[Challenges and initiatives in the prevention of healthcare associated infections: Expert consensus study]

INTRODUCTION

The objective of the project was to identify new strategies, agreed upon by experts, that help reduce the prevalence of Health Care Related Infections (HAIs) given the increase in their prevalence as a result of the pandemic and improve patient safety.

MATERIAL AND METHODS

The project was developed in three phases. The first two are framed in a sequential explanatory mixed model. Phase 1 consisted of a quantitative study (anonymous survey) to find out the perception of healthcare professionals about HAIs, risk factors, preventive measures, protocols, disinfection products and approaches. Phase 2 consisted of a qualitative exploratory study in which a panel of 15 experts analyzed the results, using focus group techniques, integrating both phases through the elaboration of metainferences. Phase 3 consisted of a qualitative descriptive study where, through nominal group techniques, agreed proposals for strategies to prevent HAIs were prepared.

RESULTS

The panel of experts defined a total of 51 proposals for new strategies: 15 in hand hygiene, 13 in surface cleaning, 13 in the use of devices, and 10 in HAI prevention training. Of all of them, 13 were agreed upon as preferable (medium-high viability and high impact) and 7 as recommendable (low viability and high impact).

CONCLUSIONS

In the prevention of HAIs, experts recommend applying different strategies simultaneously, which include innovative, technological and humanization aspects, both in data collection, intervention and training, prioritizing those with the greatest impact. and feasibility.

Diamond-like carbon coating to inner surface of polyurethane tube reduces Staphylococcus aureus bacterial adhesion and biofilm formation

Staphylococcus aureus is one of the main causative bacteria for polyurethane catheter and artificial graft infection. Recently, we developed a unique technique for coating diamond-like carbon (DLC) inside the luminal resin structure of polyurethane tubes. This study aimed to elucidate the infection-preventing effects of diamond-like carbon (DLC) coating on a polyurethane surface against S. aureus. We applied DLC to polyurethane tubes and rolled polyurethane sheets with our newly developed DLC coating technique for resin tubes. The DLC-coated and uncoated polyurethane surfaces were tested in smoothness, hydrophilicity, zeta-potential, and anti-bacterial properties against S. aureus (biofilm formation and bacterial attachment) by contact with bacterial fluids under static and flow conditions. The DLC-coated polyurethane surface was significantly smoother, more hydrophilic, and had a more negative zeta-potential than did the uncoated polyurethane surface. Upon exposure to bacterial fluid under both static and flow conditions, DLC-coated polyurethane exhibited significantly less biofilm formation than uncoated polyurethane, based on absorbance measurements. In addition, the adherence of S. aureus was significantly lower for DLC-coated polyurethane than for uncoated polyurethane under both conditions, based on scanning electron microscopy. These results show that applying DLC coating to the luminal resin of polyurethane tubes may impart antimicrobial effects against S. aureus to implantable medical polyurethane devices, such as vascular grafts and central venous catheters.

Knowledge and transmission risk awareness of tuberculosis among the pilgrims attending a religious mass gathering in India: a cross-sectional study

Background

Tuberculosis infection accounts for more annual deaths than any other single infectious disease, except the Corona Virus infection. It is a significant global issue and India is one of the most affected countries. Religious mass gatherings congregate millions of pilgrims at one place. Over-crowding is a high-risk factor for the transmission of tuberculosis. Knowledge and awareness of the disease are proven prerequisites for the spread-prevention and early diagnosis of tuberculosis. The present study was designed to explore the knowledge of tuberculosis and awareness of disease transmission risk among pilgrims attending a religious mass gathering, the Kumbh Mela (2016) in Ujjain, India.

Methods

Self-reported data on the pilgrims’ tuberculosis-knowledge were collected using a cross-sectional study design. A contextual, pre-tested questionnaire was used, using the convenience sampling method. In addition to the anonymous descriptive analyses, a composite knowledge-score was developed to enable comparisons between demographic groups.

Results

In total, 1665 pilgrims participated in the study with 38.8 years of mean age and 59% literacy rate. The most recognized symptoms of tuberculosis were “Cough for more than 15 days with sputum” (94%) and “Blood in sputum” (81%). Most participants knew that tuberculosis is an infectious disease (93%) and not hereditary (91%). Additionally, 84% considered it is a potentially lethal disease that requires extensive treatment. However, vaccine awareness was poor (4%). “Direct contact with tuberculosis patient” (78%) and “To be in a crowded area” (4%) were considered as the most important risk factors for tuberculosis transmission. For the composite knowledge-score, a significantly higher mean score was seen among those with at least ten years of schooling compared with illiterates (p <  0.001). Occupation and residency also affected the mean score.

Conclusion

Most pilgrims attending the Kumbh Mela had basic knowledge of the characteristics of tuberculosis, but some important knowledge gaps concerning the transmission risks associated with crowded situations existed. These gaps need to be addressed in future policies to enable safer mass gatherings and to end the TB epidemic, globally.

Evidence-based uncertainty: do implant-related properties of titanium reduce the susceptibility to perioperative infections in clinical fracture management? A systematic review

Background

Implant-associated infections (IAI) remain a challenging complication in osteosynthesis. There is no consensus or clear evidence whether titanium offers a relevant clinical benefit over stainless steel.

Purpose

In this systematic review, we sought to determine whether the implant properties of titanium reduce the susceptibility to IAI compared to stainless steel in fracture management.

Methods

A systematic literature search in German and English was performed using specific search terms and limits. Studies published between 1995 and 1st June 2020 in the Cochrane library, MEDLINE and Web of Science databases were included. Only clinical studies comparing titanium and stainless steel implants regarding the susceptibility to infections were selected for detailed review.

Results

Five studies out of 384 papers were identified and reviewed. From the studies meeting inclusion criteria one study was a systematic review, two studies were randomized controlled studies (RCT) and two studies were of retrospective comparative nature of level IV evidence.

Conclusion

Our results show that currently, no proven advantage for titanium implants in respect to IAI can be seen in contemporary literature. Implants preserving periosteal blood-flow and minimising soft-tissue trauma show statistically significant benefits in reducing the incidence of IAI. Clinical studies providing reliable evidence regarding the influence of titanium implants on IAI and investigating the susceptibility of titanium to infection are necessary

Impact of the COVID-19 pandemic on an interdisciplinary endoscopy unit in a German "hotspot" area: a single center experience

Background and study aims

Since December 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative pathogen of coronavirus disease 2019 (COVID-19), has posed a pandemic threat to global health and has challenged health care system in all affected countries.

Patients and methods

This is a combined study including a descriptive part about the changes in the daily work routine of an Interdisciplinary Endoscopic Unit (IEU) and a prospective analysis of patients tested positive for SARS-CoV-2 who required endoscopic interventions. Conclusively, we present the finding of a point-prevalence analysis in the staff of the IEU.

Results

We present effects of the COVID-19-related restructuring of processes in our interdisciplinary endoscopy unit (IEU) with respect to cancelation of examinations, relocation of staff to other departments, impact of SARS-CoV-2 on medical staff of the IEU, and supply of protective clothing. Additionally, we analyzed the cohort of COVID-19 patients: Sixteen endoscopic interventions were done in ten patients. In all patients with confirmed infection with SARS-CoV-2, emergency endoscopies were required for relevant bleeding situations. Re-endoscopies were required only in critically ill COVID-19 patients.

Conclusions

The restructuring of processes in the IEU was feasible in short time, effective, and can also be applied broadly at least in developed countries [Garbe et al. in Gastroenterology 159:778–780, 2020; Repici A, Pace F, Gabbiadini R, Colombo M, Hassan C, Dinelli M, Group IG-CW, Maselli R, Spadaccini M, Mutignani M, Gabbrielli A, Signorelli C, Spada C, Leoni P, Fabbri C, Segato S, Gaffuri N, Mangiavillano B, Radaelli F, Salerno R, Bargiggia S, Maroni L, Benedetti A, Occhipinti P, De Grazia F, Ferraris L, Cengia G, Greco S, Alvisi C, Scarcelli A, De Luca L, Cereatti F, Testoni PA, Mingotto R, Aragona G, Manes G, Beretta P, Amvrosiadis G, Cennamo V, Lella F, Missale G, Lagoussis P, Triossi O, Giovanardi M, De Roberto G, Cantu P, Buscarini E, Anderloni A, Carrara S, Fugazza A, Galtieri PA, Pellegatta G, Antonelli G, Rosch T, Sharma P (2020) Endoscopy units and the COVID-19 Outbreak: a Multi-Center Experience from Italy. Gastroenterology;]. The endoscopy-related rate of SARS-CoV-2 infection of staff is low, but supply of protective equipment is crucial for this. Endoscopic procedures in COVID-19 patients were not directly related to SARS-CoV-2 infection, but to other underlying diseases or typical complications of long-term ICU treatment.

[Treatment of pancreatic diseases and prevention of infection during outbreak of 2019 coronavirus disease]. Zhonghua Wai Ke Za Zhi. 2020;58:326-330. [PMID: 32107909 DOI: 10.3760/cma.j.cn112139-20200224-00123]

Objective: To explore the proper protective measures for pancreatic diseases treatment during the outbreak of 2019 coronavirus disease(COVID-19). Methods: Clinical data of four cases of patients that suffered COVID-19 from February 2(nd) to February 9(th), 2020 at Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology were reviewed induding 4 males and 1 female, aging of 50, 51, 46, 87 years old, respectively. After the first patients cuffed nosocomial infection of COVID-19, the general protective measures were updated.Only one patient was admitted to each room alone, with no more than one caregiver. The body temperature of care givers was measured twice a day.Primary protections were applied to all staff.The floor was sterilized using disinfectant with an effective chlorine concentration of 1 000 mg/L. The protective measures for interventional procedures were as follow. Primary protection was applied to the operators of central venipuncture catheter, percutaneous abdominal/pleural drainage, percutaneous retroperitoneal drainage, percutaneous transhepatic cholangial drainage and other surgical procedures with local anesthesia and epidural anesthesia. Secondary protection was applied to the operators of endoscopic retrograde cholangiopancreatography and surgical procedures with general anesthesia. Results: There were four patients who were diagnosed as COVID-19, of which one died of COVID-19, two were cured, and one was still in hospital for COVID-19. After the update of protective measures, no more nosocomial infection of COVID-19 occurred. Two central venipuncture catheter, three percutaneous abdominal or pleural drainage, one percutaneous retroperitoneal drainage, one percuteneous transhepatic cholecyst drainage and one open surgery with general anesthesia were performed with no infection of operators. Conclusions: The caregivers of patients are potential infection source of COVID-19. Enhanced protective measures including the management measures of caregivers can decrease the risk of nosocomial infection of COVID-19.

[New vaccines against tuberculosis]

With about 10 million active disease cases and 1.5 million deaths in 2018, tuberculosis (TB) remains one of the most threatening infectious diseases. Yet, the World Health Organization (WHO) aims to reduce morbidity and mortality by 90 and 95%, respectively, between 2015 and 2035. Although diagnostics, therapeutics, and a vaccine are available, it is beyond doubt that better intervention measures are needed to accomplish this ambitious goal. The vaccine bacille Calmette-Guérin (BCG) partially protects infants against TB, but it is virtually ineffective against pulmonary TB in adolescents and adults. The efficacy of this vaccine, however, has not yet been fully exploited. In addition, new vaccine candidates are currently being assessed in clinical trials.Because a quarter of all people are latently infected with Mycobacterium tuberculosis (Mtb), new vaccines must be applied not only prior to infection (pre-exposure vaccination) but also after infection (postexposure vaccination). Prevention of infection, prevention of disease, and prevention of recurrence are currently assessed as clinical endpoints. Because protection against TB is primarily mediated by T lymphocytes, TB vaccine development focuses on protective T cell responses. Protein adjuvant formulations, viral vectors, and killed and live bacterial vaccines are currently being assessed in clinical trials. Moreover, therapeutic vaccination is clinically tested, notably in adjunct to canonical drug therapy to multiresistant TB. It is likely that a single vaccine cannot accomplish the various indications and that different vaccination strategies are required.

Surgical field and skin preparation

Surgical site infection (SSI) is the third most frequent healthcare-associated infection in France. SSI rates in total hip or knee replacement are around 2%. The main bacteria implicated in SSI in clean surgery are those of the skin flora, whence the importance of skin preparation to eliminate transient flora and reduce resident flora. Guidelines for the prevention of SSI have progressed in recent years in France: firstly in 2013, and then in 2016. That preoperative hair removal and scrubbing of clean skin ahead of cutaneous asepsis is non-contributive was confirmed in 2013. A shower with normal soap taken as close to the beginning of surgery as possible is still recommended, as is use of alcoholic antiseptics for cutaneous asepsis. The debate remains open between chlorhexidine and povidone-iodine in several surgical specialties in the absence of any multicenter studies. Future choices of antiseptic may need to take account of resistance, especially to chlorhexidine, and possible side-effects. Finally, antimicrobial skin sealants and adhesive surgical drapes are not recommended for the prevention of infection.