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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

a Infection control unit, Bichat-Claude Bernard Hospital, Paris, Franceb Bacteriology laboratory, Bichat-Claude Bernard Hospital, Paris, France

ICPIC Geneva 2013

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IntroductionEpidemiological Context in France

GRE CPE

E.Faecium VR

EARSS 2011

Kp Carba-R

EARSS 2011

ICPIC Geneva 2013

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Introduction French National Recommandations, 2006-2010

Patients detected colonised with GRE or CPE:

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

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

3. Screening of contact patients already transferred, alert at readmission

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

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

ICPIC Geneva 2013

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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

ICPIC Geneva 2013

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

2. To describe adapted control measures according to the epidemiological risk analysis

Objectives

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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

Number of episodes CPE GRE GRE+CPE

7

6

5

4

3

2

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1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 122009 2010 2011 2012

ID2 case II

ID2 case II

Surg ICU1 case II

Tho surg11 case II

Diabeto1 case II

Diabeto3 case II

ID1 case II

Surg2 cas II

Pneu2 case II

Tho sur1 case II

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• 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

MethodsEpidemiological Risk Analysis

http://www.sf2h.net/

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• Factors associated to exposure:– Time from admission to HRB identification

• Factors associated the amount 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

MethodsEpidemiological Risk Analysis

http://www.sf2h.net/

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MethodsTailored Control Measures

Epidemiological Situation Control Measures

Admission of a case previously known or identified <48h

• Single room, Contact Precautions• Weekly cross-sectional screening, but no

contact patients

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MethodsTailored Control Measures

Epidemiological Situation Control Measures

Admission of a case previously known or identified <48h

• Single room, Contact Precautions• Weekly cross-sectional screening, but no

contact patients Case identification>48h after admission

• Interruption of transfers and admissions• Reinforcement of nursing staff• Screening of contact patients at D0, D7

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MethodsTailored Control Measures

Epidemiological Situation Control Measures

Admission of a case previously known or identified <48h

• Single room, Contact Precautions• Weekly cross-sectional screening, but no

contact patients Case identification>48h after admission

• Interruption of transfers and admissions• Reinforcement of nursing staff• Screening of contact patients at D0, D7

One secondary case • One unit for colonised and contact patients with dedicated staff

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MethodsTailored Control Measures

Epidemiological Situation Control Measures

Admission of a case previously known or identified <48h

• Single room, Contact Precautions• Weekly cross-sectional screening, but no

contact patients Case identification>48h after admission

• Interruption of transfers and admissions• Reinforcement of nursing staff• Screening of contact patients at D0, D7

One secondary case • One unit for colonised and contact patients with dedicated staff

Outbreak situation • Two distinct dedicated units for colonised and contact patients with dedicated nursing staff

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ResultsControl Strategy

Patients known as colonised at admission

N= 11 (5 GRE, 7 CPE)

3 Episodes with secondary cases

1 - No “contact” patients2 - Colonised patients:Contact precautionsCross sectional weekly screening

Colonised patientsDedicated area 1/2Dedicated staff 1/ 2Reinforced staff 2/2Interruption of transfers & admissions 2/2

2 episodes with 1 late 2ndary case (D18, D 53)

Colonised patientsReinforced staffInterruption of transfers & admissions

1 episodes with 2 late 2ndary cases (D32)

ResultsControl Strategy

Identification >48h after admission N = 19 (9 GRE, 11 CPE)

5 Episodes with 14 secondary cases5 GRE (D3) ; 4 GRE (D5) ; 2 GRE (D3) ; 2 GRE (D34) ; 1 CPE (D3)

Colonised patients Dedicated area (n= 3/5)Dedicated staff (n= 3/5)

« Contact » patients Dedicated area (n= 3/5)Dedicated staff (n= 2/5)Weekly screening (n= 5/5)

Additional interruption of transfers and admissions (4/5)

Colonised patientsContact precautions (n= 19)

« Contact » patientsContact precautions (n= 19)

Weekly screening (n= 19)

Interruption of transfers and admissions (n= 10)Reinforced staff (n= 10)

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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:

o 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)

o Involvement of the bacteriology labo Involvement of the hospital administration

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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 staff weariness

• Obstacles:– Difficulties to transfer colonised patients to

downstream units (very high LOS)

• More flexible national recommendations coming soon (September 2013)

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Thank you for your attention