Toward solving the global green-green dilemma between wind energy production and bat conservation.

Wind energy production is growing rapidly worldwide in an effort to reduce greenhouse gas emissions. However, wind energy production is not environmentally neutral. Negative impacts on volant animals, such as bats, include fatalities at turbines and habitat loss due to land-use change and displacement. Siting turbines away from ecologically sensitive areas and implementing measures to reduce fatalities are critical to protecting bat populations. Restricting turbine operations during periods of high bat activity is the most effective form of mitigation currently available to reduce fatalities. Compensating for habitat loss and offsetting mortality are not often practiced, because meaningful offsets are lacking. Legal frameworks to prevent or mitigate the negative impacts of wind energy on bats are absent in most countries, especially in emerging markets. Therefore, governments and lending institutions are key in reconciling wind energy production with biodiversity goals by requiring sufficient environmental standards for wind energy projects.

The coordinated action of PPR4 and EMB2654 on each intron half mediates trans-splicing of rps12 transcripts in plant chloroplasts.

The pentatricopeptide repeat proteins PPR4 and EMB2654 have been shown to be required for the trans-splicing of plastid rps12 transcripts in Zea mays (maize) and Arabidopsis, respectively, but their roles in this process are not well understood. We investigated the functions of the Arabidopsis and Oryza sativa (rice) orthologs of PPR4, designated AtPPR4 (At5g04810) and OsPPR4 (Os4g58780). Arabidopsis atppr4 and rice osppr4 mutants are embryo-lethal and seedling-lethal 3 weeks after germination, respectively, showing that PPR4 is essential in the development of both dicot and monocot plants. Artificial microRNA-mediated mutants of AtPPR4 displayed a specific defect in rps12 trans-splicing, with pale-green, yellowish or albino phenotypes, according to the degree of knock-down of AtPPR4 expression. Comparison of RNA footprints in atppr4 and emb2654 mutants showed a similar concordant loss of extensive footprints at the 3' end of intron 1a and at the 5' end of intron 1b in both cases. EMB2654 is known to bind within the footprint region in intron 1a and we show that AtPPR4 binds to the footprint region in intron 1b, via its PPR motifs. Binding of both PPR4 and EMB2654 is essential to juxtapose the two intron halves and to maintain the RNAs in a splicing-competent structure for the efficient trans-splicing of rps12 intron 1, which is crucial for chloroplast biogenesis and plant development. The similarity of EMB2654 and PPR4 orthologs and their respective binding sites across land plant phylogeny indicates that their coordinate function in rps12 trans-splicing has probably been conserved for 500 million years.

Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial.

BACKGROUND: The millions of peripheral intravenous catheters used each year are recommended for 72-96 h replacement in adults. This routine replacement increases health-care costs and staff workload and requires patients to undergo repeated invasive procedures. The effectiveness of the practice is not well established. Our hypothesis was that clinically indicated catheter replacement is of equal benefit to routine replacement. METHODS: This multicentre, randomised, non-blinded equivalence trial recruited adults (≥18 years) with an intravenous catheter of expected use longer than 4 days from three hospitals in Queensland, Australia, between May 20, 2008, and Sept 9, 2009. Computer-generated random assignment (1:1 ratio, no blocking, stratified by hospital, concealed before allocation) was to clinically indicated replacement, or third daily routine replacement. Patients, clinical staff, and research nurses could not be masked after treatment allocation because of the nature of the intervention. The primary outcome was phlebitis during catheterisation or within 48 h after removal. The equivalence margin was set at 3%. Primary analysis was by intention to treat. Secondary endpoints were catheter-related bloodstream and local infections, all bloodstream infections, catheter tip colonisation, infusion failure, catheter numbers used, therapy duration, mortality, and costs. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12608000445370. FINDINGS: All 3283 patients randomised (5907 catheters) were included in our analysis (1593 clinically indicated; 1690 routine replacement). Mean dwell time for catheters in situ on day 3 was 99 h (SD 54) when replaced as clinically indicated and 70 h (13) when routinely replaced. Phlebitis occurred in 114 of 1593 (7%) patients in the clinically indicated group and in 114 of 1690 (7%) patients in the routine replacement group, an absolute risk difference of 0·41% (95% CI -1·33 to 2·15%), which was within the prespecified 3% equivalence margin. No serious adverse events related to study interventions occurred. INTERPRETATION: Peripheral intravenous catheters can be removed as clinically indicated; this policy will avoid millions of catheter insertions, associated discomfort, and substantial costs in both equipment and staff workload. Ongoing close monitoring should continue with timely treatment cessation and prompt removal for complications. FUNDING: Australian National Health and Medical Research Council.

A hierarchical spatial modelling approach to investigate MRSA transmission in a tertiary hospital.

BACKGROUND: Most hospitals have a hierarchical design with beds positioned within cubicles and cubicles positioned within wards. Transmission of MRSA may be facilitated by patient proximity and thus the spatial arrangements of beds, cubicles and wards could be important in understanding MRSA transmission risk. Identifying high-risk areas of transmission may be useful in the design of more effective, targeted MRSA interventions. METHODS: Retrospective data on numbers of multi-resistant and non-multiresistant MRSA acquisitions were collected for 52 weeks in 2007 in a tertiary hospital in Brisbane, Australia. A hierarchical Bayesian spatio-temporal modelling approach was used to investigate spatial correlation in the hierarchically arranged datasets. The spatial component of the model decomposes cubicle-level variation into a spatially structured component and a spatially unstructured component, thereby encapsulating the influence of unmeasured predictor variables that themselves are spatially clustered and/or random. A fixed effect for the presence of another patient with the same type of MRSA in the cubicles two weeks prior was included. RESULTS: The best-fitting model for non-multiresistant MRSA had an unstructured random effect but no spatially structured random effect. The best-fitting model for multiresistant MRSA incorporated both spatially structured and unstructured random effects. While between-cubicle variability in risk of MRSA acquisition within the hospital was significant, there was only weak evidence to suggest that MRSA is spatially clustered. Presence of another patient with the same type of MRSA in the cubicles two weeks prior was a significant predictor of both types of MRSA in all models. CONCLUSIONS: We found weak evidence of clustering of MRSA acquisition within the hospital. The presence of an infected patient in the same cubicle two weeks prior may support the importance of environmental contamination as a source of MRSA transmission.

Perceptions of healthcare professionals regarding the main challenges and barriers to effective hospital infection control in Mongolia: a qualitative study.

BACKGROUND: It is not fully understood why healthcare decision-makers of developing countries often give low priority to infection control and why they are unable to implement international guidelines. This study aimed to identify the main perceived challenges and barriers that hinder the effective implementation of infection control programmes in Mongolia. METHODS: In 2008, qualitative research involving 4 group and 55 individual interviews was conducted in the capital city of Mongolia and two provincial centres. RESULTS: A total of 87 health professionals participated in the study, including policy and hospital-level managers, doctors, nurses and infection control practitioners. Thematic analysis revealed a large number of perceived challenges and barriers to the formulation and implementation of infection control policy. These challenges and barriers were complex in nature and related to poor funding, suboptimal knowledge and attitudes, and inadequate management. The study results suggest that the availability of infection control policy and guidelines, and the provision of specific recommendations for low-resource settings, do not assure effective implementation of infection control programmes. CONCLUSIONS: The current infection control system in Mongolia is likely to remain ineffective unless the underlying barriers and challenges are adequately addressed. Multifaceted interventions with logistical, educational and management components that are specific to local circumstances need to be designed and implemented in Mongolia. The importance of international peer support is highlighted.

Needleless connector nursing care - Current practices, knowledge, and attitudes: An Australian perspective.

BACKGROUND: Inappropriate needleless connector (NC) care is associated with device failure from catheter occlusion and patient blood stream infections (BSIs). This can be attributed to a lack of knowledge of connector designs and flushing, clamping, and syringe disconnection techniques. This study aimed to assess nurses' practice, knowledge, attitudes, and key influencers on appropriate care of NCs in an Australian facility and compare these with studies undertaken in the United States in 2011. METHODS: A cross-sectional online survey was sent via email with a SurveyMonkey® link to all nurses working in clinical areas (total population sampling approach; approximately 1500 nurses), at an Australian hospital, in 2018. The survey was anonymous and open for 6 weeks. Analysis was with R software. RESULTS: Response rate was approximately 19% (n = 283). Most (89%) of nurses stated that they clean NCs before each access. Only 25% correctly recognised the negative pressure NC, and 79% correctly identified the correct clamping and disconnection sequence. Positive pressure displacement devices were correctly identified by 44% of respondents, with 34% identifying the correct clamping and disconnecting technique. Nurses reported their behaviour was most influenced by local senior nurses. CONCLUSIONS: There remains a significant gap in nurses' knowledge of NC device types, as well as the correct clamping and syringe disconnection for both negative and positive displacement NCs. This survey reaffirms that senior nurses are the key influencers of nurses' adherence to best practice guidelines.

Aciclovir-resistant herpes keratitis.

Herpes simplex virus (HSV) keratitis is a common cause of ocular morbidity. Resistance to aciclovir is probably under recognized. We describe three cases of aciclovir-resistant herpes simplex virus keratitis treated with systemic foscarnet and present a review of the pharmacological options available to manage this condition.

Peripheral intravenous catheter needleless connector decontamination study-Randomized controlled trial.

BACKGROUND: Needleless connectors (NCs) were introduced to reduce health care work needlestick injuries (NSIs). If not decontaminated prior to use, NCs can be a portal for patient blood stream infections. The optimal disinfectant, and its application duration, for NC decontamination has not been empirically established. METHODS: Factorial design randomized controlled trial comparing 70% isopropyl alcohol (IPA) and 2% chlorhexidine gluconate (CHG) in 70% IPA for 5, 10, or 15 seconds, in adult medical patients with peripheral intravenous catheters. RESULTS: At baseline, 153 of 300 NCs (51%) grew microorganisms commonly found on the skin. Decontamination was successful in 150/153 (98%). There was no significant difference in decontamination between 70% IPA or 2% CHG in 70% IPA (P = .62), or decontamination for 5, 10, or 15 seconds (P = .21). CONCLUSIONS: There was no difference in the effectiveness of 70% IPA and 2% CHG in 70% IPA for NC decontamination for peripheral intravenous catheters in the clinical environment. Successful decontamination was not different for applications of 5, 10, and 15 seconds; 15 seconds did not always remove all microorganisms. Factors such as cost, feasibility of compliance, and low risk of allergy support 5 seconds decontamination with 70% IPA as an acceptable approach.

Intradermal versus intramuscular hepatitis B vaccination in hemodialysis patients: a prospective open-label randomized controlled trial in nonresponders to primary vaccination.

BACKGROUND: Primary hepatitis B virus (HBV) vaccination through the intramuscular (IM) route is less efficacious in dialysis patients than in the general population. Previous studies suggest improved seroconversion with intradermal (ID) vaccination. STUDY DESIGN: Prospective open-label randomized controlled trial. SETTING & PARTICIPANTS: Hemodialysis patients nonresponsive to primary HBV vaccination. INTERVENTION: Revaccination with either ID (10 microg of vaccine every week for 8 weeks) [DOSAGE ERROR CORRECTED] or IM (40 microg of vaccine at weeks 1 and 8) HBV vaccine . PRIMARY OUTCOME: proportion of patients achieving HBV surface antibody (anti-HBs) titer of 10 IU/L or greater within 2 months of vaccination course. SECONDARY OUTCOMES: time to seroconversion, predictors of seroconversion, peak antibody titer, duration of seroprotection, and safety and tolerability of vaccine. MEASUREMENTS: Anti-HBs titer to 24 months. RESULTS: 59 patients were analyzed. Seroconversion rates were 79% ID versus 40% IM (P = 0.002). The unadjusted odds ratio for seroconversion for ID versus IM was 5.5 (95% confidence interval [CI], 1.6 to 18.4) and increased with adjustment for baseline differences. The only factor predictive of seroconversion was the ID vaccination route. The geometric mean peak antibody titer was significantly greater in the ID versus IM group: 239 IU/L (95% CI, 131 to 434) versus 78 IU/L (95% CI, 36 to 168; P < 0.001). There was a trend toward longer duration of seroprotection with ID vaccination. ID vaccine was safe and well tolerated. LIMITATIONS: Inability to distinguish whether the mechanism of the greater efficacy of ID vaccination was the cumulative effect of multiple injections or route of administration; use of anti-HBs as a surrogate marker of protection; lack of evidence of long-term protection. CONCLUSIONS: Significantly greater seroconversion rates and peak antibody titers can be achieved with ID compared with IM vaccination in hemodialysis patients nonresponsive to primary vaccination. ID vaccination should become the standard of care in this setting.

Cost effectiveness of antimicrobial catheters in the intensive care unit: addressing uncertainty in the decision.

INTRODUCTION: Some types of antimicrobial-coated central venous catheters (A-CVC) have been shown to be cost effective in preventing catheter-related bloodstream infection (CR-BSI). However, not all types have been evaluated, and there are concerns over the quality and usefulness of these earlier studies. There is uncertainty amongst clinicians over which, if any, A-CVCs to use. We re-evaluated the cost effectiveness of all commercially available A-CVCs for prevention of CR-BSI in adult intensive care unit (ICU) patients. METHODS: We used a Markov decision model to compare the cost effectiveness of A-CVCs relative to uncoated catheters. Four catheter types were evaluated: minocycline and rifampicin (MR)-coated catheters, silver, platinum and carbon (SPC)-impregnated catheters, and two chlorhexidine and silver sulfadiazine-coated catheters; one coated on the external surface (CH/SSD (ext)) and the other coated on both surfaces (CH/SSD (int/ext)). The incremental cost per quality-adjusted life year gained and the expected net monetary benefits were estimated for each. Uncertainty arising from data estimates, data quality and heterogeneity was explored in sensitivity analyses. RESULTS: The baseline analysis, with no consideration of uncertainty, indicated all four types of A-CVC were cost-saving relative to uncoated catheters. MR-coated catheters prevented 15 infections per 1,000 catheters and generated the greatest health benefits, 1.6 quality-adjusted life years, and cost savings (AUD $130,289). After considering uncertainty in the current evidence, the MR-coated catheters returned the highest incremental monetary net benefits of AUD $948 per catheter; however there was a 62% probability of error in this conclusion. Although the MR-coated catheters had the highest monetary net benefits across multiple scenarios, the decision was always associated with high uncertainty. CONCLUSIONS: Current evidence suggests that the cost effectiveness of using A-CVCs within the ICU is highly uncertain. Policies to prevent CR-BSI amongst ICU patients should consider the cost effectiveness of competing interventions in the light of this uncertainty. Decision makers would do well to consider the current gaps in knowledge and the complexity of producing good quality evidence in this area.

SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia.

BACKGROUND: Existing severity assessment tools, such as the pneumonia severity index (PSI) and CURB-65 (tool based on confusion, urea level, respiratory rate, blood pressure, and age >or=65 years), predict 30-day mortality in community-acquired pneumonia (CAP) and have limited ability to predict which patients will require intensive respiratory or vasopressor support (IRVS). METHODS: The Australian CAP Study (ACAPS) was a prospective study of 882 episodes in which each patient had a detailed assessment of severity features, etiology, and treatment outcomes. Multivariate logistic regression was performed to identify features at initial assessment that were associated with receipt of IRVS. These results were converted into a simple points-based severity tool that was validated in 5 external databases, totaling 7464 patients. RESULTS: In ACAPS, 10.3% of patients received IRVS, and the 30-day mortality rate was 5.7%. The features statistically significantly associated with receipt of IRVS were low systolic blood pressure (2 points), multilobar chest radiography involvement (1 point), low albumin level (1 point), high respiratory rate (1 point), tachycardia (1 point), confusion (1 point), poor oxygenation (2 points), and low arterial pH (2 points): SMART-COP. A SMART-COP score of >or=3 points identified 92% of patients who received IRVS, including 84% of patients who did not need immediate admission to the intensive care unit. Accuracy was also high in the 5 validation databases. Sensitivities of PSI and CURB-65 for identifying the need for IRVS were 74% and 39%, respectively. CONCLUSIONS: SMART-COP is a simple, practical clinical tool for accurately predicting the need for IRVS that is likely to assist clinicians in determining CAP severity.

The etiology of community-acquired pneumonia in Australia: why penicillin plus doxycycline or a macrolide is the most appropriate therapy.

BACKGROUND: Available data on the etiology of community-acquired pneumonia (CAP) in Australia are very limited. Local treatment guidelines promote the use of combination therapy with agents such as penicillin or amoxycillin combined with either doxycycline or a macrolide. METHODS: The Australian CAP Study (ACAPS) was a prospective, multicenter study of 885 episodes of CAP in which all patients underwent detailed assessment for bacterial and viral pathogens (cultures, urinary antigen testing, serological methods, and polymerase chain reaction). Antibiotic agents and relevant clinical outcomes were recorded. RESULTS: The etiology was identified in 404 (45.6%) of 885 episodes, with the most frequent causes being Streptococcus pneumoniae (14%), Mycoplasma pneumoniae (9%), and respiratory viruses (15%; influenza, picornavirus, respiratory syncytial virus, parainfluenza virus, and adenovirus). Antibiotic-resistant pathogens were rare: only 5.4% of patients had an infection for which therapy with penicillin plus doxycycline would potentially fail. Concordance with local antibiotic recommendations was high (82.4%), with the most commonly prescribed regimens being a penicillin plus either doxycycline or a macrolide (55.8%) or ceftriaxone plus either doxycycline or a macrolide (36.8%). The 30-day mortality rate was 5.6% (50 of 885 episodes), and mechanical ventilation or vasopressor support were required in 94 episodes (10.6%). Outcomes were not compromised by receipt of narrower-spectrum beta-lactams, and they did not differ on the basis of whether a pathogen was identified. CONCLUSIONS: The vast majority of patients with CAP can be treated successfully with narrow-spectrum beta-lactam treatment, such as penicillin combined with doxycycline or a macrolide. Greater use of such therapy could potentially reduce the emergence of antibiotic resistance among common bacterial pathogens.

Overcrowding and understaffing in modern health-care systems: key determinants in meticillin-resistant Staphylococcus aureus transmission.

Recent decades have seen the global emergence of meticillin-resistant Staphylococcus aureus (MRSA), causing substantial health and economic burdens on patients and health-care systems. This epidemic has occurred at the same time that policies promoting higher patient throughput in hospitals have led to many services operating at, or near, full capacity. A result has been limited ability to scale services according to fluctuations in patient admissions and available staff, and hospital overcrowding and understaffing. Overcrowding and understaffing lead to failure of MRSA control programmes via decreased health-care worker hand-hygiene compliance, increased movement of patients and staff between hospital wards, decreased levels of cohorting, and overburdening of screening and isolation facilities. In turn, a high MRSA incidence leads to increased inpatient length of stay and bed blocking, exacerbating overcrowding and leading to a vicious cycle characterised by further infection control failure. Future decision making should use epidemiological and economic evidence to evaluate the effect of systems changes on the incidence of MRSA infection and other adverse events.

Conjunctival and episcleral Splendore-Hoeppli phenomenon.

The Splendore-Hoeppli phenomenon originally described in 1908 is a rare pathological state with an as yet unknown cause. Reported is the Splendore-Hoeppli phenomenon present in both eyes of a 36-year-old woman. The pathology then proceeded to resolve itself completely within 10 weeks. Of note was the fact that the patient actually developed these granulomata despite being on high doses of oral steroids with the lesions disappearing despite her steroids being withdrawn during the resolution phase. An indication is that the phenomenon is unlikely to be because of an autoimmune response.

Catheter-related bloodstream infections in intensive care units: a systematic review with meta-analysis.

AIM: This paper is a report of a systematic review and meta-analysis of strategies, other than antimicrobial coated catheters, hypothesized to reduce risk of catheter-related bloodstream infections and catheter colonization in the intensive care unit setting. BACKGROUND: Catheter-related bloodstream infections occur at a rate of 5 per 1000 catheter days in the intensive care unit setting and cause substantial mortality and excess cost. Reducing risk of catheter-related bloodstream infections among intensive care unit patients will save costs, reduce length of stay, and improve outcomes. METHODS: A systematic review of studies published between January 1985 and February 2007 was carried out using the keywords 'catheterization - central venous' with combinations of infection*, prevention* and bloodstream*. All included studies were screened by two reviewers, a validated data extraction instrument was used and data collection was completed by two blinded independent reviewers. Risk ratios for catheter-related bloodstream infections and catheter colonization were estimated with 95% confidence intervals for each study. Results from studies of similar interventions were pooled using meta-analyses. RESULTS: Twenty-three studies were included in the review. The strategies that reduced catheter colonization included insertion of central venous catheters in the subclavian vein rather than other sites, use of alternate skin disinfection solutions before catheter insertion and use of Vitacuff in combination with polymyxin, neomycin and bacitracin ointment. Strategies to reduce catheter-related bloodstream infection included staff education multifaceted infection control programmes and performance feedback. CONCLUSION: A range of interventions may reduce risks of catheter-related bloodstream infection, in addition to antimicrobial catheters.

Severe photosensitivity causing multifocal squamous cell carcinomas secondary to prolonged voriconazole therapy.

A 32-year-old woman was treated with long-term voriconazole therapy for recurrent aspergillosis associated with chronic granulomatous disease. A short time after commencement of voriconazole therapy, a severe photosensitivity reaction developed. Continued voriconazole exposure led to the development of multifocal facial squamous cell carcinomas. The photosensitivity reaction resolved after the patient changed therapy to posaconazole.

Effect of healthcare-acquired infection on length of hospital stay and cost.

OBJECTIVE: To estimate the independent effect of a single lower respiratory tract infection, urinary tract infection, or other healthcare-acquired infection on length-of-stay and variable costs and to demonstrate the bias from omitted variables that is present in previous estimates. DESIGN: Prospective cohort study.Setting. A tertiary care referral hospital and regional district hospital in southeast Queensland, Australia. PATIENTS: Adults aged 18 years or older with a minimum inpatient stay of 1 night who were admitted to selected clinical specialities. RESULTS: Urinary tract infection was not associated with an increase in length of hospital stay or variable costs. Lower respiratory tract infection was associated with an increase of 2.58 days in the hospital and variable costs of AU $24, whereas other types of infection were associated with an increased length of stay of 2.61 days but not with variable costs. Many other factors were found to be associated with increased length of stay and variable costs alongside healthcare-acquired infection. The exclusion of these variables caused a positive bias in the estimates of the costs of healthcare-acquired infection. CONCLUSIONS: The existing literature may overstate the costs of healthcare-acquired infection because of bias, and the existing estimates of excess costs may not make intuitive sense to clinicians and policy makers. Accurate estimates of the costs of healthcare-acquired infection should be made and used in appropriately designed decision-analytic economic models (ie, cost-effectiveness models) that will make valid and believable predictions of the economic value of increased infection control.

Factors associated with health care-acquired urinary tract infection.

BACKGROUND: Health care-acquired urinary tract infection is common, and the risk factors should be understood by those who manage hospitalized patients and researchers interested in interventions and programs designed to reduce rates. METHODS: We used multivariable logistic regression to identify factors that demonstrated a statistical association with infection. RESULTS: The incidence rate for infection was 1.66%, and risks increased for patients with prolonged length of stay (odd ratio [OR], 5.28; 95% confidence interval [CI]: 2.46-11.34), urinary catheter (OR, 5.16; 95% CI: 2.84-9.36), unresolved spinal injury (OR, 4.07; 95% CI: 1.04-15.92), transfer to/from another hospital (OR, 2.9; 95% CI: 1.39-6.04), some assistance for daily living prior to admission (OR, 2.58; 95% CI: 1.51-4.41), underlying neurologic disease (OR, 2.59; 95% CI: 1.49-4.49), previous stroke (OR, 1.94; 95% CI: 1.03-3.67), and fracture or dislocation on admission (OR, 3.34; 95% CI: 1.75-6.38). Male sex was protective (OR, 0.44; 95% CI: 0.26-0.77). CONCLUSION: Our data describe a general hospital population and therefore have relevance to many hospital-based health care professionals. The statistical model is a good fit to the data and has good predictive power. We identify high-risk groups and confirm the need for good decision making for managing the risks of health care-acquired urinary tract infection. This requires information on the effectiveness of risk-reducing strategies and the changes to economic costs and health benefits that result and the synthesis of these data in appropriately designed economic models.

Microorganisms present on peripheral intravenous needleless connectors in the clinical environment.

The aim of this study was to quantify culturable microorganisms on needleless connectors (NCs) attached to peripheral intravenous catheters in hospitalized adult medical patients. Half (50%) of 40 NCs were contaminated with microorganisms commonly found on the skin or mouth. Staphylococcus capitis and Staphylococcus epidermidis were most commonly isolated. Emergency department insertion and higher patient dependency were statistically associated with positive NC microorganism growth. These results reaffirm the need for NC decontamination prior to access.

Why healthcare workers don't wash their hands: a behavioral explanation.

OBJECTIVE: To elucidate behavioral determinants of handwashing among nurses. DESIGN: Statistical modeling using the Theory of Planned Behavior and relevant components to handwashing behavior by nurses that were derived from focus-group discussions and literature review. SETTING: The community and 3 tertiary care hospitals. PARTICIPANTS: Children aged 9-10 years, mothers, and nurses. RESULTS: Responses from 754 nurses were analyzed using backward linear regression for handwashing intention. We reasoned that handwashing results in 2 distinct behavioral practices--inherent handwashing and elective handwashing--with our model explaining 64% and 76%, respectively, of the variance in behavioral intention. Translation of community handwashing behavior to healthcare settings is the predominant driver of all handwashing, both inherent (weighted beta =2.92) and elective (weighted beta =4.1). Intended elective in-hospital handwashing behavior is further significantly predicted by nurses' beliefs in the benefits of the activity (weighted beta =3.12), peer pressure of senior physicians (weighted beta =3.0) and administrators (weighted beta =2.2), and role modeling (weighted beta =3.0) but only to a minimal extent by reduction in effort (weighted beta =1.13). Inherent community behavior (weighted beta =2.92), attitudes (weighted beta =0.84), and peer behavior (weighted beta =1.08) were strongly predictive of inherent handwashing intent. CONCLUSIONS: A small increase in handwashing adherence may be seen after implementing the use of alcoholic hand rubs, to decrease the effort required to wash hands. However, the facilitation of compliance is not simply related to effort but is highly dependent on altering behavioral perceptions. Thus, introduction of hand rub alone without an associated behavioral modification program is unlikely to induce a sustained increase in hand hygiene compliance.