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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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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
Introduction the spread of highly-resistant bacteria be mitigated? Epidemiological 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 the spread of highly-resistant bacteria be mitigated? 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 the spread of highly-resistant bacteria be mitigated? 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


Objectives the spread of highly-resistant bacteria be mitigated?

  • 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
Methods the spread of highly-resistant bacteria be mitigated? Description 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
Methods the spread of highly-resistant bacteria be mitigated? Epidemiological 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/


Methods the spread of highly-resistant bacteria be mitigated? Epidemiological 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
Methods the spread of highly-resistant bacteria be mitigated? Tailored Control Measures

9


Methods tailored control measures1
Methods the spread of highly-resistant bacteria be mitigated? Tailored Control Measures

10


Methods tailored control measures2
Methods the spread of highly-resistant bacteria be mitigated? Tailored Control Measures

11


Methods tailored control measures3
Methods the spread of highly-resistant bacteria be mitigated? Tailored Control Measures

12


Results control strategy
Results the spread of highly-resistant bacteria be mitigated? Control 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
Results the spread of highly-resistant bacteria be mitigated? Control 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 the spread of highly-resistant bacteria be mitigated?

  • 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? the spread of highly-resistant bacteria be mitigated?

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


Thank you for your attention the spread of highly-resistant bacteria be mitigated?


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