The impact of guidelines on sterility precautions during indwelling urethral catheterization at two acute-care hospitals in Sweden - a descriptive survey.

BACKGROUND: To support a uniform and evidence-based practice for indwelling urinary catheterization in adults The European association of Urology Nurses (EAUN) published guidelines for this procedure in 2012. The Swedish national guidelines are based on the sterility precautions advocated by EAUN. Some hospitals have local guidelines with other requirements concerning sterility and leave to staff to decide how to perform the catheterization. The aim of this descriptive survey was to investigate the nurses´ self-reported sterility precautions during indwelling urethral catheterization at two acute-care hospitals, where the local guidelines differ in their sterility requirements. The study also aimed to analyze factors affecting conformity with sterility precautions in the EAUN-guidelines. METHODS: A structured questionnaire with questions concerning the participant, working conditions and performance of indwelling urethral catheterization was left to 931 nurses in two acute care hospitals. Chi-square test, Fisher's exact test and Mann-Whitney U-test were used for descriptive statistics. Logistic regression was used to analyze variables associated with practicing the sterility precautions in the EAUN-guidelines. RESULTS: Answers were obtained from 852 persons (91.5%). Most of the participants called their insertion technique "non-sterile". Regardless of designation of the technique the participants said that the indwelling urinary catheter (IUC) should be kept sterile during procedure. Despite that not everyone used sterile equipment to maintain sterility of the catheter. The nurses´ conformity with all the sterility precautions in the EAUN-guidelines were associated with working at departments for surgery and cardiology (OR 2.35, 95% CI 1.69-3.27), use of sterile set for catheterization (OR 2.06, 95% CI 1.42-2.97), use of sterile drapes for dressing on insertion area (OR 1.91, 95% CI 1.24-2.96) and using the term "sterile technique" for indwelling urethral catheterization (OR 1.64, 95% CI 1.11-2.43). CONCLUSIONS: Only 55-74% of the nurses practiced one or more precautions that secured sterility of the IUC thus demonstrating a gap between the EAUN-guidelines and the actual performance. Adherence to the guidelines was associated with factors that facilitated an aseptic performance such as using a sterile set and sterile drapes. Healthcare-settings should ensure education and skill training including measures to ensure that the IUC is kept sterile during insertion.

[Is it time to use sputum induction as a complementary specimen collection procedure in adult patients with suspected pulmonary tuberculosis?] / Sputuminduktion bör väljas före ventrikelsköljning vid tbc-prov.

Gastric aspiration (GA) and sputum induction (SI) are used for diagnosing pulmonary tuberculosis (TB) in patients who cannot spontaneously produce sputum. This meta-analysis compares the sensitivity of GA and SI as alternative strategies for TB specimen collection in adult patients and describes procedure preference across Swedish Departments for Infectious Diseases (DID). We searched PubMed for articles on SI, GA and TB in adults. The meta-analysis included six articles (418 patients) and resulted in a crude OR 3.5 (95% CI 1.6-7.8) for positive culture from SI compared with GA. We asked all DID which procedure they currently used for collecting TB specimens (Sep 2019). Answers were received from 27/29 DID of which 67% (18/27) used SI as the primary diagnostic strategy when a patient could not spontaneously submit sputum. In conclusion, SI seems more effective than GA in detecting culture positive pulmonary TB in adult patients.

[Healthcare-associated infections in Stockholm County Council 2008-2018]. / Minskad prevalens av vårdrelaterade infektioner inom Region Stockholm.

Healthcare-associated infections (HAI) are the most common adverse events in healthcare. The aim of this study was to explore the prevalence of HAI and associated risk factors among in-patients in somatic care in Stockholm County Council (SCC) 2008-2018. In each yearly point prevalence survey 3200-3800 patients were registered. Epi Info™ software was used for statistical analysis. There were significant decreases in prevalence of HAI 15.3-7.3% (RR 0.47 [95% CI 0.41-0.54] p<0.01), indwelling urinary catheter (IUC) 24.3-21.7% (RR 0.89 [95% CI 0.82-0.97] p=0.01) and central venous catheter 13.8-10.7% (RR 0.78 [95% CI 0.69-0.88] p<0.01). Among carriers of IUC there was a significant decrease in prevalence of urinary tract infection 11.4-4.1% (RR 0.36 [95% CI 0.22-0.59] p<0.01). After analyzing potential confounders we believe that the improvement is true. Repeated point prevalence surveys could have contributed to raising awareness about HAI.

Harbouring group B streptococci in a neonatal intensive care unit led to an outbreak among preterm infants.

We report a nosocomial outbreak with group B streptococci (GBS) in a level two neonatal intensive care unit (NICU) at Sachs' Children and Youth Hospital, Stockholm, Sweden, in 2014. There were five very preterm infants with severe late-onset septicaemia, and 10 further infants were colonised. Pulsed-field gel electrophoresis and multilocus sequence typing genetic characterisation showed that one GBS strain was the cause: serotype Ia, sequence type 23, clonal complex 23. The NICU environment cultures revealed GBS reservoirs on surfaces near sick and colonised patients. We identified workflows and guidelines that could increase the risks of nosocomial infections. Conclusion: This nosocomial GBS outbreak among preterm infants demonstrates that GBS can be harboured in the NICU environment.

Vitamin D supplementation to persistent carriers of MRSA-a randomized and placebo-controlled clinical trial.

Methicillin-resistant Staphylococcus aureus (MRSA) is resistant to all beta-lactam antibiotics and can cause severe infections that are difficult to treat. Eradication strategies with conventional antibiotics are not always effective and alternative approaches are warranted. Here, we tested the hypothesis that daily supplementation with vitamin D for 12 months would reduce MRSA carriage rates among a group of persistent carriers. This was a double-blind, placebo-controlled randomized trial with n = 65 persistent MRSA carriers with 25-hydroxy vitamin D3 (25OHD) < 75 nmol/L, who were followed up with bacterial cultures at baseline and every 3 months for 1 year. The primary endpoint was the decline in MRSA positivity during the study period. The study was conducted in two MRSA outpatient clinics at the Karolinska University Hospital, Stockholm, Sweden. In total, n = 65 persistent MRSA carriers were randomized and n = 3 were lost to follow-up. Only patients deficient in vitamin D (< 75 nmol/L) were included. Vitamin D (4000 IU) or placebo/day was administered for 12 months. The decline in MRSA positivity was equal in the vitamin D and placebo group during the study period (OR, 1.00; 95% CI, 0.97-1.03; p = 0.928) and approximately 40% in both groups were MRSA-negative after 12 months. The vitamin D group produced 103 positive cultures out of 318 cultures (32.4%) from nose, throat, and perineum over the study period, whereas the placebo group produced 135/393 positive cultures (34.0%) (Fisher's exact test, p = 0.94). Vitamin D supplementation did not influence MRSA carriage. Thus, available data does not support vitamin D supplementation to persistent MRSA carriers.Trial registration: www.clinicaltrials.gov ; NCT02178488.

Acquisition of extended spectrum ß-lactamases during travel abroad-A qualitative study among Swedish travellers examining their knowledge, risk assessment, and behaviour.

BACKGROUND: Travel to foreign countries involves the risk of becoming a carrier of antibiotic-resistant bacteria, especially when the destination is a country with a high prevalence of this type of bacteria. AIM AND METHODS: The aim of this study was to learn about the knowledge of antibiotic resistance, and the behaviour and risk-taking among travellers, who had become carriers of extended spectrum beta-lactamases (ESBL)-producing bacteria during travel to a high-prevalence country. A modified version of grounded theory was used to analyse 15 open interviews. RESULTS: The analysis resulted in a core category: A need for knowledge to avoid risk-taking. Before the journey, the participants did not perceive there to be any risk of becoming a carrier of antibiotic- resistant bacteria. The low level of knowledge of antibiotic-resistant bacteria and transmission routes influenced their behaviour and risk-taking during their journey, resulting in them exposing themselves to risk situations. After their trip, the majority did not believe that their personal risk behaviour could have caused them to become carriers of ESBL. CONCLUSION: The participants' lack of knowledge of antibiotic-resistant bacteria resulted in unconscious risk-taking during their journey, which may have resulted in becoming carriers of ESBL-producing bacteria.

Comparison of three distinct clean air suits to decrease the bacterial load in the operating room: an observational study.

BACKGROUND: Lowering air-borne bacteria counts in the operating room is essential in prevention of surgical site infections in orthopaedic joint replacement surgery. This is mainly achieved by decreasing bacteria counts through dilution, with appropriate ventilation and by limiting the bacteria carrying skin particles, predominantly shed by the personnel. The aim of this study was to investigate if a single use polypropylene clothing system or a reusable polyester clothing system could offer similar air quality in the operating room as a mobile laminar airflow device-assisted reusable cotton/polyester clothing system. METHODS: Prospective observational study design, comparing the performance of three Clean Air Suits by measuring Colony Forming Units (CFU)/m(3) of air during elective hip and knee arthroplasties, performed at a large university-affiliated hospital. The amount of CFU/m(3) of air was measured during 37 operations of which 13 were performed with staff dressed in scrub suits made of a reusable mixed material (69 % cotton, 30 % polyester, 1 % carbon fibre) accompanied by two mobile laminar airflow units. During 24 procedures no mobile laminar airflow units were used, 13 with staff using a reusable olefin fabric clothing (woven polypropylene) and 11 with staff dressed in single-use suits (non-woven spunbonded polypropylene). Air from the operating field was sampled through a filter, by a Sartorius MD8, and bacterial colonies were counted after incubation. There were 6-8 measurements from each procedure, in total 244 measurements. Statistical analysis was performed by Mann-Whitney U-test. RESULTS: The single-use polypropylene suit reduced the amount of CFU/m(3) to a significantly lower level than both other clothing systems. CONCLUSION: Single-use polypropylene clothing systems can replace mobile laminar airflow unit-assisted reusable mixed material-clothing systems. Measurements in standardized laboratory settings can only serve as guidelines as environments in real operation settings present a much more difficult challenge.

Staff experiences of caring for patients with extended-spectrum ß-lactamase-producing bacteria: A qualitative study.

BACKGROUND: Patients who become carriers of antibiotic-resistant bacteria are sometimes stigmatized by health professionals. Staff members' fears of becoming infected could affect their willingness to care for these patients. METHODS: The purpose of this study was to increase the knowledge of what it means for staff in acute care settings and nursing homes to care for patients with extended-spectrum ß-lactamase (ESBL)-producing bacteria. Assistant nurses, registered nurses, and physicians from acute care settings and nursing homes were interviewed. A modified version of Grounded Theory was used for the analysis. RESULTS: The analysis resulted in the core category "to operate as an expert in a chaotic environment" in acute care settings. Despite a lack of resources, hospital staff try to provide the best possible care for patients with ESBL. The analysis of the interviews in the nursing homes resulted in the core category "the employee who, despite uncertainty, provides good care." Despite some fear, and a lack of knowledge, the study participants tried to provide the residents with good care. CONCLUSION: Staff in acute care settings and nursing homes must have adequate knowledge and reasonable working conditions to be able to provide high-quality care for patients and residents who are ESBL carriers.

Does a mobile laminar airflow screen reduce bacterial contamination in the operating room? A numerical study using computational fluid dynamics technique.

BACKGROUND: Air-borne bacteria in the operating room (OR) may contaminate the surgical wound, either by direct sedimentation from the air or indirectly, by contaminated sterile instruments. Reduced air contamination can be achieved with an efficient ventilation system. The current study assesses the additive effect of a mobile laminar airflow (MLAF) unit on the microbiological air quality in an OR supplied with turbulent-mixing air ventilation. METHODS: A recently designed OR in NKS (Nya Karolinska Sjukhuset, Stockholm, Sweden) was the physical model for this study. Simulation was made with MLAF units adjacent to the operating table and the instrument tables, in addition to conventional turbulent-mixing ventilation. The evaluation used numerical calculation by computational fluid dynamics (CFD). Sedimentation rates (CFU/m(2)/h) were calculated above the operating table and two instrument tables, and in the periphery of the OR. Bacterial air contamination (CFU/m(3)) was simulated above the surgical and instrument tables with and without the MLAF unit. RESULTS: The counts of airborne and sedimenting, bacteria-carrying particles downstream of the surgical team were reduced to an acceptable level for orthopedic/implant surgery when the MLAF units were added to conventional OR ventilation. No significant differences in mean sedimentation rates were found in the periphery of the OR. CONCLUSIONS: The MLAF screen unit can be a suitable option when the main OR ventilation system is unable to reduce the level of microbial contamination to an acceptable level for orthopedic implant surgery. However, MLAF effect is limited to an area within 1 m from the screen. Increasing air velocity from the MLAF above 0.4 m/s does not increase the impact area.

Living with extended-spectrum ß-lactamase: a qualitative study of patient experiences.

BACKGROUND: Extended-spectrum ß-lactamase (ESBL) is an enzyme that conveys resistance to most ß-lactam antibiotics. Infections caused by bacteria producing ESBL are often difficult to treat because of general multiresistance, and hospital care may be necessary even for nonserious infections. METHODS: The aim of this study was to increase our understanding of how infected individuals perceive their situation as "carriers" of multiresistant bacteria. A modified version of grounded theory was used to analyze 7 open interviews. RESULTS: The analysis resulted in the core category Being thrown into the scary and unknown without a map and compass. All informants thought they had received no or insufficient information about ESBL from the health care providers. Informants who had been given some information still had many unanswered thoughts and reflections. Health care staff were lacking in knowledge about ESBL and their own fears that led to the use of extreme hygiene measures, which increased the stigma for the patient. CONCLUSION: To manage their life situation, it is important that persons diagnosed as carriers of ESBL-producing bacteria receive adequate information from the attending doctor.

Comparison of three distinct surgical clothing systems for protection from air-borne bacteria: A prospective observational study.

BACKGROUND: To prevent surgical site infection it is desirable to keep bacterial counts low in the operating room air during orthopaedic surgery, especially prosthetic surgery. As the air-borne bacteria are mainly derived from the skin flora of the personnel present in the operating room a reduction could be achieved by using a clothing system for staff made from a material fulfilling the requirements in the standard EN 13795. The aim of this study was to compare the protective capacity between three clothing systems made of different materials - one mixed cotton/polyester and two polyesters - which all had passed the tests according to EN 13795. METHODS: Measuring of CFU/m3 air was performed during 21 orthopaedic procedures performed in four operating rooms with turbulent, mixing ventilation with air flows of 755 - 1,050 L/s. All staff in the operating room wore clothes made from the same material during each surgical procedure. RESULTS: The source strength (mean value of CFU emitted from one person per second) calculated for the three garments were 4.1, 2.4 and 0.6 respectively. In an operating room with an air flow of 755 L/s both clothing systems made of polyester reduced the amount of CFU/m3 significantly compared to the clothing system made from mixed material. In an operating room with air intake of 1,050 L/s a significant reduction was only achieved with the polyester that had the lowest source strength. CONCLUSIONS: Polyester has a better protective capacity than cotton/polyester. There is need for more discriminating tests of the protective efficacy of textile materials intended to use for operating garment.

Staphylococcus aureus bloodstream infection after cardiac surgery: risk factors and outcome.

Thirty-eight patients (10 cases and 28 controls) were included in a case-control study of Staphylococcus aureus bloodstream infection after cardiac surgery in 833 patients. All bacterial strains were found to be unique by pulsed-field gel electrophoresis. In multivariable risk-factor analysis, only valve prosthesis implantation was associated with bloodstream infection. The early and late case mortality rate was 0%.

[Urinary catheters and antibiotic treatment. Guidelines adherence could be better]. / Urinkatetrar och antibiotikabehandling--följsamheten till riktlinjer kan bli bättre.

Indwelling urinary catheter is a well-known risk for urinary tract infection (UTI). In order to minimize the risk for UTI urinary catheters should be used with prudence. On April 24th 2002 we performed a point-prevalence study on the use of indwelling urinary catheters in 31 acute hospitals and 766 long-term-care-facilities (LTCF) with 6,369 patients and 22,153 residents respectively. In the hospitals an average of 16.5% of the patients were treated with indwelling urinary catheters. The corresponding figure for LTCFs was 6.2%. Compared to 1994 there was an increase in the prevalence of urinary catheters in hospitals (from 11% to 16.5%). For LTCFs it was not possible to make such a comparison. Suprapubic catheters were used in 4% of the cases in hospitals and 10% in LTCFs. Closed drainage systems were used in about 75% both in hospitals and LTCFs. Approximately 10% of the patients/residents with indwelling urinary catheter were treated with antibiotics due to an UTI. Urinary culture was performed in only about half of those cases. To ensure patient safety hospital departments and LTCFs should, to our opinion, make enquiries on prevalence of indwelling urinary catheters, drainage systems and antibiotic treatment among their patients/residents on a regular basis.

[Important to reduce the risk of infections in residential facilities]. / Angeläget att minska infektionsrisken i särskilda boenden.

In view of the fact that Swedish nursing home care represents an integrated form of residential housing and health care and it is not possible to classify infections as either "health-care-associated" or "community-acquired". Thus it is not appropriate to use the same surveillance systems as those used in hospitals. The presence of known risk factors for infection--either related to medical devices or due to underlying illness--could however be monitored. Antibiotic treatment favours selection of resistant bacterial strains and should thus be used with prudence. At December 8th, 2000, we investigated the presence of 20 risk factors and antibiotic treatment among 2,817 residents in nursing homes in Uppsala county. Seventeen out of 20 risk factors were all present in less than 1 per cent of the residents. Pressure ulcers or leg/foot-ulcers occurred among 3.2% each, and 7.6 per cent of the residents had an indwelling urinary catheter. About 6% of the residents were treated with at least one antibiotic. Urinary tract infection was the main reason for treatment. The investigation shows that training of nursing home staff by the infection control team should focus on hand hygiene and routines for wound care and urinary catheter care in order to minimize the risk for infections among residents.