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  • International Society of Cardiovascular Infectious Diseases Guidelines for the Diagnosis, Treatment and Prevention of Disseminated Mycobacterium chimaera Infection Following Cardiac Surgery with Cardiopulmonary Bypass
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-09
    Barbara Hasse, Margaret Hannan, Peter M. Keller, Florian P. Maurer, Rami Sommerstein, Dominik Mertz, Dirk Wagner, Nuria Fernández-Hidalgo, Jim Nomura, Vinicio Manfrin, Dominique Bettex, Antonio Hernandez Conte, Emanuele Durante-Mangoni, Tommy Hing-Cheung Tang, Rhonda L. Stuart, Jens Lundgren, Steve Gordon, M. Claire Jarashow, Kiran M. Perkins

    Mycobacterial infection-related morbidity and mortality in patients following cardiopulmonary bypass surgery is high and and there is a growing need for a consensus-based expert opinion to provide international guidance for diagnosing, preventing and treating in these patients. In this document the International Society for Cardiovascular Infectious Diseases (ISCVID) covers aspects of prevention (field of hospital epidemiology), clinical management (infectious disease specialists, cardiac surgeons, ophthalmologists, others), laboratory diagnostics (microbiologists, molecular diagnostics), device management (perfusionists, cardiac surgeons) and public health aspects.

  • How do surgeons feel about the ‘Getting it Right First Time’ national audit? Results from a qualitative assessment
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-09
    G. Birgand, R. Troughton, V. Mariano, S. Hettiaratchy, S. Hopkins, J.A. Otter, A. Holmes

    The implementation of the national ‘Getting It Right First Time’ was assessed by interviewing six surgeons involved at various levels in surgical site infection (SSI) audit. The positive impacts were to create new professional collaboration, improve stakeholder engagement, and increase the profile of SSIs. One particular knowledge gap highlighted was that some participants had been unaware until that point of the criteria for diagnosing an SSI. The quality of data collected was felt to be poor due to methodological flaws. The audit was described as highly time-consuming and unsustainable if leaning on junior surgeons, without protected time and designated responsibility.

  • Global Point Prevalence Survey (Global-PPS) of Antimicrobial Consumption in Brazilian Hospitals
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-01
    Ana Paula Matos Porto, Herman Goossens, Ann Versporten, Silvia Figueiredo Costa

    Background The inappropriate use of antimicrobials and increased rates of antimicrobial resistance is a challenge all over the world. Although antibiotic stewardship is recommended by the Brazilian government, data regarding antibiotic use in Brazilian hospitals are scarce. Aim The aim of this study was to conduct a point prevalence survey of antimicrobial use in 18 Brazilian hospitals. Methods Eighteen Brazilian hospitals conducted the Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) in 2017. The study enrolled inpatients on antimicrobials. Data collection included details on the antimicrobial prescriptions. A web-based program was used for data-entry, validation and reporting. The Global-PPS was developed by the University of Antwerp and bioMérieux provided funding support. Findings We evaluated 1801 patients, of which 941 (52.2%) were on antimicrobials. Four hundred (42.5%) patients were given at least two antimicrobials. Out of the 1317 antibacterials for systemic use, 514 (39%) were prescribed for community-acquired infections, 533 (40.5%) for healthcare-associated infections and 248 (18.8%) for prophylactic use. The most frequently used antimicrobials were ceftriaxone (12.8%), meropenem (12.3%) and vancomycin (10.3%). Pneumonia or lower tract respiratory infection was the the most common site of infection (29.2%). In general, antimicrobials were given mainly parenterally (91%) and empirically (81.2%). Conclusions We observed a high prevalence of antibiotic use in the 18 Brazilian hospitals. The antibiotics were prescribed mainly empirically. Intravenous broad-spectrum antibiotics were the most frequent antimicrobials used, showing that reinforcement of de-escalation strategy is needed. The Global-PPS data can be very useful for monitoring stewardship programmes and intervention.

  • A point prevalence study to determine the inpatient rate of carbapenemase-producing organisms at a large London NHS Trust
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-10-18
    J. Henderson, H. Ciesielczuk, S.M. Nelson, M. Wilks, M.N. Cummins

    Background There has been an increase in the number of carbapenemase-producing organisms documented across the UK over the past 10 years. From these, the ‘big five’ carbapenemases (KPC, OXA-48, IMP, VIM, and NDM) are the most common types reported in the order Enterobacterales, identified from a variety of reactive screening, outbreak, inpatient surveillance, and diagnostic samples. Aim To perform a point prevalence study to determine the inpatient carriage rate of carbapenemase-producing organisms at Barts Health NHS Trust, which encompasses 2.5 million patients across four London boroughs: Tower Hamlets, Newham, Redbridge, and Waltham Forest. Methods Rectal swabs were collected from consenting inpatients, alongside details of the ward’s medical specialty, patient’s country of birth, history of foreign travel, length of hospitalization, and history of prior hospitalization. Swabs were enriched and subcultured on to mSuperCARBA selective medium. All Enterobacterales, Acinetobacter, and Pseudomonas species were identified by matrix-assisted laser desorption/ionization time-of-flight mass spectroscopy and underwent antibiotic susceptibility testing by disc diffusion, according to European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines. All isolates were screened for the ‘big five’ carbapenemases using a modified version of a published reverse transcriptase–polymerase chain reaction assay. Findings Of the 977 inpatients tested, 35 CPOs were isolated from 30 patients. NDM was the most frequently detected carbapenemase, followed by OXA-48, with an overall prevalence of 3.1%. Organisms isolated included Klebsiella pneumoniae, Enterobacter cloacae, Proteus mirabilis, and Escherichia coli. Renal and elderly care patients had the highest prevalences of CPOs, whereas the intensive care unit prevalence was low. Statistical analysis found that hospitalization abroad, any previous hospitalization, foreign travel and, specifically, travel to India, Pakistan, and Bangladesh were associated with increased risk of CPO carriage. Conclusion The overall prevalence of CPOs at Barts Health Trust was 3.1%, comprising NDM and OXA-48-type carbapenemases, which is in line with other London-based studies. Renal patients and the elderly had the highest burden of CPOs, whereas previous hospitalization and foreign travel were associated with an increased risk of CPO carriage.

  • Long-term endemic situation caused by a linezolid- and methicillin-resistant clone of Staphylococcus epidermidis in a tertiary hospital
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-10-18
    Carlos Rodríguez-Lucas, M. Rosario Rodicio, Jordi Càmara, M. Ángeles Domínguez, Miguel Alaguero, Javier Fernández

    Background Linezolid (LZD) resistant Staphylococcus epidermidis (LRSE) are increasing mainly associated with outbreaks in hospital wards with high LZD consumption. Aims To investigate the frequency of LRSE in a tertiary hospital, in the context of LZD use. Methods The frequency of LRSE and the data on LZD usage (expressed as DDDs per 100 patient-days), from 2011 to 2017, were retrospectively analysed. Selected LRSE were typed by PFGE and screened for transferable LZD resistance genes. Representative isolates were typed by MLST and ribosomal mechanisms of LZD resistance investigated. Findings A total of 435 LRSE were detected, with frequencies ranging from 13.56 to 32.93% in the ICU, where LZD consumption was high (6.34 to 8.10 DDDs), and from 2.48 to 6.80% in the remaining wards, where LZD use was considerably lower (0.63 to 2.49 DDDs). The first 44 LRSE isolates recovered (June 2013-June 2014) proved to be closely-related according to PFGE patterns, and all except one were resistant to methicillin due to mecA production. Selected isolates belonged to ST2, carried SSCmec III, and had the G2576T mutation in the V domain of each of the six copies of the 23S rRNA gene. Five out of the 44 isolates (11.36%) were positive for the cfr gene. Conclusion An ST2 LZD- and methicillin-resistant clone was established in the whole hospital, not only in the ICU but also in wards where LZD consumption is low. This highlights the need to implement and maintain infection control measures as well as antimicrobial stewardship programs in all hospital units, to preserve the efficacy of LZD.

  • Reduction of turnaround time for non-tuberculous mycobacteria detection in heater-cooler units by propidium monoazide real-time PCR
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-10-16
    Savina Ditommaso, Monica Giacomuzzi, Gabriele Memoli, Rossana Cavallo, Antonio Curtoni, Maria Avolio, Carlo Silvestre, Carla M. Zotti

    BackgroundInvasive non-tuberculous mycobacteria (NTM) infections are emerging worldwide in patients undergoing open-chest cardiac bypass surgery exposed to contaminated heater-cooler units (HCUs). Although this outbreak has been investigated by culturing bacteria isolated from HCU aerosol and water samples, these conventional methods have low-analytic sensitivity, high rates of sample contamination and long turnaround time (TAT).AimTo develop a simple and effective method to detect NTM in HCUs by real-time PCR, with a short laboratory TAT and reliable culture results.MethodsA total of 281 water samples collected from various HCUs at 7 Italian hospitals were simultaneously screened for NTM by a propidium monoazide (PMA)-PCR assay and by conventional culture testing. The results were analyzed with culture testing being the reference method.Findingsi) The agreement between culture testing and PMA-PCR was 85.0% with a Ct cut-off value of < 38 vs.80.0% with a Ct of < 43, with a moderate Cohen's kappa coefficient; ii) the Ct cut-off value of < 42 was deemed more suitable for predicting positive specimens; iii) given the low concentration of target DNA in water samples, the minimum volume to be tested was 1 lt.ConclusionWe highly recommend the use of PMA-PCR for fast detection of NTM from environmental samples in order to ascertain whether HCUs may represent a potential source of human exposure to NTM. This reliable and simple method reduces laboratory TAT compared to conventional methods (1-2 days vs. 8 weeks, respectively), thereby improving control strategies and effective management of HCUs.

  • The drugs don’t work: evaluation of educational theatre to gauge and influence public opinion on antimicrobial resistance
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-10-16
    Rabia Ahmed, Amreen Bashir, James E.P. Brown, Jonathan A.G. Cox, Anthony C. Hilton, Charlotte E. Hilton, Peter A. Lambert, Eirini Theodosiou, Jonathan Q. Tritter, Samuel J. Watkin, Tony Worthington

    Increased public awareness of antimicrobial resistance (AMR) is a key component of effective antimicrobial stewardship strategies. Educational theatre combined with an expert panel was used to engage the public about AMR through delivery of a play entitled “The drugs don’t work”. Audience knowledge and understanding of AMR were measured by pre- and post-play questionnaire. Delivery of the play and discussion with the expert panel significantly improved audience knowledge and understanding of AMR, including antibiotic misuse and prescribing. Educational theatre provides a positive learning experience and is an innovative method of public engagement to disseminate important public health messages.

  • Trends in prevalence of healthcare-associated infections and antimicrobial use in hospitals in the Netherlands: 10 years of national point-prevalence surveys
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-10-15
    T.E.M. Hopmans, E.A. Smid, J.C. Wille, T.I.I. van der Kooi, M.B.G. Koek, M.C. Vos, S.E. Geerlings, S.C. de Greeff

    BackgroundPrevalence of healthcare-associated infections (HCAIs) and antimicrobial use in hospitals in the Netherlands has been measured using voluntary biannual national point-prevalence surveys (PPSs).AimTo describe trends in the prevalence of patients with HCAI, risk factors, and antimicrobial use in 2007–2016.MethodsIn the PPS, patient characteristics, use of medical devices and antimicrobials, and presence of HCAI on the survey day are reported for all hospitalized patients, excluding patients in the day-care unit and psychiatric wards. Analyses were performed using linear and (multivariate) logistic regression, accounting for clustering of patients within hospitals.FindingsPPS data were reported for 171,116 patients. Annual prevalence of patients with HCAI with onset during hospitalization decreased from 6.1% in 2007 to 3.6% in 2016. The adjusted odds ratio (OR) for trend was 0.97 (95% confidence interval: 0.96–0.98). Most prominent trends were seen for surgical site infections (1.6% to 0.7%; OR: 0.31 (0.26–0.38)) and urinary tract infections (2.1% to 0.6%; OR: 0.18 (0.15–0.22)). From 2014 on, HCAIs at admission were also registered with a stable prevalence of approximately 1.5%. The mean length of stay decreased from 10 to 7 days. The percentage of patients treated with antibiotics increased from 31% to 36% (OR: 1.03 (1.02–1.03)).ConclusionRepeated PPS data from 2007 to 2016 show a decrease in the prevalence of patients with HCAI with onset during hospitalization, and a stable prevalence of patients with HCAI at admission. The adjusted OR of 0.97 for HCAI during hospitalization indicates a true reduction in prevalence of approximately 3% per year.

  • Antimicrobial stewardship intervention: optimizing antibiotic treatment in hospitalized patients with reported antibiotic allergy
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-10-13
    L. Lin, J.E. Nagtegaal, P.C.A.M. Buijtels, E. Jong

    Background Reported antibiotic allergy in hospitalized patients seems to be related to more adverse events, the use of reserve antibiotics and longer hospitalizations. Most patients reporting an antibiotic allergy can be de-labelled and therefore an antimicrobial stewardship intervention was set up. Aim To determine the impact of reported antibiotic allergy on the antibiotic treatment of hospitalized patients and prevent unnecessary deviation from the preferred antibiotic treatment by a proactive antimicrobial stewardship intervention. Methods An intervention study in a teaching hospital in the Netherlands. Hospitalized patients reporting an antibiotic allergy were included in a three-month period between March and May 2019. Physicians received a training and were provided with a recommendation in the electronic medical record (EMR) in case the preferred antibiotic treatment was unnecessarily avoided due to the allergy label and the patient was eligible for a drug challenge. Findings A total of 492 patients were identified accounting for 558 hospital admissions. In 93 cases the antibiotic allergy label interfered with the preferred antibiotic treatment of which 68 were eligible for a drug challenge. A total of 42 patients were challenged. In 40 (95%) patients no allergic reaction was observed, and the preferred antibiotic treatment was given. Two (5%) patients developed a non-severe skin reaction after drug challenge and continued an alternative antibiotic regimen. Conclusion This antimicrobial stewardship intervention can be used to provide patients with reported antibiotic allergy labels with the preferred antibiotic treatment and to de-label them after uneventful re-exposure to the antibiotic agent.

  • Handwashing sinks as the source of transmission of ST16 carbapenem-resistant Klebsiella pneumoniae, an international high-risk clone, in ICU
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-10-10
    Yu Feng, Li Wei, Shichao Zhu, Fu Qiao, Xiaoxia Zhang, Yan Kang, Lin Cai, Mei Kang, Alan McNally, Zhiyong Zong

    Carbapenem-resistant Klebsiella pneumoniae isolates (carrying the carbapenemase gene blaNDM-5) of sequence type 16 caused hospital-acquired bloodstream infection or gut colonization in two ICU patients. We hypothesized that handwashing sinks were the source and all handwashing sinks in the ICU were sampled. Whole genome sequencing and analysis revealed that one sink was the source of CRKP colonization/infection in the two patients instead of direct transmission of a common clone between patients. This study highlights sinks as an important source of multidrug-resistant organisms. Sink management including prohibition of disposal body fluid and daily disinfection with chlorine curbed the transmission.

  • Variable impact of an antimicrobial stewardship programme in three intensive care units: time-series analysis of 2012-2017 surveillance data
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-10-09
    Abbara S, Domenech de Cellès M, Batista R, Mira JP, Poyart C, Poupet H, Casetta A, Kernéis S

    Background Preprescription authorization (PPA) and postprescription review with feedback (PPRF) were successively implemented in 2012 and 2016 in our 1500-bed hospital. Aim We assessed their impact on carbapenems use and resistance levels of P. aeruginosa in three intensive care units (ICU). Methods Carbapenems use (in DDD/1000 occupied bed-days) and resistance of P. aeruginosa (percentage of non-susceptible (I+R) isolates to imipenem and/or meropenem) were analyzed using a controlled interrupted time-series method. Two periods were compared: 2012-2015 (PPA) and 2016-2017 (PPA+PPRF). Models were adjusted on the annual incidence of extended-spectrum β-lactamase-producing Enterobacteriacae. Findings Carbapenem use was stable over PPA period in all ICUs, with a significant change of slope over PPA+PPRF period only in ICU1 (β2= -12.8, CI=-19.5;-6.1). There was a switch from imipenem to meropenem during PPA period in all three units. Resistances of P. aeruginosa were stable over the study period in ICU1 and 2, and significantly decreased over PPA+PPRF period in ICU3 (β2=-0.18, CI=-0.3;-0.03). Conclusion In real life conditions and with the same antimicrobial stewardship programme (AMSP) led by a single team, impact of PPRF was heterogeneous between ICUs. Factors driving impact of AMSP should be further assessed in comparable settings through real life data, to target where they could prove cost-effective.

  • Transmission of multidrug-resistant Gram-negative bacteria from colonized mothers to their infants: a systematic review and meta-analysis
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-10-08
    Andre N.H. Bulabula, Angela Dramowski, Shaheen Mehtar

    Aim To review the molecular evidence supporting transmission of multidrug-resistant Gram-negative bacteria (MDR-GNB) from colonized mothers to their infants and the risk factors for MDR-GNB transmission. Methods We searched PubMed and Scopus for studies investigating the mechanisms, risk factors for and/or scale of transmission of MDR-GNB from colonized mothers to their infants. We performed random effects meta-analyses to determine pooled proportions of MDR-GNB transmission and the neonatal outcomes of transmission. Findings Eight studies were included in the narrative description and seven in the meta-analysis. Five studies used pulsed-field gel electrophoresis (PFGE) to assess relatedness of isolates from colonized mothers and their infants. Pooled proportion of MDR-GNB transmission from colonized mothers to their infants was 27% (95% confidence interval, 8 – 47%). ESBL-producing Enterobacteriaceae, were the most frequently studied MDR-GNB pathogens transmitted between mother-infant pairs. Following mother to infant transmission of an MDR-GNB pathogen, the pooled proportion for the outcome of neonatal colonization was 19% (95% CI 3 – 35%). Conclusions This systematic review strongly supports MDR- and/or ESBL Enterobacteriaceae transmission from colonized mothers to their infants, with subsequent infant colonization. The risk factors contributing to transmission of MDR-GNB between colonized mothers and their infants warrants further research.

  • Genetics, Epidemiology and Clinical Manifestations of Multidrug-Resistant Acinetobacter baumannii
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-10-04
    Payman Nasr

    Acinetobacter baumannii infections have become an emerging health concern in hospitals across the world and are often associated with nosocomial infections with poorer clinical outcomes in patients with prolonged hospital stay. Management of infections involves prompt identification of the infecting strain, isolating the source of infection, and proper choice of antibiotic regimen. However, resistance to first-line antimicrobial drugs, combined with a lack of equally effective alternatives, complicates the treatment of multidrug-resistant A. baumannii. Presently, multidrug-resistant A. baumannii is a serious health concern in hospitals and long-term care facilities and requires immediate and sustained prevention efforts to control the rate of incidence. This review describes trends in epidemiology, genetic markers, and other factors that influence the incidence of multidrug-resistant A. baumannii. Current and emerging treatments, as well as infection control strategies are also discussed.

  • Invasive Pulmonary Aspergillosis: Comparative Analysis in Cancer Patients with Underlying Haematologic Malignancies Versus Solid Tumors
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-10-01
    Rita Wilson Dib, Melissa C. Khalil, Johny Fares, Ray Y. Hachem, Ying Jiang, Anne-Marie Chaftari, Issam I. Raad

    Background Invasive pulmonary aspergillosis (IPA) is commonly associated with haematologic malignancies but also occurs with solid tumors. Aim Comparing the diagnostic approaches and therapeutic outcomes for IPA between patients with haematologic malignancies and solid cancers. Methods We conducted a retrospective study evaluating consecutive cases of proven and probable IPA from 2004 to 2016. We included patients >18 years old with an underlying solid tumor, haematologic malignancy, or haematopoietic cell transplantation (HCT) within 1 year of IPA diagnosis. Findings Of the 311 patients analyzed, 225 had haematologic malignancies and 86 had solid tumors. Patients with solid tumors were more likely to have had COPD or other pulmonary diseases, have Aspergillus fumigatus infections, and have received radiotherapy before IPA occurrence than were those with haematologic malignancies (all P<0.01). Antifungal monotherapy and voriconazole-based therapy were more often prescribed in the solid group (87% vs 56%, P<0.0001, and 77% vs 53%, P=0.0002, respectively). The median duration of primary antifungal therapy was longer in the solid group (64 days vs 20 days, P<0.0001). Complete or partial response to antifungal therapy was recorded in 66% of the solid group and 40% of the haematologic group (P=0.0001). At 12 weeks, overall mortality was similar in both groups, but IPA-attributable mortality was higher in the haematologic group (30% vs 18%, P=0.04). Conclusions Monotherapy was more often prescribed in patients with solid tumors than patients with haematologic malignancies. Patients with solid tumors had better antifungal therapy response and lower 12-week IPA-attributable mortality than did those with haematologic malignancies.

  • Mobile phones as fomites for potential pathogens in hospitals: microbiome analysis reveals hidden contaminants
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-10-01
    Rebecca Simmonds, David Lee, Emma Hayhurst

    Background Smartphones used in clinical settings harbour potentially pathogenic bacteria, and this may pose an infection risk. Previous studies have relied on culture-based methods. Aim To characterize the quantity and diversity of microbial contamination of hospital staff smartphones using culture-dependent and culture-independent methods. To determine the prevalence of antibiotic resistant potential pathogens. To compare microbial communities of hospital staff and control group phones. Methods Smartphones of 250 hospital staff and 191 control group participants were swabbed. The antibiotic resistance profile of Staphylococcus aureus and enterococcus isolates was determined. Swabs were pooled into groups according to the hospital area staff worked in, and DNA was extracted. The microbial community of the phone was characterised using an Illumina MiSeq metabarcoding pipeline. Findings Almost all (99.2%) of hospital staff smartphones were contaminated with potential pathogens, and bacterial colony forming units (CFUs) were significantly higher on hospital phones than control group. Meticillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) were only detected on hospital mobile phones. Metabarcoding revealed a far greater abundance of Gram-negative contaminants, and much greater diversity, than culture-based methods. Bacillus species were significantly more abundant in the hospital group. Conclusion This study reinforces the need to consider infection control policies to mitigate the potential risks associated with the increased use of smartphones in clinical environments, and highlights the limitations of culture-based methods for environmental swabbing.

  • A survey on the implementation status of selected infection control strategies in neonatal intensive care units in Japan
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-27
    Shutaro Suga, Takayuki Hoshina, Shun Ichikawa, Shunsuke Araki, Koichi Kusuhara

    Background Infection control strategies are implemented in all neonatal intensive care units (NICUs); however, the details of the strategies seem to differ among institutions. The purpose of this survey was to investigate the current implementation status of infection control strategies in NICUs in Japan and identify and recommend appropriate strategies for the prevention of outbreaks in neonatal units. Methods To document the current implementation status and methods of selected infection prevention and control measures (active surveillance cultures and standard precaution) in 453 Japanese NICUs/neonatal units registered with the Japan Society of Perinatal and Neonatal Medicine, using questionnaires, in May 2018. Findings The response rate was 48.1% (level I institutions, 25.5%; level II, 55.9%; level III, 64.2%). Surveillance cultures were performed every week and targeted all bacteria in most units. The proportion of level III institutions that experienced outbreaks over the previous 5 years was significantly higher than that of level II institutions (55% vs. 27%, P = 0.0003). However, wearing a mask was less frequently recommended in level III institutions (55.7%) than in level II institutions (67.9%). Methicillin-resistant Staphylococcus aureus (MRSA) was the most frequently reported bacterial pathogen responsible for NICU outbreaks. Conclusion Infection prevention and control practices regarding active pathogen surveillance cultures and the use of barrier precautions varied widely in Japanese neonatal units. National guidelines and evidence-based recommendations are needed to rationalize and standardize current infection prevention and control practices in neonatal units in Japan.

  • Infectious complications in patients receiving ticagrelor or clopidogrel before coronary artery bypass grafting
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-26
    Magnus Dalén, Fausto Biancari

    The antiplatelet agent ticagrelor has recently been found to have bactericidal activity demonstrated in vitro and in a in vivo mouse model, which warrant further clinical investigations. The aim of this study was to evaluate infectious complications after coronary artery bypass grafting in patients preoperatively treated with ticagrelor or clopidogrel. In a multicenter trial, all adult patients who were preoperatively treated with ticagrelor or clopidogrel prior to isolated primary coronary artery bypass grafting were eligible. Propensity score matching was used. Outcome measures were any sternal wound infection, deep sternal wound infection, and any in-hospital use of postoperative antibiotics. Of 2311 patients who were included, 1293 (55.9%) received clopidogrel and 1018 (44.1%) ticagrelor preoperatively. In both overall and propensity score matched analyses, ticagrelor was associated with a similar incidence of infectious complications compared to clopidogrel. Our findings do not support a clinically relevant bactericidal effect of ticagrelor in patients undergoing CABG.

  • Novel colour additive for bleach disinfectant wipes reduces corrosive damage on stainless steel
    J. Hosp. Infect. (IF 3.704) Pub Date : 2018-09-24
    K. Tyan, K. Jin, J. Kang

    Bleach disinfectant wipes are corrosive to hospital surfaces and equipment. This study measured the effect of two widely used bleach wipes, with and without Highlight® colour additive, on stainless steel to quantify the rate of corrosion and to determine the effect of Highlight® on reducing surface damage caused by bleach wipes. The two bleach wipes alone caused severe corrosion [>5 mils per year (mpy), where 1 mil = 0.001 inch], while the addition of Highlight® reduced the rate of corrosion significantly (<2 mpy) and prevented discolouration of the metal. These results indicate that Highlight® reduces the deleterious corrosive effects of bleach wipes, thus improving their viability for cleaning healthcare surfaces.

  • Hand hygiene compliance of patients’ family members in India: importance of educating the unofficial “fourth category” of healthcare personnel
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-20
    Manisha Biswal, Archana Angrup, Surria Rajpoot, Rupinder Kaur, Kulbeer Kaur, Harinder Kaur, Harpreet Kaur, Navneet Dhaliwal, Pankaj Arora, A.K. Gupta

    Introduction – In India, due to manpower constraints, patients’ family members are often actively involved in healthcare activities of their near and dear ones. They have significant contact with the patient at all WHO’s five moments for hand hygiene (HH). In this study, we analyzed the impact of decade long awareness campaigns on the HH compliance (HHC) in our patients’ carers. Methods – Trained infection control nurses observed the HHC at each of the five moments for patients’ attendants in different hospital settings from January 2014 to December 2018. Compliance was calculated as percentage of events over total opportunities. Results 7302 opportunities were observed with an overall compliance of 46.1% (35.5% in 2014 to 48.2% in 2018, p <0.0001). Compliance at WHO moments 1, 2, 3, 4 and 5 was 51.0%, 47.4%, 67.6%, 48.8% and 24.3% respectively. Among family members, mothers of new borns had a much higher HHC (77%) than others (44.5%) (p <0.0001). Also, the compliance was higher in medical versus surgical wards and pediatric wards versus adult wards (p <0.0001 in both). Conclusion – This is the first study about family members’ HHC in a hospital setting in a low and middle income country. This study shows that once trained, family members exhibit fairly good hand hygiene compliance while caring for their patients, especially mothers of new-borns. It is worthwhile empowering and educating patient attendants about the importance and process of hand hygiene as it is likely to result in immense benefit for patients.

  • Comparing mask fit and usability of traditional and nanofibre N95 filtering facepiece respirators before and after nursing procedures
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-20
    Lorna LK. Suen, Yue Ping Guo, Suki SK. Ho, Cypher H. Au-Yeung, Simon Lam

    Background The reliability of N95 filtering facepiece respirators (FFRs) depends on correct fitting. The perceived usability of FFR is equally important because discomfort during usage may affect compliance. Body movements during nursing procedures may also increase the risk of face seal leakage. Aim To evaluate the mask fit and usability of the best fit 3M N95 FFRs and nanofibre N95 FFR before and after nursing procedures. The physical properties of these FFRs were also examined. Methods This experimental study adopted one-group multiple comparison design. 104 nursing students participated and performed nursing procedures for 10 minutes when wearing the best fit 3M FFR and nanofibre FFR. The mask fit and perceived usability of the FFRs were evaluated. Findings More participants failed to obtain fit factor of ≥100 when using 3M FFR than when wearing the nanofiber FFR (33.7% versus 21.2%) after the procedures (p=0.417). The nanofibre FFR also demonstrated higher usability, in terms of facial heat, breathability, facial pressure, speech intelligibility, itchiness, difficulty of maintaining the mask in place, and comfort level than the 3M FFRs (p<0.001). The nanofiber FFR is also lighter, thinner, and has a slightly higher bacterial filtration efficiency than the 3M FFRs. Conclusion The nanofibre FFR demonstrated significantly better usability than the 3M FFRs. All respirators could not provide consistent protection for the wearer, as detected by face seal leakage after performing nursing procedures. Further improvement in the prototype design is needed to increase compliance and ensure the respiratory protection of users.

  • Risk factors for Clostridioides difficile infection in hospitalized patients and associated mortality in Japan: a multi-centred prospective cohort study
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-19
    Hitoshi Honda, Haru Kato, Margaret A. Olsen, Kimberly A. Reske, Mitsutoshi Senoh, Tadashi Fukuda, Yasuaki Tagashira, Cedric Mahe, Erik R. Dubberke

    Background Although population characteristics and antimicrobial prescribing practices suggest that the hospitalized population in Japan is at high risk of Clostridioides difficile infection (CDI), the epidemiology of CDI in Japan is poorly understood. Aim This prospective cohort study aimed to investigate the epidemiology of CDI at twelve hospitals in Japan. Methods Patients with clinically significant diarrhoea (CSD) were enrolled. Stool specimens were tested for C. difficile by toxin A and/or B enzyme immunoassay (EIA) in the hospital laboratories, and a toxigenic culture and nucleic acid amplification tests were performed at a central laboratory. The risk factors of CDI and the impact of CDI on mortality were investigated. Findings In total, 566 patients with CSD were included in the analyses. A total of 152 patients received the diagnosis of CDI by Toxin A/B EIA. Factors associated with CDI included low albumin (aOR 1.56; 95% CI 1.03 – 2.34) and length of hospital stay before stool collection >18 days (aOR 1.73; 95% CI 1.09-2.75). CDI was associated with an increased mortality on univariate analysis (OR 1.6, 95% CI 1.0-2.6) but was not associated with an increased risk of mortality on multivariable analysis. Conclusion Risk factors for CDI in Japan were similar to those identified in the US and Europe. However, CDI was not associated with an increased risk of mortality in this population of patients with CSD.

  • The Role of Antimicrobial Restrictions in Bacterial Resistance Control: A Systematic Literature Review
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-19
    Marianneta Chatzopoulou, Lucy Reynolds

    Background Antimicrobial stewardship is considered as one of the most fundamental aspects of bacterial resistance control. Among the multitude of initiatives, restrictive strategies have been widely practiced in hospital settings. However, the data concerning their potential effectiveness has not been methodically collected and evaluated so far. Aim To identify, collect and evaluate the available evidence regarding the impact of restrictive policies on bacterial resistance in hospital settings. Methods A systematic literature review was conducted in the PubMed/Medline, Embase, Global Health and CINAHL Plus databases. Findings A total of 5,555 papers were retrieved in the search process and 29 studies were finally included in analysis. Randomised studies were absent and the inherent limitations of the observational designs employed impede the deduction of safe conclusions. Seemingly beneficial interventions encompass the restriction of broad-spectrum cephalosporins in favour of beta-lactam/lactamase-inhibitor combinations as well as the restriction of fluoroquinolones. Antimicrobial restrictions might also play a role in VRE control while carbapenem stewardship in the form of preferred ertapenem use did not produce the anticipated results. Complex restrictions are not offered for informative comparative analyses. Hospital-wide policies could perhaps be superior to those confined in high-risk departments. Carbapenem-resistant A. baumannii might be difficult to control through solely formulary interventions. Conclusion The presumably effective restrictive strategies rely mostly on inadequately tested hypotheses and low-quality evidence. Therefore, systematic, high-quality research is needed to confirm and expand our comprehension of the subject so that the most successful policies are actually employed on the field.

  • Use of health databases to deal with underreporting of surgical site infections due to suboptimal post-discharge follow-up
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-13
    Carlo Gagliotti, Rossella Buttazzi, Alberto Ricciardi, Enrico Ricchizzi, Giuseppina Lanciotti, Maria Luisa Moro

    This study describes a combined surveillance of surgical site infection implemented in an Italian region, which relies on integration of the specific surveillance (SIChER) with other sources and the targeted review of a small proportion of cases. Additional information on post-surgical follow-up was obtained from hospital discharge, microbiology laboratory and emergency department databases. Based on these data, 76 patients were reclassified as possible cases and revised by the health trust representatives. Eventually 45 new cases were confirmed, leading to an increase in the infection ratio from 1.13% to 1.45%. The proposed method appears to be accurate and sustainable over time.

  • Altering Antibiotic Regimen as Additional Control Measure in Suspected Multi-Drug-Resistant Enterobacter cloacae Outbreak in a Neonatal Intensive Care Unit
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-13
    Vanessa Eichel, Cihan Papan, Sebastien Boutin, Johannes Pöschl, Klaus Heeg, Dennis Nurjadi

    Background Increased occurrence of a particular species of gram-negative (GN), especially when multi-drug-resistant (MDR), in routine screening surveillance in Neonatal Intensive Care Units (NICUs) can be evoked by selection pressure. Aim To evaluate adapting the empiric antibiotic regimen for its usefulness as control measure in suspected outbreaks in the NICU. Methods In a retrospective outbreak analysis, cases between December 1, 2017 and March 31, 2018 were identified through microbiology and hygiene surveillance records. Furthermore, risk factors for MDR-GN colonization were collected. Whole genome sequencing (WGS) was performed on all isolates. Control measure documentations and interviews were employed to define interventions. Besides infection control measures, administration of 3rd generation cephalosporins was avoided and replaced whenever clinically acceptable as part of the intervention bundle. Findings A total of 9 patients were rectally colonized with 3rd generation cephalosporin resistant E. cloacae in routine screening surveillance in the period before intervention. After implementing an infection control bundle, the incidence rapidly declined. WGS analysis revealed, that two MDR E. cloacae were transmitted, the main part emerged newly. Incidence density of MDR-GN colonization was 7.94/1000 PD before intervention and 1.68/1000 PD during the altered antibiotic regimen. Over the entire period no infections with MDR-GN occurred. Conclusions Altering the antibiotic regimen with regard to selection pressure may be considered as part of intervention bundle to rapidly control the emergence of MDR-GN in suspected outbreak situations in the NICU.

  • One Size Does NOT Fit All: The Effectiveness of Messaging for Hand Hygiene Compliance by Profession in a Tertiary Hospital
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-13
    Sharon Salmon, Mei Yen Phua, Dale Fisher

    To determine the effectiveness of our messaging for hand hygiene compliance by profession we conducted a hospital-wide survey followed by profession specific focus group discussions to investigate impact, perceptions, and areas for improvement. Results showed a good understanding that hand hygiene was a crucial part of the infection prevention programme however the acceptance and impact of messages varied between professions and required tailoring. Motivation, use of influential role models and social cohesion should be considered when designing profession specific messages to improve infection prevention - related - change uptake among health care professional groups.

  • Current status of antimicrobial stewardship programmes in Korean hospitals: results of a 2018 nationwide survey
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-09
    B. Kim, M.J. Lee, S.M. Moon, S.Y. Park, K.-H. Song, H. Lee, J.S. Park, M.S. Lee, S.-M. Choi, J.-S. Yeom, J.Y. Kim, C.-J. Kim, H.-H. Chang, E.S. Kim, T.H. Kim, H.B. Kim

    Background Antimicrobial stewardship programmes (ASPs) are suggested as a vital strategy to address antimicrobial resistance. Aim To examine the current status of ASPs in Korean hospitals, to identify problems and challenges for the implementation of proper ASPs, and to provide a reference for developing more effective ASP policies. Methods A questionnaire based on the ‘Seven Core Elements of Hospital Antibiotic Stewardship Programs’ from the US Centers for Disease Control and Prevention was developed, modified from the previous questionnaire on ASPs in Korea, 2015. ASP-participating physicians such as infectious disease specialists (IDSs), paediatric IDSs, and directors of infection control departments were targeted. Only one ASP-associated physician per hospital participated in the survey. Findings The survey response rate was 88.4% (84/95). The median number of medical personnel participating in ASPs was 3 (interquartile range (IQR): 1–5), most of whom were IDS (median: 2; IQR: 1–2). Only 6.0% (5/84) of hospitals had full-time workers for ASPs. Whereas restrictive measures for designated antimicrobials were widely implemented among Korean hospitals (88.1%, 74/84), the proportion of hospitals with interventions for inappropriate long-term antimicrobial use and a conversion strategy from parenteral to oral antimicrobial administration was only 9.5% (8/84) and 1.2% (1/84), respectively. Lack of time, personnel, and appropriate compensation was perceived as the major barrier to establishing an ASP in Korean hospitals. Conclusion ASPs in Korean hospitals were primarily carried out by one or two IDSs, and programmes mostly comprised restrictive measures for designated antimicrobials. National-level support to implement appropriate ASPs in Korean hospitals is necessary.

  • Danish experience of meticillin-resistant Staphylococcus aureus eradication with emphasis on nose-throat colonization and supplementary systemic antibiotic treatment
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-09
    Ina Sleimann Petersen, Judit Marta Christensen, Anne Bak Zeuthen, Pia Bruun Madsen

    The study-aim was to evaluate the Danish national Board of Health's guidance for treating MRSA carriage focusing on MRSA nose-throat carriage and use of supplementary systemic antibiotics. We analyze results of MRSA eradication treatment of 358 patients, focusing on those with nose (n=58) or throat (n=183) MRSA colonization. We found that the Danish guidance for treating MRSA have greater success for patients with nose colonization (66%) compared to throat colonization (41%), even though the cumulative eradication rates were equal after additional three treatment cycles (71% versus 73%). We find no positive effect of supplementing the colonization treatment with systemic antibiotics.

  • Hand antisepsis without decreasing efficacy by shortening the rub-in time of alcohol-based handrubs to 15 seconds
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-09
    Julian C. Harnoss, Stephanie J. Dancer, Christoph Friedrich Kaden, Romy Baguhl, Thomas Kohlmann, Roald Papke, Marek Zygmunt, Ojan Assadian, Miranda Suchomel, Didier Pittet, Axel Kramer

    Background A previous study among neonatal intensive care unit (NICU) nurses showed that the antibacterial efficacy of alcohol-based handrubs (ABHR) can be achieved in 15s instead of 30s with a significant increase in the frequency of hand antisepsis. This study aimed to examine 15s vs 30s antisepsis performance by measuring microbial load on fingertips and compliance among nurses in a low-risk gynaecological ward. Methods An independent trained observer monitored the frequency and compliance with hand antisepsis during shifts in a crossover design. Fingertips including thumbs were rinsed in soy broth before hand rubbing at the beginning of a shift and then hourly to determine the bacterial load. Performance activity was assigned to the contamination class of the Fulkerson scale. Immediately before the lunch break, volunteers cleaned their hands for a randomly determined application time of 15 or 30 seconds. Results Examination of bacterial load on fingertips revealed no difference between 15 vs. 30 seconds application time. Controlled hand antisepsis before the lunch break also showed no difference in efficacy for either test series. Participants rubbing for 15 seconds were more likely to perform hand antisepsis compared with those rubbing for 30 seconds (p = 0.2). The compliance increased from 54.7% to 69.5% in the 15s trial. Discussion Shortening the duration for hand antisepsis did not decrease efficacy. Shortening the application time to 15 s should be considered within the critical components of a successful multimodal intervention strategy to improve hand hygiene compliance in clinical practice.

  • Levofloxacin-resistant Stenotrophomonas maltophilia: risk factors and antibiotic susceptibility patterns in hospitalized patients
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-07
    Ching Hsun Wang, Ching-Mei Yu, Sung-Teng Hsu, Rui-Xin Wu

    Background Levofloxacin has been considered as an alternative treatment for Stenotrophomonas maltophilia infection. Levofloxacin-resistant S. maltophilia (LRSM), however, are emerging in the world. Aim The retrospective matched case-control-control study is aimed to investigate LRSM risk factors in hospitalized patients. Antibiotic susceptibility patterns of collected LRSM isolates were determined. Methods LRSM patients (the case group) were compared with two control groups: levofloxacin-susceptible S. maltophilia (LSSM) patients (control group A) and non-S. maltophilia-infected patients (control group B). Conditional logistic regression was used to analyse risk factors for LRSM occurrence. Tigecycline, ceftazidime, colistin, and trimethoprim/sulfamethoxazole (TMP/SMX) susceptibilities in collected LRSM clinical isolates were determined. Findings A total of 105 LRSM, 105 LSSM, and 105 non-S. maltophilia-infected patients were analysed. The first multivariable analysis (cases vs. group A) revealed that previous fluoroquinolones use was significantly associated with LRSM occurrence, and the second multivariable analysis (cases vs. group B) revealed that previous fluoroquinolones use, previous intensive care unit (ICU) stay, and the number of previous exposures to different classes of antibiotics were significantly associated with LRSM occurrence. Of all the LRSM isolates tested for antibiotic susceptibility, ceftazidime, TMP/SMX, tigecycline, and colistin resistance rates were 42.0, 99.0, 78.0, and 40.0%, respectively. Conclusion LRSM antibiotic susceptibility patterns revealed multiple-drug resistance, which further limits treatment options for clinicians. To reduce LRSM occurrence, proper use of antibiotics, especially fluoroquinolones, is mandatory.

  • Antibiotic decision making in surgical intensive care: a qualitative analysis
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-07
    K. Rynkiewich, D. Schwartz, S. Won, B. Stoner

    Background Antibiotic use in hospitals is high, particularly in surgical specialty and intensive care units. Antimicrobial stewardship programmes (ASPs) are increasingly intervening in antibiotic use by surgeons and intensivists. However, there is limited information on the features which characterize antibiotic decision making in the surgical intensive care unit (SICU), an area in hospital practice where critically ill surgery patients can be kept under close observation. Aim To explore the features which characterize antibiotic decision making in the SICU. Methods A total of 160 h of ethnographic observation and 10 semi-structured interviews were conducted at two teaching hospitals in the USA. Data were analysed using thematic coding. Findings Three key characteristics of SICU practice with regard to antibiotic use were identified: (1) physical proximity makes SICU clinicians acutely aware of changes in patient status; (2) communication of patient status relies on active involvement by SICU clinicians; (3) SICU clinicians have contested and variable autonomy over antibiotic decisions. Conclusions Antibiotic decision making in the SICU is a complex process involving multiple clinician teams with varying levels of physical proximity to and autonomy over patient cases. This study found that the SICU clinician team has increased physical proximity to patient cases but little autonomy over antibiotic decisions. If these characteristics are not considered, antimicrobial stewardship (AMS) interventions may have diminished success in addressing high levels of the antibiotic use in the SICU.

  • Detection of methicillin resistant Staphylococcus aureus and carbapenemase-producing enterobacteria in Danish Emergency Departments – evaluation of national screening guidelines
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-05
    Helene Skjøt-Arkil, Christian B. Mogensen, Annmarie T. Lassen, Isik S. Johansen, Ming Chen, Poul Petersen, Karen V. Andersen, Svend Ellermann-Eriksen, Jørn M. Møller, Marc Ludwig, David Fuglsang-Damgaard, Finn Erland Nielsen, Dan B. Petersen, Ulrich S. Jensen, Flemming S. Rosenvinge

    Background Multiresistant bacteria (MRB) are an emerging problem. Early identification of patients colonized with MRB is mandatory to avoid in-hospital transmission and to target antibiotic treatment. Since most patients pass through specialized emergency departments (ED), these departments are crucial in early identification. The Danish National Board of Health (DNBH) has developed exposure-based targeted screening tools to identify and isolate carriers of methicillin resistant Staphylococcus aureus (MRSA) and carbapenemase-producing enterobacteria (CPE). Aim To assess the national screening tools for detection of MRSA and CPE carriage in a cohort of acute patients. The objectives were to investigate I) if the colonized patients were detected, and II) if the colonized patients were isolated? Methods A multicenter cross-sectional survey of adults visiting EDs. The patients answered the DNBH questions, and were swabbed in the nose, throat, and rectum. The collected samples were examined for MRSA and CPE. The screening performances were calculated. Findings Of the 5117 included patients, 16 were colonized with MRSA and four with CPE. The MRSA screening tool had a sensitivity of 50% (95% confidence interval (CI) 25-75%) for carrier detection and 25% (95%CI 7-52%) for carrier isolation. The CPE screening tool had a sensitivity of 25% (95%CI 1-81%) and isolated none of the CPE carriers. Conclusion The national screening tools were of limited use since the majority of MRSA and CPE carriers will pass unidentified through the ED, and many patients will be isolated unnecessarily.

  • A Service Evaluation of Simultaneous near Patient Testing for Influenza, RSV, Clostridium difficle and Norovirus in a UK District General Hospital
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-05
    John Haigh, Maria-Teresa Cutino-Moguel, Mark Wilks, Catherine A. Welch, Mark Melzer

    Background The Cepheid® GeneXpert® (GXP) can simultaneously test for norovirus (NV), Clostridium difficile (CD), influenza A/B (IFA/B) and respiratory syncytial virus (RSV). Aim To compare centralised multiplex polymerase chain reaction (PCR) testing with localised GXP testing at a district general hospital. Methods From December 2017 – December 2018, samples received at Whipps Cross University Hospital (WCUH) were first tested at the local laboratory before transport centrally to the Royal London Hospital (RLH). At the RLH, a non-proprietary multiplex reverse transcriptase (RT) PCR assay was performed, which also tested for GI or Respiratory pathogens not tested for by the GXP. Findings 1,111 stool and respiratory samples were processed at both sites. 591 were respiratory and 520 were stool samples. Compared to centralised testing, the GXP gave sensitivity, specificity, and NPV all in excess of 97%, with the exception of RSV. The RSV assay had a sensitivity of 66.7% (95%CI 24.1, 94.0) but a NPV of 99.7% (95%CI 98.6, 99.9). At the RLH, 65 (5.9%) additional respiratory or GI viruses were detected, predominantly rhinovirus 35 (3.2%) and adenovirus 11 (1.0%). Compared to centralised testing, the median time saved for local respiratory and gastro-intestinal sample testing was 19 hours and 46 min and 17 hours and 06 min. Conclusions Local GXP testing compared to centralised multiplex PCR testing for IF, NV and CD, demonstrated sensitivities, specificities and NPV between 95% - 100%. Turnaround times were faster, enabling quicker infection prevention and control decision making. In our local setting (WCUH), the GXP demonstrated the potential to reduce NV and IFA/B outbreaks.

  • Lowbury Lecture 2018. Chlorhexidine-Based Decolonization to Reduce Healthcare-Associated Infections and Multidrug-Resistant Organisms (MDROs): Who, What, Where, When, and Why?
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-05
    Susan S. Huang

    Body surface decolonization with chlorhexidine bathing and nasal mupirocin has become a simple solution for prevention of healthcare-associated infections. The clinical trial evidence for this practice will be reviewed to understand who benefits from this practice, for what reasons, and at what times. The method of bathing and nasal decolonization will also be discussed as proper application is needed for maximal effectiveness. Finally, the conflict between current effectiveness and future potential for fueling resistance is considered.

  • Prevention of healthcare-associated invasive aspergillosis during hospital construction/renovation works
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-01-07
    A.F. Talento, M. Fitzgerald, B. Redington, N. O'Sullivan, L. Fenelon, T.R. Rogers

    The association between healthcare-associated invasive aspergillosis and hospital construction/building works is well recognized. This infection can cause significant morbidity and mortality and imposes a substantial burden on the healthcare system. The population of patients at risk for this opportunistic infection has expanded and multi-triazole drug resistance has emerged globally. Hence the need for a multi-faceted approach to prevent acquisition of invasive aspergillosis in acute care settings. This article is a summary of the Irish National Guidelines for the prevention of healthcare-associated aspergillosis which is based on published reports, international clinical guidelines, official engineering standards, and technical guidelines. We discuss the key recommendations and strategies for the prevention of invasive aspergillosis from the planning/pre-construction, construction, and post-construction phases. The importance of multi-disciplinary team involvement, education, and communication is emphasized.

  • In-vitro antibacterial and anti-encrustation performance of silver-polytetrafluoroethylene nanocomposite coated urinary catheters
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-02-22
    L. Wang, S. Zhang, R. Keatch, G. Corner, G. Nabi, S. Murdoch, F. Davidson, Q. Zhao

    Background Catheter-associated urinary tract infections (CAUTIs) are among the most common hospital-acquired infections, leading to increased morbidity and mortality. A major reason for this is that urinary catheters are not yet capable of preventing CAUTIs. Aim To develop an anti-infective urinary catheter. Methods An efficient silver-polytetrafluoroethylene (Ag-PTFE) nanocomposite coating was deposited on whole silicone catheters, and two in-vitro bladder models were designed to test antibacterial (against Escherichia coli) and anti-encrustation (against Proteus mirabilis) performances. Each model was challenged with two different concentrations of bacterial suspension. Findings Compared with uncoated catheters, coated catheters significantly inhibited bacterial migration and biofilm formation on the external catheter surfaces. The time to develop bacteriuria was an average of 1.8 days vs 4 days and 6 days vs 41 days when the urethral meatus was infected with 106 and 102 cells/mL, respectively. For anti-encrustation tests, the coated catheter significantly resisted encrustation, although it did not strongly inhibit the increases in bacterial density and urinary pH. The time to blockage, which was found to be independent of the initial bacterial concentration in the bladder, was extended from 36.2±1.1 h (uncoated) to 89.5±3.54 h (coated) following bacterial contamination with 103 cells/mL in the bladder. Moreover, the coated catheter exhibited excellent biocompatibility with L929 fibroblast cells. Conclusion Ag-PTFE coated Foley catheters should undergo further clinical trials to determine their ability to prevent CAUTIs during catheterization.

  • Four steps to clean hospitals: LOOK, PLAN, CLEAN and DRY
    J. Hosp. Infect. (IF 3.704) Pub Date : 2018-12-27
    S.J. Dancer, A. Kramer

    Background Now that cleaning and decontamination are recognized as integral to infection control, it is timely to examine the process in more detail. This is because cleaning practices vary widely within healthcare districts, and it is likely that both time and energy are needlessly wasted with ill-defined duties. Furthermore, inadequate cleaning will not reduce the risk of infection but may even enhance it. The process would benefit from a systematic appraisal, with each component placed within an evidence-based and ordered protocol. Methods A literary search was performed on ‘hospital cleaning’, focusing on manual aspects of cleaning, pathogen reservoirs and transmission, hand hygiene, staff responsibilities and patient comfort. Results No articles providing an evidence-based practical approach to systematic cleaning in hospitals were identified. This review therefore proposes a simple four-step guide for daily cleaning of the occupied bed space. Step 1 (LOOK) describes a visual assessment of the area to be cleaned; Step 2 (PLAN) argues why the bed space needs preparation before cleaning; Step 3 (CLEAN) covers surface cleaning/decontamination; and Step 4 (DRY) is the final stage whereby surfaces are allowed to dry. Conclusion Given the lack of articles providing practical cleaning guidance, this review proposes a four-step protocol based on evidence if available, or justified where not. Each step is presented, discussed and risk-assessed. It is likely that a systematic cleaning process would reduce the risk of healthcare-associated infection for everyone, including outbreaks, in addition to heightened confidence in overall quality of care.

  • Impact of test protocols and material binding on the efficacy of antimicrobial wipes
    J. Hosp. Infect. (IF 3.704) Pub Date : 2018-09-28
    R. Wesgate, A. Robertson, M. Barrell, P. Teska, J-Y. Maillard

    Background The use of effective cleaning/disinfectant products is important to control pathogens on healthcare surfaces. With the increasing number of wipe products available, there is a concern that combination of a formulation with the wrong material will decrease the efficacy of the product. This study aimed to use a range of efficacy test protocols to determine the efficacy of four formulations before and after binding to three commonly used wiping materials. Methods Two quaternary ammonium (QAC)-based products, one hydrogen-peroxide-based product and one neutral cleaner were combined with microfibre, cotton or non-woven materials and tested for efficacy against Pseudomonas aeruginosa and Staphylococcus aureus with two surface tests (ASTM E2197-17 and EN13697-15) and two ‘product’ tests (ASTM E2967-15 and EN16615-15). Findings Overall, the impact of using different materials on formulation efficacy was limited, except for an alkyl(C12-16)dimethylbenzylammonium chloride-based product used at 0.5% v/v. The hydrogen peroxide product was the most efficacious regardless of the material used. The results from wipe test ASTM E2967-15 were consistent with those from the surface tests, but not with EN16615-15 which was far less stringent. Conclusions The use of different wiping cloth materials may not impact severely on the efficacy of potent disinfectants, despite the absorption of different volumes of formulation by the materials. QAC-based formulations may be at higher risk when a low concentration is used. There were large differences in efficacy depending on the standard test performed, highlighting the need for more stringency in choosing the test to make a product claim on label.

  • Effect of disinfectant formulation and organic soil on the efficacy of oxidizing disinfectants against biofilms
    J. Hosp. Infect. (IF 3.704) Pub Date : 2018-10-26
    D. Chowdhury, A. Rahman, H. Hu, S.O. Jensen, A.K. Deva, K. Vickery

    Background Biofilms that develop on dry surfaces in the healthcare environment have increased tolerance to disinfectants. This study compared the activity of formulated oxidizing disinfectants with products containing active ingredients against Staphylococcus aureus dry-surface biofilm (DSB) alone. Methods DSB was grown in the CDC bioreactor with alternating cycles of hydration and dehydration. Disinfectant efficacy was tested before and after treatment with neutral detergent for 30 s, and in the presence or absence of standardized soil. Biofilms were treated for 5 min with peracetic acid (Surfex and Proxitane), hydrogen peroxide (Oxivir and 6% H2O2 solution) and chlorine (Chlorclean and sodium dichloroisocyanurate tablets). Residual biofilm viability and mass were determined by plate culture and protein assay, respectively. Findings Biofilm viability was reduced by 2.8 log10 for the chlorine-based products and by 2 log10 for Proxitane, but these products failed to kill any biofilm in the presence of soil. In contrast, Surfex completely inactivated biofilm (6.3 log10 reduction in titre) in the presence of soil. H2O2 products had little effect against DSB. Biofilm mass removed in the presence and absence of soil was <30% by chlorine and approximately 65% by Surfex. Detergent treatment prior to disinfection had no effect. Conclusion The additives in fully formulated disinfectants can act synergistically with active ingredients, and thus increase biofilm killing whilst decreasing the adverse effect of soil. It is suggested that purchasing officers should seek efficacy testing results, and consider whether efficacy testing has been conducted in the presence of biological soil and/or biofilm.

  • Complex design of surgical instruments as barrier for cleaning effectiveness, favouring biofilm formation
    J. Hosp. Infect. (IF 3.704) Pub Date : 2018-11-10
    L.K.O. Lopes, D.M. Costa, A.F.V. Tipple, E. Watanabe, R.B. Castillo, H. Hu, A.K. Deva, K. Vickery

    Background Inadequately reprocessed reusable surgical instruments (RSIs) may harbour infectious agents which may then be transferred to a suitable site for replication. Aim To determine the cumulative effect of 20 cycles of contamination, cleaning (manual or manual followed by automated) and steam sterilization on high-complex-design RSIs used for orthopaedic surgery. Methods New flexible medullary reamers and depth gauges were contaminated by soaking in tryptone soya broth, containing 5% sheep blood and 109 cfu/mL of Staphylococcus aureus (ATCC 25923), for 5 min. To mimic a worse-case scenario, RSIs were dried 7 h and subjected to either (a) rinsing in distilled water, (b) manual cleaning or (c) manual plus automated cleaning (reference standard), and steam sterilization. The contamination, cleaning, and sterilization cycle was repeated 20 times. Adenosine triphosphate (ATP) was measured after cleaning procedures; microbial load and residual protein were measured following the 10th and 20th reprocessing, in triplicate. Scanning electron microscopy (SEM) was used to confirm soil and biofilm presence on the RSIs after the 20th reprocessing. Findings Manual and manual plus automated cleaning significantly reduced the amount of ATP and protein residues for all RSIs. Viable bacteria were not detected following sterilization. However, SEM detected soil after automated cleaning, and soil, including biofilms, after manual cleaning. Conclusion Soil and/or biofilms were evident on complex-design RSIs following 20 cycles of contamination and reprocessing, even using the reference standard method of cleaning. Although the depth gauges could be disassembled, biological residues and biofilm accumulated in its lumen. The current design of these RSIs prevents removal of all biological soil and this may have an adverse effect on patient outcome.

  • Effect of using ceiling-mounted systems for imaging in hybrid operating rooms on the level of colony-forming units during surgery
    J. Hosp. Infect. (IF 3.704) Pub Date : 2018-10-23
    A.A.L. Traversari, S.P.M. van Heumen, A.W.J. Hoksbergen

    Background Large imaging systems in hybrid operating rooms are used increasingly. However, the effect of these ceiling-mounted imaging systems on air quality during surgical procedures has not been studied to date. Aim To evaluate the level of colony-forming units (cfu)/m3 near the surgical wound and near the instrument table during surgery. Methods Measurements were performed in four hybrid operating rooms at four different hospitals. During surgical procedures, at least three samples were taken with active slit air samplers. At the end of the day's surgical schedule, simulations involving movement of the ceiling-mounted system were also performed. The threshold value for the average cfu level during a surgical procedure was set at ≤10 cfu/m3, and for individual samples was set at ≤30 cfu/m3. Results The median value near the surgical wound was 1 cfu/m3 and at the instrument table was 2 cfu/m3. However, in one hybrid operating room (two procedures out of 16) where the instrument table was not positioned directly under the unidirectional flow (UDF) system, the threshold value for the average cfu level at the instrument table was exceeded. For one of these procedures, the maximum value for an individual sample was also exceeded. Conclusions A ceiling-mounted imaging system in combination with a UDF system can result in cfu levels near the surgical wound and at the instrument table that are well below the threshold value of 10 cfu/m3 during surgery. If the instrument table is not positioned directly under the UDF system, the cfu level is higher.

  • Observation study of water outlet design from a cross-infection/user perspective: time for a radical re-think?
    J. Hosp. Infect. (IF 3.704) Pub Date : 2018-11-14
    M.J. Weinbren, D. Scott, W. Bower, D. Milanova

    Background Handwashing is a key barrier to cross-infection performed at a handwash station (HWS). Elbow-operated outlets, if used incorrectly (with hands), become highly touched objects, potentially providing a route for cross-infection. Aim To study how elbow-operated outlets were used by staff in this hospital, whether the correct type of HWS had been installed in the various ward areas according to the Health Building Note (HBN) 00-10 Part C: Sanitary Assemblies (hands-free outlets in clinical, food preparation and laboratory areas), and factors impinging on design/setup which may affect compliance with correct use. Methods Observation of outlet use was performed by mounting a video camera above four HWSs. Review of suitability of outlet was conducted by two of the authors by visiting ward areas and assessing compliance against HBN recommendations. Angle of elbow-operated lever setup was measured using a protractor and water temperature in relation to angle of movement of elbow lever was measured using a calibrated thermocouple. Findings Ninety-two percent of staff used hands to turn on the outlet and 68% used hands to turn the outlet off, potentially re-contaminating their hands. More than 70% of users moved the lever ≤45°. Almost half of elbow levers were set up incorrectly, being flush or within 3.5 cm of the rear panel, making elbow operation extremely difficult. Selection of outlet type according to HBN was most incorrect in the intensive treatment unit but also occurred in the newly built parts of the hospital. Conclusions Although handwashing is a key barrier to cross-infection, poor selection and incorrect use of outlet undermines its effectiveness. Design and incorrect instalment further compromise the intended means of operation of elbow levers. Of equal concern is that this risk mostly goes unrecognized. There is an opportunity to improve handwashing safety, but it requires engagement across a broad stratum from Government Departments of Health and manufacturers down to the user.

  • Evaluation of the mechanical cleaning efficacy of dental handpieces
    J. Hosp. Infect. (IF 3.704) Pub Date : 2018-11-27
    Damien Offner, Lucien Brisset, Anne-Marie Musset

    Background Dental handpieces undergo a decontamination process before reutilization. Thorough cleaning is a prerequisite to effective sterilization, to guarantee safety and prevent cross-infections. Aim To assess the cleaning efficacy offered by devices dedicated to dental handpieces. Methods PIDTests©, which are patented tubes made of transparent material and designed to replace handpieces in cleaning devices, were artificially stained by Soil Test© (Browne/STERIS). Three cycles were performed with PIDTests© connected to every handpiece adapter in the four different machines tested: X-Cid 2© (Micro-Mega) with a total of nine PIDTests©; iCare+© (NSK) with nine PIDTests©; DAC Universal© (W&H) with 18 PIDTests©; and BioDA 80© (VR2M) with 24 PIDTests©. A visual evaluation and a biuret reaction test were performed. Findings In three of the tested cleaning devices (X-Cid2©, iCare+© and DAC Universal©), all of the PIDTests© showed Soil Test© residues, on the internal and external surfaces indicating cleaning was ineffective. Only the BioDA 80© showed no residual stains on all the PIDTests© and negative biuret reaction test results, making the cleaning effective. Conclusions Manufacturers should optimize the cleaning device parameters, based on the Sinner circle (grouping compensatory parameters which influence the effectiveness of a cleaning process, such as pressure, temperature, time, detergent concentration), to improve cleaning efficacy and enable dental surgeons to ensure the safety. Although PIDTests© are the only tool to provide visual indications on the cleaning efficacy of washer-disinfectors dedicated to handpieces, manufacturers should continue with the development of improved and validated tools to assess cleaning efficacy.

  • Isopropanol at 60% and at 70% are effective against ‘isopropanol-tolerant’ Enterococcus faecium
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-02-01
    J. Gebel, S. Gemein, G. Kampf, S.J. Pidot, N. Buetti, M. Exner

    The bactericidal activity of isopropanol was determined against Enterococcus faecium ATCC 6057, ST 796 (isopropanol-tolerant strain) and Enterococcus hirae ATCC 10541 (EN 13727). Isopropanol at 60% and 70% were effective (≥5.38 log10-reduction) in 15 s against all strains but 23% isopropanol was not (<0.99 log10-reduction in ≤15 min). Isopropanol at 70% was tested against E. faecium in the four-field test. Eight millilitres was not effective enough in 1 min (<5 log10-reduction), whilst 16 mL was effective (≥5.85 log10-reduction). Healthcare workers can be reassured that 60% and 70% isopropanol with an appropriate volume are effective against E. faecium.

  • Microbial water quality management of dental unit water lines at a dental school
    J. Hosp. Infect. (IF 3.704) Pub Date : 2018-11-10
    C.M.C. Volgenant, I.F. Persoon

    Contaminated dental unit water lines (DUWLs) are a possible source for spreading micro-organisms in dental practices. This study reports the microbial load of the water from DUWLs of a large dental school over time. The water quality of 231 dental chairs was tested three times over 1.5 years; 175 DUWLs at student clinics and 56 DUWLs at staff clinics. DUWLs at the staff clinics met the Dutch requirement of 100 colony-forming units/mL. An increasing number of DUWLs at the student clinics complied with this requirement, indicating that the local protocols are adequate but that compliance can be improved.

  • Clinical impacts of delayed central venous catheter removal according to the severity of comorbidities in patients with candidaemia
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-04
    Yu-Mi Lee, Dong Youn Kim, Young Jin Kim, Ki-Ho Park, Mi Suk Lee

    Background The effects of early central venous catheter (CVC) removal on the clinical outcomes of patients with candidaemia remain controversial. We evaluated the impact of delayed CVC removal on mortality according to the severity of comorbidities in patients with candidaemia. Methods Patients with candidaemia in our tertiary care hospital between January 2010 and December 2017 were retrospectively included. The severity of comorbidities was classified as low [Charlson comorbidity index (CCI) score ≤3] and high (CCI score ≥4). Cases with removal of CVC > 2 days following onset of candidaemia or without CVC removal were classified as having delayed CVC removal. Results In total, 239 patients with candidaemia were included, excluding 18 who died within 2 days of candidaemia. Of these, 149 had low CCI scores and 90 had high CCI scores. Septic shock (aOR=9.5) and delayed CVC removal (aOR=4.7) were significantly associated with increased 30-day mortality, whereas Candida parapsilosis infection (aOR=0.2) and cerebrovascular disease (aOR=0.3) were associated with decreased 30-day mortality, in patients with low CCI scores. Septic shock (aOR=13.0) was the only risk factor for 30-day mortality in those with high CCI scores. Delayed CVC removal was associated with increased 30-day mortality in patients with low CCI scores (50.0% vs. 20.3%; P = 0.001), but not in those with high CCI scores (50.0% vs. 47.9%; P = 0.87). Conclusion Early CVC removal may improve the survival of patients with candidaemia and low CCI scores, but no such protective effect was evident in those with high CCI scores.

  • Reducing Implant Infection in Orthopaedics (RIIiO): Results of a Pilot Study Comparing the Influence of Forced Air and Resistive Fabric Warming Technologies on Post-Operative Infections following Orthopaedic Implant Surgery
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-09-04
    Michelle Kümin, Joanne Deery, Sharon Turney, Carly Price, Parthiban Vinayakam, Andrew Smith, Athanasia Filippa, Lisa Wilkinson-Guy, Faye Moore, Mary O’Sullivan, Mark Dunbar, Jane Gaylard, Julie Newman, Christopher Mark Harper, Debbie Minney, Charlotte Parkin, Louise Mew, Oliver Pearce, Matthew Scarborough

    Background Active warming during surgery prevents perioperative hypothermia but the effectiveness and post-operative infection rates may differ between warming technologies. We report results of a pilot study in patients over the age of 65 undergoing hemiarthroplasty following fractured neck of femur. Aim To establish the recruitment and data management strategies needed for a full trial comparing post-operative infection rates associated with forced air versus resistive fabric warming. Methods Participants were randomised 1:1 in permuted blocks to forced air or resistive fabric warming. Hypothermia was defined as a temperature of <36ºC at the end of surgery. Primary outcomes were the number of participants recruited and the number with definitive deep surgical site infections. Findings 515 participants were randomised at 6 sites over a period of 18 months. Follow-up was completed for 70.1%. Thirty-seven participants were hypothermic (7.5% in the FAW group; 9.7 % in the RFW group). The mean temperatures before anaesthesia and at the end of surgery were similar. For the primary clinical outcome, there were 4 deep surgical site infections in the forced air warming group and 3 in the resistive fabric warming group. All participants who developed a post-operative infection had antibiotic prophylaxis, a cemented prosthesis and were operated under laminar airflow; none were hypothermic. There were no serious adverse events related to warming. Conclusion Surgical site infections were identified in both groups. Progression from the pilot to the full trial is possible but will need to take account of the high attrition rate. Trial Registration ISRCTN 74612906 (http://www.isrctn.com/ISRCTN74612906)

  • Approaches to the detection of Clostridioides difficile in the healthcare environment
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-08-24
    R.J. Grainger, N.T. Stevens, H. Humphreys

    Clostridioides difficile, a spore-forming bacillus, is a major cause of healthcare-associated infection, and can survive for prolonged periods in the inanimate environment. Environmental sampling to detect C. difficile is not routine but may be undertaken as part of outbreak management and during research projects. We conducted a literature search between 1980 and 2018 to review methods for the detection of this pathogen in the environment. There are many acceptable sampling methods used for environmental screening including contact plates, cotton swabs, flocked swabs and sponges. Most recent studies suggest that sponges are the most effective method of sampling and have the added benefit of being capable of sampling larger and curved areas. Culture methods are the most common laboratory method of detecting C. difficile from environmental samples. However, the results are variable depending on the type of agar used and the turnaround time can be long. Molecular methods such as real-time polymerase chain reaction (RT-PCR), although more commonly used to detect C. difficile from faecal specimens, has been used with varying degrees of success in environmental sampling. Further studies are needed to determine if molecular techniques could offer a more reliable, faster method of environmental sampling, giving infection prevention and control teams more reassurance that patients are being placed in adequately decontaminated hospital environments.

  • Bundled skin antiseptic preparation for complex cardiac implantable electronic device infection – a propensity score matching cohort study
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-08-23
    Huang-Chung Chen, Wei-Chieh Lee, Yung-Lung Chen, Tzu-Hsien Tsai, Kuo-Li Pan, Yu-Sheng Lin, Mien-Cheng Chen

    Background Cardiac implantable electronic device (CIED) infection, a major complication of a CIED implant procedure, can prolong hospitalization and cause mortality. Aim To evaluate the efficacy of a bundled skin antiseptic preparation for preventing infection after implantation of a complex CIED. Methods This study analyzed 1163 consecutive patients who had received a bundled skin antiseptic preparation before CIED implantation from July, 2012 to December, 2017. According to the complexity of the CIED implant procedure, the patients were divided into a complex CIED group (n=370) and a non-complex CIED group (n=793). A complex procedure was defined as a pacemaker replacement, implantation of implantable cardioverter defibrillator and cardiac resynchronization therapy, device upgrade, or lead revision. Results During a mean follow up of 2.9 ± 1.7 years, CIED infection developed in 15 patients (1.3%), and the incidence of minor and major infection was 1.1% and 0.2%, respectively. The incidence of CIED infection did not significantly differ between the complex CIED group and the non-complex CIED group (1.1% vs. 1.4%, respectively; P=NS). Multivariate analysis indicated that procedural complexity was not an independent predictor of CIED infection. After 2:1 propensity score matching, the matched non-complex CIED group and the matched complex CIED group still showed no significant difference in the incidence of CIED infection. Conclusions Bundled skin antiseptic preparation is an effective and widely applicable strategy for decreasing infection risk after a complex CIED implantation.

  • Increased fluid intake for the prevention of urinary tract infection in adults and children in all settings: A systematic review
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-08-23
    Oyebola Fasugba, Brett G. Mitchell, Elizabeth McInnes, Jane Koerner, Allen C. Cheng, Heilok Cheng, Sandy Middleton

    Background Non-antibiotic interventions for urinary tract infection (UTI) prevention have been investigated as a strategy to reduce antibiotic prescribing for UTI and subsequent antibiotic resistance. Increased hydration is widely advocated for preventing UTI; however, evidence for its effectiveness is unknown. Aim To systematically review the published literature on the effectiveness of increased fluid intake as a preventive intervention for UTI in adults and children in any setting. Methods Five electronic databases were searched from inception to February 2019 to identify published randomized controlled trials (RCT) and quasi-experimental studies evaluating the effectiveness of high (≥1.5 litres/24 hours) versus normal/low (<1.5 litres/24 hours) fluid intake for UTI prevention. The outcome was UTI incidence. Risk of bias was assessed using the Cochrane Collaboration’s tool. Due to the small number of studies identified, meta- analysis was not possible. Hence a narrative synthesis was undertaken. Findings Of the 2822 potentially relevant papers, two were eligible for inclusion: a RCT (individual randomization) and a cluster RCT. Both studies differed in regards to participants, setting, sample size, UTI definition and intervention. The RCT was assessed as having a low risk of bias while the cluster RCT had a high risk of bias. Only the RCT, which included healthy premenopausal women visiting primary care clinics, demonstrated statistical significance for the effect of high fluid intake for UTI prevention. Conclusion The lack of a sufficient number of adequately powered and robust RCTs highlights the need for further research on the effectiveness of this intervention for UTI prevention.

  • Enterococcus hirae, Enterococcus faecium and Enterococcus faecalis show different sensitivities to typical biocidal agents used for disinfection
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-08-23
    Miranda Suchomel, Anita Lenhardt, Günter Kampf, Andrea Grisold

    Background Enterococcus faecium and E. faecalis are known nosocomial pathogens. The bactericidal activity of biocidal agents used for disinfection, however, is determined with E. hirae. Aim To find out whether E. hirae is a suitable species to evaluate the efficacy of biocidal agents against the clinically relevant species E. faecalis and E. faecium. Methods The bactericidal activity was determined in suspension tests according to EN 13727 using E. faecium ATCC 6057, E. faecalis ATCC 47077 and E. hirae ATCC 10541. Glutaraldehyde, ethanol, benzalkonium chloride, peracetic acid and sodium hypochlorite were used with 3 exposure times per biocide. When major differences in the sensitivity of the three enterococcal species to the respective substance was found two more replicates were performed. The number of cfu was transformed into decimal logarithms. Results from replicate experiments were described with means and standard deviation. Findings At a 5 min exposure time E. hirae was found to be more tolerant to 0.2% glutaraldehyde and 0.0125% peracetic acid compared to E. faecium and E. faecalis whereas it was more susceptible to 40% ethanol and 3% sodium hypochlorite. Only with 0.00125% benzalkoniumchloride (15 min) the susceptibility of E. hirae was between E. faecium and E. faecalis. Conclusion E. hirae is a suitable species when a bactericidal activity should be determined against enterococci with glutaraldehyde and peracetic acid. E. hirae may not be a suitable species for ethanol or sodium hypochlorite if the bactericidal activity should include the clinical pathogens E. faecium and E. faecalis.

  • Top Research Priorities in Healthcare-Associated Infections in the United Kingdom
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-08-17
    Peter Wilson, Kurinchi S. Gurusamy, Richard Morley, Caroline Whiting, Beccy Maeso, Graham FitzGerald, Susan Bennett, Jennifer Bostock, David Brealey, Maria Cann, Martin Kiernan, David Leaper, Michael Moore, Beryl Oppenheim, Patrick Thompson, Alison Tingle

    Background There is a mismatch between research questions, which are considered to be important by patients, carers, and healthcare professionals and the research performed in many fields of medicine. We found no relevant studies which have assessed research priorities in healthcare-associated infections that have involved patients’ and carers’ opinions. Aim The Healthcare-Associated Infections (HCAI) Priority Setting Partnership was established to identify top research priorities in the prevention, diagnosis, and treatment of HCAI in the UK, taking into account the opinions of all these groups. Methods The methods broadly followed the principles of James Lind Alliance (JLA) priority setting activity. Findings 259 unique valid research questions were identified from 221 valid responses to a consultation of patients, carers and healthcare professionals after seeking their opinions for research priorities. The steering committee of the Partnership rationalised these to 50 unique questions. A literature review established that for these questions there were no recent high-quality systematic reviews, high-quality systematic reviews which concluded that further studies were necessary, or the steering committee considered that further research was required despite the conclusions of recent systematic reviews. An interim survey ranked the 50 questions and, from the top 32, 10 top research priorities were identified by consensus at a final priority setting workshop of patients, carers and healthcare professionals using group discussions. Conclusions A priority-setting process using JLA methods and principles involving patients, carers and healthcare professionals was used to identify top 10 priority areas for research related to HCAI. To address these uncertainties basic, translational, clinical, and public health research would be required.

  • VIM carbapenemase-producing Escherichia coli in a residential care home in The Netherlands
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-08-16
    M.J. Bruins, A.H. Koning ter Heege, M.I. van den Bos-Kromhout MI, R. Bettenbroek, M. van der Lubben, S.B. Debast

    Background Carbapenemase-producing Enterobacterales are an important and increasing threat to public health. In hospitals and long-term care facilities carriers should be identified to prevent transmission, however guidelines for infection control are not applicable to all types of care homes. Aim To report the outbreak investigation of a VIM-metallo-β-lactamase-producing Escherichia coli in a Dutch residential care home, where residents lived in private apartments but also used shared facilities. Methods Contact and environmental screening rounds were performed to assess carriage and colonization rates. Due to the domestic characteristics of the home, customized infection control measures were needed. A bundle of interventions was implemented, including contact precautions, improved hygiene and education. Findings In total eight CPE carriers, including the index case, were identified among 110 residents. VIM CPE spread was associated with the use of shared toilets in communal areas. Seven months after the first finding all carriers were found to be VIM negative and after one year VIM CPE was no longer detectable in the environment. Conclusion To successfully control the outbreak a customized bundled approach was necessary. Current guidelines should be adapted to be suitable for all types of residential care homes and to effectively combat the spread of multi resistant pathogens.

  • Bayesian reconstruction of a vancomycin-resistant Enterococcus transmission route using epidemiologic data and genomic variants from whole genome sequencing
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-08-16
    Y. Fujikura, T. Hamamoto, A. Kanayama, K. Kaku, J. Yamagishi, A. Kawana

    Background Outbreaks of vancomycin-resistant enterococcus (VRE) are a serious problem in hospitals. Inferring the transmission route is an important factor to institute appropriate infection control measures; however, the methodology has not been fully established. Aim To reconstruct and evaluate the transmission model using sequence variants extracted from whole genome sequencing (WGS) data and epidemiological information from patients involved in a VRE outbreak. Methods During a VRE outbreak in our hospital, 23 samples were collected from patients and environmental surfaces and analysed using WGS. By combining genome alignment information with patient epidemiological data, the VRE transmission route was reconstructed using a Bayesian approach. With the transmission model, evaluation and further analyses were performed to identify risk factors that contributed to the outbreak. Findings All VREs were identified as Enterococcus faecium belonging to sequence type 17, which consisted of two VRE genotypes: vanA (N = 8, including one environmental sample) and vanB (N = 15). The reconstruction model using the Bayesian approach showed the transmission direction with posterior probability and revealed transmission through an environmental surface. In addition, some cases acting as VRE spreaders were identified, which can interfere with appropriate infection control. Vancomycin administration was identified as a significant risk factor for spreaders. Conclusion A Bayesian approach for transmission route reconstruction using epidemiologic data and genomic variants from WGS can be applied in actual VRE outbreaks. This may contribute to the design and implementation of effective infection control measures.

  • Development of consensus based international antimicrobial stewardship competencies for undergraduate nurse education
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-08-15
    Molly Courtenay, Enrique Castro-Sánchez, Rose Gallagher, Jo McEwen, Andre N.H. Bulabula, Yolene Carre, Briёtte Du Toit, Rosely Moralez Figueiredo, Merete Elisabeth Gjerde, Nykoma Hamilton, Linda Jorgoni, Valerie Ness, Rita Olans, Maria Clara Padoveze, Joan Rout, Nantanit van Gulik, Yolanda Van Zyl

    Background There is growing recognition by national and international policy makers of the contribution nurses make towards antimicrobial stewardship. Although undergraduate education provides an ideal opportunity to prepare nurses for antimicrobial stewardship roles and activities, only two thirds of undergraduate nursing programmes incorporate any antimicrobial stewardship teaching and only 12% cover all the recommended antimicrobial stewardship principles. Nurses also report that they do not have a good knowledge of antibiotics, and many have not heard of the term antimicrobial stewardship. Aim To provide international consensus on the antimicrobial stewardship competency descriptors appropriate for undergraduate nurse education. Methods A modified Delphi approach comprising two on-line surveys delivered to an international panel of fifteen individuals reflecting expertise in prescribing and medicines management in the education and practice of nurses; and antimicrobial stewardship. Data collection took place between February and March 2019. Findings A total of 15 participants agreed to become members of the expert panel, of whom 13 (86%) completed round one questionnaire, and 13 (100%) completed round two. Consensus was achieved, with consistent high levels of agreement across panel members, on 6 overarching competency domains and 63 descriptors, essential for antimicrobial stewardship practice. Conclusion The competency descriptors should be used to direct undergraduate nurse education, and the AMS practices of qualified nurses (including those working in new roles such as Nursing Associates) given the high levels of agreement reached on competency descriptors.

  • Exogenous acquisition of Pseudomonas aeruginosa in intensive care units: a prospective multicentre study, DYNAPYO study.
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-08-13
    Maïder Coppry, Camille Leroyer, Marion Saly, Anne-Gaëlle Venier, Céline Slekovec, Xavier Bertrand, Sylvie Parer, Serge Alfandari, Emmanuelle Cambau, Bruno Megarbane, Christine Lawrence, Bernard Clair, Alain Lepape, Pierre Cassier, Dominique Trivier, Alexandre Boyer, Hélène Boulestreau, Julien Asselineau, Anne-Marie Rogues

    Pseudomonas aeruginosa remains one of the most common nosocomial pathogens in intensive care units (ICUs). Although exogenous acquisition has been widely documented in outbreaks, its importance is unclear in non-epidemic situations. We aimed to elucidate the role of exogenous origin of P. aeruginosa in ICU patients. We performed a chronological analysis of the acquisition of P. aeruginosa using samples collected in 2009 in DYNAPYO cohort study during which patients and tap water were weekly screened. Molecular relatedness of P. aeruginosa isolates was investigated by pulsed-field gel electrophoresis. Exogenous acquisition was defined as identification of a P. aeruginosa pulsotype previously isolated from another patient or tap water in the ICU. DYNAPYO cohort included 1,808 patients (10,402 samples) and 233 water taps (4,946 samples). Typing of 1,515 isolates from 373 patients and 375 isolates from 81 tap water samples identified 296 pulsotypes. Analysis showed an exogenous acquisition in 170 (45.6%) of 373 patients. The pulsotype identified was previously isolated from another patient and from a tap water sample for 86 and 29 patients respectively. The results differed according to the ICU. The exogenous acquisition of P. aeruginosa could be prevented in a half proportion of patients. The overall findings of this survey supports the need for studies on routes of transmission and risk assessment approach to better define how to control exogenous acquisition in ICUs.

  • Circulation of a community healthcare-associated multiply-resistant meticillin-resistant Staphylococcus aureus lineage in South Yorkshire identified by whole genome sequencing
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-08-10
    L. Utsi, B. Pichon, N. Arunachalam, A. Kerrane, E. Batten, M. Denton, R. Townsend, K.N. Agwuh, G.J. Hughes, A. Kearns

    Background A cluster of seven cases of skin and wound infections caused by a multiply resistant MRSA were detected in a small-town community in South Yorkshire. Initial microbiological investigations showed that all isolates belonged to a spa type observed rarely in England (t1476). Aim To describe the epidemiology of t1476 meticillin-resistant Staphylococcus aureus (MRSA) in South Yorkshire. Methods Retrospective and prospective case ascertainment was promoted through communication with local microbiology laboratories. Public health investigation included a detailed review of clinical notes for a subset of nine cases. Genomic and phylogenetic analysis was undertaken on t1476 MRSA. Findings Thirty-two cases of t1476 MRSA infection or colonization were identified between December 2014 and February 2018. Cases were older adults (aged 50–98 years). Healthcare exposures for a subset of nine cases indicated frequent contact with a team of district nurses, with all but one case receiving treatment on the same day as another case prior to their own diagnosis. No cases were admitted to hospital at the time of specimen collection. Despite detailed investigations, no carriers were detected among district nursing staff. A long-term carrier/super-shedder was not found. Phylogenetic analysis indicated that t1476 MRSA cases from South Yorkshire were monophyletic and distant from both MRSA of the same lineage from elsewhere in the UK (N = 15) and from publicly available sequences from Tanzania. Conclusion Genomic and epidemiological analyses indicate community-based transmission of a multiply resistant MRSA clone within South Yorkshire introduced around 2012–2013, prior to the detection of a spatial–temporal cluster associated with a distinct risk group. Surveillance data indicate continued circulation.

  • Prion disease and recommended procedures for flexible endoscope reprocessing – review of policies worldwide and proposal for a simplified approach
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-08-10
    Günter Kampf, Michael Jung, Miranda Suchomel, Philippe Saliou, Helen Griffiths, Margreet C. Vos

    Several guidelines recommend specific treatments for endoscopes, procedures of quarantine for endoscopes or additional treatments for the endoscope washer disinfector (EWD) in suspected or confirmed cases of CJD or vCJD but vary in many details. We therefore reviewed guidelines on reprocessing flexible endoscopes after use in patients with suspected or confirmed prion disease. In addition, a literature search was done on Medline on prion, CJD, vCJD, chemical inactivation, transmission healthcare, epidemiology healthcare, concentration tissue human and endoscope. So far no case of CJD or vCJD transmitted by flexible endoscope has been reported. In animals it was shown that oral uptake of 0.1 – 5 g of BSE-infected brain homogenate is necessary for transmission. The maximum prion concentration in other tissues (e.g. terminal ileum) is at least 1000-fold lower. Automated cleaning of endoscopes alone results in very low residual protein ≤ 5.6 mg per on duodenoscopes. Recommendations vary between countries, sometimes with additional cleaning, use of alkaline cleaners, no use of cleaners with fixative properties, use of disinfectants without fixative properties or single use disinfectants. Sodium hydroxide (1 M) and sodium hypochlorite (10,000 and 25,000 mg/l) are very effective to prevent transmission via contaminated wires implanted into animal brains but its relevance for endoscopes is questionable. Based on circumstantial evidence we propose to consider validated reprocessing as appropriate in case of a delayed suspected prion disease when immediate bedside cleaning, routine use of alkaline cleaners, no fixative agents anywhere prior to disinfection and single use brushes and cleaning solutions can be assured.

  • Sink drain contamination with extended-spectrum-beta-lactamase-producing Enterobacteriaceae (ESBLE) in intensive care units: strong correlation to the ESBLE colonization pressure in patients but not same species
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-08-10
    C. Lemarié, C. Legeay, S. Lasocki, R.Mahieu, A. Kouatchet, L. Bahier, L. Onillon, M. Corre, M. Kempf, M. Eveillard

    Sink drains (SD) of six intensive care units (ICUs) were sampled for screening contamination with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBLE). A high prevalence (59.4%) of SD contamination was observed. Analyzing the data by ICU, the ratio “number of ESBLE species isolated in SD/total number of SD sampled” was strongly correlated (Spearman coefficient, 0.87; P = .02) with the ratio “number of hospitalization days for patients with ESBLE carriage identified within the preceding year/total number of hospitalization days within the preceding year”. Concurrently, the distribution of ESBLE species was strongly different between patients and SD.

  • Effect of Chlorhexidine bathing on colonization or infection with Acinetobacter baumannii-a systematic review and meta-analysis
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-08-09
    Cheng-Yi Fan, Wan-Ting Lee, Tzu-Chun Hsu, Cheng-Han Lee, Shiao-Pei Wang, Wen-Shan Chen, Chien-Hua Huang, Chien-Chang Lee

    Background s: Healthcare-associated infections (HAI) caused by multidrug-resistant Gram-negative bacteria (MDRGNB) have increased prevalence in intensive care units (ICUs). A common strategy to prevent HAI is bathing patients with chlorhexidine gluconate (CHG). However, the effectiveness of CHG bathing against multidrug-resistant Acinetobacter baumannii (MDRAB) is still controversial. Aim To perform a systematic review and meta-analysis on the effectiveness of CHG bathing on Acinetobacter baumannii colonization and infection in the ICU setting. Methods Studies searched from PubMed, EMBASE, Web of Science and CINAHL from inception through June 2018. Randomized controlled trials (RCT), pre-post studies, or interrupted time series (ITS) studies. Number of patients with/without colonization or infection of A. baumannii in the experimental or control groups were extracted from each study. Quality assessment was performed by the related instruments of National Institute of Health. Pooled risk ratios were calculated using the random-effect model. Findings 1 RCT and 12 pre-post or ITS studies comprising 18,217 patients were included, of which 8,069 were in the CHG bathing arm and 9,051 in the control arm. CHG bathing was associated with a reduced colonization of A. baumannii (pooled RR, 0.66; 95% confidence interval, 0.57-0.77; P<0.001). 4% chlorhexidine showed a better effect than 2% chlorhexidine (Meta-regression P =0.044). CHG bathing was associated with a nonsignificant reduction of infection (Pooled RR 0.41, 95% CI: 0.13-1.25). Conclusion Our study suggests CHG bathing significantly reduce colonization of A. baumannii in the ICU setting. However, more trials are needed to confirm whether CHG bathing can reduce infectrions with A. baumannii.

  • S. Dewar et al. Point-of-care testing by healthcare workers for detection of meticillin-resistant Staphylococcus aureus, Clostridioides difficile, and norovirus
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-08-09
    S. Dewar, D. Vass, F. Mackenzie, B.J. Parcell

    Background The feasibility of introducing three separate Cepheid GeneXpert® assays was assessed: Xpert SA Nasal Complete, Xpert C. difficile, and Xpert Norovirus for point-of-care testing (POCT) on a ward in a district general hospital. Aim To establish a seven-day/24 h POCT service for meticillin-resistant Staphylococcus aureus (MRSA), Clostridioides difficile, and norovirus operated solely by healthcare workers (HCWs). Methods The Cepheid GeneXpert assays performance characteristics were assessed by comparing the assays to traditional central laboratory methods in terms of clinical turnaround times, hands-on time, number of process steps, time to result and diagnostic accuracy. HCW feedback was collected to consider the potential added value of applying this technology to improve patient flow and clinical care. Findings In total 1170 tests were carried out over the 16-month study period. The assays significantly reduced hands-on time, process steps, and time to result for identification of all three micro-organisms. Overall agreement with central laboratory testing was >98% for all three assays. Staff members fed back that POCT had a positive impact in terms of clinical utility. Conclusion Xpert SA Nasal Complete for MRSA detection, Xpert C. difficile, and Xpert Norovirus can be used as POCT solely by HCWs in a ward setting. Each assay was used throughout a seven-day/24 h period with potential positive impact on bed management and patient care.

Some contents have been Reproduced by permission of The Royal Society of Chemistry.
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