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Margaret A. Fitzpatrick et al
Fig. 1. Percentages of survey respondents expressing varying levels of agreement with statements about the Veterans Affairs 2017 carbapenem-resistant Enterobacteriaceae (CRE) guidelines. The different levels of agreement are indicated by shades of gray.
VA Multidrug Resistant Organism Program Office. It was administered using VA’s Research Electronic Data Capture (REDCap) software.6 The survey focused on laboratory CRE identification, reporting, screening, and guideline implementation, and it was pilot tested in 5 facilities to ensure clarity and reliability. Survey responses were summarized with descriptive statistics. VAMCs are classified into complexity levels determined partly by patient characteristics (levels 1a–c, 2, and 3). We defined high complexity facilities as levels 1a–c and low complexity facilities as levels 2 and 3. Dichotomous comparisons of survey responses by facility complexity and location were assessed using the Fisher exact test. The Consolidated Framework for Implementation Research (CFIR) 7 was used to code responses to open-ended questions regarding barriers and facilitators to guideline implementation.
Results
The overall survey response rate was 93.0% (120 of 129 sites). Paralleling VA acute-care facilities in general, respondents were mostly urban (80.0%) with high complexity (64.9%). Most respon- dents reported that the incidence of new cases ofCRE/CP-CRE was <1 permonth at their facility (57.5%), whereas 34.2% reported that they had never seen a CRE/CP-CRE case. Only 1.7% described their facility as located in a region with high CRE/CP-CRE preva- lence. However, 91.6% of facilities reported using VA guidelines; 20% also use the Centers for Disease Control and Prevention (CDC) guidelines; and 27.5% use state and/or local resources for additional guidance. Overall, 79.2% of facilities reported using imipenem, merope-
nem, and/or doripenem minimum inhibitory concentration (MIC) ≥4 mcg/mL as the first step to identify CRE from clinical cultures, as recommended in theVAguideline. In addition, 8 facili- ties (6.7%) reported using other carbapenem MIC cutoffs with or without ertapenem. Furthermore, 91 facilities (75.8%) routinely perform additional testing to confirm that a CRE isolate produces a carbapenemase, of which 66 facilities (72.5%) use polymerase chain reaction (PCR) assay for confirmation. Confirmatory testing is performed on site at 47.3% of the responding facilities; the others send isolates to a reference laboratory. In 72.0% of facilities, a
report of presumptive CRE is provided to either the infection control staff and/or the treating providers, and nearly 97.4% contact the infection control staff when CP-CRE are confirmed. Furthermore, 35.5% of facilities reported a 25–48-hour turnaround time for final confirmation of CP-CRE from a clinical culture, and 31% reported >72 hours to receive these laboratory results. Moreover, 79.8% of respondents reported being involved in
guideline implementation, being knowledgeable about the lab proce- dures in the guidelines, and being comfortable executing the guide- lines (Fig. 1).Many respondents agreed or strongly agreed that they had the resources needed to follow the guidelines. However, only 55.9% agreed or strongly agreed that they had adequate staffing resources and only 44.9% agreed or strongly agreed that they had adequate physical resources. Common implementation barriers reported using CFIR constructs were the availability of resources (29%; eg, limited staffing), access to knowledge and information (12%; eg, adequate training), and costs (12%; eg, laboratory supplies). Differences in survey responses were observed according to
facility complexity and location (Table 1). High-complexity facili- ties were more likely to report having had any CRE cases, to report presumptive CRE to infection control staff, to confirm carbapene- mases, and to use PCR specifically for carbapenemase confirma- tion. Both high-complexity and urban facilities were more likely to be knowledgeable about the guidelines and laboratory proce- dures, to feel comfortable executing the guidelines, and to feel they had adequate local resources for guideline implementation.
Discussion
Laboratory diagnosis and reporting ofCREis critical to conducting surveillance, allocating infection prevention resources, and imple- menting timely infection control procedures. As strategies for identifying CRE and confirming CP-CRE have evolved and improved, national VA CRE guidelines have been updated accord- ingly. However, few data are available on laboratory practices for CRE identification and reporting. Prior surveys have focused only on adherence to revised CLSI break points for Enterobacteriaceae, 8 and they did not use national data9 or addressed only infection control strategies rather than laboratory practices.10
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