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Background: ViRTUE, a virtual reality (VR) hand hygiene trainer, offers users the option of visualizing pathogen transfers during virtual patient care either in "real-time" or at the end of a level as a "summary" visualization. In this study, we aimed to evaluate the effect of different timings of pathogen visualization ("real-time" vs "summary") on in-trainer performance and user's immersion., Methods: The study included first-year medical students undergoing hand hygiene training with ViRTUE, randomized to one of three visualization set-ups: set-up 1 ("on-off-off", with "real-time" visualization at the first level only, and "summary" visualization at level 2 and 3), set-up 2 ("off-on-off"), and set-up 3 ("off-off-off"). In-trainer performance was defined by number of pathogen transmission events (=contaminations) in level 3. The virtual experience of user's (among others: immersion) was assessed with a questionnaire., Results: 173 medical students participated in the study, with 58, 54, and 61 assigned to set-up 1, set-up 2, and set-up 3, respectively. Users assigned to set-up 3 with "summary" visualization at all levels, performed best with 1.02 (standard deviation (SD) +/- 1.86) contaminations, compared to 2.34 (SD +/- 3.09) and 2.07 (SD +/- 2.52) contaminations of users assigned to the other set-ups. "Summary" visualization at all levels also resulted in higher immersion of users., Conclusions: "Real-time" visualization of pathogen transmission during VR hand hygiene training with ViRTUE may negatively affect in-trainer performance and user immersion. This emphasizes the importance of pilot testing the effect of VR-based trainings in order to understand their impact on users.

Objectives: We quantified the percentage of multidrug-resistant organism (MDRO) carriers among repatriated patients. We identified factors associated with MDRO carriage, and we evaluated the yield of MDRO detection per screened body site., Design: Retrospective cohort study., Setting: A tertiary-care center in Switzerland., Patients: Adult patients after a stay in a healthcare institution abroad., Methods: Patients were screened for MDRO carriage. Standard sites, including nose and throat, groins, and (since mid-2018) rectum, and risk-based sites (wounds, urine, tracheal secretion) were sampled. MDROs were defined as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), extended-spectrum β-lactamase (ESBL)- and carbapenemase-producing Enterobacterales (CPE), multidrug-resistant (MDR) Enterobacterales, and MDR nonfermenting gram-negative rods. Risk factors for MDRO carriage were assessed using multivariate logistic regression., Results: Between May 2017 and April 2019, 438 patients were screened and 107 (24.4%) tested positive for an MDRO, predominantly ESBL-producing and MDR Enterobacterales. Risk factors for MDRO colonization were the length of stay in hospital abroad, antibiotic treatment with 'Watch' and 'Reserve' antibiotics, and region of hospitalization abroad. Rectal swabs had the highest yield for detecting patients with MDR intestinal bacteria, but nose/throat and groins, or wound samples were more sensitive for MRSA or nonfermenting gram-negative organisms, respectively., Conclusions: We identified risk factors for MDRO carriage and body sites with the highest yield for a specific MDRO, which might help to target screening and isolation and reduce screening costs.

Objective: Little is known about the short-term dynamics of methicillin-resistant Staphylococcus aureus (MRSA) transmission between patients and their immediate environment. We conducted a real-life microbiological evaluation of environmental MRSA contamination in hospital rooms in relation to recent patient activity., Design: Observational pilot study., Setting: Two hospitals, hospital 1 in Zurich, Switzerland, and hospital 2 in Ann Arbor, Michigan, United States., Patients: Inpatients with MRSA colonization or infection., Methods: At baseline, the groin, axilla, nares, dominant hands of 10 patients and 6 environmental high-touch surfaces in their rooms were sampled. Cultures were then taken of the patient hand and high-touch surfaces 3 more times at 90-minute intervals. After each swabbing, patients' hands and surfaces were disinfected. Patient activity was assessed by interviews at hospital 1 and analysis of video footage at hospital 2. A contamination pressure score was created by multiplying the number of colonized body sites with the activity level of the patient., Results: In total, 10 patients colonized and/or infected with MRSA were enrolled; 40 hand samples and 240 environmental samples were collected. At baseline, 30% of hands and 20% of high-touch surfaces yielded MRSA. At follow-up intervals, 8 (27%) of 30 patient hands, and 10 (6%) of 180 of environmental sites were positive. Activity of the patient explained 7 of 10 environmental contaminations. Patients with higher contamination pressure score showed a trend toward higher environmental contamination., Conclusion: Environmental MRSA contamination in patient rooms was highly dynamic and was likely driven by the patient's MRSA body colonization pattern and the patient activity.

Objectives: In 2017, a point-prevalence survey was conducted with 12,931 patients in 96 hospitals across Switzerland as part of the national strategy to prevent healthcare-associated infections (HAIs). We present novel statistical methods to assess incidence proportions of HAI and attributable length-of-stay (LOS) in point-prevalence surveys., Methods: Follow-up data were collected for a subsample of patients and were used to impute follow-up data for all remaining patients. We used weights to correct length bias in logistic regression and multistate analyses. Methods were also tested in simulation studies., Results: The estimated incidence proportion of HAIs during hospital stay and not present at admission was 2.3% (95% confidence intervals [CI], 2.1-2.6), the most common type being lower respiratory tract infections (0.8%; 95% CI, 0.6-1.0). Incidence proportion was highest in patients with a rapidly fatal McCabe score (7.8%; 95% CI, 5.7-10.4). The attributable LOS for all HAI was 6.4 days (95% CI, 5.6-7.3) and highest for surgical site infections (7.1 days, 95% CI, 5.2-9.0). It was longest in the age group of 18-44 years (9.0 days; 95% CI, 5.4-12.6). Risk-factor analysis revealed that McCabe score had no effect on the discharge hazard after infection (hazard ratio [HR], 1.21; 95% CI, 0.89-1.63). Instead, it only influenced the infection hazard (HR, 1.84; 95% CI, 1.39-2.43) and the discharge hazard prior to infection (HR, 0.73; 95% CI, 0.66-0.82)., Conclusions: In point-prevalence surveys with limited follow-up data, imputation and weighting can be used to estimate incidence proportions and attributable LOS that would otherwise require complete follow-up data.

We investigated healthcare worker (HCW) behavior with regard to a voluntary methicillin-resistant Staphylococcus aureus (MRSA) staff screening during a MRSA outbreak in a neonatal ward. Avoiding MRSA transmission from HCWs to patients was the most important reason for participation. Inconvenient screening time was the most frequently cited reason for nonparticipation.

Objective: The preventable proportion of healthcare-associated infections (HAIs) may decrease over time as standards of care improve. We aimed to assess the proportion of HAIs prevented by multifaceted infection control interventions in different economic settings., Methods: In this systematic review and meta-analysis, we searched OVID Medline, EMBASE, CINAHL, PubMed, and The Cochrane Library for studies published between 2005 and 2016 assessing multifaceted interventions to reduce catheter-associated urinary tract infections (CAUTIs), central-line-associated bloodstream infections (CLABSIs), surgical site infections (SSIs), ventilator-associated pneumonia (VAP), and hospital-acquired pneumonia not associated with mechanical ventilation (HAP) in acute-care or long-term care settings. For studies reporting raw rates, we extracted data and calculated the natural log of the risk ratio and variance to obtain pooled risk ratio estimates., Results: Of the 5,226 articles identified by our search, 144 studies were included in the final analysis. Pooled incidence rate ratios associated with multifaceted interventions were 0.543 (95% confidence interval [CI], 0.445-0.662) for CAUTI, 0.459 (95% CI, 0.381-0.554) for CLABSI, and 0.553 (95% CI, 0.465-0.657) for VAP. The pooled rate ratio was 0.461 (95% CI, 0.389-0.546) for interventions aiming at SSI reduction, and for VAP reduction initiatives, the pooled rate ratios were 0.611 (95% CI, 0.414-0.900) for before-and-after studies and 0.509 (95% CI, 0.277-0.937) for randomized controlled trials. Reductions in infection rates were independent of the economic status of the study country. The risk of bias was high in 143 of 144 studies (99.3%)., Conclusions: Published evidence suggests a sustained potential for the significant reduction of HAI rates in the range of 35%-55% associated with multifaceted interventions irrespective of a country's income level.

Objective: Preventing ventilator-associated pneumonia (VAP) is an important goal for intensive care units (ICUs). We aimed to identify the optimal behavior leverage to improve VAP prevention protocol adherence., Design: Mixed-method study using adherence measurements to assess 4 VAP prevention measures and qualitative analysis of semi-structured focus group interviews with frontline healthcare practitioners (HCPs)., Setting: The 6 ICUs in the 900-bed University Hospital Zurich in Zurich, Switzerland.Patients and participantsAdherence to VAP prevention measures were assessed in patients with a device for invasive ventilation (ie, endotracheal tube, tracheostomy tube). Participants in focus group interviews included a convenience samples of ICU nurses and physicians., Results: Between February 2015 and July 2017, we measured adherence to 4 protocols: bed elevation showed adherence at 27% (95% confidence intervals [CI], 23%-31%); oral care at 41% (95% CI, 36%-45%); sedation interruption at 81% (95% CI, 74%-85%); and subglottic suctioning at 88% (95% CI, 83%-92%). Interviews were analyzed first inductively according a grounded theory approach then deductively against the behavior change wheel (BCW) framework. Main behavioral facilitators belonged to the BCW component 'reflective motivation' (ie, perceived seriousness of VAP and self-efficacy to prevent VAP). The main barriers belonged to 'physical capability' (ie, lack of equipment and staffing and side-effects of prevention measures). Furthermore, 2 primarily technical approaches (ie, 'restructuring environment' and 'enabling HCP') emerged as means to overcome these barriers., Conclusions: Our findings suggest that technical, rather than education-based, solutions should be promoted to improve VAP prevention. This theory-informed mixed-method approach is an effective means of guiding infection prevention efforts.

Objective: The transfer of pathogens may spread antimicrobial resistance and lead to healthcare-acquired infections. We performed a systematic literature review to generate estimates of pathogen transfer in relation to healthcare provider (HCP) activities., Methods: For this systematic review and meta-analysis, Medline/Ovid, EMBASE, and the Cochrane Library were searched for studies published before July 7, 2017. We reviewed the literature, examining transfer of pathogens associated with HCP activities. We included studies that (1) quantified transfer of pathogens from a defined origin to a defined destination surface; (2) reported a microbiological sampling technique; and (3) described the associated activity leading to transfer. For studies reporting transfer frequencies, we extracted data and calculated the estimated proportion using Freeman-Tukey double arcsine transformation and the DerSimonian-Laird random-effects model., Results: Of 13,121 identified articles, 32 were included. Most articles (n=27, 84%) examined transfer from patients and their environment to HCP hands, gloves, and gowns, with an estimated proportion for transfer frequency of 33% (95% confidence interval [CI], 12%-57%), 30% (95% CI, 23%-38%) and 10% (95% CI, 6%-14%), respectively. Other articles addressed transfer involving the hospital environment and medical devices. Risk factor analyses in 12 studies suggested higher transfer frequencies after contact with moist body sites (n=7), longer duration of care (n=5), and care of patients with an invasive device (n=3)., Conclusions: Recognizing the heterogeneity in study designs, the available evidence suggests that pathogen transfer to HCPs occurs frequently. More systematic research is urgently warranted to support targeted and economic prevention policies and interventions.

OBJECTIVE In this study, we sought to establish a comprehensive inventory of infectious risk moments (IRMs), defined as seemingly innocuous yet frequently occurring care manipulations potentially resulting in transfer of pathogens to patients. We also aimed to develop and employ an observational taxonomy to quantify the frequency and nature of IRMs in acute-care settings. DESIGN Prospective observational study and establishment of observational taxonomy. SETTING Intensive care unit, general medical ward, and emergency ward of a university-affiliated hospital. PARTICIPANTS Healthcare workers (HCWs) METHODS Exploratory observations were conducted to identify IRMs, which were coded based on the surfaces involved in the transmission pathway to establish a structured taxonomy. Structured observations were performed using this taxonomy to quantify IRMs in all 3 settings. RESULTS Following 129.17 hours of exploratory observations, identified IRMs involved HCW hands, gloves, care devices, mobile objects, and HCW clothing and accessories. A structured taxonomy called INFORM (INFectiOus Risk Moment) was established to classify each IRM according to the source, vector, and endpoint of potential pathogen transfer. We observed 1,138 IRMs during 53.77 hours of structured observations (31.25 active care hours) for an average foundation of 42.8 IRMs per active care hour overall, and average densities of 34.9, 36.8, and 56.3 IRMs in the intensive care, medical, and emergency wards, respectively. CONCLUSIONS Hands and gloves remain among the most important contributors to the transfer of pathogens within the healthcare setting, but medical devices, mobile objects, invasive devices, and HCW clothing and accessories may also contribute to patient colonization and/or infection. The INFORM observational taxonomy and IRM inventory presented may benefit clinical risk assessment, training and education, and future research. Infect Control Hosp Epidemiol 2018;39:272-279.

Objective: In-hospital transmission of methicillin-susceptible Staphylococcus aureus (MSSA) among neonates remains enigmatic. We describe the epidemiology of MSSA colonization and infection in a 30-bed neonatal ward., Design: Multimodal outbreak investigation, Setting: A public 800-bed tertiary care university hospital in Switzerland, Methods: Investigations in 2012-2013, triggered by a MSSA infection cluster, included prospective MSSA infection surveillance, microbiologic screening of neonates and environment, onsite observations, and a prospective cohort study. MSSA isolates were characterized by pulsed-field gel electrophoresis (PFGE) and selected isolates were examined for multilocus sequence type (MLST) and virulence factors., Results: Among 726 in 2012, 30 (4.1%) patients suffered from MSSA infections including 8 (1.1%) with bacteremia. Among 655 admissions in 2013, 13 (2.0%) suffered from MSSA infections including 2 (0.3%) with bacteremia. Among 177 neonates screened for S. aureus carriage, overall 77 (44%) tested positive. A predominant PFGE-1-ST30 strain was identified in 6 of 30 infected neonates (20%) and 30 of 77 colonized neonates (39%). This persistent clone was pvl-negative, tst-positive and belonged to agr group III. We found no environmental point source. MSSA carriage was associated with central vascular catheter use but not with a particular midwife, nurse, physician, or isolette. Observed healthcare worker behavior may have propagated transmission via hands and fomites. Despite multimodal interventions, clonal transmission and colonization continued and another clone, PFGE-6-ST5, became predominant., Conclusions: Hospital-acquired MSSA clones represent a high proportion of MSSA colonization but not MSSA infections in neonate inpatients. In contrast to persisting MSSA, transmission infection rates decreased concurrently with interventions. It remains to be established whether eradication of hospital-acquired MSSA strains would reduce infection rates further.