Infection control in the ICU

Quality indicators in intensive care medicine for Germany - fourth edition 2022

The measurement of quality indicators supports quality improvement initiatives. The German Interdisciplinary Society of Intensive Care Medicine (DIVI) has published quality indicators for intensive care medicine for the fourth time now. After a scheduled evaluation after three years, changes in several indicators were made. Other indicators were not changed or only minimally. The focus remained strongly on relevant treatment processes like management of analgesia and sedation, mechanical ventilation and weaning, and infections in the ICU. Another focus was communication inside the ICU. The number of 10 indicators remained the same. The development method was more structured and transparency was increased by adding new features like evidence levels or author contribution and potential conflicts of interest. These quality indicators should be used in the peer review in intensive care, a method endorsed by the DIVI. Other forms of measurement and evaluation are also reasonable, for example in quality management. This fourth edition of the quality indicators will be updated in the future to reflect the recently published recommendations on the structure of intensive care units by the DIVI.

Hospital-acquired and zoonotic bacteria from a veterinary hospital and their associated antimicrobial-susceptibility profiles: A systematic review

Background

Hospital-acquired infections (HAIs) are associated with increased mortality, morbidity, and an economic burden due to costs associated with extended hospital stays. Furthermore, most pathogens associated with HAIs in veterinary medicine are zoonotic. This study used published data to identify organisms associated with HAIs and zoonosis in veterinary medicine. Furthermore, the study also investigated the antimicrobial-susceptibility profile of these bacterial organisms.

Methods

A systematic literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Search terms and five electronic databases were used to identify studies published over 20 years (2000-2020). The risk of bias was assessed using the "Strengthening the Reporting of Observational Studies in Epidemiology-Vet" (STROBE-Vet) checklist.

Results

Out of the identified 628 papers, 27 met the inclusion criteria for this study. Most studies (63%, 17/27) included were either from small animal or companion animal clinics/hospitals, while 5% (4/27) were from large animal clinics/hospitals inclusive of bovine and equine hospitals. Hospital-acquired bacteria were reported from environmental surfaces (33%, 9/27), animal clinical cases (29.6%, 8/27), and fomites such as cell phones, clippers, stethoscopes, and computers (14.8%, 4/27). Staphylococcus spp. was the most (63%; 17/27) reported organism, followed by Escherichia coli (19%; 5/27), Enterococcus spp. (15%, 4/27), Salmonella spp. (15%; 4/27), Acinetobacter baumannii (15%, 4/27), Clostridioides difficile (4%, 1/27), and Pseudomonas aeruginosa (4%; 1/27). Multidrug-resistant (MDR) organisms were reported in 71% (12/17) of studies linked to Methicillin-resistant Staphylococcus aureus (MRSA), Methicillin-resistant Staphylococcus pseudintermedius (MRSP), Enterococcus spp., Salmonella Typhimurium, A. baumannii, and E. coli. The mecA gene was identified in both MRSA and MRSP, the blaCMY-2 gene in E. coli and Salmonella spp., and the vanA gene in E. faecium isolate. Six studies reported organisms from animals with similar clonal lineage to those reported in human isolates.

Conclusion

Organisms associated with hospital-acquired infections and zoonosis have been reported from clinical cases, environmental surfaces, and items used during patient treatment and care. Staphylococcus species is the most reported organism in cases of HAIs and some isolates shared similar clonal lineage to those reported in humans. Some organisms associated with HAIs exhibit a high level of resistance and contain genes associated with antibiotic resistance.

Augmented Renal Clearance: What Have We Known and What Will We Do?

Augmented renal clearance (ARC) is a phenomenon of increased renal function in patients with risk factors. Sub-therapeutic drug concentrations and antibacterial exposure in ARC patients are the main reasons for clinical treatment failure. Decades of increased research have focused on these phenomena, but there are still some existing disputes and unresolved issues. This article reviews information on some important aspects of what we have known and provides suggestion on what we will do regarding ARC. In this article, we review the current research progress and its limitations, including clinical identification, special patients, risk factors, metabolism, animal models and clinical treatments, and provide some promising directions for further research in this area.

Methods of Weaning From Mechanical Ventilation in Adult: A Network Meta-Analysis

Background/Objective: The aim of study is to assess the efficacy of each ventilator weaning method for ventilated patients in intensive care units (ICUs).

Methods: A systematic search was conducted using PubMed, Embase, and China National Knowledge Infrastructure to identify randomized control studies on ventilated patients regarding extubation associated outcomes (weaning success or failure, proportion requiring re-intubation, or mortality) from inception until April 01, 2020. Commonly used ventilation modes involved pressure support ventilation, synchronized intermittent mandatory ventilation, automatic tube compensation, continuous positive airway pressure, adaptive support ventilation, neurally adjusted ventilatory assist, proportional assisted ventilation, and SmartCare. Pooled estimates regarding extubation associated outcomes were calculated using network meta-analysis.

Results: Thirty-nine randomized controlled trials including 5,953 patients met inclusion criteria. SmartCare and proportional assist ventilation were found to be effective methods in increasing weaning success (odds ratio, 2.72, 95% confidence interval (CI), 1.33–5.58, P-score: 0.84; odds ratio, 2.56, 95% CI, 1.60–4.11, P-score: 0.83; respectively). Besides, proportional assist ventilation had superior in reducing proportion requiring re-intubation rate (odds ratio, 0.48, 95% CI, 0.25–0.92, P-score: 0.89) and mortality (odds ratio, 0.48, 95% CI, 0.26–0.92, P-score: 0.91) than others.

Conclusion: In general consideration, our study provided evidence that weaning with proportional assist ventilation has a high probability of being the most effective ventilation mode for patients with mechanical ventilation regarding a higher rate of weaning success, a lower proportion requiring reintubation, and a lower mortality rate than other ventilation modes.

Association between body mass index and short-term mortality in patients with intra-abdominal infections: a retrospective, single-centre cohort study using the Medical Information Mart for Intensive Care database

OBJECTIVES

This study aimed to determine the relationship between the body mass index (BMI) and short-term mortality of patients with intra-abdominal infection (IAI) using the Medical Information Mart for Intensive Care (MIMIC-III) database.

DESIGN

Retrospective cohort study.

SETTING

Adult intensive care units (ICUs) at a tertiary hospital in the USA .

PARTICIPANTS

Adult IAI ICU patients from 2001 to 2012 in the MIMIC-III database.

INTERVENTIONS

In univariate analysis, we compared the differences in the characteristics of patients in each BMI group. Cox regression models were used to evaluate the relationships between BMI and short-term prognosis.

PRIMARY AND SECONDARY OUTCOME MEASURES

90-day survival.

RESULTS

In total, 1161 patients with IAI were included. There were 399 (34.4%) patients with a normal BMI (<25 kg/m²), 357 (30.8%) overweight patients (25-30 kg/m²) and 405 (34.9%) obese patients (>30 kg/m²) who tended to be younger (p<0.001) and had higher Sequential Organ Failure Assessment scores (p<0.05). The mortality of obese patients at 90 days was lower than that of patients with a normal BMI (20.74% vs 23.25%, p<0.05), but their length of stay in the ICU was higher (4.9 days vs 3.6 days, p<0.001); however, their rate of mechanical ventilation utilisation was higher (61.48% vs 56.86%, p<0.05). In the Cox regression model, we also confirmed that BMI was a protective factor in patients with IAIs, and the adjusted mortality rate of patients with a higher BMI was 0.97 times lower than that of patients with a lower BMI (p<0.001, HR=0.97, 95% CI 0.96 to 0.99).

CONCLUSIONS

IAI patients with an overweight or obese status might have lower 90-day mortality than patients with a normal BMI.

Hand hygiene compliance in companion animal clinics and practices in Switzerland: An observational study

Background: Hand hygiene (HH) is one of the most important measures to prevent healthcare‐associated infections. Data on HH compliance in companion animal veterinary institutions in Europe are sparse.

Methods: This observational study assessed HH according to WHO standards in three large and two medium‐sized clinics and two primary care practices in Switzerland. Associations with HH indication, professional group, clinical area and institution were determined using a generalized linear mixed effects model.

Results: Based on 2056 observations, overall HH compliance [95% confidence interval] was 32% [30%‐34%]. HH compliance was highest in the consultation area (41% [38%‐45%]) and after contact to body fluids (45% [40%‐50%]), and lowest in the pre‐OR area (20% [15%‐24%]) and before clean/aseptic procedures (12% [9%‐15%]). Veterinarians showed a higher HH compliance (37% [34%‐40%]) than veterinary nurses (25% [22%‐28%]). HH compliance was lower before clean/aseptic procedures compared to all other indications (all p < 0.015 except ‘before touching a patient’ in medium‐sized clinics/practices, p = 0.095) and higher in the consultation area compared to all other areas in large clinics (all p < 0.04).

Conclusion: Effective HH training should urgently be promoted for all veterinary personnel with special emphasis on the importance of HH before clean/aseptic procedures.

Factors associated with patient safety in neonatal intensive care units: A multicenter study using ordinal logistic regression

AIM

This study aimed to identify nurses' staffing levels, neonatal infection experience, infection control knowledge, and infection control performance, as well as levels of patient safety, and to verify the factors influencing patient safety related to infection control in multi-centered neonatal intensive care units (NICUs).

METHODS

A self-administered questionnaire was completed by 251 NICU nurses working in seven hospitals throughout South Korea. The data were collected in February 2019 and analyzed using generalized ordinal logistic regression.

RESULTS

The distribution of patient safety was as follows: level 1 (very poor) 0%, level 2 (poor) 6.8%, level 3 (fair) 29.7%, level 4 (good) 35.0%, level 5 (very good) 21.5%, and level 6 (excellent) 7.2%. The factors influencing patient safety differed across the different levels of patient safety. Comparing patient safety level 2 with the other levels (3, 4, 5, 6), the nurse staffing level (b = 1.12) was a significant influencing factor. Comparing patient safety levels 2, 3, 4 and 5 with level 6, the influencing factors were neonatal infection experience (b = -1.18) and infection control performance (b = 5.77).

CONCLUSION

The nurse staffing level was a factor when patient safety levels were low, and nurses' neonatal infection experience and infection control performance were factors when patient safety levels were high. Institutional policy efforts are required to identify patient safety levels in NICUs to develop comprehensive strategies to ensure appropriate nurse staffing and enhance neonatal infection control performance to prevent infections.

Impact of hospital-acquired complications in long-term clinical outcomes after subarachnoid hemorrhage

OBJECTIVE

Patients with subarachnoid hemorrhage (SAH) usually have prolonged hospitalizations due to the need to closely monitor their neurological status. Therefore, these patients have higher risk of experiencing hospital-acquired complications (HACs), which can complicate their clinical course and recovery. However, there is no evidence on the impact of HACs of long-term clinical outcomes. We aimed to identify if HACs are independent risk factors for poor clinical outcomes at 12-18 months of follow-up.

PATIENTS AND METHODS

Retrospective analysis of 323 patients with SAH diagnosis from 2013 until June 2018. We collected patient-related factors (age, sex, body mass index (BMI), ethnicity), comorbidities (hypertension, smoke status, diabetes, coronary heart diseases, prothrombotic diseases and hypercholesterolemia), clinical variables (Hunt-Hess grade, modified Fisher grade, treatment, delayed cerebral ischemia), aneurysm characteristics (location, size) and HACs (pneumonia, deep vein thrombosis (DVT), urinary tract infection (UTI), external ventricular drainage (EVD) infections, sepsis, hyponatremia and acute respiratory distress syndrome). Poor outcomes were defined as mRS ≥ 3.

RESULTS

204 patients were included in the primary analysis. 82 (40.2%) experienced one or more HACs during their hospital course. Patients that developed HACs have significantly increased ICU (12.1 ± 6.6 vs 24.3 ± 23.6, p < .001) and hospital (18.7 ± 14.2 vs 35.3 ± 26.3, p < .001) length of stays. Moreover, patients with HACs had significant higher rates of delayed cerebral ischemia, non-routine discharge and poor outcomes at 90 days. 177 patients had complete follow-ups at 12-18 months, HACs were independent risk factors for poor functional outcomes at 12-18 months after adjusting for demographic, comorbidities and clinical variables [OR = 3.205, 95% CI 1.231-8.347, p < 0.001].

CONCLUSIONS

HACs are an independent risk factor of sustaining poor clinical outcomes 12-18 months after a SAH. Furthermore, HACs are significantly related with the occurrence of DCI, with non-routine discharge and 90-day poor functional outcomes.

Healthcare-Associated Infections: Not Only a Clinical Burden, But a Forensic Point of View

BACKGROUND

Healthcare-associated infections (HCAIs) occur when patients receiving treatment in a health care setting develop an infection. They represent a major public health problem, requiring the integration of clinical medicine, pathology, epidemiology, laboratory sciences, and, finally, forensic medicine.

METHODS

The determination of cause of death is fundamental not only in the cases of presumed malpractice to ascertain the causal link with any negligent behavior both of health facilities and of individual professionals, but also for epidemiological purposes since it may help to know the global burden of HCAIs, that remains undetermined because of the difficulty of gathering reliable diagnostic data. A complete methodological approach, integrating clinical data by means of autopsy and histological and laboratory findings aiming to identify and demonstrate the host response to infectious insult, is mandatory in HCAIs related deaths.

RESULTS

Important tasks for forensic specialists in hospitals and health services centers are the promotion of transparency and open communication by health-care workers on the risk of HCAIs, thus facilitating patients' engagement and the implementation of educational interventions for professionals aimed to improve their knowledge and adherence to prevention and control measures.

CONCLUSION

HCAIs are a major problem for patient safety in every health-care facility and system around the world and their control and prevention represent a challenging priority for healthcare institution and workers committed to making healthcare safer. Clinicians are at the forefront in the war against HCAIs, however, also forensic pathologists have a remarkable role.

Challenging the interprofessional epistemic boundaries: The practices of informing in nurse-physician interaction

Interprofessional management of knowledge in health care settings appears to be particularly vital for the ways in which information circulates, medical decisions are taken, and nursing practices are implemented. Drawing on an extensive ethnographic fieldwork in an Italian Intensive Care Unit, this article investigates how the nurses orient to and concurrently challenge the nurse-physician epistemic boundaries by the different ways through which they perform "informing", and make it work as a diagnostic-relevant activity. Adopting an ethnographic-nurtured discursive approach to a dataset of video-recorded morning briefings, we analyze the nurses' informing contributions in terms of sequential position, turn-taking and turn design. We identify five practices of informing and show how they display different degrees of agency and differently impact on the team's "infectious diseases diagnostic reasoning". This article contributes to nurse-physician interaction studies by showing how the epistemic imbalance at play is interactionally accomplished by participants one interaction at a time. Particularly, the analysis demonstrates that the nurses actively contribute to the teamwork by a skillful management of knowledge that precedes the exercise of the physicians' epistemic and deontic rights implied in diagnosing and planning. Our findings illustrate how the nurses: a) exert their interactional agency without crossing the institutionally sanctioned epistemic and deontic boundaries to which they are observably oriented to; b) cautiously challenge the epistemic imbalance at play in nurse-physician interaction and c) actively contribute in setting the premises of the team's collective decisions. Conclusion and practical implications are proposed.

Epidemiology and risk factors for nosocomial infection in the respiratory intensive care unit of a teaching hospital in China: A prospective surveillance during 2013 and 2015

BACKGROUND

To determine the epidemiology and risk factors for nosocomial infection (NI) in the Respiratory Intensive Care Unit (RICU) of a teaching hospital in Northwest China.

METHODS

An observational, prospective surveillance was conducted in the RICU from 2013 to 2015. The overall infection rate, distribution of infection sites, device-associated infections and pathogen in the RICU were investigated. Then, the logistic regression analysis was used to test the risk factors for RICU infection.

RESULTS

In this study, 102 out of 1347 patients experienced NI. Among them, 87 were device-associated infection. The overall prevalence of NI was 7.57% with varied rates from 7.19 to 7.73% over the 3 years. The lower respiratory tract (43.1%), urinary tract (26.5%) and bloodstream (20.6%) infections accounted for the majority of infections. The device-associated infection rates of urinary catheter, central catheter and ventilator were 9.8, 7.4 and 7.4 per 1000 days, respectively.The most frequently isolated pathogens were Staphylococcus aureus (20.9%), Klebsiella pneumoniae (16.4%) and Pseudomonas aeruginosa (10.7%). Multivariate analysis showed that the categories D or E of Average Severity of Illness Score (ASIS), length of stay (10-30, 30-60, ≥60 days), immunosuppressive therapy and ventilator use are the independent risk factors for RICU infection with an adjusted odds ratio (OR) of 1.65 (95% CI: 1.15~2.37), 5.22 (95% CI: 2.63~10.38)), 2.32 (95% CI: 1.19~4.65), 8.93 (95% CI: 3.17~21.23), 31.25 (95% CI: 11.80~63.65)) and 2.70 (95% CI: 1.33~5.35), respectively.

CONCLUSION

A relatively low and stable rate of NI was observed in our RICU through year 2013-2015. The ASIS-D、E, stay ≥10 days, immunosuppressive therapy and ventilator use are the independent risk factors for RICU infection.

Principles and Practice of Antibiotic Stewardship in the ICU

In the face of emerging drug-resistant pathogens and a decrease in the development of new antimicrobial agents, antibiotic stewardship should be practiced in all critical care units. Antibiotic stewardship should be a core competency of all critical care practitioners in conjunction with a formal antibiotic stewardship program (ASP). Prospective audit and feedback, and antibiotic time-outs, are effective components of an ASP in the ICU. As rapid diagnostics are introduced in the ICU, assessment of performance and effect on outcomes will clearly be needed. Disease-specific stewardship for community-acquired pneumonia that relies on clinical pathways may be particularly high-yield. Computerized decision support has the potential to individualize stewardship for specific patients. Finally, infection control and prevention is the cornerstone of every ASP.

Nosocomial Pathogens: An In-Depth Analysis of the Vectorial Potential of Cockroaches

Nosocomial or healthcare-associated infections are regarded as the most frequent adverse event that threatens patients' safety and has serious economic and social consequences. Cockroach infestation is common in many hospitals, especially in the developing world. Common nosocomial pathogens isolated from cockroaches include Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, and Klebsiella pneumoniae. Cockroaches also harbor epidemiologically significant antibiotic-resistant organisms, such as carbapenem-resistant Enterobacteriaceae, which complicate nosocomial infections. Therefore, cockroaches constitute an important vector for nosocomial pathogens, and there should be zero tolerance for their presence in healthcare facilities. This paper aims to elucidate the possible role of cockroaches in nosocomial infections by reviewing the relevant research publications.

Parenterally administered vancomycin in 29 dogs and 7 cats (2003-2017)

Background

Vancomycin is commonly used to treat resistant bacterial infections in people. Reported adverse effects of vancomycin in people include acute kidney injury (AKI), neutropenia, and systemic allergic reaction. Given the increased incidence of vancomycin‐resistant bacterial infections in people, support is growing for restriction of vancomycin.

Objectives

To evaluate the use of intravenous (IV) vancomycin in a university teaching hospital and to describe potential adverse effects.

Animals

Twenty‐nine dogs and 7 cats.

Methods

Medical records of dogs and cats treated with IV vancomycin at the Foster Hospital for Small Animals between January 2003 and October 2017 were reviewed. Information recorded included signalment, infection source, vancomycin dosing, potential adverse effects, and outcome.

Results

Vancomycin was used to treat infections from a range of sources with a variety of dosing intervals. The most common bacterial isolates susceptible to vancomycin included Enterococcus sp. (11/36, 30.6%), methicillin‐resistant Staphylococcus aureus (8/36, 22.2%), and methicillin‐resistant Staphylococcus pseudintermedius (2/36, 5.6%). AKI occurred in 6 of 36 patients (16.7%) during vancomycin treatment but could not definitively be attributed to vancomycin treatment in any patients because of illness severity, additional nephrotoxic treatments, or both. Neutropenia or allergic reaction was not documented in any animal. In 2 of 36 patients (5.6%), susceptibility data documented an infection that was only susceptible to vancomycin. Most patients survived to discharge (25/36, 69.4%).

Conclusions and Clinical Importance

Adverse effects attributable to vancomycin were infrequent in dogs and cats. In most cases, there were potential alternative effective antimicrobials or lack of susceptibility data to support vancomycin treatment.

Beyond the hospital infection control guidelines: a qualitative study using positive deviance to characterize gray areas and to achieve efficacy and clarity in the prevention of healthcare-associated infections

Background

The literature is replete with attempts to design and promote customized guidelines to reduce infections during the care continuum. Paradoxically, these efforts sometimes result in gray areas where many staff members are unaware of what is required of them, which then leads to confusion, frustration, and uncertainty.

We coined the phrase “gray areas” in this context to encompass the variety of situations on the care continuum that are not addressed in the accepted guidelines, and where staff members are unsure of how to proceed.

The purpose of the present study was to characterize the gray areas that were reported by staff and to identify the practices of Positive Deviance (PD) individuals. We define to PD individuals as people who independently develop creative solutions to solve problems not identified by the majority in their community.

Methods

A qualitative constructivist research methodology was used that included personal interviews, observations and video recordings of identified PD practices to enhance infection control. The study was conducted January through March 2018, in two Intensive Care Units (ICU) units at Hadassah Hospital, Jerusalem, Israel. Personal interviews were conducted with 82 staff members from the General ICU (GICU) and Medical ICU (MICU).

Results

The study confirmed that guidelines cannot cover all the different situations that arise during the care continuum and can paradoxically result in the increased spread of hospital infections. Our study found there are numerous individuals who independently develop and implement solutions for gray areas. The creative and practical solutions of PD individuals can address the barriers and difficulties on the care continuum that were encountered by the staff in their communities. For example, inserting a central venous line is a complex practice in the general guidelines, while the PDs provided clear situation-specific solutions not covered in the guidelines.

Conclusions

The recommendations of the present study are to encourage hospital personnel to create their own solutions for various situations on the care continuum, and to disseminate them within their units to achieve a bottom up change, in lieu of investing in new or specific written guidelines.

Electronic supplementary material

The online version of this article (10.1186/s13756-018-0418-x) contains supplementary material, which is available to authorized users.

Bacterial and fungal infections in acute-on-chronic liver failure: prevalence, characteristics and impact on prognosis

Bacterial infection is a frequent trigger of acute-on-chronic liver failure (ACLF), syndrome that could also increase the risk of infection. This investigation evaluated prevalence and characteristics of bacterial and fungal infections causing and complicating ACLF, predictors of follow-up bacterial infections and impact of bacterial infections on survival.

PATIENTS

407 patients with ACLF and 235 patients with acute decompensation (AD).

RESULTS

152 patients (37%) presented bacterial infections at ACLF diagnosis; 46%(n=117) of the remaining 255 patients with ACLF developed bacterial infections during follow-up (4 weeks). The corresponding figures in patients with AD were 25% and 18% (p<0.001). Severe infections (spontaneous bacterial peritonitis, pneumonia, severe sepsis/shock, nosocomial infections and infections caused by multiresistant organisms) were more prevalent in patients with ACLF. Patients with ACLF and bacterial infections (either at diagnosis or during follow-up) showed higher grade of systemic inflammation at diagnosis of the syndrome, worse clinical course (ACLF 2-3 at final assessment: 47% vs 26%; p<0.001) and lower 90-day probability of survival (49% vs 72.5%;p<0.001) than patients with ACLF without infection. Bacterial infections were independently associated with mortality in patients with ACLF-1 and ACLF-2. Fungal infections developed in 9 patients with ACLF (2%) and in none with AD, occurred mainly after ACLF diagnosis (78%) and had high 90-day mortality (71%).

CONCLUSION

Bacterial infections are extremely frequent in ACLF. They are severe and associated with intense systemic inflammation, poor clinical course and high mortality. Patients with ACLF are highly predisposed to develop bacterial infections within a short follow-up period and could benefit from prophylactic strategies.

Hand hygiene in hospitals: anatomy of a revolution

Healthcare-associated infections (HAIs) affect hundreds of millions of individuals worldwide. Performing hand hygiene is widely accepted as a key strategy of infection prevention and control (IPC) to prevent HAIs, as healthcare workers' contaminated hands are the vehicle most often implicated in the cross-transmission of pathogens in health care. Over the last 20 years, a paradigm shift has occurred in hand hygiene: the change from handwashing with soap and water to using alcohol-based hand rubs. In order to put this revolution into context and understand how such a change was able to be implemented across so many different cultures and geographic regions, it is useful to understand how the idea of hygiene in general, and hand hygiene specifically, developed. This paper aims to examine how ideas about hygiene and hand hygiene evolved from ancient to modern times, from a ubiquitous but local set of ideas to a global phenomenon. It reviews historical landmarks from the first known documented recipe for soap by the Babylon civilization to the discovery of chlorine, and significant contributions by pioneers such as Antoine Germain Labarraque, Alexander Gordon, Oliver Wendell Holmes, Ignaz Philip Semmelweis, Louis Pasteur and Joseph Lister. It recalls that handwashing with soap and water appeared in guidelines to prevent HAIs in the 1980s; describes why alcohol-based hand rub replaced this as the central tool for action within a multi-modal improvement strategy; and looks at how the World Health Organization and other committed stakeholders, governments and dedicated IPC staff are championing hand hygiene globally.

Healthcare-associated infections in the neurological intensive care unit: Results of a 6-year surveillance study at a major tertiary care center

BACKGROUND

Healthcare-associated infections (HAIs) occur frequently in neurological intensive care units (neuro-ICUs); however, data differentiating associations with various diagnostic categories and resulting burdens are limited. This prospective cohort study reported incidence rates, pathogen distribution, and patient-related outcomes of HAIs in a neuro-ICU population from April 2010 to March 2016.

METHODS

Laboratory results and specific clinical indicators were used to categorize infections as per National Healthcare Safety Network nosocomial infection surveillance definitions. Patient outcomes studied included length of stay and mortality.

RESULTS

There were 6,033 neuro-ICU admissions resulting in 20,800 neuro-ICU days over the 6-year study period. A total of 227 HAIs were identified for a rate of 10.9/1,000 ICU days. Device-associated infections accounted for 80.6% of HAIs, with incidence rates (per 1,000 device days) being 18.4 for ventilator-associated pneumonia; 4.9 for catheter-associated urinary tract infections (CAUTIs); 4.0 for ventriculostomy-associated infections; and 0.6 for central line-associated blood stream infections (CLABSIs). Of the various diagnostic categories, subdural hematoma and intracerebral/intraventricular hemorrhage were associated with the highest pooled HAIs, with incidence rates of 21.3 and 21.1 per 1,000 neuro-ICU days, respectively. Prolonged neuro-ICU length of stay was strongly associated with all HAIs.

CONCLUSIONS

This large-scale surveillance study provides estimates of the risk of common HAIs in neurocritical care patients and their effect on hospitalization. Preventive strategies kept rates of infection very low, in particular CAUTI, CLABSI, and Clostridium difficile infections, and inhibited the emergence of resistant organisms.

Current Evidence Regarding Routine Antibiotic Prophylaxis in Hand Surgery

Background: Although routine antibiotic prophylaxis immediately preceding an orthopedic surgery has become the standard of care in most cases, this practice is poorly defined in hand surgery. The purpose of this analysis is to review the most current literature of antibiotic use in hand surgery. Methods: A careful review of the literature regarding routine antibiotic prophylaxis in hand surgery was made. Current relevant resources were used in the construction of this review. Results: There is a mixed consensus on the role for prophylactic antibiotics in hand surgery with some resources and data showing support and others opposed. Conclusions: Based on the current literature, the authors recommend the following patient characteristics not receive antibiotics: clean hygienic patients, without autoimmune disease, and those not taking steroid medication. Surgical characteristics that would render prophylaxis unnecessary include those without hardware, those without reasonable risk of hematoma formation, or those performed at an ambulatory surgery center as opposed to a large hospital. However, the decision should be made on a case-by-case basis weighing the evidence presented.

Health Care-Associated Infections after Subarachnoid Hemorrhage

OBJECTIVE

Health care-associated infections (HAIs) after subarachnoid hemorrhage (SAH) are prevalent; however, data describing epidemiology of infection are limited. This study reports incidence rates, risk factors, and the resulting SAH patient-related outcomes.

METHODS

We studied the incidence of HAIs acquired in the intensive care unit (ICU) over a 6-year period. We used Bayesian Model Averaging to identify risk factors associated with an increased risk of HAIs, particularly urinary tract infections (UTI), pneumonia, and ventriculostomy-associated infections (VAI). We also examined the impact of HAIs on risk of vasospasm, ICU and hospital length of stay, and discharge disposition and adjusted for other risk factors.

RESULTS

Of 419 patients with SAH, 66 (15.8%) developed 79 HAI episodes. Mean HAI incidence rates (per 1000 ICU-days) were UTI, 7.1; pneumonia, 4.3; and VAI, 2.4. The admission characteristic associated with increased risk of overall HAI, UTI, and VAI was diabetes mellitus. Hunt and Hess grades III-V were associated with increased risk of overall HAI and VAI. Male gender, intraventricular hemorrhage, and blood glucose level (>10) were associated with increased risk of pneumonia, whereas the incidence was lower in the presence of steroids. HAI was associated with increased length of stay of 10 ICU-days and 22 hospital-days, but not vasospasm or poor discharge disposition.

CONCLUSIONS

HAIs are serious complications after SAH associated with prolonged ICU and hospital length of stay. Additional rigorous infection control measures aimed at patients with identifiable risk factors should trigger prevention, and early detection of nosocomial infections is warranted to further reduce the prevalence of HAIs.

Tracheal Infection Resulting from High Endotracheal Tube Cuff Pressure in an Unconscious Patient with Brain Trauma

Deep neck infections (DNIs) are mainly caused by dental caries, tonsillitis, and pharyngitis; however, DNIs can also occur after head and neck trauma. A 79-year-old male patient underwent a craniectomy due to an acute subdural hematoma. The patient was unconscious and continued to have a fever, but no clear cause was found. On postoperative day 9, he suddenly showed redness and swelling on the anterior neck. Enhanced computed tomography of the pharynx revealed tracheal necrosis and an abscess in the surrounding area. An incision and drainage were performed and Enterobacter aerogenes and E. faecalis were identified. The infection was controlled after antibiotic treatment. High endotracheal tube cuff pressure was suspected as the cause of the tracheal infection. Although DNIs are difficult to predict in patients who cannot report their symptoms due to unconsciousness, prevention and rapid diagnosis are important, as DNIs have serious side effects.

Examination of Changes in Infection Rates in a Restructured Anaesthesia Intensive Care Unit: A Retrospective Study

OBJECTIVE

This retrospective study aimed to evaluate the effect of a restructured anaesthesia intensive care unit (ICU) on changes in infection rates and infections.

METHODS

Organisational restructuring was done in the anaesthesia ICU of Firat University Hospital after it was relocated on 14 March 2012. This study was designed to investigate the effect of restructuring on infection rates through a comparison of periods encompassing one year before relocation and one year after relocation. Nosocomial infections were diagnosed according to modified Centers for Disease Control and Prevention (CDC) criteria. In total, 406 patients who were over 18 years old and admitted to the ICU were included; they were hospitalised for 48 h or longer and had non-infectious diseases according to physical examination, laboratory and culture results on admission. The data of 214 patients (Group A) and 192 patients (Group B) were examined.

RESULTS

Parameters such as age, gender, primary diagnosis and mean GCS score at admission and mean duration of hospitalisation showed no effect on the rates of infection, but rates of total infection (41.1% vs. 25%), urinary (18.7% vs. 10.4%) and VIP (32.7% vs. 14.6%) were detected in Groups A and B. Statistically significant differences were found for the causative pathogens Pseudomonas (15.4% vs. 6.8%), Acinetobacter (18.2% vs. 12%) and Escherichia (8.9% vs. 2.1%); the mean duration of mechanical ventilation (15.01±16.681 vs. 12.22±17.595) and discharge with improvement (31.8% vs. 44.3%).

CONCLUSION

We detected that restructuring (such as acclimatization, educated staff, hepa filter) caused a significant decline in infection rates. Because ICU staff may be a major cause of infection, we believe that providing education and conducting effective surveillance programs will be the most important factors for reducing infection rates.

Successful strategy to decrease indwelling catheter utilization rates in an academic medical intensive care unit

BACKGROUND

Duration of indwelling urinary catheterization is an important risk factor for urinary tract infections. We devised a strategy to decrease the utilization of indwelling urinary catheters (IUCs). We also highlight the challenges of managing critically ill patients without IUCs and demonstrate some of the initiatives that we undertook to overcome these challenges.

METHODS

A retrospective observational outcomes review was performed in an adult medical intensive care unit (ICU) between January 2012 and December 2016. This period included a baseline and series of intervals, whereby different aspects of the strategies were implemented. IUC utilization ratio and catheter-associated urinary tract infection (CAUTI) rates were calculated.

RESULTS

Our IUC utilization ratio had a statistically significant decrease from 0.92 (baseline) to 0.28 (after 3 interventions) (P < .0001). Similarly, CAUTI rates had a statistically significant decrease from 5.47 (baseline) to 1.08 (after 3 intervention) (P = .0134). These rates sustained a statistically significant difference over the 2-year follow-up period from the last intervention. Incontinence-associated dermatitis (IAD) was identified as a potential complication of not using an IUC. There was no statistically significant change in the IAD rates during 2013-2016.

CONCLUSIONS

Our interventions demonstrated that aggressive and comprehensive IUC restriction protocol and provider training can lead to a successful decrease in IUC use, leading to a lower IUC utilization ratio and CAUTI rate in a large complex academic ICU setting.

Struggles Over Antibiotics: Physicians' Stance-Taking Toward a Nonconforming Policy in an Intensive Care Unit

One of the most pressing contemporary health care challenges consists in rethinking antibiotic use to contrast the increase of multidrug resistant bacteria. Drawing on an ethnographic fieldwork in an Intensive Care Unit that adopts a nonconforming policy of antibiotic stewardship, this article analyzes doctor-doctor interaction concerning infectious disease diagnosis and antibiotic treatment. By analyzing examples of medical decision-making from a corpus of video-recorded morning briefings, we focus on physicians' stance-taking toward the ward's nonconforming policy and illustrate how it is contingently situated along a continuum from strong commitment to overt resistance. We suggest that physicians' oscillating stance-taking is favored by the moral load of following an extreme and "off-label" policy and, in turn, impacts on the way this policy is practically accomplished as a highly reflective interactional achievement by the team members.

Daily bathing strategies and cross-transmission of multidrug-resistant organisms: Impact of chlorhexidine-impregnated wipes in a multidrug-resistant gram-negative bacteria endemic intensive care unit

BACKGROUND

Health-care associated infections are a major cause of morbidity and mortality in critical care units. The aim of this study is to evaluate the effectiveness of chlorhexidine gluconate (CHG)-impregnated wipes in the daily bathing of patients in an intensive care unit (ICU) to prevent cross-transmission and colonization by multidrug-resistant organisms (MDROs) METHODS: Prospective cohort study with an intervention of 11 months. The intervention consisted of using CHG-impregnated wipes for the daily bathing of patients on mechanical ventilation or colonized by MDROs. Monthly trends in the number of patients colonized by MDROs and the incidence of nosocomial infections were evaluated.

RESULTS

A total of 1,675 patients were admitted to the unit during the intervention period, and 430 (25.7%) were bathed with chlorhexidine wipes. A significant decrease was observed in the incidence of colonization by MDROs over the months (β = -0.209; r² = 0.549; P = .027), and in the number of patients colonized compared with the equivalent period of the previous year (22.0% vs 18.4%; P = .01). No significant decrease was observed in the incidence of nosocomial infection between the two periods (4.11% vs 4.57%; P = .355). No dermatologic problems were observed in the treated patients.

CONCLUSIONS

The use of CHG-impregnated wipes reduces cross-transmission and colonization by MDROs in the ICUs in an endemic situation because of multidrug-resistant Enterobacteriaceae.

Quality indicators in intensive care medicine for Germany - third edition 2017

Quality improvement in medicine is depending on measurement of relevant quality indicators. The quality indicators for intensive care medicine of the German Interdisciplinary Society of Intensive Care Medicine (DIVI) from the year 2013 underwent a scheduled evaluation after three years. There were major changes in several indicators but also some indicators were changed only minimally. The focus on treatment processes like ward rounds, management of analgesia and sedation, mechanical ventilation and weaning, as well as the number of 10 indicators were not changed. Most topics remained except for early mobilization which was introduced instead of hypothermia following resuscitation. Infection prevention was added as an outcome indicator. These quality indicators are used in the peer review in intensive care, a method endorsed by the DIVI. A validity period of three years is planned for the quality indicators.

Nosocomial bacterial infections and their antimicrobial susceptibility patterns among patients in Ugandan intensive care units: a cross sectional study

Background

The intensive care unit (ICU) admits critically ill patients requiring advanced airway, respiratory, cardiac and renal support. Despite the highly-specialized interventions, the mortality and morbidity is still high due to a number of reasons including nosocomial infections, which are the most likely complications in hospitalized patients with the rates being highest among ICU patients.

Methods

In this cross-sectional study of 111 adult patients admitted to 2 of the ICUs in Uganda, we set out to describe the commonest bacterial infections, their antimicrobial susceptibility patterns and factors associated with development of a nosocomial infection.

Results

Klebsiella pneumoniae (30%), Acinetobacter species (22%) and Staphylococcus aureus (14%) were the most frequently isolated bacteria. The prevalence of multidrug resistant bacterial species was 58%; 50% Escherichia coli and 33.3% Klebsiella pneumoniae were extended spectrum beta lactamase or AmpC beta lactamase producers and 9.1% Acinetobacter species were extensive drug resistant. Imipenem was the antibiotic with the highest susceptibility rates across most bacterial species. Institution of ventilator support (P 0.003) and severe traumatic brain injury (P 0.035) were highly associated with the development of nosocomial infections.

Conclusion

Due to the high prevalence of multi drug resistant (MDR) and extensive drug resistant bacterial species, there is a need for development of strong policies on antibiotic stewardship, antimicrobial surveillance and infection control to help guide empirical antibiotic therapy and prevent the spread of MDR bacteria and antibiotic drug resistance.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2695-5) contains supplementary material, which is available to authorized users.

Resident-Driven Quality Improvement Project in Perioperative Hand Hygiene

OBJECTIVES

The goal of the project was to improve hand hygiene compliance in the perioperative setting while involving anesthesia residents in quality improvement. To achieve this goal, we facilitated direct trainee participation on patient safety and quality improvement initiatives. The result was a project for perioperative hand hygiene improvement conceived and led by anesthesiology residents.

METHODS

Anesthesiology residents contributed project ideas and participated in problem-based learning discussions to develop several interventions for improving perioperative hand hygiene compliance. Interventions included electronic and laminated posters, reminder cards, monthly aggregated performance feedback, and a simulation-based hand hygiene workshop. Monthly hand hygiene compliance data were gathered during unannounced observations for a 29-month period. Run chart analysis and χ test were used to determine the impact of these interventions on compliance rates.

RESULTS

A total of 1122 hand hygiene observations were made for 29 months. Run chart analysis showed a nonrandom shift and increasing trend during the postintervention period. The baseline hand hygiene rate was 68% (95% CI [65%-72%], n = 661), which increased to 79% post-intervention (95% CI [76%-83%], n = 461, P < 0.01).

CONCLUSIONS

Our resident-led hand hygiene program used a multifaceted approach to drive sustained increases in perioperative hand hygiene compliance, while directly engaging house staff in quality improvement initiatives.

Open and closed models of intensive care unit have different influences on infectious complications in a tertiary care center: A retrospective data analysis

Infectious complications in the intensive care unit (ICU) are associated with higher morbidity, mortality, and increased health care use. Here, we report the results of implementing 2 different models (open vs closed) on infectious complications in the ICU. The closed ICU model was associated with 52% reduction in ventilator-associated pneumonia rate (P = .038) and 25% reduction in central line-associated bloodstream infection rate (P = .631). We speculate that a closed ICU model allows clinical leadership centralization that further facilitates standardized care delivery that translates into fewer infectious complications.

Prevention of nosocomial infections in critically ill patients with lactoferrin (PREVAIL study): study protocol for a randomized controlled trial

BACKGROUND

Nosocomial infections remain an important source of morbidity, mortality, and increased health care costs in hospitalized patients. This is particularly problematic in intensive care units (ICUs) because of increased patient vulnerability due to the underlying severity of illness and increased susceptibility from utilization of invasive therapeutic and monitoring devices. Lactoferrin (LF) and the products of its breakdown have multiple biological effects, which make its utilization of interest for the prevention of nosocomial infections in the critically ill.

METHODS/DESIGN

This is a phase II randomized, multicenter, double-blinded trial to determine the effect of LF on antibiotic-free days in mechanically ventilated, critically ill, adult patients in the ICU. Eligible, consenting patients will be randomized to receive either LF or placebo. The treating clinician will remain blinded to allocation during the study; blinding will be maintained by using opaque syringes and containers. The primary outcome will be antibiotic-free days, defined as the number of days alive and free of antibiotics 28 days after randomization. Secondary outcomes will include: antibiotic utilization, adjudicated diagnosis of nosocomial infection (longer than 72 h of admission to ICU), hospital and ICU length of stay, change in organ function after randomization, hospital and 90-day mortality, incidence of tracheal colonization, changes in gastrointestinal permeability, and immune function. Outcomes to inform the conduct of a larger definitive trial will also be evaluated, including feasibility as determined by recruitment rates and protocol adherence.

DISCUSSION

The results from this study are expected to provide insight into a potential novel therapeutic use for LF in critically ill adult patients. Further, analysis of study outcomes will inform a future, large-scale phase III randomized controlled trial powered on clinically important outcomes related to the use of LF.

TRIAL REGISTRATION

The trial was registered at www.ClinicalTrials.gov on 18 November 2013.

TRIAL REGISTRATION NUMBER

NCT01996579 .

Qualitative research: a challenging paradigm for infection control

he importance of high-quality research to address our knowledge deficits in relation to the causes of hospital-acquired infection has been acknowledged by the Department of Health. However, the contribution of nursing research may be restricted by confusion over the use of different paradigms and the discipline's lack of research pedigree. This paper discusses how nursing and infection control has historically favoured quantitative methods as they are associated with rigour, objectivity, generalisation and increased credibility. However, increasingly nurse researchers are turning to qualitative methods as they better explain the complex behavioural issues that affect practice. The paper describes a number of qualitative methods and infection control studies that have adopted these approaches. It concludes by suggesting that infection control nurses, because of their close relationship with practice are well placed to consider the merits of qualitative research as a way of contributing towards the discipline's research agenda.

Urosepsis: Overview of the Diagnostic and Treatment Challenges

Urosepsis is defined as sepsis caused by an infection in the urogenital tract. In approximately 30% of all septic patients the infectious focus is localized in the urogenital tract, mainly due to obstructions at various levels, such as ureteral stones. Urosepsis may also occur after operations in the urogenital tract. In urosepsis, complete bacteria and components of the bacterial cell wall from the urogenital tract trigger the host inflammatory event and act as exogenous pyrogens on eukaryotic target cells of patients. A burst of second messenger molecules leads to several different stages of the septic process, from hyperactivity to immunosuppression. As pyelonephritis is the most frequent cause for urosepsis, the kidney function is therefore most important in terms of cause and as a target organ for dysfunction in the course of the sepsis.Since effective antimicrobial therapy must be initiated early during sepsis, the empiric intravenous therapy should be initiated immediately after microbiological sampling. For the selection of appropriate antimicrobials, it is important to know risk factors for resistant organisms and whether the sepsis is primary or secondary and community or nosocomially acquired. In addition, the preceding antimicrobial therapies should be recorded as precisely as possible. Resistance surveillance should, in any case, be performed locally to adjust for the best suitable empiric treatment. Treatment challenges arise from the rapid increase of antibiotic resistance in Gram-negative bacteria, especially extended-spectrum β-lactamase (ESBL)-producing bacteria. Treatment of urosepsis comprises four basic strategies I) supportive therapy (stabilizing and maintaining blood pressure), II) antimicrobial therapy, III) control or elimination of the complicating factor, and IV) specific sepsis therapy.

Intensive care unit-acquired infections in a tertiary care hospital: An epidemiologic survey and influence on patient outcomes

BACKGROUND AND OBJECTIVE

Nosocomial infections are common in intensive care units (ICUs), but the pattern of infections and the distribution of microorganisms vary. We studied the ICU-acquired infections and their effect on patient outcomes in our ICU.

METHODS

Patients admitted to our ICU for >48 hours were studied prospectively over a year. Infections were diagnosed based on Centers for Disease Control and Prevention guidelines. Antibiotics were administered based on culture and sensitivity. Univariate and multivariate logistic regressions were carried out to determine the factors associated with infection.

RESULTS

One hundred ninety-eight patients were studied. The crude infection rate was 50% with ventilator-associated pneumonia (40%) and bloodstream infection (21%) being the most common. Acinetobacter calcoaceticus-baumannii complex, Pseudomonas aeruginosa, and Klebsiella pneumoniae were the most common microorganisms. More than 90% of patients received antibiotics, the most common being β lactam-β lactamase inhibitors, aminoglycosides, fluoroquinolones, and carbapenems. Thirty-five percent of staphylococci were methicillin-resistant, 50% of Enterococcus strains were vancomycin-resistant, and 68% of Acinetobacter calcoaceticus-baumannii complex, 47% of Pseudomonas strains, and 35% of Klebsiella strains were multidrug-resistant. A longer duration of ventilation was associated with infection. The overall ICU mortality rate was 24% and was similar in patients with or without infection.

CONCLUSIONS

The incidence of infection and the multidrug resistance in the ICU was high. Infection was associated with duration of ventilation but not mortality.

Why Is It That Internists Do Not Follow Guidelines for Preventing Intravascular Catheter Infections?

Background and Objective:

High morbidity of CVC-related infections has led to national guidelines for their prevention. Despite recommendations for the use of maximal barrier precautions (mask, sterile gloves, gown, and large drape) and skin antisepsis with 2% Chlorhexidine gluconate during CVC insertion, internists in the United States are not implementing these practices frequently. This study sought to identify and characterize the obstacles to and potential opportunities for improving adherence.

Design:

Cross-sectional survey.

Participants:

One thousand randomly selected physician-members of the American College of Physicians-American Society of Internal Medicine.

Methods:

Several potential determinants of adherence to maximal barrier precautions were assessed, including awareness of, agreement with, and ability to implement the recommendation, as well as the practice and training characteristics of the respondents. Factors influencing antiseptic selection were also recorded.

Results:

Of 526 respondents, 178 (34%) had recently inserted CVCs. Clinician experience and subspecialty, awareness of CDC guidelines, and external influences (eg, time to collect equipment) did not affect maximal barrier precautions adherence. The only independent predictor of adherence was high outcome expectancy for the use of large sterile drapes (OR, 5.3; CI95, 2.2-12.6). Availability had the greatest influence on internists' selection of specific antiseptic agents, whereas cost was the least important determinant.

Conclusions:

Despite established efficacy, use of maximal barrier precautions and Chlorhexidine gluconate is low among internists. Because improved adherence to these practices will require increased outcome expectancy for maximal barrier precautions and availability of Chlorhexidine gluconate, targeting these areas through focused education and systems modifications is essential (Infect Control Hosp Epidemiol2005;26:525-533).

Impact of an Infection Control Program in an Intensive Care Unit in France

Objective.

To evaluate the impact of an infection control program in an intensive care unit (ICU).

Design.

Prospective before-after study. Two 6-month study periods were compared; between these periods, an infection control program based on isolation was implemented.

Setting.

Polyvalent ICU of Montpellier Teaching Hospital.

Patients.

Any patient who was hospitalized in the ICU for >48 hours and was discharged during 1 of the 2 periods.

Main Outcome Measures.

The main patient-related variables were sex, age at admission, type of patient (surgical, medical, or trauma), Simplified Acute Physiology Score II, length of ICU stay, need for intubation, duration of exposure to invasive devices, onset of nosocomial infection and pathogens responsible, and death. We compared the 2 study periods with respect to the incidence of 4 nosocomial infections (pneumonia, urinary tract infection, bacteremia, and catheter-associated infection), the frequency of infection with the main multidrug-resistant pathogens, and patient survival.

Results.

Patients in periods 1 and 2 were similar with regard to sex, age, physiology score, and exposure to invasive devices. The rates of infection with multidrug-resistant pathogens were significandy lower during period 2 than during period 1 (infection rate: 28.1% of patients in period 1 and 9.6% of patients in period 2 [P = .01]; pneumonia rate: 32.6% of patients in period 1 and 4.2% of patients in period 2 [P = .008]). The mortality rate among patients with nosocomial pneumonia was 38.2% in period 1 and 4.3% in period 2 (P = .009).

Conclusions.

After implementation of an infection control program, the rate of infection with multidrug-resistant pathogens decreased, as did the mortality rate among patients with nosocomial pneumonia.

Reconsidering the semiprivate inpatient room in u.s. Hospitals

In the past 5 years, U. S. hospitals have virtually abandoned the semiprivate inpatient room. The inconclusiveness of recent research, however, indicates that this room type remains a potentially viable care delivery setting in both developed and developing countries for specific patient cohorts and care scenarios during hospitalization. Although the U.S. healthcare industry has embraced the all-private room hospital, does the semiprivate room have a place at all in the 21st-century American hospital? Literature on the subject, both for and against, is summarized. This is followed by a proposal for a case study prototype and its functional integration within a conventional medical/surgical unit in a U.S. hospital. The results suggest that a tempered reintroduction of semiprivatism affords opportunities for socialization, patient-family transactions and amenities, and staff effectiveness without compromising patient safety. Implications for environmental stewardship with respect to the carbon-neutral hospital of the 21st century are cited, as are priorities for further evidence-based design research on this issue.

Staff-developed infection prevention program decreases health care-associated infection rates in pediatric critical care

The health care team identified the causes of health care-associated infections (HAI) and developed interventions in a pediatric intensive care unit in Gaza. A quasi-experimental pretest-posttest design was used. All 26 full-time staff members in the pediatric intensive care unit participated. The HAI rate decreased significantly from the first to the second year following the implementation of the intervention (208 vs 120.55, odds ratio: 3.21, 95% confidence interval: 1.87-5.11; P < .001).

Medical Device-Associated Candida Infections in a Rural Tertiary Care Teaching Hospital of India

Health care associated infections (HCAIs) add incrementally to the morbidity, mortality, and cost expected of the patient's underlying diseases alone. Approximately, about half all cases of HCAIs are associated with medical devices. As Candida medical device-associated infection is highly drug resistant and can lead to serious life-threatening complications, there is a need of continuous surveillance of these infections to initiate preventive and corrective measures. The present study was conducted at a rural tertiary care hospital of India with an aim to evaluate the rate of medical device-associated Candida infections. Three commonly encountered medical device-associated infections (MDAI), catheter-associated urinary tract infection (CA-UTI), intravascular catheter-related blood stream infections (CR-BSI), and ventilator-associated pneumonia (VAP), were targeted. The overall rate of MDAI in our hospital was 2.1 per 1000 device days. The rate of Candida related CA-UTI and CR-BSI was noted as 1.0 and 0.3, respectively. Untiring efforts taken by team members of Hospital Acquired Infection Control Committee along with maintenance of meticulous hygiene of the hospital and wards may explain the low MDAI rates in our institute. The present surveillance helped us for systematic generation of institutional data regarding MDAI with special reference to role of Candida spp.

Middle East respiratory syndrome: knowledge to date

OBJECTIVE

To provide a conceptual and clinical review of Middle East respiratory syndrome.

DATA SOURCES

Peer-reviewed articles were identified through searches of PubMed using the terms "Middle East respiratory syndrome," "coronavirus respiratory illness in Saudi Arabia," and "novel (beta) coronavirus and human coronavirus Erasmus Medical Center". In addition, articles were searched on the websites of the World Health Organization and the U.S. Centers for Disease Control and Prevention using the terms "Middle East respiratory syndrome" and "novel coronavirus in Middle East." The reference lists of these articles and relevant review articles were also reviewed.

STUDY SELECTION AND DATA EXTRACTION

Final references were selected for inclusion in the review on the basis of their relevance.

DATA SYNTHESIS

The emerging Middle East respiratory syndrome coronavirus causes severe pulmonary disease with multiorgan involvement and a high fatality rate. Within months after its emergence, Middle East respiratory syndrome coronavirus was reported in several countries worldwide in people who had traveled from the Middle East. Middle East respiratory syndrome coronavirus is considered a zoonotic virus that has crossed the species barrier to humans, but the pathogenesis and the routes of transmission are not completely understood. There is currently no recommended treatment for Middle East respiratory syndrome coronavirus, although supportive treatment has played an important role.

CONCLUSIONS

This syndrome has raised global public health concerns about the dissemination of an emerging infectious disease and highlights the need for a coordinated global response to contain such a disease threat.

Nosocomial Infections and Microbiologic Spectrum after Major Elective Surgery of the Pancreas, Liver, Stomach, and Esophagus

BACKGROUND

The majority of infections treated by surgeons are nosocomial infections (NI). The frequency of these infections in relation to the organ operated on as well as the organisms involved are not well defined. Detailed knowledge of these issues is essential for optimal care of surgical patients. This study aimed to determine infection rates and the responsible pathogens after major elective surgery of the pancreas, liver, stomach, and esophagus.

METHODS

Between January 1, 2005 and August 31, 2007, the records of all patients of the Department of General, Abdominal and Vascular Surgery, University Hospital Magdeburg (Germany) with elective resection of the pancreas, liver, stomach, and esophagus were evaluated retrospectively. Study parameters were: Patient number, age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, indication for resection, operation duration, length of stay (LOS) in the intensive care unit (ICU) and in hospital, mortality, organ-related rate and kind of NI, and microbiologic spectrum. Nosocomial infections were defined as: Surgical site infection (U.S. Centers for Disease Control and Prevention [CDC] 1 or 2) and intra-abdominal infection (CDC 3), urinary tract infection, clinical sepsis, blood stream and catheter-related infection, respiratory tract infection, and pneumonia.

RESULTS

A total of 358 patients were included: 150 (42%) with pancreas resection, 91 (25%) with liver resection, 105 (29%) with gastric resection, and 12 (3%) with esophagus resection. Median LOS in the ICU for all groups was 48.8 h (interquartile range [IQR] 24.9-91.8 h), median LOS in hospital was 16 d (IQR 13-23 d), and in-hospital mortality was 4.5%. Patients with NI had significantly greater in-hospital death and prolonged stay in hospital and ICU (p<0.001). In 120 (33.5%) patients, one or more NI occurred (range, 83% in esophagus patients to 21% in liver patients). Intra-abdominal (16.5%) and surgical site infections (12.3%) were most frequent; 80.8% of the NI were culture-positive. The most frequent clinically relevant isolates were Escherichia coli (12.4%), coagulase-negative staphylococci (CoNS) (12.2%), and Enterococcus faecium (9.7%). The highest resistance rates were found for Staphylococcus aureus (methicillin-resistant S. aureus [MRSA] 29.4%) and Pseudomonas aeruginosa (23.5%).

CONCLUSIONS

For patients undergoing elective surgery of the pancreas, liver, stomach, and esophagus, considerable differences in demographic factors, frequency, and kind of NI exist. The consequences of NI force surgeons to analyze pre-operative risk factors carefully, assess indications for operation thoroughly, and optimize all controllable parameters.

Preventive and therapeutic strategies in critically ill patients with highly resistant bacteria

The antibiotic pipeline continues to diminish and the majority of the public remains unaware of this critical situation. The cause of the decline of antibiotic development is multifactorial and currently most ICUs are confronted with the challenge of multidrug-resistant organisms. Antimicrobial multidrug resistance is expanding all over the world, with extreme and pandrug resistance being increasingly encountered, especially in healthcare-associated infections in large highly specialized hospitals. Antibiotic stewardship for critically ill patients translated into the implementation of specific guidelines, largely promoted by the Surviving Sepsis Campaign, targeted at education to optimize choice, dosage, and duration of antibiotics in order to improve outcomes and reduce the development of resistance. Inappropriate antimicrobial therapy, meaning the selection of an antibiotic to which the causative pathogen is resistant, is a consistent predictor of poor outcomes in septic patients. Therefore, pharmacokinetically/pharmacodynamically optimized dosing regimens should be given to all patients empirically and, once the pathogen and susceptibility are known, local stewardship practices may be employed on the basis of clinical response to redefine an appropriate regimen for the patient. This review will focus on the most severely ill patients, for whom substantial progress in organ support along with diagnostic and therapeutic strategies markedly increased the risk of nosocomial infections.