Morphological characteristics of the reversed halo sign that may strongly suggest pulmonary infarction.

AIM: To analyse the morphological characteristics of the reversed halo sign (RHS) on unenhanced chest computed tomography (CT), which raise suspicion of pulmonary infarction (PI) associated with pulmonary embolism (PE), and to compare these characteristics with those observed in the RHS caused by other diseases. MATERIAL AND METHODS: CT images of 145 patients (250 RHSs) were reviewed retrospectively. Sixty-four patients had the RHS due to PI; in 81 immunocompetent patients, the RHS was caused by alternative pulmonary diseases. All PIs secondary to PE were confirmed at CT angiography. Other diagnoses were confirmed using published criteria. Two independent thoracic radiologists, who were blinded patient demographics, clinical data, and final diagnoses, analysed the morphological CT features of the RHSs. RESULTS: Seventy-four RHSs were found in the PI group and 176 RHSs in the group of other diseases. Single RHSs were associated more frequently with PI compared with the group without PIs; three or more lesions were seen only in patients with other diseases. Low-attenuation areas inside the RHS, with or without reticulation, were observed in 94.59% of PI-associated lesions, and in no patient in the group without PI (p<0.001). Subpleural involvement (p<0.001) and lower-lung predominance (p=0.001) were also associated more frequently with PI. Pleural effusion was observed in 64.06% of patients with PI and in only 6.17% of those with other diseases (p<0.001). CONCLUSIONS: A single RHS with low-attenuation areas inside the halo, with or without reticulation, is highly suggestive of PI. Lower-lung predominance and pleural effusion also suggest PI.

Universal screening and decolonization for control of MRSA in nursing homes: follow-up of a cluster randomized controlled trial.

In 2010-11, a trial conducted in nursing homes showed no benefit of meticillin-resistant Staphylococcus aureus (MRSA) universal screening and decolonization over standard precautions to reduce the prevalence of MRSA carriage. Accordingly, no routine screening was performed from 2012. A five-year follow-up shows no new evidence supporting the intervention. Recommendations issued after trial (no screening and decolonization of MRSA residents) were retained.

New genotyping method discovers sustained nosocomial Pseudomonas aeruginosa outbreak in an intensive care burn unit.

BACKGROUND: Pseudomonas aeruginosa is a leading cause of healthcare-associated infections in the intensive care unit (ICU). AIM: To investigate an unexplained increase in the incidence of P. aeruginosa recovered from clinical samples in the ICU over a two-year period. METHODS: After unsuccessful epidemiological investigation by conventional tools, P. aeruginosa clinical isolates of all patients hospitalized between January 2010 and July 2012 were typed by a novel double-locus sequence typing (DLST) method and compared to environmental isolates recovered during the investigation period. FINDINGS: In total, 509 clinical isolates from 218 patients and 91 environmental isolates were typed. Thirty-five different genotypic clusters were found in 154 out of 218 patients (71%). The largest cluster, DLST 1-18, included 23 patients who were mostly hospitalized during overlapping periods in the burn unit. Genotype DLST 1-18 was also recovered from floor traps, shower trolleys and the shower mattress in the hydrotherapy rooms, suggesting environmental contamination of the burn unit as the source of the outbreak. After implementation of appropriate infection control measures, this genotype was recovered only once in a clinical sample from a burned patient and twice in the environment, but never thereafter during a 12-month follow-up period. CONCLUSION: The use of a novel DLST method allowed the genotyping of a large number of clinical and environmental isolates, leading to the identification of the environmental source of a large unrecognized outbreak in the burn unit. Eradication of the outbreak was confirmed after implementation of a continuous epidemiological surveillance of P. aeruginosa clones in the ICU.

Hand soap contamination by Pseudomonas aeruginosa in a tertiary care hospital: no evidence of impact on patients.

BACKGROUND: During an environmental investigation of Pseudomonas aeruginosa in intensive care units, the liquid hand soap was found to be highly contaminated (up to 8 × 10(5)cfu/g) with this pathogen. It had been used over the previous five months and was probably contaminated during manufacturing. AIM: To evaluate the burden of this contamination on patients by conducting an epidemiological investigation using molecular typing combined with whole genome sequencing (WGS). METHODS: P. aeruginosa isolates from clinical specimens were analysed by double locus sequence typing (DLST) and compared with isolates recovered from the soap. Medical charts of patients infected with a genotype identical to those found in the soap were reviewed. WGS was performed on soap and patient isolates sharing the same genotype. FINDINGS: P. aeruginosa isolates (N = 776) were available in 358/382 patients (93.7%). Only three patients (0.8%) were infected with a genotype found in the soap. Epidemiological investigations showed that the first patient was not exposed to the soap, the second could have been exposed, and the third was indeed exposed. WGS showed a high number of core single nucleotide polymorphism differences between patients and soap isolates. No close genetic association was observed between soap and patient isolates, ruling out the hypothesis of transmission. CONCLUSION: Despite a highly contaminated soap, the combined investigation with DLST and WGS ruled out any impact on patients. Hand hygiene performed with alcohol-based solution for >15 years was probably the main reason. However, such contamination represents a putative reservoir of pathogens that should be avoided in the hospital setting.

Health care workers' influenza vaccination: motivations and mandatory mask policy.

BACKGROUND: Vaccination of health care workers (HCW) against seasonal influenza (SI) is recommended but vaccination rate rarely reach >30%. Vaccination coverage against 2009 pandemic influenza (PI) was 52% in our hospital, whilst a new policy requiring unvaccinated HCW to wear a mask during patient care duties was enforced. AIMS: To investigate the determinants of this higher vaccination acceptance for PI and to look for an association with the new mask-wearing policy. METHODS: A retrospective cohort study, involving HCW of three critical departments of a 1023-bed, tertiary-care university hospital in Switzerland. Self-reported 2009-10 SI and 2009 PI vaccination statuses, reasons and demographic data were collected through a literature-based questionnaire. Descriptive statistics, uni- and multivariate analyses were then performed. RESULTS: There were 472 respondents with a response rate of 54%. Self-reported vaccination acceptance was 64% for PI and 53% for SI. PI vaccination acceptance was associated with being vaccinated against SI (OR 9.5; 95% CI 5.5-16.4), being a physician (OR 7.7; 95% CI 3.1-19.1) and feeling uncomfortable wearing a mask (OR 1.7; 95% CI 1.0-2.8). Main motives for refusing vaccination were: preference for wearing a surgical mask (80% for PI, not applicable for SI) and concerns about vaccine safety (64%, 50%) and efficacy (44%, 35%). CONCLUSIONS: The new mask-wearing policy was a motivation for vaccination but also offered an alternative to non-compliant HCW. Concerns about vaccine safety and efficiency and self-interest of health care workers are still main determinants for influenza vaccination acceptance. Better incentives are needed to encourage vaccination amongst non-physician HCW.

Mandatory infectious diseases consultation for MRSA bacteremia is associated with reduced mortality.

OBJECTIVES: Although infectious disease (ID) consultation has been associated with lower mortality in Staphylococcus aureus bloodstream infections, it is still not mandatory in many centers. This study aimed at assessing the impact of ID consultation on diagnostic and therapeutic management of methicillin-resistant S. aureus (MRSA) bacteremia. METHODS: Retrospective cohort study of all patients with MRSA bacteremia from 2001 to 2010. ID consultations were obtained on request between 2001 and 2006 and became mandatory since 2007. RESULTS: 156 episodes of MRSA bacteremia were included, mostly from central venous catheter (32%) and skin and soft tissue (19%) infections. ID consultation coverage was 58% between 2001 and 2006 and 91% between 2007 and 2010. ID consultation was associated with more echocardiography (59% vs. 26%, p < 0.01), vancomycin trough level measurements (99% vs. 77%, p < 0.01), follow-up blood cultures (71% vs. 50%, p = 0.05), deep-seated infections (43% vs. 16%, p < 0.01), more frequent infection source control (83% vs. 57%, p = 0.03), a longer duration of MRSA-active therapy (median and IQR: 17 days, 13-30, vs. 12, 3-14, p < 0.01) and a 20% reduction in 7-day, 30-day and in-hospital mortality. CONCLUSIONS: ID consultation was associated with a better management of patients with MRSA bacteremia and a reduced mortality.

Características de desempenho e eficiência alimentar de touros Purunã em crescimento de três classes de consumo alimentar residual / Performance and feed efficiency traits of Purunã growing bulls of three groups of residual feed intake

Objetivou-se avaliar as características de desempenho, consumo e eficiência alimentar de touros Purunã em crescimento de três classes de consumo alimentar residual (CAR): eficiente, intermediária e ineficiente. Foram avaliados 110 tourinhos com média de 10 meses de idade e 233kg de peso corporal (PC), distribuídos aleatoriamente em baias individuais em confinamento. A dieta, em base de matéria seca (MS), foi composta por 420g/kg de concentrado e 580g/kg de silagem de milho, e fornecida à vontade. O consumo de MS diário e o ganho médio diário (GMD) foram avaliados durante 112 dias. O PC inicial e final e o GMD foram semelhantes entre as classes de eficiência e apresentaram valores médios de 233kg, 360kg e 1,14kg/dia. Valores médios de 7,19; 7,62 e 8,10kg/dia para consumo de MS e -048; -0,01 e 0,48kg MS/dia para CAR foram observados nas classes eficiente, intermediária e ineficiente. A conversão alimentar (CA) e a eficiência alimentar bruta (EAB) foram semelhantes entre as classes eficiente e intermediária, e apresentaram média de 6,65kg MS/kg ganho e 153g ganho/kg MS. A classe ineficiente apresentou maior CA e menor EAB, com valores de 7,40kg MS/kg ganho e 138g ganho/kg MS. A eficiência parcial de crescimento (EPC) diferiu entre as classes de eficiência e apresentou valores médios de 294; 277 e 255g ganho/kg MS para crescimento nas classes eficiente, intermediária e ineficiente. O CAR apresentou correlação moderada a alta com CA, EAB e EPC, e a diminuição do CAR levou à redução da CA em 12,2%, e aumento da EAB e EPC em 13,3% e 15,5%. Tourinhos Purunã eficientes para CAR consomem menos alimento, mas mantêm o mesmo nível de produção que os ineficientes. Assim, a classificação com base no CAR permite a identificação de animais com potencial para melhorar a eficiência produtiva do rebanho.

This trial aimed to evaluate the performance, feed intake and feed efficiency traits of Purunã growing bulls of three groups of residual feed intake (RFI): efficient, intermediary and inefficient. There were used 110 growing bulls with average of 10 months of age and 233kg of body weight (BW) which were randomly allocated in individual feedlot pens. The diet was composed, in dry matter (DM) basis, by 420g/kg of concentrate and 580g/kg of corn silage, and was offered ad libitum. Daily dry matter intake (DMI) and average daily gain (ADG) were assessed during 112 days. Initial and final BW and ADG not differed between the efficiency groups and showed mean values of 233kg, 360kg and 1.14kg/d. Mean values of 7.19, 7.62 and 8.10kg/d to DMI and -0.48, -0.01 and 0.48kg DM/d to RFI were observed in efficient, intermediary and inefficient groups. Feed conversion ratio (FCR) and gross feed efficiency (GFE) not differed between efficient and intermediary groups, which showed means of 6.65kg DM/kg gain and 153g gain/kg DM. Inefficient group showed higher FCR and lower GFE, with mean values of 7.40kg DM/kg gain and 138g gain/kg DM. Partial efficiency of growth (PEG) differed between the efficiency groups and showed means of 294, 277 and 255g gain/kg DM for growth in efficient, intermediary and inefficient groups. RFI showed moderate to high correlations with FCR, GFE and PEG, and decrease of RFI resulted in decrease of FCR in 12.2%, increase of GFE in 13.3% and increase of PEG in 15.5%. Efficient Purunã growing bulls (low RFI) present lower feed intake, but maintains the same production level that inefficient ones (high RFI). Thus, RFI classification allows identifying animals with potential to improve the productive efficiency of herd.

Matrix-assisted laser desorption ionization time-of-flight mass spectrometry and PCR-based rapid diagnosis of Staphylococcus aureus bacteraemia.

Effective empirical treatment is of paramount importance to improve the outcome of patients with Staphylococcus aureus bacteraemia. We aimed to evaluate a PCR-based rapid diagnosis of methicillin resistance (GeneXpert MRSA) after early detection of S. aureus bacteraemia using matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS). Patients with a first episode of S. aureus bacteraemia identified using MALDI-TOF MS were randomized in a prospective interventional open study between October 2010 and August 2012. In the control group, antibiotic susceptibility testing was performed after MALDI-TOF MS identification on blood culture pellets. In the intervention group, a GeneXpert MRSA was performed after S. aureus identification. The primary outcome was the performance of GeneXpert MRSA directly on blood cultures. We then assessed the impact of early diagnosis of methicillin resistance on the empirical treatment. In all, 197 episodes of S. aureus bacteraemia were included in the study, of which 106 were included in the intervention group. Median time from MALDI-TOF MS identification to GeneXpert MRSA result was 97 min (range 25-250). Detection of methicillin resistance using GeneXpert MRSA had a sensitivity of 99% and a specificity of 100%. There was less unnecessary coverage of MRSA in the intervention group (17.1% versus 29.2%, p 0.09). GeneXpert MRSA was highly reliable in diagnosing methicillin resistance when performed directly on positive blood cultures. This could help to avoid unnecessary prescriptions of anti-MRSA agents and promote the introduction of earlier adequate coverage in unsuspected cases.

[Control of an outbreak of vancomycin-resistant enterococci in several hospitals of western Switzerland]. / Contrôle d'une épidémie d'entérocoques résistant à la vancomycine dans plusieurs hôpitaux de Suisse romande.

An outbreak of vancomycin-resistant enterococci (VRE) occurred in 2011 in several hospitals of western Switzerland. Given that VRE can spread rapidly within hospitals and due to the potential transfer of resistance genes to other nosocomial pathogens like MRSA, stringent control measures were implemented. Excellent coordination of control measures between partner healthcare settings was successful in stopping the outbreak.

Molecular epidemiology of methicillin-resistant Staphylococcus aureus in Switzerland: sampling only invasive isolates does not allow a representative description of the local diversity of clones.

We conducted a molecular study of MRSA isolated in Swiss hospitals, including the first five consecutive isolates recovered from blood cultures and the first ten isolates recovered from other sites in newly identified carriers. Among 73 MRSA isolates, 44 different double locus sequence typing (DLST) types and 32 spa types were observed. Most isolates belonged to the NewYork/Japan, the UK-EMRSA-15, the South German and the Berlin clones. In a country with a low to moderate MRSA incidence, inclusion of non-invasive isolates allowed a more accurate description of the diversity.