Andre Charlett

Risk factors for surgical site infection following caesarean section in England: results from a multicentre cohort study

Please cite this paper as: Wloch C, Wilson J, Lamagni T, Harrington P, Charlett A, Sheridan E. Risk factors for surgical site infection following caesarean section in England: results from a multicentre cohort study. BJOG 2012;119:1324–1333.

Rainfall and outbreaks of drinking water related disease and in England and Wales

A case-crossover study compared rainfall in the 4 weeks before drinking water related outbreaks with that in the five previous control years. This included public and private drinking water related outbreaks in England and Wales from 1910 to 1999. Of 111 outbreaks, 89 met inclusion criteria and the implicated pathogens included Giardia, Cryptosporidium, E. coli, S. Typhi, S. Paratyphi, Campylobacter and Streptobacillus moniliformis. Weather data was derived from the British Atmospheric Data Centre There was a significant association between excess cumulative rainfall in the previous 7 days and outbreaks (p=0.001). There was an excess of rainfall below 20 mm for the three weeks previous to this in outbreak compared to control weeks (p=0.002). Cumulative rainfall exceedances were associated with outbreak years. This study provides evidence that both low rainfall and heavy rain precede many drinking water outbreaks and assessing the health impacts of climate change should examine both.

The Early Transmission Dynamics of H1N1pdm Influenza in the United Kingdom.

We analyzed data on all laboratory-confirmed cases of H1N1pdm influenza in the UK to 10th June 2009 to estimate epidemiological characteristics. We estimated a mean incubation period of 2.05 days and serial interval of 2.5 days with infectivity peaking close to onset of symptoms. Transmission was initially sporadic but increased from mid-May in England and from early June in Scotland. We estimated 37% of transmission occurred in schools, 24% in households, 28% through travel abroad and the remainder in the wider community. Children under 16 were more susceptible to infection in the household (adjusted OR 5.80, 95% CI 2.99-11.82). Treatment with oseltamivir plus widespread use of prophylaxis significantly reduced transmission (estimated reduction 16%). Households not receiving oseltamivir within 3 days of symptom onset in the index case had significantly increased secondary attack rates (adjusted OR 3.42, 95% CI 1.51-8.55).

The Feedback Intervention Trial (FIT) — Improving Hand- Hygiene Compliance in UK Healthcare Workers: A Stepped Wedge Cluster Randomised Controlled Trial

Introduction Achieving a sustained improvement in hand-hygiene compliance is the WHO’s first global patient safety challenge. There is no RCT evidence showing how to do this. Systematic reviews suggest feedback is most effective and call for long term well designed RCTs, applying behavioural theory to intervention design to optimise effectiveness. Methods Three year stepped wedge cluster RCT of a feedback intervention testing hypothesis that the intervention was more effective than routine practice in 16 English/Welsh Hospitals (16 Intensive Therapy Units [ITU]; 44 Acute Care of the Elderly [ACE] wards) routinely implementing a national cleanyourhands campaign). Intervention-based on Goal & Control theories. Repeating 4 week cycle (20 mins/week) of observation, feedback and personalised action planning, recorded on forms. Computer-generated stepwise entry of all hospitals to intervention. Hospitals aware only of own allocation. Primary outcome: direct blinded hand hygiene compliance (%). Results All 16 trusts (60 wards) randomised, 33 wards implemented intervention (11 ITU, 22 ACE). Mixed effects regression analysis (all wards) accounting for confounders, temporal trends, ward type and fidelity to intervention (forms/month used). Intention to Treat Analysis Estimated odds ratio (OR) for hand hygiene compliance rose post randomisation (1.44; 95% CI 1.18, 1.76;p<0.001) in ITUs but not ACE wards, equivalent to 7–9% absolute increase in compliance. Per-Protocol Analysis for Implementing Wards OR for compliance rose for both ACE (1.67 [1.28–2.22]; p<0.001) & ITUs (2.09 [1.55–2.81];p<0.001) equating to absolute increases of 10–13% and 13–18% respectively. Fidelity to intervention closely related to compliance on ITUs (OR 1.12 [1.04, 1.20];pu200a=u200a0.003 per completed form) but not ACE wards. Conclusion Despite difficulties in implementation, intention-to-treat, per-protocol and fidelity to intervention, analyses showed an intervention coupling feedback to personalised action planning produced moderate but significant sustained improvements in hand-hygiene compliance, in wards implementing a national hand-hygiene campaign. Further implementation studies are needed to maximise the intervention’s effect in different settings. Trial Registration Controlled-Trials.com ISRCTN65246961

Adding amikacin to fluoroquinolone-based antimicrobial prophylaxis reduces prostate biopsy infection rates.

Study Type – Therapy (case series)

Enhanced surgical site infection surveillance following caesarean section: experience of a multicentre collaborative post-discharge system.

The caesarean section rate in the UK has more than doubled during the last two decades and is continuing to rise. The majority of studies carried out to determine the incidence of infection associated with this procedure have been restricted to the inpatient stay, which may give misleading results. Women undergoing caesarean section have routine contact with a community midwife after discharge. This provided an opportunity to assess whether a collaborative surveillance approach between hospital and community staff was feasible using routinely available information. Following a successful pilot study, 11 maternity units in the East Midlands participated in an extended study. Complete records were available for 5,563 (88%) women. Overall, 758 (13.6%) wound problems were reported, 84% of which developed after discharge. Of these, 488 (8.9%) met national definitions for surgical site infection (SSI); however, there was a marked inter-unit difference in incidence, ranging from 2.9% to 17.9%. Statistical models were used to examine these differences using 12 possible risk factors. Five risk factors were found to be significantly associated with the development of a surgical site infection: body mass index, age, blood loss, method of wound closure and emergency procedures. These results suggest that caesarean section is associated with high infectious morbidity, the extent of which would have been considerably underestimated without post-discharge monitoring. Almost all women with wound problems were treated with antibiotics, regardless of how minor the problem, with 97% being prescribed in the community. This indicates a requirement for local review of antibiotic prescribing practice.

Comparison of diagnostic sensitivity and specificity of seven Cryptosporidium assays used in the UK.

To compare the diagnostic sensitivity and specificity of seven Cryptosporidium diagnostic assays used in the UK, results from 259 stool samples from patients with acute gastrointestinal symptoms were compared against a nominated gold standard (real-time PCR and oocyst detection). Of the 152 true positives, 80 were Cryptosporidium hominis, 68 Cryptosporidium parvum, two Cryptosporidium felis, one Cryptosporidium ubiquitum and one Cryptosporidium meleagridis. The Cryptosporidium spp. diagnostic sensitivities of three Cryptosporidium and Giardia combination enzyme immunoassays (EIA) coupled with confirmation of positive reactions were 91.4-93.4u200a%, whilst the sensitivity of auramine phenol microscopy was 92.1u200a% and that of immunofluorescence microscopy (IFM) was 97.4u200a%, all with overlapping 95u200a% confidence intervals. However, IFM was significantly more sensitive (Pu200a=u200a0.01, paired test of proportions). The sensitivity of modified Ziehl-Neelsen microscopy was 75.4u200a%, significantly lower than those for the other tests investigated, including an immunochromatographic lateral flow assay (ICLF) (84.9u200a%) (Pu200a=u200a0.0016). Specificities were 100u200a% when the ICLF and EIA test algorithms included confirmation of positive reactions; however, four positive EIA reactions were not confirmed for either parasite. There was no significant difference in the detection of C. parvum and C. hominis by each assay, but the detection of other Cryptosporidium spp. requires further investigation, as the numbers of samples were small. EIAs may be considered for diagnostic testing, subject to local validation, and diagnostic algorithms must include confirmation of positive reactions.

Role of chronic infection and inflammation in the gastrointestinal tract in the etiology and pathogenesis of idiopathic parkinsonism. Part 3: predicted probability and gradients of severity of idiopathic parkinsonism based on H. pylori antibody profile.

Background.u2002 Eradicating Helicobacter may convert rapidly progressive idiopathic parkinsonism to quieter disease, however only a minority of probands have evidence of current infection.

Advances in electronic surveillance for healthcare- associated infections in the 21st Century: a systematic review

BACKGROUNDnTraditional methodologies for healthcare-associated infection (HCAI) surveillance can be resource intensive and time consuming. As a consequence, surveillance is often limited to specific organisms or conditions. Various electronic databases exist within the healthcare setting and may be utilized to perform HCAI surveillance.nnnAIMnTo assess the utility of electronic surveillance systems for monitoring and detecting HCAI.nnnMETHODSnA systematic review of published literature on surveillance of HCAI was performed. Databases were searched for studies published between January 2000 and December 2011. Search terms were divided into infection, surveillance and data management terms, and combined using Boolean operators. Studies were included for review if they demonstrated or proposed the use of electronic systems for HCAI surveillance.nnnFINDINGSnIn total, 44 studies met the inclusion criteria. For the majority of studies, emphasis was on the linkage of electronic databases to provide automated methods for monitoring infections in specific clinical settings. Twenty-one studies assessed the performance of their method with traditional surveillance methodologies or a manual reference method. Where sensitivity and specificity were calculated, these varied depending on the organism or condition being surveyed and the data sources employed.nnnCONCLUSIONSnThe implementation of electronic surveillance was found to be feasible in many settings, with several systems fully integrated into hospital information systems and routine surveillance practices. The results of this review suggest that electronic surveillance systems should be developed to maximize the efficacy of abundant electronic data sources existing within hospitals.

Rates of Surgical Site Infection After Hip Replacement as a Hospital Performance Indicator : Analysis of Data From the English Mandatory Surveillance System

OBJECTIVEnTo describe rates of surgical site infection (SSI) after hip replacement and to use these data to provide a simple mechanism for identifying poorly performing hospitals that takes into account variations in sample size.nnnDESIGNnProspective surveillance study.nnnSETTINGnA total of 125 acute care hospitals in England that participated in mandatory SSI surveillance from April 1, 2004 through March 31, 2005.nnnPATIENTSnPatients who underwent total hip replacement (THR) or hip hemiarthroplasty (HH).nnnMETHODSnA standard data set was collected for all eligible operations at participating hospitals for a minimum of 3 months annually. Defined methods were used to identify SSIs that occurred during the inpatient stay. Data were checked for quality and accuracy, and funnel plots were constructed by plotting the incidence of SSI against the number of operations.nnnRESULTSnData were collected on 16,765 THRs and 5,395 HHs. The cumulative SSI incidence rates were 1.26% for THR and 4.06% for HH; the incidence densities were 1.38 SSIs per 1,000 postoperative inpatient days for THR and 2.3 SSIs per 1,000 postoperative inpatient days for HH. The risk of infection associated with revision surgery was significantly higher than that associated with primary surgery (2.7% [95% confidence interval, 2.0%-3.5%] vs. 1.1% [95% confidence interval, 1.0%-1.2%]; P=.003). Rates varied considerably among hospitals. Nineteen hospitals had rates above the 90th percentile. However, the use of funnel plots to adjust for the precision of estimated SSI rates identified 7 hospitals that warranted further investigation, including 2 with crude rates below the 90th percentile.nnnCONCLUSIONSnFunnel plots of rates of SSI after hip replacement provide a valuable method of presenting hospital performance data, clearly identifying hospitals with unusually high or low rates while adjusting for the precision of the estimated rate. This information can be used to target and support local interventions to reduce the risk of infection.