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.

Contributory conditions for unexpected COVID-19 cases and nosocomial COVID-19 infection cases identified from systematic investigation in a French University Hospital.

INTRODUCTION: Nosocomial case (NC) of COVID-19 infections is a challenge for hospitals. We report the results of a seven-month prospective cohort study investigating COVID-19 patients to assess unexpected cases (UC) (no COVID-19 precautionary measure application since admission) and NC. PATIENTS AND METHODS: Investigation by an infection control team of 844 patients with COVID-19 infection hospitalized for more than 24 hours (cases). RESULTS: A total of 301 UC were identified (31% after contact tracing) with a total of 129 contact patients, and 27 secondary cases for 59 of them. In geriatric wards, 50% of cases were UC. NC represented 18% of cases (37% in geriatric wards), mainly identified after contact tracing of wandering cases. CONCLUSION: A rapid infection control response is essential to contain nosocomial transmission, along with detailed contact tracing and screening policy. Dealing with wandering elderly patients remain challenging for HCWs.

Carbapenem stewardship program in a French university children's hospital.

INTRODUCTION: Carbapenems, last-resort antibiotics, are widely used as first-line treatment in patients carrying extended-spectrum beta-lactamases (ESBL) Enterobacteriaceae, including in a pediatric setting. We aimed to implement an antibiotic stewardship program (ASP) to improve the use of carbapenems. METHODS: We implemented an ASP at the Bordeaux Children's University Hospital with 6-month audits on prescribing practice before and after an intervention (revision of antibiotic treatment protocols, a half-day educational session with feedback of the first study period). The number of carbapenem prescriptions was analyzed and two criteria were used to assess conformity of the indication for carbapenem prescription and conformity of the reassessment. A logistic regression was used to assess the overall compliance of carbapenem prescriptions over the two periods adjusted for ESBL carriage. RESULTS: A total of 57 patients were included with 37 carbapenem prescriptions before the intervention and 23 after. Overall carbapenem consumption decreased from 0.54 prescriptions per 100 admissions to 0.32 (p = 0.06). Conformity increased during the study for indication (46-87%, p = 0.004) and for reassessment (48-78%, p = 0.04) and was significantly associated with the second study period, after adjustment for ESBL carriage. CONCLUSION: Our intervention contributed to a significant improvement in the compliance to indications for carbapenem indication and in the reassessment of the prescription.

Exogenous acquisition of Pseudomonas aeruginosa in intensive care units: a prospective multi-centre study (DYNAPYO study).

BACKGROUND: Pseudomonas aeruginosa remains one of the most common nosocomial pathogens in intensive care units (ICUs). Although exogenous acquisition has been widely documented in outbreaks, its importance is unclear in non-epidemic situations. AIM: To elucidate the role of exogenous origin of P. aeruginosa in ICU patients. METHODS: A chronological analysis of the acquisition of P. aeruginosa was performed using samples collected in 2009 in the DYNAPYO cohort study, during which patients and tap water were screened weekly. Molecular relatedness of P. aeruginosa isolates was investigated by pulsed-field gel electrophoresis. Exogenous acquisition was defined as identification of a P. aeruginosa pulsotype previously isolated from another patient or tap water in the ICU. FINDINGS: The DYNAPYO cohort included 1808 patients (10,402 samples) and 233 water taps (4946 samples). Typing of 1515 isolates from 373 patients and 375 isolates from 81 tap water samples identified 296 pulsotypes. Analysis showed exogenous acquisition in 170 (45.6%) of 373 patients. The pulsotype identified had previously been isolated from another patient and from a tap water sample for 86 and 29 patients, respectively. The results differed according to the ICU. CONCLUSION: Exogenous acquisition of P. aeruginosa could be prevented in half of patients. The overall findings of this survey support the need for studies on routes of transmission and risk assessment approach to better define how to control exogenous acquisition in ICUs.

Antibiotics associated with acquisition of carbapenem-resistant Pseudomonas aeruginosa in ICUs: a multicentre nested case-case-control study.

Background: Carbapenem-resistant Pseudomonas aeruginosa (CRPA) strains are involved in severe infections, mostly in ICUs. Exposure to antibiotics other than carbapenems may be associated with isolation of CRPA; therefore, we aimed to identify those antibiotics using the case-case-control study design. Methods: A case-case-control study was conducted in 2015 in a prospective multicentre cohort that included 1808 adults hospitalized in 2009 in 10 French ICUs. Patients were screened for P. aeruginosa at admission to the ICU and then weekly. Cases were patients with CRPA and patients with carbapenem-susceptible P. aeruginosa (CSPA) isolation. Controls were patients without P. aeruginosa isolation, matched with each case according to centre, length of stay and hospitalization period. Effects of antibiotic exposure were explored, after adjusting for prior treatment with carbapenems and confounding factors comprising colonization pressure with two logistic regression models. The two models were compared to identify specific risk factors for CRPA isolation. Results: Fifty-nine CRPA, 83 CSPA and 142 controls were compared. In adjusted multivariable analyses, exposure to carbapenems and to antibiotics belonging to the group of ß-lactams inactive against P. aeruginosa were independent risk factors for CRPA isolation (OR, 1.205; 95% CI, 1.079-1.346 and OR, 1.101; 95% CI, 1.010-1.201, respectively). Conversely, exposure to ß-lactams active against P. aeruginosa was an independent protective factor for CSPA isolation (OR, 0.868; 95% CI, 0.772-0.976). Conclusions: Besides carbapenem exposure, exposure to ß-lactams inactive against P. aeruginosa was a specific risk factor for CRPA isolation. Clinicians should counterweigh the potential benefits of administering these antibiotics against the increased risk of CRPA infection.

Risk factors for colonization and infection by Pseudomonas aeruginosa in patients hospitalized in intensive care units in France.

OBJECTIVE: To assess the role of environment, medical care and individual risks factors for P. aeruginosa colonization and infection. STUDY DESIGN AND SETTING: A French multicentric prospective study involved ten ICUs for a five months period. Every adult patient newly hospitalized in ICUs with no P. aeruginosa carriage up to 48 hours after admission was included and weekly screened before discharge or death. Screening swabs were either rectal, sputum or oropharyngeal samples. Hydric environment was also sampled each week. Data on patient clinical features, environmental and device exposures, and antibiotics supports were regularly collected. Multivariate analysis was performed with a multistate model. RESULTS: The overall prevalence of P. aeruginosa carriage was 15.3% (201/1314). Risk factors associated with patient colonization were: use of inactive antibiotics against P. aeruginosa (HR = 1.60 [1.15-2.21] p<0.01), tap water contamination at the entry in the room (HR = 1.66 [1.01-2.27] p<0.05) and mechanical invasive ventilation (HR = 4.70 [2.66-8.31] p<0.0001). Active antibiotics prevented from colonization (HR = 0.67 [0.48-0.93] p = 0.02) and from infection (HR = 0.64 [0.41-1.01] p = 0.05). Interaction between hydric environment antibiotics support was not statistically associated with patient colonization. CONCLUSION: Hydric contamination and antibiotics pressure seem to remain key independent risk factors in P. aeruginosa colonization. These results advocate the need to carry on preventive and targeted interventions toward healthcare associated infections.

Risk factors for acquisition of OXA-48-producing Klebsiella pneumonia among contact patients: a multicentre study.

BACKGROUND: Cohorting carbapenemase-producing Enterobacteriaceae (CPE) carriers during hospitalization limits in-hospital spreading. AIM: To identify risk factors for CPE acquisition among contacts of an index patient in non-cohorted populations. METHODS: A multicentre retrospective matched case-control study was conducted in five hospitals. Each contact patient (case) who acquired Klebsiella pneumoniae (KP)-OXA-48 from an index patient was compared to three contact (controls) with the same index patients matched with hospitalization in the same unit and similar exposure times. FINDINGS: Fifty-one secondary cases and 131 controls were included. By univariate analysis, exposure time (odds ratio: 1.06; 95% confidence interval: 1.02-1.1; P = 0.006), concomitant infection at admission (3.23; 1.42-7.35; P = 0.005), antimicrobial therapy within the last month before hospitalization (2.88; 1.34-6.2; P = 0.007), antimicrobial therapy during the exposure time (5.36; 2.28-12.6; P < 0.001), use of at least one invasive procedure (2.99; 1.25-7.15; P = 0.014), number of invasive procedures (1.52; 1.05-2.19; P = 0.025), and geographical proximity (2.84; 1.15-7.00; P = 0.023) were associated with CPE acquisition. By multivariate analysis, antimicrobial therapy during the exposure time (odds ratio: 6.36; 95% confidence interval: 2.46-16.44; P < 0.001), at least one invasive procedure (2.92; 1.04-8.17; P = 0.041), and geographical proximity (3.69; 1.15-11.86; P = 0.028) were associated with acquisition. CONCLUSION: In this study, geographical proximity, invasive procedure, and antimicrobial therapy during exposure time were significantly associated with KP-OXA-48 acquisition.

Early and late surgical site infections in ear surgery.

A retroauricular approach is routinely used for treating chronic otitis media. The incidence of surgical site infections after ear surgery is around 10% in contaminated or dirty procedures. This observational prospective study describes surgical site infections after chronic otitis media surgery with the retroauricular approach and investigated their potential predictive factors. This observational prospective study included patients suffering from chronic otitis media and eligible for therapeutic surgery with a retroauricular approach. During follow-up, surgical site infections were defined as "early" if occurring within 30 days after surgery or as "late" if occurring thereafter. The data of 102 patients were analysed. Concerning early surgical site infections, four cases were diagnosed (3.9%) and a significant association was found with preoperative antibiotic therapy, wet ear at pre-operative examination, class III (contaminated) in the surgical wound classification, NNIS (National Nosocomial Infection Surveillance) index > 1, and oral post-operative antibiotic use. Seven late surgical site infections were diagnosed (7.1%) between 90 and 160 days after surgery and were significantly correlated to otorrhoea during the 6 months before surgery, surgery duration ≤60 minutes, canal wall down technique and use of fibrin glue. Surgical site infections after chronic otitis media surgery seem to be associated with factors related to the inflammatory state of the middle ear at the time of surgery in early infections and with chronic inflammation in late infections.

Risk factors for Pseudomonas aeruginosa acquisition in intensive care units: a prospective multicentre study.

BACKGROUND: Pseudomonas aeruginosa is a major nosocomial pathogen in intensive care units (ICUs); however, endogenous versus exogenous origin of contamination remains unclear. AIM: To identify individual and environmental ICU risk factors for P. aeruginosa acquisition. METHODS: A five-month prospective multicentric study was performed in ten French ICUs. Adult patients hospitalized in ICU for ≥ 24 h were included and screened for P. aeruginosa colonization on admission, weekly and before discharge. P. aeruginosa acquisition was defined by a subsequent colonization or infection if screening swabs on admission were negative. Water samples were obtained weekly on water taps of the ICUs. Data on patient characteristics, invasive devices exposure, antimicrobial therapy, P. aeruginosa water and patient colonization pressures, and ICU characteristics were collected. Hazard ratios (HRs) were estimated using multivariate Cox model. FINDINGS: Among the 1314 patients without P. aeruginosa on admission, 201 (15%) acquired P. aeruginosa during their ICU stay. Individual characteristics significantly associated with P. aeruginosa acquisition were history of previous P. aeruginosa infection or colonization, cumulative duration of mechanical ventilation and cumulative days of antibiotics not active against P. aeruginosa. Environmental risk factors for P. aeruginosa acquisition were cumulative daily ward 'nine equivalents of nursing manpower use score' (NEMS) [hazard ratio (HR): 1.47 for ≥ 30 points; 95% confidence interval (CI): 1.06-2.03] and contaminated tap water in patient's room (HR: 1.76; CI: 1.09-2.84). CONCLUSION: Individual risk factors and environmental factors for which intervention is possible were identified for P. aeruginosa acquisition.

Prospective follow-up of complications related to peripherally inserted central catheters.

UNLABELLED: An increased use of peripherally inserted central catheters (PICC) in French hospitals has been observed in recent years. We report complications having occurred following the placement of PICC in a teaching hospital. PATIENTS AND METHODS: A prospective study was made for 7 months, between October 2010 and April 2011, including all patients having undergone PICC placement in interventional radiology. RESULTS: Two hundred and sixty-seven PICC were inserted in 222 patients for intravenous antibiotic therapy (68%), parenteral nutrition (13%), or chemotherapy (9%). The median duration of PICC use was 17 days (min-max: 1-140) for the 200 PICC monitored until removal. The most common complication was obstruction (n=41), 16 of which motivated PICC removal (8%). Five cases of vein thrombosis (2.5%) and 20 infectious complications (10%) led to removal. There were 14 accidental removals (7%). The overall infection rate was 2.3 per 1000 catheter-days with 0.86 per 1000 catheter-days for central line-associated bloodstream infection. Thirty-four percent of PICC were removed without any complications without any difference according to use. CONCLUSION: PICC are a simple alternative to standard central venous catheter but the rate of complications is high and could be decreased by a stringent management and training for this type of catheter.

Nosocomial urinary tract infection in the intensive care unit: when should Pseudomonas aeruginosa be suspected? Experience of the French national surveillance of nosocomial infections in the intensive care unit, Rea-Raisin.

Individual and ward risk factors for P. aeruginosa-induced urinary tract infection in the case of nosocomial urinary tract infection in the intensive care unit were determined with hierarchical (multilevel) logistic regression. The 2004-2006 prospective French national intensive care unit nosocomial infection surveillance dataset was used and 3252 patients with urinary tract infection were included; 16% were infected by P. aeruginosa. Individual risk factors were male sex, duration of stay, antibiotics at admission and transfer from another intensive care unit. Ward risk factors were patient turnover and incidence of P. aeruginosa-infected patients.

Identifying new risk factors for Pseudomonas aeruginosa pneumonia in intensive care units: experience of the French national surveillance, REA-RAISIN.

Pseudomonas aeruginosa is an important pathogen of complicated pneumonia in intensive care units (ICUs). Our objective was to determine 'patient' and 'ward' risk factors for P. aeruginosa pneumonia among patients with nosocomial pneumonia in ICU. Data from the 2004-2006 prospective French national nosocomial infection surveillance in ICUs (REA-RAISIN) were used, including patients admitted for >48 h in ICU and who developed nosocomial pneumonia. Only first pneumonia was considered and categorised as either P. aeruginosa pneumonia or other micro-organism pneumonia. Multilevel logistic regression model (patient as first level and ward as second) with P. aeruginosa pneumonia as binary outcome was performed. Of 3,837 included patients from 201 different wards, 25% had P. aeruginosa pneumonia. P. aeruginosa was significantly more frequent in late onset pneumonia. Higher probability of P. aeruginosa pneumonia was associated with higher age and length of mechanical ventilation, antibiotics at admission, transfer from a medical unit or ICU, and admission in a ward with higher incidence of patients with P. aeruginosa infections. Lower probability of P. aeruginosa was associated with traumatism and admission in a ward with high patient turnover. Our analyses identified a patient's profile and some ward elements that could make suspect P. aeruginosa in case of nosocomial pneumonia.

Factors associated with the prevalence of antibiotic use for the treatment of hospital-acquired infections at 393 French hospitals: a regional variation analysis.

OBJECTIVE: The present study investigated regional variations in antibiotic use for the treatment of hospital-acquired infections (HAIs) in France by means of a multilevel analysis, to identify targets for quality improvement. METHODS: Data were obtained from the 2001 and 2006 French national point-prevalence surveys of HAIs and antibiotic use. The present study was conducted using data from 393 nonteaching public hospitals. Data included patient characteristics calculated at the hospital level (mean age and proportion of patients with the following: HAI, presence of a vascular catheter, presence of a urinary catheter, surgical procedure, and immunodeficiency) and hospital characteristics (size and presence of an intensive care unit). The regional effect was measured using a random intercept on a regional variable. RESULTS: Overall, the prevalence of antibiotic use was 5.35% for both study years. The most commonly used antibiotics for HAIs were fluoroquinolones (2001, 1.33%; 2006, 1.35%) and combinations of penicillins with a ß-lactamase inhibitor (2001, 0.92%; 2006, 1.02%). Mapping of antibiotic use showed wide variation between regions. The regional effect explained 3% of antibiotic variation in the unadjusted analysis. In the multivariable analysis, hospital size, high prevalence of patients with immunodeficiency, and infection characteristics explained 45% of the variability in antibiotic use. The regional effect was not retained in the final model. CONCLUSION: The pattern of antibiotic use for HAIs differed over time, and regional variations were mostly explained by patient characteristics; there was no regional effect. Models that take data hierarchy into account are essential to better approach antibiotic use and develop relevant strategies for improvement.

Antibiotic stewardship programmes: legal framework and structure and process indicator in Southwestern French hospitals, 2005-2008.

French hospitals are required to implement antibiotic stewardship programmes (ABS) to improve antibiotic use. We analysed the legal framework on ABS and assessed its impact on hospitals' ABS development in Southwestern France. For each official text, required measures, date of issue, means of control and incentives were analysed. Annual retrospective surveys were conducted in 84 hospitals from 2005 to 2008 to monitor implementation of ABS components: organisation, resources and actions. Evolution of individual measures and of a structure and process indicator (SPI) reflecting ABS was described for each hospital. From 2002, official texts issued by health authorities set out requirements on ABS, based on previous professional guidelines. Incentives and means of control were reinforced in 2006 and in 2007 with mandatory reporting of SPI for public disclosure. ABS implementation improved during the course of the study period. In 2008, at least 98% of hospitals had implemented formularies, antibiotic committees, surgical prophylaxis guidelines, and monitored antibiotic use; antibiotic advisors were appointed in 85% of hospitals. Little progress was made regarding time dedicated by pharmacists to antibiotic management and restrictive dispensation using stop-orders. Computerised tools, continuing education and audits remained under-used. SPI values were higher in private hospitals and rehabilitation centres than in others. Official texts and the SPI public disclosure increased professionals' and hospital managers' commitment to develop ABS, resulting in improvements. However, some actions still need to be reinforced. It appears crucial to monitor practical implementation to better approach ABS effectiveness and to adapt requirements.

Easily available adjustment criteria for the comparison of antibiotic consumption in a hospital setting: experience in France.

Hospitals in France are encouraged to monitor antibiotic consumption (AbC) and it is known that this differs among hospitals. The aim of the current study was to identify relevant and easily available adjustment criteria for the purpose of benchmarking. We analysed data from 34 public non-teaching hospitals and 43 private hospitals located in south-western France and overseas departments using retrospective data from 2005. This study investigated the relationship between AbC expressed as defined daily doses per 1000 patient-days (DDD/1000 PDs) or per 100 admissions (DDD/100 admissions) and the number of venous central lines, the number of episodes of bacteraemia and various hospital characteristics. The relationship was tested using multiple linear analyses. The median total AbC in public hospitals was 395 DDD/1000 PDs (range, 196-737) and 341 DDD/100 admissions (range, 180-792). In private hospitals this was 422 DDD/1000 PDs (range, 113-717) and 212 DDD/100 admissions (range, 38-510). The best model for public hospitals included the proportion of PDs in surgery, intensive care and medical wards and explained 84% of the variability in AbC expressed as DDD/1000 PDs. For private hospitals, the mean length of stay and the proportion of PDs in surgery and medical wards explained 68% of the variability in AbC expressed as DDD/100 admissions. Overall, this French experience shows that relevant adjustment criteria for the comparison among hospitals are easily available. It is important that each country establish its own model considering the intrinsic peculiarities of the hospital system and taking into account both indicators (DDD/1000 PDs or DDD/100 admissions) to design the best model.

Relationship between rates of antimicrobial consumption and the incidence of antimicrobial resistance in Staphylococcus aureus and Pseudomonas aeruginosa isolates from 47 French hospitals.

OBJECTIVE: To investigate relationships between rates of antimicrobial consumption and the incidence of antimicrobial resistance in Staphylococcus aureus and Pseudomonas aeruginosa isolates from hospitals. METHODS: We conducted an observational study that used retrospective data from 2002 and linear regression to model relationships. Hospitals were asked to collect data on consecutive S. aureus and P. aeruginosa isolates, consumption rates for antibiotics (ie, anti-infectives for systemic use as defined by Anatomical Therapeutic Chemical class J01), and hospital characteristics, including infection control policies. Rates of methicillin resistance in S. aureus and rates of ceftazidime and ciprofloxacin resistance in P. aeruginosa were expressed as the percentage of isolates that were nonsusceptible (ie, either resistant or intermediately susceptible) and as the incidence of nonsuceptible isolates (ie, the number of nonsuceptible isolates recovered per 1,000 patient-days). The rate of antimicrobial consumption was expressed as the number of defined daily doses per 1,000 patient-days. SETTING: Data were obtained from 47 French hospitals, and a total of 12,188 S. aureus isolates and 6,370 P. aeruginosa isolates were tested. RESULTS: In the multivariate analysis, fewer antimicrobials showed a significant association between the consumption rate and the percentage of isolates that were resistant than an association between the consumption rate and the incidence of resistance. The overall rate of antibiotic consumption, not including the antibiotics used to treat methicillin-resistant S. aureus infection, explained 13% of the variance between hospitals in the incidence of methicillin resistance among S. aureus isolates. The incidence of methicillin resistance in S. aureus isolates increased with the use of ciprofloxacin and levofloxacin and with the percentage of the hospital's beds located in intensive care units (adjusted multivariate coefficient of determination [aR(2)], 0.30). For P. aeruginosa, the incidence of ceftazidime resistance was greater in hospitals with higher consumption rates for ceftazidime, levofloxacin, and gentamicin (aR(2), 0.37). The incidence of ciprofloxacin resistance increased with the use of fluoroquinolones and with the percentage of a hospital's beds located in intensive care ( aR(2), 0.28). CONCLUSIONS: A statistically significant relationship existed between the rate of fluoroquinolone use and the rate of antimicrobial resistance among S. aureus and P. aeruginosa isolates. The incidence of resistant isolates showed a stronger association with the rate of antimicrobial use than did the percentage of isolates with resistance.

Determinants of glycopeptides consumption in hospitals.

The aim of this study was to describe consumption of glycopeptides and to study factors associated with their use in 47 French hospitals. Consumption of glycopeptides for systemic use (defined daily doses per 1,000 patient-days: DDD/1,000 PD and per 100 admissions), number of methicillin-resistant Staphylococcus aureus (MRSA) (percentage and incidence per 1,000 patient-days), and number of venous central lines and hospital characteristics (size, length of stay, number of beds: total and for each hospital inpatient areas and antibiotic policies) were recorded from January, 2002, through December, 2002. Multiple linear regression was performed to check for hospital characteristics. The median rate of total consumption of glycopeptides was 4.11(range 0.21-27.22) DDD per 1,000 PD with higher consumption in large public hospitals and in intensive care areas (median 46.51; range 7.19-134) than in surgery areas (median 4.5; range 0.17-24.76). The consumption of glycopeptides correlated with MRSA incidence, but not with the proportion of MRSA. In the multivariate analysis, the incidence of MRSA and the number of beds in surgery areas were independent predictors of total glycopeptides use in the hospital, expressed in DDD per 1,000 PD (R2 adjusted, 0.39). The incidence of MRSA, the number of venous central lines, and the number of beds in the medicine areas were significant determinants associated with higher consumption of glycopeptides expressed in DDD per 100 admissions (R2 adjusted, 0.73). To reduce glycopeptides use in hospitals, the first effort required is that hospitals focus increased attention on the prevention of cross transmission for MRSA between patients but also on the use of the venous central line. Furthermore, hospitals have to compare their data with others to identify overuse of glycopeptides and to plan control interventions.