Carriage of multidrug-resistant Gram-negative bacilli: duration and risk factors

Identification of risk factors influencing the duration of carriage of multidrug-resistant Gram-negative bacilli (MDR-GNB) may be useful for infection control. The aim of this study is to estimate the impact of several factors collected for routine hospital surveillance on the duration of carriage of selected MDR-GNB. From January 2015 to July 2021, patients with at least two clinical/surveillance samples positive for MDR-GNB different from ESBL-producing E. coli or AmpC - exclusively producing Enterobacterales were assessed. Microorganisms, age, number of admissions, clinical or rectal sample, sex, and admission service were evaluated as risk factors. Multivariate analysis was performed by a Cox proportional hazard model. A total of 1981 episodes of colonization were included. Involved microorganisms were ESBL-Klebsiella pneumoniae (KP) in 1057 cases (53.4%), other ESBL-non-E. coli Enterobacterales in 91 (4.6%), OXA-48-KP in 263 (13.3%), KPC-KP in 90 (4.5%), VIM-KP in 29 (1.5%), carbapenemase-producing non-KP Enterobacterales (CP-non-KP) in 124 (6.3%), and MDR Pseudomonas aeruginosa (MDR-PAER) in 327 (16.5%). No differences in duration of colonization were observed among ESBL-KP (median colonization time 320 days), ESBL-non-E. coli Enterobacterales (226 days), OXA48-KP (305 days), and MDR-PAER (321 days). For each group, duration of colonization was significantly longer than that of KPC-KP (median colonization time 60 days), VIM-KP (138 days), and CP-non-KP (71 days). Male sex (HR = 0.88; 95% CI 0.78-0.99), detection in Hepatology-Gastroenterology (HR = 0.71; 95% CI 0.54-0.93), clinical sample (HR = 0.61; 95% CI 0.53-0.69), and > 2 admissions after first detection (HR = 0.47; 95% CI 0.42-0.52) were independent predictors of longer carriage, whereas VIM-KP (HR = 1.61; 95% CI 1.04-2.48), KPC-KP (HR = 1.85; 95% CI 1.49-2.3), and CP-non-KP (HR = 1.92; 95% CI 1.49-2.47) were associated with shorter colonization time. Duration of colonization was significantly longer for ESBL-KP, other ESBL-non-E. coli Enterobacterales, OXA-48-KP, and MDR-PAER. For these microorganisms, prolonging surveillance up to 2.5-3 years should be considered. Male sex, clinical sample, multiple readmissions, admission service, and type of microorganism are independent predictors of the duration of carriage.

A hospital incident reporting system (2016-2019): Learning from notifier's perception on incidents' risk, severity and frequency of adverse events

Incident reporting systems (IRSs) are considered safety culture promoters. Nevertheless, they have not been contemplated to monitor professionals' perception about patient safety related risks. This study aims to describe the characteristics and evolution of incident notifications reported between 2016 and 2019 in a high complexity reference hospital in Barcelona and explores the association between notifications' characteristics and notifier's perception about incidents severity, probability of occurrence and risk. The main analysis unit was notifications reported. A descriptive analysis was performed and taxes by hospital activity were calculated. Odds ratios were obtained to study the association between the type of incident, the moment of incident, notifiers' professional category, reported incident's severity, probability and incidents' calculated risk. Through the study period, a total of 6379 notifications were reported, observing an annual increase of notifications until 2018. Falls (21.22%), Medical and procedures management (18.91%) and Medication incidents (15.49%) were the most frequently notified. Departments reporting the highest number of notifications were Emergency room and Obstetrics & Gynaecology. Incident type and notifiers' characteristics were consistently included in the models constructed to assess risk perception. Pharmaceutics were the most frequent notifiers when considering the proportion of staff members. Notification patterns can inform professionals' patient risk perception and increase awareness of professionals' misconceptions regarding patient safety.

Immunogenicity and reactogenicity of BNT162b2 booster in ChAdOx1-S-primed participants (CombiVacS): a multicentre, open-label, randomised, controlled, phase 2 trial

BACKGROUND

To date, no immunological data on COVID-19 heterologous vaccination schedules in humans have been reported. We assessed the immunogenicity and reactogenicity of BNT162b2 (Comirnaty, BioNTech, Mainz, Germany) administered as second dose in participants primed with ChAdOx1-S (Vaxzevria, AstraZeneca, Oxford, UK).

METHODS

We did a phase 2, open-label, randomised, controlled trial on adults aged 18-60 years, vaccinated with a single dose of ChAdOx1-S 8-12 weeks before screening, and no history of SARS-CoV-2 infection. Participants were randomly assigned (2:1) to receive either BNT162b2 (0·3 mL) via a single intramuscular injection (intervention group) or continue observation (control group). The primary outcome was 14-day immunogenicity, measured by immunoassays for SARS-CoV-2 trimeric spike protein and receptor binding domain (RBD). Antibody functionality was assessed using a pseudovirus neutralisation assay, and cellular immune response using an interferon-γ immunoassay. The safety outcome was 7-day reactogenicity, measured as solicited local and systemic adverse events. The primary analysis included all participants who received at least one dose of BNT162b2 and who had at least one efficacy evaluation after baseline. The safety analysis included all participants who received BNT162b2. This study is registered with EudraCT (2021-001978-37) and ClinicalTrials.gov (NCT04860739), and is ongoing.

FINDINGS

Between April 24 and 30, 2021, 676 individuals were enrolled and randomly assigned to either the intervention group (n=450) or control group (n=226) at five university hospitals in Spain (mean age 44 years [SD 9]; 382 [57%] women and 294 [43%] men). 663 (98%) participants (n=441 intervention, n=222 control) completed the study up to day 14. In the intervention group, geometric mean titres of RBD antibodies increased from 71·46 BAU/mL (95% CI 59·84-85·33) at baseline to 7756·68 BAU/mL (7371·53-8161·96) at day 14 (p<0·0001). IgG against trimeric spike protein increased from 98·40 BAU/mL (95% CI 85·69-112·99) to 3684·87 BAU/mL (3429·87-3958·83). The interventional:control ratio was 77·69 (95% CI 59·57-101·32) for RBD protein and 36·41 (29·31-45·23) for trimeric spike protein IgG. Reactions were mild (n=1210 [68%]) or moderate (n=530 [30%]), with injection site pain (n=395 [88%]), induration (n=159 [35%]), headache (n=199 [44%]), and myalgia (n=194 [43%]) the most commonly reported adverse events. No serious adverse events were reported.

INTERPRETATION

BNT162b2 given as a second dose in individuals prime vaccinated with ChAdOx1-S induced a robust immune response, with an acceptable and manageable reactogenicity profile.

FUNDING

Instituto de Salud Carlos III.

TRANSLATIONS

For the French and Spanish translations of the abstract see Supplementary Materials section.

Methodological guidelines for preparing a structured therapeutic education program: From design to evaluation

BACKGROUND AND OBJECTIVE

Therapeutic patient education (TPE) is effective and essential in the context of the growing prevalence of chronic diseases, in which tools are needed for planning structured programs. The objective of this project was to develop guidelines for designing and assessing a TPE program.

METHODS

1) We assembled a multidisciplinary group of 8 leaders in TPE, chronicity, quality and safety from the hospital and the university. 2) We conducted an exhaustive review of the scientific literature on the planning of TPE programs directed at chronically ill patients, their relatives and caregivers. 3) The final text underwent comments and suggestions by participants from the hospital and primary care centre during a course on information and TPE methodology. The recommendations were unanimously agreed upon by the writing group.

RESULTS

We obtained a standardised work procedure targeted at professionals involved in planning TPE programs, based on international recommendations. The document is structured into sections: a) Definition of the health problem and analysis of the situation; b) Program structure (human resources and materials); objectives (health-related, behaviour-related and educational) and methodology; c) Path the patient and family/caregiver follows in the program; and d) Assessment and indicators. The assessment of the procedure, in the framework of the methodology courses, was favourable.

CONCLUSIONS

The methodology provided by this document serves as an instrument for the standardised and systematic planning of educational programs and unifies the criteria in their drafting. However, the document needs to be adapted to the condition and population to which each program is directed.

A systematic scoping review to approach the construct of gender discrimination

Key messages

The heterogeneity in the conception of gender discrimination has led to different ways of assessment and to a great heterogeneity around the analysis of GD perception. This operative gender discrimination construct could add order and precision to its measurement, increase response rates and reported GD.

Analysis of the quality of patient therapeutic education and information in a high complexity reference hospital

BACKGROUND AND OBJECTIVES

The application and monitoring of quality criteria in information and therapeutic patient education can identify areas to improve care. The objectives of this study were: (1) To analyze the characteristics of patient information materials, educational activities, and self-management programs, and (2) to determine health care provider (HCP) proposals on therapeutic patient education.

MATERIALS AND METHODS

Using a cross-sectional study, an online questionnaire was sent to hospital departments in a high complexity reference hospital from September to December 2013 to record: (a) information materials, (b) patient educational activities, and self-management program characteristics, (c) HCP proposals. The materials were analyzed using Health Promoting Hospitals (HPH) recommendations.

RESULTS

(1) An analysis was performed on 258 materials (leaflets [54%]) for chronic patients (86%), acute patients (7%), and the general population (7%). More than half (55%) lacked the authors, and 43% the year issued, and 69% followed HPH recommendations. (2) An evaluation was made of 70 educational activities and 37 self-management programs addressed to patients/relatives with diabetes/obesity, musculoskeletal disorders, COPD/asthma, pelvic-floor disorders, transplantation, bowel-inflammation/liver disease, hypertension, cancer, heart failure, acquired immune deficiency syndrome, chronic renal insufficiency, splenectomy, anticoagulation and older-patient dependence. The structure, process and outcome evaluation varied. (3) HCP proposals included: standardization of materials criteria, web accessibility, list of accredited websites, cross-sectional use, and HCP training in self-management education.

CONCLUSIONS

The online questionnaire showed the weaknesses and strengths of patient information and education, and can be used to monitor their quantity and quality. These results help in the definition of a useful model to improve patient information and education policies.

Spanish and Catalan translation, cultural adaptation and validation of the Picker Patient Experience Questionnaire-15

OBJECTIVE

To develop and test a culturally adapted core set of questions to measure patients' experience after in-patient care.

MATERIAL AND METHODS

Following the methodology recommended by international guides, a basic set of patient experience questions, selected from Picker Institute Europe questionnaires (originally in English), was translated to Spanish and Catalan. Acceptability, construct validity and reliability of the adapted questionnaire were assessed via a cross-sectional validation study. The inclusion criteria were patients aged >18 years, discharged within one week to one month prior to questionnaire sending and whose email was available. Day cases, emergency department patients and deaths were excluded. Invitations were sent by email (N=876) and questionnaire was fulfilled through an online platform. An automatic reminder was sent 5 days later to non-respondents.

RESULTS

A questionnaire, in Spanish and Catalan, with adequate conceptual and linguistic equivalence was obtained. Response rate was 44.4% (389 responses). The correlation matrix was factorable. Four factors were extracted with Parallel Analysis, which explained 43% of the total variance. First factor: information and communication received during discharge. Second factor: low sensitivity attitudes of professionals. Third factor: assessment of communication of medical and nursing staff. Fourth factor: global items. The value of the Cronbach alpha was 0.84, showing a high internal consistency.

CONCLUSIONS

The obtained experience patient questionnaire, in Spanish and Catalan, shows good results in the psychometric properties evaluated and could be a useful tool to identify opportunities for health care improvement in our context. Email could become a feasible tool for greater patient participation in everything that concerns his health.

The burden of chronic disorders on hospital admissions prompts the need for new modalities of care: a cross-sectional analysis in a tertiary hospital

BACKGROUND

Chronic disorders constitute a primary concern because of their burden on healthcare systems worldwide. Integrated care strategies enhancing the interface between tertiary care and primary care are pivotal to improve chronic care.

AIM

To asses the prevalence of chronic disorders on hospital discharges and their impact on unplanned admissions and mortality.

DESIGN

Cross-sectional analysis of discharge information over 1 year (2004) in one University hospital.

METHODS

Adoption of an operational definition of chronic disorder based on the WHO.

MAIN OUTCOME

co-morbid conditions, emergency room and hospital admissions, outpatient consultations and mortality.

RESULTS

Fifty-eight percent of patients presented at least one chronic condition (19 192 patients, 53% males, 63 +/- 18 years) as primary (12 526 patients, 38%) or secondary diagnosis. The Charlson index was 2 +/- 3. Each chronic condition was associated with a 30% increase of having had an admission in the previous year. Up to 9% (1 656) of chronic patients showed multiple admissions in the previous year: two (917 patients, 55%), three (360, 22%) and four or beyond (379, 23%), being mostly unscheduled hospitalizations. The three most prevalent chronic disorders were cancer, cardiovascular diseases and chronic obstructive pulmonary disease (COPD). The rate of admissions was associated with co-morbidity (P < 0.001) and mortality (P < 0.001).

CONCLUSION

The study shows a high impact of cancer on planned hospitalizations whereas cardiovascular diseases and COPD generates a high percentage of unscheduled admissions. We conclude that integrated care services including patient-oriented guidelines are strongly needed to enhance both health and managerial outcomes.

Immunogenicity and reactogenicity of the adult tetanus-diphtheria vaccine. How many doses are necessary?

The immunogenicity and reactogenicity of the tetanus-diphtheria adult type vaccine was compared in two groups: group I (n = 201, 18-30 years old, presumably vaccinated with the DTP vaccine) and group II (n = 147, > or = 45 years old, without vaccination antecedents). Before vaccination, the seroprotection levels for tetanus were 90.5% (group I) and 30.6% (group II). These rose to 99.5% and 81.7%, respectively, after administration of one vaccine dose. For diphtheria, prevaccination seroprotection levels were 38.3% (group I) and 19.0% (group II). These rose to 85.8% and 65.7%, respectively, after vaccination. The logistic regression analysis showed an association between antibody titre and age. In group II, 3 doses of Td vaccine were needed to reach titres similar to those achieved in group I with a single dose. Stated reactogenicity was greater in: young subjects, women, those with higher titres of tetanus antibodies and those receiving other vaccines simultaneously. These results confirm the need for vaccination schedules adapted to the characteristics of each population age-group.

Cost analysis of two strategies for preventing hepatitis A virus infection in Spanish travellers to developing countries

Our objectives were to assess the prevalence of anti-hepatitis A (HAV) antibodies in Spanish travellers to developing countries and to carry out a cost analysis to allow the comparison of two vaccination strategies. Adult subjects were selected from among travellers to developing countries. Information was obtained on age, sex, destination, previous vaccination against HAV and having received immunoglobulin. Blood specimens were obtained for anti-HAV antibody determination. A total of 485 travellers were studied. The prevalence of anti-HAV antibody was 30.5% (95% CI 26-35). Antibody prevalence was inversely correlated with age: 9.8% in 18-25 years of age, rising to 75.4% in those 41-55 years of age. Cost analysis determined that the critical value of prevalence for vaccination with HAV vaccine was 37.5%. It was concluded that the youngest Spanish travellers lack anti-HAV antibodies. Vaccination without screening in those < or = 35 years of age and screening before vaccination for those > 35 years, are the preferred alternatives.

Prevalence of hepatitis B infection in long-stay mentally handicapped adults

The objective was to determine the prevalence of hepatitis B virus (HBV) infection in long-stay institutionalized mentally handicapped adults and to develop a vaccination programme for them. The study was carried out in 1994. The subjects were 171 mentally handicapped adults aged 37-76 (median age 56) with a median hospital stay of 30 years (range 6-47). Markers for infection were determined using ELISA. Seronegative patients were vaccinated using the standard schedule, and the titre of antiHBs reached was determined later. The prevalence of seropositive subjects was 81.3%. Seropositive subjects had a longer hospital stay (median stay of 32 years, range: 15-47) than seronegative ones (median stay of 15 years, range: 6-33). A total of 43.3% of the vaccinated subjects developed antiHBs antibodies (GMT: 135 IU/l). The high prevalence of HBV exposure is probably a legacy of a past era which is reflected in patients with prolonged institutionalisation in a closed regime. The need for immediate vaccination of mentally handicapped subjects is of the utmost importance, as it has been shown that the response to the vaccine worsens with age.