Improving hospital hygiene to reduce the impact of multidrug-resistant organisms in health care--a prospective controlled multicenter study

Pathogens and Shift of Resistance in Early Infections after Operative Fracture Fixation

Background: Surgical site infections (SSIs) remain a challenge for the healthcare system. During the last 30 years, the literature has shown an increase of gram-negative bacterial strains in multiple infectious sites and that cephalosporins have replaced penicillin as the gold standard in peri-operative antibiotic prophylaxis. This study aims to examine the recent bacterial spectrum in orthopedic early SSIs and to compare it with a historical cohort. Patients and Methods: Patients in a level 1 trauma center with an SSI within six weeks after open fixation of a fracture were analyzed in two adjacent periods from 2007 to 2012 (data pool 1; DP1) and 2013 to 2017 (data pool 2; DP2), retrospectively. The detected microbiologic pathogens and the associated resistograms from both time periods were compared. Results: Six hundred eighty-one smear tests and respective pathogens from the wounds of 463 patients (mean age, 62.6 ± 20 years) with SSIs were analyzed. The following pathogens were found most frequent: Staphylococcus epidermidis (DP1, 20.6%; DP2, 26.3%), Staphylococcus aureus (DP1, 27.1%; DP2, 16.5%), Enterococcus faecalis (DP1, 13.7%; DP2, 11.1%), Bacillus sp. (DP1, 3.0%; DP2, 5.3%), Escherichia coli (DP1, 5.1%; DP2, 4.1%), Pseudomonas aeruginosa (DP1, 3.7%; DP2, 2.5%). In DP2, there were lower primary early infection rates with Staphylococcus aureus than in DP1 (p = 0.002). In DP2, Staphylococcus epidermidis showed an oxacillin resistance in 90.6% and an increased resistance (79.8%; p = 0.069) to several classes of antibiotic agents compared to DP1. Conclusions: No bacterial shift toward gram-negative species was observed in this investigation. However, Staphylococcus epidermidis showed an increased antibiotic resistance in the more recent patient cohort. The incidence of SSIs with Staphylococcus aureus decreased substantially.

How is the Theoretical Domains Framework applied in designing interventions to support healthcare practitioner behaviour change? A systematic review

BACKGROUND

The use of theory is recommended to support interventions to promote implementation of evidence-based practices. However, there are multiple models of behaviour change which can be complex and lack comprehensiveness and are therefore difficult to understand and operationalize. The Theoretical Domains Framework sought to address these problems by synthesizing 33 models of behaviour or behaviour change. Given that it is 15 years since the first publication of the Theoretical Domains Framework (TDF), it is timely to reflect on how the framework has been applied in practice.

OBJECTIVE

The objective of this review is to identify and narratively synthesize papers in which the TDF, (including frameworks that incorporate the TDF) have been used have been used to develop implementation interventions.

METHODS

We searched MEDLINE, PsychINFO, CINAHL and the Cochrane databases using the terms: 'theoretical domains framework*' or TDF or Capability, Opportunity, Motivation to Behaviour (COM-B) or 'behav* change wheel' or 'BCW' AND implement* or improv* or quality or guideline* or intervention* or practice* or EBP or 'evidence based practice' and conducted citation and key author searches. The included papers were those that used any version of the TDF published from 2005 onwards. The included papers were subject to narrative synthesis.

RESULTS

A total of 3540 papers were identified and 60 were included. Thirty-two papers reported intervention design only and 28 reported intervention design and testing. Despite over 3000 citations there has been limited application to the point of designing interventions to support the best practice. In particular use of the framework has not been tried or tested in non-western countries and barely used in non-primary or acute care settings. Authors have applied the framework to assess barriers and facilitators successfully but reporting of the process of selection of behaviour change techniques and intervention design thereafter was variable.

CONCLUSION

Despite over three thousand citations of the framework there has been limited application to the point of designing interventions to support best practice. The framework is barely used in non-western countries or beyond primary or acute care settings. A stated purpose of the framework was to make psychological theory accessible to researchers and practitioners alike; if this is to be fully achieved, further guidance is needed on the application of the framework beyond the point of assessment of barriers and facilitators.

Spread of Multidrug-Resistant Bacteria by Moth Flies from Hospital Waste Water System

We documented and analyzed moth fly occurrence and spread of multidrug-resistant bacteria in a tertiary care hospital in Germany. The moth flies (Clogmia albipunctata) bred in the sewage system, then moved into the hospital, carrying biofilm and multidrug-resistant bacteria on their feet. Subsequently, the hospital developed a pest control protocol.

Healthcare-Associated Infections Due to Multidrug-Resistant Organisms: a Surveillance Study on Extra Hospital Stay and Direct Costs

BACKGROUND

The increasing antimicrobial resistance poses a challenge to surveillance systems and raises concerns about the impact of multidrug-resistant organisms on patient safety.

OBJECTIVE

The study aimed to estimate extra hospital stay and economic burden of infections due to alert organisms - mostly multidrug-resistant - in a teaching hospital.

METHODS

The present retrospective matched cohort study was conducted based on the analysis of hospital admissions at Sant'Andrea Teaching Hospital in Rome from April to December 2015. Extra hospital stay was the difference in the length of stay between each case and control. All the patients developing an infection due to an alert organism were considered cases, all others were eligible as controls. The costs of LOS were evaluated by multiplying the extra stay with the hospital daily cost.

RESULTS

Overall, 122 patients developed an infection due to alert organisms and were all matched with controls. The attributable extra stay was of 2,291 days (mean 18.8; median 19.0) with a significantly increased hospitalization in intensive care units (21.2 days), bloodstream infections (52.5 days), and infections due to Gram-negative bacteria (mean 29.2 days; median 32.6 days). Applying the single day hospital cost, the overall additional expenditure was 11,549 euro per patient. The average additional cost of antibiotic drugs for the treatment of infections was about 1,200 euro per patient.

CONCLUSION

The present study presents an accurate mapping of the clinical and economic impact of infections attributable to alert organisms demonstrating that infections due to multidrug-resistant organisms are associated with higher mortality, longer hospital stays, and increased costs. Article Highlights Box: The increasing antimicrobial resistance poses a challenge for surveillance systems and raises concerns about the impact of multidrug-resistant organisms on patient safety. • Healthcare-associated infections (HAIs) have historically been recognized as a significant public health problem requiring close surveillance. • Despite several and reliable findings have been achieved on clinical issues, our knowledge on the economic impact of healthcare-associated infections due to multidrug-resistant organisms needs to be widened. • Estimating the cost of infections due to multidrug-resistant organisms in terms of extra hospital stay and economic burden is complex, and the financial impact varies across different health systems. • Evaluations of social and economic implications of hospital infections play an increasingly important role in the implementation of surveillance systems. • The costs of infection prevention and control programs and dedicated personnel are relatively low and self-sustainable when efficient.

Susceptibility of livestock-associated methicillin-resistant Staphylococcus aureus (LA-MRSA) to chlorhexidine digluconate, octenidine dihydrochloride, polyhexanide, PVP-iodine and triclosan in comparison to hospital-acquired MRSA (HA-MRSA) and community-aquired MRSA (CA-MRSA): a standardized comparison

Background

Recent publications have raised concerns of reduced susceptibilities of clinical bacterial isolates towards biocides. This study presents a comparative investigation of the susceptibility of livestock-associated Methicillin-resistant Staphylococcus aureus (LA-MRSA), hospital-acquired MRSA (HA-MRSA) and community-aquired MRSA (CA-MRSA) to the commonly used antiseptics chlorhexidine (CHX), octenidine (OCT), polyhexanide (PHMB), PVP-iodine (PVP-I) and triclosan (TCX) based on internationally accepted standards.

Methods

In total, 28 (18 LA-, 5 HA- and 5 CA) genetically characterized MRSA strains representing a broad spectrum of hosts, clonal complexes and spa-types, as well as the reference methicillin-sensitive Staphylococcus aureus (MSSA) strain ATCC 6538, were selected. Minimal inhibitory concentration (MIC) and minimal microbicidal concentration (MBC) were determined in accordance with DIN 58940-7, 58940-8 and DIN EN ISO 20776-1. The microbicidal efficacy was determined in accordance with DIN EN 1040.

Results

Results from the MIC/MBC and quantitative suspension tests revealed differences between antiseptic substances but not between epidemiological groups of MRSA strains. OCT and PHMB were the most active substances with a minimal MIC of 1 mg/L, followed by CHX (2 mg/L), TCX (32 mg/L) and finally PVP-I (1024 mg/L). The MSSA reference strain showed a tendency to a higher susceptibility compared to the MRSA strains.

Conclusions

This investigation of the susceptibility of a range of LA-, HA- and CA-MRSA strains using standardized conditions gave no indication that LA-MRSA strains are less susceptible to commonly used antiseptics compared to HA- and CA-MRSA strains.

Would it be safe to have a dog in the MRI scanner before your own examination? A multicenter study to establish hygiene facts related to dogs and men

OBJECTIVES

To determine whether it would be hygienic to evaluate dogs and humans in the same MRI scanner.

METHODS

We compared the bacterial load in colony-forming units (CFU) of human-pathogenic microorganisms in specimens taken from 18 men and 30 dogs. In addition, we compared the extent of bacterial contamination of an MRI scanner shared by dogs and humans with two other MRI scanners used exclusively by humans.

RESULTS

Our study shows a significantly higher bacterial load in specimens taken from men's beards compared with dogs' fur (p = 0.036). All of the men (18/18) showed high microbial counts, whereas only 23/30 dogs had high microbial counts and 7 dogs moderate microbial counts. Furthermore, human-pathogenic microorganisms were more frequently found in human beards (7/18) than in dog fur (4/30), although this difference did not reach statistical significance (p = 0.074). More microbes were found in human oral cavities than in dog oral cavities (p < 0.001). After MRI of dogs, routine scanner disinfection was undertaken and the CFU found in specimens isolated from the MRI scanning table and receiver coils showed significantly lower bacteria count compared with "human" MRI scanners (p < 0.05).

CONCLUSION

Our study shows that bearded men harbour significantly higher burden of microbes and more human-pathogenic strains than dogs. As the MRI scanner used for both dogs and humans was routinely cleaned after animal scanning, there was substantially lower bacterial load compared with scanners used exclusively for humans.

KEY POINTS

• Bearded men harbour significantly more microbes than dogs. • Dogs are no risk to humans if they use the same MRI. • Deficits in hospital hygiene are a relevant risk for patients.

Bacterial contamination of ultrasound probes in different radiological institutions before and after specific hygiene training: do we have a general hygienical problem?

OBJECTIVES

Aim was to investigate hygienic conditions of ultrasound probes before and after hygiene training in radiology institutions in comparison to bacterial contamination in public places.

METHODS

In three radiology departments, bacterial contamination was evaluated using baseline agar plates for cultures taken from 36 ultrasound probes. Afterwards teams were trained by a hygiene service centre and 36 ultrasound probes were routinely disinfected with regular disinfecting wipes and then evaluated. In comparison, bacterial contamination in public places (bus poles, n = 11; toilet seats, n = 10) were analysed. Plates were routinely incubated and the number of colony forming units (CFU) analysed.

RESULTS

Cultures taken from the probes showed a median of 53 CFU before and 0 CFU after training (p < 0.001). Cultures taken from public places showed a median of 4 CFU from toilets and 28 from bus poles and had lower bacterial load in comparison to ultrasound probes before training (p = 0.055, toilets; p = 0.772, bus poles), without statistical significance.

CONCLUSIONS

Bacterial contamination of ultrasound probes prior to hygiene training proved to be high and showed higher bacterial load than toilets seats or bus poles. Radiologists should be aware that the lack of hygiene in the field of ultrasound diagnostics puts patients at risk of healthcare-associated infections.

KEY POINTS

• Hospital-associated infections are a problem for patient care. • Hygiene training of staff prevents bacterial contamination of ultrasound probes. • Disinfection of ultrasound probes is an easy method to protect patients.