and infection with carbapenemase-producing Enterobacteriaceae (CPE) in Chicago-area long-term acute-care hospitals included active surveillance and contact precautions. However, the specific effects of contact precautions applied to surveillance-detected carriers on patient-to-patient transmission are unknown, as other, concurrent intervention components or changes in facility patient dynamics also could have affected the observed outcomes. METHODS Using previously published data from before and after the CPE intervention, we designed a mathematical model with an explicit representation of postintervention surveillance. We estimated preintervention to postintervention changes of 3 parameters: β, the baseline transmission rate excluding contact precaution effects; δb, the rate of a CPE carrier progressing to bacteremia; and δc, the progression rate to nonbacteremia clinical detection. RESULTS Assuming that CPE carriers under contact precautions transmit carriage to other patients at half the rate of undetected carriers, the model produced no convincing evidence for a postintervention change in the baseline transmission rate β (+2.1% [95% confidence interval {CI}, -18% to +28%]). The model did find evidence of a postintervention decrease for δb (-41% [95% CI, -60% to -18%]), but not for δc (-7% [95% CI, -28% to +19%]). CONCLUSIONS Our results suggest that contact precautions for surveillance-detected CPE carriers could potentially explain the observed decrease in colonization by itself, even under conservative assumptions for the effectiveness of those precautions for reducing cross-transmission. Other intervention components such as daily chlorhexidine gluconate bathing of all patients and hand-hygiene education and adherence monitoring may have contributed primarily to reducing rates of colonized patients progressing to bacteremia.
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Affiliation(s)
- Damon J A Toth
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City.,Department of Internal Medicine (Epidemiology), University of Utah, Salt Lake City.,Department of Mathematics, University of Utah, Salt Lake City
| | - Karim Khader
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City.,Department of Internal Medicine (Epidemiology), University of Utah, Salt Lake City
| | - Alexander Beams
- Department of Mathematics, University of Utah, Salt Lake City
| | - Matthew H Samore
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City.,Department of Internal Medicine (Epidemiology), University of Utah, Salt Lake City
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20
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Toth DJA, Keegan LT, Samore MH, Khader K, O'Hagan JJ, Yu H, Quintana A, Swerdlow DL. Modeling the potential impact of administering vaccines against Clostridioides difficile infection to individuals in healthcare facilities. Vaccine 2020; 38:5927-5932. [PMID: 32703744 DOI: 10.1016/j.vaccine.2020.06.081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/25/2020] [Accepted: 06/30/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND A vaccine against Clostridioides difficile infection (CDI) is in development. While the vaccine has potential to both directly protect those vaccinated and mitigate transmission by reducing environmental contamination, the impact of the vaccine on C. difficile colonization remains unclear. Consequently, the transmission-reduction effect of the vaccine depends on the contribution of symptomatic CDI to overall transmission of C. difficile. METHODS We designed a simulation model of CDI among patients in a network of 10 hospitals and nursing homes and calibrated the model using estimates of transmissibility from whole genome sequencing studies that estimated the fraction of CDI attributable to transmission from other CDI patients. We assumed the vaccine reduced the rate of progression to CDI among carriers by 25-95% after completion of a 3-dose vaccine course administered to randomly chosen patients at facility discharge. We simulated the administration of this vaccination campaign and tallied effects over 5 years. RESULTS We estimated 30 times higher infectivity of CDI patients compared to other carriers. Simulations of the vaccination campaign produced an average reduction of 3-16 CDI cases per 1000 vaccinated patients, with 2-11 of those cases prevented among those vaccinated and 1-5 prevented among unvaccinated patients. CONCLUSIONS Our findings demonstrate potential for a vaccine against CDI to reduce transmissions in healthcare facilities, even with no direct effect on carriage susceptibility. The vaccine's population impact will increase if received by individuals at risk for CDI onset in high-transmission settings.
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Affiliation(s)
- Damon J A Toth
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA; Department of Internal Medicine (Epidemiology), University of Utah, Salt Lake City, UT, USA.
| | - Lindsay T Keegan
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA; Department of Internal Medicine (Epidemiology), University of Utah, Salt Lake City, UT, USA
| | - Matthew H Samore
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA; Department of Internal Medicine (Epidemiology), University of Utah, Salt Lake City, UT, USA.
| | - Karim Khader
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA; Department of Internal Medicine (Epidemiology), University of Utah, Salt Lake City, UT, USA
| | - Justin J O'Hagan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Rhea S, Jones K, Endres-Dighe S, Munoz B, Weber DJ, Hilscher R, MacFarquhar J, Sickbert-Bennett E, DiBiase L, Marx A, Rineer J, Lewis J, Bobashev G. Modeling inpatient and outpatient antibiotic stewardship interventions to reduce the burden of Clostridioides difficile infection in a regional healthcare network. PLoS One 2020; 15:e0234031. [PMID: 32525887 PMCID: PMC7289388 DOI: 10.1371/journal.pone.0234031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 05/19/2020] [Indexed: 12/14/2022] Open
Abstract
Antibiotic exposure can lead to unintended outcomes, including drug-drug interactions, adverse drug events, and healthcare-associated infections like Clostridioides difficile infection (CDI). Improving antibiotic use is critical to reduce an individual's CDI risk. Antibiotic stewardship initiatives can reduce inappropriate antibiotic prescribing (e.g., unnecessary antibiotic prescribing, inappropriate antibiotic selection), impacting both hospital (healthcare)-onset (HO)-CDI and community-associated (CA)-CDI. Previous computational and mathematical modeling studies have demonstrated a reduction in CDI incidence associated with antibiotic stewardship initiatives in hospital settings. Although the impact of antibiotic stewardship initiatives in long-term care facilities (LTCFs), including nursing homes, and in outpatient settings have been documented, the effects of specific interventions on CDI incidence are not well understood. We examined the relative effectiveness of antibiotic stewardship interventions on CDI incidence using a geospatially explicit agent-based model of a regional healthcare network in North Carolina. We simulated reductions in unnecessary antibiotic prescribing and inappropriate antibiotic selection with intervention scenarios at individual and network healthcare facilities, including short-term acute care hospitals (STACHs), nursing homes, and outpatient locations. Modeled antibiotic prescription rates were calculated using patient-level data on antibiotic length of therapy for the 10 modeled network STACHs. By simulating a 30% reduction in antibiotics prescribed across all inpatient and outpatient locations, we found the greatest reductions on network CDI incidence among tested scenarios, namely a 17% decrease in HO-CDI incidence and 7% decrease in CA-CDI. Among intervention scenarios of reducing inappropriate antibiotic selection, we found a greater impact on network CDI incidence when modeling this reduction in nursing homes alone compared to the same intervention in STACHs alone. These results support the potential importance of LTCF and outpatient antibiotic stewardship efforts on network CDI burden and add to the evidence that a coordinated approach to antibiotic stewardship across multiple facilities, including inpatient and outpatient settings, within a regional healthcare network could be an effective strategy to reduce network CDI burden.
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Affiliation(s)
- Sarah Rhea
- RTI International, Research Triangle Park, North Carolina
- * E-mail:
| | - Kasey Jones
- RTI International, Research Triangle Park, North Carolina
| | | | - Breda Munoz
- RTI International, Research Triangle Park, North Carolina
| | | | | | - Jennifer MacFarquhar
- North Carolina Department of Health and Human Services, Raleigh, North Carolina
- Career Epidemiology Field Officer Program, Division of State and Local Readiness, Center for Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Ashley Marx
- UNC Health Care, Chapel Hill, North Carolina
- UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - James Rineer
- RTI International, Research Triangle Park, North Carolina
| | - James Lewis
- North Carolina Department of Health and Human Services, Raleigh, North Carolina
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22
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Rhea S, Hilscher R, Rineer JI, Munoz B, Jones K, Endres-Dighe SM, DiBiase LM, Sickbert-Bennett EE, Weber DJ, MacFarquhar JK, Dubendris H, Bobashev G. Creation of a Geospatially Explicit, Agent-based Model of a Regional Healthcare Network with Application to Clostridioides difficile Infection. Health Secur 2020; 17:276-290. [PMID: 31433281 DOI: 10.1089/hs.2019.0021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Agent-based models (ABMs) describe and simulate complex systems comprising unique agents, or individuals, while accounting for geospatial and temporal variability among dynamic processes. ABMs are increasingly used to study healthcare-associated infections (ie, infections acquired during admission to a healthcare facility), including Clostridioides difficile infection, currently the most common healthcare-associated infection in the United States. The overall burden and transmission dynamics of healthcare-associated infections, including C difficile infection, may be influenced by community sources and movement of people among healthcare facilities and communities. These complex dynamics warrant geospatially explicit ABMs that extend beyond single healthcare facilities to include entire systems (eg, hospitals, nursing homes and extended care facilities, the community). The agents in ABMs can be built on a synthetic population, a model-generated representation of the actual population with associated spatial (eg, home residence), temporal (eg, change in location over time), and nonspatial (eg, sociodemographic features) attributes. We describe our methods to create a geospatially explicit ABM of a major regional healthcare network using a synthetic population as microdata input. We illustrate agent movement in the healthcare network and the community, informed by patient-level medical records, aggregate hospital discharge data, healthcare facility licensing data, and published literature. We apply the ABM output to visualize agent movement in the healthcare network and the community served by the network. We provide an application example of the ABM to C difficile infection using a natural history submodel. We discuss the ABM's potential to detect network areas where disease risk is high; simulate and evaluate interventions to protect public health; adapt to other geographic locations and healthcare-associated infections, including emerging pathogens; and meaningfully translate results to public health practitioners, healthcare providers, and policymakers.
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Affiliation(s)
- Sarah Rhea
- Sarah Rhea, DVM, PhD, is a Research Epidemiologist, Center for Applied Public Health Research; Rainer Hilscher, PhD, is a Research Data Scientist, Center for Data Science; James I. Rineer, MS, is Director, Geospatial Science and Technology; Breda Munoz, PhD, is a Research Statistician, Center for Applied Public Health Research; Kasey Jones, MS, is a Research Data Scientist, Center for Data Science; and Stacy M. Endres-Dighe, MPH, is a Research Epidemiologist, Center for Applied Public Health Research; all at RTI International, Research Triangle Park, NC
| | - Rainer Hilscher
- Sarah Rhea, DVM, PhD, is a Research Epidemiologist, Center for Applied Public Health Research; Rainer Hilscher, PhD, is a Research Data Scientist, Center for Data Science; James I. Rineer, MS, is Director, Geospatial Science and Technology; Breda Munoz, PhD, is a Research Statistician, Center for Applied Public Health Research; Kasey Jones, MS, is a Research Data Scientist, Center for Data Science; and Stacy M. Endres-Dighe, MPH, is a Research Epidemiologist, Center for Applied Public Health Research; all at RTI International, Research Triangle Park, NC
| | - James I Rineer
- Sarah Rhea, DVM, PhD, is a Research Epidemiologist, Center for Applied Public Health Research; Rainer Hilscher, PhD, is a Research Data Scientist, Center for Data Science; James I. Rineer, MS, is Director, Geospatial Science and Technology; Breda Munoz, PhD, is a Research Statistician, Center for Applied Public Health Research; Kasey Jones, MS, is a Research Data Scientist, Center for Data Science; and Stacy M. Endres-Dighe, MPH, is a Research Epidemiologist, Center for Applied Public Health Research; all at RTI International, Research Triangle Park, NC
| | - Breda Munoz
- Sarah Rhea, DVM, PhD, is a Research Epidemiologist, Center for Applied Public Health Research; Rainer Hilscher, PhD, is a Research Data Scientist, Center for Data Science; James I. Rineer, MS, is Director, Geospatial Science and Technology; Breda Munoz, PhD, is a Research Statistician, Center for Applied Public Health Research; Kasey Jones, MS, is a Research Data Scientist, Center for Data Science; and Stacy M. Endres-Dighe, MPH, is a Research Epidemiologist, Center for Applied Public Health Research; all at RTI International, Research Triangle Park, NC
| | - Kasey Jones
- Sarah Rhea, DVM, PhD, is a Research Epidemiologist, Center for Applied Public Health Research; Rainer Hilscher, PhD, is a Research Data Scientist, Center for Data Science; James I. Rineer, MS, is Director, Geospatial Science and Technology; Breda Munoz, PhD, is a Research Statistician, Center for Applied Public Health Research; Kasey Jones, MS, is a Research Data Scientist, Center for Data Science; and Stacy M. Endres-Dighe, MPH, is a Research Epidemiologist, Center for Applied Public Health Research; all at RTI International, Research Triangle Park, NC
| | - Stacy M Endres-Dighe
- Sarah Rhea, DVM, PhD, is a Research Epidemiologist, Center for Applied Public Health Research; Rainer Hilscher, PhD, is a Research Data Scientist, Center for Data Science; James I. Rineer, MS, is Director, Geospatial Science and Technology; Breda Munoz, PhD, is a Research Statistician, Center for Applied Public Health Research; Kasey Jones, MS, is a Research Data Scientist, Center for Data Science; and Stacy M. Endres-Dighe, MPH, is a Research Epidemiologist, Center for Applied Public Health Research; all at RTI International, Research Triangle Park, NC
| | - Lauren M DiBiase
- Lauren M. DiBiase, MS, is Associate Director, Infection Prevention, University of North Carolina Medical Center, Chapel Hill, NC
| | - Emily E Sickbert-Bennett
- Emily E. Sickbert-Bennett, PhD, MS, is Director, Infection Prevention, University of North Carolina Hospitals, Chapel Hill, NC
| | - David J Weber
- David J. Weber, MD, MPH, is Professor of Medicine, Pediatrics and Epidemiology, UNC School of Medicine and UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Jennifer K MacFarquhar
- Jennifer K. MacFarquhar, MPH, is a Career Epidemiology Field Officer, Center for Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, GA, and Communicable Disease Branch, Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, NC
| | - Heather Dubendris
- Heather Dubendris, MSPH, is an Epidemiologist, Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, NC
| | - Georgiy Bobashev
- Georgiy Bobashev, PhD, MSc, is an RTI Fellow, RTI International, and Professor of Statistics and Biostatistics, North Carolina State University, Raleigh, NC
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Ben-David D, Masarwa S, Fallach N, Temkin E, Solter E, Carmeli Y, Schwaber MJ. Success of a National Intervention in Controlling Carbapenem-resistant Enterobacteriaceae in Israel's Long-term Care Facilities. Clin Infect Dis 2020; 68:964-971. [PMID: 29986007 DOI: 10.1093/cid/ciy572] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 07/07/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Long-term care facilities (LTCFs) are a major reservoir of carbapenem-resistant Enterobacteriaceae (CRE) in healthcare facilities, contributing to rapid regional dissemination of CRE. METHODS In 2008, The Israeli National Center for Infection Control (NCIC) initiated a coordinated, comprehensive intervention in Israel's LTCFs, encompassing approximately 25000 beds in over 300 institutions. The intervention included implementation of population-tailored contact precautions and early detection of carriers. The NCIC established a real-time repository of all CRE carriers and events of acquisition, supervised information exchange between healthcare facilities and directed intervention at the institutional level during local outbreaks. CRE incidence was determined based on detection of CRE, either during LTFC stay or on admission to another facility. Prevalence was determined by a series of 5 cross-sectional surveys commenced between 2008 and 2015. RESULTS From January 2009 through December 2015, 5265 patients acquired CRE in LTCFs. During the study period, incidence of acquisition declined in all facility types, to approximately 50% of the baseline (P < .001). The number of skilled nursing facilities and nursing homes experiencing ≥ 5 CRE acquisitions annually decreased from 35 to 11 during this period. The point prevalence of newly detected CRE carriage in post-acute care hospitals decreased from 12.3% in the survey commenced in 2008 to 0.8% in that begun in 2015 (P < .001). CONCLUSIONS A national, coordinated intervention resulted in a sustained decrease in CRE incidence and prevalence in LTCFs. These results support the assumption that centrally coordinated intervention is an essential public health tool in reducing CRE in healthcare facilities.
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Affiliation(s)
- Debby Ben-David
- National Center for Infection Control, Israel Ministry of Health, Israel
| | - Samira Masarwa
- National Center for Infection Control, Israel Ministry of Health, Israel
| | - Noga Fallach
- National Center for Infection Control, Israel Ministry of Health, Israel
| | - Elizabeth Temkin
- National Center for Infection Control, Israel Ministry of Health, Israel
| | - Ester Solter
- National Center for Infection Control, Israel Ministry of Health, Israel
| | - Yehuda Carmeli
- National Center for Infection Control, Israel Ministry of Health, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Mitchell J Schwaber
- National Center for Infection Control, Israel Ministry of Health, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
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Hilliquin D, Lomont A, Zahar JR. Cohorting for preventing the nosocomial spread of Carbapenemase-Producing Enterobacterales, in non-epidemic settings: is it mandatory? J Hosp Infect 2020; 105:S0195-6701(20)30197-3. [PMID: 32315668 DOI: 10.1016/j.jhin.2020.04.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/14/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Worldwide dissemination of Carbapenemase-Producing Enterobacterales (CPE) has led to national and international guidance recommending the implementation of cohorting in healthcare settings (HS). However, in view of recent data regarding the spread of Extended-spectrum Beta-lactamase-producing Enterobacterales, we may wonder about the usefulness of this measure in a non-outbreak settings; here, individual contact isolation may be sufficient to control the risk of dissemination. AIM/METHODS We conducted a narrative review of the literature and discussed the role of cohorting. FINDINGS CPE are responsible for outbreaks in HS, which are considered the epicentre of spread of resistance strains. CPE are responsible for adverse effects such as increases in hospital stay and costs, less therapeutic options and thus higher risk of clinical failures and mortality. Environment and materials have also been described contaminated with CPE and can be the source of outbreak. Even if guidelines and publications have supported implementation of cohorting, there are no randomized studies demonstrating the mandatory nature of this measure. Most studies are descriptive and cohorting is usually one of several other measures to control outbreaks. Cohorting is not adapted to all HS, which requires human and material resources. Other measures must be strengthened such as compliance of hand hygiene, antibiotic stewardship and surveillance of contact patients. Individual risk factors of acquisition should also be evaluated. CONCLUSION Local epidemiology and resources must be assessed before implementing cohorting.
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Affiliation(s)
- Delphine Hilliquin
- Unité d'hygiène et d'épidémiologie, Hôpital Édouard Herriot, GH Centre, Hospices civils de Lyon, France; Université Lyon 1 Claude Bernard, Lyon, France.
| | - Alexandra Lomont
- Service de Microbiologie Clinique, Unité de contrôle et prévention du risque infectieux, GH Paris Seine Saint-Denis, AP-HP, Bobigny, France; IAME, Inserm 1137, Université Sorbonne Paris Nord - Paris 13, France
| | - Jean-Ralph Zahar
- Service de Microbiologie Clinique, Unité de contrôle et prévention du risque infectieux, GH Paris Seine Saint-Denis, AP-HP, Bobigny, France; IAME, Inserm 1137, Université Sorbonne Paris Nord - Paris 13, France
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Jernigan JA, Hatfield KM, Wolford H, Nelson RE, Olubajo B, Reddy SC, McCarthy N, Paul P, McDonald LC, Kallen A, Fiore A, Craig M, Baggs J. Multidrug-Resistant Bacterial Infections in U.S. Hospitalized Patients, 2012-2017. N Engl J Med 2020; 382:1309-1319. [PMID: 32242356 PMCID: PMC10961699 DOI: 10.1056/nejmoa1914433] [Citation(s) in RCA: 286] [Impact Index Per Article: 71.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Multidrug-resistant (MDR) bacteria that are commonly associated with health care cause a substantial health burden. Updated national estimates for this group of pathogens are needed to inform public health action. METHODS Using data from patients hospitalized in a cohort of 890 U.S. hospitals during the period 2012-2017, we generated national case counts for both hospital-onset and community-onset infections caused by methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), extended-spectrum cephalosporin resistance in Enterobacteriaceae suggestive of extended-spectrum beta-lactamase (ESBL) production, carbapenem-resistant Enterobacteriaceae, carbapenem-resistant acinetobacter species, and MDR Pseudomonas aeruginosa. RESULTS The hospital cohort in the study accounted for 41.6 million hospitalizations (>20% of U.S. hospitalizations annually). The overall rate of clinical cultures was 292 cultures per 1000 patient-days and was stable throughout the time period. In 2017, these pathogens caused an estimated 622,390 infections (95% confidence interval [CI], 579,125 to 665,655) among hospitalized patients. Of these infections, 517,818 (83%) had their onset in the community, and 104,572 (17%) had their onset in the hospital. MRSA and ESBL infections accounted for the majority of the infections (52% and 32%, respectively). Between 2012 and 2017, the incidence decreased for MRSA infection (from 114.18 to 93.68 cases per 10,000 hospitalizations), VRE infection (from 24.15 to 15.76 per 10,000), carbapenem-resistant acinetobacter species infection (from 3.33 to 2.47 per 10,000), and MDR P. aeruginosa infection (from 13.10 to 9.43 per 10,000), with decreases ranging from -20.5% to -39.2%. The incidence of carbapenem-resistant Enterobacteriaceae infection did not change significantly (from 3.36 to 3.79 cases per 10,000 hospitalizations). The incidence of ESBL infection increased by 53.3% (from 37.55 to 57.12 cases per 10,000 hospitalizations), a change driven by an increase in community-onset cases. CONCLUSIONS Health care-associated antimicrobial resistance places a substantial burden on patients in the United States. Further work is needed to identify improved interventions for both the inpatient and outpatient settings. (Funded by the Centers for Disease Control and Prevention.).
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Affiliation(s)
- John A Jernigan
- From the Division of Healthcare Quality Promotion (J.A.J., K.M.H., H.W., B.O., S.C.R., N.M., P.P., L.C.M., A.K., A.F., M.C., J.B.) and the Office of Antimicrobial Resistance (M.C.), Centers for Disease Control and Prevention, Atlanta; and the IDEAS Center, Veterans Affairs Salt Lake City Health Care System, and the Department of Internal Medicine, University of Utah School of Medicine - both in Salt Lake City (R.E.N.)
| | - Kelly M Hatfield
- From the Division of Healthcare Quality Promotion (J.A.J., K.M.H., H.W., B.O., S.C.R., N.M., P.P., L.C.M., A.K., A.F., M.C., J.B.) and the Office of Antimicrobial Resistance (M.C.), Centers for Disease Control and Prevention, Atlanta; and the IDEAS Center, Veterans Affairs Salt Lake City Health Care System, and the Department of Internal Medicine, University of Utah School of Medicine - both in Salt Lake City (R.E.N.)
| | - Hannah Wolford
- From the Division of Healthcare Quality Promotion (J.A.J., K.M.H., H.W., B.O., S.C.R., N.M., P.P., L.C.M., A.K., A.F., M.C., J.B.) and the Office of Antimicrobial Resistance (M.C.), Centers for Disease Control and Prevention, Atlanta; and the IDEAS Center, Veterans Affairs Salt Lake City Health Care System, and the Department of Internal Medicine, University of Utah School of Medicine - both in Salt Lake City (R.E.N.)
| | - Richard E Nelson
- From the Division of Healthcare Quality Promotion (J.A.J., K.M.H., H.W., B.O., S.C.R., N.M., P.P., L.C.M., A.K., A.F., M.C., J.B.) and the Office of Antimicrobial Resistance (M.C.), Centers for Disease Control and Prevention, Atlanta; and the IDEAS Center, Veterans Affairs Salt Lake City Health Care System, and the Department of Internal Medicine, University of Utah School of Medicine - both in Salt Lake City (R.E.N.)
| | - Babatunde Olubajo
- From the Division of Healthcare Quality Promotion (J.A.J., K.M.H., H.W., B.O., S.C.R., N.M., P.P., L.C.M., A.K., A.F., M.C., J.B.) and the Office of Antimicrobial Resistance (M.C.), Centers for Disease Control and Prevention, Atlanta; and the IDEAS Center, Veterans Affairs Salt Lake City Health Care System, and the Department of Internal Medicine, University of Utah School of Medicine - both in Salt Lake City (R.E.N.)
| | - Sujan C Reddy
- From the Division of Healthcare Quality Promotion (J.A.J., K.M.H., H.W., B.O., S.C.R., N.M., P.P., L.C.M., A.K., A.F., M.C., J.B.) and the Office of Antimicrobial Resistance (M.C.), Centers for Disease Control and Prevention, Atlanta; and the IDEAS Center, Veterans Affairs Salt Lake City Health Care System, and the Department of Internal Medicine, University of Utah School of Medicine - both in Salt Lake City (R.E.N.)
| | - Natalie McCarthy
- From the Division of Healthcare Quality Promotion (J.A.J., K.M.H., H.W., B.O., S.C.R., N.M., P.P., L.C.M., A.K., A.F., M.C., J.B.) and the Office of Antimicrobial Resistance (M.C.), Centers for Disease Control and Prevention, Atlanta; and the IDEAS Center, Veterans Affairs Salt Lake City Health Care System, and the Department of Internal Medicine, University of Utah School of Medicine - both in Salt Lake City (R.E.N.)
| | - Prabasaj Paul
- From the Division of Healthcare Quality Promotion (J.A.J., K.M.H., H.W., B.O., S.C.R., N.M., P.P., L.C.M., A.K., A.F., M.C., J.B.) and the Office of Antimicrobial Resistance (M.C.), Centers for Disease Control and Prevention, Atlanta; and the IDEAS Center, Veterans Affairs Salt Lake City Health Care System, and the Department of Internal Medicine, University of Utah School of Medicine - both in Salt Lake City (R.E.N.)
| | - L Clifford McDonald
- From the Division of Healthcare Quality Promotion (J.A.J., K.M.H., H.W., B.O., S.C.R., N.M., P.P., L.C.M., A.K., A.F., M.C., J.B.) and the Office of Antimicrobial Resistance (M.C.), Centers for Disease Control and Prevention, Atlanta; and the IDEAS Center, Veterans Affairs Salt Lake City Health Care System, and the Department of Internal Medicine, University of Utah School of Medicine - both in Salt Lake City (R.E.N.)
| | - Alex Kallen
- From the Division of Healthcare Quality Promotion (J.A.J., K.M.H., H.W., B.O., S.C.R., N.M., P.P., L.C.M., A.K., A.F., M.C., J.B.) and the Office of Antimicrobial Resistance (M.C.), Centers for Disease Control and Prevention, Atlanta; and the IDEAS Center, Veterans Affairs Salt Lake City Health Care System, and the Department of Internal Medicine, University of Utah School of Medicine - both in Salt Lake City (R.E.N.)
| | - Anthony Fiore
- From the Division of Healthcare Quality Promotion (J.A.J., K.M.H., H.W., B.O., S.C.R., N.M., P.P., L.C.M., A.K., A.F., M.C., J.B.) and the Office of Antimicrobial Resistance (M.C.), Centers for Disease Control and Prevention, Atlanta; and the IDEAS Center, Veterans Affairs Salt Lake City Health Care System, and the Department of Internal Medicine, University of Utah School of Medicine - both in Salt Lake City (R.E.N.)
| | - Michael Craig
- From the Division of Healthcare Quality Promotion (J.A.J., K.M.H., H.W., B.O., S.C.R., N.M., P.P., L.C.M., A.K., A.F., M.C., J.B.) and the Office of Antimicrobial Resistance (M.C.), Centers for Disease Control and Prevention, Atlanta; and the IDEAS Center, Veterans Affairs Salt Lake City Health Care System, and the Department of Internal Medicine, University of Utah School of Medicine - both in Salt Lake City (R.E.N.)
| | - James Baggs
- From the Division of Healthcare Quality Promotion (J.A.J., K.M.H., H.W., B.O., S.C.R., N.M., P.P., L.C.M., A.K., A.F., M.C., J.B.) and the Office of Antimicrobial Resistance (M.C.), Centers for Disease Control and Prevention, Atlanta; and the IDEAS Center, Veterans Affairs Salt Lake City Health Care System, and the Department of Internal Medicine, University of Utah School of Medicine - both in Salt Lake City (R.E.N.)
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A prolonged multispecies outbreak of IMP-6 carbapenemase-producing Enterobacterales due to horizontal transmission of the IncN plasmid. Sci Rep 2020; 10:4139. [PMID: 32139745 PMCID: PMC7057946 DOI: 10.1038/s41598-020-60659-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 02/04/2020] [Indexed: 12/03/2022] Open
Abstract
A multispecies outbreak of IMP-6 carbapenemase-producing Enterobacterales (IMP-6-CPE) occurred at an acute care hospital in Japan. This study was conducted to understand the mechanisms of IMP-6-CPE transmission by pulsed-field gel electrophoresis (PFGE), multilocus sequence typing and whole-genome sequencing (WGS), and identify risk factors for IMP-6-CPE acquisition in patients who underwent abdominal surgery. Between July 2013 and March 2014, 22 hospitalized patients infected or colonized with IMP-6-CPE (Escherichia coli [n = 8], Klebsiella oxytoca [n = 5], Enterobacter cloacae [n = 5], Klebsiella pneumoniae [n = 3] and Klebsiella aerogenes [n = 1]) were identified. There were diverse PFGE profiles and sequence types (STs) in most of the species except for K. oxytoca. All isolates of K. oxytoca belonged to ST29 with similar PFGE profiles, suggesting their clonal transmission. Plasmid analysis by WGS revealed that all 22 isolates but one shared a ca. 50-kb IncN plasmid backbone with blaIMP-6 suggesting interspecies gene transmission, and typing of plasmids explained epidemiological links among cases. A case-control study showed pancreatoduodenectomy, changing drains in fluoroscopy room, continuous peritoneal lavage and enteric fistula were associated with IMP-6-CPE acquisition among the patients. Plasmid analysis of isolates in an outbreak of IMP-6-CPE suggested interspecies gene transmission and helped to clarify hidden epidemiological links between cases.
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Whole-Genome Sequencing To Identify Drivers of Carbapenem-Resistant Klebsiella pneumoniae Transmission within and between Regional Long-Term Acute-Care Hospitals. Antimicrob Agents Chemother 2019; 63:AAC.01622-19. [PMID: 31451495 DOI: 10.1128/aac.01622-19] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 08/16/2019] [Indexed: 12/17/2022] Open
Abstract
Carbapenem-resistant Klebsiella pneumoniae (CRKP) is an antibiotic resistance threat of the highest priority. Given the limited treatment options for this multidrug-resistant organism (MDRO), there is an urgent need for targeted strategies to prevent transmission. Here, we applied whole-genome sequencing to a comprehensive collection of clinical isolates to reconstruct regional transmission pathways and analyzed this transmission network in the context of statewide patient transfer data and patient-level clinical data to identify drivers of regional transmission. We found that high regional CRKP burdens were due to a small number of regional introductions, with subsequent regional proliferation occurring via patient transfers among health care facilities. While CRKP was predicted to have been imported into each facility multiple times, there was substantial variation in the ratio of intrafacility transmission events per importation, indicating that amplification occurs unevenly across regional facilities. While myriad factors likely influence intrafacility transmission rates, an understudied one is the potential for clinical characteristics of colonized and infected patients to influence their propensity for transmission. Supporting the contribution of high-risk patients to elevated transmission rates, we observed that patients colonized and infected with CRKP in high-transmission facilities had higher rates of carbapenem use, malnutrition, and dialysis and were older. This report highlights the potential for regional infection prevention efforts that are grounded in genomic epidemiology to identify the patients and facilities that make the greatest contribution to regional MDRO prevalence, thereby facilitating the design of precision interventions of maximal impact.
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Reddy SC, Valderrama AL, Kuhar DT. Improving the Use of Personal Protective Equipment: Applying Lessons Learned. Clin Infect Dis 2019; 69:S165-S170. [DOI: 10.1093/cid/ciz619] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Abstract
Unrecognized transmission of pathogens in healthcare settings can lead to colonization and infection of both patients and healthcare personnel. The use of personal protective equipment (PPE) is an important strategy to protect healthcare personnel from contamination and to prevent the spread of pathogens to subsequent patients. However, optimal PPE use is difficult, and healthcare personnel may alter delivery of care because of the PPE. Here, we summarize recent research from the Prevention Epicenters Program on healthcare personnel contamination and improvement of the routine use of PPE as well as Ebola-specific PPE. Future efforts to optimize the use of PPE should include increasing adherence to protocols for PPE use, improving PPE design, and further research into the risks, benefits, and best practices of PPE use.
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Affiliation(s)
- Sujan C Reddy
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Amy L Valderrama
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - David T Kuhar
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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Khader K, Thomas A, Jones M, Toth D, Stevens V, Samore MH. Variation and trends in transmission dynamics of Methicillin-resistant Staphylococcus aureus in veterans affairs hospitals and nursing homes. Epidemics 2019; 28:100347. [PMID: 31171468 PMCID: PMC7006838 DOI: 10.1016/j.epidem.2019.100347] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/25/2019] [Accepted: 05/28/2019] [Indexed: 02/02/2023] Open
Abstract
Variation and differences of MRSA transmission within and between healthcare settings are not well understood. This variability is critical for understanding the potential impact of infection control interventions and could aid in the evaluation of future intervention strategies. We fit a Bayesian transmission model to detailed individual-level MRSA surveillance data from over 230 Veterans Affairs (VA) hospitals and nursing homes. Our approach disentangles the effects of potential confounders, including length of stay, admission prevalence, and clearance, estimating dynamic transmission model parameters and temporal trends. The median baseline transmission rate in hospitals was approximately four-fold higher than in nursing homes, and declined in 46% of hospitals and 9% of nursing homes, resulting in a median transmission rate reduction of 43% across hospitals and an increase of 2% in nursing homes. For first admissions into an acute care facility, the median (range) importation probability was 10.5% (5.9%–18.4%), and was nearly twice as large, 18.7% (9.2%–37.4%), in nursing homes. This analysis found differences within and between hospitals and nursing homes. The transmission rate declined substantially in hospitals and remained stable in nursing homes, while admission prevalence was considerably higher in nursing homes than in hospitals.
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Affiliation(s)
- Karim Khader
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) 2.0 Center, VA Salt Lake City Health Care System, 500 Foothill Drive Bldg. 182, Salt Lake City, UT, 84148, USA; Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Alun Thomas
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) 2.0 Center, VA Salt Lake City Health Care System, 500 Foothill Drive Bldg. 182, Salt Lake City, UT, 84148, USA; Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Makoto Jones
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) 2.0 Center, VA Salt Lake City Health Care System, 500 Foothill Drive Bldg. 182, Salt Lake City, UT, 84148, USA; Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Damon Toth
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) 2.0 Center, VA Salt Lake City Health Care System, 500 Foothill Drive Bldg. 182, Salt Lake City, UT, 84148, USA; Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Vanessa Stevens
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) 2.0 Center, VA Salt Lake City Health Care System, 500 Foothill Drive Bldg. 182, Salt Lake City, UT, 84148, USA; Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Matthew H Samore
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) 2.0 Center, VA Salt Lake City Health Care System, 500 Foothill Drive Bldg. 182, Salt Lake City, UT, 84148, USA; Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
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Colonization of intestinal microbiota with carbapenemase-producing Enterobacteriaceae in paediatric intensive care units in Cairo, Egypt. Arab J Gastroenterol 2019; 20:19-22. [DOI: 10.1016/j.ajg.2019.01.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 12/26/2018] [Accepted: 01/20/2019] [Indexed: 11/21/2022]
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31
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Zhang C, Grandits T, Härenstam KP, Hauge JB, Meijer S. A systematic literature review of simulation models for non-technical skill training in healthcare logistics. Adv Simul (Lond) 2018; 3:15. [PMID: 30065851 PMCID: PMC6062859 DOI: 10.1186/s41077-018-0072-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 06/25/2018] [Indexed: 12/31/2022] Open
Abstract
Background Resource allocation in patient care relies heavily on individual judgements of healthcare professionals. Such professionals perform coordinating functions by managing the timing and execution of a multitude of care processes for multiple patients. Based on advances in simulation, new technologies that could be used for establishing realistic representations have been developed. These simulations can be used to facilitate understanding of various situations, coordination training and education in logistics, decision-making processes, and design aspects of the healthcare system. However, no study in the literature has synthesized the types of simulations models available for non-technical skills training and coordination of care. Methods A systematic literature review, following the PRISMA guidelines, was performed to identify simulation models that could be used for training individuals in operative logistical coordination that occurs on a daily basis. This article reviewed papers of simulation in healthcare logistics presented in the Web of Science Core Collections, ACM digital library, and JSTOR databases. We conducted a screening process to gather relevant papers as the knowledge foundation of our literature study. The screening process involved a query-based identification of papers and an assessment of relevance and quality. Results Two hundred ninety-four papers met the inclusion criteria. The review showed that different types of simulation models can be used for constructing scenarios for addressing different types of problems, primarily for training and education sessions. The papers identified were classified according to their utilized paradigm and focus areas. (1) Discrete-event simulation in single-category and single-unit scenarios formed the most dominant approach to developing healthcare simulations and dominated all other categories by a large margin. (2) As we approached a systems perspective (cross-departmental and cross-institutional), discrete-event simulation became less popular and is complemented by system dynamics or hybrid modeling. (3) Agent-based simulations and participatory simulations have increased in absolute terms, but the share of these modeling techniques among all simulations in this field remains low. Conclusions An extensive study analyzing the literature on simulation in healthcare logistics indicates a growth in the number of examples demonstrating how simulation can be used in healthcare settings. Results show that the majority of studies create situations in which non-technical skills of managers, coordinators, and decision makers can be trained. However, more system-level and complex system-based approaches are limited and use methods other than discrete-event simulation.
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Affiliation(s)
- Chen Zhang
- School of Engineering Sciences in Chemistry, Biotechnology and Health, Royal Institute of Technology, 2010, Röntgenvägen 1, 14152 Huddinge, Sweden
| | - Thomas Grandits
- School of Engineering Sciences in Chemistry, Biotechnology and Health, Royal Institute of Technology, Hälsovägen 11, 14152 Huddinge, Sweden
| | - Karin Pukk Härenstam
- Pediatric Emergency Department, Karolinska University Hospital, Tomtebodavägen 18a, 17177 Stockholm, Sweden
- Department of Learning, Informatics, Management and Ethics, Karolinska Institute, Tomtebodavägen 18a, 17177 Stockholm, Sweden
| | - Jannicke Baalsrud Hauge
- School of Industrial Engineering and Management, Royal Institute of Technology, Mariekällgatan 3, 15144 Södertälje, Sweden
| | - Sebastiaan Meijer
- School of Engineering Sciences in Chemistry, Biotechnology and Health, Royal Institute of Technology, Hälsovägen 11, 14152 Huddinge, Sweden
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Hwang JH, Park JS, Lee E, Bae JY, Song KH, Choe PG, Park WB, Bang JH, Kim ES, Park SW, Kim NJ, Oh M, Kim HB. Active surveillance for carbapenem-resistant Enterobacteriaceae, vancomycin-resistant enterococci and toxigenic Clostridium difficile among patients transferred from long-term care facilities in Korea. J Hosp Infect 2018; 99:487-491. [PMID: 29476883 DOI: 10.1016/j.jhin.2018.02.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 02/15/2018] [Indexed: 11/28/2022]
Abstract
A 10-month active surveillance study was conducted to assess carriage of carbapenemase-producing Enterobacteriaceae (CPE), vancomycin-resistant enterococci (VRE) and toxigenic Clostridium difficile colonization among patients transferred to hospital from long-term care facilities (LTCFs). Four (1.4%) patients with carbapenem-resistant Enterobacteriaceae (none of which were CPE), 59 (21%) patients with VRE and 20 (7.1%) patients colonized with toxigenic C. difficile were identified from 282 rectal specimens. There was no outbreak of VRE infection during the study period. The low prevalence of CPE carriage suggests that screening all admissions from LTCFs for CPE would not be cost-effective, and that screening and use of contact precautions for VRE should be reconsidered.
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Affiliation(s)
- J-H Hwang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - J S Park
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - E Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - J Y Bae
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - K-H Song
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - P G Choe
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - W B Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - J H Bang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - E S Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - S W Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - N J Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - M Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - H B Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
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