The carbon footprint of the operating room related to infection prevention measures: a scoping review.

BACKGROUND: Infection prevention measures are widely used in operating rooms (ORs). However, the extent to which they are at odds with ambitions to reduce the health sector's carbon footprint remains unclear. AIM: To synthesize the evidence base for the carbon footprint of commonly used infection prevention measures in the OR, namely medical devices and instruments, surgical attire and air treatment systems. METHODS: A scoping review of the international scientific literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The search was performed in PubMed and Google Scholar. Articles published between 2010 and June 2021 on infection prevention measures, their impact on the health sector's carbon footprint, and risk for surgical site infections (SSIs) were included. FINDINGS: Although hospitals strive to reduce their carbon footprint, many infection prevention measures result in increased emissions. Evidence suggests that the use of disposable items instead of reusable items generally increases the carbon footprint, depending on sources of electricity. Controversy exists regarding the correlation between air treatment systems, contamination and the incidence of SSIs. The literature indicates that new air treatment systems consume more energy and do not necessarily reduce SSIs compared with conventional systems. CONCLUSION: Infection prevention measures in ORs can be at odds with sustainability. The use of new air treatment systems and disposable items generally leads to significant greenhouse gas emissions, and does not necessarily reduce the incidence of SSIs. Alternative infection prevention measures with less environmental impact are available. Implementation could be facilitated by embracing environmental impact as an additional dimension of quality of care, which should change current risk-based approaches for the prevention of SSIs.

Risk of SARS-CoV-2 transmission upon return to work in RNA-positive healthcare workers.

BACKGROUND: Healthcare workers (HCWs) are at risk for coronavirus disease 2019 (COVID-19), and for spreading severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) amongst colleagues and patients. AIM: To study the presence of SARS-CoV-2 RNA and possible onward transmission by HCWs upon return to work after COVID-19, and association with disease severity and development of antibodies over time. METHODS: Unvaccinated HCWs with positive SARS-CoV-2 reverse transcriptase polymerase chain reaction (RT-PCR) were recruited prospectively. Data on symptoms were collected via telephone questionnaires on days 2, 7, 14 and 21 after a positive test. Upon return to work, repeat SARS-CoV-2 RT-PCR was performed and serum was collected. Repeat serum samples were collected at weeks 4, 8, 12 and 16 to determine antibody dynamics over time. Phylogenetic analysis was conducted to investigate possible transmission events originating from HCWs with a positive repeat RT-PCR. FINDINGS: Sixty-one (84.7%) participants with mild/moderate COVID-19 had a repeat SARS-CoV-2 RT-PCR performed upon return to work (median 13 days after symptom onset), of which 30 (49.1%) were positive with a median cycle threshold (Ct) value of 29.2 (IQR 26.9-29.9). All HCWs developed antibodies against SARS-CoV-2. No significant differences in symptomatology and presence of antibodies were found between repeat RT-PCR-positive and -negative HCWs. Eleven direct colleagues of six participants with a repeat RT-PCR Ct value <30 tested positive after the HCW returned to work. Phylogenetic and epidemiologic analysis did not indicate onward transmission through HCWs who were SARS-CoV-2 RNA positive upon return to work. CONCLUSIONS: HCWs regularly return to work with substantial SARS-CoV-2 RNA loads. However, this study found no evidence for subsequent in-hospital transmission.

[Diagnosis and treatment of fracture-related infections]. / Diagnostiek en behandeling van fractuur-gerelateerde infecties.

Fracture-related infection (FRI) is a serious complication after fracture care and can lead to severe morbidity with loss of quality of life, a significant increase in medical expenses and loss of participation in work and social life. Early recognition, adequate surgical debridement, deep uncontaminated tissue cultures with (if indicated) soft tissue reconstruction and fracture stabilization followed by antibiotic therapy are the cornerstones of the successful management of FRI. Recently, in 2018, the AO/EBJIS consensus definition for FRI was published and both national and international working groups are being assembled and provide guidelines and tools for the care of patients with FRI. This paper is a synopsis of the Dutch guideline on FRI (2018), illustrated by a clinical case, and is aiming to provide an overview of the current knowledge on diagnosis and treatment of this disease.

Summary of track C: epidemiology and public health.

AIM: To review Track C on epidemiology and public health. DESCRIPTIVE EPIDEMIOLOGY: Recent trends in the descriptive epidemiology are reported, for example, the rapid spread of HIV in certain Asian countries and the more precise insights in the spread thanks to subtyping of HIV-1 (and HIV-2). TRANSMISSION: There is now ample evidence that sexually transmitted diseases enhance the rate of transmission. Viral load in the plasma of the mother is highly predictive for perinatal transmission. PROGRESSION: Natural history studies have shown that true non-progressors are probably rare. Preliminary evidence indicates that the progression rate to AIDS and death does not differ by HIV-1 subtype. Some genetic factors are associated with the rate of disease progression and a few with susceptibility to HIV infection. INTERVENTIONS AND PREVENTION: Needle-exchange programmes as an intervention measure for injecting drug users were hotly debated and so were HIV (home) testing and counselling. Successes in prevention were reported from Thailand and Uganda, and also from small scale programmes.

PIP: More than 1500 abstracts were submitted in the Epidemiology and Public Health Track of the XI International Conference on Acquired Immunodeficiency Syndrome (AIDS). Summarized, in this article, are papers on recent trends in the descriptive epidemiology of AIDS, the interaction between human immunodeficiency virus (HIV) and sexually transmitted diseases (STDs), determinants of perinatal transmission, aspects of the natural history of HIV (including non-progression), and intervention issues related to intravenous drug users. The data confirm that persons with STDs transmit HIV more easily through heterosexual contact than those without STDs; however, STD treatment lowers the viral load and reduces the risk of HIV transmission. The recommendation that HIV-infected women in developing countries continue to breast feed may be retracted in light of evidence that significantly more breast-fed infants become infected than bottle-fed infants.

Lower prevalence and incidence of HIV-1 syncytium-inducing phenotype among injecting drug users compared with homosexual men.

OBJECTIVE: To study the prevalence, incidence and predictive value for progression to AIDS of the HIV-1 syncytium-inducing (SI) phenotype in HIV-infected injecting drug users (IDU) compared with HIV-infected homosexual men. DESIGN: Two prospective cohort studies on HIV-1 infection among IDU and homosexual men. METHODS: HIV-infected IDU (n = 225) and homosexual men (n = 366) without AIDS were studied from March 1989 through December 1993. Data on laboratory markers, including the presence of SI variants, demographics, behavioural characteristics and clinical events were collected at every visit. RESULTS: At baseline, SI variants were detected in 4% of IDU and 17% of homosexual men. During the study period 18 IDU and 68 homosexual men switched from non-SI to SI phenotype (4-year cumulative incidence, 14.6 and 28.4%, respectively) before AIDS diagnosis. Among participants with a documented date of HIV infection the cumulative incidence of SI was lower among IDU than homosexual men (4-year cumulative incidence, 6.2 and 20.7%, respectively). At AIDS diagnosis, 21% of all AIDS cases among IDU had the SI phenotype compared with 54% among homosexual men. In both risk groups an accelerated CD4 decline was found after the non-SI-to-SI switch. The SI phenotype appeared to be a predictor of AIDS (multivariate relative hazard, 5.33), independent of CD4 cell count and p24 antigen at baseline. In the multivariate time-dependent analysis, the relative hazard of SI phenotype decreased considerably, which is consistent with the hypothesis that the effect of SI phenotype on progression to AIDS is mediated by CD4 cell count. CONCLUSION: The SI phenotype is associated with accelerated CD4 decline and progression to AIDS in both risk groups. The remarkable lower prevalence and incidence of the SI phenotype among IDU may implicate a difference in pathogenesis and natural history of HIV infection linked to transmission group.

AIDS prognosis based on HIV-1 RNA, CD4+ T-cell count and function: markers with reciprocal predictive value over time after seroconversion.

OBJECTIVE: HIV-1 RNA levels in peripheral blood are strongly associated with progression to AIDS, CD4+ T-cell decline, or death. Their predictive value is reportedly independent of the predictive value of CD4+ T-cell counts. Because the interrelations between these parameters of HIV-1 infection are poorly understood, we studied the kinetics and predictive value of serum HIV-1 RNA levels, CD4+ T-cell counts, and T-cell function. DESIGN AND METHODS: HIV RNA levels, CD4+ T-cell counts, and T-cell function were measured from seroconversion to AIDS in 123 homosexual men who seroconverted during a prospective study and were followed over 10 years. RESULTS: Two patterns of median HIV-1 RNA levels were found during infection: a steady-state and a 'U-shaped' curve. Steady-state high RNA levels were related to rapid disease progression. For the U-shaped curve, there were groups with high and low RNA levels related to disease progression. At 1 year after seroconversion, RNA level was the only marker that was strongly predictive. Furthermore, decreasing RNA levels in the first year following seroconversion were related to better prognosis than stable low levels. Low CD4+ T-cell count and T-cell function became predictive of progression to AIDS at 2 and 5 years after seroconversion, respectively. CONCLUSIONS: With ongoing infection, the predictive value of low CD4+ T-cell count and T-cell function increases, whereas the predictive value of high HIV-1 RNA level decreases. These findings reflect the observation that infection with HIV progressively leads towards immune deficiency, which in later stages is most predictive of disease progression.

Early and late HIV-1 RNA level and its association with other markers and disease progression in long-term AIDS-free homosexual men.

OBJECTIVE: To study the association between virological markers and clinical progression in individuals with long-term AIDS-free HIV infection. DESIGN: Seventy-seven HIV-infected participants in the Amsterdam cohort study who remained AIDS-free for at least 8 years were prospectively followed during that time and during a subsequent period in which 15 developed AIDS. METHODS: Serum HIV-1 RNA levels were evaluated at 1 and 8 years after study entry. Progression to AIDS following the 8 AIDS-free years was studied using Kaplan-Meier estimates and Cox proportional hazard analysis. RESULTS: HIV-1 RNA increased over time in a large proportion of these long-term AIDS-free men. Most subjects showed progressive immune system damage and/or clinical manifestations of HIV disease at year 8. High RNA levels at year 8 were significantly associated with symptomatic HIV Infection, low CD4+ T-cell count, p24 antigenaemia, low T-cell reactivity at year 8 as well as rapid annual CD4+ T-cell decline. High RNA level at year 1 was associated with high RNA levels at year 8 and low CD4+ T-cell count at year 1. In univariate analysis, RNA was associated with progression to AIDS after 8 years. In multivariate analysis, only the CD4+ T-cell count at year 8 remained significantly associated with progression to AIDS. CONCLUSIONS: In later stages of HIV infection, measures of immune deficiency may be more powerful prognostic markers than serum HIV-1 RNA level, indicating that optimal staging of the HIV-infected patient requires the combined use of RNA levels, CD4+ T-cell counts, and T-cell reactivity instead of RNA levels alone.

Sexual behaviours, perception of risk of HIV infection, and factors associated with attending HIV post-test counselling in Ethiopia.

OBJECTIVES: To describe sexual behaviours, perception of risk of HIV infection, and factors associated with attending HIV post-test counselling (PTC) among Ethiopian adults. METHODS: Data on socio-demographic characteristics, knowledge of HIV infection, sexual history, medical examination, and HIV and syphilis serological status were compared, through uni- and multivariate analysis, in relation to attending PTC within 60 days of HIV testing. RESULTS: Between February 1997 and June 1998, 751 factory workers were enrolled in a cohort study of HIV infection progression. Despite reporting high-risk sexual behaviours, mainly for males (64% of males and 6% of females had more than five sexual partners in their lifetime, 16% of males and 2% of females reported having had recent casual partners), and knowing that HIV is commonly transmitted heterosexually in Ethiopia (97% of answers being correct, both genders combined), only 17% of males and 2% of females acknowledged having had activities which had put them at risk of HIV infection. HIV prevalence was 12%, and did not differ by gender. Of all study participants, 327 (43.5%) returned for PTC within 60 days of HIV testing. PTC attendance did not differ by age, gender, or HIV serological status. Factors independently associated with PTC attendance in males were: good knowledge of HIV infection, [odds ratio (OR) = 1.661, belief that medical follow-up improves the course of HIV infection (OR = 2.02), history of genital symptoms (OR = 2.83), positive syphilis serology (OR = 2.62), recent weight loss (OR = 1.89), and, with a negative association, being a manual worker (OR = 0.40), and history of recent casual sexual relationships (OR = 0.35). In women, belief that HIV/AIDS can be cured (OR = 3.16), never having been married (OR = 5.02), having five or less children (OR = 2.16), having been raped (OR = 3.42), and having used health facilities in the past year (OR = 1.73) were all positively and independently associated with PTC attendance. CONCLUSION: Study participants reported high-risk sexual behaviours, yet had a low perception of individual risk. Men attended for PTC because of their knowledge of HIV infection, their past sexual history or their current health status. Women attended for PTC because of their plans for the future, marriage and/or children, rather than their past sexual exposure. Only in cases of rape were they willing to learn of their HIV status.

Human immunodeficiency virus infection and other risk factors for skin abscesses and endocarditis among injection drug users.

OBJECTIVE: To study incidence rates of and risk factors for skin abscesses at the site of injection and episodes of endocarditis among injection drug users (IDU). DESIGN: A comprehensive, open cohort study of drug users on the natural history of human immunodeficiency virus (HIV) infection. METHODS: From 1986 to 1994, injection drug users in Amsterdam were included in the study. Incidence rates of self-reported skin abscesses and verified episodes of endocarditis were calculated. In uni- and multivariate Poisson regression analysis, risk factors for skin abscesses and endocarditis were determined. RESULTS: 521 HIV-seronegative and 237 HIV-seropositive IDU were followed for 1640 person-years. A total of 545 skin abscesses were reported by 269 IDU (incidence 33/100 person-years). HIV infection, female gender, prostitution among females, foreign nationality, injection of heroin and cocaine, a high frequency of injecting, and obtaining syringes through the needle exchange program were independently and positively associated with skin abscesses. During follow-up, 17 verified episodes of endocarditis were observed (incidence 1.3/100 person-years). Endocarditis was independently associated with HIV infection and a previous history of endocarditis. Furthermore, women and IDU with a skin abscess appeared to be at an increased risk for endocarditis. CONCLUSIONS: HIV infection is an independent risk factor for skin abscesses and endocarditis. Also, women are at an increased risk for these injection-related infections. Prevention activities, like promotion of skin cleaning, should be directed at those IDU in whom one or more risk factors have been identified.

Incidence and risk factors for pneumonia in HIV infected and non-infected drug users.

OBJECTIVE: To study the incidence and risk factors for pneumonia in a cohort of HIV infected and non-infected drug users (DU). DESIGN: A prospective epidemiological study. SETTING AND PATIENTS: Injecting and non-injecting DU who attended the Municipal Health Service in Amsterdam for follow-up visits in the study. MAIN RESULTS: 203 HIV infected and 437 non-infected DU were followed for a total of 1749 person-years. HIV infected DU reported 111 episodes of pneumonia, which required hospitalization in 29 cases, and HIV negative DU reported 55 episodes, which required hospitalization in nine cases. The incidences among HIV positive and HIV negative DU were 0.19 and 0.05 per person-year respectively. With multivariate Poisson regression current injecting (RR 2.13), recent seroconversion (RR 3.92), asthmatic constitution (RR 2.72), CD4+ cell count between 200-500 (RR 1.67 compared to > 500), CD4+ cell count less than 200 (RR 2.23 compared to > 500) and a previous history of pneumonia (RR 2.43) were independently associated with self-reported pneumonia among HIV infected DU. Among HIV negative DU heroin smoking (RR 1.87), asthmatic constitution (RR 3.62) and a previous history of pneumonia (RR 2.84) were independently associated with self-reported pneumonia. Also a higher Quetelet Index (QI) appeared to be protective (QI > or = 21 RR 0.42, QI 19-21 RR 0.82 compared to QI < 19) among HIV negative DU. Risk factors for reported and hospitalized cases of pneumonia were comparable among HIV positive DU. CONCLUSIONS: HIV infected DU are at increased risk for pneumonia and the rate increases with lower CD4 cell counts. Also behavioural characteristics, such as injecting drug use and smoking heroin, and clinical history variables, such as a history of pneumonia or an asthmatic constitution, are risk factors for pneumonia among DU. Pneumococcal vaccination should not only be focused on HIV positive DU but also on the identified risk groups among HIV negative DU.

Emergence of syncytium-inducing human immunodeficiency virus type 1 variants coincides with a transient increase in viral RNA level and is an independent predictor for progression to AIDS.

To study the dynamics of human immunodeficiency virus (HIV)-1 RNA level around the time of conversion from non-syncytium-inducing (NSI) to syncytium-inducing (SI) phenotype and to study the predictive value of the SI phenotype for progression to AIDS, sequential samples from 123 HIV-infected homosexual men with documented intervals of seroconversion were evaluated. The NSI-to-SI phenotype conversion coincided with a 3-fold increase in median RNA level, which was not observed in matched controls in whom a viral phenotype conversion did not occur. This increase in virus was followed by a decrease to a higher steady-state RNA level than before the switch. After adjusting for RNA level and CD4 T cell count, SI phenotype was an independent marker for progression to AIDS. Hence, phenotype determination will contribute to optimal staging of HIV-infected persons in addition to virus load measurements and CD4 T cell count.

Gender differences in clinical manifestations before AIDS diagnosis among injecting drug users.

We compared incidence rates of self-reported HIV-related symptoms and illnesses, verified clinical manifestations and findings on physical examination between female and male injecting drug users (IDU) stratified by HIV serostatus in the Amsterdam cohort study on the natural history of HIV infection. HIV-positive female IDU (n = 100) reported a higher frequency of several symptoms and illnesses than male IDU (n = 139). Symptoms were reported more chronically by women compared to men, while clinical manifestations were reported by a greater proportion of women affected by these illnesses compared to men. In HIV-negative IDU (163 women and 232 men) the incidence rates were lower compared to HIV-positives, and a similar gender effect on reported symptoms and illnesses was found. Adjusting for biological, behavioral, demographic and study related variables did not change the gender effect on clinical manifestations substantially. We conclude that the gender effect among HIV-positive IDU was not caused by a differential impact of HIV infection on the incidence of the studied clinical manifestations among female and male IDU, but reflects a higher morbidity of female IDU compared to male IDU.

Differences in progression to AIDS between injection drug users and homosexual men with documented dates of seroconversion.

We compared rates of progression to AIDS for 99 injection drug users and 120 homosexual men with documented dates of HIV-1 seroconversion. The crude risk of developing AIDS was higher among homosexual men than injection drug users [relative hazard (RH) = 2.4; 95% confidence interval (CI) = 1.3-4.4]. The relative hazard was slightly smaller among participants with a seroconversion interval of < or = 1 year (RH = 2.2; 95% CI = 1.0-5.2). The effect was partially explained by the inclusion of Kaposi's sarcoma in the AIDS case definition. Excluding those with Kaposi's sarcoma, the relative hazard was 2.0 (95% CI = 1.1-3.8). Using the 1993 AIDS case definition decreased the effect (RH = 1.9; 95% CI = 1.1-3.4). Finally, the high pre-AIDS mortality among injection drug users could partially explain the difference in progression rate between injection drug users and homosexual men. Combining the effect of the above-mentioned factors resulted in a relative hazard of 1.3 (95% CI = 0.7-2.6). Thus, the slower progression to AIDS among injection drug users compared with homosexual men was largely explained by differences in the spectrum of AIDS-defining illnesses, pre-AIDS mortality, and length of seroconversion interval.