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Biomedical subjects

D Pittet

Publications and source records attributed to D Pittet.

At least 19 recordsLinked to original sources
PubMed2006

Behavioural considerations for hand hygiene practices: the basic building blocks.

Hand hygiene is considered to be the most effective measure to prevent microbial pathogen cross-transmission and healthcare-associated infections. In October 2005, the World Health Organization (WHO) World Alliance for Patient Safety launched the first Global Patient Safety Challenge 2005-2006, 'Clean Care is Safer Care', to tackle healthcare-associated infection on a large scale. Within the Challenge framework, international infection control experts and consultative taskforces met to develop new WHO Guidelines on Hand Hygiene in Healthcare. The taskforce was asked to explore aspects underlying hand hygiene behaviour that may influence its promotion among healthcare workers. The dynamics of behavioural change are complex and multi-faceted, but are of vital importance when designing a strategy to improve hand hygiene compliance. A reflection on challenges to be met and areas for future research are also proposed.

Attitude of Health Personnel↗
PubMed2006

Control of a cluster of community-associated, methicillin-resistant Staphylococcus aureus in neonatology.

To control an outbreak of community-associated MRSA (CA-MRSA) in a neonatology unit, an investigation was conducted that involved screening neonates and parents, molecular analysis of MRSA isolates and long-term follow-up of cases. During a two-month period in the summer of 2000, Panton-Valentine leukocidin (PVL)-producing CA-MRSA (strain ST5-MRSA-IV) was detected in five neonates. The mother of the index caseshowed signs of mastitis and wound infection and consequently tested positive for CA-MRSA. A small cluster of endemic, PVL-negative MRSA strains (ST228-MRSA-I) occurred in parallel. Enhanced hygiene measures, barrier precautions, topical decolonization of carriers, and cohorting of new admissions terminated the outbreak. Four months after the outbreak, the mother of another neonate developed furunculosis with the epidemic CA-MRSA strain. One infant had persistent CA-MRSA carriage resulting in skin infection in a sibling four years after the outbreak. In conclusion, an epidemic CA-MRSA strain was introduced by the mother of the index case. This spread among neonates and was subsequently transmitted to another mother and a sibling. This is the first report of a successfully controlled neonatology outbreak of genetically distinct PVL-producing CA-MRSA in Europe.

Adult↗
PubMed2006

Primary invasive aspergillosis of the digestive tract: report of two cases and review of the literature.

BACKGROUND: Disseminated aspergillosis is thought to occur as a result of vascular invasion from the lungs with subsequent bloodstream dissemination, and portals of entry other than sinuses and/or the respiratory tract remain speculative. METHODS: We report two cases of primary aspergillosis in the digestive tract and present a detailed review of eight of the 23 previously-published cases for which detailed data are available. RESULTS AND CONCLUSION: These ten cases presented with symptoms suggestive of typhlitis, with further peritonitis requiring laparotomy and small bowel segmental resection. All cases were characterized by the absence of pulmonary disease at the time of histologically-confirmed gastrointestinal involvement with vascular invasion by branched Aspergillus hyphae. These cases suggest that the digestive tract may represent a portal of entry for Aspergillus species in immunocompromised patients.

Aged↗
PubMed2005

Lack of effect of combination antibiotic therapy on mortality in patients with pneumococcal sepsis.

In order to determine whether combination antibiotic therapy decreases mortality after severe pneumococcal infection, a retrospective study of a cohort of 1,840 adult patients with severe sepsis or septic shock enrolled in two multicenter clinical trials between 1994 and 1999 was conducted. Among 107 patients with monobacterial pneumococcal sepsis, the case-fatality rate was 20% (five of 25) for patients who received antibiotic monotherapy compared with 19.5% (16 of 82) for patients who received combination therapy (adjusted hazard ratio, 1.1; 95% CI, 0.4-3.1). Similarly, monotherapy did not increase the risk of death (adjusted hazard ratio, 1.0; 95% CI, 0.2-4.8) among bacteremic patients (n=75). However, the latter analysis may have been underpowered (power, 58%) to detect a difference in mortality. Overall, in contrast to recently published reports, these results suggest that combination antibiotic therapy does not decrease mortality after severe pneumococcal sepsis.

Adult↗
PubMed2005

[Consequences of an unsufficient range of immunity in "pediatric" infectious diseases--example with measles].

From January to February 2005, the healthcare authorities of the Canton of Geneva were alerted to 15 cases of measles, in contrast to one single case in 2004. The adult status (17-44 years) of the affected persons years was unusual. Four were health care workers at the same hospital who were infected after contact with a 44-year-old patient in a single night during his stay in the emergency room. The presumption that measles are only a paediatric disease had made the diagnosis difficult. None of all these adults was immune according to the actual recommendations. Despite a federal vaccine policy, repetition of recommendations, good results of available vaccines and reimbursement of the cost by health insurance companies, voluntary vaccination prevalence is too small in Switzerland to prevent the outbreak of epidemics. In contrast to the goals of the World Health Organization (WHO) and the Swiss Federal Office of Public Health, the country is unfortunately far from displaying a sufficiently high herd immunity to prevent health care-associated and economic damage by sporadic epidemics.

Communicable Disease Control↗
PubMed2005

Pasteurella multocida endophthalmitis: case report and review of the literature.

BACKGROUND: Postoperative bacterial endophthalmitis is caused by the patient's endogenous flora in most cases (80 %). Pasteurella multocida (PM) is a Gram-negative coccobacillus found in the upper respiratory tract of dogs and cats and is very rarely implicated in postoperative endophthalmitis. HISTORY AND SIGNS: We describe a case of PM endophthalmitis that developed after cataract surgery. THERAPY AND OUTCOME: Cultures of both the conjunctiva and the aqueous humor were positive for PM. Topical, intravitreous and intravenous antibiotics were administered. Despite treatment, the outcome was unfavourable and complicated by a corneal perforation. CONCLUSIONS: The prognosis of postoperative PM endophthalmitis remains poor, despite adequate treatment of the infection. A history of recent pet exposure should alert physicians to this possible aetiological factor.

Aged↗
PubMed2004

[Challenges, treatment strategies and clinical progression of MRSA bacteremia].

DISTURBING EPIDEMIOLOGICAL DATA: Over the past decade there has been a continuous progression in the percentage of Staphylococcus aureus strains resistant to methicillin (MRSA), a slight progression in coagulase-negative staphylococci strains resistant to methicillin and a spectacular progression of enterococci resistant to glycopeptides, not only in hospitals but also in intensive care settings. The increase in nosocomial septicemia is currently a major patient safety issue. HIGHER MORTALITY IN BACTEREMIC PATIENTS: The excess mortality globally observed in cases of bacteremia (compared with patients without bacteremia) is markedly enhanced with regard to secondary bacteremia. Bacteremia is responsible for a significant increase in the overall duration of hospitalization. PROGNOSTIC FACTORS OF STAPHYLOCOCCI BACTEREMIA: The mortality rate is significantly higher in patients in whom initial therapy was inappropriate compared with those in whom it was adequate. The isolation of MRSA strains is a negative prognostic factor. PATIENTS AT RISK OF MRSA BACTEREMIA: Independent risk factors for MRSA bacteremia include prior exposure to antibiotics, a nosocomial origin, a history of hospitalization within the 6 preceding months, and the presence of a decubitus ulcer. To avoid MRSA bacteremias related to catheters, alternatives should be found to their use, all hygiene rules should be carefully respected, the insertion point should be carefully disinfected and protected, and the catheter should be removed as rapidly as possible.

Bacteremia↗
PubMed2004

The Lowbury lecture: behaviour in infection control.

The majority of healthcare-associated infections result from cross-transmission related to inappropriate patient-care practices. Improving practices frequently implies modifying healthcare workers' behaviour, a key challenge of today's infection control. To improve healthcare workers' compliance with practices, infection control should learn from the behavioural sciences. Social cognitive models can help to improve our understanding of human behaviour. Cognitive determinants that shape behaviour are acquired through the socialization process and are susceptible to change. Some models have been applied to evaluate predictors of health behaviour but, so far, none have been successfully applied to explain behaviour in the field of infection control. Successful strategies to improve infection control practices result from their multidimensional aspect. Similarly, social models that include several levels of cognitive determinants have more chance of success to explain change in behaviour. Concrete examples applied to infection control issues are presented, including special references to hand hygiene behaviour. The theory of ecological perspective, based on the idea that behaviour is viewed as being affected by and affecting multiple levels of influence, and that it both influences and is influenced by the social environment, seems promising to explain behaviour modification. Studies are needed to assess the key determinants of infection control practices and behaviour promotion among the different populations of healthcare workers, and to implement and evaluate the impact of the different components of multimodal programmes to promote optimal infection control practices.

Behavior↗
PubMed2002

Molecular epidemiology of predominant clones and sporadic strains of methicillin resistant Staphylococcus aureus in Switzerland and comparison with European epidemic clones.

OBJECTIVE: To assess the molecular epidemiology and risk factors of predominant clones and sporadic strains of methicillin-resistant Staphylococcus aureus (MRSA) in Swiss hospitals and to compare them with European strains of epidemic clones. MATERIAL AND METHODS: One-year national survey of MRSA cases. Analysis of epidemiological and molecular typing data (PFGE) of MRSA strains. RESULTS: In 1997, 385 cases of MRSA were recorded in the five Swiss university hospitals and in 47 community hospitals. Half of the cases were found in Geneva hospitals where MRSA was already known to be endemic. Molecular typing of 288 isolates (one per case) showed that 186 (65%) belong to four predominant clones, three of which were mostly present in Geneva hospitals. In contrast, the fourth clone (85 cases) was found in 23 hospitals (in one to 16 cases per hospital). The remaining 35% of the strains were clustered into 62 pulsed field gel electrophoresis types. They accounted for one to five patients per hospital and were defined as sporadic. Multivariate analysis revealed no independent risk factors for harboring a predominant versus a sporadic strain, except that transfer from a foreign hospital increases the risk of harboring a sporadic strain (OR, 42; 95% CI, 5-360). CONCLUSION: While cases with predominant clones were due to the local spread of these clones, most sporadic cases appear to be due to the continuous introduction of new strains into the country. With the exception of a transfer from a hospital outside Switzerland, no difference in the clinical or epidemiological characteristics was observed between patients harboring a predominant clone and those with a sporadic strain.

Anti-Bacterial Agents↗
PubMed2002

Overview of catheter-related infections with special emphasis on prevention based on educational programs.

Intra-vascular access is an unavoidable tool in sophisticated modern medical practice, and catheter-related infection remains a leading cause of nosocomial infections, particularly in intensive care units where it is associated with significant patient morbidity, mortality, and additional hospital costs. The incidence of catheter-related bloodstream infection ranges from 2 to 14 episodes per 1000 catheter-days. On average, microbiologically documented, device-related bloodstream infections complicate the use of a central venous line in three to five per 100 cases. But this represents only the visible part of the iceberg and most episodes of clinical sepsis are nowadays considered to be catheter-related. We briefly review the pathophysiology of these infections, highlighting the importance of the skin insertion site and the intravenous line hub as principal sources of colonization and infection. Principles of therapy are briefly addressed. A large proportion of these infections are preventable and this has been the objective of creating precise guidelines. It was recently suggested that the situation may evolve with the introduction of antibiotic/antiseptic-coated devices, whose impact on the epidemiology of antibiotic resistance remains to be determined. Recently, educational programs and/or a global preventive strategy based on the strict application of specific preventive measures and careful control of all factors associated with infection proved to be even more effective than coated devices in reducing rates of infection. Practical aspects regarding educational approaches will help clinicians to adapt and incorporate educational programs into clinical practice.

Catheterization↗
PubMed2002

Environmental controls in operating theatres.

Surgical-site infection is the leading complication of surgery. Normal skin flora of patients or healthcare workers causes more than half all infections following clean surgery, but the importance of airborne bacteria in this setting remains controversial. Modern operating theatres have conventional plenum ventilation with filtered air where particles >/=5 microm are removed. For orthopaedic and other implant surgery, laminar-flow systems are used with high-efficiency particulate air (HEPA) filters where particles >/=0.3 microm are removed. The use of ultra-clean air has been shown to reduce infection rates significantly in orthopaedic implant surgery. Few countries have set bacterial threshold limits for conventionally ventilated operating rooms, although most recommend 20 air changes per hour to obtain 50-150 colony forming units/m(3) of air. There are no standardized methods for bacterial air sampling or its frequency. With the use of HEPA filters in operating theatre ventilation, there is a tendency to apply cleanroom technology standards used in industry for hospitals. These are based on measuring the presence of particles of varying sizes and numbers, and are better suited than bacterial sampling. Environmental bacterial sampling in operating theatres should be limited to investigation of epidemics, validation of protocols, or changes made in materials which could influence the microbial content.

Air Microbiology↗
PubMed2001

Diagnostic value of procalcitonin, interleukin-6, and interleukin-8 in critically ill patients admitted with suspected sepsis.

To assess the diagnostic value of procalcitonin (PCT), interleukin (IL)-6, IL-8, and standard measurements in identifying critically ill patients with sepsis, we performed prospective measurements in 78 consecutive patients admitted with acute systemic inflammatory response syndrome (SIRS) and suspected infection. We estimated the relevance of the different parameters by using multivariable regression modeling, likelihood-ratio tests, and area under the receiver operating characteristic curves (AUC). The final diagnosis was SIRS in 18 patients, sepsis in 14, severe sepsis in 21, and septic shock in 25. PCT yielded the highest discriminative value, with an AUC of 0.92 (CI, 0.85 to 1.0), followed by IL-6 (0.75; CI, 0.63 to 0.87), and IL-8 (0.71; CI, 0.59 to 0.83; p < 0.001). At a cutoff of 1.1 ng/ml, PCT yielded a sensitivity of 97% and a specificity of 78% to differentiate patients with SIRS from those with sepsis-related conditions. Median PCT concentrations on admission (ng/ ml, range) were 0.6 (0 to 5.3) for SIRS; 3.5 (0.4 to 6.7) for sepsis; 6.2 (2.2 to 85) for severe sepsis; and 21.3 (1.2 to 654) for septic shock (p < 0.001). The addition of PCT to a model based solely on standard indicators improved the predictive power of detecting sepsis (likelihood ratio test; p = 0.001) and increased the AUC value for the routine value-based model from 0.77 (CI, 0.64 to 0.89) to 0.94 (CI, 0.89 to 0.99; p = 0.002). In contrast, no additive effect was seen for IL-6 (p = 0.56) or IL-8 (p = 0.14). Elevated PCT concentrations appear to be a promising indicator of sepsis in newly admitted, critically ill patients capable of complementing clinical signs and routine laboratory parameters suggestive of severe infection.

Adult↗
PubMed2001

Compliance with hand disinfection and its impact on hospital-acquired infections.

Hand hygiene prevents cross-infection in hospitals, but adherence to guidelines is poor among healthcare workers. Although some interventions to improve compliance have been successful, none had achieved lasting improvement until very recently. Reasons for non-compliance with recommendations occur at individual, group and institutional levels. The complexity of the process of behavioural change would suggest that the application of multimodal, multidisciplinary strategies are necessary. Both easy access to hand hygiene in a timely fashion and skin protection appear necessary prerequisites for satisfactory hand hygiene behaviour. Alcohol-based hand-rub may be superior to traditional handwashing as it requires less time, acts faster, irritates hands less often, and recently proved significantly to contribute to sustained improvement in compliance associated with decreased infection rates. This paper reviews barriers to appropriate hand hygiene and describes the results of the first successful experience of sustained hand hygiene promotion and its effectiveness on hospital-acquired infection.

Anti-Infective Agents, Local↗
PubMed2001

[Candidiasis among non-neutropenic patients: from colonization to infection].

Invasive candidiasis is a dread complication in hospitalized patients, characterized by a mortality comparable to that of septic shock (40% to 60%). Its incidence in hospitalized patients is 0.5/1000 admissions, but it complicates about 10 per 1,000 admissions in critical care where it represents 10% to 15% of all nosocomial infections. Although a high proportion of hospitalized patients may become colonized with Candida spp, the clinical signs of infection manifest only late, rending it difficult to diagnose. A better knowledge of their pathophysiology and the availability of triazoles compounds, less toxic than amphotericin B, allowed the concept of early empirical or preemptive treatment. These strategies are based on the prompt identification of risk factors and require continuous attention from skilled physicians. However, the prescription of triazoles has to be restricted to carefully selected groups of patients to avoid the emergence and the dissemination of resistant strains.

Candidiasis↗
PubMed2001

Nonantibibiotic measures for the prevention of Gram-positive infections.

While Gram-negative bacteria remain a leading cause of nosocomial infections such as ventilator-associated pneumonia and catheter-associated urinary tract infections, Gram-positive cocci are now responsible for a large majority of surgical site and bloodstream infections. A shift has occurred during the last decade and multidrug-resistant micro-organisms have become predominant in most referral centers. Severe infections with Gram-positive micro-organisms such as methicillin-resistant Staphylococcus aureus, coagulase-negative staphylococci, vancomycin-resistant enterococci, penicillin-resistant Streptococcus pneumoniae and, more recently, glycopeptide intermediate S. aureus are now regularly reported to be associated with increased morbidity and represent a true health problem in many institutions. The importance of nonantimicrobial measures to prevent infections and further spread is reviewed in this paper. New evidence of the effectiveness of basic infection control measures that have been regarded of little importance during the last two decades by the exponential progress of technologically sophisticated medicine, is discussed.

Bacteremia↗
PubMed2001

Screening for methicillin-resistant Staphylococcus aureus in the endemic hospital: what have we learned?

Control of methicillin-resistant Staphylococcus aureus (MRSA) still generates controversy among infection control practitioners. Opponents claim that once MRSA becomes endemic in an institution, control efforts are no longer justified. This review examines the usefulness, feasibility and cost-effectiveness of control programmes in acute-care hospitals where eradication of MRSA has either failed or has never been attempted; hence, the pathogen has become endemic. High endemicity is associated with increased hospital-acquired infection rates, increased use of glycopeptides and subsequent risk of emergence of antibiotic-resistant Gram-positive bacteria, and additional healthcare costs. Thus, MRSA control has many advantages. Indeed, in many institutions the actual benefit of containment efforts was manifested through the resultant decrease in the incidence of hospital-acquired MRSA infections. Successful programmes are based on an early identification of the MRSA reservoir and prompt implementation of contact precautions. The most efficacious strategy to detect occult MRSA carriage is via the screening of high-risk patients on admission to the hospital which has proven to be cost-effective in varied acute-care endemic settings.

Acute Disease↗