Assignment: Uncontrolled Pretest-post-test

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Assignment: Uncontrolled Pretest-post-test

Assignment: Uncontrolled Pretest-post-test

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excluded following full review because ESBL-E inci- dence was not measured at baseline (n 5 2),3,4 no in- tervention was studied (n 5 2),5,6 the study was conducted during an ESBL-E outbreak (n 5 1),7 or the study intervention involved antibiotic stewardship (n 5 1).8 Therefore, 4 studies were included in our systematic review.9-12

All 4 studies were conducted retrospectively. One was an interrupted time series analysis of methicillin- resistant Staphylococcus aureus incidence that exam- ined ESBL incidence in a post hoc analysis.10 The other 3 studies were uncontrolled pretest-post-test studies.9-11,12 There were no RCT or controlled trials of any type identified. No study reported obtaining ap- proval from a Research Ethics Board.

The study by Conterno et al9 was an uncontrolled pretest-post-test study conducted at a tertiary care hos- pital. Patients identified as ESBL-E colonized/infected on clinical cultures were placed in isolation, and contact precautions were used for patients at risk of contaminating their environment. The nosocomial ESBL-E incidence rose from 0.28 per 1,000 admissions in 1999 to 0.67 per 1,000 admissions in 2005 despite the initiation of the intervention in 2001. The results are difficult to interpret because the study was not con- trolled, the regional incidence of ESBL-E increased 7-fold during the study period, and the lack of active surveillance may have led to the classification of patients with unrecognized colonization at the time of admission as nosocomial cases.

The study by Johnson et al10 was an uncontrolled time series analysis conducted at a tertiary care hospital. A program to reduce methicillin-resistant Staphylococcus aureus that included a hand hygiene

intervention was identified post hoc as resulting in a re- duction in the incidence of clinical cultures positive for ESBL-E, which had been rising for 28 months before the intervention (slope . 0; P , .05) but fell to zero over the 36-month postintervention period (slope , 1; P , .05). Interpretation is limited by the lack of a control group, the post hoc nature of the analysis, the limited data on ESBL-E presented, and the possibility that the rise and fall in ESBL-E incidence may be indic- ative of a prolonged ESBL-E outbreak.

The study by Souweine et al11 was an uncontrolled pretest-post-test study conducted in a 10-bed intensive care unit. The intervention included active surveillance for antibiotic resistant organisms including ESBL- producing Klebseilla pneumoniaewith isolation and con- tact precautions for colonized/infected patients and a hand hygiene promotion. The incidence of ESBL- producing Klebseilla pneumoniae fell from 1.3 per 1,000 patient-days preintervention to 0 per 1,000 patient- days postintervention. The study is difficult to interpret because of the lack of a control group, the small sample size (only 4 cases of ESBL-Ewere identified in the study), and the possibility that the 4 cases represented a cluster.

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