Journal of Hospital Infection最新文献

Non-ventilated hospital-acquired pneumonia (NV-HAP) is associated with a significant healthcare burden, arising from high incidence and associated morbidity and mortality. However, accurate identification of cases remains challenging. At present, there is no gold-standard test for the diagnosis of NV-HAP, requiring instead the blending of non-specific signs and investigations. Causative organisms are only identified in a minority of cases. This has significant implications for surveillance, patient outcomes and antimicrobial stewardship. Much of the existing research in HAP has been conducted among ventilated patients. The paucity of dedicated NV-HAP research means that conclusions regarding diagnostic methods, pathology and interventions must largely be extrapolated from work in other settings. Progress is also limited by the lack of a widely agreed definition for NV-HAP. The diagnosis of NV-HAP has large scope for improvement. Consensus regarding a case definition will allow meaningful research to improve understanding of its aetiology and the heterogeneity of outcomes experienced by patients. There is potential to optimize the role of imaging and to incorporate novel techniques to identify likely causative pathogens. This would facilitate both antimicrobial stewardship and surveillance of an important healthcare-associated infection. This narrative review considers the utility of existing methods to diagnose NV-HAP, with a focus on the significance and challenge of identifying pathogens. It discusses the limitations in current techniques, and explores the potential of emergent molecular techniques to improve microbiological diagnosis and outcomes for patients.

Background

National and international guidance provides advice on maintenance and management of water systems in healthcare buildings; however, healthcare-associated waterborne infections (HAWIs) are increasing.

Aim

To identify parameters critical to water quality in healthcare buildings and to assess whether remote sensor monitoring can deliver safe water systems, thus reducing HAWIs.

Methods

A narrative review was performed using the following search terms: (1) consistent water temperature AND waterborne pathogen control OR nosocomial infection; (2) water throughput AND waterborne pathogen control OR nosocomial infection; (3) remote monitoring of in-premises water systems AND continuous surveillance for temperature OR throughput OR flow OR use. Databases employed were PubMed, CDSR (Clinical Study Data Request) and DARE (Database of Abstracts of Reviews of Effects) from January 2013 to March 2024.

Findings

Single ensuite-patient rooms, expansion of handwash basins, widespread glove use, alcohol gel and wipes have increased water system stagnancy resulting in amplification of waterborne pathogens and transmission risk of legionella, pseudomonas, and non-tuberculous mycobacteria. Manual monitoring does not represent temperatures across large complex water systems. This review deems that multiple-point continuous remote sensor monitoring is effective at identifying redundant and low use outlets, hydraulic imbalance and inconsistent temperature delivery across in-premises water systems.

Conclusion

As remote monitoring becomes more common there will be greater recognition of failures in temperature control, hydraulics, and balancing in water systems, and there remains much to learn as we adopt this developing technology within our hospitals.

The periphery of the hospital water system interfaces at multiple points with patients and staff in clinical areas. This comprises mostly sinks and showers and presents a significant infection control risk. Wastewater drains in particular act as a reservoir of pathogens that can be transmitted to patients. Numerous strategies have been investigated as potential methods to reduce biofilm and bacterial load including regular application of biocidal chemicals. Traditional methods of assessing the efficacy of such products relies on culture-based microbiological techniques, usually targeting a limited range of key pathogens. We assessed the efficacy of a peracetic acid containing drain disinfectant product on seven clinical handwash basin drains, taking daily samples over six weeks (before, during and after use of the drain disinfectant product). We used a rapid, culture-independent estimation of total bacterial viable count (TVC) to assess efficacy. We applied long-read metagenomic sequencing to study the entire drain microbiome, which allowed taxonomic changes to be documented following use of the drain disinfectant product. All samples were found to be heavily contaminated, however the drain disinfectant product reduced the TVC from an estimated mean of 4228 cfu/mL to 2874 cfu/mL. This reduction was sustained in the two weeks following cessation of the product. Long-read metagenomic sequencing showed a microbiome dominated with Gram-negative organisms, with some taxonomic shifts in samples before and after application of the drain disinfectant. The impact on hospital-acquired infections from reducing bioburden in hospital drains by approximately a third, along with any associated changes in bacterial composition, needs evaluation in future studies.

Background

While seasonality of hospital-acquired infections, including incisional SSI after orthopaedic surgery, is recognized, the seasonality of incisional SSI after general and gastroenterological surgeries remains unclear.

Aim

To analyse the seasonality and risk factors of incisional SSI after general and gastroenterological surgeries.

Methods

This was a retrospective, single-institute, observational study using univariate and multivariate analyses. The evaluated variables included age, sex, surgical approach, surgical urgency, operation time, wound classification, and the American Society of Anesthesiologists physical status (ASA-PS).

Findings

A total of 8436 patients were enrolled. General surgeries (N = 2241) showed a pronounced SSI incidence in summer (3.9%; odds ratio (OR): 1.87; 95% confidence interval (CI): 1.05–3.27; P = 0.025) compared to other seasons (2.1%). Conversely, gastroenterological surgeries (N = 6195) showed a higher incidence in winter (8.3%; OR: 1.38; 95% CI: 1.10–1.73; P = 0.005) than in other seasons (6.1%). Summer for general surgery (OR: 1.90; 95% CI: 1.12–3.24; P = 0.018) and winter for gastroenterological surgery (1.46; 1.17–1.82; P = 0.001) emerged as independent risk factors for incisional SSI. Open surgery (OR: 2.72; 95% CI: 1.73–4.29; P < 0.001) and an ASA-PS score ≥3 (1.64; 1.08–2.50; P = 0.021) were independent risk factors for incisional SSI in patients undergoing gastroenterological surgery during winter.

Conclusion

Seasonality exists in the incisional SSI incidence following general and gastroenterological surgeries. Recognizing these trends may help enhance preventive strategies, highlighting the elevated risk in summer for general surgery and in winter for gastroenterological surgery.

Background

Continuous fluid infusions delivered between therapies by piggy-back systems avoid disconnection and reconnection of central venous catheters (CVCs), thereby reducing opportunities for line contamination. However, the impact of continuous versus intermittent infusions on central line-associated bloodstream infections (CLABSIs) is unknown.

Aim

To investigate the effect of temporary infusion interruption and line disconnection, with or without use of a 70% isopropyl alcohol cap (IPA-C) on CLABSI rates in haematology patients.

Methods

Quasi-experimental study in two haemato-oncology units. At baseline (P1, September 2020 to August 2021), continuous intravenous piggy-back infusions were mandatory. In a first intervention phase (P2, September 2021 to August 2022), infusion disconnections were implemented with use of a 70% isopropyl alcohol cap (IPA-C) for passive decontamination. In a second intervention phase (P3, September 2022 to August 2023), infusion disconnections continued without the use of IPA-C. Rates of CLABSI were compared across the three intervention periods using segmented Poisson regression.

Findings

A total of 11,039 catheter-days across 764 CVCs and 16,226 patient-days were included. Twenty-one CLABSIs were recorded across all intervention periods. Compared with P1, incidence rate ratios (IRRs) for CLABSI did not significantly change in P2 (IRR 0.76 (95% CI 0.27–2.15)) and P3 (IRR 0.79 (95% CI 0.28–2.22)). No CVCs were removed due to occlusion during the study period. Five of 21 CLABSIs were polymicrobial, and coagulase-negative staphylococci were isolated in 19/21 cases (90%).

Conclusion

Interruption of continuous infusions in haemato-oncology patients with a CVC was not associated with a substantial change in CLABSI rates, whether or not an IPA-C was used.

Background

The global burden associated with antimicrobial resistance is of increasing concern.

Aim

To evaluate risk factors associated with multidrug-resistant (MDR) infection and its clinical impact in a cohort of patients with healthcare-associated bacteraemic urinary tract infections (BUTIs).

Methods

This was a prospective, multicentre, post-hoc analysis of patients with healthcare-associated-BUTI (ITUBRAS-2). The primary outcome was MDR profile. Secondary outcomes were clinical response (at 48–72 h and at hospital discharge) and length of hospital stay from onset of BUTI. Logistic regression was used to evaluate variables associated with MDR profile and clinical response. Length of hospital stay was evaluated using multivariate median regression.

Findings

In all, 443 episodes were included, of which 271 (61.17%) were classified as expressing an MDR profile. In univariate analysis, MDR profile was associated with E. coli episodes (odds ratio (OR): 3.13; 95% confidence interval (CI): 2.11–4.69, P < 0.001) and the extensively drug-resistant (XDR) pattern with P. aeruginosa aetiology (7.84; 2.37–25.95; P = 0.001). MDR was independently associated with prior use of fluoroquinolones (adjusted OR: 2.43; 95% CI: 1.25–4.69), cephalosporins (2.14; 1.35–3.41), and imipenem or meropenem (2.08; 1.03–4.20) but not with prior ertapenem. In terms of outcomes, MDR profile was not associated with lower frequency of clinical cure, but was associated with longer hospital stay.

Conclusion

MDR profile was independently associated with prior use of fluoroquinolones, cephalosporins, imipenem, and meropenem, but not with prior ertapenem. MDR-BUTI episodes were not associated with worse clinical cure, although they were independently associated with longer duration of hospital stay.

Background

Vancomycin-resistant Enterococcus faecium (VREfm) are significant nosocomial pathogens. Sequence type (ST) 80 vanA-encoding VREfm predominate in Irish hospitals, but their transmission is poorly understood.

Aims

To investigate transmission and persistence of predominant complex type (CT) VREfm in two wards of an Irish hospital (H1) using whole-genome sequencing, and their intra- and inter-hospital dissemination.

Methods

Rectal screening (N = 330, September 2019 to December 2022) and environmental (N = 48, November 2022 to December 2022) E. faecium were investigated. Isolate relatedness was assessed by core-genome multi-locus sequence typing (cgMLST) and core-genome single nucleotide polymorphism (cgSNP) analysis. Likely transmission chains were identified using SeqTrack (https://graphsnp.fordelab.com/graphsnp) using cgSNP data and recovery location. Well-characterized E. faecium (N = 908) from seven Irish hospitals including H1 (June 2017 to July 2022) were also investigated.

Findings

Conventional MLST assigned isolates to nine STs (ST80, 82%). cgMLST identified three predominant ST80 CTs (CT2933, CT2932 and CT1916) (55% of isolates) of related isolates (≤20 allelic differences). cgSNP analysis differentiated these CTs into multiple distinct closely related genomic clusters (≤10 cgSNPs). Parisimonious network construction identified 55 likely inter- and intra-ward transmissions with epidemiological support between patients ≤30 days involving 73 isolates (≤10 cgSNPs) from seven genomic clusters. Numerous other likely transmissions over longer time periods without evident epidemiological links were identified, suggesting persistence and unidentified reservoirs contribute to dissemination. The three CTs predominated among E. faecium (N = 1286) in seven hospitals, highlighting inter-hospital spread without known epidemiological links.

Conclusion

This study revealed the long-term intra- and inter-hospital dominance of three major CT ST80 VREfm lineages, widespread transmission and persistence, implicating unidentified reservoirs.

Background

Spatial separation in emergency departments (EDs) is empirically practised as part of transmission-based precaution. Despite its potential benefits in segregating potentially infectious patients, the effects of spatial separation on patient flow remain uncertain.

Aim

To explore the impact of spatial separation on ED patient flow and to identify specific clinical factors and flow process intervals (FPIs) influencing ED length of stay (EDLOS).

Methods

This was a retrospective study of data extracted from patients' electronic medical records from January 1^st to March 31^st, 2022 conducted at the ED of a tertiary hospital in Kuala Lumpur, Malaysia. During this period, patients were separated into respiratory areas (RA) and non-respiratory areas (NRA) based on Centers for Disease Control and Prevention recommendations. The study obtained ethics approval from the institution's ethics board.

Findings

A total of 1054 patients were included in the study, 275 allocated to RA and 779 to NRA. Patients in RA had a significantly longer median EDLOS compared with NRA (9 h 29 min vs 7 h 6 min, P < 0.001, d = 0.41). A lower proportion of patients in RA achieved an EDLOS ≤8 h compared to NRA (41.8% vs 58.3%, P < 0.001). Independent factors affecting EDLOS were: triage category; re-triaging; hypertension; performing biomedical imaging; medical, surgical, and critical care consultations; and disposition plan. Bottlenecks significantly prolonging EDLOS were decision-to-departure, ultrasound interval, and referral-to-consultation.

Conclusion

Spatial separation prolongs FPIs and EDLOS. Addressing inpatient access block and streamlining specialty review and biomedical imaging processes may reduce RA EDLOS.