Nudging physical distancing behaviors during the pandemic: a field experiment on passengers in the subway stations of shiraz, Iran.

BACKGROUND: The possibility of the emergence of new pandemics necessitates further research into using simple strategies to promote social distancing behaviors in public. Most of the current evidence on effectiveness of physical distancing interventions is based on self-report and measure of intention which will not necessarily predict actual behavior. METHODS: A field experimental study was conducted in the subway stations of Shiraz, Southern Iran. The interventions were based on intuitions from protection motivation theory and consisted of using environmental nudges to notify the passengers of the pandemic situation (threat appeal) and a verbal advice on keeping a safe physical distance as an effective method of protection against COVID-19 (coping message). Average physical distancing was estimated as the number of steps between two consecutive passengers and was compared between interventions (n = 1045) and the control (n = 855) groups. RESULTS: A total of 1900 people riding on subway escalators were directly observed during two intervention conditions and the control condition. Under either threat or coping-based interventions, passengers were two times more likely (OR 2.0, 95%CI 1.5-2.7, P <  0.001) to keep a physical distance of at least 1.2 m from the traveler in front compared with those who did receive no intervention. The Kruskal-Wallis test revealed that there was a significant improvement in physical distancing behaviors with coping advice compared with threat appeal and the control conditions (χ2 = 120.84, df = 2, p <  0.001). CONCLUSIONS: Our findings suggest that simple and inexpensive theory-based interventions can be used in crowded public spaces to promote physical distancing within the context of the pandemic.

COVID-19 in aged care homes: a comparison of effects initial government policies had in the UK (primarily focussing on England) and Australia during the first wave.

BACKGROUND: COVID-19 pandemic has had a major impact globally, with older people living in aged care homes suffering high death rates. OBJECTIVES: We aimed to compare the impact of initial government policies on this vulnerable older population between the UK and Australia during the first wave of attack. METHODS: We searched websites of governments in the UK and Australia and media outlets. We examined the key policies including the national lockdown dates and the distribution of some important resources (personal protective equipment and testing) and the effects of these initial policies on the mortality rates in the aged care homes during the first wave of attack of COVID-19. RESULTS: We found that both countries had prioritized resources to hospitals over aged care homes during the first wave of attack. Both countries had lower priority for aged care residents in hospitals (e.g. discharging without testing for COVID-19 or discouraging admissions). However, deaths in aged care homes were 270 times higher in the UK than in Australia as on 7 May 2020 (despite UK having a population only 2.5 times larger than Australia). The lower fatality rate in Australia may have been due to the earlier lockdown strategy when the total daily cases were low in Australia (118) compared to the UK (over 1000), as well as the better community viral testing regime in Australia. CONCLUSION: In conclusion, the public health policy in Australia aimed towards earlier intervention with earlier national lockdown and more viral testing to prevent new cases. This primary prevention could have resulted in more lives being saved. In contrast, the initial policy in the UK focussed mainly on protecting resources for hospitals, and there was a delay in national lockdown intervention and lower viral testing rate, resulting in more lives lost in the aged care sector.

Screening haemodialysis patients for hepatitis C in Vietnam: The inconsistency between common hepatitis C virus serological and virological tests.

Selecting the appropriate screening method and interval for the early detection of hepatitis C virus (HCV) infection in low-resourced haemodialysis settings is a challenge. The challenge occurs when patients are classified as HCV-RNA positive but negative to HCV-core antigen (HCV-coreAg), anti-HCV and genotyping tests. We aim to clarify the inconsistency between HCV-RNA, HCV-coreAg, anti-HCV and HCV genotyping tests in haemodialysis patients and determine the reliability of HCV-coreAg as a routine two-monthly screening strategy. Haemodialysis patients were tested every 2 months between 2012 and 2014 at the largest district haemodialysis unit in Ho Chi Minh City, Vietnam, for aminotransferases, anti-HCV antibodies, HCV-coreAg, HCV-RNA and HCV genotype. HCV-coreAg and anti-HCV results were tested against HCV-RNA for sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV). All 201 patients participated in the study. The HCV-coreAg test performed better than the anti-HCV test for sensitivity (100% vs 31%), NPV (100% vs 90%) and accuracy (100% vs 90%). The HCV-coreAg and anti-HCV tests performed no differently for specificity (100% and 98%, respectively) or PPV (100% and 73%, respectively). Kappa values for HCV-coreAg and anti-HCV tests were 1 and 0.39, respectively. Early detection of HCV for the purpose of infection prevention requires a high level of sensitivity and HCV-coreAg performed better in our chronic haemodialysis population as a two-monthly screening method than routine anti-HCV testing. HCV-coreAg test is less labour-intensive with a higher level of accuracy in patients with low viral loads making it cost effective for low-resourced settings. Repeating genotyping may be required in HCV-coreAg positive patients with a low viral load.

The Coroner's Role in the Prevention of Elder Abuse: A Study of Australian Coroner's Court Cases Involving Pressure Ulcers in Elders.

The prevention of elder abuse is a health priority around the globe. The Australian Law Reform Commission's 2017 report on Australian residential aged care facilities found that neglect may constitute elder abuse and that painful pressure ulcers (PUs) fall into this category. The purpose of this article is to examine deaths from PUs in elders 65 years and older. A database search of Australian cases identified four coroner's court cases. This article considers the role and potential of coroners' recommendations to prevent PUs. The origin and site of PUs, prevention, wound and pain management, quality of care and coronial recommendations were examined. Coronial recommendations were made in two of the cases. As judicial officers with a statutory public health function, coroners have the potential to play an important role in the prevention of deaths attributable to PUs. This article makes recommendations to harness the potential of the coronial jurisdiction to prevent PUs.

Dangerous practices in a hemodialysis unit in Vietnam identify from mixed methods.

BACKGROUND: Non-compliance with infection control practices poses a serious risk to patients receiving chronic hemodialysis. We aimed to identify the type and frequency of non-compliance with infection control practices in a hemodialysis unit in Vietnam where a large outbreak of hepatitis C infection had occurred. METHODS: Mixed methods approach included observations and discussions of non-compliance with all 12 nurses at the Hemodialysis Unit, District-6 Hospital in Ho Chi Minh City. Observations of nursing care activities were made between September 2013 and January 2014. Compliance with hand hygiene and glove use during nursing care activities were classified according to the potential for a serious risk of transmission of infection and reported as percentages. Each nurse was expected to provide 11 nursing care activities to three patients assigned per hemodialysis sessions. Activities were to be given on an individual patient-centered care basis, that is, one patient was to receive all 11 activities by their assigned nurse. On completion of the observations all nurses were enrolled in a focus group where observed non-compliance was discussed and transcripts were examined for themes. RESULTS: Hand hygiene compliance rate was low (27%, 95%CI 25%-28%, 1633/6140) regardless of classification of seriousness of risk from this breach. Although glove use (76%, 95%CI 74-78%, 1211/1586) and other personal protective equipment use (81%, 95%CI 78%-83%, 773/959) were high gloves were observed to be reused with multiple patients during a single nursing care activity provided to consecutive patients. Nurses explained the breakdown of providing nursing care activities on an individual patient-centered basis was a response to limited supply of gloves and hand hygiene facilities and was exacerbated by nursing being co-opted by overly demanding patients to provide services without delay. CONCLUSIONS: The adaption by the nurses to provide 11 single care activities to multiple consecutive patients in the absence of changing gloves and low hand hygiene compliance was potentially the central risk factor that facilitated the hepatitis C outbreak. Patient-centered care needs to be enforced to minimize multiple nurse-patient contacts that are associated with non-compliance classified as serious risk of infection transmission. Nurse empowerment to resist unreasonable patient demands may also be pivotal to assisting their compliance with hand hygiene and single patient-centered care. An audit program to measure infection control resources and practices may facilitate enforcement of the guidelines.

SEPSIS KILLS: early intervention saves lives.

OBJECTIVE: To implement a statewide program for the early recognition and treatment of sepsis in New South Wales, Australia. SETTING: Ninety-seven emergency departments in NSW hospitals. INTERVENTION: A quality improvement program (SEPSIS KILLS) that promoted intervention within 60 minutes of recognition, including taking of blood cultures, measuring serum lactate levels, administration of intravenous antibiotics, and fluid resuscitation. MAIN OUTCOME MEASURES: Time to antibiotics and fluid resuscitation; mortality rates and length of stay. RESULTS: Data for 13 567 patients were entered into the database. The proportion of patients receiving intravenous antibiotics within 60 minutes of triage increased from 29.3% in 2009-2011 to 52.2% in 2013. The percentage for whom a second litre of fluid was started within 60 minutes rose from 10.6% to 27.5% (each P < 0.001). The proportion of patients classed as Australasian Triage Scale (ATS) 1 increased from 2.3% in 2009-2011 to 4.2% in 2013, and the proportion classed as ATS 2 rose from 40.7% in 2009-2011 to 60.7% in 2013 (P < 0.001). There was a linear decrease in mortality from 19.3% in 2009-2011 to 14.1% in 2013; there was also a significant decline in time in intensive care and total length of stay (each P < 0.0001). The mortality rate for patients with severe sepsis (serum lactate ≥ 4 mmol/L or systolic blood pressure [SBP] < 90 mmHg) was 19.7%. The mortality rates for patients with severe sepsis admitted to intensive care and for those admitted to a ward did not change significantly over time. The proportion of patients with uncomplicated sepsis (SBP ≥ 90 mmHg, serum lactate < 4 mmol/L) transferred to a ward increased, and the mortality rate after transfer increased from 3.2% in 2009-2011 to 6.2% in 2013 (P < 0.05). The survival benefit was greatest for patients with evidence of haemodynamic instability (SBP < 90 mmHg) but normal lactate levels (P = 0.03). CONCLUSIONS: The SEPSIS KILLS program has improved the process of care for patients with sepsis in NSW hospitals. The program has focused attention on sepsis management in the wards.

Personal clothing as a potential vector of respiratory virus transmission in childcare settings.

Previous investigations of fomite transmission have focused on the presence of pathogens on inanimate objects in clinical settings. There has been limited investigation of fomite transmission in non-clinical pediatric settings where there is a high prevalence of respiratory virus infections. Over a 5 week period, this study investigated whether the personal clothing of teachers working in childcare centers was contaminated with viral RNA, and potentially could mediate virus transmission. Matched morning and evening clothing and nasal samples were collected for 313 teacher work days (TWDs). Human rhinoviruses (hRV) RNA were detected from samples using real-time PCR. Human rhinovirus RNA was detected in clothing samples on 16 TWDs and in nasal samples on 32 TWDs. There were no TWDs when teachers provided both positive nasal and clothing samples and only three TWDs when hRV persisted on clothing for the entire day. The detection of hRV RNA was significantly predicted by self-recognition of symptomatic illness by the teacher 2 days prior to detection. These findings suggest that teachers' personal clothing in childcare settings is unlikely to facilitate the transmission of hRV.

Challenges of hemodialysis in Vietnam: experience from the first standardized district dialysis unit in Ho Chi Minh City.

BACKGROUND: Hemodialysis is an increasingly common treatment in Vietnam as the diagnosis of end stage renal disease continues to rise. To provide appropriate hemodialysis treatment for end-stage renal disease patients, we conducted a 1-year cross-sectional study to measure the prevalence of bloodborne infection and factors associated with non-compliant behaviors in hemodialysis patients. METHODS: One hundred forty-two patients were tested for hepatitis B virus (HBV) surface antigen and hepatitis C virus (HCV) core antigen. They provided demographic, medical and dialysis information. Non-compliant behaviors were obtained from their medical records. RESULTS: Overall, 99 % of patients reused their dialyzers and 46 % had arteriovenous fistula on admission. Both HBV and HCV equally accounted for 8 % of patients and concurrent infection accounted for 1 %. Non-compliance rates of dietary and medication were 39 and 27 % respectively. 42 % of patients missed hemodialysis session, 8 % were verbally or physically abusive and 9 % were non-cooperative. Of the 54 % catheterized patients, 7 % improperly cared for their dialysis access. Dietary non-adherence was associated with male patients (p = 0.03) and medication non-adherence was associated with younger age (p = 0.05). Duration between diagnosis of chronic kidney disease and initiation of hemodialysis was associated with improper care of dialysis access (p = 0.04). Time on hemodialysis was associated with missed hemodialysis session (p = 0.007) and verbal or physical abuse (p = 0.01). CONCLUSION: Health services need to provide safe practice for dialyzer reuse given the endemicity of hepatitis. We believe a national survey similar to ours about seroprevalence and infection control challenges would prepare Vietnam for providing safer satellite treatment units. Safe hemodialysis services should also comprise patient preparedness, education and counseling.

Hepatitis B and C virus infections among patients with end stage renal disease in a low-resourced hemodialysis center in Vietnam: a cross-sectional study.

BACKGROUND: Hemodialysis services in Vietnam are being decentralised outside of tertiary hospitals. To identify the challenges to infection control standards for the prevention of bloodborne infections including hepatitis B virus (HBV) and hepatitis C virus (HCV) we tested the magnitude of HBV and HCV infections in the largest unit in Ho Chi Minh City servicing patients with end stage renal disease. METHODS: All 113 patients provided consent HBV surface antigen (HBsAg) and HCV core antigen (HCV-coreAg) testing. Positive patients were tested for viral genotypes. All participants completed a questionnaire on demographic characteristics, risk factors and previous attendance to other hemodialysis units. RESULTS: Seroprevalence of 113 patients enrolled was 7% (8/113, 95% CI 2.3%-11.8%) HBsAg, 6% (7/113, 95% CI 1.7%-10.6%) HCV-coreAg and 1% (1/113, 95% CI 0.8%-2.6%) co-infection. Having a HBV positive sexual partner significantly increased the risk of acquiring HBV (P = 0.016, Odds Ratio (OR) =29, 95% CI 2-365). Risk factors for HCV included blood transfusion (P = 0.049), multiple visits to different hemodialysis units (P = 0.048, OR = 5.7, 95% CI 1.2-27.5), frequency of hemodialysis (P = 0.029) and AST plasma levels >40 IU/L (P = 0.020, OR = 19.8, 95% CI 2.3-171). On multivariate analysis only blood transfusion remained significant risk factor for HCV (P = 0.027, adjusted OR = 1.2). CONCLUSIONS: HCV screening for HCV of blood products must improve to meet the infection prevention challenges of decentralizing hemodialysis services. The level of HCV and HBV in our hemodialysis unit is a warning that universal precautions will be the next challenge for decentralised hemodialysis services in Vietnam.

Doctor, do you have a moment? National Hand Hygiene Initiative compliance in Australian hospitals.

OBJECTIVES: To examine hand hygiene compliance rates for medical and nursing staff, compliance with hand hygiene before touching a patient (Moment 1 of the Five moments for hand hygiene), and the effect of differential sampling of staff on the average national rate. Also, to establish whether hand hygiene rates impact Staphylococcus aureus bloodstream infections (SABSI). DESIGN AND SETTING: Analysis of data from three different cross-sectional datasets--Hand Hygiene Australia data for 246,665 hand hygiene opportunities during the first quarter (1 January to 31 March) of 2013 from 82 public hospitals representing eight Australian states and territories, and hand hygiene rates and SABSI rates from the MyHospitals website reported for 1 July 2011 to 30 June 2012. MAIN OUTCOME MEASURES: Compliance by medical and nursing staff for each hospital size (> 400 beds, 301-400 beds, 201-300 beds, and 101-200 beds); the proportion of hospitals with hand hygiene compliance rates for before touching a patient at or above, or below the national threshold of 70%; the impact of hand hygiene on SABSI. RESULTS: Medical staff consistently performed below the national threshold for hand hygiene compliance regardless of hospital size. Nurses' compliance was consistently above the threshold, and this inflated the total average national rate. A third of the patient interaction hand hygiene opportunities recorded involved before touching a patient, for which compliance was below the national threshold in 68% of hospitals. Hand hygiene has little impact on the rate of SABSI (incidence rate ratio, 0.97; P < 0.01). CONCLUSIONS: Posting a national unadjusted average hand hygiene compliance rate on a public website conceals the fact that most hospitals and medical staff are performing below the national hand hygiene compliance threshold. Given the poor compliance after 4 years of auditing to capture non-compliance, we must shift our focus to providing medical staff with immediate feedback and move to improving a single hand hygiene indication at a time, starting with before touching a patient.

Community-onset Staphylococcus aureus Surveillance Programme annual report, 2012.

In 2012, the Australian Group on Antimicrobial Resistance (AGAR) conducted a community-onset period-prevalence survey of clinical Staphylococcus aureus isolated from hospital outpatients and general practice patients including nursing homes, long term care facilities and hospice patients. Day surgery and dialysis patients were excluded. Twenty-nine medical microbiology laboratories from all state and mainland territories participated. Isolates were tested by Vitek2® (AST-P612 card). Results were compared with previous AGAR community surveys. Nationally, the proportion of S. aureus that were methicillin-resistant S. aureus (MRSA) increased significantly from 11.5% in 2000 to 17.9% in 2012 (P<0.0001). Resistance to the non-ß-lactam antimicrobials varied between regions. No resistance was detected to vancomycin, teicoplanin or linezolid. Resistance in methicillin susceptible S. aureus was rare apart from erythromycin (12.8%) and was absent for vancomycin, teicoplanin, linezolid and daptomycin. The proportion of S. aureus characterised as health care-associated MRSA (HA-MRSA) was 5.1%. Three HA-MRSA clones were characterised, with 72.9% and 26.4% of HA-MRSA classified as ST22-IV [2B] (EMRSA-15) and ST239-III [3A] (Aus-2/3 EMRSA) respectively. Multi-clonal community-associated MRSA (CA-MRSA) accounted for 12.5% of all S. aureus. Regional variation in resistance in MRSA was primarily due to the differential distribution of the 2 major HA-MRSA clones; ST239-III [3A] (Aus-2/3 EMRSA), which is resistant to multiple non-ß-lactam antimicrobials, and ST22-IV [2B] (EMRSA-15), which is resistant to ciprofloxacin and typically erythromycin. Although the majority of CA-MRSA were non-multi-resistant, a significant expansion of Panton-Valentine leukocidin (PVL) positive CA-MRSA clones has occurred nationally. The mean age of patients (31.7 years, 95% CI 28.9-34.5) with a PVL positive CA-MRSA infection was significantly lower (P<0.0001), than the mean age of patients with a PVL negative CA-MRSA infection (55.7 years, 95% CI 50.7-60.6). This shift in the molecular epidemiology of MRSA clones in the Australian community will potentially increase the number of young Australians with skin and soft tissue infections requiring hospitalisation.

Australian Staphylococcus aureus Sepsis Outcome Programme annual report, 2013.

From 1 January to 31 December 2013, around Australia 26 institutions around Australia participated in the Australian Staphylococcal Sepsis Outcome Programme (ASSOP). The aim of ASSOP 2013 was to determine the proportion of Staphylococcus aureus bacteraemia (SAB) isolates in Australia that are antimicrobial resistant, (with particular emphasis on susceptibility to methicillin) and to characterise the molecular epidemiology of the isolates. Overall 19.1% of the 2,010 SAB episodes were methicillin resistant, which is significantly higher than that reported in most European countries. Although the SAB 30-day all cause mortality appears to be decreasing in Australia, methicillin-resistant SAB associated mortality remains high (20.1%) and was significantly higher than methicillin-sensitive SAB associated mortality (13%) (P< 0.0001). With the exception of the ß-lactams and erythromycin, antimicrobial resistance in methicillin sensitive S. aureus remains rare. However, in addition to the ß-lactams, approximately 50% of methicillin-resistant S. aureus (MRSA) were resistant to erythromycin and ciprofloxacin and approximately 20% were resistant to co-trimoxazole, tetracycline and gentamicin. Linezolid, daptomycin and teicoplanin resistance was detected in a small number of S. aureus isolates. Resistance to vancomycin was not detected. Resistance was largely attributable to 2 healthcare associated MRSA clones; ST22-IV [2B] (EMRSA-15) and ST239-III [3A] (Aus-2/3 EMRSA). ST22-IV [2B] (EMRSA-15) has now become the predominant healthcare associated clone in Australia. Approximately 60% of methicillin-resistant SAB were due to community associated clones. Although polyclonal, almost 50% of community associated clones were characterised as ST93-IV [2B] (Queensland CA-MRSA) and ST1-IV [2B] (WA1). CA-MRSA, in particular the ST45-V [5C2&5] (WA84) clone, has acquired multiple antimicrobial resistance determinants including ciprofloxacin, erythromycin, clindamycin, gentamicin and tetracycline. As CA-MRSA is well established in the Australian community, it is important antimicrobial resistance patterns in community and healthcare associated SAB is monitored as this information will guide therapeutic practices in treating S. aureus sepsis.

Genomic characterization of extended-spectrum beta-lactamase-producing and carbapenem-resistant Escherichia coli from urban wastewater in Australia.

This study investigates extended-spectrum beta-lactamase-producing and carbapenem-resistant Escherichia coli isolates from Sydney's wastewater. These isolates exhibit resistance to critical antibiotics and harbor novel resistance mechanisms. The findings highlight the importance of wastewater-based surveillance in monitoring resistance beyond the clinical setting.

Respiratory virus RNA is detectable in airborne and droplet particles.

Aerosol transmission routes of respiratory viruses have been classified by the WHO on the basis of equilibrium particle size. Droplet transmission is associated with particles sized >5 µm in diameter and airborne transmission is associated with particles sized ≤5 µm in diameter. Current infection control measures for respiratory viruses are directed at preventing droplet transmission, although epidemiological evidence suggests concurrent airborne transmission also occurs. Understanding the size of particles carrying viruses can be used to inform infection control procedures and therefore reduce virus transmission. This study determined the size of particles carrying respiratory viral RNA produced on coughing and breathing by 12 adults and 41 children with symptomatic respiratory infections. A modified six-stage Andersen Sampler collected expelled particles. Each stage was washed to recover samples for viral RNA extraction. Influenza A and B, parainfluenza 1, 2 and 3, respiratory syncytial virus (RSV), human metapneumovirus and human rhinoviruses (hRV) were detected using RT-PCR. On breathing, 58% of participants produced large particles (>5 µm) containing viral RNA and 80% produced small particles (≤5 µm) carrying viral RNA. On coughing, 57% of participants produced large particles containing viral RNA and 82% produced small particles containing viral RNA. Forty five percent of participants produced samples positive for hRV viral RNA and 26% of participants produced samples positive for viral RNA from parainfluenza viruses. This study demonstrates that individuals with symptomatic respiratory viral infections produce both large and small particles carrying viral RNA on coughing and breathing.

Australian Group on Antimicrobial Resistance Hospital-onset Staphylococcus aureus Surveillance Programme annual report, 2011.

In 2011, the Australian Group on Antimicrobial Resistance (AGAR) conducted a period-prevalence survey of clinical Staphylococcus aureus isolated from hospital inpatients. Twenty-nine microbiology laboratories from all states and mainland territories participated. Specimens were collected more than 48 hours post-admission. Isolates were tested by Vitek2® antimicrobial susceptibility card (AST-P612 card). Nationally, the proportion of S. aureus that were methicillin-resistant S. aureus (MRSA) was 30.3%; ranging from 19.9% in Western Australia to 36.8% in New South Wales/Australian Capital Territory. Resistance to the non-ß-lactam antimicrobials was common except for rifampicin, fusidic acid, high-level mupirocin and daptomycin. No resistance was detected for vancomycin, teicoplanin or linezolid. Antibiotic resistance in methicillin susceptible S. aureus (MSSA) was rare apart from erythromycin (13.2%) and there was no resistance to vancomycin, teicoplanin or linezolid. Inducible clindamycin resistance was the norm for erythromycin resistant, clindamycin intermediate/susceptible S. aureus in Australia with 90.6% of MRSA and 83.1% of MSSA with this phenotype having a positive double disc diffusion test (D-test). The proportion of S. aureus characterised as being healthcare-associated MRSA (HA-MRSA) was 18.2%, ranging from 4.5% in Western Australia to 28.0% in New South Wales/Australian Capital Territory. Four HA-MRSA clones were characterised and 98.8% of HA-MRSA isolates were classified as either ST22-IV [2B] (EMRSA-15) or ST239-III [3A] (Aus-2/3 EMRSA). Multiclonal community-associated MRSA (CA-MRSA) accounted for 11.7% of all S. aureus. In Australia, regional variation in resistance is due to the differential distribution of MRSA clones between regions, particularly for the major HA-MRSA clone, ST239-III [3A] (Aus-2/3 EMRSA), which is resistant to multiple non-ß-lactam antimicrobials.

Wastewater-based monitoring reveals geospatial-temporal trends for antibiotic-resistant pathogens in a large urban community.

Antimicrobial resistance (AMR) is one of the top ten global health threats, and current surveillance programs rarely monitor it outside healthcare settings. This limits our ability to understand and manage the spread of AMR. Wastewater testing has the potential to simply, reliably and continuously survey trends in AMR outside the healthcare settings, as it captures biological material from the entire community. To establish and evaluate such a surveillance, we monitored wastewater for four clinically significant pathogens across the urban area of Greater Sydney, Australia. Untreated wastewater from 25 wastewater treatment plants (WWTPs) covering distinct catchment regions of 5.2 million residents was sampled between 2017 and 2019. Isolates for extended-spectrum ß-lactamases-producing Enterobacteriaceae (ESBL-E) were consistently detected, suggesting its endemicity in the community. Isolates for carbapenem-resistant Enterobacteriaceae (CRE), vancomycin-resistant enterococci (VRE), and methicillin-resistant Staphylococcus aureus (MRSA) were only occasionally detected. The flow normalized relative (FNR) ESBL-E load was positively correlated with the proportion of the population between 19 and 50 years of age, completion of vocational education and the average length of hospital stay. Collectively, these variables explained only a third of the variance of the FNR ESBL-E load, indicating further, yet-unidentified factors as a contributor to the distribution. About half of the variation in the FNR CRE load was explained by the average length of hospital stay, showing healthcare-related drivers. Interestingly, variation in the FNR VRE load was not correlated to healthcare-related parameters but to the number of schools per 10,000 population. Our study provides insight into how routine wastewater surveillance can be used to understand the factors driving the distribution of AMR in an urban community. Such information can help to manage and mitigate the emergence and spread of AMR in important human pathogens.

Is it possible to achieve a target of zero central line associated bloodstream infections?

PURPOSE OF REVIEW: Central venous catheter (CVC)-associated bloodstream infections (CLABSIs) result in poorer patient outcomes and increased healthcare costs. Reduced reimbursement for CLABSI events is now provided for hospitalized patients in the United States. Although a zero target is proposed, the feasibility has not been evaluated. The objective of this review is to identify factors contributing to CLABSI and determine whether current evidence supports attainment of a zero infection rate. RECENT FINDINGS: Limitations of current surveillance methods and reporting of aggregate data impact on achieving target CLABSI rates. Standard prevention practices, including physician and patient preparation (e.g. hand hygiene), are frequently incorporated into bundles of care. CVC dwell time has been identified as means of risk stratification. Additional strategies (e.g. chlorhexidine-impregnated dressings, antimicrobial-coated devices) may be better used in patients with expected long dwell times. Non-ICU populations are increasingly targeted with prevention strategies, but expected rates of infection have not been proposed. SUMMARY: A zero CLABSI rate should be the target only for ICU populations having CVCs with a dwell time of 1-9 days following aseptic insertion. Additional measures should be reserved for patients with expected longer dwell time. Refinement and validation of surveillance methodology is required before target CLABSI rates can be proposed for non-ICU populations.

Zero risk for central line-associated bloodstream infection: are we there yet?.

OBJECTIVE: Identify the longest period a central line remains free from central line-associated bloodstream infection during an 18-month insertion-bundle project. DESIGN: Prospective cohort. SETTING: New South Wales adult intensive care units at university teaching hospitals between July 2007 and December 2008. PATIENTS: Intensive care unit adult patients whose central line was inserted in the intensive care unit. INTERVENTION: Compliance with the insertion bundle for central lines during the first 12-month roll-out period and the last 6 months. MAIN OUTCOMES: The cumulative line days that remained close to infection-free before the lowest probability of central line-associated bloodstream infection, 1 in 100 chances, was identified using conditional probability modeling. An adjusted central line-associated bloodstream infection rate was calculated for these cumulated line days and thereafter where the probability for infection increased with additional dwell time. RESULTS: The lowest probability identified for central line-associated bloodstream infection was 1 in 100 chances regardless of the phase of the project or central line type. During the first 12 months of the project, the close to infection-free period finished by the end of day 7 giving an adjusted central line-associated bloodstream infection rate of 1.8 (95% confidence interval 0.9-3.3)/1000 line days. By the last 6 months of the project the close to infection-free period was extended by 2 additional line days to the end of day 9, giving an adjusted central line-associated bloodstream infection rate of 0.9 (95% confidence interval 0.5-1.5)/1,000 line days. For dialysis and unspecified central line types, the close to infection-free period was extended by 5 additional line days, from day 2 with a rate of 4.3 (95% confidence interval 0.9-12.5)/1,000 line days to day 7, giving a rate of 0.6 (95% confidence interval 0.2-2.4)/1,000 line days. CONCLUSION: The success of the insertion bundle was identified by improved analysis that identified that the safest dwell time was extended to the first 9 days for centrally inserted lines and up to day 7 for dialysis, peripherally inserted central catheters, and unspecified central line types. Given that three quarters of intensive care unit patients have their central line removed by day 7, zero risk for central line-associated bloodstream infection should be achievable in the majority of patients where clinicians comply with the clinician and patient insertion bundles.

Using evidence-based medicine to protect healthcare workers from pandemic influenza: Is it possible?

OBJECTIVE: To use evidence-based principles to develop infection control algorithms to ensure the protection of healthcare workers and the continuity of health service provision during a pandemic. DESIGN: : Evidence-based algorithms were developed from published research as well as "needs and values" assessments. Research evidence was obtained from 97 studies reporting the protectiveness of antiviral prophylaxis, seasonal vaccination, and mask use. Needs and values assessments were undertaken by international experts in pandemic infection control and local healthcare workers. Opportunity and resources costs were not determined. SETTING: The Australian government commissioned the development of an evidence-based algorithm for inclusion in the 2008 revision of the Australian Health and Management Plan for Pandemic Influenza. PARTICIPANTS: Two international infection control teams responsible for healthcare worker safety during the Severe Acute Respiratory Syndrome outbreak reviewed the evidence-based algorithms. The algorithms were then reviewed for needs and values by eight local clinicians who were considered key frontline clinicians during the contain and sustain phases. The international teams reviewed for practicability of implementation, whereas local clinicians reviewed for clinician compliance. RESULTS: Despite strong evidence for vaccination and antiviral prophylaxis providing significant protection, clinicians believed they required the additional combinations of both masks and face shields. Despite the equivocal evidence for the efficacy of surgical and N95 masks and the provision of algorithms appropriate for the level of risk according to clinical care during a pandemic, clinicians still demanded N95 masks plus face shields in combination with prophylaxis and novel vaccination. CONCLUSIONS: Conventional evidence-based principles could not be applied to formulate recommendations due to the lack of pandemic-specific efficacy data of protection tools and the inherent unpredictability of pandemics. As an alternative, evidence-based principles have been used to formulate recommendations while giving priority to the needs and values of healthcare workers over the research evidence.