Andreas F. Widmer

No Time for Handwashing!? Handwashing Versus Alcoholic Rub Can We Afford 100% Compliance?

Handwashing is the most important and least expensive measure to prevent transmission of nosocomial infections. However, compliance rarely exceeds 40% under study conditions. Alcoholic hand disinfection (AHD) generally is used in Europe. In contrast, handwashing with medicated soap is practiced most frequently in the United States. Healthcare workers often explain the failure to comply with handwashing or AHD as due to the limited time available for this practice. We calculated a time consumption for handwashing and AHD in a representative model intensive-care unit with 12 healthcare workers, based on different compliance levels (40%, 60%, and 100%), duration of handwashing (40-80 seconds), and AHD (20 seconds). Comparing the extremes of our model, given 100% compliance, handwashing consumes 16 hours of nursing time per day shift, whereas AHD from a bedside dispenser requires only 3 hours (P = .01). We conclude that 100% compliance with handwashing may interfere with patient care and parltly explains the low compliance. In contrast, AHD, with its rapid activity, superior efficacy, and minimal time commitment, allows 100% healthcare-worker compliance without interfering with the quality of patient care.

Infections associated with orthopedic implants.

Purpose of review We review recent advances in the prevention, diagnosis and treatment of infections associated with joint prostheses and internal fixation devices. Recent findings The perioperative antimicrobial prophylaxis should be administered 60–30 min before incision or before inflation of the tourniquet. New diagnostic approaches include sonication of removed implants to dislodge adherent microorganisms growing in biofilms and the use of molecular techniques to improve diagnostic yield. Treatment of implant-associated infections without removal of the device is an established option for selected patients. Treatment with rifampin combinations in staphylococcal infections is crucial for success. As demonstrated in vitro, in animal studies and in clinical trials, quinolones are suitable combination agents with rifampin against susceptible staphylococci, but increasing antimicrobial resistance requires evaluation of alternative combination agents, such as quinpristin–dalfopristin, linezolid, and daptomycin, although clinical experience is limited. New antimicrobial agents, such as dalbavancin, tigecycline, iclaprim, and novel rifamycin derivatives are studied. Summary Better understanding of the interaction between microorganisms, the implant and the host may improve our current approach to the diagnosis and treatment of implant-associated infections. The treatment modality depends on duration of infection, stability of the implant, antimicrobial susceptibility of the pathogen and condition of the surrounding soft tissue.

New Developments in Diagnosis and Treatment of Infection in Orthopedic Implants

Orthopedic implants have revolutionized treatment of bone fractures and noninfectious joint arthritis. Today, the risk for orthopedic device-related infection (ODRI) is <1%-2%. However, the absolute number of patients with infection continuously increases as the number of patients requiring such implants grows. Treatment of ODRIs most frequently includes long-term antimicrobial treatment and removal of the implant. Recent evidence from observational trials and 1 randomized clinical trial indicate that a subset of patients can be successfully treated with retention of the implant. Patients eligible for such a treatment must meet the following criteria: acute infection defined as signs and symptoms lasting <14-28 days, an unambiguous diagnosis based on histopathology and microbiology, a stable implant, and susceptibility of the microorganism to an effective orally available antimicrobial agent.

The timing of surgical antimicrobial prophylaxis.

Objective:To obtain precise information on the optimal time window for surgical antimicrobial prophylaxis. Summary Background Data:Although perioperative antimicrobial prophylaxis is a well-established strategy for reducing the risk of surgical site infections (SSI), the optimal timing for this procedure has yet to be precisely determined. Under todays recommendations, antibiotics may be administered within the final 2 hours before skin incision, ideally as close to incision time as possible. Methods:In this prospective observational cohort study at Basel University Hospital we analyzed the incidence of SSI by the timing of antimicrobial prophylaxis in a consecutive series of 3836 surgical procedures. Surgical wounds and resulting infections were assessed to Centers for Disease Control and Prevention standards. Antimicrobial prophylaxis consisted in single-shot administration of 1.5 g of cefuroxime (plus 500 mg of metronidazole in colorectal surgery). Results:The overall SSI rate was 4.7% (180 of 3836). In 49% of all procedures antimicrobial prophylaxis was administered within the final half hour. Multivariable logistic regression analyses showed a significant increase in the odds of SSI when antimicrobial prophylaxis was administered less than 30 minutes (crude odds ratio = 2.01; adjusted odds ratio = 1.95; 95% confidence interval, 1.4–2.8; P < 0.001) and 120 to 60 minutes (crude odds ratio = 1.75; adjusted odds ratio = 1.74; 95% confidence interval, 1.0–2.9; P = 0.035) as compared with the reference interval of 59 to 30 minutes before incision. Conclusions:When cefuroxime is used as a prophylactic antibiotic, administration 59 to 30 minutes before incision is more effective than administration during the last half hour.

Throat Swabs Are Necessary to Reliably Detect Carriers of Staphylococcus aureus

The anterior nares are the most important screening site of colonization with Staphylococcus aureus. We screened 2966 individuals for S. aureus carriage with swabs of both nares and throat. A total of 37.1% of persons were nasal carriers, and 12.8% were solely throat carriers. Screening of throat swabs significantly increases the sensitivity of detection among carriers by 25.7%.

Replace Hand Washing with Use of a Waterless Alcohol Hand Rub

Hand hygiene is one of the basic components of any infection control program and is frequently considered synonymous with hand washing. However, health care workers frequently do not wash their hands, and compliance rarely exceeds 40%. Hand rubbing with a waterless, alcohol-based rub-in cleanser is commonly used in many European countries instead of hand washing. Scientific evidence and ease of use support employment of a hand rub for routine hand hygiene. It is microbiologically more effective in vitro and in vivo, it saves time, and preliminary data demonstrate better compliance than with hand washing. Therefore, a task force comprising experts from the Centers for Disease Control and Prevention and from professional societies is designing guidelines for the use of a hand rub in the United States. Today, most countries of Northern Europe recommend a hand rub for hand hygiene unless the hands are visibly soiled. Side effects are rare and are mainly related to dryness of the skin. This review evaluates the scientific and clinical evidence that support the use of alcohol-based hand rubs in health care facilities as a new option for hand hygiene.

Respiratory Syncytial Virus Infection in Patients with Hematological Diseases: Single-Center Study and Review of the Literature

BACKGROUND Respiratory syncytial virus (RSV) causes significant mortality in patients with hematological diseases, but diagnosis and treatment are uncertain. METHODS We retrospectively identified RSV-infected patients with upper or lower respiratory tract infection (RTI) by culture, antigen testing, and polymerase chain reaction from November 2002 through April 2007. Patients with severe immunodeficiency (SID; defined as transplantation in the previous 6 months, T or B cell depletion in the previous 3 months, graft-versus-host disease [grade, >or=2], leukopenia, lymphopenia, or hypogammaglobulinemia) preferentially received oral ribavirin, intravenous immunoglobulin, and palivizumab. The remaining patients with moderate immunodeficiency (MID) preferentially received ribavirin and intravenous immunoglobulin. RESULTS We identified 34 patients, 22 of whom had upper RTI (10 patients with MID and 12 with SID) and 12 of whom had lower RTI (2 with MID and 10 with SID). Thirty-one patients were tested by polymerase chain reaction (100% of these patients had positive results; median RSV load, 5.46 log(10) copies/mL), 30 were tested by culture (57% had positive results), and 25 were tested by antigen testing (40% had positive results). RSV-attributed mortality was 18% (6 patients died) and was associated with having >or=2 SID factors (P=.04), lower RTI (P=.01), and preengraftment (P=.012). Among 12 patients with MID (7 of whom received treatment), no progression or death occurred. Nine patients with SID and upper RTI received treatment (7 patients received ribavirin, intravenous immunoglobulin, and palivizumab); infection progressed to the lower respiratory tract in 2 patients, and 1 patient died. Ten patients with SID and lower RTI were treated, 5 of whom died, including 4 of 6 patients who received ribavirin, intravenous immunoglobulin, and palivizumab. The duration of RSV shedding correlated with the duration of symptoms in patients with SID but exceeded symptom duration in patients with MID (P<.05). CONCLUSIONS Lower RTI, >or=2 SID criteria, and preengraftment are risk factors for RSV-attributed mortality. Polymerase chain reaction may optimize diagnosis and monitoring. Oral ribavirin therapy seems safe, but trials are needed to demonstrate its efficacy.

2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults

These guidelines are intended for use by infectious disease specialists, orthopedic surgeons, neurosurgeons, radiologists, and other healthcare professionals who care for patients with native vertebral osteomyelitis (NVO). They include evidence and opinion-based recommendations for the diagnosis and management of patients with NVO treated with antimicrobial therapy, with or without surgical intervention.

Highly Effective Regimen for Decolonization of Methicillin-Resistant Staphylococcus aureus Carriers

OBJECTIVE To evaluate the efficacy of a standardized regimen for decolonization of methicillin-resistant Staphylococcus aureus (MRSA) carriers and to identify factors influencing decolonization treatment failure. DESIGN Prospective cohort study from January 2002 to April 2007, with a mean follow-up period of 36 months. SETTING University hospital with 750 beds and 27,000 admissions/year. PATIENTS Of 94 consecutive hospitalized patients with MRSA colonization or infection, 32 were excluded because of spontaneous loss of MRSA, contraindications, death, or refusal to participate. In 62 patients, decolonization treatment was completed. At least 6 body sites were screened for MRSA (including by use of rectal swabs) before the start of treatment. INTERVENTIONS Standardized decolonization treatment consisted of mupirocin nasal ointment, chlorhexidine mouth rinse, and full-body wash with chlorhexidine soap for 5 days. Intestinal and urinary-tract colonization were treated with oral vancomycin and cotrimoxazole, respectively. Vaginal colonization was treated with povidone-iodine or, alternatively, with chlorhexidine ovula or octenidine solution. Other antibiotics were added to the regimen if treatment failed. Successful decolonization was considered to have been achieved if results were negative for 3 consecutive sets of cultures of more than 6 screening sites. RESULTS The mean age (+/- standard deviation [SD]) age of the 62 patients was 66.2 +/- 19 years. The most frequent locations of MRSA colonization were the nose (42 patients [68%]), the throat (33 [53%]), perianal area (33 [53%]), rectum (36 [58%]), and inguinal area (30 [49%]). Decolonization was completed in 87% of patients after a mean (+/-SD) of 2.1 +/- 1.8 decolonization cycles (range, 1-10 cycles). Sixty-five percent of patients ultimately required peroral antibiotic treatment (vancomycin, 52%; cotrimoxazole, 27%; rifampin and fusidic acid, 18%). Decolonization was successful in 54 (87%) of the patients in the intent-to-treat analysis and in 51 (98%) of 52 patients in the on-treatment analysis. CONCLUSION This standardized regimen for MRSA decolonization was highly effective in patients who completed the full decolonization treatment course.

Rapid and Reliable Diagnostic Algorithm for Detection of Clostridium difficile

ABSTRACT We evaluated a two-step algorithm for detection of Clostridium difficile in 1,468 stool specimens. First, specimens were screened by an immunoassay for C. difficile glutamate dehydrogenase antigen (C.DIFF CHEK-60). Second, screen-positive specimens underwent toxin testing by a rapid toxin A/B assay (TOX A/B QUIK CHEK); toxin-negative specimens were subjected to stool culture. This algorithm allowed final results for 92% of specimens with a turnaround time of 4 h.