Nosocomial pediatric bacteremia: the role of intravenous set contamination in developing countries

Influence of hang time and location on bacterial contamination of intravenous bags in a veterinary emergency and critical care setting

OBJECTIVE

To assess the rate of bacterial contamination of fluid and ports in intravenous bags in a veterinary emergency room (ER) and intensive care unit (ICU).

DESIGN

Experimental model.

SETTING

Ninety intravenous fluid bags of lactated balanced-electrolytes solution (1 L) hung in a university hospital.

INTERVENTIONS

Bags were hung in 2 different locations in the ER (sink and bins) and one location in the ICU (sink) for 11 days. Bags were punctured 3 times daily with a sterile needle to simulate clinical use. Injection ports were swabbed and 50 mL of fluid were collected in duplicates on days 0, 2, 4, 7, and 10. Aerobic bacterial cultures were performed on the fluid and injection port. Contamination was defined as bacterial growth of a similar phenotype across 2 consecutive times. Increase in the fluid contamination rate from day 0 was tested using an exact binomial test. Port contamination rate between locations was tested using Fisher's exact test.

MAIN RESULTS

Combined bacterial growth on injection ports reached a mean (95% confidence interval) of 8.1 (0.005-16.2) cfu/port on day 10. The combined port contamination was 3.3%, 11.1%, 17.8%, and 31.1% on days 0, 2, 4, and 7, respectively. Port contamination was similar between ER and ICU. However, port contamination was higher in the sink versus the bins area (38.3% vs 16.7%, P = 0.032). No fluid bag was contaminated at days 0 and 2. The contamination rate of fluid bag was 1.1% and 4.4% on days 4 and 7, respectively. All bags with contaminated fluid were in the ER (6.7%, 95% exact binomial confidence interval 1.9-16.2%).

CONCLUSIONS

Injection port contamination reached 31.1% on day 7. Contamination was more likely when the bags were hung next to a sink. In our model of bag puncture, fluid contamination occurred between days 2 and 4.

Antimicrobial activity of copper against organisms in aqueous solution: a case for copper-based water pipelines in hospitals?

BACKGROUND

An association exists between water of poor quality and health care-associated infections. Copper shows microbiocidal action on dry surfaces; it is necessary to evaluate its antimicrobial effect against organisms in aqueous solution.

OBJECTIVE

The objective was to determine the in vitro antimicrobial activity of copper against common nosocomial pathogens in aqueous solution.

METHODS

Copper and polyvinyl chloride containers were used. Glass was used as control material. Fourteen organisms isolated from hospital-acquired infections, and 3 control strains were tested. Inocula were prepared by direct suspension of colonies in saline solution and water in each container tested. Bacterial counts in colony-forming units (CFU)/mL were determined at the beginning of the experiment; at 30 minutes; and at 1, 2, 24, and 48 hours.

RESULTS

Organisms in glass and polyvinyl chloride remained viable until the end of the experiment. Organisms in copper showed a reduction from more than 100,000 CFU/mL to 0 CFU/mL within the first 2 hours of contact (F > 4.29, P < .001).

CONCLUSION

Copper containers show microbiocidal action on organisms in aqueous solution. Copper may contribute to the quality of water for human use, particularly in hospitals.

An outbreak of Klebsiella pneumoniae late-onset sepsis in a neonatal intensive care unit in Guatemala

BACKGROUND

Gram-negative bloodstream infections are an important cause of neonatal mortality. In October 2009, we investigated a Klebsiella spp outbreak in a neonatal intensive care unit in Guatemala.

METHODS

Probable cases were defined as a Klebsiella spp isolated from blood in neonates aged <28 days in the neonatal intensive care unit between October 1 and November 10, 2009; confirmed cases were identified as Klebsiella pneumoniae. Clinical data were abstracted from medical charts. K pneumoniae isolates were genotyped by pulsed-field gel electrophoresis (PFGE) and tested for antimicrobial susceptibility. Infection control practices were inspected.

RESULTS

There were 14 confirmed cases. The median age at onset of infection was 3 days (range, 2-8 days). Nine patients died (64%). K pneumoniae isolates were resistant to multiple antimicrobials. PFGE revealed 2 distinct clusters. Breaches in infection control procedures included inappropriate intravenous solution use and inadequate hand hygiene and contact precautions.

CONCLUSIONS

We report a K pneumoniae outbreak with high neonatal mortality in Guatemala. PFGE clustering suggested a common source possibly related to reuse of a single-use intravenous medication or solution. The risk for K pneumoniae bloodstream infections in neonates in low-resource settings where sharing of solutions is common needs to be emphasized.

Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America

These updated guidelines replace the previous management guidelines published in 2001. The guidelines are intended for use by health care providers who care for patients who either have these infections or may be at risk for them.

Endemic infusate contamination and related bacteremia

BACKGROUND

Recent reports suggest that in-use contamination of intravenous infusates is uncommon in hospitals with good standards of care.

METHODS

We conducted a survey in a referral hospital in Mexico with good standards of care but no pharmacists to prepare intravenous infusates; we tested the a priori hypothesis that the contamination rate is zero. Using a sterile syringe, we took an initial infusate specimen at the time of recruitment, specimen 1, for culture. We took a second specimen, specimen 2, from administration sets that were maintained for 72 hours. Blood cultures were obtained at the discretion of the physicians caring for the patients.

RESULTS

We cultured 1093 infusate specimens from 621 administration sets comprising 421 patients. We obtained a specimen 1 from each of the enrolled sets and a specimen 2 from 472 sets (76%). We analyzed 10 significant cultures and obtained a global infusate contamination rate of 0.9% (10/1093; 95% CI: 0.5%-1.7%). Two cases of infusate-related bacteremia occurred, establishing a global rate of 0.003/72 infusion hours.

CONCLUSIONS

Even in institutions with good nursing standards, endemic in-use infusate contamination may be a present danger. We must avoid the use of intravenous therapy whenever possible.

Help or hindrance? Is current infection control advice applicable in low- and middle-income countries? A review of the literature

BACKGROUND

High-income countries with established infection control programs have demonstrated effective control of infection transmission in health care settings. The guidelines and advice underlying these effective control programs have been produced by high-income countries for their own social, economic, and health environments. These have also been adopted by low- and middle-income (LMI) countries, but these countries appear to have a limited ability to apply these principles using the same methods.

METHODS

A systematic search for literature published in English was conducted exploring the relationship between the available infection prevention and control advice and the capacity of LMI countries to apply this guidance in their health care settings. Articles relevant to this exploration were identified and subsequently informed further search terms and identified other significant documents.

RESULTS

Infection control guidelines designed for high-income countries are being utilized by LMI countries, with varying degrees of success mainly because of physical, environmental, and socioeconomic factors. There is a lack of published studies exploring the implementation of comprehensive infection control advice and programs, including the minimal advice, which is designed specifically for resource-limited settings.

CONCLUSION

What is evident from the literature is that there is a need for the development of infection control and prevention guidelines based on evidence but adapted to the specific needs of health care workers in LMI countries. This must be done in collaboration with those same LMI countries' health care workers. Equally, because of finance and health priorities, health care facilities should choose those interventions most relevant to the needs of their population and workers to prevent infection transmission. Opportunities for further research into application of available infection control advice in LMI countries are identified. Through such research, more appropriate advice may be devised to assist with the development of infection control programs in these settings.

Device-associated nosocomial infection rates in intensive care units in four Mexican public hospitals

BACKGROUND

Routine surveillance of nosocomial infections has become an integral part of infection control and quality assurance in US hospitals.

METHODS

As part of the International Nosocomial Infection Control Consortium, we performed a prospective nosocomial infection surveillance cohort study in 5 adult intensive care units of 4 Mexican public hospitals using the Centers for Disease Control and Prevention National Nosocomial Infections Surveillance system definitions. Site-specific nosocomial infection rates were calculated.

RESULTS

The overall nosocomial infection rate was 24.4% (257/1055) and 39.0 (257/6590) per 1000 patient days. The most common infection was catheter-associated bloodstream infection, 57.98% (149/257), followed by ventilator-associated pneumonia, 20.23% (52/257), and catheter-associated urinary tract infection, 21.79% (56/257). The overall rate of catheter-associated bloodstream infections was 23.1 per 1000 device-days (149/6450); ventilator-associated pneumonia rate was 21.8 per 1000 device-days (52/2390); and catheter-associated urinary tract infection rate was 13.4 per 1000 device-days (56/4184).

CONCLUSION

Our rates are similar to other hospitals of Latin America and higher than US hospitals.

Nosocomial bacteremia in neonates related to poor standards of care

BACKGROUND

In developing countries, intravenous liquids are mixed and administered by nurses, sometimes under suboptimal infection control conditions. We hypothesized that outbreaks of infusate-associated neonatal bacteremias are common, and we evaluated whether they can be detected by vigilant microbiologic surveillance of infusates.

METHODS

We studied intravenous infusates administered to neonates in a Mexican hospital where mixtures of infusates were prepared in hospital wards. The study was performed in 3 stages: stage 1, initial culturing of in-use infusates under basal conditions; stage 2, prospective culturing during a cluster of clinical sepsis; and stage 3, final culturing once the outbreak was controlled.

RESULTS

In stage 1, 68 infusates were sterile, and 1 was contaminated with Staphylococcus aureus (1.45%), from 23 patients. In stage 2, of 182 infusates from 39 patients, 51 infusates (28%) were contaminated with Gram-negative rods. On the first day of stage 2, 11 of 15 infusates were contaminated with the same strain of Klebsiella pneumoniae, which continued to appear for 26 days. Another 4 strains of Gram-negative rods were also isolated during stage 2. The association between contaminated infusate and death was significant (odds ratio, 9.4; 95% confidence interval, 2-44.3; P < 0.001). Mixtures made by nurses were more likely contaminated than commercial preparations (odds ratio, 3.1; 95% confidence interval, 1.1-8.5; P = 0.037). In stage 3, there were 42 sterile infusates from 22 patients.

CONCLUSIONS

Our study suggests that poor standards of care common in hospitals from developing countries sometimes result in outbreaks of sepsis and death for newborn patients.