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

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

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  1. 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

  2. IntroductionEpidemiological Context in France GRE CPE E.Faecium VR EARSS 2011 Kp Carba-R EARSS 2011 2 ICPIC Geneva 2013

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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/

  8. 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

  9. MethodsTailored Control Measures 9

  10. MethodsTailored Control Measures 10

  11. MethodsTailored Control Measures 11

  12. MethodsTailored Control Measures 12

  13. 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

  14. 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)

  15. 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

  16. 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

  17. Thank you for your attention

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