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Didier Pittet

Publications and source records attributed to Didier Pittet.

At least 73 records · Page 4Linked to original sources
PubMed2003

Management of Candida species infections in critically ill patients.

Invasive candidiasis is a feared infection with mortality similar to that of septic shock (40-60%). Improved knowledge of its pathophysiology and the availability of new compounds for antifungal therapy and prophylaxis have contributed to improving the prognosis of severe candidal infections among immunosuppressed patients at the possible cost of the emergence of non-albicans strains of candida with lower susceptibility to azoles. This review focuses on the management of invasive deep-seated candidiasis in critically ill, non-immunocompromised patients. We discuss antifungal use, indications, potential benefit, and main secondary effects. Prevention strategies include pre-emptive antifungal therapy and azole-based prophylaxis. For patients at lower initial risk, pre-emptive therapy should be based on a management strategy that takes into account the presence of definite risk factors and the dynamics of candida colonisation. Among critically ill patients, azole prophylaxis is effective and is not associated with acquisition of resistance; it must be restricted to highly selected groups of patients at high risk only.

Amphotericin B↗
PubMed2003

Comparison of waterless hand antisepsis agents at short application times: raising the flag of concern.

OBJECTIVE: Although alcohol-based hand rinses and gels have recommended application times of 30 to 60 seconds, healthcare workers usually take much less time for hand hygiene. We compared the efficacies of four alcohol-based hand rubs produced in Europe (hand rinses A, B, and C and one gel formulation) with the efficacy of the European Norm 1500 (EN 1500) reference waterless hand antisepsis agent (60% 2-propanol) at short application times. DESIGN: Comparative crossover study. SETTING: Infection Control Program laboratory of a large tertiary-care teaching hospital. PARTICIPANTS: Twelve healthy volunteers. INTERVENTION: Measurement of residual bacterial counts and log reduction factors following inoculation of fingertips with Staphylococcus aurens American Type Culture Collection (ATCC) 6538, Pseudomonas aeruginosa ATCC 15442, and a clinical isolate of Enterococcus faecalis. RESULTS: All hand rinses satisfied EN 1500 standards following a single application for 15 and 30 seconds, but reduction factors for the gel formulation were significantly lower for all tested organisms (all P < .025). CONCLUSIONS: Under stringent conditions similar to clinical practice, all three hand rinses proved to be more efficacious than the marketed alcohol-based gel in reducing bacterial counts on hands. Further studies are necessary to determine the in vivo efficacy of alcohol-based gels and whether they are as efficacious as alcohol-based rinses in reducing the transmission of nosocomial infections.

Anti-Infective Agents, Local↗
PubMed2003

Are there regional variations in the diagnosis, surveillance, and control of methicillin-resistant Staphylococcus aureus?

OBJECTIVE: To assess the way healthcare facilities (HCFs) diagnose, survey, and control methicillin-resistant Staphylococcus aureus (MRSA). DESIGN: Questionnaire. SETTING: Ninety HCFs in 30 countries. RESULTS: Evaluation of susceptibility testing methods showed that 8 laboratories (9%) used oxacillin disks with antimicrobial content different from the one recommended, 12 (13%) did not determine MRSA susceptibility to vancomycin, and 4 (4.5%) reported instances of isolation of vancomycin-resistant S. aureus but neither confirmed this resistance nor alerted public health authorities. A MRSA control program was reported by 55 (61.1%) of the HCFs. The following isolation precautions were routinely used: hospitalization in a private room (34.4%), wearing of gloves (62.2%), wearing of gowns (44.4%), hand washing by healthcare workers (53.3%), use of an isolation sign on the patient's door (43%), or all four. When the characteristics of HCFs with low incidence rates (< 0.4 per 1,000 patient-days) were compared with those of HCFs with high incidence rates (> or = 0.4 per 1,000 patient-days), having a higher mean number of beds per infection control nurse was the only factor significantly associated with HCFs with high incidence rates (834 vs 318 beds; P = .02). CONCLUSION: Our results emphasize the urgent need to strengthen the microbiologic and epidemiologic capacities of HCFs worldwide to prevent MRSA transmission and to prepare them to address the possible emergence of vancomycin-resistant S. aureus.

Cross Infection↗
PubMed2003

Effect of vancomycin therapy for osteomyelitis on colonization by methicillin-resistant Staphylococcus aureus: lack of emergence of glycopeptide resistance.

BACKGROUND: In treating orthopedic infections, the long-term impact of vancomycin therapy on colonization by methicillin-resistant Staphylococcus aureus (MRSA) and the emergence of vancomycin-intermediate S. aureus is unknown. DESIGN: Prospective surveillance of the effect of long-term vancomycin therapy on colonization by MRSA and the emergence of vancomycin-intermediate S. aureus. METHODS: Thirty-four patients with MRSA osteomyelitis that was microbiologically documented were longitudinally observed for the emergence of vancomycin-intermediate S. aureus at 3 body sites (wound, anterior nares, and groin) during the initial period of vancomycin therapy and at the 2-month follow-up. Twenty patients received the standard dose (20 mg/kg/d) for 34 +/- 6 days and 14 patients received a high dose (40 mg/kg/d) of vancomycin for 37 +/- 9 days. RESULTS: During vancomycin treatment, global MRSA carriage (all body sites) fell from 100% to 25% in the group of patients receiving the standard dose of vancomycin, and from 100% to 40% in the group receiving the high dose. During the 2-month follow-up period after vancomycin therapy, global MRSA carriage increased from 25% to 55% in the group receiving the standard dose and decreased from 43% to 36% in the group receiving the high dose. CONCLUSION: Therapy with a high dose of vancomycin contributes to the sustained eradication of MRSA carriage without promoting the emergence of glycopeptide resistance.

Adult↗
PubMed2003

Hand-cleansing during postanesthesia care.

BACKGROUND: Transmission of microorganisms from the hands of healthcare workers is the main source of cross-infection and can be prevented by hand-cleansing. The authors assessed the compliance rate with hand-cleansing practices in the postanesthesia care unit and investigated factors associated with noncompliance. METHODS: Patient care activities, indications for and compliance of postanesthesia care unit staff with hand-cleansing, defined as either washing hands with soap and water or rubbing hands with alcohol, were monitored at the time of patient admission and during their stay. Multivariate analysis identified predictors of noncompliance with hand-cleansing on admission after adjustment for confounders. RESULTS: A total of 3,143 patient care activities, including 1,091 opportunities for hand-cleansing at high or medium risk for cross-transmission, were recorded among 187 patients. The higher the workload, the higher the number of indications for hand-cleansing and the lower the compliance. Average compliance with hand-cleansing at postanesthesia care unit admission was 19.6%. Independent predictors for noncompliance included caring for patients older than 65 yr (odds ratio, 2.23; 95% confidence interval, 1.40-3.57) and those recovering from clean/clean-contaminated surgery (odds ratio, 2.27; 95% confidence interval, 1.11-4.76), as well as high intensity of patient care (odds ratio, 1.01 per patient care activity; 95% confidence interval, 1.0-1.02). Compliance with hand-cleansing for patients already admitted to the postanesthesia care unit was 12.5%. CONCLUSIONS: Failure to cleanse hands during patient care is common in the postanesthesia care unit and is associated with identifiable factors. The close relation between the intensity of patient care and noncompliance argues that hand-cleansing should not be viewed as a problematic individual behavior only, and system change must be considered in prevention strategies.

Adult↗
PubMed2003

Hand hygiene: improved standards and practice for hospital care.

PURPOSE OF REVIEW: To review the most recently published literature on hand hygiene practices in healthcare settings. RECENT FINDINGS: Adherence with recommendations for hand hygiene remains low, but key factors of noncompliance have been identified and corrective actions proposed. Current guidelines recommend the use of alcohol-based handrub formulations as the new standard of care, thus requiring a system change in most hospitals. In addition, healthcare worker education and motivation are obviously important to modify hand hygiene behavior and must be part of multimodal strategies to enhance compliance in hospitals. Compliance improvement is associated with reduced infection rates and resistance spread. Handrub application according to recommended practices is an alternative to conventional surgical handscrubbing with antiseptic soap and water for surgical hand preparation. SUMMARY: System change must be addressed in most hospitals where alcohol-based handrubbing has not become a standard of care. Strategies to improve hand hygiene compliance must be multimodal and include staff education and motivation, the use of performance indicators, and hospital management support. Successful campaigns will result in reduced infection rates, antimicrobial resistance spread, and enhance patient safety.

Guideline Adherence↗
PubMed2003

Bacteremic sepsis in intensive care: temporal trends in incidence, organ dysfunction, and prognosis.

OBJECTIVE: To determine whether changes have occurred at our center in the incidence, patterns of organ dysfunctions, prognostic factors, and case-fatality rate of bacteremic sepsis. DESIGN: Retrospective comparative study (1984-1988 vs. 1994-1997). SETTING: University hospital surgical intensive care unit. PATIENTS: A total of 372 critically ill patients with sepsis and positive blood cultures. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: In the 1984-1988 study, 176 patients developed bacteremic sepsis (3.2 per 100 admissions), with a fatality rate of 35% at 28 days, whereas in the 1994-1997 study, 196 patients had bacteremic sepsis (4.3 per 100 admissions), with a 28-day fatality rate of 37%. The frequency of primary bacteremia increased from 21% to 47% (p <.001), paralleled by an increase in the proportional frequency of Gram-positive microorganisms. In 1984-1988, 69% (n = 120) of patients had at least one organ dysfunction, compared with 80% (n = 156) in 1994-1997 (p =.02). The prevalence of pulmonary and cardiac dysfunction increased. The case- fatality rate of septic shock remained high (69% vs. 68%). For both cohorts, the two strongest predictors of mortality remained the Acute Physiology and Chronic Health Evaluation II score at the onset of sepsis and the number of evolving organ dysfunctions. CONCLUSION: The fatality rate of bacteremic sepsis remained constant over the study period, despite an increased incidence of bacteremia and associated organ dysfunction. Continued efforts need to be directed toward the prevention of bacteremic sepsis, given the magnitude and poor prognosis of this syndrome.

Aged↗
PubMed2003

Rapid detection of methicillin-resistant Staphylococcus aureus directly from sterile or nonsterile clinical samples by a new molecular assay.

A rapid procedure was developed for detection and identification of methicillin-resistant Staphylococcus aureus (MRSA) directly from sterile sites or mixed flora samples (e.g., nose or inguinal swabs). After a rapid conditioning of samples, the method consists of two main steps: (i) immunomagnetic enrichment in S. aureus and (ii) amplification-detection profile on DNA extracts using multiplex quantitative PCR (5'-exonuclease qPCR, TaqMan). The triplex qPCR assay measures simultaneously the following targets: (i) mecA gene, conferring methicillin resistance, common to both S. aureus and Staphylococcus epidermidis; (ii) femA gene from S. aureus; and (iii) femA gene from S. epidermidis. This quantitative approach allows discrimination of the origin of the measured mecA signal. qPCR data were calibrated using two reference strains (MRSA and methicillin-resistant S. epidermidis) processed in parallel to clinical samples. This 96-well format assay allowed analysis of 30 swab samples per run and detection of the presence of MRSA with exquisite sensitivity compared to optimal culture-based techniques. The complete protocol may provide results in less than 6 h (while standard procedure needs 2 to 3 days), thus allowing prompt and cost-effective implementation of contact precautions.

Bacterial Proteins↗
PubMed2002

Interhospital differences in nosocomial infection rates: importance of case-mix adjustment.

BACKGROUND: Nosocomial infection rates are used to assess patient safety and the effectiveness of health care systems, but adjustment for case-mix, a key factor for benchmarking, is often overlooked. OBJECTIVES: To perform a nationwide prevalence study of nosocomial infection and evaluate the impact of hospital size on infection rates. METHODS: One-week-period prevalence study in 18 acute care hospitals ranging from small primary to large tertiary care institutions. All adult inpatients in medical, surgical, and intensive care units hospitalized at time of study were included. Infection prevalence and case-mix determinants were calculated according to hospital size. After each factor was tested for its significance on the occurrence of nosocomial infection, all factors were introduced in a multivariate model with hospital size as the main explanatory variable and nosocomial infection as the dependent variable. RESULTS: Among 4252 patients, 429 developed 470 nosocomial infections, for an overall prevalence of 10.1% (intensive care units, 29.7%; medical, 9.3%; surgical, 9.2%; and mixed wards, 14.1%). Unadjusted prevalence rates were 6.1% in small, 10.0% in intermediate, and 10.9% in large hospitals (P =.007). Increased comorbidity (odds ratio, 1.80), cancer (1.68), trauma (1.75), neutropenia (4.66), antibiotic exposure (6.64), history of intensive care unit stay (2.14), referral from another hospital (1.87), intubation for 24 hours or more (2.09), and prolonged stay (3.35) were independently associated with nosocomial infection (all P<.05), but hospital size was not. CONCLUSIONS: Higher infection rates observed in larger hospitals were partly associated with unfavorable case mix. Unadjusted rates may lead to erroneous assumptions for health care prioritization.

Aged↗
PubMed2002

Prevention of severe Candida infections in nonneutropenic, high-risk, critically ill patients: a randomized, double-blind, placebo-controlled trial in patients treated by selective digestive decontamination.

OBJECTIVE: Infections caused by Candida spp. are a major cause of morbidity and mortality in critically ill patients and usually develop from endogenous colonization. We assessed the effectiveness of adding fluconazole to a selective digestive decontamination regimen to prevent candidal infections. DESIGN AND SETTING: We performed a prospective, randomized, double-blind, placebo-controlled trial among medical and surgical intensive care unit patients at a large university hospital. PATIENTS: All adult patients mechanically ventilated for at least 48 h with an expectation to remain so for at least an additional 72 h, and receiving selective decontamination of the digestive tract. INTERVENTIONS: Patients were randomly assigned fluconazole 100 mg daily (n=103) or placebo (n=101). MEASUREMENTS AND RESULTS: Candida infections occurred less frequently in the fluconazole group (5.8%) than in the placebo group (16%; rate ratio 0.35; Cl(95) 0.11-0.94). Some 90% of candidemia episodes occurred in the placebo group (rate ratio for fluconazole use 0.10; Cl(95) 0.02-0.74). The rate of treatment failure, development of candidal infection, or increased colonization, was 32% in the fluconazole group and 67% in the placebo group (P<0.001). Crude in-hospital mortality was similar in the two groups (39% fluconazole vs. 41% placebo). CONCLUSIONS: Prophylactic use of fluconazole in a selected group of mechanically ventilated patients at high risk for infection reduces the incidence of Candida infections, in particular candidemia.

Aged↗
PubMed2002

Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America.

The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission ofpathogenic microorganisms to patients and personnel in health-care settings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231-43) and the 1995 APIC guideline (Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251-69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in vivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.

Alcohols↗
PubMed2002

Legionnaires' disease in a renal transplant recipient: nosocomial or home-grown?

Legionnaires' disease is a community-acquired or hospital-acquired pneumonia, and the immunocompromised patient is at particular risk. We report a case of serogroup 1 pneumonia in a renal transplant patient shortly after grafting. No source of infection was identified in the hospital unit, but an extended investigation located patient exposure to a shower during a weekend home stay. Sampling at the hospital, in the patient's flat, other flats, and the laundry of the same building returned only one positive result from the patient's showerhead. Strain identity was confirmed by pulsed-field electrophoresis and amplified fragment length polymorphism. Guidelines recommend -free water for transplant units, but further epidemiologic evidence is required before extending this preventive approach to the patient's home.

Cross Infection↗
PubMed2002

Alcohol-based handrub improves compliance with hand hygiene in intensive care units.

BACKGROUND: Nosocomial infection is a leading complication in intensive care units. Although hand hygiene is the single most efficient preventive measure, compliance with this simple action remains low. OBJECTIVES: To assess the effect of an intervention to promote hand hygiene and to investigate risk factors for noncompliance in intensive care units. METHODS: We performed 7 observational surveys and implemented a promotional campaign after baseline in medical, surgical, and pediatric intensive care units of a teaching hospital. Health care workers were observed during routine patient care. The intervention consisted of a hospitalwide promotional campaign, including observation and performance feedback, posters display, and distribution of individual bottles of alcohol-based handrub. The main outcome measure was compliance with hand hygiene through handwashing or handrubbing. RESULTS: We observed 2743 opportunities for hand hygiene distributed over 248 periods. Overall compliance increased from 38.4% to 54.5% during the study (P<.001). Although recourse to handwashing remained stable at around 30%, handrubbing increased from 5.4% at baseline to 21.7% at the last survey (P<.001). Compliance increased among nurses and nursing assistants, but remained stable among physicians. Handwashing compliance decreased, on average, by 4.7% for an increase of 10 opportunities for hand hygiene per hour of patient care (P<.001), whereas no such association existed for handrubbing. CONCLUSIONS: Our intervention induced a marked and sustained increase in compliance with hand hygiene. In intensive care units, less time-consuming handrubbing might replace standard handwashing and overcome the barrier of time constraints.

Critical Care↗
PubMed2002

Epidemiology of methicillin-resistant Staphylococcus aureus: results of a nation-wide survey in Switzerland.

OBJECTIVE: To assess the epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) in Switzerland. MATERIAL AND METHODS: One-year national survey of all MRSA cases detected in a large sample of Swiss healthcare institutions (HCI). Analysis of epidemiological and molecular typing data (PFGE) of MRSA strains. RESULTS: During 1997, 385 cases of MRSA were recorded in the 5 university hospitals, in 33 acute care community hospitals, and 14 rehabilitation or long-term care institutions. Half of the cases were found at the University of Geneva Hospitals where MRSA was already known to be endemic (41.1 cases/10,000 admissions). The remaining cases (200) were distributed throughout Switzerland. The highest rates (>100 cases/10,000 admissions) were reported from non-acute care institutions. Rates ranged from 3.3 to 41.1 cases/10,000 admissions for university hospitals (mean 15.5); 0.67 to 90.4 for community hospitals (mean 4.8), and 28.2 to 315 for non-acute care institutions reporting MRSA (mean 85.7). Forty percent of MRSA patients were infected, while 60% were only colonised. The leading infection sites were skin and soft tissue (21%), surgical site (15%), and the urinary tract (26%). Whereas in Eastern Swiss HCI most MRSA cases occurred in acute care hospitals (n = 47, 98%), rehabilitation and long-term care institutions accounted for an important number of the identified cases (n = 107, 38%) in Western Switzerland. CONCLUSION: Low rates of MRSA were still observed in Swiss HCI, despite one outlying acute care centre with endemic MRSA and some nonacute care institutions with epidemic MRSA. Rehabilitation and long-term care institutions contributed to a substantial proportion of cases in Western Switzerland and may constitute a significant reservoir. Overall, a national approach to surveillance and control of MRSA is mandatory in order to preserve a still favourable situation, and to decrease the risk of epidemic MRSA dissemination.

Adolescent↗
PubMed2002

Limited efficacy of alcohol-based hand gels.

Alcohol-based gels have been introduced recently in many hospitals worldwide for hand antisepsis. We investigated the antimicrobial efficacy of ten gels and four rinses according to European standards (EN 1500). No gel met the EN 1500 requirements within 30 s of application, whereas all hand rinses did. The tested hand gels should be considered a retrograde step for hand hygiene because the application time in clinical practice is often shorter than 30 s; they should not replace alcohol-based liquid hand disinfectants currently used in hospitals or be implemented as first choice agents.

1-Propanol↗
PubMed2002

Infective endocarditis: too ill to be operated?

Infective endocarditis remains a disease associated with high mortality in certain groups of patients, with death resulting primarily from central nervous system complications and congestive heart failure. Combined medical and surgical therapy reduces both early and late mortality in complicated cases, especially in patients with valvular dysfunction related to heart failure. In these patients, heart failure is the strongest indication for valve replacement. There are no consensus indications for surgery, however, in the presence of neurological complications or multiple organ failure. Limited data suggest that such surgery is feasible, even in complicated cases necessitating admission to the intensive care unit, and carries an acceptable risk for in-hospital mortality. It is important that critically ill patients with infective endocarditis are enrolled into multicenter studies, using adequate severity scoring systems to assess the impact of clinical and imaging variables on patients' outcome. Until such data are obtained, clinical judgement is still the best tool in decision-making regarding the individual patient.

Critical Care↗