François L'Hériteau

Non-compliance with recommendations for the practice of antibiotic prophylaxis and risk of surgical site infection: results of a multilevel analysis from the INCISO Surveillance Network

OBJECTIVES The aim of this study was to determine which surgical antibiotic prophylaxis (SAP) practices alter surgical site infection (SSI) risk. METHODS Data were collected during a 7 year surveillance period (2001-07) from volunteer surgery wards participating in the INCISO Surveillance Network in Northern France. Main SAP practices, i.e. antibiotic choice, timing of first dose and total SAP duration, were evaluated and compliance checked based on French recommendations. The study focused on selected procedures in digestive, orthopaedic, gynaecological and cardiovascular surgery, for which standard SAP is recommended. Multilevel logistic regression analysis (a two-level random effect model) was carried out to identify SAP-, patient- and procedure-specific factors associated with SSI. RESULTS Of 8029 patients who underwent the selected surgeries, 91.3% received SAP and 2.5% developed SSI. Among those receiving SAP, 83.3% received appropriate antibiotic agents and 76.6% had an optimal timing of administration. SAP duration was considered to be appropriate in 35.0%, too long (SAP unnecessarily prolonged) in 45.2% and too short (lack of intra-operative redosing when recommended) in 19.8%. In the multivariate analysis, a too-short SAP duration remained the only inappropriate practice associated with higher SSI risk (odds ratio = 1.8, 95% confidence interval: 1.14-2.81), after adjustment for surgery procedure group, the National Nosocomial Infections Surveillance System risk index, age and infection risk variability among hospitals. No significant relationships were observed between SSI and the other SAP parameters. CONCLUSIONS A too-short SAP duration was the most important SAP malpractice associated with an increased risk of SSI. Information directed at practitioners should be reinforced based on standard recommendations.

Needlestick injury rates according to different types of safety-engineered devices: results of a French Multicenter Study.

OBJECTIVES To evaluate the incidence of needlestick injuries (NSIs) among different models of safety-engineered devices (SEDs) (automatic, semiautomatic, and manually activated safety) in healthcare settings. DESIGN This multicenter survey, conducted from January 2005 through December 2006, examined all prospectively documented SED-related NSIs reported by healthcare workers to their occupational medicine departments. Participating hospitals were asked retrospectively to report the types, brands, and number of SEDs purchased, in order to estimate SED-specific rates of NSI. Setting. Sixty-one hospitals in France. RESULTS More than 22 million SEDs were purchased during the study period, and a total of 453 SED-related NSIs were documented. The mean overall frequency of NSIs was 2.05 injuries per 100,000 SEDs purchased. Device-specific NSI rates were compared using Poisson approximation. The 95% confidence interval was used to define statistical significance. Passive (fully automatic) devices were associated with the lowest NSI incidence rate. Among active devices, those with a semiautomatic safety feature were significantly more effective than those with a manually activated toppling shield, which in turn were significantly more effective than those with a manually activated sliding shield (P < .001, chi(2) test). The same gradient of SED efficacy was observed when the type of healthcare procedure was taken into account. CONCLUSIONS Passive SEDs are most effective for NSI prevention. Further studies are needed to determine whether their higher cost may be offset by savings related to fewer NSIs and to a reduced need for user training.

Antibiotic use in 530 French hospitals: results from a surveillance network at hospital and ward levels in 2007

OBJECTIVES Antibiotic use in French hospitals is among the highest in Europe. A study was carried out to describe antibiotic consumption for inpatients at hospital and at ward levels. METHODS Data were voluntarily collected retrospectively by 530 hospitals accounting for approximately 40 million patient-days (PD) on the following: antibacterials for systemic use [J01 class of the WHO Anatomical Therapeutic Chemical (ATC) classification, defined daily doses (DDD) system, 2007], rifampicin and oral imidazole derivatives, expressed in number of DDD and number of PD in 2007. Consumption was expressed in DDD/1000 PD. RESULTS Median antibiotic use ranged from 60 DDD/1000 PD in long-term care (LTC) and psychiatric hospitals to 633 DDD/1000 PD in teaching hospitals. Penicillins and beta-lactamase inhibitors combinations were the most frequently used antibiotics, accounting for 26% of total use in cancer hospitals to 40% in LTC/psychiatric hospitals. Glycopeptides and carbapenems were mostly used in cancer and teaching hospitals. Level of consumption and pattern of use differed according to clinical ward from 60 DDD/1000 PD in psychiatric wards up to 1466 DDD/1000 PD in intensive care units (ICUs). In medicine, surgery, ICU and rehabilitation wards, fluoroquinolones accounted for 13%-19% of the total use. CONCLUSIONS This multicentre survey provided detailed information on antibiotic use in a large sample of hospitals and wards, allowing relevant comparisons and benchmarking. Analysis of consumption at the ward level should help hospitals to target practice audits to improve antibiotic use.

Specific control measures for antibiotic prescription are related to lower consumption in hospitals: results from a French multicentre pilot study

BACKGROUND In France, antibiotic consumption (ABC) is dramatically high in parallel with the high rate of multidrug-resistant bacteria. For the last few years, a nationwide policy has been implemented at the national level to control and monitor ABC. Since 2002, surveillance networks have been set up with voluntary hospitals to evaluate the antibiotic policy and consumption. The present study was conducted to identify whether specific control measures of the antibiotic policy could reduce ABC in hospitals. METHODS Based on the data from the Northern France surveillance system, local recommendations and antibiotic use were collected annually on a standardized questionnaire that had 21 items. ABC was expressed in defined daily doses (DDDs) per 1000 patient-days (PDs). The ABC indicator was the overall antibiotic consumption. A multivariate logistic regression analysis was performed using low (< or =75th percentile) and high (>75th percentile) ABC as the dependent variable. RESULTS A total of 83/111 hospitals were included in the study. In 75% of the hospitals, total ABC was < or =669.5 DDDs/1000 PDs. The less frequent practices were educational antibiotic programmes (17%), authorization from an antibiotic specialist for selected antibiotics (26%) and systematic reassessment of AB treatment after 72 h (27%). In the multivariate analysis, three variables remained significantly and independently associated (P < 0.05) with ABC: the type of hospital, the proportion of non-acute-care beds and the nominative delivery form as the only antibiotic control measure. Total ABC was lower in hospitals having a nominative delivery form, compared with hospitals not having it. Conversely, ABC was significantly higher in public teaching hospitals compared with non-teaching hospitals. Similarly, ABC was higher in hospitals with a lowest proportion (i.e. < or =25%) of non-acute-care beds compared with hospitals where this proportion was >25%. CONCLUSIONS Specific control measures could lower ABC. Sustained control efforts should focus on antibiotics with the highest potential for emerging bacterial resistance.

Antibiotics involved in the occurrence of antibiotic-resistant bacteria: a nationwide multilevel study suggests differences within antibiotic classes

OBJECTIVES To identify the antibiotics potentially the most involved in the occurrence of antibiotic-resistant bacteria from an ecological perspective in French healthcare facilities (HCFs). METHODS This study was based on data from the French antimicrobial surveillance network (ATB-RAISIN, 2007-09). Antibiotics were expressed in defined daily doses per 1000 patient-days. Antibiotic-resistant bacteria were considered as count data adjusted for patient-days. These were third-generation cephalosporin (3GC)- and ciprofloxacin-resistant Escherichia coli, cefotaxime-resistant Enterobacter cloacae, methicillin-resistant Staphylococcus aureus and ceftazidime-, imipenem- and ciprofloxacin-resistant Pseudomonas aeruginosa. Three-level negative binomial regression models were built to take into account the hierarchical structure of data: level 1, repeated measures each year (count outcome, time, antibiotics); level 2, HCFs (type and size); and level 3, regions (geographical area). RESULTS A total of 701 HCFs from 20 French regions and up to 1339 HCF-years were analysed. The use of ceftriaxone, but not of cefotaxime, was positively correlated with incidence rates of 3GC- and ciprofloxacin-resistant E. coli. In contrast, both 3GCs were positively correlated with the incidence rate of cefotaxime-resistant E. cloacae. Higher levels of use of ciprofloxacin and/or ofloxacin, but not of levofloxacin, were associated with higher incidence rates of 3GC- and ciprofloxacin-resistant E. coli, cefotaxime-resistant E. cloacae, methicillin-resistant S. aureus and ceftazidime- and ciprofloxacin-resistant P. aeruginosa. CONCLUSIONS Our study suggests differences within antibiotic classes in promoting antibiotic resistance. We identified ceftriaxone, ciprofloxacin and ofloxacin as priority targets in public health strategies designed to reduce antibiotic use and antibiotic-resistant bacteria in French HCFs.

Bacteriuria in a Geriatric Hospital: Impact of an Antibiotic Improvement Program

OBJECTIVES To prospectively evaluate a management approach to bacteriuria including advice from an infectious diseases consultant (IDC) in geriatric inpatients. DESIGN Prospective study from July 1, 2003, to June 30, 2004. SETTING A 205-bed geriatric university-affiliated hospital. PARTICIPANTS Consecutive hospitalized patients with positive urine cultures. INTERVENTION The hospitals infection control department developed recommendations about antimicrobial use for bacteriuria, which were discussed at staff meetings. Treatments for bacteriuria prescribed by ward physicians were reviewed by an IDC, who suggested changes where appropriate. Physicians were free to follow or to disregard the IDCs suggestions. MEASUREMENTS Patients with positive urine cultures (UC) were classified as having asymptomatic bacteriuria (AB), urinary tract infection (UTI) or pyelonephritis (PN). Prescribed and actual treatments were compared. RESULTS Of 252 consecutive positive UCs in 181 patients, 124 (49%) were classified as AB, 88 (35%) as UTI, and 38 (15%) as PN; 2 cases of prostatitis were excluded. The total number of prescribed antimicrobial days before IDC advice was 729 and the actual number (after IDC advice) was 577, for a 152-day (21%) reduction. Most of the reduction was generated by shortening the treatment duration. CONCLUSION Intervention of an IDC resulted in reduced antimicrobial use in older inpatients with bacteriuria.

Surveillance of surgical-site infections: impact on quality of care and reporting dilemmas

Purpose of review Among a wide range of publications on surgical-site infections (SSIs), many issues are still controversial, especially those concerning their monitoring and feedback. This review focuses on recent advances in surveillance as a tool for improving healthcare quality performance in surgery. Recent findings Recent data were obtained from many reference surveillance systems which tend to demonstrate significant decrease in SSI incidence rates over a several-year period. Most studies emphasize data feedback to surgical team is an important way to improve care quality and surgical performance. Few data demonstrated the relationship between the lack of compliance to control measures and SSI risk, including suboptimal antibiotic prophylaxis, perforated gloves, control of blood glucose, and avoidance of shaving. No clear consensus is achieved yet regarding preoperative systematic screening and decolonization of multidrug-resistant Staphylococcus aureus. There is a good amount of recent data regarding the benchmark approach for ranking surgery wards according to SSI rates. However, methodological issues on SSI indicator for public reporting are still being debated. Pilot studies attempt to demonstrate the usefulness of more cost-effective surveillance systems, especially those based on automated data process. Summary There are new exciting developments and perspectives in the field of surveillance and control of SSI. More data are needed to better establish the relationship with global care quality.

Prospective assessment of hospital-acquired bloosdstream infections: how many may be preventable?

Objective To determine the proportion of preventable hospital-acquired bloodstream infections (HA-BSIs), the authors prospectively examined consecutive cases in a large university hospital over an 18-month period. Patients and methods Medical charts were assessed with the physician in charge of the patient within 4 days after HA-BSI diagnosis to determine whether the infection was healthcare-related. Preventability was assessed using a validated tool. Results of 378 HA-BSIs (incidence rate, 1.00 per 1000 patient-days), 341 were first HA-BSI episodes in a patient, and 272 (79.8%) were secondary to an identifiable source, of whom 196 (57.5%) were related to medical management. These 196 HA-BSIs were related to an invasive procedure (n=163), a non-invasive medical management (n=30) or both (n=3). Results Of the 272 patients with HA-BSIs from identifiable sources, 55 (20.2%) had no underlying disease, 115 (42.3%) had an ultimately fatal underlying disease, 99 (36.4%) had a rapidly fatal disease, and three (1.1%) were not evaluated. Of the 196 iatrogenic HA-BSIs, 66 were considered preventable (most of them being related to an intravascular catheter), 84 were of uncertain preventability, and 46 were not preventable. In total, 66 of the 341 HA-BSIs (19.4%) were considered preventable, and 191 (56.0%) were not preventable. Conclusion Although evaluation of the preventability of hospital-associated adverse events has been reported to be difficult and of limited reliability, our simple method may help to identify wards or HA-BSI types that warrant in-depth evaluation.

Paradoxical emergence of humerus osteomyelitis during treatment of pulmonary and lymph-node tuberculosis.

A transient worsening of a pre-existing lesion (or emergence of new lesions) under appropriate antituberculous therapy has been described mainly for adenitis, intracranial tuberculoma and the lung (1). Although paradoxical expansion (PExp) is not uncommon for osteoarticular tuberculosis (TB), the emergence of tuberculous osteomyelitis under appropriate treatment is rare. We report a case of tuberculous osteomyelitis emerging under antimycobacterial therapy. A 35-y-old Sri Lankan male who had been residing in France for 1 month, was admitted for pulmonary TB and lymphadenitis. Mycobacterium tuberculosis, susceptible to all antimycobacterial agents, was isolated from sputum smears and cervical node puncture. A human immunode® ciency virus (HIV) test was negative. Antimycobacterial therapy was initiated. One month later, he complained of fever (37°C) and in ̄ ammatory pain from the lower extremity of the left humerus without local swelling or erythema. Tenderness was increased by local palpation. The C-reactive protein (CRP) level had risen from 42 to 86 mg:l. An X-ray of the left humerus was normal. A computed tomographic (CT) scan showed increased density of the lower third of the left humerus. Magnetic resonance imaging (MRI) of the left humerus performed after 40 d of appropriate treatment showed signs of osteomyelitis, i.e. a cyst-like cavity with periostal reaction. A chest CT scan revealed enlargement of the mediastinal lymph node. The occurrence of these complications despite adequate therapy and good compliance suggested PExp. Steroid therapy was therefore initiated (prednisone 60 mg:d). The abscess enlarged and was ultimately drained. Pathological examination showed an epithelioid and gigantocellular granuloma. No acid-fast bacilli were found and cultures remained negative. The pain resolved completely within 3 weeks and the patient remained symptom free. Corticosteroid therapy was then progressively reduced. PExp generally appears during the ® rst few months of therapy (1) and may vary widely in localization. It is mostly observed in haematogenous dissemination, but can also be seen in pulmonary TB. In lymph-node TB, up to 30% of patients may present with enlargement under treatment (1). A relatively high frequency of extrapulmonary disease in Asian immigrants may explain the more frequent occurrence of PExp in this population (1, 2). Several unusual localizations of PExp such as subcutaneous abscess (3) or hand tenosynovitis (4) have been reported. Tibial osteomyelitis emerging under antituberculous therapy in a 17-y-old Indian girl has also been described (2). In these cases, however, the initial lesion (miliary TB) was haematogenous. A few cases of multifocal osteoarticular PExp have also been described (5). Long-bone tuberculous osteomyelitis is generally rare compared with spine or joint involvement (6). The present case was unusual with respect to several points. PExp involved a long bone which was previously apparently unaffected. Furthermore, osteomyelitis occurred without obvious initial osteoarticular TB localization. The emergence of a new lesion in spite of appropriate antituberculous therapy should suggest the presence of PExp, the localization of which may be variable. Corticosteroid therapy may be useful in such a situation, but requires further evaluation since evidence of ef® cacy is lacking.Bacterial pili have been shown to be an important virulence factor for urinary tract infections. In this report we relate the results of studies which evaluated the influence of antipili antibody on the susceptibility of rats to ascending pyelonephritis and on several antibody-mediated antibacterial mechanisms. Rats immunized with E. coli type 1 pili, and animals infected with E. coli developed antipili antibodies in their serum. Active or passive immunization of rats with pili protected the animals from ascending pyelonephritis. Antipili antibody did not mediate complement-dependent bacteriolysis, opsonophagocytosis or promote more rapid intravascular clearance of injected E. coli. Humoral immunity to pili did, however, effectively inhibit bacterial adherence to epithelial cells. These studies indicate that type 1 E. coli pili are immunogenic and that antipili antibodies afford protection from ascending pyelonephritis. They suggest further that a mechanism of protection is inhibition of bacterial adherence.