European survey on the current surveillance practices, management guidelines, treatment pathways and heterogeneity of testing of Clostridioides difficile, 2018-2019: results from The Combatting Bacterial Resistance in Europe CDI (COMBACTE-CDI).

BACKGROUND: Awareness and compliance with international guidelines for diagnosis and clinical management of Clostridioides difficile infection (CDI) are unknown. AIM: To compare the awareness and compliance with the recommended strategies for diagnosis and clinical management of CDI across Europe in 2018-2019. METHODS: Hospital sites and their associated community practices across 12 European countries completed an online survey in 2018-2019, to report on their practices in terms of surveillance, prevention, diagnosis, and treatment of CDI. Responses were collected from 105 hospitals and 39 community general practitioners (GPs). FINDINGS: Hospital sites of 11 countries reported participation in national surveillance schemes compared with six countries for international schemes. The European Society of Clinical Microbiology and Infectious Diseases (ESCMID)-recommended CDI testing methodologies were used by 82% (86/105) of hospitals, however countries reporting the highest incidence of CDI used non-recommended tests. Over 75% (80/105) of hospitals were aware of the most recent European CDI treatment guidelines at the time of this survey compared with only 26% (10/39) of surveyed GPs. However, up to 15% (16/105) of hospitals reported using the non-recommended metronidazole for recurrent CDI cases, sites in countries with lower awareness of CDI treatment guidelines. Only 37% (39/105) of hospitals adopted contact isolation precautions in case of suspected CDI. CONCLUSION: Good awareness of guidelines for the management of CDI was observed across the surveyed European hospital sites. However, low compliance with diagnostic testing guidelines, infection control measures for suspected CDI, and insufficient awareness of treatment guidelines continued to be reported in some countries.

The effect of an intervention bundle to prevent central venous catheter-related bloodstream infection in a national programme in the Netherlands.

INTRODUCTION: Central venous catheters (CVCs) can lead to central line-related bloodstream infections (CRBSIs). A six-item bundle was introduced in 2009 to prevent CRBSI in Dutch hospitals. AIM: This study aimed to determine the impact of an intervention bundle on CRBSI risk. METHODS: Data were obtained from hospitals participating in the national CRBSI surveillance between 2009 and 2019. Bundle compliance was evaluated as a total ('overall') bundle (all six items) and as an insertion bundle (four items) and a maintenance bundle (two daily checks). We estimated the impact of the overall and partial bundles, using multi-level Cox regression. FINDINGS: Of the 66 hospitals in the CRBSI surveillance 56 (84.8%) recorded annual bundle (non)compliance for >80% of the CVCs, for one to nine years. In these 56 hospitals CRBSI incidence decreased from 4.0 to 1.6/1000 CVC days. In the intensive care units (ICUs), compliance was not associated with CRBSI risk (hazard ratio (HR) for the overall, insertion and maintenance bundle were 1.14 (95% confidence interval 0.80-1.64), 1.05 (0.56-1.95) and 1.13 (0.79-1.62)), respectively. Outside the ICU the non-significant association of compliance with the overall bundle (HR 1.36 (0.96-1.93)) resulted from opposite effects of the insertion bundle, associated with decreased risk (HR 0.50 (0.30-0.85)) and the maintenance bundle, associated with increased risk (HR 1.68 (1.19-2.36)). CONCLUSION: Following a national programme to introduce an intervention bundle, CRBSI incidence decreased significantly. In the ICU, bundle compliance was not associated with CRBSI risk, but outside the ICU improved compliance with the insertion bundle resulted in a decreased CRBSI risk.

Trends in prevalence of healthcare-associated infections and antimicrobial use in hospitals in the Netherlands: 10 years of national point-prevalence surveys.

BACKGROUND: Prevalence of healthcare-associated infections (HCAIs) and antimicrobial use in hospitals in the Netherlands has been measured using voluntary biannual national point-prevalence surveys (PPSs). AIM: To describe trends in the prevalence of patients with HCAI, risk factors, and antimicrobial use in 2007-2016. METHODS: In the PPS, patient characteristics, use of medical devices and antimicrobials, and presence of HCAI on the survey day are reported for all hospitalized patients, excluding patients in the day-care unit and psychiatric wards. Analyses were performed using linear and (multivariate) logistic regression, accounting for clustering of patients within hospitals. FINDINGS: PPS data were reported for 171,116 patients. Annual prevalence of patients with HCAI with onset during hospitalization decreased from 6.1% in 2007 to 3.6% in 2016. The adjusted odds ratio (OR) for trend was 0.97 (95% confidence interval: 0.96-0.98). Most prominent trends were seen for surgical site infections (1.6%-0.8%; OR: 0.91 (0.90-0.93)) and urinary tract infections (2.1%-0.6%; OR: 0.85 (0.83-0.87)). From 2014 on, HCAIs at admission were also registered with a stable prevalence of approximately 1.5%. The mean length of stay decreased from 10 to 7 days. The percentage of patients treated with antibiotics increased from 31% to 36% (OR: 1.03 (1.02-1.03)). CONCLUSION: Repeated PPS data from 2007 to 2016 show a decrease in the prevalence of patients with HCAI with onset during hospitalization, and a stable prevalence of patients with HCAI at admission. The adjusted OR of 0.97 for HCAI during hospitalization indicates a true reduction in prevalence of approximately 3% per year.

Burden of surgical site infections in the Netherlands: cost analyses and disability-adjusted life years.

BACKGROUND: Surgical site infections (SSIs) are associated with morbidity, mortality and costs. AIM: To identify the burden of (deep) SSIs in costs and disability-adjusted life years (DALYs) following colectomy, mastectomy and total hip arthroplasty (THA) in the Netherlands. METHODS: A retrospective cost-analysis was performed using 2011 data from the national SSI surveillance network PREZIES. Sixty-two patients with an SSI (exposed) were matched to 122 patients without an SSI (unexposed, same type of surgery). Patient records were studied until 1 year after SSI diagnosis. Unexposed patients were followed for the same duration. Costs were calculated from the hospital perspective (2016 price level), and cost differences were tested using linear regression analyses. Disease burden was estimated using the Burden of Communicable Disease in Europe Toolkit of the European Centre for Disease Prevention and Control. The SSI model was specified by type of surgery, with country- and surgery-specific parameters where possible. FINDINGS: Attributable costs per SSI were €21,569 (THA), €14,084 (colectomy) and €1881 (mastectomy), mainly caused by prolonged length of hospital stay. National hospital costs were estimated at €10 million, €29 million and €0.6 million, respectively. National disease burden was greatest for SSIs following colectomy (3200 DALYs/year, 150 DALYs/100 SSIs), while individual disease burden was highest following THA (1200 DALYs/year, 250 DALYs/100 SSIs). For mastectomy, these DALYs were <1. The total cost of DALYs for the three types of surgery exceeded €88 million. CONCLUSION: Depending on the type of surgery, SSIs cause a significant burden, both economically and in loss of years in full health. This underlines the importance of appropriate infection prevention and control measures.

Catheter application, insertion vein and length of ICU stay prior to insertion affect the risk of catheter-related bloodstream infection.

BACKGROUND: The Dutch PREZIES surveillance scheme for catheter-related bloodstream infection (CR-BSI) collects data on infection rates and related risk factors. AIM: To evaluate risk factors for CR-BSI. METHODS: Hospitals collected data for intensive care units (ICU) or for the entire hospital. All short-term central venous catheters (CVC), including Swan-Ganz catheters, present for ≥48h were surveyed, except in cases when bacteraemia was present at insertion. CVCs were monitored until infection, removal or death for up to 28 days. Data were collected on 3750 CVCs and 29,003 CVC-days. FINDINGS: Of the CVCs surveyed, 1.6% [95% confidence interval (CI) 1.2-2.0] resulted in CR-BSI, representing 2.0/1000 CVC-days (95% CI 1.6-2.6). Multi-variate analysis revealed that the length of ICU stay prior to CVC insertion, insertion in the jugular or femoral vein, and use of the CVC to deliver total parenteral nutrition increased the risk of CR-BSI, whereas use of the CVC to deliver antibiotics decreased the risk of CR-BSI. CONCLUSION: Attention to these risks has the potential to reduce the incidence of CR-BSI.

Prevalence of nosocomial infections in The Netherlands, 2007-2008: results of the first four national studies.

The PREZIES national network for the surveillance of nosocomial infections (NI) in The Netherlands has organised a national prevalence study twice a year since 2007. This paper presents the results of the first four surveys. Of 95 hospitals in The Netherlands, 41 participated in 92 surveys and 26 937 patients were included. On the survey day 6.2% had an NI (prevalence of infections 7.2%). The prevalence of infections varied from 1.4% to 16.5% between hospitals. The prevalence of surgical site infections was 4.8%, pneumonia 1.1%, primary bloodstream infection 0.5% and symptomatic urinary tract infection 1.7%. On admission to hospital, 3.3% of patients had an NI. On the day of the survey, 30.9% of the patients were receiving antibiotics. The use of antibiotics as well as medical devices differed considerably between hospitals. Both the prevalence of NI in The Netherlands and the use of antibiotics and devices were comparable to other European countries.

[Epidemiology of Clostridium difficile PCR ribotype 027 in the Netherlands 2005-present and the emergence of other subtypes]. / De epidemiologie van clostridium difficile PCR-ribotype 027 in Nederland sinds 2005 en de opkomst van andere typen.

Outbreaks of Clostridium difficile associated diarrhoea (CDAD) involving the virulent PCRribotype 027, toxinotype III were first reported in the Netherlands in 2005. This ribotype has now been detected in 26 of the 97 hospitals in the Netherlands. In 13 of the hospitals, the introduction of ribotype 027 was linked to increased CDAD incidence; this was found in 2 hospitals since December 2006. Ribotype 027 has also been detected in to nursing homes. In 2007, no evidence of ribotype 27 was found in 6 of the 12 hospitals in which ribotype 027 was confirmed in 2005-2006 and an outbreak of CDAD had occurred. The incidence of CDAD increased again in 2 hospitals that had previously had the epidemic well under control. Meanwhile, other PCR ribotypes appear to be gaining ground in the Netherlands, some of which have the same virulent characteristics as ribotype 027. Notably, ribotype 078, which appears to be associated with livestock, is becoming increasingly common.

Antibiotic use and other risk factors at hospital level for outbreaks with Clostridium difficile PCR ribotype 027.

The first Dutch outbreak due to Clostridium difficile ribotype 027 was observed in mid-2005; by the end of that year, eight hospitals were affected. To study the relationship between hospital-wide antibiotic use and the incidence of 027-linked C. difficile-associated disease (CDAD) three study groups were made: group A, all eight hospitals with an 027-associated epidemic; group B, five of a total of six hospitals with occasional 027 cases, without an increase in CDAD; and group C, ten randomly selected hospitals with no reported 027 epidemics or isolated 027 cases. Quarterly data on CDAD incidences, hygiene measures and the use of fluoroquinolones, second- and third-generation cephalosporins, extended-spectrum penicillins, penicillins with beta-lactamase inhibitors, carbapenems, lincomycins and macrolides were collected for 2004 and 2005, and divided into pre-epidemic and epidemic periods. Using a multilevel Poisson regression analysis, CDAD incidence was linked to antibiotic use in the previous quarter and to certain hygiene measures. In the pre-epidemic period, the total use of the studied antibiotics was comparable between affected and unaffected hospitals. Higher use of second-generation cephalosporins, macrolides and all of the studied antibiotics were independently associated with a small increase in CDAD incidence [relative risk (95% confidence interval): 1.14 per increase of 100 defined daily doses per 10,000 bed days (1.06-1.23), 1.10 (1.01-1.19) and 1.02 (1.01-1.03), respectively]. However the effect was too small to predict which hospitals might be more prone to 027-associated outbreaks.