Pseudomonas aeruginosa countrywide outbreak in hospitals linked to pre-moistened non-sterile washcloths, Norway, October 2021 to April 2022.

In November 2021, a clonal outbreak of Pseudomonas aeruginosa of novel sequence type ST3875 was detected in three patients who died of bloodstream infections in one hospital. By 25 April 2022, the outbreak included 339 cases from 38 hospitals across Norway. Initial hospital reports indicate Pseudomonas infection as the main contributing cause in seven deaths. In March 2022, the outbreak strain was identified in non-sterile pre-moistened disposable washcloths, used to clean patients, from three lots from the same international manufacturer.

In-hospital deaths attributable to healthcare-associated infections. / Helsetjenesteassosiert infeksjon som årsak til død i sykehus.

BACKGROUND: It is estimated that approximately one-third of in-hospital deaths in Norway are attributable to adverse events, while the proportion caused by infection is unknown. Oslo University Hospital provides a full range of medical specialties on a national and regional level while serving as a local hospital for a population of approximately 300 000. We wished to investigate in-hospital deaths associated with fatal adverse events, and healthcare-associated infections in particular. MATERIAL AND METHOD: The study is based on a review of the medical records for all patients who died in Oslo University Hospital's somatic units in 2011. Infections were classified according to the criteria of the Centers for Disease Control and Prevention, USA. RESULTS: Out of a total of 82 341 admitted patients, 1 126 died while in hospital. We identified life-shortening adverse events in 128 (11.4 %) of these. The 87 patients at Ullevål hospital had a mean age of 73 years, while the 41 patients at Rikshospitalet/the Norwegian Radium Hospital had a mean age of 62 years. A total of 108 patients (9.6 %) died from a healthcare-associated infection, 49 of whom had a predicted survival of more than four weeks (4.4 % of the fatalities). Fifty-eight patients had pneumonia. INTERPRETATION: The proportion of deaths that were attributable to adverse events was lower than previously estimated in Norway. Oslo University Hospital, with its combined functions and broad patient base, can provide representative figures for healthcare-associated infections with fatal outcome in Norwegian hospitals.

Polyhexanide - safety and efficacy as an antiseptic. / Polyheksanid - sikkerhet og effekt som antiseptikum.

BACKGROUND Polyhexamethylene biguanide hydrochloride/polyhexanide/polyaminopropyl biguanide (PHMB) is used as a disinfectant and antiseptic. This article discusses the use of the substance as an antiseptic. We summarise published data on its antimicrobial effect in vitro and its clinical effect and safety when used on skin, wounds and mucosa.MATERIAL AND METHOD A literature search was conducted in PubMed for articles published in the last five years. Articles available as of June 2014 were considered.RESULTS Of 332 articles identified, 27 were included. In vitro studies have demonstrated an antimicrobial effect on Gram-negative bacteria, Gram-positive bacteria and Candida albicans. The clinical studies are small, not well controlled and frequently sponsored by industry. Few adverse effects from the substance were reported.INTERPRETATION Better designed, larger-scale clinical studies of effect and safety are needed in order to give recommendations on the use of polyhexanide on skin, wounds and mucosa.

Factors interfering with the microflora on hands: a regression analysis of samples from 465 healthcare workers.

AIMS: This paper is a report of a study of the impact of finger rings, wrist watches, nail polish, length of fingernails, hand lotion, gender and occupation on hand microbiology of healthcare workers. BACKGROUND: The impact of the above mentioned variables on hand microbiology of healthcare workers is not well defined. Large scale studies suitable for multivariate analysis are needed to elucidate their role. METHODS: Both hands of 465 Norwegian healthcare workers were sampled by the glove juice method during two study periods (2004 and 2007), and examined for total number of bacteria and presence of Staphylococcus aureus, Enterobacteriacea and non-fermentative Gram-negative rods. Multiple regression analysis was performed. RESULTS: The use of a wrist watch was associated with an enhanced total bacterial count on hands compared to hands without a watch [(B) 3·25 (95% CI: 1·73-6·07), P <0·001], while the use of one plain finger ring increased the carriage rate of Enterobacteriaceae [odds ratio 2·71 (95% CI: 1·42-5·20), P = 0·003]. The carriage rate of Staphylococcus aureus was enhanced with fingernails longer than 2 mm [odds ratio 2·17 (95% CI: 1·29-3·66), P = 0·004] and after recent use of hand lotion [odds ratio 22·52 (95% CI: 4·05-125·30), P < 0·001]. No effect of nail polish was observed. We found an association between occupation and carriage rate of S. aureus and Enterobacteriaceae. CONCLUSIONS: Health care workers should remove finger rings and watches at work. Fingernails should be shorter than 2 mm, nail polish may be used.

[Post-exposure varicella prophylaxis]. / Profylaktisk behandling etter varicellaeksponering.

BACKGROUND: Varicella may have a serious and sometimes fatal course, especially in immunocompromised patients. Some patient groups may need prophylaxis after exposure to the varicella-zoster-virus. In this article we review the evidence for usefulness of prophylactic measures after such exposure. MATERIAL AND METHODS: The article is based on a non-systematic literature search in Medline, the Cochrane Library, UpToDate and Clinical Evidence. RESULTS: The effect of post-exposure varicella prophylaxis on disease rate and severity of varicella is only weakly documented. There is some evidence that passive immunisation with varicella-zoster immunoglobulin (VZIG) reduces the risk of serious disease when it is administered within 72-96 hours after exposure. Several studies of mostly healthy children have shown that prophylactic acyclovir is better than control treatment, but the studies are small and they are not properly designed. Post-exposure vaccination is shown to reduce disease rate and severity in otherwise healthy children. INTERPRETATION: We believe that acyclovir or valacyclovir can be used as post-exposure varicella prophylaxis in risk patients for whom the time window for VZIG-use has expired.

Quantification of aerosol dispersal from suspected aerosol-generating procedures.

BACKGROUND: Oxygen-delivering modalities like humidified high-flow nasal cannula (HFNC) and noninvasive positive-pressure ventilation (NIV) are suspected of generating aerosols that may contribute to transmission of disease such as coronavirus disease 2019. We sought to assess if these modalities lead to increased aerosol dispersal compared to the use of non-humidified low-flow nasal cannula oxygen treatment (LFNC). METHODS: Aerosol dispersal from 20 healthy volunteers using HFNC, LFNC and NIV oxygen treatment was measured in a controlled chamber. We investigated effects related to coughing and using a surgical face mask in combination with the oxygen delivering modalities. An aerodynamic particle sizer measured aerosol particles (APS3321, 0.3-20 µm) directly in front of the subjects, while a mesh of smaller particle sensors (SPS30, 0.3-10 µm) was distributed in the test chamber. RESULTS: Non-productive coughing led to significant increases in particle dispersal close to the face when using LFNC and HFNC but not when using NIV. HFNC or NIV did not lead to a statistically significant increase in aerosol dispersal compared to LFNC. With non-productive cough in a room without air changes, there was a significant drop in particle levels between 100 cm and 180 cm from the subjects. CONCLUSIONS: Our results indicate that using HFNC and NIV does not lead to increased aerosol dispersal compared to low-flow oxygen treatment, except in rare cases. For a subject with non-productive cough, NIV with double-limb circuit and non-vented mask may be a favourable choice to reduce the risk for aerosol spread.

[Tigecycline--a new antibiotic]. / Tigesyklin--et nytt antibiotikum.

Tigecycline belongs to a new class of antimicrobial agents, the glycylcyclines, which are structurally derived from tetracyclines. It is effective against both gram positive and gram negative bacteria, aerobes and anaerobes and bacteria that have developed resistance against the classic tetracyclines. Although there is an increased risk for serious adverse events, tigecycline is important for treatment of patients with complicated infections of moderate severity where other antimicrobials cannot be used.

Operating room ventilation-Validation of reported data on 108 067 primary total hip arthroplasties in the Norwegian Arthroplasty Register.

RATIONALE, AIMS, AND OBJECTIVES: The true effect of laminar airflow (LAF) systems on postoperative infection is disputed, partly due to uncertainty regarding the validity of ventilation data in register studies. The aim of this study was to validate the information on operating room (OR) ventilation reported by the orthopaedic surgeons to the Norwegian Arthroplasty Register (NAR) after primary total hip arthroplasty (THA). METHOD: Forty of the 62 public orthopaedic units performing primary THA in Norway during the period 1987-2015 were included. The hospitals' current and previous ventilation systems were evaluated in cooperation with the hospitals head engineer. We identified the type of ventilation system reported to the NAR and compared the information with the factual ventilation in the specific ORs at the time of primary THA. RESULTS: A total of 108 067 primary THAs were eligible for assessment. None of the hospitals performed THA in true "greenhouse" (GH) ventilation. Fifty-seven percent of the primary THAs were performed in ORs with LAF and 43% in ORs with conventional, turbulent ventilation (CV). Comparing the reported data with the validated data, LAF was reported with a sensitivity of 86%, specificity of 89%, and positive predictive value (PPV) of 92%, with an accuracy of 88%. CV was reported with a sensitivity of 89%, specificity of 87%, and PPV of 84%, with an accuracy of 88%. The total, mean misreporting rate was 12%. CONCLUSIONS: Surgeons were not fully aware of what kind of ventilation system they operated in. This study indicates that conclusions based on ventilation data reported on THA in the NAR should not be interpreted without considering the inaccuracy of the data.

Diversity and antibiotic resistance among Escherichia coli populations in hospital and community wastewater compared to wastewater at the receiving urban treatment plant.

Bacterial diversity and antimicrobial resistance patterns among the indicator organism Escherichia coli were monitored in wastewater samples collected over one year from a hospital (HW), a community (CW) and the receiving urban (UW) wastewater treatment plant (WWTP). We compared levels of antibiotic resistance in the different types of wastewater, and identified whether resistant strains were endemic in the wastewater system. If so, implementation of local treatment at certain resistance hotspots (e.g. hospital outlets) could be used to decrease the amount of resistant bacteria in the wastewater. E. coli from HW (n = 2644), CW (n = 2525) and UW (n = 2693) were analyzed by biochemical phenotyping (PhenePlate System) and antimicrobial susceptibility testing to nine antibiotics (AREB System). The phenotypic diversities of the total E. coli populations were similar for all three sites (Simpson's Diversity index, Di = 0.973), however for individual samples, HW showed low diversities (Median Di = 0.800) and the E. coli flora was often dominated by strains that may have originated from the fecal flora of single individuals. The diversities in CW samples was higher (Median Di = 0.936), and UW samples showed similar diversities as the whole collection of isolates (Median Di = 0.971). Resistance to at least one of the nine antibiotics was observed in 45% of the HW isolates, 44% of CW isolates, and 33% of UW isolates. Resistance to gentamicin and chloramphenicol was uncommon (3.2 and 5.3%, respectively), whereas resistance to tetracycline and ampicillin was most common (24% and 31%, respectively). Extended-spectrum beta-lactamase-producing E. coli (ESBL-EC) were more common in HW (11.5%) and in CW (6.9%) compared to UW (3.7%). A high diversity (Di = 0.974) was observed among ESBL-EC isolates from UW (n = 99), indicating absence of any clonal structure among these isolates. Common PhP types of ESBL-EC often dominated in each HW sample, but were not identified across different samples, whereas ESBL-EC in CW showed low diversity (Di = 0.857) and were dominated by a specific PhP type that was found across almost all CW samples. The antibiotic resistance rates were highest in hospital wastewater, but surprisingly they were also high in the studied community wastewater, compared to the urban wastewater. The relative contribution of HW seemed low in terms of dissemination of antibiotic resistant bacteria to the WWTP.

Impact of a single plain finger ring on the bacterial load on the hands of healthcare workers.

OBJECTIVE: To investigate the impact of a single plain finger ring on the number and types of bacteria on the hands of healthcare workers (HCWs). DESIGN: Nonequivalent control groups, posttest only (preexperimental). METHODS: A total of 121 HCWs wearing 1 plain ring and 113 HCWs wearing no rings had both hands sampled by the "glove juice" technique. Quantitative culture of the samples was performed and microorganisms were identified. SETTING: Two Norwegian acute care hospitals. PARTICIPANTS: A total of 234 HCWs who had physical contact with patients. RESULTS: Total bacterial counts did not differ when hands with rings and hands without rings were compared, both according to nonpaired analysis (which compared the ring-bearing hands of ring-wearing HCWs to the hands of HCWs who did not wear rings [P=.661]) and according to paired analysis (which compared the ring-bearing and ring-free hands of ring-wearing HCWs [P=.071]). Staphylococcus aureus was recovered from 18.6% of the hands sampled, belonging to 26.9% of the HCWs, but neither paired nor nonpaired analysis showed any association with ring wearing. Gram-negative bacteria were recovered from 20.3% of the hands sampled, belonging to 28.6% of the HCWs. Ring-wearing HCWs were significantly more likely to be carriers of Enterobacteriaceae (P=.006), but paired comparison of the ring-bearing and ring-free hands of these HCWs did not show significant differences (P=.180). Carriage of nonfermentative gram-negative rods did not differ between the 2 groups, by either paired or nonpaired analysis. CONCLUSIONS: Wearing a single plain finger ring did not increase the total bacterial load on the hands, nor was it associated with an increased rate of carriage of S. aureus or nonfermentative gram-negative rods. However, plain rings were associated with an increased rate of Enterobacteriaceae carriage.

Consensus statement: patient safety, healthcare-associated infections and hospital environmental surfaces.

Healthcare-associated infections have serious implications for both patients and hospitals. Environmental surface contamination is the key to transmission of nosocomial pathogens. Routine manual cleaning and disinfection eliminates visible soil and reduces environmental bioburden and risk of transmission, but may not address some surface contamination. Automated area decontamination technologies achieve more consistent and pervasive disinfection than manual methods, but it is challenging to demonstrate their efficacy within a randomized trial of the multiple interventions required to reduce healthcare-associated infection rates. Until data from multicenter observational studies are available, automated area decontamination technologies should be an adjunct to manual cleaning and disinfection within a total, multi-layered system and risk-based approach designed to control environmental pathogens and promote patient safety.

Should patients with hip joint prosthesis receive antibiotic prophylaxis before dental treatment?

The safety committee of the American Academy of Orthopedic Surgeons (AAOS) recommended in 2009 that clinicians should consider antibiotic prophylaxis for all patients with total joint replacement before any invasive procedure that may cause bacteremia. This has aroused confusion and anger among dentists asking for the evidence. The present review deals with different aspects of the rationale for this recommendation giving attention to views both in favor of and against it.

A large outbreak of Listeria monocytogenes infection with short incubation period in a tertiary care hospital.

OBJECTIVES: Listeria monocytogenes is a foodborne pathogen with a high mortality rate. We report a large, nosocomial outbreak of Listeria monocytogenes infection. METHODS: Patients with L. monocytogenes isolated from a sterile site, or from faeces when diarrhoea and fever were present, were included. Clinical data were collected from the patient records. The incubation period was calculated as the time between exposure and start of symptoms. RESULTS: Seventeen patients (11 women, median age 64 years) were infected of whom 15 patients were at increased risk for listeriosis. Eleven patients received empiric antibiotic treatment, eight of them with cephalosporins. Three patients died with a resulting mortality rate of 18%. The source of the outbreak was a Camembert cheese made from pasteurised milk containing up to 360 million colony forming units per portion. The median incubation period was 3-4 days. CONCLUSIONS: The incubation period in this outbreak was significantly shorter than previously reported, a fact that may be due to the high number of ingested bacteria. Furthermore, food restrictions in hospitals seem warranted, as do treatment with antibiotics effective against L. monocytogenes in at-risk populations.

Impact of finger rings on transmission of bacteria during hand contact.

OBJECTIVE: To investigate the impact of finger rings on the transmission of bacteria from the hands of healthcare workers and the impact on the microflora on the hands of healthcare workers in clinical practice. DESIGN: Our study had a nonequivalent control group posttest-only design (pre-experimental). Healthcare workers who wore finger ring(s) on 1 hand and no ring on the other hand (n = 100) and a control group of healthcare workers who did not wear any rings (n = 100) exchanged standardized hand shakes with an investigator wearing sterile gloves. Samples from the gloved hands of the investigators and the bare hands of the healthcare workers were thereafter obtained by the glove juice technique. SETTING: Two Norwegian acute care hospitals. PARTICIPANTS: Healthcare workers (n = 200) during ordinary clinical work. RESULTS: A significantly higher bacterial load (odds ratio, 2.63 [95% confidence interval, 1.28-5.43]; P = .009) and a significantly higher number of bacteria transmitted (parameter estimates, [corrected] 2.43 [95% confidence interval, 1.44-4.13]; P = .001) were associated with ringed hands, compared with control hands. However, a multiple analysis of covariance revealed no statistically significant effect of rings alone. The prevalence of nonfermentative gram-negative bacteria (42% vs 26%) and Enterobacteriaceae (26% vs 13%) was also significantly higher among persons who wore rings than among persons who did not wear rings. However, no statistically significant differences in the incidence of transmission of these pathogens were detected after hand contact. The prevalence of Staphylococcus aureus and incidence of transmission of S. aureus were the same in both groups. CONCLUSIONS: Wearing finger rings increases the carriage rate of nonfermentative gram-negative bacteria and Enterobacteriaceae on the hands of healthcare workers. However, no statistically significant differences in the incidence of transmission of nonfermentative gram-negative bacteria or Enterobacteriaceae were detected between the healthcare workers who wore rings and those who did not.