The effect of an intervention bundle to prevent central venous catheter-related bloodstream infection in a national programme in the Netherlands.

INTRODUCTION: Central venous catheters (CVCs) can lead to central line-related bloodstream infections (CRBSIs). A six-item bundle was introduced in 2009 to prevent CRBSI in Dutch hospitals. AIM: This study aimed to determine the impact of an intervention bundle on CRBSI risk. METHODS: Data were obtained from hospitals participating in the national CRBSI surveillance between 2009 and 2019. Bundle compliance was evaluated as a total ('overall') bundle (all six items) and as an insertion bundle (four items) and a maintenance bundle (two daily checks). We estimated the impact of the overall and partial bundles, using multi-level Cox regression. FINDINGS: Of the 66 hospitals in the CRBSI surveillance 56 (84.8%) recorded annual bundle (non)compliance for >80% of the CVCs, for one to nine years. In these 56 hospitals CRBSI incidence decreased from 4.0 to 1.6/1000 CVC days. In the intensive care units (ICUs), compliance was not associated with CRBSI risk (hazard ratio (HR) for the overall, insertion and maintenance bundle were 1.14 (95% confidence interval 0.80-1.64), 1.05 (0.56-1.95) and 1.13 (0.79-1.62)), respectively. Outside the ICU the non-significant association of compliance with the overall bundle (HR 1.36 (0.96-1.93)) resulted from opposite effects of the insertion bundle, associated with decreased risk (HR 0.50 (0.30-0.85)) and the maintenance bundle, associated with increased risk (HR 1.68 (1.19-2.36)). CONCLUSION: Following a national programme to introduce an intervention bundle, CRBSI incidence decreased significantly. In the ICU, bundle compliance was not associated with CRBSI risk, but outside the ICU improved compliance with the insertion bundle resulted in a decreased CRBSI risk.

Trends in prevalence of healthcare-associated infections and antimicrobial use in hospitals in the Netherlands: 10 years of national point-prevalence surveys.

BACKGROUND: Prevalence of healthcare-associated infections (HCAIs) and antimicrobial use in hospitals in the Netherlands has been measured using voluntary biannual national point-prevalence surveys (PPSs). AIM: To describe trends in the prevalence of patients with HCAI, risk factors, and antimicrobial use in 2007-2016. METHODS: In the PPS, patient characteristics, use of medical devices and antimicrobials, and presence of HCAI on the survey day are reported for all hospitalized patients, excluding patients in the day-care unit and psychiatric wards. Analyses were performed using linear and (multivariate) logistic regression, accounting for clustering of patients within hospitals. FINDINGS: PPS data were reported for 171,116 patients. Annual prevalence of patients with HCAI with onset during hospitalization decreased from 6.1% in 2007 to 3.6% in 2016. The adjusted odds ratio (OR) for trend was 0.97 (95% confidence interval: 0.96-0.98). Most prominent trends were seen for surgical site infections (1.6%-0.8%; OR: 0.91 (0.90-0.93)) and urinary tract infections (2.1%-0.6%; OR: 0.85 (0.83-0.87)). From 2014 on, HCAIs at admission were also registered with a stable prevalence of approximately 1.5%. The mean length of stay decreased from 10 to 7 days. The percentage of patients treated with antibiotics increased from 31% to 36% (OR: 1.03 (1.02-1.03)). CONCLUSION: Repeated PPS data from 2007 to 2016 show a decrease in the prevalence of patients with HCAI with onset during hospitalization, and a stable prevalence of patients with HCAI at admission. The adjusted OR of 0.97 for HCAI during hospitalization indicates a true reduction in prevalence of approximately 3% per year.

Burden of surgical site infections in the Netherlands: cost analyses and disability-adjusted life years.

BACKGROUND: Surgical site infections (SSIs) are associated with morbidity, mortality and costs. AIM: To identify the burden of (deep) SSIs in costs and disability-adjusted life years (DALYs) following colectomy, mastectomy and total hip arthroplasty (THA) in the Netherlands. METHODS: A retrospective cost-analysis was performed using 2011 data from the national SSI surveillance network PREZIES. Sixty-two patients with an SSI (exposed) were matched to 122 patients without an SSI (unexposed, same type of surgery). Patient records were studied until 1 year after SSI diagnosis. Unexposed patients were followed for the same duration. Costs were calculated from the hospital perspective (2016 price level), and cost differences were tested using linear regression analyses. Disease burden was estimated using the Burden of Communicable Disease in Europe Toolkit of the European Centre for Disease Prevention and Control. The SSI model was specified by type of surgery, with country- and surgery-specific parameters where possible. FINDINGS: Attributable costs per SSI were €21,569 (THA), €14,084 (colectomy) and €1881 (mastectomy), mainly caused by prolonged length of hospital stay. National hospital costs were estimated at €10 million, €29 million and €0.6 million, respectively. National disease burden was greatest for SSIs following colectomy (3200 DALYs/year, 150 DALYs/100 SSIs), while individual disease burden was highest following THA (1200 DALYs/year, 250 DALYs/100 SSIs). For mastectomy, these DALYs were <1. The total cost of DALYs for the three types of surgery exceeded €88 million. CONCLUSION: Depending on the type of surgery, SSIs cause a significant burden, both economically and in loss of years in full health. This underlines the importance of appropriate infection prevention and control measures.

Infection after ICD implantation: operating room versus cardiac catheterisation laboratory.

BACKGROUND/OBJECTIVES: Since the insertion of an implantable cardioverter-defibrillator (ICD) has become technically comparable to pacemaker implantation, these procedures are increasingly being performed in a cardiac catheterisation laboratory (CCL) instead of the operating room (OR). This study aims to describe the relationship between incidence of ICD infection and procedure setting and to describe the characteristics of ICD infection. METHODS: A retrospective study was performed of first ICD implantation in 677 patients admitted to our hospital between 1996 and 2006. Implantations were performed in the OR until 2003, after 2003 they were carried out in the CCL. The follow-up was censored at one year after implantation. ICD infections were defined as pocket infection or ICD-related endocarditis and a descriptive analysis was performed. RESULTS: Cardiothoracic surgeons implanted 366 ICDs in the OR Electrophysiologists performed 301 implantations in the CCL. Pulse generators were inserted using a pectoral approach with transvenous lead systems. We identified seven ICD infections (incidence rate 1.2/100 person-years), three of which had been implanted in the OR and four in the CCL. CONCLUSION: In this single-centre study no difference in the incidence of ICD infection was observed between implantation in OR and CCL. However, a larger study will be necessary to rule out a relationship with certainty. (Neth Heart J 2009;17:95-100.).

[Methicillin-resistant Staphylococcus aureus of livestock origin in Dutch hospitals: high-risk patients need only to be investigated if admitted to hospital]. / Meticillineresistente Staphylococcus aureus afkomstig uit de veestapel in Nederlandse ziekenhuizen: risicopatiënten alleen controleren bij eventuele ziekenhuisopname.

OBJECTIVE: To determine the incidence and prevalence of carriage of methicillin-resistent Staphylococcus aureus (MRSA) in patients and hospital personnel, and to examine the consequences of the revised Dutch MRSA guideline with respect to patients who have frequent contact with pigs or calves (in the course of their work). DESIGN: Retrospective and prospective observational study using questionnaires. METHOD: Since July 2006 patients who have contact with living pigs or calves have been regarded as a high-risk group for MRSA carriage, after it was established that this occupational group had an increased chance of carriage of the so-called non-typable MRSA (NT-MRSA). An inventory was made of incidence and prevalence of MRSA carriage in patients and hospital personnel, and of the consequences of the new MRSA policy, for the period July-December 2006. RESULTS: Information was obtained from 58 Dutch hospitals. On January 1 2007, 37 (64%) hospitals had changed their MRSA policy; 22% of the hospitals it was applied in accordance with the MRSA guideline. The new guideline resulted in an increase of MRSA screenings by 15% and of detected MRSA carriers by 44%. 73% of all MRSA screenings took place in the out-patients department. In regions with high pig-density the incidence of NT-MRSA was 12% in patients with risk factors for carriage. In 49% of the hospitals one or more NT-MRSA carriers were detected (range 1-19 carriers). Possible transmission of NT-MRSA in hospital was shown in 3 of 1,007 (0.3%) hospital personnel, but in none of the 183 fellow-patients, examined. In the same period transmission of typable MRSA was demonstrated in 41 of 2,019 (2.0%) patients and 33 of 5,190 (0.6%) of hospital personnel examined. Prevalence of NT-MRSA carriage in 6,197 screened hospital personnel was 0.05% (n = 3). CONCLUSION: The revised Dutch MRSA guideline lead to an increase in the number of MRSA screenings by 15%, particularly in the out-patients department, and to an increase in the number of detected MRSA carriers by 44%. During 306 months of observation no patient-to-patient transmission ofNT-MRSA was demonstrated.

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.

[Epidemic of methicillin-resistant Staphylococcus aureus due to the transfer of 2 Dutch burn patients from a hospital outside of the Netherlands; who suffers the consequences?]. / Epidemie van meticillineresistente Staphylococcus aureus door overname uit een buitenlands ziekenhuis van 2 Nederlandse brandwondpatiënten; wie draagt de gevolgen?

Two burns patients who were transferred to the Central Military Hospital Utrecht from a foreign hospital, were found to be colonised with MRSA. During their 5-week hospitalisation, 21 healthcare workers and one patient became colonised with the same MRSA strain, despite isolation precautions. The department was closed for 29 days; 96 admissions were cancelled and 1411 screening cultures for MRSA were performed. Colonised healthcare workers were temporarily unable to work and additional costs were incurred for disposables and cleaning procedures. The resultant bill for this outbreak was approximately [symbol: see text] 122,500. MRSA outbreaks occur in hospitals with some degree of regularity, but the strong dispersal during this epidemic was exceptional. The transfer of possible MRSA-colonised patients from hospitals outside of the Netherlands sometimes faces opposition due to the considerable demands it makes on a hospital's personnel, organisation and finances. If this were to be compensated, then the currently successful Dutch MRSA policy could be coupled with a willingness to accept patients from hospitals outside of the Netherlands.

Outbreak of a susceptible strain of Acinetobacter species 13 (sensu Tjernberg and Ursing) in an adult neurosurgical intensive care unit.

Between December 1999 and June 2000, an outbreak caused by Acinetobacter emerged on the neurosurgical intensive care unit of our hospital. It was shown using automated ribotyping using Eco RI and pulsed-field gel electrophoresis that the outbreak was caused by spread of a single strain, which was identified by ribotyping and amplified ribosomal DNA restriction analysis as Acinetobacter DNA group 13TU (sensu Tjernberg and Ursing). The outbreak strain, which showed no antibiotic resistance, was identified in 23 patients, five of whom developed an infection. The organism was also isolated from various environmental sites. Cross-transmission among patients continued despite contact isolation of colonized patients and reinforcement of basic disinfection procedures. Eventually, after implementation of additional stringent measures such as cohorting of positive patients and daily disinfection of the floor, the outbreak was brought under control. This study demonstrates that apart from Acinetobacter baumanii, Acinetobacter 13TU strains, even when they are fully susceptible, may cause outbreaks that are difficult to control. Correct identification to the species level of Acinetobacter by genotypic methods is necessary to get insight in the importance of the different Acinetobacter genomic species in hospital epidemiology.