1192 infection control & hospital epidemiology october 2017, vol. 38, no. 10


figure 1. Measures implemented in patients infected and/or colonized by multidrug-resistant organisms under isolation precautions, Lyon University Hospitals, 2013 and 2015, (n=477). *P<.05; *P<.001.


(P=.16), with no differences in temporal trends by hospital. However, IP implementation improved from 74.2% in 2013 to 87.1% in 2015 (P=.01) for patients with imported MDRO infection and/or colonization. Isolation precautions were implemented for 73% of patients on the day the test results were obtained, and for 91% on the day of medical prescription for IPs. Between 2013 and 2015, global improvement occurred in the presence of protective equipment, signage, and hand-rub solutions in patients with IPs (Figure 1). Table 5 shows the factors associated with lack of implementa-


tion of isolation precautions after univariate and multivariate analysis. The strength of the association between lack of medical prescription and absence of IPs was heterogeneous by specialty: crude odds ratios were respectively 15.4 (95% CI, 6.2–38.1; P<.001) in acute care, 9.7 (95% CI, 3.1–31.1; P<.001) in intensive care, and 24.8 (95% CI, 5.3–115.4; P<.001) in rehabilitation.Onmultivariate analysis, patient age, year, specialty, hospital, colonization versus infection, and lack of medical prescription for IPs were independent predictors of lack of IP implementation (Table 5). Lack of medical prescription for IPs was strongly associated with the absence of IPs (adjusted odds ratio, 17.4; 95% CI, 8.5–35.8; P<.001).


discussion


The main objective of the study was to assess the determinants of lack of IP implementation in MDRO cases. We found that incidence was stable during this period, but the proportion of nosocomial-acquired MDRO infection and/or colonization decreased. Several factors were associated with the lack of IP


implementation, but medical prescription for IPswas the main modifiable, contributing component. Significant differences in MDRO incidence were observed between specialties with higher frequency in ICUs. Our estimates agree with those of earlier French national surveillance, which reported MRSA and ESBL-E incidence rates of 0.40 and 0.39 per 1,000 patient days, with the highest incidence in ICUs.18 More recently, in Germany, MRSA incidence decreased between 2010 and 2014 (relative risk, 0.88; 95% CI, 0.84–0.91).5 The increased pro- portion of imported 3GCR-E infections and/or colonizations underlines the growing importance of community acquisition in the hospital burden of 3GCR-E, caused mainly by interna- tional travel and inappropriate antibiotic use but also by community acquisition.19 We observed similar trends in our study population. Isolation precautions were applied frequently, sometimes


despite a lack of medical prescription for IPs. After adjusting to confounding factors, 30% improvement of IP implementation was seen between the 2 study periods, while no major trans- versal campaign was instituted during this time. Improvement may be partially due to frequent on-site visits by infection control professionals in recent years in our hospitals, particu- larly in geriatric units. Continuous, prospective surveillance of MDRO cases is ongoing in all short- and extended-stay geriatric units. Each time a case is identified, an infection control professional calls the unit to establish whether IPs have been applied and whether they are appropriate. Protective equipment is most often present and is the consequence of an institutional campaign for the standardization of supports for patients who need complementary precautions.


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