In vitro comparison of methods for sampling copper-based antimicrobial surfaces.

IMPORTANCE: Self-sanitizing surfaces such as copper (Cu) are increasingly used on high-touch surfaces to prevent the spread of harmful viruses and bacteria. Being able to monitor the antimicrobial properties of Cu is fundamental in measuring its antimicrobial efficacy. Thorough investigations into reliable methods to enumerate bacteria from self-sanitizing surfaces are lacking in the literature. This study demonstrates that direct use of Petrifilm on Cu surfaces most likely revives stressed and dying bacteria, which induces increased bacterial counts. This phenomenon was not observed with indirect collection methods. Studies assessing time-kill kinetics or long-term efficacy of Cu should consider the impact of the collection method chosen.

Infection control and tuberculosis in health care workers: an assessment of 28 hospitals in South Africa.

SETTING: Twenty-eight public hospitals in the Free State Province, South Africa. OBJECTIVE: To examine the association between tuberculosis (TB) infection control (IC) scores in Free State hospitals and the incidence of TB disease among health care workers (HCWs) in 2012. DESIGN: A cross-sectional survey and mixed-methods analysis of TB IC policies, practices and infrastructure using a comprehensive, 83-item IC audit and observation tool. RESULTS: As the total IC score increased, the probability of TB in an HCW at that hospital decreased. When adjusted for other covariates in multivariate analysis, if the total score of a hospital increased by one unit, the odds of an HCW having TB decreased by 4.9% (95%CI 0.9-8.8). Significant associations were also seen for the personal protective equipment (PPE) score, where odds decreased by 11.5% (95%CI 1.8-20.1) for each unit increase in score. Administrative score, environmental score and miscellaneous score were not statistically significant in the multivariate model. CONCLUSIONS: These findings reaffirm that overall IC and PPE are essential to protect HCWs from acquiring TB. More attention to TB IC is required to protect the health care workforce and to stop the South African TB epidemic.

Occupational tuberculosis in South Africa: are health care workers adequately protected?

Setting: A provincial tertiary hospital in Gauteng province, South Africa, with a high burden of tuberculosis (TB) patients and high risk of TB exposure among health care workers (HCWs). Objective: To determine HCWs' adherence to recommended TB infection prevention and control practices, TB training and access to health services and HCW TB rates. Design: Interviews with 285 HCWs using a structured questionnaire as part of a large, international mixed-methods study. Results: Despite 10 HCWs (including seven support HCWs) acquiring clinical TB during their period of employment, 62.8% of interviewees were unaware of the hospital's TB management protocol. Receipt of training was low (34.5% of all HCWs and <5% of support HCWs trained on TB transmission; 27.5% of nurses trained on respirator use), as was use of respiratory protection (44.5% of HCWs trained on managing TB patients). Support HCWs were over 36 times more likely to use respiratory protection if trained; nurses who were trained were approximately 40 times more likely to use respirators if they were readily available. Conclusion: Improved coordination and uptake of TB infection prevention training is urgently needed, especially for non-clinical HCWs in settings of regular exposure to TB patients. Adequate supplies of appropriate respiratory protection must be made available.

Contexte : Un hôpital provincial de niveau tertiaire dans la province de Gauteng, Afrique du Sud avec de très nombreux patients avec tuberculose (TB) et un risque élevé d'exposition à la TB parmi les travailleurs de santé (HCW).Objectif : Déterminer l'observance des HCW vis-à-vis des pratiques recommandées de prévention de l'infection et de lutte contre la TB, la formation en matière de TB et l'accès aux services de santé, et le taux de TB chez les HCW.Schéma : Entretiens avec 285 HCW, basés sur un questionnaire structuré, dans le cadre d'une vaste étude internationale à multiples méthodes.Résultats : Bien que 10 HCW (dont sept personnels de soutien) aient eu une TB pendant leur période de travail, 62,8% des répondants n'étaient pas au courant du protocole de prise en charge de la TB dans l'hôpital. La couverture de la formation a été faible (34,5% de tous les HCW et moins de 5% des HCW de soutien sur la transmission de la TB ; 27,5% des infirmiers sur l'utilisation d'un masque respiratoire), tout comme l'utilisation d'une protection respiratoire (44,5% des HCW prenant en charge des patients TB). Les HCW de soutien ont été 36 fois plus susceptibles d'utiliser une protection respiratoire s'ils avaient été formés ; les infirmiers qui avaient été formés ont été environ 40 fois plus susceptibles d'utiliser des masques respiratoires s'ils étaient facilement disponibles.Conclusion : Une amélioration de la coordination et de la couverture de la formation à la prévention de l'infection TB est requise d'urgence, surtout pour les HCW de soutien dans les contextes d'exposition régulière aux patients TB. Des stocks suffisants de protection respiratoire doivent être disponibles.

Marco de referencia: Un hospital provincial de atención terciaria en la provincia de Gauteng de Suráfrica, donde se observa una alta carga de morbilidad por tuberculosis (TB) y un alto riesgo de exposición de los profesionales de salud (HCW) a la enfermedad.Objetivo: Evaluar la observancia de las prácticas de prevención y control de la infección tuberculosa, la capacitación en materia de TB y el acceso de los HCW a los servicios de atención y calcular la tasa de TB en este tipo personal.Método: Se entrevistaron 285 HCW mediante un cuestionario estructurado, en el marco de un extenso estudio internacional por métodos mixtos.Resultados: Pese a que 10 HCW (incluidos siete miembros del personal auxiliar) habían adquirido la enfermedad tuberculosa durante el período de su empleo, el 62,8% de los entrevistados no conocía el protocolo de manejo de la TB del hospital. La tasa de capacitación era baja (34,5% de todos los HCW y menos de 5% del personal auxiliar sobre la transmisión de la TB y 27,5% del HCW sobre la utilización de mascarillas respiratorias) y asimismo la utilización de la protección respiratoria (el 44,5% de los HCW que se ocupaban de pacientes con TB). La probabilidad de que personal auxiliar utilizara la protección respiratoria era 36 veces mayor al haber recibido capacitación; el personal de enfermería tenía una probabilidad 40 veces mayor de utilizar las mascarillas respiratorias cuando había sido formado y el material estaba al alcance.Conclusión: Se precisa con urgencia una mejor coordinación y una utilización más amplia de la formación sobre la prevención de la infección tuberculosa, sobre todo dirigida a los HCW auxiliares, en los entornos donde es corriente la exposición a pacientes tuberculosos. Es necesario contar con los suministros adecuados de protección respiratoria al alcance del personal.

Evaluation of a Clostridium difficile infection management policy with clinical pharmacy and medical microbiology involvement at a major Canadian teaching hospital.

WHAT IS KNOWN AND OBJECTIVE: Clostridium difficile infection (CDI) represents a spectrum of disease and is a significant concern for healthcare institutions. Our study objective was to assess whether implementation of a regional CDI management policy with Clinical Pharmacy and Medical Microbiology and Infection Control involvement would lead to an improvement in concordance in prescribing practices to an evidence-based CDI disease severity assessment and pharmacological treatment algorithm. METHODS: Conducted at a tertiary care teaching hospital, this two-phase quality assurance study consisted of a baseline retrospective healthcare record review of patients with CDI prior to the implementation of a regional CDI management policy followed by a prospective evaluation post-implementation. RESULTS AND DISCUSSION: One hundred and forty-one CDI episodes in the pre-implementation group were compared to 283 episodes post-implementation. Overall treatment concordance to the CDI treatment algorithm was achieved in 48 of 141 cases (34%) pre-implementation compared with 136 of 283 cases (48·1%) post-implementation (P = 0·01). The median time to treatment with vancomycin was reduced from five days to one day (P < 0·01), with median length of hospital stay decreasing from 30 days to 21 days (P = 0·01) post-implementation. There was no difference in 30-day all-cause mortality. WHAT IS NEW AND CONCLUSION: A comprehensive approach with appropriate stakeholder involvement in the development of clinical pathways, education to healthcare workers and prospective audit with intervention and feedback can ensure patients diagnosed with CDI are optimally managed and prescribed the most appropriate therapy based on CDI disease severity.

Clean Hands for Life: results of a large, multicentre, multifaceted, social marketing hand-hygiene campaign.

A year-long multifaceted hand-hygiene campaign entitled Clean Hands for Life targeting individual, environmental and organisational factors that influence healthcare worker (HCW) hand-hygiene behaviour was implemented in 36 acute and long-term care facilities in Vancouver Coastal Health region. The campaign involved rotation of ten novel posters, two poster contests, and distribution of multiple promotional items. A social marketing approach was used to implement and monitor the effectiveness of the campaign. Evaluation included quality assurance surveys, staff surveys (baseline, mid- and post-campaign), and focus groups. A total of 141 poster contest submissions was received, 5452 staff surveys completed and 14 focus groups conducted. Overall knowledge of the importance of hand-hygiene and intention to clean hands was high at baseline. No significant differences were observed when mid- and post-campaign scores were compared to baseline. The majority (89.5%) of HCWs reported that they preferred soap and water over alcohol hand gel. A significant increase in the self-reported use of hand-hygiene products was observed particularly among HCWs not providing direct patient care. Barriers to hand-hygiene included inappropriate placement of sinks, traffic flow issues, inadequately stocked washrooms, workload and time constraints. Organisational support was visible throughout the campaign. The results showed that social marketing is an effective approach in engaging HCWs. Hand-hygiene campaigns that focus almost exclusively on increasing awareness among HCWs may not be as successful as multifaceted campaigns or campaigns that target identified barriers to hand-hygiene.

Methicillin-resistant Staphylococcus aureus nasal carriage among injection drug users: six years later.

A survey in 2000 to detect methicillin-resistant Staphylococcus aureus (MRSA) colonization in Vancouver downtown east side injection drug users (IDUs) revealed an MRSA nasal colonization incidence of 7.4%. This is a follow-up study to determine the current prevalence of MRSA colonization and to further characterize the isolates and risk factors for colonization. In this point prevalence study of MRSA nasal carriage among IDUs, nasal swabs were cultured to detect S. aureus. Isolates were studied for their antimicrobial susceptibility patterns and the presence of mecA and Panton-Valentine leukocidin (PVL) genes and by pulsed-field gel electrophoresis (PFGE). S. aureus was isolated from 119 of 301 (39.5%) samples; three (2.5%) participants had both methicillin-sensitive S. aureus (MSSA) and MRSA, resulting in 122 isolates. Of these, 54.1% were MSSA and 45.9% were MRSA, with an overall MRSA rate of 18.6%. USA-300 (CMRSA-10) accounted for 75% of all MRSA isolates; 25% were USA-500 (CMRSA-5). None of the USA-500 isolates were positive for PVL; 41 (97.6%) USA-300 isolates contained PVL. One MSSA isolate, from an individual also carrying USA-300, was positive for PVL. The PFGE pattern of this MSSA isolate was related to that of the MRSA strain. The antibiograms of USA-300 compared to USA-500 isolates showed 100% versus 7.1% susceptibility to trimethoprim-sulfamethoxazole (TMP-SMX) and 54.8% versus 7.1% susceptibility to clindamycin. MRSA nasal colonization in this population has increased significantly within the last 6 years, with USA-300 replacing the previous strain. Most of these strains are PVL positive, and all are susceptible to TMP-SMX.

An in-use evaluation of an alcohol-based pre-surgical hand disinfectant.

OBJECTIVE: To determine whether alcohol hand disinfection is an effective alternative to traditional agents for the pre-surgical scrub. DESIGN: A prospective clinical trial of a 70% isopropanol pre-surgical hand disinfectant. SETTING: The operating room suites at two hospital sites in British Columbia. METHODS: Cases were selected to evaluate both short and longer procedures. The hand disinfectant was compared to agents in current use as surgical scrubs (4% chlorhexidine and 7.5% povidone-iodine). Surgical technique and glove use were not modified. Pre- and postoperative fingertip impression and "glove-juice" cultures were used to determine microbial burden, and hands were evaluated for skin integrity. RESULTS: There was no statistical difference between the microbial hand counts following use of the alcohol-based product or the current agents, for cases less than 2 hours' duration. Comparison of longer surgical cases revealed significantly better pre- and postoperative culture results with the alcohol hand rinse, but analysis of matched pairs showed no significant difference in microbial counts. The alcohol hand rinse was equivalent to the operative scrub in terms of skin integrity and user acceptability. CONCLUSION: An alcohol hand rinse was equivalently effective in reducing microbial hand counts as the traditional pre-surgical scrub, both immediately after hand disinfection and at the end of the surgical procedure.

Evidence of delays in transferring patients with methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus to long-term-care facilities.

This retrospective case-control study examined whether there was a difference in length of time awaiting long-term-care placement for patients identified as having methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus compared to controls. Thirty-nine patients with methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus waited for placement an average of 61 days longer than controls (P<.0002). The average number of requests for placement was 2.5 compared to 1.7 for controls (P=.015).

Rapid identification of clinical yeast isolates using the colorimetric AUXACOLOR system.

The AUXACOLOR colorimetric system (Sanofi Diagnostics Pasteur, Marnes-la-Coquette, France) for the identification of clinical yeast isolates, was compared in its identification of 100 yeast strains to conventional identification methods. Of the 94 correctly identified isolates, 47% (n = 44) were identified by 24 h, and 100% (n = 94) were identified by 48 h. AUXACOLOR is a simple, rapid and accurate method for the identification of yeast pathogens.

Economic impact of standardized orders for antimicrobial prophylaxis program.

OBJECTIVE: To assess the effect and economic impact of an intervention aimed at standardizing the timing of preoperative antimicrobial prophylaxis from the perspective of a major teaching hospital. DESIGN: A pre/post study design in which a random sample of 60 procedures from a 12-month period in the preintervention phase were reviewed. A comparative sample of 60 procedures during a seven-month postintervention phase was selected. For each prophylactic course, preoperative dose administration details were classified as early (>2 h prior to incision), on time (0-2 h prior), delayed (0-3 h after), or late (>3 after). To determine the economic impact of this intervention, we used a predictive decision analytic model using institutional costs and the published probabilities of inpatient surgical wound infections (SWIs) following administration of antimicrobials timed according to the above criteria. Two conditions were analyzed: (1) an interdisciplinary two-stage therapeutic interchange program involving staff education and modification of preoperative antimicrobial orders to ensure timely administration and (2) no intervention. SETTING: An 1100-bed tertiary care, university-affiliated institution. PATIENTS: 120 randomly selected procedures involving inpatients who received a preoperative antibiotic. OUTCOME MEASURES: Differences in preoperative antimicrobial timing and cost avoidance associated with the intervention. RESULTS: In the preintervention phase, 68% of prophylactic courses were on time, 22% were early, and the balance were delayed or late. The incidence of on-time prophylaxis increased to 97% during the postintervention phase (p = 0.001). Operating room staff involvement in antimicrobial administration increased from 57% to 92% (p = 0.001). Based on a setup and annual intervention cost of $9100 CAN ($1 CAN = $0.68 US), an annual inpatient SWI avoidance of 51 cases, an average infection-associated extended hospital stay of four days, and an average treatment cost of $1957 CAN per inpatient SWI, we estimated that 153 hospital days were avoided and there was an annual cost avoidance of $90 707 CAN ($1779 CAN saved per inpatient infection avoided) due to this intervention. Using sensitivity analyses, no plausible changes in the base case estimates altered the results of the economic model. CONCLUSIONS: An interdisciplinary approach to optimizing the timing of preoperative antimicrobial doses can impact positively on practice patterns and result in substantial cost avoidance. Costs incurred to implement such an intervention are small when compared with the annual cost avoidance to the institution.

Sharps injuries: defining prevention priorities.

OBJECTIVE: An institutional review of sharps injuries was conducted to assist in establishing priorities for resource allocation in a sharps prevention program. DESIGN: A retrospective review of 221 sharps injuries occurring during a 1-year period was conducted by a 4-member multidisciplinary team. Each injury was categorized as either moderate/high, low, or unknown risk for acquisition of bloodborne diseases by using modified provincial definitions of occupational risk for exposure to bloodborne pathogens. RESULTS: A total of 119 injuries were considered to be moderate/high risk, and 93 were at low risk for acquisition of bloodborne disease. Nine injuries could not be categorized. In 59% of high-risk injuries, education or changes in technique were identified as the primary preventive intervention. Passive devices such as needleless intravenous administration sets could theoretically address prevention of the majority of low-risk injuries. Known available safety devices could have prevented 33 (28%) high-risk injuries. CONCLUSION: Disposition of resources must take into consideration the risk of bloodborne disease acquisition and the efficiency and expense of the preventable methods employed. Institutional review of injuries combined with a cost analysis revealed that resources were best allocated to protective devices at source (eg, safety syringes) and on a comprehensive, multidisciplinary, and sustained educational program. Needleless intravenous infusion sets would mainly prevent low-risk injuries at significant cost.

Cost-minimization analysis of piperacillin/tazobactam versus imipenem/cilastatin for the treatment of serious infections: a Canadian hospital perspective.

BACKGROUND: In 1998 we reported the first Canadian double-blind, randomized, clinical trial involving a comparison of piperacillin/tazobactam (P/T) with imipenem/cilastatin (I/C). The present study was conducted to determine the feasibility of replacing I/C at our institution. OBJECTIVE: To describe the outcome of a pharmacoeconomic analysis of the clinical trial from the perspective of a tertiary acute-care institution. METHODS: A total of 150 consenting adults originally prescribed I/C were randomly assigned to receive either P/T 4.5 g i.v. (n = 75) or I/C 500 mg i.v. (n = 75) every six hours. Actual direct medical resources used in relation to the treatment of bacterial infections were prospectively assessed during a clinical trial; these included cost of study and ancillary antibiotics, hospitalization, diagnostic testing (radiology, laboratory assessments), and labor, as well as treatment of adverse drug reactions, antibiotic failures, and superinfections. RESULTS: While costs for successful treatment courses were similar across treatment arms, hospitalization costs for treatment course failures were higher for P/T recipients. Direct medical costs for treatment courses associated with a superinfection were also higher in the P/T arm. Overall costs for treatment failures with either study drug were at least twofold those observed for successful treatment courses. Mean total management cost per patient in the P/T group was $15,211 ($ CDN throughout) (95% CI $11,429 to $18,993), compared with $14,232 (95% CI $11,421 to $17,043) in the I/C group (p = 0.32), resulting in a mean cost difference of $979. Sensitivity analyses revealed that the superiority of I/C over P/T for successful treatment of serious infections was sensitive to changes in the cost of hospitalization and drug efficacy for either drug. CONCLUSIONS: Based on the results of the clinical trial, P/T and I/C offer similar clinical, microbiologic, and toxicity outcomes in hospitalized patients with serious infections. Under base-case conditions, our pharmacoeconomic analysis showed that I/C was a cost-effective alternative to P/T at the dosage regimens studied. However, this finding was sensitive to plausible changes in both clinical and economic parameters.

The toilet as a transmission vector of vancomycin-resistant enterococci.

An elderly woman, admitted to the intensive care unit of a large university teaching hospital, was found to be colonized with vancomycin-resistant enterococci leading to the temporary closure of the unit. She had acquired the organism nosocomially, most likely from an environmental source, which had been contaminated when the toilet of a former patient, also colonized with vancomycin-resistant enterococci, had become blocked and overflowed throughout his and the adjoining room. This is the first report of a hospital toilet as the transmission vector for vancomycin-resistant enterococci.

An evaluation of the AbTox Plazlyte Sterilization System.

OBJECTIVE: To evaluate the efficacy of the AbTox Plazlyte Sterilization System against selected microbial species using inoculated carriers and surgical instruments. SETTING: The microbiology laboratory of a 700-bed adult tertiary-care hospital. DESIGN: The study was conducted in two phases. In phase 1, microorganisms were inoculated to various metal, paper, plastic, and glass carriers, as well as surgical equipment, and processed in cycle II of the AbTox sterilizer. Phase 2 compared AbTox cycle III with ethylene oxide sterilization using stainless steel washers, penicylinders, and surgical equipment. In both phases, cultures of equipment and carriers were obtained after processing. The phenotypic profiles and antibiograms of positive cultures were compared to the original inoculate to rule out the possibility of contamination. RESULTS: Of a total of 350 paper carriers, 375 metal washers, and 234 pieces of equipment processed in cycle II and using trypticase soy broth as the inoculating medium, 123 metal washers (32%) and 8 instruments (3%) failed to be sterilized. Similar failures were noted with cycle III. The presence of either salt or protein adversely affected the system's ability to sterilize in either cycle. CONCLUSION: Further studies are needed to evaluate the extent to which salt or organic material compromise low-temperature gas-plasma sterilization. Meanwhile, users should exercise caution and use care in the cleaning of instruments that will be processed in the plasma-based sterilization technologies.

When the biological indicator is positive: investigating autoclave failures.

A series of positive biological indicators in steam autoclaves from different hospital departments within the same building were traced to blocked steam traps on building condensate lines. The steps taken during the investigation and a protocol for management of positive biological indicators are described.

Evaluation of the cathetron system for recycling angioplasty catheters.

The Cathetron (Minntech Corporation, Minneapolis, MN) peracetic acid-based reprocessing method for percutaneous transluminal coronary angioplasty (PTCA) catheters was evaluated for ability to sterilize and maintain catheter integrity. The balloons and lumens of 42 catheters (140 reprocessing cycles) were inoculated with suspensions of Staphylococcus epidermidis, S. aureus, Pseudomonas aeruginosa, and Bacillus circulans. Five catheters failed the initial evaluation of mechanical integrity and were discarded. Cultures from 37 catheter lumens, balloons, and hubs (n = 349) were negative following reprocessing. The Cathetron system reliably sterilized PTCA catheter, however, further studies using different brands of catheters and evaluating catheter sterility over time under storage conditions are required.