Factors potentially contributing to the decline of the mpox outbreak in the Netherlands, 2022 and 2023.

BackgroundIn 2022 and 2023, a global outbreak of mpox affected mostly gay, bisexual and other men having sex with men (GBMSM). Outbreak control in the Netherlands included isolation, quarantine, post-exposure prophylaxis vaccination and primary preventive vaccination (PPV).AimWe describe the course of the outbreak, the vaccination programme, vaccine effectiveness (VE) of full vaccination against symptomatic disease, and trends in behaviour to generate hypotheses about factors that influenced the outbreak's decline.MethodsIn this observational study, we collected data from public health services on notified cases, number of PPV invitations and PPV doses administered. We calculated PPV uptake and coverage. Trends in behavioural data of GBMSM visiting sexual health centres were analysed for all consultations in 2022. We estimated VE using the screening method.ResultsUntil 31 December 2023, 1,294 mpox cases were reported. The outbreak peaked in early July 2022 and then declined sharply. PPV started on 25 July 2022; in total 29,851 doses were administered, 45.8% received at least one dose, 35.4% were fully vaccinated. The estimated VE was 68.2% (95% CI 4.3-89.5%). We did not observe an evident decrease in high-risk behaviour.DiscussionIt is unlikely that PPV was a driver of the outbreak's decline, as incidence started to decline well before the start of the PPV programme. The possible impact of behavioural change could not be demonstrated with the available indicators, however, the data had limitations, hampering interpretation. We hypothesise that infection-induced immunity in high-risk groups was an important factor explaining the decline.

Quality of antibiotic prescribing for pediatric community-acquired Pneumonia in outpatient care.

BACKGROUND: Antibiotics remain the primary treatment for community acquired pneumonia (CAP), however rising rates of antimicrobial resistance may jeopardize their future efficacy. With higher rates of disease reported in the youngest populations, effective treatment courses for pediatric pneumonia are of paramount importance. This study is the first to examine the quality of pediatric antibiotic use by agent, dose and duration. METHODS: A retrospective cohort study included all outpatient/primary care physician visits for pediatric CAP (aged < 19 years) between January 1 2014 to December 31 2018. Relevant practice guidelines were identified, and treatment recommendations extracted. Amoxicillin was the primary first-line agent for pediatric CAP. Categories of prescribing included: guideline adherent, effective but unnecessary (excess dose and/or duration), under treatment (insufficient dose and/or duration), and not recommended. Proportions of attributable-antibiotic use were examined by prescribing category, and then stratified by age and sex. RESULT(S): A total of 42,452 episodes of pediatric CAP were identified. Of those, 31,347 (76%) resulted in an antibiotic prescription. Amoxicillin accounted for 51% of all prescriptions. Overall, 27% of prescribing was fully guideline adherent, 19% effective but unnecessary, 10% under treatment, and 44% not recommended by agent. Excessive duration was the hallmark of effective but unnecessary prescribing (97%) Macrolides accounted for the majority on non-first line agent use, with only 32% of not recommended prescribing preceded by a previous course of antibiotics. CONCLUSION(S): This study is the first in Canada to examine prescribing quality for pediatric CAP by agent, dose and duration. Utilizing first-line agents, and shorter-course treatments are targets for stewardship.

Nursing care for patients carrying multi-drug resistant organisms: Experiences, intention to use protective equipment and ability to comply with measures.

AIMS: The aims of the study were to explore the impact of caring for patients carrying multi-drug resistant organisms on nursing staff and identify factors predicting their intention to use personal protective equipment and their ability to comply with advised infection prevention and control measures. BACKGROUND: Carriage of multi-drug resistant organisms and corresponding infection prevention and control measures have a major impact on patients. Limited research has been done to investigate the impact of caring for these patients on nursing staff. DESIGN: A cross-sectional design. METHODS: Online survey among Dutch nursing staff in various healthcare settings. Prediction analyses were conducted using random forest. The STROBE checklist was used preparing the manuscript. RESULTS: 974 respondents were included. The majority of nursing staff reported to have experience in caring for patients carrying multi-drug resistant organisms. Relevant dilemmas in daily practice were identified. Important predictors of the intention to use protective equipment were practicing hand hygiene, usable protocols, favourable attitudes and perceptions, as well as knowledge. Important predictors of the ability to comply with advised measures were usable and findable protocols, a suitable work environment and practicing hand hygiene. CONCLUSION: We have gained comprehensive insight into experiences, attitudes, perceptions, knowledge and dilemmas in daily practice of nursing staff caring for patients carrying multi-drug resistant organisms. To enhance their intention to use protective equipment and their ability to comply with advised measures, activities should focus on improving hand hygiene and the usability of protocols. Additionally, efforts are needed to improve knowledge, provide better resources and a more supportive work environment. All of which need to be specifically tailored to each healthcare setting. RELEVANCE TO CLINICAL PRACTICE: The results can be used in the development of interventions to improve nursing care while reducing the unfavourable impact on nursing staff and supporting adherence to advised measures.

Rabies vaccination strategies in the Netherlands in 2018: a cost evaluation.

BackgroundThe risk of contracting rabies is low for travellers. However, the number of Dutch travellers potentially exposed abroad following an animal-associated injury and needing post-exposure prophylaxis (PEP) has increased, resulting in increased costs.AimHere, we evaluated the costs and the cost-effectiveness of different pre- and post-exposure interventions in the Netherlands, taking into account the 2018 World Health Organization (WHO) recommendations for the prevention of rabies.MethodsA decision tree-based economic model was constructed. We calculated and compared the cost of different WHO pre-exposure prophylaxis (PrEP) recommendations, intramuscular vs intradermal vaccination and PEP subsequent to increased vaccination coverage in risk groups. We estimated cost-effectiveness, expressed as incremental costs per rabies immunoglobulin (RIG) administration averted, using a societal perspective. Statistical uncertainty regarding number of travellers and vaccination coverage was assessed.ResultsTotal costs at the national level were highest using previous WHO recommendations from 2012, estimated at EUR 15.4 million annually. Intradermal vaccinations in combination with the current recommendations led to the lowest costs, estimated at EUR 10.3 million. Higher vaccination uptake resulted in higher overall costs. The incremental costs per RIG administration averted varied from EUR 21,300-46,800.ConclusionsThe change in rabies PrEP and PEP recommendations in 2018 reduced total costs. Strategies with increased pre-travel vaccination uptake led to fewer RIG administrations and fewer vaccinations after exposure but also to higher total costs. Although larger scale intradermal administration of rabies vaccine can reduce total costs of PrEP and can positively influence vaccination uptake, it remains a costly intervention.

Public health response to two imported, epidemiologically related cases of Lassa fever in the Netherlands (ex Sierra Leone), November 2019.

On 20 November 2019, Lassa fever was diagnosed in a physician repatriated from Sierra Leone to the Netherlands. A second physician with suspected Lassa fever, repatriated a few days later from the same healthcare facility, was confirmed infected with Lassa virus on 21 November. Comprehensive contact monitoring involving high- and low-risk contacts proved to be feasible and follow-up of the contacts did not reveal any case of secondary transmission in the Netherlands.

Perceptions of Dutch nurses carrying methicillin-resistant Staphylococcus aureus: a qualitative study.

BACKGROUND: Carriers of methicillin-resistant Staphylococcus aureus (MRSA) experience a variety of personal and social consequences, despite the asymptomatic nature of carriage. Some of these consequences are inherent to the application in practice of strict infection prevention guidelines. However, the experiences of nurses carrying MRSA have not been documented. This study aimed to describe the experiences of nurses carrying MRSA to get insight into the impact of MRSA carriage on nurses in a country with a "search-and-destroy" policy for MRSA. METHODS: A qualitative study was conducted among eighteen nurses who experienced MRSA carriage and were working in healthcare organizations in the Netherlands (e.g. hospitals, nursing homes and home care). Semi-structured interviews were conducted using an interview guide. The interviews were audio tape recorded, transcribed and analyzed using thematic analysis. RESULTS: MRSA carriage has an impact on the life of nurses during four distinct phases: becoming aware of carrying MRSA, processing information and guidance, experiencing consequences of carriage and, when applicable, a life after eradication of MRSA. Each phase was found to be associated with negative consequences. The impact of MRSA carriage on the daily life of nurses is mostly influenced by the experience of consequences of MRSA carriage - including a ban to work with patients, eradication treatment with antibiotics, and social isolation from others - despite the asymptomatic nature of MRSA carriage itself. In addition, lack of information and guidance increased the impact of carriage. CONCLUSIONS: This study shows nurses experience various consequences of MRSA carriage, despite the asymptomatic nature of carriage. The work ban, eradication treatment and social isolation influenced the nurses' work-related future, personal health and social environment. The impact of carriage may be reduced by clear information and guidance, and support from others. Therefore, sufficient information and guidance needs to be given to MRSA carriers by healthcare organizations.

Case of seasonal reassortant A(H1N2) influenza virus infection, the Netherlands, March 2018.

A seasonal reassortant A(H1N2) influenza virus harbouring genome segments from seasonal influenza viruses A(H1N1)pdm09 (HA and NS) and A(H3N2) (PB2, PB1, PA, NP, NA and M) was identified in March 2018 in a 19-months-old patient with influenza-like illness (ILI) who presented to a general practitioner participating in the routine sentinel surveillance of ILI in the Netherlands. The patient recovered fully. Further epidemiological and virological investigation did not reveal additional cases.

Small distances can keep bacteria at bay for days.

Transmission of pathogens between spatially separated hosts, i.e., indirect transmission, is a commonly encountered phenomenon important for epidemic pathogen spread. The routes of indirect transmission often remain untraced, making it difficult to develop control strategies. Here we used a tailor-made design to study indirect transmission experimentally, using two different zoonotic bacteria in broilers. Previous experiments using a single bacterial species yielded a delay in the onset of transmission, which we hypothesized to result from the interplay between diffusive motion of infectious material and decay of infectivity in the environment. Indeed, a mathematical model of diffusive pathogen transfer predicts a delay in transmission that depends both on the distance between hosts and on the magnitude of the pathogen decay rate. Our experiments, carried out with two bacterial species with very different decay rates in the environment, confirm the difference in transmission delay predicted by the model. These results imply that for control of an infectious agent, the time between the distant exposure and the infection event is important. To illustrate how this can work we analyzed data observed on the spread of vancomycin-resistant Enterococcus in an intensive care unit. Indeed, a delayed vancomycin-resistant Enterococcus transmission component was identified in these data, and this component disappeared in a study period in which the environment was thoroughly cleaned. Therefore, we suggest that the impact of control strategies against indirect transmission can be assessed using our model by estimating the control measures' effects on the diffusion coefficient and the pathogen decay rate.

Prolonged colonisation with Escherichia coli O25:ST131 versus other extended-spectrum beta-lactamase-producing E. coli in a long-term care facility with high endemic level of rectal colonisation, the Netherlands, 2013 to 2014.

The extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli clone ST131 (ESBL-ST131) has spread in healthcare settings worldwide. The reasons for its successful spread are unknown, but might include more effective transmission and/or longer persistence. We evaluated the colonisation dynamics of ESBL-producing E. coli (ESBL-EC), including ESBL-ST131, in a long-term care facility (LTCF) with an unusually high prevalence of rectal ESBL-EC colonisation. During a 14-month period, rectal or faecal samples were obtained from 296 residents during six repetitive prevalence surveys, using ESBL-selective culture. Transmission rates, reproduction numbers, and durations of colonisation were compared for ESBL-ST131 vs other ESBL-EC. Furthermore, the likely time required for ESBL-ST131 to disappear from the LTCF was estimated. Over time, the endemic level of ESBL-ST131 remained elevated whereas other ESBL-EC returned to low-level prevalence, despite comparable transmission rates. Survival analysis showed a half-life of 13 months for ESBL-ST131 carriage, vs two to three months for other ESBL-EC (p < 0.001). Per-admission reproduction numbers were 0.66 for ESBL-ST131 vs 0.56 for other ESBL-EC, predicting a mean time of three to four years for ESBL-ST131 to disappear from the LTCF under current conditions. Transmission rates were comparable for ESBL-ST131 vs other ESBL-EC. Prolonged rectal carriage explained the persistence of ESBL-ST131 in the LTCF.

Retrospective cohort analysis of outpatient antibiotic prescribing for community-acquired pneumonia in Canadian older adults.

BACKGROUND: This retrospective cohort study is the first in North America to examine population-level appropriate antibiotic use for community-acquired pneumonia (CAP) in older adults, by agent, dose and duration. With the highest rates of CAP reported in the elderly populations, appropriate antibiotic use is essential to improve clinical outcomes. Given the ongoing crisis of antimicrobial resistance, understanding inappropriate antibiotic prescribing is integral to direct community stewardship efforts. METHODS: All outpatient primary care visits for CAP (aged ≥65 years) were identified using physician billing codes between January 1 2014 to December 31 2018 in British Columbia (BC) and Ontario (ON). Categories of prescribing were derived from existing literature, and constructed for clinical relevance using Canadian and international guidelines available during the study period. Categories were mutually exclusive and included: guideline adherent (first-line agent, adherent dose/duration), clinically appropriate (non-first line agent, presence of comorbidities), effective but unnecessary (first-line agent, excess dose/duration), undertreatment (first-line agent, subtherapeutic dose/duration), and not recommended (non-first line agent, absence of comorbidities). Proportions of prescribing were examined by category. Temporal trends in prescribing were examined using Poisson regression. RESULTS: A total of 436,441 episodes of CAP were identified, with 46% prescribed an antibiotic in BC, and 52% in Ontario. Guideline adherent prescribing was minimal for both provinces (BC: 2%; ON: 1%) however the largest magnitude of increase was reported in this category by the final study year (BC-Rate Ratio [RR]: 3.4, 95% Confidence Interval [CI]: 2.7-4.3; ON-RR: 4.62, 95% CI: 3.4-6.5). Clinically appropriate prescribing accounted for the most antibiotics issued, across all study years (BC: 61%; ON: 74%) (BC-RR: 0.8, 95% CI: 0.8-0.8; ON-RR: 0.9, 95% CI: 0.8-0.9). Excess duration of therapy was the hallmark characteristic for effective but unnecessary prescribing (BC: 92%; ON: 99%). The most common duration prescribed was 7 days, followed by 10. Not recommended prescribing was minimal in both provinces (BC: 4%; ON: 7%) and remained stable by the final study year (BC-RR: 1.1, 95% CI: 0.9-1.2; ON-RR: 0.9, 95% CI: 0.9-1.1). CONCLUSION: Three quarters of antibiotic prescribing for CAP was appropriate in Ontario, but only two thirds in BC. Shortening durations-in line with evidence for 3 to 5-day treatment presents a focused target for stewardship efforts.

A qualitative study examining the impact of multidrug-resistant organism (MDRO) carriage on the daily lives of carriers and parents of carriers with experiences of hospital precautionary measures.

BACKGROUND: Multidrug-resistant organism (MDRO) carriage may have an adverse impact on the quality of life of carriers, in particular those who have experienced hospital precautionary measures. This study aims to gain a deeper understanding of how MDRO carriage has affected the daily lives of carriers with these experiences. METHODS: This was a qualitative study based on 15 semi-structured interviews with MDRO carriers or parents of carriers, which were analysed by thematic analysis. RESULTS: Three main themes were identified: (1) Feeling dirty and unworthy portrays the feelings that MDRO carriers often expressed and how these were related to the language usage describing the MDRO, the perceived avoidance by staff and those in their personal networks, and the effects of the precautionary measures implemented in the hospital. (2) MDROs are invisible, but impact is visible covers how the microbe, despite its apparent invisibility, still impacted carriers in their physical and psychological health. MDRO carriage disrupted their lives, by affecting their other unrelated medical conditions at times and by causing varying levels of fear for their own and others' health. (3) Carrying the burden on one's own shoulders describes the lingering questions, uncertainties and confusion that carriers continued to live with and the perceived burden and responsibility that lay on their own shoulders with respect to carrying and preventing the transmission of the MDRO. CONCLUSIONS: MDRO carriage can negatively influence the quality of people's lives in various ways. Improved support and sensitivity from health care providers (HCPs) are needed to address feelings of unworthiness among MDRO carriers and the fears that many experience. Clearer information and guidelines are also needed from HCPs to address the many questions and uncertainties that MDRO carriers face outside of the hospital in their daily lives.

A Time Series Analysis Evaluating Antibiotic Prescription Rates in Long-Term Care during the COVID-19 Pandemic in Alberta and Ontario, Canada.

The COVID-19 pandemic affected access to care, and the associated public health measures influenced the transmission of other infectious diseases. The pandemic has dramatically changed antibiotic prescribing in the community. We aimed to determine the impact of the COVID-19 pandemic and the resulting control measures on oral antibiotic prescribing in long-term care facilities (LTCFs) in Alberta and Ontario, Canada using linked administrative data. Antibiotic prescription data were collected for LTCF residents 65 years and older in Alberta and Ontario from 1 January 2017 until 31 December 2020. Weekly prescription rates per 1000 residents, stratified by age, sex, antibiotic class, and selected individual agents, were calculated. Interrupted time series analyses using SARIMA models were performed to test for changes in antibiotic prescription rates after the start of the pandemic (1 March 2020). The average annual cohort size was 18,489 for Alberta and 96,614 for Ontario. A significant decrease in overall weekly prescription rates after the start of the pandemic compared to pre-pandemic was found in Alberta, but not in Ontario. Furthermore, a significant decrease in prescription rates was observed for antibiotics mainly used to treat respiratory tract infections: amoxicillin in both provinces (Alberta: −0.6 per 1000 LTCF residents decrease in weekly prescription rate, p = 0.006; Ontario: −0.8, p < 0.001); and doxycycline (−0.2, p = 0.005) and penicillin (−0.04, p = 0.014) in Ontario. In Ontario, azithromycin was prescribed at a significantly higher rate after the start of the pandemic (0.7 per 1000 LTCF residents increase in weekly prescription rate, p = 0.011). A decrease in prescription rates for antibiotics that are largely used to treat respiratory tract infections is in keeping with the lower observed rates for respiratory infections resulting from pandemic control measures. The results should be considered in the contexts of different LTCF systems and provincial public health responses to the pandemic.

Rabies risk behaviour in a cohort of Dutch travel clinic visitors: A retrospective analysis.

BACKGROUND: Travellers to rabies endemic countries should be counselled on rabies risk and, in case of high-risk, pre-exposure vaccination is advised. However, it is not clear which travellers exactly are at high risk. In this study we determined the incidence of possible rabies exposure in travel clinic visitors and compliance with pre-travel advice. METHODS: Travellers to rabies endemic countries who visited a Dutch travel clinic between September 2017 and May 2018, were invited to participate. RESULTS: Of 980 travellers, one percent was injured by a potentially rabid animal. Compliance with advice was low as 59% reported proximity to a potentially rabid animal and only half of those exposed sought medical advice. The most important predictors of proximity to a potentially rabid animal were young age, long travel duration, visiting a monkey forest and hiking for more than one day. Travel for business was associated with lower risk. CONCLUSION: Despite pre-travel advice, rabies risk behaviour was high. Therefore, we would recommend to keep the threshold for pre-travel vaccination low. Pending more data on rabies exposure risk, the identified predictors of proximity to potentially rabid animals could be used to tailor indications for pre-travel rabies vaccination.

Rapid SARS-CoV-2 whole-genome sequencing and analysis for informed public health decision-making in the Netherlands.

In late December 2019, a cluster of cases of pneumonia of unknown etiology were reported linked to a market in Wuhan, China1. The causative agent was identified as the species Severe acute respiratory syndrome-related coronavirus and was named SARS-CoV-2 (ref. 2). By 16 April the virus had spread to 185 different countries, infected over 2,000,000 people and resulted in over 130,000 deaths3. In the Netherlands, the first case of SARS-CoV-2 was notified on 27 February. The outbreak started with several different introductory events from Italy, Austria, Germany and France followed by local amplification in, and later also outside, the south of the Netherlands. The combination of near to real-time whole-genome sequence analysis and epidemiology resulted in reliable assessments of the extent of SARS-CoV-2 transmission in the community, facilitating early decision-making to control local transmission of SARS-CoV-2 in the Netherlands. We demonstrate how these data were generated and analyzed, and how SARS-CoV-2 whole-genome sequencing, in combination with epidemiological data, was used to inform public health decision-making in the Netherlands.

Author Correction: Rapid SARS-CoV-2 whole-genome sequencing and analysis for informed public health decision-making in the Netherlands.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

The public uptake of information about antibiotic resistance in the Netherlands.

In this study, we test to what extent an educational video on the intricacies of antibiotic resistance affects public attitudes towards antibiotic resistance and how such information is absorbed by the most likely targets of public health campaigns. We use a representative sample of 2037 individuals (from 2016) to test how people respond to a video educating them about antibiotic resistance. Our results show that receiving information does increase the general awareness of antibiotic resistance among our respondents. Yet, these effects are most profound for those who are the most likely targets of such information: the least knowledgeable group and those who have a more apathetic worldview. Our results are in line with suggestions made by the knowledge deficit model and show that the influence of cultural predispositions on the uptake of information about antibiotic resistance should not be ignored in future campaigns.

[Cluster of MRSA in the home care setting: strategy for conducting a contact investigation]. / Cluster van MRSA in de thuiszorg.

Isolating a methicillin-resistant Staphylococcus aureus (MRSA) from a client receiving home care can be a reason for source and contact investigation in the home setting. However, the management of MRSA in a home care setting differs from one during a hospital admission. We describe a case of a patient with MRSA in a home care situation where both the microbiologist from the regional hospital and the communicable disease control physician from the municipal health services were involved. This case illustrates the different perspectives and points of view from both specialties, and the multidisciplinary approach that led to a strategic plan. In this article we discuss a strategy for conducting a contact investigation in public health.

How prepared are we for cross-border outbreaks? An exploratory analysis of cross-border response networks for outbreaks of multidrug resistant microorganisms in the Netherlands and Germany.

BACKGROUND: The emergence and spread of multidrug resistant microorganisms is a serious threat to transnational public health. Therefore, it is vital that cross-border outbreak response systems are constantly prepared for fast, rigorous, and efficient response. This research aims to improve transnational collaboration by identifying, visualizing, and exploring two cross-border response networks that are likely to unfold during outbreaks involving the Netherlands and Germany. METHODS: Quantitative methods were used to explore response networks during a cross-border outbreak of carbapenem resistant Enterobacteriaceae in healthcare settings. Eighty-six Dutch and German health professionals reflected on a fictive but realistic outbreak scenario (response rate ≈ 70%). Data were collected regarding collaborative relationships between stakeholders during outbreak response, prior working relationships, and trust in the networks. Network analysis techniques were used to analyze the networks on the network level (density, centralization, clique structures, and similarity of tie constellations between two networks) and node level (brokerage measures and degree centrality). RESULTS: Although stakeholders mainly collaborate with stakeholders belonging to the same country, transnational collaboration is present in a centralized manner. Integration of the network is reached, since several actors are beneficially positioned to coordinate transnational collaboration. However, levels of trust are moderately low and prior-existing cross-border working relationships are sparse. CONCLUSION: Given the explored network characteristics, we conclude that the system has a promising basis to achieve effective coordination. However, future research has to determine what kind of network governance form might be most effective and efficient in coordinating the necessary cross-border response activity. Furthermore, networks identified in this study are not only crucial in times of outbreak containment, but should also be fostered in times of non-crisis.

Quantifying Hospital-Acquired Carriage of Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae Among Patients in Dutch Hospitals.

BACKGROUND Extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-E) are emerging worldwide. Contact precautions are recommended for known ESBL-E carriers to control the spread of ESBL-E within hospitals. OBJECTIVE This study quantified the acquisition of ESBL-E rectal carriage among patients in Dutch hospitals, given the application of contact precautions. METHODS Data were used from 2 cluster-randomized studies on isolation strategies for ESBL-E: (1) the SoM study, performed in 14 Dutch hospitals from 2011 through 2014 and (2) the R-GNOSIS study, for which data were limited to those collected in a Dutch hospital in 2014. Perianal cultures were obtained, either during ward-based prevalence surveys (SoM), or at admission and twice weekly thereafter (R-GNOSIS). In both studies, contact precautions were applied to all known ESBL-E carriers. Estimates for acquisition of ESBL-E were based on the results of admission and discharge cultures from patients hospitalized for more than 2 days (both studies) and a Markov chain Monte Carlo (MCMC) model, applied to all patients hospitalized (R-GNOSIS). RESULTS The absolute risk of acquisition of ESBL-E rectal carriage ranged from 2.4% to 2.9% with an ESBL-E acquisition rate of 2.8 to 3.8 acquisitions per 1,000 patient days. In addition, 28% of acquisitions were attributable to patient-dependent transmission, and the per-admission reproduction number was 0.06. CONCLUSIONS The low ESBL-E acquisition rate in this study demonstrates that it is possible to control the nosocomial transmission of ESBL in a low-endemic, non-ICU setting where Escherichia coli is the most prevalent ESBL-E and standard and contact precautions are applied for known ESBL-E carriers. TRIAL REGISTRATION Nederlands Trialregister, NTR2799, http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2799; ISRCTN Registry, ISRCTN57648070, http://www.isrctn.com/ISRCTN57648070 Infect Control Hosp Epidemiol 2018;39:32-39.

Modifiable Risk Factors for the Spread of Klebsiella pneumoniae Carbapenemase-Producing Enterobacteriaceae Among Long-Term Acute-Care Hospital Patients.

OBJECTIVE To identify modifiable risk factors for acquisition of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae (KPC) colonization among long-term acute-care hospital (LTACH) patients. DESIGN Multicenter, matched case-control study. SETTING Four LTACHs in Chicago, Illinois. PARTICIPANTS Each case patient included in this study had a KPC-negative rectal surveillance culture on admission followed by a KPC-positive surveillance culture later in the hospital stay. Each matched control patient had a KPC-negative rectal surveillance culture on admission and no KPC isolated during the hospital stay. RESULTS From June 2012 to June 2013, 2,575 patients were admitted to 4 LTACHs; 217 of 2,144 KPC-negative patients (10.1%) acquired KPC. In total, 100 of these patients were selected at random and matched to 100 controls by LTACH facility, admission date, and censored length of stay. Acquisitions occurred a median of 16.5 days after admission. On multivariate analysis, we found that exposure to higher colonization pressure (OR, 1.02; 95% CI, 1.01-1.04; P=.002), exposure to a carbapenem (OR, 2.25; 95% CI, 1.06-4.77; P=.04), and higher Charlson comorbidity index (OR, 1.14; 95% CI, 1.01-1.29; P=.04) were independent risk factors for KPC acquisition; the odds of KPC acquisition increased by 2% for each 1% increase in colonization pressure. CONCLUSIONS Higher colonization pressure, exposure to carbapenems, and a higher Charlson comorbidity index independently increased the odds of KPC acquisition among LTACH patients. Reducing colonization pressure (through separation of KPC-positive patients from KPC-negative patients using strict cohorts or private rooms) and reducing carbapenem exposure may prevent KPC cross transmission in this high-risk patient population. Infect Control Hosp Epidemiol 2017;38:670-677.