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Howard-Anderson JR, Gottlieb LB, Beekmann SE, Polgreen PM, Jacob JT, Uslan DZ. Implementation of contact precautions for multidrug-resistant organisms in the post-COVID-19 pandemic era: An updated national Emerging Infections Network (EIN) survey. Infect Control Hosp Epidemiol 2024; 45:703-708. [PMID: 38351872 PMCID: PMC11102826 DOI: 10.1017/ice.2024.11] [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: 09/15/2023] [Revised: 12/14/2023] [Accepted: 01/03/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE To understand how healthcare facilities employ contact precautions for patients with multidrug-resistant organisms (MDROs) in the post-coronavirus disease 2019 (COVID-19) era and explore changes since 2014. DESIGN Cross-sectional survey. PARTICIPANTS Emerging Infections Network (EIN) physicians involved in infection prevention or hospital epidemiology. METHODS In September 2022, we sent via email an 8-question survey on contact precautions and adjunctive measures to reduce MDRO transmission in inpatient facilities. We also asked about changes since the COVID-19 pandemic. We used descriptive statistics to summarize data and compared results to a similar survey administered in 2014. RESULTS Of 708 EIN members, 283 (40%) responded to the survey and 201 reported working in infection prevention. A majority of facilities (66% and 69%) routinely use contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) respectively, compared to 93% and 92% in 2014. Nearly all (>90%) use contact precautions for Candida auris, carbapenem-resistant Enterobacterales (CRE), and carbapenem-resistant Acinetobacter baumannii. More variability was reported for carbapenem-resistant Pseudomonas aeruginosa and extended-spectrum β-lactamase-producing gram-negative organisms. Compared to 2014, fewer hospitals perform active surveillance for MRSA and VRE. Overall, 90% of facilities used chlorhexidine gluconate bathing in all or select inpatients, and 53% used ultraviolet light or hydrogen peroxide vapor disinfection at discharge. Many respondents (44%) reported changes to contact precautions since COVID-19 that remain in place. CONCLUSIONS Heterogeneity exists in the use of transmission-based precautions and adjunctive infection prevention measures aimed at reducing MDRO transmission. This variation reflects a need for updated and specific guidance, as well as further research on the use of contact precautions in healthcare facilities.
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Affiliation(s)
- Jessica R. Howard-Anderson
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Lindsey B. Gottlieb
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Susan E. Beekmann
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Philip M. Polgreen
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Jesse T. Jacob
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Daniel Z. Uslan
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California– Los Angeles, Los Angeles, California
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2
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Park S, Bae S, Kim EO, Chang E, Kim MJ, Chong YP, Choi SH, Lee SO, Kim YS, Jung J, Kim SH. The impact of discontinuing single-room isolation of patients with vancomycin-resistant enterococci: a quasi-experimental single-centre study in South Korea. J Hosp Infect 2024; 147:77-82. [PMID: 38492645 DOI: 10.1016/j.jhin.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVES There is limited data on the effects of discontinuing single-room isolation while maintaining contact precautions, such as the use of gowns and gloves. In April 2021, our hospital ceased single-room isolation for patients with vancomycin-resistant enterococci (VRE) because of single-room unavailability. This study assessed the impact of this policy by examining the incidence of hospital-acquired VRE bloodstream infections (HA-VRE BSI). METHODS This retrospective quasi-experimental study was conducted at a tertiary-care hospital in Seoul, South Korea. Time-series analysis was used to evaluate HA-VRE BSI incidence at the hospital level and in the haematology unit before (phase 1) and after (phase 2) the policy change. RESULTS At the hospital level, HA-VRE BSI incidence level (VRE BSI per 1000 patient-days per month) and trend did not change significantly between phase 1 and phase 2 (coefficient -0.015, 95% confidence interval (CI): -0.053 to 0.023, P=0.45 and 0.000, 95% CI: -0.002 to 0.002, P=0.84, respectively). Similarly, HA-VRE BSI incidence level and trend in the haematology unit (-0.285, 95% CI: -0.618 to 0.048, P=0.09 and -0.018, 95% CI: -0.036 to 0.000, P = 0.054, respectively) did not change significantly across the two phases. CONCLUSIONS Discontinuing single-room isolation of VRE-colonized or infected patients was not associated with an increase in the incidence of VRE BSI at the hospital level or among high-risk patients in the haematology unit. Horizontal intervention for multi-drug-resistant organisms, including measures such as enhanced hand hygiene and environmental cleaning, may be more effective at preventing VRE transmission.
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Affiliation(s)
- S Park
- Office for Infection Control, Asan Medical Center, Seoul, Republic of Korea
| | - S Bae
- Department of Infectious Disease, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - E O Kim
- Office for Infection Control, Asan Medical Center, Seoul, Republic of Korea
| | - E Chang
- Department of Infectious Disease, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - M J Kim
- Department of Infectious Disease, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Y P Chong
- Department of Infectious Disease, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S-H Choi
- Department of Infectious Disease, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S-O Lee
- Department of Infectious Disease, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Y S Kim
- Department of Infectious Disease, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - J Jung
- Office for Infection Control, Asan Medical Center, Seoul, Republic of Korea; Department of Infectious Disease, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - S-H Kim
- Office for Infection Control, Asan Medical Center, Seoul, Republic of Korea; Department of Infectious Disease, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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3
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Smith M, Crnich C, Donskey C, Evans CT, Evans M, Goto M, Guerrero B, Gupta K, Harris A, Hicks N, Khader K, Kralovic S, McKinley L, Rubin M, Safdar N, Schweizer ML, Tovar S, Wilson G, Zabarsky T, Perencevich EN. Research agenda for transmission prevention within the Veterans Health Administration, 2024-2028. Infect Control Hosp Epidemiol 2024:1-10. [PMID: 38600795 DOI: 10.1017/ice.2024.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Matthew Smith
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Chris Crnich
- William. S. Middleton Memorial VA Hospital, Madison, WI, USA
| | - Curtis Donskey
- Geriatric Research, Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL, USA
- Department of Preventive Medicine and Center for Health Services and Outcomes Research, Northwestern University of Feinberg School of Medicine, Chicago, IL, USA
| | - Martin Evans
- MRSA/MDRO Division, VHA National Infectious Diseases Service, Patient Care Services, VA Central Office and the Lexington VA Health Care System, Lexington, KY, USA
| | - Michihiko Goto
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Bernardino Guerrero
- Environmental Programs Service (EPS), Veterans Affairs Central Office, Washington, DC, USA
| | - Kalpana Gupta
- VA Boston Healthcare System and Boston University School of Medicine, Boston, MA, USA
| | - Anthony Harris
- Department of Epidemiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Natalie Hicks
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, USA
| | - Karim Khader
- DEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Stephen Kralovic
- Veterans Health Administration National Infectious Diseases Service, Washington, DC, USA
- Cincinnati VA Medical Center and University of Cincinnati, Cincinnati, OH, USA
| | - Linda McKinley
- William. S. Middleton Memorial VA Hospital, Madison, WI, USA
| | - Michael Rubin
- DEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Nasia Safdar
- William. S. Middleton Memorial VA Hospital, Madison, WI, USA
| | - Marin L Schweizer
- William. S. Middleton Memorial VA Hospital, Madison, WI, USA
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, and William S. Middleton Hospital, Madison, WI, USA
| | - Suzanne Tovar
- National Infectious Diseases Service (NIDS), Veterans Affairs Central Office, Washington, DC, USA
| | - Geneva Wilson
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines Jr. Veterans Affairs Hospital, Hines, IL, USA
- Department of Preventive Medicine, Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Trina Zabarsky
- Environmental Programs Service (EPS), Veterans Affairs Central Office, Washington, DC, USA
| | - Eli N Perencevich
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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4
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Marra AR, Nori P, Langford BJ, Kobayashi T, Bearman G. Brave new world: Leveraging artificial intelligence for advancing healthcare epidemiology, infection prevention, and antimicrobial stewardship. Infect Control Hosp Epidemiol 2023; 44:1909-1912. [PMID: 37395009 DOI: 10.1017/ice.2023.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Affiliation(s)
- Alexandre R Marra
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
| | - Priya Nori
- Division of Infectious Diseases, Department of Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Bradley J Langford
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharines, Canada
| | - Takaaki Kobayashi
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
| | - Gonzalo Bearman
- Division of Infectious Diseases, Virginia Commonwealth University Health, Virginia Commonwealth University, Richmond, Virginia, United States
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5
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Browning S, Davis JS, Mitchell BG. Have gloves and gowns had their day? An Australian and New Zealand practice and attitudes survey about contact precautions for MRSA and VRE colonisation. Infect Dis Health 2023; 28:221-225. [PMID: 37068996 DOI: 10.1016/j.idh.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 03/26/2023] [Accepted: 03/27/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND 'Contact precautions,' are recommended for hospitalised patients with known methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) colonisation. Despite increasing observational evidence suggesting that gowns and gloves are of no added benefit over hand hygiene and environmental cleaning, guidelines continue to recommend them. METHODS A cross-sectional online survey of infection prevention professionals, infectious diseases physicians and microbiologists in Australian and New Zealand hospitals was conducted. The purpose was to explore variations in current approaches to known MRSA and VRE colonisation, and determine clinical equipoise for a proposed randomised control trial (RCT) to withdraw the use of gowns and gloves in this setting. RESULTS 226 responses from 122 hospitals across all Australian jurisdiction and multiple regions of New Zealand were received. While most hospitals implement contact precautions for MRSA (86%) and VRE (92%), variations based on MRSA and VRE subtypes are common. There was strong interest in removing glove and gown use for MRSA (72% and 73%, respectively) and VRE (70% and 68%, respectively). 62% of surveyed hospitals expressed interest in participating in a proposed cluster RCT comparing discontinuation of gown and glove use as part of contact precautions for MRSA and VRE, with their ongoing use. CONCLUSION The mandated use of PPE in the context of MRSA and VRE colonisation warrants further examination. An RCT is needed to definitively address this issue and to promote a widespread change in practice, if warranted.
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Affiliation(s)
- Sarah Browning
- Infection Research Program, Hunter Medical Research Institute, Newcastle, NSW, Australia; University of Newcastle, School of Medicine and Public Health, Newcastle, NSW, Australia.
| | - Joshua S Davis
- Infection Research Program, Hunter Medical Research Institute, Newcastle, NSW, Australia; University of Newcastle, School of Medicine and Public Health, Newcastle, NSW, Australia; Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
| | - Brett G Mitchell
- Infection Research Program, Hunter Medical Research Institute, Newcastle, NSW, Australia; School of Nursing and Midwifery, University of Newcastle, Ourimbah, NSW, Australia; School of Nursing, Avondale University, Cooranbong, NSW, Australia; Central Coast Local Health District, Gosford Hospital, Gosford, NSW, Australia.
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6
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Martínez DA, Cai J, Lin G, Goodman KE, Paul R, Lessler J, Levin SR, Toerper M, Simner PJ, Milstone AM, Klein EY. Modelling interventions and contact networks to reduce the spread of carbapenem-resistant organisms between individuals in the ICU. J Hosp Infect 2023; 136:1-7. [PMID: 36907332 PMCID: PMC10315994 DOI: 10.1016/j.jhin.2023.02.016] [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: 08/22/2022] [Revised: 01/25/2023] [Accepted: 02/03/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Contact precautions are widely used to prevent the transmission of carbapenem-resistant organisms (CROs) in hospital wards. However, evidence for their effectiveness in natural hospital environments is limited. OBJECTIVE To determine which contact precautions, healthcare worker (HCW)-patient interactions, and patient and ward characteristics are associated with greater risk of CRO infection or colonization. DESIGN, SETTING AND PARTICIPANTS CRO clinical and surveillance cultures from two high-acuity wards were assessed through probabilistic modelling to characterize a susceptible patient's risk of CRO infection or colonization during a ward stay. User- and time-stamped electronic health records were used to build HCW-mediated contact networks between patients. Probabilistic models were adjusted for patient (e.g. antibiotic administration) and ward (e.g. hand hygiene compliance, environmental cleaning) characteristics. The effects of risk factors were assessed by adjusted odds ratio (aOR) and 95% Bayesian credible intervals (CrI). EXPOSURES The degree of interaction with CRO-positive patients, stratified by whether CRO-positive patients were on contact precautions. MAIN OUTCOMES AND MEASURES The prevalence of CROs and number of new carriers (i.e. incident CRO aquisition). RESULTS Among 2193 ward visits, 126 (5.8%) patients became colonized or infected with CROs. Susceptible patients had 4.8 daily interactions with CRO-positive individuals on contact precautions (vs 1.9 interactions with those not on contact precautions). The use of contact precautions for CRO-positive patients was associated with a reduced rate (7.4 vs 93.5 per 1000 patient-days at risk) and odds (aOR 0.03, 95% CrI 0.01-0.17) of CRO acquisition among susceptible patients, resulting in an estimated absolute risk reduction of 9.0% (95% CrI 7.6-9.2%). Also, carbapenem administration to susceptible patients was associated with increased odds of CRO acquisition (aOR 2.38, 95% CrI 1.70-3.29). CONCLUSIONS AND RELEVANCE In this population-based cohort study, the use of contact precautions for patients colonized or infected with CROs was associated with lower risk of CRO acquisition among susceptible patients, even after adjusting for antibiotic exposure. Further studies that include organism genotyping are needed to confirm these findings.
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Affiliation(s)
- D A Martínez
- School of Industrial Engineering, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile; Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - J Cai
- Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, MD, USA
| | - G Lin
- Center for Disease Dynamics, Economics and Policy, Washington, DC, USA
| | - K E Goodman
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD, USA
| | - R Paul
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - J Lessler
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S R Levin
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - M Toerper
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - P J Simner
- Division of Medical Microbiology, Department of Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - A M Milstone
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - E Y Klein
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Disease Dynamics, Economics and Policy, Washington, DC, USA; Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
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7
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Mietchen MS, Short CT, Samore M, Lofgren ET. Examining the impact of ICU population interaction structure on modeled colonization dynamics of Staphylococcus aureus. PLoS Comput Biol 2022; 18:e1010352. [PMID: 35877686 PMCID: PMC9352208 DOI: 10.1371/journal.pcbi.1010352] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 08/04/2022] [Accepted: 07/03/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Complex transmission models of healthcare-associated infections provide insight for hospital epidemiology and infection control efforts, but they are difficult to implement and come at high computational costs. Structuring more simplified models to incorporate the heterogeneity of the intensive care unit (ICU) patient-provider interactions, we explore how methicillin-resistant Staphylococcus aureus (MRSA) dynamics and acquisitions may be better represented and approximated.
Methods
Using a stochastic compartmental model of an 18-bed ICU, we compared the rates of MRSA acquisition across three ICU population interaction structures: a model with nurses and physicians as a single staff type (SST), a model with separate staff types for nurses and physicians (Nurse-MD model), and a Metapopulation model where each nurse was assigned a group of patients. The proportion of time spent with the assigned patient group (γ) within the Metapopulation model was also varied.
Results
The SST, Nurse-MD, and Metapopulation models had a mean of 40.6, 32.2 and 19.6 annual MRSA acquisitions respectively. All models were sensitive to the same parameters in the same direction, although the Metapopulation model was less sensitive. The number of acquisitions varied non-linearly by values of γ, with values below 0.40 resembling the Nurse-MD model, while values above that converged toward the Metapopulation structure.
Discussion
Inclusion of complex population interactions within a modeled hospital ICU has considerable impact on model results, with the SST model having more than double the acquisition rate of the more structured metapopulation model. While the direction of parameter sensitivity remained the same, the magnitude of these differences varied, producing different colonization rates across relatively similar populations. The non-linearity of the model’s response to differing values of a parameter gamma (γ) suggests simple model approximations are appropriate in only a narrow space of relatively dispersed nursing assignments.
Conclusion
Simplifying assumptions around how a hospital population is modeled, especially assuming random mixing, may overestimate infection rates and the impact of interventions. In many, if not most, cases more complex models that represent population mixing with higher granularity are justified.
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Affiliation(s)
- Matthew S. Mietchen
- Paul G. Allen School for Global Health, College of Veterinary Medicine, Washington State University, Pullman, Washington, United States of America
| | - Christopher T. Short
- Paul G. Allen School for Global Health, College of Veterinary Medicine, Washington State University, Pullman, Washington, United States of America
| | - Matthew Samore
- Department of Internal Medicine, University of Utah School of Medicine, University of Utah, Salt Lake City, Utah, United States of America
- VA Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Eric T. Lofgren
- Paul G. Allen School for Global Health, College of Veterinary Medicine, Washington State University, Pullman, Washington, United States of America
- * E-mail:
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8
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Lee AS, Huttner BD, Catho G, Harbarth S. Methicillin-Resistant Staphylococcus aureus: An Update on Prevention and Control in Acute Care Settings. Infect Dis Clin North Am 2021; 35:931-952. [PMID: 34752226 DOI: 10.1016/j.idc.2021.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) is a leading cause of health-care-associated infections. Controversies regarding the effectiveness of various control strategies have contributed to varying approaches to MRSA control. However, new evidence from large-scale studies has emerged, particularly concerning screening and decolonization. Importantly, implementation and outcomes of control measures in practice are not only influenced by scientific evidence, but also economic, administrative, and political factors, as demonstrated by decreasing MRSA rates in a number of countries after concerted and coordinated efforts at a national level. Flexibility to adapt measures based on local epidemiology and resources is essential for successful MRSA control.
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Affiliation(s)
- Andie S Lee
- Departments of Infectious Diseases and Microbiology, Royal Prince Alfred Hospital, University of Sydney, Missenden Road, Camperdown, Sydney, NSW 2050, Australia.
| | - Benedikt D Huttner
- Division of Infectious Diseases, University of Geneva Hospitals, University of Geneva, Rue Gabrielle-Perret-Gentil 4, Geneva CH-1205, Switzerland
| | - Gaud Catho
- Infection Control Programme, University of Geneva Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva CH-1205, Switzerland
| | - Stephan Harbarth
- Infection Control Programme, University of Geneva Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva CH-1205, Switzerland
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9
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Büchler AC, Dangel M, Frei R, Jäger S, Roth JA, Seth-Smith HMB, Egli A, Widmer AF. Does high adherence to contact precautions lead to low in-hospital transmission of multi-drug-resistant micro-organisms in the endemic setting? J Hosp Infect 2021; 116:53-59. [PMID: 34252477 DOI: 10.1016/j.jhin.2021.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/29/2021] [Accepted: 07/06/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Conflicting results have been published on the impact of contact precautions (CPs) on reduction of transmission of multi-drug-resistant micro-organisms (MDROs) in the endemic setting. Ambiguous definitions coupled with low adherence partly explain these differences. AIM We prospectively monitored the level of adherence to CPs and aimed to relate it to in-hospital transmission of MDROs. METHODS Between January 2016 and March 2018, all patients under CPs underwent continuous monitoring of adherence to CPs by routine on-site visits on days 0, 3 and 7 after initiating CPs using a standardized checklist. The protocol included 10 interventions that were routinely checked such as CP sign at the door as well as wearing of gowns and gloves upon entry to the patient room. Patients requiring CPs were defined as colonized or infected with MDROs (meticillin-resistant Staphylococcus aureus (MRSA), non-Escherichia coli extended-spectrum beta lactamase (ESBL) Enterobacterales, vancomycin-resistant enterococci (VRE) and carbapenem-resistant Gram-negative micro-organisms (CRGN)) as well as patients infected with respiratory viruses, norovirus, scabies and hypervirulent strains of Clostridioides difficile. FINDINGS Overall, data from 13,756 CP records from 1378 visits of 812 patients were analysed. Adherence varied between 93% and 100% for each intervention, except for "separate space for contaminated material" with an adherence of 5.3-6.1%. The incidence of in-hospital transmission during the study period was extremely low for MRSA, VRE, non-E.coli ESBL Enterobacterales and CRGN with 0.00-0.064 cases/1000 patient days. CONCLUSION High adherence coupled with continuous monitoring of CPs correlated with a very low in-hospital transmission rate. These results indicate that CPs are highly effective if routine monitoring of adherence is implemented.
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Affiliation(s)
- A C Büchler
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - M Dangel
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - R Frei
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - S Jäger
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - J A Roth
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - H M B Seth-Smith
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland; Applied Microbiology Research, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - A Egli
- Division of Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland; Applied Microbiology Research, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - A F Widmer
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland.
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10
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Khader K, Thomas A, Stevens V, Visnovsky L, Nevers M, Toth D, Keegan LT, Jones M, Rubin M, Samore MH. Association Between Contact Precautions and Transmission of Methicillin-Resistant Staphylococcus aureus in Veterans Affairs Hospitals. JAMA Netw Open 2021; 4:e210971. [PMID: 33720369 PMCID: PMC7961311 DOI: 10.1001/jamanetworkopen.2021.0971] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE The effectiveness and importance of contact precautions for endemic pathogens has long been debated, and their use has broad implications for infection control of other pathogens. OBJECTIVE To estimate the association between contact precautions and transmission of methicillin-resistant Staphylococcus aureus (MRSA) across US Department of Veterans Affairs (VA) hospitals. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used mathematical models applied to data from a population-based sample of adults hospitalized in 108 VA acute care hospitals for at least 24 hours from January 1, 2008, to December 31, 2017. Data were analyzed from May 2, 2019, to December 11, 2020. EXPOSURES A positive MRSA test result, presumed to indicate contact precautions use according to the VA MRSA Prevention Initiative. MAIN OUTCOMES AND MEASURES The main outcome was the association between contact precautions and MRSA transmission, defined as the relative transmissibility attributed to contact precautions. A contact precaution effect estimate (<1 indicates a reduction in transmission associated with contact precautions) was estimated for each hospital and then pooled over time and across hospitals using meta-regression. RESULTS In this cohort study of 108 VA hospitals, more than 2 million unique individuals had over 5.6 million admissions, of which 14.1% were presumed to have contact precautions with more than 8.4 million MRSA surveillance tests. Pooled estimates found associations between contact precautions and transmission to be stable from 2008 to 2017, with estimated transmission reductions ranging from 43% (95% credible interval [CrI], 38%-48%) to 51% (95% CrI, 46%-55%). Over the entire 10-year study period, contact precautions reduced transmission 47% (95% CrI, 45%-49%), and the intrafacility autocorrelation coefficient estimate was 0.99, suggesting consistent estimates over time within facilities. Larger facilities and those with higher admission screening compliance observed additional reductions in transmission associated with contact precautions (relative rate, 0.84; 95% CI, 0.74-0.96 and 0.74; 95% CI, 0.58-0.96, respectively) compared with smaller facilities and those with lower admission screening compliance. Facilities in the southern US had a smaller transmission reduction attributable to contact precautions (relative rate, 1.14; 95% CI, 1.01-1.28) compared with facilities in other regions in the US. CONCLUSIONS AND RELEVANCE In this cohort study of adults in VA hospitals, transmissibility of MRSA was found to be reduced by approximately 50% among patients with contact precautions. These results provide an explanation for decreasing acquisition rates in VA hospitals since the MRSA Prevention Initiative.
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Affiliation(s)
- Karim Khader
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Alun Thomas
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Vanessa Stevens
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Lindsay Visnovsky
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - McKenna Nevers
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Damon Toth
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Lindsay T. Keegan
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Makoto Jones
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Michael Rubin
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Matthew H. Samore
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
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11
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Khader K, Thomas A, Huskins WC, Stevens V, Keegan LT, Visnovsky L, Samore MH. Effectiveness of Contact Precautions to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci in Intensive Care Units. Clin Infect Dis 2021; 72:S42-S49. [PMID: 33512528 PMCID: PMC7844588 DOI: 10.1093/cid/ciaa1603] [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: 08/18/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Contact precautions for endemic methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) are under increasing scrutiny, in part due to limited clinical trial evidence. METHODS We retrospectively analyzed data from the Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in Intensive Care Units (STAR*ICU) trial to model the use of contact precautions in individual intensive care units (ICUs). Data included admission and discharge times and surveillance test results. We used a transmission model to estimate key epidemiological parameters, including the effect of contact precautions on transmission. Finally, we performed multivariate meta-regression to identify ICU-level factors associated with contact precaution effects. RESULTS We found that 21% of admissions (n = 2194) were placed on contact precautions, with most for MRSA and VRE. We found little evidence that contact precautions reduced MRSA transmission. The estimated change in transmission attributed to contact precautions was -16% (95% credible interval, -38% to 15%). VRE transmission was higher than MRSA transmission due to contact precautions, but not significantly. In our meta-regression, we did not identify associations between ICU-level factors and estimated contact precaution effects. Importation and transmission were higher for VRE than for MRSA, but clearance rates were lower for VRE than for MRSA. CONCLUSIONS We found little evidence that contact precautions implemented during the STAR*ICU trial reduced transmission of MRSA or VRE. We did find important differences in the transmission dynamics between MRSA and VRE. Differences in organism and healthcare setting may impact the efficacy of contact precautions.
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Affiliation(s)
- Karim Khader
- Informatics, Decision-Enhancement, and Analytical Sciences Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Alun Thomas
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - W Charles Huskins
- Division of Pediatric Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Vanessa Stevens
- Informatics, Decision-Enhancement, and Analytical Sciences Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Lindsay T Keegan
- Informatics, Decision-Enhancement, and Analytical Sciences Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Lindsay Visnovsky
- Informatics, Decision-Enhancement, and Analytical Sciences Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Matthew H Samore
- Informatics, Decision-Enhancement, and Analytical Sciences Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
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12
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O'Hara LM, Nguyen MH, Calfee DP, Miller LG, Pineles L, Magder LS, Johnson JK, Morgan DJ, Rasko DA, Harris AD. Risk factors for transmission of carbapenem-resistant Enterobacterales to healthcare personnel gloves and gowns in the USA. J Hosp Infect 2021; 109:58-64. [PMID: 33358930 DOI: 10.1016/j.jhin.2020.12.012] [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: 11/09/2020] [Revised: 12/17/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Hospitals are sources for acquisition of carbapenem-resistant Entero-bacterales (CRE), and it is believed that the contamination of healthcare personnel (HCP) hands and clothing play a major role in patient-to-patient transmission of antibiotic-resistant bacteria. AIM The aim of this study was to determine which HCP types, HCP-patient interactions, and patient characteristics are associated with greater transmission of CRE to HCP gloves and gowns in the hospital. METHODS This was a prospective observational cohort study that enrolled patients with recent surveillance or clinical cultures positive for CRE at five hospitals in four states in the USA. HCP gloves and gown were cultured after patient care. Samples were also obtained from patients' stool, perianal area, and skin of the chest and arm to assess bacterial burden. FINDINGS Among 313 CRE-colonized patients and 3070 glove and gown cultures obtained after patient care, HCP gloves and gowns were found to be contaminated with CRE 7.9% and 4.3% of the time, respectively. Contamination of either gloves or gowns occurred in 10.0% of interactions. Contamination was highest (15.3%) among respiratory therapists (odds ratio: 3.79; 95% confidence interval: 1.61-8.94) and when any HCP touched the patient (1.52; 1.10-2.12). Associations were also found between CRE transmission to HCP gloves or gown and: being in the intensive care unit, having a positive clinical culture, and increasing bacterial burden on the patient. CONCLUSION CRE transmission to HCP gloves and gown occurred frequently. These findings may inform evidence-based policies about what situations and for which patients contact precautions are most important.
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Affiliation(s)
- L M O'Hara
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - M H Nguyen
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - D P Calfee
- Division of Infectious Diseases, Weill Cornell Medicine, New York, NY, USA
| | - L G Miller
- LA BioMed at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - L Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - L S Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - J K Johnson
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - D J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - D A Rasko
- Institute for Genome Sciences, University of Maryland, Baltimore, MD, USA
| | - A D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA.
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13
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Jackson KA, Gokhale RH, Nadle J, Ray SM, Dumyati G, Schaffner W, Ham DC, Magill SS, Lynfield R, See I. Public Health Importance of Invasive Methicillin-sensitive Staphylococcus aureus Infections: Surveillance in 8 US Counties, 2016. Clin Infect Dis 2021; 70:1021-1028. [PMID: 31245810 DOI: 10.1093/cid/ciz323] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 04/15/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Public health and infection control prevention and surveillance efforts in the United States have primarily focused on methicillin-resistant Staphylococcus aureus (MRSA). We describe the public health importance of methicillin-susceptible S. aureus (MSSA) in selected communities. METHODS We analyzed Emerging Infections Program surveillance data for invasive S. aureus (SA) infections (isolated from a normally sterile body site) in 8 counties in 5 states during 2016. Cases were considered healthcare-associated if culture was obtained >3 days after hospital admission; if associated with dialysis, hospitalization, surgery, or long-term care facility (LTCF) residence within 1 year prior; or if a central venous catheter was present ≤2 days prior. Incidence per 100 000 census population was calculated, and a multivariate logistic regression model with random intercepts was used to compare MSSA risk factors with those of MRSA. RESULTS Invasive MSSA incidence (31.3/100 000) was 1.8 times higher than MRSA (17.5/100 000). Persons with MSSA were more likely than those with MRSA to have no underlying medical conditions (adjusted odds ratio [aOR], 2.06; 95% confidence interval [CI], 1.26-3.39) and less likely to have prior hospitalization (aOR, 0.70; 95% CI, 0.60-0.82) or LTCF residence (aOR, 0.37; 95% CI, 0.29-0.47). MSSA accounted for 59.7% of healthcare-associated cases and 60.1% of deaths. CONCLUSIONS Although MRSA tended to be more closely associated with healthcare exposures, invasive MSSA is a substantial public health problem in the areas studied. Public health and infection control prevention efforts should consider MSSA prevention in addition to MRSA.
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Affiliation(s)
- Kelly A Jackson
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Runa H Gokhale
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Susan M Ray
- Georgia Emerging Infections Program and the Atlanta Veterans Affairs Medical Center, Decatur
| | | | | | - David C Ham
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shelley S Magill
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Isaac See
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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14
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Haessler S, Martin EM, Scales ME, Kang L, Doll M, Stevens MP, Uslan DZ, Pryor R, Edmond MB, Godbout E, Abbas S, Bearman G. Stopping the routine use of contact precautions for management of MRSA and VRE at three academic medical centers: An interrupted time series analysis. Am J Infect Control 2020; 48:1466-1473. [PMID: 32634537 DOI: 10.1016/j.ajic.2020.06.219] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/29/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Contact precautions (CP) are a widely adopted strategy to prevent cross-transmission of organisms, commonly methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Some hospitals have discontinued CP for patients with MRSA or VRE; however, the impact on hospital-acquired infection rates (HAI) has not been assessed systematically. METHODS Retrospective multicenter interrupted time series between 2002 and 2017 at three academic hospitals. Participating hospitals discontinued CP for patients with contained body fluids who were colonized or infected with MRSA or VRE. The primary intervention was stopping the use of CP. Secondary interventions were horizontal infection prevention strategies. The primary outcomes were rates of central line-associated bloodstream infections, catheter-associated urinary tract infections, mediastinal surgical site infection, and ventilator-associated pneumonia due to MRSA, VRE, or any organism using Centers for Disease Control and Prevention National Healthcare Safety Network surveillance definitions. RESULTS Central line-associated bloodstream infections, catheter-associated urinary tract infections, mediastinal surgical site infection, and ventilator-associated pneumonia rates trended down at each institution. There were no statistically significant increases in these infections associated with discontinuing CP. Individual horizontal infection prevention strategies variably impacted HAI outcomes. CONCLUSIONS Stopping the routine use of CP for patients with contained body fluids who are colonized or infected with MRSA or VRE did not result in increased HAIs. Bundled horizontal infection prevention strategies resulted in sustained HAI reductions.
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Affiliation(s)
- Sarah Haessler
- Department of Medicine, Division of Infectious Diseases, University of Massachusetts Medical School-Baystate, Springfield, MA.
| | - Elise M Martin
- Division of Infectious Diseases, University of Pittsburgh Medical Center-Presbyterian Hospital, Pittsburgh, PA
| | - Mary Ellen Scales
- Division of Healthcare Quality, Baystate Medical Center, Springfield, MA
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA
| | - Michelle Doll
- Division of Infectious Diseases, Virginia Commonwealth University, Richmond, VA
| | - Michael P Stevens
- Division of Infectious Diseases, Virginia Commonwealth University, Richmond, VA
| | - Daniel Z Uslan
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Rachel Pryor
- Division of Infectious Diseases, Virginia Commonwealth University, Richmond, VA
| | - Michael B Edmond
- Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Emily Godbout
- Division of Pediatric Infectious Diseases, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA
| | - Salma Abbas
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Gonzalo Bearman
- Division of Infectious Diseases, Virginia Commonwealth University, Richmond, VA
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15
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Enninger A, Schmidt P, Hasan C, Wager J, Zernikow B. Multidrug-Resistant Organisms in Palliative Care: A Systematic Review. J Palliat Med 2020; 24:122-132. [PMID: 33085565 DOI: 10.1089/jpm.2019.0654] [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] [Indexed: 10/23/2022] Open
Abstract
Background: Multidrug-resistant organisms (MDROs) are an important health care issue. Patients in Western societies often present an increased morbidity of chronic conditions accompanied by poor immune status and the use of devices. In particular, patients in palliative care (PC) are at greater risk of MDRO colonization, due to accompanying special devices and being hospitalized. Objective: To gain an overview of the literature regarding MDROs in PC. Design: Systematic review Data sources: On the 19th of October 2019 the databases " PubMed" and " CINAHL" were used to identify studies reporting on MDROs in PC; the search was updated on 16th of May 2020. Results: Seventeen out of 486 articles were included. Six represent qualitative data, 10 quantitative data, and one a mixed methods approach. Prevalence data range from 4.0% to 18%. MDRO colonization has a negative impact on patients and families. It leads to uncertainties and higher workload by staff members. Strategies for the management of MDROs in the field of PC are predominantly available for methicillin-resistant Staphylococcus aureus. Not even half of institutions utilize existing protocols. Recommendations for dealing with MDROs indicate required staff and time resources as well as information, communication, and specific knowledge. Conclusion: There is a great need for studies examining the prevalence of all MDROs in the PC setting. Additionally, not only patients but also a public enlightenment on MDROs should be provided to decrease knowledge gaps and therefore reduce transmission on MDROs.
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Affiliation(s)
- Anna Enninger
- Department of Children's Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany
| | - Pia Schmidt
- Department of Children's Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany.,Pediatric Palliative Care Center and German Pediatric Pain Center, Children's and Adolescents' Hospital, Datteln, Witten/Herdecke University, Datteln, Germany
| | - Carola Hasan
- Pediatric Palliative Care Center and German Pediatric Pain Center, Children's and Adolescents' Hospital, Datteln, Witten/Herdecke University, Datteln, Germany
| | - Julia Wager
- Department of Children's Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany.,Pediatric Palliative Care Center and German Pediatric Pain Center, Children's and Adolescents' Hospital, Datteln, Witten/Herdecke University, Datteln, Germany
| | - Boris Zernikow
- Department of Children's Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany.,Pediatric Palliative Care Center and German Pediatric Pain Center, Children's and Adolescents' Hospital, Datteln, Witten/Herdecke University, Datteln, Germany
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16
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O'Hara LM, Calfee DP, Miller LG, Pineles L, Magder LS, Johnson JK, Morgan DJ, Harris AD. Optimizing Contact Precautions to Curb the Spread of Antibiotic-resistant Bacteria in Hospitals: A Multicenter Cohort Study to Identify Patient Characteristics and Healthcare Personnel Interactions Associated With Transmission of Methicillin-resistant Staphylococcus aureus. Clin Infect Dis 2020; 69:S171-S177. [PMID: 31517979 PMCID: PMC6761365 DOI: 10.1093/cid/ciz621] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Healthcare personnel (HCP) acquire antibiotic-resistant bacteria on their gloves and gowns when caring for intensive care unit (ICU) patients. Yet, contact precautions for patients with methicillin-resistant Staphylococcus aureus (MRSA) remains controversial despite existing guidelines. We sought to understand which patients are more likely to transfer MRSA to HCP and to identify which HCP interactions are more likely to lead to glove or gown contamination. Methods This was a prospective, multicenter cohort study of cultured HCP gloves and gowns for MRSA. Samples were obtained from patients’ anterior nares, perianal area, and skin of the chest and arm to assess bacterial burden. Results Among 402 MRSA-colonized patients with 3982 interactions, we found that HCP gloves and gowns were contaminated with MRSA 14.3% and 5.9% of the time, respectively. Contamination of either gloves or gowns occurred in 16.2% of interactions. Contamination was highest among occupational/physical therapists (odds ratio [OR], 6.96; 95% confidence interval [CI], 3.51, 13.79), respiratory therapists (OR, 5.34; 95% CI, 3.04, 9.39), and when any HCP touched the patient (OR, 2.59; 95% CI, 1.04, 6.51). Touching the endotracheal tube (OR, 1.75; 95% CI, 1.38, 2.19), bedding (OR, 1.43; 95% CI, 1.20, 1.70), and bathing (OR, 1.32; 95% CI, 1.01, 1.75) increased the odds of contamination. We found an association between increasing bacterial burden on the patient and HCP glove or gown contamination. Conclusions Gloves and gowns are frequently contaminated with MRSA in the ICU. Hospitals may consider using fewer precautions for low-risk interactions and more for high-risk interactions and personnel.
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Affiliation(s)
- Lyndsay M O'Hara
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - David P Calfee
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York
| | - Loren G Miller
- LA BioMed at Harbor-University of California-Los Angeles Medical Center, Torrance
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Laurence S Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - J Kristie Johnson
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore.,Department of Pathology, University of Maryland School of Medicine, Baltimore
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
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17
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Abstract
Purpose of review There is a continuing debate regarding contact precaution (CP) usage for endemic multidrug-resistant organisms (MDROs). In this review, we examine current recommendations for CP and highlight differences in CP use between endemic and non-endemic MDROs. Recent findings The discontinuation of CP had no effect on the incidence of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococci. The evidence regarding CP for extended-spectrum beta-lactamase producing Enterobacteriaceae is inconclusive, highlighting the need for more research to determine best infection control strategies. Carbapenem-resistant Enterobacteriaceae maintains a sporadic pattern in the USA, supporting current recommendations to use CP for colonized and infected patients. MDR Acinetobacter baumannii (MDR-AB) is extremely virulent and responsible for outbreaks in healthcare settings, emphasizing the need for CP use with MDR-AB infected patients. Candida auris (C. auris) is often misdiagnosed; it is resistant to UV light and quaternary ammonium low-level disinfection. Because little is known about the transmission of C. auris, significant caution and CP use are necessitated. There is little research on vancomycin-resistant S. aureus (VRSA) control strategies due to its rarity; thus, CP is strongly recommended. Summary Contact precautions are frequently part of a bundled infection control approach that involves meticulous hand hygiene, patient decolonization, chlorhexidine gluconate bathing, and reducing the use of invasive devices. Healthcare facilities should continue to utilize CP for non-endemic MDROs and the presence of endemic MDROs; however, CP may not add benefit to the current infection prevention bundle approach.
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18
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Russo PL, Stewardson AJ, Cheng AC, Bucknall T, Mitchell BG. Prevalence of device use and transmission based precautions in nineteen large Australian acute care public hospitals: Secondary outcomes from a national healthcare associated infection point prevalence survey. Infect Dis Health 2020; 25:262-267. [PMID: 32595104 DOI: 10.1016/j.idh.2020.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The use of invasive devices increases the risk of healthcare associated infections (HAI). The recent national HAI point prevalence survey secondary outcomes aimed to estimate the prevalence of patients with an indwelling urinary catheter device and vascular access devices; and also identify prevalence of those managed under transmission based precautions (TBP); and those colonised or infected with a multi drug resistant organism (MDRO). METHODS A point prevalence study was conducted in large acute care Australian public hospitals. All data were collected by two trained Research Assistants. Surveillance methodology was based on the European Centre for Disease Prevention and Control PPS Protocol. Data was also collected on prevalence of TBPs and MDROs. RESULTS A total of 2767 acute adult inpatients were sampled across 19 hospitals. The prevalence of peripheral vascular, central vascular and urinary catheters devices was 55.2% (95%CI: 53.3%-57.1%), 14.8% (95%CI: 13.5%-16.1%) and 20.7% (95%CI: 19.2%-22.3%) respectively. Of the 2767 patients sampled 285 (10.3%, 95%CI: 9.2%-11.5%) were documented as either being infected or colonised with a MDRO, and 781 (11.8%) patients were being managed under the hospital TBP policy. CONCLUSION This is the first national study to describe the prevalence of devices, TBPs and MDROs in Australian healthcare settings. In an era where device use should be constantly reviewed to minimise risk of HAI, and the increasing challenges of managing patients with MDROs, this data can serve as a benchmark for future studies.
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Affiliation(s)
- Philip L Russo
- Department of Nursing Research, Cabrini Institute, Malvern, VIC, Australia; Nursing and Midwifery, Monash University, Frankston, VIC, Australia; Centre for Quality and Patient Safety Research - Alfred Health Partnership, Melbourne, VIC, Australia.
| | - Andrew J Stewardson
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia.
| | - Allen C Cheng
- School of Public Health and Preventive Medicine, Monash University, Prahran, VIC, Australia; Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, VIC, Australia.
| | - Tracey Bucknall
- Centre for Quality and Patient Safety Research - Alfred Health Partnership, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Prahran, VIC, Australia; School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia.
| | - Brett G Mitchell
- School of Nursing and Midwifery, University of Newcastle, Ourimbah, NSW, Australia.
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19
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Uda K, Funaki T, Shoji K, Kato A, Miyairi I. High proportion of multidrug-resistant organisms in children hospitalized abroad. Am J Infect Control 2020; 48:578-580. [PMID: 31519478 DOI: 10.1016/j.ajic.2019.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/09/2019] [Accepted: 08/09/2019] [Indexed: 10/26/2022]
Abstract
Our infection control team initiated active screening for multidrug-resistant organisms (MDROs) among children who had been hospitalized abroad before their admission to our hospital. MDROs were detected in 19 of 34 cases (56%), including 3 isolates of Enterobacteriaceae harboring carbapenemase genes still rare in Japan. Early recognition of MDROs by screening this population may be required to avoid the introduction of new modes of resistance into the hospital environment.
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20
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Effectiveness of a multisite personal protective equipment (PPE)-free zone intervention in acute care. Infect Control Hosp Epidemiol 2020; 40:761-766. [PMID: 31172904 DOI: 10.1017/ice.2019.111] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Determine the effectiveness of a personal protective equipment (PPE)-free zone intervention on healthcare personnel (HCP) entry hand hygiene (HH) and PPE donning compliance in rooms of patients in contact precautions. DESIGN Quasi-experimental, multicenter intervention, before-and-after study with concurrent controls. SETTING All patient rooms on contact precautions on 16 units (5 medical-surgical, 6 intensive care, 5 specialty care units) at 3 acute-care facilities (2 academic medical centers, 1 Veterans Affairs hospital). Observations of PPE donning and entry HH compliance by HCP were conducted during both study phases. Surveys of HCP perceptions of the PPE-free zone were distributed in both study phases. INTERVENTION A PPE-free zone, where a low-risk area inside door thresholds of contact precautions rooms was demarcated by red tape on the floor. Inside this area, HCP were not required to wear PPE. RESULTS We observed 3,970 room entries. HH compliance did not change between study phases among intervention units (relative risk [RR], 0.92; P = .29) and declined in control units (RR, 0.70; P = .005); however, the PPE-free zone did not significantly affect compliance (P = .07). The PPE-free zone effect on HH was significant only for rooms on enteric precautions (P = .008). PPE use was not significantly different before versus after the intervention (P = .15). HCP perceived the zone positively; 65% agreed that it facilitated communication and 66.8% agreed that it permitted checking on patients more frequently. CONCLUSIONS HCP viewed the PPE-free zone favorably and it did not adversely affect PPE or HH compliance. Future infection prevention interventions should consider the complex sociotechnical system factors influencing behavior change.
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Environmental service workers as potential designers of infection control policy in long-term care settings. Am J Infect Control 2020; 48:398-402. [PMID: 32087975 DOI: 10.1016/j.ajic.2020.01.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/13/2020] [Accepted: 01/16/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Long-term care facility residents are at higher risk of methicillin-resistant Staphylococcus aureus infection and colonization than the general population. In 2009, the Department of Veterans Affairs (VA) implemented the "methicillin-resistant S. aureus prevention initiative" in long-term care facilities (ie, Community Living Centers or "CLCs"). METHODS Over 4 months, 40 semistructured interviews were conducted with staff in medicine, nursing, and environmental services at 5 geographically dispersed CLCs. Interviews addressed knowledge, attitudes, and beliefs concerning infection prevention and resident-centered care. A modified constant comparative approach was used for data analysis. RESULTS In CLCs, staff work to prevent and control infections in spaces where residents live. Nurses and Environmental Service Workers daily balance infection prevention conventions with the CLC setting. Infection control team members, who are accustomed to working in acute care settings, struggle to reconcile the CLC context with infection prevention. DISCUSSION The focus on the resident's room as the locus of care, and thus the main target of infection control, misses opportunities for addressing infection prevention in the spaces beyond the residents' rooms. CONCLUSIONS Environmental Service Workers' daily work inside the rooms and within the wider facility produces a unique perspective that might help in the design of workable infection control policies in CLCs.
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22
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Höring S, Lemmen S. [Management of patients with multidrug-resistant bacteria after hospital discharge]. MMW Fortschr Med 2020; 162:56-60. [PMID: 32248468 DOI: 10.1007/s15006-020-0343-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Steffen Höring
- Zentralbereich für Krankenhaushygiene und Infektiologie (ZfKI), Zentrum für Infektiologie (DGI), Universitätsklinikum Aachen, Pauwelsstr. 30, D-52074, Aachen, Deutschland.
| | - Sebastian Lemmen
- Leiter des Zentralbereichs für Krankenhaushygiene und Infektiologie (ZfKI), Zentrum für Infektiologie (DGI), Universitätsklinikum Aachen, Deutschland
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Nelson RE, Evans ME, Simbartl L, Jones M, Samore MH, Kralovic SM, Roselle GA, Rubin MA. Methicillin-resistant Staphylococcus aureus Colonization and Pre- and Post-hospital Discharge Infection Risk. Clin Infect Dis 2020; 68:545-553. [PMID: 30107401 DOI: 10.1093/cid/ciy507] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 08/03/2018] [Indexed: 12/28/2022] Open
Abstract
Background The Department of Veterans Affairs implemented an active surveillance program for methicillin-resistant Staphylococcus aureus (MRSA) in 2007 in which acute care inpatients are tested for MRSA carriage on admission, unit-to-unit transfer, and discharge. Using these data, we followed patients longitudinally to estimate the difference in infection rates for those who were not colonized, those who were colonized on admission (importers), and those who acquired MRSA during their stay. We examined MRSA infections that occurred prior to discharge and at 30, 90, 180, and 365 days after discharge. Methods We constructed a dataset of 985626 first admissions from January 2008 through December 2015 who had surveillance tests performed for MRSA carriage. We performed multivariable Cox proportional hazards and logistic regression models to examine the relationship between MRSA colonization status and infection. Results The MRSA infection rate across the predischarge and 180-day postdischarge time period was 5.5% in importers and 7.0% in acquirers without a direct admission to the intensive care unit (ICU) and 11.4% in importers and 11.7% in acquirers who were admitted directly to the ICU. The predischarge hazard ratio for MRSA infection was 29.6 (95% confidence interval [CI], 26.5-32.9) for importers and 28.8 (95% CI, 23.5-35.3) for acquirers compared to those not colonized. Fully 63.9% of all MRSA pre- and postdischarge infections among importers and 61.2% among acquirers occurred within 180 days after discharge. Conclusions MRSA colonization significantly increases the risk of subsequent MRSA infection. In addition, a substantial proportion of MRSA infections occur after discharge from the hospital.
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Affiliation(s)
- Richard E Nelson
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Martin E Evans
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Cincinnati, Ohio.,Lexington Veterans Affairs Medical Center, University of Kentucky College of Medicine, Lexington.,Department of Internal Medicine, University of Kentucky College of Medicine, Lexington
| | - Loretta Simbartl
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Cincinnati, Ohio
| | - Makoto Jones
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Matthew H Samore
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Stephen M Kralovic
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Cincinnati, Ohio.,Cincinnati Veterans Affairs Medical Center, University of Cincinnati School of Medicine, Ohio.,Department of Internal Medicine, University of Cincinnati School of Medicine, Ohio
| | - Gary A Roselle
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Cincinnati, Ohio.,Cincinnati Veterans Affairs Medical Center, University of Cincinnati School of Medicine, Ohio.,Department of Internal Medicine, University of Cincinnati School of Medicine, Ohio
| | - Michael A Rubin
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
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Assessment of antibiotic-resistant organism transmission among rooms of hospitalized patients, healthcare personnel, and the hospital environment utilizing surrogate markers and selective bacterial cultures. Infect Control Hosp Epidemiol 2020; 41:539-546. [PMID: 31969206 DOI: 10.1017/ice.2019.376] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess potential transmission of antibiotic-resistant organisms (AROs) using surrogate markers and bacterial cultures. DESIGN Pilot study. SETTING A 1,260-bed tertiary-care academic medical center. PARTICIPANTS The study included 25 patients (17 of whom were on contact precautions for AROs) and 77 healthcare personnel (HCP). METHODS Fluorescent powder (FP) and MS2 bacteriophage were applied in patient rooms. HCP visits to each room were observed for 2-4 hours; hand hygiene (HH) compliance was recorded. Surfaces inside and outside the room and HCP skin and clothing were assessed for fluorescence, and swabs were collected for MS2 detection by polymerase chain reaction (PCR) and selective bacterial cultures. RESULTS Transfer of FP was observed for 20 rooms (80%) and 26 HCP (34%). Transfer of MS2 was detected for 10 rooms (40%) and 15 HCP (19%). Bacterial cultures were positive for 1 room and 8 HCP (10%). Interactions with patients on contact precautions resulted in fewer FP detections than interactions with patients not on precautions (P < .001); MS2 detections did not differ by patient isolation status. Fluorescent powder detections did not differ by HCP type, but MS2 was recovered more frequently from physicians than from nurses (P = .03). Overall, HH compliance was better among HCP caring for patients on contact precautions than among HCP caring for patients not on precautions (P = .003), among nurses than among other nonphysician HCP at room entry (P = .002), and among nurses than among physicians at room exit (P = .03). Moreover, HCP who performed HH prior to assessment had fewer fluorescence detections (P = .008). CONCLUSIONS Contact precautions were associated with greater HCP HH compliance and reduced detection of FP and MS2.
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Johnstone J, Shing E, Saedi A, Adomako K, Li Y, Brown KA, Garber G. Discontinuing Contact Precautions for Vancomycin-Resistant Enterococcus (VRE) Is Associated With Rising VRE Bloodstream Infection Rates in Ontario Hospitals, 2009–2018: A Quasi-experimental Study. Clin Infect Dis 2020; 71:1756-1759. [DOI: 10.1093/cid/ciaa009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 01/09/2020] [Indexed: 12/21/2022] Open
Abstract
Abstract
In Ontario, Canada, since 2012, some hospitals discontinued contact precautions for vancomycin-resistant Enterococcus (VRE). Between 2009 and 2018, there was an associated rise in VRE bloodstream infections in hospitals where contact precautions were discontinued but not in hospitals that maintained contact precautions. These data suggest contact precautions are important for hospital VRE control programs.
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Affiliation(s)
- Jennie Johnstone
- Public Health Ontario, Toronto and Ottawa, Canada
- Dalla Lana School of Public Health, University of Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Canada
| | - Emily Shing
- Public Health Ontario, Toronto and Ottawa, Canada
| | - Arezou Saedi
- Public Health Ontario, Toronto and Ottawa, Canada
| | | | - Ye Li
- Public Health Ontario, Toronto and Ottawa, Canada
| | - Kevin A Brown
- Public Health Ontario, Toronto and Ottawa, Canada
- Dalla Lana School of Public Health, University of Toronto, Canada
| | - Gary Garber
- Public Health Ontario, Toronto and Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
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26
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The learning hospital: From theory to practice in a hospital infection prevention program. Infect Control Hosp Epidemiol 2020; 41:86-97. [DOI: 10.1017/ice.2019.318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AbstractThe learning hospital is distinguished by ceaseless evolution of erudition, enhancement, and implementation of clinical best practices. We describe a model for the learning hospital within the framework of a hospital infection prevention program and argue that a critical assessment of safety practices is possible without significant grant funding. We reviewed 121 peer-reviewed manuscripts published by the VCU Hospital Infection Prevention Program over 16 years. Publications included quasi-experimental studies, observational studies, surveys, interrupted time series analyses, and editorials. We summarized the articles based on their infection prevention focus, and we provide a brief summary of the findings. We also summarized the involvement of nonfaculty learners in these manuscripts as well as the contributions of grant funding. Despite the absence of significant grant funding, infection prevention programs can critically assess safety strategies under the learning hospital framework by leveraging a diverse collaboration of motivated nonfaculty learners. This model is a valuable adjunct to traditional grant-funded efforts in infection prevention science and is part of a successful horizontal infection control program.
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27
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Less contact isolation is more in the ICU: not sure. Intensive Care Med 2019; 46:1735-1738. [DOI: 10.1007/s00134-019-05809-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 09/26/2019] [Indexed: 10/25/2022]
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Affiliation(s)
- Ray Higginson
- Senior Lecturer in Critical Care Physiology, University of South Wales
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29
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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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30
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Schrank GM, Snyder GM, Davis RB, Branch-Elliman W, Wright SB. The discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus: Impact upon patient adverse events and hospital operations. BMJ Qual Saf 2019; 29:1-2. [PMID: 31320496 DOI: 10.1136/bmjqs-2018-008926] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 06/11/2019] [Accepted: 06/29/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Contact precautions for endemic methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) are a resource-intensive intervention to reduce healthcare-associated infections, potentially impeding patient throughput and limiting bed availability to isolate other contagious pathogens. We investigated the impact of the discontinuation of contact precautions (DcCP) for endemic MRSA and VRE on patient outcomes and operations metrics in an acute care setting. METHODS This is a retrospective, quasi-experimental analysis of the 12 months before and after DcCP for MRSA and VRE at an academic medical centre. The frequency for bed closures due to contact isolation was measured, and personal protective equipment (PPE) expenditures and patient satisfaction survey results were compared using the Wilcoxon signed-rank test. Using an interrupted time series design, emergency department (ED) admission wait times and rates of patient falls, pressure ulcers and nosocomial MRSA and VRE clinical isolates were compared using GEEs. RESULTS Prior to DcCP, bed closures for MRSA and/or VRE isolation were associated with estimated lost hospital charges of $9383 per 100 bed days (95% CI: 8447 to 10 318). No change in ED wait times or change in trend was observed following DcCP. There were significant reductions in monthly expenditures on gowns (-61.0%) and gloves (-16.3%). Patient satisfaction survey results remained stable. No significant changes in rates or trends were observed for patient falls or pressure ulcers. Incidence rates of nosocomial MRSA (1.58 (95% CI: 0.82 to 3.04)) and VRE (1.02 (95% CI: 0.82 to 1.27)) did not significantly change. CONCLUSIONS DcCP was associated with an increase in bed availability and revenue recovery, and a reduction in PPE expenditures. Benefits for other hospital operations metrics and patient outcomes were not identified.
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Affiliation(s)
- Gregory M Schrank
- Department of Medicine, Division of Infectious Diseases, University of Maryland Medical Center, Baltimore, Maryland, United States
| | - Graham M Snyder
- Department of Infection Prevention and Control, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Roger B Davis
- Department of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Westyn Branch-Elliman
- Department of Medicine, Section of Infectious Diseases, VA Boston Healthcare System, West Roxbury, Massachusetts, United States.,VA Boston Center for Healthcare Organization and Implementation Research, Boston, Massachusetts, United States.,Harvard Medical School, Boston, Massachusetts, United States
| | - Sharon B Wright
- Harvard Medical School, Boston, Massachusetts, United States.,Division of Infection Control/Hospital Epidemiology, Silverman Institute of Health Care Quality & Safety, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States.,Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
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31
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Infection control procedures for extensively drug-resistant bacteria and related adverse effects: the experience at the Lyon University Hospitals from 2011 to 2017. Clin Microbiol Infect 2019; 25:919-920. [DOI: 10.1016/j.cmi.2019.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 02/06/2019] [Accepted: 02/08/2019] [Indexed: 11/16/2022]
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Pereira MR, Rana MM. Methicillin-resistant Staphylococcus aureus in solid organ transplantation-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13611. [PMID: 31120612 DOI: 10.1111/ctr.13611] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 05/20/2019] [Indexed: 12/25/2022]
Abstract
These updated guidelines from the American Society of Transplantation Infectious Diseases Community of Practice review the epidemiology, diagnosis, prevention, and management of methicillin-resistant Staphylococcus aureus (MRSA) infections in solid organ transplantation. Despite an increasing armamentarium of antimicrobials active against MRSA, improved diagnostic tools, and overall declining rates of infection, MRSA infections remain a substantial cause of morbidity and mortality in solid organ transplant recipients. Pre- and post-transplant MRSA colonization is a significant risk factor for post-transplant MRSA infection. The preferred initial treatment of MRSA bacteremia remains vancomycin. Hand hygiene, chlorhexidine bathing in the ICU, central-line bundles that focus on reducing unnecessary catheter use, disinfection of patient equipment, and the environment along with antimicrobial stewardship are all aspects of an infection prevention approach to prevent MRSA transmission and decrease healthcare-associated infections.
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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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Goodman KE, Simner PJ, Klein EY, Kazmi AQ, Gadala A, Toerper M, Levin S, Tamma PD, Rock C, Cosgrove SE, Maragakis LL, Milstone AM. Predicting probability of perirectal colonization with carbapenem-resistant Enterobacteriaceae (CRE) and other carbapenem-resistant organisms (CROs) at hospital unit admission. Infect Control Hosp Epidemiol 2019; 40:541-550. [PMID: 30915928 PMCID: PMC6613376 DOI: 10.1017/ice.2019.42] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Targeted screening for carbapenem-resistant organisms (CROs), including carbapenem-resistant Enterobacteriaceae (CRE) and carbapenemase-producing organisms (CPOs), remains limited; recent data suggest that existing policies miss many carriers. OBJECTIVE Our objective was to measure the prevalence of CRO and CPO perirectal colonization at hospital unit admission and to use machine learning methods to predict probability of CRO and/or CPO carriage. METHODS We performed an observational cohort study of all patients admitted to the medical intensive care unit (MICU) or solid organ transplant (SOT) unit at The Johns Hopkins Hospital between July 1, 2016 and July 1, 2017. Admission perirectal swabs were screened for CROs and CPOs. More than 125 variables capturing preadmission clinical and demographic characteristics were collected from the electronic medical record (EMR) system. We developed models to predict colonization probabilities using decision tree learning. RESULTS Evaluating 2,878 admission swabs from 2,165 patients, we found that 7.5% and 1.3% of swabs were CRO and CPO positive, respectively. Organism and carbapenemase diversity among CPO isolates was high. Despite including many characteristics commonly associated with CRO/CPO carriage or infection, overall, decision tree models poorly predicted CRO and CPO colonization (C statistics, 0.57 and 0.58, respectively). In subgroup analyses, however, models did accurately identify patients with recent CRO-positive cultures who use proton-pump inhibitors as having a high likelihood of CRO colonization. CONCLUSIONS In this inpatient population, CRO carriage was infrequent but was higher than previously published estimates. Despite including many variables associated with CRO/CPO carriage, models poorly predicted colonization status, likely due to significant host and organism heterogeneity.
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Affiliation(s)
- Katherine E. Goodman
- Johns Hopkins University Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD
| | - Patricia J. Simner
- Johns Hopkins University School of Medicine, Department of Pathology, Division of Medical Microbiology, Baltimore, MD
| | - Eili Y. Klein
- Johns Hopkins University Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD
- The Center for Disease Dynamics, Economics & Policy, Washington, D.C
| | - Abida Q. Kazmi
- Johns Hopkins University School of Medicine, Department of Pathology, Division of Medical Microbiology, Baltimore, MD
| | - Avinash Gadala
- The Johns Hopkins Health System, Department of Hospital Epidemiology and Infection Control, Baltimore, MD
| | - Matthew Toerper
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD
| | - Scott Levin
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD
| | - Pranita D. Tamma
- The Johns Hopkins Health System, Department of Hospital Epidemiology and Infection Control, Baltimore, MD
- Johns Hopkins University School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Baltimore, MD
| | - Clare Rock
- The Johns Hopkins Health System, Department of Hospital Epidemiology and Infection Control, Baltimore, MD
- Johns Hopkins University School of Medicine, Department of Medicine, Division of Infectious Diseases, Baltimore, MD
| | - Sara E. Cosgrove
- The Johns Hopkins Health System, Department of Hospital Epidemiology and Infection Control, Baltimore, MD
- Johns Hopkins University School of Medicine, Department of Medicine, Division of Infectious Diseases, Baltimore, MD
| | - Lisa L. Maragakis
- Johns Hopkins University Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD
- The Johns Hopkins Health System, Department of Hospital Epidemiology and Infection Control, Baltimore, MD
- Johns Hopkins University School of Medicine, Department of Medicine, Division of Infectious Diseases, Baltimore, MD
| | - Aaron M. Milstone
- Johns Hopkins University Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD
- The Johns Hopkins Health System, Department of Hospital Epidemiology and Infection Control, Baltimore, MD
- Johns Hopkins University School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Baltimore, MD
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Gilbert GL, Kerridge I. The politics and ethics of hospital infection prevention and control: a qualitative case study of senior clinicians' perceptions of professional and cultural factors that influence doctors' attitudes and practices in a large Australian hospital. BMC Health Serv Res 2019; 19:212. [PMID: 30940153 PMCID: PMC6444390 DOI: 10.1186/s12913-019-4044-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 03/27/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Hospital infection prevention and control (IPC) programs are designed to minimise rates of preventable healthcare-associated infection (HAI) and acquisition of multidrug resistant organisms, which are among the commonest adverse effects of hospitalisation. Failures of hospital IPC in recent years have led to nosocomial and community outbreaks of emerging infections, causing preventable deaths and social disruption. Therefore, effective IPC programs are essential, but can be difficult to sustain in busy clinical environments. Healthcare workers' adherence to routine IPC practices is often suboptimal, but there is evidence that doctors, as a group, are consistently less compliant than nurses. This is significant because doctors' behaviours disproportionately influence those of other staff and their peripatetic practice provides more opportunities for pathogen transmission. A better understanding of what drives doctors' IPC practices will contribute to development of new strategies to improve IPC, overall. METHODS This qualitative case study involved in-depth interviews with senior clinicians and clinician-managers/directors (16 doctors and 10 nurses) from a broad range of specialties, in a large Australian tertiary hospital, to explore their perceptions of professional and cultural factors that influence doctors' IPC practices, using thematic analysis of data. RESULTS Professional/clinical autonomy; leadership and role modelling; uncertainty about the importance of HAIs and doctors' responsibilities for preventing them; and lack of clarity about senior consultants' obligations emerged as major themes. Participants described marked variation in practices between individual doctors, influenced by, inter alia, doctors' own assessment of patients' infection risk and their beliefs about the efficacy of IPC policies. Participants believed that most doctors recognise the significance of HAIs and choose to [mostly] observe organisational IPC policies, but a minority show apparent contempt for accepted rules, disrespect for colleagues who adhere to, or are expected to enforce, them and indifference to patients whose care is compromised. CONCLUSIONS Failure of healthcare and professional organisations to address doctors' poor IPC practices and unprofessional behaviour, more generally, threatens patient safety and staff morale and undermines efforts to minimise the risks of dangerous nosocomial infection.
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Affiliation(s)
- Gwendolyn L Gilbert
- Sydney Health Ethics, University of Sydney, Level 1, Building 1, Medical Foundation Building, 92/94 Parramatta Rd, Camperdown, NSW, 2050, Australia. .,Marie Bashir Institute for Infectious Diseases and Biosecurity, Westmead Institute for Medical Research, 176 Hawkesbury Rd, Westmead, NSW, 2145, Australia.
| | - Ian Kerridge
- Sydney Health Ethics, University of Sydney, Level 1, Building 1, Medical Foundation Building, 92/94 Parramatta Rd, Camperdown, NSW, 2050, Australia.,Department of Haematology, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia
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Jones M, Jernigan JA, Evans ME, Roselle GA, Hatfield KM, Samore MH. Vital Signs: Trends in Staphylococcus aureus Infections in Veterans Affairs Medical Centers - United States, 2005-2017. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2019; 68:220-224. [PMID: 30845116 PMCID: PMC6421970 DOI: 10.15585/mmwr.mm6809e2] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Introduction By 2007, all Department of Veterans Affairs medical centers (VAMCs) had initiated a multifaceted methicillin-resistant Staphylococcus aureus (MRSA) prevention program. MRSA and methicillin-susceptible S. aureus (MSSA) infection rates among VAMC inpatients from 2005 to 2017 were assessed. Methods Clinical microbiology data from any patient admitted to an acute-care VAMC in the United States from 2005 through 2017 and trends in hospital-acquired MRSA colonization were examined. Results S. aureus infections decreased by 43% overall during the study period (p<0.001), driven primarily by decreases in MRSA, which decreased by 55% (p<0.001), whereas MSSA decreased by 12% (p = 0.003). Hospital-onset MRSA and MSSA infections decreased by 66% (p<0.001) and 19% (p = 0.02), respectively. Community-onset MRSA infections decreased by 41% (p<0.001), whereas MSSA infections showed no significant decline. Acquisition of MRSA colonization decreased 78% during 2008–2017 (17% annually, p<0.001). MRSA infection rates declined more sharply among patients who had negative admission surveillance MRSA screening tests (annual 9.7% decline) compared with those among patients with positive admission MRSA screening tests (4.2%) (p<0.05). Conclusions and Implications for Public Health Practice Significant reductions in S. aureus infection following the VAMC intervention were led primarily by decreases in MRSA. Moreover, MRSA infection declines were much larger among patients not carrying MRSA at the time of admission than among those who were. Taken together, these results suggest that decreased MRSA transmission played a substantial role in reducing overall S. aureus infections at VAMCs. Recent calls to withdraw infection control interventions designed to prevent MRSA transmission might be premature and inadvisable, at least until more is known about effective control of bacterial pathogen transmission in health care settings. Effective S. aureus prevention strategies require a multifaceted approach that includes adherence to current CDC recommendations for preventing not only device- and procedure-associated infections, but also transmission of health care–prevalent strains.
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Bearman G, Doll M, Cooper K, Stevens MP. Hospital Infection Prevention: How Much Can We Prevent and How Hard Should We Try? Curr Infect Dis Rep 2019; 21:2. [PMID: 30710181 DOI: 10.1007/s11908-019-0660-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW To summarize the extent to which hospital-acquired infections (HAIs) are preventable and to assess expectations, challenges, and barriers to improve patient outcomes. RECENT FINDINGS HAIs cause significant morbidity and mortality. Getting to zero HAIs is a commonly stated goal yet leads to unrealistic expectations. The extent to which all HAIs can be prevented remains debatable and is subject to multiple considerations and barriers. Current infection prevention science is inexact and evolving. Evidence-based infection prevention practices are often incompletely implemented and at times controversial. Highly sensitive surveillance results in overdiagnosis, calling into question the real incidence of HAIs. Perceived reductions in HAIs by gaming the system lead to false conclusions about preventability and may cause harm. Successful HAI reduction programs require executive oversight yet keeping hospital leaders engaged in infection prevention is a challenge given competing priorities. Medicine is not a physical science with precisely defined laws; thus, infection prevention interventions are subject to variable outcomes. Perhaps up to 55-70% of HAIs are potentially preventable. This is subject to a law of diminishing returns as the preventable proportion of HAIs may reduce over time with improvements in patient safety. As the principle tenet of medicine is first do no harm, infection prevention programs should relentlessly pursue reliable, sustainable, and practical strategies for heightened patient safety.
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Affiliation(s)
- Gonzalo Bearman
- Virginia Commowealth University Hospital Infection Prevention Program, North Hospital, 2nd Floor, Room 2-073, 1300 East Marshall Street, Richmond, VA, 23298-0019, USA.
| | - Michelle Doll
- Virginia Commowealth University Hospital Infection Prevention Program, North Hospital, 2nd Floor, Room 2-073, 1300 East Marshall Street, Richmond, VA, 23298-0019, USA
| | - Kaila Cooper
- Virginia Commowealth University Hospital Infection Prevention Program, North Hospital, 2nd Floor, Room 2-073, 1300 East Marshall Street, Richmond, VA, 23298-0019, USA
| | - Michael P Stevens
- Virginia Commowealth University Hospital Infection Prevention Program, North Hospital, 2nd Floor, Room 2-073, 1300 East Marshall Street, Richmond, VA, 23298-0019, USA
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Establishing a Research Agenda for Preventing Transmission of Multidrug-Resistant Organisms in Acute-Care Settings in the Veterans Health Administration. Infect Control Hosp Epidemiol 2018; 39:189-195. [PMID: 29417927 DOI: 10.1017/ice.2017.309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Nelson RE, Jones M, Liu CF, Samore MH, Evans ME, Stevens VW, Reese T, Rubin MA. The Impact of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus Infections on Postdischarge Health Care Costs and Utilization across Multiple Health Care Systems. Health Serv Res 2018; 53 Suppl 3:5419-5437. [PMID: 30298924 DOI: 10.1111/1475-6773.13063] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To measure how much of the postdischarge cost and utilization attributable to methicillin-resistant Staphylococcus aureus (MRSA) health care-associated infections (HAIs) occur within the US Department of Veterans Affairs (VA) system and how much occurs outside. DATA SOURCES/STUDY SETTING Health care encounters from 3 different settings and payment models: (1) within the VA; (2) outside the VA but paid for by the VA (purchased care); and (3) outside the VA and paid for by Medicare. STUDY DESIGN Historical cohort study using data from admissions to VA hospitals between 2007 and 2012. METHODS We assessed the impact of a positive MRSA test result on costs and utilization during the 365 days following discharge using inverse probability of treatment weights to balance covariates. PRINCIPAL FINDINGS Among a cohort of 152,687 hospitalized Veterans, a positive MRSA test result was associated with an overall increase of 6.6 (95 percent CI: 5.7-7.5) inpatient days and $9,237 (95 percent CI: $8,211-$10,262) during the postdischarge period. VA inpatient admissions, Medicare reimbursements, and purchased care payments accounted for 60.6 percent, 22.5 percent, and 16.9 percent of these inpatient costs. CONCLUSIONS While most of the excess postdischarge health care costs associated with MRSA HAIs occurred in the VA, non-VA costs make up an important subset of the overall burden.
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Affiliation(s)
- Richard E Nelson
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Makoto Jones
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Chuan-Fen Liu
- Veterans Affairs Puget Sound Health Care System, Seattle, WA.,Department of Health Services, University of Washington, Seattle, WA
| | - Matthew H Samore
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Martin E Evans
- Lexington Veterans Affairs Medical Center, Lexington, KY.,MRSA/MDRO Program, National Infectious Diseases Service, Veterans Health Administration, Lexington, KY.,Department of Internal Medicine, University of Kentucky, Lexington, KY
| | - Vanessa W Stevens
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Thomas Reese
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, UT
| | - Michael A Rubin
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
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Krein SL, Mayer J, Harrod M, Weston LE, Gregory L, Petersen L, Samore MH, Drews FA. Identification and Characterization of Failures in Infectious Agent Transmission Precaution Practices in Hospitals: A Qualitative Study. JAMA Intern Med 2018; 178:1016-1057. [PMID: 29889934 PMCID: PMC6583062 DOI: 10.1001/jamainternmed.2018.1898] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
IMPORTANCE Using personal protective equipment (PPE) and transmission-based precautions are primary strategies for reducing the transmission of infectious agents. OBJECTIVE To identify and characterize failures in transmission-based precautions, including PPE use, by health care personnel that could result in self-contamination or transmission during routine, everyday hospital care. DESIGN, SETTING, AND PARTICIPANTS This qualitative study involved direct observation inside and outside patient rooms on clinical units from March 1, 2016, to November 30, 2016. Observations occurred in the medical and/or surgical units and intensive care units at an academic medical center and a Veterans Affairs hospital, as well as the emergency department of the university hospital. Trained observers recorded extensive field notes while personnel provided care for patients in precautions for a pathogen transmitted through contact (eg, Clostridium difficile, methicillin-resistant Staphylococcus aureus) or respiratory droplet (eg, influenza). Specific occurrences involving potential personnel self-contamination were identified through a directed content analysis. These occurrences were further categorized, using a human factors model of human error, as active failures, such as violations, mistakes, or slips. MAIN OUTCOMES AND MEASURES Number and type of failures involving use of transmission-based precautions. RESULTS In total, 325 room observations were conducted at 2 sites. At site 1, a total of 280 observations were completed (196 in medical/surgical units, 64 in intensive care units, and 20 in emergency departments). At site 2, there were 45 observations (36 in medical/surgical units and 9 in the intensive care unit). Of the total observations, 259 (79.7%) occurred outside and 66 (20.3%) inside the room. Two hundred eighty-three failures were observed, including 102 violations (deviations from safe operating practices or procedures), 144 process or procedural mistakes (failures of intention), and 37 slips (failures of execution). Violations involved entering rooms without some or all recommended PPE. Mistakes were frequently observed during PPE removal and encounters with challenging logistical situations, such as badge-enforced computer logins. Slips included touching one's face or clean areas with contaminated gloves or gowns. Each of these active failures has a substantial likelihood of resulting in self-contamination. The circumstances surrounding failures in precaution practices, however, varied not only across but within the different failure types. CONCLUSIONS AND RELEVANCE Active failures in PPE use and transmission-based precautions, potentially leading to self-contamination, were commonly observed. The factors that contributed to these failures varied widely, suggesting the need for a range of strategies to reduce potential transmission risk during routine hospital care.
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Affiliation(s)
- Sarah L Krein
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.,Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Jeanmarie Mayer
- Department of Internal Medicine, University of Utah, Salt Lake City.,Department of Veterans Affairs Medical Center, Salt Lake City, Utah
| | - Molly Harrod
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Lauren E Weston
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Lynn Gregory
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Laura Petersen
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Matthew H Samore
- Department of Internal Medicine, University of Utah, Salt Lake City.,Department of Veterans Affairs Medical Center, Salt Lake City, Utah
| | - Frank A Drews
- Department of Internal Medicine, University of Utah, Salt Lake City.,Department of Veterans Affairs Medical Center, Salt Lake City, Utah.,Department of Psychology, University of Utah, Salt Lake City
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Vokes RA, Bearman G, Bazzoli GJ. Hospital-Acquired Infections Under Pay-for-Performance Systems: an Administrative Perspective on Management and Change. Curr Infect Dis Rep 2018; 20:35. [PMID: 30051191 DOI: 10.1007/s11908-018-0638-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to explore the impact of hospital-acquired infection on payment under pay-for-performance systems, and provide perspective on the role of administrators in infection prevention. RECENT FINDINGS Hospital-acquired infections continue to pose a serious threat to patient safety and to the fiscal viability of healthcare facilities under pay-for-performance systems. There is mixed evidence that use of pay-for-performance systems leads to prevention of hospital-acquired conditions. Use of evidence-based guidelines has been shown to reduce hospital-acquired infections. Increasing use of pay-for-performance (PFP) systems results in potential loss of reimbursement for healthcare organizations that fail to prevent hospital-acquired infections (HAI). Healthcare administrators must work with front-line providers and infection control staff to establish and maintain evidence-based infection prevention policy. Additionally, infection control policy should be regularly updated to reflect best practices, and proper change management techniques should be employed in order to mobilize and empower staff to increase their ability to prevent hospital-acquired infections.
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Affiliation(s)
- Rebecca A Vokes
- Department of Health Administration, Virginia Commonwealth University, Richmond, VA, USA.
| | | | - Gloria J Bazzoli
- Department of Health Administration, Virginia Commonwealth University, Richmond, VA, USA
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10-year trends in vancomycin-resistant enterococci among allogeneic hematopoietic cell transplant recipients. J Infect 2018; 77:38-46. [DOI: 10.1016/j.jinf.2018.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 02/20/2018] [Accepted: 02/25/2018] [Indexed: 12/20/2022]
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The Impact of Isolation on Healthcare Worker Contact and Compliance With Infection Control Practices in Nursing Homes. Infect Control Hosp Epidemiol 2018; 39:683-687. [PMID: 29606163 DOI: 10.1017/ice.2018.50] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVETo directly observe healthcare workers in a nursing home setting to measure frequency and duration of resident contact and infection prevention behavior as a factor of isolation practiceDESIGNObservational studySETTING AND PARTICIPANTSHealthcare workers in 8 VA nursing homes in Florida, Maryland, Massachusetts, Michigan, Washington, and TexasMETHODSOver a 15-month period, trained research staff without clinical responsibilities on the units observed nursing home resident room activity for 15-30-minute intervals. Observers recorded time of entry and exit, isolation status, visitor type (staff, visitor, etc), hand hygiene, use of gloves and gowns, and activities performed in the room when visible.RESULTSA total of 999 hours of observation were conducted across 8 VA nursing homes during which 4,325 visits were observed. Residents in isolation received an average of 4.73 visits per hour of observation compared with 4.21 for nonisolation residents (P<.01), a 12.4% increase in visits for residents in isolation. Residents in isolation received an average of 3.53 resident care activities per hour of observation, compared with 2.46 for residents not in isolation (P<.01). For residents in isolation, compliance was 34% for gowns and 58% for gloves. Healthcare worker hand hygiene compliance was 45% versus 44% (P=.79) on entry and 66% versus 55% (P<.01) on exit for isolation and nonisolation rooms, respectively.CONCLUSIONSHealthcare workers visited residents in isolation more frequently, likely because they required greater assistance. Compliance with gowns and gloves for isolation was limited in the nursing home setting. Adherence to hand hygiene also was less than optimal, regardless of isolation status of residents.Infect Control Hosp Epidemiol 2018;39:683-687.
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Impact of Discontinuing Contact Precautions for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus: An Interrupted Time Series Analysis. Infect Control Hosp Epidemiol 2018; 39:676-682. [PMID: 29580304 DOI: 10.1017/ice.2018.57] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVETo investigate the impact of discontinuing contact precautions among patients infected or colonized with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) on rates of healthcare-associated infection (HAI). DESIGN Single-center, quasi-experimental study conducted between 2011 and 2016.METHODSWe employed an interrupted time series design to evaluate the impact of 7 horizontal infection prevention interventions across intensive care units (ICUs) and hospital wards at an 865-bed urban, academic medical center. These interventions included (1) implementation of a urinary catheter bundle in January 2011, (2) chlorhexidine gluconate (CHG) perineal care outside ICUs in June 2011, (3) hospital-wide CHG bathing outside of ICUs in March 2012, (4) discontinuation of contact precautions in April 2013 for MRSA and VRE, (5) assessments and feedback with bare below the elbows (BBE) and contact precautions in August 2014, (6) implementation of an ultraviolet-C disinfection robot in March 2015, and (7) 72-hour automatic urinary catheter discontinuation orders in March 2016. Segmented regression modeling was performed to assess the changes in the infection rates attributable to the interventions.RESULTSThe rate of HAI declined throughout the study period. Infection rates for MRSA and VRE decreased by 1.31 (P=.76) and 6.25 (P=.21) per 100,000 patient days, respectively, and the infection rate decreased by 2.44 per 10,000 patient days (P=.23) for device-associated HAI following discontinuation of contact precautions.CONCLUSIONThe discontinuation of contact precautions for patients infected or colonized with MRSA or VRE, when combined with horizontal infection prevention measures was not associated with an increased incidence of MRSA and VRE device-associated infections. This approach may represent a safe and cost-effective strategy for managing these patients.Infect Control Hosp Epidemiol 2018;39:676-682.
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DalBen MF. Transmission-Based Precautions for Multidrug-Resistant Organisms: What to Prioritize When Resources Are Limited. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0143-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Benamu E, Deresinski S. Vancomycin-resistant enterococcus infection in the hematopoietic stem cell transplant recipient: an overview of epidemiology, management, and prevention. F1000Res 2018; 7:3. [PMID: 29333263 PMCID: PMC5750719 DOI: 10.12688/f1000research.11831.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2017] [Indexed: 12/13/2022] Open
Abstract
Vancomycin-resistant enterococcus (VRE) is now one of the leading causes of nosocomial infections in the United States. Hematopoietic stem cell transplantation (HSCT) recipients are at increased risk of VRE colonization and infection. VRE has emerged as a major cause of bacteremia in this population, raising important clinical questions regarding the role and impact of VRE colonization and infection in HSCT outcomes as well as the optimal means of prevention and treatment. We review here the published literature and scientific advances addressing these thorny issues and provide a rational framework for their approach.
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Affiliation(s)
- Esther Benamu
- Division of Infectious Diseases, Department of Medicine, University of Colorado, Aurora, USA
| | - Stanley Deresinski
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, USA
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Datta R, Juthani-Mehta M. Burden and Management of Multidrug-Resistant Organisms in Palliative Care. Palliat Care 2017; 10:1178224217749233. [PMID: 29317826 PMCID: PMC5753884 DOI: 10.1177/1178224217749233] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 11/10/2017] [Indexed: 12/26/2022] Open
Abstract
Palliative care includes comprehensive strategies to optimize quality of life for patients and families confronting terminal illness. Infections are a common complication in terminal illness, and infections due to multidrug-resistant organisms (MDROs) are particularly challenging to manage in palliative care. Limited data suggest that palliative care patients often harbor MDRO. When MDROs are present, distinguishing colonization from infection is challenging due to cognitive impairment or metastatic disease limiting symptom assessment and the lack of common signs of infection. Multidrug-resistant organisms also add psychological burden through infection prevention measures including patient isolation and contact precautions which conflict with the goals of palliation. Moreover, if antimicrobial therapy is indicated per goals of care discussions, available treatment options are often limited, invasive, expensive, or associated with adverse effects that burden patients and families. These issues raise important ethical considerations for managing and containing MDROs in the palliative care setting.
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Affiliation(s)
- Rupak Datta
- Rupak Datta, Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06520, USA.
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