Azithromycin Prophylaxis for Cesarean Delivery

Rothaus, C. The New England Journal of Medicine. Published online: September 29th 2016

Cesarean delivery is the most common major surgical procedure and is associated with a rate of surgical-site infection (including endometritis and wound infection) that is 5 to 10 times the rate for vaginal delivery. Tita et al. assessed whether the addition of azithromycin to standard antibiotic prophylaxis before skin incision would reduce the incidence of infection after cesarean section among women who were undergoing nonelective cesarean delivery during labor or after membrane rupture. In this new Original Article involving women who received standard antibiotic prophylaxis for nonelective cesarean section, the risk of infection after surgery was lower with the addition of azithromycin than with placebo.

Clinical Pearl

• How does pregnancy-associated infection rank as a cause of maternal death in the United States?

Globally, pregnancy-associated infection is a major cause of maternal death and is the fourth most common cause in the United States.

Clinical Pearl

• How often do postoperative infections occur after nonelective cesarean delivery?

Despite routine use of antibiotic prophylaxis (commonly, a cephalosporin given before skin incision), infection after cesarean section remains an important concern, particularly among women who undergo nonelective procedures (i.e., unscheduled cesarean section during labor, after membrane rupture, or for maternal or fetal emergencies). As many as 60 to 70% of all cesarean deliveries are nonelective; postoperative infections occur in up to 12% of women undergoing nonelective cesarean delivery with standard preincision prophylaxis.#

Read the full Now@NEJM Blog post here

Read the original research article here

ATMs and Pedestrian Crossing Controls adjacent to major University Teaching hospitals exhibit an exclusively Gram-positive flora

Elshibly, M. et al. Journal of Hospital Infection. Published online: September 23 2016

atm-1524870_960_720

Antimicrobial resistance (AMR) has emerged as a global public health problem, largely due to the development of acquired antibiotic resistance in hitherto susceptible organisms, coupled with the transmissibility of such organisms from patient-to-patient, as well as from the environment-to-patient.

In order to help combat AMR, additional evidence is required regarding the potential occurrence, persistence and transmission of AMR organisms within and outside the healthcare environment. Whilst relatively well understood within the healthcare setting, there remains a relative paucity of evidence regarding these three attributes for organisms outside the healthcare environment.

Read the abstract here

UK NSC evidence review process

This document describes the process used by the UK National Screening Committee (UK NSC) to review the evidence relating to the introduction, modification and cessation of national population screening programmes.

The process set out in the document builds on the UK NSC’s previous practice and will be revisited and refined in winter 2016 following:

  • the pilot of the annual call for new topics
  • further work on the UK NSC’s approach to development of rapid reviews
  • completion of a statement on cost effectiveness assessments
  • completion of a framework for consideration of ethical, social and legal issues relating to screening

Overall UK NSC evidence review process:

new_review_flowchart_2

Image source: http://www.gov.uk/

Effect of Chlorhexidine Bathing Every Other Day on Prevention of Hospital-Acquired Infections in the Surgical ICU

Swan, J.T. et al. (2016) Critical Care Medicine. 44(10) pp. 1822–1832

rubber-duck-1390639_960_720Objective: To test the hypothesis that compared with daily soap and water bathing, 2% chlorhexidine gluconate bathing every other day for up to 28 days decreases the risk of hospital-acquired catheter-associated urinary tract infection, ventilator-associated pneumonia, incisional surgical site infection, and primary bloodstream infection in surgical ICU patients.

Design: This was a single-center, pragmatic, randomized trial. Patients and clinicians were aware of treatment-group assignment; investigators who determined outcomes were blinded.

Setting: Twenty-four–bed surgical ICU at a quaternary academic medical center.

Patients: Adults admitted to the surgical ICU from July 2012 to May 2013 with an anticipated surgical ICU stay for 48 hours or more were included.

Interventions: Patients were randomized to bathing with 2% chlorhexidine every other day alternating with soap and water every other day (treatment arm) or to bathing with soap and water daily (control arm).

Measurements and Main Results: The primary endpoint was a composite outcome of catheter-associated urinary tract infection, ventilator-associated pneumonia, incisional surgical site infection, and primary bloodstream infection. Of 350 patients randomized, 24 were excluded due to prior enrollment in this trial and one withdrew consent. Therefore, 325 were analyzed (164 soap and water versus 161 chlorhexidine). Patients acquired 53 infections. Compared with soap and water bathing, chlorhexidine bathing every other day decreased the risk of acquiring infections (hazard ratio = 0.555; 95% CI, 0.309–0.997; p = 0.049). For patients bathed with soap and water versus chlorhexidine, counts of incident hospital-acquired infections were 14 versus 7 for catheter-associated urinary tract infection, 13 versus 8 for ventilator-associated pneumonia, 6 versus 3 for incisional surgical site infections, and 2 versus 0 for primary bloodstream infection; the effect was consistent across all infections. The absolute risk reduction for acquiring a hospital-acquired infection was 9.0% (95% CI, 1.5–16.4%; p = 0.019). Incidences of adverse skin occurrences were similar (18.9% soap and water vs 18.6% chlorhexidine; p = 0.95).

Conclusions: Compared with soap and water, chlorhexidine bathing every other day decreased the risk of acquiring infections by 44.5% in surgical ICU patients.

Progress report on the UK 5 year antimicrobial resistance (AMR) strategy

Department of Health | Published online: 16 September 2016

dh5y.png

Image source: gov.uk

Lord O’Neill’s review, ‘Tackling drug-resistant infections globally’ made 10 recommendations on how to best prevent the challenge of antimicrobial resistance (AMR). The recommendations include raising awareness of AMR globally, reducing the use of antibiotics in animals and improving hygiene to help stop the spread of infection.

The UK government response accepts these recommendations as part of its ongoing AMR strategy. The government also published its second annual progress report on the UK’s 5 year AMR strategy.

Lord O’Neil’s report also highlights the consequences if we do not act to prevent the growing crisis – predicting 10 million deaths a year by 2050, an effect on the world economy of $100 trillion, and the potential end of modern medicine as we know it.

The UK is already leading on a range of measures aimed at preventing AMR across the globe. These include:

  • investing £265 million to strengthen the surveillance of antimicrobial use and resistance, which is already helping 11 countries worldwide and will be expanding in 2017
  • using a £50 million investment to start a global AMR innovation fund to develop new antimicrobials along with diagnostic tools and vaccines
  • investing in the development of quick diagnosis tests, making sure people are given the right drugs for the right infection at the right time, the new tests, once proven to be effective, will available in both the UK and internationally
  • almost halving the British meat poultry industry’s use of antibiotics between 2012 and 2015 through improvements in training, stewardship, and disease control

Read the full report here

Can the design of glove dispensing boxes influence glove contamination?

Assadian, O. et al. The Journal of Hospital Infection. Published online: September 15 2016

https://www.flickr.com/photos/mikecogh/20464487373

Image source: Michael Coghlan – Flickr // CC BY-SA 2.0

Background: Few studies have explored the microbial contamination of glove boxes in clinical settings. The objective of this observational study was to investigate whether a new glove packaging system in which gloves are dispensed one by one vertically with the cuff-end first has lower levels of contamination on the gloves and on the surface around the box aperture compared to conventional horizontally dispensed glove boxes.

Methods: Seven participating sites were provided with vertical glove dispensing systems and conventional boxes. Before opening boxes, the surface around the aperture was sampled microbiologically to establish base-line levels of superficial contamination. Once the boxes were opened, the first pair of gloves in each box were sampled for viable bacteria. Thereafter, testing sites were visited on a weekly basis over a period of six weeks and the same microbiological assessments made.

Results: The surface surrounding the aperture of the modified dispenser boxes became significantly less contaminated than the conventional boxes (P < 0.001) with an average of 46.7% less contamination around the aperture. Overall, gloves from modified boxes showed significantly less colony-forming units contamination than gloves from conventional boxes (P < 0.001). Comparing all sites over the entire six-week period, modified dispensed gloves had 88.9% less bacterial contamination.

Conclusion: This simple improvement to glove box design reduces contamination of unused gloves. Such modifications could decrease the risk of microbial cross-transmission in settings that utilise gloves. However, such advantages do not substitute for strict hand-hygiene compliance and appropriate use of non-sterile, single-use gloves.

Read the abstract here