International Nosocomial Infection Control Consortium (INICC) report, data summary of 36 countries, for 2004-2009

Catheter-associated urinary tract infection

This guideline contains updated recommendations on the management and prevention of CAUTIs by the Urological Association of Asia and the Asian Association of Urinary Tract Infection and Sexually Transmitted Infection.

Hand-hygiene-related clinical trials reported between 2014 and 2020: a comprehensive systematic review

BACKGROUND

There is general consensus that hand hygiene is the most effective way to prevent healthcare-associated infections. However, low rates of compliance amongst healthcare workers have been reported globally. The coronavirus disease 2019 pandemic has further emphasized the need for global improvement in hand hygiene compliance by healthcare workers.

AIM

This comprehensive systematic review provides an up-to-date compilation of clinical trials, reported between 2014 and 2020, assessing hand hygiene interventions in order to inform healthcare leaders and practitioners regarding approaches to reduce healthcare-associated infections using hand hygiene.

METHODS

CINAHL, Cochrane, EMbase, Medline, PubMed and Web of Science databases were searched for clinical trials published between March 2014 and December 2020 on the topic of hand hygiene compliance among healthcare workers. In total, 332 papers were identified from these searches, of which 57 studies met the inclusion criteria.

FINDINGS

Forty-five of the 57 studies (79%) included in this review were conducted in Asia, Europe and the USA. The large majority of these clinical trials were conducted in acute care facilities, including hospital wards and intensive care facilities. Nurses represented the largest group of healthcare workers studied (44 studies, 77%), followed by physicians (41 studies, 72%). Thirty-six studies (63%) adopted the World Health Organization's multi-modal framework or a variation of this framework, and many of them recorded hand hygiene opportunities at each of the 'Five Moments'. However, recording of hand hygiene technique was not common.

CONCLUSION

Both single intervention and multi-modal hand hygiene strategies can achieve modest-to-moderate improvements in hand hygiene compliance among healthcare workers.

Clinical Utility of In-house Metagenomic Next-generation Sequencing for the Diagnosis of Lower Respiratory Tract Infections and Analysis of the Host Immune Response

BACKGROUND

Only few pathogens that cause lower respiratory tract infections (LRTIs) can be identified due to limitations of traditional microbiological methods and the complexity of the oropharyngeal normal flora. Metagenomic next-generation sequencing (mNGS) has the potential to solve this problem.

METHODS

This prospective observational study sequentially enrolled 93 patients with LRTI and 69 patients without LRTI who visited Peking University People's Hospital in 2019. Pathogens in bronchoalveolar lavage fluid (BALF) specimens were detected using mNGS (DNA and RNA) and traditional microbiological assays. Human transcriptomes were compared between LRTI and non-LRTI, bacterial and viral LRTI, and tuberculosis and nontuberculosis groups.

RESULTS

Among 93 patients with LRTI, 20%, 35%, and 65% of cases were detected as definite or probable pathogens by culture, all microbiological tests, and mNGS, respectively. Our in-house BALF mNGS platform had an approximately 2-working-day turnaround time and detected more viruses and fungi than the other methods. Taking the composite reference standard as a gold standard, it had a sensitivity of 66.7%, specificity of 75.4%, positive-predictive value of 78.5%, and negative-predictive value of 62.7%. LRTI-, viral LRTI-, and tuberculosis-related differentially expressed genes were respectively related to immunity responses to infection, viral transcription and response to interferon-γ pathways, and perforin 1 and T-cell receptor B variable 9.

CONCLUSIONS

Metagenomic DNA and RNA-seq can identify a wide range of LRTI pathogens, with improved sensitivity for viruses and fungi. Our in-host platform is likely feasible in the clinic. Host transcriptome data are expected to be useful for the diagnosis of LRTIs.

Economic Burden of Urinary Tract Infections From Antibiotic-Resistant Escherichia coli Among Hospitalized Adult Patients in Lebanon: A Prospective Cohort Study

OBJECTIVES

The rising incidence of urinary tract infections (UTIs) attributable to Escherichia coli resistant isolates is becoming a serious public health concern. Although global rates of infection vary considerably by region, the growing prevalence of this uropathogen has been associated with a high economic burden and health strain. This study aims: (1) to estimate the differences in clinical and economic outcomes between 2 groups of adult hospitalized patients with UTIs from E. coli resistant and susceptible bacteria and (2) to investigate drivers of this cost from a payer's perspective.

METHODS

A prospective multicenter cohort study was conducted in 10 hospitals in Lebanon. The cost analysis followed a bottom-up microcosting approach; a linear regression was constructed to evaluate the predictors of hospitalization costs and a Cox proportional hazards model was used to estimate the impact of resistance on length of stay (LOS) and in-hospital mortality.

RESULTS

Out of 467 inpatients, 250 cases were because of resistant E. coli isolates. Results showed that patients with resistant uropathogens had 29% higher mean total hospitalization costs ($3429 vs $2651; P = .004), and an extended median LOS (6 days vs 5 days; P = .020) compared with susceptible cohorts. The selection of resistant bacteria and the Charlson comorbidity index predicted higher total hospitalization costs and in-hospital mortality.

CONCLUSION

In an era of increased pressure for cost containment, this study showed the burden of treating UTIs resulting from resistant bacteria. The results can inform cost-effectiveness analyses that intend to evaluate the benefit of a national action plan aimed at decreasing the impact of antibiotic resistance.

Pneumonia

Pneumonia is a common acute respiratory infection that affects the alveoli and distal airways; it is a major health problem and associated with high morbidity and short-term and long-term mortality in all age groups worldwide. Pneumonia is broadly divided into community-acquired pneumonia or hospital-acquired pneumonia. A large variety of microorganisms can cause pneumonia, including bacteria, respiratory viruses and fungi, and there are great geographical variations in their prevalence. Pneumonia occurs more commonly in susceptible individuals, including children of <5 years of age and older adults with prior chronic conditions. Development of the disease largely depends on the host immune response, with pathogen characteristics having a less prominent role. Individuals with pneumonia often present with respiratory and systemic symptoms, and diagnosis is based on both clinical presentation and radiological findings. It is crucial to identify the causative pathogens, as delayed and inadequate antimicrobial therapy can lead to poor outcomes. New antibiotic and non-antibiotic therapies, in addition to rapid and accurate diagnostic tests that can detect pathogens and antibiotic resistance will improve the management of pneumonia.

Multicenter Study of Device-Associated Infection Rates, Bacterial Resistance, Length of Stay, and Mortality in Intensive Care Units of 2 Cities of Vietnam: International Nosocomial Infection Control Consortium Findings

OBJECTIVE

The aim of the study was to report the results of the International Nosocomial Infection Control Consortium (INICC) study conducted from May 2008 to March 2015.

METHODS

A device-associated healthcare-acquired infection surveillance study in three adult intensive care units (ICUs) and 1 neonatal ICU from 4 hospitals in Vietnam using U.S. the Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC/NHSN) definitions and criteria as well as INICC methods.

RESULTS

We followed 1592 adult ICU patients for 12,580 bed-days and 845 neonatal ICU patients for 4907 bed-days. Central line-associated bloodstream infection (CLABSI) per 1000 central line-days rate was 9.8 in medical/surgical UCIs and 1.5 in the medical ICU. Ventilator-associated pneumonia (VAP) rate per 1000 mechanical ventilator-days was 13.4 in medical/surgical ICUs and 23.7 in the medical ICU. Catheter-associated urinary tract infection (CAUTI) rate per 1000 urinary catheter-days was 0.0 in medical/surgical ICUs and 5.3 in the medical ICU. While most device-associated healthcare-acquired infection rates were similar to INICC international rates (4.9 [CLABSI]; 16.5 [VAP]; 5.3 [CAUTI]), they were higher than CDC/NHSN rates (0.8 [CLABSI], 1.1 [VAP], and 1.3 [CAUTI]) for medical/surgical ICUs, with the exception of CAUTI rate for medical/surgical ICU and CLABSI rate for the medical ICU. Because of limited resources of our Vietnamese ICUs, cultures could not be taken as required by the CDC/NHSN criteria, and therefore, there was underreporting of CLABSI and CAUTI, influencing their rates. Most device utilization ratios and bacterial resistance percentages were higher than INICC and CDC/NHSN rates.

CONCLUSIONS

Device-associated healthcare-acquired infection rates found in the ICUs of our study were higher than CDC/NHSN US rates, but similar to INICC international rates. It is necessary to build more capacity to conduct surveillance and prevention strategies.

Sustained Low Incidence Rates of Central Line-Associated Blood Stream Infections in the Intensive Care Unit

Background

Central line-associated bloodstream infection (CLABSI) is an important cause of increased morbidity and mortality in ICUs. The occurrence of CLABSI in significantly higher in developing countries and contributes to the burden of healthcare-associated infections.

Methods

This prospective study was carried out from January 2016 to December 2019 in the intensive care unit at King Faisal Medical Complex in Taif, Saudi Arabia. The Society for Healthcare Epidemiology of America/Infectious Diseases Society of America (SHEA/IDSA) recommendations were introduced and implemented during 2017–2019. In the post-intervention period, observation of hand hygiene, CLABSI bundle compliance, and benchmarking of CLABSI rates were carried out.

Results

The CLABSI incidence rate was 1.12/1,000 central-line days, with a 0.51 utilization ratio in the pre-intervention period. This dropped to 0.46/1,000 central line days with a 0.44 utilization ratio in the post-intervention period. This reduction was also confirmed in benchmarking with National Healthcare Safety Network (NHSN) (50th–75th) percentile pre-intervention vs (25th–50th) percentile post-intervention. Institutional risk assessment revealed a formal educational program as a potential need for improvement. The CLABSIs were caused predominantly by multidrug-resistant Klebsiella pneumoniae.

Conclusion

We observed a reduction and sustained low incidence rate of CLABSI benchmarking to NHSN for 3 years after implementation of the basic SHEA/IDSA recommendations.

The burden of healthcare-associated infections among pediatrics: a repeated point prevalence survey from Pakistan

BACKGROUND

Healthcare-associated infections (HAIs) are considered a major threat to public health resulting in significant morbidity, mortality, and additional costs. The present study aimed to assess the current patterns and risk factors of HAIs among hospitalized children.

MATERIALS AND METHODS

Three repeated point prevalence surveys were conducted in the pediatric inpatients of four hospitals by using the methodology developed by the European Center for Disease Prevention and Control. All patients present in the ward at 8:00 AM on the survey day and not discharged from the hospital on the same day were included. A standardized data collection form containing information on the presence of HAIs and the associated risk factors was completed for the patients.

FINDINGS

Out of 888 hospitalized patients, 116 (13.1%) had the symptoms of HAIs. Most common infections were bloodstream infections (BSIs) (32.8%), pneumonia (21.0%), ear, eyes, nose and throat infections (11.8%), and skin and soft tissue infections (SSTs) (19.0%). Factors significantly associated with infections were the length of hospital stay (p = 0.000), admission to the medicine ward (p = 0.034), and male gender (p = 0.010). BSIs were most common in children belonging to the age group of less than one month (78.9%), who were admitted to intensive care units (73.7%). SSTs including surgical site infections were more prevalent in surgery wards (78.3%).

CONCLUSIONS

A high rate of HAIs among pediatrics was found in Pakistan. Infection control and prevention strategies are needed with a major focus on interventions to prevent the spread of most prevalent HAIs.

Economic Burden of Urinary Tract Infections From Antibiotic-Resistant Escherichia coli Among Hospitalized Adult Patients in Lebanon: A Prospective Cohort Study

OBJECTIVES

The rising incidence of urinary tract infections (UTIs) attributable to Escherichia coli resistant isolates is becoming a serious public health concern. Although global rates of infection vary considerably by region, the growing prevalence of this uropathogen has been associated with a high economic burden and health strain. This study aims: (1) to estimate the differences in clinical and economic outcomes between 2 groups of adult hospitalized patients with UTIs from E. coli resistant and susceptible bacteria and (2) to investigate drivers of this cost from a payer's perspective.

METHODS

A prospective multicenter cohort study was conducted in 10 hospitals in Lebanon. The cost analysis followed a bottom-up microcosting approach; a linear regression was constructed to evaluate the predictors of hospitalization costs and a Cox proportional hazards model was used to estimate the impact of resistance on length of stay (LOS) and in-hospital mortality.

RESULTS

Out of 467 inpatients, 250 cases were because of resistant E. coli isolates. Results showed that patients with resistant uropathogens had 29% higher mean total hospitalization costs ($3429 vs $2651; P = .004), and an extended median LOS (6 days vs 5 days; P = .020) compared with susceptible cohorts. The selection of resistant bacteria and the Charlson comorbidity index predicted higher total hospitalization costs and in-hospital mortality.

CONCLUSION

In an era of increased pressure for cost containment, this study showed the burden of treating UTIs resulting from resistant bacteria. The results can inform cost-effectiveness analyses that intend to evaluate the benefit of a national action plan aimed at decreasing the impact of antibiotic resistance.

Comparing rubbing and scrubbing surgical hand antisepsis with propan-1-ol 60% in accordance with European regulation UNE-EN 12791:2016+A1:2018

A crossover trial was conducted to compare hand rub and hand scrub-brush methods for reducing bacterial loads when using propan-1-ol-60% according to European regulations. Both methods significantly reduced the bacterial load immediately after antisepsis, but only the hand rub method achieved significant bacterial load reduction 3 hours after the procedure.

Bacterial superinfection pneumonia in SARS-CoV-2 respiratory failure

Background

Severe community-acquired pneumonia secondary to SARS-CoV-2 is a leading cause of death. Current guidelines recommend patients with SARS-CoV-2 pneumonia receive empirical antibiotic therapy for suspected bacterial superinfection, but little evidence supports these recommendations.

Methods

We obtained bronchoscopic bronchoalveolar lavage (BAL) samples from patients with SARS-CoV-2 pneumonia requiring mechanical ventilation. We analyzed BAL samples with multiplex PCR and quantitative culture to determine the prevalence of superinfecting pathogens at the time of intubation and identify episodes of ventilator-associated pneumonia (VAP) over the course of mechanical ventilation. We compared antibiotic use with guideline-recommended care.

Results

The 179 ventilated patients with severe SARS-CoV-2 pneumonia discharged from our hospital by June 30, 2020 were analyzed. 162 (90.5%) patients had at least one BAL procedure; 133 (74.3%) within 48 hours after intubation and 112 (62.6%) had at least one subsequent BAL during their hospitalization. A superinfecting pathogen was identified within 48 hours of intubation in 28/133 (21%) patients, most commonly methicillin-sensitive Staphylococcus aureus or Streptococcus species (21/28, 75%). BAL-based treatment reduced antibiotic use compared with guideline-recommended care. 72 patients (44.4%) developed at least one VAP episode. Only 15/72 (20.8%) of initial VAPs were attributable to multidrug-resistant pathogens. The incidence rate of VAP was 45.2/1000 ventilator days.

Conclusions

With use of sensitive diagnostic tools, bacterial superinfection at the time of intubation is infrequent in patients with severe SARS-CoV-2 pneumonia. Treatment based on current guidelines would result in substantial antibiotic overuse. The incidence rate of VAP in ventilated patients with SARS-CoV-2 pneumonia are higher than historically reported.

Intensive Care Unit Nursing Priorities in the United States

This integrative review presents the most recent and relevant critical care nursing research publications in the United States. A comprehensive search identified publications on the topics of delirium; early mobility; communication; palliative care; tele-intensive care unit; care bundle implementation; and prevention, detection, and early management of infection. The evidence is summarized for each of these topics, as well as other research, with suggestions and guidance for end users.

Device-associated health care-associated infections: The effectiveness of a 3-year prevention and control program in the Republic of Cyprus

BACKGROUND

Device-associated health care-associated infections (DA-HAIs) are a major threat to patient safety, particularly in the Intensive Care Unit (ICU). This study aimed to evaluate the effectiveness of a bundle of infection control measures to reduce DA-HAIs in the ICU of a General Hospital in the Republic of Cyprus, over a 3-year period.

METHODS

We studied 599 ICU patients with a length of stay (LOS) for at least 48 hours. Our prospective cohort study was divided into three surveillance phases. Ventilator-associated pneumonia (VAP), central line-associated blood-stream infections (CLABSI), and catheter-associated blood-stream infections (CAUTI) incidence rates, LOS, and mortality were calculated before, during, and after the infection prevention and control programme.

RESULTS

There was a statistically significant reduction in the number of DA-HAI events during the surveillance periods, associated with DA-HAIs prevention efforts. In 2015 (prior to programme implementation), the baseline DA-HAIs instances were 43: 16 VAP (10.1/1000 Device Days), 21 (15.9/1000DD) CLABSIs, and 6 (2.66/1000DD) CAUTIs, (n = 198). During the second phase (2016), CLABSIs prevention measures were implemented and the number of infections were 24: 14 VAP (12.21/1000DD), 4 (4.2/1000DD) CLABSIs, and 6 (3.22/1000DD) CAUTIs, (n = 184). During the third phase (2017), VAP and CAUTI prevention measures were again implemented and the rates were 6: (3 VAP: 12.21/1000DD), 2 (1.95/1000DD) CLABSIs, and 1 (0.41/1000DD) CAUTIs, (n = 217). There was an overall reduction of 87% in the total number of DA-HAIs instances for the period 1 January 2015 to 31 December 2017.

CONCLUSIONS

The significant overall reduction in DA-HAI rates indicates that a comprehensive infection control programme can affect DA-HAI rates.

Impact of lockdown on the microbiological status of the hospital water network during COVID-19 pandemic

The COVID-19 pandemic started in China in early December 2019, and quickly spread around the world. The epidemic gradually started in Italy at the end of February 2020, and by May 31, 2020, 232,664 cases and 33,340 deaths were confirmed. As a result of this pandemic, the Italian Ministerial Decree issued on March 11, 2020, enforced lockdown; therefore, many social, recreational, and cultural centers remained closed for months. In Apulia (southern Italy), all non-urgent hospital activities were suspended, and some wards were closed, with a consequent reduction in the use of the water network and the formation of stagnant water. This situation could enhance the risk of exposure of people to waterborne diseases, including legionellosis. The purpose of this study was to monitor the microbiological quality of the water network (coliforms, E. coli, Enterococci, P. aeruginosa, and Legionella) in three wards (A, B and C) of a large COVID-19 regional hospital, closed for three months due to the COVID-19 emergency. Our study revealed that all three wards' water network showed higher contamination by Legionella pneumophila sg 1 and sg 6 at T1 (after lockdown) compared to the period before the lockdown (T0). In particular, ward A at T1 showed a median value = 5600 CFU/L (range 0-91,000 CFU/L) vs T0, median value = 75 CFU/L (range 0-5000 CFU/L) (p-value = 0.014); ward B at T1 showed a median value = 200 CFU/L (range 0-4200 CFU/L) vs T0, median value = 0 CFU/L (range 0-300 CFU/L) (p-value = 0.016) and ward C at T1 showed a median value = 175 CFU/L (range 0-22,000 CFU/L) vs T0, median value = 0 CFU/L (range 0-340 CFU/L) (p-value < 0.001). In addition, a statistically significant difference was detected in ward B between the number of positive water samples at T0 vs T1 for L. pneumophila sg 1 and sg 6 (24% vs 80% p-value < 0.001) and for coliforms (0% vs 64% p-value < 0.001). Moreover, a median value of coliform load resulted 3 CFU/100 ml (range 0-14 CFU/100 ml) at T1, showing a statistically significant increase versus T0 (0 CFU/100 ml) (p-value < 0.001). Our results highlight the need to implement a water safety plan that includes staff training and a more rigorous environmental microbiological surveillance in all hospitals before occupying a closed ward for a longer than one week, according to national and international guidelines.

How to ventilate obstructive and asthmatic patients

Exacerbations are part of the natural history of chronic obstructive pulmonary disease and asthma. Severe exacerbations can cause acute respiratory failure, which may ultimately require mechanical ventilation. This review summarizes practical ventilator strategies for the management of patients with obstructive airway disease. Such strategies include non-invasive mechanical ventilation to prevent intubation, invasive mechanical ventilation, from the time of intubation to weaning, and strategies intended to prevent post-extubation acute respiratory failure. The role of tracheostomy, the long-term prognosis, and potential future adjunctive strategies are also discussed. Finally, the physiological background that underlies these strategies is detailed.

Comparative Analysis of Proteomes of a Number of Nosocomial Pathogens by KEGG Modules and KEGG Pathways

Nosocomial (hospital-acquired) infections remain a serious challenge for health systems. The reason for this lies not only in the local imperfection of medical practices and protocols. The frequency of infection with antibiotic-resistant strains of bacteria is growing every year, both in developed and developing countries. In this work, a pangenome and comparative analysis of 201 genomes of Staphylococcus aureus, Enterobacter spp., Pseudomonas aeruginosa, and Mycoplasma spp. was performed on the basis of high-level functional annotations—KEGG pathways and KEGG modules. The first three organisms are serious nosocomial pathogens, often exhibiting multidrug resistance. Analysis of KEGG modules revealed methicillin resistance in 25% of S. aureus strains and resistance to carbapenems in 21% of Enterobacter spp. strains. P. aeruginosa has a wide range of unique efflux systems. One hundred percent of the analyzed strains have at least two drug resistance systems, and 75% of the strains have seven. Each of the organisms has a characteristic set of metabolic features, whose impact on drug resistance can be considered in future studies. Comparing the genomes of nosocomial pathogens with each other and with Mycoplasma genomes can expand our understanding of the versatility of certain metabolic features and mechanisms of drug resistance.

Mortality due to hospital-acquired infection after cardiac surgery

PURPOSE

Hospital-acquired infections have been associated with significant morbidity and mortality in critically ill surgical patients. However, little is known about mortality due to hospital-acquired infections in cardiac surgery.

METHODS

We conducted a retrospective analysis of prospectively collected data from the cardiac surgery unit of a university hospital. All patients who underwent cardiac surgery over a 7-year period were included. Patients with hospital-acquired infections were matched 1:1 with patients with nonhospital-acquired infections based on risk factors for hospital-acquired infections and death after cardiac surgery using propensity score matching. We performed a competitive risk analysis to study the mortality fraction due to hospital-acquired infections.

RESULTS

Of 8853 patients who underwent cardiac surgery, 370 (4.2%) developed 500 postoperative infections (incidence density rate 4.2 hospital-acquired infections per 1000 patient-days). Crude hospital mortality was significantly higher in patients with hospital-acquired infections than in matched patients who did not develop hospital-acquired infections, 15.4% and 5.7%, respectively (P < .001). The in-hospital mortality fraction due to hospital-acquired infections in our cohort was 17.1% (12.3%-22.8%). Pseudomonas aeruginosa infection (hazard ratio, 2.09; 95% confidence interval, 1.23-3.49; P = .005), bloodstream infection (hazard ratio, 2.08; 95% confidence interval, 1.19-3.63; P = .010), and pneumonia (hazard ratio, 1.68; 95% confidence interval, 1.02-2.77; P = .04) were each independently associated with increased hospital mortality.

CONCLUSIONS

Although hospital-acquired infections are relatively uncommon after cardiac surgery (4.2%), these infections have a major impact on postoperative mortality (attributable mortality fraction, 17.1%).

Six-year multicenter study on short-term peripheral venous catheters-related bloodstream infection rates in 204 intensive care units of 57 hospitals in 19 cities of India: International Nosocomial Infection Control Consortium (INICC) findings

BACKGROUND

Short-term peripheral venous catheters-related bloodstream infections (PVCR-BSIs) rates have not been systematically studied in developing countries, and data on their incidence by number of device-days are not available.

METHODS

Prospective, surveillance study on PVCR-BSI conducted from September 1, 2013 to May 31, 2019 in 204 intensive care units (ICUs), members of the International Nosocomial Infection Control Consortium (INICC), from 57 hospitals in 19 cities of India. We applied US INICC definition criteria and reported methods using the INICC Surveillance Online System.

RESULTS

We followed 7,513 ICU patients for 296,893 bed-days and 295,795 short term peripheral venous catheter (PVC)-days. We identified 863 PVCR-BSIs, amounting to a rate of 2.91/1,000 PVC-days. Mortality in patients with PVC but without PVCR-BSI was 4.14%, and 11.59% in patients with PVCR-BSI. The length of stay in patients with PVC but without PVCR-BSI was 4.13 days, and 5.9 days in patients with PVCR-BSI. The micro-organism profile showed 68% of gram negative bacteria: Escherichia coli (23%), Klebsiella spp (15%), Pseudomonas aeruginosa (5%), and others. The predominant gram-positive bacteria were Staphylococcus aureus (10%).

CONCLUSIONS

PVCR-BSI rates found in our ICUs were much higher than rates published from industrialized countries. Infection prevention programs must be implemented to reduce the incidence of PVCR-BSIs.

Epidemiology and regional variation of nonsusceptible and multidrug-resistant Pseudomonas aeruginosa isolates from intensive versus non-intensive care units across multiple centers in the United States

Nonsusceptible (NS) and multidrug-resistant (MDR) Pseudomonas aeruginosa (PsA) infections are associated with considerable mortality. This retrospective study assessed NS PsA and MDR PsA prevalence in US intensive care unit (ICU) and non-ICU settings. We evaluated nonduplicate PsA isolates collected in 2017. Data were classified by hospital admission setting. PsA isolates were evaluated for NS to each of 4 drug classes and MDR. Significantly higher rates of NS PsA and MDR PsA were found in ICU versus non-ICU settings (P < .001), except for respiratory isolates, which had high rates regardless of setting; rates also correlated with source, hospital size, urban/rural status, and geographic region. NS PsA isolates for each antibacterial category (except fluoroquinolones) and MDR PsA were significantly more likely to be classified as hospital-onset than admission-onset (P < .001). These data are consistent with previous reports and emphasize the importance of testing for resistant infection upon admission and when treating hospital-acquired infections.

Six-year multicenter study on short-term peripheral venous catheters-related bloodstream infection rates in 246 intensive units of 83 hospitals in 52 cities of 14 countries of Middle East: Bahrain, Egypt, Iran, Jordan, Kingdom of Saudi Arabia, Kuwait, Lebanon, Morocco, Pakistan, Palestine, Sudan, Tunisia, Turkey, and United Arab Emirates-International Nosocomial Infection Control Consortium (INICC) findings

BACKGROUND

Short-term peripheral venous catheters-related bloodstream infections (PVCR-BSIs) rates have not been systematically studied, and data on their incidence by number of device-days is not available.

METHODS

Prospective, surveillance study on PVCR-BSI conducted from September 1st, 2013 to 31st Mays, 2019 in 246 intensive care units (ICUs), members of the International Nosocomial Infection Control Consortium (INICC), from 83 hospitals in 52 cities of 14 countries in the Middle East (Bahrain, Egypt, Iran, Jordan, Kingdom of Saudi Arabia, Kuwait, Lebanon, Morocco, Pakistan, Palestine, Sudan, Tunisia, Turkey, and United Arab Emirates). We applied U.S.

RESULTS

We followed 31,083 ICU patients for 189,834 bed-days and 202,375 short term peripheral venous catheter (PVC)-days. We identified 470 PVCR-BSIs, amounting to a rate of 2.32/1000 PVC-days. Mortality in patients with PVC but without PVCR-BSI was 10.38%, and 29.36% in patients with PVC and PVCR-BSI. The mean length of stay in patients with PVC but without PVCR-BSI was 5.94 days, and 16.84 days in patients with PVC and PVCR-BSI. The microorganism profile showed 55.2 % of gram-positive bacteria, with Coagulase-negative Staphylococci (31%) and Staphylococcus aureus (14%) being the predominant ones. Gram-negative bacteria accounted for 39% of cases, and included: Escherichia coli (7%), Klebsiella pneumoniae (8%), Pseudomonas aeruginosa (5%), Enterobacter spp. (3%), and others (29.9%), such as Serratia marcescens.

CONCLUSIONS

PVCR-BSI rates found in our ICUs were much higher than rates published from USA, Australia, and Italy. Infection prevention programs must be implemented to reduce the incidence of PVCR-BSIs.

Prevalence of metallo-β-lactamase genes among Pseudomonas aeruginosa isolated from various clinical samples in China

Background

Pseudomonas aeruginosa is an opportunistic pathogen which is associated with nosocomial infections and causes various diseases including urinary tract infection, pneumonia, soft-tissue infection and sepsis. The emergence of P. aeruginosa-acquired metallo-β-lactamase (MBL) is most worrisome and poses a serious threat during treatment and infection control. The objective of this study was to identify antibiotic susceptibility, phenotypic detection of MBL production and to determine the prevalence of MBL genes in carbapenem-resistant P. aeruginosa isolated from different clinical samples.

Methods

A total of 329 non-duplicate P. aeruginosa isolated from various clinical samples from two hospitals in China between September 2017 and March 2019 were included in this study. Phenotypic detection of MBL was performed by the combined detection method using imipenem and imipenem-ethylenediaminetetraacetic acid (EDTA) discs. MBL-encoding genes including bla VIM-1 , bla VIM-2 , bla IMP-1 , bla IMP-2 , bla SPM-1 , bla SIM , bla NDM-1 and bla GIM were detected by polymerase chain reaction (PCR).

Results

Of the 329 P. aeruginosa, majority of the isolates were resistant to imipenem (77.5%) followed by meropenem (64.7%). Of the 270 P. aeruginosa isolates tested, 149 (55.2%) isolates were found to be positive for MBL detection. Of the different samples, 57.8% (n = 26) of P. aeruginosa isolated from blood were found to be positive for MBL production. Of the various MBL genes, bla IMP-1 (28.2%) was the most predominant gene detected followed by bla VIM-2 (18.8%), bla VIM-1 (16.1%), bla NDM-1 (9.4%), bla IMP-2 (6.7%), bla SIM (6.0%), bla SPM-1 (4.0%) and bla GIM (1.3%) genes.

Conclusions

The high resistance of P. aeruginosa toward imipenem and meropenem and the high prevalence of bla IMP-1 and bla VIM-2 set the alarm on the increasing, perhaps the increased, carbapenem resistance. In addition to routine antibiotic susceptibility testings, our results emphasize the importance of both the phenotypic and genotypic MBL detection methods in routine practice for early detection of carbapenem resistance and to prevent further dissemination of this resistant pathogen.

Efficacy of Early Oral Switch with β-Lactams for Low-Risk Staphylococcus aureus Bacteremia

The aim of this study was to assess the safety of early oral switch (EOS) prior to 14 days for low-risk Staphylococcus aureus bacteremia (LR-SAB), which is the primary treatment strategy used at our institution. The usual recommended therapy is 14 days of intravenous (i.v.) antibiotics. All patients with SAB at our hospital were identified between 1 January 2014 and 31 December 2018. Those meeting low-risk criteria (health care-associated, no evidence of deep infection or demonstrated involvement of prosthetic material, and no further positive blood cultures after 72 h) were included in the study. The primary outcome was occurrence of a SAB-related complication within 90 days. There were 469 SAB episodes during the study period, 100 (21%) of whom met inclusion criteria. EOS was performed in 84 patients. In this group, line infection was the source in 79%, methicillin-susceptible S. aureus caused 95% of SABs and 74% of patients received i.v. flucloxacillin. The median durations of i.v. and oral antibiotics in the EOS group were 5 days (interquartile range [IQR], 4 to 6) and 10 days (IQR, 9 to 14), respectively. A total of 71% of patients received flucloxacillin as their EOS agent. Overall, 86% of oral step-down therapy was with beta-lactams. One patient (1%) undergoing EOS had SAB relapse within 90 days. No deaths attributable to SAB occurred within 90 days. In this low-MRSA-prevalence LR-SAB cohort, EOS was associated with a low incidence of SAB-related complications. This was achieved with oral beta-lactam therapy in most patients. Larger prospective studies are needed to confirm these findings.

Pathogenesis-Targeted Preventive Strategies for Multidrug Resistant Ventilator-Associated Pneumonia: A Narrative Review

Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection in the intensive care unit (ICU), accounting for relevant morbidity and mortality among critically ill patients, especially when caused by multidrug resistant (MDR) organisms. The rising problem of MDR etiologies, which has led to a reduction in treatment options, have increased clinician’s attention to the employment of effective prevention strategies. In this narrative review we summarized the evidence resulting from 27 original articles that were identified through a systematic database search of the last 15 years, focusing on several pathogenesis-targeted strategies which could help preventing MDR-VAP. Oral hygiene with Chlorhexidine (CHX), CHX body washing, selective oral decontamination (SOD) and/or digestive decontamination (SDD), multiple decontamination regimens, probiotics, subglottic secretions drainage (SSD), special cuff material and shape, silver-coated endotracheal tubes (ETTs), universal use of gloves and contact isolation, alcohol-based hand gel, vaporized hydrogen peroxide, and bundles of care have been addressed. The most convincing evidence came from interventions directly addressed against the key factors of MDR-VAP pathogenesis, especially when they are jointly implemented into bundles. Further research, however, is warranted to identify the most effective combination.

Phenazines as potential biomarkers of Pseudomonas aeruginosa infections: synthesis regulation, pathogenesis and analytical methods for their detection

Infectious diseases are still a worldwide important problem. This fact has led to the characterization of new biomarkers that would allow an early, fast and reliable diagnostic and targeted therapy. In this context, Pseudomonas aeruginosa can be considered one of the most threatening pathogens since it causes a wide range of infections, mainly in patients that suffer other diseases. Antibiotic treatment is not trivial given the incidence of resistance processes and the fewer new antibiotics that are placed on the market. With this scenario, relevant quorum sensing (QS) molecules that regulate the secretion of virulence factors and biofilm formation can play an important role in diagnostic and therapeutic issues. In this review, we have focused our attention on phenazines, as possible new biomarkers. They are pigmented metabolites that are produced by diverse bacteria, characterized for presenting unique redox properties. Phenazines are involved in virulence, competitive fitness and are an essential component of the bacterial QS system. Here we describe their role in bacterial pathogenesis and we revise phenazine production regulation systems. We also discuss phenazine levels previously reported in bacterial isolates and in clinical samples to evaluate them as putative good candidates to be used as P. aeruginosa infection biomarkers. Moreover we deeply go through all analytical techniques that have been used for their detection and also new approaches are discussed from a critical point. Graphical abstract.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

Changes in immune indicators and bacteriologic profile were associated with patients with ventilator-associated pneumonia

The aim of this study is to explore and identify ventilator-associated pneumonia (VAP)-related prognostic immune factors and further detect the drug-resistant pathogens to establish the theoretical guidance for clinical prevention and treatment strategies of VAP. A total of 478 patients using ventilator who were hospitalized in July 2014 to November 2016 in our hospital were enrolled in this study. About 103 patients with VAP (21.5%, 103/478) among 478 cases of patients using ventilator. Among the 103 patients with VAP, the distribution of pathogenic bacteria and drug resistance in patients with VAP were detected and analyzed. In the VAP group, 35 patients died and 43 patients had simultaneous sepsis. Compared with those of non-VAP group, the proportion of CD3 (P = .012), CD3CD4 (P = .024) and CD8CD28 ( P = .017) T cells in VAP group increased significantly, which indicated more severe immune response. Multivariate regression model analysis revealed that tracheotomy of mechanical ventilation (P = .013), mechanical ventilation time ≥7 days (P = .02) and aspiration and reflux (P = .011) were independent risk factors associated with VAP. According to the results of bacterial culture and drug sensitivity test, rational selection of antibiotics and monitoring of patients within intensive care unit can effectively control the incidence of VAP and improve the prognosis of patients.

Six-year multicenter study on short-term peripheral venous catheters-related bloodstream infection rates in 727 intensive care units of 268 hospitals in 141 cities of 42 countries of Africa, the Americas, Eastern Mediterranean, Europe, South East Asia, and Western Pacific Regions: International Nosocomial Infection Control Consortium (INICC) findings

BACKGROUND

Short-term peripheral venous catheter-related bloodstream infection (PVCR-BSI) rates have not been systematically studied in resource-limited countries, and data on their incidence by number of device days are not available.

METHODS

Prospective, surveillance study on PVCR-BSI conducted from September 1, 2013, to May 31, 2019, in 727 intensive care units (ICUs), by members of the International Nosocomial Infection Control Consortium (INICC), from 268 hospitals in 141 cities of 42 countries of Africa, the Americas, Eastern Mediterranean, Europe, South East Asia, and Western Pacific regions. For this research, we applied definition and criteria of the CDC NHSN, methodology of the INICC, and software named INICC Surveillance Online System.

RESULTS

We followed 149,609 ICU patients for 731,135 bed days and 743,508 short-term peripheral venous catheter (PVC) days. We identified 1,789 PVCR-BSIs for an overall rate of 2.41 per 1,000 PVC days. Mortality in patients with PVC but without PVCR-BSI was 6.67%, and mortality was 18% in patients with PVC and PVCR-BSI. The length of stay of patients with PVC but without PVCR-BSI was 4.83 days, and the length of stay was 9.85 days in patients with PVC and PVCR-BSI. Among these infections, the microorganism profile showed 58% gram-negative bacteria: Escherichia coli (16%), Klebsiella spp (11%), Pseudomonas aeruginosa (6%), Enterobacter spp (4%), and others (20%) including Serratia marcescens. Staphylococcus aureus were the predominant gram-positive bacteria (12%).

CONCLUSIONS

PVCR-BSI rates in INICC ICUs were much higher than rates published from industrialized countries. Infection prevention programs must be implemented to reduce the incidence of PVCR-BSIs in resource-limited countries.

Infectious complications associated with parenteral nutrition in intensive care unit and non-intensive care unit patients

INTRODUCTION

Malnutrition is associated with an increased risk of complications in hospitalized patients, and parenteral nutrition (PN) is used when oral or enteral feeding is not possible. This study aimed at analyzing associations between PN characteristics and infectious complications in hospitalized patients.

MATERIAL AND METHODS

This was a retrospective cohort study conducted in a tertiarycare university hospital. Data from consecutive adult patients submitted to PN (January 2016 to December 2017; ICU and ward) were reviewed by means of an electronic database. Patient's clinical characteristics, PN prescription and catheter insertion procedure data were extracted and analyzed. The main outcome was the development of central line-associated bloodstream infection (CLABSI). The secondary outcomes were other infectious complications and mortality, as well as factors associated with CLABSI.

RESULTS

We analyzed 165 patients and 247 catheters used for parenteral nutrition infusion. The CLABSI rate was 6.47 per 1000 catheter-days. In the univariable analysis, CLABSI was associated with longer hospitalization time, longer PN time, longer catheter time, catheter insertion performed by a surgeon or a surgical resident, and procedures performed outside the ICU. In an extended time-dependent Cox regression, no variable was associated with a higher risk of CLABSI, and additional PN days did not increase the rate of CLABSI. The overall mortality rate was 24.8%. Only the patients' comorbidity index was associated with death in the multivariable analysis.

DISCUSSION

In our study, patients who needed PN had an overall CLABSI rate of 6.47 per 1000 catheter-days. These outcomes were not associated with PN and catheter characteristics studied after adjustment for catheter time. The overall mortality rate was 24.8% and it was not associated with PN in multivariable analyses, only with Charlson comorbidity index.

Epidemiology of β-Lactamase-Producing Pathogens

β-Lactam antibiotics have been widely used as therapeutic agents for the past 70 years, resulting in emergence of an abundance of β-lactam-inactivating β-lactamases. Although penicillinases in Staphylococcus aureus challenged the initial uses of penicillin, β-lactamases are most important in Gram-negative bacteria, particularly in enteric and nonfermentative pathogens, where collectively they confer resistance to all β-lactam-containing antibiotics. Critical β-lactamases are those enzymes whose genes are encoded on mobile elements that are transferable among species. Major β-lactamase families include plasmid-mediated extended-spectrum β-lactamases (ESBLs), AmpC cephalosporinases, and carbapenemases now appearing globally, with geographic preferences for specific variants. CTX-M enzymes include the most common ESBLs that are prevalent in all areas of the world. In contrast, KPC serine carbapenemases are present more frequently in the Americas, the Mediterranean countries, and China, whereas NDM metallo-β-lactamases are more prevalent in the Indian subcontinent and Eastern Europe. As selective pressure from β-lactam use continues, multiple β-lactamases per organism are increasingly common, including pathogens carrying three different carbapenemase genes. These organisms may be spread throughout health care facilities as well as in the community, warranting close attention to increased infection control measures and stewardship of the β-lactam-containing drugs in an effort to control selection of even more deleterious pathogens.

Scan Parameter Optimization for Histotripsy Treatment of S. Aureus Biofilms on Surgical Mesh

There is a critical need to develop new noninvasive therapies to treat bacteria biofilms. Previous studies have demonstrated the effectiveness of cavitation-based ultrasound histotripsy to destroy these biofilms. In this study, the dependence of biofilm destruction on multiple scan parameters was assessed by conducting exposures at different scan speeds (0.3-1.4 beamwidths/s), step sizes (0.25-0.5 beamwidths), and the number of passes of the focus across the mesh (2-6). For each of the exposure conditions, the number of colony-forming units (CFUs) remaining on the mesh was quantified. A regression analysis was then conducted, revealing that the scan speed was the most critical parameter for biofilm destruction. Reducing the number of passes and the scan speed should allow for more efficient biofilm destruction in the future, reducing the treatment time.

Healthcare Associated Infections-A New Pathology in Medical Practice?

Background: Hospital-acquired infections (HAI) contribute to the emotional stress and functional disorders of the patient and in some cases, can lead to a state of disability that reduces quality of life. Often, HAI are one of the factors that lead to death. The purpose of this study was to analyze the cases of HAI identified in public hospitals at the county level, through case report sheets, as they are reported according to the Romanian legislation. Methods: We performed a cross sectional study design based on the case law of the data reported to the Mures Public Health Directorate, by all the public hospitals belonging to this county. We tracked hospital-acquired infections reported for 2017-2018, respectively, a number of 1024 cases, which implies a prevalence rate of 0.44%, 1024/228,782 cases discharged from these hospitals during the studied period. Results: The most frequent HAIs were reported by the intensive care units (48.4%), the most common infections being the following: bronchopneumonia (25.3%), enterocolitis with Clostridioidesdifficile (23.3%), sepsis, surgical wound infections and urinary tract infections. At the basis of HAI were 22 pathogens, but the five most common germs were Clostridioidesdifficile, Acinetobacterbaumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa and Staphylococcus aureus. Bronchopneumonia have been most frequently reported in intensive care units, the most common being identified the Acinetobacterbaumannii agent. Sepsis and central catheter infections also appeared predominantly in intensive care units, more often with Klebsiella pneumoniae. The enterocolitis with Clostridioidesdifficile, were the apanage of the medical sections. Infections with Staphylococcus aureus have been identified predominantly in the surgical sections at the level of the surgical wounds. Urinary infections had a similar distribution in the intensive care units, the medical and surgical sections, with Klebsiella pneumoniae being the most commonly incriminated agent. Conclusions: We showed a clear correspondence between the medical units and the type of HAI: what recommends the rapid, vigilant and oriented application of the prevention and control strategies of the HAI.

Incidence and risk factors for acquired colonization and infection due to extended-spectrum beta-lactamase-producing Gram-negative bacilli: a retrospective analysis in three ICUs with low multidrug resistance rate

The purpose of this study is to assess risk factors for the acquisition of extended-spectrum β-lactamase-producing Gram-negative bacilli (ESBL-GNB) colonization and infection (AI) in ICUs with low ESBL-GNB prevalence rate. We conducted a retrospective observational study in three ICUs in Bretagne, France. All patients admitted from January 2016 to September 2017 with a length of stay of 2 days or more were included. Universal screening for ESBL-GNB colonization was performed in all participating ICUs. Of the 3250 included patients, 131 (4.0%) were colonized at admission, 59 acquired colonization while hospitalized (1.9%; 95% CI [1.5–2.5%]), and 15 (0.5%; 95% CI [0.3–0.8%]) acquired ESBL-GNB infections. In the case of infection, the specificity and the negative predictive values of preexistent colonization for the ESBL-GNB etiology were 93.2% [91.5–95.1%] and 95.2% [93.5–97.1%], respectively. Colonization was the main risk factor for ESBL-GNB AI (OR = 9.61; 95% CI [2.86–32.29]; p < 0.001). Antimicrobial susceptibility of non-ESBL-GNB isolates responsible for AI was similar for any non-carbapenem β-lactam (95%) and imipenem (94%). ESBL-GNB AIs were rare in ICUs with low ESBL-GNB prevalence rate. Prior colonization was the main risk factor for subsequent infection. Empirical carbapenem therapy could be avoided in non ESBL-GNB colonized patients with suspected AI.

Early mortality attributable to PICC-lines in 4 public hospitals of Marseille from 2010 to 2016 (Revised V3)

INTRODUCTION

Peripherally inserted central catheters (PICC-line) are devices inserted through peripheral venous access. In our institution, this technology has been rapidly adopted by physicians in their routine practice. Bacteremia on catheters remains an important public health issue in France. However, the mortality attributable to bacteremia on PICC-line remains poorly evaluated in France and in the literature in general. We report in our study an exhaustive inventory of bacteremia on PICC-line and their 30 days mortality, over a 7 years period.

MATERIAL AND METHODS

From January 2010 to December 2016, we retrospectively matched PICC-line registers of the radiology department, blood culture records of the microbiology laboratory and medical records from the Hospital Information Systems.

RESULTS

The 11,334 hospital stays during which a PICC-line was inserted were included over a period of 7 years. Among them, 258 episodes of PICC-line-associated bacteremia were recorded, resulting in a prevalence of 2.27%. Hematology units: 20/324 (6.17%), oncology units: 55/1375 (4%) and hepato-gastro-enterology units: 42/1142 (3.66%) had the highest prevalence of PICC-line related bacteremia. The correlation analysis, when adjusted by exposure and year, shows that the unit profile explains 72% of the variability in the rate of bacteremia with a P = .023. Early bacteremia, occurring within 21 days of insertion, represented 75% of cases. The crude death ratio at 30 days, among patients PICC-line associated bacteremia was 57/11 334 (0.50%). The overall 30-day mortality of patients with PICC-line with and without bacteremia was 1369/11334 (12.07%). On day 30, mortality of patients with bacteremia associated PICC-line was 57/258 or 22.09% of cases, compared to a mortality rate of 1311/11076, or 11.83% in the control group (P < .05, RR 2.066 [1.54-2.75]). Kaplan-Meier survival analysis revealed a statistically significant excess mortality between patients with PICC-line associated bacteremia and PICC-line carriers without bacteremia (P < .0007, hazard ratio 1.89 [1307-2709]).

CONCLUSION

Patients with PICC-line associated bacteremia have a significant excess mortality. The implementation of a PICC-line should remain the last resort after a careful assessment of the benefit/risk ratio by a senior doctor.

Achieving a Zero Central Line-Associated Bloodstream Infection Rate in 4 Critical Care Units in Lebanon

Every health care facility aims to achieve and maintain a zero central line-associated bloodstream infection (CLABSI) rate. Infections can be costly for institutions of any size and are often not covered by health insurance. The interventions put in place in this quality improvement project were implemented in 4 phases: (1) develop a new standard of care for central lines and give nurses full responsibility for the care and handling of these lines (including blood sampling); (2) revise policy and provide educational sessions to support nurses; (3) document compliance with the new policy; and (4) document CLABSI rates. The project took place during a 15-month period between January 1, 2016 and March 30, 2017, in 4 critical care units in a university medical center in Lebanon. The results revealed a reduction in CLABSI rates from a maximum rate of more than 17 per 1000 catheter days to zero per 1000 catheter days, which was sustained for 10 months. Nurse compliance with the new policy after 3 months ranged from 95% to 99%.

Linking surveillance and clinical data for evaluating trends in bloodstream infection rates in neonatal units in England

OBJECTIVE

To evaluate variation in trends in bloodstream infection (BSI) rates in neonatal units (NNUs) in England according to the data sources and linkage methods used.

METHODS

We used deterministic and probabilistic methods to link clinical records from 112 NNUs in the National Neonatal Research Database (NNRD) to national laboratory infection surveillance data from Public Health England. We calculated the proportion of babies in NNRD (aged <1 year and admitted between 2010-2017) with a BSI caused by clearly pathogenic organisms between two days after admission and two days after discharge. We used Poisson regression to determine trends in the proportion of babies with BSI based on i) deterministic and probabilistic linkage of NNRD and surveillance data (primary measure), ii) deterministic linkage of NNRD-surveillance data, iii) NNRD records alone, and iv) linked NNRD-surveillance data augmented with clinical records of laboratory-confirmed BSI in NNRD.

RESULTS

Using deterministic and probabilistic linkage, 5,629 of 349,740 babies admitted to a NNU in NNRD linked with 6,660 BSI episodes accounting for 38% of 17,388 BSI records aged <1 year in surveillance data. The proportion of babies with BSI due to clearly pathogenic organisms during their NNU admission was 1.0% using deterministic plus probabilistic linkage (primary measure), compared to 1.0% using deterministic linkage alone, 0.6% using NNRD records alone, and 1.2% using linkage augmented with clinical records of BSI in NNRD. Equivalent proportions for babies born before 32 weeks of gestation were 5.0%, 4.8%, 2.9% and 5.9%. The proportion of babies who linked to a BSI decreased by 7.5% each year (95% confidence interval [CI]: -14.3%, -0.1%) using deterministic and probabilistic linkage but was stable using clinical records of BSI or deterministic linkage alone.

CONCLUSION

Linkage that combines BSI records from national laboratory surveillance and clinical NNU data sources, and use of probabilistic methods, substantially improved ascertainment of BSI and estimates of BSI trends over time, compared with single data sources.

Impact of International Nosocomial Infection Control Consortium's multidimensional approach on central line-associated bloodstream infection rates in Bahrain

BACKGROUND

Central line-associated bloodstream infections are serious life-threatening infections in the intensive care unit setting.

METHODS

To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Approach (IMA) and INICC Surveillance Online System (ISOS) on central line-associated bloodstream infection rates in Bahrain from January 2013 to December 2016, we conducted a prospective, before-after surveillance, cohort, observational study in one intensive care unit in Bahrain. During baseline, we performed outcome and process surveillance of central line-associated bloodstream infection on 2320 intensive care unit patients, applying Centers for Disease Control and Prevention's National Healthcare Safety Network definitions. During intervention, we implemented IMA through ISOS, including (1) a bundle of infection prevention interventions, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback on central line-associated bloodstream infection rates and consequences, and (6) performance feedback of process surveillance. Bivariate and multivariate regression analyses were performed using a logistic regression model to estimate the effect of the intervention on the central line-associated bloodstream infection rate.

RESULTS

During baseline, 672 central line days and 7 central line-associated bloodstream infections were recorded, accounting for 10.4 central line-associated bloodstream infections per 1000 central line days. During intervention, 13,020 central line days and 48 central line-associated bloodstream infections were recorded. After the second year, there was a sustained 89% cumulative central line-associated bloodstream infection rate reduction to 1.2 central line-associated bloodstream infections per 1000 central line days (incidence density rate, 0.11; 95% confidence interval 0.1-0.3; p, 0.001). The average extra length of stay of patients with central line-associated bloodstream infection was 23.3 days, and due to the reduction of central line-associated bloodstream infections, 367 days of hospitalization were saved, amounting to a reduction in hospitalization costs of US$1,100,553.

CONCLUSION

Implementing IMA was associated with a significant reduction in the central line-associated bloodstream infection rate in Bahrain.

Bacterial infections in children after liver transplantation: A single-center surveillance study of 345 consecutive transplantations

BACKGROUND

Infectious complications after pediatric liver transplantation frequently occur and are potentially serious. Data concerning strictly defined bacterial infections and their associated risk factors are lacking.

METHODS

For the pediatric liver transplant postoperative period, we analyzed data from the nosocomial infection surveillance (2006-2015).

RESULTS

A total of 235 bacterial infections in 162 transplantations (47%) occurred, including 32 bacterial pneumonia cases, 104 surgical site infections, 27 urinary tract infections, and 40 bloodstream infections. Sepsis was diagnosed in 127 cases (54%), severe sepsis in 22 (9%) cases, and septic shock in 41 (17%) cases. Thirty patients (9%) died, and septic shock was the leading cause of death. The carrier status of multi-drug resistant bacteria and a tacrolimus level >20 ng/mL were independent risk factors for surgical site infections and the occurrence of severe sepsis or septic shock. The length of mechanical ventilation was an independent risk factor for pneumonia and surgical site infection.

CONCLUSION

Bacterial infections in the early postoperative period after pediatric liver transplantation are associated with high morbidity and mortality. Physicians involved in the medical care of these patients should be aware of the specific risk factors, and further development of prevention programs is highly recommended.

Dysphagia Screening for Pneumonia Prevention in a Cancer Hospital: Results of a Quality/Safety Initiative

OBJECTIVE

Hospital-acquired aspiration pneumonia remains a rare but potentially devastating problem. The best means by which to prevent aspiration in a cancer hospital population has not been evaluated. The aim of this study was to evaluate the impact of dysphagia screening on aspiration pneumonia rates in an acute care oncology hospital.

METHODS

A prospective single-institution quality improvement dysphagia screening protocol at a comprehensive cancer center. Effect of dysphagia screening implemented in 2016 on hospital-acquired aspiration pneumonia rates coded "aspiration pneumonitis due to food/vomitus" was compared with rates from 2014 to 2015 prior to implementation. Screening compliance, screening outcomes, patient demographics, and medical data were reviewed as part of a post hoc analysis.

RESULTS

Of 12,392 admissions in 2014 to 2016, 97 patients developed aspiration pneumonia during their hospitalization. No significant change in aspiration pneumonia rate was seen during the dysphagia screening year when compared to prior years (baseline, 7.36; screening year, 8.78 per 1000 discharges; P = .33). Sixty-eight of the cases (66%) were associated with emesis/gastrointestinal obstruction or perioperative aspiration and only 15 (15%) with oropharyngeal dysphagia. Multivariate analysis found that patients admitted to gastrointestinal surgery had an aspiration risk equivalent to patients admitted to head and neck, thoracic, and pulmonary services (odds ratio, 0.65; P = .2).

DISCUSSION

Nursing-initiated dysphagia screening did not decrease aspiration pneumonia rates. The causes of aspiration-associated pneumonia were heterogeneous. Aspiration of intestinal contents is a more common source of hospital-acquired pneumonia than oropharyngeal dysphagia.

Impact of delivery mode-associated gut microbiota dynamics on health in the first year of life

The early-life microbiome appears to be affected by mode of delivery, but this effect may depend on intrapartum antibiotic exposure. Here, we assess the effect of delivery mode on gut microbiota, independent of intrapartum antibiotics, by postponing routine antibiotic administration to mothers until after cord clamping in 74 vaginally delivered and 46 caesarean section born infants. The microbiota differs between caesarean section born and vaginally delivered infants over the first year of life, showing enrichment of Bifidobacterium spp., and reduction of Enterococcus and Klebsiella spp. in vaginally delivered infants. The microbiota composition at one week of life is associated with the number of respiratory infections over the first year. The taxa driving this association are more abundant in caesarean section born children, providing a possible link between mode of delivery and susceptibility to infectious outcomes.

A hospital-wide reduction in central line-associated bloodstream infections through systematic quality improvement initiative and multidisciplinary teamwork

BACKGROUND

Few data are available on hospital-wide incidence of central line-associated bloodstream infection (CLABSI) rates in patients with central venous catheter (CVC) in China, where many systemic obstacles holding back evidence-based guidelines implementation exist.

METHODS

This study was conducted prospectively in 2 phases. The baseline and intervention phases were performed in a teaching hospital in China, between January 2017 and October 2018. A systematic quality improvement (SQI) and multidisciplinary teamwork (MDT) CLABSI infection control program was introduced in the intervention phase. In the intensive care units (ICUs) and non-ICUs, CLABSIs were continuously monitored, data collected, then analyzed.

RESULTS

After intervention, the CLABSI rate decreased from 2.84-0.56 per 1,000 CVC days in ICUs (P < .001), and from 0.82-0.47 per 1,000 CVC days in non-ICUs (P = .003). The length of time until CLABSI occurrence increased from 8.72-13.60 days in ICUs (P = .046), and from 10.00-12.00 days in non-ICUs (P = .048). The number of multidrug-resistant bacteria isolated from CLABSI episodes decreased both in ICUs and in non-ICUs.

CONCLUSIONS

The SQI and MDT CLABSI infection control program is effective in reducing hospital-wide CLABSI in patients with CVC, both in ICUs and in non-ICUs.

Chlorhexidine gluconate transparent dressing does not decrease central line‐associated bloodstream infection in critically ill patients: A randomized controlled trial

Background

Central line‐associated blood stream infections are accompanied by increased mortality and health care costs. The application of different types of dressings in infection control has not been fully investigated to date.

Aim

To assess the effects of two different dressing types on central line‐associated bloodstream infections.

Methods

A randomized, nonblinded, controlled trial was conducted. Central lines were randomly allocated to intervention (chlorhexidine gluconate transparent dressing, n = 259) and control groups (standard dressing, n = 215). The central line‐associated bloodstream infection rate was assessed.

Results

A statistically nonsignificant difference was noted in the overall central line‐associated bloodstream infection rates between the two groups. The frequency of dressing changes in the patients with the chlorhexidine gluconate transparent dressing was significantly lower than that in the patients with a standard dressing. The predominant type of infectious microorganisms isolated from the central line‐associated bloodstream infection episodes was Gram‐negative bacteria (57.2%). Gram‐positive bacteria and fungi were noted at lower percentages (28.5% and 14.3%, respectively).

Conclusion

The use of a chlorhexidine gluconate transparent dressing does not decrease the central line‐associated bloodstream infection rate, although it decreases the frequency of dressing changes so may save nursing time.

What is already known about this topic?

The use of a chlorhexidine gluconate transparent dressing has been reported to significantly reduce central line‐associated bloodstream infections or maintain low central line‐associated bloodstream infections in Western countries, but few studies have been carried out in Asian countries.

The chlorhexidine dressing does not decrease central line‐associated bloodstream infections due to the presence of Gram‐negative bacteria.

It has been reported that nurses prefer the chlorhexidine gluconate transparent dressing over the standard dressing.

What this paper adds?

Compared with the standard dressing, the chlorhexidine gluconate transparent dressing does not significantly decrease the central line‐associated bloodstream infection rate.

The predominant infectious microorganisms isolated from central line-associated bloodstream infections episodes were Gram-negative bacteria.

The cost of the chlorhexidine gluconate transparent dressing was significantly higher than that of the standard dressing, although the former could save nursing time due to the decreased frequency of dressing changes.

The implications of this paper are as follows:

The use of chlorhexidine gluconate transparent dressing does not offer any additional benefit in controlling infection.

Further studies are required to identify ways to control the colonization or infection of Gram‐negative bacteria in patients because Gram‐negative bacteria are the predominant infectious microorganisms that cause central line‐associated bloodstream infection.

The use of a chlorhexidine gluconate transparent dressing is proposed as an alternative choice that can reduce ICU nursing time in hospital settings and therefore should be considered by nursing managers for human resource cost control.

Prevention of Nosocomial Infections in Critically Ill Patients With Lactoferrin: A Randomized, Double-Blind, Placebo-Controlled Study

OBJECTIVE

To obtain preliminary evidence for the efficacy of lactoferrin as a preventative measure for nosocomial infections and inform the conduct of a definitive study.

DESIGN

Phase 2, multicenter, randomized, double-blind, placebo-controlled study.

SETTING

Medical-surgical ICUs.

PATIENTS

Adult, critically ill patients receiving invasive mechanical ventilation.

INTERVENTIONS

Randomized, eligible, consenting patients expected to require invasive mechanical ventilation more than 48 hours received lactoferrin both enterally and via an oral swab or a placebo of sterile water for up to 28 days.

MEASUREMENTS AND MAIN RESULTS

Of the 214 patients who were randomized, 212 received at least one dose of the intervention and were analyzed (107 lactoferrin and 105 placebo). Protocol adherence was 87.5%. Patients receiving lactoferrin were older (mean [SD], 66.3 [13.5] vs 62.5 [16.2] yr), had a higher Acute Physiology and Chronic Health Evaluation II score (26.8 [7.8] vs 23.5 [7.9]), and need for vasopressors (79% vs 70%). Antibiotic-free days (17.3 [9.0] vs 18.5 [7.1]; p = 0.91) and nosocomial infections (0.3 [0.7] vs 0.4 [0.6] per patient; p = 0.48) did not differ between lactoferrin and placebo groups, respectively. Clinical outcomes for lactoferrin versus placebo were as follows: ICU length of stay (14.5 [18.0] vs 15.0 [37.3] d; p = 0.82), hospital length of stay (25.0 [25.9] vs 28.1 [44.6] d; p = 0.57), hospital mortality (41.1% vs 30.5%; p = 0.11), and 90-day mortality (44.9% vs 32.4%; p = 0.06). Biomarker levels did not differ between the groups.

CONCLUSIONS

Lactoferrin did not improve the primary outcome of antibiotic-free days, nor any of the secondary outcomes. Our data do not support the conduct of a larger phase 3 trial.

Should the CDC's recommendations for promptly removing unnecessary centrally inserted central catheters be enhanced? Ultrasound-guided peripheral venous cannulation to fully comply

PURPOSE

In an effort to reduce catheter-related bloodstream infection's incidence rates in an intensive care unit, several evidence-based procedures recommended by the Centers for Disease Control and Prevention for centrally inserted central catheters were implemented. A failure to fully comply with the recommendation for prompt removal of the centrally inserted central catheters was attributed, mainly to the difficulties and inadequacies raised from establishing peripheral venous access.

METHODS

The ultrasound-guided peripheral venous cannulation method as a supplementary intervention to the Centers for Disease Control and Prevention's recommendations was incorporated and examined during the subsequent year.

RESULTS

A significant reduction on catheter-related bloodstream infection incidence rates out of the expected range was found. Centrally inserted central catheters utilization ratios were reduced by 10.7% (p < 0.05; 58%-47%) and the catheter-related bloodstream infection incidence rate was reduced by 11.7 per thousand device-days (15.9-4.16/1000 centrally inserted central catheters days (2015-2016 group, respectively)).

CONCLUSION

The reduction of catheter-related bloodstream infection was higher than that described in the published literature. This probably shows that the combination of the five evidence-based procedures recommended by the Centers for Disease Control and Prevention together with that of ultrasound-guided peripheral venous cannulation method can increase the compliance with the Category IA recommendation for removal or avoidance of unnecessary placement of centrally inserted central catheters and decrease the catheter-related bloodstream infections in a more effective way, by affecting the patients' centrally inserted central catheter exposure.

The Minimum Data Set and Quality Indicators for National Healthcare-Associated Infection Surveillance in Mainland China: Towards Precision Management

The magnitude and scope of the healthcare-associated infections (HCAIs) burden are underestimated worldwide, and have raised public concerns for their adverse effect on patient safety. In China, HCAIs still present an unneglected challenge and economic burden in recent decades. With the purpose of reducing the HCAI prevalence and enhancing precision management, China's National Nosocomial Infection Management and Quality Control Center (NNIMQCC) had developed a Minimum Data Set (MDS) and corresponding Quality Indicators (QIs) for establishing national HCAI surveillance system, the data elements of which were repeatedly discussed, investigated, and confirmed by consensus of the expert team. The total number of data elements in MDS and QIs were 70 and 64, and they were both classified into seven categorical items. The NNIMQCC also had started two pilot projects to inspect the applicability, feasibility, and reliability of MDS. After years of hard work, more than 400 health facilities in 14 provinces have realized the importance of HCAI surveillance and contributed to developing an ability of exporting automatically standardized data to meet the requirement of MDS and participate in the regional surveillance system. Generally, the emergence of MDS and QIs in China indicates the beginning of the national HCAI surveillance based on information technology and computerized process data. The establishment of MDS aimed to use electronic health process data to ensure the data accuracy and comparability and to provide instructive and ongoing QIs to estimate and monitor the burden of HCAIs, and to evaluate the effects of interventions and direct health policy decision-making.

Rapid screening and early precautions for carbapenem-resistant Acinetobacter baumannii carriers decreased nosocomial transmission in hospital settings: a quasi-experimental study

Background

Active surveillance has the potential to prevent nosocomial transmission of carbapenem-resistant Acinetobacter baumannii (CRAB). We assessed whether rapid diagnosis using clinical specimen-direct loop-mediated isothermal amplification (LAMP), a rapid molecular diagnostic assay, and subsequent intervention, could reduce CRAB nosocomial transmission in intensive care units (ICUs).

Methods

A before and after (quasi-experimental) study was conducted in two ICUs at the Mahidol University Faculty of Medicine Ramathibodi Hospital with 3 months of observational period followed by 9 months of interventional period. All patients were screened for CRAB using both the culture and LAMP method from rectal swab and/or bronchial aspirates (intubated patients only) upon admission, weekly thereafter, and upon discharge. During the pre-intervention period, we performed contact precautions based on culture results. In contrast, during the intervention period, we initiated contact precautions within a few hours after sample collection on the basis of LAMP results.

Results

A total of 1335 patients were admitted to the ICUs, of which 866 patients (pre-intervention period: 187; intervention period: 679) were eligible for this study. Incidence rate of CRAB infection decreased to 20.9 per 1000 patient-days in the intervention period from 35.2 in the pre-intervention period (P < 0.02). The calculated hazard ratio of CRAB transmission was 0.65 (95% confidence interval [CI], 0.44–0.97). Risk factors for CRAB acquisition included exposure to carbapenem (hazard ratio, 2.54 [95% CI: 1.61–5.57]).

Conclusions

LAMP screening for CRAB upon ICU admission proved feasible for routine clinical practice. Rapid screening using LAMP followed by early intervention may reduce CRAB transmission rates in ICUs when compared to conventional intervention.

Electronic supplementary material

The online version of this article (10.1186/s13756-019-0564-9) contains supplementary material, which is available to authorized users.

Management of ventilator-associated pneumonia (VAP) caused by resistant gram-negative bacteria: which is the best strategy to treat?

Introduction: Treatment of ventilator-associated pneumonia (VAP) is a major challenge. The increase in multi-drug resistant bacteria has not been accompanied by the validation of new drugs, or by any new antimicrobial strategies to exploit the available agents. VAP due to Gram-negative bacteria has increased mortality, both due to the resistant pathogens themselves and due to inappropriate treatment. Local epidemiology, patients' characteristics and clinical responses provide the most important information for therapeutic decision-making. Moreover, data on VAP therapy due to resistant bacteria are lacking, and the choice of treatment is often based on clinical practice and individual experience. Areas covered: This review summarizes the strategies available for treating the three most prevalent resistant Gram-negative organisms causing VAP: Pseudomonas aeruginosa, Acinetobacter baumannii and Enterobacteriaceae. The review covers the results of a Pubmed search, clinical practice guidelines and reviews, and the authors' experience. Expert opinion: The existing evidence focuses on bloodstream infections or other sites rather than pneumonia and there are no recommendations for the treatment of VAP by multi-drug resistant Gram-negative bacteria, especially for combination regimens. The approval of new drugs is needed to provide effective and safe alternatives for treating carbapenemase-producing strains. Precision medicine and personalized approach are also fundamental in future research.