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. 2020 Jan 16;70(3):388-394.
doi: 10.1093/cid/ciz248.

Modeling Regional Transmission and Containment of a Healthcare-associated Multidrug-resistant Organism

Prabasaj Paul  1 , Rachel B Slayton  1 , Alexander J Kallen  1 , Maroya S Walters  1 , John A Jernigan  1
Affiliations

Modeling Regional Transmission and Containment of a Healthcare-associated Multidrug-resistant Organism

Prabasaj Paul et al. Clin Infect Dis. .

Abstract

Background: The Centers for Disease Control and Prevention (CDC) recently published interim guidance for a public health response to contain novel or targeted multidrug-resistant organisms (MDROs). We assessed the impact of implementing the strategy in a US state using a mathematical model.

Methods: We used a deterministic compartmental model, parametrized via a novel analysis of carbapenem-resistant Enterobacteriaceae data reported to the National Healthcare Safety Network and patient transfer data from the Centers for Medicare and Medicaid Services. The simulations assumed that after the importation of the MDRO and its initial detection by clinical culture at an index hospital, fortnightly prevalence surveys for colonization and additional infection control interventions were implemented at the index facility; similar surveys were then also implemented at those facilities known to be connected most strongly to it as measured by patient transfer data; and prevalence surveys were discontinued after 2 consecutive negative surveys.

Results: If additional infection-control interventions are assumed to lead to a 20% reduction in transmissibility in intervention facilities, prevalent case count in the state 3 years after importation would be reduced by 76% (interquartile range: 73-77%). During the third year, these additional infection-control measures would be applied in facilities accounting for 42% (37-46%) of inpatient days.

Conclusions: CDC guidance for containing MDROs, when used in combination with information on transfer of patients among hospitals, is predicted to be effective, enabling targeted and efficient use of prevention resources during an outbreak response. Even modestly effective infection-control measures may lead to a substantial reduction in transmission events.

Keywords: healthcare epidemiology; mathematical model; multidrug-resistant organism.

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Conflict of interest statement

No authors have any potential conflicts of interest to disclose.

Figures

Figure 1
Figure 1
Patient transfer network in State A, based on the movement of Medicare fee-for-service beneficiaries. The location of hospitals do not correspond to geographical coordinates. Arrows correspond to at least 10 transfers per year.
Figure 2
Figure 2
Proportion of patients with clinical isolates that were tested positive for CRE (NHSN laboratory results from 3 states, 2015) versus average length of stay, by reporting hospital. The continuous lines represent regression fits, used for estimation of transmissibility. The blue and red lines are fitted to the blue and red dots, respectively, representing short stay hospitals from two different exemplar HRRs.
Figure 3
Figure 3
Left: Trajectories of simulated regional outbreaks with intervention that resulted in a 20% reduction in transmissibility at targeted hospitals, compared to the course of the outbreak with no intervention. Each pair of trajectories (blue and red, with and without containment, respectively) differs from other pairs in transmissibility. Right: Comparison of the number of prevalent cases three years into the outbreak, with and without containment. Each dot (and an “x” for the uniform draw) represents case counts at 3 years with and without intervention for a single draw from the two transmissibility probability distributions (short and long stay).
Figure 4
Figure 4
Course of outbreak without and with intervention, by intervention effectiveness (percent reduction in transmissibility). All four simulations assumed transmissibility were uniform within facility type (i.e., one uniform value for all short stay hospitals, and another uniform value for all long stay hospitals)..
Figure 5
Figure 5
Relative reduction in prevalent case count three years into the outbreak (left), proportion of total inpatient days that were targeted for enhanced infection control measures (intervention) during the third year of the outbreak (center), and proportion of inpatient days under additional infection control measures that were at longer stay hospitals during the third year of the outbreak (right), versus reduction in transmissibility within targeted facilities due to intervention.
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