A Role for Antimicrobial Stewardship in Clinical Sepsis Pathways

The aim of this study was to evaluate the impact of early infectious diseases (ID) antimicrobial stewardship (AMS) intervention on inpatient sepsis antibiotic management | Infection Control & Hospital Epidemiology

All patients reviewed by an ID Fellow within 24 hours of sepsis pathway trigger underwent case review and clinic file documentation of recommendations. Those not reviewed by an ID Fellow were considered controls and received standard sepsis pathway care. The primary outcome was antibiotic appropriateness 48 hours after sepsis trigger.

In total, 164 patients triggered the sepsis pathway: 6 patients were excluded (previous sepsis trigger); 158 patients were eligible; 106 had ID intervention; and 52 were control cases. Of these 158 patients, 91 (58%) had sepsis, and 15 of these 158 (9.5%) had severe sepsis. Initial antibiotic appropriateness, assessable in 152 of 158 patients, was appropriate in 80 (53%) of these 152 patients and inappropriate in 72 (47%) of these patients. In the intervention arm, 93% of ID Fellow recommendations were followed or partially followed, including 53% of cases in which antibiotics were de-escalated. ID Fellow intervention improved antibiotic appropriateness at 48 hours by 24% (adjusted risk ratio, 1.24; 95% confidence interval, 1.04–1.47; P=.035). The appropriateness agreement among 3 blinded ID staff opinions was 95%. Differences in intervention and control group mortality (13% vs 17%) and median length of stay (13 vs 17.5 days) were not statistically significant.

Sepsis overdiagnosis and delayed antibiotic optimization may reduce sepsis pathway effectiveness. Early ID AMS improved antibiotic management of non-ICU inpatients with suspected sepsis, predominantly by de-escalation.

Full reference: Burston, J. et al. (2017) A Role for Antimicrobial Stewardship in Clinical Sepsis Pathways: a Prospective Interventional Study. Infection Control & Hospital Epidemiology. Vol. 38 (Issue 9) pp. 1032-1038

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Screening programmes | Childhood flu vaccination

Public Health England has updated the following documents:

 

Carbapenem-resistant Enterobacteriaceae in patients admitted to the Emergency Department

New risk factors and occurrence in patients coming directly from the community | Journal of Hospital Infection

Aim: To investigate the prevalence of patients harboring CRE on hospital admission, risk factors associated and the acquisition rate within the emergency department (ED).

Methods: We conducted a cross-sectional with 676 patients consecutively admitted to the ED study during the months of May to July 2016. A questionnaire was performed and rectal swabs were collected from patients on admission, for culture and for multiplex real-time polymerase chain-reaction (RT-PCR). If the patient was hospitalized for more than one week in the ED, samples were taken again to determine the acquisition rate of CRE.

Findings: Forty-six patients were colonized, all positive RT-PCR were KPC. The acquisition rate was 18%. Patients CRE colonized presented a higher mortality rate. Previous exposure to healthcare in the last year, liver disease and use of antibiotics in the last month were risk factors for colonization. Six patients with no previous exposure to healthcare were CRE-colonized on admission, suggesting transmission of CRE within the community.

Conclusion: Screening of high-risk patients on admission to the ED is a strategy to early identify CRE carriage and may contribute to control CRE dissemination.

Full reference: Salomão, M.C. et al. (2017) Carbapenem-resistant Enterobacteriaceae in patients admitted to the Emergency Department: new risk factors and occurrence in patients coming directly from the community. Journal of Hospital Infection. Published online: 18 August 2017

Incidence, prevalence, and management of MRSA bacteremia across patient populations

A review of recent developments in MRSA management and treatment | Critical Care

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Image source: Annie Cavanagh – Wellcome Images // CC BY-NC 4.0

Image shows clusters of methicillin-resistant Staphylococcus aureus bacteria.

Methicillin-resistant Staphylococcus aureus (MRSA) infection is still a major global healthcare problem. Of concern is S. aureus bacteremia, which exhibits high rates of morbidity and mortality and can cause metastatic or complicated infections such as infective endocarditis or sepsis. MRSA is responsible for most global S. aureus bacteremia cases, and compared with methicillin-sensitive S. aureus, MRSA infection is associated with poorer clinical outcomes. S. aureus virulence is affected by the unique combination of toxin and immune-modulatory gene products, which may differ by geographic location and healthcare- or community-associated acquisition.

Management of S. aureus bacteremia involves timely identification of the infecting strain and source of infection, proper choice of antibiotic treatment, and robust prevention strategies. Resistance and nonsusceptibility to first-line antimicrobials combined with a lack of equally effective alternatives complicates MRSA bacteremia treatment.

This review describes trends in epidemiology and factors that influence the incidence of MRSA bacteremia. Current and developing diagnostic tools, treatments, and prevention strategies are also discussed.

Full reference: Hassoun, A. et al. (2017) Incidence, prevalence, and management of MRSA bacteremia across patient populations—a review of recent developments in MRSA management and treatment. Critical Care. 21:211

Exposure to information and seasonal influenza vaccination uptake in nurses

Coverage of annual influenza vaccination of healthcare workers (HCWs) varies and remains at a sub-optimal level in many countries | Journal of Hospital Infection

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As HCWs are often exposed to a variety of information on vaccination, their pattern of exposure may impact their decision, which deserves further investigation.

Practising nurses in Hong Kong were invited to participate in an anonymous online survey in February 2015, after the winter seasonal peak. The questionnaire covered demographics, work nature and experiences, vaccination uptake history and reasons for vaccination decisions. Two categories of behaviors with regards to information access were defined – (A) passive exposure to information, and (B) active information-seeking, as differentiated by the source, type and nature of information accessed. Chi-square test, Mann-Whitney U test, logistic regression were performed to compare between vaccinated and unvaccinated nurses.

A total of 1177 valid returns were received from nurses who had a median age of 32, of whom 86% were female. The overall vaccination rate was 33%. Passive exposure to information from workplace, professional body and social network did not predict vaccination decision, while mass media did (OR:1.78). Active information-seeking involving consulting seniors (OR:2.46), having organized promotion activities (OR:2.85) and performing information search (OR:2.43) were significantly associated with increased vaccination uptake. Cumulative effect could be demonstrated for active information seeking (OR:1.86) but not passive exposure to information.

Current strategy of promotions and campaigns for seasonal influenza vaccination in HCWs may not be effective in increasing vaccination coverage. Measures targeting information-seeking behaviors may serve as an alternative approach.

Full reference: Cheung, E.K.H. et al. (2017) Pattern of exposure to information and its impacts on seasonal influenza vaccination uptake in nurses. Journal of Hospital Infection. Published online: 11 August 2017

Candida auris: infection control in community care settings

This guidance prescribes infection control measures for community care settings where service users have been colonised with C. auris | PHE

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This guidance – for nursing homes and other community care settings – covers infection control precautions, including maintenance of cleaning standards and other special precautions appropriate when service users are, or have been, colonised with C. auris.

Read the full guidance here

Hand hygiene compliance in a universal gloving setting

The use of gloves for every patient contact (ie, universal gloving) has been suggested as an infection prevention adjunct and alternative to contact precautions | American Journal of Infection Control

https://www.flickr.com/photos/mikecogh/20464487373

Image source: Michael Coghlan – Flickr // CC BY-SA 2.0

Background: The use of gloves for every patient contact (ie, universal gloving) has been suggested as an infection prevention adjunct and alternative to contact precautions. However, gloves may carry organisms unless they are changed properly. In addition, hand hygiene is required before donning and after removing gloves, and there are scarce data regarding glove changing and hand hygiene in a universal gloving setting.

Methods: This nonrandomized observational before-after study evaluated the effect of education and feedback regarding hand hygiene. Compliance with hand hygiene and glove use was directly observed in a universal gloving setting at a 10-bed intensive care unit in a Japanese tertiary care university teaching hospital.

Results: A total of 6,050 hand hygiene opportunities were identified. Overall, hand hygiene compliance steadily increased from study period 1 (16.1%) to period 5 (56.8%), although there were indication-specific differences in the baseline compliance, the degree of improvement, and the reasons for noncompliance. There were decreases in the compliance with universal gloving and the incidence of methicillin-resistant Staphylococcus aureus.

Conclusion: It is difficult to properly perform glove use and hand hygiene in a universal gloving setting, given its complexity. Direct observation with specific feedback and education may be effective in improving compliance.

Full reference: Kuruno, N. et al. (2017) Hand hygiene compliance in a universal gloving setting. American Journal of Infection Control. Vol. 45 (Issue 8) pp. 830–834