Trends in the use of laboratory tests for the diagnosis of Clostridium difficile infection and association with incidence rates in Quebec, Canada, 2010-2014.

BACKGROUND: Several Clostridium difficile infection (CDI) surveillance programs do not specify laboratory strategies to use. We investigated the evolution in testing strategies used across Quebec, Canada, and its association with incidence rates. METHODS: Cross-sectional study of 95 hospitals by surveys conducted in 2010 and in 2013-2014. The association between testing strategies and institutional CDI incidence rates was analyzed via multivariate Poisson regressions. RESULTS: The most common assays in 2014 were toxin A/B enzyme immunoassays (EIAs) (61 institutions, 64%), glutamate dehydrogenase (GDH) EIAs (51 institutions, 53.7%), and nucleic acid amplification tests (NAATs) (34 institutions, 35.8%). The most frequent algorithm was a single-step NAAT (20 institutions, 21%). Between 2010 and 2014, 35 institutions (37%) modified their algorithm. Institutions detecting toxigenic C difficile instead of C difficile toxin increased from 14 to 37 (P < .001). Institutions detecting toxigenic C difficile had higher CDI rates (7.9 vs 6.6 per 10,000 patient days; P = .01). Institutions using single-step NAATs, GDH plus toxigenic cultures, and GDH plus cytotoxicity assays had higher CDI rates than those using an EIA-based algorithm (P < .05). CONCLUSIONS: Laboratory detection of CDI has changed since 2010. There is an association between diagnostic algorithms and CDI incidence. Mitigation strategies are warranted.

Management of a hospital outbreak of extensively drug-resistant Acinetobacter baumannii using a multimodal intervention including daily chlorhexidine baths.

BACKGROUND: Extensively drug-resistant Acinetobacter baumannii (XDR-Ab) is an increasingly important cause of healthcare-associated infection. Uncertainties remain concerning optimal control measures for healthcare-associated outbreaks. AIM: To describe the epidemiology and control of an XDR-Ab outbreak that involved multiple units of a large hospital from March 2012 to January 2014. METHODS: Case-finding included screening of rectum, groin, throat, nose, wounds, iatrogenic portals of entry, and catheterized sites. Antimicrobial susceptibility was evaluated by disc diffusion and E-test. Resistance genes were detected by polymerase chain reaction. Clonality was assessed by pulsed-field gel electrophoresis. Charts of cases were reviewed to identify risk factors for invasive infection. Control measures included isolation and cohorting of cases, hand hygiene reinforcement, environmental decontamination, and source control with daily baths using wipes pre-impregnated with chlorhexidine gluconate. FINDINGS: A single clonal strain of XDR-Ab colonized or infected 29 patients. Five patients died of XDR-Ab bacteraemia. Transmission occurred primarily on two wards. Colonization was detected at all anatomical screening sites; only 57% (16/28) of cases were rectal carriers. Advanced malignancy was a risk factor for bacteraemia (relative risk: 5.8; 95% confidence interval: 1.2-27.0). Transmission ended following implementation of the multimodal control strategy. No additional nosocomial cases occurred during the following 20 months. CONCLUSION: Our study highlights the need to screen multiple anatomic sites to diagnose carriage and identifies risk factors for XDR-Ab bacteraemia. A multimodal intervention that included daily chlorhexidine baths for cases was rapidly followed by the termination of the outbreak. Hospitals should consider similar interventions when managing future XDR-Ab outbreaks.

Clinical characteristics and outcome of patients with Clostridium difficile infection diagnosed by PCR versus a three-step algorithm.

Clinical features of Clostridium difficile infections (CDI) detected by PCR, but not by conventional methods, are poorly understood. We compared the clinical features of CDI cases detected by PCR only and cases detected by both PCR and a three-step algorithm. We performed a retrospective cohort study of patients fulfilling a standardized definition over a 13-month period. Stool specimens were tested in parallel by PCR and an algorithm based on enzyme immunoassay and cytotoxicity assay (EIA/CCA). Clinical features of CDI cases detected by PCR only and cases detected by PCR and EIA/CCA were compared by univariate logistic regression. In all, 97 patients (31 PCR+ and 66 PCR+EIA/CCA+) met the inclusion criteria. Compared with cases detected by both PCR and EIA/CCA, CDI cases detected by PCR only were younger (65.4 versus 76.3 years; p 0.001), had a lower absolute neutrophil count (mean, 9.4 × 10(9) /L versus 12.5 × 10(9) /L; p 0.04), were less likely to receive oral vancomycin (2/31 versus 25/66; p 0.005) or combination therapy (0/31 versus 16/66; p 0.04), and had fewer complications (6/31 versus 29/66; p 0.02), despite presenting a higher number of bowel movements on the day of diagnosis (median, 6.0 versus 3.0; p 0.02). They had also a lower C. difficile faecal bacterial load (mean, 5.04 versus 6.89 log10 CFU/g; p <0.001). The CDI cases detected by PCR only and cases detected by both PCR and EIA/CCA have different clinical features, but whether these two populations can be managed differently remains to be determined.

Deep sternal wound infection due to Pasteurella multocida: the first case report and review of literature.

Pasteurella multocida is a Gram-negative bacterium recovered from a wide variety of wild and domestic animals and has mostly been associated with infection following animal bites. We present the first reported case of a patient who developed a postoperative sternal wound infection due to P. multocida complicated by bloodstream infection. The outcome was favorable following surgical debridement and antimicrobial therapy. We also review the literature regarding P. multocida postoperative wound infections.

Involving the patient to ask about hospital hand hygiene: a National Patient Safety Agency feasibility study.

Healthcare-associated infections (HAIs) affect at least 300,000 patients annually in the UK and represent a significant, yet largely preventable, burden to healthcare systems. Hand hygiene by healthcare workers (HCWs) is the leading prevention measure, but compliance with good practice is generally low. The UK National Patient Safety Agency surveyed the public, inpatients, and HCWs, particularly frontline clinical staff and infection control nurses, in five acute care hospitals to determine whether they agreed that a greater level of involvement and engagement with patients would contribute to increased compliance with hand hygiene and reduce HAIs. Fifty-seven percent (302/530) of the public were unlikely to question doctors on the cleanliness of their hands as they assumed that they had already cleaned them. Forty-three percent (90/210) of inpatients considered that HCWs should know to clean their hands and trusted them to do so, and 20% (42/210) would not want HCWs to think that they were questioning their professional ability to do their job correctly. Most HCWs surveyed (178/254, 71%) said that HAI could be reduced to a greater or lesser degree if patients asked HCWs if they had cleaned their hands before touching them. Inviting patients to remind HCWs about hand hygiene through the provision of individual alcohol-based hand-rub containers and actively supporting an 'It's OK to ask' attitude were perceived as the most useful interventions by both patients and HCWs. However, further work is required to refute the myth among HCWs that patient involvement undermines the doctor- or HCW-patient relationship.

Community-associated methicillin-resistant Staphylococcus aureus: risk factors for infection, and long-term follow-up.

Uncertainty persists about risk factors for community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections in Europe and the long-term efficacy of decolonization strategies. To evaluate risk factors for CA-MRSA in Geneva, Switzerland, a hospital-based, retrospective case-control study of 26 patients with CA-MRSA infection and 60 control patients was performed. To evaluate the long-term effect of a systematic decolonization strategy (with and without concomitant systemic antibiotic therapy) for CA-MRSA patients, a prospective cohort study of 79 patients with Panton-Valentine leukocidin-producing CA-MRSA isolates was conducted. Nationality other than European Union or Swiss (adjusted OR 6.09; 95% CI 1.07-34.65) and absence of healthcare contact (adjusted OR 0.11, 95% CI 0.02-0.59) were independent predictors of CA-MRSA infection. Forty-five cases were followed (median, 22 months) to assess the long-term efficacy of the decolonization strategy; 39/45 (86.7%) had no clinical relapse and were MRSA-negative at their last follow-up, whereas six remained MRSA-positive. Five of these six cases belonged to a family cluster. Decolonization rates were similar between infected patients and asymptomatic carriers (92.6% vs. 77.8%, p = 0.20). This study shows a lack of readily modifiable risk factors for CA-MRSA infection in this population, and suggests the potential usefulness of conducting decolonization procedures in a setting with sporadic CA-MRSA infection. Further studies are needed to elucidate the role of migration as a factor contributing to the emergence of CA-MRSA in Europe.