NosoBase ID notice : 382504

Methods: Patients with CDI were randomly assigned in a 2:1:1 ratio to oral tolevamer 9 g (loading dose) followed by 3 g every 8 hours for 14 days, vancomycin 125 mg every 6 hours for 10 days, or metronidazole 375 mg every 6 hours for 10 days. The primary endpoint was clinical success, defined as resolution of diarrhea and absence of severe abdominal discomfort for more than 2 consecutive days including day 10.

Results: In a pooled analysis, 563 patients received tolevamer, 289 received metronidazole, and 266 received vancomycin. Clinical success of tolevamer was inferior to both metronidazole and vancomycin (P<.001), and metronidazole was inferior to vancomycin (P=.02; 44.2% [n=534], 72.7% [n=278], and 81.1% [n=259], respectively). Clinical success in patients with severe CDI who received metronidazole was 66.3% compared with vancomycin, which was 78.5%. (P=.059). A post-hoc multivariate analysis that excluded tolevamer found 3 factors that were strongly associated with clinical success: vancomycin treatment, treatment-naive status, and mild or moderate CDI severity. Adverse events were similar among the treatment groups.

Conclusions: Tolevamer was inferior to antibiotic treatment of CDI, and metronidazole was inferior to vancomycin.

Methods: We developed an agent-based transmission model for C. difficile that incorporates screening and contact precautions for asymptomatic carriers in a hospital ward. We simulated scenarios that vary according to screening test characteristics, colonization prevalence, and type of strain present at admission.

Results: In our baseline scenario, on average, 42% of CDI cases were community-onset cases. Within the hospital-onset (HO) cases, approximately half were patients admitted as asymptomatic carriers who became symptomatic in the ward. On average, testing for asymptomatic carriers reduced the number of new colonizations and HO-CDI cases by 40%-50% and 10%-25%, respectively, compared with the baseline scenario. Test sensitivity, turnaround time, colonization prevalence at admission, and strain type had significant effects on testing efficacy.

Conclusions: Testing for asymptomatic carriers at admission may reduce both the number of new colonizations and HO-CDI cases. Additional reductions could be achieved by preventing disease in patients who are admitted as asymptomatic carriers and developed CDI during the hospital stay.

Aim: To overview current national European guidelines for C. difficile infection (CDI) prevention and review the recommendations in respect of their evidence base and conformity to each other and the European Centre for Disease Control and Prevention (ECDC) guidance.

Methods: In 34 European countries, the ECDC healthcare-associated infection (HCAI) surveillance National Contact Points and other HCAI experts (NCPs) were invited to complete an online questionnaire and to supply their guidelines. Guidelines not available in English, French or German were translated into English. For the qualitative analysis, a matrix with key measures based on the 2008 ECDC guidance was established. The review process was conducted independently by two reviewers.

Results: All 34 NCPs responded to the questionnaire and supplied 15 guidelines in total. Six of 34 (18%) countries reported having used the ECDC guidance as a basis for the development or revision of their national guideline. There was wide variation in the scope and detailing. Only six of the documents and the ECDC guidance supplied a rating for the strength of recommendations. The rating systems varied in how the categories were defined. Furthermore, the stated strength for similar measures varied across different guidelines.

Conclusion: The ECDC guidance has not yet had a strong influence on the development or revision of national CDI prevention guidelines. One possible explanation for the variations is the necessity to adapt recommendations to national conditions. The use of internationally recognized instruments for the development of guidelines could help to improve their quality. Recommendations about monitoring or auditing the implementation would make them more useful.

Coronavirus
NosoBase ID notice : 384388

Coronavirus responsable du syndrome respiratoire du Moyen-Orient : étude cas-témoin sur des patients hospitalisés
Al-Tawfiq JA; Hinedi KJ; Ghandour J; Khairalla H; Musleh S; Ujayli A; et al. Middle East respiratory syndrome coronavirus: a case-control study of hospitalized patients. Clinical infectious diseases 2014/07/15; 59(2): 160-165.
Mots-clés : CAS TEMOIN; CORONAVIRUS; FACTEUR DE RISQUE
Background: There is a paucity of data regarding the differentiating characteristics of patients with laboratory-confirmed and those negative for Middle East respiratory syndrome coronavirus (MERS-CoV).

Methods: This is a hospital-based case-control study comparing MERS-CoV-positive patients (cases) with MERS-CoV-negative controls.

Results: A total of 17 case patients and 82 controls with a mean age of 60.7 years and 57 years, respectively (P=.553), were included. No statistical differences were observed in relation to sex, the presence of a fever or cough, and the presence of a single or multilobar infiltrate on chest radiography. The case patients were more likely to be overweight than the control group (mean body mass index, 32 vs 27.8; P=.035), to have diabetes mellitus (87% vs 47%; odds ratio [OR], 7.24; P=.015), and to have end-stage renal disease (33% vs 7%; OR, 7; P=.012). At the time of admission, tachypnea (27% vs 60%; OR, 0.24; P=.031) and respiratory distress (15% vs 51%; OR, 0.15; P=.012) were less frequent among case patients. MERS-CoV patients were more likely to have a normal white blood cell count than the control group (82% vs 52%; OR, 4.33; P=.029). Admission chest radiography with interstitial infiltrates was more frequent in case patients than in controls (67% vs 20%; OR, 8.13; P=.001). Case patients were more likely to be admitted to the intensive care unit (53% vs 20%; OR, 4.65; P=.025) and to have a high mortality rate (76% vs 15%; OR, 18.96; P<.001).

Conclusions: Few clinical predictors could enhance the ability to predict which patients with pneumonia would have MERS-CoV. However, further prospective analysis and matched case-control studies may shed light on other predictors of infection.

Design: Cost analysis.

Setting: This analysis was conducted from the perspective of a hospital leadership team selecting a blood culture collection strategy for an adult emergency department (ED) with 8,000 cultures drawn annually.

Methods: Total hospital costs associated with 3 strategies were compared: (1) usual care, with nurses collecting cultures without a standardized protocol; (2) sterile kits, with nurses using a dedicated sterile collection kit; and (3) phlebotomy teams, with cultures collected by laboratory-based phlebotomists. In the base case, contamination rates associated with usual care, sterile kits, and phlebotomy teams were assumed to be 4.34%, 1.68%, and 1.10%, respectively. Total hospital costs included costs of collecting cultures and hospitalization costs according to culture results (negative, true positive, and contaminated).

Results: Compared with usual care, annual net savings using the sterile kit and phlebotomy team strategies were $483,219 and $288,980, respectively. Both strategies remained less costly than usual care across a broad range of sensitivity analyses.

Conclusions: EDs with high blood culture contamination rates should strongly consider evidence-based strategies to reduce contamination. In addition to improving quality, implementing a sterile collection kit or phlebotomy team strategy is likely to result in net cost savings.

Methods: We carried out a quasi-experimental intervention study with before and after training session analysis to compare waste segregation. Descriptive analysis of the segregated health care waste and an evaluation of the quality of segregation were done. A comparison of monthly average waste to assess the effectiveness of the educational intervention was performed.

Results: After the intervention, there was a significant reduction in the monthly average health care waste volume of 6.2%. Statistically significant differences in the infectious waste and genotoxic/pharmaceutical waste weight segregated before and after the intervention (P<.05) were found. Because of the health care waste weight reduction and the improvement of waste classification, a savings cost of €125,205 was achieved.

Conclusions: The health care waste management training improves biomedical waste segregation at the hospital, reducing the health care waste volume and costs as an added value.

Aim: To determine if the biofilms of three different Gram-negative pathogens associated with multi-drug-resistant phenotypes can be eradicated effectively using different H₂O₂-based disinfectants.

Methods: Planktonic cultures and single-species 24-h biofilms of seven strains of Acinetobacter spp., seven strains of Klebsiella pneumoniae and seven strains of Pseudomonas aeruginosa, including clinical isolates, were exposed to working concentrations of H₂O₂ and H₂O₂-based formulations for 1min to 24h. Survival was monitored.

Findings: The levels of susceptibility of planktonic cultures to unformulated and formulated H₂O₂ were similar in all organisms and strains tested, with minimum inhibitory concentrations ranging from 0.5 to 20mM H₂O₂. However, biofilms showed up to 266-fold less sensitivity to H₂O₂ and its formulations. The level of reduced susceptibility correlated with the strain's propensity to form biofilm, and differed between species. The two formulations with additional acidic active ingredients performed better at short exposure times, whereas ethanol-containing products required longer exposure times to be effective.

Objective: Our aim was to evaluate contamination of clinically used endoscopes, using visual inspection and rapid indicator tests before and after manual cleaning. A second objective was to determine which rapid indicator instruments and methods could be used for quality improvement initiatives in endoscope reprocessing.

Design: Clinical use study of endoscope reprocessing effectiveness.

Setting: Tertiary care teaching hospital with an inpatient endoscopy center.

Methods: Researchers sampled endoscopes used for gastrointestinal procedures before and after manual cleaning. The external surfaces and 1 channel of each endoscope were visually inspected and tested with rapid indicators to measure protein, blood, and adenosine triphosphate (ATP) contamination levels.

Results: Multiple components were sampled during 37 encounters with 12 unique endoscopes. All bedside-cleaned endoscopes had high levels of ATP and detectable blood or protein, whether or not any residue was visible. Although there was no visible residue on any endoscopes after manual cleaning, 82% had at least 1 positive rapid indicator test.

Conclusions: Relying solely on visual inspection of endoscopes prior to HLD is insufficient to ensure reprocessing effectiveness. For quality assurance initiatives, tests of different endoscope components using more than 1 indicator may be necessary. Additional research is needed to validate specific monitoring protocols.


NosoBase ID notice : 384491

Epidémie d’infections à Klebsiella pneumoniae résistant aux carbapénèmes après bronchoscopie
Zweigner J; Gastmeier P; Kola A; Klefisch FR; Schweizer C; Hummel M. A carbapenem-resistant Klebsiella pneumoniae outbreak following bronchoscopy. American journal of infection control 2014/08; 42(8): 936-937.
Mots-clés : KLEBSIELLA PNEUMONIAE; ANTIBIORESISTANCE; CARBAPENEME; EPIDEMIOLOGIE; BRONCHOSCOPIE; CONTAMINATION; EPIDEMIE; SOIN INTENSIF; CHIRURGIE CARDIO-VASCULAIRE; PNEUMONIE