Use Of Barrier Precautions Research Articles

Evaluation of the incidence of central venous catheter-associated infections in patients admitted in the intensive care unit of a tertiary hospital in Nigeria

Background: Presence of a central venous catheter (CVC) though useful may lead to CVC-associated bloodstream infections (CVCBSIs), resulting in increased morbidity and mortality. Objectives: The objectives of the study were to determine the incidence of CVCBSIs, the predominant causative microorganisms, the antibiotic sensitivity pattern of the microorganisms, and the associated risk factors. Materials and Methods: This prospective observational study evaluated the incidence of CVCBSIs in patients who had the catheter inserted on admission into the intensive care unit (ICU) of a tertiary hospital in South-East, Nigeria. Sixty-eight patients were recruited for the study. Blood samples were collected aseptically from a peripheral vein on admission, 72 h after the insertion of CVC, and at removal of CVC for blood culture. The distal 5 cm of the CVC was also collected at removal for microscopy, culture, and sensitivity testing. Results: Six out of all the patients recruited developed CVCBSIs, giving an incidence rate of 9.2%, whereas 48% (n = 31) developed catheter bacterial colonization. Over one-fifth (22.7%) of the patients with catheter duration beyond 5 days had CVCBSIs. Patients whose CVC duration was beyond 5 days had a higher risk of CVCBSIs (P = 0.015) than others. The commonest microorganism isolated was Staphylococcus aureus, whereas the most susceptible antibiotic was aminoglycoside (gentamycin). Conclusion: The incidences of CVCBSIs and CVC colonization were 9.2% and 48%, respectively. The duration of catheterization was found to be a major risk factor for CVCBSIs. The most predominant organism isolated was S. aureus. The most sensitive antibiotic agent was the aminoglycoside (gentamycin). It is therefore recommended that catheter care bundle which includes hand hygiene, use of chlorhexidine for skin preparation during insertion, use of barrier precautions during insertion, and the removal of unnecessary central lines should be strictly adhered to. Gentamycin should be used as empirical antibiotics in the ICUs.

Abstract P861: The Perception of Missed Nursing Care in Patients With Acute Stroke

Background: “ Missed nursing care” is a unique type of error known as medical underuse. These errors of omission are related to events, such as patient falls, nosocomial infections, and pressure injuries, associated with increased stroke mortality and morbidity. This study aimed to measure the phenomena of missed care in patients with stroke from the perspective of staff RNs working on a stroke unit and neuro intensive care unit at a Comprehensive Stroke Center. Methods: A Missed Care Survey was developed. Building on the work by Kalisch, the new Missed Care Survey focused entirely on nurse-sensitive measures and related evidence-based bundle steps. Two versions of the 25- question ordinal survey were developed, differing only in how the responses were worded. One asked how often care was missed [never missed (5), rarely missed (4), occasionally missed (3), frequently missed (2), always missed (1)]. and the other how frequently care was completed [always completed (5),usually completed (4), etc.).Descriptive statistics were used to evaluate results. Staff volunteered to take the survey during an annual stroke review class, rating their perception of care over the last 30-days. The IRB determined that the human subject regulation did not apply. Results: Completion rate was 93% (n=140). Differences between the two surveys were minimal with the overall summary score being the same (4.1; range 3.5-4.5). Individual scores ranged from 2.6 to 5. Items most frequently described as never missed included timely administration of pre-operative antibiotics and use of barrier precautions with central venous access device insertion. Care most missed included bathing and peri-care (with/without indwelling catheter), mobility, incentive spirometry, and the prevention of loops in urinary drainage catheter tubing. There were minor changes in rankings between the two survey versions. Conclusions: Scores reflect that known interventions to prevent iatrogenic complications are frequently or occasionally missed (or only usually and occasionally completed). Next steps include validation with real time observations. When missed care is not addressed, it can become routine, known as normalization of deviance, negatively impacting patient outcomes and the quality of care.

A survey of the implementation status of selected infection control strategies in neonatal intensive care units in Japan

Infection control strategies are implemented in all neonatal intensive care units (NICUs); however, the details of the strategies seem to differ among institutions. The purpose of this survey was to investigate the current implementation status of infection control strategies in NICUs in Japan and to identify and recommend appropriate strategies for the prevention of outbreaks in neonatal units. This survey documented the current implementation status and methods of selected infection prevention and control measures (active surveillance cultures and standard precaution) in 453 Japanese NICUs/neonatal units registered with the Japan Society of Perinatal and Neonatal Medicine, using questionnaires, in May 2018. The response rate was 48.1% (level I institutions, 25.5%; level II, 55.9%; level III, 64.2%). Surveillance cultures were performed every week and targeted all bacteria in most units. The proportion of level III institutions that experienced outbreaks over the previous five years was significantly higher than that of level II institutions (55% vs 27%, P=0.0003). However, wearing a mask was less frequently recommended in level III institutions (55.7%) than in level II institutions (67.9%). Meticillin-resistant Staphylococcus aureus (MRSA) was the most frequently reported bacterial pathogen responsible for NICU outbreaks. Infection prevention and control practices regarding active pathogen surveillance cultures and the use of barrier precautions varied widely in Japanese neonatal units. National guidelines and evidence-based recommendations are needed to rationalize and standardize current infection prevention and control practices in neonatal units in Japan.

Intervention to Reduce Transmission of Resistant Bacteria in Intensive Care

Huskins, W. Charles*; Huckabee, Charmaine M.†; O’Grady, Naomi P.‡; Murray, Patrick‡; Kopetskie, Heather†; Zimmer, Louise†; Walker, Mary Ellen§; Sinkowitz-Cochran, Ronda L.∥; Jernigan, John A.∥; Samore, Matthew¶; Wallace, Dennis†; Goldmann, Donald A.**†† Author Information

Active surveillance and use of barrier precautions did not reduce colonization and infection with MRSA and VRE in adult ICUs

Source Citation Huskins WC, Huckabee CM, O’Grady NP, et al. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med. 2011;364:1407-18. 21488763

Intervention to Reduce Transmission of Resistant Bacteria in Intensive Care

Intensive care units (ICUs) are high-risk settings for the transmission of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE). In a cluster-randomized trial, we evaluated the effect of surveillance for MRSA and VRE colonization and of the expanded use of barrier precautions (intervention) as compared with existing practice (control) on the incidence of MRSA or VRE colonization or infection in adult ICUs. Surveillance cultures were obtained from patients in all participating ICUs; the results were reported only to ICUs assigned to the intervention. In intervention ICUs, patients who were colonized or infected with MRSA or VRE were assigned to care with contact precautions; all the other patients were assigned to care with universal gloving until their discharge or until surveillance cultures obtained at admission were reported to be negative. During a 6-month intervention period, there were 5434 admissions to 10 intervention ICUs, and 3705 admissions to 8 control ICUs. Patients who were colonized or infected with MRSA or VRE were assigned to barrier precautions more frequently in intervention ICUs than in control ICUs (a median of 92% of ICU days with either contact precautions or universal gloving [51% with contact precautions and 43% with universal gloving] in intervention ICUs vs. a median of 38% of ICU days with contact precautions in control ICUs, P<0.001). In intervention ICUs, health care providers used clean gloves, gowns, and hand hygiene less frequently than required for contacts with patients assigned to barrier precautions; when contact precautions were specified, gloves were used for a median of 82% of contacts, gowns for 77% of contacts, and hand hygiene after 69% of contacts, and when universal gloving was specified, gloves were used for a median of 72% of contacts and hand hygiene after 62% of contacts. The mean (±SE) ICU-level incidence of events of colonization or infection with MRSA or VRE per 1000 patient-days at risk, adjusted for baseline incidence, did not differ significantly between the intervention and control ICUs (40.4±3.3 and 35.6±3.7 in the two groups, respectively; P=0.35). The intervention was not effective in reducing the transmission of MRSA or VRE, although the use of barrier precautions by providers was less than what was required. (Funded by the National Institute of Allergy and Infectious Diseases and others; STAR*ICU ClinicalTrials.gov number, NCT00100386.).

Preparing a community hospital to manage work-related exposures to infectious agents in BioSafety level 3 and 4 laboratories.

Construction of new BioSafety Level (BSL) 3 and 4 laboratories has raised concerns regarding provision of care to exposed workers because of healthcare worker (HCW) unfamiliarity with precautions required. When the National Institutes of Health began construction of a new BSL-4 laboratory in Hamilton, Montana, USA, in 2005, they contracted with St. Patrick Hospital in Missoula, Montana, for care of those exposed. A care and isolation unit is described. We developed a training program for HCWs that emphasized the optimal use of barrier precautions and used pathogen-specific modules and simulations with mannequins and fluorescent liquids that represented infectious body fluids. The facility and training led to increased willingness among HCWs to care for patients with all types of communicable diseases. This model may be useful for other hospitals, whether they support a BSL-4 facility, are in the proximity of a BSL-3 facility, or are interested in upgrading their facilities to prepare for exotic and novel infectious diseases.

Measures to Control and PreventClostridium difficileInfection

Control of Clostridium difficile infection (CDI) outbreaks in health care facilities presents significant challenges to infection control specialists and other health care workers. C. difficile spores survive routine environmental cleaning with detergents and hand hygiene with alcohol-based gels. Enhanced cleaning of all potentially contaminated surfaces with 10% sodium hypochlorite reduces the environmental burden of C. difficile, and use of barrier precautions reduces C. difficile transmission. Thorough handwashing with chlorhexidine or with soap and water has been shown to be effective in removing C. difficile spores from hands. Achieving high-level compliance with these measures is a major challenge for infection control programs. Good antimicrobial stewardship complements infection control efforts and environmental interventions to provide a comprehensive strategy to prevent and control outbreaks of CDI. The efficacy of metronidazole or vancomycin prophylaxis to prevent CDI in patients who are receiving other antimicrobials is unproven, and treatment with these agents is ineffective against C. difficile in asymptomatic carriers.

Factors Associated With Critical-Care Healthcare Workers' Adherence to Recommended Barrier Precautions During the Toronto Severe Acute Respiratory Syndrome Outbreak

To assess factors associated with adherence to recommended barrier precautions among healthcare workers (HCWs) providing care to critically ill patients with severe acute respiratory syndrome (SARS). Fifteen acute care hospitals in Ontario, Canada. Retrospective cohort study. All patients with SARS who required intubation during the Toronto SARS outbreak in 2003. HCWs who provided care to or entered the room of a SARS patient during the period from 24 hours before intubation until 4 hours after intubation. Standardized interviews were conducted with eligible HCWs to assess their interactions with the SARS patient, their use of barrier precautions, their practices for removing personal protective equipment, and the infection control training they received. Of 879 eligible HCWs, 795 (90%) participated. In multivariate analysis, the following predictors of consistent adherence to recommended barrier precautions were identified: recognition of the patient as a SARS case (odds ratio [OR], 2.5 [95% confidence interval {CI}, 1.5-4.5); recent infection control training (OR for interactive training, 2.7 [95% CI, 1.7-4.4]; OR for passive training, 1.7 [95% CI, 1.0-3.0]), and working in a SARS unit (OR, 4.0 [95% CI, 1.8-8.9]) or intensive care unit (OR, 4.3 [95% CI, 2.0-9.0]). Two factors were associated with significantly lower rates of consistent adherence: the provision of care for patients with higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores (OR for score APACHE II of 20 or greater, 0.4 [95% CI, 0.28-0.68]) and work on shifts that required more frequent room entry (OR for 6 or more entries per shift, 0.5 [95% CI, 0.32-0.86]). There were significant deficits in knowledge about self-protection that were partially corrected by education programs during the SARS outbreak. HCWs' adherence to self-protection guidelines was most closely associated with whether they provided care to patients who had received a definite diagnosis of SARS.

Do infection control measures work for methicillin-resistant Staphylococcus aureus?

To review evidence regarding the effectiveness of control measures in reducing transmission of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals. Literature review and surveillance cultures of hospitalized patients at high risk for MRSA colonization or infection. A 500-bed, university-affiliated, community teaching hospital. The percentage of nosocomial S. aureus infections caused by MRSA increased significantly between 1982 and 2002, despite the use of various isolation and barrier precaution policies. The apparent ineffectiveness of control measures may be due to several factors including the failure to identify patients colonized with MRSA. For example, cultures of stool specimens submitted for Clostridium difficile toxin assays at one hospital found that 12% of patients had MRSA in their stool, and 41% of patients with unrecognized colonization were cared for without using barrier precautions. Other factors include the use of barrier precaution strategies that do not account for multiple reservoirs of MRSA, poor adherence of healthcare workers (HCWs) to recommended barrier precautions and handwashing, failure to identify and treat HCWs responsible for transmitting MRSA, and importation of MRSA by patients admitted from other facilities. Control programs that include active surveillance cultures (ASCs) of high-risk patients and use of barrier precautions have reduced MRSA prevalence rates and have been cost-effective. Using a staged approach to implementing ASCs can minimize logistic problems. MRSA control programs are effective if they include ASCs of high-risk patients, use of barrier precautions when caring for colonized or infected patients, hand hygiene, and treating HCWs implicated in MRSA transmission.

A Multipronged Approach to Vancomycin-Resistant Enterococcus Control in an Acute-Care Setting

BACKGROUND: Between March 1998 and October 1998, an increase in nosocomial vancomycin-resistant Enterococcus (VRE) was seen (1.80–1.98/1,000 patient days). During that time education was provided to physicians and patient-care staff regarding early detection of VRE and transmission prevention. The VRE rate did not decrease; therefore a comprehensive program was developed. METHODS: Initial interventions were targeted at ensuring that all VRE policies/procedures were in place and closely adhered to by staff. Efforts also included increased use of barrier precautions for known VRE and high-risk patients. Further analysis of data revealed that most VRE was isolated from urinary tract infections (UTIs) and from stool cultures. Endoscopes were cultured to rule out cross contamination (all cultures were negative). A silver-alloy/hydrogel–coated Foley catheter was evaluated in an effort to reduce UTIs. The final measures instituted were active culture screening, annual education on VRE policies/procedures, and provision of waterless hand foam at each door in patient-care areas. RESULTS: Use of silver-alloy–coated Foley catheters resulted in a 52% decrease in catheter-associated UTIs and a drop on the VRE rate to 0.0–0.87/1,000 patient days. Multivariate regression analysis revealed 84% of the variance in VRE transmission rates can be explained by the introduction of silver-coated urinary catheters, waterless hand foam, and active patient screening. VRE rates have remained constant at 0.0/1,000 patient days with only one exception since August 2000. CONCLUSION: While compliance with established procedures is important, we found that a more aggressive, multipronged approach to control and prevent VRE was the only way to significantly reduce our infection rate.

Percutaneous injury, blood exposure, and adherence to standard precautions: are hospital-based health care providers still at risk?

To examine factors associated with blood exposure and percutaneous injury among health care workers, we assessed occupational risk factors, compliance with standard precautions, frequency of exposure, and reporting in a stratified random sample of 5123 physicians, nurses, and medical technologists working in Iowa community hospitals. Of these, 3223 (63%) participated. Mean rates of hand washing (32%-54%), avoiding needle recapping (29%-70%), and underreporting sharps injuries (22%-62%; overall, 32%) varied by occupation (P<.01). Logistic regression was used to estimate the adjusted odds of percutaneous injury (aOR(injury)), which increased 2%-3% for each sharp handled in a typical week. The overall aOR(injury) for never recapping needles was 0.74 (95% CI, 0.60-0.91). Any recent blood contact, a measure of consistent use of barrier precautions, had an overall aOR(injury) of 1.57 (95% CI, 1.32-1.86); among physicians, the aOR(injury) was 2.18 (95% CI, 1.34-3.54). Adherence to standard precautions was found to be suboptimal. Underreporting was found to be common. Percutaneous injury and mucocutaneous blood exposure are related to frequency of sharps handling and inversely related to routine standard-precaution compliance. New strategies for preventing exposures, training, and monitoring adherence are needed.

Transmission of HIV and hepatitis C virus from a nursing home patient to a health care worker

Background: We report a case of simultaneous HIV and hepatitis C virus (HCV) transmission from a nursing home patient to a health care worker (HCW) whose HIV and HCV infections were diagnosed during routine blood donor screening. Methods: Detailed information about the HCW, possible occupational and nonoccupational blood and body fluid exposures, and possible source patient was collected. Blood samples were drawn from the HCW and patient, and HIV and HCV laboratory testing was performed at the Centers for Disease Control and Prevention. Results: The HCW, who worked as a nursing home aide, had no nonoccupational risk factors for HIV or HCV infection but provided care for 1 HIV-infected patient with dementia and urinary and fecal incontinence. The HCW had numerous exposures to the patient's emesis, feces, and urine to unprotected chapped and abraded hands. HCW and patient blood samples were positive for anti-HCV by enzyme immunoassay and recombinant immunoblot assay testing. The HCW's and patient's HCV were genotyped as 1a, and their HIV-1 was genotyped as subtype B. HIV and HCV ribonucleic acid (RNA) sequence analysis showed that the HCW's and patient's viruses were very closely related. Conclusions: HIV and HCV transmission from the patient to the HCW appears to have occurred through nonintact skin exposure. Bloodborne pathogen transmission may have been prevented in this situation by consistent, unfailing use of barrier precautions.

Barrier Precautions in Trauma: Is Knowledge Enough?

The risk of blood and body fluid exposure and, therefore, risk of blood-borne disease transmission is increased during trauma resuscitations. Use of barrier precautions (BPs) to protect health care workers (HCWs) from exposure and infection has been codified in hospital rules and in national trauma education policy. Despite these requirements, reported rates of BP compliance vary widely. The reasons for noncompliance are not known. This study assesses self-reported rates of BP usage during resuscitations among trauma professionals, explores reasons for noncompliance, and compares self-reported compliance rates with actual observed compliance rates. A survey regarding BPs was distributed to all HCWs involved in trauma resuscitations at our Level I trauma center. All surgical and emergency medicine residents as well as attending faculty from both disciplines and nursing staff were included in this study. A total of 161 surveys were distributed and 123 were returned. Most HCWs (114 of 123 [93%]) reported at least one exposure (usually intact skin contact) to blood or other body fluids. A considerable variation in the type of BP used was reported for those HCWs who reported use of BPs "all of the time." Of the HCWs who reported universal use of BPs, reported usage rates were as follows: gloves, 105 of 123 (85%); eyewear (no side protectors), 58 of 123 (47%); eyewear (side protectors), 20 of 123 (16%); gowns, 22 of 123 (18%); and masks, 5 of 123 (4%). The two most common reasons for noncompliance were "time factors" (61%) and "BPs are too cumbersome" (29%). Observed compliance rates were statistically significantly lower than self-reported rates in all BPs except gloves (p < 0.02). The wide variation in BP use and the gap between perceived and actual usage that we have observed suggest that the effectiveness of current educational approaches to ensure BP use is inadequate.

MRSA patients: proven methods to treat colonization and infection

Methicillin-resistant Staphylococcus aureus (MRSA) infections continue to cause serious nosocomial infections in many hospitals. Measures used to control the spread of these infections include ongoing laboratory-based surveillance, placing colonized and infected patients in isolation, use of barrier precautions and handwashing and hand antisepsis. Culturing hospitalized patients at high risk of acquiring MRSA can facilitate detection and isolation of colonized patients. Eradicating MRSA nasal colonization among affected patients and healthcare personnel has also been as a control measure, with variable success. Eradicating MRSA nasal carriage from epidemiologically-implicated healthcare workers has been used on a number of occasions to control outbreaks. Attempts to eradicate MRSA colonization among affected patients has proven difficult. Of more than 40 different decolonization regimens that have been tested during the last 60 years, topical intranasal application of mupirocin ointment has proven to be the most effective. However, intranasal application of mupirocin has limited effectiveness in eradicating colonization in patients who carry the organism at multiple body sites. Furthermore, because decolonization of patients has virtually always been used in combination with other control measures, its efficacy has been difficult to determine. Because MRSA is transmitted primarily on the hands of healthcare workers, greater emphasis should be given to improving hand hygiene practices among health personnel. For patients infected with MRSA, vancomycin remains a drug of choice.

Antimicrobial resistance and its control in pediatrics

The scope and magnitude of antimicrobial resistance among nosocomial pathogens have increased dramatically in recent years. The most prevalent problems among pediatric patients are Enterobacter, Klebsiella, and other gram-negative enteric bacilli resistant to broad-spectrum penicillins and third-generation cephalosporins;methicillin-resistant coagulase-negative staphylococci; and multidrug-resistant Pseudomonas aeruginosa. Methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci also are important problems, but they are still focal in their distribution. Multiple factors affect the emergence, selection, amplification, and dissemination of resistance determinants, not the least of which is the incredible capacity of bacteria to spread genes coding for resistance determinants within and among species. Inadequate infection control practices and overuse of antimicrobial agents are the important modifiable factors. Improved use of barrier precautions and alcohol-based waterless hand rubs and reduced use of broad-spectrum antimicrobial agents have been shown to reduce infection or colonization with resistant bacteria. However, more research—including more randomized controlled trials—is needed to devise strategies to effectively combat this problem. Copyright © 2001 by W.B. Saunders Company

Noncompliance of Health Care Workers With Universal Precautions During Trauma Resuscitations

Universal precautions during resuscitations are mandated by hospital regulations. We documented adherence to universal precautions during trauma resuscitations at our level I trauma center. During trauma resuscitations, a medical student using an elevated viewing platform observed health care workers (HCWs) for the use of barrier precautions (BPs): gloves, masks, gowns, and eyewear. Only HCWs having direct patient contact were included. The purpose of the observation was not disclosed to those being observed. In 12 resuscitations involving 104 HCWs, none had 100% compliance with BPs. Compliance rates for individual BPs were gloves, 98%; eyewear (any type), 52%; gowns, 38%; masks, 10%; and eyewear (with side protectors), 9%. Resuscitations in which bleeding was observed involved 59 HCWs with 38% compliance; only 2 used full BPs. No difference in compliance rates occurred during the study period. Experienced trauma care HCWs are cavalier regarding blood-borne disease exposure risks. Measures to encourage (or force) compliance are needed.

Compliance With Standard Precautions Among Pediatric Anesthesia Providers

Barrier precautions can reduce the risk of acquiring blood-borne infections, yet such precautions are frequently ignored, especially by personnel caring for pediatric patients. We observed pediatric anesthesia personnel to determine if patient and/or provider demographics influenced the use of standard precautions, and we determined whether an educational intervention would alter the behavior of anesthesia providers. Two, twelve week, observational periods were conducted during which time anesthesia provider's adherence to standard precautions was observed. The providers included student registered nurse anesthetists (SRNA), second year (CA2) and third year (CA3) anesthesia residents, fellows in pediatric anesthesiology and certified registered nurse anesthetists (CRNA). During period one, a statistically significant difference in glove use between junior and senior anesthesia providers (94% vs. 46%) was found. There were no differences in the use of standard precautions based on age, gender, or race. In the second period of the study, it was noted that compliance with standard precautions improved after an educational intervention. Prior to the educational seminar, 89% of junior providers and 40% of senior providers wore gloves during the induction of anesthesia. After the educational intervention, glove use increased to 100% for junior providers and 70% for senior providers. Glove use during emergence and the percent of providers wearing eye protection also increased. Implications: The greatest differences in the use of barrier precautions are related to the seniority of medical personnel and patient demographics do not influence the use of such precautions. A 30-minute educational inservice is effective in increasing the compliance with standard precautions.

Compliance With Standard Precautions Among Pediatric Anesthesia Providers

Barrier precautions can reduce the risk of acquiring blood-borne infections, yet such precautions are frequently ignored, especially by personnel caring for pediatric patients. We observed pediatric anesthesia personnel to determine if patient and/or provider demographics influenced the use of standard precautions, and we determined whether an educational intervention would alter the behavior of anesthesia providers. Two, twelve week, observational periods were conducted during which time anesthesia provider's adherence to standard precautions was observed. The providers included student registered nurse anesthetists (SRNA), second year (CA2) and third year (CA3) anesthesia residents, fellows in pediatric anesthesiology and certified registered nurse anesthetists (CRNA). During period one, a statistically significant difference in glove use between junior and senior anesthesia providers (94% vs. 46%) was found. There were no differences in the use of standard precautions based on age, gender, or race. In the second period of the study, it was noted that compliance with standard precautions improved after an educational intervention. Prior to the educational seminar, 89% of junior providers and 40% of senior providers wore gloves during the induction of anesthesia. After the educational intervention, glove use increased to 100% for junior providers and 70% for senior providers. Glove use during emergence and the percent of providers wearing eye protection also increased. Implications: The greatest differences in the use of barrier precautions are related to the seniority of medical personnel and patient demographics do not influence the use of such precautions. A 30-minute educational inservice is effective in increasing the compliance with standard precautions.

Epidemiology of nosocomial Clostridium difficile diarrhoea

Clostridium difficile is a frequent and clinically important cause of diarrhoea that has been strongly but not exclusively associated with the hospital setting. The vast majority of cases of C. difficile diarrhoea are associated with antecedent treatment with antibiotics, of which cephalosporins and clindamycin appear to pose the highest risk. Within hospitals and chronic-care facilities, cross-infection of C. difficile has been related to transient carriage on hands of healthcare workers and contamination of diverse environmental surfaces, including electronic rectal thermometers. Prospective epidemiologic studies have demonstrated that acquisition of C. difficile is common in hospitalized patients. Although colonized patients contribute to nosocomial transmission of C. difficile, symptom-free carriage of C. difficile appears to reduce risk of subsequent development of C. difficile diarrhoea. Antimicrobial treatment with oral metronidazole or vancomycin to attempt to eradicate symptomless carriage is not recommended. Measures to control nosocomial C. difficile diarrhoea have focused on improved handwashing, use of barrier precautions with single rooms for symptomatic patients, reduction of environmental contamination, and antibiotic restriction. Restricting clindamycin has been particularly successful in terminating outbreaks of C. difficile diarrhoea associated with its use. The epidemiologic features of C. difficile and strategies for control are similar to those for micro-organisms that have acquired antimicrobial resistance. C. difficile may be indirectly or directly contributing to spread of resistant organisms, for instance, by causing diarrhoea and thereby enhancing environmental contamination with other gastrointestinal flora such as vancomycin-resistant enterococci. Thus, a consideration of C. difficile in the larger context of the world-wide spread of antibiotic resistance offers useful insights that may help form the basis for the development of more effective control measures.