Healthcare-associated infections in adult intensive care unit patients: Changes in epidemiology, diagnosis, prevention and contributions of new technologies

Impact of Appropriate Empirical Antibiotic Treatment on the Clinical Response of Septic Patients in Intensive Care Unit: A Single-Center Observational Study

The appropriate antibiotic treatment of patients with bacterial sepsis in the intensive care unit (ICU) remains a challenge. Considering that current international guidelines recommend 7 days of antibiotic therapy as sufficient for most severe infections, our primary outcome was a comparison of clinical response to initial empirical therapy on day 7 and mortality between two groups of septic patients-with appropriate (AEAT) and inappropriate (IEAT) empirical antibiotic therapy according to the in vitro sensitivity of bacteria detected in a blood culture (BC). Adult patients admitted to the ICU between 2020 and 2023, who were diagnosed with sepsis according to the Sequential Organ Failure Assessment (SOFA) score ≥ 2 in association with a suspected or documented infection, were selected for the study. Of the 418 patients, 149 (35.6%) died within 7 days. Although the AEAT group had a lower mortality rate (30.3% vs. 34.2%) and better clinical improvement (52.8% vs. 47.4%) on day 7 after starting empirical antibiotic therapy, there was no significant difference. A causative organism was isolated from BCs in 30% of septic patients, with gram-negative bacteria (GNB) predominating in 60% of cases, and multidrug-resistant (MDR) or extensively drug-resistant (XDR) bacteria predominantly detected in the BCs of the IEAT group. Although the AEAT group had slightly worse clinical characteristics at the onset of sepsis than the IEAT group, the AEAT group showed faster improvement on days 7 and 14 of sepsis. In this retrospective cross-sectional study, the AEAT group was associated with better clinical response at day 7 after sepsis onset and lower mortality, but without a significant difference. Comorbidities and the type of bacterial pathogen should also be taken into account as they can also contribute to the prediction of the final outcome. These results demonstrate the importance of daily assessment of clinical factors to more accurately predict the clinical outcome of a septic patient.

Modified frailty index effectively predicts adverse outcomes in sepsis patients in the intensive care unit

BACKGROUND

Frailty and sepsis have a significant impact on patient prognosis. However, research into the relationship between frailty and sepsis in the general adult population remains inadequate. This paper aims to investigate the association between frailty and adverse outcomes in this population.

METHOD

This retrospective analysis investigated sepsis patients who were initially admitted to the intensive care unit (ICU). The Modified Frailty Index (MFI) was derived by tracking patients' International Classification of Diseases (ICD) codes during their hospitalization. Patients were classified into two groups based on their MFI scores: a frail group (MFI ≥ 3) and a non-frail group (MFI = 0-2). The key outcomes were mortality rates at 90 and 180 days, with secondary outcomes including the incidence of delirium and pressure injury.

RESULT

Of the 21,338 patients who were recruited for this study (median age about 68 years, 41.8 % female), 5,507 were classified as frail and 15,831 were classified as non-frail. Frail patients were significantly more likely to have delirium (48.9 % vs. 36.1 %, p < 0.001) and pressure injury (60.5 % vs. 51.4 %, p < 0.001). After controlling for confounding variables, the multifactorial Cox proportional hazard regression analyses revealed a significantly elevated mortality rate at 90 days (adjusted HR: 1.58, 95 % CI: 1.24-2.02, p < 0.001) and 180 days (adjusted HR: 1.47, 95 % CI: 1.18, 1.83, p < 0.001) in the frail group compared to their non-frail counterparts.

CONCLUSIONS

Frailty independently predisposes adult sepsis patients in the ICU to adverse outcomes. Future investigations should concentrate on evaluating frailty and developing targeted interventions to improve patient prognosis.

IMPLICATION FOR CLINICAL PRACTICE

The MFI provides a simple clinical assessment tool that can be integrated into electronic medical records for immediate calculation. This simplifies the assessment process and plays a key role in predicting patient outcomes.

Ewingella americana Infections in Humans-A Narrative Review

Ewingella americana is a Gram-negative rod that belongs to the order Enterobacterales and the family Yersiniaceae and was first identified in 1983 from 10 clinical strains in the United States of America. The present study aimed to identify all the published cases of E. americana in the literature, describe the epidemiological, clinical, and microbiological characteristics, and provide data regarding its antimicrobial resistance, treatment, and outcomes. A narrative review was performed based on a PubMed and Scopus databases search. In total, 16 studies provided data on 19 patients with infections by E. americana. The median age of the patients was 55 years, and 47.4% were male. The most common infections were those of the bloodstream, the respiratory tract, and the peritoneal cavity. Antimicrobial resistance to cephalosporins, aminoglycosides, and the combination of trimethoprim with sulfamethoxazole was minimal, and these were the most commonly used antimicrobials for treating these infections. No included study provided information on the genetic or molecular mechanism of this pathogen's antimicrobial resistance. The overall mortality was minimal, with only one patient with bacteremia succumbing to the infection. Further studies are needed to better understand this microorganism, its pathogenic potential in humans, and the genetic and molecular mechanisms underlying its antimicrobial resistance, for which very little evidence exists to date.

Nosocomial outbreak caused by disinfectant-resistant Serratia marcescens in an adult intensive care unit, Hungary, February to March 2022

In 2022, an outbreak with severe bloodstream infections caused by Serratia marcescens occurred in an adult intensive care unit (ICU) in Hungary. Eight cases, five of whom died, were detected. Initial control measures could not stop the outbreak. We conducted a matched case-control study. In univariable analysis, the cases were more likely to be located around one sink in the ICU and had more medical procedures and medications than the controls, however, the multivariable analysis was not conclusive. Isolates from blood cultures of the cases and the ICU environment were closely related by whole genome sequencing and resistant or tolerant against the quaternary ammonium compound surface disinfectant used in the ICU. Thus, S. marcescens was able to survive in the environment despite regular cleaning and disinfection. The hospital replaced the disinfectant with another one, tightened the cleaning protocol and strengthened hand hygiene compliance among the healthcare workers. Together, these control measures have proved effective to prevent new cases. Our results highlight the importance of multidisciplinary outbreak investigations, including environmental sampling, molecular typing and testing for disinfectant resistance.

The impact of sink removal and other water-free interventions in intensive care units on water-borne healthcare-associated infections: A systematic review

BACKGROUND

With increasing awareness of water sinks as potential sources of outbreaks and transmission of multi-drug resistant (MDR) bacteria in intensive care units (ICUs), there is growing interest in water-free patient care systems. This systematic review reviewed and synthesized available evidence on the effectiveness of sink removal with or without water-free activities in the ICU environment to reduce water-borne healthcare-associated infections.

METHODS

We searched five databases (PubMed, MEDLINE, Scopus, Web of Science and Embase) for studies published from 1st January 1980 to 2nd April 2024 that examined water-less or water-free activities in the ICU to reduce healthcare-associated infections and patient colonization.

RESULTS

Of 2,075 articles, seven quasi-experimental studies (total: 332 patient beds) met the study selection criteria. 6/7 studies (85.7%) were based in adult ICUs; one (14%) was in a neonatal ICU. 5/7 sites (71.4%) implemented water-less interventions after an outbreak. Water-free alternatives used included water-less bath products (6/7;85.7%), bottled water for consumption (3/7;42.9%), oral care (3/7;42.9%) and dissolving of oral medication (4/7;57.1%), designated 'contaminated' sink outside of patient and medication preparation areas for disposal of wastewater (4/7; 57.1%). Implicated pathogens studied included MDR gram-negative bacteria (4/7; 57.1%), MDR Pseudomonas aeruginosa only (2/7; 28.6%), and pulmonary non-tuberculous mycobacterium (NTB) (1/7; 14.3%). 5/7 (71.4%) studies reported outbreak cessation.

CONCLUSION

Preliminary evidence, from a limited number of studies of which the majority were conducted in an outbreak setting, suggest that sink removal and other water-free interventions in the ICU helped terminate outbreaks involving taps and decrease hospital-onset respiratory isolation of pulmonary NTB.

Infection Control Measure Performance in Long-Term Care Hospitals and Their Relationship to Joint Commission Accreditation

BACKGROUND

This study evaluated the relationship between Joint Commission accreditation and health care-associated infections (HAIs) in long-term care hospitals (LTCHs).

METHODS

This observational study used Centers for Medicare & Medicaid Services (CMS) LTCH data for the period 2017 to June 2021. The standardized infection ratio (SIR) of three measures used by the Centers for Disease Control and Prevention's National Healthcare Safety Network were used as dependent variables in a random coefficient Poisson regression model (adjusting for CMS region, owner type, and bed size quartile): catheter-associated urinary tract infections (CAUTIs), Clostridioides difficile infections (CDIs), and central line-associated bloodstream infections (CLABSIs) for the periods 2017 to 2019 and July 1, 2020, to June 30, 2021. Data from January 1 to June 30, 2020, were excluded due to the COVID-19 pandemic.

RESULTS

The data set included 244 (73.3%) Joint Commission-accredited and 89 (26.7%) non-Joint Commission-accredited LTCHs. Compared to non-Joint Commission-accredited LTCHs, accredited LTCHs had significantly better (lower) SIRs for CLABSI and CAUTI measures, although no differences were observed for CDI SIRs. There were no significant differences in year trends for any of the HAI measures. For each year of the study period, a greater proportion of Joint Commission-accredited LTCHs performed significantly better than the national benchmark for all three measures (p = 0.04 for CAUTI, p = 0.02 for CDI, p = 0.01 for CLABSI).

CONCLUSION

Although this study was not designed to establish causality, positive associations were observed between Joint Commission accreditation and CLABSI and CAUTI measures, and Joint Commission-accredited LTCHs attained more consistent high performance over the four-year study period for all three measures. Influencing factors may include the focus of Joint Commission standards on infection control and prevention (ICP), including the hierarchical approach to selecting ICP-related standards as inputs into LTCH policy.

A retrospective study of the predictors of mortality among patients in intensive care units at North West-Bank hospitals in Palestine

OBJECTIVES

The intensive care unit (ICU) mortality rate remains high, especially in developing countries, regardless of the advances in critical management. There is a lack of studies about mortality causes in hospitals and particularly ICUs in Palestine.This study evaluated the demographic and clinical characteristics of critically ill patients and determined the predictors of mortality among patients in the ICU.

METHODS

A retrospective study assessed all patients who stayed in the ICU for more than 24 h from January 2017 to January 2019. Data were collected from the patient's files. Patient characteristics (background, clinical variables, and comorbidities) were recorded.

RESULTS

The study included 227 eligible ICU patients. The cases' mean age was 55.5 (SD ± 18.2) years. The overall ICU mortality rate was 31.7%. The following factors were associated with high adjusted mortality odds: admission from inside the hospital (adjusted odds ratio (aOR), 2.1, 95% CI: 1.1-3.9, p < 0.05), creatinine level ≥2 mg/dl on admission (aOR, 2.7, 95% CI: 1.3-5.8, p < 0.01), hematology malignancy patients (aOR, 3.4, 95% CI: 1.6-6.7, p = 0.001), immune-compromised (aOR, 2.5, 95% CI: 1.3-4.7, p < 0.01), septic shock (aOR, 27.1, 95% CI: 7.9-88.3, p < 0.001), hospital-acquired infections (aOR: 13.4, 95% CI: 4.1-57.1, p < 0.001), and patients with multiple-source infection (aOR: 16.3, 95% CI: 6.4-57.1, p < 0.001). Also, high SOFA and APACHE scores predicted morality (p < 0.001).

CONCLUSION

The mortality rate among ICU patients was high. It was higher among those admitted from the hospital wards, septic shock, hospital-acquired infection, multiple infection sources, and multi-drug resistance infections. Thus, strategies should be developed to enhance the ICU environment and provide sufficient resources to minimize the effects of these predictors.

Carbapenem-resistant gram-negative bacterial infections and risk factors for acquisition in a Kenyan intensive care unit

BACKGROUND

Carbapenem-resistant Gram-negative bacteria (CR-GNB) are a critical public health threat globally; however, there are inadequate surveillance data, especially in intensive care units (ICU), to inform infection prevention and control in many resource-constrained settings. Here, we assessed the prevalence of CR-GNB infections and risk factors for acquisition in a Kenyan ICU.

METHODS

A hospital-based cross-sectional study design was adopted, recruiting 162 patients clinically presenting with bacterial infection after 48 h of ICU admission, from January to October 2022 at the Nairobi West Hospital, Kenya. Demographics and clinical data were collected by case report form. The type of sample collected, including blood, tracheal aspirate, ascitic tap, urine, stool, and sputum depended on the patient's clinical presentation and were transported to the hospital Microbiology laboratory in a cool box for processing within 2 h. The samples were analyzed by cultured and BD Phoenix system used for isolates' identity and antimicrobial susceptibility.

RESULTS

CR-GNB infections prevalence was 25.9% (42/162), with Klebsiella pneumoniae (35.7%, 15/42) and Pseudomonas aeruginosa (26.2%, 11/42) predominating. All isolates were multidrug-resistant (MDR). P. aeruginosa and A. baumannii were 100% colistin-resistant, while K. pneumoniae (33.3%) was tigecycline-resistant. History of antibiotics (aOR = 3.40, p = 0.005) and nasogastric tube (NGT) use (aOR = 5.84, p = < 0.001) were the risk factors for infection.

CONCLUSION

Our study highlights high MDR- and CR-GNB infections in ICU, with prior antibiotic exposure and NGT use as risk factors, and diminishing clinical value of colistin and tigecycline. In this study setting and beyond, strict implementation of antimicrobial stewardship programs and adherence to infection prevention and control through monitoring, evaluation and feedback are warranted to curb CR-GNB infections, especially among the risk groups.

Antibacterial efficacy, mode of action, and safety of a novel nano-antibiotic against antibiotic-resistant Escherichia coli strains

Globally rising antibiotic-resistant (AR) and multi-drug resistant (MDR) bacterial infections are of public health concern due to treatment failure with current antibiotics. Enterobacteria, particularly Escherichia coli, cause infections of surgical wound, bloodstream, and urinary tract, including pneumonia and sepsis. Herein, we tested in vitro antibacterial efficacy, mode of action (MoA), and safety of novel amino-functionalized silver nanoparticles (NH2-AgNP) against the AR bacteria. Two AR E. coli strains (i.e., ampicillin- and kanamycin-resistant E. coli), including a susceptible strain of E. coli DH5α, were tested for susceptibility to NH2-AgNP using Kirby-Bauer disk diffusion and standard growth assays. Dynamic light scattering (DLS) was used to determine cell debris and relative conductance was used as a measure of cell leakage, and results were confirmed with transmission electron microscopy (TEM). Multiple oxidative stress assays were used for in vitro safety evaluation of NH2-AgNP in human lung epithelial cells. Results showed that ampicillin and kanamycin did not inhibit growth in either AR bacterial strain with doses up to 160 μg/mL tested. NH2-AgNP exhibited broad-spectrum bactericidal activity, inhibiting the growth of all three bacterial strains at doses ≥1 μg/mL. DLS and TEM revealed cell debris formation and cell leakage upon NH2-AgNP treatment, suggesting two possible MoAs: electrostatic interactions followed by cell wall damage. Safety evaluation revealed NH2-AgNP as noncytotoxic and antioxidative to human lung epithelial cells. Taken together, these results suggest that NH2-AgNP may serve as an effective and safer bactericidal therapy against AR bacterial infections compared to common antibiotics.

Short-duration selective decontamination of the digestive tract infection control does not contribute to increased antimicrobial resistance burden in a pilot cluster randomised trial (the ARCTIC Study)

OBJECTIVE

Selective decontamination of the digestive tract (SDD) is a well-studied but hotly contested medical intervention of enhanced infection control. Here, we aim to characterise the changes to the microbiome and antimicrobial resistance (AMR) gene profiles in critically ill children treated with SDD-enhanced infection control compared with conventional infection control.

DESIGN

We conducted shotgun metagenomic microbiome and resistome analysis on serial oropharyngeal and faecal samples collected from critically ill, mechanically ventilated patients in a pilot multicentre cluster randomised trial of SDD. The microbiome and AMR profiles were compared for longitudinal and intergroup changes. Of consented patients, faecal microbiome baseline samples were obtained in 89 critically ill children. Additionally, samples collected during and after critical illness were collected in 17 children treated with SDD-enhanced infection control and 19 children who received standard care.

RESULTS

SDD affected the alpha and beta diversity of critically ill children to a greater degree than standard care. At cessation of treatment, the microbiome of SDD patients was dominated by Actinomycetota, specifically Bifidobacterium, at the end of mechanical ventilation. Altered gut microbiota was evident in a subset of SDD-treated children who returned late longitudinal samples compared with children receiving standard care. Clinically relevant AMR gene burden was unaffected by the administration of SDD-enhanced infection control compared with standard care. SDD did not affect the composition of the oral microbiome compared with standard treatment.

CONCLUSION

Short interventions of SDD caused a shift in the microbiome but not of the AMR gene pool in critically ill children at the end mechanical ventilation, compared with standard antimicrobial therapy.

Two-step interpretable modeling of ICU-AIs

We present a novel methodology for integrating high resolution longitudinal data with the dynamic prediction capabilities of survival models. The aim is two-fold: to improve the predictive power while maintaining the interpretability of the models. To go beyond the black box paradigm of artificial neural networks, we propose a parsimonious and robust semi-parametric approach (i.e., a landmarking competing risks model) that combines routinely collected low-resolution data with predictive features extracted from a convolutional neural network, that was trained on high resolution time-dependent information. We then use saliency maps to analyze and explain the extra predictive power of this model. To illustrate our methodology, we focus on healthcare-associated infections in patients admitted to an intensive care unit.

The burden of hospital-acquired infections (HAI) in sub-Saharan Africa: a systematic review and meta-analysis

Background

Hospital-acquired infections (HAI) are a leading cause of morbidity and mortality globally. These infections are diverse, but the majority are lower respiratory tract infection (LRTI), surgical site infection (SSI), bloodstream infection (BSI), and urinary tract infection (UTI). For most sub-Saharan African countries, studies revealing the burden and impact of HAI are scarce, and few systematic reviews and meta-analysis have been attempted. We sought to fill this gap by reporting recent trends in HAI in sub-Saharan Africa (SSA) with attention to key patient populations, geographic variation, and associated mortality.

Methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a literature search of six electronic databases (Web of Science, Pubmed, APA PsycInfo, CINAHL, Embase, and the Cochrane Library) to identify studies assessing the prevalence of HAI in SSA countries. Studies published between 01 January 2014 and 31 December 2023 were included. We applied no language or publication restrictions. Record screening and data extractions were independently conducted by teams of two or more reviewers. Using the R software (version 4.3.1) meta and metafor packages, we calculated the pooled prevalence estimates from random-effect meta-analysis, and further explored sources of heterogeneity through subgroup analyses and meta-regression. This study is registered with PROSPERO, CRD42023433271.

Findings

Forty-one relevant studies were identified for analysis, consisting of 15 from West Africa (n = 2107), 12 from Southern Africa (n = 2963), 11 from East Africa (n = 2142), and 3 from Central Africa (n = 124). A total of 59.4% of the patient population were associated with paediatric admissions. The pooled prevalence of HAI was estimated at 12.9% (95% CI: 8.9-17.4; n = 7336; number of included estimates [k] = 41, p < 0.001). By subregions, the pooled current prevalence of HAI in the West Africa, Southern Africa, East Africa and Central Africa were estimated at 15.5% (95% CI: 8.3-24.4; n = 2107; k = 15), 6.5% (95% CI: 3.3-10.7; n = 2963; k = 12), 19.7% (95% CI: 10.8-30.5; n = 2142; k = 11) and 10.3% (95% CI: 1.1-27.0; n = 124; k = 3) of the patient populations respectively. We estimated mortality resulting from HAI in SSA at 22.2% (95% CI: 14.2-31.4; n = 1118; k = 9).

Interpretation

Our estimates reveal a high burden of HAI in SSA with significant heterogeneity between regions. Variations in HAI distribution highlight the need for infection prevention and surveillance strategies specifically tailored to enhance prevention and management with special focus on West and East Africa, as part of the broader global control effort.

Funding

No funding was received for this study.

Application of failure mode and effect analysis in ICU admission of potentially COVID-19 infected patients

BACKGROUND

To analyze the admission and treatment process of potentially COVID-19-infected patients in the intensive care unit under normalization, prevention, and control of the pandemic.

METHODS

A multidisciplinary team was assembled to develop a flowchart of potentially COVID-19-infected patients admitted to the intensive care unit and identify potential failure steps and modes throughout the process using the failure mode and effect analysis method. Through risk priority number (RPN) analysis of each failure mode, those with the highest impact on nosocomial infection were identified, and the priority of implementation was determined. Related corrective measures have been developed to continuously improve clinical practice and management.

RESULTS

Eighty potential failure modes were identified, and 8 potential failure modes were identified with RPNs greater than 100. These high RPNs of the failure modes were associated with careless inquiries of epidemiological histories by nurses, inadequate implementation of management standards by nursing assistants, and exposure of attending physicians to potentially risky environments. Finally, 18 general corrective measures are proposed.

CONCLUSIONS

Application of the failure mode and effect analysis method for quality improvement is a powerful tool for predicting potential failures in the process and can suggest corrective measures that could help avoid nosocomial infection during a pandemic.

Impact of infection prevention and control practices, including personal protective equipment, on the prevalence of hospital-acquired infections in acute care hospitals during COVID-19: a systematic review and meta-analysis

BACKGROUND

The COVID-19 pandemic has posed an unprecedented challenge to healthcare systems globally. Personal protective equipment has played a fundamental role in protecting healthcare workers and patients, but its effectiveness in reducing hospital-acquired infections (HAIs) during the pandemic remains a subject of debate.

AIM

To conduct a synthesis and meta-analysis of the best available evidence of the prevalence of HAIs using a before/after approach.

METHODS

A three-step search strategy was undertaken to locate published and unpublished studies. A search was performed in MEDLINE, CINAHL, Embase, PsycINFO, and Google Scholar. Screening of studies, data extraction and critical appraisal were performed by four independent reviewers. Meta-analysis was conducted using Review Manager. The review is reported in accordance with PRISMA and JBI guidelines for systematic reviews.

FINDINGS

Fifteen studies were included in the review. Three studies indicated a statistically significant increase in the number of positive cultures during the COVID-19 period compared to the pre-COVID-19 period. Pooled data showed a non-significant decrease in the number of patients with positive cultures in the COVID-19 period compared to pre-COVID-19. There were no significant differences in various bacterial infections except for a significant decrease in respiratory infections. Pooled data for central line-associated bloodstream infections (CLABSIs) indicated a significant increase during the COVID-19 period, but one study reported an increase in CLABSI incidence.

CONCLUSION

The evidence from this review demonstrates a mixed impact of the COVID-19 pandemic precautions on HAIs.

When Infections Are Found: A Qualitative Study Characterizing Best Management Practices for Central Line-Associated Bloodstream Infection and Catheter-Associated Urinary Tract Infection Performance Monitoring and Feedback

Healthcare-associated infections (HAIs) remain a significant patient safety problem that can lead to illness and death, despite the implementation of clinical bundles to prevent HAIs. Management practices can support HAI prevention, but their role in HAI performance monitoring and feedback is not well understood. To address this knowledge gap, we previously conducted semi-structured interviews with staff at 18 hospitals to examine the role of management practices around the prevention of central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs). Interview transcripts were analyzed to identify themes related to HAI performance monitoring and feedback. The current analysis focuses on 10 higher-performing hospitals that were successful in preventing CLABSIs and CAUTIs. These institutions had robust practices including timely event analysis, leadership engagement, and multidisciplinary participation in HAI reviews. Across these sites, we found common goals including investigating HAIs without blame and identifying opportunities for improvement. Management practices such as timely analysis of HAIs, collaboration between facility leadership and multidisciplinary team members, and a focus on identifying the failure of a procedure or protocol, rather than the failure of staff members, are all approaches that can support infection prevention efforts. These management practices may be especially important as hospitals attempt to address increases in CLABSI and CAUTI rates that may have occurred during the coronavirus pandemic.

Culture-free detection of β-lactamase-Producing bacteria in urinary tract infections using a paper sensor

Developing simple, inexpensive, fast, sensitive, and specific probes for antibiotic-resistant bacteria is crucial for the management of urinary tract infections (UTIs). We here propose a paper-based sensor for the rapid detection of β-lactamase-producing bacteria in the urine samples of UTI patients. By conjugating a strongly electronegative group -N+(CH3)3 with the core structures of cephalosporin and carbapenem antibiotics, two visual probes were achieved to respectively target the extended-spectrum/AmpC β-lactamases (ESBL/AmpC) and carbapenemase, the two most prevalent factors causing antibiotic resistance. By integrating these probes into a portable paper sensor, we confirmed 10 and 8 cases out of 30 clinical urine samples as ESBL/AmpC- and carbapenemase-positive, respectively, demonstrating 100% clinical sensitivity and specificity. This paper sensor can be easily conducted on-site, without resorting to bacterial culture, providing a solution to the challenge of rapid detection of β-lactamase-producing bacteria, particularly in resource-limited settings.

Multidrug-resistant pathogens and ventilator-associated pneumonia in critically ill COVID-19 and non-COVID-19 patients: a prospective observational monocentric comparative study

BACKGROUND

The COVID-19 pandemic has increased the incidence of ventilator-associated pneumonia (VAP) among critically ill patients. However, a comparison of VAP incidence in COVID-19 and non-COVID-19 cohorts, particularly in a context with a high prevalence of multidrug-resistant (MDR) organisms, is lacking.

MATERIAL AND METHODS

We conducted a single-center, mixed prospective and retrospective cohort study comparing COVID-19 patients admitted to the intensive care unit (ICU) of the "Città della Salute e della Scienza" University Hospital in Turin, Italy, between March 2020 and December 2021 (COVID-19 group), with a historical cohort of ICU patients admitted between June 2016 and March 2018 (NON-COVID-19 group). The primary objective was to define the incidence of VAP in both cohorts. Secondary objectives were to evaluate the microbial cause, resistance patters, risk factors and impact on 28 days, ICU and in-hospital mortality, duration of ICU stay, and duration of hospitalization).

RESULTS

We found a significantly higher incidence of VAP (51.9% - n = 125) among the 241 COVID-19 patients compared to that observed (31.2% - n = 78) among the 252 NON-COVID-19 patients. The median SOFA score was significantly lower in the COVID-19 group (9, Interquartile range, IQR: 7-11 vs. 10, IQR: 8-13, p < 0.001). The COVID-19 group had a higher prevalence of Gram-positive bacteria-related VAP (30% vs. 9%, p < 0.001), but no significant difference was observed in the prevalence of difficult-to-treat (DTR) or MDR bacteria. ICU and in-hospital mortality in the COVID-19 and NON-COVID-19 groups were 71% and 74%, vs. 33% and 43%, respectively. The presence of COVID-19 was significantly associated with an increased risk of 28-day all-cause hospital mortality (Hazard ratio, HR: 7.95, 95% Confidence Intervals, 95% CI: 3.10-20.36, p < 0.001). Tracheostomy and a shorter duration of mechanical ventilation were protective against 28-day mortality, while dialysis and a high SOFA score were associated with a higher risk of 28-day mortality.

CONCLUSION

COVID-19 patients with VAP appear to have a significantly higher ICU and in-hospital mortality risk regardless of the presence of MDR and DTR pathogens. Tracheostomy and a shorter duration of mechanical ventilation appear to be associated with better outcomes.

Risk factors for surgical site infection following cardiac surgery in a region endemic for multidrug resistant organisms

OBJECTIVES

To identify risk factors for surgical site infections following cardiosurgery in an area endemic for multidrug resistant organisms.

DESIGN

Single-center, historical cohort study including patients who underwent cardiosurgery during a 6-year period (2014-2020).

SETTING

Joint Commission International accredited, multiorgan transplant center in Palermo, Italy.

MAIN OUTCOME MEASURES

Surgical site infection was the main outcome.

RESULTS

On a total of 3609 cardiosurgery patients, 184 developed surgical site infection (5.1 %). Intestinal colonization with multidrug resistant organisms was more frequent in patients with surgical site infections (69.6 % vs. 33.3 %; p < 0.001). About half of surgical site infections were caused by Gram-negative bacteria (n = 97; 52.7 %). Fifty surgical site infections were caused by multidrug resistant organisms (27.1 %), with extended-spectrum Beta-lactamase-producing Enterobacterales (n = 16; 8.7 %) and carbapenem-resistant Enterobacterales (n = 26; 14.1 %) being the predominant resistance problem. However, in only 24 of surgical site infections caused by multidrug resistant organisms (48 %), mostly carbapenem-resistant Enterobacterales (n = 22), a pathogen match between the rectal surveillance culture and surgical site infections clinical culture was demonstrated. Nevertheless, multivariate logistic regression analysis identified a rectal swab culture positive for multidrug resistant organisms as an independent risk factor for SSI (odds ratio 3.95, 95 % confidence interval 2.79-5.60). Other independent risk factors were female sex, chronic dialysis, diabetes mellitus, previous cardiosurgery, previous myocardial infarction, being overweight/obese, and longer intubation time.

CONCLUSION

In an area endemic for carbapenem-resistant Enterobacterales, intestinal colonization with multidrug resistant organisms was recognized as independent risk factor for surgical site infections.

IMPLICATIONS FOR CLINICAL PRACTICE

No causal relationship between colonization with resistant pathogens and subsequent infection could be demonstrated. However, from a broader epidemiological perspective, having a positive multidrug resistant organisms colonization status appeared a risk factor for surgical site infections. Therefore, strict infection control measures to prevent cross-transmission remain pivotal (e.g., nasal decolonization, hand hygiene, and skin antisepsis).

Blood Transfusion Procedure: Assessment of Serbian Intensive Care Nurses' Knowledge

Many patients require administering one or more blood components during hospitalisation in the Intensive Care Unit (ICU). Therefore, nurses' knowledge of who is responsible for immediately administering blood transfusions, monitoring patients, and identifying and managing transfusion reactions is crucial. This cross-sectional descriptive-analytical study aimed to assess the knowledge of ICU nurses in tertiary healthcare institutions about blood transfusion procedures. The questionnaire about the transfusion procedure was designed and reviewed by experts. The questionnaire consisted of 29 items divided into three domains. The scores on the knowledge test ranged from 10 to 27. Generally, 57.7% of nurses had moderate, 23.4% low, and 18.9% high levels of knowledge about the transfusion procedure. Most nurses answered correctly about refreezing fresh frozen plasma, verifying the transfusion product, and identifying the patient. Of the nurses, 91.0% would recognise mild allergic reactions, and 98.2% knew about the supervision of sedated patients. Nurses showed poor knowledge of the length of usage of the same transfusion system for red blood cells, labelling, and transfusion administration in febrile patients. Nurses with higher education and longer working experience had significantly better outcomes (p = 0.000) on the knowledge test. Continuous education of ICU nurses on safe transfusion usage is recommended.

Device-Associated Infections in COVID-19 Patients: Frequency of Resistant Bacteria, Predictors and Mortality in Medellín, Colombia

INTRODUCTION

Increased antimicrobial use during the COVID-19 pandemic has raised concerns about the spread of resistant bacteria. This study analyzed the frequency of device-associated infections (DAI) caused by resistant bacteria, the predictors of these infections, and 30-day all-cause mortality in patients with and without COVID-19.

METHODS

A retrospective cohort study was conducted on DAI patients admitted to the ICU (intensive care unit) in 20 hospitals in Medellin, Colombia (2020-2021). The exposure assessed was the COVID-19 diagnosis, and outcomes analyzed were resistant bacterial infections and 30-day mortality. Clinical and microbiological information was collected from surveillance databases. Statistical analysis included generalized linear mixed-effects models.

RESULTS

Of the 1521 patients included, 1033 (67.9%) were COVID-19-positive and 1665 DAI were presented. Carbapenem-resistant Enterobacteriaceae (CRE) infections predominated during the study (n = 98; 9.9%). The patients with COVID-19 had a higher frequency of metallo-beta-lactamase-producing CRE infections (n = 15; 33.3%) compared to patients without the disease (n = 3; 13.0%). Long-stay in the ICU (RR: 2.09; 95% CI: 1.39-3.16), diabetes (RR: 1.73; 95% CI: 1.21-2.49), and mechanical ventilation (RR: 2.13; 95% CI: 1.01-4.51) were CRE infection predictors in COVID-19 patients, with a mortality rate of 60.3%.

CONCLUSION

CRE infections were predominant in COVID-19 patients. In pandemic situations, the strategies to control DAI should be maintained to avoid infections caused by resistant bacteria, such as length of stay in the ICU and duration of mechanical ventilation.

Hub and Spoke: Next level in regional networks for infection prevention

The threat of multidrug-resistant organisms (MDROs) and antimicrobial resistance (AMR) are real and increasing every day. They affect not only healthcare systems but also communities, causing economic and public health concerns. Governments must take action to tackle AMR and prevent the spread of MDROs and regional hubs have a critical role to play in achieving this outcome. Furthermore, bacteria have no borders, consequently, cooperation networks should be extended between countries as a crucial strategy for achieving the success of infection control. Euregions, which are a specific form of cooperation between local authorities of two or more bordering European countries, can help solve common problems and improve the lives of people living on both sides of the border. Regional collaboration strategies can enhance infection control and build resilience against antimicrobial resistance. This review identifies risk factors and the correct approaches to infection prevention and control, including education and awareness programs for healthcare professionals, appropriate prescribing practices, and infection prevention control measures. These measures can help reduce the incidence of antimicrobial resistance in the region and save lives. It is therefore essential to take concrete actions and foster the creation of more effective regional and cross-border centers to ensure the success of infection control policies and the management of healthcare-associated infections. This work sheds light on the issue of MDRO infections within healthcare settings, while also acknowledging the crucial role of the One Health concept in understanding the broader context of these infections. By recognizing the interdependence of human and animal health and the environment, we can take constructive steps toward mitigating the risks of these infections and promoting better health outcomes for all.

Efficacy of Ceragenins in Controlling the Growth of Oral Microorganisms: Implications for Oral Hygiene Management

Ensuring proper dental hygiene is of paramount importance for individuals' general well-being, particularly for patients receiving medical care. There is a prevailing utilization of conventional oral hygiene items, including toothbrushes and mouthwashes, which have gained widespread acceptance; nevertheless, their limitations encourage investigating novel options in this domain. Our study indicates that ceragenins (CSAs) being lipid analogs of host defense peptides, well-recognized for their wide-ranging antimicrobial properties, may be a potentially efficacious means to augment oral hygiene in hospitalized individuals. We demonstrate that ceragenins CSA-13, CSA-44, and CSA-131 as well as undescribed to date CSA-255 display potent antimicrobial activities against isolates of fungi, aerobic, and anaerobic bacteria from Candida, Streptococcus, Enterococcus, and Bacteroides species, which are well-recognized representatives of microbes found in the oral cavity. These effects were further confirmed against mono- and dual-species fungal and bacterial biofilms. While the ceragenins showed similar or slightly diminished efficacy compared to commercially available mouthwashes, they demonstrated a highly favorable toxicity profile toward host cells, that may translate into better maintenance of host mucosal membrane stability. This suggests that incorporating ceragenins into oral hygiene products could be a valuable strategy for reducing the risk of both oral cavity-localized and secondary systemic infections and for improving the overall health outcomes of individuals receiving medical treatment.

The global epidemiology of ventilator-associated pneumonia caused by multi-drug resistant Pseudomonas aeruginosa: A systematic review and meta-analysis

OBJECTIVES

The objective of this systematic review and meta-analysis was to estimate the global prevalence of multi-drug resistant (MDR) Pseudomonas aeruginosa causing ventilator-associated pneumonia (VAP).

METHODS

The systematic search was conducted in four databases. Original studies describing MDR P. aeruginosa VAP prevalence in adults from 2012- 2022 were included. A meta-analysis, using the random effects model, was conducted for overall, subgroups (country, published year, study duration, and study design), and European data, respectively. Univariate meta-regression based on pooled estimates was also conducted. Systematic review registered in International Prospective Register of Systematic Review (CRD42022384035).

RESULTS

In total of 31 studies, containing a total of 7951 cases from 16 countries, were included. The overall pooled prevalence of MDR among P. aeruginosa causing VAP was 33% (95% confidence interval [CI] 27.7-38.3%). The highest prevalence was for Iran at 87.5% (95% CI 69-95.7%), and the lowest was for the USA at 19.7% (95% CI 18.6-20.7%). The European prevalence was 29.9% (95% CI 23.2-36.7%).

CONCLUSIONS

This review indicates that the prevalence of MDR P. aeruginosa in patients with VAP is generally high and varies significantly between countries; however, data are insufficient for many countries. The data in this study can provide a reference for VAP management and drug customisation strategies.

Infection in ECMO patients: Changes in epidemiology, diagnosis and prevention

Patients with prolonged duration of extracorporeal membrane oxygenation support (ECMO) are a vulnerable population for sepsis, particularly ventilator-associated pneumonia and bloodstream infections. Rates differ between venous-arterial and venous-venous ECMO patients and according to the cannulation technique used. The presence of particular organisms depends on local epidemiology, antibiotic exposure, and the duration of the intervention; patients undergoing ECMO for more than three weeks present a high risk of persistent candidemia. Recognizing predisposing factors, and establishing the best preventive interventions and therapeutic choices are critical to optimizing the management of these complications. Infection control practices, including shortening the period of the indwelling devices, and reducing antibiotic exposure, must be followed meticulously. Innovations in oxygenator membranes require an updated approach. Hand hygiene and avoiding breaking the circuit-oxygenator sterility are cornerstones. ECMO management would benefit from clearer definitions, optimization of infection control strategies, and updated infectious clinical practice guidelines.

Impact of Multiplex PCR in the Therapeutic Management of Severe Bacterial Pneumonia

Pneumonia is a common and severe illness that requires prompt and effective management. Advanced, rapid, and accurate tools are needed to diagnose patients with severe bacterial pneumonia, and to rapidly select appropriate antimicrobial therapy, which must be initiated within the first few hours of care. Two multiplex molecular tests, Unyvero HPN and FilmArray Pneumonia+ Panel, have been developed using the multiplex polymerase chain reaction (mPCR) technique to rapidly identify pathogens and their main antibiotic resistance mechanisms from patient respiratory specimens. Performance evaluation of these tests showed strong correlations with reference techniques. However, good knowledge of their indications, targets, and limitations is essential. Collaboration with microbiologists is, therefore, crucial for their appropriate use. Under these conditions, and with standardized management, these rapid tests can improve the therapeutic management of severe pneumonia faster, more precisely, and with narrow-spectrum antibiotic therapy. Further randomized controlled trials are needed to address the many unanswered questions about multiplex rapid molecular testing during the diagnosis and the management of severe pneumonia. This narrative review will address the current knowledge, advantages, and disadvantages of these tests, and propose solutions for their routine use.

Association between multidrug-resistant bacteria and outcomes in intensive care unit patients: a non-interventional study

Background

In intensive care units (ICUs), infections by multidrug-resistant (MDR) microorganisms should be monitored to prevent healthcare-associated infections (HAIs).

Methods

From 2018 to 2020, we investigated all medical records of patients admitted to the ICU of a public university hospital. All patients colonized/infected by MDR microorganisms and submitted to active surveillance cultures (ASCs) were included.

Results and discussion

Male patients prevailed, and 9.5% were positive for MDR bacteria. In-hospital deaths were statistically significant (p < 0.05) for older patients, patients with orotracheal tube use during previous and current hospitalization, and patients with high blood pressure, cardiac and pulmonary diseases, and chronic kidney disease. Carbapenem resistant Enterobacteriaceae was the most frequently resistance profile, followed by extended-spectrum beta-lactamase. The diagnosis or evolution of HAIs was statistically significant (p < 0.0001) for patients treated with meropenem and vancomycin, and in-hospital deaths occurred in 29.5% of patients using polypeptides while the use of macrolides reduced the odds for mortality. The BRADEN Scale demonstrated that 50% of the patients were at high risk of dying.

Conclusion

Patients hospitalized in the ICU, colonized or infected by MDR bacteria, using invasive medical devices, and with underlying medical conditions presented increased mortality rates. The prescription of meropenem and vancomycin should be carefully monitored once patients using these antimicrobials already have or develop an HAI.

Long axial field of view PET/CT in critically ill patients: lessons from a case report

The introduction of new long axial field of view (LAFOV) scanners is a major milestone in positron emission tomography/computed tomography (PET/CT) imaging. With these new systems a revolutionary reduction in scan time can be achieved, concurrently lowering tracer dose. Therefore, PET/CT has come within reach for groups of patients in whom PET/CT previously was undesirable. In this case report we discuss the procedure of a continuous bed motion (CBM) total-body [18F]FDG PET/CT scan in an intensive care patient. We emphasize the clinical and technical possibilities with this new camera system, a matched clinical protocol, and the added value of a dedicated team.

Impact of antibiotic exposure on antibiotic-resistant Acinetobacter baumannii isolation in intensive care unit patients: a systematic review and meta-analysis

BACKGROUND

Acinetobacter baumannii (AB) poses a significant threat to critically ill patients in intensive care units (ICUs). Although an association between antibiotic exposure and resistant AB is reported in the literature, a synthesis of evidence in ICU patients is still lacking.

AIM

To summarize the evidence on the association between prior antibiotic exposure and the occurrence of resistant AB in ICU patients.

METHODS

Online databases were searched for cohort and case-control studies providing data on the association of interest. Carbapenem/multidrug-resistant AB isolation was compared with non-isolation; carbapenem/multidrug-resistant AB was compared with carbapenem/antibiotic-susceptible AB; and extensively drug-resistant AB isolation was compared with non-isolation. Each comparison was subjected to a restricted maximum likelihood random-effects meta-analysis per antibiotic class, estimating pooled ORs. Stratified meta-analyses were performed by study design, outcome type and association-measure adjustment.

FINDINGS

Overall, 25 high-quality studies were retrieved. Meta-analyses showed that carbapenem/multidrug-resistant AB isolation was associated with previous exposure to aminoglycosides, carbapenems, third-generation cephalosporines, glycylcyclines, and nitroimidazoles. Increased risk of isolation of carbapenem/multidrug-resistant AB isolation vs carbapenem/antibiotic-susceptible AB was shown for prior exposure to aminoglycosides, antipseudomonal penicillins, carbapenems, fluoroquinolones, glycopeptides, and penicillins. Third-generation cephalosporin exposure increased the risk of extensively drug-resistant AB isolation vs non-isolation.

CONCLUSION

This systematic review clarifies the role of antibiotic use in antibiotic-resistant AB spread in ICUs, although for some antibiotic classes the evidence is still uncertain due to the small number of adjusted analyses, methodological and reporting issues, and limited number of studies. Future studies need to be carried out with standardized methods and appropriate reporting of multivariable models.

Epidemiology and risk factors for mortality in critically ill patients with pancreatic infection

Background

The AbSeS-classification defines specific phenotypes of patients with intra-abdominal infection based on the (1) setting of infection onset (community-acquired, early onset, or late-onset hospital-acquired), (2) presence or absence of either localized or diffuse peritonitis, and (3) severity of disease expression (infection, sepsis, or septic shock). This classification system demonstrated reliable risk stratification in intensive care unit (ICU) patients with intra-abdominal infection. This study aimed to describe the epidemiology of ICU patients with pancreatic infection and assess the relationship between the components of the AbSeS-classification and mortality.

Methods

This was a secondary analysis of an international observational study ("AbSeS") investigating ICU patients with intra-abdominal infection. Only patients with pancreatic infection were included in this analysis (n=165). Mortality was defined as ICU mortality within 28 days of observation for patients discharged earlier from the ICU. Relationships with mortality were assessed using logistic regression analysis and reported as odds ratio (OR) and 95% confidence interval (CI).

Results

The overall mortality was 35.2% (n=58). The independent risk factors for mortality included older age (OR=1.03, 95% CI: 1.0 to 1.1 P=0.023), localized peritonitis (OR=4.4, 95% CI: 1.4 to 13.9 P=0.011), and persistent signs of inflammation at day 7 (OR=9.5, 95% CI: 3.8 to 23.9, P<0.001) or after the implementation of additional source control interventions within the first week (OR=4.0, 95% CI: 1.3 to 12.2, P=0.013). Gram-negative bacteria were most frequently isolated (n=58, 49.2%) without clinically relevant differences in microbial etiology between survivors and non-survivors.

Conclusions

In pancreatic infection, a challenging source/damage control and ongoing pancreatic inflammation appear to be the strongest contributors to an unfavorable short-term outcome. In this limited series, essentials of the AbSeS-classification, such as the setting of infection onset, diffuse peritonitis, and severity of disease expression, were not associated with an increased mortality risk.ClinicalTrials.gov number: NCT03270345.

Impact of antimicrobial stewardship in organisms causing nosocomial infection among COVID-19 critically ill adults

OBJECTIVE

To evaluate the implementation of an antibiotic stewardship program in critically ill COVID-19 patients and to establish risk factors for coinfection. Secondary objective was to analyze the evolution of the etiology of respiratory nosocomial infections.

METHODS

Single-center observational cohort study of consecutive patients admitted to ICU due to COVID-19 pneumonia from March 2020 to October 2022. An antibiotic stewardship program was implemented at the end of the second wave.

RESULTS

A total of 878 patients were included during 6 pandemic waves. Empirical antibiotic consumption decreased from the 96% of the patients during the first pandemic wave, mainly in combination (90%) to the 30% of the patients in the 6th pandemic wave most in monotherapy (90%). There were not differences in ICU and Hospital mortality between the different pandemic periods. In multivariate analysis, SOFA at admission was the only independent risk factor for coinfection in critically ill COVID-19 patients (OR 1,23 95%CI 1,14 to 1,35). Differences in bacterial etiology of first nosocomial respiratory infection were observed. There was a progressive reduction in Enterobacteriaceae and non- fermentative Gram Negative Bacilli as responsible pathogens, while methicillin-sensitive Staphylococcus aureus increased during pandemic waves. In the last wave, however, a trend to increase of potentially resistant pathogens was observed.

CONCLUSIONS

Implementation of an antibiotic stewardship program was safe and not associated with worse clinical outcomes, being severity at admission the main risk factor for bacterial coinfection in covid-19 patients. A decline in potentially resistant pathogens was documented throughout the pandemic.

Healthcare Professionals' Knowledge, Attitude and Practice of Infection Prevention in Southwest Ethiopia

Introduction

Infection prevention (IP) is a practical and scientifically supported technique to prevent avoidable infections. The effectiveness of IP techniques applied will depend on the knowledge, attitudes, and behaviors of healthcare professionals.

Objective

This study aimed to assess the knowledge, attitude, and practice (KAP) of IP and its associated factors among healthcare professionals at Mizan-Tepi University Teaching Hospital (MTUTH) in southwest Ethiopia.

Methods

A cross-sectional survey was conducted from September 1 and 15, 2021 among 196 healthcare professionals at MTUTH in south-west Ethiopia. The knowledge, attitude and practice outcome variables were measured using 13, 13, and 12 questions respectively. A logistic regression analysis was used. The level of significance was declared at a P < .05.

Results

The level of good knowledge, favorable attitude, and good practice of IP were 71.9%, 63.8%, and 53.6% respectively. Being a GP/specialist [adjusted odds ratio (aOR) = 10.6, 95% CI (2.13-52.9)] and the presence of an IP manual at work [aOR = 3.43, 95% CI (1.33-8.82)] were factors connected with good IP knowledge. The presence of sufficient PPE in the work area [aOR = 2.73, 95% CI (1.36-5.50)] and IP training [aOR = 3.05, 95% CI (1.28-7.29)] were factors associated with a favorable attitude toward IP. Good IP practice was linked to having enough personal protective equipment (PPE) in the workplace [aOR = 3.63, 95% CI (1.71-7.72)] and having good IP knowledge [aOR = 3.08, 95% CI (1.39-6.86)].

Conclusion

The level of KAP of IP among study participants was poor. The provision of adequate PPE, IP manuals and in-service training will help to improve the KAP of healthcare professionals toward IP. Therefore, the hospital management authority and other concerned stakeholders like local NGOs and regional health bureau should provide consistent support to the health professionals in terms of training, resources, and infrastructure to improve and integrate universal precaution in everyday services.

Prevalence and risk factors for colonisation and infection with carbapenem-resistant Enterobacterales in intensive care units: A prospective multicentre study

OBJECTIVES

This study aimed to investigate the prevalence and risk factors for carbapenem-resistant Enterobacterales colonisation/infection at admission and acquisition among patients admitted to the intensive care unit.

RESEARCH METHODOLOGY/DESIGN

A prospective and multicentre study.

SETTING

This study was conducted in 24 intensive care units in Anhui, China.

MAIN OUTCOME MEASURES

Demographic and clinical data were collected, and rectal carbapenem-resistant Enterobacterales colonisation was detected by active screening. Multivariate logistic regression models were used to analyse factors associated with colonisation/infection with carbapenem-resistant Enterobacterales at admission and acquisition during the intensive care unit stay.

RESULTS

There were 1133 intensive care unit patients included in this study. In total, 5.9% of patients with carbapenem-resistant Enterobacterales colonisation/infection at admission, and of which 56.7% were colonisations. Besides, 8.5% of patients acquired carbapenem-resistant Enterobacterales colonisation/infection during the intensive care stay, and of which 67.6% were colonisations. At admission, transfer from another hospital, admission to an intensive care unit within one year, colonisation/infection/epidemiological link with carbapenem-resistant Enterobacterales within one year, and exposure to any antibiotics within three months were risk factors for colonisation/infection with carbapenem-resistant Enterobacterales. During the intensive care stay, renal disease, an epidemiological link with carbapenem-resistant Enterobacterales, exposure to carbapenems and beta-lactams/beta-lactamase inhibitors, and intensive care stay of three weeks or longer were associated with acquisition.

CONCLUSION

The prevalence of colonisation/infection with carbapenem-resistant Enterobacterales in intensive care units is of great concern and should be monitored systematically. Particularly for the 8.5% prevalence of carbapenem-resistant Enterobacterales acquisition during the intensive care stay needs enhanced infection prevention and control measures in these setting. Surveillance of colonisation/infection with carbapenem-resistant Enterobacterales at admission and during the patient's stay represents an early identification tool to prevent further transmission of carbapenem-resistant Enterobacterales.

IMPLICATIONS FOR CLINICAL PRACTICE

Carbapenem-resistant Enterobacterales colonization screening at admission and during the patient's stay is an important tool to control carbapenem-resistant Enterobacterales spread in intensive care units.

Current viewpoint on the epidemiology of nonfermenting Gram-negative bacterial strains

PURPOSE OF REVIEW

This article aims to review the epidemiology of nonfermenting Gram-negative bacilli (NFGNB) based on recent literature reports, particularly, of the less common, but with emerging clinical significance species.

RECENT FINDINGS

The reported frequency of multidrug-resistant Acinetobacter baumannii and Pseudomonas aeruginosa is increasing, with very significant variability, however, between different countries. Apart from the major NFGNB, that is, A. baumannii and P. aeruginosa, already recognized as of critical importance healthcare risks, several other NFGNB genera have been increasingly associated with diverse severe infections, such as Stenotrophomonas maltophilia, Burkholderia spp., Elizabethkingia spp., Chryseobacterium spp., Achromobacter spp., Alcaligenes spp., Sphingomonas spp., Shewanella spp. and Ralstonia spp., among others.

SUMMARY

The exploration of the epidemiology, as well as the pathogenic potential of the of the less frequent, but emerging and increasingly reported NFGNB, is crucial, not only for immunocompromised patients, but also for critically ill patients without overt immunosuppression. As we are heading fast towards a postantibiotic era, such information would contribute to the optimal antimicrobial management, that is, providing prompt, appropriate antimicrobial coverage when needed and, at the same time, avoiding overuse and/or inappropriate use of antimicrobial therapy. Also, it would help to better understand their transmission dynamics and to develop effective prevention strategies.

Practice of 18F-FDG-PET/CT in ICU Patients: A Systematic Review

18F-FDG-PET/CT imaging has become a key tool to evaluate infectious and inflammatory diseases. However, application of 18F-FDG-PET/CT in patients in the intensive care unit (ICU) is limited, which is remarkable since the development of critical illness is closely linked to infection and inflammation. This limited use is caused by perceived complexity and risk of planning and executing 18F-FDG-PET/CT in such patients. The aim of this systematic review was to investigate the feasibility of 18F-FDG-PET/CT in ICU patients with special emphasis on patient preparation, transport logistics and safety. Therefore, a systematic search was performed in PubMed, Embase, and Web of Science using the search terms: intensive care, critically ill, positron emission tomography and 18F-FDG or derivates. A total of 1183 articles were found of which 10 were included. Three studies evaluated the pathophysiology of acute respiratory distress syndrome, acute lung injury and acute chest syndrome. Three other studies applied 18F-FDG-PET/CT to increase understanding of pathophysiology after traumatic brain injury. The remaining four studies evaluated infection of unknown origin. These four studies showed a sensitivity and specificity between 85%-100% and 57%-88%, respectively. A remarkable low adverse event rate of 2% was found during the entire 18F-FDG-PET/CT procedure, including desaturation and hypotension. In all studies, a team consisting of an intensive care physician and nurse was present during transport to ensure continuation of necessary critical care. Full monitoring during transport was used in patients requiring mechanical ventilation or vasopressor support. None of the studies used specific patient preparation for ICU patients. However, one article described specific recommendations in their discussion. In conclusion, 18F-FDG-PET/CT has been shown to be feasible and safe in ICU patients, even when ventilated or requiring vasopressors. Specific recommendations regarding patient preparation, logistics and scanning are needed. Including 18F-FDG-PET/CT in routine workup of infection of unknown origin in ICU patients showed potential to identify source of infection and might improve outcome.

Healthcare-associated infections among neonates and children in Pakistan: findings and the implications from a point prevalence survey

BACKGROUND

Healthcare-associated infections (HAIs) increase morbidity, mortality and costs. The overall prevalence of HAIs is greater in low- and middle-income countries due to poor resources and infrastructure, with the incidence of HAIs greater among neonates and children. There is a need to understand the current situation in Pakistan including key drivers to improve future care.

METHODS

Point prevalence survey (PPS) of HAIs in the children's wards of 19 public sector secondary- and tertiary-care hospitals of Pakistan and associated key drivers.

RESULTS

A total of 1147 children were included in the PPS. 35.7% were neonates with 32.8% aged >1-5 years. 35.2% were admitted to the intensive care units (ICUs). Peripheral, central venous and urinary catheters were present in 48%, 2.9% and 5.6% of the patients, respectively. A total of 161 HAIs from various pathogens were observed in 153 cases, giving a prevalence of 13.3%. The majority of HAIs were caused by Staphylococcus aureus (31.7%) followed by Klebsiella pneumoniae (22.9%) and Escherichia coli (17.4%). Bloodstream infections were identified in 42 cases followed by lower-respiratory-tract infections in 35. Increased length of hospital stays and being admitted to the ICU, 'rapidly fatal' patients under the McCabe and Jackson criteria, central and peripheral catheterization, and invasive mechanical ventilation were, associated with higher HAIs (P<0.001). 99.7% of HAI patients fully recovered and were discharged from the hospital.

CONCLUSION

There is a high prevalence of HAIs among neonates and children admitted to health facilities in Pakistan. Infection prevention and control measures should be implemented to help prevent future HAIs.

Working Condition and Job Satisfaction of Nurses as Predicting Factors of the Prevalence of Health care-associated Infections among Elderly Inpatients

Background

Health care-Associated Infections (HCAIs) are among the most common adverse events (AEs) that can negatively affect both patients and health systems. The elderly is among patients at high risk for infections. Some controllable risk factors have received less attention in research. Therefore, this study aims to investigate the relationship between prevalence of HCAIs among elderly inpatients, job satisfaction of nurses, and working condition.

Materials and Methods

This cross-sectional study was conducted on 211 nurses working in hospitals affiliated with Iran University of Medical Sciences, Tehran, in 2021. The data were collected from HCAIs reports by the Nosocomial Infection Control Committee, a demographic questionnaire, the Practice Environment Scale of the Nursing Work Index (PES-NWI), and the Minnesota Satisfaction Questionnaire (MSQ). The data were statistically analyzed using Pearson correlation coefficient, ANOVA, t-test, and multiple linear regression (MLR) in SPSS 26.

Results

The results showed that there was a significant relationship between the PES-NWI and MSQ (r = 0.68, p < 0.00). The MLR results indicated that staffing and resource adequacy, nurse participation in hospital affairs, job satisfaction, nursing manager's leadership, and nursing foundations for quality of care are predictive factors that these could explain 78% of the changes in the prevalence of HCAIs and the goodness of fit of the regression model was acceptable [F6.210 = 129.47, p < 0.001].

Conclusions

Since job satisfaction and the work condition could predict HCAIs among the elderly patients, healthcare administers are recommended to consider these two variables in the development of HCAIs prevention and control programs.

Prolonged use of intravenous administration sets on central line associated bloodstream infection, nursing workload and material use: A before-after study

OBJECTIVES

One of the interventions to reduce risk of central line associated bloodstream infection (CLABSI) is routine replacement of the intravenous administration sets. Guidelines advises a time interval that ranges between four and seven days. However many hospitals replace intravenous administration sets every four days to prevent CLABSI.

RESEARCH METHODOLOGY

In this single centre retrospective study we analysed whether the extension of the time interval from four to seven days for routine replacement of intravenous administration sets had impact on the incidence of CLABSI and colonization of the central venous catheter. Secondary outcomes were the effects on nursing workload, material use and costs.

RESULTS

In total, 1,409 patients with 1,679 central lines were included. During the pre-intervention period 2.8 CLABSI cases per 1,000 catheter days were found in comparison with 1.3 CLABSI cases per 1,000 catheter days during the post-intervention period. The rate difference between the groups was 1.52 CLABSI cases per 1,000 catheter days (95% CI: -0.50 to +4.13, p = 0.138). The intervention resulted in a saving of 345 intravenous single use plastic administration sets and 260 hours nursing time, and reduced cost with an estimate of at least 17.250 Euros.

CONCLUSION

Extension of the time interval from four to seven days for routine replacement of intravenous administration sets did not negatively affect the incidence of CLABSI.

IMPLICATIONS FOR CLINICAL PRACTICE

Additional benefits of the prolonged time interval were saving of nursing time by avoiding unnecessary routine procedures, the reducing of waste because of reducing the use of disposable materials and healthcare costs.