High adherence to national IPC guidelines as key to sustainable VRE control in Swiss hospitals: a cross-sectional survey

Abstract

Background: Vancomycin resistant enterococci (VRE) are on the rise in many European hospitals. In 2018, Switzerland experienced its largest nosocomial VRE outbreak. The national center for infection prevention (Swissnoso) elaborated recommendations for controlling this outbreak and published guidelines to prevent epidemic and endemic VRE spread. The primary goal of this study was to evaluate adherence to this new guideline and its potential impact on the VRE epidemiology in Swiss acute care hospitals.

Methods: In March 2020, Swissnoso distributed a survey among all Swiss acute care hospitals. The level of adherence as well as changes of infection prevention and control (IPC) strategies in the years 2018 and 2019 after publication of the national guidelines were asked along with an inventory on VRE surveillance and outbreaks.

Results: Data of 97/146 (66%) participants were available, representing 81.6% of all acute care beds operated in Switzerland in 2019. The vast majority-72/81 (88%) responding hospitals-have entirely or largely adopted our new national guideline. 38/51 (74.5%) hospitals which experienced VRE cases were significantly more likely to have changed their IPC strategies than those 19/38 (50%) hospitals without VRE cases p = 0.017). The new IPC guidelines included (1) introduction of targeted admission screening in 89.5%, (2) screening of close contacts of VRE cases in 56%, and (3) contact precaution for suspected VRE cases 58% of these hospitals. 52 (54%) hospitals reported 569 new VRE cases in 2018 including 14 bacteremia, and 472 new cases in 2019 with 10 bacteremia. The ten largest outbreaks encountered between 2018 and 2019 included 671 VRE cases, of which most (93.4%) consisted of colonization events, 29 (4.3%) infections and 15 (2.2%) bacteremia.

Conclusion: Wide adoption of this VRE control guideline seemed to have a positive effect on VRE containment in Swiss acute care hospitals over two years, even if its long-term impact on the VRE epidemiology remains to be evaluated. Broad dissemination and strict implementation of a uniform national guideline may therefore serve as model for other countries to fight VRE epidemics on a national level.

Keywords: Acute care; Admission screening; Contact precautions; Infection prevention and control; Outbreak; Surveillance; Vancomycin resistant Enterococcus faecium.

Fig. 1

Flow chart of survey respondents and representing institutions

Fig. 2

Self-reported compliance with Swissnoso guideline (GL)—according to hospital size

Fig. 3

Reported infection prevention and control measures introduced since beginning of 2018, stratified by hospital size

Fig. 4

Total number of new VRE cases detected per year (2018–2019) according to size of hospitals

Fig. 5

Validation of the ANRESIS surveillance for invasive and non-invasive VRE isolates. a Total number of new VRE bacteremia cases reported by hospitals and recorded by ANRESIS per canton and year (2018–2019). The blue bars correspond to the numbers reported in the national survey, the orange bars correspond to the numbers collected by ANRESIS. Only cantons with at least one VRE case have been considered. b Bland–Altman Plots for the level of agreement between the two surveillances in reporting cases with VRE bacteremia. “diff” indicates the absolute difference in reported cases between the two systems, “lower” indicates lower limit of agreement, “upper” indicates upper limit of agreement, while “mean” indicates the mean of differences, also called bias. c Total number of new non-bacteremia VRE cases reported by hospitals and recorded by ANRESIS per canton and year (2018–2019). The blue bars correspond to the numbers reported in the national survey, the orange bars correspond to the numbers collected by ANRESIS. Only cantons with at least one VRE case have been considered. d Bland–Altman Plots for the level of agreement between the two surveillances in reporting non-bacteremia VRE cases. “diff” indicates the absolute difference in reported cases between the two systems, “lower” indicates lower limit of agreement, “upper” indicates upper limit of agreement, while “mean” indicates the mean of differences, also called bias