Infection control policies and hospital-associated infections among surgical patients: variability and associations in a multicenter pediatric setting

Surveillance of Microbiological Environment of Operation Theaters

Introduction

Control of infections in the operation theater (OT) is of utmost importance. Microbiological surveillance is an effective tool for identifying and controlling infections. The purpose of this study was to investigate the prevalence rate of microorganisms in OTs, to identify the type of microorganisms, and to detect contamination of various surfaces and air of OT.

Methods

OTs were properly cleaned with soap and water. All surfaces were disinfected, followed by fumigation with quaternary ammonium compounds. OTs were kept closed overnight. In the morning, they were opened, and samples were collected, taking all aseptic precautions. The settle plate method was used for air sampling, and the swab method was used for surface sampling. Samples were collected from four surfaces of OTs, i.e., floor, wall, table, and light, and samples of the OT air were also collected and immediately transported to the microbiology laboratory of the institution in sterile conditions.

Result

A total of 1640 swab samples were taken from eight OTs, out of which 487 (29.7%) were found positive for bacterial growth. Most of them were non-pathological microorganisms such as aerobic spore-forming Bacilli and Micrococcus. Among various OTs, septic OT showed the highest bacterial growth (82 positive cultures out of 200). In the surface sampling of various OTs, aerobic spore-forming Bacilli (221/487) was the most common isolate, followed by coagulase-negative Staphylococci (74/487), and Micrococcus (67/487). General surgery, septic, and emergency OTs had maximum air bioload (97, 93, and 91 colony-forming unit (CFU)/M³, respectively).

Conclusion

In surface sampling of OTs, it was found that septic OT and general surgery OT were most contaminated where the patient load was high. Among all the surfaces, OT walls and tables were most contaminated with pathogenic microorganisms. The average air bioload of all OTs was ranged between 79 and 97 CFU/M³.

Molecular Characterization of Isolated Multidrug-Resistant Bacteria from Tertiary Care Hospitals of Ahmedabad: A Comparison Study Between Previous to COVID-19 and Current Scenario

Hospital Acquired Infections (HAIs) are a significant concern for healthcare setups, as it increases the overall cost of treatment, patients stay in hospitals, making them susceptible to secondary and tertiary infections and, sometimes, mortality1. To prevent or control HAIs, evaluating the organisms isolated from the critically maintained areas is considered of epitome importance and everlasting practice in the healthcare industry. Identifying such organisms and screening them for antibiotic resistance is mandatory, but it also helps professionals understand colonization trends. Sensitive areas of healthcare setups were screened monthly from years 2017 to 2020. A total of 4400 samples of hospital hygiene, e.g., intravenous drip stands, ventilator surface, anesthetist’s trolley, patient’s bed, instrument trolley, etcetera, were collected. Isolated organisms were cultured and screened using the CLSI technique. E. coli, Pseudomonas spp., and Klebsiella spp. were found in both previous to COVID current samples. Multidrug-resistant organisms were subjected to molecular characterization to detect the presence of carbapenem genes. Evaluation data of both pre-and during Coronavirus Disease or COVID-19 were compared. The prevalence of pathogenic (Klebsiella spp., E. coli, and Pseudomonas spp.) and non-pathogenic (Staphylococcus aureus and Bacillus spp.) strains in healthcare setups decreased drastically (Klebsiella spp. from 80% to 20%, E.coli from 90% to 10% and Pseudomonas spp. from 80% to 20%). It is possible only because of the awareness in non-specialists and healthcare workers due to the unforeseen critical situation proving to be a blessing for the future generation.

Evaluation of the Efficacy of Alcohol-Based Hand Sanitizers Sold in Southwest Ethiopia

Background

Regarding the protection of community and health professionals suffering from a COVID-19 outbreak, currently different alcohol-based hand sanitizers have been distributed. Even though for effective protection effective alcohol-based hand sanitizers are mandatory. Their efficacy was not evaluated. This is the reason why this research was designed to assess the antimicrobial efficacy of hand sanitizers that have been sold in southern parts of Ethiopia.

Methods

Six test organisms (Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Salmonella typhimurium and Shigella boydii) were selected from different clinical specimens. Then seven locally made products of alcohol-based hand sanitizers (MTU, Folium Fine, Epharm, Harego, Taflen and Sheba) were purchased and the disc diffusion, minimum inhibition concentration and minimum bactericidal concentration test were done against selected test organisms. Quality control measures throughout the whole process of the laboratory work were implemented and descriptive parameters were analyzed.

Results

The zones of inhibition of the hand sanitizers at their claim concentration were ranged from noninhibition zone (Folium) to 27mm (Sheba). The minimum inhibitory concentration against all selected test organisms was observed at 45%, 55%, 65% and Taflen on undiluted form. The growth of test organisms was decreased across increasing the concentration gradient of different hand sanitizers. MTU except against E. coli, Fine, Hargo, Ephra and Sheba hand sanitizers were showed growth below 60% concentrations for all test micro-organisms. But a Folium product against all selected test micro-organisms and MTU product against E. coli were not bactericidal.

Conclusion

Fine, Hargo, Ephra, Sheba and Taflen sanitizers were the products that were effective in inhibiting the growth of all the selected test organisms, and they were having effective bactericidal activity in vitro at their claim concentration. But MTU product against E. coli and Folium product against all test microorganisms were not having an effective bactericidal activity. So, regulatory authorities and manufacturers should implement strict quality control measures and regular observations throughout the production to ensure the efficacy of hand sanitizers.

Microbiological Surveillance of Operation Theatres: Five Year Retrospective Analysis from a Tertiary Care Hospital in North India

Introduction:

Microbiological contamination of air and environment in the operation theaters (OTs) are major risk factor for surgical site and other hospital-associated infections.

Objectives:

The aim was to identify bacterial colonization of surfaces and equipment and to determine the microbial contamination of air in the OTs of a tertiary care hospital.

Materials and Methods:

Five years (January 2010–December 2014) retrospective analysis of the data obtained from routine microbiological surveillance of the five OTs of the hospital was done. Surface samples were taken with wet swabs from different sites and equipment. Bacterial species were isolated and identified by conventional methods. Air quality surveillance of OTs was done by settle plate method.

Results:

A total of 4387 samples were collected from surfaces and articles of various OTs. Out of these only 195 (4.4%), samples showed bacterial growth and yielded 210 isolates. The predominant species isolated was Bacillus with 184 (87.6%) isolates followed by coagulase-negative Staphylococcus 17 (8.1%), Staphylococcus aureus 6 (2.9%), and Enteroccoccus spp. 3 (1.4%). Analysis of the OT air samples showed least colony forming unit (cfu) rate of air (27 cfu/m³) in ophthalmology OT and highest rate of 133 cfu/m³ in general surgery OT.

Conclusion:

The study shows that OTs of our hospital showed a very low bacterial contamination rate on surface swabbing and a cfu count per m³ of air well within permissible limits.

Update on infection control challenges in special pediatric populations

PURPOSE OF REVIEW

Compared with adults, neonatal and pediatric populations are especially vulnerable patients who have specific diagnostic and therapeutic differences; therefore, the standard infection control practices designed for adults are sometimes not effective or need modifications to work. This review focuses on the recent literature addressing the challenges and successes in preventing healthcare-associated infections (HAIs) in children.

RECENT FINDINGS

Improving the implementation of pediatric versions of preventive bundles focusing on proper catheter insertion and maintenance, mainly as a part of a larger multimodal strategy, is effective in reducing the central-line-associated bloodstream infections in neonatal and pediatric populations including oncology patients. Appropriate feeding, antimicrobial stewardship, and infection control measures should be combined in reducing necrotizing enterocolitis in preterm neonates. Implementing a multimodal bundle strategy adapted for pediatric population is successful in preventing ventilator-associated pneumonia. Appropriate use of antimicrobial prophylaxis remains the cornerstone for preventing surgical-site infections irrespective of age, with few additional effective adjuvant preventive practices in specific pediatric patients.

SUMMARY

Several evidence-based practices are effective in reducing the incidence and the impact of HAIs in children; however, proper implementation remains a challenge. Additionally, several adult preventive practices are still unestablished in children and need further thorough examination.

Cumulative incidence of outcomes and urologic procedures after augmentation cystoplasty

OBJECTIVE

Augmentation cystoplasty (AC) is a major surgery that can be associated with long-term morbidity. This study aimed to describe the cumulative incidence of outcomes and urologic procedures in a large cohort of children who underwent AC, identify significant sources of morbidity, and to evaluate baseline factors associated with outcomes of interest.

METHODS

Children≤18 years who underwent AC in the Pediatric Health Information System from 1999 to 2010 were included. All follow-up encounters up to June 2012 were included. Cumulative incidences for 15 outcomes and urologic procedures were calculated using non-informative censoring. Sensitivity analyses were performed to determine effect of censoring assumptions and including hospitals without complete datasets. As an exploratory analysis, baseline patient factors were evaluated for associations with outcomes and urologic procedures of interest using multivariable Cox proportional hazards models adjusted for clustering by hospital.

RESULTS

2831 AC patients were identified. Based on cumulative incidence calculations and sensitivity analyses; the cumulative incidence ranges of outcomes and procedures at 1, 3, 5, and 10 years were calculated. Examples of 10-year cumulative incidence ranges are given for the following outcomes and procedures: bladder rupture (2.9-6.4%), small bowel obstruction (5.2-10.3%), bladder stones (13.3-36.0%), pyelonephritis (16.1-37.1%), cystolithopaxy (13.3-35.1%), and reaugmentation (5.2-13.4%). The development of chronic kidney disease was strongly associated with a diagnosis of lower urinary tract obstruction (HR 13.7; 95% CI 9.4-19.9). Bladder neck surgery and stoma creation at time of AC were associated with an increased hazard of bladder rupture (HR 1.9; 95% CI 1.1-3.3) and bladder stones (HR 1.4; 95% CI 1.1-1.8) respectively.

CONCLUSIONS

Outcomes of interest and urologic procedures after AC are common. Results from this large cohort can be used to counsel patients and families about expectations after AC. Pyelonephritis, chronic kidney disease, further reconstructive surgery, and calculus disease appear to cause significant morbidity. Collaborative efforts are needed to further reduce morbidity in this patient population.

Variability in spinal surgery outcomes among children's hospitals in the United States

BACKGROUND

We performed a retrospective cohort study of 7637 spinal fusion surgical cases from 2004 to 2006 at 38 children's hospitals participating in the Pediatric Health Information System database to evaluate the variability of in-hospital outcomes by patient factors and between facilities in children who underwent spinal surgery.

METHODS

Outcomes were stratified by whether children did or did not have neurological impairment. Multilevel multivariate logistic regression models were used to determine patient and hospital factors associated with in-hospital infections, surgical complications, and length of stay (LOS)≥10 days.

RESULTS

Neurologically impaired (NI) children (N=2117 out of 7637) represented 28% of the cases. The interhospital interquartile range of LOS for NI children was 6 to 8 days (median 7 d) and for non-neurologically impaired (NNI) children was 5 to 6 days (median 5 d). Children with NI had roughly 6 times higher rates of in-hospital infection and 3 times higher complication rates: major interhospital variation was seen for both of these outcomes. Hospital rates of infection ranged from 0% to 27% (median 10%) for NI and from 0% to 14% (median 2%) for NNI children. Complication rates ranged from 0% to 89% (median 33%) for NI and from 3% to 68% (median 9%) for NNI children. The following factors were associated with a LOS≥10 days: in-hospital infection (P<0.0001), surgical complication (P<0.0001), and anterior/posterior versus posterior-only surgery (P<0.0001). Hospital case volume was not associated with infection, surgical complication, or LOS≥10 days.

CONCLUSIONS

Substantial variation exists in reported outcomes for children undergoing spinal surgery in children's hospitals within the United States. Further study is needed to characterize hospital-level factors related to surgical outcome to direct future quality improvement.

Hand hygiene compliance by physicians: marked heterogeneity due to local culture?

BACKGROUND

Physician compliance with hand hygiene guidelines often has been reported as insufficient.

METHODS

The study was conducted in 2 hospitals (Hadassah Ein Kerem [EK] and Mt Scopus [MS]) in Jerusalem, Israel. Covert observations were conducted during morning rounds by trained observers. The data were recorded as the percentage of times that hand hygiene was applied out of the total contacts with patients. After the observational step, an intervention-providing an alcohol gel and encouraging its use-was instituted in several wards.

RESULTS

Physicians' compliance with hand hygiene averaged 77% at MS and 33% at EK (P < .001), and was characterized by a marked additional heterogeneity among wards. Rates of adherence ranged from as low as 4% in a gynecology ward to as high as 96% in a neonatal unit. Availability of a handwashing basin in the room and seniority status of the physician were associated with higher compliance rates but explained only a small part of the variation. Compliance improved significantly in 2 wards exposed to the intervention.

CONCLUSION

The remarkable heterogeneity in physicians' hand hygiene compliance among sites within the same institution is consistent with an important role of the local ward culture.

An integrative review of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections

BACKGROUND

The objectives of this integrative review were to critically examine the overall state of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections (HCAIs) in acute care and long-term care settings, and offer recommendations for future directions in the field based on our findings.

METHODS

We searched for original research and reviews of research published between January 1, 1996, and July 31, 2006. Studies were identified through the electronic databases Medline, CINAHL, EMBASE, PUBMED, the Cochrane Library, and through expert consultation. Our comprehensive search strategy included all English articles for which hand hygiene or handwashing-related terms were combined with HCAIs. All studies that investigated a relationship between hand hygiene practices and HCAIs in acute care facilities were considered. These hand hygiene practices included the initiation of multimodal hand hygiene initiatives, the introduction of alcohol sanitizers, the implementation or changes of the infection control practices or infection control policies, and other organizational interventions. Studies only examining hand hygiene compliance, efficacy of alcohol hand gels, plain soap, and antimicrobial soap in reducing bacteria count recovered from hands were excluded.

RESULTS

Of the 1120 articles retrieved, 35 publications, including 4 reviews of research discussed at the outset of this article, met our inclusion criteria. The remaining 31 eligible original studies included 18 (58.07%) before and after studies without control groups, 4 (12.90%) before and after studies with a control group, 3 (9.68%) cohort studies with no control group, 4 (12.90%) cohort studies with a control group, and 2 (6.45%) randomized trials. Over 50% (16 or 31) of the studies were conducted in the U.S. Two independent reviewers conducted independent evaluations of all eligible studies, critiquing and scoring each study using a rating scale for examining the fatal flaws of quasi-experimental and before and after studies.

CONCLUSIONS

There is a lack of rigorous evidence linking specific hand hygiene interventions with the prevention of HCAIs. The varied nature of the interventions used and the diverse factors affecting the acquisition of HCAIs make it difficult to show the specific effect of hand hygiene alone. The most frequent methodologies currently used in this research area are before and after observational studies without a control comparison group. Based on these findings, we recommend that researchers used a modified version of Larson's 2005 criteria to guide the design and conduct of future before and after observational studies in this area. We also argue that as we accumulate stronger evidence of which interventions are most effective, we need to develop additional research approaches to study how organizations succeed and fail in fostering the uptake of evidence-based hand hygiene interventions.