Cervical cancer screening in rural mountainous Honduras: knowledge, attitudes and barriers.

INTRODUCTION: Because cervical cancer is the leading cause of cancer mortality in Honduras, this study assessed knowledge, attitudes and barriers to cervical cancer screening services by Papanicolaou smear (pap smear) for women in rural, remote Honduras served by Virginia Commonwealth University's Global Health and Health Disparities Program (GH2DP). METHODS: Two interviewers administered an institutional review board approved, 20 question survey by convenience sample methodology to adult female patients visiting GH2DP clinics in June 2014. A total of 146 surveys were completed. Of the respondents, 30 were living in La Hicaca, the largest and wealthiest village in the region, and 116 were living in surrounding, less affluent, villages. RESULTS: On average, women from La Hicaca had 2.9 children whereas women from surrounding villages had 4.3 children (p=0.0095). There were no significant differences between La Hicaca and surrounding villages in average respondent age, age of first intercourse and number of sexual partners. Seventy three percent (22/30) of women from La Hicaca and 60% (70/116) from surrounding villages reported undergoing cervical cancer screening by pap smear (p=0.1890). Eighty-two percent (18/22) of the respondents from La Hicaca and 84% (59/70) from surrounding villages were screened in the past two years (p=0.7846). The majority of the women from surrounding villages (81%, 57/70) and 23% (5/22) from La Hicaca traveled >1 h to receive a pap smear (p≤0.0001). Women from La Hicaca (86%, 19/22) were more likely to receive their pap smear results than women from surrounding villages (60%, 42/70) (p=0.0225). Although 17% (5/30) of respondents from La Hicaca and 11% (13/116) (p=0.4175) from surrounding villages were aware of the cause of cervical cancer, 60% (18/30) of women in La Hicaca and 82% (95/116) in surrounding villages (p=0.0106) believed it is preventable. Of the 106 women (73%) who had heard of cervical cancer screening, only 92 women (63%) had been screened (p<0.0001). Women undergoing cervical cancer screening were more likely to believe that cervical cancer is preventable (n=78, p=0.0054). The most common screening barriers were lack of awareness and fear (19/54, 35%; 15/54, 28%). CONCLUSIONS: Although yearly screening services are available in this community, knowledge and access barriers exist for increased implementation. Notification of pap smear results is suboptimal. These findings will guide regional and collaborative effort to improve cervical cancer screening services.

Effect of daily chlorhexidine bathing on hospital-acquired infection.

BACKGROUND: Results of previous single-center, observational studies suggest that daily bathing of patients with chlorhexidine may prevent hospital-acquired bloodstream infections and the acquisition of multidrug-resistant organisms (MDROs). METHODS: We conducted a multicenter, cluster-randomized, nonblinded crossover trial to evaluate the effect of daily bathing with chlorhexidine-impregnated washcloths on the acquisition of MDROs and the incidence of hospital-acquired bloodstream infections. Nine intensive care and bone marrow transplantation units in six hospitals were randomly assigned to bathe patients either with no-rinse 2% chlorhexidine-impregnated washcloths or with nonantimicrobial washcloths for a 6-month period, exchanged for the alternate product during the subsequent 6 months. The incidence rates of acquisition of MDROs and the rates of hospital-acquired bloodstream infections were compared between the two periods by means of Poisson regression analysis. RESULTS: A total of 7727 patients were enrolled during the study. The overall rate of MDRO acquisition was 5.10 cases per 1000 patient-days with chlorhexidine bathing versus 6.60 cases per 1000 patient-days with nonantimicrobial washcloths (P=0.03), the equivalent of a 23% lower rate with chlorhexidine bathing. The overall rate of hospital-acquired bloodstream infections was 4.78 cases per 1000 patient-days with chlorhexidine bathing versus 6.60 cases per 1000 patient-days with nonantimicrobial washcloths (P=0.007), a 28% lower rate with chlorhexidine-impregnated washcloths. No serious skin reactions were noted during either study period. CONCLUSIONS: Daily bathing with chlorhexidine-impregnated washcloths significantly reduced the risks of acquisition of MDROs and development of hospital-acquired bloodstream infections. (Funded by the Centers for Disease Control and Prevention and Sage Products; ClinicalTrials.gov number, NCT00502476.).

Knowledge and perceptions of Chagas disease in a rural Honduran community.

INTRODUCTION: Honduras has a high prevalence of Trypanosomacruzi infection. The purpose of this study was to assess the knowledge and attitudes of Chagas disease in 17 geographically proximal rural Honduran communities. These communities are under the same local health ministry and are served by yearly medical relief efforts. La Hicaca (LH), although impoverished, is wealthier than the surrounding villages (SV). METHODS: A 15-item, interviewer-administered, convenience sample questionnaire was employed on adult patients attending a brigade clinic in LH and SV. Pearson χ² and Fisher's exact tests were used to compare knowledge and attitudes of Chagas disease, environmental risks, and access to treatment between LH and SV. RESULTS: One hundred and seventy-seven questionnaires were completed. The majority of respondents were aware of Chagas disease (90%, n=159). Only a minority of respondents understood disease transmission (2%, n=3). There was no significant difference in self-reported presence of the reduviid bug in homes in SV or LH (76% (n=85) vs 65% (n=42), p=0.11). In SV, 77% (n=74) of people had never been tested for Chagas, compared to 67% (n=42) in LH, p=0.90. Likewise, no significant difference was observed in perceived access to treatment between SV and LH (54% (n=50) vs 44% (n=24), p=0.23). Participants from SV perceived a higher risk of contracting Chagas disease than did people from LH (38% (n=40) vs 23% (n=23), p=0.05). Nearly all participants were interested in being tested for Chagas disease (90%, n=159) and in implementing preventative measures (98%, n=170). CONCLUSIONS: Prior studies reported differences in healthcare access across these communities. In contrast, these findings suggest that knowledge of Chagas disease and environmental risk factors are similar between communities, although SV respondents perceived a higher risk of disease transmission. These findings have implications for future education and prevention campaigns in the area.

Water sanitation, access, use and self-reported diarrheal disease in rural Honduras.

INTRODUCTION: Only 79% of individuals living in rural Honduras use improved water sources. Inadequate drinking water quality is related to diarrheal illness, which in Honduras contributes to 18.6 episodes of diarrhea per child year in children under five years of age. The purpose of this study was to examine and compare access to drinking water and sanitation, as well as self-reported diarrheal disease incidence among three proximal communities in the Department of Yoro area of Honduras. METHODS: An 11-item language-specific, interviewer-administered, anonymous questionnaire was administered to 263 randomly selected adults attending a June 2011 medical brigade held in the communities of Coyoles, La Hicaca, and Lomitas. Chi-square with Fisher exact tests were utilized to compare water access, sanitation, and self-reported diarrheal incidence among these communities. RESULTS: Coyoles and La Hicaca used private faucets as their primary water sources. Coyoles had the greatest use of bottled water. Lomitas used rivers as their primary water source, and did not use bottled water. Mostly, females were responsible for acquiring water. Usage of multiple water sanitation methods was most common in Coyoles, while no sanitation method was most common in Lomitas. In Lomitas and La Hicaca, water filters were mostly provided via donation by non-governmental organizations. Lomitas had the highest reported incidence of diarrhea among self and other household members. CONCLUSIONS: Critical differences in water access, sanitation, and self-reported diarrheal incidence among three geographically distinct, yet proximal, communities highlights the need for targeted interventions even in geographically proximal rural areas.

Universal staphylococcal decolonization for elective surgeries: The patient perspective.

BACKGROUND: Staphylococcal decolonization decreases the risk of Staphylococcus aureus surgical site infection. This study evaluates patient perceptions and barriers to a universal Staphylococcal decolonization (USD) protocol. METHODS: In October 2013, a protocol for the decolonization of Staphylococcal aureus in elective orthopedic, neurosurgical, and cardiac surgeries was implemented in an effort to further decrease post-operative infections rates. We surveyed patients undergoing these procedures between November 2014 and April 2015 using an anonymous, voluntary, Likert-scale survey; survey questions targeted compliance with the protocol as well as barriers to protocol completion. RESULTS: A sample of 546 patients (n=1289, 42%) undergoing elective neurosurgical and orthopedic surgeries completed surveys. Respondents had 85% compliance with USD. Insufficient time prior to the procedure to complete the protocol was the largest barrier to USD completion. CONCLUSIONS: This study provides evidence that USD is acceptable to patients, and that the biggest barriers are logistical.

Impact of Discontinuing Contact Precautions for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus: An Interrupted Time Series Analysis.

OBJECTIVETo investigate the impact of discontinuing contact precautions among patients infected or colonized with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) on rates of healthcare-associated infection (HAI). DESIGN: Single-center, quasi-experimental study conducted between 2011 and 2016.METHODSWe employed an interrupted time series design to evaluate the impact of 7 horizontal infection prevention interventions across intensive care units (ICUs) and hospital wards at an 865-bed urban, academic medical center. These interventions included (1) implementation of a urinary catheter bundle in January 2011, (2) chlorhexidine gluconate (CHG) perineal care outside ICUs in June 2011, (3) hospital-wide CHG bathing outside of ICUs in March 2012, (4) discontinuation of contact precautions in April 2013 for MRSA and VRE, (5) assessments and feedback with bare below the elbows (BBE) and contact precautions in August 2014, (6) implementation of an ultraviolet-C disinfection robot in March 2015, and (7) 72-hour automatic urinary catheter discontinuation orders in March 2016. Segmented regression modeling was performed to assess the changes in the infection rates attributable to the interventions.RESULTSThe rate of HAI declined throughout the study period. Infection rates for MRSA and VRE decreased by 1.31 (P=.76) and 6.25 (P=.21) per 100,000 patient days, respectively, and the infection rate decreased by 2.44 per 10,000 patient days (P=.23) for device-associated HAI following discontinuation of contact precautions.CONCLUSIONThe discontinuation of contact precautions for patients infected or colonized with MRSA or VRE, when combined with horizontal infection prevention measures was not associated with an increased incidence of MRSA and VRE device-associated infections. This approach may represent a safe and cost-effective strategy for managing these patients.Infect Control Hosp Epidemiol 2018;39:676-682.

Description of a restriction program for gram-positive antimicrobial agents at an academic medical center.

This report examines the effectiveness of antimicrobial restriction at 1 tertiary care health care system by analyzing the consumption of restricted versus nonrestricted gram-positive agents over time for medical versus surgical units. Significant reductions in restricted antibiotic use were detected in 57% of medical units versus none of the surgical units. There were no significant reductions in nonrestricted antibiotic use. We think looking at antibiotic consumption by service line provides opportunities for targeted antibiotic restriction program refinement.

Acceptability and Necessity of Training for Optimal Personal Protective Equipment Use.

Healthcare workers routinely self-contaminate even when using personal protective equipment. Observations of donning/ doffing practices on inpatient units along with surveys were used to assess the need for a personal protective equipment training program. In contrast to low perceived risk, observed doffing behaviors demonstrate significant personal protective equipment technique deficits. Infect Control Hosp Epidemiol 2017;38:226-229.

Antimicrobial stewardship practices in Virginia.

The Society of Healthcare Epidemiology of America, the Centers for Disease Control and Prevention, and the President's Council of Advisors on Science and Technology recognize the need to combat antimicrobial resistance through the promotion of antimicrobial stewardship programs. Health care facilities in Virginia were surveyed using a 23-item survey focused on facility characteristics and antimicrobial stewardship strategies. Antimicrobial stewardship activities were highly variable and many are missing key personnel and resources.

Ultraviolet-C light as a means of disinfecting anesthesia workstations.

BACKGROUND: Anesthesia workstations (AWs) are a reservoir for pathogenic organisms potentially associated with surgical site infections. This study examined the effectiveness of the Tru-D SmartUVC device (Tru-D LLC, Nashville, TN) on bioburden reduction (BR) on AWs. METHODS: Strips of tissue inoculated with a known concentration of either Staphylococcus aureus, Enterococcus faecalis, or Acinetobacter sp were placed on 22 high-touch surfaces of an AW. Half of the AW surfaces received direct ultraviolet (UV) light exposure and half received indirect exposure. Two inoculated strips, in sterile tubes outside of the room, represented the control. Trials were conducted on AWs in an operating room and a small room. Strips were placed in a saline solution, vortexed, and plated on blood agar to assess BR by the number of colony forming units. RESULTS: All experimental trials, compared with controls, exhibited a BR >99%. There was a significantly greater reduction of E faecalis colony forming units in the operating room AW under direct exposure (P = .019) compared with indirect exposure. There was no significant difference in reduction when comparing AWs between rooms. CONCLUSION: Regardless of room size and exposure type, automated UV-C treatment greatly influences BR on AW high-touch surfaces. Hospitals instituting an automated UV-C system as an infection prevention adjunct should consider utilizing it in operating rooms for BR as part of a horizontal infection prevention surgical site infection-reduction strategy.

Barriers, perceptions, and adherence: Hand hygiene in the operating room and endoscopy suite.

We examined the perceptions and barriers to nonsurgical scrubbed hand hygiene in the operating room and endoscopy procedure room using 2 anonymous Likert-scale surveys. Results indicated poor role modeling, inconvenience, and the need to monitor hand hygiene and feedback data to providers because of poor self-awareness of hand hygiene practices.

Continued non-compliance with the American College of Surgeons recommendations to decrease infectious exposure in the operating room: why?

BACKGROUND: The American College of Surgeons (ACS) Statement on Sharps Safety recommends the use of double gloving (DG), hands-free zone (HFZ), and blunt-tip suture needles (BTSN) in the operating room to decrease needlestick injuries. Despite this endorsement, compliance is low. This survey determined the perceptions, attitudes, and barriers to compliance with these guidelines. METHODS: A survey using a voluntary convenience sample of surgical staff members in which queries related to understanding of the ACS recommendations were posed. A total of 107 of the 324 surveys were completed and returned, for a response rate of 33%. Most respondents were residents (64%) or attending surgeons (29%). RESULTS: Respondents were most familiar with recommendations for DG (58% of residents and 68% of attendings) and HFZ (61% for both groups) but less so for BTSN (48% of residents and 52% of attendings). More than 50% of the staff believed that DG decreased the risk of needlesticks, yet fewer than half used DG more than 75% of the time. Half believed that HFZ protected from sticks, yet fewer than 10% used it at least 75% of the time. Fewer than 50% believed that BTSN minimizes the risk of injury, with fewer than 10% of respondents using them at least 75% of the time. Reasons for non-compliance included decreased tactile sensation with DG, lack of training with HFZ, and lack of availability of BTSN. CONCLUSIONS: To improve compliance with the ACS recommendations, institutions must improve awareness of the guidelines and the benefits associated with compliance and remove barriers to their incorporation into standard practice.

Access and Barriers to Healthcare Vary among Three Neighboring Communities in Northern Honduras.

Objective. The aim of this study is to describe and compare access and barriers to health services in three proximal yet topographically distinct communities in northern Honduras served by the nonprofit organization the Honduras Outreach Medical Brigada Relief Effort (HOMBRE). Methods. Study personnel employed a 25-item questionnaire in Spanish at the point of care during HOMBRE clinics in Coyoles, Lomitas, and La Hicaca (N = 220). We describe and compare the responses between sites, using Chi-squared and Fisher Exact tests. Results. Respondents in Lomitas demonstrated the greatest limitations in access and greatest barriers to care of all sites. Major limitations in access included "never" being able to obtain a blood test, obtain radiology services, and see a specialist. Major barriers were cost, distance, facility overcrowding, transportation, being too ill to go, inability to take time off work, and lack of alternate childcare. Conclusions. Despite being under the same local health authority, geographically remote Honduran communities experience greater burdens in healthcare access and barriers than neighboring communities of the same region.

A crossover trial of antimicrobial scrubs to reduce methicillin-resistant Staphylococcus aureus burden on healthcare worker apparel.

BACKGROUND: The impact of antimicrobial scrubs on healthcare worker (HCW) bacterial burden is unknown. Objective. To determine the effectiveness of antimicrobial scrubs on hand and apparel bacterial burden. DESIGN: Prospective, crossover trial. SETTING AND PARTICIPANTS: Thirty HCWs randomized to study versus control scrubs in an intensive care unit. METHODS: Weekly microbiology samples were obtained from scrub abdominal area, cargo pocket, and hands. Mean log colony-forming unit (CFU) counts were calculated. Compliance with hand hygiene practices was measured. Apparel and hand mean log CFU counts were compared. RESULTS: Adherence measures were 78% (910/1,173) for hand hygiene and 82% (223/273) for scrubs. Culture compliance was 67% (306/460). No differences were observed in bacterial hand burden or in HCWs with unique positive scrub cultures. No difference in vancomycin-resistant enterococci (VRE) and gram-negative rod (GNR) burden was observed. A difference in mean log methicillin-resistant Staphylococcus aureus (MRSA) CFU count was found between study and control scrubs for leg cargo pocket (mean log CFUs, 11.84 control scrub vs 6.71 study scrub; [Formula: see text]), abdominal area (mean log CFUs, 11.35 control scrub vs 7.54 study scrub; [Formula: see text]), leg cargo pocket at the beginning of shift (mean log CFUs, 11.96 control scrub vs 4.87 study scrub; [Formula: see text]), and abdominal area pocket at the end of shift (mean log CFUs, 12.14 control scrubs vs 8.22 study scrub; [Formula: see text]). CONCLUSIONS: Study scrubs were associated with a 4-7 mean log reduction in MRSA burden but not VRE or GNRs. A prospective trial is needed to measure the impact of antimicrobial impregnated apparel on MRSA transmission rates.

Trial of universal gloving with emollient-impregnated gloves to promote skin health and prevent the transmission of multidrug-resistant organisms in a surgical intensive care unit.

OBJECTIVE: To compare the efficacy of universal gloving with emollient-impregnated gloves with standard contact precautions for the control of multidrug-resistant organisms (MDROs) and to measure the effect on healthcare workers' (HCWs') hand skin health. DESIGN: Prospective before-after trial. SETTING: An 18-bed surgical intensive care unit. METHODS: During phase 1 (September 2007 through March 2008) standard contact precautions were used. During phase 2 (March 2008 through September 2008) universal gloving with emollient-impregnated gloves was used, and no contact precautions. Patients were screened for vancomycin-resistant Enterococcus (VRE) and methicillin-resistant Staphylococcus aureus (MRSA). HCW hand hygiene compliance and hand skin health and microbial contamination were assessed. The incidences of device-associated infection and Clostridium difficile infection (CDI) were determined. RESULTS: The rate of compliance with contact precautions (phase 1) was 67%, and the rate of compliance with universal gloving (phase 2) was 78% (P = .01). Hand hygiene compliance was higher during phase 2 than during phase 1 (before patient care, 40% vs 35% of encounters; P = .001; after patient care, 63% vs 51% of encounters; P < .001). No difference was observed in MDRO acquisition. During phases 1 and 2, incidences of device-related infections, in number of infections per 1,000 device-days, were, respectively, 3.7 and 2.6 for bloodstream infection (P = .10), 8.9 and 7.8 for urinary tract infection (P = .10), and 1.0 and 1.1 for ventilator-associated pneumonia (P = .09). The CDI incidence in phase 1 and in phase 2 was, respectively, 2.0 and 1.4 cases per 1,000 patient-days (P = .53). During phase 1, 29% of HCW hand cultures were MRSA positive, compared with 13% during phase 2 (P = .17); during phase 1, 2% of hand cultures were VRE positive, compared with 0 during phase 2 (P = .16). Hand skin health improved during phase 2. CONCLUSIONS: Compared with contact precautions, universal gloving with emollient-impregnated gloves was associated with improved hand hygiene compliance and skin health. No statistically significant change in the rates of device-associated infection, CDI, or patient MDRO acquisition was observed. Universal gloving may be an alternative to contact precautions.