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NosoVeille – Bulletin de veille Mars 2012

NosoVeille n°3Mars 2012

Rédacteurs : Nathalie Sanlaville, Sandrine Yvars, Annie Treyve

Ce bulletin de veille est une publication mensuelle qui recueille les publications scientifiques publiées au cours du mois écoulé.

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AntibiotiqueBactériémieChirurgie Clostridium difficileEHPAD / Personne âgéeEndoscopieEnvironnementEpidémieGestion des risquesGrippeHémodialyseHygiène des mainsInfection urinaireLegionellaLégislationPersonnelPneumoniePréventionRougeoleStaphylococcusSurveillanceTuberculoseVaccination

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Antibiotique

NosoBase n° 33196Poids des micro-organismes multirésistants aux antibiotiques sur les centres hospitaliers universitaires représenté par des patients ayant séjourné récemment dans des établissements de soins de longue durée

Marchaim D; Chopra T; Bogan C; Bheemreddy S; Sengstock D; Jagarlamudi R; et al. The burden of multidrug-resistant organisms on tertiary hospitals posed by patients with recent stays in long-term acute care facilities. American journal of infection control 2012; in press: 6 pages.

Mots-clés : ANTIBIORESISTANCE; MULTIRESISTANCE; SOIN DE LONGUE DUREE; CENTRE HOSPITALIER UNIVERSITAIRE; ETUDE RETROSPECTIVE; ENTEROBACTERIE; CARBAPENEME; ACINETOBACTER BAUMANNII; RISQUE; MICROBIOLOGIE; HEMODIALYSE; MORTALITE; DUREE DE SEJOUR

Background: Long-term acute care (LTAC) facilities admit patients with complex, advanced disease states. Study aims were to determine the burden posed on hospitals associated with LTAC exposure and analyze the differences between "present on admission" (POA) multidrug-resistant (MDR), gram-negative organisms (GNO) and POA MDR gram-positive organisms (GPO).Methods: A multicenter retrospective study was conducted in 13 hospitals from southeast Michigan, from September 1, 2008, to August 31, 2009. Cultures obtained in the first 72 hours of hospitalization (ie, POA) of MDR-GPO and MDR-GNO were reviewed. LTAC exposures in the previous 6 months and direct admission from a LTAC were recorded.Results: Overall, 5,297 patients with 7,147 MDR POA cultures were analyzed: 2,619 (36.6%) were MDR-GNO, and 4,528 (63.4%) were MDR-GPO. LTAC exposure in the past 6 months was present in 251 (5.2%) infectious episodes and was significantly more common among POA MDR-GNO than MDR-GPO (158 [8.6%] and 94 [3.1%], respectively, odds ratio, 2.87; P < .001). Recent LTAC exposure was strongly associated with both carbapenem-resistant Enterobacteriaceae (CRE) (31.6% of all CRE cases, P < .001) and Acinetobacter baumannii (14.9% of all A baumannii cases, P < .001).Conclusion: Nearly 10% of MDR-GNO POA had recent LTAC exposure. Hospital efforts to control the spread of MDR-GNO should focus on collaborations and communications with referring LTACs and interventions targeted towards patients with recent LTAC exposure.

NosoBase n° 33214"Nager dans la résistance" : co-colonisation par des entérobactéries résistant aux carbapénèmes et Acinetobacter baumannii ou Pseudomonas aeruginosa

Marchaim D; Perez F; Lee J; Bheemreddy S; Hujer AM; Rudin S; et al. "Swimming in resistance": co-colonization with carbapenem-resistant enterobacteriaceae and Acinetobacter baumannii or Pseudomonas aeruginosa. American journal of infection control 2012; in press: 6 pages.

Mots-clés : ANTIBIORESISTANCE; CARBAPENEME; ENTEROBACTERIE; PSEUDOMONAS AERUGINOSA ; ACINETOBACTER BAUMANNII ; COLONISATION ; MULTIRESISTANCE ; MORTALITE ; TYPAGE ; BIOLOGIE MOLECULAIRE

Background: Co-colonization of patients with carbapenem-resistant Enterobacteriaceae (CRE) and Acinetobacter baumannii (AB) or Pseudomonas aeruginosa (PA) is reported to be associated with increased antibiotic resistance and mortality.Methods: CREs isolated between September 2008 and September 2009 were analyzed at Detroit Medical Center. Patients who had an additional isolation of AB or PA during the period spanning 7 days before to 7 days after CRE isolation were considered co-colonized. Molecular typing was used to determine genetic similarity among CRE strains.Results: Eighty-six unique patient isolates of CREs were analyzed. Thirty-four patients (40%) were co-colonized, and 26 (79%) had AB or PA isolated on the same day as the CRE. High Charlson Comorbidity Index score was an independent predictor for co-colonization. Recent stay at a long-term acute-care facility and previous therapy with antimicrobials with activity only against gram-positive microorganisms also were associated with co-colonization, but did not remain significant independent predictors. Co-colonization was associated with higher levels of resistance to carbapenems among CREs and increased 90-day mortality. Molecular typing revealed CRE polyclonality in co-colonized patients.

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Conclusions: Co-colonization is found in patients with the greatest disease burden in the hospital and occurs due to the dissemination of multiple CRE strains. This finding calls into question the practice of cohorting patients with CRE in close proximity to patients with AB or PA.

NosoBase n° 33201Mise en place d'un protocole d'antibioprophylaxie dans une unité de réanimation

Maria de Almeida S; Marra AR; Wey SB; Silva Victor E; Pavao dos Santos OF; Edmond MB. Implementation of an antibiotic prophylaxis protocol in an intensive care unit. American journal of infection control 2012; in press: 5 pages.

Mots-clés : PROTOCOLE; ANTIBIOPROPHYLAXIE; SOIN INTENSIF; CHIRURGIE; OBSERVANCE; ETUDE PROSPECTIVE; CAS TEMOIN; APPARIEMENT; SITE OPERATOIRE; ANTIBIOTIQUE; CONSOMMATION; SECURITE; GESTION DES RISQUES

Background: When properly employed, the prophylactic use of antimicrobials is associated with a reduction in surgical site infections (SSIs). We found that the appropriate use of antimicrobial prophylaxis was only 50.5% (53/105) among patients undergoing surgery in the adult intensive care unit of our hospital. In 2001, a protocol was designed to improve compliance with recommended practice. Methods: We used a prospective interventional study and a case control study carried out between 2001 and 2007, including follow-up and daily intervention to improve compliance with antimicrobial prophylaxis guidelines and to monitor antimicrobial consumption and SSI rates. Cases of noncompliance to the prophylaxis protocol (group I) were matched to controls (group II) with appropriate prophylaxis and compared with regards to type of surgery, operative duration, intraoperative antimicrobial use, type of antimicrobial used, length of hospital stay, severity of illness, comorbidities, invasive devices, possible adverse reactions, and death. Results: Compliance with antimicrobial prophylaxis metrics reached 85%; however, we were unable to detect a change in SSI rate or consumption and cost of antimicrobials. Inappropriate use was not associated with higher likelihood of death. There were no other significant differences between the 2 groups. Conclusion: Our intervention increased compliance with appropriate antimicrobial surgical prophylaxis with no negative impact on patient safety.

NosoBase n° 32099Emergence de souches de Klebsiella pneumoniae autochtones et communautaires productrices de NDM-1 en Europe

Nordmann P; Couard JP; Sansot D; Poirel L. Emergence of an autochthonous and community-acquired NDM-1-producing Klebsiella pneumoniae in Europe. Clinical infectious diseases 2012/01/01; 54(1): 150-151.

Mots-clés : KLEBSIELLA PNEUMONIAE; CARBAPENEME; ANTIBIORESISTANCE; EUROPE; INFECTION COMMUNAUTAIRE

NosoBase n° 33213Facteurs de risque d'acquisition, communautaire ou nosocomiale, d'infections à bactéries productrices de bêta-lactamase à spectre étendu parmi des patients du centre hospitalier universitaire du Minnesota, Fairview

Siedelman L; Kline S; Duval S. Risk factors for community- and health facility-acquired extended-spectrum beta-lactamase-producing bacterial infections in patients at the University of Minnesota medical center, Fairview. American journal of infection control 2012; in press: 5 pages.

Mots-clés : FACTEUR DE RISQUE; CENTRE HOSPITALIER UNIVERSITAIRE; BETA-LACTAMASE A SPECTRE ELARGI; BACTERIE; ANTIBIORESISTANCE; CAS TEMOIN; ESCHERICHIA COLI; ANTIBIOTIQUE; CATHETER; INFECTION URINAIRE

Background: This study examined risk factors for extended-spectrum ß-lactamase (ESBL) infection in patients at the University of Minnesota Medical Center, Fairview. Methods: Laboratory-confirmed cases of ESBL infection between January 2005 and June 2008 were evaluated in a case-control study. Risk factors were assessed based on source of infection, either health facility-acquired (HFA) or community-acquired (CA). Cases were identified through hospital infection control

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department ESBL surveillance records. Controls were selected from the patient population present within the same facility as the cases. Results: Our evaluation revealed that 60.6% of the health facility-acquired ESBL infections were due to Escherichia coli. Risk factors included previous antibiotic use (odds ratio [OR], 23.7; P < .0001), recurrent urinary tract infection (OR, 7.0; P < .022), venous or arterial catheter use (OR, 12.5; P < .0001), and long-term care facility residence (OR, 7.7; P = .043). For each day of antibiotic use, the risk of infection increased by 2%. Similarly, 76.5% of the community-acquired ESBL infections were due to E coli. Risk factors included previous antibiotic use (OR, 5.1; P = .0005) and recurrent urinary tract infection (OR, 9.1; P = .0098). For each day of antibiotic use, the risk of infection increased by 1%. Conclusions: Developing policies and methods to promote good antibiotic stewardship and reduce the incidence of urinary tract infections will decrease the risk of ESBL infection.

NosoBase n° 33232Facteurs prédictifs de non-conformité d'antibioprophylaxie chirurgicale au cours d'un audit clinique prospectif

Simon AM; Dzierzek AC; Djossou F; Couppie P; Blaise N; Marie M; et al. Factors associated with non-compliance to surgical antimicrobial prophylaxis guidelines during a prospective audit. Annales françaises d'anesthésie et de réanimation 2012/02; 31(2): 126-131.

Mots-clés : ANTIBIOPROPHYLAXIE; AUDIT; CHIRURGIE; CONFORMITE; EVALUATION; EVALUATION DES PRATIQUES PROFESSIONNELLES; CENTRE HOSPITALIER GENERAL; PRESCRIPTION; CHIRURGIE PROPRE; CHIRURGIE PROPRE-CONTAMINEE; CHIRURGIE ORTHOPEDIQUE; CHIRURGIE GYNECOLOGIQUE; URGENCE; RECOMMANDATION; CHIRURGIEN

Objectifs : Evalué lors d’un audit prospectif, la compliance aux recommandations des pratiques d’antibioprophylaxie (ATBP) chirurgicale et identifier les facteurs prédictifs de non-conformité. Patients et méthode : Etude prospective entre le 1er février et le 30 avril 2008 des conformités de l’indication (recommandée et prescrite ou non recommandée et non prescrite), de l’administration (molécule, dose, horaire et durée) ainsi que la conformité globale (indication et administration) des ATBP pour l’ensemble des patients admis pour une chirurgie propre ou propre-contaminée. Les facteurs prédictifs de non-conformité globale ont été estimés à partir d’analyse de régression logistique multivariée. Résultats : Au total, 481 pratiques ont été évaluées. La conformité de l’indication a été de 83 %, celle de l’administration a été de 56 %. La conformité globale n’a été que de 37 %. Après analyse multivariée, la prescription par un chirurgien (RR = 3,4, IC 95 % : 1,6–7,5), la chirurgie propre-contaminée (2,2 ; 1,4–3,7), la chirurgie traumatologique (1,87 ; 1,1–3,3), la chirurgie digestive (3,7 ; 1,8-7,5) et la chirurgie de la tête et du cou (11,4 ; 2,3–56,3) étaient prédicteurs de non-conformité globale. Conclusion : Cet audit a confirmé la variabilité de la conformité aux pratiques d’ATBP selon le type de chirurgie et la classe de contamination. Plus pédagogique, il a estimé un risque plus élevé de non-respect du protocole en cas de prescription par les chirurgiens. Des plans d’actions spécifiques ont été mis en oeuvre suite à la restitution des résultats à l’ensemble des acteurs concernés.

Bactériémie

NosoBase n° 32735Investigation et contrôle d'une épidémie de bactériémies à Achromobacter xylosoxidans

Behrens-Muller B; Conway J; Yoder J; Conover CS. Investigation and control of an outbreak of Achromobacter xylosoxidans bacteremia. Infection control and hospital epidemiology 2012/02; 33(2): 180-184.

Mots-clés : BACTERIEMIE; INVESTIGATION; CONTROLE; EPIDEMIE

Objective: To define the extent of an outbreak of Achromobacter xylosoxidans bacteremia, determine the source of the outbreak, and implement control measures.Design: An outbreak investigation, including environmental and infection control assessment, and evaluation of hypotheses using the binomial distribution and case control studies.Setting: A 50-bed medical surgical unit in a hospital in Illinois during the period January 1-July 15, 2006.Interventions: Discontinuation of use of opioid delivery via patient-controlled analgesia (PCA) until the source of the outbreak was identified and implementation of new protocols to ensure more rigorous observation of PCA pump cartridge manipulations.

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Results: Calculations based on the binomial distribution indicated the probability that all 9 patients with A. xylosoxidans bacteremia were PCA pump users by chance alone was <.001. A subsequent case control study identified PCA pump use for administration of morphine as a risk factor for A. xylosoxidans bacteremia (odds ratio, undefined; P < .001). Having a PCA pump cartridge with morphine started by nurse C was significantly associated with becoming a case-patient (odds ratio, 46; 95% confidence interval, 4.0-525.0; P < .001).Conclusions: We hypothesize that actions related to diversion of morphine by nurse C were the likely cause of the outbreak. An aggressive pain control program involving the use of opioid medication warrants an equally aggressive policy to prevent diversion of medication by staff.

NosoBase n° 33173Epidémie de bactériémies nosocomiales à Pantoea agglomerans associées à une solution citrate-dextrose anticoagulant contaminé : nouveau nom, vieux microbe ?

Boszczowski I; Nobrega de Almeida Junior JN; Peixoto de Miranda EJ; Pinheiro Freire M; Guimaraes T; Chaves CE; et al. Nosocomial outbreak of Pantoea agglomerans bacteraemia associated with contaminated anticoagulant citrate dextrose solution: new name, old bug? The Journal of hospital infection 2012/03; 80(3): 255-258.

Mots-clés : CONTAMINATION; BACTERIEMIE; EPIDEMIE; TYPAGE; PFGE; IDENTIFICATION; HEMODIALYSE; BACILLE GRAM NEGATIF

We describe an outbreak investigation of Pantoea agglomerans bacteraemia associated with anticoagulant citrate-dextrose 46% (ACD) solution prepared in-house. A healthy man presented with septic shock during plasmapheresis for granulocyte donation. The solution used for priming and blood samples were sent for culture. Identification of the isolate to species level was performed by gyrB sequencing. Typing was performed by pulsed-field gel electrophoresis (PFGE). In total, eight cases were identified during a three-week period. P. agglomerans was also cultured from six ACD solution bags. Isolates from patients and ACD bags were identical by PFGE. All isolates were susceptible to ampicillin, cephazolin, gentamicin, ciprofloxacin, cefepime and imipenem.

NosoBase n° 33303Réduire les bactériémies associées aux voies centrales en unité de réanimation pédiatrique : résultats sur trois ans

Miller MR; Niednoir MF; Huskins C; Colantuoni E; Yenokyan G; Moss M; et al. Reducing PICU central line-associated bloodstream infections: 3-year results. Pediatrics 2011/11; 128(5): e1077-e1083.

Mots-clés : CATHETER; BACTERIEMIE; PEDIATRIE; SOIN INTENSIF; PROTOCOLE; CHLORHEXIDINE; PREVENTION; QUALITE; OBSERVANCE; CATHETER VEINEUX CENTRAL

Objectives: To evaluate the long-term impact of pediatric central line care practices in reducing PICU central line-associated bloodstream infection (CLA-BSI) rates and to evaluate the added impact of chlorhexidine scrub and chlorhexidine-impregnated sponges. Methods: A 3-year, multi-institutional, interrupted time-series design (October 2006 to September 2009), with historical control data, was used. A nested, 18-month, nonrandomized, factorial design was used to evaluate 2 additional interventions. Twenty-nine PICUs were included. Two central line care bundles (insertion and maintenance bundles) and 2 additional interventions (chlorhexidine scrub and chlorhexidine-impregnated sponges) were used. CLA-BSI rates (January 2004 to September 2009), insertion and maintenance bundle compliance rates (October 2006 to September 2009), and chlorhexidine scrub and chlorhexidine-impregnated sponge compliance rates (January 2008 to June 2009) were assessed.Results: The average aggregate baseline PICU CLA-BSI rate decreased 56% over 36 months from 5.2 CLA-BSIs per 1000 line-days (95% confidence interval [CI]: 4.4-6.2 CLA-BSIs per 1000 line-days) to 2.3 CLA-BSIs per 1000 line-days (95% CI: 1.9-2.9 CLA-BSIs per 1000 line-days) (rate ratio: 0.44 [95% CI: 0.37-0.53]; P<.0001). No statistically significant differences in CLA-BSI rate decreases between PICUs using or not using either of the 2 additional interventions were found. Conclusions: Focused attention on consistent adherence to the use of pediatrics-specific central line insertion and maintenance bundles produced sustained, continually decreasing PICU CLA-BSI rates. Additional use of either chlorhexidine for central line entry scrub or chlorhexidine-impregnated sponges did not produce any statistically significant additional reduction in PICU CLA-BSI rates.

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NosoBase n° 33172La pose d'un cathéter, l'insertion veineuse et la durée du séjour en réanimation préalable à l'insertion affectent le risque de bactériémie liée au cathéter

Van der Kooi TI; Wille JC; Van Benthem B. Catheter application, insertion vein and length of ICU stay prior to insertion affect the risk of catheter-related bloodstream infection. The Journal of hospital infection 2012/03; 80(3): 238-244.

Mots-clés : CATHETER; RISQUE; DUREE DE SEJOUR; SOIN INTENSIF; CATHETER VEINEUX CENTRAL; FACTEUR DE RISQUE; ANTIBIOTIQUE; BACTERIEMIE; SURVEILLANCE; SOIN INTENSIF; ALIMENTATION PARENTERALE.

Background: The Dutch PREZIES surveillance scheme for catheter-related bloodstream infection (CR-BSI) collects data on infection rates and related risk factors. AIM: To evaluate risk factors for CR-BSI.Methods: Hospitals collected data for intensive care units (ICU) or for the entire hospital. All short-term central venous catheters (CVC), including Swan-Ganz catheters, present for =48h were surveyed, except in cases when bacteraemia was present at insertion. CVCs were monitored until infection, removal or death for up to 28 days. Data were collected on 3750 CVCs and 29,003 CVC-days. Findings: Of the CVCs surveyed, 1.6% [95% confidence interval (CI) 1.2-2.0] resulted in CR-BSI, representing 2.0/1000 CVC-days (95% CI 1.6-2.6). Multi-variate analysis revealed that the length of ICU stay prior to CVC insertion, insertion in the jugular or femoral vein, and use of the CVC to deliver total parenteral nutrition increased the risk of CR-BSI, whereas use of the CVC to deliver antibiotics decreased the risk of CR-BSI. Conclusion: Attention to these risks has the potential to reduce the incidence of CR-BSI.

NosoBase n° 33170Evolution des bactériémies liées aux cathéters veineux centraux selon l'observance des recommandations : expérience de 91 épisodes

Wintenberger C; Epaulard O; Hincky-Vitrat V; Brion JP; Recule C; François P; et al. Outcome of central venous catheter-related bacteraemia according to compliance with guidelines: experience with 91 episodes. The Journal of hospital infection 2012/03; 80(3): 245-251.

Mots-clés : CATHETER VEINEUX CENTRAL; BACTERIEMIE; OBSERVANCE; RECOMMANDATION; ANTIBIOTIQUE; CATHETER; PRATIQUE; MORTALITE; TRAITEMENT

Background: Infection is a major complication associated with the use of central venous catheters. Guidelines for medical management of catheter-related bacteraemia have been published, but no study has assessed the appropriateness of physician practices. AIM: To assess medical practices in cases of central venous catheter-related bacteraemia (CRB) in a university hospital. Methods: Cases were recorded over a period of 12 months and their management was evaluated. All cases of positive blood cultures based on central venous catheter sampling were analysed, and episodes of CRB were determined in this group of patients. Medical management and patient outcome were analysed independently by two physicians. Findings: In all, 187 cases of positive blood culture were recorded and 91 cases of CRB were analysed. Systemic antimicrobial therapy was optimal in 56% of the episodes. In 51 episodes, catheter salvage was attempted, for 29 with an indication in agreement with the guidelines but without antibiotic-lock therapy in 20 episodes. The overall medical management was appropriate in 41.8% of the episodes. The overall cure rate was 72.5%. CRB-related death occurred in 5.5% of the episodes. Cure was associated with guideline compliance (P=0.03) and with adaptation of systemic antimicrobial therapy (P<0.01). Conservative treatment success was associated with compliance with the guidelines for the indication (P=0.01).Conclusion: Medical management of CRB did not closely adhere to international guidelines. CRB outcome was associated with the appropriateness of this management, particularly when conservative treatment was attempted.

Chirurgie

NosoBase n° 33123Pratiques concernant la préparation cutanée de l'opéré : résultats de l'étude nationale française en 2007

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Borgey F; Thibon P; Ertzscheid MA; Bernet C; Gautier C; Mourens C; et al. Pre-operative skin preparation practices: results of the 2007 french national assessment. The Journal of hospital infection 2012; in press: 8 pages.

Mots-clés : PRATIQUE; HYGIENE CORPORELLE; PRE-OPERATOIRE; PREVENTION; CHIRURGIE; RECOMMANDATION; OBSERVANCE; ETUDE PROSPECTIVE; AUDIT; INFORMATION; DOUCHE; DEPILATION

Background: Pre-operative skin preparation, aimed at reducing the endogenous microbial flora, is one of the main preventive measures employed to decrease the likelihood of surgical site infection. National recommendations on pre-operative management of infection risks were issued in France in 2004. Aim: To assess compliance with the French national guidelines for pre-operative skin preparation in 2007. Methods: A prospective audit was undertaken in French hospitals through interviews with patients and staff, and observation of professional practice. Compliance with five major criteria selected from the guidelines was studied: patient information, pre-operative showering, pre-operative hair removal, surgical site disinfection and documentation of these procedures. Findings: Data for 41,188 patients from all specialties at 609 facilities were analysed. Patients were issued with information about pre-operative showering in 88.2% of cases [95% confidence interval (CI) 87.9-88.5]. The recommended procedure for pre-operative showering, including hairwashing, with an antiseptic skin wash solution was followed by 70.3% of patients (95% CI 69.9-70.8); this percentage was higher when patients had received appropriate information (P < 0.001). Compliance with hair removal procedures was observed in 91.5% of cases (95% CI 91.2-91.8), and compliance with surgical site disinfection recommendations was observed in 25,529 cases (62.0%, 95% CI 61.5-62.5). The following documentary evidence was found: information given to patient, 35.6% of cases; pre-operative surgical hygiene, 82.3% of cases; and pre-operative site disinfection, 71.7% of cases. Conclusion: The essential content of the French guidelines seems to be understood, but reminders need to be issued. Some recommendations may need to be adapted for certain specialties.

NosoBase n° 32731Coût-efficacité d'un traitement par de la mupirocine par voie nasale en préopératoire pour prévenir les infections du site opératoire chez les patients subissant une prothèse totale de hanche ou de genou : une analyse coût-efficacité

Courville XF; Tomek IM; Kirkland KB; Birhle M; Kantor SR; Finlayson SR. Cost-effectiveness of preoperative nasal mupirocin treatment in preventing surgical site infection in patients undergoing total hip and knee arthroplasty: a cost-effectiveness analysis. Infection control and hospital epidemiology 2012/02; 33(2): 152-159.

Mots-clés : COUT-EFFICACITE; PREVENTION; MUPIROCINE; TRAITEMENT; COLONISATION; STAPHYLOCOCCUS AUREUS; CHIRURGIE ORTHOPEDIQUE; MATERIEL ETRANGER; PRE-OPERATOIRE; SITE OPERATOIRE; RISQUE; COHORTE

Interventions: A simple decision tree model compared 3 strategies in a hypothetical cohort of patients with TJA: (1) obtaining preoperative screening cultures for all patients, followed by administration of mupirocin to patients with cultures positive for Staphylococcus aureus; (2) providing empirical preoperative treatment with mupirocin for all patients without screening; and (3) providing no preoperative treatment or screening. We assessed the costs and benefits over a 1-year period. Data inputs were obtained from a literature review and from our institution's internal data. Utilities were measured in quality-adjusted life-years, and costs were measured in 2005 US dollars.Main outcome measure: Incremental cost-effectiveness ratio.Results: The treat-all and screen-and-treat strategies both had lower costs and greater benefits, compared with the no-treatment strategy. Sensitivity analysis revealed that this result is stable even if the cost of mupirocin was over $100 and the cost of SSI ranged between $26,000 and $250,000. Treating all patients remains the best strategy when the prevalence of S. aureus carriers and surgical site infection is varied across plausible values as well as when the prevalence of mupirocin-resistant strains is high.Conclusions: Empirical treatment with mupirocin ointment or use of a screen-and-treat strategy before TJA is performed is a simple, safe, and cost-effective intervention that can reduce the risk of SSI. S. aureus decolonization with nasal mupirocin for patients undergoing TJA should be considered.

NosoBase n° 33251Infection et chirurgie de la cataracte : ouvrez l'oeil !

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Frison E; Gautier C; Venier AG. Risques et qualité en milieu de soins 2011/12; VIII(4): 275-284.

Mots-clés : CHIRURGIE OPHTALMOLOGIQUE; ANALYSE DES CAUSES; CHIRURGIE AMBULATOIRE; SIGNALEMENT; INVESTIGATION; CCLIN; PRE-OPERATOIRE; POST-OPERATOIRE; ENDOPHTALMIE

Cet article présente l'analyse d'un cas d'endophtalmie après chirurgie de la cataracte, porté à la connaissance du CCLIN Sud-Ouest, dans le cadre du signalement externe des infections nosocomiales. Il s'agit d'un patient ayant présenté une endophtalmie à germe non identifié onze jours après une chirurgie de la cataracte réalisée en ambulatoire dans un établissement de soins privé. Sa prise en charge, médicale dans un premier temps puis chirurgicale, a duré plus d'un mois et a permis une évolution favorable de son état de santé.

NosoBase n° 32069Impact du volume d'activité sur les infections du site opératoire après arthroscopie et prothèses totales de genou et de hanche

Meyer E; Weitzel-Kage D; Sohr D; Gastmeier P. Impact of department volume on surgical site infections following arthroscopy, knee replacement or hip replacement. BMJ quality and safety 2011/12; 20(12): 725-732.

Mots-clés : SITE OPERATOIRE; PROTHESE TOTALE DE GENOU; PROTHESE TOTALE DE HANCHE; QUALITE

Objective: To examine the association between surgical department volume and the risk of surgical site infections (SSI) after orthopaedic procedures. Background: A minimum volume regulation of at least 50 knee replacements per year was implemented in 2006 in German surgical departments. Methods: SSI rates were obtained from Krankenhaus-Infektions-Surveillance-System, the German national nosocomial infections surveillance system (January 2003-June 2008). The authors analysed the data by linear regression models. The adjusted ORs were estimated based on general estimating equation models to assess the independent effect of department volume (low, ie, ≤50, medium, ie, >50 and ≤100, and high, ie, >100 procedures annually). Results: A total of 206 surgical departments performed 14,339 arthroscopies, 63,045 knee replacements and 43,180 hip replacements during the 5.5-year study period. SSI rates were significantly higher in departments with a procedure volume of ≤50 arthroscopies and knee replacements. A higher threshold of 100 procedures per year did lead to a significant decrease in SSI rates for all three procedures in the univariate analysis. The multivariate analysis showed that the risk of SSI in low volume departments was sevenfold higher for arthroscopies and twofold higher for knee replacement than in medium volume departments. SSI risk after hip replacement was significantly lower in high volume centres. Conclusion: The authors' findings offer some support for recommendations to concentrate arthroscopy and knee replacement in surgical departments with more than 50 procedures and hip replacement in departments with more than 100 procedures per year in order to reduce SSI.

NosoBase n° 33128L'anesthésie générale est associée à un risque augmenté d'infection du site opératoire après césarienne par comparaison à une anesthésie neuraxiale : étude de population

Tsai PS; Hsu CS; Fan YC; Huang CJ. General anaesthesia is associated with increased risk of surgical site infection after caesarean delivery compared with neuraxial anaesthesia: a population-based study. British journal of anaesthesia 2011/11; 107(5): 757-761.

Mots-clés : RISQUE; CESARIENNE; SITE OPERATOIRE; ANESTHESIE; ANESTHESIE GENERALE; ANESTHESIE LOCO-REGIONALE; RACHIANESTHESIE; ANESTHESIE PERIDURALE; INCIDENCE

Background: This study compared the odds ratio (OR) of surgical site infection (SSI) within 30 days after operation with general anaesthesia (GA) or neuraxial anaesthesia (NA) in Taiwanese women undergoing Caesarean delivery (CD). Methods: An epidemiologic design was used. The study population was based on the records of all deliveries in hospitals or obstetric clinics between January 2002 and December 2006 in Taiwan. Anonymized claim data from the Taiwan National Health Insurance Research Database (NHIRD) were analysed. Women who received CD were identified from the NHIRD by Diagnosis-Related Group codes. The mode of anaesthesia was defined by order codes. Multivariate logistic regression was used to estimate the OR and associated

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95% confidence interval (CI) of post-CD SSIs for GA when compared with NA. The outcome was whether a woman had been diagnosed as having an SSI during the hospitalization or was re-hospitalized within 30 days after CD for the treatment of SSIs using five or 81 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Results: Among the 303 834 Taiwanese women who underwent CD during the 5 yr observation period, the 30 day post-CD SSI rate was 0.3% or 0.9% based on five or 81 ICD-9-CM codes. The multivariate-adjusted OR of having post-CD SSIs in the GA group was 3.73 (95% CI, 3.07-4.53) compared with the NA group (P<0.001) using five ICD-9-CM codes for the definition of SSI. Conclusions: GA for CD was associated with a higher risk of SSI when compared with neuraxial anaesthesia.

Clostridium difficile

NosoBase n° 33184Etude de données administratives pour l'évaluation des changements dans l'acquisition des infections à Clostridium difficile en Angleterre

Jen MH; Saxena S; Bottle A; Pollok R; Holmes A; Aylin P. Assessment of administrative data for evaluating the shifting acquisition of Clostridium difficile infection in England. The Journal of hospital infection 2012/03; 80(3): 229-237.

Mots-clés : CLOSTRIDIUM DIFFICILE; TAUX; STATISTIQUE

Background: Little is known about the acquisition of Clostridium difficile infection (CDI) and whether it represents hospital- or community-acquired infection. AIM: To test the feasibility and value of using national hospital admissions data from Hospital Episode Statistics to examine trends in CDI in England. Methods: Hospital Episode Statistics from the period 1997/98 to 2009/10 were used. Time trends were analysed using two different denominators of hospital activity: total admissions and total bed-days. We explored the impact of sociodemographic factors, comorbidity and healthcare pathways on the risk of CDI.Findings: CDI rates per admission and per bed-days increased from 1997/98 to 2006/07, then decreased significantly by >50% from 2008/9 and 2009/10. This pattern was similar for patients regardless of probable source of infection but the proportion of probable community-acquired CDI cases rose steadily from 7% in 1997/98 to 13% in 2009/10. CDI rates were higher among older patients (odds ratio: >65 years, 10.9), those with more comorbid conditions (odds ratio for Charlson index: >5, 5.6), and among patients admitted as an emergency compared with elective admissions, but no relationship was found with deprivation score.Conclusion: Our findings support not only the falling trend in CDI found in the national mandatory surveillance scheme from the Health Protection Agency, but a growing proportion of CDI presenting on admission with no evidence of prior hospital exposure in the previous 90 days. We suggest that these may be community-acquired CDI cases.

NosoBase n° 32734Proportion élevée de tests immunoenzymatiques faux-positifs pour la détection des toxines A et B de Clostridium difficile en pédiatrie

Toltzis P; Nerandzic MM; Saade E; O'Riordan MA; Smathers S; Zaoutis T; et al. High proportion of false-positive Clostridium difficile enzyme immunoassays for toxin A and B in pediatric patients. Infection control and hospital epidemiology 2012/02; 33(2): 175-179.

Mots-clés : CLOSTRIDIUM DIFFICILE; PEDIATRIE; DEPISTAGE; PCR; IMMUNOGENICITE; TEST

Objectives: To determine the frequency of false-positive Clostridium difficile toxin enzyme immunoassay (EIA) results in hospitalized children and to examine potential reasons for this false positivity.Design: Nested case-control.Setting: Two tertiary care pediatric hospitals.Methods: As part of a natural history study, prospectively collected EIA-positive stools were cultured for toxigenic C. difficile, and characteristics of children with false-positive and true-positive EIA results were compared. EIA-positive/culture-negative samples were recultured after dilution and enrichment steps, were evaluated for presence of the tcdB gene by polymerase chain reaction (PCR), and were further cultured for Clostridium sordellii, a cause of false-positive EIA toxin assays.Results: Of 112 EIA-positive stools cultured, 72 grew toxigenic C. difficile and 40 did not, indicating a positive predictive value of 64% in this population. The estimated prevalence of C. difficile infection (CDI) in the study sites among children tested for this pathogen was 5%-7%. Children with false-positive EIA results were significantly younger than those with true-positive tests but did not differ in other characteristics. No false-

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positive specimens yielded C. difficile when cultured after enrichment or serial dilution, 1 specimen was positive for tcdB by PCR, and none grew C. sordellii.Conclusions: Approximately one-third of EIA tests used to evaluate pediatric inpatients for CDI were falsely positive. This finding was likely due to the low prevalence of CDI in pediatric hospitals, which diminishes the test's positive predictive value. These data raise concerns about the use of EIA assays to diagnosis CDI in children.

NosoBase n° 32092La fidaxomicine : un nouvel antibiotique macrocyclique pour le traitement des infections à Clostridium difficile

Venugopal AA; Johnson S. Fidaxomicin: a novel macrocyclic antibiotic approved for treatment of Clostridium difficile infection. Clinical infectious diseases 2012/02/15; 54(4): 568-574.

Mots-clés : ANTIBIOTIQUE; CLOSTRIDIUM DIFFICILE; TRAITEMENT

Fidaxomicin, a nonabsorbed macrocyclic compound, is the first antimicrobial agent approved by the FDA for the treatment of Clostridium difficile infection (CDI) in adults over the last 25 years. It is bactericidal, and its mechanism of action relates to inhibition of a RNA polymerase at a site distinct from where rifamycins interact. Fidaxomicin, 200 milligrams by mouth twice daily, is not inferior to vancomycin, 125 milligrams by mouth 4 times daily, for treatment of CDI as determined by clinical response after 10 days of treatment and is superior to vancomycin for sustained response without recurrence 25 days after treatment completion. These results are a significant advance in the treatment of CDI and herald the development of narrow-spectrum anti-C. difficile agents that relatively spare the indigenous fecal microbiota. Continued vigilance for the development of resistance and unanticipated side affects will be important as the drug is introduced into clinical practice.

EHPAD / Personne âgée

NosoBase n° 33181Infections associées aux soins dans des établissements de soins de longue durée en Irlande : résultats de la première étude nationale de prévalence

Cotter M; Donlon S; Roche F; Byrne H; Fitzpatrick F. Healthcare-associated infection in irish long-term care facilities: results from the First National Prevalence Study. The Journal of hospital infection 2012/03; 80(3): 212-216.

Mots-clés : PREVALENCE; ANTIBIOTIQUE; CONSOMMATION; SURVEILLANCE; FACTEUR DE RISQUE; INFECTION URINAIRE; CATHETER; ANTIBIOPROPHYLAXIE; APPAREIL RESPIRATOIRE; PEAU; EHPAD; SOIN DE LONGUE DUREE; REEDUCATION

Background: Prevalence of healthcare-associated infection (HCAI) and antimicrobial use in Irish long-term care facilities (LTCFs) has never been studied. Aim: To collect baseline data on HCAI prevalence and antibiotic use in Irish LTCFs to inform national LTCF policy and plan future HCAI prevention programmes.Methods: A prevalence study of HCAI and antibiotic use was undertaken in Irish LTCFs. Participation was voluntary. Data on HCAI risk factors, signs and symptoms of infection and antimicrobial use were collected prospectively on a single day in each institution. Findings: Sixty-nine Irish LTCFs participated and 4170 eligible residents were surveyed; 472 (11.3%) had signs/symptoms of infection (266, 6.4%) and/or were on antibiotics (426, 10.2%). A third of residents (1430, 34.3%) were aged =85 years and more than half disorientated (2110, 50.6%) with impaired mobility (2101, 50.4%). HCAI prevalence was 3.7% (range: 0-22.2%). The most common HCAI was urinary tract infection (UTI) (62 residents, 40% of HCAI). Presence of a urinary catheter was associated with UTI (P<0.0000001). Antibiotics were prescribed for treatment (262 residents, 57.8%) and prophylaxis (182 residents, 40.2%) of infection. The most common indication for prophylaxis was UTI prevention (35.8% of total prescriptions). Fourteen (10.2%) residents on UTI prophylaxis had a urinary catheter. The most common indications for therapy included respiratory tract infections (35.1%), UTI (32.1%) and skin infection (21.8%). Conclusion: This study highlights the frequency of prophylactic antimicrobial prescribing and provides an important baseline to inform future preventive strategies.

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Endoscopie

NosoBase n° 33215Mycobactérie résistante aux aldéhydes associée à l'usage des systèmes de traitement des endoscopes

Fisher CW; Fiorello A; Shaffer D; Jackson M; McDonnell GE. Aldehyde-resistant mycobacteria bacteria associated with the use of endoscope reprocessing systems. American journal of infection control 2012; in press: 3 pages.

Mots-clés : ENDOSCOPIE; MYCOBACTERIE; RESISTANCE; DESINFECTANT; DESINFECTION; RISQUE ; CONTAMINATION; MYCOBACTERIE ATYPIQUE; ALDEHYDE; GLUTARALDEHYDE

Bacteria can develop resistance to antibiotics, but little is known about their ability to increase resistance to chemical disinfectants. This study randomly sampled 3 automated endoscope reprocessors in the United States using aldehydes for endoscope disinfection. Bacterial contamination was found after disinfection in all automated endoscope reprocessors, and some mycobacteria isolates demonstrated significant resistance to glutaraldehyde and ortho-phthaldehyde disinfectants. Bacteria can survive aldehyde-based disinfection and may pose a cross-contamination risk to patients.

Environnement

NosoBase n° 33174Impact du revêtement et de la finition des surfaces sur la nettoyabilité des barrières de lit et la dissémination de Staphylococcus aureus

Ali S; Moore G; Wilson A. Effect of surface coating and finish upon the cleanability of bed rails and the spread of Staphylococcus aureus. The Journal of hospital infection 2012/03; 80(3): 192-198.

Mots-clés : NETTOYAGE; LIT; STAPHYLOCOCCUS AUREUS; SURFACE; ENVIRONNEMENT; EFFICACITE; TRANSMISSION; RISQUE; PREVENTION

Background: Bacterial reservoirs in the near-patient environment are likely vectors of healthcare-acquired infection. Aim: To conduct a laboratory-based study to confirm a previous clinical finding of higher numbers of bacteria on plastic than on painted steel bed rails. Methods: Six different surfaces were inoculated with Staphylococcus aureus suspended in a range of synthetic soils. Aerobic colony counts and ATP bioluminescence were used to assess the efficacy of cleaning with microfibre cloths and antibacterial wipes. The ease with which S. aureus was transferred between fingertips and each bed rail was also investigated. Findings: Antibacterial wipes reduced bacterial numbers to below detectable levels on all rails but were less effective than microfibre cloths in removing organic debris. Surfaces that were comparatively easy to clean were more likely to transfer S. aureus on contact. If inadequately disinfected these rails could pose the greatest risk in terms of cross-transmission. In the absence of contaminating soil, bacterial transfer from fingertips to rail ranged from 38% to 64%. Transfer from rail to fingertip ranged from 22% to 38%. Surface material and rugosity were important factors in determining cleanability and transfer rate. However, the presence of organic soils affected bacterial transfer from all bed rails regardless of material or finish.Conclusion: Bed rails can become heavily contaminated. Regular wiping with antibacterial wipes could be a cost-effective means of maintaining low numbers of bacteria near to the patient. To minimize the risk of cross-transmission, cleaning protocols should be validated to ensure effective removal of microbial and non-microbial surface contamination.

NosoBase n° 33182Aspects portant sur l'efficacité, l'efficience et la sécurité des systèmes de désinfection des chambres à la vapeur de peroxyde d'hydrogène ou par aérosols de peroxyde d'hydrogène

Fu TY; Gent P; Kumar V. Efficacy, efficiency and safety aspects of hydrogen peroxide vapour and aerosolized hydrogen peroxide room disinfection systems. The Journal of hospital infection 2012/03; 80(3): 199-205.

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Mots-clés : EFFICACITE; SECURITE; PEROXYDE D'HYDROGENE; AEROSOL; DESINFECTION; VAPEUR; STAPHYLOCOCCUS AUREUS; CLOSTRIDIUM DIFFICILE; ACINETOBACTER BAUMANNII

Background: This was a head-to-head comparison of two hydrogen-peroxide-based room decontamination systems. Aim: To compare the efficacy, efficiency and safety of hydrogen peroxide vapour (HPV; Clarus R, Bioquell, Andover, UK) and aerosolized hydrogen peroxide (aHP; SR2, Sterinis, now supplied as Glosair, Advanced Sterilization Products (ASP), Johnson & Johnson Medical Ltd, Wokingham, UK) room disinfection systems. Method: Efficacy was tested using 4- and 6-log Geobacillus stearothermophilus biological indicators (BIs) and in-house prepared test discs containing approximately 10(6) meticillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile and Acinetobacter baumannii. Safety was assessed by detecting leakage of hydrogen peroxide using a hand-held detector. Efficiency was assessed by measuring the level of hydrogen peroxide using a hand-held sensor at three locations inside the room, 2 h after the start of the cycles.Findings: HPV generally achieved a 6-log reduction, whereas aHP generally achieved less than a 4-log reduction on the BIs and in-house prepared test discs. Uneven distribution was evident for the aHP system but not the HPV system. Hydrogen peroxide leakage during aHP cycles with the door unsealed, as per the manufacturer's operating manual, exceeded the short-term exposure limit (2 ppm) for more than 2 h. When the door was sealed with tape, as per the HPV system, hydrogen peroxide leakage was <1 ppm for both systems. The mean concentration of hydrogen peroxide in the room 2 h after the cycle started was 1.3 [standard deviation (SD) 0.4] ppm and 2.8 (SD 0.8) ppm for the four HPV and aHP cycles, respectively. None of the readings were <2 ppm for the aHP cycles. Conclusion: The HPV system was safer, faster and more effective for biological inactivation.

NosoBase n° 33209Contamination environnementale par des bêta-lactamases à spectre étendu : y'a-t-il une différence entre Escherichia coli et Klebsiella spp. ?

Guet-Revillet H; Le Monnier A; Breton N; Descamps P; Lecuyer H; Alaabouche I; et al. Environmental contamination with extended-spectrum beta-lactamases: is there any difference between Escherichia coli and Klebsiella spp? American journal of infection control 2012; in press: 4 pages.

Mots-clés : ESCHERICHIA COLI; KLEBSIELLA; CONTAMINATION; ENVIRONNEMENT; BETA-LACTAMASE A SPECTRE ELARGI; ENTEROBACTERIE; FACTEUR DE RISQUE; BIOLOGIE MOLECULAIRE; PFGE; PEDIATRIE; SURFACE; ANALYSE MULTIVARIEE; CHAMBRE

Background: The hospital environment contributes to the spread of extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae (ESBL-PE) during outbreaks. We aimed to assess the rate of environmental contamination in rooms occupied by ESBL carriers or infected children and to identify risk factors associated with contamination.Methods: Five environmental surface samples were systematically performed in rooms occupied by ESBL-PE carrier or infected children.Results: Forty-six Escherichia coli and 48 Klebsiella infected/carrier patients were included in the study. Nineteen (4%) of the 470 environmental samples performed yielded ESBL-PE. Klebsiella spp was the most frequent species isolated (16, 89%), whereas E coli and Citrobacter freundii were reported twice and once, respectively. Ten of the 19 (52%) isolates were identical to the corresponding strains isolated from children. Multivariate analysis highlighted ESBL-producing Klebsiella carriage/infection as the only risk factor significantly associated with surface contamination (P = .024).Conclusion: Our data suggest that hospital environmental contamination is more frequent in instances of fecal carriage or infection with ESBL-producing Klebsiella than ESBL-producing E coli. Reinforcing hygiene measures around ESBL-producing Klebsiella might be necessary to reduce the spread of ESBL-PE in hospital environments.

Epidémie

NosoBase n° 33189Epidémies consécutives multiclonales à Serratia marcescens dans une unité de réanimation néonatale

Maltezou HC; Tryfinopoulou K; Katerelos P; Ftika L; Pappa O; Tseroni M; et al. Consecutive Serratia marcesens multiclone outbreaks in a neonatal intensive care unit. American journal of infection control 2012; in press: 6 pages.

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Mots-clés : EPIDEMIE; SERRATIA; SERRATIA MARCESCENS; NEONATALOGIE; SOIN INTENSIF; DEPISTAGE; ENVIRONNEMENT; PREVALENCE; PFGE; FACTEUR DE RISQUE; ALIMENTATION PARENTERALE; MICROBIOLOGIE; EPIDEMIOLOGIE; CAS TEMOIN; ANALYSE

Background: This report describes 3 consecutive outbreaks caused by genetically unrelated Serratia marcescens clones that occurred in a neonatal intensive care unit (NICU) over a 35-month period.Methods: Carriage testing in neonates and health care workers and environmental investigation were performed. An unmatched case-control study was conducted to identify risk factors for S marcescens isolation. Results: During the 35-month period, there were 57 neonates with S marcescens isolation in the NICU, including 37 carriers and 20 infected neonates. The prevalence rate of S marcescens isolation was 12.3% in outbreak 1, 47.4% in outbreak 2, and 42% in outbreak 3. Nine of the 20 infected neonates died (45% case fatality rate). A total of 10 pulsed field gel electrophoresis types were introduced in the NICU in various times; 4 of these types accounted for the 9 fatal cases. During outbreak 3, a type VIII S marcescens strain, the prevalent clinical clone during this period, was detected in the milk kitchen sink drain. Multiple logistic regression revealed that the only statistically significant factor for S marcencens isolation was the administration of total parenteral nutrition. Conclusions: Total parenteral nutrition solution might constitute a possible route for the introduction of microorganisms in the NICU. Gaps in infection control should be identified and strict measures implemented to ensure patient safety.

NosoBase n° 32089Epidémie d'aspergillose invasive après chirurgie cardiaque causée par des spores présentes dans l'air du service de réanimation

Pelaez T; Munoz P; Guinea J; Valerio M; Giannella M; Klaassen CH; et al. Outbreak of invasive aspergillosis after major heart surgery caused by spores in the air of the intensive care unit. Clinical infectious diseases 2012/02/01; 54(3): e24-e31.

Mots-clés : EPIDEMIE; ASPERGILLUS; CHIRURGIE CARDIO-VASCULAIRE; AIR; AEROBIOCONTAMINATION; SOIN INTENSIF

Background: Outbreaks of invasive aspergillosis (IA) are believed to be caused by airborne Aspergillus conidia. Few studies have established a correlation between high levels of Aspergillus fumigatus conidia and the appearance of new cases of IA or have demonstrated matching genotypes between clinical isolates and those from the environment.Methods: We detected an outbreak of IA (December 2006 through April 2008) in the major heart surgery intensive care unit (MHS-ICU) of our institution. Our local surveillance program consists of monthly environmental air sampling in operating rooms and ICUs for quantitative and qualitative identification of filamentous fungi. During the study period, we obtained 508 environmental samples from 3 different periods: 6 months before the outbreak, during it, and 6 months after it. Available environmental and clinical strains were genotyped according to the short tandem repeats assay.Results: Seven patients developed proven or probable IA (5 with lung infection, 1 with mediastinitis, and 1 with lung infection and mediastinitis). A. fumigatus was involved in 6 cases. The underlying conditions of the patients were heart transplantation (n = 3), corticosteroid-dependent conditions (n = 2), and diabetes mellitus (n = 2). The mortality rate was 85.7%. Before and after the outbreak (±6 months), the median airborne A. fumigatus conidia levels were 0 colony-forming units (CFUs) per cubic meter, and no cases of IA occurred during these periods. However, during the outbreak period, the occurrence of the 6 cases of IA caused by A. fumigatus was linked to peaks of abnormally high A. fumigatus airborne conidia levels (175, 50, 25, 20, 160, and 400 CFUs/m(3)) in the MHS-ICU, whereas counts in the air of both operating rooms remained negative. Matches between A. fumigatus genotypes collected from the air of the MHS-ICU and from representative clinical samples were found in 3 of the 6 patients. The outbreak abated when high-efficiency particulate air filters were installed in the affected areas.Conclusions: Our study revealed that abnormally high levels of airborne A. fumigatus conidia correlated with new cases of IA, even in patients who were not severely immunocompromised. The demonstration of matches between air and clinical genotypes reinforces the role of environmental air in the acquisition of IA during the period following MHS. Environmental monitoring of Aspergillus spores in the air of postoperative units is mandatory, even when these units receive nonimmunocompromised patients undergoing major surgery.

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Gestion des risques

NosoBase n° 33300Sécurité du patient et de l'établissement en hémodialyse : opportunités et stratégies pour le développement d'une culture de la sécurité

Garrick R; Kliger A; Stefanchik B. Patient and facility safety in hemodialysis: opportunities and strategies to develop a culture of safety. Clinical journal of the american society of nephrology 2012; in press: 9 pages.

Mots-clés : HEMODIALYSE; BIBLIOGRAPHIE; SECURITE; GESTION DES RISQUES; USAGER; QUALITE; PERSONNEL; BIBLIOGRAPHIE

Patient safety is the foundation of high-quality health care. More than 350,000 patients receive dialysis in the United States, and the safety of their care is ultimately the responsibility of the facility medical director. The medical director must establish a culture of safety in the dialysis unit and lead the quality assessment and performance improvement process. Several lines of investigation, including surveys of patients and dialysis professionals, have helped to identify important areas of safety risk in dialysis facilities. Among these are lapses in communication, medication errors, patient falls, errors in machine and membrane preparation, failure to follow established policies, and lapses in infection control. The quality assessment and performance improvement process should include a dedicated safety team to focus on specifically identified areas of risk and to establish outcome goals guided by best practices and agreed-upon measures of success. A safety questionnaire can be given to patients and staff and the responses evaluated to improve understanding of the prevailing attitudes and concerns about safety. By sharing these results, openly acknowledging the challenges, and using a blame-free root cause process to identify action plans, the facility can begin to establish a culture of safety.

NosoBase n° 33249La gestion globale des risques : échanges de savoir-faire entre le secteur sanitaire et le secteur médico-social

Leblanc G; Dumay MF; Moulaire M; De Montgolfier T; Serrano A. Global risk management: sharing know-how between the health sector and the care and welfare sector. Risques et qualité en milieu de soins 2011/12; VIII(4): 253-265.

Mots-clés : GESTION DES RISQUES; EHPAD; LEGISLATION; EVALUATION; HISTORIQUE ; STRUCTURE DE SOINS

La gestion globale des risques dans les établissements de santé s'est construite progressivement depuis une vingtaine d'années, avec une réelle structuration depuis 2004. La méthodologie, les outils et concepts sur lesquels s'appuie la démarche sont identiques quel que soit le secteur d'activité dans lequel ils sont appliqués ; ils doivent donc permettre aux différents acteurs partie prenante de disposer du savoir-faire dont ils ont besoin pour améliorer de manière continue la qualité et la sécurité des prestations qui sont délivrées, et ce aussi bien dans le secteur sanitaire que dans le secteur médico-social. Comme dans les établissements de santé, de multiples obligations réglementaires s'imposent déjà en la matière aux gestionnaires d'établissements médico-sociaux, toutefois leurs spécificités, en particulier liées à la taille des établissements mais aussi à la durée de séjour des résidents qu'ils accueillent, nécessite un accompagnement des autorités publiques qui se dessine actuellement. L'objectif est d'inscrire la gestion globale des risques dans une démarche apprenante et non punitive où chaque acteur prend conscience de son rôle dans un dispositif visant à diminuer les occurrences d'événements défavorables tant pour les résidents et les professionnels que pour les visiteurs des structures. Son application doit être suffisamment simple et perçue comme utile par tous, elle doit également être efficiente dans un contexte budgétaire contraint.

NosoBase n° 32072Est-ce que les infirmières et les patients partagent des antécédents communs ? Analyse des liens entre climat de sécurité et conditions de travail

Taylor JA; Dominici F; Agnew J; Gerwin D; Morlock L; Miller MR. Do nurse and patient injuries share common antecedents? An analysis of associations with safety climate and working conditions. BMJ quality and safety 2012/02; 21(2): 101-111.

Mots-clés : EXPOSITION AU SANG; INFIRMIER; QUALITE; GESTION DES RISQUES14 / 32


Background: Safety climate and nurses' working conditions may have an impact on both patient outcomes and nurse occupational health, but these outcomes have rarely been examined concurrently. Objective: To examine the association of unit-level safety climate and specific nurse working conditions with injury outcomes for both nurses and patients in a single hospital. Research design: A cross-sectional study was conducted using nursing-unit level and individual-level data at an urban, level-one trauma centre in the USA. Multilevel logistic regressions were used to examine associations among injury outcomes, safety climate and working conditions on 29 nursing units, including a total of 723 nurses and 28876 discharges. Measures: Safety climate was measured in 2004 using the Safety Attitudes Questionnaire (SAQ). Working conditions included registered nursing hours per patient day (RNHPPD) and unit turnover. Patient injuries included 290 falls, 167 pulmonary embolism/deep vein thrombosis (PE/DVT), and 105 decubitus ulcers. Nurse injury was defined as a reported needle-stick, splash, slip, trip, or fall (n=78). Working conditions and outcomes were measured in 2005. Results: The study found a negative association between two SAQ domains, Safety and Teamwork, with the odds of both decubitus ulcers and nurse injury. RNHPPD showed a negative association with patient falls and decubitus ulcers. Unit turnover was positively associated with nurse injury and PE/DVT, but negatively associated with falls and decubitus ulcers. Conclusions: Safety climate was associated with both patient and nurse injuries, suggesting that patient and nurse safety may actually be linked outcomes. The findings also indicate that increased unit turnover should be considered a risk factor for nurse and patient injuries.

Grippe

NosoBase n° 33291Vaccination contre la grippe du personnel de santé dans des centres hospitaliers universitaires : étude cas-témoin de son impact sur les grippes nosocomiales parmi les patients

Benet T; Regis C; Voirin N; Robert O; Lina B; Cronenberger S; et al. Influenza vaccination of healthcare workers in acute-care hospitals: a case-control study of its effect on hospital-acquired influenza among patients. BMC infectious diseases 2012; in press: 12 pages.

Mots-clés : GRIPPE; VACCIN; PERSONNEL; CENTRE HOSPITALIER UNIVERSITAIRE; CAS TEMOIN; DEPISTAGE; EFFICACITE; OBSERVANCE

Background: In acute-care hospitals, no evidence of a protective effect of healthcare worker (HCW) vaccination on hospital-acquired influenza (HAI) in patients has been documented. Our study objective was to ascertain the effectiveness of influenza vaccination of HCW on HAI among patients.Methods: A nested case-control investigation was implemented in a prospective surveillance study of influenza-like illness (ILI) in a tertiary acute-care university hospital. Cases were patients with virologically-confirmed influenza occurring >=72 h after admission, and controls were patients with ILI presenting during hospitalisation with negative influenza results after nasal swab testing. Four controls per case, matched per influenza season (2004-05, 2005-06 and 2006-07), were randomly selected. Univariate and multivariate conditional logistic regression models were fitted to assess factors associated with HAI among patients.Results: In total, among 55 patients analysed, 11 (20%) had laboratory-confirmed HAI. The median HCW vaccination rate in the units was 36%. The median proportion of vaccinated HCW in these units was 11.5% for cases vs. 36.1% for the controls (P = 0.11); 2 (20%) cases and 21 (48%) controls were vaccinated against influenza in the current season (P = 0.16). The proportion of >=35% vaccinated HCW in short-stay units appeared to protect against HAI among patients (odds ratio = 0.07; 95% confidence interval 0.005-0.98), independently of patient age, influenza season and potential influenza source in the units.Conclusions: Our observational study indicates a shielding effect of more than 35% of vaccinated HCW on HAI among patients in acute-care units. Investigations, such as controlled clinical trials, are needed to validate the benefits of HCW vaccination on HAI incidence in patients.

NosoBase n° 33254Couverture de la vaccination contre la grippe un an après la pandémie de grippe A (H1N1), en France, 2010-2011

Guthmann JP; Fonteneau L; Bonmarin I; Levy-Bruhl D. Influenza vaccination coverage one year after the A(H1N1) influenza pandemic, France, 2010-2011. Vaccine 2012/02/01; 30(6): 995-997.

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Mots-clés : GRIPPE; VACCIN; VIRUS INFLUENZA TYPE A; OBSERVANCE; INFECTION COMMUNAUTAIRE

We report influenza vaccination coverage in target groups for the 2010-2011 influenza season, one year after the A(H1N1) pandemic. Data were collected through a one-stage cross-sectional national random telephone survey conducted in January 2011 among a sample of the population of mainland France connected to a land telephone line. Influenza vaccination coverage was below 75%, ranging from 28% for health professionals to 71% in the "65+" group with an underlying condition. Coverage was higher in the "65+" compared to the "<65" with an underlying condition. It was not significantly lower compared to the previous season. Our results do not suggest that the controversies related to the pandemic vaccination campaign of 2009-2010 have had a negative impact on subsequent seasonal influenzavaccination coverage.

NosoBase n° 33218Analyse de présentations délivrant un désinfectant pour les mains à base d'alcool : efficacité de la mousse, du gel et de lingettes contre le virus de la grippe A (H1N1) sur les mains

Larson EL; Cohen B; Baxter KA. Analysis of alcohol-based hand sanitizer delivery systems: efficacy of foam, gel, and wipes against influenza A (H1N1) virus on hands. American journal of infection control 2012; in press: 4 pages.

Mots-clés : HYGIENE DES MAINS; PRODUIT HYDROALCOOLIQUE; GEL HYDROALCOOLIQUE; VIRUS; GRIPPE; GRIPPE A; MAIN; EFFICACITE; ALCOOL

Background: Minimal research has been published evaluating the effectiveness of hand hygiene delivery systems (ie, rubs, foams, or wipes) at removing viruses from hands. The purposes of this study were to determine the effect of several alcohol-based hand sanitizers in removing influenza A (H1N1) virus, and to compare the effectiveness of foam, gel, and hand wipe products. Methods: Hands of 30 volunteers were inoculated with H1N1 and randomized to treatment with foam, gel, or hand wipe applied to half of each volunteer's finger pads. The log(10) count of each subject's treated and untreated finger pads were averaged. Log(10) reductions were calculated from these differences and averaged within treatment group. Between-treatment analysis compared changes from the untreated finger pads using analysis of covariance with treatment as a factor and the average log(10) untreated finger pads as the covariate. Results: Log(10) counts on control finger pads were 2.7-5.3 log(10) of the 50% infectious dose for tissue culture (TCID(50)/0.1 mL) (mean, 3.8 ± 0.5 log(10) TCID(50)/0.1 mL), and treated finger pad counts for all test products were 0.5-1.9 log(10) TCID(50)/0.1 mL (mean, 0.53 ± 0.17 log(10) TCID(50)/0.1 mL). Treatments with all products resulted in a significant reduction in viral titers (>3 logs) at their respective exposure times that were statistically comparable. Conclusions: All 3 delivery systems (foam, gel, and wipe) produced significantly reduced viral counts on hands.

NosoBase n° 32078Efficacité et efficience des vaccins contre la grippe : revue systématique et méta-analyse

Osterholm MT; Kelley NS; Sommer A; Belongia EA. Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis. The Lancet infectious diseases 2012/01; 12(1): 36-44.

Mots-clés : GRIPPE; VACCIN; EFFICACITE; AGE

Background: No published meta-analyses have assessed efficacy and effectiveness of licensed influenza vaccines in the USA with sensitive and highly specific diagnostic tests to confirm influenza.Methods: We searched Medline for randomised controlled trials assessing a relative reduction in influenza risk of all circulating influenza viruses during individual seasons after vaccination (efficacy) and observational studies meeting inclusion criteria (effectiveness). Eligible articles were published between Jan 1, 1967, and Feb 15, 2011, and used RT-PCR or culture for confirmation of influenza. We excluded some studies on the basis of study design and vaccine characteristics. We estimated random-effects pooled efficacy for trivalent inactivated vaccine (TIV) and live attenuated influenza vaccine (LAIV) when data were available for statistical analysis (eg, at least three studies that assessed comparable age groups).Findings: We screened 5707 articles and identified 31 eligible studies (17 randomised controlled trials and 14 observational studies). Efficacy of TIV was shown in eight (67%) of the 12 seasons analysed in ten randomised controlled trials (pooled efficacy 59% [95% CI 51-67] in adults aged 18-65 years). No such trials

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met inclusion criteria for children aged 2-17 years or adults aged 65 years or older. Efficacy of LAIV was shown in nine (75%) of the 12 seasons analysed in ten randomised controlled trials (pooled efficacy 83% [69-91]) in children aged 6 months to 7 years. No such trials met inclusion criteria for children aged 8-17 years. Vaccine effectiveness was variable for seasonal influenza: six (35%) of 17 analyses in nine studies showed significant protection against medically attended influenza in the outpatient or inpatient setting. Median monovalent pandemic H1N1 vaccine effectiveness in five observational studies was 69% (range 60-93).Interpretation: Influenza vaccines can provide moderate protection against virologically confirmed influenza, but such protection is greatly reduced or absent in some seasons. Evidence for protection in adults aged 65 years or older is lacking. LAIVs consistently show highest efficacy in young children (aged 6 months to 7 years). New vaccines with improved clinical efficacy and effectiveness are needed to further reduce influenza-related morbidity and mortality.

NosoBase n° 33275Rôle des masques et de l'hygiène des mains dans la prévention de la transmission dans les familles : résultats d'un essai randomisé en grappe à Berlin, Allemagne, 2009-2011

Suess T; Remschmidt C; Schink SB; Schweiger B; Nitsche A; Schroeder K; et al. The role of facemasks and hand hygiene in the prevention of influenza transmission in households: results from a cluster randomised trial; Berlin, Germany, 2009-2011. BMC infectious diseases 2012/01/26; 12(26): 1-16.

Mots-clés : MASQUE; HYGIENE DES MAINS; PREVENTION; INFECTION COMMUNAUTAIRE; TRANSMISSION; GRIPPE; RANDOMISATION; EFFICACITE; TOLERANCE; EPIDEMIE; TAUX

Background: Previous controlled studies on the effect of non-pharmaceutical interventions (NPI) - namely the use of facemasks and intensified hand hygiene - in preventing household transmission of influenza have not produced definitive results. We aimed to investigate efficacy, acceptability, and tolerability of NPI in households with influenza index patients. Methods: We conducted a cluster randomized controlled trial during the pandemic season 2009/10 and the ensuing influenza season 2010/11. We included households with an influenza positive index case in the absence of further respiratory illness within the preceding 14 days. Study arms were wearing a facemask and practicing intensified hand hygiene (MH group), wearing facemasks only (M group) and none of the two (control group). Main outcome measure was laboratory confirmed influenza infection in a household contact. We used daily questionnaires to examine adherence and tolerability of the interventions. Results: We recruited 84 households (30 control, 26 M and 28 MH households) with 82, 69 and 67 household contacts, respectively. In 2009/10 all 41 index cases had a influenza A (H1N1) pdm09 infection, in 2010/11 24 had an A (H1N1) pdm09 and 20 had a B infection. The total secondary attack rate was 16% (35/218). In intention-to-treat analysis there was no statistically significant effect of the M and MH interventions on secondary infections. When analysing only households where intervention was implemented within 36 h after symptom onset of the index case, secondary infection in the pooled M and MH groups was significantly lower compared to the control group (adjusted odds ratio 0.16, 95% CI, 0.03-0.92). In a per-protocol analysis odds ratios were significantly reduced among participants of the M group (adjusted odds ratio, 0.30, 95% CI, 0.10-0.94). With the exception of MH index cases in 2010/11 adherence was good for adults and children, contacts and index cases. Conclusions: Results suggest that household transmission of influenza can be reduced by the use of NPI, such as facemasks and intensified hand hygiene, when implemented early and used diligently. Concerns about acceptability and tolerability of the interventions should not be a reason against their recommendation.

Hémodialyse

NosoBase n° 33300Sécurité du patient et de l'établissement en hémodialyse : opportunités et stratégies pour le développement d'une culture de la sécurité

Garrick R; Kliger A; Stefanchik B. Patient and facility safety in hemodialysis: opportunities and strategies to develop a culture of safety. Clinical journal of the American Society of nephrology 2012; in press: 9 pages.

Mots-clés : HEMODIALYSE; BIBLIOGRAPHIE; SECURITE; GESTION DES RISQUES; USAGER; QUALITE; PERSONNEL; BIBLIOGRAPHIE

Patient safety is the foundation of high-quality health care. More than 350,000 patients receive dialysis in the United States, and the safety of their care is ultimately the responsibility of the facility medical director. The medical director must establish a culture of safety in the dialysis unit and lead the quality assessment and

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performance improvement process. Several lines of investigation, including surveys of patients and dialysis professionals, have helped to identify important areas of safety risk in dialysis facilities. Among these are lapses in communication, medication errors, patient falls, errors in machine and membrane preparation, failure to follow established policies, and lapses in infection control. The quality assessment and performance improvement process should include a dedicated safety team to focus on specifically identified areas of risk and to establish outcome goals guided by best practices and agreed-upon measures of success. A safety questionnaire can be given to patients and staff and the responses evaluated to improve understanding of the prevailing attitudes and concerns about safety. By sharing these results, openly acknowledging the challenges, and using a blame-free root cause process to identify action plans, the facility can begin to establish a culture of safety.

Hygiène des mains

NosoBase n° 32730Programme de promotion de l'hygiène basé sur le modèle PRECEDE : améliorer les comportements d'hygiène des mains chez le personnel soignant

Aboumatar H; Ristaino P; Davis RO; Thompson CB; Maragakis L; Cosgrove S; et al. Infection prevention promotion program based on the PRECEDE model: improving hand hygiene behaviors among healthcare personnel. Infection control and hospital epidemiology 2012/02; 33(2): 144-151.

Mots-clés : PREVENTION; PERSONNEL; HYGIENE DES MAINS

Background: Healthcare-associated infections (HAIs) result in significant morbidity and mortality. Hand hygiene remains a cornerstone intervention for preventing HAIs. Unfortunately, adherence to hand hygiene guidelines among healthcare personnel is poor.Objective: To assess short- and long-term effects of an infection prevention promotion program on healthcare personnel hand hygiene behaviors.Design: Time series design.Setting: Our study was conducted at a tertiary care academic center.Participants: Hospital healthcare personnel.Methods: We developed a multimodal program that included a multimedia communications campaign, education, leadership engagement, environment modification, team performance measurement, and feedback. Healthcare personnel hand hygiene practices were measured via direct observations over a 3-year period by "undercover" observers.Results: Overall hand hygiene compliance increased by 2-fold after full program implementation (P < .001), and this increase was sustained over a 20-month follow-up period (P < .001). The odds for compliance with hand hygiene increased by 3.8-fold in the 6 months after full program implementation (95% confidence interval, 3.53-4.23; P<.001), and this increase was sustained. There was even a modest increase at 20 months of follow up. Hand hygiene compliance increased among all disciplines and hospital units. Hand hygiene compliance increased from 35% in the first 6 months after program initiation to 77% in the last 6 months of the study period among nursing providers (P<.001), from 38% to 62% among medical providers (P<.001), and from 27% to 75% among environmental services staff (P<.001).Conclusions: Implementation of the infection prevention promotion program was associated with a significant and sustained increase in hand hygiene practices among healthcare personnel of various disciplines.

NosoBase n° 33204Impact sur la croissance bactérienne de protocoles de désinfection chirurgicale des mains par friction par produit de friction traditionnel et par produit de friction sans eau dans le cadre d'infections du site opératoire

Chen CF; Han CL; Kan CP; Chen SG; Hung PW. Effect of surgical site infections with waterless and traditional hand scrubbing protocols on bacterial growth. American journal of infection control 2012; in press: 3 pages.

Mots-clés : HYGIENE DES MAINS; PRODUIT DE FRICTION POUR LES MAINS; ALCOOL; CHLORHEXIDINE; BLOC OPERATOIRE; PERSONNEL; DESINFECTION CHIRURGICALE DES MAINS PAR FRICTION; RANDOMISATION; EFFICACITE ; SITE OPERATOIRE; PROTOCOLE; PREVENTION; INCIDENCE

Background: Alcohol-based antiseptic scrub formulation has long been used for hand cleansing in the operating room. Recently, a waterless surgical scrub formulation containing 1% chlorhexidine gluconate was

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developed to provide a comparable antiseptic effect. The present study explored the scrub time required when using waterless hand scrub and traditional hand scrub formulations for operating room staff and compared bacterial growth on the hands after surgical hand scrubbing in the 2 groups.Methods: Operating room staff members (n=100) were recruited randomly from medical centers in Taiwan. Two days in July 2010 were chosen for testing in advance, and the participants were assigned equally to use either a waterless scrub or traditional scrub formulation on 2 separate days. Scrub times were recorded and microorganisms on hands after scrubbing were sampled on 2 separate days. Two days after sampling, the colonies grown on bacterial culture plates were counted and expressed as colony-forming units (CFU) per plate.Results: At 48 hours after sampling, microorganisms were found on 7 of the 50 plates in the waterless scrub group (1-9 CFU) and on 7 of the 50 plates in the traditional scrub group (1-5 CFU). The difference between the groups was no statistically significant (95% CI, 0.85-1.71). Nine surgical patients were found to have contact with the 14 participants with microorganisms found after scrubbing in the operating room. Among these 9 patients, 1 patient with diabetes who underwent amputation developed local reddish swelling suggestive of surgical site infection necessitating a 7-day course of cefalexin. The incidence of surgical site infection was not signifcantly different in the 2 groups.Conclusions: Our findings suggest that waterless hand scrub is as effective as traditional hand scrub in cleansing the hands of microorganisms and more efficient in terms of scrub time.

NosoBase n° 33217Protocoles de friction des mains à l'aide d'un produit hydro-alcoolique et de lavage des mains à la chlorhexidine pour la pratique en routine à l'hôpital : essai clinique randomisé de l'efficacité du protocole et de l'efficience dans le temps

Chow A; Arah OA; Chan SP; Poh BF; Krishnan P; Ng WK; et al. Alcohol handrubbing and chlorhexidine handwashing protocols for routine hospital practice: a randomized clinical trial of protocol efficacy and time effectiveness. American journal of infection control 2012; in press: 6 pages.

Mots-clés : PROTOCOLE; CHLORHEXIDINE; HYGIENE DES MAINS; PRODUIT DE FRICTION POUR LES MAINS; RANDOMISATION; EFFICACITE; PRODUIT HYDROALCOOLIQUE; MEDECIN; INFIRMIER; PREVENTION; TRAITEMENT HYGIENIQUE DES MAINS PAR FRICTION; ANTISEPTIQUE; PRATIQUE

Background: The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) recommend the use of alcohol handrubs to prevent health care-associated infections. However, the efficacy and time effectiveness of different alcohol handrubbing protocols have yet to be evaluated.Methods: We conducted a randomized controlled trial in the general wards of a 1,300-bed, acute, tertiary care hospital to compare the effectiveness of 3 hand hygiene protocols during routine inpatient care: (1) handrubbing with alcohol covering all hand surfaces, (2) handrubbing with alcohol using the standard 7-step technique, and (3) handwashing with chlorhexidine using the standard 7-step technique. Hand samples were obtained from 60 medical and 60 nursing staff, before and after hand hygiene. Quantitative and qualitative bacterial evaluations were carried out by microbiologists blinded to the protocol. Results: All 3 protocols were effective in reducing hand bacterial load (P < .01). During routine patient care, alcohol handrubbing covering all hand surfaces required less time (median, 26.0 seconds) than alcohol handrubbing using the 7-step technique (median 38.5 seconds; P = .04) and chlorhexidine handwashing (median, 75.5 seconds; P < .001).Conclusion: Alcohol handrubbing protocols are as efficacious as chlorhexidine handwashing. Alcohol handrubbing covering all hand surfaces is the most time-effective protocol for routine patient care activities in busy general wards.

NosoBase n° 33193Raisons auto-rapportées dans trois groupes de professionnels de santé concernant l'observance de l'hygiène des mains

McLaughlin AC; Walsh F. Self-reported reasons for hand hygiene in 3 groups of health care workers. American journal of infection control 2012; in press: 6 pages.

Mots-clés : HYGIENE DES MAINS; PERSONNEL; TRAVAIL; ATTITUDE; PERCEPTION; OBSERVANCE; PRATIQUE; PSYCHOLOGIE; ENVIRONNEMENT; QUESTIONNAIRE; INFIRMIER; INFIRMIER HYGIENISTE

Background: The hands of health care workers continue to be the main vector for nosocomial infection in hospitals. The purpose of the current research was to capture the health beliefs and self-reported behaviors

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of US health care workers to better understand why workers avoid hand hygiene and what prompts them to wash.Methods: An online survey of health care workers assessed their reasons for washing their hands, reasons for not washing, and what cues prompted the decision to wash or not wash in a variety of locations.Results: The findings were that hand hygiene could be cued by an external situation but tended to be motivated internally. Hand hygiene was avoided because of situational barriers.Conclusion: The reasons for performing hand hygiene can be situated in the internally motivated Theory of Planned Behavior; however, the reasons for not performing hand hygiene tend to be situational and affected by the environment. The results may be used to design programs, products, and systems that promote appropriate hand hygiene practices. Principles for design of these programs and products are provided.

NosoBase n° 33178Où vont les mains ? Audit des événements séquentiels "touché par les mains" dans un service hospitalier

Smith SJ; Young V; Robertson C; Dancer SJ. Where to hands go? An audit of sequential hand-touch events on a hospital ward. The Journal of hospital infection 2012/03; 80(3): 206-211.

Mots-clés : AUDIT; MAIN; HYGIENE DES MAINS; SURFACE; EQUIPEMENT; OBSERVANCE; PERSONNEL; CHAMBRE; LIT; ORDINATEUR; ETUDE PROSPECTIVE; SURVEILLANCE; ENVIRONNEMENT

Background: Reservoirs of pathogens could establish themselves at forgotten sites on a ward, posing a continued risk for transmission to patients via unwashed hands. AIM: To track potential spread of organisms between surfaces and patients, and to gain a greater understanding into transmission pathways of pathogens during patient care. Methods: Hand-touch activities were audited covertly for 40 x 30 min sessions during summer and winter, and included hand hygiene on entry; contact with near-patient sites; patient contact; contact with clinical equipment; hand hygiene on exit; and contact with sites outside the room. Findings: There were 104 entries overall: 77 clinical staff (59 nurses; 18 doctors), 21 domestic staff, one pharmacist and five relatives. Hand-hygiene compliance among clinical staff before and after entry was 25% (38/154), with higher compliance during 20 summer periods [47%; 95% confidence interval (CI): 35.6-58.8] than during 20 winter periods (7%; 95% CI: 3.2-14.4; P<0.0001). More than half of the staff (58%; 45/77) touched the patient. Staff were more likely to clean their hands prior to contact with a patient [odds ratio (OR): 3.44; 95% CI: 0.94-16.0); P = 0.059] and sites beside the patient (OR: 6.76; 95% CI: 1.40-65.77; P = 0.0067). Nearly half (48%; 37/77) handled patient notes and 25% touched the bed. Most frequently handled equipment inside the room were intravenous drip (30%) and blood pressure stand (13%), and computer (26%), notes trolley (23%) and telephone (21%) outside the room. Conclusion: Hand-hygiene compliance remains poor during covert observation; understanding the most frequent interactions between hands and surfaces could target sites for cleaning.

NosoBase n° 32073Amélioration de l'hygiène des mains dans un hôpital pédiatrique : une approche d'amélioration de la qualité multimodale

Tjamal A; O'Grady G; Harnett E; Dalton D; Andresen D. Improving hand hygiene in a paediatric hospital: a multimodal quality improvement approach. BMJ quality and safety 2012/02; 21(2): 171-176.

Mots-clés : HYGIENE DES MAINS; QUALITE; PEDIATRIE; OBSERVANCE; CONNAISSANCE; INFORMATION; FORMATION

Background: Effective hand hygiene has long been recognised as an important way to reduce the transmission of bacterial and viral pathogens in healthcare settings. However, many studies have shown that adherence to hand hygiene remains low, and improvement efforts have often not delivered sustainable results. The Children's Hospital at Westmead is the largest tertiary paediatric hospital in Sydney, Australia. The hospital participated in a state-wide 'Clean hands save lives' campaign which was initiated in 2006. Intervention: Strong leadership, good stakeholder engagement, readily accessible alcohol-based hand rub at the point of patient care, a multifaceted education programme, monitoring of staff, adherence to recommended hand hygiene practices and contemporaneous feedback of performance data have significantly improved and maintained compliance with hand hygiene. Results: Hand hygiene compliance has increased from 23% in 2006 to 87% in 2011 (p<0.001). Sustained improvement in compliance with hand hygiene has been evident in the last 4 years. A decline in a set of

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hospital-acquired infections (including rotavirus, multiresistant organism transmission, and nosocomial bacteraemia) has also been noted as hand hygiene rates have improved. Monthly usage of alcohol-based hand rub has increased from 16 litres/1000 bed days to 51 litres/1000 bed days during this same period. Conclusion: This project has delivered sustained improvement in hand hygiene compliance by establishing a framework of multimodal evidence-based strategies.

NosoBase n° 33198Efficacité à court terme et à long terme d'un programme multidisciplinaire d'amélioration de l'hygiène des mains

Tromp M; Huis A; De Guchteneire I; Van der Meer J; Van Achterberg T; Hulscher M; et al. The short-term and long-term effectiveness of a multidisciplinary hand hygiene improvement program. American journal of infection control 2012; in press: 5 pages.

Mots-clés : HYGIENE DES MAINS; QUALITE; EFFICACITE; FORMATION; ETUDE PROSPECTIVE; CONNAISSANCE; OBSERVANCE; CENTRE HOSPITALIER UNIVERSITAIRE; MEDECIN; INFIRMIER

Background: Although hand hygiene (HH) compliance has been an important issue for years, the compliance rate is still a problem in health care today.Methods: This was an observational, prospective, before-and-after study. We measured HH knowledge and HH compliance before (baseline), directly after (poststrategy), and 6 months after the performance of HH team strategies (follow-up). The study was composed of employed nurses and physicians working in the department of internal medicine of a university hospital. We performed a multifaceted improvement program including HH education, feedback, reminders, social influence activities including the use of role models, and improvement of HH facilities.Results: Ninety-two nurses and physicians were included. Compared with baseline, there was a significant improvement in the overall mean HH knowledge score at poststrategy (from 7.4 to 8.4) and follow-up (from 7.4 to 8.3). The overall HH compliance was 27% at baseline, 83% at poststrategy, and 75% at follow-up. At baseline, the compliance rate was 17% in nurses and 43% in physicians and significantly improved to 63% in nurses and 91% in physicians at follow-up.Conclusion: Our multifaceted HH improvement program resulted in a sustained improvement of HH knowledge and compliance in nurses as well as physicians.

Infection urinaire

NosoBase n° 33208Adoption de protocoles destinés à la prévention des infections urinaires associées aux cathéters dans des unités de réanimation aux Etats-Unis

Conway LJ; Pogorzelska M; Larson E; Stone PW. Adoption of policies to prevent catheter-associated urinary tract infections in United States intensive care units. American journal of infection control 2012; in press: 6 pages.

Mots-clés : INFECTION URINAIRE; SONDAGE URINAIRE; PREVENTION; CATHETER; SOIN INTENSIF; INCIDENCE; TAUX; QUESTIONNAIRE; OBSERVANCE; PROTOCOLE

Background: Little is known about whether recommended strategies to prevent catheter-associated urinary tract infection (CAUTI) are being implemented in intensive care units (ICU) in the United States.Objectives: Our objectives were to describe the presence of and adherence to CAUTI prevention policies in ICUs, to identify variations in policies based on organizational characteristics, and to determine whether a relationship exists between prevention policies and CAUTI incidence rates.Methods: Four hundred forty-one hospitals that participate in the National Healthcare Safety Network were surveyed in spring 2008.Results: Two hundred fifty hospitals provided information for 415 ICUs (response rate, 57%). A small proportion of ICUs surveyed had policies supporting bladder ultrasound (26%, n=106), condom catheters (20%, n=82), catheter removal reminders (12%, n=51), or nurse-initiated catheter discontinuation (10%, n=39). ICUs in hospitals with = 500 beds were half as likely as those in smaller hospitals to have adopted at least 1 CAUTI prevention policy (odds ratio, 0.52; 95% confidence interval: 0.33-0.86), and ICUs in hospitals where the infection control director reported always having access to key decision makers for planning were more than twice as likely as those with less access to have adopted a policy (odds ratio, 2.41; 95% confidence interval: 1.56-3.72).

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Conclusion: Little attention is currently placed on CAUTI prevention in ICUs in the United States. Further research is needed to elucidate relationships between adherence to CAUTI prevention recommendations and CAUTI incidence rates.

NosoBase n° 33277Taux élevé de résistance aux quinolones parmi des infections urinaires dans le service des urgences

Khawcharoenporn T; Vasoo S; Ward E; Singh K. High rate of quinolone resistance among urinary tractinfections in the ED. The American journal of emergency medicine 2012/01; 30(1): 68-74.

Mots-clés : QUINOLONE; URGENCE; INFECTION URINAIRE; ANTIBIORESISTANCE; ANTIBIOTIQUE; TRAITEMENT; ETUDE RETROSPECTIVE; FACTEUR DE RISQUE; PREVALENCE; ESCHERICHIA COLI; KLEBSIELLA: LEVOFLOXACINE

Objectives: The objectives of this study are to examine antibiotic resistance rates and to determine appropriate empiric oral antibiotic for patients with urinary tract infections (UTIs) evaluated and discharged from the ED.Methods: A retrospective, single-institution chart review study from August 2008 to March 2009 was conducted. Adult patients seen in the ED with UTI were identified for study inclusion from review of microbiology records. Hospitalized or asymptomatic bacteriuria cases were excluded. Health care-associated (HA)-UTI was defined as UTI with indwelling urinary catheters, health care exposure, or urologic procedures within 3 months. Prevalence of causative bacteria, antibiotic resistance rates, and risk factors for quinolone resistance were determined.Results: There were 337 eligible patients with 83% women. The most common uropathogens among 357 bacterial isolates were Escherichia coli (71%) and Klebsiella spp. (9%). Overall levofloxacin resistance rate was 17%. Resistance rates for HA-UTIs were significantly greater than those for community-associated-UTI: levofloxacin, 38% vs 10%; trimethoprim-sulfamethoxazole, 26% vs 17%; amoxicillin, 53% vs 45%; and amoxicillin-clavulanate, 16% vs 6%. Nitrofurantoin resistance rates were similar (9%). Independent risk factors for levofloxacin resistance were long-term medical conditions (adjusted odds ratio [aOR], 4.23; P = .001), HA-UTI (aOR, 2.56; P = .006), and prior quinolone use within 1 week (aOR, 14.90; P = .02) and within 1 to 4 weeks (aOR, 4.62; P = .04).Conclusions: We report high rates of quinolone resistance in ED patients with UTIs at our institution. For patients with risk factors for quinolone resistance, empiric therapy with cephalosporins or nitrofurantoin may be preferred. Urine culture and susceptibility testing should be performed to guide definitive therapy for HA-UTIs.

NosoBase n° 32820Réduction de la prévention inappropriée des infections urinaires dans des établissements de séjour de longue durée pour personnes âgées

Rummukainen ML; Jakobsson A; Matsinen M; Jarvenpaa S; Nissinen A; Karppi P; et al. Reduction in inappropriate prevention of urinary tract infections in long-term care facilities. American journal of infection control 2012; in press: 4 pages.

Mots-clés : PREVENTION; INFECTION URINAIRE; ANTIBIOTIQUE; PRESCRIPTION; PSYCHIATRIE; EHAPD; STRUCTURE DE SOINS; PERSONNEL; MEDECIN; INFECTIOLOGIE; GERIATRIE; INFIRMIER HYGIENISTE; ANTIBIOPROPHYLAXIE; PERSONNE AGEE

Background: Urinary tract infection (UTI) is the most common diagnosis made in prescribing antimicrobials in long-term care facilities (LTCF). The diagnostic criteria for UTI vary among institutions and prescribers. Our aim was to reduce the inappropriate use of antimicrobials in LTCFs. Methods: A team comprising infectious disease consultant, infection control nurse, and geriatrician visited all LTCFs for older persons (2,321 patients in 25 primary care hospitals and 39 nursing homes and dementia units) in the Central Finland Healthcare District (population 267,000) during 2004-2005. The site visits consisted of a structured interview concerning patients, ongoing systematic antimicrobials, and diagnostic practices for UTI. Following the visits, regional guidelines for prudent use of antimicrobials in LTCFs were published, and the use of antimicrobials was followed up by an annual questionnaire. Results: The proportions of patients receiving antimicrobials in 2005, 2006, 2007, and 2008 were 19.9%, 16.9%, 16.2%, and 15.4%, respectively. Most of the antibiotics were used for UTI (range by year, 66.6%- 81.1%). From 2005 through 2008, the proportion of patients on antibiotic prophylaxis for UTI decreased from 13% to 6%. The decrease was statistically significant in both types of settings.

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Conclusion: The visits and guidelines were associated with a reduction in the usage of antimicrobials. To sustain this, UTI surveillance and close collaboration between infection control experts and LTCFs are crucial.

Legionella

NosoBase n° 32736Une épidémie de légionellose associée à l'eau d'une fontaine murale décorative dans un hôpital

Haupt TE; Heffernan RT; Kazmierczak JJ; Nehls-Lowe H; Rheineck B; Powell C; et al. An outbreak of legionnaires disease associated with a decorative water wall fountain in a hospital. Infection control and hospital epidemiology 2012/02; 33(2): 185-191.

Mots-clés : EAU; LEGIONELLA; FONTAINE REFRIGERANTE; MAINTENANCE; EPIDEMIE; INVESTIGATION; VISITE; QUESTIONNAIRE; LABORATOIRE; PERSONNEL; ENVIRONNEMENT; NETTOYAGE

Objective: To detect an outbreak-related source of Legionella, control the outbreak, and prevent additional Legionella infections from occurring.Design and setting: Epidemiologic investigation of an acute outbreak of hospital-associated Legionnaires disease among outpatients and visitors to a Wisconsin hospital.Patients: Patients with laboratory-confirmed Legionnaires disease who resided in southeastern Wisconsin and had illness onsets during February and March 2010.Methods: Patients with Legionnaires disease were interviewed using a hypothesis-generating questionnaire. On-site investigation included sampling of water and other potential environmental sources for Legionella testing. Case-finding measures included extensive notification of individuals potentially exposed at the hospital and alerts to area healthcare and laboratory personnel.Results: Laboratory-confirmed Legionnaires disease was diagnosed in 8 patients, all of whom were present at the same hospital during the 10 days prior to their illness onsets. Six patients had known exposure to a water wall-type decorative fountain near the main hospital entrance. Although the decorative fountain underwent routine cleaning and maintenance, high counts of Legionella pneumophila serogroup 1 were isolated from cultures of a foam material found above the fountain trough.Conclusion: This outbreak of Legionnaires disease was associated with exposure to a decorative fountain located in a hospital public area. Routine cleaning and maintenance of fountains does not eliminate the risk of bacterial contamination. Our findings highlight the need to evaluate the safety of water fountains installed in any area of a healthcare facility.

NosoBase n° 33176Contamination à Legionella pneumophila dans un chauffe serviettes à vapeur d'un centre hospitalier

Higa F; Koide M; Haroon A; Haranaga S; Yamashiro T; Tateyama M; et al. Legionella pneumophila contamination in a steam towel warmer in a hospital setting. The Journal of hospital infection 2012/03; 80(3): 259-261.

Mots-clés : LEGIONELLA PNEUMOPHILA; CONTAMINATION; LEGIONELLA; ENVIRONNEMENT; EAU; TOILETTE DU PATIENT

For prevention of nosocomial legionellosis, environmental investigation to identify possible infectious sources is essential. An environmental study in a ward of our hospital revealed that a steam towel warmer was contaminated with legionella whereas no legionella was detected in tap water supplies and shower heads. Water in the apparatus may be a reservoir of legionella. We abandoned the use of all steam towel warmers in our hospital. Based on this finding, we recommend that steam towel warmers in hospital settings be avoided. Otherwise, the apparatus should be drained, cleaned and dried every day.

NosoBase n° 32094Une pneumonie associée au réseau d'eau utilisé pour des soins dentaires

Ricci ML; Fontana S; Pinci F; Fiumana E; Pedna MF; Farolfi P, et al. Pneumonia associated with a dental unit waterline. Lancet 2012/02/18; 379(9816): 684.

Mots-clés : PNEUMONIE; LEGIONELLA; EAU; ODONTOLOGIE

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Une patiente âgée de 82 ans est décédée d'une légionellose en Italie contractée lors de soins dentaires. Durant la période d'incubation (2 à 10 jours), la patiente n'a été exposée à aucun risque évident d'exposition à des légionelles. Elle n'a quitté son domicile qu'à deux reprises pour deux rendez-vous chez son dentiste. Après investigation, les chercheurs concluent que l'eau contaminée aérolisée à partir de la turbine dentaire a été la source la plus probable de l'infection. Il s'agit du premier cas de légionellose associé à cette source d'exposition décrit dans la littérature, soulignent les chercheurs.

Législation

NosoBase n° 33335Circulaire n° DGOS/PF2/2012/72 du 14/02/2012 relative au management de la qualité de la prise en charge médicamenteuse dans les établissements de santé

Ministère du travail, de l'emploi et de la santé. Non parue au journal officiel 2012: 16 pages.

Mots-clés : LEGISLATION; MEDICAMENT; QUALITE; STRUCTURE DE SOINS; USAGER; CIRCUIT; HOSPITALISATION A DOMICILE; PHARMACIE; TRANSPORT; STOCKAGE; INFORMATIQUE

Accompagnement et appui à la mise en œuvre de l’arrêté du 06/04/2011 relatif au management de la qualité de la prise en charge médicamenteuse et aux médicaments dans les établissements de santé

NosoBase n° 33336Instruction n° DGOS/PF2/2012/93 du 10/02/2012 relative à la participation des établissements de santé à l'enquête nationale de prévalence des infections nosocomiales 2012, et informant des grandes actions programmées en 2012 sur la sécurité des soins


Mots-clés : PREVALENCE; LEGISLATION; ENQUETE; INDICATEUR; GESTION DES RISQUES; HYGIENE DES MAINS

La présente instruction a pour objet d’informer les établissements et professionnels de santé sur le calendrier 2012 des principales actions en matière de sécurité des soins, dont l’enquête nationale de prévalence des infections nosocomiales 2012.

NosoBase n° 33337Instruction n° DGOS/PF2/DGS/RI3/2012/75 du 13/02/2012 relative au signalement externe des infections nosocomiales par les établissements de santé et les structures mentionnées à l'article R.6111-12 du Code de la santé publique ainsi qu'aux modalités de gestion des situations signalées


Mots-clés : LEGISLATION; SIGNALEMENT; ARS; CCLIN; ARLIN; INFORMATION; USAGER

L’objectif de la présente instruction est de porter à la connaissance des établissements de santé, des Agences régionales de santé, et des Centres de coordination de la lutte contre les infections nosocomiales et de leurs antennes régionales de lutte contre les infections nosocomiales, les nouvelles modalités de signalement externe des infections nosocomiales.

Personnel

NosoBase n° 33180Transmettre le message en hygiène hospitalière : un défi de communication

Farrugia C; Borg MA. Delivery the infection control message: a communication challenge. The Journal of hospital infection 2012/03; 80(3): 224-228.

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Mots-clés : INFORMATION; PERSONNEL; EOH; INFIRMIER; MEDECIN; INTERNET; PREVENTION; HYGIENE DES MAINS; EXPOSITION AU SANG; STAPHYLOCOCCUS AUREUS; METICILLINO-RESISTANCE; TUBERCULOSE; ANTIBIORESISTANCE

Background: Hospital infection control teams (ICTs) worldwide face a constant challenge to deliver timely information to audiences with specific and diverse information needs. AIM: Our study investigated the communication flow between the ICT and healthcare workers (HCWs) at St Luke's Hospital, Malta, using an exploratory descriptive research design. Method: Using a self-administered questionnaire, data were collected from a stratified random sample of nurses (N=143) and doctors (N=63) working within inpatient wards; a response rate of 97% was achieved. Findings: HCWs felt most comfortable receiving information from members of their same profession. Information transfer was mainly vertically up and down the hierarchy. Respondents preferred to receive information through educational activities (35%, N=69) and through face-to-face contact (31%, N=62). Electronic channels (e-mail and intranet) were ranked least preferable; however, only 41% (N=81) had regular access to a computer system at work. The majority of respondents 91% (N=181) trusted the information by the ICT and 60% (N=118) regarded it as being consistent. Nevertheless, this did not guarantee constant compliance; 54% (N=106) of respondents implemented IC measures only when they perceived a risk for their health. Greater presence of the ICT on the wards was recommended. Conclusion: Notwithstanding the electronic age, the study confirms that face-to-face contact between ICTs and HCWs remains the most effective way of disseminating IC information.

NosoBase n° 33179Etude prospective sur l'impact des manches de chemises et des cravates sur la transmission de bactéries aux patients

Weber RL; Khan PD; Fader RC; Weber RA. Prospective study on the effect of shirt sleeves and ties on the transmission of bacteria to patients. The Journal of hospital infection 2012/03; 80(3): 252-254.

Mots-clés : TRANSMISSION; ETUDE PROSPECTIVE; TENUE VESTIMENTAIRE

Costs associated with hospital-acquired infections lead to policies aimed at decreasing their incidence. Clothing restrictions are often implemented in response, but they are based on little scientific evidence. This study is a prospective, controlled investigation of the effect of shirt sleeves and ties on the transmission of bacteria from doctors to patients. Results show that wearing an unsecured tie results in greater transmission, but that sleeve length does not affect transmission rate. The design is a possible model for further controlled experiments to fill the evidence gap regarding the transmission of micro-organisms from healthcare workers to patients.

Pneumonie

NosoBase n° 33401Validation d'un score clinique pour évaluer le risque lié aux pathogènes résistants chez les patients présentant une pneumonie aux urgences

Shorr AF; Zilberberg MD; Reichley R; Kan J; Hoban A; Hoffman J; et al. Validation of a clinical score for assessing the risk of resistant pathogens in patients with pneumonia presenting to the emergency department. Clinical infectious diseases 2012/01/15; 54(2): 193-198.

Mots-clés : ANTIBIORESISTANCE; SCORE; PNEUMONIE; URGENCE; COHORTE

Background: Resistant organisms (ROs) are increasingly implicated in pneumonia in patients presenting to the emergency department (ED). The concept of healthcare-associated pneumonia (HCAP) exists to help identify patients infected with ROs but may be overly broad. We sought to validate a previously developed score for determining the risk for an RO and to compare it with the HCAP definition.Methods: We evaluated adult patients admitted via the ED with bacterial pneumonia (January-December 2010). We defined methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, and extended-spectrum ß-lactamases as ROs. The risk score was as follows: 4, recent hospitalization; 3, nursing home; 2, chronic hemodialysis; 1, critically ill. We evaluated the screening value of the score and of HCAP by determining their areas under the receiver-operating characteristic (AUROC) curves for predicting ROs.Results: The cohort included 977 patients, and ROs were isolated in 46.7%. The most common organisms included MRSA (22.7%), P. aeruginosa (19.1%), and Streptococcus pneumoniae (19.1%). The risk score was

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higher in those with an RO (median score, 4 vs 1; P < .001). The AUROC for HCAP equaled 0.62 (95% confidence interval [CI], .58-.65) versus 0.71 (95% CI, .66-.73) for the risk score. As a screening test for ROs, a score > 0 had a high negative predictive value (84.5%) and could lead to fewer patients unnecessarily receiving broad-spectrum antibiotics.Conclusions: ROs are common in patients presenting to the ED with pneumonia. A simple clinical risk score performs moderately well at classifying patients regarding their risk for an RO.

Prévention

NosoBase n° 33324Efficacité des interventions d'hygiène buccale sur les réservoirs oraux et oropharyngés de bacilles à Gram négatif aérobies et anaérobies facultatif

Lam OL; McGrath C; Li L; Samaranayake LP. Effectiveness of oral hygiene interventions against oral and oropharyngeal reservoirs of aerobic and facultatively anaerobic gram-negative bacilli. American journal of infection control 2012/03; 40(2): 175-182.

Mots-clés : EFFICACITE; BACILLE GRAM NEGATIF; PREVENTION; DEFICIT IMMUNITAIRE; ANTISEPTIQUE; CHLORHEXIDINE; POLYVIDONE IODEE; COLONISATION; SOIN INTENSIF; TRANSPLANTATION; SOIN DE BOUCHE; BIBLIOGRAPHIE

Background: Aerobic and facultatively anaerobic gram-negative bacilli (AGNB) are opportunistic pathogens and continue to cause a large number of hospital-acquired infections. AGNB residing in the oral cavity and oropharynx have been linked to nosocomial pneumonia and septicemia. Although AGNB are not considered members of the normal oral and oropharyngeal flora, medically compromised patients have been demonstrated to be susceptible to AGNB colonization.Methods: A literature search was conducted to retrieve articles that evaluated the effectiveness of oral hygiene interventions in reducing the oral and oropharyngeal carriage of AGNB in medically compromised patients.Results: Few studies have documented the use of mechanical oral hygiene interventions alone against AGNB. Although a number of studies have employed oral hygiene interventions complemented by antiseptic agents such as chlorhexidine and povidone iodine, there appears to be a discrepancy between their in vitro and in vivo effectiveness.Conclusion: With the recognition of the oral cavity and oropharynx as a reservoir of AGNB and the recent emergence of multidrug and pandrug resistance in hospital settings, there is a pressing need for additional high-quality randomized controlled trials to determine which oral hygiene interventions or combination of interventions are most effective in eliminating or reducing AGNB carriage.

Rougeole

NosoBase n° 32081La rougeole

Amoss WJ; Griffin DE. Measles. Lancet 2012/01/14; 379(9811): 153-164.

Mots-clés : ROUGEOLE; BIBLIOGRAPHIE; DIAGNOSTIC; EPIDEMIOLOGIE; PREVENTION; VACCIN; MORTALITE

Measles is a highly contagious disease caused by measles virus and is one of the most devastating infectious diseases of man-measles was responsible for millions of deaths annually worldwide before the introduction of the measles vaccines. Remarkable progress in reducing the number of people dying from measles has been made through measles vaccination, with an estimated 164,000 deaths attributed to measles in 2008. This achievement attests to the enormous importance of measles vaccination to public health. However, this progress is threatened by failure to maintain high levels of measles vaccine coverage. Recent measles outbreaks in sub-Saharan Africa, Europe, and the USA show the ease with which measles virus can re-enter communities if high levels of population immunity are not sustained. The major challenges for continued measles control and eventual eradication will be logistical, financial, and the garnering of sufficient political will. These challenges need to be met to ensure that future generations of children do not die of measles.

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Staphylococcus

NosoBase n° 32098Facteurs de risque d'abcès mammaire à Staphylococcus aureus

Branch-Elliman W; Golen TH; Gold HS; Yassa DS; Baldini LM; et al. Risk factors for Staphylococcus aureus postpartum breast abscess. Clinical infectious diseases 2012/01/01; 54(1): 71-77.

Mots-clés : FACTEUR DE RISQUE; ABCES; SEIN; STAPHYLOCOCCUS AUREUS; METICILLINO-RESISTANCE

Background: Staphylococcus aureus (SA) breast abscesses are a complication of the postpartum period. Risk factors for postpartum SA breast abscesses are poorly defined, and literature is conflicting. Whether risk factors for methicillin-resistant SA (MRSA) and methicillin-susceptible SA (MSSA) infections differ is unknown. We describe novel risk factors associated with postpartum breast abscesses and the changing epidemiology of this infection.Methods: We conducted a cohort study with a nested case-control study (n=216) involving all patients with culture-confirmed SA breast abscess among >30 000 deliveries at our academic tertiary care center from 2003 through 2010. Data were collected from hospital databases and through abstraction from medical records. All SA cases were compared with both nested controls and full cohort controls. A subanalysis was completed to determine whether risk factors for MSSA and MRSA breast abscess differ. Univariate analysis was completed using Student's t test, Wilcoxon rank-sum test, and analysis of variance, as appropriate. A multivariable stepwise logistic regression was used to determine final adjusted results for both the case-control and the cohort analyses.Results: Fifty-four cases of culture-confirmed abscess were identified: 30 MRSA and 24 MSSA. Risk factors for postpartum SA breast abscess in multivariable analysis include in-hospital identification of a mother having difficulty breastfeeding (odds ratio, 5.00) and being a mother employed outside the home (odds ratio, 2.74). Risk factors did not differ between patients who developed MRSA and MSSA infections.

NosoBase n° 32091Progrès vers un vaccin contre Staphylococcus aureus

Daum RS; Spellberg B. Progress toward a Staphylococcus aureus vaccine. Clinical infectious diseases 2012/02/15; 54(4): 560-567.

Mots-clés : STAPHYLOCOCCUS AUREUS; VACCIN

High attack rates and the ability of Staphylococcus aureus to develop resistance to all antibiotics in medical practice heightens the urgency for vaccine development. S. aureus causes many disease syndromes, including invasive disease, pneumonia, and skin and soft tissue infections. It remains unclear whether a single vaccine could protect against all of these. Vaccine composition is also challenging. Active immunization with conjugated types 5 and 8 capsular polysaccharides, an iron scavenging protein, isdB, and passive immunization against clumping factor A and lipoteichoic acid have all proven unsuccessful in clinical trials. Many experts advocate an approach using multiple antigens and have suggested that the right combination of antigens has not yet been identified. Others advocate that a successful vaccine will require antigens that work by multiple immunologic mechanisms. Targeting staphylococcal protein A and stimulating the T-helper 17 lymphocyte pathway have each received recent attention as alternative approaches to vaccination in addition to the more traditional identification of opsonophagocytic antibodies. Many questions remain as to how to successfully formulate a successful vaccine and to whom it should be deployed.

NosoBase n° 33310Quelle est la fiabilité des données de surveillance nationale ? Résultats d'un audit canadien sur les données de surveillance de Staphylococcus aureus méticillino-résistant

Forrester L; Collet JC; Mitchell R; Pelude L; Henderson E; Vayalumkal J; et al. How reliable are national surveillance data? Findings from an audit of Canadian methicillin-resistant Staphylococcus aureus surveillance data. American journal of infection control 2012/03; 40(2): 102-107.

Mots-clés : STAPHYLOCOCCUS AUREUS; METICILLINO-RESISTANCE; AUDIT; SURVEILLANCE; EPIDEMIOLOGIE; INCIDENCE; QUALITE

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Background: The Canadian Nosocomial Infection Surveillance Program (CNISP) has conducted surveillance for incident cases of methicillin-resistant Staphylococcus aureus (MRSA) in sentinel hospitals since 1995. In 2007, a reliability audit of the 2005 data was conducted. Methods: In 2005, 5,652 cases were submitted to the CNISP from 43 hospitals. A proportional sample of submitted forms (up to 25) from each site were randomly selected. Stratified random sampling was used to obtain the comparison data. The original data were compared with the reabstracted data for congruence on 7 preselected variables. Results: Reabstracted data were received from 30 out of 43 hospitals (70%), providing 443 of the 598 case forms requested (74%). Of these, 397 (90%) had matching case identification numbers. Overall, the percentage of discordant responses was 7.0%, ranging from 3.5% for sex and up to 23.7% for less well-defined variables (eg, where MRSA was acquired). Conclusion: Our findings suggest that, in general, the 2005 MRSA data are reliable. However to improve reliability a data quality framework with quality assurance practices, including ongoing auditing should be integrated into the CNISP's surveillance programs. Providing training to data collectors and standard definitions with practical examples may help to improve data quality, especially for those variables that require clinical judgment.

NosoBase n° 33287Diminuer les infections associées aux soins est une méthode efficace pour diminuer les infections associées aux soins à Staphylococcus aureus méticillino-résistant (SARM) - Données de la résistance aux antibiotiques du réseau national KISS de surveillance des infections nosocomiales

Gastmeier P; Schwab F; Behnke M; Geffers C. Decreasing healthcare-associated infections (HAI) is an efficient method to decrease healthcare-associated methicillin-resistant S. aureus (MRSA) infections antimicrobial resistance data from the German national nosocomial surveillance systems KISS. Antimicrobial resistance and infection control 2012/01/26; 1(3): 1-4.

Mots-clés : STAPHYLOCOCCUS AUREUS; METICILLINO-RESISTANCE; ANTIBIORESISTANCE; SURVEILLANCE; RESEAU; SOIN INTENSIF; TAUX; INCIDENCE

Background: By analysing the data of the intensive care unit (ICU) component of the German national nosocomial infection surveillance system (KISS) during the last ten years, we have observed a steady increase in the MRSA rates (proportions) from 2001 to 2005 and only a slight decrease from 2006 to 2010. The objective of this study was to investigate the development of the incidence density of nosocomial MRSA infections because this is the crucial outcome for patients. Findings: Data from 103 ICUs with ongoing participation during the observation period were included. The pooled incidence density of nosocomial MRSA infections decreased significantly from 0.37 per 1000 patient days in 2001 to 0.15 per 1000 patient days in 2010 (RR=0.40; CI95 0.29-0.55). This decrease was proportional to the significant decrease of all HCAI during the same time period (RR=0.61; CI95 0.58-0.65).Conclusions: The results underline the need to concentrate infection control activities on measures to control HCAI in general rather than focusing too much on specific MRSA prevention measures. MRSA rates (proportions) are not a very useful indicator of the situation.

Surveillance

NosoBase n° 32087Surveillance rapide et reproductible des pneumonies associées à la ventilation

Klompas M; Kleinman K; Khan Y; Evans RS; Lloyd JF; Stevenson K; et al. Rapid and reproducible surveillance for ventilator-associated pneumonia. Clinical infectious diseases 2012/02/01; 54(3): 370-377.

Mots-clés : PNEUMONIE; VENTILATION ASSISTEE; SURVEILLANCE; ETUDE RETROSPECTIVE; MORTALITE; SOIN INTENSIF

Background: The complexity and subjectivity of ventilator-associated pneumonia (VAP) surveillance limit its value in assessing and comparing quality of care for ventilated patients. A simpler, more quantitative VAP definition may increase utility.Methods: We streamlined the Centers for Disease Control and Prevention definition of VAP to increase objectivity and efficiency. Qualitative criteria were replaced with quantitative criteria, and changes in ventilator settings were used to screen patients for worsening oxygenation. We retrospectively compared surveillance

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time, reproducibility, and outcomes for streamlined versus conventional surveillance among medical and surgical patients on mechanical ventilation in 3 university hospitals.Results: Application of the streamlined definition was faster (mean 3.5 minutes vs 39.0 minutes per patient) and more objective (interrater reliability k 0.79 vs 0.45) than the conventional definition. On multivariate analysis, the streamlined definition predicted increases in ventilator days (6.5 days [95% CI, 4.1-10.0] vs 6.4 days [95% CI, 4.7-8.6]), intensive care days (5.6 days [95% CI, 3.2-8.9] vs 6.2 days [95% CI, 4.6-8.2]), and hospital mortality (odds ratio [OR] 0.84 [95% CI, 0.31-2.29] vs OR 0.69 [95% CI, 0.30-1.55]) as effectively as conventional surveillance. The conventional definition was a marginally superior predictor of increased hospital days (5.2 days [95% CI, 3.4-7.6] vs 2.1 days [95% CI, -0.5-5.6]).Conclusions: A streamlined version of the VAP definition was faster, more objective, and predicted patients' outcomes almost as effectively as the conventional definition. VAP surveillance using the streamlined method may facilitate more objective and efficient quality assessment for ventilated patients.

NosoBase n° 33169Etude de prévalence des infections associées aux soins en Argentine ; comparaison avec l'Angleterre, le Pays de Galles, l'Irlande du Nord et l'Afrique du Sud

Durlach R; McIllvenny G; Newcombe RG; Reid G; Doherty L; Freuler C; et al. Prevalence survey of healthcare-associated infections in Argentina; comparison with England, Wales, Northern Ireland and South Africa. The Journal of hospital infection 2012/03; 80(3): 217-223.

Mots-clés : PREVALENCE; STAPHYLOCOCCUS AUREUS; METICILLINO-RESISTANCE; SURVEILLANCE; PNEUMONIE; INFECTION URINAIRE; SITE OPERATOIRE; CATHETER; FACTEUR DE RISQUE; VENTILATION ASSISTEE; CHIRURGIE; BACTERIEMIE

Background: Prevalence surveillance methodology is the systematic observation of the occurrence and distribution of healthcare-associated infections (HCAIs) so that appropriate actions can be taken. AIM: The objectives of a prevalence survey with an international validated methodology were to determine the prevalence of HCAIs for the first time in Argentina, and to provide data which could be used for international benchmarking. Methods: In 2008, an HCAI prevalence survey was carried out in 39 hospitals in seven of 23 provinces in Argentina, with methodology identical to that employed by the Hospital Infection Society in the third prevalence survey of HCAIs in acute hospitals in the British Isles. Data collected were processed and analysed at the Northern Ireland Healthcare-Associated Infection Surveillance Centre at Belfast. Findings: A total of 4249 patients were surveyed; 480 of these had at least one HCAI, resulting in a prevalence of 11.3% of patients. Male prevalence was 13.6% and female 9.0%. The most common HCAIs were pneumonia (3.3%), urinary tract infection (3.1%), surgical site infection (2.9%), primary bloodstream infection (1.5%), and soft tissue infections (1.2%). Among the 1027 patients who underwent surgery, the prevalence of surgical site infection was 10.2%. The prevalence of meticillin-resistant Staphylococcus aureus was 1.1%, accounting for 10.0% of all HCAI isolates. The results for Argentina show higher HCAI rates compared with corresponding findings for England, Wales, Northern Ireland and South Africa. Conclusion: This survey will contribute to the prioritization of resources and help to inform Departments of Health and hospitals in the continuing effort to reduce HCAIs.

NosoBase n° 33333Surveillance des infections du site opératoire en France en 2009-2010 - Résultats

Institut de veille sanitaire (InVS); Réseau d'alerte d'investigation et de surveillance des infections Nosocomiales (RAISIN); CClin Ouest. Institut de veille sanitaire 2012/02: 1-69.

Mots-clés : SITE OPERATOIRE; SURVEILLANCE; RESEAU; CHIRURGIE; STATISTIQUE; INCIDENCE; FACTEUR DE RISQUE; CESARIENNE; CHIRURGIE DIGESTIVE; CHIRURGIE ORTHOPEDIQUE; CHIRURGIE GYNECOLOGIQUE; NEUROCHIRURGIE; UROLOGIE

La réduction d'incidence des infections du site opératoire (ISO) est l'un des objectifs du programme national de lutte contre les infections nosocomiales (IN). Depuis 1999, les surveillances interrégionales des ISO sont coordonnées par le Réseau d'alerte, d'investigation et de surveillance des infections nosocomiales (Raisin). Chaque année, les services de chirurgie volontaires recueillent des informations concernant le patient ou l'intervention dont les composants de l'index de risque NNIS. Tous les patients inclus devaient être suivis jusqu'au 30e jour postopératoire. Les ISO étaient définies selon les critères standard usuels. En 2010, 2 270 services ont inclus 304 007 interventions chirurgicales ; ces chiffres étaient respectivement de 1889 et 231851 en 2009. En 2010, plus des deux tiers des interventions incluses concernaient l'orthopédie (28,9 %),

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la chirurgie digestive (19,2 %) et la gynécologie-obstétrique (15,2 %). L'incidence des ISO était de 0,96 % (2 931 infections) en 2010 contre 1 % en 2009 (2330 infections). En 2009-2010, l'incidence variait de 0,61 % pour les patients à faible risque (NNIS-0) à 9,20 % pour les plus à risque (NNIS-3). De 2006 à 2010, l'incidence globale des ISO a diminué de 24 %. Pour la chirurgie du côlon, l'incidence a diminué de 27 %, les césariennes de 30 %, la chirurgie des veines périphériques de 34 % et la chirurgie du sein de 5 %. Le nombre de services avec un fort taux d'incidence des ISO a fortement baissé durant cette période. La surveillance des ISO est aujourd'hui bien implantée en France et la réduction de leur incidence se poursuit. Le taux d'ISO sera un des indicateurs d'évaluation du programme national de lutte contre les IN 2009-201.

NosoBase n° 33334Surveillance des bactéries multirésistantes dans les établissements de santé en France - Réseau BMR-RAISIN - Résultats 2010

Institut de veille sanitaire (InVS); Réseau d'alerte d'investigation et de surveillance des infections Nosocomiales (RAISIN); CClin Paris-Nord. Institut de veille sanitaire 2012/02: 1-84.

Mots-clés : MULTIRESISTANCE; SURVEILLANCE; RESEAU; INCIDENCE; STAPHYLOCOCCUS AUREUS; METICILLINO-RESISTANCE; ENTEROBACTERIE; ESCHERICHIA COLI; KLEBSIELLA PNEUMONIAE

La maîtrise de la diffusion des bactéries multirésistantes (BMR) dans les établissements de santé (ES) est une priorité du Programme national de lutte contre les infections nosocomiales (IN) depuis le milieu des années 1990 avec une incitation des ES au travers de recommandations nationales à la prévention et à la surveillance. Depuis 2002, le Réseau d'alerte, d'investigation et de surveillance des infections nosocomiales (Raisin) coordonne une surveillance nationale des Staphylococcus aureus résistants à la méticilline (Sarm) et des entérobactéries productrices de béta-lactamases à spectre étendu (EBLSE) isolées de prélèvements à visée diagnostique dans les ES français. Cette surveillance en réseau est organisée trois mois par an et le nombre de prélèvements est rapporté au nombre de journées d'hospitalisation (JH). Les tendances ont été étudiées pour les ES participants chaque année depuis 2005. En 2010, 933 ES ont participé à la surveillance soit une augmentation de 95 % par rapport à 2002. Pour les Sarm, la densité d'incidence (DI) globale était de 0,40 pour 1 000 JH et variait peu selon l'interrégion. Elle était plus élevée en court séjour (0,52) et en réanimation (1,14) qu'en SSR-SLD (0,27). Depuis 2005, la DI des Sarm a diminué globalement de 34 % et de 55 % en réanimation. Pour les EBLSE, la DI globale était de 0,39 pour 1 000 JH, variant de 0,23 à 0,66 selon l'interrégion. Elle était deux fois plus élevée en court séjour (0,52) qu'en SSR-SLD (0,23). Depuis 2005, la DI des EBLSE a augmenté de 232 %. Sur l'ensemble des ES participants, la proportion de l'espèce Escherichia coli au sein des EBLSE a augmenté de 18,5 % en 2002 à 59,7 % en 2010. La diminution de la densité d'incidence des Sarm suggère un impact positif des actions de prévention instituées dans les services participants au réseau. Le nombre d'IN à SARM pour l'année 2010 est toutefois estimé entre 39 000 et 46 000, dont environ 5 000 bactériémies. A l'opposée, la densité d'incidence des EBLSE continue d'augmenter, en particulier celle des Escherichia coli, et doit mobiliser l'ensemble des professionnels de santé.

Tuberculose

NosoBase n° 33231Surveillance de la résistance aux anti-tuberculeux dans le monde : analyse actualisée 2007-2010

Zignol M; Van Germert W; Falzon D; Sismanidis C; Glaziou P; Floyd K; et al. Surveillance of anti-tuberculosis drug resistance in the world: an updated analysis, 2007-2010. Bulletin of the World Health Organization 2012/02; 90(2): 111-119.

Mots-clés : SURVEILLANCE; RESISTANCE; ANTITUBERCULEUX; MULTIRESISTANCE; FACTEUR DE RISQUE; AGENT ANTI-INFECTIEUX

Objectif : Présenter une mise à jour globale de la tuberculose (TB) pharmacorésistante et explorer les tendances de 1994 à 2010. Méthodes : Les données relatives à la résistance aux médicaments des nouveaux patients de TB et de ceux traités antérieurement, telles que rapportées par les pays à l’Organisation mondiale de la Santé, ont été analysées. Ces données sont recueillies par des enquêtes représentatives auprès des patients ou des systèmes de surveillance basés sur des tests systématiques de sensibilité. Les associations entre la tuberculose ultrarésistante (TB-UR), le virus de l’immunodéficience humaine (VIH) et le sexe ont été explorées par régression logistique.Résultats : En 2007-2010, 80 pays et 8 territoires ont fourni des données de surveillance. Parmi les cas nouveaux et traités antérieurement, la TB-UR était la plus élevée dans la Fédération de Russie (oblast de

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Mourmansk, 28,9%) et la République de Moldavie (65,1%), respectivement. Dans trois pays de l’ex-Union soviétique et en Afrique du Sud, plus de 10% des cas de TB-UR étaient ultra-résistants. Globalement, en 1994-2010, la multirésistance aux médicaments a été observée chez 3,4% (intervalle de confiance 95%, IC: 1,9 à 5,0) de tous les nouveaux cas de TB et 19,8% (IC 95%: 14,4 à 25,1) des cas de TB traités antérieurement. Aucune association générale entre la TB-UR et l’infection au VIH (rapports de cotes, OR: 1,4, IC 95%: 0,7 à 3,0) ou le sexe (OR: 1,1, IC 95%: 0,8 à 1,4) n’a été trouvée. Entre 1994 et 2010, les taux de TB-UR dans la population générale ont augmenté au Botswana, en République de Corée et au Pérou et diminué en Estonie, Lettonie et aux Etats-Unis d’Amérique. Conclusion : Les taux mondiaux les plus élevés jamais signalés de TBUR ont été documentés en 2009 et 2010. Les tendances de la TB-UR sont encore peu claires dans la plupart des paramètres. De meilleures données de surveillance ou d’enquête sont nécessaires, surtout en provenance d’Afrique et d’Inde.

Vaccination

NosoBase n° 32097Ampleur des biais potentiels dans une étude cas-témoins simulée sur l'efficacité de la vaccination anti-grippale

Ferdinands JM; Shay DK. Magnitude of potential biases in a simulated case-control study of the effectiveness of influenza vaccination. Clinical infectious diseases 2012/01/01; 54(1): 25-32.

Mots-clés : VACCIN; GRIPPE; EFFICACITE; BIAIS

Background: Many influenza vaccine effectiveness estimates have been made using case-control methods. Although several forms of bias may distort estimates of vaccine effectiveness derived from case-control studies, there have been few attempts to quantify the magnitude of these biases.Methods: We estimated the magnitude of potential biases in influenza vaccine effectiveness values derived from case-control studies from several factors, including bias from differential use of diagnostic testing based on influenza vaccine status, imperfect diagnostic test characteristics, and confounding. A decision tree model was used to simulate an influenza vaccine effectiveness case-control study in children. Using probability distributions, we varied the value of factors that influence vaccine effectiveness estimates, including diagnostic test characteristics, vaccine coverage, likelihood of receiving a diagnostic test for influenza, likelihood that a child hospitalized with acute respiratory infection had influenza, and others. Bias was measured as the difference between the effectiveness observed in the simulated case-control study and a true underlying effectiveness value.Results and conclusions: We found an average difference between observed and true vaccine effectiveness of -11.9%. Observed vaccine effectiveness underestimated the true effectiveness in 88% of model iterations. Diagnostic test specificity exhibited the strongest association with observed vaccine effectiveness, followed by the likelihood of receiving a diagnostic test based on vaccination status and the likelihood that a child hospitalized with acute respiratory infection had influenza. Our findings suggest that the potential biases in case-control studies that we examined tend to result in underestimates of true influenza vaccine effects.

NosoBase n° 33258Coût-efficacité des programmes de vaccination contre la varicelle et des programmes combinés varicelle et zona au Royaume-Uni

Hoek A; Melegaro A; Gay N; Bilcke J; Edmunds WJ. The cost-effectiveness of varicella and combined varicella and herpes zoster vaccination programmes in the United Kingdom. Vaccine 2012/02/01; 30(6): 1225-1234.

Mots-clés : VARICELLE; VACCIN; HERPES ZOSTER VIRUS; VIRUS; COUT; COUT-EFFICACITE

Background: Despite the existence of varicella vaccine, many developed countries have not introduced it into their national schedules, partly because of concerns about whether herpes zoster (HZ, shingles) will increase due to a lack of exogenous boosting. The magnitude of any increase in zoster that might occur is dependent on rates at which adults and children mix - something that has only recently been quantified - and could be reduced by simultaneously vaccinating older individuals against shingles. This study is the first to assess the cost-effectiveness of combined varicella and zoster vaccination options and compare this to alternative programmes. Methods and findings: The cost-effectiveness of various options for the use of varicella-zoster virus (VZV) containing vaccines was explored using a transmission dynamic model. Underlying contact rates are estimated from a contemporary survey of social mixing patterns, and uncertainty in these derived from

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bootstrapping the original sample. The model was calibrated to UK data on varicella and zoster incidence. Other parameters were taken from the literature. UK guidance on perspective and discount rates were followed. The results of the incremental cost-effectiveness analysis suggest that a combined policy is cost-effective. However, the cost-effectiveness of this policy (and indeed the childhood two-dose policy) is influenced by projected benefits that accrue many decades (80-100 years or more) after the start of vaccination. If the programme is evaluated over shorter time frames, then it would be unlikely to be deemed cost-effective, and may result in declines in population health, due to a projected rise in the incidence of HZ. The findings are also sensitive to a number of parameters that are inaccurately quantified, such as the risk of HZ in varicella vaccine responders. Conclusions: Policy makers should be aware of the potential negative benefits in the first 30-50 years after introduction of a childhood varicella vaccine. This can only be partly mitigated by the introduction of a herpes zoster vaccine. They have to decide how they value the potential benefits beyond this time to consider childhood vaccination cost effective.

Pour tout renseignement, contacter le centre de coordination de lutte contre les infections nosocomiales de votre inter-région :

CCLIN EstTél : 03.83.15.34.73 Fax : [email protected]

CCLIN OuestTél : 02.99.87.35.31Fax : [email protected]

CCLIN Paris-NordTél : 01.40.27.42.00 Fax : [email protected]

CCLIN Sud-EstTél : 04.78.86.49.50Fax : [email protected]

CCLIN Sud-OuestTél : 05.56.79.60.58Fax : [email protected]

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