Christian Wegner

Cost comparison of MRSA screening and management – a decision tree analysis

BackgroundMethicillin-resistant Staphylococcus aureus (MRSA) infections represent a serious challenge for health-care institutions. Rapid and precise identification of MRSA carriers can help to reduce both nosocomial transmissions and unnecessary isolations and associated costs. The practical details of MRSA screenings (who, how, when and where to screen) remain a controversial issue.MethodsAim of this study was to determine which MRSA screening and management strategy causes the lowest expected cost for a hospital. For this cost analysis a decision analytic cost model was developed, primary based on data from peer-reviewed literature. Single and multiplex sensitivity analyses of the parameters “costs per MRSA case per day”, “costs for pre-emptive isolation per day”, “MRSA rate of transmission not in isolation per day” and “MRSA prevalence” were conducted.ResultsThe omission of MRSA screening was identified as the alternative with the highest risk for the hospital. Universal MRSA screening strategies are by far more cost-intensive than targeted screening approaches. Culture confirmation of positive PCR results in combination with pre-emptive isolation generates the lowest costs for a hospital. This strategy minimizes the chance of false-positive results as well as the possibility of MRSA cross transmissions and therefore contains the costs for the hospital. These results were confirmed by multiplex and single sensitivity analyses. Single sensitivity analyses have shown that the parameters “MRSA prevalence” and the “rate of MRSA of transmission per day of non-isolated patients” exert the greatest influence on the choice of the favorite screening strategy.ConclusionsIt was shown that universal MRSA screening strategies are far more cost-intensive than the targeted screening approaches. In addition, it was demonstrated that all targeted screening strategies produce lower costs than not performing a screening at all.

One-day point prevalence of emerging bacterial pathogens in a nationwide sample of 62 German hospitals in 2012 and comparison with the results of the one-day point prevalence of 2010.

Background: Antibiotic resistance of bacterial pathogens is an emerging problem worldwide. To combat multidrug resistant organisms (MRDOs) networks of care providers have been established in all states in Germany. The HICARE-network, a project to combat MRDOs, founded by the Federal Ministry of Education and Research, has published data from 2010 of a voluntary, German-wide, multicenter point-prevalence survey in 2011 conducted in collaboration with the German Society of Hospital Hygiene. The aim of the present survey was the re-evaluation of the situation in 2012. Method: The survey was conducted as a voluntary, anonymous, point-prevalence in May 2012 using routine data of microbiological diagnostics of the hospitals. As in the former survey of 2010 it was differentiated between primary, secondary and tertiary care hospitals and only data from intensive care units, surgical and medical wards were collected. Based on the survey form used in 2010, an updated version was used including more pathogens and corrected issues observed in the former survey. Methicillin-resistant Staphylococcus aureus (MRSA) (total as well as separated in hospital-acquired (HA), community-acquired (CA) and lifestock-associated (LA) MRSA), vancomycin resistant Staphylococcus aureus (VRSA/GRSA), vancomycin resistant Enterococcus faecalis resp. Enterococcus faecium (VR-E. faecalis resp. VR-E. faecium), extended-spectrum-beta-lactamase-building (ESBL) E. coli (ESBL-EC) and Klebsiella pneumoniae (ESBL-KP), multiresistant Acinetobacter spp. (MAB), multiresistant Pseudomonas spp. (MRP), carbapenemase-producing Enterobacteriaceae (CRE) as well as Clostridium difficile (CD) infections and severe infections requiring ICU-treatment were included in the survey along with additional data on screening strategy, the equipment with infection control staff and possible confounders. Results: Out of 1,550 hospitals asked to participate, 62 returned data (4%). Data from 56 hospitals including primary (26), secondary (20) and tertiary (10) care hospitals were analyzable (3.6%). The most frequently reported organisms were MRSA 1.53% [CI95: 1.32–1.75], followed by CDAD 1.30% [CI95: 1.11–1.50], ESBL-EC 0.97% [CI95: 0.80–1.14], and ESBL-KP 0.27% [CI95: 0.18–0.36], regardless of the level of care. Prevalence of MRDOs depended on the level of care and on the type of ward, as expected. Overall prevalence was highest on intensive care wards, and prevalences were remarkably high on medical wards compared to surgical wards. All tertiary care providers employed their own infection control nurse, while only ~70% of the secondary and primary care hospitals did. Surprisingly, in two of the ten participating tertiary care providers neither an internal nor an external infection control doctor was available. Discussion: With more than 13,000 patients in 56 hospitals distributed all over Germany, the survey included more than three times as many patients as the first survey and therefore not only adds valuable information about the epidemiology of emerging nosocomial pathogens, but also helps to raise awareness of the problem of antibacterial resistance in Germany. The prevalences reported seem to be comparable to the results of the former survey and of other surveys published. Some hospitals reported to have no infection control personnel available at all. This statement is in line with another survey published in this issue.

One-day point prevalence of emerging bacterial pathogens in four secondary and five tertiary care German hospitals - results from a pilot study of the German Society for Hospital Hygiene (Deutsche Gesellschaft für Krankenhaushygiene, DGKH).

Objective: Data on the prevalence of emerging bacterial pathogens like extended-spectrum-lactamase-building (ESBL) Gram negative organisms, multiresistant Pseudomonas and Acinetobacter species or toxin-building Clostridium difficile in German hospitals are sparse. To provide data for different regions in Germany, a one-day point prevalence study with five tertiary care hospitals and four secondary care hospitals was conducted on the 10th of February 2010. Method: For participating hospitals, the level of care (primary/secondary/tertiary), staffing with infection prevention personnel, availability of a MRSA-screening, microbiological support and the prevalence of five emerging bacterial pathogens in intensive care, surgical and medical wards was assessed by questionnaire. Results: Overall, 3411 patients were included. In tertiary hospitals, the following prevalences were given: MRSA 1.8%, ESBL E. coli 0.45%, ESBL Klebsiella spp. 0.41%, multiresistant Pseudomonas 0.53%, multiresistant Acinetobacter species 0.15%, VRE 0.49% und Clostridium difficile 1.01%. In secondary hospitals, as prevalences resulted for MRSA 3.48%, ESBL E. coli 0.4%, ESBL Klebsiella spp. 0.4%, multiresistant Pseudomonas 0%, multiresistant Acinetobacter species 0%, VRE 0.13% und Clostridium difficile 1.34%. Discussion: The prevalence of MRSA found is comparable to other prevalence studies published in the last years, but remarkably higher than reported by the German National Surveillance System (KISS). As no prevalence data for other pathogens as MRSA could be found, only data from the ITS-KISS are available for comparison. Again, the prevalences found in the present study are much higher than reported by the KISS. Whether this is by chance or indicates a systematic underreporting in the KISS remains unclear. Conclusion: The results from this one day point prevalence study show that prevalences of emerging bacterial pathogens differ markedly between regions, departments and hospitals. This can be explained by regional, methodical and other difference associated with the level of care provided by these hospitals. Still, the prevalences found fit well to other prevalence studies from the last years but are remarkably higher than to be expected by the KISS. As questionnaire-based one-day prevalence studies have been shown to be inexpensive and feasible, such studies, using a fixed day and protocol, should be extendedly used in the future to collect representative data for Germany. By such initiatives, scientific societies as the DGKH can take part in collecting valuable epidemiological data of emerging bacterial pathogens.

Impact of different diagnostic technologies for MRSA admission screening in hospitals – a decision tree analysis

BackgroundHospital infections with multiresistant bacteria, e.g., Methicillin-resistant Staphylococcus aureus (MRSA), cause heavy financial burden worldwide. Rapid and precise identification of MRSA carriage in combination with targeted hygienic management are proven to be effective but incur relevant extra costs. Therefore, health care providers have to decide which MRSA screening strategy and which diagnostic technology should be applied according to economic criteria.AimThe aim of this study was to determine which MRSA admission screening and infection control management strategy causes the lowest expected cost for a hospital. Focus was set on the Point-of-Care Testing (PoC).MethodsA decision tree analytic cost model was developed, primarily based on data from peer-reviewed literature. In addition, univariate sensitivity analyses of the different input parameters were conducted to study the robustness of the results.FindingsIn the basic analysis, risk-based PoC screening showed the highest mean cost savings with 14.98 € per admission in comparison to no screening. Rapid universal screening methods became favorable at high MRSA prevalence, while in situations with low MRSA transmission rates omission of screening may be favorable.ConclusionEarly detection of MRSA by rapid PoC or PCR technologies and consistent implementation of appropriate hygienic measures lead to high economic efficiency of MRSA management. Whether general or targeted screening is more efficient depends mainly on epidemiological and infrastructural parameters.

Multiresistente Erreger (MRE) und C. difficile in Münchner Akutkliniken

To combat multidrug resistant organisms (MRDOs), networks have been established all over Germany. Here we show here how those networks can survey the prevalence of MRDOs and C. difficile (CD), as well as structure data (e.g. staffing with hygiene control personnel), with reasonable efforts. We conducted a questionnaire-based point prevalence survey in May 2012. The prevalence (colonisation or infection) of inpatient cases with methicillin-resistant S. aureus (MRSA), vancomycin resistant S. aureus (VRSA), vancomycin resistant E. faecalis/E. faecium (VR-E. faecalis/VR-E. faecium), extended-spectrum-beta-lactamase-producing E. coli (ESBL-EC) and K. pneumoniae (ESBL-KP), multiresistant Acinetobacter spp. (MAB), multiresistant Pseudomonas spp. (MRP), carbapenemase-producing Enterobacteriaceae (CRE) as well as infections with Clostridium difficile (CD) were assessed. Out of 45 hospitals asked to participate, 89% sent back forms. Forms were filled out mostly by infection control personnel. In total 7154 patients were included. The most frequently reported MDROs were MRSA (prevalence: 1.37% of all included patients), ESBL-EC (1.12%), ESBL-KP (0.43%) and VRE (0.38%). VRSA and CRE were not reported. The prevalence of MRP (0.13%) and MAB (0.03%), was very low. The most frequently reported pathogen was CD (1.66%). Point prevalence surveys are a feasible way to gain regional data on the epidemiology of MDROs and to raise local awareness. Staffing with infection control personnel remains an issue, given the prevalence of nosocomial pathogens.

Prospective pilot study on the incidence of infections caused by peripheral venous catheters at a general surgical ward.

Device-associated infections comprise a significant proportion of all nosocomial infections. In this prospective, observational pilot study the incidence of infections in 89 peripheral venous catheters (PVCs) was documented on a general surgical ward employing an infection data sheet developed by the Institute of Hygiene and Environmental Medicine, Greifswald in adherence to CDC standards for infections. 16 of 20 infections were documented during a four-week time period when medical students in the first four months of their practical year performed their compulsory rotation on the general surgical ward. Insufficient knowledge of adequate hygienic measures as well as non-compliance to aseptical procedural measures prior to and following insertion of a peripheral venous catheter are the assumed instigators of these infections. In order to ensure a uniform hygienic standard in the performance of applied procedures, it is essential that medical students during this practical year receive not only theoretical, but also hands-on schooling prior to initiation of their subsequent official residency.

[Multidrug-resistant organisms and C. difficile in Munich acute-care clinics: Results from a point prevalence study of clinical routine data].

To combat multidrug resistant organisms (MRDOs), networks have been established all over Germany. Here we show here how those networks can survey the prevalence of MRDOs and C. difficile (CD), as well as structure data (e.g. staffing with hygiene control personnel), with reasonable efforts. We conducted a questionnaire-based point prevalence survey in May 2012. The prevalence (colonisation or infection) of inpatient cases with methicillin-resistant S. aureus (MRSA), vancomycin resistant S. aureus (VRSA), vancomycin resistant E. faecalis/E. faecium (VR-E. faecalis/VR-E. faecium), extended-spectrum-beta-lactamase-producing E. coli (ESBL-EC) and K. pneumoniae (ESBL-KP), multiresistant Acinetobacter spp. (MAB), multiresistant Pseudomonas spp. (MRP), carbapenemase-producing Enterobacteriaceae (CRE) as well as infections with Clostridium difficile (CD) were assessed. Out of 45 hospitals asked to participate, 89% sent back forms. Forms were filled out mostly by infection control personnel. In total 7154 patients were included. The most frequently reported MDROs were MRSA (prevalence: 1.37% of all included patients), ESBL-EC (1.12%), ESBL-KP (0.43%) and VRE (0.38%). VRSA and CRE were not reported. The prevalence of MRP (0.13%) and MAB (0.03%), was very low. The most frequently reported pathogen was CD (1.66%). Point prevalence surveys are a feasible way to gain regional data on the epidemiology of MDROs and to raise local awareness. Staffing with infection control personnel remains an issue, given the prevalence of nosocomial pathogens.

Multiresistente Erreger (MRE) und C. difficile in Münchner Akutkliniken@@@Multidrug-resistant organisms and C. difficile in Munich acute-care clinics: Ergebnisse einer Punktprävalenzuntersuchung aus klinischen Routinedaten@@@Results from a point prevalence study of clinical routine data

To combat multidrug resistant organisms (MRDOs), networks have been established all over Germany. Here we show here how those networks can survey the prevalence of MRDOs and C. difficile (CD), as well as structure data (e.g. staffing with hygiene control personnel), with reasonable efforts. We conducted a questionnaire-based point prevalence survey in May 2012. The prevalence (colonisation or infection) of inpatient cases with methicillin-resistant S. aureus (MRSA), vancomycin resistant S. aureus (VRSA), vancomycin resistant E. faecalis/E. faecium (VR-E. faecalis/VR-E. faecium), extended-spectrum-beta-lactamase-producing E. coli (ESBL-EC) and K. pneumoniae (ESBL-KP), multiresistant Acinetobacter spp. (MAB), multiresistant Pseudomonas spp. (MRP), carbapenemase-producing Enterobacteriaceae (CRE) as well as infections with Clostridium difficile (CD) were assessed. Out of 45 hospitals asked to participate, 89% sent back forms. Forms were filled out mostly by infection control personnel. In total 7154 patients were included. The most frequently reported MDROs were MRSA (prevalence: 1.37% of all included patients), ESBL-EC (1.12%), ESBL-KP (0.43%) and VRE (0.38%). VRSA and CRE were not reported. The prevalence of MRP (0.13%) and MAB (0.03%), was very low. The most frequently reported pathogen was CD (1.66%). Point prevalence surveys are a feasible way to gain regional data on the epidemiology of MDROs and to raise local awareness. Staffing with infection control personnel remains an issue, given the prevalence of nosocomial pathogens.