A National Intervention to Prevent the Spread of Carbapenem-Resistant Enterobacteriaceae in Israeli Post-Acute Care Hospitals

2014 ◽  
Vol 35 (7) ◽  
pp. 802-809 ◽  
Author(s):  
Debby Ben-David ◽  
Samira Masarwa ◽  
Amos Adler ◽  
Hagit Mishali ◽  
Yehuda Carmeli ◽  
...  
Keyword(s):  
Infection Control ◽  
Acute Care ◽  
Acute Care Hospitals ◽  
Control Measures ◽  
Resistant Bacteria ◽  
Carbapenem Resistant ◽  
Control Intervention ◽  
The Impact ◽  
Carbapenem Resistant Enterobacteriaceae ◽  
Post Acute Care

ObjectivePatients hospitalized in post-acute care hospitals (PACHs) constitute an important reservoir of antimicrobial-resistant bacteria. High carriage prevalence of carbapenem-resistant Enterobacteriaceae (CRE) has been observed among patients hospitalized in PACHs. The objective of the study is to describe the impact of a national infection control intervention on the prevalence of CRE in PACHs.DesignA prospective cohort interventional study.SettingThirteen PACHs in Israel.InterventionA multifaceted intervention was initiated between 2008 and 2011 as part of a national program involving all Israeli healthcare facilities. The intervention has included (1) periodic on-site assessments of infection control policies and resources, using a score comprised of 16 elements; (2) assessment of risk factors for CRE colonization; (3) development of national guidelines for CRE control in PACHs involving active surveillance and contact isolation of carriers; and (4) 3 cross-sectional surveys of rectal carriage of CRE that were conducted in representative wards.ResultsThe infection control score increased from 6.8 to 14.0 (P < .001) over the course of the study period. A total of 3,516 patients were screened in the 3 surveys. Prevalence of carriage among those not known to be carriers decreased from 12.1% to 7.9% (P = .008). Overall carrier prevalence decreased from 16.8% to 12.5% (P = .013). Availability of alcohol-based hand rub, appropriate use of gloves, and a policy of CRE surveillance at admission to the hospital were independently associated with lower new carrier prevalence.ConclusionA nationwide infection control intervention was associated with enhanced infection control measures and a reduction in the prevalence of CRE in PACHs.

scholarly journals How Long-Term Acute Care Hospitals Can Play an Important Role in Controlling Carbapenem-Resistant Enterobacteriaceae in a Region: A Simulation Modeling Study

2020 ◽  
Author(s):  
Bruce Y Lee ◽  
Sarah M Bartsch ◽  
Michael Y Lin ◽  
Lindsey Asti ◽  
Joel Welling ◽  
...  
Keyword(s):  
Intensive Care ◽  
Intensive Care Units ◽  
Acute Care ◽  
Acute Care Hospitals ◽  
Control Measures ◽  
Metropolitan Region ◽  
Drug Resistant ◽  
Carbapenem Resistant ◽  
Carbapenem Resistant Enterobacteriaceae

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.

National Policy for Carbapenem-Resistant Enterobacteriaceae (CRE) Clearance and Discontinuation of Contact Precautions for CRE Carriers in Post–Acute Care Hospitals in Israel: Impact on Isolation-Days and New Acquisitions

2020 ◽  
Author(s):  
Debby Ben-David ◽  
Samira Masarwa ◽  
Noga Fallach ◽  
Elizabeth Temkin ◽  
Ester Solter ◽  
...  
Keyword(s):  
Acute Care ◽  
National Policy ◽  
Acute Care Hospitals ◽  
Carrier Status ◽  
Median Percentage ◽  
Contact Isolation ◽  
Carbapenem Resistant ◽  
Ward Level ◽  
Carbapenem Resistant Enterobacteriaceae ◽  
Post Acute Care

Abstract Background In 2009, the Israeli Ministry of Health implemented in post–acute care hospitals (PACHs) a process of discontinuing carbapenem-resistant Enterobacteriaceae (CRE) carrier status. We evaluated the policy’s impact on isolation-days, CRE prevalence among known carriers who had completed clearance testing, and CRE acquisition among noncarriers. Methods This retrospective study summarized findings from all 15 PACHs in 2009–2017. CRE carriers were considered cleared and removed from contact isolation after 2 rectal cultures negative for CRE and polymerase chain reaction negative for carbapenemases. Data sources included routine surveillance and 4 point prevalence surveys conducted from 2011 to 2017. Results During the study period, 887 of 6101 CRE carriers (14.5%) completed clearance testing. From 2013 to 2016, the percentage of patient-days in CRE isolation decreased from 9.4% to 3.9% (P = .008). In all surveys combined, there were 819 known CRE carriers; 411 (50%) had completed clearance testing. Of these, 11.4% (47/411) were CRE positive in the survey. At the ward level, the median percentage of patients with no CRE history who were positive on survey decreased from 11.3% in 2011 to 0% in 2017 (P &lt; .001). We found no ward-level correlation between the proportion of carriers who completed clearance and new acquisitions (ρ = 0.02, P = .86). Conclusions A process for discontinuing CRE carrier status in PACHs led to a significant reduction in the percentage of patient-days in contact isolation without increasing CRE acquisitions among noncarriers.

scholarly journals Neonates with Maternal Colonization of Carbapenemase-Producing, Carbapenem-Resistant Enterobacteriaceae: A Mini-Review and a Suggested Guide for Preventing Neonatal Infection

Children ◽  
2021 ◽  
Vol 8 (5) ◽  
pp. 399
Author(s):  
Judy Seesahai ◽  
Paige Terrien Church ◽  
Elizabeth Asztalos ◽  
Melanee Eng-Chong ◽  
Jo Arbus ◽  
...  
Keyword(s):  
Neonatal Intensive Care ◽  
Neonatal Infection ◽  
Control Measures ◽  
Resistant Bacteria ◽  
Negative Consequences ◽  
Duration Of Treatment ◽  
Contact Precautions ◽  
Carbapenem Resistant ◽  
Carbapenem Resistant Enterobacteriaceae

Carbapenemase-producing, carbapenem-resistant Enterobacteriaceae (CP-CRE) are highly drug-resistant Gram-negative bacteria. They include New Delhi metallo-ß-lactamase (NDM)-producing carbapenemase (50.4% of all species in Ontario). Antibiotic challenges for resistant bacteria in neonates pose challenges of unknown dosing and side effects. We report two antenatally diagnosed CP-CRE colonization scenarios with the NDM 1 gene. The case involves extreme preterm twins who had worsening respiratory distress at birth requiring ventilator support, with the first twin also having cardiovascular instability. They were screened for CP-CRE, and a polymyxin antibiotic commenced. In the delivery room, neonatal intensive care unit (NICU) and the follow-up clinic, in collaboration with the interdisciplinary group, contact precautions and isolation procedures were instituted. None of the infants exhibited infection with CP-CRE. Consolidating knowledge with regard to CP-CRE and modifying human behavior associated with its spread can mitigate potential negative consequences. This relates to now and later, when travel and prolific human to human contact resumes, from endemic countries, after the current COVID-19 pandemic. Standardized efforts to curb the acquisition of this infection would be judicious given the challenges of treatment and continued emerging antibiotic resistance. Simple infection control measures involving contact precautions, staff education and parental cohorting can be useful and cost-effective in preventing transmission. Attention to NICU specific measures, including screening of at-risk mothers (invitro fertilization conception) and their probands, careful handling of breastmilk, judicious antibiotic choice and duration of treatment, is warranted. What does this study add? CP-CRE is a nosocomial infection with increasing incidence globally, and a serious threat to public health, making it likely that these cases will present with greater frequency to the NICU team. Only a few similar cases have been reported in the neonatal literature. Current published guidelines provide a framework for general hospital management. Still, they are not specific to the NICU experience and the need to manage the parents’ exposure and the infants. This article provides a holistic framework for managing confirmed or suspected cases of CP-CRE from the antenatal care through the NICU and into the follow-up clinic targeted at preventing or containing the spread of CP-CRE.

scholarly journals Antimicrobial Stewardship Program, COVID-19, and Infection Control: Spread of Carbapenem-Resistant Klebsiella Pneumoniae Colonization in ICU COVID-19 Patients. What Did Not Work?

2020 ◽  
Vol 9 (9) ◽  
pp. 2744 ◽  
Author(s):  
Beatrice Tiri ◽  
Emanuela Sensi ◽  
Viola Marsiliani ◽  
Mizar Cantarini ◽  
Giulia Priante ◽  
...  
Keyword(s):  
Klebsiella Pneumoniae ◽  
Infection Control ◽  
Prone Position ◽  
Antimicrobial Stewardship ◽  
Control Measures ◽  
Resistant Bacteria ◽  
Infection Control Measures ◽  
Carbapenem Resistant ◽  
Stewardship Program ◽  
Prolonged Contact

The Italian burden of disease associated with infections due to antibiotic-resistant bacteria has been very high, largely attributed to Carbapenem-Resistant Klebsiella pneumoniae (CR-Kp). The implementation of infection control measures and antimicrobial stewardship programs (ASP) has been shown to reduce healthcare-related infections caused by multidrug resistance (MDR) germs. Since 2016, in our teaching hospital of Terni, an ASP has been implemented in an intensive care unit (ICU) setting, with the “daily-ICU round strategy” and particular attention to infection control measures. We performed active surveillance for search patients colonized by Carbapenem-Resistant Enterobacteriaceae (CRE). In March 2020, coronavirus disease 2019 (COVID-19) arrived and the same ICU was reserved only for COVID-19 patients. In our retrospective observational study, we analyzed the bimonthly incidence of CRE colonization patients and the incidence of CRE acquisition in our ICU during the period of January 2019 to June 2020. In consideration of the great attention and training of all staff on infection control measures in the COVID-19 era, we would have expected a clear reduction in CRE acquisition, but this did not happen. In fact, the incidence of CRE acquisition went from 6.7% in 2019 to 50% in March–April 2020. We noted that 67% of patients that had been changed in posture with prone position were colonized by CRE, while only 37% of patients that had not been changed in posture were colonized by CRE. In our opinion, the high intensity of care, the prone position requiring 4–5 healthcare workers (HCWs), equipped with personal protective equipment (PPE) in a high risk area, with extended and prolonged contact with the patient, and the presence of 32 new HCWs from other departments and without work experience in the ICU setting, contributed to the spread of CR-Kp in our ICU, determining an increase in CRE acquisition colonization.

Much to Do about Carbapenem-Resistant Enterobacteriaceae: Why Supplementing Surveillance May Be the Key to Stopping Spread

2014 ◽  
Vol 35 (8) ◽  
pp. 984-986 ◽  
Author(s):  
Christopher D. Pfeiffer ◽  
Zintars G. Beldavs
Keyword(s):  
Public Health ◽  
Acute Care ◽  
Artery Bypass ◽  
Vital Signs ◽  
Surgical Site Infections ◽  
Acute Care Hospitals ◽  
Colon Surgery ◽  
The United States ◽  
Carbapenem Resistant ◽  
Carbapenem Resistant Enterobacteriaceae

(See the article by Thaden et al, on pages 978–983.)It is critical to the future of public health to understand the burden of carbapenem-resistant Enterobacteriaceae (CRE) so that we can effectively target efforts to limit potential spread. The Centers for Disease Control and Prevention (CDC) classifies CRE as 1 of 3 “urgent” antibiotic resistance threats to public health because of the high mortality associated with CRE infection and its rapid dissemination in the United States.What is the current burden of CRE disease? We can glean a snapshot of the national epidemiology of CRE from the CDC’s national surveillance. Rapid geographic spread is evident in the CDC’s national map of CRE, which indicates that all but 3 states now have identified CRE. Incidence by facility type, procedure, device, and organism all have considerable variation, providing preliminary indications where future prevention efforts might best be focused. The 2013 CRE Vital Signs states that 3.9% of short-stay acute care hospitals and 17.8% of long-term acute care hospitals have identified cases of CRE infection among those with catheter-associated urinary tract infection (CAUTI) or central line–associated bloodstream infection (CLABSI). The CDC also reported that 10% of Klebsiella species in intensive care unit (ICU) CLABSIs, ICU CAUTIs, and surgical site infections after colon surgery or coronary artery bypass grafting in 2011 were carbapenem resistant. Although CRE have been reported in most states, it is increasingly clear that wide regional variation exists, from regions of hyperendemicity, such as parts of New York City, to regions apparently free of CRE, such as Maine.

Evaluating Movement of Patients With Carbapenem-resistant Enterobacteriaceae Infections in the Greater Atlanta Metropolitan Area Using Social Network Analysis

2019 ◽  
Vol 70 (1) ◽  
pp. 75-81 ◽  
Author(s):  
Chris W Bower ◽  
Daniel W Fridkin ◽  
Hannah M Wolford ◽  
Rachel B Slayton ◽  
Julianne N Kubes ◽  
...  
Keyword(s):  
Acute Care ◽  
Metropolitan Area ◽  
Acute Care Hospitals ◽  
Population Based ◽  
Nursing Facilities ◽  
Medicare Patient ◽  
Patient Movement ◽  
Carbapenem Resistant ◽  
Centrality Metrics ◽  
Carbapenem Resistant Enterobacteriaceae

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 &lt; .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.

scholarly journals Infection Control for a Carbapenem-Resistant Enterobacteriaceae Outbreak in an Advanced Emergency Medical Services Center

Antibiotics ◽  
2021 ◽  
Vol 10 (12) ◽  
pp. 1537
Author(s):  
Yoshiro Sakai ◽  
Kenji Gotoh ◽  
Ryuichi Nakano ◽  
Jun Iwahashi ◽  
Miho Miura ◽  
...  
Keyword(s):  
Infection Control ◽  
Medical Service ◽  
Control Measures ◽  
Infection Control Team ◽  
Partial Closure ◽  
Infection Control Measures ◽  
Carbapenem Resistant ◽  
Emergency Medical ◽  
Lactamase Gene ◽  
Carbapenem Resistant Enterobacteriaceae

Background: A carbapenem-resistant Enterobacteriaceae (CRE) outbreak occurred in an advanced emergency medical service center [hereafter referred to as the intensive care unit (ICU)] between 2016 and 2017. Aim: Our objective was to evaluate the infection control measures for CRE outbreaks. Methods: CRE strains were detected in 16 inpatients located at multiple sites. Environmental cultures were performed and CRE strains were detected in 3 of 38 sites tested. Pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), and detection of β-lactamase genes were performed against 25 CRE strains. Findings: Molecular typing showed the PFGE patterns of two of four Klebsiella pneumoniae strains were closely related and the same MLST (ST2388), and four of five Enterobacter cloacae strains were closely related and same MLST (ST252). Twenty-three of 25 CRE strains harbored the IMP-1 β-lactamase gene and 15 of 23 CRE strains possessed IncFIIA replicon regions. Despite interventions by the infection control team, new inpatients with the CRE strain continued to appear. Therefore, the ICU was partially closed and the inpatients with CRE were isolated, and the ICU staff was divided into two groups between inpatients with CRE and non-CRE strains to avoid cross-contamination. Although the occurrence of new cases dissipated quickly after the partial closure, a few months were required to eradicate the CRE outbreak. Conclusion: Our data suggest that the various and combined measures that were used for infection control were essential in stopping this CRE outbreak. In particular, partial closure to isolate the ICU and division of the ICU staff were effective.

scholarly journals Knowing More of the Iceberg: How Detecting a Greater Proportion of Carbapenem-Resistant Enterobacteriaceae Carriers Influences Transmission

2019 ◽  
Vol 221 (11) ◽  
pp. 1782-1794 ◽  
Author(s):  
Sarah M Bartsch ◽  
Kim F Wong ◽  
Owen J Stokes-Cawley ◽  
James A McKinnell ◽  
Chenghua Cao ◽  
...  
Keyword(s):  
Control Measures ◽  
Infection Prevention And Control ◽  
Healthcare Facilities ◽  
Contact Precautions ◽  
Carbapenem Resistant ◽  
Adult Inpatient ◽  
Prevention And Control Measures ◽  
And Control ◽  
The Impact ◽  
Carbapenem Resistant Enterobacteriaceae

Abstract Background Clinical testing detects a fraction of carbapenem-resistant Enterobacteriaceae (CRE) carriers. Detecting a greater proportion could lead to increased use of infection prevention and control measures but requires resources. Therefore, it is important to understand the impact of detecting increasing proportions of CRE carriers. Methods We used our Regional Healthcare Ecosystem Analyst–generated agent-based model of adult inpatient healthcare facilities in Orange County, California, to explore the impact that detecting greater proportions of carriers has on the spread of CRE. Results Detecting and placing 1 in 9 carriers on contact precautions increased the prevalence of CRE from 0% to 8.0% countywide over 10 years. Increasing the proportion of detected carriers from 1 in 9 up to 1 in 5 yielded linear reductions in transmission; at proportions &gt;1 in 5, reductions were greater than linear. Transmission reductions did not occur for 1, 4, or 5 years, varying by facility type. With a contact precautions effectiveness of ≤70%, the detection level yielding nonlinear reductions remained unchanged; with an effectiveness of &gt;80%, detecting only 1 in 5 carriers garnered large reductions in the number of new CRE carriers. Trends held when CRE was already present in the region. Conclusion Although detection of all carriers provided the most benefits for preventing new CRE carriers, if this is not feasible, it may be worthwhile to aim for detecting &gt;1 in 5 carriers.

scholarly journals 1. Incidence of Nosocomial COVID-19 in Patients Hospitalized at a Large U.S. Academic Medical Center

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S1-S1
Author(s):  
Chanu Rhee ◽  
Meghan Baker ◽  
Vineeta Vaidya ◽  
Robert Tucker ◽  
Andrew S Resnick ◽  
...  
Keyword(s):  
Infection Control ◽  
Acute Care ◽  
Academic Medical Center ◽  
Acute Care Hospitals ◽  
Control Measures ◽  
Cumulative Number ◽  
Rt Pcr ◽  
Infection Control Program ◽  
Asymptomatic Patients ◽  
Hospital Acquired

Abstract Background Many patients are avoiding essential care for fear of contracting Covid-19 in healthcare settings. However, the incidence of nosocomial Covid-19 infection in U.S. acute care hospitals is unknown. Methods We conducted an observational study of all patients admitted to Brigham and Women’s Hospital in Boston, Massachusetts between March 7 (when the first Covid-19 patient was admitted) and May 30, 2020. During this period, a comprehensive infection control program was implemented including dedicated Covid-19 units with airborne infection isolation rooms, personal protective equipment (PPE) in accordance with CDC recommendations, PPE donning and doffing monitors, universal masking, restriction of visitors, and liberal RT-PCR testing of symptomatic and asymptomatic patients. We reviewed the medical records of all patients who tested positive for SARS-CoV-2 by RT-PCR on hospital day 3 or later or within 14 days of hospital discharge to determine whether infection was community or hospital-acquired based on timing of RT-PCR tests, clinical course, and exposures. Results Over the 12-week period, 9,149 patients were admitted, in whom 7,394 SARS-CoV-2 RT-PCR tests were performed and 697 Covid-19 cases were confirmed, translating into a total 8,656 days of Covid-19-related care (Figure). The inpatient Covid-19 census peaked at 171 on April 21. Twelve of the 697 Covid-19 patients (1.7%) were first diagnosed by RT-PCR on hospital day 3 or later (median 4 days, range 3–15 days). Of these, only one was deemed hospital-acquired and was most likely acquired from his pre-symptomatic spouse who was visiting daily and diagnosed with Covid-19 before visitor restrictions were implemented. Amongst 8,370 non-Covid-19 patients discharged through June 17, 11 (0.1%) subsequently tested positive within 14 days (median time to diagnosis 6 days, range 1–14). Only one was deemed likely to have been hospital-acquired, albeit with no known exposures. Figure. Timeline of implementation of major infection control policies and cumulative number of hospitalized COVID-19 cases (total and hospital-onset) Conclusion Nosocomial Covid-19 infection was exceedingly rare during the height of the pandemic in a hospital with rigorous infection control measures. Our findings may inform practices in other institutions and provide reassurance to patients regarding the safety of receiving care in acute care hospitals. Disclosures All Authors: No reported disclosures

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