Hospital-acquired urinary tract infections in Turkey: a nationwide multicenter point prevalence study

Investigation of the activity of new derivatives of 1,3-diazinone-4 and their acyclic precursors with respect to bacteria of the genus Proteus

Introduction: The present paper provides a study of the activity of the new 1,3-diazinon-4 derivatives and their acyclic precursors under the laboratory cipher PYaTd1, PYaTs2, PYaTs3 and PYaTs4 against microorganisms of the genus Proteus, which is of high importance at the moment as the growing resistance of the Proteus to previously highly active antibiotics dictates the need to search for effective antimicrobial agents that meet modern safety requirements.

Materials and Methods: The study of the activity of the compounds was carried out on collection and freshly isolated strains from patients with different pathologies. The strains were identified using the BIOMIC V3 apparatus (Giles Scientific, USA) to verify genus and species identity. The strains used in the study were previously examined for susceptibility to antibacterial drugs by the Disc Method to assess the presence or absence of resistance. The activity of the new compounds was studied by the serial dilution method.

Results: The results of the study showed that the compounds PYaTd1, PYaTs2, PYaTs3 and PYaTs4 show a different activity against bacteria of the genus Proteus. The substance PYaTs2 is ineffective. With respect to strains P.mirabilis and P.rettgeri, the minimum inhibitory concentration of the compounds PYaTs3, PYaTs4 and PYaTd1 ranges from 4 μg/ml to 16 μg/ml.

Conclusion: Thus, by the average aggregate indices, regardless of the species and strain of bacteria, the most effective compound is PYaTd1, the MIC50 of which is within 10 μg/ml, which proves it to be promising and makes further development worthwhile.

Efficacy of a care bundle to prevent multiple infections in the intensive care unit: A quasi-experimental pretest-posttest design study

BACKGROUND

Healthcare-associated infections extend hospitalization time, increase treatment costs and increase morbidity-mortality rates.

OBJECTIVES

To evaluate the efficacy of a care bundle aimed at preventing three most frequent intensive care unit-acquired infections.

MATERIALS AND METHOD

This quasi-experimental study occurred in an 18-bed tertiary care intensive care unit at a university hospital in Turkey. The sample consisted of 120 patients older than 18years and receiving invasive mechanical ventilation therapy, or had a central venous catheter or urinary catheter. The study comprised three stages. In stage one, the intensive care unit nurses were trained in infection measures, VAP, CA-UTIs and CLABSIs sections of the care bundle. In stage two, the trained nurses applied the care bundle and received feedback on any problematic issues. In stage three, the nurses' compatibility and efficacy of the infection prevention care bundle on the infection rates of VAP, CA-UTIs and CLABSIs were evaluated over three 3-month periods.

RESULTS

Over 1000 ventilation days, ventilator-associated pneumonia infection rates were 23.4, 12.6, and 11.5, during January-March, April-June and July-September, respectively, with January-March and April-June showing a significant decrease (χ²=6.934, p=0.031). The central line-associated bloodstream infection rates were 8.9, 4.2, and 9.9 per 1000 catheter days, during January-March, April-June and July-September, respectively, but were not significantly different based on pair-wise comparisons (p>0.05). The catheter-associated urinary tract infection rates were higher during July-September (6.7/1000 catheter days) compared to January-March (5.7/1000 catheter days) and April-June (10.4/1000 catheter days) but the differences were not significant (p>0.05).

CONCLUSIONS

The infection rates decreased with increased compatibility of the care bundle prepared from evidence-based guidelines.

Interactions of uroseptic Escherichia coli with renal (A-498) and gastrointestinal (HT-29) cell lines

We investigated the ability of Escherichia coli isolated from septic patients with urinary tract infection (UTI) to translocate through the gastrointestinal (GI) tract of the same patients using cell-culture models. Forty-seven hospitalized patients with urosepsis were included in this study. E. coli was isolated from their urine and blood (total 94 isolates) and investigated for genetic relatedness and interaction with the cell lines A-498 and HT-29. An initial comparison of the strains isolated from urine and blood showed that 44 out of 47 patients (94 %) had identical strains in their blood and urine. The blood isolates adhered to both cell lines, although their rate of adherence to A-498 cells was significantly higher than that to HT-29 cells (5.8±3.8 per cell vs 2.8±1.9; P<0.0001). The rate of translocation in A-498 cells was also significantly higher after 120 min (8.7×10(5) vs 2.9×10(5); P = 0.0006). Three non-identical blood isolates were unable to translocate in HT-29 cells, indicating that host immune factors might be more important than bacterial ability to translocate the GI epithelium in these patients. Our data showed that blood isolates from uroseptic patients are able to adhere to and translocate through both cell lines. This suggests that E. coli in patients with UTI may translocate from either the GI tract or the urinary tract, hence questioning the assumption that the urinary tract is the only source of septicaemia in these patients.

Hospital-acquired urinary tract infection point prevalence in Turkey: differences in risk factors among patient groups

Background

The aim of this study was to determine the point prevalence of nosocomial urinary tract infections (UTIs) and to investigate risk factors for pathogen type (E. coli vs. others) and extended-spectrum beta-lactamase (ESBL) positivity among nosocomial UTI patients.

Methods

A questionnaire consisting of 44 questions on demographic data and risk factors of UTI cases was sent to 51 tertiary care hospitals. Univariate and multivariate analyses were conducted.

Results

The overall prevalence of UTI was 1.82% (483/26534). The prevalence of UTI was higher in intensive care units (ICUs) with 6.77% versus 1.45% outside ICUs. Hospitals of the Ministry of Health (compared to university hospitals), hospitals in less developed provinces and hospitals with bed capacity < 500 had higher UTI prevalence. Patients without a urinary catheter were more likely to have received immunosuppressive therapy, current corticosteroid use, renal transplantation and uterine prolapsus and less likely to have another infection outside the urinary tract, as compared to catheterized patients. Among the 422 culture-positive patients, the most common pathogen was E. coli (45.5%). The risk factors increasing the likelihood of E. coli in urine culture were being female, history of urinary tract operation, no use of antibiotics in the preceding three months and infection outside the urinary tract. There were 247 patients with E. coli or Klebsiella spp. positive in culture. Among these, 61% (n=151) were ESBL- positive. Among patients having E. coli/Klebsiella positive in culture, antibiotic use in the preceding three months and history of urinary tract operation were the independent risk factors significantly increasing the risk of ESBL.

Conclusions

The reasons underlying the high prevalence of nosocomial UTIs, and a better understanding of the risk factors might lead to improved control of these infections.

Prevalence and pathogenesis of extended-spectrum beta-lactamase producing Escherichia coli causing urinary tract infection in hospitalized patients

A total of 296 E. coli strains isolated from hospitalized patients with urinary tract infection were included in this study. These strains were tested for their resistance to 22 antimicrobial drugs and the presence of ESBLs genes coding for TEM, SHV, OXA, and CTX-M. We further characterized them for their interaction with a renal cell line (A-498) and a gastrointestinal cell line (Caco-2). Strains were also typed using a combination of RAPD-PCR, PhP-typing and phylogenetic grouping. Only eight strains (2.7 %) were confirmed as ESBLs producers. The most common clonal type contained 35 isolates and only two of them were ESBLs producers and both showed a high degree of adhesion to both cell lines but only one was able to translocate in Caco-2 cells. These strains belonged to phylogenetic group B2, were resistant to nine antibiotics and carried CTX-M-type of ESBL. The remaining six strains belonged to single clones with different phylogenetic groups and ESBL genotypes and were resistant to between 12 and 15 antibiotics. They also showed a high rate of adhesion to A-498 cells (19 ± 2 to 35 ± 3 CFU/cell) and all translocated in this cell line. The rate of adhesion of ESBL-producing strains to Caco-2 cells (11 ± 3.4 CFU/cell) was significantly lower than A-498 cells (26 ± 8 CFU/cell) (p = 0.0002) and only four of them translocated in Caco-2 cells. Our results suggest that the ESBL-producing clones of E. coli have a potential to translocate and cause septicemia in hospitalized patients with UTI.

European Surveillance of Antimicrobial Consumption (ESAC): value of a point-prevalence survey of antimicrobial use across Europe

All 27 EU member states and another seven countries participate in the European Surveillance of Antimicrobial Consumption (ESAC) project. ESAC carried out three hospital point-prevalence surveys on antimicrobial use. Point-prevalence surveys linked antimicrobial use to indication and also assessed dosing using a standardized methodology for data collection and online data submission with feedback capability using a dedicated web-based tool. The objectives of the ESAC hospital point-prevalence surveys were to first determine the feasibility of a pan-European survey and identify targets for quality improvement. Hospitals were voluntarily selected by the lead national or hospital representatives for each country. The WHO Anatomical Therapeutic Chemical Classification of drugs was used for classification of antimicrobials. The three surveys were carried out during a maximum of 2 weeks in the second quarter of 2006, 2008 and 2009. Each department had to be surveyed in 1 day. All systemic antibacterials (J01), rifampicin (J04AB), oral vancomycin (A07AA) and oral/rectal metronidazole (P01AB) were the antimicrobials surveyed, including the prescribed regimen. The number of participating hospitals increased from 20 to 172 from 2006 to 2009. The patient demographics and indications for treatment were similar throughout the three point-prevalence surveys. 'Reason in notes' and 'surgical prophylaxis >24 hours' were also similar. Guideline compliance (51%) was only introduced in the 2009 point-prevalence survey, replacing 'sample for culture and sensitivity' (<50% in 2006 and 2008) since samples were either not taken or no information was available for the majority (>50%) of patients. The use of combination therapy, although exhibiting a wide range within each category, was related to hospital type, with teaching and tertiary hospitals having a significantly higher use of combination therapy (teaching : non-teaching hospitals [p < 0.0001]; and primary : tertiary hospitals [p < 0.0001]). Point-prevalence surveys are useful when time and resources do not allow for continuous surveillance. Repeated point-prevalence surveys within the same institution(s) can be used to monitor trends and effectiveness of antimicrobial-stewardship initiatives. Targets should be set as quality indicators for the individual hospital(s) and effectiveness of any intervention monitored through repeated point-prevalence surveys. Spin-off initiatives, such as the Antibiotic Resistance and Prescribing in European Children, and the European Centre for Disease Prevention and Control point-prevalence survey on healthcare-associated infections and antimicrobial use, will utilize adapted versions of WebPPS, the point-prevalence survey software developed by ESAC. WebPPS will also be made available for non-commercial use to third parties. Interest has been shown from three continents outside Europe, namely North America, Australia and Africa.

A prospective study of nosocomial urinary tract infection in hip fracture patients

AIM

To investigate risk factors and consequences of nosocomial urinary tract infection in hip fracture patients.

BACKGROUND

Nosocomial urinary tract infection is a well-known problem in hip fracture patients. There are several risk factors for nosocomial urinary tract infection described in the literature.

DESIGN

Prospective observational study with a descriptive and comparative design.

METHODS

Hip fracture patients were included consecutively between April 2006-March 2007. Excluded were those under 50, having an indwelling urinary catheter, signs of cognitive impairment or additional severe physical problems at the time of admission. To verify nosocomial urinary tract infection, a urine specimen was taken at admission and discharge. Patients with and without nosocomial urinary tract infection were compared.

RESULTS

The study included 86 hip fracture patients, of whom 45 (52·3%) contracted nosocomial urinary tract infection in hospital. Earlier reported risk factors for nosocomial urinary tract infection were not confirmed in this study, with one exception: diabetes. All diabetic patients in the study contracted urinary tract infections. Patients receiving cloxacillin as antibiotic prophylaxis for wound infection contracted UTI less often than other patients. There were no statistical differences between groups with regard to urinary tract infection frequency four months after fracture or with regard to mortality after one year.

CONCLUSION

Diabetes was the only previously known risk factor for nosocomial urinary tract infection confirmed among hip fracture patients in this study. Cloxacillin as antibiotic prophylaxis for surgery seemed to offer a certain protection against nosocomial urinary tract infection.

RELEVANCE TO CLINICAL PRACTICE

Nurses in clinical practice should be aware of the risk of urinary tract infections in hip fracture patients and especially in hip fracture patients with diabetes. Patients given cloxacillin as antibiotic prophylaxis seem less likely to contract nosocomial urinary tract infection.

Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis

BACKGROUND

Health-care-associated infection is the most frequent result of unsafe patient care worldwide, but few data are available from the developing world. We aimed to assess the epidemiology of endemic health-care-associated infection in developing countries.

METHODS

We searched electronic databases and reference lists of relevant papers for articles published 1995-2008. Studies containing full or partial data from developing countries related to infection prevalence or incidence-including overall health-care-associated infection and major infection sites, and their microbiological cause-were selected. We classified studies as low-quality or high-quality according to predefined criteria. Data were pooled for analysis.

FINDINGS

Of 271 selected articles, 220 were included in the final analysis. Limited data were retrieved from some regions and many countries were not represented. 118 (54%) studies were low quality. In general, infection frequencies reported in high-quality studies were greater than those from low-quality studies. Prevalence of health-care-associated infection (pooled prevalence in high-quality studies, 15·5 per 100 patients [95% CI 12·6-18·9]) was much higher than proportions reported from Europe and the USA. Pooled overall health-care-associated infection density in adult intensive-care units was 47·9 per 1000 patient-days (95% CI 36·7-59·1), at least three times as high as densities reported from the USA. Surgical-site infection was the leading infection in hospitals (pooled cumulative incidence 5·6 per 100 surgical procedures), strikingly higher than proportions recorded in developed countries. Gram-negative bacilli represented the most common nosocomial isolates. Apart from meticillin resistance, noted in 158 of 290 (54%) Staphylococcus aureus isolates (in eight studies), very few articles reported antimicrobial resistance.

INTERPRETATION

The burden of health-care-associated infection in developing countries is high. Our findings indicate a need to improve surveillance and infection-control practices.

FUNDING

World Health Organization.

Prevalence of nosocomial infections at intensive care units in Turkey: A multicentre 1-day point prevalence study

In order to determine the prevalence of intensive care unit (ICU)-acquired infection at ICUs in Turkey and to identify associated risk factors, predominant infecting organisms and mortality rates, a 1-d point prevalence study was carried out on 19 September 2001. A total of 56 ICUs from 22 university and teaching hospitals participated and a total of 236 completed case report forms were accepted for analyses. A total of 115 patients (48.7%) had 1 or more ICU- related nosocomial infections on the study d. Pneumonia and lower respiratory tract infection (28.0%), laboratory confirmed blood stream infection (23.3%) and urinary tract infection (15.7%) were the most frequent types. Endotracheal tube, urinary catheter, multi-trauma on admission, stress ulcer prophylaxis, nasogastric feeding and mechanical ventilation were risk factors. The most frequently reported isolates were Pseudomonas aeruginosa (20.8%), Staphylococcus aureus (18.2%), Acinetobacter spp. (18.2%) and Klebsiella spp. (16.1%). Of the patients, 72.9% were receiving antimicrobials on the study d for treatment or prophylaxis. Most frequently administered antimicrobials were aminoglycosides (37.2%), carbapenems (31.4%), glycopeptides (23.3%), cephalosporins (18.0%) and antifungals (5.8%). According to a 4-week follow-up, 70 (29.7%) patients died, 22 (9.3%) of whom died from ICU related infections. In conclusion this study showed that ICU related infections are common and often associated with resistant microorganisms. The results provide epidemiological information that will help to implement infection control policies in ICUs.

Surveillance of healthcare-associated infections in Indonesian hospitals

A cross-sectional surveillance of healthcare-associated infections (HAIs) and exposure to risk factors was undertaken in two Indonesian teaching hospitals (Hospitals A and B). Patients from internal medicine, surgery, obstetrics and gynaecology, paediatrics, a class department and intensive care were included. Patient demographics, antibiotic use, culture results, presence of HAI [phlebitis, surgical site infection (SSI), urinary tract infection (UTI) and septicaemia] and risk factors were recorded. To check for interobserver variation, a validation study was performed in Hospital B. In Hospitals A and B, 1,334 and 888 patients were included, respectively. Exposure to invasive devices and surgery was 59%. In Hospital A, 2.8% of all patients had phlebitis, 1.7% had SSI, 0.9% had UTI and 0.8% had septicaemia. In Hospital B, 3.8% had phlebitis, 1.8% had SSI, 1.1% had UTI and 0.8% had septicaemia. In the validation study, the prevalence as recorded by the first team was 2.6% phlebitis, 1.8% SSI, 0.9% UTI and no septicaemia, and that recorded by the second team was 2.2% phlebitis, 2.6% SSI, 3.5% UTI and 0.9% septicaemia. This study is the first to report on HAI in Indonesia. Prevalence rates are comparable to those in other countries. The reliability of the surveillance was insufficient as a considerable difference in prevalence rates was found in the validation study. The surveillance method used is a feasible tool for hospitals in countries with limited healthcare resources to estimate their level of HAI and make improvements in infection control. Efficiency can be improved by restricting the surveillance to include only those patients with invasive procedures. This can help to detect 90% of all infections while screening only 60% of patients.

Risk factors for hospital-acquired bacteremia

OBJECTIVE

Bacteremia is one of the most serious health problems associated with high morbidity and mortality. The aim of this study was to identify risk factors for bacteremia in daily medical care to facilitate rapid and accurate clinical decisions about treatment.

PATIENTS AND METHODS

We studied 306 inpatients retrospectively. Age, peripheral neutrophil count, C-reactive protein (CRP), platelets, serum total cholesterol, total protein, albumin and cholinesterase were compared in patients with positive- and negative-blood cultures. The associations between blood culture positivity and glucose tolerance, bedridden state, presence of a central venous catheter (CVC) or urinary catheter were examined. On October 14, 2002, strategies for prevention of catheter-related infection were altered in our hospital. We studied the impact of these changes on the risk of bacteremia.

RESULTS

Sixty-seven patients had positive and 239 had negative blood cultures. Age, neutrophil, platelets, total protein, albumin, and cholinesterase were significantly different between the culture-positive patients and the culture-negative patients. Multivariate analysis showed albumin and platelets as independent predictors. The bedridden state and catheter-inserted states (central venous or urinary) conferred significantly higher positive blood culture rates. Multivariate analysis showed using urinary catheters and indwelling femoral CVCs as independent risk factors. There was no significant difference in the blood culture-positive rate before and after the change in prevention strategies; before the change, 6 of 9 catheter-inserted blood culture-positive cases yielded MRSA, while 4 of 12 cultures yielded Staphylococcus epidermidis after the change.

CONCLUSION

Our study highlights the risk factors of bacteremia in vulnerable patients.