During community outbreaks, hospitals often initiate screening for multidrug-resistant organisms (MDROs) in patients transferred from other local hospitals, particularly those patients known to have high rates of infection. New research supports taking a broader view of the strategy--not just between institutions or communities, but between nations. Other studies find that focusing on patients hospitalized abroad who have specific risk factors can keep the screening process from becoming cost prohibitive.
The prevalence of MDROs varies significantly between countries; a significant impact is whether good antimicrobial stewardship (AMS) practices are adopted. For instance, the number of cases of Klebsiella pneumoniae resistant to third generation cephalosporins ranges from less than 2% in Finland, to 10%-25% in France and Germany, to 25%-50% in Italy, and to nearly 75% in Bulgaria.
European hospitals have implemented a number of programs to slow the emergence of antimicrobial resistance of all organisms and to prevent the spread of MDROs within their facilities. In one study, a hospital in the Netherlands implemented a screening protocol for admitted patients who had been hospitalized in the prior two months in any other country.1 This process seems to have impacted patient care, as the Netherlands has a low prevalence rate of MDROs.
The hospital screened patients for carriage of any MDRO from July 2012 to July 2013 and tracked associations with demographic characteristics, region and country of prior hospitalization as well as type of intervention during the prior hospitalization.
Of the 194 patients previously hospitalized abroad, the researchers had screening results for 148. Of those with screening results 19 carried an MDRO. Three had methicillin-resistant Staphylococcus aureus and 16 had a multidrug-resistant gram negative bacteria, including Acinetobacter baumannii XMR, Klebsiella pneumoniae Oxa 48 and extended-spectrum beta-lactamase (ESBL)-positive bacteria.
Twenty percent of patients recently hospitalized in Asia or the Middle East carried an MDRO as did 16.4% of those who had been inpatient in a facility in Southern or Eastern Europe.
While patients recently hospitalized abroad who sought outpatient care were not screened initially, about a quarter of them required hospitalization within three months of their outpatient visit. Of those patients, six had positive results for MDROs.
The researchers concluded that targeted MDRO screening could be a feasible and cost-effective strategy when trying to prevent MDRO transmission in low and middle-income countries. The authors further recommended that, where financially feasible, facilities should also consider screening for MDROs in outpatient departments.
In another study, the infection prevention team at a Swiss hospital implemented a screening process for all adult patients who had been admitted to or treated in an outpatient unit of a foreign medical center or a high-prevalence in Switzerland region (one with ESBL K. pneumoniae or MRSA rates greater than 10%) within the previous six months. These transfer patients were screened for MRSA, ESBL-positive and carbapenemase-producing gram negative bacteria from January 1, 2012 through December 31, 2013.
Of the 235 transfer patients, 43 were positive for an MDRO and 42 of them yielded gram negative bacteria. Several individuals also carried MRSA in addition. Researchers found that hospitalization outside of Europe and active infection on admission were independently predictive of Gram-negative MDRO colonization.
Because 82% of those screened were found to not be colonized, the Swiss researchers recommended that transfer patients meet additional criteria before being screened. This criteria includes the presence of skin lesions or other active infection, antibiotic treatment or surgical procedure abroad, or hospitalization outside of Europe.
By quickly identifying and limiting the spread of gram negative bacteria that can easily share genetic material that confers resistance to other bacteria, screening serves an important function in a robust antimicrobial stewardship program.
Taken together, these two studies indicate that establishing screening programs for international transfer patients can help facilities quickly identify patients colonized with MDROs. Including other factors that increase the likelihood of colonization can make screening programs more cost effective than universal screening of all patients hospitalized abroad.
Identifying colonization as well as infection with resistant organisms, particularly gram negative bacteria, can provide a valuable weapon in the battle against MDROs and potentially save both money and lives by extending the useful life of available antibiotics.
Kaspar T, Schweiger A, Droz S and Marschall J. Colonization with resistant microorganisms in patients transferred from abroad: who needs to be screened? Antimicrobial Resistance and Infection Control 2015, 4:31.