Genomic Epidemiology of Complex, Multispecies, Plasmid-Borne blaKPC Carbapenemase in Enterobacterales in the United Kingdom from 2009 to 2014.

Carbapenem resistance in Enterobacterales is a public health threat. Klebsiella pneumoniae carbapenemase (encoded by alleles of the blaKPC family) is one of the most common transmissible carbapenem resistance mechanisms worldwide. The dissemination of blaKPC historically has been associated with distinct K. pneumoniae lineages (clonal group 258 [CG258]), a particular plasmid family (pKpQIL), and a composite transposon (Tn4401). In the United Kingdom, blaKPC has represented a large-scale, persistent management challenge for some hospitals, particularly in North West England. The dissemination of blaKPC has evolved to be polyclonal and polyspecies, but the genetic mechanisms underpinning this evolution have not been elucidated in detail; this study used short-read whole-genome sequencing of 604 blaKPC-positive isolates (Illumina) and long-read assembly (PacBio)/polishing (Illumina) of 21 isolates for characterization. We observed the dissemination of blaKPC (predominantly blaKPC-2; 573/604 [95%] isolates) across eight species and more than 100 known sequence types. Although there was some variation at the transposon level (mostly Tn4401a, 584/604 [97%] isolates; predominantly with ATTGA-ATTGA target site duplications, 465/604 [77%] isolates), blaKPC spread appears to have been supported by highly fluid, modular exchange of larger genetic segments among plasmid populations dominated by IncFIB (580/604 isolates), IncFII (545/604 isolates), and IncR (252/604 isolates) replicons. The subset of reconstructed plasmid sequences (21 isolates, 77 plasmids) also highlighted modular exchange among non-blaKPC and blaKPC plasmids and the common presence of multiple replicons within blaKPC plasmid structures (>60%). The substantial genomic plasticity observed has important implications for our understanding of the epidemiology of transmissible carbapenem resistance in Enterobacterales for the implementation of adequate surveillance approaches and for control.

Patient experience of hospital screening for carbapenemase-producing Enterobacteriaceae: A qualitative study.

AIM: To explore patients' accounts of screening and being managed for colonisation with the antimicrobial resistant organism, carbapenemase-producing Enterobacteriaceae (CPE), when in hospital. BACKGROUND: Antimicrobial resistance (AMR) has been identified as one of the biggest global health challenges of the 21st Century. As the threat from AMR grows, screening to identify patients who are colonised with resistant organisms such as CPE is becoming an increasingly important aspect of nursing practice, in order to reduce risk of transmission of infection within hospitals. There is currently little research evidence on the patient experience of hospital management of CPE colonisation. METHODS: Qualitative semi-structured telephone interviews were undertaken, using a topic guide. Nine patients participated in the study. The data were analysed thematically, and rigour was maintained through peer review. The COREQ checklist was used. RESULTS: Two main themes were identified: "I can't make sense of CPE," illustrating limitations in patients' understandings of CPE; and, "I feel as if they are saying it is my fault," indicating the feelings of responsibility and blame which patients experienced. CONCLUSIONS: This paper contributes original evidence to the limited literature on patients' experiences of being colonised with CPE. The findings suggest that support and information provided for patients by healthcare professionals needs to be based on current evidence-based guidance on the nature of CPE and its implications for patient care, as well as being responsive to patients' emotional needs. RELEVANCE TO CLINICAL PRACTICE: This study has international relevance for nursing practice. As the global threat of AMR grows, the demands on healthcare providers to manage resistant organisms and their implications for patient care within healthcare settings are increasing. Enabling healthcare professionals to engage sensitively with patients being managed for colonisation with CPE is paramount to providing patient-centred care.

Intraoperative interventions for preventing surgical site infection: an overview of Cochrane Reviews.

BACKGROUND: Surgical site infection (SSI) rates vary from 1% to 5% in the month following surgery. Due to the large number of surgical procedures conducted annually, the costs of these SSIs can be considerable in financial and social terms. Many interventions are used with the aim of reducing the risk of SSI in people undergoing surgery. These interventions can be broadly delivered at three stages: preoperatively, intraoperatively and postoperatively. The intraoperative interventions are largely focused on decontamination of skin using soap and antiseptics; the use of barriers to prevent movement of micro-organisms into incisions; and optimising the patient's own bodily functions to promote best recovery. Both decontamination and barrier methods can be aimed at people undergoing surgery and operating staff. Other interventions focused on SSI prevention may be aimed at the surgical environment and include methods of theatre cleansing and approaches to managing theatre traffic. OBJECTIVES: To present an overview of Cochrane Reviews of the effectiveness and safety of interventions, delivered during the intraoperative period, aimed at preventing SSIs in all populations undergoing surgery in an operating theatre. METHODS: Published Cochrane systematic reviews reporting the effectiveness of interventions delivered during the intraoperative period in terms of SSI prevention were eligible for inclusion in this overview. We also identified Cochrane protocols and title registrations for future inclusion into the overview. We searched the Cochrane Library on 01 July 2017. Two review authors independently screened search results and undertook data extraction and 'Risk of bias' and certainty assessment. We used the ROBIS (risk of bias in systematic reviews) tool to assess the quality of included reviews, and we used GRADE methods to assess the certainty of the evidence for each outcome. We summarised the characteristics of included reviews in the text and in additional tables. MAIN RESULTS: We included 32 Cochrane Reviews in this overview: we judged 30 reviews as being at low risk of bias and two at unclear risk of bias. Thirteen reviews had not been updated in the past three years. Two reviews had no relevant data to extract. We extracted data from 30 reviews with 349 included trials, totaling 73,053 participants. Interventions assessed included gloving, use of disposable face masks, patient oxygenation protocols, use of skin antiseptics for hand washing and patient skin preparation, vaginal preparation, microbial sealants, methods of surgical incision, antibiotic prophylaxis and methods of skin closure. Overall, the GRADE certainty of evidence for outcomes was low or very low. Of the 77 comparisons providing evidence for the outcome of SSI, seven provided high- or moderate-certainty evidence, 39 provided low-certainty evidence and 31 very low-certainty evidence. Of the nine comparisons that provided evidence for the outcome of mortality, five provided low-certainty evidence and four very low-certainty evidence.There is high- or moderate-certainty evidence for the following outcomes for these intraoperative interventions. (1) Prophylactic intravenous antibiotics administered before caesarean incision reduce SSI risk compared with administration after cord clamping (10 trials, 5041 participants; risk ratio (RR) 0.59, 95% confidence interval (CI) 0.44 to 0.81; high-certainty evidence - assessed by review authors). (2) Preoperative antibiotics reduce SSI risk compared with placebo after breast cancer surgery (6 trials, 1708 participants; RR 0.74, 95% CI 0.56 to 0.98; high-certainty evidence - assessed by overview authors). (3) Antibiotic prophylaxis probably reduce SSI risk in caesarean sections compared with no antibiotics (82 relevant trials, 14,407 participants; RR 0.40, 95% CI 0.35 to 0.46; moderate-certainty evidence; downgraded once for risk of bias - assessed by review authors). (4) Antibiotic prophylaxis probably reduces SSI risk for hernia repair compared with placebo or no treatment (17 trials, 7843 participants; RR 0.67, 95% CI 0.54 to 0.84; moderate-certainty evidence; downgraded once for risk of bias - assessed by overview authors); (5) There is currently no clear difference in the risk of SSI between iodine-impregnated adhesive drapes compared with no adhesive drapes (2 trials, 1113 participants; RR 1.03, 95% CI 0.66 to 1.60; moderate-certainty evidence; downgraded once for imprecision - assessed by review authors); (6) There is currently no clear difference in SSI risk between short-term compared with long-term duration antibiotics in colorectal surgery (7 trials; 1484 participants; RR 1.05 95% CI 0.78 to 1.40; moderate-certainty evidence; downgraded once for imprecision - assessed by overview authors). There was only one comparison showing negative effects associated with the intervention: adhesive drapes increase the risk of SSI compared with no drapes (5 trials; 3082 participants; RR 1.23, 95% CI 1.02 to 1.48; high-certainty evidence - rated by review authors). AUTHORS' CONCLUSIONS: This overview provides the most up-to-date evidence on use of intraoperative treatments for the prevention of SSIs from all currently published Cochrane Reviews. There is evidence that some interventions are useful in reducing SSI risk for people undergoing surgery, such as antibiotic prophylaxis for caesarean section and hernia repair, and also the timing of prophylactic intravenous antibiotics administered before caesarean incision. Also, there is evidence that adhesive drapes increase SSI risk. Evidence for the many other treatment choices is largely of low or very low certainty and no quality-of-life or cost-effectiveness data were reported. Future trials should elucidate the relative effects of some treatments. These studies should focus on increasing participant numbers, using robust methodology and being of sufficient duration to adequately assess SSI. Assessment of other outcomes such as mortality might also be investigated as part of non-experimental prospective follow-up of people with SSI of different severity, so the risk of death for different subgroups can be better understood.

Systems and people under pressure: the discharge process in an acute hospital.

AIMS: To understand the perspective of hospital-based health professionals with regard to preparing patients for discharge from an acute hospital in England. BACKGROUND: The hospital experience in England over recent years is characterised by increasing admission rates and decreasing length of stay. Legislation and policy initiatives have also focussed upon the need to reduce delayed discharges. Discharge preparation is known to be a complex intervention with multiple obstacles within and outside of the hospital setting. DESIGN: Qualitative. METHODS: Posters were displayed within a hospital asking health professionals to take part in a focus group. Maximum variation, in terms of job titles, was sought for within the sample. Focus groups were held in December 2006. Six senior members of staff divided into pairs to run them. All groups were taped and transcribed verbatim and analysed using a framework approach. RESULTS: Three focus groups were conducted, which involved 11 nurses, 15 allied health professionals, five social workers and one doctor. Analysis identified the following themes and sub themes: 1 Conflicting pressures on staff: Keeping patients in hospital vs. getting them out; Striving for flexibility within a system; A paucity of intermediary provision. 2 Casualties arising from conflicting pressures: Professionals losing their sense of professionalism; Patients being 'systematised'. CONCLUSIONS: Pressures described during focus groups stemmed from five main sources: external targets placed upon the system, internal hospital inflexibility and poor communication, the dominance of the medical model of care, a desire to address the complex needs of individuals and a lack of community services. Staff felt themselves to be victims of these competing pressures and that many of the solutions were beyond their influence. Staff described the dehumanising effect of sometimes having to ignore patient concerns, wishes and choices. RELEVANCE TO CLINICAL PRACTICE: Understanding of the pressures surrounding discharge could inform relevant service improvements.