In all ICU’s combined, CRE acquisition decreased significantly from 90% in period 2 to 48% in period 8 during the intervention. The decrease was most pronounced in the PICU and SICU: from 100 and 78% period 2, to 43% and 22% period 8, respectively. In the NICU, a significant decrease of CRE acquisition was detected from period 2 (93%) to period 6 (62%), however an increase to period 8 (71%). The NICU has the most beds per room, highest rate of admission, several concurrent cohorting of respiratory syncytial virus (RSV) infections, HAI and preterm neonates, and suffered from overcrowding towards the end of the study, likely explaining the increase seen in latter periods. In the SICU, the CREpos cohort was treated in an isolation room. Smaller cohorts and isolation rooms with designated personnel could further decrease the risk for CRE acquisition.
Point prevalence survey result
,7,7] have shown a constant high- and increasing rate of CRE colonization in Vietnamese hospitals and ICU’s.
CRE colonization secondary endpoints
,4].Colonization was associated with increased risk for HAI and mortality [7,8,3,5,9,20,21,22,23,24] This strategy has been successful in high income country hospitals [25,
,7,2,3,7,26]. CRE surveillance in province hospitals is needed to contain the transmission.
Patients with CRE colonization and acquisition had significantly higher rates of culture confirmed HAI with Enterobacteriaceae,2). Correlation between colonization and HAI was shown in our previous study  and has been established in other studies also [27,25,28].
,E. coli; 38% K. pneumoniae; 26% KESC and 13% for other G-negative bacteria. In our previous PPS from 2017 [7,K. pneumoniae, and 58.5% for E. coli .,K. pneumoniae,Enterobacteriaceae, such as Acinetobacter baumannii and Pseudomonas aeruginosa, which are also an important cause of severe HAI with high mortality in Vietnamese pediatric ICU’s .
The mortality rate in CRE colonized patients with culture confirmed HAI was significantly higher (24%) compared to non-colonized patients with HAI (7%). Similar results was seen in our previous 2017 study [7,7]. Other studies have also shown high mortality rates in patients with infections caused by CRE [12,20,Enterobacteriaceae,,
The hospital cost in Vietnam is to a high extent covered by the health insurance, provided for free to children up to 6 years of age. At the time of the intervention, the costs for CRE screening were not reimbursed, despite potentially being able to save large resources for the health insurance. Patients with HAI occupy an ICU place for a longer time and blocks new admissions that require more investigations, hence pose an economic burden for the hospitals, in addition to increased patient mortality and morbidity.
The intervention was performed at a low cost, about 3 USD per agar plate, which can be used for two cultures. Costs for laboratory and ICU labor was however not accounted for. The aim of this intervention was to perform it at a cost level, which would allow a continuous CRE screening and cohort care.
Strengths and limitations
One major limitation in this study is that it was an interventional study with no control group. Further, the intervention, for ethical reasons, started immediately after a patients CRE status was revealed. As this was no randomized controlled trial of CRE screening and cohort care, the results of this study can only be interpreted as indicative. The intervention was performed in pre-existing facilities and without extra staff, beside the research team. The cohorts could in most situations not be completely physically separated and it was not always possible to have designated staff. The high CRE colonization rate at admission made it challenging to isolate patients. Of 604 patients screened CREneg at admission, only 244 (40.4%) were re-screened. Reasons for this include that many patients were admitted for < 48 h, patients were moved with short notice when discharged from ICU, lack of staff and reluctance to rectal swab patients after death. Despite these limitations, which in LMIC are a realistic actual setting, our study showed that admission CRE screening and cohort care intervention significantly can reduce the rates of CRE acquisition and HAI as well as shorten hospital stays and decrease costs.
Higher levels of HAI, higher treatment costs and a higher level of HAI-related mortality was seen in CREpos patients when compared to CREneg. One possible confounder is whether CREpos patients represents a group of patients with higher levels of co-morbidities (more ill patients) and therefore more prone to get colonized, have longer treatment periods in the hospital and be more likely to get nosocomial infections (HAI’s) and suffer a mortal outcome from these. The intervention design without a control group does not allow for determining whether associations of CRE colonization (initial) and acquisition with HAI, costs, and mortality (later), are causal. The group of patients treated in a separate cohort while awaiting their admission CRE screening results contained both CREneg and CREpos patients. Although it was the ambition to distance the patients in the group, possibly exposure could not be excluded, providing a risk of patients initially screening CREneg becoming colonized while awaiting their screening results. Some patients were likely colonized during this waiting period, which was deemed non-preventable in this intervention. In ideal conditions, complete isolation of patients from one another would be preferred but was not possible within the VNCH ICU’s. The 7-day follow-up screening on all admitted patients was used, to limit the transmission of CRE in the CREneg cohort.