Strengthening respiratory protection from SARS-CoV-2 in certain general practice contexts.

We recommend a precautionary approach to respiratory protection for healthcare workers potentially exposed to SARS-CoV-2 until the efficacy of surgical masks can be proven.

Staphylococcus aureus bacteraemia as a quality indicator for hospital infection control.

OBJECTIVE: To evaluate the practicality and effectiveness of a new program that made health care-associated Staphylococcus aureus bacteraemia (SAB) a quality indicator at Austin Health. DESIGN AND SETTING: Roll-out of the program over 9 months and review over 27 months from January 2006. Every episode of SAB at Austin Health was promptly reviewed, and classified as community- or health care-associated and as inpatient- or non-inpatient-related. Feedback was provided to treating clinicians for every SAB episode considered potentially preventable, and education-based interventions were introduced where appropriate. MAIN OUTCOME MEASURE: Episodes of SAB associated with health care at Austin Health per 1000 separations (hospital discharges) per month. RESULTS: We identified 131 episodes of health care-associated SAB, of which 90 (68.7%) were caused by methicillin-susceptible S. aureus, 96 (73.3%) occurred in inpatients, and 65 (49.6%) were associated with a vascular access device. The health care-associated SAB rate was 1.1 per 1000 separations in the first 9 months, and fell by 55% to 0.51 per 1000 separations in the subsequent 18 months. We estimated that there were 80 fewer SAB episodes (95% CI, 20-140) than expected had the initial rate remained unchanged, a national saving of $1.75 million to Austin Health over 27 months. About 16 hours per month of clinical nurse consultant time was required to maintain the program, representing a 0.1 equivalent full-time position, or a cost of $7000-$9000 per year. CONCLUSION: Introducing a structured program to investigate all health care-associated SABs, rather than only infections with methicillin-resistant S. aureus, revealed a large under-recognised burden of potentially preventable infections. The program was simple and low-cost, and the rate of health care-associated SAB has fallen significantly since its introduction.

Significant reductions in methicillin-resistant Staphylococcus aureus bacteraemia and clinical isolates associated with a multisite, hand hygiene culture-change program and subsequent successful statewide roll-out.

OBJECTIVE: To assess the efficacy of a multimodal, centrally coordinated, multisite hand hygiene culture-change program (HHCCP) for reducing rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia and disease in Victorian hospitals. DESIGN, PARTICIPANTS AND SETTING: A pilot HHCCP was conducted over a 24-month period (October 2004 to September 2006) in six Victorian health care institutions (4 urban, 2 rural; total beds, 2379). Subsequently, we assessed the efficacy of an identical program implemented throughout Victorian public hospitals over a 12-month period (beginning between March 2006 and July 2006). MAIN OUTCOME MEASURES: Rates of hand hygiene (HH) compliance; rates of MRSA disease (patients with bacteraemia and number of clinical isolates per 100 patient discharges [PD]). RESULTS: Mean HH compliance improved significantly at all pilot program sites, from 21% (95% CI, 20%-22%) at baseline to 48% (95% CI, 47%-49%) at 12 months and 47% (95% CI, 46%-48%; range, 31%-75%) at 24 months. Mean baseline rates for the number of patients with MRSA bacteraemia and the number of clinical MRSA isolates were 0.05/100 PD per month (range, 0.00-0.13) and 1.39/100 PD per month (range, 0.16-2.39), respectively. These were significantly reduced after 24 months to 0.02/100 PD per month for bacteraemia (P = 0.035 for trend; 65 fewer patients with bacteraemia) and 0.73/100 PD per month for MRSA isolates (P = 0.003; 716 fewer isolates). Similar findings were noted 12 months after the statewide roll-out, with an increase in mean HH compliance (from 20% to 53%; P < 0.001) and reductions in the rates of MRSA isolates (P = 0.043) and bacteraemias (P = 0.09). CONCLUSIONS: Pilot and subsequent statewide implementation of a multimodal HHCCP was effective in significantly improving HH compliance and reducing rates of MRSA infection.

Personal protective equipment and antiviral drug use during hospitalization for suspected avian or pandemic influenza.

For pandemic influenza planning, realistic estimates of personal protective equipment (PPE) and antiviral medication required for hospital healthcare workers (HCWs) are vital. In this simulation study, a patient with suspected avian or pandemic influenza (API) sought treatment at 9 Australian hospital emergency departments where patient-staff interactions during the first 6 hours of hospitalization were observed. Based on World Health Organization definitions and guidelines, the mean number of "close contacts" of the API patient was 12.3 (range 6-17; 85% HCWs); mean "exposures" were 19.3 (range 15-26). Overall, 20-25 PPE sets were required per patient, with variable HCW compliance for wearing these items (93% N95 masks, 77% gowns, 83% gloves, and 73% eye protection). Up to 41% of HCW close contacts would have qualified for postexposure antiviral prophylaxis. These data indicate that many current national stockpiles of PPE and antiviral medication are likely inadequate for a pandemic.

Concurrent analysis of nose and groin swab specimens by the IDI-MRSA PCR assay is comparable to analysis by individual-specimen PCR and routine culture assays for detection of colonization by methicillin-resistant Staphylococcus aureus.

The IDI-MRSA assay (Infectio Diagnostic, Inc., Sainte-Foy, Quebec, Canada) with the Smart Cycler II rapid DNA amplification system (Cepheid, Sunnyvale, CA) appears to be sensitive and specific for the rapid detection of nasal colonization by methicillin-resistant Staphylococcus aureus (MRSA). We assessed the sensitivity and specificity of this assay under conditions in which both the nose and cutaneous groin specimens were analyzed together and compared the accuracy of this PCR approach to that when these specimens were tested separately and by culture assays in an inpatient population with known high rates (12 to 15%) of MRSA colonization. Of 211 patients screened, 192 had results assessable by all three methods (agar-broth culture, separate nose and groin IDI-MRSA assay, and combined nose-groin IDI-MRSA assay), with MRSA carriage noted in 31/192 (16.1%), 41/192 (21.4%), and 36/192 (18.8%) patients by each method, respectively. Compared to agar culture results, the sensitivity and specificity of the combined nose-groin IDI-MRSA assay were 88.0% and 91.6%, respectively, whereas when each specimen was processed separately, the sensitivities were 90.0% (nose) and 83.3% (groin) and the specificities were 91.7% (nose) and 90.2% (groin). IDI-MRSA assay of a combined nose-groin specimen appears to have an accuracy similar to that of the current recommended PCR protocol, providing results in a clinically useful time frame, and may represent a more cost-effective approach to using this assay for screening for MRSA colonization.

Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection.

OBJECTIVE: To assess the effect of a multifaceted hand hygiene culture-change program on health care worker behaviour, and to reduce the burden of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infections. DESIGN AND SETTING: Timetabled introduction of interventions (alcohol/chlorhexidine hand hygiene solution [ACHRS], improved cleaning of shared ward equipment, targeted patient decolonisation, comprehensive "culture change" package) to five clinical areas of a large university teaching hospital that had high levels of MRSA. MAIN OUTCOME MEASURES: Health care worker hand hygiene compliance; volume of ACHRS used; prevalence of patient and health care worker MRSA colonisation; environmental MRSA contamination; rates of clinical MRSA infection; and rates of laboratory detection of ESBL-producing Escherichia coli and Klebsiella spp. RESULTS: In study wards, health care worker hand hygiene compliance improved from a pre-intervention mean of 21% (95% CI, 20.3%-22.9%) to 42% (95% CI, 40.2%-43.8%) 12 months post-intervention (P < 0.001). ACHRS use increased from 5.7 to 28.6 L/1000 bed-days. No change was observed in patient MRSA colonisation or environmental colonisation/contamination, and, except in the intensive care unit, colonisation of health care workers was unchanged. Thirty-six months post-intervention, there had been significant reductions in hospital-wide rates of total clinical MRSA isolates (40% reduction; P < 0.001), patient-episodes of MRSA bacteraemia (57% reduction; P = 0.01), and clinical isolates of ESBL-producing E. coli and Klebsiella spp (90% reduction; P < 0.001). CONCLUSIONS: Introduction of ACHRS and a detailed culture-change program was effective in improving hand hygiene compliance and reducing nosocomial MRSA infections, despite high-level MRSA endemicity.

Surgical-site infection rates and risk factor analysis in coronary artery bypass graft surgery.

BACKGROUND: The Victorian Infection Control Surveillance Project (VICSP) is a multicenter collaborative surveillance project established by infection control practitioners. Five public hospitals contributed data for patients undergoing coronary artery bypass graft (CABG) surgery. OBJECTIVE: To determine the aggregate and comparative interhospital surgical-site infection (SSI) rates for patients undergoing CABG surgery and the risk factors for SSI in this patient group. METHOD: Each institution used standardized definitions of SSI, risk adjustment, and reporting methodology according to the National Nosocomial Infections Surveillance System of the Centers for Disease Control and Prevention. Data on potential risk factors were prospectively collected. RESULTS: For 4,474 patients undergoing CABG surgery, the aggregate SSI rate was 7.8 infections per 100 procedures (95% confidence interval [CI95], 7.0-8.5), with individual institutions ranging between 4.5 and 10.7 infections per 100 procedures. Multivariate risk factor analysis demonstrated age (odds ratio [OR], 1.02; CI95, 1.01-1.04; P < .001), obesity (OR, 1.8; CI95, 1.4-2.3; P < .001), and diabetes mellitus (OR, 1.6; CI95, 1.2-2.1; P < .001) as independent predictors of SSI. Three hundred thirty-four organisms were isolated from 296 SSIs. Of the total SSIs, methicillin-resistant Staphylococcus aureus was isolated from 32%, methicillin-sensitive S. aureus from 24%, gram-negative bacilli (eg, Enterobacter and Escherichia coli) from 18%, and miscellaneous organisms from the remainder. CONCLUSION: We documented aggregate and comparative SSI rates among five Victorian public hospitals performing CABG surgery and defined specific independent risk factors for SSI. VICSP data offer opportunities for targeted interventions to reduce SSI following cardiac surgery.