Abstract：
BACKGROUND: Spread of resistant bacteria causes severe morbidity and mortality. Stringent control measures can be expensive and disrupt hospital organization. In the present study, we assessed the effectiveness and cost-effectiveness of control strategies to prevent the spread of Carbapenemase-producing Enterobacterales (CPE) in a general hospital ward (GW).
METHODS: A dynamic, stochastic model simulated the transmission of CPE by the hands of healthcare workers (HCWs) and the environment in a hypothetical 25-bed GW. Input parameters were based on published data; we assumed the prevalence at admission of 0.1%. 12 strategies were compared to the baseline (no control) and combined different prevention and control interventions: targeted or universal screening at admission (TS or US), contact precautions (CP), isolation in a single room, dedicated nursing staff (DNS) for carriers and weekly screening of contact patients (WSC). Time horizon was one year. Outcomes were the number of CPE acquisitions, costs, and incremental cost-effectiveness ratios (ICER). A hospital perspective was adopted to estimate costs, which included laboratory costs, single room, contact precautions, staff time, i.e. infection control nurse and/or dedicated nursing staff, and lost bed-days due to prolonged hospital stay of identified carriers. The model was calibrated on actual datasets. Sensitivity analyses were performed.
RESULTS: The baseline scenario resulted in 0.93 CPE acquisitions/1000 admissions and costs 32,050 €/1000 admissions. All control strategies increased costs and improved the outcome. The efficiency frontier was represented by: (1) TS with DNS at a 17,407 €/avoided CPE case, (2) TS + DNS + WSC at a 30,700 €/avoided CPE case and (3) US + DNS + WSC at 181,472 €/avoided CPE case. Other strategies were dominated. Sensitivity analyses showed that TS + CP might be cost-effective if CPE carriers are identified upon admission or if the cases have a short hospital stay. However, CP were effective only when high level of compliance with hand hygiene was obtained.
CONCLUSIONS: Targeted screening at admission combined with DNS for identified CPE carriers with or without weekly screening were the most cost-effective options to limit the spread of CPE. These results support current recommendations from several high-income countries.
METHODS: A dynamic, stochastic model simulated the transmission of CPE by the hands of healthcare workers (HCWs) and the environment in a hypothetical 25-bed GW. Input parameters were based on published data; we assumed the prevalence at admission of 0.1%. 12 strategies were compared to the baseline (no control) and combined different prevention and control interventions: targeted or universal screening at admission (TS or US), contact precautions (CP), isolation in a single room, dedicated nursing staff (DNS) for carriers and weekly screening of contact patients (WSC). Time horizon was one year. Outcomes were the number of CPE acquisitions, costs, and incremental cost-effectiveness ratios (ICER). A hospital perspective was adopted to estimate costs, which included laboratory costs, single room, contact precautions, staff time, i.e. infection control nurse and/or dedicated nursing staff, and lost bed-days due to prolonged hospital stay of identified carriers. The model was calibrated on actual datasets. Sensitivity analyses were performed.
RESULTS: The baseline scenario resulted in 0.93 CPE acquisitions/1000 admissions and costs 32,050 €/1000 admissions. All control strategies increased costs and improved the outcome. The efficiency frontier was represented by: (1) TS with DNS at a 17,407 €/avoided CPE case, (2) TS + DNS + WSC at a 30,700 €/avoided CPE case and (3) US + DNS + WSC at 181,472 €/avoided CPE case. Other strategies were dominated. Sensitivity analyses showed that TS + CP might be cost-effective if CPE carriers are identified upon admission or if the cases have a short hospital stay. However, CP were effective only when high level of compliance with hand hygiene was obtained.
CONCLUSIONS: Targeted screening at admission combined with DNS for identified CPE carriers with or without weekly screening were the most cost-effective options to limit the spread of CPE. These results support current recommendations from several high-income countries.
摘要：
背景：耐药细菌的传播会导致严重的发病率和死亡率。严格的控制措施可能是昂贵的，并且会破坏医院的组织。在本研究中,我们评估了预防产碳青霉烯酶肠杆菌(CPE)在综合医院病房(GW)中传播的控制策略的有效性和成本效益.
方法：动态，随机模型模拟了假设的25床GW中医护人员（HCWs）和环境的CPE传输。输入参数基于已发布的数据；我们假设入院时的患病率为0.1％。将12种策略与基线（无对照）进行比较，并结合不同的预防和控制干预措施：入院时的针对性或普遍筛查（TS或US），接触预防措施(CP),隔离在一个房间里，专职护理人员（DNS）为携带者和每周筛查接触患者（WSC）。时间跨度是一年。结果是CPE收购的数量，成本,和增量成本效益比(ICER)。采用医院的观点来估计成本，其中包括实验室费用，单人间,接触预防措施,员工时间,即感染控制护士和/或专职护理人员，以及由于已确定的携带者的住院时间延长而导致的床位减少。该模型在实际数据集上进行了校准。进行了敏感性分析。
结果：基准情景导致0.93CPE购置/1000入场和成本32,050€/1000入场。所有控制策略都增加了成本并改善了结果。效率边界表示为：（1）TS与DNS在17,407欧元/避免CPE情况下，（2）TS+DNS+WSC为30,700欧元/避免CPE案件，（3）US+DNS+WSC为181,472欧元/避免CPE案件。其他策略占主导地位。敏感性分析表明，如果入院时确定CPE携带者或住院时间短，则TSCP可能具有成本效益。然而,CP仅在获得高水平的手部卫生依从性时才有效。
结论：入院时进行有针对性的筛查，结合DNS对已确定的CPE携带者进行每周或不进行每周筛查，是限制CPE传播的最具成本效益的选择。这些结果支持了几个高收入国家目前的建议。
方法：动态，随机模型模拟了假设的25床GW中医护人员（HCWs）和环境的CPE传输。输入参数基于已发布的数据；我们假设入院时的患病率为0.1％。将12种策略与基线（无对照）进行比较，并结合不同的预防和控制干预措施：入院时的针对性或普遍筛查（TS或US），接触预防措施(CP),隔离在一个房间里，专职护理人员（DNS）为携带者和每周筛查接触患者（WSC）。时间跨度是一年。结果是CPE收购的数量，成本,和增量成本效益比(ICER)。采用医院的观点来估计成本，其中包括实验室费用，单人间,接触预防措施,员工时间,即感染控制护士和/或专职护理人员，以及由于已确定的携带者的住院时间延长而导致的床位减少。该模型在实际数据集上进行了校准。进行了敏感性分析。
结果：基准情景导致0.93CPE购置/1000入场和成本32,050€/1000入场。所有控制策略都增加了成本并改善了结果。效率边界表示为：（1）TS与DNS在17,407欧元/避免CPE情况下，（2）TS+DNS+WSC为30,700欧元/避免CPE案件，（3）US+DNS+WSC为181,472欧元/避免CPE案件。其他策略占主导地位。敏感性分析表明，如果入院时确定CPE携带者或住院时间短，则TSCP可能具有成本效益。然而,CP仅在获得高水平的手部卫生依从性时才有效。
结论：入院时进行有针对性的筛查，结合DNS对已确定的CPE携带者进行每周或不进行每周筛查，是限制CPE传播的最具成本效益的选择。这些结果支持了几个高收入国家目前的建议。
