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Controlling the Diffusion of Multidrug-Resistant Organisms in Intensive Care Units
Solen Kernéis1,2,3, Jean-Christophe Lucet4,5
1Faculté de médecine, Université de Paris, Sorbonne Paris cité, Paris, France.
Abstract:
The prevalence of multidrug-resistant organisms (MDROs) in intensive care units (ICUs) is increasing worldwide, with very large variations across countries, microorganisms, and settings. Emerging MDR gram-negative bacteria and fungi raise particular concerns that require improved prevention and control strategies. Vertical approaches are mainly based on screening and contact precautions and/or decolonization of MDRO carriers. On the other hand, horizontal strategies are not pathogen-specific and include standard precautions (i.e., hand hygiene), universal decolonization, antimicrobial stewardship, and environmental cleaning. The impacts of the different strategies vary between MDROs and compliance with control measures, and are intermixed in most infection control programs. Based on historical data, hand hygiene remains the cornerstone to prevent transmission of MDROs in ICUs. In the context of high hand hygiene compliance, screening and contact precautions for carriers seem to have a limited additional effect, particularly for MDR gram-negative bacteria. Studies on skin decolonization with chlorhexidine bathing show conflicting results, impairing its widespread adoption. Selective oral and digestive decontaminations have shown positive impact on clinical outcomes in ICUs with low levels of antibiotic resistance, but raised ecological concerns in high-prevalence settings. Antibiotic stewardship programs have been associated with reductions in antimicrobial use, duration of stay, and costs with no negative impact on mortality and should be widely promoted in ICUs. Whatever the strategy, compliance with the recommended measures is of crucial importance and implementation should rely on behavioral approach and change in the institutional and safety culture.
Insights
Hand hygiene is crucial for preventing multidrug-resistant organism (MDRO) spread in intensive care units (ICUs). While other strategies exist, high compliance with hand hygiene offers significant protection against MDRO transmission.
Area of Science:
- Infectious Diseases
- Critical Care Medicine
- Public Health
Background:
- The global prevalence of multidrug-resistant organisms (MDROs) in intensive care units (ICUs) is rising, necessitating enhanced prevention and control strategies.
- Emerging multidrug-resistant (MDR) gram-negative bacteria and fungi present significant challenges in healthcare settings.
- Current control strategies include vertical (screening, contact precautions, decolonization) and horizontal (standard precautions, antimicrobial stewardship, environmental cleaning) approaches.
Purpose of the Study:
- To review and evaluate the effectiveness of various strategies for preventing and controlling MDRO transmission in ICUs.
- To identify the most impactful interventions, considering different MDROs and compliance levels.
- To emphasize the importance of compliance and a supportive safety culture for successful implementation.
Main Methods:
- Review of historical data and existing studies on MDRO control strategies in ICUs.
- Analysis of the impact of vertical and horizontal approaches on MDRO prevalence.
- Evaluation of evidence for hand hygiene, screening, contact precautions, decolonization, and antimicrobial stewardship.
Main Results:
- Hand hygiene remains the most effective measure for preventing MDRO transmission in ICUs.
- Screening and contact precautions show limited additional benefit when hand hygiene compliance is high, especially for MDR gram-negative bacteria.
- Selective decontamination shows mixed results, with concerns in high-prevalence settings, while antibiotic stewardship effectively reduces antimicrobial use and costs.
Conclusions:
- Effective MDRO control in ICUs relies on a combination of strategies, with a strong emphasis on hand hygiene.
- Implementation of effective infection control requires high compliance, behavioral changes, and a robust institutional safety culture.
- Antimicrobial stewardship programs should be widely promoted due to their proven benefits in reducing antimicrobial use and associated costs.
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