Joost Hopman

Global outbreak of severe Mycobacterium chimaera disease after cardiac surgery: a molecular epidemiological study

BACKGROUNDnSince 2013, over 100 cases of Mycobacterium chimaera prosthetic valve endocarditis and disseminated disease were notified in Europe and the USA, linked to contaminated heater-cooler units (HCUs) used during cardiac surgery. We did a molecular epidemiological investigation to establish the source of these patients disease.nnnMETHODSnWe included 24 M chimaera isolates from 21 cardiac surgery-related patients in Switzerland, Germany, the Netherlands, and the UK, 218 M chimaera isolates from various types of HCUs in hospitals, from LivaNova (formerly Sorin; London, UK) and Maquet (Rastatt, Germany) brand HCU production sites, and unrelated environmental sources and patients, as well as eight Mycobacterium intracellulare isolates. Isolates were analysed by next-generation whole-genome sequencing using Illumina and Pacific Biosciences technologies, and compared with published M chimaera genomes.nnnFINDINGSnPhylogenetic analysis based on whole-genome sequencing of 250 isolates revealed two major M chimaera groups. Cardiac surgery-related patient isolates were all classified into group 1, in which all, except one, formed a distinct subgroup. This subgroup also comprised isolates from 11 cardiac surgery-related patients reported from the USA, most isolates from LivaNova HCUs, and one from their production site. Isolates from other HCUs and unrelated patients were more widely distributed in the phylogenetic tree.nnnINTERPRETATIONnHCU contamination with M chimaera at the LivaNova factory seems a likely source for cardiothoracic surgery-related severe M chimaera infections diagnosed in Switzerland, Germany, the Netherlands, the UK, the USA, and Australia. Protective measures and heightened clinician awareness are essential to guarantee patient safety.nnnFUNDINGnPartly funded by the EU Horizon 2020 programme, its FP7 programme, the German Center for Infection Research (DZIF), the Swiss National Science Foundation, the Swiss Federal Office of Public Health, and National Institute of Health Research Oxford Health Protection Research Units on Healthcare Associated Infection and Antimicrobial Resistance.

Preparedness of institutions around the world for managing patients with Ebola virus disease: an infection control readiness checklist

BackgroundIn response to global concerns about the largest Ebola virus disease (EVD), outbreak to-date in West Africa documented healthcare associated transmission and the risk of global spread, the International Society of Chemotherapy (ISC) Infection Control Working Group created an Ebola Infection Control Readiness Checklist to assess the preparedness of institutions around the globe. We report data from the electronic checklist that was disseminated to medical professionals from October to December 2014 and identify action needed towards better preparedness levels.FindingsData from 192 medical professionals (one third from Africa) representing 125 hospitals in 45 countries around the globe were obtained through a specifically developed electronic survey. The survey contained 76 specific questions in 7 major sections: Administrative/operational support; Communications; Education and audit; Human resources, Supplies, Infection Prevention and Control practices and Clinical management of patients. The majority of respondents were infectious disease specialists/infection control consultants/clinical microbiologists (75; 39xa0%), followed by infection control professionals (59; 31xa0%) and medical doctors of other specialties (17; 9xa0%). Nearly all (149; 92xa0%) were directly involved in Ebola preparedness activities. Whilst, 54xa0% indicated that their hospital would need to handle suspected and proven Ebola cases, the others would subsequently transfer suspected cases to a specialized centre.ConclusionThe results from our survey reveal that the general preparedness levels for management of potentially suspected cases of Ebola virus disease is only partially adequate in hospitals. Hospitals designated for admitting EVD suspected and proven patients had more frequently implemented Infection Control preparedness activities than hospitals that would subsequently transfer potential EVD cases to other centres. Results from this first international survey provide a framework for future efforts to improve hospital preparedness worldwide.

Reduced rate of intensive care unit acquired gram-negative bacilli after removal of sinks and introduction of 'water-free' patient care

BackgroundSinks in patient rooms are associated with hospital-acquired infections. The aim of this study was to evaluate the effect of removal of sinks from the Intensive Care Unit (ICU) patient rooms and the introduction of ‘water-free’ patient care on gram-negative bacilli colonization rates.MethodsWe conducted a 2-year pre/post quasi-experimental study that compared monthly gram-negative bacilli colonization rates pre- and post-intervention using segmented regression analysis of interrupted time series data. Five ICUs of a tertiary care medical center were included. Participants were all patients of 18xa0years and older admitted to our ICUs for at least 48xa0h who also received selective digestive tract decontamination during the twelve month pre-intervention or the twelve month post-intervention period. The effect of sink removal and the introduction of ‘water-free’ patient care on colonization rates with gram-negative bacilli was evaluated. The main outcome of this study was the monthly colonization rate with gram-negative bacilli (GNB). Yeast colonization rates were used as a ‘negative control’. In addition, colonization rates were calculated for first positive culture results from cultures taken ≥3, ≥5, ≥7, ≥10 and ≥14xa0days after ICU-admission, rate ratios (RR) were calculated and differences tested with chi-squared tests.ResultsIn the pre-intervention period, 1496 patients (9153 admission days) and in the post-intervention period 1444 patients (9044 admission days) were included. Segmented regression analysis showed that the intervention was followed by a statistically significant immediate reduction in GNB colonization in absence of a pre or post intervention trend in GNB colonization. The overall GNB colonization rate dropped from 26.3 to 21.6 GNB/1000 ICU admission days (colonization rate ratio 0.82; 95%CI 0.67–0.99; Pxa0=xa00.02). The reduction in GNB colonization rate became more pronounced in patients with a longer ICU-Length of Stay (LOS): from a 1.22-fold reduction (≥2xa0days), to a 1.6-fold (≥5xa0days; Pxa0=xa00.002), 2.5-fold (for ≥10xa0days; Pxa0<xa00.001) to a 3.6-fold (≥14xa0days; Pxa0<xa00.001) reduction.ConclusionsRemoval of sinks from patient rooms and introduction of a method of ‘water-free’ patient care is associated with a significant reduction of patient colonization with GNB, especially in patients with a longer ICU length of stay.

Spread of carbapenem-resistant international clones of Acinetobacter baumannii in Turkey and Azerbaijan: a collaborative study.

Epidemic clones of Acinetobacter baumannii, described as European clones I, II, and III, are associated with hospital epidemics throughout the world. We aimed to determine the molecular characteristics and genetic diversity between European clones I, II, and III from Turkey and Azerbaijan. In this study, a total of 112 bloodstream isolates of carbapenem-resistant Acinetobacter spp. were collected from 11 hospitals across Turkey and Azerbaijan. The identification of Acinetobacter spp. using conventional and sensitivity tests was performed by standard criteria. Multiplex polymerase chain reaction (PCR) was used to detect OXA carbapenemase-encoding genes (blaOXA-23-like, blaOXA-24-like, blaOXA-51-like, and blaOXA-58-like). Pulsed-field gel electrophoresis (PFGE) typing was used to investigate genetic diversity. The blaOXA-51-like gene was present in all 112 isolates, 75 (67xa0%) carried blaOXA-23-like, 7 (6.2xa0%) carried blaOXA-58-like genes, and 5 (4.5xa0%) carried blaOXA-24-like genes. With a 90xa0% similarity cut-off value, 15 clones and eight unique isolates were identified. The largest clone was cluster D, with six subtypes. Isolates from clusters D and I were widely spread in seven different geographical regions throughout Turkey. However, F cluster was found in the northern and eastern regions of Turkey. EU clone I was grouped within J cluster with three isolates found in Antalya, Istanbul, and Erzurum. EU clone II was grouped in the U cluster with 15 isolates and found in Kayseri and Diyarbakır. The blaOXA-24-like gene in carbapenemases was identified rarely in Turkey and has been reported for the first time from Azerbaijan. Furthermore, this is the first multicenter study in Turkey and Azerbaijan to identify several major clusters belonging to European clones I and II of A. baumannii.

0.2% chlorhexidine acetate as skin disinfectant prevents skin lesions in extremely preterm infants: a preliminary report.

Objective The skin disinfectant ‘0.5% chlorhexidine gluconate in 70% alcohol’ (0.5% CHG-70% alc) may cause skin lesions in extremely preterm infants (gestational age <26u2009weeks). In April 2013, 0.2% chlorhexidine gluconate solution in acetate (0.2% CHG-acetate) was introduced as skin disinfectant for extremely preterm infants in our neonatal intensive care units. We aimed to compare the incidence of skin lesions and central line-associated bloodstream infection (CLABSI) among extremely preterm infants when using 0.5% CHG-70% alc and 0.2% CHG-acetate. Design Retrospective pre-post comparison cohort study. Patients All electronic patient records of extremely preterm infants born between January 2011–March 2013 (‘0.5% CHG-70% alc’ cohort) and April 2013–October 2015 (‘0.2% CHG-acetate’ cohort) were reviewed. Main outcome measures The incidence of skin lesions and CLABSI. Skin lesions were defined as the presence of erythema, blisters, excoriation, oedema or induration. CLABSI was defined according to the definition of the US Centers for Disease Control and Prevention. Results The incidence of skin lesions was 22% (95% CI 11% to 37%) in the ‘0.5% CHG-70% alc’ cohort (n=41) and 5% (95% CI 1% to 15%; p=0.02) in the ‘0.2% CHG-acetate’ cohort (n=41). The incidence of CLABSI was the same in both groups (28%; 95%u2009CI 14% to 46% in ‘0.5% CHG-70% alc’ vs 27%; 95%u2009CI 14% to 44% in ‘0.2% CHG-acetate’; p=0.98). Conclusions Using 0.2% CHG-acetate as skin disinfectant in extremely preterm infants resulted in statistically significant reduction of skin lesions, without increasing the risk of CLABSI as compared with 0.5% CHG-70% alc.

Efficacy of chlorine solutions used for hand hygiene and gloves disinfection in Ebola settings: a systematic review.

Chlorine solutions (CS) have been widely used for hand hygiene (HH) in the West African countries affected by the current Ebola outbreak. However, no HH guidelines recommend the use of CS for HH practices.

Decolonisation of meticillin-resistant Staphylococcus aureus (MRSA) carriage in adopted children with cleft lip and palate

This study aimed to determine the percentage success and to investigate influencing factors of meticillin-resistant Staphylococcus aureus (MRSA) decolonisation treatment in children with cleft lip and/or palate (CLP) who are adopted to The Netherlands. This was a historic cohort study in nine Dutch hospitals with a CLP treatment centre of children who were adopted from abroad in 2005-2012 who had CLP and MRSA carriage upon arrival in The Netherlands. A total of 55 adopted children with CLP and MRSA carriage were eligible for the study. Most children were adopted from China and had cheilognathopalatoschisis. Fourteen children were not treated for MRSA carriage, of whom six became MRSA-negative spontaneously. Forty-one children received decolonisation treatment (either topical treatment and disinfectant body wash or these combined with oral antibiotics). Overall, eighteen children [44%; 95% confidence interval (CI) 29-59%] became MRSA-negative after treatment. Treatment success was higher (56%; 95% CI 33-77%) in the group of children treated according to the Dutch guideline for treatment of MRSA carriage (odds ratio=6.1, 95% CI 4.4-26.4; p=0.017). In conclusion, MRSA decolonisation treatment in adopted children with CLP was successful in 44% of cases and the success percentage was higher in the group of children treated in accordance with the national guideline for treatment of MRSA carriage. However, given the percentage of children who turned MRSA-negative without treatment, waiting for spontaneous clearance of MRSA carriage can be advised after careful consideration of the benefits and risks of decolonisation treatment.

Long-term Staphylococcus aureus decolonization in patients on home parenteral nutrition: study protocol for a randomized multicenter trial

BackgroundPatients with long-term intestinal failure are usually treated by means of home parenteral nutrition (HPN) where they administer their nutritional formulation intravenously via a central venous access device (mostly a catheter). This implies that such patients are exposed to a lifelong risk of developing Staphylococcus aureus bacteremia (SAB). SAB poses a threat to both catheter and patient survival and may lead to frequent hospitalization and a permanent loss of vascular access. In other clinical settings, S. aureus carriage eradication has been proven effective in the prevention of S. aureus infections. Unfortunately, there is a complete lack of evidence in HPN support on the most effective and safe S. aureus decolonization strategy in S. aureus carriers. We hypothesized that long-term S. aureus decolonization in HPN patients can only be effective if it is aimed at the whole body (nasal and extra-nasal) and is given chronically or repeatedly on indication. Besides this, we believe that S. aureus carriage among caregivers, who are in close contact with the patient, are of great importance in the S. aureus transmission routes.Methods/designThe CARRIER trial is a randomized, open-label, multicenter clinical trial in Dutch and Danish hospitals that treat patients on HPN. A total of 138 adult HPN patients carrying S. aureus will be randomly assigned to a search and destroy (SD) strategy, a quick and short, systemic antibiotic treatment, or a continuous suppression (CS) strategy, a repeated chronic topical antibiotic treatment. The primary outcome measure is the proportion of patients in whom S. aureus is totally eradicated during a 1-year period. Secondary outcomes are time to successful eradication, long-term antimicrobial resistance, adverse events, patient compliance, incidence of (S. aureus) infections, catheter removals, mortality rates, S. aureus transmission routes, quality of life, and health care costs.DiscussionThe CARRIER trial is designed to identify the most safe and effective long-term S. aureus carriage decolonization strategy in HPN patients. This will eventually lead to a better understanding of long-term S. aureus decolonization treatments in general. The results of this study will have a great impact on our daily clinical practice, which eventually may result in less S. aureus-related infections.Trial registrationClinicalTrials.gov; NCT03173053. Registered on 1 June 2017.

Multisite evaluation of environmental cleanliness of high-touch surfaces in intensive care unit patient rooms

HighlightsLarge variations of environmental cleanliness of high‐touch surfaces after discharge cleaning and disinfection are identified in ICU patient rooms in Brazil, Canada, the Netherlands and the US.Major differences exist in used cleaning and disinfection protocols, detergents and disinfectants.Monitoring of staff cleaning compliance using rapid methods such as reflective surface markers or adenosine triphosphate with ongoing staff feedback can ensure optimal cleaning and disinfection of high touch surfaces.The total aerobic count on high‐touch surfaces provided limited value for routine cleanliness monitoring and should be used selectively during outbreaks. &NA; The efficacy of discharge cleaning and disinfection of high‐touch surfaces of intensive care unit patient rooms in Brazil, Canada, the Netherlands, and the United States was evaluated and the effect of an educational intervention was determined. Significant site‐to‐site differences in cleaning regimens and baseline cleanliness levels were observed using ATP levels, colony‐forming units, and reflective surface marker removal percent pass rates. An educational intervention that includes rapid feedback of the ATP measurements could significantly improve the quality of the cleaning and disinfection regimens.

Automatic discontinuation of isolation precautions and electronic alerts of MDRO positive patients: safe or sorry?

The Netherlands have a low prevalence of Multi drug Resistant organisms (MDRO), in part due to their national guideline concerning MDRO carriers. Apart from being flagged in Electronic Health Records, immediate isolation precautions must be taken if the last MDRO positive culture is less than 1 year ago. No clear guidance is given on duration and termination of electronic alerts and isolation precautions for MDRO positive patients.