Infection Control & Hospital Epidemiology (2019), 40, 447–456 doi:10.1017/ice.2018.359
Review
Transmission pathways of multidrug-resistant organisms in the hospital setting: a scoping review
Natalia Blanco PhD, MPH , Lyndsay M. O’Hara PhD, MPH and Anthony D. Harris MD, MPH Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
Abstract
Background: Prevalence of multidrug-resistant microorganisms (MDROs) continues to increase, while infection control gaps in healthcare settings facilitate their transmission between patients. In this setting, 5 distinct yet interlinked pathways are responsible for transmission. The complete transmission process is still not well understood. Designing and conducting a single research study capable of investigating all 5 complex and multifaceted pathways of hospital transmission would be costly and logistically burdensome. Therefore, this scoping review aims to synthesize the highest-quality published literature describing each of the 5 individual potential transmission pathways of MDROs in the healthcare setting and their overall contribution to patient-to-patient transmission.
Methods: In 3 databases, we performed 2 separate systematic searches for original research published during the last decade. The first search focused on MDRO transmission via the HCW or the environment to identify publications studying 5 specific transmission pathways: (1) patient to HCW, (2) patient to environment, (3) HCW to patient, (4) environment to patient, and (5) environment to HCW. The second search focused on overall patient-to-patient transmission regardless of the transmission pathway. Both searches were limited to transmission of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus, multidrug-resistant A. baumannii, and carbape- nem-resistant Enterobacteriaceae. After abstract screening of 5,026 manuscripts, researchers independently reviewed and rated the remaining papers using objective predefined criteria to identify the highest quality and most influential manuscripts.
Results: High-quality manuscripts were identified for all 5 routes of transmission. Findings from these studies were consistent for all pathways; however, results describing the routes from the environment/HCW to a noncolonized patient were more limited and variable. Additionally, most research focused on MRSA, instead of other
MDROs.The second search yielded 10 manuscripts (8 cohort studies) that demonstrated the overall contribution of patient-to-patient transmission in hospitals regardless of the transmission route. For MRSA, the reported cross-trans- mission was as high as 40%.
Conclusions: This scoping review brings together evidence supporting all 5 possible transmission pathways and illustrates the complex nature of patient-to-patient transmission of MDROs in hospitals. Our findings also confirm that transmission of MDROs in hospitals occurs frequently, suggesting that ongoing efforts are necessary to strengthen infection prevention and control to prevent the spread of MDROs.
(Received 6 November 2018; accepted 13 December 2018)
The prevalence of multidrug-resistant microorganisms (MDROs) continues to increase in healthcare settings in the United States. For instance, methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) colonization among intensive care unit (ICU) patients have been reported as high as 16% and 25% respectively in US hospitals.1 Likewise, multidrug- resistant Acinetobacter baumannii and carbapenem-resistant Enterobacteriacea (CRE) colonization rates have been reported to be as high as 41%2 and 45%3 in hospitalized patients. On average, 21VREorMRSAnewacquisitions per 1,000 patient days at risk have been observed in ICU settings across the United States.4 The continuing emergence of MDROs and their spread across
healthcare settings are believed to be due to multiple causal factors, including antibiotic use and transmission due to gaps in infection
Author for correspondence: Anthony D. Harris, Email:
aharris@epi.umaryland.edu Cite this article: Blanco N, et al. (2019). Transmission pathways of multidrug-resistant
organisms in the hospital setting: a scoping review. Infection Control & Hospital Epidemiology, 40: 447–456,
https://doi.org/10.1017/ice.2018.359
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved.
control.5 Although low or moderate levels of health care worker (HCW) carriage of MDRO have been observed,6,7 HCW hands, gloves, and gown contamination have been consistently reported.8–10 Moreover,HCWapparel (ie, scrubs, and white coats) and the hospital environment have been shown to carry a high burden of MDROs.6,11,12,13 Therefore, HCWs and the healthcare environment can function as intermediate transmission vectors of MDROs among patients. Although hospital settings are commonly considered hot spots
for MDRO transmission, the complete transmission process is still not well understood. Furthermore, the relative importance of each potential transmission pathway in the overall patient-to-patient transmission process in healthcare settings is still controversial. The design and implementation of a single research study to appro- priately investigate all potential pathways simultaneously and their intercorrelations is largely infeasible due to cost and logistics. Nevertheless, the lack of clear evidence and understanding of the complexity and multifaceted nature of MDRO transmission
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