Historic methicillin-resistant Staphylococcus aureus: expanding current knowledge using molecular epidemiological characterization of a Swiss legacy collection

BACKGROUND

Few methicillin-resistant Staphylococcus aureus (MRSA) from the early years of its global emergence have been sequenced. Knowledge about evolutionary factors promoting the success of specific MRSA multi-locus sequence types (MLSTs) remains scarce. We aimed to characterize a legacy MRSA collection isolated from 1965 to 1987 and compare it against publicly available international and local genomes.

METHODS

We accessed 451 historic (1965-1987) MRSA isolates stored in the Culture Collection of Switzerland, mostly collected from the Zurich region. We determined phenotypic antimicrobial resistance (AMR) and performed whole genome sequencing (WGS) using Illumina short-read sequencing on all isolates and long-read sequencing on a selection with Oxford Nanopore Technology. For context, we included 103 publicly available international assemblies from 1960 to 1992 and sequenced 1207 modern Swiss MRSA isolates from 2007 to 2022. We analyzed the core genome (cg)MLST and predicted SCCmec cassette types, AMR, and virulence genes.

RESULTS

Among the 451 historic Swiss MRSA isolates, we found 17 sequence types (STs) of which 11 have been previously described. Two STs were novel combinations of known loci and six isolates carried previously unsubmitted MLST alleles, representing five new STs (ST7843, ST7844, ST7837, ST7839, and ST7842). Most isolates (83% 376/451) represented ST247-MRSA-I isolated in the 1960s, followed by ST7844 (6% 25/451), a novel single locus variant (SLV) of ST239. Analysis by cgMLST indicated that isolates belonging to ST7844-MRSA-III cluster within the diversity of ST239-MRSA-III. Early MRSA were predominantly from clonal complex (CC)8. From 1980 to the end of the twentieth century, we observed that CC22 and CC5 as well as CC8 were present, both locally and internationally.

CONCLUSIONS

The combined analysis of 1761 historic and contemporary MRSA isolates across more than 50 years uncovered novel STs and allowed us a glimpse into the lineage flux between Swiss-German and international MRSA across time.

Treatment effect of remdesivir on the mortality of hospitalised COVID-19 patients in Switzerland across different patient groups: a tree-based model analysis

AIMS OF THE STUDY

Remdesivir has shown benefits against COVID-19. However, it remains unclear whether, to what extent, and among whom remdesivir can reduce COVID-19-related mortality. We explored whether the treatment response to remdesivir differed by patient characteristics.

METHODS

We analysed data collected from a hospital surveillance study conducted in 21 referral hospitals in Switzerland between 2020 and 2022. We applied model-based recursive partitioning to group patients by the association between treatment levels and mortality. We included either treatment (levels: none, remdesivir within 7 days of symptom onset, remdesivir after 7 days, or another treatment), age and sex, or treatment only as regression variables. Candidate partitioning variables included a range of risk factors and comorbidities (and age and sex unless included in regression). We repeated the analyses using local centring to correct the results for the propensity to receive treatment.

RESULTS

Overall (n = 21,790 patients), remdesivir within 7 days was associated with increased mortality (adjusted hazard ratios 1.28-1.54 versus no treatment). The CURB-65 score caused the most instability in the regression parameters of the model. When adjusted for age and sex, patients receiving remdesivir within 7 days of onset had higher mortality than those not treated in all identified eight patient groups. When age and sex were included as partitioning variables instead, the number of groups increased to 19-20; in five to six of those branches, mortality was lower among patients who received early remdesivir. Factors determining the groups where remdesivir was potentially beneficial included the presence of oncological comorbidities, male sex, and high age.

CONCLUSIONS

Some subgroups of patients, such as individuals with oncological comorbidities or elderly males, may benefit from remdesivir.

Influence of environmental temperature and heatwaves on surgical site infection after hip and knee arthroplasty: a nationwide study

BACKGROUND

Previous studies reported higher incidence of surgical site infection (SSI) after procedures performed in summer or with high temperatures. However, no study used detailed climate data to assess this risk after hip and knee arthroplasty, and no study specifically investigated the role of heatwaves.

AIM

To assess the impact of higher environmental temperatures and heatwaves on SSI rates after hip and knee arthroplasty.

METHODS

Data on hip and knee arthroplasty procedures performed between 01/2013 - 09/2019 in hospitals participating in the Swiss SSI surveillance were linked to climate data extracted from weather stations located in their vicinity. The association between temperature, heatwaves and SSI was studied using mixed effects logistic regression models fitted at the patient level. Poisson mixed models were fitted for both calendar year and month of the year to investigate the SSI incidence trajectory over time.

RESULTS

We included 116,981 procedures performed in 122 hospitals. Significantly higher SSI rates were observed for procedures performed in the summertime (incidence rate ratio 1.39, 95% CI [1.20-1.60], p<0.001; reference: autumn) or in calendar months in which the mean temperature was above 20°C (reference 05-10°C; odds ratio 1.59, 95% CI [1.27, 1.98] p<0.001). We observed a slight but non-significant increase in the rate of SSI during heatwaves (1.44% versus 1.01%, p=0.2).

CONCLUSION

SSI rates after hip and knee replacement appear to increase with higher environmental temperature. To establish if, and to what extent, heatwaves increase the risk of SSI, studies involving geographical areas with larger variability in temperature are needed.

[Establishment of genomic pathogen surveillance to strengthen pandemic preparedness and infection prevention in Germany]

The SARS-CoV‑2 pandemic has shown a deficit of essential epidemiological infrastructure, especially with regard to genomic pathogen surveillance in Germany. In order to prepare for future pandemics, the authors consider it urgently necessary to remedy this existing deficit by establishing an efficient infrastructure for genomic pathogen surveillance. Such a network can build on structures, processes, and interactions that have already been initiated regionally and further optimize them. It will be able to respond to current and future challenges with a high degree of adaptability.The aim of this paper is to address the urgency and to outline proposed measures for establishing an efficient, adaptable, and responsive genomic pathogen surveillance network, taking into account external framework conditions and internal standards. The proposed measures are based on global and country-specific best practices and strategy papers. Specific next steps to achieve an integrated genomic pathogen surveillance include linking epidemiological data with pathogen genomic data; sharing and coordinating existing resources; making surveillance data available to relevant decision-makers, the public health service, and the scientific community; and engaging all stakeholders. The establishment of a genomic pathogen surveillance network is essential for the continuous, stable, active surveillance of the infection situation in Germany, both during pandemic phases and beyond.

Hospital Outcomes of Community-Acquired SARS-CoV-2 Omicron Variant Infection Compared With Influenza Infection in Switzerland

IMPORTANCE

With the ongoing COVID-19 pandemic, it is crucial to assess the current burden of disease of community-acquired SARS-CoV-2 Omicron variant in hospitalized patients to tailor appropriate public health policies. Comparisons with better-known seasonal influenza infections may facilitate such decisions.

OBJECTIVE

To compare the in-hospital outcomes of patients hospitalized with the SARS-CoV-2 Omicron variant with patients with influenza.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was based on a national COVID-19 and influenza registry. Hospitalized patients aged 18 years and older with community-acquired SARS-CoV-2 Omicron variant infection who were admitted between January 15 and March 15, 2022 (when B.1.1.529 Omicron predominance was >95%), and hospitalized patients with influenza A or B infection from January 1, 2018, to March 15, 2022, where included. Patients without a study outcome by August 30, 2022, were censored. The study was conducted at 15 hospitals in Switzerland.

EXPOSURES

Community-acquired SARS-CoV-2 Omicron variant vs community-acquired seasonal influenza A or B.

MAIN OUTCOMES AND MEASURES

Primary and secondary outcomes were defined as in-hospital mortality and admission to the intensive care unit (ICU) for patients with the SARS-CoV-2 Omicron variant or influenza. Cox regression (cause-specific and Fine-Gray subdistribution hazard models) was used to account for time-dependency and competing events, with inverse probability weighting to adjust for confounders with right-censoring at day 30.

RESULTS

Of 5212 patients included from 15 hospitals, 3066 (58.8%) had SARS-CoV-2 Omicron variant infection in 14 centers and 2146 patients (41.2%) had influenza A or B in 14 centers. Of patients with the SARS-CoV-2 Omicron variant, 1485 (48.4%) were female, while 1113 patients with influenza (51.9%) were female (P = .02). Patients with the SARS-CoV-2 Omicron variant were younger (median [IQR] age, 71 [53-82] years) than those with influenza (median [IQR] age, 74 [59-83] years; P < .001). Overall, 214 patients with the SARS-CoV-2 Omicron variant (7.0%) died during hospitalization vs 95 patients with influenza (4.4%; P < .001). The final adjusted subdistribution hazard ratio (sdHR) for in-hospital death for SARS-CoV-2 Omicron variant vs influenza was 1.54 (95% CI, 1.18-2.01; P = .002). Overall, 250 patients with the SARS-CoV-2 Omicron variant (8.6%) vs 169 patients with influenza (8.3%) were admitted to the ICU (P = .79). After adjustment, the SARS-CoV-2 Omicron variant was not significantly associated with increased ICU admission vs influenza (sdHR, 1.08; 95% CI, 0.88-1.32; P = .50).

CONCLUSIONS AND RELEVANCE

The data from this prospective, multicenter cohort study suggest a significantly increased risk of in-hospital mortality for patients with the SARS-CoV-2 Omicron variant vs those with influenza, while ICU admission rates were similar.

High adherence to national IPC guidelines as key to sustainable VRE control in Swiss hospitals: a cross-sectional survey

Background

Vancomycin resistant enterococci (VRE) are on the rise in many European hospitals. In 2018, Switzerland experienced its largest nosocomial VRE outbreak. The national center for infection prevention (Swissnoso) elaborated recommendations for controlling this outbreak and published guidelines to prevent epidemic and endemic VRE spread. The primary goal of this study was to evaluate adherence to this new guideline and its potential impact on the VRE epidemiology in Swiss acute care hospitals.

Methods

In March 2020, Swissnoso distributed a survey among all Swiss acute care hospitals. The level of adherence as well as changes of infection prevention and control (IPC) strategies in the years 2018 and 2019 after publication of the national guidelines were asked along with an inventory on VRE surveillance and outbreaks.

Results

Data of 97/146 (66%) participants were available, representing 81.6% of all acute care beds operated in Switzerland in 2019. The vast majority—72/81 (88%) responding hospitals—have entirely or largely adopted our new national guideline. 38/51 (74.5%) hospitals which experienced VRE cases were significantly more likely to have changed their IPC strategies than those 19/38 (50%) hospitals without VRE cases p = 0.017). The new IPC guidelines included (1) introduction of targeted admission screening in 89.5%, (2) screening of close contacts of VRE cases in 56%, and (3) contact precaution for suspected VRE cases 58% of these hospitals. 52 (54%) hospitals reported 569 new VRE cases in 2018 including 14 bacteremia, and 472 new cases in 2019 with 10 bacteremia. The ten largest outbreaks encountered between 2018 and 2019 included 671 VRE cases, of which most (93.4%) consisted of colonization events, 29 (4.3%) infections and 15 (2.2%) bacteremia.

Conclusion

Wide adoption of this VRE control guideline seemed to have a positive effect on VRE containment in Swiss acute care hospitals over two years, even if its long-term impact on the VRE epidemiology remains to be evaluated. Broad dissemination and strict implementation of a uniform national guideline may therefore serve as model for other countries to fight VRE epidemics on a national level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01051-9.

Pre-frail older adults show improved cognition with StayFitLonger computerized home-based training: a randomized controlled trial

Multidomain interventions have shown tremendous potential for improving cognition in older adults. It is unclear if multidomain interventions can be delivered remotely and whether remote intervention is beneficial for older adults who are vulnerable or at risk of cognitive decline. In a 26-week multi-site, home-based, double-blind, randomized controlled trial, 120 cognitively healthy older adults (75 robust, 45 pre-frail; age range = 60-94) recruited from Switzerland, Canada, and Belgium were randomized to receive either the StayFitLonger (SFL) computerized multidomain training program or an active control intervention. Delivered on tablets, the SFL intervention combined adapted physical exercises (strength, balance, and mobility), cognitive training (divided attention, problem solving, and memory), opportunities for social and contributive interactions, and psychoeducation. The active control intervention provided basic mobilization exercises and access to video games. Cognitive outcomes were global cognition (Z-scores of attention, verbal fluency, and episodic memory for nondemented older adults; ZAVEN), memory, executive function, and processing speed. Linear mixed model analyses indicated improved performance on the ZAVEN global cognition score in the SFL group but not in the active control group. Stratified analyses by frailty status revealed improved ZAVEN global cognition and processing speed scores following SFL in the pre-frail group but not in the robust group. Overall, the study indicates that a computerized program providing a multidomain intervention at home can improve cognition in older adults. Importantly, pre-frail individuals, who are at higher risk of cognitive decline, seem to benefit more from the intervention. Trial registration: ClinicalTrials.gov, NCT037519 Registered on January 22, 2020-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04237519 .

Measuring perception of mental well-being in patients under isolation precautions: a prospective comparative study

OBJECTIVES

Isolation precautions (IP) are applied to prevent transmission of pathogens in healthcare settings. Potential negative health outcomes experienced by patients have been previously described but results remain conflicting. We aimed at evaluating the psychological impact of IP in adult patients in isolation using a novel psychological assessment tool.

STUDY DESIGN

Prospective matched cohort study.

SETTING

Tertiary care centre in Switzerland.

PARTICIPANTS

Hospitalised patients under IP and non-isolated patients were matched by ward, age and illness severity.

OUTCOME MEASURES

We measured surrogates of mental and social well-being by using the Pictorial Representation of Illness and Self Measure (PRISM) instrument once during hospitalisation. PRISM is a visual psychometric instrument that has been validated as a quantitative measure of suffering. Smaller distance in self-to-illness separation (SIS) signifies higher importance for a patient.

RESULTS

156 patients agreed to participate of which 63 were under IP and 93 were matched controls. Median (IQR) duration of isolation was 5 days (2-10). The median SIS (IQR) for perceived inferior nurses' care was 22.8 (18.5-24.3) and 23.8 (23.3-25.5) for isolated and non-isolated patients, respectively (p<0.001). Similarly, median SIS (IQR) was significantly smaller in isolated than non-isolated patients for avoidance by visitors with 17.5 (7.7-22.0) and 22.2 (21.8-22.6), for loneliness with 7.5 (3.6-16.0) and 18 (10.2-21.6) and for feeling impure with 19 (17.0-21.5) and 21.5 (18.9-22.1), respectively (all p values<0.05).

CONCLUSIONS

IP to prevent transmission of pathogens may negatively impact mental and social well-being. Measures to alleviate adverse effects of IP should be taken routinely.

Hospital outcomes of community-acquired COVID-19 versus influenza: Insights from the Swiss hospital-based surveillance of influenza and COVID-19

BackgroundSince the onset of the COVID-19 pandemic, the disease has frequently been compared with seasonal influenza, but this comparison is based on little empirical data.AimThis study compares in-hospital outcomes for patients with community-acquired COVID-19 and patients with community-acquired influenza in Switzerland.MethodsThis retrospective multi-centre cohort study includes patients > 18 years admitted for COVID-19 or influenza A/B infection determined by RT-PCR. Primary and secondary outcomes were in-hospital mortality and intensive care unit (ICU) admission for patients with COVID-19 or influenza. We used Cox regression (cause-specific and Fine-Gray subdistribution hazard models) to account for time-dependency and competing events with inverse probability weighting to adjust for confounders.ResultsIn 2020, 2,843 patients with COVID-19 from 14 centres were included. Between 2018 and 2020, 1,381 patients with influenza from seven centres were included; 1,722 (61%) of the patients with COVID-19 and 666 (48%) of the patients with influenza were male (p < 0.001). The patients with COVID-19 were younger (median 67 years; interquartile range (IQR): 54-78) than the patients with influenza (median 74 years; IQR: 61-84) (p < 0.001). A larger percentage of patients with COVID-19 (12.8%) than patients with influenza (4.4%) died in hospital (p < 0.001). The final adjusted subdistribution hazard ratio for mortality was 3.01 (95% CI: 2.22-4.09; p < 0.001) for COVID-19 compared with influenza and 2.44 (95% CI: 2.00-3.00, p < 0.001) for ICU admission.ConclusionCommunity-acquired COVID-19 was associated with worse outcomes compared with community-acquired influenza, as the hazards of ICU admission and in-hospital death were about two-fold to three-fold higher.

Evaluation of existing and desired measures to monitor, prevent and control healthcare-associated infections in Swiss hospitals

OBJECTIVES

Optimal surveillance and prevention of healthcare-associated infections (HAI) are crucial for a well-functioning health care system. With a view to establishing a national state-of-the-art programme for surveillance and prevention of HAIs, the Swiss National Center for Infection Control, Swissnoso, developed a survey to explore the options for expanding the existing Swiss HAI surveillance system.

METHODS

An online survey was sent to all Swiss acute care hospitals. Local infection prevention and control (IPC) professionals were asked to answer on behalf of their institutions. The questions covered the structure and organisation of IPC programmes, current preventive measures, availability and capacity of electronic medical record (EMR) systems, and ability and willingness to establish and participate in the proposed new surveillance modules. An invitation was sent to the 156 acute care hospitals and hospital networks in June 2020. Responses were collected up to the end of August 2020.

RESULTS

Ninety-four hospitals and hospital networks out of 156 (60%) completed the survey. Among 84 hospitals reporting the number of acute care beds, 61 (73%) were small (&lt;200 beds), 16 (19%) medium (200&ndash;650 beds) and 7 (8%) large hospitals (&gt;650 beds). Twenty-nine different EMR systems were used in the participating hospitals. Twenty-two hospitals were using a different EMR system in their intensive care unit. There were 17 hospitals (18%) without an EMR system but which planned to introduce one soon, and eight small hospitals (9%) neither had an EMR system nor were preparing to introduce one. Surveillance for central-line associated bloodstream infection, catheter-associated urinary tract infection and ventilator-associated pneumonia were already established in 26 (28%), 15 (16%) and 15 (16%) hospitals, respectively. Thirty hospitals (36%) would be willing to participate in the pilot phase of a new surveillance system. Of these, 15 stated that they wanted to be part of the pilot hospital network, 6 could provide hospital-wide surveillance denominators (such as catheter-days and patient-days) to compute incidence rates, and 8 indicated interest in doing both. Large hospitals interested in participating in the pilot phase reported more full-time equivalent staff available for surveillance activities than those who did not declare an interest.

CONCLUSIONS

Baseline information on hospital IPC structure and process indicators are essential for the roll-out of national surveillance programmes and for improving surveillance activities. Having an EMR system in place and adequate personnel resources dedicated for surveillance activities are crucial prerequisites for developing and implementing an effective HAI surveillance system. The lack of an EMR system and the diversity and capacities of EMR solutions will be the main challenges for successful implementation of national HAI surveillance modules.

Transition From PCR-Ribotyping to Whole Genome Sequencing Based Typing of Clostridioides difficile

Clostridioides difficile causes nosocomial outbreaks which can lead to severe and even life-threatening colitis. Rapid molecular diagnostic tests allow the identification of toxin-producing, potentially hypervirulent strains, which is critical for patient management and infection control. PCR-ribotyping has been used for decades as the reference standard to investigate transmission in suspected outbreaks. However, the introduction of whole genome sequencing (WGS) for molecular epidemiology provides a realistic alternative to PCR-ribotyping. In this transition phase it is crucial to understand the strengths and weaknesses of the two technologies, and to assess their correlation. We aimed to investigate ribotype prediction from WGS data, and options for analysis at different levels of analytical granularity. Ribotypes cannot be directly determined from short read Illumina sequence data as the rRNA operons including the ribotype-defining ISR fragments collapse in genome assemblies, and comparison with traditional PCR-ribotyping results becomes impossible. Ribotype extraction from long read Oxford nanopore data also requires optimization. We have compared WGS-based typing with PCR-ribotyping in nearly 300 clinical and environmental isolates from Switzerland, and in addition from the Enterobase database (n=1778). Our results show that while multi-locus sequence type (MLST) often correlates with a specific ribotype, the agreement is not complete, and for some ribotypes the resolution is insufficient. Using core genome MLST (cgMLST) analysis, there is an improved resolution and ribotypes can often be predicted within clusters, using cutoffs of 30-50 allele differences. The exceptions are ribotypes within known ribotype complexes such as RT078/RT106, where the genome differences in cgMLST do not reflect the ribotype segregation. We show that different ribotype clusters display different degrees of diversity, which could be important for the definition of ribotype cluster specific cutoffs. WGS-based analysis offers the ultimate resolution to the SNP level, enabling exploration of patient-to-patient transmission. PCR-ribotyping does not sufficiently discriminate to prove nosocomial transmission with certainty. We discuss the associated challenges and opportunities in a switch to WGS from conventional ribotyping for C. difficile.

A review of recommendations for infective endocarditis prevention in patients undergoing transcatheter aortic valve implantation

Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is a new disease entity. The rate of IE after TAVI is similar to that after surgical aortic valve replacement (SAVR), but mortality and prevalence of Enterococcus spp. as causing pathogens are significantly higher. Guidelines on infection prevention measures before TAVI procedures are currently lacking. We performed a structured review of the available data to provide interim recommendations based on guidelines to prevent infections issued by the World Health Organization as well as guidelines by professional societies from Europe and the USA. Such interim recommendations based on expert opinions are probably justified until large randomised trials provide strong evidence for infection control in TAVI, because IE after TAVI is often related to the TAVI procedure itself and the associated mortality rate is high. Antibiotic prophylaxis should be adapted from an intravenous cephalosporin to, e.g., amoxicillin/clavulanic acid, to cover enterococci. In addition, infection control should follow operating room standards as far as is reasonable, even if the evidence for this recommendation is very low. These recommendations are endorsed by the International Society for Cardiovascular Infectious Diseases (ISCVID).

Cohort profile: SARS-CoV-2/COVID-19 hospitalised patients in Switzerland

BACKGROUND

SARS-CoV-2/COVID-19, which emerged in China in late 2019, rapidly spread across the world with several million victims in 213 countries. Switzerland was severely hit by the virus, with 43,000 confirmed cases as of 1 September 2020.

AIM

In cooperation with the Federal Office of Public Health, we set up a surveillance database in February 2020 to monitor hospitalised patients with COVID-19, in addition to their mandatory reporting system.

METHODS

Patients hospitalised for more than 24 hours with a positive polymerase chain-reaction test, from 20 Swiss hospitals, are included. Data were collected in a customised case report form based on World Health Organisation recommendations and adapted to local needs. Nosocomial infections were defined as infections for which the onset of symptoms was more than 5 days after the patient&rsquo;s admission date.

RESULTS

As of 1 September 2020, 3645 patients were included. Most patients were male (2168, 59.5%), and aged between 50 and 89 years (2778, 76.2%), with a median age of 68 (interquartile range 54&ndash;79). Community infections dominated with 3249 (89.0%) reports. Comorbidities were frequently reported, with hypertension (1481, 61.7%), cardiovascular diseases (948, 39.5%) and diabetes (660, 27.5%) being the most frequent in adults; respiratory diseases and asthma (4, 21.1%), haematological and oncological diseases (3, 15.8%) were the most frequent in children. Complications occurred in 2679 (73.4%) episodes, mostly respiratory diseases (2470, 93.2% in adults; 16, 55.2% in children), and renal (681, 25.7%) and cardiac (631, 23.8%) complications for adults. The second and third most frequent complications in children affected the digestive system and the liver (7, 24.1%). A targeted treatment was given in 1299 (35.6%) episodes, mostly with hydroxychloroquine (989, 76.1%). Intensive care units stays were reported in 578 (15.8%) episodes. A total of 527 (14.5%) deaths were registered, all among adults.

CONCLUSION

The surveillance system has been successfully initiated and provides a robust set of data for Switzerland by including about 80% (compared with official statistics) of SARS-CoV-2/COVID-19 hospitalised patients, with similar age and comorbidity distributions. It adds detailed information on the epidemiology, risk factors and clinical course of these cases and, therefore, is a valuable addition to the existing mandatory reporting.

The Detection of Vancomycin in Sweat: A Next-Generation Digital Surrogate Marker for Antibiotic Tissue Penetration: A Pilot Study

BACKGROUND

Assuring adequate antibiotic tissue concentrations at the point of infection, especially in skin and soft tissue infections, is pivotal for an effective treatment and cure. Despite the global issue, a reliable AB monitoring test is missing. Inadequate antibiotic treatment leads to the development of antimicrobial resistances and toxic side effects. β-lactam antibiotics were already detected in sweat of patients treated with the respective antibiotics intravenously before. With the emergence of smartphone-based biosensors to analyse sweat on the spot of need, next-generation molecular digital biomarkers will be increasingly available for a non-invasive pharmacotherapy monitoring.

OBJECTIVE

Here, we investigated if the glycopeptide antibiotic vancomycin is detectable in sweat samples of in-patients treated with intravenous vancomycin.

METHODS

Eccrine sweat samples were collected using the Macroduct Sweat Collector®. Along every sweat sample, a blood sample was taken. Bio-fluid analysis was performed by Ultra-high Pressure Liquid Chromatograph-Tandem Quadrupole Mass Spectrometry coupled with tandem mass spectrometry.

RESULTS

A total of 5 patients were included. Results demonstrate that vancomycin was detected in 5 out of 5 sweat samples. Specifically, vancomycin concentrations ranged from 0.011 to 0.118 mg/L in sweat and from 4.7 to 8.5 mg/L in blood.

CONCLUSION

Our results serve as proof-of-concept that vancomycin is detectable in eccrine sweat and may serve as a surrogate marker for antibiotic tissue penetration. A targeted vancomycin treatment is crucial in patients with repetitive need for antibiotics and a variable antibiotic distribution such as in peripheral artery disease to optimize treatment effectiveness. If combined with on-skin smartphone-based biosensors and smartphone applications, the detection of antibiotic concentrations in sweat might enable a first digital, on-spot, lab-independent and non-invasive therapeutic drug monitoring in skin and soft tissue infections.

Effect of COVID-19 on acute treatment of ST-segment elevation and Non-ST-segment elevation acute coronary syndrome in northwestern Switzerland

Background

To investigate the effect of the corona virus disease 2019 (COVID-19) pandemic on the acute treatment of patients with ST-segment elevation (STEMI) and Non-ST-segment elevation acute coronary syndrome (NSTE-ACS).

Methods

We retrospectively identified patients presenting to the emergency department (ED) with suspected ACS. We evaluated the number of percutaneous coronary interventions (PCIs) for STEMI, NSTE-ACS, and elective PCI cases. In STEMI patients, we assessed the time from chest pain onset (cpo) to ED presentation, post-infarction left ventricular ejection fraction (LVEF), and time from ED presentation to PCI. We directly compared cases from two time intervals: January/February 2020 versus March/April 2020 (defined as 2 months before and after the COVID-19 outbreak). In a secondary analysis, we directly compared cases from March/April 2020 with patients from the same time interval in 2019.

Results

From January to April 2020, 765 patients presented with acute chest pain to the ED. A dramatic reduction of ED presentations after compared to before the COVID-19 outbreak (31% relative reduction) was observed. Overall, 398 PCIs were performed, 220/398 PCIs (55.3%) before versus 178/398 PCIs (44.7%) after the outbreak. While numbers for NSTE-ACS and elective interventions declined by 21% and 31%, respectively, the number of STEMI cases remained stable. Time from cpo to ED presentation, post-infarction LVEF, and median door-to-balloon time remained unchanged.

Conclusions

In contrast to previous reports, our findings do not confirm the dramatic drop in STEMI cases and interventions in northwestern Switzerland as observed in other regions and hospitals around the world.

Candida auris - recommendations on infection prevention and control measures in Switzerland

Candida auris, a globally emerging pathogen, has been repeatedly introduced into European healthcare settings, leading to large and long-lasting nosocomial outbreaks. The pathogen has already been isolated in Switzerland, requiring clinicians and microbiologists to become alert. This is the first comprehensive guidance document on prevention and control of C. auris in Swiss acute care hospitals. It brings to light the most recent evidence from published original articles and reviews. We emphasise the importance of quickly identifying this yeast by means of screening in order to prevent an outbreak that could be difficult to contain. Key containment strategies include reinforcing early detection, hand hygiene, application of strict contact precautions for colonised and infected patients, and thorough specific environmental cleaning and disinfection.

Epidemiology of Severe Acute Respiratory Syndrome Coronavirus 2 Emergence Amidst Community-Acquired Respiratory Viruses

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in China as the cause of coronavirus disease 2019 in December 2019 and reached Europe by late January 2020, when community-acquired respiratory viruses (CARVs) are at their annual peak. We validated the World Health Organization (WHO)-recommended SARS-CoV-2 assay and analyzed the epidemiology of SARS-CoV-2 and CARVs.

METHODS

Nasopharyngeal/oropharyngeal swabs (NOPS) from 7663 patients were prospectively tested by the Basel S-gene and WHO-based E-gene (Roche) assays in parallel using the Basel N-gene assay for confirmation. CARVs were prospectively tested in 2394 NOPS by multiplex nucleic acid testing, including 1816 (75%) simultaneously for SARS-CoV-2.

RESULTS

The Basel S-gene and Roche E-gene assays were concordant in 7475 cases (97.5%) including 825 (11%) SARS-CoV-2 positives. In 188 (2.5%) discordant cases, SARS-CoV-2 loads were significantly lower than in concordant positive ones and confirmed in 105 (1.4%). Adults were more frequently SARS-CoV-2 positive, whereas children tested more frequently CARV positive. CARV coinfections with SARS-CoV-2 occurred in 1.8%. SARS-CoV-2 replaced CARVs within 3 weeks, reaching 48% of all detected respiratory viruses followed by rhinovirus/enterovirus (13%), influenza virus (12%), coronavirus (9%), respiratory syncytial virus (6%), and metapneumovirus (6%).

CONCLUSIONS

Winter CARVs were dominant during the early SARS-CoV-2 pandemic, impacting infection control and treatment decisions, but were rapidly replaced, suggesting competitive infection. We hypothesize that preexisting immune memory and innate immune interference contribute to the different SARS-CoV-2 epidemiology among adults and children.

Rationale and protocol of the StayFitLonger study: a multicentre trial to measure efficacy and adherence of a home-based computerised multidomain intervention in healthy older adults

Background

In older adults, multidomain training that includes physical and cognitive activities has been associated with improvement of physical and cognitive health. The goal of the multisite StayFitLonger study is to assess a home-based computerised training programme, which combines physical exercises, stimulating cognitive activities and virtual coaching.

Methods

One hundred twenty-eight cognitively healthy older adults will be recruited from the community in Switzerland, Canada and Belgium. The study will comprise (1) a 26-week double-blind randomized controlled efficacy trial and (2) a 22-week pragmatic adherence sub-study. In the efficacy trial, participants will be randomly assigned to an experimental or an active control intervention. In the experimental intervention, participants will use the StayFitLonger programme, which is computerised on a tablet and provides content that combines physical activities with a focus on strength and balance, as well as divided attention, problem solving and memory training. Outcomes will be measured before and after 26 weeks of training. The primary efficacy outcome will be performance on the “Timed-Up & Go” test. Secondary outcomes will include measures of frailty, cognition, mood, fear of falling, quality of life, and activities of daily living. Age, sex, education, baseline cognition, expectation, and adherence will be used as moderators of efficacy. Following the 26-week efficacy trial, all participants will use the experimental programme meaning that participants in the control group will ‘cross over’ to receive the StayFitLonger programme for 22 weeks. Adherence will be measured in both groups based on dose, volume and frequency of use. In addition, participants’ perception of the programme and its functionalities will be characterised through usability, acceptability and user experience.

Discussion

This study will determine the efficacy, adherence and participants’ perception of a home-based multidomain intervention programme and its functionalities. This will allow for further development and possible commercialization of a scientifically validated training programme.

Trial registration

ClinicalTrials.gov, NCT04237519 Registered on January 22, 2020 - Retrospectively registered.

Non-invasive Drug Monitoring of β-Lactam Antibiotics Using Sweat Analysis-A Pilot Study

Background: Antimicrobial resistance is a major challenge in treating infectious diseases. Therapeutic drug monitoring (TDM) can optimize and personalize antibiotic treatment. Previously, antibiotic concentrations in tissues were extrapolated from skin blister studies, but sweat analyses for TDM have not been conducted. Objective: To investigate the potential of sweat analysis as a non-invasive, rapid, and potential bedside TDM method. Methods: We analyzed sweat and blood samples from 13 in-house patients treated with intravenous cefepime, imipenem, or flucloxacillin. For cefepime treatment, full pharmacokinetic sampling was performed (five subsequent sweat samples every 2 h) using ultra-high-performance liquid chromatography coupled with triple quadrupole mass spectrometry. The ClinicalTrials.gov registration number is NCT03678142. Results: In this study, we demonstrated for the first time that flucloxacillin, imipenem, and cefepime are detectable in sweat. Antibiotic concentration changes over time demonstrated comparable (age-adjusted) dynamics in the blood and sweat of patients treated with cefepime. Patients treated with standard flucloxacillin dosage showed the highest mean antibiotic concentration in sweat. Conclusions: Our results provide a proof-of-concept that sweat analysis could potentially serve as a non-invasive, rapid, and reliable method to measure antibiotic concentration and as a surrogate marker for tissue penetration. If combined with smart biosensors, sweat analysis may potentially serve as the first lab-independent, non-invasive antibiotic TDM method.

National point prevalence survey on healthcare-associated infections in acute care hospitals, Switzerland, 2017

Background

As a part of the national strategy on the prevention of healthcare-associated infections (HAI), a point prevalence survey (PPS) was conducted in acute care hospitals in Switzerland.

Aim

Our objective was to assess the burden of HAI in Swiss acute care hospitals.

Methods

All acute care hospitals were invited to participate in this cross-sectional survey during the second quarter of 2017. The protocol by the European Centre for Disease Prevention and Control was applied. Patients of all ages, hospitalised on the day of survey were included, except when admitted to outpatient clinics, emergency and psychiatry.

Results

Ninety-six acute care hospitals (79% of all hospitals ≥ 100 beds) provided data on 12,931 patients. Pooled and randomised HAI prevalences were 5.9% (95% confidence interval (CI): 5.5–6.3) and 5.4% (95% CI: 4.8–6.0), respectively. The HAI incidence was estimated at 4.5 (95% CI: 4.0–5.0). The most common type of HAI was surgical site infection (29.0%), followed by lower respiratory tract (18.2%), urinary tract (14.9%) and bloodstream (12.8%) infections. The highest prevalence was identified in intensive care (20.6%), in large hospitals > 650 beds (7.8%), among elderly patients (7.4%), male patients (7.2%) and patients with an ultimately (9.3%) or rapidly (10.6%) fatal McCabe score.

Discussion

This is the first national PPS of Switzerland allowing direct comparison with other European countries. The HAI prevalence was at European Union average (5.9% in 2016 and 2017), but higher than in some countries neighbouring Switzerland. Based on the limited information from previous surveys, HAI appear not to decrease.

Risk of SARS-CoV-2 transmission by aerosols, the rational use of masks, and protection of healthcare workers from COVID-19

OBJECTIVES

To determine the risk of SARS-CoV-2 transmission by aerosols, to provide evidence on the rational use of masks, and to discuss additional measures important for the protection of healthcare workers from COVID-19.

METHODS

Literature review and expert opinion.

SHORT CONCLUSION

SARS-CoV-2, the pathogen causing COVID-19, is considered to be transmitted via droplets rather than aerosols, but droplets with strong directional airflow support may spread further than 2 m. High rates of COVID-19 infections in healthcare-workers (HCWs) have been reported from several countries. Respirators such as filtering face piece (FFP) 2 masks were designed to protect HCWs, while surgical masks were originally intended to protect patients (e.g., during surgery). Nevertheless, high quality standard surgical masks (type II/IIR according to European Norm EN 14683) appear to be as effective as FFP2 masks in preventing droplet-associated viral infections of HCWs as reported from influenza or SARS. So far, no head-to-head trials with these masks have been published for COVID-19. Neither mask type completely prevents transmission, which may be due to inappropriate handling and alternative transmission pathways. Therefore, compliance with a bundle of infection control measures including thorough hand hygiene is key. During high-risk procedures, both droplets and aerosols may be produced, reason why respirators are indicated for these interventions.

Risk of SARS-CoV-2 transmission by aerosols, the rational use of masks, and protection of healthcare workers from COVID-19

OBJECTIVES

To determine the risk of SARS-CoV-2 transmission by aerosols, to provide evidence on the rational use of masks, and to discuss additional measures important for the protection of healthcare workers from COVID-19.

METHODS

Literature review and expert opinion.

SHORT CONCLUSION

SARS-CoV-2, the pathogen causing COVID-19, is considered to be transmitted via droplets rather than aerosols, but droplets with strong directional airflow support may spread further than 2 m. High rates of COVID-19 infections in healthcare-workers (HCWs) have been reported from several countries. Respirators such as filtering face piece (FFP) 2 masks were designed to protect HCWs, while surgical masks were originally intended to protect patients (e.g., during surgery). Nevertheless, high quality standard surgical masks (type II/IIR according to European Norm EN 14683) appear to be as effective as FFP2 masks in preventing droplet-associated viral infections of HCWs as reported from influenza or SARS. So far, no head-to-head trials with these masks have been published for COVID-19. Neither mask type completely prevents transmission, which may be due to inappropriate handling and alternative transmission pathways. Therefore, compliance with a bundle of infection control measures including thorough hand hygiene is key. During high-risk procedures, both droplets and aerosols may be produced, reason why respirators are indicated for these interventions.

Cefiderocol for Extensively Drug-Resistant Gram-Negative Bacterial Infections: Real-world Experience From a Case Series and Review of the Literature

Cefiderocol is a new siderophore cephalosporin with activity against carbapenem-resistant gram-negative bacteria. Data on its clinical efficacy are limited to complicated urinary tract infections. We present a series of 3 patients successfully treated with cefiderocol for complicated health care–associated infections and review published case reports.

Not sick enough to worry? "Influenza-like" symptoms and work-related behavior among healthcare workers and other professionals: Results of a global survey

BACKGROUND

Healthcare workers (HCWs) and non-HCWs may contribute to the transmission of influenza-like illness (ILI) to colleagues and susceptible patients by working while sick (presenteeism). The present study aimed to explore the views and behavior of HCWs and non-HCWs towards the phenomenon of working while experiencing ILI.

METHODS

The study was a cross-sectional online survey conducted between October 2018 and January 2019 to explore sickness presenteeism and the behaviour of HCWs and non-HCWs when experiencing ILI. The survey questionnaire was distributed to the members and international networks of the International Society of Antimicrobial Chemotherapy (ISAC) Infection Prevention and Control (IPC) Working Group, as well as via social media platforms, including LinkedIn, Twitter and IPC Blog.

RESULTS

In total, 533 respondents from 49 countries participated (Europe 69.2%, Asia-Pacific 19.1%, the Americas 10.9%, and Africa 0.8%) representing 249 HCWs (46.7%) and 284 non-HCWs (53.2%). Overall, 312 (58.5%; 95% confidence interval [CI], 56.2-64.6) would continue to work when sick with ILI, with no variation between the two categories. Sixty-seven (26.9%) HCWs and forty-six (16.2%) non-HCWs would work with fever alone (p<0 .01) Most HCWs (89.2-99.2%) and non-HCWs (80%-96.5%) would work with "minor" ILI symptoms, such as sore throat, sinus cold, fatigue, sneezing, runny nose, mild cough and reduced appetite.

CONCLUSION

A future strategy to successfully prevent the transmission of ILI in healthcare settings should address sick-leave policy management, in addition to encouraging the uptake of influenza vaccine.

The potential negative impact of antibiotic pack on antibiotic stewardship in primary care in Switzerland: a modelling study

BACKGROUND

In Switzerland, oral antibiotics are dispensed in packs rather than by exact pill-count. We investigated whether available packs support compliance with recommended primary care treatment regimens for common infections in children and adults.

METHODS

Hospital-based guidelines for oral community -based treatment of acute otitis media, sinusitis, tonsillopharyngitis, community-acquired pneumonia and afebrile urinary tract infection were identified in 2017 in an iterative process by contacting hospital pharmacists and infectious diseases specialists. Furthermore, newly available national guidelines published in 2019 were reviewed. Available pack sizes for recommended solid, dispersible and liquid antibiotic formulations were retrieved from the Swiss pharmaceutical register and compared with recommended regimens to determine optimal (no leftovers) and adequate (optimal +/- one dose) matches.

RESULTS

A large variety of recommended regimens were identified. For adults, optimal and adequate packs were available for 25/70 (36%) and 8/70 (11%) regimens, respectively. Pack-regimen matching was better for WHO Watch (optimal: 15/24, 63%) than Access antibiotics (optimal: 7/39, 18%). For the four paediatric weight-examples and 42 regimens involving child-appropriate formulations, optimal and adequate packs were available for only 14/168 (8%) and 27/168 (16%), respectively. Matching was better for older children with higher body and for longer treatment courses > 7 days.

CONCLUSIONS

Fixed antibiotic packs often do not match recommended treatment regimens, especially for children, potentially resulting in longer than necessary treatments and leftover doses in the community. As part of national stewardship, a move to an exact pill-count system, including for child-appropriate solid formulations, should be considered.

Reproductive number of the COVID-19 epidemic in Switzerland with a focus on the Cantons of Basel-Stadt and Basel-Landschaft

The reproductive number in Switzerland was between 1.5 and 2 during the first third of March, and has consistently decreased to around 1. After the announcement of the latest strict measure on 20 March 2020, namely that gatherings of more than five people in public spaces are prohibited, the reproductive number dropped significantly below 1; the authors of this study estimate the reproductive number to be between 0.6 and 0.8 in the first third of April.

Phenotypic and Genomic Analyses of Burkholderia stabilis Clinical Contamination, Switzerland

A recent hospital outbreak related to premoistened gloves used to wash patients exposed the difficulties of defining Burkholderia species in clinical settings. The outbreak strain displayed key B. stabilis phenotypes, including the inability to grow at 42°C; we used whole-genome sequencing to confirm the pathogen was B. stabilis. The outbreak strain genome comprises 3 chromosomes and a plasmid, sharing an average nucleotide identity of 98.4% with B. stabilis ATCC27515 BAA-67, but with 13% novel coding sequences. The genome lacks identifiable virulence factors and has no apparent increase in encoded antimicrobial drug resistance, few insertion sequences, and few pseudogenes, suggesting this outbreak was an opportunistic infection by an environmental strain not adapted to human pathogenicity. The diversity among outbreak isolates (22 from patients and 16 from washing gloves) is only 6 single-nucleotide polymorphisms, although the genome remains plastic, with large elements stochastically lost from outbreak isolates.

1233. Surveillance Quality Correlates with SSI Rates in Prosthetic Hip and Knee Surgery: A Call to Action to Adjust Reporting of SSI rates

Background

Methods

Results

Conclusion

Disclosures

Control of Candida auris in healthcare institutions: Outcome of an International Society for Antimicrobial Chemotherapy expert meeting

Candida auris (C. auris) is an emerging fungal pathogen causing invasive infections and outbreaks that have been difficult to control in healthcare facilities worldwide. There is a lack of current evidence for pragmatic infection prevention and control recommendations. The aim of this paper was to review the epidemiology of C. auris and identify best practices with a panel of experts, in order to provide guidance and recommendations for infection prevention and control measures based on available scientific evidence, existing guidelines and expert opinion. The Infection Prevention and Control working group of the International Society of Antimicrobial Chemotherapy organised an expert meeting with infection prevention and mycology experts to review recommendations for healthcare workers on infection prevention and control measures for C. auris at inpatient healthcare facilities. The most common interventions included: screening, standard precautions, cleaning and disinfection, inpatient transfer, outbreak management, decolonisation, and treatment.

Antimicrobial use in acute care hospitals: national point prevalence survey on healthcare-associated infections and antimicrobial use, Switzerland, 2017

BackgroundA point prevalence survey (PPS) on healthcare-associated infections (HAI) and antimicrobial use was conducted in Swiss acute care hospitals in 2017.AimOur objective was to assess antimicrobial use in Swiss acute care hospitals.MethodsAll patients hospitalised in any acute care hospital in Switzerland were eligible. We used the most recent version of the PPS protocol of the European Centre for Disease Prevention and Control.ResultsData from 12,931 patients of 96 hospitals were collected. Of these, 4,265 (33%; 95% confidence interval (CI): 32.2-33.8) were on 5,354 antimicrobials for 4,487 indications. Most of the 2,808 therapeutic indications addressed 1,886 community-acquired infections (67.2%; 95% CI: 65.4-68.9). Of the 1,176 surgical prophylaxes, 350 (29.8%; 95% CI: 27.1-32.4) exceeded the duration of 1 day. Of the 1,090 antimicrobial regimens that were changed, 309 (28.3%; 95% CI: 25.7-31.0) were escalated and 337 (30.9%; 95% CI: 28.2-33.7) were de-escalated. Amoxicillin/clavulanic acid was the most frequent antimicrobial (18.8%; 95% CI: 17.7-19.8), prescribed mainly for therapeutic indications (76.0%; 95% CI: 73.3-78.7). A total of 1,931 (37.4%; 95% CI: 36.1-38.8) of the 5,158 antimicrobials for systemic use were broad-spectrum antibiotics, most frequently third- and fourth-generation cephalosporins (35.9%; 95% CI: 33.8-38.1).ConclusionsAntimicrobial consumption was at European average, the use of broad-spectrum antibiotics in the lower third. Swiss acute care hospitals should invest in antimicrobial stewardship, particularly in reducing the use of broad-spectrum antibiotics.

Vaginal-perineal cultures for detecting group B streptococci and extended spectrum β-lactamase producing bacteria in pregnancy

OBJECTIVE

To compare the detection rates of vaginal-perineal cultures for group B streptococci (GBS) with the standard vaginal and rectal cultures and evaluate the diagnostic yield of vaginal-perineal vs. rectal swabs for extended spectrum β-lactamase producing Enterobacterales (ESBL-E) during the third trimester of pregnancy.

STUDY DESIGN

Vagino-perineal and rectal swabs were collected cross-sectionally from pregnant women between 35-37 weeks gestation and tested for the presence of GBS and ESBL-E. Accuracy of the vagino-perineal swab was compared to the combined vagino-perineal/rectal swab. Risk factors for ESBL carriage were examined. Degrees of pain, discomfort and stress related to the rectal swab were analyzed on visual analogue scales.

RESULTS

48 out of 250 participants (19.2%) were GBS positive. The vagino-perineal swab was positive in 44 of 48 women (91.7%) yielding a negative predictive value of 98.1%. Agreement (kappa) between the two methods was 0.95. Six out of 190 women with additional ESBL-E screening (3.2%) tested positive by rectal swab. Of these, only two had also a positive vagino-perineal swab. The rectal swab caused overall little subjective discomfort, pain or stress, as indicated by low scores indicated on the visual scales.

CONCLUSIONS

The GBS detection rate of the vagino-perineal swab was lower compared to the reference standard. However, agreement between the two screening methods was high and there were no cases of GBS neonatal sepsis in the recruited population, supporting this less invasive screening strategy. In contrast, the vaginal-perineal swab was inferior to the rectal swab for detecting ESBL-E, indicating that this less invasive method for detecting antibiotic resistant bacteria that may be potentially transferred to the neonate during labor and delivery would be inappropriate for ESBL-E screening in pregnant women. The low ESBL-E carriage rate among pregnant women likely reflects the prevalence in the general population.

Technology for the prevention of antimicrobial resistance and healthcare-associated infections; 2017 Geneva IPC-Think Tank (Part 2)

Background

The high burden of healthcare-associated infections (HAIs) and antimicrobial resistance (AMR) is partially due to excessive antimicrobial use both in human and animal medicine worldwide. How can technology help to overcome challenges in infection prevention and control (IPC) and to prevent HAI and emerging AMR?

Methods

In June 2017, 42 international experts convened in Geneva, Switzerland to discuss four potential domains of technology in IPC and AMR: 1) role and potential contribution of microbiome research; 2) whole genome sequencing; 3) effectiveness and benefit of antimicrobial environmental surfaces; and 4) future research in hand hygiene.

Results

Research on the microbiome could expand understanding of antimicrobial use and also the role of probiotics or even faecal transplantation for therapeutic purposes. Whole genome sequencing will provide new insights in modes of transmission of infectious diseases. Although it is a powerful tool for public health epidemiology, some challenges with interpretation and costs still need to be addressed. The effectiveness and cost-effectiveness of antimicrobially coated or treated environmental high-touch surfaces requires further research before they can be recommended for routine use. Hand hygiene implementation can be advanced, where technological enhancement of surveillance, technique and compliance are coupled with reminders for healthcare professionals.

Conclusions

The four domains of technological innovation contribute to the prevention of HAI and AMR at different levels. Microbiome research may offer innovative concepts for future prevention, whole genome sequencing could detect new modes of transmission and become an additional tool for effective public health epidemiology, antimicrobial surfaces might help to decrease the environment as source of transmission but continue to raise more questions than answers, and technological innovation may have a role in improving surveillance approaches and supporting best practice in hand hygiene.

Long-term safety of secukinumab in patients with moderate-to-severe plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis: integrated pooled clinical trial and post-marketing surveillance data

BACKGROUND

Secukinumab, a fully human immunoglobulin G1-kappa monoclonal antibody that directly inhibits interleukin (IL)-17A, has been shown to have robust efficacy in the treatment of moderate-to-severe psoriasis (PsO), psoriatic arthritis (PsA), and ankylosing spondylitis (AS) demonstrating a rapid onset of action and sustained long-term clinical responses with a consistently favorable safety profile in multiple Phase 2 and 3 trials. Here, we report longer-term pooled safety and tolerability data for secukinumab across three indications (up to 5 years of treatment in PsO and PsA; up to 4 years in AS).

METHODS

The integrated clinical trial safety dataset included data pooled from 21 randomized controlled clinical trials of secukinumab 300 or 150 or 75 mg in PsO (14 Phase 3 trials and 1 Phase 4 trial), PsA (3 Phase 3 trials), and AS (3 Phase 3 trials), along with post-marketing safety surveillance data with a cut-off date of June 25, 2017. Adverse events (AEs) were reported as exposure-adjusted incident rates (EAIRs) per 100 patient-years. Analyses included all patients who received ≥ 1 dose of secukinumab.

RESULTS

A total of 5181, 1380, and 794 patients from PsO, PsA, and AS clinical trials representing secukinumab exposures of 10,416.9, 3866.9, and 1943.1 patient-years, respectively, and post-marketing data from patients with a cumulative exposure to secukinumab of ~ 96,054 patient-years were included in the analysis. The most frequent AE was upper respiratory tract infection. EAIRs across PsO, PsA, and AS indications were generally low for serious infections (1.4, 1.9, and 1.2, respectively), Candida infections (2.2, 1.5, and 0.7, respectively), inflammatory bowel disease (0.01, 0.05, and 0.1, respectively), and major adverse cardiac events (0.3, 0.4, and 0.6, respectively). No cases of tuberculosis reactivation were reported. The incidence of treatment-emergent anti-drug antibodies was low with secukinumab across all studies, with no discernible loss of efficacy, unexpected alterations in pharmacokinetics, or association with immunogenicity-related AEs.

CONCLUSIONS

Secukinumab demonstrated a favorable safety profile over long-term treatment in patients with PsO, PsA, and AS. This comprehensive assessment demonstrated that the safety profile of secukinumab was consistent with previous reports in patients with PsO, PsA, and AS, supporting its long-term use in these chronic conditions.

Nation-wide survey of screening practices to detect carriers of multi-drug resistant organisms upon admission to Swiss healthcare institutions

As emergence and spread of multi-drug resistant organisms (MDRO) requires a standardized preventive approach, we aimed to evaluate current MDRO admission screening practices in Swiss hospitals and to identify potential barriers impeding their implementation. In early 2018, all Swiss public and private healthcare institutions providing inpatient care were contacted with a 34-item questionnaire to investigate current MDRO admission screening policies. Among 139 respondents representing 180 institutions (response rate, 79%), 83% (149) of institutions implemented MDRO admission screening, while 28% of private and 9% of public institutions did not perform any screening. Targeted high-risk screening included carbapenemase producers, extended-spectrum beta-lactamase producers and methicillin-resistant Staphylococcus aureus at the institutional level for respectively 78% (115), 81% (118) and 98% (145) of screening institutions. Vancomycin-resistant enterococci (44% of institutions), multi-resistant Acinetobacter baumanii (41%) and Pseudomonas aeruginosa (37%) were systematically searched only by a minority of screening institutions. A large diversity of risk factors for targeted screening and some heterogeneity in body sites screened were also observed. Admission-screening practices were mostly impeded by a difficulty to identify high-risk patients (44%) and non-compliance of healthcare workers (35%). Heterogeneous practices and gaps in small and privately-owned institutions, as well as a mismatch between current epidemiologic MDRO trends and screening practices were noticed. These results highlight the need for uniform national MDRO screening standards.

Emergence of vancomycin-resistant enterococci in Switzerland: a nation-wide survey

This nation-wide survey on the epidemiology of vancomycin-resistant enterococci (VRE) included 142 healthcare institutions and showed an increasing number of VRE colonizations and infections in Switzerland, probably for the most part due to nosocomial dissemination. The introduction and spread of a new clone, gaps in VRE screening policies as well as heterogeneity regarding the management of VRE clusters may be possible explanations.

2137. Risk Factors for Surgical Site Infection After Joint Replacement Surgery: Data from the Swiss National Surveillance System

Background

Surgical site infections (SSIs) are infrequently observed after joint replacement surgery but have devastating consequences. Since 2009, a large network of Swiss hospitals prospectively collects data for the national SSI surveillance system. The aim of this observational study was to identify risk factors for SSI among patients undergoing elective hip and knee arthroplastic procedures.

Methods

Risk factors for SSI were identified using both univariate and multivariate logistic regression, appropriately adjusted for hospital level correlation effects among the 173 participating hospitals. We included procedural characteristics and risk categories in our analysis.

Results

We analyzed a total of 113,495 joint replacement procedures that occurred between June 2009 and September 2017. A 12-month follow-up was completed in 92.5% of cases. Overall, the cumulative SSI rate was 1.3% (n = 1,458), varying from 1.1% for knee to 1.4% for hip arthroplasty. Repeat surgery (unplanned or planned), higher ASA level, and longer than anticipated procedural time were associated with a significantly increased risk of infection (figure). Ninety-one percent of all SSIs (1,328) were detected in the post-discharge follow-up. Risk factors for pre-discharge SSIs were very similar to those mentioned above. Fifty-six percent of SSIs were observed within 30 days, 27% from 30 to 90 days after incision and 17% were observed >90 days after the procedure.

Conclusion

The SSI incidence after joint replacement surgery was low, with no significant difference between knee and hip surgery. Almost all SSIs occurred post-discharge, with risk factors being broadly the same, independent of when the infection occurred. Limiting the follow-up period to 90 days would have resulted in missing 17% of SSIs, which argues in favor of extended follow-up.

Disclosures

A. Widmer, Swiss national science foundation: Grant Investigator, Grant recipient.

Patient engagement with surgical site infection prevention: an expert panel perspective

Despite remarkable developments in the use of surgical techniques, ergonomic advancements in the operating room, and implementation of bundles, surgical site infections (SSIs) remain a substantial burden, associated with increased morbidity, mortality and healthcare costs. National and international recommendations to prevent SSIs have been published, including recent guidelines by the World Health Organization, but implementation into clinical practice remains an unresolved issue. SSI improvement programs require an integrative approach with measures taken during the pre-, intra- and postoperative care from the numerous stakeholders involved. The current SSI prevention strategies have focused mainly on the role of healthcare workers (HCWs) and procedure related risk factors. The importance and influence of patient participation is becoming an increasingly important concept and advocated as a means to improve patient safety. Novel interventions supporting an active participative role within SSI prevention programs have not been assessed. Empowering patients with information they require to engage in the process of SSI prevention could play a major role for the implementation of recommendations. Based on available scientific evidence, a panel of experts evaluated options for patient involvement in order to provide pragmatic recommendations for pre-, intra- and postoperative activities for the prevention of SSIs. Recommendations were based on existing guidelines and expert opinion. As a result, 9 recommendations for the surgical patient are presented here, including a practice brief in the form of a patient information leaflet. HCWs can use this information to educate patients and allow patient engagement.

Screening for fecal carriage of MCR-producing Enterobacteriaceae in healthy humans and primary care patients

Background

The extent of the occurrence of the plasmid-encoded colistin resistance genes mcr-1 and mcr-2 among humans is currently sparsely studied in Western Europe.

Objectives

To determine the occurrence of MCR-producing Enterobacteriaceae in fecal samples of healthy humans with high occupational exposure to food and primary care patients in Switzerland.

Methods

Stool samples from 1091 healthy individuals and fecal swabs from 53 primary care patients were screened for polymyxin-resistant Enterobacteriaceae using LB agar containing 4 mg/L colistin. Minimal inhibitory concentrations (MICs) of colistin were determined for non-intrinsic colistin-resistant isolates. Isolates were screened by PCR for the presence of mcr-1 and mcr-2 genes.

Results

The fecal carriage rate of colistin resistant (MIC value >2 mg/l) Enterobacteriaceae was 1.5% for healthy people and 3.8% for primary care patients. Isolates included Hafnia alvei (n = 9), Escherichia coli (n = 3), Enterobacter cloacae (n = 4), Klebsiella pneumoniae (n = 1) and Raoultella ornithinolytica (n = 1). None of the isolates harbored the mcr-1 or mcr-2 genes.

Conclusions

There is no evidence for the presence of MCR-producers in the fecal flora of healthy people or primary care patients. Therefore, the risk of transfer of mcr genes from animals, food or the environment to humans is likely to be low in Switzerland.

Workload even affects hand hygiene in a highly trained and well-staffed setting: a prospective 365/7/24 observational study

INTRODUCTION

Compliance with hand hygiene (HH) has often not proved satisfactory; high workload is a commonly self-reported reason. Previous studies comparing workload and compliance have not measured workload precisely and have focused on certain times of day. This study aimed to investigate the association between HH compliance and workload, both electronically defined 365/7/24 (primary endpoint). In addition, the quality of commonly used compliance defining methods (hand disinfectant usage, direct observation) was investigated (secondary endpoint).

MATERIALS AND METHODS

Correlation of electronically measured HH compliance (hand-rub activities (HRA)/HH opportunities) with electronically determined workload (nursing time output/nursing time input) was undertaken over one year at a stem cell transplant unit at University Hospital Basel, Switzerland. HRA and procedures requiring HRA according to the five World Health Organization indications were recorded continuously (365/7/24) using electronic dispensers and electronic documentation, and compliance was calculated accordingly. Hand disinfectant usage was calculated using spending records for one year; direct observation was performed for approximately 1800 HH opportunities.

RESULTS

During the investigation, 208,184 HRA, translating into 57 [standard deviation (SD) 10] HRA/patient-day (PD), were performed. Electronically determined compliance ranged from 24% to 66% [mean 42.39% (SD 8%)]. The higher the workload, the lower the compliance (R=-0.411; P<0.001). HRA/PD (r=-0.037), hand disinfectant usage (mean 160mL/PD) and observed compliance (95%; 1734 HRA/1813 HH opportunities) were not found to be associated with workload.

CONCLUSION

Calculated compliance was inversely associated with nurses' workload. HRA/PD, observer-determined compliance and amount of disinfectant dispensed were used as surrogates for compliance, but did not correlate with actual compliance and thus should be used with caution.

Local adaptation (mostly) remains local: reassessing environmental associations of climate-related candidate SNPs in Arabidopsis halleri

Numerous landscape genomic studies have identified single-nucleotide polymorphisms (SNPs) and genes potentially involved in local adaptation. Rarely, it has been explicitly evaluated whether these environmental associations also hold true beyond the populations studied. We tested whether putatively adaptive SNPs in Arabidopsis halleri (Brassicaceae), characterized in a previous study investigating local adaptation to a highly heterogeneous environment, show the same environmental associations in an independent, geographically enlarged set of 18 populations. We analysed new SNP data of 444 plants with the same methodology (partial Mantel tests, PMTs) as in the original study and additionally with a latent factor mixed model (LFMM) approach. Of the 74 candidate SNPs, 41% (PMTs) and 51% (LFMM) were associated with environmental factors in the independent data set. However, only 5% (PMTs) and 15% (LFMM) of the associations showed the same environment-allele relationships as in the original study. In total, we found 11 genes (31%) containing the same association in the original and independent data set. These can be considered prime candidate genes for environmental adaptation at a broader geographical scale. Our results suggest that selection pressures in highly heterogeneous alpine environments vary locally and signatures of selection are likely to be population-specific. Thus, genotype-by-environment interactions underlying adaptation are more heterogeneous and complex than is often assumed, which might represent a problem when testing for adaptation at specific loci.

Personalized Prescription Feedback Using Routinely Collected Data to Reduce Antibiotic Use in Primary Care: A Randomized Clinical Trial

IMPORTANCE

Feedback interventions using routinely collected health data might reduce antibiotic use nationwide without requiring the substantial resources and structural efforts of other antibiotic stewardship programs.

OBJECTIVE

To determine if quarterly antibiotic prescription feedback over 2 years reduces antibiotic use when implemented in a complex health care system.

DESIGN, SETTING, AND PARTICIPANTS

Pragmatic randomized trial using routinely collected claims data on 2900 primary care physicians with the highest antibiotic prescription rates in Switzerland.

INTERVENTIONS

Physicians were randomized to quarterly updated personalized antibiotic prescription feedback over 2 years (n = 1450) or usual care (n = 1450). Feedback was provided both by mail and online from October 2013 to October 2015 and was supported by an initial 1-time provision of evidence-based guidelines.

MAIN OUTCOMES AND MEASURES

The primary outcome was the prescribed defined daily doses (DDD) of any antibiotic to any patient per 100 consultations in the first year analyzed by intention-to-treat. We further analyzed prescriptions of specific antibiotics, age groups, and sex for the first and second year to investigate persistency of effects over time.

RESULTS

The 2900 physicians had 10 660 124 consultations over 2 years of follow-up, prescribed 1 175 780 packages of antibiotics with 10 290 182 DDD. Physicians receiving feedback prescribed the same amount of antibiotics to all patients in the first year (between-group difference, 0.81%; 95% CI, -2.56% to 4.30%; P = .64) and second year (between-group difference, -1.73%; 95% CI, -5.07% to 1.72%; P = .32) compared with the control group. Prescribing to children aged 6 to 18 years was -8.61% lower in the feedback than in the control group in the first year (95% CI, -14.87% to -1.90%; P = .01). This difference diminished in the second year (between-group difference, -4.10%; 95% CI, -10.78% to 3.07%; P = .25). Physicians receiving feedback prescribed fewer antibiotics to adults aged 19 to 65 years in the second year (between-group difference, -4.59%; 95% CI, -7.91% to -1.16%; P < .01). Prescribing to other patient groups or of specific antibiotic types was not significantly different between groups.

CONCLUSIONS AND RELEVANCE

This nationwide antibiotic stewardship program with routine feedback on antibiotic prescribing was not associated with a change of antibiotic use. In older children, adolescents, and younger adults less antibiotics were prescribed, but not consistently over the entire intervention period.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01773824.

Of means and ends: The financialization and regulation of health care

Health care is at a critical stage: doctors and patients, the central protagonists in this field, are less and less satisfied with the outcomes. Much of the debate about health care has focused on the choice between large public or corporate solutions. This creates a false dichotomy and wrongheaded solution. As we evaluate proposed healthcare solutions, we ought to apply the frameworks of Catholic Social Doctrine. We can have a medical system that both meets financial objectives and makes a radical commitment to the person.

Personalized prescription feedback to reduce antibiotic overuse in primary care: rationale and design of a nationwide pragmatic randomized trial

Background

Antimicrobial resistance has become a serious worldwide public health problem and is associated with antibiotic overuses. Whether personalized prescription feedback to high antibiotic prescribers using routinely collected data can lower antibiotic use in the long run is unknown.

Methods

We describe the design and rationale of a nationwide pragmatic randomized controlled trial enrolling 2900 primary care physicians in Switzerland with high antibiotic prescription rates based on national reimbursement claims data. About 1450 physicians receive quarterly postal and online antibiotic prescription feedback over 24 months allowing a comparison of the individual prescription rates with peers. Initially, they also receive evidence based treatment guidelines. The 1450 physicians in the control group receive no information. The primary outcome is the amount of antibiotics prescribed over a one year-period, measured as defined daily doses per 100 consultations. Other outcomes include the amount of antibiotics prescribed to specific age groups (<6, 6 to 18, 19 to 65, >65 years), to male and female patients, in addition to prescriptions of specific antibiotic groups. Further analyses address disease-specific quality indicators for outpatient antibiotic prescriptions, the acceptance of the intervention, and the impact on costs.

Discussion

This trial investigates whether continuous personalized prescription feedback on a health system level using routinely collected health data reduces antibiotic overuse. The feasibility and applicability of a web-based interface for communication with primary care physicians is further assessed.

Trial registration

ClinTrials.gov NCT01773824 (Date registered: August 24, 2012).