Patient experience of hospital screening for carbapenemase-producing Enterobacteriaceae: A qualitative study

Understanding the lived-experience and support-needs of people living with antimicrobial resistance in the UK through interpretative phenomenological analysis

In the UK nearly 54,000 infections were caused by serious resistant bacteria in 2022 but there is a lack of evidence regarding the long-term impact on patients' lives nor what support they need. This research aimed to answer the question: "What are the key elements of experience and support needs of people living with AMR in the UK?". In-depth semi-structured interviews were undertaken with nine people who had been living with resistant infections or colonisation for 12-months or longer. Interpretive Phenomenological Analysis was used to study the accounts and illustrate individuals' experiences and support-needs. Participants experienced marginalisation and isolation but also empowerment; described across three major themes: (1) I live in fear and stigma: The long-term impact of AMR; (2) I am battling on my own: A journey toward self-advocacy; and (3) I like to share my story: The role of AMR communities. All participants perceived a lack of knowledge, information, and support from clinicians; difficulties accessing reliable and understandable information; and lack of understanding from family and friends. Charities and online groups provided support with coping with their situation and improving mental health and wellbeing. Understandable and relatable information regarding the science of AMR, transmission, prevention, and living with AMR needs to be provided by clinicians and healthcare services around the time of diagnosis to readily available after diagnosis.

Model-based evaluation of admission screening strategies for the detection and control of carbapenemase-producing Enterobacterales in the English hospital setting

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.

Adverse Events Associated with Patient Isolation: A Systematic Literature Revue and Meta-analysis

BACKGROUND

Patient isolation is widely recommended and used in healthcare institutions to prevent transmission of MDRO. However, its risk-benefit ratio is debated.

AIM

We undertook a systematic literature review and meta-analysis since 2009 to assess, based on the newly published studies, whether or not there are physical and psychological adverse events associated with patient isolation.

METHODS

Systematic literature review and meta-analysis were performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Studies were systematically searched from PubMed, from the 1^st of may 2009 till the 31^st of January 2020. The concepts of the research questions were defined as: "Adverse events", "patient isolation or cohorting", and "multi-drug resistant organisms colonized or infection patients". Three reviewers independently screened studies and extracted data. All statistical analysis was performed with Stata Software and R.

FINDINGS

After screening titles of 15921 articles, abstracts of 196 and reviewing full texts of 50 studies, we included 19 studies. Studies were divided into 3 groups: 4 qualitative studies, 7 observational studies suitable for meta-analysis and 8 other observational studies. Meta-analysis shows no adverse events related to clinical care or patient's experience associated with patient isolation.

CONCLUSIONS

More studies with correct methodology, including a control group and standardized inclusion criteria, must be conducted to confirm our results.

Perceived barriers and enablers for preventing the spread of carbapenem producing gram-negative bacteria during patient transfers: a mixed methods study among healthcare providers

BACKGROUND

Antimicrobial resistance (AMR) increasingly threatens public health. Carbapenem-producing gram-negative bacteria (CPB) pose the biggest threat. The risk for CPB spread is heightened during the transfer of a CPB-positive patient between different healthcare institutions or healthcare providers. We aimed to gain insight into the frequency of CPB-positive patients in the Dutch provinces of Noord-Holland (NH) and Flevoland (FL). Secondly, we aimed to obtain a deeper understanding of the communication between healthcare providers during transfers of CPB-positive patients and explore possible communication-related risk situations for CPB spread.

METHODS

This mixed-methods study consisted of a quantitative and qualitative section. For the quantitative section, 14 laboratories that provide diagnostics in NH and FL voluntarily reported carbapenem-producing Enterobacteriaceae (CPE) positive patients between February 2018 and February 2019. Additionally, two laboratories reported carbapenem-resistant Acinetobacter spp. (CRA) and carbapenem-resistant Pseudomonas aeruginosa (CRP) positive patients. For the qualitative section, healthcare providers of reported patients were interviewed about information exchange during patient transfers, precautionary measures and knowledge and beliefs concerning CPB.

RESULTS

In total, 50 CPE-positive, 10 CRA-positive and 4 CRP-positive patients were reported during the inclusion period. Eighteen index-specific and 2 general interviews were conducted with 20 different care providers of 9 patients. The interviews revealed that, in most cases, information concerning the patient was transferred timely, but often a standardized method for sharing the information within and between institutions was lacking. Factors that enhanced care providers' motivation to adhere to precautionary measures were taking responsibility for the health of other patients, (pregnant) colleagues and for ones own health. Factors that reduced motivation were not acknowledging the relevance of the precautionary measures, a perceived negative impact of the measures on patients' recovery, differences in precautionary measures between healthcare settings and incomprehension for changes in precautionary measures.

CONCLUSIONS

CPB-positivity occurred more frequently than expected in the Dutch provinces of NH and FL. Standardizing the transference of information concerning CPB-positive patients, implementing transmural agreements, training personnel on CPB knowledge and procedures, launching a national website on CPB and assigning one or several designated employees for CPB within healthcare institutions could improve communication between healthcare providers and thereby decrease the risk of CPB transmission.