Infection Control & Hospital Epidemiology Table 1. Survey Responses Facility Complexity Survey Response
Laboratory practices No CRE cases seen at facility
Use carbapenem MIC to initially identify CRE Provide preliminary report of CRE to IC Confirm carbapenemase production If yes, confirm with PCR
Implementationb Lab involved in guidelines implementation Generally knowledgeable about guidelines Knowledgeable about laboratory procedures Comfortable executing guidelines
Adequate national dissemination of guidelines Adequate local resources required for implementation Education/training Staffing Physical
Laboratory No. of Responsesa
120 120 118 118 91
119 119 118 118 118 118 118 118 118 118
High (n=78), No. (%)
16 (20.5) 65 (83.3) 61 (78.2) 65 (83.3) 43 (82.7)
65 (83.3) 71 (91.0) 71 (91.0) 67 (87.0) 54 (70.1) 54 (70.1) 56 (72.7) 47 (61.0) 37 (48.1) 55 (71.4)
particular question. bResponses considered positive for implementation questions were ‘strongly agree’ and ‘agree.’
Our survey found that most VAMCs have encountered CRE
and use the 2017 VA guidelines, following recommendations for initial CRE identification using updated carbapenem break points. Most laboratories helped implement the CRE guidelines, reported being knowledgeable and comfortable with the guidelines, and received guideline training and information. Notably, both low- complexity and rural facilities described being less knowledgeable and reported inadequate local resources for guideline implemen- tation. Low complexity facilities were also less likely to perform on-site confirmatory testing for carbapenemases and were less likely to use PCR for confirmation. This result may reflect low CRE prevalence at these facilities, less knowledge of the guidelines, and/or limited availability of laboratory resources. Overall, lack of onsite PCR testing was one of the most commonly cited barriers to full guideline implementation; only half of facilities confirm CP-CRE using PCR. Some facilities addressed this limitation by sending isolates to other labs; however, this raises issues regarding timeliness of reporting, as evidenced by the fact that more than one-third of facilities reported final confirmation turnaround time >72 hours. Alimitation of this study is that it was conducted within the VA,
and survey respondents and laboratory practices may be different than non-VA hospitals. Furthermore, as with most survey studies, recall bias may have affected the accuracy of respondents’ answers. Our high survey response rate (93%) may have minimized the impact of isolated inaccuracies in survey responses due to recall bias in an individual respondent. In summary, many VA laboratories have experience in identi-
fying CRE, rapidly began following the 2017 VA guidelines, and reported active engagement in guideline implementation.
However, many facilities do not confirm carbapenemases using PCR or send isolates to other laboratories for testing, with most respondents citing limited staffing, training, and financial/labora- tory resources. These barriers must be addressed to support full and successful guideline implementation and to optimize identifi- cation, reporting, and control of CRE.
Author ORCIDs. Margaret A. Fitzpatrick, 0000-0002-1919-9238
Acknowledgements. The authors thank Dr. Michael Lin for guidance with the survey questions. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.
Financial support. This work was supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development Quality Enhancement Research Initiative (grant no. QUE 15-269).
Conflicts of interest. All authors report no conflicts of interest or financial disclosures relevant to this article.
References
1. Xu L, Sun X, Ma X. Systematic review and meta-analysis of mortality of patients infected with carbapenem-resistant Klebsiella pneumoniae. Ann Clin Microbiol Antimicrob 2017;16:18.
2. 2017 Guideline for Control of Carbapenemase-Producing Carbapenem- Resistant Enterobacteriaceae (CP-CRE). Washington, DC: National Infectious Disease Service MDRO Prevention Office, Veterans Health Administration, Department of Veterans Affairs; 2017.
3. Facility Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE): November 2015 Update–CRE Toolkit. Centers for Disease Control
Low (n=42), No. (%)
25 (59.5) 30 (71.4) 24 (60.0) 26 (65)
9 (17.3)
30 (73.2) 28 (68.3) 30 (83.3) 30 (73.2) 19 (46.3) 17 (41.5) 21 (51.2) 19 (46.3) 16 (39.0) 21 (51.2)
P Value
<.01 .16 .05 .03 .01
.23
<.01 .01 .08 .02
<.01 .03 .17 .43 .04
Facility Location
Rural (n=24), No. (%)
19 (79.2) 17 (70.8) 13 (56.5) 15 (65.2) 6 (11.5)
14 (58.3) 16 (66.7) 16 (69.6) 15 (65.2) 10 (43.5) 9 (39.1) 10 (43.5) 6 (26.1) 8 (34.8) 9 (39.1)
Urban (n=96), No. (%)
83 (86.5) 78 (81.3) 72 (75.8) 76 (80.0) 46 (88.5)
81 (85.3) 83 (87.4) 85 (89.5) 82 (86.3) 63 (66.3) 62 (65.3) 67 (70.5) 60 (63.2) 45 (47.4) 67 (70.5)
P Value
.35 .27 .07 .17 .16
.01 .03 .02 .03 .06 .03 .03
<.01 .35
<.01
Note. CRE, carbapenem-resistant Enterobacteriaceae; MIC, minimum inhibitory concentration; IC, infection control; PCR, polymerase chain reaction assay. aNumber of facilities that answered that particular question of the 120 total facilities responding to the survey. Percentages were calculated using the number of facilities responding to a
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