Gabriel Birgand

Duration of colonization by extended-spectrum β-lactamase-producing Enterobacteriaceae after hospital discharge

BACKGROUND The duration of gastrointestinal colonization with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) may play a major role in the spread of these organisms. We evaluated the time to, and factors associated with, ESBL-E clearance after hospital discharge. METHODS We retrospectively reviewed prospective surveillance results obtained over 14 years in a 1,000-bed hospital. The surveillance collected demographic, hospital stay, microbiologic, and outcome data. An automatic alert system identified readmitted patients with prior ESBL-E carriage. ESBL-E clearance was defined as a negative rectal screening sample at readmission with no new positive clinical sample during the stay. Variables associated with ESBL-E clearance were identified using a Cox model. RESULTS We included 1,884 patients with 2,734 admissions. Four hundred forty-eight patients with readmission screening formed the basis for the study. Of 448 patients with 1 to 16 readmissions, 180 (40%) were persistent carriers. The median time to ESBL-E clearance was 6.6 months. Variables independently associated with clearance was having the first positive culture in a screening sample only (adjusted hazard ratio, 1.31; 95% confidence interval, 1.02-1.69; P = .04) and period 2005-2010 (hazard ratio, 1.88; 95% confidence interval, 1.33-2.67; P < .01). CONCLUSION We found a long duration of ESBL-E carriage after hospital discharge. An automatic alert system was useful for identifying, screening, and isolating previous ESBL-E carriers.

Agreement among Healthcare Professionals in Ten European Countries in Diagnosing Case-Vignettes of Surgical-Site Infections

Objective Although surgical-site infection (SSI) rates are advocated as a major evaluation criterion, the reproducibility of SSI diagnosis is unknown. We assessed agreement in diagnosing SSI among specialists involved in SSI surveillance in Europe. Methods Twelve case-vignettes based on suspected SSI were submitted to 100 infection-control physicians (ICPs) and 86 surgeons in 10 European countries. Each participant scored eight randomly-assigned case-vignettes on a secure online relational database. The intra-class correlation coefficient (ICC) was used to assess agreement for SSI diagnosis on a 7-point Likert scale and the kappa coefficient to assess agreement for SSI depth on a three-point scale. Results Intra-specialty agreement for SSI diagnosis ranged across countries and specialties from 0.00 (95%CI, 0.00–0.35) to 0.65 (0.45–0.82). Inter-specialty agreement varied from 0.04 (0.00–0.62) in to 0.55 (0.37–0.74) in Germany. For all countries pooled, intra-specialty agreement was poor for surgeons (0.24, 0.14–0.42) and good for ICPs (0.41, 0.28–0.61). Reading SSI definitions improved agreement among ICPs (0.57) but not surgeons (0.09). Intra-specialty agreement for SSI depth ranged across countries and specialties from 0.05 (0.00–0.10) to 0.50 (0.45–0.55) and was not improved by reading SSI definition. Conclusion Among ICPs and surgeons evaluating case-vignettes of suspected SSI, considerable disagreement occurred regarding the diagnosis, with variations across specialties and countries.

Is high consumption of antibiotics associated with Clostridium difficile polymerase chain reaction-ribotype 027 infections in France?

We compared antibiotic consumption between hospitals affected by a strain of Clostridium difficile designated as polymerase chain reaction-ribotype 027 (CD-027) and those unaffected during an outbreak in northern France. The mean consumption of several beta-lactams, amikacin, and fluoroquinolones was high in affected hospitals (P < .05). However, only levofloxacin and imipenem remained associated with emerging CD-027 in the multivariate analysis, suggesting that those antibiotics should be better targeted by prevention campaigns.

Measures to eradicate multidrug-resistant organism outbreaks: how much do they cost?

This study aimed to assess the economic burden of infection control measures that succeeded in eradicating multidrug-resistant organisms (MDROs) in emerging epidemic contexts in hospital settings. The MEDLINE, EMBASE and Ovid databases were systematically interrogated for original English-language articles detailing costs associated with strict measures to eradicate MDROs published between 1 January 1974 and 2 November 2014. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Overall, 13 original articles were retrieved reporting data on several MDROs, including glycopeptide-resistant enterococci (n = 5), carbapenemase-producing Enterobacteriacae (n = 1), methicillin-resistant Staphylococcus aureus (n = 5), and carbapenem-resistant Acinetobacter baumannii (n = 2). Overall, the cost of strict measures to eradicate MDROs ranged from €285 to €57 532 per positive patient. The major component of these overall costs was related to interruption of new admissions, representing €2466 to €47 093 per positive patient (69% of the overall mean cost; range, 13-100%), followed by mean laboratory costs of €628 to €5849 (24%; range, 3.3-56.7%), staff reinforcement costs of €6204 to €148 381 (22%; range, 3.3-52%), and contact precautions costs of €166 to €10 438 per positive patient (18%; range, 0.7-43.3%). Published data on the economic burden of strict measures to eradicate MDROs are limited, heterogeneous, and weakened by several methodological flaws. Novel economic studies should be performed to assess the financial impact of current policies, and to identify the most cost-effective strategies to eradicate emerging MDROs in healthcare facilities.

Time-to-positivity-based discrimination between Enterobacteriaceae, Pseudomonas aeruginosa and strictly anaerobic Gram-negative bacilli in aerobic and anaerobic blood culture vials.

Time-to-positivity (TTP) of first positive blood cultures growing Gram-negative bacilli (GNB) was investigated. When anaerobic vials were positive first, TTP ≤ 18 h differentiated Enterobacteriaceae from strict anaerobic Gram-negative bacilli (PPV 98.8%). When the aerobic ones were first, TTP ≤ 13 h differentiated Enterobacteriaceae from Pseudomonas aeruginosa and other GNB (PPV 80.8%).

Capacity of English NHS hospitals to monitor quality in infection prevention and control using a new European framework: a multilevel qualitative analysis

Objective (1) To assess the extent to which current English national regulations/policies/guidelines and local hospital practices align with indicators suggested by a European review of effective strategies for infection prevention and control (IPC); (2) to examine the capacity of local hospitals to report on the indicators and current use of data to inform IPC management and practice. Design A national and local-level analysis of the 27 indicators was conducted. At the national level, documentary review of regulations/policies/guidelines was conducted. At the local level data collection comprised: (a) review of documentary sources from 14 hospitals, to determine the capacity to report performance against these indicators; (b) qualitative interviews with 3 senior managers from 5 hospitals and direct observation of hospital wards to find out if these indicators are used to improve IPC management and practice. Setting 2 acute English National Health Service (NHS) trusts and 1 NHS foundation trust (14 hospitals). Participants 3 senior managers from 5 hospitals for qualitative interviews. Primary and secondary outcome measures As primary outcome measures, a ‘Red-Amber-Green’ (RAG) rating was developed reflecting how well the indicators were included in national documents or their availability at the local organisational level. The current use of the indicators to inform IPC management and practice was also assessed. The main secondary outcome measure is any inconsistency between national and local RAG rating results. Results National regulations/policies/guidelines largely cover the suggested European indicators. The ability of individual hospitals to report some of the indicators at ward level varies across staff groups, which may mask required improvements. A reactive use of staffing-related indicators was observed rather than the suggested prospective strategic approach for IPC management. Conclusions For effective patient safety and infection prevention in English hospitals, routine and proactive approaches need to be developed. Our approach to evaluation can be extended to other country settings.

Overcoming the obstacles of implementing infection prevention and control guidelines

Reasons for a successful or unsuccessful implementation of infection prevention and control (IPC) guidelines are often multiple and interconnected. This article reviews key elements from the national to the individual level that contribute to the success of the implementation of IPC measures and gives perspectives for improvement. Governance approaches, modes of communication and formats of guidelines are discussed with a view to improve collaboration and transparency among actors. The culture of IPC influences practices and varies according to countries, specialties and healthcare providers. We describe important contextual aspects, such as relationships between actors and resources and behavioural features including professional background or experience. Behaviour change techniques providing goal-setting, feedback and action planning have proved effective in mobilizing participants and may be key to trigger social movements of implementation. The leadership of international societies in coordinating actions at international, national and institutional levels using multidisciplinary approaches and fostering collaboration among clinical microbiology, infectious diseases and IPC will be essential for success.

Comparison of governance approaches for the control of antimicrobial resistance: Analysis of three European countries

Policy makers and governments are calling for coordination to address the crisis emerging from the ineffectiveness of current antibiotics and stagnated pipe-line of new ones – antimicrobial resistance (AMR). Wider contextual drivers and mechanisms are contributing to shifts in governance strategies in health care, but are national health system approaches aligned with strategies required to tackle antimicrobial resistance? This article provides an analysis of governance approaches within healthcare systems including: priority setting, performance monitoring and accountability for AMR prevention in three European countries: England, France and Germany. Advantages and unresolved issues from these different experiences are reported, concluding that mechanisms are needed to support partnerships between healthcare professionals and patients with democratized decision-making and accountability via collaboration. But along with this multi-stakeholder approach to governance, a balance between regulation and persuasion is needed.

Compliance with clothing regulations and traffic flow in the operating room: a multi-centre study of staff discipline during surgical procedures

This multi-centre study assessed operating room (OR) staff compliance with clothing regulations and traffic flow during surgical procedures. Of 1615 surgical attires audited, 56% respected the eight clothing measures. Lack of compliance was mainly due to inappropriate wearing of jewellery (26%) and head coverage (25%). In 212 procedures observed, a median of five people [interquartile range (IQR) 4-6] were present at the time of incision. The median frequency of entries to/exits from the OR was 10.6/h (IQR 6-29) (range 0-93). Reasons for entries to/exits from the OR were mainly to obtain materials required in the OR (N=364, 44.5%). ORs with low compliance with clothing regulations tended to have higher traffic flows, although the difference was not significant (P=0.12).

Universal or targeted approach to prevent the transmission of extended-spectrum beta-lactamase-producing Enterobacteriaceae in intensive care units: a cost-effectiveness analysis

Objective Several control strategies have been used to limit the transmission of multidrug-resistant organisms in hospitals. However, their implementation is expensive and effectiveness of interventions for the control of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) spread is controversial. Here, we aim to assess the cost-effectiveness of hospital-based strategies to prevent ESBL-PE transmission and infections. Design Cost-effectiveness analysis based on dynamic, stochastic transmission model over a 1-year time horizon. Patients and setting Patients hospitalised in a hypothetical 10-bed intensive care unit (ICU) in a high-income country. Interventions Base case scenario compared with (1) universal strategies (eg, improvement of hand hygiene (HH) among healthcare workers, antibiotic stewardship), (2) targeted strategies (eg, screening of patient for ESBL-PE at ICU admission and contact precautions or cohorting of carriers) and (3) mixed strategies (eg, targeted approaches combined with antibiotic stewardship). Main outcomes and measures Cases of ESBL-PE transmission, infections, cost of intervention, cost of infections, incremental cost per infection avoided. Results In the base case scenario, 15 transmissions and five infections due to ESBL-PE occurred per 100 ICU admissions, representing a mean cost of €94 792. All control strategies improved health outcomes and reduced costs associated with ESBL-PE infections. The overall costs (cost of intervention and infections) were the lowest for HH compliance improvement from 55%/60% before/after contact with a patient to 80%/80%. Conclusions Improved compliance with HH was the most cost-saving strategy to prevent the transmission of ESBL-PE. Antibiotic stewardship was not cost-effective. However, adding antibiotic restriction strategy to HH or screening and cohorting strategies slightly improved their effectiveness and may be worthy of consideration by decision-makers.