Good Infection Control Practices Research Articles

Infection control in general practices in Buffalo City and OR Tambo District Municipalities, South Africa

BackgroundGood infection control practices are effective in reducing rates of infection in health care settings. Studies in primary care in developed countries indicate that many general practitioners (GPs) do not comply with optimal infection control practices. There are no published studies from developing countries in Southern Africa.ObjectivesThe aim of this study was to describe infection control practices in private GP surgeries in the Buffalo City and OR Tambo District Municipalities in the Eastern Cape Province, South Africa.MethodA literature review was conducted to appraise current best practice with respect to Standard Infection Control and Transmission Based Precautions. A questionnaire, inquiring into GPs’ actual practices, was posted to each surgery.ResultsThe valid response rate was 34% (47/140). Methods used to sterilise instruments in 40 practices were: ultraviolet sterilisation (23), chemical disinfection (14), boiling water (7), and steam autoclave (2). Compounds used for chemical disinfection included organotin quaternary, chlorhexidine and benzyl ammonium chloride with a quaternary complex. Twenty-two (47%) used a hand rub. Sixteen (35%) GPs stated that they had a policy to promptly triage patients who are coughing, and 23 (50%) had a policy for airflow movement in the surgery. All practices appropriately disposed of sharps. Thirty-seven (80%) expressed interest in a seminar on infection control.ConclusionsOverall, GPs were aware of infection control precautions. Ultraviolet sterilisers and chlorhexidine are not recommended, however, for sterilisation or high level disinfection of medical instruments, and their use should be discontinued. Hand rubs are underutilised. GPs should implement Transmission Based Precautions to prevent airborne and droplet infections.

“Save Antibiotics, Save lives”: an Indian success story of infection control through persuasive diplomacy

BackgroundCarbapenem resistant Enterobacteriaceae is a worldwide threat, with increasing prevalence in many countries. Restricted usage of higher end antibiotics, especially carbapenem is of great importance in tackling these super bugs. Purpose of this retrospective study was to analyse the impact of antibiotic stewardship activities on the prevalence of carbapenem resistant Enterobacteriaceae in our hospital.FindingsIn the first Quarter of 2009, average usage of carbapenem group of antibiotics was 955 vials a month while in 2010, the usage dropped to 745 vials per month. Carbapenem resistant E.coli rate dropped from 3.7% in 2009 to 1.6% in 2010 and Klebsiella rate reduced from 6% in 2009 to 3.6% in 2010.ConclusionsStrict antibiotic stewardship strategies in conjunction with good infection control practices are useful in restricting higher end antibiotic usage and reducing the prevalence of carbapenem resistant Enterobacteriaceae.

Antibiotic prescription and resistance: A contemporary literature review

Worldwide, antibiotics are among the most commonly used and misused drugs because of the perception in some practitioners and patients that antibiotic resistance is theoretical or only a minor risk. This review therefore aims to update knowledge and promote proper antibiotic prescription with the goal of optimizing use and halting the trend of rising resistance. A literature and internet (Medline, embase, HINARI and Cochrane data bases) search showed that prescription of antibiotics only when indicated following standard guidelines minimizes the incidence and spread of resistance. Mechanisms of resistance development include bacterial mutation or horizontal transfer from plasmids, transposons, integrons and gene cassettes between commensal organisms and potential pathogens by transduction, translocation, transposition, transformation or conjugation. Resistance may emerge following indiscriminate use of antibiotics, unhygienic conditions, poor drug handling and non-adherence. To halt resistance, priority areas include prudent use of antibiotics; development of antimicrobials with novel mechanisms of action; use of bioinformatics and genomic techniques to identify and study new targets of attack; use of alternatives to antibiotics such as bacteriophage-derived therapy or chemical agents that can block or reverse resistance pathways; use of agents in natural products, vaccines and pro-biotics as well as implementing public health strategies and education of the populace. In response, initiatives at the local, national and international levels are now directed towards promoting good antibiotic stewardship, infection control, sanitation and hygiene practices. Key words: Antibiotic, antimicrobials, prescription, resistance, contemporary, review

Antibiotic prescription and resistance: A contemporary literature review

Worldwide, antibiotics are among the most commonly used and misused drugs because of the perception in some practitioners and patients that antibiotic resistance is theoretical or only a minor risk. This review therefore aims to update knowledge and promote proper antibiotic prescription with the goal of optimizing use and halting the trend of rising resistance. A literature and internet (Medline, embase, HINARI and Cochrane data bases) search showed that prescription of antibiotics only when indicated following standard guidelines minimizes the incidence and spread of resistance. Mechanisms of resistance development include bacterial mutation or horizontal transfer from plasmids, transposons, integrons and gene cassettes between commensal organisms and potential pathogens by transduction, translocation, transposition, transformation or conjugation. Resistance may emerge following indiscriminate use of antibiotics, unhygienic conditions, poor drug handling and nonadherence. To halt resistance, priority areas include prudent use of antibiotics; development of antimicrobials with novel mechanisms of action; use of bioinformatics and genomic techniques to identify and study new targets of attack; use of alternatives to antibiotics such as bacteriophagederived therapy or chemical agents that can block or reverse resistance pathways; use of agents in natural products, vaccines and pro-biotics as well as implementing public health strategies and education of the populace. In response, initiatives at the local, national and international levels are now directed towards promoting good antibiotic stewardship, infection control, sanitation and hygiene practices.

Use of a systematic review to inform the infection risk for biomedical engineers and technicians servicing biomedical devices

Many microorganisms responsible for hospital-acquired infections are able to stay viable on surfaces with no visible sign of contamination, in dry conditions and on non-porous surfaces. The infection risk to biomedical staff when servicing biomedical devices is not documented. An indirect approach has been used to examine the different aspects that will affect the risk of infection including a systematic review of microbial contamination and transmission relating to biomedical devices. A systematic review found 58% of biomedical devices have microbial contamination with 13% having at least one pathogenic organism. These microbes can persist for some months. Occupational-infections of biomedical service staff are low compared to other healthcare workers. A biomedical device with contaminated surface or dust was identified as the source of patient outbreaks in 13 papers. The cleaning agent most tested for removal of micro-organisms from devices was alcohol swabs, but sterile water swabs were also effective. However, manufacturers mainly recommend (74%) cleaning devices with water and detergent. Biomedical engineers and technicians have a small risk of being exposed to dangerous micro-organisms on most biomedical devices, but without skin breakage, this exposure is unlikely to cause ill-health. It is recommended that biomedical staff follow good infection control practices, wipe devices with detergent, sterile water or alcohol swabs as recommended by the manufacturer before working on them, and keep alcohol hand rubs accessible at all benches.

Diagnostic testing for Clostridium difficile: a comprehensive survey of laboratories in England

Recent studies have shown poor performance of commonly used toxin enzyme immunoassays (EIAs) for laboratory testing for Clostridium difficile infection (CDI). In 2009-2010, the UK Health Protection Agency and the European Society of Clinical Microbiology and Infectious Diseases stated that toxin EIA testing alone is suboptimal, and recommended a two-step testing protocol (i.e. screening with one method and confirming the results with another method). All acute English National Health Service trusts were surveyed to determine their testing methods and positivity rates using freedom of information requests. Replies were received from 168 of 170 trusts (99% response rate). Seventy percent of trusts were using a toxin EIA as a standalone testing method, with positive predictive values (PPVs) as low as 20% in some cases. The mean positivity rate decreased from 6.45% in 2008 to 4.47% in 2009, which will have a negative effect on the PPVs of these tests. The UK Department of Health publishes CDI rates as a measure of quality of care and good infection control practice. However, this may not provide valid comparisons because of the wide disparity between testing methods. The present study demonstrates wide variation in testing practices for CDI in England, and laboratories should reconsider their current testing strategies.

Phlebotomy tourniquets- vectors for bacterial pathogens

Nosocomial infection is a significant problem. Good hand hygiene is the single most effective preventive measure. However, maintaining a clean patient environment is also necessary. Studies have shown that objects...

Evaluation of a cesarean section postoperative wound infection surveillance program at Kenézy Hospital, Debrecen, Hungary

Wound infection is a typical, partly preventable complication of cesarean sections. We started extended recording of cesarean section data in October, 2008 as part of our general wound infection surveillance program. Aim: To describe the circumstances and outcomes of the sections and analyze associations between them. Methods: We analyzed 523 cases over the period October 1, 2008 to September 30, 2009. Variables were assessed using descriptive statistics. Associations between explanatory factors and wound infection were evaluated using logistic regression. Results: Infections (overall rate: 3.6%) were more frequent in younger subjects, those with anemia, subcutaneous hematoma, in pregnancies with meconium stained or purulent amniotic fluid, and decreased to about a third after infection control was tightened. Conclusions: by being a proxy variable of factors with which wound infection is associated, age is a clinically valuable predictive variable. Good infection control practice is effective in preventing wound infections. The results are consistent with appropriate prescription practices of prophylactic antibiotic use, and with prophylactic measures being effective. Orv. Hetil., 2011, 152, 14–22.

Isolation Precautions

Isolation Precautions

Cluster randomised controlled trial of an infection control education and training intervention programme focusing on meticillin-resistant Staphylococcus aureus in nursing homes for older people

The aim of this cluster randomised controlled trial was to test the impact of an infection control education and training programme on meticillin-resistant Staphylococcus aureus (MRSA) prevalence in nursing homes. Nursing homes were randomised to intervention (infection control education and training programme; N=16) or control (usual practice continued; N=16). Staff in intervention homes were educated and trained (0, 3 and 6 months) in the principles and implementation of good infection control practice with infection control audits conducted in all sites (0, 3, 6 and 12 months) to assess compliance with good practice. Audit scores were fed back to nursing home managers in intervention homes, together with a written report indicating where practice could be improved. Nasal swabs were taken from all consenting residents and staff at 0, 3, 6 and 12 months. The primary outcome was MRSA prevalence in residents and staff, and the secondary outcome was a change in infection control audit scores. In all, 793 residents and 338 staff were recruited at baseline. MRSA prevalence did not change during the study in residents or staff. The relative risk of a resident being colonised with MRSA in an intervention home compared with a control home at 12 months was 0.99 (95% confidence interval: 0.69, 1.42) after adjustment for clustering. Mean infection control audit scores were significantly higher in the intervention homes (82%) compared with the control homes (64%) at 12 months (P<0.0001). Consideration should be given to other approaches which may help to reduce MRSA in this setting.

Significant Reduction of Ventilator-Associated Pneumonia Rates Associated With the Introduction of a Prevention Protocol and Maintained for 10 Years

Objective: To determine if the institution of a ventilator-associated pneumonia (VAP) prevention protocol was associated with VAP decrease in mechanically ventilated patients at a long-term acute care (LTAC) hospital over time. Introduction: VAP is the most common serious nosocomial infectious disease in mechanically ventilated patients. It has a high mortality and morbidity and significantly increases the cost of care. Design: A prospective preintervention and postintervention observational study comparing the number of episodes of VAP per 1000 patient ventilator-days in the 16 months preceding and 120 months (10 years) after the introduction of a VAP prevention protocol. Setting: A 73-bed, university-affiliated LTAC hospital. Methods: The implementation of a VAP prevention protocol included the following: (1) head of bed raised at 30°; (2) twice-weekly whole-body chlorhexidine-based bath with mupirocin 2% ointment applied to nares; (3) adequate hand washing; (4) adequate nutrition; (5) early tracheotomy by Day 7 if patients had endotracheal tubes; (6) monitor staff compliance; (7) infection control–run campaign involving posters, handouts, small group education events, positive reinforcement of good infection control practices, and focus on hand washing and universal precautions. Results: The initial VAP rate of 6.1 fell to 1.98/1000 ventilator-days within 5 months ( P &lt; .001), and this was maintained. Relative risk was 0.32 ( P = .001) (68% relative risk reduction). Conclusion: The institution of a VAP prevention protocol showed a significant reduction in VAP episodes after the first 5 months of implementation. This rate was sustained for 10 years.

Nigerian Dental Students’ Willingness to Treat HIV‐Positive Patients

Dental care of HIV-positive individuals plays a vital role in improving their nutritional intake, medication tolerance and effectiveness, treatment success rate, and quality of life. It is therefore important to ensure optimal dental care of this group of people, especially since more of them, with or without knowledge of their serologic status, are now utilizing dental services. The objective of this study was to assess Nigerian dental students' willingness to treat HIV-positive individuals. A descriptive cross-sectional survey of all seventy-six final-year dental students of the University of Benin, Nigeria, was conducted in December 2007 using a self-administered questionnaire that elicited information on the students' demography, self-rated knowledge on HIV/AIDS, attitude towards homosexuals, infection control practices, occupational risk perception, and willingness to provide care for HIV-positive individuals. The response rate was 76.3 percent. Over 77 percent of the respondents were in the twenty-five to thirty years age group. The male-female ratio was approximately 1.6:1. HIV-related knowledge was reported as high by only 31 percent of the respondents. Eighty-one percent showed great interest in HIV-related information, while about half (53.4 percent) exhibited significant worry about occupational contagion. Forty-eight (82.7 percent) desired more knowledge about safety precautions during treatment of HIV patients. Fifty respondents (86.2 percent) reported good infection control practices. About three-fourths (74.2 percent) rated the risk of HIV contagion from patients high, while only one-fourth (25.8 percent) reported having an unsympathetic attitude towards homosexuals. Almost all respondents (98.3 percent) agreed that oral care for HIV-positive individuals improves their quality of life, but only 58.8 percent expressed a willingness to treat HIV-positive patients and only 46.5 percent said they will render volunteer dental services in HIV centers. HIV prevalence will determine the location of practice of 41.4 percent of the respondents. The result suggests the need to have a comprehensive educational/motivational program for the next generation of dentists in Nigeria in order to ensure adequate care of HIV-positive individuals. The perceived deficiency revealed in this study can also serve as a vital guide for curriculum change on HIV-related issues.

Description of the outcomes of prior authorization of palivizumab for prevention of respiratory syncytial virus infection in a managed care organization.

Respiratory syncytial virus (RSV) is the leading cause of upper and lower respiratory tract infections in infants and young children. Most children are exposed to the virus before they are 2 years old and experience such symptoms as cough, fever, and irritability. In a select population of infants, the virus can cause hypoxemia and hospitalization. To avoid hospitalization, good infection control practices should be employed, and for those infants at high risk, prophylaxis with palivizumab is indicated. Palivizumab has been shown to reduce hospitalization rates in high-risk infants by 50%. Because of the high cost of palivizumab, it is prudent to use this medication in the population in which it will be most effective. The American Academy of Pediatrics (AAP) established the criteria for those infants who would benefit the most from palivizumab prophylaxis, and these criteria were the foundation for a prior authorization (PA) program to determine coverage of palivizumab in a health plan of approximately 500,000 members. To (a) analyze the appropriateness of this PA program for palivizumab used prophylactically for RSV, and (b) determine the financial cost associated with the medication and disease for this health plan. A 3-year, retrospective study was conducted from the 2005- 2006 RSV season through the 2007-2008 season. The primary endpoint outcome was the hospitalization rate associated with RSV infection. Secondary endpoints included the cost of palivizumab and RSV-related emergency room (ER) utilization. Infants were placed into 2 groups: those who received PA approval for use of palivizumab and those who were denied coverage in the PA process. Disease-related hospitalization and ER visits were identified by at least 1 administrative claim containing either a primary or secondary ICD-9-CM code for any of the following: RSV (079.6), acute bronchiolitis caused by RSV (466.11), or pneumonia caused by RSV (480.1). Drug cost was defined as the health plan's allowed amount, which is based on a predefined fee schedule for the Current Procedural Terminology (CPT) code 90378 for palivizumab. Hospital and ER costs are the health plan allowed amounts (health plan plus member cost) based on the reimbursement rates determined by diagnosis related group (DRG) and other coding, and the plan-allowed amount based on DRGs includes all services and drugs provided in the specific encounter. Drug cost avoided was calculated as the average cost of palivizumab treatment per episode multiplied by the number of infants denied coverage of palivizumab over the 3-year study period. Over 3 RSV seasons through May 2008, the PA program received 1,090 requests for coverage of palivizumab, of which 348 (31.9%) were denied. Of 742 PA-approved infants, 629 received at least 1 dose of palivizumab. The mean (SD) gestational age of the PA-denied group was 34.4 (2.5) weeks versus 32.5 (4.0) weeks for the PA-approved group (P < 0.001). In the PA-denied group, 14 infants (4.0%) were subsequently hospitalized with an RSV infection, and 5 (1.4%) had an RSV-related ER visit versus 40 (6.4%) hospitalized and 14 (2.2%) with ER visits for infants in the PA-approved group (P = 0.055 and P = 0.019, respectively); 15 (4.3%) of the PA-denied group had either a hospitalization or an ER visit versus 42 (6.6%) in the PA-approved group (P = 0.060). One patient in the palivizumab PA-approved group died. Over the 3 RSV seasons, the mean number of palivizumab doses and mean allowed palivizumab cost per treatment episode (per infant per season) were 3.64 and $6,950, respectively, and the average allowed palivizumab cost was $7,702 per utilizing infant. Total per infant costs for palivizumab, RSV hospitalizations, and RSV-related ER visits were $8,534 for infants receiving palivizumab compared with $223 for those denied palivizumab coverage (P = 0.002). Drug cost avoidance associated with the PA program was estimated to be $2,418,600 (348 infants times $6,950 palivizumab cost per episode) over the 3 RSV seasons. In a 500,000-member health plan, a PA program to restrict palivizumab use in accordance with AAP recommendations was associated with estimated palivizumab drug cost avoidance of more than $2.4 million over 3 years. There was no significant difference in the RSV-related hospitalization rate for the PA-denied versus the PA-approved groups, but the PA-denied group had a slightly lower rate of RSV-related ER visits.

Swine origin influenza (swine flu)

Swine origin influenza was first recognized in the border area of Mexico and United States in April 2009 and during a short span of two months became the first pandemic. The currently circulating strain of swine origin influenza virus of the H1N1 strain has undergone triple reassortment and contains genes from the avian, swine and human viruses. It is transmitted by droplets or fomites. Incubation period is 2 to 7 days. Common clinical symptoms are indistinguishable by any viral respiratory illness, and include fever, cough, sore throat and myalgia. A feature seen more frequently with swine origin influenza is GI upset. Less than 10% of patients require hospitalization. Patients at risk of developing severe disease are - younger than five years, elderly, pregnant women, with chronic systemic illnesses, adolescents on aspirin. Of the severe manifestations of swine origin influenza, pneumonia and respiratory failure are the most common. Unusual symptoms reported are conjunctivitis, parotitis, hemophagocytic syndrome. Infants may present with fever and lethargy with no respiratory symptoms. Diagnosis is based on RT PCR, Viral culture or increasing neutralizing antibodies. Principle of treatment consist of isolation, universal precautions, good infection control practices, supportive care and use of antiviral drugs. Antiviral drugs effective against H1N1 virus include: oseltamivir and zamanavir. With good supportive care case fatality is less than 1%. Preventive measures include: social distancing, practicing respiratory etiquette, hand hygiene and use of chemoprohylaxis with antiviral drugs. Vaccine against H1N1 is not available at present, but will be available in near future.

Healthcare-associated hepatitis C virus transmission among patients in an abdominal organ transplant center.

De novo hepatitis C virus (HCV) infection among transplant patients is rarely recognized but can have severe consequences. We investigated the scope, source, and mode of HCV transmission within a transplant center after incident HCV infection was identified in 2 patients who had liver transplantation in late 2006. Patients were interviewed, and transplant logs, medical records, and staff practices were reviewed to identify opportunities for HCV transmission. Infection via receipt of blood or organs was evaluated. Molecular epidemiology was used to determine the relatedness between persons with incident and chronic HCV infection. HCV from infected blood or organ donors was ruled out. Among the 308 patients who underwent transplant in 2006, no additional incident HCV infections were identified. Eighty-five (28%) had pre-transplant chronic HCV infection; 13 were considered possible HCV source patients based upon shared days on the inpatient unit, nursing assignment, or invasive procedures in common with incident HCV case-patients. Viral isolates from 1 HCV source patient and 1 incident case-patient were found to be highly related by quasispecies analysis, confirming patient-to-patient HCV transmission. Possible modes of transmission identified were the improper use of multidose vials, sharing of blood-contaminated glucometers, and touch contamination. Sporadic transmission or endemic levels of HCV transmission might be overlooked in a setting with high HCV prevalence, such as liver transplant units, where multiple, repeated opportunities for patient-to-patient HCV transmission can occur. Surveillance through pre- and post-transplant screening is necessary to identify incident HCV infection in this setting. Constant, meticulous attention must be paid to maintaining aseptic technique and good infection control practices to eliminate HCV transmission opportunities.

Survey of ESBL Producing Escherichia coli and Klebsiella pneumoniae and MRSA in a Tertiary Care Facility in United Arab Emirates

Introduction: There are no reports to date on prevalence of extended-spectrum ˇ-lactamase (ESBL) producing strains in the UAE. The aim of this study was to evaluate the prevalence of extended-spectrum ˇ-lactamase producing E. coli and K. pneumoniae and MRSA in UAE. Methods: Retrospective analysis of microbiology laboratory data between January 2005 and 30 November 2006 was carried out. ESBL production was confirmed by double disk diffusion approximation test or by the combined disk method. Isolates from the same patient in one month and the same site of isolation with the same antimicrobial susceptibility were considered as duplicates and eliminated. The values for the year 2005 and 2006 were compared. Statistical analysis was carried out by SPSS software. Results: In 2005, 7.3% (64/883) of total E.coli isolates and 7.3% (21/286) of K. pneumoniae isolates were ESBL producers. In 2006 this value significantly increased for E. coli to 11.2% (96/854), while K. pneumoniae remained unchanged at 7.3% (20/276). Inpatient isolates were significantly higher than in outpatients. ESBL production in E.coli for outpatients increased from 4.15%(27/650) in 2005 to 6.91%(42/608) in 2006 (P = 0.043). There was a trend towards increasing ESBL production among inpatients for K. pneumoniae (9.8 to 14.2%) and for E. coli (15.9 to 22%). The MRSA rates for the years 2005 and 2006 were 6.7% (41/616) and 7.0% (34/484) respectively. There was no significant change in MRSA prevalence in inpatients (9 Vs. 10.7%) or outpatients (4.4 Vs. 4.5%). Conclusions: This study shows that there is a relatively high prevalence of ESBL E. coli and K. pneumoniae in our institution which is comparable to that reported from other countries in this region. This is likely driven by the unrestricted use of antimicrobials particularly 3rd generation cephalosporins. Antimicrobial stewardship programs and good infection control practices are required to stem the increasing resistance.

Inside AAMI

Despite many recent advances in the safety of medical and surgical care, infections continue to be a significant problem in healthcare facilities.According to AAMI's Ethylene Oxide Sterilization Hospital Practices Working Group, one way to prevent some of these infections in healthcare facilities is effectively reprocessing and sterilizing medical devices by using ethylene oxide (EO).To help facilities accomplish this, the working group has published a combined revision of three existing documents, entitled ANSI/AAMI ST41:2008, Ethylene oxide sterilization in health care facilities: Safety and effectiveness.ST41:2008 provides guidelines for EO sterilization processing, which are intended to promote sterility assurance and to assist healthcare personnel in the proper use of processing equipment. It also intends to help ensure the safe use of EO by defining equipment and procedures, including controls to minimize personnel exposure to EO or its residuals.“Ethylene oxide gas must be used with care because of its toxicity and its flammability and explosiveness,” notes ST41. The document suggests that because of these reasons, “EO should be used to sterilize only those items that cannot undergo the steam sterilization process.”EO gas and its mixtures are effective sterilants that are primarily used for heat-and moisture-sensitive medical devices that cannot be steam sterilized. The delivery of sterile products for use in patient care depends not only on the efficacy of the sterilization process itself; but also on efficient facility design; good infection prevention and control practices; effective quality control; and other aspects of device processing before, during, and after sterilization. ST41:2008 addresses these items, as well as staff qualifications and other personnel considerations; installation, operation, care, and maintenance of EO equipment; and environmental and employee health monitoring.To order, visit http://marketplace.aami.org or call (877) 249-8226. List price: $200. AAMI member price: $100. Order code: ST41. Source code: HI.

The Impact of Requiring Completion of an Online Infection Control Course on Health Professionals’ Intentions to Comply with Infection Control Guidelines: A Comparative Study

Ensuring good infection control practice in health care facilities is a constant concern, yet evidence shows that the compliance of health care professionals with proper procedures is lacking, despite the existence of guidelines and training programs. An online infection control module was developed to provide ready access to training. Controversy exists about whether successfully completing such a course should be mandatory or strongly encouraged for all health care professionals. The objective of the present study was to compare the perception of safety culture and intention to comply with infection control guidelines in professionals who were required by their supervisors to take the course, and those who did so voluntarily. Survey responses on learning environment, safety climate and intention to comply with infection control guidelines in health care professionals who were required to take the course (supervisor-required group [n=143]) and those who took the same course voluntarily (voluntary group [n=105]) were compared. Because randomization was thought to be too difficult to implement in the policy context in which the study was conducted, significant differences between the two groups were taken into account in the analysis. Those required to take the course had a significantly better perception of the institutional safety climate (P<0.001), and had a higher reported intention to comply with infection control guidelines (P=0.040) than those who took the course voluntarily. Requiring that staff complete a 30 min interactive online infection control module increased their intention to comply with infection control guidelines compared with those who voluntarily accessed this material based on promotional material. Consideration should be given to making the successful completion of an online infection control module a requirement for all health care professionals.

Frequency of biocide resistance genes, antibiotic resistance and the effect of chlorhexidine exposure on clinical methicillin-resistant Staphylococcus aureus isolates

To detect genes conferring resistance to biguanides, quaternary ammonium compounds, beta-lactams and fluoroquinolones in clinical methicillin-resistant Staphylococcus aureus (MRSA) and to demonstrate whether reduced susceptibility is spread clonally and if the presence of any of the detected genes links to a specific epidemic MRSA. Finally, to identify if exposure to chlorhexidine may cause reduced susceptibility to antibiotics and chlorhexidine. In total, 120 clinical MRSA isolates were isolated. qacA/B, qacG, qacH, norA, smr and blaZ genes were amplified by PCR. MICs of eight antibiotics were determined and PFGE was used for typing. Surface disinfection and residue tests were performed for chlorhexidine and a selection of isolates. qacA/B (8.3%), qacH (3.3%), norA (36.7%), smr (44.2%) and blaZ (97.5%) were prevalent within the population but qacG was not detected. EMRSA-15 (19.2%), EMRSA-16 (15%), P3 (15%) and H (12.5%) were the most common PFGE types. Clinical isolates demonstrated various degrees of susceptibility to chlorhexidine in the surface disinfection [mean microbiocidal effect (ME) = 0-1.91] and biocide residue (mean ME = 0.29-3.74) tests. Increases in post-exposure MICs were observed in both EMRSA-16 and the susceptible S. aureus control. In our study, isolates resembling PFGE type EMRSA-16 harboured more biocide resistance genes than other types. The observed reduction in susceptibility of clinical isolates to chlorhexidine may mean that a selective pressure is being exerted by residues in the clinical environment, and highlights the importance of efficacy testing on clinical strains and good infection control practices. The development of reduced microbial susceptibility to biocides represents a serious cause for concern in the clinical environment.

The Current State of Multidrug‐Resistant Gram‐Negative Bacilli in North America

Although much of today's media focuses on multidrug-resistant gram-positive bacteria such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus, resistance within gram-negative bacilli continues to rise, occasionally creating situations in which few or no antibiotics that retain activity are available. Extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella sp are emerging threats nationally. Although carbapenems are considered the antibiotic class of choice to treat ESBL-producing Enterobacteriaceae, the ability of these organisms to produce carbapenemases has now become apparent in some regions throughout the United States. Although still rare, Klebsiella sp that produce KPC-2 retain susceptibility only to tigecycline, polymyxins, and occasionally aminoglycosides. Multidrug resistance among Pseudomonas aeruginosa and Acinetobacter sp has always been apparent across many hospitals in the United States. Recent surveillance indicates increasing resistance to all currently available antibiotics, including carbapenems, cephalosporins, penicillins, fluoroquinolones, and aminoglycosides. Against many strains, only polymyxins retain activity; however, resistance has also been reported to these agents. Fortunately, resistance mechanisms such as metallo-beta-lactamases are still rare in the United States. As no new antibiotics with novel mechanisms against many of these gram-negative bacilli are expected to be developed in the foreseeable future, careful and conservative use of agents combined with good infection control practices is required.