Clostridioides difficile infection (CDI) epidemiology and patient characteristics in Switzerland.

OBJECTIVES: Clostridioides difficile infection (CDI) is a disease with high morbidity and mortality rates. The objective of this study was to describe CDI epidemiology and patient characteristics over a 5-year period in Switzerland and assess risk factors for mortality, recurrence and severe CDI. PATIENTS AND METHODS: We retrospectively included all consecutive CDI cases having occurred in adult patients hospitalized in two tertiary centers: the Lausanne University Hospital (1000 beds) and the University Hospital of Zurich (900 beds), between 2014 and 2018. Suspected cases of CDI were identified from the microbiology laboratory database on the basis of a positive test and confirmed by records review. RESULTS: During first CDI episodes, the median age was 67 years and the median Charlson comorbidity index (CCI) score was 5. All in all, 299 out of 826 patients (36.2%) had severe infection based on the Infectious Diseases Society of America criteria. In the multivariable analysis, CCI was associated with increased risk of mortality. None of the factors recorded on admission were significantly associated with increased risk of recurrence. In the multivariable analysis, male sex and CCI were associated with severity, while immunosuppression was associated with less severe presentation. CONCLUSIONS: If we did not identify any criteria on admission that could be predictive of recurrences, this could be explained the retrospective nature of the study. A higher comorbidity index is a key driver for severe CDI and mortality. Reporting of CDI is not mandatory in Switzerland; structuration of CDI reporting should be a short-term priority.

Evaluation of the performance of rapid tests for screening carriers of acquired ESBL-producing Enterobacterales and their impact on turnaround time.

BACKGROUND: Extended-spectrum ß-lactamase (ESBL)-producing Enterobacterales constitute a global burden for hospital infection, and the identification of carriers by screening patients at risk is recommended by several guidelines. AIM: To evaluate the impact of rapid ESBL tests on the turnaround time (TAT) of screening. METHODS: Rectal swabs were analysed by culture and synergism tests for identification of non-Esherichia coli Enterobacterales that produce ESBLs (NEcESBL-producing Enterobacterales). The Rapid ESBL NP and NG CTX-M MULTI tests were performed on colonies grown on chromogenic media. The results of polymerase chain reaction and sequencing of ESBL genes were used as the gold standard. RESULTS: Among 473 analysed swabs, 75 (15.9%) grew NEcESBL-producing Enterobacterales, leading to 89 isolates. Sensitivities of the synergism, Rapid ESBL NP and NG CTX-M MULTI tests were 0.97 [95% confidence interval (CI) 0.88-0.99], 0.81 (95% CI 0.69-0.89) and 0.90 (95% CI 0.80-0.96), respectively. Specificities were 0.92 (95% CI 0.73-0.99), 0.85 (95% CI 0.64-0.95) and 0.96 (95% CI 0.78-1.00), respectively. Considering the 473 rectal swabs, ESBL screening using the synergism, Rapid ESBL NP and NG CTX-M MULTI tests was calculated. Sensitivities were 0.96 (95% CI 0.86-0.99), 0.81 (95% CI 0.68-0.90) and 0.91 (95% CI 0.79-0.97); specificities were 1.00 (95% CI 0.98-1.00), 0.99 (95% CI 0.98-1.00) and 1.00 (95% CI 0.99-1.00); positive predictive values were 0.96 (95% CI 0.86-0.99), 0.94 (95% CI 0.81-0.98) and 1.00 (95% CI 0.91-1.00); and negative predictive values were 1.00 (95% CI 0.98-1.00), 0.98 (95% CI 0.96-0.99) and 0.99 (95% CI 0.97-1.00), respectively. When no NEcESBL-producing Enterobacterales were observed, the mean TAT was 30 h. When NEcESBL-producing Enterobacterales were identified, the mean TATs were 74.7, 38.0 and 36.7 h for the synergism, Rapid ESBL NP and NG CTX-M MULTI tests, respectively. CONCLUSION: The two rapid ESBL tests showed good performance and allowed a reduction in TAT for screening protocols to identify patients carrying ESBL-producing Enterobacterales.

Preventing SARS-CoV-2 transmission in rehabilitation pools and therapeutic water environments.

SARS-CoV-2 is mainly transmitted by respiratory droplets and contact with contaminated surfaces. It can be retrieved in faeces but there is no evidence of faecal-oral transmission, which is the main route of contamination in recreational waters. Standard cleaning and disinfecting procedures, microbiological control and health rules aim to prevent infectious risk regardless of the micro-organisms. In the context of progressive lockdown exit and hospital activities recovery, we assessed the risk of SARS-CoV-2 transmission in rehabilitation pools and therapeutic water environments in order to provide specific recommendations to control the spread of SARS-CoV-2 while ensuring essential rehabilitation care for patients.

An educational intervention about the classification of penicillin allergies: effect on the appropriate choice of antibiotic therapy in pregnant women.

BACKGROUND: Most pregnant women who self-report penicillin allergy are not truly penicillin-allergic and this misunderstanding often leads to administration of inappropriate antibiotic therapy. Decision algorithms have been developed to guide antibiotic selection but major discrepancies have been reported between guidelines and clinical practice. We aimed to optimize the prescription of antibiotics for pregnant women who self-reported penicillin allergy, using an educational intervention about the classification of penicillin allergies that targeted gynecologists, anesthesiologists and midwives. METHODS: This quasi-experimental study assessed the effect of an educational intervention about the classification of penicillin allergy. For six months, a combination of two strategies was used, namely dissemination of printed educational materials and group education. The principal study endpoint was the appropriateness of the antibiotic therapy, defined in advance for each level of allergic risk. RESULTS: The pre-intervention phase included 903 women; one year after its conclusion, the post-intervention phase began and included 892 women. The prevalence of self-reported penicillin allergy was stable over the two periods (6.8% before vs 5.4% after, P=0.24). The clinical classification of penicillin allergies was more often used after the educational intervention (68% vs 100%, P<0.001). The appropriateness of the antibiotic therapy prescribed to self-reported penicillin allergic-women increased significantly between the two periods, from 5/29 (17.2%) to 18/27 (66.7%, P<0.001). CONCLUSION: An educational intervention about penicillin allergy classification was associated with an improvement in the choice of appropriate antibiotic therapy among women who had reported penicillin allergy.

Evaluation of three consecutive versions of a commercial rapid PCR test to screen for methicillin-resistant Staphylococcus aureus.

OBJECTIVES: Screening for methicillin-resistant Staphylococcus aureus (MRSA) is part of many recommendations to control MRSA. Several rapid PCR tests are available commercially and updated versions are constantly released. We aimed to evaluate the performance of three consecutive versions (G3, Gen3 and NxG) of the XpertMRSA test. METHODS: Routine samples for MRSA screening were simultaneously tested by culture and rapid PCR. The three versions of XpertMRSA were used successively and compared with culture. RESULTS: A total of 3512, 2794 and 3288 samples were analysed by culture and by the G3, Gen3 and NxG XpertMRSA versions, respectively. The rates of positive-by-culture in the three groups were 5.0%, 4.7% and 4.3%, respectively. The sensitivity improved over time (71.4, 95% CI 64.0-77.9; 82.3, 95% CI 74.4-88.2; and 84.3%, 95% CI 77.0-89.7, respectively), but not significantly. The specificity (98.4, 95% CI 97.9-98.8; 96.8, 95% CI 96.0-97.4; and 99.1, 95% CI 98.7-99.4, respectively) and the positive likelihood ratios (45.7, 95% CI 34.4-60.8; 25.6, 95% CI 20.5-32.0; and 97.1, 95% CI 66.3-142.4) were significantly lower in the Gen3 version (p < 0.00001). CONCLUSIONS: These significant differences in performance show the importance of evaluating each new version of a commercial test.

A systematic review of surgical site infections following day surgery: a frequentist and a Bayesian meta-analysis of prevalence.

BACKGROUND: Since 1990, several studies have focused on safety and patient satisfaction in connection with day surgery. However, to date, no meta-analysis has investigated the overall prevalence of surgical site infections (SSI). AIM: To estimate the overall prevalence of SSI following day surgery, regardless of the type of surgery. METHOD: A systematic review and a meta-analysis of the prevalence of SSI following day surgery, regardless of the type of surgery, was conducted, seeking all studies before June 2016. A pooled random effects model using the DerSimonian and Laird approach was used to estimate overall prevalence. A double arcsine transformation was used to stabilize the variance of proportions. After performing a sensitivity analysis to validate the robustness of the method, univariate and multi-variate meta-regressions were used to test the effect of date of publication, country of study, study population, type of specialty, contamination class, time of postoperative patient visit after day surgery, and duration of hospital care. FINDINGS: Ninety articles, both observational and randomized, were analysed. The estimated overall prevalence of SSI among patients who underwent day surgery was 1.36% (95% confidence interval 1.1-1.6), with a Bayesian probability between 1 and 2% of 96.5%. The date of publication was associated with the prevalence of SSI (coefficient -0.001, P = 0.04), and the specialty (digestive vs non-digestive surgery) tended to be associated with the prevalence of SSI (coefficient 0.03, P = 0.064). CONCLUSION: The meta-analysis showed a low prevalence of SSI following day surgery, regardless of the surgical procedure.

Emergence of plasmid-mediated colistin resistance (mcr-1) among Enterobacteriaceae strains: Laboratory detection of resistance and measures to control its dissemination.

The increasing use of colistin has contributed to the emergence of resistant bacteria and to an increase in the frequency of infections caused by naturally resistant Enterobacteriaceae strains such as Proteus, Providencia, Morganella, and Serratia. In August 2016, the French High Council for Public Health (French acronym HCSP) received a request from the Ministry of Health on the advice of the French National Public Health agency (Santé publique France) with regard to measures that should be taken to tackle the emergence of plasmid-mediated colistin resistance among Enterobacteriaceae strains. French healthcare facilities were asked to take the necessary measures as soon as possible, such as updating the definition of emerging highly resistant bacteria and defining the identification methods so as to take account of the evolving epidemiology of this type of resistance. This article describes the epidemiological context of the discovery of this emergence in France and worldwide, the resistance mechanisms, the microbiological methods of routine laboratory detection and the level of hygiene measures to implement in French facilities.

Risk factors for acquisition of OXA-48-producing Klebsiella pneumonia among contact patients: a multicentre study.

BACKGROUND: Cohorting carbapenemase-producing Enterobacteriaceae (CPE) carriers during hospitalization limits in-hospital spreading. AIM: To identify risk factors for CPE acquisition among contacts of an index patient in non-cohorted populations. METHODS: A multicentre retrospective matched case-control study was conducted in five hospitals. Each contact patient (case) who acquired Klebsiella pneumoniae (KP)-OXA-48 from an index patient was compared to three contact (controls) with the same index patients matched with hospitalization in the same unit and similar exposure times. FINDINGS: Fifty-one secondary cases and 131 controls were included. By univariate analysis, exposure time (odds ratio: 1.06; 95% confidence interval: 1.02-1.1; P = 0.006), concomitant infection at admission (3.23; 1.42-7.35; P = 0.005), antimicrobial therapy within the last month before hospitalization (2.88; 1.34-6.2; P = 0.007), antimicrobial therapy during the exposure time (5.36; 2.28-12.6; P < 0.001), use of at least one invasive procedure (2.99; 1.25-7.15; P = 0.014), number of invasive procedures (1.52; 1.05-2.19; P = 0.025), and geographical proximity (2.84; 1.15-7.00; P = 0.023) were associated with CPE acquisition. By multivariate analysis, antimicrobial therapy during the exposure time (odds ratio: 6.36; 95% confidence interval: 2.46-16.44; P < 0.001), at least one invasive procedure (2.92; 1.04-8.17; P = 0.041), and geographical proximity (3.69; 1.15-11.86; P = 0.028) were associated with acquisition. CONCLUSION: In this study, geographical proximity, invasive procedure, and antimicrobial therapy during exposure time were significantly associated with KP-OXA-48 acquisition.

Preoperative hair removal and surgical site infections: network meta-analysis of randomized controlled trials.

Preoperative hair removal has been used to prevent surgical site infections (SSIs) or to prevent hair from interfering with the incision site. We aimed to update the meta-analysis of published randomized controlled trials about hair removal for the prevention of SSIs, and conduct network meta-analyses to combine direct and indirect evidence and to compare chemical depilation with clipping. The PubMed, ScienceDirect and Cochrane databases were searched for randomized controlled trials analysing different hair removal techniques and no hair removal in similar groups. Paired and network meta-analyses were conducted. Two readers independently assessed the study limitations for each selected article according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method. Nineteen studies met the inclusion criteria. No study compared clipping with chemical depilation. Network meta-analyses with shaving as the reference showed significantly fewer SSIs with clipping, chemical depilation, or no depilation [relative risk 0.55, 95% confidence interval 0.38-0.79; 0.60, 0.36-0.97; and 0.56, 0.34-0.96, respectively]. No significant difference was observed between the absence of depilation and chemical depilation or clipping (1.05, 0.55-2.00; 0.97, 0.51-1.82, respectively] or between chemical depilation and clipping (1.09, 0.59-2.01). This meta-analysis of 19 randomized controlled trials confirmed the absence of any benefit of depilation to prevent surgical site infection, and the higher risk of surgical site infection when shaving is used for depilation. Chemical depilation and clipping were compared for the first time. The risk of SSI seems to be similar with both methods.

French recommendations for the prevention of 'emerging extensively drug-resistant bacteria' (eXDR) cross-transmission.

Controlling the spread of multi- or extensively drug-resistant bacteria (MDR or XDR) includes a dual strategy for reducing antibiotic prescriptions and preventing their spread from patient carriers. Standard precautions are applicable to all health professionals caring for any patients; additional barrier precautions (isolation) are recommended for patients carrying transmissible infectious diseases or MDR bacteria in sporadic or epidemic situations. Moreover, additional precautions may be required for populations at particular risk of infection or colonization by emerging XDR (eXDR), defined in our country as carbapenemase-producing Enterobacteriaceae and vancomycin-resistant enterococci. Our ability to detect and identify eXDR carriers early and ensure their follow-up, through effective communication between all those involved, is a significant challenge for controlling their spread. Thus, the French High Committee for Public Health has updated and standardized all French existing recommendations concerning the prevention of the cross-transmission of these bacteria, and these recommendations are summarized in this review. The recommendations are based on scientific and operational knowledge up to 2013. Different preventive strategies are recommended for patients found to be carrying eXDR and those who are considered to be at risk of having eXDR because of a history of contact. The local context, the experience of the infection control team, the different times at which detection of eXDR takes place (during admission, hospitalization, etc.) and the epidemiological situation (sporadic cases, clusters, outbreaks, widespread epidemic) must be included in risk assessments that in turn inform the control measures that should be applied in each clinical circumstance.

Control of emerging extensively drug-resistant organisms (eXDRO) in France: a survey among infection preventionists from 286 healthcare facilities.

We performed a multicenter survey in May-June 2012 to assess strategies in preventing the spread of emerging extensively drug-resistant organisms (eXDRO), including glycopeptide-resistant enterococci and carbapenemase-producing Enterobacteriaceae, in a convenient sample of French healthcare facilities (HCFs). The collected data included organization and measures to: (1) identify patients at risk for carrying eXDRO, (2) investigate and control sporadic cases or outbreaks, and (3) describe prior 2010-2012 episodes with one or more colonized patients. Of the 286 participating HCFs, 163 (57 %) and 134 (47 %) reported having a specific procedure to detect repatriates or patients hospitalized in foreign countries within the last year, respectively. Among the 97 HCFs with prior at-risk patient management experience, contact precautions, hospitalization in a single room, and screening for eXDRO carriage were quasi-systematically performed (n = 92/97, 95 %). The alleged time between admission and alert ranged from 24 to 48 h after the patient's admission; 203 (71 %) HCFs recommended obtaining three successive negative screening samples to declare a patient free of eXDRO colonization. During the last two years, 64 HCFs (23 %) had to manage at least one eXDRO case, with a total of 20 outbreaks with more than one secondary case. This first national survey shows that French HCFs were not totally ready to control eXDRO spread in 2012. Their previous experiences and capacities in controlling eXDRO outbreaks are quite heterogeneous from one hospital to another. Further researches are needed in order to understand the constraints in applying national guidance.

[Carbapenemase-producing enterobacteriae: epidemiology, strategies to control their spread and issues]. / Maîtrise de la diffusion des entérobactéries productrices de carbapénémases : épidémiologie, stratégies de prévention et enjeux.

The increasing bacterial resistance to antibiotics has become a major public health concern bringing the threat of therapeutic impasses. In this context, control of the spread of highly-resistant bacteria emerging antibiotics (BHRe), such as glycopeptide-resistant enterococci (VRE) and Enterobacteriaceae producing carbapenemases (CPE), is based on a dual strategy of reducing the prescription of antibiotics to limit the pressure selection and preventing the spread from carriers. Prevention strategy is based on three different levels such as standard precautions for all patients with a particular focus on the management of excreta, and additional precautions for BHRe carriers. What makes it difficult is that carriage is usually completely asymptomatic, enterobacteria and enterococci are normal commensal of gut microbiota. Explosive dissemination of Enterobacteriaceae producing extended spectrum beta-lactamases in hospital and community heralds the emergence of CPE whose import by patients with a history of hospitalization in abroad may be the main source of spread in France.

[Ebola and others, those viruses coming from far away]. / Ebola et autres, ces virus venus d'ailleurs.

In the last decade, we faced a large number of emerging pathogens. As a consequence we had to adapt our medical practice as well as our health system. This review summarizes the main features of the recent emerging pathogens with a particular focus on the recent and ongoing Ebola outbreak, we tried to evaluate the consequences on our national health management.

Should public reporting be made for performance indicators on healthcare-associated infections?

There are still many uncertainties regarding the benefit of public reporting on indicators of healthcare-associated infections. Publishing the results of performance indicators in healthcare facilities seems to stimulate quality insurance activity, but for the moment, without any demonstrated impact on the rates of healthcare-associated infections. Furthermore, it is not proved that public reporting of these results is beneficial. The French Society for Hospital Hygiene, in this synthesis, considered the advantages and drawbacks of public reporting of healthcare-associated infections. Beyond the difficult choice of indicators, public reporting of such indicators requires taking many precautions listed in this article, including a broad dialogue between the various stakeholders involved, a test period, and mandatory control of the produced indicator validity by health authorities.

A prospective study of nosocomial-infection-related mortality assessed through mortality reviews in 14 hospitals in Northern France.

AIM: To determine the number of deaths associated with nosocomial infection (NI) occurring in French hospitals, and to evaluate the role of hospital mortality reviews in assessing the preventability of NI-associated death. METHODS: The study considered 13,537 consecutive deaths occurring in 14 French hospitals in 2007 and 2008. An expert commission including attending physicians and nurses determined the likelihood that deaths could be attributed to NI, and the preventability of NI and death. FINDINGS: Medical records of the 2355 eligible patients with a McCabe score of 0 or 1 who died more than 48 h after admission were reviewed. Among them, 33% had at least one NI. Death was attributable to NI in 182 patients, and was considered preventable in 35 cases. Among these, 10 deaths were unexpected. CONCLUSION: Extrapolating these figures nationally, approximately 3500 [95% confidence interval (CI) 2605-4036] deaths attributable to NI occur in France annually. Among these, approximately 1300 NIs (95% CI 357-2196) and 800 deaths (95% CI 51-1481) can be considered preventable. Hospital mortality review commissions can help to improve the quality of health care by identifying circumstances associated with NI contributing to death, and targeting specific preventative measures. Such hospital commissions should involve all healthcare personnel.

[Detection of extended-spectrum ß-lactamase-producing Enterobacteriaceae in rectal swabs with the Mastdiscs™ ID AmpC ßLSE detection set]. / Dépistage du portage digestif des entérobactéries productrices de ß-lactamase à spectre étendu par ensemencement direct des écouvillons rectaux à l'aide de la méthode Mastdiscs™ ID AmpC ßLSE.

OBJECTIVES: The double-disk synergy test was compared to the Mastdiscs™ ID AmpC and ESßL method for detection of ESßL production in rectal swab. METHODS: Two hundred and forty-nine rectal swabs were directly inoculated onto Mueller-Hinton plates and analyzed according to both methods. RESULTS: A total of 41 (16%) and 208 (84%) were positive and negative for ESßL, respectively. Twelve (29%) and 20 (49%) of the 41 rectal swabs positive for ESßL were detected after 24h of incubation with the double-disk synergy test and the Mastdiscs™ method, respectively (P=0.013). One hundred fifty-eight (76%) et 183 (88%) of the 208 rectal swabs were detected negative for ESßL after 24h of incubation with the double-disk synergy test and the Mastdiscs™ method, respectively (P<0.001). Finally, 79 (32%) and 46 (18%) rectal swabs respectively inoculated according to the double-disk synergy test and the Mastdiscs™ method were inconclusive after 24h of incubation. The better performance of the Mastdiscs™ method was due to an easier detection of cephalosporinase producing bacteria. CONCLUSIONS: The Mastdiscs™ method is a simple phenotypic method that detects more easily ESßL and non-ESßL producing bacteria in rectal swab.