Interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in intensive care units: an interrupted time series study and cluster randomised trial - 17/12/13

Doi : 10.1016/S1473-3099(13)70295-0

Lennie P G Derde, MD ^a,^⁎ , Ben S Cooper, PhD ^d, Herman Goossens, PhD ^e, Surbhi Malhotra-Kumar, PhD ^e, Rob J L Willems, PhD ^b, Marek Gniadkowski, PhD ^f, Waleria Hryniewicz, PhD ^g, Joanna Empel, PhD ^f, Mirjam J D Dautzenberg, MD ^c, Djillali Annane, PhD ^h, Irene Aragão, MD ⁱ, Annie Chalfine, MD ^j, Uga Dumpis, MD ^k, Francisco Esteves, MD ^l, Helen Giamarellou, PhD ^m, Igor Muzlovic, PhD ⁿ, Giuseppe Nardi, PhD ^o, George L Petrikkos, PhD ^p, Viktorija Tomic, PhD ^q, Antonio Torres Martí, PhD ^r, Pascal Stammet, MD ^s, Christian Brun-Buisson, PhD ^t,^{^{†
Equally responsible for supervising the study}}, Marc J M Bonten, PhD ^b,^c,^{^{†
Equally responsible for supervising the study}}
on behalf of the MOSAR WP3 Study Team
^a Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, Netherlands
^b Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, Netherlands
^c Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
^d Centre for Clinical Vaccinology and Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
^e Department of Medical Microbiology, Vaccine & Infectious Disease Institute, Antwerp University, University Hospital Antwerp, Antwerp, Belgium
^f Department of Molecular Microbiology, National Medicines Institute, Warsaw, Poland
^g Division of Microbiology and Infection Prevention, National Medicines Institute, Warsaw, Poland
^h Service de Réanimation Médicale, Hôpital Raymond Poincaré, Garches, France
ⁱ Polyvalent Intensive Care Unit, Central Hospital of Porto, Porto, Portugal
^j Infection Control Unit, Groupe Hospitalier Paris—Saint Joseph, Paris, France
^k Department of Infection Control, Paul Stradins University Hospital, Riga, Latvia
^l ICU and Emergency Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Vila Real, Portugal
^m 4th Department of Internal Medicine, Athens University Medical School, Attikon General Hospital, Athens, Greece
ⁿ Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, Ljubljana, Slovenia
^o Shock and Trauma Unit, Intensive Care Unit, Azienda Ospedaliera S Camillo Forlanini, Rome, Italy
^p Infectious Diseases Unit, Laikon General Hospital, University of Athens, Athens, Greece
^q Laboratory for Respiratory Microbiology, University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
^r Pneumology Department, Hospital Clinic of Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Ciber de Enfermedades Respiratorias, University of Barcelona, Barcelona, Spain
^s Intensive Care Unit, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
^t Service de réanimation médicale and INSERM U657, Institut Pasteur, APHP GH Henri Mondor, Université Paris Est-Créteil, Creteil, France

^*Correspondence to: Lennie P G Derde, Department of Intensive Care Medicine, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, Netherlands

Summary

Background

Intensive care units (ICUs) are high-risk areas for transmission of antimicrobial-resistant bacteria, but no controlled study has tested the effect of rapid screening and isolation of carriers on transmission in settings with best-standard precautions. We assessed interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in European ICUs.

Methods

We did this study in three phases at 13 ICUs. After a 6 month baseline period (phase 1), we did an interrupted time series study of universal chlorhexidine body-washing combined with hand hygiene improvement for 6 months (phase 2), followed by a 12–15 month cluster randomised trial (phase 3). ICUs were randomly assigned by computer generated randomisation schedule to either conventional screening (chromogenic screening for meticillin-resistant Staphylococcus aureus [MRSA] and vancomycin-resistant enterococci [VRE]) or rapid screening (PCR testing for MRSA and VRE and chromogenic screening for highly resistant Enterobacteriaceae [HRE]); with contact precautions for identified carriers. The primary outcome was acquisition of resistant bacteria per 100 patient-days at risk, for which we calculated step changes and changes in trends after the introduction of each intervention. We assessed acquisition by microbiological surveillance and analysed it with a multilevel Poisson segmented regression model. We compared screening groups with a likelihood ratio test that combined step changes and changes to trend. This study is registered with ClinicalTrials.gov, number NCT00976638.

Findings

Seven ICUs were assigned to rapid screening and six to conventional screening. Mean hand hygiene compliance improved from 52% in phase 1 to 69% in phase 2, and 77% in phase 3. Median proportions of patients receiving chlorhexidine body-washing increased from 0% to 100% at the start of phase 2. For trends in acquisition of antimicrobial-resistant bacteria, weekly incidence rate ratio (IRR) was 0·976 (0·954–0·999) for phase 2 and 1·015 (0·998–1·032) for phase 3. For step changes, weekly IRR was 0·955 (0·676–1·348) for phase 2 and 0·634 (0·349–1·153) for phase 3. The decrease in trend in phase 2 was largely caused by changes in acquisition of MRSA (weekly IRR 0·925, 95% CI 0·890–0·962). Acquisition was lower in the conventional screening group than in the rapid screening group, but did not differ significantly (p=0·06).

Interpretation

Improved hand hygiene plus unit-wide chlorhexidine body-washing reduced acquisition of antimicrobial-resistant bacteria, particularly MRSA. In the context of a sustained high level of compliance to hand hygiene and chlorhexidine bathings, screening and isolation of carriers do not reduce acquisition rates of multidrug-resistant bacteria, whether or not screening is done with rapid testing or conventional testing.

Funding

European Commission.

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Vol 14 - N° 1

P. 31-39 - janvier 2014 Retour au numéro

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Interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in intensive care units: an interrupted time series study and cluster randomised trial - 17/12/13

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