Hayden Mary K, Lin Michael Y, Lolans Karen, Weiner Shayna, Blom Donald, Moore Nicholas M, Fogg Louis, Henry David, Lyles Rosie, Thurlow Caroline, Sikka Monica, Hines David, Weinstein Robert A
Departments of Medicine, Division of Infectious Diseases Pathology.
Departments of Medicine, Division of Infectious Diseases.
Clin Infect Dis. 2015 Apr 15;60(8):1153-61. doi: 10.1093/cid/ciu1173. Epub 2014 Dec 23.
Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae (hereafter "KPC") are an increasing threat to healthcare institutions. Long-term acute-care hospitals (LTACHs) have especially high prevalence of KPC.
Using a stepped-wedge design, we tested whether a bundled intervention (screening patients for KPC rectal colonization upon admission and every other week; contact isolation and geographic separation of KPC-positive patients in ward cohorts or single rooms; bathing all patients daily with chlorhexidine gluconate; and healthcare-worker education and adherence monitoring) would reduce colonization and infection due to KPC in 4 LTACHs with high endemic KPC prevalence. The study was conducted between 1 February 2010 and 30 June 2013; 3894 patients were enrolled during the preintervention period (lasting from 16 to 29 months), and 2951 patients were enrolled during the intervention period (lasting from 12 to 19 months).
KPC colonization prevalence was stable during preintervention (average, 45.8%; 95% confidence interval [CI], 42.1%-49.5%), declined early during intervention, then reached a plateau (34.3%; 95% CI, 32.4%-36.2%; P<.001 for exponential decline). During intervention, KPC admission prevalence remained high (average, 20.6%, 95% CI, 19.1%-22.3%). The incidence rate of KPC colonization fell during intervention, from 4 to 2 acquisitions per 100 patient-weeks (P=.004 for linear decline). Compared to preintervention, average rates of clinical outcomes declined during intervention: KPC in any clinical culture (3.7 to 2.5/1000 patient-days; P=.001), KPC bacteremia (0.9 to 0.4/1000 patient-days; P=.008), all-cause bacteremia (11.2 to 7.6/1000 patient-days; P=.006) and blood culture contamination (4.9 to 2.3/1000 patient-days; P=.03).
A bundled intervention was associated with clinically important and statistically significant reductions in KPC colonization, KPC infection, all-cause bacteremia, and blood culture contamination in a high-risk LTACH population.
产肺炎克雷伯菌碳青霉烯酶的肠杆菌科细菌（以下简称“KPC”）对医疗机构的威胁日益增加。长期急性病医院（LTACHs）中KPC的患病率尤其高。
采用阶梯楔形设计，我们测试了一项综合干预措施（入院时及每隔一周对患者进行KPC直肠定植筛查；对KPC阳性患者在病房队列或单人房间进行接触隔离和空间分隔；每天用葡萄糖酸氯己定给所有患者洗澡；以及对医护人员进行教育并监测其依从性）是否会降低4所KPC高流行的LTACHs中KPC的定植和感染情况。该研究于2010年2月1日至2013年6月30日进行；在干预前期（持续16至29个月）纳入3894例患者，在干预期（持续12至19个月）纳入2951例患者。
在干预前期，KPC定植患病率稳定（平均为45.8%；95%置信区间[CI]，42.1%-49.5%），在干预早期下降，然后达到平台期（34.3%；95%CI，32.4%-36.2%；指数下降，P<.001）。在干预期，KPC入院患病率仍然很高（平均为20.6%，95%CI，19.1%-22.3%）。KPC定植的发生率在干预期下降，从每100患者周4例降至2例（线性下降，P=.004）。与干预前期相比，干预期间临床结局的平均发生率下降：任何临床培养中KPC（从3.7/1000患者日降至2.5/1000患者日；P=.001）、KPC菌血症（从0.9/1000患者日降至0.4/1000患者日；P=.008）、全因菌血症（从11.2/1000患者日降至7.6/1000患者日；P=.006）和血培养污染（从4.9/1000患者日降至2.3/1000患者日；P=.03）。
在高风险的LTACH人群中，综合干预措施与KPC定植、KPC感染、全因菌血症和血培养污染在临床上的显著降低以及统计学上的显著减少相关。
