Control of a methicillin-resistant Staphylococcus aureus (MRSA) outbreak in a day-care institution.

This article describes an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) in two institutions for multi-handicapped children in Copenhagen. The aim of the study was to determine whether it was possible to eradicate MRSA in a setting with multi-handicapped children and staff where there was a high degree of physical interaction. This was a prospective interventional uncontrolled cohort study that took place from January 2003 to March 2005. All individuals in close contact with the two institutions and/or in close contact with an MRSA-colonized subject from the outbreak were included in the study: 38 children, 60 staff members and 12 close relatives of colonized subjects. Infection control measures included screening all individuals. When MRSA infection or colonization was found, an attempt was made to eradicate MRSA, staff education was undertaken and attempts were made to determine the route of transmission. Eleven individuals were found to be positive for MRSA (10.0%). All isolates were identical by pulsed-field gel electrophoresis and harboured the staphylococcal cassette chromosome mec (SCCmec) type IV. All colonized and infected individuals were associated with a single room in one of the institutions. MRSA was eradicated from all the colonized and infected subjects. This study shows that it is possible to control an MRSA outbreak in institutions for multi-handicapped children where there is a high degree of physical contact.

Reduced rates of hospital-acquired UTI in medical patients. Prevalence surveys indicate effect of active infection control programmes.

Prevalence surveys have been part of the Danish infection control programme since 1974. Nationwide surveys were carried out in 1978, 1979, 1980, 1991 and 1999. The results indicate a net reduction of approximately 25%, mainly due to a reduction of urinary tract infections (UTIs) in medical patients. Results from the nationwide surveys are validated by results of occasional independent surveys performed in regions or single hospitals. The reduction coincides with preventive programmes focused on catheter policy and UTI. We conclude that the prevalence survey is an important part of our strategic programme for infection control in hospitals.

High antibiotic consumption in Danish intensive care units?

Decreased antibiotic susceptibility among microorganisms isolated from intensive care unit (ICU) patients is found to be associated with high total antibiotic consumption or inappropriate use of antibiotics in the ICUs. The aims of this study were: 1) to characterize the antibiotic consumption in Danish ICUs, and in four ICUs with expectedly large differences in levels of antibiotic consumption, 2) to estimate the association between antibiotic susceptibility among isolated microorganisms and antibiotic consumption. This was done by: 1) a retrospective questionnaire study of the annual supply of antibiotics in 1995 to 30 ICUs in Denmark, and 2) a 2-month prospective study of patients and microbiological samples in four Danish ICUs in 1996. We found that the supply of antibiotics to Danish ICUs was substantial, with a median value of 124 DDD/100 patient days. No association was found between high consumption of antibiotics and decreased antibiotic susceptibility in the four ICUs.

Reuse of single-use sterile medical devices in Danish hospitals after report discourages it.

The extent to which sterile medical devices marked for single-use are reused was surveyed recently in 100 hospitals in Denmark, Finland, Norway, and Sweden. The same method was used in a survey of Danish hospitals two years earlier. This has enabled us

Prevalence of hospital-acquired infection in a Lithuanian hospital.

A prevalence survey in the biggest Lithuanian hospital was undertaken as part of the hospital infection control programme in Lithuania, in collaboration with Statens Seruminstitut, Denmark, to introduce modern methods and technologies in infection control. It aimed to test the methodology of prevalence studies identifying features of community- and hospital-acquired infections, use of clinical microbiology and antibiotics. It was found that 27.3% of all patients had an infection at the time of the survey. The prevalence rate of community-acquired infection (CAI) was 20.5% and of hospital-acquired infection (HAI), 9.2%. Almost one third of all HAI were acquired in other hospitals but still active at the time of the survey. HAIs were more prevalent in children (14.9%) than in adult patients (7.7%). The prevalence of HAI varied from 1.0% in neurological departments to 61.5% in the burns unit. Respiratory tract infections were the most common accounting up to 49.1% of all HAI and 28.3% of CAI. At the time of survey 26.0% of patients were receiving antibiotic treatment although more than one third of these were recorded as having no infection. Microbiological investigations were performed in 41.1% cases of HAI. In this hospital, the survey data indicated an array of preventive priorities which will be exploited during the current hospital infection control programme. A national prevalence study is planned using the experience gained.

Infection control practices in intensive care units of 14 European countries. The EURO.NIS Study Group.

OBJECTIVE: To evaluate compliance with recommended patient-care practices for the prevention of hospital-acquired infections (HAI) in the intensive care unit (ICU). DESIGN: European descriptive survey by questionnaire mailed to all the directors of ICUs. PATIENTS AND PARTICIPANTS: A total of 1642 general ICUs with more than three beds in 14 countries were contacted; 1005 units participated in the study (overall response rate of 61.2%). MEASUREMENTS AND RESULTS: Data on the general characteristics of the hospital and of the ICU, surveillance activities, and patient-care practices relevant to the control of HAIs were collected. Compliance varied significantly by the type of practice evaluated. Comprehensive programs adopting all the recommended preventive practices for specific infections were maintained in a very low proportion of units, ranging from 18% for antibiotic policy to 39% for urinary tract infections. Moreover, 14% of the units claimed to adopt three or more practices that are clearly unsafe, and only 35% of the units claimed not to adopt any risky practice. The presence of an infection control nurse was significantly associated with a lower frequency of substandard care. A great variability was observed by country in the adoption of 29 patient-care practices, mostly for practices for which clear-cut guidelines are lacking. CONCLUSION: Interpretation of data is made difficult by the lack of consensus among experts with respect to some of the practices investigated. Nevertheless, the implementation of standard practices for preventing HAIs is far from satisfactory in the hospitals surveyed, even in a high priority hospital area such as intensive care. Documented European guidelines could be worth-while in increasing awareness of the ICU staff. The availability of at least one infection control nurse in each hospital should be strongly advocated.

Staphylococcus aureus carriage and infections among patients in four haemo- and peritoneal-dialysis centres in Denmark. The Danish Study Group of Peritonitis in Dialysis (DASPID).

A three-month prospective surveillance study was undertaken in four dialysis centres to establish the prevalence of Staphylococcus aureus carriage in a Danish population of patients on haemodialysis (HD) or on continuous ambulatory peritoneal dialysis (CAPD). General data such as sex, age, diagnosis, number of months in dialysis, hospital and ward were registered on a precoded form. Standardized nose and four skin swabs (axillae, groins, perineum) were performed on the first day of the survey. After one and two months, nose swabs were collected. Infections were registered and cultures were sent for phage-typing together with the S. aureus strains isolated from the swabs; 59.5% of HD patients and 51.2% of CAPD patients carried S. aureus. Permanent carriage was most frequent (P < 0.00009), primarily in the nose (44.0 and 34.9%, respectively in HD and CAPD). Skin carriage alone was rare (2.4 and 4.7%). Approximately one third (36.6 and 40.7%) of infections were caused by S. aureus. Although diabetics were not significantly more frequent carriers (60.5%) than non-diabetics (55.0%), the incidence of infection was much higher (26.3% vs. 10.3%, P = 0.004). In CAPD, peritonitis and tunnel/exit-site infections predominated (81.4%), often caused by S. aureus (34.8%). More than two thirds of the infections in HD patients were related to intravascular catheterization. The most serious infection was septicaemia, in all cases due to S. aureus. S aureus infections occurred significantly more frequently among carriers (P = 0.005), and more than half the patients were infected by the same or possibly the same strain as they carried in the nose or on skin. Different regimens for the elimination of S. aureus carriage in dialysis patients are discussed. A policy for risk assessment of patients should be developed, and the elimination of S. aureus carriage before dialysis should be encouraged. Controlled trials comparing the cost-effectiveness of recommended regimens to eliminate carriage in HD/CAPD patients are needed. Nose swabs are reliable indicators of carriage in dialysis patients.

HELICS: a European project to standardise the surveillance of hospital acquired infection, 1994-1995.

During the 1990s several European countries began to set up national or regional networks for the surveillance of hospital acquired infections. Most of these networks were based on the US Centers for Disease Control and Prevention (CDC) National Nosocomia

[An outbreak of Streptococcus pyogenes infections in institutions for the mentally retarded in Greater Copenhagen 1995]. / Et udbrud af infektioner med Streptococcus pyogenes på institutioner for psykisk udviklingshaemmede i Storkøbenhavn 1995.

The largest reported outbreak of infections due to Streptococcus pyogenes, M-type 18, in recent years is described. Ninety persons at institutions for mentally retarded (73% residents) had infections due to the epidemic strain. Pharyngitis and scarlatina were the most common infections. Six patients died, five having a streptococcal toxic shock syndrome. During the outbreak an intensive surveillance was carried out together with improved infection control measures and prompt culturing of residents and employees before antimicrobial treatment. The primary outbreak was confined but a secondary outbreak could not be prevented. This was probably due to difficulties in implementing proper isolation precautions in this setting.

Failure to detect a general reduction of surgical wound infections in Danish hospitals.

The aim of this study was to see if introduction of continuous monitoring of the incidence of surgical wound infections would result in a reduction in the cumulated infection rates. Data from a Danish sentinel system, including more than 65,000 operations, are shown to be sufficiently representative to be used as the basis of a national surveillance system for surgical wound infections. The overall infection rates increased with age and with contamination of the wound. Antibiotic prophylaxis was used in 36% of the operations, with a higher fraction among elderly patients, and in contaminated or major operations. The length of stay was significantly and equally extended for patients with superficial or deep infections, compared to patients without wound infections. The results from 13 departments could be followed at least two years from the beginning of the registration. No general preventive effects of the continuous monitoring were found in these surgical units.

Towards European Union standards in hospital infection control.

Some providers of health care within the European Union (EU)--whether public or private--seem to give little priority to the establishment of quality control and common standards for infection control. Though uniform practice of infection control in hospitals was recommended by The Council of Europe no formal declaration about conformity or quality assessment of this important area seems to have been actively promoted within the EU. This is the setting against which local, and even international infection control protocols are promoted and discussed mainly by dedicated individuals and within informal groups, which may be endorsed by professional societies. So far no definite attempt to formulate European coordination has been recognized apart from initiatives taken by the World Health Organization (WHO) regional office for Europe. We may have a long way to go towards EU standards for infection control even though the benefits of European cooperation in the field of infection control have been recognized, and there are still serious doubts within the medical profession as to the feasibility of harmonization of these activities. EU standards in hospital infection control should be based on the best documented evidence and set at an appropriate level allowing wide participation. The medical profession must be involved and the inclusion of indicators of outcome must be considered.

[Pneumonia among patients admitted to intensive care units. An epidemiological multicenter study of APACHE II score, incidence and course]. / Pneumoni blandt patienter indlagt på intensiv terapiafsnit. Epidemiologisk multicenterstudie of APACHE II-score, incidens og forløb.

Pneumonia in patients in intensive care units (ICU) is associated with several diagnostic difficulties and high mortality. This study was conducted to describe the diagnostic procedures and clinical characteristics of the pneumonic and critically ill patient in relation to APACHE II score. The material consisted of 193 patients admitted to seven Danish ICUs and is also included in a European epidemiologic survey (EURO.NIS). Twenty-eight (14.5%) developed pneumonia and 18 (9.3%) of these were nosocomial (> 48h after admission). Patients with pneumonia had a significantly higher APACHE II score, duration of stay and mortality. The techniques used to diagnose pneumonia were mainly conventional and did not or only seldom include protected brush, bronchoalveolar lavage or pulmonary biosy. The predominant pathogens isolated in tracheal aspirate were Gram-negative bacilli (50%). The APACHE II scoring system was found to stratify patients with respect to mortality, duration of stay and pneumonia diagnosed in ICU.

[Long-term carrier state of methicillin resistant Staphylococcus aureus after hospitalization]. / Langvarig baerertilstand med meticillinresistent Staphylococcus aureus efter hospitalsindlaeggelse i udlandet.

In Denmark, strains of methicillin-resistant (MR) Staphylococcus aureus constitute less than 0.1% of all S. aureus isolates and are often acquired abroad. A strain of MR S. aureus phage type 77+ was isolated from a patient, who had been hospitalized in a Portuguese hospital three months earlier. In Denmark, the patient had been admitted to a private clinic for replacement of the aortic valve and a coronary bypass operation. The strain did not produce detectable soluble coagulase, and it was multiply resistant, including resistance to gentamicin, tetracycline, erythromycin, and rifampicin. It was probably non-invasive. Thirty-seven members of the staff were screened for MR S. aureus with negative results. The patient was treated with chlorhexidine to eliminate carriage, but, eight weeks after treatment, he was still colonized. Thus, in the current epidemiological situation in Denmark, it is important to take into consideration that carriage of MR S. aureus may last several months. We therefore suggest, that specific guidelines for hospital hygiene should be upheld not only for patients, who are transferred directly from hospitals in other countries, but also for patients, who have been hospitalized abroad within the last three to six months.

Prevalence of infections and use of antibiotics among hospitalized patients in Mauritius. A nationwide survey for the planning of a national infection control programme.

As part of a programme for improving hospital infection control in Mauritius a nationwide survey, including a prevalence study, was carried out in order to identify characteristics of the hospitals, the population, and the infections. Community-acquired infections were three times more prevalent than nosocomial infections: 15.0% and 4.9%, respectively. Surgical wound infection was by far the most common nosocomial infection, with a prevalence rate of 8.2 per 100 operations, followed by urinary tract infection with a low rate of 0.8 per 100 admissions. The survey showed that these hospitals in Mauritius housed mainly a young population (mean of 36.8 years for females and 39.4 years for males) with few risk factors for acquiring nosocomial infection. Although diabetes mellitus is prevalent in Mauritius the diagnosis of diabetes was not associated with nosocomial infection. The spectrum of operations offered was limited, and Caesarean section was the most prevalent operation. The amount and types of antibiotics used in hospitalized patients were recorded. More than one third of the patients received antibiotic treatment at the time of the survey, which is comparable to figures reported from large teaching hospitals in Western Europe. The information gathered from the survey, the interviews and the inspection were used to establish priorities for a collaborative programme for improved infection control. It included the draft of a set of custom-made guidelines, which were eventually studied by staff members from hospitals in Mauritius during a training period in Denmark. We believe that a prevalence survey is useful for initiating infection control programmes in hospitals in developing countries.

[Importance of surgical masks for peroperative asepsis]. / Det kirurgiske mundbinds betydning for den peroperative aseptik.

For more than 70 years, the surgical mask has been used under operations as part of the maintenance of aseptic conditions in the operational field. Experiments with models and investigations of sources of infection carried out over the past 20 years have shown, however, that the bacterial flora of the upper respiratory tract do not contribute to airborne contamination of the surgical wound, but that persons who are situated directly beside the field may contaminate the wound directly by droplets released by speech, sneezing or coughing. Over the last ten years the usefulness of the surgical mask has been disputed several times, and a few controlled clinical trials have been able to confirm any benefits associated with use of surgical masks. There is therefore no reason from the point of view of preventing infection to maintain a general requirement for the use of surgical masks by others than those persons who may be situated within an arm's length of the operational field or instrument table.