Influence of environmental temperature and heatwaves on surgical site infection after hip and knee arthroplasty: a nationwide study.

BACKGROUND: Previous studies reported higher incidence of surgical site infection (SSI) after procedures performed in summer or with high temperatures. However, no study used detailed climate data to assess this risk after hip and knee arthroplasty, and no study specifically investigated the role of heatwaves. AIM: To assess the impact of higher environmental temperatures and heatwaves on SSI rates after hip and knee arthroplasty. METHODS: Data on hip and knee arthroplasty procedures performed between January 2013 and September 2019 in hospitals participating in the Swiss SSI surveillance were linked to climate data extracted from weather stations located in their vicinity. The association between temperature, heatwaves and SSI was studied using mixed effects logistic regression models fitted at the patient level. Poisson mixed models were fitted for both calendar year and month of the year to investigate the SSI incidence trajectory over time. RESULTS: We included 116,981 procedures performed in 122 hospitals. Significantly higher SSI rates were observed for procedures performed in the summertime (incidence rate ratio 1.39, 95% CI (1.20-1.60), P<0.001; reference: autumn) or in calendar months in which the mean temperature was above 20 °C (reference 5-10 °C; odds ratio 1.59, 95% CI (1.27, 1.98), P<0.001). We observed a slight but non-significant increase in the rate of SSI during heatwaves (1.44% versus 1.01%, P=0.2). CONCLUSION: SSI rates after hip and knee replacement appear to increase with higher environmental temperature. To establish whether, and to what extent, heatwaves increase the risk of SSI, studies involving geographical areas with larger variability in temperature are needed.

Pre-frail older adults show improved cognition with StayFitLonger computerized home-based training: a randomized controlled trial.

Multidomain interventions have shown tremendous potential for improving cognition in older adults. It is unclear if multidomain interventions can be delivered remotely and whether remote intervention is beneficial for older adults who are vulnerable or at risk of cognitive decline. In a 26-week multi-site, home-based, double-blind, randomized controlled trial, 120 cognitively healthy older adults (75 robust, 45 pre-frail; age range = 60-94) recruited from Switzerland, Canada, and Belgium were randomized to receive either the StayFitLonger (SFL) computerized multidomain training program or an active control intervention. Delivered on tablets, the SFL intervention combined adapted physical exercises (strength, balance, and mobility), cognitive training (divided attention, problem solving, and memory), opportunities for social and contributive interactions, and psychoeducation. The active control intervention provided basic mobilization exercises and access to video games. Cognitive outcomes were global cognition (Z-scores of attention, verbal fluency, and episodic memory for nondemented older adults; ZAVEN), memory, executive function, and processing speed. Linear mixed model analyses indicated improved performance on the ZAVEN global cognition score in the SFL group but not in the active control group. Stratified analyses by frailty status revealed improved ZAVEN global cognition and processing speed scores following SFL in the pre-frail group but not in the robust group. Overall, the study indicates that a computerized program providing a multidomain intervention at home can improve cognition in older adults. Importantly, pre-frail individuals, who are at higher risk of cognitive decline, seem to benefit more from the intervention. Trial registration: ClinicalTrials.gov, NCT037519 Registered on January 22, 2020-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04237519 .

Prevalence of enterococcal groin colonization in patients undergoing cardiac interventions: challenging antimicrobial prophylaxis with cephalosporins in patients undergoing transcatheter aortic valve replacement.

BACKGROUND: Cephalosporins are recommended for prophylaxis before transcatheter aortic valve replacement (TAVR). Infective endocarditis (IE) after TAVR is caused by enterococci in up to 30% of cases, particularly early after TAVR. Enterococcal colonization in the groin has been postulated as a source of infection, not only because prophylaxis does not cover enterococci but also because most TAVR procedures are performed by transfemoral access. There are few data analysing the groin microbiome to demonstrate the presence of enterococci. AIM: To assess the prevalence of enterococci in the groins of cardiological patients receiving transfemoral interventions. METHODS: This prospective cohort study was undertaken at University Hospital Basel, Switzerland between February and August 2020. Two skin swabs were taken from the groins of consecutive patients undergoing transfemoral cardiac interventions before the administration of antibiotic prophylaxis; for each patient, swabs were taken before and after groin disinfection. Swabs were analysed in the local microbiological laboratory following validated culture methods. FINDINGS: Of 290 included patients, 245 (84.5%) underwent coronary angiography, 31 (10.7%) underwent TAVR, eight (2.8%) underwent right heart catheterization, five (1.7%) underwent closure of patent foramen ovale, and one (0.3%) underwent a MitraClip procedure. Enterococci were detected before disinfection in 48 patients, enterococci were still cultured after disinfection in three patients, and enterococci were detected after disinfection alone (i.e. not detected before disinfection) in one patient. The prevalence of enterococci was 16.6% before disinfection and 1.4% after disinfection. Patients colonized with enterococci had a significantly higher body mass index and were more likely to be diabetic than uncolonized patients. CONCLUSION: Common enterococcal colonization of the groin, coupled with frequent isolation of enterococci from patients with TAVR-associated IE, provides strong evidence that the current recommendation of antimicrobial prophylaxis with cephalosporins before TAVR should be changed to antimicrobial prophylaxis with a compound that is active against enterococci.

Matching Clostridioides difficile strains obtained from shoe soles of healthcare workers epidemiologically linked to patients and confirmed by whole-genome sequencing.

BACKGROUND: The source of transmission of Clostridioides difficile in healthcare institutions is frequently unknown. The aim of this prospective cohort study was to assess the association between strains cultured from patients and shoe soles of healthcare workers (HCWs), as already shown in the operating theatre, but not on general hospital wards in an acute-care institution. METHODS: We conducted a study at a university tertiary care centre in Switzerland. From October 2019 to July 2020, shoe soles of HCWs were cultured for C. difficile twice per shift while taking care of a patient infected with toxigenic C. difficile. Additional risk factors were assessed by interviewing involved HCWs. Patients' faecal samples were processed by routine microbiological methods. Similarity of the HCWs' and patients' strains was determined by whole-genome sequencing (WGS). RESULTS: A total of 103 HCWs exposed to 42 hospitalized patients participated in the study, providing 206 samples. Contamination of shoe soles with C. difficile was detected in 37 samples (17.8%) of HCWs taking care of patients infected with C. difficile. Overall, transmission was suspected by epidemiological link and matching strains demonstrated by WGS in 74%. CONCLUSIONS: HCWs' shoe soles were positive in 17.8% with C. difficile strains linked epidemiologically and confirmed by WGS to infected patients suggesting potential transmission by HCWs' shoe soles. This pilot study provides sufficient evidence to further evaluate this potential mode of healthcare-associated transmission of C. difficile by a larger clinical trial.

Does high adherence to contact precautions lead to low in-hospital transmission of multi-drug-resistant micro-organisms in the endemic setting?

BACKGROUND: Conflicting results have been published on the impact of contact precautions (CPs) on reduction of transmission of multi-drug-resistant micro-organisms (MDROs) in the endemic setting. Ambiguous definitions coupled with low adherence partly explain these differences. AIM: We prospectively monitored the level of adherence to CPs and aimed to relate it to in-hospital transmission of MDROs. METHODS: Between January 2016 and March 2018, all patients under CPs underwent continuous monitoring of adherence to CPs by routine on-site visits on days 0, 3 and 7 after initiating CPs using a standardized checklist. The protocol included 10 interventions that were routinely checked such as CP sign at the door as well as wearing of gowns and gloves upon entry to the patient room. Patients requiring CPs were defined as colonized or infected with MDROs (meticillin-resistant Staphylococcus aureus (MRSA), non-Escherichia coli extended-spectrum beta lactamase (ESBL) Enterobacterales, vancomycin-resistant enterococci (VRE) and carbapenem-resistant Gram-negative micro-organisms (CRGN)) as well as patients infected with respiratory viruses, norovirus, scabies and hypervirulent strains of Clostridioides difficile. FINDINGS: Overall, data from 13,756 CP records from 1378 visits of 812 patients were analysed. Adherence varied between 93% and 100% for each intervention, except for "separate space for contaminated material" with an adherence of 5.3-6.1%. The incidence of in-hospital transmission during the study period was extremely low for MRSA, VRE, non-E.coli ESBL Enterobacterales and CRGN with 0.00-0.064 cases/1000 patient days. CONCLUSION: High adherence coupled with continuous monitoring of CPs correlated with a very low in-hospital transmission rate. These results indicate that CPs are highly effective if routine monitoring of adherence is implemented.

Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review.

Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolong hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach whereby different strategies may be implemented together, next to targeted, risk-based approaches, in order to reduce the risk of HAIs for patients. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. This review focuses on routine environmental cleaning and disinfection including areas with a moderate risk of contamination, such as general wards. As scientific evidence has not yet resulted in universally accepted guidelines nor led to universally accepted practical recommendations pertaining to surface cleaning and disinfection, this review provides expert guidance for healthcare workers in their daily practice. It also covers outbreak situations and suggests practical guidance for clinically relevant pathogens. Key elements of environmental cleaning and disinfection, including a fundamental clinical risk assessment, choice of appropriate disinfectants and cleaning equipment, definitions for standardized cleaning processes and the relevance of structured training, are reviewed in detail with a focus on practical topics and implementation.

Rationale and protocol of the StayFitLonger study: a multicentre trial to measure efficacy and adherence of a home-based computerised multidomain intervention in healthy older adults.

BACKGROUND: In older adults, multidomain training that includes physical and cognitive activities has been associated with improvement of physical and cognitive health. The goal of the multisite StayFitLonger study is to assess a home-based computerised training programme, which combines physical exercises, stimulating cognitive activities and virtual coaching. METHODS: One hundred twenty-eight cognitively healthy older adults will be recruited from the community in Switzerland, Canada and Belgium. The study will comprise (1) a 26-week double-blind randomized controlled efficacy trial and (2) a 22-week pragmatic adherence sub-study. In the efficacy trial, participants will be randomly assigned to an experimental or an active control intervention. In the experimental intervention, participants will use the StayFitLonger programme, which is computerised on a tablet and provides content that combines physical activities with a focus on strength and balance, as well as divided attention, problem solving and memory training. Outcomes will be measured before and after 26 weeks of training. The primary efficacy outcome will be performance on the "Timed-Up & Go" test. Secondary outcomes will include measures of frailty, cognition, mood, fear of falling, quality of life, and activities of daily living. Age, sex, education, baseline cognition, expectation, and adherence will be used as moderators of efficacy. Following the 26-week efficacy trial, all participants will use the experimental programme meaning that participants in the control group will 'cross over' to receive the StayFitLonger programme for 22 weeks. Adherence will be measured in both groups based on dose, volume and frequency of use. In addition, participants' perception of the programme and its functionalities will be characterised through usability, acceptability and user experience. DISCUSSION: This study will determine the efficacy, adherence and participants' perception of a home-based multidomain intervention programme and its functionalities. This will allow for further development and possible commercialization of a scientifically validated training programme. TRIAL REGISTRATION: ClinicalTrials.gov , NCT04237519 Registered on January 22, 2020 - Retrospectively registered.

Impact of an infection control service in a university psychiatric hospital: significantly lowering healthcare-associated infections during 18 years of surveillance.

BACKGROUND: Healthcare-associated infections (HAIs) lead to high morbidity and mortality. Data for HAIs in psychiatric hospitals are scarce, and are not derived from long-term surveillance. AIM: To assess the impact of an infection control service on the prevalence of HAIs in a psychiatric hospital over an 18-year period. METHODS: In 1999, a professional infection control service was initiated at the University Psychiatric Hospital in Basel, Switzerland, with a part-time infection control nurse, a hospital epidemiologist, and administrative support. In addition to monitoring rates of multi-drug-resistant pathogens, eight prevalence studies using definitions outlined by the Centers for Disease Control and Prevention (CDC) were conducted between 2001 and 2018. For the primary outcome, a Poisson regression model was fitted to confirm cases of HAIs, standardized for patients at risk as a model offset. FINDINGS: Overall, the predicted prevalence of nosocomial infections decreased from 3.7% (95% confidence interval (CI) 2.2-5.3%) in 2001 to 1.0% (95% CI 0.2-1.8%) in 2018 after introduction of an infection control service (incidence ratio rate (IRR) for yearly decrease of 0.93, 95% CI 0.87-0.98, P=0.007). CONCLUSIONS: Implementation of an infection control service may lead to a significant long-term decrease in HAIs, even in an institution caring for patients with low risk for HAIs, such as in psychiatric hospitals. In addition, epidemics and clusters were rapidly contained. Infection control services from acute-care hospitals should be expanded to psychiatric institutions, in order to decrease the incidence of HAIs and meet new challenges in times of emergence of multi-drug-resistant pathogens.

Long-term safety of secukinumab in patients with moderate-to-severe plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis: integrated pooled clinical trial and post-marketing surveillance data.

BACKGROUND: Secukinumab, a fully human immunoglobulin G1-kappa monoclonal antibody that directly inhibits interleukin (IL)-17A, has been shown to have robust efficacy in the treatment of moderate-to-severe psoriasis (PsO), psoriatic arthritis (PsA), and ankylosing spondylitis (AS) demonstrating a rapid onset of action and sustained long-term clinical responses with a consistently favorable safety profile in multiple Phase 2 and 3 trials. Here, we report longer-term pooled safety and tolerability data for secukinumab across three indications (up to 5 years of treatment in PsO and PsA; up to 4 years in AS). METHODS: The integrated clinical trial safety dataset included data pooled from 21 randomized controlled clinical trials of secukinumab 300 or 150 or 75 mg in PsO (14 Phase 3 trials and 1 Phase 4 trial), PsA (3 Phase 3 trials), and AS (3 Phase 3 trials), along with post-marketing safety surveillance data with a cut-off date of June 25, 2017. Adverse events (AEs) were reported as exposure-adjusted incident rates (EAIRs) per 100 patient-years. Analyses included all patients who received ≥ 1 dose of secukinumab. RESULTS: A total of 5181, 1380, and 794 patients from PsO, PsA, and AS clinical trials representing secukinumab exposures of 10,416.9, 3866.9, and 1943.1 patient-years, respectively, and post-marketing data from patients with a cumulative exposure to secukinumab of ~ 96,054 patient-years were included in the analysis. The most frequent AE was upper respiratory tract infection. EAIRs across PsO, PsA, and AS indications were generally low for serious infections (1.4, 1.9, and 1.2, respectively), Candida infections (2.2, 1.5, and 0.7, respectively), inflammatory bowel disease (0.01, 0.05, and 0.1, respectively), and major adverse cardiac events (0.3, 0.4, and 0.6, respectively). No cases of tuberculosis reactivation were reported. The incidence of treatment-emergent anti-drug antibodies was low with secukinumab across all studies, with no discernible loss of efficacy, unexpected alterations in pharmacokinetics, or association with immunogenicity-related AEs. CONCLUSIONS: Secukinumab demonstrated a favorable safety profile over long-term treatment in patients with PsO, PsA, and AS. This comprehensive assessment demonstrated that the safety profile of secukinumab was consistent with previous reports in patients with PsO, PsA, and AS, supporting its long-term use in these chronic conditions.

Overall bioburden by total colony count does not predict the presence of pathogens with high clinical relevance in hospital and community environments.

BACKGROUND: Healthcare-associated infections (HAIs) affect millions of patients, increasing morbidity and mortality. Pathogens of HAIs originate from both the patient's own flora and the environment, including multi-drug-resistant organisms. AIMS: To determine the bioburden on different types of high-touch surfaces, and to identify cultures to species level and stratify strains into those of low and high clinical relevance. DESIGN: Association between bioburden and presence of pathogens of high clinical relevance (PHCR) in a tertiary care centre and urban environment. METHODS: The overall bioburden measured by total colony count (TCC) was assessed using tryptic soy agar contact plates and two selective agars to improve detection of PHCR. Isolates were routinely identified to species level using matrix-assisted laser desorption/ionization - time of flight mass spectrometry (MALDI-TOF). The definition of PHCR was based on listings outlined by the Centers for Disease Control and Prevention. FINDINGS: In total, 1431 contact plates were processed from 477 surfaces: 153 from hospitals and 324 from publicly accessible institutions or devices. At least one PHCR was identified from cultures from 73 samples. TCC was found to be poorly correlated with the presence of PHCR. CONCLUSION: TCC poorly predicted the presence of PHCR, rendering the results from environmental sampling difficult to interpret. MALDI-TOF enables the identification of large numbers of isolates from the environment at low cost. Further studies on environmental contamination should use MALDI-TOF to identify all pathogens grown.

Time-dependent differences in management and microbiology of orthopaedic internal fixation-associated infections: an observational prospective study with 229 patients.

OBJECTIVES: Little information has been published on orthopaedic internal fixation-associated infections. We aimed to analyse time-dependent microbiology, treatment, and outcome. METHODS: Over a 10-year period, all consecutive patients with internal fixation-associated infections at the University Hospital of Basel, were prospectively followed and clinical, microbiological and outcome data were acquired. Infections were classified as early (0-2 weeks after implantation), delayed (3-10 weeks), and late (>10 weeks). RESULTS: Two hundred and twenty-nine patients were included, with a median follow-up of 773 days (IQR 334-1400). Staphylococcus aureus was the most prevalent pathogen (in 96/229 patients, 41.9%). Enterobacteriaceae were frequent in early infections (13/49, 26.5%), whereas coagulase-negative staphylococci (36/92, 39.1%), anaerobes (15/92, 16.3%) and streptococci (10/92, 10.9%) increased in late revisions. Failure was observed in 27/229 (11.7%). Implants were retained in 42/49 (85.7%) in early, in 51/88 (57.9%) in delayed, and in 9/92 (9.8%) in late revisions (p < 0.01). Early revisions failed in 6/49 (12.2%), delayed in 9/88 (10.2%), and late in 11/92 (13.0%) (p 0.81). Debridement and retention failed in 6/42 (14.3%) for early, in 6/51 (11.8%) for delayed, and in 3/9 (33.3%) for late revisions (p 0.21). Biofilm-active antibiotic therapy tailored to resistance correlated with improved outcome for late revisions failure (6/72, 7.7% versus 6/12, 50.0%; p < 0.01) but not for early revisions failure (5/38, 13.2% versus 1/11, 9.1%; p 1.0). CONCLUSIONS: Treatment of internal fixation-associated infections showed a high success rate of 87-90% over all time periods. Implant retention was highly successful in early and delayed infections but only limited in late infections.

Culture of Bone Biopsy Specimens Overestimates Rate of Residual Osteomyelitis After Toe or Forefoot Amputation.

BACKGROUND: Guidelines recommend both histological analysis and culture for definite diagnosis of osteomyelitis. It is not clear if histological and culture criteria can be used interchangeably in the clinical scenario of toe amputation. We therefore prospectively compared the results of intraoperative culture and those of histological examination in this setting. METHODS: Consecutive patients requiring toe or forefoot amputation at the University Hospital Basel during a 2-year period were included in the study. Biopsy specimens from the residual bone were cultured according to microbiological standards. Histological analysis was performed using standardized criteria for osteomyelitis. Clinical outcomes were assessed retrospectively via chart review. RESULTS: Of 51 patients included in the study, 33 (65%) had a positive culture of residual bone and 14 (27%) showed histological signs of osteomyelitis. A negative histological result but a positive culture was found for 21 (41%) of the patients, suggesting that culture has a high false-positive rate if histological analysis is used as the reference to rule out osteomyelitis. The recommended criteria of both positive histological findings and positive culture were fulfilled by 12 (24%) of the 51 patients. CONCLUSIONS: Positive cultures of residual bone after forefoot or toe amputation overestimate the true rate of osteomyelitis as defined by histological analysis, presumably because of contamination from soft tissue at the time of surgery. Additional studies are needed to evaluate the indications for, and the duration of, antibiotic treatment according to these findings. CLINICAL RELEVANCE: Our results cast doubt on the strategy of relying solely on culture of bone biopsy specimens when deciding whether antibiotic treatment for osteomyelitis is necessary after toe or forefoot amputation.

Guidance document for prevention of Clostridium difficile infection in acute healthcare settings.

SCOPE: Clostridium difficile infection (CDI) is the most important infective cause of healthcare-associated diarrhoea in high income countries and one of the most important healthcare-associated pathogens in both Europe and the United States. It is associated with high morbidity and mortality resulting in both societal and financial burden. A significant proportion of this burden is potentially preventable by a combination of targeted infection prevention and control measures and antimicrobial stewardship. The aim of this guidance document is to provide an update on recommendations for prevention of CDI in acute care settings to provide guidance to those responsible for institutional infection prevention and control programmes. METHODS: An expert group was set up by the European society of clinical microbiology and infectious diseases (ESCMID) Study Group for C. difficile (ESGCD), which performed a systematic review of the literature on prevention of CDI in adults hospitalized in acute care settings and derived respective recommendations according to the GRADE approach. Recommendations are stratified for both outbreak and endemic settings. QUESTIONS ADDRESSED BY THE GUIDELINE AND RECOMMENDATIONS: This guidance document provides thirty-six statements on strategies to prevent CDI in acute care settings, including 18 strong recommendations. No recommendation was provided for three questions.

New insights into transmission of Clostridium difficile infection-narrative review.

BACKGROUND: Traditionally, Clostridium difficile has been considered a typical healthcare-associated pathogen-that is, one transmitted within healthcare facilities and thus prevented by implementation of standard infection control measures. Recently this concept has been challenged by studies suggesting a relevant role for community acquisition of C. difficile. AIMS: To discusses the current literature, compiled during the last decade, reporting on sources of acquisition of C. difficile and subsequent transmission. SOURCES: The databases PubMed, Medline, Embase and the Cochrane Database were searched for articles published from 1 January 2007 to 30 June 2017 reporting on possible transmission pathways of C. difficile and/or suggesting a source of acquisition of C. difficile. All study types reporting on adult populations were considered; case reports and series were excluded. The PRISMA guidelines for the reporting of systematic reviews were followed. CONTENT: Among 24 original articles included, 63% report on transmission of C. difficile in healthcare settings and 37% investigate sources and transmission of C. difficile in the community. Contact with symptomatic carriers (53.3%), the hospital environment (40.0%) and asymptomatic carriers (20%) were the most commonly reported transmission pathways within healthcare settings. The leading sources for acquisition of C. difficile in the community include direct contact with symptomatic and asymptomatic carriers in the community, including infants (30%) and residents of long-term non-acute care facilities (30%), followed by contact with contaminated environments in outpatient care settings (20%) and exposure to livestock or livestock farms (20%). IMPLICATIONS: In healthcare settings, future control efforts may need to focus on extending cleaning and disinfection procedures beyond the immediate surroundings of symptomatic carriers. Potential targets to prevent acquisition of C. difficile in the community include household settings, long-term care facilities and outpatient settings, while the role of livestock in entertaining transmission requires further investigation.

Cardiac Events after Noncardiac Surgery in Patients Undergoing Preoperative Dobutamine Stress Echocardiography: Findings From the Mayo Poce-DSE Investigators.

BACKGROUND: Current guidelines support the use of dobutamine stress echocardiography (DSE) prior to noncardiac surgery in higher-risk patients who are unable to perform at least 4 metabolic equivalents of physical activity. We evaluated postoperative outcomes of patients in different operative risk categories after preoperative DSE. METHODS: We collected data from the medical record on 4494 patients from January 1, 2006 to December 31, 2011 who had DSE up to 90 days prior to a noncardiac surgery. Patients were divided into low, intermediate, and high preoperative surgery-specific risk. Baseline demographic data and risk factors were abstracted from the medical record, as were postoperative cardiac events including myocardial infarction, cardiac arrest, and mortality within 30 days after surgery. RESULTS: There were 103 cardiac outcomes (2.3%), which included myocardial infarction (n = 57, 1.3%), resuscitated cardiac arrest (n = 26, 0.6%), and all-cause mortality (n = 40, 0.9%). Cardiac event rates were 0.0% (95% confidence interval [CI], 0.0%-3.9%) in the low-surgical-risk group, 2.1% (95% CI, 1.6%-2.5%) in the intermediate-surgical-risk group, and 3.4% (95% CI, 2.0%-4.4%) in the high-risk group. Thirty-day postoperative mortality rates were 0%, 0.9%, and 0.8% for the low-risk, intermediate-risk, and high-risk surgical groups, respectively, and were not statistically different. CONCLUSIONS: These findings demonstrate low cardiac event rates in patients who underwent a DSE prior to noncardiac surgery. The previously accepted construct of low-, intermediate-, and high-risk surgeries based on postoperative events of <1%, 1%-5%, and >5% overestimates the actual risk in contemporary settings.

Temporal trends and epidemiology of Staphylococcus aureus surgical site infection in the Swiss surveillance network: a cohort study.

BACKGROUND: Staphylococcus aureus is the leading pathogen in surgical site infections (SSI). AIM: To explore trends and risk factors associated with S. aureus SSI. METHODS: Risk factors for monomicrobial S. aureus SSI were identified from the Swiss multi-centre SSI surveillance system using multi-variate logistic regression. Both in-hospital and postdischarge SSI were identified using standardized definitions. FINDINGS: Over a six-year period, data were collected on 229,765 surgical patients, of whom 499 (0.22%) developed monomicrobial S. aureus SSI; 459 (92.0%) and 40 (8.0%) were due to meticillin-susceptible S. aureus (MSSA) and meticillin-resistant S. aureus (MRSA), respectively. There was a significant decrease in the rate of MSSA SSI (P = 0.007), but not in the rate of MRSA SSI (P = 0.70). Independent protective factors for S. aureus SSI were older age [≥75 years vs <50 years: odds ratio (OR) 0.60, 95% confidence interval (CI) 0.44-0.83], laparoscopy/minimally invasive surgery (OR 0.68, 95% CI 0.50-0.92), non-clean surgery [OR 0.78 (per increase in wound contamination class), 95% CI 0.64-0.94] and correct timing of pre-operative antibiotic prophylaxis (OR 0.80, 95% CI 0.65-0.98). Independent risk factors were male sex (OR 1.38, 95% CI 1.14-1.66), higher American Society of Anesthesiologists' score (per one-point increment: OR 1.30, 95% CI 1.13-1.51), re-operation for non-infectious reasons (OR 4.59, 95% CI 3.59-5.87) and procedure type: cardiac surgery, laminectomy, and hip or knee arthroplasty had two-to nine-fold increased odds of S. aureus SSI compared with other procedures. CONCLUSIONS: SSI due to S. aureus are decreasing and becoming rare events in Switzerland. High-risk procedures that may benefit from specific preventive measures were identified. Unfortunately, many of the independent risk factors are not easily modifiable.

Patient engagement with surgical site infection prevention: an expert panel perspective.

Despite remarkable developments in the use of surgical techniques, ergonomic advancements in the operating room, and implementation of bundles, surgical site infections (SSIs) remain a substantial burden, associated with increased morbidity, mortality and healthcare costs. National and international recommendations to prevent SSIs have been published, including recent guidelines by the World Health Organization, but implementation into clinical practice remains an unresolved issue. SSI improvement programs require an integrative approach with measures taken during the pre-, intra- and postoperative care from the numerous stakeholders involved. The current SSI prevention strategies have focused mainly on the role of healthcare workers (HCWs) and procedure related risk factors. The importance and influence of patient participation is becoming an increasingly important concept and advocated as a means to improve patient safety. Novel interventions supporting an active participative role within SSI prevention programs have not been assessed. Empowering patients with information they require to engage in the process of SSI prevention could play a major role for the implementation of recommendations. Based on available scientific evidence, a panel of experts evaluated options for patient involvement in order to provide pragmatic recommendations for pre-, intra- and postoperative activities for the prevention of SSIs. Recommendations were based on existing guidelines and expert opinion. As a result, 9 recommendations for the surgical patient are presented here, including a practice brief in the form of a patient information leaflet. HCWs can use this information to educate patients and allow patient engagement.

Workload even affects hand hygiene in a highly trained and well-staffed setting: a prospective 365/7/24 observational study.

INTRODUCTION: Compliance with hand hygiene (HH) has often not proved satisfactory; high workload is a commonly self-reported reason. Previous studies comparing workload and compliance have not measured workload precisely and have focused on certain times of day. This study aimed to investigate the association between HH compliance and workload, both electronically defined 365/7/24 (primary endpoint). In addition, the quality of commonly used compliance defining methods (hand disinfectant usage, direct observation) was investigated (secondary endpoint). MATERIALS AND METHODS: Correlation of electronically measured HH compliance (hand-rub activities (HRA)/HH opportunities) with electronically determined workload (nursing time output/nursing time input) was undertaken over one year at a stem cell transplant unit at University Hospital Basel, Switzerland. HRA and procedures requiring HRA according to the five World Health Organization indications were recorded continuously (365/7/24) using electronic dispensers and electronic documentation, and compliance was calculated accordingly. Hand disinfectant usage was calculated using spending records for one year; direct observation was performed for approximately 1800 HH opportunities. RESULTS: During the investigation, 208,184 HRA, translating into 57 [standard deviation (SD) 10] HRA/patient-day (PD), were performed. Electronically determined compliance ranged from 24% to 66% [mean 42.39% (SD 8%)]. The higher the workload, the lower the compliance (R=-0.411; P<0.001). HRA/PD (r=-0.037), hand disinfectant usage (mean 160mL/PD) and observed compliance (95%; 1734 HRA/1813 HH opportunities) were not found to be associated with workload. CONCLUSION: Calculated compliance was inversely associated with nurses' workload. HRA/PD, observer-determined compliance and amount of disinfectant dispensed were used as surrogates for compliance, but did not correlate with actual compliance and thus should be used with caution.