Control of Carbapenem-resistant Enterobacteriaceae, Acinetobacter baumannii, and Pseudomonas aeruginosa in Healthcare Facilities: A Systematic Review and Reanalysis of Quasi-experimental Studies

Abstract

Carbapenem-resistant Enterobacteriaceae (CRE), Acinetobacter baumannii (CRAB), and Pseudomonas aeruginosa (CRPsA) are a serious cause of healthcare-associated infections, although the evidence for their control remains uncertain. We conducted a systematic review and reanalysis to assess infection prevention and control (IPC) interventions on CRE-CRAB-CRPsA in inpatient healthcare facilities to inform World Health Organization guidelines. Six major databases and conference abstracts were searched. Before-and-after studies were reanalyzed as interrupted time series if possible. Effective practice and organization of care (EPOC) quality criteria were used. Seventy-six studies were identified, of which 17 (22%) were EPOC-compatible and interrupted time series analyses, assessing CRE (n = 11; 65%), CRAB (n = 5; 29%) and CRPsA (n = 3; 18%). IPC measures were often implemented using a multimodal approach (CRE: 10/11; CRAB: 4/5; CRPsA: 3/3). Among all CRE-CRAB-CRPsA EPOC studies, the most frequent intervention components included contact precautions (90%), active surveillance cultures (80%), monitoring, audit and feedback of measures (80%), patient isolation or cohorting (70%), hand hygiene (50%), and environmental cleaning (40%); nearly all studies with these interventions reported a significant reduction in slope and/or level. The quality of EPOC studies was very low to low.

Keywords: Acinetobacter; Pseudomonas; Enterobacteriaceae; carbapenem resistance; prevention and control.

Figure 1.

Flow chart of study selection. Abbreviations: CRAB, carbapenem-resistant Acinetobacter baumannii; CRE, carbapenem-resistant Enterobacteriaceae; CRPsA, carbapenem-resistant Pseudomonas aeruginosa; EPOC, effective practice and organization of care. *Includes 3 studies that described CRE, CRAB and CRPsA; 1 study that described CRE and CRAB; and 2 studies that described CRAB and CRPsA. **Includes one study that described both CRE and CRAB.

Figure 2.

Summary of effective practice and organization of care studies showing significant decrease in slope (ie, trend) or level (ie, immediate change) from pre-intervention to post-intervention periods. Abbreviations: CRAB, carbapenem-resistant Acinetobacter baumannii; CRE, carbapenem-resistant Enterobacteriaceae; CRPsA, carbapenem-resistant Pseudomonas aeruginosa.

Figure 3.

Selected results of high-quality carbapenem-resistant Enterobacteriaceae (CRE) studies with change in both slope (ie, trend) and level (ie, immediate change) from pre-intervention to post-intervention. A, Ben-David et al: Intervention included active surveillance using rectal swabs of intensive care unit and step-down unit patients on admission/weekly and contacts; infected patient database to identify readmissions; contact precautions; daily prevalence reporting to management. B, Borer et al: Intervention included active surveillance of high-risk patients on admission/weekly; emergency department flagging to identify high-risk patients; contact precautions; cohort ward for positive cases with dedicated staff/equipment; cultures of environment and healthcare worker hands; carbapenem prescribing restriction policy; management reporting. C, Schwaber et al: Intervention included isolation measures; single rooms or cohorts including dedicated staff/equipment; re-isolation of known carriers on admission; creation of a task force on antimicrobial resistance and infection control that performed regular site visits; feedback to appointed hospital representatives; mandatory reporting to public health authorities; and distribution of guidelines for active CRE surveillance in acute-care hospitals later in the intervention period. D, Kim at al: Intervention included contact precautions; cohorting; hand hygiene enforcement and compliance monitoring; enhanced antimicrobial stewardship. Abbreviation: CRE, carbapenem-resistant Enterobacteriaceae.