Clinical practice recommendations for nurse-administered intramuscular injections in mental health: A modified Delphi study

AIM

To develop clinical practice recommendations for nurse-administered intramuscular injections in mental health.

BACKGROUND

Intramuscular injection is the main route of long-acting injectable antipsychotics' administration that appear to improve the long-term prognosis of mental illness. Specific guidelines related to the nurse administration of intramuscular injections need to be updated and to explore not only the technical aspects of this procedure.

DESIGN

A modified RAND/University of California Los Angeles (UCLA) appropriateness method Delphi study was conducted between October 2019 and September 2020.

METHODS

A multidisciplinary steering committee conducted a literature review and developed a list of 96 recommendations. These recommendations were submitted in a two-round Delphi electronic survey to a panel of 49 experienced practicing nurses from five mental health hospitals in France. Each recommendation was rated for its appropriateness and applicability in clinical practice on a 9-point Likert scale. Consensus among nurses was evaluated. The steering committee discussed the results after each round and approved the final set of recommendations.

RESULTS

A final set of 79 specific recommendations were accepted for their appropriateness and applicability in clinical practice. Recommendations were classified in five domains: legal and quality assurance aspects, nurse-patient relationship, hygiene, pharmacology, and injection technique.

CONCLUSION

The established recommendations placed patients at the heart of the decisions concerning the intramuscular injection and underlined the need for specific training programs. Future research should focus on the integration of these recommendations in clinical practice, by both before-and-after studies and regular assessments of professional practices with relevant indicators.

IMPACT

The recommendations developed for good nursing practices explored not only the technical aspects but integrated the nurse-patient relationship. These recommendations may impact usual practices of administration of long-acting injectable antipsychotics and most of them could be applied in many countries.

NO PATIENT OR PUBLIC CONTRIBUTION

Due to the study design.

Evaluation of two detergent-disinfectants and a detergent on a Klebsiella pneumoniae biofilm formed within Tygon tubes

BACKGROUND

Transmission of infections via contaminated endoscopes is a common problem. Manual cleaning, using at least a detergent, is an important step in endoscope processing and should be performed as soon as possible to avoid drying of organic residues that might interfere with high-level disinfection and promote biofilm formation.

AIM

To assess the efficacy of two detergent-disinfectants, enzymatic and non-enzymatic, and of an enzymatic detergent used during the manual cleaning against a Klebsiella pneumoniae biofilm.

METHODS

A 24 h biofilm statically formed in a Tygon tube was exposed to detergent-disinfectants at 20 °C and 35 °C for 10 mn, and to enzymatic detergent at 45 °C for 60 mn. The logarithmic reduction in bacteria in the Tygon tube and the number of bacteria in the product supernatant were calculated.

FINDINGS

Biofilm formation was reproducible between assays. After exposure to detergent-disinfectants, the logarithmic reduction was between 6.32 and 6.71 log10 cfu/cm2 in the Tygon tubes. No bacteria were found in their supernatants. Results in the detergent-disinfectant group were not affected by the exposure temperature or the addition of enzymes. No decrease in the bacterial load was observed in the Tygon tubes after exposure to the enzymatic detergent. Bacteria were found in its supernatant.

CONCLUSION

These results show the importance of the choice of products used during the manual cleaning phase. They also show the potential benefit of combining detergent and disinfectant activity to decrease the bacterial load during the manual cleaning step of endoscope processing.

Intermediate hepatitis B virus infection prevalence among 1622 pregnant women in rural Burkina Faso and implications for mother-to-child transmission

In highly endemic countries for hepatitis B virus (HBV) infection, childhood infection, including mother-to-child transmission (MTCT), represents the primary transmission route. High maternal DNA level (viral load ≥ 200,000 IU/mL) is a significant factor for MTCT. We investigated the prevalence of HBsAg, HBeAg, and high HBV DNA among pregnant women in three hospitals in Burkina Faso and assessed the performance of HBeAg to predict high viral load. Consenting pregnant women were interviewed on their sociodemographic characteristics and tested for HBsAg by a rapid diagnostic test, and dried blood spot (DBS) samples were collected for laboratory analyses. Of the 1622 participants, HBsAg prevalence was 6.5% (95% CI, 5.4-7.8%). Among 102 HBsAg-positive pregnant women in DBS samples, HBeAg was positive in 22.6% (95% CI, 14.9-31.9%), and viral load was quantified in 94 cases, with 19.1% having HBV DNA ≥ 200,000 IU/mL. HBV genotypes were identified in 63 samples and predominant genotypes were E (58.7%) and A (36.5%). The sensitivity of HBeAg by using DBS samples to identify high viral load in the 94 cases was 55.6%, and the specificity was 86.8%. These findings highlight the need to implement routine HBV screening and effective MTCT risk assessment for all pregnant women in Burkina Faso to enable early interventions that can effectively reduce MTCT.

Moving from assessments to implementation: promising practices for strengthening multisectoral antimicrobial resistance containment capacity

BACKGROUND

Antimicrobial resistance (AMR) poses a global threat to human, animal, and environmental health. AMR is a technical area in the Global Health Security Agenda initiative which uses the Joint External Evaluation tool to evaluate national AMR containment capacity. This paper describes four promising practices for strengthening national antimicrobial resistance containment capacity based on the experiences of the US Agency for International Development's Medicines, Technologies, and Pharmaceutical Services Program work with 13 countries to implement their national action plans on AMR in the areas of multisectoral coordination, infection prevention and control, and antimicrobial stewardship.

METHODS

We use the World Health Organization (WHO) Benchmarks on International Health Regulations Capacities (2019) to guide national, subnational, and facility actions that advance Joint External Evaluation capacity levels from 1 (no capacity) to 5 (sustainable capacity). Our technical approach is based on scoping visits, baseline Joint External Evaluation scores, benchmarks tool guidance, and country resources and priorities.

RESULTS

We gleaned four promising practices to achieve AMR containment objectives: (1) implement appropriate actions using the WHO benchmarks tool, which prioritizes actions, making it easier for countries to incrementally increase their Joint External Evaluation capacity from level 1 to 5; (2) integrate AMR into national and global agendas. Ongoing agendas and programs at international, regional, and national levels provide opportunities to mainstream and interlink AMR containment efforts; (3) improve governance through multisectoral coordination on AMR. Strengthening multisectoral bodies' and their technical working groups' governance improved functioning, which led to better engagement with animal/agricultural sectors and a more coordinated COVID-19 pandemic response; and (4) mobilize and diversify funding for AMR containment. Long-term funding from diversified funding streams is vital for advancing and sustaining countries' Joint External Evaluation capacities.

CONCLUSIONS

The Global Health Security Agenda work has provided practical support to countries to frame and conduct AMR containment actions in terms of pandemic preparedness and health security. The WHO benchmarks tool that Global Health Security Agenda uses serves as a standardized organizing framework to prioritize capacity-appropriate AMR containment actions and transfer skills to help operationalize national action plans on AMR.

Plasmidome analysis of a hospital effluent biofilm: Status of antibiotic resistance

Plasmids are widely involved in the dissemination of characteristics within bacterial communities. Their genomic content can be assessed by high-throughput sequencing of the whole plasmid fraction of an environment, the plasmidome. In this study, we analyzed the plasmidome of a biofilm formed in the effluents of the teaching hospital of Clermont-Ferrand (France). Our analysis discovered >350 new complete plasmids, with a length ranging from 1219 to 40,193 bp. Forty-two plasmid incompatibility (Inc) groups were found among all the plasmid contigs. Ten large plasmids, described here in detail, were reconstructed from plasmid contigs, seven of which carried antibiotic resistance genes. Four plasmids potentially confer resistance to numerous families of antibiotics, including carbapenems, aminoglycosides, colistin, and chloramphenicol. Most of these plasmids were affiliated to Proteobacteria, a phylum of Gram-negative bacteria. This study therefore illustrates the composition of an environmental mixed biofilm in terms of plasmids and antibiotic resistance genes.

Strong off-target antibody reactivity to malarial antigens induced by RTS,S/AS01E vaccination is associated with protection

The RTS,S/AS01E vaccine targets the circumsporozoite protein (CSP) of the Plasmodium falciparum (P. falciparum) parasite. Protein microarrays were used to measure levels of IgG against 1000 P. falciparum antigens in 2138 infants (age 6–12 weeks) and children (age 5–17 months) from 6 African sites of the phase III trial, sampled before and at 4 longitudinal visits after vaccination. One month postvaccination, IgG responses to 17% of all probed antigens showed differences between RTS,S/AS01E and comparator vaccination groups, whereas no prevaccination differences were found. A small subset of antigens presented IgG levels reaching 4- to 8-fold increases in the RTS,S/AS01E group, comparable in magnitude to anti-CSP IgG levels (~11-fold increase). They were strongly cross-correlated and correlated with anti-CSP levels, waning similarly over time and reincreasing with the booster dose. Such an intriguing phenomenon may be due to cross-reactivity of anti-CSP antibodies with these antigens. RTS,S/AS01E vaccinees with strong off-target IgG responses had an estimated lower clinical malaria incidence after adjusting for age group, site, and postvaccination anti-CSP levels. RTS,S/AS01E-induced IgG may bind strongly not only to CSP, but also to unrelated malaria antigens, and this seems to either confer, or at least be a marker of, increased protection from clinical malaria.

[Role of helical computed tomography in petrous bone trauma: about 12 cases at the University Hospital Ibn Rochd of Casablanca]

Temporal bone injuries occur in 14-22% of skull fractures occurring due to head trauma. The purpose of this study is to understand the role of helical computed tomography in petrous bone trauma and to show the different types of fractures and the associated lesions. We conducted a retrospective study of 12 patients with petrous bone trauma (including 10 men and 2 women) over a period of 14 months. The average age of patients was 30, ranging from 18 to 42 years. High-resolution multi-slice computed tomography of petrous bone without contrast agent injection, with infra-millimeter slices thickness of 0.6mm every 0.3mm, allowed to detect the following fractures: 8 extralabyrinthine transverse fractures; 1 extralabyrinthine longitudinal fracture; 2 translabyrinthine fractures and 1 oblique fracture. The associated lesions were dominated by: 5 ossicular lesions; 4 cases of temporal bone involvement and 2 cases of geniculate ganglion involvement. High-resolution computed tomography can confirm the presence of a fracture, show the orientation of the fracture line and specify the different structures affected. It can be performed for emergency assessment or after a period of observation.

Altered Ex-Vivo Cytokine Responses in Children With Asymptomatic Plasmodium falciparum Infection in Burkina Faso: An Additional Argument to Treat Asymptomatic Malaria?

Introduction

Patients with clinical malaria have an increased risk for bacterial bloodstream infections. We hypothesized that asymptomatic malaria parasitemia increases susceptibility for bacterial infections through an effect on the innate immune system. We measured circulating cytokine levels and ex-vivo cytokine production capacity in asymptomatic malaria and compared with controls.

Methods

Data were collected from asymptomatic participants <5 years old with and without positive malaria microscopy, as well as from hospitalized patients <5 years old with clinical malaria, bacteremia, or malaria/bacteremia co-infections in a malaria endemic region of Burkina Faso. Circulating cytokines (TNF-α, IFN-γ, IL-6, IL-10) were measured using multiplex assays. Whole blood from asymptomatic participants with and without positive malaria microscopy were ex-vivo stimulated with S. aureus, E. coli LPS and Salmonella Typhimurium; cytokine concentrations (TNF-α, IFN-γ, IL-1β, IL-6, IL-10) were measured on supernatants using ELISA.

Results

Included were children with clinical malaria (n=118), bacteremia (n=22), malaria and bacteremia co-infection (n=9), asymptomatic malaria (n=125), and asymptomatic controls (n=237). Children with either clinical or asymptomatic malaria had higher plasma cytokine concentrations than controls. Cytokine concentrations correlated positively with malaria parasite density with the strongest correlation for IL-10 in both asymptomatic (r=0.63) and clinical malaria (r=0.53). Patients with bacteremia had lower circulating IL-10, TNF-α and IFN-γ and higher IL-6 concentrations, compared to clinical malaria. Ex-vivo whole blood cytokine production to LPS and S. aureus was significantly lower in asymptomatic malaria compared to controls. Whole blood IFN-γ and IL-10 production in response to Salmonella was also lower in asymptomatic malaria.

Interpretation

In children with asymptomatic malaria, cytokine responses upon ex-vivo bacterial stimulation are downregulated. Further studies are needed to explore if the suggested impaired innate immune response to bacterial pathogens also translates into impaired control of pathogens such as Salmonella spp.

Practice guidelines for intramuscular injection in mental health: A delphi method

Introduction

Intramuscular injections (IMI) remain a frequent practice in mental health. The available guidelines for IMI in mental health only focus on the technical side of the practices. Moreover, no recent update has been performed to improve practice of IMI in mental health

Objectives

To assess a formalized consensus agreement regarding the best practice concerning IMI in mental health and to develop practice guidelines.

Methods

A two-round Delphi method was used. The scientific committee consisted in one psychiatrist, one orthopaedic surgeon, one infection control practitioner, one hospital pharmacist, one mental health nurse, one nurse exploring care relationship and one nurse educator. From literature review, each expert proposed specific recommendations. The panel experts were asked to rate the appropriateness and the applicability in current practice of each recommendation on a 9-point Likert scale. Panel members were recruited in five mental health institutions. The first round questionnaire was emailed to each respondent on February 2020 and the second one on June. Propositions were considered appropriate and applicable in current practice if the median was >=7. Agreement among experts were judged by the statistical measure of the Interpercentile Range

Results

From the first round, 46 recommendations were retained by 49 nurses. 27 propositions were retained after this second round by 32 nurses. The scientific committee added 12 other recommendations because of their importance in the literature and clinical practice.

Conclusions

This study provides consensus-based recommendations on IMI in mental health. Nursing staff need to be educated about the new guidelines from both the theoretical and clinical perspectives

Disclosure

No significant relationships.

[Role of computed tomography in bronchial carcinoid tumors for diagnosis and local staging]

PURPOSE

Report radiographic aspects and assess the contribution of computed tomography for the diagnosis and search for extension of bronchial carcinoid tumors.

MATERIAL AND METHODS

This retrospective study included 9 patients with a bronchial carcinoid tumor during a four years period. In all patients, the exploration included standard chest radiography, computed tomography (CT) and abdominal ultrasonography.

RESULTS

This series included three females and six males, mean age 25 years (age range 20-52 years). The average time between clinical symptoms and diagnosis was 24 months. The important signs were chest pain, dry cough and dyspnea in 7 cases, hemoptysis in 4 cases. Chest radiography has objectified a rounded opacity speculated in 4 cases, opacity systematized in 3 cases and an opaque lung in 2 cases. Computed tomography (CT) revealed an endobronchial process with a endobronchial budding in 5 cases, pneumonia systematized in 4 cases, collapse in 7 cases, a localized dilatation of bronchus in 2 cases, lymph node metastases in 4 cases. Bronchoscopy has the macroscopic diagnosis in all cases. All patients have surgical treatment, the lobectomy in 4 cases, pneumonectomy in 3 cases and bilobectomy in 2 cases.

CONCLUSION

CT is indispensable for positive diagnosis, and topographic localization of extension of bronchial carcinoid tumors. The main contribution of CT compared with fibroscopy is to demonstrate exobronchial tumor development and upstream pulmonary complications.

Postoperative empyema following chronic subdural hematoma surgery: Clinically based medicine

INTRODUCTION

Subdural empyema (SDE) is a rare complication of chronic subdural hematoma (CSDH) surgery. We introduced antibiotic prophylaxis (AP) for this procedure in 2014 following a morbidity-mortality conference (MMC) in our department. We report the results of retrospective data analysis to assess the effect of systematic AP and to identify risk factors for SDE.

MATERIAL AND METHODS

Two hundred eight patients were recruited between January 2013 and December 2015; 5 were excluded for incomplete data: 107 without and 96 with AP (n=203). SDE was confirmed by clinical examination, imaging and bacteriological analysis. Comparisons between AP-(no cefuroxime) and AP+ (cefuroxime) groups were made with Chi² test and Student's t-test.

RESULTS

One empyema was found in each group, indicating that AP had no effect (P=1). The only criterion associated with SDE for these two patients was a greater number of reoperations for CSDH recurrence (P=0.013).

DISCUSSION

The incidence of postoperative empyema was 1%, similar to the range of 0.2%-2.1% reported in the literature. This rare incidence explains why we found no significant effect of AP. The medical decision taken at the MMC did not help to reduce the rate of postoperative SDE. MMCs can help to define factors associated with adverse surgical events and identify opportunities for improvement.

CONCLUSION

AP, introduced after an MMC, did not impact SDE rates. In practice, AP should be required only in case of reoperation for CSDH recurrence. However, we still continue to use AP following the MMC considering different parameters discussed in the manuscript.

Climate disturbance impact assessment in West Africa: evidence from field survey and satellite imagery analysis

Extreme drought events from climate disturbances are weakening livelihood and limiting agriculture and livestock production in the Sahel region. The lack of relevant information to anticipate coping measures has exacerbated impacts leading to climate adaptation failure in most parts. In this regard, the current research paper has collected important datasets with an objective to assess the impact of extreme drought events on household's livelihoods for better understanding impacts, local people's perception, and the changes on vegetation cover in order to support a robust adaptation strategy to drought. The study conducted a household survey and collected satellite data for comparative analysis. The first survey was conducted in 2013 to collect data from 465 household heads through a structured questionnaire. Supplementary focus group discussions (FGDs) were also conducted in 2018 to collect qualitative information from targeted respondents such as village leaders and members of other key groups including women and youth. Descriptive statistics and correlation coefficient matrix were used to characterize the impact on households' main livelihoods and logistic regression to predict people's perception on pasture depletion over the last 20 years. Satellite data were used to derive spectral vegetation of land covers and unsupervised classification indexes. Both individual survey and focus group discussions identified drought as the main climate constraint which reduced crop production, water and pastures. The logistic analysis revealed that if the respondent's major occupation is livestock, the probability to perceive a depletion of pasture will increase by 28%. Concurrently, the satellite image observation in perfect agreement with the field survey showed 6.78% and 6.01% losses of water surface and vegetation cover respectively between 1986 and 2016 in the study area. These findings showed that logistic regression coupled with satellite information can inform on past and future impacts which are extremely crucial for sound adaptation planning in the Sahel region.

Bacterial skin recolonization in the operating room: comparison between various antisepsis protocols

BACKGROUND

Surgical site infection (SSI) largely implicates the patient's endogenous skin microbiota. Perioperative disinfection protocols do not follow a general agreement.

AIM

To compare antisepsis and skin protection protocols on quantitative analysis of recolonization in the operating room at regular time-steps. The study hypothesis was that one protocol would be more effective than others.

METHODS

A single-centre prospective interventional study was conducted between January and June 2019. Healthy volunteers were randomized between protocols and served as their own controls. The protocols began ahead of scheduled orthopaedic surgery with a preoperative shower, mechanical cleansing, application of major antiseptics (alcoholic Bétadine™ 5% or alcoholic chlorhexidine 0.5%), sterile draping, then adhesive draping (3M™ Steri-Drape™ or iodine-impregnated 3M™ Ioban2™). Sampling was by swabbing in the operating room at 30 min intervals up to 90 min after draping. Cultures were performed under aerobic and anaerobic conditions. Qualitative and quantitative (cfu/mL) bacteriology was performed in the laboratory by direct reading on the blood agar plates.

FINDINGS

Thirty subjects were included; none was lost to follow-up or excluded from analysis. Bacterial load before manipulation (T0) was significantly higher in males (P < 0.0001) despite a significantly shorter shower-to-sampling interval (P = 0.03). Smoking (P = 0.85), body mass index (P = 0.38), and depilation (P = 0.50) did not significantly affect preoperative load. Mean load increased significantly under all protocols up to T90 min, without significant superiority for any one protocol. Associated Bétadine™/Ioban™ showed the lowest T90 load, and chlorhexidine alone the highest, but without significant difference. Isolates at T0 were predominantly healthy skin commensals: coagulase-negative staphylococci, micrococci, and coryneforms.

CONCLUSION

No one protocol demonstrated superiority, whether in immediate bactericidal action or in preventing skin recolonization in the operating room. Further studies are needed to define generally agreed protocols for SSI risk management.

Long-term immunogenicity and immune memory response to the hepatitis B antigen in the RTS,S/AS01E malaria vaccine in African children: a randomized trial

RTS,S/AS01_E malaria vaccine contains the hepatitis B virus surface antigen and may thus serve as a potential hepatitis B vaccine. To evaluate the impact of RTS,S/AS01_E when implemented in the Expanded Program of Immunization, infants 8-12 weeks old were randomized to receive either RTS,S/AS01_E or a licensed hepatitis B control vaccine (HepB), both co-administered with various combinations of the following childhood vaccines: diphtheria-tetanus-acellular pertussis-Haemophilus influenzae type b, trivalent oral poliovirus, pneumococcal non-typeable Haemophilus influenzae protein D conjugate and human rotavirus vaccine. Long-term persistence of antibodies against the circumsporozoite (CS) protein and hepatitis B surface antigen (HBsAg) were assessed, together with the immune memory response to the HB antigen following a booster dose of HepB vaccine. Subgroups receiving RTS,S or the HepB control vaccine were pooled into RTS,S groups and HepB groups, respectively. One month post-HepB booster vaccination, 100% of participants in the RTS,S groups and 98.3% in the control groups had anti-HBs antibody concentrations ≥10 mIU/mL with the geometric mean concentrations (GMCs) at 46634.7 mIU/mL (95% CI: 40561.3; 53617.6) and 9258.2 mIU/mL (95% CI: 6925.3; 12377.0), respectively. Forty-eight months post-primary vaccination anti-CS antibody GMCs ranged from 2.3 EU/mL to 2.7 EU/mL in the RTS,S groups compared to 1.1 EU/mL in the control groups. Hepatitis B priming with the RTS,S/AS01_E vaccine was effective and resulted in a memory response to HBsAg as shown by the robust booster response following an additional dose of HepB vaccine. RTS,S/AS01E when co-administered with PHiD-CV, HRV and other childhood vaccines, had an acceptable safety profile.

[Intramedullary lipoma: about a case]

Les lipomes intramédullaires sont des lésions bénignes rares qui représentent environ 1% de l'ensemble des tumeurs de la moelle épinière. Nous rapportons un nouveau cas de lipome intramédullaire non dysraphique confirmé histologiquement. Il s'agissait d'une patiente âgée de 46 ans ayant bénéficié d'une biopsie chirurgicale pour un lipome médullaire il y a 6 mois. Nous ne disposons pas de documents radiologiques antérieurs à cette chirurgie. Elle présente actuellement des rachialgies, des troubles sensitifs, des troubles de la marche et une faiblesse musculaire d'aggravation récente. L'IRM médullaire objective une formation en hypersignal T1 et T2 bien limitée de 8cm x 2,5cm prenant le cône terminal. L'imagerie par résonance magnétique occupe une place primordiale dans l'exploration des lipomes intramédullaires, elle permet le diagnostic précoce et ainsi une prise en charge chirurgicale avant la survenue de complications neurologiques irréversibles.

Biofilms in hospital effluents as a potential crossroads for carbapenemase-encoding strains

Bacterial resistance to carbapenem, which is mainly due to the successful dissemination of carbapenemase-encoding genes, has become a major health problem. Few studies have aimed to characterize the level of resistance in the environment, notably in hospital wastewater, which is a likely hotspot for exchange of antibiotic resistance genes. In this work, we looked for the presence of imipenem-resistant bacteria and imipenem in the effluent of the teaching hospital of Clermont-Ferrand, France. Selective growth of bacteria from 14-day old biofilms formed in the pipe sewer showed that 22.1% of the isolates were imipenem-resistant and identified as Aeromonas (n = 23), Pseudomonas (n = 10), Stenotrophomonas (n = 4) and Acinetobacter (n = 1). Fifteen of these strains harbored acquired carbapenemase-encoding genes bla_VIM (n = 11), bla_OXA-48 (n = 2), bla_GES (n = 1), bla_NDM (n = 1). All isolates also harbored associated resistances to aminoglycosides, fluoroquinolones and/or tetracyclin. S1-nuclease pulsed-field gel electrophoresis analysis of eight selected isolates showed that four of them harbored one to two plasmids of molecular weight between 48.5 Kb and 194 Kb. In vitro transformation assays evidenced the presence of bla_VIM and bla_NDM on plasmids with the bla_VIM harboring 80 Kb plasmid having conjugative capacity. The predicted environmental concentration of imipenem in the hospital effluent was 3.16 μg/L, suggesting that biofilm bacteria are subjected to sub-MICs of imipenem within the effluent. However, no imipenem molecule was detected in the hospital effluent, probably owing to its instability: in vitro assays indicated that imipenem's biological activity was no longer detectable after 45 h of storage. However, the predictive value of the hazard quotient relative to the development of resistance was >1.0 (HQr = 28.9 ± 1.9), which indicates a possible risk. The presence of carbapenemase-encoding genes in hospital effluent biofilm strains and their ability to transfer are therefore a potential hazard that should not be neglected and points to the need for monitoring antibiotic resistance in hospital wastewater.

Immune response to the hepatitis B antigen in the RTS,S/AS01 malaria vaccine, and co-administration with pneumococcal conjugate and rotavirus vaccines in African children: A randomized controlled trial

The RTS,S/AS01 malaria vaccine (Mosquirix) reduces the incidence of Plasmodium falciparum malaria and is intended for routine administration to infants in Sub-Saharan Africa. We evaluated the immunogenicity and safety of 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV; Synflorix) and human rotavirus vaccine (HRV; Rotarix) when co-administered with RTS,S/AS01 (www.clinicaltrials.gov NCT01345240) in African infants. 705 healthy infants aged 8–12 weeks were randomized to receive three doses of either RTS,S/AS01 or licensed hepatitis B (HBV; Engerix B) vaccine (control) co-administered with diphtheria-tetanus-acellular pertussis-Haemophilus influenzae type-b-conjugate vaccine (DTaP/Hib) and trivalent oral poliovirus vaccine at 8–12-16 weeks of age, because DTaP/Hib was not indicated before 8 weeks of age. The vaccination schedule can still be considered broadly applicable because it was within the age range recommended for EPI vaccination. PHiD-CV or HRV were either administered together with the study vaccines, or after a 2-week interval. Booster doses of PHiD-CV and DTaP/Hib were administered at age 18 months.

Non-inferiority of anti-HBV surface antigen antibody seroprotection rates following co-administration with RTS,S/AS01 was demonstrated compared to the control group (primary objective). Pre-specified non-inferiority criteria were reached for PHiD-CV (for 9/10 vaccine serotypes), HRV, and aP antigens co-administered with RTS,S/AS01 as compared to HBV co-administration (secondary objectives). RTS,S/AS01 induced a response to circumsporozoite protein in all groups. Pain and low grade fever were reported more frequently in the PHiD-CV group co-administered with RTS,S/AS01 than PHiD-CV co-administered with HBV. No serious adverse events were considered to be vaccine-related. RTS,S/AS01 co-administered with pediatric vaccines had an acceptable safety profile. Immune responses to RTS,S/AS01 and to co-administered PHiD-CV, pertussis antigens and HRV were satisfactory.

Cost assessment of a new oral care program in the intensive care unit to prevent ventilator-associated pneumonia

OBJECTIVES

Ventilator-associated pneumonia (VAP) is the most frequent hospital-acquired infections in intensive care units (ICU). In the bundle of care to prevent the VAP, the oral care is very important strategies, to decrease the oropharyngeal bacterial colonization and presence of causative bacteria of VAP. In view of the paucity of medical economics studies, our objective was to determine the cost of implementing this oral care program for preventing VAP.

MATERIALS AND METHODS

In five ICUs, during period 1, caregivers used a foam stick for oral care and, during period 2, a stick and tooth brushing with aspiration. Budgetary effect of the new program from the hospital's point of view was analyzed for both periods. The costs avoided were calculated from the incidence density of VAP (cases per 1000 days of intubation). The cost study included device cost, benefit lost, and ICU cost (medication, employer and employee contributions, blood sample analysis…).

RESULTS

A total of 2030 intubated patients admitted to the ICUs benefited from oral care. The cost of implementing the study protocol was estimated to be €11,500 per year. VAP rates decreased significantly between the two periods (p1 = 12.8% and p2 = 8.5%, p = 0.002). The VAP revenue was ranged from €28,000 to €45,000 and the average cost from €39,906 to €42,332. The total cost assessment calculated was thus around €1.9 million in favor of the new oral care program.

CONCLUSION AND CLINICAL RELEVANCE

Our study showed that the implementation of a simple strategy improved the quality of patient care is economically viable.

TRIAL REGISTRATION

NCT02400294.

Evaluation of Malaria Screening during Pregnancy with Rapid Diagnostic Tests Performed by Community Health Workers in Burkina Faso

One of the current strategies to prevent malaria in pregnancy is intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP). However, in order for pregnant women to receive an adequate number of SP doses, they should attend a health facility on a regular basis. In addition, SP resistance may decrease IPTp-SP efficacy. New or additional interventions for preventing malaria during pregnancy are therefore warranted. Because it is known that community health workers (CHWs) can diagnose and treat malaria in children, in this study screening and treatment of malaria in pregnancy by CHWs was evaluated as an addition to the regular IPTp-SP program. CHWs used rapid diagnostic tests (RDTs) for screening and artemether-lumefantrine was given in case of a positive RDT. Overall, CHWs were able to conduct RDTs with a sensitivity of 81.5% (95% confidence interval [CI] 67.9-90.2) and high specificity of 92.1% (95% CI 89.9-93.9) compared with microscopy. After a positive RDT, 79.1% of women received artemether-lumefantrine. When treatment was not given, this was largely due to the woman being already under treatment. Almost all treated women finished the full course of artemether-lumefantrine (96.4%). In conclusion, CHWs are capable of performing RDTs with high specificity and acceptable sensitivity, the latter being dependent on the limit of detection of RDTs. Furthermore, CHWs showed excellent adherence to test results and treatment guidelines, suggesting they can be deployed for screen and treat approaches of malaria in pregnancy.

Comparative study of 2 oral care protocols in intensive care units

BACKGROUND

The quality of oral care is important in limiting the emergence of ventilator-associated pneumonia (VAP) in intubated patients. Our main objective was to measure the quality improvement in oral care following the implementation of a new oral care protocol. We also monitored VAP rates.

MATERIAL/METHODS

This was a cohort study of patients in 5 adult ICUs covering different specialties. During period 1, caregivers used a foam stick for oral care and during period 2 a stick and tooth brushing with aspiration. Oral chlorhexidine was used during both periods. The caregivers rated improvement in oral health on the basis of 4 criteria (tongue, mucous membranes, gingivae, and teeth). Caregiver satisfaction was also assessed. The incidence of VAP was monitored.

RESULTS

A total of 2,030 intubated patients admitted to intensive care units benefited from oral care. The patient populations during the 2 periods were similar with regard to demographic data and VAP potential risk factors. Oral health was significantly better from the third day of oral care in period 2 onward (period 1, 6.4 ± 2.1; period 2, 5.6 ± 1.8; P = .043). Caregivers found the period 2 protocol easier to implement and more effective. VAP rates decreased significantly between the 2 periods (period 1, 12.8%; period 2, 8.5%; P = .002).

CONCLUSIONS

Our study showed that the implementation of a simple strategy improved the quality of oral care of patients in intensive care units, and decreased VAP rates.

Ciprofloxacin residue and antibiotic-resistant biofilm bacteria in hospital effluent

Discharge of antimicrobial residues and resistant bacteria in hospital effluents is supposed to have strong impacts on the spread of antibiotic resistant bacteria in the environment. This study aimed to characterize the effluents of the Gabriel Montpied teaching hospital, Clermont-Ferrand, France, by simultaneously measuring the concentration of ciprofloxacin and of biological indicators resistant to this molecule in biofilms formed in the hospital effluent and by comparing these data to ciprofloxacin consumption and resistant bacterial isolates of the hospital. Determination of the measured environmental concentration of ciprofloxacin by spot sampling and polar organic chemical integrative (POCIS) sampling over 2 weeks, and comparison with predicted environmental concentrations produced a hazard quotient >1, indicating a potential ecotoxicological risk. A negative impact was also observed with whole hospital effluent samples using the Tetrahymena pyriformis biological model. During the same period, biofilms were formed within the hospital effluent, and analysis of ciprofloxacin-resistant isolates indicated that Gamma-Proteobacteria were numerous, predominantly Aeromonadaceae (69.56%) and Enterobacteriaceae (22.61%). Among the 115 isolates collected, plasmid-mediated fluoroquinolone-resistant genes were detected, with mostly aac(6')-lb-cr and qnrS. In addition, 60% of the isolates were resistant to up to six antibiotics, including molecules mostly used in the hospital (aminosides and third-generation cephalosporins). In parallel, 1247 bacteria isolated from hospitalized patients and resistant to at least one of the fluoroquinolones were collected. Only 5 of the 14 species identified in the effluent biofilm were also found in the clinical isolates, but PFGE typing of the Gram-negative isolates found in both compartments showed there was no clonality among the strains. Altogether, these data confirm the role of hospital loads as sources of pollution for wastewater and question the role of environmental biofilms communities as efficient shelters for hospital-released resistance genes.

Outbreak of Colonization and Infection With Vancomycin-ResistantEnterococcus faeciumin a French University Hospital

An outbreak of infection with vancomycin-resistantEnterococcus faeciumoccurred at Hôtel-Dieu Hospital (Clermont-Ferrand, France). A case-control study was performed in the infectious diseases and hematology units of the hospital. Urinary catheter use (odds ratio [OR], 12 [95% confidence interval {CI}, 1.5-90];P<.02), prior exposure to a third-generation cephalosporin (OR, 22 [95% CI, 3-152];P= .002), and prior exposure to antianaerobials (OR, 11 [95% CI, 1.5-88];P<.02) were independently predictive of vancomycin-resistantEnterococcus faeciumcarriage.

[Osteoid osteoma: about a case]

Osteoid osteoma is a benign primary bone tumor. This tumor is relatively frequent, accounting for 12% of all benign bone tumors and about 2-3% of all bone tumors. We report a new case of osteoid osteoma confirmed histologically. A 30-year old patient was referred for evaluation of chronic ankle pain. Front and lateral radiographs of the ankle showed a heterogeneous lesion located in the neck of the talus without soft tissue abnormalities. The CT scan of the ankle showed a nodular, hypodense lesion located in the neck of the talus with a limited osteosclerotic reaction.

[MRI relevance in femoral head osteonecrosis: 3 case studies]

INTRODUCTION

Aseptic osteonecrosis of the femoral head is the partial or total destruction of the femoral head due to impaired blood flow. It affects young adults (30-60 years), predominantly male (3 male:1 female) and is often bilateral. The aim of the present work is to define the role of MRI in the diagnosis, classification and therapeutic management of osteonecrosis of the femoral head.

MATERIALS AND METHODS

This study focused on three observations of osteonecrosis of the femoral head in the 20 Aout Radiology Department of the Ibn Rochd of Casablanca University Hospital with a review of the literature. All patients underwent MRI of both hips with sagittal sequences, coronal T1, T2 and T2 SE DP Fat Sat.

RESULTS

The ages of our patients were 62 years for case 1 (male); 37 years for case 2 (female) and 58 years for case 3 (male). The MRI in all 3 patients objectified: subchondral bone fragment on the outer compartment of the femoral head bilaterally with minimal bilateral effusion in the first patient. In the other two patients, we note the presence of subcortical signal abnormalities of the femoral heads with demarcation piping T1 hypointense, T2 hyperintense and associated subchondral fractures. A minimal effusion was also observed.

CONCLUSION

Medical imaging is an essential element of the radiological diagnosis of osteonecrosis of the femoral head. MRI finds its best indication in the precocious and differential diagnosis, as well as the classification of osteonecrosis of the femoral head.

[Security of hospital infusion practices: From an a priori risk analysis to an improvement action plan]

OBJECTIVES

Infusion in care units, and all the more in intensive care units, is a complex process which can be the source of many risks for the patient. Under cover of an institutional approach for the improvement of the quality and safety of patient healthcare, a risk mapping infusion practices was performed.

METHODS

The analysis was focused on intravenous infusion situations in adults, the a priori risk assessment methodology was applied and a multidisciplinary work group established.

RESULTS

Forty-three risks were identified for the infusion process (prescription, preparation and administration). The risks' assessment and the existing means of control showed that 48% of them would have a highly critical patient security impact. Recommendations were developed for 20 risks considered to be most critical, to limit their occurrence and severity, and improve their control level. An institutional action plan was developed and validated in the Drug and Sterile Medical Devices Commission.

CONCLUSION

This mapping allowed the realization of an exhaustive inventory of potential risks associated with the infusion. At the end of this work, multidisciplinary groups were set up to work on different themes and regular quarterly meetings were established to follow the progress of various projects. Risk mapping will be performed in pediatric and oncology unit where the risks associated with the handling of toxic products is omnipresent.

[Bessef Hogen's disease, or exostosis disease, with spinal cord compression: a case in the service of the Paediatric CHU Ouedraogo, Ouagadougou, BF]

CA, 14 old years, female, born last uterine siblings of 9 children, 4 died of various causes, was admitted in the pediatric service of CHU-YO for functional impairment of the lower limbs. Physical examination revealed swelling and deformation harsh, uneven surfaces, the circumferential upper and lower limbs and lumbar spine associated with spastic paraplegia. Sphincter disturbances accompany this clinical picture. The radiographic bone marrow hypertrophy individually with images of exostosis at the epiphyses. Multiple exostosis or BESSEF Hogen's disease is rare and has a reserve functional prognosis because of outcome of low spinal cord compression and vascular compression. We felt it appropriate to bring this case discovered during our clinical practice because of its rarity and the risk of malignant degeneration.

[Aorto-pulmonary fistula found in a 9 year old girl at the Yalgado Ouedraogo University Hospital, Ouagadougou Burkina Faso]

The CS child, aged 9, is evacuated from a health center located 200km away from Ouagadougou (capital of BF) for decompensated heart failure. Clinically we noted a syndrome of congestive heart failure. No obvious cause has been found outside of the advancing age of parents (50 years) and the potential risks of rubella infection. A Doppler echocardiography revealed a fistula aorto-pulmonary 17mm wide associated with a pericardial effusion of average circumferential abundance and a dilation of the left ventricular. Pulmonary radiography showed a large cardiomegaly and left pleurisy. The discovery of congenital heart disease between 2 and 4 years is very rare but the prognosis is good with surgical treatment.

Antibiotic resistance and plasmid transfer capacity in biofilm formed with a CTX-M-15-producing Klebsiella pneumoniae isolate

OBJECTIVES

To characterize a CTX-M-15-producing Klebsiella pneumoniae isolate that was identified during an outbreak involving 16 patients who had undergone endoscopic retrograde cholangiopancreatography between December 2008 and August 2009. The strain was also detected in one endoscope used for these examinations.

METHODS

Disc diffusion assays, MICs and isoelectric focusing were used to characterize the plasmidic CTX-M-15 β-lactamase. PCRs were used to check for the presence of genes associated with virulence or antibiotic resistance. Antibiotic tolerance tests and plasmid transfer were carried out in both planktonic and biofilm conditions.

RESULTS

The strain belonged to sequence type 14 and to the virulent capsular serotype K2, but produced little glucuronic acid. It contained a 62.5 kb conjugative plasmid carrying the bla(CTX-M-15), bla(OXA-1) and aac(6')-Ib-cr genes and harboured few virulence genes (uge, wabG, kfu and mrkD). The strain was highly resistant to cefotaxime (MIC 516 mg/L) and the presence of this antibiotic at sub-MIC concentrations enhanced biofilm formation. The isolate was susceptible to ofloxacin (MIC 2 mg/L), but the bactericidal effect of this antibiotic was greater in planktonic cultures and 6 h old biofilm than in 24 or 48 h old biofilms. The K. pneumoniae strain was notable for its ability to transfer its plasmid, especially in biofilm conditions, in which the rate of plasmid transfer was about 0.5/donor.

CONCLUSIONS

These findings demonstrate the ability of this strain to survive in a hospital environment and to transfer its extended-spectrum β-lactamase-encoding plasmid.

Fatal adenovirus infection in a neonate and transmission to health-care workers

BACKGROUND

Human adenovirus (HAdV) infections, while common in infancy and childhood, occur rarely in the neonatal period but may be fatal.

OBJECTIVES

To describe a transmission of HAdV from a patient with fatal pneumonia to heath-care workers that could be considered as a model of respiratory virus transmission in a care unit.

STUDY DESIGN

Case report with virologic studies.

RESULTS

A 10-day-old neonate developed pneumonia with acute respiratory distress, external pulmonary bleeding and coagulopathy and died 36h after admission of multivisceral failure. An adenovirus was isolated from pulmonary biopsy and detected by PCR in blood and respiratory secretions. Ten days later, three members of medical staff in charge of this infant, who used neither masks nor glasses for close patient contact, developed keratoconjunctivitis. Molecular analysis of the infant's and one of the pediatrician's isolates identified a species D HAdv and showed 100% identity, thereby demonstrating viral transmission.

CONCLUSION

In view of the serious outcome, HAdV infections should be considered in the differential diagnosis of pneumonia in neonates. This case illustrates the epidemic potential of viruses with respiratory transmission and underlines the importance of complying with standard precautions to prevent viral spread in routine practice.

Impact of rapid enterovirus molecular diagnosis on the management of infants, children, and adults with aseptic meningitis

Enteroviruses (EV) are the main etiological agents of aseptic meningitis. Diagnosis is made by detecting the genome using RT-PCR. The aim of the study was to evaluate the impact of a positive diagnosis on the management of infants, children, and adults. During 2005, 442 patients were admitted to hospital with suspected meningitis. Clinical and laboratory data and initial treatment were recorded for all patients with enteroviral meningitis. The turnaround time of tests and the length of hospital stay were analyzed. The results showed that EV-PCR detected EV in 69 patients (16%), 23% (16/69) were adults. About 18% of CSF samples had no pleocytosis. After positive PCR results, 63% of children were discharged immediately (mean 2 hr 30 min) and 95% within 24 hr. Infants and adults were discharged later (after 1.8 and 2 days, respectively). The use of antibiotics was significantly lower in children than in infants and adults. The PCR results allowed discontinuation of antibiotics in 50-60% of all patients treated. Patients received acyclovir in 16% of cases (7% children vs. 50% adults) and 23% (11% vs. 69%) underwent a CT scan. Clinical data were compared between patients whose positive EV-PCR results were available within 24 hr (n = 32) and those whose results were available > 24 hr after collection of CSF (n = 14). Duration of antibiotic treatment (difference: 2.3 days; P = 0.05) was reduced between the two groups. No statistical difference in the length of stay was observed. The EV-PCR assay should be performed daily in hospital laboratory practice and considered as part of the initial management of meningitis.

Evolution of genetic diversity and drug resistance mutations in HIV-1 among untreated patients from Mali between 2005 and 2006

OBJECTIVES

To describe HIV-1 variants circulating in Mali and to estimate the rate of transmission of HIV-1 drug resistance in 2006.

PATIENTS AND METHODS

Viral reverse transcriptase (RT) and protease (PR) genes from 198 antiretroviral (ARV)-naive patients diagnosed HIV-1 positive in May 2006 in Bamako and Segou were sequenced.

RESULTS

Although CRF02_AG was always the predominant HIV-1 subtype observed (72%), a higher genetic diversity than that in 2005 was observed. The overall prevalence of primary resistance is 11.5% in Mali in 2006, according to the 2007 IAS-USA list of mutations [nucleoside RT inhibitor (NRTI): 1.5%, non-NRTI (NNRTI): 9% and PI: 1%], and 2.5% (NRTI: 1%, NNRTI: 1.5% and PI: 0%), according to the Stanford list of mutations. There was no significant difference between 2005 and 2006 in the overall primary resistance prevalence or in the prevalence of mutations in the different ARV classes. Resistance mutations found in RT and PR genes are in agreement with the highly active antiretroviral therapy regimen available in Mali, except for V90I, V106I and A98G mutations which are associated with etravirine resistance, but polymorphic in non-B subtypes.

CONCLUSIONS

HIV-1 genetic diversity seems increased in Mali, but the overall HIV-1 primary resistance prevalence remains low. This is consistent with the findings from other West African countries where prevalence rates are lower than 5%. However, considering the large scaling up of ARV use in this country, it is necessary to regularly monitor the development of primary resistance in Mali.

Structural effects of amino acid variations between B and CRF02-AG HIV-1 integrases

HIV-1 integrase is one of the three essential enzyme required for viral replication and has a great potential as a novel target for anti-HIV drugs. The sequence variability of the entire integrase (IN) was examined in HIV-1 subtype B and CRF02-AG antiretroviral naïve infected patients for the presence of naturally occurring polymorphisms IN gene sequences and protein structures from both subtypes were compared. The phylogenetic analysis showed a total concordance between the 3 pol gene sequences for patients identified as subtype B whereas 3% of patients identified as CRF02-AG showed a mixture of subtypes. The analysis of IN aa sequences showed that 13 positions (K/R14, V/I31, L/I101, T/V112, T/A124, T/A125, G/N134, I/V135, K/T136, V/I201, T/S206, L/I234, and S/G283) differed between subtypes B and CRF02-AG. As observed in the 3D model of the preintegration complex, these differences may impact the functional property of IN. The fact that most variations were grouped suggests that some of them are linked together through compensatory mechanisms. This comparison allowed us to identify several variations of amino acids in HIV-1 IN subtype CRF02-AG that could have a putative impact on anti-integrase sensitivity. In particular, the region formed by Thr125, Thr124, Val31 contains at least one residue, T125, which variation has been involved in eliciting resistance to the naphtyridine carboxamide L870,810 IN inhibitor. In conclusion, virological response to anti-integrase should be studied carefully, according to the subtype, in clinical trials.

An in-use microbiological comparison of two surgical hand disinfection techniques in cardiothoracic surgery: hand rubbing versus hand scrubbing

Surgical site infection after heart surgery increases morbidity and mortality. The method of presurgical hand disinfection could influence the infection risk. From February to April 2003, we compared the microbiological efficacy of hand-rubbing (R) and hand-scrubbing (S) procedures. The surgical team alternately used hand-scrubbing or hand-rubbing techniques every two weeks. Fingertip impressions were taken before and immediately after hand disinfection, every 2h and at the end of the operation. Acceptability of hand rubbing was assessed by a questionnaire. Mean durations of surgical procedures were 259+/-68 and 244+/-69min for groups S and R respectively (P=0.43). Bacterial counts immediately after hand disinfection were comparable with the two techniques, but significantly lower in group R at the end of surgery. No differences were observed between the percentages of negative samples taken after 2h, 4h and at the end of surgery between the two groups. Bacterial skin flora reduction immediately after hand disinfection, after 2h and 4h of operating time and at the end of surgery was better in group R, but the difference was not statistically significant. Before surgery, the hand-rubbing method with alcohol solution preceded by hand washing with mild neutral soap is as effective as hand scrubbing to reduce bacterial counts on hands. It decreased the bacterial counts both immediately after hand disinfection and at the end of long cardiothoracic surgical procedures. The acceptability of hand rubbing was excellent and it can be considered to be a valid alternative to the conventional hand-scrubbing protocol.

Genetic diversity and drug resistance mutations in HIV type 1 from untreated patients in Bamako, Mali

OBJECTIVE

To determine the genetic diversity of HIV-1 reverse transcriptase (RT) and protease sequences and the presence of mutations linked to antiretroviral (ARV) resistance in treatment-naive, HIV-1-infected individuals living in Mali.

METHODS

Ninety-eight samples from ARV drug-naive, HIV-1-infected patients were collected in one clinical centre in Bamako, Mali in 2005. RT and protease genes were sequenced in order to perform phylogenetic and resistance analyses.

RESULTS

The most prevalent subtype was CRF02-AG (75% of cases), followed by the CRF06-cpx subtype (20%). Intersubtype recombinants between CRF02-AG, CRF01-AE and CRF06-cpx were also described in 5% of cases. After 4 years of ARV use in Mali, two previously untreated individuals (2%; 95% CI: 0.00-4.77%) were found to have resistant viruses, one with a single nucleoside mutation and one with K103N non-nucleoside reverse transcriptase inhibitor resistance mutation. No evidence of transmitted protease inhibitor resistance mutations was found.

CONCLUSION

These data provide direct evidence for the circulation of HIV-1 isolates containing resistance mutations in treatment-naive patients in Mali. Since ARV use in Mali began, more than 5000 patients have started treatment, mostly with Triomune (stavudine/lamivudine/nevirapine). The resistance-associated mutations detected in the present study are consistent with this treatment regimen. Continued surveillance will be required to monitor the emergence of ARV resistance in this country.

Genetic Diversity and Drug Resistance Mutations in HIV type 1 from Untreated Patients in Bamako, Mali

Objective

To determine the genetic diversity of HIV-1 reverse transcriptase (RT) and protease sequences and the presence of mutations linked to antiretroviral (ARV) resistance in treatment-naive, HIV-1-infected individuals living in Mali.

Methods

Ninety-eight samples from ARV drug-naive, HIV-1-infected patients were collected in one clinical centre in Bamako, Mali in 2005. RT and protease genes were sequenced in order to perform phylogenetic and resistance analyses.

Results

The most prevalent subtype was CRF02-AG (75% of cases), followed by the CRF06-cpx subtype (20%). Intersubtype recombinants between CRF02-AG, CRF01-AE and CRF06-cpx were also described in 5% of cases. After 4 years of ARV use in Mali, two previously untreated individuals (2%; 95% CI: 0.00–4.77%) were found to have resistant viruses, one with a single nucleoside mutation and one with K103N non-nucleoside reverse transcriptase inhibitor resistance mutation. No evidence of transmitted protease inhibitor resistance mutations was found.

Conclusion

These data provide direct evidence for the circulation of HIV-1 isolates containing resistance mutations in treatment-naive patients in Mali. Since ARV use in Mali began, more than 5,000 patients have started treatment, mostly with Triomune (stavudine/lamivu-dine/nevirapine). The resistance-associated mutations detected in the present study are consistent with this treatment regimen. Continued surveillance will be required to monitor the emergence of ARV resistance in this country.

Liquid versus gel handrub formulation: a prospective intervention study

INTRODUCTION

Hand hygiene is one of the cornerstones of the prevention of health care-associated infection, but health care worker (HCW) compliance with good practices remains low. Alcohol-based handrub is the new standard for hand hygiene action worldwide and usually requires a system change for its successful introduction in routine care. Product acceptability by HCWs is a crucial step in this process.

METHODS

We conducted a prospective intervention study to compare the impact on HCW compliance of a liquid (study phase I) versus a gel (phase II) handrub formulation of the same product during daily patient care. All staff (102 HCWs) of the medical intensive care unit participated. Compliance with hand hygiene was monitored by a single observer. Skin tolerance and product acceptability were assessed using subjective and objective scoring systems, self-report questionnaires, and biometric measurements. Logistic regression was used to estimate the association between predictors and compliance with the handrub formulation as the main explanatory variable and to adjust for potential risk factors.

RESULTS

Overall compliance (phases I and II) with hand hygiene practices among nurses, physicians, nursing assistants, and other HCWs was 39.1%, 27.1%, 31.1%, and 13.9%, respectively (p = 0.027). Easy access to handrub improved compliance (35.3% versus 50.6%, p = 0.035). Nurse status, working on morning shifts, use of the gel formulation, and availability of the alcohol-based handrub in the HCW's pocket were independently associated with higher compliance. Immediate accessibility was the strongest predictor. Based on self-assessment, observer assessment, and the measurement of epidermal water content, the gel performed significantly better than the liquid formulation.

CONCLUSION

Facilitated access to an alcohol-based gel formulation leads to improved compliance with hand hygiene and better skin condition in HCWs.

Pseudomonas aeruginosa and Pseudomonas putida outbreak associated with contaminated water outlets in an oncohaematology paediatric unit

This paper describes an outbreak of Pseudomonas aeruginosa and Pseudomonas putida that occurred in an oncohaematology paediatric unit between January and April 2005. Eight children had nosocomial infections due to P. aeruginosa (N=5) or P. putida (N=3), which were recovered from central venous catheter blood cultures (N=4), the catheter exit site alone (N=2), or the catheter exit site and the catheter tip (N=2). Subsequent investigation showed that contaminated water outlets represented the possible source of spread. Studies of nursing and environmental cleaning practices revealed two modes of catheter contamination. A reduction in the size of the catheter dressing at the exit site gave less protective cover during showers, and a detergent-disinfectant diluted with tap water had contaminated perfusion bottles. Repetitive intergenic consensus polymerase chain reaction indicated two discrete patterns for P. aeruginosa and one for P. putida. The water network was chlorinated, and disposable seven-day filters were fitted on all taps and showers. Due to the deleterious effects of chlorination on the water network and the cost of the weekly filter change, a water loop producing microbiologically controlled water was installed. In addition, the concentration of the detergent-disinfectant was increased and refillable sprayers were replaced with ready-to-use detergent-disinfectant solution for high-risk areas. Following these measures, no Pseudomonas spp. have since been isolated in clinical or environmental samples from the ward.

Entérocoques résistant aux glycopeptides dans un contexte endémo-épidémique

OBJECTIVES

To evaluate a strategy based on screening and isolation at admission to a department of infectious diseases during an epidemic of vancomycin-resistant Enterococcus (VRE) at the University Hospital of Clermont-Ferrand.

METHODS

Systematic screening for VRE by anal swabs began on November 15, 2004. Patients were isolated on admission if (a) they had been hospitalized more than 24 h in an at-risk department of our hospital or (b) they had received a course of wide-spectrum antimicrobial therapy for longer than 48 h in the three months preceding admission. Patients hospitalized in our department were screened weekly if they were treated with wide-spectrum antibiotics, had a urinary catheter left in place for one week, or were neutropenic.

RESULTS

Through May 15, 2005, 12 (3.5%) of 341 swabs were found to be positive for VRE: eight were detected on admission and four during hospitalization. In all, 81 patients were isolated on admission. A case-control study confirmed that the criteria for patient isolation were indeed risk factors for VRE. Isolation was well accepted when it was clearly explained. No new case has been detected since March 2005.

CONCLUSION

An isolation strategy based on known risk factors for VRE with systematic screening on admission appears to be an effective way to control an outbreak of VRE, perhaps in part because it helps to keep the medical staff alert to this problem. Isolation is well tolerated as long as it is explained clearly.

Processes of diversification and dispersion of rice yellow mottle virus inferred from large-scale and high-resolution phylogeographical studies

Phylogeography of Rice yellow mottle virus (RYMV) was reconstructed from the coat protein gene sequences of a selection of 173 isolates from the 14 countries of mainland Africa where the disease occurred and from the full sequences of 16 representative isolates. Genetic variation was linked to geographical distribution and not to host species as isolates from wild rice always clustered with isolates from cultivated rice of the same region. Genetic variation was not associated to agro-ecology, viral interference and insect vector species. Distinct RYMV lineages occurred in East, Central and West Africa, although the Central African lineage included isolates from Benin, Togo and Niger at the west, adjacent to countries of the West African lineage. Genetic subdivision at finer geographical scales was apparent within lineages of Central and West Africa, although less pronounced than in East Africa. Physical obstacles, but also habitat fragmentation, as exemplified by the small low-lying island of Pemba offshore Tanzania mainland, explained strain localization. Three new highly divergent strains were found in eastern Tanzania. By contrast, intensive surveys in Cote d'Ivoire and Guinea at the west of Africa did not reveal any new variant. Altogether, this supported the view that the Eastern Arc Mountains biodiversity hotspot was the centre of origin of RYMV and that the virus spread subsequently from east to west across Africa. In West Africa, specific strains occurred in the Inner Niger Delta and suggested it was a secondary centre of diversification. Processes for diversification and dispersion of RYMV are proposed.

Comparison of bacteriophage and enteric virus removal in pilot scale activated sludge plants

AIMS

The aim of this experimental study was to determine comparatively the removal of two types of bacteriophages, a somatic coliphage and an F-specific RNA phage and of three types of enteric viruses, hepatitis A virus (HAV), poliovirus and rotavirus during sewage treatment by activated sludge using laboratory pilot plants.

METHODS AND RESULTS

The cultivable simian rotavirus SA11, the HAV HM 175/18f cytopathic strain and poliovirus were quantified by cell culture. The bacteriophages were quantified by plaque formation on the host bacterium in agar medium. In each experiment, two pilots simulating full-scale activated sludge plants were inoculated with viruses at known concentrations, and mixed liquor and effluent samples were analysed regularly. In the mixed liquor, liquid and solid fractions were analysed separately. The viral behaviour in both the liquid and solid phases was similar between pilots of each experiment. Viral concentrations decreased rapidly following viral injection in the pilots. Ten minutes after the injections, viral concentrations in the liquid phase had decreased from 1.0 +/- 0.4 log to 2.2 +/- 0.3 log. Poliovirus and HAV were predominantly adsorbed on the solid matters of the mixed liquor while rotavirus was not detectable in the solid phase. In our model, the estimated mean log viral reductions after 3-day experiment were 9.2 +/- 0.4 for rotavirus, 6.6 +/- 2.4 for poliovirus, 5.9 +/- 3.5 for HAV, 3.2 +/- 1.2 for MS2 and 2.3 +/- 0.5 for PhiX174.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study demonstrates that the pilots are useful models to assess the removal of infectious enteric viruses and bacteriophages by activated sludge treatment. Our results show the efficacy of the activated sludge treatment on the five viruses and suggest that coliphages could be an acceptable indicator of viral removal in this treatment system.