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Prevention of central-line–associated bloodstream infection (CLABSI) represents a complex challenge for the teams involved in device insertion and maintenance. First-tier practices for CLABSI prevention are well established.
We describe second-tier prevention practices in Israeli medical-surgical ICUs and assess their association with CLABSI rates.
In June 2017, an online survey assessing infection prevention practices in general ICUs was sent to all Israeli acute-care hospitals. The survey comprised 14 prevention measures supplementary to the established measures that are standard of care for CLABSI prevention. These measures fall into 2 domains: technology and implementation. The association between the number of prevention measures and CLABSI rate during the first 6 months of 2017 was assessed using Spearman’s correlation. We used negative binomial regression to calculate the incidence rate ratio (IRR) associated with the overall number of prevention measures and with each measure individually.
The CLABSI rates in 24 general ICUs varied between 0.0 and 17.0 per 1,000 central-line days. Greater use of preventive measures was associated with lower CLABSI rates (ρ, –0.70; P < .001). For each additional measure, the incidence of CLABSI decreased by 19% (IRR, 0.81; 95% CI, 0.73–0.89). Specific measures associated with lower rates were involvement of ward champions (IRR, 0.47; 95% CI, 0.31–0.71), auditing of insertions by infection control staff (IRR, 0.35; 95% CI, 0.19–0.64), and simulation-based training (IRR, 0.38; 95% CI, 0.22–0.64).
Implementation of second-tier preventive practices was protective against CLABSI. Use of more practices was correlated with lower rates.
Since 2006, Israel has been confronting an outbreak of carbapenem-resistant Enterobacteriaceae (CRE), and in 2007 Israel implemented a national strategy to contain spread. The intervention was initially directed toward acute-care hospitals and later expanded to include an established reservoir of carriage in long-term-care hospitals. It included regular reporting of CRE cases to a central registry and daily oversight of management of the outbreak at the institutional level. Microbiological methodologies were standardized in clinical laboratories nationwide. Uniform requirements for carrier screening and isolation were established, and a protocol for discontinuation of carrier status was formulated. In response to the evolving epidemiology of CRE in Israel and the continued need for uniform guidelines for carrier detection and isolation, the Ministry of Health in 2016 issued a regulatory circular updating the requirements for CRE screening, laboratory diagnosis, molecular characterization, and carrier isolation, as well as reporting and discontinuation of isolation in healthcare institutions nationwide. The principal elements of the circular are contained herein.
Patients 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.
A prospective cohort interventional study.
Thirteen PACHs in Israel.
A 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.
The 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.
A nationwide infection control intervention was associated with enhanced infection control measures and a reduction in the prevalence of CRE in PACHs.
To assess the prevalence of and risk factors for carbapenem-resistant Klebsiella pneumoniae (CRKP) carriage among patients in post-acute-care facilities (PACFs) in Israel.
Design, Setting, and Patients.
A cross-sectional prevalence survey was conducted in 12 PACFs. Rectal swab samples were obtained from 1,144 patients in 33 wards. Risk factors for CRKP carriage were assessed among the cohort. Next, a nested, matched case-control study was conducted to define individual risk factors for colonization. Finally, the cohort of patients with a history of CRKP carriage was characterized to determine risk factors for continuous carriage.
The prevalence of rectal carriage of CRKP among 1,004 patients without a history of CRKP carriage was 12.0%. Independent risk factors for CRKP carriage were prolonged length of stay (odds ratio [OR], 1.001; P < .001), sharing a room with a known carrier (OR, 3.09; P = .02), and increased prevalence of known carriers on the ward (OR, 1.02; P = .013). A policy of screening for carriage on admission was protective (OR, 0.41; P = .03). Risk factors identified in the nested case-control study were antibiotic exposure during the prior 3 months (OR, 1.66; P = .03) and colonization with other resistant pathogens (OR, 1.64; P = .03). Among 140 patients with a history of CRKP carriage, 47% were colonized. Independent risk factors for continued CRKP carriage were antibiotic exposure during the prior 3 months (OR, 3.05; P = .04), receipt of amoxicillin-clavulanate (OR, 4.18; P = .007), and screening within 90 days of the first culture growing CRKP (OR, 2.9; P = .012).
We found a large reservoir of CRKP in PACFs. Infection-control polices and antibiotic exposure were associated with patient colonization.
The recent emergence of carbapenem resistance among Enterobacteriaceae is a major threat for hospitalized patients, and effective strategies are needed.
To assess the effect of an intensified intervention, which included active surveillance, on the incidence of infection with carbapenem-resistant Klebsiella pneumoniae.
Sheba Medical Center, a 1,600-bed tertiary care teaching hospital in Tel Hashomer, Israel.
The medical records of all the patients who acquired a carbapenem-resistant K. pneumoniae infection during 2006 were reviewed. An intensified intervention was initiated in May 2007. In addition to contact precautions, active surveillance was initiated in high-risk units. The incidence of clinical carbapenem-resistant K. pneumoniae infection over time was measured, and interrupted time-series analysis was performed.
The incidence of clinical carbapenem-resistant K. pneumoniae infection increased 6.42-fold from the first quarter of 2006 up to the initiation of the intervention. In 2006, of the 120 patients whose clinical microbiologic culture results were positive for carbapenem-resistant K. pneumoniae, 67 (56%) developed a nosocomial infection. During the intervention period, the rate of carbapenem-resistant K. pneumoniae rectal colonization was 9%. Of the 390 patients with carbapenem-resistant K. pneumoniae colonization or infection, 204 (52%) were identified by screening cultures. There were a total of 12,391 days of contact precautions, and of these, 4,713 (38%) were added as a result of active surveillance. After initiation of infection control measures, we observed a significant decrease in the incidence of carbapenem-resistant K. pneumoniae infection.
The use of active surveillance and contact precautions, as part of a multifactorial intervention, may be an effective strategy to decrease rates of nosocomial transmission of carbapenem-resistant K. pneumoniae colonization or infection.
To examine the impact of methicillin resistance on in-hospital mortality, length of stay, and hospital cost after the onset of nosocomial Staphylococcus aureus bloodstream infection (BSI).
A retrospective cohort study.
A tertiary care hospital in Rhode Island.
A cohort of 182 consecutive patients who developed nosocomial BSI due to methicillin-susceptible and methicillin-resistant S. aureus (MSSA and MRSA, respectively)
Patients with MRSA BSI had a significantly longer total length of hospital and intensive care unit (ICU) stay before the onset of BSI and a higher average daily cost. Compared with ICU patients with MSSA BSI, those with MRSA BSI had a higher median total hospital cost ($42,137 vs $113,852), higher hospital cost after infection ($17,603 vs $51,492), and greater length of stay after infection (10.5 vs 20.5 days). After multivariable adjustment, ICU patients with MRSA BSI had significantly increased total hospital cost, hospital cost after infection, and length of stay after infection. However, using a propensity score approach, we found that, among ICU patients, the difference in cost after infection and the difference in length of stay after infection for MRSA, compared with MSSA BSI, were not significant. The differences among non-ICU patients who developed MRSA or MSSA BSI were not significant after multivariable adjustment or by propensity score.
On the basis of propensity score, we found that methicillin resistance did not independently increase hospital cost or length of stay after onset of S. aureus BSI. We believe that use of a propensity score on a comparable subset of patients may be a better method than multivariable adjustment for assessing the impact of methicillin resistance in cohort studies.
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