Healthcare-acquired Infections

Blood stream infections with Pseudomonas aeruginosa or Serratia subspecies in preterm infants are associated with a markedly elevated risk of same-pathogen bloodstream infections in other infants in the NICU, based on results from a large database in Germany.

Blood stream infections involving P. aeruginosa or Serratia subspecies, while rare, are “exceptional in their potential to spread in the NICU and attack very low birth weight infants. Because they are also those pathogens with the highest reported BSI (blood stream infection)-related mortality rates, vigorous attempts should be made to intensify infection control measures whenever P. aeruginosa or Serratia have been isolated from a patient in the NICU,” researchers led by Dr. Felix Reichert reported online March 8 in Pediatrics.

Dr. Reichert of the department of neonatology at Charité University Medical Center, Berlin, and his associates used data from the German National Neonatal Infection Surveillance System to estimate the probability of a hospitalized very-low-birth-weight infant to develop a bloodstream infection with a particular pathogen when another infant previously diagnosed with a bloodstream infection from the same pathogen was being cared for in the same unit (Pediatrics 2016 Mar 8. doi: 10.1542/peds.2015-2860). They limited their search to 44,818 very-low-birth-weight infants (defined as less than 1,500 g) who were born between Jan. 1, 2000, and Dec. 31, 2011.

The researchers found 2004 culture-positive bloodstream infections; 407 were from methicillin-sensitive Staphylococcus aureus; 246 to Enterobacter spp; 243 to vancomycin-sensitive Enterococcus spp; 210 to cefotaxime-sensitive Escherichia coli; 190 to cefotaxime-sensitive Klebsiella spp; 138 to Candida albicans; 58 to Serratia; and 38 to P. aeruginosa. Pathogens with 30 or fewer bloodstream infections were not analyzed further.

Rates of bloodstream infections acquired while another infant with a same-pathogen infection was being cared for in the unit varied between 2.2 (Enterococcus) and 8.2 (Serratia) per 100 exposed infants. The relative risk for acquiring a bloodstream infection in the presence or absence of an infant with a preceding same-pathogen bloodstream infection varied between 4.3 (Enterococcus) and 77.5 (Serratia).

When a same-pathogen bloodstream infection was observed in the same unit during the preceding 30 days, rates of blood stream infection per 100 exposed infants varied between 1.4 (C. albicans) and 6.5 (Serratia). The relative risk for acquiring a bloodstream infection while a same-pathogen infection had been diagnosed in the preceding 30 days in the same department varied between 2.3 (Enterococcus) and 59.5 (Serratia)

The authors acknowledged certain limitations of the study, including the fact that the reporting system used “made no distinction between various strains of Enterococcus, Enterobacter, or Serratia, and there was no genotyping of the pathogens involved. Thus, two temporally related BSIs [blood stream infections] in the same department might well be a coincidence.”

The German National Neonatal Infection Surveillance System is supported by the Federal Department of Health and funds from the Charité University Medical Center. The authors reported having no financial disclosures.

[email protected]

Blood stream infections with Pseudomonas aeruginosa or Serratia subspecies in preterm infants are associated with a markedly elevated risk of same-pathogen bloodstream infections in other infants in the NICU, based on results from a large database in Germany.

Blood stream infections involving P. aeruginosa or Serratia subspecies, while rare, are “exceptional in their potential to spread in the NICU and attack very low birth weight infants. Because they are also those pathogens with the highest reported BSI (blood stream infection)-related mortality rates, vigorous attempts should be made to intensify infection control measures whenever P. aeruginosa or Serratia have been isolated from a patient in the NICU,” researchers led by Dr. Felix Reichert reported online March 8 in Pediatrics.

Dr. Reichert of the department of neonatology at Charité University Medical Center, Berlin, and his associates used data from the German National Neonatal Infection Surveillance System to estimate the probability of a hospitalized very-low-birth-weight infant to develop a bloodstream infection with a particular pathogen when another infant previously diagnosed with a bloodstream infection from the same pathogen was being cared for in the same unit (Pediatrics 2016 Mar 8. doi: 10.1542/peds.2015-2860). They limited their search to 44,818 very-low-birth-weight infants (defined as less than 1,500 g) who were born between Jan. 1, 2000, and Dec. 31, 2011.

The researchers found 2004 culture-positive bloodstream infections; 407 were from methicillin-sensitive Staphylococcus aureus; 246 to Enterobacter spp; 243 to vancomycin-sensitive Enterococcus spp; 210 to cefotaxime-sensitive Escherichia coli; 190 to cefotaxime-sensitive Klebsiella spp; 138 to Candida albicans; 58 to Serratia; and 38 to P. aeruginosa. Pathogens with 30 or fewer bloodstream infections were not analyzed further.

Rates of bloodstream infections acquired while another infant with a same-pathogen infection was being cared for in the unit varied between 2.2 (Enterococcus) and 8.2 (Serratia) per 100 exposed infants. The relative risk for acquiring a bloodstream infection in the presence or absence of an infant with a preceding same-pathogen bloodstream infection varied between 4.3 (Enterococcus) and 77.5 (Serratia).

When a same-pathogen bloodstream infection was observed in the same unit during the preceding 30 days, rates of blood stream infection per 100 exposed infants varied between 1.4 (C. albicans) and 6.5 (Serratia). The relative risk for acquiring a bloodstream infection while a same-pathogen infection had been diagnosed in the preceding 30 days in the same department varied between 2.3 (Enterococcus) and 59.5 (Serratia)

The authors acknowledged certain limitations of the study, including the fact that the reporting system used “made no distinction between various strains of Enterococcus, Enterobacter, or Serratia, and there was no genotyping of the pathogens involved. Thus, two temporally related BSIs [blood stream infections] in the same department might well be a coincidence.”

The German National Neonatal Infection Surveillance System is supported by the Federal Department of Health and funds from the Charité University Medical Center. The authors reported having no financial disclosures.

[email protected]

Blood stream infections with Pseudomonas aeruginosa or Serratia subspecies in preterm infants are associated with a markedly elevated risk of same-pathogen bloodstream infections in other infants in the NICU, based on results from a large database in Germany.

Blood stream infections involving P. aeruginosa or Serratia subspecies, while rare, are “exceptional in their potential to spread in the NICU and attack very low birth weight infants. Because they are also those pathogens with the highest reported BSI (blood stream infection)-related mortality rates, vigorous attempts should be made to intensify infection control measures whenever P. aeruginosa or Serratia have been isolated from a patient in the NICU,” researchers led by Dr. Felix Reichert reported online March 8 in Pediatrics.

Dr. Reichert of the department of neonatology at Charité University Medical Center, Berlin, and his associates used data from the German National Neonatal Infection Surveillance System to estimate the probability of a hospitalized very-low-birth-weight infant to develop a bloodstream infection with a particular pathogen when another infant previously diagnosed with a bloodstream infection from the same pathogen was being cared for in the same unit (Pediatrics 2016 Mar 8. doi: 10.1542/peds.2015-2860). They limited their search to 44,818 very-low-birth-weight infants (defined as less than 1,500 g) who were born between Jan. 1, 2000, and Dec. 31, 2011.

The researchers found 2004 culture-positive bloodstream infections; 407 were from methicillin-sensitive Staphylococcus aureus; 246 to Enterobacter spp; 243 to vancomycin-sensitive Enterococcus spp; 210 to cefotaxime-sensitive Escherichia coli; 190 to cefotaxime-sensitive Klebsiella spp; 138 to Candida albicans; 58 to Serratia; and 38 to P. aeruginosa. Pathogens with 30 or fewer bloodstream infections were not analyzed further.

Rates of bloodstream infections acquired while another infant with a same-pathogen infection was being cared for in the unit varied between 2.2 (Enterococcus) and 8.2 (Serratia) per 100 exposed infants. The relative risk for acquiring a bloodstream infection in the presence or absence of an infant with a preceding same-pathogen bloodstream infection varied between 4.3 (Enterococcus) and 77.5 (Serratia).

When a same-pathogen bloodstream infection was observed in the same unit during the preceding 30 days, rates of blood stream infection per 100 exposed infants varied between 1.4 (C. albicans) and 6.5 (Serratia). The relative risk for acquiring a bloodstream infection while a same-pathogen infection had been diagnosed in the preceding 30 days in the same department varied between 2.3 (Enterococcus) and 59.5 (Serratia)

The authors acknowledged certain limitations of the study, including the fact that the reporting system used “made no distinction between various strains of Enterococcus, Enterobacter, or Serratia, and there was no genotyping of the pathogens involved. Thus, two temporally related BSIs [blood stream infections] in the same department might well be a coincidence.”

The German National Neonatal Infection Surveillance System is supported by the Federal Department of Health and funds from the Charité University Medical Center. The authors reported having no financial disclosures.

[email protected]

Probiotics were used by 2.6% of patients who had been discharged from 145 U.S. hospitals in 2012, according to an analysis of data by Sarah H. Yi of the Centers for Disease Control and Prevention and her colleagues.

“Whether probiotics are effective in preserving or restoring a healthy microbiome remains unknown, but the high prevalence of probiotic use among hospitalized patients may indicate a growing belief among clinicians that these agents may be an effective strategy for doing so,” Ms. Yi and her colleagues wrote.

©CharlieAJA/Thinkstock

The researchers used information contained in the Truven Health MarketScan Hospital Drug Database to estimate probiotic use in the inpatient setting.

Among 1,976,167 pediatric and adult patients discharged from 145 hospitals in 2012, 51,723 (2.6%) of the patients used probiotics. The individuals who used probiotics had been patients at 139 of the 145 hospitals. Compared with patients who had not used probiotics, the patients who had used probiotics were 21 times more likely to have a discharge diagnosis of Clostridium difficile infection (P less than .0001), almost 9 times more likely to have used antimicrobials (P less than .0001), more likely to have been admitted from another inpatient health care facility (P less than .0001), and more likely to have been transferred to another health care facility at discharge (P less than .001). Each of the probiotic formulations used contained between one and four organisms identified at the species level. Saccharomyces boulardii, Lactobacillus acidophilus, L. bulgaricus, and L. rhamnosus were the most commonly used probiotic formulations.

The top five diagnoses for the patients who received probiotics were septicemia (except in labor); pneumonia (except that caused by tuberculosis or sexually transmitted disease); intestinal infection; skin and subcutaneous tissue infections; and urinary tract infections. For those patients not taking probiotics, live-born infants, osteoarthritis, septicemia (except during labor), pneumonia (except that caused by tuberculosis or sexually transmitted disease), and heart failure (nonhypertensive) were the most commonly received diagnoses.

The researchers also analyzed a study of the use of probiotics at 60 hospitals during 2006-2012, which showed annual increases of probiotic use among discharged patients and an overall 2.9-fold increase in probiotic use during those years. Specifically, 10,722 discharged patients used probiotics in 2006, compared with 28,871 patients in 2012.

“Because the patients most likely to benefit [from probiotic use] are also most at risk for an adverse event, preclinical research focused on the selection of likely probiotics and carefully designed clinical trials with systematic assessment of safety is particularly important,” the researchers said.

Among the questions needed to addressed in future research on probiotic use is “which strain-specific organisms, which patient populations, at what doses, and in what time frames (related to antibiotic use in particular) are both safe and effective in the prevention or treatment of which diseases?” according to the researchers.

Read the study in American Journal of Infection Control (doi: 10.1016/j.ajic.2015.12.001).

[email protected]

Probiotics were used by 2.6% of patients who had been discharged from 145 U.S. hospitals in 2012, according to an analysis of data by Sarah H. Yi of the Centers for Disease Control and Prevention and her colleagues.

“Whether probiotics are effective in preserving or restoring a healthy microbiome remains unknown, but the high prevalence of probiotic use among hospitalized patients may indicate a growing belief among clinicians that these agents may be an effective strategy for doing so,” Ms. Yi and her colleagues wrote.

©CharlieAJA/Thinkstock

The researchers used information contained in the Truven Health MarketScan Hospital Drug Database to estimate probiotic use in the inpatient setting.

Among 1,976,167 pediatric and adult patients discharged from 145 hospitals in 2012, 51,723 (2.6%) of the patients used probiotics. The individuals who used probiotics had been patients at 139 of the 145 hospitals. Compared with patients who had not used probiotics, the patients who had used probiotics were 21 times more likely to have a discharge diagnosis of Clostridium difficile infection (P less than .0001), almost 9 times more likely to have used antimicrobials (P less than .0001), more likely to have been admitted from another inpatient health care facility (P less than .0001), and more likely to have been transferred to another health care facility at discharge (P less than .001). Each of the probiotic formulations used contained between one and four organisms identified at the species level. Saccharomyces boulardii, Lactobacillus acidophilus, L. bulgaricus, and L. rhamnosus were the most commonly used probiotic formulations.

The top five diagnoses for the patients who received probiotics were septicemia (except in labor); pneumonia (except that caused by tuberculosis or sexually transmitted disease); intestinal infection; skin and subcutaneous tissue infections; and urinary tract infections. For those patients not taking probiotics, live-born infants, osteoarthritis, septicemia (except during labor), pneumonia (except that caused by tuberculosis or sexually transmitted disease), and heart failure (nonhypertensive) were the most commonly received diagnoses.

The researchers also analyzed a study of the use of probiotics at 60 hospitals during 2006-2012, which showed annual increases of probiotic use among discharged patients and an overall 2.9-fold increase in probiotic use during those years. Specifically, 10,722 discharged patients used probiotics in 2006, compared with 28,871 patients in 2012.

“Because the patients most likely to benefit [from probiotic use] are also most at risk for an adverse event, preclinical research focused on the selection of likely probiotics and carefully designed clinical trials with systematic assessment of safety is particularly important,” the researchers said.

Among the questions needed to addressed in future research on probiotic use is “which strain-specific organisms, which patient populations, at what doses, and in what time frames (related to antibiotic use in particular) are both safe and effective in the prevention or treatment of which diseases?” according to the researchers.

Read the study in American Journal of Infection Control (doi: 10.1016/j.ajic.2015.12.001).

[email protected]

Probiotics were used by 2.6% of patients who had been discharged from 145 U.S. hospitals in 2012, according to an analysis of data by Sarah H. Yi of the Centers for Disease Control and Prevention and her colleagues.

“Whether probiotics are effective in preserving or restoring a healthy microbiome remains unknown, but the high prevalence of probiotic use among hospitalized patients may indicate a growing belief among clinicians that these agents may be an effective strategy for doing so,” Ms. Yi and her colleagues wrote.

©CharlieAJA/Thinkstock

The researchers used information contained in the Truven Health MarketScan Hospital Drug Database to estimate probiotic use in the inpatient setting.

Among 1,976,167 pediatric and adult patients discharged from 145 hospitals in 2012, 51,723 (2.6%) of the patients used probiotics. The individuals who used probiotics had been patients at 139 of the 145 hospitals. Compared with patients who had not used probiotics, the patients who had used probiotics were 21 times more likely to have a discharge diagnosis of Clostridium difficile infection (P less than .0001), almost 9 times more likely to have used antimicrobials (P less than .0001), more likely to have been admitted from another inpatient health care facility (P less than .0001), and more likely to have been transferred to another health care facility at discharge (P less than .001). Each of the probiotic formulations used contained between one and four organisms identified at the species level. Saccharomyces boulardii, Lactobacillus acidophilus, L. bulgaricus, and L. rhamnosus were the most commonly used probiotic formulations.

The top five diagnoses for the patients who received probiotics were septicemia (except in labor); pneumonia (except that caused by tuberculosis or sexually transmitted disease); intestinal infection; skin and subcutaneous tissue infections; and urinary tract infections. For those patients not taking probiotics, live-born infants, osteoarthritis, septicemia (except during labor), pneumonia (except that caused by tuberculosis or sexually transmitted disease), and heart failure (nonhypertensive) were the most commonly received diagnoses.

The researchers also analyzed a study of the use of probiotics at 60 hospitals during 2006-2012, which showed annual increases of probiotic use among discharged patients and an overall 2.9-fold increase in probiotic use during those years. Specifically, 10,722 discharged patients used probiotics in 2006, compared with 28,871 patients in 2012.

“Because the patients most likely to benefit [from probiotic use] are also most at risk for an adverse event, preclinical research focused on the selection of likely probiotics and carefully designed clinical trials with systematic assessment of safety is particularly important,” the researchers said.

Among the questions needed to addressed in future research on probiotic use is “which strain-specific organisms, which patient populations, at what doses, and in what time frames (related to antibiotic use in particular) are both safe and effective in the prevention or treatment of which diseases?” according to the researchers.

Read the study in American Journal of Infection Control (doi: 10.1016/j.ajic.2015.12.001).

[email protected]

ATLANTA – Preincisional azithromycin reduced postcesarean maternal infections by half, and significantly cut postpartum trips to the hospital.

Given in tandem with standard prophylactic antibiotics, broad-spectrum intravenous azithromycin was highly effective, with a number needed to treat of 17 to prevent one postsurgical infection, and 43 to prevent one case of endometritis, Dr. Alan Tita reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

“We also saw fewer maternal adverse events, and the protocol was safe for the newborn,” said Dr. Tita, a professor of obstetrics and gynecology at the University of Alabama, Birmingham.

The Study of Effectiveness and Safety of Azithromycin-Based Extended-Spectrum Prophylaxis to Prevent Post Cesarean Infection (C/SOAP) trial enrolled 2,013 women at 14 sites. All patients had singleton pregnancies of at least 24 weeks’ gestation. Patients had a cesarean after at least 4 hours of active labor or 4 hours after rupture of membranes.

All women received standard narrow-spectrum antibiotic prophylaxis with either cefazolin or clindamycin. They were randomized to either preincisional intravenous azithromycin 500 mg or saline placebo. The study had a pragmatic design, so skin disinfection was performed according to each facility’s standard protocol.

The primary outcome was a composite of endometritis, wound infection, abscess, pelvic septic thrombophlebitis, pyelonephritis, pneumonia, and meningitis. Secondary outcomes were maternal fever, unscheduled visits to health care providers (including hospital readmissions and emergency department visits), and death.

The neonatal outcome was a composite of death; primary or suspected sepsis; and serious neonatal morbidities, including respiratory distress syndrome, necrotizing enterocolitis, periventricular leukomalacia, intraventricular hemorrhage of grade 3 or higher, and bronchopulmonary dysplasia.

There were no baseline differences in the indication for cesarean or type of skin and uterine incision, Dr. Tita said. Most patients (88%) received their study drug before the incision.

The rate of the primary composite outcome was reduced by half in women who had azithromycin added to their cephalosporin prophylaxis (6% vs. 12%; relative risk, 0.49). Wound infection was cut by 65% (2.4% vs. 6.6%; RR, 0.35).

Azithromycin significantly improved the secondary maternal outcomes over placebo, including fever (5% vs. 8.2%; RR, 0.61), and readmissions or unscheduled visits (8.2% vs. 12.4%; RR, 0.66). The addition of azithromycin was associated with a significant decrease in the rate of severe maternal adverse events (1.5% vs. 2.9%).

Study site, obesity, and the type of skin prep did not significantly affect any of these outcomes, Dr. Tita noted.

The addition of azithromycin was safe for neonates. The composite neonatal safety outcome occurred in 14.3% of the treated group and 13.6% of the placebo group – not a significant difference. There were no differences in suspected or confirmed sepsis (11.8% vs. 12.5%), serious neonatal morbidities (4.4% vs. 3.4%), or NICU admission (16.8% vs. 17%), Dr. Tita reported.

There were no deaths in either mothers or infants. There were 11 maternal allergic reactions, five admissions to intensive care, and five suspected cardiac events.

When asked whether even brief systemic exposure to azithromycin could alter the fetal microbiome, Dr. Tita said he shares that concern but the answer is still unknown.

“We have collected additional information and specimens and we will be looking at these to try and answer this. We also hope to get funding to do a long-term evaluation of these kids. I will say that we collected adverse event data on them for 3 months and we did not see anything concerning, but I agree more needs to be done,” he said. “Having said that, azithromycin is something we already use quite a lot in obstetrics, and overall it has been shown to be safe for the newborn.”

The study was sponsored by the National Institute of Child Health and Human Development. Dr. Tita reported having no financial disclosures.

[email protected]

ATLANTA – Preincisional azithromycin reduced postcesarean maternal infections by half, and significantly cut postpartum trips to the hospital.

Given in tandem with standard prophylactic antibiotics, broad-spectrum intravenous azithromycin was highly effective, with a number needed to treat of 17 to prevent one postsurgical infection, and 43 to prevent one case of endometritis, Dr. Alan Tita reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

“We also saw fewer maternal adverse events, and the protocol was safe for the newborn,” said Dr. Tita, a professor of obstetrics and gynecology at the University of Alabama, Birmingham.

The Study of Effectiveness and Safety of Azithromycin-Based Extended-Spectrum Prophylaxis to Prevent Post Cesarean Infection (C/SOAP) trial enrolled 2,013 women at 14 sites. All patients had singleton pregnancies of at least 24 weeks’ gestation. Patients had a cesarean after at least 4 hours of active labor or 4 hours after rupture of membranes.

All women received standard narrow-spectrum antibiotic prophylaxis with either cefazolin or clindamycin. They were randomized to either preincisional intravenous azithromycin 500 mg or saline placebo. The study had a pragmatic design, so skin disinfection was performed according to each facility’s standard protocol.

The primary outcome was a composite of endometritis, wound infection, abscess, pelvic septic thrombophlebitis, pyelonephritis, pneumonia, and meningitis. Secondary outcomes were maternal fever, unscheduled visits to health care providers (including hospital readmissions and emergency department visits), and death.

The neonatal outcome was a composite of death; primary or suspected sepsis; and serious neonatal morbidities, including respiratory distress syndrome, necrotizing enterocolitis, periventricular leukomalacia, intraventricular hemorrhage of grade 3 or higher, and bronchopulmonary dysplasia.

There were no baseline differences in the indication for cesarean or type of skin and uterine incision, Dr. Tita said. Most patients (88%) received their study drug before the incision.

The rate of the primary composite outcome was reduced by half in women who had azithromycin added to their cephalosporin prophylaxis (6% vs. 12%; relative risk, 0.49). Wound infection was cut by 65% (2.4% vs. 6.6%; RR, 0.35).

Azithromycin significantly improved the secondary maternal outcomes over placebo, including fever (5% vs. 8.2%; RR, 0.61), and readmissions or unscheduled visits (8.2% vs. 12.4%; RR, 0.66). The addition of azithromycin was associated with a significant decrease in the rate of severe maternal adverse events (1.5% vs. 2.9%).

Study site, obesity, and the type of skin prep did not significantly affect any of these outcomes, Dr. Tita noted.

The addition of azithromycin was safe for neonates. The composite neonatal safety outcome occurred in 14.3% of the treated group and 13.6% of the placebo group – not a significant difference. There were no differences in suspected or confirmed sepsis (11.8% vs. 12.5%), serious neonatal morbidities (4.4% vs. 3.4%), or NICU admission (16.8% vs. 17%), Dr. Tita reported.

There were no deaths in either mothers or infants. There were 11 maternal allergic reactions, five admissions to intensive care, and five suspected cardiac events.

When asked whether even brief systemic exposure to azithromycin could alter the fetal microbiome, Dr. Tita said he shares that concern but the answer is still unknown.

“We have collected additional information and specimens and we will be looking at these to try and answer this. We also hope to get funding to do a long-term evaluation of these kids. I will say that we collected adverse event data on them for 3 months and we did not see anything concerning, but I agree more needs to be done,” he said. “Having said that, azithromycin is something we already use quite a lot in obstetrics, and overall it has been shown to be safe for the newborn.”

The study was sponsored by the National Institute of Child Health and Human Development. Dr. Tita reported having no financial disclosures.

[email protected]

ATLANTA – Preincisional azithromycin reduced postcesarean maternal infections by half, and significantly cut postpartum trips to the hospital.

Given in tandem with standard prophylactic antibiotics, broad-spectrum intravenous azithromycin was highly effective, with a number needed to treat of 17 to prevent one postsurgical infection, and 43 to prevent one case of endometritis, Dr. Alan Tita reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

“We also saw fewer maternal adverse events, and the protocol was safe for the newborn,” said Dr. Tita, a professor of obstetrics and gynecology at the University of Alabama, Birmingham.

The Study of Effectiveness and Safety of Azithromycin-Based Extended-Spectrum Prophylaxis to Prevent Post Cesarean Infection (C/SOAP) trial enrolled 2,013 women at 14 sites. All patients had singleton pregnancies of at least 24 weeks’ gestation. Patients had a cesarean after at least 4 hours of active labor or 4 hours after rupture of membranes.

All women received standard narrow-spectrum antibiotic prophylaxis with either cefazolin or clindamycin. They were randomized to either preincisional intravenous azithromycin 500 mg or saline placebo. The study had a pragmatic design, so skin disinfection was performed according to each facility’s standard protocol.

The primary outcome was a composite of endometritis, wound infection, abscess, pelvic septic thrombophlebitis, pyelonephritis, pneumonia, and meningitis. Secondary outcomes were maternal fever, unscheduled visits to health care providers (including hospital readmissions and emergency department visits), and death.

The neonatal outcome was a composite of death; primary or suspected sepsis; and serious neonatal morbidities, including respiratory distress syndrome, necrotizing enterocolitis, periventricular leukomalacia, intraventricular hemorrhage of grade 3 or higher, and bronchopulmonary dysplasia.

There were no baseline differences in the indication for cesarean or type of skin and uterine incision, Dr. Tita said. Most patients (88%) received their study drug before the incision.

The rate of the primary composite outcome was reduced by half in women who had azithromycin added to their cephalosporin prophylaxis (6% vs. 12%; relative risk, 0.49). Wound infection was cut by 65% (2.4% vs. 6.6%; RR, 0.35).

Azithromycin significantly improved the secondary maternal outcomes over placebo, including fever (5% vs. 8.2%; RR, 0.61), and readmissions or unscheduled visits (8.2% vs. 12.4%; RR, 0.66). The addition of azithromycin was associated with a significant decrease in the rate of severe maternal adverse events (1.5% vs. 2.9%).

Study site, obesity, and the type of skin prep did not significantly affect any of these outcomes, Dr. Tita noted.

The addition of azithromycin was safe for neonates. The composite neonatal safety outcome occurred in 14.3% of the treated group and 13.6% of the placebo group – not a significant difference. There were no differences in suspected or confirmed sepsis (11.8% vs. 12.5%), serious neonatal morbidities (4.4% vs. 3.4%), or NICU admission (16.8% vs. 17%), Dr. Tita reported.

There were no deaths in either mothers or infants. There were 11 maternal allergic reactions, five admissions to intensive care, and five suspected cardiac events.

When asked whether even brief systemic exposure to azithromycin could alter the fetal microbiome, Dr. Tita said he shares that concern but the answer is still unknown.

“We have collected additional information and specimens and we will be looking at these to try and answer this. We also hope to get funding to do a long-term evaluation of these kids. I will say that we collected adverse event data on them for 3 months and we did not see anything concerning, but I agree more needs to be done,” he said. “Having said that, azithromycin is something we already use quite a lot in obstetrics, and overall it has been shown to be safe for the newborn.”

The study was sponsored by the National Institute of Child Health and Human Development. Dr. Tita reported having no financial disclosures.

[email protected]

ORLANDO – New consensus definitions for sepsis and septic shock focus on host dysregulation in the face of infection, propose a three-item quick-scoring option for bedside assessment, and introduce serum lactate as an important marker of cellular metabolic stress in identifying septic shock.

Sepsis is now defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection,” according to a 19-member task force convened jointly by the U.S. Society for Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) (JAMA. 2016;315[8]:801-10. doi: 10.1001/jama.2016.0287).

Since sepsis itself is inherently a life-threatening diagnosis, the term “severe sepsis” is redundant and should be eliminated, according to Dr. Mervyn Singer and his fellow task force members and coauthors. Together with his coauthors, Dr. Singer, professor of intensive care medicine at University College London, also recommended moving away from an “excessive focus on inflammation” and “the misleading model that sepsis follows a continuum through severe sepsis to shock.”

Systemic inflammatory response syndrome (SIRS) is a serious manifestation of an appropriate host response to infection, rather than the dysregulated host response that characterizes sepsis. So although it’s no longer included in sepsis criteria. “We are not discounting SIRS,” Dr. Singer said in a presentation at the Critical Care Congress, sponsored by the Society for Critical Care Medicine. The consensus statement was released and the presentation was made simultaneously.

Organ dysfunction, for the purposes of the revised definition, is defined as a 2 or more point increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score. This increase is associated with a 10% or more rise in mortality while in hospital. Task force members, after review, recommended standardizing sepsis assessment with the SOFA score.

The criteria require an increase of 2 or more points on the SOFA score because many patients suspected of sepsis will have comorbidities that will “earn” them SOFA points at baseline, said Dr. Singer.

Operationalizing the sepsis definition through SOFA made sense, said Dr. Singer, because the set of five laboratory measures and one clinician-administered scale – the Glasgow Coma Scale (GCS) – are already likely to be part of daily assessments for a seriously ill hospitalized adult.

Septic shock, as defined by the task force, is associated with in-hospital mortality of over 40%. Septic shock is now defined as “a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.” Clinically, patients have septic shock if they require a vasopressor to maintain a mean arterial pressure of 65 mm Hg or greater, and have a serum lactate level greater than 18 mg/dL (2 mmol/L) without hypovolemia.

The definitions introduce an abbreviated bedside sepsis identification tool termed quickSOFA (qSOFA). For adults suspected of infection, qSOFA requires two of the three clinical criteria of respiratory rate of 22 breaths/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less. “This model was robust to multiple sensitivity analyses,” wrote Dr. Singer and his coauthors, and worked well in out-of-hospital, emergency department, and ward settings both within and outside of the United States. “We are encouraging prospective validation in different health care settings,” for example, in resource-poor environments, said Dr. Singer.

The extensive review process included a large meta-analysis and systematic review of observational studies of adults with sepsis to evaluate diagnostic systems and criteria currently in use. The results of the review were used to inform the task force’s Delphi study, which then led to cohort studies to test the proposed variables, through the Surviving Sepsis Campaign. A comprehensive description of the work of the task force was published concurrently with the new sepsis and septic shock definitions (JAMA. 2016;315[8]:775-87. doi: 10.1001/jama.2016.0289).

“We had what I call a soft launch” of the new definitions, said Dr. Singer. The definitions and criteria have been available for review and discussion for about a year, and discussions in the public forum are already shaping thoughts about the way forward. “We expect lots and lots of discussion,” said Dr. Singer.

Limitations of the new definitions were enumerated by Dr. Singer and his coauthors, and also brought forward in an accompanying editorial by Dr. Edward Abraham, dean of the Wake Forest School of Medicine, Winston-Salem, N.C. These include that sepsis is not defined for children, that the reliance on serum lactate levels may not be feasible in resource-poor environments, and that there are limitations to the datasets used to generate the new guidelines.

The guidelines also offer suggested International Classification of Diseases-9 (ICD-9) and ICD-10 codes for sepsis and septic shock, in the hope that “greater clarity and consistency will also facilitate research and more accurate coding,” wrote Dr. Singer and his coauthors.

Multiple task force members reported relationships with pharmaceutical companies. The work of the task force was supported in part by grants from SCCM and ESICM.

The guidelines and accompanying information are available at www.sccm.org/sepsisredefined.

[email protected]

On Twitter @karioakes

ORLANDO – New consensus definitions for sepsis and septic shock focus on host dysregulation in the face of infection, propose a three-item quick-scoring option for bedside assessment, and introduce serum lactate as an important marker of cellular metabolic stress in identifying septic shock.

Sepsis is now defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection,” according to a 19-member task force convened jointly by the U.S. Society for Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) (JAMA. 2016;315[8]:801-10. doi: 10.1001/jama.2016.0287).

Since sepsis itself is inherently a life-threatening diagnosis, the term “severe sepsis” is redundant and should be eliminated, according to Dr. Mervyn Singer and his fellow task force members and coauthors. Together with his coauthors, Dr. Singer, professor of intensive care medicine at University College London, also recommended moving away from an “excessive focus on inflammation” and “the misleading model that sepsis follows a continuum through severe sepsis to shock.”

Systemic inflammatory response syndrome (SIRS) is a serious manifestation of an appropriate host response to infection, rather than the dysregulated host response that characterizes sepsis. So although it’s no longer included in sepsis criteria. “We are not discounting SIRS,” Dr. Singer said in a presentation at the Critical Care Congress, sponsored by the Society for Critical Care Medicine. The consensus statement was released and the presentation was made simultaneously.

Organ dysfunction, for the purposes of the revised definition, is defined as a 2 or more point increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score. This increase is associated with a 10% or more rise in mortality while in hospital. Task force members, after review, recommended standardizing sepsis assessment with the SOFA score.

The criteria require an increase of 2 or more points on the SOFA score because many patients suspected of sepsis will have comorbidities that will “earn” them SOFA points at baseline, said Dr. Singer.

Operationalizing the sepsis definition through SOFA made sense, said Dr. Singer, because the set of five laboratory measures and one clinician-administered scale – the Glasgow Coma Scale (GCS) – are already likely to be part of daily assessments for a seriously ill hospitalized adult.

Septic shock, as defined by the task force, is associated with in-hospital mortality of over 40%. Septic shock is now defined as “a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.” Clinically, patients have septic shock if they require a vasopressor to maintain a mean arterial pressure of 65 mm Hg or greater, and have a serum lactate level greater than 18 mg/dL (2 mmol/L) without hypovolemia.

The definitions introduce an abbreviated bedside sepsis identification tool termed quickSOFA (qSOFA). For adults suspected of infection, qSOFA requires two of the three clinical criteria of respiratory rate of 22 breaths/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less. “This model was robust to multiple sensitivity analyses,” wrote Dr. Singer and his coauthors, and worked well in out-of-hospital, emergency department, and ward settings both within and outside of the United States. “We are encouraging prospective validation in different health care settings,” for example, in resource-poor environments, said Dr. Singer.

The extensive review process included a large meta-analysis and systematic review of observational studies of adults with sepsis to evaluate diagnostic systems and criteria currently in use. The results of the review were used to inform the task force’s Delphi study, which then led to cohort studies to test the proposed variables, through the Surviving Sepsis Campaign. A comprehensive description of the work of the task force was published concurrently with the new sepsis and septic shock definitions (JAMA. 2016;315[8]:775-87. doi: 10.1001/jama.2016.0289).

“We had what I call a soft launch” of the new definitions, said Dr. Singer. The definitions and criteria have been available for review and discussion for about a year, and discussions in the public forum are already shaping thoughts about the way forward. “We expect lots and lots of discussion,” said Dr. Singer.

Limitations of the new definitions were enumerated by Dr. Singer and his coauthors, and also brought forward in an accompanying editorial by Dr. Edward Abraham, dean of the Wake Forest School of Medicine, Winston-Salem, N.C. These include that sepsis is not defined for children, that the reliance on serum lactate levels may not be feasible in resource-poor environments, and that there are limitations to the datasets used to generate the new guidelines.

The guidelines also offer suggested International Classification of Diseases-9 (ICD-9) and ICD-10 codes for sepsis and septic shock, in the hope that “greater clarity and consistency will also facilitate research and more accurate coding,” wrote Dr. Singer and his coauthors.

Multiple task force members reported relationships with pharmaceutical companies. The work of the task force was supported in part by grants from SCCM and ESICM.

The guidelines and accompanying information are available at www.sccm.org/sepsisredefined.

[email protected]

On Twitter @karioakes

ORLANDO – New consensus definitions for sepsis and septic shock focus on host dysregulation in the face of infection, propose a three-item quick-scoring option for bedside assessment, and introduce serum lactate as an important marker of cellular metabolic stress in identifying septic shock.

Sepsis is now defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection,” according to a 19-member task force convened jointly by the U.S. Society for Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) (JAMA. 2016;315[8]:801-10. doi: 10.1001/jama.2016.0287).

Since sepsis itself is inherently a life-threatening diagnosis, the term “severe sepsis” is redundant and should be eliminated, according to Dr. Mervyn Singer and his fellow task force members and coauthors. Together with his coauthors, Dr. Singer, professor of intensive care medicine at University College London, also recommended moving away from an “excessive focus on inflammation” and “the misleading model that sepsis follows a continuum through severe sepsis to shock.”

Systemic inflammatory response syndrome (SIRS) is a serious manifestation of an appropriate host response to infection, rather than the dysregulated host response that characterizes sepsis. So although it’s no longer included in sepsis criteria. “We are not discounting SIRS,” Dr. Singer said in a presentation at the Critical Care Congress, sponsored by the Society for Critical Care Medicine. The consensus statement was released and the presentation was made simultaneously.

Organ dysfunction, for the purposes of the revised definition, is defined as a 2 or more point increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score. This increase is associated with a 10% or more rise in mortality while in hospital. Task force members, after review, recommended standardizing sepsis assessment with the SOFA score.

The criteria require an increase of 2 or more points on the SOFA score because many patients suspected of sepsis will have comorbidities that will “earn” them SOFA points at baseline, said Dr. Singer.

Operationalizing the sepsis definition through SOFA made sense, said Dr. Singer, because the set of five laboratory measures and one clinician-administered scale – the Glasgow Coma Scale (GCS) – are already likely to be part of daily assessments for a seriously ill hospitalized adult.

Septic shock, as defined by the task force, is associated with in-hospital mortality of over 40%. Septic shock is now defined as “a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.” Clinically, patients have septic shock if they require a vasopressor to maintain a mean arterial pressure of 65 mm Hg or greater, and have a serum lactate level greater than 18 mg/dL (2 mmol/L) without hypovolemia.

The definitions introduce an abbreviated bedside sepsis identification tool termed quickSOFA (qSOFA). For adults suspected of infection, qSOFA requires two of the three clinical criteria of respiratory rate of 22 breaths/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less. “This model was robust to multiple sensitivity analyses,” wrote Dr. Singer and his coauthors, and worked well in out-of-hospital, emergency department, and ward settings both within and outside of the United States. “We are encouraging prospective validation in different health care settings,” for example, in resource-poor environments, said Dr. Singer.

The extensive review process included a large meta-analysis and systematic review of observational studies of adults with sepsis to evaluate diagnostic systems and criteria currently in use. The results of the review were used to inform the task force’s Delphi study, which then led to cohort studies to test the proposed variables, through the Surviving Sepsis Campaign. A comprehensive description of the work of the task force was published concurrently with the new sepsis and septic shock definitions (JAMA. 2016;315[8]:775-87. doi: 10.1001/jama.2016.0289).

“We had what I call a soft launch” of the new definitions, said Dr. Singer. The definitions and criteria have been available for review and discussion for about a year, and discussions in the public forum are already shaping thoughts about the way forward. “We expect lots and lots of discussion,” said Dr. Singer.

Limitations of the new definitions were enumerated by Dr. Singer and his coauthors, and also brought forward in an accompanying editorial by Dr. Edward Abraham, dean of the Wake Forest School of Medicine, Winston-Salem, N.C. These include that sepsis is not defined for children, that the reliance on serum lactate levels may not be feasible in resource-poor environments, and that there are limitations to the datasets used to generate the new guidelines.

The guidelines also offer suggested International Classification of Diseases-9 (ICD-9) and ICD-10 codes for sepsis and septic shock, in the hope that “greater clarity and consistency will also facilitate research and more accurate coding,” wrote Dr. Singer and his coauthors.

Multiple task force members reported relationships with pharmaceutical companies. The work of the task force was supported in part by grants from SCCM and ESICM.

The guidelines and accompanying information are available at www.sccm.org/sepsisredefined.

[email protected]

On Twitter @karioakes

With an outbreak of the extensively drug-resistant pathogen Acinetobacter baumannii (XDR-Ab), patient screening and daily chlorhexidine baths were part of a comprehensive outbreak control strategy, a new study suggested.

XDR-Ab transmission within hospitals has been documented via direct and indirect patient contact, inadequate sterilization of medical devices, contamination of rooms, and colonized health care workers, said Dr. Yves Longtin, chair of the infection prevention and control unit at Jewish General Hospital in Montreal. Dr. Longtin and his coauthors described the epidemiology and control of an XDR-Ab outbreak that involved multiple units of a large Canadian hospital in a recent article published in the Journal of Hospital Infection.

James Gathany, CDC

The outbreak was the result of a single clonal strain of XDR-Ab that colonized or infected 29 patients, 5 of whom died of XDR-Ab bacteremia. Transmission occurred primarily on two wards, either directly between patients or indirectly through staff, shared equipment, or the environment, investigators found. There is currently no consensus on optimal screening procedures, nor on the best combination of interventions to prevent transmission among patients, Dr. Longtin and his colleagues said.

The outbreak described in the study ended following the application of intensive screening, environmental disinfection, source control, reinforcement of routine hygiene, and isolation procedures including cohorting and unit closure. Intensive screening – screening of rectum, groin, throat, urine (in catheterized patients), wounds, and other catheter sites – revealed that 57% of infected patients were rectal carriers of the bacterium. Thus, a single rectal screening, considered standard for detection of carbapenem-resistant Enterobacteriaceae, would not have been sufficient to detect all infected patients.

Colonized patients received daily chlorhexidine baths, a strategy that is a useful tool in the control of other antibiotic-resistant nosocomial pathogens, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, but is not mentioned in the recent acinetobacter-specific guidelines or reviews, Dr. Longtin and coauthors said. They hypothesized that the prompt resolution of the outbreak may have been due in part to the use of the chlorhexidine baths.

Read the full study in the Journal of Hospital Infection (doi: 10.1016/j.jhin.2015.12.013).

[email protected]

On Twitter @richpizzi

With an outbreak of the extensively drug-resistant pathogen Acinetobacter baumannii (XDR-Ab), patient screening and daily chlorhexidine baths were part of a comprehensive outbreak control strategy, a new study suggested.

XDR-Ab transmission within hospitals has been documented via direct and indirect patient contact, inadequate sterilization of medical devices, contamination of rooms, and colonized health care workers, said Dr. Yves Longtin, chair of the infection prevention and control unit at Jewish General Hospital in Montreal. Dr. Longtin and his coauthors described the epidemiology and control of an XDR-Ab outbreak that involved multiple units of a large Canadian hospital in a recent article published in the Journal of Hospital Infection.

James Gathany, CDC

The outbreak was the result of a single clonal strain of XDR-Ab that colonized or infected 29 patients, 5 of whom died of XDR-Ab bacteremia. Transmission occurred primarily on two wards, either directly between patients or indirectly through staff, shared equipment, or the environment, investigators found. There is currently no consensus on optimal screening procedures, nor on the best combination of interventions to prevent transmission among patients, Dr. Longtin and his colleagues said.

The outbreak described in the study ended following the application of intensive screening, environmental disinfection, source control, reinforcement of routine hygiene, and isolation procedures including cohorting and unit closure. Intensive screening – screening of rectum, groin, throat, urine (in catheterized patients), wounds, and other catheter sites – revealed that 57% of infected patients were rectal carriers of the bacterium. Thus, a single rectal screening, considered standard for detection of carbapenem-resistant Enterobacteriaceae, would not have been sufficient to detect all infected patients.

Colonized patients received daily chlorhexidine baths, a strategy that is a useful tool in the control of other antibiotic-resistant nosocomial pathogens, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, but is not mentioned in the recent acinetobacter-specific guidelines or reviews, Dr. Longtin and coauthors said. They hypothesized that the prompt resolution of the outbreak may have been due in part to the use of the chlorhexidine baths.

Read the full study in the Journal of Hospital Infection (doi: 10.1016/j.jhin.2015.12.013).

[email protected]

On Twitter @richpizzi

With an outbreak of the extensively drug-resistant pathogen Acinetobacter baumannii (XDR-Ab), patient screening and daily chlorhexidine baths were part of a comprehensive outbreak control strategy, a new study suggested.

XDR-Ab transmission within hospitals has been documented via direct and indirect patient contact, inadequate sterilization of medical devices, contamination of rooms, and colonized health care workers, said Dr. Yves Longtin, chair of the infection prevention and control unit at Jewish General Hospital in Montreal. Dr. Longtin and his coauthors described the epidemiology and control of an XDR-Ab outbreak that involved multiple units of a large Canadian hospital in a recent article published in the Journal of Hospital Infection.

James Gathany, CDC

The outbreak was the result of a single clonal strain of XDR-Ab that colonized or infected 29 patients, 5 of whom died of XDR-Ab bacteremia. Transmission occurred primarily on two wards, either directly between patients or indirectly through staff, shared equipment, or the environment, investigators found. There is currently no consensus on optimal screening procedures, nor on the best combination of interventions to prevent transmission among patients, Dr. Longtin and his colleagues said.

The outbreak described in the study ended following the application of intensive screening, environmental disinfection, source control, reinforcement of routine hygiene, and isolation procedures including cohorting and unit closure. Intensive screening – screening of rectum, groin, throat, urine (in catheterized patients), wounds, and other catheter sites – revealed that 57% of infected patients were rectal carriers of the bacterium. Thus, a single rectal screening, considered standard for detection of carbapenem-resistant Enterobacteriaceae, would not have been sufficient to detect all infected patients.

Colonized patients received daily chlorhexidine baths, a strategy that is a useful tool in the control of other antibiotic-resistant nosocomial pathogens, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, but is not mentioned in the recent acinetobacter-specific guidelines or reviews, Dr. Longtin and coauthors said. They hypothesized that the prompt resolution of the outbreak may have been due in part to the use of the chlorhexidine baths.

Read the full study in the Journal of Hospital Infection (doi: 10.1016/j.jhin.2015.12.013).

[email protected]

On Twitter @richpizzi

ATLANTA – A chlorhexidine/alcohol skin antiseptic cut cesarean section surgical site infections by half, compared with a solution of iodine and alcohol.

The chlorhexidine solution significantly reduced the risk of both superficial and deep incisional infections, Dr. Methodius G. Tuuli reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine. The study was simultaneously published in the New England Journal of Medicine (2016 Feb 4. doi: 10.1056/NEJMoa1511048).

The randomized trial is the first to examine the two antiseptics in obstetric surgery, noted Dr. Tuuli of Washington University, St. Louis. The results echo those repeatedly found in the general surgical literature, and, he said, clearly show that chlorhexidine-based skin prep is more effective than the more often–employed iodine-based prep.

“We become comfortable doing the things we have always done, because that’s the way we were taught, and we see no reason to change,” he said in an interview. “I think now is the time to make a change for our patients.”

Dr. Tuuli’s study comprised 1,147 patients who delivered via cesarean section from 2011-2015. They were randomized to either a chlorhexidine/alcohol antiseptic (2% chlorhexidine gluconate with 70% isopropyl alcohol) or the iodine/alcohol combination (8.3% povidone-iodine with 72.5% isopropyl alcohol). Both groups received standard-of-care systemic antibiotic prophylaxis.

They were followed daily until discharge from the hospital, and then with a telephone call 30 days after delivery to assess whether a surgical site infection had occurred, as well as any visits to a physician’s office or emergency department that were related to a wound complication.

The co-primary endpoints were superficial and deep incisional infections. Secondary endpoints included length of hospital stay; physician office visits; hospital readmissions for infection-related complications; endometritis; positive wound culture; skin irritation; and allergic reaction.

Surgical site infections occurred in 23 patients in the chlorhexidine group and 42 in the iodine group (4.0% vs. 7.3%) – a significant 45% risk reduction (relative risk, 0.55). Superficial infections were significantly less common in the chlorhexidine group (3.0% vs. 4.9%), as were deep infections (1.0% vs. 2.4%).

A subgroup analysis examined unscheduled vs. scheduled cesarean; obese vs. nonobese patients; suture vs. staple closure; diabetes vs. no diabetes; and chronic comorbidities vs. none. Chlorhexidine was significantly more effective than iodine in each of these groups.

Antiseptic type did not affect rates of skin separation, seroma, hematoma, or cellulitis. Nor did it affect the rates of endometritis, hospitalization for infectious complications, or length of hospital stay. However, those in the chlorhexidine group were significantly less likely to visit a physician for wound care (7.9% vs. 12.5%)

Cultures were obtained on 32 patients with a confirmed infection; 27 of these specimens were positive. About half of the positive cultures were polymicrobial. The most common isolate was Staphylococcus aureus (37%). Methicillin-resistant S. aureus (MRSA) was present in 12% of cultures in the chlorhexidine group and 17% in the iodine group.

In an interview, Dr. Tuuli said that chlorhexidine has several properties that make it more effective than iodine. It is effective against both gram-negative and gram-positive organisms, including MRSA, and is not inactivated by organic matter. Although chlorhexidine is more likely than iodine to provoke an allergic reaction, none were observed in this study.

The study was supported by a grant from the National Institutes of Health. Dr. Tuuli reported having no financial disclosures; the antiseptics were procured and paid for by the medical center.

Watch Dr. Tuuli discuss the study results here.

[email protected]

ATLANTA – A chlorhexidine/alcohol skin antiseptic cut cesarean section surgical site infections by half, compared with a solution of iodine and alcohol.

The chlorhexidine solution significantly reduced the risk of both superficial and deep incisional infections, Dr. Methodius G. Tuuli reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine. The study was simultaneously published in the New England Journal of Medicine (2016 Feb 4. doi: 10.1056/NEJMoa1511048).

The randomized trial is the first to examine the two antiseptics in obstetric surgery, noted Dr. Tuuli of Washington University, St. Louis. The results echo those repeatedly found in the general surgical literature, and, he said, clearly show that chlorhexidine-based skin prep is more effective than the more often–employed iodine-based prep.

“We become comfortable doing the things we have always done, because that’s the way we were taught, and we see no reason to change,” he said in an interview. “I think now is the time to make a change for our patients.”

Dr. Tuuli’s study comprised 1,147 patients who delivered via cesarean section from 2011-2015. They were randomized to either a chlorhexidine/alcohol antiseptic (2% chlorhexidine gluconate with 70% isopropyl alcohol) or the iodine/alcohol combination (8.3% povidone-iodine with 72.5% isopropyl alcohol). Both groups received standard-of-care systemic antibiotic prophylaxis.

They were followed daily until discharge from the hospital, and then with a telephone call 30 days after delivery to assess whether a surgical site infection had occurred, as well as any visits to a physician’s office or emergency department that were related to a wound complication.

The co-primary endpoints were superficial and deep incisional infections. Secondary endpoints included length of hospital stay; physician office visits; hospital readmissions for infection-related complications; endometritis; positive wound culture; skin irritation; and allergic reaction.

Surgical site infections occurred in 23 patients in the chlorhexidine group and 42 in the iodine group (4.0% vs. 7.3%) – a significant 45% risk reduction (relative risk, 0.55). Superficial infections were significantly less common in the chlorhexidine group (3.0% vs. 4.9%), as were deep infections (1.0% vs. 2.4%).

A subgroup analysis examined unscheduled vs. scheduled cesarean; obese vs. nonobese patients; suture vs. staple closure; diabetes vs. no diabetes; and chronic comorbidities vs. none. Chlorhexidine was significantly more effective than iodine in each of these groups.

Antiseptic type did not affect rates of skin separation, seroma, hematoma, or cellulitis. Nor did it affect the rates of endometritis, hospitalization for infectious complications, or length of hospital stay. However, those in the chlorhexidine group were significantly less likely to visit a physician for wound care (7.9% vs. 12.5%)

Cultures were obtained on 32 patients with a confirmed infection; 27 of these specimens were positive. About half of the positive cultures were polymicrobial. The most common isolate was Staphylococcus aureus (37%). Methicillin-resistant S. aureus (MRSA) was present in 12% of cultures in the chlorhexidine group and 17% in the iodine group.

In an interview, Dr. Tuuli said that chlorhexidine has several properties that make it more effective than iodine. It is effective against both gram-negative and gram-positive organisms, including MRSA, and is not inactivated by organic matter. Although chlorhexidine is more likely than iodine to provoke an allergic reaction, none were observed in this study.

The study was supported by a grant from the National Institutes of Health. Dr. Tuuli reported having no financial disclosures; the antiseptics were procured and paid for by the medical center.

Watch Dr. Tuuli discuss the study results here.

[email protected]

ATLANTA – A chlorhexidine/alcohol skin antiseptic cut cesarean section surgical site infections by half, compared with a solution of iodine and alcohol.

The chlorhexidine solution significantly reduced the risk of both superficial and deep incisional infections, Dr. Methodius G. Tuuli reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine. The study was simultaneously published in the New England Journal of Medicine (2016 Feb 4. doi: 10.1056/NEJMoa1511048).

The randomized trial is the first to examine the two antiseptics in obstetric surgery, noted Dr. Tuuli of Washington University, St. Louis. The results echo those repeatedly found in the general surgical literature, and, he said, clearly show that chlorhexidine-based skin prep is more effective than the more often–employed iodine-based prep.

“We become comfortable doing the things we have always done, because that’s the way we were taught, and we see no reason to change,” he said in an interview. “I think now is the time to make a change for our patients.”

Dr. Tuuli’s study comprised 1,147 patients who delivered via cesarean section from 2011-2015. They were randomized to either a chlorhexidine/alcohol antiseptic (2% chlorhexidine gluconate with 70% isopropyl alcohol) or the iodine/alcohol combination (8.3% povidone-iodine with 72.5% isopropyl alcohol). Both groups received standard-of-care systemic antibiotic prophylaxis.

They were followed daily until discharge from the hospital, and then with a telephone call 30 days after delivery to assess whether a surgical site infection had occurred, as well as any visits to a physician’s office or emergency department that were related to a wound complication.

The co-primary endpoints were superficial and deep incisional infections. Secondary endpoints included length of hospital stay; physician office visits; hospital readmissions for infection-related complications; endometritis; positive wound culture; skin irritation; and allergic reaction.

Surgical site infections occurred in 23 patients in the chlorhexidine group and 42 in the iodine group (4.0% vs. 7.3%) – a significant 45% risk reduction (relative risk, 0.55). Superficial infections were significantly less common in the chlorhexidine group (3.0% vs. 4.9%), as were deep infections (1.0% vs. 2.4%).

A subgroup analysis examined unscheduled vs. scheduled cesarean; obese vs. nonobese patients; suture vs. staple closure; diabetes vs. no diabetes; and chronic comorbidities vs. none. Chlorhexidine was significantly more effective than iodine in each of these groups.

Antiseptic type did not affect rates of skin separation, seroma, hematoma, or cellulitis. Nor did it affect the rates of endometritis, hospitalization for infectious complications, or length of hospital stay. However, those in the chlorhexidine group were significantly less likely to visit a physician for wound care (7.9% vs. 12.5%)

Cultures were obtained on 32 patients with a confirmed infection; 27 of these specimens were positive. About half of the positive cultures were polymicrobial. The most common isolate was Staphylococcus aureus (37%). Methicillin-resistant S. aureus (MRSA) was present in 12% of cultures in the chlorhexidine group and 17% in the iodine group.

In an interview, Dr. Tuuli said that chlorhexidine has several properties that make it more effective than iodine. It is effective against both gram-negative and gram-positive organisms, including MRSA, and is not inactivated by organic matter. Although chlorhexidine is more likely than iodine to provoke an allergic reaction, none were observed in this study.

The study was supported by a grant from the National Institutes of Health. Dr. Tuuli reported having no financial disclosures; the antiseptics were procured and paid for by the medical center.

Watch Dr. Tuuli discuss the study results here.

[email protected]