Download Screening suspected cases for carbapenemase

Letters to the Editor
493
References
1. Ortega M, Marco F, Soriano A, Almela M, Martınez JA, Pitart C,
et al. Epidemiology and prognostic determinants of bacteraemic catheter-acquired urinary tract infection in a single institution from 1991 to 2010. J Infect 2013 Oct;67(4):282e7.
2. Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE,
Rice JC, et al. Diagnosis, prevention, and treatment of
catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010;50(5):625e63.
3. Cancer Therapy Evaluation Program. Protocol Development.
Common Terminology Criteria or Adverse Events. http://
ctep.cancer.gov/protocolDevelopment/electronic_
applications/ctc.htm#ctc_40.
4. Trautneret BW, Darouiche RO. Prevention of urinary tract
infection in patients with spinalcord injury. J Spinal Cord
Med 2002;25(4):277e83.
5. Morton SC, Shekelle PG, Adams JL, Bennett C, Dobkin BH,
Montgomerie J, et al. Antimicrobial prophylaxis for urinary
tract infection in persons with spinal cord dysfunction. Arch
Phys Med Rehabil Jan. 2002;83(1):129e38.
€l-Weise BS, van den Broek PJ, da Silva EM, Silva LA. Urinary
6. Nie
catheter policies for long-term bladder drainage. Cochrane Library 2006;3. John Wiley & Sons, Ltd.
Claire Poirier
Antimicrobialstewardship, CH Victor Jousselin, Dreux
Hospital, Dreux, France
Infectious Disease Department, CHRU Bretonneau, University Hospital of Tours, François Rabelais University, Tours,
France
lien Dinh
Aure
ro
^me Salomon
Je
Infectious Disease Department, CHU Raymond Poincare,
University Hospital of Paris, Versailles Saint Quentin University, Garches, France
Nathalie Grall
Antoine Andremont
Microbiology Department, CHU Bichat, University Hospital
of Paris, Denis Diderot University, Paris, France
Louis Bernard*
Infectious Disease Department, CHRU Bretonneau, University Hospital of Tours, François Rabelais University, Tours,
France
*Corresponding author. Infectious Diseases Department, Univer , 37044 Tours, France.
sity Hospital of Tours, 2 Boulevard Tonnelle
Tel.: þ33 (0) 218370644.
E-mail address: [email protected] (L. Bernard)
Accepted 3 June 2015
http://dx.doi.org/10.1016/j.jinf.2015.06.001
ª 2015 The British Infection Association. Published by Elsevier Ltd.
All rights reserved.
Screening suspected cases for
carbapenemase-producing
Enterobacteriaceae, inclusion criteria and
demand
Sir,
Carbapenems are the last resort antibiotics and the
emergence of carbapenemase-producing Enterobacteriaceae (CPE)1 has engendered national toolkits to limit their
spread. These include guidelines from the US Centre of Disease Control2 and the Australian Commission of Safety and
Quality in Health Care.3 In December 2013, Public Health
England (PHE) produced its Toolkit,4 asking each acute hospital in England to screen and isolate at admission each suspected case for CPE. This is stated as “a patient who, in the
last 12 months, has been (a) an inpatient in a hospital
abroad or (b) an inpatient in a UK hospital which has problems with spread of carbapenemase-producing Enterobacteriaceae (if known) or (c) is a ‘previously’ positive case”.
A suspect case should be isolated and tested with three
consecutive tests and de-isolated after the third negative
test. However, there has been no estimation of the number
of tests and isolation beds that implementing the PHE Toolkit in all English acute hospitals would create.
We compare the number of tests and isolation beds that
would be required if the PHE Toolkit were implemented
nationwide vs. an alternative strategy. In this analysis, the
above mentioned inclusion criteria (a) and (b) were
considered for the PHE Toolkit. Admissions to intensive
care, nephrology, cardiothoracic surgery, neurosurgery and
oncology were considered for the alternative. The assumption was that due to their medical conditions, these
admissions are more likely, than other admissions, to
have been previously treated with invasive devices, which
is a risk factor for CPE infection.5e7
Estimates were based on available data. The proportion
of admissions falling under the PHE Toolkit criteria for
testing and isolation was derived from one prevalence
survey carried out by a West London Hospital8 in 2014. According to this survey, in the previous 12 months, 2% of the
admissions “had received healthcare abroad” and 17.4%
“had health care in a London hospital, subsequently identified as a high-risk group” for a total 19.4% suspected cases.
The total NHS admissions in 2013e149 were multiplied by
19.4% to provide the suspected cases according to the
PHE Toolkit. The same NHS data source provided the number of admissions to the key specialties considered by the
alternative screening strategy.
The numbers of tests and isolation days were estimated
according to the PHE Toolkit criteria. Each suspected case
should have received three consecutive tests at “day 0, day
2 and day 4” and should have remained isolated until the
third consecutive negative test. Given the very low prevalence of CPE in the UK, we assume that most suspected
cases would have turned out negative, receiving all the
three consecutive tests and remaining isolated for the five
days required for the tests.
494
Letters to the Editor
Table 1
Demand in tests and isolation beds for CPE screening, NHS, 2013e14.
Inclusion criteria
Suspected
cases
per year
Tests per
year
Isolation days
per year
Daily average
isolation
beds requireda
Proportion of
total daily
bed capacity
in the NHS
PHE Toolkit
Admissions to specialties:
Intensive Care Units (ICU)
ICU þ Nephrology (N)
ICU þ N þ Neurosurgery (NS)
ICU þ N þ NS þ Cardiothoracic
Surgery (CS)
ICU þ N þ NS þ CS þ Oncology
2,999,639
5,999,278
8,998,917
24,655
5.89%
13,763
149,266
233,007
295,357
27,526
298,532
466,014
590,714
41,289
447,798
699,021
886,071
113
1227
1915
2428
0.03%
0.29%
0.46%
0.58%
914,589
1,829,178
2,743,767
7517
1.80%
a
The average isolation beds per day was obtained by dividing the total isolation days by 365 (days in a year).
However, not all suspected cases would have remained
hospitalised for the required five days. The hospital average
and median length of stay in 2013e14 were five days and one
day respectively,9 meaning that half of the patients were discharged after one day. Therefore, the demand for tests and
isolation days was based on the assumption that half of the suspected cases would have received one test and would have
contributed to one isolation day, with the other half receiving
three tests and remaining isolated for five days. The total number of isolation days were divided by 365 (days in a year) to
provide the required average daily number of isolation beds.
Table 1 provides the expected number of tests and isolation beds that would have been required in 2013e14 if the
screening had been implemented nationwide. The PHE Toolkit would have identified about 3 million suspected cases,
requiring a total of 6 million tests and a daily average of
24,655 isolation beds. The second to the fifth row of Table
1 shows the demand in tests and isolation beds for the alternative strategy, starting with just the ICU admissions, adding
up the Nephrology ones, and so on until all the key specialties
were included. Depending on the number of specialties to be
included, the annual number of suspected cases would have
varied between 13,763 and 0.9 million, requiring between
27,526 and 1.8 million tests per year, and needing a daily
average between 113 and 7517 isolation beds.
As the NHS data does not provide the national availability of isolation beds, we have estimated the proportion of
the total available beds that would have been occupied by
the suspected cases. In 2013e14, there was a daily average
of 418,323 overnight beds in all acute hospitals,10 with a
daily average occupancy rate of 88%. The isolation beds
would have accounted to 5.9% of the total NHS bed capacity
if the PHE Toolkit had been applied, versus 0.03%e1.8% for
the alternative screening.
These results suggest that screening the admissions to
specialties at risk have several advantages. Even including
all the specialties considered in this analysis, the alternative strategy would have accounted for less than one-third
of the demand required by the PHE Toolkit criteria. It is
conceivable that targeting key specialties at risk would
have also generated higher detection and lower false
positivity rates because of their likely higher CPE prevalence. Screening admissions to key specialties are also
clearer in terms of defining suspected cases and are more
flexible in terms of expanding the number of specialties to
be included according to capacity.
The limitations are inevitable and help to identify the
gaps. These include only one prevalence survey to estimate
the size of the target groups envisaged by the PHR Toolkit.
No CPE prevalence rates by specialty to estimate the
incremental diagnostic yield compared with the PHE Toolkit
criteria. No percentile distributions of the length stay to
provide a better estimate of the demand in tests and
isolation beds. No national estimates of available isolation
beds and no test turnaround time to check capacity.
However, notwithstanding these limitations, the estimates
are based on reasonable assumptions and are unlikely to be
very far off-track. With due modifications, the method used
in this analysis can provide a sound basis to estimate the
demand for CPE screening in other countries.
Conflicts of interest
The authors do not have conflicts of interest
Acknowledgment
The research was funded by the National Institute for
Health Research Health Protection Research Unit (NIHR
HPRU) in Healthcare Associated Infection and Antimicrobial
Resistance at Imperial College London in partnership with
Public Health England (PHE). The views expressed are those
of the author(s) and not necessarily those of the NHS, the
NIHR, the Department of Health or Public Health England.
References
1. Munoz-Price LS, Quinn JP. Deconstructing the infection control
bundles for the containment of carbapenem-resistant Enterobacteriaceae. Curr Opin Infect Dis 2013 Aug;26(4):378e87.
http://dx.doi.org/10.1097/01.qco.0000431853.
71500.77. Review. PubMed PMID: 23806900.
2. Guidance for control of carbapenem-resistant Enterobacteriaceae (CRE) e 2012 CRE Tollkit. CDC; 2012 http://www.cdc.
gov/hai/pdfs/cre/CRE-guidance-508.pdf.
3. Australian Commission on Safety and Quality in Health Care.
Recommendations for the control of multi-drug resistant
Letters to the Editor
4.
5.
6.
7.
8.
9.
10.
Gram-negatives: carbapenem resistant Enterobacteriaceae
(October 2013). Sydney: ACSQHC; 2013 http://www.
safetyandquality.gov.au/wp-content/uploads/2013/12/MRGNGuide-Enterobacteriaceae-PDF-1.89MB.pdf.
PHE publications gateway number: 2013314. London Acute trust
toolkit for the early detection management and control of carbapenemase producing Enterobacteriaceae. December 2013
https://www.gov.uk/government/publications/carbapene
mase-producing-enterobacteriaceae-early-detectionmanagement-and-control-toolkit-for-acute-trusts.
Jacobsen SM, Stickler DJ, Mobley HL, Shirtliff ME. Complicated
catheter-associated urinary tract infections due to Escherichia
coli and Proteus mirabilis. Clin Microbiol Rev 2008 Jan;21(1):
26e59. http://dx.doi.org/10.1128/CMR.00019-07. Review.
PubMed PMID: 18202436; PubMed Central PMCID: PMC2223845.
Jones RN. Microbial etiologies of hospital-acquired bacterial
pneumonia and ventilator-associated bacterial pneumonia.
Clin Infect Dis 2010 Aug 1;51(Suppl 1):S81e7. http:
//dx.doi.org/10.1086/653053. Review. Erratum in: Clin Infect
Dis. 2010 Nov 1;51(9):1114. PubMed PMID: 20597676.
European Centre for Disease Prevention and Control. Risk
assessment on the spread of carbapenemase-producing Enterobacteriaceae (CPE) through patient transfer between healthcare facilities, with special emphasis on cross-border transfer.
Stockholm:
ECDC;
2011
http://ecdc.europa.eu/en/
publications/Publications/110913_Risk_assessment_resistant_
CPE.pdf.
Scott J, Mack D. Assessing the burden of carbapenemaseproducing organisms from interhospital patient transfers and
from patients receiving healthcare abroad. Abstracts published
at Infection Prevention 2014, Glasgow J Infect Prev 2014;15:S4
http://bji.sagepub.com/content/15/1_suppl/S3.full.
Hospital Episode Statistics, Admitted Patient Care, England e
2013e14 [NS] Publication date: January 28, 2015 http://www.
hscic.gov.uk/searchcatalogue?productidZ17192&qZ201314&topicsZ0%2fHospitalþcare&sortZRelevance&sizeZ10&
pageZ1#top.
Beds availability and occupancy data overnight. NHS England
https://www.england.nhs.uk/statistics/category/statistics/
beds/.
Vella Venanzio*
Myriam Gharbi
Luke S.P. Moore
Health Protection Research Unit in Healthcare Associated
Infections and Antimicrobial Resistance, Imperial College
London, Hammersmith Campus, Du Cane Road, London W12
0NN, United Kingdom
Julie Robotham
Modelling and Economics Unit, Public Health England,
London NW9 5EQ, United Kingdom
E-mail address: [email protected] (J. Robotham)
Frances Davies
Eimear Brannigan
Tracey Galletly
Imperial College Healthcare NHS Trust, Hammersmith
Hospital, Du Cane Road, London W12 0HS, United Kingdom
E-mail addresses: [email protected] (F. Davies), [email protected] (E. Brannigan),
[email protected] (T. Galletly)
Alison H. Holmes
Health Protection Research Unit in Healthcare Associated
Infections and Antimicrobial Resistance, Imperial College
495
London, Hammersmith Campus, Du Cane Road, London W12
0NN, United Kingdom
E-mail address: [email protected] (A.H.
Holmes)
*Corresponding author. Imperial College, Department of Infectious Diseases and Immunity, 8th floor Commonwealth Building,
Hammersmith Hospital, Du Cane Road, London W12 0NN, United
Kingdom. Tel.: þ44 (0)2033132732; fax: þ44 (0)2083833394.
E-mail addresses: [email protected] (V. Venanzio),
[email protected] (M. Gharbi), [email protected] (L.S.P. Moore)
Accepted 3 June 2015
http://dx.doi.org/10.1016/j.jinf.2015.06.002
ª 2015 The British Infection Association. Published by Elsevier Ltd.
All rights reserved.
Response to Hepatitis B virus
vaccine in young adults with
perinatally acquired HIV infection
Dear Editor,
We read with interest the article by Rowley et al.1 in
this journal, in which they described the determinants of
serological response to booster vaccination with hepatitis
B virus (HBV) vaccine in HIV-infected non-responders. We
now describe data to complement their study, in which
we investigated the influence of vaccine dosing interval
and other immunological determinants of response to the
primary series of HBV vaccine in HIV-infected adolescents
and young adults.
HBV infection is a major public health problem worldwide, despite the availability of an effective vaccine.
Individuals with HIV are at greater risk of acquiring HBV
and HIV/HBV co-infection has worse outcomes than HBV
mono-infection.2 HBV vaccination is not currently included
in the routine UK childhood immunisation schedule. The
2013 British HIV Association (BHIVA) guidelines recommend
HBV vaccination of all HIV-infected individuals with 4 doses
of double-dose vaccine (40mcg per dose) at 0, 1, 2 and 6
months with a check of the antibody level 4e8 weeks after
the 4th dose.3 A successful vaccine response is indicated by
an HBV surface Ag-specific antibody level >10 IU/L, and a
level >100 IU/L is considered ideal.4 Previous recommendations5 advocated either a 3-dose schedule at 0, 1 and 6
months or a 4-dose schedule at 0, 1, 2, 12 months using a
standard dose (20mcg per dose). Successfully achieving
these specific dosing intervals requires optimal attendance,
and is a challenge for adolescents and young adults where
clinic attendance maybe less regular than for younger children or older adults.6 Pragmatic management of such
erratic attenders has been to offer opportunistic vaccination at irregular intervals; however effects on vaccine