Promoting hand hygiene in healthcare through national/subnational campaigns.

The World Health Organization (WHO) First Global Patient Safety Challenge conducted a baseline survey of coordinated large-scale activities in improving hand hygiene in healthcare in 2007. The survey was repeated in early 2009 to assess current status and generate information on factors contributing to success. Coordinated activities were identified through WHO regional offices and experts in the field. An online survey using a structured questionnaire was conducted during March-April 2009. Personnel involved in all 38 campaigns/programmes in 2009 completed the survey. Of these, 29 were active national/subnational-level initiatives and 22 (75.8%) were initiated after the Challenge launch in October 2005. Main targets were general, district, and university hospitals with increasing coverage of long-term care facilities and primary care. The scope varied from awareness-raising to formal scaled-up activities with ongoing evaluation. Most initiatives (20/29) obtained funding from multiple sources with governments among the main funders; governments also initiated 25/29 (86.2%) programmes. The facilitator role played by the Challenge in initiating and supporting activities with tools and recommendations was clearly identified. The perceived significance of specific barriers varied considerably across initiatives. Those related to commitment (priority and support) and resource availability were important across all regions. Hand hygiene is being promoted in healthcare in many nations/subnations with clear objectives, strategies, and governmental support through policies and resource allocation. While this is important for sustainability, further action is required to initiate coordinated activities across the world, including countries with limited resources.

Nested polymerase chain reaction on blood clots for gene encoding 56 kDa antigen and serology for the diagnosis of scrub typhus.

PURPOSE: Scrub typhus is a zoonotic illness endemic in the Asia-Pacific region. Early diagnosis and appropriate management contribute significantly to preventing adverse outcomes including mortality. Serology is widely used for diagnosing scrub typhus. Recent reports suggest that polymerase chain reaction (PCR) could be a rapid and reliable alternative. This study assessed the utility of these tests for scrub typhus diagnosis. MATERIALS AND METHODS: Nested PCR to detect the 56 kDa antigen gene of O. tsutsugamushi was performed on blood clots from 87 individuals with clinically suspected scrub typhus. Weil-Felix test and scrub typhus IgM ELISA were performed on serum samples from the same patients. As a gold standard reference test was not available, latent class analysis (LCA) was used to assess the performance of the three tests. RESULTS: The LCA analysis showed the sensitivity of Weil-Felix test, IgM ELISA and PCR to be 59%, 100% and 58% respectively. The specificity of ELISA was only 73%, whereas those of the Weil-Felix test and PCR were 94% and 100% respectively. CONCLUSION: Nested PCR using blood clots while specific, lacked sensitivity as compared to IgM ELISA. In resource-poor settings Weil-Felix test still remains valuable despite its moderate sensitivity.

Educating healthcare workers to optimal hand hygiene practices: addressing the need.

The education of healthcare workers is essential to improve practices and is an integral part of hand hygiene promotional strategies. According to the evidence reviewed here, healthcare worker education has a positive impact on improving hand hygiene and reducing healthcare-associated infection. Detailed practical guidance on steps for the organization of education programmes in healthcare facilities and teaching-learning strategies are provided using the World Health Organization (WHO) Guidelines for Hand Hygiene in Health Care as the basis for recommendations. Several key elements for a successful educational programme are also identified. A particular emphasis is placed on concepts included in the tools developed by WHO for education, monitoring and performance feedback.

Prevention and control of health care-associated infections through improved hand hygiene.

Determined actions are required to address the burden due to health care-associated infections worldwide and improve patient safety. Improving hand hygiene among health care workers is an essential intervention to achieve these goals. The World Health Organization (WHO) First Global Patient Safety Challenge, Clean Care is Safer Care, pledged to tackle the problem of health care-associated infection at its launch in 2005 and has elaborated a comprehensive set of guidelines for use in both developed and developing countries worldwide. The final version of the WHO Guidelines on Hand Hygiene in Health Care was issued in March 2009 and includes recommendations on indications, techniques, and products for hand hygiene. In this review, we discuss the role of hands in the transmission of health care-associated infection, the benefits of improved compliance with hand hygiene, and the recommendations, implementation strategies and tools recommended by WHO. We also stress the need for action to increase the pace with which these recommendations are implemented in facilities across India.

Evaluation of IgM ELISA using a sonicate and a lipopolysaccharide antigen for the serodiagnosis of melioidosis.

Melioidosis, caused by Burkholderia pseudomallei, has variable manifestations. The disease can present as an acute or a chronic form or localized or disseminated or can remain latent for many years. Acute septicaemic melioidosis has a high fatality rate when untreated and therefore, an early diagnosis is critical. Lack of testing facilities and of an awareness of the manifestations of the disease makes it likely that it is underreported in India. A sonicate and a lipopolysaccharide (LPS) antigen were evaluated by an IgM enzyme immunoassay in patients with culture-confirmed melioidosis (n = 29), fever of unknown origin (n = 214) and healthy controls (n = 109). Patients with melioidosis had significantly higher optical density values than both control categories, but the sensitivity of both tests was low (25% for sonicate, 62% for LPS). These data highlight the problems with serodiagnosis in endemic settings, where high cut-off values are required for specificity, and result in low sensitivity.

Methods to evaluate the microbicidal activities of hand-rub and hand-wash agents.

In vitro carrier tests, suspension tests, time-kill curves, and determinations of minimum inhibitory concentrations to evaluate the microbicidal activities of hand antiseptics provide only a preliminary indication of the antimicrobial spectrum and speed of action of a given formulation. Ex vivo testing with human or animal skin at human skin temperature and at contact times reflecting field conditions may give a better indication of a formulation's ability to tackle hand-transmitted pathogens. Field testing of hands for levels of skin microbiota before and after antisepsis may be easier to perform, but it is subject to many uncontrollable factors. Whereas randomised clinical trials may be the ultimate approach to assess the effectiveness of hand hygiene protocols and products in preventing microbial cross-transmission and, ultimately, infections, they can be prohibitively expensive, time-consuming, difficult to design, and therefore impractical. Hence, the primary emphasis should be on in vivo testing on human hands, using a well-designed protocol that closely simulates the recommended field use of the formulation, and possibly followed by clinical studies. The use of these method is the most likely to yield useful data on the potential of a formulation to interrupt the spread of pathogens transmitted by hands in healthcare settings. This review provides a critical assessment of the methods currently used to meet regulatory requirements for hand antiseptics in Europe and North America.

Comparison of national and subnational guidelines for hand hygiene.

Hand hygiene promotion is considered as the cornerstone for healthcare-associated infection prevention. Over the past years, hand hygiene guidelines have been developed by different agencies at international, national and subnational levels. A comparison of these documents could help in understanding recommendations in different parts of the world and the methods used for their development. Guidelines were identified through search engines, electronic libraries, and personal contacts, and their content was analysed using an adapted version of a tool from the European DG XII-funded HARMONY project. Twenty-two guidelines were retrieved and 21 were evaluated. Documents varied in scope, approach, content and terminology. Some were primarily advisory directives, whereas others focused on the technical issues of why, when, and how to perform hand hygiene. The extent to which evidence was collected and assessed varied considerably and details were provided only in very few. Grading systems and definitions to indicate the strength of evidence and recommendations also differed. The intended outcome was to improve hand hygiene practices in healthcare, thus leading to a reduction of healthcare-associated infections and/or antimicrobial resistance. Although overall agreement on indications and procedures was noted, the range and depth of recommendations on best practices and implementation varied. Essential aspects such as compliance measurement and audits to assess guideline effectiveness were neglected in most documents. In conclusion, there is a need for a more consistent approach leading to recommendations based on a thorough evaluation of evidence and applicable worldwide. Aspects related to implementation and impact monitoring deserve greater attention.

Clinicopathologic profile of normocomplementemic and hypocomplementemic urticarial vasculitis: a study from South India.

BACKGROUND: This study aims to study the clinical and histopathological characteristics of hypocomplementemic and normocomplementemic urticarial vasculitis (HUVS and NUV) among dermatology clinic attendees in a tertiary care hospital in South India. PATIENTS AND METHODS: A prospective study was conducted in the dermatology department from February 2003 to May 2004. Seventy-five patients met the inclusion criteria for UV. Sixty-eight patients in whom complement levels were available were classified into either NUV or HUVS groups. Clinical features, laboratory parameters and histological features were compared, and the significance of differences was established using Pearson's Chi-squared test. RESULTS: There was a female preponderance among patients with HUVS. Wheals > 24 h were seen in 90% of patients, and in 54.4% of patients, the wheals were partially blanching or non-blanching. Angioedema was more prevalent in patients with NUV than HUVS (44.4% vs. 21.4%). Systemic involvement was seen in 64.3% of patients with HUVS and 44.4% of patients with NUV. Fever, ANA positivity and systemic lupus erythematosus (SLE) were significantly associated with HUVS. In most cases of UV, a provoking factor could not be identified. Neutrophilic small vessel vasculitis was seen in 42.9% of patients with HUVS and 16.6% patients with NUV. Direct immunofluorescence test showing immunoreactants at the dermo-epidermal junction were present in 60% of patients with HUVS and 33.3% patients with NUV. CONCLUSION: The clinical features of Indian patients with UV were similar to those reported from the West. Fever, ANA positivity and SLE were significantly associated with HUVS.

Usefulness of alternate prognostic serum and plasma markers for antiretroviral therapy for human immunodeficiency virus type 1 infection.

In developing countries, the usability of peripheral blood constituents that are low-cost alternatives to CD4-positive (CD4+) T-cell and human immunodeficiency virus type 1 (HIV-1) RNA estimation should be evaluated as prognostic markers. The aim of our study was to investigate the use of plasma levels of dehydroepiandrosterone sulfate (DHEAS), albumin, and C-reactive protein (CRP) as alternate prognostic markers for antiretroviral treatment (ART) response in place of HIV-1 load measurements. Paired blood samples were collected from 30 HIV-infected individuals before and after initiation of ART, 13 HIV-infected individuals before and after completion of antituberculosis therapy (ATT), and 10 HIV-infected individuals not on either ATT or ART. Because of the nonavailability of samples, the CRP estimation was done for samples from only 19, 9, and 8 individuals in groups 1, 2, and 3, respectively. The measurements of all three markers, i.e., DHEAS, albumin, and CRP, were carried out with commercial assays. The differences in the albumin levels before and after ART or ATT were significant (P < 0.05), while the differences in DHEAS and CRP levels were not significant (P > 0.05). When levels of DHEAS among the individuals who were followed up were analyzed, 13 (44.8%) in the ART group and 9 (69%) in the ATT group showed an increase following treatment. Prior to treatment of HIV-infected individuals, there was a significant positive correlation of CD4+ T-cell counts and a negative correlation of viral load with albumin and DHEAS levels (P < 0.01). Among the three plasma markers we tested, plasma albumin and, to some extent, DHEAS show promise as prognostic markers in monitoring HIV infection.

Melioidosis presenting as genitourinary infection in two men with diabetes.

Melioidosis is an infectious disease caused by Burkholderia pseudomallei. It occurs predominantly in tropical regions. The manifestations are protean which include pneumonia, visceral abscesses, septic arthritis, osteomyelitis, acute suppurative and chronic granulomatous lesions with involvement of almost all organ systems. Fulminant sepsis is much more common and is associated with high mortality. Hence prompt recognition and early treatment is warranted. We report unusual presentations of urinary tract melioidosis in two diabetic men.

The clinical and microbiological correlates of premature rupture of membranes.

Prematurity is the cause of 85% of neonatal morbidity and mortality. Premature rupture of the membranes (PROM) is associated with 30-40% of preterm deliveries. A case-control study conducted between July 2002 and 2003 examined the correlates and risk factors for PROM in Mysore, India. WBCs in vaginal fluid, leucocytes in urine, UTI and infection with E. coli, S. aureus, C. albicans and BV were significantly associated with PROM. BV, E. coli and WBCs in vaginal fluid were independent risk factors. Screening and treatment of BV and E. coli infection in pregnancy may reduce the risk of PROM.

Scrub typhus among hospitalised patients with febrile illness in South India: magnitude and clinical predictors.

OBJECTIVES: To derive a clinical algorithm for diagnosis of scrub typhus among patients hospitalized with febrile illness and to determine predictors of bad prognosis. METHODS: Patients hospitalized with febrile illness of 5-30 days duration were evaluated for common aetiologies. Sera were tested for antibodies (IgM and IgG) to Orientia tsutsugamushi using ELISA kit. RESULTS: Among 207 patients, 50 had elevated levels of IgM antibodies. The data of these patients were compared with that of 16 controls having febrile illnesses in whom rickettsial infection was ruled out. Transaminase elevation (>twice normal) was present in 90% and was significantly (P=0.004) more common in those with scrub typhus. If a combination of elevated transaminases, thrombocytopenia and leukocytosis is used, the specificity and positive predictive value are about 80%. Case fatality rate was 14%. Univariate analysis showed that hyperbilirubinemia (>1.5mg%) has a RR of 9 (95% CI=1.48-58.5) and elevated creatinine level (>1.4 mg%) had a RR of 43.99 (95% CI=3.65-530.5) for death. Elevated creatinine level was found to be an independent predictor of mortality (P=0.02). CONCLUSION: In developing countries with limited diagnostic facilities, it is prudent to recommend empiric therapy in patients with undifferentiated febrile illness having evidence of multiple system involvement especially if there is transaminase elevation. Elevated creatinine may predict bad outcome.

Tuberculosis among healthcare workers in a tertiary-care hospital in South India.

It is possible that tuberculosis is transmitted from patients to healthcare workers (HCWs). However, there are few data on this from developing countries. The object of this study was to document the incidence of tuberculosis among HCWs in the Christian Medical College (CMC), Vellore, India during a 10-year period (January 1992-December 2001). Data were collected from records maintained in the staff and students health services of CMC. A total of 125 cases were diagnosed during the period of study. The overall incidence of sputum positive cases was similar to that observed in the general population, during most years. However, it appears that focal outbreaks occur with transmission between HCWs. The chance of developing extra-pulmonary tuberculosis was higher in HCWs compared with the general population.

Use of CHROMagar medium in the differentiation of Candida species: is it cost-effective in developing countries?

The opportunistic infection of humans with Candida is becoming more common. As several species of Candida are relatively insusceptible to the commonly used antifungal drugs, rapid identification of the species involved can facilitate effective treatment. CHROMagar Candida medium (CCM) is a commercial product designed to allow the rapid identification of Candida to species level. To explore the potential usefulness of CCM in a developing country, attempts were made to identify the Candida species in 107 Indian isolates (obtained, consecutively, from 90 clinical specimens, over a year-long period, in a tertiary-level teaching hospital), using CCM and more conventional methods in parallel. The most common species appeared to be C. tropicalis (representing 40% of the isolates), followed by C. albicans (28%) and C. glabrata (23%). Although use of CCM allowed the isolates from 84 (93.3%) of the clinical specimens to identified to species level within 48 h, it took at least 7 days to identify the yeasts in 90% of the specimens using the more conventional procedures. With the results of the conventional methods set as the 'gold standard', the use of CCM appeared to allow all of the C. albicans, C. tropicalis and C. krusei isolates and most (92%) of the C. glabrata to be correctly identified. The costs/isolate identified with the CCM were no more than those of the conventional methods. As many (67%) of the isolates examined were of potentially drug-resistant yeasts (C. tropicalis, C. glabrata or C. krusei), there is clearly a need to identify local isolates quickly, to prevent treatment with ineffective drugs. In terms of both performance and cost, CCM appears to be a good method to use.

Outbreak of scrub typhus in southern India during the cooler months.

Orientia tsutsugamushi, the agent of scrub typhus, is a strict intracellular bacterium which is found in many parts of Asia including India. During the past few years, the number of patients with rickettsial infection and scrub typhus has increased, especially during the cooler months. We report in this study a recent outbreak of scrub typhus recorded during the cooler months (October 2001 to February 2002) in patients admitted to our hospital with acute febrile illness associated with diverse signs and symptoms. Overall, 28 patients were clinically and serologically confirmed to have scrub typhus. Fever for more than one week was the only common manifestation. Myalgias was the next most common feature (52%), and rash was observed in only 22% of the cases. Seventeen patients treated with doxycycline recovered in 1 to 3 days, as well as two patients who received chloramphenicol. In five patients who received ciprofloxacin, fever subsided only after five days. Finally three patients (10.7%) died, including one patient treated with doxycycline. These data indicate that scrub typhus is a reemerging infectious disease in India with a possibility of drug resistance. This reemergence emphasizes the need for further prospective studies to design effective control measures.

Case reports: scrub typhus during pregnancy in India.

Scrub typhus, caused by Orientia tsutsugamushi, is a rural zoonosis endemic in the Asian Pacific region. Doxycycline and chloramphenicol, the recommended drugs for treating this infection, may not be safe during pregnancy. We report on 5 patients with scrub typhus during pregnancy who were seen in India between October 2001 and February 2002. Four of the 5 women were treated initially with ciprofloxacin. Three women had stillbirths, 1 an abortion and 1 a low birthweight baby, which suggests that ciprofloxacin should not be used for treating pregnant women and that scrub typhus leads to severe adverse effects during pregnancy. Randomized controlled trials are urgently needed to ascertain the optimal drug choice, given that currently recommended drugs are contraindicated in pregnant women.

Audit of management of pregnant women with positive VDRL tests.

BACKGROUND: Syphilis is a preventable cause of foetal loss and congenital disease. Although the VDRL test is an integral part of routine antenatal care in India, little is known about the disease burden in pregnancy in India. Therefore, we carried out a study to determine the prevalence of VDRL positivity and syphilis among pregnant women in Vellore and to audit the management and outcome of VDRL-positive pregnancies. METHODS: A retrospective review of case records. RESULTS: Only 0.98% of pregnant women were positive by the VDRL test. However, foetal loss occurred in 16 (32%) of the 50 seropositive women; 15 of these did not receive antenatal care. Seventeen of the 34 seropositive multiparous women had had previous foetal losses. Only 16 women had received penicillin. CONCLUSION: Although the seroprevalence of syphilis in pregnancy is low, it is an unrecognized cause of foetal loss in Vellore. An audit of the testing and management of VDRL positivity in pregnancy provides valuable information on the quality of antenatal care in an area.