PRAISE: providing a roadmap for automated infection surveillance in Europe

Introduction: Healthcare-associated infections (HAI) are among the most common adverse events of medical care. Surveillance of HAI is a key component of successful infection prevention programmes. Conventional surveillance - manual chart review - is resource intensive and limited by concerns regarding interrater reliability. This has led to the development and use of automated surveillance (AS). Many AS systems are the product of in-house development efforts and heterogeneous in their design and methods. With this roadmap, the PRAISE network aims to provide guidance on how to move AS from the research setting to large-scale implementation, and how to ensure the delivery of surveillance data that are uniform and useful for improvement of quality of care. Methods: The PRAISE network brings together 30 experts from ten European countries. This roadmap is based on the outcome of two workshops, teleconference meetings and review by an independent panel of international experts. Results: This roadmap focuses on the surveillance of HAI within networks of healthcare facilities for the purpose of comparison, prevention and quality improvement initiatives. The roadmap does the following: discusses the selection of surveillance targets, different organizational and methodologic approaches and their advantages, disadvantages and risks; defines key performance requirements of AS systems and suggestions for their design; provides guidance on successful implementation and maintenance; and discusses areas of future research and training requirements for the infection prevention and related disciplines. The roadmap is supported by accompanying documents regarding the governance and information technology aspects of implementing AS. Conclusions: Large-scale implementation of AS requires guidance and coordination within and across surveillance networks. Transitions to large-scale AS entail redevelopment of surveillance methods and their interpretation, intensive dialogue with stakeholders and the investment of considerable resources. This roadmap can be used to guide future steps towards implementation, including designing solutions for AS and practical guidance checklists

National Surveillance for Clostridioides difficile Infection, Sweden, 2009–2016

We report results from a national surveillance program for Clostridioides difficile infection (CDI) in Sweden, where CDI incidence decreased by 22% and the proportion of multidrug-resistant isolates decreased by 80% during 2012–2016. Variation in incidence between counties also diminished during this period, which might be attributable to implementation of nucleic acid amplification testing as the primary diagnostic tool for most laboratories. In contrast to other studies, our study did not indicate increased CDI incidence attributable the introduction of nucleic acid amplification testing. Our results also suggest that successful implementation of hygiene measures is the major cause of the observed incidence decrease. Despite substantial reductions in CDI incidence and prevalence of multidrug-resistant isolates, Sweden still has one of the highest CDI incidence levels in Europe. This finding is unexpected and warrants further investigation, given that Sweden has among the lowest levels of antimicrobial drug use

Preventing introduction of livestock associated MRSA in a pig population--benefits, costs, and knowledge gaps from the Swedish perspective.

Antibiotic resistance is a growing concern in human, as well as in veterinary medicine. Part of the problem concerns how to respond to the risk presented by animal reservoirs of resistant bacteria with the potential of spreading to humans. One example is livestock associated methicillin-resistant Staphylococcus aureus (LA-MRSA). In countries where LA-MRSA is endemic in the pig population, people in contact with pigs have a higher risk of being colonised with LA-MRSA, and persons from this group are subjected to precautionary measures when visiting health care facilities. In the present study, it is assumed that, if LA-MRSA was introduced to the Swedish pig population, the prevalence in the risk groups would be the same as in Denmark or the Netherlands (two countries with low human prevalence that have implemented measures to detect, trace and isolate human LA-MRSA cases and, therefore, have comprehensive data with good coverage regarding prevalence of LA-MRSA), and that similar interventions would be taken in Swedish health care facilities. It is also assumed that the Swedish pig population is free of MRSA or that the prevalence is very low. We analyse if it would be efficient for Sweden to prevent its introduction by testing imported live breeding pigs. Given that quarantining and testing at import will prevent introduction to the pig population, the study shows that the preventive measures may indeed generate a societal net benefit. Benefits are estimated to be between € 870 720 and € 1 233 511, and costs to € 211 129. Still, due to gaps in knowledge, the results should be confirmed when more information become available

High Gastrointestinal Colonization Rate with Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae in Hospitalized Patients: Emergence of Carbapenemase-Producing K. pneumoniae in Ethiopia.

We investigated the gastrointestinal colonization rate and antibiotic resistance patterns of Extended-Spectrum Beta-Lactamase (ESBL)- producing Escherichia coli and Klebsiella pneumoniae in hospitalized patients admitted at Ethiopia's largest tertiary hospital. Fecal samples/swabs from 267 patients were cultured on chrome agar. ESBL. Bacterial species identification, verification of ESBL production and antibiotic susceptibility testing were done using Vitek 2 system (bioMérieux, France). Phenotype characterization of ESBL-E.coli and ESBL- K.pneumoniae was done using Neo-Sensitabs™. ESBL positivity rate was much higher in K. pneumoniae (76%) than E. coli (45%). The overall gastrointestinal colonization rate of ESBL producing Enterobacteriaceae (ESBL-E) in hospitalized patients was 52% (95%CI; 46%-58%) of which, ESBL-E. coli and K.pneumoniae accounted for 68% and 32% respectively. Fecal ESBL-E carriage rate in neonates, children and adults was 74%, 59% and 46% respectively. Gastrointestinal colonization rate of ESBL-E.coli in neonates, children and adults was 11%, 42% and 42% respectively. Of all E. coli strains isolated from adults, children and neonates, 44%, 49% and 22% were ESBL positive (p = 0.28). The prevalence of ESBL-K.pneumoniae carriage in neonates, children and adults was 68%, 22% and 7% respectively. All K. pneumoniae isolated from neonates (100%) and 88% of K. pneumoniae isolated from children were ESBL positive, but only 50% of K.pneumoniae isolated from adults were ESBL positive (p = 0.001). Thirteen patients (5%) were carriers of both ESBL-E.coli and ESBL-KP. The overall carrier rate of ESBL producing isolates resistant to carbapenem was 2% (5/267), all detected in children; three with E.coli HL cephalosporinase (AmpC), resistant to ertapenem and two with K. pneumoniae Carbapenemase (KPC) resistant to meropenem, ertapenem and impenem. We report a high gastrointestinal colonization rate with ESBL-E and the emergence of carbapenems-resistant K. pneumoniae in Ethiopia. Urgent implementation of infection control measures, and surveillance are urgently needed to limit the spread within healthcare facilities and further to the community

The Swedish risk group.

<p>^a)SvDHV.</p><p>^b)Swedish National Food Agency.</p><p>^c)SJV.</p><p>^d) According to Statistics Sweden, the average Swedish household consists of two persons.</p><p>The Swedish risk group.</p

Lessons learnt during 20 years of the Swedish strategic programme against antibiotic resistance

Increasing use of antibiotics and rising levels of bacterial resistance to antibiotics are a challenge to global health and development. Successful initiatives for containing the problem need to be communicated and disseminated. In Sweden, a rapid spread of resistant pneumococci in the southern part of the country triggered the formation of the Swedish strategic programme against antibiotic resistance, also known as Strama, in 1995. The creation of the programme was an important starting point for long-term coordinated efforts to tackle antibiotic resistance in the country. This paper describes the main strategies of the programme: committed work at the local and national levels; monitoring of antibiotic use for informed decision-making; a national target for antibiotic prescriptions; surveillance of antibiotic resistance for local, national and global action; tracking resistance trends; infection control to limit spread of resistance; and communication to raise awareness for action and behavioural change. A key element for achieving long-term changes has been the bottom-up approach, including working closely with prescribers at the local level. The work described here and the lessons learnt could inform countries implementing their own national action plans against antibiotic resistance

Event-tree for the risk group with respect to LA-MRSA interventions.

<p>Event-tree for the risk group with respect to LA-MRSA interventions.</p

Expected annual number of visits and probabilities in Fig 1.

<p>^a)Estimated using data from Swedish Board of Health and Welfare and SKL.</p><p>^b)Estimated using data from Andre et al [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0122875#pone.0122875.ref031" target="_blank">31</a>] and Swedish Board of Health and Welfare.</p><p>^c) Voss et al. [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0122875#pone.0122875.ref032" target="_blank">32</a>], Wulf et al. [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0122875#pone.0122875.ref037" target="_blank">37</a>], van den Broek et al. [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0122875#pone.0122875.ref033" target="_blank">33</a>], van Cleef et al [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0122875#pone.0122875.ref034" target="_blank">34</a>].</p><p>^d)van den Broek et al. [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0122875#pone.0122875.ref033" target="_blank">33</a>].</p><p>^e)van Cleef et al. [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0122875#pone.0122875.ref035" target="_blank">35</a>], and Gilbert et al [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0122875#pone.0122875.ref036" target="_blank">36</a>].</p><p>^f)Wulf et al [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0122875#pone.0122875.ref037" target="_blank">37</a>].</p><p>^g)Computed from <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0122875#pone.0122875.t001" target="_blank">Table 1</a> above.</p><p>^h)Personal communication, FOI.</p><p>Expected annual number of visits and probabilities in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0122875#pone.0122875.g001" target="_blank">Fig 1</a>.</p

Probability of at least one boar being MRSA-positive, annual number of imported boars, batches, insemination doses produced per boar, and prices of insemination doses (€, 2011 prices).

<p>^a)Based on the herd prevalence of MRSA in Norway in 2012 [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0122875#pone.0122875.ref047" target="_blank">47</a>].</p><p>^b)Personal communication, breeding companies.</p><p>^c)Breeding companies’ home pages [45, 46 both accessed 2014-04-23.</p><p>Probability of at least one boar being MRSA-positive, annual number of imported boars, batches, insemination doses produced per boar, and prices of insemination doses (€, 2011 prices).</p

Cost for MRSA-test, destruction of MRSA-positive boars (€, 2011 prices) and price elasticity.

<p>^a)Personal communication SJV and SvDHV.</p><p>^b) Personal communication SVA.</p><p>^c)Personal communication Svensk Lantbrukstjänst.</p><p>^d)Breeding companies’ homepages (<a href="http://avelspoolen.se" target="_blank">http://avelspoolen.se</a> and <a href="http://www.qgenetics.se" target="_blank">http://www.qgenetics.se</a>) both accessed 2014-04-23.</p><p>Cost for MRSA-test, destruction of MRSA-positive boars (€, 2011 prices) and price elasticity.</p