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Little is known about the short-term dynamics of methicillin-resistantObservational pilot study.Two hospitals, hospital 1 in Zurich, Switzerland, and hospital 2 in Ann Arbor, Michigan, United States.Inpatients with MRSA colonization or infection.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.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.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.

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.

Background Understaffing has been previously reported as a risk factor for central line-associated bloodstream infections (CLABSI). No previous study addressed the question whether fluctuations in staffing have an impact on CLABSI incidence. We analyzed prospectively collected CLABSI surveillance data and data on employee turnover of health care workers (HCW) to address this research question. Methods In January 2016, a semiautomatic surveillance system for CLABSI was implemented at the University Hospital Zurich, a 940 bed tertiary care hospital in Switzerland. Monthly incidence rates (CLABSI/1000 catheter days) were calculated and correlations with human resources management-derived data on employee turnover of HCWs (defined as number of leaving HCWs per month divided by the number of employed HCWs) investigated. Results Over a period of 24 months, we detected on the hospital level a positive correlation of CLABSI incidence rates and turnover of nursing personnel (Spearman rank correlation, r = 0.467, P = 0.022). In more detailed analyses on the professional training of nursing personnel, a correlation of CLABSI incidence rates and licensed practical nurses (Spearman rank correlation, r = 0.26, P = 0.038) or registered nurses (r = 0.471, P = 0.021) was found. Physician turnover did not correlate with CLABSI incidence (Spearman rank correlation, r = −0.058, P = 0.787). Conclusions Prospectively determined CLABSI incidence correlated positively with the degree of turnover of nurses overall and nurses with advanced training, but not with the turnover of physicians. Efforts to maintain continuity in nursing staff might be helpful for sustained reduction in CLABSI rates.

As 2019 draws to a close, the Journal of Patient Safety and Risk Management has reached a milestone for a new academic publishing enterprise: we have completed our first two full volumes. These are made up of 12 issues of research, case studies, descriptions of programs and policy, and related scholarship, on patient safety and medicolegal risk. In the Northern Hemisphere, we are approaching the winter solstice and the longest nights of the year. Also at hand are the corresponding festivities which originally must have been intended at least in part to ward off the dark and cold. To observe the season, we offer gifts of wisdom on patient safety and health care quality, nominated by our editors and international editorial board. In medicine, these bon mots are sometimes referred to as “pearls.” Although a few are freshly minted, most are venerable. As a rule, their origin is obscure. One of our members described his offerings as grains of sand rather than pearls, suggesting their potential to irritate more than enlighten. But over the years they have been repeated, paraphrased and repackaged on the wards by countless clinicians, much like nursery rhymes reinvented on the playground by generations of small children.

Objective:To reduce surgical site infection (SSI) incidence in plastic surgery and hand surgery.Design:Uncontrolled before-and-after study.Setting:Department of plastic surgery and hand surgery of a tertiary-care teaching hospital.Patients:Patients undergoing surgery between January 2016 and April 2018.Intervention:A comprehensive unit-based safety program (CUSP) consisting of a bundle of evidence-based SSI prevention strategies and a change in safety culture was fully implemented after a 14-month baseline surveillance and implementation period. SSI surveillance was performed over an intervention period of another 14 months, and differences in SSI rates between the 2 periods were calculated. Adherence with bundle components and risk factors for SSI were further evaluated in a case-cohort analysis.Results:Of 3,321 patients, 63 (1.9%) developed an SSI, 38 of 1,722 (2.2%) in the baseline group and 25 of 1,599 (1.6%) in the intervention group (P = .20). The CUSP was associated with an adjusted relative SSI risk reduction of 41% (95% confidence interval [CI], 0.4%–65%; P = .048) in multivariable analysis, whereas the need for revision surgery increased SSI risk (odds ratio [OR], 2.63; 95% CI, 1.31–5.30; P = .007). During the intervention period, the proportion of checklists completed was 62.4%, and no difference in adherence with bundle components between patients with and without SSI was observed.Conclusions:This CUSP helped reduce SSI in a surgical specialty with a low baseline SSI incidence, even though adherence with checklist completion was moderate and the main modifiable risk factors remained unchanged over time. Programs that include safety culture change may more effectively promote SSI reduction than prevention bundles alone.

The rapid spread of the coronavirus disease 2019 pandemic urged immense testing capacities as one cornerstone of infection control. Many institutions opened outpatient SARS-CoV-2 test centers to allow large number of tests in comparatively short time frames. With increasing positive test rates, concerns for a possible airborne or droplet contamination of specimens leading to false-positive results were raised. In our experimental series performed in a dedicated SARS-CoV-2 test center, 40 open collection tubes placed for defined time periods in proximity to individuals were found to be SARS-CoV-2 negative. These findings argue against false-positive SARS-CoV-2 results due to droplet or airborne contamination.

Hand hygiene is widely recognized as an important measure to prevent the transmission of microorganisms that may be involved in healthcare-associated infections. Yet correct hand hygiene remains challenging and healthcare providers struggle to improve adherence. While seemingly straightforward, performing hand hygiene at the right indication using the right technique becomes difficult within the context of complex work processes. We believe that an important barrier to hand hygiene is the invisible nature of microorganisms and delayed expression of healthcare associated infections. This delayed or missing feedback makes it difficult to associate unsafe behaviors with their negative consequences. In this chapter, we describe an application of experiential learning theory to guide the development of a virtual reality hand hygiene trainer in which visual feedback about microorganism transmission and infectious outcomes are introduced in the virtual environment. With this immersive trainer, our aim is to enhance experiential learning and increase intrinsic motivation to perform hand hygiene., Intelligent Systems Reference Library, 196, ISSN:1868-4394, Recent Advances in Technologies for Inclusive Well-Being, ISBN:978-3-030-59607-1, ISBN:978-3-030-59608-8

Daily chlorhexidine bathing has been associated with a reduction in central line-associated bloodstream infections (CLABSI). In the setting of an already established CLABSI surveillance system and an implemented CLABSI prevention bundle, we analysed the effect of daily chlorhexidine bathing in ICU patients on CLABSI incidence and its causative pathogens.This was a before-and-after study in intensive care units (ICUs) at a tertiary-care centre in Switzerland. Prospective surveillance of CLABSIs and their aetiologies was established. The intervention consisted of daily chlorhexidine bathing of ICU patients with a central venous catheter. A baseline period of 19 months was followed by an intervention period of 9 months.A total of 5008 patients were included. In the baseline period a mean CLABSI rate of 2.45/1000 catheter days (95% confidence interval (CI) 1.93-3.07) was observed, followed by 1.00/1000 catheter days (95% CI 0.55-1.67; P0.001) in the intervention period. Introduction of chlorhexidine bathing was independently associated with a reduced risk of CLABSI (adjusted odds ratio 0.47, 95% CI 0.26-0.84, P=0.011). We did not observe a significant change in aetiology except for an increase of Serratia marcescens in the intervention period.Introduction of daily chlorhexidine bathing resulted in a decline in CLABSI incidence on ICUs. Starting from a baseline CLABSI rate that can be considered standard in a high-income setting and several measures for CLABSI prevention implemented, chlorhexidine bathing proved helpful for a further reduction.

BackgroundSuper-spreaders are individuals infecting disproportionately large numbers of contacts. They probably play a crucial role in the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We describe a super-spreading event within a team working in an open-space office and investigate factors potentially having facilitated SARS-CoV-2 transmission.MethodsIn this retrospective cohort study, semi-structured telephone interviews with all team members were carried out to identify symptoms, contacts, and adherence to basic hygiene measures. During site visits, we gathered information about workplace and seating arrangements. The secondary attack rate in office and households was calculated. Potential respiratory viral co-infections were assessed by multiplex PCR. SARS-CoV-2 whole-genome sequencing was performed using a tiled-amplicon sequencing approach.ResultsOf 13 team members, 11 fell ill with Coronavirus disease 2019 (COVID-19). Due to the sequence of events and full genome sequence data, one person was considered the index case for this outbreak, directly infecting 67 to 83% of the teammates. All team members reported repetitive close contacts among themselves during joint computer work, team meetings and a “Happy Birthday” serenade. Two individuals shared nuts and dates. The arrangement of the office and meeting rooms precluded sufficient adherence to physical distancing. The index case and a further individual were diagnosed with an adenovirus serotype 4 co-infection.ConclusionWe identified several environmental and behavioral factors that probably have facilitated the transmission of SARS-CoV-2. The relevance of the adenovirus co-infection remains unclear and merits further investigation.

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.

SUMMARY Objective The international outbreak of cardiac-surgery-associated Mycobacterium chimaera infections was traced back to infectious aerosols originating from contaminated water reservoirs of heater-cooler devices (HCDs). In general, non-tuberculous mycobacteria (NTM) frequently colonize water systems and can contaminate medical devices. Data on detection of NTM other than M. chimaera in samples gathered from HCDs are scarce. The present study summarizes prospective mycobacterial surveillance of five HCDs over more than 4 years. Methods Five LivaNova 3T (London, UK) HCDs, acquired factory-new in 2014, were followed prospectively. Until mid-April 2014, the HCDs were maintained according to the manufacturer's recommendations, and subsequently, they were maintained according to an intensified in-house protocol including exhaust air evacuation. Mycobacterial surveillance cultures consisted of monthly water samples gathered from patient and cardioplegia circuits, as well as airflow samples. Results Of 441 water samples, 170 (38.6%) revealed NTM growth. The most frequently detected NTM were M. chimaera [N=120 (67.4%)], Mycobacterium gordonae [N=35 (19.7 %)] and Mycobacterium paragordonae [N=17 (9.6%)]. Growth of NTM, M. chimaera and M. paragordonae was significantly more common in water samples derived from the patient circuit than the cardioplegia circuit of the HCD. Three (2.0%) of 150 air samples grew NTM. Conclusion Growth of NTM in HCD water samples was common. Diverse NTM species were detected, with M. chimaera being the most common. The majority of air samples remained negative. The relevance of NTM other than M. chimaera contaminating HCDs is poorly defined, but a recent report on an HCD-associated outbreak with Mycobacterium abscessus confirmed a potential threat.

BACKGROUND: The increase in antimicrobial resistance is of worldwide concern. Surrogate tracers attempt to simulate microbial transmission by avoiding the infectious risks associated with live organisms. We evaluated silica nanoparticles with encapsulated DNA (SPED) as a new promising surrogate tracer in healthcare. METHODS: SPED and Escherichia coli were used to implement three experiments in simulation rooms and a microbiology laboratory in 2017-2018. Experiment 1 investigated the transmission behaviour of SPED in a predefined simulated patient-care scenario. SPED marked with 3 different DNA sequences (SPED1-SPED3) were introduced at 3 different points of the consecutive 13 touch sites of a patient-care scenario that was repeated 3 times, resulting in a total of 288 values. Experiment 2 evaluated SPED behaviour following hand cleaning with water and soap and alcohol-based handrub. Experiment 3 compared transfer dynamics of SPED versus E. coli in a laboratory using a gloved finger touching two consecutive sites on a laminate surface after a first purposefully contaminated site. RESULTS: Experiment 1: SPED adhesiveness on bare skin after a hand-to-surface exposure was high, leading to a dissemination of SPED1-3 on all consecutive surface materials with a trend of decreasing recovery rates, also reflecting touching patterns in concordance with contaminated fingers versus palms. Experiment 2: Hand washing with soap and water resulted in a SPED reduction of 96%, whereas hand disinfection led to dispersal of SPED from the palm to the back of the hand. Experiment 3: SPED and E. coli concentration decreased in parallel with each transmission step - with SPED showing a trend for less reduction and variability. CONCLUSIONS: SPED represent a convenient and safe instrument to simulate pathogen spread by contact transmission simultaneously from an infinite number of sites. They can be further developed as a central asset for successful infection prevention in healthcare., Antimicrobial Resistance and Infection Control, 9 (1), ISSN:2047-2994

Background Manual disinfection of medical devices is prone to failure. Disinfection by aerosolized hydrogen peroxide might be a promising adjunctive method. We aimed to assess effectiveness of dry mist of hydrogen peroxide (HPDM) on noncritical medical equipment. Methods One cycle of HPDM was applied on a convenience sample of 16 different types of "ready to use" noncritical medical devices in a closed, but nonsealed room. Of every object, 2 adjacent areas with assumed similar bacterial burden were swabbed before and after HPDM deployment, respectively. After culturing, colony forming units (CFU) were counted, and bacterial burden per cm2 calculated. Results Of 160 objects included in the study, 36 (23%) showed a CFU-count of zero both before and after HPDM use. A decrease from a median of 0.14 CFU/cm2 (range: 0.00-125.00/cm2) to a median of 0.00 CFU/cm2 (range: 0.00-4.00/cm2) (P Discussion HPDM reduced bacterial burden on noncritical medical items. Since cleanliness of the included "ready to use" objects was high and no pathogens were found before nebulization, the HPDM device did not increase patient safety in this setting. Conclusion HPDM nebulization can be a useful nonmanual adjunctive disinfection method in high-risk settings.

Using prospectively collected surveillance data at a tertiary care hospital in Central Europe, we investigated seasonal differences in central line-associated bloodstream infection incidence. Central line-associated bloodstream infection incidence rates were highest during the third quarter over an observation period of 24 months. Investigating influence of meteorological parameters identified a significant correlation with precipitation (r = 0.460, P = .023).

OBJECTIVETo assess the structure and quality of surveillance activities and to validate outcome detection in the Swiss national surgical site infection (SSI) surveillance program.DESIGNCountrywide survey of SSI surveillance quality.SETTING147 hospitals or hospital units with surgical activities in Switzerland.METHODSSite visits were conducted with on-site structured interviews and review of a random sample of 15 patient records per hospital: 10 from the entire data set and 5 from a subset of patients with originally reported infection. Process and structure were rated in 9 domains with a weighted overall validation score, and sensitivity, specificity, positive predictive value, and negative predictive value were calculated for the identification of SSI.RESULTSOf 50 possible points, the median validation score was 35.5 (range, 16.25–48.5). Public hospitals (PP=.021), and hospitals with longer participation in the surveillance (P=.018) had higher scores than others. Domains that contributed most to lower scores were quality of chart review and quality of data extraction. Of 49 infections, 15 (30.6%) had been overlooked in a random sample of 1,110 patient records, accounting for a sensitivity of 69.4% (95% confidence interval [CI], 54.6%–81.7%), a specificity of 99.9% (95% CI, 99.5%–100%), a positive predictive value of 97.1% (95% CI, 85.1%–99.9%), and a negative predictive value of 98.6% (95% CI, 97.7%–99.2%).CONCLUSIONSIrrespective of a well-defined surveillance methodology, there is a wide variation of SSI surveillance quality. The quality of chart review and the accuracy of data collection are the main areas for improvement.Infect Control Hosp Epidemiol 2017;38:1172–1181

Background Timely diagnosis of influenza infection in patients might help reduce antibiotic use during influenza seasons and, consequently, antibiotic selection pressure. In this retrospective cohort study, we aimed to evaluate whether time to influenza diagnosis in patients with severe influenza is associated with the duration of antibiotic therapy. Methods We retrospectively included all hospitalized patients >16 years who tested positive for influenza A or B by polymerase chain reaction during influenza seasons 2013/2014 or 2014/2015 at the University Hospital Zurich. The primary aim was to assess the association between timing of laboratory-confirmed influenza diagnosis and duration of antibiotic therapy. Secondary outcomes were length of hospital stay, duration of isolation precautions, and mortality. Early diagnosis was defined as laboratory confirmation on the day of or the day after hospital admission or symptom onset. Results A total of 126 patients were included (median age 57 years). Timing of influenza diagnosis was not associated with the duration of antibiotic treatment, the duration of isolation precautions, or mortality. Early influenza was associated with reduced length of hospital stay (median 7 vs 9 days [P=.014]) in patients with community-acquired influenza. Conclusions Although the duration of antibiotic therapy and mortality were found unaffected by early influenza diagnosis, our data indicate that it is linked with a reduction in the length of hospitalization in patients with community-acquired influenza. This highlights a need to also fully understand the effect of time to diagnosis of bacterial pathogens on antibiotic prescribing patterns in order to exploit the potential of early influenza diagnosis in patient care.

Summary Background Hand hygiene compliance of health-care workers remains suboptimal despite standard multimodal promotion, and evidence for the effectiveness of novel interventions is urgently needed. We aimed to assess the effect of enhanced performance feedback and patient participation on hand hygiene compliance in the setting of multimodal promotion. Methods We did a single-centre, cluster randomised controlled trial at University of Geneva Hospitals (Geneva, Switzerland). All wards hosting adult, lucid patients, and all health-care workers and patients in these wards, were eligible. After a 15-month baseline period, eligible wards were assigned by computer-generated block randomisation (1:1:1), stratified by the type of ward, to one of three groups: control, enhanced performance feedback, or enhanced performance feedback plus patient participation. Standard multimodal hand hygiene promotion was done hospital-wide throughout the study. The primary outcome was hand hygiene compliance of health-care workers (according to the WHO Five Moments of Hand Hygiene) at the opportunity level, measured by direct observation (20-min sessions) by 12 validated infection control nurses, with each ward audited at least once every 3 months. This trial is registered with ISRCTN, number ISRCTN43599478. Findings We randomly assigned 67 wards to the control group (n=21), enhanced performance feedback (n=24), or enhanced performance feedback plus patient participation (n=22) on May 19, 2010. One ward in the control group became a high-dependency unit and was excluded from analysis. During 1367 observation sessions, 12 579 hand hygiene opportunities were recorded. Between the baseline period (April 1, 2009, to June 30, 2010) and the intervention period (July 1, 2010, to June 30, 2012), mean hand hygiene compliance increased from 66% (95% CI 62–70) to 73% (70–77) in the control group (odds ratio [OR] 1·41, 95% CI 1·21–1·63), from 65% (62–69) to 75% (72–77) in the enhanced performance feedback group (1·61, 1·41–1·84), and from 66% (62–70) to 77% (74–80) in the enhanced performance feedback plus patient participation group (1·73, 1·51–1·98). The absolute difference in compliance attributable to interventions was 3 percentage points (95% CI 0–7; p=0·19) for the enhanced performance feedback group and 4 percentage points (1–8; p=0·048) for the enhanced performance feedback plus patient participation group. Hand hygiene compliance remained significantly higher than baseline in all three groups (OR 1·21 [1·00–1·47] vs 1·38 [1·19–1·60] vs 1·36 [1·18–1·57]) during the post-intervention follow-up (Jan 1, 2013, to Dec 31, 2014). Interpretation Hand hygiene compliance improved in all study groups, and neither intervention had a clinically significant effect compared with control. Improvement in control wards might reflect cross-contamination, highlighting challenges with randomised trials of behaviour change. Funding Swiss National Science Foundation.

Investigations of a worldwide epidemic of invasive Mycobacterium chimaera associated with heater-cooler devices in cardiac surgery have been hampered by low clinical awareness and challenging diagnoses. Using data from Switzerland, we estimated the burden of invasive M. chimaera to be 156-282 cases/year in 10 major cardiac valve replacement market countries.

Objectives Conducting manual surveillance of non-ventilator-associated hospital-acquired pneumonia (nvHAP) using ECDC (European Centre for Disease Prevention and Control) surveillance criteria is very resource intensive. We developed and validated a semi-automated surveillance system for nvHAP, and describe nvHAP incidence and aetiology at our hospital. Methods We applied an automated classification algorithm mirroring ECDC definition criteria to distinguish patients ‘not at risk' from patients ‘at risk' for suffering from nvHAP. ‘At risk'-patients were manually screened for nvHAP. For validation, we applied the reference standard of full manual evaluation to three validation samples comprising 2091 patients. Results Among the 39 519 University Hospital Zurich inpatient discharges in 2017, the algorithm identified 2454 ‘at-risk' patients, reducing the number of medical records to be manually screened by 93.8%. From this subset, nvHAP was identified in 251 patients (0.64%, 95%CI: 0.57–0.73). Sensitivity, negative predictive value, and accuracy of semi-automated surveillance versus full manual surveillance were lowest in the validation sample consisting of patients with HAP according to the International Classification of Diseases (ICD-10) discharge diagnostic codes, with 97.5% (CI: 93.7–99.3%), 99.2% (CI: 97.9–99.8%), and 99.4% (CI: 98.4–99.8%), respectively. The overall incidence rate of nvHAP was 0.83/1000 patient days (95%CI: 0.73–0.94), with highest rates in haematology/oncology, cardiac and thoracic surgery, and internal medicine including subspecialties. Conclusions The semi-automated surveillance demonstrated a very high sensitivity, negative predictive value, and accuracy. This approach significantly reduces manual surveillance workload, thus making continuous nvHAP surveillance feasible as a pivotal element for successful prevention efforts.

Infections caused by carbapenemase-producing, multidrug-resistant (MDR), or extensively drug-resistant (XDR) Gram-negative bacteria constitute a major therapeutic challenge. Whether combination antibiotic therapy is superior to monotherapy remains unknown. In this systematic review and meta-analysis OVID MEDLINE, EMBASE, PubMed, The Cochrane Library, and Scopus databases were searched for randomized controlled trials (RCTs) and observational studies published by December 2016 comparing mono- with combination antibiotic therapy for infections with carbapenemase-producing, MDR, or XDR Gram-negative bacteria. Mortality and clinical cure rates served as primary and secondary outcome measures, respectively. Of 8847 initially identified studies, 53 studies – covering pneumonia (n = 10 studies), blood stream (n = 15), osteoarticular (n = 1), and mixed infections (n = 27) - were included. 41% (n = 1848) of patients underwent monotherapy, and 59% (n = 2666) combination therapy. In case series/cohort studies (n = 45) mortality was lower with combination- vs. monotherapy (RR 0.83, CI 0.73–0.93, p = 0.002, I2 = 24%). Subgroup analysis revealed lower mortality with combination therapy with at least two in-vitro active antibiotics, in blood stream infections, and carbapenemase-producing Enterobacteriaceae. No mortality difference was seen in case-control studies (n = 6) and RCTs (n = 2). Cure rates did not differ regardless of study type. The two included RCTs had a high and unknown risk of bias, respectively. 16.7% (1/6) of case-control studies and 37.8% (17/45) of cases series/cohort studies were of good quality, whereas quality was poor in the remaining studies. In conclusion, combination antimicrobial therapy of multidrug-resistant Gram-negative bacteria appears to be superior to monotherapy with regard to mortality.

Background A Surgical Unit-based Safety Programme (SUSP) has been shown to improve perioperative prevention practices and to reduce surgical site infections (SSI). It is critical to understand the factors influencing the successful implementation of the SUSP approach in low- and middle-income settings. We undertook a qualitative study to assess viability, and understand facilitators and barriers to implementing the SUSP approach in 5 African hospitals. Methods Qualitative study based on interviews with individuals from all hospitals participating in a WHO-coordinated before-after SUSP study. The SUSP intervention consisted of a multimodal strategy including multiple SSI prevention measures combined with an adaptive approach aimed at improving teamwork and safety culture. Results Thirteen interviews (5 head surgeons, 3 surgeons, 5 nurses) were conducted with staff from five hospital sites. Identified facilitators included influential individuals (intrinsic motivation of local SUSP teams, boundary spanners, multidisciplinary engagement, active leadership support), peer-to-peer learning (hospital networking and positive deviance, benchmarking), implementation fitness (enabling infrastructures, momentum from previous projects), and timely feedback of infection rates and process indicators. Barriers (organisational ‘constipators’, workload, mistrust, turnover) and local solutions to these were also identified. Conclusions Participating hospitals benefitted from the SUSP programme structures (e.g. surveillance, hospital networks, formation of multidisciplinary teams) and adaptive tools (e.g. learning from defects, executive rounds guide) to change perceptions around patient safety and improve behaviours to prevent SSI. The combination of technical and adaptive elements represents a promising approach to facilitate the introduction of evidence-based best practices and to improve safety culture through local team engagement in resource-limited settings.

Background Education is a cornerstone strategy to prevent health-associated infections. Trainings benefit from being interactive, simulation-based, team-orientated, and early in professional socialization. We conceived an innovative inter-professional peer-teaching module with operating room technician trainees (ORTT) teaching infection prevention behavior in the operating room (OR) to medical students (MDS). Methods ORTT delivered a 2-h teaching module to small groups of MDS in a simulated OR setting with 4 posts: ‘entering OR’; ‘surgical hand disinfection’; ‘dressing up for surgery and preparing a surgical field’, ‘debriefing’. MDS and ORTT evaluated module features and teaching quality through 2 specific questionnaires. Structured field notes by education specialist observers were analyzed thematically. Results On Likert scales from − 2 to + 2, mean overall satisfaction was + 1.91 (±0.3) for MDS and + 1.66 (±0.6 SD) for ORTT while teaching quality was rated + 1.89 (±0.3) by MDS and self-rated with + 1.34 (±0.5) by ORTT. Students and observers highlighted that the training fostered mutual understanding and provided insight into the corresponding profession. Conclusions Undergraduate inter-professional teaching among ORTT and MDS in infection prevention and control proved feasible with high educational quality. Inducing early mutual understanding between professional groups might improve professional collaboration and patient safety. Electronic supplementary material The online version of this article (10.1186/s13756-019-0526-2) contains supplementary material, which is available to authorized users.

ObjectivesWe explored patient perceptions regarding physician attire in different clinical contexts and resultant effects on the physician–patient relationship.SettingThe 900-bed University Hospital Zurich, Switzerland.ParticipantsA convenience sample of patients receiving care in dermatology, infectious diseases and neurology ambulatory clinics of the University Hospital Zurich participated in a paper-based survey.Primary and secondary outcome measuresThe survey instrument was randomised and showed photographs of male or female physicians wearing various forms of attire. On the basis of the respondents’ ratings of how the physician’s attire affected perceptions across five domains (knowledgeable, trustworthy, caring, approachable and comfort with the physician), a composite preference score for attire was calculated as the primary outcome. Secondary outcomes included variation in preferences by respondent characteristics and context in which care was provided.ResultsOf 834 patient respondents (140 in dermatology, 422 in infectious diseases and 272 in neurology), 298 (36%) agreed that physician attire was important. When compared with all available choices, the combination of white scrubs with white coat was rated highest while a business suit ranked lowest. Variation in preferences and opinions for attire were noted relative to respondent demographics and the clinical setting in which the survey was administered. For example, compared with younger patients, respondents ≥65 years of age more often reported that physician dress was both important to them and influenced how happy they were with their care (p=0.047 and p=0.001, respectively).ConclusionsOutpatients at a large Swiss University hospital prefer their physicians to be dressed in white scrubs with white coat. Substantial variation among respondents based on demographics, type of physician and clinical setting were observed. Healthcare systems should consider context of care when defining policies related to dress code.

Background Pathogen transmission plays a major role in the development of healthcare-associated infections. The “patient zone” concept developed as part of the World Health Organization’s “Five moments of hand hygiene” aims to distinguish surfaces primarily contaminated by flora of a single patient, i.e. inside the patient zone, from those outside the patient zone containing foreign and potentially harmful microorganisms. Discrepancies in healthcare provider (HCP) internal conceptual representations (i.e. mental models) of the patient zone may lead to missed infection prevention measures that could result in patient harm. We explored HCPs’ mental models of the patient zone that shape how they interact with the work environment. Methods We conducted individual concept mapping interviews supported by a card-sorting technique to examine HCPs’ mental models of the patient zone and compared these to IPC expert models. Ten participants (five nurses, five physicians) without IPC specialization and two IPC experts provided definitions of the patient zone and allocated 32 items to “inside” or “outside” the patient zone while verbalizing their thought processes. We calculated similarity as percent agreement among participants and accuracy as percent allocated consistently with expert consensus. A content analysis of interview recordings served to identify mental models underlying the allocation decisions. Results Our study revealed limited similarity among participants, with seven of 32 items allocated consistently among all participants. Overall, 68% of items were sorted accurately according to expert consensus. Identified mental models were categorized as follows: “Patient contact”, the patient zone defined according to objects having patient contact; “Sectors”, the patient zone as a defined physical space; “Disinfection”, the patient zone deduced based on need to disinfect hands and objects; and “Context-dependency”, the patient zone defined depending on the context of an object’s use. Conclusions Our study revealed ambiguity surrounding the patient zone concept as evidenced by low similarity between participants and important discrepancies between participant and expert mental models. Such ambiguity may lead to inconsistent application of the patient zone concept and represents a patient safety risk. Initiatives to improve understanding and application of the patient zone concept should focus on establishing consistent, theoretically founded mental models.

Background Standard precautions are essential to prevent pathogen transmission and nosocomial infections. We assessed learning effect (primary outcome) and satisfaction (secondary outcome) of watching a 5-min humorous “edutainment (=education and entertainment) video” on Standard Precautions compared to reading a written standard operating procedure (SOP) or receiving no intervention. Methods This randomized controlled trial was executed at the University Hospital Zurich, Switzerland, a tertiary care centre with a state-of-the-art infection prevention programme. Healthcare providers (HCPs) of different medical departments were 1:1:1 randomized to watching the edutainment video (video group), reading the SOP (SOP group), or no study-specific intervention (no-intervention group). Online questionnaires included a knowledge assessment about Standard Precautions at time point (TP) 1 immediately after intervention, TP2 after 1 month, and TP3 after 3 months. Information about HCPs’ satisfaction with the learning method was collected. Variables were assessed within and between groups using the appropriate non-parametric tests. Predictors for knowledge of Standard Precautions were assessed by uni- and multivariable linear regression. Results Overall, 363 predominantly female (78.2%) HCPs were included. At TP 1 and TP3, the video group scored better on the knowledge assessment against both the SOP and the no-intervention group (TP1 p

Background Data on long-term effects of interventions in infection control are scarce. We aimed to evaluate the 8-year sustainability of a successful intervention to reduce urinary tract infections (UTIs) through restriction of urinary catheter (UC) use in an orthopedic surgical population. Methods Prospective UTI surveillance from November 2009-January 2010 was conducted to compare the results against the 2-year sustainability assessment performed in 2004. Semistructured staff interviews focused on UC indication, training, insertion techniques, and recall of the former intervention. Results A total of 336 consecutive patients were included (median age, 63 years; range, 16-95 years; 55% women). A UC was placed in 17.6% of patients (operating room [OR], 10.1%; postanesthesia care unit [PACU], 3.6%; surgical wards [SW], 3.9%) compared with 20.0% in 2004 (OR, 15.7%; PACU, 1.0%; SW, 3.7%). The incidence rate of UTI was 2.4 per 1,000 patient-days in 2010 versus 2.6 per 1,000 patient-days in 2004; adjusted incidence rate ratio 0.76; 95% confidence interval, 0.21-2.76; P = .67. The qualitative inquiry demonstrated poor recall of the intervention and knowledge of guidelines except in the OR, where we identified a champion leader. Discussion The intervention effect was sustained with regard to overall UTI rate and UC placement in the OR, but less in the PACU and SW. Conclusions Continuous leadership of a single opinion leader in a pivotal position can contribute critically to sustainability.

All such units should be separated from air that can gain access to sterile areas., Heater–cooler units (HCUs) were recently identified as a source of Mycobacterium chimaera causing surgical site infections. We investigated transmission of this bacterium from HCUs to the surgical field by using a thermic anemometer and particle counter, videotape of an operating room equipped with an ultraclean laminar airflow ventilation system, and bacterial culture sedimentation plates in a nonventilated room. Smoke from the HCU reached the surgical field in 23 s by merging with ultraclean air. The HCU produced on average 5.2, 139, and 14.8 particles/min in the surgical field at positions Off, On/oriented toward, and On/oriented away, respectively. Culture plates were positive for M. chimaera

Background: Methicillin-resistant Staphylococcus aureus (MRSA) colonization of patients and contamination of their immediate environmental surfaces is common in the acute care setting, but there is much to be learned about the dynamics of MRSA transmission over a short period of time. Methods: A prospective, observational time-motion qualitative study was conducted at 2 hospitals: 1 in Michigan (hospital 1) and 1 in Zurich, Switzerland (hospital 2)—between November 2018 and July 2019. Hospitalized patients with a MRSA infection or colonization were enrolled. Microbiologic cultures for MRSA were collected from patient nares, axilla, groin and hands and several high-touch surfaces in their room (bed controls, call button, tray table, etc) at the first visit, and patient hands and high-touch surfaces continued to be swabbed every 90 minutes over the course of 5 hours. Patient hands and environment were disinfected after each swabbing. Clinical data were collected from patient’s medical chart. Results: We recruited 10 MRSA colonized or infected patients for the study with 50 hours of observation and obtained 360 patient and environmental swabs. Most were women (7 of 10); the average age was 52.8 years (Table 1). At the first visit, 8 (80%) patients were MRSA-colonized (at 1 or more body sites) and 5 (50%) rooms were MRSA-contaminated (at 1 or more surfaces). Also, 6 patients (60%) had an active MRSA infection and were actively receiving an anti-MRSA agent (eg, Vancomycin). Among those 6 patients receiving an anti-MRSA agent, 4 patients (67%) and 2 rooms (33%) were contaminated at the first visit. Among those 4 patients not receiving an anti-MRSA agent, all 4 patients (100%) and 3 rooms (75%) were contaminated at the baseline visit. Acquisitions (ie, MRSA recovered from a site it was not previously recovered from) occurred on 3 of 7 patient hands (43%) and on 6 occasions in the room (among 5 patients), most commonly at the toilet seat (2 of 6 times). MRSA prevalence on patient and room surfaces for the 5 patients enrolled at hospital 2 are illustrated in Figure 1, which shows colonization of patient and contamination of environment as well as activities performed by the patient in between culturing. Conclusions: We evaluated transmission of MRSA over brief periods of time; our results show that transmission of MRSA depended on patient activity in the room. Furthermore, degree of patient colonization is reflected by environmental contamination and supports the notion of constant transmission of MRSA from patients to environment.Funding: NoneDisclosures: None

Background The impact of healthcare personnel hand contamination in multidrug-resistant organism (MDRO) transmission is important and well studied; however, the role of patient hand contamination needs to be characterized further. Methods Patients from 2 hospitals in southeast Michigan were recruited within 24 hours of arrival to their room and followed prospectively using microbial surveillance of nares, dominant hand, and 6 high-touch environmental surfaces. Sampling was performed on admission, days 3 and 7, and weekly until discharge. Paired samples of methicillin-resistant Staphylococcus aureus (MRSA) isolated from the patients’ hand and room surfaces were evaluated for relatedness using pulsed-field gel electrophoresis and staphylococcal cassette chromosome mec, and Panton-Valentine leukocidin typing. Results A total of 399 patients (mean age, 60.8 years; 49% male) were enrolled and followed for 710 visits. Fourteen percent (n = 56/399) of patients were colonized with an MDRO at baseline; 10% (40/399) had an MDRO on their hands. Twenty-nine percent of rooms harbored an MDRO. Six percent (14/225 patients with at least 2 visits) newly acquired an MDRO on their hands during their stay. New MDRO acquisition in patients occurred at a rate of 24.6/1000 patient-days, and in rooms at a rate of 58.6/1000 patient-days. Typing demonstrated a high correlation between MRSA on patient hands and room surfaces. Conclusions Our data suggest that patient hand contamination with MDROs is common and correlates with contamination on high-touch room surfaces. Patient hand hygiene protocols should be considered to reduce transmission of pathogens and healthcare-associated infections., In a prospective study of 399 hospital patients, we show that multidrug-resistant organisms (MDROs) on patient hands are common on admission and correlate with room contamination. New MDRO acquisition is frequent, suggesting a need to develop patient hand hygiene protocols in hospitals.

ObjectiveThe 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.MethodsIn 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.ResultsOf 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%).ConclusionsPublished 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.

Background Hand Hygiene (HH) compliance was shown to be poor in several studies. Improving the availability of alcohol-based hand rub (ABHR) is a cornerstone for increasing HH compliance. Methods In this study, we introduced wearable dispensers for ABHR in an Emergency Department (ED) well equipped with mounted ABHR dispensers and accompanied this single-modal intervention by a quasi-experimental mixed-method study. The study was performed in the ED of the University Hospital Zurich, Switzerland, a 950-bed tertiary teaching hospital. During a five-week baseline period and a seven-week intervention period, we observed HH compliance according to the WHO ‘Five Moments’ concept, measured ABHR consumption, and investigated perceived ABHR availability, self-reported HH compliance and knowledge of HH indications by questionnaire. Multivariable logistic regression was used to identify independent determinants for HH compliance. In addition, semi-structured interviews were conducted and thematically analyzed to assess barriers and facilitators for the use of the newly introduced dispensers. Results Across 811 observed HH opportunities, the HH compliance for all moments was 56% (95% confidence interval (CI), 51–62%) during baseline and 64% (CI, 59–68%) during intervention period, respectively. In the multivariable analysis adjusted for sex, profession, and WHO HH moment, there was no difference in HH compliance between baseline and intervention (adjusted Odds ratio: 1.22 (0.89–1.66), p = 0.22), No significant changes were observed in consumption and perceived availability of ABHR. During intervention, 7.5% ABHR was consumed using wearable dispensers. HCP perceived wearable dispensers as unnecessary since mounted dispensers were readily accessible. Poor ergonomic design of the wearable dispenser emerged as a main barrier, especially its lid and fastening mechanism. Interviewees identified two ideal situations for wearable dispensers, HCP who accompany patients from ED to other wards, and HCP approaching a patient from a non-patient areas in the ED such as the central working station or the meeting room. Conclusion The introduction of wearable dispensers did not increase observed hand hygiene compliance or ABHR consumption in an ED already well equipped with mounted dispensers. For broader acceptance and use, wearable dispensers might benefit from an optimized ergonomic design.

ObjectivePreventing 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.DesignMixed-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).SettingThe 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.ResultsBetween 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.ConclusionsOur 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.

Hand hygiene is an important measure to prevent healthcare-associated infections. However, healthcare provider adherence to hand hygiene remains low. Due to the invisible nature of microorganisms and delayed expression of healthcare associated infections, healthcare providers are rarely aware of transmission dynamics and they don't receive feedback about the consequences of missed hand hygiene. This situation makes it difficult to associate unsafe behaviors with their negative consequences. We introduce the concept of an experiential virtual training environment for hand hygiene, where feedback about microorganism transmission and infectious outcomes are introduced visually, thereby enhancing associative learning and increasing intrinsic motivation to perform hand hygiene.

OBJECTIVEIn 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.DESIGNProspective observational study and establishment of observational taxonomy.SETTINGIntensive care unit, general medical ward, and emergency ward of a university-affiliated hospital.PARTICIPANTSHealthcare workers (HCWs)METHODSExploratory 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.RESULTSFollowing 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.CONCLUSIONSHands 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

OBJECTIVETo elicit expert consensus on the likelihood of infectious outcomes (patient colonization or infection) following a broad range of infectious risk moments (IRMs) from observations in acute care.DESIGNExpert consensus study using modified Delphi technique.PARTICIPANTSPanel of 40 international experts including nurses, physicians and microbiologists specialized in infectious diseases and infection prevention and control (IPC).METHODSThe modified Delphi process consisted of 3 online survey rounds, with feedback of mean ratings and expert comments between rounds. The Delphi survey comprised 52 care scenarios representing observed IRMs organized into 6 sections: hands, gloves, medical devices, mobile objects, invasive procedures, and additional moments. For each scenario, experts indicated the likelihood of both patient colonization and infection on a scale from 0 to 5 (high). Expert ratings were plotted against frequencies of IRMs observed during actual patient care resulting in a risk index.RESULTSFollowing 3 rounds, consensus was achieved for 92 of 104 items (88.5%). The mean ratings across all scenarios for likelihood of colonization and infection were 2.68 and 2.02, respectively. The likelihood of colonization was rated higher than infection for 48 of 52 scenarios. Ratings were significantly higher for colonization (P=.001) and infection (PCONCLUSIONSThe design of effective IPC strategies requires the selection of behaviors according to their impact on patient outcomes. The IRM index reported here provides a basis for standardizing and prioritizing targets for quality improvement initiatives, training, and future research in acute health care.Infect Control Hosp Epidemiol 2018;39:280–289

As surveillance of hospital-acquired pneumonia (HAP) is very resource intensive, alternatives for HAP surveillance are needed urgently. This study compared HAP rates according to routine discharge diagnostic codes of the International Classification of Diseases, 10th Revision (ICD-10; ICD-HAP) with HAP rates according to the validated surveillance definitions of the Hospitals in Europe Link for Infection Control through Surveillance (HELICS/IPSE; HELICS-HAP) by manual retrospective re-evaluation of patient records. The positive predictive value of ICD-HAP for HELICS-HAP was 0.35, and sensitivity was 0.59. Therefore, the currently available ICD-10-based routine discharge data do not allow reliable identification of patients with HAP.

To test the effectiveness of a central venous catheter (CVC) insertion strategy and a hand hygiene (HH) improvement strategy to prevent central venous catheter-related bloodstream infections (CRBSI) in European intensive care units (ICUs), measuring both process and outcome indicators. Adult ICUs from 14 hospitals in 11 European countries participated in this stepped-wedge cluster randomised controlled multicentre intervention study. After a 6 month baseline, three hospitals were randomised to one of three interventions every quarter: (1) CVC insertion strategy (CVCi); (2) HH promotion strategy (HHi); and (3) both interventions combined (COMBi). Primary outcome was prospective CRBSI incidence density. Secondary outcomes were a CVC insertion score and HH compliance. Overall 25,348 patients with 35,831 CVCs were included. CRBSI incidence density decreased from 2.4/1000 CVC-days at baseline to 0.9/1000 (p

Established preoperative antibiotic prophylaxis in cardiac surgery is ineffective against methicillin-resistant coagulase-negative staphylococci (CoNS). This case–control study aimed to determine factors predicting deep sternal wound infections due to methicillin-resistant CoNS. All cardiac surgery patients undergoing sternotomy between June 2009 and March 2013 prospectively documented in a Swiss tertiary care center were included. Among 1999 patients, 82 (4.1%) developed deep sternal wound infection. CoNS were causal in 36 (44%) patients, with 25/36 (69%) being methicillin resistant. Early reintervention for noninfectious causes (odds ratio (OR) 4.3; 95% confidence interval (CI) 1.9–9.5) was associated with methicillin-resistant CoNS deep sternal wound infection. Among CoNS deep sternal wound infection, perioperative antimicrobial therapy (p 0.002), early reintervention for noninfectious causes (OR 7.9; 95% CI 0.9–71.1) and time between surgery and diagnosis of infection over 21 days (OR 10.8; 95% CI 1.2–97.8) were associated with methicillin resistance. These findings may help to better tailor preoperative antimicrobial prophylaxis.

Summary Background A growing number of Mycobacterium chimaera infections after cardiosurgery have been reported by several countries. These potentially fatal infections were traced back to contaminated heater–cooler devices (HCDs), which use water as a heat transfer medium. Aerosolization of water contaminated with M. chimaera from HCDs enables airborne transmission to patients undergoing open chest surgery. Infection control teams test HCD water samples for mycobacterial growth to guide preventive measures. The detection limit of M. chimaera in water samples, however, has not previously been investigated. Aim To determine the detection limit of M. chimaera in water samples using laboratory-based serial dilution tests. Methods An M. chimaera strain representative of the international cardiosurgery-associated M. chimaera outbreak was used to generate a logarithmic dilution series. Two different water volumes, 50 and 1000 mL, were inoculated, and, after identical processing (centrifugation, decantation, and decontamination), seeded on mycobacteria growth indicator tube (MGIT) and Middlebrook 7H11 solid media. Findings MGIT consistently showed a lower detection limit than 7H11 solid media, corresponding to a detection limit of ≥1.44 × 104 cfu/mL for 50 mL and ≥2.4 cfu/mL for 1000 mL water samples. Solid media failed to detect M. chimaera in 50 mL water samples. Conclusion Depending on water volume and culture method, major differences exist in the detection limit of M. chimaera. In terms of sensitivity, 1000 mL water samples in MGIT media performed best. Our results have important implications for infection prevention and control strategies in mitigation of the M. chimaera outbreak and healthcare water safety in general.

BACKGROUND: Invasive Mycobacterium chimaera infections were diagnosed in 2012 in 2 heart surgery patients on extracorporeal circulation. We launched an outbreak investigation to identify the source and extent of the potential outbreak and to implement preventive measures. METHODS: We collected water samples from operating theaters, intensive care units, and wards, including air samples from operating theaters. Mycobacterium chimaera strains were characterized by randomly amplified polymorphic DNA polymerase chain reaction (RAPD-PCR). Case detection was performed based on archived histopathology samples and M. chimaera isolates since 2006, and the patient population at risk was prospectively surveyed. RESULTS: We identified 6 male patients aged between 49 and 64 years with prosthetic valve endocarditis or vascular graft infection due to M. chimaera, which became clinically manifest with a latency of between 1.5 and 3.6 years after surgery. Mycobacterium chimaera was isolated from cardiac tissue specimens, blood cultures, or other biopsy specimens. We were able also to culture M. chimaera from water circuits of heater-cooler units connected to the cardiopulmonary bypass, and air samples collected when the units were in use. RAPD-PCR demonstrated identical patterns among M. chimaera strains from heater-cooler unit water circuits and air samples, and strains in 2 patient clusters. CONCLUSIONS: The epidemiological and microbiological features of this prolonged outbreak provided evidence for the airborne transmission of M. chimaera from contaminated heater-cooler unit water tanks to patients during open-heart surgery.

Objective:Although alcohol-based hand rinses and gels have recommended application times of 30 to 60 seconds, healthcare workers usually take much less time for hand hygiene. We compared the efficacies of four alcohol-based hand rubs produced in Europe (hand rinses A, B, and C and one gel formulation) with the efficacy of the European Norm 1500 (EN 1500) reference waterless hand antisepsis agent (60% 2-propanol) at short application times.Design:Comparative crossover study.Setting:Infection Control Program laboratory of a large tertiary-care teaching hospital.Participants:Twelve healthy volunteers.Intervention:Measurement of residual bacterial counts and log reduction factors following inoculation of fingertips with Staphylococcus aureus American Type Culture Collection (ATCC) 6538, Pseudomonas aeruginosa ATCC 15442, and a clinical isolate of Enterococcus faecalis.Results:All hand rinses satisfied EN 1500 standards following a single application for 15 and 30 seconds, but reduction factors for the gel formulation were significantly lower for all tested organisms (all P < .025).Conclusions:Under stringent conditions similar to clinical practice, all three hand rinses proved to be more efficacious than the marketed alcohol-based gel in reducing bacterial counts on hands. Further studies are necessary to determine the in vivo efficacy of alcohol-based gels and whether they are as efficacious as alcohol-based rinses in reducing the transmission of nosocomial infections.

Mycobacterium chimaera infections following cardiac surgery have been reported from an increasing number of countries. These infections are characterized by a poor prognosis with a case fatality rate around 50% despite treatment. Since the first description in 2013, our understanding has grown steadily. Several outbreak investigations, case series, and experiments with heater-cooler units (HCUs) have been published. This review summarizes the current knowledge.M. chimaera transmission occurs during cardiopulmonary bypass via bioaerosols emitted from contaminated HCU water systems. Manifestations of M. chimaera infection comprise endocarditis, vascular graft infections, surgical site infections, and dissemination. So far, all cases were exposed to a single HCU brand. Samples from the manufacturing site as well as clonality of M. chimaera strains isolated from HCUs and patients suggest a contamination already at time of delivery representing the main source for the outbreak. Nevertheless, HCU contamination in hospitals cannot be excluded.Improved awareness of physicians of M. chimaera infection is crucial to prompt adequate diagnostic workup in patients that have been exposed to HCU presenting with compatible symptoms. For risk mitigation, strict separation between the air volume in contact with HCUs and critical clinical areas such as operating rooms is essential.