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Multicenter Study
. 2020 May 11;221(11):1782-1794.
doi: 10.1093/infdis/jiz288.

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

Sarah M Bartsch  1   2 , Kim F Wong  3 , Owen J Stokes-Cawley  1   2 , James A McKinnell  4   5 , Chenghua Cao  6   7 , Gabrielle M Gussin  6   7 , Leslie E Mueller  1   2 , Diane S Kim  6   7 , Loren G Miller  5 , Susan S Huang  6   7 , Bruce Y Lee  1   2
Affiliations
Multicenter Study

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

Sarah M Bartsch et al. J Infect Dis. .

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.

Keywords: CRE; burden; detection; iceberg; unknown carriers.

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Figures

Figure 1.
Figure 1.
Simulated average prevalence of carbapenem-resistant Enterobacteriaceae (CRE) over time when detecting various fractions of CRE carriers in all healthcare facilities since CRE introduction in all healthcare facilities countywide (A), acute care hospitals countywide (B), long-term acute care hospitals (LTACHs) countywide (C), and nursing homes countywide (D). Scenarios assumed a 40% effectiveness of contact precautions and a 50% likelihood of interfacility communication of a transferring patient’s CRE status.
Figure 2.
Figure 2.
Simulated average prevalence of carbapenem-resistant Enterobacteriaceae (CRE) over time when detecting various fractions of CRE carriers in all healthcare facilities when CRE is already present in all healthcare facilities countywide (A), acute care hospitals countywide (B), long-term acute care hospitals (LTACHs) countywide (C), and nursing homes countywide (D). Scenarios assumed a 40% effectiveness of contact precautions and a 50% likelihood of interfacility communication of a transferring patient’s CRE status.
Figure 3.
Figure 3.
Number of new carbapenem-resistant Enterobacteriaceae (CRE) carriers per month since CRE introduction over 10 years when increasing the fraction of CRE carriers detected in all healthcare facilities countywide and by facility type for various levels of contact precautions effectiveness. Scenarios assumed 50% likelihood of interfacility communication of a transferring patient’s CRE status.
Figure 4.
Figure 4.
Number of new carbapenem-resistant Enterobacteriaceae (CRE) carriers per month when CRE was already present over 10 years when increasing the fraction of CRE carriers detected in all healthcare facilities countywide and by facility type for various levels of contact precautions effectiveness. Scenarios assumed 50% likelihood of interfacility communication of a transferring patient’s CRE status.
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