Screening, isolation, and decolonization strategies for vancomycin-resistant enterococci or extended spectrum Beta-lactamase-producing organisms: a systematic review of the clinical evidence and health services impact.

Bacterial resistance to antibiotics is an increasing problem in Canada and worldwide.1–4 Vancomycin-resistant enterococci (VRE) are strains of Enterococcus faecium or Enterococcus faecalis that contain genes conferring resistance to vancomycin.5,6Escherichia coli (E. coli), Klebsiella pneumonia (K. pneumonia), and other gram-negative bacteria may produce the enzymes known as extended spectrum beta-lactamases (ESBLs). These have the ability to inactivate beta-lactam antibiotics such as penicillin, ampicillin, and the cephalosporins.7,8 The presence and growth (colonization) of VRE and ESBL-producing micro-organisms in the gastrointestinal tract is usually of no consequence for the host; but under certain circumstances — such as immunosuppression, gastrointestinal surgery, or physical debilitation — they may serve as a source of infection for the carrier. These hosts may also serve as a reservoir for the transmission of VRE and ESBL-producing organisms to other persons.9,10 Results from the Canadian Nosocomial Infection Surveillance Program showed that, from 1999 to 2005, the rate of VRE colonization and VRE infection increased from 0.37 to 1.32 cases, and from 0.02 to 0.05 cases, respectively, per 1,000 patients admitted to hospital.11 The laboratory-based Canadian Ward Surveillance Study in 2008 found that ESBL-producing E. coli were identified in all Canadian geographic regions, and that 4.9% of E. coli isolates were ESBL producers.12 Specific prevention and control measures for antibiotic-resistant organisms (AROs) include screening (a process to identify persons colonized with AROs) and isolation of the carriers. Hospital infection prevention and control strategies have been developed in some Canadian jurisdictions,13–16 and these are compatible with other national and international documents.17,18 Non-specific strategies for controlling ARO transmission and infection include hand hygiene, environmental cleaning, antimicrobial stewardship, and bundled practices such as those to prevent central line-associated blood stream infections. Antibiotic-resistant organisms, such as VRE and ESBL-producers, lead to the increased use of hospital resources due to extended hospital stays, laboratory tests, physician consultations, medications if a VRE or ESBL-related infection were to arise, and the need to adhere to infection prevention and control measures to prevent the further spread of these pathogens.19 Some of the increased resource usage results from the morbidity caused by VRE or ESBL-producing organism infections, while some is a consequence of control strategies. For example, it may be harder to transfer a patient to a rehabilitation facility if the patient is currently in isolation, which will in and of itself prolong the length of stay. The objective of this systematic review is to evaluate the clinical evidence for the effectiveness of screening, isolation, and decolonization strategies for persons colonized or infected with VRE and ESBL-producing organisms in acute and long-term care facilities. The health services impact of these strategies will be discussed. Objective The objective of the report is to answer the following research questions: What is the clinical evidence on the effectiveness of selective versus universal versus no screening of patients (adult and pediatric) for VRE or ESBL-producing organisms? What is the clinical evidence on the effectiveness of patient isolation for VRE or ESBL-producing organisms? What is the clinical evidence on the impact of isolation on the patient? What is the clinical evidence for the effectiveness of decolonizing patients known to be carrying VRE or ESBL-producing organisms? What is the clinical evidence on the effectiveness of additional precautions in the operating room or post-anesthesia recovery room in patients colonized with VRE or ESBL-producing organisms? What is the health services impact of screening, isolating, and decolonizing patients known to be carrying VRE or ESBL-producing organisms on blocked beds, cancelled or limited surgeries, or the range of services a facility can provide? Methods For the clinical evidence, an information specialist performed the literature search using a peer-reviewed search strategy. Methodological filters were applied to limit retrieval to health technology assessments, systematic reviews, meta-analyses, randomized controlled trials, and non-randomized studies. Trials were eligible for inclusion if they involved adults or pediatric patients in acute or long-term care facilities, with VRE or ESBL-producing organisms; compared the effectiveness of screening, isolation, and decolonization with no screening, no isolation, and no decolonization; and reported outcomes related to detection, transmission, and infection of VRE or ESBL-producing organisms. The information specialist also conducted a search on the health services impact of the related main search concepts, using the same methodology as for the clinical evidence. Trials were eligible for inclusion if they involved adults or pediatric patients in acute or long-term care facilities with VRE or ESBL-producing organisms and discussed the impact of screening, isolation, and decolonization of these patients on hospital resources. Regular alerts were established to update the search until the publication of the final report. Grey literature (literature that is not commercially published) was identified by searching relevant sections of the Grey Matters checklist (http://cadth.ca/resources/grey-matters).

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