Preintubation application of oral chlorhexidine does not provide additional benefit in prevention of early-onset ventilator-associated pneumonia

BACKGROUND

Daily application of oral chlorhexidine gluconate (CHX) following intubation to reduce the risk of ventilator-associated pneumonia (VAP) is now the standard of care in many ICUs. This randomized clinical trial evaluated the benefit of adding a preintubation CHX dose to the known benefit of postintubation CHX to reduce the risk of early-onset VAP. A secondary aim was to test the effect of a preintubation oral application of CHX on early endotracheal tube (ETT) colonization.

METHODS

Subjects (N = 314) were recruited from two teaching hospitals and were randomly assigned to oral application of 5 mL CHX 0.12% solution before intubation (intervention group, n = 157), or to a control group (n = 157) who received no CHX before intubation. All subjects received CHX bid after intubation. Groups were compared using a repeated-measures model with Clinical Pulmonary Infection Score (CPIS) as the response variable. In a planned subset of subjects, ETTs were cultured at extubation.

RESULTS

Application of a preintubation dose of CHX did not provide benefit over the intervention period beyond that afforded by daily oral CHX following intubation. ETT colonization at extubation was < 20% in both groups (no statistically significant difference). Mean CPIS remained below 6 (VAP threshold score) in both groups.

CONCLUSIONS

Although it is feasible to deliver CHX prior to intubation (including emergent or urgent intubation), the results suggest that preintubation CHX may be inconsequential when the ventilator bundle, including daily oral CHX, is in place. During the preintubation period, providers should focus their attention on other critical activities.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00893763; URL: www.clinicaltrials.gov.

Chlorhexidine bathing and health care-associated infections: a randomized clinical trial

IMPORTANCE

Daily bathing of critically ill patients with the broad-spectrum, topical antimicrobial agent chlorhexidine is widely performed and may reduce health care-associated infections.

OBJECTIVE

To determine if daily bathing of critically ill patients with chlorhexidine decreases the incidence of health care-associated infections.

DESIGN, SETTING, AND PARTICIPANTS

A pragmatic cluster randomized, crossover study of 9340 patients admitted to 5 adult intensive care units of a tertiary medical center in Nashville, Tennessee, from July 2012 through July 2013.

INTERVENTIONS

Units performed once-daily bathing of all patients with disposable cloths impregnated with 2% chlorhexidine or nonantimicrobial cloths as a control. Bathing treatments were performed for a 10-week period followed by a 2-week washout period during which patients were bathed with nonantimicrobial disposable cloths, before crossover to the alternate bathing treatment for 10 weeks. Each unit crossed over between bathing assignments 3 times during the study.

MAIN OUTCOMES AND MEASURES

The primary prespecified outcome was a composite of central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonia (VAP), and Clostridium difficile infections. Secondary outcomes included rates of clinical cultures that tested positive for multidrug-resistant organisms, blood culture contamination, health care-associated bloodstream infections, and rates of the primary outcome by ICU.

RESULTS

During the chlorhexidine bathing period, 55 infections occurred: 4 CLABSI, 21 CAUTI, 17 VAP, and 13 C difficile. During the control bathing period, 60 infections occurred: 4 CLABSI, 32 CAUTI, 8 VAP, and 16 C difficile. The primary outcome rate was 2.86 per 1000 patient-days during the chlorhexidine and 2.90 per 1000 patient-days during the control bathing periods (rate difference, -0.04; 95% CI, -1.10 to 1.01; P = .95). After adjusting for baseline variables, no difference between groups in the rate of the primary outcome was detected. Chlorhexidine bathing did not change rates of infection-related secondary outcomes including hospital-acquired bloodstream infections, blood culture contamination, or clinical cultures yielding multidrug-resistant organisms. In a prespecified subgroup analysis, no difference in the primary outcome was detected in any individual intensive care unit.

CONCLUSION AND RELEVANCE

In this pragmatic trial, daily bathing with chlorhexidine did not reduce the incidence of health care-associated infections including CLABSIs, CAUTIs, VAP, or C difficile. These findings do not support daily bathing of critically ill patients with chlorhexidine.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02033187.

Introducing Alcohol-Based Hand Rub for Hand Hygiene The Critical Need for Training

Background.

Use of an alcohol-based hand rub for hand hygiene has recently been recommended by the Centers for Disease Control and Prevention. However, the proper technique for using hand rub has not been well described and is not routinely taught in hospitals.

Objective.

To evaluate the impact of training on proper technique as outlined by the European Standard for testing alcohol-based hand rubs (European Norm 1500) in a clinical study.

Design, Setting, and Patients.

Prospective study including 180 healthcare workers (HCWs) in a 450-bed, university-affiliated geriatric hospital where alcohol-based hand rub was introduced in the late 1970s.

Intervention.

Structured training program in hand hygiene with alcohol-based hand rub. Technique for using hand rub was tested by the addition of a fluorescent dye to the disinfectant and the number of areas missed was quantified by a validated visual assessment method. In addition, the number of bacteria eradicated was estimated by calculating the difference between the log10 number of colony-forming units (cfu) of bacteria on the fingertips before and after the procedure, and reported as reduction factor (RF).

Main Outcome Measure.

Log10 cfu bacterial counts on fingertips before and after training in the appropriate technique for using hand rub.

Results.

At baseline, only 31% of HCWs used proper technique, yielding a low RF of 1.4 log10 cfu bacterial count. Training improved HCW compliance to 74% and increased the RF to 2.2 log10 cfu bacterial count, an increase of almost 50% (P < .001). Several factors, such as applying the proper amount of hand rub, were significantly associated with the increased RF.

Conclusion.

These results demonstrate that education on the proper technique for using hand rub, as outlined in EN 1500, can significantly increase the degree of bacterial killing.

Population Kinetics of the Skin Flora on Gloved Hands Following Surgical Hand Disinfection With 3 Propanol-Based Hand Rubs: A Prospective, Randomized, Double-Blind Trial

Objective.

To study the bacterial population kinetics on gloved hands following hand treatment with 3 optically indistinguishable, alcohol-based surgical hand rubs, with and without supplements to delay bacterial regrowth.

Design.

Prospective, randomized, double-blind, balanced quasi-Greco-Latin square design.

Setting.

Microbiology laboratory of the Medical University Vienna, Austria.

Participants.

Twenty-four healthy adult volunteers without skin lesions.

Surgical Hand Rubs.

The following hand rubs, all stained blue, were applied to the hands for 3 minutes: 1-propanol 60% vol/vol (A); 2-propanol 70% m/m plus chlorhexidine gluconate 0.5% wt/wt (B); 2-propanol 45% wt/wt plus 1-propanol 30% wt/wt plus mecetronium etilsulfate 0.2% wt/wt (C). As a reference formulation (R), 1-propanol 60% vol/vol, unstained, was applied for the same amount of time.

Method.

In 8 once-weekly tests, 24 subjects randomly assigned to use the 4 hand rubs in groups of 6 persons each performed hand hygiene according to the method described in European Norm 12791. Every subject used one preparation at a time, the antimicrobial effect of which was evaluated at 2 sampling times. After week 8, each volunteer had tested every preparation at every preset sampling time. All preparations were tested in parallel.

Results.

The mean pretreatment counts of viable bacteria (in colony-forming units per milliliter) in fluid samples were not significantly different between week 1 and week 8, nor between the right and left hands (analysis of variance [ANOVA], P > .1). Immediately after applying the formulation (t0), bactericidal effects of the blinded formulations A and C were equivalent to that of the reference formulation R, whereas the effect of B was questionable. The population kinetics of the flora on the hands proceeded from large and fast initial reductions of the skin flora by 2.7 log units (A), 3.1 log units (B), 3.3 log units (reference formulation), and 3.5 log units (C), to slow regrowth. However, even after 6 hours wearing gloves viable bacterial counts remained significantly (P < .01) below the baseline values (by 0.9 log [reference formulation], 1.1 log [A and B], and 1.5 log [C]). The slowest regrowth 1 and 3 hours after application (∆ from t0, 0.1 log and 0.7 log respectively) was seen with formulation C, and the slowest regrowth after 6 hours was seen with formulation B (∆ from t0, 1.6 log). These differences did, however, not reach statistical significance.

Conclusions.

With respect to the rapid and dramatic antibacterial action of suitable alcohols at high concentrations and with appropriate neutralizers, the contribution of supplements to the delay of bacterial regrowth on gloved hands appears rather minor, if a product only exerts an immediate effect equivalent to that of the reference disinfection procedure described in EN 12791.

[Comparison of root canal system disinfection effectiveness with and without rubber dam use]

INTRODUCTION

Endodontic treatment consists in necrotic pulp removal, proper root canal preparation, and sealed obliteration. The effectiveness of treatment depends on careful root canal disinfection of existing bacteria. Modern endodontics recommends the use of a rubber dam, not only to protect the patient from endodontic instrument aspiration, but also to protect root canals from bacteria existing in saliva. The aim of the study is a comparison of root canal disinfection among patients treated with and without rubber dam protection.

MATERIAL AND METHODS

Endodontic treatient of 36 patients who came to the Department of Conservative Dentistry and Endodontics was performed. 36 teeth were qualified to the treatment. In 17 patients the whole treatment was done with rubber dam protection. In the other 19 (II group) the treated tooth was isolated only by cotton rolls. After chamber trepanation, and after chemo-mechanical root canal preparation, samples of root canal bacteria were taken. After 24h incubation, the density of bacterial suspension was checked using a spectrophotometer.

RESULTS

In both groups of patients very similar results were obtained: a high density of bacterial suspension in samples taken before treatment, and a significantly lower density in samples taken after chemo-mechanical root canal preparation.

CONCLUSIONS

In our research the use or lack of use of a rubber dam does not change the effectiveness of root canal disinfection.

Effectivity of antiseptics against some pathogens

INTRODUCTION

The efficacy of antiseptics against bacteria and fungi is different. The choice of optimal antiseptic solution is very important in prophylaxis of hospital infections.

MATERIAL AND METHODS

In this study the efficacy of different antiseptics against some pathogens (Klebsiella pneumoniae ESBL (+), Acinetobacter baumannii, Pseudomonas aeruginosa, Staphylococcus aureus MRSA, Candida dublinensis) was analyzed. The disc diffusion, similar to the method used in antibiotic sensitivity testing was applied. We assumed that the size of inhibition zone of bacterial growth corresponds with the efficacy of antiseptic.

RESULTS AND CONCLUSION

The 2% alcoholic solution of chlorhexidine was the most effective antiseptic in our study.

Quaternary ammonium biocides: efficacy in application

Quaternary ammonium compounds (QACs) are among the most commonly used disinfectants. There has been concern that their widespread use will lead to the development of resistant organisms, and it has been suggested that limits should be place on their use. While increases in tolerance to QACs have been observed, there is no clear evidence to support the development of resistance to QACs. Since efflux pumps are believe to account for at least some of the increased tolerance found in bacteria, there has been concern that this will enhance the resistance of bacteria to certain antibiotics. QACs are membrane-active agents interacting with the cytoplasmic membrane of bacteria and lipids of viruses. The wide variety of chemical structures possible has seen an evolution in their effectiveness and expansion of applications over the last century, including non-lipid-containing viruses (i.e., noroviruses). Selection of formulations and methods of application have been shown to affect the efficacy of QACs. While numerous laboratory studies on the efficacy of QACs are available, relatively few studies have been conducted to assess their efficacy in practice. Better standardized tests for assessing and defining the differences between increases in tolerance versus resistance are needed. The ecological dynamics of microbial communities where QACs are a main line of defense against exposure to pathogens need to be better understood in terms of sublethal doses and antibiotic resistance.

Phenol Toxicity Following Cutaneous Exposure to Creolin®: A Case Report

INTRODUCTION

Phenol is a caustic that may cause cutaneous or gastrointestinal burns depending on the route of exposure. Significant absorption may result in systemic toxicity. We present a case of topical phenol exposure resulting in cutaneous burns and systemic phenol toxicity.

CASE REPORT

A 9-year-old girl was exposed to Creolin(®), a general-purpose disinfectant containing phenol, when her mother applied this product to her head and upper torso. The patient required endotracheal intubation due to depressed mental status; she had cutaneous erythema in the distribution of contact with the cleanser. An initial EKG revealed sinus tachycardia with brief runs of monomorphic ventricular tachycardia. On hospital day (HD) 1, the area of erythema extended to both upper extremities and hyperpigmentation developed over the affected areas, which continued to darken during the hospital course. The patient was extubated late on HD 1. On HD 2, the patient's urine was noted to be a dark green color that resolved later that day. On HD 3, areas of desquamation and decreased sensation developed in skin areas of maximal contact with the cleanser. The patient developed a mild transaminitis with peak AST and ALT levels of 84 units/l and 99 units/l, respectively. The patient was discharged to home on HD 4.

DISCUSSION

Our patient presented with signs of cutaneous and systemic phenol toxicity characterized by dermal burns, depressed mental status, cardiac dysrhythmias, and elevated hepatic transaminases. Phenol exposure may cause systemic toxicity following limited dermal exposure.

Comparison of two different neonatal skin care practices and their influence on transepidermal water loss in healthy newborns within first 10 days of life

AIM

Physiologic post-partum skin adaptation to the relative dry extra-uterine environment is a dynamic process which begins immediately after birth. Considering the differences from adult skin, the neonatal skin is more prone to damage by environmental factors; therefore, skin care regimens should be age adapted to ensure a good epidermal maturation. The effects of two different skin care practices were evaluated by transepidermal water loss (TEWL) measurement in 94 newborns aged ≤ 10 days: group 1 (G1), newborns washed only with a cotton washcloth moistened with water; group 2 (G2), newborns washed with liquid baby cleansers and hydrated with moisturizers. These recordings were compared to TEWL baseline values of the same neonates and to adults' values.

METHODS

A prospective study was conducted in healthy full-term newborns, measuring TEWL with TEWAMETER® TM300. The areas tested were the volar forearm and the popliteal fossa.

RESULTS

In G1 (52 subjects), TEWL mean values were 6.65 ± 2.81 SD (g/m2/h) at volar forearm and 7.49 ± 2.47 SD (g/m2/h) at popliteal fossa. In G2 (42 subjects), TEWL mean values were 8.83 ± 3.05 SD (g/m2/h) at volar forearm and 10.18 ± 3.64 SD (g/m2/h) at popliteal fossa. There were statistically significant differences of TEWL mean values between G1 and G2, newborns and adults, baseline and post-skin care procedures.

CONCLUSION

Tested skin care regimens could influence the process of functional adaptation of skin, in the early postnatal period. We could hypothesize that daily washing with liquid baby cleansers and moisturizing may delay the natural maturation of skin barrier function.

Prevention of transmission of multidrug-resistant organisms during catheter exchange using antimicrobial catheters

Exchanging a central venous catheter (CVC) over a guide wire for a fresh uncoated CVC in the presence of bacteremia can result in cross-infection of the newly exchanged CVC. A recent retrospective clinical study showed that exchanging a catheter over a guide wire in the presence of bacteremia using an antimicrobial minocycline-rifampin (M/R) catheter may improve outcomes. To expand on this, we developed an in vitro cross-contamination model of exchange to evaluate the efficacy of different antimicrobial CVCs in preventing cross-contamination of multidrug-resistant organisms during exchange. Uncoated CVCs were allowed to form biofilm by methicillin-resistant Staphylococcus aureus (MRSA), Staphylococcus epidermidis, Escherichia coli, Pseudomonas aeruginosa, and Candida albicans. After 24 h, the biofilm-colonized CVCs were placed in a glass tube containing bovine calf serum plus Mueller-Hinton broth, and each catheter was exchanged over a guide wire for a fresh uncoated or an M/R-, chlorhexidine-silver sulfadiazine (CHX/SS)-, or chlorhexidine-M/R (CHX-M/R)-coated CVC. Cross-contamination of exchanged catheters was enumerated by sonication and quantitative plating methods. The exchange of M/R CVCs completely prevented cross-contamination by MRSA biofilms compared to control exchanged CVCs (P<0.0001). Exchange with CHX/SS CVCs reduced but did not completely prevent cross-contamination by MRSA (P=0.005). Exchange with CHX-M/R CVCs completely prevented cross-contamination by MRSA, P. aeruginosa, and C. albicans biofilms (P<0.0001). Furthermore, CHX-M/R CVCs were superior to M/R CVCs against P. aeruginosa and C. albicans (P=0.003) and were superior to CHX/SS CVCs against MRSA and P. aeruginosa (P=0.01). In conclusion, exchange with the novel CHX-M/R CVC was the only exchange effective in completely and concurrently preventing cross-contamination from bacteria and Candida.

[Formation of Enterobacter cloacae resistance to disinfectants under the effect of bactericidal concentrations of quaternry ammonium compounds in the experiment]

AIM

Study the possibility of formation of induced resistance of purulent-septic infection (PSI) causative agents against disinfectants (DI) in bactericidal concentrations.

MATERIALS AND METHODS

Daily exposure to bactericidal concentrations of preparations from the group of quaternary ammonium compounds (QAC) on Enterobacter cloacae strain that has incomplete sensitivity to the same disinfectants on the same test objects was carried out in experiments on test objects from wood and plastic. Exposure was carried out until the moment of transition from incomplete sensitivity to resistance.

RESULTS

E. cloacae strain that initially had incomplete sensitivity to various disinfectants of the QAC group in antibacterial concentrations according to manuals acquires resistance on test objects from wood and plastic after 2 - 12 exposures to the preparations.

CONCLUSION

The data obtained give evidence that the resistance of PSI causative agents to disinfectants can take place not only under the influence of low concentrations of the preparations but also during use of disinfectants at bactericidal concentrations.

[Sensitivity of nosocomial purulent-septic infection causative agents to disinfection agents and antibiotics]

AIM

Study the sensitivity of nosocomial purulent-septic infection (PSI) causative agents to disinfectants (DA) and antibiotics (AB).

MATERIALS AND METHODS

Sensitivity to DA and AB of 209 PSI causative agent strains isolated from patients and the environment of 2 obstetric and 3 surgical hospitals was studied in 2009-2011. Sensitivity to DA of 94 strains and to AB of 189 strains of Pseudomonas aeruginosa isolated from patients with signs of PSI of reanimation and intensive therapy and surgical departments of a multi-field hospital was studied in 2012. Sensitivity to DA was determined on test-surfaces and in solution according to guidelines by V.V. Shkarin et al., 2010; sensitivity to AB - by disc-diffusion method.

RESULTS

Among PSI causative agents resistant to DA the portion of poly-antibiotic resistant strains is higher than among microorganisms sensitive to DA, and among antibiotic resistant bacteria the number of strains resistant to DA is higher than among sensitive to antibiotics. The increase of resistance to DA and AB of P. aeruginosa strains is observed in parallel to the increase of volume of the antibacterial preparations used.

CONCLUSION

The results obtained give evidence of the possibility of formation of combined (associated) resistance to DA and AB by nosocomial PSI causative agents against the background of increase of their consumption.

Larvicidal effect of disinfectant soap on Anopheles gambiae s.s (Diptera: Culicidae) in laboratory and semifield environs

BACKGROUND

Mosquito larval control using chemicals and biological agents is of paramount importance in vector population and disease incidence reduction. A commercial synthetic disinfectant soap was evaluated against larvae of Anopheles gambiae s.s. in both laboratory and semi field conditions.

METHOD

Five concentrations of commercial synthetic disinfectant soap (0.0001, 0.001, 0.01, 0.1 and 1%) were prepared and evaluated against third instar larvae in laboratory and semi field environments. Mortality was scored at 12, 24, 48, and 72 hrs. Each dosage had 6 replicates, having twenty 3rd instar larvae of An.gambiae s.s.

RESULTS

In the laboratory phase, all dosages had significantly higher larval mortalities than in controls, while in semi field conditions, the dosages of 0.0001, 0.001 and 0.01% had lower mortalities than laboratory trials. In the comparison between semi field and laboratory trials, only 0.1 and 1% dosage had significant difference with more mortality in semifield conditions. Proportions of larvae that died during mortality monitoring intervals in laboratory and semi field had significant differences only at 12 hrs and 72 hrs.

CONCLUSION

The findings of this study have demonstrated that the mortality of larvae caused by commercial synthetic disinfectant soap is worth further studies in open water bodies. More studies are necessary to find out the effect of sunlight on the chemistry of the synthetic disinfectant and other variables in small scale full field trials.

Hand sanitizer-dispensing door handles increase hand hygiene compliance: a pilot study

Improving rates of hand hygiene compliance (HHC) has been shown to reduce nosocomial disease. We compared the HHC for a traditional wall-mounted unit and a novel sanitizer-dispensing door handle device in a hospital inpatient ultrasound area. HHC increased 24.5%-77.1% (P < .001) for the exam room with the sanitizer-dispensing door handle, whereas it remained unchanged for the other rooms. Technical improvements like a sanitizer-dispensing door handle can improve hospital HHC.

Infection control link nurse program: an interdisciplinary approach in targeting health care-acquired infection

BACKGROUND

We describe a successful interdisciplinary liaison program that effectively reduced health care-acquired (HCA), methicillin-resistant Staphylococcus aureus (MRSA) in a university hospital setting.

METHODS

Baseline was from January 2006 to March 2008, and intervention period was April 2008 to September 2009. Staff nurses were trained to be liaisons (link nurses) to infection prevention (IP) personnel with clearly defined goals assigned and with ongoing monthly education. HCA-MRSA incidence per 1,000 patient-days (PD) was compared between baseline and intervention period along with total and non-HCA-MRSA, HCA and non-HCA-MRSA bacteremia, and hand soap/sanitizer usage. Hand hygiene compliance was assessed.

RESULTS

A reduction in MRSA rates was as follows in intervention period compared with baseline: HCA-MRSA decreased by 28% from 0.92 to 0.67 cases per 1,000 PD (incidence rate ratio, 0.72; 95% confidence interval: 0.62-0.83, P < .001), and HCA-MRSA bacteremia rate was reduced by 41% from 0.18 to 0.10 per 1,000 PD (incidence rate ratio, 0.59; 95% confidence interval: 0.42-0.84, P = .003). Total MRSA rate and MRSA bacteremia rate also showed significant reduction with nonsignificant reductions in overall non-HCA-MRSA and non-HCA-MRSA bacteremia. Hand soap/sanitizer usage and compliance with hand hygiene also increased significantly during IP.

CONCLUSION

Link nurse program effectively reduced HCA-MRSA. Goal-defined metrics with ongoing re-education for the nurses by IP personnel helped drive these results.

Inactivation kinetics of formaldehyde on N-acetyl-β-D-glucosaminidase from Nile tilapia (Oreochromis niloticus)

Formaldehyde is a widely used sanitizer in aquaculture in China, while the appropriate concentration is not available to be used effectively and without damage to tilapia much less to its reproductive function. N-acetyl-β-D-glucosaminidase (EC 3.2.1.52, NAGase), hydrolyzing the oligomers of N-acetyl-β-D-glucosamine into monomer, is proved to be correlated with reproduction of male animals. In this paper, NAGase from spermary of tilapia was chosen as the material to study the effects of formaldehyde on its activity in order to further investigate the effects of formaldehyde use on tilapia reproduction. The results showed the relationship between the residual enzyme activity and the concentration of formaldehyde was concentration dependent, and the IC50 value was estimated to be 3.2 ± 0.1 %. Appropriate concentration of formaldehyde leaded to competitive reversible inhibition on tilapia NAGase. Moreover, formaldehyde could reduce the thermal and pH stability of the enzyme. The inactivation kinetics of formaldehyde on the enzyme was studied using the kinetic method of substrate reaction. The inactivation model was setup, and the rate constants were determined. The results showed that the inactivation of formaldehyde on tilapia NAGase was a slow, reversible reaction with partially residual activity. The results will give some basis to determine the concentration of formaldehyde used in tilapia culture.

Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis

OBJECTIVES

To determine the effect on mortality of selective digestive decontamination, selective oropharyngeal decontamination, and topical oropharyngeal chlorhexidine in adult patients in general intensive care units and to compare these interventions with each other in a network meta-analysis.

DESIGN

Systematic review, conventional meta-analysis, and network meta-analysis. Medline, Embase, and CENTRAL were searched to December 2012. Previous meta-analyses, conference abstracts, and key journals were also searched. We used pairwise meta-analyses to estimate direct evidence from intervention-control trials and a network meta-analysis within a Bayesian framework to combine direct and indirect evidence.

INCLUSION CRITERIA

Prospective randomised controlled trials that recruited adult patients in general intensive care units and studied selective digestive decontamination, selective oropharyngeal decontamination, or oropharyngeal chlorhexidine compared with standard care or placebo.

RESULTS

Selective digestive decontamination had a favourable effect on mortality, with a direct evidence odds ratio of 0.73 (95% confidence interval 0.64 to 0.84). The direct evidence odds ratio for selective oropharyngeal decontamination was 0.85 (0.74 to 0.97). Chlorhexidine was associated with increased mortality (odds ratio 1.25, 1.05 to 1.50). When each intervention was compared with the other, both selective digestive decontamination and selective oropharyngeal decontamination were superior to chlorhexidine. The difference between selective digestive decontamination and selective oropharyngeal decontamination was uncertain.

CONCLUSION

Selective digestive decontamination has a favourable effect on mortality in adult patients in general intensive care units. In these patients, the effect of selective oropharyngeal decontamination is less certain. Both selective digestive decontamination and selective oropharyngeal decontamination are superior to chlorhexidine, and there is a possibility that chlorhexidine is associated with increased mortality.

The value of ready-to-use disinfectant wipes: compliance, employee time, and costs

Cleaning and disinfection practices of environmental surfaces are critical interventions for reducing health care-associated infections. We studied the value of ready-to-use cleaning and disinfection wipes compared with the traditional towel and bucket method. When using ready-to-use wipes, we found compliance to be significantly higher, a more rapid cleaning and disinfection process, and potential cost savings. Facilities should consider these products when making environmental services product selections.

Chlorhexidine-silver sulfadiazine-impregnated venous catheters save costs

BACKGROUND

Previous cost-effectiveness analyses have found that the use of chlorhexidine-silver sulfadiazine (CHSS)-impregnated catheters is associated with decreased catheter-related bloodstream infections (CRBSI) and central venous catheter (CVC)-related costs. However, in these analyses, the CVC-related cost included the increase of hospital stay.

OBJECTIVE

Our aim was to determine the immediate CVC-related cost (including only the cost of CVC, diagnosis of CRBSI, and antimicrobials for the treatment of CRBSI) of using a CHSS or a standard catheter in internal jugular venous access.

METHODS

We performed a prospective, observational, cohort study of patients admitted to the intensive care unit (ICU), Hospital Universitario de Canarias (Tenerife, Spain), who received 1 or more internal jugular venous catheters.

RESULTS

The study included 245 CHSS-impregnated catheters and 391 standard catheters. Exact logistic regression analysis showed that CHSS-impregnated catheters were associated with a lower incidence of CRBSI, controlling for catheter duration, than standard catheters (0 vs 5.04 CRBSI per 1,000 catheter-days, respectively; odds ratio, 0.80; 95% confidence interval: 0.712-0.898; P < .001). Poisson regression showed that CHSS-impregnated catheters were associated with lower CVC-related cost per day than standard catheters (€3.78 ± €4.45 vs €7.28 ± €16.71, respectively; odds ratio, 0.52; 95% confidence interval: 0.504-0.535; P < .001). Survival analysis showed that CHSS-impregnated catheters were associated with increased CRBSI-free time compared with standard catheters (χ(2) = 14.9; P < .001).

CONCLUSION

The use of CHSS-impregnated catheters reduced the incidence of CRBSI and immediate CVC-related costs in the internal jugular venous access.

Poorly processed reusable surface disinfection tissue dispensers may be a source of infection

BACKGROUND

Reusable surface disinfectant tissue dispensers are used in hospitals in many countries because they allow immediate access to pre-soaked tissues for targeted surface decontamination. On the other hand disinfectant solutions with some active ingredients may get contaminated and cause outbreaks. We determined the frequency of contaminated surface disinfectant solutions in reusable dispensers and the ability of isolates to multiply in different formulations.

METHODS

Reusable tissue dispensers with different surface disinfectants were randomly collected from healthcare facilities. Solutions were investigated for bacterial contamination. The efficacy of two surface disinfectants was determined in suspension tests against two isolated species directly from a contaminated solution or after 5 passages without selection pressure in triplicate. Freshly prepared use solutions were contaminated to determine survival of isolates.

RESULTS

66 dispensers containing disinfectant solutions with surface-active ingredients were collected in 15 healthcare facilities. 28 dispensers from nine healthcare facilities were contaminated with approximately 107 cells per mL of Achromobacter species 3 (9 hospitals), Achromobacter xylosoxidans or Serratia marcescens (1 hospital each). In none of the hospitals dispenser processing had been adequately performed. Isolates regained susceptibility to the disinfectants after five passages without selection pressure but were still able to multiply in different formulations from different manufacturers at room temperature within 7 days.

CONCLUSIONS

Neglecting adequate processing of surface disinfectant dispensers has contributed to frequent and heavy contamination of use-solutions based on surface active ingredients. Tissue dispenser processing should be taken seriously in clinical practice.

[Influence of immobilized forms of sodium hypochlorite on the immediate and long-term results of treatment of the patients with diffuse peritonitis]

An analysis of complex examination and results of treatment was made in 290 patients with diffuse peritonitis. The patients were divided into two groups according to way of sanation of the abdominal cavity. The sanation with 0.03% aqueous solution of sodium hypochlorite was used for the first group of 155 patients. The immobilized forms of sodium hypochlorite in carboxymethyl cellulose gel were applied in the second group. The rate of postoperative complications was decreased on 15.4%, the lethality--on 8.2% in the case of application of the immobilized forms of sodium hypochlorite. The developed technology allowed increasing of physical component of life quality of the patients in 1.3 times, though it didn't influence on psychical component.

Pin site care for preventing infections associated with external bone fixators and pins

BACKGROUND

Metal pins are used to apply skeletal traction or external fixation devices in the management of orthopaedic fractures. These percutaneous pins protrude through the skin, and the way in which they are treated after insertion may affect the incidence of pin site infection. This review set out to summarise the evidence of pin site care on infection rates.

OBJECTIVES

To assess the effect on infection rates of different methods of cleansing and dressing orthopaedic percutaneous pin sites.

SEARCH METHODS

In September 2013, for this third update, we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL.

SELECTION CRITERIA

We evaluated all randomised controlled trials (RCTs) that compared the effect on infection and other complication rates of different methods of cleansing or dressing orthopaedic percutaneous pin sites.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the citations retrieved by the search strategies for reports of relevant RCTs, then independently selected trials that satisfied the inclusion criteria, extracted data and undertook quality assessment.

MAIN RESULTS

A total of eleven trials (572 participants) were eligible for inclusion in the review but not all participants contributed data to each comparison. Three trials compared a cleansing regimen (saline, alcohol, hydrogen peroxide or antibacterial soap) with no cleansing (application of a dry dressing), three trials compared alternative sterile cleansing solutions (saline, alcohol, peroxide, povidone iodine), three trials compared methods of cleansing (one trial compared identical pin site care performed daily or weekly and the two others compared sterile with non sterile techniques), one trial compared daily pin site care with no care and six trials compared different dressings (using different solutions/ointments and dry and impregnated gauze or sponges). One small blinded study of 38 patients found that the risk of pin site infection was significantly reduced with polyhexamethylene biguanide (PHMB) gauze when compared to plain gauze (RR 0.23, 95% CI 0.12 to 0.44) (infection rate of 1% in the PHMB group and 4.5% in the control group) but this study was at high risk of bias as the unit of analysis was observations rather than patients. There were no other statistically significant differences between groups in any of the other trials.

AUTHORS' CONCLUSIONS

The available trial evidence was not extensive, was very heterogeneous and generally of poor quality, so there was insufficient evidence to be able to identify a strategy of pin site care that minimises infection rates. Adequately-powered randomised trials are required to examine the effects of different pin care regimens, and co-interventions - such as antibiotic use - and other extraneous factors must be controlled in the study designs.

Catheter lubrication and fixation: interventions

This article looks at the indications for catheterisation, the anatomy of the urethra, the importance of asepsis and the rationale for the use of urethral lubrication for catheter insertion. The variations of lubrication available are discussed, including the use of products containing lidocaine and chlorhexidine. It then considers the problems caused by traction to the catheter and discusses the securement devices available for preventing tissue damage at the bladder neck, within the urethra and also at the meatus. The variation of devices is examined along with the potential problems associated with their use. Finally, it discusses the importance of clinicians being knowledgeable about the problems looked at and how to resolve them.