CPE; Infection control; ESBL; Clinical trial; Test diagnostique rapide
Martischang Romain, Iten Anne, Arm Isabelle, Abbas Mohamed, Meyer Benjamin, Yerly Sabine, Eckerle Isabella, Pralong Jacques, Sauser Julien, Suard Jean-Claude, Kaiser Laurent, Pittet Didier, Harbarth Stephan (2021), Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) seroconversion and occupational exposure of employees at a Swiss university hospital: A large longitudinal cohort study, in Infection Control & Hospital Epidemiology
Martischang Romain, Riccio Maria E., Abbas Mohamed, Stewardson Andrew J., Kluytmans Jan A. J. W., Harbarth Stephan (2020), Household carriage and acquisition of extended-spectrum β-lactamase–producing Enterobacteriaceae: A systematic review, in Infection Control & Hospital Epidemiology
, 41(3), 286-294.
Martischang Romain, Buetti Niccolo, Balmelli Carlo, Saam Mirko, Widmer Andreas, Harbarth Stephan (2019), Nation-wide survey of screening practices to detect carriers of multi-drug resistant organisms upon admission to Swiss healthcare institutions, in Antimicrobial Resistance & Infection Control
, 8(1), 37-37.
Zahar Jean-Ralph, Blot Stijn, Nordmann Patrice, Martischang Romain, Timsit Jean-François, Harbarth Stephan, Barbier François (2019), Screening for Intestinal Carriage of Extended-spectrum Beta-lactamase–producing Enterobacteriaceae in Critically Ill Patients: Expected Benefits and Evidence-based Controversies, in Clinical Infectious Diseases
, 68(12), 2125-2130.
Colonization with antimicrobial-resistant pathogens such as extended-spectrum beta-lactamase-producing enterobacteriacae (ESBL-PE) or carbapenemase-producing enterobacteriacae (CPE) places patients at high risk of antibiotic-resistant nosocomial infection. Early and rapid identification of critically ill patients colonized with ESBL-PE/CPE, and subsequent prevention of patient-to-patient spread of ESBL-PE/CPE through proper infection control are potentially useful interventions to control ESBL-PE/CPE cross-infection in the intensive care unit (ICU). Thus, targeted ESBL-PE/CPE screening on admission may help to identify unknown ESBL carriers, prevent transmission and could help to reduce time to adequate treatment in case of ESBL-PE/CPE infection. However, current microbiologic screening methods to detect previously unknown ESBL-PE/CPE carriers are slow. This delay impacts the discontinuation of pre-emptive isolation measures among patients at high risk of ESBL-PE/CPE carriage and may increase healthcare costs and preventable adverse events. To further complicate matters, there is ongoing controversy whether carriers of ESBL-producing E.coli require contact precautions, in contrast to other ESBL-PE, such as Klebsiella spp and Enterobacter spp.There is an ongoing need for a fast, reliable and inexpensive diagnostic screening method for ESBL-PE and CPE strains of major concern in Switzerland, which may also include the capacity to identify transmissible and virulent ESBL-E.coli clones requiring contact precautions in the ICU setting. A novel strategy with 2 rapid diagnostic methods could allow individualizing and speeding up the implementation of appropriate infection control measures, or discontinue preemptive isolation as fast as possible. First, the loop-mediated isothermal amplification reaction (LAMP) is an isothermal molecular amplification method already developed and previously validated in our institution. Compared to conventional PCRs for the detection of the predominant ESBL-PE and CPE types, this new technique is faster and potentially more cost-beneficial, but with a similar diagnostic accuracy. Second, we have recently developed a specific molecular test able to detect the virulent and transmissible ESBL-E. coli strain ST131 H30 in order to tailor the implementation of preventive measures to this specific E.coli clone.This study aims to evaluate the effectiveness of an innovative screening strategy based on 2 rapid tests to improve the implementation or discontinuation of ESBL-PE/CPE control measures among critically ill patients, including also a specific test to risk-stratify ESBL-producing E. coli in order to discriminate epidemic clones (ST131 H30) requiring contact precautions. We will test the specific hypotheses that a screening program with a novel diagnostic strategy enabling early detection of ESBL-PE and CPE carriage in 2 ICUs at HUG can:1.Decrease unnecessary isolation-days for patients suspected to be colonized with ESBL-PE and CPE, but who are finally screening-negative;2.Decrease the time between patient screening and contact isolation of previously unknown ESBL-PE and CPE carriers in this high-risk setting;3.Decrease the risk of nosocomial cross-transmission of ESBL-PE;4.Reduce unnecessary costs from an institutional perspective and provide a cost-effective screening option.To test these hypotheses, we propose a a quasi-experimental, prospective, cross-over cohort study conducted over 3 years (2018-2020) to compare a rapid ESBL-PE/CPE screening strategy with the currently used routine diagnostic method. Patients will be screened by rectal swabs on admission (targeted screening of high-risk patients) and once weekly (universal screening) in 2 mixed medico-surgical ICUs with a total of 36 beds and current ESBL-PE prevalence of 10%. During the first interventional phase in 2019 (6 months), one ICU will implement (or discontinue) contact precautions according to the standard microbiologic method while the other ward will use the novel diagnostic strategy. The protocol will be switched between these two ICUs during the second phase (6 months), after a wash-out period of 2 months. During both phases, routine tests will be continued in parallel to the novel diagnostic strategy. Statistical analysis will be performed in the 3rd year of the study (2020). Time (h) to notification and implementation (or discontinuation) of isolation measures will be measured as primary endpoints, stratified by diagnostic method (novel strategy vs. current method). As secondary outcome, transmission events will be analyzed through weekly prevalence surveys and a cost-effectiveness study will compare the benefit of spared isolation days and the cost of diagnostic tests.Overall, this proposal allows application of a novel rapid diagnostic strategy to detect ESBL-PE/CPE colonization and improve patient safety by rapid identification and isolation of ICU patients carrying these multi-resistant bacteria. It will also allow earlier discontinuation of preemptive isolation in high-risk patients with negative screening results. Thus, this project will promote technological development with a direct impact on clinical care.