BackgroundThe World Health Organization's Infection Prevention and Control Assessment Framework (IPCAF) is widely used to evaluate infection prevention and control (IPC) quality in hospitals, but IPC standards in long-term care facilities (LTCFs) are less studied and standardized. The IPCAF has not previously been used in LTCFs. This study aimed to pilot an adapted version of the IPCAF in Dutch LTCFs to assess its usability, perceived feasibility and acceptability in this context.MethodsFirst, the IPCAF was translated and adapted to the Dutch LTCF context through expert consultation for relevance. In this pilot, the adapted IPCAF was then completed during face-to-face interviews together with a multidisciplinary team in fourteen healthcare groups between May and September 2024. Second, LTCF characteristics were collected in advance through a separate questionnaire on LTCF level. Finally, after receiving feedback reports, LTCFs completed a separate web-based survey about their experiences with the process. Data were summarized descriptively and group differences were tested using the Kruskal-Wallis test.ResultsMost participants found the adapted IPCAF clear and informative, appreciating its ability to highlight areas needing attention and identify priorities for improvement. About a quarter of LTCFs expressed willingness to use the adapted IPCAF in the future, while over half were hesitant. IPC standards were generally high, with the highest scores for 'Workload, staffing and bed occupancy' and 'Environments, materials and equipment for IPC'. The lowest scores were for 'HAI surveillance' and 'IPC education', with only five LTCFs including HAI surveillance in their IPC programs.ConclusionsThis is the first study to adapt the WHO IPCAF as a tool for measuring IPC in LTCFs and to evaluate its usability, perceived feasibility, and acceptability in this context. The adapted IPCAF can be implemented in LTCFs and may help identify IPC priorities and areas for improvement. However, greater familiarity and support may be needed to enable wider adoption. While IPC standards were relatively high in the LTCFs included in this pilot, ongoing attention to surveillance and education remains essential. Further research may be needed to validate our findings in larger and more diverse LTCF populations and to explore its impact on IPC outcomes.

INTRODUCTION:Antimicrobial resistance (AMR) has become one of the leading global health threats. It is critical to understand the burden of AMR, particularly among vulnerable populations such as people with intellectual disabilities residing in long-term care facilities (ID-LTCFs). Traditional study methods to estimate the burden of AMR in these settings, such as rectal swabs to measure the prevalence of MDRO carriage, are considered burdensome for this population. This underscores the importance of a non-invasive method to assess the burden of AMR among people living in ID-LTCFs. This publication describes a study protocol for an alternative approach to estimate AMR, specifically Extended Spectrum Beta-Lactamase (ESBL) and carbapenemase-producing Enterobacterales (CPE), in ID-LTCFs in the Netherlands, through wastewater measurements combined with analysis of stool collected from diaper material. The protocol provides detailed information about the study design and methodologies proposed for a pilot study. METHODS AND ANALYSIS:Wastewater samples will be obtained from the sewers of ID-LCTFs using passive samplers. Additionally, as a considerable part of ID-LTCF residents are incontinent, stool samples will be collected from diaper material which will be obtained from incontinent residents living in participating ID-LTCFs. The wastewater and stool samples will be cultured on selective media to detect ESBL-producing Enterobacterales and carbapenem producing Enterobacterales (CPE) strains. Determination of strains will be carried out using MALDI-TOF and phenotypical tests will be carried out to confirm ESBL and CPE producing strains. In wastewater samples, bacterial concentrations will be determined, expressed in colony forming unit (CFU) per passive sampler, while in stool from diaper material the presence or absence of ESBL and CPE will be reported in proportions. ETHICS AND DISSEMINATION:The procedures described in this study protocol will be conducted in line with principles outlined in the Declaration of Helsinki, Code of Conduct for Health research, as well as the General Data Protection Regulation. Approval in advance by an ethical research committee or institutional review board is deemed unnecessary by current national and European legislation.

Recently, several methicillin-resistant Staphylococcus aureus (MRSA) community outbreaks occurred in the Netherlands, including one caused by an impetigo-causing MRSA strain resistant to fusidic acid. Since fusidic acid and flucloxacillin are the main treatment options for impetigo, increasing resistance limits treatment possibilities. We examined trends in fusidic acid resistance levels among MRSA isolates in the Netherlands. Data on routine bacteriological cultures between 2016-2023 from 30 laboratories were extracted from the national surveillance system on antimicrobial resistance (ISIS-AR). Fusidic acid resistance rates per year were calculated both overall and per age group for all MRSA isolates, and more specific, for the subset of MRSA isolates from wound/pus/skin samples collected by general practitioners (WPS-GP-samples). Trends were determined using logistic regression and compared with trends among methicillin-susceptible S. aureus (MSSA) isolates. We found an increasing trend in fusidic acid resistance among MRSA isolates from 15% in 2016 to 30% in 2023 (p<0.001) which differed significantly from the trend among MSSA isolates (p<0.001). An increase was also found in MRSA WPS-GP-samples, both among young children and the population of 13-64 years old, but not among elderly. The trends remained significant after exclusion of isolates associated with known fusidic acid-resistant MRSA outbreaks, both among MRSA isolates overall (OR = 1.10, 95% CI: 1.07-1.14, p<0.001) and among MRSA WPS-GP-samples (OR = 1.14, 1.07-1.21, p<0.001). In conclusion, an increasing trend in fusidic acid resistance was found among MRSA isolates. Since impaired treatment for impetigo might ease the spread of (fusidic acid-resistant) MRSA, extra vigilance is warranted.

Background Antimicrobial resistance (AMR) has become one of the major public health threats worldwide, emphasizing the necessity of preventing the development and transmission of drug resistant microorganisms. This is particularly important for people with vulnerable health conditions, such as people with intellectual disabilities (ID) and long-term care residents. This study aimed to assess the current status of AMR, antimicrobial stewardship (AMS) and infection prevention and control (IPC) in Dutch long-term care facilities for people with intellectual disabilities (ID-LTCFs). Methods A web-based cross-sectional survey distributed between July and November 2023, targeting (both nonmedically and medically trained) healthcare professionals working in ID-LTCFs in The Netherlands, to study knowledge, attitudes and perceptions regarding AMR, AMS and IPC. Results In total, 109 participants working in 37 long-term care organizations for people with intellectual disabilities throughout the Netherlands completed the questionnaire. The knowledge levels of AMR and IPC among nonmedically trained professionals (e.g., social care professionals) were lower than those among medically trained professionals (p = 0.026). In particular regarding the perceived protective value of glove use, insufficient knowledge levels were found. Furthermore, there was a lack of easy-read resources and useful information regarding IPC and AMR, for both healthcare professionals as well as people with disabilities. The majority of the participants (> 90%) reported that AMR and IPC need more attention within the disability care sector, but paradoxically, only 38.5% mentioned that they would like to receive additional information and training about IPC, and 72.5% would like to receive additional information and training about AMR. Conclusion Although the importance of AMR and IPC is acknowledged by professionals working in ID-LTCFs, there is room for improvement in regards to appropriate glove use and setting-specific IPC and hygiene policies. As nonmedically trained professionals comprise most of the workforce within ID-LTCFs, it is also important to evaluate their needs. This can have a substantial impact on developing and implementing AMR, AMS and/or IPC guidelines and policies in ID-LTCFs.

OBJECTIVES:Recently, reports on antimicrobial-resistant Bacteroides and Prevotella isolates have increased in the Netherlands. This urged the need for a surveillance study on the antimicrobial susceptibility profile of Bacteroides, Phocaeicola, Parabacteroides and Prevotella isolates consecutively isolated from human clinical specimens at eight different Dutch laboratories. METHODS:Each laboratory collected 20-25 Bacteroides (including Phocaeicola and Parabacteroides) and 10-15 Prevotella isolates for 3 months. At the national reference laboratory, the MICs of amoxicillin, amoxicillin/clavulanic acid, piperacillin/tazobactam, meropenem, imipenem, metronidazole, clindamycin, tetracycline and moxifloxacin were determined using agar dilution. Isolates with a high MIC of metronidazole or a carbapenem, or harbouring cfiA, were subjected to WGS. RESULTS:Bacteroides thetaiotaomicron/faecis isolates had the highest MIC90 values, whereas Bacteroides fragilis had the lowest MIC90 values for amoxicillin/clavulanic acid, piperacillin/tazobactam, meropenem, imipenem and moxifloxacin. The antimicrobial profiles of the different Prevotella species were similar, except for amoxicillin, for which the MIC50 ranged from 0.125 to 16 mg/L for Prevotella bivia and Prevotella buccae, respectively. Three isolates with high metronidazole MICs were sequenced, of which one Bacteroides thetaiotaomicron isolate harboured a plasmid-located nimE gene and a Prevotella melaninogenica isolate harboured a nimA gene chromosomally.Five Bacteroides isolates harboured a cfiA gene and three had an IS element upstream, resulting in high MICs of carbapenems. The other two isolates harboured no IS element upstream of the cfiA gene and had low MICs of carbapenems. CONCLUSIONS:Variations in resistance between species were observed. To combat emerging resistance in anaerobes, monitoring resistance and conducting surveillance are essential.

Abstract Background Antimicrobial resistance (AMR) has become one of the major public health threats worldwide. However, little is known about antimicrobial resistance and infection prevention and control (IPC) in long-term care facilities for people with intellectual disabilities. This study aims to assess knowledge, attitudes and perceptions towards AMR and IPC among healthcare professionals working in long-term care facilities for people with intellectual disabilities (ID-LTCFs) in the Netherlands. Methods We conducted a web-based cross-sectional survey study among medical and nonmedical trained healthcare professionals working in ID-LTCFs in the Netherlands. The survey study was carried out between July and November 2023 and consisted of validated survey items expanded with expert opinion and setting-specific items. Results In total, 109 medical and nonmedical trained healthcare professionals working in 37 long-term care organizations for people with intellectual disabilities throughout the Netherlands completed the questionnaire. Overall, knowledge levels about AMR and IPC differed between medical and nonmedical trained healthcare professionals working in ID-LCTFs, with medically trained professionals having a significant overall higher score on both topics. Knowledge regarding the perceived protective value of glove use was found to be insufficient. Moreover, healthcare professionals expressed a need for easy-to-read resources and tailored setting-specific information on AMR and IPC targeting both healthcare professionals as well as people with disabilities. Conclusions There is room for improvement regarding setting-specific IPC and hygiene policies, such as appropriate glove use in ID-LTCFs. As nonmedically trained professionals comprise most of the workforce within this setting, it is important to further tailor follow-up studies to the underlying factors that influence knowledge, attitudes and perceptions of these specific professionals within ID-LTCFs. Key messages • Developing setting and context-specific policies for infection prevention and control is crucial, particularly in long-term care facilities for people with intellectual disabilities. • Inclusive policy-making is key to combating antimicrobial resistance, and improving infection prevention and control in long-term care facilities for people with intellectual disabilities.

Objective: We assessed trends in the prevalence of healthcare-associated infections (HCAIs) and associated resident and facility characteristics in a national network of long-term care facilities (LTCFs) in the Netherlands from 2009 to 2019.Methods: Participating LTCFs registered the prevalence of urinary tract infection (UTI), lower respiratory tract infection (LRTI), gastrointestinal infection (GI), bacterial con-junctivitis, sepsis and skin infection, using standardized definitions, in biannual point-prevalence surveys (PPSs). In addition, resident and LTCF characteristics were col-lected. Multi-level analyses were performed to study changes in the HCAI prevalence over time and to identify resident and LTCF-related risk factors. Analyses were performed for HCAIs overall and for UTI, LRTI and GI combined as these were recorded throughout the period.Results: Overall, 1353 HCAIs were registered in 44,551 residents with a prevalence of 3.0% (95% confidence interval: 2.8-3.1; range between years 2.3-5.1%). When including only UTI, LRTI and GI the prevalence decreased from 5.0% in 2009 to 2.1% in 2019. Multi -variable regression analyses for UTI, LRTI and GI combined indicated that both pro-longed participation and calendar time were independently associated with HCAI preva-lence; in LTCFs that participated >4 years, the HCAI risk was decreased (OR 0.72 (0.57-0.92)) compared with the first year, and the OR per calendar year was 0.93 (0.88-0.97).Conclusions: Over 11 years of PPS in LTCFs the HCAI prevalence decreased over time. Prolonged participation further reduced the HCAI prevalence, in particular UTIs, despite the increasing age and associated frailty of the LTCF population, illustrating the potential value of surveillance.(c) 2023 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

BACKGROUND:At the beginning of the COVID-19 pandemic in 2020, little was known about the spread of COVID-19 in Dutch nursing homes while older people were particularly at risk of severe symptoms. Therefore, attempts were made to develop a nationwide COVID-19 repository based on routinely recorded data in the electronic health records (EHRs) of nursing home residents. This study aims to describe the facilitators and barriers encountered during the development of the repository and the lessons learned regarding the reuse of EHR data for surveillance and research purposes. METHODS:Using inductive content analysis, we reviewed 325 documents written and saved during the development of the COVID-19 repository. This included meeting minutes, e-mails, notes made after phone calls with stakeholders, and documents developed to inform stakeholders. We also assessed the fitness for purpose of the data by evaluating the completeness, plausibility, conformity, and timeliness of the data. RESULTS:Key facilitators found in this study were: 1) inter-organizational collaboration to create support; 2) early and close involvement of EHR software vendors; and 3) coordination and communication between partners. Key barriers that hampered the fitness of EHR data for surveillance were: 1) changes over time in national SARS-CoV-2 testing policy; 2) differences between EHR systems; 3) increased workload in nursing homes and lack of perceived urgency; 4) uncertainty regarding the legal requirements for extracting EHR data; 5) the short notice at which complete and understandable information about the repository had to be developed; and 6) lack of clarity about the differences between various COVID-19 monitors. CONCLUSIONS:Despite the urgent need for information on the spread of SARS-CoV-2 among nursing home residents, setting up a repository based on EHR data proved challenging. The facilitators and barriers found in this study affected the extent to which the data could be used. We formulated nine lessons learned for developing future repositories based on EHR data for surveillance and research purposes. These lessons were in three main areas: legal framework, contextual circumstances, and quality of the data. Currently, these lessons are being applied in setting up a new registry in the nursing home sector.

Abstract Background People with intellectual disabilities (ID) are an often overlooked high-risk group for health-related issues. In the Netherlands, people with ID may reside at home, in small communities, or within long-term care facilities. This diverse living arrangement challenges the healthcare system, with responsibilities spread among multiple formal and informal caregivers. During an outbreak with multidrug-resistant organisms (MDROs), coordinated efforts should be made to prevent further spread throughout all healthcare settings. Therefore, adequate infection prevention and control (IPC) practices, are required to improve or maintain individual health outcomes. To understand the complexity of MDROs in long-term care for people with ID, it is important to gain insight into knowledge, attitudes and perceptions of involved healthcare professionals and, investigate innovative strategies that could play a role in surveillance or monitoring an outbreak within this setting. Methods We conduct several studies in long-term care for people with ID, using a wide scale of methodologies including a cross-sectional survey study and innovative quantitative methods, such as wastewater surveillance. Results We have identified several challenges in long-term care for people with ID related to IPC and MDROs. First, while IPC and MDRO guidelines exist, they lack specific context and applicability to the long-term care setting. Second, proper use of hand gloves among healthcare professionals demands increased attention as knowledge about this preventive measure seems to be insufficient. Finally, given the challenges in sample collection for MDRO screening, non-invasive strategies are needed to offer insight during outbreaks, serving surveillance or outbreak management purposes. Conclusions Insights from these studies could inform future strategies to prevent or respond early in case of an MDRO outbreak within long-term care for people with ID.

ABSTRACTWe investigated to what extent the consumption of raw or undercooked vegetables, fruits, and fresh herbs influences carriage rates of ESBL/pAmpC-producing Escherichia coli and Klebsiella pneumoniae (ESBL-E/K) in the general population. We assessed long-term carriage and changes in ESBL-E/K prevalence over time, by comparing the results to findings in the same population 5 years earlier. Between July and December 2021, participants sent in two fecal samples and questionnaires, 3 months apart. Food frequency questionnaires were sent on a monthly basis. Fecal samples were cultured and screened for ESBL-E/K, and phenotypically positive isolates were sequenced. Multivariable logistic regression models were established to assess the association between the consumption of fresh produce and ESBL-E/K carriage. The ESBL-E/K prevalence was 7.6% [41/537; 95% confidence interval (CI): 5.7–10.2] in the first sampling round and 7.0% (34/489; 95% CI: 5.0–9.6) in the second. Multivariable models did not result in statistical significance for any of the selected fruit and vegetable types. Trends for increased carriage rates were observed for the consumption of raspberry and blueberry in the summer period. ESBL-E/K prevalence was comparable with the prevalence in the same cohort 5 years earlier (7.5%; 95% CI: 5.6–10.1%). In six persons (1.2%) a genetically highly homologous ESBL-E/K was found. In conclusion, the contribution of the consumption of raw fruits, vegetables, and herbs to ESBL-E/K carriage in humans in the Netherlands is probably low. Despite COVID-19 containment measures (e.g., travel restrictions, social distancing, and hygiene) the ESBL-E/K prevalence was similar to 5 years earlier. Furthermore, indications for long-term carriage were found.IMPORTANCEESBL-producing bacteria are resistant against important classes of antibiotics, including penicillins and cephalosporines, which complicates treatment of infections. Food is one of the main routes of transmission for carriage of these bacteria in the general population. Although fruits, vegetables, and herbs are generally less frequently contaminated with ESBL-producing bacteria compared to meat, exposure might be higher since these products are often eaten raw or undercooked. This research showed that the contribution of the consumption of raw or undercooked fresh produce to ESBL-E/K carriage in the general Dutch population was low. No specific types of fruit or vegetables could be identified that gave a higher risk of carriage. In addition, we demonstrated the presence of genetically highly homologous ESBL-E/K in six persons after a period of 5 years, indicative for long-term carriage.

Introduction: Central venous catheters (CVCs) can lead to central line-related bloodstream infections (CRBSIs). A six-item bundle was introduced in 2009 to prevent CRBSI in Dutch hospitals. Aim: This study aimed to determine the impact of an intervention bundle on CRBSI risk. Methods: Data were obtained from hospitals participating in the national CRBSI surveillance between 2009 and 2019. Bundle compliance was evaluated as a total ('overall') bundle (all six items) and as an insertion bundle (four items) and a maintenance bundle (two daily checks). We estimated the impact of the overall and partial bundles, using multi-level Cox regression. Findings: Of the 66 hospitals in the CRBSI surveillance 56 (84.8%) recorded annual bundle (non)compliance for >80% of the CVCs, for one to nine years. In these 56 hospitals CRBSI incidence decreased from 4.0 to 1.6/1000 CVC days. In the intensive care units (ICUs), compliance was not associated with CRBSI risk (hazard ratio (HR) for the overall, insertion and maintenance bundle were 1.14 (95% confidence interval 0.80-1.64), 1.05 (0.56-1.95) and 1.13 (0.79-1.62)), respectively. Outside the ICU the non-significant association of compliance with the overall bundle (HR 1.36 (0.96-1.93)) resulted from opposite effects of the insertion bundle, associated with decreased risk (HR 0.50 (0.30-0.85)) and the maintenance bundle, associated with increased risk (HR 1.68 (1.19-2.36)). Conclusion: Following a national programme to introduce an intervention bundle, CRBSI incidence decreased significantly. In the ICU, bundle compliance was not associated with CRBSI risk, but outside the ICU improved compliance with the insertion bundle resulted in a decreased CRBSI risk. (c) 2022 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Introduction: Due to COVID-19, care capacity has been put to the test. Objectives: We investigated how the first wave affected the frequency of bloodstream infection (BSI), the distribution of associated pathogens and the care for patients with a CVC. Methods: Hospitals can monitor CVC-related (CR)BSI in the national PREZIES surveillance. All 24 hospitals participating in 2020 received a survey on changes in care for patients with CVCs on COVID-19 ICU/wards. The frequency and distribution of pathogens were studied in data on blood isolates from patients sampled before (October 2019 to February 2020), during (March to May 2020), and after (June to September 2020) the first COVID-19 wave from the Dutch Infectious Disease Surveillance System-Antimicrobial Resistance (ISIS-AR) database. Results: CRBSI data entry is delayed by COVID-19, but increased rates were observed. Nine hospitals responded to the survey. During the wave bed capacity increased (9 ICU;3 wards) and external staff assisted (ICU 9;wards 8). Hospitals reported less frequent oral care and/or washing (5), dressing (2), and CVC set changes in the ICU (1), due to the prone position of the patient and/or work pressure. The total number of patients with a positive diagnostic blood sample during the first wave remained similar to before, but the mean monthly number of patients with a positive sample in the ICU increased from 268 (10% [95% CI = 10-11]) to 409 (15% [14-16]), and decreased again to 246 (9% [9-10]) after the first wave. In the ICU the proportion of several pathogens changed during the wave (table). All values normalized afterwards. Conclusion: All hospitals reported increased demand of care, support of external staff and in some downscaled or hampered CVC and patient care. This may partly explain the more frequently sampled CNS in blood during the first COVID-19 wave. (Figure Presented).

Abstract Infections due to extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) are often preceded by asymptomatic carriage. Higher incidences in enteric infectious diseases during summer have been reported. Here, we assessed whether the presence of seasonality in intestinal ESBL-Escherichia coli/Klebsiella pneumoniae (ESBL-E/K) carriage in the general Dutch population exists. From 2014 to 2017, the faecal carriage of ESBL-E/K in healthy individuals was determined in three cross-sectional studies in the Netherlands, including 5985 subjects. Results were pooled to identify seasonal trends in prevalence (by month of sampling). Multivariate logistic regression analysis was used to calculate pooled odds ratios and 95% confidence intervals. Results were adjusted for age, sex, antibiotic use and travel. Overall prevalence of ESBL-E/K carriage was 4.3% (n = 260 ESBL-E/K-positive), with differences between months ranging from 2.6% to 7.4%. Compared to January, the monthly prevalence of ESBL-E carriage was highest in August (OR 1.88, 95% CI 1.02–3.49) and September (OR 2.25, 95% CI 1.30–3.89). The observed monthly differences in ESBL-E/K carriage rates suggest that there is seasonal variation in exposure to ESBL-E/K other than due to travelling and antibiotic use. This should be taken into account in designing future ESBL-E prevalence studies in temperate regions.

Background: Prevalence of healthcare-associated infections (HCAIs) and antimicrobial use in hospitals in the Netherlands has been measured using voluntary biannual national point-prevalence surveys (PPSs). Aim: To describe trends in the prevalence of patients with HCAI, risk factors, and antimicrobial use in 2007-2016. Methods: In the PPS, patient characteristics, use of medical devices and antimicrobials, and presence of HCAI on the survey day are reported for all hospitalized patients, excluding patients in the day-care unit and psychiatric wards. Analyses were performed using linear and (multivariate) logistic regression, accounting for clustering of patients within hospitals. Findings: PPS data were reported for 171,116 patients. Annual prevalence of patients with HCAI with onset during hospitalization decreased from 6.1% in 2007 to 3.6% in 2016. The adjusted odds ratio (OR) for trend was 0.97 (95% confidence interval: 0.96-0.98). Most prominent trends were seen for surgical site infections (1.6%-0.8%; OR: 0.91 (0.90-0.93)) and urinary tract infections (2.1%-0.6%; OR: 0.85 (0.83-0.87)). From 2014 on, HCAIs at admission were also registered with a stable prevalence of approximately 1.5%. The mean length of stay decreased from 10 to 7 days. The percentage of patients treated with antibiotics increased from 31% to 36% (OR: 1.03 (1.02-1.03)). Conclusion: Repeated PPS data from 2007 to 2016 show a decrease in the prevalence of patients with HCAI with onset during hospitalization, and a stable prevalence of patients with HCAI at admission. The adjusted OR of 0.97 for HCAI during hospitalization indicates a true reduction in prevalence of approximately 3% per year. (C) 2019 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Objectives: Clostridium difficile infections (CDI) account for 1.5% of diarrhoeic episodes in patients attending a general practitioner in the Netherlands, but its sources are unknown. We searched for community clusters to recognize localized point sources of CDI. Methods: Between October 2010 and February 2012, a community-based prospective nested case-control study was performed in three laboratories in the Netherlands with a study population of 2 810 830 people. Bernoulli spatial scan and space-time permutation models were used to detect spatial and/or temporal clusters of CDI. In addition, a multivariate conditional logistic regression model was constructed to test livestock exposure as a supposed risk factor in CDI patients without hospital admission within the previous 12 weeks (community-acquired (CA) CDI). Results: In laboratories A, B and C, 1.3%, 1.8% and 2.1% of patients with diarrhoea tested positive for CDI, respectively. The mean age of CA-CDI patients (n = 124) was 49 years (standard deviation, 22.6); 64.5% were female. No spatial or temporal clusters of CDI cases were detected compared to C. difficile-negative diarrhoeic controls. Except for one false-positive signal, no spatiotemporal interaction amongst CDI cases was found. Livestock exposure was not related to CA-CDI (odds ratio, 0.99; 95% confidence interval, 0.44-2.24). Ten percent of CA-CDIs was caused by PCR ribotype 078, spatially dispersed throughout the study area. Conclusions: The absence of clusters of CDI cases in a community cohort of diarrhoeic patients suggests a lack of localized point sources of CDI in the living environment of these patients. (C) 2018 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Background Surgical site infections (SSIs) are associated with morbidity, mortality and costs. Aim To identify the burden of (deep) SSIs in costs and disability-adjusted life years (DALYs) following colectomy, mastectomy and total hip arthroplasty (THA) in the Netherlands. Methods A retrospective cost-analysis was performed using 2011 data from the national SSI surveillance network PREZIES. Sixty-two patients with an SSI (exposed) were matched to 122 patients without an SSI (unexposed, same type of surgery). Patient records were studied until 1 year after SSI diagnosis. Unexposed patients were followed for the same duration. Costs were calculated from the hospital perspective (2016 price level), and cost differences were tested using linear regression analyses. Disease burden was estimated using the Burden of Communicable Disease in Europe Toolkit of the European Centre for Disease Prevention and Control. The SSI model was specified by type of surgery, with country- and surgery-specific parameters where possible. Findings Attributable costs per SSI were €21,569 (THA), €14,084 (colectomy) and €1881 (mastectomy), mainly caused by prolonged length of hospital stay. National hospital costs were estimated at €10 million, €29 million and €0.6 million, respectively. National disease burden was greatest for SSIs following colectomy (3200 DALYs/year, 150 DALYs/100 SSIs), while individual disease burden was highest following THA (1200 DALYs/year, 250 DALYs/100 SSIs). For mastectomy, these DALYs were <1. The total cost of DALYs for the three types of surgery exceeded €88 million. Conclusion Depending on the type of surgery, SSIs cause a significant burden, both economically and in loss of years in full health. This underlines the importance of appropriate infection prevention and control measures.

BACKGROUND:In 2011-2012, the European Centre for Disease Prevention and Control (ECDC) initiated the first European point prevalence survey (PPS) of healthcare-associated infections (HCAIs) in addition to targeted surveillance of the incidence of specific types of HCAI such as surgical site infections (SSIs). AIM:To investigate whether national and multi-country SSI incidence can be estimated from ECDC PPS data. METHODS:In all, 159 hospitals were included from 15 countries that participated in both ECDC surveillance modules, aligning surgical procedures in the incidence surveillance to corresponding specialties from the PPS. National daily prevalence of SSIs was simulated from the incidence surveillance data, the Rhame and Sudderth (R&S) formula was used to estimate national and multi-country SSI incidence from the PPS data, and national incidence per specialty was predicted using a linear model including data from the PPS. FINDINGS:The simulation of daily SSI prevalence from incidence surveillance of SSIs showed that prevalence fluctuated randomly depending on the day of measurement. The correlation between the national aggregated incidence estimated with R&S formula and observed SSI incidence was low (correlation coefficient = 0.24), but specialty-specific incidence results were more reliable, especially when the number of included patients was large (correlation coefficients ranging from 0.40 to 1.00). The linear prediction model including PPS data had low proportion of explained variance (0.40). CONCLUSION:Due to a lack of accuracy, use of PPS data to estimate SSI incidence is recommended only in situations where incidence surveillance of SSIs is not performed, and where sufficiently large samples of PPS data are available.

We studied trends in the incidence of health care-associated infections (HAIs) in LTCFs between 2009 and 2015 and determined the effect of participation in our network. Elder-care physicians reported weekly the number of cases of influenza-like illness, gastroenteritis, (probable) pneumonia, urinary tract infections (UTIs) and all-cause mortality. Trends in the incidence of infection and mortality in relation to LTCF characteristics were calculated using multilevel univariate and multivariate logistic regression. Thirty LTCF participated for 3 years or more, 16 for 2 years and the remaining 12 LTCF for 1 year. During the study period, the median number of beds decreased from 158 to 139, whereas the percentage of residents with private bedrooms increased from 14% to 87%. UTIs were the most frequently reported infections, followed by (probable) pneumonia and gastroenteritis. Adjusted for calendar year and season, we observed a statistically significant decrease in the incidence of influenza-like illness (odds ratio (OR) = 0.8, P < 0.01) and (probable) pneumonia (OR = 0.8, P < 0.01) for each extra year an LTCF participated. Although there are other likely contributors, such as more private rooms and enhanced infection control measures, the decreasing trend of HAI in LTCFs participating in surveillance implies that surveillance is a valuable addition to current strategies to optimise infection control.

BACKGROUND:Clostridioides difficile infection (CDI) is increasingly reported in the community. The aim of this study was to analyze characteristics of hospitalized patients with community-onset CDI (CO-CDI).METHODS:In the Netherlands, 24 hospitals (university-affiliated and general hospitals) participate in the sentinel CDI surveillance program. Clinical characteristics and 30-day outcomes of hospitalized patients >2 years old diagnosed with CDI are registered. Samples of these patients are sent to the national reference laboratory for polymerase chain reaction ribotyping. Data obtained for this surveillance from May 2012 to May 2018 were used to compare CO-CDI with hospital-onset (HO)-CDI episodes.RESULTS:Of 5405 registered cases, 2834 (52.4%) were reported as HO-CDI, 2174 (40.2%) were CO-CDI, and 339 (6.3%) had onset of symptoms in another healthcare facility (eg, nursing home). The proportion of CO-CDI increased over the years and was lower during winter months. Hospitalized patients with CO-CDI were younger (63.8 vs 68.0 years, P < .001) and more often females (53.0% vs 49.6%, P = .02) than patients with HO-CDI. Median time between onset of symptoms and CDI testing was longer in CO-CDI (4 vs 1 day, P < .001). Similar ribotypes were found in CO-CDI and HO-CDI, but ribotype 001 was more frequent among HO-CDI, whereas ribotype 023 was more frequent in CO-CDI. Six of 7 (85.7%) surgeries due to CDI, 27 of 50 (54%) ICU admissions due to CDI, and 48 of 107 (44.9%) of CDI-associated deaths were attributable to CO-CDI.CONCLUSIONS:Our study demonstrates that patients hospitalized with CO-CDI contribute substantially to the total number of CDI episodes and CDI-associated complications in hospitals, stressing the need for awareness and early testing for CDI in community and outpatient settings and also in patients admitted from community with diarrhoea. Surveillance programs that also target nonhospitalized CDI patients are needed to understand the true burden and dynamics of CDI.

BACKGROUND:Surveillance of surgical site infections (SSIs) is a core component of effective infection control practices, though its impact has not been quantified on a large scale. AIM:To determine the time-trend of SSI rates in surveillance networks. METHODS:SSI surveillance networks provided procedure-specific data on numbers of SSIs and operations, stratified by hospitals' year of participation in the surveillance, to capture length of participation as an exposure. Pooled and procedure-specific random-effects Poisson regression was performed to obtain yearly rate ratios (RRs) with 95% confidence intervals (CIs), and including surveillance network as random intercept. FINDINGS:Of 36 invited networks, 17 networks from 15 high-income countries across Asia, Australia and Europe participated in the study. Aggregated data on 17 surgical procedures (cardiovascular, digestive, gynaecological-obstetrical, neurosurgical, and orthopaedic) were collected, resulting in data concerning 5,831,737 operations and 113,166 SSIs. There was a significant decrease in overall SSI rates over surveillance time, resulting in a 35% reduction at the ninth (final) included year of surveillance (RR: 0.65; 95% CI: 0.63-0.67). There were large variations across procedure-specific trends, but strong consistent decreases were observed for colorectal surgery, herniorrhaphy, caesarean section, hip prosthesis, and knee prosthesis. CONCLUSION:In this large, international cohort study, pooled SSI rates were associated with a stable and sustainable decrease after joining an SSI surveillance network; a causal relationship is possible, although unproven. There was heterogeneity in procedure-specific trends. These findings support the pivotal role of surveillance in reducing infection rates and call for widespread implementation of hospital-based SSI surveillance in high-income countries.