Carbapenem-Resistant Enterobacteriaceae, Long-Term Acute Care Hospitals, and Our Distortions of Reality

2013 ◽  
Vol 34 (8) ◽  
pp. 835-837 ◽  
Author(s):  
L. Silvia Munoz-Price
Keyword(s):  
Acute Care ◽  
Acute Care Hospitals ◽  
Carbapenem Resistant ◽  
Carbapenem Resistant Enterobacteriaceae

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

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

Abstract Typically, long-term acute care hospitals (LTACHs) have less experience in and incentives to implementing aggressive infection control for drug-resistant organisms such as carbapenem-resistant Enterobacteriaceae (CRE) than acute care hospitals. Decision makers need to understand how implementing control measures in LTACHs can impact CRE spread regionwide. Using our Chicago metropolitan region agent-based model to simulate CRE spread and control, we estimated that a prevention bundle in only LTACHs decreased prevalence by a relative 4.6%–17.1%, averted 1,090–2,795 new carriers, 273–722 infections and 37–87 deaths over 3 years and saved $30.5–$69.1 million, compared with no CRE control measures. When LTACHs and intensive care units intervened, prevalence decreased by a relative 21.2%. Adding LTACHs averted an additional 1,995 carriers, 513 infections, and 62 deaths, and saved $47.6 million beyond implementation in intensive care units alone. Thus, LTACHs may be more important than other acute care settings for controlling CRE, and regional efforts to control drug-resistant organisms should start with LTACHs as a centerpiece.

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

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

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

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

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

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

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

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

Abstract Background Carbapenem-resistant Enterobacteriaceae (CRE) are an urgent threat with potential for rapid spread. We evaluated the role of Medicare patient movement between facilities to model the spread of CRE within a region. Methods Through population-based CRE surveillance in the 8-county Atlanta (GA) metropolitan area, all Escherichia coli, Enterobacter spp., or Klebsiella spp. resistant to ≥1 carbapenem were reported from residents. CRE was attributed to a facility based on timing of culture and facility exposures. Centrality metrics were calculated from 2016 Medicare data and compared to CRE-transfer derived centrality metrics by Spearman correlation. Results During 2016, 283 incident CRE cases with concurrent or prior year facility stays were identified; cases were attributed mostly to acute care hospitals (ACHs; 141, 50%) and skilled nursing facilities (SNFs; 113, 40%), and less frequently to long-term acute care hospitals (LTACHs; 29, 10%). Attribution was widespread, originating at 17 of 20 ACHs (85%), 7 of 8 (88%) LTACHs, but only 35 of 65 (54%) SNFs. Betweenness of Medicare patient transfers strongly correlated with betweenness of CRE case-transfer data in ACHs (r = 0.75; P &lt; .01) and LTACHs (r = 0.77; P = .03), but not in SNFs (r = 0.02; P = 0.85). We noted 6 SNFs with high CRE-derived betweenness but low Medicare-derived betweenness. Conclusions CRE infections originate from almost all ACHs and half of SNFs. We identified a subset of SNFs central to the CRE transfer network but not the Medicare transfer network; other factors may explain CRE patient movement in these facilities.

Establishment of a Statewide Network for Carbapenem-Resistant Enterobacteriaceae Prevention in a Low-Incidence Region

2014 ◽  
Vol 35 (4) ◽  
pp. 356-361 ◽  
Author(s):  
Christopher D. Pfeiffer ◽  
Margaret C. Cunningham ◽  
Tasha Poissant ◽  
Jon P. Furuno ◽  
John M. Townes ◽  
...  
Keyword(s):  
Acute Care ◽  
Infection Prevention ◽  
Long Term Care ◽  
Term Care ◽  
Carbapenem Resistant ◽  
Care Facilities ◽  
Low Incidence ◽  
Acute Care Facilities ◽  
Carbapenem Resistant Enterobacteriaceae

Objective.To establish a statewide network to detect, control, and prevent the spread of carbapenem-resistant Enterobacteriaceae (CRE) in a region with a low incidence of CRE infection.Design.Implementation of the Drug Resistant Organism Prevention and Coordinated Regional Epidemiology (DROP-CRE) Network.Setting and Participants.Oregon infection prevention and microbiology laboratory personnel, including 48 microbiology laboratories, 62 acute care facilities, and 140 long-term care facilities.Methods.The DROP-CRE working group, comprising representatives from academic institutions and public health, convened an interdisciplinary advisory committee to assist with planning and implementation of CRE epidemiology and control efforts. The working group established a statewide CRE definition and surveillance plan; increased the state laboratory capacity to perform the modified Hodge test and polymerase chain reaction for carbapenemases in real time; and administered surveys that assessed the needs and capabilities of Oregon infection prevention and laboratory personnel. Results of these inquiries informed CRE education and the response plan.Results.Of 60 CRE reported from November 2010 through April 2013, only 3 were identified as carbapenemase producers; the cases were not linked, and no secondary transmission was found. Microbiology laboratories, acute care facilities, and long-term care facilities reported lacking carbapenemase testing capability, reliable interfacility communication, and CRE awareness, respectively. Survey findings informed the creation of the Oregon CRE Toolkit, a state-specific CRE guide booklet.Conclusions.A regional epidemiology surveillance and response network has been implemented in Oregon in advance of widespread CRE transmission. Prospective surveillance will determine whether this collaborative approach will be successful at forestalling the emergence of this important healthcare-associated pathogen.

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

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

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

Risk Factors for Colonization due to Carbapenem-Resistant Enterobacteriaceae among Patients: Exposed to Long-Term Acute Care and Acute Care Facilities

2014 ◽  
Vol 35 (4) ◽  
pp. 398-405 ◽  
Author(s):  
Ashish Bhargava ◽  
Kayoko Hayakawa ◽  
Ethan Silverman ◽  
Samran Haider ◽  
Krishna Chaitanya Alluri ◽  
...  
Keyword(s):  
Risk Factors ◽  
Hospital Admission ◽  
Acute Care ◽  
Entire Cohort ◽  
Carbapenem Resistant ◽  
Increased Risk ◽  
Surveillance Programs ◽  
Acute Care Facilities ◽  
Carbapenem Resistant Enterobacteriaceae

Background.This study aimed to identify risk factors associated with carbapenem-resistant Enterobacteriaceae (CRE) colonization among patients screened with rectal cultures upon admission to a hospital or long-term acute care (LTAC) center and to compare risk factors among patients who were screen positive for CRE at the time of hospital admission with those screen positive prior to LTAC admission.Methods.A retrospective nested matched case-control study was conducted from June 2009 to December 2011. Patients with recent LTAC exposure were screened for CRE carriage at the time of hospital admission, and patients admitted to a regional LTAC facility were screened prior to LTAC admission. Cases were patients with a positive CRE screening culture, and controls (matched in a 3:1 ratio to cases) were patients with negative screening cultures.Results.Nine hundred five cultures were performed on 679 patients. Forty-eight (7.1%) cases were matched to 144 controls. One hundred fifty-eight patients were screened upon hospital admission and 521 prior to LTAC admission. Independent predictors for CRE colonization included Charlson's score greater than 3 (odds ratio [OR], 4.85 [95% confidence interval (CI), 1.64–14.41]), immunosuppression (OR, 3.92 [95% CI, 1.08–1.28]), presence of indwelling devices (OR, 5.21 [95% CI, 1.09–2.96]), and prior antimicrobial exposures (OR, 3.89 [95% CI, 0.71–21.47]). Risk factors among patients screened upon hospital admission were similar to the entire cohort. Among patients screened prior to LTAC admission, the characteristics of the CRE-colonized and noncolonized patients were similar.Conclusions.These results can be used to identify patients at increased risk for CRE colonization and to help target active surveillance programs in healthcare settings.

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