[Experience feedback committee: a method for patient safety improvement]. / Le comité de retour d'expérience (CREX): une méthode pour l'amélioration de la sécurité des soins.

BACKGROUND: An experience feedback committee (CREX, Comité de Retour d'EXpérience) is a method which contributes to the management of safety of care in a medical unit. Originally used for security systems of civil aviation, the method has been adapted to health care facilities and successfully implemented in radiotherapy units and in other specialties. METHODS: We performed a brief review of the literature for studies reporting data on CREX established in hospitals. The review was performed using the main bibliographic databases and Google search results. RESULTS: The CREX is designed to analyse incidents reported by professionals. The method includes monthly meetings of a multi-professional committee that reviews the reported incidents, chooses a priority incident and designates a "pilot" responsible for investigating the incident. The investigation of the incident involves a systemic analysis method and a written synthesis presented at the next meeting of the committee. The committee agrees on actions for improvement that are suggested by the analysis and follows their implementation. Systems for the management of health care, including reporting systems, are organized into three levels: the medical unit, the hospital and the country as a triple loop learning process. The CREX is located in the base level, short loop of risk management and allows direct involvement of care professionals in patient safety. CONCLUSION: Safety of care has become a priority of health systems. In this context, the CREX can be a useful vehicle for the implementation of a safety culture in medical units.

SARS-CoV-2 nosocomial infection acquired in a French university hospital during the 1st wave of the Covid-19 pandemic, a prospective study.

BACKGROUND: In healthcare facilities, nosocomial transmissions of respiratory viruses are a major issue. SARS-CoV-2 is not exempt from nosocomial transmission. Our goals were to describe COVID-19 nosocomial cases during the first pandemic wave among patients in a French university hospital and compliance with hygiene measures. METHODS: We conducted a prospective observational study in Grenoble Alpes University Hospital from 01/03/2020 to 11/05/2020. We included all hospitalised patients with a documented SARS-CoV-2 diagnosis. Nosocomial case was defined by a delay of 5 days between hospitalisation and first symptoms. Hygiene measures were evaluated between 11/05/2020 and 22/05/2020. Lockdown measures were effective in France on 17/03/2020 and ended on 11/05/2020. Systematic wearing of mask was mandatory for all healthcare workers (HCW) and visits were prohibited in our institution from 13/03/2021 and for the duration of the lockdown period. RESULTS: Among 259 patients included, 14 (5.4%) were considered as nosocomial COVID-19. Median time before symptom onset was 25 days (interquartile range: 12-42). Eleven patients (79%) had risk factors for severe COVID-19. Five died (36%) including 4 deaths attributable to COVID-19. Two clusters were identified. The first cluster had 5 cases including 3 nosocomial acquisitions and no tested HCWs were positive. The second cluster had 3 cases including 2 nosocomial cases and 4 HCWs were positive. Surgical mask wearing and hand hygiene compliance were adequate for 95% and 61% of HCWs, respectively. CONCLUSIONS: The number of nosocomial COVID-19 cases in our hospital was low. Compliance regarding mask wearing, hand hygiene and lockdown measures drastically reduced transmission of the virus. Monitoring of nosocomial COVID-19 cases during the first wave enabled us to determine to what extent the hygiene measures taken were effective and patients protected. Trial registration Study ethics approval was obtained retrospectively on 30 September 2020 (CECIC Rhône-Alpes-Auvergne, Clermont-Ferrand, IRB 5891).

[Results of 4 years of microbiological testing of bronchoscopes]. / Endoscopes bronchiques: bilan de quatre années de contrôles microbiologiques.

INTRODUCTION: In the context of reducing endoscopy-related infectious risk and new national guidelines on microbiological samples from bronchoscopy, the results of a surveillance program set up in a hospital center were analyzed. METHODS: Over 4 years, scheduled samples were taken from disinfected bronchoscopes. Bacteriology and mycology tests were used to search for microorganisms. The results were interpreted as falling within three levels: target, alert, and action. Factors that could explain the contamination were studied: age of the bronchoscope, number of uses per year, brand, and model. RESULTS: Out of 96 scheduled samples taken, the compliance rate for the period was 83% and increased (p=0.06) over the 4 years. We identified 15 Pseudomonas (six aeruginosa and nine other species), one Stenotrophomonas, one enterobacterium, and two filamentous fungi. None of the factors studied had a significant effect on sample contamination. CONCLUSION: The microbiological surveillance of bronchoscopes is an indispensable part of the quality assurance of bronchoscope maintenance. It can lead to maintenance of the bronchoscope when a noncompliant result is found.

Incidence and prevention of infective endocarditis and bacteraemia after transcatheter aortic valve implantation in a French university hospital: a retrospective study.

Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is a rare but severe complication. Among 326 patients who underwent TAVI at Grenoble Alpes University Hospital, six (1.8%) cases of IE and 11 (3.4%) cases of bacteraemia were identified. No cases of IE were linked to the intervention; one was due to Staphylococcus aureus despite a screening and targeted decolonization strategy. This underscores the need for randomized studies to evaluate the benefit and cost-effectiveness of this policy.

A neonatal specialist with recurrent methicillin-resistant Staphylococcus aureus (MRSA) carriage implicated in the transmission of MRSA to newborns.

This study reports an investigation of outbreaks of methicillin-resistant Staphylococcus aureus (MRSA) infection and colonization involving 17 newborns in the neonatal unit of a teaching hospital. A neonatal specialist colonized with MRSA that eventually became mupirocin-resistant was implicated as a recurrent source of transmission of MRSA to newborns.

Evaluation of a new packaging process for non-autoclavable endoscopes: results for the first 100 microbiological samples.

BACKGROUND: A new process for packaging endoscopes (SureStore®, Medical Innovations Group) immediately after they exit from washing and disinfection in an automated endoscope reprocessor (AER) allows for endoscopes to be stored for up to 15 days. AIM: To describe the microbiological quality of samples from gastrointestinal endoscopes following this process. METHODS: Three-month prospective study using microbiological sampling from a stock of 38 gastrointestinal endoscopes carried out in a French University Hospital. The compliance rate (proportion of samples ≤25 cfu with no pathogenic micro-organisms) and the rate of sterile samples (proportion of germ-free samples) were calculated. We then used multivariate analysis to determine the factors associated with the maintenance of sterility. FINDINGS: One hundred samples were taken from stored endoscopes: 31 stored for ≤3 days, 34 stored between 3 and 7 days, and 35 after storage between 7 and 15 days. The compliance rate was 98% and the sterile sample rate was 60%. Only the time between leaving the AER and packaging was significantly associated with the sterility of samples (P = 0.02). The probability of having a sterile sample decreased 17-fold when the endoscope was packaged >2 h after leaving the AER (P = 0.04) compared to an endoscope packaged within 1 h after leaving the AER. CONCLUSION: The SureStore process seems capable of satisfactorily maintaining compliance (98%) of samples taken from endoscopes stored for up to 15 days. The delay in packaging should not exceed 1 h, as the rate of sterile samples decreases thereafter.

Hospital-wide prospective mandatory surveillance of invasive aspergillosis in a French teaching hospital (2000-2002).

A multidisciplinary working group devoted to epidemiological surveillance of invasive aspergillosis (IA) was created in January 2000 in Grenoble University Hospital. This article presents the results of a three-year IA surveillance. The multidisciplinary working group surveyed all hospitalized patients, and the mycology laboratory detected most suspected IA cases. Cases were reviewed monthly by the Aspergillosis Committee, and were classified according to international consensus criteria. Possible nosocomial acquisition was determined. Among the 490 alerts, 74 IA cases were observed: six proven cases (8%), 36 (49%) probable cases and 32 (43%) possible cases. The incidence was 4.4 (95% CI 3.4-5.4) IA/100 000 patient-days. Among the proven and probable IA cases, we observed 10 nosocomial cases and six cases of undetermined origin. No cases were noted in the protected rooms in the haematology unit. Only one cluster of cases (three nosocomial cases) was detected in the haematology unit. Forty-three percent of cases (N=32) were hospitalized in the haematology unit, and all other cases were hospitalized elsewhere. This three-year survey found a high rate of non-nosocomial IA cases and a high frequency of IA cases hospitalized in units other than haematology. Thus, this study shows the importance of IA surveillance in haematology units and all high-risk units.

En-suite bathrooms in protected haematology wards: a source of filamentous fungal contamination?

BACKGROUND: In spite of 25 recently built high-risk haematology rooms with a protected environment and fitted with en-suite bathrooms in our university hospital centre in 2008, sporadic cases of hospital-acquired invasive aspergillosis remained in these wards. AIM: This study aimed to identify unsuspected environmental sources of filamentous fungal contamination in these rooms. METHODS: Over two months, environmental fungal flora in the air (150 samples) as well as air particle counting and physical environmental parameters (airspeed, temperature, humidity, pressure) were prospectively monitored twice on the sampling day in all 25 protected rooms and en-suite bathrooms in use, and on bathroom surfaces (150 samples). FINDINGS: In rooms under laminar airflow, in the presence of patients during sampling sessions, fungi were isolated in two samples (4%, 2/50) with a maximum value of 2cfu/500L (none was Aspergillus sp.). However, 88% of the air samples (44/50) in the bathroom were contaminated with a median range and maximum value of 2 and 16cfu/500L. Aspergillus spp. were involved in 24% of contaminated samples (12/44) and A. fumigatus in 6% (3/44). Bathroom surfaces were contaminated by filamentous fungi in 5% of samples (8/150). CONCLUSION: This study highlighted that en-suite bathrooms in protected wards are likely to be a source of fungi. Before considering specific treatment of air in bathrooms, technicians have first corrected the identified deficiencies: replacement of high-efficiency particulate air filters, improvement of air control automation, and restoration of initial technical specifications. Assessment of measure effectiveness is planned.

Monitoring rotavirus environmental contamination in a pediatric unit using polymerase chain reaction.

Rotavirus environmental contamination in a pediatric unit was investigated. Surfaces were swabbed, then viruses eluted, ultracentrifuged, and detected by polymerase chain reaction (PCR) amplification. Of 55 samples, 25 (46%) tested positive. Rotavirus RNA was more prevalent on surfaces in direct contact with children (thermometers and play mats) than on other environmental surfaces (washbasins, door handles, etc). PCR has proved useful for monitoring rotavirus environmental contamination.

Eight-year surveillance of environmental fungal contamination in hospital operating rooms and haematological units.

An eight-year fungal environmental surveillance was carried out in 15 operating theatres and two haematological units. Sampling was performed twice a year in each room, using contact plates for plane surfaces and sterile swabs for grids. From 1992 to 1999, individual rooms in the 17 units were sampled on 1094 occasions and 3822 samples were collected. The percentage of rooms without fungus increased regularly between 1992 and 1999 (41.1% and 74.8%, respectively). The units were classified according to the fungal contamination during the eight years: the operating theatres which required the highest protection (cardiological, thoracic, vascular, hand, orthopaedic and neurosurgery) and the adult haematological unit showed least contamination (71.8% rooms were negative). The most frequent species isolated were Penicillium spp. (28.4%), Cladosporium spp. (15.6%) and Aspergillus spp. (7.6%). Aspergillus fumigatus was rarely isolated (3.7%), and was mainly isolated at the beginning of the study. This study demonstrates that environmental control programmes are effective in reducing environmental mould contamination and could be useful in establishing exposure guidelines, especially by defining an acceptable level of biocontamination in zones at risk.

[Prevention of post-transfusional malaria in France: a descriptive survey]. / Prévention du paludisme post-transfusionnel en France: enquête descriptive.

Due to an expansion in international travel, an increasing number of blood donors are at risk of exposure to malaria. Preventions of transfusional malaria is required by law in France. Acting as National Reference Center for Malarial Immunology we noticed that this regulation was not being respected by all blood banks. We conducted a questionnaire study concerning 181 blood banks to evaluate under which circumstances serological tests were requested, the policy employed in case of seropositivity, the cost of screening, and wishes concerning modification of the law. The response rate was 46.9%. We noticed a great variability in attitude: only 21% of blood banks followed the regulation; 63% added extra criteria to the law; 16% did not follow the regulation. Indirect immunofluorescence was the main method used by 91.5% of blood banks. However the specificity threshold fluctuated. The fate of the blood unit in case of seropositivity was variable (discard of blood bags, plasma fractionation, blood used). Centers who answered to questionnaire performed 2,513,687 blood donations during the survey. A serology was carried out in 2.6% of donations, and was positive in 9.4% of cases i.e. 0.24% of donations. The average cost of screening was 35 FF. The profit loss due to discard of positive blood was estimated at 1.7 million FF. for the duration of the survey and the blood banks studied. 99% of centers answering the questionnaire expressed desire for standardisation of screening method.

[Study of a brucellosis epidemic in a horticultural school]. / Etude d'une épidémie de brucellose dans une collectivité scolaire horticole.

An epidemiological survey was conducted after the observation of 4 cases of acute brucellosis in an horticultural school. Of a total number of 215 attendants, eventually exposed to a single contamination, 65 cases of brucellosis were thus identified. The source of contamination was probably a practical lesson where the pupils studied a bovine gravid uterus. More stringent regulations are needed in order to avoid further similar epidemics.

[Human salmonellosis and turtles in France]. / Salmonelloses humaines en rapport avec les tortues aquatiques dans le déparement de l'Isère.

Two immunosuppressed children were infected with Salmonella, due to turtles living in water. So we investigated the carriage of Salmonella among those animals. Among the 95 investigated animals, 10 were carrying Salmonella (Arizonae, Rissen, Pomona and Blockley). The water of 6 containers out of 20 contained Salmonella. Comparing our data to others in the litterature, we conclude that human salmonellosis, acquired from turtles are not, by now, a major problem in France. Nevertheless, a number of those animals are carrying Salmonella. So an epidemiological survey is necessary, and immunosuppressed patients should avoid contact with those animals.

[Clinical trial of an antipneumococcal vaccine in elderly subjects living in institutions]. / Essai clinique du vaccin antipneumococcique chez des personnes âgées vivant en institution.

Pneumococcal vaccine effectiveness was assessed in a randomized trial among 1,686 old people (mean age: 74, standard deviation: 4 years) living in 24 geriatric hospitals and 26 homes for the aged in our district; 937 were vaccinated with Merck-Sharp and Dohme pneumococcal vaccine (14 serotypes). The 749 others composed the reference group. This study was performed during 2 years, since December 1980. Both groups were randomized after a two-criteria stratification: by clinical risk assessed before the study, and by type of homes for the aged. Forty pneumonias were diagnosed, with 13 proved pneumococcal etiology. The incidence of pneumonia was significantly reduced in the vaccinated group (p less than 10(-4) but the mortality rate was not modified. We concluded in favor of the effectiveness of pneumococcal vaccine: etiological fraction 77.1% (51.2%-89.3% confidence limits, 95% risk) in the population we studied. The incidence of pneumococcal-proved pneumonia was not significantly reduced.

[Evaluation of the impact of individual antibiotic order forms on consumption of antibiotics]. / Evaluation de l'impact d'une prescription nominative sur les consommations d'antibiotiques.

The aim of the study was to assess the impact of an individual patient order form which concerned the 21 most costly antibiotics in a university hospital. Antibiotics expenditures were monitored from 1995 to 1999 and were expressed in 1999 French Francs per 100 patient days (p.d.). The time series were analyzed by auto-regressive models. The trend of antibiotics expenditures which were concerned by the individual patient order form was a yearly increase of 50 FF/100 p.d. (p < 0.01). The individual patient order form had no significant impact on global antibiotics expenditures but there were some differences across departments: antibiotics costs decreased 1.293 FF/100 p.d. (p = 0.02) in intensive care departments. Monitoring antibiotics consumption should be continued in order to increase power of analysis and to assess the impact of the implementation of guidelines.

[Virus resistance in a hospital environment: overview of the virucide activity of disinfectants used in liquid form]. / Résistance des virus dans l'environnement hospitalier: le point sur l'activité virucide des désinfectants utilisés à l'état liquide.

Human pathogenic viruses can be detected in the hospital environment, on contaminated surfaces or medical instruments. Their transmission to patients or staff has already been reported. Lipophilic viruses (HIV, HBV, HCV,...) are susceptible to many liquid chemicals, but they can survive during short time on inadequately disinfected surfaces. Hydrophilic viruses, without envelope, are more resistant, but generally not associated with severe illnesses. Viruses survival in environment depends on many factors and is always improved with viral aggregation and low temperature, whereas organic matters and relative humidity effects are contrasted. The mechanism of virucide disinfectants is not yet well established, and their targets are not known with precision. Different disinfection procedures (disinfectant concentration, contact time, temperature, pH) can provide a similar virucidal activity on a given virus. The virucidal activity of a disinfectant is evaluated with a cell culture assay in Afnor guidelines. But, there are three major problems with this method, concerning need of high viruses titers, residual disinfectant cytotoxicity on cell culture, and non cultivable viruses. Non standardized tests are also described in papers, but their results can generally not be compared. Molecular biology improvements may lead to reproducible and sensitive tests. At present, no general disinfection procedure effective for most of the viruses, without risks for staff or materials, and with an acceptable economic cost can be recommended.

[First intention treatment with josamycin in primary acute pneumopathies of infectious origin in adults]. / Traitement de première intention par josamycine au cours des pneumopathies aiguës primitives d'origine infectieuse chez l'adulte.

In a prospective study 128 community acquired pneumoniae were treated with a macrolide (josamycin) by oral route. Patients improved in 94 p. 100 (113). Complications were as following: 2 deaths, 2 sequels, 3 failures. Authors discuss macrolides effectiveness in acute pneumoniae, particularly pneumococcal ones. They conclude macrolides are a good choice in first intention in acute pneumoniae of adults.

[Economic benefit of using antibiotics prophylactically in cesarean sections with little risk of infection]. / Bénéfice économique de l'antibioprophylaxie dans les césariennes dépourvues de haut risque infectieux.

A randomised double trial was carried out in 266 women who had Caesarean without any high risk of infection in order to study the efficacy of prophylactic antibiotics given during the operation. One group received 1 gram of cefotetan when the cord was being clamped and the other had an injection of placebo under the self-same conditions. Apart from studying the clinical efficacy, evaluation of the economics of the treatment was carried out using, as parameters, the length of stay in hospital and the cost of the antibiotics which were prescribed after the operation. The following results were obtained: 75% of the Caesarean operations carried out in the Maternity Units of the University Regional Hospital Centre were without high risk of infection. Prophylactic antibiotics are proficient because they reduce post Caesarean morbidity due to: endometritis, superficial and deep abscesses and septicaemia. 12.5% in the group who had antibiotics developed infections as against 26% in the placebo group. Post Caesarean infections which required antibiotics cost on an average for each Caesarean 16 francs in the groups who received antibiotics as against 52 francs in the groups that received the placebo. Even including the cost of the antibiotics given prophylactically the costs of antibiotics (prophylactic and curative) was higher in the antibiotic group than in the placebo group. The length of hospital stay was significantly reduced in the group that received prophylactic antibiotics.

[Economic aspects of surgical antibiotic prophylaxis]. / Aspects économiques de l'antibioprophylaxie chirurgicale.

The cost of an antibiotic is easily evaluated in the case of antimicrobial prophylaxis. The other expenses, either direct or indirect costs, are much more difficult to assess. Studies evaluating the economical impact of the prophylactic antibiotics are rather rare. Antibiotic prescription for prophylaxis is evaluated to represent about 20 to 30% of the total antibiotic administration in French hospitals. The most significant studies evaluate the cost/benefit ratio and demonstrate the advantage of prophylaxis in orthopaedic, vascular and gynaecologic surgery.

[Congenital toxoplasmosis, evaluation of the prevention policy]. / Toxoplasmose congénitale, évaluation de la politique de prévention.

OBJECTIVES: This study was performed to assess the effect of a prevention programme against congenital toxoplasmosis conducted as part of the French health policy developed in the Rhône department. METHODS: A descriptive epidemiological survey was conducted in 1991 including 806 post-partum women who were hospitalized in 22 maternities in the Rhône department. RESULTS: Forty-nine percent of the women had negative serology tests. French legislation requiring detecting non-immunized women at diagnosis of pregnancy was applied satisfactorily by the attending physicians. Inversely, women at risk were insufficiently informed: only 17% of the women at risk were aware of the three main routes of contamination; 63% believed vaccination is possible and 11% though they had been vaccinated. Deficient information was probably the cause of poor compliance to preventive measures as observed in this sample: only 17% of the serologically negative women stated they had applied anti-toxoplasmosis prophylaxy measures. CONCLUSION: Women at risk must be informed to convince them to modify their behaviour during pregnancy. The role of the attending physician and biologist is of major importance.