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D Pittet

Publications and source records attributed to D Pittet.

At least 55 records · Page 3Linked to original sources
PubMed1999

Compliance with handwashing in a teaching hospital. Infection Control Program.

BACKGROUND: Transmission of microorganisms from the hands of health care workers is the main source of cross-infection in hospitals and can be prevented by handwashing. OBJECTIVE: To identify predictors of noncompliance with handwashing during routine patient care. DESIGN: Observational study. SETTING: Teaching hospital in Geneva, Switzerland. PARTICIPANTS: Nurses (66%), physicians (10%), nursing assistants (13%), and other health care workers (11%). MEASUREMENTS: Compliance with handwashing. RESULTS: In 2834 observed opportunities for handwashing, average compliance was 48%. In multivariate analysis, noncompliance was higher among physicians (odds ratio [OR], 2.8 [95% CI, 1.9 to 4.1]), nursing assistants (OR, 1.3 [CI, 1.0 to 1.6]), and other health care workers (OR, 2.1 [CI, 1.4 to 3.2]) than among nurses and was lowest on weekends (OR, 0.6 [CI, 0.4 to 0.8]). Noncompliance was higher in intensive care than in internal medicine units (OR, 2.0 [CI, 1.3 to 3.1]), during procedures that carry a high risk for contamination (OR, 1.8 [CI, 1.4 to 2.4]), and when intensity of patient care was high (compared with < or = 20 opportunities for handwashing per hour of care, 21 to 40 opportunities: OR, 1.3 [CI, 1.0 to 1.7]; 41 to 60 opportunities: OR, 2.1 [CI, 1.5 to 2.9]; and > 60 opportunities: OR, 2.1 [CI, 1.3 to 3.5]). CONCLUSIONS: Compliance with handwashing was moderate. Variation across hospital ward and type of health care worker suggests that targeted educational programs may be useful. Even though observational data cannot prove causality, the association between noncompliance and intensity of care suggests that understaffing may decrease quality of patient care.

Hand Disinfection↗
PubMed1999

The role of glycopeptide antibiotics in the treatment of infective endocarditis.

There are several sets of guidelines for the treatment of infective endocarditis, reflecting the need for differing treatment in various countries and times. This review considers the need for differing treatment modalities and in particular the utility of the glycopeptide antibiotics vancomycin and teicoplanin. Specific recommendations are offered as to when to consider the use of glycopeptides, appropriate dosage, length of treatment course and whether to use monotherapy or combined therapy. Used judiciously, the glycopeptides give results as good as can be achieved with other antimicrobial agents without exceptional toxicity. The potential of teicoplanin for use in the outpatient treatment of infective endocarditis is considered.

Anti-Bacterial Agents↗
PubMed1999

Routine disinfection of patients' environmental surfaces. Myth or reality?

We have evaluated the need for daily disinfection of environmental surfaces not contaminated by biological fluids, in patient areas of a medical unit with two wings [North (N) and South (S)] at the University Hospitals of Geneva, Switzerland. Weekly bacteriological monitoring of surfaces was carried out at random (N = 1356 samples). In the S wing (control), we used detergent/disinfectant for daily cleaning of the floors and furniture. In the N wing we began by using a detergent for floors and furniture; after four weeks the results suggested changing to a rotation of detergent, dust attracting disposable dry mops and disinfectant. During this period the furniture was cleaned with an active oxygen-based compound. The average differences in contamination before and after cleaning floors were (mean reduction in bacterial counts and 95% confidence intervals; CI95): disposable mops: 92.7 cfu/24 cm2 (CI95; 74-112), active oxygen based compound 111.1 (90-133), and quaternary ammonium compound -0.6 (-27-26). Use of detergent alone was associated with a significant increase in bacterial colony counts: on average by 103.6 cfu (CI95 73-134). The quaternary ammonium compound was inadequate for disinfecting bathrooms and toilets but the active oxygen based compound was satisfactory. For furniture, there was a significant reduction in bacterial counts with both the methods using disinfectants. As the detergent was contaminated, by using it alone for cleaning, we were actually seeding surfaces with bacteria. A total of 1117 patients was studied and we observed no change in the incidence of nosocomial infections during the four months of the trial. In conclusion, uncontrolled routine disinfection of environmental surfaces does not necessarily make it safe for the patient and could seed the environment with potential pathogens.

Analysis of Variance↗
PubMed1999

Impact and pattern of gram-negative bacteraemia during 6 y at a large university hospital.

In order to characterize the impact and pattern of Gram-negative bacteraemia (GNB) at a Swiss University hospital and to assess the effect of multi-resistance on mortality, we conducted a 6-y retrospective cohort study using linear regression and multivariate Cox-proportional hazard analysis. 1766 patients had 1835 episodes of GNB; 61% were community-acquired. The incidence of GNB increased linearly (r2 = 0.90, p = 0.014) from 7.07 episodes to 8.32 episodes per 1000 admissions, but this trend was no longer significant after adjustment for the number of blood cultures drawn/y. The in-hospital mortality for patients with GNB decreased from 20% in 1989 to 16% in 1994 (r2 = 0.94, p = 0.005). The risk ratio for death remained unchanged over the study period and was 7-fold higher for patients with GNB than for patients without GNB. Factors independently associated with an increased hazard of death after GNB were: severity of illness as measured by exposure to intensive care (hazard ratio [HR], 1.5); age = 66-79 y (HR 1.8); GNB due to Klebsiella spp. (HR 1.7) or Pseudomonas aeruginosa (HR 1.6); and polymicrobial infection (HR 1.6). Multi-resistance was not associated with an increased risk of death (HR 1.0). Although the crude mortality of GNB decreased, the population-attributable risk ratio for death remained significant. These data suggest the absence of a major impact of multi-resistant GNB on patient mortality.

Adult↗
PubMed1999

Prevalence and risk factors for nosocomial infections in four university hospitals in Switzerland.

OBJECTIVE: To determine the prevalence and risk factors for nosocomial infections (NIs) in four Swiss university hospitals. DESIGN AND SETTING: A 1-week period-prevalence survey conducted in May 1996 in medical, surgical, and intensive-care wards of four Swiss university hospitals (900-1,500 beds). Centers for Disease Control and Prevention definitions were used, except that asymptomatic bacteriuria was not categorized as NI. Study variables included patient demographics, primary diagnosis, comorbidities, exposure to medical and surgical risk factors, and use of antimicrobials. Risk factors for NIs were determined using logistic regression with adjustment for length of hospital stay, study center, device use, and patients' comorbidities. RESULTS: 176 NI were recorded in 156 of 1,349 screened patients (11.6%; interhospital range, 9.8%-13.5%). The most frequent NI was surgical-site infection (53; 30%), followed by urinary tract infection (39; 22%), lower respiratory tract infection (27; 15%), and bloodstream infection (23; 13%). Prevalence of NI was higher in critical-care units (25%) than in medical (9%) and surgical wards (12%). Overall, 65% of NIs were culture-proven; the leading pathogens were Enterobacteriaceae (44; 28%), Staphylococcus aureus (20; 13%), Pseudomonas aeruginosa (17; 11%), and Candida species (16; 10%). Independent risk factors for NI were central venous catheter (CVC) use (odds ratio [OR], 3.35; 95% confidence interval [CI95], 2.91-3.80), admission to intensive care (OR, 1.75; CI95, 1.30-2.21), emergency admission (OR, 1.57; CI95, 1.15-2.00), impaired functional status (Karnofsky index 1-4: OR, 2.56; CI95, 1.953.17), and McCabe classification of ultimately fatal (OR, 2.50; CI95, 2.04-2.96) or rapidly fatal (OR, 2.25; CI95, 1.52-2.98) underlying condition. CONCLUSIONS: According to the results of this survey, NIs are frequent in Swiss university hospitals. This investigation confirms the importance of CVCs as a major risk factor for NI. Patient comorbidities must be taken into account to adjust for case mix in any study comparing interhospital or intrahospital infection rates.

Adolescent↗
PubMed1999

Outbreak of Enterobacter cloacae related to understaffing, overcrowding, and poor hygiene practices.

OBJECTIVE: To determine the cause and mode of transmission of a cluster of infections due to Enterobacter cloacae. DESIGN AND SETTING: Retrospective cohort study in a neonatal intensive-care unit (NICU) from December 1996 to January 1997; environmental and laboratory investigations. SUBJECTS: 60 infants hospitalized in the NICU during the outbreak period. MAIN OUTCOME MEASURES: Odds ratios (OR) linking E. cloacae colonization or infection and various exposures. All available E. cloacae isolates were typed and characterized by contour-clamped homogenous electric-field electrophoresis to confirm possible cross-transmission. RESULTS: Of eight case-patients, two had bacteremia; one, pneumonia; one, soft-tissue infection; and four, respiratory colonization. Infants weighing <2,000 g and born before week 33 of gestation were more likely to become cases (P<.001). Multivariate analysis indicated that the use of multidose vials was independently associated with E. cloacae carriage (OR, 16.3; 95% confidence interval [CI95], 1.8-infinity; P=.011). Molecular studies demonstrated three epidemic clones. Cross-transmission was facilitated by understaffing and overcrowding (up to 25 neonates in a unit designed for 15), with an increased risk of E. cloacae carriage during the outbreak compared to periods without understaffing and overcrowding (relative risk, 5.97; CI95 2.2-16.4). Concurrent observation of healthcare worker (HCW) handwashing practices indicated poor compliance. The outbreak was terminated after decrease of work load, increase of hand antisepsis, and reinforcement of single-dose medication. CONCLUSIONS: Several factors caused and aggravated this outbreak: (1) introduction of E. cloacae into the NICU, likely by two previously colonized infants; (2) further transmission by HCWs' hands, facilitated by substantial overcrowding and understaffing in the unit; (3) possible contamination of multidose vials with E. cloacae. Overcrowding and understaffing in periods of increased work load may result in outbreaks of nosocomial infections and should be avoided.

Cross Infection↗
PubMed1999

Randomized, placebo-controlled, double-blind trial to evaluate the efficacy of mupirocin for eradicating carriage of methicillin-resistant Staphylococcus aureus.

Mupirocin has been widely used for the clearance of nasal methicillin-resistant Staphylococcus aureus (MRSA) carriage during outbreaks, but no placebo-controlled trial has evaluated its value for eradicating MRSA carriage at multiple body sites in settings where MRSA is not epidemic. In a 1,500-bed teaching hospital with endemic MRSA, 102 patients colonized with MRSA were randomized into a double-blind, placebo-controlled trial and treated with either mupirocin (group M) or placebo (group P) applied to the anterior nares for 5 days; both groups used chlorhexidine soap for body washing. Follow-up screening, susceptibility testing, and genotyping were performed to evaluate treatment success, mupirocin or chlorhexidine resistance, and exogenous recolonization. At baseline, MRSA carriage was 60% in the nares, 38% in the groin, and 62% in other sites (skin lesions, urine). The MRSA eradication rate (all body sites) was 25% in group M (12 of 48 patients), compared to 18% in group P (9 of 50 patients; relative risk [RR], 0.72; 95% confidence interval [CI95], 0.33 to 1.55). At the end of follow-up, 44% of patients (19 of 43) were free of nasal MRSA in group M, compared to 23% (11 of 44) in group P (RR, 0.57; CI95, 0.31 to 1.04). Ten patients developed MRSA infections (three in group M and seven in group P). One mupirocin treatment failure was due to exogenous MRSA recolonization. No MRSA isolate showed chlorhexidine resistance or high-level mupirocin resistance; however, we observed an association (P = 0.003) between low-level mupirocin resistance at study entry (prevalence, 23%) and subsequent treatment failure in both study arms. These results suggest that nasal mupirocin is only marginally effective in the eradication of multisite MRSA carriage in a setting where MRSA is endemic.

Adult↗
PubMed1999

Impact of immunomodulating therapy on morbidity in patients with severe sepsis.

We assessed the impact, over a 28-d period, of therapy with the tumor necrosis factor (TNF) neutralizing receptor fusion protein (p55-IgG) on the incidence of end-organ failures in patients with severe sepsis or early septic shock in a subgroup of 165 patients recruited into a randomized, multicenter clinical trial to receive placebo (n = 78) or a single infusion of p55-IgG, 0.083 mg/kg (n = 87). At study entry, distribution of organ dysfunctions and other baseline characteristics were similar for the two study groups. Treatment with p55-IgG was associated with a trend toward reduced 28-d mortality (p = 0.07), a decreased incidence of new organ dysfunctions (relative risk [RR], 0.57; 95% confidence interval [95% CI] 0.29 to 1.10, p = 0.10), and a decreased overall incidence-density of organ failures (RR 0.65; 95% CI 0.60 to 0.71, p = 0.0001). Patients treated with p55-IgG had more organ failure-free days after study entry than those who received placebo. Average intensive care unit (ICU) stay was 2.6 d shorter (95% CI 0.2 to 5.0) for patients who received p55-IgG than for those who received placebo. For those patients who survived, this difference was 4.1 d (95% CI 1.6 to 6.6). Duration of ventilatory support was 3.2 d shorter (95% CI 0.1 to 6.3) among 28-d survivors who received p55-IgG, compared with placebo. In conclusion, in the population of septic patients studied, treatment with p55-IgG was associated with a trend toward shorter need for mechanical ventilatory support, a decreased length of stay (LOS), and a decreased incidence and duration of organ failure.

APACHE↗
PubMed1998

[Prevalence of nosocomial infections in a university hospital: distribution, predisposing factors and diagnostic indices].

Nosocomial infections are a major challenge for modern medicine and contribute to increased resource use in health care systems. The first hospital-wide prevalence survey of nosocomial infections was conducted at the University of Geneva Hospitals in 1994. At the time of the study, 16.9% of admitted patients had nosocomial infections (168/994). Leading infection sites were: urinary tract (30%), respiratory tract (17%), surgical wounds (12%) and bloodstream (9.6%). Rates of infection varied between hospital wards: intensive care (21%), surgery (19%), rehabilitation (18%), internal medicine (13%). However, the distribution of nosocomial infections varied according to surveillance and attribution rules. Optimal detection of nosocomial infections requires ward surveillance, including revision of microbiology, nursing (Kardex) and medical records; the combination of fever above 38 degrees C, prescription of antimicrobial agent(s), and positive microbiological records suggested the diagnosis of nosocomial infections in 95% of situations. Priorities for infection control were derived from these results.

Adolescent↗
PubMed1998

Impact of methicillin resistance on the outcome of patients with bacteremia caused by Staphylococcus aureus.

BACKGROUND: Uncertainties remain about the contribution of methicillin resistance to morbidity and mortality associated with bacteremia caused by Staphylococcus aureus. OBJECTIVE: To assess the impact of methicillin resistance on patient outcome after staphylococcal bacteremia. METHODS: We investigated a cohort of 145 patients with methicillin-sensitive S aureus bloodstream infection (MSSA BSI) and 39 patients with methicillin-resistant S aureus bloodstream infection (MRSA BSI) and further performed a pairwise-matched (1:1) case-control study. All patients in the University Hospital of Geneva, Geneva, Switzerland, with clinically significant staphylococcal bacteremia between January 1, 1994, and December 31, 1995, were included in the study. For the case-control study, cases were defined as patients with MRSA BSI; control patients with MSSA BSI were selected in a stepwise manner according to the following matching variables: age, sex, number of comorbidities, severity of underlying illness, and prior length of stay in the hospital. Matching was successful for 97% of the cohort. MAIN OUTCOME MEASURE: The in-hospital mortality after staphylococcal bacteremia. RESULTS: In the population-based study, the relative hazard of death among patients with MRSA BSI (n = 39, 14 deaths, 36% fatality rate) compared with patients with MSSA BSI (n = 145, 40 deaths, 28% fatality rate) was 1.1 (95% confidence interval, 0.5-2.1), after adjusting for age and length of stay from admission to the onset of bloodstream infection. Following pairwise matching (n = 38), the in-hospital mortality was 34% in both groups (odds ratio, 1.0; 95% confidence interval, 0.4-2.5). Infection was the probable or definite cause of death in 54% of patients with MRSA BSI and 69% of patients with MSSA BSI who died. CONCLUSION: Methicillin resistance in patients with S aureus bacteremia had no significant impact on patient outcome as measured by in-hospital mortality after adjustment was made for major confounders.

Adult↗
PubMed1998

Epidemiology, diagnosis and treatment of systemic Candida infection in surgical patients under intensive care.

The incidence of systemic Candida infections in patients requiring intensive care has increased substantially in recent years as a result of a combination of factors. More patients with severe underlying disease or immunosuppression from anti-neoplastic or anti-rejection chemotherapy and at risk from fungal infection are now admitted to the ICU. Improvements in supportive medical and surgical care have led to many patients who would previously have died as a result of trauma or disease surviving to receive intensive care. Moreover, some therapeutic interventions used in the ICU, most notably broad-spectrum antibiotics and intravascular catheters, are also associated with increased risks of candidiasis. Systemic Candida infections are associated with a high morbidity and mortality, but remain difficult to diagnose and ICU staff need to be acutely aware of this often insidious pathogen. A number of studies have identified risk factors for systemic Candida infection which may be used to identify those at highest risk. Such patients may be potential candidates for early, presumptive therapy. Here we review the epidemiology, pathogenesis, morbidity and mortality of systemic Candida infections in the ICU setting, and examine predisposing risk factors. Antifungal treatment, including the use of amphotericin B, flucytosine and fluconazole, and the roles of early presumptive therapy and prophylaxis, is also reviewed.

Antifungal Agents↗
PubMed1998

Infective endocarditis and glycopeptides.

BACKGROUND: Despite the number of antibacterial agents currently available, endocarditis remains a difficult disease to treat and the mortality rate has not fallen in recent years. The glycopeptides have good activity against the Gram-positive bacteria commonly implicated in endocarditis (staphylococci, both coagulase-positive and negative; enterococci and streptococci). OBJECTIVES: To assess the impact of the glycopeptides vancomycin and teicoplanin on the therapy of infectious endocarditis caused by Gram-positive bacteria. METHODS: A retrospective review of all major published or recently conducted studies using vancomycin or teicoplanin to treat endocarditis. RESULTS: Cure rates obtained with vancomycin and teicoplanin are similar, but there are no controlled studies to investigate this. Vancomycin nephrotoxicity limits its use in endocarditis, in particular when used in combination with an aminoglycoside. By contrast, teicoplanin shows little nephrotoxic potential, even in patients with some degree of renal impairment or when given in combination with an aminoglycoside. Teicoplanin should be used at doses of 6 mg/kg/day or higher to achieve satisfactory cure rates. CONCLUSIONS: Clinical data on the use of glycopeptides in endocarditis suffer from a lack of controlled trials. Although teicoplanin appears to offer some advantages over vancomycin in the therapy of endocarditis, there is an urgent need for randomized, clinical trials before definitive conclusions can be drawn.

Anti-Bacterial Agents↗
PubMed1998

The dynamics of disease progression in sepsis: Markov modeling describing the natural history and the likely impact of effective antisepsis agents.

We conducted a 9-month prospective cohort study of 2,527 patients with systemic inflammatory response syndrome in three intensive care units and three general wards in a tertiary health care institution. Markov models were developed to predict the probability of movement to and from more severe stages--sepsis, severe sepsis, or septic shock--at 1, 3, and 7 days. For patients with sepsis, severe sepsis, and septic shock, the probabilities of remaining in the same category after 1 day were .65, .68, and .61, respectively. The probability for progression after 1 day was .09 for sepsis to severe sepsis and .026 for severe sepsis to shock. The probability of patients with sepsis, severe sepsis, and septic shock dying after 1 day was .005, .009, and .079, respectively. The model can be used to predict the reduction in end organ dysfunction and mortality with use of increasingly effective antisepsis agents.

Disease Progression↗
PubMed1998

Influenza immunization: improving compliance of healthcare workers.

OBJECTIVE: In spite of yearly recalls, influenza immunization rates of healthcare workers (HCWs) remained low (10%) at the University Hospitals of Geneva. This study was conducted to identify HCWs' reasons for rejection of immunization, to design specific intervention methods based on these reasons, and to evaluate the impact of such interventions. METHODS: Three departments with high-risk patients (geriatrics, obstetrics, and pediatrics) were selected as main targets. Questionnaires were distributed in these units. Based on HCWs' perceptions, different intervention methods were designed and used either in these departments only (educational conferences, on-site availability of a vaccination nurse) or in the whole institution (posters, personal letters). Immunization rates were collected throughout the institution. RESULTS: 797 completed questionnaires from 1,092 HCWs (73%) were returned. Major reasons for immunization rejection were confidence that their bodies' self-defense mechanisms would ward off infection (32%), perception of low exposure risk (23%), and doubts concerning vaccine efficacy (19%). The use of intervention methods designed to address these factors increased influenza immunization rates in the three targeted departments from 13% (95% confidence interval [CI95], 11.4-15.6) in 1995 and 1996 to 37% (CI95, 34.5-40.3) in the following season (P<.001). In all other departments, immunization rates rose from 9% (CI95, 8.5-10.3) to 23% (CI95, 21.6-24.1; P<.001). Nurses were, and remained, more reluctant to be immunized compared to other HCWs. CONCLUSIONS: Influenza immunization rates can be increased significantly by specific interventions based on local concerns of HCWs, among which educational conferences and the on-site availability of a vaccination nurse appeared important.

Cross Infection↗