Incorporation of skin preparation guidelines in local surgical facility protocols: what kind of barriers does it face? A multi-centre study in France.

BACKGROUND: Surgical site infection (SSI) is the most frequent and severe adverse event after surgery. Among preventive measures, the preoperative skin preparation (PSP) is known to be heterogeneously implemented in routine practice. A prerequisite would be the actual incorporation of guidelines in French surgical local protocols. AIM: To assess whether PSP recommendations have been incorporated in local protocols and to identify the reasons for the non-incorporation. METHODS: An online survey was proposed to all infection control teams (ICTs) in facilities participating in the French national surveillance and prevention of SSI network Spicmi. The reference recommendations were based on the French Society for Hospital Hygiene guidelines. FINDINGS: In all, 485 healthcare facilities completed the questionnaire. The incorporation of recommendations in the facility protocol varied between 30% and 98% according to the recommendation. The measures most frequently incorporated were antisepsis with an alcoholic product and cessation of systematic hair removal. The least frequently incorporated were the use of plain soap for preoperative shower and the non-compulsory skin cleaning in the operating room. Barriers reported were either specific to PSP (e.g. 'Concern about an increase of SSI', 'Scepticism about recommendations', 'Force of habit') or non-specific (e.g. 'The protocol not yet due to be updated'). CONCLUSION: We suggest that although some major prevention measures have been incorporated in the local protocol of most facilities, local protocols still frequently include some non-evidence based former recommendations. Communication about evolution of SSI rates, diffusion of guidelines by learned societies, and exchange with judiciary experts could make clear the conditions for applying recommendations.

Awareness among French healthcare workers of the transmission of multidrug resistant organisms: a large cross-sectional survey.

Background: Much effort has been made over the last two decades to educate and train healthcare professionals working on antimicrobial resistance in French hospitals. However, little has been done in France to assess perceptions, attitudes and knowledge regarding multidrug resistant organisms (MDROs) and, more globally, these have never been evaluated in a large-scale population of medical and non-medical healthcare workers (HCWs). Our aim was to explore awareness among HCWs by evaluating their knowledge of MDROs and the associated control measures, by comparing perceptions between professional categories and by studying the impact of training and health beliefs. Methods: A multicentre cross-sectional study was conducted in 58 randomly selected French healthcare facilities with questionnaires including professional and demographic characteristics, and knowledge and perception of MDRO transmission and control. A knowledge score was calculated and used in a logistic regression analysis to identify factors associated with higher knowledge of MDROs, and the association between knowledge and perception. Results: Between June 2014 and March 2016, 8716/11,753 (participation rate, 74%) questionnaires were completed. The mean knowledge score was 4.7/8 (SD: 1.3) and 3.6/8 (SD: 1.4) in medical and non-medical HCWs, respectively. Five variables were positively associated with higher knowledge: working in a university hospital (adjusted odds ratio, 1.41, 95% CI 1.16-1.70); age classes 26-35 years (1.43, 1.23-1.6) and 36-45 years (1.19, 1.01-1.40); medical professional status (3.7, 3.09-4.44), working in an intensive care unit (1.28, 1.06-1.55), and having been trained on control of antimicrobial resistance (1.31, 1.16-1.48). After adjustment for these variables, greater knowledge was significantly associated with four cognitive factors: perceived susceptibility, attitude toward hand hygiene, self-efficacy, and motivation. Conclusions: We found a low level of MDRO awareness and knowledge of associated control measures among French HCWs. Training on hand hygiene and measures to control MDRO spread may be helpful in shaping beliefs and perceptions on MDRO control among other possible associated factors. Messages should be tailored to professional status and their perception. Other approaches should be designed, with more effective methods of training and cognitive interventions. Trial registration: Clinical Trials.gov NCT02265471. Registered 16 October 2014 - Retrospectively registered.

Impact of participation in a surgical site infection surveillance network: results from a large international cohort study.

BACKGROUND: Surveillance of surgical site infections (SSIs) is a core component of effective infection control practices, though its impact has not been quantified on a large scale. AIM: To determine the time-trend of SSI rates in surveillance networks. METHODS: SSI surveillance networks provided procedure-specific data on numbers of SSIs and operations, stratified by hospitals' year of participation in the surveillance, to capture length of participation as an exposure. Pooled and procedure-specific random-effects Poisson regression was performed to obtain yearly rate ratios (RRs) with 95% confidence intervals (CIs), and including surveillance network as random intercept. FINDINGS: Of 36 invited networks, 17 networks from 15 high-income countries across Asia, Australia and Europe participated in the study. Aggregated data on 17 surgical procedures (cardiovascular, digestive, gynaecological-obstetrical, neurosurgical, and orthopaedic) were collected, resulting in data concerning 5,831,737 operations and 113,166 SSIs. There was a significant decrease in overall SSI rates over surveillance time, resulting in a 35% reduction at the ninth (final) included year of surveillance (RR: 0.65; 95% CI: 0.63-0.67). There were large variations across procedure-specific trends, but strong consistent decreases were observed for colorectal surgery, herniorrhaphy, caesarean section, hip prosthesis, and knee prosthesis. CONCLUSION: In this large, international cohort study, pooled SSI rates were associated with a stable and sustainable decrease after joining an SSI surveillance network; a causal relationship is possible, although unproven. There was heterogeneity in procedure-specific trends. These findings support the pivotal role of surveillance in reducing infection rates and call for widespread implementation of hospital-based SSI surveillance in high-income countries.

New insights on antimicrobial efficacy of copper surfaces in the healthcare environment: a systematic review.

OBJECTIVES: Hospital-acquired infections (HAIs) are a major public health issue. The potential of antimicrobial copper surfaces in reducing HAIs' rates is of interest but remains unclear. We conducted a systematic review of studies assessing the activity of copper surfaces (colony-forming unit (CFU)/surface, both in vitro and in situ) as well as clinical studies. In vitro study protocols were analysed through a tailored checklist developed specifically for this review, in situ studies and non-randomized clinical studies were assessed using the ORION (Outbreak Reports and Intervention studies Of Nosocomial infection) checklist and randomized clinical studies using the CONSORT guidelines. METHODS: The search was conducted using PubMed database with the keywords 'copper' and 'surfaces' and 'healthcare associated infections' or 'antimicrobial'. References from relevant articles, including reviews, were assessed and added when appropriate. Articles were added until 30 August 2016. Overall, 20 articles were selected for review including 10 in vitro, eight in situ and two clinical studies. RESULTS: Copper surfaces were found to have variable antimicrobial activity both in vitro and in situ, although the heterogeneity in the designs and the reporting of the results prevented conclusions from being drawn regarding their spectrum and activity/time compared to controls. Copper effect on HAIs incidence remains unclear because of the limited published data and the lack of robust designs. Most studies have potential conflicts of interest with copper industries. CONCLUSIONS: Copper surfaces have demonstrated an antimicrobial activity but the implications of this activity in healthcare settings are still unclear. No clear effect on healthcare associated infections has been demonstrated yet.

Health insurance database for post-discharge surveillance of surgical site infection following arthroplasty.

BACKGROUND: Surgical site infection surveillance (SSI) is important for the improvement of care and patient safety. Most SSI surveillance systems focus on hospital settings, whereas numerous infectious events occur after discharge. AIM: To evaluate the patient care trajectory after discharge, we linked the hospital discharge database and the National Health Insurance Cross-Schemes Information System (NHI-CIS) to trace hip or knee arthroplasty infection (HKAI). METHODS: A retrospective analysis was performed using the permanent 1/97th sample of the whole NHI-CIS database. A total of 1739 patients underwent hip or knee arthroplasty between January 1st, 2011 and December 31st, 2011. Patients rehospitalized for HKAI were detected using a specific published algorithm. Non-rehospitalized HKAI patients were identified using a novel tracking algorithm based on ambulatory care consumption: nurse intervention, antibiotics and bandage purchase. FINDINGS: Of the 1739 studied patients, 20 patients (1.1%) were rehospitalized for HKAI. Fourteen (70%) of the HKAI events occurred within the first two months after surgery, two occurring during the patients' surgical hospital stay. Using ambulatory care data, 10 additional cases were suspected of developing HKAI in the year following their surgery. HKAI incidence rate was then estimated to be 1.76% (95% confidence interval: 1.14-2.38%). CONCLUSION: Although the study sample was limited, we demonstrated that each HKAI occurring after discharge could not be traced by the in-hospital information system alone. This result emphasizes the need for having a passive routine tool for post-discharge surveillance such as the NHI-CIS database.

National point prevalence survey of healthcare-associated infections and antimicrobial use in French home care settings, May to June 2012.

In May and June 2012, a national point prevalence survey (PPS) of healthcare-associated infections (HAIs) and antimicrobial use was conducted among French patients under home-based hospital care (HBHC). Data from 5,954 patients in 179 volunteer HBHC providers were collected. Prevalence of patients with at least one active HAI was 6.8% (95% confidence interval (CI): 6.1­7.4). Prevalence of those receiving at least one antimicrobial agent was 15.2% (95% CI: 14.3­16.1). More than a third (35.5%) of HAIs were HBHC-associated, 56% were imported from a healthcare facility and 8.5% of indeterminate origin. The main infection sites were urinary tract (26.6%), skin and soft tissue (17.6%), surgical site (15%), and pneumonia or other respiratory tract infections (13.5%). In multivariate analysis, three risk factors were associated with HBHC-associated infections: urinary catheter, at least one vascular catheter and a McCabe score 1 or 2. The most frequently isolated microorganism was Staphylococcus aureus (20.7%), 28.1% of them meticillin-resistant. Non-susceptibility to third-generation cephalosporins was reported in 25.3% of Enterobacteriaceae, of which 16.1% were extended spectrum beta-lactamase-producing strains. The most prescribed antimicrobials were fluoroquinolones (16.1%), and third-generation cephalosporins (14.5%). PPS may be a good start in HBHC to obtain information on epidemiology of HAIs and antimicrobial use.

Prolonged delay for controlling KPC-2-producing Klebsiella pneumoniae outbreak: the role of clinical management.

BACKGROUND: Carbapenemase-producing Enterobacteriaceae (CPE) are becoming of immediate concern for infection control policies. Prompt detection of CPE on health care setting admission is crucial to halt the spread of an outbreak. We report a cluster of 13 Klebsiella pneumoniae carbapenemase (KPC)-2-producing K pneumoniae cases in a tertiary care hospital.The objective of this study was to identify contributing factors originating the outbreak. METHODS: An outbreak investigation was conducted using descriptive epidemiology, observation of health care practices, and interviews of management staff. A root cause analysis was performed to identify patent and latent failures of infection control measures using the association of litigation and risk management method. RESULTS: The main patent failure was the delay in identifying KPC-2-producing K pneumoniae carriers. Contributing factors were work and environmental factors: understaffing, lack of predefined protocols, staff members' characteristics, and underlying patients' characteristics. Latent failures were as follows: no promotion of the national guidelines for prevention of CPE transmission, no clear procedure for the management of patients hospitalized abroad, no clear initiative for promoting a culture of quality in the hospital, biologic activity recently outsourced to a private laboratory, and poor communication among hospital members. CONCLUSION: Clinical management should be better promoted to control hospital outbreaks and should include team work and safety culture.

Control of emerging extensively drug-resistant organisms (eXDRO) in France: a survey among infection preventionists from 286 healthcare facilities.

We performed a multicenter survey in May-June 2012 to assess strategies in preventing the spread of emerging extensively drug-resistant organisms (eXDRO), including glycopeptide-resistant enterococci and carbapenemase-producing Enterobacteriaceae, in a convenient sample of French healthcare facilities (HCFs). The collected data included organization and measures to: (1) identify patients at risk for carrying eXDRO, (2) investigate and control sporadic cases or outbreaks, and (3) describe prior 2010-2012 episodes with one or more colonized patients. Of the 286 participating HCFs, 163 (57 %) and 134 (47 %) reported having a specific procedure to detect repatriates or patients hospitalized in foreign countries within the last year, respectively. Among the 97 HCFs with prior at-risk patient management experience, contact precautions, hospitalization in a single room, and screening for eXDRO carriage were quasi-systematically performed (n = 92/97, 95 %). The alleged time between admission and alert ranged from 24 to 48 h after the patient's admission; 203 (71 %) HCFs recommended obtaining three successive negative screening samples to declare a patient free of eXDRO colonization. During the last two years, 64 HCFs (23 %) had to manage at least one eXDRO case, with a total of 20 outbreaks with more than one secondary case. This first national survey shows that French HCFs were not totally ready to control eXDRO spread in 2012. Their previous experiences and capacities in controlling eXDRO outbreaks are quite heterogeneous from one hospital to another. Further researches are needed in order to understand the constraints in applying national guidance.

Surveillance of prosthetic joint infections: international overview and new insights for hospital databases.

Since the US National Nosocomial Infections Surveillance System was implemented in the 1970s, several countries have developed their own surveillance systems, all including surgical site infection (SSI) as a major target. However, the performance of such systems needs to be evaluated further in terms of data quality and cost-effectiveness. The current article presents a literature overview of the main strategies used for SSI surveillance worldwide, focusing on hip and knee arthroplasty infections, and discusses new issues for further development of surveillance databases.

Probable nosocomial transmission of listeriosis in neonates.

Listeria monocytogenes was isolated in two neonates born consecutively in the same hospital in France. The isolates had indistinguishable pulsed-field electrophoresis profiles. Retrospective epidemiological investigations found no evidence of a food-borne or environmental source. Infection control protocols and decontamination processes were in accordance with standard recommendations. The timing of onset of these infections within the same maternity unit, and the similarity of pulsed-field gel electrophoresis profiles suggests cross-infection of L. monocytogenes between the two neonates.

Awareness of standard precautions for 4439 healthcare professionals in 34 institutions in France.

OBJECTIVE: The study objective was to assess the awareness of standard precautions (SP) among healthcare professionals, 1 year after the latest national guidelines were issued. METHODS: A multicenter cross-sectional survey was conducted in 34 volunteer institutions in 2010. Data was collected using an anonymous and self-administered questionnaire. The data was analyzed with a program developed from Epi-Info software. RESULTS: Four thousand four hundred and thirty-nine questionnaires were analyzed. Most respondents were nurses (44.1%) or nurses' aides (26.7%) followed by physicians (3.5%). 25% of respondents had participated in specific PS training in the previous 5 years. The percentage of correct answers for each question ranged from 37.1 to 91%. There was 72.6% of correct answers on hand hygiene but only 7.3% of correct answers on use of appropriate barriers and disposal of needles. 39.3% of respondents gave correct answers to eight or more of the 10 SP questions. The level of knowledge of nurses was higher compared to other professionals. The lowest level of knowledge was observed in long-term care and psychiatric institutions. CONCLUSIONS: The knowledge of healthcare professionals on use of appropriate protective barriers and disposal of needles is still too limited. The survey results should be used to develop adequate and targeted educational interventions.

[NEOCAT, surveillance network of catheter-related bloodstream infections in neonates: 2010 data]. / Surveillance en réseau des bactériémies sur cathéter en néonatologie : résultats 2010 du réseau NEOCAT.

The NEOCAT surveillance network was implemented in 2006 in order to address catheter-associated bloodstream infections (BSIs) in neonates. The results for 2010 surveillance are presented herein. Neonatal intensive care units (NICUs) participated in the study on a voluntary basis. Umbilical catheters (UCs) and central venous catheters (CVCs) were analyzed separately. In 2010, 26NICUs participated. Overall, 2953 neonates were included (median weight, 1550 g; median gestational age, 32 weeks). These neonates had 2551UCs (median insertion duration, 4 days) and 2147CVCs (median insertion duration, 12 days). Thirty-three BSIs associated with UCs were reported, yielding a 2.9/1000UC-day incidence density, 95% confidence interval (95%CI) (1.9-3.8). UC-associated BSIs appeared after a median period of 5 days after UC insertion. The main microorganism isolated from blood cultures was coagulase negative staphylococci (CNS, n=27), S. aureus (n=3), and Enterobacteriaceae (n=5). Three hundred and six CVC-associated BSIs were recorded, yielding a 11.2/1000 CVC-day incidence density (95%CI, 10.0-12.5). These BSIs occurred after a median period of 12 days after CVC insertion. The main microorganisms were CNS (83%), S. aureus (6%), and Enterobacteriaceae (5%). The NEOCAT network provides a useful benchmark for participating wards.

[Non-tuberculous mycobacterial infections related to esthetic care in France, 2001-2010]. / Infections à mycobactéries atypiques liées à des soins esthétiques en France, 2001-2010.

Non-tuberculous mycobacteria (NTM) infections usually occur in immunocompromised patients but also in immunocompetent patients following invasive procedures, especially for esthetic purposes. Since 2001, 20 episodes (57 cases) of NTM infections, seven of which (43 cases) were related to esthetic care, have been reported to the regional infection control coordinating centers (RICCC), the local health authorities (LHA), and the national institute for public health surveillance. Four notifications (40 cases) were related to non-surgical procedures performed by general practitioners in private settings: mesotherapy, carboxytherapy, and sclerosis of microvaricosities. The three other notifications (three cases) concerned surgical procedures-lifting and mammary prosthesis. Practice evaluations performed by the RICCC and LHA for five notifications showed deficiency of standard hygiene precautions and tap water misuse for injection equipment cleaning, or skin disinfection. Microbiological investigations (national reference center for mycobacteria) demonstrated the similarity of patient and environmental strains: in one episode (16 cases after mesotherapy), M. chelonae isolated from tap water was similar to those isolated from 11 cases. Healthcare-associated NTM infections are rare but have a potentially severe outcome. These cases stress the need of healthcare-associated infection notifications in outpatient settings.

Imipenem and ciprofloxacin consumption as factors associated with high incidence rates of resistant Pseudomonas aeruginosa in hospitals in northern France.

In France, Pseudomonas aeruginosa is the third most common isolate from nosocomial infections. To determine whether high consumption rates of some antibiotics are risk factors for resistance to ceftazidime, imipenem, ciprofloxacin and amikacin in P. aeruginosa, we conducted a study based on data from the Antimicrobial Surveillance Network in northern France and the French public reporting system of infection control indicators. These data were related to hospital characteristics (size, type, proportion of non-acute care beds), antibiotic consumption, incidence rates of some key resistances and quality indicators of healthcare-associated infection (HAI) control. In univariate analysis, high total and specific antibiotic consumption (except amoxicillin/clavulanate and imidazoles) were associated with high P. aeruginosa resistance rates. In multivariate analysis, high resistance rates were related to high imipenem and ciprofloxacin consumption [odds ratio (95% confidence interval): 7.9 (2.24-28.09), P<0.05 for both], but were not significantly related to quality indicators of HAI control. These findings suggest that imipenem and ciprofloxacin use could play a major role in driving P. aeruginosa resistance, independent of other infection control performance.

Infection control--a European research perspective for the next decade.

A symposium was held in June 2009 near Freiburg in Germany. Twenty-nine attendees from several European countries participated, most of whom are actively involved in research and hospital infection prevention and control. The following topics were presented and discussed: isolation and screening for control of multidrug-resistant organisms; impact of the environment on healthcare-associated infection (HAI); new technologies to control infection--state of evidence; surveillance of HAI; methodological challenges and research priorities for infection control and control of HAI: learning from each other in a united Europe. This Leader summarises the main issues for debate and the number of consensus points agreed amongst delegates.

Control of a multi-hospital outbreak of KPC-producing Klebsiella pneumoniae type 2 in France, September to October 2009.

An outbreak of Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae type 2 was detected in September 2009 in two hospitals in a suburb south of Paris, France. In total, 13 KPC-producing K. pneumoniae type 2 cases (four with infections and nine with digestive-tract colonisations) were identified, including a source case transferred from a Greek hospital. Of the 13 cases, seven were secondary cases associated with use of a contaminated duodenoscope used to examine the source case (attack rate: 41%) and five were secondary cases associated with patient-to-patient transmission in hospital. All isolated strains from the 13 patients: (i) exhibited resistance to all antibiotics except gentamicin and colistin, (ii) were more resistant to ertapenem (minimum inhibitory concentration (MIC) always greater than 4 mg/L) than to imipenem (MIC: 1­8 mg/L, depending on the isolate), (iii) carried the blaKPC-2 and blaSHV12 genes and (iv) had an indistinguishable pulsed-field gel electrophoresis (PFGE) pattern. These cases occurred in three hospitals: some were transferred to four other hospitals. Extended infection control measures implemented in the seven hospitals included: (i) limiting transfer of cases and contact patients to other wards, (ii) cohorting separately cases and contact patients, (iii) reinforcing hand hygiene and contact precautions and (iv) systematic screening of contact patients. Overall, 341 contact patients were screened. A year after the outbreak, no additional case has been identified in these seven hospitals. This outbreak emphasises the importance of rapid identification and notification of emerging highly resistant K. pneumoniae strains in order to implement reinforced control measures.

Investigation of a large outbreak of Clostridium difficile PCR-ribotype 027 infections in northern France, 2006-2007 and associated clusters in 2008-2009.

In 2006 and 2007, a large outbreak of Clostridium difficile infections (CDIs) with PCR-ribotype 027 was identified in northern France. Overall, 38 healthcare facilities notified 529 CDIs over a 22-month period, including 281 laboratory-confirmed CDI 027 and 248 non-confirmed CDI 027 cases (incidence rate per 10,000 elective bed days: 1.63, range: 0.07 to 7.94). The cases occurred mainly in long-term care hospital facilities and nursing homes, near the border between France and Belgium. An active surveillance and prevention campaign was launched at the first epidemic peak including hygiene precautions for healthcare professionals, which supported healthcare facilities to improve care organisation. The outbreak was controlled at the end of 2007, but sporadic cases were identified until the end of 2009. A bundle of appropriate control measures may halt the spread of such outbreaks, provided that substantial human resources and financial support are available.

[Tuberculosis among healthcare workers in Northern France (2002-2007): descriptive analysis of notified cases and contact tracing]. / Tuberculose pulmonaire chez les personnels de santé de l'inter-région Nord (2002-2007): description des cas signalés et des campagnes de dépistage des sujets contacts.

UNLABELLED: The regional centre for infection control in northern France (CCLIN Nord) has received 28 notifications of pulmonary tuberculosis cases (PTC) in healthcare workers (HCWs), in 30 healthcare institutions, since the implementation of the French notification system for nosocomial infections. METHOD: A descriptive analysis of PTC investigations in healthcare workers was performed over a five-year period using a standardized form. RESULTS: Smear and culture of bronchial samples were positive for 22 PTC and 15 presented radiological cavities. Overall, 7730 contact patients were selected (91.6 % informed) and 4000 healthcare workers (100 % informed). Eighteen percent of adult contact patients, 75 % of children and 50 % of HCWs were investigated. Latent infection was identified in 34 HCWs, 80 adult patients, and ten children. A prophylactic treatment was prescribed for 692 newborns. Tuberculous disease was identified in one adult patient and two HCWs. CONCLUSION: Few cases of tuberculosis infection or disease were diagnosed around HCWs presenting with contagious tuberculosis. The effectiveness of broad information campaigns on exposed HCWs remains hard to assess because of the complexity of tuberculosis infection diagnosis, the high number of lost to follow-up, and the lack of adequate targeting. The role of health care management and occupational medicine remains crucial.

Reducing surgical site infection incidence through a network: results from the French ISO-RAISIN surveillance system.

Surgical-site infections (SSIs) are a key target for nosocomial infection control programmes. We evaluated the impact of an eight-year national SSI surveillance system named ISO-RAISIN (infection du site opératoire - Réseau Alerte Investigation Surveillance des Infections). Consecutive patients undergoing surgery were enrolled during a three-month period each year and surveyed for 30 days following surgery. A standardised form was completed for each patient including SSI diagnosis according to standard criteria, and several risk factors such as wound class, American Society of Anesthesiologists (ASA) score, operation duration, elective/emergency surgery, and type of surgery. From 1999 to 2006, 14,845 SSIs were identified in 964,128 patients (overall crude incidence: 1.54%) operated on in 838 participating hospitals. The crude overall SSI incidence decreased from 2.04% to 1.26% (P<0.001; relative reduction: -38%) and the National Nosocomial Infections Surveillance system (NNIS)-0 adjusted SSI incidence from 1.10% to 0.74% (P<0.001; relative reduction: -33%). The most significant SSI incidence reduction was observed for hernia repair and caesarean section, and to a lesser extent, cholecystectomy, hip prosthesis arthroplasty, and mastectomy. Active surveillance striving for a benchmark throughout a network is an effective strategy to reduce SSI incidence.