Acetic acid as a decontamination method for ICU sink drains colonized by carbapenemase-producing Enterobacteriaceae and its effect on CPE infections.

BACKGROUND: Carbapenemase-producing Enterobacteriaceae (CPE) are emerging pathogens representing a major concern for public health. In Belgium, the OXA-48 carbapenemase resistance gene is identified most frequently. Sink drains in intensive care units (ICUs) are known to be colonized by Gram-negative bacilli. A correlation between environmental contamination and CPE infections in ICUs has been established. A long-term CPE epidemic in a local ICU proved difficult to control. METHODS AND RESULTS: A variety of CPE strains, all carrying the OXA-48 resistance gene, were isolated from almost all sinks in patient rooms in the ICU. Decontamination of the sinks with 250 mL 25% acetic acid three times weekly was implemented. Sink drain colonization was followed up for six months thereafter. Both the number of CPE-colonized sinks and the number of patients colonized or infected with CPE decreased drastically, to the extent that the epidemic was considered to be eradicated. In-vitro growth of all isolates was inhibited by a concentration of acetic acid equal to or smaller than that used for decontamination. Epidemiological analysis demonstrated a positive and significant relationship between contaminated sinks and CPE acquisition of patients admitted to ICU rooms, indicating the importance of contaminated sinks as the environmental reservoir of the epidemic. CONCLUSION: Decontamination of sink drains with acetic acid is a valuable alternative to other methods, such as heated sinks and water-free care, especially when other options are not feasible in the short term. Acetic acid is cheap, widely available, effective and manageable from a safety and technical point of view.

The 2007 Belgian national prevalence survey for hospital-acquired infections.

Despite ongoing targeted surveillance efforts, no overall in-hospital prevalence data for hospital-acquired infections (HAIs) have been published for Belgium. Sixty-three Belgian acute hospitals participated in a point-prevalence study among either all patients admitted in their institution or 50% of the patients in each ward. HAIs were registered bed-site at a single day per ward during the period October-November 2007. The diagnosis was made according to the Centers for Disease Control and Prevention (CDC) criteria implemented in a custom-made rule-based software expert system available on a portable computer. The total number of patients surveyed nationally was 17 343, from 543 distinct hospital wards. The overall prevalence of HAIs was 7.1% (95% confidence interval: 6.7-7.4%); 6.2% (5.9-6.5%) of the patients suffered from at least one HAI. Prevalence of HAIs on adult intensive care was 31.3%. The major proportion of HAIs was observed among patients admitted on non-intensive care unit (non-ICU) wards, mainly on the wards of internal medicine, surgery, geriatrics and rehabilitation. Urinary tract infections were the most common type of HAI at geriatric and rehabilitation wards. This study demonstrates that the use of a portable computer system with a designated expert system for diagnosing HAIs according to the CDC criteria in a large point prevalence study is feasible and may reduce the within-subject variation. In Belgium, the prevalence of HAIs in acute hospitals thus identified is similar to that of neighbouring countries. As more than 80% of all HAIs occur on non-ICU wards, preventive efforts need to extend beyond the ICU.

Contribution of two molecular assays as compared to selective culture for MRSA screening in a low MRSA prevalence population.

BACKGROUND: As the prompt detection of methicillin-resistant Staphylococcus aureus (MRSA) carriers upon admission is fundamental in the MRSA prevention strategy of our hospital, the infection control team is eagerly seeking the most sensitive and rapid screening method. The aim of this study was to compare the performance of two molecular techniques with a conventional MRSA-selective culture test (Bio-Rad chromogenic MRSASelect) in order to elucidate the suitability of the assays specifically in an expected low MRSA prevalence population. PATIENTS AND METHODS: The anterior nares and throat of 500 patients and visitors attending the emergency department of Sint-Jan General Hospital between May and June 2007 were sampled, and MRSA carriage was determined by selective culture after enrichment and the BD GeneOhm StaphSR and the Cepheid Xpert MRSA assays. RESULTS: Eight MRSA carriers were detected by selective culture (1.6% prevalence). The sensitivity, specificity, positive [corrected] predictive value, and negative [corrected] predictive value were 62.5, 99.0, 50.0, and 99.4% for BD GeneOhm StaphSR and 62.5, 97.7, 31.3, and 99.4% for Cepheid Xpert MRSA, respectively. CONCLUSIONS: We conclude that MRSA rapid screening techniques must be interpreted cautiously in a low-prevalence population, as the sensitivity is lower than in selected high-risk populations. MRSA carriers detected with molecular techniques must be confirmed by conventional culture methods for follow-up. The specificity and negative predictive value indicate that molecular rapid methods are worthwhile to be considered in MRSA-preventive strategies.

10th survey of antimicrobial resistance in noninvasive clinical isolates of Streptococcus pneumoniae collected in Belgium during winter 2007-2008.

OBJECTIVES: The aim of the study was to evaluate the antibiotic resistance in noninvasive clinical isolates of Streptococcus pneumoniae collected in Belgium during winter 2008-2007. METHOD: Four hundred and forty eight unduplicated isolates collected by 15 laboratories were tested by microdilution following CLSI. RESULTS: Insusceptibility rates (I+R) were as follows: penicillin G (PEN) 11.6% (4.0% R), ampicillin 11.4% (4.0% R), amoxicillin+/-clavulanic acid 0, cefaclor 10.3% (9.6% R), cefuroxime 9.2% (8.7% R), cefuroxime-axetil 8.7% (7.8% R), cefotaxime, ceftazidime and cefepime 2.0% (0% R), imipenem 2.5% (0% R), ciprofloxacin and ofloxacin 5.1% (0.4% R), levofloxacin 0.7% (0.4% R), moxifloxacin 0.4% (0.2% R), erythromycin (ERY) 29.7% (29.2% R), azithromycin 29.7% (28.8% R), telithromycin 0%, clindamycin 26.3% (25.4% R) and tetracycline (TET) 21.9% (16.5% R). From 2001 to 2008, a significant decrease in penicillin-insusceptibility (21.0% to 11.6%), penicillin-resistance (9.7% to 4.0%) and ciprofloxacin-insusceptibility (11.2% to 5.1%) was found. Cross-resistance between penicillin and other betalactams in penicillin-insusceptible isolates was incomplete: all these isolates remained fully susceptible to amoxicillin. Erythromycin-insusceptibility was significantly higher in children than in adults (43.9%/27.4%), while penicillin-insusceptibility significantly higher in Brussels than in the Flanders (22.9%/8.1%). The commonest resistance phenotype was ERY-TET (12.7%) followed by ERY (7.4%) and PEN-ERY-TET (5.8%). Capsular types 19 (25%), 14 (19.3%), 23 (15.4%) and 15 (13.5%) were the most important in penicillin-insusceptible. CONCLUSION: We noted a decrease in resistance to the majority of the compounds. Insusceptibility rates were higher in children than in adults and the difference between the north and the south of Belgium became less marked.

Achievements of the Belgian Antibiotic Policy Coordination Committee (BAPCOC).

A Belgian Antibiotic Policy Coordination Committee (BAPCOC) was officially established in 1999 by Royal Decree. The overall objective of BAPCOC is to promote judicious use of antibiotics in humans and animals and to promote infection control and hospital hygiene, with the overall aim to reduce antibiotic resistance. BAPCOC fostered strong and interdisciplinary public health, scientific and political leadership, which led to many evidence-based interventions such as multimedia campaigns to promote the prudent use of antibiotics in the community, national campaigns to promote hand hygiene in hospitals, publication of clinical practice guidelines, staffing and technical support for establishment of antibiotic management teams in all Belgian hospitals, surveillance programmes on antibiotic use and resistance in humans and animals and the promotion of research. These activities and interventions resulted in a measurable decrease in antibiotic use and resistance in the community and hospitals.

Cost of the meticillin-resistant Staphylococcus aureus search and destroy policy in a Dutch university hospital.

Costs related to a search and destroy policy and treatment for Staphylococcus aureus bacteraemia in the University Hospital Maastricht were calculated for the period 2000 and 2004. The financial cost-benefit break-even point of the search and destroy policy was determined by modelling. On average 22,412 patients were admitted per year for an average of 8.7 days. Each year 246 patients were screened for meticillin-resistant Staphylococcus aureus (MRSA) and 74 patients were decolonised and nursed in preventive isolation. The prevalence of MRSA in the University Hospital Maastricht was 0.7%, as calculated from positive blood cultures, and mean length of stay for all patients with S. aureus bloodstream infections was 39.9 days. The annual cost of pro-active searching for MRSA in the University Hospital Maastricht was euro 1,383,200, and euro 2,736,762 for MRSA prevention and treatment of S. aureus bloodstream infections. Simulation of a variety MRSA/meticillin-susceptible S. aureus (MSSA) ratios showed that even if the MRSA prevalence reaches 8%, prevention costs are still lower than the cost of treating S. aureus infections. In conclusion, the total cost of a search and destroy policy is lower than the cost of treating S. aureus bloodstream infections in the University Hospital Maastricht. At an MRSA prevalence of

Complicated community-acquired soft tissue infection by MRSA from porcine origin.

Methicillin-resistant Staphylococcus aureus (MRSA) is a rare cause of community acquired soft tissue infection in Europe. We report a case of severe soft tissue infection caused by a MRSA strain originating from a pig bite.

Dual infection with polyomavirus BK and acyclovir-resistant herpes simplex virus successfully treated with cidofovir in a bone marrow transplant recipient.

A hematopoietic stem cell transplant recipient developed a mucosal herpes simplex virus-1 (HSV-1) infection while under acyclovir (ACV) treatment (HSV was later shown to be resistant to ACV). Concomitantly, the patient presented a hemorrhagic cystitis (HC) due to polyomavirus BK, for which intravenous cidofovir (CDV) was prescribed. The patient benefited from the broad-spectrum anti-DNA virus activity of CDV, and not only the HC resolved without signs of nephrotoxicity but also the HSV-1 lesions disappeared. This is the first report describing the effect of CDV on 2 simultaneous and unrelated DNA viral infections in an immunosuppressed transplant recipient. In addition, we describe here that this HSV-1 isolate possesses a unique phenotype and genotype.

Surveillance of antibiotic resistance in non invasive clinical isolates of Streptococcus pneumoniae collected in Belgium during winters 2003 and 2004.

A total of 391 and 424 non-invasive isolates of Streptococcus pneumoniae collected by 15 laboratories during the 2003 and 2004 survey were tested for their susceptibility by a microdilution technique following NCCLS recommendations. Insusceptibility rates (IR) in the two surveys (2003/2004) were as follows: penicillin 15.0/14.7% [8.4/6.4% Resistance (R)], ampicillin 17.4/14.6% (R 9.0/7.1%), amoxicillin +/- clavulanic acid 2.6/1.2 % (R 0/0%), cefaclor 14.3/14.1% (R 11.5/13.4%), cefuroxime 13.6/12.7% (R 10.5/11.8%), cefuroxime-axetil 10.5/11.8% (R 10.0/9.2%) (breakpoints based on 250 mg), cefotaxime 4.9/6.2% (R 1.3/2.4%), ceftazidime NotTested (NT)/6.4 (R NT/2.6%), cefepime NT/6.4 (R NT/2.6%), imipenem 7.7/8.9 % (R 1.8/1.4%), ertapenem 0.8/NT% (R O/NT%), ciprofloxacin 13.8/9.0% (R 4.3/2.4%), levofloxacin 3.3/2.8% (R 1.5/0.2%), moxifloxacin 0.6/0.2% (R 0.3/0%), ofloxacin 13.5/9.0% (R 4.3/2.4%), erythromycin 26.1/24.7% (R 25.3/24.5%), azithromycin 25.4/24.7% (R 24.6/24.5%), telithromycin 0.8/0.2% (R 0.5/0%), clindamycin 21.2/18.4% (R 19.2/17.7%) and tetracycline 32.3/22.1% (R 29.2/19.3%). There were only minor differences in resistance rates according to age, sample site, admission type (i.e. ambulatory, hospitalized or long-term care facility patients), gender and geographic origin. Overall, telithromycin (MIC50, MIC90 in 2003/2004: 0.015 microg/ml, 0.12 microg/ml/ 0.008,0.06 respectively), ertapenem (0.03; 0.25/NT), moxifloxacin (0.06; 0.25/0.06, 0.12), and amoxicillin +/- clavulanic acid (0.03; 0.25/0.015, 0.5) were the most active compounds in both surveys. In 2003, the most common resistance phenotype was isolated insusceptibility to tetracycline (10.5%) followed by combined insusceptibility to erythromycin and tetracycline (9.3%). Erythromycin-tetracycline resistance (10.4%) was the most common in 2004. Isolates showing resistance to an antibiotic were significantly more present in 2003 than in 2004 (50.4% versus 40.8%). In penicillin-insusceptible isolates, MICs of all beta-lactams were increased but cross-resistance between penicillin and other beta-lactams in the penicillin-insusceptible isolates was not complete. In the 2003 survey, most of these isolates remained fully susceptible to ertapenem (94.9%) and amoxicillin +/- clavulanic acid (83.1%). In the 2004 survey, 91.9% of the penicillin insusceptible isolates remained susceptible to amoxicillin +/- clavulanic acid. In both surveys, the most common serotypes in penicillin insusceptible isolates were 14, 23,19 and 9 (20.0%, 20.0%, 16.4% and 10.9% respectively in 2003; 41.6%, 11.7%, 15.0% and 18.3% respectively in 2004).

Models for the organisation of hospital infection control and prevention programmes.

Hospital infection control is an essential part of infectious disease management and must be firmly structured and professionally organised. Prevention, limitation and eradication of nosocomial infections requires specific expertise not fully provided by clinical microbiologists and/or infectious disease consultants. Therefore, dedicated infection control physicians and nurses are essential. The basic components for successful hospital infection control include: (1) personnel and supporting resources proportional to size, complexity and estimated risk of the population served; (2) trained hospital infection control practitioners; and (3) the necessary structure to implement changes in medical, nursing and logistical organisation. The identification of areas of concern, provision of written policies and education still constitute the backbone of infection control. The infection control team must propose priorities and necessary resources, objectives, development methods, implementation and follow-up. The strategic approach must be discussed and approved by the infection control committee, comprising the hospital administrator(s), medical and nursing directors, a microbiologist, a hospital pharmacist and a delegation of clinicians. Follow-up of the projects is regularly presented to the committee by the infection control team. To what extent may evolution in the organisation of hospital infection control contribute to the optimisation of allocated resources and fulfillment of these objectives? From the Belgian experience, we conclude that structural changes represent an essential incentive. The impact of changes is greater when they are directed by the national authorities, providing resources and imposing new standards. Recommendations for staffing must consider not only the number of beds but also the objectives, complexity and characteristics of the patient population.

The training curriculum in hospital infection control.

Standardised training curricula for infection control nurses (ICNs) and recognition of the specialty exist in many European countries, but infection control physician (ICP) is not a specialty recognised by the UEMS. To gather information on curricula for ICPs, members of the ESCMID Study Group on Nosocomial Infections received a questionnaire. There is discussion about which 'professions' should be included in an infection control team. Within the 12 countries included, the average full-time equivalents (FTEs) for ICPs and ICNs per 1000 beds were 1.2 and 3.4, respectively. In addition to ICNs and ICPs, an infection control team should also include a data manager, an epidemiologist, secretarial/administrative support, and possibly, surveillance technicians. Overall, the composition of an ideal infection control team was estimated to be 9.3 FTE per 1000 beds. The background of ICPs can be clinical microbiology or infectious diseases. Among the participants, it was predominantly clinical microbiology. The ideal training curriculum for the ICP should include 6 years of postgraduate training. Of these, at least 2 years should be 'clinical training' (e.g., internal medicine) to acquire experience in the management of high-risk patients. Furthermore, training with regard to infection control and hospital epidemiology should be offered as a 'common trunk' for those being trained in clinical microbiology or infectious diseases. Important issues that remain are: implementation/standardisation of training curricula for doctors, recognition of ICP as a separate specialty or sub-specialty of clinical microbiology and/or infectious diseases, validation of on-the-job training facilities in terms of the number of doctors and nurses who can give training and the category of patients/problems present, and mandatory postgraduate education/continuing medical education specific for infection control for doctors and nurses in the field.

Environmental investigations and molecular typing of Aspergillus flavus during an outbreak of postoperative infections.

After an outbreak of sternal surgical-site infections (SSSI) with Aspergillus flavus following cardiac surgery, a mycological survey of air and surfaces (41 and 149 samples, respectively) was performed throughout the surgical ward (SW) and in other areas of the hospital. Results showed massive contamination by A. flavus: more than 100 cfu per contact plate were frequently observed in some areas of the SW. The distribution of the A. flavus spores in the building, and especially in the SW, enabled the location of a possible source within the non-medical part of the SW, but the true source could not be identified. Four other surveys were made to follow up the decontamination process; the contamination level did not fall rapidly, needing repetitive cleaning operations. Strains from patients and from the hospital environment selected all over the SW were typed by random amplification of polymorphic DNA (RAPD), using two different primers (ERIC-1, BG-2). All these strains showed the same genotype, proving the clonal single-source of the environmental contamination and the intra-operative acquisition of A. flavus in the SSSI outbreak.

Evaluation of a disk diffusion method with cefoxitin (30 microg) for detection of methicillin-resistant Staphylococcus aureus.

The emergence of heterogeneous populations of methicillin-resistant Staphylococcus aureus (MRSA) causes major problems in routine screening for MRSA. In heterogeneous MRSA populations, a proportion of bacterial cells show low-level resistance to oxacillin, with minimal inhibitory concentrations (MICs) of oxacillin ranging between 1 and 100 mg/l, while in homogeneous MRSA populations, the MIC of oxacillin for all cells is >100 mg/l. Routine oxacillin disk diffusion tests often fail to detect heterogeneous MRSA populations. In the present study, a recently proposed disk diffusion method that employs a cephamycin antibiotic (cefoxitin 30 microg; BD Sensi-disc, Becton Dickinson, Germany) was evaluated using 155 clinical isolates of S. aureus (73 mecA positive and 82 mecA negative). The results were compared with those of other MRSA screening techniques: a disk diffusion test with oxacillin 1 microg and cefoxitin 30 microg (BD Sensi-disc; Becton Dickinson), an MRSA latex agglutination test (Denka Seiken, Japan), and an oxacillin screen agar test (6 microg/ml; Becton Dickinson). Detection of the mecA gene by polymerase chain reaction was considered the gold standard. The performances of the different methods were determined and compared. The results showed that the cefoxitin disk diffusion test is preferable to the oxacillin disk diffusion method for routine screening to detect MRSA.

Surveillance of antibiotic resistance in clinical isolates of Streptococcus pneumoniae collected in Belgium during winter 2000-2001.

A total of 314 isolates of Streptococcus pneumoniae collected by 10 different laboratories were tested for their susceptibility by using a microdilution technique following NCCLS recommendations. The following antibiotics were included: penicillin, ampicillin, amoxicillin, amoxicillin/clavulanate, cefaclor, cefuroxime, cefotaxime, imipenem, ciprofloxacin, gemifloxacin, levofloxacin, erythromycin, clarithromycin, azithromycin, miocamycin, clindamycin and tetracycline. The insusceptibility rate (IR) to penicillin was 21.0% [10.8% intermediate (> or = 0.12-1 microgram/mL) and 10.2% high-level (> or = 2 micrograms/mL)], to cefotaxime 7.3% [3.5% intermediate (> or = 1 microgram/mL) and 3.8% high-level (> or = 2 micrograms/mL)], to imipenem 3.8% [3.8% intermediate (> or = 0.25-0.5 microgram/mL) and 0% high-level (> or = 1 microgram/mL)], to ciprofloxacin 11.2% [8.3% intermediate (2 micrograms/mL) and 3.9% high-level (> or = 4 micrograms/mL)], to erythromycin 30.3% [3.5% intermediate (0.5 microgram/mL) and 26.8% high-level (> or = 1 microgram/mL)] and to tetracycline 38.5% [0.9% intermediate (4 micrograms/mL) and 37.6% high-level (> or = 8 micrograms/mL)]. No decreased susceptibility was found for gemifloxacin (> or = 0.5 microgram/mL). This compound was the most active with MIC50, MIC90 and an IR of 0.015 microgram/mL, 0.03 microgram/mL and 0% respectively, followed by amoxicillin/clavulanate, amoxicillin and imipenem (MIC50, MIC90 and IR: 0.015 microgram/mL, 1 microgram/mL, 1.6%/0.015 microgram/mL, 1 microgram/mL, 1.9%/0.008 microgram/mL, 0.12 microgram/mL, 3.8% respectively). Compared to the 1999 surveillance, penicillin and tetracycline-insusceptibility increased with 4.9% and 15.6% respectively, while cefotaxime, erythromycin and ciprofloxacin insusceptibility decreased with 5.4%, 5.8% and 4.4% respectively. MICs of all beta-lactams rose with those of penicillin for penicillin-insusceptible isolates. Imipenem, cefotaxime, amoxicillin and amoxicillin/clavulanate were generally 4, 2, 1 and 1 doubling dilutions respectively more potent than penicillin on these isolates while ampicillin, cefuroxime and cefactor were generally 1, 2 and 4 dilutions respectively [table: see text] less potent. Most penicillin-insusceptible isolates remained fully susceptible to amoxicillin/clavulanate (92.4%), amoxicillin (90.9%) and imipenem (81.8%). Erythromycin-tetracycline insusceptibility was the most common resistance phenotype (14.3%). Three- and four-fold resistance was found in 12.4% and 1.6% respectively of the isolates. Most penicillin-insusceptible isolates were of capsular types 14 (22.7%), 23 (21.2%), 6 (18.2%), 9 (13.6%) and 19 (12.1%).

Tuberculosis of the skull: a case report.

Tuberculosis of the skull is rare. We describe a case of skull tuberculosis in a Somali fugitive. The patient presented with a history of a painful mass at the vertex of the skull. The diagnosis, suspected on histological grounds was established by culture of the operative biopsy. Surgery was performed and antituberculous treatment was started.

Diagnosis and treatment of Aspergillus flavus sternal wound infections after cardiac surgery.

We report the clinical data for 9 patients affected during an outbreak of Aspergillus flavus sternal wound infections after cardiac surgery. In 7 patients, the infection had a locally invasive character, with 3 of these patients having multiple relapses; 2 patients had fulminant mediastinitis and died. Most patients received combined surgical and medical treatment.

Differentiation and identification of Enterococcus durans, E. hirae and E. villorum.

AIMS: To compare different tests in the identification of Enterococcus durans, E. hirae and E. villorum strains. These bacteria belong to the E. faecium species group and are phylogenetically closely related, as evidenced by 16S rRNA sequence homologies of over 98.8%. METHODS AND RESULTS: Sodium dodecyl sulphate-polyacrylamide gel electrophoresis analysis of whole-cell protein, tRNA interpacer polymerase chain reaction (PCR) and arbitrarily-primed (D11344-primed AP) -PCR analysis correctly identified all three species in a collection of strains from very diverse origins. In contrast, biochemical reactions only allowed the unequivocal differentiation of the three species as a group from the other enterococci. Within this group, D-xylose acidification can be used to differentiate E. villorum, but exceptions occur. Strains highly susceptible to clindamycin can be identified as E. durans, but many strains of this species cannot be differentiated from E. hirae and E. villorum due to acquired resistance. CONCLUSIONS: Despite their close relationship, E. durans, E. hirae and E. villorum can be differentiated by genomic methods and by whole-cell protein analysis. SIGNIFICANCE AND IMPACT OF THE STUDY: Only a minority of strains of these three enterococcal species can be identified reliably by the currently available and commonly applied phenotypic tests.

Primary meningococcal arthritis of the hip in an immunocompetent adolescent.

The clinical spectrum of meningococcal infection ranges from asymptomatic carriage to fulminant sepsis, with meningitis and septicemia being well-recognized clinical presentations. Meningococcal arthritis as a complication of Neisseria meningitidis infection occurs in about 2-10% of cases, whereas primary meningococcal arthritis (PMA) is a relatively rare phenomenon, even in children. We report here a case of meningococcal infection in an immunocompetent adolescent suffering from acute pain of the right hip as the only symptom upon presentation at the hospital. In such a situation, meningococci are not usually considered as a possible causative agent.

Recurrent bacteremia by Chryseobacterium indologenes in an oncology patient with a totally implanted intravascular device.

Chryseobacterium indologenes was isolated from the blood cultures of an oncological patient with a totally implantable device. Because a catheter-related infection was suspected, the Port-A-Cath was removed after a 10-day course of piperacillin-tazobactam. Differences in susceptibility may exist if either the criteria for either Pseudomonas or Enterobacteriaceae are used.

Pasteurella dagmatis septicaemia in an immunocompromised patient without a history of dog or cat bites.

We report a rare case of Pasteurella dagmatis septicaemia in a 66-year-old immunocompromised patient, without a history of cat bites, dog bites or scratches.