isolation precautions against mdros 1189
compliance with IPs and limit MDRO spread. Barriers to IP implementation may be related to patient characteristics, type of infection (ie, urinary tract vs other infections) or orga- nizational factors (ie, specialty or medical prescription for IPs). To the best of our knowledge, these factors have rarely been reported, and the relationships between them have been poorly investigated in a nonoutbreak context.16,17 In view of the changing epidemiology ofMDROin hospitals
and the dearth of knowledge of IPs against MDRO infections, we conducted a multicenter, hospital-based, observational study and an audit of practices at our university center in France. Our primary study objective was to identify factors associated with lack of IP implementation in patients infected or colonized with MRSA and 3GCR-E. The secondary objec- tives were to estimate the incidence of infections and/or colonizations with MRSA and 3GCR-E and to report IP compliance in 2015 compared to 2013.
methods
Standardized monitoring of IPs and epidemiological surveillance were undertaken for all patients hospitalized between April 1, 2013, and June 30, 2013, and between April 1, 2015, and June 30, 2015, in 4 Lyon University hospitals in France: Hôpital de la Croix-Rousse, Hôpital Edouard Herriot, Hôpital Gériatrique, and Hôpital Lyon-Sud. Surveillance of a local section of the MDRO Surveillance Network in southeastern France was based on standardized definitions.18 Implementation of IPs was based on a local protocol (Table 1); patients withMRSA nasal carriage without any site of infection or respiratory sign do not necessitate isolation precautions. Information on new positive culture results for MRSA and 3GC-E are normally reported in the electronic medical record, and microbiological staff orally inform practi- tioners. In addition, an automatic daily e-mail was sent to infec- tion control practitioners. Overall, 3,713 and 3,454 hospital beds were monitored in 2013 and 2015, respectively.
Each MDRO case patient had at least 1 positive clinical sample
of MRSA or 3GCR-E after culture. The exclusion criterion was MRSA or 3GCR-E detection by rectal, nasal, or cutaneous screening. A standardized data collection form was completed for each case, with information on demographic characteristics, microbiological results, infections or colonizations, and acquisi- tion type (hospital-acquired or imported). Colonization was defined as identification of MRSA or a 3GCR-E from a clinical sample, without clinical and therapeutic consequences for the patient, at a level below microbiological threshold. Infection was clinically defined as identification of MRSA or a 3GCR-E above the microbiological threshold, with clinical and/or radio- logical signs. This information was validated by an infection control practitioner, and uncertain cases were discussed with the physician in charge of the patient. For each patient, a new MDRO event was counted if (1) another clinical sample was positive from the same patient during study period but with different species or (2) another clinical sample fromthe same patient identified the same species with different antibiogram. An additional questionnaire concerning IPs was completed for type of isolationmeasures recommended and observed, prescription, and
personal protective equipment available (Table 1). This form was filled out either by observation (30.0%) or by telephone contact (70.0%) with a healthcare worker from the unit. Bacteria were identified using biochemical strips (Vitek 2 or
Vitek Compact System, bioMérieux, Marcy l’Étoile, France) or matrix-assisted laser desorption/ionization time offlight(MALDI- TOF) mass spectrometry (Vitek MS System, bioMérieux). For Enterobacteriaceae, 3GCR-E was analyzed by broth dilution (Vitek 2 System, bioMérieux) or diffusion with antibiotic (ceftazidim, ceftriaxone, and cefotaxim) discs (SIRScan System, i2a, Perols Cedex, France). MRSA was recognized by cefoxitin testing with broth dilution (Vitek 2 System, bioMérieux), diffusion with cefoxitin disc (SIRScan System, i2a), mecA gene detection with “homemade” polymerase chain reaction, or PLP2a (PBP2a Culture Colony Test, Alere, Waltham, MA).
table 1. Recommended Measures in Cases of Methicilin-Resistant Staphylococcus aureus (MRSA) or Cultures Positive for Third-Generation Cephalosporin-Resistant Enterobacteriaceae (3GCR-E) in University of Lyon Hospitals
Microorganism Characteristics Clinical site
Type of isolation No isolation
Contact precautions Droplet precautions
Positive for MRSA Nasala Pulmonary
Yes No No Yes No Yesb
HCW responsible for starting isolation MD MD Medical prescription for isolation precautions Yes Automated post-discharge reminder
Yes No No
NOTE. HCW, healthcare worker; MD, medical doctor. aSite not included in the present study. bIf respiratory signs are present.
Positive for 3GCR-E
Blood, Urinary, or Other Rectala Pulmonary
No Yes No
No No Yes
Yes Yes No Yesb
MD MD MD Yes No
Yes No No
Blood, Urinary, or Other
No Yes No
MD Yes No
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