Resistance to first-line antibiotic therapy among patients with uncomplicated acute cystitis in Melbourne, Australia: prevalence, predictors and clinical impact.

Background: Australian guidelines recommend trimethoprim or nitrofurantoin as first-line agents for uncomplicated urinary tract infections (UTIs). Laboratory surveillance indicates high rates of trimethoprim resistance among urinary bacterial isolates, but there are scant local clinical data about risk factors and impact of trimethoprim resistance. Objectives: To determine the prevalence, risk factors, mechanism and impact of resistance to first-line antibiotic therapy for uncomplicated UTIs in the community setting. Methods: A prospective observational study from October 2019 to November 2021 in four general practices in Melbourne, Australia. Female adult patients prescribed an antibiotic for suspected or confirmed uncomplicated acute cystitis were eligible. Primary outcome was urine isolates with resistance to trimethoprim and/or nitrofurantoin. Results: We recruited 87 participants across 102 UTI episodes with median (IQR) age of 63 (47-76) years. Escherichia coli was the most common uropathogen cultured (48/62; 77%); 27% (13/48) were resistant to trimethoprim (mediated by a dfrA gene) and none were resistant to nitrofurantoin. Isolates with resistance to a first-line therapy were more common among patients reporting a history of recurrent UTIs [risk ratio (RR): 2.08 (95% CI: 1.24-3.51)] and antibiotic use in the previous 6 months [RR: 1.89 (95% CI: 1.36-2.62)]. Uropathogen resistance to empirical therapy was not associated with worse clinical outcomes. Conclusions: Resistance to trimethoprim is common in uncomplicated UTIs in Australia but may not impact clinical outcomes. Further research is warranted on the appropriateness of trimethoprim as empirical therapy, particularly for patients with antimicrobial resistance risk factors.

Future Prediction of Close Contacts in IoT-based Contact Tracing System using a New Real-Life Dataset.

Contact tracing is an effective method for mitigating the infectious diseases spread and it played a crucial role in reducing COVID-19 outbreak. Since the pandemic, there has been an increased concern regarding people's health in hospital and office settings, as these limited air exchange spaces provide a conductive medium for virus spread. Various technologies were used to recognize close contacts autonomously, in addition, multiple machine learning attempts were carried out to determine proximity in contact tracing. This study, however, proposes a unique concept in contact tracing: forecasting future close contact prior to occurrence in order to regulate and control it rather than tracking past occurrences. For our research, we constructed a completely new real-life dataset that was collected during the pandemic in a hospital infectious ward (Alfred Hospital, Melbourne, Australia) utilizing a Bluetooth Low Energy (BLE) Internet of Things (IoT) system. Our prediction technique considers two types of environments: single transceiver environments and multiple transceivers settings, these transceivers record the nearby tags' BLE received signal strength indicator (RSSI) values. The system employs mathematical models and supervised machine learning (ML) algorithms to solve regression and classification problems for workers' pattern recognition within the environment. The output is compared using different metrics, such as efficiency, which reached more than 80%, root mean square errors and mean absolute errors which were as low as 2.4 and 1.2 respectively in some models.

Prevalence and incidence of emergency department presentations and hospital separations with injecting-related infections in a longitudinal cohort of people who inject drugs.

People who inject drugs are at risk of acute bacterial and fungal injecting-related infections. There is evidence that incidence of hospitalizations for injecting-related infections are increasing in several countries, but little is known at an individual level. We aimed to examine injecting-related infections in a linked longitudinal cohort of people who inject drugs in Melbourne, Australia. A retrospective descriptive analysis was conducted to estimate the prevalence and incidence of injecting-related infections using administrative emergency department and hospital separation datasets linked to the SuperMIX cohort, from 2008 to 2018. Over the study period, 33% (95%CI: 31-36%) of participants presented to emergency department with any injecting-related infections and 27% (95%CI: 25-30%) were admitted to hospital. Of 1,044 emergency department presentations and 740 hospital separations, skin and soft tissue infections were most common, 88% and 76%, respectively. From 2008 to 2018, there was a substantial increase in emergency department presentations and hospital separations with any injecting-related infections, 48 to 135 per 1,000 person-years, and 18 to 102 per 1,000 person-years, respectively. The results emphasize that injecting-related infections are increasing, and that new models of care are needed to help prevent and facilitate early detection of superficial infection to avoid potentially life-threatening severe infections.

Telehealth for Comprehensive Care to Quarantine Residents: A Novel Approach and Lessons Learned.

Proactive engagement and care with regular and timely information are required to manage the health and well-being of people in quarantine. At Australia's Howard Springs International Quarantine Facility, a telehealth model was rapidly established using trained non-clinical Customer Service Officers (CSO's) with the aim to provide comprehensive care to residents, maximize staff safety, and reduce clinical workforce capacity pressures. We describe this model, whereby CSO's provided residents with daily COVID-19 symptom and well-being screening, weekly psychological screening, and ongoing linkage to additional clinical and administrative services. In addition, CSO's went beyond these duties to deliver personalized care through delivery of care packages and attendance of the departure point to farewell residents. From October 2020 to May 2021, across 7105 residents, we estimated that CSO's prevented over 75 000 face-to-face resident visits, which reduced workforce requirements and preserved staff safety through minimizing potential COVID-19 transmission and time spent in personal protective equipment in the challenging ambient environment. We share key lessons learned which may inform future telehealth models and guide a positive experience for quarantine residents.

Rapid SARS-CoV-2 Seroprevalence Survey in Central and Western Divisions of Fiji, 2021.

During November-December 2021, we performed a SARS-CoV-2 seroprevalence survey in Central and Western Divisions of Fiji. A total of 539 participants 8-70 years of age were 95.5% (95% CI 93.4%-97.1%) seropositive, indicating high community levels of immunity. Seroprevalence studies can inform public health responses to emerging SARS-CoV-2 variants.

Building a safety culture for infection prevention and control adherence at Howard Springs: A workplace survey.

BACKGROUND: Building a safety culture is essential to facilitate infection prevention and control (IPC) adherence in workplaces. We aimed to explore perceptions, barriers and facilitators to IPC procedures by the Australian Medical Assistance Team (AUSMAT) at Howard Springs International Quarantine Facility (HSIQF). METHODS: We performed a descriptive analysis of a cross-sectional survey administered to the AUSMAT employed at HSQIF from October 2020 to April 2021. We described motivation, training and compliance to IPC adherence and Likert scales described the level of agreement to the success of IPC procedures across the domains of communication, risk, trust, safety and environment, from the individual, team and organisational perspective. RESULTS: There were 101 participants (response rate 59%, 101/170) and 70% (71/101) were clinical. There was strong agreement to the success of IPC procedures, with a median 4 (agree) or 5 (strongly agree) across each domain and perspective of the 67 Likert items. Clinical staff reported slightly higher agreement than non-clinical staff across Likert items. To improve IPC compliance, most reported that daily training should be provided (77/97, 79%) and daily training was very or extremely effective (91/97, 93%). Participants were motivated by protecting self, friends, family and the community rather than workplace pressures. Barriers to IPC compliance were the ambient environment and fatigue. CONCLUSIONS: A safety culture was successfully built at HSQIF to optimise IPC adherence whilst managing multiple hazards including prevention of COVID-19 transmission. Strategies implemented by AUSMAT at the quarantine facility may inform the development of safety culture in other settings.

Acute injection-related infections requiring hospitalisation among people who inject drugs: Clinical features, microbiology and management.

INTRODUCTION: People who inject drugs are at risk of hospitalisation with injection-related infections (IRI). We audited the clinical features, microbiology and management of IRI at a tertiary service in Melbourne to describe the burden and identify quality improvement opportunities. METHODS: We performed retrospective review of IRI admissions from January 2017 to April 2019. We extracted admissions where ICD-10 codes or triage text suggested injecting drug use, and the diagnosis suggested IRI. We reviewed these for eligibility and extracted data using a standardised form. We performed mixed-effects logistic regression to determine predictors of unplanned discharge. RESULTS: From 574 extracted candidate admissions, 226 were eligible, representing 178 patients. Median age was 41 years (interquartile range 36-47), 66% (117/178) male and 49% (111/226) had unstable housing. Over 50% (96/178) had a psychiatric diagnosis and 35% (62/178) were on opioid agonist therapy (OAT) on admission. Skin and soft tissue infection was the most common IRI (119/205, 58%), followed by bacteraemia (36/205, 18%) and endocarditis (26/205, 13%). Management included addictions review (143/226, 63%), blood-borne virus screening (115/226, 51%), surgery (77/226, 34%) and OAT commencement (68/226, 30%). Aggression events (54/226, 15%) and unplanned discharge (69/226, 30%) complicated some admissions. Opioid use without OAT was associated with almost 3-fold increased odds of unplanned discharge compared to no opioid use (odds ratio 2.90, 95% confidence interval 1.23, 6.85, p = 0.015). DISCUSSION AND CONCLUSION: Comorbidities associated with IRI may be amenable to opportunistic intervention during hospitalisation. Further research is needed to develop optimal models of care for this vulnerable patient group.

Electronic monitoring of doffing using video surveillance to minimise error rate and increase safety at Howard Springs International Quarantine Facility.

BACKGROUND: Safe donning and doffing of personal protective equipment (PPE) are critical to prevent transmission of infectious diseases. Novel strategies to improve infection prevention and control (IPC) adherence can optimise safety. We describe and quantify video surveillance of doffing at an outdoor hotel quarantine facility led by the Australian Medical Assistance Team in the Northern Territory, Australia. METHODS: Motion-activated video cameras were installed in seven areas where personnel doffed PPE upon exit from an area dedicated to quarantined residents. Video footage was reviewed daily and compliance issues were identified using a standardised checklist and risk graded to initiate feedback. We collated audit data from 1 February to 18 April 2021 to describe trends by month, staff group, doffing component and risk. RESULTS: In 235 h of video footage, 364 compliance issues were identified, of which none were considered high-risk compromising to PPE integrity. Compliance issues were low risk (55/364, 15%) or moderate risk (309/364, 85%) and the most common issue was missed or inadequate hand hygiene (156/364, 43%). Compliance issues per minute of video footage reviewed decreased following introduction of the activity, from 24 per 1000 in February to 7 per 1000 in March and April. CONCLUSION: Video surveillance with feedback supported rapid response to improve IPC adherence in a challenging ambient environment. The activity focused on perfection to identify compliance issues that would go unreported in most healthcare settings and contributed to a suit of activities that prevented any high-risk PPE breaches or compromises to safety.

An outdoor hotel quarantine facility model in Australia: best practice with optimal outcomes.

OBJECTIVE: To describe the operationalisation of a novel outdoor quarantine facility managed by the Australian Medical Assistance Team, the Howard Springs International Quarantine Facility (HSIQF) at the Centre for National Resilience in the Northern Territory, Australia. METHODS: We collated documentation and data from HSIQF to describe policies and procedures implemented and performed a descriptive analysis of key procedures and outcomes. RESULTS: From 23 October 2020 to 31 March 2021, 2.2% (129/5,987) of residents were confirmed COVD-19 cases. On average per day, 82 [Interquartile Range (IQR): 29-95] staff completed personal protective equipment (PPE) training, 94 [IQR: 90-104] staff completed antigen testing and 51 [IQR: 32-136] staff completed polymerase chain reaction testing. The operation focused on building a safe environment with infection prevention and control adherence and workforce sustainability. There was no leakage of SARS-CoV-2 to staff or the community and no PPE compromises requiring staff to quarantine for 14 days. CONCLUSION: HSIQF demonstrates the operationalisation of an effective, safe and replicable quarantine system. IMPLICATIONS FOR PUBLIC HEALTH: Quarantine is a critical public health tool for pandemic control. The HSIQF operations may be useful to inform the establishment and management of quarantine facilities for future and current disease outbreaks.

Hospitalisation with injection-related infections: Validation of diagnostic codes to monitor admission trends at a tertiary care hospital in Melbourne, Australia.

INTRODUCTION: Injection-related infections (IRI) cause morbidity and mortality in people who inject drugs. Hospital administrative datasets can be used to describe hospitalisation trends, but there are no validated algorithms to identify injecting drug use and IRIs. We aimed to validate International Classification of Diseases (ICD) codes to identify admissions with IRIs and use these codes to describe IRIs within our hospital. METHODS: We developed a candidate set of ICD codes to identify current injecting drug use and IRI and extracted admissions satisfying both criteria. We then used manual chart review data from 1 January 2017 to 30 April 2019 to evaluate the performance of these codes and refine our algorithm by selecting codes with a high-positive predictive value (PPV). We used the refined algorithm to describe trends and outcomes of people who inject drugs with an IRI at Alfred Hospital, Melbourne from 2008 to 2020. RESULTS: Current injecting drug use was best predicted by opioid-related disorders (F11), 80% (95% confidence interval [CI] 74-85%), and other stimulant-related disorders (F15), 82% (95% CI 70-90%). All PPVs were ≥67% to identify specific IRIs, and ≥84% for identifying any IRI. Using these codes over 12 years, IRIs increased from 138 to 249 per 100 000 admissions, and skin and soft tissues infections (SSTI) were the most common (797/1751, 46%). DISCUSSION AND CONCLUSION: Validated ICD-based algorithms can inform passive surveillance systems. Strategies to reduce hospitalisation with IRIs should be supported by early intervention and prevention, particularly for SSTIs which may represent delayed access to care.

Feasibility of Bluetooth Low Energy wearable tags to quantify healthcare worker proximity networks and patient close contact: A pilot study.

BACKGROUND: The hospital environment is characterised by a dense network of interactions between healthcare workers (HCWs) and patients. As highlighted by the coronavirus pandemic, this represents a risk for disease transmission and a challenge for contact tracing. We aimed to develop and pilot an automated system to address this challenge and describe contacts between HCWs and patients. METHODS: We developed a bespoke Bluetooth Low Energy (BLE) system for the hospital environment with anonymous tags worn by HCWs and fixed receivers at patient room doors. Proximity between wearable tags inferred contact between HCWs. Tag-receiver interactions inferred patient room entry and exit by HCWs. We performed a pilot study in four negative pressure isolation rooms from 13 April to 18 April 2021. Nursing and medical staff who consented to participate were able to collect one of ten wearable BLE tags during their shift. RESULTS: Over the four days, when divided by shift times, 27 nursing tags and 3 medical tags were monitored. We recorded 332 nurse-nurse interactions, for a median duration of 58 s [interquartile range (IQR): 39-101]. We recorded 45 nursing patient room entries, for a median 7 min [IQR: 3-21] of patient close contact. Patient close contact was shorter in rooms on airborne precautions, compared to those not o transmission-based precautions. CONCLUSION: This pilot study supported the functionality of this approach to quantify HCW proximity networks and patient close contact. With further refinements, the system could be scaled-up to support contact tracing in high-risk environments.

An evaluation of enhanced surveillance of hospitalised COVID-19 patients to inform the public health response in Victoria.

BACKGROUND: Public health surveillance is crucial for supporting a rapid and effective response to public health emergencies. In response to the coronavirus disease (COVID-19) pandemic, an enhanced surveillance system of hospitalised COVID-19 patients was established by the Victorian Department of Health and Human Services (DHHS) and the Victorian Healthcare Associated Infection Surveillance System Coordinating Centre. The system aimed to reduce workforce capacity constraints and increase situational awareness on the status of hospitalised patients. METHODS: The system was evaluated, using guidelines from the United States Centers for Disease Control and Prevention, against eight attributes: acceptability; data quality; flexibility; representativeness; simplicity; stability; timeliness; and usefulness. Evidence was generated from stakeholder consultation, participant observation, document review, systems review, issues log review and audits. Data were collected and analysed over a period of up to three months, covering pre- and post-implementation from March to June 2020. RESULTS: This system was rapidly established by leveraging established relationships and infrastructure. Stakeholders agreed that the system was important but was limited by a reliance on daily manual labour (including weekends), which impeded scalability. The ability of the system to perform well in each attribute was expected to shift with the severity of the pandemic; however, at the time of this evaluation, when there were an average 23 new cases per day (0.3 cases per 100,000 population per day), the system performed well. CONCLUSION: This enhanced surveillance system was useful and achieved its key DHHS objectives during the COVID-19 public health emergency in Victoria. Recommendations for improvement were made to the current and future systems, including the need to plan alternatives to improve the system's scalability and to maintain stakeholder acceptability.

An audit of nitrofurantoin use in three Australian hospitals.

BACKGROUND: International guidelines have recommended the long-acting formulation of nitrofurantoin as first-line treatment for uncomplicated urinary tract infections (UTIs) since 2010. Australian guidelines have only recently listed nitrofurantoin as a first-line agent, but the long-acting formulation is not available. In the setting of increasing multidrug-resistance, the unavailability of the long-acting formulation of nitrofurantoin in Australia, and anecdotal perception of confusion regarding dosing, we audited nitrofurantoin use. METHODS: We performed a retrospective audit of nitrofurantoin use at Alfred Health. All patients dispensed nitrofurantoin from January 2016 to June 2018, as identified from pharmacy dispensing records, were eligible. We used a standardised case report form to extract data from medical records, including dosing regimen and indication. RESULTS: We included 150 patients with 151 nitrofurantoin prescriptions in the analysis, of whom 74% [111/150] were female. Nitrofurantoin was most commonly dispensed for the treatment of UTIs (68% [103/151] versus 32% [48/151] for UTI prophylaxis). For the treatment of uncomplicated UTIs, the most frequently used dose was 100 mg twice daily for five days. In male patients, the 100 mg twice daily for seven days was the most popular regimen. The prophylactic dose of 50 mg once daily was used in women but rarely in men. We did not find evidence of dose adjustment for renal impairment. CONCLUSION: While treatment duration was consistent with guidelines, the dosage and frequency used was often incorrect for the formulation and was not adjusted for renal function. Nitrofurantoin use is likely to increase, so clarification regarding optimal nitrofurantoin dosing regimens may be appropriate.

Strategies to reduce non-ventilator-associated hospital-acquired pneumonia: A systematic review.

BACKGROUND: Point prevalence studies identify that pneumonia is the most common healthcare associated infection. However, non-ventilator associated healthcare associated pneumonia (NV-HAP) is both underreported and understudied. Most research conducted to date, focuses on ventilator associated pneumonia. We conducted a systematic review, to provide the latest evidence for strategies to reduce NV-HAP and describe the methodological approaches used. METHODS: We performed a systematic search to identify research exploring and evaluating NV-HAP preventive measures in hospitals and aged-care facilities. The electronic database Medline was searched, for peer-reviewed articles published between 1st January 1998 and 31st August 2018. An assessment of the study quality and risk of bias of included articles was conducted using the Newcastle-Ottawa Scale. RESULTS: The literature search yielded 1551 articles, with 15 articles meeting the inclusion criteria. The majority of strategies for NV-HAP prevention focussed on oral care (n = 9). Three studies evaluated a form of physical activity, such as passive movements, two studies used dysphagia screening and management; and another study evaluated prophylactic antibiotics. Most studies (n = 12) were conducted in a hospital setting. Six of the fifteen studies were randomised controlled trials. CONCLUSION: There was considerable heterogeneity in the included studies, including the type of intervention, study design, methods and definitions used to diagnose the NV-HAP. To date, interventions to reduce NV-HAP appear to be based broadly on the themes of improving oral care, increased mobility or movement and dysphagia management.