A prospective multicentre screening study on multidrug-resistant organisms in intensive care units in the Dutch-German cross-border region, 2017 to 2018: the importance of healthcare structures

Infection prevention and control measures for multidrug-resistant organisms: a systematic review and network meta-analysis

BACKGROUND

The effectiveness of infection prevention and control measures combating multidrug-resistant organisms (MDROs) in healthcare settings remains controversial.

METHODS

PubMed, Embase, MEDLINE, Cochrane Library, and CINAHL were searched from inception to June 1, 2024. The interventions encompassed standard precautions (SP), contact precautions (CP), hand hygiene (HH), environmental cleaning (ENV), antimicrobial stewardship programs (ASP), decolonization (DCL), and chlorhexidine baths (CHG). The primary outcome were the acquisition, infection, and colonization of MDROs. Secondary outcomes were all-cause mortality and MDROs-associated bacteraemia. Effect indicators were expressed as rate ratios (RRs) with 95% confidence intervals (CIs).

RESULTS

The study included a total of 97 articles, comprising 19 RCTs and 78 non-RCTs. The results showed that the most effective combination interventions for the acquisition, infection, and colonization of MDROs compared to SP varied as follows: CP + CHG (RR, 0.38 [0.18, 0.79]), SP + CP + ENV (RR, 0.04 [0.02, 0.08]), and SP + CHG (RR, 0.28 [0.14, 0.56]). In subgroup analyses, CP + CHG (RR, 0.36 [0.20,0.64]) was the most effective intervention for the acquisition of MDROs in the ICU setting, whereas SP + CP + ASP (RR, 0.35 [0.14,0.92]) was the most effective hospital-wide. Across subgroups, SP + CP + ENV (RR, 0.04 to 0.09 [95% CI, 0.01 to 0.99]) was identified as the most effective intervention for MDROs infections. In the ICU setting, SP + CHG (RR, 0.28 [0.14,0.56]) demonstrated the highest effectiveness in reducing the colonization of MDROs, whereas SP + CP + ENV + CHG (RR, 0.15 [0.06,0.38]) was the most effective on a hospital-wide scale. SP + CP + DCL (RR, 0.28 [0.24, 0.32]) was associated with reduced CRE colonization. The results of this study were robust according to the sensitivity analysis. None of the analyses related to secondary outcomes were statistically significant. In terms of article quality assessment, 94.7% of the RCTs were medium to high risk, while 92.31% of the non-RCTs. The primary limitation of the RCTs were related to the randomization process, whereas the non-RCTs were primarily affected by confounding bias.

CONCLUSIONS

Effective interventions differ based on carriage status, intervention setting, and the resistant strain. Additionally, contact precautions is a crucial component of these combinations. Consequently, healthcare organizations can select appropriate interventions based on their unique resistance profiles to optimize precision and resource efficiency.

Infection prevention and control without borders: comparison of guidelines on multidrug-resistant organisms in the northern Dutch-German cross-border region

Infections due to multidrug-resistant organisms (MDROs) are a health threat due to increasing patient morbidity and mortality and the burden on healthcare systems. Robust infection prevention and control (IPC) measures are needed to minimize their emergence in hospitals. Therefore, various international and national IPC guidelines exist, yet the lack of harmonized IPC guidelines complicates the management of patients seeking healthcare across European borders. This study explores the similarities and differences in IPC measures for vancomycin-resistant enterococci (VRE) and multidrug-resistant (MDR) Enterobacterales both on local and national levels within the northern Dutch-German cross-border region. In Germany, IPC efforts are often led by hospital hygiene doctors, whereas in the Netherlands, they involve a collaboration between infection preventionists and clinical microbiologists, with local variations. The local guidelines in both countries, as expected, are based on national recommendations, yet introduce specific regulations in various aspects. The Dutch guidelines are more stringent for VRE management compared to the German guidelines, often imposing additional local measures beyond national requirements. The Dutch and German guidelines largely diverge in definitions of MDR Gram-negative bacteria. Unlike the Dutch guidelines, the German guidelines do not currently recommend screening or isolation for extended-spectrum beta-lactamase-producing Enterobacterales. For carbapenem-resistant and carbapenemase-producing Enterobacterales, there is no notable distinction between the countries' guidelines, with both sharing the objective of maintaining a low prevalence and actively working towards containment. Inconsistencies in guidelines can lead to inefficient information exchange and inconsistent hygienic measures during patient transfers. Despite common commitments, differences in focus may reflect evolving understanding of MDRO transmission and ongoing debates on their management. Our findings highlight the divergence of IPC guidelines for the management of MDROs across two countries and call for collaboration in cross-border regions to increase the effectiveness of MDRO management in these regions and improve patient care.

Management of vancomycin-resistant Enterococcus faecium in Dutch healthcare institutes: a nationwide survey

BACKGROUND

Vancomycin-resistant Enterococcus faecium (VREfm) is an opportunistic pathogen, which can cause outbreaks in hospitals. In the Netherlands, several national guidelines and guidance documents on different aspects of VREfm management are available. Most available guidelines are written towards the hospital setting and only few on long-term care facilities (LTCFs). Moreover, not all aspects of VREfm management are covered, recommendations differ and the level of compliance to these guidelines is unknown. The aim of this study was to get insight into the routine VREfm policies in Dutch healthcare facilities with regard to screening, diagnostics and infection control measures.

METHODS

Online questionnaires were sent to representatives of Dutch hospitals and LTCFs. The questionnaire included questions regarding the definition of VRE, screening, diagnostics, patient isolation, cleaning procedures, VREfm clearance and VREfm outbreaks.

FINDINGS

The questionnaire was completed by 61 hospitals with a response rate of 84.1% and 57 LTCFs, mostly nursing homes. Most hospitals reported VREfm outbreaks in the previous decade, whereas only one LTCF reported an outbreak. Of the hospitals, 87% perform VREfm screening versus 50% of the LTCFs. VREfm-positive patients are isolated in 98% of hospitals and 83% of LTCFs. Protocols regarding how to unlabel VREfm-positive patients are in place in 84% of the hospitals and in 51% of LTCFs. The details of these measures differ substantially between healthcare facilities.

CONCLUSION

This study has shown that most hospitals and some LTCFs in the Netherlands have standard procedures for VREfm management to some level, although the comprehensiveness and details of the measures differ per hospital. More uniform policies would improve comparability of VREfm data on a regional/national level.

Multidrug-Resistant Klebsiella pneumoniae Strains in a Hospital: Phylogenetic Analysis to Investigate Local Epidemiology

Multidrug-resistant Klebsiella pneumoniae is a significant healthcare challenge that particularly affects vulnerable patients through opportunistic nosocomial infections. Surveillance is crucial for monitoring the prevalence of these infections. Eighty-four KPC K. pneumoniae strains (2019-2022) were collected from patients admitted in Fondazione Policlinico Universitario Campus Bio-Medico. Strains were identified by MALDI-TOF and tested for antimicrobial susceptibility, and gene amplification was performed to identify the different blaKPC variants. Phylogenetic reconstructions were carried out using Bayesian methods. Additionally, to create a Bayesian skyline plot (BSP), additional analyses were conducted, running a simulation of 100 million generations under a Bayesian skyline model along with the uncorrelated log-normal relaxed clock model. To identify potential subgroups within genetic clusters and evaluate genetic variability among sequences, principal coordinate analysis (PCoA) was performed. In total, 84 Klebsiella pneumoniae isolates were classified as multidrug-resistant (MDR), characterized by resistance to three or more antibiotic classes, including carbapenems, and testing positive for KPC gene presence, and were included in the study. The Bayesian evolutionary tree for K. pneumoniae showed strongly supported branches but no genetic structure related to sampling dates or hospital departments. Phylogenetic analysis revealing a 73-year evolutionary span of K. pneumoniae strains. PCoA analysis identified three genetic outliers from 2022 and one from 2021, indicating higher genetic distances. The Bayesian skyline plot revealed increased genetic variability peaking at the end of 2019, followed by stabilization from early 2020 onward, with no significant changes in genetic variability thereafter. Overall, the study found no genetic structure correlating with sampling date or hospital department, suggesting significant variability in pathogen introduction during the pandemic. The increase in multidrug-resistant K. pneumoniae was linked to the influx of severe COVID-19 cases, prolonged hospitalizations, and heightened broad-spectrum antibiotic use, which likely facilitated resistance development and transmission amidst altered infection control practices.

Frequently Touched Sites in the Intensive Care Unit Environment Returning 100 Colony-Forming Units per Surface Area Sampled Are Associated With Increased Risk of Major Bacterial Pathogen Detection

BACKGROUND

A threshold for surface hygiene has not been defined for the healthcare arena. We aimed to identify the magnitude of bacterial contamination of frequently touched sites in the intensive care unit (ICU) environment that could be used to guide quality improvement initiatives.

METHODS

Nineteen patients in a mixed ICU environment (providing care for medical and surgical patients) were followed from admission for 72 hours in 2010. Baseline cultures of frequently touched environmental sites were obtained at time zero following active decontamination and at 12, 24, 48, and 72 hours without further disinfection. We tested for an association of environmental reservoirs returning ≥ 100 colony-forming units (CFU) per surface area sampled with major bacterial pathogen detection.

RESULTS

There were 446 ICU room, day, and reservoir combinations sampled from 19 patients. There were pathogens detected in 40% (79/199) of samples with ≥ 100 CFU vs. 14% (35/247) of samples returning < 100 CFU. The relative risk was 2.80 (95% CI: 1.97-3.98, P <0.0001). The odds ratio adjusted for time in hours was 3.11 (95% CI: 1.84-5.34, P < 0.0001).

CONCLUSIONS

Frequently touched ICU environmental sites returning ≥ 100 CFU are associated with major bacterial pathogen detection. This threshold for surface hygiene can be used to ensure compliance with ICU environmental cleaning protocols and to guide quality improvement initiatives.

Hub and Spoke: Next level in regional networks for infection prevention

The threat of multidrug-resistant organisms (MDROs) and antimicrobial resistance (AMR) are real and increasing every day. They affect not only healthcare systems but also communities, causing economic and public health concerns. Governments must take action to tackle AMR and prevent the spread of MDROs and regional hubs have a critical role to play in achieving this outcome. Furthermore, bacteria have no borders, consequently, cooperation networks should be extended between countries as a crucial strategy for achieving the success of infection control. Euregions, which are a specific form of cooperation between local authorities of two or more bordering European countries, can help solve common problems and improve the lives of people living on both sides of the border. Regional collaboration strategies can enhance infection control and build resilience against antimicrobial resistance. This review identifies risk factors and the correct approaches to infection prevention and control, including education and awareness programs for healthcare professionals, appropriate prescribing practices, and infection prevention control measures. These measures can help reduce the incidence of antimicrobial resistance in the region and save lives. It is therefore essential to take concrete actions and foster the creation of more effective regional and cross-border centers to ensure the success of infection control policies and the management of healthcare-associated infections. This work sheds light on the issue of MDRO infections within healthcare settings, while also acknowledging the crucial role of the One Health concept in understanding the broader context of these infections. By recognizing the interdependence of human and animal health and the environment, we can take constructive steps toward mitigating the risks of these infections and promoting better health outcomes for all.

Prevalence and risk factors for colonisation and infection with carbapenem-resistant Enterobacterales in intensive care units: A prospective multicentre study

OBJECTIVES

This study aimed to investigate the prevalence and risk factors for carbapenem-resistant Enterobacterales colonisation/infection at admission and acquisition among patients admitted to the intensive care unit.

RESEARCH METHODOLOGY/DESIGN

A prospective and multicentre study.

SETTING

This study was conducted in 24 intensive care units in Anhui, China.

MAIN OUTCOME MEASURES

Demographic and clinical data were collected, and rectal carbapenem-resistant Enterobacterales colonisation was detected by active screening. Multivariate logistic regression models were used to analyse factors associated with colonisation/infection with carbapenem-resistant Enterobacterales at admission and acquisition during the intensive care unit stay.

RESULTS

There were 1133 intensive care unit patients included in this study. In total, 5.9% of patients with carbapenem-resistant Enterobacterales colonisation/infection at admission, and of which 56.7% were colonisations. Besides, 8.5% of patients acquired carbapenem-resistant Enterobacterales colonisation/infection during the intensive care stay, and of which 67.6% were colonisations. At admission, transfer from another hospital, admission to an intensive care unit within one year, colonisation/infection/epidemiological link with carbapenem-resistant Enterobacterales within one year, and exposure to any antibiotics within three months were risk factors for colonisation/infection with carbapenem-resistant Enterobacterales. During the intensive care stay, renal disease, an epidemiological link with carbapenem-resistant Enterobacterales, exposure to carbapenems and beta-lactams/beta-lactamase inhibitors, and intensive care stay of three weeks or longer were associated with acquisition.

CONCLUSION

The prevalence of colonisation/infection with carbapenem-resistant Enterobacterales in intensive care units is of great concern and should be monitored systematically. Particularly for the 8.5% prevalence of carbapenem-resistant Enterobacterales acquisition during the intensive care stay needs enhanced infection prevention and control measures in these setting. Surveillance of colonisation/infection with carbapenem-resistant Enterobacterales at admission and during the patient's stay represents an early identification tool to prevent further transmission of carbapenem-resistant Enterobacterales.

IMPLICATIONS FOR CLINICAL PRACTICE

Carbapenem-resistant Enterobacterales colonization screening at admission and during the patient's stay is an important tool to control carbapenem-resistant Enterobacterales spread in intensive care units.

Vancomycin-resistant enterococci (VRE) in hospital settings across European borders: a scoping review comparing the epidemiology in the Netherlands and Germany

The rising prevalence of vancomycin-resistant enterococci (VRE) is a matter of concern in hospital settings across Europe without a distinct geographical pattern. In this scoping review, we compared the epidemiology of vancomycin-resistant Enterococcus spp. in hospitals in the Netherlands and Germany, between 1991 and 2022. We searched PubMed and summarized the national antibiotic resistance surveillance data of the two countries. We included 46 studies and summarized national surveillance data from the NethMap in the Netherlands, the National Antimicrobial Resistance Surveillance database in Germany, and the EARS-Net data. In total, 12 studies were conducted in hospitals in the Netherlands, 32 were conducted in German hospitals, and an additional two studies were conducted in a cross-border setting. The most significant difference between the two countries was that studies in Germany showed an increasing trend in the prevalence of VRE in hospitals, and no such trend was observed in studies in the Netherlands. Furthermore, in both Dutch and German hospitals, it has been revealed that the molecular epidemiology of VREfm has shifted from a predominance of vanA towards vanB over the years. According to national surveillance reports, vancomycin resistance in Enterococcus faecium clinical isolates fluctuates below 1% in Dutch hospitals, whereas it follows an increasing trend in German hospitals (above 20%), as supported by individual studies. This review demonstrates that VRE is more frequently encountered in German than in Dutch hospitals and discusses the underlying factors for the difference in VRE occurrence in these two neighboring countries by comparing differences in healthcare systems, infection prevention control (IPC) guidelines, and antibiotic use in the Netherlands and Germany.

[Therapy-relevant antibiotic resistances in a One Health context]

One Health refers to a concept that links human, animal, and environmental health. In Germany, there is extensive data on antibiotic resistance (AMR) and multidrug-resistant (micro)organisms (MDRO) in human and veterinary medicine, as well as from studies in various environmental compartments (soil, water, wastewater). All these activities are conducted according to different specifications and standards, which makes it difficult to compare data. A focus on AMR and MDRO of human therapeutic importance is helpful to provide some guidance. Most data are available across sectors on methicillin-resistant Staphylococcus aureus (MRSA) and multiresistant Enterobacterales such as Escherichia coli and Klebsiella pneumoniae. Here, the trends of resistance are heterogeneous. Antibiotic use leads to MRE selection, which is well documented. Success in minimizing antibiotic use has also been demonstrated in recent years in several sectors and could be correlated with success in containing AMR and MDRO (e.g., decrease in MRSA in human medicine). Sector-specific measures to reduce the burden of MDRO and AMR are also necessary, as not all resistance problems are linked to other sectors. Carbapenem resistance is still rare, but most apparent in human pathogens. Colistin resistance occurs in different sectors but shows different mechanisms in each. Resistance to antibiotics of last resort such as linezolid is rare in Germany, but shows a specific One Health correlation. Efforts to harmonize methods, for example in the field of antimicrobial susceptibility testing and genome-based pathogen and AMR surveillance, are an important first step towards a better comparability of the different data collections.