Genome-based typing reveals rare events of patient contamination with Pseudomonas aeruginosa from other patients and sink traps in a medical intensive care unit

AIM

We used genome-based typing data with the aim of identifying the routes of acquisition of Pseudomonas aeruginosa by patients hospitalized in a medical intensive care unit (MICU) over a long period in a non-epidemic context.

METHODS

This monocentric prospective study took place over 10 months in 2019 in a 15-bed MICU that applies standard precautions of hygiene. Lockable sink traps installed at all water points of use were bleach disinfected twice a week. We sampled all sink traps weekly to collect 404 P. aeruginosa environmental isolates and collected all P. aeruginosa isolates (N = 115) colonizing or infecting patients (N = 65). All isolates had their phenotypic resistance profile determined and their genome sequenced, from which we identified resistance determinants and assessed the population structure of the collection at the nucleotide level to identify events of P. aeruginosa transmission.

FINDINGS

All sink traps were positive for P. aeruginosa, each sink trap being colonized for several months by one or more clones. The combination of genomic and spatiotemporal data identified one potential event of P. aeruginosa transmission from a sink trap to a patient (1/65, 1.5%) and six events of patient cross-transmission, leading to the contamination of five patients (5/65, 7.7%). All transmitted isolates were fully susceptible to β-lactams and aminoglycosides.

CONCLUSIONS

Genome-based typing revealed the contamination of patients by P. aeruginosa originating from sink traps to be infrequent (1.5%) in an MICU with sink trap-bleaching measures, and that only 7.7% of the patients acquired P. aeruginosa originating from another patient.

Antibiotic resistance in elderly patients: Comparison of Enterobacterales causing urinary tract infections between community, nursing homes and hospital settings

OBJECTIVE

The objective was to compare the prevalence of antibiotic resistance of, Escherichia coli, Proteus mirabilis, and Klebsiella pneumoniae in elderly patients in, three sectors: community, nursing homes, and hospital settings.

MATERIAL AND METHODS

This study was a retrospective observational study conducted in, Bourgogne Franche-Comté (France). We collected positive urine samples from, patients over 75 years of age from six private laboratories.

RESULTS

Antibiotic resistance rate for E. coli in nursing homes was close to that of the, ommunity setting. Conversely, resistance of K. pneumoniae in nursing homes was, close to hospital settings. No difference in resistance of P. mirabilis was observed, between the three healthcare sectors.

CONCLUSIONS

Patients living in nursing homes should not be considered more at risk of, infection by multi-drug resistant E. coli than patients living in community setting. Screening of multi-drug resistant K. pneumoniae could be of interest for nursing home, patients.

[What academic training for pharmacy students for clinical pharmacy? Example of shared medication report]

OBJECTIVES

In 2018, the implementation of shared medication reports in pharmacy encourages pharmacists to cooperate with other healthcare professionals. This job allows a decrease of medication errors in elderly. This requires a reorganization of the training offered by universities (initial and continuing training). The aim is to present the results of this pedagogical experimentation.

METHODS

The experimentation (years 2017-2018 and 2018-2019) required the creation of a course to allow students to carry out a pharmaceutical analysis suitable to elderly people, to set up and carry out a shared medication report in pharmacy. Then, during their 6th year internship, students had to carry out at least one shared medication report per month. A monthly follow-up was organized with a database online.

RESULTS

Sixty-four students and 35 internship supervisors participated in the experimentation. All the students improved their ease in using clinical pharmacy tools (pharmaceutical analysis, pharmaceutical interventions, assessment of adherence, etc.). They carried out 345 shared medication reports. In 24.3% of cases, an improvement in the prescription was proposed to the doctor (general practitioner or specialist). For 80% of the internship supervisors, the initial training of the students helped to set up this new pharmacy activity.

CONCLUSIONS

This teaching is appreciated by students and internship supervisors. It enabled the adoption of the various tools essential for carrying out shared medication reports in pharmacy. Shared medication reports reinforce the multidisciplinary work of pharmacists, especially with general practitioners.

[Implementation of prehospital transfusion in case of trauma shock]

Transfusion plays a major role in the management of hemorrhagic shock where every minute counts. A pre-hospital transfusion protocol is established in the medical vehicle within the emergency department of CHR hospital Liège. It is based on predefined clinical and biological severity criteria which allow us to start a massive transfusion protocol as early as possible and thus to optimize its effect during traumatic hemorrhagic shock.

Prevalence, genetic diversity of and factors associated with ESBL-producing Enterobacterales carriage in residents of French nursing homes

OBJECTIVE

To determine the prevalence and genotypic characteristics of extended-spectrum β-lactamase-producing Enterobacterales (ESBLE) and carbapenemase-producing Enterobacterales (CPE) in nursing homes (NHs) in a French region. Risk factors associated with their carriage were also investigated.

METHODS

A point-prevalence survey was proposed from November 2017 to June 2018 to NHs in the study region. Volunteer residents were screened for ESBLE and CPE carriage. Escherichia coli and Klebsiella pneumoniae isolates were genotyped using multi-locus sequence typing, pulsed-field gel electrophoresis (PFGE) and phylogrouping (for E. coli alone). Collective and individual data were analysed by random-effects logistic regression.

RESULTS

The study was conducted in 18 NHs and included 262 patients. Fifty-two patients (19.8%) carried at least one ESBLE, corresponding to 56 isolates (42 E. coli, 11 K. pneumoniae and three others), while no CPE was detected. The majority (27/42) of ESBL E. coli belonged to phylogroup B2, and ST131 was over-represented in this subset (21/27). PFGE analysis revealed ST131 cross-transmission within NHs. Regarding ESBL K. pneumoniae, nine of 11 isolates belonged to ST663, and PFGE suggested diffusion of the clone in six NHs. Significant individual risk factors for colonization by ESBLE were: use of a shared bathroom, previous antibiotic use and recent history of hospitalization. Significant collective protective factors were proper compliance with glove use and support of the NH by a healthcare facility.

CONCLUSION

This study shows that NHs in the study region are an important reservoir of ESBLE, whereas no residents were CPE carriers. The control of ESBLE in NHs should focus on antibiotic stewardship and excreta management policies.

[A case of periodic thyrotoxic paralysis]

Periodic thyrotoxic paralysis (TPP) is a disease that usually affects Asian men from 20 to 50 years. It is secondary to genetic mutations of ion channels for the transport of sodium and potassium. It is characterized by recurrent and brutal bouts of paresis / flaccid paralysis, without sensory involvement, in a context of hyperthyroidism. Seizures preferentially affect proximal muscles and are often associated with severe hypokalemia. However, serious repercussions are rare, except in cases of extreme weakness of the respiratory muscles or cardiac arrhythmia induced by hypokalemia. The treatment of ionic disorders, followed by the correction of hyperthyroïdism, leads to the complete disappearance of symptoms.

[Subarachnoid hemorrhage resulting from a ruptured aneurysm : management in an emergency department]

Subarachnoid hemorrhage is a neurovascular emergency affecting relatively young adults. A ruptured cerebral aneurysm is the main non-traumatic cause. Except for the non-specific symptom of headache, which frequently occurs in subarachnoid hemorrhage, the clinical presentation is atypical, making the diagnosis difficult with possible dramatic consequences. The diagnosis is based on the CT scan without contrast, which, when negative, will be followed by a lumbar puncture. The etiologic analysis is based on an urgent arteriography, revealing the characteristics of the aneurysm such as the anatomy of the intracerebral vessels, the identification of the bleeding site and the size and location of the aneurysm. The main complications are bleeding relapse, hydrocephaly and vasospasm. Early treatment is based on the final repair of the aneurysm through two possible approaches: microvascular neurosurgical clipping or coiling via endovascular access. This article discusses the diagnostic and therapeutic aspects of subarachnoid hemorrhage.

[Mediastinitis on oesphagal perforation]

Vomiting is less benign than it seems … Esophageal perforations and ruptures cause the contents of the esophageal lumen to leak into the cervical retroesophageal space, the mediastinum or the abdomen, which can trigger, among other adverse events, a mediastinitis, the diagnosis of which is difficult and should be established as promptly as possible. It's a rare pathology involving a high risk of diagnostic errors.

[How I treat … a poisoning with tricyclic antidepressants : potential role of a treatment with lipid emulsion]

Poisoning with tricyclic antidepressants is common and can be life-threatening. The classic management is well known (chelating gastrointestinal, sodium bicarbonate, benzodiazepine, norepinephrine). A few years ago, a treatment with lipid emulsion, previously used in local anesthetics poisoning, has been successfully tested in tricyclic poisoning with cardiac arrest. We are currently unable to explain the exact mechanism of this treatment but it could have a place in the treatment of severe tricyclic poisoning with hemodynamic instability in addition to the conventional treatment.

Detection of temporal clusters of health care-associated infections or colonizations with Pseudomonas aeruginosa

We investigated temporal clusters of Pseudomonas aeruginosa cases between 2005 and 2014 in 1 French university hospital, overall and by ward, using the Kulldorff method. Clusters of positive water samples were also investigated at the whole hospital level. Our results suggest that water outlets are not closely involved in the occurrence of clusters of P aeruginosa cases.

Association between Pseudomonas aeruginosa positive water samples and healthcare-associated cases: nine-year study at one university hospital

OBJECTIVE

To study the association between the results of water samples and Pseudomonas aeruginosa healthcare-associated cases in a French university hospital.

METHODS

Generalized Estimating Equations were used on complete case and imputed datasets. The spatial unit was the building and the time unit was the quarter.

RESULTS

For the period 2004-2013, 2932 water samples were studied; 17% were positive for P. aeruginosa. A higher incidence of P. aeruginosa cases was associated with a higher proportion of positive water samples (P=0.056 in complete case analysis and P=0.031 with the imputed dataset). The association was no longer observed when haematology and intensive care units were excluded, but was significant in analyses of data concerning intensive care units alone (P<0.001).

CONCLUSION

This study suggests that water outlet contamination in hospitals can lead to an increase in healthcare-associated P. aeruginosa cases in wards dealing with susceptible patients, but does not play a significant role in other wards.

Appropriateness of aminoglycoside prescriptions in a French university hospital

INTRODUCTION

Aminoglycosides are a major class of antibiotics. Their use is particularly interesting in the treatment of severe infections but their toxicity is well known. They are mostly prescribed combined with other agents and as first-line treatments. We aimed to assess the appropriateness of aminoglycoside prescriptions in a French university hospital on the basis of the latest French recommendations published in 2011.

METHOD

We conducted a prospective study between January 17th and February 4th, 2014 to assess prescription modalities of aminoglycosides on the basis of the following criteria: indication, duration of treatment, dosing schedule, administration modalities, and drug level monitoring. Prescriptions were then compared to the 2011 national guidelines.

RESULTS

A total of 68 consecutive prescriptions were analyzed and only 47.8% complied with guidelines. Most physicians complied with recommendations, particularly with the indication for severe infections (95.6%), the administration of a single daily dose (92.6%), and the slow intravenous infusion (30minutes) administration (84%). However, physicians tended to prescribe lower doses than recommended (40.3%), especially to patients presenting with renal insufficiency, and drug level monitoring was not optimal.

CONCLUSION

Although new and accurate national recommendations were recently published, aminoglycoside prescription is still not optimal, in particular for dosing and plasma concentration monitoring.

Clonal complex 398 methicillin-susceptible Staphylococcus aureus bloodstream infections are associated with high mortality

Within the last decade, methicillin-resistant Staphylococcus aureus belonging to clonal complex 398 (CC398) has become a worldwide threat associated with livestock. More recently, methicillin-susceptible S. aureus (MSSA) belonging to CC398 have been increasingly reported as a cause of invasive infections in patients without livestock contact. We investigated risk factors associated with CC398 bloodstream infections (BSIs) compared with non-CC398 BSIs with a case-control study in a French university Hospital. From January 2010 to December 2014, nonduplicate Staphylococcus aureus (SA) isolates responsible for BSIs in adult patient were typed to identify those belonging to CC398. Each adult patient with a CC398 SA BSI (cases) was matched with 2 non-CC398 SA BSI controls randomly selected on the basis of the time at risk, the unit of hospitalization and susceptibility to methicillin. We retrospectively extracted the clinical information from electronic medical records and used conditional logistic regression for univariate and multivariate analyses. We identified 67 CC398 isolates among the 770 SA responsible for BSI in adult patients. All CC398 isolates were susceptible to methicillin. The proportion of CC398 among MSSA increased steadily from 4.6% in 2010 to 15.1% in 2013 and then stabilized at 13.8% in 2014. Factors significantly associated with CC398 MSSA BSIs were healthcare-associated infection (odds ratio (OR) 3.02, 95% confidence interval (CI) 1.19-7.63), history of neurologic disease (OR 2.51, 95% CI 1.13-5.65) and 30-day mortality (OR 2.44, 95% CI 1.23-4.85).

What happens in hospitals does not stay in hospitals: antibiotic-resistant bacteria in hospital wastewater systems

Hospitals are hotspots for antimicrobial-resistant bacteria (ARB) and play a major role in both their emergence and spread. Large numbers of these ARB will be ejected from hospitals via wastewater systems. In this review, we present quantitative and qualitative data of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli, vancomycin-resistant enterococci and Pseudomonas aeruginosa in hospital wastewaters compared to community wastewaters. We also discuss the fate of these ARB in wastewater treatment plants and in the downstream environment. Published studies have shown that hospital effluents contain ARB, the burden of these bacteria being dependent on their local prevalence. The large amounts of antimicrobials rejected in wastewater exert a continuous selective pressure. Only a few countries recommend the primary treatment of hospital effluents before their discharge into the main wastewater flow for treatment in municipal wastewater treatment plants. Despite the lack of conclusive data, some studies suggest that treatment could favour the ARB, notably ESBL-producing E. coli. Moreover, treatment plants are described as hotspots for the transfer of antibiotic resistance genes between bacterial species. Consequently, large amounts of ARB are released in the environment, but it is unclear whether this release contributes to the global epidemiology of these pathogens. It is reasonable, nevertheless, to postulate that it plays a role in the worldwide progression of antibiotic resistance. Antimicrobial resistance should now be seen as an 'environmental pollutant', and new wastewater treatment processes must be assessed for their capability in eliminating ARB, especially from hospital effluents.

Detection of Escherichia coli sequence type 131 by matrix-assisted laser desorption ionization time-of-flight mass spectrometry: implications for infection control policies?

BACKGROUND

Sequence type 131 (ST131) is a predominant lineage among extraintestinal pathogenic Escherichia coli. It plays a major role in the worldwide dissemination of extended-spectrum β-lactamase (ESBL)-producing E. coli. The ST131 pandemic is mainly the result of clonal expansion of the single well-adapted subclone H30-Rx, which is acquired in hospitals more frequently than other ESBL-producing E. coli clones.

AIM

To develop a rapid method using matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) to identify ST131 for infection control purposes.

METHODS

Peak biomarkers of ST131 were identified from the mass spectrum profiles of 109 E. coli isolates (including 50 ST131 isolates).

FINDINGS

The models accurately identified ST131 isolates from mass spectrum profiles obtained with and without protein extraction.

CONCLUSIONS

The rapid identification of ST131 isolates with MALDI-TOF MS can be easily implemented in the laboratory, and could help to target infection control measures in patients carrying multi-drug-resistant E. coli that are more likely to spread.

Risk factors for Pseudomonas aeruginosa acquisition in intensive care units: a prospective multicentre study

BACKGROUND

Pseudomonas aeruginosa is a major nosocomial pathogen in intensive care units (ICUs); however, endogenous versus exogenous origin of contamination remains unclear.

AIM

To identify individual and environmental ICU risk factors for P. aeruginosa acquisition.

METHODS

A five-month prospective multicentric study was performed in ten French ICUs. Adult patients hospitalized in ICU for ≥ 24 h were included and screened for P. aeruginosa colonization on admission, weekly and before discharge. P. aeruginosa acquisition was defined by a subsequent colonization or infection if screening swabs on admission were negative. Water samples were obtained weekly on water taps of the ICUs. Data on patient characteristics, invasive devices exposure, antimicrobial therapy, P. aeruginosa water and patient colonization pressures, and ICU characteristics were collected. Hazard ratios (HRs) were estimated using multivariate Cox model.

FINDINGS

Among the 1314 patients without P. aeruginosa on admission, 201 (15%) acquired P. aeruginosa during their ICU stay. Individual characteristics significantly associated with P. aeruginosa acquisition were history of previous P. aeruginosa infection or colonization, cumulative duration of mechanical ventilation and cumulative days of antibiotics not active against P. aeruginosa. Environmental risk factors for P. aeruginosa acquisition were cumulative daily ward 'nine equivalents of nursing manpower use score' (NEMS) [hazard ratio (HR): 1.47 for ≥ 30 points; 95% confidence interval (CI): 1.06-2.03] and contaminated tap water in patient's room (HR: 1.76; CI: 1.09-2.84).

CONCLUSION

Individual risk factors and environmental factors for which intervention is possible were identified for P. aeruginosa acquisition.

Molecular epidemiology of OXA-48-producing Klebsiella pneumoniae in France

We characterized 53 OXA-48-producing Klebsiella pneumoniae (OXA-48-Kp) isolated between 2011 and 2013 in 21 French hospitals. All the isolates were genotyped using MLST and PFGE and the population structure of the species was determined by a nucleotide-based analysis of the entire K. pneumoniae MLST database. Most of the OXA-48-Kp isolates also produced CTX-M-15 and remained susceptible to imipenem and meropenem. The isolates were distributed into 20 STs, of which five were dominant (ST15, ST101, ST147, ST395 and ST405). All the OXA-48-Kp clustered in the major clade of K. pneumoniae KpI.

Hospital cross-transmission of extended-spectrum β-lactamase producing Escherichia coli and Klebsiella pneumoniae

OBJECTIVES

We had for objective to measure the incidence and the clonal diversity of Escherichia coli and Klebsiella pneumoniae producing extended-spectrum β-lactamases (ESBL) in order to assess the role of patient stay in amplification of the phenomenon, in our teaching hospital.

MATERIAL AND METHODS

We measured the quarterly incidence rates of E. coli and K. pneumoniae producing or not producing ESBL in clinical samples between 1999 and 2010. The incidence of ESBL-producing isolates was season-adjusted. We determined the pulsotype of and identified the ESBL in all non-redundant strains isolated between 2009 and 2010.

RESULTS

The incidence for 1000 hospitalization days increased from 0.00 to 0.44 for ESBL-producing E. coli, from 0.012 to 0.24 for ESBL-producing K. pneumoniae, from 1999 to 2010. Fifty-three different clones of E. coli were identified among the 61 genotyped isolates. The 28 K. pneumoniae isolates genotyped clustered into 11 different clones, among which one major epidemic clone that included 18 isolates. Respectively 66 and 75% of E. coli and K. pneumoniae isolates produced a CTX-M group 1 ESBL.

CONCLUSION

The hospital seems to play a different role in the amplification of ESBL according to the producing species (K. pneumoniae or E. coli). ESBL-producing E. coli seem to have a limited cross-transmission within the hospital and seem to be added to non-producers. Conversely, ESBL-producing K. pneumoniae seem to be cross-transmitted within the hospital and to replace non-producers.

[Fungal and bacterial contamination of 30 general practitioners' consultation room in Franche-Comté (eastern France)]

OBJECTIVE

To evaluate the level of microbial contamination of general pratice environment.

METHODS

Ten points, including air, water and surfaces were sampled in general practitioner's consultation room of 30 general practices in Franche-Comté region (eastern France). For each sample, a global microbial count was assessed as well as the presence of potential pathogen microorganisms: Aspergillus fumigatus, Staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacteriaceae.

RESULTS

We note that 66.3% of the samples (n=202) were on the target level (<51 ufc/25 cm (2), <101 ufc/m(3), <100 ufc/mL in total bacteria, without pathogenic species and without A. fumigatus respectively on surfaces, air and water, without isolation of coliforme bacteria or P. aeruginosa for 100mL of water). A. fumigatus, S. aureus, P. aeruginosa and Enterobacteriaceae were recovered in 8.0%, 2.1%, 0.7%, 0% respectively. However, 66.7% of air sampling were positive to A. fumigatus with 2 to 12 cfu/m(3).

CONCLUSION

This study shows a low level of bacterial contamination of general practitioner's consultation room. A. fumigatus frequency in air samples seems equivalent to that found in housing without air treatment.

[Control of the bacterial risk of transfusion in France in 2013]

Bacterial contamination of blood products (BP) remains the most important infectious risks of blood transfusion in 2013. Platelet concentrates (PC) are the blood products the most at risk, whether CPA or MCPS. In France, the residual risk has been steadily declining since 1994. For the platelets, the frequency of transfusion reaction due to bacterial contamination (TRBC) is now about at one per 50,000 CP distributed. The number of deaths has remained stable since 1994 with one death per year (300,000 distributed CP). The progressive decrease in the number of cases of TRBCs is the result of steady improvement of practices and prevention methods at all stages from collection to the transfusion of BP. But if all these improvements have significantly reduced the incidence of TRBCs, mortality is not changed with the CP and the reduction of this risk is a priority for the French Blood Establishment (EFS). Detection methods of CP contaminated or pathogen inactivation are two approaches available and can provide a significant reduction (for the former) or deletion (for seconds) of the risk of transfused contaminated CP. Currently, the choice is in favor of the detection of bacteria. New detection "rapid tests" methods were added to the panel of candidates and are being evaluated. Inactivation of pathogens remains the safest prospect of eliminating this adverse effect of transfusion. Implementation of one method for bacterial detection is probably a transitional measure.

Antibiotic prescription in nursing homes for dependent elderly people: a cross-sectional study in Franche-Comté

OBJECTIVES

We had for objective to determine the rate of patients treated with antibiotics and the determinants of antibiotic stewardship in nursing homes for dependent elderly people (French acronym EHPAD), of a French region (Franche-Comté).

PATIENTS AND METHODS

A representative sample of EHPAD, in Franche-Comté, was included in a cross-sectional study made between April and June 2012. An external auditor and the EHPAD head physician collected data on the facility and on residents receiving antibiotics on the study day. An infectious diseases specialist and an infection control practitioner analyzed each prescription, a posteriori, to assess criteria of antimicrobial stewardship including re-assessment of the prescription between 48 and 72h after initiation of antibiotic treatment.

RESULTS

Sixty-one (2.76%) of the 2210 residents in 18 nursing homes were under antibiotic treatment. This rate ranged from 0% to 7.5% among nursing homes. Sixty-two percent of prescriptions complied with recommendations regarding the choice of the drug, and 41.5% could not be improved by choosing an agent with a weaker ecological impact. Globally, 17.8% of prescriptions met all stewardship criteria including re-assessment of the prescription between 48 and 72h after initiation of antibiotic treatment.

CONCLUSIONS

The study results differed. The rate of antibiotic prescription was low in Franche-Comté EHPAD compared to available European data, but antibiotic therapy could be greatly improved. This stresses the need to better train EHPAD physicians for antibiotic stewardship.

[Chronic wound care leads to the bacterial contamination of the environment]

AIM

The aim of this study was to determine levels of bacterial contamination of the environment during chronic wound dressing changes.

METHODS

Sampling of chronic wounds and of the environment (air and surfaces) was performed during changing of chronic wound dressing. A series of samples was defined as the entire sample for a given day for a given patient. Five sequential samples of air and six samples of surfaces were taken for each series. Staphylococcus aureus, Pseudomonas aeruginosa and enterobacteria were specifically cultured.

RESULTS

Thirty series of samples were taken for 26 different patients. Twenty-seven out of these 30 series were colonized with one or two of the target species. For 13 series of the latter samples (13/27, 48.1%), bacteria isolated from the wound were recovered in the environment, namely S. aureus and P. aeruginosa. The six enterobacteria isolated from wounds were not retrieved in the environment. Air samples were more often positive than surfaces samples.

CONCLUSION

We demonstrated frequent contamination of the hospital environment with bacteria colonizing wounds during dressing changes. This indicates that wearing of masks and hand disinfection after contact with the environment constitute key measures in the control of bacterial cross-transmission.

Temporal effects of infection control practices and the use of antibiotics on the incidence of MRSA

BACKGROUND

Meticillin-resistant Staphylococcus aureus (MRSA) has spread throughout the world and has become highly endemic worldwide. The need for implementing MRSA control strategies is no longer a matter of debate.

AIM

To determine the temporal association between various infection control practices, the use of antibiotics and the incidence of MRSA in a 1200-bed French university hospital.

METHODS

A multi-variate time-series analysis, based on monthly data from a nine-year period (January 2000-December 2008), was performed in a 1200-bed French university hospital to determine the temporal association between different variables and the incidence of MRSA. MRSA colonization pressure, infection control practices and use of antibiotics were considered in the analysis.

FINDINGS

Time-series analysis showed a positive significant relationship between the incidence of hospital-acquired MRSA (HA-MRSA) and MRSA colonization pressure, the use of antibiotics (fluoroquinolones, macrolides and aminoglycosides) and the use of gloves. Conversely, a global negative correlation was observed between the incidence of HA-MRSA and the use of alcohol-based hand rub. Overall, the model explained 40.5% of the variance in the monthly incidence of MRSA.

CONCLUSION

This study showed that admission of patients with MRSA, the use of antibiotics and infection control practices contributed to the incidence of HA-MRSA. This suggests that efforts should be focused on high compliance with hand disinfection. These results also raise concerns about the use of gloves when caring for patients with MRSA.

Bacterial contamination of the hospital environment during wound dressing change

INTRODUCTION

The hospital environment plays a role in the cross-transmission of multidrug-resistant bacteria. The aim of this study was to evaluate the bacterial contamination of the hospital environment during chronic wound dressing change.

PATIENTS AND METHODS

This study was performed from July 2010 to May 2011. Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumannii and Enterobacteriaceae were counted in environmental samples (air and surfaces) that were obtained in the rooms of patients with wounds colonized (cases, n=9) or not (controls, n=15) during or not during wound dressing change. Bacterial contamination was compared to that found in the rooms of patients without colonized wounds.

RESULTS

The environment was frequently contaminated during wound dressing change (38% of the sampled series were positive). In comparison, the contamination was less frequent in the environment of patients with colonized wounds when the wounds were not being dressed (14.3%) and in controls (3.8%). S. aureus was the most frequent species identified in positive samples.

DISCUSSION

These results suggest that previously recommended measures such as hand hygiene after contact with the environment and wearing a mask are justified. Moreover, other measures should be suggested, in particular cleaning the room before and after dressing change of colonized wounds.

LEVEL OF EVIDENCE

Level III: case control study.

Point prevalence survey of antibiotic use in French hospitals in 2009

OBJECTIVES

To evaluate the feasibility of a point prevalence survey for monitoring antibiotic use in a voluntary sample of French hospitals.

METHODS

Demographic and medical data were collected for all inpatients. Additional characteristics regarding antimicrobial treatment, type of infection and microbiological results were collected only for patients receiving antimicrobials.

RESULTS

Among 3964 patients in 38 hospitals, 343 (8.7%) received antimicrobial prophylaxis and 1276 (32.2%) antimicrobial therapy. The duration of surgical antimicrobial prophylaxis was >1 day in 41 out of 200 (21%) of the cases. Among patients with antimicrobial therapy, 959 (75.2%) received β-lactams (including 34.8% penicillins with β-lactam inhibitors, 22.1% third-generation cephalosporins and 7.8% carbapenems) and 301 (23.6%) received fluoroquinolones (50% orally). A total of 518 (40.6%) patients were treated with more than one drug and 345 (27.2%) were treated for >7 days. Patients treated for hospital-acquired infections (39.2%) were more likely to receive combinations (47.6% versus 34.4%, P < 0.01), carbapenems (14.4% versus 2.6%, P < 0.01), glycopeptides (14.4% versus 3.7%, P < 0.01) and antifungals (17% versus 5.3%, P < 0.01) for a longer duration (7.8 versus 6 days, P < 0.01). Fifty-six patients (4.4%) were treated for >7 days and did not have any microbiological sample drawn. The time allocated for the survey represented 18.3-25.0 h for 100 patients.

CONCLUSIONS

The data provide directions for further interventions, such as better use of diagnostic tools, decreasing the treatment duration and the use of combinations. In addition, the survey shows that, although cumbersome, it is feasible to improve the representativeness of national data in European surveys.

Mupirocin resistance is not an inevitable consequence of mupirocin use

The rate of mupirocin resistance in meticillin-resistant Staphylococcus aureus (MRSA) in Besançon University Hospital is low with a decreasing trend, from 10% in 2004 to 3% in 2009. This trend in resistance paralleled mupirocin consumption. Genotyping results showed that this decrease was not linked to a change in MRSA clones. It appears that the way in which the mupirocin is used, rather than the volume, plays a role in the emergence of resistance and that its cautious use is likely to maintain the mupirocin resistance at a low level, thus preserving its efficacy.

[Mephedrone]

Mephedrone is a designer drug recently appeared on the belgian market of the drugs of misuse. The aim of this journal paper is to provide a review on the available data about mephedrone and to call the attention of the first line practitioners who will have to face this emerging problem.

Relationship between prevalence of device-associated infections and alcohol-based hand-rub consumption: a multi-level approach

Using a multi-level logistic regression model, we determined whether there was any relationship between alcohol-based hand-rub consumption and prevalence of device-associated infections (DAIs) in French healthcare facilities (HCFs). Two national databases were used: the 2006 French prevalence survey of nosocomial infections, and the 2006 French infection control indicator database which includes alcohol-based hand-rub consumption as an indicator (ICSHA: indicateur de consommation de solution hydro-alcoolique). Only patients with at least one medical device (urinary catheter, vascular catheter or tracheal tube) who were present in an HCF for at least two days were included in the analysis. A multi-level statistical analysis was performed to assess the joint effect of patient-level and hospital-level variables. In all, 814 HCFs, each with a minimum of 15 study patients, were included, giving a total of 53,459 patients. The overall prevalence of DAI was 6.7% (95% confidence interval: 6.4-6.9). The median value of ICSHA was 37.2%. There was no association between DAI prevalence and ICSHA, but all patient-level variables were associated with DAI prevalence. Patient-level variables explain 25% of the hospital-level variation in DAI prevalence, although 60% of this variation remains unexplained when both patient and hospital variables are included in the model. To further assess any association between DAI prevalence and hand hygiene, additional studies on hand hygiene practices specifically associated with invasive medical device manipulation are required.

Bacterial contamination of organ graft preservation solution and infection after transplantation

Infectious complications represent a major cause of morbidity and mortality in patients with organ transplantation. Contamination of preservation solution (PS) can lead to life-threatening complications in the recipients. For a 3-year period, we investigated the bacterial contamination of both PSs and graft fragments, recipient infections, and explored the link between them. In total 137 organs were transplanted, and 131 organ and perfusate cultures out of 426 tested (30.8%) gave a positive bacterial culture, mainly with coagulase-negative staphylococci. Overall, 80 recipients out of 137 (58.4%) had at least 1 infection during the 4-month post-graft surveillance period. Twelve recipients had an infection with the same bacterial species that was recovered in the corresponding graft. However, based on pulsed-field gel electrophoresis typing results, only 1 case was very likely cross-transmitted via the transplantation.

[Is surveillance of Pseudomonas aeruginosa carriage in intensive care units useful?]

OBJECTIVE

To evaluate the potential interest of screening of Pseudomonas aeruginosa on admission and during hospitalisation in intensive care units patients.

METHOD

A retrospective study was carried out in two adult ICU of the University-Hospital of Besançon in 2007. P. aeruginosa screening was performed on admission and once a week during ICU stay. Clinical samples positive with P. aeruginosa were collected.

RESULTS

Among the 754 patients included, 146 had a screening sample positive giving an average incidence of 19.4 per 100 patients. Thirty-five were imported and 111 ICU-acquired. Sixty-one patients had at least one positive clinical sample, that is an incidence 8.1 cases per 100 admitted patients. Sensibility, specificity, positive and negative predictive values of screening as an indicator of subsequent infection were 54.1%, 86.9%, 26.6% and 95.6%, respectively.

CONCLUSION

Screening samples are necessary to assess P. aeruginosa endemicity in intensive care units. The high negative predictive value of screening suggests that use of specifics anti-Pseudomonas antimicrobials could be reduced. However, the benefit of this strategy remains to be evaluated.