Americo Agostinho

Decolonization of intestinal carriage of extended-spectrum β-lactamase-producing Enterobacteriaceae with oral colistin and neomycin: a randomized, double-blind, placebo-controlled trial

OBJECTIVES Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) are an increasingly frequent cause of infections in the community and the healthcare setting. In this study, we aimed to investigate whether intestinal carriage of ESBL-E can be eradicated. METHODS We conducted a double-blind, randomized, placebo-controlled, single-centre trial to assess the efficacy of an oral decolonization regimen on intestinal ESBL-E carriage in adult patients with an ESBL-E-positive rectal swab. Fifty-eight patients were allocated 1 : 1 to either placebo or colistin sulphate (50 mg 4×/day) and neomycin sulphate (250 mg 4×/day) for 10 days plus nitrofurantoin (100 mg 3×/day) for 5 days in the presence of ESBL-E bacteriuria. The primary outcome was detection of ESBL-E by rectal swab 28 ± 7 days after the end of treatment. Missing primary outcome data were imputed based on the last available observation. Additional cultures (rectal, inguinal and urine) were taken on day 6 of treatment and on days 1 and 7 post-treatment. The study protocol has been registered with ClinicalTrials.gov (NCT00826670). RESULTS Among 54 patients (27 in each group) included in the primary analysis, there was no statistically significant difference between the groups with regard to the primary outcome [14/27 (52%) versus 10/27 (37%), P = 0.27]. During treatment and shortly afterwards, there was significantly lower rectal ESBL-E carriage in the treatment group: 9/26 versus 19/22 on day 6 of treatment (P < 0.001) and 8/25 versus 20/26 on day 1 post-treatment (P = 0.001). This effect had disappeared by day 7 post-treatment (18/27 versus 17/25, P = 0.92). Liquid stools were more common in the treatment group (7/27 versus 2/29, P = 0.05). CONCLUSIONS The regimen used in this study temporarily suppressed ESBL-E carriage, but had no long-term effect.

A Predictive Model for Identifying Surgical Patients at Risk of Methicillin-Resistant Staphylococcus aureus Carriage on Admission

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.

Low risk despite high endemicity of methicillin-resistant Staphylococcus aureus infections following elective total joint arthroplasty: a 12-year experience

Abstract Background. It is unknown if low rates of arthroplasty infections due to methicillin-resistant Staphylococcus aureus (MRSA) can be achieved in a setting with endemic MRSA (30%). Methods. We performed a 12-year prospective cohort study (1996–2008) of patients undergoing elective knee and hip joint arthroplasties with long-term follow-up. Retrospective MRSA surveillance was undertaken using electronic databases. Results. A total of 6,100 total joint arthroplasties (4001 hip; 2099 knee; 441 (7%) revisions) were monitored for a total of 34,281 person-years of follow-up (median 64 months). MRSA carriage was detected in 126 (2.1%) episodes before arthroplasty and in 147 (2.4%) after arthroplasty. Seven (0.11%) deep arthroplasty infections due to MRSA were retrieved for an overall incidence of 2 episodes per 10,000 person-years. Six were primary surgical site infections, while one infection resulted from endocarditis. MRSA colonization pressure was 11,411 MRSA-positive days for a total of 138,044 patient-days (8.3%) among all orthopedic patients. Conclusion. Institution-wide MRSA endemicity does not necessarily lead to a high MRSA infection risk after elective hip and knee arthroplasty.

Randomized, placebo-controlled, double-blind clinical trial to evaluate the efficacy of polyhexanide for topical decolonization of MRSA carriers

OBJECTIVES The objective of this study was to evaluate the efficacy of polyhexanide (Prontoderm(®)) in eliminating MRSA carriage. METHODS In a 1900 bed teaching hospital, MRSA-colonized patients were randomized into a double-blind, placebo-controlled superiority trial between January 2011 and July 2014. Patients were treated with either polyhexanide or placebo applied to the anterior nares (thrice daily) and skin (once daily) for 10 days. The primary outcome was MRSA decolonization at day 28 (D28) after the end of treatment assessed by ITT responder and PP analyses (microbiological follow-up ± 7 days and topical treatment ≥ 5 days). Secondary outcomes included safety, emergence of resistance and MRSA genotype changes. Registered trial number ISRCTN02288276. RESULTS Of 2590 patients screened, 146 (polyhexanide group, 71; placebo group, 75) were included. ITT analysis showed that 24/71 (33.8%) patients in the polyhexanide group versus 22/75 (29.3%) in the placebo group were MRSA-free at D28 (risk difference, 4.5%; 95% CI, -10.6% to 19.5%; P = 0.56). PP analysis confirmed the results with 19/53 (35.8%) decolonized polyhexanide-treated patients versus 17/56 (30.4%) in the placebo arm (risk difference, 5.5%; 95% CI, -12.2% to 23%; P = 0.54). Nine serious adverse events occurred in the polyhexanide group versus 12 in the placebo group; none was attributable to study medication. Emergence of polyhexanide resistance or cross-resistance between polyhexanide and chlorhexidine was not observed. No case of exogenous recolonization by a genotypically different MRSA strain was documented. CONCLUSIONS This study suggests that under real-life conditions, a single polyhexanide decolonization course is not effective in eradicating MRSA carriage.

Occurrence of fever in the first postoperative week does not help to diagnose infection in clean orthopaedic surgery.

Postoperative fever is often misinterpreted as a sign of infection, especially when occurring after the third postoperative day. We assessed the epidemiology of postoperative fever in adult orthopaedic patients and its association with infection. Among 1,073 patients participating in a prospective observational study, 198 (19%) had a postoperative fever (>38°C). Thirteen patients (1.2%) had a surgical site infection and 78 patients (7.3%) had remote bacterial infections during their hospital stay. Including asymptomatic bacteriuria, 174 patients were given antibiotic therapy for a median duration of six days. In multivariate analysis, no clinical parameter was associated with fever, including haematoma (odds ratio 0.9, 95%CI 0.6–1.3), infection (1.6, 0.7–3.7), or antibiotic use (1.6, 0.9–3.0). The maximum temperature on each of the first seven postoperative days did not differ between infected and uninfected patients (Wilcoxon rank-sum tests; p > 0.10). We conclude that fever, even up to the seventh postoperative day, is not substantially helpful to distinguish infection from general inflammation in clean orthopaedic surgery.

Epidemiology and acquisition of extended-spectrum beta-lactamase-producing Enterobacteriaceae in a septic orthopedic ward

Wards cohorting infected orthopaedic patients may be particularly prone to transmitting extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E). We analyze their epidemic pattern by performing molecular typing of ESBL-E isolated from patients and healthcare workers (HCW) from our septic ward. Between March 2010 and November 2011, 186 patients were admitted. Among 565 anal swabs, ESBL-E were detected in 204 samples from 45 patients, suggesting prolonged carriage in affected patients. Among 25 cases with identical ESBL-E species and positive epidemiological links, only 9 were really attributable to our service. We also screened 41 healthcare workers (HCW) on 49 occasions during the study period. Six samples (13%) were positive. None of the ESBL-E detected in HCW were related to any of the patient isolates. Among 60 environmental samples taken at the peak of the epidemic none revealed ESBL-E. We conclude that HCW also were anal carriers of ESBL-E, however the ESBL- strains from the HCW were not the same strains isolated from patients in the septic ward. Moreover, the epidemiological attribution of ESBL by simple vicinity, timing, and species identification might grossly overestimate transmission within a given unit.

Eight-year sustainability of a successful intervention to prevent urinary tract infection: A mixed-methods study

BACKGROUND Data on long-term effects of interventions in infection control are scarce. We aimed to evaluate the 8-year sustainability of a successful intervention to reduce urinary tract infections (UTIs) through restriction of urinary catheter (UC) use in an orthopedic surgical population. METHODS Prospective UTI surveillance from November 2009-January 2010 was conducted to compare the results against the 2-year sustainability assessment performed in 2004. Semistructured staff interviews focused on UC indication, training, insertion techniques, and recall of the former intervention. RESULTS A total of 336 consecutive patients were included (median age, 63 years; range, 16-95 years; 55% women). A UC was placed in 17.6% of patients (operating room [OR], 10.1%; postanesthesia care unit [PACU], 3.6%; surgical wards [SW], 3.9%) compared with 20.0% in 2004 (OR, 15.7%; PACU, 1.0%; SW, 3.7%). The incidence rate of UTI was 2.4 per 1,000 patient-days in 2010 versus 2.6 per 1,000 patient-days in 2004; adjusted incidence rate ratio 0.76; 95% confidence interval, 0.21-2.76; P = .67. The qualitative inquiry demonstrated poor recall of the intervention and knowledge of guidelines except in the OR, where we identified a champion leader. DISCUSSION The intervention effect was sustained with regard to overall UTI rate and UC placement in the OR, but less in the PACU and SW. CONCLUSIONS Continuous leadership of a single opinion leader in a pivotal position can contribute critically to sustainability.

One- vs 2-Stage Bursectomy for Septic Olecranon and Prepatellar Bursitis

Objective: To assess the optimal surgical approach and costs for patients hospitalized with septic bursitis. Patients and Methods: From May 1, 2011, through December 24, 2014, hospitalized patients with septic bursitis at University of Geneva Hospitals were randomized (1:1) to receive 1‐ vs 2‐stage bursectomy. All the patients received postsurgical oral antibiotic drug therapy for 7 days. Results: Of 164 enrolled patients, 130 had bursitis of the elbow and 34 of the patella. The surgical approach used was 1‐stage in 79 patients and 2‐stage in 85. Overall, there were 22 treatment failures: 8 of 79 patients (10%) in the 1‐stage arm and 14 of 85 (16%) in the 2‐stage arm (Pearson χ2 test; P=.23). Recurrent infection was caused by the same pathogen in 7 patients (4%) and by a different pathogen in 5 (3%). Outcomes were better in the 1‐ vs 2‐stage arm for wound dehiscence for elbow bursitis (1 of 66 vs 9 of 64; Fisher exact test P=.03), median length of hospital stay (4.5 vs 6.0 days), nurses’ workload (605 vs 1055 points), and total costs (SwF6881 vs SwF11,178; all P<.01). Conclusion: For adults with moderate to severe septic bursitis requiring hospital admission, bursectomy with primary closure, together with antibiotic drug therapy for 7 days, was safe, effective, and resource saving. Using a 2‐stage approach may be associated with a higher rate of wound dehiscence for olecranon bursitis than the 1‐stage approach. Trial Registration: Clinicaltrials.gov Identifier: NCT01406652.

Original articleOne- vs 2-Stage Bursectomy for Septic Olecranon and Prepatellar Bursitis: A Prospective Randomized Trial

Objective: To assess the optimal surgical approach and costs for patients hospitalized with septic bursitis. Patients and Methods: From May 1, 2011, through December 24, 2014, hospitalized patients with septic bursitis at University of Geneva Hospitals were randomized (1:1) to receive 1‐ vs 2‐stage bursectomy. All the patients received postsurgical oral antibiotic drug therapy for 7 days. Results: Of 164 enrolled patients, 130 had bursitis of the elbow and 34 of the patella. The surgical approach used was 1‐stage in 79 patients and 2‐stage in 85. Overall, there were 22 treatment failures: 8 of 79 patients (10%) in the 1‐stage arm and 14 of 85 (16%) in the 2‐stage arm (Pearson χ2 test; P=.23). Recurrent infection was caused by the same pathogen in 7 patients (4%) and by a different pathogen in 5 (3%). Outcomes were better in the 1‐ vs 2‐stage arm for wound dehiscence for elbow bursitis (1 of 66 vs 9 of 64; Fisher exact test P=.03), median length of hospital stay (4.5 vs 6.0 days), nurses’ workload (605 vs 1055 points), and total costs (SwF6881 vs SwF11,178; all P<.01). Conclusion: For adults with moderate to severe septic bursitis requiring hospital admission, bursectomy with primary closure, together with antibiotic drug therapy for 7 days, was safe, effective, and resource saving. Using a 2‐stage approach may be associated with a higher rate of wound dehiscence for olecranon bursitis than the 1‐stage approach. Trial Registration: Clinicaltrials.gov Identifier: NCT01406652.

One- vs 2-Stage Bursectomy for Septic Olecranon and Prepatellar Bursitis: A Prospective Randomized Trial

Objective: To assess the optimal surgical approach and costs for patients hospitalized with septic bursitis. Patients and Methods: From May 1, 2011, through December 24, 2014, hospitalized patients with septic bursitis at University of Geneva Hospitals were randomized (1:1) to receive 1‐ vs 2‐stage bursectomy. All the patients received postsurgical oral antibiotic drug therapy for 7 days. Results: Of 164 enrolled patients, 130 had bursitis of the elbow and 34 of the patella. The surgical approach used was 1‐stage in 79 patients and 2‐stage in 85. Overall, there were 22 treatment failures: 8 of 79 patients (10%) in the 1‐stage arm and 14 of 85 (16%) in the 2‐stage arm (Pearson χ2 test; P=.23). Recurrent infection was caused by the same pathogen in 7 patients (4%) and by a different pathogen in 5 (3%). Outcomes were better in the 1‐ vs 2‐stage arm for wound dehiscence for elbow bursitis (1 of 66 vs 9 of 64; Fisher exact test P=.03), median length of hospital stay (4.5 vs 6.0 days), nurses’ workload (605 vs 1055 points), and total costs (SwF6881 vs SwF11,178; all P<.01). Conclusion: For adults with moderate to severe septic bursitis requiring hospital admission, bursectomy with primary closure, together with antibiotic drug therapy for 7 days, was safe, effective, and resource saving. Using a 2‐stage approach may be associated with a higher rate of wound dehiscence for olecranon bursitis than the 1‐stage approach. Trial Registration: Clinicaltrials.gov Identifier: NCT01406652.