1. “Can I swab your rectum please
“Can I swab your rectum please?” Improving compliance with rectal screening for CRE
Eleonora Dyakova, Karen N. Bisnauthsing, Antonio Querol-Rubiera, Amita Patel, Chioma Ahanonu, Olga Tosas Auguet, Jonathan D. Edgeworth, Simon D. Goldenberg, Jonathan A. Otter

2. Issues to be considered
Public acceptability of CRE and other resistant Enterobacteriaceae, such as ESBL, screening
Who should perform rectal screens?
Age and CRE screening
Message to the patients

3. Why rectal swabs?
blaKPC (copies)/16SrRNA(copies)
Lerner et al. believe that rectal swabs are as accurate as stool samples in detecting CRE by culture-based analysis or qPCR based method.1
Papst et al. suggests that rectal swabs are 90% sensitive for ESBL detection, while throat swabs are positive in 17.2% and urine in 36.2% of cases.2
Time (days)
Lerner et al. Antimicrob Agents Chemother 2013;57:
Papst et al. Infect Dis (Lond) 2015;47:

4. MDR-GNR admission screening study, GSTT
Targeted all patients to be screened within the first 72 hours of their admission.
Target sample size ~4,500 patients.
Patients provided verbal consent.
Rectal and perineal swab collected & risk factor questionnaire.
The study was approved by the NHS Research Ethics Committee.

5. ESBL carriage rate
n=4207. p<0.001 comparing carriage rate by rectal and perineal swabs.

6. Age and the likelihood of self-collecting the rectal screen
n=2862. Significant correlation (r2 = 0.94)

7. Self-collected vs. staff-collected swabs
ESBL carriage rate
n=4207. Significant difference in rate of carriage (rectal p<0.03, perineal p<0.01).

8. Patient recruitment process. How we did it first.
“Bug” focused message
50% decline rate!!!
Detailed scientific language

9. Driving down the decline rate
Improved staff training programme
‘Patient focused’ approach
Personnel changes
Reason for decline
Nr of patients %
Refused because of the rectal swabs 86 2%
Other reason
226 5%
No reason 99
Total decline
451 9%
n=4861

10. New message to the patients
“Why is it important to be screened?”
“What would happen if you had CRE?”
“You and those close to you!”
“If you get an infection, we can put you on the right antibiotics straight away.”

11. Summary We recommend rectal swabs for CRE screening.
The detection rate from a self-collected rectal swab is significantly lower than a staff-collected swab.
Clear message about CRE colonisation improved patients acceptability of CRE screening in the study. Would the results be similar if CRE screening was presented as service?
Dramatic decline rate in the research study was associated with patient focused message as well as carefully trained personnel and right personalities in the team.

12. Imperial researchers at IPS
Oral presentations
Abstract ID: Otter J, Dyakova E, Bisnauthsing K, Querol-Rubiera A, Girdham S, Patel A, Ahanonu C, Tosas Auguet O, Edgeworth J, Goldenberg S. Who’s carrying CRE? Universal admission screening in London
Abstract ID: Dyakova E, Bisnauthsing K, Querol-Rubiera A, Girdham S, Patel A, Ahanonu C, Tosas Auguet O, Edgeworth J, Goldenberg S, Otter J. “Can I swab your rectum, please?”: Improving compliance with rectal screening for CRE
Abstract ID: Mookerjee S, Sullivan J, Davies F, Donaldson H, Brannigan E, Holmes A, Otter J. Risk factors for patients with carbapenemase-producing Enterobacteriaceae (CPE) in a Northwest London hospital Trust, 2014 – 2015
Posters
Abstract ID: Ahmad R, Castro-Sanchez E, Iwami M, Husson F, Holmes A. Knowledge, perceptions and decision making: What matters to patients?
Abstract ID: Record C, Gilchrist M, Patel D, Jiao L. Infection prevention in splenectomy patients: An audit of practice in a regional hepatobiliary centre
Abstract ID: Turnbull A, Moore L, Azadian B. To PPE or not to PPE
Abstract ID: Batten L, Holmes A, Otter J, Castro-Sanchez E. Estimating the isolation burden if overseas residents are pre-emptively isolated during CRE admission screening
Abstract ID: Mookerjee S, Sullivan J, Davies F, Donaldson H, Brannigan E, Holmes A, Otter J. Real-time surveillance of carbapenem-resistant Enterobacteriaceae (CRE) using live microbiology culture data in a North-West London Hospital Trust, 2014–2015
Abstract ID: Alexander M, Mookerjee S, Nelson D, Holmes A, Otter J. An audit of single room capacity for isolation at a London hospital Trust  
Abstract ID: Galletly T, Bateman A, Brannigan E, Holmes A, Otter J. Thematic analysis of post 48-hour bloodstream infections: What did we learn?
Abstract ID: Acharya A , Samarasinghe D , Singleton J, Brannigan E, Galletly T, Donaldson H, Holmes A, Otter J. Pilot evaluation of environmental hygiene using fluorescent markers and microbiological cultures
Abstract ID: Gilchrist M , Galletly T, Brannigan E, Holmes A, Otter J. How much Clostridium difficile is preventable?
Abstract ID: 3867 – Dyakova E, Goldberg S, Bisnauthsing K, Querol-Rubiera A, Patel A, Ahanonu C, Tosas Auguet O, Edgeworth J, Otter J. Poor sensitivity of perineal compared with rectal swabs for detecting ESBL Enterobacteriaceae

13. “Can I swab your rectum please
“Can I swab your rectum please?” Improving compliance with rectal screening for CRE
Eleonora Dyakova, Karen N. Bisnauthsing, Antonio Querol-Rubiera, Amita Patel, Chioma Ahanonu, Olga Tosas Auguet, Jonathan D. Edgeworth, Simon D. Goldenberg, Jonathan A. Otter