Hugo Sax received medical training in Zürich and specialized in infectious diseases and infection control. He holds the position of a deputy leader of the infection control program at the University of Geneva Hospitals since 2003. He served as a leader in several national infection control surveillance and intervention programs and as a president of the Swiss Society of Infection Control and the SwissNOSO group. He is author or co-author of over 50 original scientific publications and several book chapters. His actual research interest focuses on translation of research into clinical practice in the field of infection control by means of human factors design and social marketing.
Abstract: Many factors may influence the level of compliance with hand hygiene recommendations by healthcare workers. Lack of products and facilities as well as their inappropriate and non-ergonomic location represent important barriers. Targeted actions aimed at making hand hygiene practices feasible during healthcare delivery by ensuring that the necessary infrastructure is in place, defined as 'system change', are essential to improve hand hygiene in healthcare. In particular, access to alcohol-based hand rubs (AHRs) enables appropriate and timely hand hygiene performance at the point of care. The feasibility and impact of system change within multi-modal strategies have been demonstrated both at institutional level and on a large scale. The introduction of AHRs overcomes some important barriers to best hand hygiene practices and is associated with higher compliance, especially when integrated within multi-modal strategies. Several studies demonstrated the association between AHR consumption and reduction in healthcare-associated infection, in particular, meticillin-resistant Staphylococcus aureus bacteraemia. Recent reports demonstrate the feasibility and success of system change implementation on a large scale. The World Health Organization and other investigators have reported the challenges and encouraging results of implementing hand hygiene improvement strategies, including AHR introduction, in settings with limited resources. This review summarizes the available evidence demonstrating the need for system change and its importance within multi-modal hand hygiene improvement strategies. This topic is also discussed in a global perspective and highlights some controversial issues.
Abstract: The implementation of evidence-based infection control practices is essential, yet challenging for healthcare institutions worldwide. Although acknowledged that implementation success varies with contextual factors, little is known regarding the most critical specific conditions within the complex cultural milieu of varying economic, political, and healthcare systems. Given the increasing reliance on unified global schemes to improve patient safety and healthcare effectiveness, research on this topic is needed and timely. The 'InDepth' work package of the European FP7 Prevention of Hospital Infections by Intervention and Training (PROHIBIT) consortium aims to assess barriers and facilitators to the successful implementation of catheter-related bloodstream infection (CRBSI) prevention in intensive care units (ICU) across several European countries.
Abstract: Exposure to urinary catheters is considered the most important risk factor for healthcare-associated urinary tract infection (UTI) and is associated with significant morbidity and substantial extra-costs. In this study, we assessed the impact of urinary catheterisation (UC) on symptomatic healthcare-associated UTI among hospitalized patients.
Abstract: Hand hygiene is the single most important intervention for reducing healthcare associated infections and preventing the spread of antimicrobial resistance. This sentence begins most publications regarding hand hygiene in the medical literature. But why - as we mark 150 years since the publication of Ignaz Semmelweis' landmark monograph on the subject - do we continue to repeat it? One might be tempted to regard it as a truism. However, while tremendous progress has certainly been made in this field, a significant amount of work is yet to be done in both strengthening the evidence regarding the impact of hand hygiene and maximizing its implementation. Hand hygiene cannot yet be taken for granted. This article summarizes historical perspectives, dynamics of microbial colonization and efficacy of hand cleansing methods and agents, elements and impacts of successful hand hygiene promotion, as well as scale-up and sustainability. We also explore hand hygiene myths and current challenges such as monitoring, behavior change, patient participation and research priorities.
Abstract: A symposium was held in June 2009 near Freiburg in Germany. Twenty-nine attendees from several European countries participated, most of whom are actively involved in research and hospital infection prevention and control. The following topics were presented and discussed: isolation and screening for control of multidrug-resistant organisms; impact of the environment on healthcare-associated infection (HAI); new technologies to control infection--state of evidence; surveillance of HAI; methodological challenges and research priorities for infection control and control of HAI: learning from each other in a united Europe. This Leader summarises the main issues for debate and the number of consensus points agreed amongst delegates.
Abstract: We examined hand hygiene practices in surgical wards in 9 countries in Europe and Israel through direct practice observation. There was marked interhospital variation in hand hygiene compliance (range, 14%-76%), as well as glove and alcohol-based handrub use. After multivariable analysis, surgical subspecialty, professional category, type of care activity, and workload were independently associated with compliance. Hand hygiene practices are influenced by numerous factors, and a tailored approach may be required to improve practices.
Abstract: OBJECTIVE: To assess the feasibility and effectiveness of the World Health Organization hand hygiene improvement strategy in a low-income African country. DESIGN: A before-and-after study from December 2006 through June 2008, with a 6-month baseline evaluation period and a follow-up period of 8 months from the beginning of the intervention. SETTING: University Hospital, Bamako, Mali. Participants. Two hundred twenty-four healthcare workers. METHODS: The intervention consisted of introducing a locally produced, alcohol-based handrub; monitoring hand hygiene compliance; providing performance feedback; educating staff; posting reminders in the workplace; and promoting an institutional safety climate according to the World Health Organization multimodal hand hygiene improvement strategy. Hand hygiene infrastructure, compliance, healthcare workers' knowledge and perceptions, and handrub consumption were evaluated at baseline and at follow-up. RESULTS: Severe deficiencies in the infrastructure for hand hygiene were identified before the intervention. Local handrub production and quality control proved to be feasible, affordable, and satisfactory. At follow-up, handrubbing was the quasi-exclusive hand hygiene technique (93.3%). Compliance increased from 8.0% at baseline to 21.8% at follow-up (P < .001). Improvement was observed across all professional categories and medical specialities and was independently associated with the intervention (odds ratio, 2.50; 95% confidence interval, 1.8-3.5). Knowledge enhanced significantly (P < .05), and perception surveys showed a high appreciation of each strategy component by staff. CONCLUSIONS: Multimodal hand hygiene promotion is feasible and effective in a low-income country. Access to handrub was critical for its success. These findings motivated the government of Mali to expand the intervention nationwide. This experience represents a significant advancement for patient safety in developing countries.
Abstract: This article deals with data on nosocomial infections acquired in the Geneva University Hospitals. Goal of the work is to derive a model from a hospital-acquired infection (HAI) prevalence survey of year Y and apply them to a prevalence survey of years Y+1, Y+2. This analysis permits to evaluate the effectiveness of preventive measures taken after the prevalence survey in year Y. It also analyzes the robustness of the SVM algorithm on time-variable attributes. The model build on the dataset of year Y gives better results than in a previous study. The application of the model on the Y+1 and Y+2 prevalence surveys shows simultaneously improvements and deteriorations of 5 performance measures. This highlights the effectiveness of prevention and reduces the risk of HAI after the prevalence survey of year Y. We introduce a new method to detect redundancy in a dataset with the SVM algorithm.
Abstract: Patient participation is increasingly recognized as a key component in the redesign of health care processes and is advocated as a means to improve patient safety. The concept has been successfully applied to various areas of patient care, such as decision making and the management of chronic diseases. We review the origins of patient participation, discuss the published evidence on its efficacy, and summarize the factors influencing its implementation. Patient-related factors, such as acceptance of the new patient role, lack of medical knowledge, lack of confidence, comorbidity, and various sociodemographic parameters, all affect willingness to participate in the health care process. Among health care workers, the acceptance and promotion of patient participation are influenced by other issues, including the desire to maintain control, lack of time, personal beliefs, type of illness, and training in patient-caregiver relationships. Social status, specialty, ethnic origin, and the stakes involved also influence patient and health care worker acceptance. The London Declaration, endorsed by the World Health Organization World Alliance for Patient Safety, calls for a greater role for patients to improve the safety of health care worldwide. Patient participation in hand hygiene promotion among staff to prevent health care-associated infection is discussed as an illustrative example. A conceptual model including key factors that influence participation and invite patients to contribute to error prevention is proposed. Further research is essential to establish key determinants for the success of patient participation in reducing medical errors and in improving patient safety.
Abstract: The education of healthcare workers is essential to improve practices and is an integral part of hand hygiene promotional strategies. According to the evidence reviewed here, healthcare worker education has a positive impact on improving hand hygiene and reducing healthcare-associated infection. Detailed practical guidance on steps for the organization of education programmes in healthcare facilities and teaching-learning strategies are provided using the World Health Organization (WHO) Guidelines for Hand Hygiene in Health Care as the basis for recommendations. Several key elements for a successful educational programme are also identified. A particular emphasis is placed on concepts included in the tools developed by WHO for education, monitoring and performance feedback.
Abstract: Although a large proportion of healthcare-associated infections are avoidable, healthcare workers do not always practice evidence-based preventive strategies. Marketing technologies might help to improve patient safety. This article presents the basic principles of marketing and its potential use to promote good infection control practices. The marketing mix (Product, Price, Place, and Promotion) should be taken into account to induce behaviour change. By placing the emphasis on the perceived "profits" for healthcare workers the approach might lose its moral aspect and gain in effectiveness. VigiGerme, a non-commercial registered trademark, applies social marketing techniques to infection control and prevention.
Abstract: BACKGROUND: Research suggests that patients could improve healthcare workers' compliance with hand hygiene recommendations by reminding them to cleanse their hands. OBJECTIVE: To assess patients' perceptions of a patient-participation program to improve healthcare workers' compliance with hand hygiene. DESIGN: Cross-sectional survey of patient knowledge and perceptions of healthcare-associated infections, hand hygiene, and patient participation, defined as the active involvement of patients in various aspects of their health care. SETTING: Large Swiss teaching hospital. RESULTS: Of 194 patients who participated, most responded that they would not feel comfortable asking a nurse (148 respondents [76%]) or a physician (150 [77%]) to perform hand hygiene, and 57 (29%) believed that this would help prevent healthcare-associated infections. In contrast, an explicit invitation from a healthcare worker to ask about hand hygiene doubled the intention to ask a nurse (from 34% to 83% of respondents; P < .001) and to ask a physician (from 30% to 78%; P < .001). In multivariate analysis, being nonreligious, having an expansive personality, being concerned about healthcare-associated infections, and believing that patient participation would prevent healthcare-associated infections were associated with the intention to ask a nurse or a physician to perform hand hygiene (P < .05). Being of Jewish, Eastern Orthodox, or Buddhist faith was associated also with increased intention to ask a nurse (P < .05), compared with being of Christian faith. CONCLUSIONS: This study identifies several sociodemographic characteristics associated with the intention to ask nurses and physicians about hand hygiene and underscores the importance of a direct invitation from healthcare workers to increase patient participation and foster patient empowerment. These findings could guide the development of future hand hygiene-promotion strategies.
Abstract: The World Health Organization's Guidelines on Hand Hygiene in Health Care have been issued by WHO Patient Safety on 5 May 2009 on the occasion of the launch of the Save Lives: Clean Your Hands initiative. The Guidelines represent the contribution of more than 100 international experts and provide a comprehensive overview of essential aspects of hand hygiene in health care, evidence- and consensus-based recommendations, and lessons learned from testing their Advanced Draft and related implementation tools.
Abstract: Staphylococcal infections are one of the main causes of complications in patients with implanted foreign prosthetic material. Implants are associated with a significant reduction of the threshold at which contaminating Gram-positive bacteria, particularly Staphylococcus epidermidis, become infectious and develop a biofilm with phenotypic resistance to almost all antibiotics. A 1000-fold increase in minimal bactericidal levels against most antibiotics except rifampin has been repeatedly observed. Since only removal of the foreign material reverses these phenomena, the clinical challenge consists in finding approaches to cure the infection without removal of the implanted device. Rifampin combinations with other antibiotics, administration of exceedingly high antibiotic concentrations in situ, and early therapy before biofilm development are efficacious. Although these strategies have dramatically improved the outcome of foreign body infections, an improved understanding of biofilm-grown S. epidermidis is necessary to develop new antibacterial agents. Here, we review the pathogenesis, prevention, and treatment of implant infections due to S. epidermidis and highlight some new compounds with already promising in vitro results.
Abstract: Monitoring hand hygiene adherence and providing performance feedback to health care workers is a critical component of multimodal hand hygiene promotion programs, but important variations exist in the way adherence is measured. Within the framework of the World Health Organization's (WHO) First Global Patient Safety Challenge known as "Clean Care is Safer Care," an evidence-based, user-centered concept, "My five moments for hand hygiene," has been developed for measuring, teaching, and reporting hand hygiene adherence. This concept is an integral part of the WHO's hand hygiene improvement strategy conceived to translate the WHO Guidelines on Hand Hygiene in Health Care into practice. It has been tested in numerous health care facilities worldwide to ensure its applicability and adaptability to all settings irrespective of the resources available. Here we describe the WHO hand hygiene observation method in detail-the concept, the profile and the task of the observers, their training and validation, the data collection form, the scope, the selection of the observed staff, and the observation sessions-with the objective of making it accessible for universal use. Sample size estimates, survey analysis and report, and major bias and confounding factors associated with observation are discussed.
Abstract: We developed a patient-based survey to evaluate the impact of a respiratory hygiene and cough etiquette implementation strategy on infection control practices in the emergency department. The frequency of self-reported mask use by coughing patients was low (27%) and often inconsistent. The frequency of use was highest among patients who presented with myalgia (odds ratio, 14.7; P = .02) and among patients who visited the emergency department during January (odds ratio, 4.1; P = .04).
Abstract: Catheter-related bloodstream infections (CRBSIs) are among the most frequent healthcare-associated infections and cause considerable morbidity, mortality, and resource use. CRBSI surveillance serves quality improvement, but is often restricted to intensive care units (ICUs). We conducted a four-month prospective cohort study of all non-cuffed central venous catheters (CVCs) to design an efficient CRBSI surveillance and prevention programme. CVCs were assessed on a daily basis for ward exposure time, care parameters, and the occurrence of laboratory-confirmed CRBSI. Overall, 248 patients with 426 CVCs accounted for 3567 CVC-days (median: 5) and 15 CRBSI episodes. CVCs were inserted by anaesthetists, ICU physicians and internists in 45%, 47%, and 8% of cases, respectively. CVC utilisation rates for intensive care, internal medicine, non-abdominal surgery and abdominal surgery were 29.8, 3.8, 1.7 and 4.9 per 100 patient-days, respectively. Fourteen percent of patients changed wards while having a CVC in place, so spending CVC-days at risk within multiple departments. CRBSI incidence densities for ICU, internal medicine, surgery and abdominal surgery were 5.6, 1.9, 2.4 and 7.7 per 1000 CVC-days at risk, respectively. In a univariate Cox proportional hazards model, the high CRBSI rate in abdominal surgery was associated with longer CVC duration, frequent use of parenteral nutrition and CVC insertion by anaesthetists. CRBSI numbers were insufficient to perform a multivariate analysis. Our surveillance revealed similar CRBSI rates in both ICU and non-ICU departments, and when frequent ward transfers occurred. Hospital-wide CRBSI surveillance is advisable when a large proportion of CVC-days occur outside the ICU.
Abstract: Daskalaki and colleagues (3) recently reported the identification of mixed clonally-derived Staphylococcus aureus isolates responsible for recurrent bacteremia, showing important genetic rearrangements during the timeframe of an infection. ...
Abstract: CONTEXT: Experts and policy makers have repeatedly called for universal screening at hospital admission to reduce nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. OBJECTIVE: To determine the effect of an early MRSA detection strategy on nosocomial MRSA infection rates in surgical patients. DESIGN, SETTING, AND PATIENTS: Prospective, interventional cohort study conducted between July 2004 and May 2006 among 21 754 surgical patients at a Swiss teaching hospital using a crossover design to compare 2 MRSA control strategies (rapid screening on admission plus standard infection control measures vs standard infection control alone). Twelve surgical wards including different surgical specialties were enrolled according to a prespecified agenda, assigned to either the control or intervention group for a 9-month period, then switched over to the other group for a further 9 months. INTERVENTIONS: During the rapid screening intervention periods, patients admitted to the intervention wards for more than 24 hours were screened before or on admission by rapid, multiplex polymerase chain reaction. For both intervention (n=10 844) and control (n=10 910) periods, standard infection control measures were used for patients with MRSA in all wards and consisted of contact isolation of MRSA carriers, use of dedicated material (eg, gown, gloves, mask if indicated), adjustment of perioperative antibiotic prophylaxis of MRSA carriers, computerized MRSA alert system, and topical decolonization (nasal mupirocin ointment and chlorhexidine body washing) for 5 days. MAIN OUTCOME MEASURES: Incidence of nosocomial MRSA infection, MRSA surgical site infection, and rates of nosocomial acquisition of MRSA. RESULTS: Overall, 10 193 of 10 844 patients (94%) were screened during the intervention periods. Screening identified 515 MRSA-positive patients (5.1%), including 337 previously unknown MRSA carriers. Median time from screening to notification of test results was 22.5 hours (interquartile range, 12.2-28.2 hours). In the intervention periods, 93 patients (1.11 per 1000 patient-days) developed nosocomial MRSA infection compared with 76 in the control periods (0.91 per 1000 patient-days; adjusted incidence rate ratio, 1.20; 95% confidence interval, 0.85-1.69; P = .29). The rate of MRSA surgical site infection and nosocomial MRSA acquisition did not change significantly. Fifty-three of 93 infected patients (57%) in the intervention wards were MRSA-free on admission and developed MRSA infection during hospitalization. CONCLUSION: A universal, rapid MRSA admission screening strategy did not reduce nosocomial MRSA infection in a surgical department with endemic MRSA prevalence but relatively low rates of MRSA infection. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN06603006.
Abstract: OBJECTIVE: The study aimed to assess prevalence and risk factors for nosocomial infection (NI) in 21 hospitals of the Veneto Region (Italy). METHODS: In May 2003, a one-week-period prevalence study of NI was carried out in 21 hospitals, representing 63% of all hospital beds for acute patients of the Veneto Region. Intensive care units represented 84% of all intensive care beds of the Region. Long term care, neonatal intensive care, burn, psychiatric and dermatology units were excluded. RESULTS: Overall, 6,352 patients were surveyed. The prevalence of NI was 7.6% (range 2.6%-17.7%), while 6.9% of patients (range 2.6%-15.5%) were affected by at least one NI. The prevalence of patients with NI in medical, surgical and intensive care areas was 6.6%, 5.0% and 25.8%, respectively. The sites most frequently affected were the following: urinary tract (28.4%), surgical site (20.3%), blood stream (19.3%), pulmonary and lower respiratory tract (17.6%). At multivariate analysis risk factors independently associated to NI were: Charlson index score >1, severity of underlying disease, exposure to antibiotics, surgical intervention, trauma at admission, presence of central venous catheter >24 h, urinary catheter, intubation, tracheostomy, and duration since admission >15 days. CONCLUSION: The study provided baseline data of NI in the Veneto Region hospitals. It showed that NI are frequent, and display a wide inter-hospital variability of rates. The highest prevalence has been reported in intensive care units. The unusual high frequency of blood stream infections and the relatively lower prevalence rate of surgical site infections highlighted the limits of prevalence studies.
Abstract: The economic and clinical burden of ventilator-associated pneumonia (VAP) is uncontested. In many hospitals, VAP surveillance is conducted to identify outbreaks and to monitor infection rates. Here, we discuss the concept of benchmarking in health care as modeled on industry, and we contribute personal arguments against considering the VAP rate as a potential candidate for benchmarking or for monitoring the quality of patient care. Accurate benchmarking of VAP rates currently seems to be unfeasible, because the patient case mix is often too diverse and complicated to be adjusted for, and diagnostic criteria and surveillance protocols vary. Thus, the risk of drawing inaccurate comparisons is high. In contrast, some risk factors for VAP are modifiable and can be monitored and used as quality indicators. Process-oriented surveillance permits bypass of case-mix and diagnostic constraints. A well-defined interhospital surveillance system is necessary to prove that interventions on procedures do really lead to a reduction of VAP rates.
Abstract: Nosocomial infections (NIs) - those acquired in health care settings - represent one of the major causes of increased mortality in hospitalized patients. As they are a real problem for both patients and health authorities, the development of an effective surveillance system to monitor and detect them is of paramount importance. This paper presents a retrospective analysis of a prevalence survey of NIs done in the Geneva University Hospital. The objective is to identify patients with one or more NIs based on clinical and other data collected during the survey. In this classification task, the main difficulty lies in the significant imbalance between positive and negative cases. To overcome this problem, we investigate one-class Parzen density estimator which can be trained to differentiate two classes taking examples from a single class. The results obtained are encouraging: whereas standard 2-class SVMs scored a baseline sensitivity of 50.6% on this problem, the one-class approach increased sensitivity to as much as 88.6%. These results suggest that one-class Parzen density estimator can provide an effective and efficient way of overcoming data imbalance in classification problems.
Abstract: OBJECTIVES: The aim of this study was to determine the temporal relation between the use of antibiotics and alcohol-based hand rubs (ABHRs) and the incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. METHODS: An interventional time-series analysis was performed to evaluate the impact of two promotion campaigns on the consumption of ABHRs and to assess their effect on the incidence of non-duplicate clinical isolates of MRSA and C. difficile from February 2000 through September 2006. This analysis was combined with a transfer function model of aggregated data on antibiotic use. RESULTS: Consumption of ABHRs correlated with MRSA, but not with C. difficile. The final model demonstrated the immediate effect of the second hand hygiene promotion campaign and an additional temporal effect of fluoroquinolone (time lag, 1 month; i.e. antibiotic effect delayed for 1 month), macrolide (lag 1 and 4 months), broad-spectrum cephalosporins (lag 3, 4 and 5 months) and piperacillin/tazobactam (lag 3 months) use. The final model explained 57% of the MRSA variance over time. In contrast, the model for C. difficile showed only an effect for broad-spectrum cephalosporins (lag 1 month). CONCLUSIONS: We observed an aggregate-level relation between the monthly MRSA incidence and the use of different antibiotic classes and increased consumption of ABHR after a successful hand hygiene campaign, while no association with ABHR use was detected for C. difficile.
Abstract: BACKGROUND: Legislative mandates and current guidelines for control of nosocomial transmission of methicillin-resistant Staphylococcus aureus (MRSA) recommend screening of patients at risk of MRSA carriage on hospital admission. Indiscriminate application of these guidelines can result in a large number of unnecessary screening tests. STUDY DESIGN: This study was conducted to develop and validate a prediction model to define surgical patients at risk of previously unknown MRSA carriage on admission. We used data from two prospective studies to derivate and validate predictors of previously unknown MRSA carriage on admission, using logistic regression analysis. RESULTS: A total of 13,262 patients (derivation cohort, 3,069; validation cohort, 10,193) were admitted to the surgery department and screened for MRSA. Prevalence of MRSA carriage at time of admission increased from 3.2% in 2003 to 5.1% in the period 2004 to 2006, with a majority of newly identified MRSA carriers (64%). Three independent factors were correlated with previously unknown MRSA carriage: recent antibiotic treatment (adjusted odds ratio [OR]: 4.5; p < 0.001), history of hospitalization (adjusted OR: 2.7; p = 0.03), and age older than 75 years (adjusted OR: 1.9; p = 0.048). A score (range 0 to 9 points) calculated from these variables was developed. Probability of previously unknown MRSA carriage was 5% (8 of 152) in patients with a low score (< 2 points), 11% (19 of 166) in those with an intermediate score (2 to 6 points), and 34% (30 of 87) in those with a high score (> or = 7 points). Limiting screening to patients with all 3 risk factors (21% and 26% of patients in the derivation and validation cohort, respectively) would have correctly identified 53% and 37% of MRSA carriers in both cohorts. CONCLUSIONS: A predictive model using three easily retrievable determinants might help to better target surgical patients at risk of MRSA carriage on admission.
Abstract: Infections are a frequent consequence of natural disasters. Repatriated victims may require hospital care due to multiple fractures, pneumonia or wound infections caused by multi-resistant pathogens that require specific infection control measures. To address potential pitfalls of infection control and clinical care in repatriated patients, we sought to provide microbiological insight into the possible origins of multi-drug antibiotic resistance in survivors of natural disasters. A review of the medical literature was performed from 1986 to 2006 with an emphasis on the 2004 tsunami disaster in the Indian Ocean. After natural disasters, polymicrobial infections may occur following heavy inoculation during trauma. Multi-resistant Gram-negative pathogens are more prevalent than Gram-positive bacteria. A high incidence of extended spectrum beta-lactamase-producing bacteria and difficult-to-treat fungal infections in otherwise immunocompetent hosts may challenge routine hospital care. We recommend that survivors of natural disasters should be kept in pre-emptive contact isolation during air transport and hospitalisation until the results of all microbiological cultures become available. A meticulous diagnostic work-up is necessary upon admission and empiric antibiotic treatment should be avoided. Infections may also become manifest after several weeks of hospitalisation. In case of life-threatening infection, antibiotic therapy should cover non-fermenting pathogens.
Abstract: A high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) carriage at hospital readmission among previous MRSA carriers warrants screening and preemptive isolation precautions. The replacement of culture on chromogenic agar with rapid quantitative polymerase chain reaction for readmission screening reduces the number of unnecessary preemptive isolation-days by 54% (from 6.88 to 3.14 isolation-days) and related costs by 45% (from US dollars 113.2 to US dollars 62.1) for patients who test negative for MRSA.
Abstract: OBJECTIVE: The purpose of this article is to compare the Charlson comorbidity index derived from a rapid single-day chart review with the same index derived from administrative data to determine how well each predicted inpatient mortality and nosocomial infection. DESIGN: Cross-sectional study. SETTING: The study was conducted in the context of the Swiss Nosocomial Infection Prevalence (SNIP) study in six hospitals, canton of Valais, Switzerland, in 2002 and 2003. PARTICIPANTS: We included 890 adult patients hospitalized from acute care wards. MAIN OUTCOME MEASURES: The Charlson comorbidity index was recorded during one single-day for the SNIP study, and from administrative data (International Classification of Disease, 10th revision codes). Outcomes of interest were hospital mortality and nosocomial infection. RESULTS: Out of 17 comorbidities from the Charlson index, 11 had higher prevalence in administrative data, 4 a lower and two a similar compared with the single-day chart review. Kappa values between both databases ranged from - 0.001 to 0.56. Using logistic regression to predict hospital outcomes, Charlson index derived from administrative data provided a higher C statistic compared with single-day chart review for hospital mortality (C = 0.863 and C = 0.795, respectively) and for nosocomial infection (C = 0.645 and C = 0.614, respectively). CONCLUSIONS: The Charlson index derived from administrative data was superior to the index derived from rapid single-day chart review. We suggest therefore using administrative data, instead of single-day chart review, when assessing comorbidities in the context of the evaluation of nosocomial infections.
Abstract: Hand hygiene is considered to be the most effective measure to prevent microbial pathogen cross-transmission and healthcare-associated infections. In October 2005, the World Health Organization (WHO) World Alliance for Patient Safety launched the first Global Patient Safety Challenge 2005-2006, 'Clean Care is Safer Care', to tackle healthcare-associated infection on a large scale. Within the Challenge framework, international infection control experts and consultative taskforces met to develop new WHO Guidelines on Hand Hygiene in Healthcare. The taskforce was asked to explore aspects underlying hand hygiene behaviour that may influence its promotion among healthcare workers. The dynamics of behavioural change are complex and multi-faceted, but are of vital importance when designing a strategy to improve hand hygiene compliance. A reflection on challenges to be met and areas for future research are also proposed.
Abstract: Hand hygiene is a core element of patient safety for the prevention of healthcare-associated infections and the spread of antimicrobial resistance. Its promotion represents a challenge that requires a multi-modal strategy using a clear, robust and simple conceptual framework. The World Health Organization First Global Patient Safety Challenge 'Clean Care is Safer Care' has expanded educational and promotional tools developed initially for the Swiss national hand hygiene campaign for worldwide use. Development methodology involved a user-centred design approach incorporating strategies of human factors engineering, cognitive behaviour science and elements of social marketing, followed by an iterative prototype test phase within the target population. This research resulted in a concept called 'My five moments for hand hygiene'. It describes the fundamental reference points for healthcare workers (HCWs) in a time-space framework and designates the moments when hand hygiene is required to effectively interrupt microbial transmission during the care sequence. The concept applies to a wide range of patient care activities and healthcare settings. It proposes a unified vision for trainers, observers and HCWs that should facilitate education, minimize inter-individual variation and resource use, and increase adherence. 'My five moments for hand hygiene' bridges the gap between scientific evidence and daily health practice and provides a solid basis to understand, teach, monitor and report hand hygiene practices.
Abstract: OBJECTIVE: To compare healthcare workers' skin tolerance for and acceptance of 3 alcohol-based hand rub formulations. DESIGN: Double-blind, randomized, crossover clinical trial. SETTING: Intensive care unit in a university hospital. PARTICIPANTS: Thirty-eight healthcare workers (HCWs). INTERVENTION: A total of 3 alcohol-based hand rub formulations (hereafter, formulations A, B, and C) were used in random order for 3-5 consecutive working days during regular nursing shifts. Formulations A and B contained the same emollient, and formulations B and C contained the same alcohol at the same concentration. Use of each test formulation was separated by a "washout" period of at least 2 days. A visual assessment of skin integrity by a blinded observer using a standard 6-item scale was conducted before and after the use of each formulation. Univariate and multivariate analyses were used for the assessment of risk factors for skin alteration, and product acceptability was assessed by use of a customized questionnaire after the use of each formulation. RESULTS: Thirty-eight HCWs used each of 3 formulations for a median of 3 days (range, 3-5 days). The mean amount of product used daily (+/-SD) was 54.9+/-23.5 mL (median, 50.9 mL). Both subjective and objective evaluation of skin conditions after use showed lower HCW tolerance for product C. Male sex (odds ratio [OR], 3.17 [95% confidence interval {CI}, 1.1-8.8]), fair or very fair skin (OR, 3.01 [95% CI, 1.1-7.9]), skin alteration before hand rub use (OR, 3.73 [95% CI, 1.7-8.1]), and use of formulation C (OR, 8.79 [95% CI, 2.7-28.4]) were independently associated with skin alteration. CONCLUSIONS: This protocol permits a fast-track comparison of HCWs' skin tolerance for different alcohol-based hand rub formulations that are used in healthcare settings. The emollient in formulation C may account for its inferior performance.
Abstract: OBJECTIVE: To quantify the different behavioral components of healthcare workers' motivation to comply with hand hygiene in a healthcare institution with a 10-year history of hand hygiene campaigning. DESIGN: Cross-sectional study, by use of an anonymous, self-administered questionnaire. SETTING: A 2,200-bed university teaching hospital. PARTICIPANTS: A stratified random sample of 2,961 medical and nursing staff. RESULTS: A total of 1,042 questionnaires (35.2%) were returned. Of the respondents, 271 (26.0%) were physicians, 629 (60.4%) were nurses, and 141 (13.5%) were nursing assistants. Overall, 1,008 respondents provided information about sex; 718 (71.2%) of these were women. Respondents provided demographic information and data about various behavioral, normative, and control beliefs that determined their intentions with respect to performing hand hygiene. Among behavioral beliefs, the perception that healthcare-associated infections are severe for patients was highly ranked as a determinant of behavior by 331 (32.1%) of the respondents, and the perception that hand hygiene is effective at preventing these infections was ranked highly by 891 respondents (86.0%). Among normative beliefs, perceived social pressure from patients to perform hand hygiene was ranked highly by 760 respondents (73.7%), pressure from superiors was ranked highly by 687 (66.8%), pressure from colleagues was ranked highly by 596 (57.9%), and pressure from the person perceived to be most influential was ranked highly by 687 (68.8%). Among control beliefs, the perception that hand hygiene is relatively easy to perform was rated highly by 670 respondents (65.1%). High self-reported rates of adherence to hand hygiene (defined as performance of proper hand hygiene during 80% or more of hand hygiene opportunities) was independently associated with female sex, receipt of training in hand hygiene, participation in a previous hand hygiene campaign, peer pressure from colleagues, perceived good adherence by colleagues, and the perception that hand hygiene is relatively easy to perform. CONCLUSIONS: In a setting with a long tradition of hand hygiene campaigns, behavioral beliefs are strongly in favor of hand hygiene, but adherence is driven by peer pressure and the perception of high self-efficacy, rather than by reasoning about the impact of hand hygiene on patient safety. Female sex, training, and campaign exposure increased the likelihood of compliance with hand hygiene. This additional insight can help to shape future promotional activity.
Abstract: Adults more than 40 years old are not necessarily immune to measles. A measles outbreak that involved healthcare workers occurred after contact with a 44-year-old patient. Results of a hospital-wide program of mass screening revealed that 117 (4.5%) of 2,600 individuals tested seronegative for measles; 31 (26.1%) of these 117 individuals were more than 40 years old.
Abstract: BACKGROUND: Urinary tract infection is the most frequent health care-associated complication. We hypothesized that the implementation of a multifaceted prevention strategy could decrease its incidence after surgery. METHODS: In a controlled, prospective, before-after intervention trial with 1328 adult patients scheduled for orthopedic or abdominal surgery, nosocomial infection surveillance was conducted until hospital discharge. A multifaceted intervention including specifically tailored, locally developed guidelines for the prevention of urinary tract infection was implemented for orthopedic surgery patients, and abdominal surgery patients served as control subjects. Infectious and noninfectious complications, adherence to guidelines, and antibiotic use were monitored before and after the intervention and again 2 years later. RESULTS: The incidence of urinary tract infection decreased from 10.4 to 3.9 episodes per 100 patients in the intervention group (incidence-density ratio, 0.41; 95% CI, 0.20-0.79; P=.004). Adherence to guidelines was 82.2%. Both the frequency and the duration of urinary catheterization decreased following the intervention. Recourse to antibiotic therapy after surgery dropped in the intervention group from 17.9 to 15.6 defined daily doses per 100 patient-days (P<.005) because of a reduced need for the treatment of urinary tract infection (P<.001). Follow-up after 2 years revealed a sustained impact of the strategy and a subsequent low use of antibiotics, consistent with stable adherence to guidelines (80.8%). CONCLUSIONS: A multifaceted prevention strategy can dramatically decrease postoperative urinary tract infection and contribute to the reduction of the overall use of antibiotics after surgery.
Abstract: Hand cleansing is the primary action to reduce health-care-associated infection and cross-transmission of antimicrobial-resistant pathogens. Patient-to-patient transmission of pathogens via health-care workers' hands requires five sequential steps: (1) organisms are present on the patient's skin or have been shed onto fomites in the patient's immediate environment; (2) organisms must be transferred to health-care workers' hands; (3) organisms must be capable of surviving on health-care workers' hands for at least several minutes; (4) handwashing or hand antisepsis by the health-care worker must be inadequate or omitted entirely, or the agent used for hand hygiene inappropriate; and (5) the caregiver's contaminated hand(s) must come into direct contact with another patient or with a fomite in direct contact with the patient. We review the evidence supporting each of these steps and propose a dynamic model for hand hygiene research and education strategies, together with corresponding indications for hand hygiene during patient care.
Abstract: To control an outbreak of community-associated MRSA (CA-MRSA) in a neonatology unit, an investigation was conducted that involved screening neonates and parents, molecular analysis of MRSA isolates and long-term follow-up of cases. During a two-month period in the summer of 2000, Panton-Valentine leukocidin (PVL)-producing CA-MRSA (strain ST5-MRSA-IV) was detected in five neonates. The mother of the index caseshowed signs of mastitis and wound infection and consequently tested positive for CA-MRSA. A small cluster of endemic, PVL-negative MRSA strains (ST228-MRSA-I) occurred in parallel. Enhanced hygiene measures, barrier precautions, topical decolonization of carriers, and cohorting of new admissions terminated the outbreak. Four months after the outbreak, the mother of another neonate developed furunculosis with the epidemic CA-MRSA strain. One infant had persistent CA-MRSA carriage resulting in skin infection in a sibling four years after the outbreak. In conclusion, an epidemic CA-MRSA strain was introduced by the mother of the index case. This spread among neonates and was subsequently transmitted to another mother and a sibling. This is the first report of a successfully controlled neonatology outbreak of genetically distinct PVL-producing CA-MRSA in Europe.
Abstract: OBJECTIVE: An important problem that arises in hospitals is the monitoring and detection of nosocomial or hospital acquired infections (NIs). This paper describes a retrospective analysis of a prevalence survey of NIs done in the Geneva University Hospital. Our goal is to identify patients with one or more NIs on the basis of clinical and other data collected during the survey. METHODS AND MATERIAL: Standard surveillance strategies are time-consuming and cannot be applied hospital-wide; alternative methods are required. In NI detection viewed as a classification task, the main difficulty resides in the significant imbalance between positive or infected (11%) and negative (89%) cases. To remedy class imbalance, we explore two distinct avenues: (1) a new re-sampling approach in which both over-sampling of rare positives and under-sampling of the noninfected majority rely on synthetic cases (prototypes) generated via class-specific sub-clustering, and (2) a support vector algorithm in which asymmetrical margins are tuned to improve recognition of rare positive cases. RESULTS AND CONCLUSION: Experiments have shown both approaches to be effective for the NI detection problem. Our novel re-sampling strategies perform remarkably better than classical random re-sampling. However, they are outperformed by asymmetrical soft margin support vector machines which attained a sensitivity rate of 92%, significantly better than the highest sensitivity (87%) obtained via prototype-based re-sampling.
Abstract: PURPOSE: We determined the prevalence and risk profile of patients with previously unknown carriage of methicillin-resistant Staphylococcus aureus (MRSA) at hospital admission. SUBJECTS AND METHODS: We conducted a 7-month, prospective case-controlled study in adult inpatients admitted to a university hospital with endemic MRSA. Multivariate conditional logistic regression for data sets matched 1:4 was performed to identify the risk profile of newly identified MRSA carriers. RESULTS: Overall, 399 of 12072 screened admissions (prevalence, 3.3%) were found colonized (n = 368, 92%) or infected (n = 31, 8%) with MRSA. In 204 cases (prevalence, 1.7%), MRSA carriage was newly identified. Without screening on admission, 49% (196/399) of MRSA carriers would have been missed. We identified nine independent risk factors for newly identified MRSA carriage at admission (adjusted odds ratio): male sex (1.9); age greater than 75 years (2.0); receipt of fluoroquinolones (2.7), cephalosporins (2.1), and carbapenems (3.2) in the last 6 months; previous hospitalization (1.9) or intravenous therapy (1.7) during the last 12 months; urinary catheter at admission (2.0); and intrahospital transfer (2.4). A risk score (range, 0-13) was calculated by adding points assigned to these variables. On the basis of analysis of 1006 patients included in the case-controlled study, the probability of MRSA carriage was 8% (28/342) in patients with a low score (< or =1), 19% (92/482) in patients with an intermediate score (2-4), and 46% (84/182) in patients with a high score (> or =5). The risk score had good discrimination (c-statistic, 0.73) and showed excellent calibration (P = .88). CONCLUSIONS: On-admission prevalence of previously unknown MRSA carriers was high. Applying the risk score to newly admitted patients with an intermediate or high probability of MRSA carriage could allow a more effective MRSA control strategy.
Abstract: Health-care-associated infection (HAI) is a major issue of patient safety with a substantial impact on morbidity, mortality, and use of additional resources worldwide. In April 2004, the WHO Regional Office for Europe organised the first international consultation to address the issue of HAI in eastern and central Europe. The main objectives of the consultation were to identify the primary needs and obstacles for the prevention and control of HAI at country level, to design the essential components of an international strategy to effectively address the issue of HAI, and to identify specific priorities and recommendations for interventions by the WHO and other international institutions. An update on HAI activities and related networks throughout Europe, together with the outcome of the meeting, are presented, with special emphasis on future considerations for a European WHO strategy on HAI prevention.
Abstract: OBJECTIVES: to determine the prevalence and characteristics of previously unknown methicillin-resistant Staphylococcus aureus (MRSA) carriers at admission. DESIGN: two prospective case-control studies. SUBJECTS: 1,621 elderly patients were screened for MRSA carriage within 24 hours after admission to a geriatric hospital in Geneva, Switzerland. METHODS: risk factors associated with previously unknown MRSA carriage were determined in the derivation group, and the resulting risk score was evaluated in the validation cohort using logistic regression analysis. RESULTS: prevalence of MRSA carriage at admission increased from 7.3% (53/724 patients) in 2001 to 8.7% (78/897 patients) in 2003, with a corresponding prevalence of unknown MRSA carriers of 4.6 and 5.8%, respectively. Three variables were independently associated with previously unknown MRSA carriage: recent antibiotic treatment (adjusted OR (aOR) 2.3; 95% CI 1.0-5.1), intra-hospital transfer (aOR 2.5; 95% CI 1.2-5.3), and hospitalization in the past 2 years (aOR 2.7; 95% CI 1.1-6.7). In the validation cohort, the probability of MRSA carriage increased across risk scores: 0 point, 4% prevalence (6/146); 1 point, 15% (21/136); and $2 points, 31% (21/68; P<0.001). The risk score showed good discrimination and calibration in both groups. CONCLUSIONS: our risk score, which used a simple additive point system to estimate the likelihood of unknown MRSA carriage, had good accuracy and generalised well in an independent sample of patients. Once validated in a clinical trial, our risk score may be used as a tool to optimise MRSA control.
Abstract: OBJECTIVE: To assess the level of knowledge regarding and attitudes toward standard and isolation precautions among healthcare workers in a hospital. METHOD: A confidential, self-administered questionnaire survey was conducted in a random sample of 1500 nurses and 500 physicians in a large teaching hospital. RESULTS: A total of 1,241 questionnaires were returned (response rate, 62%). The median age of respondents was 39 years; 71.9% were women and 21.2% had senior staff status. One-fourth had previously participated in specific training regarding transmission precautions for pathogens conducted by the infection control team. More than half (55.9%) gave correct answers to 10 or more of the 13 knowledge-type questions. The following reasons for noncompliance with guidelines were judged as "very important": lack of knowledge (47%); lack of time (42%); forgetfulness (39%); and lack of means (28%). For physicians and healthcare workers in a senior position, lack of time and lack of means were significantly less important (P < .0005). On multivariate linear regression, knowledge was independently associated with exposure to training sessions (coefficient, 0.33; 95% confidence interval, 0.08 to 0.57; P = .009) and less professional experience (coefficient per increasing professional experience, -0.024; 95% confidence interval, -0.035 to -0.012; P < .0005). CONCLUSIONS: Despite a training effort targeting opinion leaders, knowledge of transmission precautions for pathogens remained insufficient. Nevertheless, specific training proved to be the major determinant of "good knowledge".
Abstract: OBJECTIVES: To describe the epidemiology of nosocomial coagulase-negative staphylococci (CoNS) bacteremia and to evaluate the clinical significance of a single blood culture positive for CoNS. DESIGN: A 3-year retrospective cohort study based on data prospectively collected through hospital-wide surveillance. Bacteremia was defined according to CDC criteria, except that a single blood culture growing CoNS was not systematically considered as a contaminant. All clinically significant blood cultures positive for CoNS nosocomial bacteremia were considered for analysis. SETTING: A large university teaching hospital in Geneva, Switzerland. RESULTS: A total of 2,660 positive blood cultures were identified. Of these, 1,108 (41.7%) were nosocomial; CoNS were recovered from 411 nosocomial episodes (37.1%). Two hundred thirty-four episodes of CoNS bacteremia in the presence of signs of sepsis were considered clinically relevant and analyzed. Crude mortality and associated mortality were 24.4% and 12.8%, respectively. Associated mortality was similar among patients with one positive blood culture and those with two or more (16.2% vs 10.8%, respectively; P = .3). Mortality rates after bacteremia for patients with a single positive blood culture and for those with two or more were 15.3% and 7.0%, respectively, at day 14 (RR, 2.2; CI95, 0.87-5.46) and 20.8% and 11.3%, respectively, at day 28 (RR, 1.9; CI95, 0.9-3.8). On multivariate analysis, only age and a rapidly fatal disease were independently associated with death. CONCLUSION: CoNS bacteremia harbor a significant mortality and a single positive blood culture in the presence of signs of sepsis should be considered as clinically relevant.
Abstract: From January to February 2005, the healthcare authorities of the Canton of Geneva were alerted to 15 cases of measles, in contrast to one single case in 2004. The adult status (17-44 years) of the affected persons years was unusual. Four were health care workers at the same hospital who were infected after contact with a 44-year-old patient in a single night during his stay in the emergency room. The presumption that measles are only a paediatric disease had made the diagnosis difficult. None of all these adults was immune according to the actual recommendations. Despite a federal vaccine policy, repetition of recommendations, good results of available vaccines and reimbursement of the cost by health insurance companies, voluntary vaccination prevalence is too small in Switzerland to prevent the outbreak of epidemics. In contrast to the goals of the World Health Organization (WHO) and the Swiss Federal Office of Public Health, the country is unfortunately far from displaying a sufficiently high herd immunity to prevent health care-associated and economic damage by sporadic epidemics.
Abstract: Primary bloodstream infection (BSI) is a leading, preventable infectious complication in critically ill patients and has a negative impact on patients' outcome. Surveillance definitions for primary BSI distinguish those that are microbiologically documented from those that are not. The latter is known as clinical sepsis, but information on its epidemiologic importance is limited. We analyzed prospective on-site surveillance data of nosocomial infections in a medical intensive care unit. Of the 113 episodes of primary BSI, 33 (29%) were microbiologically documented. The overall BSI infection rate was 19.8 episodes per 1,000 central-line days (confidence interval [CI] 95%, 16.1 to 23.6); the rate fell to 5.8 (CI 3.8 to 7.8) when only microbiologically documented episodes were considered. Exposure to vascular devices was similar in patients with clinical sepsis and patients with microbiologically documented BSI. We conclude that laboratory-based surveillance alone will underestimate the incidence of primary BSI and thus jeopardize benchmarking.
Abstract: Nosocomial infections are a leading cause of morbidity and mortality among hospitalized patients. These infections have made newspaper headlines recently in many countries, and both patients and their relatives are now perfectly aware of their existence and of the risks which are inherent to any medical activity. However, significant improvements in the knowledge of the pathophysiology and epidemiology of nosocomial infections allow us to prevent them efficiently. Accordingly, they should no longer be considered as an inevitable tribute to pay to the continuous progress of medicine, but as a real challenge in the process of improving the quality of patient care. This is particularly the case for bloodstream infections, of which at least 80% are considered to be catheter associated. This paper reviews the epidemiology and impact of infections associated with the use of intravenous catheters. Principles of therapy are reviewed, as well as major aspects of prevention.
Abstract: PURPOSE OF REVIEW: There is growing concern that changes in nurse workforce and hospital-restructuring interventions negatively impact on patient outcomes. This review focuses on the association between understaffing and health-care-associated infections. RECENT FINDINGS: There is a large number of studies showing that overcrowding, understaffing or a misbalance between workload and resources are important determinants of nosocomial infections and cross-transmission of microorganisms. Importantly, not only the number of staff but also the level of their training affects outcomes. The nurse workforce is ageing, mainly due to fewer individuals' engaging in a nursing career. This phenomenon, combined with cost-driven downsizing, contributes to a nursing shortage, and this tendency is not expected to revert unless important system changes are implemented. The causal pathway between understaffing and infection is complex, and factors might include lack of time to comply with infection control recommendations, job dissatisfaction, job-related burnout, absenteeism and a high staff turnover. SUMMARY: The evidence that cost-driven downsizing and changes in staffing patterns causes harm to patients cannot be ignored, and should not be considered as an inevitable outcome. More research is needed to better define the optimal patient-to-nurse ratio in various hospital settings and to estimate the economical impact of the nursing shortage. All quality-improvement interventions should carefully take into account systems and processes to be successful, as the issue of staffing is essentially a structural problem.
Abstract: We evaluated the costs associated with a sustained and successful campaign for hand hygiene promotion that emphasized alcohol-based handrubs. The total cost of the hand hygiene promotion corresponded to less than 1% of the costs associated with nosocomial infections. Successful hand hygiene promotion is probably cost-saving.
Abstract: OBJECTIVE: To acquire data on pediatric nosocomial infections (NIs), which are associated with substantial morbidity and mortality and for which data are scarce. DESIGN: Prevalence survey and evaluation of a new comorbidity index. SETTING: Seven Swiss pediatric hospitals. PATIENTS: Those hospitalized for at least 24 hours in a medical, surgical, intensive care, or intermediate care ward. RESULTS: Thirty-five NIs were observed among 520 patients (6.7%; range per hospital, 1.4% to 11.8%). Bacteremia was most frequent (2.5 per 100 patients), followed by urinary tract infection (1.3 per 100 patients) and surgical-site infection (1.1 per 100 patients; 3.2 per 100 patients undergoing surgery). The median duration until the onset of infection was 19 days. Independent risk factors for NI were age between 1 and 12 months, a comorbidity score of 2 or greater, and a urinary catheter. Among surgical patients, an American Society of Anesthesiologists (ASA) score of 2 or greater was associated with any type of NI (P = .03). Enterobacteriaceae were the most frequent cause of NI, followed by coagulase-negative staphylococci; viruses were rarely the cause. CONCLUSIONS: This national prevalence survey yielded valuable information about the rate and risk factors of pediatric NI. A new comorbidity score showed promising performance. ASA score may be a predictor of NI. The season in which a prevalence survey is conducted must be considered, as this determines whether seasonal viral infections are observed. Periodic prevalence surveys are a simple and cost-effective method for assessing NI and comparing rates among pediatric hospitals.
Abstract: Nosocomial infections (NIs)---those acquired in health care settings---are among the major causes of increased mortality among hospitalized patients. They are a significant burden for patients and health authorities alike; it is thus important to monitor and detect them through an effective surveillance system. This paper describes a retrospective analysis of a prevalence survey of NIs done in the Geneva University Hospital. Our goal is to identify patients with one or more NIs on the basis of clinical and other data collected during the survey. In this two-class classification task, the main difficulty lies in the significant imbalance between positive or infected (11%) and negative (89%) cases. To cope with class imbalance, we investigate one-class SVMs which can be trained to distinguish two classes on the basis of examples from a single class (in this case, only "normal" or non infected patients). The infected ones are then identified as "abnormal" cases or outliers that deviate significantly from the normal profile. Experimental results are encouraging: whereas standard 2-class SVMs scored a baseline sensitivity of 50.6% on this problem, the one-class approach increased sensitivity to as much as 92.6%. These results are comparable to those obtained by the authors in a previous study on asymmetrical soft margin SVMs; they suggest that one-class SVMs can provide an effective and efficient way of overcoming data imbalance in classification problems.
Abstract: AIM: To assess the incidence of legionella infection over a 27 month period at a large university hospital. MATERIAL AND METHODS: The present retrospective cohort study enrolled patients with legionellosis, defined as those presenting a positive urinary antigen for legionella together with a medical history, clinical findings, and radiological findings consistent with pneumonia. These patients were evaluated to determine the relation between their test results and changes in treatment modalities. A control group of patients with pneumonia but a negative urinary antigen test for legionella were also analysed. RESULTS: Twenty seven of 792 assessed patients tested positive for legionella. In 22 of these patients, legionella active antibiotics were administered empirically. In seven patients, the test results prompted a legionella specific treatment, whereas in 12 cases, non-specific antibiotics were stopped within 24 hours. Overall, treatment was altered in more than half of the patients as a result of the test results. CONCLUSIONS: The urinary antigen may have a direct impact on clinical management of pulmonary legionellosis. However, patient comorbidities and individual clinical judgment are still important for determining the best treatment to be given in each individual case.
Abstract: The first multi-center prevalence study of nosocomial infections in Switzerland took place in 1996. Since then, the number of participating hospitals has steadily increased. Today, 72 hospitals of various sizes are part of the Swiss-NOSO surveillance network and represent 30% of all Swiss acute care hospitals, which include approximately 10,000 acute care beds. This article describes the methodology of the national prevalence studies and the results of the 1999 and 2002 surveys. The proportion of infected patients was 10.1% and 8.1% in 1999 and 2002, respectively. The highest prevalence occurred in intensive care units. The most prevalent nosocomial infections were surgical site infections, urinary tract infections, pneumonia, and bloodstream infections. Increasingly, crude rates of nosocomial infections serve as a quality indicator and are used for interhospital comparison and benchmarking. This may be misleading due to differences in case-mix between hospitals as shown in the 1999 study. Using a coordinated approach within a national network, surveillance of nosocomial infections has established itself as an indispensible part of infection control and prevention in Swiss hospitals.
Abstract: The proportion of nosocomial infections potentially preventable under routine working conditions remains unclear. We performed a systematic review to describe multi-modal intervention studies, as well as studies assessing exogenous cross-infection published during the last decade, in order to give a crude estimate of the proportion of potentially preventable nosocomial infections. The evaluation of 30 reports suggests that great potential exists to decrease nosocomial infection rates, from a minimum reduction effect of 10% to a maximum effect of 70%, depending on the setting, study design, baseline infection rates and type of infection. The most important reduction effect was identified for catheter-related bacteraemia, whereas a smaller, but still substantial potential for prevention seems to exist for other types of infections. Based on these estimates, we consider at least 20% of all nosocomial infections as probably preventable, and hope that this overview will stimulate further research on feasible and cost-effective prevention of nosocomial infections for daily practice.
Abstract: OBJECTIVE: To determine the influence of using different denominators on risk estimates of ventilator-associated pneumonia (VAP). DESIGN AND SETTING: Prospective cohort study in the medical ICU of a large teaching hospital. PATIENTS: All consecutive patients admitted for more than 48 h between October 1995 and November 1997. MEASUREMENTS AND RESULTS: We recorded all ICU-acquired infections using modified CDC criteria. VAP rates were reported per 1,000 patient-days, patient-days at risk, ventilator-days, and ventilator-days at risk. Of the 1,068 patients admitted, VAP developed in 106 (23.5%) of those mechanically ventilated. The incidence of the first episode of VAP was 22.8 per 1,000 patient-days (95% CI 18.7-27.6), 29.6 per 1,000 patient-days at risk (24.2-35.8), 35.7 per 1,000 ventilator-days (29.2-43.2), and 44.0 per 1,000 ventilator-days at risk (36.0-53.2). When considering all episodes of VAP (n=127), infection rates were 27.3 episodes per 1,000 ICU patient-days (95% CI 22.6-32.1) and 42.8 episodes per 1,000 ventilator-days (35.3-50.2). CONCLUSIONS: The method of reporting VAP rates has a significant impact on risk estimates. Accordingly, clinicians and hospital management in charge of patient-care policies should be aware of how to read and compare nosocomial infection rates.
Abstract: OBJECTIVE: Although alcohol-based hand rinses and gels have recommended application times of 30 to 60 seconds, healthcare workers usually take much less time for hand hygiene. We compared the efficacies of four alcohol-based hand rubs produced in Europe (hand rinses A, B, and C and one gel formulation) with the efficacy of the European Norm 1500 (EN 1500) reference waterless hand antisepsis agent (60% 2-propanol) at short application times. DESIGN: Comparative crossover study. SETTING: Infection Control Program laboratory of a large tertiary-care teaching hospital. PARTICIPANTS: Twelve healthy volunteers. INTERVENTION: Measurement of residual bacterial counts and log reduction factors following inoculation of fingertips with Staphylococcus aurens American Type Culture Collection (ATCC) 6538, Pseudomonas aeruginosa ATCC 15442, and a clinical isolate of Enterococcus faecalis. RESULTS: All hand rinses satisfied EN 1500 standards following a single application for 15 and 30 seconds, but reduction factors for the gel formulation were significantly lower for all tested organisms (all P < .025). CONCLUSIONS: Under stringent conditions similar to clinical practice, all three hand rinses proved to be more efficacious than the marketed alcohol-based gel in reducing bacterial counts on hands. Further studies are necessary to determine the in vivo efficacy of alcohol-based gels and whether they are as efficacious as alcohol-based rinses in reducing the transmission of nosocomial infections.
Abstract: The development of antibiotic resistance, known since the early days of antibiotic therapy, has accelerated in recent years and makes a postantibiotic era a realistic future scenario. The battle against increasingly resistant strains has become a major concern for infectious disease and infection control specialists worldwide. The issue has now gained heightened awareness among physicians in all specialties and the public, and has become a challenge to hospital leadership. Detailed evidence about the causes and conditions of antibiotic resistance is accumulating, but the main axes have been known for some time: overuse and misuse of antibiotic therapy and transmission of multiresistant pathogens or genetic material between humans. Selection pressure by the systematic use of antibiotics as growth promoters in animal husbandry and the resulting transmission by the food chain is an additional important cause. This overview presents the most promising strategies to contain further resistance spread and hopefully inverse the current trend.
Abstract: Legionnaires' disease is a community-acquired or hospital-acquired pneumonia, and the immunocompromised patient is at particular risk. We report a case of serogroup 1 pneumonia in a renal transplant patient shortly after grafting. No source of infection was identified in the hospital unit, but an extended investigation located patient exposure to a shower during a weekend home stay. Sampling at the hospital, in the patient's flat, other flats, and the laundry of the same building returned only one positive result from the patient's showerhead. Strain identity was confirmed by pulsed-field electrophoresis and amplified fragment length polymorphism. Guidelines recommend -free water for transplant units, but further epidemiologic evidence is required before extending this preventive approach to the patient's home.
Abstract: BACKGROUND: Nosocomial infection rates are used to assess patient safety and the effectiveness of health care systems, but adjustment for case-mix, a key factor for benchmarking, is often overlooked. OBJECTIVES: To perform a nationwide prevalence study of nosocomial infection and evaluate the impact of hospital size on infection rates. METHODS: One-week-period prevalence study in 18 acute care hospitals ranging from small primary to large tertiary care institutions. All adult inpatients in medical, surgical, and intensive care units hospitalized at time of study were included. Infection prevalence and case-mix determinants were calculated according to hospital size. After each factor was tested for its significance on the occurrence of nosocomial infection, all factors were introduced in a multivariate model with hospital size as the main explanatory variable and nosocomial infection as the dependent variable. RESULTS: Among 4252 patients, 429 developed 470 nosocomial infections, for an overall prevalence of 10.1% (intensive care units, 29.7%; medical, 9.3%; surgical, 9.2%; and mixed wards, 14.1%). Unadjusted prevalence rates were 6.1% in small, 10.0% in intermediate, and 10.9% in large hospitals (P =.007). Increased comorbidity (odds ratio, 1.80), cancer (1.68), trauma (1.75), neutropenia (4.66), antibiotic exposure (6.64), history of intensive care unit stay (2.14), referral from another hospital (1.87), intubation for 24 hours or more (2.09), and prolonged stay (3.35) were independently associated with nosocomial infection (all P<.05), but hospital size was not. CONCLUSIONS: Higher infection rates observed in larger hospitals were partly associated with unfavorable case mix. Unadjusted rates may lead to erroneous assumptions for health care prioritization.
Abstract: OBJECTIVE: To assess the added value of surveying patients after discharge from the intensive care unit. DESIGN: Prospective cohort study. SETTING: Medical intensive care unit of a large teaching hospital. PATIENTS: All patients admitted to the intensive care unit for 48 hrs or more from October 1995 to November 1997. MEASUREMENTS AND MAIN RESULTS: We prospectively surveyed 1,068 patients during their intensive care unit stay and for 5 days after intensive care unit discharge. We detected 554 intensive care unit-acquired infections, yielding an infection rate of 70.7 per 1,000 patient days. Of these, only 31 infections (5.6%) in 27 patients were detected after intensive care unit discharge. If postdischarge surveillance was targeted on patients who had had a central vascular catheter while in the intensive care unit, only one infected patient would have been missed, but only 554 out of 889 would have been followed up (sensitivity, 96.2%; specificity, 38.7%; negative predictive value, 99.7%). CONCLUSIONS: Surveillance of all patients discharged from the medical intensive care unit is not recommended, as it is resource demanding and allows the detection of few additional infections. However, targeted postdischarge surveillance could be a rational alternative, and selection criteria need to be refined and validated.
Abstract: Over the past years, there have been very few imported cases of VHF in Switzerland: one confirmed and four suspected cases of Ebola fever in Basel in 1994, two suspected cases of Ebola and Lassa fevers in Lausanne in 2000, and in the same year, six suspected cases of Lassa fever in Geneva. Given the considerable diversity in the management of patients with suspected or confirmed VHF, national guidelines are needed, as well as the establishment of a national reference centre.
Abstract: BACKGROUND: Concurrent potent therapy of hepatitis C (HCV) and HIV includes at least five antiviral drugs. Drug interactions, toxicity, tolerance and acceptance by patients of such treatment regimens are unknown. STUDY DESIGN: A prospective open randomized pilot trial was conducted to test interferon-alpha (6 million units/day for the 1st month followed by 6 million thrice weekly) and amantadine versus interferon-alpha monotherapy for tolerability and feasibility among HIV and HCV co-infected patients on stable antiretroviral combination therapy. RESULTS: 1,013 HIV-infected patients were consecutively evaluated. 314 were anti-HCV antibody positive; only eight (2.4%) were eligible. Major reasons for exclusion were: normal transaminase levels (34%), ongoing intravenous drug use (33%), or recent change in antiretroviral therapy (31%). Study drugs were stopped in all of the seven patients enrolled because of side effects and/or failure of anti-HCV therapy. CD4 lymphocyte counts and HIV-1 RNA remained stable. CONCLUSION: Among patients on highly active antiretroviral therapy, the addition of interferon-alpha with or without amantadine was inefficient and poorly tolerated, but had no negative influence on HIV infection. Eligibility for the study was unexpectedly low.
Abstract: A study was performed to estimate the prevalence of nosocomial infections (NI) and assess differences between medical care settings in one hospital complex. A seven-day period-prevalence survey was conducted in May 1998 in a large primary and tertiary healthcare centre in Geneva, Switzerland, that included all patients in acute, sub-acute and chronic care settings. Variables included demography, exposure to invasive devices and antibiotics, surgical history, and patients' localization. Overall prevalence of NI was 11.3% (acute, 8.4%; sub-acute, 11.4%; chronic care setting, 16.4%) in the 1928 patients studied, and ranged from 0% in ophthalmology to 23% in critical care units. Odds of infection in sub-acute and chronic care settings were significantly higher than in the acute care setting even after adjustment for case-mix [OR, 2.59; 95% confidence interval (CI(95)) 1.53-4.41; and OR, 2.34; Cl(95)1.38-3.95, respectively]. As a distinct group, patients in the geriatric location (belonging to the sub-acute care setting) showed a significant proportion of urinary (39%) and respiratory (21%) tract infections, contrasting with a relatively low exposure to urinary catheters (6.1%) and orotracheal intubation (0%). In conclusion, sub-acute and chronic care settings are associated with high infection prevalence even after case-mix adjustment. Prevalence studies are an easy surveillance tool that can be exploited further by analysing data according to hospital care settings to identify high-risk areas.
Abstract: Biocides are helpful in different healthcare settings to reduce or eradicate harmful pathogens on the skin, medical devices, and in the environment. This article reviews recent advances in hand hygiene, instrument sterilization, decolonization with mupirocin, and the challenges posed by environmental contamination, and prion disease. Do biocides induce resistance?
Abstract: The impact of an infectious disease (ID) service on the optimal antibiotic management of 103 patients with bloodstream infections, defined as bacteremia and systemic inflammatory response syndrome, was evaluated. The optimal antibiotic management was defined according to the Sanford Guide to Antimicrobial Therapy (1996) or written internal guidelines. The judgment on optimal antibiotic management was made at the time of reporting the positive blood culture results. Switching from a broad-spectrum to a narrow-spectrum agent was carried out significantly more often by the ID service than by the attending physicians (25 of 25 vs. 20 of 40; P<0.001). In patients without empirical therapy, the ID service initiated optimal antimicrobial therapy significantly more often than physicians without training in infectious diseases (12 of 12 vs. 4 of 10, P=0.0028). Three of 12 patients in whom the attending physician misinterpreted the positive blood culture result needed 8 days to 4 months of additional hospitalization. In summary, patients for whom an ID service was provided received appropriate treatment more often and experienced significantly fewer complications.
Abstract: The incidence of nosocomial infections is one of the most important quality indicators in health care. It increases the economical burden, augments morbidity, lengthens hospital stay, and is associated with a high mortality rate. Infection control programs are designed to minimize such adverse events. An effective infection control program can reduce the incidence of nosocomial infections by over 30%. It is regarded as among the most cost-efficient medical interventions available in modern public health. The national law for health insurance (KVG) makes quality in health care also a legal issue. This law enforces quality assurance on a scientific basis. In Switzerland there are no national guidelines to define the nature and extent of infection control in health care institutions as in many other European countries. In the United States quality standards are part of accreditation of any health care institution. Evaluating scientific evidence and international experience this article provides the rationale for a quality standard for infection control in Swiss hospitals. It features three general rules and five elements of structural quality. The recommendations are: (1) Every hospital must have a system to control nosocomial infection in patients, care givers and visitors. (2) This program consists of defined elements of structural quality. (3) The program is permanently being improved in its quality. The basic elements are: (1) infection control committee, (2) infection control team, (3) guidelines, (4) surveillance, (5) infrastructure. The feasability and impact of this standard has to be evaluated.
Abstract: OBJECTIVE: To assess the prognostic significance of drug-associated mutations in the protease and reverse transcriptase (RT) genes on virological response to salvage therapy. PATIENTS: All patients from four centres of the Swiss HIV Cohort Study who were switched, between February and October 1997, to nelfinavir plus other antiretroviral drugs following failure of highly active antiretroviral therapy (HIV-1 RNA >1000 copies/ml after > 3 months). METHODS: Direct sequencing of RT and protease genes derived from plasma RNA was performed in 62 patients before salvage therapy. Baseline predictors (drug-resistance mutations, drug exposure, clinical and biological parameters) of virological response after 4-12 weeks of therapy were assessed by linear regression analyses. RESULTS: Patients had been treated with RT inhibitors and protease inhibitors for a median duration of 35.6 and 12.2 months, respectively. Baseline median CD4 cell count was 113 x 10(6)/l and HIV-1 RNA 5.16 log10 copies/ml. The median decrease of HIV-1 RNA was 0.38 log10; 32% of the patients showed > 1 log10 decrease. At baseline, 90% of the patients had RT inhibitor-resistance mutations with a median number per patient of four (range, 0-7). Primary and secondary protease inhibitor-resistance mutations were detected in 69% and 89% of the patients, respectively. The median number of total protease inhibitor-resistance mutations per patient was four (range, 0-9). In univariate analysis, virological response to salvage therapy was associated with number of RT inhibitors, primary and secondary protease inhibitor-resistance mutations, history of protease inhibitor use (duration and number), but not with clinical stage, HIV-1 RNA level or CD4 cell count. After adjustment for all variables, the number of RT inhibitor plus protease inhibitor-resistance mutations was the only independent predictor. CONCLUSIONS: In patients with advanced HIV infection, the virological response to salvage therapy containing nelfinavir is best predicted by the number of baseline RT inhibitor plus protease inhibitor-resistance mutations.
Abstract: Despite significant progress in antibiotic therapy and orthopedic surgery, osteomyelitis remains a difficult-to-treat infection that is often associated with recurrence. In this paper we summarize the most recent developments in understanding the pathogenesis of this complex disease, as well as novel means for its diagnosis and treatment.
Abstract: Autoantibodies against platelet glycoproteins (anti-GP) are found in the majority of patients with autoimmune thrombocytopenia (AITP) as well as in thrombocytopenia associated with systemic lupus erythematosus (SLE). Some of these patients may have anti-phospholipid antibodies (anti-PL). To evaluate the pathogenetic significance of anti-PL and anti-GP antibodies in AITP and SLE patients, we investigated anti-cardiolipin (anti-CL), anti-phosphatidylserine (anti-PS) and anti-GP antibodies (anti-GPIIb-IIIa and anti-GPIb-IX) in 71 patients with AITP and 3 thrombocytopenic patients with SLE. Anti-GP antibodies were detected in 52 (70%) patients. Fifty-six (73%) patients showed anti-PL antibodies. Seven patients (6 AITP, 1 SLE) with both anti-GPIIb-IIIa and IgG anti-PL antibodies were followed during treatment with corticosteroids. Antibodies were measured before treatment and at the time of platelet-peak. Anti-GPIIb-IIIa antibodies decreased in all or became undetectable in five. In contrast, IgG anti-PS and IgG anti-CL antibodies decreased only moderately or remained positive. Adsorption experiments, using gelfiltered platelets, erythrocyte (Ec)-inside-out-vesicles and purified GPIIb-IIIa, showed that anti-GP and anti-PL antibodies have distinct specificities and do not crossreact. We conclude that anti-PL and anti-GP antibodies may be present simultaneously in some patients with immune mediated thrombocytopenia. Although anti-PS as well as anti-CL antibodies may be responsible for thrombocytopenia, we speculate that anti-GPIIb-IIIa antibodies are more related to the severity of thrombocytopenia.
