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.

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.

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.

[Before surgery predictability of malignant ovarian tumors based on ADNEX model and its use in clinical practice]. / Prédictibilité préopératoire de la malignité des tumeurs ovariennes à partir du score ADNEX et utilisation en pratique clinique.

OBJECTIVE: The principal aim of this study was the predictability of malignant ovarian tumors and to determine a cut-off value for this score to indicate the risk of malignancy that would be easy to use in clinical practice. METHODS: We retrospectively calculated the ADNEX score for all patients who underwent surgery for ovarian tumours in two Burgundy hospitals (Dijon University Hospital and Chalon-sur-Saône Hospital). We used the nine criteria of the ADNEX model. The inclusion criteria were the presence of all of the ADNEX criteria and a histology result. We analysed the sensitivity, specificity, PPV and PNV of four cut-offs (3%, 5%, 10% and 15%) for the entire pool then by age groups; from 14 to 42 (group 1) and 43 and more (group 2) RESULTS: Two hundred and eighty-four patients managed for an ovarian tumour were included between the 1st January 2013 and the 31st December 2015. Our AUC was of 0.94 (95% CI [0.903-0.977]) for discrimination between benign and malignant ovarian tumors. For a cut-off of 10%, sensitivity was 90%, specificity was 81.1%, PPV was 34.6% and PNV 98.5%. Results were lower for young women than for the second group. For a cut-off of 10%, group 1 had a sensitivity of 77.7% and specificity of 89.6%, PPV of 46.6% and PNV 97.5%. For the group 2, sensitivity was 95.2%, specificity was 76.6%, PPV was 33.8% and PNV was 99.2%. The most reasonable cut-off for the whole pool was 10%. For group 1 a cut-off of 5% was retained due to the less satisfying detection of "borderline" tumours more frequent in younger patients. For group 2 the cut-off of 10% gave the best results. CONCLUSION: In our study, a lower cut-off for younger women seemed better suited to discriminate borderline tumours. In practice, the ADNEX score associated with the peroperative laparoscopic examination seems to be the best way to use the ADNEX model. Our study showed that the ADNEX model allows a good predictability of malignant ovarian tumours. The predictability becomes less satisfying for the youngest patients. A cut-off malignity value allowing surgical treatment of patients in a specialised facility was reached for two age groups: a cut-off of 5% for women under 42 years old and a cut-off of 10% for women over 43 years old.

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.

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.

[Comparing results of methicillin-resistant Staphylococcus aureus (MRSA) surveillance using the French DRG-based information system (PMSI)]. / État des lieux et évaluation de la surveillance des Staphylococcus aureus résistants à la méticilline (SARM) : PMSI versus surveillance Raisin.

BACKGROUND: The surveillance of methicillin-resistant Staphylococcus aureus (MRSA) is a national priority. The rate of MRSA infections is one of six indicators tracked by the Department of Health. Since 2002, the French institute for public health surveillance (InVS) has monitored MRSA infections to estimate incidence density. Today, the use of the French administrative database (PMSI) could facilitate this surveillance. The aim of this study was to compare MRSA incidence density computed at a national level using PMSI databases with the results from the InVS taken as the reference. METHODS: PMSI databases for the years 2006 to 2009 were used. The reference results were those published by the InVS from 2006 to 2009. MRSA density defined as the number of MRSA infections recorded per year over 1000 hospital stays was computed. It was then compared with the MRSA incidence density measured by InVS. The time course of MRSA incidence in the PMSI records was modeled using a Poisson regression. RESULTS: The incidence density measured by the InVS was higher than the MRSA density computed using the PMSI, but this difference appeared to decrease over time. The PMSI density/InVS MRSA incidence density ratio was 0.8% in 2006 and about 9.2% in 2009. We observed inverted trends with a growing trend in MRSA density identified by the PMSI. Furthermore, the year of study was significantly associated with incidence density (P=0.01). CONCLUSION: Using PMSI data as an additional source of information in the hospital MRSA surveillance process makes it possible to detect and analyze patient repeats at the regional and national levels with linkage facilities. Estimation of incidence density for hospitals not participating to this surveillance system will be the next step.

[Plication of suburethral slings as treatment of persisting or recurring stress urinary incontinence]. / Plicature de la bandelette sous-urétrale comme traitement de l'incontinence urinaire d'effort persistante ou récidivante.

OBJECTIVE OF THE STUDY: Feasibility and efficiency study of mesh readjustment in suburethral slings by overcoat plication in case of persisting of recurring stress urinary incontinence in patients with suburethral slings. METHODS: Retrospective and monocentric study including patients that present with a failure or recurring incontinency after suburethral slings surgery. The eligibility was evaluated after a complete clinical and paraclinical statement, proving the recurrence of the incontinence and its mechanism. Surgery consisted in a plication in an overcoat. RESULTS: Nineteen patients were included. The medium delay between initial surgery and the plication was 23.4months (ds=25.5). Results were evaluated subjectively by the MHU questionnaire and objectively by the urodynamic appraisal. The medium survey was 27.2months (ds=37.3). The procedure lasts about 30minutes. According to MHU, 73.7% of patients were cured and for 10.3% the symptoms were lessened. The difference in the MHU score of stress urinary incontinence before and after mesh readjustment was significant (P=0.0005) and get down from 2.31 (ds=0.75) to 0.56 (ds=0.92) as an average. There was no complication during surgery. There were two cases of postoperative acute urinary retention which were reoperated by simply cutting a thread allowing the sling to relax without losing the benefit of the plicature. There was no significant increase in urge incontinence or dysuria. CONCLUSION: The results of this study confirmed the feasibility, the efficiency and the low morbidity of mesh readjustment for the suburethral sling.

Cephalosporin and fluoroquinolone combinations are highly associated with CTX-M ß-lactamase-producing Escherichia coli: a case-control study in a French teaching hospital.

The aim of this study was to investigate the risk factors associated with CTX-M-producing Escherichia coli strains isolated from infected or colonized patients. From 191 clinical samples, a case-control study was designed. From January 2005 to December 2007, 98 hospitalized patients infected or colonized with CTX-M-producing E. coli were included in the study. They were matched 1 : 1 with controls that had a non-CTX-M-producing E. coli infection on the basis of the site of sample, the unit of hospitalization and the time at risk. The rate of CTX-M-producing E. coli among those producing extended spectrum ß-lactamases was always ≥90% from 2005 to 2008. All strains were susceptible to carbapenems. However, we observed a high rate of co-resistance to ciprofloxacin (61%), sulphonamides (86%) and gentamicin (34%). Significant risk factors identified by multivariate analysis were recurrent infections (OR = 2.93), presence of artificial nutrition (OR = 3.99), and recent exposure to quinolones (OR = 4.39), third- or fourth-generation cephalosporin (OR = 3.49) and the combination of both antibiotic classes (OR = 5.50). This report highlights the dramatic increase of CTX-M-producing E. coli and the need for changes in the use of antimicrobial drugs and in infection control measures to manage this major health concern.

Meta-analysis of intraoperative povidone-iodine application to prevent surgical-site infection.

BACKGROUND: The effectiveness of intraoperative povidone-iodine (PVI) application in the reduction of surgical-site infection (SSI) remains controversial. This meta-analysis was performed to assess the effect of intraoperative PVI application compared with no antiseptic solution (saline or nothing) on the SSI rate. METHODS: The meta-analysis included randomized controlled trials that compared intraoperative PVI lavage with no PVI in patients undergoing surgery with SSI as the primary outcome. A fixed-effects or random-effects model was used as appropriate, and heterogeneity was assessed by the Cochran Q and the I(2) value. RESULTS: Twenty-four randomized controlled trials totalling 5004 patients (2465 patients with PVI and 2539 patients without) were included: 15 in the main analysis and nine in the sensitivity analysis. The rate of SSI was 8.0 per cent in the PVI group and 13.4 per cent in the control group. Intraoperative PVI application significantly decreased the SSI rate (relative risk 0.58, 95 per cent confidence interval 0.40 to 0.83; P = 0.003) and consistent results were observed in subgroup analyses according to the method of PVI administration, its timing and the type of surgery. CONCLUSION: The meta-analysis results suggested that the use of intraoperative PVI reduced rates of SSI.

Randomisation and sample size for clinical audit on infection control.

Clinical audit is both a part of clinical governance and an essential component of infection prevention and control. It is frequently performed on a proportion of the target population. The sample should represent the source population and be sufficient for statistical analysis. In a hospital, infection control practices are likely to be quite similar within the same clinical area (cluster effect). This must be taken into consideration when calculating the necessary number of patients. Sample size is determined by the desired level of precision for estimating the compliance rate, or by the difference between observed and expected rates, or on the difference before and after implementation of interventions. To estimate the hospital-wide compliance rate without additional costs we suggest focusing the audit on a large number of wards, even if fewer observations within each ward are obtained, rather than auditing a large number of practices on a restricted number of wards.

Factors associated with mucoid transition of Pseudomonas aeruginosa in cystic fibrosis patients.

Although the mucoid form of Pseudomonas aeruginosa (Pa) is largely responsible for the progression of lung disease in cystic fibrosis (CF), the relationship between factors relating daily-care regimes to mucoidy acquisition are as yet poorly investigated. Fifty-two CF patients registered at the CF centre of Dijon, France, were retrospectively evaluated from the date of Pa colonization either to the first positive sputum culture for mucoid Pa (n = 26) or to the last culture in which the Pa remained non-mucoid (n = 26). All clinical, pathological and therapeutic events were recorded. The association between the parameters collected and mucoid transition of Pa was assessed in a Cox model with time-dependant covariables. The mean follow-up was 4.7 + or - 4.3 years. Three independent parameters were associated with the higher risk of mucoid transition of Pa: persistence of Pa in sputum (OR 7.89; p <0.01), use of inhaled bronchodilators (OR 3.40; p = 0.04), and the use of inhaled colimycin (OR 4.04; p = 0.02). Isolation of Staphylococcus aureus, Haemophilus influenzae or Streptococcus pneumoniae in sputum was associated with a lower risk (OR 0.24; p < 0.01). Mucoid transition of Pa was associated with variables that reflected the severity of both lung disease and Pa colonization. Although they do not lead to prophylactic measures, these results corroborate the need to avoid Pa persistence.