Universal risk assessment upon hospital admission for screening of carriage with multidrug-resistant micro-organisms in a Dutch tertiary care centre.

BACKGROUND: In Dutch hospitals a six-point questionnaire is currently mandatory for risk assessment to identify carriers of multidrug-resistant organisms (MDROs) at the time of hospitalization. Presence of one or more risk factors is followed by pre-emptive isolation and microbiological culturing. AIM: To evaluate the yield of the universal risk assessment in identifying MDRO carriers upon hospitalization. METHODS: A cross-sectional study was performed using routine healthcare data in a Dutch tertiary hospital between January 1st, 2015 and August 1st, 2019. MDRO risk assessment upon hospitalization included assessment of: known MDRO carriage, previous hospitalization in another Dutch hospital during an outbreak or a foreign hospital, living in an asylum centre, exposure to livestock farming, and household membership of a meticillin-resistant Staphylococcus aureus carrier. FINDINGS: In total, 144,051 admissions of 84,485 unique patients were included; 4480 (3.1%) admissions had a positive MDRO risk assessment. In 1516 (34%) admissions microbiological screening was performed, of which 341 (23%) yielded MDRO. Eighty-one patients were categorized as new MDRO carriers, as identified through MDRO risk assessment, reflecting 0.06% (95% confidence interval: 0.04-0.07) of all admissions and 1.8% (1.4-2.2) of those with positive risk assessment. As a result, the number of 'MDRO risk assessments needed to perform' and individual 'MDRO questions needed to ask' to detect one new MDRO carrier upon hospitalization were 1778 and 10,420, respectively. CONCLUSION: The yield of the current strategy of MDRO risk assessment upon hospitalization is limited and it needs thorough reconsideration.

Raman spectroscopy-based identification of nosocomial outbreaks of the clonal bacterium Escherichia coli.

DNA-based techniques are frequently used to confirm the relatedness of putative outbreak isolates. These techniques often lack the discriminatory power when analyzing closely related microbes such as E. coli. Here the value of Raman spectroscopy as a typing tool for E. coli in a clinical setting was retrospectively evaluated.

Decontamination of the digestive tract and oropharynx in ICU patients.

BACKGROUND: Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) are infection-prevention measures used in the treatment of some patients in intensive care, but reported effects on patient outcome are conflicting. METHODS: We evaluated the effectiveness of SDD and SOD in a crossover study using cluster randomization in 13 intensive care units (ICUs), all in The Netherlands. Patients with an expected duration of intubation of more than 48 hours or an expected ICU stay of more than 72 hours were eligible. In each ICU, three regimens (SDD, SOD, and standard care) were applied in random order over the course of 6 months. Mortality at day 28 was the primary end point. SDD consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach. SOD consisted of oropharyngeal application only of the same antibiotics. Monthly point-prevalence studies were performed to analyze antibiotic resistance. RESULTS: A total of 5939 patients were enrolled in the study, with 1990 assigned to standard care, 1904 to SOD, and 2045 to SDD; crude mortality in the groups at day 28 was 27.5%, 26.6%, and 26.9%, respectively. In a random-effects logistic-regression model with age, sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, intubation status, and medical specialty used as covariates, odds ratios for death at day 28 in the SOD and SDD groups, as compared with the standard-care group, were 0.86 (95% confidence interval [CI], 0.74 to 0.99) and 0.83 (95% CI, 0.72 to 0.97), respectively. CONCLUSIONS: In an ICU population in which the mortality rate associated with standard care was 27.5% at day 28, the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD. (Controlled Clinical Trials number, ISRCTN35176830.)

Prevalence of hospital-acquired infections during successive surveillance surveys conducted at a university hospital in the Netherlands.

OBJECTIVE: To monitor hospital-wide trends in the prevalence of hospital-acquired infections (HAIs) in order to identify areas where the risk of infection is increasing. METHODS: Successive surveillance surveys were conducted twice yearly, from November 2001 until May 2004, to determine the prevalence of HAIs at 2 Dutch hospitals, using Centers for Disease Control and Prevention criteria. RESULTS: In all, 340 HAIs were observed in 295 (11.1%) of 2,661 patients surveyed. The overall prevalence per survey varied from 10.2% to 15.6%, with no significant differences between successive surveys. In the surgical department, the prevalence of HAIs increased from 10.8 cases per 100 surgeries in November 2001 to 20.4 cases per 100 surgeries in May 2002. Further analysis revealed a high prevalence of surgical site infection among patients who had an orthopedic procedure performed. In the neurology-neurosurgery department, the prevalence increased from 13.0 cases per 100 patients in May 2002 to 26.6 cases per 100 patients in May 2003 and involved several types of infection. Further analysis retrieved exceptionally high incidences of infections associated with cerebrospinal fluid drainage. Specific infection control interventions were developed and implemented in both departments. The total cost of the surveys was estimated to be euro9,100 per year. CONCLUSION: Successive performance of surveillance surveys is a simple and cheap method to monitor the prevalence of infection throughout the hospital and appeared instrumental in identifying 2 departments with increased infection rates.

Genotyping and preemptive isolation to control an outbreak of vancomycin-resistant Enterococcus faecium.

BACKGROUND: Control of vancomycin-resistant Enterococcus faecium (VRE) in European hospitals is hampered because of widespread asymptomatic carriage of VRE by healthy Europeans. In 2000, our hospital (The University Medical Center Utrecht, Utrecht, The Netherlands) was confronted with a large outbreak of VRE. INTERVENTION: On the basis of genotyping (by pulsed-field gel electrophoresis), epidemic and nonepidemic VRE strains were distinguished, and infection-control measures were exclusively targeted toward epidemic VRE. The outbreak was retrospectively divided into 3 periods of different infection-control measures. Compliance with use of alcohol-based hand rubs was enforced during all periods. Period I involved active surveillance, isolation of carriers, and cohorting (duration, 4 months); preemptive isolation of high-risk patients for VRE colonization was added in period II (7 months); and cohorting and preemptive isolation were abandoned in period III (18 months). METHODS: When the outbreak was identified, 27 patients in 6 wards were colonized; 93% were colonized with an epidemic VRE strain. Detection rates of nonepidemic VRE were 3.5%, 3.0%, and 2.9% among 683, 810, and 977 screened patients in periods I, II, and III, respectively, comparable to a prevalence of 2% (95% confidence interval [CI], 1%-3.5%) among 600 nonhospitalized persons. The relative risks of detecting epidemic VRE in periods II and III, compared with period I, were 0.67 (95% CI, 0.41-1.10) for period II and 0.02 (95% CI, 0.002-0.6) for period III. Infection-control measures were withheld for patients colonized with nonepidemic VRE (76 [54%] of 140 patients with a test result positive for VRE). Use of alcohol-based hand rubs increased by 31%-275% in outbreak wards. CONCLUSION: Genotyping-targeted infection control, isolation of VRE carriers, enhancement of hand-hygiene compliance, and preemptive isolation successfully controlled nosocomial spread of epidemic VRE infection.

Acquisition and duration of vancomycin-resistant enterococcal carriage in relation to strain type.

In May 2000, the first outbreak of vancomycin-resistant Enterococcus faecium (VREF) was detected in the University Medical Center Utrecht in the nephrology ward. The question arose why some VREF strains spread among hospitalized patients, whereas other strains do not. Thirty patients who were found to be colonized with VREF between May and November 2000 were included in the study. Molecular typing confirmed that 19 of them carried an identical epidemic strain which harbored the esp gene while 11 were colonized by nonepidemic strains that were all esp negative. Acquisition of the outbreak strain was significantly associated with diabetes mellitus, renal transplantation, and extensive use of antibiotics, especially cephalosporins, in the 2-month period before the first isolation of VREF. To establish the duration of colonization, prospective surveillance of VREF carriage for a 6-month period starting from the first isolation of VREF was realized for 20 patients. After 6 months, VREF was still recovered from 60% of carriers of the outbreak strain versus 20% of carriers of nonepidemic strains (P < 0.01). However, antibiotic use during the follow-up period was significantly higher by carriers of the outbreak strain than by carriers of nonepidemic strains. The fact that the outbreak strain was recovered for a longer period of time than nonepidemic strains may facilitate dissemination of the strain. The results support a careful restrictive antibiotic policy for wards at risk for spread of VREF and implementation of isolation precautions for patients who are colonized with esp-positive outbreak strains.

[Increase in rate of resistance to fusidic acid among Staphylococcus aureus isolates from patients admitted with atopic dermatitis]. / Toename van resistentie tegen fusidinezuur van Staphylococcus aureus-isolaten bij opgenomen patiënten met constitutioneel eczeem.

To determine whether there has been an increase in the incidence of resistance to fusidic acid among Staphylococcus aureus isolates in the Netherlands, a retrospective study was carried out. The resistance pattern of S. aureus isolates from patients with atopic dermatitis at the Dermatology inpatient department of the University Medical Centre Utrecht was determined during the period 1995-2001. The rate of resistance increased from 9.7% to 23.4% during this period, whereas the rate of resistance of S. aureus to methicillin remained stable at around 0.5%. Prolonged topical use of fusidic acid is probably the main cause for the increase in fusidin resistance. Therefore it is advised to limit the use of fusidic acid for infected dermatitis to short periods of about two weeks, and only after sensitivity of the strain to fusidin has been confirmed.

Presence of integron-associated resistance in the community is widespread and contributes to multidrug resistance in the hospital.

Integrons are strongly associated with the multidrug resistance seen in gram-negative bacilli in the hospital environment. No data, however, are available on their prevalence in the community. This study is the first to show that integrons are widespread in Enterobacteriaceae in the community and that integron-associated resistance genes in the community constitute a substantial reservoir for multidrug resistance in the hospital.