Personal protection and delivery of rhinologic and endoscopic skull base procedures during the COVID-19 outbreak.

On March 11th 2020, the World Health Organization (WHO) declared COVID-19 pandemic, with subsequent profound impact on the entire health care system. During the COVID-19 outbreak, activities in the rhinology outpatient clinic and operation rooms are limited to emergency care only. Health care practitioners are faced with the need to perform rhinological and skull base emergency procedures in patients with a positive or unknown COVID-19 status. This article aims to provide recommendations and relevant information for rhinologists, based on the limited amount of (anecdotal) data, to guarantee high-quality patient care and adequate levels of infection prevention in the rhinology clinic.

Performance of three generations of Xpert MRSA in routine practice: approaching the aim?

The aim of this study was to evaluate retrospectively the performance of the Xpert MRSA assay in routine practice and its current use in the intensive care unit (ICU) setting of our hospital, since a pre-emptive isolation strategy has been applied. A total of 6473 patients were routinely screened with ESwab for methicillin-resistant Staphylococcus aureus (MRSA) using three generations of rapid real-time polymerase chain reaction (PCR) (Cepheid GeneXpert) over three consecutive periods of time. Performance was evaluated using broth enrichment culture as the reference method. Our results show that the last generation of Xpert MRSA (NxG) assay is more specific (99.2% vs. 97.9%) but not more sensitive (77.8% vs. 86.9%) than the third generation. Considering the low prevalence of MRSA in our hospital, we obtained an overall low positive predictive value. In conclusion, it remains difficult to abandon the reference method in routine practice considering the possible implications of an erroneous MRSA result in the ICU.

Adherence to infection control guidelines in surgery on MRSA positive patients : A cost analysis.

In surgical units, similar to other healthcare departments, guidelines are used to curb transmission of methicillin resistant Staphylococcus aureus (MRSA). The aim of this study was to calculate the extra costs for material and extra working hours for compliance to MRSA infection control guidelines in the operating rooms of a University Hospital. The study was based on observations of surgeries on MRSA positive patients. The average cost per surgery was calculated utilizing local information on unit costs. Robustness of the calculations was evaluated with a sensitivity analysis. The total extra costs of adherence to MRSA infection control guidelines averaged €â€Š340.46 per surgical procedure (range €â€Š207.76- €â€Š473.15). A sensitivity analysis based on a standardized operating room hourly rate reached a cost of €â€Š366.22. The extra costs of adherence to infection control guidelines are considerable. To reduce costs, the logistical planning of surgeries could be improved by for instance a dedicated room.

Performance of different culture methods and of a commercial molecular assay for the detection of carbapenemase-producing Enterobacteriaceae in nursing homes and rehabilitation centers.

Over the last several years, carbapenemase-producing Enterobacteriaceae (CPE) have been increasingly detected not only among patients in acute care hospitals, but also in long-term care facilities. In this point prevalence survey, residents from three nursing homes and patients in one rehabilitation center were screened for asymptomatic intestinal carriage of CPE by rectal swabs. The first objective was to evaluate the hypothesis of the establishment of a CPE reservoir in a geriatric/chronic care population. Secondly, we evaluated the comparative performances of different culture methods (chromID(®) CARBA, chromID(®) OXA-48, MacConkey with temocillin/meropenem, ertapenem enrichment broth) and a commercial molecular assay (Check-Direct CPE). From the 257 included residents, only one had evidence for CPE carriage. From the rectal swabs of this resident, an OXA-48-producing Klebsiella pneumoniae could be isolated and was confirmed by a molecular assay both on the strain and on the rectal swab. The specificity of the different culture methods and Check-Direct CPE was at least 97 %. Neither enrichment broth nor prolonged incubation up to 48 h increased the yield of CPE. This point prevalence survey shows a low CPE prevalence of 0.39 %. Larger scaled studies are needed in order to confirm the role of chronic care settings as secondary CPE reservoirs and to adjust the infection control and prevention recommendations.

Shedding a light on ultraviolet-C technologies in the hospital environment.

Ultraviolet (UV)-C light for disinfection has experienced a surge in popularity since the outbreak of COVID-19. Currently, many different UV-C systems, with varied properties that impact disinfection performance, are available on the market. Therefore this review aims to bundle the available information on UV-C disinfection to obtain an overview of its advantages, disadvantages, and performance-influencing parameters. A literature search was performed using the snowball search method in Google Scholar and PubMed with the following keywords: UV-C disinfection, UV-C dose, UV-C light source, UV-C repair mechanism, UV-C photoreactivation, and UV-C disinfection standards. The main parameters of UV-C disinfection are wavelength, dose, relative humidity, and temperature. There is no consensus about their optimal values, but, in general, light at a high dose and a spectrum of wavelengths containing 260 nm is preferred in an environment at room temperature with low relative humidity. This light can be generated by mercury-vapour, light-emitting diode (LED), pulsed-xenon, or excimer lamps. Multiple factors are detrimental to disinfection performance such as shadowing, a rough surface topography, a high level of contamination, repair mechanisms, and the lack of standardization. Also, there are health and safety risks associated with the UV-C technology when used in the proximity of people. UV-C disinfection systems have promising features and the potential to improve in the future. However, clarifications surrounding the different parameters influencing the technologies' effectiveness in hospital environment are needed. Therefore UV-C disinfection should currently be considered for low-level rather than high-level disinfection.

Practice testing of generic quality indicators for responsible antibiotic use in nine hospitals in the Dutch-Belgian border area.

BACKGROUND: Inpatient quality indicators (IQIs) were previously developed to assess responsible antibiotic use. AIM: Practice testing of these QIs in the hospital setting. METHOD: This study was performed within a Dutch-Belgian border network of hospitals implementing the Infection Risk Scan (IRIS) point prevalence survey (PPS) as part of the i-4-1-Health project. Twenty out of 51 DRIVE-AB IQIs, including 13 structure and seven process IQIs, were tested. Data on structure IQIs were obtained through a web-based questionnaire sent to the hospital medical microbiologists. PPS data from October to December 2018 were used to calculate performance scores for the process QIs. FINDINGS: Nine hospitals participated. Regarding structure IQIs: the lowest performance scores were observed for recommendations for microbiological investigations in the guidelines and the use of an approval system for restricted antibiotics. In addition, most hospitals reported that some antibiotics were out of stock due to shortages. Regarding process IQIs: 697 systemic antibiotic prescriptions were used to calculate performance scores. The lowest score was observed for documentation of an antibiotic plan in the medical file (58.8%). Performance scores for IQIs on guideline compliance varied between 74.1% and 82.3% for different aspects of the antibiotic regimen (duration, choice, route, timing). CONCLUSION: This multicentre practice testing of IQIs identified improvement targets for stewardship efforts for both structure and process aspects of antibiotic care (approval system for restricted antibiotics, documentation of antibiotic plan). These results can guide the design of future PPS studies and a more extensive evaluation of the clinimetric properties of the IQIs.

[Generalized or targeted screening for carriage of MRSA on admission to a geriatric hospital]. / Veralgemeende of selectieve screening voor dragerschap van methicilline resistente Staphylococcus aureus bij opname op een geriatrische dienst.

OBJECTIVES: To confirm previously risk factors for MRSA carriage in our geriatric patient population and to suggest a simplified risk score with a combination of these risk factors, to test the Novel Score and to check if a targeted MRSA screening on admission is possible to reduce the screening workload and cost. DESIGN: a prospective in-hospital cohort study. SUBJECTS: 1125 geriatric patients were screened for MRSA carriage within 24 hours after admission to a geriatric hospital. METHODS: Risk factors, based on recently published risk scores (Preop Score and Ger Score) were determined. RESULTS: Prevalence of MRSA carriage was 8.44%. In a multivariate analysis age > or = 87 year (OR 1,864; 95% CI 1,145-3,035), presence of a long-term catheter (OR 2,813; 95% CI 1,562-5,065) and prior carriage of MRSA (OR 13,25; 95% CI 8,007-21,926) remained predictors of MRSA carriage. The Novel Score (cut-off > or = 1) had a sensitivity of 73.7%, a specificity of 64%, PPV 15.9%, NPV 96.3% and AUC of 0.688. The Novel Score allows reduction of the screening load by 57.2%, but misses 26% of positive cases. 16% of MRSA carriers develop an infection that needs to be treated with vancomycin. CONCLUSION: With targeted MRSA screening on admission based on a risk score a substantial reduction of workload and costs is possible compared to generalized screening for MRSA. Because MRSA carriers can be missed with a risk score, the epidemiological context and the risk of transmission and infection with MRSA must be taken in to account when introducing a targeted screening.

Infection assessment of totally implanted long-term venous access devices.

AIM: Comparison of catheter tip versus port content culture techniques to assess infection in totally implanted vascular access devices (TIVAD). MATERIALS AND METHODS: Comparison of pocket swab, catheter-tip and port content cultures after removing the silicon puncture septum in a prospectively collected consecutive series of 102 TIVAD removed for clinical suspicion of infection, between May 2000 and March 2003. RESULTS: 102 totally implanted port-catheters in 98 patients, age ranging from 1 to 90 years (median 53 years), were removed 7 to 2616 days after insertion (median 210 days). Infection of the pocket surrounding the port was found in 21 cases, all proven by a positive culture of the pocket swab. Out of the remaining 81 cases without pocket infection, 32 had only a positive catheter tip culture, whereas 56 had a positive port content culture (p = 0.0002). Always the same microorganism was isolated in the 32 patients with positive catheter tip and port content cultures. The main organisms identified within TIVAD were Coagulase Negative Staphylococcus (CNS) (41 cases) and Candida sp (15 cases). Eight out of the 21 pocket infections were caused by Staphylococcus aureus. CONCLUSION: In the presence of local signs of infection, taking cultures of the pocket surrounding the port is sufficient for diagnostic purposes. When infection is localized within the device only, port content cultures taken after removal of the silicon septum are more often positive than cultures of the catheter tip, and constitute therefore a more reliable tool for the assessment of TIVAD infection.

Origin and transmission of methicillin-resistant Staphylococcus aureus in an endemic situation: differences between geriatric and intensive-care patients.

Imported vs. hospital-acquisition of MRSA was assessed in > 6000 patients at a large tertiary care teaching hospital. About five percent (5.1%) of patients carried MRSA on admission, mostly without clinical symptoms; the highest percentage (11.6%) being in geriatric patients. Hospital-acquisition of MRSA occurred in 1.7% of patients and was particularly high in intensive-care units (5.2%). Phenotype and genotype analysis of 158 MRSA strains isolated from 61 patients revealed a cluster of closely related strains in the hospital-acquired MRSA infections and the close relationship of this cluster to the regional epidemic MRSA strain. The MRSA strains imported by geriatric patients were genetically different, did not spread between geriatric patients and were only a minor source of nosocomial infection.

Staphylococcus aureus adherence to nasal epithelial cells in a physiological in vitro model.

Nasal carriage of Staphylococcus aureus represents a risk factor for subsequent invasive infections and interpatient transmission of strains. No physiological in vitro model of nasal epithelial cells is available to study both patient- and bacteria-related characteristics and their interaction, leading to adherence and colonization. Starting with tissues from human nasal polyps, a confluent, squamous, nonkeratinized epithelium in collagen-coated 96-well microtiter plates was obtained after 14 d. This in vitro cell-layer was characterized histologically, ultrastructurally, and immunohistochemically and showed features that were indistinguishable from those observed in the squamous nonkeratinized epithelium found in the posterior part of the vestibulum nasi. Adherence experiments were performed with four different 3H-thymidine-labeled Staphylococcus aureus strains. The effect of bacterial inoculum size, temperature of incubation, and incubation medium were studied. The adherence results were found to be reproducible, reliable and sensitive, allowing detection of small quantitative differences in adherence between the Staphylococcus aureus strains. There was no significant difference in adherence at 23 degrees C and 37 degrees C, nor between the incubation medium M199 and phosphate-buffered saline. Plastic adherence could be reduced and standardized with use of siliconized tips and a constant bacterial inoculum volume of 100 microl/well. This physiological and reliable in vitro cell-culture model offers a unique opportunity to study Staphylococcus aureus adherence to squamous, nonkeratinized nasal epithelial cells and both patient and bacterial characteristics involved in this interaction.

Carbapenemase producing Enterobacteriaceae in Belgian nursing homes: myth or real danger?

Prevalence of carbapenemase-producing Enterobacteriaceae (CPE) is increasing both in hospitals and in the community. In this point prevalence study, rectal CPE colonization was investigated among 150 nursing home residents. No CPE were detected. Epidemiological data directly linked with CPE colonization in community and nursing home settings are currently lacking. Further research will show whether the preventive measures taken, including a strong focus on standard precautions, a dedicated isolation policy, and antibiotic restriction will retain CPE to invade nursing homes.

Fever of unknown origin due to inflammatory pseudotumour of lymph nodes.

The clinical features of inflammatory pseudotumour of lymph nodes, a distinct non-malignant histopathological entity firstly described in 1988, are summarized based upon a detailed analysis of 4 personal cases and 47 cases reported in the literature. The mean age of the patients is 38 years (range 8 to 82 years) and there is no gender predilection. One third present with asymptomatic lymphadenopathy and 47% present with fever, nearly all meeting the criteria of fever of unknown origin. Abdominal complaints are occasionally present. Intermittence of symptoms is common. Hepatosplenomegaly is unusual. All lymph node areas may be involved but abnormalities are mostly confined to one or two anatomic regions. No extranodal involvement has been reported although inflammatory pseudotumour may occur in several organs with similar morphological features and identical signs of inflammations. Routine blood tests are normal except for signs of inflammation. The lesions are Gallium-avid. Diagnosis is based upon typical histopathological features. The prognosis is favorable and surgical resection frequently leads to cure. Spontaneous resolution of symptoms has been reported and nonsteroidal anti-inflammatory drugs may suppress the clinical manifestations.