Using a stacker crane for sterile storage in the operating theatre: initial environmental microbiological qualification.

BACKGROUND: Adequate storage of sterile surgical devices must prevent contamination and the introduction of microbial contaminants inside the operating room. For functional and economic purposes, stacker cranes (STCs) could replace the traditional sterile storage room (TSSR). STCs are large, multi-stage, computer-assisted systems used to automatically store and retrieve loads from defined locations. However, their microbiological performance has not been evaluated. AIM: As part of the opening of a new building that included an operating theatre, we qualified a new STC and compared its microbiological control performance to that of the previous TSSR. METHODS: From December 2020 to March 2021, 590 environmental specimens (air, N = 56; surfaces, N = 534) were collected and interpreted according to the NF S90-351 French Association for Standardization standards. FINDINGS: Thorough surface disinfection was not sufficient for controlling microbial contamination in the STC. Thus, the initial qualification testing was conducted following an aggressive aerial chemical decontamination of the STC. Despite the lack of a HEPA filtered air system, the overall non-conformity rates were lower in the STC than in the TSSR (8.3% vs 21.4%, P=0.33 for air, respectively, and 9.7% vs 41.7% P<0.001 for surfaces). The air-controlled barrier in front of the loading zone appeared to be sufficient to prevent bacterial contamination. The presence of fungi must be carefully monitored. CONCLUSION: This is the first study supporting the contribution of STCs in saving space and improving the maintenance of sterile surgical device storage and availability under acceptable environmental conditions. Further studies are needed to assess the long-term microbiological contamination inside the STC.

Local outbreak of extended-spectrum ß-lactamase SHV2a-producing Pseudomonas aeruginosa reveals the emergence of a new specific sub-lineage of the international ST235 high-risk clone.

BACKGROUND: Pseudomonas aeruginosa is a major bacterial pathogen responsible for hospital-acquired infections. Although its epidemiology is considered as non-clonal, certain international high-risk multidrug-resistant clones have been recognized. AIM: From the first report of an intra-hospital outbreak due to an SHV2a-producing P. aeruginosa strain, to describe the emergence of a new ST235-specific lineage harbouring this rare extended-spectrum ß-lactamase (ESBL). METHODS: Between May and October 2018, four patients hospitalized in the cardiovascular intensive care unit of a French teaching hospital were infected by a multidrug-resistant P. aeruginosa isolate. Serotype and antimicrobial susceptibility were tested; multi-locus sequence type (MLST), core genome MLST, and resistome were determined through whole genome sequencing. A phylogenetic analysis based on single nucleotide polymorphism was performed using available ST235 genomes. FINDINGS: The four strains were susceptible to colistin, ciprofloxacin, ceftazidime-avibactam, and ceftolozane-tazobactam. blaSHV2a was identified in each genome of this ST235-O11 serotype cluster that showed an identical cgMLST profile (0-2 out of 4162 different alleles). The phylogenic analysis of 162 ST235 genomes showed that only four other strains harboured a blaSHV2a, originating from France and USA, clustering together although being different from the outbreak strains. CONCLUSIONS: Among the ST235 P. aeruginosa strains, a sub-lineage sharing a common genetic background and harbouring the blaSHV2a ESBL seems to emerge from different locations, yielding secondary local outbreaks.

Contribution and limits of clinical specimens for the screening of intestinal multi-drug-resistant bacteria in view of laboratory automation.

The detection of multi-drug-resistant bacteria carriers constitutes a race against time for infection preventionists. Alongside standard analysis for diagnostic purposes and a rectal screening strategy, the authors tested a heavy-loaded selective method against 562 clinical specimens from 439 patients to detect extended-spectrum beta-lactamase-producing (ESBL) or carbapenemase-producing Enterobacteriaceae (CPE) and vancomycin-resistant enterococci (VRE). The approach identified five more specimens positive for ESBL-producing Enterobacteriaceae than standard analysis, and six out of nine known VRE/CPE carriers (three new CPE/VRE strains were also identified in this cohort). In view of the ongoing automation of laboratories, this approach focusing on urine and stool specimens may be an alternative or complementary approach to dedicated rectal screening.

Misuse of gloves: the foundation for poor compliance with hand hygiene and potential for microbial transmission?

Improvement in hand hygiene compliance is important for reducing cross-infection by micro-organisms. The objective of this prospective observational study was to measure how the improper use of gloves limits compliance to hand hygiene and exposes patient's to infection. The study was conducted in five wards (three intensive care units and two medical wards) in a French university hospital. Staff-patient and staff-environment contacts were observed in 120 healthcare workers caring for patients colonized or infected with pathogenic bacteria. Hand hygiene was not undertaken due to improper gloving in 64.4% (95%CI, 64.1% to 65.1%) of instances. Possible microbial transmission might have occurred in 18.3% (95%CI, 17.8% to 18.8%) of all contacts because used gloves were not removed before performing care activities that necessitated strict aseptic precautions. Failure to change or remove contaminated gloves was a major component in the poor compliance with hand hygiene and carried a high-risk of microbial transmission. Improving hand hygiene compliance will require changing healthcare workers behaviour towards glove use.

Multicenter trial of intravenous anisoylated plasminogen streptokinase activator complex (APSAC) in acute myocardial infarction: effects on infarct size and left ventricular function.

Two hundred thirty-one patients with a first acute myocardial infarction were randomly allocated within 5 h after the onset of symptoms either to treatment with anisoylated plasminogen streptokinase activator complex (APSAC), 30 U over 5 min, or to conventional heparin therapy, 5,000 IU in a bolus injection. Heparin was reintroduced in both groups 4 h after initial therapy at a dosage of 500 IU/kg per day. One hundred twelve patients received APSAC and 119 received heparin within a mean period of 188 +/- 62 min after the onset of symptoms. Both groups were similar in age, location of the acute myocardial infarction, Killip functional class and time of randomization. Elective coronary arteriography was performed on an average of 4 +/- 1.2 days after initial therapy. Follow-up radionuclide angiography and thallium-201 single photon emission computed tomography were performed before hospital discharge. Infarct size was estimated from single photon emission computed tomography and expressed as a percent of total myocardial volume. The patency rate of the infarct-related artery was 77% in the APSAC group and 36% in the heparin group (p less than 0.001). Left ventricular ejection fraction determined from contrast angiography was significantly higher in the APSAC group than in the heparin group. This was true for the entire study group (0.53 +/- 0.13 versus 0.47 +/- 0.12; p = 0.002) as well as for the subgroups of patients with anterior and inferior wall infarction (0.47 +/- 0.13 versus 0.40 +/- 0.11; p = 0.04 and 0.56 +/- 0.10 versus 0.51 +/- 0.11; p = 0.02, respectively). At 3 weeks, the difference remained significant for the anterior myocardial infarction subgroup. A significant 31% reduction in infarct size was found in the APSAC group (33% for the anterior infarction subgroup [p less than 0.05] and 16% for the inferior infarction subgroup [p = NS]). A close inverse relation was found between the values of left ventricular ejection fraction and infarct size (r = -0.73, p less than 0.01). By the end of a 3 week follow-up period, seven APSAC-treated patients and six heparin-treated patients had died. In conclusion, the early infusion of APSAC in acute myocardial infarction produced a high early patency rate, significant limitation of infarct size and significant preservation of left ventricular systolic function, mainly in anterior wall infarction.

[Exertion-induced parameters of left ventricular function in patients with chronic cardiac insufficiency. An isotope study]. / Evolution à l'effort des paramètres de fonction ventriculaire gauche chez des patients atteints d'une insuffisance cardiaque chronique. Etude isotopique.

Exercise-induced changes in haemodynamic values were studied by radionuclide ventriculography in 21 patients with permanent systolic dysfunction (15 with non-obstructive cardiomyopathy and 6 with ischaemic heart disease). The results were compared with those obtained in 8 control subjects with normal heart. In healthy subjects, during exercise the ejection fraction increased due to constant diminution of the end-systolic volume; the end-diastolic volume and the systolic ejection volume did not significantly vary; the cardiac output augmented only because of the accelerated heart rate. In patients with permanent left ventricular dysfunction, the ejection fraction remained unchanged during exercise, whereas the end-systolic volume increased significantly. Yet the systolic ejection volume increased due to a rise in end-diastolic volume. Heart rate and cardiac index increased, but not as much as in normal subjects. There was a close correlation between changes in end-diastolic and end-systolic volumes. It was the relative importance of changes in these two ventricular volumes that determined the direction and amplitude of variations in ejection fraction. It is concluded that in patients with permanent left ventricular dysfunction: (1) the end-systolic volume increases during exercise, thus betraying a worsening of the systolic dysfunction; (2) however, the systolic ejection volume is maintained or increases due to an increase in end-diastolic volume; (3) the changes in ejection fraction observed during exercise are of little value to characterize the modifications that occur in left ventricular work performance.

Adaptation of the left ventricular function parameters to dynamic exercise in aortic stenosis.

The left ventricular volumes, the left ventricular ejection fraction, the stroke volume index and the cardiac index were non-invasively determined in 47 patients suffering from moderate to severe pure aortic stenosis using radionuclide angiography at rest and at peak supine exercise. Each patient was previously submitted to right and left heart catheterization and to selective coronary angiography. The left ventricular ejection fraction decreased significantly during exercise (0.62 +/- 0.09 to 0.59 +/- 0.09, P less than 0.01). End-systolic volume, end-diastolic volume, stroke volume index and cardiac index increased significantly. The stroke volume variations were linked to the end-diastolic volume variations by a strong relationship (r = 0.84, P less than 0.001) and to left ventricular mass by a weak, but significant, inverse relationship (r = -0.42, P less than 0.05). No relation existed between stroke volume index variations and any other variables, particularly systolic gradient, aortic valve area and resting left ventricular ejection fraction. The results suggest that, in aortic stenosis, the adaptation of the left ventricular pump function during exercise is mostly dependent upon the diastolic properties of the left ventricular wall and is limited by the progression of left ventricular hypertrophy, i.e. diastolic stiffness. By contrast, the role of the basal systolic pump function and of the severity of the valvular obstruction seems of limited importance.