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As of December 2021, the coronavirus disease 2019 (COVID-19) pandemic has claimed millions of deaths and caused disruptions in health systems around the world. The short- and long-term effects of COVID-19 on antimicrobial resistance (AMR), which was already a global threat before the pandemic, are manifold and complex. In this expert review, we summarize how COVID-19 might be affecting AMR in the short term (by influencing the key determinants antibiotic use, infection control practices and international/local mobility) and which additional factors might play a role in the long term. Whereas reduced outpatient antibiotic use in high-income countries, increased awareness for hand hygiene, and reduced mobility have likely mitigated the emergence and spread of AMR in the short term, factors such as overuse of antibiotics in COVID-19 patients, shortage of personal protective equipment, lack of qualified healthcare staff, and patient overcrowding have presumably facilitated its propagation. Unsurprisingly, international and national AMR surveillance data for 2020 show ambiguous trends. Although disruptions in antibiotic stewardship programs, AMR surveillance and research might promote the spread of AMR, other developments could prove beneficial to the cause in the long term. These factors include the increased public awareness for infectious diseases and infection control issues, the strengthening of the One Health perspective as outlined by the Centers for Disease Control and Prevention, and the unprecedented number of international research collaborations and platforms. These factors could even serve as leverage and provide opportunities to better combat AMR in the future.
Nosocomial transmission of influenza is a major concern for infection control. We aimed to dissect transmission dynamics of influenza, including asymptomatic transmission events, in acute care.
Prospective surveillance study during 2 influenza seasons.
Volunteer sample of inpatients on medical wards and healthcare workers (HCWs).
Participants provided daily illness diaries and nasal swabs for influenza A and B detection and whole-genome sequencing for phylogenetic analyses. Contacts between study participants were tracked. Secondary influenza attack rates were calculated based on spatial and temporal proximity and phylogenetic evidence for transmission.
In total, 152 HCWs and 542 inpatients were included; 16 HCWs (10.5%) and 19 inpatients (3.5%) tested positive for influenza on 109 study days. Study participants had symptoms of disease on most of the days they tested positive for influenza (83.1% and 91.9% for HCWs and inpatients, respectively). Also, 11(15.5%) of 71 influenza-positive swabs among HCWs and 3 (7.9%) of 38 influenza-positive swabs among inpatients were collected on days without symptoms; 2 (12.5%) of 16 HCWs and 2 (10.5%) of 19 inpatients remained fully asymptomatic. The secondary attack rate was low: we recorded 1 transmission event over 159 contact days (0.6%) that originated from a symptomatic case. No transmission event occurred in 61 monitored days of contacts with asymptomatic influenza-positive individuals.
Influenza in acute care is common, and individuals regularly shed influenza virus without harboring symptoms. Nevertheless, both symptomatic and asymptomatic transmission events proved rare. We suggest that healthcare-associated influenza prevention strategies that are based on preseason vaccination and barrier precautions for symptomatic individuals seem to be effective.
The incidence of surgical site infections may be underreported if the data are not routinely validated for accuracy. Our goal was to investigate the communicated SSI rate from a large network of Swiss hospitals compared with the results from on-site surveillance quality audits.
Retrospective cohort study.
In total, 81,957 knee and hip prosthetic arthroplasties from 125 hospitals and 33,315 colorectal surgeries from 110 hospitals were included in the study.
Hospitals had at least 2 external audits to assess the surveillance quality. The 50-point standardized score per audit summarizes quantitative and qualitative information from both structured interviews and a random selection of patient records. We calculated the mean National Healthcare Safety Network (NHSN) risk index adjusted infection rates in both surgery groups.
The median NHSN adjusted infection rate per hospital was 1.0% (interquartile range [IQR], 0.6%–1.5%) with median audit score of 37 (IQR, 33–42) for knee and hip arthroplasty, and 12.7% (IQR, 9.0%–16.6%), with median audit score 38 (IQR, 35–42) for colorectal surgeries. We observed a wide range of SSI rates and surveillance quality, with discernible clustering for public and private hospitals, and both lower infection rates and audit scores for private hospitals. Infection rates increased with audit scores for knee and hip arthroplasty (P value for the slope = .002), and this was also the case for planned (P = .002), and unplanned (P = .02) colorectal surgeries.
Surveillance systems without routine evaluation of validity may underestimate the true incidence of SSIs. Audit quality should be taken into account when interpreting SSI rates, perhaps by adjusting infection rates for those hospitals with lower audit scores.
To assess influenza symptoms, adherence to mask use recommendations, absenteesm and presenteeism in acute care healthcare workers (HCWs) during influenza epidemics.
The TransFLUas influenza transmission study in acute healthcare prospectively followed HCWs prospectively over 2 consecutive influenza seasons. Symptom diaries asking for respiratory symptoms and adherence with mask use recommendations were recorded on a daily basis, and study participants provided midturbinate nasal swabs for influenza testing.
In total, 152 HCWs (65.8% nurses and 13.2% physicians) were included: 89.1% of study participants reported at least 1 influenza symptom during their study season and 77.8% suffered from respiratory symptoms. Also, 28.3% of HCW missed at least 1 working day during the study period: 82.6% of these days were missed because of symptoms of influenza illness. Of all participating HCWs, 67.9% worked with symptoms of influenza infection on 8.8% of study days. On 0.3% of study days, symptomatic HCWs were shedding influenza virus while at work. Among HCWs with respiratory symptoms, 74.1% adhered to the policy to wear a mask at work on 59.1% of days with respiratory symptoms.
Respiratory disease is frequent among HCWs and imposes a significant economic burden on hospitals due to the number of working days lost. Presenteesm with respiratory illness, including influenza, is also frequent and poses a risk for patients and staff.
In this prospective cohort of 1,012 Swiss hospital employees, 3 different assays were used to screen serum for SARS-CoV-2 antibodies. Seropositivity was 1%; the positive predictive values of the lateral-flow immunoassay were 64% (IgG) and 13% (IgM). History of fever and myalgia most effectively differentiated seropositive and seronegative participants.
We assessed infection prevention in Swiss hospitals via a national survey focusing on infection prevention practices prior to a large national infection prevention initiative. Of the 59 hospitals that responded (77%), 98% had infection prevention teams and 40% very good or excellent leadership support. However, a minority of hospitals used recommended infection prevention practices and surveillance systems regularly.
Background: Adults are at risk of being exposed to influenza from many sources. Healthcare personnel (HCP) have the additional risk of being exposed to ill patients.
To determine whether HCP were at higher risk than adults working in nonhealthcare roles (non-HCP).
Prospective cohort study.
Acute-care hospitals and other businesses in Toronto, Ontario, Canada.
Adults aged 18–69 years were enrolled for 1 or more of the 2010/2011, 2011/2012, and 2012/2013 influenza seasons. Swabs collected during acute respiratory illnesses were tested for influenza and pre- and postseason blood samples were tested for influenza-specific immune response.
The adjusted odds of influenza were similar for HCP and non-HCP (odds ratio [OR], 1.29; 95% confidence interval [CI], 0.63–2.63). Older adults and those vaccinated against influenza had lower odds, and those who shared their workspace and who used corrective eyewear had higher odds of influenza.
HCP and other working adults are at similar risk of influenza infection.
To reduce surgical site infection (SSI) incidence in plastic surgery and hand surgery.
Uncontrolled before-and-after study.
Department of plastic surgery and hand surgery of a tertiary-care teaching hospital.
Patients undergoing surgery between January 2016 and April 2018.
A comprehensive unit-based safety program (CUSP) consisting of a bundle of evidence-based SSI prevention strategies and a change in safety culture was fully implemented after a 14-month baseline surveillance and implementation period. SSI surveillance was performed over an intervention period of another 14 months, and differences in SSI rates between the 2 periods were calculated. Adherence with bundle components and risk factors for SSI were further evaluated in a case-cohort analysis.
Of 3,321 patients, 63 (1.9%) developed an SSI, 38 of 1,722 (2.2%) in the baseline group and 25 of 1,599 (1.6%) in the intervention group (P = .20). The CUSP was associated with an adjusted relative SSI risk reduction of 41% (95% confidence interval [CI], 0.4%–65%; P = .048) in multivariable analysis, whereas the need for revision surgery increased SSI risk (odds ratio [OR], 2.63; 95% CI, 1.31–5.30; P = .007). During the intervention period, the proportion of checklists completed was 62.4%, and no difference in adherence with bundle components between patients with and without SSI was observed.
This CUSP helped reduce SSI in a surgical specialty with a low baseline SSI incidence, even though adherence with checklist completion was moderate and the main modifiable risk factors remained unchanged over time. Programs that include safety culture change may more effectively promote SSI reduction than prevention bundles alone.
Afternoon aortic valve replacement surgery may provide perioperative myocardial protection and improve patient outcomes compared with morning surgery. The results of our large observational study based on Swiss cardiac surgical site infection surveillance data suggest that the current evidence is insufficient to generally promote afternoon cardiac surgeries.
The preventable proportion of healthcare-associated infections (HAIs) may decrease over time as standards of care improve. We aimed to assess the proportion of HAIs prevented by multifaceted infection control interventions in different economic settings.
In this systematic review and meta-analysis, we searched OVID Medline, EMBASE, CINAHL, PubMed, and The Cochrane Library for studies published between 2005 and 2016 assessing multifaceted interventions to reduce catheter-associated urinary tract infections (CAUTIs), central-line–associated bloodstream infections (CLABSIs), surgical site infections (SSIs), ventilator-associated pneumonia (VAP), and hospital-acquired pneumonia not associated with mechanical ventilation (HAP) in acute-care or long-term care settings. For studies reporting raw rates, we extracted data and calculated the natural log of the risk ratio and variance to obtain pooled risk ratio estimates.
Of the 5,226 articles identified by our search, 144 studies were included in the final analysis. Pooled incidence rate ratios associated with multifaceted interventions were 0.543 (95% confidence interval [CI], 0.445–0.662) for CAUTI, 0.459 (95% CI, 0.381–0.554) for CLABSI, and 0.553 (95% CI, 0.465–0.657) for VAP. The pooled rate ratio was 0.461 (95% CI, 0.389–0.546) for interventions aiming at SSI reduction, and for VAP reduction initiatives, the pooled rate ratios were 0.611 (95% CI, 0.414–0.900) for before-and-after studies and 0.509 (95% CI, 0.277–0.937) for randomized controlled trials. Reductions in infection rates were independent of the economic status of the study country. The risk of bias was high in 143 of 144 studies (99.3%).
Published evidence suggests a sustained potential for the significant reduction of HAI rates in the range of 35%–55% associated with multifaceted interventions irrespective of a country’s income level.
The transfer of pathogens may spread antimicrobial resistance and lead to healthcare-acquired infections. We performed a systematic literature review to generate estimates of pathogen transfer in relation to healthcare provider (HCP) activities.
For this systematic review and meta-analysis, Medline/Ovid, EMBASE, and the Cochrane Library were searched for studies published before July 7, 2017. We reviewed the literature, examining transfer of pathogens associated with HCP activities. We included studies that (1) quantified transfer of pathogens from a defined origin to a defined destination surface; (2) reported a microbiological sampling technique; and (3) described the associated activity leading to transfer. For studies reporting transfer frequencies, we extracted data and calculated the estimated proportion using Freeman-Tukey double arcsine transformation and the DerSimonian-Laird random-effects model.
Of 13,121 identified articles, 32 were included. Most articles (n=27, 84%) examined transfer from patients and their environment to HCP hands, gloves, and gowns, with an estimated proportion for transfer frequency of 33% (95% confidence interval [CI], 12%–57%), 30% (95% CI, 23%–38%) and 10% (95% CI, 6%–14%), respectively. Other articles addressed transfer involving the hospital environment and medical devices. Risk factor analyses in 12 studies suggested higher transfer frequencies after contact with moist body sites (n=7), longer duration of care (n=5), and care of patients with an invasive device (n=3).
Recognizing the heterogeneity in study designs, the available evidence suggests that pathogen transfer to HCPs occurs frequently. More systematic research is urgently warranted to support targeted and economic prevention policies and interventions.
To assess the structure and quality of surveillance activities and to validate outcome detection in the Swiss national surgical site infection (SSI) surveillance program.
Countrywide survey of SSI surveillance quality.
147 hospitals or hospital units with surgical activities in Switzerland.
Site visits were conducted with on-site structured interviews and review of a random sample of 15 patient records per hospital: 10 from the entire data set and 5 from a subset of patients with originally reported infection. Process and structure were rated in 9 domains with a weighted overall validation score, and sensitivity, specificity, positive predictive value, and negative predictive value were calculated for the identification of SSI.
Of 50 possible points, the median validation score was 35.5 (range, 16.25–48.5). Public hospitals (P<.001), hospitals in the Italian-speaking region of Switzerland (P=.021), and hospitals with longer participation in the surveillance (P=.018) had higher scores than others. Domains that contributed most to lower scores were quality of chart review and quality of data extraction. Of 49 infections, 15 (30.6%) had been overlooked in a random sample of 1,110 patient records, accounting for a sensitivity of 69.4% (95% confidence interval [CI], 54.6%–81.7%), a specificity of 99.9% (95% CI, 99.5%–100%), a positive predictive value of 97.1% (95% CI, 85.1%–99.9%), and a negative predictive value of 98.6% (95% CI, 97.7%–99.2%).
Irrespective of a well-defined surveillance methodology, there is a wide variation of SSI surveillance quality. The quality of chart review and the accuracy of data collection are the main areas for improvement.
In-hospital transmission of methicillin-susceptible Staphylococcus aureus (MSSA) among neonates remains enigmatic. We describe the epidemiology of MSSA colonization and infection in a 30-bed neonatal ward.
Multimodal outbreak investigation
A public 800-bed tertiary care university hospital in Switzerland
Investigations in 2012–2013, triggered by a MSSA infection cluster, included prospective MSSA infection surveillance, microbiologic screening of neonates and environment, onsite observations, and a prospective cohort study. MSSA isolates were characterized by pulsed-field gel electrophoresis (PFGE) and selected isolates were examined for multilocus sequence type (MLST) and virulence factors.
Among 726 in 2012, 30 (4.1%) patients suffered from MSSA infections including 8 (1.1%) with bacteremia. Among 655 admissions in 2013, 13 (2.0%) suffered from MSSA infections including 2 (0.3%) with bacteremia. Among 177 neonates screened for S. aureus carriage, overall 77 (44%) tested positive. A predominant PFGE-1-ST30 strain was identified in 6 of 30 infected neonates (20%) and 30 of 77 colonized neonates (39%). This persistent clone was pvl-negative, tst-positive and belonged to agr group III. We found no environmental point source. MSSA carriage was associated with central vascular catheter use but not with a particular midwife, nurse, physician, or isolette. Observed healthcare worker behavior may have propagated transmission via hands and fomites. Despite multimodal interventions, clonal transmission and colonization continued and another clone, PFGE-6-ST5, became predominant.
Hospital-acquired MSSA clones represent a high proportion of MSSA colonization but not MSSA infections in neonate inpatients. In contrast to persisting MSSA, transmission infection rates decreased concurrently with interventions. It remains to be established whether eradication of hospital-acquired MSSA strains would reduce infection rates further.
Infect. Control Hosp. Epidemiol. 2015;36(11):1305–1312
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