NosoVeille Bulletin de veille septembre 2009 NosoVeille n9 Septembre 2009 Rdacteurs : Nathalie Sanlaville, Sandrine Yvars, Annie Treyve Ce bulletin de veille est une publication mensuelle qui recueille les publications scientifiques publies au cours du mois coul. La recherche documentaire est effectue dans la base de donnes Pour recevoir, tous les mois, NosoVeille dans votre messagerie : Abonnement / Dsabonnement Sommaire de ce numro Antibiotique Bactrimie Candida Chirurgie Clostridium Dsinfection/Strilisation Entrocoque Environnement Hmodialyse Hpatite Hygine des mains Pdiatrie Personnel Pneumonie Prvention Ranimation Staphylocoque CCLIN Sud-Est cclinse@chu-lyon.fr 1 / 23

NosoVeille Bulletin de veille septembre 2009 Antibiotique NosoBase n 25233 Cellulite orbitaire et endophtalmie endogne secondaire une cholcystite Proteus mirabilis Argelich R; Ibanez-Flores N; Bardavio J; Bures-Jelstrup A; Garcia-Segarra G; Coll-Colell R; et al. Orbital cellulitis and endogenous endophthalmitis secondary to Proteus mirabilis cholecystitis. Diagnostic microbiology and infectious disease. 2009/08; 64(4): 442-444 Mots-cls : ENDOPHTALMIE; OEIL; VESICULE BILIAIRE; PROTEUS MIRABILIS; BACTERIEMIE We report the first case of orbital cellulitis and endogenous endophthalmitis secondary to Proteus mirabilis bacteremia that resulted from a calculus cholecystitis. Despite resolution of the gallbladder infection with antimicrobial therapy, the patient required evisceration of the affected eye. The pathogenesis of hematogenous endophthalmitis due to Gram-negative bacilli is discussed. NosoBase n 24902 Programme national franais pour la prvention des infections nosocomiales et de lantibiorsistance, 1992-2008 : amlioration constate mais ncessit de poursuivre laction Carlet J; Astagneau P; Brun-Buisson C; Coignard B; Salomon V; Tran B; et al. French national program for prevention of healthcare-associated infections and antimicrobial resistance, 1992-2008: positive trends, but perseverance needed. Infection control and hospital epidemiology 2009/08; 30(8): 737-745 Mots-cls : PREVENTION; ANTIBIORESISTANCE; CHIRURGIE; STAPHYLOCOCCUS AUREUS; PREVALENCE Objective: To describe the French program for the prevention of healthcare-associated infections and antibiotic resistance and provide results for some of the indicators available to evaluate the program. In addition to structures and process indicators, the 2 outcome indicators selected were the rate of surgical site infection and the proportion of methicillin-resistant Staphylococcus aureus (MRSA) isolates among the S. aureus isolates recovered. Design: Descriptive study of the evolution of the national structures for control of healthcare-associated infections since 1992. Through national surveillance networks, process indicators were available from 1993 to 2006, surgical site infection rates were available from 1999 to 2005, and prevalence rates for MRSA infection were available from 2001 to 2007. Results: A comprehensive national program has gradually been set up in France during the period from 1993 to 2004, which included strengthening of organized infection control activities at the local, regional, and national levels and developing large networks for surveillance of specific infections and antibiotic resistance. These achievements were complemented by instituting mandatory notification for unusual nosocomial events, especially outbreaks. The second phase of the program involved the implementation of 5 national quality indicators with public reporting. Surgical site infection rates decreased by 25% over a 6-year period. In France, the median proportion of MRSA among S. aureus isolates recovered from patients with bacteremia decreased from 33.4% to 25.7% during the period from 2001 to 2007, whereas this proportion increased in many other European countries. Conclusions: Very few national programs have been evaluated since the Study on the Efficacy of Nosocomial Infection Control. Although continuing efforts are required, the French program appears to have been effective at reducing infection rates. NosoBase n 24911 Epidmiologie de lantibiorsistance de micro-organismes Gram ngatif isols chez des patients hospitaliss dans les services long sjour dun rseau hospitalier multi-tats des USA Lautenbach E; Marsicano R; Tolomeo P; Heard M; Serrano S; Stieritz DD. Epidemiology of antimicrobial resistance among gram-negative organisms recovered from patients in a multistate network of long-term care facilities. Infection control and hospital epidemiology 2009/08; 30(8): 790-793 Mots-cls : EPIDEMIOLOGIE; ANTIBIORESISTANCE; BACTERIE A GRAM-NEGATIF; EHPAD; FLUOROQUINOLONE; ESCHERICHIA COLI CCLIN Sud-Est cclinse@chu-lyon.fr 2 / 23

NosoVeille Bulletin de veille septembre 2009 We identified 1,805 gram-negative organisms in cultures of urine samples obtained over a 10-month period from residents of 63 long-term care facilities. The prevalence of fluoroquinolone resistance in Escherichia coli was 51% (446 of 874 isolates), whereas the prevalences of ceftazidime and imipenem resistance in Klebsiella species were 26% and 6% (84 and 19 of 323 isolates), respectively. The prevalence of resistance varied significantly by facility type, size, and geographic location. NosoBase n 25152 Epoque de rsistance et de slection des antibiotiques Wilcox MH. The tide of antimicrobial resistance and selection International journal of antimicrobial agents. 2009/08; 34(Supplment 3): S6-S10 Mots-cls : ANTIBIORESISTANCE; PRESSION DE SELECTION; CARBAPENEME; STAPHYLOCOCCUS AUREUS; METICILLINO-RESISTANCE; ANTIBIOTIQUE; TIGECYCLINE; CLOSTRIDIUM DIFFICILE The cumulative ecological damage, both to the individual patient and to patient populations, secondary to antibiotic prescribing is increasingly recognised. The impact of antibiotics on pathogens and normal flora should be a criterion for antimicrobial selection. Measures to reduce the use of third-generation cephalosporins and fluoroquinolones should be considered. Increased reliance on carbapenems may accelerate the emergence of extremely resistant isolates, and these antimicrobials should be restricted to key scenarios. There is a clear need for new agents with novel modes of action and low ecological damage potential to treat nosocomial infections. Tigecycline has a spectrum of activity that theoretically may reduce the selection pressure for key nosocomial pathogens, and represents an alternative to carbapenems. Further studies are needed to confirm this potentially low selection pressure. Bactrimie NosoBase n 25191 Evolution de la rsistance aux antibiotiques des isolats sanguins d'Escherichia coli : tude de population, 1998-2007 Al-Hasan MN; Lahr BD; Eckel-Passow JE; Baddour LM. Antimicrobial resistance trends of Escherichia coli bloodstream isolates: a population-based study, 1998-2007. The Journal of antimicrobial chemotherapy 2009/07; 64(1): 169-174 Mots-cls : ANTIBIORESISTANCE; ESCHERICHIA COLI; ANTIBIOTIQUE Background: There have been contradictory results regarding temporal changes in the antimicrobial resistance of Escherichia coli from tertiary care centres. Therefore, we performed a population-based investigation to examine in vitro antimicrobial resistance trends of E. coli bloodstream isolates. Methods: In this retrospective population-based incidence study, we identified 461 unique patients with first episodes of E. coli bloodstream infection (BSI) from 1 January 1998 to 31 December 2007 through microbiology records at the two laboratories in Olmsted County, Minnesota. Logistic regression was used to examine temporal changes in antimicrobial resistance and Poisson regression for changes in incidence rates. Results: The median age of patients with E. coli BSI was 69 years; 306 (66.4%) were female. The ageadjusted incidence rate of E. coli BSI per 100000 person-years was 48.0 (95% CI: 42.5-53.4) in females and 34.0 (95% CI: 28.6-39.6) in males. The urinary tract was the most common primary source of infection (79.8%). During the study period, resistance rates of E. coli bloodstream isolates increased from 32% to 53% for ampicillin, from 23% to 45% for ampicillin/ sulbactam, from 9% to 28% for trimethoprim/ sulfamethoxazole and from 0% to 12% for ciprofloxacin. Resistance rates to carbapenems, cephalosporins and piperacillin/tazobactam remained low and stable. Conclusions: To our knowledge, this is the first population-based study on antimicrobial resistance trends of E. coli bloodstream isolates in the USA. We demonstrated linear trends of increasing resistance among these isolates to three different classes of antimicrobial over the past decade. NosoBase n 25275 Rduction des bactrimies associes une voie centrale chez des patients neutropniques donco- hmatologie grce une surveillance CCLIN Sud-Est cclinse@chu-lyon.fr 3 / 23

NosoVeille Bulletin de veille septembre 2009 Chaberny IF; Ruseva E; Sohr D; Buchholz S; Ganser A; Mattner F; et al. Surveillance with successful reduction of central line-associated bloodstream infections among neutropenic patients with hematologic or oncologic malignancies. Annals of hematology 2009/09; 88(9): 907-912 Mots-cls : SURVEILLANCE; HEMATOLOGIE; BACTERIEMIE; MOELLE OSSEUSE; TRANSPLANTATION; CATHETER VEINEUX CENTRAL; ANALYSE MULTIVARIEE; INCIDENCE; FACTEUR DE RISQUE; ONCOLOGIE To determine nosocomial catheter-associated bloodstream infections (CA-BSIs) and to improve the prevention measures, we performed a prospective surveillance in our hematopoietic stem cell transplantation unit at our university hospital. During the 36-month study period all patients with at least two consecutive neutropenic days (NDs) were included. After the first 18 months the recorded data were analyzed and compared with reference data and were then presented to the clinical staff. An intensive training to improve the handling of central venous lines was performed afterwards. At the end of the last 18- month study period the data were evaluated and a multivariate analysis was conducted. Altogether 268 patients were treated for a period of 10,013 patient days including 4,286 NDs. A total of 202/268 (75.4%) patients underwent transplantation (157/76.6% allogeneic, 48/23.4% autologous). Eighty-seven CA-BSIs were identified. The incidence density was 24.3 CA-BSI episodes per 1,000 NDs in the first period and 16.2 in the second. A significant reduction in the CA-BSI rate of adults was achieved (OR 0.58; 95% CI 0.339.0.987; p23.6 kg/m2; (ii) estimated blood volume loss >810 mL; (iii) presence of postoperative bile leakage of organ/space SSI; and (iv) use of the sliding scale method for postoperative glucose control. There was no observed SSI after liver resection in the group whose postoperative blood glucose levels were controlled by an artificial pancreas. This study reveals that lack of postoperative glycaemic control is associated with a significantly higher incidence of postoperative infectious complications and longer hospitalisation. Obesity and the level of intraoperative estimated blood loss and CCLIN Sud-Est cclinse@chu-lyon.fr 7 / 23

NosoVeille Bulletin de veille septembre 2009 bile leakage after hepatic resection are also risk factors with predictive value for SSI. Artificial pancreas is a safe and beneficial device to perform postoperative strict glycaemic control without hypoglycaemia for patients who undergo hepatic resection for liver diseases. Clostridium NosoBase n 25188 Effets temporels de l'utilisation de l'antibiotique et infections Clostridium difficile Verbaz N; Hill K; Leggeats S; Nathwani D; Philips G; Bonnabry P; et al. Temporal effects of antibiotic use and Clostridium difficile infections. The Journal of antimicrobial chemotherapy 2009/06; 63(6): 1272-1275 Mots-cls : ANTIBIOTIQUE; CLOSTRIDIUM; CEPHALOSPORINE; PENICILLINE; FLUOROQUINOLONE Objectives: We tested a previously published model for the analysis of the temporal relationship between antibiotic use and the incidence of Clostridium difficile infection in a hospital with stable incidence of infection at >1 case per 1000 admissions per month. Methods: The study period was from April 2004 to June 2008 and used data from Infection Control and Hospital Pharmacy. We first described the monthly variation in C. difficile infection and then constructed a multivariate transfer function model that included lag time (cases of C. difficile infection in previous months and delays between changes in antibiotic use and changes in C. difficile infection). Results: The average incidence of C. difficile infection was 1.5 cases per 1000 patients per month with no significant increase over 3 years. The number of cases of C. difficile infection in 1 month was dependent on the average number of cases of C. difficile infection in the previous 2 months. The models with data from the whole hospital showed a statistically significant relationship between the number of both hospital-acquired C. difficile infections and total C. difficile infections and consumption of piperacillin/tazobactam, ciprofloxacin and cefuroxime. The association between C. difficile infection and consumption of co-amoxiclav was only significant for hospital-acquired C. difficile infection. The model for hospital-acquired C. difficile infections explained 61% of the variance in C. difficile infections. Conclusions: These results provide support for antibiotic policies that minimize the use of broad-spectrum penicillins (co-amoxiclav and piperacillin/tazobactam), cephalosporins and fluoroquinolones. Dsinfection/Strilisation NosoBase n 25303 Efficacit de la dsinfection contre les parvovirus compare aux virus de rfrence Eterpi M; Mcdonnell G; Thomas V. Disinfection efficacy against parvoviruses compared with reference viruses. The Journal of hospital infection 2009/09; 73(1): 64-70 Mots-cls : DESINFECTION; VIRUS; PARVOVIRUS; DESINFECTANT; GLUTARALDEHYDE; ACIDE PERACETIQUE; VIRUCIDIE; ETHANOL Some virus species can resist harsh environmental conditions, surviving on surfaces for long periods with the possibility of being transmitted to susceptible hosts. Studies are limited on the efficacy of disinfectants against viruses dried onto surfaces, in particular, with the identification of new pathogenic non-enveloped viruses that are expected to have high resistance to disinfection, such as parvoviruses. In this study a range of commonly used biocides, including heat, was tested against porcine parvovirus (PPV), minute virus of mice (a parvovirus), poliovirus type 1, adenovirus type 5, and vaccinia virus dried onto surfaces. PPV was the most resistant species identified, since many biocides generally considered as effective against non- enveloped viruses and used for high level disinfection demonstrated limited activity. Ethanol had poor activity against all nonenveloped viruses. Effectiveness against these viruses may be important in preventing nosocomial transmission of emerging pathogenic species such as bocavirus and other parvoviruses. This work confirms the need to validate disinfection products against viruses dried onto surfaces and demonstrates that PPV is a particularly resistant surrogate. NosoBase n 24907 Inactivation de prions dorigine humaine et animale par une strilisation par gaz plasma de proxyde dhydrogne CCLIN Sud-Est cclinse@chu-lyon.fr 8 / 23

NosoVeille Bulletin de veille septembre 2009 Rogez-Kreuz C; Yousfi R; Eng M; Soufflet C; Quadrio I; Yan ZX; et al. Inactivation of animal and human prions by hydrogen peroxide gas plasma sterilization. Infection control and hospital epidemiology 2009/08; 30(8): 769-777 Mots-cls : STERILISATION; PRION; PEROXIDE DHYDROGENE Prions cause various transmissible spongiform encephalopathies. They are highly resistant to the chemical and physical decontamination and sterilization procedures routinely used in healthcare facilities. The decontamination procedures recommended for the inactivation of prions are often incompatible with the materials used in medical devices. In this study, we evaluated the use of low-temperature hydrogen peroxide gas plasma sterilization systems and other instrument-processing procedures for inactivating human and animal prions. We provide new data concerning the efficacy of hydrogen peroxide against prions from in vitro or in vivo tests, focusing on the following: the efficiency of hydrogen peroxide sterilization and possible interactions with enzymatic or alkaline detergents, differences in the efficiency of this treatment against different prion strains, and the influence of contaminating lipids. We found that gaseous hydrogen peroxide decreased the infectivity of prions and/or the level of the protease-resistant form of the prion protein on different surface materials. However, the efficiency of this treatment depended strongly on the concentration of hydrogen peroxide and the delivery system used in medical devices, because these effects were more pronounced for the new generation of Sterrad technology. The Sterrad NX sterilizer is 100% efficient (0% transmission and no protease-resistant form of the prion protein signal detected on the surface of the material for the mouse-adapted bovine spongiform encephalopathy 6PB1 strain and a variant Creutzfeldt-Jakob disease strain). Thus, gaseous or vaporized hydrogen peroxide efficiently inactivates prions on the surfaces of medical devices. Entrocoque NosoBase n 24910 Entrocoques rsistants la vancomycine dans des services de long sjour Benenson S; Cohen MJ; Block C; Stern S; Weiss Y; Moses AE. Vancomycin-resistant enterococci in long- term care facilities. Infection control and hospital epidemiology 2009/08; 30(8): 786-789 Mots-cls : ENTEROCOCCUS; VANCOMYCINE; LONG SEJOUR Knowledge of the prevalence rates and associated risk markers of vancomycin-resistant enterococci (VRE) colonization among long-term care facility (LTCF) residents could be used to improve screening policies among newly admitted hospital inpatients. In a cross-sectional survey among 1,215 residents of LTCFs in Jerusalem, the VRE carriage rate was 9.6%. Previous hospitalization and antibiotic treatment were associated with elevated VRE colonization rate. In contrast, moderate and severe levels of dependency and prolonged stay in an LTCF were associated with a decrease in the VRE colonization rate. NosoBase n 25176 Ecologie, pidmiologie et virulence d'Enterococcus Fisher K; Phillips C. The ecology, epidemiology and virulence of Enterococcus. Microbiology 2009/06; 155(6): 1749-1757 Mots-cls : EPIDEMIOLOGIE; ENTEROCOCCUS; ANTIBIORESISTANCE; VANCOMYCINE; BIBLIOGRAPHIE Enterococci are Gram-positive, catalase-negative, non-spore-forming, facultative anaerobic bacteria, which usually inhabit the alimentary tract of humans in addition to being isolated from environmental and animal sources. They are able to survive a range of stresses and hostile environments, including those of extreme temperature (5-65 C), pH (4.5-10.0) and high NaCl concentration, enabling them to colonize a wide range of niches. Virulence factors of enterococci include the extracellular protein Esp and aggregation substances (Agg), both of which aid in colonization of the host. The nosocomial pathogenicity of enterococci has emerged in recent years, as well as increasing resistance to glycopeptide antibiotics. Understanding the ecology, epidemiology and virulence of Enterococcus species is important for limiting urinary tract infections, hepatobiliary sepsis, endocarditis, surgical wound infection, bacteraemia and neonatal sepsis, and also stemming the further development of antibiotic resistance. CCLIN Sud-Est cclinse@chu-lyon.fr 9 / 23

NosoVeille Bulletin de veille septembre 2009 Environnement NosoBase n 25296 Chambres disolement pour les maladies infectieuses hautement pathognes : un inventaire des capacits dans les pays Europens Fusco FM; Puro V; Baka A; Bannister B; Brodt HR; Broupui P; et al. Isolation rooms for highly infectious diseases: an inventory of capabilities in European countries. Journal of hospital infection 2009/09; 73(1): 15-23 Mots-cls : PRECAUTION COMPLEMENTAIRE; CHAMBRE; EUROPE; ENQUETE Isolation of patients with highly infectious diseases (HIDs) in hospital rooms with adequate technical facilities is essential to reduce the risk of spreading disease. The European Network for Infectious Diseases (EUNID), a project co-funded by European Commission and involving 16 European Union member states, performed an inventory of high level isolation rooms (HIRs, hospital rooms with negative pressure and anteroom). In participating countries, HIRs are available in at least 211 hospitals, with at least 1789 hospital beds. The adequacy of this number is not known and will depend on prevailing circumstances. Sporadic HID cases can be managed in the available HIRs. HIRs could also have a role in the initial phases of an influenza pandemic. However, large outbreaks due to natural or to bioterrorist events will need management strategies involving healthcare facilities other than HIRs. NosoBase n 25199 Aspergillose nosocomiale et travaux de construction Haiduven D. Nosocomial aspergillosis and building construction. Medical mycology 2009; 47(Supplment 1): S1-S7 Mots-cls : ASPERGILLUS; TRAVAUX HOSPITALIERS; EPIDEMIE; AIR; CONTROLE Healthcare-associated infections (HAI) with Apergillus pose a serious threat to those most severely immune suppressed patients. Outbreaks of nosocomial aspergillosis have occurred mainly among neutropenic patients, but with several important exceptions. HAI due to aspergillosis has occurred in association with environmental disturbances including but not limited to: hospital construction, maintenance, demolition and renovation; contaminated fireproofing materials; air filters in hospital ventilation systems, and via contaminated carpeting. It behoves those in the practice of patient care to prevent these situations before they occur, as opposed to dealing with them once they happen. The framework of the six links in the infectious disease process will be used to examine healthcare- associated invasive aspergillosis: causative agent, portal of entry, susceptible host, portal of exit, reservoir and mode of transmission. Two particular interventions: the Protective Environment (PE), and the Infection Control Risk Assessment (ICRA), will be outlined. Building construction projects and the number of neutropenic patients are likely to continue to increase. Therefore, future directions need to focus on reducing the susceptibility of the susceptible host and reducing the exposure to Aspergillus from environmental sources. In addition, recently released guidelines with control measures aimed at reducing environmental exposure to Aspergillus need to be further studied. NosoBase n 25297 Changement de la flore bactrienne environnementale dans une nouvelle construction hospitalire Narui K; Noguchi N; Matsunaga N; Namiki Y; Yamanaka Y; Kumaki Y; et al. Change in environmental bacterial flora in a new hospital building. Journal of hospital infection 2009/09; 73(1): 24-33 Mots-cls : ENVIRONNEMENT; TRAVAUX HOSPITALIERS; AIR; SURFACE Microbial surveillance of environmental bacteria was performed in order to study the microbial changes in a newly established hospital building. Airborne bacteria and surface-associated bacteria on floors and sinks were systematically collected between 2002 and 2005. The number of isolates obtained from frequently used floors was significantly higher than that obtained from those floors used less often. A significant increase in Staphylococcus aureus, the appearance of Pseudomonas aeruginosa, and changes among species of Gram-negative bacilli were observed 8e11 months after the new building had been opened. CCLIN Sud-Est cclinse@chu-lyon.fr 10 / 23

NosoVeille Bulletin de veille septembre 2009 Furthermore, pulsed-field gel electrophoresis (PFGE) typing of meticillin-resistant S. aureus (MRSA) and P. aeruginosa showed that strains of the same PFGE groups were isolated from different sinks, floors and the adjoining old buildings. The number of MRSA isolates obtained from the new building increased as time passed. The sinks from which P. aeruginosa strains of the same PFGE type were isolated are connected by the same drainage pipe. Human movement has considerable effects on bacterial flora and their subsequent spread. NosoBase n 25149 Une tude de niveaux de microbes ariens dans diffrents secteurs d'un hpital Ortiz G; Yague G; Segovia M; Catalan V. A study of air microbe levels in different areas of a hospital. Current microbiology 2009/07; 59(1): 53-58 Mots-cls : AIR; MICRO-ORGANISME; ASPERGILLUS; TRAVAUX HOSPITALIERS Airborne transmission is an important route for many microbial pathogens in outdoor and indoor environments, including hospitals. A 2-year-long survey of bioaerosol quality in operating theatres (OT), hospital rooms (HR) and maternity wards (MW) at a hospital in Murcia, Spain, was performed. Total aerobic counts (TAC) and fungal load (FL) were assessed using a microbiological air sampler (MAS-100 single- stage impactor). While fungal levels were below 1 cfu/m3 (0-7.33 cfu/m3) in OT, they were higher in MW (mean, 6.9 cfu/m3; range 0.44-44.67 cfu/m3) and in HR (mean, 10.6 cfu/m3; range, 0-266 cfu/m3). In OT the aerobic counts were considerably higher, with a mean of 25.6 cfu/m3 (range, 1.67-157 cfu/m3). MW and HR also showed higher means for total aerobic counts compared to OT. Seasonal changes were not detected in mould and bacteria levels in OT. Hospital renovation occurred during this study and OT adjacent to renovated areas were closed. A survey of TAC and FL in OT resumed when renovation was completed.We observed an outstanding increase in FL (more than 100 cfu/m3), particularly Aspergillus spp., during this period, but no significant changes in TAC were observed after renovation. NosoBase n 24906 Cas groups de lgionelloses nosocomiales lies la contamination dune fontaine dcorative installe dans un hpital Palmore TN; Stock F; White M; Bordner M; Michelin A; Bennett JE; et al. A cluster of cases of nosocomial legionnaires disease linked to a contaminated hospital decorative water fountain. Infection control and hospital epidemiology 2009/08; 30(8): 764-768 Mots-cls : CONTAMINATION; EAU; LEGIONELLOSE Background: Nosocomial outbreaks of Legionnaires disease have been linked to contaminated water in hospitals. Immunocompromised patients are particularly vulnerable and, when infected, have a high mortality rate. We report the investigation of a cluster of cases of nosocomial pneumonia attributable to Legionella pneumophila serogroup 1 that occurred among patients on our stem cell transplantation unit. Methods: We conducted a record review to identify common points of potential exposure, followed by environmental and water sampling for Legionella species from those sources. We used an air sampler to in an attempt to detect aerosolized Legionella and pulsed-field gel electrophoresis to compare clinical and environmental isolates. Results: The most likely sources identified were the water supply in the patients' rooms and a decorative fountain in the radiation oncology suite. Samples from the patients' rooms did not grow Legionella species. Cultures of the fountain, which had been restarted 4 months earlier after being shut off for 5 months, yielded L. pneumophila serogroup 1. The isolates from both patients and the fountain were identical by pulsed-field gel electrophoresis. Both patients developed pneumonia within 10 days of completing radiation therapy, and each reported having observed the fountain at close range. Both patients' infections were identified early and treated promptly, and both recovered. Conclusions: This cluster was caused by contamination of a decorative fountain despite its being equipped with a filter and ozone generator. Fountains are a potential source of nosocomial Legionnaires disease despite standard maintenance and sanitizing measures. In our opinion, fountains present unacceptable risk in hospitals serving immunocompromised patients. NosoBase n 25117 CCLIN Sud-Est cclinse@chu-lyon.fr 11 / 23

NosoVeille Bulletin de veille septembre 2009 Les cravates et les stylos sont-ils vecteurs d'infections nosocomiales ? Pisipati S; Bassett D; Pearce I. Do neckties and pens act as vectors of hospital-acquired infections? BJU international 2009/06; 103(12): 1604-1605 Mots-cls : PERSONNEL; ENVIRONNEMENT; TRANSMISSION; TENUE VESTIMENTAIRE Hpatite NosoBase n 25285 Evolution dune pidmie patient-patient dhpatite C gnotype 3a Mailliard ME; Capadano ME; Hrnicek MJ; Gilroy RK; Gulizia JM. Outcomes of a patient-to-patient outbreak of genotype 3a hepatitis C. Hepatology 2009/08; 50(2): 361-368 Mots-cls : HEPATITE C; EPIDEMIE; TRANSMISSION SOIGNE-SOIGNE; MORTALITE Between March 2000 and July 2001, at least 99 persons acquired a hepatitis C virus genotype 3a (HCV-3a) infection in an oncology clinic. This nosocomial HCV outbreak provided an opportunity to examine the subsequent clinical course in a well-defined cohort. This was a retrospective/prospective observational study of the short-term significant health outcomes of a large, single-source, patient-to-patient HCV-3a outbreak. Outbreak patients or their legal representatives consenting to study were enrolled between September 2002 and December 2007. We measured history and physical examinations, medical records, HCV serology, HCV RNA and genotype, liver enzymes, histology, response to antiviral therapy, and liver-related morbidity and mortality. Sixty-four of the 99 known HCV-3a outbreak patients participated. During a 6-year period, six patients developed life-threatening complications from liver disease, three died, one received a liver transplant, and two were stable after esophageal variceal banding or diuretic therapy of ascites. Thirty-three patients underwent antiviral therapy, with 28 achieving a sustained viral remission. One patient acquired HCV-3a infection sexually from an outbreak patient and was successfully treated. Eleven study patients died of malignancy, including two that had achieved a sustained viral remission after antiviral therapy. Conclusion: Our patient cohort had a nosocomial source and an oncologic or hematologic comorbidity. Compared with previous HCV outcome studies, a patient-to-patient HCV outbreak in an oncology clinic exhibited significant morbidity and mortality. Attention is needed to the public health risk of nosocomial HCV transmission, emphasizing infection control, early diagnosis, and therapy. Hygine des mains NosoBase n 25338 Inactivation du gluconate de chlorhexidine sur la peau par des gels pour la dsinfection des mains base d'alcool incompatibles Kaiser N; Klein D; Karanja P; Greten Z; Newman J. Inactivation of chlorhexidine gluconate on skin by incompatible alcohol hand sanitizing gels. American journal of infection control 2009; 37(7): 569-573 Mots-cls : CHLORHEXIDINE; PEAU; GEL HYDROALCOOLIQUE; EFFICACITE Incompatibility of leave-on products with an antimicrobial residual can negate the efficacy benefits of chlorhexidine gluconate (CHG) persistence. Two marketed alcohol products containing Carbomer were tested using a pigskin substrate model against Staphylococcus aureus. The CHG residual achieved a 4.22 log10 reduction (standard deviation [SD] 5 0.32) in this study, which was dramatically reduced to a 0.54 (SD 5 0.50) and 0.46 (SD 5 0.56) after subsequent treatment with incompatible alcohol gel products. A marketed alcohol product containing a nonionic thickener maintained the efficacy of the CHG chemical reservoir (log10 reduction5 4.26, SD50.00). Similar findings were demonstrated when alcohol solutions containing the individual thickening agents were tested as simple formulations. An in vivo test using human forearms and Serratia marcescens similarly demonstrated that the activity of a CHG reservoir (log10 reduction 5 3.73, SD 5 0.86) was not reduced by a nonionic thickened product (log10 reduction 5 3.98, SD 5 0.72) but was significantly reduced by treatment with alcohol products containing anionic thickeners carbomer (log10 reduction 5 20.32,SD50.34) or acrylates/C10-30 alkyl acrylate crosspolymer (log10 reduction520.20, SD50.32). The use of anionic thickeners or emulsifiers in leave-on products, including alcohol hand sanitizers, may inactivate the persistent antibacterial activity of CHG. CCLIN Sud-Est cclinse@chu-lyon.fr 12 / 23

NosoVeille Bulletin de veille septembre 2009 NosoBase n 25337 LE-learning peut amliorer ladhrence aux solutions hydro-alcooliques : une tude de cohorte Laustsen S; Bibby BM; Kristensen B; Moller JK; Thulstrup AM. E-learning may improve adherence to alcohol-based hand rubbing : a cohort study. American journal of infection control 2009; 37(7): 565-568 Mots-cls : SOLUTION HYDROALCOOLIQUE; HYGIENE DES MAINS; INFORMATIQUE; FORMATION Background: Since 2004, we have promoted alcohol-based hand rubbing (HR) with an e-learning program (ELP) among hospital staff. This study sought to determine whether an ELP improves adherence to correct HR. Methods: This was a cohort study of staff members at Aarhus University Hospital, Skejby, Denmark who completed the ELP and were repeatedly observed for correct HR before and after clinical procedures in 2006 and/or 2007. Results: Of the 496 participants, 13% completed the ELP in both 2006 and 2007, 29% completed the ELP only in 2006, 15% completed the ELP only in 2007, and 43% never completed the ELP. Compared with non completers, completers of the 2006 and 2007 ELP had a significantly higher adherence to correct HR both before clinical procedures (odds ratio [OR] = 1.54; 95% confidence interval [CI] = 1.11 to 2.13) and after clinical procedures (OR = 1.40; 95% CI = 1.03 to 1.89). Time since completing the ELP seemed to be inversely associated with adherence to correct HR. Conclusion: Completion of an ELP may have a positive impact on the performance of correct HR. The demands of lifelong education and training of hospital staff may call for the use of an ELP as a supplement to existing efforts aimed at improving HR to help prevent health care related infections. Pdiatrie NosoBase n 25223 Infections fongiques invasives dans la population pdiatrique et nonatale : diagnostics et volutions de la prise en charge Arendrup MC; Fisher BT; Zaoutis TE. Invasive fungal infections in the paediatric and neonatal population: diagnostics and management issues Clinical microbiology and infection 2009/07; 15(7): 613-624 Mots-cls : PEDIATRIE; NEONATALOGIE; MYCOLOGIE; DIAGNOSTIC; TRAITEMENT; CANDIDA; EPIDEMIOLOGIE; BIBLIOGRAPHIE Invasive fungal infections in children appear to have increased over the past few decades. Especially neonates and children with primary and secondary immunodeficiencies are at risk. Candida and Aspergillus spp. are the most commonly isolated organisms. In addition, Malassezia may cause systemic infections in newborns and zygomycosis is important because of its rising incidence and high case fatality rate. Timely diagnosis and initiation of appropriate antifungal therapy is imperative for improving outcomes. However, traditional techniques are timeconsuming and representative sample material, using invasive procedures, may be difficult to obtain in the paediatric setting. This review provides an overview of the advances in detection and rapid species identification, with a focus on issues relevant in these settings. Subsequently, the current antifungal treatment options for neonates and children are discussed in light of the antifungal spectrum of the available agents and the specific pharmacokinetic properties in different age groups. Although a multitude of newer antifungal compounds have become available within the last decade, further studies are necessary to clearly establish the role for each of these agents among neonates and children. NosoBase n 25343 Etude pilote destine tudier la frquence de la colonisation et les voies d'acquisition de Staphylococcus aureus par des nouveaux-ns en bonne sant Gries DM; Zemzars TF; Gibson KA; OHern E; Iyer M; Myers M. A pilot study to assess frequency of carriage and routes of acquisition of Staphylococcus aureus by healthy infants. American journal of infection control 2009/09; 37(7): 598-600 Mots-cls : STAPHYLOCOCCUS AUREU; COLONISATION; ETUDE PROSPECTIVE; NEONATALOGIE; PFGE; COLONISATION NASALE; DEPISTAGE CCLIN Sud-Est cclinse@chu-lyon.fr 13 / 23

NosoVeille Bulletin de veille septembre 2009 Personnel NosoBase n 25332 Patient-jour : une meilleure mesure d'incidence des accidents d'exposition au sang Chen LF; Sexton DJ; Kaye KS; Anderson DJ. Patient-days : a better measure of incidence of occupational bloodborne exposures. American journal of infection control 2009; 37(7): 534-540 Mots-cls : INCIDENCE; EXPOSITION AU SANG; PIQURE; EPIDEMIOLOGIE; EFFECTIF Background: There is currently no accepted standard denominator to calculate and to report the incidence of occupational exposures to bloodborne pathogens (OEBBPs) in health care. Methods: We performed a multicenter study of OEBBP injuries reported from 31 community hospitals in the southeastern United States from January 2003 to December 2006. A qualitative design was used to assess 4 commonly used denominators to calculate the incidence of OEBBP: patient-days; staffed beds; occupied beds and full-time employee equivalents (FTEs). Six criteria were used to assess the quality and suitability of each denominator as a standard method to calculate incidence of OEBBP. We also analyzed the correlation of hospital rankings produced by these 4 denominators. Results: During 4 years of study, a total of 3375 occupational exposures were reported. Patient-days outperformed others as a denominator to calculate rates of OEBBP when judged by 6 predefined criteria. Data for staffed beds, occupied beds, and FTE were manually collected, infrequently reported, and often subject to missing data. Furthermore, FTE and staffed beds data also captured unoccupied beds and non- clinical employee data that were not associated with risk of OEBBP. Conclusion: Patient-days may be the most suitable and readily available denominator for standard reporting and benchmarking of incidence of OEBBP. Patient-days may be used as a standard method for comparing rates of OEBBP. NosoBase n 25335 Attitudes et pratiques de la vaccination contre la grippe chez les infirmiers amricains Clark SJ; Cowan AE; Wortley PM; Arbor A. Influenza vaccination attitudes and practices among US registered nurses. American journal of infection control 2009; 37(7): 551-556 Mots-cls : GRIPPE; VACCIN; INFIRMIER; ENQUETE; ATTITUDE Background: The influenza vaccination rate among US health care personnel (HCP) remains low and may vary by occupational categories. The objective of this study was to explore knowledge, attitudes, and beliefs associated with influenza vaccination in a broad population of registered nurses. Methods: The study used a cross-sectional mail survey, administered January-March 2006, of 2000 registered nurses in 4 US states. Results: Of the 2000 surveys sent, 1310 (72%) were returned, and 1017 (67%) were eligible for analysis. The majority of respondents (59%) reported receiving influenza vaccine during the 2005-2006 influenza season. The most common reason for being vaccinated was protecting oneself from illness (95%), and the most common reason for not being vaccinated was concern about adverse reactions (39%). Respondents who reported their patient population as high risk related to influenza were more likely to be vaccinated and to agree with statements regarding influenza disease and influenza vaccination of HCP. Conclusion: Concerns about adverse reactions and vaccine effectiveness continue to be barriers to influenza vaccination among registered nurses. Those most knowledgeable about influenza vaccination of HCP have higher vaccination rates. Future efforts to improve vaccination rates should include data on vaccine effectiveness and adverse effects, as well as descriptions of high-risk populations. NosoBase n 25295 Limpact des facteurs dorganisation et de gestion sur le contrle de linfection dans les hpitaux : revue Griffiths P; Renz JH; Rafferty AM. Impact of organisation and management factors on infection control in hospitals : a scoping review. The Journal of hospital infection 2009/09; 73(1): 1-14 Mots-cls : CONTROLE; PERSONNEL; INFIRMIER; BIBLIOGRAPHIE; ORGANISATION CCLIN Sud-Est cclinse@chu-lyon.fr 14 / 23

NosoVeille Bulletin de veille septembre 2009 This scoping review sought evidence about organisational and management factors affecting infection control in general hospital settings. A literature search yielded a wide range of studies, systematic reviews and reports, but high quality direct evidence was scant. The majority of studies were observational and the standard of reporting was generally inadequate. Positive leadership at ward level and above appears to be a prerequisite for effective action to control infection, although the benefits of good clinical leadership are diffused by supervision of large numbers of staff. Senior clinical leaders need a highly visible presence and clear role boundaries and responsibilities. Team stability and morale are linked to improved patient outcomes. Organisational mechanisms for supporting training, appraisal and clinical governance are important determinants of effective practice and successful change. Rates of infection have been linked to workload, in terms of nurse staffing, bed occupancy and patient turnover. The organisational characteristics identified in the review should be considered risk factors for infection. They cannot always be eliminated or avoided completely, but appropriate assessment will enable targeted action to protect patients. NosoBase n 25288 Connaissances, attitude et couverture vaccinale du personnel de sant pour ce qui concerne les vaccinations professionnelles Loulergue P; Moulin F; Vidal-Trecan G; Absi Z; Demontpion C; Menager C; et al. Knowledge, attitudes and vaccination coverage of healthcare workers regarding occupational vaccinations. Vaccine 2009/06; 27(31): 4240-4243 Mots-cls : VACCIN; PERSONNEL; ATTITUDE; CONNAISSANCE; GRIPPE; VARICELLE; HEPATITE B ; ROUGEOLE; BORDETELLA PERTUSSI; TAUX Objectives: Immunization of healthcareworkers (HCWs) is a major issue for infection control in healthcare facilities. The aim of this study was to evaluate knowledge regarding occupational vaccinations, HBV, varicella and influenza vaccination rates and attitudes towards influenza vaccine among HCWs. Design and setting: A cross-sectional survey was conducted in two wards (Medicine and Paediatrics) of a 1182-bed teaching hospital in Paris, France. Methods: A standardized, anonymous, self-administered questionnaire was used. Results: Of 580 HCWs, 395 (68%) completed the questionnaire. Knowledge about the occupational vaccinations of HCWs was low. HBV (69%), tuberculosis (54%) and influenza (52%) were the most cited vaccinations. Paediatric staff was more aware of influenza and pertussis immunizations (p < .05). HBV vaccination rate was 93%, among whom 65% were aware of their immune status. Influenza vaccination rate for 2006-2007was 30% overall, ranging from 50% among physicians to 20% among paramedical staff (p < . 05). Physicians based their refusal on doubts about vaccine efficacy, although paramedics feared side effects. Influenza vaccination was associated with knowledge of vaccine recommendations [OR = 1.75, 95% CI: 1.13.2.57] and contact with patients [OR = 3.05, 95% CI: 1.50.5.91]. Conclusions: Knowledge of recommended occupational vaccinations is insufficient in HCWs, except for HBV and influenza. Although the HBV vaccine coverage of HCWs is satisfactory, a large proportion of them is unaware of immune status. Influenza vaccine coverage remains low, especially among paramedical staff because of fear of side effects. As vaccine coverage is associated with knowledge, educational campaigns should be strengthened to increase the adhesion of HCWs to vaccinations. NosoBase n 25221 Epidmie de kratoconjonctivites adnovirus chez les internes en mdecine Pantoja Melendez C; Florentino MM; Lopez Martinez I; Lopez HM. Outbreak of epidemic keratoconjunctivitis caused by adenovirus in medical residents. Molecular vision 2009; 15: 557-562 Mots-cls : EPIDEMIE; OEIL; ADENOVIRUS; CONJONCTIVE; PERSONNEL; ETUDIANT Purpose: The present work documents an outbreak of epidemic keratoconjunctivitis among ophthalmology residents, its influence in the presentation of the community cases, the use of molecular techniques for its diagnosis, and the implementation of successful control measures for its containment. Methods: Isolation of the etiologic agent was achieved using cultured African green monkey kidney epithelial cells (VERO). Through molecular tests, such as polymerase chain reaction (PCR) and DNA sequencing, the genotype of the isolated virus was identified. The sequences obtained were aligned with data reported in the NCBI GenBank. A scheme of outbreak control measures was designed to enforce correct sanitary measures CCLIN Sud-Est cclinse@chu-lyon.fr 15 / 23

NosoVeille Bulletin de veille septembre 2009 in the clinic. The statistical program, Epi info 2002, and open Epi were used to determine the attack rate. The Excel Microsoft. program was used to elaborate the endemic channel. Results: Nine of the ten samples studied were isolated from the culture and identified by Adenovirus-specifc PCR.Sequencing allowed identification of Ad8 as the agent responsible for the outbreak. The attack rate was 24.39 cases per 100. The epidemic curve allowed identification of a disseminated source in the Institute of Ophthalmology Conde de Valenciana. It was not possible to calculate the incubation periods among the cases. The endemic channel showed the presence of an epidemic keratoconjunctivitis among the patients that had been cared for at the out-patient services of the institute. Conclusions: One outbreak of a disseminated source caused by Ad8 was detected in the institute among its medical residents, probably associated with relaxation of the habitual sanitary measures during an epidemic of hemorrhagic conjunctivitis among the patients cared for at the institute. The proposed scheme to control the outbreak allowed for its containment and controlled the epidemic of associated cases. NosoBase n 25331 Prvalence et facteurs de risque des blessures percutanes rpertories chez les infirmiers dhospitalisation domicile Robyn R; Gershon M; Pearson JM; Sherman MF; Samar SM; Canton AN; et al. The prevalence and risk factors for percutaneous injuries in registered nurses in the home health care sector. American journal of infection control 2009; 37(7): 525-533 Mots-cls : PREVALENCE Background: Patients continue to enter home health care (HHC) sicker and quicker often with complex health problems that require extensive intervention. This higher level of acuity may increase the risk of percutaneous injury (PI), yet information on the risk and risk factors for PI and other types of exposures in this setting is exceptionally sparse. To address this gap, a large cross-sectional study of self-reported exposures in HHC registered nurses (RNs) was conducted. Methods: A convenience sample of HHC RNs (N5738) completed a survey addressing 5 major constructs: (1) worker-centered characteristics, (2) patient-related characteristics, (3) household characteristics, (4) organizational factors, and (5) prevalence of PIs and other blood and body fluid exposures. Analyses were directed at determining significant risk factors for exposure. Results: Fourteen percent of RNs reported one or more PIs in the past 3 years (7.6 per 100 person-years). Nearly half (45.8%) of all PIs were not formally reported. PIs were significantly correlated with a number of factors, including lack of compliance with Standard Precautions (odds ratio [OR], 1.72; P5.019; 95% confidence interval [CI]: 1.09-2.71); recapping of needles (OR, 1.78; P5.016; 95% CI: 1.11-2.86); exposure to household stressors (OR, 1.99; P5.005; 95% CI: 1.22-3.25); exposure to violence (OR, 3.47; P5.001; 95% CI: 1.67-7.20); mandatory overtime (OR, 2.44; P5.006; 95% CI: 1.27-4.67); and safety climate (OR, 1.88; P5.004; 95% CI: 1.21-2.91) among others. Conclusion: The prevalence of PI was substantial. Underreporting rates and risk factors for exposure were similar to those identified in other RN work populations, although factors uniquely associated with home care were also identified. Risk mitigation strategies tailored to home care are needed to reduce risk of exposure in this setting. NosoBase n 25206 La vignette de l'tudiant : conseils pratiques pour la rdaction d'un cas clinique Scheen AJ; Moonen G. Practical advices for writing a case report. Revue de mdecine lige 2009; 64(7-8): 418-422 Mots-cls : ETUDIANT; RECOMMANDATION; BIBLIOGRAPHIE; MEDECINE Le cas clinique est le type de publication le plus aisment "accessible" l'tudiant en mdecine ou au praticien. La slection du cas clinique qui mrite d'tre rapport reprsente une premire tape importante. Ensuite, la rdaction proprement dite mrite un soin tout particulier, la fois sur le plan du fond et de la forme. Le message principal retenir du cas doit tre mis en exergue et aussi bien argument que possible. L'exercice, difficile au premier abord, constitue un bon entranement pour la rdaction ultrieure d'autres publications scientifiques plus complexes. Nous donnons ici quelques conseils pratiques pour aider l'tudiant en mdecine ou le praticien qui dsirerait prsenter ou publier un cas clinique. CCLIN Sud-Est cclinse@chu-lyon.fr 16 / 23

NosoVeille Bulletin de veille septembre 2009 NosoBase n 25336 Une chelle pour mesurer le comportement d'hygine : dveloppement, fiabilit et validit Stevenson RJ; Case TI; Hodgson D; Porzig-Drummond R; Barouei J; et al. A scale for measuring hygiene behavior : development, reliability and validity. American journal of infection control 2009; 37(7): 557-564 Mots-cls : ATTITUDE; ENQUETE; USAGER; HYGIENE CORPORELLE; HYGIENE DES MAINS Background: There is currently no general self-report measure for assessing hygiene behavior. This article details the development and testing of such a measure. Methods: In studies 1 to 4, a total of 855 participants were used for scale and subscale development and for reliability and validity testing. The latter involved establishing the relationships between self-reported hygiene behavior and existing measures, hand hygiene behavior, illness rates, and a physiological marker of immune function. In study 5, a total of 507 participants were used to assess the psychometric properties of the final revised version of the scale. Results: The final 23-item scale comprised 5 subscales: general, household, food-related, handwashing technique, and personal hygiene. Studies 1 to 4 confirmed the scales reliability and validity, and study 5 confirmed the scales 5-factor structure. Conclusions: The scale is potentially suitable for multiple uses, in various settings, and for experimental and correlational approaches. Pneumonie NosoBase n 25192 Mise jour sur le traitement des pneumonies Pseudomonas aeruginosa El Solh AA; Alhajhusain A. Update on the treatment of Pseudomonas aeruginosa pneumonia. The Journal of antimicrobial chemotherapy 2009/08; 64(2): 229-238 Mots-cls : PSEUDOMONAS; PNEUMONIE; TRAITEMENT; ANTIBIOTIQUE; CARBAPENEME; AEROSOL Pseudomonas aeruginosa is an important cause of nosocomial pneumonia associated with a high morbidity and mortality rate. This bacterium expresses a variety of factors that confer resistance to a broad array of antimicrobial agents. Empirical antibiotic therapy is often inadequate because cultures from initial specimens grow strains that are resistant to initial antibiotics. Surveillance data, hospital antibiogram and individualization of regimens based on prior antibiotic use may reduce the risk of inadequate therapy. The use of combination therapies for P. aeruginosa pneumonia has been a long-advocated practice, but the potential increased value of combination therapy over monotherapy remains controversial. Doripenem and biapenem are new carbapenems that have excellent activity against P. aeruginosa; however, they lack activity against strains that express resistance to the currently available carbapenems. The polymyxins remain the most consistently effective agents against multidrug-resistant P. aeruginosa. Strains that are panantibiotic-resistant are rare, but their incidence is increasing. Antibiotic combinations that yield some degree of susceptibility in vitro are the recourse, although the efficacy of these regimens has yet to be established in clinical studies. Experimental polypeptides may provide a new therapeutic approach. Among these, the anti-PcrV immunoglobulin G antibody that blocks the type III secretion system-mediated virulence of P. aeruginosa has recently entered Phase I/II clinical trials. NosoBase n 25140 Pneumonies prcoces et tardives : est-ce toujours une classification utile ? Gastmeier P; Sohrr D; Geffers C; Ruden H; Vonberg RP; Welte T. Early- and late-onset pneumonia: is this still a useful classification? Antimicrobial agents and chemotherapy 2009/07; 53(7): 2714-2718 Mots-cls : PNEUMONIE; KLEBSIELLA; KLEBESIELLA PNEUMONIAE; STAPHYLOCOCCUS AUREUS; PSEUDOMONAS AERUGINOSA; ESCHERICHIA COLI The choice of empirical treatment of nosocomial pneumonia in the intensive-care unit (ICU) used to rely on the interval after the start of mechanical ventilation. Nowadays, however, the question of whether in fact there is a difference in the distribution of causative pathogens is under debate. Data from 308 ICUs from the German National Nosocomial Infection Surveillance System, including information on relevant pathogens CCLIN Sud-Est cclinse@chu-lyon.fr 17 / 23

NosoVeille Bulletin de veille septembre 2009 isolated in 11,285 cases of nosocomial pneumonia from 1997 to 2004, were used for our evaluation. Each individual pneumonia case was allocated either to early- or to late-onset pneumonia, with three differentiation criteria: onset on the 4th day, the 5th day, or the 7th day in the ICU. The frequency of pathogens was evaluated according to these categories. A total of 5,066 additional cases of pneumonia were reported from 2005 to 2006, after the CDC criteria had been modified. From 1997 to 2004, the most frequent microorganisms were Staphylococcus aureus (2,718 cases, including 720 with methicillin [meticillin]-resistant S. aureus), followed by Pseudomonas aeruginosa (1,837 cases), Klebsiella pneumoniae (1,305 cases), Escherichia coli (1,137 cases), Enterobacter spp. (937 cases), streptococci (671 cases), Haemophilus influenzae (509 cases), Acinetobacter spp. (493 cases), and Stenotrophomonas maltophilia (308 cases). The order of the four most frequent pathogens (accounting for 53.7% of all pathogens) was the same in both groups and was independent of the cutoff categories applied: S. aureus was first, followed by P. aeruginosa, K. pneumoniae, and E. coli. Thus, the predictabilities of the occurrence of pathogens were similar for the earlier (1997-to-2004) and later (2005-to-2006) time frames. This classification is no longer helpful for empirical antibiotic therapy, since the pathogens are the same for both groups. NosoBase n 25271 Une altration de la dose feedback affecte significativement la probabilit d'radication des agents pathognes dans les pneumonies nosocomiales Scaglione F; Esposito S; Leone S; Lucini V; Pannacci M; Ma L; et al. Feedback dose alteration significantly affects probability of pathogen eradication in nosocomial pneumonia. European respiratory journal 2009/08; 34(2): 394-400 Mots-cls : PNEUMONIE; ANTIBIOTIQUE; CME; AMINOSIDE; BETALACTAMINE; FLUOROQUINOLONE Nosocomial pneumonia (NP) is associated with considerable morbidity and mortality. Data have shown that inadequate initial antibiotic therapy is a major risk for infection attributed mortality. The aim of the present study was to measure antibiotic concentration and minimum inhibitory concentration (MIC) in infected hospitalised patients early in therapy, in order to determine whether dose alterations, in those with low drug concentrations, could affect outcomes. Only patients treated with aminoglycosides, fluoroquinolones, and b- lactams were evaluated. MICs were determined using standard National Committee for Clinical Laboratory Standards procedures. Antibiotics were assayed using validated high-performance liquid chromatographic methods. Pharmacokinetic/pharmacodynamic markers adopted were: aminoglycoside peak/MIC ratio o8 mgL-1; fluoroquinolone peak/MIC o10 mgL-1; b-lactam peak/MIC o4 mgL-1 and time that plasma levels remain above the MIC o70%. 638 patients with NP were included in the study. In 205 patients, both drug concentration and isolate MIC were available, while in other patients, used as controls, one or both parameters were lacking. For clinical outcome, the Acute Physiology and Chronic Health Evaluation II score (p,0.0001), the presence of combination therapy (p50.0014) and whether both MIC and drug concentration(s) were measured (p50.0002) significantly affected the probability of a good outcome. For microbiological outcome, the MIC for the b-lactams (f2 mg?L-1; p,0.0001) and whether the second drug was a fluoroquinolone or aminoglycoside (fluoroquinolones were better than aminoglycosides; p50.0177), as well as whether both MIC and drug concentration(s) were measured (p50.02), affected the probability of eradication. Measurement of drug concentrations and determination of pathogen MIC values with subsequent dose alteration significantly improves the probability of good clinical outcome and pathogen eradication in NP. NosoBase n 24905 Analyse cot-efficacit de lutilisation de sondes endotrachales imprgnes dargent pour rduire lincidence des pneumonies acquises sous ventilation Shorr AF; Zilberberg MD; Kollef M. Cost-effectiveness analysis of a silver-coated endotracheal tube to reduce the incidence of ventilator-associated pneumonia. Infection control and hospital epidemiology 2009/08; 30(8): 759-763 Mots-cls : COUT; INCIDENCE; PNEUMONIE; VENTILATION Objective: To conduct a cost-effectiveness analysis of the economic outcomes of ventilator-associated pneumonia (VAP) prevention associated with silver-coated endotracheal tubes versus uncoated endotracheal tubes. CCLIN Sud-Est cclinse@chu-lyon.fr 18 / 23

NosoVeille Bulletin de veille septembre 2009 Design: We used a simple decision model based on a hypothetical 1,000-patient cohort intubated with silver- coated or uncoated endotracheal tubes. The primary end point was marginal hospital savings per case of VAP prevented (savings from using silver-coated endotracheal tubes minus acquisition cost divided by number of VAP cases prevented). Methods: We followed each branch of the decision model to VAP or no VAP and conducted Monte Carlo simulations and sensitivity analyses. Inputs for VAP incidence, relative risk reduction, and hospital costs were derived from publicly available sources. Relative risk reduction was derived from the pivotal study of the silver-coated endotracheal tube. Results: In the base-case analysis, we reduced the pivotal study relative risk in incidence of microbiologically confirmed VAP in patients intubated 24 hours from 35.9% to 24%. Thus, 23 of 97 expected cases of VAP could be prevented with silver-coated endotracheal tubes. The savings per case of VAP prevented was $12,840 in the base case, with assumed marginal VAP cost of $16,620 and costs of $90.00 for coated and $2.00 for uncoated endotracheal tubes. Estimates were most sensitive to assumptions regarding VAP cost and relative risk reduction with silver-coated endotracheal tubes. Nonetheless, in multivariate sensitivity analyses, the silver-coated endotracheal tubes yielded persistent savings (95% confidence interval, $9,630-$16,356) per case of VAP prevented. With other base-case inputs held constant, break-even cost for silver-coated endotracheal tubes was $388. Conclusions: The silver-coated endotracheal tube represents a strategy for preventing VAP that may yield hospital savings. Prvention NosoBase n 25417 Circulaire DHOS/E2/DGS/RI/ 2009-272 du 26 aot 2009 relative la mise en oeuvre du programme national de prvention des infections nosocomiales 2009/2013 Ministre de la sant et des sports, Direction de lhospitalisation et de lorganisation des soins. Non parue au Journal ofiiciel, 32 pages. Mots-cls : PREVENTION; INDICATEUR; QUALITE; SOIN; SURVEILALNCE; USAGER; MULTIRESISTANCE; INFORMATION; SIGNALEMENT; EVALUATION; EOH; HYGIENE DES MAINS Le programme national de prvention des infections nosocomiales 2009-2013 repose sur six orientations : 1 . Promouvoir une culture partage de qualit et scurit des soins 2 . Optimiser le recueil et lutilisation des donnes de surveillance 3 . Anticiper et dtecter lmergence dagents pathognes potentiel pidmique 4 . Maintenir lusager au centre du dispositif 5 . Amliorer lorganisation du dispositif de prvention des infections nosocomiales 6 . Promouvoir la recherche sur les infections nosocomiales Il dfinit des objectifs atteindre tant au plan national quau niveau des tablissements de sant. Leur ralisation sera value en fin de programme, sur les donnes recueillies pour lanne 2012. NosoBase n 25329 Circulaire interministrielle DGS/DHOS/DGAS 2009-264 du 19 aot 2009 relative la mise en oeuvre du plan stratgique national 2009-2013 de prvention des infections associes aux soins Ministre de la sant et des sports, Ministre du travail, des relations sociales, de la famille, de la solidarit et de la ville, Direction gnrale de la sant, et al. Non parue au Journal officiel, 39pages. Mots-cls : PREVENTION; STRUCTURE DE SOINS; MEDECINE GENERALE; SIGNALEMENT; MULTIRESISTANCE; ABTIBIOTIQUE; CCLIN; ARLIN; INDICATEUR; TABLEAU DE BORD; EVALUATION Le plan stratgique national 2009-2013 de prvention des infections associes aux soins (IAS) dfinit la stratgie nationale en fixant le cadre de la prvention des IAS au niveau national, rgional et local. Il comprend les modalits dorganisation et les actions structurantes de ces diffrents niveaux. Il couvre les trois secteurs de soins : tablissements de sant, tablissements mdicosociaux et soins de ville. Le plan se structure autour de trois axes : 1 . dvelopper une politique globale de prvention des IAS, prenant en compte les spcificits sectorielles et territoriales ; 2 . mobiliser les acteurs sur la prvention et la matrise des IAS ; CCLIN Sud-Est cclinse@chu-lyon.fr 19 / 23

NosoVeille Bulletin de veille septembre 2009 3 . agir sur les dterminants du risque infectieux associ aux soins. Ranimation NosoBase n 25280 Contamination d'un quipement de radiographie portable avec une bactrie rsistante dans un service de ranimation Levin PD; Shatz O; Sviri S; Moriah D; Or-Barbash A; Sprung CL; et al. Contamination of portable radiograph equipment with resistant bacteria in the ICU. Chest 2009/08; 136(2): 426-432 Mots-cls : CONTAMINATION; SOIN INTENSIF; RADIOLOGIE; OBSERVANCE; BACILLE GRAM NEGATIF; GANT Background: Approximately 15% of nosocomial infections in the ICU result from spread of bacteria on caregivers. hands. The routine chest radiograph provides an unexamined opportunity for bacterial spread: close contact with each patient and sequential examination of ICU patients. This study examined infection control procedures performed during routine chest radiographs, assessed whether resistant bacteria were transferred to the radiograph machine, and determined whether improved infection control practices by radiograph technicians could reduce bacterial transfer. Methods: Radiograph technicians were observed performing chest radiographs on all ICU patients. Culture specimens were taken from the radiograph machine. An educational intervention directed at technicians was instituted, and its effect on infection control and machine contamination was measured. Results: Surveillance of 173, 113, and 120 chest radiographs during observation, intervention, and follow-up periods was performed. Adequate infection control was practiced during the performance of 2 of 173 observation period radiographs (1%), 48 of 113 intervention period radiographs (42%; p < 0.001), and 12 of 120 follow-up period radiographs (10%; (p < 0.001) [follow-up vs intervention and observation periods]. Radiograph machine surface culture samples yielded resistant Gramnegative bacteria on 12 of 30 occasions (39%), 0 of 29 occasions, and 7 of 14 occasions (50%), respectively, for the observation, intervention, and follow-up periods (p < 0.001). Conclusion: Multiresistant bacteria are frequently transferred from patients to the radiograph machine in the presence of poor infection control practices, and may be a source of cross-infection/colonization. Improved infection control practices decrease the occurrence of resistant organisms on the radiograph equipment. Radiograph technicians should be included in efforts to improve infection control measures. NosoBase n 25286 Infections virales rares et communes en ranimation. Relier la physiopathologie la prsentation clinique Stollenwerk N; Harper RW; Sandrock CE. Bench-to-bedside review: rare and common viral infections in the intensive care unit - linking pathophysiology to clinical presentation. Critical care 2009/07; 12(4): 9 pages. (Epub) Mots-cls : SOIN INTENSIF; GRIPPE; VIRUS; APPAREIL RESPIRATOIRE; PNEUMOVIRUS; SRAS; HERPES ZOSTER VIRUS; ADENOVIRUS; CYTOMEGALVIRUS; FIEVRE HEMORRAGIQUE Viral infections are common causes of respiratory tract disease in the outpatient setting but much less common in the intensive care unit. However, a finite number of viral agents cause respiratory tract disease in the intensive care unit. Some viruses, such as influenza, respiratory syncytial virus (RSV), cytomegalovirus (CMV), and varicella-zoster virus (VZV), are relatively common. Others, such as adenovirus, severe acute respiratory syndrome (SARS)-coronavirus, Hantavirus, and the viral hemorrhagic fevers (VHFs), are rare but have an immense public health impact. Recognizing these viral etiologies becomes paramount in treatment, infection control, and public health measures. Therefore, a basic understanding of the pathogenesis of viral entry, replication, and host response is important for clinical diagnosis and initiating therapeutic options. This review discusses the basic pathophysiology leading to clinical presentations in a few common and rare, but important, viruses found in the intensive care unit: influenza, RSV, SARS, VZV, adenovirus, CMV, VHF, and Hantavirus. Staphylocoque CCLIN Sud-Est cclinse@chu-lyon.fr 20 / 23

NosoVeille Bulletin de veille septembre 2009 NosoBase n 24908 Un programme pour matriser les infections Staphylococcus aureus rsistant la mticilline dans un centre hospitalier : un suivi de 5 ans Chowers MY; Paitan Y; Gottesman BS; Gerber B; Ben-Nissan Y; Shitrit P. Hospital-wide methicillin-resistant Staphylococcus aureus control program: a 5-year follow-up. Infection control and hospital epidemiology 2009/08; 30 (8): 778-781 Mots-cls : STAPHYLOCOCCUS AUREUS; METICILLINO-RESISTANCE; SURVEILLANCE; BACTERIEMIE We investigated the influence of different interventions (active surveillance, contact isolation, monitoring, and rapid diagnostic testing) on the number of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia cases. An interrupted time-series analysis was used. MRSA bacteremia cases were reduced by 70% when all interventions were in place. We proved monitoring to be an essential component. NosoBase n 25341 La clinique du pied diabtique : ne constitue pas une source significative dacquisition de Staphylococcus aureus rsistant la mticilline Lagace-Wiens P; Ormiston D; Nicolle LE; Hilderman T; Embil J. The diabetic foot clinic : not a significant source for acquisition of methicillin-resistant Staphylococcus aureus. American journal of infection control 2009, 37(7): 587-589 Mots-cls : DIABETE; STAPHYLOCOCCUS AUREUS; METICILLINO-RESISTANCE; EPIDEMIOLOGIE; INCIDENCE; TRANSMISSION; ELECTROPHORESE EN CHAMP PULSE; ETUDE RETROSPECTIVE Background: Diabetic foot clinics have been reported as a source of acquisition of methicillin-resistant Staphylococcus aureus (MRSA). We undertook a 10-year review of patients infected or colonized with MRSA from a tertiary care hospital diabetic foot clinic and describe the epidemiology and genotypes of newly acquired MRSA in comparison with the community at large. Methods: All new MRSA cases from the diabetic foot clinic, the hospital, and the province were reviewed to identify and compare the 10-year trend in MRSA incidence. Pulsed-field gel electrophoresis using SmaI of all clinic isolates was performed, and standard genotypes were assigned to assess the genetic heterogeneity of MRSA in the clinic. Results: Analysis of trends revealed a low-potential, clinic-attributable incidence and a total clinic incidence that was comparable with regional and hospital MRSA rates. Strains recovered from clinic patients were genetically heterogeneous. Conclusion: Our 10-year analysis of trends in MRSA acquisition and MRSA genotypes data does not support significant transmission of MRSA in this clinic setting. NosoBase n 25196 Evolution de lincidence des infections Staphylococcus aureus mticillino-rsistant de survenue tardive dans des units de ranimation nonatale. Donnes du rseau national de surveillance des infections nosocomiales, 1995-2004 Lessa FC; Edwards JR; Fridkin SK; Tenover FC; Horan TC; Gorwitz RJ. Trends in incidence of late-onset methicillin-resistant Staphylococcus aureus infection in neonatal intensive care units. Data from the national nosocomial infections surveillance system, 1995-2004. The Pediatric infectious disease journal 2009/07; 28 (7): 577-581 Mots-cls : INCIDENCE; STAPHYLOCOCCUS AUREUS; METICILLINO-RESISTANCE; SOIN INTENSIF; SURVEILLANCE; NEONATALOGIE ; RESEAU Background: Methicillin-resistant Staphylococcus aureus (MRSA) is increasingly being reported to cause outbreaks in neonatal intensive care units (NICUs). We assessed the scope and magnitude of MRSA infections with disease onset after 3 days of age (late-onset MRSA infections) in NICUs. Methods: We analyzed data reported by NICUs participating in the National Nosocomial Infections Surveillance system from 1995 through 2004. For each surveillance month, all healthcare-associated infections as defined by National Nosocomial Infections Surveillance criteria were reported, along with CCLIN Sud-Est cclinse@chu-lyon.fr 21 / 23

NosoVeille Bulletin de veille septembre 2009 antimicrobial susceptibility patterns of the isolates. We pooled the data from all NICUs by birth weight category and calendar year. Poisson regression was used to assess changes in incidence of late-onset MRSA infections per 10,000 patient-days. Results: Overall, 149 NICUs reported 4831 S. aureus infections and 5,878,139 patient-days. Methicillin testing data were available for 4302 S. aureus isolates, of which 975 (23%) were MRSA. Incidence of late- onset MRSA infection per 10,000 patient-days, combining all birthweight categories, increased 308% from 0.7 in 1995 to 3.1 in 2004 (P 0.001). A significant increase in incidence of MRSA infections was observed among all 4 birthweight categories analyzed separately (1000 g, 1001.1500 g, 1501.2500 g, and 2500 g). The distribution of MRSA infection by type of infection did not vary during the study period; 299 (31%) of MRSA infections were bloodstream infections, 174 (18%) were pneumonia, and 161 (17%) were conjunctivitis. Conclusion: The incidence of late-onset MRSA infections increased substantially between 1995 and 2004, indicating a need to reinforce infection control recommendations and to explore potential sources and routes of transmission. NosoBase n 25207 Staphylococcus pidermidis - le pathogne "accidentel" Otto M. Staphylococcus epidermidis - the "accidental" pathogen. Nature reviews Microbiology 2009/08; 7 (8): 555-567 Mots-cls : STAPHYLOCOCCUS; BIOFILM; ANTIBIORESISTANCE; BIBLIOGRAPHIE Although nosocomial infections by Staphylococcus epidermidis have gained much attention, this skin- colonizing bacterium has apparently evolved not to cause disease, but to maintain the commonly benign relationship with its host. Accordingly, S. epidermidis does not produce aggressive virulence determinants. Rather, factors that normally sustain the commensal lifestyle of S. epidermidis seem to give rise to additional benefits during infection. Furthermore, we are beginning to comprehend the roles of S. epidermidis in balancing the epithelial microflora and serving as a reservoir of resistance genes. In this Review, I discuss the molecular basis of the commensal and infectious lifestyles of S. epidermidis. NosoBase n 25340 Une investigation des facteurs de risque dinfection Staphylococcus aureus mticillino-rsistant chez les patients dans une unit de ranimation nonatale SakakI H; Nishioka M; Kanda K; Takahashi Y. An investigation of the risk factors for infection with methicillin- resistant Staphylococcus aureus among patients in a neonatal intensive care unit. American journal of infection control 2009; 37(7): 580-586 Mots-cls : SOIN INTENSIF; STAPHYLOCOCCUS AUREUS Background: The aims of this study were to investigate the risk factors of methicillin-resistant Staphylococcus aureus (MRSA) infection among infants to establish effective infection control measures for neonatal intensive care unit (NICU). Methods: Data were prospectively collected from 961 infants hospitalized in a teaching hospital in Japan, from July 2002 through December 2005. Results: Among all infants, 28 (2.9%) developed MRSA infections. Multivariate logistic regression analyses demonstrated the risk factors for developing MRSA infections to include a low birth weight (odds ratio [OR], 0.91; 95% confidence interval [CI]: 0.93-0.99), the presence of eye mucous (OR, 6.78; 95% CI: 2.87-16.01), the practice of kangaroo mother care (OR, 3.82; 95% CI:1.11-13.13), and the MRSA colonization rate (OR, 11.12; 95% CI: 1.32-93.89). Conclusion: The risk factors for developing a MRSA infection among infants in NICU were a low birth weight, the presence of eye mucous, the practice of kangaroo mother care, and a high MRSA colonization rate. Therefore, extra attention should be given to infants in high-risk groups demonstrating a low birth weight and the presence of eye mucous and who have undergone kangaroo mother care. As a result, the cohort isolation of infants with MRSA may therefore be an effective strategy to prevent MRSA infections. NosoBase n 25346 CCLIN Sud-Est cclinse@chu-lyon.fr 22 / 23

NosoVeille Bulletin de veille septembre 2009 Survie de Staphylococcus et dautres bactries dans des solutions dallergnes pour prick-tests cutans Veillette M; Cormier Y; Duchaine C. Survival of Staphylococcus aureus and other bacteria in skin prick test antigens solutions. American journal of infection control 2009; 37(7): 606-608 Mots-cls : STAPHYLOCOCCUS; PCR; COLONISATION; ALLERGIE Background: Skin prick tests are commonly used for human allergy testing and determination. Because solutions are kept at 4C and patients skin is cleaned, the same solutions are used on many patients with the same applicators without sterilization. Objectives: Our objectives were to determine whether a model bacteria could survive in antigen solutions and whether bacteria from patients skin could be found in clinical antigen solutions. Methods: Unused antigen solutions were spiked using Staphylococcus epidermidis. Concentration was followed from time = 0 to time = 21 days. Clinical samples consisted of antigen solutions used on a daily basis, from different hospital centers (n = 146). These were tested for total bacterial counts and detection of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycinresistant Enterococci. Isolates were identified by 16S rDNA sequencing. Results: The concentration of S epidermidis remained stable over the 21 days. Twenty-three percent of the clinical antigen solutions contained bacteria. As expected, species like S aureus, S hominis, S epidermidis, and Micrococcus luteus were highly represented (62.5%) within a total of 20 different species. Conclusion: Skin bacteria can survive in antigen solutions used in skin prick tests. Moreover, even if no MRSA were observed in field samples, nosocomial infections could be a concern if pathogens were present on the skin of some tested patients. NosoBase n 25216 Comparaison des taux de colonisation de Staphylococcus aureus producteurs de slime sur les revtements de sol en vinyl et les carrelages en cramique Yazgi H; Ayyildiz A. Comparison of slime-producing coagulase-negative Staphylococcus colonization rates on vinyl and ceramic tile flooring materials. The Journal of international medical research 2009/06; 37(3): 668-673 Mots-cls : STAPHYLOCOQUE A COAGULASE NEGATIVE; COLONISATION; REVETEMENT; SURFACE; TAUX This study investigated the colonization of slime-producing coagulase-negative Staphylococcus (CoNS) in 80 patient wards in Turkey (40 vinyl and 40 ceramic tile floors). A total of 480 samples that included 557 CoNS isolates were obtained. Slime production was investigated with the Christensen method and methicillin-susceptibility was tested by the disk-diffusion method. There was a significant difference in the percentage of slime-producing CoNS isolates on vinyl (12,4 %) versus ceramic tile flooring (4,5 %). From vinyl flooring, the percentage of slime producing methicillin-resistant CoNS (MRCoNs) (8,9 %) was significantly higher than for methicillin-sensitive CoNS (MSCoNs) (3,6 %), whereas there was no difference from ceramic tile flooring (2,5 % MRCoNs versus 1,8 % MSCoNS). The most commonly isolated slime- producing CoNS species was S. epidermidis on both types of flooring. It is concluded that vinyl flooring seems to be a more suitable colonization surface for slime-producing CoNS than ceramic tile floors. Further studies are needed to investigate bacterial strains colonized on flooring materials, which are potential pathogens for nosocomial infections. CCLIN Sud-Est cclinse@chu-lyon.fr 23 / 23