Risk factors for transmission of carbapenem-resistant Enterobacterales to healthcare personnel gloves and gowns in the USA

BACKGROUND

Hospitals are sources for acquisition of carbapenem-resistant Entero-bacterales (CRE), and it is believed that the contamination of healthcare personnel (HCP) hands and clothing play a major role in patient-to-patient transmission of antibiotic-resistant bacteria.

AIM

The aim of this study was to determine which HCP types, HCP-patient interactions, and patient characteristics are associated with greater transmission of CRE to HCP gloves and gowns in the hospital.

METHODS

This was a prospective observational cohort study that enrolled patients with recent surveillance or clinical cultures positive for CRE at five hospitals in four states in the USA. HCP gloves and gown were cultured after patient care. Samples were also obtained from patients' stool, perianal area, and skin of the chest and arm to assess bacterial burden.

FINDINGS

Among 313 CRE-colonized patients and 3070 glove and gown cultures obtained after patient care, HCP gloves and gowns were found to be contaminated with CRE 7.9% and 4.3% of the time, respectively. Contamination of either gloves or gowns occurred in 10.0% of interactions. Contamination was highest (15.3%) among respiratory therapists (odds ratio: 3.79; 95% confidence interval: 1.61-8.94) and when any HCP touched the patient (1.52; 1.10-2.12). Associations were also found between CRE transmission to HCP gloves or gown and: being in the intensive care unit, having a positive clinical culture, and increasing bacterial burden on the patient.

CONCLUSION

CRE transmission to HCP gloves and gown occurred frequently. These findings may inform evidence-based policies about what situations and for which patients contact precautions are most important.

Infection control and tuberculosis in health care workers: an assessment of 28 hospitals in South Africa

SETTING

Twenty-eight public hospitals in the Free State Province, South Africa.

OBJECTIVE

To examine the association between tuberculosis (TB) infection control (IC) scores in Free State hospitals and the incidence of TB disease among health care workers (HCWs) in 2012.

DESIGN

A cross-sectional survey and mixed-methods analysis of TB IC policies, practices and infrastructure using a comprehensive, 83-item IC audit and observation tool.

RESULTS

As the total IC score increased, the probability of TB in an HCW at that hospital decreased. When adjusted for other covariates in multivariate analysis, if the total score of a hospital increased by one unit, the odds of an HCW having TB decreased by 4.9% (95%CI 0.9-8.8). Significant associations were also seen for the personal protective equipment (PPE) score, where odds decreased by 11.5% (95%CI 1.8-20.1) for each unit increase in score. Administrative score, environmental score and miscellaneous score were not statistically significant in the multivariate model.

CONCLUSIONS

These findings reaffirm that overall IC and PPE are essential to protect HCWs from acquiring TB. More attention to TB IC is required to protect the health care workforce and to stop the South African TB epidemic.

Occupational tuberculosis in South Africa: are health care workers adequately protected?

Setting: A provincial tertiary hospital in Gauteng province, South Africa, with a high burden of tuberculosis (TB) patients and high risk of TB exposure among health care workers (HCWs). Objective: To determine HCWs' adherence to recommended TB infection prevention and control practices, TB training and access to health services and HCW TB rates. Design: Interviews with 285 HCWs using a structured questionnaire as part of a large, international mixed-methods study. Results: Despite 10 HCWs (including seven support HCWs) acquiring clinical TB during their period of employment, 62.8% of interviewees were unaware of the hospital's TB management protocol. Receipt of training was low (34.5% of all HCWs and <5% of support HCWs trained on TB transmission; 27.5% of nurses trained on respirator use), as was use of respiratory protection (44.5% of HCWs trained on managing TB patients). Support HCWs were over 36 times more likely to use respiratory protection if trained; nurses who were trained were approximately 40 times more likely to use respirators if they were readily available. Conclusion: Improved coordination and uptake of TB infection prevention training is urgently needed, especially for non-clinical HCWs in settings of regular exposure to TB patients. Adequate supplies of appropriate respiratory protection must be made available.

Considerations for preparing a randomized population health intervention trial: lessons from a South African-Canadian partnership to improve the health of health workers

Background

Community-based cluster-randomized controlled trials (RCTs) are increasingly being conducted to address pressing global health concerns. Preparations for clinical trials are well-described, as are the steps for multi-component health service trials. However, guidance is lacking for addressing the ethical and logistic challenges in (cluster) RCTs of population health interventions in low- and middle-income countries.

Objective

We aimed to identify the factors that population health researchers must explicitly consider when planning RCTs within North–South partnerships.

Design

We reviewed our experiences and identified key ethical and logistic issues encountered during the pre-trial phase of a recently implemented RCT. This trial aimed to improve tuberculosis (TB) and Human Immunodeficiency Virus (HIV) prevention and care for health workers by enhancing workplace assessment capability, addressing concerns about confidentiality and stigma, and providing onsite counseling, testing, and treatment. An iterative framework was used to synthesize this analysis with lessons taken from other studies.

Results

The checklist of critical factors was grouped into eight categories: 1) Building trust and shared ownership; 2) Conducting feasibility studies throughout the process; 3) Building capacity; 4) Creating an appropriate information system; 5) Conducting pilot studies; 6) Securing stakeholder support, with a view to scale-up; 7) Continuously refining methodological rigor; and 8) Explicitly addressing all ethical issues both at the start and continuously as they arise.

Conclusion

Researchers should allow for the significant investment of time and resources required for successful implementation of population health RCTs within North–South collaborations, recognize the iterative nature of the process, and be prepared to revise protocols as challenges emerge.