This nation-wide survey on the epidemiology of vancomycin-resistant enterococci (VRE) included 142 healthcare institutions and showed an increasing number of VRE colonizations and infections in Switzerland, probably for the most part due to nosocomial dissemination. The introduction and spread of a new clone, gaps in VRE screening policies as well as heterogeneity regarding the management of VRE clusters may be possible explanations.
Abstract Background Early in the COVID-19 pandemic many healthcare facilities experienced shortages of personal protective equipment (PPE), which required them to conserve and prioritize PPE. We wanted to determine the effect a gown conservation strategy had on nosocomial methicillin-resistant Staphylococcus aureus (MRSA), Clostridioides difficile (C.diff.) and infections with vancomycin-resistant enterococci (VRE). Methods Prior to the pandemic, isolation gowns were required for patients colonized or infected with multidrug-resistant organisms (MDROs) at BJC Healthcare, a 15-site hospital group with >3,000 acute care beds. In April 2020, we initiated a modified contact precautions (CP) strategy for acute care patients colonized with MDROs (identified via surveillance cultures or based on past MDRO infection). Healthcare workers were instructed to wear gloves and follow standard precautions when seeing patients on modified CP. Patients with active MDRO infection and C.diff. were excluded from modified CP. Rates of NHSN laboratory identified (LabID) MRSA bacteremia and C.diff., and nosocomial VRE from blood/urine cultures, were compared before and after the modified CP. The study period was divided into baseline CP (1/01/2019- 8/30/2019) and modified CP (1/01/2021-8/30/2021) periods. Results There was no difference in LabID MRSA bacteremia or LabID C.diff. rates in the baseline CP versus the modified CP period (MRSA: 0.069 baseline vs 0.062 modified CP per 1000 pt days, p=0.64, and C.diff.: 3.96 baseline vs 3.66 modified CP per 10,000 pt days, p=0.45), respectively. There was no difference in the nosocomial VRE bacteremia & bacteriuria combined rate (0.097 baseline vs 0.116 per 1000 pt days modified CP, p=0.37). There was no difference in the subsets of nosocomial VRE bacteremia (0.038 baseline vs 0.047 modified CP, p=0.51) or VRE bacteriuria (0.059 baseline vs 0.069 per 1000 pt days modified CP, p=0.54). Conclusion We limited gown use to cases of MRSA, VRE and C. difficile infection in a conservation effort, and no longer required it for MRSA or VRE colonization; this change was not associated with increases of MRSA or C.difficile LabID rates nor with nosocomial VRE cases. Our findings highlight the importance of monitoring and evaluating PPE conservation strategies to document their safety. Disclosures All Authors: No reported disclosures
Importance Perioperative antibiotic prophylaxis (PAP) reduces the incidence of surgical site infections (SSIs). Guidelines recommend 24 hours or less of PAP for cystectomy with urinary diversion; however, evidence specifying optimal PAP duration for this surgery is lacking, and prolonged administration of PAP is common practice. Objective To establish noninferiority of 24-hour PAP vs extended-duration PAP in preventing SSIs within 90 days after cystectomy with urinary diversion. Design, Setting, and Participants This single-center, noninferiority randomized clinical trial was performed from April 18, 2018, to August 18, 2022, in patients aged older than 18 years undergoing elective open cystectomy with urinary diversion. Exclusion criteria were contraindications to administered drugs and inability to follow study procedures. Intervention PAP administered for 24 hours (24-hour PAP group) vs PAP until all catheters and stents were removed (extended PAP group). Main Outcome and Measures The primary end point was the rate of SSI, and the secondary end points included all-cause mortality, both within 90 days after surgery. Noninferiority of the 24-hour PAP treatment was assessed by comparing the 90% CI (corresponding to a significance level of α = .05) with the predefined noninferiority margin of 10%. Results A total of 95 patients were randomly assigned to the 24-hour PAP group (median [IQR] age, 69.3 [63.1-76.8] years; 66 males [69.5%]) and 98 to the extended PAP group (median [IQR] age, 69.5 [60.8-75.5] years; 68 males [69.4%]). Patients in the 24-hour PAP group received PAP for a median of 1 day (IQR, 1-1 day), and patients in the extended PAP group received PAP for a median of 8 days (IQR, 7-10 days). No significant differences in SSIs occurring within 90 days were found (24-hour PAP group, 8 patients [8.4%]; extended PAP group, 12 patients [12.2%]; P = .53). The risk difference for 90-day cumulative SSI incidence was −3.8% (90% CI, −11.1% to 3.4%), establishing noninferiority of 24-hour PAP vs extended PAP to prevent SSI. Mortality was not significantly different between groups. Conclusions and Relevance The findings of this randomized clinical trial demonstrate noninferiority of 24-hour PAP vs extended-duration PAP in preventing SSIs within 90 days after cystectomy with urinary diversion and may contribute to antibiotic stewardship efforts in urology. Trial Registration ClinicalTrials.gov Identifier: NCT03305627
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Abstract Recurrent urinary tract infections are a common health problem. The only comprehensive synthesis on antibiotic prophylaxis in the last 15 years has been a guideline-embedded meta-analysis. We conducted a systematic review and meta-analysis of randomized controlled trials published up to October 13, 2020, evaluating patients age ≥12 years with either ≥2 episodes of lower urinary tract infection (UTI) within 6 months or ≥3 in the past year. Placebo or antibiotics were allowed as comparators. Study quality was low. In the 11 placebo-controlled trials, the risk for developing UTI was 85% lower with prophylaxis in comparison with placebo (risk ratio [RR], 0.15; 95% CI, 0.08–0.29). In the 9 head-to-head trials, the efficacy of the antibiotic agents appeared similar: The pooled RR indicated no difference between nitrofurantoin and comparators (RR, 1.01; 95% CI, 0.74–1.37), nor trimethoprim (+/- sulfamethoxazole; RR, 1.34; 95% CI, 0.89–2.03) or norfloxacin and comparators (RR, 1.17; 95% CI, 0.43–1.70). Studies comparing intermittent (postcoital) with continuous strategies revealed intermittent application to be equally effective.
Abstract In this overview, we articulate research needs and opportunities in the field of infection prevention that have been identified from insights gained during operative infection prevention work, our own research in healthcare epidemiology, and from reviewing the literature. The 10 areas of research need are: 1) transmissions and interruptions, 2) personal protective equipment and other safety issues in occupational health, 3) climate change and other crises, 4) device, diagnostic, and antimicrobial stewardship, 5) implementation and de-implementation, 6) health care outside the acute care hospital, 7) low- and middle-income countries, 8) networking with the “neighbors”, 9) novel research methodologies, and 10) the future state of surveillance. An introduction and chapters 1–5 are presented in part I of the article, and chapters 6–10 and the discussion in part II. There are many barriers to advancing the field, such as finding and motivating the future IP workforce including professionals interested in conducting research, a constant confrontation with challenges and crises, the difficulty of performing studies in a complex environment, the relative lack of adequate incentives and funding streams, and how to disseminate and validate the often very local quality improvement projects. Addressing research gaps now (i.e., in the postpandemic phase) will make healthcare systems more resilient when facing future crises.
We describe an outbreak of Burkholderia stabilis associated with contaminated washing gloves, a commercially available Class I medical device. Triggered by an increase in Burkholderia cepacia complex (BCC) bacteremias and the detection of BCC in unopened packages of washing gloves, an ad hoc national outbreak committee comprising representatives of a public health organisation, a regulatory agency, and an expert association convened and commissioned an outbreak investigation. The investigation included retrospective case finding across Switzerland and whole genome sequencing (WGS) of isolates from cases and gloves. The investigation revealed that BCC were detected in clinical samples of 46 cases aged 17 to 91 years (33% females) from nine institutions between May 2015 and August 2016. Twenty-two isolates from case patients and 16 from washing gloves underwent WGS. All available outbreak isolates clustered within a span of < 19 differing alleles, while 13 unrelated clinical isolates differed by > 1,500 alleles. This BCC outbreak was rapidly identified, communicated, investigated and halted by an ad hoc collaboration of multiple stakeholders. WGS served as useful tool for confirming the source of the outbreak. This outbreak also highlights current regulatory limitations regarding Class I medical devices and the usefulness of a nationally coordinated outbreak response.
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