Hand hygiene in the intensive care unit:

In Vitro Performance of a Long-Range Surface Plasmon Hydrogel Aptasensor for Continuous and Real-Time Vancomycin Measurement in Human Serum

This study investigated the suitability of surface modification for a long-range surface plasmon (LRSP) aptasensor using two different hydrogels, aiming at real-time monitoring of vancomycin (VCM) in undiluted serum and blood. Three different layer structures were formed on a gold surface of LRSP sensor chip using poly[2-methacryloyloxyethyl phosphorylcholine (MPC)-co-N-methacryloyl-(L)-tyrosinemethylester (MAT)] (PMM) and poly[MPC-co-2-ethylhexyl methacrylate (EHMA)-co-MAT] (PMEM). The peptide aptamer for VCM was immobilized in PMM and PMEM via MAT. Among four differently prepared sensor chips, the LRSP hydrogel aptasensor with PMM, referred to as the PMM hydrogel, exhibited the highest sensor output and superior antifouling properties. Following the optimization of the PMM hydrogel preparation conditions, the shelf life of the PMM hydrogel was determined to exceed 2 weeks, and the same sensor chip could be used for 102 days without significant performance deterioration. The PMM hydrogel was then applied for VCM measurement in undiluted serum in vitro, where it demonstrated a limit of detection of 0.098 μM and a dynamic range of 0.18-100 μM, covering the therapeutic range. Additionally, the PMM hydrogel enabled the continuous measurement of various VCM concentrations in serum without rinsing and showed a concentration-dependent output in undiluted blood. These findings underscore the potential of the PMM hydrogel for real-time and direct monitoring of VCM in body fluids.

Quality Indicators in Adult Critical Care Medicine

Quality indicators are increasingly used in the intensive care unit (ICU) to compare and improve the quality of delivered healthcare. Numerous indicators have been developed and are related to multiple domains, most importantly patient safety, care timeliness and effectiveness, staff well-being, and patient/family-centered outcomes and satisfaction. In this review, we describe pertinent ICU quality indicators that are related to organizational structure (such as the availability of an intensivist 24/7 and the nurse-to-patient ratio), processes of care (such as ventilator care bundle), and outcomes (such as ICU-acquired infections and standardized mortality rate). We also present an example of a quality improvement project in an ICU indicating the steps taken to attain the desired changes in quality measures.

A qualitative study exploring hand hygiene practices in a neonatal unit in Blantyre, Malawi: implications for controlling healthcare-associated infections

Background: Neonatal sepsis causes morbidity and mortality in sub-Saharan Africa. Antimicrobial resistance exacerbates outcomes. Poor Infection Prevention and Control practices (IPC) by healthcare workers and caregivers drive infection transmission. The Chatinkha Neonatal Unit in Malawi has experienced Klebsiella pneumoniae outbreaks of neonatal sepsis. We aimed to identify barriers to optimal IPC, focusing on hand hygiene. Methods: We used a focused ethnography to meet the study aim. Combining participant observation over a seven-month period with semi structured interviews with health care workers and patient carers (23) to provide an in-depth understanding of activities relating to hygiene and IPC existing on the ward. To analyse the data, we drew on the framework approach. Results: We found that staff and caregivers had a good understanding and recognition of the importance of ideal IPC, but faced substantial structural limitations and scarce resources, which hindered the implementation of best practices. We present two key themes: (1) structural and health systems barriers that shaped IPC. These included scarce material resources and overwhelming numbers of patients meant the workload was often unmanageable. (2) individual barriers related to the knowledge of frontline workers and caregivers, which were shaped by training and communication practices on the ward. We highlight the importance of addressing both structural and individual barriers to improve IPC practices and reduce the burden of neonatal sepsis in resource-limited settings. Conclusion: For IPC to be improved, interventions need to address the chronic shortages of material resources and create an enabling environment for HCWs and patient caregivers.

A qualitative study exploring hand hygiene practices in a neonatal unit in Blantyre, Malawi: implications for controlling healthcare-associated infections

Background: Neonatal sepsis is responsible for a considerable burden of morbidity and mortality in sub-Saharan African countries. Outcomes from neonatal sepsis are worsening due to increasing rates of antimicrobial resistance. Sub-optimal Infection Prevention and Control (IPC) practices of health care workers and caregivers are important drivers of infection transmission. The Chatinkha Neonatal Unit at Queen Elizabeth Central Hospital, Blantyre, Malawi has experienced multiple outbreaks of neonatal sepsis, associated with drug resistant Klebsiella pneumoniae. We aimed to understand the barriers to implementation of optimal IPC focusing on hand hygiene practice. Methods: We used a qualitative research methodology to meet the study aim. Combining participant observation (PO) over a seven-month period with semi structured interviews (SSI) to provide an in-depth understanding of activities relating to hygiene and IPC existing on the ward. Results: While most staff and some caregivers, had a good understanding of ideal IPC and understood the importance of good handwashing practices, they faced substantial structural limitations, and scarce resources (both material and human) which made implementation challenging.  For staff, the overwhelming numbers of patients meant the workload was often unmanageable and practicing optimal IPC was challenging.  Caregivers lacked access to basic amenities, including linen and chairs, meaning that it was almost impossible for them to maintain good hand hygiene. Limited access to soap and the erratic water supply for both caregivers and healthcare workers further worsened the situation. Communication challenges between different cadres of staff and with patient caregivers meant that those handling neonates and cleaning the wards were often unaware of outbreaks of drug resistant infection. Conclusion: For IPC to be improved, interventions need to address the chronic shortages of material resources and create an enabling environment for HCWs and patient caregivers.

Long-range surface plasmon aptasensor for label-free monitoring of vancomycin

Vancomycin (VCM) causes poisoning symptoms at high concentrations; thus, therapeutic drug monitoring is recommended to measure and control blood levels regularly. However, blood analysis at regular intervals does not allow knowing the detailed temporal change in concentration. To address this challenge, we developed a long-range surface plasmon (LRSP) aptasensor for measuring VCM label-free and real-time by combining a sensitive LRSP sensor and a peptide aptamer with a VCM recognition site. First, three different biosensors for VCM were compared. One was prepared by immobilizing the peptide aptamer directly on (Direct-Apt) or via a self-assembled monolayer (SAM) on a gold surface (SAM-Apt). The other used anti-VCM antibodies immobilized on a gold surface via the SAM (SAM-Ab). The Direct-Apt showed larger sensor output to VCM than the other biosensors. The dynamic range for VCM was 0.78-100 μM, including the therapeutic range (6.9-13.8 μM). The Direct-Apt also showed the sensor output only from VCM among four different antibiotics, demonstrating the high selectivity for VCM. The VCM captured by the aptamer could be removed by rinsing with phosphate-buffered saline. The measurement was rapid, with 72- and 77-sec response and recovery times, allowing not only repeated but also real-time measurements. Finally, the Direct-Apt in 20% serum solutions showed comparable sensitivity to VCM in the buffer solution, indicating high capability for real-sample.

Limiting the Spread of Multidrug-Resistant Bacteria in Low-to-Middle-Income Countries: One Size Does Not Fit All

The spread of multidrug-resistant organisms (MDRO) is associated with additional costs as well as higher morbidity and mortality rates. Risk factors related to the spread of MDRO can be classified into four categories: bacterial, host-related, organizational, and epidemiological. Faced with the severity of the MDRO predicament and its individual and collective consequences, many scientific societies have developed recommendations to help healthcare teams control the spread of MDROs. These international recommendations include a series of control measures based on surveillance cultures and the application of barrier measures, ranging from patients' being isolated in single rooms, to the reinforcement of hand hygiene and implementation of additional contact precautions, to the cohorting of colonized patients in a dedicated unit with or without a dedicated staff. In addition, most policies include the application of an antimicrobial stewardship program. Applying international policies to control the spread of MDROs presents several challenges, particularly in low-to-middle-income countries (LMICs). Through a review of the literature, this work evaluates the real risks of dissemination linked to MDROs and proposes an alternative policy that caters to the means of LMICs. Indeed, sufficient evidence exists to support the theory that high compliance with hand hygiene and antimicrobial stewardship reduces the risk of MDRO transmission. LMICs would therefore be better off adopting such low-cost policies without necessarily having to implement costly isolation protocols or impose additional contact precautions.

Management of Bacterial and Fungal Infections in the ICU: Diagnosis, Treatment, and Prevention Recommendations

Bacterial and fungal infections are common issues for patients in the intensive care unit (ICU). Large, multinational point prevalence surveys have identified that up to 50% of ICU patients have a diagnosis of bacterial or fungal infection at any one time. Infection in the ICU is associated with its own challenges. Causative organisms often harbour intrinsic and acquired mechanisms of drug-resistance, making empiric and targeted antimicrobial selection challenging. Infection in the ICU is associated with worse clinical outcomes for patients. We review the epidemiology of bacterial and fungal infection in the ICU. We discuss risk factors for acquisition, approaches to diagnosis and management, and common strategies for the prevention of infection.

A qualitative study exploring health workers and patient caregivers’ hand hygiene practices in a neonatal unit in Blantyre, Malawi, implications for controlling outbreaks of drug resistant infections

Background: Neonatal sepsis is responsible for a considerable burden of morbidity and mortality in sub-Saharan African countries. Outcomes from neonatal sepsis are worsening due to increasing rates of antimicrobial resistance. Sub-optimal Infection Prevention and Control (IPC) practices of health care workers and caregivers are important drivers of infection transmission. The Chatinkha Neonatal Unit at Queen Elizabeth Central Hospital, Blantyre, Malawi has experienced multiple outbreaks of neonatal sepsis, associated with drug resistant Klebsiella pneumoniae. We aimed to understand the barriers to implementation of optimal IPC focusing on hand hygiene practice. Methods: We used a qualitative research methodology to meet the study aim. Combining participant observation (PO) over a seven-month period with semi structured interviews (SSI) to provide an in-depth understanding of activities relating to hygiene and IPC existing on the ward. Results: While most staff and some caregivers, had a good understanding of ideal IPC and understood the importance of good handwashing practices, they faced substantial structural limitations, and scarce resources (both material and human) which made implementation challenging.  For staff, the overwhelming numbers of patients meant the workload was often unmanageable and practicing optimal IPC was challenging.  Caregivers lacked access to basic amenities, including linen and chairs, meaning that it was almost impossible for them to maintain good hand hygiene. Limited access to soap and the erratic water supply for both caregivers and healthcare workers further worsened the situation. Communication challenges between different cadres of staff and with patient caregivers meant that those handling neonates and cleaning the wards were often unaware of outbreaks of drug resistant infection. Conclusion: For IPC to be improved, interventions need to address the chronic shortages of material resources and create an enabling environment for HCWs and patient caregivers.

Bacterial Colonization of Intensive Care Unit Environment and Healthcare Workers in A Tertiary Care Hospital in Kolar Region, India

Direct shedding of microbes by patients and health care workers results in contamination of Intensive care unit environment. Intensive care unit acquired infections due to microbial contamination is a major concern because the patient’s immunity is already compromised. To determine the rate of bacterial contamination on environmental surfaces of Intensive care unit and health care workers and to determine the antibiogram of the isolates. Air samples and swabs from healthcare workers, their accessories, surrounding environmental surfaces were collected randomly over a period of 2 months in Adult Intensive care units. Bacterial isolates were identified by standard microbiological techniques. Antibiotic sensitivity testing was performed by Kirby Bauer disc diffusion method and data analyzed by Statistical Product and Service Solutions 22 version software. A total of 208 samples were randomly collected over 2 months, of which 56 samples yielded positive bacterial growth. Of 56 growth, 12 isolates were detected from air sampling method and 44 isolates from swabs. Among 44 isolates identified from swabs, 10 were isolated from healthcare workers, 4 from health care worker’s accessories and 30 from environmental surfaces. Six different bacterial isolates were identified, Coagulase Negative Staphylococcus (24) and Micrococcus (15) were the major isolates followed by Non fermenters (6), Staphylococcus aureus(4), Bacillus species(4) and diphtheroids (3) The antimicrobial sensitivity pattern of these bacterial isolates were sensitive to commonly used antibacterial agents. Study results showed Intensive care unit staff and environmental surfaces as probable sources of bacterial contamination. Study highlights the importance of cleaning and disinfection process and educate the health care workers about the possible sources of infections within Intensive care unit.

Compliance measurement and observed influencing factors of hand hygiene based on COVID-19 guidelines in China

BACKGROUND

Higher requirement is put forward in the measurement of hand hygiene (HH) during a pandemic. This study aimed to describe HH compliance measurement and explore observed influencing factors with respect to coronavirus disease 2019 (COVID-19) guidelines in China.

METHODS

Compliance was measured as the percentage of compliant opportunities based on criteria for 17 moments. The criteria for compliance included HH behavior, procedure, duration, hand drying method, and the overall that counts them all. The observed influencing factors included different departments and areas and protection motivation. Descriptive analysis and logistic regression were performed.

RESULTS

The compliance of overall criteria, HH behavior, procedure, duration, and hand drying method were 79.44%, 96.71%, 95.74%, 88.93%, and 88.42%, respectively, which were significantly different from each other (P < .001). Meanwhile, the overall and hand drying method compliance in semi-contaminated areas (odds ratio [OR] = 1.829, P < .001; OR = 2.149, P = .001) and hygienic areas (OR = 1.689, P = .004; OR = 1.959, P = .015) were significantly higher than those in contaminated area. The compliance with HH behavior for the motivation of patient-protection (OR = 0.362, P < .001) was lower than that for the motivation of self-protection.

CONCLUSIONS

HH compliance was firstly measured using different criteria for 17 moments according to COVID-19 guidelines in China. The measurement of HH compliance needs clearer definition and comprehensive practice. Contaminated areas and motivation of patient-protection contribute to lower compliance, which may be addressed by allocating more human resources and increasing supervision and education.

Hand hygiene compliance and behavioural determinants in a paediatric intensive care unit: An observational study

BACKGROUND

Hand hygiene is considered the single most effective means of reducing healthcare-associated infections, but improving and sustaining hand hygiene compliance remains a great challenge.

OBJECTIVES

To compare hand hygiene compliance before and after interventions to promote adherence in a paediatric intensive care unit (PICU) and to identify predictors of intention to perform the behaviour "hand hygiene during patient care in the PICU".

METHODS

A before and after study was conducted in three phases. Based on the World Health Organization guideline for hand hygiene compliance monitoring, 1261 hand hygiene opportunities were directly observed during routine patient care by two observers simultaneously, in a nine-bed PICU in Brazil, before and after infrastructure and educational interventions. To identify predictors of healthcare professionals' intention to perform the behaviour hand hygiene during patient care, a data collection instrument was designed based on the Theory of Planned Behaviour. Statistical analyses were undertaken using Chi-square test or the Fisher's exact test and regression analysis. A significance level of 5% (p < 0.05) was applied to all analyses.

RESULTS

The hand hygiene compliance rate increased significantly from 27.3% in the "pre-intervention phase" to 33.1% in "phase 1-post-intervention," to 37.0% in "phase 2-post-intervention" (p = .010). Perceived social pressure (p = .026) was a determinant factor of intention to perform the behaviour.

CONCLUSIONS

Hand hygiene compliance raised significantly after infrastructure, educational, and performance feedback interventions. However, despite the significant effect of the implemented interventions, the overall hand hygiene compliance rate was low. Perceived social pressure characterised a determinant factor of intention to perform the behaviour "hand hygiene during patient care in the PICU", reinforcing the need for behaviour determinants analysis when designing promotional interventions.

Hand Hygiene and Tuberculosis Risk in Korea: An Ecological Association

Hand hygiene is a basic but effective strategy against infectious disease. This study investigated an ecological association between hand hygiene and tuberculosis (TB) risk in Korea. Hand hygiene data were obtained from the 2015 Community Health Survey. Information on TB incidence and mortality in 2015 were obtained from the National Infectious Diseases Surveillance System and death monitoring database, respectively. In multiple linear regression analysis, frequent hand washing rates after using the restroom (B = -0.78, P = .037), after returning from the outdoors (B = -0.28, P = .049), and with soap or hand sanitizer (B = -0.54, P = .018) were negatively associated with TB incidence. TB mortality were associated with frequent hand washing rates after returning from the outdoors (B = -0.05, P = .035), and with soap or hand sanitizer (B = -0.10, P = .010), respectively. Hand washing was associated with lower TB incidence and mortality at the community level. These results could contribute to develop community-based health promotion strategies.

Healthcare workers' knowledge and perceptions of the risks associated with emerging extensively drug-resistant bacteria

OBJECTIVE

Guidelines have been issued in 2010 to prevent the spread of emerging extensively resistant bacteria (eXDR), but their implementation is difficult. We aimed to evaluate healthcare workers' (HCW) knowledge and their risk perception to identify barriers to the implementation of guidelines.

METHODS

Semi-structured interviews were conducted at a University Hospital, where case patients are regularly admitted. The interviews focused on HCW's knowledge, risk perception, and challenges met. The evaluation of HCW's knowledge and contagiousness and perception of severity of eXDR carriage were analyzed statistically. Risk perception and opinion about guidelines were analyzed by qualitative description.

RESULTS

One hundred and twenty-one HCWs were interviewed. The category of HCW, having searched for information on resistant bacteria, and having taken care of case patients were associated with better knowledge. The HCW category, age, type of unit, seniority, and having taken care of case patients were associated with risk perceptions. Qualitative analysis identified 61 themes. HCWs were extremely concerned by the spread of bacteria within the hospital. The main challenges identified were organizational and communication issues.

CONCLUSION

HCWs reported a lack of knowledge and a lack of resources to implement guidelines. Strategies to improve guidelines implementation must be based on a better availability of resources, better communication, and new educational methods.

Carbapenem-resistant enterobacteriaceae: occult threat in the intensive care unit

Carbapenem-resistant Enterobacteriaceae are a group of virulent, drug-resistant gram-negative bacteria that are increasingly the cause of infection. Such infections are associated with a high morbidity and mortality and increased health care costs. Management of these infections requires recognition of patients at risk for multidrug-resistant microbial colonization and infections, identification of the causative organism, and rapid, appropriate treatment. Lack of awareness of proper isolation of patients harboring these organisms and delay in prescribing antibiotics such as tigecycline and polymyxins contribute to the spread of infection in intensive care units. Surveillance and infection control measures are paramount in preventing outbreaks of infection caused by carbapenem-resistant Enterobacteriaceae. Critical care nurses are in a vital position to monitor patients at risk for such infections and to promote infection prevention measures.

Changes in hand hygiene compliance after a multimodal intervention among health-care workers from intensive care units in Southwestern Saudi Arabia

The aim of this study is to measure the degree of compliance with hand hygiene practices among health-care workers (HCWs) in intensive care facilities in Aseer Central Hospital, Abha, Saudi Arabia, before and after a multimodal intervention program based on WHO strategies. Data were collected by direct observation of HCWs while delivering routine care using standardized WHO method: "Five moments for hand hygiene approach". Observations were conducted before (February-April 2011) and after (February-April 2013) the intervention by well-trained, infection-control practitioners during their routine visits. The study included 1182 opportunities (observations) collected before and 2212 opportunities collected after the intervention. The overall, hand hygiene compliance increased significantly from 60.8% (95% CI: 57.9-63.6%) before the intervention to reach 86.4% (95% CI: 84.9-97.8%) post-intervention (P=0.001). The same trend was observed in different intensive care facilities. In logistic regression analyses, HCWs were significantly more compliant (aOR=3.2, 95% CI: 2.6-3.8) after the intervention. Similarly, being a nurse and events after patient contact were significant determinants of compliance. It is important to provide sustained intensified training programs to help embed efficient and effective hand hygiene into all elements of care delivery. New approaches like accountability, motivation and sanctions are needed.

Laboratory evidence of norwalk virus contamination on the hands of infected individuals

Human norovirus (NoV) outbreak investigations suggest that the hands of infected individuals play an important role in NoV transmission. However, there is no experimental evidence documenting the likelihood and degree of NoV contamination on hands. As part of a clinical trial designed to evaluate the efficacy of high-pressure processing for Norwalk virus (NV) inactivation in oysters, 159 hand rinse samples were collected from 6 infected and 6 uninfected subjects. NV was concentrated from the samples by polyethylene glycol precipitation, followed by RNA extraction using an automated guanidinium isothiocyanate-silica method. NV RNA was detected and quantified using multiple NV-specific reverse transcription-quantitative PCR (RT-qPCR) assays. A total of 25.4% (18/71) of the hand rinse samples collected from 6 infected volunteers were presumptively positive for NV, with an average of 3.86 log10 genomic equivalent copies (GEC) per hand. Dot blot hybridization of PCR products obtained using a different primer set, and DNA sequencing of selected amplicons, provided further confirmation of the presence of NV in the hand rinses. NV contamination was also detected in two hand rinse samples obtained from one uninfected subject. These findings provide definitive evidence of NV contamination on the hands of infected subjects observed under controlled clinical research conditions. Such data support the need for better hand hygiene strategies to prevent NoV transmission.

Promotion of hand hygiene strengthening initiative in a Nigerian teaching hospital: implication for improved patient safety in low-income health facilities

Background

Health care-associated infection remains a significant hazard for hospitalized patients. Hand hygiene is a fundamental action for ensuring patient safety.

Objective

To promote adoption of World Health Organization Hand Hygiene Guidelines to enhance compliance among doctors and nurses and improve patient safety.

Methods

The study design was a cross sectional intervention in a Federal Teaching Hospital South-eastern Nigeria. Interventions involved training/education; introduction of hand rub; and hand hygiene reminders. The impact of interventions and hand hygiene compliance were evaluated using World Health Organization direct observation technique.

Results

The post-intervention hand hygiene compliance rate was 65.3%. Hand hygiene indications showed highest compliance rate ‘after body fluid exposure’ (75.3%) and ‘after touching a patient’ (73.6%) while the least compliance rate was recorded ‘before touching a patient’ (58.0%). Hand hygiene compliance rate was significantly higher among nurses (72.9%) compared to doctors (59.7%) (χ² = 23.8, p < 0.05). Hand hygiene indication with significantly higher compliance rate was “before clean/aseptic procedure” (84.4%) (χ² = 80.74, p < 0.05). Out of the 815 hand hygiene practices recorded 550 (67.5%) were hand rub action.

Conclusions

hand hygiene campaigns using the World Health Organization tools and methodology can be successfully executed in a tertiary health facility of a low-income setting with far reaching improvements in compliance.

Infection prevention and control during prolonged human space travel

Prolonged human spaceflight to another planet or an asteroid will introduce unique challenges of mitigating the risk of infection. During space travel, exposure to microgravity, radiation, and stress alter human immunoregulatory responses, which can in turn impact an astronaut's ability to prevent acquisition of infectious agents or reactivation of latent infection. In addition, microgravity affects virulence, growth kinetics, and biofilm formation of potential microbial pathogens. These interactions occur in a confined space in microgravity, providing ample opportunity for heavy microbial contamination of the environment. In addition, there is the persistence of aerosolized, microbe-containing particles. Any mission involving prolonged human spaceflight must be carefully planned to minimize vulnerabilities and maximize the likelihood of success.

Neonatology in the emerging countries: the strategies and health-economics challenges related to prevention of neonatal and infant infections

The prevalence of neonatal and infant infections is higher in emerging countries when compared to the developed world. Major factors associated to this increased frequency include the scarcity of trained health personnel, overcrowding of the neonatal units, late onset and slow advance of feeding, use of formula instead of breastfeeding, failure to comply with handwashing recommendations, and excessive use of antibiotics, resulting in the emergence of resistant strains. Infants discharged home frequently share rooms with a large number of siblings and other cohabitants, increasing the risk of infection by respiratory viruses. Several strategies are described that could decrease these serious problems which impact increasing significantly neonatal and infant mortality rates in developing countries.

Methicillin-resistant Staphylococcus aureus (MRSA) on the skin of long-term hospitalised horses

Given the significance of methicillin-resistant Staphylococcus aureus (MRSA) infections for both horses and staff in equine veterinary hospitals, protocols are required to minimise the risk of nosocomial transmission, including the screening of the skin and nasal chambers of equine patients for evidence of infection. The objective of this study was to clarify the potential existence and extent of MRSA on the skin of horses requiring long-term hospitalisation (≥ 6 months). Thirty such horses were sampled at eight different locations on their skin and from their nasal chambers. MRSA was isolated from 12 animals (40%), with all sample sites testing positive on at least one occasion. Organisms were most frequently detected in the nasal chambers (relative sensitivity, 83.3%; 34.5% positive horses; isolation rate 33.3%). Skin presence was found in 30% of animals with the highest isolation rates found at the carpus (16.7%), neck, withers and croup (13.3% each). To achieve a relative screening sensitivity of >90%, at least one skin site was required in addition to nasal sampling. This evidence of skin as well as nasal reservoirs of MRSA in long-term hospitalised horses should facilitate the design of effective screening and containment protocols.

A call to arms: the imperative for antimicrobial stewardship

Antimicrobial resistance is a major public health crisis. The prevalence of drug-resistant organisms, such as the emerging NAP1 strain of Clostridium difficile, now highly resistant to fluoroquinolones, Acinetobacter species, Klebsiella pneumoniae carbapenemase-producing organisms, and methicillin-resistant Staphylococcus aureus, is increasing nationwide. The sources of antimicrobial resistance are manifold, but there is a well-documented causal relationship between antimicrobial use and misuse and the emergence of antimicrobial-resistant pathogens. As the development of new antimicrobial agents is on the decline, the medical community, across all specialties and in conjunction with public health services, must develop and implement programs and strategies designed to preserve the integrity and effectiveness of the existing antimicrobial armamentarium. Such strategies are collectively known as antimicrobial stewardship programs and have the potential to minimize the emergence of resistant pathogens.

Hospital-acquired viral infection increases mortality in children with severe viral respiratory infection

OBJECTIVE

To investigate the association of method of acquisition (hospital-acquired vs. community-acquired) and mortality in children with severe viral respiratory infection.

DESIGN

Retrospective cohort study.

SETTING

: Pediatric intensive care unit at an urban academic tertiary care children's hospital.

PATIENTS

All patients aged <18 yrs admitted to our pediatric intensive care unit with laboratory-confirmed respiratory syncytial virus, influenza, parainfluenza, or adenovirus infection between October 2002 and September 2008.

INTERVENTIONS

We stratified patients by method of viral acquisition and identified those patients with chronic medical conditions associated with an increased risk of complications from viral illness.

MEASUREMENTS AND MAIN RESULTS

There were 289 patients admitted to the pediatric intensive care unit with laboratory-confirmed viral respiratory infection during the period of study. Fifty-three patients (18%) had hospital-acquired infection and 117 patients (40%) had chronic medical conditions associated with an increased risk of complications from viral illness. Hospital-acquired infection was associated with increased mortality and length of stay (all p < .001). Adjusting for age, chronic medical conditions, severity of illness index, and catheter-associated bloodstream infections, patients with hospital-acquired infection had a 5.8 (95% confidence interval 2.1-15.6) times greater odds (p = .001) of mortality.

CONCLUSIONS

Our results suggest that in children with severe viral respiratory infection, hospital acquisition of infection is associated with increased mortality even after adjusting for chronic medical conditions that predispose to an increased risk of complications from viral illness.

Antimicrobial resistance in the intensive care unit: mechanisms, epidemiology, and management of specific resistant pathogens

Infections caused by drug-resistant and multidrug-resistant microbial pathogens pose tremendous challenges to health care systems, including challenges related to the diagnosis, treatment, and containment of these infections. These challenges are amplified in the intensive care unit (ICU), where pressures for selection and emergence of resistance and risks of transmission of resistant pathogens are highest, and where the threat of resistance drives selection of empiric antimicrobial regimens. This article reviews basic concepts of resistance to antibacterial agents including mechanisms and modes of transmission, and discusses management issues for the important drug-resistant pathogens found in the ICU.

Infection control in the intensive care unit: progress and challenges in systems and accountability

Attention to the improvement of safety in healthcare lately has focused on healthcare-associated infections, including many that occur in the intensive care unit, such as catheter-related bloodstream infections and ventilator-associated pneumonias. Great strides have been made in decreasing the rates of intensive care unit hospital-acquired infections in the past decade. This is attributable to a number of factors, including standardization of care, technological advances, provider payment reform, and consumer activism. Teamwork and communication remain the most important facets in patient safety. The papers in this supplement examine the roles of human factors and process engineering, survey a spectrum of infection control and safety challenges encountered by critical care practitioners, and assess the future challenges for continued improvement in our systems of care.