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Kunishima H, Ichiki K, Ohge H, Sakamoto F, Sato Y, Suzuki H, Nakamura A, Fujimura S, Matsumoto K, Mikamo H, Mizutani T, Morinaga Y, Mori M, Yamagishi Y, Yoshizawa S. Japanese Society for infection prevention and control guide to Clostridioides difficile infection prevention and control. J Infect Chemother 2024; 30:673-715. [PMID: 38714273 DOI: 10.1016/j.jiac.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 05/09/2024]
Affiliation(s)
- Hiroyuki Kunishima
- Department of Infectious Diseases. St. Marianna University School of Medicine, Japan.
| | - Kaoru Ichiki
- Department of Infection Control and Prevention, Hyogo Medical University Hospital, Japan
| | - Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, Japan
| | - Fumie Sakamoto
- Quality Improvement and Safety Center, Itabashi Chuo Medical Center, Japan
| | - Yuka Sato
- Department of Infection Control and Nursing, Graduate School of Nursing, Aichi Medical University, Japan
| | - Hiromichi Suzuki
- Department of Infectious Diseases, University of Tsukuba School of Medicine and Health Sciences, Japan
| | - Atsushi Nakamura
- Department of Infection Prevention and Control, Graduate School of Medical Sciences, Nagoya City University, Japan
| | - Shigeru Fujimura
- Division of Clinical Infectious Diseases and Chemotherapy, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University, Japan
| | | | - Yoshitomo Morinaga
- Department of Microbiology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Minako Mori
- Department of Infection Control, Hiroshima University Hospital, Japan
| | - Yuka Yamagishi
- Department of Clinical Infectious Diseases, Kochi Medical School, Kochi University, Japan
| | - Sadako Yoshizawa
- Department of Laboratory Medicine/Department of Microbiology and Infectious Diseases, Faculty of Medicine, Toho University, Japan
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Jeong Y. Status of infection prevention and control capacity in Korean hospitals: implications for disaster response and pandemic preparedness. Public Health 2022; 213:100-106. [PMID: 36402088 DOI: 10.1016/j.puhe.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/08/2022] [Accepted: 10/05/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES This study aims to explore the association of hospital infection prevention and control (IPC) structure (i.e. a dedicated IPC team and/or IPC committee) and IPC capacity in Korean hospitals, as well as its implications in the response and preparedness to COVID-19. STUDY DESIGN This was a cross-sectional study using data collected through a nationwide survey. METHODS Participating hospitals completed an online questionnaire. Participation was voluntary. The survey questionnaire was developed by the government in consultation with IPC experts. The questionnaire was distributed to 2108 hospitals, including both acute and long-term care hospitals. The independent variables were the presence of an IPC team and/or IPC committee. The dependent variables were IPC activities and capacity measures, which were based on the World Health Organisation (WHO) recommendations on the core components in IPC. RESULTS A total of 1442 hospitals completed the survey. Hospitals with IPC structures conducted significantly more IPC activities in all outcome measures compared with hospitals without IPC structures, with the exceptions of monitoring hand hygiene and screening for infectious diseases that showed non-significant differences. Hospitals with IPC structures showed a significant difference in performance in IPC risk assessment, operating outbreak response teams and appraisal of hospital IPC policies compared with hospitals without IPC structures. CONCLUSIONS The presence of a dedicated IPC team and IPC committee was associated with increased IPC activities and IPC capacity. Hospitals with IPC teams and IPC committees showed strong implementation of planning, appraisal, resource management and outbreak response, indicating that strengthening IPC structures within hospitals is the key to more effective IPC and disaster response.
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Affiliation(s)
- Y Jeong
- Ministry of Health and Welfare, Sejong, Republic of Korea.
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Papanikolopoulou A, Maltezou HC, Gargalianos-Kakolyris P, Pangalis A, Pantazis N, Pantos C, Tountas Y, Tsakris A, Kantzanou M. Association between consumption of antibiotics, infection control interventions and Clostridioides difficile infections: Analysis of six-year time-series data in a tertiary-care hospital in Greece. Infect Dis Health 2022; 27:119-128. [PMID: 35153189 DOI: 10.1016/j.idh.2022.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/21/2021] [Accepted: 01/16/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND To investigate the association between Clostridioides difficile infection (CDI), antibiotic use, and infection control interventions, during an antibiotic stewardship program (ASP) implemented in a tertiary-care hospital in Greece from 2013 to 2018. METHODS Analysis was applied for the following monthly indices: 1. consumption of antibiotics; 2. use of hand hygiene disinfectant solutions; 3. percentage of isolations of patients either with multidrug-resistant (MDR) bacteria, or CDI, or admitted from another hospital; and 4. percentage of patients with CDI divided into two groups: community-acquired CDI (CACDI) and hospital-associated CDI (HACDI) (onset ≤72 h and >72 h after admission, respectively). RESULTS During the study, a significant reduction in CACDI rate from 0.3%/admissions [95% CI 0.1-0.6] to 0.1%/admissions [95% CI 0.0-0.3] (p-value = 0.035) was observed in adults ICU, while CDI rates were stable in the rest of the hospital. Antibiotic consumption showed a significant reduction in total hospital, from 91.7 DDDs [95% CI 89.7-93.7] to 80.1 DDDs [95% CI 79.1-81.1] (p-value<0.001), except adults ICU. Non-advanced antibiotics correlated with decreased CDI rates in Adults Clinic Departments and ICU. Isolation of patients one and two months earlier correlated with decreased CACDI rates per 20% [95% CI 0.64-1.00, p-value = 0.046] and HACDI per 23% [95% CI 0.60-1.00, p-value = 0.050] in Adults Clinic Departments. Consumption of disinfectant solutions current month correlated with decreased rate for CACDI per 33% [95% CI 0.49-0.91, p-value = 0.011] and HACDI per 38% [95% CI 0.40-0.98, p-value = 0.040] in total Hospital Clinics. CONCLUSION Rational antibiotic prescribing during ASP along with multipronged intervention strategy focusing on hand hygiene and patient isolation measures prevent and control CDI outbreaks in the hospital setting.
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Affiliation(s)
| | - Helena C Maltezou
- Directorate of Research, Studies and Documentation, National Public Health Organization, Athens, 15123 Greece.
| | | | - Anastasia Pangalis
- Biopathology Department, Athens Medical Center, Marousi, Athens, 15125 Greece
| | - Nikos Pantazis
- Department of Hygiene, Epidemiology and Medical Statistics, Faculty of Medicine, School of Health Sciences, National and Kapodistrian University of Athens, Athens, 15772 Greece
| | - Constantinos Pantos
- Department of Pharmacology, School of Medicine, National and Kapodistrian University of Athens, Athens, 15772 Greece
| | - Yannis Tountas
- Department of Hygiene, Epidemiology and Medical Statistics, Faculty of Medicine, School of Health Sciences, National and Kapodistrian University of Athens, Athens, 15772 Greece
| | - Athanasios Tsakris
- Department of Microbiology, School of Medicine, National and Kapodistrian University of Athens, Athens, 15772 Greece
| | - Maria Kantzanou
- Department of Hygiene, Epidemiology and Medical Statistics, Faculty of Medicine, School of Health Sciences, National and Kapodistrian University of Athens, Athens, 15772 Greece
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COFINI VINCENZA, MUSELLI MARIO, GENTILE ALESSANDRA, LUCARELLI MARCO, LEPORE RAFFAELLAANNA, MICOLUCCI GIOVANNA, NECOZIONE STEFANO. Clostridium difficile outbreak: epidemiological surveillance, infection prevention and control. JOURNAL OF PREVENTIVE MEDICINE AND HYGIENE 2021; 62:E514-E519. [PMID: 34604594 PMCID: PMC8451359 DOI: 10.15167/2421-4248/jpmh2021.62.2.1548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 05/17/2021] [Indexed: 11/28/2022]
Abstract
Introduction Clostridium difficile infection (CDI) is currently considered the most common cause of health care-associated infections. The aim is to describe the trend of CDI in an Italian hospital and to assess the efficacy of the measures adopted to manage the burden. Methods Data were retrieved in the San Salvatore Hospital of L’Aquila, from 1 January 2016 to 31 December 2018. Incidence rate of CDIs was calculated as the number of new infected persons per 10,000 patient-days. Changes in the CDI rate during the period considered were analysed using a Joinpoint regression model and related to the preventive strategies adopted. The strategies adopted focused mainly on patient isolation, reinforcement of proper hand hygiene techniques, antimicrobial stewardship and environmental disinfection. Results CDI/10,000 patient-days was 6.27 in 2016 and increased to 7.71 in 2017, then drastically decreased to 2.76 during 2018. The Joinpoint regression analysis identified three Joinpoints: Sep-2016, Jan-2017, and Sep-2017. There was a reduction from 2016/01 to 2016/09 (slope = -1.44; p = 0.67), then there was an increase from September 2016 to February 2017 (slope = 30.01; p = 0.29), both statistically not significant. Therefore, there was an important decrement from February 2017 to September 2017, statistically significant (slope = -15.84; p = 0.012). Conclusions Reports based on routine laboratory data can accurately measure population burden of CDI with limited surveillance resources. The adoption of multi-pronged strategies has proven effective in reducing CDI. It’s important to keep attention high regarding preventive measures of CDI, also a continuous joint effort by all health professionals, caregivers and patients is needed.
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Affiliation(s)
- VINCENZA COFINI
- Department of Life, Health and Environmental Science, University of L’Aquila, Italy
| | - MARIO MUSELLI
- Department of Life, Health and Environmental Science, University of L’Aquila, Italy
- Correspondence: Mario Muselli, University of L’Aquila, via Giuseppe Petrini, Edificio Delta 6, 67100 Coppito (AQ) - Tel.: +39 3339416963 - E-mail:
| | - ALESSANDRA GENTILE
- Department of Life, Health and Environmental Science, University of L’Aquila, Italy
| | - MARCO LUCARELLI
- Department of Life, Health and Environmental Science, University of L’Aquila, Italy
| | | | | | - STEFANO NECOZIONE
- Department of Life, Health and Environmental Science, University of L’Aquila, Italy
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Chasing the rate: An interrupted time series analysis of interventions targeting reported hospital onset Clostridioides difficile, 2013-2018. Infect Control Hosp Epidemiol 2020; 41:1142-1147. [PMID: 32493530 DOI: 10.1017/ice.2020.247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess the impact of major interventions targeting infection control and diagnostic stewardship in efforts to decrease Clostridioides difficile hospital onset rates over a 6-year period. DESIGN Interrupted time series. SETTING The study was conducted in an 865-bed academic medical center. METHODS Monthly hospital-onset C. difficile infection (HO-CDI) rates from January 2013 through January 2019 were analyzed around 5 major interventions: (1) a 2-step cleaning process in which an initial quaternary ammonium product was followed with 10% bleach for daily and terminal cleaning of rooms of patients who have tested positive for C. difficile (February 2014), (2) UV-C device for all terminal cleaning of rooms of C. difficile patients (August 2015), (3) "contact plus" isolation precautions (June 2016), (4) sporicidal peroxyacetic acid and hydrogen peroxide cleaning in all patient areas (June 2017), (5) electronic medical record (EMR) decision support tool to facilitate appropriate C. difficile test ordering (March 2018). RESULTS Environmental cleaning interventions and enhanced "contact plus" isolation did not impact HO-CDI rates. Diagnostic stewardship via EMR decision support decreased the HO-CDI rate by 6.7 per 10,000 patient days (P = .0079). When adjusting rates for test volume, the EMR decision support significance was reduced to a difference of 5.1 case reductions per 10,000 patient days (P = .0470). CONCLUSION Multiple aggressively implemented infection control interventions targeting CDI demonstrated a disappointing impact on endemic CDI rates over 6 years. This study adds to existing data that outside of an outbreak situation, traditional infection control guidance for CDI prevention has little impact on endemic rates.
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When is an outbreak an outbreak? Using literature and discharge data to define Clostridioides difficile incidence changes referred to as outbreaks. J Hosp Infect 2020; 105:225-231. [DOI: 10.1016/j.jhin.2020.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/16/2020] [Indexed: 11/24/2022]
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Implementation of a Clostridioides difficile prevention bundle: Understanding common, unique, and conflicting work system barriers and facilitators for subprocess design. Infect Control Hosp Epidemiol 2019; 40:880-888. [PMID: 31190669 DOI: 10.1017/ice.2019.150] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Clostridioides difficile (C. difficile) poses a major challenge to the healthcare system. We assessed factors that should be considered when designing subprocesses of a C. difficile infection (CDI) prevention bundle. DESIGN Phenomenological qualitative study. METHODS We conducted 3 focus groups of environmental services (EVS) staff, physicians, and nurses to assess their perspectives on a CDI prevention bundle. We used the Systems Engineering Initiative for Patient Safety (SEIPS) model to examine 5 subprocesses of the CDI bundle: diagnostic testing, empiric isolation, contact isolation, hand hygiene, and environmental disinfection. We coded transcripts to the 5 SEIPS elements and ensured scientific rigor. We sought to determine common, unique, and conflicting factors across stakeholder groups and subprocesses of the CDI bundle. RESULTS Each focus group lasted 1.5 hours on average. Common work-system barriers included inconsistencies in knowledge and practice of CDI management procedures; increased workload; poor setup of aspects of the physical environment (eg, inconvenient location of sinks); and inconsistencies in CDI documentation. Unique barriers and facilitators were related to specific activities performed by the stakeholder group. For instance, algorithmic approaches used by physicians facilitated timely diagnosis of CDI. Conflicting barriers or facilitators were related to opposing objectives; for example, clinicians needed rapid placement of a patient in a room while EVS staff needed time to disinfect the room. CONCLUSIONS A systems engineering approach can help to holistically identify factors that influence successful implementation of subprocesses of infection prevention bundles.
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Loo VG, Davis I, Embil J, Evans GA, Hota S, Lee C, Lee TC, Longtin Y, Louie T, Moayyedi P, Poutanen S, Simor AE, Steiner T, Thampi N, Valiquette L. Association of Medical Microbiology and Infectious Disease Canada treatment practice guidelines for Clostridium difficile infection. ACTA ACUST UNITED AC 2018. [DOI: 10.3138/jammi.2018.02.13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Vivian G Loo
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Ian Davis
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John Embil
- Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gerald A Evans
- Kingston Health Sciences Centre, Queen’s University, Kingston, Ontario, Canada
| | - Susy Hota
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Christine Lee
- St. Joseph’s Healthcare, McMaster University, Hamilton, Ontario, Canada
| | - Todd C Lee
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Yves Longtin
- Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Thomas Louie
- Peter Lougheed Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Paul Moayyedi
- Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada
| | - Susan Poutanen
- Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrew E Simor
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Theodore Steiner
- Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nisha Thampi
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Louis Valiquette
- Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec, Canada
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McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, Dubberke ER, Garey KW, Gould CV, Kelly C, Loo V, Shaklee Sammons J, Sandora TJ, Wilcox MH. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2018; 66:e1-e48. [PMID: 29462280 PMCID: PMC6018983 DOI: 10.1093/cid/cix1085] [Citation(s) in RCA: 1266] [Impact Index Per Article: 211.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.
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Affiliation(s)
| | | | - Stuart Johnson
- Edward Hines Jr Veterans Administration Hospital, Hines
- Loyola University Medical Center, Maywood, Illinois
| | | | - Karen C Carroll
- Johns Hopkins University School of Medicine, Baltimore, Maryl
| | | | - Erik R Dubberke
- Washington University School of Medicine, St Louis, Missouri
| | | | - Carolyn V Gould
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ciaran Kelly
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vivian Loo
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
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Clostridium Difficile Infection in Acute Care Hospitals: Systematic Review and Best Practices for Prevention. Infect Control Hosp Epidemiol 2018; 38:476-482. [PMID: 28300019 DOI: 10.1017/ice.2016.324] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Prevention of Clostridium difficile infection (CDI) in acute-care hospitals is a priority for hospitals and clinicians. We performed a qualitative systematic review to update the evidence on interventions to prevent CDI published since 2009. DESIGN We searched Ovid, MEDLINE, EMBASE, The Cochrane Library, CINAHL, the ISI Web of Knowledge, and grey literature databases from January 1, 2009 to August 1, 2015. SETTING We included studies performed in acute-care hospitals. PATIENTS OR PARTICIPANTS We included studies conducted on hospitalized patients that investigated the impact of specific interventions on CDI rates. INTERVENTIONS We used the QI-Minimum Quality Criteria Set (QI-MQCS) to assess the quality of included studies. Interventions were grouped thematically: environmental disinfection, antimicrobial stewardship, hand hygiene, chlorhexidine bathing, probiotics, bundled approaches, and others. A meta-analysis was performed when possible. RESULTS Of 3,236 articles screened, 261 met the criteria for full-text review and 46 studies were ultimately included. The average quality rating was 82% according to the QI-MQCS. The most effective interventions, resulting in a 45% to 85% reduction in CDI, included daily to twice daily disinfection of high-touch surfaces (including bed rails) and terminal cleaning of patient rooms with chlorine-based products. Bundled interventions and antimicrobial stewardship showed promise for reducing CDI rates. Chlorhexidine bathing and intensified hand-hygiene practices were not effective for reducing CDI rates. CONCLUSIONS Daily and terminal cleaning of patient rooms using chlorine-based products were most effective in reducing CDI rates in hospitals. Further studies are needed to identify the components of bundled interventions that reduce CDI rates. Infect Control Hosp Epidemiol 2017;38:476-482.
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Esfandiari A, Salari H, Rashidian A, Masoumi Asl H, Rahimi Foroushani A, Akbari Sari A. Eliminating Healthcare-Associated Infections in Iran: A Qualitative Study to Explore Stakeholders' Views. Int J Health Policy Manag 2018; 7:27-34. [PMID: 29325400 PMCID: PMC5745865 DOI: 10.15171/ijhpm.2017.34] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 03/13/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Although preventable, healthcare-associated infections (HAIs) continue to pose huge health and economic burdens on countries worldwide. Some studies have indicated the numerous causes of HAIs, but only a tiny literature exists on the multifaceted measures that can be used to address the problem. This paper presents stakeholders' opinions on measures for controlling HAIs in Iran. METHODS We used the qualitative research method in studying the phenomenon. Through a purposive sampling approach, we conducted 24 face-to-face interviews using a semi-structured interview guide. Participants were mainly key informants, including policy-makers, health professionals, and technical officers across the national and subnational levels, including the Ministry of Health (MoH), medical universities, and hospitals in Iran. We performed thematic framework analysis using the software MAXQDA10. RESULTS Four main interdisciplinary themes emerged from our study of measures of controlling HAIs: strengthening governance and stewardship; strengthening human resources policies; appropriate prescription and usage of antibiotics; and environmental sanitation and personal hygiene. CONCLUSION According to our findings, elimination of HAIs demands multifactorial interventions. While the ultimate recommendation of policy-makers is to have HAIs among the priorities of the national agenda, financial commitment and the creation of an enabling work environment in which both patients and healthcare workers can practice personal hygiene could lead to a significant reduction in HAIs in Iran.
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Affiliation(s)
| | | | - Arash Rashidian
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Masoumi Asl
- Center for Communicable Diseases Control, Ministry of Health and Medical Education, Tehran, Iran.,Research Center of Pediatric Infectious Diseases, Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Abbas Rahimi Foroushani
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Akbari Sari
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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12
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Environmental cleaning and disinfection of patient areas. Int J Infect Dis 2017; 67:52-57. [PMID: 29102556 DOI: 10.1016/j.ijid.2017.10.014] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/13/2017] [Accepted: 10/18/2017] [Indexed: 12/19/2022] Open
Abstract
The healthcare setting is predisposed to harbor potential pathogens, which in turn can pose a great risk to patients. Routine cleaning of the patient environment is critical to reduce the risk of hospital-acquired infections. While many approaches to environmental cleaning exist, manual cleaning supplemented with ongoing assessment and feedback may be the most feasible for healthcare facilities with limited resources.
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Barker A, Ngam C, Musuuza J, Vaughn VM, Safdar N. Reducing Clostridium difficile in the Inpatient Setting: A Systematic Review of the Adherence to and Effectiveness of C. difficile Prevention Bundles. Infect Control Hosp Epidemiol 2017; 38:639-650. [PMID: 28343455 PMCID: PMC5654380 DOI: 10.1017/ice.2017.7] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is the most common infectious cause of nosocomial diarrhea, and its prevention is an urgent public health priority. However, reduction of CDI is challenging because of its complex pathogenesis, large reservoirs of colonized patients, and the persistence of infectious spores. The literature lacks high-quality evidence for evaluating interventions, and many hospitals have implemented bundled interventions to reduce CDI with variable results. Thus, we conducted a systematic review to examine the components of CDI bundles, their implementation processes, and their impact on CDI rates. METHODS We conducted a comprehensive literature search of multiple computerized databases from their date of inception through April 30, 2016. The protocol was registered in PROSPERO, an international prospective register of systematic reviews. Bundle effectiveness, adherence, and study quality were assessed for each study meeting our criteria for inclusion. RESULTS In the 26 studies that met the inclusion criteria for this review, implementation and adherence factors to interventions were variably and incompletely reported, making study reproducibility and replicability challenging. Despite contextual differences and the variety of bundle components utilized, all 26 studies reported an improvement in CDI rates. However, given the lack of randomized controlled trials in the literature, assessing a causal relationship between bundled interventions and CDI rates is currently impossible. CONCLUSION Cluster randomized trials that include a rigorous assessment of the implementation of bundled interventions are urgently needed to causally test the effect of intervention bundles on CDI rates. Infect Control Hosp Epidemiol 2017;38:639-650.
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Affiliation(s)
- Anna Barker
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Caitlyn Ngam
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jackson Musuuza
- Institute of Clinical and Translational Research, University of Wisconsin, Madison, WI, USA
| | - Valerie M. Vaughn
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- The Patient Safety Enhancement Program, University of Michigan and VA Ann Arbor Health System, Ann Arbor, MI, USA
| | - Nasia Safdar
- William S. Middleton Memorial Veterans Affairs Hospital, Madison, WI, USA
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Infection Control, University of Wisconsin Hospital and Clinics, Madison, WI, USA
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Electronic Clostridium difficile Infection Bundle Reduces Time to Initiation of Contact Precautions. Infect Control Hosp Epidemiol 2016; 38:242-244. [PMID: 27821198 DOI: 10.1017/ice.2016.250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The impact of computerized order-entry bundles on timing of contact precaution initiation for C. difficile infection (CDI) remains largely unexplored. Implementation of an electronic CDI prevention and management bundle that included an automatic isolation component significantly reduced time to initiation of contact precautions from 33.7 to 22.4 hours. Infect Control Hosp Epidemiol 2016;242-244.
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Gingras G, Guertin MH, Laprise JF, Drolet M, Brisson M. Mathematical Modeling of the Transmission Dynamics of Clostridium difficile Infection and Colonization in Healthcare Settings: A Systematic Review. PLoS One 2016; 11:e0163880. [PMID: 27690247 PMCID: PMC5045168 DOI: 10.1371/journal.pone.0163880] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 09/15/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND We conducted a systematic review of mathematical models of transmission dynamic of Clostridium difficile infection (CDI) in healthcare settings, to provide an overview of existing models and their assessment of different CDI control strategies. METHODS We searched MEDLINE, EMBASE and Web of Science up to February 3, 2016 for transmission-dynamic models of Clostridium difficile in healthcare settings. The models were compared based on their natural history representation of Clostridium difficile, which could include health states (S-E-A-I-R-D: Susceptible-Exposed-Asymptomatic-Infectious-Resistant-Deceased) and the possibility to include healthcare workers and visitors (vectors of transmission). Effectiveness of interventions was compared using the relative reduction (compared to no intervention or current practice) in outcomes such as incidence of colonization, CDI, CDI recurrence, CDI mortality, and length of stay. RESULTS Nine studies describing six different models met the inclusion criteria. Over time, the models have generally increased in complexity in terms of natural history and transmission dynamics and number/complexity of interventions/bundles of interventions examined. The models were categorized into four groups with respect to their natural history representation: S-A-I-R, S-E-A-I, S-A-I, and S-E-A-I-R-D. Seven studies examined the impact of CDI control strategies. Interventions aimed at controlling the transmission, lowering CDI vulnerability and reducing the risk of recurrence/mortality were predicted to reduce CDI incidence by 3-49%, 5-43% and 5-29%, respectively. Bundles of interventions were predicted to reduce CDI incidence by 14-84%. CONCLUSIONS Although CDI is a major public health problem, there are very few published transmission-dynamic models of Clostridium difficile. Published models vary substantially in the interventions examined, the outcome measures used and the representation of the natural history of Clostridium difficile, which make it difficult to synthesize results and provide a clear picture of optimal intervention strategies. Future modeling efforts should pay specific attention to calibration, structural uncertainties, and transparent reporting practices.
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Affiliation(s)
- Guillaume Gingras
- SP-POS, Centre de recherche du CHU de Québec-Université Laval, 1050 Chemin Sainte-Foy, Québec, Qc, Canada.,Départment de Médecine Sociale et Préventive, Université Laval, Québec, Qc, Canada
| | - Marie-Hélène Guertin
- SP-POS, Centre de recherche du CHU de Québec-Université Laval, 1050 Chemin Sainte-Foy, Québec, Qc, Canada.,Départment de Médecine Sociale et Préventive, Université Laval, Québec, Qc, Canada
| | - Jean-François Laprise
- SP-POS, Centre de recherche du CHU de Québec-Université Laval, 1050 Chemin Sainte-Foy, Québec, Qc, Canada
| | - Mélanie Drolet
- SP-POS, Centre de recherche du CHU de Québec-Université Laval, 1050 Chemin Sainte-Foy, Québec, Qc, Canada
| | - Marc Brisson
- SP-POS, Centre de recherche du CHU de Québec-Université Laval, 1050 Chemin Sainte-Foy, Québec, Qc, Canada.,Départment de Médecine Sociale et Préventive, Université Laval, Québec, Qc, Canada.,Department of Infectious Disease Epidemiology, Imperial College, London, United Kingdom
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Evolution of an audit and monitoring tool into an infection prevention and control process. J Hosp Infect 2016; 94:32-40. [DOI: 10.1016/j.jhin.2016.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 04/29/2016] [Indexed: 11/22/2022]
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Dickstein Y, Nir-Paz R, Pulcini C, Cookson B, Beović B, Tacconelli E, Nathwani D, Vatcheva-Dobrevska R, Rodríguez-Baño J, Hell M, Saenz H, Leibovici L, Paul M. Staffing for infectious diseases, clinical microbiology and infection control in hospitals in 2015: results of an ESCMID member survey. Clin Microbiol Infect 2016; 22:812.e9-812.e17. [PMID: 27373529 DOI: 10.1016/j.cmi.2016.06.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 06/16/2016] [Accepted: 06/21/2016] [Indexed: 10/24/2022]
Abstract
We aimed to assess the current status of infectious diseases (ID), clinical microbiology (CM) and infection control (IC) staffing in hospitals and to analyse modifiers of staffing levels. We conducted an Internet-based survey of European Society of Clinical Microbiology and Infectious Diseases members and affiliates, collecting data on hospital characteristics, ID management infrastructure, ID/IC-related activities and the ratio of physicians per 100 hospital beds. Regression analyses were conducted to examine factors associated with the physician-bed ratio. Five hundred sixty-seven hospital responses were collected between April and June 2015 from 61 countries, 81.2% (384/473) from Europe. A specialized inpatient ward for ID patients was reported in 58.4% (317/543) of hospitals. Rates of antibiotic stewardship programmes (ASP) and surveillance activities in survey hospitals were high, ranging from 88% to 90% for local antibiotic guidelines and 70% to 82% for programmes monitoring hospital-acquired infections. The median ID/CM/IC physician per 100 hospital beds ratio was 1.12 (interquartile range 0.56-2.13). In hospitals performing basic ASP and IC (including local antibiotic guidelines and monitoring device-related or surgical site infections), the ratio was 1.21 (interquartile range 0.57-2.14). Factors independently associated with higher ratios included compliance with European Union of Medical Specialists standards, smaller hospital size, tertiary-care institution, presence of a travel clinic, beds dedicated to ID and a CM unit. More than half of respondents estimated that additional staffing is needed for appropriate IC or ID management. No standard of physician staffing for ID/CM/IC in hospitals is available. A ratio of 1.21/100 beds will serve as an informed point of reference enabling ASP and infection surveillance.
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Affiliation(s)
- Y Dickstein
- Division of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - R Nir-Paz
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - C Pulcini
- Université de Lorraine, Université Paris Descartes, EA 4360 APEMAC and CHU de Nancy, Service de Maladies Infectieuses et Tropicales, Nancy, France
| | - B Cookson
- Division of Infection and Immunity, University College London, Gower Street, London, United Kingdom
| | - B Beović
- Department of Infectious Diseases, University Medical Centre, Ljubljana, Slovenia
| | - E Tacconelli
- Division of Infectious Diseases, Department of Internal Medicine I, DZIF Center, Tübingen University Hospital, Tübingen, Germany
| | - D Nathwani
- Ninewells Hospital and Medical School, Dundee DD1 9SY, United Kingdom
| | - R Vatcheva-Dobrevska
- Department of Microbiology and Virology, University Hospital Queen Joanna, Sofia, Bulgaria
| | - J Rodríguez-Baño
- Unidad Clínica Intercentros de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío, Seville, Spain; Departamento de Medicina, Universidad de Sevilla, Seville, Spain
| | - M Hell
- Department of Hospital Epidemiology and Infection Control, University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - H Saenz
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Basel, Switzerland
| | - L Leibovici
- Medicine E, Rabin Medical Centre, Beilinson Hospital, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - M Paul
- Division of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine-Technion, Israel Institute of Technology, Haifa, Israel.
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Waqar S, Nigh K, Sisler L, Fanning M, Tancin S, Brozik E, Jones R, Briggs F, Keller L, LaSala PR, Krautz S, Khakoo R. Multidisciplinary performance improvement team for reducing health care-associated Clostridium difficile infection. Am J Infect Control 2016; 44:352-4. [PMID: 26541068 DOI: 10.1016/j.ajic.2015.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 09/16/2015] [Accepted: 09/17/2015] [Indexed: 02/08/2023]
Abstract
Clostridium difficile is the most frequent cause of health care-associated diarrhea and is a significant cause of morbidity and mortality. It is also associated with a considerable financial burden. A concerted multidisciplinary approach is required for prevention.
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Blakney R, Yanke E, Fink C, Wigton R, Safdar N. Optimizing diagnostic testing for Clostridium difficile: The perceptions of physicians and nurses on when to order testing for C difficile. Am J Infect Control 2015; 43:889-91. [PMID: 25957816 DOI: 10.1016/j.ajic.2015.03.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 03/20/2015] [Accepted: 03/23/2015] [Indexed: 11/19/2022]
Abstract
Physicians and nurses at a single hospital were surveyed on which risk factors were most important in deciding to order Clostridium difficile diagnostic testing. Disagreement between physicians and nurses on the relative importance of several of the risk factors warrants further investigation.
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Affiliation(s)
- Rebekah Blakney
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI; Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI
| | - Eric Yanke
- Department of Medicine, William S. Middleton Memorial Veterans Hospital, Madison, WI
| | - Cory Fink
- Coronary Care Unit, William S. Middleton Memorial Veterans Hospital, Madison, WI
| | - Robert Wigton
- University of Nebraska Medical Center College of Medicine, Omaha, NE
| | - Nasia Safdar
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI; Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI; Department of Medicine, William S. Middleton Memorial Veterans Hospital, Madison, WI; Infectious Diseases, Department of Medicine, University of Wisconsin Medical School, Madison, WI.
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Khanafer N, Voirin N, Barbut F, Kuijper E, Vanhems P. Hospital management of Clostridium difficile infection: a review of the literature. J Hosp Infect 2015; 90:91-101. [DOI: 10.1016/j.jhin.2015.02.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 02/17/2015] [Indexed: 12/11/2022]
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21
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Containment of Clostridium difficile infection without reduction in antimicrobial use in Hong Kong. Eur J Clin Microbiol Infect Dis 2015; 34:1381-6. [DOI: 10.1007/s10096-015-2362-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/06/2015] [Indexed: 02/05/2023]
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Pereira JB, Farragher TM, Tully MP, Jonathan Cooke J. Association between Clostridium difficile infection and antimicrobial usage in a large group of English hospitals. Br J Clin Pharmacol 2015; 77:896-903. [PMID: 24868578 DOI: 10.1111/bcp.12255] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIMS This study aimed to determine the association between the reduction in the number of Clostridium difficile infection (CDI) cases reported by the English National Health Service (NHS) hospitals and concurrent antimicrobial use. METHODS A retrospective ecological study for January 2005 to December 2008 was conducted using data from 26 of the 29 NHS trusts (i.e. a trust manages one or more hospitals) located in the North West Strategic Health Authority of England. Antimicrobial use data, for patients of all ages, were provided by IMS Health, and CDI case data for patients aged ≥65 years were provided by the Health Protection Agency. Antimicrobial use was converted into defined daily doses (DDDs). The overall association between antimicrobial use and CDI for the trusts was investigated using multilevel models. RESULTS Our study shows a positive significant association between the CDI cases and the use of the following antimicrobials: ‘third-generation cephalosporins’ [11.62 CDI cases per 1000 DDDs; 95% confidence interval (CI), 5.92–17.31]; ‘fluoroquinolones’ (4.79 CDI cases per 1000 DDDs; 95% CI, 2.83–6.74); and ‘second-generation cephalosporins’ (4.25 CDI cases per 1000 DDDs; 95% CI, 1.66–6.83). The strength of this association was not significantly different (95% CI) among the antimicrobial groups. CONCLUSIONS This study shows that the reduction in the number of CDI cases reported by the English NHS hospitals is associated with concurrent reductions in antimicrobial use. This means that the number of CDI cases over time decreased in a similar fashion to the usage of various antimicrobials.
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Zingg W, Holmes A, Dettenkofer M, Goetting T, Secci F, Clack L, Allegranzi B, Magiorakos AP, Pittet D. Hospital organisation, management, and structure for prevention of health-care-associated infection: a systematic review and expert consensus. THE LANCET. INFECTIOUS DISEASES 2015; 15:212-24. [DOI: 10.1016/s1473-3099(14)70854-0] [Citation(s) in RCA: 278] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Abstract
The control of Clostridium difficile infection is paramount. C difficile spores are difficult to eradicate and can survive on surfaces for prolonged periods of time. Hand washing with either plain or antimicrobial soap is effective in removing C difficile spores from hands. Patients should be placed in private rooms and under contact precautions to prevent transmission to other patients. Regular hospital germicides are not sporicidal and hypochlorite solutions are required for surface disinfection. In outbreak situations, a multifaceted approach is required.
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Affiliation(s)
- Vivian G Loo
- Departments of Medicine and Microbiology, McGill University Health Centre, 687 Pine Avenue West, Room L5.06, Montreal, Quebec H3A 1A1, Canada.
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25
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Gilca R, Hubert B, Fortin E, Gaulin C, Dionne M. Epidemiological Patterns and Hospital Characteristics Associated with Increased Incidence ofClostridium difficileInfection in Quebec, Canada, 1998–2006. Infect Control Hosp Epidemiol 2015; 31:939-47. [DOI: 10.1086/655463] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective.To explore epidemiological patterns of the incidence ofClostridium difficileinfection (CDI) and hospital characteristics associated with increased incidence during nonepidemic and epidemic years.Design.Retrospective and prospective ecological study.Setting.Eighty-three acute care hospitals participating in CDI surveillance in the province of Quebec, Canada.Methods.A Serfling-type regression model applied to data obtained from an administrative database (1998-2006) and prospective Quebec CDI surveillance (2004-2006) was used to calculate expected CDI baseline incidence and to detect incidence exceeding the defined epidemic threshold at the provincial and hospital level. Multivariable Poisson regression was used to determine hospital characteristics associated with increased incidence during nonepidemic (1998-2001) and epidemic (2003-2005) periods.Results.During the study period (1998-2006), 4,525,847 discharges, including 45,508 with a CDI in any diagnosis field, were reported by 83 hospitals. During 1998-2001, the average Quebec incidence of CDI was 10,304 cases in 1,775,822 discharges (5.8 cases per 1,000 discharges) and presented a pattern of seasonality, with similar patterns at the hospital level for some hospitals. The Quebec epidemic started in October-November 2002 and peaked in March 2004 at 845 cases in 40,852 discharges (20.7 cases per 1,000 discharges). In multivariable analysis, higher incidence was associated with location in Montreal and surrounding regions, greater hospital size, larger proportion of hospitalized elderly patients, longer length of stay, and greater proportion of comorbidities in patients, whereas teaching profile was associated with decreased incidence during both nonepidemic and epidemic periods. The effect of geographical location on incidence was greater during the epidemic.Conclusion.Baseline incidence from nonepidemic years and hospital characteristics associated with CDI incidence should be taken into account when estimating the efficacy of interventions.
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Yakob L, Riley TV, Paterson DL, Marquess J, Clements AC. Assessing control bundles for Clostridium difficile: a review and mathematical model. Emerg Microbes Infect 2014; 3:e43. [PMID: 26038744 PMCID: PMC4078791 DOI: 10.1038/emi.2014.43] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 03/14/2014] [Accepted: 04/17/2014] [Indexed: 01/01/2023]
Abstract
Clostridium difficile is the leading cause of infectious diarrhea in
hospitalized patients. Integrating several infection control and prevention methods is a
burgeoning strategy for reducing disease incidence in healthcare settings. We present an
up-to-date review of the literature on ‘control bundles' used to mitigate the
transmission of this pathogen. All clinical studies of control bundles reported
substantial reductions in disease rates, in the order of 33%–61%.
Using a biologically realistic mathematical model we then simulated the efficacy of
different combinations of the most prominent control methods: stricter antimicrobial
stewardship; the administering of probiotics/intestinal microbiota transplantation; and
improved hygiene and sanitation. We also assessed the health gains that can be expected
from reducing the average length of stay of inpatients. In terms of reducing the rates of
colonization, all combinations had the potential to give rise to marked improvements. For
example, halving the number of inpatients on broad-spectrum antimicrobials combined with
prescribing probiotics or intestinal microbiota transplantation could cut pathogen
carriage by two-thirds. However, in terms of symptomatic disease incidence reduction,
antimicrobials, probiotics and intestinal microbiota transplantation proved substantially
less effective. Eliminating within-ward transmission by improving sanitation and reducing
average length of stay (from six to three days) yielded the most potent symptomatic
infection control combination, cutting rates down from three to less than one per 1000
hospital bed days. Both the empirical and theoretical exploration of C. difficile
control combinations presented in the current study highlights the potential gains that
can be achieved through strategically integrated infection control.
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Affiliation(s)
- Laith Yakob
- The University of Queensland, School of Population Health , Herston 4006, Australia
| | - Thomas V Riley
- The University of Western Australia, School of Pathology and Laboratory Medicine , Crawley 6009, Australia
| | - David L Paterson
- The University of Queensland, Centre of Clinical Research , Herston 4029, Australia
| | - John Marquess
- The University of Queensland, School of Population Health , Herston 4006, Australia
| | - Archie Ca Clements
- The Australian National University, Research School of Population Health , Canberra 0200, Australia
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Kundrapu S, Sunkesula V, Sitzlar BM, Fertelli D, Deshpande A, Donskey CJ. More cleaning, less screening: evaluation of the time required for monitoring versus performing environmental cleaning. Infect Control Hosp Epidemiol 2013; 35:202-4. [PMID: 24442088 DOI: 10.1086/674852] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Sirisha Kundrapu
- Case Western Reserve University School of Medicine, Cleveland, Ohio
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Sitzlar B, Deshpande A, Fertelli D, Kundrapu S, Sethi AK, Donskey CJ. An environmental disinfection odyssey: evaluation of sequential interventions to improve disinfection of Clostridium difficile isolation rooms. Infect Control Hosp Epidemiol 2013; 34:459-65. [PMID: 23571361 DOI: 10.1086/670217] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE. Effective disinfection of hospital rooms after discharge of patients with Clostridium difficile infection (CDI) is necessary to prevent transmission. We evaluated the impact of sequential cleaning and disinfection interventions by culturing high-touch surfaces in CDI rooms after cleaning. DESIGN. Prospective intervention. SETTING. A Veterans Affairs hospital. INTERVENTIONS. During a 21-month period, 3 sequential tiered interventions were implemented: (1) fluorescent markers to provide monitoring and feedback on thoroughness of cleaning facility-wide, (2) addition of an automated ultraviolet radiation device for adjunctive disinfection of CDI rooms, and (3) enhanced standard disinfection of CDI rooms, including a dedicated daily disinfection team and implementation of a process requiring supervisory assessment and clearance of terminally cleaned CDI rooms. To determine the impact of the interventions, cultures were obtained from CDI rooms after cleaning and disinfection. RESULTS. The fluorescent marker intervention improved the thoroughness of cleaning of high-touch surfaces (from 47% to 81% marker removal; P < .0001). Relative to the baseline period, the prevalence of positive cultures from CDI rooms was reduced by 14% (P=.024), 48% (P <.001), and 89% (P=.006) with interventions 1, 2, and 3, respectively. During the baseline period, 67% of CDI rooms had positive cultures after disinfection, whereas during interventions periods 1, 2, and 3 the percentages of CDI rooms with positive cultures after disinfection were reduced to 57%, 35%, and 7%, respectively. CONCLUSIONS. An intervention that included formation of a dedicated daily disinfection team and implementation of a standardized process for clearing CDI rooms achieved consistent CDI room disinfection. Culturing of CDI rooms provides a valuable tool to drive improvements in environmental disinfection.
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Affiliation(s)
- Brett Sitzlar
- Case Western Reserve University School of Medicine, Cleveland, Ohio
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Aronhalt KC, McManus J, Orenstein R, Faller R, Link M. Patient and Environmental Service Employee Satisfaction of Using Germicidal Bleach Wipes for Patient Room Cleaning. J Healthc Qual 2013; 35:30-6. [DOI: 10.1111/j.1945-1474.2011.00202.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Maziade PJ, Andriessen JA, Pereira P, Currie B, Goldstein EJC. Impact of adding prophylactic probiotics to a bundle of standard preventative measures for Clostridium difficile infections: enhanced and sustained decrease in the incidence and severity of infection at a community hospital. Curr Med Res Opin 2013; 29:1341-7. [PMID: 23931498 DOI: 10.1185/03007995.2013.833501] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND In 2003, hospitals in Quebec, Canada experienced an increase of NAP1/027 Clostridium difficile infections following antibiotic administration (CDIAA). At Pierre-Le Gardeur Hospital (PLGH), the incidence increased from 10 to over 25 cases per 1000 patient admissions. METHODS We report a quasi-experimental, prospective cohort study evaluating the effect on CDIAA of a probiotic added to existing C. difficile infection (CDI) standard preventative measures (SPM) in 31,832 hospitalized patients receiving antibiotics. Phase I (1580) measured the impact of SPM alone. In Phase II, 50 to 60 × 10(9) cfu daily dose of oral Lactobacillus acidophilus CL1285 and L. casei LBC80R probiotic formula (Bio-K+) was administered to all patients receiving antibiotics. Phase III included the same intervention after a move to a new hospital facility. Phases II and III included 4968 patients. During Phase IV, 25,284 patients were submitted to the same regimen but outcome data were compared to those of similar hospitals in Quebec. RESULTS At the end of Phase III, CDIAA had decreased from more than 18 cases per 1000 patient admissions in Phase I to less than 5 cases. Reductions of CDI cases (73%) (p < 0.001) and severe CDI cases (76.4%) (p < 0.001) were observed. CDI recurrence rate was reduced by 39% (p < 0.001). During the following 6 years, the CDI rate averaged 2.71 cases per 10,000 patient-days at PLGH compared to 8.50 cases per 10,000 patient-days in equivalent hospitals located in Quebec. STUDY LIMITATION This study is not a randomized clinical trial; it is an open prospective study and should be treated as such. Also, following Phase II, PLGH moved into a new facility and this could have contributed to lower CDI. CONCLUSIONS Specific probiotic product added to SPM and antibiotic stewardship activities resulted in a further reduction in CDI rates and was shown to be safe.
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Affiliation(s)
- P-J Maziade
- Pierre-Le Gardeur Hospital , Lachenaie, Quebec , Canada
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Piacenti FJ, Leuthner KD. Antimicrobial stewardship and Clostridium difficile-associated diarrhea. J Pharm Pract 2013; 26:506-13. [PMID: 23946208 DOI: 10.1177/0897190013499528] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Antimicrobial stewardship programs are essential to health care institutions to promote the appropriate use of antibiotics not only to decrease antimicrobial resistance but to prevent the spread and infection of Clostridium difficile. Clostridium difficile-associated diarrhea is increasing rapidly in the United States and is now considered a major public health problem that poses an immediate threat to the health of patients prescribed antibiotics, more so than antimicrobial resistance. Clostridium difficile-associated disease is the result of collateral damage to the normal bacterial flora of the human body, which is an inevitable consequence of any antibiotic use. Antimicrobial stewardship programs such as audit with feedback and antibiotic restriction are designed to help limit Clostridium difficile infections and other hospital-associated organisms by optimizing antimicrobial selection, dosing, de-escalation, and duration of therapy. These programs also incorporate implementation of hospital-wide guidelines, staff education, enforcement of infection-control policies, and the use of electronic medical records when possible to help control antibiotic use. This article reviews the literature on how antimicrobial stewardship programs impact Clostridium difficile rates and discusses experiences in designing, implementing, monitoring, and follow-through of such programs.
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Montoya M, Detorres O. Antimicrobial selection and its impact on the incidence of Clostridium difficile-associated diarrhea. J Pharm Pract 2013; 26:483-7. [PMID: 23940122 DOI: 10.1177/0897190013499524] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The study objective was to determine which antimicrobials place patients at a higher risk for Clostridium difficile-associated diarrhea (CDAD) and which interventions can reduce their risk. All patients with diarrhea and a positive toxin assay for Clostridium difficile for 3 months were included in the study. Patients were broken down into either community-acquired infection or health care-associated infection based on symptom onset, antibiotic usage prior to admission, and where the patient was admitted from. Physicians were educated on antimicrobials that place patients at higher risk for CDAD and alternative agents to use. Physician education consisted of in-service presentations, posters, Medical Grand Rounds, and an article in the physician newsletter highlighting the initial results of this study and alternative antimicrobial regimens. After implementation of educational programs, a repeat sample of patients was reviewed to determine effectiveness of the physician education. Cases of CDAD increased secondary to testing changes at our facility. Implicated antimicrobial usage did decrease after educational program implementation.
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Donskey CJ. Does improving surface cleaning and disinfection reduce health care-associated infections? Am J Infect Control 2013; 41:S12-9. [PMID: 23465603 DOI: 10.1016/j.ajic.2012.12.010] [Citation(s) in RCA: 185] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 12/07/2012] [Accepted: 12/08/2012] [Indexed: 01/04/2023]
Abstract
Contaminated environmental surfaces provide an important potential source for transmission of health care-associated pathogens. In recent years, a variety of interventions have been shown to be effective in improving cleaning and disinfection of surfaces. This review examines the evidence that improving environmental disinfection can reduce health care-associated infections.
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Affiliation(s)
- Curtis J Donskey
- Geriatric Research, Education, and Clinical Center, Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA.
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Weiss K, Allgren RL, Sellers S. Safety analysis of fidaxomicin in comparison with oral vancomycin for Clostridium difficile infections. Clin Infect Dis 2012; 55 Suppl 2:S110-5. [PMID: 22752858 PMCID: PMC3388027 DOI: 10.1093/cid/cis390] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Fidaxomicin is a novel macrocyclic antibiotic recently approved by the US Food and Drug Administration for the treatment of Clostridium difficile–associated diarrhea in adults. We reviewed safety data from nonclinical studies and clinical trials (phases 1, 2A, and 3) with fidaxomicin. In nonclinical studies, fidaxomicin was administered orally at approximately 1 g/kg/d to dogs for up to 3 months with no significant target-organ toxicities observed. A total of 728 adults have received oral fidaxomicin in clinical trials to date: 116 healthy volunteers and 612 patients with C. difficile infection. In phase 3 clinical trials, fidaxomicin was well tolerated, with a safety profile comparable with oral vancomycin. There were no differences in the incidence of death or serious adverse events between the 2 drugs. Fidaxomicin appears to be well tolerated. Continued monitoring of adverse events in the postmarketing setting will provide additional information about the full safety profile of fidaxomicin.
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Affiliation(s)
- Karl Weiss
- Department of Infectious Diseases and Microbiology, Maisonneuve-Rosemont Hospital, Faculty of Medicine, University of Montreal, Quebec, Canada.
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Davey P, Sneddon J, Nathwani D. Overview of strategies for overcoming the challenge of antimicrobial resistance. Expert Rev Clin Pharmacol 2012; 3:667-86. [PMID: 22111749 DOI: 10.1586/ecp.10.46] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The discovery of penicillin undoubtedly transformed the management of life-threatening bacterial infections. However, a less comfortable aspect of the antibiotic revolution was that within 10 years, over 80% of patients with acute bronchitis were receiving antibiotics without any evidence of clinical benefit. Antibiotic use inevitably causes collateral damage to the normal human flora and increases the risk of infection with antibiotic-resistant bacteria and Clostridium difficile. The twin aims of antibiotic stewardship are first to ensure effective treatment for patients with bacterial infection and second to provide convincing evidence and information to educate and support professionals and patients to reduce unnecessary use and minimize collateral damage. We review evidence of progress with these aims in Europe and nationally in Scotland.
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Affiliation(s)
- Peter Davey
- Division of Community and Population Sciences and Education, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK.
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Brady RRW, Rodrigues MA, Harrison R, Rae C, Graham C, Poxton IR, Gibb AP. Knowledge of Clostridium difficile infection among UK health-care workers: development of a knowledge assessment tool. Scott Med J 2012; 57:124-30. [DOI: 10.1258/smj.2012.012015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Doctors’ knowledge provides the basis to support good practice in infection prevention and control. However, there exists a paucity of validated knowledge assessment tools that can be reliably employed to identify poor knowledge levels of Clostridium difficile infection (CDI) within populations of doctors, preventing the effective identification of knowledge deficiencies and focused targeting of educational interventions. Here, we describe a development process to validate a novel CDI knowledge assessment tool for doctors. Two previously published CDI knowledge questionnaires were amalgamated to produce a combined questionnaire. Content was further evaluated by a panel of CDI experts, producing the ‘Lothian’ questionnaire. These questionnaires were tested in control populations comprising either infection control nurse (ICN) specialists or non-clinically trained individuals, and a cohort of medical staff. We compared the efficacy of the ‘Lothian’ questionnaire against that of previous questionnaire reports. We found that all of the questionnaires studied significantly discriminated between non-clinical and clinical populations (ICNs and medical staff) ( P < 0.001) and had similar levels of sensitivity and specificity in discrimination between these targeted populations. This study describes the development of a robust CDI knowledge assessment tool that can be used to evaluate knowledge levels among doctors, compare populations and assist the targeting of educational interventions and plot trends following such interventions.
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Affiliation(s)
- R R W Brady
- Department of Colorectal Surgery, Western General Hospital, Edinburgh, Scotland, UK
| | - M A Rodrigues
- Department of Colorectal Surgery, Western General Hospital, Edinburgh, Scotland, UK
| | - R Harrison
- Department of Acute Medicine, Western General Hospital, Edinburgh, Scotland, UK
| | - C Rae
- Infection Control Services, Western General Hospital, Edinburgh, Scotland, UK
| | - C Graham
- Epidemiology and Statistics Core, University of Edinburgh, WTCRF, Edinburgh, Scotland, UK
| | - I R Poxton
- Centre for Infectious Diseases, University of Edinburgh, Edinburgh, Scotland, UK
| | - A P Gibb
- Department of Laboratory Medicine, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
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Rosenberg DJ. Infections, bacterial resistance, and antimicrobial stewardship: the emerging role of hospitalists. J Hosp Med 2012; 7 Suppl 1:S34-43. [PMID: 23677633 DOI: 10.1002/jhm.978] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Revised: 08/09/2011] [Accepted: 08/28/2011] [Indexed: 11/10/2022]
Abstract
The care of patients with serious infections both within and outside healthcare settings is increasingly complicated by the high prevalence of resistant or multidrug-resistant (MDR) pathogens. Moreover, infections caused by MDR versus susceptible bacteria or other pathogens are associated with significantly higher mortality, length of hospital stay, and healthcare costs. Antimicrobial misuse or overuse is the primary driver for development of antimicrobial resistance, suggesting that better use of antimicrobials will translate into improved patient outcomes, more efficient use of hospital resources, and lowered healthcare costs. Antimicrobial stewardship refers to the various practices and procedures utilized to optimize antimicrobial use. The primary goal of antimicrobial stewardship is to improve patient outcomes and lower antimicrobial resistance and other unintended consequences of antimicrobial therapy. Secondary goals are to reduce length of hospital stays and healthcare-related costs. Hospitalists are increasingly involved in the care of hospitalized patients throughout the United States. Expertise in managing conditions requiring hospitalization, and experience in quality improvement across a wide range of clinical conditions, make hospitalists well positioned to participate in the development and implementation of hospital-based antimicrobial stewardship programs designed to improve patient outcomes, reduce antimicrobial resistance, and provide more efficient and lower-cost hospital care.
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Affiliation(s)
- David J Rosenberg
- Department of Medicine, Division of General Internal Medicine, North Shore University Hospital, Manhasset, NY 11030, USA. .
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Epidemiology and control of Clostridium difficile infections in healthcare settings: an update. Curr Opin Infect Dis 2011; 24:370-6. [PMID: 21505332 DOI: 10.1097/qco.0b013e32834748e5] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW The epidemiology of Clostridium difficile infections (CDIs) has dramatically changed over the last decade in both North America and Europe. The objectives of this review are to highlight the recent epidemiological data and to provide an overview of the current knowledge of infection control measures. RECENT FINDINGS Since 2003, many countries have reported increased incidence of CDI and outbreaks of severe cases of CDI. This trend is assumed to be due, in part, to the emergence and rapid spread of a 'hypervirulent' strain, known as 027/BI/NAP1. This strain has become endemic in many hospitals in North America and Europe. CDI rates have also increased in the community and new genotypes (e.g. PCR ribotype 078) are emerging in both humans and animals. To prevent cross-contamination and to reduce the incidence of CDI, infection control guidelines, based primarily on experience of hospitals during outbreaks, have been recently updated in Europe and the United States. CDI prevention relies on a bundle of measures including antimicrobial stewardship, prompt diagnosis, and the implementation of contact precautions. Currently, most of these measures have appeared effective in controlling outbreaks, but the best methods to reduce CDI incidence in settings of endemicity are still unknown. SUMMARY The recent changes in CDI epidemiology have pushed infection control healthcare workers and scientific societies to revisit and update their guidelines for infection control.
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Nathwani D, Sneddon J, Malcolm W, Wiuff C, Patton A, Hurding S, Eastaway A, Seaton RA, Watson E, Gillies E, Davey P, Bennie M. Scottish Antimicrobial Prescribing Group (SAPG): development and impact of the Scottish National Antimicrobial Stewardship Programme. Int J Antimicrob Agents 2011; 38:16-26. [PMID: 21515030 DOI: 10.1016/j.ijantimicag.2011.02.005] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Accepted: 02/02/2011] [Indexed: 11/27/2022]
Abstract
In 2008, the Scottish Management of Antimicrobial Resistance Action Plan (ScotMARAP) was published by the Scottish Government. One of the key actions was initiation of the Scottish Antimicrobial Prescribing Group (SAPG), hosted within the Scottish Medicines Consortium, to take forward national implementation of the key recommendations of this action plan. The primary objective of SAPG is to co-ordinate and deliver a national framework or programme of work for antimicrobial stewardship. This programme, led by SAPG, is delivered by NHS National Services Scotland (Health Protection Scotland and Information Services Division), NHS Quality Improvement Scotland, and NHS National Education Scotland as well as NHS board Antimicrobial Management Teams. Between 2008 and 2010, SAPG has achieved a number of early successes, which are the subject of this review: (i) through measures to optimise prescribing in hospital and primary care, combined with infection prevention measures, SAPG has contributed significantly to reducing Clostridium difficile infection rates in Scotland; (ii) there has been engagement of all key stakeholders at local and national levels to ensure an integrated approach to antimicrobial stewardship within the wider healthcare-associated infection agenda; (iii) development and implementation of data management systems to support quality improvement; (iv) development of training materials on antimicrobial stewardship for healthcare professionals; and (v) improving clinical management of infections (e.g. community-acquired pneumonia) through quality improvement methodology. The early successes achieved by SAPG demonstrate that this delivery model is effective and provides the leadership and focus required to implement antimicrobial stewardship to improve antimicrobial prescribing and infection management across NHS Scotland.
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Affiliation(s)
- Dilip Nathwani
- Infection Unit, East Block, Level 4, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK.
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Infection prevention and control practices related to Clostridium difficile infection in Canadian acute and long-term care institutions. Am J Infect Control 2011; 39:177-82. [PMID: 21458680 DOI: 10.1016/j.ajic.2011.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Revised: 01/12/2011] [Accepted: 01/20/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND Clostridium difficile is an important pathogen in Canadian health care facilities, and infection prevention and control (IPC) practices are crucial to reducing C difficile infections (CDIs). We performed a cross-sectional study to identify CDI-related IPC practices in Canadian health care facilities. METHODS A survey assessing facility characteristics, CDI testing strategies, CDI contact precautions, and antimicrobial stewardship programs was sent to Canadian health care facilities in February 2005. RESULTS Responses were received from 943 (33%) facilities. Acute care facilities were more likely than long-term care (P < .001) and mixed care facilities (P = .03) to submit liquid stools from all patients for CDI testing. Physician orders were required before testing for CDI in 394 long-term care facilities (66%)-significantly higher than the proportions in acute care (41%; P < .001) and mixed care sites (49%; P < .001). A total of 841 sites (93%) had an infection control manual, 639 (76%) of which contained CDI-specific guidelines. Antimicrobial stewardship programs were reported by 40 (29%) acute care facilities; 19 (54%) of these sites reported full enforcement of the program. CONCLUSION Canadian health care facilities have widely varying C difficile IPC practices. Opportunities exist for facilities to take a more active role in IPC policy development and implementation, as well as antimicrobial stewardship.
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Comparison of strain typing results for Clostridium difficile isolates from North America. J Clin Microbiol 2011; 49:1831-7. [PMID: 21389155 DOI: 10.1128/jcm.02446-10] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Accurate strain typing is critical for understanding the changing epidemiology of Clostridium difficile infections. We typed 350 isolates of toxigenic C. difficile from 2008 to 2009 from seven laboratories in the United States and Canada. Typing was performed by PCR-ribotyping, pulsed-field gel electrophoresis (PFGE), and restriction endonuclease analysis (REA) of whole-cell DNA. The Cepheid Xpert C. difficile test for presumptive identification of 027/NAP1/BI isolates was also tested directly on original stool samples. Of 350 isolates, 244 (70%) were known PCR ribotypes, 224 (68%) were 1 of 8 common REA groups, and 187 (54%) were known PFGE types. Eighty-four isolates typed as 027, NAP1, and BI, and 83 of these were identified as presumptive 027/NAP1/BI by Xpert C. difficile. Eight additional isolates were called presumptive 027/NAP1/BI by Xpert C. difficile, of which three were ribotype 027. Five PCR ribotypes contained multiple REA groups, and three North American pulsed-field (NAP) profiles contained both multiple REA groups and PCR ribotypes. There was modest concordance of results among the three methods for C. difficile strains, including the J strain (ribotype 001 and PFGE NAP2), the toxin A-negative 017 strain (PFGE NAP9 and REA type CF), the 078 animal strain (PFGE NAP7 and REA type BK), and type 106 (PFGE NAP11 and REA type DH). PCR-ribotyping, REA, and PFGE provide different but overlapping patterns of strain clustering. Unlike the other methods, the Xpert C. difficile 027/NAP1/BI assay gave results directly from stool specimens, required only 45 min to complete, but was limited to detection of a single strain type.
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Huang SS, Avery TR, Song Y, Elkins KR, Nguyen CC, Nutter SK, Nafday AA, Condon CJ, Chang MT, Chrest D, Boos J, Bobashev G, Wheaton W, Frank SA, Platt R, Lipsitch M, Bush RM, Eubank S, Burke DS, Lee BY. Quantifying interhospital patient sharing as a mechanism for infectious disease spread. Infect Control Hosp Epidemiol 2011; 31:1160-9. [PMID: 20874503 DOI: 10.1086/656747] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Assessments of infectious disease spread in hospitals seldom account for interfacility patient sharing. This is particularly important for pathogens with prolonged incubation periods or carrier states. METHODS We quantified patient sharing among all 32 hospitals in Orange County (OC), California, using hospital discharge data. Same-day transfers between hospitals were considered "direct" transfers, and events in which patients were shared between hospitals after an intervening stay at home or elsewhere were considered "indirect" patient-sharing events. We assessed the frequency of readmissions to another OC hospital within various time points from discharge and examined interhospital sharing of patients with Clostridium difficile infection. RESULTS In 2005, OC hospitals had 319,918 admissions. Twenty-nine percent of patients were admitted at least twice, with a median interval between discharge and readmission of 53 days. Of the patients with 2 or more admissions, 75% were admitted to more than 1 hospital. Ninety-four percent of interhospital patient sharing occurred indirectly. When we used 10 shared patients as a measure of potential interhospital exposure, 6 (19%) of 32 hospitals "exposed" more than 50% of all OC hospitals within 6 months, and 17 (53%) exposed more than 50% within 12 months. Hospitals shared 1 or more patient with a median of 28 other hospitals. When we evaluated patients with C. difficile infection, 25% were readmitted within 12 weeks; 41% were readmitted to different hospitals, and less than 30% of these readmissions were direct transfers. CONCLUSIONS In a large metropolitan county, interhospital patient sharing was a potential avenue for transmission of infectious agents. Indirect sharing with an intervening stay at home or elsewhere composed the bulk of potential exposures and occurred unbeknownst to hospitals.
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Affiliation(s)
- Susan S Huang
- Division of Infectious Diseases and Health Policy Research Institute, University of California Irvine, Irvine, California, USA.
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Freeman J, Bauer MP, Baines SD, Corver J, Fawley WN, Goorhuis B, Kuijper EJ, Wilcox MH. The changing epidemiology of Clostridium difficile infections. Clin Microbiol Rev 2010; 33 Suppl 1:S42-5. [PMID: 20610822 DOI: 10.1016/s0924-8579(09)70016-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The epidemiology of Clostridium difficile infection (CDI) has changed dramatically during this millennium. Infection rates have increased markedly in most countries with detailed surveillance data. There have been clear changes in the clinical presentation, response to treatment, and outcome of CDI. These changes have been driven to a major degree by the emergence and epidemic spread of a novel strain, known as PCR ribotype 027 (sometimes referred to as BI/NAP1/027). We review the evidence for the changing epidemiology, clinical virulence and outcome of treatment of CDI, and the similarities and differences between data from various countries and continents. Community-acquired CDI has also emerged, although the evidence for this as a distinct new entity is less clear. There are new data on the etiology of and potential risk factors for CDI; controversial issues include specific antimicrobial agents, gastric acid suppressants, potential animal and food sources of C. difficile, and the effect of the use of alcohol-based hand hygiene agents.
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Affiliation(s)
- J Freeman
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom
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45
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Malkan AD, Pimiento JM, Maloney SP, Palesty JA, Scholand SJ. Unusual manifestations of Clostridium difficile infection. Surg Infect (Larchmt) 2010; 11:333-7. [PMID: 19795991 DOI: 10.1089/sur.2008.099] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) is an increasing nosocomial problem. New, more-virulent strains of C. difficile have spread across North America and Europe. Health care institutions now face a greater incidence of disease, often with greater severity. A need for surgical management for control of infection is on the increase. The clinical appearance of CDI is changed. METHODS We report four unusual and severe cases of CDI in surgical patients with a review of the relevant literature. RESULTS One patient developed CDI and required a colectomy for a perforated viscus. He developed C. difficile ileitis 12 days later that responded to medical therapy. Another patient who underwent a colectomy for infrarenal aortic occlusion, later in his hospital course, developed C. difficile ileitis and died. The third patient was hospitalized for several months for hypertension and associated morbidities. Eventually he developed severe abdominal pain and was found to have a small bowel mural abscess that grew C. difficile on culture. A fourth patient, taking long-term antibiotics for a surgical site infection of the knee, developed unexplained leukocytosis without diarrhea. Colonoscopy revealed pseudomembranous colitis that advanced to toxic megacolon. She required a colectomy and ultimately died from the disease. CONCLUSIONS Patients are at high risk from CDI in this modern era. Disease manifestations may differ from the typical presentation. A heightened awareness for diagnosing this dangerous, evolving disease is paramount.
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Affiliation(s)
- Alpin D Malkan
- Department of Surgery, Saint Mary's Health System, Waterbury, Connecticut 06705, USA.
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Lanini S, Abbate I, Puro V, Soscia F, Albertoni F, Battisti W, Ruta A, Capobianchi MR, Ippolito G. Molecular epidemiology of a hepatitis C virus epidemic in a haemodialysis unit: outbreak investigation and infection outcome. BMC Infect Dis 2010; 10:257. [PMID: 20799943 PMCID: PMC2940904 DOI: 10.1186/1471-2334-10-257] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Accepted: 08/27/2010] [Indexed: 12/23/2022] Open
Abstract
Background HCV is a leading cause of liver chronic diseases all over the world. In developed countries the highest prevalence of infection is reported among intravenous drug users and haemodialysis (HD) patients. The present report is to identify the pathway of HCV transmission during an outbreak of HCV infection in a privately run haemodialysis (HD) unit in Italy in 2005. Methods Dynamics of the outbreak and infection clinical outcomes were defined through an ambi-directional cohort study. Molecular epidemiology techniques were used to define the relationships between the viral variants infecting the patients and confirm the outbreak. Risk analysis and auditing procedures were carried out to define the transmission pathway(s). Results Of the 50 patients treated in the HD unit 5 were already anti-HCV positive and 13 became positive during the study period (AR = 28.9%). Phylogenic analysis identified that, all the molecularly characterized incident cases (10 out of 13), were infected with the same viral variant of one of the prevalent cases. The multivariate analysis and the auditing procedure disclosed a single event of multi-dose vials heparin contamination as the cause of transmission of the infection in 11 out of the 13 incident cases; 2 additional incident cases occurred possibly as a result of inappropriate risk management. Discussion More than 30% of all HCV infections in developed countries results from poor application of standard precautions during percutaneous procedures. Comprehensive strategy which included: educational programmes, periodical auditing on standard precaution, use of single-dose vials whenever possible, prospective surveillance for blood-borne infections (including a system of prompt notification) and risk assessment/management dedicated staff are the cornerstone to contain and prevent outbreaks in HD Conclusions The outbreak described should serve as a reminder to HD providers that patients undergoing dialysis are at risk for HCV infection and that HCV may be easily transmitted whenever standard precautions are not strictly applied.
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Affiliation(s)
- Simone Lanini
- Istituto Nazionale per le Malattie Infettive Lazzaro Spallanzani via Portuense 292 00149 Rome, Italy.
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Simor AE. Diagnosis, Management, and Prevention of Clostridium difficile Infection in Long-Term Care Facilities: A Review. J Am Geriatr Soc 2010; 58:1556-64. [DOI: 10.1111/j.1532-5415.2010.02958.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Freeman J, Bauer MP, Baines SD, Corver J, Fawley WN, Goorhuis B, Kuijper EJ, Wilcox MH. The changing epidemiology of Clostridium difficile infections. Clin Microbiol Rev 2010; 23:529-49. [PMID: 20610822 PMCID: PMC2901659 DOI: 10.1128/cmr.00082-09] [Citation(s) in RCA: 625] [Impact Index Per Article: 44.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The epidemiology of Clostridium difficile infection (CDI) has changed dramatically during this millennium. Infection rates have increased markedly in most countries with detailed surveillance data. There have been clear changes in the clinical presentation, response to treatment, and outcome of CDI. These changes have been driven to a major degree by the emergence and epidemic spread of a novel strain, known as PCR ribotype 027 (sometimes referred to as BI/NAP1/027). We review the evidence for the changing epidemiology, clinical virulence and outcome of treatment of CDI, and the similarities and differences between data from various countries and continents. Community-acquired CDI has also emerged, although the evidence for this as a distinct new entity is less clear. There are new data on the etiology of and potential risk factors for CDI; controversial issues include specific antimicrobial agents, gastric acid suppressants, potential animal and food sources of C. difficile, and the effect of the use of alcohol-based hand hygiene agents.
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Affiliation(s)
- J. Freeman
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - M. P. Bauer
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - S. D. Baines
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - J. Corver
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - W. N. Fawley
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - B. Goorhuis
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - E. J. Kuijper
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - M. H. Wilcox
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
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Rodrigues MA, Brady RR, Rodrigues J, Graham C, Gibb AP. Clostridium difficile infection in general surgery patients; identification of high-risk populations. Int J Surg 2010; 8:368-72. [PMID: 20580865 DOI: 10.1016/j.ijsu.2010.05.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2010] [Revised: 04/01/2010] [Accepted: 05/07/2010] [Indexed: 11/24/2022]
Abstract
BACKGROUND Risk factors associated with Clostridium difficile infection (CDI) in general surgical patients are poorly characterised. This study aimed to characterise the incidence and associations of C. difficile positivity (CDP) in general surgical inpatients to aid in the design of future policies regarding focused screening and risk-stratification mechanisms in this patient subpopulation. MATERIALS AND METHODS Discharge, laboratory and coding data from all general surgery inpatients admitted to a large tertiary referral general surgical unit, between March 2005 and May 2007, were examined. RESULTS 21,371 patient records were interrogated. 101 (0.47%) CDP cases were identified from laboratory records and compared with non-CDP controls for age, gender, length of stay (LOS), admission to intensive care unit or high dependency unit (ICU/HDU), co-morbidities and surgical procedures. Univariate analysis identified a range of risk factors associated with positivity. Multivariate analysis identified malignancy, gastrointestinal disease, anaemia, respiratory disease, circulatory disease, diabetes mellitus, those undergoing gastrointestinal surgery and increasing age to be independently associated with CDP status. CONCLUSIONS This study identifies incidence and risk factor associations of those who tested CDP in a large contemporary general surgery inpatient population. Focused screening programmes based on high-risk populations may provide information on further risk factors and allow risk-stratification. Further healthcare worker education regarding risk factors may reduce the clinical impact of CDI by encouraging increased vigilance and therefore earlier detection.
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Affiliation(s)
- M A Rodrigues
- Department of General Medicine, Western General Hospital, Edinburgh, Scotland, United Kingdom.
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Hardy KJ, Gossain S, Thomlinson D, Pillay DG, Hawkey PM. Reducing Clostridium difficile through early identification of clusters and the use of a standardised set of interventions. J Hosp Infect 2010; 75:277-81. [PMID: 20227140 DOI: 10.1016/j.jhin.2009.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2009] [Accepted: 12/07/2009] [Indexed: 12/13/2022]
Abstract
In recent years the rates of Clostridium difficile infection (CDI) have increased worldwide with several large outbreaks occurring within the UK. New guidance from the UK Department of Health describes measures to investigate periods of increased incidence (PII) of CDI which include informing staff, ribotyping isolates, enhanced cleaning, audits and monitoring of antibiotic prescribing. This study aimed to determine whether a standardised set of measures could be used to control the incidence of CDI within an acute hospital setting over an 18 month period. During the study period a total of 102 PII involving 439 patients were investigated. The number of PII per month ranged from 14 in February 2008 to one in June 2009. From January 2008 to September 2008, ribotyping of patient isolates was only carried out on PII involving more than 10 patients, but from October 2008 it was carried out on all PII. During the period October 2008 to June 2009, 28 PII were investigated on 21 different wards, with seven wards having two PII. Ribotyping of the isolates confirmed nine (32%) of these PII to be outbreaks, with three being due to ribotype 027, two ribotype 078 and the others distinct ribotypes. Use of a set of standardised interventions has resulted in a decrease in the incidence of PII and a reduction in the number of patients involved. By taking early action with a set of standardised measures the incidence of hospital-acquired CDI can be reduced.
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Affiliation(s)
- K J Hardy
- West Midlands Public Health Laboratory, Heart of England NHS Foundation Trust, Birmingham B9 5SS, UK.
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