Sustained improvement in hand hygiene compliance using a multi-modal improvement programme at a Swiss multi-site regional hospital.

BACKGROUND: Evidence of sustained improvement in hand hygiene compliance at the institutional level is scarce. AIM: To assess the impact and sustainability of a hospital-wide improvement programme on hand hygiene compliance of staff. METHODS: Analysis of trends of hand hygiene compliance for all clinical staff, measured through direct observation by trained observers, within a 450-bed multi-centre teaching hospital in the county of Neuchâtel, Switzerland. INTERVENTION: Implementation of a multi-modal improvement programme based on the World Health Organization (WHO) strategy, with the goal of reaching overall compliance of at least 80%. The strategy content included increasing access to alcohol hand rub; healthcare worker education; two-month interval compliance measurement; and hospital-wide open communication about ward-level results, point-of-care reminders, communication via a dedicated in-house newsletter and leadership engagement. The implementation phase was followed by a consolidation phase. FINDINGS: In total, 33,476 observations were collected from September 2012 to March 2014 (mean >3000 opportunities per audit). Overall compliance improved from 61.4% at baseline to 83.6% after the 18-month improvement programme (P<0.001), and was sustained at 85.3% 18 months later (i.e. 18 months after the programme finished) (P=0.08). The same trend (significant and clinically relevant improvement during the intervention, sustained after 18 months) was measured for all professional categories. CONCLUSIONS: This WHO-inspired improvement programme was associated with a significant improvement in hand hygiene compliance, globally and for each professional category. The results were sustained over an 18-month period.

Outbreak of human listeriosis associated with tomme cheese in northwest Switzerland, 2005.

During an eight week period in spring 2005, 10 cases of listeriosis were reported in a small area of northwest Switzerland (150,000 inhabitants). Eight cases were in older immunocompromised patients who became ill with bacteraemia (three deaths), and two cases were in pregnant women who had septic abortion. All cases were due to a serotype 1/2a isolate with one of two pulsovars found by PFGE. Patient interviews quickly revealed that a locally made and distributed soft cheese (known as 'tomme') was the food source responsible for the outbreak. Samples of this cheese, and of butter made in the same factory, revealed Listeria monocytogenes sv 1/2a of the same pulsovar in amounts of 1000-10 000 and 10-100 cfu/g, respectively. The prompt suspension of production, the market recall of the product, and a public alert terminated the outbreak. However, two cases of febrile gastroenteritis due to the same strains were reported within 10 days of product recall. The restricted distribution area of the contaminated cheese and the collaboration of local physicians, medical microbiologists and food health services all contributed to a rapid and successful investigation. This small outbreak of listeriosis reinforces the need for a laboratory-based surveillance system with rapid typing, as well as collaboration between physicians and microbiologists.

[Infectious disease]. / Maladies infectieuses.

Several articles published in 2005 offer new knowledge in infectious diseases treated by practitioners. This paper discusses viral (influenza) and bacterial (pneumococci and legionella) respiratory infections. Resistant staphylococci, different from healthcare-associated MRSA, are now found in community. The article assesses that epidemics of Norovirus infections are common during winter time. The screening for treatment of asymptomatic bacteriuria is not recommended. The possible development of a successful vaccine to prevent herpes zoster is finally reminded.

Outbreak of human listeriosis associated with tomme cheese in northwest Switzerland, 2005.

During an eight week period in spring 2005, 10 cases of listeriosis were reported in a small area of northwest Switzerland (150 000 inhabitants). Eight cases were in older immunocompromised patients who became ill with bacteraemia (three deaths), and two cases were in pregnant women who had septic abortion.

Pyosalpinx: not always a sexual transmitted disease? Pyosalpinx caused by Plesiomonas shigelloides in an immunocompetent host.

Plesiomonas shigelloides are ubiquitous Gram-negative bacteria that are found in fresh or marine water, particularly in tropical or warm climates; they were recently implicated in diarrhoeal disease. Patients usually present with a history of recent travel to tropical regions or consumption of uncooked seafood. Extraintestinal disease has rarely been reported, occurring generally in neonates or immunocompromised patients, and is often fatal. We report a case of right pyosalpinx due to P. shigelloides acquired by swimming in contaminated water. Laparoscopic salpingectomy led to a good outcome.

Community-acquired pneumonia. A prospective outpatient study.

We initiated a prospective study with a group of practitioners to assess the etiology, clinical presentation, and outcome of community-acquired pneumonia in patients diagnosed in the outpatient setting. All patients with signs and symptoms suggestive of pneumonia and an infiltrate on chest X-ray underwent an extensive standard workup and were followed over 4 weeks. Over a 4-year period, 184 patients were eligible, of whom 170 (age range, 15-96 yr; median, 43 yr) were included and analyzed. In 78 (46%), no etiologic agent could be demonstrated. In the remaining 92 patients, 107 etiologic agents were implicated: 43 were due to "pyogenic" bacteria (39 Streptococcus pneumoniae, 3 Haemophilus spp., 1 Streptococcus spp.), 39 were due to "atypical" bacteria (24 Mycoplasma pneumoniae, 9 Chlamydia pneumoniae, 4 Coxiella burnetii, 2 Legionella spp.), and 25 were due to viruses (20 influenza viruses and 5 other respiratory viruses). There were only a few statistically significant clinical differences between the different etiologic categories (higher age and comorbidities in viral or in episodes of undetermined etiology, higher neutrophil counts in "pyogenic" episodes, more frequent bilateral and interstitial infiltrates in viral episodes). There were 2 deaths, both in patients with advanced age (83 and 86 years old), and several comorbidities. Only 14 patients (8.2%) required hospitalization. In 6 patients (3.4%), the pneumonia episode uncovered a local neoplasia. This study shows that most cases of community-acquired pneumonia have a favorable outcome and can be successfully managed in an outpatient setting. Moreover, in the absence of rapid and reliable clinical or laboratory tests to establish a definite etiologic diagnosis at presentation, the spectrum of the etiologic agents suggest that initial antibiotic therapy should cover both S. pneumoniae and atypical bacteria, as well as possible influenza viruses during the epidemic season.

[Is there a role for infectious disease specialists in private practice?]. / Un rôle pour l'infectiologue en pratique privée?

For the last 20 years infectious diseases have gained increasing importance for hospital medicine. As a specialty, infectious diseases have been recognized only recently by the Swiss medical association. However, the precise role of infectious disease specialist operating in private practice remain to be defined. The medical community faces many challenges for which infectious disease specialist must provide answers. Knowledge in microbiology has progressed enormously and many very sophisticated and, partly, expensive diagnostic techniques are widely available. New treatment options are introduced while numerous microbial species demonstrate increasing resistance to antimicrobial agents. The intervention of infectious disease specialist could thus contribute to optimize treatment and limit the use of economic resources. Infectious disease specialist in private practice are also facing new activities such as parenteral outpatient treatment for severe infections and HIV infection, which clearly require a specialized professional approach. Infectious disease specialist in private practice will need great care to find a responsible equilibrium between clinical consultation and telephone consultation.

[Risk taking users of an anonymous HIV screening center: trying to understand the psychodynamics]. / Prise de risques des usagers d'un centre de dépistage anonyme du VIH: essai de compréhension psychodynamique.

This article shows the importance of the part of the unconscious, which has been under-estimated till now when users of a VIH anonymous depistage center are taking risks. Considering some clinical situations, we can underline the limits of the prevention campaigns, which can only be directed at groups and not at individuals. Most of the users have a good idea of the protection tools recommended through the preventive campaigns; the authors also describe the negative attitudes that therapeutist can feel towards persons who are seeking sexual satisfaction in risk behaviours.

[HIV infection and splenectomy: 3 cases and literature review]. / Infection VIH et splénectomie: trois cas et revue de la littérature.

3 splenectomized patients infected by the human immunodeficiency virus (HIV) are described. They all presented with more than 500 CD4/mm3 but, surprisingly, with a CD4 percentage below 15, positive p24 antigenemia and a CD4/CD8 ratio below 0.24. 2 patients had repeated episodes of oropharyngeal candidiasis while their CD4 counts exceeded 800/mm3. These episodes suggested the presence of a certain degree of immuno-suppression and prompted us to introduce anti-HIV therapy. 2 patients also presented with a pulmonary infection, due to Klebsiella pneumoniae and Haemophilus influenzae respectively. The third patient had septicemia due to Streptococcus pneumoniae type 22, despite vaccination and a CD4 count above 700/mm3. In splenectomized HIV-infected patients the number of CD4 lymphocytes should be interpreted with caution, as this number increases after splenectomy. The CD4 percentage and CD4/CD8 ratio correlated better with the clinical stage of HIV infection and gave more valuable indications as to the degree of immunosuppression. A possible correlation between viremia and the number of CD4 lymphocytes in this subset of patients remains to be established. In HIV-infected patients, infections due to S. pneumoniae, H. influenzae, S. aureus and enteric gram-negative bacteria are frequent. After splenectomy, susceptibility to encapsulated bacteria increases even in HIV-negative patients. Early vaccination against the main strains of S. pneumoniae is essential, as vaccinal response is uncertain in patients with less than 400 CD4/mm3.

[Extrapulmonary tuberculosis: 2 cases with hepatic, splenic, peritoneal and cerebral involvement]. / Tuberculose extrapulmonaire: deux cas avec atteintes hépatiques, spléniques, péritonéales et cérébrales.

Two cases of unusual extrapulmonary tuberculosis are presented. One patient was suffering of a pulmonary tuberculosis involving the brain, liver, spleen and peritoneum, with headaches, ascites, weight loss and night sweats. The other patient had lymph nodes and nodular liver tuberculosis and complained of fever, right upper quadrant pain, anorexia and weight loss. This tuberculosis form is extremely rare; only 23 cases were reported between 1950 and 1990. Furthermore, a drug-induced hepatitis developed in a liver already damaged by the tuberculosis and a chronic active C hepatitis. These two cases remind us that the diagnosis of extrapulmonary tuberculosis may be extremely difficult. It must be suspected mostly in patients that are immuno-depressed or whose origins are not caucasian. Other diagnoses are often wrongly suggested, such as tumors, inflammatory diseases or other infectious diseases. As a result, the correct diagnosis or other infectious diseases. As a result, the correct diagnosis is often delayed. If cultures are negative and the chest roentgenogram is normal, procedures such as transbronchial, liver, bone marrow or lymph node biopsies may help to properly identify the disease.

Human endometrial maturation is markedly improved after luteal supplementation of gonadotrophin-releasing hormone analogue/human menopausal gonadotrophin stimulated cycles.

In human cycles stimulated for ovulation with gonadotrophin-releasing hormone (GnRH) agonists and human menopausal gonadotrophin (HMG), a luteal phase defect has been described. To evaluate the influence on the endometrium, endometrial development in GnRH agonist/HMG stimulated cycles was assessed in cycles with and without luteal phase supplementation. Endometrial histological maturation, ultrastructure and oestrogen receptor (ER) and progesterone receptor (PR) status were analysed in the mid-luteal phase. Serum concentrations of oestradiol and progesterone were measured daily from days 1-5 of the luteal phase. Supplementation of the luteal phase was achieved with either human chorionic gonadotrophin or natural progesterone, administered intramuscularly or intravaginally. In non-supplemented cycles all endometrial features were consistent with an impaired progesterone bioavailability. After supplementation of the luteal phase, fewer signs of luteal phase deficiency were visible, especially with the intravaginal route of progesterone administration. We concluded that the endometrial parameters confirm the need for luteal support in GnRH agonist/HMG stimulated cycles.

[Neurological manifestations of Lyme disease]. / Les manifestations neurologiques de la maladie de Lyme.

Lyme's disease, transmitted by Borrelia Burgdorferi (BB), is a polymorphic and multisystemic illness. Its neurological manifestations are encountered in 10-50% of cases and occur in the acute disseminated stage as well as in the late stage. This article initially reviews the principal clinical pictures of the neuroborreliosis and distinguishes them from neurological disorders whose association with BB infection is not proven. The paper then discusses the relative usefulness of the different ancillary tests in the diagnostic workup. We hope to stimulate interest in the research of intrathecal specific antibody production (especially in the early central nervous system diseases), instead of measuring levels of anti-BB antibodies in the serum and in the cerebrospinal fluid. Finally, a treatment plan is proposed, whose efficiency constitutes another argument in favor of the correct diagnosis but whose failure may reflect a diagnostic error.

[Importance of infectious diseases and role of the infection specialist in a non-university hospital]. / Importance des maladies infectieuses et rôle de l'infectiologue dans un hôpital non universitaire.

More than 3000 infectious diseases treated in the past 10 years at the Department of Medicine of the Cadolles Hospital in Neuchâtel (Switzerland) have been gathered from a computer data base. The infectious disease specialist is directly involved in the diagnosis and treatment of the most severe or rare affections. However, he influences in a more general fashion the management of anti-infectious treatments by directing the treatment plan and helping to choose the proper antibiotics. He also is responsible for the prevention of nosocomial infections. The role and function of the infectious disease specialist as well as the importance of this specialty in a community hospital are discussed.

Comparison of two local anaesthetics in transvaginal ultrasound-guided oocyte retrieval.

Transvaginal ultrasound-guided oocyte retrieval is an accepted procedure in most in-vitro fertilization programmes. In order to simplify the anaesthetic procedure into a minimally invasive one, we perform the oocyte retrieval under a modified para-cervical block combined with a standard pre-medication. In order to maximize the patient's comfort we evaluated two different local anaesthetics and their side-effects. Patients were allocated at random to receive a modified para-cervical block with mepivacaine 1% (n = 46) or with prilocaine 1% (n = 54). The patients were asked to fill in a visual analogue scale (VAS) including assessment of anxiety, pain and comfort concerning the procedure. The two local anaesthetics were both effective in reducing pain during transvaginal oocyte retrieval. The mean VAS scores were acceptable and were efficient as indicators of patient's comfort during the procedure. Mepivacaine was selected for routine use since prilocaine induced methaemoglobinaemia.

Pituitary gonadotrophin secretory capacity during the luteal phase in superovulation using GnRH-agonists and HMG in a desensitization or flare-up protocol.

Pituitary gonadotrophin reserve and basal gonadotrophin secretion were tested during the luteal phase in women superovulated with buserelin/human menopausal gonadotrophin (HMG) in a desensitization (n = 17) or flare-up protocol (n = 7). In the desensitization protocol the luteinizing hormone-releasing hormone (LHRH) stimulated serum LH and follicle stimulating hormone (FSH) concentrations remained impaired at least until day 14 after arrest of the agonist. In the flare-up protocol basal and stimulated LH secretion was still abnormal on days 14 and 15 after human chorionic gonadotrophin (HCG) injection. Normal basal serum FSH concentrations were measured at the end of the luteal phase in the flare-up protocol, but the response of FSH to LHRH injection was still subnormal. We conclude that gonadotrophin function remained impaired until the end of the luteal phase after desensitization and flare-up GnRH-agonist and HMG stimulation protocols. Corpus luteum stimulation with exogenous HCG or substitution therapy using natural progesterone are required to prevent the possible negative effects resulting from pituitary dysfunction after GnRH-agonist treatment.

Incidence of severe ovarian hyperstimulation syndrome after GnRH agonist/HMG superovulation for in-vitro fertilization.

In 1673 treatment cycles stimulated with buserelin and HMG, for IVF, GIFT or ZIFT, the severe ovarian hyperstimulation syndrome (OHSS) occurred in 10 cycles (0.6%). Eight patients were hyperandrogenic and showed an increased ovarian response to HMG. After replacement of a maximum of three embryos or zygotes, seven women became pregnant. Three women had a multiple gestation. All patients recovered uneventfully with conservative treatment. Support with progesterone or continuation of the agonist during the luteal phase did not prevent OHSS, confirming that the ovulatory HCG dose is the most important factor in inducing this severe complication. Luteal supplementation with HCG and/or HCG production during implantation could exacerbate OHSS.