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  • Sources of viral respiratory infections in Canadian acute care hospital healthcare personnel
    J. Hosp. Infect. (IF 3.704) Pub Date : 2020-01-16
    Steven Buckrell; Brenda L. Coleman; Shelly A. McNeil; Kevin Katz; Matthew P. Muller; Andrew Simor; Mark Loeb; Jeff Powis; Stefan P. Kuster; Julia M. Di Bella; Kristy KL. Coleman; Steven J. Drews; Philipp Kohler; Allison McGeer

    Background Viral respiratory illnesses are common causes of outbreaks and can be fatal to some patients. Aim To investigate the association between laboratory-confirmed viral respiratory infections and potential sources of exposure during the previous 7 days. Methods In this nested case-control analysis, healthcare personnel from 9 Canadian hospitals who developed acute respiratory illnesses during the winters of 2010/11-2013/14 submitted swabs that were tested for viral pathogens. Associated illness diaries and non-ill participants’ weekly diaries provided information on contact with people displaying symptoms of acute respiratory illness in the previous week. Conditional logistic regression assessed the association between cases, who were matched by study week and site with controls with no respiratory symptoms. Findings There were 814 laboratory-confirmed viral respiratory illnesses. The adjusted odds ratio (aOR) of a viral illness was higher for healthcare personnel reporting exposures to ill household members (7.0, 95% CI 5.4, 9.1), co-workers (3.4, 95% CI 2.4, 4.7) or other social contacts (5.1, 95% CI 3.6, 7.1). Exposures to patients with respiratory illness were not associated with infection (aOR 0.9, 95% CI 0.7, 1.2), however healthcare personnel with direct patient contact did have higher odds (aOR 1.3, 95% CI 1.1, 1.6). The aORs for exposure and for direct patient contact were similar for illnesses caused by influenza. Conclusion Community and co-worker contacts are important sources of viral respiratory illness in healthcare personnel while exposure to patients with recognized respiratory infections is not associated. The comparatively low risk associated with direct patient contact may reflect transmission related to asymptomatic patients or unrecognized infections.

  • Imaging in the investigation and management of Staphylococcus aureus bacteraemia: A role for advanced imaging techniques
    J. Hosp. Infect. (IF 3.704) Pub Date : 2020-01-14
    Anna L. Goodman; Gary J. Cook; Vicky Goh

    Staphylococcus aureus bacteraemia (SAB) continues to affect ∼25 000 patients in the UK per year with a high crude mortality of 30% at 90 days. Prompt source control improves outcomes in sepsis and SAB and is included in sepsis guidelines. A recent clinical trial of adjunctive antibiotic treatment in SAB found that the majority of recurrences of SAB were associated with a failure of source management. In this condition, the ability to control the source of infection may be limited by the ability to detect a focus of infection. Echocardiogram is now a routinely used tool to detect such unknown foci in the form of unexpected infectious vegetations. We review the literature to explore the utility of advanced imaging techniques, such as 18F-FDG PET/CT and MRI (including whole-body MRI, WB-MRI), to detect foci which may otherwise be missed. As unknown foci are associated with increased mortality, we propose that increasing the detection of foci could enable improved source control and result in improved outcomes in SAB.

  • Direct Medical Burden of Antimicrobial Resistant Healthcare-Associated Infections - Empirical Evidence from China
    J. Hosp. Infect. (IF 3.704) Pub Date : 2020-01-10
    Xinliang Liui; Dan Cu; Hao Li; Quan Wang; Zongfu Mao; Liang Fang; Nili Ren; Jing Sune

    Background Antimicrobial resistance (AMR) and healthcare-associated infection (HAI) are among the biggest global public health challenges, and overlap widely. These infections cause significant morbidity and mortality, put pressure on health systems, and incur rising direct and indirect costs. Objective This study analyzed the direct medical burden attributable to antimicrobial-resistant healthcare-associated infections in Chinese public tertiary hospitals, and aimed to inform both the medical regulators and hospital managers for better control of HAI and containment of AMR. Methods The propensity score matching method (γ=0.25σ, nearest neighbor 1:1 matching) was applied to conduct a retrospective cohort study in five public tertiary hospitals in the Hubei province of China during 2013-2015. Descriptive analysis, Pearson Chi-Square test, Mann–Whitney U test, Wilcoxon signed-rank test and paired/independent Z/T test were conducted. The statistically significant level was set at P < 0.05. Results From 2013 to 2015 in overall, the additional total medical expenditure per HAI-AMR inpatient was US$ 15 557.25 compared with that of the non-HAIs, and the additional length of per hospital stay of the HAI-AMR inpatient was 41 days compared with that of the non-HAIs (P<0.001). Conclusions In combination with AMR, HAI caused significant additional medical expenses and affected the turnover rate of hospital beds. Most of the increased medical costs fell to patients and their families. These findings call for more effective control of HAI and containment of AMR. A national study is needed to estimate the medical, social and economic burden of HAI in combination with AMR.

  • Antimicrobial Stewardship in Care Homes: Outcomes of Importance to Stakeholders
    J. Hosp. Infect. (IF 3.704) Pub Date : 2020-01-10
    Hoa Q. Nguyen; Declan T. Bradley; Michael M. Tunney; Carmel M. Hughes

    Background Heterogeneity of outcomes measured in trials to improve antimicrobial stewardship (AMS) in care homes has compromised quality of evidence. A core outcome set (COS) is needed to facilitate interpretation and synthesis of evidence in this area. Aim To determine outcomes deemed important by relevant stakeholders for interventions aimed at improving AMS in care homes, and to produce a refined list of outcomes that could be considered for use in future research. Methods Semi-structured face-to-face or telephone interviews were conducted with key stakeholders. Outcomes reported in previous randomised controlled trials (RCTs) of AMS in care homes were included in a topic guide for interviews. Content analysis was undertaken to identify potential outcomes suggested by participants, followed by further review. Findings Twenty-seven outcomes reported in RCTs were refined into a list of 12 overarching outcomes. Interviews with participants (six researchers, 31 healthcare professionals, and four family members of care home residents) identified 40 additional outcomes that were important to them. From these 52 outcomes, the total number of antimicrobials, the appropriateness of antimicrobial prescribing and adherence to guidelines were highlighted by most participants. After reviewing all 52 outcomes, a refined list of 14 outcomes potentially feasible for use in AMS trials in care homes was generated. Conclusion A number of potential outcomes for AMS in care homes, some of which had not been reported in previous studies, were identified. The refined list of 14 outcomes will be used in a future study to agree a COS for care home AMS trials.

  • Accuracy of the ELITe MGB® assays for the detection of carbapenemases, CTX-M, Staphylococcus aureus and mecA/C genes directly from respiratory samples
    J. Hosp. Infect. (IF 3.704) Pub Date : 2020-01-10
    Matteo Boattini; Gabriele Bianco; Marco Iannaccone; Lorena Charrier; André Almeida; Gianfranco De Intinis; Rossana Cavallo; Cristina Costa

    Introduction Bacterial lower respiratory tract infections (BLRTI) may represent serious clinical conditions which can lead to respiratory failure, ICU admission and high hospital costs. The detection of carbapenemase- and extended-spectrum β-lactamase (ESBL)-producing Enterobacterales, as well as methicillin-resistant Staphylococcus aureus (MRSA), has become a major issue especially in health care associated infections. This study aimed to determine whether molecular assays could detect genes encoding carbapenemases, ESBL and MRSA, directly from respiratory samples, so as to expedite appropriate therapy and infection control for patients with BLRTI. Methods The CRE, ESBL and MRSA/SA ELITe MGB® assays were performed directly on 354 respiratory specimens sampled from 318 patients admitted with BLRTI. Molecular results were compared to routine culture-based diagnostics results. Results Positive (PPV) and negative (NPV) predictive values of the CRE ELITe MGB® kit were 75.9% [IC 95%: 60.3-86.7] and 100%, respectively. PPV and NPV of the ESBL ELITe MGB® kit were 80.8% [IC 95%: 63.6-91] and 99.1% [IC 95%: 96.6-99.8], respectively. PPV and NPV predictive values of the MRSA/SA ELITe MGB® kit were 91.7% [IC 95%: 73.7-97.7]/100% and 98.3% [IC 95%: 89.8-99.3]/96.8% [IC 95%: 81.6-99.5], respectively. Discussion Validity assessment of molecular assays detecting the main antibiotic resistance genes directly from respiratory samples showed a high accuracy when compared to culture-based results. Molecular assays detecting the main carbapenemase, ESBL, S. aureus and methicillin resistance encoding genes provide an interesting tool with potential to expedite optimization of antibiotic therapy and infection control practices in patients with BLRTI.

  • Risk factors for Klebsiella pneumoniae carbapenemase (KPC) gene acquisition and clinical outcomes across multiple bacterial species
    J. Hosp. Infect. (IF 3.704) Pub Date : 2020-01-10
    Amy J. Mathers; Kasi Vegesana; Ian German Mesner; John Ainsworth; Aaron Pannone; Derrick W. Crook; Costi D. Sifri; Anna Sheppard; Nicole Stoesser; Tim Peto; A. Sarah Walker; David W. Eyre

    Introduction Risk factors for carbapenemase-producing Enterobacteriales (CPE) acquisition/infection and associated clinical outcomes have been evaluated in the context of clonal, species-specific outbreaks; equivalent analyses for complex, multi-species outbreaks, which are increasingly common, are lacking. Methods We performed, Dec 2010-Jan 2017, a case-control study of Klebsiella pneumoniae carbapenemase (KPC)-producing organism (KPCO) acquisition using electronic health records from inpatients in a US academic medical centre and long-term acute care hospital (LTACH) with ongoing multi-species KPCO transmission despite a robust CPE screening programme. Cases had a first KPCO-positive culture >48 hours after admission, and included colonizations and infections (defined by clinical records). Controls had ≥2 negative peri-rectal screens and no positive cultures. Risk-factors for KPCO acquisition, first infection following acquisition, and 14-day mortality following each infection episode were identified using multivariable logistic regression. Results In 303 cases (89 with ≥1 infection) and 5929 controls, risk-factors for KPCO acquisition included: longer inpatient stay, transfusion, complex thoracic pathology, mechanical ventilation, dialysis, and exposure to carbapenems and β-lactam/β-lactamase inhibitors. Exposure to other KPCO-colonized patients was only a risk factor for acquisition in a single unit, suggesting that direct patient-to-patient transmission did not play a major role. There were 15 species of KPCO; 61 (20%) cases were colonized/infected with >1 species. 14-day mortality following non-urinary KPCO infection was 20% (20/97 episodes) and was associated with failure to achieve source control. Conclusions Healthcare exposures, antimicrobials and invasive procedures increased risk of KPCO colonization/infection suggesting potential targets for infection control interventions in multi-species outbreaks. Evidence for patient-to-patient transmission was limited.

  • Surveillance of Surgical Site Infection in a teaching hospital in Ghana: A prospective cohort study.
    J. Hosp. Infect. (IF 3.704) Pub Date : 2020-01-10
    Antoinette Bediako-Bowan; Enid Owusu; Samuel Debrah; Anne Kjerulf; Mercy Jemima Newman; Jørgen Anders Lindholm Kurtzhals; Kåre Mølbak

    Background Surveillance systems for surgical site infections (SSI), as a measure of patient safety, helps health institutions devise strategies to reduce or prevent them. No surveillance systems exist to monitor SSI in Ghana. Aim This study aimed to establish a system for monitoring trends and detecting outbreaks in order to create awareness of and control SSI. Methods An active 30-day surveillance was undertaken at the general surgical unit of the Korle-Bu Teaching Hospital, from 1st July 2017 to 31st December 2018 to identify SSI. It involved a daily in-patient surveillance of patients who had a surgical procedure, followed by a post discharge surveillance by means of a healthcare personnel-based survey and a patient-based telephone survey. We provided quarterly feedback of results to surgeons. Findings Among the 3267 patients included, 331 were identified with an SSI, a 10% incidence risk. Patients who acquired an SSI experienced increased morbidity including nine extra days in hospital and an adjusted relative mortality risk of 1.2 (95% CI 0.8-1.9) (p=0.3) compared to patients without SSI. Forty-nine percent (161/331) of SSI were diagnosed post-discharge using the healthcare personnel-based survey. The patient-based telephone survey contributed 12 additional cases. SSI incidence risk reduced from 12.8% to 7.5% over the study period. Conclusion Post-discharge surveillance is feasible using existing healthcare personnel, and the results highlight the high risk and burden of SSI in Ghana. A surveillance system with feedback for monitoring SSI may contribute to reducing SSI, however firm conclusions as regards the impact need longer observation time.

  • Management of peripheral venous catheters and implementation of guidelines in Germany: a national survey
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-27
    Seven Johannes Sam Aghdassi; Christine Geffers; Michael Behnke; Alexander Gropmann; Petra Gastmeier; Tobias Siegfried Kramer

    Background Due to their frequent use, peripheral venous catheters (PVCs) are relevant regarding catheter-related infections and their prevention. In 2017, revised national guidelines for the prevention of PVC-related infections were published in Germany. Aim Our objective was to describe the practices of PVC handling and assess the implementation of national guidelines for prevention of PVC-related infections in German acute care hospitals, 10 months after their release. Methods An online survey on the management of PVCs in hospital wards was conducted. For this, 1191 acute care hospitals participating in the national surveillance system for healthcare-associated infections in Germany were invited to participate. Each hospital was asked to complete the survey for an intensive care unit (ICU), as well as a medical and surgical ward. Participation in the survey was voluntary. Findings Altogether, 701 hospitals (59% response rate) participated and provided data on 1449 wards (599 ICUs, 446 medical wards, 404 surgical wards). Around 43% of wards reported having implemented the new national guidelines where necessary. Structured surveillance for PVC-associated infections was established in only 21% of wards. While 94% of wards reported including aspects of PVC handling in their general infection prevention education, questions on the methods of training yielded diverse results. Around 59% of wards reported not routinely using a combination of alcohol and a remanant disinfectant for skin disinfection before PVC insertion. Conclusion Generally, PVC management in Germany is well organized. However, potentials for improvement were identified especially considering surveillance and implementation of selected national guidelines.

  • Faecal Microbiota Transplantation for Recurrent Clostridioides difficile Infection: Experience with Lyophilized Oral Capsules
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-26
    E. Reigadas; E. Bouza; M. Olmedo; S. Vázquez-Cuesta; L. Villar-Gómara; L. Alcalá; M. Marín; S. Rodríguez-Fernández; M. Valerio; P. Muñoz

    Background Faecal microbiota transplantation (FMT) is a highly effective approach for refractory and recurrent Clostridioides difficile infection (CDI). Despite its excellent efficacy, FMT is not yet a routine procedure in most centres. There is very little experience with FMT based on lyophilized capsules, and data from European institutions are lacking. Here, we describe our experience with FMT to treat recurrent CDI using lyophilized oral capsules. Methods We analyzed a prospectively recorded single-center case series of patients with recurrent CDI who underwent FMT between January 2018 and May 2019. The primary outcome was defined as resolution of CDI without recurrences over a 2-month period. Overall resolution was defined as resolution of diarrhea without recurrence of CDI within 2 months after a further cycle of FMT. The FMT process involved oral ingestion of 4-5 lyophilized capsules in a single dose. All stool donors were rigorously screened. Results FMT was performed in 32 patients. There were no procedure-related adverse events, and no complications were observed. Primary cure was achieved in 81.3% of patients, and the overall cure rate was 87.5%. FMT via lyophilized capsules was well tolerated. No FMT procedure–related adverse events and no further complications were observed for lyophilized capsule FMT. Conclusions Our initial clinical experience suggests that FMT based on oral lyophilized preparations is a safe, well-tolerated, and highly effective treatment for recurrent CDI. Administration of oral lyophilized capsules seems feasible in hospital routine and will enable FMT to be more widely used.

  • Laminar flow does not affect risk of prosthetic joint infection after primary total knee replacement in Asian patients
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-24
    B.J.X. Teo; Y.L. Woo; J.K.S. Phua; H.-C. Chong; W. Yeo; A.H.C. Tan

    Background The role of laminar flow (LAF) is contradictory with several studies failing to replicate risk reduction. The 2016 World Health Organization guidelines identified this lack of good comparative studies. Aim To analyse the use of LAF and the incidence of prosthetic joint infections (PJIs) in Asian patients undergoing total knee replacement (TKR). Methods Patients who underwent standard cemented posterior-stabilized TKR from 2004 to 2014 were reviewed from a prospectively collected single-surgeon database. Revision, traumatic and/or inflammatory cases were excluded. The type of airflow used was identified. The technique and surgical protocol for all procedures were similar. Tourniquets and inserted drains were routinely used. Patellar resurfacing was not performed. Patients were followed up at the outpatient clinics at regular intervals up to two years. At each visit, the patient was assessed for the occurrence of PJI. Findings Of the 1028 procedures, 453 (44.1%) were performed in an LAF operating theatre (OT) whereas 575 (55.9%) were performed in a non-LAF OT. There were no significant differences between the two groups in terms of age, gender, or side of procedure. The overall incidence of PJI was 0.6% (N = 6). Three (50%) occurred in an LAF OT whereas three (50%) occurred in a non-LAF OT. This was not statistically significant. Conclusion Laminar flow systems are costly to procure and maintain. With modern aseptic techniques, patient optimization, and use of prophylactic antibiotics, laminar flow does not appear to further reduce risk of PJI in Asian patients after TKR.

  • Asymptomatic carriage of extensively drug-resistant bacteria (eXDR), a simple way to assess spontaneous clearance
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-24
    Eric Farfour; Anne-Gaëlle Si Larbi; Jeanne Couturier; Marion Lecuru; Jean-Winoc Decousser; Aurélie Renvoise; Frédéric Faibis; Christine Lawrence; Simone Nerome; Didier Lecointe

    The duration of eXDR carriage depends on several factors that might be difficult to recover. We aim to assess the duration of eXDR carriage by using a simple to recover parameter: the number of consecutive negative screening. 131 eXDR carriers (51 VRE and 80 CPE) were included. The number of consecutive negative screenings was strongly associated with eXDR clearance. All patients displaying at least three negative screenings over a seven-month period were never screened positive thereafter. Taking into account the number of negative screenings as a part of a case-by-case risk assessment would be helpful for the decision to maintain or lift eXDR-focused precautions.

  • Testing of the WHO Infection Prevention and Control Assessment Framework at the Acute Health Care Facility Level
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-21
    S. Tomczyk; S. Aghdassi; J. Storr; S. Hansen; A.J. Stewardson; P. Bischoff; P. Gastmeier; B. Allegranzi

    Background Monitoring and evaluation are an essential part of infection prevention and control (IPC) implementation. We developed an IPC assessment framework (IPACF) to support the World Health Organization (WHO) Guidelines on IPC Core Components implementation in acute health care facilities. Aim We aimed to evaluate the usability and reliability of the IPCAF tool for global use. Methods The IPCAF is a questionnaire with a scoring system to measure the level of IPC implementation according to the eight WHO core components. The tool was qualitatively pre-tested, revised and selectively translated. A convenience sample of hospitals was invited to participate in the final testing. At least two IPC professionals from each hospital independently completed the IPCAF and a usability questionnaire online. The tool’s internal consistency and inter-observer reliability or intra-class correlation coefficient (ICC) were assessed and usability questions were descriptively summarised. Findings A total of 46 countries, 181 hospitals, and 324 individuals participated; 52 (16%) and 55 (17%) individual respondents came from low- and lower-middle income countries, respectively. 52% took less than one hour to complete the IPCAF. Overall, we found adequate internal consistency and a high ICC (0.92 [95% CI: 0.89-0.94]). Ten individual questions had poor reliability (ICCs < 0.4), which were considered for revision according to usability feedback and expert opinion. Conclusions The WHO IPCAF was tested using a robust global study. We believe this enables it to be a more effective tool for IPC improvement in health care facilities.

  • Can we explain environmental contamination by particular traits associated with patients?
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-20
    Benoit Pilmis; Typhaine Billard-Pomares; Maelyss Martin; Christelle Clarempuy; Celine Lemezo; Christelle Saint-Marc; Nathalie Bourlon; Delphine Seytre; Etienne Carbonnelle; Jean-Ralph Zahar

    Background Little is known about patient risk factors associated with environmental contamination. The aim of this study was to both evaluate the rate of environmental contamination and to investigate individual risk factors. Methods We conducted a prospective cohort study. Each day, 5 rooms occupied by patients were selected. Five critical surfaces were systematically swabbed twice a day before and after cleaning. For each included patients’ clinical characteristics were collected. Logisitic regression was performed to evaluate the association between environmental contamination and patients’ characteristics. Results One hundred and seven consecutive patients were included and 1052 environmental samples were performed. Nineteen (18%) patients were known previously colonized/infected with a multidrug-resistant organism (MDRO). Respectively, 723 (69%) and 112 (11%) samples grew with ≥1cfu/cm2 and >2.5cfu/cm2 bacteria, resulting in 62 (58%) contaminated rooms. Considering positive samples with at least one pathogenic bacterium, 16 (15%) rooms were contaminated. By univariate and multivariate analysis, no variables analyzed were associated with the environmental contamination. Considering contaminated rooms with > 2.5 cfu/cm2, 3 factors were protective for environmental contamination: known MDRO carriers/infected patients (OR=0.25, 95%CI 0.09-0.72, p=0.01), patients with urinary catheter (OR=0.19, 95%CI 0.04-0.89,p=0.03) and hospitalization in single room (OR=0.3, 95%CI 0.15-0.6, p<0.001). Conclusions Our study conducted in a non-outbreak situation, show a low rate of environmental contamination with pathogenic bacteria. Only 11% of our environmental samples grew with more than 2.5cfu/cm2, and they were related to non-pathogenic bacteria. We were unable to identify risk factors associated with the environmental contamination.

  • Excess burden associated with Clostridioides difficile infection in haematological patients occurring during hospitalization with induction chemotherapy in the United States
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-20
    Lola Duhalde; Lise Lurienne; Sebastian M. Wingen-Heimann; Lucien Guillou; Renaud Buffet; Pierre-Alain Bandinelli

    BACKGROUND Patients with haematological diseases are at high risk of developing Clostridioides difficile infection (CDI). AIM The study aim was to describe excess length of stay and costs associated with CDI during the hospital stay for induction chemotherapy in the United States (US). METHODS A retrospective analysis was conducted utilizing data from US databases of Truven Health Analytics®. Comprehensive hospitalization data of patients with induction chemotherapy due to acute myeloid leukaemia (AML), acute lymphoblastic leukaemia, Hodgkin lymphoma and non-Hodgkin lymphoma (NHL) were analyzed. Patients with CDI occurring during the hospital stay were compared to controls through a case-control comparison of the direct treatment costs and length of stay was performed with an exact matching algorithm. FINDINGS 2,611 patients were included between 01/2014 and 12/2017. NHL (43.5%) and AML (38.4%) were the predominant underlying diseases and 15% of patients received a stem cell transplantation. During the matching, 105 CDI cases (CDI+) were compared with 801 controls (CDI-). On average, hospitalization costs were increased by US$36,113 in CDI+ compared to CDI- patients (p=0.009) and patients with CDI spent on average 8.9 additional days in hospital (p=0.003). CONCLUSION The findings highlight a significant burden associated with CDI in haematological patients undergoing induction chemotherapy in the US. There is an important need for prevention of CDI in this specific patient population.

  • Risk factors for cerebrospinal fluid shunt infections during an outbreak: A case control study
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-20
    McAlpine AK; Sauve LJ; Collet JC; D.M. Goldfarb; Guest E; McDonald PJ; Zheng A; Srigley JA

    Background There are few published reports of cerebrospinal fluid (CSF) shunt infection outbreaks. In 2017-2018, British Columbia Children’s Hospital (BCCH) experienced an increase in CSF shunt infections co-incident with a move to new operating rooms and a change in shunt catheters used. Aims To describe how an outbreak was detected, investigations done to determine the cause, risk factors associated with CSF shunt infection during the outbreak, and changes implemented to attempt to control it. Methods Retrospective case-control study. Population included patients who underwent new shunt insertion or revision. Univariate logistic regression models were fitted for each of the variables. Associations with p-values less than 0.2 were considered of potential interest for further investigation. Findings There were 6 cases of CSF shunt infection and 19 controls. The causative organism was different in each case. The only risk factors that met criteria for further investigation were being a neonate at the time of surgery (odds ratio [OR] 9.0, 95% confidence interval [CI] 0.7-125.3, p=0.10) and the presence of gastrointestinal disease (OR 3.8, 95% CI 0.5-26.2, p=0.18). No association was found with the operating room used or the surgical staff. In response to the outbreak, human traffic through the operating rooms was limited, rigid adherence to the wearing of surgical masks was enforced, and return to the previous CSF shunt catheters used was implemented. Conclusion No modifiable risk factors were associated with CSF shunt infection. After implementation of surgical protocol changes, no further cases of CSF shunt infection linked to the outbreak were identified.

  • Economic Evaluation of Vancomycin-Resistant Enterococci (VRE) Control Practices: A Systematic Review
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-17
    Colin MacDougall; Jennie Johnstone; Chatura Prematunge; Kwaku Adomako; Emily Nadolny; Eva Truong; Arezou Saedi; Gary Garber; Beate Sander

    Background Preventing vancomycin-resistant enterococci (VRE) infection is a healthcare priority. However, the cost-effectiveness of VRE control interventions is unclear. Aim To synthesize evidence on economic evaluation of VRE control practices such as screening, contact precautions, patient cohorting, and others. Methods We searched literature from January 1985 to June 2018, and included economic evaluations of VRE control practices in hospital settings, published in English. Findings A total of 4,711 articles were screened; 9 primary studies met our criteria. All studies evaluated some form of VRE screening and contact precautions, in populations ranging from single hospital wards (or select patient groups) to multiple health care facilities. There was significant variability in the interventions and comparisons used. Most studies (n=7) conducted a cost-effectiveness analysis; two studies were cost-consequence studies. All economic evaluations were from the hospital perspective. Four studies found implementing enhanced VRE-specific control practices to be cost-effective/cost-saving and two studies found that discontinuing VRE-specific control practices was not cost-effective. Three studies found decreasing VRE-specific control practices to be cost-effective/cost-saving. The quality of the included studies was generally low according to the JBI checklist for economic evaluations; major limitations included risks of bias in intervention effect estimates, and a lack of sensitivity analyses. Conclusion Most studies show that some form of VRE screening and use of Contact Precautions is cost-effective. The low study quality and heterogeneity of interventions and comparators precludes definitive conclusions about the cost effectiveness of specific VRE control interventions. Additional high-quality economic evaluations are needed to strengthen the available evidence.

  • Core genome MLST as an essential tool in a high cost livestock associated MRSA CC398 hospital outbreak
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-16
    Marie Louise Slott Jensen; Marianne Nielsine Skov; Helle Pries Kristiansen; Annette Toft; Hanne Lundgaard; Heidi Gumpert; Henrik Westh; Anette Holm; Hans Jørn Kolmos; Michael Kemp

    Background Livestock-associated meticillin resistant Staphylococcus aureus (LA-MRSA) CC398 can be transmitted and cause morbidity and mortality in hospitals. The economic cost of stopping hospital transmission of LA-MRSA CC398 is poorly described. Early detection of transmission may limit the extent of the intervention. Aim. The aims of this study were to evaluate core genome MLST (cgMLST) for detecting transmission chains and to estimate the costs for interventions to prevent further spread after discovery of hospital transmission of LA-MRSA CC398. Methods Five patients were involved in two episodes of transmission of LA-MRSA CC398 in a hospital. Standard interventions including MRSA-screening of patients and healthcare-workers were initiated. Whole genome sequences of the five isolates and 17 epidemiologically unrelated MRSA CC398 isolates from other hospitalized patients were analysed by single-nucleotide polymorphism (SNP)-comparisons and cgMLST. The economic costs of constraining transmission were calculated from relevant sources. Findings. The five isolates suspected to be involved in hospital transmission clustered with ≤ two SNPs in the draft genome sequences with some distance to other isolates. CgMLST allocated the five isolates to the same type, which was different from all but two of the sporadic isolates. Furthermore, cgMLST separated the five transmission isolates from all other isolates. The economic costs of the outbreak interventions exceeded €11.000 per patient. Conclusion LA-MRSA CC398 is transmittable in hospitals, and intervention against transmission may reach considerable costs. CgMLST is useful in surveillance of hospital transmission of LA-MRSA.

  • Costs associated with measles in healthcare personnel during the 2017-2018 epidemic in Greece: a real-world data cost-of-illness analysis
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-13
    Helena C. Maltezou; Xanthi Dedoukou; Elpida Pavi; Maria Thoeodoridou; Kostas Athanasakis

    Measles represents an occupational risk for healthcare personnel (HCP). A total of 117 cases of measles among HCP were notified in Greece during 2017-2018. We were able to contact 46 of them. Most of those contacted had a serious clinical course with complications, necessitating hospitalization in 67% of cases. All HCP reported absenteeism, for a mean duration of 21.2 working days (range: 3-60 days); 54.3% of HCP reported being at work whilst symptomatic for a mean duration of 2.3 working days (range: 1-7 days). The average total cost-of-illness was 4,739 euros per HCP. The total direct and indirect costs of the 117 notified cases among HCP amount to 554,494 euros, which is likely to be an underestimate of the true cost.

  • Prevalence, genetic diversity of- and factors associated with ESBL-producing Enterobacteriaceae carriage in residents of French Nursing Homes
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-13
    M. Broussier; H. Gbaguidi-Haoré; F. Rachidi-Berjamy; X. Bertrand; C. Slekovec

    Objective To determine the prevalence and genotypic characteristics of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBLE) and Carbapenemase-producing Enterobacteriaceae (CPE) in Nursing Homes (NHs) in a French region. Risk factors associated with their carriage were also investigated. Methods A point-prevalence survey was proposed from November 2017 to June 2018 to NHs of our region. Volunteer residents were screened for ESBLE and CPE carriage. We genotyped E. coli and K. pneumoniae isolates using, MLST, PFGE and phylogrouping (only for E. coli). Collective and individual data were analyzed by random-effects logistic regression. Results The study was conducted in 18 nursing homes and included 262 patients. Fifty-two of them (19.8%) carried at least one ESBLE, corresponding to 56 isolates (42 E. coli, 11 K. pneumoniae, and 3 others) while no CPE was detected. A majority (27/42) of ESBL-E. coli belonged to phylogroup B2 and ST131 was overrepresented in this subset (21/27). PFGE analysis revealed ST131 cross-transmission within NHs. Regarding ESBL-K. pneumoniae, 9 out of 11 isolates belonged to ST663 and PFGE suggested the diffusion of the clone in six NHs. Significant individual risk factors for colonization by ESBLE were: use of non-private toilettes, previous antibiotic use and recent history of hospitalization. Significant collective protective factors were proper compliance with gloves use and support of the NH by a healthcare facility. Conclusion This study shows that NHs within our region are an important reservoir of ESBLE, whereas no residents were CPE carrier. ESBLE control in NHs should focus on antibiotic stewardship and excreta management policies.

  • Can educational speech intervention improve visitors hand hygiene compliance?
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-11
    El Marjiya Villarreal Salma, Khan Samiha, Oduwole Modupe, Sutanto Edward, Vleck Karen, Katz Morgan, William B. Greenough

    Background Hand hygiene, a simple and low-cost measure, remains the leading intervention for reducing the burden related to healthcare-associated infections (HAIs). While many interventions have been tested to improve staff hand hygiene compliance, hospital visitors continue to have low compliance rates, which increase the risk of HAIs and resistant organisms’ transmission into hospitals and out to the community. Aim To assess the effectiveness of educational speech intervention (ESI) in increasing hand hygiene compliance rate among hospital visitors. Methods This interventional study was conducted from March to June 2019 in an inpatient unit of a large academic hospital. Visitor hand hygiene compliance was observed before and after implementation of ESI. ESI provided to the visitors in the intervention phase was to remind them about the importance of hand hygiene and the proper method to clean hands. Post-intervention data were collected using the survey questionnaires. Unpaired t-test compared the hand hygiene compliance rate before and after the intervention. Findings Baseline hand hygiene compliance rate was 9.73% while hand hygiene compliance rate post-intervention increased to 87.06% (p<0.001). Barriers to hand hygiene compliance included both hands occupied, improper location of hand hygiene supplies, past habit, and inadequate knowledge on visitors’ role in preventing spread of infections. Visitors preferred being reminded about hand hygiene by verbal reminder (57%), followed by signage (38%), and wristband notices (5%). Conclusion The ESI substantially increased visitors’ hand hygiene compliance rate. Further studies are warranted to assess the sustainability of ESI and address other barriers to visitors’ hand hygiene compliance.

  • Comparison of a rapid detection fluorescence-based assay targeting tuberculocidal efficacy with EN 14348 and EN 14563
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-11
    Katrin Steinhauer, Karin Teckemeyer, Peter Goroncy-Bermes

    Background A rapid test system using fluorescent Mycobacterium terrae to evaluate the tuberculocidal efficacy of disinfectants has recently been published. Results were obtained in a significantly shorter time than was previously possible. Thus the aim of this study was to compare the European Standard test system with the fluorescence assay and to validate the rapid test system, including particularly the quantitative suspension test. Methods Quantitative suspension tests and quantitative carrier tests were carried out according to EN 14348 and EN 14563, respectively. Quantitative carrier tests and subsequent green fluorescent protein (GFP)-based determination of germicidal efficacy were carried out as described previously. A peracetic acid-based formulation was used as a test germicide. Findings Testing of the germicide in the quantitative suspension test EN 14348 and in the quantitative carrier test EN 14563 revealed tuberculocidal efficacy at a concentration of 1% after 15 min contact time. Accordingly, data obtained from the fluorescence assay demonstrated that a germicide concentration of 1% was effective after 15 min, indicating no live mycobacteria following this treatment. Thus, identical in-use parameters for tuberculocidal efficacy were obtained by either applying the quantitative suspension and quantitative carrier tests EN 14348 and EN 14563 or by using the GFP-based rapid test system. Conclusion The GFP-based rapid test system compares well with the established European Standard test procedure including both phase 2, step 1 and phase 2, step 2 tests and provides a rapid and sensitive tool for testing germicides for relevant in-use concentrations and contact times.

  • Usefulness of the Bristol Stool Form Chart Scoring System for the Laboratory Processing of Faecal Samples in Suspected Clostridioides difficile Cases
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-10
    R.A. Corrigan, K. Sithamparanathan, C. Kenny, T.H.N. Wong

    Clostridioides difficile infection (CDI) remains a threat to hospitalized patients. All patients with diarrhoea (defined as Bristol Stool Form Chart (BSFC) types 5-7) not attributable to another cause should be tested for CDI. Samples should both quarter-fill and take the shape of the specimen container. Use of the BSFC definition of diarrhoea to determine which samples should be tested for CDI in the laboratory was assessed. In this study, two thirds of GDH positive toxin positive samples were rated BSFC score <5. Therefore, the BSFC should not be used by laboratories to determine which samples are tested for CDI.

  • Nosocomial infections caused by Crimean-Congo haemorrhagic fever virus
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-09
    Katerina Tsergouli, Theodoros Karampatakis, Anna-Bettina Haidich, Symeon Metallidis, Anna Papa

    Crimean-Congo haemorrhagic fever (CCHF) is an acute febrile illness, often accompanied by haemorrhagic manifestations, with high case fatality rate (CFR). The causative agent is CCHF virus (CCHFV) and is transmitted to humans mainly through tick bites or exposure to blood or tissues of viremic patients or livestock. Human-to-human transmission usually occurs in hospital settings and health care workers (HCWs) are mainly affected. A review on nosocomial CCHFV infections was performed to elucidate the routes and circumstances of CCHFV transmission in hospital settings. From 1953 to 2016, 158 published cases of CCHFV nosocomial infection in 20 countries in Africa, Asia and Europe were found. Almost all cases were symptomatic (92.4%) with an overall CFR of 32.4%. The majority occurred in hospital clinics (92.0%), and 10 cases (8.0%) in laboratories. Most cases occurred among HCWs (86.1%), followed by visitors (12.7%) and hospitalized patients (1.3%). Nursing staff (44.9%) and doctors (32.3%) were the most affected HCWs, followed by laboratory staff (6.3%). The primary transmission route was percutaneous contact (34.3%). Cutaneous contact accounted for 22.2%, followed by exposure to aerosols (proximity) (18.2%), indirect contact (17.2%) and exposure to patient’s environment (8.1%). CCHFV can cause nosocomial infections with a high CFR. During the care and treatment of CCHF patients, standard contact precautions, barrier precautions and airborne preventive measures should be applied. Guidelines and education for HCWs, to ensure that CCHF is appropriately included in differential diagnoses, so that early diagnosis and implementation of infection prevention measures is achieved is important to improve patient safety and reduce healthcare-associated CCHFV exposure.

  • Evaluation of a new sink design incorporating ozonated water
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-06
    J. Cooper, Y. Himaras, T. Wong, E. Bryce

    Background Novel sink and U-trap designs have been developed to reduce contamination by users and diminish biofilm. Real world experience with new sink designs and adjunctive measures such as ozone has been limited. Aim Objectives were two-fold a) to assess a new sink design for splashback and b) to evaluate the ozonated water feature for reduction of microbial bioburden. Methods A portable sink unit was created that permitted the application of white absorbent paper to plexiglass shields beside and behind the sink. Participants, wearing painter coveralls and mask, spread 30 ml of tempera paint over hands and washed for 20 seconds with neutral soap. Each participant repeated this five times sequentially and cumulative results recorded. Escherichia coli was exposed to ozonated water from the sink unit and to regular tap water and evaluated for microbial survival. Findings Compared to a conventional sink, the SmartFLO3™ sink had less environmental contamination within the sink, the surrounding area, and splash back on the hand washing participant. Despite modifications to enhance ozone generation, readings of reactive oxygen species never went above 0.3 ppm and significant bactericidal effect was not demonstrated. Conclusions The SmarFLO3™ sink reduces splashback and has the potential to reduce pathogen transmission from sinks. At the low levels of ozone generated in our study, no clear bacterial killing effect was observed compared to tap water alone.

  • Specific antibacterial activity of copper alloy touch surfaces in five long-term care facilities for older adults
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-03
    Marius Colin, Emilie Charpentier, Flora Klingelschmitt, Cyril Bontemps, Christophe De Champs, Fany Reffuveille, Sophie C. Gangloff

    Background Pathogens involved in healthcare-associated infections can quickly spread in the environment, particularly to frequently touched surfaces, which can be reservoirs for pathogens. Aim The purpose of this study was to investigate naturally occurring bacterial contamination on touch surfaces in five French long-term care facilities and to compare bacterial populations recovered from copper and control surfaces. Methods More than 1300 surfaces were sampled. The collected bacteria were identified to obtain a global view of the cultivable bacterial populations colonizing touch surfaces. Haemolytic colonies and putative pathogens were also screened using specific agar plates and then identified with matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) mass spectrometry. In total, more than 3400 colonies were analysed. Findings Staphylococcus and Micrococcus were the two predominant genera present on touch surfaces, respectively occurring on 51,8% and 48,0% of control surfaces. In these facilities with relatively low bioburden, copper surfaces efficiently reduced the occurrence frequencies of three genera: Staphylococcus, Streptococcus and Roseomonas. Pathogenic species such as Staphylococcus aureus, Enterococcus faecalis and Enterococcus faecium were observed in very few samples. In addition, methicillin-resistant Staphylococcus aureus was observed on five control surfaces and one copper surface. Conclusion Contamination of healthcare facilities touch surfaces can be the source for the spread of bacteria through the institution. This in situ study shows that the frequency of the contamination as well as the specific bacterial population bioburden is reduced on copper alloy surfaces.

  • Twelve Year Analysis of Aerobic-Only Blood Cultures for Routine Detection of Bacteraemia.
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-12-03
    Simon Stoneham, William Schilling, Alberto San Francisco, Martin Llewelyn

    Sampling practices determine the accuracy of blood culture in diagnosing bloodstream infection. Our main acute hospital introduced aerobic-only routine blood cultures aiming to increase the volume and number of aerobic samples. At a smaller acute site aerobic-anaerobic pairs were sent routinely. We compared culture yield and sampling practices at these two sites and found anaerobic cultures increased the yield of pathogens including facultative anaerobes. Volume cultured and number of samples sent fell short of national recommendations. The aerobic-only policy did not result in more blood being cultured. Based on these findings we are reintroducing aerobic-anaerobic pairs for routine culture.

  • Perils of the Pneumatic Tube: How Clean Are Your Pods?
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-29
    P. McMullen, P. Lewis, O. McGugan, K. Mortimer

    Pneumatic tube systems (PTS) are useful features in hospitals for efficient transport of items but further scrutiny reveals their potential risks. We investigated the extent of contamination of pods, used within the PTS with specific alert organisms, namely meticillin-resistant Staphylococcus aureus (MRSA), vancomycin resistant enterococci (VRE) and carbapenemase-producing Enterobacterales (CPE). Results revealed contamination with VRE (53%) and MRSA (3%), which were reduced to only 3% (VRE) and 0% (MRSA) following disinfection. However recontamination occurred quickly following use. Our findings indicate that PTS could be an efficient method of transfer of potential pathogens around the hospital.

  • Evaluation of PCR assays for direct screening of Carbapenemase-Producing Enterobacteriaceae (CPE) from rectal swabs: a diagnostic meta-analysis
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-29
    Rindala Saliba, Ludwig Serge Aho Glélé, Dolla Karam Sarkis, Jean-Ralph Zahar

    Background Recently, molecular assays have been demonstrated to be reliable for rapid detection of CPE directly from positive blood cultures, reducing significantly the time for identification. Few studies have tested their performance on rectal swabs and no comprehensive conclusion have been reached regarding their utility for infection control management. Aim Tto review and assess the overall diagnostic test accuracy of PCR for the detection of CPE in rectal swabs. Methods We searched the electronic database PubMed, up to October 1, 2019, without language restriction or publication date restrictions. We began by defining the concepts of the research questions: “Carbapenemase-producing Enterobacteriaceae”, “molecular testing”, “test detection” and “rectal screening”. Two reviewers independently screened studies, extracted data, and assessed quality using the QUADAS-2 instrument. Statistical analyses were carried out in STATA using the bivariate model. Findings One hundred forty-three articles were screened and 16 studies were included. Five (31%) of the studies were conducted in a context of a CPE outbreak, 1 study (6%) included patients pre-identified with CPE in clinical samples (blood or tracheal secretions), while the rest (63%) collected rectal swabs from patients considered at high-risk of colonization. The molecular assays evaluated have a relatively good sensitivity of 0.95 (IC: 0.902-0.989), and an excellent specificity of 0.994 (IC: 0.965-1). Conclusions Molecular techniques seem to be a useful accurate diagnostic tool in screening for carriage of CPE in contact patients around a fortuitous discovery of a non-isolated hospitalized carrier patient.

  • Adherence to personal protective equipment use among nurses in Japanese tertiary care hospitals: What determines variability?
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-29
    Shinichiro Morioka, Taichi Tajima, Yuko Sugiki, Kayoko Hayakawa, Norio Ohmagari

    Objective Though nurses have frequent contact with patients, their personal protective equipment (PPE) compliance rate is low, which poses a significant challenge in infection control. This study thus aimed to investigate the relative influence of specific factors on PPE compliance. Methods A sequential two-stage mixed methods design was applied. In a qualitative study, semi-structured interviews were conducted from May 2018 to July 2018. In a quantitative study, a nationwide, cross-sectional survey was conducted from January 2019 to March 2019, in which a questionnaire was mailed to 735 nurses in 28 tertiary care hospitals in Japan. Results In the quantitative study, we obtained a total of 435 (59.2%) analyzable responses. In the linear regression analysis, the lack of the knowledge that “standard precaution was the fundamental infection countermeasure applied when patients had signs of infections, and these countermeasures could be terminated if there was no infection found” was significantly associated with decreased PPE adherence, while an antimicrobial resistant bacteria outbreak or a ward shutdown due to an outbreak and the belief “I must never be the cause of spreading infection” were significantly associated with increased PPE adherence. The beta of standard coefficients and t-values of the items were -0.344, -7.784, 0.090, 2.089, 0.088, 2.018, respectively. Conclusions This survey systematically identified nursing-associated factors that contribute to PPE compliance. As a practical approach to ensure positive outcomes, we suggest educating nurses by providing adequate knowledge on appropriate PPE use and sharing outbreak or ward shutdown experiences.

  • Prevalence, incidence, and risk factors of urinary tract infection among immobile inpatients in China: a prospective, multi-centre study
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-29
    Chen Zhu, Hongpeng Liu, Yu Wang, Jing Jiao, Zhen Li, Jing Cao, Baoyun Song, Jingfen Jin, Yilan Liu, Xianxiu Wen, Shouzhen Cheng, Xinjuan Wu

    Background Immobile inpatients have a high risk of urinary tract infection (UTI). Additional epidemiological data regarding UTI among immobile inpatients are needed. Aim To investigate the prevalence and incidence of, and risk factors for, UTI among immobile patients in 25 hospitals throughout China. Methods This was a national multi-centre cross-sectional investigation. We recruited 6 tertiary hospitals, 12 non-tertiary hospitals, and 7 community hospitals. We obtained data regarding demographics, clinically related variables, and UTI-specific variables from immobile patients during their hospitalization. We performed univariate and multivariable analyses, and binary logistic regression analysis was used to identify risk factors. Findings Among 23 985 immobile patients, 393 had UTI. The prevalence and incidence of UTI in hospitalized immobile patients was 1.64% (393/23 985) and 0.69 per 1000 patient-days, respectively. The infection rate of catheter-associated urinary tract infection was 2.25 per 1000 urinary catheter-days. We found that a greater number of bedridden days, longer length of hospital stay, being in a medical ward, the presence of an indwelling urethral catheter, prolonged duration of an indwelling catheter, use of glucocorticoids, female sex, diabetes mellitus, and older age were independent risk factors of UTI. Conclusion Immobile patients had similar risk factors for UTI as the general population, as well as some additional risk factors. Greater attention is needed in the management of UTI among the population of immobile hospitalized patients.

  • The Influence of National Culture and Context on Healthcare Worker Perceptions of Infection Prevention in Greek Neonatal Intensive Care Units
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-29
    Vasiliki Triantafillou, Ioannis Kopsidas, Areti Kyriakousi, Theoklis E. Zaoutis, Julia E. Szymczak

    Background Healthcare-associated infections (HAIs) in the neonatal intensive care unit (NICU) result in increased morbidity, mortality, and healthcare costs. Rates of HAIs in Greek NICUs are among the highest in Europe. There is a need to identify the factors that influence the transmission of HAIs and implementation of prevention interventions in this setting. Aim To understand healthcare workers’ perceptions about HAI prevention in Greek NICUs. Methods We conducted qualitative interviews with NICU staff (physicians and nurses) and infection-prevention stakeholders (infectious diseases physicians and infection control nurses) working in three hospitals in Athens. Interviews were conducted in Greek, transcribed and translated into English, and analyzed using a modified grounded theory approach. Findings Interviews were conducted with 37 respondents (20 physicians and 17 nurses). Four main barriers to HAI prevention were identified: (1) resource limitations leading to understaffing and cramped space; (2) low HAI prevention knowledge; (3) Greek-specific cultural norms, including hierarchy-driven decisions, a reluctance for public workers to do more than they are paid for, a belief that personal experience trumps evidence-based knowledge, and reactive rather than proactive approaches to societal challenges; and (4) lack of a national infection prevention infrastructure. Respondents believed that these barriers could be overcome through organized initiatives, high-quality HAI performance data, interpersonal interactions to build engagement around HAI prevention, and leveraging the hierarchy to promote change from the "top down." Conclusion Implementing HAI prevention interventions in Greek NICUs will require consideration of contextual features surrounding the delivery of care, with particular attention paid to national culture.

  • Pseudo-outbreak of Mycobacterium paragordonae in a hospital: possible relation to the aerator/rectifier connected to the faucet of the water supply system
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-28
    I. Takajo, C. Iwao, M. Aratake, Y. Nakayama, A. Yamada, N. Takeda, Y. Saeki, K. Umeki, T. Toyama, Y. Hirabara, M. Fukuda, A. Okayama

    Background Pseudo-outbreaks of non-tuberculous mycobacteria (NTM) in association with the water supply system in hospitals have been previously reported. Aim Because we found that the frequency of NTM isolation in clinical samples increased after the reconstruction and renovation of a hospital in Japan in 2014, we analysed NTM, their possible relationship with the hospital water supply system and outcomes of preventive measures. Methods Environmental samples obtained from the water supply in hospital wards were tested for NTM. On obtaining positive results, the bacteria were further analysed using polymerase chain reaction (PCR). Findings The PCR products of NTM showed that most samples tested positive for Mycobacterium paragordonae. Because none of the analysed patients developed any disease due to these bacteria, this event was considered a pseudo-outbreak. Investigation of the water supply system revealed that samples obtained from the recently attached aerators/rectifiers during hospital renovation tested positive for these bacteria. Therefore, measures to remove aerators/rectifiers and prevent patients from drinking tap water in the hospital were introduced. Thereafter, the frequency of NTM-positive samples significantly decreased in the hospital. Conclusion Our study is one of the few reports which reveal the possibility of pseudo-outbreaks of M. paragordonae in hospitals. This study raises the question whether aerators/rectifiers should be used in hospitals at all, because their mesh structure can promote NTM proliferation in supplied water. The importance of surveillance of bacteria derived from the environment, particularly after hospital reconstruction/renovation, is re-emphasised.

  • Microbiological evaluation of environment cleanliness in hematopoietic cell transplanted (HCT) patient rooms: implementing JACIE standards
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-28
    Anita Zeneli, Massimiliano Petrini, Flavia Foca t, Marna Bernabini, Sonia Ronconi, Sandra Montalti, Elena Pancisi, Valentina Soldati, Monica Golinucci, Giovanni Luca Frassineti, Mattia Altini

    Background Environmental hygiene is one of the most important strategies to prevent hospital-acquired infections (HAI) by reducing pathogens in hematopoietic cell transplanted (HCT) patient rooms. The present study was designed in response to JACIE requirements for microbiological monitoring and aimed to assess environmental hygiene in protective isolation rooms. Methods Environmental cleanliness was assessed by measuring microbial loads in at-rest and operational conditions sampled from target surfaces, and in passive and active air from rooms occupied by patients with different grades of neutropenia. We also evaluated whether microbial loads were influenced by isolation precautions. Results The failure rate of cleanliness on target surfaces in at-rest conditions was 0% compared to 37% for surfaces and 13% for passive and active air samples in operational conditions. Differences in failure rates were observed in the rooms of patients with different levels of neutropenia (P= 0.036 for surfaces; 0.028% for passive air). No relation was found between infections and microbial loads. Conclusions Microbiological assessment integrated with an enhanced monitoring programme for hospital hygiene provides invaluable information to drive infection control policies in HCT patients. Our results highlight the need to set and validate strict standards for cleanliness assessment in a clinical setting.

  • Outbreak of carbapenemase-producing Enterobacteriaceae associated with contaminated water dispenser and sink drain in cardiology units in a Korean hospital
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-27
    Jiwon Jung, Hye-Suk Choi, Jeong-Young Lee, Seung Hee Ryu, Sun-Kyung Kim, Min Jee Hong, Sun Hee Kwak, Hwa Jung Kim, Moo-Song Lee, Heungsup Sung, Mi-Na Kim, Sung-Han Kim

    Background Concerns are growing over the importance of the hospital water environment for the transmission of carbapenemase-producing Enterobacteriaceae (CPE). Aim We report a large outbreak in the cardiology units involving intensive care units (ICU) and wards at a tertiary care hospital. Methods Contact tracing, case-control study to find the risk factors for acquisition of CPE and environmental sampling were performed during a CPE outbreak between July and December 2018. Findings A total of 87 patients with CPE infection or colonization were identified at cardiology units. Diverse organisms were identified containing blakpc, blaNDM-1, blaVIM or blaIMP, blaOXA-48, and co-producing organisms. Case-control study indicated that using the sinks in the ward patient room bathroom for teeth brushing was associated with CPE acquisition (83% vs. 30%; P = 0.03). We cultured the environment and isolated KPC-producing Escherichia coli from a water dispenser and NDM-1-producing Citrobacter freundii and Enterobacter cloacae from sinks in patient rooms. Pulsed-field gel electrophoresis (PFGE) analysis of KPC-producing E. coli from patients and the water dispenser in ICU and NDM-1-producing E. cloacae from patient and sink drain showed the same pulsotypes. Conclusions The water dispenser and sink drain were suspected as possible reservoirs of CPE in this outbreak. Close contacts with contaminated water such as tooth brushing were identified as risk factors of CPE acquisition. The education for the adequate use of water environment system as well as the control of hospital water environment should be implemented to prevent the CPE outbreaks.

  • How to carry out microbiological sampling of healthcare environment surfaces? A review of current evidence
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-07-29
    S. Rawlinson, L. Ciric, E. Cloutman-Green

    There is increasing evidence that the hospital surface environment contributes to the spread of pathogens. However, evidence on how best to sample these surfaces is inconsistent and there is no guidance or legislation in place on how to do this. The aim of this review was to assess current literature on surface sampling methodologies, including the devices used, processing methods, and the environmental and biological factors that might influence results. Studies published prior to March 2019 were selected using relevant keywords from ScienceDirect, Web of Science, and PubMed. Abstracts were reviewed and all data-based studies in peer-reviewed journals in the English language were included. Microbiological air and water sampling in the hospital environment were not included. Although the numbers of cells or virions recovered from hospital surface environments were generally low, the majority of surfaces sampled were microbiologically contaminated. Of the organisms detected, multidrug-resistant organisms and clinically significant pathogens were frequently isolated and could, therefore, present a risk to vulnerable patients. Great variation was found between methods and the available data were incomplete and incomparable. Available literature on sampling methods demonstrated deficits with potential improvements for future research. Many of the studies included in the review were laboratory-based and not undertaken in the real hospital environment where sampling recoveries could be affected by the many variables present in a clinical environment. It was therefore difficult to draw overall conclusions; however, some recommendations for the design of routine protocols for surface sampling of healthcare environments can be made.

  • Two-year analysis of Clostridium difficile ribotypes associated with increased severity
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-06-18
    R. Herbert, J. Hatcher, E. Jauneikaite, M. Gharbi, S. d’Arc, N. Obaray, T. Rickards, M. Rebec, O. Blandy, R. Hope, A. Thomas, K. Bamford, A. Jepson, S. Sriskandan

    Background Certain Clostridium difficile ribotypes have been associated with complex disease phenotypes including recurrence and increased severity, especially the well-described hypervirulent RT027. This study aimed to determine the pattern of ribotypes causing infection and the 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 culture. All C. difficile isolates were ribotyped, and associated clinical and demographic patient data were retrieved and linked to ribotyping data. Results In total, 86 distinct ribotypes were identified from 705 isolates of C. difficile. RT002 and RT015 were the most prevalent (22.5%, N=159). Only five isolates (0.7%) were hypervirulent RT027. Ninety of 450 (20%) patients with clinical information available died within 30 days of C. difficile isolation. RT220, one of the 10 most common ribotypes, was associated with elevated median C-reactive protein and significantly increased 30-day all-cause mortality compared with 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.

  • Difficulty in removing biofilm from dry surfaces
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-07-04
    F. Parvin, H. Hu, G.S. Whiteley, T. Glasbey, K. Vickery

    Cleaning is fundamental to infection control. This report demonstrates that a Staphylococcus aureus biofilm is significantly more difficult to remove than dried planktonic bacteria. A single wiping action removed >99.9% (>3 log10) of dried planktonic bacteria, whereas only 1.4 log10 of biofilm (96.66%) was removed by 50 wiping actions with a standardized wiping process.

  • 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
    A.P. Meijs, I. Prantner, T. Kärki, J.A. Ferreira, P. Kinross, E. Presterl, P. Märtin, O. Lyytikäinen, S. Hansen, A. Szőnyi, E. Ricchizzi, R. Valinteliėnė, S. Zerafa, S.C. de Greeff, T.C. Berg, P.A. Fernandes, M. Štefkovičová, A. Asensio, M.B.G. 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 (HCAIs) in addition to targeted surveillance of the incidence of specific types of HCAI such as surgical site infections (SSIs). Aim To investigate whether national and multi-country SSI incidence can be estimated from ECDC PPS data. Methods In all, 159 hospitals were included from 15 countries that participated in both ECDC surveillance modules, aligning surgical procedures in the incidence surveillance to corresponding specialties from the PPS. National daily prevalence of SSIs was simulated from the incidence surveillance data, the Rhame and Sudderth (R&S) formula was used to estimate national and multi-country SSI incidence from the PPS data, and national incidence per specialty was predicted 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 to 1.00). The linear prediction model including PPS data had low proportion of explained variance (0.40). Conclusion Due to a lack of accuracy, use of PPS data to estimate SSI incidence is recommended only in situations where incidence surveillance of SSIs is not performed, and where sufficiently large samples of PPS data are available.

  • In-vitro activity of active ingredients of disinfectants against drug-resistant fungi
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-07-27
    R. Stauf, D. Todt, E. Steinmann, P-M. Rath, H. Gabriel, J. Steinmann, F.H.H. Brill

    The biocidal activities of peracetic acid and ethanol were tested against nine clinical fungal isolates and four reference strains. Ethanol was active (≥4.0 log10 reduction) against yeasts at a concentration of 50% v/v and against moulds at 80% v/v. Exposure times in both cases were 1 min. Peracetic acid was active as a 0.25% solution against yeasts and as a 0.5% solution against moulds; exposure times in both cases were 5 min. Compared with the reference strains, clinical isolates, including multi-drug-resistant strains, showed similar or higher sensitivity to the active ingredients of disinfectants in vitro.

  • Novel photodynamic coating reduces the bioburden on near-patient surfaces thereby reducing the risk for onward pathogen transmission: a field study in two hospitals
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-07-29
    A. Eichner, T. Holzmann, D.B. Eckl, F. Zeman, M. Koller, M. Huber, S. Pemmerl, W. Schneider-Brachert, W. Bäumler

    Background Near-patient surfaces are recognized as a source for hospital-acquired infections. Such surfaces act as reservoirs for microbial contamination by which pathogens can be transmitted from colonized or infected patients to susceptible patients. Routine disinfection of surfaces only results in a temporal elimination of pathogens, and recontamination inevitably occurs shortly between disinfections. Aim A novel antimicrobial coating based on photodynamics was tested under laboratory conditions and subsequently in a field study in two hospitals under real-life conditions. Methods Identical surfaces received a photodynamic or control coating. Bacterial counts [colony-forming units (cfu)/cm2) were assessed regularly for up to 6 months. Findings The laboratory study revealed a mean reduction of several human pathogens of up to 4.0 ± 0.3 log10. The field study in near-patient environments demonstrated mean bacterial values of 6.1 ± 24.7 cfu/cm2 on all control coatings. Photodynamic coatings showed a significantly lower mean value of 1.9 ± 2.8 cfu/cm2 (P<0.001). When considering benchmarks of 2.5 cfu/cm2 or 5 cfu/cm2, the relative risk for high bacterial counts on surfaces was reduced by 48% (odds ratio 0.38, P<0.001) or 67% (odds ratio 0.27, P<0.001), respectively. Conclusion Photodynamic coatings provide a significant and lasting reduction of bacterial counts on near-patient surfaces, particularly for high bacterial loads, in addition to routine hygiene. The promising results of this proof-of-concept study highlight the need for further studies to determine how this novel technology is correlated with the frequency of hospital-acquired infections.

  • Local outbreak of extended-spectrum β-lactamase SHV2a-producing Pseudomonas aeruginosa reveals the emergence of a new specific sub-lineage of the international ST235 high-risk clone
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-07-29
    G. Royer, F. Fourreau, B. Boulanger, M. Mercier-Darty, D. Ducellier, F. Cizeau, A. Potron, I. Podglajen, N. Mongardon, J.-W. Decousser

    Background Pseudomonas aeruginosa is a major bacterial pathogen responsible for hospital-acquired infections. Although its epidemiology is considered as non-clonal, certain international high-risk multidrug-resistant clones have been recognized. Aim From the first report of an intra-hospital outbreak due to an SHV2a-producing P. aeruginosa strain, to describe the emergence of a new ST235-specific lineage harbouring this rare extended-spectrum β-lactamase (ESBL). Methods Between May and October 2018, four patients hospitalized in the cardiovascular intensive care unit of a French teaching hospital were infected by a multidrug-resistant P. aeruginosa isolate. Serotype and antimicrobial susceptibility were tested; multi-locus sequence type (MLST), core genome MLST, and resistome were determined through whole genome sequencing. A phylogenetic analysis based on single nucleotide polymorphism was performed using available ST235 genomes. Findings The four strains were susceptible to colistin, ciprofloxacin, ceftazidime–avibactam, and ceftolozane–tazobactam. blaSHV2a was identified in each genome of this ST235-O11 serotype cluster that showed an identical cgMLST profile (0–2 out of 4162 different alleles). The phylogenic analysis of 162 ST235 genomes showed that only four other strains harboured a blaSHV2a, originating from France and USA, clustering together although being different from the outbreak strains. Conclusions Among the ST235 P. aeruginosa strains, a sub-lineage sharing a common genetic background and harbouring the blaSHV2a ESBL seems to emerge from different locations, yielding secondary local outbreaks.

  • Comparative evaluation of a novel fluorescent marker and environmental surface cultures to assess the efficacy of environmental cleaning practices at a tertiary care hospital
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-21
    Ankita Dewangan, Ujjwala Gaikwad

    Background Cleaning high touch surfaces serves as a crucial step towards controlling the transmission of multidrug resistant pathogens in hospital environments. The process can be made most effective if scientifically monitored using a simple, feasible and reliable technique, especially in resource poor settings. Aim To identify a novel florescent marker (FM) comparable to the already existing commercial FM systems and to assess its efficacy in evaluating cleaning of high touch surfaces in hospital environment. Methods A liquid detergent used for washing purposes was identified as a novel FM. Pre and post cleaning sampling were done from 250 high touch surfaces in different patient care areas using this marker and aerobic colony counts. Concordance between the two methods was assessed and compared by Cohen’s kappa coefficient. The sensitivity, specificity, positive predictive and negative predictive value for the new FM method were calculated against the microbiological method. Findings A good correlation (k = 0.60) with overall concordance of 79.6% was observed between the two methods. The sensitivity, specificity, positive predictive value and negative predictive value of the FM were 79.58% (95% CI- 72-85.85%), 79.63% (95% CI - 70.79-86.78), 83.70% (95% CI - 76.38-89.50) and 74.78% (95% CI - 65.83-82.38), respectively. Conclusions The FM used in the present study proved to be a simple and cost-effective alternative to commercially available FMs for assessing environmental cleaning practices on daily basis in resource-poor settings. Additional studies making direct comparison of it with the established ones, are warranted before they can be generalized for use.

  • Financial and Temporal Costs of Patient Isolation in Norwegian Hospitals
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-21
    Håvard Haugnes, Petter Elstrøm, Oliver Kacelnik, Urszula Jadczak, Torbjørn Wisløff, Birgitte Freiesleben de Blasio

    Background Isolation of patients colonised or infected by antibiotic-resistant bacteria is an established infection control measure taken in Norway. Local reliable data on the costs of this isolation are needed. Methods A micro-costing study from a healthcare perspective was conducted on infectious disease wards in three general acute hospitals, utilising direct observation, staff registration, interviews and survey data. Findings The daily additional cost of isolation was €56.8 (95% CI 42.4–72.7) for non-bedridden patients and €87.5 (95% CI 48.3–129.6) for bedridden patients. Of these sums, labour costs accounted for the largest share (71–72%), followed by the costs of personal protective equipment (21–23%) and waste management (6–8%). Overall, isolation-specific workload amounted to 65 minutes/day for non-bedridden patients and 95 minutes/day for bedridden patients, predominantly in the form of extra time used by nurses. Higher isolation costs for bedridden patients were largely attributable to resources used for personal hygiene practices. One-time isolation costs incurred for room cleaning after patient discharge averaged at €14.0 (95% CI 10.7–17.6). Conclusions Our study provides novel, detailed evidence on resource use attributable to patient isolation in hospitals that can be used to inform future assessments directed toward precautionary hygienic measures. Our results suggest that allocating additional nurse staffing to wards with large numbers of isolated patients should be considered.

  • Do pneumatic tube transport systems transmit potential pathogens? A hygienic risk assessment in a University hospital
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-20
    Lina Khaznadar, Stephanie J. Dancer, Astrid Petersmann, Ulrike Seifert, Harald Below, Roald Papke, Miranda Suchomel, Thomas Kohlmann, Axel Kramer

    Background Prompted by an outbreak of vancomycin-resistant enterococci (VRE) in a medical facility, this study examined a pneumatic tube transport system (PTS) as a potential transmission channel. Method Samples from receiving station and entry-racks were gathered via smear technique. Then sponges used for PTS decontamination were soaked with 0.89% NaCl and transported through the channel. Microorganisms from the tubes and cleaning sponges were recovered using a wash-away technique. Air sampling was performed at the receiving station in order to detect any airborne contamination. Tubes were then artificially inoculated with Escherichia coli K12 NCTC 10538 and Staphylococcus epidermidis DSM 20044 and sent through the PTS to investigate channel contamination. Results No pathogens were detected in effluent air from the PTS or on tubes during routine operation. The entry racks for the test tubes were contaminated with coagulase-negative staphylococci (CNS), aerobic bacilli, moulds and vancomycin-susceptible Enterococcus faecium. E. coli proved unsuitable for detecting bacterial transmission by the PTS due to low persistence but S. epidermidis was more resilient. After sending contaminated test tubes through the PTS, levels of S. epidermidis decreased only marginally. Sponges soaked with disinfectant solution were then put through the system and these completely eliminated S. epidermidis from the first attempt. Discussion Routine hygienic maintenance of the PTS makes pathogen transmission by PTS highly unlikely, although entry racks should be regularly disinfected. Any involvement of the PTS in our VRE outbreak was also unlikely.

  • Assessment of the potential for pathogen dispersal during high-flow nasal therapy
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-20
    Masakazu Kotoda, Sohei Hishiyama, Kazuha Mitsui, Takamune Tanikawa, Sho Morikawa, Ayasa Takamino, Takashi Matsukawa

    High-flow nasal therapy is increasingly used in hospitals because of its effectiveness and patient comfort. However, pathogens in the patient’s nasal and oral cavities may be dispersed by forced air. This study aimed to investigate the risk of pathogen dispersal during high-flow nasal therapy. Liquid and bacterial dispersal were assessed via in vitro experimental set-ups using a manikin. Thickened water or fresh yeast solution mimicked saliva and nasal mucus secretions. Dispersal was limited to the proximal area of the face and nasal cannula, suggesting that high-flow nasal therapy does not increase the risk of droplet and contact infection.

  • 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
    M. Fortier, P. Pistre, V. Ferreira, M. Pinsonneault, J.M. Charbonneau, C. Proulx, A. Buisson, P. Morency-Potvin, D. Williamson, A. Ang

    Background 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' assessments 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 antimicrobials 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 (CIs), 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 decrease DOT for all antimicrobials, but decreased DOT-ES and LOT upon its implementation.

  • Chlorhexidine sensitivity in staphylococci isolated from patients with central line-associated bloodstream infection
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-07-15
    K.I. Jun, Y. Choi, K. Kwon, M.J. Shin, J.S. Park, K-H. Song, E.S. Kim, K-H. Park, S-I. Jung, S.H. Cheon, Y-S. Kim, N-R. Yoon, D.M. Kim, P.G. Choe, N.J. Kim, H.B. 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 analysed. 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.

  • 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
    J. Pan, K. Kavanagh, C. Marwick, P. Davey, C. Wuiff, S. Bryson, C. Robertson, M. 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 hospitalizations. All validated cases of HA-CDI (August 2010 to 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. A sensitivity analysis was conducted to consider the impact of unmeasured hospital antimicrobial prescribing. Results Nine-hundred and thirty 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) = 1.41 (95% confidence interval (CI) 1.13–1.75) for HA-CDI compared with those without. Individuals exposed to high-risk antimicrobials (cephalosporins, clindamycin, co-amoxiclav or fluoroquinolones) had an OR = 1.86 (95% CI: 1.33–2.59). After accounting for the likely impact of unmeasured hospital prescribing, the community exposure, particulary 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.

  • 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
    M.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

    Background Surgical site infections (SSIs) are associated with morbidity, mortality and costs. Aim To 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. Methods A retrospective cost-analysis was performed using 2011 data from the national SSI surveillance network PREZIES. Sixty-two patients with an SSI (exposed) were matched to 122 patients without an SSI (unexposed, same type of surgery). Patient records were studied until 1 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 Burden of Communicable Disease in Europe Toolkit of the European Centre for Disease Prevention and Control. The SSI model was specified by type of surgery, with country- and surgery-specific parameters where possible. Findings Attributable costs per SSI were €21,569 (THA), €14,084 (colectomy) and €1881 (mastectomy), mainly caused by prolonged length of hospital stay. National hospital costs were estimated at €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 <1. The total cost of DALYs for the three types of surgery exceeded €88 million. Conclusion Depending on the type of surgery, SSIs cause a significant burden, both economically and in loss of years in full health. This underlines the importance of appropriate infection prevention and control measures.

  • Variations in antibiotic use across India: multi-centre study through Global Point Prevalence survey
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-06-03
    S.K. Singh, S. Sengupta, R. Antony, S. Bhattacharya, C. Mukhopadhyay, V. Ramasubramanian, A. Sharma, S. Sahu, S. Nirkhiwale, S. Gupta, A. Rohit, S. Sharma, V. Raghavan, P. Barman, S. Sood, D. Mamtora, S. Rengaswamy, A. Arora, A. 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 October to December 2017 in 16 tertiary care hospitals across India. The survey included all inpatients receiving an antimicrobial on the day of PPS and collected data were analysed using a web-based application of the University of Antwerp. In all, 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.

  • Effect of gloved hand disinfection on hand hygiene before infection-prone procedures on a stem cell ward
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-06-18
    P. Fehling, J. Hasenkamp, S. Unkel, I. Thalmann, S. Hornig, L. Trümper, S. Scheithauer

    Background Hand hygiene compliance even before infection-prone procedures (indication 2, ‘before aseptic tasks’, according to the World Health Organization (WHO)) remains disappointing. Aim 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 of hospital-acquired multidrug-resistant bacteria was recorded by active surveillance. Findings Hand hygiene compliance improved significantly 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 (from 6.0 to 2.5 per 1000 patient-days) whereas transmission of multidrug-resistant organisms was not affected. Conclusion 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.

  • Antibiotic prophylaxis in spine surgery: a comparison of single-dose and 72-hour protocols
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-04-30
    A. Maciejczak, A. Wolan-Nieroda, M. Wałaszek, M. Kołpa, Z. Wolak

    Background Despite the general consensus on the use of single-dose antimicrobial prophylaxis (AMP) in instrumented spine surgery, evidence supporting this approach is not robust. Aim To compare the efficacies of single-dose and 72 h AMP protocols for the prevention of surgical site infection (SSI) in instrumented spine surgery (ISS) in a before-and-after study. Methods Prospective non-randomized cohort study on 5208 patients who underwent spine surgery in one neurosurgical department between 2003 and 2014. Two protocols of AMP were compared in ISS: a single-dose protocol from 2003 to 2008, and a 72 h protocol from 2009 to 2014. Patients undergoing non-instrumented spine surgery (NSS) received single-dose prophylaxis throughout both periods. The outcome measure was the incidence of SSI. Findings For ISS, the SSI incidences were 5.3% for the single-dose protocol and 2.2% for the 72 h protocol (P < 0.01). For NSS, the SSI incidence was 0.8% between 2003 and 2008 and 1.2% between 2009 and 2014 (P = 0.054). Multiple correspondence analysis showed that in surgeries with an implant a one-dose prophylaxis carries a 7.1% risk of SSI; patients who received 72 h prophylaxis had a lower (3.6%) risk of SSI. Conclusion Analysis of individual categories of data suggests that 72 h prophylaxis was the most important factor for minimizing the risk of wound infection in our study group.

  • Epidemiology and impact of norovirus outbreaks in Norwegian healthcare institutions, 2005–2018
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-06-22
    L. Espenhain, T.C. Berg, H. Bentele, K. 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 An analysis of all reported norovirus outbreaks in hospitals and long-term-care facilities (LTCFs) was carried out from week 34, 2005 to week 33, 2018. Seasonality, symptoms and number of cases among personnel and patients were described. Findings A total of 20,544 cases, including 7044 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 one-third of the municipalities having at least one outbreak in LTCFs during the study period. The start of the outbreak season happened almost four 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 on both hospital and LTCFs all over Norway, especially during the winter months. That up to half of all cases were healthcare professionals emphasizes 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.

  • Norovirus recovery from floors and air after various decontamination protocols
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-06-02
    C.L. Ciofi-Silva, C.Q.M. Bruna, R.C.C. Carmona, A.G.C.S. Almeida, F.C.P. Santos, N.M. Inada, V.S. Bagnato, K.U. Graziano

    Background The dispersal of airborne norovirus (NoV) particles from the floor after contamination with faeces or vomit 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 floors and airborne particles following various floor decontamination procedures. Methods Two types of floor (vinyl and granite) were contaminated intentionally 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 C (UV-C) light device. Swab samples were taken from the floors, 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 UV-C light exposure (P<0.001). Viral particles were detected in 27 of 36 air samples after cleaning, with no significant difference between the two floor types. On average, 617 genome copies/sample were identified in air samples after cleaning, but the number decreased gradually after disinfection. Conclusion NoV-GII can be aerosolized during floor cleaning, and its particles may be inhaled and then swallowed or can settle on surfaces. Therefore, residual viral particles on floors must be fully eliminated. Cleaning followed by 10 min of 1% sodium hypochlorite disinfection proved to be the superior decontamination protocol.

  • Nosocomial infection by human bocavirus and human rhinovirus among paediatric patients with respiratory risks
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-05-09
    H. Kobayashi, M. Shinjoh, K. Sudo, S. Kato, M. Morozumi, G. Koinuma, T. Takahashi, Y. Takano, Y. Tamura, N. Hasegawa

    Background Nosocomial infections by respiratory viruses undetected by rapid tests are not often diagnosed. For paediatric patients with background diseases, nosocomial infection could be fatal. Aim To determine the relationship between developing symptoms by respiratory viruses undetectable by rapid tests and respiratory risks and to improve the management of infection control. Methods Two episodes of nosocomial infection by human bocavirus (HBoV) and human rhinovirus (HRV) were retrospectively investigated in a tertiary hospital paediatric ward in Japan. Viruses were identified by polymerase chain reaction to determine infection control management. When viruses of the same species were detected from different patients, the virus homology was investigated. The relationship between respiratory risks and developing symptoms was statistically investigated. Findings Three and four patients with respiratory risks in the HBoV and HRV outbreaks, respectively, developed respiratory symptoms. The nucleotide sequences of two patients in the HBoV outbreak and all four patients in the HRV outbreak were phylogenetically close. In both outbreaks, the patients with respiratory risks developed significantly more symptoms than those without any risk (P = 0.035 and 0.018, respectively). After the patients with respiratory infection were separated from those with respiratory risks, no additional nosocomial infection occurred. Conclusion Patients with respiratory risks easily develop respiratory symptoms and acquire severe symptoms of nosocomial infection by those viruses. In a paediatric ward, we should adopt not only standard precautions but also isolation management of the patients with respiratory symptoms, even if they have negative results in rapid tests.

  • Molecular epidemiology of an outbreak of human parainfluenza virus 3 among oncology patients
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-07-26
    E.S. Bailey, E. Lobaugh-Jin, B. Smith, C. Sova, J. Misuraca, N. Henshaw, G.C. Gray

    A hospital outbreak of human parainfluenza virus type 3 (HPIV-3) in haematologic oncology patients is described in 12 patients over a four-week period. Exposure histories and molecular analysis of HPIV-3 isolates suggest that both community-acquired and nosocomially transmitted infections occurred during this outbreak. Molecular analysis of HPIV-3 isolates indicated that a chain of transmission occurred among multiple patients in an oncology ward. This transmission was later determined to be associated with the movement of fomites, visitors, and activities in the unit. The infection prevention team stopped nosocomial spread of HPIV-3 through interventions including advanced cleaning procedures.

  • Genetic relationship between bacteria isolated from intraoperative air samples and surgical site infections at a major teaching hospital in Ghana
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-16
    Marius Ahm Stauning, Antoinette Bediako-Bowan, Stephanie Bjerrum, Leif Percival Andersen, Sergio Andreu-Sánchez, Appiah-Korang Labi, Jørgen Kurtzhals, Rasmus L. Marvig, Japheth A. Opintan

    Background In low- and middle-income countries (LMIC) the rate of surgical site infections (SSI) is high, leading to negative patient outcomes and excess health care costs. A causal relationship between airborne bacteria in the operating room and SSI has not been established, at a molecular or genetic level. We studied the relationship between intraoperative airborne bacteria and bacteria causing SSI in a LMIC. Methods Active air sampling using a portable impactor was performed during clean or clean-contaminated elective surgical procedures. Active patient follow-up consisting of phone calls and clinical examinations was performed 3, 14 and 30 days after surgery. Bacterial isolates recovered from SSI and air samples were compared by MALDI-TOF identification, ribotyping, whole genome sequencing (WGS), and metagenomic analysis. Results Of 128 included patients, 116 (91%) completed follow-up and 11 (9%) developed SSI. Known pathogenic bacteria were isolated from intraoperative air samples in all cases with SSI. A match between air and SSI isolates were found by MALDI-TOF in 8 cases. Matching ribotypes were found in 6 cases and in one case both WGS and metagenomic analysis showed identity between air- and SSI-isolates. Conclusion The study showed high levels of intraoperative airborne bacteria, an SSI-rate of 9% and a genetic link between intraoperative airborne bacteria and bacteria isolated from SSI. This indicates the need for awareness of intraoperative air quality in LMIC.

  • Mucosal impact of alcoholic povidone iodine indicated in preoperative disinfection
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-16
    Franck Bruyère, Paul Laine, Gael Saint-Jalmes, Sandra Malavaud, Benjamin Pradere

    Background Alcoholic povidone iodine (API) used as skin disinfection reduces the risk of postoperative infection but there is no evidence for its use on mucous membranes. We therefore conducted a tolerance study on the glans of men operated in urology. Aim To confirm the safety of using API on mucous membranes Methods The impact of applying API on the glans mucosa was measured using a chromameter. Caucasian men, without any dermatological lesion of the glans, operated by endoscopic trans-urethral route, were included. Measurements (L*a*b*) were made preoperatively and postoperatively by an independent person. Parameters were compared using the recognized formula ΔE= √(ΔL2+ Δa2+ Δb2). Findings Ninety-six patients, average age 68.9 ± 10.4 years, were included. For L*, the mean pre- and postoperative difference was +2.36 (p = 0.168). For a* and b*, the mean pre- and postoperative differences were +0.13 (p = 0.9085) and -0.12 (p = 0.17089), respectively. DE was equal to 13.92 ± 17.49, which is a non-significant difference. Conclusions Our study is the first study analyzing the impact of API on genital mucous membranes. In our study conditions, API had no impact on the mucous membranes, suggesting that it can be used safely.

  • Implementing a multifaceted framework for proprietorship of hand hygiene compliance in a network of South African hospitals – Leveraging the Ubuntu philosophy
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-15
    A.J. Brink, A.P. Messina, C. Maslo, K. Swart, D. Chunnilall, D. van den Bergh

    Background Given the lack of hospital-wide ownership and shortage of nurses the ideal model for large-scale implementation of hand hygiene (HH) behaviour change (BC) in low-middle-income countries is unknown. Aim The aim of the multimodal strategy was to engender hospital accountability for HH compliance. Methods The quasi-experimental study was conducted in 50 South African hospitals (November 2015 - July 2017) and involved five overlapping phases: Executive governance and corporate BC, group-wide systematic situational analysis, development of an electronic-assisted direct-observed data collection and analysis application, launch and implementation and accountable governance. Measurement of intra- and inter-hospital variance to six HH opportunities was calculated and data compliance dashboards were emailed weekly to hospital leadership teams in order to provide feedback of recorded HH compliance and behaviour to frontline teams. Baseline comparison (July 2016) of compliance were compared versus post-implementation (July 2017). Results Baseline HH compliance of ≤ 60% was documented for 16% (8/50) of hospitals whilst overall, 48% (24/50) of hospitals demonstrated a significant improvement (p<0.01). Over the 13- month observation period, 523 422 observations were recorded with a mean rate of 277 ± 223 observations per 1000 patient days. The group mean composite compliance improved 7.8% (p<0.01) from 77.4% ± 12.8% to 85.2% ± 8.8% between July 2016 and July 2017, respectively. Conclusions Implementation of a multifaceted HH model in a large diverse group of SA hospitals translated into changes in the organizational systems and accountability, standardized HH compliance management and feedback that lead to HH proprietorship.

  • Whole-genome sequencing identifies highly related Pseudomonas aeruginosa strains in multiple washbasin U-bends at several locations in one hospital: evidence for trafficking of potential pathogens via wastewater pipes
    J. Hosp. Infect. (IF 3.704) Pub Date : 2019-11-15
    E.M. Moloney, E.C. Deasy, J.S. Swan, G.I. Brennan, M.J. O’Donnell, D.C. Coleman

    Background Hand washbasin U-bends have increasingly been associated with nosocomial outbreaks by Gram-negative bacteria, including Pseudomonas aeruginosa which is virtually ubiquitous in U-bends. Wastewater networks servicing U-bends are potential highways for trafficking pathogenic bacteria. Aim To use P. aeruginosa to investigate trafficking of bacteria between hospital washbasin U-bends. Methods Twenty-five washbasin U-bends in five locations in Dublin Dental University Hospital (DDUH) were investigated for trafficking of P. aeruginosa: 10 in Clinic 2 (C2), 10 in the Accident & Emergency Department (A&E) and five in three other locations. In addition, washbasin tap samples (N=80) and mains and tap water samples (N=72) were cultured for P. aeruginosa. Selected P. aeruginosa isolates recovered over 29 months underwent whole-genome sequencing, and relatedness was interpreted using whole-genome multi-locus sequence typing and pairwise single nucleotide polymorphism (SNP) analysis. Findings P. aeruginosa was recovered from all U-bends but not from taps or water. Eighty-three isolates yielded 10 sequence types (STs), with ST560 and ST179 from A&E, C2 and two other locations predominating (70%). ST560 was also recovered from a common downstream pipe. Isolates within ST560 and ST179 were highly related regardless of source. ST560 was divided into Cluster I (N=25) and Cluster II (N=2) with average allelic differences and SNPs of 3 and 0, and 2 and 5, respectively. The 31 ST179 isolates exhibited an average allelic difference and SNPs of 3 and 12, respectively. Conclusion Highly related P. aeruginosa strains were identified in multiple U-bends in several DDUH locations, indicating trafficking via the wastewater network.

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