ABSTRACT In 1998, an outbreak of systemic infections caused by Bacillus cereus occurred in the Neonatal Intensive Care Unit of the University Hospital Vrije Universiteit, Amsterdam, The Netherlands. Three neonates developed sepsis with positive blood cultures. One neonate died, and the other two neonates recovered. An environmental survey, a prospective surveillance study of neonates, and a case control study were performed, in combination with molecular typing, in order to identify potential sources and transmission routes of infection. Genotypic fingerprinting by amplified-fragment length polymorphism (AFLP) showed that the three infections were caused by a single clonal type of B. cereus . The same strain was found in trachea aspirate specimens of 35 other neonates. The case control study showed mechanical ventilation with a Sensormedics ventilation machine to be a risk factor for colonization and/or infection (odds ratio, 9.8; 95% confidence interval, 1.1 to 88.2). Prospective surveillance showed that colonization with B. cereus occurred exclusively in the respiratory tract of mechanically ventilated neonates. The epidemic strain of B. cereus was found on the hands of nursing staff and in balloons used for manual ventilation. Sterilization of these balloons ended the outbreak. We conclude that B. cereus can cause outbreaks of severe opportunistic infection in neonates. Typing by AFLP proved very useful in the identification of the outbreak and in the analysis of strains recovered from the environment to trace the cause of the epidemic.
IMPORTANCE Selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) are prophylactic antibiotic regimens used in intensive care units (ICUs) and associated with improved patient outcome.Controversy exists regarding the relative effects of both measures on patient outcome and antibiotic resistance.OBJECTIVE To compare the effects of SDD and SOD, applied as unit-wide interventions, on antibiotic resistance and patient outcome.DESIGN, SETTING, AND PARTICIPANTS Pragmatic, cluster randomized crossover trial comparing 12 months of SOD with 12 months of SDD in 16 Dutch ICUs between August 1, 2009, and February 1, 2013.Patients with an expected length of ICU stay longer than 48 hours were eligible to receive the regimens, and 5957 and 6040 patients were included in the clinical outcome analysis for SOD and SDD, respectively.INTERVENTIONS Intensive care units were randomized to administer either SDD or SOD.MAIN OUTCOMES AND MEASURES Unit-wideprevalenceofantibiotic-resistantgram-negativebacteria.Secondary outcomes were day-28 mortality, ICU-acquired bacteremia, and length of ICU stay. RESULTSIn point-prevalence surveys, prevalences of antibiotic-resistant gram-negative bacteria in perianal swabs were significantly lower during SDD compared with SOD; for aminoglycoside resistance, average prevalence was 5.6% (95% CI, 4.6%-6.7%)during SDD and 11.8% (95% CI, 10.3%-13.2%)during SOD (P < .001).During both interventions the prevalence of rectal carriage of aminoglycoside-resistant gram-negative bacteria increased 7% per month (95% CI, 1%-13%) during SDD (P = .02)and 4% per month (95% CI, 0%-8%) during SOD (P = .046;P = .40for difference).Day 28-mortality was 25.7% and 23.8% during SOD and SDD, respectively (adjusted odds ratio, 0.85 [95% CI, 0.77-0.93];P = .001),and this difference was similar between surgical and nonsurgical patients.Intensive care unit-acquired bacteremia occurred in 5.9% and 4.5% of the patients during SOD and SDD, respectively (odds ratio, 0.74 [95% CI, 0.63-0.88];P < .001;number needed to treat, 69).CONCLUSIONS AND RELEVANCE Unit-wide application of SDD and SOD was associated with low levels of antibiotic resistance.Compared with SOD, SDD was associated with lower day-28 mortality, rectal carriage of antibiotic-resistant gram-negative bacteria, and ICU-acquired bacteremia but a more pronounced gradual increase in aminoglycosideresistant gram-negative bacteria.
From December 1999 to March 2000 a nosocomial outbreak of multiresistant Enterobacter cloacae occurred in the neonatal intensive care unit (NICU) at the VU Medical Center, Amsterdam, the Netherlands. Twenty-six patients were infected or colonized with this strain resistant to third generation cephalosporins and with decreased sensitivity for aminoglycosides. Three neonates experienced sepsis with E. cloacae with serious clinical symptoms and two of them died. Comparison of the Enterobacter isolates by amplified-fragment length polymorphism indicated that this outbreak was caused by the spread of a single strain. Infection control precautions were initiated in order to stop further spread; barrier precautions, enforcement of hand disinfection and cohorting of colonized patients. A multidisciplinary crisis team coordinated these infection control precautions and informed all persons involved. Analysis of antibiotic usage in 1999 showed an increase in the use of third generation cephalosporins from November onwards. Due to the resistance pattern of the epidemic strain the use of third generation cephalosporins was discontinued in February 2000. At the end of February the NICU was temporarily closed. The epidemic strain of E. cloacae was isolated from one digital rectal thermometer. Patient use of thermometers and disposable coverings for rectal thermometers were introduced to eliminate this possible means of spread. No spread of multiresistant E. cloacae was found following the introduction of these interventions. Once all the neonates had been transferred, the NICU was disinfected and reopened in March.
From December 1999 to March 2000 a nosocomial outbreak of multiresistant Enterobacter cloacae occurred in the neonatal intensive care unit (NICU) at the VU Medical Center, Amsterdam, the Netherlands. Twenty-six patients were infected or colonized with this strain resistant to third generation cephalosporins and with decreased sensitivity for aminoglycosides. Three neonates experienced sepsis with E. cloacae with serious clinical symptoms and two of them died. Comparison of the Enterobacter isolates by amplified-fragment length polymorphism indicated that this outbreak was caused by the spread of a single strain. Infection control precautions were initiated in order to stop further spread; barrier precautions, enforcement of hand disinfection and cohorting of colonized patients. A multidisciplinary crisis team coordinated these infection control precautions and informed all persons involved. Analysis of antibiotic usage in 1999 showed an increase in the use of third generation cephalosporins from November onwards. Due to the resistance pattern of the epidemic strain the use of third generation cephalosporins was discontinued in February 2000. At the end of February the NICU was temporarily closed. The epidemic strain of E. cloacae was isolated from one digital rectal thermometer. Patient use of thermometers and disposable coverings for rectal thermometers were introduced to eliminate this possible means of spread. No spread of multiresistant E. cloacae was found following the introduction of these interventions. Once all the neonates had been transferred, the NICU was disinfected and reopened in March.
In recent decades, minimally invasive surgery has become the favoured surgical technique, with increasing utilisation of robotic surgery to enhance patient outcomes. However, the design complexity of surgical robotic instruments can pose challenges in maintaining adequate cleaning, disinfection and sterilisation—particularly of the device’s interior. In our hospital, robotic instruments are reused for a maximum of ten successive patients, following the manufacturer’s guidelines. To the best of our knowledge, neither the manufacturer nor ISO standards have specified any methods to determine the sterility of robotic instruments after cleaning, disinfection and sterilisation procedures. In a small pilot study, we used a locally developed protocol to evaluate the sterility of 20 da Vinci SI robotic instruments, with the aim of determining whether the recommended cleaning, disinfection and sterilisation process is adequate to achieve safe usage in subsequent patients. None of the 20 instruments showed viable micro-organisms, therefore the robotic instruments were considered sterile, and suitable for re-use. We recommend our protocol to other hospitals, to be used as an essential control element in the assessment of their unique reprocessing technique for robotic instruments.
Background: Surgical site infections (SSI) are the most common postoperative complications and substantially increase healthcare costs. There remains uncertainty which preoperative skin antiseptic solution and concentration is most effective. Published meta-analyses as well as international guidelines show discrepancies. We compared the efficacy of different skin preparation solutions and concentrations in the prevention of SSI. Additionally, we provide an overview of important guidelines.Methods: This systematic review and network meta-analysis (NMA) compared different preoperative skin antiseptics in the prevention of SSI in adult patients undergoing surgery of any wound class. We searched for randomised controlled trials (RCT) in MEDLINE, Embase and Cochrane CENTRAL, directly comparing two or more antiseptic agents (chlorhexidine (CHG), iodine or olanexidine) or concentrations in aqueous and alcohol-based solutions up to November 2021. We conducted a frequentist random-effects NMA to estimate the network effects of the skin preparation solutions on SSI. Risk of bias and GRADE-assessment were carried out to determine the quality of the evidence.Findings: Overall, 2631 articles were identified and 27 studies with 18,125 patients reporting 2,144 SSI (overall incidence of 12%) were included in quantitative analysis. Only 2-2.5% CHG-alcohol (risk ratio [RR] 0.75, 95% confidence interval [CI]: 0.61 - 0.92) and 1.5% olanexidine (RR 0.49, 95% CI 0.26 - 0.92) showed a significant reduction of SSI rate compared with aqueous iodine. For clean surgery, we found no difference in efficacy between different concentrations of CHG-alcohol.Interpretation: In adult patients undergoing a surgical procedure of any wound classification, skin preparation using either 2-2.5% CHG-alcohol or 1.5% olanexidine is most effective in the prevention of SSI, particularly in non-clean surgery. Efficacy of olanexidine is based on one single randomised trial and further investigation is needed. PROSPERO: CRD42021293554.Funding: This study is funded by the Dutch Association for Quality Funds Medical Specialists (SKMS)Registration Details: PROSPERO: CRD42021293554.Funding Information: This study is funded by the Dutch Association for Quality Funds Medical Specialists (SKMS).Declaration of Interests: MB reported receiving institutional grants from J&J/Ethicon, KCI/3M, Bard and New Compliance; and being a speaker and/or instructor for 3M/KCI, J&J/Ethicon, Allergan/LifeCell, BD Bard, Gore, Smith & Nephew, GDM, Medtronic. No other disclosures were reported. All other authors report no conflicts of interest.Ethics Approval Statement: All data is publicly available, ethics committee approval or patient consent for publication is not applicable.
We describe an outbreak of vancomycin-resistant Enterococcus faecium (VRE) on the haematology ward of a Dutch university hospital. After the occurrence of three consecutive cases of bacteraemia with VRE, strains were genotyped and found to be identical. During the next 4 months an intensive surveillance programme identified 21 additional patients to be colonized with VRE, while two more patients developed bacteraemia. A case-control study was carried out to identify risk factors for VRE acquisition. In comparison with VRE-negative control patients (n=49), cases (n=24) had a longer stay on the ward during the year preceding the outbreak (25.8 versus 10.1 d, P=0.02), more cases with acute myeloid leukaemia [11 versus 4, odds ratio (OR) 9.5, 95% confidence interval (CI95) 2.4-32.2] and higher grades of mucositis (P=0.03). Logistic regression analysis identified antibiotic use within 1 month before admission (OR 13.0, CI95 2.1-80.5, P=0.006) and low albumin levels at baseline (OR 1.2, CI95 1.1-1.3, P=0.02) to be independent risk factors. Four patients with VRE-bacteraemia were successfully treated with quinupristin/dalfopristin (Synercid). Control of the outbreak was achieved by step-wise implementation of intensive infection control measures, which included the cohorting of patients, allocation of nurses and reinforcement of hand hygiene.
