1. 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 a Infection control unit, Bichat-Claude Bernard Hospital, Paris, France b Bacteriology laboratory, Bichat-Claude Bernard Hospital, Paris, France ICPIC Geneva 2013

2. 2 Introduction Epidemiological Context in France GRECPE E.Faecium VR EARSS 2011 Kp Carba-R EARSS 2011 ICPIC Geneva 2013

3. 3 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

4. 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 ICPIC Geneva 2013

5. 5 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

6. 6 Methods Description 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. 7 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 Methods E pidemiological Risk Analysis http://www.sf2h.net/

8. 8 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 Methods Epidemiological Risk Analysis http://www.sf2h.net/

9. 9 Methods Tailored 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

10. 10 Methods Tailored 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

11. 11 Methods Tailored 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

12. 12 Methods Tailored 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

13. 13 Results Control Strategy Patients known as colonised at admission N= 11 (5 GRE, 7 CPE) 3 Episodes with secondary cases 1 - No “contact” patients 2 - Colonised patients: Contact precautions Cross sectional weekly screening Colonised patients Dedicated area 1/2 Dedicated staff 1/ 2 Reinforced staff 2/2 Interruption of transfers & admissions 2/2 2 episodes with 1 late 2ndary case (D18, D 53) Colonised patients Reinforced staff Interruption of transfers & admissions 1 episodes with 2 late 2ndary cases (D32)

14. Results Control Strategy Identification >48h after admission N = 19 (9 GRE, 11 CPE) 5 Episodes with 14 secondary cases 5 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 patients Contact precautions (n= 19) « Contact » patients Contact precautions (n= 19) Weekly screening (n= 19) Interruption of transfers and admissions (n= 10) Reinforced staff (n= 10)

15. 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: oInvolvement 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) oInvolvement of the bacteriology lab oInvolvement of the hospital administration

16. 16 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)

17. 17 Thank you for your attention