The management of healthcare-related infections through lean methodology: systematic review and meta-analysis of observational studies.

Introduction: Lean is largely applied to the health sector and on the healthcare-associated infections (HAI). However, a few results on the improvement of the outcome have been reported in literature. The purpose of this study is to analyze if the lean application can reduce the HAI rate. Methods: A comprehensive search was performed on PubMed/Medline, Scopus, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the following keywords: "lean" and "infection". Inclusion criteria were: 1) research articles with quantitative data and relevant information on lean methodology and its impact on healthcare infections; 2) prospective studies. The risk of bias and the study quality was independently assessed by two researchers using the "The National Institutes of Health (NIH) quality assessment tool for before-after (Pre-Post) study with no control group". The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines has been used. 22 studies were included in the present meta-analysis. Results: Lean application demonstrated a significant protective role on healthcare-associated infections rate (RR 0.50; 95% C.I.: 0.38-0.66) with significant impact on central line-associated bloodstream infections (CLABSIs) (RR 0.47; 95% C.I.: 0.28-0.82). Conclusions: Lean has a positive impact on the decreasing of HAIs and on the improvement of compliance and satisfaction of the staff.

Evaluation of Multidrug-Resistant P. aeruginosa in Healthcare Facility Water Systems.

According to the WHO, P. aeruginosa is one of the antibiotic-resistant bacteria that represent the biggest threat to public health. The aim of the study was to establish the prevalence of antibiotic-resistant P. aeruginosa in the water systems of various healthcare facilities over the course of nine years. A total of 4500 tap water system samples were taken from seventeen healthcare facilities. The culture method was used to detect P. aeruginosa, and the isolates were then tested for antibiotic resistance using the standardised disc diffusion method. Eleven antibiotics from five different classes were tested. P. aeruginosa was found to have contaminated 2.07% (no. 93) of the water samples. The majority of positive samples came from the dental units (30.11%) and the ward kitchens (23.66%). Considering the total isolates, 56.99% (no. 3) were resistant to at least one of the antibiotics tested. A total of 71.43% of P. aeruginosa isolated from water emerging from dental unit handpieces was antibiotic-resistant, with 45% of it resistant to ≥3 classes of antibiotics. Out of the total isolates, 19.35% showed resistance to carbapenems. It would be advisable to systematically screen tap water for opportunistic micro-organisms such as P. aeruginosa, as many countries already do, including this in the Water Safety Plan.

Microbial Air Monitoring in Turbulent Airflow Operating Theatres: Is It Possible to Calculate and Hypothesize New Benchmarks for Microbial Air Load?

Multiple studies have demonstrated the presence of microorganisms commonly associated with surgical site infections (SSIs), in the air within the operating theatre (OT). In some countries such Italy, the limit of microbial concentration in the air for OT with turbulent airflows is 35 CFU/m3 for an empty OT and 180 CFU/m3 during activity. This study aims to hypothesize new benchmarks for the airborne microbial load in turbulent airflow operating theatres in operational and at rest conditions using the percentile distribution of data through a 17-year environmental monitoring campaign in various Italian hospitals that implemented a continuous quality improvement policy. The quartile distribution analysis has shown how in operational and at rest conditions, 75% of the values were below 110 CFU/m3 and 18 CFU/m3, respectively, which can be considered a new benchmark for the monitored OTs. During the initial stages of the monitoring campaign, 28.14% of the concentration values in operational conditions and 29.29% of the values in at rest conditions did not conform to the Italian guidelines' reference values. In contrast, during the last 5 years, all values in both conditions conformed to the reference values and 98.94% of these values were below the new benchmarks. Continuous improvement has allowed contamination to be reduced to levels well below the current reference values.

Is Post-Reprocessing Microbiological Surveillance of Duodenoscopes Effective in Reducing the Potential Risk in Transmitting Pathogens?

Background: The use of a contaminated endoscope may lead to infections due to the transmission of potential pathogens from patient to patient. Methods: Post-reprocessing microbiological surveillance of four duodenoscopes was carried out over a three-year period in the Digestive Endoscopy Unit of an Italian hospital. Sampling of duodenoscopes was performed after the devices have been reprocessed. The initial phase of surveillance involved the contemporary evaluation of the four duodenoscopes; afterwards, microbiological surveillance proceeded at monthly intervals. Results: The initial phase of surveillance revealed that three duodenoscopes presented a high level of contamination with "high-concern" micro-organisms, some of which were multi-drug-resistant. The highest values of contamination regarded the species P. aeruginosa (2500 CFU/duodenoscope), K. pneumoniae (2580 CFU/duodenoscope), and A. baumannii (2600 CFU/duodenoscope). Since the cultures were repeatedly positive on three successive occasions, the contaminated devices were sent to the manufacturer for evaluation. Audits were carried out with the personnel responsible for reprocessing, which was aimed to optimize the procedures used, and subsequently, only one case of non-conformity was found. Conclusions: Our study highlighted both the potential risk of transmitting pathogens through the use of duodenoscopes and the importance of implementing a well-structured system of microbiological surveillance and training programs, in order to reduce the risk of spreading retrograde cholangiopancreatography (ERCP)-associated infections.

Coffee Consumption and Risk of Colorectal Cancer: A Systematic Review and Meta-Analysis of Prospective Studies.

Coffee is a blend of compounds related to gastrointestinal physiology. Given its popularity and the epidemiology of colorectal cancer, the impact of this beverage on public health could be considerable. Our aim was to provide an updated synthesis of the relationship between coffee consumption and the risk of colorectal cancer. We conducted a systematic review and meta-analysis of 26 prospective studies. Regarding colorectal cancer, no significant relationship was detected. Stratifying for ethnicity, a protective effect emerged in US subjects. Concerning colon cancer, coffee proved to exert a protective effect in men and women combined and in men alone. Stratifying for ethnicity, a significant protective effect was noted in European men only and in Asian women only. Concerning rectal cancer, no association was found. Decaffeinated coffee exhibited a protective effect against colorectal cancer in men and women combined. Studies were appraised for their quality by means of the Newcastle-Ottawa Quality Assessment Scale for Cohort studies. Only one study proved to be of low quality. Ethnicity could explain the heterogeneity of the studies. However, little is known about the relationship between the genetic make-up and the risk of colorectal cancer associated with coffee. Further research is warranted.

Epidemiology, management, and outcome of carbapenem-resistant Klebsiella pneumoniae bloodstream infections in hospitals within the same endemic metropolitan area.

In the last decade, carbapenem-resistant Klebsiella pneumoniae (CR-Kp) has become endemic in several countries, including Italy. In the present study, we assessed the differences in epidemiology, management, and mortality of CR-Kp bloodstream infection (BSI) in the three main adult acute-care hospitals of the metropolitan area of Genoa, Italy. From January 2013 to December 2014, all patients with CR-Kp BSI were identified through the computerized microbiology laboratory databases of the three hospitals. The primary endpoints of the study were incidence and characteristics of CR-Kp BSI in hospitals within the same endemic metropolitan area. Secondary endpoints were characteristics of CR-Kp BSI in hospitals with and without internal infectious diseases consultants (IDCs) and 15-day mortality. During the study period, the incidence of healthcare-associated CR-Kp BSI in the entire study population was 1.35 episodes per 10,000 patient-days, with substantial differences between the three hospitals. Patients admitted to the two hospital with internal IDCs were more likely to receive post-susceptibility test combined therapy including carbapenems (77% vs. 26%, p<0.001), adequate post-susceptibility test therapies (86% vs. 52%, p<0.001), and post-susceptibility therapies prescribed by an infectious diseases specialist (84% vs. 14%, p<0.001). Overall, the crude 15-days mortality was 26%. In the final multivariable model, only septic shock at BSI presentation was unfavorably and independently associated with 15-days mortality (odds ratio [OR] 6.7, 95% confidence intervals [CI] 2.6-17.6, p<0.001), while a protective effect was observed for post-susceptibility test combined therapies including a carbapenem (OR 0.11, 95% CI 0.03-0.43, p=0.002). Mortality of CR-Kp remains high. Differences in the incidence of CR-Kp BSI were detected between acute-care centers within the same endemic metropolitan area. Efforts should be made to improve the collaboration and coordination between centers, to prevent further diffusion of CR-Kp.

Chemical characterisation of the coarse and fine particulate matter in the environment of an underground railway system: cytotoxic effects and oxidative stress-a preliminary study.

BACKGROUND: Exposure to the particulate matter produced in underground railway systems is arousing increasing scientific interest because of its health effects. The aim of our study was to evaluate the airborne concentrations of PM10 and three sub-fractions of PM2.5 in an underground railway system environment in proximity to platforms and in underground commercial areas within the system, and to compare these with the outdoor airborne concentrations. We also evaluated the metal components, the cytotoxic properties of the various fractions of particulate matter (PM) and their capacity to induce oxidative stress. METHOD: We collected the coarse fraction (5-10 µm) and the fine fractions (1-2.5 µm; 0.5-1 µm; 0.25-0.5 µm). Chemical characterisation was determined by means of spectrometry. Cytotoxicity and oxidative stress were evaluated by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay and Reactive Oxygen Species (ROS) assessment. RESULTS: The concentrations of both PM10 and PM2.5 proved to be similar at the three sampling sites. Iron and other transition metals displayed a greater concentration at the subway platform than at the other two sites. The 2.5-10 µm and 1-2.5 µm fractions of PM from all three sampling sites determined a greater increase in ROS; the intensity of oxidative stress progressively declined as particle diameter diminished. Moreover, ROS concentrations were correlated with the concentrations of some transition metals, namely Mn, Cr, Ti, Fe, Cu, Zn, Ni and Mo. All particulate matter fractions displayed lower or similar ROS values between platform level and the outdoor air. CONCLUSIONS: The present study revealed that the underground railway environment at platform level, although containing higher concentrations of some particularly reactive metallic species, did not display higher cytotoxicity and oxidative stress levels than the outdoor air.

Can particulate air sampling predict microbial load in operating theatres for arthroplasty?

Several studies have proposed that the microbiological quality of the air in operating theatres be indirectly evaluated by means of particle counting, a technique derived from industrial clean-room technology standards, using airborne particle concentration as an index of microbial contamination. However, the relationship between particle counting and microbiological sampling has rarely been evaluated and demonstrated in operating theatres. The aim of the present study was to determine whether particle counting could predict microbiological contamination of the air in an operating theatre during 95 surgical arthroplasty procedures. This investigation was carried out over a period of three months in 2010 in an orthopedic operating theatre devoted exclusively to prosthetic surgery. During each procedure, the bacterial contamination of the air was determined by means of active sampling; at the same time, airborne particulate contamination was assessed throughout the entire procedure. On considering the total number of surgical operations, the mean value of the total bacterial load in the center of the operating theatre proved to be 35 CFU/m(3); the mean particle count was 4,194,569 no./m(3) for particles of diameter ≥0.5 µm and 13,519 no./m(3) for particles of diameter ≥5 µm. No significant differences emerged between the median values of the airborne microbial load recorded during the two types of procedure monitored. Particulates with a diameter of ≥0.5 µm were detected in statistically higher concentrations (p<0.001) during knee-replacement procedures. By contrast, particulates with a diameter of ≥5 µm displayed a statistically higher concentration during hip-replacement procedures (p<0.05). The results did not reveal any statistically significant correlation between microbial loads and particle counts for either of the particle diameters considered (≥0.5 µm and ≥5 µm). Consequently, microbiological monitoring remains the most suitable method of evaluating the quality of air in operating theatres.

Spread of multidrug carbapenem-resistant Acinetobacter baumannii in different wards of an Italian hospital.

BACKGROUND: Multidrug-resistant Acinetobacter baumannii (MDRAB) is an important cause of hospital acquired infection. We describe a 7-month outbreak of a MDRAB infection involving various wards of an Italian hospital and an investigation of the possible source of the infection was conducted. METHODS: A baumannii was isolated from various biological samples from 22 colonized or infected patients, and was identified and characterized for its antibiotic sensitivity. Typing of A baumannii was performed by multilocus sequence typing (MLST). Investigation of the outbreak involved extensive microbiological sampling of the environment. RESULTS: In 50% of cases the infection occurred in the ICU. Invasive procedures were performed in 63.6% of patients. The strain isolated proved to be resistant to all the antibiotics tested, including carbapenems, and displayed the same allelic profile in all patients. None of the 141 samples taken during environmental monitoring showed positivity for A baumannii. CONCLUSION: The results of the present study reveal the importance of strict adherence to control measures by all health care personnel and highlight the fact that regular staff training and frequent revision of control measures are essential to the successful management of an outbreak.

Evaluation of the risk of infection through exposure to aerosols and spatters in dentistry.

BACKGROUND: Many dental procedures produce extensive aerosols and splatters that are routinely contaminated with microorganisms. METHODS: Air containing blood-bearing aerosols and surfaces contaminated by sedimenting blood particulate was sampled in 5 different dental cubicles. To assess contamination by blood particulate, the concentration of hemoglobin (Hb) in the air and on the sedimentation surfaces was determined. RESULTS: The mean concentration of Hb in the air aspirated in the 5 cubicles was 0.14 +/- 0.23 microg/m(3), corresponding to a blood volume of 8.7 x 10(-4) microL/m(3). Similarly, the mean concentration of blood particulate sedimented on surfaces was calculated and found to be 1.56 microL/m(2). In 80% of the cubicles monitored, 100% positivity to the Hb determination test was recorded in all of the surface samples. CONCLUSIONS: The results obtained revealed contamination of both air and surfaces by blood particulate. Moreover, with the exception of those obtained in 1 cubicle, all of the samples of sedimenting particulate analyzed were positive for the presence of Hb.

Evaluation of environmental contamination by glutaraldehyde in an outpatient facility for digestive endoscopy in an Italian hospital.

The potential harmful effects of glutaraldehyde on human health are well known, and in recent years various new substitutes for this compound have been proposed for the disinfection and thorough sterilization of medical instruments. Nevertheless, glutaraldehyde is still widely used in hospital environments. In order to evaluate environmental contamination by glutaraldehyde vapours, the rooms of a hospital out-patient department of digestive endoscopy were monitored in 2005; a total of 52 samples were taken. The mean environmental concentration of glutaraldehyde was 3.7+/-7.4 microg/m(3). The number of efficacious air exchanges per hour was 6.3 v/h in all of the environments monitored. The study revealed that, in a hospital setting, adequate structural and functional planning, combined with responsible management on the part of the personnel and constant careful checking of the results obtained can minimize the risk of occupational exposure to glutaraldehyde.

A new microbiological problem in intensive care units: environmental contamination by MRSA with reduced susceptibility to glycopeptides.

The present study evaluated the percentage of methicillin-resistant Staphylococcus aureus strains with reduced susceptibility to glycopeptides in four intensive care units (ICU) by means of environmental sampling of air and representative surfaces. The total bacterial count was taken and possible S. aureus strains were subsequently isolated. To assess methicillin resistance, an antibiogram was performed on the colonies that were positive to the coagulase test. A standard E-test was then carried out on the colonies that developed, in order to evaluate glycopeptide resistance, and any heterogeneous resistance was confirmed by means of a macromethod E-test. The antibiogram performed on the colonies of S. aureus revealed that 85.7% of all air samples were positive for MRSA, and that 64.3% of all the samples proved to be heterogeneously resistant to glycopeptides. Methicillin resistance was recorded in 41.0% of surface samples, and 32.5% of all samples proved positive for hGISA.