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Active screening for CRE feasible in ICUs
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Researchers said it is feasible to screen patients on admission for carbapenem-resistant Enterobacteriaceae, or CRE — especially high-risk patients — but findings published in Infection Control & Hospital Epidemiology suggest that interfacility communication of CRE status is poor.
“To prevent spread of CRE, some health care facilities may consider screening patients for silent carriage of CRE at the time of admission,” Michael Lin, MD, MPH, associate professor in the division of infectious diseases at Rush University Medical Center, told Infectious Disease News. “We published our hospital’s experience in screening patients for CRE with the goal of helping other hospitals design their own screening programs.”
From 2013 to 2016, Lin and colleagues conducted a retrospective, observational study to assess the implementation and outcomes of CRE admission screening. The study was split into two periods to analyze the different screening practices. Period one took place from February 2013 to October 2013, and all adult patients admitted to the ICU or transferred from outside facilities to the general ward received active CRE rectal culture screening. Period two occurred from November 2013 to January 2016, and only patients who were transferred from outside facilities were screened, according to the study. Transfer paperwork was reviewed for appropriate CRE documentation for the subset of transferred patients who had previously been reported as a CRE positive to the health department.
Over the total study period, Rush University Medical Center received 29,230 admissions, and 11,757 patients were eligible for CRE screening. Of the eligible patients, providers appropriately ordered CRE screening cultures for 80.3% (n = 9,450), and CRE cultures were collected from 72.9% (n = 8,569) of qualifying patients. Lin and colleagues emphasized that positive CRE screening rates — determined by the number of positive CRE screening cultures divided by the total number of collected CRE screening cultures — differed by period, previous facility type and current inpatient location.
Lin and colleagues observed that CRE screening adherence in ICUs was higher in period one than in period two (83.4% vs. 67.3%; P < .001). During period two, the highest CRE culture positivity was a combined rate of 3.3% in the medical intensive care unit (MICU) and the surgical intensive care unit (SICU), but the combined rate for the MICU and SICU during period one was only 0.7% (P < .001). According to the study, CRE culture positivity in the MICU and SICU during period two was also higher than rates in other wards, which was 0.6% (P < .001).
Researchers found that some patients with CRE were missed when screening practices targeted only transferred patients during period two. During period one, 21 patients in the ICU were positive for CRE, but 47.6% (n = 10) of the patients would have been missed using period two criteria because they were not directly transferred from an outside institution. Additionally, patients in the ICU who had been transferred from short- or long-term acute-care hospitals had a 1.9% CRE positivity rate, whereas the rate among patients who were not transferred was 0.5% (P <.001).
According to the study, period two had 45 unique CRE-positive patients and 13 were known to be CRE-positive at other institutions a median of 65 days (interquartile range = 20-176.5) before transfer to Rush University Medical Center. Lin and colleagues reported that appropriate documentation of CRE-positive status was available only for 30.8% (n = 4), but 92.3% were on contact precautions because of a previous infection or colonization with a different multidrug-resistant organism.
Although CRE screening has been shown to be feasible, Lin and colleagues highlighted the need to consider the CRE risk differences associated with the origin of patient transfers and hospital wards. They suggested a standardization of infection control forms to improve interfacility communications and the reliability of patient CRE status.
“More research is needed to evaluate the impact of CRE screening on CRE transmission in the health care facilities,” Lin said. – By Marley Ghizzone
Disclosures: Lin reports receiving research support in the form of contributed product from OpGen and Sage Products, which is now part of Stryker. He has also reported receiving an investigator-initiated grant from CareFusion Foundation, which is now part of Becton Dickinson. Please see the study for all other authors’ relevant financial disclosures.
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