Incorporation of skin preparation guidelines in local surgical facility protocols: what kind of barriers does it face? A multi-centre study in France.

BACKGROUND: Surgical site infection (SSI) is the most frequent and severe adverse event after surgery. Among preventive measures, the preoperative skin preparation (PSP) is known to be heterogeneously implemented in routine practice. A prerequisite would be the actual incorporation of guidelines in French surgical local protocols. AIM: To assess whether PSP recommendations have been incorporated in local protocols and to identify the reasons for the non-incorporation. METHODS: An online survey was proposed to all infection control teams (ICTs) in facilities participating in the French national surveillance and prevention of SSI network Spicmi. The reference recommendations were based on the French Society for Hospital Hygiene guidelines. FINDINGS: In all, 485 healthcare facilities completed the questionnaire. The incorporation of recommendations in the facility protocol varied between 30% and 98% according to the recommendation. The measures most frequently incorporated were antisepsis with an alcoholic product and cessation of systematic hair removal. The least frequently incorporated were the use of plain soap for preoperative shower and the non-compulsory skin cleaning in the operating room. Barriers reported were either specific to PSP (e.g. 'Concern about an increase of SSI', 'Scepticism about recommendations', 'Force of habit') or non-specific (e.g. 'The protocol not yet due to be updated'). CONCLUSION: We suggest that although some major prevention measures have been incorporated in the local protocol of most facilities, local protocols still frequently include some non-evidence based former recommendations. Communication about evolution of SSI rates, diffusion of guidelines by learned societies, and exchange with judiciary experts could make clear the conditions for applying recommendations.

Compliance with good practice guidelines for the prevention of vascular access infections: the multi-centre PHYDEL survey in French haemodialysis units.

BACKGROUND: French guidelines for the prevention of vascular access infections in a haemodialysis setting were released in 2005. Compliance with these guidelines is currently unknown. The aim of this study was to assess compliance with the guidelines for vascular access infection prevention in French haemodialysis units, and to describe the difficulties reported. METHODS: A cross-sectional survey was conducted between March and December 2019 in 200 haemodialysis units in France, selected at random. Data were collected via questionnaire, completed by telephone interview with an infection control practitioner. A practice was deemed compliant when >85% of units declared that they always complied with the guidelines. RESULTS: In total, 103 units (51.5%) agreed to participate. Most practices complied with the guidelines; however, some practices did not reach the 85% compliance threshold for working in pairs when connecting central venous catheter (CVC) lines, performing hand hygiene before disconnecting lines, rinsing antiseptic soap before painting CVC exit site or arteriovenous fistula (AVF) puncture site, allowing antiseptic paint to dry, handling CVC branches with antiseptic impregnated gauze, performing hand hygiene after AVF compression with gloves, wearing protective eyewear when connecting/disconnecting CVC or when puncturing AVF, and wearing a gown when puncturing AVF. The most frequently reported difficulties were understaffing, difficulties with skin preparation because of exit site skin damage, and lack of buttonhole technical expertise. CONCLUSIONS: Despite good overall compliance, this survey highlights some shortcomings in compliance with infection prevention guidelines, which could be associated with either higher risk of vascular access infection or increased blood-borne virus transmission.

Lack of effect of a poster-based intervention to reduce the number of blood culture samples collected.

OBJECTIVE: To reduce the number of blood culture samples collected. PATIENTS AND METHOD: We performed a cluster randomized controlled trial in adult acute care, and subacute care and rehabilitation wards in a university hospital in France. A poster associating an image of eyes looking at the reader with a summary of blood culture sampling guidelines was displayed in hospital wards in the intervention group. The incidence rate of blood cultures per 1000 days during pre- and post-intervention periods was calculated. RESULTS: Thirty-one wards participated in the study. The median difference in blood cultures/1000 days between periods was -1.863 [-11.941; 1.007] in the intervention group and -5.824 [-14.763; -2.217] in the control group (P=0.27). CONCLUSION: The intervention did not show the expected effect, possibly due to the choice of blood cultures as a target of good practice, but also to confounding factors such as the stringent policy of decreasing unnecessary costly testing.

Reassessment of antibiotic therapy in hospitals.

INTRODUCTION: French national guidelines state that antibiotic therapies should be reassessed between 48 and 72hours after treatment initiation and that reassessment of antibiotic therapy (RA) must be recorded in patients' files. OBJECTIVE: To determine whether RA is performed and recorded in patients' files in hospitals in a region of France. METHODS: Setting: hospitals participating in the National nosocomial infection point- prevalence survey (NPS) in Upper-Normandy, France. Patients included those receiving antibiotic therapy (excluding antibiotic prophylaxis) on NPS day, started in the hospital in which the survey was conducted and ongoing for more than 72hours. Data collected included characteristics of participating hospitals and, for each included patient, characteristics of ward, infection and antibiotic therapy, and mention in the patients' files of explicit or implicit RA. The rate of explicit and implicit RA was calculated and factors associated with explicit or implicit RA were evaluated using a univariate analysis. RESULTS: Thirty-three hospitals representing 87% of hospital beds region-wide were included in the study. In addition, 933 prescriptions were assessed for 724 infections in 676 patients. The overall rate of RA was 67.6% (49.3% of explicit RA and 18.3% of implicit RA). The rate of RA differed significantly according to infection and antibiotic class but not according to hospital or ward characteristics. CONCLUSION: Our study provides new and reassuring results regarding reassessment of antibiotic therapy.

Pandemic A/H1N1/2009 influenza in a paediatric haematology and oncology unit: successful management of a sudden outbreak.

Viral respiratory infections are potentially life-threatening among children treated for cancer. We report a nosocomial outbreak of six cases of pandemic influenza A/H1N1/2009 on a paediatric haematology and oncology ward. Three patients developed pneumonia and two of them sustained haemodynamic collapse. The source was probably a relative of the first infected patient. The outbreak was probably spread by cross-infection between patients during communal activities. A few days' delay in identifying the outbreak promoted spread of the influenza. Infection control measures included the use of oral oseltamivir treatment for all hospitalised patients, isolation of the infected patients, strict personal protective controls and a restriction on visitors. No new cases occurred after implementation of these containment measures. At the time when the outbreak was identified, all the patients were already isolated for other reasons. We conclude that A/H1N1/2009 influenza may spread rapidly and cause severe infection in paediatric cancer patients but can be efficiently contained. Identification of isolated or clustered cases should lead to the rapid implementation of appropriate infection control measures.

The changing pattern of Crohn's disease incidence in northern France: a continuing increase in the 10- to 19-year-old age bracket (1988-2007).

BACKGROUND: Crohn's disease incidence rates have stabilised in industrialised countries since the 1980s. Conversely, a continuing increase in childhood-onset Crohn's disease incidence has been reported. AIM: To confirm trends in inflammatory bowel disease (IBD) incidence in northern France over an extended time period (1988-2007) with a focus on childhood-onset Crohn's disease. METHODS: The IBD patients recorded in the EPIMAD registry between 1988 and 2007 were included. Standardised incidence rates were calculated for Crohn's disease and ulcerative colitis in the entire population, and separately according to age. Evolution of phenotypes at diagnosis was also studied. RESULTS: A total of 12 084 incident IBD cases (7428 Crohn's disease and 4656 ulcerative colitis) were recorded. Crohn's disease incidence rates increased from 5.2 cases/100 000 persons in 1988-1990 to 6.7 in 2006-2007 (+29%), stabilising after a peak at 7.1 in 1997-1999. Crohn's disease incidence rates in the 10-19-year age category increased by 71%, from 6.5 (1988-1990) to 11.1 (2006-2007). The frequency of initial ileo-colonic localisation increased from 52.9% in 1988-1990 to 68.6% in 2006-2007 (P<0.0001). Ulcerative colitis incidence rates decreased during the same period. CONCLUSIONS: From 1988 to 2007, Crohn's disease incidence increased by 29% in northern France and by 71% in the 10-19-year-old age group. Consequently, studies on Crohn's disease risk factors should focus on the population under 20 years of age.

[Information for patients about hospital infections in psychiatry: An assessment of healthcare professionals' knowledge, opinion and attitude]. / Connaissances, opinions et pratiques des professionnels concernant l'information des patients sur les infections nosocomiales : évaluation en milieu psychiatrique.

INTRODUCTION: French legislation makes mandatory for healthcare providers the disclosure of hospital infection (HI) risk and actual occurrence to the patient. Given the specific diseases encountered in psychiatry, some difficulties may be expected in practical application of this regulation. OBJECTIVES: The aim of our study was to describe the knowledge, declared practices and opinions of healthcare workers (HCW) in psychiatry concerning information for patients about HI. METHODS: We randomly selected doctors, nurses and head nurses from four hospitals with psychiatric activity in Normandy. The HCW were asked to self-complete an anonymous questionnaire, including data describing the responding HCW and questions aiming at describing his/her knowledge, attitude in routine daily practice and opinion about information to patients about HI. RESULTS: One hundred and forty-one HCW were initially selected, of which 114 (80.9%) eventually agreed to complete the questionnaire. Only eight HCW (7.0%) were considered to have a correct overall knowledge of legal obligations. Main errors concerned the obligation to inform the patient of the HI risk according to the medical procedures that are to be performed (43.9% of correct answers) and the obligation to inform the patient of the HI risk according to his/her medical condition (46.5%). The obligation to inform the patient of the occurrence of a HI was largely known (84.2%). HCW usually giving information about the risk of HI to patients without HI accounted for 5.3%. Main reasons advocated for not informing patients were a low level risk of HI in psychiatry (80.4%) and the lack of patients' demand (59.8%). In the case of HI occurrence, the percentage of HCW routinely informing patients was 13.2%. HCW systematically informing the patient's family about the occurrence of HI accounted for 9.6%. A large proportion of HCW supported delivering information to patients about HI (86.0%). HCW expected from information better approval of prevention programs by the patients (87.7%) but feared an increased anxiety in patients (75.4%) and a higher rate of care refusal (48.2%). CONCLUSION: Whereas a very large proportion of HCW in psychiatry support delivering information to patients about HI, our study shows HCW's lack of awareness of regulations and lack of declared practices. Among factors explaining this contrast, a lower perceived HI risk and severity level are to be mentioned. Training programs focusing on risk and mechanisms of HI could be offered to professionals in psychiatry. The issue of specific communication difficulties with psychiatric patients should be addressed as well. In order to develop information on HI, specific methods suited to those patients should be developed.

Influence of infection control report cards on patients' choice of hospital: pilot survey.

The impact on patients' attitudes of quality report cards on infection control in hospitals has never previously been studied. In 2006, the French government implemented a mandatory report card on infection control activity (ICALIN) in all hospitals. This approach was aimed at encouraging professionals to change their routine practices in case they should lose patients due to a low ICALIN score. Our objective was to assess what impact ICALIN could have on patients' attitude as regards hospital choice. We performed a survey of patients and visitors in 14 randomly selected hospitals of various ICALIN scores. A convenience sample of 381 patients and visitors completed an anonymous questionnaire on ICALIN, their reasons for choosing a hospital and attitude in the event of a low ICALIN score. Factors associated with interest in ICALIN and impact of ICALIN on hospital choice were assessed by logistic regression. Our results showed that 77% of participants were interested in ICALIN. ICALIN was ranked sixth as a reason for choosing a hospital. In the case of a low ICALIN, 24.1% of participants would refuse admission and 54.9% would seek advice from their general practitioner. Sociodemographic factors had no influence on patients' attitude. In conclusion, our survey suggests that patients take note of poor performance on infection control report cards. As most patients rely on their general practitioner to interpret these report cards, there is a definite need for further communication with general practitioners on this issue.

[Efficacy of a multidisciplinary team for preventing hospital-acquired invasive aspergillosis: five years' experience]. / Efficacité des mesures environnementales dans la prévention de l'aspergillose invasive nosocomiale liée aux travaux: bilan de cinq années d'expérience.

Invasive hospital-acquired aspergillosis (IA) is responsible for lethal outbreaks. In 2002, an interdisciplinary team was created in the teaching hospital of Rouen in order to organize the surveillance of construction sites by the implementation of environmental measures of prevention. The aim of our study was to estimate the efficiency of these measures using an indirect indicator, reflecting the incidence of the cases of invasive nosocomial aspergillosis (AI): the consumption of antifungals. From the nominative prescriptions established, we studied the medical files about 210 patients to track down the number of IA cases in intensive care unit (ICUI) and in pediatric hematology-oncology units between 2002 and 2006. The incidence of the cases was put in parallel with the various periods of level 5-risk works during these five years. The relative risk of appearance of the disease was calculated. In pediatric haematology-oncology unit, 35 cases were diagnosed on 99 medical files which have been studied and in ICU 19 cases were classified on 93 studied files. The follow-up of the incidence in both units stake in parallel with the periods of level 5-risk works does not show increase of the number of cases. The calculated relative risk indicates the same result: the level 5-risk works are not a factor facilitating the appearance of invasive aspergillosis cases. This study shows the importance of the environmental measures of prevention during the periods of works within services for risk. The coordination of the actors within an interdisciplinary cell seems thus essential for the prevention of AIN.

Mycoplasma hominis wound infection after a vascular allograft.

Cases of Mycoplasma hominis infections after allograft are rare. We report a case of M. hominis wound infection after a vascular allograft. The allograft was positive before having any contact with the recipient, and our investigation suggests that M. hominis may have been transmitted from the donor to the recipient. It is not clear, however, whether specific diagnosis of M. hominis should be performed on tissue before grafting in order to prevent such donor-to-host transmission.

What factors influence healthcare professionals' opinion and attitude regarding information for patients about hospital infection?

Although informing patients about medical risks is said to decrease the number of malpractice claims, most inpatients receive no information about hospital infection. Using a self-administered questionnaire, we surveyed 1270 healthcare workers randomly selected from 22 French hospitals to assess their opinion on information for patients about hospital infection risks, and their practice of informing patients with, or without, hospital infection. The influence of healthcare worker characteristics on opinion and practice was assessed using logistic regression. Response rate was 87.2%. Although 85.4% supported giving more information, only 17.0% routinely informed non-infected patients and 31.6% informed infected patients about infection. Attitudes were influenced by healthcare worker characteristics and environmental factors. Knowledge of obligations influenced practice when informing non-infected patients, but not those with hospital-acquired infection. Further research is needed to help healthcare professionals improve risk communication and disclosure of hospital infection.

Alcohol-based hand rub: influence of healthcare workers' knowledge and perception on declared use.

Handrubbing with alcohol-based hand rub (AHR) is a validated alternative to handwashing. The aims of this study were to compare knowledge and declared use of AHR between different categories of healthcare worker (HCW), and to assess factors associated with the use of AHR. A standardized questionnaire was sent to all HCWs in a tertiary care university hospital. The following data were collected for each HCW: job title (physician, nurse, nursing assistant or other), sources of information about AHR; knowledge and perception of AHR and declared use of AHR in daily practice instead of unmedicated or antiseptic soap. Of 5238 questionnaires, 1811 were returned. Physicians had better knowledge about AHR than other HCWs. HCWs' knowledge of AHR efficacy and skin tolerance were independently associated with the use of AHR instead of unmedicated or antiseptic soap. The declared use of AHR differed according to professional category.

Surgical hand rubbing compared with surgical hand scrubbing: comparison of efficacy and costs.

The aim of this study was to compare the efficacy of surgical hand rubbing (SHR) with the efficacy of surgical hand scrubbing (SHS), and to determine the costs of both techniques for surgical hand disinfection. A review of studies reported in the literature that compared the efficacy of SHS and SHR was performed using MEDLINE. The costs of SHR and SHS were estimated based on standard hospital costs. The literature showed that SHR had immediate efficacy that was similar to that of SHS, but SHR had a more lasting effect. SHR reduced costs by 67%. In conclusion, SHR is a cost-effective alternative to SHS.

Knowledge and opinions of surgical patients regarding nosocomial infections.

UNLABELLED: Sixty-five inpatients in various surgery departments were questioned about their knowledge and opinions regarding nosocomial infection, the information they were given on nosocomial infection, and their supposed attitude should they contract a nosocomial infection. RESULTS: Seventeen (26%, [16-39%]) were able to describe nosocomial infections as infections acquired in hospital. Identification of nosocomial infections as hospital-acquired infections was significantly associated with a high educational level and with having a member of their own family working in a health-related field. Fifty-two patients (80.0%, [68.2-88.9%]) stated that during their hospitalization they had received no information concerning nosocomial infections and 50 patients (76.9% [64.8-86.5]) mentioned that patients would welcome information about nosocomial infections. Thirty-three patients [50.8, 95% CI(38.6-62.9%)] declared that they would seek legal action against the hospital should they contract a nosocomial infection. There was a trend toward a higher probability of legal action in patients who rated their own risk of nosocomial infection as low or absent versus those who rated their own risk of nosocomial infection as medium or high (58.0% vs. 28.6%, p=0.051). The intention of seeking legal action against the hospital in case of nosocomial infection was not significantly influenced by patients' opinion regarding nosocomial infection preventability.

Environmental risk factors in paediatric inflammatory bowel diseases: a population based case control study.

BACKGROUND: Environmental exposures in early life have been implicated in the aetiology of inflammatory bowel disease. OBJECTIVE: To examine environmental risk factors prior to the development of inflammatory bowel disease in a paediatric population based case control study. METHODS: A total of 222 incident cases of Crohn's disease and 60 incident cases of ulcerative colitis occurring before 17 years of age between January 1988 and December 1997 were matched with one control subject by sex, age, and geographical location. We recorded 140 study variables in a questionnaire that covered familial history of inflammatory bowel disease, events during the perinatal period, infant and child diet, vaccinations and childhood diseases, household amenities, and the family's socioeconomic status. RESULTS: In a multivariate model, familial history of inflammatory bowel disease (odds ratio (OR) 4.3 (95% confidence interval 2.3-8)), breast feeding (OR 2.1 (1.3-3.4)), bacille Calmette-Guerin vaccination (OR 3.6 (1.1-11.9)), and history of eczema (OR 2.1 (1-4.5)) were significant risk factors for Crohn's disease whereas regular drinking of tap water was a protective factor (OR 0.56 (0.3-1)). Familial history of inflammatory bowel disease (OR 12.5 (2.2-71.4)), disease during pregnancy (OR 8.9 (1.5-52)), and bedroom sharing (OR 7.1 (1.9-27.4)) were risk factors for ulcerative colitis whereas appendicectomy was a protective factor (OR 0.06 (0.01-0.36)). CONCLUSIONS: While family history and appendicectomy are known risk factors, changes in risk based on domestic promiscuity, certain vaccinations, and dietary factors may provide new aetiological clues.