Which antiseptic to use for a caesarean section? A systematic review and network meta-analysis of randomized controlled trials.

Guidelines for pre-operative skin antisepsis recommend using chlorhexidine in an alcohol-based solution. However, other antiseptics such as aqueous povidone-iodine or alcohol-based solutions continue to be used. Randomized controlled trials (RCTs) in caesarean section are rare and do not include all possible comparisons of antiseptics. The aim of this study was to assess the efficacy (reduction of surgical site infections) of chlorhexidine at two different concentrations (0.3% and 2%) and povidone-iodine in aqueous or alcohol-based solutions using a network meta-analysis, including only RCTs of caesarean sections. Fragility indices and prediction intervals were also estimated. A systematic literature review and network meta-analysis were performed. RCTs published up to February 2024 were collected from PubMed, ScienceDirect and the Cochrane Library. Interventions included alcohol-based povidone-iodine, aqueous povidone-iodine, and alcohol-based chlorhexidine 2% and 0.3%. The primary outcome measure was surgical site infection. Nine RCTs with 4915 patients and four interventions were included in the network meta-analysis. All credible intervals of the compared interventions overlapped. Alcohol-based 2% chlorhexidine had the highest probability of being effective in preventing surgical site infections, followed by alcohol-based povidone-iodine. The fragility index ranged from 4 to 18. The prediction intervals were wide. On the basis of rank probabilities, chlorhexidine 2% in an alcohol-based solution was most likely to be effective in preventing surgical site infections after caesarean section, followed by alcohol-based povidone-iodine. Given the paucity of literature and the relatively small difference between povidone-iodine and chlorhexidine found in our meta-analysis, we suggest that either can be used in an alcohol-based solution as antisepsis for planned or emergency caesarean section.

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.

Association between SARS-Cov-2 infection during pregnancy and adverse pregnancy outcomes: A re-analysis of the data reported by Wei et al. (2021).

OBJECTIVES AND BACKGROUND: Wei et al. have published a meta-analysis (MA), which aimed to evaluate the association between SARS-CoV-2 infection during pregnancy and adverse pregnancy outcomes. Using classical random-effects model, they found that SARS-CoV-2 infection was associated with preeclampsia, preterm birth and stillbirth. Performing MA with low event rates or with few studies may be challenging insofar as MA relies on several within and between-study distributional assumptions. The objective was to assess the robustness of the results provided by Wei et al. METHODS: We performed a sensitivity analysis using frequentist and Bayesian meta-analysis methods. We also estimated fragility indexes. RESULTS: For eclampsia, the confidence intervals of most frequentist models contain 1. All beta-binomial models (Bayesian) lead to credible intervals containing 1. The prediction interval, based on DL method, ranges from 0.75 to 2.38. The fragility index is 2 for the DL method. For preterm, the confidence (credible) intervals exclude 1. The prediction interval is broad, ranging from 0.84 to 20.61. The fragility index ranges from 27 to 10. For stillbirth, the confidence intervals of most frequentist models contain 1. Six Bayesian MA models lead to credible intervals containing 1. The prediction interval ranges from 0.52 to 8.49. The fragility index is 3. CONCLUSION: Given the available data and the results of our broad sensitivity analysis, we can suggest that SARS-CoV-2 infection during pregnancy is associated with preterm, and that it may be associated with preeclampsia. For stillbirth, more data are needed as none of the Bayesian analyses are conclusive.

Preventing SARS-CoV-2 transmission in rehabilitation pools and therapeutic water environments.

SARS-CoV-2 is mainly transmitted by respiratory droplets and contact with contaminated surfaces. It can be retrieved in faeces but there is no evidence of faecal-oral transmission, which is the main route of contamination in recreational waters. Standard cleaning and disinfecting procedures, microbiological control and health rules aim to prevent infectious risk regardless of the micro-organisms. In the context of progressive lockdown exit and hospital activities recovery, we assessed the risk of SARS-CoV-2 transmission in rehabilitation pools and therapeutic water environments in order to provide specific recommendations to control the spread of SARS-CoV-2 while ensuring essential rehabilitation care for patients.

Clinical management of adolescents and young adults suffering from sarcoma in the French Rhône-Alpes region: A prospective exhaustive cohort with 10 years follow up.

INTRODUCTION: Survival of adolescents and young adults (AYA) with sarcoma is lower than in younger patients. The objective of this study was to describe the regional healthcare circuits, the differences in the management between adult, paediatric and mixed units and to assess the prognostic impact of compliance with clinical practice guidelines (CPGs) on overall survival (OS) and on relapse free survival (RFS). MATERIALS AND METHODS: Retrospective analysis of the management and long term follow-up of all 13-25 year old patients with a sarcoma diagnosed in the Rhône-Alpes area between 2000 and 2005. RESULTS: 140 patients satisfied inclusion criteria and were selected. The majority of 13-25 year old patients were treated in paediatric units. Joint management resulted in a higher rate of discussion in multidisciplinary tumour board, inclusion in clinical trials, and fertility preservation. Non-compliance with guidelines was observed in 65% of cases. Overall compliance was not reported to correlate to survival. Compliance of radiotherapy with CPG's seemed associated with a better prognosis for OS (HR = 0.20, 95% CI = [0.10-0.40]; p < 0.0001) and RFS (HR = 0.18, 95% CI = [0.09-0.37; p < 0.0001) as well as compliance of surgery for OS (HR = 0.43, 95% CI = [0.23-0.81]; p = 0.01). Multivariate Cox regression analysis revealed other independent predictors of OS like age at diagnosis, stage and histological subtype. CONCLUSIONS: Management of AYA in joint units seems to improve the quality of care. Compliance of surgery and radiotherapy with CGP's seems to improve survival.

Evaluation of polymerase chain reaction assays for direct screening of carbapenemase-producing Enterobacteriaceae from rectal swabs: a diagnostic meta-analysis.

Recently, molecular assays have been demonstrated to be reliable for rapid detection of carbapenemase-producing Enterobacteriaceae (CPE) directly from positive blood cultures, reducing significantly the time for identification. Few studies have tested their performance on rectal swabs and no comprehensive conclusions have been reached regarding their utility for infection control management. Our aim was to review and assess the overall diagnostic test accuracy of polymerase chain reaction for the detection of CPE in rectal swabs. The electronic database PubMed was searched, up to October 1st, 2019, without language restriction or publication date restrictions. First, the concepts of the research questions were defined: 'carbapenemase-producing Enterobacteriaceae', 'molecular testing', 'test detection', and 'rectal screening'. Two reviewers independently screened studies, extracted data, and assessed quality using the QUADAS-2 instrument. Statistical analyses were carried out in Stata software using the bivariate model. In all, 143 articles were screened and 16 studies were included. Five (31%) of the studies were conducted in the context of a CPE outbreak; one study (6%) included patients pre-identified with CPE in clinical samples (blood or tracheal secretions), whereas the rest (63%) collected rectal swabs from patients considered at high risk of colonization. The molecular assays evaluated had a relatively good sensitivity of 0.95 (95% confidence interval (CI): 0.902-0.989), and an excellent specificity of 0.994 (95% CI: 0.965-1). Molecular techniques seem to be a useful, accurate diagnostic tool in screening for carriage of CPE in contact patients around a fortuitous discovery of a non-isolated hospitalized carrier patient.

Malnutrition in type 2 diabetic patients does not affect healing of foot ulcers.

AIM: Protein-energy malnutrition is known to be involved in wound healing. While wound healing in patients with diabetic foot ulcers (DFU) is a complex and multifactorial process, the role of malnutrition in this case has rarely been explored. The objective of this study was to determine whether the nutritional status of diabetic patients influences the healing of DFU. METHODS: 48 patients were included in this prospective, single-center study. All patients with comorbidities or factors involving malnutrition or influencing biological measurements were excluded. Patients were followed up for 24 weeks. RESULTS: The malnutrition rate was 29.2% at baseline and 25.6% at the end of the study. The difference was not significant. Of the 35 patients with wound healing, 29% were undernourished at inclusion and 17% at the end of the study. Of the 12 patients without wound healing, 50% were undernourished at inclusion, and 42% at the end of the study. These differences were not significant. Rate and speed of wound healing were not associated with malnutrition at inclusion. 15% of patients without malnutrition at baseline had final malnutrition. CONCLUSION: We demonstrated that wound healing was not affected by the initial presence of malnutrition. In our study, there is no evidence to support nutritional intervention to improve wound healing in diabetic patients. Nevertheless, malnutrition is responsible for an increase in morbidity and mortality and it is essential to identify malnutrition systematically for all patients with DFU, initially and during follow-up to treat it quickly and efficiently.

Are systematic drain tip or drainage fluid cultures predictive of surgical site infections?

Systematic cultures of drain tips or drainage fluids for the early detection of surgical site infections (SSIs) are controversial. To examine the association between the results of systematic drain tip or drainage fluid cultures and the occurrence of SSIs in clean or clean-contaminated surgery. Searches were performed in the PubMed, and Cat.inist databases for observational studies published before 31st March 2017. Studies reporting results of drain tip or drainage fluid systematic cultures and SSIs after clean or clean-contaminated surgeries were included, and meta-analyses were performed. Seventeen studies, including 4390 patients for drain tip cultures and 1288 for drainage fluid cultures, were selected. The pooled negative predictive values were high (99%, 95% confidence interval (CI) 98-100 for drain tip cultures and 98%, 95% CI 94-100 for drainage fluid cultures). The positive predictive values were low (11%, 95% CI 2-24 for drain tip cultures and 12%, 95% CI 3-24 for drainage fluid cultures). The sensitivities were low (41%, 95% CI 12-73 for drain tip cultures and 37%, 95% CI 16-60 for drainage fluid cultures). The specificities were high (93%, 95% CI 88-96) for drain tip cultures and moderate (77%, 95% CI 54-94) for drainage fluid cultures. Systematic cultures of drain tips or drainage fluids appear not to be relevant, because their positive predictive values were low in the prediction of SSIs.

A systematic review of surgical site infections following day surgery: a frequentist and a Bayesian meta-analysis of prevalence.

BACKGROUND: Since 1990, several studies have focused on safety and patient satisfaction in connection with day surgery. However, to date, no meta-analysis has investigated the overall prevalence of surgical site infections (SSI). AIM: To estimate the overall prevalence of SSI following day surgery, regardless of the type of surgery. METHOD: A systematic review and a meta-analysis of the prevalence of SSI following day surgery, regardless of the type of surgery, was conducted, seeking all studies before June 2016. A pooled random effects model using the DerSimonian and Laird approach was used to estimate overall prevalence. A double arcsine transformation was used to stabilize the variance of proportions. After performing a sensitivity analysis to validate the robustness of the method, univariate and multi-variate meta-regressions were used to test the effect of date of publication, country of study, study population, type of specialty, contamination class, time of postoperative patient visit after day surgery, and duration of hospital care. FINDINGS: Ninety articles, both observational and randomized, were analysed. The estimated overall prevalence of SSI among patients who underwent day surgery was 1.36% (95% confidence interval 1.1-1.6), with a Bayesian probability between 1 and 2% of 96.5%. The date of publication was associated with the prevalence of SSI (coefficient -0.001, P = 0.04), and the specialty (digestive vs non-digestive surgery) tended to be associated with the prevalence of SSI (coefficient 0.03, P = 0.064). CONCLUSION: The meta-analysis showed a low prevalence of SSI following day surgery, regardless of the surgical procedure.

Association between Pseudomonas aeruginosa positive water samples and healthcare-associated cases: nine-year study at one university hospital.

OBJECTIVE: To study the association between the results of water samples and Pseudomonas aeruginosa healthcare-associated cases in a French university hospital. METHODS: Generalized Estimating Equations were used on complete case and imputed datasets. The spatial unit was the building and the time unit was the quarter. RESULTS: For the period 2004-2013, 2932 water samples were studied; 17% were positive for P. aeruginosa. A higher incidence of P. aeruginosa cases was associated with a higher proportion of positive water samples (P=0.056 in complete case analysis and P=0.031 with the imputed dataset). The association was no longer observed when haematology and intensive care units were excluded, but was significant in analyses of data concerning intensive care units alone (P<0.001). CONCLUSION: This study suggests that water outlet contamination in hospitals can lead to an increase in healthcare-associated P. aeruginosa cases in wards dealing with susceptible patients, but does not play a significant role in other wards.

Detection of temporal clusters of health care-associated infections or colonizations with Pseudomonas aeruginosa.

We investigated temporal clusters of Pseudomonas aeruginosa cases between 2005 and 2014 in 1 French university hospital, overall and by ward, using the Kulldorff method. Clusters of positive water samples were also investigated at the whole hospital level. Our results suggest that water outlets are not closely involved in the occurrence of clusters of P aeruginosa cases.

Investigation of a Case of Genotype 5a Hepatitis C Virus Transmission in a French Hemodialysis Unit Using Epidemiologic Data and Deep Sequencing.

BACKGROUND Hepatitis C virus (HCV) is a major cause of chronic liver disease worldwide. A patient was recently found to be HCV seropositive during hemodialysis follow-up. OBJECTIVE To determine whether nosocomial transmission had occurred and which viral populations were transmitted. DESIGN HCV transmission case. SETTING A dialysis unit in a French hospital. METHODS Molecular and epidemiologic investigations were conducted to determine whether 2 cases were related. Risk analysis and auditing procedures were performed to determine the transmission pathway(s). RESULTS Sequence analyses of the NS5b region revealed a 5a genotype in the newly infected patient. Epidemiologic investigations suggested that a highly viremic genotype 5a HCV-infected patient who underwent dialysis in the same unit was the source of the infection. Phylogenetic analysis of NS5b and hypervariable region-1 sequences revealed a genetically related virus (>99.9% nucleotide identity). Deep sequencing of hypervariable region-1 indicated that HCV quasispecies were found in the source whereas a single hypervariable region-1 HCV variant was found in the newly infected patient, and that this was identical to the major variant identified in the source patient. Risk analysis and auditing procedures were performed to determine the transmission pathway(s). Nosocomial patient-to-patient transmission via healthcare workers' hands was the most likely explanation. In our dialysis unit, this unique incident led to the adjustment of infection control policy. CONCLUSIONS The data support transmission of a unique variant from a source with a high viral load and genetic diversity. This investigation also underlines the need to periodically evaluate prevention and control practices.

Potential influence of Type A personality on plasma C-reactive protein levels in people with diabetes.

AIM: Type A personality, although classically known as a factor linked to increased vascular risk, has recently been associated with increased survival in patients with diabetes. As low-grade inflammation predicts a poor outcome, the present study explored the potential associations between Type A and plasma levels of C-reactive protein (CRP) in diabetes. METHODS: Type A personality was assessed by the Bortner questionnaire in people with diabetes. The association between Type A and plasma CRP levels was examined by multivariable linear regression, and structural equation modelling (SEM) was performed to determine the impact of the major clinical, biological and psychological confounders. RESULTS: The study included 626 participants with type 1 and type 2 diabetes from the Diabetes and Psychological Profile study. Multivariable analyses showed an independent inverse association between Type A score and CRP levels. The structural model adjusted for age, gender, diabetes type and duration, body mass index (BMI), smoking status, alcohol abuse, oral antidiabetic and statin treatments, HbA1c levels, lipids, perceived stress, anxiety and depression revealed significant associations between CRP and Type A (ß=-0.135, 95% CI: -0.242, -0.028; P=0.014), BMI (ß=0.194, 95% CI: 0.038, 0.350; P=0.015) and HDL cholesterol (ß=-0.132, 95% CI: -0.245, -0.020; P=0.014). CONCLUSION: Our present study data indicate that Type A personality is independently associated with lower CRP levels. This lower level of inflammation might explain the better clinical outcomes associated with Type A personality in patients with diabetes.

Preoperative hair removal and surgical site infections: network meta-analysis of randomized controlled trials.

Preoperative hair removal has been used to prevent surgical site infections (SSIs) or to prevent hair from interfering with the incision site. We aimed to update the meta-analysis of published randomized controlled trials about hair removal for the prevention of SSIs, and conduct network meta-analyses to combine direct and indirect evidence and to compare chemical depilation with clipping. The PubMed, ScienceDirect and Cochrane databases were searched for randomized controlled trials analysing different hair removal techniques and no hair removal in similar groups. Paired and network meta-analyses were conducted. Two readers independently assessed the study limitations for each selected article according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method. Nineteen studies met the inclusion criteria. No study compared clipping with chemical depilation. Network meta-analyses with shaving as the reference showed significantly fewer SSIs with clipping, chemical depilation, or no depilation [relative risk 0.55, 95% confidence interval 0.38-0.79; 0.60, 0.36-0.97; and 0.56, 0.34-0.96, respectively]. No significant difference was observed between the absence of depilation and chemical depilation or clipping (1.05, 0.55-2.00; 0.97, 0.51-1.82, respectively] or between chemical depilation and clipping (1.09, 0.59-2.01). This meta-analysis of 19 randomized controlled trials confirmed the absence of any benefit of depilation to prevent surgical site infection, and the higher risk of surgical site infection when shaving is used for depilation. Chemical depilation and clipping were compared for the first time. The risk of SSI seems to be similar with both methods.

Information concerning multidrug-resistant bacterial colonization or infection in the medical transfer letter.

OBJECTIVES: The aim of this study was to evaluate the proportion of transfer letters that contained information relative to infection or colonization by multidrug-resistant (MDR) bacteria and factors associated with the presence of that information. PATIENTS AND METHODS: Patients for whom at least one of these selected MDR bacteria (methicillin-resistant Staphylococcus aureus, extended-spectrum ß-lactamase-producing Enterobacteriaceae, or MDR Pseudomonas aeruginosa) was isolated during their hospitalization and who were transferred to another health care facility between 2009 and 2012 were included. Information of the MDR bacterium and the mention of isolation precautions were evaluated in the electronic medical record. RESULTS: Information (mention of MDR bacterium or isolation precaution) was present in 57% [52; 65] of records. Full information (genus and species, concept of MDR bacterium and mention of isolation precaution) was found in 20% [16; 25]. The presence of a dedicated item in the standard medical discharge letter was associated with more frequent information. Less information was retrieved with P. aeruginosa cases than with the other 2 MDR bacteria. CONCLUSION: The presence of the information has improved, but it is still insufficiently reported. Measures to improve information are needed. Indeed, information on MDR bacterial colonization or infection is the first step for isolation precautions. An item could be added to all standard medical discharge letters. An item could also be added to the indicators used to assess quality and safety in healthcare facilities.

Is surgical site scrubbing before painting of value? Review and meta-analysis of clinical studies.

BACKGROUND: Surgical site infections are major surgical complications. Surgical site scrubbing before painting is controversial. AIM: To conduct a meta-analysis of clinical trials that compared pre-operative scrubbing before painting with painting alone for the prevention of surgical site infections. METHODS: A systematic review and meta-analysis of clinical trials in Pubmed, ScienceDirect and Cochrane databases that compared pre-operative scrubbing before painting with painting alone, and reported surgical site infections, skin colonization or adverse effects as an outcome, was undertaken. A fixed-effect model and a random-effect model were tested. Sensitivity analysis was conducted by removing non-randomized controlled trials. FINDINGS: The systematic review identified three studies, involving 570 patients, for surgical site infection outcomes, and four other studies, involving 1082 patients, for positive skin culture outcomes. No significant differences were observed between scrubbing before painting vs painting alone in terms of surgical site infection or positive skin culture. CONCLUSION: Further research is needed to draw conclusions. Only one study in this meta-analysis identified adverse effects, but there were too few events to compare the various methods. It is believed that there is no need to scrub the surgical site if the skin is visibly clean and/or if the patient has had a pre-operative shower.

Case fatality rates of Ebola virus diseases: a meta-analysis of World Health Organization data.

OBJECTIVE: Our objective was to estimate the case fatality rates of Zaire, Sudan, and Bundibugyo Ebola species, responsible for sometimes-lethal hemorrhagic fevers. METHODS: We performed a meta-analysis of World Health Organization data on outbreaks of infections due to theses species. RESULTS: Twenty outbreaks, including the current one, were studied. The estimated case fatality rate was 65.4% (CI 95% [54.6%; 75.5%]) and varied among the outbreaks. A species effect was identified, with a higher case fatality rate for the Zaire species than for Sudan and Bundibugyo species. The case fatality rate of the Zaire species tended to decrease with time. CONCLUSION: The case fatality rates associated with these 3 species was high. A great variability was observed. It could be explained partly by a species effect and by the decrease of Zaire species case fatality rate, with time.