Lack of care giver hand contamination with endemic bacterial pathogens in a nursing home

How often are health care personnel hands colonized with multidrug- resistant organisms? A systematic review and meta-analysis

BACKGROUND

Hands of health care personnel (HCP) can transmit multidrug-resistant organisms (MDROs), resulting in infections. Our aim was to determine MDRO prevalence on HCP hands in adult acute care and nursing facility settings.

METHODS

A systematic search of PubMed/MEDLINE, Web of Science, CINAHL, Embase, and Cochrane CENTRAL was performed. Studies were included if they reported microbiologic culture results following HCP hands sampling; included prevalent MDROs, such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus, Clostridium difficile, Acinetobacter baumannii, or Pseudomonas aeruginosa, and were conducted in acute care or nursing facility settings.

RESULTS

Fifty-nine articles comprising 6,840 hand cultures were included. Pooled prevalence for MRSA, P aeruginosa, A baumannii, and vancomycin-resistant Enterococcus were 4.26%, 4.59%, 6.18%, and 9.03%, respectively. Substantial heterogeneity in rates of pathogen isolation were observed across studies (I² = 81%-95%). Only 4 of 59 studies sampled for C difficile, with 2 of 4 finding no growth. Subgroup analysis of MRSA revealed the highest HCP hand contamination rates in North America (8.28%). Sample collection methods used were comparable for MRSA isolation (4%-7%) except for agar direct contact (1.55%).

CONCLUSIONS

Prevalence of common MDROs on HCP hands vary by pathogen, care setting, culture acquisition method, study design, and geography. When obtained at an institutional level, these prevalence data can be utilized to enhance knowledge, practice, and research to prevent health care-associated infections.

A user report on the trial use of gesture commands for image manipulation and X-ray acquisition

Touchless environment for image manipulation and X-ray acquisition may enhance the current infection control measure during X-ray examination simply by avoiding any touch on the control panel. The present study is intended at designing and performing a trial experiment on using motion-sensing technology to perform image manipulation and X-ray acquisition function (the activities a radiographer frequently performs during an X-ray examination) under an experimental setup. Based on the author's clinical experience, several gesture commands were designed carefully to complete a single X-ray examination. Four radiographers were randomly recruited for the study. They were asked to perform gesture commands in front of a computer integrated with a gesture-based touchless controller. The translational movements of the tip of their thumb and index finger while performing different gesture commands were recorded for analysis. Although individual operators were free to decide the extent of movement and the speed at which their fingers and thumbs moved while performing these gesture commands, the result of our study demonstrated that all operators could perform our proposed gesture commands with good consistency, suggesting that motion-sensing technology could, in practice, be integrated into radiographic examinations. To summarize, although the implementation of motion-sensing technology as an input command in radiographic examination might inevitably slow down the examination throughput considering that extra procedural steps are required to trigger specific gesture commands in sequence, it is advantageous in minimizing the potential of the pathogen contamination during image operation and image processing that leads to cross infection.

Cost-effectiveness of strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in an intensive care unit

OBJECTIVE To create a national policy model to evaluate the projected cost-effectiveness of multiple hospital-based strategies to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection. DESIGN Cost-effectiveness analysis using a Markov microsimulation model that simulates the natural history of MRSA acquisition and infection. PATIENTS AND SETTING Hypothetical cohort of 10,000 adult patients admitted to a US intensive care unit. METHODS We compared 7 strategies to standard precautions using a hospital perspective: (1) active surveillance cultures; (2) active surveillance cultures plus selective decolonization; (3) universal contact precautions (UCP); (4) universal chlorhexidine gluconate baths; (5) universal decolonization; (6) UCP + chlorhexidine gluconate baths; and (7) UCP+decolonization. For each strategy, both efficacy and compliance were considered. Outcomes of interest were: (1) MRSA colonization averted; (2) MRSA infection averted; (3) incremental cost per colonization averted; (4) incremental cost per infection averted. RESULTS A total of 1989 cases of colonization and 544 MRSA invasive infections occurred under standard precautions per 10,000 patients. Universal decolonization was the least expensive strategy and was more effective compared with all strategies except UCP+decolonization and UCP+chlorhexidine gluconate. UCP+decolonization was more effective than universal decolonization but would cost $2469 per colonization averted and $9007 per infection averted. If MRSA colonization prevalence decreases from 12% to 5%, active surveillance cultures plus selective decolonization becomes the least expensive strategy. CONCLUSIONS Universal decolonization is cost-saving, preventing 44% of cases of MRSA colonization and 45% of cases of MRSA infection. Our model provides useful guidance for decision makers choosing between multiple available hospital-based strategies to prevent MRSA transmission.

Impact of hand hygiene on the infectious risk in nursing home residents: A systematic review

BACKGROUND

In nursing homes, the infectious risk is high, making infection control using approaches such as hand hygiene (HH) a major issue. However, the effectiveness of HH in these settings is not well documented, and HH compliance is low.

METHODS

We systematically searched PubMed, Scopus, Web of Science, and Cochrane Clinical Trials for studies in nursing homes that either described a HH-related intervention or assessed HH compliance and included a measured infectious outcome. Two reviewers independently performed the study selection.

RESULTS

Fifty-six studies met the inclusion criteria and were reviewed. Most were outbreak reports (39%), followed by observational studies (23%), controlled trials (23%), and before-after intervention studies (14%). Thirty-five studies (63%) reported results in favor of HH on at least one of their outcome measures; in addition, the infection control success rate was higher when at least one HH-related intervention (eg, staff education on HH, increased availability of handrub solution) was included (70% vs 30% for no intervention). However, only 25% of randomized trials concluded that HH-related interventions led to a reduction in the infectious risk.

CONCLUSION

The results of this systematic review suggest that more evidence on HH effectiveness in nursing homes is needed. Future interventional studies should enhance methodologic rigor using clearly defined outcome measures, standardized reporting of findings, and a relevant HH observation tool.

Asymptomatic carriers of toxigenic C. difficile in long-term care facilities: a meta-analysis of prevalence and risk factors

Background

The impact of Clostridium difficile colonization in C. difficile infection (CDI) is inadequately explored. As a result, asymptomatic carriage is not considered in the development of infection control policies and the burden of carrier state in long-term care facilities (LTCFs) is unknown.

Purpose

To explore the epidemiology of C. difficile colonization in LTCFs, identify predisposing factors and describe its impact on healthcare management.

Data Sources

PubMed, Embase and Web of Science (up to June 2014) without language restriction, complemented by reference lists of eligible studies.

Study Selection

All studies providing extractable data on the prevalence of toxigenic C. difficile colonization among asymptomatic residents in LTCFs.

Data Extraction

Two authors extracted data independently.

Statistical Methods

The pooled colonization estimates were calculated using the double arcsine methodology and reported along with their 95% random-effects confidence intervals (CIs), using DerSimonian-Laird weights. We assessed the impact of patient-level covariates on the risk of colonization and effects were reported as odds ratios (OR, 95% CI). We used the colonization estimates to simulate the effective reproduction number R through a Monte Carlo technique.

Results

Based on data from 9 eligible studies that met the specified criteria and included 1,371 subjects, we found that 14.8% (95%CI 7.6%-24.0%) of LTCF residents are asymptomatic carriers of toxigenic C. difficile. Colonization estimates were significantly higher in facilities with prior CDI outbreak (30.1% vs. 6.5%, p = 0.01). Patient history of CDI (OR 6.07; 95% CI 2.06–17.88; effect derived from 3 studies), prior hospitalization (OR 2.11; 95% CI 1.08–4.13; derived from 3 studies) and antimicrobial use within previous 3 months (OR 3.68; 95% CI 2.04–6.62; derived from 4 studies) were associated with colonization. The predicted colonization rate at admission was 8.9%.

Conclusion

Asymptomatic carriage of toxigenic C. difficile represents a significant burden in LTCFs and is associated with prior CDI outbreaks in the facility, a history of CDI, prior hospitalization and antimicrobial use. These findings can impact infection control measures at LTCFs.

Antibiotic use and resistance in long term care facilities

INTRODUCTION

The common occurrence of infectious diseases in nursing homes and residential care facilities may result in substantial antibiotic use, and consequently antibiotic resistance. Focusing on these settings, this article aims to provide a comprehensive overview of the literature available on antibiotic use, antibiotic resistance, and strategies to reduce antibiotic resistance.

METHODS

Relevant literature was identified by conducting a systematic search in the MEDLINE and EMBASE databases. Additional articles were identified by reviewing the reference lists of included articles, by searching Google Scholar, and by searching Web sites of relevant organizations.

RESULTS

A total of 156 articles were included in the review. Antibiotic use in long term care facilities is common; reported annual prevalence rates range from 47% to 79%. Part of the prescribed antibiotics is potentially inappropriate. The occurrence of antibiotic resistance is substantial in the long term care setting. Risk factors for the acquisition of resistant pathogens include prior antibiotic use, the presence of invasive devices, such as urinary catheters and feeding tubes, lower functional status, and a variety of other resident- and facility-related factors. Infection with antibiotic-resistant pathogens is associated with increased morbidity, mortality, and health care costs. Two general strategies to reduce antibiotic resistance in long term care facilities are the implementation of infection control measures and antibiotic stewardship.

CONCLUSION

The findings of this review call for the conduction of research and the development of policies directed at reducing antibiotic resistance and its subsequent burden for long term care facilities and their residents.

Diarrhea, clostridium difficile, and intestinal inflammation in residents of a long-term care facility

INTRODUCTION

Long-term care facilities (LTCF) residents have been estimated to have the highest incidence of diarrheal illness among adults living in the developed world. This study describes undiagnosed diarrhea, intestinal inflammation, and Clostridium difficile colonization in a LTC population and explores whether these are associated with functional decline, as defined by weight loss or a change in cognitive or ADL status.

METHODS

An observational study of a convenience sampling of residents in a 180-bed LTCF was obtained; evaluation of stool and medical records was done. Stool specimens were evaluated for consistency, gross blood, inflammation (via quantitative fecal lactoferrin, IBD-SCAN), and C difficile (via PCR for gdh). SPSS and STATA were used and significance was set at P < .05.

RESULTS

There were 46 stools collected; 13 of the subjects were male, 28 were older than 65 years, and 35 were prescribed 5 to 15 medications. Twenty-six of the 46 stools collected had elevated quantitative fecal lactoferrin levels. Although only 5 subjects were reported to have diarrhea (4 with elevated lactoferrin), 28 stool specimens were observed to be liquid or semi-solid (19 with elevated lactoferrin), and these liquid/ semisolid stools were significantly correlated with lactoferrin positivity (P = .017). In analysis of functional status, there was no statistically significant association between change in ADL (n = 17) or cognitive status (n = 5) and elevated lactoferrin. However, all 3 subjects who had significant weight loss had elevated lactoferrin, although the mean fecal lactoferrin was not statistically different from those without weight loss. Of the 2 samples with C difficile, both were liquid and, when compared with all other liquid stools (n = 22), the mean lactoferrin was statistically higher (134.1 versus 28.8 microg/mL, P = .008). These 2 subjects had neither weight loss nor change in cognitive status, but 1 had a change in ADL status.

DISCUSSION AND CONCLUSIONS

Diarrhea in LTCF residents is underdiagnosed. Diarrhea and the presence of C difficile in the stool are associated with intestinal inflammation, as detected by fecal lactoferrin. With our small numbers, we were not able to identify a specific link; however, we were able to identify a correlation between weight loss and intestinal inflammation, but, with just 2 samples, not C difficile colonization. This relationship highlights the importance of larger studies to further examine the rate of diarrhea in LTCF; the effect of diarrhea and intestinal inflammation on weight loss; and the interaction of C difficile colonization with weight loss, malnutrition, and functional decline.

The influence of knowledge, perceptions, and beliefs, on hand hygiene practices in nursing homes

There are few studies that have assessed factors influencing infection control practices among health care workers (HCW) in nursing homes. We conducted a cross-sectional survey of HCWs (N = 392) in 4 nursing homes to assess whether knowledge, beliefs, and perceptions influence reported hand hygiene habits. Positive perceptions and beliefs regarding effectiveness of infection control in nursing homes were associated with reported appropriate glove use and fingernail characteristics, respectively, among HCWs. Further research on hand hygiene interventions, including targeted educational in-services should be conducted in the nursing home setting.

Infections in residents of nursing homes

Infectious diseases are a very common occurrence in nursing homes. While the reasons for preventing infections are the same in nursing homes and in acute hospitals, several considerations relevant to prevention of infection differ in nursing homes. Infection control measures should be based upon the particularities of the specific setting of a nursing home and its residents.

Antimicrobial resistance patterns of colonizing flora on nurses' hands in the neonatal intensive care unit

BACKGROUND

The Centers for Disease Control and Prevention recommends the use of an alcohol-based handrub for health care worker hand hygiene. The purpose of this study was to examine effects of hand hygiene product and skin condition on the antimicrobial resistance patterns of colonizing hand flora among nurses.

METHODS

Colonizing hand flora of 119 nurses working in 2 neonatal intensive care units was compared during a 22-month crossover study using alcohol handrub or antiseptic soap.

RESULTS

Altogether, 1442 isolates from 834 hand cultures (mean, 7 cultures/nurse) were obtained. In 3 of 9 regression analyses modeling for resistant staphylococcal flora, the use of antiseptic soap was a significant predictor of resistance, and nurses with damaged skin were 2.79 times more likely to carry Staphylococcus warneri isolates resistant to gentamicin.

CONCLUSION

Hand hygiene product and skin condition may influence resistance patterns of hand flora of care providers.

Assessing Nurses’ Hand Hygiene Practices by Direct Observation or Self-Report

Methods of obtaining data on hand hygiene practices have not been well validated. The purpose of this study was to compare two methods of assessment of hand hygiene practices—direct observation and self-report using diaries. For 22 months, nursing staff (n= 119) from two neonatal ICUs recorded their hand hygiene practices on a diary card one shift/month (n= 1,071 diary cards). The same data were collected in monthly 1-hour direct observation sessions (n= 206 hours). Amount of time in gloves and total hand hygiene episodes/hour did not differ significantly by diary or observation, but four other specific parameters were significantly different. If hand hygiene practices are to be assessed over time, the same method must be used. Given these measurement limitations, more valid, practical, and less costly methods are needed.

The Asthma Belief Survey: Development and Testing

Accurate evaluation of asthma self-efficacy is essential to the effective management of asthma. This article describes the development and testing of the Asthma Belief Survey (ABS). The instrument is a 15-item tool that uses a 5-point self-report scale to measure asthma self-efficacy in relation to daily asthma maintenance and an asthma crisis. This instrument was tested with a sample of 79 African American school children, who attended eight inner-city elementary schools. The mean age of the sample was 11.05 years with a range of 8 to 14 years. The majority of students had been diagnosed with asthma prior to the age of 5 years. The Asthma Belief Survey demonstrated good psychometric properties: good Cronbach’s α reliability coefficient (.83), coherence as a single scale measuring children’s self-efficacy in treating their own asthma, and significant relationships with scales of asthma knowledge (r= .51,p< .000) and asthma self-care practices (r= .52,p< .001). The Asthma Belief Survey has sound reliability and validity evidence to support its use to measure a child’s asthma self-management self-efficacy. The practitioner can use this instrument to assess a child’s self-efficacy in the areas of asthma health maintenance and avoidance of asthma episodes.

Microbial flora of hands of homemakers

OBJECTIVES AND METHODS

Because of increasing concern about antimicrobial resistance in the community, aerobic flora of hands of 224 healthy homemakers in northern Manhattan, New York, were examined.

RESULTS

Mean log colony-forming unit counts before and after handwashing were 5.72 and 5.69, respectively, P =.60; mean number of species identified/sample was 3.6 before washing and 3.3 after (P =.02). After handwashing gram-negative bacteria were isolated from 75.1% of subjects; yeast from 32.9%; and Staphylococcus aureus from 18.5%, 1 of which (2.4%) was oxacillin-resistant. Generally, these community isolates were more sensitive than isolates from inpatients in the local hospital, although community isolates of Pseudomonas aeruginosa were significantly more resistant than inpatient isolates for 4/10 agents tested.

CONCLUSIONS

Hands of healthy persons in the community were usually colonized with gram-negative bacteria, a single handwash had little impact on microbial counts, and hands of healthy adults may increasingly become one reservoir for antimicrobial resistance.

Clostridium difficile in long-term-care facilities for the elderly

Antimicrobial agents are among the most frequently prescribed medications in long-term-care facilities (LTCFs). Therefore, it is not surprising that Clostridium difficile colonization and C. difficile-associated diarrhea (CDAD) occur commonly in elderly LTCF residents. C. difficile has been identified as the most common cause of non-epidemic acute diarrheal illness in nursing homes, and outbreaks of CDAD in LTCFs have also been recognized. This position paper reviews the epidemiology and clinical features of CDAD in elderly residents of LTCFs and, using available evidence, provides recommendations for the management of C. difficile in this setting.

Effectiveness of infection control program in controlling nosocomial Clostridium difficile

OBJECTIVE

To report the effectiveness of use of comprehensive infection control measures to reduce the incidence of Clostridium difficile (CD) in an acute-care teaching hospital.

METHODS

All CD infections were reviewed by the infection control coordinator from 1987 to 1996. The Centers for Disease Control and Prevention's nosocomial infection definition was used. CD-inclusion criteria remained unchanged during the study period. Interventions were started in 1990.

INTERVENTIONS

The interventions used were: (1) Isolation policy-revision and enforcement, which included universal precautions policy, (2) educational program-monthly to all health care workers, (3) phenolic disinfectant for environmental cleaning, (4) triclosan (0.03%) soap for handwashing, (5) centralization of sterilization department, (6) cart-washer installation, and (7) aggressive surveillance activity.

RESULTS

From 1987 to 1989, before the interventions, a total of 466 CD infections (mean 155 per year) occurred. From 1990 to 1996, after the interventions, 475 infections (mean 67 per year) occurred. Incidence of CD decreased by 60% from 1990 to 1996.

CONCLUSION

The sustained decrease of nosocomial CD during the 7-year period demonstrated the effectiveness of aggressive infection control measures that involve multiple disciplines.

Clostridium difficile-associated diarrhea and colitis: clinical manifestations, diagnosis, and treatment

PURPOSE

This review examines the pathogenesis, clinical manifestations, diagnosis, and current medical and operative strategies in the treatment of Clostridium difficile diarrhea and colitis. Prevention and future avenues of research are also investigated.

METHODS

A review of the literature was conducted with the use of MEDLINE.

RESULTS

C. difficile is a gram-positive, spore-forming bacterium capable of causing toxigenic colitis in susceptible patients, usually those receiving antibiotics. Overgrowth of toxigenic strains may result in a spectrum of disease, including becoming an asymptomatic carrier, diarrhea, self-limited colitis, fulminant colitis, and toxic megacolon. Diagnosis requires a high index of suspicion and depends on clinical data, laboratory stool studies (enzyme-linked immunoabsorbent assay and cytotoxin test), and endoscopy in selected cases. Protocols for treatment of primary and relapsing infections are provided in algorithm format. Discontinuation of antibiotics may be enough to resolve symptoms. Medical management with oral metronidazole or vancomycin is the first-line therapy for those with symptomatic colitis. Teicoplanin, Saccharomyces spp. and Lactobacillus spp., and intravenous IgG antitoxin are reserved for more recalcitrant cases. Refractory or relapsing infections may require vancomycin given orally or other newer modalities. Fulminant colitis and toxic megacolon warrant subtotal colectomy. Cost, in terms of extended hospital stay, medical and surgical management, and, in some cases, ward closure, is thought to be formidable. Review of perioperative antibiotic policies and analysis of hospital formularies may contribute to prevention and decreased costs.

CONCLUSION

C. difficile diarrhea and colitis is a nosocomial infection that may result in significant morbidity, mortality, and medical costs. Standard laboratory studies and endoscopic evaluation assist in the diagnosis of clinically suspicious cases. Appropriate perioperative antibiotic dosing, narrowing the antibiotic spectrum when treating infections, and discontinuing antibiotics at appropriate intervals prevent toxic sequelae.

Surgical aspects of Clostridium difficile colitis

BACKGROUND

There has been a marked increase in the number of surgical patients developing Clostridium difficile colitis. The epidemiology, pathogenesis, diagnosis and management of C. difficile infection were reviewed from a surgical perspective.

METHODS

A literature review was carried out based primarily on a Medline search of all English language publications containing the term C. difficile.

RESULTS

The recent dramatic increase in diagnosis of C. difficile infection amongst surgical patients results from heightened awareness of the condition, better methods of diagnosis, more widespread use of antibiotics for treatment and prophylaxis, and the increasing numbers of elderly and immunocompromised patients with malignancy, sepsis, and (multiple) organ failure being cared for within intensive therapy and high-dependency units. In addition to morbidity and mortality, the economic burden of C. difficile infection in terms of delayed discharge and other hospital costs is considerable.

CONCLUSION

Appropriate use of antibiotics, isolation of affected patients and meticulous hygiene measures on the part of staff are vital if the morbidity, mortality and economic consequences of this nosocomial infection are to be minimized.

Infections and antibiotic resistance in nursing homes

Infections occur frequently in nursing home residents. The most common infections are pneumonia, urinary tract infection, and skin and soft tissue infection. Aging-associated physiologic and pathologic changes, functional disability, institutionalization, and invasive devices all contribute to the high occurrence of infection. Antimicrobial agent use in nursing homes is intense and usually empiric. All of these factors contribute to the increasing frequency of antimicrobial agent-resistant organisms in nursing homes. Programs that will limit the emergence and impact of antimicrobial resistance and infections in nursing homes need to be developed.

Colonization by Staphylococcus species resistant to methicillin or quinolone on hands of medical personnel in a skilled-nursing facility

We report here a pilot survey of colonization with methicillin- and/or ciprofloxacin-resistant Staphylococcus species on hands of nursing personnel in a private skilled-nursing facility. We found only one nurses aide who carried methicillin-resistant Staphylococcus aureus and one who carried ciprofloxacin-resistant S. aureus, each on only one of the surveys. None of the control nonmedical personnel were found to carry methicillin-resistant S. aureus or ciprofloxacin-resistant S. aureus. The colonization rate of methicillin-resistant coagulase-negative staphylococci on the hands of medical personnel was 59%, compared with 13% for the nonmedical personnel, and the counts of methicillin-resistant coagulase-negative staphylococci were also significantly higher for nursing personnel. For ciprofloxacin-resistant coagulase-negative staphylococci, 30% of nursing personnel had positive cultures whereas no ciprofloxacin-resistant coagulase-negative staphylococci strains were recovered from the nonmedical control cohort. Three of the patients had presumptive infections with methicillin- or ciprofloxacin-resistant coagulase-negative staphylococci, all urinary tract infections. Personnel hands represent a likely mode of transmission of such strains between patients, and skilled-nursing facility patients may represent a reservoir for carrying the coagulase-negative staphylococci back to acute care facilities.

Management and control of a large outbreak of diarrhoea due to Clostridium difficile

In the six-month period 1 November 1991 to 1 May 1992 175 patients developed diarrhoea due to Clostridium difficile in three hospitals in Manchester, UK. Most patients (90%) were over 60 years old and had been admitted to acute geriatric or medical wards with other illnesses. Infection is thought to have contributed to 17 deaths. Twenty-two patients relapsed clinically after antibiotic treatment. The outbreak began in one ward and affected 15 patients and two nurses. During the following months cases occurred on 34 wards. The pattern of spread suggested that a ward index case was followed by several secondary cases. Pyrolysis mass spectrometry showed that 79% of isolates of C. difficile belong to a single cluster and this putative outbreak strain also extensively colonizes the hospital environment. It was also responsible for a smaller outbreak in 1991 and many 'sporadic' cases in our hospitals before then. An outbreak control team was convened at an early stage and expert opinion co-opted. Infection control measures included: intensive education of staff; increased vigilance; strict enteric precautions; cohort nursing in a designated ward; rigorous cleaning procedures including emptying and 'deep' cleaning of wards where several cases had occurred; restriction of staff and patient movement; and restriction of antibiotic use. Subsequent to these measures there has been a substantial and sustained decrease in the number of new cases.