Infection control--a European research perspective for the next decade

A symposium was held in June 2009 near Freiburg in Germany. Twenty-nine attendees from several European countries participated, most of whom are actively involved in research and hospital infection prevention and control. The following topics were presented and discussed: isolation and screening for control of multidrug-resistant organisms; impact of the environment on healthcare-associated infection (HAI); new technologies to control infection--state of evidence; surveillance of HAI; methodological challenges and research priorities for infection control and control of HAI: learning from each other in a united Europe. This Leader summarises the main issues for debate and the number of consensus points agreed amongst delegates.

Control of a multi-hospital outbreak of KPC-producing Klebsiella pneumoniae type 2 in France, September to October 2009

An outbreak of Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae type 2 was detected in September 2009 in two hospitals in a suburb south of Paris, France. In total, 13 KPC-producing K. pneumoniae type 2 cases (four with infections and nine with digestive-tract colonisations) were identified, including a source case transferred from a Greek hospital. Of the 13 cases, seven were secondary cases associated with use of a contaminated duodenoscope used to examine the source case (attack rate: 41%) and five were secondary cases associated with patient-to-patient transmission in hospital. All isolated strains from the 13 patients: (i) exhibited resistance to all antibiotics except gentamicin and colistin, (ii) were more resistant to ertapenem (minimum inhibitory concentration (MIC) always greater than 4 mg/L) than to imipenem (MIC: 1–8 mg/L, depending on the isolate), (iii) carried the blaKPC-2 and blaSHV12 genes and (iv) had an indistinguishable pulsed-field gel electrophoresis (PFGE) pattern. These cases occurred in three hospitals: some were transferred to four other hospitals. Extended infection control measures implemented in the seven hospitals included: (i) limiting transfer of cases and contact patients to other wards, (ii) cohorting separately cases and contact patients, (iii) reinforcing hand hygiene and contact precautions and (iv) systematic screening of contact patients. Overall, 341 contact patients were screened. A year after the outbreak, no additional case has been identified in these seven hospitals. This outbreak emphasises the importance of rapid identification and notification of emerging highly resistant K. pneumoniae strains in order to implement reinforced control measures.

Investigation of a large outbreak of Clostridium difficile PCR-ribotype 027 infections in northern France, 2006-2007 and associated clusters in 2008-2009

In 2006 and 2007, a large outbreak of Clostridium difficile infections (CDIs) with PCR-ribotype 027 was identified in northern France. Overall, 38 healthcare facilities notified 529 CDIs over a 22-month period, including 281 laboratory-confirmed CDI 027 and 248 non-confirmed CDI 027 cases (incidence rate per 10,000 elective bed days: 1.63, range: 0.07 to 7.94). The cases occurred mainly in long-term care hospital facilities and nursing homes, near the border between France and Belgium. An active surveillance and prevention campaign was launched at the first epidemic peak including hygiene precautions for healthcare professionals, which supported healthcare facilities to improve care organisation. The outbreak was controlled at the end of 2007, but sporadic cases were identified until the end of 2009. A bundle of appropriate control measures may halt the spread of such outbreaks, provided that substantial human resources and financial support are available.

[Update on Clostridium difficile infections]

PURPOSE

Clostridium difficile is an anaerobic gram positive, spore-forming bacterium which is responsible for 15-25% of antibiotic-associated diarrhea and for more than 95% of pseudomembranous colitis (PMC). This paper will review the main knowledge on C. difficile-associated infections and their recent evolution.

CURRENT KNOWLEDGE AND KEY POINTS

Since 2003, outbreaks of severe C. difficile-associated diarrhea (CDAD) have been increasingly reported in Canada and the United States. This trend is assumed to be associated with the rapid emergence and spread of a specific clone of C. difficile belonging to PCR-ribotype 027 or North American Pulsotype 1, pulsotype (NAP1). This clone is characterized by the overproduction of toxins A and B and is positive for a third toxin named binary toxin. This clone has spread in UK, in Belgium, in the Netherlands, and, more recently, in France where it has been responsible for large outbreaks mainly in northern France.

FUTURE PROSPECTS AND PROJECTS

A systematic reporting of C. difficile incidence by health facilities should enable a better assessment of this pathology in France.

[Risk of hepatitis C related to traditional medicine: a case control study in Ho Chi Minh City, Vietnam]

BACKGROUND

The transmission of hepatitis C virus (HCV) is strongly associated with blood transfusion and drug abuse. However, in about a third of HCV-infected subjects, the risk factors are not clearly identified though some cases are likely to be healthcare associated. In an Asian country such as Vietnam, invasive procedures used for traditional and beauty care could be potential risk factors. The aim of the present study was to identify the risk factors of HCV infection in a population sample in Ho Chi Minh City.

METHOD

A case-control study matched by gender and age was performed among blood adults donors at the Centre of hematological diseases and blood transfusion. Cases were defined as blood donors with HCV-positive Elisa. Controls were selected at random among ELISA HCV-negative donors. A standardized questionnaire was used to collect data focusing on invasive medical procedures, beauty care and on invasive procedures related to traditional medicine.

RESULT

Among the 80 cases and 240 controls, the independent predictors of anti-HCV positivity using a stepwise logistic regression were: blood transfusion, intravenous drug abuse, acupuncture, ventoused scarification and practice of scarification (adjusted odds ratio and IC95%: 3.8 [1.1-13.1], 3.5 [1.7-7.3], 5.4 [2.3-12.7], 5.4 [2.5-11.7], 6.6 [1.6-26.4] respectively). The other risk factors such as past hospitalization surgery, tattooing, being a healthcare worker, or practising tattooing or piercing were not associated with HCV infection.

CONCLUSION

To be exposed to ventoused scarifications or acupuncture are risk factors for the transmission of HCV in Vietnam. A wide information campaign on hygiene practices for general population as well as the practitioners is needed to ensure safer health cares in traditional medicine.

Impact of a six-year control programme on surgical site infections in France: results of the INCISO surveillance

Surgical site infections (SSI) are a key target of nosocomial infection control policy. We evaluated the impact of a six-year surveillance system based on data from INCISO, a network of volunteer surgical wards from hospitals in Northern France. Each year surgical patients were enrolled consecutively and surveyed during their in- and out-hospital stay until 30 days following surgery. A standardised form was completed for each patient including SSI diagnosis according to standard criteria and several risk factors such as wound class, American Society of Anesthesiologists score, operation duration, elective/emergency, videoscopy and type of surgery. A dashboard was displayed at the end of each annual survey, so that participants could compare with other surgery adjusted for National Nosocomial Infections Surveillance system (NNIS) risk index and standardised incidence ratio (SIR). Over the six years, 3661 SSI were identified in 150 440 surgical patients (crude incidence: 2.4%) from 548 surgery wards. The crude SSI incidence decreased from 3.8 to 1.7% (P for trend <0.0001, relative reduction: -55%) and the NNIS-0 adjusted SSI incidence from 2.0 to 1% (P for trend <0.0001; relative reduction: -50%). An active surveillance system striving for benchmark through a network is an effective strategy to reduce SSI incidence. Sustaining control efforts have to be made to maintain low SSI level beyond the three primer years.

Impact of a five-year surveillance of central venous catheter infections in the REACAT intensive care unit network in France

Central venous catheter (CVC)-related infections (CRIs) are a key target for infection control in intensive care units (ICUs). The aim of this study was to describe temporal trends of CRI incidence in a network of volunteer ICUs in Northern France. During a 4 month surveillance period each year, all CVCs in place for more than 48h were prospectively followed until removal or patient discharge. Standard clinical and microbiological criteria were used to define colonization and CRI. The standardized incidence ratio (SIR) was estimated by dividing the number of observed CRIs by the number of expected CRIs, which was computed using a logistic regression model including risk factors for CRI. CRI incidence and SIR were fed back to ICUs as a benchmark at the end of each period. From 2001 to 2005, 135 ICUs participated for at least one surveillance period. Overall, 11 703 CVC in 9182 patients (122 495 CVC-days) were included. CRI incidence was 2.8 per 1000 CVC-days. Among 35 ICUs that participated for three or more consecutive periods, CRI incidence decreased significantly by 58.6%. SIR also decreased significantly from the first to the third surveillance period in these ICUs. These results suggest that surveillance programmes have a significant impact on CRI risk in ICUs and remain an important strategy for combating nosocomial infections in these settings.