RESUMO
Background: Despite intensified efforts to reduce hospital-onset Clostridium difficile infection (HO-CDI), its clinical and economic impacts continue to worsen. Many institutions have adopted bundled interventions that vary considerably in composition, strength of evidence, and effectiveness. Considerable gaps remain in our knowledge of intervention effectiveness and disease transmission, which hinders HO-CDI prevention. Methods: We developed an agent-based model of C. difficile transmission in a 200-bed adult hospital using studies from the literature, supplemented with primary data collection. The model includes an environmental component and 4 distinct agent types: patients, visitors, nurses, and physicians. We used the model to evaluate the comparative clinical effectiveness of 9 single interventions and 8 multiple-intervention bundles at reducing HO-CDI and asymptomatic C. difficile colonization. Results: Daily cleaning with sporicidal disinfectant and C. difficile screening at admission were the most effective single-intervention strategies, reducing HO-CDI by 68.9% and 35.7%, respectively (both P < .001). Combining these interventions into a 2-intervention bundle reduced HO-CDI by 82.3% and asymptomatic hospital-onset colonization by 90.6% (both, P < .001). Adding patient hand hygiene to healthcare worker hand hygiene reduced HO-CDI rates an additional 7.9%. Visitor hand hygiene and contact precaution interventions did not reduce HO-CDI, compared with baseline. Excluding those strategies, healthcare worker contact precautions were the least effective intervention at reducing hospital-onset colonization and infection. Conclusions: Identifying and managing the vast hospital reservoir of asymptomatic C. difficile by screening and daily cleaning with sporicidal disinfectant are high-yield strategies. These findings provide much-needed data regarding which interventions to prioritize for optimal C. difficile control.
Assuntos
Clostridioides difficile/isolamento & purificação , Infecções por Clostridium/transmissão , Infecção Hospitalar/prevenção & controle , Controle de Infecções/métodos , Análise de Sistemas , Adulto , Infecções Assintomáticas , Infecções por Clostridium/epidemiologia , Infecções por Clostridium/microbiologia , Infecções por Clostridium/prevenção & controle , Reservatórios de Doenças/microbiologia , Higiene das Mãos , Pessoal de Saúde , Hospitais , Humanos , Incidência , Admissão do Paciente , Resultado do Tratamento , Visitas a PacientesRESUMO
BACKGROUND: Infection by Staphylococcus aureus (S. aureus) is a major cause of morbidity and mortality. Colonization by S. aureus increases the risk of infection. Little is known about decolonization strategies for S. aureus beyond antibiotics, however probiotics represent a promising alternative. A randomized controlled trial was conducted to determine the efficacy of Lactobacillus rhamnosus (L. rhamnosus) HN001 in reducing carriage of S. aureus at multiple body sites. METHODS: One hundred thirteen subjects, positive for S. aureus carriage, were recruited from the William S. Middleton Memorial Medical Center, Madison, WI, USA, and randomized by initial site of colonization, either gastrointestinal (GI) or extra-GI, to 4-weeks of oral L. rhamnosus HN001 probiotic, or placebo. Nasal, oropharyngeal, and axillary/groin swabs were obtained, and serial blood and fecal samples were collected. Differences in prevalence of S. aureus carriage at the end of the 4-weeks of treatment were assessed. RESULTS: The probiotic and placebo groups were similar in age, gender, and health history at baseline. S. aureus colonization within the stool samples of the extra-GI group was 15% lower in the probiotic than placebo group at the endpoint of the trial. Those in the probiotic group compared to the placebo group had 73% reduced odds (OR 0.27, 95% CI 0.07-0.98) of methicillin-susceptible S. aureus presence, and 83% reduced odds (OR 0.17, 95% CI 0.04-0.73) of any S. aureus presence in the stool sample at endpoint. CONCLUSION: Use of daily oral L. rhamnosus HN001 reduced odds of carriage of S. aureus in the GI tract, however it did not eradicate S. aureus from other body sites. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01321606 . Registered March 21, 2011.
Assuntos
Trato Gastrointestinal/microbiologia , Lacticaseibacillus rhamnosus , Probióticos/uso terapêutico , Infecções Estafilocócicas/prevenção & controle , Adulto , Idoso , Fezes/microbiologia , Feminino , Humanos , Masculino , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Staphylococcus aureus Resistente à Meticilina/patogenicidade , Pessoa de Meia-Idade , Staphylococcus aureus/isolamento & purificação , Staphylococcus aureus/patogenicidade , VeteranosRESUMO
BACKGROUND: Clostridium difficile is the most common cause of hospital-acquired infections, responsible for >450000 infections annually in the USA. Probiotics provide a promising, well-tolerated adjunct therapy to standard C. difficile infection (CDI) treatment regimens, but there is a paucity of data regarding their effectiveness for the treatment of an initial CDI. OBJECTIVES: We conducted a pilot randomized controlled trial of 33 participants from February 2013 to February 2015 to determine the feasibility and health outcomes of adjunct probiotic use in patients with an initial mild to moderate CDI. METHODS: The intervention was a 28 day, once-daily course of a four-strain oral probiotic capsule containing Lactobacillus acidophilus NCFM, Lactobacillus paracasei Lpc-37, Bifidobacterium lactis Bi-07 and B. lactis Bl-04. The control placebo was identical in taste and appearance. Registered at clinicaltrials.gov: trial registration number = NCT01680874. RESULTS: Probiotic adjunct therapy was associated with a significant improvement in diarrhoea outcomes. The primary duration of diarrhoea outcome (0.0 versus 1.0 days; P = 0.039) and two exploratory outcomes, total diarrhoea days (3.5 versus 12.0 days; P = 0.005) and rate of diarrhoea (0.1 versus 0.3 days of diarrhoea/stool diary days submitted; P = 0.009), all decreased in participants with probiotic use compared with placebo. There was no significant difference in the rate of CDI recurrence or functional improvement over time between treatment groups. CONCLUSIONS: Probiotics are a promising adjunct therapy for treatment of an initial CDI and should be further explored in a larger randomized controlled trial.
Assuntos
Antibacterianos/uso terapêutico , Infecções por Clostridium/terapia , Probióticos/uso terapêutico , Adulto , Idoso , Antibacterianos/administração & dosagem , Bifidobacterium animalis/fisiologia , Clostridioides difficile/efeitos dos fármacos , Terapia Combinada , Diarreia/microbiologia , Diarreia/terapia , Método Duplo-Cego , Fezes/microbiologia , Feminino , Humanos , Lactobacillus/fisiologia , Masculino , Pessoa de Meia-Idade , Projetos PilotoRESUMO
BACKGROUND: Antibiotic resistance is a global public health crisis. In India alone, multi-drug resistant organisms are responsible for over 58,000 infant deaths each year. A major driver of drug resistance is antibiotic misuse, which is a pervasive phenomenon worldwide. Due to a shortage of trained doctors, access to licensed allopathic doctors is limited in India's villages. Pharmacists and unlicensed medical providers are commonly the primary sources of healthcare. Patients themselves are also key participants in the decision to treat an illness with antibiotics. Thus, better understanding of the patient-provider interactions that may contribute to patients' inappropriate use of antibiotics is critical to reducing these practices in urban and rural Indian villages. METHODS: We conducted a qualitative study of the social determinants of antibiotic use among twenty community members in Haryana, India. Semi-structured interview questions focused on two domains: typical antibiotic use and the motivation behind these practices. A cross-sectional pilot survey investigated the same twenty participants' understanding and usage of antibiotics. Interview and open-ended survey responses were translated, transcribed, and coded for themes. RESULTS: Antibiotics and the implications of their misuse were poorly understood by study participants. No participant was able to correctly define the term antibiotics. Participants with limited access to an allopathic doctor, either for logistic or economic reasons, were more likely to purchase medications directly from a pharmacy without a prescription. Low income participants were also more likely to prematurely stop antibiotics after symptoms subsided. Regardless of income, participants were more likely to seek an allopathic doctor for their children than for themselves. CONCLUSIONS: The prevalent misuse of antibiotics among these community members reinforces the importance of conducting research to develop effective strategies for stemming the tide of antibiotic resistance in India's villages.
Assuntos
Antibacterianos/uso terapêutico , Uso Indevido de Medicamentos sob Prescrição/estatística & dados numéricos , Adulto , Resistência Microbiana a Medicamentos , Feminino , Humanos , Índia , Masculino , Motivação , Uso Indevido de Medicamentos sob Prescrição/psicologia , Pesquisa Qualitativa , População Rural/estatística & dados numéricos , Fatores Socioeconômicos , Inquéritos e Questionários , População Urbana/estatística & dados numéricosRESUMO
BACKGROUND: There is substantial evidence that patients with COVID-19 were treated with sustained deep sedation during the pandemic. However, it is unknown whether such guideline-discordant care had spillover effects to patients without COVID-19. RESEARCH QUESTION: Did patterns of early deep sedation change during the pandemic for patients on mechanical ventilation without COVID-19? STUDY DESIGN AND METHODS: We used electronic health record data from 4,237 patients who were intubated without COVID-19. We compared sedation practices in the first 48 h after intubation across prepandemic (February 1, 2018, to January 31, 2020), pandemic (April 1, 2020, to March 31, 2021), and late pandemic (April 1, 2021, to March 31, 2022) periods. RESULTS: In the prepandemic period, patients spent an average of 13.0 h deeply sedated in the first 48 h after intubation. This increased 1.9 h (95% CI, 1.0-2.8) during the pandemic period and 2.9 h (95% CI, 2.0-3.8) in the late pandemic period. The proportion of patients that spent over one-half of the first 48 h deeply sedated was 18.9% in the prepandemic period, 22.3% during the pandemic period, and 25.9% during the late pandemic period. Ventilator-free days decreased during the pandemic, with a subdistribution hazard ratio of being alive without mechanical ventilation at 28 days of 0.87 (95% CI, 0.79-0.95) compared with the prepandemic period. Tracheostomy placement increased during the pandemic period compared with the prepandemic period (OR, 1.41; 95% CI, 1.08-1.82). In the medical ICU, early deep sedation increased 2.5 h (95% CI, 0.6-4.4) during the pandemic period and 4.9 h (95% CI, 3.0-6.9) during the late pandemic period, compared with the prepandemic period. INTERPRETATION: We found that among patients on mechanical ventilation without COVID-19, sedation use increased during the pandemic. In the subsequent year, these practices did not return to prepandemic standards.
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COVID-19 , Sedação Profunda , Respiração Artificial , Humanos , COVID-19/epidemiologia , COVID-19/prevenção & controle , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Respiração Artificial/estatística & dados numéricos , Idoso , SARS-CoV-2 , Pandemias , Adulto , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/uso terapêutico , Intubação Intratraqueal/estatística & dados numéricosRESUMO
PDCD2 is a conserved eukaryotic protein implicated in cell cycle regulation by virtue of its interactions with HCFC1 and the NCOR1/SIN3A corepressor complex. Pdcd2 transcripts are enriched in ES cells and other somatic stem cells, and its ortholog is essential for hematopoietic stem cell maintenance in Drosophila. To characterize the physiological role(s) of mammalian PDCD2, we created a disruption allele in mice. Pdcd2(-/-) embryos underwent implantation but did not undergo further development. Inner cell masses (ICMs) from Pdcd2(-/-) blastocysts failed to outgrow in vitro. Furthermore, embryonic stem cells (ESCs) require PDCD2 as demonstrated by the inability to generate Pdcd2(-/-) ESCs in the absence of an ectopic transgene. Upon differentiation of ESCs by retinoic acid treatment or LIF deprivation, PDCD2 levels declined. In conjunction with prior studies, these results indicate that in vivo, PDCD2 is critical for blastomere and ESC maintenance by contributing to the regulation of genes in a manner essential to the undifferentiated state of these cells.
Assuntos
Proteínas Reguladoras de Apoptose/metabolismo , Massa Celular Interna do Blastocisto/citologia , Massa Celular Interna do Blastocisto/metabolismo , Células-Tronco Embrionárias/citologia , Células-Tronco Embrionárias/metabolismo , Alelos , Animais , Proteínas Reguladoras de Apoptose/deficiência , Proteínas Reguladoras de Apoptose/genética , Sequência de Bases , Diferenciação Celular/efeitos dos fármacos , Diferenciação Celular/genética , Diferenciação Celular/fisiologia , Primers do DNA/genética , Desenvolvimento Embrionário/genética , Desenvolvimento Embrionário/fisiologia , Células-Tronco Embrionárias/efeitos dos fármacos , Feminino , Regulação da Expressão Gênica no Desenvolvimento , Técnicas de Silenciamento de Genes , Marcação de Genes , Técnicas In Vitro , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Camundongos Knockout , Células-Tronco Pluripotentes/citologia , Células-Tronco Pluripotentes/metabolismo , Polimorfismo de Nucleotídeo Único , Gravidez , RNA Interferente Pequeno/genética , Distribuição Tecidual , Tretinoína/farmacologiaRESUMO
PURPOSE: As legal recreational marijuana use expands rapidly across the U.S., there is growing concern that this will lead to higher rates of use among college-aged young adults. Given the limited research addressing this issue, a longitudinal study was conducted to evaluate the effects of legalizing recreational use on the attitudes, intentions, and marijuana use behaviors of college students in two different legalization contexts, Washington State and Wisconsin. METHODS: Survey data assessing marijuana attitudes, intentions, and use behavior were collected from 2011 to 2016 on a longitudinal cohort of 338 students at two large public universities in Washington and Wisconsin. Time series analyses were conducted to evaluate postlegalization changes in ever use, 28-day use, and mean attitude and intention-to-use scores in Washington state, using Wisconsin participants as the control group. RESULTS: Ever use, attitude, and intention-to-use scores did not change significantly more in Washington after legalization than in Wisconsin. However, among prior users, the proportion using in the last 28 days rose faster in Washington after legalization that it did in Wisconsin (p < .001). CONCLUSIONS: The findings suggest that legalization had the greatest effects on current marijuana users, who are surrounded by a climate that is increasingly supportive of its use.
Assuntos
Cannabis , Fumar Maconha , Atitude , Humanos , Intenção , Estudos Longitudinais , Estudantes , Washington , Wisconsin , Adulto JovemRESUMO
Importance: Visitor contact precautions (VCPs) are commonly used to reduce the transmission of Clostridioides difficile at health care institutions. Implementing VCPs requires considerable personnel and personal protective equipment resources. However, it is unknown whether VCPs are associated with reduced hospital-onset C difficile infection (HO-CDI) rates. Objective: To estimate the association between VCPs and HO-CDI rates using simulation modeling. Design, Setting, and Participants: This simulation study, conducted between July 27, 2020, and August 11, 2020, used an established agent-based simulation model of C difficile transmission in a 200-bed acute care adult hospital to estimate the association between VCPs and HO-CDI while varying assumptions about factors such as patient susceptibility, behavior, and C difficile transmission. The model simulated hospital activity for 1 year among a homogeneous, simulated adult population. Interventions: No VCP use vs ideal use of VCPs under different hospital configurations. Main Outcomes and Measures: The rate of HO-CDI per 10â¯000 patient-days according to the Centers for Disease Control and Prevention's definition of HO-CDI. Results: With use of the simulation model, the baseline rate of HO-CDI was 7.94 10â¯000 patient-days (95% CI, 7.91-7.98 per 10â¯000 patient-days) with no VCP use compared with 7.97 per 10â¯000 patient-days (95% CI, 7.93-8.01 per 10â¯000 patient-days) with ideal VCP use. Visitor contact precautions were not associated with a reduction of more than 1% in HO-CDI rates in any of the tested scenarios and hospital settings. Independently increasing the hand-hygiene compliance of the average health care worker and environmental cleaning compliance by no more than 2% each was associated with greater HO-CDI reduction compared with all other scenarios, including VCPs. Conclusions and Relevance: In this simulation study, the association between VCPs and HO-CDI was minimal, but improvements in health care worker hand hygiene and environmental cleaning were associated with greater reductions in estimated HO-CDI. Hospitals may achieve a higher rate of reduction for HO-CDI by focusing on making small improvements in compliance with interventions other than VCP.
Assuntos
Infecções por Clostridium/prevenção & controle , Infecção Hospitalar/prevenção & controle , Controle de Infecções/métodos , Visitas a Pacientes , Clostridioides difficile , Infecções por Clostridium/epidemiologia , Infecções por Clostridium/transmissão , Simulação por Computador , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/transmissão , Desinfecção , Higiene das Mãos , Humanos , Enfermeiras e Enfermeiros , MédicosRESUMO
BACKGROUND: Forward genetic screens in mice provide an unbiased means to identify genes and other functional genetic elements in the genome. Previously, a large scale ENU mutagenesis screen was conducted to query the functional content of a ~50 Mb region of the mouse genome on proximal Chr 5. The majority of phenotypic mutants recovered were embryonic lethals. RESULTS: We report the high resolution genetic mapping, complementation analyses, and positional cloning of mutations in the target region. The collection of identified alleles include several with known or presumed functions for which no mutant models have been reported (Tbc1d14, Nol14, Tyms, Cad, Fbxl5, Haus3), and mutations in genes we or others previously reported (Tapt1, Rest, Ugdh, Paxip1, Hmx1, Otoe, Nsun7). We also confirmed the causative nature of a homeotic mutation with a targeted allele, mapped a lethal mutation to a large gene desert, and localized a spermiogenesis mutation to a region in which no annotated genes have coding mutations. The mutation in Tbc1d14 provides the first implication of a critical developmental role for RAB-GAP-mediated protein transport in early embryogenesis. CONCLUSION: This collection of alleles contributes to the goal of assigning biological functions to all known genes, as well as identifying novel functional elements that would be missed by reverse genetic approaches.
Assuntos
Mapeamento Cromossômico , Cromossomos/efeitos dos fármacos , Análise Mutacional de DNA , Desenvolvimento Embrionário/genética , Camundongos/genética , Mutação , Animais , Clonagem Molecular , Etilnitrosoureia/toxicidade , Genes Letais , Teste de Complementação Genética , Masculino , Camundongos Endogâmicos C57BL , Deleção de Sequência , Espermatogênese/genéticaRESUMO
BACKGROUND: Cohorting of patients and staff is a control strategy often used to prevent the spread of infection in healthcare institutions. However, a comprehensive evaluation of cohorting as a prevention approach is lacking. METHODS: We performed a systematic review of studies that used cohorting as part of an infection control strategy to reduce hospital-acquired infections. We included studies published between 1966 and November 30, 2019, on adult populations hospitalized in acute-care hospitals. RESULTS: In total, 87 studies met inclusion criteria. Study types were quasi-experimental "before and after" (n = 35), retrospective (n = 49), and prospective (n = 3). Case-control analysis was performed in 7 studies. Cohorting was performed with other infection control strategies in the setting of methicillin-resistant Staphylococcus aureus (MRSA, n = 22), Clostridioides difficile infection (CDI, n = 6), vancomycin-resistant Enterococcus (VRE, n = 17), carbapenem-resistant Enterobacteriaceae infections (CRE, n = 22), A. baumannii (n = 15), and other gram-negative infections (n = 5). Cohorting was performed either simultaneously (56 of 87, 64.4%) or in phases (31 of 87, 35.6%) to help contain transmission. In 60 studies, both patients and staff were cohorted. Most studies (77 of 87, 88.5%) showed a decline in infection or colonization rates after a multifaceted approach that included cohorting as part of the intervention bundle. Hand hygiene compliance improved in approximately half of the studies (8 of 15) during the respective intervention. CONCLUSION: Cohorting of staff, patients, or both is a frequently used and reasonable component of an enhanced infection control strategy. However, determining the effectiveness of cohorting as a strategy to reduce transmission of MDRO and C. difficile infections is difficult, particularly in endemic situations.
Assuntos
Infecções por Clostridium/prevenção & controle , Infecção Hospitalar , Infecções por Bactérias Gram-Negativas/prevenção & controle , Controle de Infecções/métodos , Clostridioides difficile , Infecção Hospitalar/prevenção & controle , Atenção à Saúde , Farmacorresistência Bacteriana Múltipla , Enterococcus , Humanos , Staphylococcus aureus Resistente à Meticilina , Estudos Prospectivos , Estudos Retrospectivos , Infecções Estafilocócicas/prevenção & controleRESUMO
Importance: Clostridioides difficile infection is the most common hospital-acquired infection in the United States, yet few studies have evaluated the cost-effectiveness of infection control initiatives targeting C difficile. Objective: To compare the cost-effectiveness of 9 C difficile single intervention strategies and 8 multi-intervention bundles. Design, Setting, and Participants: This economic evaluation was conducted in a simulated 200-bed tertiary, acute care, adult hospital. The study relied on clinical outcomes from a published agent-based simulation model of C difficile transmission. The model included 4 agent types (ie, patients, nurses, physicians, and visitors). Cost and utility estimates were derived from the literature. Interventions: Daily sporicidal cleaning, terminal sporicidal cleaning, health care worker hand hygiene, patient hand hygiene, visitor hand hygiene, health care worker contact precautions, visitor contact precautions, C difficile screening at admission, and reduced intrahospital patient transfers. Main Outcomes and Measures: Cost-effectiveness was evaluated from the hospital perspective and defined by 2 measures: cost per hospital-onset C difficile infection averted and cost per quality-adjusted life-year (QALY). Results: In this agent-based model of a simulated 200-bed tertiary, acute care, adult hospital, 5 of 9 single intervention strategies were dominant, reducing cost, increasing QALYs, and averting hospital-onset C difficile infection compared with baseline standard hospital practices. They were daily cleaning (most cost-effective, saving $358â¯268 and 36.8 QALYs annually), health care worker hand hygiene, patient hand hygiene, terminal cleaning, and reducing intrahospital patient transfers. Screening at admission cost $1283/QALY, while health care worker contact precautions and visitor hand hygiene interventions cost $123â¯264/QALY and $5â¯730â¯987/QALY, respectively. Visitor contact precautions was dominated, with increased cost and decreased QALYs. Adding screening, health care worker hand hygiene, and patient hand hygiene sequentially to the daily cleaning intervention formed 2-pronged, 3-pronged, and 4-pronged multi-intervention bundles that cost an additional $29â¯616/QALY, $50â¯196/QALY, and $146â¯792/QALY, respectively. Conclusions and Relevance: The findings of this study suggest that institutions should seek to streamline their infection control initiatives and prioritize a smaller number of highly cost-effective interventions. Daily sporicidal cleaning was among several cost-saving strategies that could be prioritized over minimally effective, costly strategies, such as visitor contact precautions.
Assuntos
Clostridioides difficile , Infecções por Clostridium/prevenção & controle , Infecção Hospitalar/prevenção & controle , Controle de Infecções/economia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Infecções por Clostridium/epidemiologia , Infecções por Clostridium/transmissão , Análise Custo-Benefício , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/transmissão , Desinfecção das Mãos , Humanos , Tempo de Internação/estatística & dados numéricos , Pessoa de Meia-Idade , Anos de Vida Ajustados por Qualidade de Vida , Adulto JovemRESUMO
OBJECTIVE: Clostridioides difficile infection (CDI) is rapidly increasing in children's hospitals nationwide. Thus, we aimed to compare the effectiveness of 9 infection prevention interventions and 6 multiple-intervention bundles at reducing hospital-onset CDI and asymptomatic C. difficile colonization. DESIGN: Agent-based simulation model of C. difficile transmission. SETTING: Computer-simulated, 80-bed freestanding, tertiary-care pediatric hospital, including 8 identical wards with 10 single-bed patient rooms each. PARTICIPANTS: The model includes 5 distinct agent types: patients, visitors, caregivers, nurses, and physicians. INTERVENTIONS: Daily and terminal environmental disinfection, screening at admission, reduced intrahospital patient transfers, healthcare worker (HCW), visitor, and patient hand hygiene, and HCW and visitor contact precautions. RESULTS: The model predicted that daily environmental disinfection with sporicidal product, combined with screening for asymptomatic C. difficile at admission, was the most effective 2-pronged infection prevention bundle, reducing hospital-onset CDI by 62.0% and asymptomatic colonization by 88.4%. Single-intervention strategies, including daily disinfection, terminal disinfection, asymptomatic screening at admission, HCW hand hygiene, and patient hand hygiene, as well as decreasing intrahospital patient transfers, all also reduced both hospital-onset CDI and asymptomatic colonization in the model. Visitor hand hygiene and visitor and HCW contact precautions were not effective at reducing either measure. CONCLUSIONS: Hospitals can achieve substantial reduction in hospital-onset CDIs by implementing a small number of highly effective interventions.
Assuntos
Infecções por Clostridium/prevenção & controle , Infecção Hospitalar/prevenção & controle , Desinfecção/métodos , Clostridioides difficile , Simulação por Computador , Infecção Hospitalar/microbiologia , Hospitais Pediátricos , Humanos , Controle de Infecções/métodosRESUMO
Using an innovative, covert, in-room observer method to evaluate infection control practices for patients with Clostridioides difficile infection, we found no difference between physician and nursing hand hygiene compliance and contact precaution usage. There was also no diurnal variation in hand hygiene practices, but decreased contact precaution usage at night. Conversely, hospital-wide data from overt observations collected over the same time period showed significantly higher hand hygiene compliance among nurses than physicians.
Assuntos
Infecções por Clostridium/prevenção & controle , Infecção Hospitalar/prevenção & controle , Clostridium , Fidelidade a Diretrizes , Desinfecção das Mãos/métodos , Higiene das Mãos/métodos , Hospitais , Humanos , Controle de Infecções/métodos , Enfermeiras e Enfermeiros , Cooperação do Paciente , MédicosRESUMO
OBJECTIVE To identify facilitators and barriers to implementation of a Clostridium difficile screening intervention among bone marrow transplant (BMT) patients and to evaluate the clinical effectiveness of the intervention on the rate of hospital-onset C. difficile infection (HO-CDI). DESIGN Before-and-after trial SETTING A 505-bed tertiary-care medical center PARTICIPANTS All 5,357 patients admitted to the BMT and general medicine wards from January 2014 to February 2017 were included in the study. Interview participants included 3 physicians, 4 nurses, and 4 administrators. INTERVENTION All BMT patients were screened within 48 hours of admission. Colonized patients, as defined by a C. difficile-positive polymerase chain reaction (PCR) stool result, were placed under contact precautions for the duration of their hospital stay. METHODS Interview responses were coded according to the Systems Engineering Initiative for Patient Safety conceptual framework. We compared pre- and postintervention HO-CDI rates on BMT and general internal medicine units using time-series analysis. RESULTS Stakeholder engagement, at both the person and organizational level, facilitates standardization and optimization of intervention protocols. While the screening intervention was generally well received, tools and technology were sources of concern. The mean incidence of HO-CDI decreased on the BMT service postintervention (P<.0001). However, the effect of the change in the trend postintervention was not significantly different on BMT compared to the control wards (P=.93). CONCLUSIONS We report the first mixed-methods study to evaluate a C. difficile screening intervention among the BMT population. The positive nature by which the intervention was received by front-line clinical staff, laboratory staff, and administrators is promising for future implementation studies. Infect Control Hosp Epidemiol 2018;39:177-185.
Assuntos
Clostridioides difficile/isolamento & purificação , Infecções por Clostridium/microbiologia , Infecções por Clostridium/prevenção & controle , Infecção Hospitalar/diagnóstico , Infecção Hospitalar/prevenção & controle , Controle de Infecções/métodos , Atitude do Pessoal de Saúde , Transplante de Medula Óssea , Infecções por Clostridium/diagnóstico , Infecções por Clostridium/mortalidade , Infecção Hospitalar/microbiologia , Infecção Hospitalar/mortalidade , Fezes/microbiologia , Humanos , Entrevistas como Assunto , Tempo de Internação , Reação em Cadeia da Polimerase , Análise de Regressão , Centros de Atenção Terciária , Wisconsin/epidemiologiaRESUMO
Patients with Clostridium difficile infection (CDI) are placed in contact precautions. We surveyed 31 visitors of CDI patients to understand their compliance, knowledge, and perceptions of contact precautions. Although most visitors knew where to find the required personal protective equipment, only 42% were fully compliant with gown and gloves. Family members accounted for 90% of visitors, and roughly half of the reasons given for not gowning were related to a lack of perceived risk for family members. Nursing staff are fundamental sources of personal protective equipment (PPE) information for visitors; however, we found variation in staff communication regarding need for visitor PPE use.
Assuntos
Fidelidade a Diretrizes , Controle de Infecções , Isolamento de Pacientes/métodos , Roupa de Proteção/normas , Visitas a Pacientes , Infecção Hospitalar/prevenção & controle , Coleta de Dados , Conhecimentos, Atitudes e Prática em Saúde , Hospitais/normas , Humanos , Política Organizacional , Inquéritos e QuestionáriosRESUMO
OBJECTIVES: There are only 0.70 licensed physicians per 1000 people in India. Thus, pharmacies are a primary source of healthcare and patients often seek their services directly, especially in village settings. However, there is wide variability in a pharmacy employee's training, which contributes to inappropriate antibiotic dispensing and misuse. These practices increase the risk of antibiotic resistance and poor patient outcomes. This study seeks to better understand the factors that drive inappropriate antibiotic dispensing among pharmacy employees in India's village communities. DESIGN: We conducted a mixed-methods study of the antibiotic dispensing practices, including semistructured interviews and a pilot cross-sectional Knowledge, Attitudes and Practice survey. All data were transcribed, translated from Hindi into English, and coded for themes. SETTING: Community pharmacies in villages in Haryana, India. PARTICIPANTS: We recruited 24 community pharmacy employees (all male) by convenience sampling. Participants have a range of characteristics regarding village location, monthly income, baseline antibiotic knowledge, formal education and licensure. RESULTS: 75% of pharmacy employees in our study were unlicensed practitioners, and the majority had very limited understanding of antibiotic resistance. Furthermore, only half could correctly define the term antibiotics. All reported that at times they dispensed antibiotics without a prescription. This practice was more common when treating patients who had limited access to a licensed physician because of economic or logistic reasons. Many pharmacy workers also felt pressure to provide shortened medication courses to poorer clientele, and often dispensed only 1 or 2â days' worth of antibiotics. Such patients rarely returned to the pharmacy for the complete course. CONCLUSIONS: This study highlights the need for short-term, intensive training programmes on antibiotic prescribing and resistance that can be disseminated to village pharmacies. Programme development should take into account the realities of working with poor clientele, especially in areas of limited healthcare access.
Assuntos
Antibacterianos , Atitude do Pessoal de Saúde , Serviços Comunitários de Farmácia , Resistência Microbiana a Medicamentos , Farmácias , Farmacêuticos , Farmácia , Antibacterianos/uso terapêutico , Estudos Transversais , Prescrições de Medicamentos , Educação em Farmácia , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Acessibilidade aos Serviços de Saúde , Humanos , Índia , Licenciamento , Masculino , Pobreza , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Healthcare facilities in low- and middle-income countries, including the Philippines, face substantial challenges in achieving effective infection control. Early stages of interventions should include efforts to understand perceptions held by healthcare workers who participate in infection control programs. METHODS: We performed a qualitative study to examine facilitators and barriers to infection control at an 800-bed, private, tertiary hospital in Manila, Philippines. Semi-structured interviews were conducted with 22 nurses, physicians, and clinical pharmacists using a guide based on the Systems Engineering Initiative for Patient Safety (SEIPS). Major facilitators and barriers to infection control were reported for each SEIPS factor: person, organization, tasks, physical environment, and technology and tools. RESULTS: Primary facilitators included a robust, long-standing infection control committee, a dedicated infection control nursing staff, and innovative electronic hand hygiene surveillance technology. Barriers included suboptimal dissemination of hand hygiene compliance data, high nursing turnover, clinical time constraints, and resource limitations that restricted equipment purchasing. CONCLUSIONS: The identified facilitators and barriers may be used to prioritize possible opportunities for infection control interventions. A systems engineering approach is useful for conducting a comprehensive work system analysis, and maximizing resources to overcome known barriers to infection control in heavily resource-constrained settings.
RESUMO
Contact precautions are complex behavioral interventions. To better understand barriers to compliance, we conducted a prospective study that compared the time burden for health care workers caring for contact precautions patients versus other patients. We found that nurses spent significantly more time in the rooms of contact precautions patients. There was no significant change in physician timing. Future studies need to evaluate workflow changes so that barriers to contact precaution implementation can be fully understood and addressed.
Assuntos
Doenças Transmissíveis/diagnóstico , Doenças Transmissíveis/terapia , Infecção Hospitalar/prevenção & controle , Transmissão de Doença Infecciosa/prevenção & controle , Enfermeiras e Enfermeiros , Isolamento de Pacientes/métodos , Médicos , Humanos , Estudos Prospectivos , Fatores de TempoRESUMO
BACKGROUND Clostridium difficile infection (CDI) is the most common infectious cause of nosocomial diarrhea, and its prevention is an urgent public health priority. However, reduction of CDI is challenging because of its complex pathogenesis, large reservoirs of colonized patients, and the persistence of infectious spores. The literature lacks high-quality evidence for evaluating interventions, and many hospitals have implemented bundled interventions to reduce CDI with variable results. Thus, we conducted a systematic review to examine the components of CDI bundles, their implementation processes, and their impact on CDI rates. METHODS We conducted a comprehensive literature search of multiple computerized databases from their date of inception through April 30, 2016. The protocol was registered in PROSPERO, an international prospective register of systematic reviews. Bundle effectiveness, adherence, and study quality were assessed for each study meeting our criteria for inclusion. RESULTS In the 26 studies that met the inclusion criteria for this review, implementation and adherence factors to interventions were variably and incompletely reported, making study reproducibility and replicability challenging. Despite contextual differences and the variety of bundle components utilized, all 26 studies reported an improvement in CDI rates. However, given the lack of randomized controlled trials in the literature, assessing a causal relationship between bundled interventions and CDI rates is currently impossible. CONCLUSION Cluster randomized trials that include a rigorous assessment of the implementation of bundled interventions are urgently needed to causally test the effect of intervention bundles on CDI rates. Infect Control Hosp Epidemiol 2017;38:639-650.
Assuntos
Clostridioides difficile , Enterocolite Pseudomembranosa/prevenção & controle , Fidelidade a Diretrizes , Pacotes de Assistência ao Paciente , Gestão de Antimicrobianos , Desinfecção , Equipamentos Descartáveis , Luvas Protetoras , Higiene das Mãos , Zeladoria Hospitalar , Humanos , Pacotes de Assistência ao Paciente/métodos , Educação de Pacientes como Assunto , Isolamento de Pacientes , Recursos Humanos em Hospital/educaçãoRESUMO
BACKGROUND: Hospital acquired infections occur at higher rates in low- and middle-income countries, like India, than in high-income countries. Effective implementation of infection control practices is crucial to reducing the transmission of hospital acquired infections at hospitals worldwide. Yet, no comprehensive assessments of the barriers to sustained, successful implementation of hospital interventions have been performed in Indian healthcare settings to date. The Systems Engineering Initiative for Patient Safety (SEIPS) model examines problems through the lens of interactions between people and systems. It is a natural fit for investigating the behavioral and systematic components of infection control practices. METHODS: We conducted a qualitative study to assess the facilitators and barriers to infection control practices at a 1250 bed tertiary care hospital in Haryana, northern India. Twenty semi-structured interviews of nurses and physicians, selected by convenience sampling, were conducted in English using an interview guide based on the SEIPS model. All interview data was subsequently transcribed and coded for themes. RESULTS: Person, task, and organizational level factors were the primary barriers and facilitators to infection control at this hospital. Major barriers included a high rate of nursing staff turnover, time spent training new staff, limitations in language competency, and heavy clinical workloads. A well developed infection control team and an institutional climate that prioritizes infection control were major facilitators. CONCLUSIONS: Institutional support is critical to the effective implementation of infection control practices. Prioritizing resources to recruit and retain trained, experienced nursing staff is also essential.