Model-based Assessment of the Effect of Contact Precautions Applied to Surveillance-detected Carriers of Carbapenemase-producing Enterobacteriaceae in Long-term Acute Care Hospitals

Abstract Background An intervention that successfully reduced colonization and infection with carbapenemase-producing Enterobacteriaceae (CPE) in Chicago-area long-term acute-care hospitals included active surveillance and contact precautions. However, the specific effects of contact precautions applied to surveillance-detected carriers on patient-to-patient transmission are unknown, as other, concurrent intervention components or changes in facility patient dynamics also could have affected the observed outcomes. Methods Using previously published data from before and after the CPE intervention, we designed a mathematical model with an explicit representation of postintervention surveillance. We estimated preintervention to postintervention changes of 3 parameters: β, the baseline transmission rate excluding contact precaution effects; δb, the rate of a CPE carrier progressing to bacteremia; and δc, the progression rate to nonbacteremia clinical detection. Results Assuming that CPE carriers under contact precautions transmit carriage to other patients at half the rate of undetected carriers, the model produced no convincing evidence for a postintervention change in the baseline transmission rate β (+2.1% [95% confidence interval {CI}, −18% to +28%]). The model did find evidence of a postintervention decrease for δb (−41% [95% CI, −60% to −18%]), but not for δc (−7% [95% CI, −28% to +19%]). Conclusions Our results suggest that contact precautions for surveillance-detected CPE carriers could potentially explain the observed decrease in colonization by itself, even under conservative assumptions for the effectiveness of those precautions for reducing cross-transmission. Other intervention components such as daily chlorhexidine gluconate bathing of all patients and hand-hygiene education and adherence monitoring may have contributed primarily to reducing rates of colonized patients progressing to bacteremia. We mathematically modeled a bundled intervention that successfully reduced carbapenemase-producing Enterobacteriaceae in long-term acute care hospitals. Results show that contact precautions for surveillance-detected carriers plausibly can explain the observed reduction in carriage prevalence without substantial contribution from other intervention components.