The novel application and effect of an ultraviolet light decontamination strategy on the healthcare acquisition of carbapenem-resistant Enterobacterales in a hospital setting.

BACKGROUND: The role of the hospital environment as contributory to healthcare acquisition of multidrug-resistant organisms (MDROs) is increasingly recognized. Ultraviolet light decontamination can minimize the environmental bioburden, thereby potentially reducing healthcare acquisition. This effect has been demonstrated for typical environmental MDROs, e.g. meticillin-resistant Staphylococcus aureus, vancomycin-resistant entero-cocci, and Clostridioides difficile; however, its role in reducing carbapenem-resistant Enterobacterales (CRE) incidence rates is unclear. AIM: To evaluate the impact of continuous ultraviolet light (C-UV) on healthcare acquisition rates of CRE. METHODS: A 26-month pragmatic, prospective interventional study with addition of C-UV decontamination to standard cleaning was conducted in units at high risk for CRE acquisition. Introduction of C-UV followed a 12 month baseline period, with a two-month wash-in period. Implementation included terminal decontamination at discharge and a novel in-use protocol, whereby rooms occupied for ≥48 h were decontaminated during the course of the patients' in-hospital stay. Incidence density rates of CRE during the intervention period were compared to the baseline period using interrupted time series regression. Rates were adjusted for ward/admission prevalence and analysed according to C-UV protocol. FINDINGS: The in-use C-UV protocol demonstrated a significant negative association with the incidence density rate of CRE when adjusting for CRE admission rate (P = 0.0069). CRE incidence density rates decreased significantly during the intervention period (P = 0.042). Non-intervention units demonstrated no change in incidence density rates when adjusting for ward and/or admission prevalence. CONCLUSION: C-UV decontamination can potentially reduce healthcare acquisition of CRE when implemented with an in-use protocol.

Procalcitonin-guided antibiotic therapy for suspected and confirmed sepsis of patients in a surgical trauma ICU: a prospective, two period cross-over, interventional study.

BACKGROUND: Biomarkers like procalcitonin (PCT) are an important antimicrobial stewardship tool for critically ill patients. There is little evidence regarding the use of PCT-guided antibiotic algorithms in developing countries. Evidence is also lacking for PCT-based antibiotic algorithms in surgical trauma patients admitted to the intensive care unit (ICU). METHODS: A prospective, two period cross-over study was conducted in a surgical trauma intensive care unit in South Africa. In the first period, 40 patients were recruited into the control group and antibiotics were discontinued as per standard of care. In the second period, 40 patients were recruited into the procalcitonin group and antibiotics were discontinued if the PCT decreased by ≥ 80% from the peak PCT level, or to an absolute value of less than 0.5 µg/L. Antibiotic duration of treatment was the primary outcome. Patients were followed up for 28 days from the first sepsis event. RESULTS: For the first sepsis event the PCT group had a mean antibiotic duration of 9.3 days while the control group had a mean duration of 10.9 days (p = 0.10). Patients in the intervention group had higher mean (SD) antibiotic free days alive of 7.7 (6.57) days compared to the control group mean (SD) of 3.8 (5.22) days, (p = 0.004). In-hospital mortality rate was lower in the intervention group (15%) compared to the control group (30%) and was statistically significant (p = 0.045). CONCLUSION: There was no significant difference in duration of antibiotic treatment between the two groups. However, the PCT group had more antibiotic free days alive and lower in-hospital mortality compared to the control group.

The 'ins and outs' of faecal microbiota transplant for recurrent Clostridium difficile diarrhoea at Wits Donald Gordon Medical Centre, Johannesburg, South Africa.

BACKGROUND: Clostridium difficile-associated diarrhoea (CDAD) is a potentially life-threatening condition that is becoming increasingly common. A persistent burden of this infectious illness has been demonstrated over the past 4 years at Wits Donald Gordon Medical Centre (WDGMC), Johannesburg, South Africa, through implementation of active surveillance of hospital-acquired infections as part of the infection prevention and control programme. Oral treatment with metronidazole or vancomycin is recommended, but there is a major problem with symptomatic recurrence after treatment. Replacement of normal flora by the administration of donor stool through colonoscopy or nasogastric/duodenal routes is becoming increasingly popular. OBJECTIVES: To identify risk factors for the development of CDAD in patients referred for faecal microbiota transplant (FMT) and evaluate the safety of administration of donor stool as an outpatient procedure, including via the nasogastric route. METHODS: A retrospective record review of patients with recurrent CDAD referred for FMT at WDGMC between 1 January 2012 and 31 December 2016 was conducted. RESULTS: Twenty-seven patients were identified, all of whom fulfilled the criteria for recurrent CDAD. One-third were aged >65 years, and the majority were female. The most common risk factors were prior exposure to antibiotics or proton-pump inhibitors and underlying inflammatory bowel disease. Three procedures were carried out as inpatients and 24 in the outpatient gastroenterology unit. At 4-week follow-up, all patients reported clinical resolution of their diarrhoea after a single treatment and there were no recurrences. The FMT procedure was associated with no morbidity (with particular reference to the risk of aspiration when administered via the nasogastric route) or mortality. CONCLUSIONS: This case series confirms that FMT is a safe and effective therapy for recurrent CDAD. In most cases it can be administered via the nasogastric route in the outpatient department. We propose that the recently published South African Gastroenterology Society guidelines be reviewed with regard to recommendations for the route of administration of FMT and hospital admission. Meticulous prescription practice by clinicians practising in hospitals and outpatient settings, with particular attention to antimicrobials and chronic medication, is urgently required to prevent this debilitating and potentially life-threatening condition.

Erratum to: Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA).

[This corrects the article DOI: 10.1186/s13017-016-0089-y.].