Role of antiseptics in the prevention and treatment of infections in nursing homes.

Inadequate infection control, wound care, and oral hygiene protocols in nursing homes pose challenges to residents' quality of life. Based on the outcomes from a focus group meeting and a literature search, this narrative review evaluates the current and potential roles of antiseptics within nursing home infection management procedures. We examine contemporary strategies and concerns within the management of meticillin-resistant Staphylococcus aureus (MRSA; including decolonization regimes), chronic wound care, and oral hygiene, and review the available data for the use of antiseptics, with a focus on povidone-iodine. Compared with chlorhexidine, polyhexanide, and silver, povidone-iodine has a broader spectrum of antimicrobial activity, with rapid and potent activity against MRSA and other microbes found in chronic wounds, including biofilms. As no reports of bacterial resistance or cross-resistance following exposure to povidone-iodine exist, it may be preferable for MRSA decolonization compared with mupirocin and chlorhexidine, which can lead to resistant MRSA strains. Povidone-iodine oral products have greater efficacy against oral pathogens compared with other antiseptics such as chlorhexidine mouthwash, highlighting the clinical benefit of povidone-iodine in oral care. Additionally, povidone-iodine-based products, including mouthwash, have demonstrated rapid in-vitro virucidal activity against SARS-CoV-2 and may help reduce its transmission if incorporated into nursing home coronavirus 2019 control protocols. Importantly, povidone-iodine activity is not adversely affected by organic material, such as that found in chronic wounds and the oral cavity. Povidone-iodine is a promising antiseptic agent for the management of infections in the nursing home setting, including MRSA decolonization procedures, chronic wound management, and oral care.

Fatigue and the wear-off effect in adult patients with common variable immunodeficiency.

Patients with common variable immunodeficiency (CVID) have increased fatigue compared with the general population. Fatigue is associated with lower quality of life (QoL), which is associated with higher mortality in CVID. This study aimed to determine the prevalence of self-reported fatigue for patients with CVID and to identify its possible drivers and burden on QoL. We analysed data from the 2013 Immune Deficiency Foundation (IDF) treatment survey. Answers were included from 873 CVID patients who responded (respondents). Of the 873 respondents included in the analysis, 671 (76·9%) reported fatigue, of whom 400 (83·7%) were receiving intravenous (i.v.) immunoglobulins (IVIG) and 271 (68·6%) were receiving subcutaneous (s.c.) immunoglobulins. This difference in fatigue between patients receiving IVIG and SCIG was statistically significant (P < 0·001). Dose and frequency of immunoglobulin replacement therapy (IgGRT) did not affect fatigue prevalence. Fatigued patients on IVIG reported greater infection rates and required more anti-microbials during the wear-off period. Fatigued patients reported worse health status than non-fatigued patients, and had lower rates of employment, education, household income and school attendance than their non-fatigued counterparts. Fatigue is increased in CVID, especially among patients receiving IVIG, compared to SCIG. Fatigue has a significant impact on QoL and productivity in patients with CVID. Further studies to identify the mechanisms of fatigue are warranted to help advance therapeutic measures to treat this disease and improve patients' QoL and wellbeing.

Latent therapeutic demand model for the immunoglobulin replacement therapy of primary immune deficiency disorders in the USA.

BACKGROUND AND OBJECTIVES: Our research aim is to model latent therapeutic demand (LTD) for the immunoglobulin replacement therapy (IgGRT) of primary immune deficiency disorders (PIDDs) in the USA. Given the high level of variability of IgGRT use and major differences among American and European practices in the management of patients with PIDDs, we develop a USA-specific LTD model for common variable immune deficiency (CVID), hyper IGM syndrome, severe combined immune deficiency, Wiskott-Aldrich syndrome and X-linked agammaglobulinemia (XLA). METHODS AND MATERIALS: We use decision analysis methods to model the underlying IgGRT demand for PIDDs by assessing USA-specific epidemiology and treatment. Data for the epidemiology and treatment variables were obtained from the medical literature, USIDNET and Immune Deficiency Foundation. The uncertainty surrounding the variables was modelled using probability distributions and evaluated using Monte Carlo simulation. RESULTS: The mean treatment dose from USIDNET and European Society for Immunodeficiencies (ESID) was significantly different for treating CVID, and the number of annual infusions from USIDNET and ESID was significantly different for treating CVID and XLA. The mean and standard deviation of LTD for all PIDDs is 105·1 ± 88·5 g per 1000 population, with CVID contributing the most to LTD. CONCLUSION: Estimating country-specific LTD is important to ensure an adequate supply of IgGRT and an optimal treatment for patients with PIDDs and for improving national healthcare policymaking and production planning.

[Intravitreal injections: AFSSAPS guide to good practice]. / Injections intravitréennes: mise au point de l'AFSSAPS.

Intravitreal injections are very commonly performed in the daily practice of Ophthalmology and become a leading procedure in the management of age-related macular degeneration, diabetic retinopathy, infectious endophthalmitis or retinitis, uveitis and retinal vein occlusions. Based on the comments of a group of experts, including ophthalmologists, pharmacists and hygienists, the French Agency for the Safety of Health Products (AFSSAPS) edited a guide to good practice of intravitreal injections, revisiting those previously published in 2006. The overall experience accumulated during time is a valuable source of information to determine the most appropriate protocol. Therefore, the simplification of the procedure is reasonably proposed even though safety remains a major issue, in order to avoid complications, especially infections.

Guidelines for infection control in nursing homes: a Delphi consensus web-based survey.

A nationwide survey was performed using a two-round web-based Delphi procedure to develop a set of consensus guidelines for preventing infections among residents in nursing homes (NHs). The research group was led by an investigative group of six specialists. Research analysts conducted a literature search and review of practice guidelines, systematic reviews and articles or abstracts published in English and French on the topic of infection prevention. The literature search was examined by 23 specialists (who compiled a preliminary list of 301 recommendations). Using a Delphi survey online instrument, 81 experts from all relevant medical specialties in the fields of infection prevention and control and geriatrics rated their agreement with each of the recommendations using a nine-point scale (1 = strongly disagree, 9 = strongly agree). During the second round, 79 participants received anonymous feedback from the first round and assessed a narrowed list of 130 recommendations. Recommendations were retained and classified according to the overall median score and ratings percentages by stakeholders. A total of 79 raters rated ≥ 10% of items, and 264 recommendations were retained and rated as follows: 240 items reached consensus, 24 items reached near consensus, 37 items were discarded and one recommendation was deleted. Many infections, though not all, can be prevented in the frail elderly. Thus, these guidelines should be adopted by each healthcare professional and facility to implement routine infection control procedures.

[Antibioprophylaxis in ocular surgery: AFSSAPS recommendations]. / Antibioprophylaxie en chirurgie ophtalmologique. À propos des recommandations de l'AFSSAPS.

According to the literature and to the advice of experts, the French Agency for the Safety of Health Products (AFSSAPS) edited recommendations about the antibioprophylaxis in ocular surgery. One goal was to avoid the extensive use of oral and topical fluoroquinolones in antibioprophylaxis, in order to preserve their antibacterial activity for curative treatments of severe eye infections. The medical team decides for the indication and the type of antibioprophylaxis for each patient. A topical antibiotic is recommended for any eye surgery until the etancheity of incisions. Due to the risk of selection of bacterial resistance topical fluoroquinolones are not recommended in this indication. In open eye surgery, an additional antibioprophylaxis is recommended: in cataract surgery, injection in the anterior chamber at the end of the procedure of 1mg of cefuroxime; in other open eye surgeries, only in case of risk factors for endophthalmitis, administration of 500 mg oral levofloxacin tablet 12 hours and two hours before surgery. For ocular punctures and intravitreal injections, only a topical postoperative antibiotic is recommended until healing.

[Evaluation of practices involving a cross infection risk in anaesthesia]. / Evaluation des pratiques en anesthésie exposant au risque infectieux par transmission croisée.

OBJECTIVE: The practice of anaesthesiology has the potential for transmitting a number of infectious agents to the patient. In France, several recent cases have been identified, so that a wide survey on anaesthesiology practice has been enhanced. METHODS: An anonymous questionnaire, based on the recommendations of the French Society of Anaesthesiology and Intensive Care (Sfar), was send to 8,771 anaesthesiologists and intensive care practitioners and to 2,070 nurses practicing anaesthesiology. RESULTS: A total of 1,343 questionnaires were analyzed (response rate of 12.4%). The study shows that some recommendations were routinely applied, such as: availability of alcohol-based hand hygiene solution in operating rooms (94%), use of antimicrobial filters for respiratory circuits (99%), use of single-use laryngoscope blades (77%), aseptic technique for central venous catheterization (99%), hand hygiene after contact with body fluids (96%). In contrast, the study showed that some recommendations were partially applied: hand hygiene practice (52%), wear of gloves when a risk of blood exposure exists (23%), cleaning of reusable laryngoscope blades (19%), and incorrect wear of masks (71%). The reuse of the same syringe for several patients was described in 2% of the responses. CONCLUSION: This results, similar to those previously described in the literature, must be followed by appropriate training and education of anaesthesia personnel, implementation of the recommendations, and evaluation of practices. Reuse of the same syringe for several patients have to be eradicated because of the high risk of viral transmission.

[Surveillance of infections in chronic hemodialysis patients]. / Surveillance des infections chez les hémodialysés chroniques en centre.

OBJECTIVE: To confirm rates of infections from a previous survey in chronic hemodialysis patients; to get information about incidents and manipulations of vascular access-site, number and reasons of hospitalisation; to asses a relationship between the frequency of vascular access-site infections (VASI) and quality of care during the procedures of vascular access-site use. DESIGN: Prospective, multicenter survey performed from February 2000 to January 2001, including all patients underwent chronic hemodialysis in 5 participating centers. Standardized definitions used and different clinical and biological risk factors recorded. RESULTS: 429 patients for a total of 4273 dialysis months (DM) were enrolled. 245 infections in 164 infected patients were reported. The overall rate was 5.73 infections per 100 DM (18 VASI, 25 bacteraemia, 84 respiratory, 29 urinary tract, 1 endocarditis and 88 other infections). 50% of infections were microbiologically documented. 19 of 21 antibiotics resistant microorganisms were meticillin resistant Staphylococcus aureus. Compared to the incidence rate of fistula (0.05 per 1000 days of follow-up) or prosthesis related VASI (0.11), the incidence rate of catheter related VASI (0.65) was significantly higher. Poor hygiene and duration of catheter use were the significant risk factors for VASI showed by logistic analysis regression. VASI and bacteraemia occurred more frequently after incident or manipulation of the vascular access-site. The decrease of VASI between the 2 periods of survey was significantly higher in centers having reduced the catheter use and implemented written protocols. CONCLUSIONS: This second period of surveillance has confirmed the frequency of infections rate in chronic hemodialysis patients and particularly bacteraemia and VASI. This study has allowed to establish risk factors for infections and showed that VASI in hemodialysis are related to factors in part preventable.

[Resources and organization of 124 health-care institutions in South-East France for standard precautions and isolation]. / Ressources et organisation de 124 etablissements de l'interrégion Sud-Est pour la mise en oeuvre des précautions standard et d'isolement septique.

OBJECTIVES: The authors had aimed to evaluate resources and organization necessary for applying guidelines issued 5 years earlier in various institutions: standard precautions, septic isolation, prevention against spread of multidrug-resistant bacteria. MATERIAL AND METHODS: Volunteer institutions were surveyed for hygiene product consumption, architectural requirements, inventory of protocols, description septic patients'management, and available personnel. RESULTS: One hundred and twenty-four institutions (40,784 beds) were included in the study. Eleven percent had no hygiene physician or nurse; the rates of personnel specialized in hygiene practice were 0.4 physicians per 800 beds and 0.8 registered nurses per 400 beds. Eighty-eight percent of the studied institutions had a protocol for standard precautionary measures, 77% had a septic isolation protocol. A multidrug-resistant bacteria identification sheet was attached to examination reports in 87% of cases. Multidrug-resistant bacteria screening was practiced by 18.1% of the institutions. Hygiene product consumption for 1000 days of hospitalization was 7861 disposable gloves, 2.3 1 of hydroalcoholic solution, and 63 disposable gowns. 28.9% of the wards lacked water hand washing points, 32.2% had no sinks, and 48.5% had no local equipment maintenance. In addition, 40.7% of the beds were in single rooms, 4.8% of the institutions had no single rooms. Differences were observed depending on specialties and institutions. CONCLUSION: Analysis of consumption shows insufficient application of standard precautions, notably for hydroalcoholic solutions. The number of single rooms is acceptable, architectural requirements were not adequate in too many wards. These results can explain some problems encountered in applying the guidelines.

[Technical requirements for buying a heat and humidity exchanger for ventilation during anesthesia. French Society of Anesthesia and Intensive Care]. / Clauses techniques pour l'achat d'un filtre échangeur de chaleur et d'humidité destiné à la ventilation en anesthésie. Société française d'anesthésie réanimation.

To prevent cross infection and to improve the management of anaesthetic circuits, the French society of anesthesia and intensive care recommended the use of heat and moisture exchange filter (HMEF). Buying a HMEF needs a procedure with different steps and a product request form must delineate precise needed requirements of the device. In the absence of standardized methods to assess filtration performance, required specifications are established from both manufacturer data and scientific published studies. Proposed purchasing method and criteria help the health care workers at the time of final decision for objective comparison between the different devices on the market.

[Surveillance of nosocomial infections related to anesthesia. A multicenter study]. / Surveillance des infections nosocomiales liées à l'anesthésie. Etude multicentrique.

OBJECTIVES: To determine incidence rate, main characteristics and risk factors of nosocomial infections associated with anesthesia (NIAA). STUDY DESIGN: Prospective, descriptive multicentre survey. PATIENTS: All patients aged more than 15 years and undergoing surgery (except cardio-thoracic, ENT or ambulatory surgery) under general or regional anaesthesia. METHODS: Voluntary participation of surgical units from public or private hospitals. Use of pre-established definitions of infections and a 72 hours postanesthetic follow-up. Anaesthesia and operation related risk factors collected. End point based on occurrence, or not, of clinical infection. Record, control, treatment and analysis of the data by Epi Info--5.0 software. Statistics used: Fischer's exact test, Mantel-Haenszel test, Anova method, Kruskall-Wallis test. RESULTS: Among 7,300 patients belonging to 13 hospitals, 25 developed an infection (nine vascular catheter related infections, 12 respiratory tract infections, two infections of the eye and two of the mouth). Only two infections have been bacteriologically documented. The overall incidence of NIAA was 3.4 per 1,000 patients. It was significantly higher after an anaesthetic of more than 2 hours and after transfusion. CONCLUSIONS: This first prospective survey of NIAA confirmed that nosocomial infections are a real problem in the practice of anaesthesia and the necessity to use preventive measures. A survey with a larger sample size would allow to specify the respective part of the various risk factors and to develop a risk index.

Phosphorylation of cytosolic phospholipase A2 and the release of arachidonic acid in human neutrophils.

Kinases mediating phosphorylation and activation of cytosolic phospholipase A2 (cPLA2) in intact cells remain to be fully characterized. Platelet-activating factor stimulation of human neutrophils increases cPLA2 phosphorylation. This increase is inhibited by PD 98059, a mitogen-activated protein (MAP)/extracellular signal-regulating kinase (erk) 1 inhibitor, but not by SB 203580, a p38 MAP kinase inhibitor, indicating that this action is mediated through activation of the p42 MAP kinase (erk2). However, platelet-activating factor-induced arachidonic acid release is inhibited by both PD 98059 and SB 203580. Stimulation by TNF-alpha increases cPLA2 phosphorylation, which is inhibited by SB 203580, but not PD 98059, suggesting a role for p38 MAP kinase. LPS increases cPLA2 phosphorylation and arachidonic acid release. However, neither of these actions is inhibited by either PD 98059 or SB 203580. PMA increases cPLA2 phosphorylation. This action is inhibited by PD 98059 but not SB 203580. Finally, FMLP increases cPLA2 phosphorylation and arachidonic acid release. Interestingly, while the FMLP-induced phosphorylation of cPLA2 is not affected by the inhibitors of the p38 MAP kinase or erk cascades, both inhibitors significantly decrease arachidonic acid release stimulated by FMLP. SB 203580 or PD 98059 has no inhibitory effects on the activity of coenzyme A-independent transacylase.

Ambulatory radical retropubic prostatectomy.

OBJECTIVES: To review the experience of 40 consecutive patients who underwent radical retropubic prostatectomy and to determine if and how the procedure could be performed safely on an ambulatory basis. METHODS: Between June 20, 1994 and November 26, 1996, 40 consecutive men with clinically localized prostate carcinoma underwent radical retropubic prostatectomy. Retrospective data regarding the patient population, patient satisfaction, clinical outcome, and length of hospitalization were evaluated. RESULTS: The average age for the patients was 62.6 years (range 44 to 75) with an average PSA of 10.44 ng/mL. Eighty percent (32 of 40) of the patients were discharged on postoperative day 1, 17.5% (7 of 40) were discharged on postoperative day 2, and 2.5% (1 of 40) were discharged on postoperative day 7. The average operative time was 89.5 minutes (range 65 to 135), measured from the time of incision to completion of closure. The organ-confined rate was 80% (32 of 40). The continence evaluated at 6 months was 90.9% (30 of 33). The potency at 4 months was 35% (10 of 28) and at 1 year was 55.6% (10 of 18). Postoperative complications were minimal, with 7.5% (3 of 40) bladder neck contractures and 2.5% (1 of 40) wound infections. Patient satisfaction assessed by questionnaires revealed that 90% (36 of 40) thought that the length of hospitalization was adequate and 97.5% (39 of 40) would choose to have the procedure again. A second series of 15 patients have also undergone radical retropubic prostatectomy utilizing a pelvic block to expedite discharge. Of these 15 procedures, 10 were performed on an ambulatory basis. CONCLUSIONS: Radical retropubic prostatectomy can be performed expediently with the maintenance of patient satisfaction, continence rates, potency rates, recurrence rates, complication rates, and pathologic results. The advantage to such an approach is expedited patient discharge, cost savings to the medical system, and no alteration in patient recovery or clinical outcome, such as organ-confined rate, potency, and continence. In this series, the majority of patients were discharged on postoperative day 1. On the basis of this experience, we have performed the procedure on an outpatient basis, while maintaining the same high quality of care. To date, 10 patients have undergone ambulatory radical retropubic prostatectomy and were discharged the same day of surgery without complications.

Ethyl propionate is more effective and less cytotoxic than methyl tert-butyl ether for topical gallstone dissolution.

BACKGROUND & AIMS: Ethyl propionate and isopropyl acetate were identified as gallstone solvents with more favorable physicochemical properties than the currently used solvent methyl tert-butyl ether (MTBE). In this study, their efficacy and toxicity were compared. METHODS: To compare efficacy, matched stones from 33 patients were subjected to dissolution with each solvent. To evaluate cytotoxicity, jejunal segments of the anesthetized rat were exposed to each solvent or saline; the segments were then perfused with markers for active absorption and passive permeability. RESULTS: For 23 gallstone sets that dissolved completely with all three solvents, the average dissolution time was shorter with ethyl propionate (38 +/- 8 minutes) than with MTBE (60 +/- 13 minutes) (P = 0.03) or isopropyl acetate (55 +/- 12 minutes) (P < 0.001). Four stones did not dissolve with ethyl propionate, seven with MTBE, and eight with isopropyl acetate. After 2 minutes of exposure to the solvents, the dry weight of the segments decreased by 36% after MTBE but was unchanged after the other two solvents (P < 0.001). MTBE caused more inhibition of active absorption than the other solvents (P < 0.001) and a greater increase in passive permeation (P < 0.03). CONCLUSIONS: Ethyl propionate and isopropyl acetate are less toxic to the intestinal mucosa than MTBE, and ethyl propionate is more effective for gallstone dissolution.