Infection control systems in transition: the challenges for post-Soviet Bloc countries.

BACKGROUND: Just two decades ago, 30 of today's countries in Europe and Asia had socialist governments under Soviet dominance or direct administration. Intensive health system reforms have altered infection control in many of these countries. However, much of the literature from these countries is difficult to access by international scientists. AIM: To summarize existing infection control policies and practices in post-Soviet Bloc countries. METHODS: In addition to PubMed and Google search engines, we explored local websites and grey literature. In total, 192 references published in several languages were reviewed. FINDINGS: Infection control in these countries is in the midst of transition. Three groups of countries were identified. First, Eastern European and Baltic countries building surveillance systems for specific pathogens and antibiotic use; second, European post-Soviet Bloc countries focusing on the harmonization of recently established infection control infrastructure with European surveillance programmes; third, countries such as those formerly in the Union of Soviet Socialist Republics, Mongolia and post-conflict Eastern European countries that are in the first stages of reform. Poor commitment, resource scarcity and shortages of expertise were identified. Underreporting of official infection control statistics is widespread. CONCLUSIONS: Guidance from international organizations has been crucial in initiating and developing contemporary infection control programmes. More support from the international community will be needed for the third group of countries, where infection control has remained a neglected issue.

Do staffing and workload levels influence the risk of new acquisitions of meticillin-resistant Staphylococcus aureus in a well-resourced intensive care unit?

BACKGROUND: Staffing deficits and workload have may a bearing on transmission of meticillin-resistant Staphylococcus aureus (MRSA) within intensive care units (ICUs). New MRSA acquistions may provide a clearer picture of the relationship between MRSA acquisition and staffing in the ICU setting. AIM: To determine whether staffing and bed occupancy rates had an immediate or delayed impact on the number of new MRSA acquisitions in a well-staffed ICU, and whether these variables could be used as predictors of future MRSA acquisitions. METHODS: Data on new MRSA acquisitions in the ICU of a 796-bed metropolitan Australian hospital between January 2003 and December 2006 were used to build a model to predict the probabilility of actual new MRSA acquisitions in 2007. Cross validation was performed using receiver operator characteristic analysis. FINDINGS: Sixty-one new MRSA acquisitions (21 infections, 40 colonizations) were identified in 51 individual weeks over the study period. The number of non-permanent staffing hours was relatively small. The area under the curve in the cross-validation analysis was 0.46 [95% CI 0.25-0.67] which suggests that the model, built on data from 2003-2006, was not able to predict weeks in which new MRSA acquisitions occurred in 2007. CONCLUSION: The risks posed by high workloads may have been mitigated by good compliance with infection control measures, nurse training and adequate staffing ratios in the ICU. Consequently, staffing policies and the infection control practices in the ICU do not need to be modified to address the rate of new MRSA acquisitions.

Funnel plots and risk-adjusted count data adverse events. A limitation of indirect standardisation.

Reporting of hospital adverse event data is becoming increasingly mandated and this has motivated work on methods for the analysis and display of these data for groups of institutions. Currently, the method preferred by many workers is the funnel plot. Often, indirect standardisation is employed to produce these plots. It appears that, when used to display binary data such as surgical site infection or mortality data, the method is satisfactory. Increasingly, these data are risk-adjusted. However, risk adjustment of these data usually involves individual patients undergoing the same or similar procedures and the method does not appear to mislead. However, when dealing with count data such as bacteraemias it appears that this method can mislead, particularly where methods for risk adjustment of these data are used. Information about the hospitals or units of interest rather than individual patients is employed. For example, one hospital may have plastic and cardiac surgery units in which bacteraemias occur infrequently whereas another may provide treatment for renal failure (including transplantation) and have a large haematology-oncology unit (also including transplantation), each of which would expect higher bacteraemia rates. Moreover, the hospitals and units within them may differ substantially in size. It is well known that indirect standardisation can give biased results when denominators differ substantially. We illustrate this difficulty with risk-adjusted bacteraemia data from the Queensland Health Centre for Healthcare Infection, Surveillance and Prevention (CHRISP) database.

Nocardia cyriacigeorgica abscess of the conus medullaris in an immunocompetent host.

Conus medullaris abscesses are a distinct and rare subset of spinal intramedullary infections. We report a patient with a pyogenic abscess of the conus from which we cultured Nocardia cyriacigeorgica following operative evacuation. This is the first report identifying this species as a pathogen in conus abscess formation.

Organisation of hospital infection control in Mongolia.

As with other areas of the public sector in Mongolia, the healthcare system has undergone significant structural and policy reforms since the early 1990s. The previous infection control system, characterised as a sanitary-epidemiological network, was dismantled with no replacement. A new infection control management system was established in 1997 with the adoption of infection control policies and guidelines, establishment of hospital infection control programmes in all major hospitals, training of health professionals and the commencement of passive surveillance of hospital-acquired infections (HAIs). Recent health statistics claim that HAIs occur in 0.01-0.02% of all hospital admissions with the highest percentage (0.05%) in tertiary hospitals in the capital city Ulaanbaatar, but this is very likely to be an underestimate. In 2002 the Government approved a national programme to establish a sentinel surveillance system for HAIs with improved laboratory-based monitoring. However, implementation has been delayed due to insufficient support from stakeholders and a shortage of resources and trained infection control professionals. Non-governmental infection control initiatives are limited by time and coverage.

Prevalence of hospital-acquired infections and antibiotic use in two tertiary Mongolian hospitals.

Health statistics of Mongolia indicate that hospital-acquired infections (HAIs) occur in 0.01-0.05% of all hospital admissions. This is considerably lower than internationally reported rates. A one-day survey was conducted in two tertiary hospitals of Ulaanbaatar in September 2008 to estimate HAI prevalence, associated risk factors and patterns of antibiotic usage. Among 933 patients surveyed, 50 (5.4%) were diagnosed with HAI. Prevalence of surgical site infection was 1.1% (3.9% among surgical patients), bloodstream infection 0.3%, respiratory tract infection 1.3%, urinary tract infection 1.3%, and other HAI 1.4%. Microbiological investigations were only documented for 18.9% of all patients. A total of 558 patients (59.8%) were taking 902 courses of antibiotics; 92.1% of patients were prescribed antibiotics without a sensitivity test. Multiple logistic regression analysis revealed that HAI was significantly associated with the admission source, the hospital, length of hospital stay, surgical and other invasive procedures, urinary catheters and other indwelling devices. The study results were comparable with reports from some other developing countries and confirm that official statistics underestimate the true frequency of HAI in Mongolia.

Hospital adverse events and control charts: the need for a new paradigm.

Control charts are being increasingly used to summarise sequential rates of hospital adverse events (AEs). They are designed to detect departures from stable, predictable processes and are therefore appropriate when information about the mean value and variability of the relevant time-series data is available, from when the process is or has been in a stable, predictable state. This is often the case with binary data AEs such as surgical site infections and surgical mortality. However, it may not always be possible to determine the stable predictable rate at which events such as patient falls, pressure ulcers, medication errors or new isolates of a multiresistant organism (MRO) occur. Furthermore, such a rate may sometimes not exist, as is frequently the case with antibiotic usage and MRO prevalence data. It may then be better to employ time-series methods to analyse and present the data. A convenient approach is to employ spline-regression or a generalised additive model.

Improved hospital-level risk adjustment for surveillance of healthcare-associated bloodstream infections: a retrospective cohort study.

BACKGROUND: To allow direct comparison of bloodstream infection (BSI) rates between hospitals for performance measurement, observed rates need to be risk adjusted according to the types of patients cared for by the hospital. However, attribute data on all individual patients are often unavailable and hospital-level risk adjustment needs to be done using indirect indicator variables of patient case mix, such as hospital level. We aimed to identify medical services associated with high or low BSI rates, and to evaluate the services provided by the hospital as indicators that can be used for more objective hospital-level risk adjustment. METHODS: From February 2001-December 2007, 1719 monthly BSI counts were available from 18 hospitals in Queensland, Australia. BSI outcomes were stratified into four groups: overall BSI (OBSI), Staphylococcus aureus BSI (STAPH), intravascular device-related S. aureus BSI (IVD-STAPH) and methicillin-resistant S. aureus BSI (MRSA). Twelve services were considered as candidate risk-adjustment variables. For OBSI, STAPH and IVD-STAPH, we developed generalized estimating equation Poisson regression models that accounted for autocorrelation in longitudinal counts. Due to a lack of autocorrelation, a standard logistic regression model was specified for MRSA. RESULTS: Four risk services were identified for OBSI: AIDS (IRR 2.14, 95% CI 1.20 to 3.82), infectious diseases (IRR 2.72, 95% CI 1.97 to 3.76), oncology (IRR 1.60, 95% CI 1.29 to 1.98) and bone marrow transplants (IRR 1.52, 95% CI 1.14 to 2.03). Four protective services were also found. A similar but smaller group of risk and protective services were found for the other outcomes. Acceptable agreement between observed and fitted values was found for the OBSI and STAPH models but not for the IVD-STAPH and MRSA models. However, the IVD-STAPH and MRSA models successfully discriminated between hospitals with higher and lower BSI rates. CONCLUSION: The high model goodness-of-fit and the higher frequency of OBSI and STAPH outcomes indicated that hospital-specific risk adjustment based on medical services provided would be useful for these outcomes in Queensland. The low frequency of IVD-STAPH and MRSA outcomes indicated that development of a hospital-level risk score was a more valid method of risk adjustment for these outcomes.

Esomeprazole induces upper gastrointestinal tract transmucosal permeability increase.

BACKGROUND: Proton pump inhibitors (PPIs) are one of the most widely used drug classes in the US and are now frontline medications for gastro-oesophageal reflux disease (GERD) and dyspepsia. In a previous work, we observed that a transmucosal, upper gastrointestinal (GI) leak exists in Barrett's oesophagus (BO) patients. PPI medications are commonly used by Barrett's patients. AIM: To examine if the PPI, esomeprazole, affects the barrier function of the upper GI tract. METHODS: The sucrose permeability test (SPT) was used to assess the possible effect of the PPI, esomeprazole, on upper GI leak in 37 first-time-presenting GERD patients and 25 healthy controls. RESULTS: Esomeprazole induced a significant transmucosal leak in the upper GI tract of patients taking the drug for the first time. The leak occurred quickly, within days of first taking the drug. The leak was also reversed within days of stopping the medication. CONCLUSIONS: This is the first patient-based study showing that a PPI compromises upper GI barrier function. There are potential implications for transmucosal leak of other medications that a patient on a PPI may be taking, as well as possible leak of endogenous peptides/proteins. The clinical consequences of this phenomenon are currently unknown, but are potentially important.

Who bears the cost of healthcare-acquired surgical site infection?

The aim of this study was to estimate the economic costs of healthcare-acquired surgical site infection (HA-SSI) and show how they are distributed between the in-hospital and post-discharge phases of care and recovery. A quantitative model of the epidemiology and economic consequences of HA-SSI was used, with data collected from a prospective cohort of surgical patients and other relevant sources. A logical model structure was specified and data applied to model parameters. A hypothetical cohort of 10 000 surgical patients was evaluated. We found that 111 cases of infection would be diagnosed in hospital and 784 cases would first appear after discharge. Of the total costs incurred, either 31% or 67% occurred during the hospital phase, depending on whether production losses incurred after discharge were included. Most of the costs incurred by the hospital sector arose from lost bed-days and only a small proportion arose from variable costs. We discuss the issues relating to the size of these costs and provide data on where they are incurred. These results can be used to inform subsequent cost-effectiveness analyses that evaluate the efficiency of programmes to reduce the risks of HA-SSI.

Post-discharge surgical site surveillance: does patient education improve reliability of diagnosis?

Post-discharge surgical infection surveillance by patients remains an integral part of many infection control programmes despite proven unreliability. We attempted to improve the validity of patient recognition of signs and symptoms of wound infection and post-discharge postal questionnaire responses through specific education prior to discharge. In total, 588 patients were studied after random assignment into two intervention groups, one of which received relevant education. Both groups were followed for four weeks post-operatively, with features of infection assessed weekly by experienced infection control nurses (ICNs) and by patient responses to routine postal questionnaires. Those patients who received education demonstrated a significantly poorer correlation with ICN diagnosis compared to the non-educated group (Kappa 0.69 and 0.81 respectively, P=0.05). Both patient groups achieved the same sensitivity for recall (83.3%), with high specificity demonstrated by both groups [educated (93.7%); non-educated (98.1%)]. The positive predictive value was 65.2% for the educated group and 83.3% for the non-educated patient group. When infected wounds identified by patients were examined for the proportion that were overdiagnosed, the excess of SSI identified by the educated patient group was 44.4% and by the non-educated group 16.7%. These results suggest that pre-discharge education causes patients to overdiagnose clinical features of wound infection and fails to improve the validity of diagnosis. This outcome further questions the value of post-discharge infection rates obtained by patient self-assessment as a measure of quality of performance.

Risk stratification for surgical site infections in Australia: evaluation of the US National Nosocomial Infection Surveillance risk index.

This study evaluated the US National Nosocomial Infection Surveillance (NNIS) risk index (RI) in Australia for different surgical site infection (SSI) outcomes (overall, in-hospital, post-discharge, deep-incisional and superficial-incisional infection) and investigated local risk factors for SSI. A SSI surveillance dataset containing 43 611 records for 13 common surgical procedures, conducted in 23 hospitals between February 2001 and June 2005, was used for the analysis. The NNIS RI was evaluated against the observed SSI data using diagnostic test evaluation statistics (sensitivity, specificity, positive predictive value, negative predictive value). Sensitivity was low for all SSI outcomes (ranging from 0.47 to 0.69 and from 0.09 to 0.20 using RI thresholds of 1 and 2 respectively), while specificity varied depending on the RI threshold (0.55 and 0.93 with thresholds of 1 and 2 respectively). Mixed-effects logistic regression models were developed for the five SSI outcomes using a range of available potential risk factors. American Society of Anaesthesiologists (ASA) physical status score >2, duration of surgery, absence of antibiotic prophylaxis and type of surgical procedure were significant risk factors for one or more SSI outcomes, and risk factors varied for different SSI outcomes. The discriminatory ability of the NNIS RI was insufficient for its use as an accurate risk stratification tool for SSI surveillance in Australia and its sensitivity was too low for it to be appropriately used as a prognostic indicator.

Behavioural considerations for hand hygiene practices: the basic building blocks.

Hand hygiene is considered to be the most effective measure to prevent microbial pathogen cross-transmission and healthcare-associated infections. In October 2005, the World Health Organization (WHO) World Alliance for Patient Safety launched the first Global Patient Safety Challenge 2005-2006, 'Clean Care is Safer Care', to tackle healthcare-associated infection on a large scale. Within the Challenge framework, international infection control experts and consultative taskforces met to develop new WHO Guidelines on Hand Hygiene in Healthcare. The taskforce was asked to explore aspects underlying hand hygiene behaviour that may influence its promotion among healthcare workers. The dynamics of behavioural change are complex and multi-faceted, but are of vital importance when designing a strategy to improve hand hygiene compliance. A reflection on challenges to be met and areas for future research are also proposed.

Fluid flow in carbon nanotubes and nanopipes.

Nanoscale carbon tubes and pipes can be readily fabricated using self-assembly techniques and they have useful electrical, optical and mechanical properties. The transport of liquids along their central pores is now of considerable interest both for testing classical theories of fluid flow at the nanoscale and for potential nanofluidic device applications. In this review we consider evidence for novel fluid flow in carbon nanotubes and pipes that approaches frictionless transport. Methods for controlling such flow and for creating functional device architectures are described and possible applications are discussed.

Crossover promotion and prevention.

Homologous recombination is an important mechanism for the repair of double-strand breaks in DNA. One possible outcome of such repair is the reciprocal exchange or crossing over of DNA between chromosomes. Crossovers are beneficial during meiosis because, as well as generating genetic diversity, they promote proper chromosome segregation through the establishment of chiasmata. However, crossing over in vegetative cells can potentially result in loss of heterozygosity and chromosome rearrangements, which can be deleterious. Consequently, cells have evolved mechanisms to limit crossing over during vegetative growth while promoting it during meiosis. Here, we provide a brief review of how some of these mechanisms are thought to work.

Making crossovers during meiosis.

Homologous recombination (HR) is required to promote both correct chromosome segregation and genetic variation during meiosis. For this to be successful recombination intermediates must be resolved to generate reciprocal exchanges or 'crossovers' between the homologous chromosomes (homologues) during the first meiotic division. Crossover recombination promotes faithful chromosome segregation by establishing connections (chiasmata) between the homologues, which help guide their proper bipolar alignment on the meiotic spindle. Recent studies of meiotic recombination in both the budding and fission yeasts have established that there are at least two pathways for generating crossovers. One pathway involves the resolution of fully ligated four-way DNA junctions [HJs (Holliday junctions)] by an as yet unidentified endonuclease. The second pathway appears to involve the cleavage of the precursors of ligated HJs, namely displacement (D) loops and unligated/nicked HJs, by the Mus81-Eme1/Mms4 endonuclease.

A study of the distribution of dose across the hands of interventional radiologists and cardiologists.

The magnitude and distribution of doses across the hands of interventional radiologists and cardiologists have been studied. The aims were to determine the region of highest dose, investigate variations in dose distribution, and propose an effective method for dose monitoring. Doses have been measured using sets of up to 18 thermoluminescent dosemeters (TLDs) for 183 single procedures. Important factors influencing the dose to the hand are the type of procedure, particularly the access route, the X-ray equipment used, and the experience of the operator. Radiologists performing percutaneous procedures received the highest doses, because of the proximity of their hands to the X-ray tube. The majority of procedures involve a combination of twisting and prodding actions, and the relative proportions of each determine the parts of the fingers which receive a higher dose. For most interventional radiology and cardiology procedures the bases of the ring and little fingers receive the highest dose. However, during percutaneous procedures the tips of the middle and ring fingers could receive doses which were 20-30% higher than this. For radiologists and cardiologists with a mixed workload, monitoring using TLD rings located at the base of the little or the ring fingers on either hand should provide a reasonable estimate of dose to the most exposed area. Monitoring is recommended for operators who may receive over 50 mSv to their hands per year, and should be considered for operators carrying out therapeutic procedures involving patient dose-area products over 500 Gy cm2 per month.