Assignment: Gram-negative Organisms
he study by Soulier et al12 was an uncontrolled pretest-post-test study conducted in an 11-bed inten- sive care unit. An educational intervention was used to improve hand hygiene and environmental cleaning. The proportion of ESBL-E colonized patients fell from 70% during a 3-month preintervention period to 40% during a 7-month postintervention period (P 5 .001). This study is also difficult to interpret because of the lack of a control group, and the high proportion of col- onized patients suggests the possibility of an extensive ESBL-E outbreak.
Our systematic review did not identify any prospec- tive, controlled, or randomized trials addressing the ef- ficacy of infection control interventions for the control of ESBL-E incidence in the nonoutbreak setting. The in- cluded studies were all retrospective, uncontrolled, quasi-experimental studies with a variety of additional methodologic flaws (eg, no description of baseline ap- proach to ESBL-E control; confounders not measured; presence of cointerventions; limited sample size; post hoc analysis; failure to exclude an outbreak). No con- clusions regarding the efficacy of any of the interven- tions studied can therefore be made.
Our review demonstrates that, despite the recogni- tion that gram-negative resistance is a public health crisis requiring urgent action,13 there is little research activity addressing the control of ESBL-E transmission in hospitals. This is emphasized by the lack of pro- spective or Research Ethics Board approved studies identified. Whereas included studies represent the laudable efforts of infection control programs to retro- spectively evaluate their efforts to control ESBL-E transmission, this should not be viewed as a replace- ment for the conduct of high-quality, prospective re- search that addresses the optimal way for hospitals to reduce ESBL-E incidence (and the incidence of other multidrug-resistant, gram-negative organisms).
We therefore recommend that researchers and fund- ing agencies prioritize studies designed to identify ef- fective infection control strategies for the control of ESBL-E and other multidrug-resistant, gram-negative organisms. Such studies should be prospective studies using a cluster randomized, time series, or controlled quasi-experimental design. Additional recommenda- tions for future studies are presented in Table 1.
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