Infection Control Bundle Research Articles

The impact of Infection Prevention and control (IPC) bundle implementationon IPC compliance during the Ebola virus outbreak in Mbandaka/Democratic Republic of the Congo: a before and after design

ObjectivesTo assess the impact of refresher training of healthcare workers (HCWs) in infection prevention and control (IPC), ensuring consistent adequate supplies and availability of IPC kits and carrying out weekly...

Use of a cohorting-unit and systematic surveillance cultures to control a Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae outbreak.

Describe the epidemiological and molecular characteristics of an outbreak of Klebsiella pneumoniae carbapenemase (KPC)-producing organisms and the novel use of a cohorting unit for its control. Observational study. A 566-room academic teaching facility in Milwaukee, Wisconsin. Solid-organ transplant recipients. Infection control bundles were used throughout the time of observation. All KPC cases were intermittently housed in a cohorting unit with dedicated nurses and nursing aids. The rooms used in the cohorting unit had anterooms where clean supplies and linens were placed. Spread of KPC-producing organisms was determined using rectal surveillance cultures on admission and weekly thereafter among all consecutive patients admitted to the involved units. KPC-positive strains underwent pulsed-field gel electrophoresis and whole-genome sequencing. A total of 8 KPC cases (5 identified by surveillance) were identified from April 2016 to April 2017. After the index patient, 3 patients acquired KPC-producing organisms despite implementation of an infection control bundle. This prompted the use of a cohorting unit, which immediately halted transmission, and the single remaining KPC case was transferred out of the cohorting unit. However, additional KPC cases were identified within 2 months. Once the cohorting unit was reopened, no additional KPC cases occurred. The KPC-positive species identified during this outbreak included Klebsiella pneumoniae, Enterobacter cloacae complex, and Escherichia coli. blaKPC was identified on at least 2 plasmid backbones. A complex KPC outbreak involving both clonal and plasmid-mediated dissemination was controlled using weekly surveillances and a cohorting unit.

Preventing Bloodstream Infections and Death in Zambian Neonates: Impact of a Low-cost Infection Control Bundle.

Sepsis is a leading cause of neonatal mortality in low-resource settings. As facility-based births become more common, the proportion of neonatal deaths due to hospital-onset sepsis has increased. We conducted a prospective cohort study in a neonatal intensive care unit in Zambia where we implemented a multifaceted infection prevention and control (IPC) bundle consisting of IPC training, text message reminders, alcohol hand rub, enhanced environmental cleaning, and weekly bathing of babies ≥1.5 kg with 2% chlorhexidine gluconate. Hospital-associated sepsis, bloodstream infection (BSI), and mortality (>3 days after admission) outcome data were collected for 6 months prior to and 11 months after bundle implementation. Most enrolled neonates had a birth weight ≥1.5 kg (2131/2669 [79.8%]). Hospital-associated mortality was lower during the intervention than baseline period (18.0% vs 23.6%, respectively). Total mortality was lower in the intervention than prior periods. Half of enrolled neonates (50.4%) had suspected sepsis; 40.8% of cultures were positive. Most positive blood cultures yielded a pathogen (409/549 [74.5%]), predominantly Klebsiella pneumoniae (289/409 [70.1%]). The monthly rate and incidence density rate of suspected sepsis were lower in the intervention period for all birth weight categories, except babies weighing <1.0 kg. The rate of BSI with pathogen was also lower in the intervention than baseline period. A simple IPC bundle can reduce sepsis and death in neonates hospitalized in high-risk, low-resource settings. Further research is needed to validate these findings in similar settings and to identify optimal implementation strategies for improvement and sustainability. NCT02386592.

Evidence-based interventions to reduce obstetric-related infections at an army training facility

Background ObjectiveObstetric-related infections are a major cause of maternal morbidity and mortality worldwide. Our team implemented an evidence-based infection control bundle aimed at reducing obstetric-related infections at our facility. MethodsA multidisciplinary team at Tripler Army Medical Center developed, implemented, and evaluated an evidence-based maternal safety infection control bundle (MSICB) on labor and delivery aimed at reducing the incidence of surgical site infections (SSI) and chorioamnionitis. Adenosine triphosphate testing of patient care–related surfaces was performed while behavioral and environmental interventions were implemented. Incidence rates for chorioamnionitis, SSI, and endometritis were compared between pre- and during-MSICB implementation using Fisher exact test and Poisson regression, adjusting for year and quarter. The decision science analysts at US Army Medical Command, Fort Sam Houston, Texas responsible for our facility utilized diagnosis-related group and ICD-10 Procedure Coding to determine infection-related costs. ResultsPrior to implementation of the MSICB, the rates of chorioamnionitis, SSI, and endometritis in the first half of 2016 were 6.3%, 3.4%, and 0.4%, respectively. After implementation of the MSICB, in the first 6 months of 2017, the rates of chorioamnionitis and SSI decreased to 1.7% and 1.0%, respectively, with no change in the rate of endometritis. The rate was significantly lower after implementation for chorioamnionitis (P < .001), and there was a statistically nonsignificant decrease for SSI (P = .060) and no difference for postpartum endometritis (P = 1.00). These reductions resulted in an estimated net cost savings of $671,218. ConclusionsA multidisciplinary approach with evidence-based strategies resulted in a significant decrease (P < .001) in chorioamnionitis and a statistically nonsignificant decrease (P = .060) in the SSI rate, which resulted in a significant cost savings for the hospital. There was no change in our postpartum endometritis rate.

Outbreak report: a nosocomial outbreak of vancomycin resistant enterococci in a solid organ transplant unit

BackgroundVancomycin resistant enterococci (VRE) are an emerging problem in health care settings. The purpose of the investigation was to assess the extent of the outbreak including environmental contamination and to limit further transmission.MethodsWe used retrospective patient and laboratory data including pulse field gel electrophoresis (PFGE) typing and virulence and resistance gene analysis. For comparison of medians the Mann-Whitney and for comparison of proportions the Fisher exact tests were used.ResultsPFGE typing of VRE strains of an outbreak of 15 VRE cases in a solid transplant unit revealed that nine of the cases belonged to one identical pattern (A), which was only found twice in the environment. Eleven further positive environmental samples showed a different, but identical PFGE pattern E. Only one patient was infected with this environmental strain.Two of nine (22.2%) PFGE A, but nine of eleven (81.2%) PFGE E samples were positive for gelatinase E (p = 0.01), which is described as enhancing biofilm production, suggesting a survival benefit for this strain on inanimate surfaces.ConclusionRoutine disinfection was not able to stop the cluster, but after repeated enforcement of the infection prevention and control (IPC) bundle such as training, strict adherence to hand hygiene and surface disinfection no further cases were observed. We conclude that certain VRE strains predominate in the environment whereas others predominate in humans. Enforcement of the IPC bundle is essential for controlling VRE outbreaks and reducing further transmission.

Trends in late-onset sepsis in a neonatal intensive care unit following implementation of infection control bundle: A 15-year audit.

Late-onset sepsis (LOS) is a frequent and important cause of morbidity and mortality in newborn infants admitted to neonatal intensive care units (NICUs). The objective of this study is to evaluate the impact of various infection control quality measures introduced as a bundle on the trends of the LOS in a NICU. This was a prospective quality improvement study involving all neonates admitted to a NICU over a 15-year period between 2002 and 2016. The main focus areas of the bundle included collaborative team effort, hand hygiene, education, central line insertion and maintenance bundles and parenteral nutrition. The main outcome measures were LOS and central line-associated bloodstream infections. Yearly admissions increased during study period, from 776 in 2002 to 952 in 2016. There was a progressive decrease in LOS rate, from 4.3 to 1.6 per 1000 patient days (B coefficient -0.17, 95% confidence interval -0.25, -0.09; P < 0.001), and the central line-associated bloodstream infection rate dropped from 25 in 2003 to 5 in 2016 per 1000 central line days (B coefficient -1.20, 95% confidence interval -1.84, -0.56; P = 0.001). Hand hygiene compliance rates remained consistent, over 80%. During the study period, coagulase-negative staphylococcus caused 56% and Gram-negative organisms 18% of the total infections. Multifaceted infection control bundle practices with a concerted team effort in the implementation, with continuing education, feedback and reinforcement of best infection control practices, can sustain the gains achieved by infection control for a long period of time.

Diversity of the epidemiology of carbapenemase-producing Enterobacteriaceae in long-term acute care rehabilitation settings from an area of hyperendemicity, and evaluation of an intervention bundle

Long-term acute care rehabilitation facilities (LTACRFs) are affected by carbapenem-resistant Enterobacteriaceae (CRE) in endemic areas. However, the contribution of different subpopulations of patients has not been investigated in these settings. To study the epidemiology of CRE in an LTACRF, and the effect of an infection control intervention. A surveillance programme was implemented in a large Italian LTACRF. The intervention included screening for CRE carriage at admission and weekly (for negative patients), and enforcement of contact precautions plus cohorting (in wards and rehabilitation areas) for presumed and confirmed carriers. Prevalence and incidence of CRE colonization and the number of CRE bacteraemias were monitored over one year. Overall, 1084 patients underwent screening (adherence 89.8%). At admission, 11.6% of patients were colonized, and 9.9% of those negative at admission subsequently became colonized. These percentages were significantly higher among patients with severe brain injuries (SBIs) who were exposed to a higher intensity of care (44.1% vs 8.6% and 63.5% vs 6.8%, respectively). The majority of CRE bacteraemias occurred in the SBI ward. The intervention was associated with a decline in the incidence of CRE colonization in the SBI ward (from 17.7 to 7.2 acquisitions/100 at-risk patient-weeks), but not in other wards. All CRE isolates were Klebsiella pneumoniae carbapenemase-producing K.pneumoniae. A peculiar CRE epidemiology was observed in a LTACRF from Italy, with very high rates of carriage and cross-transmission in SBI patients. A simplified infection control bundle was effective at reducing the incidence of CRE colonization in the SBI ward.

Best practice perioperative strategies and surgical techniques for preventing caesarean section surgical site infections: a systematic review of reviews and meta-analyses.

Surgical site infection (SSI) following caesarean section is a problem for women and health services. Caesarean section is a high volume procedure and the estimated incidence of SSI may be as high as 9%. The objective of this study was to identify a suite of perioperative strategies and surgical techniques that reduce the risk of SSI following caesarean section. Six electronic databases were searched to systematically review literature reviews, systematic reviews and meta-analyses published from 2006 to 2016. Search terms included: endometritis, SSI, caesarean section, meta-analysis, review, systematic. Studies were sought in which competing perioperative strategies and surgical techniques relevant for caesarean section were identified and quantifiable infection outcomes were reported. General infection control strategies were excluded. Data on study characteristics and clinical effectiveness were extracted. Quality, including bias within individual studies, was examined using a modified A Measurement Tool to Assess Systematic Reviews (AMSTAR) checklist. Recommendations for SSI risk-reducing strategies were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Of 466 records retrieved, 44 studies were selected for the evidence synthesis. Recommended strategies were: administer pre-incision antibiotic prophylaxis, prepare the vagina with iodine-povidone solution and spontaneous placenta removal. We recommend clinicians implement pre-incision antibiotic prophylaxis, vaginal preparation and spontaneous placenta removal as an infection control bundle for caesarean section. Queensland University of Technology. Infection control for caesarean: pre-incision AB prophylaxis, vaginal prep, spontaneous placenta removal.

Molecular characteristics and successful management of a respiratory syncytial virus outbreak among pediatric patients with hemato-oncological disease

BackgroundRespiratory syncytial virus (RSV) is responsible for upper and lower respiratory tract infection in adults and children. Especially immunocompromised patients are at high risk for a severe course of infection, and mortality is increased. Moreover RSV can spread in healthcare settings and can cause outbreaks. Herein we demonstrate the successful control and characteristics of a RSV outbreak that included 8 patients in our Department of Pediatric Hematology and Oncology.MethodsWe performed an epidemiologic investigation and a molecular analysis of the outbreak strains. Moreover we present the outbreak control bundle and our concept for RSV screening in the winter season.ResultsRSV A and B strains caused the outbreak. RSV B strains affected 3 patients, 2 of whom were co-infected with RSV A. Exactly this RSV A strain was detected in another 5 patients. Our multimodal infection control bundle including prophylactic RSV screening was able to rapidly stop the outbreak.ConclusionAn infection control bundle in RSV outbreaks should address all potential transmission pathways. In pediatric settings the restriction of social activities might have a temporal negative impact on quality of life but helps to limit transmission opportunities. Molecular analysis allows better understanding of RSV outbreaks and, if done in a timely manner, might be helpful for guidance of infection control measures.

Infection control interventions affected by resource shortages: impact on the incidence of bacteremias caused by carbapenem-resistant pathogens.

We evaluated an infection control (IC) program influenced by personnel and material resource shortages on the incidence of bloodstream infections (BSI) due to carbapenem-resistant Klebsiella pneumoniae (CRKP), Acinetobacter baumannii (CRAB), and Pseudomonas aeruginosa (CRPA) in an endemic region. Between January 2010 and December 2015, all BSI episodes caused by CRKP, CRAB, and CRPA were recorded. An IC bundle was implemented in January 2012. We evaluated the effect of the interventions on BSI rates between the pre-intervention (2010-2011) and intervention (2012-2013) periods, using an interrupted time-series model. From 2014, when interventions were still applied, BSI incidence was gradually increased. For this reason, we evaluated with a linear mixed effects model several factors possibly contributing to this increase for the years 2012-2015, which was considered as the intervention/follow-up period. During the study period, 351 patients with BSI were recorded, with a total of 538 episodes; the majority (83.6%) occurred in the intensive care unit (ICU). The BSI incidence rate per year during 2010-2015 for ICU patients was 21.03/19.63/17.32/14.45/22.85/25.02 per 1000 patient-days, respectively, with the reduction in BSI levels after the start of intervention marginal (p=0.054). During the follow-up period (2014-2015), the most influential factors for the increased BSI incidence were the reduced participation in educational courses and compliance with hand hygiene. The implementation of IC interventions reduced the BSI incidence rates, particularly for ICU patients. However, factors possibly related to the restrictions of human and material resources apparently contributed to the observed expansion of BSI in our endemic setting.

A Multidisciplinary Infection Control Bundle to Reduce the Number of Spinal Cord Stimulator Infections

To investigate the effect of a quality improvement project that resulted in an infection control bundle to reduce the number of spinal cord stimulator (SCS) infections. The study was performed in a single center for neuromodulation from January 1, 2014, through May31, 2016. In response to a high number of surgical site infections (SSIs) after SCS surgery, a multidisciplinary team analyzed the surgical process and developed an infection prevention bundle consisting of five items: 1) showering and decolonization for five days prior to surgery and showering in the hospital on the morning of surgery; 2) performing the SCS implantation as the first in the daily operating room (OR) program; 3) maintaining a minimal number of people in the OR; 4) providing home care nurses with a folder with SCS wound care instructions including pictures; 5) giving oral specific wound care instructions to patients. The number of infections was calculated for the baseline, implementation, and sustainability phases. A total of 410 SCS surgeries were performed during the study period. In the preintervention phase, 26/249 (10.4%) SCS surgeries were infected. During the implementation and sustainability phase, 2/59 (3.4%) and 1/102 (1.0%) SCS surgeries were infected, respectively. The reduction in the number of infections in pre and postintervention phase was statistically significant (p = 0.003). Multidisciplinary measures to reduce SSIs reduced the number of SCS associated infections in our study setting.

Outbreak of Klebsiella pneumoniae Carbapenemase-Producing Citrobacter freundii at a Tertiary Acute Care Facility in Miami, Florida.

OBJECTIVE To describe the investigation and control of a rare cluster of Klebsiella pneumoniae carbapenemase-producing Citrobacter freundii in a hospital in southern Florida. METHODS An epidemiologic investigation, review of infection prevention procedures, and molecular studies including whole genome sequencing were conducted. RESULTS An outbreak of K. pneumoniae carbapenemase-3-producing C. freundii was identified at a tertiary hospital in Florida in 2014. Of the 6 cases identified, 3 occurred in the same intensive care unit and were caused by the same clone. For 2 of the 3 remaining cases, the isolates had low carbapenem minimum inhibitory concentrations and were unrelated by whole genome sequencing. As a response to the outbreak, supplementary environmental cleaning was implemented, including closure and terminal cleaning of the unit where the 3 cases clustered, in addition to the infection control bundle already in place at the time. No further cases were identified after these additional interventions. CONCLUSIONS Although C. freundii is not a species that commonly demonstrates carbapenem resistance, our findings suggest that carbapenemase-producing C. freundii may be underdetected even when active surveillance is in place and has a potential to cause hospital outbreak. Infect Control Hosp Epidemiol 2017;38:320-326.

Influence of a total joint infection control bundle on surgical site infection rates

Quality improvement initiatives combined with pulsed xenon ultraviolet room disinfection were implemented to reduce surgical site infections (SSIs) in patients undergoing total joint procedures. After 12months, knee SSIs were reduced from 4 to 0 (P=.03) and hip SSIs were reduced from 3 to 0 (P=.15) for a combined prevention of 7 SSIs (P=.01) and a savings of $290,990.

Reducing ventilator-associated pneumonia in neonatal intensive care unit using "VAP prevention Bundle": a cohort study.

BackgroundVentilator-associated pneumonia (VAP) is a serious health care- associated infection, resulting in high morbidity and mortality. It also prolongs hospital stay and drives up hospital costs. Measures employed in preventing ventilator- associated pneumonia in developing countries are rarely reported. In this study we tried to assess the efficacy of our designed “VAP prevention bundle” in reducing VAP rate in our neonatal intensive care unit (NICU).MethodThis prospective before-and-after study was conducted at university hospital NICU, all neonates who had mechanical ventilation for ≥ 48 h were eligible. VAP rates were evaluated before (phase-I) and after (phase-II) full implementation of comprehensive preventive measures specifically designed by our infection control team.ResultsOf 143 mechanically ventilated neonates, 73 patients developed VAP (51 %) throughout the study period (2500 mechanical ventilation days). The rate of VAP was significantly reduced from 67.8 % (42/62) corresponding to 36.4 VAP episodes/1000 mechanical ventilation days (MV days) in phase-I to 38.2 % (31/81) corresponding to 23 VAP/1000 MV days (RR 0.565, 95 % confidence interval 0.408-0.782, p = 0.0006) after VAP prevention bundle implementation (phase-II). Parallel significant reduction in MV days/case were documented in post-intervention period (21.50 ± 7.6 days in phase-I versus 10.36 ± 5.2 days in phase-II, p = 0.000). There were a trend toward reduction in NICU length of stay (23.9 ± 10.3 versus 22.8 ± 9.6 days, p = 0.56) and overall mortality (25 % versus 17.3 %, p = 0.215) between the two phases but didn’t reach statistical significance. The commonest micro-organisms isolated throughout the study were gram-negative bacteria (63/66, 95.5 %) particularly Klebsilla pneumonia (55/66, 83.4 %).ConclusionImplementation of multifaceted infection control bundle resulted in reduction of VAP rate, length of stay in our NICU.

Effects of infection control bundle to prevent nosocomial infection in the ICU

Multidrug-resistant organism (MDRO) infections in critically ill patients are often life-threatening. To prevent nosocomial infections of MDRO, we made an infection control bundle in our ICU in 2013. In this study we evaluated the effect of our infection control bundle to prevent nosocomial MDRO transmission and infection.

Infection control intervention on meticillin resistant Staphylococcus aureus transmission in residential care homes for the elderly.

The objectives were to evaluate the effectiveness of an infection control bundle in controlling the meticillin resistant Staphylococcus aureus (MRSA) transmission in residential care homes for the elderly (RCHEs) in Hong Kong. This was a two-arm cluster randomised controlled trial. Infection control bundles focused on hand hygiene (HH), environmental hygiene, and modified contact precautions were applied to the intervention arm. Nasal swabs from residents; staff HH compliance and effectiveness; and environmental hygiene were assessed by microbiological sampling or observation at the baseline and quarterly after the intervention. A total of 2776 residents from 36 RCHEs were recruited. The overall MRSA prevalence was 20.4% (95% confidence interval, 18.9%-21.9%). The intervention elicited an immediate effect of 2.4% absolute decrease in the prevalence and 3.7% in the intra-facility transmission, though the difference between the two arms was insignificant. Staff HH compliance increased substantially from 5.9% to 45.6% post-intervention (p < 0.001). We initiated the infection control culture into the RCHEs and gained their acceptance. However, this behavioural change takes time to emerge. Our study shows that relying on the bundle alone could not bring sustainable MRSA reduction. Administrative control for strengthening infection control infrastructure is important for continuous compliance and improvement.

Action Plan to combat infections due to carbapenem-resistant, Gram-negative pathogens in acute-care hospitals in Greece.

The prevalence of carbapenem-resistant pathogens (CRPs) has increased worldwide. Given the importance of CRPs for public health and the high rates of carbapenem resistance observed in Greece, the Hellenic Center for Disease Control and Prevention (HCDCP) under the auspices of the Ministry of Health has undertaken initiatives to develop an Action Plan (i) to estimate the burden of CRP infections in acute-care hospitals in Greece and (ii) to implement infection control measures to limit the intrahospital transmission of these organisms. Starting in November 2010, specific infections caused by CRPs were reported to the HCDCP weekly. Results showed that CRP infections constitute a significant public health problem in acute-care hospitals in this country, with a mean incidence of 0.48 per 1000 patient-days and a crude 28-day mortality rate of 34.4%. The second phase of the Action Plan consists of systemic evaluation for adherence to an infection control bundle including enhanced standard infection control practices, separation of carriers and infected patients from non-carriers, and strict implementation of contact precautions. Communication between hospitals and public health authorities has been established to facilitate rapid notification and feedback.

Reducing the spread of Acinetobacter baumannii and methicillin-resistant Staphylococcus aureus on a burns unit through the intervention of an infection control bundle

Methicillin-resistant Staphylococcus aureus (MRSA) and Acinetobacter baumannii are major nosocomial pathogens in burns units. We investigated the impact of an infection control bundle on the incidence of nosocomial MRSA and A. baumannii in our burns unit, comparing a pre-intervention period (December 2006–August 2008) with an intervention period (September 2008–December 2009). The bundle comprised regular hydrogen peroxide vapour (HPV) disinfection of the rooms following discharge of patients colonized or infected by multidrug-resistant bacteria, pre-emptive cohort isolation of newly admitted patients before being proven culture negative, cohorting of colonized or infected patients, installation of two air disinfection systems in the corridors of the unit and improvement of material storage. We also investigated the microbiological efficacy of HPV disinfection by sampling the environment before and after HPV treatments. HPV disinfection eliminated pathogens from the environment and significantly reduced total bacterial surface counts, and total fungal air and surface counts, on both a unit and room scale. The incidence of nosocomial MRSA infection or colonization fell by 89.3% from 7.22 to 0.77 cases/1000 patient days (p<0.0001) and A. baumannii fell by 88.8% from 6.92 to 0.77 cases/1000 patient days (p=0.002) in the intervention period with no further outbreaks of these organisms occurring in this period. The infection control bundle resulted in a significant reduction in the incidence of nosocomial MRSA and A. baumannii in our burns unit and prevented further outbreaks of these organisms.

Implementation of an Infection Control Bundle in a School to Reduce Transmission of Influenza-Like Illness during the Novel Influenza A 2009 H1N1 Pandemic

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Prevention of nosocomial transmission of swine-origin pandemic influenza virus A/H1N1 by infection control bundle

After the outbreak of severe acute respiratory syndrome in Hong Kong, the importance of preventing nosocomial transmission of respiratory viruses has become a top priority in infection control. During the containment and early mitigation phases of the swine-origin influenza virus (S-OIV) A H1N1 pandemic, an infection control bundle consisting of multiple coherent measures was organised by our infection control team to minimise nosocomial transmission. This included repeated open staff forum achieving high attendance; early recognition of index cases among inpatients by liberal testing; early relief of sick staff from work; directly observed hand hygiene practice during outbreaks; and monitoring of compliance with infection control practice. During the first 100 days (from 1 May to 8 August 2009) when the first 100 laboratory-confirmed patients with S-OIV and 12 infected healthcare workers (HCWs) were identified, a total of 836 asymptomatic exposed persons (184 patients and 652 HCWs) were required to undergo a seven-day medical surveillance. The infection control nurses monitored them for the onset of symptoms. Four (0.48%) exposed persons (one house officer, two non-clinical staff, and one patient) were virologically confirmed with S-OIV. Not wearing a surgical mask either by the exposed persons during contact with the index cases (4/4 vs 264/832, P = 0.010) or vice versa (4/4 vs 300/832, P = 0.017, Fisher's exact test) were found to be significant risk factors for nosocomial acquisition of S-OIV.