Prospective evaluation of a closed-incision negative pressure wound therapy system in kidney transplantation and its association with wound complications

Introduction

Wound complications can cause considerable morbidity in kidney transplantation. Closed-incision negative pressure wound therapy (ciNPWT) systems have been efficacious in reducing wound complications across surgical specialties. The aims of this study were to evaluate the use of ciNPWT, Prevena™, in kidney transplant recipients and to determine any association with wound complications.

Material and methods

A single-center, prospective observational cohort study was performed in 2018. A total of 30 consecutive kidney transplant recipients deemed at high risk for wound complications received ciNPWT, and the results were compared to those of a historical cohort of subjects who received conventional dressings. Analysis for recipients with obesity and propensity score matching were performed.

Results

In total, 127 subjects were included in the analysis. Of these, 30 received a ciNPWT dressing and were compared with 97 subjects from a non-study historical control group who had conventional dressing. The overall wound complication rate was 21.3% (27/127). There was no reduction in the rate of wound complications with ciNPWT when compared with conventional dressing [23.3% (7/30) and 20.6% (20/97), respectively, p = 0.75]. In the obese subset (BMI ≥30 kg/m2), there was no significant reduction in wound complications [31.1% (5/16) and 36.8% (7/19), respectively, p = 0.73]. Propensity score matching yielded 26 matched pairs with equivalent rates of wound complications (23.1%, 6/26).

Conclusion

This is the first reported cohort study evaluating the use of ciNPWT in kidney transplantation. While ciNPWT is safe and well tolerated, it is not associated with a statistically significant reduction in wound complications when compared to conventional dressing. The findings from this study will be used to inform future studies associated with ciNPWT in kidney transplantation.

Burden of five healthcare associated infections in Australia

Background

Healthcare associated infections are of significant burden in Australia and globally. Previous estimates in Australia have relied on single-site studies, or combinations thereof, which have suggested the burden of these infections is high in Australia. Here, we estimate the burden of five healthcare associated infections (HAIs) in Australian public hospitals using a standard international framework, and compare these estimates to those observed in Europe.

Methods

We used data from an Australian point prevalence survey to estimate the burden of HAIs amongst adults in Australian public hospitals using an incidence-based approach, introduced by the ECDC Burden of Communicable Diseases in Europe.

Results

We estimate that 170,574 HAIs occur in adults admitted to public hospitals in Australia annually, resulting in 7583 deaths. Hospital acquired pneumonia is the most frequent HAI, followed by surgical site infections, and urinary tract infections. We find that blood stream infections contribute a small percentage of HAIs, but contribute the highest number of deaths (3207), more than twice that of the second largest, while pneumonia has the higher impact on years lived with disability.

Conclusion

This study is the first time the national burden of HAIs has been estimated for Australia from point prevalence data collected using validated surveillance definitions. Per-capita, estimates are similar to that observed in Europe, but with significantly higher occurrences of bloodstream infections and healthcare-associated pneumonia, primarily amongst women. Overall, the estimated burden is high and highlights the need for continued investment in HAI prevention.

Protocol on establishing a prospective enhanced surveillance of vaccine preventable diseases in residential aged care facilities in Central Queensland, Australia: an observational study

INTRODUCTION

Infectious diseases are a major cause of mortality and morbidity among the highly vulnerable occupants of residential aged care facilities (RACFs). The burden of vaccine preventable diseases (VPDs) among RACFs residents is mostly unknown and there is a lack of quality data from population-based prospective VPD surveillance in RACFs. The increasing burden of emerging and existing VPDs (eg, COVID-19, influenza, pneumococcal, pertussis and varicella-zoster) necessitates the establishment of an active enhanced surveillance system to provide real-time evidence to devise strategies to reduce the burden of VPDs in RACFs.

METHOD AND ANALYSIS

This study proposes a prospective active enhanced surveillance that will be implemented in RACFs across the Central Queensland (CQ) region. The study aims to measure the burden, identify aetiologies, risk factors, predictors of severe outcomes (eg, hospitalisations, mortality) and impact of the existing National Immunization Program (NIP) funded vaccines in preventing VPDs in this vulnerable population. CQ Public Health Unit (CQPHU) will implement the active surveillance by collecting demographic, clinical, pathological, diagnostic, therapeutic and clinical outcome data from the RACFs based on predefined selection criteria and case report forms as per routine public health practices. Descriptive statistics, univariate and multivariate regression analysis will be conducted to identify the predictors of morbidity and clinical outcomes following infection.

ETHICS AND DISSEMINATION

The study has been approved by the CQHHS Human Research Ethics Committee (HREC) (reference number HREC/2021/QCQ/74305). This study involves data that is routinely collected as part of the surveillance of notifiable conditions under the Public Health Act 2005. The CQHHS HREC approved a request to waive consent requirements of study participants as researchers will be provided non-identifiable data. The findings from the study will be actively disseminated through publication in peer-reviewed journals, conference presentations, social and print media, federal, state, and local authorities to reflect on the results that may facilitate revision of policy and highlight the stakeholders, funding bodies both locally and internationally.

The Impact of Differences in Surveillance Definitions of Hospital Acquired Urinary Tract Infections (HAUTI)

Hospital-acquired urinary tract infections (HAUTI) are common and most cases are related to catheters (CAUTI). HAUTI and CAUTI surveillance is mandatory in many countries as a measure to reduce the incidence of infections and appropriately direct the allocation of preventable resources. The surveillance criteria issued by the Israeli Ministry of Health (IMOH), differ somewhat from that of the U.S. Centers for Disease Control and Prevention (CDC). Our study aims were to query and quantify the impact of these differences. In a retrospective cohort study conducted at Shamir Medical Center, for calendar year 2017, the surveillance criteria of both IMOH and CDC were applied on 644 patient-unique adults with “positive” urine cultures (per similar definitions). The incidence of HAUTI per IMOH was significantly higher compared to CDC (1.24/1000 vs. 1.02/1000 patient-days, p = 0.02), with no impact on hospitalization’s outcomes. The agreement rate between methods was high for CAUTI (92%), but much lower for all HAUTI (83%). The major error rate, i.e., patients diagnosed with HAUTI per IMOH but had no UTI per CDC, was 31%. To conclude, in order for surveillance to reflect the relative situation and direct allocation of preventable resources based on scientific literature, the process should be uniform worldwide.

Evaluation of Antimicrobial Stewardship Programs (ASPs) and their perceived level of success at Makkah region hospitals, Kingdom of Saudi Arabia

Antimicrobial stewardship programs (ASPs) are collaborative efforts to optimize antimicrobial use in healthcare institutions through evidence-based quality improvement strategies. The general administration of pharmaceutical care in the Saudi ministry of health (MOH) is putting outstanding efforts in implementing antimicrobial stewardship in Saudi health care settings. Several surveys have been conducted globally and reported many types of antimicrobial stewardship strategies in health institutions and their effectiveness. This study aims to identify ASPs in Makkah region hospitals and their perceived level of success. We administered a regional survey to explore current progress and issues related to the implementation of ASPs in Makkah region hospitals at the pharmacy level (n = 25). Among responding hospitals, 19 (76%) hospitals, the most commonly reported ASP were as following: formulary restrictions (90%) for broad-spectrum antimicrobials and use of prospective feedback on antimicrobial prescribing (68%), use of clinical guidelines and pathways (100%), and use of automatic stop orders (68%) to limit inappropriate antimicrobial therapy. The study outcomes will also be of pivotal importance to devise policies and strategies for antimicrobial stewardship implementation in other non-MOH settings in the Makkah region. Based on our results, all reported institutions have at least one antimicrobial stewardship program in a process with a high success rate. A multidisciplinary ASP approach, active involvement of drug & therapeutic committee, formulary restrictions, and availability of education & training of pharmacists and physicians on ASP are the primary elements for perceived successful antimicrobial stewardship programs in the Makkah region hospitals.

Clinical and economic benefits of de-escalating stress ulcer prophylaxis therapy in the intensive care unit: A quality improvement study

Stress ulcer prophylaxis is commonly prescribed in the intensive care unit but can be inappropriately commenced or continued on discharge, exposing patients to potential harm. We aimed to evaluate whether a prescribing guideline, education program and pharmacist oversight would reduce inappropriate continuation of stress ulcer prophylaxis. This was a multicentre pre- (2014) and post- (2016) quality improvement study across five Australian intensive care units. Cost data were estimated using local information about prescribing patterns, and the relationship between long-term use and adverse events. A total of 531 patients were included in the pre- and 393 in the post-implementation periods. The proportion of hospital survivors inappropriately continued on stress ulcer prophylaxis reduced from 78/184 (42.4%) to 11/143 (7.7%) in the post-implementation period (odds ratio = 8.83; 95% confidence interval 4.47–17.45; P < 0.0001). Clostridium difficile–associated disease reduced from 10 patients to one in the pre- to post-implementation groups. The extrapolated direct savings to all Australian intensive care units from reduced proton pump inhibitor prescribing are relatively small (AUD$2.08 million/year), but the reduction in complications has both benefits for patients and indirect savings of AUD$16.59 million/year nationally. In patients admitted to the intensive care unit, the introduction of a simple, bundled intervention resulted in a significant decrease in inappropriate continuation of stress ulcer prophylaxis at hospital discharge and a reduction in recognised complications, and substantial cost savings.

Pediatric bloodstream infections in metropolitan Australia

BACKGROUND

Bloodstream infections (BSIs) cause significant morbidity and mortality of children worldwide. The aim of this study was to investigate BSI in children and determine the identity of causative organism and their susceptibility patterns in a metropolitan public hospital in Australia.

METHODS

We retrospectively reviewed children aged 0-16 years admitted to a public hospital from January 1, 2010 to August 31, 2014 inclusive, and whose blood cultures revealed bacteraemia. Data were collected regarding patient demographics, species of bacteria isolated, antimicrobial susceptibility of these isolates, and clinical outcomes.

RESULTS

Out of 96 patients with BSI, 55 (57.3%) were males. The median age was 3.35 years (IQR 0.44-7.46), and there were 2 mortalities. Common sites of infection were the respiratory tract (16.6%, n = 16), bone and joints (15.6%, n = 15) and the urinary tract (11.5%, n = 11). The most frequent isolates were Staphylococcus aureus (27.0%), Escherichia coli (14.0%) and Streptococcus pneumoniae (12.0%). Whilst most bacterial isolates displayed susceptibility (> 90%) to common antimicrobial agents, only 57.1% (8/14) of Escherichia coli isolates were susceptible to ampicillin and 58.3% (7/12) were susceptible to co-trimoxazole.

CONCLUSIONS

Gram-positive bacteria accounted for the majority of pediatric BSIs, of which invasive pneumococcal disease remains a noteworthy cause. The majority of isolates, except Escherichia coli, were susceptible to commonly used antimicrobials. This study confirms the knowledge of high rates of resistance of Escherichia coli to ampicillin. Therefore, empirical treatment should still include gentamicin. Monitoring of resistance patterns is warranted to ensure that antibiotic therapy remains appropriate.

Surgical site infection-a population-based study in Australian adults measuring the compliance with and correct timing of appropriate antibiotic prophylaxis

Prophylaxis for surgical site infection (SSI) is often at variance with guidelines, despite the prevalence of SSI and its associated cost, morbidity, and mortality. The CareTrack Australia study, undertaken by a number of the authors, demonstrated that appropriate care (in line with evidence- or consensus-based guidelines) was provided at 38% of eligible SSI healthcare encounters. Here, we report the indicator-level CareTrack Australia findings for SSI prophylaxis. Indicators were extracted from Australian and international clinical guidelines and ratified by clinical experts. A sample designed to be representative of the Australian population was recruited (n=1154). Participants' medical records were reviewed and analysed for compliance with the five SSI indicators. The main outcome measure was the percentage of eligible healthcare encounters with documented compliance with indicators for appropriate SSI prophylaxis. Of the 35,145 CareTrack Australia encounters, 702 (2%) were eligible for scoring against the SSI indicators. Where antibiotics were recommended, compliance was 49% for contaminated surgery, 57% for clean-contaminated surgery and 85% for surgery involving a prosthesis: these fell to 8%, 10% and 14%, respectively (an average of 11%), when currently recommended timing of antibiotic administration was included. Where antibiotics were not indicated, 72% of patients still received them. SSI prophylaxis in our sample was poor; over two-thirds of patients were given antibiotics, whether indicated or not, mainly at the wrong time. There is a need for national agreement on clinical standards, indicators and tools to guide, document and monitor SSI prophylaxis, with both local and national measures to increase and monitor their uptake.

A point prevalence cross-sectional study of healthcare-associated urinary tract infections in six Australian hospitals

OBJECTIVES

Urinary tract infections (UTIs) account for over 30% of healthcare-associated infections. The aim of this study was to determine healthcare-associated UTI (HAUTI) and catheter-associated UTI (CAUTI) point prevalence in six Australian hospitals to inform a national point prevalence process and compare two internationally accepted HAUTI definitions. We also described the level and comprehensiveness of clinical record documentation, microbiology laboratory and coding data at identifying HAUTIs and CAUTIs.

SETTING

Data were collected from three public and three private Australian hospitals over the first 6 months of 2013.

PARTICIPANTS

A total of 1109 patients were surveyed. Records of patients of all ages, hospitalised on the day of the point prevalence at the study sites, were eligible for inclusion. Outpatients, patients in adult mental health units, patients categorised as maintenance care type (ie, patients waiting to be transferred to a long-term care facility) and those in the emergency department during the duration of the survey were excluded.

OUTCOME MEASURES

The primary outcome measures were the HAUTI and CAUTI point prevalence.

RESULTS

Overall HAUTI and CAUTI prevalence was 1.4% (15/1109) and 0.9% (10/1109), respectively. Staphylococcus aureus and Candida species were the most common pathogens. One-quarter (26.3%) of patients had a urinary catheter and fewer than half had appropriate documentation. Eight of the 15 patients ascertained to have a HAUTI based on clinical records (6 being CAUTI) were coded by the medical records department with an International Classification of Diseases (ICD)-10 code for UTI diagnosis. The Health Protection Agency Surveillance definition had a positive predictive value of 91.67% (CI 64.61 to 98.51) compared against the Centers for Disease Control and Prevention definition.

CONCLUSIONS

These study results provide a foundation for a national Australian point prevalence study and inform the development and implementation of targeted healthcare-associated infection surveillance more broadly.

Secondary bacterial infections of buruli ulcer lesions before and after chemotherapy with streptomycin and rifampicin

Buruli ulcer (BU), caused by Mycobacterium ulcerans is a chronic necrotizing skin disease. It usually starts with a subcutaneous nodule or plaque containing large clusters of extracellular acid-fast bacilli. Surrounding tissue is destroyed by the cytotoxic macrolide toxin mycolactone produced by microcolonies of M. ulcerans. Skin covering the destroyed subcutaneous fat and soft tissue may eventually break down leading to the formation of large ulcers that progress, if untreated, over months and years. Here we have analyzed the bacterial flora of BU lesions of three different groups of patients before, during and after daily treatment with streptomycin and rifampicin for eight weeks (SR8) and determined drug resistance of the bacteria isolated from the lesions. Before SR8 treatment, more than 60% of the examined BU lesions were infected with other bacteria, with Staphylococcus aureus and Pseudomonas aeruginosa being the most prominent ones. During treatment, 65% of all lesions were still infected, mainly with P. aeruginosa. After completion of SR8 treatment, still more than 75% of lesions clinically suspected to be infected were microbiologically confirmed as infected, mainly with P. aeruginosa or Proteus miriabilis. Drug susceptibility tests revealed especially for S. aureus a high frequency of resistance to the first line drugs used in Ghana. Our results show that secondary infection of BU lesions is common. This could lead to delayed healing and should therefore be further investigated.