Preventing Infections and Controlling Multiresistant Pathogens in Orthopaedic and Trauma Surgery

Orthopaedic surgery has low HAI incidences compared to other surgical disciplines. However, when they do occur, these infections are associated with substantial morbidity, prolonged hospital stay, exorbitant costs, and difficulties in eradication with life-long recurrence risks of around 10-20%, especially in the case of multi-resistant pathogens. Prevention remains of the utmost importance and harbours some hallmarks not shared with other surgical disciplines: low inoculum for implant infections; pathogenicity of coagulase-negative staphylococci and other skin commensals; possible haematogenous origin; and long post-discharge surveillance periods. An adequate screening and decolonization policy regarding multi-resistant pathogens, cautious antimicrobial use, and iterative epidemiologic interventions remain essential when dealing with multi-morbid patients hospitalised in specialised septic orthopaedic wards under the constant influence of high-dose and long-lasting antibiotic therapies. Among the many measures to prevent orthopaedic SSI, only some are based on strong evidence, and there is insufficient evidence to show which element is superior over any other. This highlights the need for multimodal approaches involving active post-discharge surveillance, as well as measures at every step of the care process. These range from pre-operative care to surgery and post-operative care, at the individual patient level to department-wide interventions targeting all HAI, including antibiotic stewardship. Although theoretically reducible to zero, the maximal realistic extent to decrease SSI in elective orthopaedic surgery remains unknown

Staffing level: a determinant of late-onset ventilator-associated pneumonia

INTRODUCTION: The clinical and economic burden of ventilator-associated pneumonia (VAP) is uncontested. We conducted the present study to determine whether low nurse-to-patient ratio increases the risk for VAP and whether this effect is similar for early-onset and late-onset VAP. METHODS: This prospective, observational, single-centre cohort study was conducted in the medical intensive care unit (ICU) of the University of Geneva Hospitals. All patients who were at risk for ICU-acquired infection admitted from January 1999 to December 2002 were followed from admission to discharge. Collected variables included patient characteristics, admission diagnosis, Acute Physiology and Chronic Health Evaluation II score, co-morbidities, exposure to invasive devices, daily number of patients and nurses on duty, nurse training level and all-site ICU-acquired infections. VAP was diagnosed using standard definitions. RESULTS: Among 2,470 patients followed during their ICU stay, 262 VAP episodes were diagnosed in 209/936 patients (22.3%) who underwent mechanical ventilation. Median duration of mechanical ventilation was 3 days (interquartile range 2 to 6 days) among patients without VAP and 11 days (6 to 19 days) among patients with VAP. Late-onset VAP accounted for 61% of all episodes. The VAP rate was 37.6 episodes per 1,000 days at risk (95% confidence interval 33.2 to 42.4). The median daily nurse-to-patient ratio over the study period was 1.9 (interquartile range 1.8 to 2.2). By multivariate Cox regression analysis, we found that a high nurse-to-patient ratio was associated with a decreased risk for late-onset VAP (hazard ratio 0.42, 95% confidence interval 0.18 to 0.99), but there was no association with early-onset VAP. CONCLUSION: Lower nurse-to-patient ratio is associated with increased risk for late-onset VAP

Managing diabetic foot infections: a review of the new guidelines

Foot infections are amongst the most frequent and severe complications linked to diabetes mellitus and are the most common non-traumatic cause of lower limb amputation. Appropriate management of these infections, however, can improve their outcome. The Infectious Diseases Society of America (IDSA) constituted a panel of multidisciplinary experts in 2004 to develop guidelines for the diagnosis and treatment of diabetic foot infections, which have been widely used and validated. Because there have been many new publications in the field, and the IDSA updated the format for all guidelines, they asked the diabetic foot infection committee to revise the 2004 publication. The revised guidelines, based on a thorough and systematic review of the literature, were published in 2012. They are built around 10 key questions concerning diagnosis and treatment; these are answered, with a summary of the evidence provided, and given a GRADE rating for the strength of the recommendation and quality of the evidence. The updated guidelines also include advice on implementing these recommendations, suggestions for regulatory changes to enhance care for diabetic foot infections, recommendations on performance measures and suggested areas for future research. They also include 14 tables, 1 figure, and 345 references, most of which were published after the first guidelines in 2004. Implementing these guidelines should improve outcomes in patients with a DFI

Management of Gram-positive bacteraemia

PURPOSE OF REVIEW: Gram-positive bacteraemic infections are frequent and associated with high morbidity and mortality. This paper reviews publications focusing exclusively on new findings related to Gram-positive bacteraemia in the published literature from July 2006 to June 2007. RECENT FINDINGS: Ninety-eight articles have been reviewed. Of the 66 incorporated in this review, 21 focused on epidemiology or prevention. Thirty-two concerned staphylococcal bacteraemia, while 11 addressed other Gram-positive pathogens. There were seven articles on daptomycin, nine on endocarditis, seven on diagnostic issues, five on haemodialysis-related bacteraemia, and four on antibiotic lock techniques. SUMMARY: In contrast to the large amount of articles dealing with epidemiological issues, the past year did not reveal any new fundamental insights into the treatment of Gram-positive bacteraemia. The rise in the minimal inhibitory concentrations of Staphylococcus aureus to vancomycin may become a threat. Several publications underlined the in-vivo efficacy of daptomycin, the new kid on the block against Gram-positive bacteraemia and endocarditis. The antibiotic lock technique showed some promising potential for secondary prevention or treatment of catheter-related infection, while rapid molecular techniques for early species identification may become a valuable diagnostic tool. Most evidence was not based on large, randomized trials and needs future confirmation