Healthcare infection最新文献

Introduction

Reusable medical devices are sterilized and stored before their use in hospital settings. The length of time the sterilized item can be stored (shelf life) to maintain sterility has been discussed in the literature over the last four decades, with a shift to an event rather than time-related determination of shelf life. This paper reviews the evidence and provides a summary of some key issues for consideration when adopting event-related or time-based shelf life recommendations for packaged sterile items in Australian hospitals.

Discussion

Australian and international standards provide guidelines for procedures to be used for sterilization of reusable medical devices and storage conditions following sterilization. Reusable medical devices are sterilized by commercial manufacturers or sterilizing departments located in hospitals. Commercial manufacturers allocate expiry dates on sterilized items which should be respected, unless sterility is compromised by an event. The shelf life of items sterilized in hospital is debated, with growing support for event- rather than time-related sterility. Many factors determine whether event- or time-related shelf life should be followed. Well designed experimental studies into shelf life of sterilized items are lacking, with some small studies indicating that items can remain sterile for 12 to 24 months. Factors for consideration by hospitals are outlined and an algorithm to assist in implementation of event-related or time-based shelf life for reprocessed reusable medical devices is provided.

Conclusion

The method of determining shelf life in hospitals is dependent on adequacy of processes for sterilization, monitoring of sterility over time and storage conditions.

Background

Inappropriate disposal of clinical waste has a considerable environmental and financial impact. Other studies have shown substantial opportunities for improvement in healthcare waste disposal. This study aims to show these opportunities through a clinical waste audit and to gain a greater understanding into approaches required for successful waste disposal behaviour change.

Methods

A clinical waste audit was conducted in an eight-bed intensive care unit in Melbourne. A baseline audit was followed by a questionnaire and education (in-services and signage). A follow up audit was performed to analyse the effect of education.

Results

Results of the initial clinical waste audit showed 41% clinical waste, 44% general waste and 14% sharps waste. Post-education, clinical waste was slightly greater than general waste and sharps waste had markedly decreased to 3.5%, however, study limitations were present. The marked decline in sharps waste appears to mainly be due to the clarification of a misnomer regarding disposal of glass. Questionnaires showed a lack of knowledge but a desire to learn, and a preference for learning through signage and in-services.

Conclusion

The study shows that more than one in-service and increased signage is needed for successful behaviour change. This supports findings that active staff involvement is essential to achieve sustainable waste management.

Background

The prevention of healthcare-associated infections (HAI) and the rise of multi-resistant organisms are significant public health issues. Infections caused by multi-resistant organisms (MRO) can have similar clinical manifestations to infections caused by non-multi-resistant organisms (non-MROHAI) but antibiotic treatment options are more limited, which can result in treatment failure. This study aimed to reduce the incidence of MRO HAI in a specific South Australian hospital setting by identifying factors that are associated with MRO transmission.

Methods

Using a case-control design, we analysed data from 1017 adult patients who developed an HAI in the 9-year period from 2003 to 2011 in a private South Australian hospital. We compared risk factors in patients who developed MRO HAI (cases) with risk factors in patients who developed non-MRO HAI (controls). Data were collected from the hospital's patient management database and individual medical records, and analysed using univariate and multivariate techniques.

Results

Independent predictors for the development of MRO HAI were the presence of an indwelling urinary catheter and renal disease. The development of a secondary infection was significantly more likely in MRO relative to non-MRO HAI, as was secondary bloodstream infection following a primary urinary tract infection.

Conclusion

All effective interventions for reducing MRO, specifically in UTI, should be implemented where feasible. Increased healthcare worker education on aseptic non-touch technique, and safe insertion and management of an IDC, particularly important in patients with underlying renal disease, could assist in decreasing the risk of MRO HAI in this setting.

Background

Vancomycin-resistant enterococci (VRE) colonisation serves as a reservoir and increases the risk of developing an infection with VRE. Treatment difficulties and infection control measures associated with vancomycin-resistant enterococci present significant costs to health care facilities. To determine the incidence of VRE colonisation in ICU, data collected included hospital and ICU admission, discharge dates, positive and negative VRE swabs for each hospital or ICU admission.

Methods

This study was performed to identify the number of VRE colonisations occurring in the Intensive Care Unit (ICU) and the outcome of these colonised patients. The clinical records of 99 VRE patients identified as having been to ICU during 2009 and 2010 were reviewed.

Results

These patients had a total of 111 ICUadmissions. Of these, 30 were classified as definite or probable ICUacquired VRE colonisations. This equated to 30.1 acquisitions per 10 000 occupied bed days. Thirty-eight patients acquired their VRE from clinical areas other than ICU. In 24 other patients the place of VRE could not be ascertained. In another 19 patients VRE was present when they were admitted from the community but 15 of these (79%) had been hospitalised within the last year. Of the 30 ICU-colonised patients, none developed infections. However, three patients initially colonised in another clinical area developed an infection with VRE while in ICU.

Conclusion

Our study supports the findings of others that most people at risk of VRE colonisation or infection are severely unwell. The high level of colonisation occurring in other clinical areas added to the healthcare expenses in ICU. The increased costs associated with VRE and our findings indicate a greater need to better control VRE transmission not only in the ICU, but in all health care settings.

Aims

To describe long-term survival (beyond 200 days) following Staphylococcus aureus bacteraemia (SAB) and to determine if certain patient subgroups had poorer long-term survival outcomes.

Methods

A single-centre, retrospective, cohort study of all SAB cases at The Canberra Hospital, a tertiary referral centre, from January 1998 to December 2007 was performed. Clinical and demographic data were obtained from a pre-existing prospectively collected database. Patients were followed-up for a minimum of 9 months. Subsets within the cohort were analysed for differences in long-term survival. The main outcome measure was death from any cause.

Results

During the 3889-day study observation period, 439 patients had SAB and were followed for a total of 546 360 person-days. The overall median survival was 3169 days. The mortality rates were 9.6%, 17%, 24%, 29% and 32% at 7, 30, 90, 180 and 365 days respectively. Atotal of 188 (43%) patients died. Of the 188 deaths, 22%, 40%, 55%, 67% and 75% occurred within the first 7, 30, 90, 180 and 365 days respectively after their SAB episode. Initial analysis showed poorer long-term survival in those patients with older age, MRSA, with an unknown focus of infection, and who were not admitted under the Infectious Diseases team. However, on multivariate analysis, the only independent risk factors for poorer survival were older age, unknown focus of infection and not being admitted under the Infectious Diseases team. MRSA, sex, surgical vs non-surgical admitting team and an association with an intravascular device were not associated with poorer long-term survival.

Conclusions

High rates of death continue for many months after patients have an episode of SAB. Short-term follow-up studies (30 days or less) may miss large numbers of SAB-associated deaths. If accurate data on SAB associated mortality is needed, then follow-up of these patients will be needed for at least 90 days, ideally performed prospectively with a matched control group consisting of hospitalised patients without SAB.

Infection prevention and control services are well established within publically funded hospitals within New Zealand. In 2007, the Ministry of Health Quality Improvement Committee developed a set of National Quality Improvement Programs including an Infection Prevention and Control project. This project, the implementation of a national hand hygiene program, provision of guidance to reduce central line associated bacteraemia and recommendations for a national surgical site infection surveillance program, was the first nationally coordinated infection prevention and control program. More recently the Health Quality and Safety Commission has been established and the responsibility of the program delivery shifted to the Commission. District Health Boards have agreed to participate in the programs and the recently introduced Quality and Safety Markers will track the progress of these programs. Ongoing committed to increasing the workforce capacity and capability is required to ensure the successful delivery of these programs.

Introduction

Hand hygiene compliance rates for medical staff are consistently lower than those for nurses. Strong leadership to improve compliance has been repeatedly called for, but studies exploring medical staff leadership influence are limited. The qualitative study reported here aimed to explore the perceptions that medical staff have of their clinical leaders and the extent to which they influence hand hygiene practice in their clinical units, and to compare this with unit specific compliance data.

Method

Thirty junior doctors from a major tertiary hospital were interviewed or surveyed to uncover their perceptions of clinical leadership and its influence on hand hygiene behaviours. Compliance data for their clinical areas for the corresponding period was obtained and compared with their views on the influence of leadership on hand hygiene behaviour.

Findings

Consultants, rather than infection control nurses, were seen to have the most influence over medical hand hygiene practices. The unit that scored the best on compliance was also the one where the consultant was perceived to have the most influence.

Conclusion

Junior medical staff know that hand hygiene is important but the extent to which they comply with it depends on the influence of the consultant. Infection control staff need to engage consultants in order to improve medical compliance rates, rather than directing their efforts to medical staff in general.

Background

Transrectal ultrasound guided prostate biopsy (TRUSPB) is the mainstay of diagnosis for prostate cancer. Clinical trials have established that antibiotic prophylaxis is effective in reducing infective complications, but breakthrough bacteraemia has been described with multiresistant organisms. We reviewed the rate of bacteraemia and re-admission in patients undergoing TRUSPB.

Methods

The Alfred Hospital is a tertiary referral hospital in Melbourne, Australia. The routine antibiotic prophylactic regimen is gentamicin and norfloxacin. Patients undergoing TRUSPB at the Alfred Hospital were linked to databases of blood and urine cultures, and to admissions with infective complications within 14 days.

Results

Between June 2007 and July 2010, 459 patients underwent TRUSPB at the Alfred Hospital. No patient (95% CI: 0, 0.8%) had a positive blood culture, and one patient had a positive urine culture (95% CI: 0.04, 1.2%) within 14 days of the procedure. There were two readmissions: a 66 year old man with systemic culture-negative sepsis, and a 54 year old man with a urinary tract infection. In 50 randomly selected patients, all patients received norfloxacin but only 80% of patients received gentamicin. Between 2007 and 2010, 6.0% of isolates were non-susceptible to norfloxacin, 5.8% were non-susceptible to gentamicin and 3.2% were non-susceptible to both gentamicin and norfloxacin.

Conclusions

Recent reports of breakthrough bacteraemia suggest that effectiveness of single agent fluoroquinolone or gentamicin prophylaxis may be compromised by increasing rates of resistance. Combination prophylaxis with gentamicin and norfloxacin is associated with a low rate of infective complications.

Background

The environment is increasingly appreciated as a factor in healthcare associated infections. Several methods for measuring environmental contamination are available. Our goal was to compare quantitative microbiology to adenosine triphosphate (ATP) detection on a sample of hospital surfaces both pre- and post-cleaning, and to assess fluorescent marker results in the same rooms.

Methods

In a sample of 10 rooms, ATP readings by relative light units (RLU) and quantitative determination of colony forming units (CFU) were measured pre- and post-cleaning on 10 high-touch hospital environmental surfaces. Removal of fluorescent markers (FM) was evaluated post-cleaning in the same rooms. Methods were compared using correlational analyses.

Results

The ATP readings were usually higher than CFU readings compared with their respective norms for cleanliness. The direction of change in cleanliness assessment (usually down after cleaning) was consistent between the RLU and CFU methods. In addition, CFU and RLU values correlated pre-cleaning, but not postcleaning. Areceiver operating characteristic (ROC) curve suggested a ‘clean’ cutoff of 8 RLU/cm² for the ATP assay, higher than 2.5 RLU/cm² cutoff most often used. Neither method correlated well with FM results.

Conclusions

The methods for measuring environmental cleanliness have shown inconsistent correlation, but measure different parameters. Additional studies are needed to assess the correlation and predictive value of the three methods for room cleanliness assessment.

Purpose

A review of the incidence of Clostridium. difficile infection (CDI) at our hospital was performed due to the morbidity of CDI in its fulminate form, reports of the increased incidence of CDI in the United States and the increased use of medications associated with its onset.

Methods

The study was retrospective and took place over a 9-month period, from 1 January 2009 through 30 September 2009.

Results

There were 88 cases of CDI in the course of the review which amounted to 5.1 infections per 1000 patient hospital admissions. The percentage of overall admissions that were prescribed antibiotics and proton pump inhibitors (PPI), PPI alone or antibiotics alone were 17.1%, 15.5% and 24.3%, respectively. Of all cases of CDI, 59.1% of patients were on both a PPI and antibiotic, 9.1% were on a PPI alone and 13.6% were on an antibiotic alone. Patients on both proton pump inhibitors and antibiotics had an odds ratio of 8.30 (P < 0.0001) compared with patients on neither of these medications.