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Can the strict search-and-isolate strategy for controlling the spread of highly-resistant bacteria be mitigated?. G Birgand a , I Lolom a , E Ruppe b , L Armand-Lefèvre b , S Belorgey a , A Andremont b , JC Lucet a

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G birgand a i lolom a e ruppe b l armand lef vre b

Can the strict search-and-isolate strategy for controlling the spread of highly-resistant bacteria be mitigated?

G Birgand a, I Lolom a, E Ruppe b, L Armand-Lefèvre b,

S Belorgey a, A Andremont b , JC Lucet a

aInfection control unit, Bichat-Claude Bernard Hospital, Paris, France

bBacteriology laboratory, Bichat-Claude Bernard Hospital, Paris, France

ICPIC Geneva 2013


Introduction epidemiological context in france

IntroductionEpidemiological Context in France

GRE

CPE

E.Faecium VR

EARSS 2011

Kp Carba-R

EARSS 2011

2

ICPIC Geneva 2013


Introduction french national recommandations 2006 2010

Introduction French National Recommandations, 2006-2010

Patients detected colonised with GRE or CPE:

Single room + contact precautions for case patients along their entire hospital stay

Single room + contact precautions for contact patients, until three negative weekly rectal screening (D0, D7, D15)

Screening of contact patients already transferred, alert at readmission

Cohorting of cases and contact patients in 2 different dedicated areas with dedicated staff 24/7

Interruption of transfers of carriers and contact patients +interruption of new admissions, pending results of screening

3

ICPIC Geneva 2013


Introduction potential consequences

Introduction Potential consequences

Medical impact:

Unintended deleterious adverse effects for patients ?

Disruption for the ward

Loss of chance for patient due to inappropriate care

Economical impact:

Lost income due to interruption of transfers and admissions

Cost of lab techniques and contact precautions

Cost of additional staff for cohorting

4

ICPIC Geneva 2013


G birgand a i lolom a e ruppe b l armand lef vre b

Objectives

  • To describe the episodes of HRB during a 4-year period in a 1000-bed University Hospital

  • To describe adapted control measures according to the epidemiological risk analysis


Methods description of the episodes

MethodsDescription of the Episodes

30 episodes from January 2009 to December 2012:

  • 14 Glycopeptide-resistant Enterococcus faecium (GRE)

    • 10 vanA

    • 4 vanB

  • 18 Carbapenemase-producing enterobacteriacae (CPE)

    • 13 OXA-48 producers

    • 4 KPC

    • 2 E. coli NDM-1


Methods e pidemiological risk analysis

MethodsEpidemiological Risk Analysis

  • Ward associated factors:

    • Workload

    • Previous experience of the ward with HRBs

    • Ward organisation and management

    • Compliance with hand hygiene: Alcoholic handrub consumption

    • Geographical distribution of the ward

    • Number of contact patients

  • Cross disciplinary factors:

    • Expertise and impact of the Infection control team

    • Reactivity of the bacteriology lab

    • Expertise of the lab to identify HRB (PCR, enrichment)

    • Involvement and support of the hospital administration

http://www.sf2h.net/


G birgand a i lolom a e ruppe b l armand lef vre b

MethodsEpidemiological Risk Analysis

http://www.sf2h.net/

  • Factors associated toexposure:

    • Time from admission to HRB identification

  • Factors associated theamount of HRB:

    • Type of positive sample: infection > colonisation

    • Positive screening : direct plating or after enrichment

    • Antibiotic treatment  bacterial burden

  • Factors associated with workload:

    • Nurse-to-patient ratio

    • Dependence in nursing care of case patients

    • Presence of invasive devices


Methods tailored control measures

MethodsTailored Control Measures

9


Methods tailored control measures1

MethodsTailored Control Measures

10


Methods tailored control measures2

MethodsTailored Control Measures

11


Methods tailored control measures3

MethodsTailored Control Measures

12


Results control strategy

ResultsControl Strategy

1 - No “contact” patients

2 - Colonised patients:

Contact precautions

Cross sectional weekly screening

Patients known as

colonised at admission

N= 11 (5 GRE, 7 CPE)

3 Episodes with secondary cases

1 episodes with 2 late

2ndary cases (D32)

2 episodes with 1 late

2ndary case (D18, D 53)

Colonised patients

Dedicated area 1/2

Dedicated staff 1/ 2

Reinforced staff 2/2

Interruption of transfers & admissions 2/2

Colonised patients

Reinforced staff

Interruption of transfers & admissions


Results control strategy1

ResultsControl Strategy

Identification >48h after admission

N = 19 (9 GRE, 11 CPE)

« Contact » patients

Contact precautions (n= 19)

Weekly screening (n= 19)

Colonised patients

Contact precautions (n= 19)

Interruption of transfers and admissions (n= 10)

Reinforced staff (n= 10)

5 Episodes with 14 secondary cases

5 GRE (D3) ; 4 GRE (D5) ; 2 GRE (D3) ; 2 GRE (D34) ; 1 CPE (D3)

« Contact » patients

Dedicated area (n= 3/5)

Dedicated staff (n= 2/5)

Weekly screening (n= 5/5)

Colonised patients

Dedicated area (n= 3/5)

Dedicated staff (n= 3/5)

Additional interruption of transfers and admissions (4/5)


Discussion

Discussion

  • French national guidelines are costly and difficult to implement

  • Local experience suggests the possibility to adapt control measures according to the epidemiological risk

  • However … several prerequisites:

    • Involvement of the infection control team

      • Frequent presence of the ICT in the affected ward

      • Education of nursing staff day/night

      • Alert system for colonised and contact patients (admission and transfer)

    • Involvement of the bacteriology lab

    • Involvement of the hospital administration


Discussion conclusion

Which lessons from epidemic situations?

Delay in the identification of HRB

Higher risk of GRE transmission than CPE

Prolonged length of stay with staffweariness

Obstacles:

Difficulties to transfer colonised patients to downstream units (very high LOS)

More flexible national recommendations coming soon (September 2013)

Discussion - Conclusion


G birgand a i lolom a e ruppe b l armand lef vre b

Thank you for your attention


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