Prevention of nosocomial bloodstream infections: a national and international priority

Preventing nosocomial bloodstream infections (NBSIs) by implementing hospitalwide, department-level, self-investigations: A NBSIs frontline ownership intervention

BACKGROUND

Nosocomial bloodstream infections (NBSIs) are adverse complications of hospitalization. Most interventions focus on intensive care units. Data on interventions involving patients' personal care providers in hospitalwide settings are limited.

OBJECTIVE

To evaluate the impact of department-level NBSI investigations on infection incidence.

METHODS

Beginning in 2016, positive cultures, classified as suspected of being hospital acquired, were prospectively investigated by patients' unit-based personal healthcare providers using a structured electronic questionnaire. After analyzing the conclusions of the investigation, a summary was sent quarterly to the departments and to hospital management. NBSI rates and clinical data during a 5-year period (2014-2018) were calculated and compared before and after the intervention (2014-2015 versus 2016-2018), using interrupted time-series analysis.

RESULTS

Among 4,135 bloodstream infections (BSIs), 1,237 (30%) were nosocomial. The rate of NBSI decreased from 4.58 per 1,000 admissions days in 2014 and 4.82 in 2015, to 3.81 in 2016, 2.94 in 2017 and 2.86 in 2018. Following a 4-month lag after introducing the intervention, the NBSI rate per 1000 admissions dropped significantly by 1.33 (P = .04; 95% CI, -2.58 to -0.07). The monthly NBSI rate continued to decrease significantly by 0.03 during the intervention period (P = .03; 95% CI, -0.06 to -0.002).

CONCLUSIONS

Detailed department-level investigations of NBSI events performed by healthcare providers, increased staff awareness and frontline ownership and were associated with a decrease in NBSI rates hospitalwide.

Long-term epidemiology of bacterial susceptibility profiles in adults suffering from febrile neutropenia with hematologic malignancy after antibiotic change

Objective:

The aim of this study was to investigate the epidemiology and antibiotic susceptibility profiles of isolated bacterial organisms in relation to empiric treatment of neutropenic fever over a 15-year period.

Methods:

All patients with or at risk for febrile neutropenia and treated in the hematology ward of the Antwerp University Hospital during 1994–2008 were prospectively included. Skin, blood, and urine cultures were taken. Oral quinolone prophylaxis was started in patients with neutropenia without fever. Empiric starting therapy consisted of amikacin in combination with cefepime.

Results:

A total of 3624 bacteria were isolated. The most common pathogens were coagulase-negative Staphylococci (46%), followed by Escherichia coli (25%), Enterobacteriaceae (15.6%), Staphylococcus aureus (7.2%), and Pseudomonas aeruginosa (3.8%). The balance between Gram-positive and Gram-negative bacteria remained stable, with a majority of Gram-positive bacteria. A shift from oxacillin-sensitive to oxacillin-resistant coagulase-negative Staphylococci was observed. Regarding susceptibility patterns, no vancomycin resistance was detected in coagulase-negative Staphylococci or in S. aureus. The E. coli susceptibility rates remained stable. However, 66% of bloodstream infections were ciprofloxacin-resistant. A reduced susceptibility of P. aeruginosa strains to meropenem was noticed.

Conclusions:

Improvement in antibiotic susceptibility of inducible Enterobacteriaceae following a switch of empiric antibiotic therapy was maintained 15 years after starting the latter treatment. Further improvement in antibiotic susceptibility of these bacteria to ceftazidime was observed, but continuous vigilance is warranted.

The efficacy of two different lipid-based amphotericin B in neonatal Candida septicemia

BACKGROUND

Fungal sepsis is becoming more frequent in neonatal intensive care units (NICU) and has a high mortality rate due to the invasive nature of the disease and to the insufficiency of low doses and high incidence of renal problems with effective doses of amphotericin B. New generation lipid formulated amphotericin B preparations may be more efficient because they are less toxic to be applied in target doses. However, there is limited experience in neonates and preterm infants.

METHODS

The charts of 917 patients admitted to NICU between 2001 and 2003 were reviewed and the data of 21 patients with systemic Candida infection, requiring different amphotericin B therapy, were analyzed.

RESULTS

Infants with fungal septicemia were treated with amphotericin B lipid complex (Abelcet)(n = 10) and liposomal amphotericin B (AmBisome)(n = 9) for a mean duration of 21 and 18 days. The mean gestational age of the patients was 30.9 +/- 4.2 weeks and mean birth weight was 1536 +/- 714 g. Two patients in the Abelcet group and one patient in the AmBisome group died during therapy. Fungal eradication was achieved in 16 surviving infants and mean eradication time was 8.1 +/- 2.6 days and mean duration of therapy was 19.2 +/- 4.1 days. Mortality rates related to treatment failure were similar being 20% in the Abelcet group and 11% in the AmBisome group. No patient showed severe side-effects from the antifungal therapy; the incidence of minimal side-effects were similar in both groups and they were elevated serum transaminase levels in six patients, increased serum creatinine in one patient and hypokalemia in one patient.

CONCLUSION

Both preparations have the same benefits for the treatment of neonatal fungal sepsis and they can be used safely in neonates including very low birth weight infants. However, the clinician must keep in mind the cost of treatment.

Infection Control: Old Problems and New Challenges

Infection control faces radical changes at the beginning of the third millennium. The first part of this review focuses on problems not yet solved, such as 1) surveillance systems, which should be active and extremely flexible; 2) infection outbreaks in hospitals and strategies to avoid them; 3) hand washing and alternatives such as rapid hand antisepsis; 4) water and food in the hospital as potential reservoirs of nosocomial pathogens; 5) upgrading of infection control programs to turn them into systems to improve the quality of care; 6) fatal Gram-negative bacteremias in hospitals from developing countries, which can be avoided with better standards of care; 7) the elemental role of the microbiology laboratory in the prevention and control of infections; 8) the unprecedented crisis due to the emergence of specific multi-resistant pathogens; 9) the risks for healthcare workers, such as tuberculosis, hepatitis, HIV, SARS, and hemorrhagic fevers; and 10) the need for the consistent application of guidelines. The second part of this review focuses on new challenges for infection control, such as 1) the ever-growing number of immunocompromised patients and basic control measures to avoid opportunistic infections; 2) the concerns about the capacity of the public health systems to deal with terrorist acts; 3) the practice of high-risk procedures in facilities lacking trained personnel, efficient laboratories, and protective items; and 4) gene therapy and its potential infectious complications. Consideration is given to the asymmetric development of infection control globally.

Open-label, multicentre, emergency-use study of clinafloxacin (CI-960) in the treatment of patients with serious life-threatening infections

In an open-label emergency-use study, 23 patients with bacterial infections caused by multiply drug resistant pathogens were treated with clinafloxacin. Efficacy and safety were evaluated by tabulating investigators' assessments at the end of treatment, treatment discontinuations and adverse event data. Most of the patients were seriously ill and had multi-organ infections, primarily respiratory tract infections such as nosocomial pneumonia and gastrointestinal infections. Eleven patients were successfully treated, two had treatment failure and 10 were not evaluable because the patients died of their underlying disease. Considering that most of the patients had several infections caused by multiply resistant pathogens, clinafloxacin may be useful for the treatment of such life-threatening episodes.

Parenteral infusions bacterial contamination in a multi-institutional survey in Mexico: considerations for nosocomial mortality

BACKGROUND

Parenteral infusions can be contaminated during administration (extrinsic contamination). A previous survey found that extrinsic contamination was not uncommon in a hospital in Mexico with lapses in aseptic techniques. To determine whether this problem exists in other similar institutions, we undertook a multi-institutional study.

METHODS

We surveyed 6 hospitals (A to F) lacking an infection control committee to determine the level of extrinsic contamination. We visited each hospital and obtained samples of all the parenteral infusions in use, drawing 0.5-1 mL from the tubing injection port. Quantitative and qualitative bacterial cultures were performed. Chlorine levels of the tap water were measured. Visits were repeated until the survey was completed.

RESULTS

A total of 751 infusions were cultured, of which 16 (2.13%) were contaminated. Hospital contamination rates varied from zero to 5.56%. Klebsiella pneumoniae was the most common isolate (10 cases). During the first sampling day in hospital C, the 7 infusions from the pediatric ward were found to be contaminated with a similar K pneumoniae strain. In-service education was started in this hospital. Infusion contamination was eliminated followed by a reduction in mortality rate. Overall, a higher risk for infusion contamination was noted for pediatric patients (P =.01, odds ratio = 3.28, 95% CI, 1.10-9.91) and in wards with inadequate water chlorine levels (P =. 02, odds ratio = 3.64, 95% CI, 1.08-13.51).

CONCLUSIONS

If the hospitals surveyed are representative of others in developing countries, an endemic level of parenteral infusion contamination could exist in many hospitals throughout the world.

Expanded activity and utility of the new fluoroquinolones: a review

In general, the fluoroquinolones developed over the past few years have greater potency, a broader spectrum of antimicrobial activity, greater in vitro efficacy against resistant organisms, and a better safety profile than other antimicrobial agents, including the older quinolones. The present review focuses on 4 new quinolones that are commercially available (levofloxacin, trovafloxacin, grepafloxacin, and sparfloxacin) and 3 that are currently undergoing clinical trials (gatifloxacin, moxifloxacin, and clinafloxacin). Examination of the minimum inhibitory concentrations of these drugs against gram-positive, gram-negative, anaerobic, and atypical organisms demonstrates their increased potency in vitro. The available clinical evidence, although sparse, suggests the potential enhanced efficacy of these drugs in the treatment of various community-acquired and nosocomial infections (eg, respiratory, urinary tract, and skin infections and sexually transmitted diseases). Compared with ciprofloxacin, their pharmacokinetic profiles demonstrate equivalent or greater bioavailability, higher plasma concentrations, and increased tissue penetration, as reflected in greater volume of distribution. Adverse events seen with most quinolones are mild. Serious adverse effects that may occur are phototoxicity (particularly with sparfloxacin) and prolongation of the QTc interval (seen with sparfloxacin and grepafloxacin). Drug interactions are possible between multivalent cation-containing compounds and all quinolones and between theophylline and both ciprofloxacin and grepafloxacin. Drugs that prolong the QTc interval should not be coadministered with sparfloxacin and grepafloxacin. Step-down therapy, a therapeutic and cost-saving advantage possible with gatifloxacin, levofloxacin, and moxifloxacin, allows the switching of patients from intravenous to oral therapy without having to change the dosage regimen or class of antibiotics. In addition to shortening the hospital stay and reducing the risk of venous complications, step-down therapy has been shown to cut hospital drug costs by 40% and hospitalization costs by 20%.