Burden of Surgical Site Infections in The Netherlands: Cost analyses and Disability Adjusted Life Years J. Hosp. Infect. (IF 3.704) Pub Date : 2019-07-19 Mayke B.G. Koek, T.I.I. van der Kooi, F.C.A. Stigter, P.T. de Boer, B. de Gier, T.E.M. Hopmans, S.C. de Greeff
BackgroundSurgical site infections (SSIs) are associated with morbidity, mortality and costs.AimTo identify the burden of (deep) SSIs in costs and Disability Adjusted Life Years (DALYs), following colectomy, mastectomy and total hip arthroplasty (THA) in the Netherlands.MethodsA retrospective cost-analysis was performed using 2011 data from the national SSI surveillance network PREZIES. 62 patients with an SSI (exposed) were matched to 122 patients without SSI (unexposed, same type of surgery). Patient records were studied until one year after SSI diagnosis. Unexposed patients were followed for the same duration. Costs were calculated from the hospital perspective (2016 price level), and cost-differences were tested using linear regression analyses.Disease burden was estimated using the BCoDE toolkit of the European Center for Disease Control. The SSI model was specified per surgery-type with country- and surgery-specific parameters where possible.FindingsAttributable costs per SSIs were €21,569 (THA), €14,084 (colectomy) and €1881 (mastectomy), mainly caused by prolonged length of stay. National hospital costs were estimated €10 million, €29 million, and €0.6 million respectively. National disease burden was greatest for SSIs following colectomy (3200 DALYs/year, 150 DALYs/100 SSIs), while individual disease burden was highest following THA (1200 DALYs/year, 250 DALYs/100 SSIs). For mastectomy these DALYs were below 1. Total costs of DALYs for the three surgery-types exceeded €88 million.ConclusionDepending on the type of surgery, SSIs cause a significant burden; economically as well as expressed in loss of years in full health. This underlines the importance of appropriate infection prevention and control measures.
Effectiveness and core components of infection prevention and control programmes in long-term care facilities: a systematic review J. Hosp. Infect. (IF 3.704) Pub Date : 2019-02-19 M.H. Lee, G.A. Lee, S.H. Lee, Y-H. Park
BackgroundInfection prevention and control (IPC) is a measure to prevent healthcare-associated infections in healthcare settings. There is limited evidence of the effectiveness of IPC programmes in long-term care facilities (LTCFs).AimTo review and analyse the effectiveness and the components of IPC programmes in LTCFs for older adults.MethodsElectronic databases (PubMed, EMBASE, CINAHL and Cochrane CENTRAL) were searched systematically for English-language articles assessing IPC interventions in LTCFs, published over the last decade (2007–2016). The components of IPC programmes were analysed based on the World Health Organization (WHO) manuals for improving IPC activities. Two reviewers independently assessed the quality of studies using the Cochrane risk-of-bias tool and the risk-of-bias assessment tool for non-randomized studies.FindingsSeventeen studies met the eligibility criteria; 10 studies were randomized trials (58.8%) and the others were non-randomized trials to examine the impact of IPC programmes on infection and/or performance outcomes of healthcare workers. None of the included studies implemented all of the WHO core components. Behavioural change strategies using education, monitoring and feedback were reported to be successful interventions for reducing the threat of healthcare-associated infections. Generally, studies using four or more elements of the WHO multi-modal strategy reported significant reductions in infection rates.ConclusionsThere is some evidence for the effectiveness of IPC interventions using education, monitoring, feedback and four or more elements of the WHO multi-modal strategy to control healthcare-associated infections in LTCFs.
Psychometric evaluation of a measure of factors influencing hand hygiene behaviour to inform intervention J. Hosp. Infect. (IF 3.704) Pub Date : 2019-02-13 S. Lydon, C. Greally, O. Tujjar, K. Reddy, K. Lambe, C. Madden, C. Walsh, S. Fox, P. O'Connor
BackgroundAlthough the hand hygiene (HH) procedure is simple, the related behaviour is complex and is not readily understood, explained or changed. There is a need for practical tools to provide data that can guide healthcare managers and practitioners not only on the ‘what’ (the standards that must be met), but also the ‘how’ (guidance on how to achieve the standards).AimTo develop a valid questionnaire to evaluate attitudes to the factors that influence engagement in HH behaviour that can be readily completed, administered and analysed by healthcare professionals to identify appropriate intervention strategies. Construct validity was assessed using confirmatory factor analysis, predictive validity was assessed through comparison with self-reported HH behaviour, and convergent validity was assessed through direct unit-level observation of HH behaviour.MethodsThe Capability, Opportunity, Motivation-Behaviour (COM-B) model was used to design a 25-item questionnaire that was distributed to intensive care unit (ICU) personnel in Ireland. Direct observation of HH behaviour was carried out at two ICUs.FindingsIn total, 292 responses to the survey (response rate 41.0%) were included in the analysis. Confirmatory factor analysis resulted in a 17-item questionnaire. Multiple regression revealed that a model including capability, opportunity and motivation was a significant predictor of self-reported behavioural intention [F(3,209)=22.58, P<0.001]. However, the opportunity factor was not found to make a significant contribution to the regression model.ConclusionThe COM-B HH questionnaire is reliable and valid, and provides data to support the development and evaluation of HH interventions that meet the needs of specific healthcare units.
Healthcare workers' attitudes towards hand-hygiene monitoring technology J. Hosp. Infect. (IF 3.704) Pub Date : 2019-03-02 C. Tarantini, P. Brouqui, R. Wilson, K. Griffiths, P. Patouraux, P. Peretti-Watel
BackgroundAutomated radio-frequency identification (RFID)-based hand-hygiene monitoring technology was implemented in an infectious disease department to study healthcare workers' (HCWs') practices and to improve hand hygiene.AimTo assess HCWs' attitudes towards this innovative monitoring device in order to anticipate resistance to change and facilitate future implementation.MethodsIn-depth interviews and an ethnographic approach.FindingsFrom the perspective of HCWs, while they recognize the usefulness of RFID technology to prevent the transmission of infections to patients, they expressed concerns about risks related to RFID electromagnetic waves, as well as control by their superiors. Overall, HCWs' opinions oscillated between positive feelings characterized by enthusiasm for the possibility of changing their practices using technologies and research, and negative feelings marked by strong criticisms of these technologies and research. These criticisms included blaming hand-hygiene monitoring technology for decontextualizing HCWs' practices. They perceived the technologies through the prism of the local and national contexts in which they are embedded. From their point of view, technologies are primarily in the best interests of the project team. Thus, they affirm and maintain the different interests and objectives between themselves and the project team, crystallizing a conflict of professional norms and values between these two groups. The forms of resistance taken by HCWs were practical as well as oral.ConclusionInnovative technologies should be developed to address HCWs' attitudes surrounding RFIDs. It is crucial to inform HCWs about the nature of these technologies, although some criticisms about monitoring systems are based on more structural causes.
Healthcare-associated infections and antimicrobial use in long-term care facilities (HALT3): an overview of the Italian situation J. Hosp. Infect. (IF 3.704) Pub Date : 2019-02-19 M.F. Furmenti, P. Rossello, S. Bianco, E. Olivero, R. Thomas, I.N. Emelurumonye, C.M. Zotti
BackgroundAwareness of healthcare-associated infections (HAIs) and antimicrobial use in long-term care facilities (LTCFs) is increasing. In 2017, the third national point prevalence survey (PPS) was conducted in Italy as part of the third ‘Healthcare-Associated Infections in European Long-Term Care Facilities’ (HALT3) study.AimTo report the results of HALT3 and analyse the resident population of LTCFs, implementation of good practices, prevalence of infections and antimicrobial use.MethodsThe survey was designed as a PPS, carried out from April to June 2017. All residents who lived full-time in the institution were included. All facilities were asked to complete an institutional questionnaire, a ward list for all residents, and a resident questionnaire for those residents presenting with signs/symptoms of active infection and/or receiving an antimicrobial agent.FindingsIn total, 418 facilities took part in the study; 24,132 residents were eligible, and most were aged >85 years, disoriented and incontinent. The prevalence of HAIs was 3.9%, and 50% of the institutions reported that they had a professional trained in infection control on their staff. Only 26.4% of infections were confirmed by a microbiological sample, and 26.9% of the isolated micro-organisms were resistant to at least one antimicrobial class. In total, 1022 residents received at least one antimicrobial agent, and cephalosporins were prescribed most commonly.ConclusionThe number of infection control and antimicrobial stewardship measures implemented was found to be considerably higher in this study compared with previous studies. This could lead to a reduction in the prevalence of HAIs, antimicrobial use and antimicrobial resistance. Further studies are needed to monitor these aspects.
Ozonized water as an alternative to alcohol-based hand disinfection J. Hosp. Infect. (IF 3.704) Pub Date : 2019-02-05 H.J. Breidablik, D.E. Lysebo, L. Johannessen, Å. Skare, J.R. Andersen, O.T. Kleiven
BackgroundHand hygiene plays a vital role in the prevention of transmission of micro-organisms. Ozone (O3) is a highly reactive gas with a broad spectrum of antimicrobial effects on bacteria, viruses, and protozoa. It can easily be produced locally in small generators, and dissolved in tap water, and quickly transmits into ordinary O2 in the surrounding air.AimTo compare ozonized tap water and alcohol rub in decontamination of bacterially contaminated hands.MethodsA cross-over study among 30 nursing students. Hands were artificially contaminated with Escherichia coli (ATCC 25922), then sanitized with ozonized tap water (0.8 or 4 ppm) or 3 mL standard alcohol-based rub (Antibac 85%). The transient microbes from fingers were cultivated and colony-forming units (cfu)/mL were counted. The test procedure was modified from European Standard EN 1500:2013.FindingsAll contaminated hands before disinfection showed cfu >30,000/mL. The mean (SD) bacterial counts in (cfu/mL) on both hands combined were 1017 (1391) after using ozonized water, and 2337 (4664) after alcohol hand disinfection. The median (range) values were 500 (0–6700) and 250 (0–16,000) respectively (non-significant difference). Twenty per cent of participants reported adverse skin effects (burning/dryness) from alcohol disinfection compared with no adverse sensations with ozone.ConclusionOzonized tap water is an effective decontaminant of E. coli, and it could be an alternative to traditional alcohol-fluid hand disinfectants both in healthcare institutions and public places. Ozonized water may be especially valuable for individuals with skin problems.
Emergence of Candida auris in Russia J. Hosp. Infect. (IF 3.704) Pub Date : 2019-03-06 N.E. Barantsevich, O.E. Orlova, E.V. Shlyakhto, E.M. Johnson, N. Woodford, C. Lass-Floerl, I.V. Churkina, S.D. Mitrokhin, A.S. Shkoda, E.P. Barantsevich
This paper reports the emergence of Candida auris infections in an intensive care unit at a hospital in Moscow. Forty-nine cases were diagnosed in 2016–2017, and the risk factors and antifungal susceptibilities are described. The 30-day all-cause mortality for 19 bloodstream infections in patients who did not receive appropriate antifungal therapy was 42.1%. Phylogenetic analysis of the internal transcribed spacer and D1–D2 regions and K143R substitution in the ERG11 gene indicated that the studied C. auris strains were of South Asian origin. This first reported series of C. auris infections in Russia demonstrates the rapid dissemination of this species, and the need for international surveillance and control measures.
Results of a multi-faceted educational intervention to prevent peripheral venous catheter-associated bloodstream infections J. Hosp. Infect. (IF 3.704) Pub Date : 2019-02-13 M. Garcia-Gasalla, M. Arrizabalaga-Asenjo, C. Collado-Giner, L. Ventayol-Aguiló, A. Socias-Mir, A. Rodríguez-Rodríguez, M.-C. Pérez-Seco, A. Payeras-Cifré
Peripheral venous catheter-associated bloodstream infections (PVC-BSIs) lead to prolonged hospitalization, morbidity and increased costs. The impact of infection-prevention measures on the rate of PVC-BSIs in a university hospital in Spain was assessed. An active surveillance programme was initiated in 2015, which revealed a high PVC-BSI incidence ratio (0.48/1000 patient-days). A bundle aimed at nurses, medical staff and patients was implemented, and a Catheter Infection Team (CIT) was set up. The intervention achieved a decrease in PVC-BSI rate: 0.34 in 2016, 0.29 in 2017, and 0.17 in 2018. The decline was greatest for Gram-negative PVC-BSIs (67.6% in 2015, 35.3% in 2018).
The socio-economic impact of multidrug-resistant nosocomial infections: a qualitative study J. Hosp. Infect. (IF 3.704) Pub Date : 2018-08-29 Y. Mo, I. Low, S.K. Tambyah, P.A. Tambyah
The burden of healthcare-associated infections (HCAIs) has traditionally been measured using clinical and economic outcomes. We conducted semi-structured interviews with 18 patients or their caregivers affected by HCAI caused by multidrug-resistant organisms to better understand the human impact of HCAI. Most patients had misconceptions about HCAI and antimicrobial resistance, leading to strong negative feelings towards HCAIs despite positive views of their healthcare providers. Communication issues across power imbalances need to be addressed to help deal with trauma of HCAIs. A holistic approach to HCAIs incorporating patient perspectives will likely help guide policymakers developing solutions to improve patient outcomes.
Chlorhexidine sensitivity in staphylococci isolated from patients with central line-associated bloodstream infection J. Hosp. Infect. (IF 3.704) Pub Date : 2019-07-15 Kang Il Jun, Yunjung Choi, Kyungmi Kwon, Myoung Jin Shin, Jeong Su Park, Kyoung-Ho Song, Eu Suk Kim, Kyung-Hwa Park, Sook-In Jung, Shin Hye Cheon, Yeon-Sook Kim, Na-Ra Yoon, Dong Min Kim, Pyeong Gyun Choe, Nam Joong Kim, Hong Bin Kim
Since 2011, 2% chlorhexidine in 70% isopropyl alcohol (2% chlorhexidine tincture) has been widely used in Korea. To investigate changes in chlorhexidine sensitivity of staphylococci causing central line-associated bloodstream infections, 264 blood culture isolates from adult patients treated in intensive care units of five university hospitals between 2008 and 2016 were analyzed. We observed no significant changes in chlorhexidine minimum inhibitory and bactericidal concentrations, or in the prevalence of resistance-associated genes before and after introduction of 2% chlorhexidine tincture. Thus, there was no evidence of increased resistance to chlorhexidine in staphylococci causing central line-associated bloodstream infections.
Comparison of two methods for cleaning breast pump milk collection kits in human milk banks J. Hosp. Infect. (IF 3.704) Pub Date : 2019-07-10 B. Flores-Antón, J. Martín-Cornejo, M.A. Morante-Santana, N.R. García-Lara, G. Sierra-Colomina, J. De la Cruz-Bértolo, C. Martín-Arriscado-Arroba, D. Escuder-Vieco, M. Soriano-Ramos, F. Chaves, C.R. Pallás-Alonso
Background Appropriate decontamination of breast pump milk collection kits (BPK) is critical to obtain safe milk for infants and to avoid discarding donor human milk (DHM). Aim To evaluate two strategies for BPK decontamination by assessing microbial cultures and the proportion of discarded DHM, according to NICE criteria for pre-pasteurisation cultures. Methods Prospective comparative study, allocation ratio 1:1, microbiologist-blind. Participants: 47 new donors in a Human Milk Bank (Madrid). Interventions study group (n=21): washing the BPK with water and detergent after each use and further steam decontamination within a microwavable bag; control group (n=26): washing, rinsing and drying only. Five samples: first by hand expression and four additional samples (one per week) collected using the same pump and method. Outcomes Primary: proportion of DHM discarded due to contamination. Secondary: comparison of the microbiota between samples obtained by hand expression and breast pump in both groups. Findings 217 milk samples, 47 by hand expression and 170 by pump expression (78 from study group). Decontamination with a microwavable bag after washing the BPK resulted in a lower proportion of discarded DHM samples (1.3% vs 18.5%; p<0.001) and of samples contaminated with Enterobacteriaceae (1.3% vs 22.8%, p<0.001) and Candida sp. (1.3% vs 14.1%, p<0.05) when compared to samples collected with a BPK that were only washed. There were no differences in bacterial contamination between samples obtained by steam decontaminated kits and those obtained by hand expression. Conclusions Using a microwavable bag after washing the BPK decreases the amount of discarded DHM and the number of samples with potentially pathogenic bacteria.
Bacterial contamination rate and associated factors during bone and tendon allograft procurement from Spanish donors: exploring the contamination patterns J. Hosp. Infect. (IF 3.704) Pub Date : 2019-02-14 J.M. Viñuela-Prieto, A.M. Soria-García, M. González-Romero, F.J. Candel
Background Allograft contamination during extraction represents a major limiting factor for tissue bank availability. Contamination rates remain persistently high independent of the hospital, country or year considered. Aim To analyse the factors associated with contamination of bone and tendon samples extracted from Spanish donors. Methods Data for 1162 bone and tendon samples extracted from 102 donors between 2014 and 2017 were collected retrospectively from the hospital database. Descriptive statistics, potentially associated factors and correlation of contamination between samples extracted from different anatomical locations of the same donor were analysed. Findings In total, 227 (19.54%) of the extracted samples [131 (18.49%) bone samples and 96 (20.92%) tendon samples] rendered positive cultures and were discarded. Male sex [odds ratio (OR) 2.023; P=0.019], extraction of >10 samples per donor (OR 1.997; P<0.001) and extraction time >240 min (OR 1.755; P=0.001) were factors independently associated with a higher contamination rate. Meanwhile, the tissue sample type ‘bone-patellar tendon-bone’ was associated with a significantly lower contamination rate (OR 0.446; P=0.001). Significant correlation between certain localization of contaminated samples and the concordance of bacterial species was also observed. Conclusion Factors related to the extraction procedure, such as total extraction time, extraction sequence, number of samples extracted and anatomical location of extracted samples, play a major role in allograft contamination. Further optimization of procedures, guided by the contamination patterns analysed in this study, should help to increase tissue bank availability.
Evaluation of an ‘all-in-one’ seven-day whole-genome sequencing solution in the investigation of a Staphylococcus aureus outbreak in a neonatal intensive care unit J. Hosp. Infect. (IF 3.704) Pub Date : 2019-02-14 C. Rouard, N. Bourgeois-Nicolaos, L. Rahajamanana, O. Romain, L. Pouga, V. Derouin, D. De Luca, F. Doucet-Populaire
Background Meticillin-susceptible and -resistant Staphylococcus aureus (MSSA and MRSA) are responsible for outbreaks in intensive care units. MSSA infections have the same morbidity and mortality rate as MRSA infections but are studied less often. Whole-genome sequencing (WGS) is used increasingly for outbreak monitoring, but still requires specific installation and trained personnel to obtain and analyse the data. Aim To evaluate the workflow and benefits of EpiSeq solution (bioMérieux, Marcy l’Etoile, France) in exploring the increased incidence of S. aureus bloodstream infections in a neonatal intensive care unit (NICU). Methods Four S. aureus bacteraemia isolates and 27 colonization isolates obtained between January and July 2016 were submitted to the ‘all in one solution’ EpiSeq [WGS, quality data assessment, multi-locus sequence typing (MLST), spa typing, virulome and resistome characterization, and phylogenetic tree construction]. More in-depth analyses were performed (whole-genome MLST and whole-genome single nucleotide polymorphism (wgSNP)] with BioNumerics software (Applied Maths, Sint-Martens-Latem, Belgium). Findings Nine different sequence types and 13 different spa types were found among the 31 isolates studied. Among those isolates, 11 (seven patients) were ST146 spa type t002, five (four patients) were ST30 and four (four patients) were ST398. The 11 ST146 isolates had a maximum of seven pairwise SNP differences. Conclusion Use of EpiSeq solution allowed fast demonstration of the polyclonal profile of the MSSA population in neonates, and enabled the suspicion of a global outbreak to be ruled out. However, wgSNP analysis showed the transmission and persistence of one sequence type for over six months in the NICU, and enabled the infection control team to adapt its response.
Potential distribution of viable norovirus after simulated vomiting J. Hosp. Infect. (IF 3.704) Pub Date : 2019-02-21 C. Makison Booth, G. Frost
Background Vomiting is one way in which the body rids itself of harmful gastric contents rapidly. Whilst this process is generally beneficial for the emetic individual, it can pose significant infection control issues if they are infected with a highly communicable pathogen such as norovirus. It is not known how far norovirus could spread through vomiting while remaining viable, particularly in far-reaching droplets and splashes that might be missed during cleaning. Aim To identify the potential level of dissemination of viable norovirus after simulated vomiting. Methods This study used a system called ‘Vomiting Larry’ to simulate vomiting with infection medium containing the norovirus surrogate feline calicivirus (FCV) as a worst-case scenario for distribution and survival of viruses after simulated vomiting. Air and floor samples were taken after simulated vomiting, and analysed for viable virus via plaque assay. Analysis of covariance investigated differences in FCV concentration by sample volume and location. Findings Whilst viable virus was not isolated from any air samples taken after simulated vomiting, FCV concentrations of ≥10 plaque-forming units/mL were recovered from almost all samples taken from the floor (88/90). These included small droplets of fluid that travelled 3 m away from the vomiting system. There was evidence that FCV concentration depended on both sample volume and location. Conclusion This study suggests that norovirus can survive being ejected even within small far-reaching droplets at concentrations capable of eliciting infection. Such droplets could easily go unnoticed and be overlooked during cleaning, adding to the challenge of controlling norovirus outbreaks.
Lessons learned from a pneumocystis pneumonia outbreak at a Scottish renal transplant centre J. Hosp. Infect. (IF 3.704) Pub Date : 2019-02-23 A. McClarey, P. Phelan, D. O'Shea, L. Henderson, R. Gunson, I.F. Laurenson
Background Pneumocystis pneumonia (PCP) is an opportunistic infection occurring in renal transplant patients. Over a 14-month period an increase in PCP cases was identified among our renal transplant cohort. Aim The outbreak population was studied to identify potential risk factors for the development of PCP. Methods A retrospective analysis of hospital records was carried out, with each case being matched with two case-linked controls. Information was collected on patient demographics, laboratory tests, and hospital visits pre and post development of infection. Findings No patients were receiving PCP prophylaxis at the time of infection and mean time from transplantation to developing PCP was 4.7 years (range: 0.51–14.5). The PCP group had a significantly lower mean estimated glomerular filtration rate than the control group (29.3 mL/min/1.73 m2 vs 70 mL/min−1 (P = 0.0007)). Three patients were treated for active cytomegalovirus (CMV) infection prior to PCP diagnosis and two had active CMV at the time of diagnosis compared to none in the control group (P = 0.001). Those who developed PCP were more likely to have shared a hospital visit with another patient who went on to develop PCP; 37% of clinic visits vs 19% (P = 0.014). Conclusion This study highlights the ongoing risk of opportunistic infection several years after transplantation and adds weight to potential person-to-person Pneumocystis jirovecii transmission. Risk factors have been identified which may highlight those most at risk, enabling targeted rather than blanket long-term PCP prophylaxis.
Prospective surveillance of bacterial colonization and primary sepsis: findings of a tertiary neonatal intensive and intermediate care unit J. Hosp. Infect. (IF 3.704) Pub Date : 2019-02-01 C. Baier, S. Pirr, S. Ziesing, E. Ebadi, G. Hansen, B. Bohnhorst, F.-C. Bange
Background Preterm infants and critically ill neonates are predisposed to nosocomial infections as sepsis. Moreover, these infants acquire commensal bacteria, which might become potentially harmful. On-ward transmission of these bacteria can cause outbreaks. Aim To report the findings of a prospective surveillance of bacterial colonization and primary sepsis in preterm infants and neonates. Methods The results of the surveillance of bacterial colonization of the gut and the respiratory tract, targeting meticillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and Gram-negative bacteria from November 2016 to March 2018 were analysed. Bacterial colonization was compared to surveillance of sepsis. Findings Six-hundred and seventy-one patients were admitted and 87.0 % (N=584) of the patients were screened; 48.3% (N=282) of the patients screened were colonized with at least one of the bacteria included in the screening; 26.2% of them (N=74) had multi-drug-resistant strains. A total of 534 bacterial isolates were found. The most frequently found species were Escherichia coli, Enterobacter cloacae, Klebsiella oxytoca and Klebsiella pneumoniae. Three MRSA but no VRE were detected. The surveillance detected a K. pneumoniae cluster involving nine patients. There were 23 blood-culture-confirmed sepsis episodes; 60.9% (N=14) were caused by staphylococci. Gram-negative bacteria (one Klebsiella aerogenes and two E. cloacae) caused three sepsis episodes which were preceded by colonization with the respective isolates. Conclusions Surveillance of colonization provided a comprehensive overview of species and antibiotic resistance patterns. It allowed early detection of a colonization cluster. Knowledge of colonization and surveillance of sepsis is useful for guiding infection control measures and antibiotic treatment.
Real-time whole genome sequencing to control a Streptococcus pyogenes outbreak at a national orthopaedic hospital J. Hosp. Infect. (IF 3.704) Pub Date : 2019-07-05 H. Sharma, M.R. Ong, D. Ready, J. Coelho, N. Groves, V. Chalker, S. Warren
Background Whole genome sequencing (WGS) of Streptococcus pyogenes linked to invasive disease has been used to identify and investigate outbreaks. The clinical application of WGS in real-time for outbreak control is seldom employed. Aims A fatal case of bacteraemia at a national orthopaedic hospital prompted an outbreak investigation to identify carriers and halt transmission using real-time WGS. Methods Retrospective surveillance was conducted to identify patients with Streptococcus pyogenes infections in the last year. Upon contact tracing, four patients and 179 staff were screened for Streptococcus pyogenes carriage. All isolates identified were emm-typed. Whole genome sequencing (WGS) was performed in real-time on a subset of isolates. Findings 12 isolates of Streptococcus pyogenes from the index case, two patients and eight staff were identified. Six isolates were emm 1.0, including the index case and five staff isolates. The remaining isolates belonged to distinct emm-types. WGS analysis was undertaken on the six emm 1.0 isolates. Five were indistinguishable by single-nucleotide polymorphism (SNP) analysis, with a 0 SNP distance, and one had one SNP difference, supporting the hypothesis of recent local transmission. All screen positive healthcare workers were offered treatment with penicillin or clindamycin. No further cases were identified. Conclusion The increased molecular discrimination of WGS confirmed the clustering of these cases and the outbreak was contained. This demonstrates the clinical utility of WGS in managing outbreaks of invasive Streptococcus pyogenes in real-time and we recommend its implementation as a routine clinical service.
The difficulty in removing biofilms from dry surfaces J. Hosp. Infect. (IF 3.704) Pub Date : 2019-07-04 Farhana Parvin, Honghua Hu, Greg S. Whiteley, Trevor Glasbey, Karen Vickery
Cleaning is fundamental to infection control. This report demonstrates that a Staphylococcus aureus biofilm is significantly harder to remove than dried planktonic bacteria. A single wipe removed >99.9% (>3Log10) of dried planktonic bacteria, whereas only 1.48Log10 of biofilm (96.66%) was removed by a standardised wiping process after 50 wipes.
Can Real-Time PCR Allow a Faster Recovery of Hospital Activity in Cases of an Incidental Discovery of Carbapenemase-Producing Enterobacteriaceae and Vancomycin-Resistant Enterococci Carriers? J. Hosp. Infect. (IF 3.704) Pub Date : 2019-07-04 Rindala Saliba, Caroline Neulier, Delphine Seytre, Alain Fiacre, Frédéric Faibis, Pierre Leduc, Marlène Amara, Françoise Jauréguy, Etienne Carbonnelle, Jean-Ralph Zahar, Laurence Marty
Background Detection of faecal carriers of carbapenemase-producing Enterobacteriaceae (CPE) and vancomycin-resistant enterococci (VRE) has become a routine medical practice in many countries. In an outbreak setting, several public health organizations recommend threenweekly rectal screenings to rule-out acquisition in contact patients. This strategy, associated with bed closures and reduction of medical activity for a relatively long time, seems costly. Aim The objective of this study was to test the positive and negative predictive values of RT-PCR(GeneXpert®) carried-out at Day-0, compared to conventional three weekly culture-based rectal screenings, in identifying, among contact patients, those who acquired CPE/VRE. Methods We conducted a multicentre retrospective study from January2015 to October2018. We included all contact patients (CP) identified from index patients (IP) colonized or infected with CPE/VRE, incidentally discovered. Each CP was investigated at Day-0 by PCR (GeneXpert®), and by the recommended three weekly screenings. Findings Twenty-two IP and 159 CP were included. An average of 0.77 secondary case per patient was noted, with a mean duration of contact of 10 days [range 1-64]. Among the 159 CP, 16 (10%) had a CPE/VRE-positive culture during the monitoring period. Rectal screenings were positive at Day-0 (10 patients), Day-7 (2 patients), Day-14 (4 patients). Thirteen out of 16 patients with positive culture had at Day-0 a positive PCR. Overall, a concordance of 97.5% (155/159) was observed between the three-weekly screenings and Day-0 PCR results. When performed on CP at Day-0 of the identification of an IP, PCR(GeneXpert®) allowed to shorten turnaround time by 5 to 27days, compared to three weekly screenings. PPV and NPV were respectively 100% and 98%. Conclusions RT-PCR (GeneXpert®) can avoid three weekly rectal samplings needed to rule-out acquisition of CPE/VRE.
Indoor hospital air and the impact of ventilation on bioaerosols: a systematic review J. Hosp. Infect. (IF 3.704) Pub Date : 2019-07-04 Rebecca E. Stockwell, Emma L. Ballard, Peter O’Rourke, Luke D. Knibbs, Lidia Morawska, Scott C. Bell
Hospital-acquired infections (HAI) continue to persist in hospitals, despite the use of increasingly strict infection control precautions. Opportunistic airborne transmission of potentially pathogenic bioaerosols may be one possible reason for this persistence. Therefore, we aimed to systematically review the concentrations and compositions of indoor bioaerosols in different areas within hospitals and the effects of different ventilation systems. Electronic databases (Medline and Web of Science) were searched to identify articles of interest. The search was restricted to articles published from 2000 to 2017 in English. Aggregate data was used to examine the differences in mean colony forming units per cubic metre (CFU/m3) between different hospital areas and ventilation types. A total of 36 journal articles met the eligibility criteria. The mean total bioaerosol concentrations in the different areas of the hospitals were highest in the inpatient facilities (77 CFU/m3, 95% confidence interval (CI), 55-108) compared with the restricted (4 CFU/m3, 95% CI, 10-15) and public areas (14 CFU/m3, 95% CI, 10-19). Hospital areas with natural ventilation had the highest total bioaerosol concentrations (201 CFU/m3, 95% CI, 135-300) compared with areas using conventional mechanical ventilation systems (20 CFU/m3, 95% CI, 16-24). Hospital areas using sophisticated mechanical ventilation systems (such as increased air changes per hour, directional flow and filtration systems) had the lowest total bioaerosol concentrations (9 CFU/m3, 95% CI, 7-13). Operating sophisticated mechanical ventilation systems in hospitals contributes to improved indoor air quality within hospitals, which assists in reducing the risk of airborne transmission of HAI.
Evaluation of droplet production by a new design of clinical hand wash basin for the healthcare environment J. Hosp. Infect. (IF 3.704) Pub Date : 2019-07-03 Samuel Yui, Monika Muzslay, Kush Karia, Bronwen Shuttleworth, Shanom Ali, Natalia Dudzinska, Peter Wilson
Splashing from handwash basins may be a source of bacteria in the healthcare environment. A novel splash-reducing basin was assessed for its ability to reduce droplet formation during simulated handwashing. The basin was compared to two conventional basins commonly used in healthcare. Basins were mounted in a test system and tap flushed for 30 seconds with and without handwashing. Droplets were visualised with fluorescent dye. With conventional basins, >1000 droplets were formed during 30 second flushes and found to spread further than 2m. The novel basin significantly reduced the number of droplets formed during handwashing and reduced the distance spread.
Prevalence and incidence of surgical site infections in the European Union/European Economic Area: how do these measures relate? J. Hosp. Infect. (IF 3.704) Pub Date : 2019-06-29 Anouk P. Meijs, Ida Prantner, Tommi Kärki, José A. Ferreira, Pete Kinross, Elisabeth Presterl, Pille Märtin, Outi Lyytikäinen, Sonja Hansen, Andrásné Szőnyi, Enrico Ricchizzi, Rolanda Valinteliėnė, Simeone Zerafa, Sabine de Greeff, Thale Cathrine Berg, Paulo André Fernandes, Mária Štefkovičová, Angel Asensio Vegas, Mayke BG. Koek
Background In 2011-2012, the European Centre for Disease Prevention and Control (ECDC) initiated the first European point prevalence survey (PPS) of healthcare-associated infections (HAIs) in addition to targeted surveillance of the incidence of specific types of HAIs such as surgical site infections (SSIs). Aim To investigate whether national and multi-country SSI incidence can be estimated from ECDC PPS data. Methods We included 159 hospitals from 15 countries that participated in both ECDC surveillance modules, aligning surgical procedures in the incidence surveillance to corresponding specialties from the PPS. We simulated national daily prevalence of SSIs from the incidence surveillance data, used the Rhame and Sudderth (R&S) formula to estimate national and multi-country SSI incidence from the PPS data, and predicted national incidence per specialty using a linear model including data from the PPS. Findings The simulation of daily SSI prevalence from incidence surveillance of SSIs showed that prevalence fluctuated randomly depending on the day of measurement. The correlation between the national aggregated incidence estimated with R&S formula and observed SSI incidence was low (correlation coefficient = 0.24), but specialty-specific incidence results were more reliable, especially when the number of included patients was large (correlation coefficients ranging from 0.40 – 1.00). The linear prediction model including PPS data had low proportion of explained variance (0.40). Conclusion Due to a lack of accuracy, we recommend using PPS data to estimate SSI incidence only in situations where incidence surveillance of SSIs is not performed, and sufficiently large samples of PPS data are available.
Epidemiology and impact of norovirus outbreaks in Norwegian healthcare institutions, 2005-2018 J. Hosp. Infect. (IF 3.704) Pub Date : 2019-06-22 Laura Espenhain, T.C. Berg, H. Bentele, Karin Nygård, O. Kacelnik
Aim The aim of this study was, for the first time, to describe in detail the epidemiology and impact of norovirus outbreaks in healthcare institituions (HCIs) in Norway to identify areas which may improve outbreak response. Methods We carried out an analysis of all reported norovirus outbreaks in hospitals and long-term care facilities (LTCFs) from week 34, 2005 to week 33, 2018. We described seasonality, symptoms and number of cases among personnel and patients. Findings A total of 20,544 cases, including 7,044 healthcare personnel were reported in 965 outbreaks; 740 from LTCFs and 225 from hospitals. Median number of cases per outbreak was 15, interquartile range (IQR) [8-25] in LTCF and 17, IQR [10-28] in hospitals. All regions reported outbreaks, with 1/3 of the municipalities having at least one outbreak in LTCFs during the study period. The start of the outbreak season happened almost three weeks earlier in hospitals than in LTCFs. The estimated average number of working days lost for healthcare personnel per year ranged from 1590 to 1944. Conclusions Norovirus outbreaks in Norwegian HCIs appears to have a substantial impact both hospital and LTCFs all over Norway, especially during the winter months. That up to half of of all cases were healthcare professionals emphasizes is a need for further focus on infection control. Our results suggest that hospitals, affected first, could alert LTCFs in the area in order to prevent further outbreaks.
Impact of a checklist used by pharmacists on hospital antimicrobial use: A patient-level interrupted time series study J. Hosp. Infect. (IF 3.704) Pub Date : 2019-06-21 Maude Fortier, Pauline Pistre, Victor Ferreira, Mariam Pinsonneault, Jeannie Medeiros Charbonneau, Catherine Proulx, Audrey Buisson, Philippe Morency-Potvin, David Williamson, Anita Ang
Backgroud. Antimicrobial misuse leading to drug resistance is a growing concern for clinicians. Improving antimicrobial stewardship programmes through development of new tools could be part of the solution. Aim. To evaluate antimicrobial use in hospitalized patients after implementation of an antimicrobial checklist for ward-based clinical pharmacists. Methods A checklist based on quality indicators of optimal antimicrobial use was implemented to standardize hospital pharmacists’ assessment of antimicrobial therapy. Antimicrobial use metrics from adults hospitalized during the control and intervention periods were assessed in an interrupted time series analysis of individual patient data. The primary endpoint was days of therapy (DOT) for all antimicrobial per 1000 days present for included patients. Secondary endpoints were the DOT of extended-spectrum antimicrobials (DOT-ES), length of therapy of all antimicrobials (LOT) and the number of pharmacist interventions. Findings. One thousand six hundred and nineteen patients were included: 800 and 819 in the pre- and post-checklist implementation periods, respectively. As indicated by the point estimates and their 95% confidence intervals (CI), there were no changes in trend for DOT, DOT-ES or LOT. A change in level was not found for the DOT, while a change of -118 DOT-ES [-209,-28] and -51 LOT [-97,-4] was documented. Furthermore, pharmacists’ interventions regarding antimicrobials increased by 18.7% (14.0, 23.5) and progress notes by 32.3% (27.8, 36.8). Conclusion An antimicrobial checklist used by ward-based clinical pharmacists did not decreased DOT for all antimicrobials, but decreased DOT-ES and LOT upon its implementation.
‘Off the Rails’: Hospital bed rail design, contamination, and the evaluation of their microbial ecology J. Hosp. Infect. (IF 3.704) Pub Date : 2019-06-21 Maria A. Boyle, Aoife Kearney, Philip Carling, Hilary Humphreys
Microbial contamination of the near-patient environment is an acknowledged reservoir for nosocomial pathogens. The hospital bed and specifically bed rails have been shown to be frequently and heavily contaminated in observational and interventional studies. While the complexity of bedrail design has evolved over the years, the microbial contamination of these surfaces has been incompletely evaluated. In many published studies, key design variables are not described, compromising the extrapolation of results to other settings. This report reviews the evolving structure of hospital beds and bed rails, the possible impact of different design elements on microbial contamination and their role in pathogen transmission. Our findings support the need for clearly defined standardized assessment protocols to accurately assess bedrail and similar patient zone surfaces levels of contamination, as part of environmental hygiene investigations.
Ex vivo and in vivo evaluation of residual chlorhexidine gluconate on skin following repetitive exposure to saline and wiping with 2% chlorhexidine gluconate/70% isopropyl alcohol pre-operative skin preparations J. Hosp. Infect. (IF 3.704) Pub Date : 2018-10-16 M.H. Bashir, A. Hollingsworth, D. Schwab, K.S. Prinsen, J.E. Paulson, D.J. Morse, S.F. Bernatchez
Are systematic drain tip or drainage fluid cultures predictive of surgical site infections? J. Hosp. Infect. (IF 3.704) Pub Date : 2018-11-27 H. Macaigne, V.G. Ruggieri, L.Vallet-Tadeusz, V. Vernet-Garnier, L.S. Aho-Glélé, O. Bajolet, A. Lefebvre
Systematic cultures of drain tips or drainage fluids for the early detection of surgical site infections (SSIs) are controversial. To examine the association between the results of systematic drain tip or drainage fluid cultures and the occurrence of SSIs in clean or clean-contaminated surgery. Searches were performed in the PubMed, and Cat.inist databases for observational studies published before 31st March 2017. Studies reporting results of drain tip or drainage fluid systematic cultures and SSIs after clean or clean-contaminated surgeries were included, and meta-analyses were performed. Seventeen studies, including 4390 patients for drain tip cultures and 1288 for drainage fluid cultures, were selected. The pooled negative predictive values were high (99%, 95% confidence interval (CI) 98–100 for drain tip cultures and 98%, 95% CI 94–100 for drainage fluid cultures). The positive predictive values were low (11%, 95% CI 2–24 for drain tip cultures and 12%, 95% CI 3–24 for drainage fluid cultures). The sensitivities were low (41%, 95% CI 12–73 for drain tip cultures and 37%, 95% CI 16–60 for drainage fluid cultures). The specificities were high (93%, 95% CI 88–96) for drain tip cultures and moderate (77%, 95% CI 54–94) for drainage fluid cultures. Systematic cultures of drain tips or drainage fluids appear not to be relevant, because their positive predictive values were low in the prediction of SSIs.
Impact of participation in a surgical site infection surveillance network: results from a large international cohort study J. Hosp. Infect. (IF 3.704) Pub Date : 2018-12-07 M. Abbas, M.E.A. de Kraker, E. Aghayev, P. Astagneau, M. Aupee, M. Behnke, A. Bull, H.J. Choi, S.C. de Greeff, S. Elgohari, P. Gastmeier, W. Harrison, M.B.G. Koek, T. Lamagni, E. Limon, H.L. Løwer, O. Lyytikäinen, K. Marimuthu, S. Harbarth
Background Surveillance of surgical site infections (SSIs) is a core component of effective infection control practices, though its impact has not been quantified on a large scale. Aim To determine the time-trend of SSI rates in surveillance networks. Methods SSI surveillance networks provided procedure-specific data on numbers of SSIs and operations, stratified by hospitals' year of participation in the surveillance, to capture length of participation as an exposure. Pooled and procedure-specific random-effects Poisson regression was performed to obtain yearly rate ratios (RRs) with 95% confidence intervals (CIs), and including surveillance network as random intercept. Findings Of 36 invited networks, 17 networks from 15 high-income countries across Asia, Australia and Europe participated in the study. Aggregated data on 17 surgical procedures (cardiovascular, digestive, gynaecological-obstetrical, neurosurgical, and orthopaedic) were collected, resulting in data concerning 5,831,737 operations and 113,166 SSIs. There was a significant decrease in overall SSI rates over surveillance time, resulting in a 35% reduction at the ninth (final) included year of surveillance (RR: 0.65; 95% CI: 0.63–0.67). There were large variations across procedure-specific trends, but strong consistent decreases were observed for colorectal surgery, herniorrhaphy, caesarean section, hip prosthesis, and knee prosthesis. Conclusion In this large, international cohort study, pooled SSI rates were associated with a stable and sustainable decrease after joining an SSI surveillance network; a causal relationship is possible, although unproven. There was heterogeneity in procedure-specific trends. These findings support the pivotal role of surveillance in reducing infection rates and call for widespread implementation of hospital-based SSI surveillance in high-income countries.
Effects of the application of vitamin E and silicone dressings vs conventional dressings on incisional surgical site infection in elective laparoscopic colorectal surgery: a prospective randomized clinical trial J. Hosp. Infect. (IF 3.704) Pub Date : 2018-11-03 J. Ruiz-Tovar, C. Llavero, M. Perez-Lopez, A. Garcia-Marin
Aim To compare the effect of conventional wound dressings (CD) with vitamin E and silicone (E-Sil) dressings on incisional surgical site infection (SSI) in patients undergoing elective colorectal laparoscopic surgery. Patients and methods A prospective, randomized study was performed. Patients were assigned at random into two groups: an E-Sil group and a CD group. Incisional SSI, postoperative pain and acute phase reactants were investigated. Results In total, 120 patients were included in this study (60 in each group). The incisional SSI rate was 3.4% in the E-Sil group and 17.2% in the CD group (P = 0.013). Bacteroides fragilis alone grew in the cultures of infected wounds in the E-Sil group, while cultures for infected wounds in the CD group were polymicrobial. Mean postoperative pain 48 h after surgery was 27.1 [standard deviation (SD) 10.7] mm in the E-Sil group and 41.6 (SD 16.9) mm in the CD group (P < 0.001). White blood cell (WBC) count and C-reactive protein (CRP) level were lower in the E-Sil group, even after the exclusion of patients presenting with postoperative complications. Conclusion Use of an E-sil dressing to cover the Pfannestiel wound after elective laparoscopic colorectal surgery leads to a reduction in the incisional SSI rate, lower postoperative pain, and a decrease in CRP level and WBC count.
Predictive models of surgical site infections after coronary surgery: insights from a validation study on 7090 consecutive patients J. Hosp. Infect. (IF 3.704) Pub Date : 2019-01-15 G. Gatti, M. Rochon, S.G. Raja, R. Luzzati, L. Dreas, A. Pappalardo
Background The role of specific scoring systems in predicting risk of surgical site infections (SSIs) after coronary artery bypass grafting (CABG) has not been established. Aim To validate the most relevant predictive systems for SSIs after CABG. Methods Five predictive systems (eight models) for SSIs after CABG were evaluated retrospectively in 7090 consecutive patients undergoing isolated (73.9%) or combined (26.1%) CABG. For each model, accuracy of prediction, calibration, and predictive power were assessed with area under receiver–operating characteristic curve (aROC), the Hosmer–Lemeshow test, and the Goodman–Kruskal γ-coefficient, respectively. Six predictive scoring systems for 30-day in-hospital mortality after cardiac operations were evaluated as to prediction of SSIs. The models were compared one-to-one using the Hanley–McNeil method. Findings There were 724 (10.2%) SSIs. Whereas all models showed satisfactory calibration (P = 0.176–0.656), accuracy of prediction was low (aROC: 0.609–0.650). Predictive power was moderate (γ: 0.315–0.386) for every model but one (γ: 0.272). When compared one-to-one, the Northern New England Cardiovascular Disease Study Group mediastinitis score had a higher discriminatory power both in overall series (aROC: 0.634) and combined CABG patients (aROC: 0.648); in isolated CABG patients, both models of the Fowler score showed a higher discriminatory power (aROC: 0.651 and 0.660). Accuracy of prediction for SSIs was low (aROC: 0.564–0.636) even for six scoring systems devised to predict mortality after cardiac surgery. Conclusion In this validation study, current predictive models for SSIs after CABG showed low accuracy of prediction despite satisfactory calibration and moderate predictive power.
Influence of bacterial resistance on mortality in intensive care units: a registry study from 2000 to 2013 (IICU Study) J. Hosp. Infect. (IF 3.704) Pub Date : 2019-01-17 V. Bonnet, H. Dupont, S. Glorion, M. Aupée, E. Kipnis, J.L. Gérard, J.L. Hanouz, M.O. Fischer
Background Bacterial resistance to antibiotics is a daily concern in intensive care units. However, few data are available concerning the clinical consequences of in-vitro-defined resistance. Aim To compare the mortality of patients with nosocomial infections according to bacterial resistance profiles. Methods The prospective surveillance registry in 29 French intensive care units (ICUs) participating during the years 2000–2013 was retrospectively analysed. All patients presenting with a nosocomial infection in ICU were included. Findings The registry contained 88,000 eligible patients, including 10,001 patients with a nosocomial infection. Among them, 3092 (36.7%) were related to resistant micro-organisms. Gram-negative bacilli exhibited the highest rate of resistance compared to Gram-positive cocci (52.8% vs 48.1%; P < 0.001). In-hospital mortality was higher in cases of patients with antibiotic-resistant infectious agents (51.9% vs 45.5%; P < 0.001), and critical care length of stay was longer (33 ± 26 vs 29 ± 22 days; P < 0.001). These results remained significant after SAPS II matching (P < 0.001) and in the Gram-negative bacilli and Gram-positive cocci subgroups. No difference in mortality was found with respect to origin prior to admission. Conclusion Patients with bacterial resistance had higher ICU mortality and increased length of stay, regardless of the bacterial species or origin of the patient.
Detection of hepatitis C virus in an exhumed body identified the origin of a nosocomial transmission that caused multiple fatal diseases J. Hosp. Infect. (IF 3.704) Pub Date : 2019-01-08 J. McDermott, S.G. Parisi, I. Martini, C. Boldrin, E. Franchin, F. Dal Bello, A. Gianelli Castiglione, E. Boeri, M. Sampaolo, M. Basso, P. Menegazzi, L. Tagliaferro, G. Palù, O.E. Varnier
Background Medico-legal conflicts arise when it is difficult to prove the cause of nosocomial infections. Aim To report an outbreak of patient-to-patient transmission of hepatitis C virus (HCV) through the repeated use of a multi-dose saline flask during the rinsing of central venous catheters. Methods Blood samples were taken from each patient for the comparative analysis of their HCV RNA strains. No samples were available for one patient who died before the investigation started. Despite the known lability of HCV RNA, the body was exhumed four months after burial and postmortem samples were collected. HCV RNA was extracted successfully from liver and spleen samples. Genotyping of all the HCV strains was performed by sequence analysis of the 5′NC untranslated region, the E1 core conserved region and the E1/E2 hypervariable region. Findings Forensic investigators retraced the route used by two ward nurses, when saline catheter flushes were given to 14 patients with each nurse administering to seven patients. The comparative phylogenetic analysis of all case strains identified the deceased patient as the source of contamination to five patients. Conclusions This study highlights the value of sequence analysis as a tool for solving medico-legal conflicts. The High Court of Justice found that a health worker's re-use of a contaminated needle resulted in the nosocomial transmission of HCV.
Multi-centre study on cultural dimensions and perceived attitudes of nurses towards influenza vaccination uptake J. Hosp. Infect. (IF 3.704) Pub Date : 2018-11-28 K.O. Kwok, K.K. Li, S.S. Lee, P.H.Y. Chng, V.W.I. Wei, N.H. Ismail, N. Mosli, D. Koh, A. Lai, J.W. Lim
This study explored how cultural values affected Health Belief Model (HBM) components and the influenza vaccine uptake among nurses across three Asian populations using a survey conducted in 2017 (N = 3971). The vaccination coverages were 33.5% (Brunei), 35.6% (Hong Kong) and 69.5% (Singapore). Three HBM components (perceived susceptibility, perceived benefits and cues to action) were positively associated with vaccination. A direct negative link and an indirect positive link via HBM were observed between collectivism and vaccination, whereas a negative indirect link via HBM between power distance and vaccination was observed. Cultural values, notably collectivism, advanced HBM to study nurses' vaccination.
Vancomycin use in surrounding patients during critical illness and risk for persistent colonization with vancomycin-resistant Enterococcus J. Hosp. Infect. (IF 3.704) Pub Date : 2019-01-11 P. Zachariah, D.E. Freedberg
The optimal duration of contact precautions for vancomycin-resistant enterococcus (VRE)-colonized patients is uncertain and individual patient characteristics alone may not predict risk of prolonged colonization. Using a cohort of adult patients who underwent testing for VRE at intensive care unit (ICU) admission, we tested the association between local (unit-level) vancomycin use and persistent colonization with VRE. Higher unit-level vancomycin use significantly prolonged VRE colonization (P=0.03) independent of patient-level vancomycin use and unit VRE density.
Candidaemia in an Irish intensive care unit setting between 2004 and 2018 reflects increased incidence of Candida glabrata J. Hosp. Infect. (IF 3.704) Pub Date : 2019-01-19 P. Ryan, C. Motherway, J. Powell, A. Elsaka, A.A. Sheikh, A. Jahangir, N.H. O'Connell, C.P. Dunne
The cumulative incidence of candidaemia in an Irish intensive care unit (ICU) setting between January 2004 and August 2018 was 17/1000 ICU admissions. Candida albicans was responsible for 55% (N=41) of cases. C. glabrata (N=21, 28%) was the next most prevalent species, and has been identified most frequently since 2012. C. glabrata was associated with a higher mortality rate (57%) than C. albicans (29%). All isolates were susceptible to caspofungin (0.05 μg/mL). Notably, 37% of C. glabrata isolates were resistant to fluconazole, with 13% resistant to amphotericin B, highlighting the need for prudent antifungal stewardship to impede development of multi-drug-resistant C. glabrata in the ICU setting.
Incremental Clinical and Economic Burden of Suspected Respiratory Infections due to Multidrug-Resistant Pseudomonas aeruginosa in the United States J. Hosp. Infect. (IF 3.704) Pub Date : 2019-06-19 Ying P. Tabak, Sanjay Merchant, Gang Ye, Latha Vankeepuram, Vikas Gupta, Stephen G. Kurtz, Laura A. Puzniak
Background Multidrug resistant (MDR) Pseudomonas aeruginosa can negatively affect patients and hospitals. Aim To evaluate excess mortality and cost burden among patients hospitalized with suspected respiratory infections due to MDR P. aeruginosa versus patients with non-MDR P. aeruginosa in 78 United States (US) hospitals. Methods We analyzed electronically captured microbiological and outcomes data of patients hospitalized with nonduplicate P. aeruginosa isolates from respiratory source collected ≥3 days after admission to identify hospital-onset MDR or non-MDR P. aeruginosa per the Centers for Disease Control and Prevention definition. We estimated the risk of multidrug resistance on mortality, length of stay (LOS), cost, operation gain/loss, and 30-day readmission. We conducted a sensitivity analysis utilizing a cohort with pharmacy data available. Findings Of 523 MDR and 1381 non-MDR P. aeruginosa cases, unadjusted mortality was 23.7% versus 18.0% and multivariable-adjusted mortality was 20.0% (95% confidence interval [CI]: 14.3%–27.2%) versus 15.5% (95% CI: 11.2%–20.9%; P=0.026), the average adjusted excess LOS was 6.7 days (P<0.001); excess cost per case was US$22 370 higher (P=0.002) and operational loss per case was US$10 661 (P=0.024) greater, and the multivariable adjusted readmission rate was 16.2% (95% CI: 11.2%–22.9%) versus 11.1% (95% CI: 7.8%–15.6%; P=0.006). The sensitivity analysis yielded similar results. Conclusions Compared with suspected infections due to non-MDR P. aeruginosa, patients with MDR P. aeruginosa had higher risk of mortality, readmission, and longer LOS, as well as US$20 000 incremental cost and >US$10 000 incremental net loss per case after controlling for patient and hospital characteristics.
Gloved hand disinfection improved hand hygiene before infection prone procedures on a stem cell ward J. Hosp. Infect. (IF 3.704) Pub Date : 2019-06-18 Patrick (P) Fehling, Justin (J) Hasenkamp, Steffen (S) Unkel, Ina (I) Thalmann, Sandra (S) Hornig, Lorenz (L) Trümper, Simone (S) Scheithauer
Background Hand hygiene compliance even before infection prone procedures (indication 2, “before aseptic tasks”, according to WHO) remains disappointing. The aim of this study was to improve hand hygiene compliance by implementing gloved hand disinfection as a resource-neutral process optimization strategy. Methods We performed a three-phase intervention study on a stem cell transplant ward. After baseline evaluation of hand hygiene compliance (phase 1) gloved hand disinfection was allowed (phase 2) and restricted (phase 3) to evaluate and differentiate intervention-derived from learning and time effects. The incidence of severe infections as well as hospital-acquired multi drug-resistant bacteria (MDRO) was recorded by active surveillance. Findings Hand hygiene compliance significantly improved from 50% to 76% (p<0.001) when gloved hand disinfection was allowed. The biggest increase was for infection-prone procedures (WHO 2) from 31% to 65%; p<0.001. Severe infections decreased by trend (6.0 to 2.5 per 1000 patient day) whereas transmission of multi drug-resistant organisms was not affected, respectively. Taken together, gloved hand disinfection significantly improved compliance with the hand hygiene, especially in activities relevant to infections and infection prevention. Thus, this process optimization may be an additional easy implementable, resource-neutral tool for a highly vulnerable patient cohort.
Two year analysis of Clostridium difficile ribotypes associated with increased severity J. Hosp. Infect. (IF 3.704) Pub Date : 2019-06-18 Rachel Herbert, James Hatcher, Elita Jauneikaite, Myriam Gharbi, Stephanie d’Arc, Nelofar Obaray, Tony Rickards, Monica Rebec, Oliver Blandy, Russell Hope, Anthony Thomas, Kathleen Bamford, Annette Jepson, Shiranee Sriskandan
Background Certain Clostridium difficile ribotypes have been associated with complex disease phenotypes including recurrence and increased severity, especially the well-described hypervirulent ribotype RT027. In this study we set out to determine the pattern of ribotypes causing infection and association if any with severity. Methods All faecal samples submitted to a large diagnostic laboratory for C. difficile testing between 2011 and 2013 were subject to routine testing and cultured. All C. difficile isolates were ribotyped and associated clinical and demographic patient data were retrieved then linked to ribotyping data. Results A total of 86 distinct ribotypes were identified from 705 isolates of C. difficile. Ribotypes RT002 and RT015 were the most prevalent (22.5%, n=159). Only five isolates (0.7%) were the hypervirulent RT027. Ninety of 450 (20%) patients with clinical information available died within 30-days of C. difficile isolation. Ribotype RT220, one of the ten commonest ribotypes, was associated with elevated median C-reactive protein and significantly increased 30-day all-cause mortality when compared with ribotypes RT002 and RT015, and with all other ribotypes found in the study. Conclusions A wide range of C. difficile ribotypes were responsible for C. difficile infection presentations. Although C. difficile-associated mortality has reduced in recent years, expansion of lineages associated with increased severity could herald increases in future mortality. Enhanced surveillance for emerging lineages such as RT220 that are associated with more severe disease is required, with genomic approaches to dissect pathogenicity.
Candida auris exhibits resilient biofilm characteristics in vitro: implications for environmental persistence J. Hosp. Infect. (IF 3.704) Pub Date : 2019-06-18 Bryn Short, Jason Brown, Christopher Delaney, Leighann Sherry, Craig Williams, Gordon Ramage, Ryan Kean
Surfaces within healthcare play a key role in the transmission of drug-resistant pathogens. Candida auris is an emerging multi-drug resistant yeast which has the ability to survive for prolonged periods on environmental surfaces. Here we show that the ability to form cellular aggregates increases survival after 14 days, which coincides with the upregulation of biofilm-associated genes. Additionally, the aggregating strain demonstrated tolerance to clinical concentrations of sodium hypochlorite and remain viable 14 days’ post treatment. The ability of C. auris to adhere and persist on environmental surfaces emphasises our need to better understand the biology of this fungal pathogen.
Interlaboratory reproducibility of a test method following 4-field test methodology to evaluate the susceptibility of Clostridium difficile spores J. Hosp. Infect. (IF 3.704) Pub Date : 2019-06-12 Stefanie Gemein, Jürgen Gebel, Katrin Steinhauer, Bärbel Christiansen, Heike Martiny, Bernhard Meyer, Christiane Ostermeyer, Hans-Joachim Rödger, Lutz Vossebein, Lars Paßvogel, Florian H.H. Brill, Maja Decius, Maren Eggers, Torsten Koburger-Janssen, Maren Meckel, Heike Vogelsang, Sebastian Werner, Birgit Hunsinger, Martin Exner
Sporicidal surface disinfection is recommended to control transmission of Clostridium difficile in healthcare facilities. EN 17126 provides a method to determine the sporicidal activity in suspension and has been approved as European standard. In addition, a sporicidal surface test has been proposed. Aim of the study was to determine the interlaboratory reproducibility of a test method for evaluating the susceptibility of a C. difficile spore preparation to a biocidal formulation following the 4-field test (EN 16615 methodology). Nine laboratories participated. C. difficile NCTC 13366 spores were used. Glutaraldehyde (1% and 6%, 15 min) and peracetic acid (PAA; 0.01% and 0.04%; 15 min) were used to determine the spores’ susceptibility in suspension in triplicate. 1% glutaraldehyde revealed a mean decimal log (lg) reduction of 1.03 with variable results in the 9 laboratories (0.37 – 1.49) and a reproducibility of 0.38. The effect of 6% glutaraldehyde was stronger (mean: 2.05; range: 0.96 – 4.29; reproducibility: 0.86). PAA revealed similar results. An exemplary biocidal formulation based on 5% PAA was used at 0.5% (non-effective concentration) and 4% (effective concentration) to determine the sporicidal efficacy (4-field test) under clean conditions in triplicate with a contact time of 15 min. When used at 0.5% it demonstrated an overall lg reduction of 2.68 (range: 2.35 – 3.57) and at 4% of 4.61 (range: 3.82 – 5.71). The residual contamination on the 3 primarily uncontaminated test fields was < 50 cfu/25 cm2 in 1 of 9 laboratories (0.5%) and in 7 of 9 laboratories (4%). The interlaboratory reproducibility seems to be robust.
Residual effect of community antimicrobial exposure on risk of hospital onset healthcare associated Clostridioides difficile infection: a case-control study using national linked data J. Hosp. Infect. (IF 3.704) Pub Date : 2019-06-05 Jiafeng Pan, Kimberley Kavanagh, Charis Marwick, Peter Davey, Camilla Wuiff, Scott Bryson, Chris Robertson, Marion Bennie
Background Associations between antimicrobial exposure in the community and community-associated Clostridioides difficile infection (CA-CDI) are well documented but associations with healthcare-associated CDI (HA-CDI) are less clear. This study estimates the association between antimicrobial prescribing in the community and HA-CDI. Methods A matched case-control study was conducted by linking three national patient level datasets covering CDI cases, community prescriptions and hospitalisations. All validated cases of HA-CDI (August 2010 - July 2013) were extracted and up to three hospital-based controls were matched to each case on the basis of gender, age, hospital and date of admission. Conditional logistic regression was applied to estimate the association between antimicrobial prescribing in the community and HA-CDI. We conducted sensitivity analysis to consider the impact of unmeasured hospital antimicrobial prescribing. Results 930 unique cases of HA-CDI with onset in hospital and no hospital discharge in the 12 weeks prior to index admission were linked with 1810 matched controls. Individuals with prior prescription of any antimicrobial in the community had an odds ratio (OR) = 1.40 (95% CI 1.13-1.73) for HA-CDI compared to those without. Individuals exposed to high risk antimicrobials (cephalosporins, clindamycin, co-amoxiclav, or fluoroquinolones) had an OR=1.83 (95% CI: 1.31-2.56). After accounting for the likely impact of unmeasured hospital prescribing, the community exposure, particular to high risk antimicrobials, was still associated with elevated HA-CDI risk. Conclusions Community antimicrobial exposure is an independent risk factor for HA-CDI and should be considered as part of the risk assessment of patients developing diarrhoea in hospital.
Variations In Antibiotic Use Across India – Multicentre Study Through Global Point Prevalence Survey J. Hosp. Infect. (IF 3.704) Pub Date : 2019-06-03 Sanjeev K. Singh, Sharmila Sengupta, Remya Antony, Sanjay Bhattacharya, Chiranjay Mukhopadhyay, V. Ramasubramanian, Anita Sharma, Suneeta Sahu, .Suhas Nirkhiwale, Dr.Sweta Gupta, Anusha Rohit, Sunil Sharma, Vaidehi Raghavan, Purabi Barman, Smita Sood, Dhruv Mamtora, Sukhanya Rengaswamy, Anita Arora, Ann Versporten
The aim of the study was to assess antimicrobial prescribing patterns, and variation in practice, in India. A point prevalence survey (PPS) was conducted in Oct-Dec 2017 in 16 tertiary care hospitals across India. The survey included all inpatients receiving an antimicrobial on the day of PPS and collected data was analysed using a web-based application of University of Antwerp. 1750 patients were surveyed, of whom 1005 were receiving a total of 1578 antimicrobials. Among the antimicrobials prescribed, 26.87% were for community acquired infections; 19.20% for hospital acquired infections; 17.24% for medical prophylaxis; 28.70% for surgical prophylaxis; and 7.99% for other or undetermined reasons. Antibiotic prescribing quality indicators such as reason in notes and post-prescription review score were low. This PPS showed widespread antibiotic usage, underlining the need for antibiotic stewardship to promote evidence-based practice.
Norovirus Recovery from Floors and Air after Different Decontamination Protocols J. Hosp. Infect. (IF 3.704) Pub Date : 2019-06-02 Caroline L. Ciofi-Silva, Camila Q.M. Bruna, Rita D.C. Carmona, Alda G.C.D. Almeida, Fabiana C.P. dos Santos, Natalia M. Inada, Vanderlei S. Bagnato, Kazuko U. Graziano
Background The dispersal of airborne norovirus (NoV) particles from the floor after faecal or vomit contamination is a challenge for infection control, as this pathogen is infectious at low doses. Therefore, it is imperative to establish a safe protocol for floor decontamination. Aim To assess the presence of residual NoV-GII particles on floor and airborne particles following different floor decontamination procedures. Methods Two types of floors (vinyl and granite) were intentionally contaminated with 10% human faeces positive for NoV-GII. Two decontamination protocols were implemented: cleaning followed by disinfection using 1% sodium hypochlorite and cleaning followed by disinfection using a manual ultraviolet-light device. Swab samples were taken from the floor, and air samples were obtained using an air sampler. The TaqMan® method for real-time reverse transcription-quantitative polymerase chain reaction was employed for analysis. Findings The disinfection protocol using 1% sodium hypochlorite after cleaning proved to be more effective than cleaning followed by ultraviolet-light exposure (p<0.001). Viral particles were detected in 27 of 36 air samples after cleaning, with no statistically significant difference between the two floor types. On average, 617 genome copies/sample were identified in air samples after cleaning, but the number gradually decreased after disinfection. Conclusion NoV-GII can be aerosolized during floor cleaning, and its particles may be inhaled and then swallowed or can settle onto surfaces. Therefore, residual viral particles on floors must be fully eliminated. Cleaning followed by ten minutes of 1% sodium hypochlorite disinfection proved to be the superior decontamination protocol.
Mitigation of microbial contamination from waste water and aerosolization by sink design J. Hosp. Infect. (IF 3.704) Pub Date : 2019-05-28 Kathryn Cole, James E. Talmadge
Background Health care associated infections (HAIs) are a significant cause of increased medical costs, morbidity, mortality, and have been partly associated with sinks, their waste water outlets and associated pipework. Aim Determine if an engineered sink could limit microbial aerosol contaminants in the air and sink basin. Methods Multiple comparisons were undertaken between an experimental sink, designed to limit aerosolization and p-trap contamination to a control hospital sink; both connected to a common drain system. The experimental sink was equipped with ultraviolet light (UV), an aerosol containment hood, ozonated water generator and a flush system to limit bacterial growth/aerosolization and limit microbial growth in the p-trap. Nutrient material was added daily to simulate typical material discarded into a hospital sink. Surface collection swabs, settle plates and p-trap contamination levels were assessed for bacteria and fungi. Findings The experimental sink had significantly decreased levels of bacterial and fungal p-trap contamination (99.9% for Tryptic Soy (TSA) and Sabouraud agar (SAB) plates) relative to the initial levels. Aerosol induced contaminant from the p-traps was significantly lower for the experimental versus the control sink for TSA (76%) and SAB (86%) agar settle plates. Conclusions Limiting microbial contamination is critical for the control of nosocomial infections of in-room sinks, which provide a major source of contamination. Our experimental sink studies document that regular ozonated water rinsing of the sink surface, decontamination of p-trap water, and UV decontamination of surfaces limits microbial aerosolization and surface contamination, with potential to decrease patient exposure and reduce hospital acquired infections.
Continuous Monitoring of Aerial Bioburden within Intensive Care Isolation Rooms and Identification of ‘High Risk’ Activities J. Hosp. Infect. (IF 3.704) Pub Date : 2019-05-27 L.R. Dougall, M.G. Booth, E. Khoo, H. Hood, S.J. MacGregor, J.G. Anderson, I.V. Timoshkin, M. Maclean
Background The spread of pathogens via the airborne route is often underestimated and little is known about the extent to which airborne microbial contamination levels vary throughout the day and night in hospital facilities. Aims This study evaluates airborne contamination levels within ICU isolation rooms over 10-24 hr periods, with the aim of improving the understanding of the variability of environmental aerial bioburden, and the extent to which ward activities may contribute to this. Methods Environmental air monitoring was conducted within occupied and vacant inpatient isolation rooms. A sieve impactor sampler was used to collect 500 L air samples every 15 minutes over 10-hour (08:00-18:00 h) and 24-hour (08:00-08:00 h) periods. Samples were collected, room activity logged, and the bacterial contamination levels were recorded as cfu/m3 of air. Findings A high degree of variability in levels of airborne contamination was observed across all scenarios in the studied isolation rooms. Air bioburden increased as room occupancy increased, with air contamination levels highest in rooms occupied for the longest time during the study (10 days) with a mean value of 104.4 cfu/m3 and a range of 12–510 cfu/m3. Counts were lowest in unoccupied rooms, with an average value of 20 cfu/m3 and during the night. Conclusion Peaks in airborne contamination showed a direct relation to an increase in activity levels. This study provides first clear evidence of the extent of variability in microbial airborne levels over 24-hour periods in ICU isolation rooms and directly correlates microbial load to ward activity.
An Outbreak of MRSA colonisation in a Neonatal intensive care unit: use of a case control study to investigate and control it and lessons learned J. Hosp. Infect. (IF 3.704) Pub Date : 2019-05-24 Brown NM, Reacher M, Rice W, Roddick I, Reeve L, Verlander NQ, Broster S, A.L. Ogilvy-Stuart, D’Amore A, Ahluwalia J, Robinson S, Thaxter R, Moody C, Kearns A, Greatorex J, Martin H, Török ME, Enoch DA
Objective We describe the investigation and management of an MRSA outbreak on a neonatal intensive care unit (NICU) and the lessons learnt. Study design Outbreak report and case-control study. Study setting and participants: The study was conducted in a 40-cot NICU in a tertiary referral hospital and included all infants colonised/infected with gentamicin-resistant MRSA. Interventions Standard infection control measures including segregation of infants, barrier precautions, enhanced cleaning, assessment of staff practice including hand hygiene, and increased MRSA screening of infants were implemented. Continued MRSA acquisitions led to screening of all NICU staff. A case-control study was performed to assess staff contact with colonised babies and inform the management of the outbreak. Results Eight infants were colonised with MRSA (spa type t2068), one of whom subsequently developed an MRSA bacteraemia. MRSA colonisation was significantly associated with lower gestational age; lower birthweight and with being a twin. Three nurses were MRSA colonised but only nurse 45 was colonised with MRSA spa type t2068. Multivariable logistic regression analysis identified being cared for by nurse 45 as an independent risk factor for MRSA colonisation. Interpretation Lack of accurate recording of which nurses looked after which infants (and when) made identification of the risk posed by being cared for by particular nurses difficult. If this had been clearer, it may have enabled earlier identification of the colonised nurse, avoiding subsequent cases. We highlight the benefit of using a case-control study which showed that most nurses had no association with colonised infants.
A survey to quantify wet loads after steam sterilisation processes in healthcare facilities J. Hosp. Infect. (IF 3.704) Pub Date : 2019-05-24 Josephus P.C.M. van Doornmalen, Francesco Tessarolo, Nicole Lapanaitis, Krist Henrotin, Agostino Inglese, Harry Oussoren, Rafael Queiroz de Souza
Wet loads after steam sterilisation of medical devices in health care facilities are unacceptable. However, little is known about their frequency in daily practice. Via four national sterilisation associations, in Australia (VIC SRACA), Belgium (VSZ), Italy (AIOS), and the Netherlands (VDSMH), an online survey was distributed. 78% of 125 hospital sterilisation facilities recognised wet loads, occurring at frequencies ranging from monthly to every load. Usually, wet loads were identified by the presence of water droplets; these loads were repacked and re-sterilised. Given the pervasiveness of wet loads, and their impact loads on reprocessing times and costs, strategies to reduce their frequency are needed.
Escherichia coli bloodstream infection outcomes and preventability; a 6 month prospective observational study J. Hosp. Infect. (IF 3.704) Pub Date : 2019-05-23 Patrick J. Lillie, Greta Johnson, Monica Ivan, Gavin D. Barlow, Peter J. Moss
Background Escherichia coli bloodstream infection (BSI) is a common and serious infection problem, with an incidence and antibiotic resistance increasing. Aim We sought to understand the drivers of outcomes and factors associated with preventable cases in our institution. Methods Between 1st November 2017 and 30th April 2018, cases of E. coli BSI in adults treated as inpatients at our institution were included in a prospective cohort. Clinical, demographic and laboratory features were recorded, with 7, 30 and 90 day mortality recorded, together with length of hospital stay post BSI. Qualitative data on preventability were reviewed independently by 2 infection specialists. Findings 195 cases in 188 patients were included in the analysis. Empirical antibiotics showed in vitro resistance in 30.9% of cases. 30 day mortality was 23.6%, with a median length of hospital stay of 7 days. In multivariable analysis 30 day mortality was associated with higher Charlson score, Residential home residence, higher respiratory rate and higher serum urea, whilst prolonged length of stay was associated with hospital acquired E. coli BSI. 50 patients were felt to have avoidable BSI, all of which were health care associated, with urinary catheter use, antibiotic related, and procedural complications being the areas of preventability. Conclusions E. coli BSI has an appreciable mortality, with little in the way of modifiable risk factors for mortality or prolonged hospital stay. Attention to urinary catheter use is likely to be the most useful way to reduce the incidence, but current UK reduction targets may be unachievable.
Whole genome sequencing of toxigenic Clostridium difficile in asymptomatic carriers: insights into possible role in transmission J. Hosp. Infect. (IF 3.704) Pub Date : 2018-10-22 F.D. Halstead, A. Ravi, N. Thomson, M. Nuur, K. Hughes, M. Brailey, B.A. Oppenheim
Background Estimates of the prevalence of asymptomatically carried Clostridium difficile in elderly patients in long-term care range from 0% to 51%. Asymptomatic carriage is possibly a risk factor for the development of infection, and there is ongoing debate surrounding the role of asymptomatic carriage in transmission. Aim To investigate the prevalence of asymptomatic carriage amongst patients residing in intermediate care (bedded) facilities (ICBFs), and to investigate whether asymptomatically carried C. difficile strains contribute to nosocomial C. difficile infection (CDI). Methods Stools were collected from eligible asymptomatic patients in ICBFs, and a subset was also processed from symptomatic patients accessing primary or secondary care outside of ICBFs. All samples were cultured for C. difficile, and resulting colonies were processed through whole genome sequencing. Findings In total, 151 asymptomatic patients were sampled, 22 of which were positive for C. difficile through stool culture, representing a carriage rate of 14.6%. Sequencing of these isolates, alongside 14 C. difficile polymerase chain reaction and culture-positive isolates from symptomatic individuals, revealed that all asymptomatic patients were carrying toxigenic C. difficile, and these strains were genetically similar to those from symptomatic patients. Conclusion This small study of asymptomatic carriage revealed a rectal asymptomatic carriage rate of 14.6% in patients nursed in ICBFs, and a high level of genetic similarity of these strains to those recovered from symptomatic patients. As such, asymptomatic carriers may be important for the transmission of symptomatic CDI, although it is acknowledged that this study was small, and many other factors govern whether C. difficile is carried asymptomatically or causes symptoms.
Burden of Clostridium (Clostridioides) difficile infection during inpatient stays in the USA between 2012 and 2016 J. Hosp. Infect. (IF 3.704) Pub Date : 2019-01-25 S. Mollard, L. Lurienne, S.M. Heimann, P-A. Bandinelli
Background The healthcare burden of Clostridium (Clostridioides) difficile infection (CDI) is high but not fully characterized. Aim To assess hospitalization costs, length of hospital stay (LOS) and in-hospital mortality attributable to CDI in the USA by analysing nationwide hospital discharge records over the 2012–2016 period. Methods A retrospective, observational study based on the Truven Health MarketScan Hospital Drug Database was conducted, in which 46,097 inpatient stays with a diagnosis of CDI were analysed. Costs, LOS and in-hospital mortality were studied for patients with either a principal or secondary (comorbidity) diagnosis of CDI, and for patients re-admitted because of CDI. If CDI was a comorbidity, its attributable burden was estimated by coarsened exact matching, comparing 17,273 CDI stays with 84,164 stays in a control group without a CDI diagnosis. Findings Inpatients for whom CDI was the main reason for hospitalization incurred mean costs of US$10,528 and an average LOS of 5.9 days. For CDI as a comorbidity, the mean additional cost was US$11,938 and the additional LOS was 4.4 days. CDI also increased the in-hospital mortality rate by 4.1%, on average. Conclusion This study is consistent with previous publications which demonstrated the high economic burden of CDI for healthcare settings and health insurance systems. When recorded as a comorbidity, CDI significantly increased hospital costs and LOS. These results highlight the need for innovative therapeutic approaches in the prevention and treatment of CDI.
Clostridium difficile-related hospitalizations and risk factors for in-hospital mortality in Spain between 2001 and 2015 J. Hosp. Infect. (IF 3.704) Pub Date : 2018-09-18 M.D. Esteban-Vasallo, J. de Miguel-Díez, A. López-de-Andrés, V. Hernández-Barrera, R. Jiménez-García
Aims To examine trends in the incidence, characteristics and in-hospital outcomes of Clostridium difficile infection (CDI) hospitalizations from 2001 to 2015, to compare clinical variables among patients according to the diagnosis position (primary or secondary) of CDI, and to identify factors associated with in-hospital mortality (IHM). Methods A retrospective study was performed using the Spanish National Hospital Discharge Database, 2001–2015. The study population included patients who had CDI as the primary or secondary diagnosis in their discharge report. Annual hospitalization rates were calculated and trends were assessed using Poisson regression models and Jointpoint analysis. Multi-variate logistic regression models were performed to identify variables associated with IHM. Findings In total, 49,347 hospital discharges were identified (52.31% females, 33.69% with CDI as the primary diagnosis). The rate of hospitalization increased from 3.9 cases per 100,000 inhabitants in 2001–2003 to 12.97 cases per 100,000 inhabitants in 2013–2015. Severity of CDI and mean cost per patient increased from 6.36% and 3750.11€ to 11.19% and 4340.91€, respectively, while IHM decreased from 12.66% to 10.66%. Age, Charlson Comorbidity Index, severity, length of hospital stay and mean cost were significantly higher in patients with a primary diagnosis of CDI. Irrespective of the CDI diagnosis position, IHM was associated with male sex, older age, comorbidities, readmission and severity of CDI. Primary diagnosis of CDI was associated with lower IHM (odds ratio 0.60; 95% confidence interval 0.56–0.65). Conclusion CDI-related hospitalization rates are increasing, leading to a high cost burden, although IHM has decreased in recent years. Factors associated with IHM should be considered in strategies for the prevention and management of CDI.
Hospital-acquired Clostridium difficile infection: an institutional costing analysis J. Hosp. Infect. (IF 3.704) Pub Date : 2019-01-25 K.B. Choi, K.N. Suh, K.A. Muldoon, V.R. Roth, A.J. Forster
Background Healthcare-acquired Clostridium difficile infection (HA-CDI) is a common infection and a financial burden on the healthcare system. Aim To estimate the hospital-based financial costs of HA-CDI by comparing time-fixed statistical models that attribute cost to the entire hospital stay to time-varying statistical models that adjust for the time between admission, diagnosis of HA-CDI, and discharge and that only attribute HA-CDI costs post diagnosis. Methods A retrospective cohort study was conducted (April 2008 to March 2011) using clinical and administrative costing data of inpatients (≥15 years) who were admitted to The Ottawa Hospital with stays >72 h. Two time-fixed analyses, ordinary least square regression and generalized linear regression, were contrasted with two time-dependent approaches using Kaplan–Meier survival curve. Findings A total of 49,888 admissions were included and 366 (0.73%) patients developed HA-CDI. Estimated total costs (Canadian dollars) from time-fixed models were as high as $74,928 per patient compared to $28,089 using a time-varying model, and these were 1.47-fold higher compared to a patient without HA-CDI (incremental cost $8,997 per patient). The overall annual institutional cost at The Ottawa Hospital associated with HA-CDI was as high as $10.07 million using time-fixed models and $1.62 million using time-varying models. Conclusion When calculating costs associated with HA-CDI, accounting for the time between admission, diagnosis, and discharge can substantially reduce the estimated institutional costs associated with HA-CDI.
Effect of using fidaxomicin on recurrent Clostridium difficile infection J. Hosp. Infect. (IF 3.704) Pub Date : 2019-01-04 M. Biggs, T. Iqbal, E. Holden, V. Clewer, M.I. Garvey
Fidaxomicin is a macrocyclic antibiotic licensed for treating Clostridium difficile infection (CDI). In the UK, fidaxomicin is often reserved for severe CDI or recurrences. At Queen Elizabeth Hospital Birmingham, all courses of fidaxomicin during 2017/2018 were reviewed. Thirty-eight patients received fidaxomicin, of which 64% responded to treatment when fidaxomicin was given during the first episode of mild CDI. Conversely, all patients with recurrent CDI failed treatment with fidaxomicin. There were mixed results for the use of fidaxomicin for severe CDI, with only 42% of patients responding. These results suggest that fidaxomicin is best suited as a treatment for mild CDI during a patient's first episode.
Effectiveness of behavioural interventions to reduce urinary tract infections and Escherichia coli bacteraemia for older adults across all care settings: a systematic review J. Hosp. Infect. (IF 3.704) Pub Date : 2018-10-22 L.F. Jones, J. Meyrick, J. Bath, O. Dunham, C.A.M. McNulty
Background Escherichia coli bacteraemia rates in the UK have risen; rates are highest among older adults. Previous urinary tract infections (UTIs) and catheterization are risk factors. Aim To examine effectiveness of behavioural interventions to reduce E. coli bacteraemia and/or symptomatic UTIs for older adults. Methods Sixteen databases, grey literature, and reference lists were searched. Titles and/or abstracts were scanned and selected papers were read fully to confirm suitability. Quality was assessed using Critical Appraisal Skills Programme guidelines and Scottish Intercollegiate Guidelines Network grading. Findings Twenty-one studies were reviewed, and all lacked methodological quality. Six multi-faceted hospital interventions including education, with audit and feedback or reminders reduced UTIs but only three supplied statements of significance. One study reported decreasing catheter-associated UTI (CAUTI) by 88% (F (1,20) = 7.25). Another study reported reductions in CAUTI from 11.17 to 10.53 during Phase I and by 0.39 during Phase II (χ2 = 254). A third study reported fewer UTIs per patient week (risk ratio = 0.39). Two hospital studies of online training and catheter insertion and care simulations decreased CAUTIs from 33 to 14 and from 10.40 to 0. Increasing nursing staff, community continence nurses, and catheter removal reminder stickers reduced infection. There were no studies examining prevention of E. coli bacteraemias. Conclusion The heterogeneity of studies means that one effective intervention cannot be recommended. We suggest that feedback should be considered because it facilitated reductions in UTI when used alone or in multi-faceted interventions including education, audit or catheter removal protocols. Multi-faceted education is likely to be effective. Catheter removal protocols, increased staffing, and patient education require further evaluation.
Indwelling urethral versus suprapubic catheters in nursing home residents: determining the safest option for long-term use J. Hosp. Infect. (IF 3.704) Pub Date : 2018-07-26 K.E. Gibson, S. Neill, E. Tuma, J. Meddings, L. Mody
Background The incidence of infectious complications has not been previously compared for two types of common urinary catheters used in the long-term care setting: indwelling urethral catheters and suprapubic catheters. Aim To compare catheter-associated urinary tract infection (CAUTI) rates and multidrug-resistant organism (MDRO) colonization between nursing home residents with indwelling urethral and suprapubic catheters. Methods Participants included 418 nursing home residents with an indwelling device enrolled in a previously published prospective targeted infection prevention study conducted between 2010 and 2013. Resident age, gender, function, comorbidities, and information on infections, antibiotic use, and recent hospitalizations were obtained at study enrolment, day 14, and every 30 days thereafter for up to one year. Microbiological samples were obtained from several anatomic sites at each visit. Cox proportional hazard models were adjusted for facility-level clustering and other covariates. Findings In all, 208 study participants had an indwelling urinary catheter, contributing 21,700 device-days; 173 (83%) with a urethral catheter, 35 (17%) with a suprapubic catheter. After covariate adjustment, the suprapubic group had a lower incidence of CAUTI (6.6 vs 8.8 per 1000 device-days; P = 0.05), were half as likely to be hospitalized (hazard ratio (HR) = 0.46; P < 0.01) and were 23% less likely to have had antibiotics in the past 30 days (HR = 0.77; P = 0.02). Among residents catheterized ≥90 days, the mean number of MDROs isolated in the suprapubic group was significantly higher than in the urethral group (0.57 vs 0.44; P = 0.01). Ciprofloxacin-resistant Gram-negative bacilli were frequent in both groups. Conclusion Residents with a suprapubic catheter may have fewer CAUTIs, less hospitalization and less antibiotic use, but are more likely colonized with MDROs.
Automated detection of outbreaks of antimicrobial-resistant bacteria in Japan J. Hosp. Infect. (IF 3.704) Pub Date : 2018-10-12 A. Tsutsui, K. Yahara, A. Clark, K. Fujimoto, S. Kawakami, H. Chikumi, M. Iguchi, T. Yagi, M.A. Baker, T. O'Brien, J. Stelling
Background Hospital outbreaks of antimicrobial-resistant (AMR) bacteria should be detected and controlled as early as possible. Aim To develop a framework for automatic detection of AMR outbreaks in hospitals. Methods Japan Nosocomial Infections Surveillance (JANIS) is one of the largest national AMR surveillance systems in the world. For this study, all bacterial data in the JANIS database were extracted between 2011 and 2016. WHONET, a free software for the management of microbiology data, and SaTScan, a free cluster detection tool embedded in WHONET, were used to analyse 2015–2016 data of eligible hospitals. Manual evaluation and validation of 10 representative hospitals around Japan were then performed using 2011–2016 data. Findings Data from 1031 hospitals were studied; mid-sized (200–499 beds) hospitals accounted for 60%, followed by large hospitals (≥500 beds; 24%) and small hospitals (<200 beds; 16%). More clusters were detected in large hospitals. Most of the clusters included five or fewer patients. From the in-depth analysis of 10 hospitals, ∼80% of the detected clusters were unrecognized by infection control staff because the bacterial species involved were not included in the priority pathogen list for routine surveillance. In two hospitals, clusters of more susceptible isolates were detected before outbreaks of more resistant pathogens. Conclusion WHONET-SaTScan can automatically detect clusters of epidemiologically related patients based on isolate resistance profiles beyond lists of high-priority AMR pathogens. If clusters of more susceptible isolates can be detected, it may allow early intervention in infection control practices before outbreaks of more resistant pathogens occur.
Transferring knowledge into practice: a multi-modal, multi-centre intervention for enhancing nurses' infection control competency in Bangladesh J. Hosp. Infect. (IF 3.704) Pub Date : 2018-08-03 L. Ara, F. Bashar, M.E.H. Tamal, N.K.A. Siddiquee, S.M.N. Mowla, S.A. Sarker
Background Nurses are considered as the key to infection prevention as they play a major role in treatment as well as taking care of patients. Aim To assess the role of a multi-modal intervention (MMI) in improving nurses' competency and adherence to standard infection control practices in Bangladesh. Methods The study adopted a pretest–post-test intervention approach, in three different periods (from 2012 to 2017) in five hospitals (two public, two private, and one autonomous) in Bangladesh. Each study period was divided into three phases: pretest, MMI, and post-test. Data were collected on 642 nurses using direct observation method through a structured checklist. Findings After implementing the MMI, overall hand hygiene compliance significantly increased before patient contact (from 1.3% to 50.2%; P < 0.000) and after patient contact (from 2.8% to 59.6%; P < 0.000). Remarkable improvements were also achieved in adherence to use of gloves (from 14.6% to 57.6%; P < 0.000), maintaining sterility of equipment during aseptic techniques (from 34.9% to 86%; P < 0.000), biomedical waste segregation (from 1.8% to 81.3%; P < 0.000) and labelling of procedural sites (from 0% to 85.7%; P < 0.000). Moreover, needlestick injury rate notably decreased (from 6.2% to 0.6%; P < 0.000). Conclusion MMI can play a vital role in improving nurses' compliance with the standard infection control practices. Such context-specific interventions, which are crucial for preventing healthcare-associated infections and for decreasing occupational hazards, should be replicated in resource-poor countries for achieving universal health coverage by 2030.
Combining detergent/disinfectant with microfibre material provides a better control of microbial contaminants on surfaces than the use of water alone J. Hosp. Infect. (IF 3.704) Pub Date : 2019-05-18 Robertson A, Barrell M, Maillard J-Y
The use of microfibre cloths with either water, detergent or disinfectant is currently recommended for hospital cleaning. We explore the efficacy of a microfibre cloth with either water or detergent/disinfectant or sporicidal products using the ASTM2967-15 standard against Staphylococcus aureus, Acinetobacter baumannii and spores Clostridium difficile spores. The use of detergent/disinfectant or sporicidal products had a significantly (ANOVA, p<0.001) better activity than water alone in reducing bacteria and spores’ viability, and in reducing the transfer microorganisms between surfaces. The use of water alone with a microfibre cloth is less effective and should not replace the use of biocidal products.
Evaluation of a Web-Based Tool for Labelling Potential Hospital Outbreaks, a Mixed Methods Study J. Hosp. Infect. (IF 3.704) Pub Date : 2019-05-13 Brice Leclère, David L. Buckeridge, Didier Lepelletier
Background Labelling outbreaks in surveillance data is necessary to train advanced analytical methods for outbreak detection, but there is a lack of software tools dedicated to this task. Aim The goal of this study was to evaluate the usability of a web-based tool by infection control practitioners for labelling potential outbreaks. Methods A mixed-methods design was used to evaluate how 25 experts from France and Canada interacted with a web-based application to identify potential outbreaks. Each expert used the application to retrospectively review eleven to twelve one-year incidence time series from 23 different types of microorganisms. The interactions between the users and the application were recorded and analysed using mixed-effect models. The users’ comments were analysed via qualitative methods. Findings Over the 240 reviews completed, 439 potential outbreaks were labelled, about half of with a high probability. A significant heterogeneity was observed between users regarding their answers and behaviours (evaluation time, usage of the different options). A significant learning effect was also observed on the experts’ interactions with the tool, but it did not seem to impact their answers. The content analysis of the comments highlighted the difficulty of early outbreak identification for practitioners, but also the potential utility of web applications such as the one evaluated for routine surveillance. Conclusion The interactive web application was both usable and useful for infection control practitioners. Its implementation in routine practice could help professionals identify potential outbreaks while creating data to train automated detection algorithms.
Spread of ESBL-producing Escherichia coli in nursing home residents in Ireland and the Netherlands may reflect infrastructural differences J. Hosp. Infect. (IF 3.704) Pub Date : 2019-05-09 Elisabeth M. Terveer, Muireann Fallon, Margriet E.M. Kraakman, Angela Ormond, Margaret Fitzpatrick, Monique A.A. Caljouw, Alan Martin, Sofie M. van Dorp, Man C. Wong, Ed J. Kuijper, Fidelma Fitzpatrick
A prevalence study in two nursing homes (ine each in the Netherlands and Ireland) found four (11%) Dutch and six (9%) Irish residents colonised with 11 extended-spectrum B-lactamase (ESBL)-producing Escherichia coli, ten containing CTX-M-15. Four Dutch isolates, from three residents of the same ward belonged to E. coli O25:H4, sequence type (ST) 131 and were part of the same cluster type by whole genome sequencing. Four Irish residents on three different wards were colonised with an identical E. coli O89:H9, ST131, complex type 1478. Cross-transmission between three Irish wards may reflect differences in nursing home infrastructure specifically communal areas and multi-bedded resident rooms.
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