The Tipping Point: Patients predisposed to Clostridium difficile infection and a hospital antibiotic stewardship programme

Stites, S. The Journal of Hospital Infection. Published online: 5 September 2016

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Image source: USCDCP

Background: The incidence and severity of Clostridium difficile infections (CDIs) have increased in recent years. Predictive models may help to identify at-risk patients before the onset of infection. Early identification of high-risk patients could help antimicrobial stewardship (AMS) programmes and other initiatives to better prevent C. difficile in these patients.

Aim: The purpose of this study was to develop a predictive model that identified patients at high-risk for CDI at the time of hospitalization. This approach to early identification was evaluated to determine if it could improve upon a preexisting AMS programme.

Methods: Generalized linear regression and receiver operand characteristic (ROC) curve analyses were used to develop an analytic model to predict CDI risk at the time of hospitalization in a retrospective cohort of inpatients. The model was then validated in a prospective cohort. Concurrence between the model’s risk predictions and a preexisting ABS programme was assessed.

Findings: 
The model identified 55% of patients as high-risk for CDI at the time of admission and who later tested positive. One in every 32 high-risk patients with potentially modifiable antibiotic risk factors tested positive for CDI. Half (53%) tested positive before meeting the risk criteria for the hospital’s AMS programme.

Conclusion: Analytic models can prospectively identify most patients at the time of admission who later test positive for C. difficile. This approach to early identification may help AMS programmes pursue susceptibility testing and modifications to antibiotic therapies sooner in order to better prevent CDI.

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Severe community-acquired pneumonia: timely management measures in the first 24 hours

Phua, J. et al. Critical Care. Published online: 28 August 2016

Mortality rates for severe community-acquired pneumonia (CAP) range from 17 to 48 % in published studies.

In this review, we searched PubMed for relevant papers published between 1981 and June 2016 and relevant files. We explored how early and aggressive management measures, implemented within 24 hours of recognition of severe CAP and carried out both in the emergency department and in the ICU, decrease mortality in severe CAP.

These measures begin with the use of severity assessment tools and the application of care bundles via clinical decision support tools. The bundles include early guideline-concordant antibiotics including macrolides, early haemodynamic support (lactate measurement, intravenous fluids, and vasopressors), and early respiratory support (high-flow nasal cannulae, lung-protective ventilation, prone positioning, and neuromuscular blockade for acute respiratory distress syndrome).

CC flow chart

While the proposed interventions appear straightforward, multiple barriers to their implementation exist. To successfully decrease mortality for severe CAP, early and close collaboration between emergency medicine and respiratory and critical care medicine teams is required. We propose a workflow incorporating these interventions.

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Skin antisepsis for reducing central venous catheter-related infections

Researchers supported by the National Institutes of Health have shown that it’s possible to diagnose a bacterial infection from a small sample of blood — based on the immune system’s response to the bacteria — in infants with fevers who are 2 months of age or younger.

With additional research, the new technique could be an improvement over the standard method, which requires isolating live bacteria from blood, urine or spinal fluid and growing them in a laboratory culture.

Full reference: Mahajan, P.  Association of RNA Biosignatures With Bacterial Infections in Febrile Infants Aged 60 Days or Younger  Journal of the American Medical Association. Aug. 23, 2016

Surface cleaning effectiveness in a walk-in emergency care unit: Influence of a multifaceted intervention

Frota, P.O. et al. American Journal of Infection Control. Published online: 24 August 2016

Highlights

  • The interventions immediately improved the effectiveness of cleaning.
  • These improvements disappeared after four months of interventions.
  • Microfiber cloths did not impact any increase in cleaning effectiveness.
  • Continuous education and feedback on cleaning practices appear to be warranted.
  • This policy should be adapted to the particularities of each health care setting.

Abstract

Background: Cleaning of surfaces is essential in reducing environmental bioburdens and health care-associated infection in emergency units. However, there are few or no studies investigating cleaning surfaces in these scenarios. Our goal was to determine the influence of a multifaceted intervention on the effectiveness of routine cleaning of surfaces in a walk-in emergency care unit.

Methods: This prospective, before-and-after interventional study was conducted in 4 phases: phase I (situational diagnosis), phase II (implementation of interventions—feedback on results, standardization of cleaning procedures, and training of nursing staff), phase III (determination of the immediate influence of interventions), and phase IV (determination of the late influence of interventions). The surfaces were sampled before and after cleaning by visual inspection, adenosine triphosphate bioluminescence assay, and microbiologic culture.

Results: We sampled 240 surfaces from 4 rooms. When evaluated by visual inspection and adenosine triphosphate bioluminescence, there was a progressive reduction of surfaces found to be inadequate in phases I-IV (P < .001), as well as in culture phases I-III. However, phase IV showed higher percentages of failure by culture than phase I (P = .004).

Conclusions: The interventions improved the effectiveness of cleaning. However, this effect was not maintained after 2 months.

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JCVI statement on the nasal spray flu vaccine

Department of Health | First published: 26 August 2016

Using the nasal spray flu vaccine for the UK childhood influenza immunisation programme: advice from JCVI

JCVI
Image source: gov.uk

The Joint Committee on Vaccination and Immunisation (JCVI) has reviewed updated data from the 2015 to 2016 season in the UK and other countries on the effectiveness of the nasal spray vaccine, in light of emerging evidence of low effectiveness of the nasal spray vaccine reported in the United States (US).

This statement sets out the committee’s advice for continuation of the childhood influenza immunisation programme in using the live attenuated influenza vaccine (LAIV, the nasal spray vaccine).

Read the full statement here

Antibiotic use in the acute setting

Fawcett, N. et al. Antibiotic use and clinical outcomes in the acute setting under management by an infectious diseases acute physician versus other clinical teams: a cohort study. BMJ Open Volume 6 Issue 8

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Abstract

Objectives To assess the magnitude of difference in antibiotic use between clinical teams in the acute setting and assess evidence for any adverse consequences to patient safety or healthcare delivery.

Design Prospective cohort study (1 week) and analysis of linked electronic health records (3 years).

Setting UK tertiary care centre.

Participants All patients admitted sequentially to the acute medical service under an infectious diseases acute physician (IDP) and other medical teams during 1 week in 2013 (n=297), and 3 years 2012–2014 (n=47 585).

Primary outcome measure Antibiotic use in days of therapy (DOT): raw group metrics and regression analysis adjusted for case mix.

Secondary outcome measures 30-day all-cause mortality, treatment failure and length of stay.

Results Antibiotic use was 173 vs 282 DOT/100 admissions in the IDP versus non-IDP group. Using case mix-adjusted zero-inflated Poisson regression, IDP patients were significantly less likely to receive an antibiotic (adjusted OR=0.25 (95% CI 0.07 to 0.84), p=0.03) and received shorter courses (adjusted rate ratio (RR)=0.71 (95% CI 0.54 to 0.93), p=0.01). Clinically stable IDP patients of uncertain diagnosis were more likely to have antibiotics held (87% vs 55%; p=0.02). There was no significant difference in treatment failure or mortality (adjusted p>0.5; also in the 3-year data set), but IDP patients were more likely to be admitted overnight (adjusted OR=3.53 (95% CI 1.24 to 10.03), p=0.03) and have longer length of stay (adjusted RR=1.19 (95% CI 1.05 to 1.36), p=0.007).

Conclusions The IDP-led group used 30% less antibiotic therapy with no adverse clinical outcome, suggesting antibiotic use can be reduced safely in the acute setting. This may be achieved in part by holding antibiotics and admitting the patient for observation rather than prescribing, which has implications for costs and hospital occupancy. More information is needed to indicate whether any such longer admission will increase or decrease risk of antibiotic-resistant infections.

Characterisation of occupational blood and body fluid exposures beyond the Needlestick Safety and Prevention Act

Green-McKenzie, J. et al. (2016) Journal of Infection Prevention17 (5). pp. 226-232

Objective: To describe the use of mandated safety engineered sharps devices (SESDs) and personal protective equipment in healthcare workers (HCWs) with occupational body fluid exposures (BFE) since the Needlestick Safety and Prevention Act.

Methods: Two questionnaires were administered, over 3 years, to HCWs who reported sharps or splash BFEs. Descriptive statistics and chi-square analysis were used.

Results: Of the 498 questionnaires completed, nurses completed 262 (53%), house staff 155 (32 %), technicians 63 (13%) and phlebotomists 11 (2%). Four (1%) completers reported ‘other’ and three (1%) reported unknown. Sharps injuries accounted for 349 (70%) of the BFEs. SESDs were utilised 43% (128/299) of the time with a 54% (70/130) activation rate. Phlebotomists (80%; 8/10) and nurses (59%; 79/267) used SESDs more than doctors (27%; 31/86) and technicians (26%; 10/39) (P <0.0001). Fifty-four percent (185/207) of HCWs reported having had training on SESD use; nurses (64%; 98/154) and phlebotomists (70%; 7/8) significantly more so than house staff (44%; 59/133) and technicians (44%; 21/48) (P <0.05). Most splash BFEs were to the eyes 73% (91/149). Five percent (4/79) of HCWs used protective eyewear.

Conclusions: Systematic regular training, appropriate protocols and iteratively providing the safest SESDs based on HCW experience and technological advances will further reduce the physical and emotional toll of BFEs.

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Infection risks associated with peripheral vascular catheters

Zhang, L. et al. (2016) Journal of Infection Prevention. 17 (5). pp. 207-213

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Image source: Calleamanecer – Wikipedia // CC BY-SA 3.0

Background: Peripheral vascular catheters (PVC) are the most frequently used invasive medical devices in hospitals, with 330 million sold each year in the USA alone. One in three UK inpatients at any one time has at least one PVC in situaccording to the Scottish National Prevalence survey.

Method: A narrative review of studies describing the infection risks associated with PVCs.

Results: It is estimated that 30–80% of hospitalised patients receive at least one PVC during their hospital stay. Despite their prevalence, PVCs are not benign devices, and the high number of PVCs inserted annually has resulted in serious catheter-related bloodstream infections and significant morbidity, prolonged hospital stay and increased healthcare system costs. To date, PVC infections have been under-evaluated. Most studies focus on central venous catheter rather than PVC-associated bloodstream infections. Risks associated with PVC infection must be addressed to reduce patient morbidity and associated costs of prolonged hospital admission and treatment.

Discussion: This article discusses the sources and routes of PVC-associated infection and outlines known effective prevention and intervention strategies.

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Impact of observing hand hygiene in practice and research: a methodological reconsideration

Gould, D.J. et al. Journal of Hospital Infection. Published online: August 18, 2016

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Healthcare-associated infection is often spread by direct contact, and the importance of hand hygiene to break the chain of infection is recognised internationally. In many countries hand hygiene is regularly audited as part of quality assurance based on recommendations issued by the World Health Organization (WHO).

Direct observation is the recommended audit method but is associated with a number of disadvantages, including potential for being observed to alter usual behaviour. The Hawthorne effect in relation to hand hygiene is equated with productivity by increasing the frequency that hand hygiene is undertaken. Unobtrusive and/or frequent observation to accustom staff to the presence of observers is considered an acceptable way of reducing the Hawthorne effect but little has been written about how to implement these techniques or assess their effectiveness. There is evidence that awareness of being watched can disrupt the usual behaviour of individuals in complex and unpredictable ways other than simple productivity effect. In the presence of auditors health workers might defer or avoid activities that require hand hygiene, but these issues are not addressed in guidelines for practice or research studies. This is an important oversight with implications for the validity of hand hygiene audit findings. It needs to be considered if such findings are taken as indicators of quality of care and if the results of hand hygiene research are used to inform future policy and practice.

Measuring hand hygiene product use overcomes avoidance tactics. It is cheaper and generates data continuously to give a 24 hour picture of compliance for all clinicians without disrupting patient care. Disadvantages are the risk of over-estimating uptake through spillage, wastage or use by visitors and non-clinical staff entering patient care areas. Electronic devices can overcome Hawthorne and avoidance effects but are costly and are not widely used outside research studies.

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