Evidence-Based Infection Control In Clinical Practice: If You Buy Clothes for the Emperor, Will He Wear Them?

Antimicrobial resistance and self-reported hand hygiene awareness before and after an infection prevention and control programme: A 7-year analysis in a small animal veterinary teaching hospital

Infection prevention and control (IPC) in veterinary medicine is crucial to protect patients, owners, staff, and the public. An IPC programme is recommended for every animal hospital. The objective of this retrospective longitudinal study was to describe the changes in bacterial and multidrug-resistant (MDR) bacterial isolates and self-reported hand hygiene awareness and practices after an IPC programme to assess the long-term effect of this programme in small animal veterinary medicine. The IPC programme was implemented at our veterinary teaching hospital in April 2018, which included the establishment of an infection control task force, regular IPC lectures and poster campaigns, infrastructure improvement, and manual refinement. Laboratory-based surveillance was retrospectively conducted before and after the programme (January 2016-December 2022). Level and slope changes in bacterial isolates were evaluated using interrupted time-series analysis. Self-reported hand hygiene awareness and practices were assessed using an annual questionnaire. Additionally, hygiene product purchases during the study period were investigated. The monthly number of total and MDR bacterial isolates decreased significantly after the programme (MDR level change: -0.426; 95% confidence interval: -0.744, -0.109; P = 0.009; and MDR slope change: -0.035; 95% confidence interval: -0.058, -0.011; P = 0.003). Additionally, awareness of hand hygiene before touching animals improved after the programme. Overall self-reported hand hygiene practices improved, and hygiene product purchases significantly increased. These results suggested that the IPC programme may have long-term effects regarding reducing total and MDR bacterial isolates and improving hand hygiene awareness in veterinary medicine.

Antimicrobial Resistance and Extended-Spectrum Beta-Lactamase Genes in Enterobacterales, Pseudomonas and Acinetobacter Isolates from the Uterus of Healthy Mares

Antibiotic-resistant bacteria are a growing concern for human and animal health. The objective of this study was to determine the antimicrobial resistance and extended-spectrum beta-lactamase genes in Enterobacterales, Pseudomonas spp. and Acinetobacter spp. isolates from the uterus of healthy mares. For this purpose, 21 mares were swabbed for samples, which were later seeded on blood agar and MacConkey agar. The isolates were identified using MALDI-TOF and the antimicrobial susceptibility test was performed using the Kirby-Bauer technique. To characterize the resistance genes, a polymerase chain reaction (PCR) scheme was performed. Of the isolates identified as Gram-negative, 68.8% were Enterobacterales, represented by E. coli, Enterobacter cloacae, Citrobacter spp., and Klebsiella pneumoniae; 28.1% belonged to the genus Acinetobacter spp.; and 3.1% to Pseudomonas aeruginosa. A 9.3% of the isolates were multidrug-resistant (MDR), presenting resistance to antibiotics from three different classes, while 18.8% presented resistance to two or more classes of different antibiotics. The diversity of three genes that code for ESBL (blaTEM, blaCTX-M and blaSHV) was detected in 12.5% of the strains. The most frequent was blaSHV, while blaTEM and blaCTX-M were present in Citrobacter spp. and Klebsiella pneumoniae. These results are an alarm call for veterinarians and their environment and suggest taking measures to prevent the spread of these microorganisms.

[Management and hygiene measures during an outbreak of herpes, influenza, strangles or infections with multidrug resistant bacteria]

The aim of this review is to describe general guidelines of hygiene measures in the horse stable as well as to provide current recommendations for an outbreak of a common infectious disease. General cleanliness, hand hygiene, avoidance of stress, regular deworming, and vaccinations belong to the basic hygiene measures in a horse herd. All new or returning equids should be submitted to a quarantine period as an important prevention measure. Repeated washing and disinfection of hands may prevent spreading of infectious agents to people and horses.The conception of a hygiene plan, including general biosecurity procedures and standard operating procedures in a case of an outbreak of an infectious disease, zoonosis, or colonization with multi-resistant bacteria is strongly recommended. As soon as the disease is suspected, extended hygiene measures including protective clothing, cleaning, disinfection, and isolation of potentially infected animals should be implemented. Prompt confirmation of the causative agent by examination of appropriate samples is crucial. It is important to adjust all safety measures based on the contagious nature of the respective pathogen and its major transmission routes. Apart from a lock-down of the stable, clinic or show grounds, the segregation of horses plays an important role. Implementation of the "traffic light system" is recommended. In this, the red group ("infected") include animals with clinical signs of the disease or that have been tested positive. All horses with possible pathogen contact should be allocated to a yellow group ("suspected") and regularly controlled for the signs of infection and fever. Clinically normal horses without contact to the infected animals belong to the green group ("healthy"). A change of protective clothing and an extensive disinfection should be performed when moving between the groups.The extended hygiene measures are to be maintained until all animals have been tested negative or fail to exhibit clinical signs of the disease for a certain time period.

Long-lasting nosocomial persistence of chlorhexidine-resistant Serratia marcescens in a veterinary hospital

Healthcare-associated infections (HAIs) are often overlooked in veterinary medicine. Serratia marcescens isolates were recovered over a ten-year period from companion animals in a French veterinary hospital. The pets were sampled either for diagnostic purposes or to monitor colonization. A retrospective study showed that 32 S. marcescens isolates were identified as HAI cases and a further 22 cases were associated with colonization of the surgical site. Two S. marcescens lineages were responsible for two different outbreaks during the study period. Chlorhexidine solution (1%) used to impregnate gauze was found to be the source of the second S. marcescens outbreak and all isolates had high MIC values for chlorhexidine (MIC = 128 mg/L). This study reports, for the first time to our knowledge, the nosocomial spread of chlorhexidine-resistant S. marcescens in a veterinary setting and highlights consequences of the improper use of disinfectants.

Infection control practices employed within small animal veterinary practices-A systematic review

Effective infection control (IC) provides a safe environment for staff, clients and animals of veterinary practices by reducing the risk of nosocomial and zoonotic infections, which are associated with increased hospital stays, costs, morbidity and mortality. An equally important issue arising from nosocomial infection is the loss of trust between the client and the veterinary practice that has potential negative impacts on the veterinary practice in terms of economic risk and the well-being of staff. Furthermore, an emerging and significant threat, in this context, is antimicrobial resistance. The aim of this systematic review was to critically review published reports that documented current IC practices and evaluated interventions to improve IC practices. A systematic literature search using ten databases to identify papers published over a 20-year period (February 1996 to February 2016) was conducted for studies that met the inclusion criteria. Included studies were assessed using the PRISMA and STROBE-Vet statements. A total of 14 of 1,615 identified studies met our inclusion criteria. Infection control practices included hand hygiene, sharps handling, environmental cleaning, personal protective equipment and personnel vaccination. Descriptive studies were the predominant research design for assessing IC compliance. Only three studies were interventions. Compliance with IC protocols was poor and only marginally increased with multimodal educational campaigns. There was significant variation in the implementation of IC by veterinary staff. Workplaces that had IC policies, management support and a staff member supporting their implementation were more likely to embrace good IC. Infection control data in veterinary practices were inconsistently reported and collected. Clearly defining IC and determining prevalence of these practices within the veterinary field is important given the limited research in this area. Further, developing and implementing educational campaigns for this sector is needed.

Extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Acinetobacter baumannii among horses entering a veterinary teaching hospital: The contemporary "Trojan Horse"

Pathogens frequently associated with multi-drug resistant (MDR) phenotypes, including extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae (ESBL-E) and Acinetobacter baumannii isolated from horses admitted to horse clinics, pose a risk for animal patients and personnel in horse clinics. To estimate current rates of colonization, a total of 341 equine patients were screened for carriage of zoonotic indicator pathogens at hospital admission. Horses showing clinical signs associated with colic (n = 233) or open wounds (n = 108) were selected for microbiological examination of nostril swabs, faecal samples and wound swabs taken from the open wound group. The results showed alarming carriage rates of Gram-negative MDR pathogens in equine patients: 10.7% (34 of 318) of validated faecal specimens were positive for ESBL-E (94%: ESBL-producing Escherichia coli), with recorded rates of 10.5% for the colic and 11% for the open wound group. 92.7% of the ESBL-producing E. coli were phenotypically resistant to three or more classes of antimicrobials. A. baumannii was rarely detected (0.9%), and all faecal samples investigated were negative for Salmonella, both directly and after two enrichment steps. Screening results for the equine nostril swabs showed detection rates for ESBL-E of 3.4% among colic patients and 0.9% in the open wound group, with an average rate of 2.6% (9/340) for both indications. For all 41 ESBL-producing E. coli isolated, a broad heterogeneity was revealed using pulsed-field gel electrophoresis (PFGE) patterns and whole genome sequencing (WGS) -analysis. However, a predominance of sequence type complex (STC)10 and STC1250 was observed, including several novel STs. The most common genes associated with ESBL-production were identified as bla_CTX-M-1 (31/41; 75.6%) and bla_SHV-12 (24.4%).

The results of this study reveal a disturbingly large fraction of multi-drug resistant and ESBL-producing E. coli among equine patients, posing a clear threat to established hygiene management systems and work-place safety of veterinary staff in horse clinics.

Multi-drug-resistant Acinetobacter calcoaceticus-Acinetobacter baumannii complex infection outbreak in dogs and cats in a veterinary hospital

BACKGROUND

Members of the Acinetobacter calcoaceticus-Acinetobacter baumannii complex cause severe outbreaks in humans, and are increasingly reported in animals.

OBJECTIVE AND METHODS

A retrospective study, describing a severe outbreak in dogs and cats caused by a multidrug resistant member of the Acinetobacter calcoaceticus-Acinetobacter baumannii complex in a veterinary hospital, between July 2010 and November 2012.

RESULTS

The study included 19 dogs and 4 cats. Acinetobacter calcoaceticus-Acinetobacter baumannii complex bacteria were isolated from urine (9 animals), respiratory tract (11), tissues (3) and blood (1). The most common infection-associated findings included fever, purulent discharge from endotracheal tubes, hypotension, and neutropaenia. Infections led to pneumonia, urinary tract infection, cellulitis and sepsis. Infection was transmitted in the intensive care unit, where 22 of 23 animals were initially hospitalised. The mortality rate was 70% (16 of 23 animals), and was higher in cases of respiratory infection compared to other infections. Aggressive environmental cleaning and disinfection, with staff education for personal hygiene and antisepsis, sharply decreased the infection incidence.

CLINICAL SIGNIFICANCE

Health care-associated outbreaks with multidrug resistant Acinetobacter calcoaceticus-Acinetobacter baumannii complex in dogs and cats are potentially highly fatal and difficult to eradicate, warranting monitoring, antiseptic techniques and judicious antibiotic use.

Patient management

Hospital-associated infections, including those caused by zoonotic agents, represent an increasing concern in veterinary practice. Veterinarians and hospital staff are obligated and expected to provide education about and protection from transmission of pathogens among animal patients and between animal patients and human beings (eg, veterinary staff, volunteers, owners) who come into contact with infected animals. Patient management involves assessing risks of pathogen transmission, identification of animals either suspected of or proved to be infected with a transmissible infectious disease agent, and the implementation of measures that minimize the likelihood of transmission of the infectious agent.

Fighting surgical site infections in small animals: are we getting anywhere?

A diverse array of pathogen-related, patient-related, and caretaker-related issues influence risk and prevention of surgical site infections (SSIs). The entire surgical team involved in health care settings in which surgical procedures are performed play a pivotal role in the prevention of SSIs. In this article, current knowledge of SSI risk factors and prevention methods is reviewed. Although new avenues that can be explored in the prevention of SSIs in veterinary medicine are described, the main conclusion drawn is that the best method for prevention of SSI is to adhere to what we already know.

Veterinary hospital surveillance systems

We cannot manage what we do not measure. In order to provide optimal patient care appropriate effort must be given to the prevention of infectious disease transmission through the development and maintenance of an infection control program that is founded on results obtained through organized surveillance efforts. Every facility is unique - thus efforts should be tailored to distinctive physical attributes and organizational limitations of individual practices. There is not only an ethical responsibility to do so, but there is a legal responsibility to meet the minimum standard of practice with respect to veterinary infection prevention and control.

A pre- and post-intervention study of infection control in equine hospitals in Sweden

Background

Detection of nosocomial methicillin-resistant Staphylococcus aureus infections in horses in Sweden has increased attention on infection control (IC) in equine hospitals. This study established baseline data on IC programmes within such settings, evaluated compliance with some IC procedures before and after an education intervention, and examined barriers to compliance.

The study was carried out between 2008 and 2011 in four Swedish equine hospitals. Data on current IC of each hospital, purchase data on hand sanitisers and disposable gloves per patient, and direct observations of compliance with procedures were monitored pre- and post-intervention. The intervention comprised a lecture on common IC and a review of each hospital’s current procedures. For comparison, retrospective purchase data were reviewed. A questionnaire on individual compliance, experiences and opinions of IC was issued to employees.

Results

Three hospitals completed the study, while the fourth reported its IC procedures and completed the questionnaire. Actual numbers of procedures, content and level of documentation differed among the hospitals. Similarities were poor or absent IC implementation strategy, lack of active surveillance of compliance with procedures and no monitoring of such as nosocomial infections. Among the hospitals which completed the study, two reported pre-intervention observation of compliance, while all three reported post-intervention observations. The purchase data showed trends for changes over time, although not uniformly related to the intervention. One hospital demonstrated a significant post-intervention increase in compliance with glove procedures, accompanied by a non-significant post-intervention increase in purchases figures. Compliance with dress code and personal appearance was high in all three hospitals (92-100%), while compliance with hand hygiene procedures was generally poorer. Barriers to compliance cited in the questionnaire (data from four hospitals) included insufficient supplies of hygiene products, lack of readily accessible places for cleaning, insufficient knowledge and high workload.

Conclusions

Potential for easily attainable improvements in IC, such as traceability of documents, implementation strategies and surveillance of efficacy, was revealed. Attention to hand hygiene implementation and improvement of logistics appeared important. Data on purchases per patient were readily available and therefore applicable for intra-hospital surveillance of IC trends over time.

Infection control in equine critical care settings

There is a recognizable standard of practice for infection control in veterinary medicine. Effort must be given to control and prevention of infectious disease transmission within a facility and among animal populations. In the critical care setting, patients typically have a high degree of systemic illness and immune compromise, are commonly subjected to invasive procedures and placement of indwelling devices, and frequently receive antimicrobials and gastric protectants. Every equine critical care unit is distinctive in its physical and operational features and the types of patients that are managed. Infection control programs must therefore be tailored to each facility's needs.