Changes to clinician attire have done more harm than good.

The introduction of 'bare below the elbows' policies to facilitate handwashing led to the disappearance of the white coat from medical and surgical wards. While rates of key healthcare acquired infections in hospitals, e.g. Clostridium difficile and methicillin-resistant Staphylococcus aureus bacteraemia, have fallen, argument continues around the contribution of hand hygiene and dress codes to these changes. Conversely, the number of complaints against clinicians continues to rise, and respect for medical staff is falling. Are these phenomena linked to the disappearance of the white coat? Here, we debate the effects of these changes to clinician attire and ask whether the putative benefits in terms of infection control are outweighed by the possible harms to the doctor-patient relationship alleged to be caused by the loss of the white coat.

MRSA: why have we got it and can we do anything about it?

MRSA, first identified in 1960, became a major cause of healthcare-associated infection with the emergence of epidemic strains EMRSA 15 and 16 in the 1990 s. MRSA bacteraemia surveillance in England showed a peak of 7700 in 2003-2004. A target was set to halve MRSA bacteraemias by 2008 backed by a central improvement programme for infection prevention and control. Healthcare-associated infection is a patient safety issue with joint responsibility between: clinicians responsible for patient care; managers responsible for the organisation of services; and the government/Department of Health responsible for national strategy, prioritisation and performance management, together with introducing a statutory Code of Practice. By 2011, the number of MRSA bacteraemias had reduced by 80% to 1481. The key drivers of improvement were management responsibility, enhanced surveillance, adherence to clinical protocols and care bundles for invasive procedures, hand hygiene and environmental cleaning, and improved isolation procedures and antibiotic stewardship. The target has been translated into an ongoing MRSA objective, and further control of MRSA is supported by a screening programme aimed at all relevant hospital admissions. Sustaining the reduction will depend upon joint responsibility between management maintaining compliance assurance with policies and individual clinicians keeping it as a priority in patient safety.

Analysis of prevalence, risk factors and molecular epidemiology of Clostridium difficile infection in Kuwait over a 3-year period.

We conducted a prospective study to evaluate the prevalence and epidemiology of CDI in Kuwait government hospitals over a 3-year period, January 2003 to December 2005, to determine the ribotypes responsible for CDI and to estimate the prevalence of ribotype 027. We also conducted a case-control study to identify the risk factors in our patient population. A total of 697 stool samples from patients with suspected CDI were obtained and sent to Anaerobe Reference Laboratory, Faculty of Medicine, Kuwait University for Clostridium difficile toxin detection, culture and PCR ribotyping. During the period, 73 (10.5%) out of 697 patients met the case definition of CDI. Of these, 56 (76.7%) were hospital-acquired and 17 (23.3%) were from outpatient clinics. Thus, the prevalence of hospital-acquired CDI amongst patients with diarrhoea was 8% over the study period; the prevalence in 2003, 2004 and 2005 was 9.7%, 7.8% and 7.2%, respectively. Our data showed that 42.9% of the CDI patients were above 60 years, of which >79% were aged 71 years and above. Patients with CDI were more likely than the controls to have been exposed to immunosuppressive drugs and feeding via nasogastric tube. The most common ribotypes isolated during this study were 002, 001, 126 and 140 and they represent 55.1% of all isolates. PCR ribotype 027 was not isolated.

Correlation of multidrug resistance, toxinotypes and PCR ribotypes in Clostridium difficile isolates from Kuwait.

Clostridium difficile is a common cause of nosocomial diarrhea. its role in community-acquired diarrhea is also becoming an important public health concern. Hardly any studies have correlated strain ribotypes, toxinotypes and multidrug resistant (MDR) profiles. To investigate these characteristics, 65 C. difficile isolates obtained from stool samples of patients whose cultures were negative on admission but became positive after 48 h of admission to the ICUs of our hospitals were studied to determine the prevalent ribotypes, toxinotypes and their relationship with the MDR profiles using ELISA/cytotoxicity assays, PCR and Etest methods. The toxin-producing strains were toxinotyped by the PCR-RFLP technique. Of the 65 isolates, 42 (64.6%) were toxigenic (T). The isolates were of diverse ribotypes but types 097, 078, 056 and 039 (NT) were predominant. thirty (71.4%) of 42 T and 13 (56.5%) of 23 NT strains were multiresistant to 3 or more antibiotics. Only 3 toxinotypes (0, "V-like" and XII) were encountered. Of the 42 t strains, 30 (71.4%) were of toxinotype 0, and 12 belonged to variant toxinotypes: 4 (9.4%) to toxinotype XII and 8 (19%) to "V-like" toxinotype in which amplified B1 PCR fragments was amplified as expected for toxinotype V but the A3 PCR fragment could not be amplified. The 43 mDR strains were assigned to 3 arbitrary resistance groups; groups 1, 11 and III. the most prevalent isolates (37; 86.1%) were in group II. Of the predominant T ribotypes (097, 078 and 056), c. 62% clustered in group II. Although the number of strains toxinotyped was small, ribotyping and toxinotyping correlated well with the published literature, except for 078 with a novel "V-like" toxinotype. Antibiogram was not as clear-cut.

Responsibility for managing healthcare-associated infections: where does the buck stop?

The prevention and control of healthcare-associated infections (HCAIs) requires a tripartite partnership between clinicians and carers, managers and government/Department of Health (DoH) across the whole health and social care community. Mandatory surveillance of meticillin-resistant Staphylococcus aureus bacteraemia and Clostridium difficile infection has shown a significant fall from peak numbers in 2003/04 and 2006, respectively, and there is now a zero tolerance approach to preventable infections and poor practice. Success so far has been based on senior management commitment, enhanced real-time surveillance, implementation of clinical protocols (high impact interventions, prudent prescribing), improved hand hygiene and environmental cleaning, and training and audit, backed up by a heightened performance management focus through targets and legislation (Code of Practice). DoH improvement teams have supported National Health Service trusts in implementing change. Responsibility for managing HCAI is a combination of managerial responsibility based upon compliance assurance that procedures and protocols are being implemented and personal professional responsibility of all clinicians and other healthcare workers.

Distribution and antimicrobial susceptibility patterns of Clostridium difficile PCR ribotypes in English hospitals, 2007-08.

A surveillance study designed to provide a representative sample of the strains of Clostridium difficile causing infections in hospitals in England was in operation from April 2007 to the end of March 2008. Six hundred and seventy-seven isolates were obtained from 186 hospitals in the nine geographical regions of England as recognised by the Health Protection Agency's Regional Microbiology Network. Typing studies revealed that PCR ribotype 027 is now the most common strain isolated from symptomatic patients, accounting for over 41.3% of isolates in English hospitals. Type 106 was the second most common strain (20.2%) and Type 001, which was once the most common strain associated with hospital outbreaks, has now been reduced to only 7.8% of the total. A mixture of 44 other PCR ribotypes accounted for the remaining 28.9% of isolates. This represents a changing distribution of strains when compared to a previous study performed two years earlier which showed roughly equal proportions of types 106, 001 and 027. Antimicrobial susceptibility testing by the E test method revealed significantly lower susceptibility to metronidazole in the more common strains when compared to the less common ribotypes, although none were classified as clinically resistant. Similarly, no resistance to vancomycin was detected. However, common PCR ribotypes were more resistant to moxifloxacin and erythromycin than the less common strains, which may indicate a selective advantage for resistance to these agents, and combined resistance to these two agents was a good indicator of a common ribotype.

Infection control measures to limit the spread of Clostridium difficile.

Clostridium difficile-associated diarrhoea (CDAD) presents mainly as a nosocomial infection, usually after antimicrobial therapy. Many outbreaks have been attributed to C. difficile, some due to a new hyper-virulent strain that may cause more severe disease and a worse patient outcome. As a result of CDAD, large numbers of C. difficile spores may be excreted by affected patients. Spores then survive for months in the environment; they cannot be destroyed by standard alcohol-based hand disinfection, and persist despite usual environmental cleaning agents. All these factors increase the risk of C. difficile transmission. Once CDAD is diagnosed in a patient, immediate implementation of appropriate infection control measures is mandatory in order to prevent further spread within the hospital. The quality and quantity of antibiotic prescribing should be reviewed to minimise the selective pressure for CDAD. This article provides a review of the literature that can be used for evidence-based guidelines to limit the spread of C. difficile. These include early diagnosis of CDAD, surveillance of CDAD cases, education of staff, appropriate use of isolation precautions, hand hygiene, protective clothing, environmental cleaning and cleaning of medical equipment, good antibiotic stewardship, and specific measures during outbreaks. Existing local protocols and practices for the control of C. difficile should be carefully reviewed and modified if necessary.

Soft tissue infections caused by spore-forming bacteria in injecting drug users in the United Kingdom.

From 2000 to May 2004 there has been a marked increase in illness resulting from spore-forming bacteria in injecting heroin users in the United Kingdom. Clostridium novyi caused 63 cases of severe illness in 2000 and seven further cases from 2001. Wound botulism first occurred in 2000 (six cases) with 51 further cases to March 2004. Tetanus occurred in 20 cases between late 2003 and March 2004. Infections with C. histolyticum (nine cases), C. sordellii (one case) and Bacillus cereus (one case) were also reported. The reasons for the increase in illness are unclear. The major risk factor was skin- or muscle-popping. The problem appears to be here to stay. This review describes the causative organisms, pathogenesis, clinical presentation, epidemiology and treatment of cases. Clinical vigilance and a high standard of anaerobic microbiology are essential. Clinicians and laboratories must report such cases (or likely cases) rapidly so that clusters can be rapidly identified, in order to control disease. Prevention relies on tetanus immunization.

Molecular characterization of nitroimidazole resistance in metronidazole-resistant bacteroides species isolated from hospital patients in Kuwait.

OBJECTIVES: The aim of this study was to screen for infections caused by metronidazole (MTZ)-resistant Bacteroides spp., and to characterize the genes that encode the MTZ resistance. MATERIALS AND METHODS: A total of 7 MTZ-resistant Bacteroides spp. were isolated from 5 patients with MTZ-resistant infections. These organisms were investigated for carriage of genes that encode MTZ resistance. The presence of these genes was investigated by PCR and the PCR products were subjected to PCR-RFLP analysis. RESULTS: The strains were MTZ-resistant with minimum inhibitory concentrations of > 32 microg/ml. The presence of nim genes was indicated by PCR in all 7 strains. PCR-RFLP analysis of the nim gene products demonstrated two of the five reported resistance genes, nimA-nimE. These two resistance genes were nimE in 5 of the 7 isolates and nimA in 2 strains. CONCLUSION: MTZ-resistant Bacteroides spp. have been isolated from patients in Kuwait. Nim genes, specifically nimE and nimA, mediate the drug resistance in these isolates. The methods used in detecting these genes are rapid, accurate and relatively inexpensive and could be adopted easily to help in monitoring emergence of MTZ resistance determinants in Kuwait.

Prevalent PCR ribotypes of clinical and environmental strains of Clostridium difficile isolated from intensive-therapy unit patients in Kuwait.

Ninety-five isolates of Clostridium difficile from symptomatic and asymptomatic patients and 18 from their environment in the intensive-therapy units (ITUs) of four teaching hospitals in Kuwait were typed by PCR amplification of rRNA intergenic spacer regions (PCR ribotyping). A total of 32 different ribotypes was detected among the clinical isolates. The predominant ribotypes from the clinical isolates were types 097 and 078, which accounted for approximately 40 % of all isolates in the ITUs in Kuwait. Ribotypes 097 (toxigenic), 078 (toxigenic) and 039 (non-toxigenic) were three distinct clones that were circulating in all four hospitals. Ribotypes 097, 078 and 076 (i.e. 50 % of isolates from symptomatic patients) were the predominant isolates associated with C. difficile-associated disease (CDAD). The environmental isolates belonged to a diverse range of ribotypes, with no particular types common to all the hospitals. Ribotype 078 was found only in the patient environment in Mubarak hospital, while ribotype 097 was restricted to Amiri hospital. The hospital environment occupied by symptomatic as well as symptom-free patients was contaminated with C. difficile. Eight new strains that did not match any in the PCR ribotype library established at the PHLS Anaerobe Reference Unit, Cardiff, UK, were assigned ribotypes 105, 125, 128, 129, 131, 134, 140 and 141. These findings show that the isolates associated with CDAD in Kuwait are different from those found in the UK and some other European countries.

Antibiotic susceptibilities of Gram-positive anaerobic cocci: results of a sentinel study in England and Wales.

OBJECTIVE: A sentinel study was carried out to determine the antimicrobial susceptibilities of Gram-positive anaerobic cocci (GPAC) freshly isolated from clinical material in diagnostic laboratories in England and Wales. METHODS: A total of 113 GPAC isolates consisting predominantly of current or former members of the genus Peptostreptococcus was obtained from 17 sentinel laboratories in England and one in Wales. Minimum inhibitory concentrations (MICs) of 10 antimicrobial agents were determined by the Etest method. The agents tested were: penicillin, tetracycline, erythromycin, cefoxitin, clindamycin, chloramphenicol, imipenem, co-amoxiclav, piperacillin/tazobactam and metronidazole. MIC50 and MIC90 values for each drug-species combination were calculated whenever suitable numbers of each species were obtained. RESULTS: Excellent spectra of activity (0% resistance) against GPAC were seen for metronidazole, piperacillin/tazobactam, cefoxitin, imipenem and chloramphenicol. Low degrees of resistance to co-amoxiclav (3.5%), clindamycin (7.1%), penicillin (7.1%) and significant degrees of resistance to tetracycline (41.6%) and erythromycin (27.4%) were detected. Some examples of putative macrolide-lincosamide linked resistance were noted in seven (6.2%) isolates of GPAC. CONCLUSION: This study is one of the largest susceptibility studies specifically on GPAC carried out to date and the resulting data may be of value to those involved in the empirical treatment of infections involving Gram-positive anaerobic cocci.

Heat and acid tolerance of Clostridium novyi Type A spores and their survival prior to preparation of heroin for injection.

Clostridium novyi Type A was implicated as a cause of an outbreak of serious illness and deaths among drug users in the United Kingdom who injected heroin intramuscularly. A contaminated batch of heroin was believed to be the source of infection. To test the ability of the outbreak strain to survive certain processes associated with heroin use, it was tested for its ability to survive a range of temperature and pH and the process used in preparation of "street" heroin for injection. C. novyi spores survived temperatures of up to 100 degrees C in aqueous solution for 5 min and survived pH 2.0 at ambient temperatures for a similar time. However, a combination of low pH and raised temperatures reduced survival times. An experiment reconstructing the "street" preparation of heroin demonstrated that any C. novyi spores present would survive this process and thus be capable of initiating infection under the right conditions.

Isolation and identification of Clostridium spp. from infections associated with the injection of drugs: experiences of a microbiological investigation team.

Pathogenic species of the genus Clostridium may contaminate the materials used in the injection of drugs and under the right conditions may cause serious or life-threatening disease. C. novyi type A was implicated in an outbreak of severe infection with high mortality in injecting drug users who injected heroin extravascularly. The isolation of such highly oxygen-sensitive clostridia from clinical material may require adherence to enhanced methods and, once isolated, commercially available anaerobe identification kits alone may not give an accurate identification. Additional phenotypic tests that are useful in recognising the main pathogenic species are described. Differentiation of C. novyi type A from C. botulinum type C in reference laboratories was based on 16S rDNA sequence data and specific neutralisation of cytopathic effects in tissue culture.

Fusobacterium necrophorum infections in England and Wales 1990-2000.

In response to a marked increase in both the number of Fusobacterium necrophorum bacteraemia reports to the PHLS Communicable Disease Surveillance Centre and the number of F. necrophorum isolates referred to the PHLS Anaerobe Reference Unit in 1999, the data from both sources on F. necrophorum infections were reviewed for the decade 1990-2000. There were 208 reports of F. necrophorum bacteraemia (average 19/year; range 14-34/year) with a peak in incidence in the late winter months; 68% were from male patients and the peak age range was 16-23 years. Of 205 referred isolates of F. necrophorum, 122 (59%) were from blood cultures and these represented 58% of the bacteraemia reports; the others were from brain and soft tissue abscesses, pleural and joint fluids, eyes, ears and lymphatic tissue. The average number of referrals was 19/year (range 9-37/year). The peak year for bacteraemia reports (34) and isolate referrals (37) was 1999; this increase was not sustained in 2000. All isolates were susceptible to metronidazole, but 2% were resistant to penicillin and 15% to erythromycin. F. necrophorum continues to be a regular but uncommon cause of bacteraemia and metastatic abscesses following an acute sore throat, especially in young, otherwise healthy adults.

Identification of clinical isolates of actinomyces species by amplified 16S ribosomal DNA restriction analysis.

Amplified 16S ribosomal DNA (rDNA) restriction analysis (ARDRA), using enzymes HaeIII and HpaII, was applied to 176 fresh and 299 stored clinical isolates of putative Actinomyces spp. referred to the Anaerobe Reference Unit of the Public Health Laboratory Service for confirmation of identity. Results were compared with ARDRA results obtained previously for reference strains and with conventional phenotypic reactions. Identities of some strains were confirmed by analysis of partial 16S rDNA sequences. Of the 475 isolates, 331 (70%) were clearly assigned to recognized Actinomyces species, including 94 isolates assigned to six recently described species. A further 52 isolates in 12 ARDRA profiles were designated as apparently resembling recognized species, and 44 isolates, in 18 novel profiles, were confirmed as members of genera other than Actinomyces. The identities of 48 isolates in nine profiles remain uncertain, and they may represent novel species of Actinomyces. For the majority of species, phenotypic results, published reactions for the species, and ARDRA profiles concurred. However, of 113 stored isolates originally identified as A. meyeri or resembling A. meyeri by phenotypic tests, only 21 were confirmed as A. meyeri by ARDRA; 63 were reassigned as A. turicensis, 7 as other recognized species, and 22 as unidentified actinomycetes. Analyses of incidence and clinical associations of Actinomyces spp. add to the currently sparse knowledge of some recently described species.

Wound microbiology and associated approaches to wound management.

The majority of dermal wounds are colonized with aerobic and anaerobic microorganisms that originate predominantly from mucosal surfaces such as those of the oral cavity and gut. The role and significance of microorganisms in wound healing has been debated for many years. While some experts consider the microbial density to be critical in predicting wound healing and infection, others consider the types of microorganisms to be of greater importance. However, these and other factors such as microbial synergy, the host immune response, and the quality of tissue must be considered collectively in assessing the probability of infection. Debate also exists regarding the value of wound sampling, the types of wounds that should be sampled, and the sampling technique required to generate the most meaningful data. In the laboratory, consideration must be given to the relevance of culturing polymicrobial specimens, the value in identifying one or more microorganisms, and the microorganisms that should be assayed for antibiotic susceptibility. Although appropriate systemic antibiotics are essential for the treatment of deteriorating, clinically infected wounds, debate exists regarding the relevance and use of antibiotics (systemic or topical) and antiseptics (topical) in the treatment of nonhealing wounds that have no clinical signs of infection. In providing a detailed analysis of wound microbiology, together with current opinion and controversies regarding wound assessment and treatment, this review has attempted to capture and address microbiological aspects that are critical to the successful management of microorganisms in wounds.

PCR-restriction fragment length polymorphism analysis for identification of Bacteroides spp. and characterization of nitroimidazole resistance genes.

Bacteroides spp. are opportunist pathogens that cause blood and soft tissue infections and are often resistant to antimicrobial agents. We have developed a combined PCR-restriction fragment length polymorphism (RFLP) technique to characterize the 16S rRNA gene for identification purposes and the nitroimidazole resistance (nim) gene for detection of resistance to the major antimicrobial agent used to treat Bacteroides infections: metronidazole (MTZ). PCR-RFLP analysis of 16S ribosomal (rDNA) with HpaII and TaqI produced profiles that enabled discrimination of type strains and identification of 70 test strains to the species level. The 16S rDNA PCR-RFLP identification results agreed with routine phenotypic testing for 62 of the strains. The discrepancies between phenotypic and PCR-RFLP methods for eight strains were resolved by 16S rDNA sequencing in three cases, but five strains remain unidentified. The presence of nim genes was indicated by PCR in 25 of 28 strains that exhibited reduced sensitivity to MTZ. PCR-RFLP of the nim gene products identified the four reported genes (nimA, -B, -C, and -D) and indicated the presence of a previously unreported nim gene in 5 strains. This novel nim gene exhibited 75% DNA sequence similarity with nimB. These rapid, accurate, and inexpensive methods should enable improved identification of Bacteroides spp. and the detection of MTZ resistance determinants.