Trends of Incidence and Risk Factors of Ventilator-Associated Pneumonia in Elderly Patients Admitted to French ICUs Between 2007 and 2014.

OBJECTIVES: To assess trends and risk factors of ventilator-associated pneumonia according to age, particularly in the elderly admitted to French ICUs between 2007 and 2014. DESIGN: Multicenter, prospective French national Healthcare-Associated Infection surveillance network of ICUs ("Réseau REA-Raisin"). SETTINGS: Two-hundred fifty six ICUs in 246 settings in France. PATIENTS: Included were all adult patients hospitalized greater than or equal to 48 hours in ICUs participating in the network. INTERVENTIONS: Ventilator-associated pneumonia surveillance over time. MEASUREMENTS AND MAIN RESULTS: Overall and multidrug-resistant organism-related ventilator-associated pneumonia incidence rates were expressed per 1,000 intubation days at risk. Age was stratified into three groups: young (18-64 yr old), old (65-74 yr old), and very old (75+ yr old). Age-stratified multivariate mixed-effects Poisson regressions were undertaken to assess trends of ventilator-associated pneumonia incidence over time, with center as the random effect. Ventilator-associated pneumonia risk factors were also evaluated. Of 206,223 patients, 134,510 were intubated: 47.8% were young, 22.3% were old, and 29.9% were very old. Ventilator-associated pneumonia incidence was lower in the very old group compared with the young group (14.51; 95% CI, 16.95-17.70 vs 17.32; 95% CI, 16.95-17.70, respectively, p < 0.001). Methicillin-resistant Staphylococcus aureus and third-generation cephalosporin-resistant Enterobacteriaceae were identified more frequently in very old patients (p < 0.001 and 0.014, respectively). Age-stratified models disclosed that adjusted ventilator-associated pneumonia incidence decreased selectively in the young and old groups over time (adjusted incidence rate ratios, 0.88; 95% CI, 0.82-0.94; p < 0.001 and adjusted incidence rate ratios, 0.95; 95% CI, 0.86-1.04; p = 0.28, respectively). Male gender and trauma were independently associated with ventilator-associated pneumonia in the three age groups, whereas antibiotics at admission was a protective factor. Scheduled surgical ICU and immunodeficiency were risk factors of ventilator-associated pneumonia in the old group (p = 0.003). CONCLUSIONS: Ventilator-associated pneumonia incidence is lower but did not decrease over time in very old patients compared with young patients.

[Accidents exposing to blood in France]. / Accidents exposant au sang en France.

Occupational blood and body fluids exposure. Occupational blood and body fluids exposure (BBFE) is a serious daily risk to healthcare workers (HCW) wherever they work (i.e. hospital, nursing home or private care). The knowledge of BBFE epidemiology over these 3 sectors of care allows HCF to be aware of BBFE circumstances and can enhance prevention in order to improve overall BBFE prevention. The improvement for compliance with standard precautions and protocols to prevent exposure to BBFE and the increase of safety device disposal use are the main keys of HCW safety.

Accidents exposant au sang en france Les professionnels de santé, quel que soit leur lieu d'activité (hôpital, établissement médico-social et ville), sont, au quotidien, susceptibles d'être victimes d'accidents exposant au sang. La connaissance des données épidémiologiques de ces accidents dans les trois secteurs de l'offre de soins permet aux professionnels de santé d'être conscients des circonstances de ces accidents pour mettre en place les mesures de prévention ad hoc. L'amélioration du respecter des précautions standard et des protocoles pour prévenir l'exposition au sang et aux liquides biologiques ainsi que la mise à disposition croissante des dispositifs médicaux de sécurité sont les principales clefs de la sécurité d'exercice des professionnels.

Antibiotics involved in the occurrence of antibiotic-resistant bacteria: a nationwide multilevel study suggests differences within antibiotic classes.

OBJECTIVES: To identify the antibiotics potentially the most involved in the occurrence of antibiotic-resistant bacteria from an ecological perspective in French healthcare facilities (HCFs). METHODS: This study was based on data from the French antimicrobial surveillance network (ATB-RAISIN, 2007-09). Antibiotics were expressed in defined daily doses per 1000 patient-days. Antibiotic-resistant bacteria were considered as count data adjusted for patient-days. These were third-generation cephalosporin (3GC)- and ciprofloxacin-resistant Escherichia coli, cefotaxime-resistant Enterobacter cloacae, methicillin-resistant Staphylococcus aureus and ceftazidime-, imipenem- and ciprofloxacin-resistant Pseudomonas aeruginosa. Three-level negative binomial regression models were built to take into account the hierarchical structure of data: level 1, repeated measures each year (count outcome, time, antibiotics); level 2, HCFs (type and size); and level 3, regions (geographical area). RESULTS: A total of 701 HCFs from 20 French regions and up to 1339 HCF-years were analysed. The use of ceftriaxone, but not of cefotaxime, was positively correlated with incidence rates of 3GC- and ciprofloxacin-resistant E. coli. In contrast, both 3GCs were positively correlated with the incidence rate of cefotaxime-resistant E. cloacae. Higher levels of use of ciprofloxacin and/or ofloxacin, but not of levofloxacin, were associated with higher incidence rates of 3GC- and ciprofloxacin-resistant E. coli, cefotaxime-resistant E. cloacae, methicillin-resistant S. aureus and ceftazidime- and ciprofloxacin-resistant P. aeruginosa. CONCLUSIONS: Our study suggests differences within antibiotic classes in promoting antibiotic resistance. We identified ceftriaxone, ciprofloxacin and ofloxacin as priority targets in public health strategies designed to reduce antibiotic use and antibiotic-resistant bacteria in French HCFs.

Surveillance of surgical-site infections: impact on quality of care and reporting dilemmas.

PURPOSE OF REVIEW: Among a wide range of publications on surgical-site infections (SSIs), many issues are still controversial, especially those concerning their monitoring and feedback. This review focuses on recent advances in surveillance as a tool for improving healthcare quality performance in surgery. RECENT FINDINGS: Recent data were obtained from many reference surveillance systems which tend to demonstrate significant decrease in SSI incidence rates over a several-year period. Most studies emphasize data feedback to surgical team is an important way to improve care quality and surgical performance. Few data demonstrated the relationship between the lack of compliance to control measures and SSI risk, including suboptimal antibiotic prophylaxis, perforated gloves, control of blood glucose, and avoidance of shaving. No clear consensus is achieved yet regarding preoperative systematic screening and decolonization of multidrug-resistant Staphylococcus aureus. There is a good amount of recent data regarding the benchmark approach for ranking surgery wards according to SSI rates. However, methodological issues on SSI indicator for public reporting are still being debated. Pilot studies attempt to demonstrate the usefulness of more cost-effective surveillance systems, especially those based on automated data process. SUMMARY: There are new exciting developments and perspectives in the field of surveillance and control of SSI. More data are needed to better establish the relationship with global care quality.

Antibiotic use in 530 French hospitals: results from a surveillance network at hospital and ward levels in 2007.

OBJECTIVES: Antibiotic use in French hospitals is among the highest in Europe. A study was carried out to describe antibiotic consumption for inpatients at hospital and at ward levels. METHODS: Data were voluntarily collected retrospectively by 530 hospitals accounting for approximately 40 million patient-days (PD) on the following: antibacterials for systemic use [J01 class of the WHO Anatomical Therapeutic Chemical (ATC) classification, defined daily doses (DDD) system, 2007], rifampicin and oral imidazole derivatives, expressed in number of DDD and number of PD in 2007. Consumption was expressed in DDD/1000 PD. RESULTS: Median antibiotic use ranged from 60 DDD/1000 PD in long-term care (LTC) and psychiatric hospitals to 633 DDD/1000 PD in teaching hospitals. Penicillins and beta-lactamase inhibitors combinations were the most frequently used antibiotics, accounting for 26% of total use in cancer hospitals to 40% in LTC/psychiatric hospitals. Glycopeptides and carbapenems were mostly used in cancer and teaching hospitals. Level of consumption and pattern of use differed according to clinical ward from 60 DDD/1000 PD in psychiatric wards up to 1466 DDD/1000 PD in intensive care units (ICUs). In medicine, surgery, ICU and rehabilitation wards, fluoroquinolones accounted for 13%-19% of the total use. CONCLUSIONS: This multicentre survey provided detailed information on antibiotic use in a large sample of hospitals and wards, allowing relevant comparisons and benchmarking. Analysis of consumption at the ward level should help hospitals to target practice audits to improve antibiotic use.

How to measure hospital antibiotic consumption: comparison of two methods from data surveillance in France.

BACKGROUND: Antibiotic use (ABU) surveillance in healthcare facilities (HCFs) is essential to guide stewardship. Two methods are recommended: antibiotic consumption (ABC), expressed as the number of DDD/1000 patient-days; and prevalence of antibiotic prescription (ABP) measured through point prevalence surveys. However, no evidence is provided about whether they lead to similar conclusions. OBJECTIVES: To compare ABC and ABP regarding HCF ranking and their ability to identify outliers. METHODS: The comparison was made using 2012 national databases from the antibiotic surveillance network and prevalence study. HCF rankings according to each method were compared with Spearman's correlation coefficient. Analyses included the ABU from entire HCFs as well as according to type, clinical ward and by antibiotic class and specific molecule. RESULTS: A total of 1076 HCFs were included. HCF rankings were strongly correlated in the whole cohort. The correlation was stronger for HCFs with a higher number of beds or with a low or moderate proportion of acute care beds. ABU correlation between ABC or ABP was globally moderate or weak in specific wards. Furthermore, the two methods did not identify the same outliers, whichever HCF characteristics were analysed. Correlation between HCF ranking varied according to the antibiotic class. CONCLUSIONS: Both methods ranked HCFs similarly overall according to ABC or ABP; however, major differences were observed in ranking of clinical wards, antibiotic classes and detection of outliers. ABC and ABP are two markers of ABU that could be used as two complementary approaches to identify targets for improvement.

Non-compliance with recommendations for the practice of antibiotic prophylaxis and risk of surgical site infection: results of a multilevel analysis from the INCISO Surveillance Network.

OBJECTIVES: The aim of this study was to determine which surgical antibiotic prophylaxis (SAP) practices alter surgical site infection (SSI) risk. METHODS: Data were collected during a 7 year surveillance period (2001-07) from volunteer surgery wards participating in the INCISO Surveillance Network in Northern France. Main SAP practices, i.e. antibiotic choice, timing of first dose and total SAP duration, were evaluated and compliance checked based on French recommendations. The study focused on selected procedures in digestive, orthopaedic, gynaecological and cardiovascular surgery, for which standard SAP is recommended. Multilevel logistic regression analysis (a two-level random effect model) was carried out to identify SAP-, patient- and procedure-specific factors associated with SSI. RESULTS: Of 8029 patients who underwent the selected surgeries, 91.3% received SAP and 2.5% developed SSI. Among those receiving SAP, 83.3% received appropriate antibiotic agents and 76.6% had an optimal timing of administration. SAP duration was considered to be appropriate in 35.0%, too long (SAP unnecessarily prolonged) in 45.2% and too short (lack of intra-operative redosing when recommended) in 19.8%. In the multivariate analysis, a too-short SAP duration remained the only inappropriate practice associated with higher SSI risk (odds ratio = 1.8, 95% confidence interval: 1.14-2.81), after adjustment for surgery procedure group, the National Nosocomial Infections Surveillance System risk index, age and infection risk variability among hospitals. No significant relationships were observed between SSI and the other SAP parameters. CONCLUSIONS: A too-short SAP duration was the most important SAP malpractice associated with an increased risk of SSI. Information directed at practitioners should be reinforced based on standard recommendations.

Specific control measures for antibiotic prescription are related to lower consumption in hospitals: results from a French multicentre pilot study.

BACKGROUND: In France, antibiotic consumption (ABC) is dramatically high in parallel with the high rate of multidrug-resistant bacteria. For the last few years, a nationwide policy has been implemented at the national level to control and monitor ABC. Since 2002, surveillance networks have been set up with voluntary hospitals to evaluate the antibiotic policy and consumption. The present study was conducted to identify whether specific control measures of the antibiotic policy could reduce ABC in hospitals. METHODS: Based on the data from the Northern France surveillance system, local recommendations and antibiotic use were collected annually on a standardized questionnaire that had 21 items. ABC was expressed in defined daily doses (DDDs) per 1000 patient-days (PDs). The ABC indicator was the overall antibiotic consumption. A multivariate logistic regression analysis was performed using low (< or =75th percentile) and high (>75th percentile) ABC as the dependent variable. RESULTS: A total of 83/111 hospitals were included in the study. In 75% of the hospitals, total ABC was < or =669.5 DDDs/1000 PDs. The less frequent practices were educational antibiotic programmes (17%), authorization from an antibiotic specialist for selected antibiotics (26%) and systematic reassessment of AB treatment after 72 h (27%). In the multivariate analysis, three variables remained significantly and independently associated (P < 0.05) with ABC: the type of hospital, the proportion of non-acute-care beds and the nominative delivery form as the only antibiotic control measure. Total ABC was lower in hospitals having a nominative delivery form, compared with hospitals not having it. Conversely, ABC was significantly higher in public teaching hospitals compared with non-teaching hospitals. Similarly, ABC was higher in hospitals with a lowest proportion (i.e. < or =25%) of non-acute-care beds compared with hospitals where this proportion was >25%. CONCLUSIONS: Specific control measures could lower ABC. Sustained control efforts should focus on antibiotics with the highest potential for emerging bacterial resistance.

Safety-engineered devices in medical office / Matériels de sécurité au cabinet médical

Safety-engineered devices in medical office. Safety-engineered devices are designed to inactivate the needle or the blade after completion of an invasive procedure and before device disposal, in order to prevent needlestick injuries. Safety-engineered devices include manual (bi or uni manual) activation devices, semi-automatic, and automatic activation devices with an increasing security level provided against needlestick injuries risk. This paper briefly describes the different types of safety-engineered devices available in the medical office setting.

Les matériels de sécurité au cabinet médical. Les matériels de sécurité sont des dispositifs médicaux destinés à la réalisation de gestes invasifs et équipés pour mettre en sécurité l'aiguille ou la lame, après la réalisation du geste et avant l'élimination du dispositif, dans le but de prévenir la survenue d'accidents exposant au sang. Selon le mécanisme d'activation de la sécurité et son mécanisme d'action, on décrit des matériels à activation manuelle (bi- ou unimanuelle), semi-automatique ou automatique. Le niveau de sécurité apporté par ces différents matériels vis-à-vis du risque d'accidents est variable. Ce texte décrit les principaux types de matériels de sécurité disponibles au cabinet médical.

ICU-acquired candidaemia in France: Epidemiology and temporal trends, 2004-2013 - A study from the REA-RAISIN network.

OBJECTIVE: Candidaemia is a life-threatening infectious disease, associated with septic shock, multiple organ failure, and a high mortality rate. In France, reported data on the incidence of ICU-acquired candidaemia and the causative Candida species are scarce. The objective of this study was to determine temporal trends in epidemiology and risk factors of intensive care unit-acquired candidaemia (ICU-Cand) and ICU mortality among a very large population of ICU patients. METHOD: Demographics, patient risk factors, invasive device exposure and nosocomial infection in ICU patient were collected from 2004 to 2013 in a national network of 213 ICUs: REA-RAISIN. Incidence and risk factors for candidaemia and ICU mortality were assessed. RESULTS: Out of 246,459 ICU patients, 851 developed an ICU-cand, representing 0.3 per 1000 patients-days. The incidence rose sharply over time. Candida albicans was the main species. The overall and ICU mortality was 52.4% in ICU-cand patients. The main risk factors of ICU-cand were length of stay, severity of illness and antimicrobial therapy at ICU admission, immune status and use of invasive procedure. ICU-cand was an independent risk factor of mortality (OR: 1.53; 95%CI [1.40-1.70]); in a sub-group analysis, independent effects on mortality were observed with C. albicans (OR: 1.45 [1.23-1.71]), Candida tropicalis (OR: 2.11 [1.31-3.39]) and "other" Candida species (OR: 1.64 [1.09-2.45]). CONCLUSION: ICU candidaemia ranked sixth among bloodstream infections, and its average annual incidence was 0.3 per 1000 patients days. Despite of new therapy and international recommendation, the incidence rose sharply during the study period, and ICU mortality remained high.

Clinical, virological, and biological parameters associated with outcomes of Ebola virus infection in Macenta, Guinea.

BACKGROUND. The pathogenesis of Ebola virus (EBOV) disease (EVD) is poorly characterized. The establishment of well-equipped diagnostic laboratories close to Ebola treatment centers (ETCs) has made it possible to obtain relevant virological and biological data during the course of EVD and to assess their association with the clinical course and different outcomes of the disease. METHODS. We were responsible for diagnosing EBOV infection in patients admitted to two ETCs in forested areas of Guinea. The pattern of clinical signs was recorded, and an etiological diagnosis was established by RT-PCR for EBOV infection or a rapid test for malaria and typhoid fever. Biochemical analyses were also performed. RESULTS. We handled samples from 168 patients between November 29, 2014, and January 31, 2015; 97 patients were found to be infected with EBOV, with Plasmodium falciparum coinfection in 18%. Overall mortality for EVD cases was 58%, rising to 86% if P. falciparum was also present. Viral load was higher in fatal cases of EVD than in survivors, and fatal cases were associated with higher aspartate aminotransferase (AST) and alanine aminotransferase (ALT), C-reactive protein (CRP), and IL-6 levels. Furthermore, regardless of outcome, EVD was characterized by higher creatine kinase (CPK), amylase, and creatinine levels than in febrile patients without EVD, with higher blood urea nitrogen (BUN) levels in fatal cases of EVD only. CONCLUSION. These findings suggest that a high viral load at admission is a marker of poor EVD prognosis. In addition, high AST, ALT, CRP, and IL-6 levels are associated with a fatal outcome of EVD. Damage to the liver and other tissues, with massive rhabdomyolysis and, probably, acute pancreatitis, is associated with EVD and correlated with disease severity. Finally, biochemical analyses provide substantial added value at ETCs, making it possible to improve supportive rehydration and symptomatic care for patients. FUNDING. The French Ministry of Foreign Affairs, the Agence Française de Développement, and Institut Pasteur.

Variation in blood and body fluids exposure when small-gauge needles or peripheral venous catheters were implicated: results of a 4-year surveillance in France.

The blood and body fluids exposure (BBFE) risk for health care workers varies according to numerous factors. Based on a needlestick surveillance in 13 French hospitals from 1997 to 2000, we evaluated incidence and temporal trends of BBFE according to medical devices causing needlestick injuries. We observed that the BBFE incidence per 100,000 peripheral venous catheters purchased decreased from 12.9 to 4.9, whereas incidence per 100,000 subcutaneous needles purchased increased from 8.7 to 14.3.

Assessment of preventive measures for accidental blood exposure in operating theaters: a survey of 20 hospitals in Northern France.

BACKGROUND: Accidental exposures to blood of body fluids (ABE) expose health care workers (HCW) to the risk of occupational infection. OBJECTIVES: Our aim was to assess the prevention equipment available in the operating theater (OT) with reference to guidelines or recommendations and its use by the staff in that OT on that day and past history of ABE. METHODS: Correspondents of the Centre de Coordination de la Lutte contre les Infections Nosocomiales (CCLIN) Paris-Nord ABE Surveillance Taskforce carried out an observational multicenter survey in 20 volunteer French hospitals. RESULTS: In total, 260 operating staff (including 151 surgeons) were investigated. Forty-nine of the 260 (18.8%) staff said they double-gloved for all patients and procedures, changing gloves hourly. Blunt-tipped suture needles were available in 49.1% of OT; 42 of 76 (55.3%) of the surgeons in these OT said they never used them. Overall, 60% and 64% of surgeons had never self-tested for HIV and hepatitis C virus (HCV), respectively. Fifty-five surgeons said they had sustained a total of 96 needlestick injuries during the month preceding the survey. Ten of these surgeons had notified of 1 needlestick injury each to the occupational health department of their hospital (notification rate, 10.4%). CONCLUSION: The occurrence of needlestick injury remained high in operating personnel in France in 2000. Although hospitals may improve access to protective devices, operating staff mindful of safety in the OT should increase their use of available devices, their knowledge of their own serostatus, and their ABE notification rate to guide well-targeted prevention efforts.

Nosocomial infection and multidrug-resistant bacteria surveillance in intensive care units: a survey in France.

OBJECTIVES: To evaluate nosocomial infection (NI) surveillance strategies in French ICUs and to identify similar patterns defining subsets within which comparisons can be made. DESIGN: A questionnaire was sent to all French ICUs, and a random sample of nonresponders was interviewed. PARTICIPANTS: Three hundred ninety-five responder ICUs (69%) in France. RESULTS: In 282 ICUs (71%), a dedicated ICU staff member was responsible for infection control activities. The microbiology laboratory was usually in the hospital (90%) and computerized (94%) but issued regular hospital microbiology records in only 48% of cases. Patients receiving mechanical ventilation, central venous catheterization, and urinary catheterization were 90%, 79%, and 60%, respectively. Patients were screened for carriage of multidrug-resistant bacteria on admission and during the stay in 70% and 60% of ICUs, respectively, most often targeting MRSA. Quantitative cultures were used to diagnose ventilator-associated pneumonia (VAP) in 90% of ICUs, including distal specimens in 80% and bronchoscopy specimens in 60%. Quantitative central venous catheter (CVC)-segment cultures were used in 70% of ICUs. All CVCs were cultured routinely in 53% of the ICUs. Despite wide variations in infection control and surveillance strategies, multiple correspondence analysis identified 13 key points (4 structural variables and 9 variables concerning the diagnosis of VAP, the surveillance and diagnosis of catheter-related and urinary tract infections, and the mode of screening of MRSA carriers) that categorize the variability of French ICUs' approaches to NIs. CONCLUSION: This study revealed profound differences in NI surveillance strategies across ICUs, indicating a need for caution when using NI surveillance data for comparisons and benchmarking.

Management of nurse shortage and its impact on pathogen dissemination in the intensive care unit.

INTRODUCTION: Studies provide evidence that reduced nurse staffing resources are associated to an increase in health care-associated infections in intensive care units, but tools to assess the contribution of the mechanisms driving these relations are still lacking. We present an agent-based model of pathogen spread that can be used to evaluate the impact on nosocomial risk of alternative management decisions adopted to deal with transitory nurse shortage. MATERIALS AND METHODS: We constructed a model simulating contact-mediated dissemination of pathogens in an intensive-care unit with explicit staffing where nurse availability could be temporarily reduced while maintaining requisites of patient care. We used the model to explore the impact of alternative management decisions adopted to deal with transitory nurse shortage under different pathogen- and institution-specific scenarios. Three alternative strategies could be adopted: increasing the workload of working nurses, hiring substitute nurses, or transferring patients to other intensive-care units. The impact of these decisions on pathogen spread was examined while varying pathogen transmissibility and severity of nurse shortage. RESULTS: The model-predicted changes in pathogen prevalence among patients were impacted by management decisions. Simulations showed that increasing nurse workload led to an increase in pathogen spread and that patient transfer could reduce prevalence of pathogens among patients in the intensive-care unit. The outcome of nurse substitution depended on the assumed skills of substitute nurses. Differences between predicted outcomes of each strategy became more evident with increasing transmissibility of the pathogen and with higher rates of nurse shortage. CONCLUSIONS: Agent-based models with explicit staff management such as the model presented may prove useful to design staff management policies that mitigate the risk of healthcare-associated infections under episodes of increased nurse shortage.

Improving prediction of surgical site infection risk with multilevel modeling.

BACKGROUND: Surgical site infection (SSI) surveillance is a key factor in the elaboration of strategies to reduce SSI occurrence and in providing surgeons with appropriate data feedback (risk indicators, clinical prediction rule). AIM: To improve the predictive performance of an individual-based SSI risk model by considering a multilevel hierarchical structure. PATIENTS AND METHODS: Data were collected anonymously by the French SSI active surveillance system in 2011. An SSI diagnosis was made by the surgical teams and infection control practitioners following standardized criteria. A random 20% sample comprising 151 hospitals, 502 wards and 62280 patients was used. Three-level (patient, ward, hospital) hierarchical logistic regression models were initially performed. Parameters were estimated using the simulation-based Markov Chain Monte Carlo procedure. RESULTS: A total of 623 SSI were diagnosed (1%). The hospital level was discarded from the analysis as it did not contribute to variability of SSI occurrence (p  = 0.32). Established individual risk factors (patient history, surgical procedure and hospitalization characteristics) were identified. A significant heterogeneity in SSI occurrence between wards was found (median odds ratio [MOR] 3.59, 95% credibility interval [CI] 3.03 to 4.33) after adjusting for patient-level variables. The effects of the follow-up duration varied between wards (p<10-9), with an increased heterogeneity when follow-up was <15 days (MOR 6.92, 95% CI 5.31 to 9.07]). The final two-level model significantly improved the discriminative accuracy compared to the single level reference model (p<10-9), with an area under the ROC curve of 0.84. CONCLUSION: This study sheds new light on the respective contribution of patient-, ward- and hospital-levels to SSI occurrence and demonstrates the significant impact of the ward level over and above risk factors present at patient level (i.e., independently from patient case-mix).

Role of the central venous catheter in bloodstream infections caused by coagulase-negative staphylococci in very preterm neonates.

BACKGROUND: Pathogenesis of coagulase-negative staphylococcal bloodstream infections among preterm neonates is debated: central venous catheters (CVCs) are considered the major cause and the cornerstone of prevention measures. The role of other means of transmission is unknown. METHODS: We developed a specific quantitative polymerase chain reaction assay targeting the dnaJ gene from Staphylococcus epidermidis and Staphylococcus capitis to detect DNA from CVC used in preterms. Performance of the polymerase chain reaction was tested against 2 control groups of CVC yielding positive (n = 24) or negative (n = 63) conventional cultures. We also explored retrospectively the DNA load of CVC having a negative conventional bacterial culture and obtained from 34 very preterm neonates with catheter-related bloodstream infections (CR-BSIs) established by usual clinical and biologic criteria. RESULTS: The molecular approach allowed detection of corresponding DNA from all the positive control catheters. Among the 34 episodes of CR-BSI yielding a negative conventional CVC culture, 8 (23.5%) had a positive polymerase chain reaction signal (5 S. epidermidis and 3 S. capitis). This percentage did not significantly differ according to the staphylococcal species, the delay between the CVC insertion and the beginning of the sepsis or between the blood culture collection and the CVC removal. These results conform to the previously published 70% of CR-BSI for whom the origin could be questioned. CONCLUSIONS: CVC removal in preterms is often performed in cases of CR-BSI; our study supports the hypothesis that in some cases the responsibility of CVC is questionable.

Needlestick injury rates according to different types of safety-engineered devices: results of a French multicenter study.

OBJECTIVES: To evaluate the incidence of needlestick injuries (NSIs) among different models of safety-engineered devices (SEDs) (automatic, semiautomatic, and manually activated safety) in healthcare settings. DESIGN: This multicenter survey, conducted from January 2005 through December 2006, examined all prospectively documented SED-related NSIs reported by healthcare workers to their occupational medicine departments. Participating hospitals were asked retrospectively to report the types, brands, and number of SEDs purchased, in order to estimate SED-specific rates of NSI. Setting. Sixty-one hospitals in France. RESULTS: More than 22 million SEDs were purchased during the study period, and a total of 453 SED-related NSIs were documented. The mean overall frequency of NSIs was 2.05 injuries per 100,000 SEDs purchased. Device-specific NSI rates were compared using Poisson approximation. The 95% confidence interval was used to define statistical significance. Passive (fully automatic) devices were associated with the lowest NSI incidence rate. Among active devices, those with a semiautomatic safety feature were significantly more effective than those with a manually activated toppling shield, which in turn were significantly more effective than those with a manually activated sliding shield (P < .001, chi(2) test). The same gradient of SED efficacy was observed when the type of healthcare procedure was taken into account. CONCLUSIONS: Passive SEDs are most effective for NSI prevention. Further studies are needed to determine whether their higher cost may be offset by savings related to fewer NSIs and to a reduced need for user training.

Prospective assessment of hospital-acquired bloosdstream infections: how many may be preventable?

OBJECTIVE: To determine the proportion of preventable hospital-acquired bloodstream infections (HA-BSIs), the authors prospectively examined consecutive cases in a large university hospital over an 18-month period. PATIENTS AND METHODS: Medical charts were assessed with the physician in charge of the patient within 4 days after HA-BSI diagnosis to determine whether the infection was healthcare-related. Preventability was assessed using a validated tool. Results of 378 HA-BSIs (incidence rate, 1.00 per 1000 patient-days), 341 were first HA-BSI episodes in a patient, and 272 (79.8%) were secondary to an identifiable source, of whom 196 (57.5%) were related to medical management. These 196 HA-BSIs were related to an invasive procedure (n=163), a non-invasive medical management (n=30) or both (n=3). RESULTS: Of the 272 patients with HA-BSIs from identifiable sources, 55 (20.2%) had no underlying disease, 115 (42.3%) had an ultimately fatal underlying disease, 99 (36.4%) had a rapidly fatal disease, and three (1.1%) were not evaluated. Of the 196 iatrogenic HA-BSIs, 66 were considered preventable (most of them being related to an intravascular catheter), 84 were of uncertain preventability, and 46 were not preventable. In total, 66 of the 341 HA-BSIs (19.4%) were considered preventable, and 191 (56.0%) were not preventable. CONCLUSION: Although evaluation of the preventability of hospital-associated adverse events has been reported to be difficult and of limited reliability, our simple method may help to identify wards or HA-BSI types that warrant in-depth evaluation.