Prevention of hospital infections by intervention and training (PROHIBIT): results of a pan-European cluster-randomized multicentre study to reduce central venous catheter-related bloodstream infections.

PURPOSE: To test the effectiveness of a central venous catheter (CVC) insertion strategy and a hand hygiene (HH) improvement strategy to prevent central venous catheter-related bloodstream infections (CRBSI) in European intensive care units (ICUs), measuring both process and outcome indicators. METHODS: Adult ICUs from 14 hospitals in 11 European countries participated in this stepped-wedge cluster randomised controlled multicentre intervention study. After a 6 month baseline, three hospitals were randomised to one of three interventions every quarter: (1) CVC insertion strategy (CVCi); (2) HH promotion strategy (HHi); and (3) both interventions combined (COMBi). Primary outcome was prospective CRBSI incidence density. Secondary outcomes were a CVC insertion score and HH compliance. RESULTS: Overall 25,348 patients with 35,831 CVCs were included. CRBSI incidence density decreased from 2.4/1000 CVC-days at baseline to 0.9/1000 (p < 0.0001). When adjusted for patient and CVC characteristics all three interventions significantly reduced CRBSI incidence density. When additionally adjusted for the baseline decreasing trend, the HHi and COMBi arms were still effective. CVC insertion scores and HH compliance increased significantly with all three interventions. CONCLUSIONS: This study demonstrates that multimodal prevention strategies aiming at improving CVC insertion practice and HH reduce CRBSI in diverse European ICUs. Compliance explained CRBSI reduction and future quality improvement studies should encourage measuring process indicators.

Molecular screening of carbapenemase-producing Gram-negative strains in Romanian intensive care units during a one year survey.

This is the first study, to our knowledge, performed on a significant number of strains (79 carbapenem-resistant Enterobacteriaceae and 84 carbapenem-resistant non-fermenting Gram-negative rods, GNRs) isolated from tissue samples taken from patients in the intensive care units of two large hospitals in Bucharest, Romania, between 2011 and 2012. The results revealed a high prevalence and great diversity of carbapenemase genes (CRG), in both fermenting and non-fermenting Gram-negative carbapenem-resistant strains. The molecular screening of carbapenem-resistant GNRs revealed the presence of worldwide-distributed CRGs (i.e. blaOXA-48 and blaNDM-1 in Enterobacteriaceae and blaOXA-23, blaVIM-4, blaOXA-10-like, blaOXA-60-like, blaSPM-like and blaGES-like in non-fermenting GNRs), reflecting the rapid evolution and spread of carbapenemase producers, particularly in hospitals. Rapid identification of the colonized or infected patients is required, as are epidemiological investigations to establish the local or imported origin of the respective strains.

Antibiotic resistance profiles of Acinetobacter sp. strains isolated from intensive-care unit patients.

UNLABELLED: Multidrug resistance and the increasing number of severe infections caused by Acinetobacter sp. strains are a major issue for intensive care units (ICUs), where patients with severe diseases and often destabilized physiological condition are admitted. The aim of this study was to investigate the antibiotic resistance profiles of 200 Acinetobacter spp. isolated from tracheal aspirates in patients admitted to ICU, Fundeni Clinical Institute (FCI). METHODS: the samples were collected from intubated patients between January 2006-December 2007. The microbial strains were identified with the help of the BD Phoenix system. The investigation of the antibiotic resistance patterns was performed by agar disk diffusion method according to CLSI recommendations, and the production of metallo-betalactamases (MBL) was confirmed by MBL E-test. RESULTS: the majority of the studied strains (80%) were multidrug resistant with a high percentage of panresistance (32%). Metallo-beta-lactamases production among the strains with resistance to imipenem was high (over 83%), these strains being also resistant to the majority of the other tested antibiotics with the exception of colistin. CONCLUSIONS: Our results confirmed that the multidrug resistance is the major threat of Acinetobacter sp. infections, especially when they occur in high risk patients.

A retrospective study of bacterial infections in cirrhosis.

AIM: To evaluate the incidence of bacterial infections (BI) in hepatic cirrhosis (HC), the pathogen agents involved, to define the risk factors and impact on prognosis. METHODS: There was a retrospective study that enrolled a total of 1046 patients with HC admitted in our clinic between 1.10.2008-31.03.2009 (6 months). Clinical, biological and bacteriological data were monitored. RESULTS: 51 patients (4.9%) were found with BI. In one patient BI was located in three sites: peritoneal, blood and urine, and in 7 patients BI was located in 2 sites. BI location was: peritoneal-26 cases, urinary-20 cases, pneumonia - 8 cases, skin - 4 cases and bacteremia -1 case. 43 episodes were community acquired, while 17 episodes were - nosocomial (peritoneal - 3 cases, lung - 6 cases, skin - 2 cases, urinary - 5 cases). Of the 26 cases with bacterial peritonitis, the etiologic agent was identified in three: E. coli, Klebsiella, Alcaligenes. 18% of patients with HC and BI presented upper GI bleeding. 12 cases required admission to the Intensive Care Unit, where the death rate reached 83%. The risk factors for BI in HC were: decompensated HC OR=58,23 (95% CI 8.63÷1141.31), p-value 10-12, Child Pugh score C: OR =1.99 (95% CI 1.04÷3.8), p-value= 0.02. CONCLUSIONS: In this study the rate of bacterial infections in HC is low compared with the literature (4.9% vs. 15-30%), because the study was retrospective, hence recorded only severe infections. We must actively seek infections in all hospitalized patients with HC, especially in the ones with decompensated cirrhosis and with upper GI bleeding.

Antibiotic resistance of Gram negative bacilli strains isolated from the Intensive Care Unit in Fundeni Clinical Institute, Bucharest, Romania.

UNLABELLED: The aim of this study was to investigate the antibiotic resistance profile of 58 Gram negative bacilli strains (GNB): 36 non-fermentative GNB (NGNB), including 19 strains of Acinetobacter spp., 11 of Pseudomonas aeruginosa, 6 of Stenotrophomonas maltophilia and 22 enterobacterial strains (14 strains of KEHSs, 6 belonging to the group Proteus-Providencia and 2 Escherichia coli) isolated from nasal, pharyngeal exudates and also from bronchial secretions, from immuno-depressed patients admitted in the Intensive Care Unit of Fundeni Clinical Institute. METHHODS: the antibiotic susceptibility testing was performed according to CLSI 2009 recommendations and the production of beta-lactamases was investigated by ESBL chromogenic media, double disc diffusion test, ESBL E-test, Amp C E-test and MBL E-test. RESULTS: 68% of the enterobacterial strains produced extended-spectrum beta- lactamases (ESBL), 13.63% of them expressing simultaneously the Amp C enzyme. All enterobacterial strains were susceptible to carbapenems (Imipenem and Ertapenem). Metallo-beta lactamases production among NGNB strains with resistance to Imipenem was high (80%), these strains being also multi-resistant to the majority of tested antibiotics with the exception of colistin. CONCLUSIONS: our results showed that the majority of the analyzed strains were multi-drug resistant. Antibiotic multi-resistance and the increasing number of severe infections caused by these strains are a major issue for ICU, where patients with severe diseases and destabilized physiological condition are often admitted.