The relative importance of large problems far away versus small problems closer to home: insights into limiting the spread of antimicrobial resistance in England

Journal article

Background To combat the spread of antimicrobial resistance (AMR), hospitals are advised to screen high-risk patients for carriage of antibiotic-resistant bacteria on admission. This often includes patients previously admitted to hospitals with a high AMR prevalence. However, the ability of such a strategy to identify introductions (and hence prevent onward transmission) is unclear, as it depends on AMR prevalence in each hospital, numbers of patients moving between hospitals, and the number of hospitals considered 'high-risk'. Methods We tracked patient movements, using data from the National Health Service of England Hospital Episode Statistics, and estimated differences in regional AMR prevalences, using, as an exemplar, data collected through the national reference laboratory service of Public Health England on carbapenemase-producing Enterobacteriaceae (CPE) from 2008-2014. Combining these datasets, we calculated expected CPE introductions into hospitals from across the hospital network, to assess the effectiveness of admission screening based on defining high-prevalence hospitals as high-risk. Results Based on numbers of exchanged patients, the English hospital network can be divided into 14 referral regions. England saw a sharp increase in numbers of CPE isolates referred to the national reference laboratory over seven years, from 26 isolates in 2008 to 1649 in 2014. Large regional differences in numbers of confirmed CPE isolates overlapped with regional structuring of patient movements between hospitals. However, despite these large differences in prevalence between regions, we estimated that hospitals received only a small proportion (1.8%) of CPE-colonised patients from hospitals outside their own region, which decreased over time. Conclusions In contrast to the focus on import screening based on assigning a few hospitals as ‘high-risk’, patient transfers between hospitals with small AMR problems in the same region often pose a larger absolute threat than patient transfers from hospitals in other regions with large problems, even if the prevalence in other regions is orders of magnitude higher. Because the difference in numbers of exchanged patients, between and within regions, was mostly larger than the difference in CPE prevalence, it would be more effective for hospitals to focus on their own populations or region to inform control efforts, rather than focussing on problems elsewhere.

Authors: Donker, T; Henderson, K; Hopkins, K; Dodgson, A; Thomas, S

• Publication status: Published
• Peer review status: Peer reviewed
• Publisher: BioMed Central
• Journal: BMC Medicine
• Volume: 15
• Issue: 1
• Article number: 86
• Publication date: 2017-01-01
• Acceptance date: 2017-03-24
• DOI: 10.1186/s12916-017-0844-2
• ISSN: 1741-7015