Review of management priorities for invasive infections in people who inject drugs: highlighting the need for patient-centred multidisciplinary care

There has been a global increase in the burden of invasive infections in people who inject drugs (PWID). It is essential that patient-centred multidisciplinary care is provided in the management of these infections to engage PWID in care and deliver evidence-based management and preventive strategies. The multidisciplinary team should include infectious diseases, addictions medicine (inclusive of alcohol and other drug services), surgery, psychiatry, pain specialists, pharmacy, nursing staff, social work and peer support workers (where available) to help address the comorbid conditions that may have contributed to the patient's presentation. PWID have a range of antimicrobial delivery options that can be tailored in a patient-centred manner and thus are not limited to prolonged hospital admissions to receive intravenous antimicrobials for invasive infections. These options include discharge with outpatient parenteral antimicrobial therapy, long-acting lipoglycopeptides (dalbavancin and oritavancin) and early oral antimicrobials. Open and respectful discussion with PWID including around harm reduction strategies may decrease the risk of repeat presentations with injecting-related harms.

P2/N95 respirators & surgical masks to prevent SARS-CoV-2 infection: Effectiveness & adverse effects

BACKGROUND

Millions of people have acquired and died from SARS-CoV-2 infection during the COVID-19 pandemic. Healthcare workers (HCWs) are required to wear personal protective equipment (PPE), including surgical masks and P2/N95 respirators, to prevent infection while treating patients. However, the comparative effectiveness of respirators and masks in preventing SARS-CoV-2 infection and the likelihood of experiencing adverse events (AEs) with wear are unclear.

METHODS

Searches were carried out in PubMed, Europe PMC and the Cochrane COVID-19 Study Register to 14 June 2021. A systematic review of comparative epidemiological studies examining SARS-CoV-2 infection or AE incidence in HCWs wearing P2/N95 (or equivalent) respirators and surgical masks was performed. Article screening, risk of bias assessment and data extraction were duplicated. Meta-analysis of extracted data was carried out in RevMan.

RESULTS

Twenty-one studies were included, with most having high risk of bias. There was no statistically significant difference in respirator or surgical mask effectiveness in preventing SARS-CoV-2 infection (OR 0.85, [95%CI 0.72, 1.01]). Healthcare workers experienced significantly more headaches (OR 2.62, [95%CI 1.18, 5.81]), respiratory distress (OR 4.21, [95%CI 1.46, 12.13]), facial irritation (OR 1.80, [95%CI 1.03, 3.14]) and pressure-related injuries (OR 4.39, [95%CI 2.37, 8.15]) when wearing respirators compared to surgical masks.

CONCLUSION

The existing epidemiological evidence does not enable definitive assessment of the effectiveness of respirators compared to surgical masks in preventing infection. Healthcare workers wearing respirators may be more likely to experience AEs. Effective mitigation strategies are important to ensure the uptake and correct use of respirators by HCWs.

Hospitalisation with injection-related infections: Validation of diagnostic codes to monitor admission trends at a tertiary care hospital in Melbourne, Australia

INTRODUCTION

Injection-related infections (IRI) cause morbidity and mortality in people who inject drugs. Hospital administrative datasets can be used to describe hospitalisation trends, but there are no validated algorithms to identify injecting drug use and IRIs. We aimed to validate International Classification of Diseases (ICD) codes to identify admissions with IRIs and use these codes to describe IRIs within our hospital.

METHODS

We developed a candidate set of ICD codes to identify current injecting drug use and IRI and extracted admissions satisfying both criteria. We then used manual chart review data from 1 January 2017 to 30 April 2019 to evaluate the performance of these codes and refine our algorithm by selecting codes with a high-positive predictive value (PPV). We used the refined algorithm to describe trends and outcomes of people who inject drugs with an IRI at Alfred Hospital, Melbourne from 2008 to 2020.

RESULTS

Current injecting drug use was best predicted by opioid-related disorders (F11), 80% (95% confidence interval [CI] 74-85%), and other stimulant-related disorders (F15), 82% (95% CI 70-90%). All PPVs were ≥67% to identify specific IRIs, and ≥84% for identifying any IRI. Using these codes over 12 years, IRIs increased from 138 to 249 per 100 000 admissions, and skin and soft tissues infections (SSTI) were the most common (797/1751, 46%).

DISCUSSION AND CONCLUSION

Validated ICD-based algorithms can inform passive surveillance systems. Strategies to reduce hospitalisation with IRIs should be supported by early intervention and prevention, particularly for SSTIs which may represent delayed access to care.

The effect of hand hygiene frequency on reducing acute respiratory infections in the community: a meta-analysis

Hand hygiene is a simple, low-cost intervention that may lead to substantial population-level effects in suppressing acute respiratory infection epidemics. However, quantification of the efficacy of hand hygiene on respiratory infection in the community is lacking. We searched PubMed for randomised controlled trials on the effect of hand hygiene for reducing acute respiratory infections in the community published before 11 March 2021. We performed a meta-regression analysis using a Bayesian mixed-effects model. A total of 105 publications were identified, out of which six studies reported hand hygiene frequencies. Four studies were performed in household settings and two were in schools. The average number of handwashing events per day ranged from one to eight in the control arms, and four to 17 in the intervention arms. We estimated that a single hand hygiene event is associated with a 3% (80% credible interval (-1% to 7%)) decrease in the daily probability of an acute respiratory infection. Three of these six studies were potentially at high risk of bias because the primary outcome depended on self-reporting of upper respiratory tract symptoms. Well-designed trials with an emphasis on monitoring hand hygiene adherence are needed to confirm these findings.

Search and Contain: Impact of an Integrated Genomic and Epidemiological Surveillance and Response Program for Control of Carbapenemase-producing Enterobacterales

BACKGROUND

Multiresistant organisms (MROs) pose a critical threat to public health. Population-based programs for control of MROs such as carbapenemase-producing Enterobacterales (CPE) have emerged and evaluation is needed. We assessed the feasibility and impact of a statewide CPE surveillance and response program deployed across Victoria, Australia (population 6.5 million).

METHODS

A prospective multimodal intervention including active screening, carrier isolation, centralized case investigation, and comparative pathogen genomics was implemented. We analyzed trends in CPE incidence and clinical presentation, risk factors, and local transmission over the program's first 3 years (2016-2018).

RESULTS

CPE case ascertainment increased over the study period to 1.42 cases/100 000 population, linked to increased screening without a concomitant rise in active clinical infections (0.45-0.60 infections/100 000 population, P = .640). KPC-2 infection decreased from 0.29 infections/100 000 population prior to intervention to 0.03 infections/100 000 population in 2018 (P = .003). Comprehensive case investigation identified instances of overseas community acquisition. Median time between isolate referral and genomic and epidemiological assessment for local transmission was 11 days (IQR, 9-14). Prospective surveillance identified numerous small transmission networks (median, 2; range, 1-19 cases), predominantly IMP and KPC, with median pairwise distance of 8 (IQR, 4-13) single nucleotide polymorphisms; low diversity between clusters of the same sequence type suggested genomic cluster definitions alone are insufficient for targeted response.

CONCLUSIONS

We demonstrate the value of centralized CPE control programs to increase case ascertainment, resolve risk factors, and identify local transmission through prospective genomic and epidemiological surveillance; methodologies are transferable to low-prevalence settings and MROs globally.

Attributable Length of Stay, Mortality Risk, and Costs of Bacterial Health Care-Associated Infections in Australia: A Retrospective Case-cohort Study

Background

Unbiased estimates of the health and economic impacts of health care–associated infections (HAIs) are scarce and focus largely on patients with bloodstream infections (BSIs). We sought to estimate the hospital length of stay (LOS), mortality rate, and costs of HAIs and the differential effects on patients with an antimicrobial-resistant infection.

Methods

We conducted a multisite, retrospective case-cohort of all acute-care hospital admissions with a positive culture of 1 of the 5 organisms of interest (Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus, or Enterococcus faecium) from 1 January 2012 through 30 December 2016. Data linkage was used to generate a data set of statewide hospital admissions and pathology data. Patients with bloodstream, urinary, or respiratory tract infections were included in the analysis and matched to a sample of uninfected patients. We used multistate survival models to generate LOS, and logistic regression to derive mortality estimates.

Results

We matched 20 390 cases to 75 635 uninfected control patients. The overall incidence of infections due to the 5 studied organisms was 116.9 cases per 100 000 patient days, with E. coli urinary tract infections (UTIs) contributing the largest proportion (51 cases per 100 000 patient days). The impact of a UTI on LOS was moderate across the 5 studied pathogens. Resistance significantly increased LOS for patients with third-generation cephalosporin-resistant K. pneumoniae BSIs (extra 4.6 days) and methicillin-resistant S. aureus BSIs (extra 2.9 days). Consequently, the health-care costs of these infections were higher, compared to corresponding drug-sensitive strains.

Conclusions

The health burden remains highest for BSIs; however, UTIs and respiratory tract infections contributed most to the health-care system expenditure.

Antimicrobial anaphylaxis: the changing face of severe antimicrobial allergy

OBJECTIVES

The epidemiology, clinical characteristics and outcomes of antimicrobial-associated anaphylaxis remain ill-defined. We sought to examine antimicrobial anaphylaxis with regard to: (i) the frequency of implicated antimicrobials; (ii) attributable mortality; and (iii) referral for definitive allergy assessment.

METHODS

This was conducted through a national retrospective multicentre cohort study at five Australian tertiary hospitals (January 2010 to December 2015). Cases of antimicrobial anaphylaxis were identified from ICD-10 coding and adverse drug reaction committee databases.

RESULTS

There were 293 participants meeting the case definition of antimicrobial anaphylaxis and 310 antimicrobial anaphylaxis episodes. Of 336 implicated antimicrobials, aminopenicillins (62/336, 18.5%) and aminocephalosporins (57/336, 17%) were implicated most frequently. ICU admission occurred in 43/310 (13.9%) episodes; however, attributable mortality was low (3/310, 1%). The rate of anaphylaxis to IV antibiotics was 3.5 (95% CI=2.9-4.3) per 100 000 DDDs and the rate of hospital-acquired anaphylaxis was 1.9 (95% CI=2.1-3.3) per 100 000 occupied bed-days. We observed overall low rates of hospital discharge documentation (222/310, 71.6%) and follow-up by specialist allergy services (73/310, 23.5%), which may compromise medication safety and antimicrobial prescribing in future.

CONCLUSIONS

This study demonstrated that a high proportion of severe immediate hypersensitivity reactions presenting or acquired in Australian hospitals are secondary to aminopenicillins and aminocephalosporins. Overall rates of hospital-acquired anaphylaxis, predominantly secondary to cephalosporins, are low, and also associated with low inpatient mortality.

Multicentre stepped-wedge cluster randomised controlled trial of an antimicrobial stewardship programme in residential aged care: protocol for the START trial

INTRODUCTION

Antimicrobial resistance is a growing global health threat, driven by increasing inappropriate use of antimicrobials. High prevalence of unnecessary use of antimicrobials in residential aged care facilities (RACFs) has driven demand for the development and implementation of antimicrobial stewardship (AMS) programmes. The Stepped-wedge Trial to increase antibiotic Appropriateness in Residential aged care facilities and model Transmission of antimicrobial resistance (START) will implement and evaluate the impact of a nurse-led AMS programme on antimicrobial use in 12 RACFs.

METHODS AND ANALYSIS

The START trial will implement and evaluate a nurse-led AMS programme via a stepped-wedge cluster randomised controlled trial design in 12 RACFs over 16 months. The AMS programme will incorporate education, aged care-specific treatment guidelines, documentation forms, and audit and feedback strategies that will target aged care staff, general practitioners, pharmacists, and residents and their families. The intervention will primarily focus on urinary tract infections, lower respiratory tract infections, and skin and soft tissue infections. RACFs will transition from control to intervention phases in random order, two at a time, every 2 months, with a 2-month transition, wash-in period. The primary outcome is the cumulative proportion of residents within each facility prescribed an antibiotic during each month and total days of antibiotic use per 1000 occupied bed days. Secondary outcomes include the number of courses of systemic antimicrobial therapy, antimicrobial appropriateness, antimicrobial resistant organisms, Clostridioides difficile infection, change in antimicrobial susceptibility profiles, hospitalisations and all-cause mortality. Analyses will be conducted according to the intention-to-treat principle.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Alfred Hospital Human Research Ethics Committee (HREC/18/Alfred/591). Research findings will be disseminated through peer-reviewed publications, conferences and summarised reports provided to participating RACFs.

TRIAL REGISTRATION NUMBER

NCT03941509.

Bringing evidence from press release to the clinic in the era of COVID-19

The urgent need to develop effective therapeutics and disseminate information from clinical studies has led to data from clinical trials being made available by alternate methods prior to peer-reviewed publication, including press releases, social media and pre-print papers. While this allows clinicians more open access to these data, a trust has to be placed with the investigators releasing these data without the availability of scientifically rigorous peer review. The examples of results from trials studying dexamethasone and hydroxychloroquine for treatment of COVID-19 have had contrasting outcomes, including the potential for significant numbers of lives saved with the early release of results from the RECOVERY trial studying dexamethasone contrasting with unsubstantiated data being presented from trials studying hydroxychloroquine. Clinicians and researchers must maintain a healthy scepticism when reviewing results prior to peer-reviewed publication, but also consider when these opportunities may allow for early implementation of potentially lifesaving interventions for people infected with COVID-19.

Aminoglycoside use in paediatric febrile neutropenia - Outcomes from a nationwide prospective cohort study

Aminoglycosides are commonly prescribed to children with febrile neutropenia (FN) but their impact on clinical outcomes is uncertain and extent of guideline compliance is unknown. We aimed to review aminoglycoside prescription and additional antibiotic prescribing, guideline compliance and outcomes for children with FN. We analysed data from the Australian Predicting Infectious ComplicatioNs in Children with Cancer (PICNICC) prospective multicentre cohort study, in children <18 years with FN between November 2016 and January 2018. Impact of aminoglycoside use in the first 12 hours of FN on composite unfavourable outcome of death, ICU admission, relapse of infection or late-onset sepsis was assessed using multivariable Cox regression. The study was conducted in Australia where antimicrobial resistance among gram negative organisms is relatively low. Data from 858 episodes of FN in 462 children from 8 centres were assessed, median age 5.8 years (IQR 3.5-10.8 years). Early empiric aminoglycosides were prescribed in 255 episodes (29.7%). Guideline non-compliance was common: in 46% (184/400) of eligible episodes, patients did not receive aminoglycosides, while aminoglycosides were prescribed in 9% (39/458) of guideline-ineligible episodes. Adjusted hazard of the composite unfavourable outcome was 3.81 times higher among patients prescribed empiric aminoglycosides than among those who weren't (95% confidence interval, 1.89-7.67), with no increased risk of unfavourable outcome in eligible patients who did not receive aminoglycosides. In a large paediatric FN cohort, aminoglycoside prescription was common and was often non-compliant with guidelines. There was no evidence for improved outcome with aminoglycosides, even in those who met guideline criteria, within a low-resistance setting. Empiric aminoglycoside prescription for children with FN requires urgent review in guidelines and in national practice.

Prevalence of healthcare-associated infections and antimicrobial use among inpatients in a tertiary hospital in Fiji: a point prevalence survey

Background

Healthcare-associated infections (HAIs) and antimicrobial use (AMU) are important drivers of antimicrobial resistance, yet there is minimal data from the Pacific region. We sought to determine the point prevalence of HAIs and AMU at Fiji’s largest hospital, the Colonial War Memorial Hospital (CWMH) in Suva. A secondary aim was to evaluate the performance of European Centre for Diseases Prevention and Control (ECDC) HAI criteria in a resource-limited setting.

Methods

We conducted a point prevalence survey of HAIs and AMU at CWMH in October 2019. Survey methodology was adapted from the ECDC protocol. To evaluate the suitability of ECDC HAI criteria in our setting, we augmented the survey to identify patients with a clinician diagnosis of a HAI where diagnostic testing criteria were not met. We also assessed infection prevention and control (IPC) infrastructure on each ward.

Results

We surveyed 343 patients, with median (interquartile range) age 30 years (16–53), predominantly admitted under obstetrics/gynaecology (94, 27.4%) or paediatrics (83, 24.2%). Thirty patients had one or more HAIs, a point prevalence of 8.7% (95% CI 6.0% to 12.3%). The most common HAIs were surgical site infections (n = 13), skin and soft tissue infections (7) and neonatal clinical sepsis (6). Two additional patients were identified with physician-diagnosed HAIs that failed to meet ECDC criteria due to insufficient investigations. 206 (60.1%) patients were receiving at least one antimicrobial. Of the 325 antimicrobial prescriptions, the most common agents were ampicillin (58/325, 17.8%), cloxacillin (55/325, 16.9%) and metronidazole (53/325, 16.3%). Use of broad-spectrum agents such as piperacillin/tazobactam (n = 6) and meropenem (1) was low. The majority of prescriptions for surgical prophylaxis were for more than 1 day (45/76, 59.2%). Although the number of handwashing basins throughout the hospital exceeded World Health Organization recommendations, availability of alcohol-based handrub was limited and most concentrated within high-risk wards.

Conclusions

The prevalence of HAIs in Fiji was similar to neighbouring high-income countries, but may have been reduced by the high proportion of paediatric and obstetrics patients, or by lower rates of inpatient investigations. AMU was very high, with duration of surgical prophylaxis an important target for future antimicrobial stewardship initiatives.

The pharmacokinetics of nitrofurantoin in healthy female volunteers: a randomized crossover study

BACKGROUND

Use of nitrofurantoin has increased significantly since its recent repositioning as a first-line agent for uncomplicated cystitis by multiple guidelines. However, current dosing regimens were developed in an era before robust pharmacokinetic testing and may not be optimal. Furthermore, formulations have been modified over the years.

OBJECTIVES

To reassess the plasma and urinary pharmacokinetic profile of macrocrystalline nitrofurantoin in two commonly used dosing regimens.

METHODS

In this open-label, randomized crossover pharmacokinetic trial, 12 healthy adult female volunteers were randomized to receive oral nitrofurantoin 100 mg q8h on days 1 and 2 and, after a washout period, 50 mg q6h on days 30 and 31, or the same dosing schemes in reversed order. Urine and blood were collected at steady state and analysed by UPLC. Pharmacokinetic analysis was performed by WinNonlin.

RESULTS

Plasma peak concentrations were low (mean 0.33 mg/L, SD 0.08, and 0.69 mg/L, SD 0.35, after 50 and 100 mg, respectively) and dose dependent. The AUC0-24 was higher (6.49 versus 4.43 mg·h/L, P = 0.021) for the 100 mg q8h dosing regimen, but the dose-normalized AUC was similar for the two regimens. In contrast, urinary concentrations were dose independent: increasing the nitrofurantoin dose delayed the time to peak urinary concentration, while steady-state AUC0-24 values remained unchanged (943.49 and 855.95 mg·h/L at 50 mg q6h and 100 mg q8h, respectively).

CONCLUSIONS

Plasma concentrations were relatively low and dose dependent. The dose-independent urinary concentrations suggest that excretion of nitrofurantoin into the urine is saturable. Pharmacodynamic studies are urgently required to determine the impact of these findings.

Prevalence of device use and transmission based precautions in nineteen large Australian acute care public hospitals: Secondary outcomes from a national healthcare associated infection point prevalence survey

BACKGROUND

The use of invasive devices increases the risk of healthcare associated infections (HAI). The recent national HAI point prevalence survey secondary outcomes aimed to estimate the prevalence of patients with an indwelling urinary catheter device and vascular access devices; and also identify prevalence of those managed under transmission based precautions (TBP); and those colonised or infected with a multi drug resistant organism (MDRO).

METHODS

A point prevalence study was conducted in large acute care Australian public hospitals. All data were collected by two trained Research Assistants. Surveillance methodology was based on the European Centre for Disease Prevention and Control PPS Protocol. Data was also collected on prevalence of TBPs and MDROs.

RESULTS

A total of 2767 acute adult inpatients were sampled across 19 hospitals. The prevalence of peripheral vascular, central vascular and urinary catheters devices was 55.2% (95%CI: 53.3%-57.1%), 14.8% (95%CI: 13.5%-16.1%) and 20.7% (95%CI: 19.2%-22.3%) respectively. Of the 2767 patients sampled 285 (10.3%, 95%CI: 9.2%-11.5%) were documented as either being infected or colonised with a MDRO, and 781 (11.8%) patients were being managed under the hospital TBP policy.

CONCLUSION

This is the first national study to describe the prevalence of devices, TBPs and MDROs in Australian healthcare settings. In an era where device use should be constantly reviewed to minimise risk of HAI, and the increasing challenges of managing patients with MDROs, this data can serve as a benchmark for future studies.

Diagnosis, management and prevention of Candida auris in hospitals: position statement of the Australasian Society for Infectious Diseases

Candida auris is an emerging drug-resistant yeast responsible for hospital outbreaks. This statement reviews the evidence regarding diagnosis, treatment and prevention of this organism and provides consensus recommendations for clinicians and microbiologists in Australia and New Zealand. C. auris has been isolated in over 30 countries (including Australia). Bloodstream infections are the most frequently reported infections. Infections have crude mortality of 30-60%. Acquisition is generally healthcare-associated and risks include underlying chronic disease, immunocompromise and presence of indwelling medical devices. C. auris may be misidentified by conventional phenotypic methods. Matrix-assisted laser desorption ionisation time-of-flight mass spectrometry or sequencing of the internal transcribed spacer regions and/or the D1/D2 regions of the 28S ribosomal DNA are therefore required for definitive laboratory identification. Antifungal drug resistance, particularly to fluconazole, is common, with variable resistance to amphotericin B and echinocandins. Echinocandins are currently recommended as first-line therapy for infection in adults and children ≥2 months of age. For neonates and infants <2 months of age, amphotericin B deoxycholate is recommended. Healthcare facilities with C. auris should implement a multimodal control response. Colonised or infected patients should be isolated in single rooms with Standard and Contact Precautions. Close contacts, patients transferred from facilities with endemic C. auris or admitted following stay in overseas healthcare institutions should be pre-emptively isolated and screened for colonisation. Composite swabs of the axilla and groin should be collected. Routine screening of healthcare workers and the environment is not recommended. Detergents and sporicidal disinfectants should be used for environmental decontamination.

Does skin surface temperature variation account for Buruli ulcer lesion distribution?

Background

Buruli ulcer is a necrotising infection of skin and soft tissue caused by Mycobacterium ulcerans (M. ulcerans). Buruli ulcer most often occurs on limbs, and it is hypothesized this is explained by direct exposure to the environment. However, even on exposed areas Buruli ulcer is not randomly distributed. M. ulcerans prefers an in vitro temperature of 30–33°C and growth is inhibited at higher temperatures. This study investigated whether variations in skin surface temperature distribution in healthy volunteers could partly account for Buruli ulcer lesion distribution.

Methodology/Principal findings

In this observational study, a thermal camera (FLIR E8) was used to measure skin surface temperature at the sternal notch and at 44 predetermined locations on the limbs of 18 human participants. Body locations of high, middle and low Buruli ulcer incidence were identified from existing density maps of lesion distribution. Skin temperature of the three incidence location groups were compared, and differences in age and sex groups were also analysed.

We found an inverse relationship between skin temperature and lesion distribution, where high incidence locations were significantly cooler and low incidence locations significantly warmer (Kruskal-Wallis test p<0.0001). Linear mixed effects regression analysis estimated that skin surface temperature accounts for 22.0% of the variance in Buruli ulcer lesion distribution (marginal R-squared = 0.219) in the anterior location group, and 0.6% in the posterior group (marginal R-squared 0.006). Men had warmer upper and lower limbs than females (Mann-Whitney U test p = 0.0003 and p<0.0001 respectively).

Conclusions/Significance

We have found an inverse relationship between skin temperature and Buruli ulcer lesion distribution, however this association is weak. Additional unknown factors are likely to be involved that explain the majority of the variation in Buruli lesion distribution.

Testing of the WHO Infection Prevention and Control Assessment Framework at acute healthcare facility level

BACKGROUND

Monitoring and evaluation are an essential part of infection prevention and control (IPC) implementation. The authors developed an IPC assessment framework (IPCAF) to support implementation of the World Health Organization (WHO) guidelines on core components of IPC programmes in acute healthcare facilities.

AIM

To evaluate the usability and reliability of the IPCAF tool for global use.

METHODS

The IPCAF is a questionnaire with a scoring system to measure the level of IPC implementation according to the eight WHO core components. The tool was pre-tested qualitatively, revised and translated selectively. A convenience sample of hospitals was invited to participate in the final testing. At least two IPC professionals from each hospital independently completed the IPCAF and a usability questionnaire online. The tool's internal consistency and interobserver reliability or intraclass correlation coefficient (ICC) were assessed, and usability questions were summarized descriptively.

FINDINGS

In total, 46 countries, 181 hospitals and 324 individuals participated; 52 (16%) and 55 (17%) individual respondents came from low- and lower-middle income countries, respectively. Fifty-two percent of respondents took less than 1 h to complete the IPCAF. Overall, there was adequate internal consistency and a high ICC (0.92, 95% confidence interval 0.89-0.94). Ten individual questions had poor reliability (ICC <0.4); these were considered for revision according to usability feedback and expert opinion.

CONCLUSIONS

The WHO IPCAF was tested using a robust global study and revised as necessary. It is now an effective tool for IPC improvement in healthcare facilities.

International Society of Cardiovascular Infectious Diseases Guidelines for the Diagnosis, Treatment and Prevention of Disseminated Mycobacterium chimaera Infection Following Cardiac Surgery with Cardiopulmonary Bypass

Mycobacterial infection-related morbidity and mortality in patients following cardiopulmonary bypass surgery is high and there is a growing need for a consensus-based expert opinion to provide international guidance for diagnosing, preventing and treating in these patients. In this document the International Society for Cardiovascular Infectious Diseases (ISCVID) covers aspects of prevention (field of hospital epidemiology), clinical management (infectious disease specialists, cardiac surgeons, ophthalmologists, others), laboratory diagnostics (microbiologists, molecular diagnostics), device management (perfusionists, cardiac surgeons) and public health aspects.

Long-term impacts of antibiotic allergy testing on patient perceptions and antibiotic utilization

Objectives

To define the long-term impacts of antibiotic allergy testing (AAT) on patient allergy perception and antibiotic utilization.

Methods

Patients were identified from a prospective AAT database as having completed testing during a 15 month period beginning January 2017. Patients were contacted for a follow-up survey at least 12 months post-AAT. For those contacted, baseline demographics, antibiotic allergy label (AAL) history, age-adjusted Charlson comorbidity index, infection history, antibiotic de-labelling (≥1 AAL removed following AAT) and antibiotic usage for 12 months prior to testing (pre-AAT) and 12 months following testing (post-AAT) were recorded for each patient.

Results

From the follow-up survey of 112 patients post-AAT, 95.2% (59/62) of patients with complete AAL removal expressed willingness to use ‘de-labelled’ antibiotics and 91.9% (57/62) were adherent to allergy label modification. Comparing antibiotic utilization 12 months pre-AAT versus 12 months post-AAT, AAT was associated with a significant increase in preferred antibiotic therapy [adjusted odds ratio (aOR) 3.29, 95% CI 1.56–6.92] and reduction in restricted antibiotic utilization (aOR 0.42, 95% CI 0.19–0.93).

Conclusions

An antimicrobial stewardship (AMS)-led AAT programme was safe and effective in the long term in the promotion of preferred and narrow-spectrum antibiotic usage, and favourable patient perception towards the AAT testing results was identified. This study further supports the routine incorporation of AAT into AMS programmes, confirming safety and durability of testing impacts on patients as well as increasing preferred antibiotic utilization.

The prevalence of healthcare associated infections among adult inpatients at nineteen large Australian acute-care public hospitals: a point prevalence survey

Background

Australia does not have a national healthcare associated infection (HAI) surveillance program. Only one HAI point prevalence study has been undertaken in 1984. The objective of this study was to estimate the burden of healthcare associated infection (HAI) in acute adult inpatients in Australia.

Methods

A cross sectional point prevalence study (PPS) was conducted in a sample of large acute care hospitals. All data were collected by two trained Research Assistants. Surveillance methodology was based on the European Centre for Disease Prevention and Control (ECDC) PPS Protocol with variation in the sampling method in that only acute inpatients ≥ 18 years old were included. ECDC HAI definitions were applied.

Results

Data was collected between August and November 2018. A total of 2767 patients from 19 hospitals were included in the study. The median age of patients was 67, and 52.9% of the sample were male. Presence of a multi-drug resistant organism was documented for 10.3% of the patients. There were 363 HAIs present in 273 patients. The prevalence of patients with a HAI was 9.9% (95%CI: 8.8-11.0). Hospital prevalence rates ranged from 5.7% (95%CI:2.9-11.0) to 17.0% (95%CI:10.7-26.1). The most common HAIs were surgical site infection, pneumonia and urinary tract infection, comprising 64% of all HAIs identified.

Conclusion

This is the first HAI PPS to be conducted in Australia in 34 years. The prevalence rate is higher than the previous Australian study and that reported by the ECDC, however differences in methodology limit comparison. Regular, large scale HAI PPS should be undertaken to generate national HAI data to inform and drive national interventions.