Emmanuelle Girou

Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial

Abstract Objective: To compare the efficacy of handrubbing with an alcohol based solution versus conventional handwashing with antiseptic soap in reducing hand contamination during routine patient care. Design: Randomised controlled trial during daily nursing sessions of 2 to 3 hours Setting: Three intensive care units in a French university hospital Participants: 23 healthcare workers Interventions: Handrubbing with alcohol based solution (n=12) or handwashing with antiseptic soap (n=11) when hand hygiene was indicated before and after patient care. Imprints taken of fingertips and palm of dominant hand before and after hand hygiene procedure. Bacterial counts quantified blindly Main outcome measures: Bacterial reduction of hand contamination. Results: With handrubbing the median percentage reduction in bacterial contamination was significantly higher than with handwashing (83% v 58%, P=0.012), with a median difference in the percentage reduction of 26% (95% confidence interval 8% to 44%). The medianduration of hand hygiene was 30 seconds in each group. Conclusions: During routine patient care handrubbing with an alcohol based solution is significantly more efficient in reducing hand contamination than handwashing with antiseptic soap.

Selective Screening of Carriers for Control of Methicillin-Resistant Staphylococcus aureus (MRSA) in High-Risk Hospital Areas with a High Level of Endemic MRSA

Screening for methicillin-resistant Staphylococcus aureus (MRSA) carriage in patients at risk was evaluated as part of a control program in a 26-bed medical intensive care unit (ICU) of a university hospital with a high level of endemic MRSA. Control measures included isolation and barrier precautions, skin decolonization with chlorhexidine of patients from whom MRSA was recovered, and mupirocin treatment of nasal carriers of MRSA. Of 3,686 patients admitted during a 4-year period, 44% were screened, which occurred during admission for 38%; MRSA was recovered from 293 patients (8%). There were 150 imported cases and 143 ICU-acquired cases, of which 51% and 45%, respectively, were first identified through screening. Nasal swab cultures identified 84% of MRSA carriers. The incidence of all ICU-acquired cases and of acquired colonization or infection decreased from 5.8% and 5.6% to 2.6% and 1.4% (P = .002 and P < .001), respectively, whereas that of imported cases remained unchanged (range, 3.8% to 4.3%; P = .8). Selective screening for nasal carriage during admission to high-risk areas may contribute to identification of a substantial proportion of cases of MRSA and to early implementation of effective control measures.

The risk associated with hyperoncotic colloids in patients with shock

ObjectiveCrystalloids, artificial and natural colloids have been opposed as representing different strategies for shock resuscitation, but it may be relevant to distinguish fluids based on their oncotic characteristics. This study assessed the risk of renal adverse events in patients with shock resuscitated using hypooncotic colloids, artificial hyperoncotic colloids, hyperoncotic albumin or crystalloids, according to physician’s choice.Participants and settingInternational prospective cohort study including 1,013 ICU patients needing fluid resuscitation for shock. Patients suffering from cirrhosis or receiving plasma were excluded.Measurements and resultsInfluence of different types of colloids and crystalloids on the occurrence of renal events (twofold increase in creatinine or need for dialysis) and mortality was assessed using multivariate analyses and propensity score. Statistical adjustment was based on severity at the time of resuscitation, risks factor for renal failure, and on variables influencing physicians’ preferences regarding fluids. A renal event occurred in 17% of patients. After adjustment on potential confounding factors and on propensity score for the use of hyperoncotic colloids, the use of artificial hyperoncotic colloids [OR: 2.48 (1.24–4.97)] and hyperoncotic albumin [OR: 5.99 (2.75–13.08)] was significantly associated with occurrence of renal event. Overall ICU mortality was 27.1%. The use of hyperoncotic albumin was associated with an increased risk of ICU death [OR: 2.79 (1.42–5.47)].ConclusionsThis study suggests that harmful effects on renal function and outcome of hyperoncotic colloids may exist. Although an improper usage of these compounds and confounding factors cannot be ruled out, their use should be regarded with caution, especially because suitable alternatives exist.

Comparison of the Efficacy of a Hydrogen Peroxide Dry‐Mist Disinfection System and Sodium Hypochlorite Solution for Eradication of Clostridium difficile Spores

OBJECTIVE To compare a hydrogen peroxide dry-mist system and a 0.5% hypochlorite solution with respect to their ability to disinfect Clostridium difficile-contaminated surfaces in vitro and in situ. DESIGN Prospective, randomized, before-after trial. SETTING Two French hospitals affected by C. difficile. INTERVENTION In situ efficacy of disinfectants was assessed in rooms that had housed patients with C. difficile infection. A prospective study was performed at 2 hospitals that involved randomization of disinfection processes. When a patient with C. difficile infection was discharged, environmental contamination in the patients room was evaluated before and after disinfection. Environmental surfaces were sampled for C. difficile by use of moistened swabs; swab samples were cultured on selective plates and in broth. Both disinfectants were tested in vitro with a spore-carrier test; in this test, 2 types of material, vinyl polychloride (representative of the rooms floor) and laminate (representative of the rooms furniture), were experimentally contaminated with spores from 3 C. difficile strains, including the epidemic clone ribotype 027-North American pulsed-field gel electrophoresis type 1. RESULTS There were 748 surface samples collected (360 from rooms treated with hydrogen peroxide and 388 from rooms treated with hypochlorite). Before disinfection, 46 (24%) of 194 samples obtained in the rooms randomized to hypochlorite treatment and 34 (19%) of 180 samples obtained in the rooms randomized to hydrogen peroxide treatment showed environmental contamination. After disinfection, 23 (12%) of 194 samples from hypochlorite-treated rooms and 4 (2%) of 180 samples from hydrogen peroxide treated rooms showed environmental contamination, a decrease in contamination of 50% after hypochlorite decontamination and 91% after hydrogen peroxide decontamination (P < .005). The in vitro activity of 0.5% hypochlorite was time dependent. The mean (+/-SD) reduction in initial log(10) bacterial count was 4.32 +/- 0.35 log(10) colony-forming units after 10 minutes of exposure to hypochlorite and 4.18 +/- 0.8 log(10) colony-forming units after 1 cycle of hydrogen peroxide decontamination. CONCLUSION In situ experiments indicate that the hydrogen peroxide dry-mist disinfection system is significantly more effective than 0.5% sodium hypochlorite solution at eradicating C. difficile spores and might represent a new alternative for disinfecting the rooms of patients with C. difficile infection.

The costs of septic syndromes in the intensive care unit and influence of hospital-acquired sepsis

ObjectiveTo document the costs and outcomes of the various forms of the septic syndromes [systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, septic shock), particularly those associated with infection acquired in an intensive care unit (ICU).DesignProspective data collection for all septic patients admitted to a medical ICU during a 1-year period. Costs were computed from the viewpoint of the hospital.ResultsMean total hospital costs were €26,256, €35,185, and €27,083 for patients with sepsis, severe sepsis, and septic shock, respectively. Total costs varied slightly according to the site of infection and the severity of sepsis but were influenced mostly by its mode of acquisition: patients having sepsis associated with ICU-acquired infection incurred total costs about three times those of patients presenting with infection and sepsis on ICU admission (from €39,908 in patients with ICU acquired sepsis to €44,851 in patients with ICU-acquired septic shock). Stratifying patients by the presence of ICU-acquired infection also showed that a first episode of infection complicated by ICU-acquired sepsis incurred at least 2.5 times more costs than a single episode of sepsis.ConclusionsIn this series the medical costs of sepsis were not markedly influenced by its severity but by its mode of acquisition. Due to wide variations in ICU costs cost-effectiveness analyses of treatments for sepsis should document the case-mix of patients and the contribution to this of nosocomial infections.

Mortality Attributable to Nosocomial Infections in the ICU

Although a direct relationship between nosocomial infection and mortality in intensive care unit (ICU) patients has not always been demonstrated formally, it is possible to conclude that nosocomial infections increase the risk of death in critically ill patients. A more precise analysis indicates that: 1) this effect is highly probable for pneumonia, doubtful for bacteremia, and uncertain for urinary tract infection; 2) risk increases with duration of stay in the ICU; 3) bacterial etiology modifies the risk; and 4) this effect is stronger in less severely ill patients, probably because the severity of underlying disease remains the most significant factor.

Comparison of systematic versus selective screening for methicillin-resistant Staphylococcus aureus carriage in a high-risk dermatology ward.

OBJECTIVE To compare two strategies for screening methicillin-resistant Staphylococcus aureus (MRSA) carriers in a high-risk dermatology ward: systematic screening of all admitted patients versus selective screening of patients at risk. DESIGN The two strategies were applied prospectively during two consecutive periods. In period A (8.5 months), only patients transferred from other wards, or with a history of prior hospitalization, or presenting chronic wounds or disease with denuded skin were considered at high risk of MRSA carriage and sampled. In period B (7.5 months), all admitted patients were systematically screened. End-points were the number of patients having a MRSA-positive screening sample on admission during period B and having none of the risk factors used in period A, the rate of imported MRSA cases, and the rate of acquired cases. SETTING A 1,032-bed university hospital with a 19-bed inpatient dermatology ward, a referral center for toxic epidermal necrolysis and severe extensive dermatoses. PATIENTS The study included 729 dermatology inpatients (370 in period A and 359 in period B). RESULTS During period A, screening samples were obtained on admission for 30% of patients (77% of the patients at risk) and identified 25 MRSA carriers. During period B, 90.5% of admitted patients were screened, and 26 MRSA carriers were detected on admission; all of these patients belonged to at least one predefined category at risk for carriage. Overall rates of imported and acquired cases were similar between the two periods (6.8% vs 7.5%, and 2.9% vs 2.4%, respectively). CONCLUSIONS A screening strategy targeted to patients at risk of harboring MRSA has similar sensitivity and is more cost-effective than a strategy of systematic screening to identify MRSA carriers on admission.

An intranet-based automated system for the surveillance of nosocomial infections: prospective validation compared with physicians' self-reports.

OBJECTIVE To examine the reliability of the data produced by an automated system for the surveillance of nosocomial infections. SETTING A 906-bed, tertiary-care teaching hospital. DESIGN Three surveillance techniques were concurrently performed in seven high-risk units during an 11-week period: automated surveillance (AS) based on the prospective processing of computerized medical records; laboratory-based ward surveillance (LBWS) based on the retrospective verification by ward clinicians of weekly reports of positive bacteriologic results; and a reference standard (RS) consisting of the infection control team reviewing case records of patients with positive bacteriology results. Bacteremia, urinary tract infections, and catheter-related infections were recorded for all inpatients. The performances (sensitivity, specificity, and time consumption) of AS and LBWS were compared with those of RS. RESULTS Of 548 positive bacteriology samples included during the study period, 229 (42%) were classified as nosocomial infections. The overall sensitivity was 91% and 59% for AS and LBWS, respectively. The two methods had the same overall specificity value (91%). Kappa measures of agreement were 0.81 and 0.54 for AS and LBWS, respectively. AS required less time to collect data (54 seconds per week per unit) compared with LBWS (7 minutes and 43 seconds per week per unit) and RS (37 minutes and 15 seconds per week per unit). CONCLUSION Our results confirm that the retrospective review of charts and laboratory data by physicians lacks sensitivity for the surveillance of nosocomial infections. The intranet-based automated method developed for this purpose was more accurate and less time-consuming than the weekly, retrospective LBWS method.

Surgical Site Infection After Surgery to Repair Femoral Neck Fracture: A French Multicenter Retrospective Study

OBJECTIVE Femoral neck fracture is the most frequent orthopedic emergency among elderly persons. Despite a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) carriage in this population, no multicenter study of antibiotic prophylaxis practices and the rate and microbiological characteristics of surgical site infection (SSI) has been performed in France. DESIGN Retrospective, multicenter cohort study. SETTING Twenty-two university and community hospitals in France. PATIENTS Each center provided data on 25 consecutive patients who underwent surgery for femoral neck fracture during the first quarter of 2005. Demographic, clinical, and follow-up characteristics were recorded, and most patients had a follow-up office visit or were involved in a telephone survey 1 year after surgery. RESULTS These 22 centers provided data on 541 patients, 396 (73%) of whom were followed up 1 year after surgery. Of 504 (93%) patients for whom antibiotic prophylaxis was recorded, 433 (86%) received a cephalosporin. Twenty-two patients had an SSI, for a rate of 5.6% (95% confidence interval, 3.7-8.0). SSI was reported for 15 (6.9%) of patients who had a prosthesis placed and for 7 (3.9%) who underwent osteosynthesis (P=.27). SSI was diagnosed a median of 30 days after surgery (interquartile range, 21-41 days); 7 (32%) of these SSIs were superficial infections, and 15 (68%) were deep or organ-space infections. MRSA caused 7 SSIs (32%), Pseudomonas aeruginosa caused 5 (23%), other staphylococci caused 4 (18%), and other bacteria caused 2 (9%); the etiologic pathogen was unknown in 4 cases (18%). Reoperation was performed for 14 patients with deep or organ-space SSI, including 6 of 7 patients with MRSA SSI. The mortality rate 1 year after surgery was 20% overall but 50% among patients with SSI. In univariate analysis, only the National Nosocomial Infections Surveillance System risk index score was significantly associated with SSI (P=.006). CONCLUSIONS SSI after surgery for femoral neck fracture is severe, and MRSA is the most frequently encountered etiologic pathogen. A large, multicenter prospective trial is necessary to determine whether the use of antibiotic prophylaxis effective against MRSA would decrease the SSI rate in this population.

Reassessment of intravenous antibiotic therapy using a reminder or direct counselling

OBJECTIVES Encouraging reassessment of intravenous antibiotic therapy at days 3-4 is an important step in the management of patients and may be done by delivering a questionnaire or through systematic infectious disease physician (IDP) advice to prescribers. PATIENTS AND METHODS In this before-and-after study, prescriptions of 13 selected intravenous antibiotics from surgical or medical wards were screened from a computer-generated listing and prospectively included. Three strategies were compared over three consecutive 8 week periods: conventional management by the attending physician (control group); distribution of a questionnaire to the physician (questionnaire group); or distribution of the questionnaire followed by IDP advice (Q-IDP group). The primary outcome was the percentage of modifications of antibiotic therapy at day 4, including withdrawal of therapy, de-escalation, oral switch or reducing the planned duration of therapy. RESULTS Overall, 402 prescriptions were included. At day 4, 48.9% and 54.5% of prescriptions were modified in the control and questionnaire groups, respectively (P = 0.35). In contrast, more prescriptions (66.2%) were modified in the Q-IDP group as compared with the control group (P = 0.004). Stopping therapy in the absence of apparent bacterial infection occurred significantly more often in the Q-IDP group than in the control (P < 0.0001) or questionnaire groups (P = 0.002). CONCLUSIONS This study shows a modest impact of only distributing a questionnaire aimed at reminding physicians to reassess therapy, whereas systematic IDP intervention improves the modification rate.