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Guidelines for the Prevention and Control of Carbapenem-Resistant Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa in Health Care Facilities. Geneva: World Health Organization; 2017.

Cover of Guidelines for the Prevention and Control of Carbapenem-Resistant Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa in Health Care Facilities

Guidelines for the Prevention and Control of Carbapenem-Resistant Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa in Health Care Facilities.

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References

1.
Cerceo E, Deitelzweig SB, Sherman BM, Amin AN. Multidrug-resistant gram-negative bacterial infections in the hospital setting: overview, implications for clinical practice, and emerging treatment options. Microb Drug Resist. 2016;22(5):412–31. [PubMed: 26866778]
2.
Kaye KS, Pogue JM. Infections caused by resistant gram-negative bacteria: epidemiology and management. Pharmacotherapy. 2015;35(10):949–62. [PubMed: 26497481]
3.
Labarca JA, Salles MJ, Seas C, Guzman-Blanco M. Carbapenem resistance in Pseudomonas aeruginosa and Acinetobacter baumannii in the nosocomial setting in Latin America. Crit Rev Microbiol. 2016;42(2):276–92. [PubMed: 25159043]
4.
Savard P, Perl TM. Combating the spread of carbapenemases in Enterobacteriaceae: a battle that infection prevention should not lose. Clin Microbiol Infect. 2014;20(9):854–61. [PubMed: 24980472]
5.
Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control. 2007;35(10 Suppl 2):S65–164. [PMC free article: PMC7119119] [PubMed: 18068815]
6.
WHO guidelines on hand hygiene in health care. Geneva: World Health Organization; 2009 (http://apps​.who.int/iris​/bitstream/10665​/44102/1/9789241597906_eng.pdf, accessed 26 October 2017).
7.
Hand hygiene technical reference mannual. Geneva: World Health Organization; 2009 (http://www​.who.int/infection-prevention​/tools​/handhygiene/evaluation_feedback​/en/, accessed 26 October 2017).
8.
Report on the endemic burden of healthcare-associated infection worldwide. Geneva: World Health Organization; 2011 (http://apps​.who.int/iris​/bitstream/10665​/80135/1/9789241501507_eng.pdf, accessed 26 October 2017).
9.
Allegranzi B, Bagheri Nejad S, Combescure C, Graafmans W, Attar H, Donaldson L, et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet. 2011;377(9761):228–41. [PubMed: 21146207]
10.
Shekelle PG PP, Wachter RM, McDonald KM, Schoelles K, Dy SM, et al. Top 10 patient safety strategies that can be encouraged for adoption now. Ann Intern Med. 2013;58(5 Pt 2):365–8. [PubMed: 23460091]
11.
Tangden T, Giske CG. Global dissemination of extensively drug-resistant carbapenemase-producing Enterobacteriaceae: clinical perspectives on detection, treatment and infection control. J Int Med. 2015;277(5): 501–12. [PubMed: 25556628]
12.
Core components for infection control prevention and control programmes. Geneva: World Health Organization; 2009 (http://www​.who.int/csr​/resources/publications​/WHO_HSE_EPR_2009_1/en/index.html, accessed 26 October 2017).
13.
Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016 (http://www​.who.int/gpsc​/ipc-components-guidelines/en/, accessed 26 October 2017). [PubMed: 27977095]
14.
WHO handbook for guideline development. 2nd ed. Geneva: World Health Organization; 2014 (http://apps​.who.int/iris​/bitstream/10665​/75146/1/9789241548441_eng.pdf, accessed 26 October 2017).
15.
Brozek JL, Akl EA, Alonso-Coello P, Lang D, Jaeschke R, Williams JW, et al. Grading quality of evidence and strength of recommendations in clinical practice guidelines. Part 1 of 3. An overview of the GRADE approach and grading quality of evidence about interventions. Allergy. 2009;64(5):669–77. [PubMed: 19210357]
16.
Antimicrobial resistance surveillance in Europe: technical report. Stockholm: European Centre for Disease Prevention and Control; 2015 (https://ecdc​.europa.eu​/sites/portal/files​/media/en/publications​/Publications/antimicrobialresistance-europe-2015.pdf, accessed 26 October 2017).
17.
Rapid risk assessment: carbapenem-resistant Acinetobacter baumannii in healthcare settings. Stockholm: European Centre for Disease Prevention and Control; 2016. (https://ecdc​.europa.eu​/sites/portal/files​/media/en/publications​/Publications/8-Dec-2016-RRA-Acinetobacter​%20baumannii-Europe.pdf, accessed 26 October 2017).
18.
Point prevalence survey of healthcare-associated infections and antimicrobial use in European hospitals 2011–2012. Stockholm: European Centre for Disease Prevention and Control; 2013. (https://ecdc​.europa.eu​/sites/portal/files​/media/en/publications​/Publications/healthcareassociated-infections-antimicrobial-use-PPS.pdf, accessed 26 October 2017).
19.
CDC’s Antibiotic Resistance Patient Safety Atlas 2016. Atlanta: Centers for Disease Control and Prevention; 2016 (http://www​.cdc.gov/hai​/surveillance/ar-patientsafety-atlas​.html, accessed 26 October 2017).
20.
Antimicrobial resistance: global report on surveillance 2014. Geneva: World Health Organization; 2014 (http://apps​.who.int/iris​/bitstream/10665​/112642/1/9789241564748_eng.pdf?ua=1, accessed 26 October 2017).
21.
Logan LK, Weinstein RA. The epidemiology of carbapenem-resistant Enterobacteriaceae: the impact and evolution of a global menace. J Infect Dise. 2017;215(Suppl. 1):S28–s36. [PMC free article: PMC5853342] [PubMed: 28375512]
22.
Castanheira M, Griffin MA, Deshpande LM, Mendes RE, Jones RN, Flamm RK. Detection of mcr-1 among Escherichia coli clinical isolates collected worldwide as part of the SENTRY Antimicrobial Surveillance Program in 2014 and 2015. Antimicrob Agents Chemother. 2016;60(9):5623–4. [PMC free article: PMC4997847] [PubMed: 27401568]
23.
Borgia S, Lastovetska O, Richardson D, Eshaghi A, Xiong J, Chung C, et al. Outbreak of carbapenem-resistant Enterobacteriaceae containing blaNDM-1, Ontario, Canada. Clin Infect Dis. 2012;55(11):e109–17. [PubMed: 22997214]
24.
Jin Y, Shao C, Li J, Fan H, Bai Y, Wang Y. Outbreak of multidrug resistant NDM-1-producing Klebsiella pneumoniae from a neonatal unit in Shandong Province, China. PloS One. 2015;10(3):e0119571. [PMC free article: PMC4370709] [PubMed: 25799421]
25.
Silva KE, Cayo R, Carvalhaes CG, Patussi Correia Sacchi F, Rodrigues-Costa F, Ramos da Silva AC, et al. Coproduction of KPC-2 and IMP-10 in carbapenem-resistant Serratia marcescens isolates from an outbreak in a Brazilian teaching hospital. J Clin Microbiol. 2015;53(7):2324–8. [PMC free article: PMC4473237] [PubMed: 25878341]
26.
Jamal WY, Albert MJ, Rotimi VO. High prevalence of New Delhi metallo-betalactamase-1 (NDM-1) producers among carbapenem-resistant Enterobacteriaceae in Kuwait. PloS One. 2016;11(3):e0152638. [PMC free article: PMC4816385] [PubMed: 27031521]
27.
Chitnis AS, Caruthers PS, Rao AK, Lamb J, Lurvey R, Beau De Rochars V, et al. Outbreak of carbapenem-resistant Enterobacteriaceae at a long-term acute care hospital: sustained reductions in transmission through active surveillance and targeted interventions. Infect Control Hosp Epidemiol. 2012;33(10):984–92. [PubMed: 22961017]
28.
Schwaber MJ, Lev B, Israeli A, Solter E, Smollan G, Rubinovitch B, et al. Containment of a country-wide outbreak of carbapenem-resistant Klebsiella pneumoniae in Israeli hospitals via a nationally implemented intervention. Clin Infect Dis. 2011;52(7):848–55. [PubMed: 21317398]
29.
Forde C, Stierman B, Ramon-Pardo P, dos Santos T, Singh N. Carbapenem-resistant Klebsiella pneumoniae in Barbados: driving change in practice at the national level. PloS One. 2017;12(5):e0176779. [PMC free article: PMC5444594] [PubMed: 28542162]
30.
Rapid risk assessment: carbapenem-resistant Enterobacteriaceae. Stockholm: European Centre for Disease Prevention and Control; 2016 (https://ecdc​.europa.eu​/sites/portal/files​/media/en/publications​/Publications/carbapenemresistant-enterobacteriaceae-risk-assessmentapril-2016.pdf, accessed 26 October 2017).
31.
Carbapenemase-producing bacteria in Europe: technical report. Stockholm; European Centre for Disease Control and Prevention; 2013 (https://ecdc​.europa.eu​/sites/portal/files​/media/en/publications​/Publications/antimicrobialresistance-carbapenemase-producing-bacteriaeurope​.pdf, accessed 26 October 2017).
32.
Fournier PE, Richet H. The epidemiology and control of Acinetobacter baumannii in health care facilities. Clin Infect Dis. 2006;42(5):692–9. [PubMed: 16447117]
33.
Liu WL, Liang HW, Lee MF, Lin HL, Lin YH, Chen CC, et al. The impact of inadequate terminal disinfection on an outbreak of imipenem-resistant Acinetobacter baumannii in an intensive care unit. PloS One. 2014;9(9):e107975. [PMC free article: PMC4177873] [PubMed: 25255439]
34.
Voor In ‘t Holt AF, Severin JA, Lesaffre EM, Vos MC. A systematic review and meta-analyses show that carbapenem use and medical devices are the leading risk factors for carbapenem-resistant Pseudomonas aeruginosa. Antimicrob Agents Chemother. 2014;58(5):2626–37. [PMC free article: PMC3993224] [PubMed: 24550343]
35.
Rutala WA, Weber DJ. Outbreaks of carbapenem-resistant Enterobacteriaceae infections associated with duodenoscopes: what can we do to prevent infections? Am J Infect Control. 2016;44(Suppl. 5):e47–51. [PubMed: 27131135]
36.
Otter JA, Burgess P, Davies F, Mookerjee S, Singleton J, Gilchrist M, et al. Counting the cost of an outbreak of carbapenemase-producing Enterobacteriaceae: an economic evaluation from a hospital perspective. Clin Microbiol Infect. 2017;23(3):188–96. [PubMed: 27746394]
37.
Falagas ME, Tansarli GS, Karageorgopoulos DE, Vardakas KZ. Deaths attributable to carbapenem-resistant Enterobacteriaceae infections. Emerg Infect Dis. 2014;20(7): 1170–5. [PMC free article: PMC4073868] [PubMed: 24959688]
38.
Villegas MV, Pallares CJ, Escand_n-Vargas K, Hern_ndez-G_mez C, Correa A, _lvarez C, et al. Characterization and clinical impact of bloodstream infection caused by carbapenemase-producing Enterobacteriaceae in seven Latin American countries. PloS One. 2016;11(4):e0154092. [PMC free article: PMC4841576] [PubMed: 27104910]
39.
Zhang Y, Chen XL, Huang AW, Liu SL, Liu WJ, Zhang N, et al. Mortality attributable to carbapenem-resistant Pseudomonas aeruginosa bacteremia: a meta-analysis of cohort studies. Emerg Microbes Infect. 2016;5:e27. [PMC free article: PMC4820673] [PubMed: 27004762]
40.
Lemos EV, de la Hoz FP, Einarson TR, McGhan WF, Quevedo E, Casta_eda C, et al. Carbapenem resistance and mortality in patients with Acinetobacter baumannii infection: systematic review and meta-analysis. Clin Microbiol Infect. 2013;20(5):416–23. [PubMed: 24131374]
41.
Haverkate MR, Weiner S, Lolans K, Moore NM, Weinstein RA, Bonten MJM, et al. Duration of colonization with Klebsiella pneumoniae carbapenemase-producing bacteria at long-term acute care hospitals in Chicago, Illinois. Open Forum Infect Dis. 2016;3(4):ofw178. [PMC free article: PMC5063543] [PubMed: 27747253]
42.
Guidance on ethics of tuberculosis prevention, care and control. 2010. Geneva: World Health Organization; 2010 (http://apps​.who.int/iris​/bitstream/10665​/44452/1/9789241500531_eng.pdf?ua=1, accessed 26 October 2017).
43.
Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62(10):e51–e77. [PMC free article: PMC5006285] [PubMed: 27080992]
44.
WHO AWaRe framework for AB treatments of infections caused by these bacteria. Geneva: World Health Organization; 2017.
45.
Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700. [PMC free article: PMC2714672] [PubMed: 19622552]
46.
Balshem H HM, Schunemann HJ, Oxman AD, Kunz R, Brozek J, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401–6. [PubMed: 21208779]
47.
Guyatt G OA, Akl EA, Kunz R, Vist G, Brozek J, et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64(4):383–94. [PubMed: 21195583]
48.
DalBen MF, Teixeira Mendes E, Moura ML, Abdel Rahman D, Peixoto D, Alves Dos Santos S, et al. A model-based strategy to control the spread of carbapenem-resistant Enterobacteriaceae: simulate and implement. Infect Control Hosp Epidemiol. 2016;37(11):1315–22. [PubMed: 27609341]
49.
Viale P, Tumietto F, Giannella M, Bartoletti M, Tedeschi S, Ambretti S, et al. Impact of a hospital-wide multifaceted programme for reducing carbapenem-resistant Enterobacteriaceae infections in a large teaching hospital in northern Italy. Clin Microbiol Infect. 2015;21(3):242–7. [PubMed: 25658534]
50.
Enfield KB, Huq NN, Gosseling MF, Low DJ, Hazen KC, Toney DM, et al. Control of simultaneous outbreaks of carbapenemase-producing Enterobacteriaceae and extensively drug-resistant Acinetobacter baumannii infection in an intensive care unit using interventions promoted in the Centers for Disease Control and Prevention 2012 carbapenemase-resistant Enterobacteriaceae toolkit. Infect Control Hospital Epidemiol. 2014;35(7):810–7. [PubMed: 24915208]
51.
Hayden MK, Lin MY, Lolans K, Weiner S, Blom D, Moore NM, et al. Prevention of colonization and infection by Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae in long-term acute-care hospitals. Clin Infect Dis. 2015;60(8):1153–61. [PMC free article: PMC8381216] [PubMed: 25537877]
52.
Gagliotti C, Cappelli V, Carretto E, Marchi M, Pan A, Ragni P, et al. Control of carbapenemase-producing Klebsiella pneumoniae: a region-wide intervention. Euro Surveill. 2014;19.(43) [PubMed: 25375901]
53.
Ciobotaro P, Oved M, Nadir E, Bardenstein R, Zimhony O. An effective intervention to limit the spread of an epidemic carbapenem-resistant Klebsiella pneumoniae strain in an acute care setting: from theory to practice. Am J Infect Control. 2011;39(8):671–7. [PubMed: 21864942]
54.
Kim NH, Han WD, Song KH, Seo HK, Shin MJ, Kim TS, et al. Successful containment of carbapenem-resistant Enterobacteriaceae by strict contact precautions without active surveillance. Am J Infect Control. 2014;42(12):1270–3. [PubMed: 25465255]
55.
Borer A, Eskira S, Nativ R, Saidel-Odes L, Riesenberg K, Livshiz-Riven I, et al. A multifaceted intervention strategy for eradication of a hospital-wide outbreak caused by carbapenem-resistant Klebsiella pneumoniae in Southern Israel. Infect Control Hosp Epidemiol. 2011;32(12):1158–65. [PubMed: 22080653]
56.
Ben-David D, Maor Y, Keller N, Regev-Yochay G, Tal I, Shachar D, et al. Potential role of active surveillance in the control of a hospital-wide outbreak of carbapenem-resistant Klebsiella pneumoniae infection. Infect Control Hosp Epidemiol. 2010;31(6):620–6. [PubMed: 20370465]
57.
Cho OH, Bak MH, Baek EH, Park KH, Kim S, Bae IG. Successful control of carbapenem-resistant Acinetobacter baumannii in a Korean university hospital: a 6-year perspective. Am J Infect Control. 2014;42(9):976–9. [PubMed: 25179329]
58.
DalBen MF, Basso M, Garcia CP, Costa SF, Toscano CM, Jarvis WR, et al. Colonization pressure as a risk factor for colonization by multiresistant Acinetobacter spp and carbapenem-resistant Pseudomonas aeruginosa in an intensive care unit. Clinics. 2013;68(8):1128–33. [PMC free article: PMC3752633] [PubMed: 24037009]
59.
Munoz-Price LS, Carling P, Cleary T, Fajardo-Aquino Y, DePascale D, Jimenez A, et al. Control of a two-decade endemic situation with carbapenem-resistant Acinetobacter baumannii: electronic dissemination of a bundle of interventions. Am J Infect Control. 2014;42(5):466–71. [PubMed: 24773784]
60.
Nagao M, Iinuma Y, Igawa J, Saito T, Yamashita K, Kondo T, et al. Control of an outbreak of carbapenem-resistant Pseudomonas aeruginosa in a haemato-oncology unit. J Hosp Infect. 2011;79(1):49–53. [PubMed: 21722990]
61.
Suarez C, Pena C, Arch O, Dominguez MA, Tubau F, Juan C, et al. A large sustained endemic outbreak of multiresistant Pseudomonas aeruginosa: a new epidemiological scenario for nosocomial acquisition. BMC Infect Dis. 2011;11:272. [PMC free article: PMC3203071] [PubMed: 21995287]
62.
Chung YK, Kim JS, Lee SS, Lee JA, Kim HS, Shin KS, et al. Effect of daily chlorhexidine bathing on acquisition of carbapenem-resistant Acinetobacter baumannii (CRAB) in the medical intensive care unit with CRAB endemicity. Am J Infect Control. 2015;43(11):1171–7. [PubMed: 26297525]
63.
Campbell E, Neelakanta A, Sitaras, J, Schmidt M, Passaretti C. Impact of expanded carbapenem resistant Enterobacteriacae (CRE) screening on rates of hospital acquired (HA) CRE infection. IDWeek; New Orleans (LA): 26–30 October 2016; poster55–333.
64.
Maben J, Griffiths P, Penfold C, Simon M, Pizzo E, Anderson J, et al. Evaluating a major innovation in hospital design: workforce implications and impact on patient and staff experiences of all single room hospital accommodation. Health Serv Delivery Res. 3.3. Southampton (UK): NIHR Journals Library; 2015 Feb. [PubMed: 25719188]
65.
Addressing ethical issues in pandemic influenza planning. Geneva: World Health Organization; 2008 (http://www​.who.int/ethics​/influenza_project/en/, accessed 26 October 2017).
66.
Thomas JC, Sage M, Dillenberg J, Guillory VJ. A code of ethics for public health. Am J Public Health. 2002;92(7):1057–9. [PMC free article: PMC1447186] [PubMed: 12084677]
67.
Childress JF, Bernheim RG. Public health ethics. Public justification and public trust. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz. 2008;51(2):158–63. [PubMed: 18259709]
68.
Allegranzi B, Gayet-Ageron A, Damani N, Bengaly L, McLaws ML, Moro ML, et al. Global implementation of WHO’s multimodal strategy for improvement of hand hygiene: a quasi-experimental study. Lancet Infect Dis. 2013;13(10):843–51. [PubMed: 23972825]
69.
Luangasanatip N, Hongsuwan M, Limmathurotsakul D, Lubell Y, Lee AS, Harbarth S, et al. Comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis. BMJ. 2015;351:h3728. [PMC free article: PMC4517539] [PubMed: 26220070]
70.
Evidence of hand hygiene as the building block for infection prevention and control. Geneva: World Health Organization; 2017 (http://www​.who.int/infection-prevention​/campaigns​/clean-hands/evidence.pdf?ua=1, accessed 26 October 2017).
71.
Pittet D, Panesar SS, Wilson K, Longtin Y, Morris T, Allan V, et al. Involving the patient to ask about hospital hand hygiene: a National Patient Safety Agency feasibility study. J Hosp Infect. 2011;77(4):299–303. [PubMed: 21236515]
72.
McGuckin M, Govednik J. Patient empowerment begins with knowledge: consumer perceptions and knowledge sources for hand hygiene compliance rates. Am J Infect Control. 2014;42(10):1106–8. [PubMed: 25278403]
73.
McGuckin M, Govednik J. Patient empowerment and hand hygiene, 1997–2012. J Hosp Infect. 2013;84(3):191–9. [PubMed: 23608002]
74.
Stewardson AJ, Sax H, Gayet-Ageron A, Touveneau S, Longtin Y, Zingg W, et al. Enhanced performance feedback and patient participation to improve hand hygiene compliance of health-care workers in the setting of established multimodal promotion: a single-centre, cluster randomised controlled trial. Lancet Infect Dis. 2016;16(12):1345–55. [PubMed: 27599874]
75.
Sattar SA, Maillard JY. The crucial role of wiping in decontamination of high-touch environmental surfaces: review of current status and directions for the future. Am J Infect Control. 2013;41:S97–S104. [PubMed: 23622759]
76.
Essential environmental health standards in health care. Geneva: World Health Organization; 2008 (http://apps​.who.int/iris​/bitstream/10665​/43767/1/9789241547239_eng.pdf?ua=1, accessed 26 October 2017).
77.
Guide to the implementation of the WHO multimodal hand hygiene improvement strategy. Geneva; World Health Organization; 2009 (http://www​.who.int/gpsc​/5may/Guide_to_Implementation.pdf, accessed 26 October 2017).
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