Knowing More of the Iceberg: How Detecting a Greater Proportion of Carbapenem-Resistant Enterobacteriaceae Carriers Influences Transmission

• Published in: The Journal of infectious diseases Vol. 221; no. 11; pp. 1782 - 1794
• Main Authors: Bartsch, Sarah M, Wong, Kim F, Stokes-Cawley, Owen J, McKinnell, James A, Cao, Chenghua, Gussin, Gabrielle M, Mueller, Leslie E, Kim, Diane S, Miller, Loren G, Huang, Susan S, Lee, Bruce Y
• Format: Journal Article
• Language: English
• Published: US Oxford University Press 11.05.2020
• Subjects: Antibiotics; Bacterial infections; Carbapenem-Resistant Enterobacteriaceae - isolation & purification; Carrier State - diagnosis; Carrier State - epidemiology; Carrier State - transmission; Contact Tracing; CRE bacteria; Disease transmission; Drug resistance; Editor's Choice; Enterobacteriaceae; Enterobacteriaceae Infections - diagnosis; Enterobacteriaceae Infections - epidemiology; Enterobacteriaceae Infections - prevention & control; Enterobacteriaceae Infections - transmission; Hospitals - statistics & numerical data; Humans; Infection Control - methods; Major and Brief Reports; Nursing Homes - statistics & numerical data; Prevalence; iceberg; detection; unknown carriers; CRE; burden
• ISSN: 0022-1899; 1537-6613
• DOI: 10.1093/infdis/jiz288

Abstract Background Clinical testing detects a fraction of carbapenem-resistant Enterobacteriaceae (CRE) carriers. Detecting a greater proportion could lead to increased use of infection prevention and control measures but requires resources. Therefore, it is important to understand the impact of detecting increasing proportions of CRE carriers. Methods We used our Regional Healthcare Ecosystem Analyst–generated agent-based model of adult inpatient healthcare facilities in Orange County, California, to explore the impact that detecting greater proportions of carriers has on the spread of CRE. Results Detecting and placing 1 in 9 carriers on contact precautions increased the prevalence of CRE from 0% to 8.0% countywide over 10 years. Increasing the proportion of detected carriers from 1 in 9 up to 1 in 5 yielded linear reductions in transmission; at proportions >1 in 5, reductions were greater than linear. Transmission reductions did not occur for 1, 4, or 5 years, varying by facility type. With a contact precautions effectiveness of ≤70%, the detection level yielding nonlinear reductions remained unchanged; with an effectiveness of >80%, detecting only 1 in 5 carriers garnered large reductions in the number of new CRE carriers. Trends held when CRE was already present in the region. Conclusion Although detection of all carriers provided the most benefits for preventing new CRE carriers, if this is not feasible, it may be worthwhile to aim for detecting >1 in 5 carriers. Increasing the percentage of detected carbapenem-resistant Enterobacteriaceae (CRE) carriers from 11% to 20% yielded linear reductions in transmission, with nonlinear gains occurring at >20%. Findings were robust to changes in CRE prevalence, contact precautions effectiveness, and interfacility CRE status communication.