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Interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in intensive care units: An interrupted time series study and cluster randomised trial

机译：减少重症监护病房中抗药性细菌定居和传播的干预措施：中断时间序列研究和整群随机试验

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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 Staphylococcus aureus [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 ClinicalTrials.gov, number NCT00976638. 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 0·976 (0·954-0·999) for phase 2 and 1·015 (0·998-1·032) for phase 3. For step changes, weekly IRR was 0·955 (0·676-1·348) for phase 2 and 0·634 (0·349-1·153) for phase 3. The decrease in trend in phase 2 was largely caused by changes in acquisition of MRSA (weekly IRR 0·925, 95% CI 0·890-0·962). Acquisition was lower in the conventional screening group than in the rapid screening group, but did not differ significantly (p=0·06). 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. © 2014 Derde et al. Open Access article distributed under the terms of CC BY-NC-SA.
机译：背景：重症监护病房（ICUs）是耐药菌传播的高风险区域，但尚无对照研究以最佳标准的预防措施测试了快速筛选和隔离携带者对传播的影响。我们评估了减少欧洲重症监护病房中抗药性细菌定植和传播的干预措施。方法：我们在13个ICU上分三个阶段进行了这项研究。在6个月的基线期（第1阶段）之后，我们进行了一个中断时间序列研究，研究了普遍的洗必泰洗手结合改善手部卫生状况的情况（第2阶段），然后进行了12-15个月的整群随机试验（第3阶段） ）。通过计算机生成的随机化安排将ICU随机分配至常规筛查（对耐甲氧西林金黄色葡萄球菌[MRSA]和耐万古霉素的肠球菌[VRE]进行显色筛查）或快速筛查（针对MRSA和VRE的PCR检测以及对高耐药性进行发色筛查肠杆菌科[HRE]）；以及针对已识别承运人的接触预防措施。主要结局是每100个患者-天有风险获得抗药性细菌，为此我们计算了每次干预后的步长变化和趋势变化。我们通过微生物监测评估了采集，并使用多层Poisson分段回归模型对其进行了分析。我们将筛查组与似然比检验进行了比较，该检验结合了步骤变化和趋势变化。该研究已在ClinicalTrials.gov上注册，编号为NCT00976638。结果：七个ICU被分配到快速筛查，六个被分配到常规筛查。平均手卫生依从性从第一阶段的52％提高到第二阶段的69％，第三阶段达到77％。在第二阶段开始时，接受洗必泰沐浴液清洗的患者的中位数比例从0％增加到100％。在获取抗药性细菌时，第二阶段的每周发生率比（IRR）为0·976（0·954-0·999），第三阶段为1·015（0·998-1·032）。变化，阶段2的每周IRR为0·955（0·676-1·348），阶段3的每周IRR为0·634（0·349-1·153）。阶段2趋势的下降主要是由于收购MRSA（每周内部收益率0·925，95％CI 0·890-0·962）。常规筛查组的获取率低于快速筛查组，但差异无统计学意义（p = 0·06）。解释：改善手部卫生并进行全单位洗必泰洗手，减少了对抗菌素耐药细菌（尤其是MRSA）的获取。在持续高度遵守手部卫生和洗必泰沐浴的背景下，无论是否通过快速检测或常规检测进行筛查，携带者的筛查和隔离都不会降低耐多药细菌的获取率。资金来源：欧盟委员会。 ©2014 Derde等。根据CC BY-NC-SA条款分发的Open Access文章。

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