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1.  Reviewer acknowledgement 2013 
Contributing reviewers
Antimicrobial Resistance and Infection Control would like to thank the following colleagues for their assistance with peer review of manuscripts for the journal in 2013.
doi:10.1186/2047-2994-3-1
PMCID: PMC3896811  PMID: 24433391
2.  Reviewer acknowledgement 2012 
Contributing reviewers
Antimicrobial Resistance and Infection Control would like to thank the following colleagues for their assistance with peer review of manuscripts for the journal in 2012.
doi:10.1186/2047-2994-2-4
PMCID: PMC3626655  PMID: 23369500
3.  Hand hygiene and aseptic techniques during routine anesthetic care - observations in the operating room 
Background
More knowledge is needed about task intensity in relation to hand hygiene in the operating room during anesthetic care in order to choose effective improvement strategies. The aim of this study was to explore the indications and occurrence of hand hygiene opportunities and the adherence to hand hygiene guidelines during routine anesthetic care in the operating room.
Methods
Structured observational data on hand hygiene during anesthetic care during 94 surgical procedures was collected using the World Health Organization’s observational tool in a surgical department consisting of 16 operating rooms serving different surgical specialties such as orthopedic, gynecological, urological and general surgery.
Results
A total of 2,393 opportunities for hand hygiene was recorded. The number of hand hygiene opportunities when measured during full-length surgeries was mean = 10.9/hour, SD 6.1 with an overall adherence of 8.1%. The corresponding numbers for the induction phase were, mean =77.5/h, SD 27.4 with an associated 3.1% adherence to hand hygiene guidelines. Lowest adherence was observed during the induction phase before an aseptic task (2.2%) and highest during full-length surgeries after body fluid exposure (15.9%).
Conclusions
There is compelling evidence for low adherence to hand hygiene guidelines in the operating room and thus an urgent need for effective improvement strategies. The conclusion of this study is that any such strategy should include education and practical training in terms of how to carry out hand hygiene and aseptic techniques and how to use gloves correctly. Moreover it appears to be essential to optimize the work processes in order to reduce the number of avoidable hand hygiene opportunities thereby enhancing the possibilities for adequate use of HH during anesthetic care.
doi:10.1186/s13756-015-0042-y
PMCID: PMC4328079
4.  The costs of nosocomial resistant gram negative intensive care unit infections among patients with the systemic inflammatory response syndrome- a propensity matched case control study 
Background
Infections due to multi-drug resistant gram negative bacilli (RGNB) in critically ill patients have been reported to be associated with increased morbidity and costs and only a few studies have been done in Asia. We examined the financial impact of nosocomial RGNB infections among critically ill patients in Singapore.
Methods
A nested case control study was done for patients at medical and surgical ICUs of a tertiary university hospital (August 2007-December 2011) matched by propensity scores. Two groups of propensity-matched controls were selected for each case patient with nosocomial drug resistant gram negative infection: at-risk patients with no gram negative infection or colonization (Control A) and patients with ICU acquired susceptible gram negative infection (SGNB) (Control B). The costs of the hospital stay, laboratory tests and antibiotics prescribed as well as length of stay were compared using the Wilcoxon matched-pairs signed rank test.
Results
Of the 1539 patients included in the analysis, 76 and 65 patients had ICU acquired RGNB and SGNB infection respectively. The median(range) total hospital bill per day for patients with RGNB infection was 1.5 times higher than at-risk patients without GNB infection [Singapore dollars 2637.8 (458.7-20610.3) vs. 1757.4 (179.9-6107.4), p0.0001]. The same trend was observed when compared with SGNB infected patients. The median costs per day of antibiotics and laboratory investigations were also found to be significantly higher for patients with RGNB infection. The length of stay post infection was not found to be different between those infected with RGNB and SGNB.
Conclusion
The economic burden of RGNB infections to the patients and the hospital is considerable. Efforts need to be taken to prevent their occurrence by cost effective infection control practices.
doi:10.1186/s13756-015-0045-8
PMCID: PMC4316763  PMID: 25653851
Resistant gram negative infection; Sensitive gram negative infection; Critically ill patient; ICU; Costs
5.  Extensively drug-resistant Acinetobacter baumannii in a Thai hospital: a molecular epidemiologic analysis and identification of bactericidal Polymyxin B-based combinations 
Background
Limited knowledge of the local molecular epidemiology and the paucity of new effective antibiotics has resulted in an immense challenge in the control and treatment of extensively drug-resistant (XDR) Acinetobacter baumannii infections in Thailand. Antimicrobial combination regimens may be the only feasible treatment option in such cases. We sought to characterize the local molecular epidemiology and assess the bactericidal activity of various antibiotics individually and in combination against XDR A. baumannii in a Thai hospital.
Methods
All XDR A. baumannii isolates from Thammasat University Hospital were collected between October 2010 and May 2011. Susceptibility testing was conducted according to reference broth dilution methods. Pulse-field gel electrophoresis was used to genotype the isolates. Carbapenemase genes were detected using polymerase chain reaction. In vitro testing of clinically-relevant concentrations of imipenem, meropenem, doripenem, rifampicin and tigecycline alone and in combination with polymyxin B was conducted using multiple combination bactericidal testing.
Results
Forty-nine polymyxin B-susceptible XDR A. baumannii isolates were identified. blaOXA-23 and blaOXA-51 genes were detected in all isolates. Eight clonally related clusters were identified, resulting in the initiation of several infection control measures. Imipenem, meropenem, doripenem, rifampicin, and tigecycline in combination with PB respectively, exhibited bactericidal killing in 100%, 100%, 98.0%, 100% and 87.8% isolates respectively at 24 hours.
Conclusion
Molecular epidemiologic analysis can aid the early detection of infection outbreak within the institution, resulting in the rapid containment of the outbreak. Imipenem/meropenem/rifampicin in combination with polymyxin B demonstrated consistent bactericidal effect against 49 blaOXA-23-harbouring XDR A. baumannii clinical isolates, suggesting a role of combination therapy in the treatment of these infections.
doi:10.1186/s13756-015-0043-x
PMCID: PMC4314787  PMID: 25648393
Combination therapy; Carbapenem resistance; Acinetobacter baumannii
6.  “The Chennai declaration” - Indian doctors’ fight against antimicrobial resistance 
“The Chennai Declaration” is the result of the first ever joint meeting of medical societies in India addressing antibiotic resistance. The declaration is not a policy by itself, but a call for a national policy. The Declaration has looked into all major aspects of the problem of antimicrobial resistance, has suggested practical solutions, explained in detail the responsibility of each and every stakeholder.
doi:10.1186/2047-2994-2-7
PMCID: PMC3600017  PMID: 23452398
7.  Measuring the quality of infection control in Dutch nursing homes using a standardized method; the Infection prevention RIsk Scan (IRIS) 
Background
We developed a standardised method to assess the quality of infection control in Dutch Nursing Home (NH), based on a cross-sectional survey that visualises the results. The method was called the Infection control RIsk Infection Scan (IRIS). We tested the applicability of this new tool in a multicentre surveillance executed June and July 2012.
Methods
The IRIS includes two patient outcome-variables, i.e. the prevalence of healthcare associated infections (HAI) and rectal carriage of Extended-Spectrum Beta-Lactamase (ESBL) producing Enterobacteriaceae (ESBL-E); two patient-related risk factors, i.e. use of medical devices, and antimicrobial therapy; and three ward-related risk factors, i.e. environmental contamination, availability of local guidelines, and shortcomings in infection prevention preconditions. Results were categorised as low-, intermediate- and high risk, presented in an easy-to-read graphic risk spider-plot. This plot was given as feedback to management and healthcare workers of the NH.
Results
Large differences were found among most the variables in the different NH. Common shortcomings were the availability of infection control guidelines and the level of environmental cleaning. Most striking differences were observed in the prevalence of ESBL carriage, ranged from zero to 20.6% (p < 0.001).
Conclusions
The IRIS provided a rapid and easy to understand assessment of the infection control situation of the participating NH. The results can be used to improve the quality of infection control based on the specific needs of a NH but needs further validation in future studies. Repeated measurement can determine the effectiveness of the interventions. This makes the IRIS a useful tool for quality systems.
doi:10.1186/2047-2994-3-26
PMCID: PMC4169692  PMID: 25243067
Nursing homes; Healthcare associated infections; Antimicrobial resistance; Infection control; Quality improvement; Surveillance
8.  Temporal trends and risk factors for extended-spectrum beta-lactamase-producing Escherichia coli in adults with catheter-associated urinary tract infections 
Background
Extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli cause up to 10% of catheter-associated urinary tract infections (CAUTI). We report changes in ESBL prevalence among CAUTIs in an adult acute care hospital from 2006-2012 and describe factors associated ESBL-production among E. coli CAUTI.
Findings
Data on patients ≥18 years discharged from a 647-bed tertiary/quaternary care hospital (2006-2012), a 221-bed community hospital (2007-2012), and a 914-bed tertiary/quaternary care hospital (2008) were obtained retrospectively from an electronic database (N = 415,430 discharges). Infections were identified using a previously validated electronic algorithm. Information on medical conditions and treatments were collected from electronic health records and discharge billing codes. A case-control design was used to determine factors associated with having a CAUTI caused by an ESBL-producing E. coli versus a non-ESBL-producing E. coli. Changes in yearly proportion of ESBL E. coli CAUTI at the 647-bed tertiary/quaternary care hospital were evaluated. ESBL increased from 4% in 2006 to 14% in 2012, peaking at 18% in 2009. Prior antibiotic treatment and urinary tract disease significantly increased odds of ESBL.
Conclusions
This study provides evidence that treatment with beta-lactam and non-beta-lactam antibiotics is a risk factor for acquiring ESBL-producing E. coli CAUTI, and the prevalence of this organism may be increasing in acute care hospitals.
doi:10.1186/s13756-014-0039-y
PMCID: PMC4306238  PMID: 25625011
Catheter-associated urinary tract infections; Extended-spectrum beta-lactamase-producing Escherichia coli; Antimicrobial resistance
9.  The strength of coughing may forecast the likelihood of spread of multi-drug resistant microorganisms from the respiratory tract of colonized patients 
Background
Current recommendations indicate that patients who are coughing and have multidrug resistant microorganisms (MDROs) in their sputum are considered to be shedders and should be cared for in single room isolation at least until symptoms resolve. Airborne spread and subsequent contamination of surfaces adjacent to patients may contribute to transmission. Hence, isolation measures for patients colonized or infected with MDRO at their respiratory tract are intended to interrupt such transmission. However, the potential for microbial shedding in patients with MDRO-positive microbiological reports from their respiratory tract and factors justifying the need for single room isolation are viewed controversially.
Methods
Cough aerosol produced by patients colonized with MDROs was measured for viable counts. Descriptive analysis together with logistic regression analysis was performed to assess the impact of strength of cough on growth of MDRO on culture plates.
Results
In 18% (23/128) MDRO were transmitted. Multivariate analysis revealed that strength of cough significantly predicts the yield of MDRO on culture plates (P = 0.012).
Conclusion
Based on these results it can be concluded that risk stratification for decision of single room isolation of patients colonized or infected with MDROs at their respiratory tract may also take the severity of cough into consideration. However, more work is required in order to assess the severity of cough objectively.
doi:10.1186/s13756-014-0038-z
PMCID: PMC4271473  PMID: 25530847
Multidrug resistant microorganism; Cough; Aerogene spread; Risk factors; Single room isolation; Infection Control
10.  A longitudinal assessment of antimicrobial susceptibility among important pathogens collected as part of the Tigecycline Evaluation and Surveillance Trial (T.E.S.T.) in France between 2004 and 2012 
Background
Clinically important Gram-positive and -negative isolates were collected from patients in France between 2004 and 2012 as a part of the Tigecycline Evaluation and Surveillance Trial.
Methods
MICs were determined using methodology described by the Clinical and Laboratory Standards Institute.
Results
In total, 17,135 isolates were contributed by 29 medical centres; respiratory (25.1%) and cardiovascular (20.3%) sources predominated. High susceptibility was observed among Enterococcus spp. and Staphylococcus aureus (including methicillin-resistant S. aureus [MRSA]) to linezolid (100%), tigecycline (≥99.8%) and vancomycin (≥94.6%). The percentage of MRSA decreased from 34.3% in 2004 to 20.0% in 2009 before increasing to 34.7% in 2012. Vancomycin, linezolid, levofloxacin and carbapenems were highly active (≥99.6%) against Streptococcus pneumoniae; 3.2% were PRSP. Escherichia coli showed peak susceptibility to the carbapenems (≥99.9%), tigecycline (99.3%) and amikacin (97.9%); significant (p < 0.01) decreases in susceptibility were observed for ampicillin, cefepime and ceftriaxone between 2004 and 2012. ESBL production among E. coli increased from 3.0% (2004) to 14.9% (2012). High susceptibility was noted among Haemophilus influenzae to levofloxacin (100%), amoxicillin-clavulanate (99.2%), carbapenems (≥98.7%) and ceftriaxone (98.5%); β-lactamase production fluctuated with no notable trend between 18.1% (2007) and 27.7% (2011). Klebsiella spp. were highly susceptible to carbapenems (≥99.6%) and amikacin (≥96.4%); significant (p < 0.01) decreases in amoxicillin-clavulanate, cefepime, ceftriaxone, levofloxacin, piperacillin-tazobactam and tigecycline susceptibility were observed among K. pneumoniae between 2004 and 2012. Only imipenem was highly active (96.5% susceptible) against Acinetobacter baumannii. Imipenem and amikacin (87.7% and 87.1% susceptible) were the most active agents against P. aeruginosa; 10.2% of isolates were categorized as multidrug resistant.
Conclusions
Carbapenems, linezolid, tigecycline and vancomycin conserved good in vitro activity against most pathogens (according to their spectrum of activity) in France between 2004 and 2012.
Electronic supplementary material
The online version of this article (doi:10.1186/2047-2994-3-36) contains supplementary material, which is available to authorized users.
doi:10.1186/2047-2994-3-36
PMCID: PMC4322957  PMID: 25671097
France; Antimicrobial resistance; Antimicrobial surveillance; Multidrug resistance; MDR; Tigecycline
11.  Elizabethkingia Meningoseptica Engodenous Endophthalmitis – a case report 
Elizabethkingia meningoseptica is a nosocomial non-fermenting gram-negative bacillus that has an increasing prevalence in health care settings, especially in intensive care environments. While it has long been recognized as a rare but serious cause of neonatal meningitis and sepsis, its role as a cause of ocular pathology is not well-known. We report the first case of E. meningoseptica endogenous endophthalmitis caused by bacteraemia by the same organism. In view of its aggressiveness and virulence in the eye, and the high rate of misdiagnosis or missed diagnosis of endogenous endophthalmitis especially given its low incidence, we may wish to consider screening all cases of E. menigoseptica bloodstream infections for endophthalmitis in future, similar to how it has become routine to refer all patients with Klebsiella bacteraemia to ophthalmologists for screening for endophthalmitis in our local hospitals.
doi:10.1186/2047-2994-3-35
PMCID: PMC4322812  PMID: 25671096
Elizabethkingia meningoseptica; Endogenous endophthalmitis; Infections of the eye
12.  Evaluation of early implementations of antibiotic stewardship program initiatives in nine Dutch hospitals 
Background
Antibiotic resistance is a global threat to patient safety and care. In response, hospitals start antibiotic stewardship programs to optimise antibiotic use. Expert-based guidelines recommend strategies to implement such programs, but local implementations may differ per hospital. Earlier published assessments determine maturity of antibiotic stewardship programs based on expert-based structure indicators, but they disregard that there may be valid deviations from these expert-based programs.
Aim
To analyse the progress and barriers of local implementations of antibiotic stewardship programs with stakeholders in nine Dutch hospitals and to develop a toolkit that guides implementing local antibiotic stewardship programs.
Methods
An online questionnaire based on published guidelines and recommendations, conducted with seven clinical microbiologists, seven infectious disease physicians and five clinical pharmacists at nine Dutch hospitals.
Results
Results show local differences in antibiotic stewardship programs and the uptake of interventions in hospitals. Antibiotic guidelines and antibiotic teams are the most extensively implemented interventions. Education, decision support and audit-feedback are deemed important interventions and they are either piloted in implementations at academic hospitals or in preparation for application in non-academic hospitals. Other interventions that are recommended in guidelines - benchmarking, restriction and antibiotic formulary - appear to have a lower priority. Automatic stop-order, pre-authorization, automatic substitution, antibiotic cycling are not deemed to be worthwhile according to respondents.
Conclusion
There are extensive local differences in the implementation of antibiotic stewardship interventions. These differences suggest a need to further explore the rationale behind the choice of interventions in antibiotic stewardship programs. Rather than reporting this rationale, this study reports where rationale can play a key role in the implementation of antibiotic stewardship programs. A one-size-fits-all solution is unfeasible as there may be barriers or valid reasons for local experts to deviate from expert-based guidelines. Local experts can be supported with a toolkit containing advice based on possible barriers and considerations. These parameters can be used to customise an implementation of antibiotic stewardship programs to local needs (while retaining its expert-based foundation).
Electronic supplementary material
The online version of this article (doi:10.1186/2047-2994-3-33) contains supplementary material, which is available to authorized users.
doi:10.1186/2047-2994-3-33
PMCID: PMC4228167  PMID: 25392736
Evaluation; Implementation; Antibiotic stewardship programs; Maturity; Hospital infections
13.  Clinical and economic consequences of hospital-acquired resistant and multidrug-resistant Pseudomonas aeruginosa infections: a systematic review and meta-analysis 
Background
Increasing rates of resistant and multidrug-resistant (MDR) P. aeruginosa in hospitalized patients constitute a major public health threat. We present a systematic review of the clinical and economic impact of this resistant pathogen.
Methods
Studies indexed in MEDLINE and Cochrane databases between January 2000-February 2013, and reported all-cause mortality, length of stay, hospital costs, readmission, or recurrence in at least 20 hospitalized patients with laboratory confirmed resistant P. aeruginosa infection were included. We accepted individual study definitions of MDR, and assessed study methodological quality.
Results
The most common definition of MDR was resistance to more than one agent in three or more categories of antibiotics. Twenty-three studies (7,881 patients with susceptible P. aeruginosa, 1,653 with resistant P. aeruginosa, 559 with MDR P. aeruginosa, 387 non-infected patients without P. aeruginosa) were analyzed. A random effects model meta-analysis was feasible for the endpoint of all-cause in-hospital mortality. All-cause mortality was 34% (95% confidence interval (CI) 27% – 41%) in patients with any resistant P. aeruginosa compared to 22% (95% CI 14% – 29%) with susceptible P. aeruginosa. The meta-analysis demonstrated a > 2-fold increased risk of mortality with MDR P. aeruginosa (relative risk (RR) 2.34, 95% CI 1.53 – 3.57) and a 24% increased risk with resistant P. aeruginosa (RR 1.24, 95% CI 1.11 – 1.38), compared to susceptible P. aeruginosa. An adjusted meta-analysis of data from seven studies demonstrated a statistically non-significant increased risk of mortality in patients with any resistant P. aeruginosa (adjusted RR 1.24, 95% CI 0.98 – 1.57). All three studies that reported infection-related mortality found a statistically significantly increased risk in patients with MDR P. aeruginosa compared to those with susceptible P. aeruginosa. Across studies, hospital length of stay (LOS) was higher in patients with resistant and MDR P. aeruginosa infections, compared to susceptible P. aeruginosa and control patients. Limitations included heterogeneity in MDR definition, restriction to nosocomial infections, and potential confounding in analyses.
Conclusions
Hospitalized patients with resistant and MDR P. aeruginosa infections appear to have increased all-cause mortality and LOS. The negative clinical and economic impact of these pathogens warrants in-depth evaluation of optimal infection prevention and stewardship strategies.
Electronic supplementary material
The online version of this article (doi:10.1186/2047-2994-3-32) contains supplementary material, which is available to authorized users.
doi:10.1186/2047-2994-3-32
PMCID: PMC4219028  PMID: 25371812
Pseudomonas aeruginosa; Resistance; All-cause mortality
14.  Surface micropattern limits bacterial contamination 
Background
Bacterial surface contamination contributes to transmission of nosocomial infections. Chemical cleansers used to control surface contamination are often toxic and incorrectly implemented. Additional non-toxic strategies should be combined with regular cleanings to mitigate risks of human error and further decrease rates of nosocomial infections. The Sharklet micropattern (MP), inspired by shark skin, is an effective tool for reducing bacterial load on surfaces without toxic additives. The studies presented here were carried out to investigate the MP surfaces capability to reduce colonization of methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant S. aureus (MRSA) compared to smooth control surfaces.
Methods
The MP and smooth surfaces produced in acrylic film were compared for remaining bacterial contamination and colonization following inoculation. Direct sampling of surfaces was carried out after inoculation by immersion, spray, and/or touch methods. Ultimately, a combination assay was developed to assess bacterial contamination after touch transfer inoculation combined with drying (persistence) to mimic common environmental contamination scenarios in the clinic or hospital environment. The combination transfer and persistence assay was then used to test antimicrobial copper beside the MP for the ability to reduce MSSA and MRSA challenge.
Results
The MP reduced bacterial contamination with log reductions ranging from 87-99% (LR = 0.90-2.18; p < 0.05) compared to smooth control surfaces. The MP was more effective than the 99.9% pure copper alloy C11000 at reducing surface contamination of S. aureus (MSSA and MRSA) through transfer and persistence of bacteria. The MP reduced MSSA by as much as 97% (LR = 1.54; p < 0.01) and MRSA by as much as 94% (LR = 1.26; p < 0.005) compared to smooth controls. Antimicrobial copper had no significant effect on MSSA contamination, but reduced MRSA contamination by 80% (LR = 0.70; p < 0.005).
Conclusion
The assays developed in this study mimic hospital environmental contamination events to demonstrate the performance of a MP to limit contamination under multiple conditions. Antimicrobial copper has been implemented in hospital room studies to evaluate its impact on nosocomial infections and a decrease in HAI rate was shown. Similar implementation of the MP has potential to reduce the incidence of HAIs although future clinical studies will be necessary to validate the MP’s true impact.
doi:10.1186/2047-2994-3-28
PMCID: PMC4166016  PMID: 25232470
15.  Driving forces of vancomycin-resistant E. faecium and E. faecalis blood-stream infections in children 
Background
Rates of invasive vancomycin-resistant Enterococcus (VRE) in the USA remains on the rise. Efforts to control vancomycin use and nosocomial transmission have had limited success in halting the spread of this pathogen. The role of antibiotic exposure remains a topic of controversy. We evaluated the association between emergence of VRE-blood-stream infections (BSI), aggregate and individual-patient vancomycin- exposure, and clonal transmission of VRE at an academic pediatric tertiary care hospital.
Methods
E. faecium and E. faecalis isolates recovered from blood specimens from hospitalized children from 2003–2010 were retrieved from the microbiology database. Aggregate vancomycin use and individual-patient vancomycin exposure 6 months preceding each event of bacteremia were recorded. Pulse-field electrophoresis was performed on selected VRE isolates.
Results
Of 151 episodes of E. faecium and E. faecalis BSI among hospitalized children <18 years of age, 9% (14) were due to VRE. Of these, 5 (36%) were due to nosocomial transmission. Aggregate (r .19, P = 0.3) and individual-patient vancomycin-exposure (X 2  = .26; P = .87) were not associated with VRE-BSI. On bivariate analysis, OR for developing VRE-BSI among patients infected with clonal isolates was 36 (P < .0001). Infection control interventions, rather than antimicrobial stewardship interventions to decrease vancomycin use, proved to be effective in reducing the rates of VRE-BSI.
Conclusions
In our experience, VRE-BSI was associated with nosocomial transmission and was independent of aggregate and individual-patient vancomycin-exposure. Molecular epidemiology is a crucial tool to differentiate the role of nosocomial transmission and antibiotic exposure in the emergence of invasive VRE infections among hospitalized children.
doi:10.1186/2047-2994-3-29
PMCID: PMC4158385  PMID: 25206975
Enterococcus faecium; Enterococcus faecalis; Enterococcus spp; Vancomycin; Bacteremia
16.  Differences in risk-factor profiles between patients with ESBL-producing Escherichia coli and Klebsiella pneumoniae: a multicentre case-case comparison study 
Background
Generic epidemiological differences between extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (ESBL-EC) and Klebsiella pneumoniae (ESBL-KP), are poorly defined. Nonetheless, defining such differences and understanding their basis could have strategic implications for infection control policy and practice.
Methods
Between 2009 and 2011 patients with bacteraemia due to ESBL-EC or ESBL-KP across all three acute hospitals in the city of Auckland, New Zealand, were eligible for inclusion. Recognised risk factors for ESBL bacteraemia were compared between species in a retrospective case-case study design using multivariate logistic regression. Representative isolates underwent ESBL gene characterisation and molecular typing.
Results
170 patients and 176 isolates were included in the study (92 patients with ESBL-EC, 78 with ESBL-KP). 92.6% had CTX-Ms. 39% of EC were ST131 while 51% of KP belonged to 3 different STs (i.e. ST20, ST48 & ST1087). Specific sequence types were associated with specific hospitals for ESBL-KP but not ESBL-EC. Variables positively associated with ESBL-EC on multivariate analysis were: community acquired infection (odds ratio [OR] 7.9; 95% CI: 2.6-23.9); chronic pulmonary disease (OR 5.5; 95% CI: 1.5-20.1); and high prevalence country of origin (OR 4.3; 95% CI: 1.6-11.6). Variables negatively associated with ESBL-EC were previous transplant (OR 0.06; 95% CI: 0.007-0.6); Hospital 2 (OR 0.3; 95% CI: 0.1-0.7) and recent ICU admission (OR 0.3; 95% CI: 0.07-0.9).
Conclusions
Differences in risk profiles between patients with ESBL-EC and ESBL-KP suggest fundamental differences in transmission dynamics. Understanding the biological basis for these differences could have implications for infection control practice. Tailoring of infection control measures according to ESBL species may be indicated in some instances.
doi:10.1186/2047-2994-3-27
PMCID: PMC4166396  PMID: 25237477
ESBL; Klebsiella pneumoniae; Escherichia coli; Bacteraemia; Risk factors
17.  Incidence and predictors of surgical site infections following caesarean sections at Bugando Medical Centre, Mwanza, Tanzania 
Background
Surgical site infection (SSI) is the second most common infectious complication after urinary tract infection following a delivery by caesarean section (CS). At Bugando Medical Centre there has no study documenting the epidemiology of SSI after CS despite the large number of CSs performed and the relatively common occurrence of SSIs.
Methods
This was a prospective cohort study involving pregnant women who underwent a CS between October 2011 and February 2012 at Bugando Medical Centre. A total of 345 pregnant women were enrolled. Preoperative, intraoperative and postoperative data were collected using a standardized questionnaire. Wound specimens were collected and processed as per standard operative procedures; and susceptibility testing was carried out using a disc diffusion technique. Data was analyzed using STATA version 11.
Results
The overall cumulative incidence of SSI was 10.9% with an incidence rate of 37.5 per 10,000 people/day (95% CI, 26.8-52.4). The median time from CS to the development of SSI was 7 days (interquartile range [IQR] = 6–9 days). Six independent risk factors for post caesarean SSI as identified in this study by multivariate analysis are: hypertensive disorders of pregnancy (HR: 2.5; 95% CI, 1.1-5.6; P = 0.021), severe anaemia (HR: 3.8; 95% CI, 1.2-12.4, P = 0.028), surgical wound class III (HR: 2.4; 95% CI, 1.1-5.0; P = 0.021), multiple vaginal examinations (HR: 2.5; 95% CI, 1.2-5.1; P = 0.011), prolonged duration of operation (HR: 2.6; 95% CI, 1.2-5.5; P = 0.015) and an operation performed by an intern or junior doctor (HR: 4.0; 95% CI, 1.7-9.2; P = 0.001). Staphylococcus aureus was the most common organism (27.3%), followed by Klebsiella pneumoniae (22.7%). Patients with a SSI had a longer average hospital stay than those without a SSI (12.7 ± 6.9 vs. 4 ± 1.7; P < 0.0001) and the case fatality rate among patients with a SSI was 2.9%.
Conclusion
SSIs are common among women undergoing CSs at Bugando Medical Centre. SSIs were commonly associated with multiple factors. Strategies to control these factors are urgently needed to control SSIs post CS at Bugando Medical Centre and other centres in developing countries.
doi:10.1186/2047-2994-3-25
PMCID: PMC4131772  PMID: 25126415
18.  Carriage of Staphylococcus aureus in Thika Level 5 Hospital, Kenya: a cross-sectional study 
Background
Methicillin-resistant Staphylococcus aureus (MRSA) is an important nosocomial pathogen but little is known about its circulation in hospitals in developing countries. We aimed to describe carriage of S.aureus amongst inpatients in a mid-sized Kenyan government hospital.
Methods
We determined the frequency of S.aureus and MRSA carriage amongst inpatients in Thika Hospital, Kenya by means of repeated cross-sectional ward surveys. For all S.aureus isolates, we performed antibiotic susceptibility tests, genomic profiling using a DNA microarray and spa typing and MLST.
Results
In this typical mid-sized Kenyan Government hospital, we performed 950 screens for current carriage of S.aureus amongst inpatients over a four month period. We detected S.aureus carriage (either MSSA or MRSA) in 8.9% (85/950; 95%CI 7.1-10.8) of inpatient screens, but patients with multiple screens were more likely have detection of carriage. MRSA carriage was rare amongst S.aureus strains carried by hospital inpatients – only 7.0% (6/86; 95%CI 1.5-12.5%) of all isolates were MRSA. Most MRSA (5/6) were obtained from burns patients with prolonged admissions, who only represented a small proportion of the inpatient population. All MRSA strains were of the same clone (MLST ST239; spa type t037) with concurrent resistance to multiple antibiotic classes. MSSA isolates were diverse and rarely expressed antibiotic resistance except against benzyl-penicillin and co-trimoxazole.
Conclusions
Although carriage rates for S.aureus and the MRSA prevalence in this Kenyan hospital were both low, burns patient were identified as a high risk group for carriage. The high frequency of genetically indistinguishable isolates suggests that there was local transmission of both MRSA and MSSA.
doi:10.1186/2047-2994-3-22
PMCID: PMC4107749  PMID: 25057351
Staphylococcus aureus; MRSA; Kenya; Hospitals; Carriage prevalence
19.  Staphylococcus aureus in a neonatal care center: methicillin-susceptible strains should be a main concern 
Background
In the context of a methicillin-susceptible Staphylococcus aureus (MSSA) outbreak, we aimed to improve our knowledge of S. aureus (SA) epidemiology in the neonatal care center (NCC) of a tertiary care teaching hospital.
Methods
We performed a complete one-year review of SA carrier, colonized or infected patients. Monthly prevalence and incidence of SA intestinal carriage, colonization and infection were calculated and the types of infection analysed. During the MSSA outbreak, strains were studied for antimicrobial resistance, content of virulence genes and comparative fingerprint in Pulsed-Field Gel Electrophoresis. Hand hygiene and catheter-related practices were assessed by direct observational audits. Environmental investigation was performed in search of a SA reservoir.
Results
Epidemiological analyses showed 2 or 3 prevalence peaks on a background of SA endemicity. In the NCC, during 2009, overall MSSA prevalence did not decrease below 5.5%, while mean MRSA prevalence was about 1.53%. Analysis of infection cases revealed that the outbreak corresponded to the emergence of catheter-related infections and was probably related to the relaxation in infection control practices in a context of high colonization pressure. Health care workers’ white coats appeared as a potential environmental reservoir that could perpetuate SA circulation in the ward.
Conclusion
This report emphasizes the importance of integrating MSSA along with methicillin-resistant SA in a program of epidemiological surveillance in the NCC.
doi:10.1186/2047-2994-3-21
PMCID: PMC4118615  PMID: 25089196
Staphylococcus aureus; Prevalence; Catheter-related infections; White coat contamination; Methicillin-susceptible Staphylococcus aureus
20.  Utility of surveillance blood cultures in patients undergoing hematopoietic stem cell transplantation 
Background
Surveillance blood cultures are often obtained in hematopoietic stem cell transplant (HSCT) patients for detection of bloodstream infection. The major aims of this retrospective cohort study were to determine the utility of the practice of obtaining surveillance blood cultures from asymptomatic patients during the first 100 post-transplant days and to determine if obtaining more than one positive blood culture helps in the diagnosis of bloodstream infection.
Methods
We conducted a 17-month retrospective analysis of all blood cultures obtained for patients admitted to the hospital for HSCT from January 2010 to June 2011. Each patient’s clinical course, vital signs, diagnostic testing, treatment, and response to treatment were reviewed. The association between number of positive blood cultures and the final diagnosis was analyzed.
Results
Blood culture results for 205 patients were reviewed. Cultures obtained when symptoms of infection were present (clinical cultures) accounted for 1,033 culture sets, whereas 2,474 culture sets were classified as surveillance cultures (no symptoms of infection were present). The total number of positive blood cultures was 185 sets (5.3% of cultures obtained) and accounted for 84 positive culture episodes. Incidence of infection in autologous, related allogeneic and unrelated allogeneic transplants was 8.3%, 20.0%, and 28.6% respectively. Coagulase-negative staphylococci were the most common organisms isolated. Based on our application of predefined criteria there were 29 infections and 55 episodes of positive blood cultures that were not infections. None of the patients who developed infection were diagnosed by surveillance blood cultures. None of the uninfected patients with positive blood cultures showed any clinical changes after receiving antibiotics. There was a significant difference between the incidence of BSI in the first and second 50-day periods post-HSCT. There was no association between the number of positive blood cultures and the final diagnosis.
Conclusion
Surveillance blood cultures in patients who have undergone HSCT do not identify bloodstream infections. The number of positive blood cultures was not helpful in determining which patients had infection. Patients are at higher risk of infection in the first 50 days post-transplant period.
doi:10.1186/2047-2994-3-20
PMCID: PMC4082284  PMID: 24999384
21.  Attributable healthcare utilization and cost of pneumonia due to drug-resistant streptococcus pneumonia: a cost analysis 
Background
The burden of disease due to S. pneumoniae (pneumococcus), particularly pneumonia, remains high despite the widespread use of vaccines. Drug resistant strains complicate clinical treatment and may increase costs. We estimated the annual burden and incremental costs attributable to antibiotic resistance in pneumococcal pneumonia.
Methods
We derived estimates of healthcare utilization and cost (in 2012 dollars) attributable to penicillin, erythromycin and fluoroquinolone resistance by taking the estimate of disease burden from a previously described decision tree model of pneumococcal pneumonia in the U.S. We analyzed model outputs assuming only the existence of susceptible strains and calculating the resulting differences in cost and utilization. We modeled the cost of resistance from delayed resolution of illness and the resulting additional health services.
Results
Our model estimated that non-susceptibility to penicillin, erythromycin and fluoroquinolones directly caused 32,398 additional outpatient visits and 19,336 hospitalizations for pneumococcal pneumonia. The incremental cost of antibiotic resistance was estimated to account for 4% ($91 million) of direct medical costs and 5% ($233 million) of total costs including work and productivity loss. Most of the incremental medical cost ($82 million) was related to hospitalizations resulting from erythromycin non-susceptibility. Among patients under age 18 years, erythromycin non-susceptibility was estimated to cause 17% of hospitalizations for pneumonia and $38 million in costs, or 39% of pneumococcal pneumonia costs attributable to resistance.
Conclusions
We estimate that antibiotic resistance in pneumococcal pneumonia leads to substantial healthcare utilization and cost, with more than one-third driven by macrolide resistance in children. With 5% of total pneumococcal costs directly attributable to resistance, strategies to reduce antibiotic resistance or improve antibiotic selection could lead to substantial savings.
doi:10.1186/2047-2994-3-16
PMCID: PMC4029811  PMID: 24851182
Streptococcus pneumoniae; Antibiotic resistance; Healthcare utilization; DRSP
22.  Prevalence of nosocomial infections and anti-infective therapy in Benin: results of the first nationwide survey in 2012 
Background
Data on nosocomial infections in hospitals in low-income countries are scarce and often inconsistent. The objectives of this study were to estimate the prevalence of nosocomial infections and antimicrobial drug use in Benin hospitals.
Methods
All hospitals were invited to participate in the first national point prevalence study conducted between 10–26 October 2012 using the protocol developed by the “Hospitals in Europe Link for Infection Control through Surveillance” (HELICS) project. Infection prevalence rates and the proportion of infected patients and exposure to antimicrobials were assessed.
Results
Overall, 87% (39/45) of hospitals participated. Of 3130 inpatients surveyed, 972 nosocomial infections were identified among 597 patients, representing an overall prevalence of infected patients of 19.1%. The most frequent infections were related to the urinary tract (48.2%), vascular catheter use (34.7%), and surgical site (24.7%). 64.6% of patients surveyed were treated with antibiotics, including a significant proportion (30%) of non-infected patients and a high proportion of self-medication (40.8%). Resistance of leading nosocomial pathogens to antimicrobials included methicillin-resistance (52.5%) among Staphylococcus aureus, vancomycin resistance among enterococci (67.5%), cefotaxime resistance among Escherichia coli (67.6%), and ceftazidime resistance among Acinetobacter baumannii (100%) and Pseudomonas aeruginosa (68.2%).
Conclusions
Benin has high nosocomial infection rates and calls for the implementation of new national infection control policies. Patient safety education and training of all individuals involved in healthcare delivery will be critical to highlight awareness of the burden of disease. The high use of antimicrobials needs to be addressed, particularly their indiscriminate use in non-infected patients.
doi:10.1186/2047-2994-3-17
PMCID: PMC4039045  PMID: 24883183
Nosocomial infection; Prevalence; Antimicrobial resistance; Co-morbidity; Antibiotic use; Infection control; National surveillance; Surveillance; Africa; Low-/middle-income countries
23.  Small volumes of n-propanol (60%) applied for 3 minutes may be ineffective for surgical hand disinfection 
Background
There is a trend in some countries to recommend the use of surgical hand disinfectants at volumes as low as 4 ml per application.
Aim
To determine whether the volume applied and hand size influence the efficacy of surgical hand disinfection.
Methods
Thirteen experiments, according to EN 12791, resulting in 269 datasets from 75 subjects were analyzed. Hands were first washed for one minute with soap. The pre-values were obtained by rubbing the finger tips in tryptic soy broth for one minute. Each subject treated his/her hands with n-propanol (60%, v/v), with as many portions as necessary to keep the hands wet for three minutes (6–12 ml). Bacterial post-values were taken from one hand (immediate effect); the other hand was gloved for three hours (sizes 7–9). The second post-value was taken when the glove was removed (3 h effect).
Results
The mean immediate log10 reduction of CFU was 2.56 ± 1.12. The glove size had no significant effect on the efficacy of disinfection (p = 0.182; ANOVA). However, a volume of 6 ml was significantly less effective than 9 ml for glove sizes of 7.5–8 (p < 0.05; Tukey post hoc analysis). The mean log10 reduction after 3 h was 2.12 ± 1.24. A volume of 6 ml was again significantly less effective than 12 ml for glove size 7 and than 9 ml for glove sizes 7.5–8 (p < 0.05).
Conclusions
The application of small volumes of surgical hand disinfectant when using the EN 12791 reference procedure is likely to yield poor efficacy results, regardless of hand size.
doi:10.1186/2047-2994-3-15
PMCID: PMC4017236  PMID: 24822090
Surgical hand disinfection; n-propanol; Applied volume; EN 12791; Hand size
24.  Intestinal carriage of methicillin-resistant Staphylococcus aureus in nasal MRSA carriers hospitalized in the neonatal intensive care unit 
Background
The current data regarding the correlation between the methicillin-resistant Staphylococcus aureus (MRSA) clones carried in the nasal cavity and digestive tract are inadequate.
Methods
MRSA strains were isolated from both the feces and nasal swabs of 21 nasal-MRSA carriers ranging from 10 to 104 days of age treated at the neonatal intensive care units of two hospitals. The molecular epidemiological characteristics of the isolates were determined: multilocus sequence types, spa-types, staphylococcal cassette chromosome mec (SCCmec) types, carriage of four exotoxin genes, and genes contained in commercially available kit.
Results
The feces of all nasal carriers contained MRSA at levels ranging from 4.0 × 102 to 2.8 × 108 colony forming units/g feces. The MRSA clones isolated from the feces and the nasal swabs of each patient were the same. Four MRSA clones, clonal complex (CC) 8-SCCmec IVl, CC8-SCCmec IVb, CC1-SCCmec IVa and CC5-SCCmec IIa were identified from 21 patients. All CC8-SCCmec IVl strains and one of three CC5-SCCmec IIa strains carried the toxic shock syndrome toxin gene.
Conclusions
The feces of tested MRSA carriers contained the same MRSA clones as the nasal isolates in considerable amounts, suggesting that more careful attention should be paid for the handling of excrement in the case of newborn babies or infants than that of adults.
doi:10.1186/2047-2994-3-14
PMCID: PMC4012148  PMID: 24808943
MRSA; Infection control; Intestinal carriage; Nosocomial infection; NICU
25.  Infection control interventions in small rural hospitals with limited resources: results of a cluster-randomized feasibility trial 
Background
There are few reports on the feasibility of conducting successful infection control (IC) interventions in rural community hospitals.
Methods
Ten small rural community hospitals in Idaho and Utah were recruited to participate in a cluster-randomized trial of multidimensional IC interventions to determine their feasibility in the setting of limited resources. Five hospitals were randomized to develop individualized campaigns to promote HH, isolation compliance, and outbreak control. Five hospitals were randomized to continue with current IC practices. Regular blinded observations of hand hygiene (HH) compliance were conducted in all hospitals as the primary outcome measure. Additionally, periodic prevalence studies of patient colonization with resistant pathogens were performed. The 5-months intervention time period was compared to a 4-months baseline period, using a multi-level logistic regression model.
Results
The intervention hospitals implemented a variety of strategies. The estimated average absolute change in “complete HH compliance” in intervention hospitals was 20.1% (range, 7.8% to 35.5%) compared to −3.1% (range −6.3% to 5.9%) in control hospitals (p = 0.001). There was an estimated average absolute change in “any HH compliance” of 28.4% (range 17.8% to 38.2%) in intervention hospitals compared to 0.7% (range −16.7 to 20.7%) in control hospitals (p = 0.010). Active surveillance culturing demonstrated an overall prevalence of MRSA carriage of 9.7%.
Conclusions
A replicable intervention significantly improved hand hygiene as a primary outcome measure despite barriers of geographic distance and lack of experience with study protocols. Active surveillance culturing identified unsuspected reservoirs of MRSA colonization and further promoted IC activity.
doi:10.1186/2047-2994-3-10
PMCID: PMC3986470  PMID: 24678604
Hand hygiene; Epidemiology; United States; Transmission; Clinical trial; MRSA

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