Antibiotics associated with acquisition of carbapenem-resistant Pseudomonas aeruginosa in ICUs: a multicentre nested case-case-control study.

Background: Carbapenem-resistant Pseudomonas aeruginosa (CRPA) strains are involved in severe infections, mostly in ICUs. Exposure to antibiotics other than carbapenems may be associated with isolation of CRPA; therefore, we aimed to identify those antibiotics using the case-case-control study design. Methods: A case-case-control study was conducted in 2015 in a prospective multicentre cohort that included 1808 adults hospitalized in 2009 in 10 French ICUs. Patients were screened for P. aeruginosa at admission to the ICU and then weekly. Cases were patients with CRPA and patients with carbapenem-susceptible P. aeruginosa (CSPA) isolation. Controls were patients without P. aeruginosa isolation, matched with each case according to centre, length of stay and hospitalization period. Effects of antibiotic exposure were explored, after adjusting for prior treatment with carbapenems and confounding factors comprising colonization pressure with two logistic regression models. The two models were compared to identify specific risk factors for CRPA isolation. Results: Fifty-nine CRPA, 83 CSPA and 142 controls were compared. In adjusted multivariable analyses, exposure to carbapenems and to antibiotics belonging to the group of ß-lactams inactive against P. aeruginosa were independent risk factors for CRPA isolation (OR, 1.205; 95% CI, 1.079-1.346 and OR, 1.101; 95% CI, 1.010-1.201, respectively). Conversely, exposure to ß-lactams active against P. aeruginosa was an independent protective factor for CSPA isolation (OR, 0.868; 95% CI, 0.772-0.976). Conclusions: Besides carbapenem exposure, exposure to ß-lactams inactive against P. aeruginosa was a specific risk factor for CRPA isolation. Clinicians should counterweigh the potential benefits of administering these antibiotics against the increased risk of CRPA infection.

Contributory conditions for unexpected COVID-19 cases and nosocomial COVID-19 infection cases identified from systematic investigation in a French University Hospital.

INTRODUCTION: Nosocomial case (NC) of COVID-19 infections is a challenge for hospitals. We report the results of a seven-month prospective cohort study investigating COVID-19 patients to assess unexpected cases (UC) (no COVID-19 precautionary measure application since admission) and NC. PATIENTS AND METHODS: Investigation by an infection control team of 844 patients with COVID-19 infection hospitalized for more than 24 hours (cases). RESULTS: A total of 301 UC were identified (31% after contact tracing) with a total of 129 contact patients, and 27 secondary cases for 59 of them. In geriatric wards, 50% of cases were UC. NC represented 18% of cases (37% in geriatric wards), mainly identified after contact tracing of wandering cases. CONCLUSION: A rapid infection control response is essential to contain nosocomial transmission, along with detailed contact tracing and screening policy. Dealing with wandering elderly patients remain challenging for HCWs.

Healthcare worker protection against mpox contamination: position paper of the French Society for Hospital Hygiene.

In the context of the recent re-emergence of mpox worldwide, the French Society for Hospital Hygiene (SF2H) performed a literature review of the transmission paths and proposed specific recommendations for healthcare workers (HCWs) caring for patients with suspected or confirmed MPXV. In developed countries, the risk of contamination among HCWs in healthcare facilities seemed to be very low, limited to contamination through needle stick injuries. Two additional contamination cases were reported and not fully explained. Beyond healthcare settings, the analysis of the literature highlighted (i) a main contamination route during sexual intercourse, mainly among men who have sex with men, and (ii) a very low secondary attack rate in other contexts, such as schools or jails. Numerous studies have reported molecular or virus identification on surfaces or in the air surrounding patients, without any association with the low secondary case incidence; moreover, the minimum infectious dose through air or mucosal exposure is still unknown. Owing to the lack of evidence of MPXV respiratory transmission in the healthcare setting, the SF2H recommends the implementation of standard and contact precautions combined with medical/surgical mask use. Owing to the lack of evidence of transcutaneous contamination, the SF2H recommends the use of gloves only if contact with cutaneous lesions or mucous membranes occurs. Regarding the risk of contamination from the environment in healthcare facilities, additional studies must be conducted to investigate this.

Carbapenem stewardship program in a French university children's hospital.

INTRODUCTION: Carbapenems, last-resort antibiotics, are widely used as first-line treatment in patients carrying extended-spectrum beta-lactamases (ESBL) Enterobacteriaceae, including in a pediatric setting. We aimed to implement an antibiotic stewardship program (ASP) to improve the use of carbapenems. METHODS: We implemented an ASP at the Bordeaux Children's University Hospital with 6-month audits on prescribing practice before and after an intervention (revision of antibiotic treatment protocols, a half-day educational session with feedback of the first study period). The number of carbapenem prescriptions was analyzed and two criteria were used to assess conformity of the indication for carbapenem prescription and conformity of the reassessment. A logistic regression was used to assess the overall compliance of carbapenem prescriptions over the two periods adjusted for ESBL carriage. RESULTS: A total of 57 patients were included with 37 carbapenem prescriptions before the intervention and 23 after. Overall carbapenem consumption decreased from 0.54 prescriptions per 100 admissions to 0.32 (p = 0.06). Conformity increased during the study for indication (46-87%, p = 0.004) and for reassessment (48-78%, p = 0.04) and was significantly associated with the second study period, after adjustment for ESBL carriage. CONCLUSION: Our intervention contributed to a significant improvement in the compliance to indications for carbapenem indication and in the reassessment of the prescription.

Exogenous acquisition of Pseudomonas aeruginosa in intensive care units: a prospective multi-centre study (DYNAPYO study).

BACKGROUND: Pseudomonas aeruginosa remains one of the most common nosocomial pathogens in intensive care units (ICUs). Although exogenous acquisition has been widely documented in outbreaks, its importance is unclear in non-epidemic situations. AIM: To elucidate the role of exogenous origin of P. aeruginosa in ICU patients. METHODS: A chronological analysis of the acquisition of P. aeruginosa was performed using samples collected in 2009 in the DYNAPYO cohort study, during which patients and tap water were screened weekly. Molecular relatedness of P. aeruginosa isolates was investigated by pulsed-field gel electrophoresis. Exogenous acquisition was defined as identification of a P. aeruginosa pulsotype previously isolated from another patient or tap water in the ICU. FINDINGS: The DYNAPYO cohort included 1808 patients (10,402 samples) and 233 water taps (4946 samples). Typing of 1515 isolates from 373 patients and 375 isolates from 81 tap water samples identified 296 pulsotypes. Analysis showed exogenous acquisition in 170 (45.6%) of 373 patients. The pulsotype identified had previously been isolated from another patient and from a tap water sample for 86 and 29 patients, respectively. The results differed according to the ICU. CONCLUSION: Exogenous acquisition of P. aeruginosa could be prevented in half of patients. The overall findings of this survey support the need for studies on routes of transmission and risk assessment approach to better define how to control exogenous acquisition in ICUs.

Risk factors for colonization and infection by Pseudomonas aeruginosa in patients hospitalized in intensive care units in France.

OBJECTIVE: To assess the role of environment, medical care and individual risks factors for P. aeruginosa colonization and infection. STUDY DESIGN AND SETTING: A French multicentric prospective study involved ten ICUs for a five months period. Every adult patient newly hospitalized in ICUs with no P. aeruginosa carriage up to 48 hours after admission was included and weekly screened before discharge or death. Screening swabs were either rectal, sputum or oropharyngeal samples. Hydric environment was also sampled each week. Data on patient clinical features, environmental and device exposures, and antibiotics supports were regularly collected. Multivariate analysis was performed with a multistate model. RESULTS: The overall prevalence of P. aeruginosa carriage was 15.3% (201/1314). Risk factors associated with patient colonization were: use of inactive antibiotics against P. aeruginosa (HR = 1.60 [1.15-2.21] p<0.01), tap water contamination at the entry in the room (HR = 1.66 [1.01-2.27] p<0.05) and mechanical invasive ventilation (HR = 4.70 [2.66-8.31] p<0.0001). Active antibiotics prevented from colonization (HR = 0.67 [0.48-0.93] p = 0.02) and from infection (HR = 0.64 [0.41-1.01] p = 0.05). Interaction between hydric environment antibiotics support was not statistically associated with patient colonization. CONCLUSION: Hydric contamination and antibiotics pressure seem to remain key independent risk factors in P. aeruginosa colonization. These results advocate the need to carry on preventive and targeted interventions toward healthcare associated infections.

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.

Relationship between rates of antimicrobial consumption and the incidence of antimicrobial resistance in Staphylococcus aureus and Pseudomonas aeruginosa isolates from 47 French hospitals.

OBJECTIVE: To investigate relationships between rates of antimicrobial consumption and the incidence of antimicrobial resistance in Staphylococcus aureus and Pseudomonas aeruginosa isolates from hospitals. METHODS: We conducted an observational study that used retrospective data from 2002 and linear regression to model relationships. Hospitals were asked to collect data on consecutive S. aureus and P. aeruginosa isolates, consumption rates for antibiotics (ie, anti-infectives for systemic use as defined by Anatomical Therapeutic Chemical class J01), and hospital characteristics, including infection control policies. Rates of methicillin resistance in S. aureus and rates of ceftazidime and ciprofloxacin resistance in P. aeruginosa were expressed as the percentage of isolates that were nonsusceptible (ie, either resistant or intermediately susceptible) and as the incidence of nonsuceptible isolates (ie, the number of nonsuceptible isolates recovered per 1,000 patient-days). The rate of antimicrobial consumption was expressed as the number of defined daily doses per 1,000 patient-days. SETTING: Data were obtained from 47 French hospitals, and a total of 12,188 S. aureus isolates and 6,370 P. aeruginosa isolates were tested. RESULTS: In the multivariate analysis, fewer antimicrobials showed a significant association between the consumption rate and the percentage of isolates that were resistant than an association between the consumption rate and the incidence of resistance. The overall rate of antibiotic consumption, not including the antibiotics used to treat methicillin-resistant S. aureus infection, explained 13% of the variance between hospitals in the incidence of methicillin resistance among S. aureus isolates. The incidence of methicillin resistance in S. aureus isolates increased with the use of ciprofloxacin and levofloxacin and with the percentage of the hospital's beds located in intensive care units (adjusted multivariate coefficient of determination [aR(2)], 0.30). For P. aeruginosa, the incidence of ceftazidime resistance was greater in hospitals with higher consumption rates for ceftazidime, levofloxacin, and gentamicin (aR(2), 0.37). The incidence of ciprofloxacin resistance increased with the use of fluoroquinolones and with the percentage of a hospital's beds located in intensive care ( aR(2), 0.28). CONCLUSIONS: A statistically significant relationship existed between the rate of fluoroquinolone use and the rate of antimicrobial resistance among S. aureus and P. aeruginosa isolates. The incidence of resistant isolates showed a stronger association with the rate of antimicrobial use than did the percentage of isolates with resistance.

Determinants of glycopeptides consumption in hospitals.

The aim of this study was to describe consumption of glycopeptides and to study factors associated with their use in 47 French hospitals. Consumption of glycopeptides for systemic use (defined daily doses per 1,000 patient-days: DDD/1,000 PD and per 100 admissions), number of methicillin-resistant Staphylococcus aureus (MRSA) (percentage and incidence per 1,000 patient-days), and number of venous central lines and hospital characteristics (size, length of stay, number of beds: total and for each hospital inpatient areas and antibiotic policies) were recorded from January, 2002, through December, 2002. Multiple linear regression was performed to check for hospital characteristics. The median rate of total consumption of glycopeptides was 4.11(range 0.21-27.22) DDD per 1,000 PD with higher consumption in large public hospitals and in intensive care areas (median 46.51; range 7.19-134) than in surgery areas (median 4.5; range 0.17-24.76). The consumption of glycopeptides correlated with MRSA incidence, but not with the proportion of MRSA. In the multivariate analysis, the incidence of MRSA and the number of beds in surgery areas were independent predictors of total glycopeptides use in the hospital, expressed in DDD per 1,000 PD (R2 adjusted, 0.39). The incidence of MRSA, the number of venous central lines, and the number of beds in the medicine areas were significant determinants associated with higher consumption of glycopeptides expressed in DDD per 100 admissions (R2 adjusted, 0.73). To reduce glycopeptides use in hospitals, the first effort required is that hospitals focus increased attention on the prevention of cross transmission for MRSA between patients but also on the use of the venous central line. Furthermore, hospitals have to compare their data with others to identify overuse of glycopeptides and to plan control interventions.

Infection control practices and infectious complications in dermatological surgery.

The aim of this study was to assess infection control practices and their impact upon infectious complications in skin surgery conducted by private dermatologists. A prospective study was carried out by 73 volunteers belonging to the Surgical Group of the Société Française de Dermatologie over a period of three months. Data were collected for surgical procedures performed during this period, including the excision of all benign or malignant tumours, but excluding sebaceous cysts and pyodermas. A total of 3491 dermatological surgical procedures were included in the survey. Post-operative infections occurred in 67 patients (1.9%), with superficial suppuration accounting for 92.5% of surgical site infections. The incidence was higher in the excision group with a reconstructive procedure (4.3%) than in excisions alone (1.6%). Infection control precautions varied according to the site of procedure; multivariate analysis showed that haemorrhagic complications were an independent factor for infection in both types of surgical procedure. The male gender, immunosuppressive therapy and not wearing sterile gloves were independent factors for infections occurring following excisions with reconstruction. Not all of the procedures needed the use of a hospital theatre. It is clear that for excisions with a reconstructive procedure or for certain anatomical sites, such as the nose, there should be more emphasis upon infection control precautions. Further studies are needed to establish optimal guidelines for this kind of surgery.

Contribution of tap water to patient colonisation with Pseudomonas aeruginosa in a medical intensive care unit.

This study examined tap water as a source of Pseudomonas aeruginosa in a medical intensive care setting. We prospectively screened specimens of patients, tap water and hands of healthcare workers (HCWs) over a six-month period in a 16-bed medical intensive care unit. Molecular relatedness of P. aeruginosa strains was investigated by pulsed-field gel electrophoresis. A total of 657 tap water samples were collected from 39 faucets and 127 hands of HCWs were sampled. P. aeruginosa was found in 11.4% of 484 tap water samples taken from patients' rooms and in 5.3% of 189 other tap water samples (P<0.01). P. aeruginosa was isolated from 38 patients. Typing of 73 non-replicate isolates (water samples, hands of HCWs and patients) revealed 32 major DNA patterns. Eleven (52.4%) of the 21 faucets were contaminated with a patient strain, found before isolation from tap water in the corresponding room in nine cases, or from the neighbouring room in two cases. Among seven P. aeruginosa strains isolated from HCW hands, the genotype obtained was the same as that from the last patient they had touched in six cases, and in the seventh with the last tap water sample used. More than half of P. aeruginosa carriage in patients was acquired via tap water or cross-transmission. Carriage of P. aeruginosa by patients was both the source and the consequence of tap water colonisation. These results emphasise the need for studies on how to control tap water contamination.

[Relationship between antibiotic policies and antibiotic consumption in hospitals]. / Relation entre politique de bon usage et consommation des antibiotiques dans les établissements de santé.

OBJECTIVE: The authors had for aim to study the relationship between antibiotic policies and antibiotic consumption in hospitals. DESIGN: A component analysis was used to summarize the various measures of the antibiotic policies developed by hospitals. Antibiotics consumption was expressed as a number of Daily Defined Doses per 1,000 patient-days. The relation was studied by a multiple linear regression model with adjustment on hospital activity. RESULTS: The first component illustrated an active program of antibiotic policies associating: a local antibiotic committee, an infectious diseases consultant, written local guidelines for prescriptions and restrictive measures before dispensing. The highest antibiotic consumption was associated with active policies, especially for carbapenems, glycopeptides, and aminoglycosides. However the relationship differed according to the type of hospital, with lower antibiotic consumption, especially for penicillins, in private hospitals that had more active policies. CONCLUSION: The difference between public and private hospitals could be explained by the type of institution but also by the unit used to measure antibiotic consumption.

[Reservoirs and transmission of Pseudomonas aeruginosa in intensive care unit]. / Réservoirs et transmission de Pseudomonas aeruginosa en réanimation médicale.

OBJECTIVE: The authors had for aim to study reservoirs and transmission of Pseudomonas aeruginosa in an intensive care unit. DESIGN: A 6-month prospective descriptive study was made on water samples, samples from hands of health care workers, and clinical samples. P. aeruginosa strains were compared by pulsed-field gel electrophoresis. RESULTS: Among the 211 patients hospitalized during the study, 14 (6.6%) were infected by P. aeruginosa. Out of 494 water samples, 80 were contaminated by P. aeruginosa. The regularly disinfected water taps were more rarely contaminated than the others (P<10(-5)). Out of 140 hand samples, one showed contamination from an infected patient. CONCLUSIONS: aeruginosa cross transmission was observed during this study. We should follow strict hygienic precautions such as wearing gloves and performing thorough alcoholic rub disinfection. Water taps are often contaminated and require regular disinfection.

Early and late surgical site infections in ear surgery.

A retroauricular approach is routinely used for treating chronic otitis media. The incidence of surgical site infections after ear surgery is around 10% in contaminated or dirty procedures. This observational prospective study describes surgical site infections after chronic otitis media surgery with the retroauricular approach and investigated their potential predictive factors. This observational prospective study included patients suffering from chronic otitis media and eligible for therapeutic surgery with a retroauricular approach. During follow-up, surgical site infections were defined as "early" if occurring within 30 days after surgery or as "late" if occurring thereafter. The data of 102 patients were analysed. Concerning early surgical site infections, four cases were diagnosed (3.9%) and a significant association was found with preoperative antibiotic therapy, wet ear at pre-operative examination, class III (contaminated) in the surgical wound classification, NNIS (National Nosocomial Infection Surveillance) index > 1, and oral post-operative antibiotic use. Seven late surgical site infections were diagnosed (7.1%) between 90 and 160 days after surgery and were significantly correlated to otorrhoea during the 6 months before surgery, surgery duration ≤60 minutes, canal wall down technique and use of fibrin glue. Surgical site infections after chronic otitis media surgery seem to be associated with factors related to the inflammatory state of the middle ear at the time of surgery in early infections and with chronic inflammation in late infections.

Twelve cases of pituitary apoplexy.

In 12 cases of pituitary apoplexy, a preexisting unsuspected adenoma was found. The initial manifestations were sudden onset of headache (12 patients), signs of meningeal irritation (10) with fever (four), altered consciousness (12), and ophthalmologic disturbances (eight). The diagnosis was retrospective in three cases. Radiologic investigations were always suggestive if carefully considered. The plain skull roentgenograms, in particular, showed an enlarged sella turcica in 11 cases. Three patients had prolactin adenomas, and nine had nonfunctional adenomas. Medical treatment was successful in only three patients; surgery was performed in 10 cases by means of a sublabial transseptal microsurgical approach. Postoperative neurologic complications were serious in two cases. Endocrine insufficiencies were common: eight cases of permanent panhypopituitarism, two cases of pluritropic anterior pituitary dysfunction, and three cases of persistent hyperprolactinemia.

Clarithromycin and other antimicrobial agents in the treatment of disseminated Mycobacterium avium infections in patients with acquired immunodeficiency syndrome.

BACKGROUND: Disseminated infection with Mycobacterium avium is common with late-stage acquired immunodeficiency syndrome (AIDS), and no antimicrobial agent has been found to be clearly effective. METHODS: A multicenter open trial was conducted to assess the antimicrobial activity and clinical efficacy of clarithromycin--a new macrolide antibiotic--against disseminated M avium in 77 patients with late-stage AIDS. Blood cultures were taken at baseline and during treatment; side effects were also evaluated. RESULTS: Mycobacterium avium was eradicated from blood cultures in 11 (63%) of 16 evaluable patients receiving daily doses or 500 or 1000 mg, (n = 21) and in 45 of 46 (98%) of those receiving 1500 or 2000 mg (n = 56). Eradication after 2 months was influenced by continuity of drug treatment; 36 of 42 patients with no relapse had received continuous treatment vs six of 14 patients whose drug treatment had been stopped for 7 days or longer. After 2 to 7 months of treatment, acquired resistance associated with relapse was observed. Drug side effects were elevated liver enzyme levels (26%) and impaired hearing (4%). Concomitant AIDS drugs had no favorable effect on outcome and may have worsened liver toxicity. CONCLUSIONS: Clarithromycin has bacteriologic efficacy against M avium infection in late-stage AIDS, although drug resistance eventually develops. Further studies are needed to investigate safe, effective concomitant drugs.

[Prevention of Legionella infections in health centers]. / Prévention de la légionellose dans les établissements de santé.

This report updates French guidelines for the prevention of Legionella infection in health care facilities. The recommendations relate to water supply networks, from designing, maintenance, and supervision to the daily use of water by caregivers.

[Policies for the use of antibiotic in 99 Southwestern French hospitals in 2002]. / Politique d'utilisation des antibiotiques: état des lieux dans 99 établissements de santé de l'interrégion Sud-Ouest.

OBJECTIVE: Increasing antimicrobial resistance in bacteria is a major health problem and requires the implementation of stringent policies to optimize the use of antibiotics. DESIGN: In 2003 the authors conducted a study in southwestern French hospitals, using a questionnaire to assess the implementation of antibiotic policies according to national guidelines issued by the French government in 2002. RESULTS: The most frequent actions quoted by the 99 respondents were: issuing of a list of available antibiotics, issuing of information regarding antibiotic consumption and bacterial resistance, and control of antibiotics dispensation. Local guidelines were available in 45% of hospitals for curative treatment and in 87% for antibioprophylaxis in surgery. The evaluation of antibiotic use and computer links between clinical settings, pharmacy and microbiology lab were the less widespread measures. The number and type of actions were related to hospital size and activity. CONCLUSIONS: These findings support that policies for an appropriate use of antimicrobials should be reinforced by issuing treatment guidelines and specific tools for dispensation and evaluation. This survey also emphasizes the need for appropriate policies relating to the size and medical activities of healthcare institutions.