NosoVeille mars 2010

NosoVeille – Bulletin de veille mars 2010
CCLIN Sud-Est – [e-mail] 1 / 29
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NosoVeille n°3
Mars 2010
Rédacteurs : Nathalie Sanlaville, Sandrine Yvars, Annie Treyve
Ce bulletin de veille est une publication mensuelle qui recueille les publications
scientifiques publiées au cours du mois écoulé.
La recherche documentaire est effectuée dans la base de données
Pour recevoir, tous les mois, NosoVeille dans votre messagerie :
Abonnement / Désabonnement
Sommaire de ce numéro
Antibiotique
Appareil respiratoire
Candida
Cathétérisme
Chirurgie
Clostridium
Désinfection
Environnement
Grippe
Hémodialyse
Hygiène des mains
Néonatalogie
Ophtalmologie
Organisation
Personne âgée
Personnel
Soins intensifs
Staphylococcus
Surveillance
Tatouage

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Antibiotique
NosoBase n° 26369
Améliorer l'hygiène environnementale dans 27 unités de réanimation afin de diminuer la
transmission de bactéries multirésistantes aux antibiotiques
Carling PC; Parry MF; Bruno-Murtha LA; Dick B. Improving environmental in 27 intensive care units
todecrease multidrug-resistant bacterial transmission. Critical care medicine 2010; in press: 6 pages.
Mots-clés : SOIN INTENSIF; TRANSMISSION; ENVIRONNEMENT; MULTIRESISTANCE;
BIONETTOYAGE; CHAMBRE; QUALITE; ETUDE PROSPECTIVE; SURFACE
Objective: To determine the thoroughness of terminal disinfection and cleaning of patient rooms in hospital
intensive care units and to assess the value of a structured intervention program to improve the quality of
cleaning as a means of reducing environmental transmission of multidrug-resistant organisms within the
intensive care unit.
Design: Prospective, multicenter, and pre- and postinterventional study.
Setting: Intensive care unit rooms in 27 acute care hospitals. Hospitals ranged in size from 25 beds to 709
beds (mean, 206 beds).
Interventions: A fluorescent targeting method was used to objectively evaluate the thoroughness of terminal
room cleaning before and after structured educational, procedural, and administrative interventions.
Systematic covert monitoring was performed by infection control personnel to assure accuracy and lack of
bias.
Measurements and main results: In total, 3532 environmental surfaces (14 standardized objects) were
assessed after terminal cleaning in 260 intensive care unit rooms. Only 49.5% (1748) of surfaces were
cleaned at baseline (95% confidence interval, 42% to 57%). Thoroughness of cleaning at baseline did not
correlate with hospital size, patient volume, case mix index, geographic location, or teaching status. After
intervention and multiple cycles of objective performance feedback to environmental services staff,
thoroughness of cleaning improved to 82% (95% confidence interval, 78% to 86%).
Conclusions: Significant improvements in intensive care unit room cleaning can be achieved in most
hospitals by using a structured approach that incorporates a simple, highly objective surface targeting
method and repeated performance feedback to environmental services personnel. Given the documented
environmental transmission of a wide range of multidrug-resistant pathogens, our findings identify a
substantial opportunity to enhance patient safety by improving the thoroughness of intensive care unit
environmental hygiene.
NosoBase n° 26388
Contrôler la dissémination de pathogènes à Gram négatif producteurs de carbapénèmases :
approche thérapeutique et lutte contre le risque infectieux
Carmeli Y; Akova M; Cornaglia G; Daikos Gl; Garau J; Harbarth S; et al. Controlling the spread of
carbapenemase-producing gram-negatives: therapeutic approach and infection control
Clinical microbiology and infection 2010/02; 16(2): 102-111.
Mots-clés : BACILLE GRAM NEGATIF; CARBAPENEME; ANTIBIORESISTANCE; TRAITEMENT;
CONTROLE; BIBLIOGRAPHIE; EUROPE
Although the rapid spread of carbapenemase-producing Gram-negatives (CPGNs) is providing the scientific
community with a great deal of information about the molecular epidemiology of these enzymes and their
genetic background, data on how to treat multidrug-resistant or extended drug-resistant carbapenemase-
producing Enterobacteriaceae and how to contain their spread are still surprisingly limited, in spite of the
rapidly increasing prevalence of these organisms and of their isolation from patients suffering from life-
threatening infections. Limited clinical experience and several in vitro synergy studies seem to support the
view that antibiotic combinations should be preferred to monotherapies. But, in light of the data available to
date, it is currently impossible to quantify the real advantage of drug combinations in the treatment of these
infections. Comprehensive clinical studies of the main therapeutic options, broken down by pathogen,
enzyme and clinical syndrome, are definitely lacking and, as carbapenemases keep spreading, are urgently
needed. This spread is unveiling the substantial unpreparedness of European public health structures to
face this worrisome emergency, although experiences from different countries-chiefly Greece and Israel-
have shown that CPGN transmission and cross-infection can cause a substantial threat to the healthcare
system. This unpreparedness also affects the treatment of individual patients and infection control policies,

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with dramatic scarcities of both therapeutic options and infection control measures. Although correct
implementation of such measures is presumably cumbersome and expensive, the huge clinical and public
health problems related to CPGN transmission, alongside the current scarcity of therapeutic options, seem
to fully justify this choice.
NosoBase n° 26530
Désescalade après traitement empirique par le méropénème en réanimation : fiction ou réalité ?
De Waele JJ; Ravyts M; Depuydt P; Blot Si; Decruyenaere J; vogelaers D. De-escalation after empirical
meropenem treatment in the intensive care unit: fiction or reality? Journal of critical care 2010; in press: 6
pages.
Mots-clés : TRAITEMENT; SOIN INTENSIF; MEROPENEME; ANTIBIOTIQUE; ANALYSE; ETUDE
RETROSPECTIVE; CHIRURGIE; MORTALITE
Introduction: De-escalation of antimicrobial therapy is often advocated to reduce the use of broad-spectrum
antibiotics in critically ill patients. However, little data are available on the application of this strategy in daily
clinical practice.
Methods: This is a retrospective analysis of all meropenem prescriptions in a surgical intensive care unit
(ICU) during 1 year. Age, Acute Physiology and Chronic Health Evaluation II score on admission to the ICU,
site of infection, causative organism, duration of meropenem administration, other antibiotic prescription for
the same infectious episode for which meropenem was administered, and ICU mortality were recorded. De-
escalation was defined as the administration of an antibiotic with a narrower spectrum within 3 days of the
start of meropenem.
Results: Data from 113 meropenem prescriptions were available for analysis. Pulmonary (46%) and
complicated intraabdominal (31%) infections were the most frequent infections. In 37 patients, meropenem
was used after identification of a multiresistant gram-negative organism (MRGN), whereas in 76 patients,
empirical treatment with meropenem was started. Empirical prescription of meropenem was de-escalated in
42% of the patients. In the majority of the patients in whom de-escalation was not done, no conclusive
cultures were available to guide treatment; also, colonization with MRGN at other sites was frequently
associated with non-de-escalation. Patients in whom antibiotics were de-escalated had a trend toward a
lower mortality rate (7% vs 21%, P = .12).
Conclusions: De-escalation after empirical treatment with meropenem was performed in less than half of the
patients. Reasons for not de-escalating included the absence of conclusive microbiology and colonization
with MRGN.
NosoBase n° 26212
Augmentation de la résistance des Acinetobacter à l’imipénème dans des hôpitaux des Etats-Unis,
1999-2006
Hoffmann MS; Eber MR; Laxminarayan R. Increasing resistance of Acinetobacter species to imipenem in
United States hospitals, 1999-2006. Infection control and hospital epidemiology 2010/02; 31(2): 196-197.
Mots-clés : ANTIBIORESISTANCE; MULTIRESISTANCE; ACINETOBACTER; IMIPENEME; SENSIBILITE;
SURVEILLANCE; LABORATOIRE
NosoBase n° 26206
Comparaison entre les taux de contamination des hémocultures après antisepsie cutanée au
gluconate de chlorhexidine et à la povidone-iodine dans un service d’urgence pédiatrique
Marlowe L; Mistry RD; Coffin S; Leckerman KH; Mcgowan KL; Dai D; et al. Blood culture contamination
rates after skin antisepsis with chlorhexidine gluconate versus povidone-iodine in a pediatric emergency
department. Infection control and hospital epidemiology 2010/02; 31(2): 171-176.
Mots-clés : CONTAMINATION; PEAU; CHLORHEXIDINE; POLYVIDONE IODEE; ANTISEPTIQUE;
PEDIATRIE; HEMOCULTURE; URGENCE; ETUDE RETROSPECTIVE

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Objective: To determine blood culture contamination rates after skin antisepsis with chlorhexidine, compared
with povidone-iodine.
Design: Retrospective, quasi-experimental study.
Setting: Emergency department of a tertiary care children's hospital.
Patients: Children aged 2-36 months with peripheral blood culture results from February 2004 to June 2008.
Control patients were children younger than 2 months with peripheral blood culture results.
Methods: Blood culture contamination rates were compared using segmented regression analysis of time-
series data among 3 patient groups: (1) patients aged 2-36 months during the 26-month preintervention
period, in which 10% povidone-iodine was used for skin antisepsis before blood culture; (2) patients aged 2-
36 months during the 26-month postintervention period, in which 3% chlorhexidine gluconate was used; and
(3) patients younger than 2 months not exposed to the chlorhexidine intervention (ie, the control group).
Results: Results from 11,595 eligible blood cultures were reviewed (4,942 from the preintervention group,
4,274 from the postintervention group, and 2,379 from the control group). For children aged 2-36 months,
the blood culture contamination rate decreased from 24.81 to 17.19 contaminated cultures per 1,000
cultures (P < .05) after implementation of chlorhexidine. This decrease of 7.62 contaminated cultures per
1,000 cultures (95% confidence interval, -0.781 to -15.16) represented a 30% relative decrease from the
preintervention period and was sustained over the entire postintervention period. No change in
contamination rate was observed in the control group (P = .337).
Conclusion: Skin antisepsis with chlorhexidine significantly reduces the blood culture contamination rate
among young children, as compared with povidone-iodine.
NosoBase n° 26389
Carbapénèmases acquises dans des pathogènes bactériens à Gram négatif : détection et
surveillance
Miriagou V; Cornaglia G; Edelstein M; Galani I; Giske CG; Gniadkowski M; et al. Acquired carbapenemases
in gram-negative bacterial pathogens: detection and surveillance issues. Clinical microbiology and infection
2010/02; 16(2): 112-122.
Mots-clés : BACILLE GRAM NEGATIF; CARBAPENEME; ANTIBIORESISTANCE; SURVEILLANCE;
PSEUDOMONAS AERUGINOSA; ACINETOBACTER; ANTIBIOTIQUE; KLEBSIELLA PNEUMONIAE;
DIAGNOSTIC BIOLOGIQUE; BIBLIOGRAPHIE
Acquired carbapenemases are emerging resistance determinants in Gram-negative pathogens, including
Enterobacteriaceae, Pseudomonas aeruginosa and other Gram-negative non-fermenters. A consistent
number of acquired carbapenemases have been identified during the past few years, belonging to either
molecular class B (metallo-beta-lactamases) or molecular classes A and D (serine carbapenemases), and
genes encoding these enzymes are associated with mobile genetic elements that allow their rapid
dissemination in the clinical setting. Therefore, detection and surveillance of carbapenemase-producing
organisms have become matters of major importance for the selection of appropriate therapeutic schemes
and the implementation of infection control measures. As carbapenemase production cannot be simply
inferred from the resistance profile, criteria must be established for which isolates should be suspected and
screened for carbapenemase production, and for which tests (phenotypic and/or genotypic) should be
adopted for confirmation of the resistance mechanism. Moreover, strategies should be devised for
surveillance of carbapenemase producers in order to enable the implementation of effective surveillance
programmes. The above issues are addressed in this article, as a follow-up to an expert meeting on
acquired carbapenemases that was recently organized by the ESCMID Study Group for Antibiotic
Resistance Surveillance.
NosoBase n° 26488
Précautions contact pour des microorganismes multirésistants aux antibiotiques :
recommandations actuelles et pratiques réelles
Clock SA; Cohen B; Behta M; Ross B; Larson EL. Contact precautions for multidrug-resistant organisms:
current recommendations and actual practice. American journal of infection control 2010/03; 38(2): 105-111.
Motst-clés : RECOMMANDATION; MULTIRESISTANCE; PRECAUTION CONTACT; PRATIQUE; TAUX;
OBSERVANCE; ENTEROCOCCUS; VANCOMYCINE; ANTIBIORESISTANCE; STAPHYLOCOCCUS
AUREUS; METICILLINO-RESISTANCE; PREVENTION; GANT; BLOUSE

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Background: Contact precautions are recommended for interactions with patients colonized/infected with
multidrug-resistant organisms; however, actual rates of implementation of contact precautions are unknown.
Methods: Observers recorded the availability of supplies and staff/visitor adherence to contact precautions
at rooms of patients indicated for contact precautions. Data were collected at 3 sites in a New York City
hospital network.
Results: Contact precautions signs were present for 85.4% of indicated patients. The largest proportions
were indicated for isolation for vancomycin-resistant enterococci and methicillin-resistant Staphylococcus
aureus cultures. Isolation carts were available outside 93.7% to 96.7% of rooms displaying signs, and
personal protective equipment was available at rates of 49.4% to 72.1% for gloves (all sizes: small, medium,
and large) and 91.7% to 95.2% for gowns. Overall adherence rates on room entry and exit, respectively,
were 19.4% and 48.4% for hand hygiene, 67.5% and 63.5% for gloves, and 67.9% and 77.1% for gowns.
Adherence was significantly better in intensive care units (P < .05) and by patient care staff (P < .05), and
patient care staff compliance with one contact precautions behavior was predictive of adherence to
additional behaviors (P < .001).
Conclusions: Our findings support the recommendation that methods to monitor contact precautions and
identify and correct nonadherent practices should be a standard component of infection prevention and
control programs.
NosoBase n° 26432
Schémas des traitements antibiotiques dans des infections nosocomiales sévères : choix
empiriques, proportion de traitements appropriés et taux d'adaptation. Etude multicentrique
d'observation
Vogelaers D; De Bels D; Foret F; Cran S; Gilbert E; Schoonheydt K; et al. Patterns of antimicrobial therapy
in severe nosocomial infections: empiric choices, proportion of appropriate therapy, and adaptation rates - a
multicentre, observational survey in critically ill patients. International journal of antimicrobial agents 2010, in
press: 7 pages
Mots-clés : INFECTION TRAITEMENT; ANTIBIOTIQUE; ETUDE PROSPECTIVE; TAUX; SOIN INTENSIF;
PNEUMONIE; BACTERIEMIE; FACTEUR DE RISQUE; VENTILATION ASSISTEE; MEROPENEME
This prospective, observational multicentre (n=24) study investigated relationships between antimicrobial
choices and rates of empiric appropriate or adequate therapy, and subsequent adaptation of therapy in 171
ICU patients with severe nosocomial infections. Appropriate antibiotic therapy was defined as in vitro
susceptibility of the causative pathogen and clinical response to the agent administered. In non-
microbiologically documented infections, therapy was considered adequate in the case of favourable clinical
response <5 days. Patients had pneumonia (n=127; 66 ventilator-associated), intra-abdominal infection
(n=23), and bloodstream infection (n=21). Predominant pathogens were Pseudomonas aeruginosa (n=29)
Escherichia coli (n=26), Staphylococcus aureus (n=22), and Enterobacter aerogenes (n=21). In 49.6% of
infections multidrug-resistant (MDR) bacteria were involved, mostly extended-spectrum beta-lactamase
(EBSL)-producing Enterobacteriaceae and MDR non-fermenting Gram-negative bacteria. Prior antibiotic
exposure and hospitalisation in a general ward prior to ICU admission were risk factors for MDR. Empiric
therapy was appropriate/adequate in 63.7% of cases. Empiric schemes were classified according to
coverage of (i) ESBL-producing Enterobacteriaceae and non-fermenting Gram-negative bacteria
("meropenem-based"), (ii) non-fermenting Gram-negative bacteria (schemes with an antipseudomonal
agent), and (iii) first-line agents not covering ESBL-Enterobacteriaceae nor non-fermenting Gram-negative
bacteria. Meropenem-based schemes allowed for significantly higher rates of appropriate/adequate therapy
(p<0.001). This benefit remained when only patients without risk factors for MDR were considered
(p=0.021). In 106 patients (61%) empiric therapy was modified: in 60 cases following initial
inappropriate/inadequate therapy, in 46 patients in order to refine empiric therapy. In this study reflecting
real-life practice, first-line use of meropenem provided significantly higher rates of the appropriate/adequate
therapy, irrespective of presence of risk factors for MDR.
Appareil respiratoire
NosoBase n° 26540
Fréquence, prévention, évolution et traitement des trachéobronchites associées à la ventilation :
revue systématique et méta-analyse