Rump B, Timen A, Hulscher M, Verweij M.

Ethics of Infection Control Measures for Carriers of Antimicrobial Drug-Resistant Organisms.

Emerg Infect Dis. 2018 Sep;24(9):1609-1616.

Abstract
Many countries have implemented infection control measures directed at carriers of multidrug-resistant organisms. To explore the ethical implications of these measures, we analyzed 227 consultations about multidrug resistance and compared them with the literature on communicable disease in general. We found that control measures aimed at carriers have a range of negative implications. Although moral dilemmas seem similar to those encountered while implementing control measures for other infectious diseases, 4 distinct features stand out for carriage of multidrug-resistant organisms: carriage presents itself as a state of being; carriage has limited relevance for the health of the carrier; carriage has little relevance outside healthcare settings; and antimicrobial resistance is a slowly evolving threat on which individual carriers have limited effect. These features are of ethical relevance because they influence the way we traditionally think about infectious disease control and urge us to pay more attention to the personal experience of the individual carrier.

Gysin DV, Cookson B, Saenz H, Dettenkofer M;: Widmer AF; ESCMID Study Group for Nosocomial Infections (ESGNI).

Variability in contact precautions to control the nosocomial spread of multi-drug resistant organisms in the endemic setting: a multinational cross-sectional survey. 

Antimicrob Resist Infect Control. 2018 Jul 9;7:81.

Abstract
Background: 
Definitions and practices regarding use of contact precautions and isolation to prevent the spread of gram-positive and gram-negative multidrug-resistant organisms (MDRO) are not uniform.
Methods: 
We conducted an on-site survey during the European Congress on Clinical Microbiology and Infectious Diseases 2014 to assess specific details on contact precaution and implementation barriers.
Results: 
Attendants from 32 European (EU) and 24 non-EU countries participated (n = 213). In EU-respondents adherence to contact precautions and isolation was high for Methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Enterobacteriaceae, and MDR A. baumannii (84.7, 85.7, and 80%, respectively) whereas only 68% of EU-respondents considered any contact precaution measures for extended-spectrum-beta-lactamase (ESBL) producing non-E. coli. Between 30 and 45% of all EU and non-EU respondents did not require health-care workers (HCW) to wear gowns and gloves at all times when entering the room of a patient in contact isolation. Between 10 and 20% of respondents did not consider any rooming specifications or isolation for gram-positive MDRO and up to 30% of respondents abstain from such interventions in gram-negative MDRO, especially non-E. coli ESBL. Understaffing and lack of sufficient isolation rooms were the most commonly encountered barriers amongst EU and non-EU respondents.
Conclusion: 
The effectiveness of contact precautions and isolation is difficult to assess due to great variation in components of the specific measures and mixed levels of implementation. The lack of uniform positive effects of contact isolation to prevent transmission may be explained by the variability of interpretation of this term. Indications for contact isolation require a global definition and further sound studies.

Coppéré Z, Voiriot G, Blayau C, Gibelin A, Labbe V, Fulgencio JP, Fartoukh M, Djibré M. 

Disparity of the «screen-and-isolate» policy for multidrug-resistant organisms: a national survey in French adult ICUs.

Am J Infect Control. 2018 Jul 3.  

Abstract
BACKGROUND: 
The prevalence of multidrug-resistant organisms (MDROs) has dramatically increased. The aim of this survey was to describe and analyze the different screening and isolation policies regarding MDROs in French adult intensive care units (ICUs).
MATERIALS AND METHODS: 
A multicenter online survey was performed among French ICUs, including 63 questions distributed into 4 parts: characteristics of the unit, MDRO screening policy, policy regarding contact precautions, and ecology of the unit.
RESULTS: 
From April 2015 to June 2016, 73 of 301 ICUs (24%) participated in the survey. MDRO screening was performed on admission in 96% of ICUs, for at least 1 MDRO (78%). MDRO screening was performed weekly during ICU stay in 83% of ICUs. Preemptive isolation was initiated on admission in 82% of ICUs, mostly in a targeted way (71%). Imported and acquired MDRO rates >10% were reported in 44% and 27% of ICUs, respectively. An MDRO outbreak had occurred within the past 3 years in 48% of cases.
CONCLUSION: 
French ICUs have variable screening and isolation approaches for MDROs, as up to 10 combinations were met. Discrepancies with the 2009 national guidelines were observed. Very few ICUs practice without some form of screening and isolation of patients upon admission.

Furuya EY, Cohen B, Jia H, Larson EL.

Long-Term Impact of Universal Contact Precautions on Rates of Multidrug-Resistant Organisms in ICUs: A Comparative Effectiveness Study.

Infect Control Hosp Epidemiol. 2018 May;39(5):534-540. 

Abstract
OBJECTIVE
To evaluate the impact of universal contact precautions (UCP) on rates of multidrug-resistant organisms (MDROs) in intensive care units (ICUs) over 9 yearsDESIGNRetrospective, nonrandomized observational studySETTINGAn 800-bed adult academic medical center in New York CityPARTICIPANTSAll patients admitted to 6 ICUs, 3 of which instituted UCP in 2007.

METHODS
Using a comparative effectiveness approach, we studied the longitudinal impact of UCP on MDRO incidence density rates, including methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and carbapenem-resistant Klebsiella pneumoniae. Data were extracted from a clinical research database for 2006-2014. Monthly MDRO rates were compared between the baseline period and the UCP period, utilizing time series analyses based on generalized linear models. The same models were also used to compare MDRO rates in the 3 UCP units to 3 ICUs without UCPs.
RESULTS
Overall, MDRO rates decreased over time, but there was no significant decrease in the trend (slope) during the UCP period compared to the baseline period for any of the 3 intervention units. Furthermore, there was no significant difference between UCP units (6.6% decrease in MDRO rates per year) and non-UCP units (6.0% decrease per year; P=.840).
CONCLUSION
The results of this 9-year study suggest that decreases in MDROs, including multidrug-resistant gram-negative bacilli, were more likely due to hospital-wide improvements in infection prevention during this period and that UCP had no detectable additional impact.Infect Control Hosp Epidemiol 2018;39:534-540.

Datta R, Juthani-Mehta M.

Burden and Management of Multidrug-Resistant Organisms in Palliative Care.

Palliat Care. 2017 Dec 19;10:1178224217749233.

Abstract
Palliative care includes comprehensive strategies to optimize quality of life for patients and families confronting terminal illness. Infections are a common complication in terminal illness, and infections due to multidrug-resistant organisms (MDROs) are particularly challenging to manage in palliative care. Limited data suggest that palliative care patients often harbor MDRO. When MDROs are present, distinguishing colonization from infection is challenging due to cognitive impairment or metastatic disease limiting symptom assessment and the lack of common signs of infection. Multidrug-resistant organisms also add psychological burden through infection prevention measures including patient isolation and contact precautions which conflict with the goals of palliation. Moreover, if antimicrobial therapy is indicated per goals of care discussions, available treatment options are often limited, invasive, expensive, or associated with adverse effects that burden patients and families. These issues raise important ethical considerations for managing and containing MDROs in the palliative care setting.

Burnham JP, Kwon JH, Olsen MA, Babcock HM, Kollef MH.

Readmissions With Multidrug-Resistant Infection in Patients With Prior Multidrug Resistant Infection.

Journal of Infect Control Hosp Epidemiol. 2018 Jan;39(1):12-19.  

Abstract
OBJECTIVE 
To determine incidence of and risk factors for readmissions with multidrug-resistant organism (MDRO) infections among patients with previous MDRO infection. DESIGN Retrospective cohort of patients admitted between January 1, 2006, and October 1, 2015. 
SETTING 
Barnes-Jewish Hospital, a 1,250-bed academic tertiary referral center in St Louis, Missouri. METHODS We identified patients with MDROs obtained from the bloodstream, bronchoalveolar lavage (BAL)/bronchial wash, or other sterile sites. Centers for Disease Control and prevention (CDC) and European CDC definitions of MDROs were utilized. All readmissions ≤1 year from discharge from the index MDRO hospitalization were evaluated for bloodstream, BAL/bronchial wash, or other sterile site cultures positive for the same or different MDROs. 
RESULTS 
In total, 4,429 unique patients had a positive culture for an MDRO; 3,453 of these (78.0%) survived the index hospitalization. Moreover, 2,127 patients (61.6%) were readmitted ≥1 time within a year, for a total of 5,849 readmissions. Furthermore, 512 patients (24.1%) had the same or a different MDRO isolated from blood, BAL/bronchial wash, or another sterile site during a readmission. Bone marrow transplant, end-stage renal disease, lymphoma, methicillin-resistant Staphylococcus aureus, or carbapenem-resistant Pseudomonas aeruginosa during index hospitalization were factors associated with increased risk of having an MDRO isolated during a readmission. MDROs isolated during readmissions were in the same class of MDRO as the index hospitalization 9%-78% of the time, with variation by index pathogen. 
CONCLUSIONS 
Readmissions among patients with MDRO infections are frequent. Various patient and organism factors predispose to readmission. When readmitted patients had an MDRO, it was often a pathogen in the same class as that isolated during the index admission, with the exception of Acinetobacter (~9%).

Marra AR, Schweizer ML, Edmond MB.

No-Touch Disinfection Methods to Decrease Multidrug-Resistant Organism Infections: A Systematic Review and Meta-analysis.

Infect Control Hosp Epidemiol. 2018 Jan;39(1):20-31.

Abstract
BACKGROUND 
Recent studies have shown that using no-touch disinfection technologies (ie, ultraviolet light [UVL] or hydrogen peroxide vapor [HPV] systems) can limit the transmission of nosocomial pathogens and prevent healthcare-associated infections (HAIs). To investigate these findings further, we performed a systematic literature review and meta-analysis on the impact of no-touch disinfection methods to decrease HAIs. 
METHODS 
We searched PubMed, CINAHL, CDSR, DARE and EMBASE through April 2017 for studies evaluating no-touch disinfection technology and the nosocomial infection rates for Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and other multidrug-resistant organisms (MDROs). We employed random-effect models to obtain pooled risk ratio (pRR) estimates. Heterogeneity was evaluated with I2 estimation and the Cochran Q statistic. Pooled risk ratios for C. difficile, MRSA, VRE, and MDRO were assessed separately. 
RESULTS 
In total, 20 studies were included in the final review: 13 studies using UVL systems and 7 studies using HPV systems. When the results of the UVL studies were pooled, statistically significant reduction ins C. difficile infection (CDI) (pRR, 0.64; 95% confidence interval [CI], 0.49-0.84) and VRE infection rates (pRR, 0.42; 95% CI, 0.28-0.65) were observed. No differences were found in rates of MRSA or gram-negative multidrug-resistant pathogens. 
CONCLUSIONS `
Ultraviolet light no-touch disinfection technology may be effective in preventing CDI and VRE infection. Infect Control Hosp Epidemiol 

Meißner A, Hasenclever D, Brosteanu O, Chaberny IF.

EFFECT of daily antiseptic body wash with octenidine on nosocomial primary bacteraemia and nosocomial multidrug-resistant organisms in intensive care units: design of a multicentre, cluster-randomised, double-blind, cross-over study.

BMJ Open. 2017 Nov 8;7(11):e016251. American Journal of Infection Control, 2017, 45(11) : 1249-1253

Abstract
INTRODUCTION: 
Nosocomial infections are serious complications that increase morbidity, mortality and costs and could potentially be avoidable. Antiseptic body wash is an approach to reduce dermal micro-organisms as potential pathogens on the skin. Large-scale trials with chlorhexidine as the antiseptic agent suggest a reduction of nosocomial infection rates. Octenidine is a promising alternative agent which could be more effective against Gram-negative organisms. We hypothesise that daily antiseptic body wash with octenidine reduces the risk of intensive care unit (ICU)-acquired primary bacteraemia and ICU-acquired multidrug-resistant organisms (MDRO) in a standard care setting.
METHODS AND ANALYSIS: 
EFFECT is a controlled, cluster-randomised, double-blind study. The experimental intervention consists in using octenidine-impregnated wash mitts for the daily routine washing procedure of the patients. This will be compared with using placebo wash mitts. Replacing existing washing methods is the only interference into clinical routine.Participating ICUs are randomised in an AB/BA cross-over design. There are two 15-month periods, each consisting of a 3-month wash-out period followed by a 12-month intervention and observation period. Randomisation determines only the sequence in which octenidine-impregnated or placebo wash mitts are used. ICUs are left unaware of what mitts packages they are using.The two coprimary endpoints are ICU-acquired primary bacteraemia and ICU-acquired MDRO. Endpoints are defined based on individual ward-movement history and microbiological test results taken from the hospital information systems without need for extra documentation. Data on clinical symptoms of infection are not collected. EFFECT aims at recruiting about 45 ICUs with about 225 000 patient-days per year.
ETHICS AND DISSEMINATION: 
The study was approved by the ethics committee of the University of Leipzig (number 340/16-ek) in November 2016. Findings will be published in peer-reviewed journals.

Araos R, Montgomery V, Ugalde JA, Snyder GM, D’Agata EMC.

Microbial Disruption Indices to Detect Colonization With Multidrug-Resistant Organisms.

Infect Control Hosp Epidemiol. 2017 Nov;38(11):1312-1318.

Abstract
OBJECTIVE
To characterize the microbial disruption indices of hospitalized patients to predict colonization with multidrug-resistant organisms (MDROs). DESIGN A cross-sectional survey of the fecal microbiome was conducted in a tertiary referral, acute-care hospital in Boston, Massachusetts. PARTICIPANTS The study population consisted of adult patients hospitalized in general medical/surgical wards. 
METHODS 
Rectal swabs were obtained from patients within 48 hours of hospital admission and screened for MDRO colonization using conventional culture techniques. The V4 region of the 16S rRNA gene was sequenced to assess the fecal microbiome. Microbial diversity and composition, as well as the functional potential of the microbial communities present in fecal samples, were compared between patients with and without MDRO colonization. 
RESULTS 
A total of 44 patients were included in the study, of whom 11 (25%) were colonized with at least 1 MDRO. Reduced microbial diversity and high abundance of metabolic pathways associated with multidrug-resistance mechanisms characterized the fecal microbiome of patients colonized with MDRO at hospital admission. 
CONCLUSIONS 
Our data suggest that microbial disruption indices may be key to predicting MDRO 

Hur EY, Jin YJ, Jin TX, Lee SM.

Development and evaluation of the automated risk assessment system for multidrug-resistant organisms (autoRAS-MDRO).

J Hosp Infect. 2018 Feb;98(2):202-211.

Abstract
BACKGROUND: 
A high proportion of infections acquired in hospitals are caused by multidrug-resistant organisms (MDROs). The priority in MDRO prevention is to detect high-risk patients and implement preventive intervention as soon as possible.
AIM: 
To develop an automated risk assessment system for MDROs (autoRAS-MDRO) to screen for patients at MDRO infection risk and evaluate the predictive validity of the autoRAS-MDRO.
METHODS:
Data for 4200 variables were extracted from the electronic health records (EHRs) for constructing the MDRO risk-scoring algorithm, which was based on a logistic regression model. The autoRAS-MDRO was designed such that the MDRO risk classification (high, moderate, low risk) could be automatically displayed on the nursing Kardex screen in the EHRs system. For the development of the MDRO risk-scoring algorithm, 1000 patients with MDROs and 4000 patients without MDROs were selected; similarly, for the evaluation, 2173 and 8692 patients with and without MDROs, respectively, were selected.
FINDINGS: 
The predictive validity of the autoRAS-MDRO was as follows: (i) at the 6-month evaluation: sensitivity, 81%; specificity, 79%; positive predictive value (PPV), 49%; negative predictive value (NPV), 94%; and Youden index, 0.60; (ii) at the 12-month evaluation: sensitivity 79%, specificity 78%, PPV 47%, NPV 94%, and Youden index, 0.57.
CONCLUSION: 
The autoRAS-MDRO had moderate predictive validity. It could be useful in redirecting nurses’ time and efforts required for MDRO risk assessment and implementation of infection control measures, and in reducing the incidence of MDRO infection in hospitals, thereby contributing to patient safety.

Bénet T, Girard R, Gerbier-Colomban S, Dananché C, Hodille E, Dauwalder O, Vanhems P.

Determinants of Implementation of Isolation Precautions Against Infections by Multidrug-Resistant Microorganisms: A Hospital-Based, Multicenter, Observational Study.

Infect Control Hosp Epidemiol. 2017 Oct;38(10):1188-1195.

Abstract
OBJECTIVES 
We aimed to ascertain the factors associated with lack of isolation precautions (IP) in patients infected or colonized by third-generation cephalosporin-resistant Enterobacteriaceae (3GCR-E) and methicillin-resistant Staphylococcus aureus (MRSA) in hospital settings. 
DESIGN 
Prospective surveillance and audit of practices. SETTING The study included 4 university hospitals in Lyon, France. 
PARTICIPANTS 
All patients hospitalized between April and June in 2013 and 2015 were included. Case patients had ≥1 clinical sample positive for MRSA and/or 3GCR-E. METHODS Factors associated with the lack of IP implementation were identified using multivariate logistic regression. The incidence of MDRO infections was expressed per 10,000 patient days. 
RESULTS 
Overall, 57,222 patients accounting for 192,234 patient days of hospitalization were included, and 635 (1.1%) MDRO cases were identified. MRSA incidence was 2.5 per 10,000 patient days (95% confidence interval [95% CI], 2.1-3.0) and 3GCR-E incidence was 10.1 per 10,000 patient days (95% CI, 9.2-11.0), with no crude difference between 2013 and 2015 (P=.15 and P=.11, respectively). Among 3GCR-E, the main species were Escherichia coli (43.8%) and Klebsiella pneumoniae (31.0%). Isolation precautions were implemented in 78.5% of cases. Lack of IP implementation was independently associated with patient age, year, specialty, hospital, colonization compared with infection, and lack of medical prescription for IPs (adjusted odds ratio, 17.4; 95% CI, 8.5-35.8; P<.001). 
CONCLUSIONS 
MRSA and 3GCR-E infections and/or colonizations are frequent in healthcare settings, and IPs are implemented in most cases. When IPs are lacking, the main factor is the absence of medical prescription for IPs, underscoring the need for alerts to physicians by the microbiological laboratory and/or the infection control team. Infect Control Hosp Epidemiol 2017;38:1188-1195.