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Selective reporting of antibiotic susceptibility test (AST) results is one possible laboratory-based antibiotic stewardship intervention. The primary aim of this study was to identify where and how selective reporting of AST results is implemented in Europe both in inpatient and in outpatient settings. An ESCMID cross-sectional, self-administered, internet-based survey was conducted among all EUCIC (European Committee on Infection Control) or EUCAST (European Committee on Antimicrobial Susceptibility Testing) national representatives in Europe and Israel. Of 38 countries, 36 chose to participate in the survey. Selective reporting of AST results was implemented in 11/36 countries (31%), was partially implemented in 4/36 (11%) and was limited to local initiatives or was not adopted in 21/36 (58%). It was endorsed as standard of care by health authorities in only three countries. The organisation of selective reporting was everywhere discretionally managed by each laboratory, with a pronounced intra-and inter-country variability. The most frequent application was in uncomplicated community-acquired infections, particularly urinary tract and skin and soft-tissue infections. The list of reported antibiotics ranged from a few first-line options, to longer reports where only last-resort antibiotics were hidden. Several barriers to implementation were reported, mainly lack of guidelines, poor system support, insufficient resources, and lack of professionals' capability. In conclusion, selective reporting of AST results is poorly implemented in Europe and is applied with a huge heterogeneity of practices. Development of an international framework, based on existing initiatives and identified barriers, could favour its dissemination as one important element of antibiotic stewardship programmes. KEYWORDS: Antibiotic prescription; Antibiotic resistance; Antibiotic stewardship; Antibiotic susceptibility testing; Questionnaire; Selective reporting PMID: 28093208 DOI: 10.1016/j.ijantimicag.2016.11.014, Selective reporting of antibiotic susceptibility test (AST) results is one possible laboratory-based antibiotic stewardship intervention. The primary aim of this study was to identify where and how selective reporting of AST results is implemented in Europe both in inpatient and in outpatient settings. An ESCMID cross-sectional, self-administered, internet-based survey was conducted among all EUCIC (European Committee on Infection Control) or EUCAST (European Committee on Antimicrobial Susceptibility Testing) national representatives in Europe and Israel. Of 38 countries, 36 chose to participate in the survey. Selective reporting of AST results was implemented in 11/36 countries (31%), was partially implemented in 4/36 (11%) and was limited to local initiatives or was not adopted in 21/36 (58%). It was endorsed as standard of care by health authorities in only three countries. The organisation of selective reporting was everywhere discretionally managed by each laboratory, with a pronounced intra- and inter-country variability. The most frequent application was in uncomplicated community-acquired infections, particularly urinary tract and skin and soft-tissue infections. The list of reported antibiotics ranged from a few first-line options, to longer reports where only last-resort antibiotics were hidden. Several barriers to implementation were reported, mainly lack of guidelines, poor system support, insufficient resources, and lack of professionals' capability. In conclusion, selective reporting of AST results is poorly implemented in Europe and is applied with a huge heterogeneity of practices. Development of an international framework, based on existing initiatives and identified barriers, could favour its dissemination as one important element of antibiotic stewardship programmes.

Staphylococcus aureus is the leading pathogen in surgical site infections (SSI).To explore trends and risk factors associated with S. aureus SSI.Risk factors for monomicrobial S. aureus SSI were identified from the Swiss multi-centre SSI surveillance system using multi-variate logistic regression. Both in-hospital and postdischarge SSI were identified using standardized definitions.Over a six-year period, data were collected on 229,765 surgical patients, of whom 499 (0.22%) developed monomicrobial S. aureus SSI; 459 (92.0%) and 40 (8.0%) were due to meticillin-susceptible S. aureus (MSSA) and meticillin-resistant S. aureus (MRSA), respectively. There was a significant decrease in the rate of MSSA SSI (P = 0.007), but not in the rate of MRSA SSI (P = 0.70). Independent protective factors for S. aureus SSI were older age [≥75 years vs50 years: odds ratio (OR) 0.60, 95% confidence interval (CI) 0.44-0.83], laparoscopy/minimally invasive surgery (OR 0.68, 95% CI 0.50-0.92), non-clean surgery [OR 0.78 (per increase in wound contamination class), 95% CI 0.64-0.94] and correct timing of pre-operative antibiotic prophylaxis (OR 0.80, 95% CI 0.65-0.98). Independent risk factors were male sex (OR 1.38, 95% CI 1.14-1.66), higher American Society of Anesthesiologists' score (per one-point increment: OR 1.30, 95% CI 1.13-1.51), re-operation for non-infectious reasons (OR 4.59, 95% CI 3.59-5.87) and procedure type: cardiac surgery, laminectomy, and hip or knee arthroplasty had two-to nine-fold increased odds of S. aureus SSI compared with other procedures.SSI due to S. aureus are decreasing and becoming rare events in Switzerland. High-risk procedures that may benefit from specific preventive measures were identified. Unfortunately, many of the independent risk factors are not easily modifiable.

Background Proliferation of terms describing the science of effectively promoting and supporting the use of research evidence in healthcare policy and practice has hampered understanding and development of the field. To address this, an international Terminology Working Group developed and published a simplified framework of interventions to promote and integrate evidence into health practices, systems, and policies. This paper presents results of validation work and a second international workgroup meeting, culminating in the updated AIMD framework [Aims, Ingredients, Mechanism, Delivery]. Methods Framework validity was evaluated against terminology schemas (n = 51); primary studies (n = 37); and reporting guidelines (n = 10). Framework components were independently categorized as fully represented, partly represented, or absent by two researchers. Opportunities to refine the framework were systematically recorded. A meeting of the expanded international Terminology Working Group updated the framework by reviewing and deliberating upon validation findings and refinement proposals. Results There was variation in representativeness of the components across the three types of literature, in particular for the component ‘causal mechanisms’. Analysis of primary studies revealed that representativeness of this concept lowered from 92 to 68% if only explicit, rather than explicit and non-explicit references to causal mechanisms were included. All components were very well represented in reporting guidelines, however the level of description of these was lower than in other types of literature. Twelve opportunities were identified to improve the framework, 9 of which were operationalized at the meeting. The updated AIMD framework comprises four components: (1) Aims: what do you want your intervention to achieve and for whom? (2) Ingredients: what comprises the intervention? (3) Mechanisms: how do you propose the intervention will work? and (4) Delivery: how will you deliver the intervention? Conclusions The draft simplified framework was validated with reference to a wide range of relevant literature and improvements have enhanced useability. The AIMD framework could aid in the promotion of evidence into practice, remove barriers to understanding how interventions work, enhance communication of interventions and support knowledge synthesis. Future work needs to focus on developing and testing resources and educational initiatives to optimize use of the AIMD framework in collaboration with relevant end-user groups. Electronic supplementary material The online version of this article (doi:10.1186/s12874-017-0314-8) contains supplementary material, which is available to authorized users.

An outbreak of invasive Mycobacterium chimaera infections associated with heater-cooler devices (HCDs) has now affected patients in several countries on different continents. Clinical infections are characterized by delayed diagnosis, inadequate treatment response to antimicrobial agents, and poor prognosis. Outbreak investigators found M. chimaera in HCD water circuits and air samples while HCDs were running, suggesting that transmission from the HCD to the surgical site occurs via the airborne route. New HCDs at the manufacturing site were also contaminated with M. chimaera, and recent whole-genome sequencing data suggest a point source. Some guidance on screening for M. chimaera colonization in HCD water and exhaust air is available. In contrast, reliable disinfection procedures are not well described, and it is not yet known whether eradication of M. chimaera from a contaminated HCD can be achieved. Meanwhile, strict separation of the HCD from operating room air is necessary to ensure patient safety, and these efforts may require engineering solutions. While our understanding of the causes and the extent of the M. chimaera outbreak is growing, several aspects of patient management, device handling, and risk mitigation still require clarification.Infect Control Hosp Epidemiol 2016;1–6

Invasive Mycobacterium chimaera infections after open-heart surgery have been reported internationally. These devastating infections result from aerosols generated by contaminated heater-cooler units used with extracorporeal circulation during surgery. Despite intensified cleaning and disinfection, surveillance samples from factory-new units acquired during 2014 grew nontuberculous mycobacteria after a median of 174 days.

Human factors design interventions have been suggested to mitigate infection risk in health care. Among such solutions, many are easily identified and theoretically simple and quick to realize. These are called low-hanging fruit. We present a case of infection risk associated with syringe manipulation that could easily be solved by introducing user-centered design solutions. Yet, organizational complexity makes implementation of such solutions hardly reachable. We therefore advocate embedding human factors macroergonomic expertise on an organizational level.

Background In acute care hospitals, urinary catheters are often inserted and kept without proper indication, and may lead to catheter-associated urinary tract infection (CAUTI) and various non-infectious complications. In this pilot study, we attempted to decrease urinary catheterization via an awareness campaign and an intervention bundle, consisting of (1) an indication list for urinary catheterization, (2) daily evaluation of the need for ongoing catheterization, and (3) education on proper catheter insertion and maintenance. Methods We conducted a before/after intervention study in seven small, mid-size and academic hospitals distributed across Switzerland. After a 3-month pre-intervention surveillance, the intervention period started with a workshop for local project leaders who then implemented the intervention bundle. During the 3-month post-intervention surveillance, the primary outcome was catheter utilization; secondary outcomes were CAUTI, non-infectious outcomes, and process indicators (proportion of indicated catheters, frequency of catheter evaluation). Results We analyzed data on 25,880 mostly general medical or surgical patients, 13,171 of which pre-intervention (August–October 2016) and 12,709 post-intervention (August–October 2017). Catheter utilization dropped from 23.7% to 21.0% [adjusted odds ratio 0.9 (95% confidence interval, CI, 0.84–0.96); P = 0.001]. There were 1.02 CAUTI per 1,000 catheter-days (before) and 1.33 (after) [aOR 1.2 (0.6–2.4); P = 0.6]. Non-infectious complications decreased slightly from 39.4 to 35.4 events per 1,000 catheter-days [aOR 0.9 (0.77–1.07); P = 0.2]. The proportion of catheters with a documented proper indication went from 74.5% to 90.0% [aOR 4.1 (3.35–4.95); P < 0.001]. Reevaluations increased from 167 to 623 per 1,000 catheter-days [aOR 3.12 (2.92–3.36); P < 0.001]. Conclusion In this before/after intervention study, a simple bundle of 3 evidence-based measures reduced catheter utilization and led to increases in indicated urinary catheters and daily evaluations. The intervention had a small impact on non-infectious complications, whereas the CAUTI rate remained on a low level. The next step is planning the national rollout of both the surveillance module and the intervention bundle. Disclosures All authors: No reported disclosures.

Objective.To assess the feasibility and effectiveness of the World Health Organization hand hygiene improvement strategy in a low-income African country.Design.A before-and-after study from December 2006 through June 2008, with a 6-month baseline evaluation period and a follow-up period of 8 months from the beginning of the intervention.Setting.University Hospital, Bamako, Mali.Participants.TWO hundred twenty-four healthcare workers.Methods.The intervention consisted of introducing a locally produced, alcohol-based handrub; monitoring hand hygiene compliance; providing performance feedback; educating staff; posting reminders in the workplace; and promoting an institutional safety climate according to the World Health Organization multimodal hand hygiene improvement strategy. Hand hygiene infrastructure, compliance, healthcare workers' knowledge and perceptions, and handrub consumption were evaluated at baseline and at follow-up.Results.Severe deficiencies in the infrastructure for hand hygiene were identified before the intervention. Local handrub production and quality control proved to be feasible, affordable, and satisfactory. At follow-up, handrubbing was the quasi-exclusive hand hygiene technique (93.3%). Compliance increased from 8.0% at baseline to 21.8% at follow-up (P< .001). Improvement was observed across all professional categories and medical specialities and was independently associated with the intervention (odds ratio, 2.50; 95% confidence interval, 1.8-3.5). Knowledge enhanced significantly (P< .05), and perception surveys showed a high appreciation of each strategy component by staff.Conclusions.Multimodal hand hygiene promotion is feasible and effective in a low-income country. Access to handrub was critical for its success. These findings motivated the government of Mali to expand the intervention nationwide. This experience represents a significant advancement for patient safety in developing countries.

Background.Research suggests that patients could improve healthcare workers' compliance with hand hygiene recommendations by reminding them to cleanse their hands.Objective.To assess patients' perceptions of a patient-participation program to improve healthcare workers' compliance with hand hygiene.Design.Cross-sectional survey of patient knowledge and perceptions of healthcare-associated infections, hand hygiene, and patient participation, defined as the active involvement of patients in various aspects of their health care.Setting.Large Swiss teaching hospital.Results.Of 194 patients who participated, most responded that they would not feel comfortable asking a nurse (148 respondents [76%]) or a physician (150 [77%]) to perform hand hygiene, and 57 (29%) believed that this would help prevent healthcare-associated infections. In contrast, an explicit invitation from a healthcare worker to ask about hand hygiene doubled the intention to ask a nurse (from 34% to 83% of respondents; P < .001) and to ask a physician (from 30% to 78%; P < .001). In multivariate analysis, being nonreligious, having an expansive personality, being concerned about healthcare-associated infections, and believing that patient participation would prevent healthcare-associated infections were associated with the intention to ask a nurse or a physician to perform hand hygiene (P < .05). Being of Jewish, Eastern Orthodox, or Buddhist faith was associated also with increased intention to ask a nurse (P < .05), compared with being of Christian faith.Conclusions.This study identifies several sociodemographic characteristics associated with the intention to ask nurses and physicians about hand hygiene and underscores the importance of a direct invitation from healthcare workers to increase patient participation and foster patient empowerment. These findings could guide the development of future hand hygiene-promotion strategies.

Staphylococcal infections are one of the main causes of complications in patients with implanted foreign prosthetic material. Implants are associated with a significant reduction of the threshold at which contaminating Gram-positive bacteria, particularly Staphylococcus epidermidis, become infectious and develop a biofilm with phenotypic resistance to almost all antibiotics. A 1000-fold increase in minimal bactericidal levels against most antibiotics except rifampin has been repeatedly observed. Since only removal of the foreign material reverses these phenomena, the clinical challenge consists in finding approaches to cure the infection without removal of the implanted device. Rifampin combinations with other antibiotics, administration of exceedingly high antibiotic concentrations in situ, and early therapy before biofilm development are efficacious. Although these strategies have dramatically improved the outcome of foreign body infections, an improved understanding of biofilm-grown S. epidermidis is necessary to develop new antibacterial agents. Here, we review the pathogenesis, prevention, and treatment of implant infections due to S. epidermidis and highlight some new compounds with already promising in vitro results.

OBJECTIVEIn-hospital transmission of methicillin-susceptibleStaphylococcus aureus(MSSA) among neonates remains enigmatic. We describe the epidemiology of MSSA colonization and infection in a 30-bed neonatal ward.DESIGNMultimodal outbreak investigationSETTINGA public 800-bed tertiary care university hospital in SwitzerlandMETHODSInvestigations 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.RESULTSAmong 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 forS. aureuscarriage, 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 waspvl-negative,tst-positive and belonged toagrgroup 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.CONCLUSIONSHospital-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.Infect. Control Hosp. Epidemiol.2015;36(11):1305–1312

Aims We identified 10 patients with disseminated Mycobacterium chimaera infections subsequent to open-heart surgery at three European Hospitals. Infections originated from the heater–cooler unit of the heart–lung machine. Here we describe clinical aspects and treatment course of this novel clinical entity. Methods and results Interdisciplinary care and follow-up of all patients was documented by the study team. Patients’ characteristics, clinical manifestations, microbiological findings, and therapeutic measures including surgical reinterventions were reviewed and treatment outcomes are described. The 10 patients comprise a 1-year-old child and nine adults with a median age of 61 years (range 36–76 years). The median duration from cardiac surgery to diagnosis was 21 (range 5–40) months. All patients had prosthetic material-associated infections with either prosthetic valve endocarditis, aortic graft infection, myocarditis, or infection of the prosthetic material following banding of the pulmonary artery. Extracardiac manifestations preceded cardiovascular disease in some cases. Despite targeted antimicrobial therapy, M. chimaera infection required cardiosurgical reinterventions in eight patients. Six out of 10 patients experienced breakthrough infections, of which four were fatal. Three patients are in a post-treatment monitoring period. Conclusion Healthcare-associated infections due to M. chimaera occurred in patients subsequent to cardiac surgery with extracorporeal circulation and implantation of prosthetic material. Infections became clinically apparent after a time lag of months to years. Mycobacterium chimaera infections are easily missed by routine bacterial diagnostics and outcome is poor despite long-term antimycobacterial therapy, probably because biofilm formation hinders eradication of pathogens.

Hand hygiene is a core activity of patient safety for the prevention of healthcare-associated infections (HCAIs). To standardize hand hygiene practices globally the World Health Organization (WHO) released Guidelines on Hand Hygiene in Health Care and introduced the 'My five moments for hand hygiene' concept to define indications for hand hygiene rooted in an evidence-based model for transmission of micro-organisms by healthcare workers' (HCWs) hands. Central to the concept is the division of the healthcare environment into two geographical care zones, the patient zone and the healthcare zone, that requires the HCW to comply with specific hand hygiene moments. In resource-limited, overcrowded healthcare settings inadequate or no spatial separation between beds occurs frequently. These conditions challenge the HCW's ability to visualize and delineate patient zones. The 'My five moments for hand hygiene' concept has been adapted for these conditions with the aim of assisting hand hygiene educators, auditors, and HCWs to minimize ambiguity regarding shared patient zones and achieve the ultimate goal set by the WHO Guidelines - the reduction of infectious risks.

Background Optimizing user satisfaction with alcohol-based hand rubs (ABHR) may be vital to enhance hand hygiene performance. This study tested the tolerability and acceptability of a new ABHR (EVO9; Ecolab) in healthcare workers under daily working conditions and evaluated the practicability of the corresponding WHO protocol. Methods We strictly applied the WHO single product ABHR evaluation protocol. A trained observer assessed hand skin conditions of healthy volunteers using at least 30 ml ABHR per day during their clinical work at baseline, day 3–5 and one month (visit 1–3). Participants rated ABHR tolerability and acceptability at visit 2 and 3. Additionally, we registered study time for participants and study team. Results Among 46 volunteers, 76% were female; 37% nurses, 28% physicians. Skin was observer-rated “not” or “incidentally” dry in 64.4%, 77.8%, and 90.9% participants at visit 1, 2, and 3, respectively. EVO9 was scored ≥5 (progressive scale, 1–7) for appearance, intactness, moisture content, and sensation by 95.7%, 97.7%, 88.9%, and 97.8% participants at visit 3, respectively. All WHO benchmarks were exceeded except for “speed of drying” at visit 2, and “texture” at visit 2 and 3. Cumulative study time expenditure was 14 days for the observer and four days for participants. Conclusions EVO9 was well tolerated and accepted according to the WHO single ABHR evaluation protocol with the potential for improvement for stickiness. The WHO protocol is feasible but requires considerable time and logistics. It does not preclude bias, in this case especially due to the necessary switch to personal dispensers.

Hand cleansing is the primary action to reduce health-care-associated infection and cross-transmission of antimicrobial-resistant pathogens. Patient-to-patient transmission of pathogens via health-care workers' hands requires five sequential steps: (1) organisms are present on the patient's skin or have been shed onto fomites in the patient's immediate environment; (2) organisms must be transferred to health-care workers' hands; (3) organisms must be capable of surviving on health-care workers' hands for at least several minutes; (4) handwashing or hand antisepsis by the health-care worker must be inadequate or omitted entirely, or the agent used for hand hygiene inappropriate; and (5) the caregiver's contaminated hand(s) must come into direct contact with another patient or with a fomite in direct contact with the patient. We review the evidence supporting each of these steps and propose a dynamic model for hand hygiene research and education strategies, together with corresponding indications for hand hygiene during patient care.

To control an outbreak of community-associated MRSA (CA-MRSA) in a neonatology unit, an investigation was conducted that involved screening neonates and parents, molecular analysis of MRSA isolates and long-term follow-up of cases. During a two-month period in the summer of 2000, Panton-Valentine leukocidin (PVL)-producing CA-MRSA (strain ST5-MRSA-IV) was detected in five neonates. The mother of the index caseshowed signs of mastitis and wound infection and consequently tested positive for CA-MRSA. A small cluster of endemic, PVL-negative MRSA strains (ST228-MRSA-I) occurred in parallel. Enhanced hygiene measures, barrier precautions, topical decolonization of carriers, and cohorting of new admissions terminated the outbreak. Four months after the outbreak, the mother of another neonate developed furunculosis with the epidemic CA-MRSA strain. One infant had persistent CA-MRSA carriage resulting in skin infection in a sibling four years after the outbreak. In conclusion, an epidemic CA-MRSA strain was introduced by the mother of the index case. This spread among neonates and was subsequently transmitted to another mother and a sibling. This is the first report of a successfully controlled neonatology outbreak of genetically distinct PVL-producing CA-MRSA in Europe.

Von Januar bis Mitte Februar 2005 wurden dem Kantonsarzt von Genf 15 Fälle von bestätigten Masern gemeldet; verglichen zu einem einzelnen Fall im 2004. Ungewöhnlich an dieser Epidemie war das Alter der betroffenen Personen von 17 bis 44 Jahren. Vier unter ihnen waren Mitarbeiter eines öffentlichen Spitals, die sich nach Kontakt zu einem einzigen, 44-jährigen Patienten ansteckten und die Infektion zum Teil weiter übertrugen. Die Annahme, dass Masern eine pädiatrische Infektion sind, erschwerte die Diagnose. Keiner der betroffenen Erwachsenen war immun nach dem heutigen Stand der Empfehlungen. Trotz vorhandenem Impfplan, behördlichen Empfehlungen, Kostenübernahme durch die Krankenkassen und den guten Impfergebnissen mit den heute zur Verfügung stehenden Vakzinen, ist die freiwillige Durchimpfungsrate in der Schweiz unter Kindern und Erwachsenen zu gering um den Ausbruch von Epidemien zu verhindern. Im Gegensatz zu den Zielen des Bundesamt für Gesundheit (BAG) und der Weltgesundheitsorganisation (WHO) sind wir in der Schweiz aus verschiedenen Gründen noch nicht so weit eine genügend hohe Herdimmunität aufzubauen, um gesundheitliche und volkswirtschaftliche Schäden durch aufflackernde Epidemien zu verhindern.

Objective:To assess the level of knowledge regarding and attitudes toward standard and isolation precautions among healthcare workers in a hospital.Method:A confidential, self-administered questionnaire survey was conducted in a random sample of 1,500 nurses and 500 physicians in a large teaching hospital.Results:A total of 1,241 questionnaires were returned (response rate, 62%). The median age of respondents was 39 years; 71.9% were women and 21.2% had senior staff status. One-fourth had previously participated in specific training regarding transmission precautions for pathogens conducted by the infection control team. More than half (55.9%) gave correct answers to 10 or more of the 13 knowledge-type questions. The following reasons for noncompliance with guidelines were judged as “very important”: lack of knowledge (47%); lack of time (42%); forget-Mness (39%); and lack of means (28%). For physicians and healthcare workers in a senior position, lack of time and lack of means were significantly less important (P < .0005). On multivariate linear regression, knowledge was independently associated with exposure to training sessions (coefficient, 0.33; 95% confidence interval, 0.08 to 0.57; P = .009) and less professional experience (coefficient per increasing professional experience, -0.024; 95% confidence interval, -0.035 to -0.012; P < .0005).Conclusions:Despite a training effort targeting opinion leaders, knowledge of transmission precautions for pathogens remained insufficient. Nevertheless, specific training proved to be the major determinant of “good knowledge”.

Aim: To assess the incidence of legionella infection over a 27 month period at a large university hospital. Material and Methods: The present retrospective cohort study enrolled patients with legionellosis, defined as those presenting a positive urinary antigen for legionella together with a medical history, clinical findings, and radiological findings consistent with pneumonia. These patients were evaluated to determine the relation between their test results and changes in treatment modalities. A control group of patients with pneumonia but a negative urinary antigen test for legionella were also analysed. Results: Twenty seven of 792 assessed patients tested positive for legionella. In 22 of these patients, legionella active antibiotics were administered empirically. In seven patients, the test results prompted a legionella specific treatment, whereas in 12 cases, non-specific antibiotics were stopped within 24 hours. Overall, treatment was altered in more than half of the patients as a result of the test results. Conclusions: The urinary antigen may have a direct impact on clinical management of pulmonary legionellosis. However, patient comorbidities and individual clinical judgment are still important for determining the best treatment to be given in each individual case.

Nosocomial infections are a leading cause of morbidity and mortality among hospitalized patients. These infections have made newspaper headlines recently in many countries, and both patients and their relatives are now perfectly aware of their existence and of the risks which are inherent to any medical activity. However, significant improvements in the knowledge of the pathophysiology and epidemiology of nosocomial infections allow us to prevent them efficiently. Accordingly, they should no longer be considered as an inevitable tribute to pay to the continuous progress of medicine, but as a real challenge in the process of improving the quality of patient care. This is particularly the case for bloodstream infections, of which at least 80% are considered to be catheter associated. This paper reviews the epidemiology and impact of infections associated with the use of intravenous catheters. Principles of therapy are reviewed, as well as major aspects of prevention.

Die Resistenzentwicklung, bekannt seit der Erfindung der Antibiotika, beschleunigte sich in den letzten Jahren, so dass am Horizont bereits eine postantibiotische Ära ausgemacht wird. Der Kampf gegen eine weitere Zunahme von Resistenzen ist zu einem zentralen Thema von Infektiologen und Epidemiologien geworden, muss jetzt aber alle Ärzte, die Führungsetagen der Spitäler und das breite Publikum interessieren. Die Erkenntnisse über die Ursachen der Antibiotikaresistenz werden immer weiter detailliert, sind aber in ihren Hauptachsen bereits seit längerem klar: Der übermäßige und unkluge Einsatz von Antibiotika und die Übertragung von resistenten Keimen zwischen Individuen innerhalb und außerhalb von Gesundheitseinrichtungen. In dieser Arbeit werden die wichtigsten erfolgversprechenden Strategien zur Bekämpfung der Resistenz und ihr praktischer Einsatz besprochen.

Much of the effort devoted to promoting better hand hygiene is based on the belief that poor hand hygiene reflects poor motivation. We argue, however, that automatic unconscious behaviour driven by 'mental models' is an important contributor to what actually happens. Mental models are concepts of reality--imaginary, often blurred, and sometimes unstable. Human beings use them to reduce mental load and free up capacity in the conscious mind to focus on deliberate activities. They are pragmatic solutions to the complexity of life. Knowledge of such mental processes helps healthcare designers and clinicians overcome barriers to behavioural change. This article reviews the concept of mental models and considers how it can be used to improve hand hygiene and patient safety.

We pilot tested a novel human factors–informed concept to identify infectious risk moments (IRMs) that occur with high frequency during routine intensive care. Following 30 observation-hours, 28 potential IRMs related to hand hygiene, gloves, and objects were expert rated. A comprehensive IRM inventory may provide valuable taxonomy for research, training, and intervention.Infect Control Hosp Epidemiol 2014;35(8):1051–1055

Objective.To explore differences in the prevalence of healthcare-associated infections (HAIs) according to survey methodology.Design.Repeated point and period prevalence survey strategies.Setting.University-affiliated primary and tertiary care center.Methods.Analysis of data collected from 2006 to 2012 from annual HAI prevalence surveys using definitions proposed by the US Centers for Disease Control and Prevention. The study design allowed the analysis of the same data in the format of a point or a period prevalence survey.Results.Pooled point and period HAI prevalence was 7.46% and 9.84% (+32%), respectively. This additional 32% was mainly attributable to infections of the lower respiratory tract (2.42% vs 3.20% [+32%]) and the urinary tract (1.76% vs 2.62% [+49%]). Differences in surgical site infections (1.02% vs 1.20% [+19%]) and bloodstream infections (0.76% vs 0.86% [+13%]) were smaller. HAI prevalence for the point and period methodology in acute and long-term care were 7.47% versus 9.38 (+26%) and 8.37% versus 11.89% (+42%), respectively. Differences were stable over time. Focusing on the 4 major HAIs (respiratory tract, urinary tract, surgical site, and bloodstream infections) misses one-quarter of all HAIs.Conclusions.More HAIs are identified by the period prevalence method, especially those of shorter duration (lower respiratory and urinary tract), which would make this method more suitable to be used in long-term care. Results of the 2 study methods cannot be benchmarked against each other.Infect Control Hosp Epidemiol2014;35(6):674–684

Objective.To test the hypothesis that methicillin-susceptible Staphylococcus aureus (MSSA) carriage may protect against nosocomial methicillin-resistant S. aureus (MRSA) acquisition by competing for colonization of the anterior nares.Design.Prospective cohort and nested case-control study.Setting.Swiss university hospital.Patients.All adult patients admitted to 14 wards of the general medicine division between April 1 and October 31, 2007.Methods.Patients were screened for MRSA and MSSA carriage at admission to and discharge from the division. Associations between nosocomial MRSA acquisition and MSSA colonization at admission and other confounders were analyzed by univariable and multivariable analysis.Results.Of 898 patients included, 183 (20%) were treated with antibiotics. Nosocomial MRSA acquisition occurred in 70 (8%) of the patients (case patients); 828 (92%) of the patients (control subjects) were free of MRSA colonization at discharge. MSSA carriage at admission was 20% and 21% for case patients and control subjects, respectively. After adjustment by multivariate logistic regression, no association was observed between MSSA colonization at admission and nosocomial MRSA acquisition (adjusted odds ratio [aOR], 1.2 [95% confidence interval (CI), 0.6–2.3]). By contrast, 4 independent predictors of nosocomial MRSA acquisition were identified: older age (aOR per 1-year increment, 1.05 [95% CI, 1.02–1.08]); increased length of stay (aOR per 1-day increment, 1.05 [95% CI, 1.02–1.09]); increased nursing workload index (aOR per 1-point increment, 1.02 [95% CI, 1.01–1.04]); and previous treatment with macrolides (aOR, 5.6 [95% CI, 1.8–17.7]).Conclusions.Endogenous MSSA colonization does not appear to protect against nosocomial MRSA acquisition in a population of medical patients without frequent antibiotic exposure.

Objective: To determine the integrity of microscope covers and bacterial contamination at the end of lumbar spinal decompressive surgery. Materials and Methods: A prospective study of 25 consecutive lumbar spinal decompressions with the use of a surgical microscope was performed. For detection of perforations, the microscope covers were filled with water at the end of surgery and the presence of water leakage in 3 zones (objective, ocular and control panel) was examined. For detection of bacterial contamination, swabs were taken from the covers at the same locations before and after surgery. Results: Among the 25 covers, 1 (4%) perforation was observed and no association between perforation and bacterial contamination was seen; 3 (4%) of 75 smears from the 25 covers showed post-operative bacterial contamination, i.e. 2 in the ocular zone and 1 in the optical zone, without a cover perforation. Conclusions: The incidence of microscope cover perforation was very low and was not shown to be associated with bacterial contamination. External sources of bacterial contamination seem to outweigh the problem of contamination due to failure of cover integrity.

BACKGROUND Concurrent potent therapy of hepatitis C (HCV) and HIV includes at least five antiviral drugs. Drug interactions, toxicity, tolerance and acceptance by patients of such treatment regimens are unknown. STUDY DESIGN A prospective open randomized pilot trial was conducted to test interferon-alpha (6 million units/day for the 1st month followed by 6 million thrice weekly) and amantadine versus interferon-alpha monotherapy for tolerability and feasibility among HIV and HCV co-infected patients on stable antiretroviral combination therapy. RESULTS 1,013 HIV-infected patients were consecutively evaluated. 314 were anti-HCV antibody positive; only eight (2.4%) were eligible. Major reasons for exclusion were: normal transaminase levels (34%), ongoing intravenous drug use (33%), or recent change in antiretroviral therapy (31%). Study drugs were stopped in all of the seven patients enrolled because of side effects and/or failure of anti-HCV therapy. CD4 lymphocyte counts and HIV-1 RNA remained stable. CONCLUSION Among patients on highly active antiretroviral therapy, the addition of interferon-alpha with or without amantadine was inefficient and poorly tolerated, but had no negative influence on HIV infection. Eligibility for the study was unexpectedly low.

A study was performed to estimate the prevalence of nosocomial infections (NI) and assess differences between medical care settings in one hospital complex. A seven-day period-prevalence survey was conducted in May 1998 in a large primary and tertiary healthcare centre in Geneva, Switzerland, that included all patients in acute, sub-acute and chronic care settings. Variables included demography, exposure to invasive devices and antibiotics, surgical history, and patients' localization. Overall prevalence of NI was 11.3% (acute, 8.4%; sub-acute, 11.4%; chronic care setting, 16.4%) in the 1928 patients studied, and ranged from 0% in ophthalmology to 23% in critical care units. Odds of infection in sub-acute and chronic care settings were significantly higher than in the acute care setting even after adjustment for case-mix [OR, 2.59; 95% confidence interval (CI(95)) 1.53-4.41; and OR, 2.34; Cl(95)1.38-3.95, respectively]. As a distinct group, patients in the geriatric location (belonging to the sub-acute care setting) showed a significant proportion of urinary (39%) and respiratory (21%) tract infections, contrasting with a relatively low exposure to urinary catheters (6.1%) and orotracheal intubation (0%). In conclusion, sub-acute and chronic care settings are associated with high infection prevalence even after case-mix adjustment. Prevalence studies are an easy surveillance tool that can be exploited further by analysing data according to hospital care settings to identify high-risk areas.

The impact of an infectious disease (ID) service on the optimal antibiotic management of 103 patients with bloodstream infections, defined as bacteremia and systemic inflammatory response syndrome, was evaluated. The optimal antibiotic management was defined according to the Sanford Guide to Antimicrobial Therapy (1996) or written internal guidelines. The judgment on optimal antibiotic management was made at the time of reporting the positive blood culture results. Switching from a broad-spectrum to a narrow-spectrum agent was carried out significantly more often by the ID service than by the attending physicians (25 of 25 vs. 20 of 40; P

Despite significant progress in antibiotic therapy and orthopedic surgery, osteomyelitis remains a difficult-to-treat infection that is often associated with recurrence. In this paper we summarize the most recent developments in understanding the pathogenesis of this complex disease, as well as novel means for its diagnosis and treatment.

OBJECTIVE: To assess the prognostic significance of drug-associated mutations in the protease and reverse transcriptase (RT) genes on virological response to salvage therapy. PATIENTS: All patients from four centres of the Swiss HIV Cohort Study who were switched, between February and October 1997, to nelfinavir plus other antiretroviral drugs following failure of highly active antiretroviral therapy (HIV-1 RNA >1000 copies/ml after > 3 months). METHODS: Direct sequencing of RT and protease genes derived from plasma RNA was performed in 62 patients before salvage therapy. Baseline predictors (drug-resistance mutations, drug exposure, clinical and biological parameters) of virological response after 4-12 weeks of therapy were assessed by linear regression analyses. RESULTS: Patients had been treated with RT inhibitors and protease inhibitors for a median duration of 35.6 and 12.2 months, respectively. Baseline median CD4 cell count was 113 x 10(6)/l and HIV-1 RNA 5.16 log10 copies/ml. The median decrease of HIV-1 RNA was 0.38 log10; 32% of the patients showed > 1 log10 decrease. At baseline, 90% of the patients had RT inhibitor-resistance mutations with a median number per patient of four (range, 0-7). Primary and secondary protease inhibitor-resistance mutations were detected in 69% and 89% of the patients, respectively. The median number of total protease inhibitor-resistance mutations per patient was four (range, 0-9). In univariate analysis, virological response to salvage therapy was associated with number of RT inhibitors, primary and secondary protease inhibitor-resistance mutations, history of protease inhibitor use (duration and number), but not with clinical stage, HIV-1 RNA level or CD4 cell count. After adjustment for all variables, the number of RT inhibitor plus protease inhibitor-resistance mutations was the only independent predictor. CONCLUSIONS: In patients with advanced HIV infection, the virological response to salvage therapy containing nelfinavir is best predicted by the number of baseline RT inhibitor plus protease inhibitor-resistance mutations.

Objective We studied whether the change in antibiotic susceptibility testing (AST) guidelines from CLSI to EUCAST influenced cumulative antibiograms in a tertiary care hospital in Switzerland. Methods Antibiotic susceptibilities of non-duplicate isolates collected within a one-year period before (period A) and after (period B) changing AST interpretation from CLSI 2009 to EUCAST 1.3 (2011) guidelines were analysed. In addition, period B isolates were reinterpreted according to the CLSI 2009, CLSI 2013 and EUCAST 3.1 (2013) guidelines. Results The majority of species/drug combinations showed no differences in susceptibility rates comparing periods A and B. However, in some gram-negative bacilli, decreased susceptibility rates were observed when comparing CLSI 2009 with EUCAST 1.3 within period B: Escherichia coli / cefepime, 95.8% (CLSI 2009) vs. 93.1% (EUCAST 1.3), P=0.005; Enterobacter cloacae / cefepime, 97.0 (CLSI 2009) vs. 90.5% (EUCAST 1.3), P=0.012; Pseudomonas aeruginosa / meropenem, 88.1% (CLSI 2009) vs. 78.3% (EUCAST 1.3), P=0.002. These differences were still evident when comparing susceptibility rates according to the CLSI 2013 guideline with EUCAST 3.1 guideline. For P. aeruginosa and imipenem, a trend towards a lower antibiotic susceptibility rate in ICUs compared to general wards turned into a significant difference after the change to EUCAST: 87.9% vs. 79.8%, P=0.08 (CLSI 2009) and 86.3% vs. 76.8%, P=0.048 (EUCAST 1.3). Conclusions The change of AST guidelines from CLSI to EUCAST led to a clinically relevant decrease of susceptibility rates in cumulative antibiograms for defined species/drug combinations, particularly in those with considerable differences in clinical susceptibility breakpoints between the two guidelines.

Background The implementation of evidence-based infection control practices is essential, yet challenging for healthcare institutions worldwide. Although acknowledged that implementation success varies with contextual factors, little is known regarding the most critical specific conditions within the complex cultural milieu of varying economic, political, and healthcare systems. Given the increasing reliance on unified global schemes to improve patient safety and healthcare effectiveness, research on this topic is needed and timely. The ‘InDepth’ work package of the European FP7 Prevention of Hospital Infections by Intervention and Training (PROHIBIT) consortium aims to assess barriers and facilitators to the successful implementation of catheter-related bloodstream infection (CRBSI) prevention in intensive care units (ICU) across several European countries. Methods We use a qualitative case study approach in the ICUs of six purposefully selected acute care hospitals among the 15 participants in the PROHIBIT CRBSI intervention study. For sensitizing schemes we apply the theory of diffusion of innovation, published implementation frameworks, sensemaking, and new institutionalism. We conduct interviews with hospital health providers/agents at different organizational levels and ethnographic observations, and conduct rich artifact collection, and photography during two rounds of on-site visits, once before and once one year into the intervention. Data analysis is based on grounded theory. Given the challenge of different languages and cultures, we enlist the help of local interpreters, allot two days for site visits, and perform triangulation across multiple data sources. Qualitative measures of implementation success will consider the longitudinal interaction between the initiative and the institutional context. Quantitative outcomes on catheter-related bloodstream infections and performance indicators from another work package of the consortium will produce a final mixed-methods report. Conclusion A mixed-methods study of this scale with longitudinal follow-up is unique in the field of infection control. It highlights the ‘Why’ and ‘How’ of best practice implementation, revealing key factors that determine success of a uniform intervention in the context of several varying cultural, economic, political, and medical systems across Europe. These new insights will guide future implementation of more tailored and hence more successful infection control programs. Trial registration Trial number: PROHIBIT-241928 (FP7 reference number)

Background Exposure to urinary catheters is considered the most important risk factor for healthcare-associated urinary tract infection (UTI) and is associated with significant morbidity and substantial extra-costs. In this study, we assessed the impact of urinary catheterisation (UC) on symptomatic healthcare-associated UTI among hospitalized patients. Methods A nationwide period prevalence survey of healthcare-associated infections was conducted during 1 May to 30 June 2004 in 49 Swiss hospitals and included 8169 adult patients (4313 female; 52.8%) hospitalised in medical, surgical, intermediate, and intensive care wards. Additional data were collected on exposure to UC to investigate factors associated with UTI among hospitalised adult patients exposed and non-exposed to UC. Results 1917 (23.5%) patients were exposed to UC within the week prior to survey day; 126 (126/8169; 1.5%) developed UTI. Exposure to UC preceded UTI only in 73 cases (58%). By multivariate logistic regression analysis, UTI was independently associated with exposure to UC (odds ratio [OR], 3.9 [95% CI, 2.6-5.9]), female gender (OR, 2.1 [95% CI, 1.4-3.1]), an American Society of Anesthesiologists’ score > 2 points (OR, 3.2 [95% CI, 1.1-9.4], and prolonged hospital stay >20 days (OR, 1.9 [95% CI, 1.4-3.2]. Further analysis showed that the only significant factor for UTI with exposure to UC use was prolonged hospital stay >40 days (OR, 2.9 [95% CI, 1.3-6.1], while female gender only showed a tendency (OR, 1.6 [95% CI, 1.0-2.7]. In the absence of exposure to UC, the only significant risk factor for UTI was female gender (OR, 3.3 [95% CI, 1.7-6.5]). Conclusions Exposure to UC was the most important risk factor for symptomatic healthcare-associated UTI, but only concerned about half of all patients with UTI. Further investigation is warranted to improve overall infection control strategies for UTI.

Many factors may influence the level of compliance with hand hygiene recommendations by healthcare workers. Lack of products and facilities as well as their inappropriate and non-ergonomic location represent important barriers. Targeted actions aimed at making hand hygiene practices feasible during healthcare delivery by ensuring that the necessary infrastructure is in place, defined as 'system change', are essential to improve hand hygiene in healthcare. In particular, access to alcohol-based hand rubs (AHRs) enables appropriate and timely hand hygiene performance at the point of care. The feasibility and impact of system change within multi-modal strategies have been demonstrated both at institutional level and on a large scale. The introduction of AHRs overcomes some important barriers to best hand hygiene practices and is associated with higher compliance, especially when integrated within multi-modal strategies. Several studies demonstrated the association between AHR consumption and reduction in healthcare-associated infection, in particular, meticillin-resistant Staphylococcus aureus bacteraemia. Recent reports demonstrate the feasibility and success of system change implementation on a large scale. The World Health Organization and other investigators have reported the challenges and encouraging results of implementing hand hygiene improvement strategies, including AHR introduction, in settings with limited resources. This review summarizes the available evidence demonstrating the need for system change and its importance within multi-modal hand hygiene improvement strategies. This topic is also discussed in a global perspective and highlights some controversial issues.