Designing an optimal infection prevention service: Part 1.

Background: Healthcare-associated infections (HCAIs) pose a significant threat to the health and safety of patients, staff, and visitors. Infection prevention and control (IPC) teams play a crucial role in ensuring that systems and processes are in place to keep everyone safe within the healthcare environment. Aim: The aim of this study was to identify components of infection prevention services, priorities, indicators of successes and how they are measured, and facilitators and barriers to success. Methods: A survey questionnaire was developed and circulated to infection prevention leaders and managers. Findings/results: Seventy IPC leaders/managers completed the survey. Participants were responsible for a range of IPC services within and across healthcare organisations, with significant variations to IPC delivery components. Additionally, a range of budget availability was reported. Several IPC service requirements were considered core work of IPC teams, including providing IPC advice and support, surveillance and audit and education and training. Discussion: An optimal IPC service needs to be in place to ensure HCAIs are minimised or prevented. In a post pandemic era, this is more important than ever before. This is also as crucial for the health and wellbeing of those working in IPC, who have endured unprecedented demand for their services during the pandemic.

An evaluation of an infection prevention link nurse programme in community hospitals and development of an implementation model.

BACKGROUND: Little evidence exists to show the exact impact of the link nurse role in promoting best practice in infection prevention. This paper is a report of the implementation and evaluation of a link nurse programme for community hospitals across one NHS organisation. AIM/OBJECTIVES: The main aim of the study was to implement and evaluate an infection prevention link programme. The study objectives were: 1) to develop materials for a bespoke infection prevention programme which incorporated education, behaviour change, reward and recognition and 2) to evaluate the implementation of the programme, and to learn about barriers and enablers to implementation. METHOD: Data were collected using semi-structured telephone interviews, contact logs and online course evaluation. Data were analysed using thematic analysis. FINDINGS: We identified four overarching themes that, collectively, construct a model for the implementation of the link nurse role in infection prevention. The themes are labelled as: selection process, support networks, essential roots, and turning points for success. DISCUSSION: This study contributes to understanding the contribution of link nurses in infection prevention. We suggest our findings are transferable to different settings, and the model provides guidance to support future link nurse programmes and promote best practice in infection prevention practice.

WGS to determine the extent of Clostridioides difficile transmission in a high incidence setting in North Wales in 2015.

OBJECTIVES: Rates of Clostridioides (Clostridium) difficile infection (CDI) are higher in North Wales than elsewhere in the UK. We used WGS to investigate if this is due to increased healthcare-associated transmission from other cases. METHODS: Healthcare and community C. difficile isolates from patients across North Wales (February-July 2015) from glutamate dehydrogenase (GDH)-positive faecal samples underwent WGS. Data from patient records, hospital management systems and national antimicrobial use surveillance were used. RESULTS: Of the 499 GDH-positive samples, 338 (68%) were sequenced and 299 distinct infections/colonizations were identified, 229/299 (77%) with toxin genes. Only 39/229 (17%) toxigenic isolates were related within ≤2 SNPs to ≥1 infections/colonizations from a previously sampled patient, i.e. demonstrated evidence of possible transmission. Independent predictors of possible transmission included healthcare exposure in the last 12 weeks (P = 0.002, with rates varying by hospital), infection with MLST types ST-1 (ribotype 027) and ST-11 (predominantly ribotype 078) compared with all other toxigenic STs (P < 0.001), and cephalosporin exposure in the potential transmission recipient (P = 0.02). Adjusting for all these factors, there was no additional effect of ward workload (P = 0.54) or failure to meet cleaning targets (P = 0.25). Use of antimicrobials is higher in North Wales compared with England and the rest of Wales. CONCLUSIONS: Levels of transmission detected by WGS were comparable to previously described rates in endemic settings; other explanations, such as variations in antimicrobial use, are required to explain the high levels of CDI. Cephalosporins are a risk factor for infection with C. difficile from another infected or colonized case.

Implementing clinical guidelines to prevent catheter-associated urinary tract infections and improve catheter care in nursing homes: Systematic review.

BACKGROUND: Catheter-associated urinary tract infection is the most common health care-associated infection, is considered avoidable, and has cost implications for health services. Prevalence is high in nursing homes, but little research has been undertaken to establish whether implementing clinical guidelines can reduce infection rates in long-term care or improve quality of urinary catheter care. METHODS: Systematic search and critical appraisal of the literature. RESULTS: Three studies evaluated the impact of implementing a complete clinical guideline. Five additional studies evaluated the impact of implementing individual elements of a clinical guideline. CONCLUSIONS: Prevention of catheter-associated urinary tract infection in nursing homes has received little clinical or research attention. Studies concerned with whole guideline implementation emerged as methodologically poor using recognized criteria for critically appraising epidemiologic studies concerned with infection prevention. Research evaluating the impact of single elements of clinical guidelines is more robust, and their findings could be implemented to prevent urinary infections in nursing homes.

'Hands on' or 'hands off'.

This is a new standard series to supplement our Cochrane Corner and Research Unwrapped evidence series. The aim of Guideline commentary is to support you to critique and utilise newly published guidelines enabling translation of appropriate recommendations to practice. The objective is to scrutinise recent guidelines to encourage an understanding of the key issues, recommendations and midwifery practice implications.

Educational interventions for preventing vascular catheter bloodstream infections in critical care: evidence map, systematic review and economic evaluation.

BACKGROUND: Bloodstream infections resulting from intravascular catheters (catheter-BSI) in critical care increase patients' length of stay, morbidity and mortality, and the management of these infections and their complications has been estimated to cost the NHS annually £19.1-36.2M. Catheter-BSI are thought to be largely preventable using educational interventions, but guidance as to which types of intervention might be most clinically effective is lacking. OBJECTIVE: To assess the effectiveness and cost-effectiveness of educational interventions for preventing catheter-BSI in critical care units in England. DATA SOURCES: Sixteen electronic bibliographic databases - including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, Cumulative Index to Nursing and Allied Health Literature (CINAHL), NHS Economic Evaluation Database (NHS EED), EMBASE and The Cochrane Library databases - were searched from database inception to February 2011, with searches updated in March 2012. Bibliographies of systematic reviews and related papers were screened and experts contacted to identify any additional references. REVIEW METHODS: References were screened independently by two reviewers using a priori selection criteria. A descriptive map was created to summarise the characteristics of relevant studies. Further selection criteria developed in consultation with the project Advisory Group were used to prioritise a subset of studies relevant to NHS practice and policy for systematic review. A decision-analytic economic model was developed to investigate the cost-effectiveness of educational interventions for preventing catheter-BSI. RESULTS: Seventy-four studies were included in the descriptive map, of which 24 were prioritised for systematic review. Studies have predominantly been conducted in the USA, using single-cohort before-and-after study designs. Diverse types of educational intervention appear effective at reducing the incidence density of catheter-BSI (risk ratios statistically significantly < 1.0), but single lectures were not effective. The economic model showed that implementing an educational intervention in critical care units in England would be cost-effective and potentially cost-saving, with incremental cost-effectiveness ratios under worst-case sensitivity analyses of < £5000/quality-adjusted life-year. LIMITATIONS: Low-quality primary studies cannot definitively prove that the planned interventions were responsible for observed changes in catheter-BSI incidence. Poor reporting gave unclear estimates of risk of bias. Some model parameters were sourced from other locations owing to a lack of UK data. CONCLUSIONS: Our results suggest that it would be cost-effective and may be cost-saving for the NHS to implement educational interventions in critical care units. However, more robust primary studies are needed to exclude the possible influence of secular trends on observed reductions in catheter-BSI. STUDY REGISTRATION: The study is registered with PROSPERO as CRD42012001840. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Managing and preventing outbreaks of Gram-negative infections in UK neonatal units.

De novo guidance on the management of Gram-negative bacteria outbreaks in UK neonatal units was developed in 2012 by a Department of Health, England Antimicrobial Resistance and Healthcare Associated Infection working group. The recommendations included activation of an organisational response and establishing a control team when an outbreak is suspected; screening for the specific organism only during an outbreak; undertaking multidisciplinary reviews of cleaning routines, hand hygiene and Gram-negative bacteria transmission risks; considering deep-cleaning; cohorting colonised and infected babies preferably but not necessarily in isolation cubicles; and considering reducing beds or closing a unit to new admissions as a way of improving spacing and staff:patient ratios until the outbreak is under control. The group advised establishing mechanisms to communicate effectively across the network; informing parents of the outbreak as early as possible, and providing prewritten 'infection outbreak' information sheets. For prevention of outbreaks, the group advised meeting national staffing and cot-spacing requirements; following a Water Action Plan; using infection reduction care bundles and benchmarking; and introducing breast milk early and limiting antibiotic use.

Birthing alone: a concern for midwives?

The purpose of the two articles has been to provoke thoughts around the issues of supporting women who request a birth experience that challenges the norm. In the present climate of choice, midwives and obstetricians are falling short of providing the support that some women are requesting and who feel coerced into giving birth alone. We want to see a close in the gap between women, midwives, SOMs and obstetricians for all to work together to ensure that the risks and benefits of choice are provided and documented in a way that is legally adequate and desirable to women.

Infection control is everyone's business.

IN FEBRUARY 2000, the National Audit Office (NAO) published The Management and Control of Hospital Acquired Infection in NHS Trusts in England.

Chiral oxime ethers in asymmetric synthesis. O-(1-Phenylbutyl)benzyloxyacetaldoxime, a versatile reagent for the asymmetric synthesis of protected 1,2-aminoalcohols, alpha-amino acid derivatives, and 2-hydroxymethyl nitrogen heterocycles including iminosugars.

Addition of a range of organolithium and Grignard reagents to (E)-O-(1-phenylbutyl)benzyloxyacetaldoxime 1 in the presence of boron trifluoride diethyl etherate is highly diastereoselective. The resulting hydroxylamines undergo N-O bond cleavage upon treatment with zinc-acetic acid or molybdenum hexacarbonyl to give, after N-protection, protected 1,2-aminoalcohols 3 in high enantiomeric purity. Debenzylation of 3a and 3d gave N-Boc (R)-alaninol and (S)-phenylalaninol respectively. The hydroxylamines 2 also serve as alpha-amino acid precursors, 2i being converted into N-formyl-(R)-alaninyl-(S)-(4-bromo)phenylalanine ester 7, the N-terminal dipeptide of a natural depsipeptide. The versatility of the 1,2-aminoalcohol derivatives was further illustrated by their conversion into 5-, 6- and 7-membered 2-hydroxymethyl nitrogen heterocycles 15-19 in high enantiomeric excess by a ring-closing metathesis reaction. Further reaction of the dihydropyrrole 15 gave the iminosugar 1,4-dideoxy-1,4-imino-D-ribitol.

Asymmetric synthesis of N-protected amino acids by the addition of organolithium carboxyl synthons to ROPHy/SOPHy-derived aldoximes and ketoximes.

A new asymmetric synthesis of alpha-amino acids is described in which the key step is the highly diastereoselective addition of organolithium carboxyl synthons (2-furyllithium, phenyllithium, vinyllithium) to (R)- and (S)-O-(1-phenylbutyl) oximes to give hydroxylamines, with vinyllithium being the most satisfactory nucleophilic reagent. Subsequent reductive cleavage of the N-O bond in hydroxylamines, followed by N-protection, and oxidative cleavage of the carboxyl precursor gave a range of N-protected amino acids and esters. The method was exemplified by the synthesis of a range of derivatives of non-proteinogenic amino acids such as 4-bromophenylalanine, tert-leucine, norvaline, cyclohexyl- and aryl-glycines, 2-amino-8-oxodecanoic acid (Aoda) and alpha-methylvaline.