Poor Infection Control Practices Research Articles

Middle East respiratory syndrome coronavirus (MERS-CoV): what lessons can we learn?

SummaryThe Middle East Respiratory Coronavirus (MERS-CoV) was first isolated from a patient who died with severe pneumonia in June 2012. As of 19 June 2015, a total of 1,338 MERS-CoV infections have been notified to the World Health Organization (WHO). Clinical illness associated with MERS-CoV ranges from mild upper respiratory symptoms to rapidly progressive pneumonia and multi-organ failure. A significant proportion of patients present with non-respiratory symptoms such as headache, myalgia, vomiting and diarrhoea. A few potential therapeutic agents have been identified but none have been conclusively shown to be clinically effective. Human to human transmission is well documented, but the epidemic potential of MERS-CoV remains limited at present. Healthcare-associated clusters of MERS-CoV have been responsible for the majority of reported cases. The largest outbreaks have been driven by delayed diagnosis, overcrowding and poor infection control practices. However, chains of MERS-CoV transmission can be readily interrupted with implementation of appropriate control measures. As with any emerging infectious disease, guidelines for MERS-CoV case identification and surveillance evolved as new data became available. Sound clinical judgment is required to identify unusual presentations and trigger appropriate control precautions.Evidence from multiple sources implicates dromedary camels as natural hosts of MERS-CoV. Camel to human transmission has been demonstrated, but the exact mechanism of infection remains uncertain. The ubiquitously available social media have facilitated communication and networking amongst healthcare professionals and eventually proved to be important channels for presenting the public with factual material, timely updates and relevant advice.

Emergence of isolates that are intrinsically resistant to colistin in critically ill patients: are we selecting them out?

Poor infection control practices along with irrational usage of antibiotics lead to emergence of multidrug-resistant (MDR) organisms. Increasing use of colistin for treating MDR infections leads to selection of organisms that are intrinsically resistant to colistin. There are limited Indian literatures which evaluated the incidence of intrinsically resistant isolates to colistin in critically ill patients. Our study aimed to investigate the incidence of true pathogen or colonizer with the prior antibiotic exposure and patient's clinical outcome.

Attitudes, knowledge and practices of healthcare workers regarding occupational exposure of pulmonary tuberculosis.

BackgroundHealthcare-associated tuberculosis (TB) has become a major occupational hazard for healthcare workers (HCWs). HCWs are inevitably exposed to TB, due to frequent interaction with patients with undiagnosed and potentially contagious TB. Whenever there is a possibility of exposure, implementation of infection prevention and control (IPC) practices is critical.ObjectiveFollowing a high incidence of TB among HCWs at Maluti Adventist Hospital in Lesotho, a study was carried out to assess the knowledge, attitudes and practices of HCWs regarding healthcare-associated TB infection and infection controls.MethodsThis was a cross-sectional study performed in June 2011; it involved HCWs at Maluti Adventist Hospital who were involved with patients and/or sputum. Stratified sampling of 140 HCWs was performed, of whom, 129 (92.0%) took part. A self-administered, semi-structured questionnaire was used.ResultsMost respondents (89.2%) had appropriate knowledge of transmission, diagnosis and prevention of TB; however, only 22.0% of the respondents knew the appropriate method of sputum collection. All of the respondents (100.0%) were motivated and willing to implement IPC measures. A significant proportion of participants (36.4%) reported poor infection control practices, with the majority of inappropriate practices being the administrative infection controls (> 80.0%). Only 38.8% of the participants reported to be using the appropriate N-95 respirator.ConclusionPoor infection control practices regarding occupational TB exposure were demonstrated, the worst being the first-line administrative infection controls. Critical knowledge gaps were identified; however, there was encouraging willingness by HCWs to adapt to recommended infection control measures. Healthcare workers are inevitably exposed to TB, due to frequent interaction with patients with undiagnosed and potentially contagious TB. Implementation of infection prevention and control practices is critical whenever there is a possibility of exposure.

Nosocomial transmission of group B streptococci proven by positive environmental culture.

Neonates usually acquire Group B streptococcal infection vertically from the maternal birth canal during delivery. In January 2010, a Group B streptococcal outbreak investigation was conducted in response to an increased number of clinical specimens from our neonatal intensive care unit. Microbiology laboratory records were reviewed to identify Group B streptococcal from specimens originating from the neonatal intensive care unit during December 2009 and January 2010. Patients from whom these specimens were collected were identified and their charts reviewed. Environmental samples to screen for Group B streptococcal were collected from the unit, clinical and environmental isolates were compared by pulsed field gel electrophoresis. Point prevalence screening was conducted twice before declaring the outbreak over. Pulsed field gel electrophoresis patterns of three clinical strains from six patients were indistinguishable. One environmental strain was isolated from one of the patients monitor, and had identical pulsed field gel electrophoresis pattern to that of the three clinical strains. Infection control measures were implemented in the neonatal intensive care unit and follow-up point prevalence screening identified no new cases. Although poor infection control practice has been implicated in previous reports of nosocomial outbreaks of Group B streptococcal infection in neonatal intensive care units, our finding provides unique evidence that the environment can act as a reservoir of Group B streptococcal and play a key role in nosocomial transmission.

Physical space and its impact on waste management in the neonatal care setting.

This paper reports an investigation intended to obtain some understanding of how the working environment might influence the practice and knowledge of those involved in the management of healthcare waste. The National Health Service (NHS) has a continuing waste problem, and the way it manages waste harms the environment and consumes resources. It has been estimated that the carbon footprint of the NHS in England is approximately 20 million tons of CO2e. It has been suggested that better waste segregation could lead to more effective recycling, saving up to 42,000 tonnes of CO2. This qualitative study employed non-participant observation and semi-structured interviews. The interviews were carried out with the key informants within the participating neonatal intensive care unit. Findings from this study indicate that space and the physical arrangement of the environment are significant and influential factors in clinical practice. Where the clinical environment is not supportive, poor infection control and waste management practice is likely to occur. However, proximity of staff caused by a lack of physical space might facilitate situated learning and a collective development of knowledge in practice. The implementation of sustainable waste management practices would be more likely to succeed in an environment that facilitates correct waste segregation.

Antimicrobial Resistance in Microorganisms

Implication for health policy/practice/research/medical education: This research used in the microbiological sciences. Copyright © 2014, Hamadan University of Medical Sciences; Published by Safnek. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The World Health Organization has warned that presently there is a real threat posed by antimicrobial resistant (AMR) organisms. Antimicrobial resistance is resistance of a microorganism to an antimicrobial medicine to which it was originally sensitive (1). Antibiotic resistance has been detected in microbes that cause common and serious diseases, such as urinary tract infections and pneumonia in all regions of the world. This means that when we are most vulnerable and in need of these drugs, there is a chance that they may not work as currently antimicrobial resistance threatens the effective avoidance and treatment of an ever-increasing range of infections caused by bacteria, parasites, viruses and fungi. Resistant organisms are able to withstand attacks by antimicrobial medicines, such as antibiotics, so that standard treatments become ineffective and infections persist, increasing risk of spread to others. The evolution of resistant strains is a natural phenomenon that occurs when microorganisms are exposed to antimicrobial drugs, and resistant traits can be exchanged between certain types of bacteria (2). The misuse and overuse of antimicrobial medicines accelerates this natural phenomenon. Poor infection control practices encourage the spread of AMR. In general, bacterial resistance to antimicrobial agents is classified into multidrug-resistant (MDR), extensively drug-resistant (XDR) and pandrug-resistant (PDR); MDR has been defined as acquired non-susceptibility to at least one agent in three or more antimicrobial categories, XDR means bacterial isolates remain susceptible to only one or two categories and PDR has been defined as non-susceptibility to all agents in all antimicrobial categories (3). When bacteria become resistant to an antibiotic, that medicine becomes less effective. Medical treatment of patients infected with these drug-resistant organisms can become more complicated, leading to longer hospital stays, increased health care costs and in extreme cases, untreatable infections. Without effective antimicrobials for care and prevention of infections, the success of treatments such as organ transplantation, cancer chemotherapy and major surgery would be compromised. Generally speaking, the growth of global trade and travel allows resistant microorganisms to spread rapidly to distant countries and continents through humans and food (4).

A prospective evaluation of interventions to reduce the MDRO rate in ICU

Background: Carbapenem resistance among the Gram negative rods is on the increase. Poor infection control practices are a major cause of these bugs becoming “endemic” in various ICUs. Hypothesis: Providing the nurses with target based incentives is an effective method for implementation of infection control principles. Methods & Materials: All admissions to the MDICU during the 18 months (January 1st 2012 to June 30th 2013) were included. Only Carbapenem Resistant Isolates among Gram Negative Bacilli were included in the surveillance. MDRO rates were calculated every month as Number of Carbapenem Resistant Isolates among Gram Negative bugs per 100 ICU admissions. Average Length of Stay in the ICU was calculated. Hand Hygiene compliance rates were calculated using the WHO Five Moments format every month. Interventions were introduced in sequential manner (every 6 months). The first intervention bundle comprised of cohorting of patients, enhanced training, evaluation of cleaning with ATP based monitoring and feedback, and a Restrictive policy on Carbapenem use. (only for hemodynamically unstable/immuno-compromised patients or based on culture results). After 6 months the incentives for target achievement were introduced.The nurses were provided with a target–to reduce Carbapenem Resistant isolates by 25% of the baseline (preceding 6 months average) within 3 months–and an incentive on achieving this target–cash awards & Letter of Appreciation from the Hospital Management followed by 15% increase over the regular yearly increment in pay if the rates stayed low (sustained effect) over next one year. Results: The MDRO rate came down from 15.5% in January 2012 (baseline) to 6% in June 2013 (end of 18 months)The hand hygiene compliance rates increased from 49% to 77% during the study period.The Average Length of Stay in the MDICU decreased from 5.7 days to 4.7 days during the study period.There was no significant change in the bed occupancy rate (97% to 95%)There was no significant change in Meropenem consumption during the study period. Conclusion: The preliminary results do suggest that incentives for achieving reasonable targets would be very effective in improving compliance to infection control practices as evidenced by the fall in MDRO rates.

Outcome of carbapenem resistant Klebsiella pneumoniae infection in tertiary care centre in India

Background: CRE rates in India are between 15% to 60% in various studies. Poor infection control practices have ensured that the incidence of these organisms is on the rise. We hope to highlight the impact of these infections in terms of mortality and length of stay in hospital. Methods & Materials: Consecutive patients admitted during 24 months (1st January 2011 to 31st December 2012) with CR Klebsiella isolates from any site where included. The patient was evaluated clinically and with APACHE-II scores done at a time nearest to the sampling and also followed up for modification of antibiotic therapy based on culture reports, and finally the outcome (death or discharge as cured from the hospital). Assuming a mortality of 40% for serious CR-Klebsiella infections (BSI) from published data, sample strength of 58 was calculated for adequately powering the study at 95% CI & 5% error. Fischer’s Exact Test was used for analysing the statistical significance of outcome differences between Colistin based therapy and non-Colistin based therapy. Absolute mortality and Severity Adjusted Mortality (SAM=observedmortality/expectedmortality as per APACHE-II scores X 100) were calculated. Results: A) Out of 87 isolates 59 were proven infections. Most common site of infection was urinary, followed by blood stream infection, pneumonia and skin & soft tissue. B) The mean age of cases was 53.6 years. 64% were males and 36% were females C) The absolute mortality in infections was–25% for UTI, 46% for Pneumonia, 33.3% for BSI and 9.1% for SSTI. The Severity Adjusted Mortality was 100 for UTI, 60.6 for SSTI, 184.4 for pneumonia and 222.2 for BSI. D) The ALOS was 20.2 days, 42% had more than 7 days of hospitalization before isolating the CRKlebsiella. Conclusion: Carbapenem resistant Klebsiella infections are associated with high mortality (SAM>100 especially for pneumonia and blood stream infections). The study was possible not powered to make a comparison between various antibiotic regimens. CR Klebsiella infections are associated with significantly prolonged length of stay–both before isolation and after infection.

Ebola Outbreak in Africa: Current Issues - A Mini Review

Ebola hemorrhagic Disease (EHD) is a severe, often-fatal disease in humans that was first identified in 1976 in Democratic Republic of the Congo (formerly Zaire) in Africa. Ebola hemorrhagic disease (EHD) is one of the most feared diseases known to mankind. This is because of the high mortality rate (up to 90%) associated with the disease, and also its propensity for person-to-person spread through close contact with infected tissues and body fluids of affected persons, particularly in the unprotected home-care setting and during preparation of bodies for burial, while spread is amplified in hospitals with poor infection control practices. Several western parts of the African continent are currently experiencing an unprecedented outbreak that has proved particularly challenging to contain. A hemorrhagic fever outbreak requires a comprehensive and intensive public health response that would put even an ideal healthcare system to the test. Substantial external support is always required during these events to ensure appropriate clinical management of patients, sufficient infection control procedures in difficult healthcare environments, intensive contact tracing to identify the chains of transmission of the virus. Clinical management of cases involves employing strict isolation procedures and providing symptomatic and supportive treatment as required.

Multidrug resistance: an emerging crisis.

The resistance among various microbial species (infectious agents) to different antimicrobial drugs has emerged as a cause of public health threat all over the world at a terrifying rate. Due to the pacing advent of new resistance mechanisms and decrease in efficiency of treating common infectious diseases, it results in failure of microbial response to standard treatment, leading to prolonged illness, higher expenditures for health care, and an immense risk of death. Almost all the capable infecting agents (e.g., bacteria, fungi, virus, and parasite) have employed high levels of multidrug resistance (MDR) with enhanced morbidity and mortality; thus, they are referred to as “super bugs.” Although the development of MDR is a natural phenomenon, the inappropriate use of antimicrobial drugs, inadequate sanitary conditions, inappropriate food-handling, and poor infection prevention and control practices contribute to emergence of and encourage the further spread of MDR. Considering the significance of MDR, this paper, emphasizes the problems associated with MDR and the need to understand its significance and mechanisms to combat microbial infections.

What are the costs and benefits of patient notification exercises following poor infection control practices in dentistry?

BackgroundAllegations of serious failures in infection control practice were made against a dentist practicing in the South West of England. The dentist (who tested negative for Blood Borne Viruses (BBVs)) was immediately suspended. MethodsBecause inadequate infection control presents a potential risk of transmitting BBVs between patients, a notification exercise was undertaken. Of 7625 patients contacted, 2780 (37%) were tested. ResultsNine cases of Hepatitis B (HBV) and four cases of Hepatitis C (HCV) were identified, of which seven were previously diagnosed. None of these were children. All of the six newly diagnosed cases had recognized risk factors for BBVs. The costs of the notification exercise were estimated at £311,500 of which £165,000 was staff costs, (£51,916 per newly diagnosed case). ConclusionThis study did not demonstrate any patient-to-patient transmission of blood-borne viruses but the response rate was relatively low. There are significant costs associated with undertaking notification exercises. These findings should inform future recommendations and practice in this area.

P263: Infection control-uphill task in India

In an environment of limited resources and where medical practice is biased towards intervention rather than prevention, it is not surprising that basic infection control (IC) programmes are often lacking in India. Multiple factors like lack or shortage of basic requirement (e.g gloves, hand washing facility) negligible administrative support, financial constraints, overcrowding, understaffing, low levels of staff preparedness and knowledge of key factors contribute to poor IC practices. There is wide gap between knowing and doing.

Remembering the importance of preventing blood‐borne infections in the critical care setting

Remembering the importance of preventing blood‐borne infections in the critical care setting

An outbreak of neonatal Candidemia due to non-albicans Candida species in a resource constrained setting of Uttarakhand State, India

This case report describes the outbreak of candidemia caused by non-albicans Candida (NAC) species, which within a short period of 11 days, affected six neonates housed in the same room of neonatal intensive care unit of a rural tertiary care center in Uttarakhand state, India. The NAC species isolated showed complete resistance to azole compounds tested. All the neonates were having central venous catheters at the time of diagnosis, received total parenteral nutrition and were on broad spectrum antibiotics. Though two neonates survived the infection, but four of them had an unfortunate outcome and they died despite of aggressive therapy with amphotericin B. It was concluded that candidemia was associated with previously described risk factors and that poor infection control practices were likely responsible for outbreak.

Molecular Characterization of Citrobacter freundii Isolated from Neonates in Neonatal Intensive Care Unit of Nepal

Introduction: Nosocomial Citrobacter spp. is emerging as a successful nosocomial pathogen in neonates in Nepal. The important risk factor being poor infection prevention and control practices. The objective of this study was to investigate the clonal relatedness of Citrobacter freundii isolated from clinical and nonclinical sources in Neonatal Intensive Care Unit (NICU) and to determine the presence of Extended Spectrum Beta-Lactamase (ESBL) genes and class 1 integron element. Materials and Methods: Polymerase chain Reaction (PCR) and PCR-Randomly Amplified Polymorphic DNA typing of the isolates were performed in three isolates to amplify class 1 integron element integrase gene, ESBL genes, and to study the clonal relatedness, respectively. Results: Two isolates harbored class 1 integron element. The blaCTX-M was present in all isolates and blaTEM-1 was present in one isolate. An isolate carried blaCTX-M and blaTEM-1 genes. All of these isolates were not clonally related. Conclusion: The study for the first time documented the emergence and spread of ESBL genes and class 1 integron element in multidrug resistant C. freundii in Nepal and urge for monitoring and surveillance of these strains. J. Nepal Paediatr. Soc. 32(2) 2012 132-135 doi: http://dx.doi.org/10.3126/jnps.v32i2.5804

A narrative review of infections associated with personal service establishments Part I: Aesthetics

Personal service establishments (PSEs) offer a range of services to their clientele, including manicures, pedicures, facials, waxing, and hairstyling and (or) barbering services. Several key gaps exist with respect to regulations, guidelines, and best practices for PSEs. One major gap is the lack of information on infection risks associated with PSEs. To address this, we conducted a review of the scientific literature to investigate the relationship between bacterial, viral, and fungal infections and specific PSE services. Using the Ebsco database, we identified case-control studies, cross-sectional surveys, case reports, and review studies investigating this relationship. Bacterial infections, particularly, mycobacterium infections are commonly reported, while viral risks are less well characterized. No information was found on fungal infection risks. Very limited evidence is available for some services, including manicures, hair styling, and barbering. Studies related to pedicures, although few, do establish a clear link between mycobacterium infections of the lower legs and the use of re-circulating footbaths. Waxing has been implicated in bacterial infection outbreaks due to poor infection control practices. The majority of studies identified are case reports, which provide limited information on the specifics of the services, and do not allow for an assessment of the PSE-related burden of illness. Some studies, however, do point to specific risk factors, routes of transmission, and research needs that can help to better inform PSE-related policy and practice.

Infection control in delivery care units, Gujarat state, India: a needs assessment.

BackgroundIncreasingly, women in India attend health facilities for childbirth, partly due to incentives paid under government programs. Increased use of health facilities can alleviate the risks of infections contracted in unhygienic home deliveries, but poor infection control practices in labour and delivery units also cause puerperal sepsis and other infections of childbirth. A needs assessment was conducted to provide information on procedures and practices related to infection control in labour and delivery units in Gujarat state, India.MethodsTwenty health care facilities, including private and public primary health centres and referral hospitals, were sampled from two districts in Gujarat state, India. Three pre-tested tools for interviewing and for observation were used. Data collection was based on existing infection control guidelines for clean practices, clean equipment, clean environment and availability of diagnostics and treatment. The study was carried out from April to May 2009.ResultsSeventy percent of respondents said that standard infection control procedures were followed, but a written procedure was only available in 5% of facilities. Alcohol rubs were not used for hand cleaning and surgical gloves were reused in over 70% of facilities, especially for vaginal examinations in the labour room. Most types of equipment and supplies were available but a third of facilities did not have wash basins with "hands-free" taps. Only 15% of facilities reported that wiping of surfaces was done immediately after each delivery in labour rooms. Blood culture services were available in 25% of facilities and antibiotics are widely given to women after normal delivery. A few facilities had data on infections and reported rates of 3% to 5%.ConclusionsThis study of current infection control procedures and practices during labour and delivery in health facilities in Gujarat revealed a need for improved information systems, protocols and procedures, and for training and research. Simply incentivizing the behaviour of women to use health facilities for childbirth via government schemes may not guarantee safe delivery.

Transmission of Hepatitis C Virus During Myocardial Perfusion Imaging in an Outpatient Clinic

Reports of health care--associated viral hepatitis transmission have been increasing in the United States. Transmission due to poor infection control practices during myocardial perfusion imaging (MPI) has not previously been reported. The aim of this study was to identify the source of incident hepatitis C virus (HCV) infection in a patient without identified risk factors who had undergone MPI 6 weeks before diagnosis. Practices at the cardiology clinic and nuclear pharmacy were evaluated, and HCV testing was performed in patients with shared potential exposures. Clinical and epidemiologic information was obtained for patients with HCV infection, and molecular testing was performed to assess viral relatedness. Evidence of HCV transmission among patients who had undergone MPI at the cardiology clinic on 2 separate dates was found, involving 2 potential source patients and a total of 5 newly infected patients. Molecular testing identified a high degree of genetic homology among viruses from patients with common procedure dates. The nuclear medicine technologist routinely drew up flush from multidose vials of saline solution using the same needle and syringe that had been used to administer radiopharmaceutical doses. Multipatient use of vials was not observed, but a review of purchasing invoices and interviews with staff members suggested that this had occurred. No evidence of transmission via contamination of radiopharmaceuticals at the nuclear pharmacy was found. In conclusion, transmission of HCV occurred because of unsafe injection practices during MPI. Cardiologists should carefully review their infection control practices and the practices of other staff members involved with these procedures.

The continuing crisis in antibiotic resistance

The emergence of antibiotic resistance in bacterial pathogens is an inevitable consequence of antibiotic use. Despite repeated warnings, negligent antibiotic use and poor infection-control practice have led to the continuing development of extensive resistance problems worldwide. Multidrug-resistant pathogens are now characterized by their heterogeneity, increasing virulence, resistance even to reserve agents and spread within and between hospitals and the community. Examples are glycopeptide-resistant meticillin-resistant Staphylococcus aureus (MRSA) and enterococci, extended-spectrum β-lactamase- and carbapenemase-producing coliforms, and toxin-hyperproducing Clostridium difficile. Effective national and international programmes of control to combat these problems are urgently needed. The potential for success of such coordinated efforts has been demonstrated by the recent dramatic reductions in MRSA and C. difficile infections in England.

“Somebody else’s problem?” Staff perceptions of the sources and control of meticillin-resistant Staphylococcus aureus

Meticillin-resistant Staphylococcus aureus (MRSA) is endemic within the United Kingdom health care sector. Recent campaigns to reduce health care-associated infection have rested on increasing staff accountability and ownership of the problem and its solutions. However, the existence of reservoirs of colonization in the community now creates ambiguity about sources, which may undermine preventative strategies. The theoretical framework of causal attribution was applied to explore staff biases in perceptions and effects on infection control behaviors on both sides of the hospital/care home interface. Forty-four staff from 1 acute care hospital and 53 staff from 6 care homes estimated prevalence, risk, and sources of MRSA. Focus groups (6 care home and 8 hospital) were used to elicit group perceptions. Staff tended to attribute the causes of MRSA to external (not self) human factors including patient risk factors and poor infection control practices of others. Teams tend to attribute their "successes" in infection control to dispositional attributions (good team policy and performance) and attribute "lapses" to situational factors (client group, patient movement, work pressures). Variations in information needs, ownership, and infection control practices could be addressed by better interorganizational working and support for staff teams to assess their own responses to the problem.