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ECDC Risk assessment on the spread of carbapenemase-producing Enterobacteriaceae (CPE) through patient transfer between healthcare facilities, with special emphasis on cross-border transfer (ECDC, Sept 13 2011)

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  • ECDC Risk assessment on the spread of carbapenemase-producing Enterobacteriaceae (CPE) through patient transfer between healthcare facilities, with special emphasis on cross-border transfer (ECDC, Sept 13 2011)

    [Source: European Centre for Disease Prevention and Control (ECDC), full page: (LINK). Edited.]
    ECDC Risk assessment on the spread of carbapenemase-producing Enterobacteriaceae (CPE) through patient transfer between healthcare facilities, with special emphasis on cross-border transfer

    13 Sep 2011

    ECDC

    The risk assessment on the spread of carbapenemase-producing Enterobacteriaceae (CPE) is based on two systematic reviews ? on the risk factors for patient colonisation or infection with CPE and on the effectiveness of infection control measures to stop the spread of CPE within healthcare institutions. In addition, a group of ten experts on infectious diseases and control provided their expert opinion on the systematic reviews.

    Patient transfer between healthcare facilities, in particular cross border transfer of patients, is a risk factor for the spread of resistance to last line antibiotics bacteria, concludes the report. For highly resistant bacteria, like CPE, the risk is heightened when patients are transferred from, or have received previous medical care in areas with high rates of resistance.
    The infection control measures, found effective in the risk assessment are:
    • a) active surveillance (active screening of all cross-border patients on admission and a prompt laboratory detection);
    • b) additional precautions for CPE-positive patients (e.g. contact precautions, such as wearing of disposable gloves and gown, and isolation measures);
    • c) cohort nursing by a separate, dedicated team for all suspected and positive CPE patients.

    Additional suggestions from ECDC are for countries to perform active surveillance on any patient transferred across borders upon admission to a hospital or other healthcare facility; to develop national guidance for how to stop the spread of CPE and to actively report cases of CPE to public health authorities.
    Risk assessment on the spread of carbapenemase-producing Enterobacteriaceae (CPE) through patient transfer between healthcare facilities, with special emphasis on cross-border transfer

    Press release ?Cross-border transfer increases patients? risk of resistant bacteria?


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  • #2
    Re: ECDC Risk assessment on the spread of carbapenemase-producing Enterobacteriaceae (CPE) through patient transfer between healthcare facilities, with special emphasis on cross-border transfer (ECDC, Sept 13 2011)

    [Source: European Centre for Disease Prevention and Control, full PDF document: (LINK). Estract, edited.]

    TECHNICAL REPORT

    Risk assessment on the spread of carbapenemase-producing Enterobacteriaceae (CPE) through patient transfer between healthcare facilities, with special emphasis on cross-border transfer


    This report of the European Centre for Disease Prevention and Control (ECDC) was produced and written by a core ECDC working group:
    • Anna-Pelagia Magiorakos, Marc Struelens, Aftab Jasir with participation from an internal ECDC ad hoc working group:
      • Frode Forland, Niels Kleinkauf, Dominique L. Monnet, J. Todd Weber, Johan Giesecke, Denis Coulombier.
    • The following external experts participated in a consultation meeting on 24 November 2010. All experts involved in this risk assessment signed Declaration of Interest forms prior to the meeting.
      • Rafael Cant?n, Servicio de Microbiolog?a and CIBER en Epidemiolog?a y Salud P?blica (CIBERESP), Instituto Ram?n y Cajal de Investigaci?n Sanitaria (IRYCIS), Hospital Universitario Ram?n y Cajal. Madrid, Spain
      • Yehuda Carmeli, Division of Epidemiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
      • Bruno Coignard, Healthcare-associated Infection and Antimicrobial Resistance Unit, Infectious Disease Department, Institut de Veille Sanitaire, Paris, France
      • Christian Giske, Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
      • Hajo Grundmann, University Medical Centre Groningen & National Institute for Public Health and the Environment, Bilthoven, the Netherlands
      • Vincent Jarlier, Bact?riologie-Hygi?ne, H?pital Piti?-Salp?tri?re (AP-HP), Universit? Pierre et Marie Curie (UPMC) Paris, France
      • Alan Johnson, Department of Healthcare-Associated Infection & Antimicrobial Resistance, Centre for Infections, Health Protection Agency, London, United Kingdom
      • Gian Maria Rossolini, University of Siena, Faculty of Medicine & Microbiology and Virology Unit, Siena University Hospital, Siena, Italy
      • George Saroglou, Infectious Diseases Nursing Department, University of Athens, Athens, Greece
      • Gunnar Skov Simonsen, Norwegian Organisation for Surveillance of Antimicrobial Resistance ? NORM, University Hospital of North Norway, Troms?, Norway
      • Athanassios Tsakris, Department of Microbiology, Medical School, University of Athens, Athens, Greece.
    Suggested citation: European Centre for Disease Prevention and Control. Risk assessment on the spread of carbapenemase-producing Enterobacteriaceae (CPE) through patient transfer between healthcare facilities.

    Stockholm: ECDC; 2011.
    Stockholm, September 2011
    ISBN 978-92-9193-310-5
    doi: 10.2900/58154

    ? European Centre for Disease Prevention and Control, 2011
    Reproduction is authorised, provided the source is acknowledged.



    Summary and conclusions of ECDC risk assessment and guidance for prevention and control

    In May 2010, due to concern about the increasing number of outbreaks and the spread of arbapenemase-producing Enterobacteriaceae (CPE) in healthcare facilities across Europe, the EU Member States submitted a proposal to the European Centre for Disease Prevention and Control?s Advisory Forum for a risk assessment. The purpose of the Risk assessment on the spread of carbapenemase-producing Enterobacteriaceae through patient transfer between healthcare facilities, with special emphasis on cross-border transfer was to evaluate the risk to the citizens of Europe of CPE spread through patient mobility and to assess the effectiveness of infection control methods to stop the spread of CPE within healthcare institutions.

    Carbapenemases, a group of clinically important β-lactamases that efficiently hydrolyse most β-lactams, including the carbapenems, have emerged and spread among the Enterobacteriaceae family of bacteria worldwide.

    Although the exact prevalence of CPE in healthcare facilities and within the community in Europe is unknown, publications from Member States and surveillance systems indicate that CPE is endemic in certain countries.

    Similar risk factors to those associated with other multidrug-resistant organisms (MDROs) have been identified for CPE and include severity of illness, a history of hospitalisation or a stay in an intensive care unit, prior antimicrobial use and immunosuppression. Patient mobility has also recently been highlighted as a risk factor for the acquisition of CPE in many reports by Member States discussing the introduction and spread of carbapenemases into healthcare settings as a result of patient transfer, mostly from endemic areas, across borders.

    Transfer of patients across borders has been shown to be a documented risk factor for the introduction of carbapenemase-producing Enterobacteriaceae into healthcare settings and systems. CPE are easily introduced because they are highly transmissible, resulting in colonisation or infection of patients. Dissemination of mobile genetic elements coding for resistance and of epidemic, multidrug-resistant strains has been the cause of many reported outbreaks. Infections with CPE are a threat to patient safety due to their resistance to multiple antimicrobials, meaning that there are very few therapeutic options with which to treat infected patients. Furthermore, human infections with CPE are associated with poorer patient outcomes, increased morbidity, mortality and higher hospital costs. The risk for humans becomes greater since therapeutic options are limited because there are very few novel antimicrobial agents in the development pipeline.

    This risk assessment is based on two systematic reviews. The first review looked at the risk factors for patient colonisation or infection with CPE and the second examined the effectiveness of using screening and/or targeted infection control measures to decrease the incidence of colonisation or infection in acute healthcare settings. In addition, a group of ten experts in infectious diseases, infection control, public health and microbiology attended a meeting in Stockholm, Sweden on 24 November 2010 to give feedback on the systematic reviews, and to provide their expert opinion and recommendations, which are all included in the risk assessment. The following document presents the conclusions from this risk assessment.



    Cross-border transfer of patients

    There is strong evidence from the descriptive studies included in the systematic literature review that when patients infected or colonised with carbapenemase-producing Enterobacteriaceae are transferred across borders this increases the risk of CPE being introduced and spread into healthcare facilities in the country of destination. Cross-border transfer of patients poses a clear risk for the transmission of CPE, especially when patients are transferred from areas with high rates of CPE to healthcare facilities in another country or have received medical care abroad in areas with high rates of CPE.

    The group of experts concurred with these conclusions and stated that, despite the potential publication bias and/or ascertainment bias of the descriptive studies included, the evidence was still compelling and the risk was still inherent. Publication and ascertainment bias, however, can obscure the exact prevalence of CPE in Europe. Good data is therefore required on the epidemiology of CPE in Europe. Countries are encouraged to actively report cases of CPE by making all clinical cases notifiable to public health authorities. There is a need to have a European network counting cases/outbreaks of infection with CPE, to implement early warning electronic platforms like the Epidemic Intelligence System (EPIS) or the Early Warning and Response System (EWRS), and to perform regular surveys to collect data on the prevalence of CPE in Europe.



    Prudent use of antimicrobials

    The experts agreed with the results from the systematic review that, prior use of all antimicrobial agents (more specifically the carbapenems, 3rd and 4th generation cephalosporins and fluoroquinolones) increased the risk of infection or colonisation with CPE. Additionally, they stressed the importance of recognising that antimicrobial pressure is associated with the emergence and spread of resistance determinants in general. High rates of MDROs, e.g. extended-spectrum β-lactamase (ESBL)-producing bacteria, represent an indirect risk for the spread of carbapenem resistance mechanisms because they are associated with an increased prescription of carbapenem antibiotics to treat patients infected with these MDROs. It is therefore imperative not only to control the misuse of antimicrobial agents, but also the high rates of MDROs (e.g. ESBL-producing Enterobacteriaceae), since their presence necessitates the use of antimicrobials, especially the carbapenems.

    The result is an interminable cycle of antimicrobial use, antimicrobial pressure and high rates of antimicrobial resistance. Decisive action is therefore needed to promote prudent use of antimicrobial agents.



    Infection control measures

    The results of the systematic review demonstrate that there is limited evidence available on the effectiveness of infection control measures to prevent and control nosocomial transmission of CPE in acute healthcare facilities, and no evidence for other healthcare settings. The effectiveness of containment strategies, to combat secondary transmission following cross-border CPE transmission due to patient transfer, is also unclear because reporting on infection control management in the studies is incomplete.

    The group of experts emphasised that for infection control purposes CPEs will behave similarly to other MDROs. Therefore, infection control measures able to effectively halt the spread of other MDROs, e.g. ESBL-producing Enterobacteriaceae, in acute healthcare settings should also be used and recommended for CPEs.

    Evidence from outbreaks of other MDROs, such as ESBL-producing Enterobacteriaceae in acute care hospitals, consistently supports the effectiveness of a) early implementation of active surveillance by rectal screening for CPE carriage, b) additional precautions for the care of CPE-positive patients, including the wearing of disposable gloves and gown and c) cohort nursing by a separate, dedicated team.

    Existing guidance documents from the USA and Europe and the group of experts recommend the implementation of comprehensive, multifaceted infection control programmes, with well-defined structures and processes, and continuous evaluation of the implemented measures to prevent the spread of CPE in acute care facilities. Use of Standard Precautions, and especially adherence to hand hygiene policies, is the cornerstone for preventing transmission of MDROs, including CPE, in healthcare settings. Colonisation and/or infection of patients with MDROs may be unknown and it is therefore of paramount importance that healthcare workers adhere strictly to basic hand hygiene policies during patient care to prevent cross-infection.

    Additional recommended infection control measures include: active screening cultures on admission or transfer of all high-risk patients; routine use of clinical laboratory screening tests for accurate detection of CPE; pre-emptive isolation of high-risk patients pending the results of the active surveillance and, if positive, continuous active surveillance; contact precautions and isolation or cohorting care for all CPE-colonised patients; dedicated staff and cohort nursing for all isolated patients who are carriers of CPE; prudent use of antimicrobial agents and a system for monitoring compliance with all the aforementioned measures.



    Active screening

    Active surveillance by rectal screening of any patient transferred across borders into a healthcare facility in another country is strongly recommended by the group of experts. However, drawing up lists of high-risk countries from which transferred patients should be screened for CPE is discouraged. Due to patient mobility and the unknown reservoir of CPE in Europe and globally, any patient transferred from any country is at risk of carrying CPE. The group of experts emphatically recommended that any patient transferred across borders between healthcare systems should be screened upon admission and that all countries should develop a guidance document that includes this recommendation. This is already standard practice in countries such as France, Norway, Sweden and Israel and is consistently reported as an integral part of the success of national task forces to control and prevent CPE.



    Detection

    Detection, diagnosis and confirmation of the presence of carbapenemases is important for surveillance, infection control and treatment purposes. Necessary elements include a local microbiological laboratory performing highly sensitive tests for rapid detection of carbapenemases and CPE, especially for active screening purposes, and a fast diagnostic turnaround time and timely communication of laboratory results to physicians, nurses and the infection control team. Confirmatory tests for the presence of carbapenemases are widely available and easy to implement as long as the necessary resources are available and laboratory staff have received the appropriate training. If this is not possible locally, isolates should be sent to reference laboratories, which may cause delays, hampering implementation of infection control measures. Both the experts and guidance documents strongly recommended that all confirmed clinical cases of carbapenemase and CPE should be notifiable to the public health authorities.



    Public health

    As the spread of CPE continues and new carbapenemases are reported, it is clear that public health preparedness for the surveillance and containment of CPE in Europe needs to be intensified. Guidelines and reports from countries with recent and/or ongoing epidemics have underscored the need for better public health infrastructure, including the creation of public health laboratory networks and national task forces focusing on infection control.

    Other proposed measures for improving public health infrastructure include the standardisation of laboratory testing methodologies; use of similar interpretive criteria to ensure adequate EU-wide laboratory capacity for timely and accurate detection of carbapenemases and CPE; making public health reporting of CPE mandatory; strengthening collaboration between reference laboratories and the European Antimicrobial Resistance Surveillance Network (EARS-Net) and ensuring that countries actively participate in electronic early warning platforms such as the Epidemic Intelligence System (EPIS) or the Early Warning and Response System (EWRS).



    Research needs

    To better assess the effectiveness of infection control and other measures for the prevention and control of CPE transmission in acute and other healthcare facilities in endemic and non-endemic regions, there is a need for better designed and reported studies of the benefit and harm of infection control measures.

    In order to obtain the best data from case-control studies and, where possible, eliminate bias these studies should be designed to clearly identify and report whether bacterial isolates represent cases of infection or colonisation. A guidance document specifying quality indicators for the design and reporting of these studies would be a helpful tool to ensure that all necessary elements are included. Lastly, in order to avoid publication and ascertainment bias, it is necessary to encourage countries to more actively report cases of cross-border transfer of CPE from countries in Europe and globally. Issues of awareness, lack of resources and laboratory capacity and unwillingness to report data may limit the implementation of such a system.


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