Description of the included studies
From the total of included studies, 15 correspond to interrupted time series
20- Baek EH
- Kim SE
- Kim S
- et al.
Successful control of an extended-spectrum beta-lactamase-producing Klebsiella pneumoniae ST307 outbreak in a neonatal intensive care unit.
, 21- Ben-David D
- Maor Y
- Keller N
- et al.
Potential role of active surveillance in the control of a hospital-wide outbreak of carbapenem-resistant Klebsiella pneumoniae infection.
, 22- Borer A
- Eskira S
- Nativ R
- et al.
A multifaceted intervention strategy for eradication of a hospital-wide outbreak caused by carbapenem-resistant Klebsiella pneumoniae in Southern Israel.
, 23- Ciobotaro P
- Oved M
- Nadir E
- Bardenstein R
- Zimhony O.
An effective intervention to limit the spread of an epidemic carbapenem-resistant Klebsiella pneumoniae strain in an acute care setting: from theory to practice.
, 24- Gagliotti C
- Cappelli V
- Carretto E
- et al.
Control of carbapenemase-producing Klebsiella pneumoniae: a region-wide intervention.
, 25- Geladari A
- Karampatakis T
- Antachopoulos C
- et al.
Epidemiological surveillance of multidrug-resistant gram-negative bacteria in a solid organ transplantation department.
, 26- Goto M
- O'Shea AMJ
- Livorsi DJ
- et al.
The effect of a nationwide infection control program expansion on hospital-onset gram-negative rod bacteremia in 130 veterans health administration medical centers: an interrupted time-series analysis.
, 27- Hayden MK
- Lin MY
- Lolans K
- et al.
Prevention of colonization and infection by Klebsiella pneumoniae carbapenemase-producing enterobacteriaceae in long-term acute-care hospitals.
, 28- Kousouli E
- Zarkotou O
- Politi L
- et al.
Infection control interventions affected by resource shortages: impact on the incidence of bacteremias caused by carbapenem-resistant pathogens.
, 29- Li M
- Wang X
- Wang J
- et al.
Infection-prevention and control interventions to reduce colonisation and infection of intensive care unit-acquired carbapenem-resistant Klebsiella pneumoniae: a 4-year quasi-experimental before-and-after study.
, 30- Li S
- Guo FZ
- Zhao XJ
- et al.
Impact of individualised active surveillance of carbapenem-resistant enterobacteriaceae on the infection rate in intensive care units: a 3-year retrospective study in a teaching hospital of People's Republic of China.
, 31- Nagao M
- Iinuma Y
- Igawa J
- et al.
Control of an outbreak of carbapenem-resistant Pseudomonas aeruginosa in a haemato-oncology unit.
, 32- Otter JA
- Mookerjee S
- Davies F
- et al.
Detecting carbapenemase-producing Enterobacterales (CPE): an evaluation of an enhanced CPE infection control and screening programme in acute care.
, 33- Spyridopoulou K
- Psichogiou M
- Sypsa V
- et al.
Containing Carbapenemase-producing Klebsiella pneumoniae in an endemic setting.
, 34- Valencia-Martín R
- Gonzalez-Galan V
- Alvarez-Marín R
- et al.
baumannii eradication program. A multimodal intervention program to control a long-term Acinetobacter baumannii endemic in a tertiary care hospital.
and one to a controlled before-after study.
35- Viale P
- Tumietto F
- Giannella M
- et al.
Impact of a hospital-wide multifaceted programme for reducing carbapenem-resistant Enterobacteriaceae infections in a large teaching hospital in northern Italy.
Most studies were conducted in tertiary care general hospitals from the United States, Europe, and Asia, and included adult patients hospitalized on general wards and intensive care units. One study was carried out in a neonatal intensive care unit (NICU),
20- Baek EH
- Kim SE
- Kim S
- et al.
Successful control of an extended-spectrum beta-lactamase-producing Klebsiella pneumoniae ST307 outbreak in a neonatal intensive care unit.
two in hematology or oncology units,
31- Nagao M
- Iinuma Y
- Igawa J
- et al.
Control of an outbreak of carbapenem-resistant Pseudomonas aeruginosa in a haemato-oncology unit.
,33- Spyridopoulou K
- Psichogiou M
- Sypsa V
- et al.
Containing Carbapenemase-producing Klebsiella pneumoniae in an endemic setting.
and one in a Solid Organ Transplantation Department.
25- Geladari A
- Karampatakis T
- Antachopoulos C
- et al.
Epidemiological surveillance of multidrug-resistant gram-negative bacteria in a solid organ transplantation department.
Most studies (n=11 68.75%) were conducted in the setting of an outbreak.
Eleven studies (68.75%) assessed screening strategies to detect CRE alone,
20- Baek EH
- Kim SE
- Kim S
- et al.
Successful control of an extended-spectrum beta-lactamase-producing Klebsiella pneumoniae ST307 outbreak in a neonatal intensive care unit.
, 21- Ben-David D
- Maor Y
- Keller N
- et al.
Potential role of active surveillance in the control of a hospital-wide outbreak of carbapenem-resistant Klebsiella pneumoniae infection.
, 22- Borer A
- Eskira S
- Nativ R
- et al.
A multifaceted intervention strategy for eradication of a hospital-wide outbreak caused by carbapenem-resistant Klebsiella pneumoniae in Southern Israel.
, 23- Ciobotaro P
- Oved M
- Nadir E
- Bardenstein R
- Zimhony O.
An effective intervention to limit the spread of an epidemic carbapenem-resistant Klebsiella pneumoniae strain in an acute care setting: from theory to practice.
, 24- Gagliotti C
- Cappelli V
- Carretto E
- et al.
Control of carbapenemase-producing Klebsiella pneumoniae: a region-wide intervention.
,27- Hayden MK
- Lin MY
- Lolans K
- et al.
Prevention of colonization and infection by Klebsiella pneumoniae carbapenemase-producing enterobacteriaceae in long-term acute-care hospitals.
,29- Li M
- Wang X
- Wang J
- et al.
Infection-prevention and control interventions to reduce colonisation and infection of intensive care unit-acquired carbapenem-resistant Klebsiella pneumoniae: a 4-year quasi-experimental before-and-after study.
,30- Li S
- Guo FZ
- Zhao XJ
- et al.
Impact of individualised active surveillance of carbapenem-resistant enterobacteriaceae on the infection rate in intensive care units: a 3-year retrospective study in a teaching hospital of People's Republic of China.
,32- Otter JA
- Mookerjee S
- Davies F
- et al.
Detecting carbapenemase-producing Enterobacterales (CPE): an evaluation of an enhanced CPE infection control and screening programme in acute care.
,33- Spyridopoulou K
- Psichogiou M
- Sypsa V
- et al.
Containing Carbapenemase-producing Klebsiella pneumoniae in an endemic setting.
,35- Viale P
- Tumietto F
- Giannella M
- et al.
Impact of a hospital-wide multifaceted programme for reducing carbapenem-resistant Enterobacteriaceae infections in a large teaching hospital in northern Italy.
one study (6.25%) assessed CRAB alone,
34- Valencia-Martín R
- Gonzalez-Galan V
- Alvarez-Marín R
- et al.
baumannii eradication program. A multimodal intervention program to control a long-term Acinetobacter baumannii endemic in a tertiary care hospital.
one study (6.25%) assessed CRPA alone,
31- Nagao M
- Iinuma Y
- Igawa J
- et al.
Control of an outbreak of carbapenem-resistant Pseudomonas aeruginosa in a haemato-oncology unit.
one study (6.25%) assessed CRE and CRPA,
26- Goto M
- O'Shea AMJ
- Livorsi DJ
- et al.
The effect of a nationwide infection control program expansion on hospital-onset gram-negative rod bacteremia in 130 veterans health administration medical centers: an interrupted time-series analysis.
and 2 studies (12.5%) assessed CRE, CRAB and CRPA.
25- Geladari A
- Karampatakis T
- Antachopoulos C
- et al.
Epidemiological surveillance of multidrug-resistant gram-negative bacteria in a solid organ transplantation department.
,28- Kousouli E
- Zarkotou O
- Politi L
- et al.
Infection control interventions affected by resource shortages: impact on the incidence of bacteremias caused by carbapenem-resistant pathogens.
Regarding outcomes, all studies reported colonization or infection (details and definitions available in
Appendix D).
20- Baek EH
- Kim SE
- Kim S
- et al.
Successful control of an extended-spectrum beta-lactamase-producing Klebsiella pneumoniae ST307 outbreak in a neonatal intensive care unit.
, 21- Ben-David D
- Maor Y
- Keller N
- et al.
Potential role of active surveillance in the control of a hospital-wide outbreak of carbapenem-resistant Klebsiella pneumoniae infection.
, 22- Borer A
- Eskira S
- Nativ R
- et al.
A multifaceted intervention strategy for eradication of a hospital-wide outbreak caused by carbapenem-resistant Klebsiella pneumoniae in Southern Israel.
, 23- Ciobotaro P
- Oved M
- Nadir E
- Bardenstein R
- Zimhony O.
An effective intervention to limit the spread of an epidemic carbapenem-resistant Klebsiella pneumoniae strain in an acute care setting: from theory to practice.
, 24- Gagliotti C
- Cappelli V
- Carretto E
- et al.
Control of carbapenemase-producing Klebsiella pneumoniae: a region-wide intervention.
, 25- Geladari A
- Karampatakis T
- Antachopoulos C
- et al.
Epidemiological surveillance of multidrug-resistant gram-negative bacteria in a solid organ transplantation department.
, 26- Goto M
- O'Shea AMJ
- Livorsi DJ
- et al.
The effect of a nationwide infection control program expansion on hospital-onset gram-negative rod bacteremia in 130 veterans health administration medical centers: an interrupted time-series analysis.
, 27- Hayden MK
- Lin MY
- Lolans K
- et al.
Prevention of colonization and infection by Klebsiella pneumoniae carbapenemase-producing enterobacteriaceae in long-term acute-care hospitals.
, 28- Kousouli E
- Zarkotou O
- Politi L
- et al.
Infection control interventions affected by resource shortages: impact on the incidence of bacteremias caused by carbapenem-resistant pathogens.
, 29- Li M
- Wang X
- Wang J
- et al.
Infection-prevention and control interventions to reduce colonisation and infection of intensive care unit-acquired carbapenem-resistant Klebsiella pneumoniae: a 4-year quasi-experimental before-and-after study.
, 30- Li S
- Guo FZ
- Zhao XJ
- et al.
Impact of individualised active surveillance of carbapenem-resistant enterobacteriaceae on the infection rate in intensive care units: a 3-year retrospective study in a teaching hospital of People's Republic of China.
, 31- Nagao M
- Iinuma Y
- Igawa J
- et al.
Control of an outbreak of carbapenem-resistant Pseudomonas aeruginosa in a haemato-oncology unit.
, 32- Otter JA
- Mookerjee S
- Davies F
- et al.
Detecting carbapenemase-producing Enterobacterales (CPE): an evaluation of an enhanced CPE infection control and screening programme in acute care.
, 33- Spyridopoulou K
- Psichogiou M
- Sypsa V
- et al.
Containing Carbapenemase-producing Klebsiella pneumoniae in an endemic setting.
, 34- Valencia-Martín R
- Gonzalez-Galan V
- Alvarez-Marín R
- et al.
baumannii eradication program. A multimodal intervention program to control a long-term Acinetobacter baumannii endemic in a tertiary care hospital.
, 35- Viale P
- Tumietto F
- Giannella M
- et al.
Impact of a hospital-wide multifaceted programme for reducing carbapenem-resistant Enterobacteriaceae infections in a large teaching hospital in northern Italy.
Two studies reported all-cause mortality
27- Hayden MK
- Lin MY
- Lolans K
- et al.
Prevention of colonization and infection by Klebsiella pneumoniae carbapenemase-producing enterobacteriaceae in long-term acute-care hospitals.
,30- Li S
- Guo FZ
- Zhao XJ
- et al.
Impact of individualised active surveillance of carbapenem-resistant enterobacteriaceae on the infection rate in intensive care units: a 3-year retrospective study in a teaching hospital of People's Republic of China.
and 4 studies reported length of hospital stay.
26- Goto M
- O'Shea AMJ
- Livorsi DJ
- et al.
The effect of a nationwide infection control program expansion on hospital-onset gram-negative rod bacteremia in 130 veterans health administration medical centers: an interrupted time-series analysis.
,27- Hayden MK
- Lin MY
- Lolans K
- et al.
Prevention of colonization and infection by Klebsiella pneumoniae carbapenemase-producing enterobacteriaceae in long-term acute-care hospitals.
,28- Kousouli E
- Zarkotou O
- Politi L
- et al.
Infection control interventions affected by resource shortages: impact on the incidence of bacteremias caused by carbapenem-resistant pathogens.
,30- Li S
- Guo FZ
- Zhao XJ
- et al.
Impact of individualised active surveillance of carbapenem-resistant enterobacteriaceae on the infection rate in intensive care units: a 3-year retrospective study in a teaching hospital of People's Republic of China.
None of the included studies reported an economic analysis.
Two studies assessed the effect of screening strategies alone
30- Li S
- Guo FZ
- Zhao XJ
- et al.
Impact of individualised active surveillance of carbapenem-resistant enterobacteriaceae on the infection rate in intensive care units: a 3-year retrospective study in a teaching hospital of People's Republic of China.
,32- Otter JA
- Mookerjee S
- Davies F
- et al.
Detecting carbapenemase-producing Enterobacterales (CPE): an evaluation of an enhanced CPE infection control and screening programme in acute care.
and 14 studies assessed the effect of screening strategies as part of a multimodal intervention to detect carbapenem-resistant gram-negative bacteria.
20- Baek EH
- Kim SE
- Kim S
- et al.
Successful control of an extended-spectrum beta-lactamase-producing Klebsiella pneumoniae ST307 outbreak in a neonatal intensive care unit.
, 21- Ben-David D
- Maor Y
- Keller N
- et al.
Potential role of active surveillance in the control of a hospital-wide outbreak of carbapenem-resistant Klebsiella pneumoniae infection.
, 22- Borer A
- Eskira S
- Nativ R
- et al.
A multifaceted intervention strategy for eradication of a hospital-wide outbreak caused by carbapenem-resistant Klebsiella pneumoniae in Southern Israel.
, 23- Ciobotaro P
- Oved M
- Nadir E
- Bardenstein R
- Zimhony O.
An effective intervention to limit the spread of an epidemic carbapenem-resistant Klebsiella pneumoniae strain in an acute care setting: from theory to practice.
, 24- Gagliotti C
- Cappelli V
- Carretto E
- et al.
Control of carbapenemase-producing Klebsiella pneumoniae: a region-wide intervention.
, 25- Geladari A
- Karampatakis T
- Antachopoulos C
- et al.
Epidemiological surveillance of multidrug-resistant gram-negative bacteria in a solid organ transplantation department.
, 26- Goto M
- O'Shea AMJ
- Livorsi DJ
- et al.
The effect of a nationwide infection control program expansion on hospital-onset gram-negative rod bacteremia in 130 veterans health administration medical centers: an interrupted time-series analysis.
, 27- Hayden MK
- Lin MY
- Lolans K
- et al.
Prevention of colonization and infection by Klebsiella pneumoniae carbapenemase-producing enterobacteriaceae in long-term acute-care hospitals.
, 28- Kousouli E
- Zarkotou O
- Politi L
- et al.
Infection control interventions affected by resource shortages: impact on the incidence of bacteremias caused by carbapenem-resistant pathogens.
, 29- Li M
- Wang X
- Wang J
- et al.
Infection-prevention and control interventions to reduce colonisation and infection of intensive care unit-acquired carbapenem-resistant Klebsiella pneumoniae: a 4-year quasi-experimental before-and-after study.
,31- Nagao M
- Iinuma Y
- Igawa J
- et al.
Control of an outbreak of carbapenem-resistant Pseudomonas aeruginosa in a haemato-oncology unit.
,33- Spyridopoulou K
- Psichogiou M
- Sypsa V
- et al.
Containing Carbapenemase-producing Klebsiella pneumoniae in an endemic setting.
, 34- Valencia-Martín R
- Gonzalez-Galan V
- Alvarez-Marín R
- et al.
baumannii eradication program. A multimodal intervention program to control a long-term Acinetobacter baumannii endemic in a tertiary care hospital.
, 35- Viale P
- Tumietto F
- Giannella M
- et al.
Impact of a hospital-wide multifaceted programme for reducing carbapenem-resistant Enterobacteriaceae infections in a large teaching hospital in northern Italy.
Multimodal interventions to control infection in addition to detection strategies were used in all studies,
20- Baek EH
- Kim SE
- Kim S
- et al.
Successful control of an extended-spectrum beta-lactamase-producing Klebsiella pneumoniae ST307 outbreak in a neonatal intensive care unit.
, 21- Ben-David D
- Maor Y
- Keller N
- et al.
Potential role of active surveillance in the control of a hospital-wide outbreak of carbapenem-resistant Klebsiella pneumoniae infection.
, 22- Borer A
- Eskira S
- Nativ R
- et al.
A multifaceted intervention strategy for eradication of a hospital-wide outbreak caused by carbapenem-resistant Klebsiella pneumoniae in Southern Israel.
, 23- Ciobotaro P
- Oved M
- Nadir E
- Bardenstein R
- Zimhony O.
An effective intervention to limit the spread of an epidemic carbapenem-resistant Klebsiella pneumoniae strain in an acute care setting: from theory to practice.
, 24- Gagliotti C
- Cappelli V
- Carretto E
- et al.
Control of carbapenemase-producing Klebsiella pneumoniae: a region-wide intervention.
, 25- Geladari A
- Karampatakis T
- Antachopoulos C
- et al.
Epidemiological surveillance of multidrug-resistant gram-negative bacteria in a solid organ transplantation department.
, 26- Goto M
- O'Shea AMJ
- Livorsi DJ
- et al.
The effect of a nationwide infection control program expansion on hospital-onset gram-negative rod bacteremia in 130 veterans health administration medical centers: an interrupted time-series analysis.
, 27- Hayden MK
- Lin MY
- Lolans K
- et al.
Prevention of colonization and infection by Klebsiella pneumoniae carbapenemase-producing enterobacteriaceae in long-term acute-care hospitals.
, 28- Kousouli E
- Zarkotou O
- Politi L
- et al.
Infection control interventions affected by resource shortages: impact on the incidence of bacteremias caused by carbapenem-resistant pathogens.
, 29- Li M
- Wang X
- Wang J
- et al.
Infection-prevention and control interventions to reduce colonisation and infection of intensive care unit-acquired carbapenem-resistant Klebsiella pneumoniae: a 4-year quasi-experimental before-and-after study.
, 30- Li S
- Guo FZ
- Zhao XJ
- et al.
Impact of individualised active surveillance of carbapenem-resistant enterobacteriaceae on the infection rate in intensive care units: a 3-year retrospective study in a teaching hospital of People's Republic of China.
, 31- Nagao M
- Iinuma Y
- Igawa J
- et al.
Control of an outbreak of carbapenem-resistant Pseudomonas aeruginosa in a haemato-oncology unit.
, 32- Otter JA
- Mookerjee S
- Davies F
- et al.
Detecting carbapenemase-producing Enterobacterales (CPE): an evaluation of an enhanced CPE infection control and screening programme in acute care.
, 33- Spyridopoulou K
- Psichogiou M
- Sypsa V
- et al.
Containing Carbapenemase-producing Klebsiella pneumoniae in an endemic setting.
, 34- Valencia-Martín R
- Gonzalez-Galan V
- Alvarez-Marín R
- et al.
baumannii eradication program. A multimodal intervention program to control a long-term Acinetobacter baumannii endemic in a tertiary care hospital.
, 35- Viale P
- Tumietto F
- Giannella M
- et al.
Impact of a hospital-wide multifaceted programme for reducing carbapenem-resistant Enterobacteriaceae infections in a large teaching hospital in northern Italy.
including contact precautions, monitoring, audit, and feedback of preventive measures, patient isolation, or cohorts, hand hygiene, environmental sanitation, and cleaning.
The strategy and definitions employed to select which patients to consider for surveillance cultures varied among studies: all studies included surveillance cultures to high-risk patients
20- Baek EH
- Kim SE
- Kim S
- et al.
Successful control of an extended-spectrum beta-lactamase-producing Klebsiella pneumoniae ST307 outbreak in a neonatal intensive care unit.
, 21- Ben-David D
- Maor Y
- Keller N
- et al.
Potential role of active surveillance in the control of a hospital-wide outbreak of carbapenem-resistant Klebsiella pneumoniae infection.
, 22- Borer A
- Eskira S
- Nativ R
- et al.
A multifaceted intervention strategy for eradication of a hospital-wide outbreak caused by carbapenem-resistant Klebsiella pneumoniae in Southern Israel.
, 23- Ciobotaro P
- Oved M
- Nadir E
- Bardenstein R
- Zimhony O.
An effective intervention to limit the spread of an epidemic carbapenem-resistant Klebsiella pneumoniae strain in an acute care setting: from theory to practice.
, 24- Gagliotti C
- Cappelli V
- Carretto E
- et al.
Control of carbapenemase-producing Klebsiella pneumoniae: a region-wide intervention.
, 25- Geladari A
- Karampatakis T
- Antachopoulos C
- et al.
Epidemiological surveillance of multidrug-resistant gram-negative bacteria in a solid organ transplantation department.
, 26- Goto M
- O'Shea AMJ
- Livorsi DJ
- et al.
The effect of a nationwide infection control program expansion on hospital-onset gram-negative rod bacteremia in 130 veterans health administration medical centers: an interrupted time-series analysis.
, 27- Hayden MK
- Lin MY
- Lolans K
- et al.
Prevention of colonization and infection by Klebsiella pneumoniae carbapenemase-producing enterobacteriaceae in long-term acute-care hospitals.
, 28- Kousouli E
- Zarkotou O
- Politi L
- et al.
Infection control interventions affected by resource shortages: impact on the incidence of bacteremias caused by carbapenem-resistant pathogens.
, 29- Li M
- Wang X
- Wang J
- et al.
Infection-prevention and control interventions to reduce colonisation and infection of intensive care unit-acquired carbapenem-resistant Klebsiella pneumoniae: a 4-year quasi-experimental before-and-after study.
, 30- Li S
- Guo FZ
- Zhao XJ
- et al.
Impact of individualised active surveillance of carbapenem-resistant enterobacteriaceae on the infection rate in intensive care units: a 3-year retrospective study in a teaching hospital of People's Republic of China.
, 31- Nagao M
- Iinuma Y
- Igawa J
- et al.
Control of an outbreak of carbapenem-resistant Pseudomonas aeruginosa in a haemato-oncology unit.
, 32- Otter JA
- Mookerjee S
- Davies F
- et al.
Detecting carbapenemase-producing Enterobacterales (CPE): an evaluation of an enhanced CPE infection control and screening programme in acute care.
, 33- Spyridopoulou K
- Psichogiou M
- Sypsa V
- et al.
Containing Carbapenemase-producing Klebsiella pneumoniae in an endemic setting.
, 34- Valencia-Martín R
- Gonzalez-Galan V
- Alvarez-Marín R
- et al.
baumannii eradication program. A multimodal intervention program to control a long-term Acinetobacter baumannii endemic in a tertiary care hospital.
, 35- Viale P
- Tumietto F
- Giannella M
- et al.
Impact of a hospital-wide multifaceted programme for reducing carbapenem-resistant Enterobacteriaceae infections in a large teaching hospital in northern Italy.
and 7 studies reported contact surveillance strategy.
21- Ben-David D
- Maor Y
- Keller N
- et al.
Potential role of active surveillance in the control of a hospital-wide outbreak of carbapenem-resistant Klebsiella pneumoniae infection.
,22- Borer A
- Eskira S
- Nativ R
- et al.
A multifaceted intervention strategy for eradication of a hospital-wide outbreak caused by carbapenem-resistant Klebsiella pneumoniae in Southern Israel.
,23- Ciobotaro P
- Oved M
- Nadir E
- Bardenstein R
- Zimhony O.
An effective intervention to limit the spread of an epidemic carbapenem-resistant Klebsiella pneumoniae strain in an acute care setting: from theory to practice.
,24- Gagliotti C
- Cappelli V
- Carretto E
- et al.
Control of carbapenemase-producing Klebsiella pneumoniae: a region-wide intervention.
,28- Kousouli E
- Zarkotou O
- Politi L
- et al.
Infection control interventions affected by resource shortages: impact on the incidence of bacteremias caused by carbapenem-resistant pathogens.
,32- Otter JA
- Mookerjee S
- Davies F
- et al.
Detecting carbapenemase-producing Enterobacterales (CPE): an evaluation of an enhanced CPE infection control and screening programme in acute care.
,35- Viale P
- Tumietto F
- Giannella M
- et al.
Impact of a hospital-wide multifaceted programme for reducing carbapenem-resistant Enterobacteriaceae infections in a large teaching hospital in northern Italy.
None of the studies included a point prevalence survey strategy.
High-risk patients were defined as: (1) Patients admitted at high risk-units (ICU, step-down units, long‐term acute care hospital, hemato-oncology unit, NICU),
20- Baek EH
- Kim SE
- Kim S
- et al.
Successful control of an extended-spectrum beta-lactamase-producing Klebsiella pneumoniae ST307 outbreak in a neonatal intensive care unit.
,21- Ben-David D
- Maor Y
- Keller N
- et al.
Potential role of active surveillance in the control of a hospital-wide outbreak of carbapenem-resistant Klebsiella pneumoniae infection.
,22- Borer A
- Eskira S
- Nativ R
- et al.
A multifaceted intervention strategy for eradication of a hospital-wide outbreak caused by carbapenem-resistant Klebsiella pneumoniae in Southern Israel.
,24- Gagliotti C
- Cappelli V
- Carretto E
- et al.
Control of carbapenemase-producing Klebsiella pneumoniae: a region-wide intervention.
,27- Hayden MK
- Lin MY
- Lolans K
- et al.
Prevention of colonization and infection by Klebsiella pneumoniae carbapenemase-producing enterobacteriaceae in long-term acute-care hospitals.
,28- Kousouli E
- Zarkotou O
- Politi L
- et al.
Infection control interventions affected by resource shortages: impact on the incidence of bacteremias caused by carbapenem-resistant pathogens.
,29- Li M
- Wang X
- Wang J
- et al.
Infection-prevention and control interventions to reduce colonisation and infection of intensive care unit-acquired carbapenem-resistant Klebsiella pneumoniae: a 4-year quasi-experimental before-and-after study.
,30- Li S
- Guo FZ
- Zhao XJ
- et al.
Impact of individualised active surveillance of carbapenem-resistant enterobacteriaceae on the infection rate in intensive care units: a 3-year retrospective study in a teaching hospital of People's Republic of China.
,31- Nagao M
- Iinuma Y
- Igawa J
- et al.
Control of an outbreak of carbapenem-resistant Pseudomonas aeruginosa in a haemato-oncology unit.
,32- Otter JA
- Mookerjee S
- Davies F
- et al.
Detecting carbapenemase-producing Enterobacterales (CPE): an evaluation of an enhanced CPE infection control and screening programme in acute care.
,33- Spyridopoulou K
- Psichogiou M
- Sypsa V
- et al.
Containing Carbapenemase-producing Klebsiella pneumoniae in an endemic setting.
,34- Valencia-Martín R
- Gonzalez-Galan V
- Alvarez-Marín R
- et al.
baumannii eradication program. A multimodal intervention program to control a long-term Acinetobacter baumannii endemic in a tertiary care hospital.
,35- Viale P
- Tumietto F
- Giannella M
- et al.
Impact of a hospital-wide multifaceted programme for reducing carbapenem-resistant Enterobacteriaceae infections in a large teaching hospital in northern Italy.
(2) Patients with a high risk at hospital admission. High risk was defined as a recent hospital stay or transfer in from another facility,
26- Goto M
- O'Shea AMJ
- Livorsi DJ
- et al.
The effect of a nationwide infection control program expansion on hospital-onset gram-negative rod bacteremia in 130 veterans health administration medical centers: an interrupted time-series analysis.
,30- Li S
- Guo FZ
- Zhao XJ
- et al.
Impact of individualised active surveillance of carbapenem-resistant enterobacteriaceae on the infection rate in intensive care units: a 3-year retrospective study in a teaching hospital of People's Republic of China.
and patients transferred from other acute hospitals and long-term care facilities or coming from endemic countries,
24- Gagliotti C
- Cappelli V
- Carretto E
- et al.
Control of carbapenemase-producing Klebsiella pneumoniae: a region-wide intervention.
,26- Goto M
- O'Shea AMJ
- Livorsi DJ
- et al.
The effect of a nationwide infection control program expansion on hospital-onset gram-negative rod bacteremia in 130 veterans health administration medical centers: an interrupted time-series analysis.
,32- Otter JA
- Mookerjee S
- Davies F
- et al.
Detecting carbapenemase-producing Enterobacterales (CPE): an evaluation of an enhanced CPE infection control and screening programme in acute care.
(3) All patients admitted to the hospital
26- Goto M
- O'Shea AMJ
- Livorsi DJ
- et al.
The effect of a nationwide infection control program expansion on hospital-onset gram-negative rod bacteremia in 130 veterans health administration medical centers: an interrupted time-series analysis.
and (4) Patients with recognized risk factors (defined differently in each study).
28- Kousouli E
- Zarkotou O
- Politi L
- et al.
Infection control interventions affected by resource shortages: impact on the incidence of bacteremias caused by carbapenem-resistant pathogens.
,30- Li S
- Guo FZ
- Zhao XJ
- et al.
Impact of individualised active surveillance of carbapenem-resistant enterobacteriaceae on the infection rate in intensive care units: a 3-year retrospective study in a teaching hospital of People's Republic of China.
,32- Otter JA
- Mookerjee S
- Davies F
- et al.
Detecting carbapenemase-producing Enterobacterales (CPE): an evaluation of an enhanced CPE infection control and screening programme in acute care.
Contacts of a newly diagnosed carrier or infected patient were defined as (1) Roommates,
23- Ciobotaro P
- Oved M
- Nadir E
- Bardenstein R
- Zimhony O.
An effective intervention to limit the spread of an epidemic carbapenem-resistant Klebsiella pneumoniae strain in an acute care setting: from theory to practice.
,35- Viale P
- Tumietto F
- Giannella M
- et al.
Impact of a hospital-wide multifaceted programme for reducing carbapenem-resistant Enterobacteriaceae infections in a large teaching hospital in northern Italy.
(2) Patients staying in the same hospital unit,
24- Gagliotti C
- Cappelli V
- Carretto E
- et al.
Control of carbapenemase-producing Klebsiella pneumoniae: a region-wide intervention.
,32- Otter JA
- Mookerjee S
- Davies F
- et al.
Detecting carbapenemase-producing Enterobacterales (CPE): an evaluation of an enhanced CPE infection control and screening programme in acute care.
(3) Patients with ‘epidemiologic links’ to the index case (definition not provided).
21- Ben-David D
- Maor Y
- Keller N
- et al.
Potential role of active surveillance in the control of a hospital-wide outbreak of carbapenem-resistant Klebsiella pneumoniae infection.
Three studies did not provide a definition of contact.
22- Borer A
- Eskira S
- Nativ R
- et al.
A multifaceted intervention strategy for eradication of a hospital-wide outbreak caused by carbapenem-resistant Klebsiella pneumoniae in Southern Israel.
,28- Kousouli E
- Zarkotou O
- Politi L
- et al.
Infection control interventions affected by resource shortages: impact on the incidence of bacteremias caused by carbapenem-resistant pathogens.
,32- Otter JA
- Mookerjee S
- Davies F
- et al.
Detecting carbapenemase-producing Enterobacterales (CPE): an evaluation of an enhanced CPE infection control and screening programme in acute care.
Appendix D. provides the complete description of the characteristics of the included studies.
Risk of bias in the included studies
All included studies had serious issues with bias due to confounding, deviation from intended intervention, and bias in the selection of the reported results. Overall, 7 studies had a serious risk of bias and 9 studies had a critical risk of bias
Table 1. summarizes the risk of bias assessment of each domain.
Table 1Risk of bias in the included studies assessed by ROBINS-I tool
C, Critical; L, Low; M, Moderate; NI, No information S, Serious.
The included studies correspond to interrupted time series and controlled before-after studies. It was not possible to pool results in a meta-analysis since there was substantial variability in the study setting, patient characteristics, interventions, and ways of reporting the outcome data. Therefore the results are presented as a narrative synthesis.
The main results are presented in the Summary of Findings table. Effect of screening strategies to detect carbapenem-resistant gram-negative bacteria
Table 2.Table 2Summary of findings table
GRADE, Grading of Recommendations Assessment, Development and Evaluation.
We identified two interrupted time series assessing the effect of screening strategies to detect carbapenem-resistant gram-negative bacteria. In both studies, the strategy was oriented to the detection of CRE.
One study
30- Li S
- Guo FZ
- Zhao XJ
- et al.
Impact of individualised active surveillance of carbapenem-resistant enterobacteriaceae on the infection rate in intensive care units: a 3-year retrospective study in a teaching hospital of People's Republic of China.
compared the CRE infection rate between the pre-intervention period (where a multimodal intervention was implemented) and the intervention period (where active surveillance was implemented in addition to previous strategies) in high-risk adult patients. During the pre-intervention period, the monthly percent change of CRE infection rate was 13.04% (95% CI: 5.2-21.5) and the infection rate peaked at 4.32% (7/162). During the intervention period, a total of 2,162 high-risk patients were admitted to the ICU. Most of these patients (1,916/2,063; 92.9%) qualified for CRE active screening (according to the following criteria: age >65 years; hospital stay >7 days; carbapenems, third- or fourth-generation cephalosporin or fluoroquinolone treatment for >3 days during 2 weeks before admission to the ICU; hematological malignancies; and immunosuppressive agent treatment for >1 week during 1 month before admission to the ICU). The incidence of CRE colonization significantly decreased, with a monthly percent change of −3.02% (95% CI: −4.7 to −1.3). Meanwhile, the incidence of CRE infection significantly decreased, with a monthly percent change of −3.57% (95% CI: −6.9 to −0.1).
30- Li S
- Guo FZ
- Zhao XJ
- et al.
Impact of individualised active surveillance of carbapenem-resistant enterobacteriaceae on the infection rate in intensive care units: a 3-year retrospective study in a teaching hospital of People's Republic of China.
This study also reported that no differences were observed on length of ICU stay (pre-intervention period: median 1 day (IQR= 1-6); post-intervention period: median 1 day (IQR=1-6)) and mortality in ICU (pre-intervention period: 232/2637, (8.8%); intervention period: 247/2735 (9.0%)).
30- Li S
- Guo FZ
- Zhao XJ
- et al.
Impact of individualised active surveillance of carbapenem-resistant enterobacteriaceae on the infection rate in intensive care units: a 3-year retrospective study in a teaching hospital of People's Republic of China.
A second study that included patients admitted to specialties considered to be high risk (adult and pediatric ICU
32- Otter JA
- Mookerjee S
- Davies F
- et al.
Detecting carbapenemase-producing Enterobacterales (CPE): an evaluation of an enhanced CPE infection control and screening programme in acute care.
) compared a limited screening program (pre-intervention period) to an enhanced screening program (intervention period). The number of positive cultures for CRE per month decreased from a peak of 10 in the pre-intervention period to a mean of 3 (range 1-5) per month over the last quarter of the study (intervention period). During the intervention period, the number of new cases of colonization or infection detected per month increased (from 18 to 50) in proportion to the number of surveillance cultures obtained (from 2,621, when the enhanced screening approach was started to 10,589).
32- Otter JA
- Mookerjee S
- Davies F
- et al.
Detecting carbapenemase-producing Enterobacterales (CPE): an evaluation of an enhanced CPE infection control and screening programme in acute care.
The monthly rate of CRE detection per 1,000 admissions increased from 1.0/1,000 admissions when the intervention was implemented to 2.7/1,000 admissions, but the proportion of positive screens remained at approximately 0.4% (854/220,814 screens, range 0.2%-0.6%) throughout the study period.
32- Otter JA
- Mookerjee S
- Davies F
- et al.
Detecting carbapenemase-producing Enterobacterales (CPE): an evaluation of an enhanced CPE infection control and screening programme in acute care.
Effect of screening strategies to detect carbapenem-resistant gram-negative bacteria as part of a multimodal intervention
We identified 14 studies that included screening strategies in addition to other measures to control CRE, CRAB, or CRPA infection or colonization. Thirteen corresponded to interrupted time series
20- Baek EH
- Kim SE
- Kim S
- et al.
Successful control of an extended-spectrum beta-lactamase-producing Klebsiella pneumoniae ST307 outbreak in a neonatal intensive care unit.
, 21- Ben-David D
- Maor Y
- Keller N
- et al.
Potential role of active surveillance in the control of a hospital-wide outbreak of carbapenem-resistant Klebsiella pneumoniae infection.
, 22- Borer A
- Eskira S
- Nativ R
- et al.
A multifaceted intervention strategy for eradication of a hospital-wide outbreak caused by carbapenem-resistant Klebsiella pneumoniae in Southern Israel.
, 23- Ciobotaro P
- Oved M
- Nadir E
- Bardenstein R
- Zimhony O.
An effective intervention to limit the spread of an epidemic carbapenem-resistant Klebsiella pneumoniae strain in an acute care setting: from theory to practice.
, 24- Gagliotti C
- Cappelli V
- Carretto E
- et al.
Control of carbapenemase-producing Klebsiella pneumoniae: a region-wide intervention.
, 25- Geladari A
- Karampatakis T
- Antachopoulos C
- et al.
Epidemiological surveillance of multidrug-resistant gram-negative bacteria in a solid organ transplantation department.
, 26- Goto M
- O'Shea AMJ
- Livorsi DJ
- et al.
The effect of a nationwide infection control program expansion on hospital-onset gram-negative rod bacteremia in 130 veterans health administration medical centers: an interrupted time-series analysis.
, 27- Hayden MK
- Lin MY
- Lolans K
- et al.
Prevention of colonization and infection by Klebsiella pneumoniae carbapenemase-producing enterobacteriaceae in long-term acute-care hospitals.
, 28- Kousouli E
- Zarkotou O
- Politi L
- et al.
Infection control interventions affected by resource shortages: impact on the incidence of bacteremias caused by carbapenem-resistant pathogens.
, 29- Li M
- Wang X
- Wang J
- et al.
Infection-prevention and control interventions to reduce colonisation and infection of intensive care unit-acquired carbapenem-resistant Klebsiella pneumoniae: a 4-year quasi-experimental before-and-after study.
,31- Nagao M
- Iinuma Y
- Igawa J
- et al.
Control of an outbreak of carbapenem-resistant Pseudomonas aeruginosa in a haemato-oncology unit.
,33- Spyridopoulou K
- Psichogiou M
- Sypsa V
- et al.
Containing Carbapenemase-producing Klebsiella pneumoniae in an endemic setting.
,34- Valencia-Martín R
- Gonzalez-Galan V
- Alvarez-Marín R
- et al.
baumannii eradication program. A multimodal intervention program to control a long-term Acinetobacter baumannii endemic in a tertiary care hospital.
and one to a controlled before-after study.
35- Viale P
- Tumietto F
- Giannella M
- et al.
Impact of a hospital-wide multifaceted programme for reducing carbapenem-resistant Enterobacteriaceae infections in a large teaching hospital in northern Italy.
Nine studies assessed CRE alone,
20- Baek EH
- Kim SE
- Kim S
- et al.
Successful control of an extended-spectrum beta-lactamase-producing Klebsiella pneumoniae ST307 outbreak in a neonatal intensive care unit.
, 21- Ben-David D
- Maor Y
- Keller N
- et al.
Potential role of active surveillance in the control of a hospital-wide outbreak of carbapenem-resistant Klebsiella pneumoniae infection.
, 22- Borer A
- Eskira S
- Nativ R
- et al.
A multifaceted intervention strategy for eradication of a hospital-wide outbreak caused by carbapenem-resistant Klebsiella pneumoniae in Southern Israel.
, 23- Ciobotaro P
- Oved M
- Nadir E
- Bardenstein R
- Zimhony O.
An effective intervention to limit the spread of an epidemic carbapenem-resistant Klebsiella pneumoniae strain in an acute care setting: from theory to practice.
, 24- Gagliotti C
- Cappelli V
- Carretto E
- et al.
Control of carbapenemase-producing Klebsiella pneumoniae: a region-wide intervention.
,27- Hayden MK
- Lin MY
- Lolans K
- et al.
Prevention of colonization and infection by Klebsiella pneumoniae carbapenemase-producing enterobacteriaceae in long-term acute-care hospitals.
,29- Li M
- Wang X
- Wang J
- et al.
Infection-prevention and control interventions to reduce colonisation and infection of intensive care unit-acquired carbapenem-resistant Klebsiella pneumoniae: a 4-year quasi-experimental before-and-after study.
,33- Spyridopoulou K
- Psichogiou M
- Sypsa V
- et al.
Containing Carbapenemase-producing Klebsiella pneumoniae in an endemic setting.
,35- Viale P
- Tumietto F
- Giannella M
- et al.
Impact of a hospital-wide multifaceted programme for reducing carbapenem-resistant Enterobacteriaceae infections in a large teaching hospital in northern Italy.
one assessed CRAB alone
34- Valencia-Martín R
- Gonzalez-Galan V
- Alvarez-Marín R
- et al.
baumannii eradication program. A multimodal intervention program to control a long-term Acinetobacter baumannii endemic in a tertiary care hospital.
and one assessed CRPA alone.
31- Nagao M
- Iinuma Y
- Igawa J
- et al.
Control of an outbreak of carbapenem-resistant Pseudomonas aeruginosa in a haemato-oncology unit.
One study assessed CRE and CRPA
26- Goto M
- O'Shea AMJ
- Livorsi DJ
- et al.
The effect of a nationwide infection control program expansion on hospital-onset gram-negative rod bacteremia in 130 veterans health administration medical centers: an interrupted time-series analysis.
and two studies assessed CRE, CRAB, and CRPA.
25- Geladari A
- Karampatakis T
- Antachopoulos C
- et al.
Epidemiological surveillance of multidrug-resistant gram-negative bacteria in a solid organ transplantation department.
,28- Kousouli E
- Zarkotou O
- Politi L
- et al.
Infection control interventions affected by resource shortages: impact on the incidence of bacteremias caused by carbapenem-resistant pathogens.
Baek et al reported that after implementing the reinforced program (without active surveillance) the incidence of bacteremia caused by CRE in healthcare-associated infections was 6.0/1,000 patients-days on neonatal intensive care units. After implementing the enhanced program (with active surveillance cultures, in addition to other measures), the incidence decreased to 0.0/1,000 patient-days. The incidence of CRE infections decreased gradually from 45.0 to 18.5/1,000 patient-days during the intervention period.
20- Baek EH
- Kim SE
- Kim S
- et al.
Successful control of an extended-spectrum beta-lactamase-producing Klebsiella pneumoniae ST307 outbreak in a neonatal intensive care unit.
In another study
21- Ben-David D
- Maor Y
- Keller N
- et al.
Potential role of active surveillance in the control of a hospital-wide outbreak of carbapenem-resistant Klebsiella pneumoniae infection.
which included adult patients hospitalized in ICU and step-down units, the number of infections with CRE (specifically
Klebsiella pneumoniae) increased gradually from 3 to 5 cases each month (ie 1.08 cases/10,000 patient-days) to 22-24 cases each month (ie 6.93 cases/10,000 patient-days) during the pre-intervention period (detection of CRE was based on culture of clinical samples only). During the intervention period, active surveillance cultures were implemented in addition to other infection control measures. The incidence of infection with CRE decreased from 6.93 cases/10,000 patient-days during the last quarter of the pre-intervention period to 1.8 cases/10,000 patient-days during the intervention period.
21- Ben-David D
- Maor Y
- Keller N
- et al.
Potential role of active surveillance in the control of a hospital-wide outbreak of carbapenem-resistant Klebsiella pneumoniae infection.
Borer et al reported that CRE infection was identified in 370 patients (49.5% during the pre-intervention and 51.5% during the post-intervention period), including adult patients hospitalized in high-risk wards. Two hundred and five (55%) infections were hospital-acquired. During the pre-intervention period, where no detection strategy was implemented, CRE infection incidence per 10,000 patient-days was 5.26. After the implementation of a package of interventions, the incidence decreased to 2.91, followed by 1.91, 1.28, and 0.18. Positive colonization prevalence was 10.4, 6.09, 3.65, and 2.31 positive rectal cultures per 100 patients admitted by year for May-December 2007, 2008, 2009, and January-May 2010, respectively (intervention period).
22- Borer A
- Eskira S
- Nativ R
- et al.
A multifaceted intervention strategy for eradication of a hospital-wide outbreak caused by carbapenem-resistant Klebsiella pneumoniae in Southern Israel.
In another study that included patients admitted to the intensive care unit, Ciobotaro et al compared a limited surveillance strategy that was performed during the pre-intervention period (months 1-13). Between months 5 and 12, an average of 5 new patients per month were diagnosed with CRE (colonized), for an incidence of 3.4/10,000 patient-days. During the 13-14 months, the incidence peaked at 8.2/10,000 patient-days. During the intervention period, active surveillance culture was implemented as part of a multimodal intervention (14-56 months). The average incidence of CRE cases declined from 6.6/10,000 patient-days to 2.5/ 10,000 patient-days. From months 25 to 56, the average incidence of CRE infection was 0.5/10,000 patient-days, which was 16-fold lower than the peak incidence. The rate of cross-infection decreased significantly from 6% at the beginning of the intervention period to 2.7% at the end of the study.
23- Ciobotaro P
- Oved M
- Nadir E
- Bardenstein R
- Zimhony O.
An effective intervention to limit the spread of an epidemic carbapenem-resistant Klebsiella pneumoniae strain in an acute care setting: from theory to practice.
Gagliotti et al reported a linear increase of incident cultures positive for CRE over time in the pre-intervention period, while the number of cases remained stable after the launch of the infection control measures (including active surveillance culture). Considering the patients hospitalized in 5 Health Trusts that provided detailed data on incident cases, a downward trend was observed in incidence during the intervention period (from 32 to 15 cases per 100,000 hospital patient-days), where active surveillance of CRE was implemented in addition to other measures.
24- Gagliotti C
- Cappelli V
- Carretto E
- et al.
Control of carbapenemase-producing Klebsiella pneumoniae: a region-wide intervention.
Hayden et al reported that the prevalence of CRE (specifically
Klebsiella pneumoniae) rectal colonization was stable during the pre-intervention period (average, 45.8%; 95% CI 42.1%‐49.5%), declined early in the intervention period, and then reached a plateau (34.3%; 95% CI 32.4%‐36.2%) in adults hospitalized in all general medical wards and high‐risk units. Average rates of CRE in any clinical culture decreased from 3.7 events/1,000 patient-days in the pre-intervention period (95% CI: 3.4-4.09) to 2.5 events/1,000 patient-days (95% CI 2.2 to -2.8) in the intervention period. CRE bacteremia decreased from 0.9 events/1,000 patient-days (95% CI 0.8-1.1) in the pre-intervention period to 0.4 events/10,00 patient-days in the intervention period (95% CI 0.3-0.5). The multimodal intervention resulted in a 32% reduction in the rate of isolation of CRE from any clinical culture and a 56% reduction in CRE bacteremia.
27- Hayden MK
- Lin MY
- Lolans K
- et al.
Prevention of colonization and infection by Klebsiella pneumoniae carbapenemase-producing enterobacteriaceae in long-term acute-care hospitals.
This study also reported that no difference was observed on the length of hospital stay (pre-intervention period: median 28 days (IQR: 16‐43); post-intervention period: median 26 days, [IQR 17‐39]) and in‐hospital mortality (pre-intervention period: 21.5%; post-intervention period: 17.6%).
27- Hayden MK
- Lin MY
- Lolans K
- et al.
Prevention of colonization and infection by Klebsiella pneumoniae carbapenemase-producing enterobacteriaceae in long-term acute-care hospitals.
In another study, Li et al reported that the monthly incidence of CRE colonization/infection in hospitalized adults was 10.08 (95% CI 4.43-17.46) cases per 1,000 ICU patient-days at the baseline (no intervention was performed and only regular culture surveys were conducted). Infection-prevention and control (IPC) interventions were associated with a clear significant decrease to 3.18 (95% CI 2.98-6.18) but was followed by several increases in the incidence. The prevalence rates stabilized and decreased during the implementation of the modified IPC intervention (5.76, 95% CI 2.77-6.34) and follow-up periods (5.78; 95% CI 3.52-8.47) as compared to the baseline period. The monthly incidence of ICU-acquired CRE was 10.08 (95% CI 4.43-16.43) cases per 1,000 ICU patient-days at baseline, and IPC interventions were associated with a decrease to 3.12 (95% CI 2.98-5.40) but was followed by several increases in the incidence. The prevalence rates stabilized and decreased during the implementation of the modified IPC interventions (5.62; 95% CI 0.69-6.34) and follow-up periods (2.84, 95% CI 2.80-2.89) as compared to the baseline period.
29- Li M
- Wang X
- Wang J
- et al.
Infection-prevention and control interventions to reduce colonisation and infection of intensive care unit-acquired carbapenem-resistant Klebsiella pneumoniae: a 4-year quasi-experimental before-and-after study.
Spyridopoulou K et al reported that the admission prevalence of CRE (
Klebsiella pneumonia) colonisation (p < 0.001 for linear trend) and the incidence rate of CRE colonization (
P = .072 for linear trend) were declining during the intervention period when a multimodal intervention (including active surveillance cultures) was implemented in a hematology unit of a tertiary-care hospital. The monthly prevalence of CRE colonization among hospitalized patients progressively decreased from 15.9% to 0% and the colonization incidence during hospitalization decreased from 10.6/1,000 patient-days to 0/1,000 patient-days during the intervention period.
33- Spyridopoulou K
- Psichogiou M
- Sypsa V
- et al.
Containing Carbapenemase-producing Klebsiella pneumoniae in an endemic setting.
More importantly, this study reported that the intervention measures halted the increasing incidence of CRE blood-stream infections observed in the pre-intervention period and eventually resulted in a decline from 1.58/1,000 patient-days in the beginning of the first intervention period to 0/1,000 patient-days in the third intervention period.
33- Spyridopoulou K
- Psichogiou M
- Sypsa V
- et al.
Containing Carbapenemase-producing Klebsiella pneumoniae in an endemic setting.
Viale et al assessed the implementation of a multimodal intervention including active surveillance of high-risk adult patients and contacts. The study reported that the monthly incidence of CRE bloodstream infections increased at a rate of 0.05 cases/10,000 patient days per month (incidence rate ratio: 1.05, 95% CI 0.99-1.11) during the pre-intervention period (where no detection strategies were mentioned). During the intervention period 1,571 CRE-positive cultures were detected, with Klebsiella being the CRE most frequently isolated (1,501/1,571, 95%). Following the intervention, the incidence rate of CRE bloodstream infections (risk reduction 0.96, 95% CI 0.92-0.99) and CRE colonization (risk reduction 0.96, 95% CI 0.95-0.97) significantly decreased over 30 months.
35- Viale P
- Tumietto F
- Giannella M
- et al.
Impact of a hospital-wide multifaceted programme for reducing carbapenem-resistant Enterobacteriaceae infections in a large teaching hospital in northern Italy.
Valencia-Martín et al explored the use of enhanced infection control measures including active surveillance culture in the setting of CRAB infection in adult patients admitted to ICU and wards. The incidence density of CRAB (infected or colonized) was 10.9 cases/1,000 patients-days at the beginning of the infection control program implementation. The incidence density of CRAB bacteremia at the beginning of the program was 0.026 cases/1,000 patients-days. Three trimesters later, no new cases of CRAB bacteremia were observed.
34- Valencia-Martín R
- Gonzalez-Galan V
- Alvarez-Marín R
- et al.
baumannii eradication program. A multimodal intervention program to control a long-term Acinetobacter baumannii endemic in a tertiary care hospital.
Nagao et al included surveillance cultures in addition to other measures to help control CRPA infection or colonization in a hemato-oncology unit. Seventeen patients infected with CRPA were identified (11 had active CRPA infection) during the pre-intervention study period, where a multimodal intervention was performed. During the intervention period, active surveillance, restriction of carbapenem use and other measures to ensure strict adherence to the infection control measures were implemented and the rate of CRPA infection was reduced to zero.
31- Nagao M
- Iinuma Y
- Igawa J
- et al.
Control of an outbreak of carbapenem-resistant Pseudomonas aeruginosa in a haemato-oncology unit.
Goto et al assessed infection control measures on veterans who were admitted to acute care wards and intensive care units (active surveillance program in addition to other interventions) to prevent hospital-onset gram-negative bacteremia, including a subgroup analysis from those multidrug-resistant gram-negative. Hospital-onset multidrug resistant bacteremia had a significant decline in intercept (-19.8; 95% CI -27.6-11.0) and downward change of slopes from +1.0% per month (95% CI 0.6-1.5) to -0.4% per month (95% CI -0.6% to -0.3%) before and after implementation. Hospital-onset gram-negative bacteremia incidence rates showed a significant change of slope by the end of the initiative, from +0.3%/mo) to –0.4%/mo. However, specific CRE (
Klebsiella pneumonia) and CRPA rates data was not available. The study also showed no differences between both periods on length of hospital stay (pre-intervention= range 5.4-6.0; intervention period: range 4.8-5.4).
26- Goto M
- O'Shea AMJ
- Livorsi DJ
- et al.
The effect of a nationwide infection control program expansion on hospital-onset gram-negative rod bacteremia in 130 veterans health administration medical centers: an interrupted time-series analysis.
Geladari et al compared the implementation of a multimodal intervention (including active surveillance cultures) with a pre-intervention period without infection control measures. The monthly incidence of CRE, CRAB and CRPA infections increased from 1.9 cases/1,000 patient-days to 3.9 cases/1,000 patient-days during the pre-intervention period. During the intervention period, 74/250 patients colonized by CRE (
Klebsiella pneumonia), CRPA or CRAB were found. Over this period, there was a significant decline in the incidence of colonization (from 19% to 9%). At the same time, the prevalence of colonization increased from 36% in the first week to 50% in the 69th week (intervention period). During the intervention period, monthly incidence of infection caused by carbapenem-resistant bacteria increased from 2.8 to 6.9/1,000 bed-days.
25- Geladari A
- Karampatakis T
- Antachopoulos C
- et al.
Epidemiological surveillance of multidrug-resistant gram-negative bacteria in a solid organ transplantation department.
Another study
28- Kousouli E
- Zarkotou O
- Politi L
- et al.
Infection control interventions affected by resource shortages: impact on the incidence of bacteremias caused by carbapenem-resistant pathogens.
compared limited surveillance cultures with active surveillance cultures in addition to infection control measures to all adult ICU patients. During the study period, 351 patients with bloodstream infections caused by CRE, CRAB, and CRPA were identified and the yearly incidence rate of bloodstream infections for all hospital patients changed from 0.91/1.04 per 1,000 patient-days during pre-intervention period to 0.87/0.78/1.05/1.26 per 1,000 patient-days during the intervention period. For ICU patients, the incidence rate was 21.03/19.63 and 17.32/14.45/22.85/25.02 per 1,000 patient-days, respectively. No significant trend was found for the pre-intervention period, as well as no significant trend change within the intervention period. The study also showed no differences between both periods on length of hospital stay (total hospital: pre-intervention, range 3.92-4.10; intervention period, range 3.89-4.19. ICU: pre-intervention, range 16.37-24.06; intervention period, range 16.20-20.61).
28- Kousouli E
- Zarkotou O
- Politi L
- et al.
Infection control interventions affected by resource shortages: impact on the incidence of bacteremias caused by carbapenem-resistant pathogens.