Ulrika Ransjö

A prospective study of infections in burn patients

In a 3-year prospective study, all infections presenting in the burns unit of a university hospital were registered in a specially designed database. Two-hundred and thirty adult patients were included. Eighty-three patients had in all 176 infections, giving an infection rate of 48 per 1000 patient days including both nosocomial and community-acquired infections. Thirty-five blood-stream infections (BSI) occurred in 22 patients; most common micro-organisms were coagulase-negative staphylococci and methicillin-sensitive Staphylococcus aureus. The device-specific BSI rate was 6 per 1000 central venous catheter days, which is low compared to other burn units. The pneumonia rate was 41 per 1000 ventilator days. Seventy-two patients had 107 burn wound infections. Antibiotics were given to only 50% of the burn patients, including 96% of the patients with infection and 26% of those without infection. Most frequently used antimicrobials were cloxacillin, penicillin and gentamicin. The antibiotic resistance rates were low, and multi-resistant bacteria or fungi were rare. The database can be used to evaluate the effects of changes in burn treatment, staffing and design of burn units, and antimicrobial resistance development in relation to antibiotic usage.

Rotavirus infections in newborns: an epidemiological and clinical study

An outbreak of rotavirus infections among newborns at Karolinska Hospital, Stockholm, which has been going on for greater than 2 years has been followed with clinical and epidemiological investigations. About one third of the babies born in the hospital were infected at the age of 3 days. The clinical symptoms were mild, 8.8% of the rotavirus positive babies had loose stools compared to 1.9% of those who did not excrete the virus. An epidemiological survey in the neonatal intensive care unit suggested that rotavirus was introduced into the unit by babies admitted from the obstetric wards. The main reservoir of rotavirus was the babies and rotavirus was not found among staff or mothers. In the beginning hygienic measures seemed to be effective but after some weeks the colonization rate again increased. Electropherotyping of samples collected during different periods showed that one single rotavirus electropherotype belonging to the subgroup 1 of human rotavirus was found throughout the outbreak.

Hospital outbreak control requires joint efforts from hospital management, microbiology and infection control

An outbreak of multidrug-resistant Klebsiella pneumoniae producing the extended-spectrum beta-lactamase CTX-M15 affected 247 mainly elderly patients in more than 30 wards in a 1000-bedded swedish teaching hospital between May 2005 and August 2007. A manual search of the hospital administrative records for possible contacts between cases in wards and outpatient settings revealed a complex chain of transmission. Faecal screening identified twice as many cases as cultures from clinical samples. Transmission occurred by direct and indirect patient-to-patient contact, facilitated by patient overcrowding. Interventions included formation of a steering group with economic power, increased bed numbers, better compliance with alcohol hand disinfection and hospital dress code, better hand hygiene for patients and improved cleaning. The cost of the interventions was estimated to be euro3 million. Special infection control policies were not necessary, but resources were needed to make existing policies possible to follow, and for educational efforts to improve compliance.

Mechanical bowel preparation does not affect the intramucosal bacterial colony count

PurposeThe aim of this study was to determine if mechanical bowel preparation (MBP) influences the intramucosal bacterial colony count in the colon.Materials and methodsMacroscopically normal colon mucosa was collected from 37 patients (20 with and 17 without MBP) who were undergoing elective colorectal surgery at three hospitals. The biopsies were processed and cultured in the same laboratory. Colony counts of the common pathogens Escherichia coli and Bacteroides as well as of total bacteria were conducted. The study groups were comparable with regard to age, gender, antibiotics use, diagnosis and type of resection.ResultsMBP did not influence the median colony count of E. coli, Bacteroides or total bacteria in our study.ConclusionsMBP did not affect the intramucosal bacterial count in this study. Further studies are suggested to confirm these findings.

Long-term Antibiotic Resistance Surveillance of Gram-negative Pathogens Suggests that Temporal Trends can be Used as a Resistance Warning System

Antibiotic resistance among Gram-negative bacteria and antibiotic consumption were investigated at the Karolinska Hospital, Stockholm, Sweden over a 12-y period. The investigation showed an increase in ciprofloxacin resistance of Escherichia coli from 0% in 1991 to 7% in 1997 and to 11% in 1999. Resistance among Pseudomonas aeruginosa isolates to ciprofloxacin increased from 2.5% in 1991 to 9.0% in 1997 and to 13% in 1999. Resistance levels for norfloxacin showed the same high statistical significance in terms of the temporal trend. A more detailed analysis showed higher resistance against norfloxacin in specific wards. Relationships between antibiotic use and antibiotic susceptibility showed different patterns. The increased ciprofloxacin resistance of E. coli and P. aeruginosa during the study period was paralleled by an increased consumption of quinolones. During the 12-y study period the total use of cephalosporins increased 2.5-fold, while the levels of E. coli resistance to cefuroxime and cefotaxime remained stable. A third pattern was seen with trimethoprim-sulfamethoxazole, namely increasing resistance of E. coli as the use of trimethoprim-sulfamethoxazole declined. The analysis of resistance levels and antibiotic consumption in the present study suggests different mechanisms for the increased resistance. The significant trend of increased resistance to antibiotics over time constitutes an important warning system.

Infection prevention and control interventions in the first outbreak of methicillin-resistant Staphylococcus aureus infections in an equine hospital in Sweden

BackgroundThe first outbreak of methicillin-resistant Staphylococcus aureus (MRSA) infection in horses in Sweden occurred in 2008 at the University Animal Hospital and highlighted the need for improved infection prevention and control. The present study describes interventions and infection prevention control in an equine hospital setting July 2008 - April 2010.MethodThis descriptive study of interventions is based on examination of policy documents, medical records, notes from meetings and cost estimates. MRSA cases were identified through clinical sampling and telephone enquiries about horses post-surgery. Prospective sampling in the hospital environment with culture for MRSA and genotyping of isolates by spa-typing and pulsed-field gel electrophoresis (PFGE) were performed.ResultsInterventions focused on interruption of indirect contact spread of MRSA between horses via staff and equipment and included: Temporary suspension of elective surgery; and identification and isolation of MRSA-infected horses; collaboration was initiated between authorities in animal and human public health, human medicine infection control and the veterinary hospital; extensive cleaning and disinfection was performed; basic hygiene and cleaning policies, staff training, equipment modification and interior renovation were implemented over seven months.Ten (11%) of 92 surfaces sampled between July 2008 and April 2010 tested positive for MRSA spa-type 011, seven of which were from the first of nine sampling occasions. PFGE typing showed the isolates to be the outbreak strain (9 of 10) or a closely related strain. Two new cases of MRSA infection occurred 14 and 19 months later, but had no proven connections to the outbreak cases.ConclusionsCollaboration between relevant authorities and the veterinary hospital and formation of an infection control committee with an executive working group were required to move the intervention process forward. Support from hospital management and the dedication of staff were essential for the development and implementation of new, improved routines. Demonstration of the outbreak strain in the environment was useful for interventions such as improvement of cleaning routines and interior design, and increased compliance with basic hygienic precautions. The interventions led to a reduction in MRSA-positive samples and the outbreak was considered curbed as no new cases occurred for over a year.

Ventilation, isolators or skin suits: Where should we place our money for infection control?

WHEN the burn unit at Uppsala University Hospital was opened in 1968, it was designed after the principles of Colebrook’s classic work (1950). It has 6 single patient isolation rooms with individual air locks and plenum ventilation at 44 air changes per hour. During every visit to an isolation room staff wore full operating room dress with a sterile cotton gown, cap, mask, sterile gloves and shoe covers. Despite these costly and cumbersome efforts, the crosscolonization rate in the burn patients with Staphylococcus aureus soon rose to above 70 per cent (Hambraeus, 1973a). This rate is as high as that found in bum patients nursed in conventional wards (Cason et al., 1966). Experiments with airborne tracer particles showed that the spread of S. aureus between isolation rooms was primarily airborne in less than 0.5 per cent of the cases (Hambraeus, 1973b). S. aureus from other patients, found in the air of a room, were mainly carried on nurses’ clothes and redispersed from the clothes when the nurses moved (Hambraeus, 1973c), a finding which has also been confirmed in general wards (Lidwell et al., 1975). The purpose of this investigation was to evaluate attempts to prevent cross-colonization between bum patients via clothes.

Antibiotic Usage in Surgery in a Large Teaching Hospital

A prevalence study of the antibiotic usage in the surgical departments at the Karolinska Hospital, Stockholm, showed that 126/517 hospitalized patients (24%) received antibiotics and that 100/306 operated patients (33%) received antibiotics. 44 (44%) of the operated patients were given their antibiotics as prophylaxis and 46 (37%) of all patients receiving antibiotics were given them as prophylaxis. Antibiotics were administered intravenously to 35 (28%) patients, orally to 75 (60%), and topically to 16 patients (13%) (eye department only). The most commonly used drugs in prophylaxis were isoxazolylpenicillins and trimethoprim-sulphonamide while cephalosporins accounted for a minor part. In therapy the most commonly used drug was isoxazolylpenicillin, followed by ampicillin derivatives, metronidazole, tetracyclines, trimethoprim-sulphonamide and cephalosporins. The pattern of antibiotic usage differed markedly between departments.