Impact of surgical-site infection on health utility values: a meta-analysis.

BACKGROUND: Surgical-site infections (SSIs) are recognized as negatively affecting patient quality of life. No meta-analysis of SSI utility values is available in the literature to inform estimates of this burden and investment decisions in prevention. METHODS: A systematic search of PubMed, MEDLINE, CINAHL, and the National Health Service Economic Evaluation Database was performed in April 2022 in accordance with PROSPERO registration CRD 42021262633. Studies were included where quality-of-life data were gathered from adults undergoing surgery, and such data were presented for those with and without an SSI at similar time points. Two researchers undertook data extraction and quality appraisal independently, with a third as arbiter. Utility values were converted to EuroQol 5D (EQ-5D™) estimates. Meta-analyses were conducted using a random-effects model across all relevant studies, with subgroup analyses on type and timing of the SSI. RESULTS: In total, 15 studies with 2817 patients met the inclusion criteria. Six studies across seven time points were used in the meta-analysis. The pooled mean difference in EQ-5D™ utility in all studies combined was -0.08 (95 per cent c.i. -0.11 to -0.05; prediction interval -0.16 to -0.01; I2 = 40 per cent). The mean difference in EQ-5D™ utility associated with deep SSI was -0.10 (95 per cent c.i. -0.14 to -0.06; I2 = 0 per cent) and the mean difference in EQ-5D™ utility persisted over time. CONCLUSION: The present study provides the first synthesized estimate of SSI burden over the short and long term. EQ-5D™ utility estimates for a range of SSIs are essential for infection prevention planning and future economic modelling.

A new method for near real-time, nationwide surveillance of nosocomial COVID-19 in Norway: providing data at all levels of the healthcare system, March 2020 to March 2022.

BackgroundGreat efforts have been made to minimise spread and prevent outbreaks of COVID-19 in hospitals. However, there is uncertainty in identifying nosocomial vs community-acquired infections. To minimise risks and evaluate measures, timely data on infection risk in healthcare institutions are required.AimsTo design an automated nationwide surveillance system for nosocomial COVID-19 using existing data to analyse the impact of community infection rates on nosocomial infections, to explore how changes in case definitions influence incidence and to identify patients and wards at highest risk and effects of SARS-CoV-2 variants.MethodsWe used data from the Norwegian real-time emergency preparedness register (Beredt C19), which includes all patients nationwide admitted to Norwegian hospitals between March 2020 and March 2022 with a positive SARS-CoV-2 PCR test during their hospital stay or within 7 days post-discharge. COVID-19 cases were assigned to categories depending on the time between admission and testing.ResultsInfection rates for definite/probable nosocomial COVID-19 increased from 0.081% in year 1 to 0.50% in year 2 in hospital admissions 7 days or longer. Varying the definitions resulted in large changes in registered nosocomial infections. Infection rates were similar across different ward types. By 2022, 58% of patients with a definite/probable nosocomial infection had received three vaccine doses.ConclusionAutomated national surveillance for nosocomial COVID-19 is possible based on existing data sources. Beredt C19 provided detailed information with only 5% missing data on hospitals/wards. Epidemiological definitions are possible to standardise, enabling easier comparison between regions and countries.

Revisiting the personal protective equipment components of transmission-based precautions for the prevention of COVID-19 and other respiratory virus infections in healthcare.

The COVID-19 pandemic highlighted some potential limitations of transmission-based precautions. The distinction between transmission through large droplets vs aerosols, which have been fundamental concepts guiding infection control measures, has been questioned, leading to considerable variation in expert recommendations on transmission-based precautions for COVID-19. Furthermore, the application of elements of contact precautions, such as the use of gloves and gowns, is based on low-quality and inconclusive evidence and may have unintended consequences, such as increased incidence of healthcare-associated infections and spread of multidrug-resistant organisms. These observations indicate a need for high-quality studies to address the knowledge gaps and a need to revisit the theoretical background regarding various modes of transmission and the definitions of terms related to transmission. Further, we should examine the implications these definitions have on the following components of transmission-based precautions: (i) respiratory protection, (ii) use of gloves and gowns for the prevention of respiratory virus infections, (iii) aerosol-generating procedures and (iv) universal masking in healthcare settings as a control measure especially during seasonal epidemics. Such a review would ensure that transmission-based precautions are consistent and rationally based on available evidence, which would facilitate decision-making, guidance development and training, as well as their application in practice.

The effectiveness of hand hygiene interventions for preventing community transmission or acquisition of novel coronavirus or influenza infections: a systematic review.

BACKGROUND: Novel coronaviruses and influenza can cause infection, epidemics, and pandemics. Improving hand hygiene (HH) of the general public is recommended for preventing these infections. This systematic review examined the effectiveness of HH interventions for preventing transmission or acquisition of such infections in the community. METHODS: PubMed, MEDLINE, CINAHL and Web of Science databases were searched (January 2002-February 2022) for empirical studies related to HH in the general public and to the acquisition or transmission of novel coronavirus infections or influenza. Studies on healthcare staff, and with outcomes of compliance or absenteeism were excluded. Study selection, data extraction and quality assessment, using the Cochrane Effective Practice and Organization of Care risk of bias criteria or Joanna Briggs Institute Critical Appraisal checklists, were conducted by one reviewer, and double-checked by another. For intervention studies, effect estimates were calculated while the remaining studies were synthesised narratively. The protocol was pre-registered (PROSPERO 2020: CRD42020196525). RESULTS: Twenty-two studies were included. Six were intervention studies evaluating the effectiveness of HH education and provision of products, or hand washing against influenza. Only two school-based interventions showed a significant protective effect (OR: 0.64; 95% CI 0.51, 0.80 and OR: 0.40; 95% CI 0.22, 0.71), with risk of bias being high (n = 1) and unclear (n = 1). Of the 16 non-intervention studies, 13 reported the protective effect of HH against influenza, SARS or COVID-19 (P < 0.05), but risk of bias was high (n = 7), unclear (n = 5) or low (n = 1). However, evidence in relation to when, and how frequently HH should be performed was inconsistent. CONCLUSIONS: To our knowledge, this is the first systematic review of effectiveness of HH for prevention of community transmission or acquisition of respiratory viruses that have caused epidemics or pandemics, including SARS-CoV-1, SARS-CoV-2 and influenza viruses. The evidence supporting the protective effect of HH was heterogeneous and limited by methodological quality; thus, insufficient to recommend changes to current HH guidelines. Future work is required to identify in what circumstances, how frequently and what product should be used when performing HH in the community and to develop effective interventions for promoting these specific behaviours in communities during epidemics.

Antimicrobial use in European acute care hospitals: results from the second point prevalence survey (PPS) of healthcare-associated infections and antimicrobial use, 2016 to 2017.

Antimicrobial agents used to treat infections are life-saving. Overuse may result in more frequent adverse effects and emergence of multidrug-resistant microorganisms. In 2016-17, we performed the second point-prevalence survey (PPS) of healthcare-associated infections (HAIs) and antimicrobial use in European acute care hospitals. We included 1,209 hospitals and 310,755 patients in 28 of 31 European Union/European Economic Area (EU/EEA) countries. The weighted prevalence of antimicrobial use in the EU/EEA was 30.5% (95% CI: 29.2-31.9%). The most common indication for prescribing antimicrobials was treatment of a community-acquired infection, followed by treatment of HAI and surgical prophylaxis. Over half (54.2%) of antimicrobials for surgical prophylaxis were prescribed for more than 1 day. The most common infections treated by antimicrobials were respiratory tract infections and the most commonly prescribed antimicrobial agents were penicillins with beta-lactamase inhibitors. There was wide variation of patients on antimicrobials, in the selection of antimicrobial agents and in antimicrobial stewardship resources and activities across the participating countries. The results of the PPS provide detailed information on antimicrobial use in European acute care hospitals, enable comparisons between countries and hospitals, and highlight key areas for national and European action that will support efforts towards prudent use of antimicrobials.

Prevalence of healthcare-associated infections, estimated incidence and composite antimicrobial resistance index in acute care hospitals and long-term care facilities: results from two European point prevalence surveys, 2016 to 2017.

Point prevalence surveys of healthcare-associated infections (HAI) and antimicrobial use in the European Union and European Economic Area (EU/EEA) from 2016 to 2017 included 310,755 patients from 1,209 acute care hospitals (ACH) in 28 countries and 117,138 residents from 2,221 long-term care facilities (LTCF) in 23 countries. After national validation, we estimated that 6.5% (cumulative 95% confidence interval (cCI): 5.4-7.8%) patients in ACH and 3.9% (95% cCI: 2.4-6.0%) residents in LTCF had at least one HAI (country-weighted prevalence). On any given day, 98,166 patients (95% cCI: 81,022-117,484) in ACH and 129,940 (95% cCI: 79,570-197,625) residents in LTCF had an HAI. HAI episodes per year were estimated at 8.9 million (95% cCI: 4.6-15.6 million), including 4.5 million (95% cCI: 2.6-7.6 million) in ACH and 4.4 million (95% cCI: 2.0-8.0 million) in LTCF; 3.8 million (95% cCI: 3.1-4.5 million) patients acquired an HAI each year in ACH. Antimicrobial resistance (AMR) to selected AMR markers was 31.6% in ACH and 28.0% in LTCF. Our study confirmed a high annual number of HAI in healthcare facilities in the EU/EEA and indicated that AMR in HAI in LTCF may have reached the same level as in ACH.

Non-susceptibility of Escherichia coli, Klebsiella spp., Pseudomonas spp., Streptococcus pneumoniae and Staphylococcus aureus in the UK: temporal trends in England, Northern Ireland, Scotland and Wales.

OBJECTIVES: To monitor and compare trends in the non-susceptibility of bloodstream isolates of pathogens to key antibiotics in the constituent countries of the UK between 2010 and 2014. METHODS: Routinely generated antibiotic susceptibility test results for bloodstream isolates of Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca, Pseudomonas spp., Streptococcus pneumoniae and Staphylococcus aureus were collected from hospital microbiology laboratories in each country. RESULTS: With the exception of a decrease in the proportion of S. aureus that were MRSA, non-susceptibility to key antibiotics among the pathogens studied remained largely unchanged over the 5 year study period, with any increases in non-susceptibility being small. Although some intercountry variation in the proportions of non-susceptible isolates was seen, apart from MRSA, the differences were generally small (<5%) and fluctuated from year to year, with no country showing consistently higher or lower rates of resistance. CONCLUSIONS: Collaboration between the constituent countries of the UK allows an integrated approach to nationwide surveillance of antibiotic resistance.

Growth in nurse prescribing of antibiotics: the Scottish experience 2007-13.

OBJECTIVES: The objective of this study was to retrospectively analyse patterns of primary care antibiotic prescribing by nurse prescribers in Scotland. METHODS: Data on dispensed antibiotic prescriptions written by nurse prescribers in 2007-13 were obtained from the Prescribing Information System, a database of all NHS prescriptions dispensed in Scotland. RESULTS: Since 2007, there has been a steady increase in the volume of antibiotic prescribing in primary care undertaken by nurse prescribers. There was considerable variability in the frequency of antibiotic prescribing among nurses and across NHS regions. Since 2007, an increasing proportion of antibiotics prescribed by nurses are those recommended for first-line empirical treatment of infection, with a reduction in the proportion of broader-spectrum agents. Other measures of prescribing quality (duration of treatment of adult females with urinary tract infection and use of recommended doses) have improved since 2007. CONCLUSIONS: This paper is the first, to our knowledge, to present an analysis of data on antibiotic prescribing in primary care by nurse prescribers. Inappropriate prescribing is a problem and, given the impact that antibiotic prescribing has on antimicrobial resistance, it is important that the prescribing behaviour of nurses is explored. This is especially significant as this is a growing body of prescribers who predominately work in the community, where the majority of antibiotics are prescribed. This analysis showed that practice varies across NHS regions and between prescribers and although more information is needed to establish whether nurse prescribers are prescribing appropriately, some quality indicators may suggest that they are following best practice.

Methicillin-resistant Staphylococcus aureus screening as a patient safety initiative: using patients' experiences to improve the quality of screening practices.

AIMS AND OBJECTIVES: To explore the patient experience and acceptability of methicillin-resistant Staphylococcus aureus screening of inpatient admissions to acute hospital settings. BACKGROUND: Prevention of healthcare-associated infections such as methicillin-resistant Staphylococcus aureus is a major patient safety concern internationally. Screening of patients for methicillin-resistant Staphylococcus aureus colonisation is becoming a routine aspect of hospital admission; however, evidence of the patient experience and acceptability of methicillin-resistant Staphylococcus aureus screening is limited. DESIGN: A mixed-methods study set in six acute care hospitals in three Scottish regions. METHODS: Data collection involved postdischarge self-report survey of patients who had been screened (n = 54) and qualitative patient interviews (n = 10). Theoretical constructs derived from the Health Belief Model and Theory of Planned Behaviour used in analysis. RESULTS: Findings indicated that methicillin-resistant Staphylococcus aureus screening was broadly acceptable to patients. The experience of screening did not appear to be problematic; responses demonstrate that screening provided reassurance and generated confidence that health organisations were tackling healthcare-associated infections. Patients were less positive regarding the provision of information, the possibility of refusing a screen and the consequences of a positive test result. Furthermore, there were indications that patients wanted to be told the results of the screen and strong support for screening of hospital staff. CONCLUSIONS: Analysis of constructs from our theoretical frameworks provides evidence that attitudes were largely positive; responses indicate a belief in the beneficial impact of methicillin-resistant Staphylococcus aureus screening for patients and the wider community. However, it is important that health professionals continually assess the patient experience of 'routine' aspects of health care such as MRSA screening. RELEVANCE TO CLINICAL PRACTICE: The findings from this study suggest that while methicillin-resistant Staphylococcus aureus screening is generally acceptable to patients as a regular patient safety initiative, to enhance the quality of the patient experience, clinicians should consider the timing, content and effectiveness of information provision.

Interventions for preventing or controlling health care-associated infection among health care workers or patients within primary care facilities: A scoping review.

BACKGROUND: This review aimed to synthesize the evidence on infection prevention and control interventions for the prevention of health care-associated infection among health care workers or patients within primary care facilities. METHODS: PubMed, CINAHL, EMBASE, and CENTRAL databases were searched for quantitative studies published between 2011 and 2022. Study selection, data extraction, and quality assessment using Cochrane and Joanna Briggs tools, were conducted by independent review with additional sensitivity checking performed on study selection. RESULTS: Four studies were included. A randomized trial and a cross-sectional survey, respectively, found no statistical difference in laboratory-confirmed influenza in health care workers wearing N95 versus medical masks (P = .18) and a significant inverse association between the implementation of tuberculosis control measures and tuberculosis incidence (P = .02). For the prevention of surgical site infections following minor surgery, randomized trials found nonsterile gloves (8.7%; 95% confidence interval, 4.9%-12.6%) to be noninferior to sterile gloves (9.3%; 95% confidence interval, 7.4%-11.1%) and no significant difference between prophylactic antibiotics compared to placebo (P = .064). All studies had a high risk of bias. CONCLUSIONS: Evidence for infection prevention and control interventions for the prevention of health care-associated infection in primary care is very limited and insufficient to make practice recommendations. Nevertheless, the findings highlight the need for future research.

Effectiveness of national and subnational interventions for prevention and control of health-care-associated infections in acute hospitals in high-income and upper-middle-income counties: a systematic review update.

This systematic review, commissioned and funded by WHO, aimed to update a review of infection prevention and control (IPC) interventions at a national level to inform a review of their IPC Core Components guidelines (PROSPERO CRD42021297376). CENTRAL, CINAHL, Embase, MEDLINE, and WHO IRIS were searched for studies meeting Cochrane's Effective Practice and Organisation of Care (EPOC) design criteria, published from April 19, 2017, to Oct 14, 2021. Primary research studies examining national IPC interventions in acute hospitals in any country with outcomes related to rates of health-care-associated infections were included. Two independent reviewers extracted data and assessed quality using the EPOC risk of bias criteria. 36 studies were categorised per intervention type and synthesised narratively: care bundles (n=2), care bundles with implementation strategies (n=9), IPC programmes (n=16), and regulations (n=9). Designs included 21 interrupted time-series, nine controlled before-and-after studies, four cluster-randomised trials, and two non-randomised trials. Evidence supports the effectiveness of care bundles with implementation strategies. However, evidence for IPC programmes and regulations was inconclusive as studies were heterogeneous regarding populations, interventions, and outcomes. The overall risk of bias was high. Recommendations include the involvement of implementation strategies in care bundles and for further research on national IPC interventions with robust study designs and in low-income and middle-income settings.

Systematic review on factors influencing the effectiveness of alcohol-based hand rubbing in healthcare.

BACKGROUND: The effectiveness of hand rubbing with alcohol-based handrub (ABHR) is impacted by several factors. To investigate these, World Health Organization (WHO) commissioned a systematic review. AIM: To evaluate the impact of ABHR volume, application time, rubbing friction and hand size on microbiological load reduction, hand surface coverage or drying time. METHODS: Medline, CINAHL, Web of Science and ScienceDirect databases were searched for healthcare or laboratory-based primary studies, published in English, (1980- February 2021), investigating the impact of ABHR volume, application time, rubbing friction or hand size on bacterial load reduction, hand coverage or drying time. Two reviewers independently performed data extraction and quality assessment. The results are presented narratively. FINDINGS: Twenty studies were included in the review. Categories included: ABHR volume, application time and rubbing friction. Sub-categories: bacterial load reduction, hand size, drying time or hand surface coverage. All used experimental or quasi-experimental designs. Findings showed as ABHR volume increased, bacterial load reduced, and drying times increased. Furthermore, one study showed that the application of sprayed ABHR without hand rubbing resulted in significantly lower bacterial load reduction than poured or sprayed ABHR with hand rubbing (- 0.70; 95%CI: - 1.13 to - 0.28). Evidence was heterogeneous in application time, volume, technique, and product. All studies were assessed as high risk of bias. CONCLUSIONS: There is insufficient evidence to change WHO recommendation of a palmful of ABHR in a cupped hand applied for 20-30 s or manufacturer-recommended volume applied for about 20 s (Centers for Disease Control and Prevention). Future hand hygiene research should standardise volume, application time, and consider hand size.

Comparing the effectiveness of hand hygiene techniques in reducing the microbial load and covering hand surfaces in healthcare workers: Updated systematic review.

BACKGROUND: This review, commissioned by the World Health Organization (WHO), examined the effectiveness of the WHO 6-step hand hygiene (HH) technique in reducing microbial load on hands and covering hand surfaces, and compared its effectiveness to other techniques. METHODS: Medline, CINAHL, ProQuest, Web of Science, Mednar, and Google Scholar were searched for primary studies, published in English (1978-February 2021), evaluating the microbiological effectiveness or hand surface coverage of HH techniques in healthcare workers. Reviewers independently performed quality assessment using Cochrane tools. The protocol for the narrative review was registered (PROSPERO 2021: CRD42021236138). RESULTS: Nine studies were included. Evidence demonstrated that the WHO technique reduced microbial load on hands. One study found the WHO technique more effective than the 3-step technique (P = .02), while another found no difference between these 2 techniques (P = .08). An adapted 3-step technique was more effective than the WHO technique in laboratory settings (P = .021), but not in clinical practice (P = .629). One study demonstrated that an adapted 6-step technique was more effective than the WHO technique (P = .001). Evidence was heterogeneous in application time, product, and volume. All studies were high risk of bias. CONCLUSIONS: Eight studies found that the WHO 6-step technique reduced microbial load on healthcare workers' hands; but the studies were heterogeneous and further research is required to identify the most effective, yet feasible technique.

Knowledge and Attitudes about Antibiotics and Antibiotic Resistance of 2404 UK Healthcare Workers.

BACKGROUND: Using the COM-B model as a framework, an EU-wide survey aimed to ascertain multidisciplinary healthcare workers' (HCWs') knowledge, attitudes and behaviours towards antibiotics, antibiotic use and antibiotic resistance. The UK findings are presented here. METHODS: A 43-item questionnaire was developed through a two-round modified Delphi consensus process. The UK target quota was 1315 respondents. RESULTS: In total, 2404 participants responded. The highest proportion were nursing and midwifery professionals (42%), pharmacists (23%) and medical doctors (18%). HCWs correctly answered that antibiotics are not effective against viruses (97%), they have associated side effects (97%), unnecessary use makes antibiotics ineffective (97%) and healthy people can carry antibiotic-resistant bacteria (90%). However, fewer than 80% correctly answered that using antibiotics increases a patient's risk of antimicrobial resistant infection or that resistant bacteria can spread from person to person. Whilst the majority of HCWs (81%) agreed there is a connection between their antibiotic prescribing behaviour and the spread of antibiotic-resistant bacteria, only 64% felt that they have a key role in controlling antibiotic resistance. The top three barriers to providing advice or resources were lack of resources (19%), insufficient time (11%) and the patient being uninterested in the information (7%). Approximately 35% of UK respondents who were prescribers prescribed an antibiotic at least once in the previous week to responding to the survey due to a fear of patient deterioration or complications. CONCLUSION: These findings highlight that a multifaceted approach to tackling the barriers to prudent antibiotic use in the UK is required and provides evidence for guiding targeted policy, intervention development and future research. Education and training should focus on patient communication, information on spreading resistant bacteria and increased risk for individuals.

Probabilistic microsimulation to examine the cost-effectiveness of hospital admission screening strategies for carbapenemase-producing enterobacteriaceae (CPE) in the United Kingdom.

BACKGROUND: Antimicrobial resistance has been recognised as a global threat with carbapenemase- producing-Enterobacteriaceae (CPE) as a prime example. CPE has similarities to COVID-19 where asymptomatic patients may be colonised representing a source for onward transmission. There are limited treatment options for CPE infection leading to poor outcomes and increased costs. Admission screening can prevent cross-transmission by pre-emptively isolating colonised patients. OBJECTIVE: We assess the relative cost-effectiveness of screening programmes compared with no- screening. METHODS: A microsimulation parameterised with NHS Scotland date was used to model scenarios of the prevalence of CPE colonised patients on admission. Screening strategies were (a) two-step screening involving a clinical risk assessment (CRA) checklist followed by microbiological testing of high-risk patients; and (b) universal screening. Strategies were considered with either culture or polymerase chain reaction (PCR) tests. All costs were reported in 2019 UK pounds with a healthcare system perspective. RESULTS: In the low prevalence scenario, no screening had the highest probability of cost-effectiveness. Among screening strategies, the two CRA screening options were the most likely to be cost-effective. Screening was more likely to be cost-effective than no screening in the prevalence of 1 CPE colonised in 500 admitted patients or more. There was substantial uncertainty with the probabilities rarely exceeding 40% and similar results between strategies. Screening reduced non-isolated bed-days and CPE colonisation. The cost of screening was low in relation to total costs. CONCLUSION: The specificity of the CRA checklist was the parameter with the highest impact on the cost-effectiveness. Further primary data collection is needed to build models with less uncertainty in the parameters.

PRAISE: providing a roadmap for automated infection surveillance in Europe.

INTRODUCTION: Healthcare-associated infections (HAI) are among the most common adverse events of medical care. Surveillance of HAI is a key component of successful infection prevention programmes. Conventional surveillance - manual chart review - is resource intensive and limited by concerns regarding interrater reliability. This has led to the development and use of automated surveillance (AS). Many AS systems are the product of in-house development efforts and heterogeneous in their design and methods. With this roadmap, the PRAISE network aims to provide guidance on how to move AS from the research setting to large-scale implementation, and how to ensure the delivery of surveillance data that are uniform and useful for improvement of quality of care. METHODS: The PRAISE network brings together 30 experts from ten European countries. This roadmap is based on the outcome of two workshops, teleconference meetings and review by an independent panel of international experts. RESULTS: This roadmap focuses on the surveillance of HAI within networks of healthcare facilities for the purpose of comparison, prevention and quality improvement initiatives. The roadmap does the following: discusses the selection of surveillance targets, different organizational and methodologic approaches and their advantages, disadvantages and risks; defines key performance requirements of AS systems and suggestions for their design; provides guidance on successful implementation and maintenance; and discusses areas of future research and training requirements for the infection prevention and related disciplines. The roadmap is supported by accompanying documents regarding the governance and information technology aspects of implementing AS. CONCLUSIONS: Large-scale implementation of AS requires guidance and coordination within and across surveillance networks. Transitions to large-scale AS entail redevelopment of surveillance methods and their interpretation, intensive dialogue with stakeholders and the investment of considerable resources. This roadmap can be used to guide future steps towards implementation, including designing solutions for AS and practical guidance checklists.

Comparing national point prevalence surveys of healthcare-associated infection and antimicrobial prescribing: a methodological approach to adjust for differences in case-mix.

BACKGROUND: National point prevalence surveys (PPS) of healthcare-associated infection (HAI) and antimicrobial prescribing in hospitals were conducted in 2011 and 2016 in Scotland. When comparing results of PPS, it is important to adjust for any differences in patient case-mix that may confound the comparison. AIM: To describe the methodology used to compare prevalence for the two surveys and illustrate the importance of taking case-mix (patient and hospital stay characteristics) into account. METHODS: Multivariate models (clustered logistic regression) that adjusted for differences in patient case-mix were used to describe the difference in prevalence of six outcomes (HAI, antimicrobial prescribing and four devices: central vascular catheter, peripheral vascular catheter, urinary catheterisation and intubation) between the 2011 and 2016 PPS. Univariate models that did not adjust for these differences were also developed for comparison to show the importance of adjusting for confounders. RESULTS: Without adjustment for case-mix, HAI and intubation prevalence estimates were not significantly different in 2016 compared with 2011 although with adjustment, the prevalence of both was significantly lower (P=0.03 and P=0.02, respectively). These associations were only identified after adjustment for confounding by case-mix. CONCLUSIONS: While prevalence surveys do not provide intelligence on temporal trends as an incidence-based surveillance system would, if limitations and caveats are acknowledged, it is possible to compare two prevalence surveys to describe changing epidemiology. Adjusting for differences in case-mix is essential for robust comparisons. This methodology may be useful for other countries that are conducting large, repeated prevalence surveys.

How do we evaluate the cost of nosocomial infection? The ECONI protocol: an incidence study with nested case-control evaluating cost and quality of life.

INTRODUCTION: Healthcare-associated or nosocomial infection (HAI) is distressing to patients and costly for the National Health Service (NHS). With increasing pressure to demonstrate cost-effectiveness of interventions to control HAI and notwithstanding the risk from antimicrobial-resistant infections, there is a need to understand the incidence rates of HAI and costs incurred by the health system and for patients themselves. METHODS AND ANALYSIS: The Evaluation of Cost of Nosocomial Infection study (ECONI) is an observational incidence survey with record linkage and a nested case-control study that will include postdischarge longitudinal follow-up and qualitative interviews. ECONI will be conducted in one large teaching hospital and one district general hospital in NHS Scotland. The case mix of these hospitals reflects the majority of overnight admissions within Scotland. An incidence survey will record all HAI cases using standard case definitions. Subsequent linkage to routine data sets will provide information on an admission cohort which will be grouped into HAI and non-HAI cases. The case-control study will recruit eligible patients who develop HAI and twice that number without HAI as controls. Patients will be asked to complete five questionnaires: the first during their stay, and four others during the year following discharge from their recruitment admission (1, 3, 6 and 12 months). Multiple data collection methods will include clinical case note review; patient-reported outcome; linkage to electronic health records and qualitative interviews. Outcomes collected encompass infection types; morbidity and mortality; length of stay; quality of life; healthcare utilisation; repeat admissions and postdischarge prescribing. ETHICS AND DISSEMINATION: The study has received a favourable ethical opinion from the Scotland A Research Ethics Committee (reference 16/SS/0199). All publications arising from this study will be published in open-access peer-reviewed journal. Lay-person summaries will be published on the ECONI website. TRIAL REGISTRATION NUMBER: NCT03253640; Pre-results.

Interventions to improve healthcare workers' hand hygiene compliance: A systematic review of systematic reviews.

OBJECTIVE: To synthesize the existing evidence base of systematic reviews of interventions to improve healthcare worker (HCW) hand hygiene compliance (HHC). METHODS: PRISMA guidelines were followed, and 10 information sources were searched in September 2017, with no limits to language or date of publication, and papers were screened against inclusion criteria for relevance. Data were extracted and risk of bias was assessed. RESULTS: Overall, 19 systematic reviews (n=20 articles) were included. Only 1 article had a low risk of bias. Moreover, 15 systematic reviews showed positive effects of interventions on HCW HHC, whereas 3 reviews evaluating monitoring technology did not. Findings regarding whether multimodal rather than single interventions are preferable were inconclusive. Targeting social influence, attitude, self-efficacy, and intention were associated with greater effectiveness. No clear link emerged between how educational interventions were delivered and effectiveness. CONCLUSIONS: This is the first systematic review of systematic reviews of interventions to improve HCW HHC. The evidence is sufficient to recommend the implementation of interventions to improve HCW HHC (except for monitoring technology), but it is insufficient to make specific recommendations regarding the content or how the content should be delivered. Future research should rigorously apply behavior change theory, and recommendations should be clearly described with respect to intervention content and how it is delivered. Such recommendations should be tested for longer terms using stronger study designs with clearly defined outcomes.

Understanding the patient experience of health care-associated infection: A qualitative systematic review.

BACKGROUND: The global burden of health care-associated infection (HAI) is well recognized; what is less well known is the impact HAI has on patients. To develop acceptable, effective interventions, greater understanding of patients' experience of HAI is needed. This qualitative systematic review sought to explore adult patients' experiences of common HAIs. METHODS: Five databases were searched. Search terms were combined for qualitative research, HAI terms, and patient experience. Study selection was conducted by 2 researchers using prespecified criteria. Critical Appraisal Skills Programme quality appraisal tools were used. Internationally recognized Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were applied. The Noblit and Hare (1988) approach to meta-synthesis was adopted. RESULTS: Seventeen studies (2001-2017) from 5 countries addressing 5 common types of HAI met the inclusion criteria. Four interrelated themes emerged: the continuum of physical and emotional responses, experiencing the response of health care professionals, adapting to life with an HAI, and the complex cultural context of HAI. CONCLUSIONS: The impact of different HAIs may vary; however, there are many similarities in the experience recounted by patients. The biosociocultural context of contagion was graphically expressed, with potential impact on social relationships and professional interactions highlighted. Further research to investigate contemporary patient experience in an era of antimicrobial resistance is warranted.