A search strategy for detecting duodenoscope-associated infections: a retrospective observational study

BACKGROUND

Duodenoscope-associated infections (DAIs) are exogenous infections resulting from the use of contaminated duodenoscopes. Though numerous outbreaks of DAI have involved multidrug-resistant micro-organisms (MDROs), outbreaks involving non-MDROs are also likely to occur. Detection challenges arise as these infections often resolve before culture or because causative strains are not retained for comparison with duodenoscope strains.

AIM

To identify and analyse DAIs spanning a seven-year period in a tertiary care medical centre.

METHODS

This was a retrospective observational study. Duodenoscope cultures positive for gastrointestinal flora between March 2015 and September 2022 were paired with duodenoscope usage data to identify patients exposed to contaminated duodenoscopes. Analysis encompassed patients treated after a positive duodenoscope culture and those treated within the interval from a negative to a positive culture. Patient identification numbers were cross-referenced with a clinical culture database to identify patients developing infections with matching micro-organisms within one year of their procedure. A 'pair' was established upon a species-level match between duodenoscope and patient cultures. Pairs were further analysed via antibiogram comparison, and by whole-genome sequencing (WGS) to determine genetic relatedness.

FINDINGS

Sixty-eight pairs were identified; of these, 21 exhibited matching antibiograms which underwent WGS, uncovering two genetically closely related pairs categorized as DAIs. Infection onset occurred up to two months post procedure. Both causative agents were non-MDROs.

CONCLUSION

This study provides crucial insights into DAIs caused by non-MDROs and it highlights the challenge of DAI recognition in daily practice. Importantly, the delayed manifestation of the described DAIs suggests a current underestimation of DAI risk.

ICU-acquired infections in immunocompromised patients

Immunocompromised patients account for an increasing proportion of the typical intensive care unit (ICU) case-mix. Because of the increased availability of new drugs for cancer and auto-immune diseases, and improvement in the care of the most severely immunocompromised ICU patients (including those with hematologic malignancies), critically ill immunocompromised patients form a highly heterogeneous patient population. Furthermore, a large number of ICU patients with no apparent immunosuppression also harbor underlying conditions altering their immune response, or develop ICU-acquired immune deficiencies as a result of sepsis, trauma or major surgery. While infections are associated with significant morbidity and mortality in immunocompromised critically ill patients, little specific data are available on the incidence, microbiology, management and outcomes of ICU-acquired infections in this population. As a result, immunocompromised patients are usually excluded from trials and guidelines on the management of ICU-acquired infections. The most common ICU-acquired infections in immunocompromised patients are ventilator-associated lower respiratory tract infections (which include ventilator-associated pneumonia and tracheobronchitis) and bloodstream infections. Recently, several large observational studies have shed light on some of the epidemiological specificities of these infections-as well as on the dynamics of colonization and infection with multidrug-resistant bacteria-in these patients, and these will be discussed in this review. Immunocompromised patients are also at higher risk than non-immunocompromised hosts of fungal and viral infections, and the diagnostic and therapeutic management of these infections will be covered. Finally, we will suggest some important areas of future investigation.

[The structural and spatial design of German intensive care units from the point of view of infection control measures : Survey among ICU-KISS participants]

INTRODUCTION

Intensive care unit (ICU) structural and spatial design may play a role in infection prevention and control.

METHODS

Between 09/2021 and 11/2021 we performed an online survey among ICUs in Germany, Austria and Switzerland.

RESULTS

A total of 597 (40%) of the invited ICUs answered the survey; 20% of the ICUs were built before 1990. The median number of single rooms with interquartile range is 4 (IQR 2-6). The median total room number is 8 (IQR 6-12). The median room size is 19 (IQR 16-22) m2 for single rooms and 31 (26-37.5) m2 for multiple bed rooms. Furthermore, 80% of ICUs have sinks and 86.4% have heating, ventilation, air conditioning (HVAC) systems in patient rooms. 54.6% of ICUs must store materials outside of storage rooms due to lack of space and only 33.5% have a room dedicated to disinfection and cleaning of used medical devices. Comparing ICUs built before 1990 and after 2011 we could show a slightly increase of single rooms (3 [IQR 2-5] before 1990 vs. 5 [IQR 2-8] after 2011; p < 0.001).

DISCUSSION

A large proportion of German ICUs do not meet the requirements of German professional societies regarding the number of single rooms and size of the patient rooms. Many ICUs lack storage space and other functional rooms.

CONCLUSION

There is an urgent need to support the construction and renovation of intensive care units in Germany with adequate funding.

Mortality amongst hospitalized COVID-19 cases by acquisition and pandemic wave in Wales, UK, February 2020-March 2022

BACKGROUND

Hospital populations are vulnerable to COVID-19, but the relative severity of hospital acquisition compared to community is unknown. We investigated differences in mortality between hospital and community acquired cases in Wales.

METHODS

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) polymerase chain reaction tests from February 2020 to March 2022 were linked with hospital admissions to identify likely hospital-acquired cases. All-cause mortality within 28 days of a positive SARS-CoV-2 were measured by source of acquisition. Multi-variable logistic regression was used to compare mortality by source of acquisition, adjusting for confounders, computing adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

There were 25,263 hospital-acquired cases of COVID-19 and 5490 (22%) deaths in the study period. Although significant on univariate analysis, adjustment for confounding showed no association with increased mortality for hospital-acquired cases compared with cases admitted with COVID-19 (aOR 0.8, 95% CI 0.7-0.8). Vaccination (aOR 0.6, 95% CI 0.5-0.7) and infection in later pandemic waves (aOR 0.5, 95% CI 0.4-0.6) were associated with lower mortality; older age (≥85 vs <25 years: aOR 76.4, 95% CI 41.8-160.5) and male sex (aOR 1.5, 95% CI 1.4-1.6) were associated with higher mortality.

CONCLUSION

One in five hospitalised COVID-19 cases died within a month of infection. Mortality in nosocomial cases was not worse than those admitted with COVID-19, possibly reflecting early identification of nosocomial cases through screening.

Seasonality and Strain Specificity Drive Rapid Co-evolution in an Ostreococcus-Virus System from the Western Baltic Sea

Marine viruses are a major driver of phytoplankton mortality and thereby influence biogeochemical cycling of carbon and other nutrients. Phytoplankton-targeting viruses are important components of ecosystem dynamics, but broad-scale experimental investigations of host-virus interactions remain scarce. Here, we investigated in detail a picophytoplankton (size 1 µm) host's responses to infections by species-specific viruses from distinct geographical regions and different sampling seasons. Specifically, we used Ostreococcus tauri and O. mediterraneus and their viruses (size ca. 100 nm). Ostreococcus sp. is globally distributed and, like other picoplankton species, play an important role in coastal ecosystems at certain times of the year. Further, Ostreococcus sp. is a model organism, and the Ostreococcus-virus system is well-known in marine biology. However, only few studies have researched its evolutionary biology and the implications thereof for ecosystem dynamics. The Ostreococcus strains used here stem from different regions of the Southwestern Baltic Sea that vary in salinity and temperature and were obtained during several cruises spanning different sampling seasons. Using an experimental cross-infection set-up, we explicitly confirm species and strain specificity in Ostreococcus sp. from the Baltic Sea. Moreover, we found that the timing of virus-host co-existence was a driver of infection patterns as well. In combination, these findings prove that host-virus co-evolution can be rapid in natural systems.

Investigating Pseudomonas aeruginosa population structure and frequency of cross-infection in UK cystic fibrosis clinics - a reference laboratory perspective

BACKGROUND

We aimed to describe the UK Pseudomonas aeruginosa population structure amongst people with cystic fibrosis (PWCF), and to examine evidence for cross-infection.

METHODS

Variable Number Tandem Repeat (VNTR) typing was performed on 4640 isolates from 2619 PWCF received from 55 hospital laboratories between 2017 and 2019. A combination of whole genome sequence (WGS)-based analysis of four clusters from one hospital, and epidemiological analysis of shared strains in twelve hospitals evaluated cross-infection.

RESULTS

Of 2619 PWCF, 1324 (51%) harboured common clusters or known transmissible strains, while 1295 carried unique strains/those shared among small numbers of patients. Of the former, 9.5% (250 patients) harboured the Liverpool epidemic strain (LES), followed in prevalence by clone C (7.8%; 205 patients), cluster A (5%;130 patients), and cluster D (3.6%; 94 patients). WGS analysis of 10 LES isolates, 9 of cluster D and 6 isolates each of cluster A and clone C from one hospital revealed LES formed the tightest cluster (between 7 and 205 SNPs), and cluster D the loosest (between 53 and 1531 SNPs). Hospital-specific shared strains were found in some centres, although cross-infection was largely historical, with few new acquisitions. Fifty-nine PWCF (2.3%) harboured "high-risk" clones; one ST235 isolate carried a blaIMP-1 allele.

CONCLUSION

Of 2619 PWCF who had P. aeruginosa isolates submitted for VNTR, 51% harboured either common clusters or known transmissible strains, of which LES was the most common. Limited evidence of recent patient-to-patient strain transmission was found, suggesting cross-infection prevention measures and surveillance effectively reduce transmission.

Multimodal environmental cleaning strategies to prevent healthcare-associated infections

Infection transmission in healthcare is multifaceted and by in large involves the complex interplay between a pathogen, a host and their environment. To prevent transmission, infection prevention strategies must also consider these complexities and incorporate targeted interventions aimed at all possible transmission pathways. One strategy to prevent and control infection is environmental cleaning. There are many aspects to an environmental cleaning strategy. We believe the key to successfully reducing the risk of healthcare-associated infections through the environment, is to design and implement a multimodal intervention. This paper aims to provide an overview of important considerations for designing a meaningful and sustainable environmental program for healthcare facilities.

Misidentification as Pseudomonas aeruginosa in hospital water supply samples

Drinking water in hospitals is often tested for Pseudomonas aeruginosa because of its virulence potential. This article describes a case where, based on EN ISO 16266, seven of 11 (64%) samples taken simultaneously from the drinking water system at a single hospital tested positive for P. aeruginosa. This resulted in extensive investigations and interventions, and a number of measures were implemented. However, supplementary analyses with more discriminatory power (matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, 16S-rRNA sequencing) ruled out P. aeruginosa completely. The authors wish to raise awareness of this problem, and suggest that diagnostic uncertainty of results obtained by EN ISO 16266 should be indicated on laboratory reports. Wrongly assuming the presence of P. aeruginosa in hospital water supply systems can lead to unnecessary control measures, as analytical uncertainty massively influences the health risk assessment and the remediation measures initiated in medical environments.

A randomised controlled trial investigating the effect of improving the cleaning and disinfection of shared medical equipment on healthcare-associated infections: the CLEaning and Enhanced disiNfection (CLEEN) study

BACKGROUND

Healthcare-associated infections (HAIs) are a common, costly, yet largely preventable complication impacting patients in healthcare settings globally. Improving routine cleaning and disinfection of the hospital environment has been shown to reduce the risk of HAI. Contaminated shared medical equipment presents a primary transmission route for infectious pathogens, yet is rarely studied. The CLEEN study will assess how enhanced cleaning and disinfection of shared medical equipment affects the rate of HAIs in a tertiary hospital setting. The initiative is an evidence-based approach combining staff training, auditing and feedback to environmental services staff to enhance cleaning and disinfection practices.

METHODS

The CLEEN study will use a stepped wedge randomised controlled design in 10 wards of one large Australian hospital over 36 weeks. The intervention will consist of 3 additional hours per weekday for the dedicated cleaning and disinfection of shared medical equipment on each ward. The primary outcome is to demonstrate the effectiveness of improving the quality and frequency of cleaning shared medical equipment in reducing HAIs, as measured by a HAI point prevalence study (PPS). The secondary outcomes include the thoroughness of equipment cleaning assessed using fluorescent marker technology and the cost-effectiveness of the intervention.

DISCUSSION

Evidence from the CLEEN study will contribute to future policy and practice guidelines about the cleaning and disinfection of shared medical equipment. It will be used by healthcare leaders and clinicians to inform decision-making and implementation of best-practice infection prevention strategies to reduce HAIs in healthcare facilities.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry ACTRN12622001143718.

Nosocomial COVID-19: A Nationwide Spanish Study

INTRODUCTION

SARS-CoV-2 is a highly contagious virus, and despite professionals' best efforts, nosocomial COVID-19 (NC) infections have been reported. This work aimed to describe differences in symptoms and outcomes between patients with NC and community-acquired COVID-19 (CAC) and to identify risk factors for severe outcomes among NC patients.

METHODS

This is a nationwide, retrospective, multicenter, observational study that analyzed patients hospitalized with confirmed COVID-19 in 150 Spanish hospitals (SEMI-COVID-19 Registry) from March 1, 2020, to April 30, 2021. NC was defined as patients admitted for non-COVID-19 diseases with a positive SARS-CoV-2 test on the fifth day of hospitalization or later. The primary outcome was 30-day in-hospital mortality (IHM). The secondary outcome was other COVID-19-related complications. A multivariable logistic regression analysis was performed.

RESULTS

Of the 23,219 patients hospitalized with COVID-19, 1,104 (4.8%) were NC. Compared to CAC patients, NC patients were older (median 76 vs. 69 years; p < 0.001), had more comorbidities (median Charlson Comorbidity Index 5 vs. 3; p < 0.001), were less symptomatic (p < 0.001), and had normal chest X-rays more frequently (30.8% vs. 12.5%, p < 0.001). After adjusting for sex, age, dependence, COVID-19 wave, and comorbidities, NC was associated with lower risk of moderate/severe acute respiratory distress syndrome (ARDS) (adjusted odds ratio [aOR]: 0.72; 95% confidence interval [CI]: 0.59-0.87; p < 0.001) and higher risk of acute heart failure (aOR: 1.40; 1.12-1.72; p = 0.003), sepsis (aOR: 1.73; 1.33-2.54; p < 0.001), and readmission (aOR: 1.35; 1.03-1.83; p = 0.028). NC was associated with a higher case fatality rate (39.1% vs. 19.2%) in all age groups. IHM was significantly higher among NC patients (aOR: 2.07; 1.81-2.68; p < 0.001). Risk factors for increased IHM in NC patients were age, moderate/severe dependence, malignancy, dyspnea, moderate/severe ARDS, multiple organ dysfunction syndrome, and shock; odynophagia was associated with lower IHM.

CONCLUSIONS

NC is associated with greater mortality and complications compared to CAC. Hospital strategies to prevent NC must be strengthened.

Important interventions in the operating room to prevent bacterial contamination and surgical site infections

BACKGROUND

The aim of this study was to explore interventions that Swedish operating room (OR) nurses considered important for the prevention of bacterial contamination and surgical site infections (SSIs).

METHODS

A web-based cross-sectional survey with an open-ended question was answered by OR nurses and analyzed using summative content analysis and descriptive statistics.

RESULTS

The OR nurses (n = 890) worked within 11 surgical specialties and most of them worked at university hospitals (37%) or county hospitals (53%). The nurses described twelve important interventions to prevent bacterial contamination and SSI: skin disinfection (25.9%), the OR environment (18.2%), aseptic technique (16.4%), OR clothes (13.4%), draping (9.8%), preparation (6.1%), dressing (3.6%), basic hygiene (3.4%), normothermia (2.1%), communication (0.7%), knowledge (0.3%), and work strategies (0.2%).

DISCUSSION

Skin disinfection was considered the most important intervention in order to prevent bacterial contamination and SSI. The responses indicated that many OR nurses believed the patients' skin to be sterile after the skin disinfection process. This is not a certainty, but skin disinfection does significantly decrease the amount of bacterial growth.

CONCLUSIONS

This study shows that many OR nurses' interventions are in line with recommendations. Although, knowledge regarding the effect of skin disinfection needs further research, and continued education.

Nosocomial infections in an Iranian educational hospital: an evaluation study of the Iranian nosocomial infection surveillance system

Background

Nosocomial infection (NI) or cross-infection is a major health problem in hospitals worldwide.

Aim

This study aimed to report the status of NIs and to evaluate the Iranian nosocomial infection surveillance system (INISS) in a teaching hospital in the south of Iran.

Methods

This is a comparative historical study on the records of hospital admitted patients from 2018 to 2019. Data on patients who were diagnosed with NI was extracted from the INISS database. The database includes data on the incidence of different types of NIs in each hospital ward, the patient’s infection outcome, the agents involved, and the site of infection.

Results

The results indicated that the rate of NI (cases of NI/ 100 admissions) in the hospital was %2.95. The highest rate of NIs was reported from ICUs. Of the infected patients, 45.61% were female, 98.95% had underlying diseases, and 30.88% died due to nosocomial infections. The median (IQR) of the duration of hospital stay among infected patients was 13 (7–18). The most common site of infection was VAE (ventilator-associated events) (39.40%) and the most common isolated agent, irrespective of the organ involved, was Acinetobacter (spp.) (22.75%).

Conclusions

We reported ICU and Acinetobacter (spp.) as the most affected ward and most common agent involved in recorded NIs respectively. The rate of NI in the study hospital was exceptionally low when compared to its counterparts in a few other developed countries. The INISS needs to be further evaluated with regard to the completeness and representativeness of the surveillance system. Also, we need to evaluate the adherence to the INISS guidelines among staff and physicians in reporting the NIs.

How can biophotonics help dentistry to avoid or minimize cross infection by SARS-CoV-2?

Biophotonics is defined as the combination of biology and photonics (the physical science of the light). It is a general term for all techniques that deal with the interaction between biological tissues/cells and photons (light). Biophotonics offers a great variety of techniques that can facilitate the early detection of diseases and promote innovative theragnostic approaches. As the COVID-19 infection can be transmitted due to the face-to-face communication, droplets and aerosol inhalation and the exposure to saliva, blood, and other body fluids, as well as the handling of sharp instruments, dental practices are at increased risk of infection. In this paper, a literature review was performed to explore the application of Biophotonics approaches in Dentistry focusing on the COVID-19 pandemic and how they can contribute to avoid or minimize the risks of infection in a dental setting. For this, search-related papers were retrieved from PubMED, Scielo, Google Schoolar, and American Dental Association and Centers for Disease Control and Prevention databases. The body of evidence currently available showed that Biophotonics approaches can reduce microorganism load, decontaminate surfaces, air, tissues, and minimize the generation of aerosol and virus spreading by minimally invasive, time-saving, and alternative techniques in general. However, each clinical situation must be individually evaluated regarding the benefits and drawbacks of these approaches, but always pursuing less-invasive and less aerosol-generating procedures, especially during the COVID-19 pandemic.

Ebola virus disease nosocomial infections in the Democratic Republic of the Congo: a descriptive study of cases during the 2018-2020 outbreak

•

Health workers were among those most affected by nosocomial Ebola virus disease (EVD) in this outbreak.

•

Children had a higher case fatality rate compared with other patients with nosocomial EVD.

•

Referral health facilities and privately owned health facilities had the highest number of nosocomial infections (NI).

•

Clear case definition of NI is required to prompt transmission chain interruption.

Objectives

To describe the characteristics of nosocomial cases of Ebola virus disease (EVD) in the Democratic Republic of the Congo between July 2018 and May 2020 in order to inform future interventions.

Methods

Nosocomial cases of EVD were identified during outbreak response surveillance, and a retrospective analysis of cases was conducted according to demographic characteristics and type of health facility (HF).

Results

Of 3481 cases of EVD, 579 (16.6%) were nosocomial. Of these, 332 cases occurred in women (57.3%). Patients and visitors accounted for 419 cases (72.4%), of which 79 (18.9%) were aged 6–≤18 years and 108 (25.8%) were aged ≤5 years. Health workers (HWs) accounted for the remaining 160 (27.6%) nosocomial cases. The case fatality rate (CFR) for HWs (66/160, 41.3%) was significantly lower than the CFR for patients and visitors (292/419, 69.7%) (P<0.001). The CFR was higher among cases aged 6–≤18 years (54/79, 68.4%) and ≤5 years (89/108, 82.4%). Referral HFs (>39 beds) had the highest prevalence of nosocomial EVD (148/579, 25.6%). Among HFs with at least one case of nosocomial infection, 50.0% (98/196) were privately owned.

Conclusions

Nurses and traditional healers should be targeted for infection prevention and control training, and supportive supervision should be provided to HFs to mitigate EVD transmission.

Microbial contamination of resin composites inside their dispensers: An increased risk of cross-infection?

OBJECTIVES

To evaluate the effects of microorganisms' contamination inside the dispensing syringes of different types of resin-based composites (RBCs).

METHODS

This study encompassed two sections. First, an anonymous electronic survey was submitted via Google forms to Italian dentists to acquire information about composite handling during clinical procedures. Then, a bench test was performed on nanohybrid RBCs differing in matrix chemistry and fillers [FiltekTM Supreme XTE (3MTM); Venus Pearl (Kulzer GmbH); Admira Fusion x-tra (Voco)] to evaluate the microbial viability on their surfaces with/out photocuring. Uncured RBCs were exposed to standardized inocula of Streptococcus Mutans, Candida Albicans, Lactobacillus Rhamnosus, or mixt plaque in an in vitro model reproducing clinical restorative procedures. Half of the RBC specimens were cured after exposure. Microbial viability was assessed using an MTT-based test. Statistical analysis included three-way ANOVA and Tukey's tests (p<0.05).

RESULTS

Among 300 dentists completing the survey, the majority declared to use the spatula to carry the RBCs from the syringe to the dental cavity (50% same spatula; 35% two spatulas). However, 80% of respondents had personal feelings that using one spatula could be a source of cross-contamination. In vitro results using one spatula showed microbial contamination of all RBCs after one hour of storage. The contamination levels depended on the used strain and RBC type (p<0.0001), but photocuring did not reduce contamination (p = 0.2992).

CONCLUSIONS

Microbial species' viability on uncured RBCs and after photocuring shows the existence of a considerable risk of cross-infection. Clinical procedures in Restorative Dentistry need to acknowledge and to reduce such risk during RBCs handling.

CLINICAL SIGNIFICANCE

Dentists must be aware of the possibility of cross-infection during restorative procedures, especially when the same spatula is repeatedly used for placing RBC in the cavity.

Sacbrood viruses cross-infection between Apis cerana and Apis mellifera: Rapid detection, viral dynamics, evolution and spillover risk assessment

Recent outbreaks of sacbrood virus (SBV) have caused serious epizootic disease in Apis cerana populations across Asia including Taiwan. Earlier phylogenetic analyses showed that cross-infection of AcSBV and AmSBV in both A. cerana and A. mellifera seems common, raising a concern of cross-infection intensifying the risk of disease resurgence in A. cerana. In this study, we analyzed the dynamics of cross-infection in three different types of apiaries (A. mellifera-only, A. cerana-only and two species co-cultured apiaries) over one year in Taiwan. Using novel, genotype-specific primer sets, we showed that SBV infection status varies across apiaries: AmSBV-AM and AcSBV-AC were the major genotype in the A. mellifera-only and the A. cerana-only apiaries, respectively, while AmSBV-AC and AcSBV-AC were the dominant genotypes in the co-cultured apiaries. Interestingly, co-cultured apiaries were among the only apiary type that harbored all variants and dual infections (i.e., AC and AM genotype co-infection in a single sample), indicating the interactions between hosts may form a conduit for cross-infection. The cross-infection between the two honey bee species appears to occur in a regular cycle with temporal fluctuation of AmSBV-AC and AcSBV-AC prevalence synchronized to each other in the co-cultured apiaries. Artificial infection of AcSBV in A. mellifera workers showed the suppression of viral replication, suggesting the potential of A. mellifera serving as a AcSBV reservoir that may contribute to virus spillover. Furthermore, the survival rate of A. cerana larvae was significantly reduced after artificial infections of both SBVs, indicating fitness costs of cross-infection on A. cerana and thus a high risk of disease resurgence in co-cultured apiaries. Our field and laboratory data provide baseline information that facilitates understanding of the risk of SBV cross-infection, and highlights the urgent need of SBV monitoring in co-cultured apiaries.

Experimental study on the control effect of different ventilation systems on fine particles in a simulated hospital ward

In recent years, a large number of respiratory infectious diseases (especially COVID-19) have broken out worldwide. Respiratory infectious viruses may be released in the air, resulting in cross-infection between patients and medical workers. Indoor ventilation systems can be adjusted to affect fine particles containing viruses. This study was aimed at performing a series of experiments to evaluate the ventilation performance and assess the exposure of healthcare workers (HW) to virus-laden particles released by patients in a confined experimental chamber. In a typical ward setting, four categories (top supply and exhaust, side supply and exhaust) were evaluated, encompassing 16 different air distribution patterns. The maximum reduction in the cumulative exposure level for HW was 70.8% in ventilation strategy D (upper diffusers on the sidewall supply and lower diffusers on the same sidewall return). The minimum value of the cumulative exposure level for a patient close to the source of the contamination pertained to Strategy E (upper diffusers on the sidewall supply and lower diffusers on the opposite sidewall return). Lateral ventilation strategies can provide significant guidance for ward operation to minimizing the airborne virus contamination. This study can provide a reference for sustainable buildings to construct a healthy indoor environment.

Colonization resistance against multi-drug-resistant bacteria: a narrative review

Colonization resistance by gut microbiota is a fundamental phenomenon in infection prevention and control. Hospitalized patients may be exposed to multi-drug-resistant bacteria when hand hygiene compliance among healthcare workers is not adequate. An additional layer of defence is provided by the healthy gut microbiota, which helps clear the exogenous bacteria and acts as a safety net when hand hygiene procedures are not followed. This narrative review focuses on the role of the gut microbiota in colonization resistance against multi-drug-resistant bacteria, and its implications for infection control. The review discusses the underlying mechanisms of colonization resistance (direct or indirect), the concept of resilience of the gut microbiota, the link between the antimicrobial spectrum and gut dysbiosis, and possible therapeutic strategies. Antimicrobial stewardship is crucial to maximize the effects of colonization resistance. Avoiding unnecessary antimicrobial therapy, shortening the antimicrobial duration as much as possible, and favouring antibiotics with low anti-anaerobe activity may decrease the acquisition and expansion of multi-drug-resistant bacteria. Even after antimicrobial therapy, the resilience of the gut microbiota often occurs spontaneously. Spontaneous resilience explains the existence of a window of opportunity for colonization of multi-drug-resistant bacteria during or just after antimicrobial therapy. Strategies favouring resilience of the gut microbiota, such as high-fibre diets or precision probiotics, should be evaluated.

Familial cluster of Inquilinus limosus infection among three brothers with cystic fibrosis

Inquilinus limosus is an uncommon, poorly understood bacterium capable of infecting the respiratory tracts of people with cystic fibrosis. The transmission, clinical relevance and changes in antimicrobial resistance of I. limosus over time are unclear due to the low frequency of identification. We report three co-habiting brothers with cystic fibrosis who developed chronic I. limosus infection and document the clinical and microbiological features of the infections. Clinical evolution after Inquilinus infection varied but was associated with an initial decline in lung function. Familial clustering of this rare pathogen raises the possibility of cross-infection as a potential mechanism of transmission of Inquilinus between CF patients.

The frequency of urinary tract infections and the value of antiseptics in community-dwelling people who undertake intermittent urinary catheterization: A systematic review

BACKGROUND

This systematic review had 2 aims. First to identify the incidence of urinary tract infection (UTI) and bacteriuria in people undertaking intermittent catheterization (IC), second to determine the effectiveness of antiseptic cleaning of the meatal area prior to IC in reducing the incidence of UTI and bacteriuria.

METHODS

A systematic review was conducted. Medline and the Cumulative Index to Nursing and Allied Health Literature electronic databases were systematically searched between January 1, 1990 and January 31, 2020, to identify studies that reported either the incidence of UTI or bacteriuria or the impact of using antiseptics for meatal cleaning prior to IC on incidence of these same outcomes.

RESULTS

Twenty-five articles were identified for the first aim, 2 articles for the second. The proportion of participants experiencing ≥1 UTIs per year ranged from 15.4% to 86.6%. Synthesis of these studies suggest a combined incidence of 44.2% (95%CI 40.2%-48.5%) of participants having ≥1 UTIs per year. One of the 2 studies exploring the benefit of antiseptics in reducing UTI suggest some potential benefit of using chlorhexidine in reducing UTIs. Both studies have significant limitations, making interpretation difficult.

CONCLUSIONS

A large proportion of people undertaking IC in the community have UTIs each year. Evidence on the role of antiseptics in the prevention of UTI for people who undertake IC remains unclear.

Implementation of an educational module on nosocomial infection control measures: a randomised hospital-based trial

Background

Previous cross-sectional studies have reported limited knowledge and practices among nurses regarding controlling nosocomial infections (NIs). Even though health institutions offer many irregular in-service training courses to solve such issues, a three year-nursing educational programme at institutions is not adequate to enable nurses to handle NIs. Therefore, this study aims to evaluate the implementation of an educational module on NIs control measures among Yemeni nurses.

Methods

A single-blinded randomised hospital-based trial was undertaken involving 540 nurses assigned to two intervention groups and a waitlist group. Intervention group-1 received a face-to-face training course comprising 20 h spread over six weeks and a hard copy of the module, while intervention group-2 only received the hard copy of the module “without training”. In contrast, the waitlist group did not receive anything during the period of collecting data. A self-administered NI control measures-evaluation questionnaire was utilised in collecting the data from the participants; before the intervention, at six weeks and 3 months after the end of the intervention. The period of data collection was between 1^st May and 30^th October 2016.

Results

The results from collecting and analysing the data showed a statistically significant difference in the mean knowledge scores between the intervention groups that were detectable immediately post-intervention with a mean difference (MD) of 4.31 (P < 0.001) and 3 months after the end of the intervention (MD = 4.48, P < 0.001) as compared to the waitlist group. Similarly, the results showed a statistically significant difference in the mean practice scores between the intervention groups immediately post-intervention (MD = 2.74, P < 0.001) and 3 months after the intervention (MD = 2.46, P < 0.001) as compared to the waitlist group. Intervention-1 (face-to-face training + module) was more effective than intervention-2 (module only) in improving Yemeni nurses’ knowledge and practices regarding NI control measures compared to the waitlist group.

Conclusion

The findings of this study found that intervention-1 could be offered to nurses in the form of an in-service training course every six months. The NI course should also be included in nursing curricula, particularly for the three-year-nursing diploma in Yemen.

Trial registration

Nosocomial infection educational module for nurses ISRCTN19992640, 20/6/2017. The study protocol was retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00551-0.

COVID-19 Management in Clinical Dental Care. Part I: Epidemiology, Public Health Implications, and Risk Assessment

Coronavirus disease 2019 (COVID-19), a viral disease declared a pandemic by the World Health Organization (WHO) in March 2020, has posed great changes to many sectors of society across the globe. Its virulence and rapid dissemination have forced the adoption of strict public health measures in most countries, which, collaterally, resulted in economic hardship.

This article is the first in a series of 3 that aims to contextualise the clinical impact of COVID-19 for the dental profession. It presents the epidemiological conditions of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), namely, its modes of transmission, incubation, and transmissibility period, signs and symptoms, immunity, immunological tests, and risk management in dental care.

Individuals in dental care settings are exposed to 3 potential sources of contamination with COVID-19: close interpersonal contacts (<1 m), contact with saliva, and aerosol-generating dental procedures. Thus, a risk management model is propsoed for the provision of dental care depending on the epidemiological setting, the patient's characteristics, and the type of procedures performed in the office environment.

Although herd immunity seems difficult to achieve, a significant number of people has been infected throughout the first 9 months of the pandemic and vaccination has been implemented, which means that there will be a growing number of presumable “immune” individuals that might not require many precautions that differ from those before COVID-19.

In conclusion, dental care professionals may manage their risk by following the proposed model, which considers the recommendations by local and international health authorities, thus providing a safe environment for both professionals and patients.

Emergency Management in a Dental Clinic During the Coronavirus Disease 2019 (COVID-19) Epidemic in Beijing

Background

In mid-March 2020, the World Health Organization declared that COVID-19 was to be characterised as a pandemic. The purpose of this article is to recommend emergency management procedures for dental clinics during this public health emergency.

Materials and Methods

We have implemented a series of emergency management measures to prevent cross-infection in our dental clinic during the COVID-19 pandemic, including personnel scheduling, division of the clinic into functional areas, limitation or delay of non-emergency patients, staff protection and infection controls, clinical environmental disinfection, and the use of online consultation services, among others.

Results

Due to public health policy and dental emergency management, the number of dental visitors to our clinic dropped sharply, and no COVID-19 suspected cases or high-risk patients received treatment. There have been no reports of infection of dental staff or patients during dental treatment in China to date.

Conclusion

These public health policies and dental emergency management measures were effective in controlling cross-infection of COVID-19 in the dental clinic.

Practical Implications

We share control measures for COVID-19, and hope that they will be helpful for dental professionals worldwide to continue to provide dental care in a safe and orderly manner.

A quality improvement project to standardise decontamination procedures in a single NHS board in Scotland

Background

A project was designed to improve decontamination procedures in our hospitals. This included: improving skills with training provided within clinical areas, simplifying procedures to reduce variation and increasing access to decontamination products.

Aim

To make it easy for healthcare workers (HCWs) to do the right thing and for HCWs to be confident that they were doing the right thing.

Methods

A pre-intervention survey of 120 HCWs in 10 wards on three hospital sites identified variations in the products used, variations in precautions taken and deficits in HCWs' capabilities due to unmet training needs.

Intervention

We streamlined the available products, provided an education programme and then undertook a second survey involving 133 HCWs in 12 wards.

Results

Significant improvements were attained in the reported time taken to clean and disinfect (P < 0.0001) and in HCW capability (P < 0.0001) (reported training received); other improvements in the use of appropriate products and the use of personal protective equipment were evident. The key finding was that a large, previously unrecognised, unmet training need existed; only 44% of HCWs in the pre-intervention survey reported having received training on the topic.

Conclusion

The utility of a pre-intervention survey is critical to knowing whether any change becomes improvement and to set the priorities for change. By focusing on the process rather than the outcomes, greater improvements can be attained. The assumption that all nurses know how to clean is erroneous.

Healthcare workers' perceptions and acceptance of an electronic reminder system for hand hygiene

BACKGROUND

Healthcare-associated infections (HCAIs) have a large negative impact on morbidity, mortality, and quality of life. Approximately 9% of all patients hospitalized in Sweden suffer from HCAI. Hand hygiene plays a key role and is considered the single most important measure to reduce HCAI. The hospital organization works actively to reduce HCAI. Implementing electronic systems to remind and/or notify healthcare workers raises awareness of and adherence to hand hygiene. However, there is a paucity of studies addressing individuals' perceptions of having such a system and how the organization works.

AIM

To investigate healthcare workers' perceptions of infection prevention in the healthcare organization and perceptions and acceptance of an electronic reminder system that encourages good hand hygiene.

METHODS

Qualitative descriptive design with data collected in eight focus group interviews including assistant nurses, nurses, and physicians (N = 38). Content analysis was applied and data were related to the Theory of Planned Behaviour.

FINDINGS

Healthcare workers perceive lack of feedback from the hospital organization and are positive towards an electronic reminder system to increase adherence to hand hygiene. The electronic reminder system should not register data at an individual level since it could be used as an instrument for control by the management that could be stressful for staff.

CONCLUSION

In general, there is positive acceptance of the electronic reminder system, and the respondents perceived it as having the ability to change behaviour. However, the concept has to be further developed to protect the individual's integrity and needs to be used with feedback on a group level.

Prospective diary survey of preschool children's social contact patterns: A pilot study

Purpose

This pilot study aimed to describe children's social contact patterns and to analyze factors related to their social contacts.

Methods

The participants were 30 children aged ≥13 months to <7 years, whose teachers at childcare centers and parents at home were asked to maintain diaries of their social contacts prospectively for 24 hours. Data were collected from November 30, 2018, to January 7, 2019.

Results

The 30 participating children were in contact with 363 persons in a 24-hours period (mean, 12.1±9.1). The number of contacts showed significant relationships with day of the week (p<.001), number of family members/cohabitants (p=.015), area of residence (p=.003), and type of housing (p=.002). A multiple regression model showed significantly higher numbers of contacts on weekdays (B=10.64, p=.010). Physical versus non-physical types of contact showed significant differences in terms of duration, location, and frequency (p<.001). The duration of contacts showed significant relationships with their location and frequency (p<.001), while the frequency of contacts was significantly related to their location (p<.001).

Conclusion

This is the first survey describing the characteristics of Korean preschool children's social contacts. Further large-scale social contact studies of children should be conducted.

Silica nanoparticles with encapsulated DNA (SPED) - a novel surrogate tracer for microbial transmission in healthcare

Background

The increase in antimicrobial resistance is of worldwide concern. Surrogate tracers attempt to simulate microbial transmission by avoiding the infectious risks associated with live organisms. We evaluated silica nanoparticles with encapsulated DNA (SPED) as a new promising surrogate tracer in healthcare.

Methods

SPED and Escherichia coli were used to implement three experiments in simulation rooms and a microbiology laboratory in 2017–2018. Experiment 1 investigated the transmission behaviour of SPED in a predefined simulated patient-care scenario. SPED marked with 3 different DNA sequences (SPED1-SPED3) were introduced at 3 different points of the consecutive 13 touch sites of a patient-care scenario that was repeated 3 times, resulting in a total of 288 values. Experiment 2 evaluated SPED behaviour following hand cleaning with water and soap and alcohol-based handrub. Experiment 3 compared transfer dynamics of SPED versus E. coli in a laboratory using a gloved finger touching two consecutive sites on a laminate surface after a first purposefully contaminated site.

Results

Experiment 1: SPED adhesiveness on bare skin after a hand-to-surface exposure was high, leading to a dissemination of SPED1–3 on all consecutive surface materials with a trend of decreasing recovery rates, also reflecting touching patterns in concordance with contaminated fingers versus palms. Experiment 2: Hand washing with soap and water resulted in a SPED reduction of 96%, whereas hand disinfection led to dispersal of SPED from the palm to the back of the hand. Experiment 3: SPED and E. coli concentration decreased in parallel with each transmission step – with SPED showing a trend for less reduction and variability.

Conclusions

SPED represent a convenient and safe instrument to simulate pathogen spread by contact transmission simultaneously from an infinite number of sites. They can be further developed as a central asset for successful infection prevention in healthcare.

Development of a tool to assess evidence for causality in studies implicating sink drains as a reservoir for hospital-acquired gammaproteobacterial infection

BACKGROUND

Decades of studies document an association between Gammaproteobacteria in sink drains and hospital-acquired infections, but the evidence for causality is unclear.

AIM

We aimed to develop a tool to assess the quality of evidence for causality in research studies that implicate sink drains as reservoirs for hospital-acquired Gammaproteobacterial infections.

METHODS

We used a modified Delphi process with recruited experts in hospital epidemiology to develop this tool from a pre-existing causal assessment application.

FINDINGS

Through four rounds of feedback and revision we developed the 'Modified CADDIS Tool for Causality Assessment of Sink Drains as a Reservoir for Hospital-Acquired Gammaproteobacterial Infection or Colonization'. In tests of tool application to published literature during development, mean percent agreement ranged from 46.7% to 87.5%, and the Gwet's AC1 statistic (adjusting for chance agreement) ranged from 0.13 to 1.0 (median 68.1). Areas of disagreement were felt to result from lack of a priori knowledge of causal pathways from sink drains to patients and uncertain influence of co-interventions to prevent organism acquisition. Modifications were made until consensus was achieved that further iterations would not improve the tool. When the tool was applied to 44 articles by two independent reviewers in an ongoing systematic review, percent agreement ranged from 93% to 98%, and the Gwet's AC1 statistic was 0.91-0.97.

CONCLUSION

The modified causality tool was useful for evaluating studies that implicate sink drains as reservoirs for hospital-acquired infections and may help guide the conduct and reporting of future research.

Hospital-acquired infective endocarditis during Covid-19 pandemic

BACKGROUND

The COVID pandemic has had a major impact on healthcare in hospitals, including the diagnosis and treatment of infections. Hospital-acquired infective endocarditis (HAIE) is a severe complication of medical procedures that has shown a progressive increase in recent years.

OBJECTIVES

To determine whether the incidence of HAIE during the first two months of the epidemic (March-April 2020) was higher than previously observed and to describe the clinical characteristics of these cases. The probability of the studied event (HAIE) during the study period was calculated by Poisson distribution.

RESULTS

Four cases of HAIE were diagnosed in our institution during the study period. The incidence of HAIE during the study period was 2/patient-month and 0.3/patient-month during the same calender months in the previous 5 years (p=0.033). Two cases presented during admission for COVID-19 with pulmonary involvement treated with methylprednisolone and tocilizumab. The other two cases were admitted to the hospital during the epidemic. All cases underwent central venous and urinary catheterization during admission. The etiology of HAIE was Enterococcus faecalis (2 cases), Staphylococcus aureus and Candida albicans (one case each). A source of infection was identified in three cases (central venous catheter, peripheral venous catheter, sternal wound infection, respectively). One patient was operated on. Two patients died during hospital admission.

CONCLUSIONS

The incidence of HAIE during COVID-19 pandemic in our institution was higher than usual. In order to reduce the risk of this serious infection, optimal catheter care and early treatment of every local infection should be prioritized during coronavirus outbreaks.

Cross-contamination and infection control in intraoral digital imaging: a comprehensive review

Dental health care workers are subjected to various infectious disease agents that are present in patients' saliva and blood which make infection control and universal prevention methods indispensable to the dental practice given that some of these diseases cause loss of work and time for dental staff and patients; some of them cause serious morbidity; and some of them currently have a poor prognosis and no effective treatments. Although dental radiographic procedures are not invasive, and there are no incidents such as injuries caused by dental instruments, they are a potential infection source because of contamination with saliva and blood, and comprehensive infection control procedures also apply to the radiology clinic. In addition, contact with a large number of patients in dental schools and clinics in a short period of time, and the fact that radiographic procedures are performed in the same environment as other dental procedures in dental offices increase the significance of infection control in dental radiology. Major advances in computer technology have enabled digital imaging systems to develop rapidly and to become common in dental practice as an alternative to conventional film-based imaging. The use of digital sensors in dental radiology introduced unique infection control challenges and required the revision and modification of existing infection control techniques. In this review, studies concerning the risk of cross-contamination and challenges of infection control with digital image sensors are comprehensively reviewed and infection control protocols that should be followed in intraoral digital imaging using both direct and indirect systems are thoroughly examined.

Does the application of Opsite⋄ Flexigrid⋄ occlude the oxygen saturation readings in healthy individuals using the moorVMS-OXY machine?

Background

A proportion of people who have been diagnosed with peripheral arterial disease and diabetes mellitus will be susceptible to chronic wounds. Oxygen is vital for wound healing, so oxygen measurements should to be taken as predictive values for wound healing in patients. When measuring oxygen at the wound bed, there is potentially a risk of cross-infection if no protective barrier is used; and skin stripping if an adhesive barrier is used on the wound bed. This cross sectional within subject repeated measures pilot study, aims to determine if the application of opsite film, as an infection control measure, in one or two layers, impacts on tissue oxygenation readings obtained when using the MoorVMS-OXY.

Methods

Mean oxygen saturation percentages were measured from 29 limbs of 18 healthy participants. Oxygen saturation was measured for 20 s and analysed at the first metatarsophalangeal joint using no film, one and two layers using the MoorVMS-OXY. A one-way repeated ANOVA with a Bonferroni post hoc test was performed to test for statistically significant differences between the values of the three parameters and multiple pairwise comparisons was completed.

Results

Amongst the three layers, there was a statistically significant difference in oxygen saturation between the two layers of Opsite Flexigrid and none; and also between the two layers of Flexigrid and single layer (p < 0.05). It was also established that there was no statistically significant difference between the single layer of Opsite Flexigrid and no Flexigrid layer (p > 0.05).

Conclusions

The results imply that one layer of Opsite Flexigrid is a suitable protective barrier to use when establishing capillary bed oxygen perfusion with the MoorVMS-OXY. However, the application of two Opsite Flexigrid layers, to prevent skin stripping, decreases the recorded values of oxygen saturation percentages significantly, therefore providing inaccurate results. Indicating that a double layer cannot be used over ulceration sites if measuring oxygen levels at the wound bed.

Managing emerging challenges of Coronavirus disease 2019 (COVID-19) in dentistry

Dental centers have been referred to as a hub or reservoir for infection, where healthcare professionals and other staff, patients and the public together may potentially spread pathogenic microorganisms. This may occur via saliva, skin or indirectly through air, water, and contaminated surfaces or instruments. Everyone should therefore be considered as potential sources of infection. During a pandemic, limiting unnecessary care has been adopted as a clinical measure for some patient's, to reduce the risk of cross-infection in the short term. However, in order to enable continuation of necessary and qualified care, dental processes need to follow specific infection control strategies in order to prevent transmission of emerging pandemic risks following COVID-19. In this article, we develop a tool with practical recommendations to mitigate infection risks before, during and following pandemics to enable ongoing dental care provision in primary and secondary care based on national and global recommendations.

Development of a Social Contact Survey Instrument Relevant to the Spread of Infectious Disease and Its Application in a Pilot Study Among Korean Adults

OBJECTIVES

This study aimed to develop a valid social contact survey instrument and to verify its feasibility for use among Korean adults.

METHODS

The Delphi technique was used to develop an instrument to assess social contacts, which was then applied in a cross-sectional pilot study. A panel of 15 medical professionals reviewed the feasibility and validity of each item. The minimum content validity ratio was 0.49. Thirty participants used the developed measure to record contacts during a 24-hour period.

RESULTS

After a systematic review, the survey instrument (parts I and II) was developed. Part I assessed social contact patterns over a 24-hour period, and part II assessed perceptions of contacts in daily life and preventive behaviors (hand hygiene and coughing etiquette). High validity and feasibility were found. In the pilot study, the 30 participants had a combined total of 198 contacts (mean, 6.6 daily contacts per person). The participants' age (p=0.012), occupation (p&lt;0.001), household size (p&lt;0.001), education (p&lt;0.001), personal income (p=0.003), and household income (p&lt;0.001) were significantly associated with the number of contacts. Contacts at home, of long duration, and of daily frequency were relatively likely to be physical. Assortative mixing was observed between individuals in their 20s and 50s. Contact type differed by location, duration, and frequency (p&lt;0.001).

CONCLUSIONS

The developed social contact survey instrument demonstrated high validity and feasibility, suggesting that it is viable for implementation.

Is there competition between Haemonchus contortus and Haemonchus placei in a pasture grazed by only sheep?

This study aimed to evaluate the dynamics of Haemonchus contortus and Haemonchus placei infections and hybridization between these species in grazing sheep without contact with cattle. On January 14, 2014, sixteen young sheep were infected with 4000 infective H. placei third-stage larvae L3; 11 days later, another group n = 16 was infected with 4000 H. contortus L3. The establishment rates of H. contortus and H. placei L3 were, on average, 61.6 % and 56.8 %, respectively, in the permanent sheep. After the establishment of patent infections, all permanent sheep were allocated together in the same clean pasture where they grazed for the next 12 months. Euthanasia of a sample of the permanent sheep was performed every three months: in May, August, November and February. Two weeks before the sheep were removed for euthanasia, 2 worm-free tracer sheep were introduced to the pasture to evaluate the larval population in the field. The tracer sheep grazed alongside the permanent sheep for 2 weeks. Then, they were housed indoors for 20 days; at the end of this period, they were euthanized. Parasites were recovered from the permanent and tracer sheep and identified using morphological and molecular techniques. A total of 432 worms (from permanent and tracer animals) were analyzed by PCR using species-specific primer pairs. Of these specimens, only two (0.46 %) male worms were identified as hybrids: one was recovered from a permanent animal euthanized in August and the other from a tracer sheep that grazed in May. The last detection of adult H. placei worms occurred in sheep euthanized in May (approximately 3.5 months after the beginning of the grazing period). The morphological evaluation of the L3 produced in fecal cultures showed that H. placei were progressively replaced by H. contortus populations starting in March. The last trace of H. placei L3 was found in August, when a small percentage (0.5 %) of infective larvae with H. placei morphology was identified in a fecal culture. In conclusion, hybridization between H. contortus and H. placei can occur in the field during coinfection. It was demonstrated that H. placei established successfully in artificially infected worm-free sheep; however, with concomitant natural reinfection with H. contortus, the H. placei population showed a rapid decrease and was eliminated within a few months in an environment without cattle.

Current infection control practices used in Australian and New Zealand cystic fibrosis centers

BACKGROUND

The 2013 update of the Infection Prevention and Control (IP&C) Guideline outlined recommendations to prevent the spread of CF respiratory pathogens. We aimed to investigate the current infection control practices used in Australian and New Zealand (NZ) CF centers.

METHODS

Two online surveys were distributed to Australian and NZ CF centers regarding the uptake of selected IP&C recommendations. One survey was distributed to all the Medical Directors and Lead CF Nurses and the second survey was distributed to all the Lead CF Physiotherapists.

RESULTS

The response rate was 60% (60/100) for medical/nursing and 58% (14/24) for physiotherapy. Over 90% (55/60) of CF centers followed CF-specific infection control guidelines and consistent infection control practices were seen in most CF centers; 76% (41/54) had implemented segregation strategies for ambulatory care and no CF centers housed people with CF in shared inpatient accommodation. However, the application of contact precautions (wearing gloves and apron/gown) by healthcare professionals when reviewing a CF person was variable between CF center respondents but was most often used when seeing CF persons with MRSA infection in both ambulatory care and hospital admission (20/50, 40% and 42/45, 93% of CF centers, respectively). Mask wearing by people with CF was implemented into 61% (36/59) of centers. Hospital rooms were cleaned daily in 79% (37/47) of CF centers and the ambulatory care consult rooms were always cleaned between consults (49/49, 100%) and at the end of the clinic session (51/51, 100%); however the staff member tasked with cleaning changed with 37% (18/49) of CF centers responding that CF multidisciplinary team (MDT) members cleaned between patients whereas at the end of the clinic session, only 12% (6/51) of the CF MDT cleaned the consult room.

CONCLUSIONS

Overall, Australian and NZ CF centers have adopted many recommendations from the IP&C. Although, the application of contact precautions was inconsistent and had overall a low level of adoption in CF centers. In ~ 25% of centers, mixed waiting areas occurred in the ambulatory care. Given the variability of responses, additional work is required to achieve greater consistency between centers.

Parasite-host specificity: A cross-infection study of the parasite Ophryocystis elektroscirrha

Many parasites are constrained to only one or a few hosts, showing host specificity. It remains unclear why some parasites are specialists and other parasites are generalists. The parasite Ophryocystis elektroscirrha (OE) is a neogregarine protozoan thought to be restricted to monarch butterflies, Danaus plexippus (Nymphaliae) and D. gilippus. Recently, we found OE-like spores in other Lepidoptera, specifically in three noctuid moths: Helicoverpa armigera, H. assulta and H. punctigera, as well as another nymphalid, Parthenos sylvia. To our knowledge, this is the first report of OE-like parasite infections in species other than the genus Danaus. In sequencing 558 bp of 18S rRNA, we found the genetic similarity between OE from D. plexippus and OE-like parasite from the moths H. armigera and H. punctigera to be 95.2%. When we conducted cross-species infection experiments, we could not infect the moths with OE from D. plexippus, but OE-like parasite from H. armigera did infect D. plexippus and a closely related moth species Heliothis virescens. Interestingly, we did not find the OE-like parasite in the H. armigera population from Spain. Inter-population infection experiments with H. armigera demonstrated a higher sensitivity to OE-like infection in the population from Spain compared to the populations from Australia and China. These results suggest geographic variation in OE-like susceptibility and coevolution between parasite and host. Our findings give important new insights into the prevalence and host specificity of OE and OE-like parasites, and provide opportunities to study parasite transmission over spatial and temporal scales.

Recommendations of protective measures for orthopedic surgeons during COVID-19 pandemic

PURPOSE

It was the primary purpose of the present systematic review to identify the optimal protection measures during COVID-19 pandemic and provide guidance of protective measures for orthopedic surgeons. The secondary purpose was to report the protection experience of an orthopedic trauma center in Wuhan, China during the pandemic.

METHODS

A systematic search of the PubMed, Cochrane, Web of Science, Google Scholar was performed for studies about COVID-19, fracture, trauma, orthopedic, healthcare workers, protection, telemedicine. The appropriate protective measures for orthopedic surgeons and patients were reviewed (on-site first aid, emergency room, operating room, isolation wards, general ward, etc.) during the entire diagnosis and treatment process of traumatic patients.

RESULTS

Eighteen studies were included, and most studies (13/18) emphasized that orthopedic surgeons should pay attention to prevent cross-infection. Only four studies have reported in detail how orthopedic surgeons should be protected during surgery in the operating room. No detailed studies on multidisciplinary cooperation, strict protection, protection training, indications of emergency surgery, first aid on-site and protection in orthopedic wards were found.

CONCLUSION

Strict protection at every step in the patient pathway is important to reduce the risk of cross-infection. Lessons learnt from our experience provide some recommendations of protective measures during the entire diagnosis and treatment process of traumatic patients and help others to manage orthopedic patients with COVID-19, to reduce the risk of cross-infection between patients and to protect healthcare workers during work.

LEVEL OF EVIDENCE

IV.

Nation-wide survey of screening practices to detect carriers of multi-drug resistant organisms upon admission to Swiss healthcare institutions

As emergence and spread of multi-drug resistant organisms (MDRO) requires a standardized preventive approach, we aimed to evaluate current MDRO admission screening practices in Swiss hospitals and to identify potential barriers impeding their implementation. In early 2018, all Swiss public and private healthcare institutions providing inpatient care were contacted with a 34-item questionnaire to investigate current MDRO admission screening policies. Among 139 respondents representing 180 institutions (response rate, 79%), 83% (149) of institutions implemented MDRO admission screening, while 28% of private and 9% of public institutions did not perform any screening. Targeted high-risk screening included carbapenemase producers, extended-spectrum beta-lactamase producers and methicillin-resistant Staphylococcus aureus at the institutional level for respectively 78% (115), 81% (118) and 98% (145) of screening institutions. Vancomycin-resistant enterococci (44% of institutions), multi-resistant Acinetobacter baumanii (41%) and Pseudomonas aeruginosa (37%) were systematically searched only by a minority of screening institutions. A large diversity of risk factors for targeted screening and some heterogeneity in body sites screened were also observed. Admission-screening practices were mostly impeded by a difficulty to identify high-risk patients (44%) and non-compliance of healthcare workers (35%). Heterogeneous practices and gaps in small and privately-owned institutions, as well as a mismatch between current epidemiologic MDRO trends and screening practices were noticed. These results highlight the need for uniform national MDRO screening standards.

Influence of bacterial resistance on mortality in intensive care units: a registry study from 2000 to 2013 (IICU Study)

BACKGROUND

Bacterial resistance to antibiotics is a daily concern in intensive care units. However, few data are available concerning the clinical consequences of in-vitro-defined resistance.

AIM

To compare the mortality of patients with nosocomial infections according to bacterial resistance profiles.

METHODS

The prospective surveillance registry in 29 French intensive care units (ICUs) participating during the years 2000-2013 was retrospectively analysed. All patients presenting with a nosocomial infection in ICU were included.

FINDINGS

The registry contained 88,000 eligible patients, including 10,001 patients with a nosocomial infection. Among them, 3092 (36.7%) were related to resistant micro-organisms. Gram-negative bacilli exhibited the highest rate of resistance compared to Gram-positive cocci (52.8% vs 48.1%; P < 0.001). In-hospital mortality was higher in cases of patients with antibiotic-resistant infectious agents (51.9% vs 45.5%; P < 0.001), and critical care length of stay was longer (33 ± 26 vs 29 ± 22 days; P < 0.001). These results remained significant after SAPS II matching (P < 0.001) and in the Gram-negative bacilli and Gram-positive cocci subgroups. No difference in mortality was found with respect to origin prior to admission.

CONCLUSION

Patients with bacterial resistance had higher ICU mortality and increased length of stay, regardless of the bacterial species or origin of the patient.

Virulence and resistance determinants of Klebsiella pneumoniae isolated from a Portuguese tertiary university hospital centre over a 31-year period

INTRODUCTION

The rapid and complex evolution of bacterial resistance mechanisms in Klebsiella pneumoniae producing extended-spectrum β-lactamases and carbapenemases in Klebsiella pneumoniae is one of the most significant threats to public health. However, questions and controversies regarding the interactions between resistance and virulence in multidrug-resistant K. pneumoniae isolates remain unclear.

METHODS

A retrospective cohort study was performed with 100 K. pneumoniae isolates recovered from a tertiary care university hospital centre in Lisbon over a 31-year period. Resistance and virulence determinants were screened using molecular methods (PCR, M13-PCR and MLST).

RESULTS

The predominant virulence profile (fimH, mrkD_v1, khe) was shared by all isolates, indicative of an important role of type 1 and 3 fimbrial adhesins and haemolysin, regardless of the type of β-lactamase produced. However, accumulation of virulence factors was identified in KPC-3-producers, with a higher frequency (p<0.05) of capsular serotype K2 and iucC aerobactin when compared with non-KPC-3 β-lactamases or carbapenemases. Additionally, 9 different virulence profiles were found, indicating that the KPC-3 carbapenemase producers seem to adapt successfully to the host environment and maintain virulence via several pathways.

CONCLUSION

This study describes an overlapping of multidrug-resistance and virulence determinants in ST-14^K2 KPC-3 K. pneumoniae clinical isolates that may impose an additional challenge in the treatment of infections caused by this pathogen.

Evaluation of the mechanical cleaning efficacy of dental handpieces

BACKGROUND

Dental handpieces undergo a decontamination process before reutilization. Thorough cleaning is a prerequisite to effective sterilization, to guarantee safety and prevent cross-infections.

AIM

To assess the cleaning efficacy offered by devices dedicated to dental handpieces.

METHODS

PIDTests©, which are patented tubes made of transparent material and designed to replace handpieces in cleaning devices, were artificially stained by Soil Test© (Browne/STERIS). Three cycles were performed with PIDTests© connected to every handpiece adapter in the four different machines tested: X-Cid 2© (Micro-Mega) with a total of nine PIDTests©; iCare+© (NSK) with nine PIDTests©; DAC Universal© (W&H) with 18 PIDTests©; and BioDA 80© (VR2M) with 24 PIDTests©. A visual evaluation and a biuret reaction test were performed.

FINDINGS

In three of the tested cleaning devices (X-Cid2©, iCare+© and DAC Universal©), all of the PIDTests© showed Soil Test© residues, on the internal and external surfaces indicating cleaning was ineffective. Only the BioDA 80© showed no residual stains on all the PIDTests© and negative biuret reaction test results, making the cleaning effective.

CONCLUSIONS

Manufacturers should optimize the cleaning device parameters, based on the Sinner circle (grouping compensatory parameters which influence the effectiveness of a cleaning process, such as pressure, temperature, time, detergent concentration), to improve cleaning efficacy and enable dental surgeons to ensure the safety. Although PIDTests© are the only tool to provide visual indications on the cleaning efficacy of washer-disinfectors dedicated to handpieces, manufacturers should continue with the development of improved and validated tools to assess cleaning efficacy.

Application of a ventilator associated pneumonia prevention guideline and outcomes: A quasi-experimental study

OBJECTIVE

Ventilator associated pneumonia is the most frequent health-care-associated infection in Intensive Care Units, causing increased antibiotic consumption and resistance, length of stay, plus multiple health and economic costs. The aim of the study was to assess whether a customised guideline implementation would improve ventilator-associated pneumonia incidence and associated intensive care outcomes.

DESIGN

This was a quasi-experimental, before-after study consisting of pre-intervention, intervention and post-intervention periods.

SETTING

Three intensive care units at a well-known Portuguese hospital centre.

INTERVENTION

A set of eight recommendations was implemented after a guideline adaptation process.

PATIENTS

Adult patients admitted to the intensive care units over the study periods, aged 18 years or older and under invasive ventilation through an endotracheal tube or tracheostomy cannula.

MEASUREMENTS AND MAIN RESULTS

Data related to patient characterisation, guideline compliance and health outcomes were analysed. From a population of 1970 patients, a study sample of 828 was studied. Compliance with the recommendations was high. We identified a significant reduction in the incidence of ventilator-associated pneumonia in two of the units (p = 0.020 and p = 0.001) and a reduction in duration of invasive ventilation, intensive care unit length of stay and mortality in all the three units. We found associations between some recommendations and the implementation of the set of recommendations and intensive care unit length of stay, duration of invasive ventilation and mortality.

CONCLUSION

The implementation of an evidence-based, locally customised guideline may improve ventilator associated pneumonia incidence and several outcomes.

Risk of Bacterial Transmission in Bronchiectasis Outpatient Clinics

Purpose of Review

The purpose of this review is to discuss the risk of bacterial cross-infection for bronchiectasis patients in the outpatient setting. Cross-infection has primarily been a matter of concern in cystic fibrosis (CF). There is considerable evidence of transmission of pathogens between CF patients, and this has led to guideline recommendations advocating strict segregation policies. Guidelines in bronchiectasis do not specifically address the issue of cross-infection. If cross-infection is prevalent, it may have significant implications for patients and the practical running of specialist care.

Recent Findings

Multiple UK-based studies have now published evidence of cross-infection with Pseudomonas aeruginosa within cohorts of bronchiectasis patients; however, the risk does not appear to be high. There is also evidence suggesting cross-infection from CF patients to bronchiectasis patients.

Summary

The current evidence for cross-infection in bronchiectasis is limited, but suggests a small risk with Pseudomonas aeruginosa. Longitudinal studies looking at Pseudomonas aeruginosa and other pathogens are now required.

Promoting and sustaining a historical and global effort to prevent sepsis: the 2018 World Health Organization SAVE LIVES: Clean Your Hands campaign

Sepsis is estimated to affect more than 30 million patients with potentially five million deaths every year worldwide. Prevention of sepsis, as well as early recognition, diagnosis and treatment, can’t be overlooked to mitigate this global public health threat. World Health Organization (WHO) promotes hand hygiene in health care through its annual global campaign, SAVE LIVES: Clean Your Hands campaign on 5 May every year. The 2018 campaign targets sepsis with the overall theme “It’s in your hands; prevent sepsis in health care”.

Risk factors for development of surgical site infections among liver transplantation recipients: An integrative literature review

BACKGROUND

Surgical site infection (SSI) is an important complication in the postoperative period of recipients of liver transplantation. The purpose of this integrative literature review is to summarize the knowledge available about the risk factors contributing to the development SSI among adults undergoing liver transplantation.

METHODS

We reviewed the Medical Literature Analysis and Retrieval System Online/PubMed, the Cumulative Index to Nursing and Allied Health Literature, the Latin American and Caribbean Health Sciences Literature, Scopus, and Web of Science databases.

RESULTS

Two hundred sixteen articles were identified and the final sample of 9 articles was analyzed in full length. The SSI rate found in the investigations ranged between 9.6% and 35.5%. Risk factors for SSI were grouped into categories related to the preoperative period, such as Model for End-Stage Renal Disease score > 35 and ventilated support on day of transplant; to the intraoperative period activity, such as transfusion of packed red blood cells, extended surgical time, hyperglycemia >200 mg/dL, use of vasopressor drugs, and ascites flow >1 L; and to the donor/recipient relationship, such as age differences >10 years, ratio of donor liver mass to recipient body mass < 0.01. Additionally, centers that annually perform <50 transplants appear to have higher rates of SSI.

CONCLUSIONS

Few studies have addressed the subject of SSI in relation to liver transplantation in the scientific literature. Risk factors for SSI in patients who underwent liver transplantation vary between institutions.

Assessing students' knowledge of healthcare-associated infections: a global perspective

The aim of this review was to explore students' knowledge of healthcare-associated infections (HCAIs) from a global perspective. HCAIs may be the result of treatment in or contact with healthcare or social care settings and have been shown to cause an increase in morbidity, mortality and increased length of hospital stay. Student placements may involve interactions between university students, patients and/or health professionals and this may be a source of cross-contamination of the microbial agents that cause HCAIs. This situation may be exacerbated in some countries owing to variations in the levels of infrastructure development, knowledge, and economic status. A literature search was carried out, resulting in 12 studies selected for review. Findings were organised into two themes: nursing students' knowledge of HCAIs and students in other health-related subjects' knowledge of HCAIs. Nursing students' knowledge was adequate in some aspects of HCAIs, although poor in certain areas. Knowledge of HCAIs varied between students studying different health-related subjects. Curriculum differences between the student groups may account for this variation. A review of the curricula for healthcare students should ensure they include training and practical skills in the prevention of HCAIs, including modes of disease transmission, handwashing and disinfection techniques.

Antibiotic perturbation of mixed-strain Pseudomonas aeruginosa infection in patients with cystic fibrosis

Background

Pulmonary exacerbations in cystic fibrosis (CF) remain poorly understood and treatment is usually targeted at Pseudomonas aeruginosa. Within Australia a predominant shared P. aeruginosa strain (AUST-02) is associated with greater treatment needs. This single centre study assessed temporal shared strain population dynamics during and after antibiotic treatment of exacerbations.

Methods

Sputum was collected from 12 adult patients with a history of chronic AUST-02 infection at four time-points during and after treatment of an exacerbation. Forty-eight P. aeruginosa isolates within each sample underwent AUST-02 allele-specific PCR and SNP-based strain genotyping.

Results

Various commonly shared Australian strains (AUST-01, 0.1%; AUST-02, 54.3%; AUST-06, 36.6%; AUST-07, 4.6%; AUST-11, 4.3%) and two unique strains (0.1%) were identified from 45 sputum samples (2160 isolates). Based on within-patient relative abundance of strains, a “single-strain infection” (n = 7) or “mixed-strain infection” (n = 5) was assigned to each patient. A significant temporal variation in the P. aeruginosa population composition was found for those with mixed-strain infection (P < 0.001). Patients with mixed-strain infections had more long-term treatment requirements than those with single-strain infection. Moreover, despite both groups having similar lung function at study entry, patients with single-strain infection had greater improvement in FEV₁% predicted following their exacerbation treatment (P = 0.02).

Conclusion

Pulmonary exacerbations may reveal multiple, unrelated P. aeruginosa strains whose relative abundance with one another may change rapidly, in a sustained and unpredictable manner.

Electronic supplementary material

The online version of this article (10.1186/s12890-017-0482-7) contains supplementary material, which is available to authorized users.

Reducing the risk of mouth-to-mouth transmission of pathogens via re-usable, machine-read parking tickets: an observational cohort study

The car parks at the study hospital are accessed using re-usable, machine-read tickets. In the initial phase of this study, 598 staff members were observed entering the car park, and 21.6% of them put their parking ticket in their mouth. Ultraviolet dye was used to demonstrate card-to-card cross-contamination. Swabs of the ticket machine yielded commensal bacteria: coagulase-negative staphylococci and a Bacillus sp. After placing a poster on the ticket-reading machine highlighting the potential risk of infection, a further 1366 observations demonstrated a significant and persistent decline in the proportion of staff who put their ticket in their mouth (P<0.001).