Contact Precautions Research Articles

Community Healthcare-Associated Infections: Enhancing Control with Software and Tailored Protocols

Abstract Issue/Problem Healthcare-associated infections are major global public health challenges. In Portugal, the prevalence of resistant Enterobacteriaceae is particularly alarming. Studies typically focus on hospitals and long-term care facilities, neglecting community settings where patients, particularly the elderly with multiple comorbidities, often transition between hospital and home. Description of the problem Effective control measures are vital across all healthcare environments. In home care, sporadic implementation of Contact Precautions, due to the lack of specific guidelines and challenges in accessing colonization information, has been a major gap. This project aimed to close this gap by integrating a software, previously used only in hospitals, to enhance infection control in domiciliary care. The intervention adapted contact transmission-based precautions for home settings and used data from the previous year’s infections and colonization to tailor recommendations for each patient, preventing transmission between homes and enhancing caregiver education. Results Preliminary data from a two-month monitoring period involved 40 patients under the care of three domiciliary teams. Eleven had records of infections involving 19 microorganisms, including 7 Enterobacteriaceae, five of which were carbapenemase producers. This led to five customized recommendations for improved precautions. The intervention also heightened nurses’ awareness of patients’ microbiological histories, evidenced by increased inquiries to the infection control team. Lessons Adapting measures to the unique dynamics of home care, distinct from hospital settings, is critical. Involvement of care teams in decision-making ensures practical adherence and enhances measure effectiveness. Regular monitoring is crucial for compliance, making this approach a model for other settings. Key messages • Adapting hospital protocols to community settings and offering close support to caregiving teams increases compliance. • Implementing software that facilitates communication about infection and colonization enhances infection control effectiveness in community settings.

A-288 Active Surveillance Cultures: Frequency of Microorganisms and Phenotypic Resistance Profile From Brazilian Public Hospitals After COVID-19 Pandemic Peak

Abstract Background Surveillance cultures are routinely used by public health authorities to screen for multidrug-resistant bacteria. Recently, the overuse of antibiotics intensified by the COVID-19 pandemic worldwide brought concerns about potential impacts on the acquisition and/or selective pressure of resistance genes, that in general carried by plasmids, which contribute to the rapid resistance spread within specific bacterial populations. The purpose of this study was to determine the prevalence of multidrug-resistant (MDR) organisms recovered from surveillance cultures (rectal, anal, nasal, and axillary) isolated from several Brazilian public hospitals. Methods Surveillance samples were analyzed from 1st January to 31st December 2023. All the swab samples were collected from patients admitted from high-risk settings or transferred from areas with high rates of MDR organisms. All clinical specimens were inoculated onto a selective media (ChromID media, bioMerieux) and incubated at 35±2°C for 18-24 h. The screening test was performed to Gram-negative bacilli (GNB) using the antibiotics ertapenem, imipenem and meropenem and for Gram-positive Cocci (GPC) screening was tested oxacillin (methicillin) and vancomycin using disc diffusion method. Bacteria identification was performed by MALDI-TOF mass spectrometry (Vitek-MS and bioMerieux) and as required, the minimal inhibitory concentrations (MIC) of antibiotics were determined using the Vitek 2 System (bioMerieux). Results A total of 71,064 rectal swab samples were processed. 4,652/71,064 (6.5%) samples showed positive results for the presence of 5.255 MDR microorganisms. Out of which, 4,477/5,255 (85.2%) were Gram-negative Bacilli (GNB) and 778/5,255 (14.8%) were Gram-positive Cocci (GPC). The majority of the isolated carbapenems resistance was Klebsiella spp. [2,791/5,255 (53.1%)], which the Klebsiella pneumoniae was the predominant species, followed by Acinetobacter baumannii [1,268/5,255 (24.1%)], Pseudomonas aeruginosa [263/5,255 (5%)], Enterobacter spp. [96/5255 (1.8%)], Serratia spp. [31/5,255 (0.6%)], Citrobacter spp. [22/5,255 (0.4%)], and others BGN [6/5,255 (0.2%)]. The resistance to vancomycin and methicillin were observed in 10% (525/5,255) of Enterococcus spp. and 4.8% (253/5,255) of Staphylococcus aureus, respectively. Conclusions The study found that K. pneumoniae carbapenem-resistant and Enterococcus spp. vancomycin-resistant were the main Gram-negative and Gram-positive organisms recovered from surveillance culture samples. However, our data draws attention to the increased cases of carbapenem-resistant Acinetobacter baumannii as the second most frequent pathogen isolated from surveillance samples after the last wave of COVID-19 pandemic. Active surveillance culture for target microorganisms followed by contact precautions to minimize the chance of transmitting MDR organisms from colonized to non-colonized patients consist of an important activity of infection control policy.

Cumulative incidence of vancomycin-resistant Enterococcus faecium detection by patient characteristics or possible exposures: prioritization of patients for active screening culture

The target population for active surveillance culture (ASC) of vancomycin-resistant Enterococcus species (VRE) by stool or rectal swabs has not been fully determined during VRE outbreaks in healthcare settings in non-VRE endemic situation. We evaluated cumulative incidences of VRE detection during a vancomycin-resistant Enterococcus faecium outbreak to determine reasonable target populations for ASC. Cases included inpatients whose first VRE-positive sample was obtained at Shizuoka General Hospital between February 2022 and January 2023, during which we conducted admission screening for possible high-risk patients, biweekly screening of all inpatients, admission and discharge screening in the high-care unit, and screening of contacts in each ward by using stool or rectal samples. We calculated cumulative incidences of VRE detection for those screened by patient characteristics or possible exposure. Among 60 cases identified, 55 (92%) were by ASC. Cumulative incidence was higher for contacts (6.4%, 15/234) than for those identified by other screening methods (0.5%, 40/8565). Among the patients identified through admission screening, those previously hospitalized in areas of reported VRE outbreaks had the highest cumulative incidence (6.6%, 5/78) followed by patients requiring toilet assistance (3.7%, 6/161). A bundle approach including ASC and prompt contact precautions by the hospital infection control team, local public health centre, and local and national infection control experts helped terminate the outbreak in seven months. Patients with contacts, prior hospitalization in areas with known VRE outbreaks, and who need toilet assistance appear to be high-risk populations for VRE detection and are candidates for ASC.

Multimodal surveillance of Care-related infections by Alert microorganisms in Ospedali Riuniti di Vittoria e Comiso ASP Ragusa

Background: monitoring the incidence and surveillance of alert microorganism infections detected in inpatients of the Ospedali Riuniti di Vittoria and Comiso in 2023. Objectives: early identification and implementation of shared pathways aimed at prevention and control of care-related infections. the spread of colonization and infections; promotion and implementation of effective risk assessment programs. Methods: a multicenter study was conducted on 79 patients with infections with Alert microorganisms, in ordinary hospitalization, day service, and day hospital, of the "R. Guzzardi" hospitals of Vittoria and "R. Margherita" of Comiso. Sample stratification was performed according to gender, females 51.9% and males 48%, and the four age groups: 18-40 (4.8%), 41-60 (9.5%), 61-80 (45.2%), >80 (40.5%), x̄ 51.90. The calculated mortality rate was n.16 (20.25%). The types, number and frequency of use of invasive devices were described (n.68, 86%, including 64.5% urinary bladder catheter). Results: the operating unit in which there is significant positivity to Alert infections is the UOC of Internal Medicine (40.5%), followed by RSA (16.46%) and ICU (8.86%), table1. The most representative Alert is Acinetobacter baumannii (24.05%), other microorganisms isolated are Klebsiella P. (22.78%), Escherichia c. (21.52%), and Staphylococcus A. (18.99%). In addition, a significant correlation between microorganisms and sample type is confirmed (p=0.019). Inpatient days are proportional to the care complexity index (p=0.0021). In addition, there is no correlation between inpatient days and microorganism type. Conclusions: the reduction of inpatient time and the move toward territorial continuity of care will promote the community spread of selected antibiotic-resistant bacteria in the hospital. Surveillance measures include early identification of patients positive to Alerts, active follow-up of colonized patients, isolation of colonized/infected patients, and adoption of contact precautions in the management of such patients.

Prevention in adults of transmission of infection with multidrug-resistant organisms: an updated systematic review from Making Healthcare Safer IV

BackgroundHealthcare-associated infections due to multidrug-resistant organisms (MDROs) remain a high priority patient safety topic, despite broad acceptance as standard-of-care safety practices to prevent central line-associated bloodstream infection, catheter-associated urinary tract...

Doff Thy Gown-Shedding Contact Precautions for COVID-19.

SARS-CoV-2 is predominantly transmitted through aerosols (ie, airborne transmission); however, the US Centers for Disease Control and Prevention continue to recommend the use of contact precautions (a gown and gloves) for the care of patients with COVID-19. Infection-prevention guidelines should reflect the current science and eliminate this wasteful practice.

Monkeypox in Pakistan-First case report

Monkeypox (mpox) is an uncommon zoonotic contagious viral ailment, resulting from the poxvirus. Symptoms include fever, headache, muscle aches, and a characteristic rash. There is no specific treatment, and only a limited number of antiviral drugs and vaccines are available. Employing stringent contact and respiratory precautions is essential to curb disease transmission. Till April 17, 2023, no mpox cases have been reported from Pakistan. Here we present the case of a 41-year-old male with a travel history to Saudi Arabia and a week-long history of multiple nodular and pustular eruptions on various parts of the body. It is essential to emphasise that due to its infrequency, a high index of clinical suspicion is imperative in facilitating an accurate diagnosis. Keywords: mpox, MPXV, Pakistan, Travel history. Orthopoxvirus. Vaccine.

Complex Infection-Control Measures with Disinfectant Switch Help the Successful Early Control of Carbapenem-Resistant Acinetobacter baumannii Outbreak in Intensive Care Unit.

A carbapenem-resistant Acinetobacter baumannii (CRAB) outbreak in an intensive care unit (ICU) was contained by an improved infection-control measure that included a disinfectant policy. In our retrospective cohort study, we describe the epidemiological investigations and infection-control measures during this outbreak. Descriptive analysis was used to summarize patient demographics, neurological diseases, surgical treatment, underlying diseases, infection, and outcomes. In December 2023, two CARB-positive patients were observed in the ICU, and four more patients became CRAB-positive in January. During this outbreak, there was an overlap of hospitalization periods among the CRAB-positive patients, and CRAB was isolated from the environment; the isolated CRAB strain was identical. Infection-control measures, including hand hygiene, contact precautions and isolation, surveillance, decolonization, environmental cleaning, and disinfection, were reviewed and modified. The aim of this study was to examine the molecular background of the effectiveness of the disinfectant shift used during successful outbreak control. Experiments were carried out to study the phenotypic sensitivity and genetic background of different disinfectant agents. A thorough analysis of the detected CRAB strain included whole-genome sequencing (WGS), investigation of the qacE and qacEΔ1 genes' relative expression by qPCR after exposure to different disinfectant solutions, as well as an analysis of biofilm formation. WGS analysis of the CRAB strain identified that an ST2 high-risk clone was responsible for the outbreak, which produced OXA-83 and ADC-30 beta-lactamases; in addition, qacE and qacEΔ1 genes were also detected, which confer resistance to disinfectants containing quaternary ammonium compounds (QACs). A qPCR analysis demonstrated that after exposure to different disinfectants, the gene expression levels of qacE and qacEΔ1 increased and correlated with concentrations of QACs of disinfectants. During the outbreak, the standard-of-care QAC-based disinfectant was changed to a mainly alcohol-based agent in the ICU, which contributed to the successful control of this outbreak, and no additional patients were identified with CRAB. We conclude that continuous surveillance and hand hygiene training combined with fast identification and reaction to new cases, as well as an in-depth analysis of multidrug-resistant outbreak strains and investigation of their disinfectant tolerance/resistance during an outbreak, are essential to effectively control the spread of nosocomial pathogens. The smart policy of disinfectant agent selection played a crucial role in controlling the outbreak and ensuring patient safety in the ICU.

Healthcare Workers' Perception and Compliance on Personal Protective Equipment Use in Critical Care Units of a Tertiary Care Hospital in Bahrain.

Introduction Contact precautions or the use of personal protective equipment (PPE), specifically gowns and gloves, has become a common practice in intensive care units (ICUs) as part of robust infection prevention and control efforts. Hence, a positive attitude toward PPE used among healthcare workers (HCWs) is critical to prevent healthcare-associated infections (HAIs). Aim This study aimed to determine the perception and compliance of HCWs working at critical care units regarding PPE used at government hospitals (GHs) in Bahrain. Subject and methods A cross-sectional study was conducted among HCWs working in critical units at GHs, Bahrain. A self-administered questionnaire consisting of three sections was sent to the targeted HCWs. The questionnaire consisted of socio-demographic characteristics (i.e., age, gender, job category, etc.), previous participation in PPE training, and a 15-item questionnaire to assess the perception and compliance of HCWs regarding PPE use. Results Among the 119 HCWs enrolled, 73.1% were females, and 48.7% were between 31 and 40 years old. The results of this study suggested that although 95.8% of participants received education about PPE use, only 48.7% had a good perception of PPE, and an even smaller percentage (12.6%) demonstrated good compliance. A positive, highly statistically significant correlation was found between perception and compliance scores (p<0.001). Increased perception and compliance scores were associated with increasing age, non-Bahrainis, and years of experience. Interestingly, doctors were more likely to demonstrate lower perception and compliance scores toward PPE use. Conclusion The perception of HCWs regarding PPE use was adequate, but their actual adherence was unsatisfactory. However, doctors' perceptions and compliance with PPE use were significantly lower than other HCWs. Further larger studies are required to establish the level of perception and compliance among HCWs in our region.

Performance of an Autonomous Sanitary Sterilisation Ultraviolet Machine (ASSUM) on terminal disinfection of surgical theaters and rooms of an intensive-intermediate care unit

Ultraviolet- C (UV-C) light is effective for reducing environmental bioburden in hospitals, and the use of robots to deliver it may be advantageous. To evaluate the feasibility and clinical efficacy of an autonomous programmable UV-C robot in surgical and intensive care unit (ICU) rooms of a tertiary hospital. During ten consecutive months, the device was used in six theatres where cardiac, colorectal and orthopaedic surgeries were performed, and in the rooms previously occupied by patients subjected to contact precautions of a 14-bed ICU. Surgical site infection (SSI) rates of procedures performed in the UV-cleaned theatres were compared with those of the previous year. Incidence in clinical samples of ICU-acquired multiple-drug resistant (MDR) microorganisms was compared with that of the same period of the previous year. An UV-C exposure study done by semi-quantitative dosimeters and a survey of the bioburden on surfaces were carried out. SSI rates in the pre- and post-intervention periods were 8.67% (80/922) and 7.5% (61/813), respectively (p=0.37). Incidence of target microorganisms in clinical samples remained unchanged (38.4 vs. 39.4 per 10,000 patient-days, p=0.94). All the dosimeters exposed to ≤1 meter received ≥500 mJ/cm2. The bacterial load on surfaces decreased after the intervention, particularly in ICU rooms (from 4.57±7.4 CFU to 0.27±0.8 CFU, p<0.0001). Deployment of an UV-C robot in surgical and ICU rooms is feasible, ensures adequate delivery of germicidal UV-C light and reduces the environmental bacterial burden. Rates of surgical site infections or acquisition of MDR in clinical samples of critically-ill patients remained unchanged.

Rate of nosocomial MRSA transmission evaluated via contact screening

BackgroundThe prevention of methicillin-resistant S. aureus (MRSA) transmission in the healthcare setting is a priority in Infection Control practices. A cornerstone of this policy is contact tracing of nosocomial contacts after an unexpected MRSA finding. The objective of this retrospective study was to quantify the rates of MRSA transmission in different clinical settings.MethodsThis multi-centre study included MRSA contact screening results from two regional hospitals and one academic hospital. MRSA contact tracing investigations from 2000 until 2019 were reviewed and post-contact screening results were included of index patients with an MRSA-positive culture and their unprotected contacts. Available typing results were used to rule out incidental findings.ResultsOf 27,377 contacts screened after MRSA exposure, 21,488 were Health Care Workers (HCW) and 4816 patients. Post-contact screening was initiated for a total of 774 index cases, the average number of screened contacts per index case was 35.7 (range 1 to 640). MRSA transmission was observed in 0.15% (41) of the contacts, 19 (0.09%) HCW and 22 (0.46%) patients. The number needed to screen to detect one MRSA transmission was 667. The highest risk of MRSA transmission occurred during patient-to-patient contacts, with transmission rates varying from 0.32 to 1.32% among the participating hospitals. No transmissions were detected in HCW (n=2834) in the outpatient setting, and the rate of transmissions among HCW contacts on the wards was 0.13% (19 of 15,874). Among 344 contacts of patients with contact precautions, no transmissions were detected.ConclusionsReconsidering current MRSA contact tracing practices may lead to a more targeted approach with a lower number needed to screen.

Pfizer-BioNTech (BNT162b2) Vaccine Effectiveness against Symptomatic Laboratory-Confirmed COVID-19 Infection among Outpatients in Sentinel Sites, Lebanon, July-December 2021.

On 14 February 2021, Lebanon implemented nationwide vaccination, offering the Pfizer-BioNTech (BNT162b2) vaccine to adults over 50 years of age. We estimated the effectiveness of the Pfizer-BioNTech vaccine in preventing symptomatic laboratory-confirmed COVID-19. We conducted a test-negative case-control (TND) study among symptomatic adults aged 50 years and older who presented with influenza-like illness (ILI) or COVID-19-like illness (CLI) in surveillance sentinel sites between 1 July and 31 December 2021. Unvaccinated participants did not receive any vaccine dose before symptom onset. Vaccinated participants received at least one dose within 14 days before onset of symptoms. We estimated vaccine effectiveness against symptomatic laboratory-confirmed COVID-19, adjusted for demographic and behavioral factors, using multivariable logistic regression. Out of 457 participants with symptoms, 150 (33%) were positive and 307 (67%) were negative for SARS-CoV-2. Adjusted vaccine effectiveness was 22% (95% CI: -70-65%) for those partially vaccinated and 44% (95% CI: 6-67%) for those fully vaccinated. Vaccination with two doses of the Pfizer-BioNTech vaccine was effective in preventing COVID-19 symptomatic illness in the older population. Vaccine effectiveness was lower for those partially vaccinated. We recommend enhancing vaccine uptake with at least one dose among risk groups for COVID-19 and keeping general recommendations on contact and droplet precautions in the general population.

Efficacy and Safety of Oral Neomycin for the Decolonization of Carbapenem-Resistant Enterobacterales: An Open-Label Randomized Controlled Trial.

Patients with carbapenem-resistant Enterobacterales (CRE) in the gastrointestinal (GI) tract are at risk for subsequent infections and transmission, necessitating contact precautions. Neomycin has shown in vitro activity against CRE in 66-85% of isolates. This study evaluated the efficacy and safety of neomycin for CRE decolonization. In this open-label randomized controlled trial, stool/rectal swab samples from high-risk patients were collected and tested for CRE colonization in the GI tract. Patients who had CRE and met eligible criteria were divided into a neomycin group (n = 26; treated with 4.2 g/day neomycin for 5 days) and a control group (n = 26). CRE detection in stool/rectal swabs was performed on days 7 ± 2 and 14 ± 2. The two groups' baseline characteristics were similar. CRE presence on day 7 ± 2 was significantly lower in the neomycin group (46.2%) than in the control group (80.8%, p = 0.01). Efficacy of neomycin (4.2 g/day for 5 days) for CRE decolonization was 42.8-53.8% by day 7. By day 14 ± 2, the CRE rate in the neomycin group had risen to align with the control group's rate (73.1% vs. 61.5%, p = 0.56). The neomycin group experienced mild, temporary, gastrointestinal side-effects. Neomycin effectively reduced CRE colonization on day 7 ± 2, but its impact waned by day 14 ± 2. This suggests that neomycin dosage was too low and the duration of treatment was too short for lasting CRE decolonization.

Viewpoint: The impending pandemic of resistant organisms - a paradigm shift towards source control is needed.

The United States needs a paradigm shift in its approach to control infectious diseases. Current recommendations are often made in a siloed feedback loop. This may be the driver for such actions as the abandonment of contact precautions in some settings, the allowance of nursing home residents who are carriers of known pathogens to mingle with others in their facility, and the determination of an intervention's feasibility based upon budgetary rather than health considerations for patients and staff. Data from both the U.S. Veterans Health Administration and the U.K.'s National Health Service support the importance of carrier identification and source control. Both organizations observed marked decreases in methicillin-resistant Staphylococcus aureus (MRSA), but not methicillin-susceptible Staphylococcus aureus infections with the implementation of MRSA admission screening measures. Facilities are becoming over-reliant on horizontal prevention strategies, such as hand hygiene and chlorhexidine bathing. Hand hygiene is an essential practice, but the goal should be to minimize the risk of workers' hands becoming contaminated with defined pathogens, and there are conflicting data on the efficacy of chlorhexidine bathing in non-ICU settings. Preemptive identification of dedicated pathogens and effective source control are needed. We propose that the Centers for Disease Control and Prevention should gather and publicly report the community incidence of dedicated pathogens. This will enable proactive rather than reactive strategies. In the future, determination of a patient's microbiome may become standard, but until then we propose that we should have knowledge of the main pathogens that they are carrying.

Active follow-up of patients identified with multidrug-resistant Gram-negative bacteria to discontinue contact precautions and isolation measures

It is essential to refrain from unnecessary isolation measures indicated for patients identified with multidrug-resistant Gram-negative bacteria (MDR-GNB). To evaluate whether a pro-active follow-up strategy to discontinue isolation measures of patients identified with MDR-GNB (without carbapenemase production) resulted in reduced isolation days during hospitalization, compared to passive follow-up. A comparison was made between active and passive follow-up strategies over a two-year period after first MDR-GNB identification. Patients could be declared negative after two consecutive negative screening cultures. Active follow-up patients received a questionnaire for screening cultures within six months of MDR-GNB identification. Of the 2208 patients included, 1424 patients (64.5%) underwent passive follow-up and 784 patients (35.5%) underwent active follow-up. A significantly higher proportion of active follow-up patients who had sufficient (at least two) screening cultures were declared MDR-GNB negative compared to those with passive follow-up; 66.9% vs 20.6% (P < 0.001) for adult patients and 76.0% vs 17.1% (P < 0.001) for paediatric patients. A comparison between active follow-up patients with sufficient versus those with active follow-up but insufficient cultures revealed a reduction of isolation days for paediatric patients (median 10.6 vs 1.6 days; P= 0.031). Though this difference was not statistically significant for adults (median 5.3 vs 4.2 isolation days), there was a valuable decrease in the number of isolation days for both adult and paediatric patients under active follow-up with sufficient (≥2) cultures, indicating clinical relevance. We recommend an active follow-up strategy for patients identified with an MDR-GNB, to prevent further unneeded infection prevention measures.

Investigating transmission patterns among preterm neonates during an outbreak of necrotizing enterocolitis related to Clostridium butyricum using whole-genome sequencing

BackgroundNecrotizing enterocolitis is the most severe life-threatening acquired gastrointestinal disorder among preterm neonates. We describe here an outbreak of Clostridium butyricum-related necrotizing enterocolitis in preterm neonates that occurred in three different neonatal centres, in southeast France. MethodsWe defined a confirmed case of C. butyricum-related necrotizing enterocolitis in preterm neonates by the presence of clinical signs according to modified Bell criteria and C. butyricum identified from stools sample using real-time polymerase chain reaction or culture. A phylogenetic analysis of the isolated strains by whole genome sequencing was also performed. ResultsBetween 5 and 27 January 2022, we identified ten confirmed cases of C. butyricum-related necrotizing enterocolitis, including five from neonatal centre 1, four from neonatal centre 2, and one from neonatal centre 3. The attack rate of necrotizing enterocolitis in neonatal centre 1 was 7.1% (5/70). The positivity rate of C. butyricum detected from stool samples was higher during the outbreak period (37/276; 13.4%) than outside this period (7/369; 1.9%), while systematic screening was maintained (P<0.001). Phylogenetic analysis showed a clonality between strains inside four clusters. Two clusters included neonates hospitalised in different neonatal centres, suggesting the transmission of C. butyricum strains during the transfer of neonates between neonatal centres. ConclusionsThis outbreak of C. butyricum-related necrotizing enterocolitis confirms a cross-transmission between preterm neonates, including twin or triplet siblings, and involving necrotizing enterocolitis cases together with asymptomatic carriers. After three months of follow-up, no further cases were identified following the implementation of contact precautions with sporicidal agents.

Using contact network dynamics to implement efficient interventions against pathogen spread in hospital settings: A modelling study.

Long-term care facilities (LTCFs) are hotspots for pathogen transmission. Infection control interventions are essential, but the high density and heterogeneity of interindividual contacts within LTCF may hinder their efficacy. Here, we explore how the patient-staff contact structure may inform effective intervention implementation. Using an individual-based model (IBM), we reproduced methicillin-resistant Staphylococcus aureus colonisation transmission dynamics over a detailed contact network recorded within a French LTCF of 327 patients and 263 staff over 3 months. Simulated baseline cumulative colonisation incidence was 21 patients (prediction interval: 11, 31) and 35 staff (prediction interval: 19, 54). We examined the potential impact of 3 types of interventions against transmission (reallocation reducing the number of unique contacts per staff, reinforced contact precautions, and hypothetical vaccination protecting against acquisition), targeted towards specific populations. All 3 interventions were effective when applied to all nurses or healthcare assistants (median reduction in MRSA colonisation incidence up to 35%), but the benefit did not exceed 8% when targeting any other single staff category. We identified "supercontactor" individuals with most contacts ("frequency-based," overrepresented among nurses, porters, and rehabilitation staff) or with the longest cumulative time spent in contact ("duration-based," overrepresented among healthcare assistants and patients in elderly care or persistent vegetative state (PVS)). Targeting supercontactors enhanced interventions against pathogen spread in the LTCF. With contact precautions, targeting frequency-based staff supercontactors led to the highest incidence reduction (20%, 95% CI: 19, 21). Vaccinating a mix of frequency- and duration-based staff supercontactors led to a higher reduction (23%, 95% CI: 22, 24) than all other approaches. Although based on data from a single LTCF, when varying epidemiological parameters to extend to other pathogens, our results suggest that targeting supercontactors is always the most effective strategy, indicating this approach could be applied to prevent transmission of other nosocomial pathogens. By characterising the contact structure in hospital settings and identifying the categories of staff and patients more likely to be supercontactors, with either more or longer contacts than others, interventions against nosocomial spread could be more effective. We find that the most efficient implementation strategy depends on the intervention (reallocation, contact precautions, vaccination) and target population (staff, patients, supercontactors). Importantly, both staff and patients may be supercontactors, highlighting the importance of including patients in measures to prevent pathogen transmission in LTCF.

Regional variation in the interpretation of contact precautions for multi-drug-resistant Gram-negative bacteria: a cross-sectional survey

Contact precautions are recommended when caring for patients with carbapenemase-producing Enterobacterales (CPE), carbapenemase-producing Pseudomonas aeruginosa (CPPA), and extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E). Our aim was to determine the interpretation of contact precautions and associatedinfection prevention and control (IPC) measures in the non-ICU hospital settingfor patients with CPE, CPPA or ESBL-E in 11 hospitals in the Southwest of the Netherlands. A cross-sectional survey was developed to collect information on all implemented IPC measures, including use of personal protective equipment, IPC measures for visitors, cleaning and disinfection, precautions during outpatient care and follow-up strategies. All 11 hospitals were invited to participate between November 2020 and April 2021. The survey was filled together with each hospital. All hospitals installed isolation precautions for patients with CPE and CPPA during inpatient care and day admissions, whereas 10 hospitals (90.9%) applied isolation precautions for patients with ESBL-E. Gloves and gowns were always used during physical contact with the patient in isolation. Large variations were identified in IPC measures for visitors, cleaning and disinfection products used, and precautions during outpatient care. Four hospitals (36.4%) actively followed up on CPE or CPPA patients with the aim of declaring them CPE- or CPPA-negative as timely as possible, and two hospitals (20.0%) actively followed up on ESBL-E patients. Contact precautions are interpreted differently between hospitals, leading to regional differences in IPC measures applied in clinical settings. Harmonizing infection-control policies between the hospitals could facilitate patient transfers and benefit collective efforts of preventing transmission of multi-drug-resistant Gram-negative bacteria.

Impact of Discontinuing Contact Precautions for Multidrug-resistant Gram-negative Enterobacteriaceae in a Large Health System

Background: Contact precautions (CP) to prevent transmission of multidrug-resistant gram-negative (MDRGN) Enterobacteriaceae are recommended, although studies of discontinuation of CP (DcCP) have found no change in healthcare associated infections (HAI) due to extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae. Limited data exists on DcCP for MDRGN in a large health system. Methods: We performed a retrospective observational study analyzing the relationship between use of CP and HAI due to two definitions of MDRGN Enterobacteriaceae: ESBL, and non-susceptibility to ≥3 drug classes (3DC-GNR), with carbapenem resistant Enterobacteriaceae (CRE) serving as control. The study included all inpatient admissions from 2/2017 through 9/2022 at 21 acute care hospitals. Hospitals had latitude to determine CP practices based on local risk assessment, but in 2/2018, system-wide transmission-based precautions guidance was updated to recommend DcCP for MDRGN Enterobacteriaceae and in 12/2019 was updated to clarify DcCP specifically for ESBL and 3DC-GNR while continuing CP for carbapenem-resistant organism carriage. We interviewed infection preventionists to define when CP were used for CRE, ESBL, and 3DC-GNR Enterobacteriaceae. HAI were defined using National Healthcare Safety Network criteria including all HAI categories. We compared the incidence rate of HAI attributable to the two MDRGN types in hospital months with and without use of CP, with HAI due to CRE as a comparison group since all hospitals used CP for CRE throughout the study period. Results: The periods of CP use, by hospital, are shown in Figure 1. Throughout the study period, there were 987 HAI attributed to ESBL Enterobacteriaceae, 579 due to 3DC-GNR Enterobacteriaceae, and 329 due to CRE. Figure 2 shows the unadjusted aggregate rate of HAI for each of the three MRGN types, including among hospitals with and without CP in each month, for ESBL and 3DC-GNR. In months with and without CP, the rate of HAI was 1.482/10,000 and 1.093/10,000 patient days (incidence rate ratio [IRR], 1.356 [95% confidence interval, 1.195-1.540]) for ESBL Enterobacteriaceae. In months with and without CP, the rate of HAI was 1.071/10,000 and 0.493/10,000 patient days (IRR,2.173[95% confidence interval, 1.838-2.569]) for 3DC-GNR Enterobacteriaceae. Conclusion: DcCP was not associated with an increase in HAI due to ESBL and 3DC-GNR Enterobacteriaceae in aggregated facilities that self-selected for DcCP. Facilities that used CP were associated with significantly higher rates of ESBL and 3DC-GNR Enterobacteriaceae, a relationship that did not change as hospitals DcCP for these MDRGN. Further analyses are necessary to assess for a causal relationship.

Timesavers: Clinical Decision Support and Automation of MRSA and VRE Deisolation

Background: Most healthcare facilities in the US apply contact precautions (CP) for patients with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE) infection and/or colonization. Most individuals with MRSA or VRE colonization will clear over time; however, frontline clinicians rarely evaluate for discontinuation of CP, resulting in increased burden on infection preventionists (IPs). Automation of time- and test-based evaluation using clinical decision support systems (CDSS) embedded in electronic health records (EHR) may increase evaluation and discontinuation of CP when appropriate, while preserving IP resources. Methods: This quality improvement initiative was implemented at Mass General Brigham (MGB), an integrated healthcare system, where patients with MRSA or VRE infection/colonization are identified in the EHR with a corresponding “infection status” and CP applied. Following MGB policy (Figure 1), CDSS features included: 1) automated time-based resolution from 2/15/2023-11/13/2023 and 2) automated ordering of screening assays for patients eligible for test-based evaluation from 6/20/2023-11/14/2023 (Figure 2). Counts of CP discontinuation and automated ordering were performed. IPs at one MGB facility performing manual review of patients self-recorded the time spent evaluating for CP discontinuation. Using these time reports, the average time to complete these tasks and the projected time savings were calculated over the implementation period. Results: Four IPs recorded the time to review patients for CP discontinuation, including reviewing recent antimicrobial administration, microbiology results, ordering screening test(s), and contacting the primary team. Twenty-five patient encounters were timed with a mean of 4.7 minutes documented per encounter. Over a 9-month period after initiation of the automated time-based resolution, the monthly mean number of patients with CP for MRSA and VRE which were automatically discontinued was 247 and 100, respectively. Projected IP time savings over the same 9-month period for MRSA and VRE were 174.1 and 70.5 hours, respectively. Over a 5-month period after initiation of automated ordering of MRSA polymerase chain reaction (PCR)/culture, as well as VRE culture for test-based evaluation, the monthly mean number of MRSA culture, MRSA PCR, and VRE culture automatically ordered for patients on CP for MRSA and VRE were 176, 24, and 145, respectively. Projected IP time savings over the same 5-month period for MRSA and VRE were 78.3 and 56.8 hours, respectively.Conclusion: Healthcare systems that enhance their EHR with CDSS to automate CP evaluations may improve frontline clinician workflow, patient flow and bed capacity, while optimizing use of IP resources.