Management of multidrug-resistant pathogens: implications for the transition from inpatient to outpatient care

In health care, the transitions between inpatient and outpatient sectors pose a particular challenge. From the patient's perspective, the definition of treatment paths and their ongoing optimization along clearly defined interfaces are of essential importance. Accordingly, improving intersectoral communication and collaboration is one of the key goals of many initiatives, measures and associations. In the Baltic Sea Coast health region, HICARE1 – Action Alliance against Multi-Resistant Pathogens (MRE) – aims to implement model regional concepts and support them with health services research. From the perspective of practicing physicians*, this article aims to present challenges and perspectives in the transition of patients with colonization or infection with MRE between sectors. Suggestions for this were given by established colleagues* in the region.

>> MDROs are a serious and growing issue in both inpatient and outpatient care. In inpatient settings, they are particularly problematic due to the concentration of patients at risk of infection. Therefore, it is important to detect these pathogens as early as possible during inpatient admissions and, at the same time, to establish effective protective measures to prevent complications or transmission to staff and fellow patients. However, it is equally important that the statutory health insurance sector be aware of its responsibility for MDRO prevention (Kramer et al. 2011).
The HICARE collaborative project, conducted between 2011 and 2014, aimed to develop effective, standardized, and transferable intervention strategies to combat the spread of MDROs in a regionally coordinated approach. Participants in the HICARE project include the universities of Greifswald and Rostock, 12 acute care hospitals, four rehabilitation facilities, and a total of over 40 institutional and industrial partners (www.hicare.de). For the prevention and control of methicillin-resistant Staphylococcus aureus (MRSA) strains in hospitals and other medical facilities, the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute (RKI) first developed comprehensive recommendations in 1999, which were updated in 2008 and 2014. In 2012, KRINKO also issued recommendations on hygiene measures for infections or colonization with multidrug-resistant Gram-negative rod bacteria (MRGN).
With the 2011 amendment to the Infection Protection Act (IfSG), the KRINKO recommendations became binding (BMJV 2013; BMG 2011). These KRINKO recommendations were implemented within the framework of the HICARE project and incorporated into the regional HICARE recommendations for the prevention and treatment of MDROs. With the help of internal and international study results, the screening and prevention strategy for vancomycin-resistant enterococci (VRE) were also implemented in HICARE.
To support the implementation of recommendations for the prevention of MRSA, VRE, ESBL-producing bacteria, and MRGN, questionnaires, documentation forms, and patient information forms have been developed for inpatient care. In addition to a questionnaire on MRE risk factors upon inpatient admission, a treatment form (Fig. 1) for systematically documenting the MRE diagnosis and any follow-up swabs has been developed and tested. The documentation form also addresses the transfer of patients and is made available to the physician providing further treatment. This information helps comply with Section 11 of the Mecklenburg-Western Pomerania Hospital Hygiene Ordinance (MedHyg VO MV)2 regarding the dissemination of infection-related information from patients with MRE.
Transfer of MRE patients from inpatient to outpatient care
In practice, it must be considered that the transfer form can contain a large amount of information and may therefore not be self-explanatory for all recipients. The attending physician is then faced with questions such as, "What can I, as a general practitioner, do for the patient based on the information on the form?" "Is decolonization an option, and if so, which follow-up swabs are necessary to monitor its success?" and "What do I, as a general practitioner, actually do with the information on the form?" Therefore, general practitioners have expressed a desire for the discharge letter to contain suggested courses of action based on current recommendations.
Requirements for the treatment of MRE-positive patients in outpatient settings
Outpatient physician practices are an essential point of contact for patients, both in the pre- and post-hospital care of inpatient stays and in the care of patients at home. The MDRO issue affects outpatient care in the areas of education and counseling, diagnostics, MRSA eradication treatment, and long-term MRSA eradication monitoring (Fig. 2). The billable services (Infobox 1) relate to MRSA and have been defined as part of the Uniform Assessment Standard (EBM) since April 1, 2014. The entry requirement is that the patient is a "high-risk patient" (Infobox 2). Furthermore, proof of appropriate continuing education is required for reimbursement. Contract physicians authorized to bill must have additional training in "Infectious Diseases" and/or "MRSA" certification. This can be acquired either through the "Outpatient MRSA Care" continuing education seminar or by participating in an online continuing education course on MRSA. Further information is available at the following website: www.ebm.de; MRSA training (KBV 2014).
In addition to the issues mentioned above, the MDRO problem also encompasses other factors, which are listed below (also Fig. 2). The risk factors for MDRO vary depending on the pathogen and have been studied to varying degrees. For MRSA, in addition to the factors described in Infobox 2, a number of additional risk factors have been identified that vary depending on the pathogen subtype (RKI 2013; Köck et al. 2011). Frequent antibiotic therapies promote selection pressure on the microorganisms and the development of resistance. As part of the HICARE project, regional antibiotic recommendations for initial calculated antibiotic therapy were (further) developed at the University Medical Center Greifswald, which are intended to promote the targeted and critically reviewed use of antibiotics. There are plans to expand these recommendations for outpatient care.
The following example illustrates the need for comprehensive and specific information on MRE to ensure the care of MRE-positive individuals: A resident of a retirement home returns to the facility after hospital treatment. The transfer form reveals that the patient's urine contains E. faecalis with
Vancomycin resistance (VRE) has been detected. What does this mean for the retirement home and the treating physician? What further steps are necessary? What hygiene measures are indicated? Discussions between practicing physicians, hygienists, and microbiologists within the HICARE network have shown that there are many questions and uncertainties among those affected regarding the MRE issue. It should be taken into account, among other things, that the recommendations for inpatient care are much more specific than for the statutory health insurance sector. Furthermore, the questions that arise in the home setting are sometimes completely different from those in the hospital. Low case numbers of MRE in individual practices limit the frequency with which a practicing physician is actually confronted with the MRE problem. If only a small number of patients are affected, a careful consideration may be necessary. A representative from the private practice sector stated: "If there are only a few cases per year [for the individual practice], then [...] [establishing a uniform procedure] can be difficult. [...] The problem is that if you spend a total of about one and a half to two hours on the first patient, you start to think twice about whether you can afford to spend that much time again with the second." However, with increasing experience in dealing with MRE-positive patients, the workload for the individual decreases accordingly.
Collegial exchange is also helpful when dealing with MDROs. Within the framework of HICARE, it has repeatedly become clear that both contracted physicians and nursing homes have the necessary sensitivity and openness to improve MDRO management, a basis upon which regional networks can build. One approach based on self-organization is, for example, the appointment of regional contact persons. This was successfully initiated in the Baltic Sea coast health region by a physician network in the Greifswald/Wolgast region, alongside regular workshops—for example, on the daily handling of MDROs in doctor's offices or on rational antibiotic therapy in outpatient settings.
Conclusion
In recent years, the outpatient sector has received increasing attention with regard to the care of patients with MDROs. This is reflected, for example, in the introduction of special billing codes for the continuation of treatment initiated in hospital for MRSA patients around two years ago, which allow for reimbursement of the services provided. Recently, a separate section for MRSA services was introduced in the EBM. Nevertheless, it appears necessary to involve the outpatient sector more closely in the design and implementation of regional MDRO care structures, as well as to offer target group-specific training and information on the topic of MDROs. Health services research can help to learn more about the conditions (e.g., prevalence of MDROs) and needs (e.g., regarding information and cooperation) in the outpatient sector and, based on this, to optimize cross-sectoral care.