National surveillance pilot study unveils a multicenter, clonal outbreak of VIM-2-producing Pseudomonas aeruginosa ST111 in the Netherlands between 2015 and 2017.

Verona Integron-encoded Metallo-beta-lactamase (VIM) is the most frequently-encountered carbapenemase in the healthcare-related pathogen Pseudomonas aeruginosa. In the Netherlands, a low-endemic country for antibiotic-resistant bacteria, no national surveillance data on the prevalence of carbapenemase-producing P. aeruginosa (CPPA) was available. Therefore, in 2016, a national surveillance pilot study was initiated to investigate the occurrence, molecular epidemiology, genetic characterization, and resistomes of CPPA among P. aeruginosa isolates submitted by medical microbiology laboratories (MMLs) throughout the country. From 1221 isolates included in the study, 124 (10%) produced carbapenemase (CIM-positive); of these, the majority (95, 77%) were positive for the blaVIM gene using PCR. Sequencing was performed on 112 CIM-positive and 56 CIM-negative isolates (n = 168), and genetic clustering revealed that 75/168 (45%) isolates were highly similar. This genetic cluster, designated Group 1, comprised isolates that belonged to high-risk sequence type ST111/serotype O12, had similar resistomes, and all but two carried the blaVIM-2 allele on an identical class 1 integron. Additionally, Group 1 isolates originated from around the country (i.e. seven provinces) and from multiple MMLs. In conclusion, the Netherlands had experienced a nationwide, inter-institutional, clonal outbreak of VIM-2-producing P. aeruginosa for at least three years, which this pilot study was crucial in identifying. A structured, national surveillance program is strongly advised to monitor the spread of Group 1 CPPA, to identify emerging clones/carbapenemase genes, and to detect transmission in and especially between hospitals in order to control current and future outbreaks.

Mortality associated with carbapenem-susceptible and Verona Integron-encoded Metallo-ß-lactamase-positive Pseudomonas aeruginosa bacteremia.

BACKGROUND: Studies on various Gram-negative bacteria suggest that resistance to carbapenem antibiotics is responsible for increased mortality in patients; however, results are not conclusive. We first assessed the 28-day in-hospital all-cause mortality in patients with Verona Integron-encoded Metallo-ß-lactamase-positive Pseudomonas aeruginosa (VIM-PA) bacteremia compared to patients with VIM-negative, carbapenem-susceptible P. aeruginosa (CS-PA) bacteremia. Second, we identified determinants for mortality and survival. METHODS: All patients with a positive blood culture with VIM-PA or CS-PA between January 2004 and January 2016 were included. Kaplan-Meier survival curves were constructed, and survivors and non-survivors were compared on relevant clinical parameters using univariate analyses, and multivariable analyses using a Cox-proportional hazard model. RESULTS: In total, 249 patients were included, of which 58 (23.3%) died. Seventeen out of 40 (42.5%) patients with VIM-PA died, compared to 41 out of 209 (19.6%) patients with CS-PA (difference = 22.9%, P-value = 0.001). Assumed acquisition of the bacterium at the intensive care unit was significantly associated with mortality (HR = 3.32, 95%CI = 1.60-6.87), and having had adequate antibiotic therapy in days 1-14 after the positive blood culture was identified as a determinant for survival (HR = 0.03, 95%CI = 0.01-0.06). VIM-PA vs CS-PA was not identified as an independent risk factor for mortality. CONCLUSIONS: The crude mortality rate was significantly higher in patients with a VIM-PA bacteremia compared to patients with a CS-PA bacteremia; however, when analyzing the data in a multivariable model this difference was non-significant. Awareness of the presence of P. aeruginosa in the hospital environment that may be transmitted to patients and rapid microbiological diagnostics are essential for timely administration of appropriate antibiotics. Acquisition of P. aeruginosa should be prevented, independent of resistance profile.

Mortality related to Verona Integron-encoded Metallo-ß-lactamase-positive Pseudomonas aeruginosa: assessment by a novel clinical tool.

Background: Verona Integron-encoded Metallo-ß-lactamase-positive Pseudomonas aeruginosa (VIM-PA) can cause nosocomial infections and may be responsible for increased mortality. Multidrug resistance in VIM-PA complicates treatment. We aimed to assess the contribution of VIM-PA to mortality in patients in a large tertiary care hospital in the Netherlands. Methods: A focus group of five members created a scheme to define related mortality based on clinical and diagnostic findings. Contribution to mortality was categorized as "definitely", "probably", "possibly", or "not" related to infection with VIM-PA, or as "unknown". Patients were included when infected with or carrier of VIM-PA between January 2008 and January 2016. Patient-related data and specific data on VIM-PA cultures were retrieved from the electronic laboratory information system. For patients who died in our hospital, medical records were independently reviewed and thereafter discussed by three physicians. Results: A total of 198 patients with any positive culture with VIM-PA were identified, of whom 95 (48.0%) died. Sixty-seven patients died in our hospital and could be included in the analysis. The death of 15 patients (22.4%) was judged by all reviewers to be definitely related to infection with VIM-PA. In 17 additional patients (25.4%), death was probably or possibly related to an infection with VIM-PA. The level of agreement was 65.7% after the first evaluation, and 98.5% after one session of discussion. Conclusion: Using our assessment tool, infections with VIM-PA were shown to have an important influence on mortality in our complex and severely ill patients. The tool may be used for other (resistant) bacteria as well but this needs further exploration.

An unusual case of congestive heart failure in the Netherlands.

INTRODUCTION: Chagas disease is caused by infection with the protozoan Trypanosoma cruzi. It is endemic to the American continent due to the distribution of its insect vectors. The disease is occasionally imported to other continents by travel of infected individuals. It is rarely diagnosed in the Netherlands and exact numbers of infected individuals are unknown. Clinical manifestations can start with an acute phase of 4-8 weeks with non-specific, mild symptoms and febrile illness. In the chronic phase, it can lead to fatal cardiac and gastro-intestinal complications. CASE PRESENTATION: We describe a case of a 40-year-old man with end-stage cardiomyopathy due to Chagas disease. He lived in Surinam for more than 20 years and had an unremarkable medical history until he was hospitalized due to pneumonia and congestive heart failure. Despite antibiotic treatment and optimizing cardiac medication, his disease progressed to end-stage heart failure for which cardiac transplantation was the only remaining treatment. A left ventricular assist device (LVAD) was implanted as a bridge to transplantation. Tissue analysis after LVAD surgery revealed ongoing myocarditis caused by Chagas disease. Based on a literature review, a scheme for follow up and treatment after transplantation was postulated. CONCLUSION: Chagas disease should be taken into account in patients from endemic countries who have corresponding clinical signs. Heart transplantation in patients with Chagas cardiomyopathy is accompanied by specific challenges due to the required immunosuppressive therapy and the thereby increased risk of reactivation of a latent T. cruzi infection.

Program for laparoscopic urologic skills: a newly developed and validated educational program.

OBJECTIVE: To develop and evaluate a program for laparoscopic urologic skills (PLUS) to determine the face, content, and construct validation to achieve uniformity and standardization in training residents in urology. METHODS: The PLUS consists of 5 basic laparoscopic tasks. Three tasks were abstracted from the Fundamentals of Laparoscopic Surgery program, and 2 additional tasks were developed under continuous evaluation by expert urologists. Fifty participants were recruited from different hospitals and performed the final PLUS training. They all completed a questionnaire after performance. Three outcome parameters were measured: performance quality, time, and dropped objects. The relationship between laparoscopic experience and the outcome parameters was investigated. RESULTS: Of the 50 participants, 13 were students, 20 were residents, and 17 were urologists. Double-log linear regression analysis for all 5 tasks showed a significant effect (effect size range 0.53-0.82; P < .0005) for laparoscopic experience on performance time. Substantial correlations were found between experience and quality ratings (log-linear regression effect size 0.37; P = .012) and the number of dropped objects (Spearman correlation effect size 0.49; P < .01). The usefulness of the PLUS model as a training tool for basic laparoscopic skills was rated 4.55 on a scale from 1 (not useful) to 5 (useful) (standard deviation 0.58; range 3-5). CONCLUSION: The results of the present study indicated the face, content, and construct validity for the PLUS. The training is considered appropriate for use as a primary training tool for an entry test or as part of a step-wise training program in which basic and procedural laparoscopic skills are integrated.

Effect of distraction on the performance of endourological tasks: a randomized controlled trial.

OBJECTIVE: • To establish the effect of distraction on the performance of cystoscopy and basic endourological tasks by using a virtual reality (VR) simulator. SUBJECTS AND METHODS: • A total of 86 third-year medical students from Maastricht University, who had no previous experience in performing the tasks on a VR simulator, were randomly assigned to an intervention or control group. • All participants performed three endourological tasks on the VR simulator. Participants in the intervention group were distracted 1 min into the third task. The distraction consisted of being asked to answer questions about a medical case that had been presented to all the participants before the hands-on session. After two adequate verbal responses the conversation was terminated. • Number of traumata, number of missed lesions in the bladder and time to completion were measured by the VR simulator. RESULTS: • Number of traumata and missed lesions, as well as time to completion were significantly higher in the intervention than in the control group with effect sizes (using Cohen's categorization) of 0.48, 0.41 and 0.50 respectively. • Nevertheless, only 9.5% of the participants in the intervention group reported feeling burdened by the distraction. CONCLUSIONS: • Distraction during the performance of endourological skills results in significantly poorer performance by medical students on all the variables measured in a controlled learning environment. • Most students do not realize they are affected by distraction. • Further research is needed to determine the impact of distraction on more experienced participants and on patient safety.

The effect of distractions in the operating room during endourological procedures.

BACKGROUND: Professionals working in the operating room (OR) are subject to various distractions that can be detrimental to their task performance and the quality of their work. This study aimed to quantify the frequency, nature, and effect on performance of (potentially) distracting events occurring during endourological procedures and additionally explored urologists' and residents' perspectives on experienced ill effects due to distracting factors. METHODS: First, observational data were collected prospectively during endourological procedures in one OR of a teaching hospital. A seven-point ordinal scale was used to measure the level of observed interference with the main task of the surgical team. Second, semistructured interviews were conducted with eight urologists and seven urology residents in two hospitals to obtain their perspectives on the impact of distracting factors. RESULTS: Seventy-eight procedures were observed. A median of 20 distracting events occurred per procedure, which corresponds to an overall rate of one distracting event every 1.8 min. Equipment problems and procedure-related and medically irrelevant communication were the most frequently observed causes of interruptions and identified as the most distracting factors in the interviews. Occurrence of distracting factors in difficult situations requiring high levels of concentration was perceived by all interviewees as disturbing and negatively impacting performance. The majority of interviewees (13/15) thought distracting factors impacted more strongly on residents' compared to urologists' performance due to their different levels of experience. CONCLUSION: Distracting events occur frequently in the OR. Equipment problems and communication, the latter both procedure-related and medically irrelevant, have the largest impact on the sterile team and regularly interrupt procedures. Distracting stimuli can influence performance negatively and should therefore be minimized. Further research is required to determine the direct effect of distraction on patient safety.

Analysis of pitfalls encountered by residents in transurethral procedures in master-apprentice type of training.

BACKGROUND AND PURPOSE: Today's simulators are frequently limited in their possibilities to train all aspects of endourological procedures. It is therefore indicated to first make an inventory of training needs before (re)developing simulators. This study examined pitfalls encountered by residents in real-time transurethral procedures. MATERIALS AND METHODS: First, difficulties that residents encounter in transurethral procedures (transurethral resection of the bladder tumor [TURBT], transurethral resection of the prostate [TURP], ureterorenoscopy [URS]) were identified by asking urologists and residents to complete an open questionnaire. Based on their answers a list of pitfalls was designed and tested in 28 pilot observations. Then, two raters (interrater agreement 0.72, 0.70, and 0.75 for TURBT, TURP, and URS, respectively) categorized all observed procedure-related interactions between residents and supervisors in 80 procedures as (1) (type of ) pitfall or (2) no pitfall. RESULTS: Pitfalls most frequently encountered were as follows: (1) planning/anticipation on new situations (median 27.3%, 29.3%, and 31.8% of total pitfalls in TURBT, TURP, and URS, respectively); (2) handling of instruments (11.5%, 10.6%, and 20.0% for TURBT, TURP, and URS); (3) irrigation management for TURBT (7.7%), depth of resection for TURP (8.9%), and use of X-ray for URS (13.3%). CONCLUSION: Designers of endourological simulators should include possibilities to train planning/anticipation on new situations, handling of instruments in all transurethral procedures, and irrigation management in TURBT, depth of resection in TURP, and timing usage of X-ray in URS.

The effect of a low-fidelity model on cystoscopic skill training: a single-blinded randomized controlled trial.

INTRODUCTION: Models for training urological procedures without burdening patients are available at varying costs. We examined the value of training on a low-fidelity model in addition to training on a high-fidelity simulator in a cystoscopy training program. METHODS: Thirty-two medical students were randomized to an intervention and a control group. The former started by performing cystoscopy on a low-cost, low-fidelity, glass globe model before moving on to training on the URO Mentor (UM), a computerized simulator. The control group took part in the same UM training program but not in the low-fidelity training. Performance on UM was assessed by a global rating score, percentage of correctly inspected areas of the bladder (% inspected areas), time, and number of traumas caused. RESULTS: The intervention group had generally higher scores. Its global rating score on task 1 was significantly higher than that of the control group (Mann-Whitney U test, P = 0.046, effect size 0.6) and the group also scored higher, albeit not significantly, on time and % inspected areas. All students said they valued training with UM, but the appreciation of the intervention group was stronger (mean 8.9 vs. 8.1 on a scale from 1 to 10, P = 0.017, effect size 1.8). CONCLUSION: A low-fidelity glass globe model seemed to be an inexpensive educational tool to practice the first steps of cystoscopy. It may reduce training time on the UM simulator. The combined use of a low- and high-fidelity training model may provide an optimal learning effect.

A simulator for teaching transrectal ultrasound procedures: how useful and realistic is it?

INTRODUCTION: : We describe a new simulator for teaching transrectal ultrasound (TRUS) and present the results of a preliminary evaluation of the simulator's realism and usefulness for training. METHODS: : A simulator for abdominal ultrasound was adjusted by the developer to enable simulation of TRUS by providing an opening for inserting a dummy rectal probe. To enable TRUS simulation, data from ultrasound prostate imaging of eight real patients obtained with our regular ultrasound machine were transferred to the simulator by connecting the computer of the simulator to the ultrasound machine. These data were used to create images in the TRUS simulator. Residents and urologists used the simulator to perform TRUS in one of the eight patient cases and judged the simulator's realism and usefulness. RESULTS: : We were able to construct an initial urological module for the TRUS simulator. The images shown on the monitor of the simulator are quite realistic. The simulator can be used without difficulty to collect data, to create cases, and to perform TRUS. The absence of an option for prostate biopsy and the lack of tissue resistance were mentioned as two important shortcomings. Forty-seven participants rated the simulator's overall realism and usefulness for training purposes as 3.8 (standard deviation: 0.7) and 4.0 (standard deviation: 0.8) on a five-point Likert scale, respectively. CONCLUSIONS: : The simulator we describe can be used as a training tool for TRUS. It enables training with different patient cases and minimizes the burden to patients. Simulation of prostate biopsies should be added to increase the model's usefulness.