NosoVeille n°8 Août 2014

NosoVeille n°8 Août 2014

Ce bulletin de veille est une publication mensuelle qui recueille les publications scientifiques publiées au cours du mois écoulé.

Patients et méthodes : Etude rétrospective sur 2 ans (2012/2013) dans un hôpital général de Seine-Saint-Denis des patients porteurs d’EPC avec description clinique. Les coûts étaient estimés en comparant l’activité des services concernés lors des périodes en présence de patients porteurs d’EPC ou « contact », aux mêmes périodes de l’année n-1. Les dépenses en heures supplémentaires et dépistages étaient comptabilisées.

Résultats : Seize patients porteurs d’EPC ont été identifiés : 10 hommes et 6 femmes, d’âge moyen 65 ans ± 10 ans. Sept patients ont acquis l’EPC à l’hôpital lors de 2 épidémies en 2012. Quatre patients présentaient une infection (péritonite, infection de cathéter et 2 pyélonéphrites obstructives) d’évolution favorable. La durée médiane de séjour était de 21 jours [4 ; 150]. Il y a eu 6 décès, dont un indirectement imputable à l’EPC en raison d’une antibiothérapie probabiliste inadaptée. Une diminution d’activité était observée par rapport à l’année précédente avec une perte évaluée à 547 303 €. Les 1779 heures supplémentaires demandées ont coûté 63 870 €, et les 716 prélèvements de dépistage en rapport 30 931 €. Le surcoût global est estimé à 642 104 € pour l’établissement.

Conclusion : L’instauration d’une équipe dédiée pour les porteurs d’EPC et l’isolement des patients contact, indispensables pour éviter/contrôler les épidémies, ont un surcoût important. Une valorisation de leur prise en charge et une meilleure organisation en aval sont indispensables.

Méthodologie : Traitement et analyse des données 2008 DREES, ICATB et ATB Raisin et enquête auprès des utilisateurs.

Observation : Il existe d’importantes disparités pour les objectifs, le taux de participation des établissements, les unités de consommation, les modalités de recueil, de consolidation et de contrôle des données et le délai de mise à disposition des résultats. Les données de consommation pour des mêmes établissements sont différentes d’une base à l’autre, remettant en cause la fiabilité de ces recueils. Nous avons précisé les attentes des utilisateurs : pouvoir croiser les données de consommation et de résistance, réaliser un benchmarking, disposer des données traduisant les habitudes de prescription au niveau des unités de soin, ou accompagner les interprétations des résultats.

Préconisations : Il est nécessaire de pouvoir disposer d’un outil fiable, unique et automatisé de pilotage des données de consommation d’antibiotiques, croisées avec les données de résistances, à plusieurs niveaux (national, régional, établissement, services de soins) et pouvant permettre une rétro-information locale rapide et un benchmarking pédagogique.

Aim: To assess the molecular epidemiology, risk factors and outcomes of nosocomial infections caused by MBL-PA in a teaching hospital in Southern Brazil.

Methods: From January 2001 to December 2008, 142 carbapenem-resistant P. aeruginosa strains were isolated from distinct clinical samples from hospitalized patients. These isolates were screened for MBLs, and underwent polymerase chain reaction, sequencing and pulsed-field gel electrophoresis (PFGE). Patients infected with carbapenem-resistant MBL-PA were considered as cases, and patients infected with non-MBL-PA were considered as controls.

Findings: Eighty-four of 142 patients with positive carbapenem-resistant P. aeruginosa cultures met the criteria of the Centers for Disease Control and Prevention for infection. Fifty-eight patients were infected with MBL-PA (69%) and 26 patients were infected with non-MBL-PA (31%). Multi-variate analysis revealed that ICU stay [P=0.003, odds ratio (OR) 4.01, 95% confidence interval (CI) 1.15–14.01] and urinary tract infection (P=0.001, OR 9.67, 95% CI 1.72–54.48) were important risk factors for MBL-PA infection. Patients infected with MBL-PA showed faster onset of infection (P=0.002) and faster progression to death (P=0.04).

Conclusions: These results showed the severity of MBL-PA infections, and demonstrated the urgent need for strategies to improve infection control measures to prevent an increase in these nosocomial infections.


NosoBase ID notice : 382584

Difficulté à contrôler la dissémination de producteurs de carbapénèmase dans des entérobactéries au niveau mondial
Nordmann P; Poirel L. The difficult-to-control spread of carbapenemase producers in Enterobacteriaceae worldwide. Clinical microbiology and infection 2014; in press: 47 pages.
Mots-clés : CARBAPENEME; ANTIBIORESISTANCE; ENTEROBACTERIE; CONTROLE; REVUE DE LA LITTERATURE
Spread of carbapenemase producers in Enterobacteriaceae is now identified worldwide. Three main carbapenemases are reported which belong to three classes of ß-lactamases that are KPC, NDM and OXA-48. The main reservoirs of KPC are Klebsiella pneumoniae in the USA, Israel, Greece and Italy, of NDM are K. pneumoniae and Escherichia coli in the Indian subcontinent, and of OXA-48 are K. pneumoniae and E. coli in North Africa and Turkey. KPC producers remain mostly identified in nosocomial isolates whereas NDM and OXA-48 producers are both nosocomial and community-acquired pathogens. Control of their spread is still possible in hospital settings and relies on the use of rapid diagnostic techniques and strict implemention of hygiene measures.


NosoBase ID notice : 384274

Taux croissants d’entérobactéries résistantes aux carbapénèmes dans les centres hospitaliers : étude des pratiques épidémiologiques et microbiologiques par méthode mixte dans un réseau de centres hospitaliers du Sud-Est des Etats-Unis
Thaden JT; Lewis SS; Hazen KC; Huslage K; Fowler VG; Moehring RW; et al. Rising rates of carbapenem-resistant enterobacteriaceae in community hospitals: a mixed-methods review of epidemiology and microbiology practices in a network of community hospitals in the southeastern United States. Infection control and hospital epidemiology 2014/08; 35(8): 978-983.
Mots-clés : EPIDEMIOLOGIE; TAUX; ENTEROBACTERIE; ANTIBIORESISTANCE; CARBAPENEME; MICROBIOLOGIE; PRATIQUE; ETUDE RETROSPECTIVE; INFECTION; COLONISATION; KLEBSIELLA PNEUMONIAE
Objective: Describe the epidemiology of carbapenem-resistant Enterobacteriaceae (CRE) and examine the Effect of lower carbapenem breakpoints on CRE detection.

Design: Retrospective cohort.

Setting: Inpatient care at community hospitals.

Patients: All patients with CRE-positive cultures were included.

Methods: CRE isolated from 25 community hospitals were prospectively entered into a centralized database from January 2008 through December 2012. Microbiology laboratory practices were assessed using questionnaires.

Results: A total of 305 CRE isolates were detected at 16 hospitals (64%). Patients with CRE had symptomatic infection in 180 cases (59%) and asymptomatic colonization in the remainder (125 cases; 41%). Klebsiella pneumoniae (277 isolates; 91%) was the most prevalent species. The majority of cases were healthcare associated (288 cases; 94%). The rate of CRE detection increased more than fivefold from 2008 (0.26 cases per 100,000 patient-days) to 2012 (1.4 cases per 100,000 patient-days; incidence rate ratio (IRR), 5.3 [95% confidence interval (CI), 1.22-22.7]; P=.01). Only 5 hospitals (20%) had adopted the 2010 Clinical and Laboratory Standards Institute (CLSI) carbapenem breakpoints. The 5 hospitals that adopted the lower carbapenem breakpoints were more likely to detect CRE after implementation of breakpoints than before (4.1 vs 0.5 cases per 100,000 patient-days; P<.001; IRR, 8.1 [95% CI, 2.7-24.6]). Hospitals that implemented the lower carbapenem breakpoints were more likely to detect CRE than were hospitals that did not (3.3 vs 1.1 cases per 100,000 patient-days; P=.01).

Conclusions: The rate of CRE detection increased fivefold in community hospitals in the southeastern United States from 2008 to 2012. Despite this, our estimates are likely underestimates of the true rate of CRE detection, given the low adoption of the carbapenem breakpoints recommended in the 2010 CLSI guidelines.

Bactériémie
NosoBase ID notice : 384285

Changements dans les bactériémies nosocomiales à Staphylococcus aureus après l’introduction d’un programme national pour l’hygiène des mains
BarnettAG; Page K; Campbell M; Brain D; Martin E; Rashleigh-Rolls R; et al. Changes in healthcare-associated Staphylococcus aureus bloodstream infections after the introduction of a national hand hygiene initiative. Infection control and hospital epidemiology 2014/08; 35(8): 1029-1036.
Mots-clés : STAPHYLOCOCCUS AUREUS; HYGIENE DES MAINS; BACTERIEMIE; TAUX; PERSONNEL; STATISTIQUE
Background: Interventions that prevent healthcare-associated infection should lead to fewer deaths and shorter hospital stays. Cleaning hands (with soap or alcohol) is an effective way to prevent the transmission of organisms, but rates of compliance with hand hygiene are sometimes disappointingly low. The National Hand Hygiene Initiative in Australia aimed to improve hand hygiene compliance among healthcare workers, with the goal of reducing rates of healthcare-associated infection.

Methods: We examined whether the introduction of the National Hand Hygiene Initiative was associated with a change in infection rates. Monthly infection rates for healthcare-associated Staphylococcus aureus bloodstream infections were examined in 38 Australian hospitals across 6 states. We used Poisson regression and examined 12 possible patterns of change, with the best fitting pattern chosen using the Akaike information criterion. Monthly bed-days were included to control for increased hospital use over time.

Results: The National Hand Hygiene Initiative was associated with a reduction in infection rates in 4 of the 6 states studied. Two states showed an immediate reduction in rates of 17% and 28%, 2 states showed a linear decrease in rates of 8% and 11% per year, and 2 showed no change in infection rates.

Conclusions: The intervention was associated with reduced infection rates in most states. The failure in 2 states may have been because those states already had effective initiatives before the national initiative's introduction or because infection rates were already low and could not be further reduced.

Aim: To survey infection control and antibiotic stewardship practices within European hospitals and to identify initiatives that correlate with reduced MRSA prevalence.

Methods: Online questionnaires were sent to European hospitals about their surveillance, hand hygiene, intravenous device management, admission screening, isolation, antibiotic prescribing, hospital demographics and MRSA blood culture isolates during 2010.

Findings: In all, 269 replies were received from hospitals in 29 European countries. Lower MRSA prevalence showed significant association with presence of incidence surveillance, performance of root cause analysis, mandatory training requirements for hand hygiene, accountability measures for persistent non-compliance, and multi-stakeholder teamwork in antibiotic prescribing. Presence of policies on intravenous catheter insertion and management showed no variation between different MRSA prevalence groups. However, low-prevalence hospitals reported more competency assessment programmes in insertion and maintenance of peripheral and central venous catheters. Hospitals from the UK and Ireland reported the highest uptake of infection control and antibiotic stewardship practices that were significantly associated with low MRSA prevalence, whereas Southern European hospitals exhibited the lowest. In multiple regression analysis, isolation of high-risk patients, performance of root cause analysis, obligatory training for nurses in hand hygiene, and undertaking joint ward rounds including microbiologists and infectious disease physicians remained significantly associated with lower MRSA prevalence.