Outbreak of Pseudomonas aeruginosa producing VIM carbapenemase in an intensive care unit and its termination by implementation of waterless patient care.

Long-term outbreaks of multidrug-resistant Gram-negative bacilli related to hospital-building water systems have been described. However, successful mitigation strategies have rarely been reported. In particular, environmental disinfection or replacement of contaminated equipment usually failed to eradicate environmental sources of Pseudomonas aeruginosa. We report the investigation and termination of an outbreak of P. aeruginosa producing VIM carbapenemase (PA-VIM) in the adult intensive care unit (ICU) of a Swiss tertiary care hospital with active case finding, environmental sampling and whole genome sequencing (WGS) of patient and environmental strains. We also describe the implemented control strategies and their effectiveness on eradication of the environmental reservoir. Between April 2018 and September 2020, 21 patients became either infected or colonized with a PA-VIM strain. For 16 of them, an acquisition in the ICU was suspected. Among 131 environmental samples collected in the ICU, 13 grew PA-VIM in sink traps and drains. WGS confirmed the epidemiological link between clinical and environmental strains and the monoclonal pattern of the outbreak. After removing sinks from patient rooms and implementation of waterless patient care, no new acquisition was detected in the ICU within 8 months after the intervention. Implementation of waterless patient care with removal of the sinks in patient rooms was successful for termination of a PA-VIM ICU outbreak linked to multiple environmental water sources. WGS provides highly discriminatory accuracy to investigate environment-related outbreaks

Digitalizing Clinical Guidelines: Experiences in the Development of Clinical Decision Support Algorithms for Management of Childhood Illness in Resource-Constrained Settings.

Clinical decision support systems (CDSSs) can strengthen the quality of integrated management of childhood illness (IMCI) in resource-constrained settings. Several IMCI-related CDSSs have been developed and implemented in recent years. Yet, despite having a shared starting point, the IMCI-related CDSSs are markedly varied due to the need for interpretation when translating narrative guidelines into decision logic combined with considerations of context and design choices. Between October 2019 and April 2021, we conducted a comparative analysis of 4 IMCI-related CDSSs. The extent of adaptations to IMCI varied, but common themes emerged. Scope was extended to cover a broader range of conditions. Content was added or modified to enhance precision, align with new evidence, and support rational resource use. Structure was modified to increase efficiency, improve usability, and prioritize care for severely ill children. The multistakeholder development processes involved syntheses of recommendations from existing guidelines and literature; creation and validation of clinical algorithms; and iterative development, implementation, and evaluation. The common themes surrounding adaptations of IMCI guidance highlight the complexities of digitalizing evidence-based recommendations and reinforce the rationale for leveraging standards for CDSS development, such as the World Health Organization's SMART Guidelines. Implementation through multistakeholder dialogue is critical to ensure CDSSs can effectively and equitably improve quality of care for children in resource-constrained settings

Study protocol for an international, multicentre stepped-wedge cluster randomised trial to evaluate the impact of a digital antimicrobial stewardship smartphone application

Introduction With the widespread use of electronic health records and handheld electronic devices in hospitals, informatics-based antimicrobial stewardship interventions hold great promise as tools to promote appropriate antimicrobial drug prescribing. However, more research is needed to evaluate their optimal design and impact on quantity and quality of antimicrobial prescribing. Methods and analysis Use of smartphone-based digital stewardship applications (apps) with local guideline directed empirical antimicrobial use by physicians will be compared with antimicrobial prescription as per usual as primary outcome in three hospitals in the Netherlands, Sweden and Switzerland. Secondary outcomes will incl

Management of emerging multidrug-resistant tuberculosis in a low-prevalence setting

AbstractMultidrug-resistant (MDR) tuberculosis (TB) is an emerging concern in communities with a low TB prevalence and a high standard of public health. Twenty-three consecutive adult MDR TB patients who were treated at our institution between 2007 and 2013 were reviewed for demographic characteristics and anti-TB treatment management, which included surgical procedures and long-term patient follow-up. This report of our experience emphasizes the need for an individualized approach as MDR TB brings mycobacterial disease management to a higher level of expertise, and for a balance to be found between international current guidelines and patient-tailored treatment strategies

Clinical, functional and genetic characterization of 16 patients suffering from chronic granulomatous disease variants - identification of 11 novel mutations in CYBB

Chronic granulomatous disease (CGD) is a rare inherited disorder in which phagocytes lack nicotinamide adenine dinucleotide phosphate (NADPH) oxidase activity. The most common form is the X-linked CGD (X91-CGD), caused by mutations in the CYBB gene. Clinical, functional and genetic characterizations of 16 CGD cases of male patients and their relatives were performed. We classified them as suffering from different variants of CGD (X910, X91- or X91+), according to NADPH oxidase 2 (NOX2) expression and NADPH oxidase activity in neutrophils. Eleven mutations were novel (nine X910-CGD and two X91--CGD). One X910-CGD was due to a new and extremely rare double missense mutation Thr208Arg-Thr503Ile. We investigated the pathological impact of each single mutation using stable transfection of each mutated cDNA in the NOX2 knock-out PLB-985 cell line. Both mutations leading to X91--CGD were also novel; one deletion, c.-67delT, was localized in the promoter region of CYBB; the second c.253-1879A>G mutation activates a splicing donor site, which unveils a cryptic acceptor site leading to the inclusion of a 124-nucleotide pseudo-exon between exons 3 and 4 and responsible for the partial loss of NOX2 expression. Both X91--CGD mutations were characterized by a low cytochrome b558 expression and a faint NADPH oxidase activity. The functional impact of new missense mutations is discussed in the context of a new three-dimensional model of the dehydrogenase domain of NOX2. Our study demonstrates that low NADPH oxidase activity found in both X91--CGD patients correlates with mild clinical forms of CGD, whereas X910-CGD and X91+-CGD cases remain the most clinically severe forms.</p

Use of stewardship smartphone applications by physicians and prescribing of antimicrobials in hospitals : A systematic review

Background Antimicrobial stewardship (AMS) programs promote appropriate use of antimicrobials and reduce antimicrobial resistance. Technological developments have resulted in smartphone applications (apps) facilitating AMS. Yet, their impact is unclear. Objectives Systematically review AMS apps and their impact on prescribing by physicians treating in-hospital patients. Data sources EMBASE, MEDLINE (Ovid), Cochrane Central, Web of Science and Google Scholar. Study eligibility criteria Studies focusing on smartphone or tablet apps and antimicrobial therapy published from January 2008 until February 28th 2019 were included. Participants Physicians treating in-hospital patients. Interventions AMS apps Methods Systematic review. Results Thirteen studies met the eligibility criteria. None was a randomized controlled trial. Methodological study quality was considered low to moderate in all but three qualitative studies. The primary outcomes were process indicators, adherence to guidelines and user experience. Guidelines were more frequently accessed by app (53.0% - 89.6%) than by desktop in three studies. Adherence to guidelines increased (6.5% - 74.0%) significantly for several indications after app implementation in four studies. Most users considered app use easy (77.4%—&gt;90.0%) and useful (71.0%—&gt;90%) in three studies and preferred it over guideline access by web viewer or booklet in two studies. However, some physicians regarded app use adjacent to colleagues or patients unprofessional in three qualitative studies. Susceptibility to several antimicrobials changed significantly post-intervention (from 5% decrease to 10% - 14% increase) in one study. Conclusions Use of AMS apps seems to promote access to and knowledge of antimicrobial prescribing policy, and increase adherence to guidelines in hospitals. However, this has been assessed in a limited number of studies and for specific indications. Good quality studies are necessary to properly assess the impact of AMS apps on antimicrobial prescribing. To improve adherence to antimicrobial guidelines, use of AMS apps could be considered

Infections postchirurgie artérielle des membres inférieurs : peut-on mieux faire? [Surgical site infection after lower limb arterial reconstruction: can we improve prevention?]

Infections associated with arterial reconstructions of the lower limbs are associated with high morbidity. This article reviews the risk factors for infection associated with this surgery and the preventive measures. These include smoking cessation and glycemic control preoperatively; avoiding unnecessary exposure to antibiotics or corticosteroids; optimal peripheral wound care; rigorous antisepsis and antibiotic prophylaxis in the operating theatre ; and finally, meticulous post-operative wound monitoring. The benefit of Staphylococcus aureus decolonization in vascular surgery is less clearly established than in cardiac and thoracic surgery, but it is still recommended in cases of implant placement or where there is a high risk of S. aureus infection, depending on the planned approach and type of surgery

Disseminated actinomycosis treated with clindamycin

International audienceActinomycosis is a rare bacterial disease caused by Actinomyces spp., an anaerobic bacteria from the oropharynx, digestive, and female genital tracts. Initial clinical presentation often mimics malignancy, which can lead to a delay in diagnosis. Cervico-facial, genitourinary, digestive, and respiratory features are the most frequent. Few cases are reported in children and risk factors are not well known in this population. We report on the case of an 8-year-old boy with disseminated actinomycosis with cervico-facial, pulmonary, and bone involvement caused by Actinomyces israelii. The infiltrative appearance initially suggested malignancy and the patient was started on chemotherapy for presumed histiocytosis. Evaluation of subsequent tissue samples demonstrated the presence of filamentous structures consistent with fungal or filamentous bacterial infection. Prolonged culture yielded the correct diagnosis. The patient had a severe allergic reaction to piperacillin/tazobactam and was therefore transitioned to clindamycin to complete a 9-month course. This treatment, which has not been reported in children, led to a favorable clinical, biological, and radiological response, with a good clinical tolerance

Enfants au contact d’individus atteints d’une tuberculose multi-résistante : quelles stratégies adopter ? Analyse de 46 enfants contacts et revue de la littérature

International audienceINTRODUCTION: Tuberculosis-related morbidity and mortality remain important. Emergence and diffusion of multidrug-resistance tuberculosis (MDR-TB) is a global public health concern. Cases of MDR-TB in children are a sentinel event indicating the spread of a mycobacterial strain within a community. Latent TB precedes MDR-TB and screening and follow-up of contact individuals are key points of TB infection control. METHODS: We performed the case-investigation of 20 adult cases of MDR-TB managed in our institution. RESULTS: Forty-six pediatric contact individuals were identified. A high proportion of these children were lost to follow-up (80% at 12 months), showing that monitoring this reservoir population with migrant history is challenging. Five (11%) children presented a secondary infection: one child was diagnosed with active TB infection (positive tuberculin skin test associated with abnormalities on chest computer tomography [CT] scan). Four children were diagnosed with latent TB infection (isolated positive tuberculin skin test with normal CT scan). Two of these children received a treatment adjusted to the strain of the index case. DISCUSSION: In the setting of emerging MDR-TB, tuberculin skin test may be likely replaced by specific interferon-gamma release assays (IGRA), independent of prior BCG vaccination. In addition, chest CT scan is preferred to chest X-ray to detect TB lesions. The management of latent TB infection is controversial: immediate treatment with second-line anti-TB drugs adapted to the index case strain or, consistently with WHO guidelines, a simple follow-up with subsequent treatment in case of active TB.IntroductionMalgré une incidence en lente décroissance, la morbi-mortalité de la tuberculose (TB) reste importante. L’émergence et la diffusion de souches multi-résistantes (MR) constituent actuellement un problème mondial majeur de santé publique. Les cas pédiatriques de TB-MR sont un évènement sentinelle indiquant une circulation de souches au sein d’une communauté. L’infection tuberculeuse latente (ITL) précède les cas de TB-MR. La détection et le suivi des sujets contacts sont des axes clés de la lutte anti-TB.MéthodesAutour de 20 cas adultes atteints de TB-MR pris en charge dans notre institution 46 enfants contacts ont été recensés.RésultatsDurant le suivi, le nombre d’enfants perdus de vue était élevé (80 % à 1 an) attestant de la difficulté de suivre une jeune population « réservoir » issue de l’immigration. Le taux d’incidence d’une infection tuberculeuse secondaire était de 11 % : un enfant a développé une TB-maladie (virage tuberculinique associé à des anomalies tomodensitométriques thoraciques) ; quatre enfants ont développé une ITL (virage tuberculinique à tomodensitométrie thoracique normale). Deux enfants ont reçu un traitement adapté à la souche du cas index (préventif ou curatif).DiscussionDans ce contexte d’émergence de la TB-MR, la substitution de l’IDR par les tests de libération d’interféron (TLI), aussi sensibles et plus spécifiques (indépendants du BCG), semble pertinente. De même, la TDM thoracique optimise la détection de lésions infra-radiographiques. La stratégie de traitement de l’ITL en post-exposition d’une TB-MR avec une combinaison adaptée à la souche du cas index est débattue au profit d’une stratégie proposée par l’OMS de surveillance prolongée avec traitement curatif d’une TB active le cas échéant