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Effectiveness of healthcare worker screening in hospital outbreaks with gram-negative pathogens: a systematic review. Antimicrob Resist Infect Control 2018; 7:36. [PMID: 29556377 PMCID: PMC5845297 DOI: 10.1186/s13756-018-0330-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 02/25/2018] [Indexed: 01/26/2023] Open
Abstract
Background Identifying the source of an outbreak is the most crucial aspect of any outbreak investigation. In this review, we address the frequently discussed question of whether (rectal) screening of health care workers (HCWs) should be carried out when dealing with outbreaks caused by gram negative bacteria (GNB). A systematic search of the medical literature was performed, including the Worldwide Outbreak Database and PubMed. Outbreaks got included if a HCW was the source of the outbreak and the causative pathogen was an Escherichia coli, Klebsiella spp., Enterobacter spp., Serratia spp., Pseudomonas aeruginosa, or Acinetobacter baumannii. This was true for 25 articles in which there were 1196 (2.1%) outbreaks due to GNB, thereof 14 HCWs who were permanently colonized by the outbreak strain. Rectal screening of HCWs was helpful in only 2 of the 1196 (0.2%) outbreaks. Instead, the hands of HCWs served as a reservoir for the outbreak strain in at least 7 articles – especially when they suffered from onychomycosis or used artificial fingernails or rings. Conclusion Due to very weak evidence, we do not recommend rectal screening of HCWs in an outbreak situation with GNB. However, besides a critical review of hand hygiene habits, it might be useful to examine the hands of staff carefully. This measure is cheap, quick to perform, and seems to be quite effective. Electronic supplementary material The online version of this article (10.1186/s13756-018-0330-4) contains supplementary material, which is available to authorized users.
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Stapleton PJM, Murphy M, McCallion N, Brennan M, Cunney R, Drew RJ. Outbreaks of extended spectrum beta-lactamase-producing Enterobacteriaceae in neonatal intensive care units: a systematic review. Arch Dis Child Fetal Neonatal Ed 2016; 101:F72-8. [PMID: 26369370 DOI: 10.1136/archdischild-2015-308707] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 08/27/2015] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To establish the number of outbreaks of extended spectrum beta-lactamase (ESBL) producing organisms in neonatal intensive care units (NICUs), to determine causes, mortality rates, proportions of infants colonised and infected and the interventions that terminated outbreaks. METHODS A systematic review of the literature in English, Spanish and French was undertaken with searches in four databases. The review conformed to the PRISMA guidelines, and the data extraction was modelled on the ORION criteria for studies of nosocomial infection. RESULTS 75 studies fulfilled the inclusion criteria. There were 1185 cases of colonisation, 860 infections and 139 deaths. The median outbreak duration was 6.2 months (IQR 2.0-7.5 months). Klebsiella pneumoniae was the most frequently implicated pathogen. Understaffing was the most frequent risk factor for outbreaks. The most commonly identified source was admission of an ESBL-colonised infant with subsequent horizontal dissemination. The main interventions described were improved infection-control procedures and screening of staff and the environment. 26 studies were included in the quantitative analysis. Random effects meta-analysis indicated high mortality rates in infants who developed infection (31%, 95% CI 20% to 43%). CONCLUSION ESBL outbreaks in NICUs are associated with significant mortality and prolonged disruption. Understaffing is a major risk factor, but is infrequently addressed by interventions. Poor infection-control procedures are frequently implicated as contributing to ESBL spread. Better reporting of outbreaks may help clarify the role for routine ESBL screening in NICUs.
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Affiliation(s)
- Patrick J M Stapleton
- Department of Microbiology, Temple Street Children's University Hospital, Dublin, Ireland
| | | | - Naomi McCallion
- Department of Neonatology, Rotunda Hospital, Dublin, Ireland Department of Paediatrics, Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Marion Brennan
- Department of Midwifery, Rotunda Hospital, Dublin, Ireland
| | - Robert Cunney
- Department of Microbiology, Temple Street Children's University Hospital, Dublin, Ireland HSE Health Protection Surveillance Centre, Dublin, Ireland
| | - Richard J Drew
- Department of Microbiology, Rotunda Hospital, Dublin, Ireland Department of Microbiology, Royal College of Surgeons of Ireland, Dublin, Ireland
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Hendrik TC, Voor in ‘t holt AF, Vos MC. Clinical and Molecular Epidemiology of Extended-Spectrum Beta-Lactamase-Producing Klebsiella spp.: A Systematic Review and Meta-Analyses. PLoS One 2015; 10:e0140754. [PMID: 26485570 PMCID: PMC4617432 DOI: 10.1371/journal.pone.0140754] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 09/30/2015] [Indexed: 12/30/2022] Open
Abstract
Healthcare-related infections caused by extended-spectrum beta-lactamase (ESBL)-producing Klebsiella spp. are of major concern. To control transmission, deep understanding of the transmission mechanisms is needed. This systematic review aimed to identify risk factors and sources, clonal relatedness using molecular techniques, and the most effective control strategies for ESBL-producing Klebsiella spp. A systematic search of PubMed, Embase, and Outbreak Database was performed. We identified 2771 articles from November 25th, 1960 until April 7th, 2014 of which 148 were included in the systematic review and 23 in a random-effects meta-analysis study. The random-effects meta-analyses showed that underlying disease or condition (odds ratio [OR] = 6.25; 95% confidence interval [CI] = 2.85 to 13.66) generated the highest pooled estimate. ESBL-producing Klebsiella spp. were spread through person-to-person contact and via sources in the environment; we identified both monoclonal and polyclonal presence. Multi-faceted interventions are needed to prevent transmission of ESBL-producing Klebsiella spp.
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Affiliation(s)
- Tirza C. Hendrik
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Anne F. Voor in ‘t holt
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Margreet C. Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- * E-mail:
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Calbo E, Garau J. The changing epidemiology of hospital outbreaks due to ESBL-producing Klebsiella pneumoniae: the CTX-M-15 type consolidation. Future Microbiol 2015; 10:1063-75. [DOI: 10.2217/fmb.15.22] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Klebsiella pneumoniae is responsible for a large number of hospital outbreaks. In the 1990s, there were clonal epidemics, affecting mostly intensive care patients, which carried SHV and TEM enzyme types. With the advent of CTX-M-15 enzymes in the 2000, plasmids encoding multiple extended-spectrum β-lactamase (ESBL) types were described and, frequently, nosocomial outbreaks reported polyclonal dissemination and involved multiple Enterobacteriaceae. Worryingly, the interface between community and hospital is becoming blurred, and there is increasing evidence for the presence of ESBL-producing K. pneumoniae in the community. Furthermore, carbapenem resistance is increasingly reported in ESBL-producing K. pneumoniae strains. Infection control measures and stewardship programs are vital weapons in controlling the pandemic evolution of multidrug-resistant K. pneumoniae.
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Affiliation(s)
- Esther Calbo
- Service of Internal Medicine, Infectious Disease Unit, Hospital Universitari Mútua de Terrassa, Plaza Dr Robert 5, 08221 Terrassa, Barcelona, Spain
| | - Javier Garau
- Service of Internal Medicine, Infectious Disease Unit, Hospital Universitari Mútua de Terrassa, Plaza Dr Robert 5, 08221 Terrassa, Barcelona, Spain
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Maciel ALP, de Assis DB, Madalosso G, Padoveze MC. Evaluating the quality of outbreak reports on health care-associated infections in São Paulo, Brazil, during 2000-2010 using the ORION statement findings and recommendations. Am J Infect Control 2014; 42:e47-53. [PMID: 24679583 DOI: 10.1016/j.ajic.2013.12.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 12/18/2013] [Accepted: 12/19/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND The standard of outbreak reports must be improved to a level where they are robust enough to properly influence preventive strategies. We aimed to verify compliance with mandatory outbreak notification, describing epidemiologic characteristics and management, and evaluating the quality of outbreak reports on health care-associated infections in São Paulo State, Brazil. METHODS A systematic search was carried out on PubMed, the Latin American and Caribbean Health Sciences Literature database, Embase, Outbreak Database, the Annals of Brazilian Conferences on Healthcare-Associated Infection Prevention and Infectious Diseases, and reports from the São Paulo State Hospital Infection Division. The quality of reports was evaluated according to the Outbreak Reports and Intervention studies of Nosocomial Infection (ORION) statement guidelines. RESULTS A total of 87 outbreak reports were identified; however, only 15 outbreaks (17.2%) were reported to the São Paulo State Hospital Infection Division. Bloodstream infection and neonatal intensive care units were mostly implicated (23% and 19.5%, respectively). Quality, evaluated according to ORION statement recommendations, was generally poor. The ORION categories of Background, Objectives, Participants, Setting, Infection-Related Outcomes, and Generality were properly described in 32.2%, 74.7%, 2.3%, 46%, 2.3%, and 12.6% of reports, respectively. Interventions and Culture-Typing were described with details in 51.9% and 55.2% of outbreak reports, respectively. CONCLUSIONS Our findings pointed out the need for strategies to improve competence in outbreak reports, and the ORION statement guidelines may help in this matter. Efforts to promote confidence and consequent compliance with mandatory notification of outbreak reports are essential.
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Maltezou HC, Papacharalambous E, Tryfinopoulou K, Ftika L, Maragos A, Kyriakeli G, Katerelos P, Trakateli C, Polemis M, Roilides E, Vatopoulos A, Nikolaidis N. Outbreak of pan-susceptible Klebsiella pneumoniae in a neonatal intensive care unit. ACTA ACUST UNITED AC 2013; 45:872-7. [PMID: 23902586 DOI: 10.3109/00365548.2013.816441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We describe the outbreak of a pan-susceptible Klebsiella pneumoniae strain in a neonatal intensive care unit. A total of 7 neonates developed bacteraemia (37% attack rate), of whom 3 died (43% case fatality rate). A birth weight < 1500 g was the only statistically significant risk factor. Despite an extensive environmental investigation, the source was not identified.
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Affiliation(s)
- Helena C Maltezou
- From the 1 Department for Interventions in Health Care Facilities, Hellenic Centre for Disease Control and Prevention , Athens
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Rettedal S, Löhr IH, Natås O, Sundsfjord A, Øymar K. Risk factors for acquisition of CTX-M-15 extended-spectrum beta-lactamase-producing Klebsiella pneumoniae during an outbreak in a neonatal intensive care unit in Norway. ACTA ACUST UNITED AC 2012; 45:54-8. [DOI: 10.3109/00365548.2012.713116] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Tomblyn M, Chiller T, Einsele H, Gress R, Sepkowitz K, Storek J, Wingard JR, Young JAH, Boeckh MJ, Boeckh MA. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant 2009; 15:1143-238. [PMID: 19747629 PMCID: PMC3103296 DOI: 10.1016/j.bbmt.2009.06.019] [Citation(s) in RCA: 1147] [Impact Index Per Article: 76.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Accepted: 06/23/2009] [Indexed: 02/07/2023]
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Risk factors for colonisation of newborn infants during an outbreak of extended-spectrum β-lactamase-producing Klebsiella pneumoniae in an intermediate-risk neonatal unit. J Hosp Infect 2009; 71:340-7. [DOI: 10.1016/j.jhin.2008.11.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Accepted: 11/14/2008] [Indexed: 11/20/2022]
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Abstract
BACKGROUND Hospitalized neonates are exposed to antibiotic-resistant bacterial pathogens and develop nosocomial infections. Limited data are available regarding the neonatal pharmacokinetics of meropenem, a broad spectrum carbapenem antibiotic. METHODS Neonates <2 months of age received a single dose of meropenem at 10 or 20 mg/kg. Meropenem serum concentrations were measured at specified times during the 24 hours postinfusion. Population pharmacokinetics (PPK) were evaluated using NONMEM. Using Monte Carlo simulation (MCS), the probability of pharmacokinetic-pharmacodynamic target attainment was evaluated by computer modeling from predictions extrapolated from PPK data, using "virtual" dosing regimens of 10, 20, and 40 mg/kg administered every 8 or 12 hours against community- and hospital-acquired pathogens. RESULTS Thirty-seven neonates were enrolled, 22 were born at <36 weeks (range, 23-41 weeks) gestational age. Meropenem clearance was greater in neonates with older chronologic ages and in those born at later gestational ages. Serum creatinine and postconceptional age (PCA) were the best overall predictors of meropenem elimination: CL (L/h/kg) = 0.041 + 0.040/SCr + 0.003 x (PCA-35). MCS demonstrated that in infants during the first 2 weeks of life, a dosage of 20 mg/kg/dose every 8 hours achieved the desired PD target in 95% of preterm neonates and 91% of term neonates against Pseudomonas aeruginosa isolated from patients managed in adult and pediatric intensive care units in the United States. CONCLUSIONS MCS based on PPK determinations demonstrated that a meropenem dose of 20 mg/kg every 8 hours should provide adequate therapy for most nosocomial Gram-negative pathogens.
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Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control 2007; 35:S65-164. [PMID: 18068815 PMCID: PMC7119119 DOI: 10.1016/j.ajic.2007.10.007] [Citation(s) in RCA: 1626] [Impact Index Per Article: 95.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Lautenbach E, Polk RE. Resistant gram-negative bacilli: A neglected healthcare crisis? Am J Health Syst Pharm 2007; 64:S3-21; quiz S22-4. [DOI: 10.2146/ajhp070477] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Ebbing Lautenbach
- University of Pennsylvania School of Medicine, 825 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021
| | - Ron E. Polk
- Department of Pharmacy, School of Pharmacy, Virginia Commonwealth University/Medical College of Virginia Campus, 410 North 12th Street, PO Box 980533, Richmond, VA 23298-0533
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Gilad J, Borer A. Prevention of catheter-related bloodstream infections in the neonatal intensive care setting. Expert Rev Anti Infect Ther 2007; 4:861-73. [PMID: 17140361 DOI: 10.1586/14787210.4.5.861] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Nosocomial infection causes substantial morbidity and mortality among neonates treated in the neonatal intensive care setting. Colonization and subsequent infection of central venous catheters leading to catheter-related bloodstream infection is among the most common causes of nosocomial sepsis in this patient population. Prevention of catheter-related bloodstream infection is a major challenge and numerous strategies have been attempted in this context with varying success. Given the dynamic epidemiology of nosocomial infection among neonates and the emergence of antimicrobial resistance, novel prevention strategies are urgently required.
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Affiliation(s)
- Jacob Gilad
- Clinical Microbiology Laboratory, Tel-Aviv Sourasky Medical Center, 6 Weizman St., Tel-Aviv 64239, Israel.
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Pittet D, Allegranzi B, Sax H, Dharan S, Pessoa-Silva CL, Donaldson L, Boyce JM. Evidence-based model for hand transmission during patient care and the role of improved practices. THE LANCET. INFECTIOUS DISEASES 2006; 6:641-52. [PMID: 17008173 DOI: 10.1016/s1473-3099(06)70600-4] [Citation(s) in RCA: 446] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Hand cleansing is the primary action to reduce health-care-associated infection and cross-transmission of antimicrobial-resistant pathogens. Patient-to-patient transmission of pathogens via health-care workers' hands requires five sequential steps: (1) organisms are present on the patient's skin or have been shed onto fomites in the patient's immediate environment; (2) organisms must be transferred to health-care workers' hands; (3) organisms must be capable of surviving on health-care workers' hands for at least several minutes; (4) handwashing or hand antisepsis by the health-care worker must be inadequate or omitted entirely, or the agent used for hand hygiene inappropriate; and (5) the caregiver's contaminated hand(s) must come into direct contact with another patient or with a fomite in direct contact with the patient. We review the evidence supporting each of these steps and propose a dynamic model for hand hygiene research and education strategies, together with corresponding indications for hand hygiene during patient care.
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Affiliation(s)
- Didier Pittet
- Infection Control Programme, University of Geneva Hospitals, Geneva, Switzerland.
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