Under Armour - Use of personal protective equipment for simulated CPR of COVID-19 patients: an observational study.

BACKGROUND: Personal protective equipment (PPE) protects healthcare workers and patients. Data on guideline compliance on how to dress (donning) or remove (doffing) PPE and the assistance among multiple participants (buddying) are limited. This study assesses the quality of donning, doffing, and buddying of PPE in a simulated medical emergency. METHOD: Physicians handling a simulated cardiac arrest of a COVID-19 patient. Adjacent to the victim, PPE was available. The appropriateness of PPE choice was assessed by using video recordings, with each individual participant being analyzed from the beginning of the simulation scenario from two perspectives regarding the selection of items during donning and doffing, hygiene aspects, time, and team support (buddying). The primary outcome was the number of participants being appropriately protected, defined as both wearing (a) all PPE items provided, and (b) all PPE items correctly at the time of first patient contact (FPC). Secondary outcomes included the timing of participants being appropriately protected. Statistical analysis was performed using SPSS (version 28). Mann-Whitney test, chi-square test, and linear regression analysis were performed as appropriate. RESULTS: At first patient contact 21% (91/437) were correctly protected. One or more incorrect PPE items were found in 4% (19/437), whereas 61% (265/437) wore one or more PPE items incorrectly. In 14% (62/437), one or more PPE items were missing. The time interval between donning start and FPC was 66 (55-78) sec. Time to FPC was longer in correctly than in incorrectly protected participants 77 (66-87) vs. 64 (54-75) sec; p < 0.001) and decreased by 7 ± 2 s per PPE item omitted (P = 0.002). Correct doffing was observed in 192/345 (56%), while buddying occurred in 120 participants (27%), indicating that they either assisted other participants in some manner (verbally or physically) or received assistance themselves. CONCLUSIONS: Our findings imply a need for education in correct and timely PPE donning and doffing. Donning PPE as intended delayed FPC. This and the influence of buddying needs further investigation (German study register number DRKS00023184).

D-dimer levels for Risk Stratification in Patients with Suspected COVID-19 - A Prospective Observational Study.

BACKGROUND: Elevated D-dimer levels have been observed in COVID-19 and are of prognostic value, but have not been compared to an appropriate control group. METHODS: Observational cohort study including emergency patients with suspected or confirmed COVID-19. Logistic regression defined the association of D-dimer levels, COVID-19 positivity, age, and gender with 30-day-mortality. RESULTS: 953 consecutive patients (median age 58, 43% women) presented with suspected COVID-19: 12 (7.4%) patients with confirmed SARS-CoV-2-infection died, compared with 28 (3.5%) patients without SARS-CoV-2-infection. Overall, most (56%) patients had elevated D-dimer levels (≥0.5mg/l). Age (OR 1.07, CI 1.05-1.10), D-dimer levels ≥0.5mg/l (OR 2.44, CI 0.98-7.39), and COVID-19 (OR 2.79, CI 1.28-5.80) were associated with 30-day-mortality. CONCLUSION: D-dimer levels are effective prognosticators in both patient groups.

Impact of an infection control service in a university psychiatric hospital: significantly lowering healthcare-associated infections during 18 years of surveillance.

BACKGROUND: Healthcare-associated infections (HAIs) lead to high morbidity and mortality. Data for HAIs in psychiatric hospitals are scarce, and are not derived from long-term surveillance. AIM: To assess the impact of an infection control service on the prevalence of HAIs in a psychiatric hospital over an 18-year period. METHODS: In 1999, a professional infection control service was initiated at the University Psychiatric Hospital in Basel, Switzerland, with a part-time infection control nurse, a hospital epidemiologist, and administrative support. In addition to monitoring rates of multi-drug-resistant pathogens, eight prevalence studies using definitions outlined by the Centers for Disease Control and Prevention (CDC) were conducted between 2001 and 2018. For the primary outcome, a Poisson regression model was fitted to confirm cases of HAIs, standardized for patients at risk as a model offset. FINDINGS: Overall, the predicted prevalence of nosocomial infections decreased from 3.7% (95% confidence interval (CI) 2.2-5.3%) in 2001 to 1.0% (95% CI 0.2-1.8%) in 2018 after introduction of an infection control service (incidence ratio rate (IRR) for yearly decrease of 0.93, 95% CI 0.87-0.98, P=0.007). CONCLUSIONS: Implementation of an infection control service may lead to a significant long-term decrease in HAIs, even in an institution caring for patients with low risk for HAIs, such as in psychiatric hospitals. In addition, epidemics and clusters were rapidly contained. Infection control services from acute-care hospitals should be expanded to psychiatric institutions, in order to decrease the incidence of HAIs and meet new challenges in times of emergence of multi-drug-resistant pathogens.

[Breast pain and fever in a 46-year-old immunosuppressed patient with breast implants]. / Schmerzen im Bereich der Mamma und Fieber bei einer 46­Jährigen mit Immunsuppression und Mammaaugmentation.

A 46-year-old immunosuppressed patient presented with a breast implant-associated infection 10 years after breast augmentation in Southeast Asia. No pathogen was identified in the initial conventional microbiological workup. Subsequently, infection with Mycobacterium abscessus-a nontuberculous mycobacteria-was diagnosed using a special culture technique. Increased rates of such infections are reported after cosmetic surgery in foreign countries, presumably due to inoculation with these ubiquitous pathogens. This case highlights the fact that the differential diagnosis and thus the microbiological workup should be extended in cases without initial pathogen detection.

Time-dependent differences in management and microbiology of orthopaedic internal fixation-associated infections: an observational prospective study with 229 patients.

OBJECTIVES: Little information has been published on orthopaedic internal fixation-associated infections. We aimed to analyse time-dependent microbiology, treatment, and outcome. METHODS: Over a 10-year period, all consecutive patients with internal fixation-associated infections at the University Hospital of Basel, were prospectively followed and clinical, microbiological and outcome data were acquired. Infections were classified as early (0-2 weeks after implantation), delayed (3-10 weeks), and late (>10 weeks). RESULTS: Two hundred and twenty-nine patients were included, with a median follow-up of 773 days (IQR 334-1400). Staphylococcus aureus was the most prevalent pathogen (in 96/229 patients, 41.9%). Enterobacteriaceae were frequent in early infections (13/49, 26.5%), whereas coagulase-negative staphylococci (36/92, 39.1%), anaerobes (15/92, 16.3%) and streptococci (10/92, 10.9%) increased in late revisions. Failure was observed in 27/229 (11.7%). Implants were retained in 42/49 (85.7%) in early, in 51/88 (57.9%) in delayed, and in 9/92 (9.8%) in late revisions (p < 0.01). Early revisions failed in 6/49 (12.2%), delayed in 9/88 (10.2%), and late in 11/92 (13.0%) (p 0.81). Debridement and retention failed in 6/42 (14.3%) for early, in 6/51 (11.8%) for delayed, and in 3/9 (33.3%) for late revisions (p 0.21). Biofilm-active antibiotic therapy tailored to resistance correlated with improved outcome for late revisions failure (6/72, 7.7% versus 6/12, 50.0%; p < 0.01) but not for early revisions failure (5/38, 13.2% versus 1/11, 9.1%; p 1.0). CONCLUSIONS: Treatment of internal fixation-associated infections showed a high success rate of 87-90% over all time periods. Implant retention was highly successful in early and delayed infections but only limited in late infections.

Overall bioburden by total colony count does not predict the presence of pathogens with high clinical relevance in hospital and community environments.

BACKGROUND: Healthcare-associated infections (HAIs) affect millions of patients, increasing morbidity and mortality. Pathogens of HAIs originate from both the patient's own flora and the environment, including multi-drug-resistant organisms. AIMS: To determine the bioburden on different types of high-touch surfaces, and to identify cultures to species level and stratify strains into those of low and high clinical relevance. DESIGN: Association between bioburden and presence of pathogens of high clinical relevance (PHCR) in a tertiary care centre and urban environment. METHODS: The overall bioburden measured by total colony count (TCC) was assessed using tryptic soy agar contact plates and two selective agars to improve detection of PHCR. Isolates were routinely identified to species level using matrix-assisted laser desorption/ionization - time of flight mass spectrometry (MALDI-TOF). The definition of PHCR was based on listings outlined by the Centers for Disease Control and Prevention. FINDINGS: In total, 1431 contact plates were processed from 477 surfaces: 153 from hospitals and 324 from publicly accessible institutions or devices. At least one PHCR was identified from cultures from 73 samples. TCC was found to be poorly correlated with the presence of PHCR. CONCLUSION: TCC poorly predicted the presence of PHCR, rendering the results from environmental sampling difficult to interpret. MALDI-TOF enables the identification of large numbers of isolates from the environment at low cost. Further studies on environmental contamination should use MALDI-TOF to identify all pathogens grown.

Guidance document for prevention of Clostridium difficile infection in acute healthcare settings.

SCOPE: Clostridium difficile infection (CDI) is the most important infective cause of healthcare-associated diarrhoea in high income countries and one of the most important healthcare-associated pathogens in both Europe and the United States. It is associated with high morbidity and mortality resulting in both societal and financial burden. A significant proportion of this burden is potentially preventable by a combination of targeted infection prevention and control measures and antimicrobial stewardship. The aim of this guidance document is to provide an update on recommendations for prevention of CDI in acute care settings to provide guidance to those responsible for institutional infection prevention and control programmes. METHODS: An expert group was set up by the European society of clinical microbiology and infectious diseases (ESCMID) Study Group for C. difficile (ESGCD), which performed a systematic review of the literature on prevention of CDI in adults hospitalized in acute care settings and derived respective recommendations according to the GRADE approach. Recommendations are stratified for both outbreak and endemic settings. QUESTIONS ADDRESSED BY THE GUIDELINE AND RECOMMENDATIONS: This guidance document provides thirty-six statements on strategies to prevent CDI in acute care settings, including 18 strong recommendations. No recommendation was provided for three questions.

New insights into transmission of Clostridium difficile infection-narrative review.

BACKGROUND: Traditionally, Clostridium difficile has been considered a typical healthcare-associated pathogen-that is, one transmitted within healthcare facilities and thus prevented by implementation of standard infection control measures. Recently this concept has been challenged by studies suggesting a relevant role for community acquisition of C. difficile. AIMS: To discusses the current literature, compiled during the last decade, reporting on sources of acquisition of C. difficile and subsequent transmission. SOURCES: The databases PubMed, Medline, Embase and the Cochrane Database were searched for articles published from 1 January 2007 to 30 June 2017 reporting on possible transmission pathways of C. difficile and/or suggesting a source of acquisition of C. difficile. All study types reporting on adult populations were considered; case reports and series were excluded. The PRISMA guidelines for the reporting of systematic reviews were followed. CONTENT: Among 24 original articles included, 63% report on transmission of C. difficile in healthcare settings and 37% investigate sources and transmission of C. difficile in the community. Contact with symptomatic carriers (53.3%), the hospital environment (40.0%) and asymptomatic carriers (20%) were the most commonly reported transmission pathways within healthcare settings. The leading sources for acquisition of C. difficile in the community include direct contact with symptomatic and asymptomatic carriers in the community, including infants (30%) and residents of long-term non-acute care facilities (30%), followed by contact with contaminated environments in outpatient care settings (20%) and exposure to livestock or livestock farms (20%). IMPLICATIONS: In healthcare settings, future control efforts may need to focus on extending cleaning and disinfection procedures beyond the immediate surroundings of symptomatic carriers. Potential targets to prevent acquisition of C. difficile in the community include household settings, long-term care facilities and outpatient settings, while the role of livestock in entertaining transmission requires further investigation.

Secular trends of bloodstream infections during neutropenia in 15 181 haematopoietic stem cell transplants: 13-year results from a European multicentre surveillance study (ONKO-KISS).

OBJECTIVES: Antibacterial resistance is emerging in patients undergoing haematopoietic stem cell transplantation (HSCT), and most data on the epidemiology of bloodstream infections (BSI)-causing pathogens come from retrospective single-centre studies. This study sought to investigate trends in the epidemiology of BSI in HSCT patients from a prospective multicentre cohort. METHODS: We investigated changes in the incidence of causative organisms of BSI during neutropenia among adult HSCT patients for 2002-2014. The data were collected from a prospective cohort for infection surveillance in 20 haematologic cancer centres in Germany, Austria and Switzerland (ONKO-KISS). RESULTS: A total of 2388 of 15 181 HSCT patients with neutropenia (1471 allogeneic (61.6%) and 917 autologous (38.4%) HSCT) developed BSI (incidence 15.8% per year). The incidence of Gram-negative BSI increased over time both in patients after allogeneic HSCT (allo-HSCT) and autologous HSCT (auto-HSCT). BSI caused by Escherichia coli in allo-HSCT patients increased from 1.1% in 2002 to 3.8% in 2014 (3/279 vs. 31/810 patients, p <0.001), and the incidence of BSI caused by enterococci increased from 1.8% to 3.3% (5 vs. 27 patients, p <0.001). In contrast, the incidence of BSI due to coagulase-negative staphylococci decreased in allo-HSCT patients from 8.2% to 5.1%, (23 vs. 40 patients, p <0.001) and in auto-HSCT patients from 7.7% to 2.0% (13/167 vs. 30/540 patients; p = 0.028 for period 2002-2011). No significant trends were observed for the incidence of BSI due to methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci or extended-spectrum ß-lactamase-producing Enterobacteriaceae. The BSI case fatality remained unchanged over the study period (total of 477 fatalities, 3.1%). CONCLUSIONS: The incidence of Gram-negative BSI significantly increased over time in this vulnerable patient population, providing evidence for reevaluating empiric therapy for neutropenic fever in HSCT patients.

Simplifying the WHO 'how to hand rub' technique: three steps are as effective as six-results from an experimental randomized crossover trial.

OBJECTIVES: The World Health Organization (WHO) issued guidelines on hand hygiene recommending a six-step 'how to hand rub' technique for applying alcohol-based hand rub. However, adherence to all six steps is poor. We assessed a simplified three-step technique and compared it to the conventional WHO six-step technique in terms of bacterial count reduction on healthcare workers' hands. METHODS: Thirty-two participants were randomly assigned to clean their hands following the six-step 'how to hand rub' technique (WHO reference group) or a simplified three-step technique (intervention group). Assignments were reversed after 1 day. The degree of bacterial killing was assessed following the European norm for testing hand hygiene products. Hands were contaminated with Escherichia coli, and the mean logarithmic reduction in bacterial counts was compared between both techniques. RESULTS: Bacterial density before hand hygiene performance did not differ between the WHO reference group (median 6.37 log10 CFU, interquartile range (IQR) 6.19-6.54) and the intervention group (median 6.34 log10 CFU, IQR 6.17-6.60, p 0.513). After hand hygiene, the logarithmic reduction factor was higher in the intervention group (median 4.45, IQR 4.04-5.15) compared to the WHO reference group (median 3.91, IQR 3.69-4.62, p 0.021). CONCLUSIONS: The WHO six-step 'how to hand rub' technique can be simplified to a 3-step procedure based on the reduction of bacterial counts on healthcare workers' hands achieved under experimental conditions. The proposed technique is easier to perform and could improve adherence to the execution of hand hygiene action.

Outbreak investigation for toxigenic Corynebacterium diphtheriae wound infections in refugees from Northeast Africa and Syria in Switzerland and Germany by whole genome sequencing.

Toxigenic Corynebacterium diphtheriae is an important and potentially fatal threat to patients and public health. During the current dramatic influx of refugees into Europe, our objective was to use whole genome sequencing for the characterization of a suspected outbreak of C. diphtheriae wound infections among refugees. After conventional culture, we identified C. diphtheriae using matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) and investigated toxigenicity by PCR. Whole genome sequencing was performed on a MiSeq Illumina with >70×coverage, 2×250 bp read length, and mapping against a reference genome. Twenty cases of cutaneous C. diphtheriae in refugees from East African countries and Syria identified between April and August 2015 were included. Patients presented with wound infections shortly after arrival in Switzerland and Germany. Toxin production was detected in 9/20 (45%) isolates. Whole genome sequencing-based typing revealed relatedness between isolates using neighbour-joining algorithms. We detected three separate clusters among epidemiologically related refugees. Although the isolates within a cluster showed strong relatedness, isolates differed by >50 nucleotide polymorphisms. Toxigenic C. diphtheriae associated wound infections are currently observed more frequently in Europe, due to refugees travelling under poor hygienic conditions. Close genetic relatedness of C. diphtheriae isolates from 20 refugees with wound infections indicates likely transmission between patients. However, the diversity within each cluster and phylogenetic time-tree analysis suggest that transmissions happened several months ago, most likely outside Europe. Whole genome sequencing offers the potential to describe outbreaks at very high resolution and is a helpful tool in infection tracking and identification of transmission routes.

Validation of a treatment algorithm for orthopaedic implant-related infections with device-retention-results from a prospective observational cohort study.

Success rates for treatment regimens involving retention of an infected implant are conflicting and failure rates of up to 80% have been reported. We aimed to validate a proposed treatment algorithm, based on strict selection criteria, by assessing long-term outcome of treatment for orthopaedic device-related infection (ODRI) with retention. From January 1999 to December 2009, all patients diagnosed with ODRI at the University Hospital Basel, Switzerland were eligible for treatment with open surgical debridement, implant-retention and antibiotics, if duration of clinical symptoms was ≤3 weeks, the implant was stable, the soft-tissue had no abscess or sinus tract, and the causative pathogen was susceptible to antimicrobial agents with activity against surface-adhering microorganisms. Antimicrobial treatment was administered according to a predefined algorithm. The primary outcome was treatment failure after 2-year follow up. A total of 455 patients were diagnosed with an ODRI, of whom 233 (51.2%) patients were eligible for treatment involving implant-retention. Causative pathogens were mainly Staphylococcus aureus (41.6%) and coagulase-negative staphylococci (33.9%). Among patients with ODRIs related to prostheses, failure was documented in 10.8% (12/111) and in patients with ODRIs related to osteosyntheses, failure occurred in 9.8% (12/122) after 2 years of follow up. In all, 90% of ODRIs were successfully cured with surgical debridement and implant-retention in addition to long-term antimicrobial therapy according to a predefined treatment algorithm: if patients fulfilled strict selection criteria and there was susceptibility to rifampin for Gram-positive pathogens and ciprofloxacin for Gram-negative pathogens.

Low sensitivity of fecal toxin A/B enzyme immunoassay for diagnosis of Clostridium difficile infection in immunocompromised patients.

The optimal approach in laboratory diagnosis of Clostridium difficile infection (CDI) is still not well defined. Toxigenic culture (TC) or alternatively fecal toxin assay by cell cytotoxicity neutralization assay are considered to be the reference standard, but these methods are time-consuming and labor intensive. In many medical centers, diagnosis of CDI is therefore still based on fecal toxin A/B enzyme immunoassay (EIA) directly from stool alone, balancing cost and speed against limited diagnostic sensitivity. The aim of the study was to assess in which patient population the additional workload of TC is justified. All consecutive stool specimens submitted for diagnosis of suspected CDI between 2004 and 2011 at a tertiary-care center were examined by toxin EIA and TC. Clinical data of patients with established diagnosis of CDI were collected in a standardized case-report form. From 12,481 stool specimens submitted to the microbiologic laboratory, 480 (3.8%) fulfilled CDI criteria; 274 (57.1%) were diagnosed by toxin EIA; and an additional 206 (42.9%) were diagnosed by TC when toxin EIA was negative. Independent predictors for negative toxin EIA but positive TC were high-dose corticosteroids (odds ratio (OR) 2.97, 95% confidence interval (CI) 1.50-5.90, p 0.002), leukocytopenia <1000/µL (OR 2.52, 95% CI 1.22-5.23, p 0.013) and nonsevere CDI (OR 2.21, 95% CI 1.39-3.50, p 0.001). There was no difference in outcomes such as in-hospital mortality and recurrence between both groups. In conclusion, negative toxin EIA does not rule out CDI in immunocompromised patients in the setting of relevant clinical symptoms. Methods with improved sensitivity such as TC or PCR should be used, particularly in this patient population.

Is admission screening for Pseudomonas aeruginosa useful in haematologic patients? A prospective study with 1310 patients.

Screening for Pseudomonas aeruginosa is recommended to guide empirical antimicrobial therapy in patients on high-risk units. However, evidence for this approach is scarce. We therefore screened 1310 patients with severe haematologic diseases for P. aeruginosa colonization at admission: 108 (8.2%) were positive, but only nine (0.7%; six with the same clone as in the screening isolate) subsequently developed a P. aeruginosa bloodstream infection (positive predictive value of screening, 8.6%; negative predictive value of screening, 99.5%). Routine screening for P. aeruginosa at admission did not sufficiently predict subsequent bloodstream infections caused by P. aeruginosa.

Resistance or adaptation? How susceptible is a 'glutaraldehyde-resistant' Pseudomonas aeruginosa isolate in the absence of selection pressure?

The activities of glutaraldehyde solution and an instrument disinfectant based on glutaraldehyde on a Pseudomonas aeruginosa isolate with reduced susceptibility to glutaraldehyde after the first and fifth passages were determined using three concentrations and temperatures. No significant difference was found between the first and fifth passages so phenotypic adaptation is unlikely.

Factors associated with positive blood cultures in outpatients with suspected bacteremia.

Blood cultures are routinely taken in outpatients with fever and suspected bacterial infections. However, in the majority of cases, they are not informative and of limited value for clinical decision making. The aim of this study was therefore to investigate factors associated with positive blood cultures in outpatients presenting to an outpatient clinic and emergency room. This was a case-control study of all outpatients with positive blood cultures from January 1, 2006 to October 31, 2007 and matched control patients with negative blood cultures in the same time period. Microbiology results and medical charts were reviewed to determine factors associated with positive blood cultures. The presence of a systemic inflammation response syndrome (SIRS) (OR 2.7, 95% Cl 1.0-7.2) and increased C-reactive protein (CRP) (OR 1.1 per 10 mg/l, 95% Cl 1.0-1.2) were the most powerful predictive values for the development of positive blood cultures. In positive cases serum albumin was lower (35 mg/l versus 39 mg/l) than in controls. SIRS, increasing CRP and low albumin were associated with positive blood cultures in outpatients. With simple clinical assessment and few laboratory tests indicative of infection, it is possible to define a group at higher risk for bacteremia in outpatients.

Pseudo-outbreak of Pseudomonas mendocina in stem cell cultures.

Pseudomonas mendocina was first isolated in the 1970s from soil and water samples collected in the province of Mendoza, Argentina. Its recovery from human clinical specimens other than urine and leg ulcers was not documented until 1992, when a case report of an endocarditis caused by P. mendocina was published. We report the detection of P. mendocina in diagnostic stem cell cultures in the haematology unit, which initiated an outbreak investigation after identification of P. mendocina from three diagnostic stem cell cultures. Culture of a reagent used for the preparation of the diagnostic stem cell cultures revealed P. mendocina. Further outbreak investigation at the manufacturing site confirmed contamination of the product. This is the first report of an outbreak caused by P. mendocina from a commercial 'sterile' product. We conclude that this environmental pathogen has the potential to cause contamination of reagents used in clinical settings. Detection of P. mendocina should alert hospital personnel to possible product contamination.