- 作者：Lennie P G Derde ; Ben S Cooper ; Herman Goossens ; Surbhi Malhotra-Kumar ; Rob J L Willems ; Marek Gniadkowski ; Waleria Hryniewicz ; Joanna Empel ; Mirjam J D Dautzenberg ; Djillali Annane ; Irene Arag茫o ; Annie Chalfine ; Uga Dumpis ; Francisco Esteves ; Helen Giamarellou ; Igor Muzlovic ; Giuseppe Nardi ; George L Petrikkos ; Viktorija Tomic ; Antonio Torres Mart铆 ; et al.
- 刊名：The Lancet Infectious Diseases
- 出版年：January, 2014
- 年：2014
- 卷：14
- 期：1
- 页码：31-39
- 全文大小：375 K
Summary
Background
Intensive care units (ICUs) are high-risk areas for transmission of antimicrobial-resistant bacteria, but no controlled study has tested the effect of rapid screening and isolation of carriers on transmission in settings with best-standard precautions. We assessed interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in European ICUs.Methods
We did this study in three phases at 13 ICUs. After a 6 month baseline period (phase 1), we did an interrupted time series study of universal chlorhexidine body-washing combined with hand hygiene improvement for 6 months (phase 2), followed by a 12-15 month cluster randomised trial (phase 3). ICUs were randomly assigned by computer generated randomisation schedule to either conventional screening (chromogenic screening for meticillin-resistant <em>Staphylococcus aureusem> [MRSA] and vancomycin-resistant enterococci [VRE]) or rapid screening (PCR testing for MRSA and VRE and chromogenic screening for highly resistant Enterobacteriaceae [HRE]); with contact precautions for identified carriers. The primary outcome was acquisition of resistant bacteria per 100 patient-days at risk, for which we calculated step changes and changes in trends after the introduction of each intervention. We assessed acquisition by microbiological surveillance and analysed it with a multilevel Poisson segmented regression model. We compared screening groups with a likelihood ratio test that combined step changes and changes to trend. This study is registered with , number .
Findings
Seven ICUs were assigned to rapid screening and six to conventional screening. Mean hand hygiene compliance improved from 52% in phase 1 to 69% in phase 2, and 77% in phase 3. Median proportions of patients receiving chlorhexidine body-washing increased from 0% to 100% at the start of phase 2. For trends in acquisition of antimicrobial-resistant bacteria, weekly incidence rate ratio (IRR) was 0路976 (0路954-0路999) for phase 2 and 1路015 (0路998-1路032) for phase 3. For step changes, weekly IRR was 0路955 (0路676-1路348) for phase 2 and 0路634 (0路349-1路153) for phase 3. The decrease in trend in phase 2 was largely caused by changes in acquisition of MRSA (weekly IRR 0路925, 95% CI 0路890-0路962). Acquisition was lower in the conventional screening group than in the rapid screening group, but did not differ significantly (p=0路06).
Interpretation
Improved hand hygiene plus unit-wide chlorhexidine body-washing reduced acquisition of antimicrobial-resistant bacteria, particularly MRSA. In the context of a sustained high level of compliance to hand hygiene and chlorhexidine bathings, screening and isolation of carriers do not reduce acquisition rates of multidrug-resistant bacteria, whether or not screening is done with rapid testing or conventional testing.
Funding
European Commission.