Hepatitis A infection: prevention and control guidance

Guidance to help public health professionals manage hepatitis A infections and recommendations for pre-exposure immunisation.

This guidance has been developed to aid the public health management of hepatitis A infection which aims to reduce the occurrence of secondary infections and to prevent and control outbreaks.

The guidance has been developed based on a review of the current epidemiology of hepatitis A in England and Wales and a review of the literature on the efficacy of human normal immunoglobulin (HNIG) and hepatitis A vaccine for post-exposure prophylaxis. This guidance updates the 2009 Guidance for the Prevention and Control of Hepatitis A Infection.

Prevention of central venous line associated bloodstream infections in adult intensive care units

Despite the potential benefits central venous lines can have for patients, there is a high risk of bloodstream infection associated with these catheters | Intensive and Critical Care Nursing

hospital-834152_960_720.jpg

Aim: Identify and critique the best available evidence regarding interventions to prevent central venous line associated bloodstream infections in adult intensive care unit patients other than anti-microbial catheters.

Methods: A systematic review of studies published from January 2007 to February 2016 was undertaken. A systematic search of seven databases was carried out: MEDLINE; CINAHL Plus; EMBASE; PubMed; Cochrane Library; Scopus and Google Scholar. Studies were critically appraised by three independent reviewers prior to inclusion.

Results: Nineteen studies were included. A range of interventions were found to be used for the prevention or reduction of central venous line associated bloodstream infections. These interventions included dressings, closed infusion systems, aseptic skin preparation, central venous line bundles, quality improvement initiatives, education, an extra staff in the Intensive Care Unit and the participation in the ‘On the CUSP: Stop Blood Stream Infections’ national programme.

Conclusions: Central venous line associated bloodstream infections can be reduced by a range of interventions including closed infusion systems, aseptic technique during insertion and management of the central venous line, early removal of central venous lines and appropriate site selection.

Full reference: Velasquez Reyes, D.C. et al. (2017) Prevention of central venous line associated bloodstream infections in adult intensive care units: A systematic review. Intensive and Critical Care Nursing. Published online: 26 June 2017

Tobacco use as a screener for Clostridium difficile infection outcomes

A retrospective cohort study to evaluate the utility of self-reported tobacco use for developing a clinical prediction rule for poor outcomes of Clostridium difficile infection | Journal of Hospital Infection

cigarettes-1626480_960_720.png

We found that patients with any history of smoking were significantly less likely than never smokers to be cured of their infection within two weeks. Disease recurrence, readmission within thirty days, death before treatment completion, and the severity of Clostridium difficile infection were not associated with smoking status.

Full reference: Barker, A.K. et al. (2017) Tobacco use as a screener for Clostridium difficile infection outcomes. Journal of Hospital Infection. Published online: 26 June 2017

Relationship between hospital ward design and healthcare associated infection rates

The systematic review published by Stiller et al. in Antimicrobial Resistance & Infection Control in November 2016 concludes that single-patient bedrooms confer a significant benefit for protecting patients from healthcare associated infection and colonization | Antimicrobial Resistance & Infection Control

This conclusion is not substantiated by the evidence included in their review which has been largely drawn from uncontrolled before and after studies in the absence of a transparent assessment of the risk of bias. There are also errors in the analysis of supporting data. Evaluating the specific impact of single rooms on preventing transmission from a sound epidemiological perspective is essential to assure safe and effective care and a clear evidence-base for infection prevention and control advice.

Full reference: Wilson, J. et al. (2017) Relationship between hospital ward design and healthcare associated infection rates: what does the evidence really tell us? Comment on Stiller et al. 2016. Antimicrobial Resistance & Infection Control. vol 6 (no. 71)

Risk of Central Line-Associated Bloodstream Infection in Neonates

Umbilical venous catheters (UVC) or peripherally inserted central catheters (PICC), commonly used in high risk neonates, may have a threshold dwell time for subsequent increased risk of central line associated blood stream infection (CLABSI) | The Journal of Hospital Infection

Aim: To evaluate the CLABSI risks in neonates having either UVC, PICC or those having both sequentially.

Methods: Study included 3985 infants who had UVC or PICC inserted between 2007 and 2009 cared for in 10 regional Neonatal Intensive Care Units: 1392 having UVC only (Group 1), 1317 PICC only (Group 2) and 1276 both UVC and PICC (Group 3).

Results: There were 403 CLABSI among 6000 venous catheters inserted, totalling 43302 catheter days. CLABSI rates were higher in Group 3 infants who were of lowest gestation (16.9/1000 UVC days and 12.5/1000 PICC days; median 28 weeks) when compared with Group 1 (3.3/1000 UVC days; 37 weeks) and Group 2 (4.8/1000 PICC days; 30 weeks). Life table and Kaplan-Meier hazard analysis showed UVC CLABSI rate increased stepwise to 42/1000 UVC days by day 10, with the highest rate in Group 3 (85/1000 UVC days). PICC CLABSI rates remained relatively stable at 12-20/1000 PICC days. Compared to PICC, UVC had a higher adjusted CLABSI risk controlled for dwell time. Among Group 3, replacing UVC electively before day 4 may have a trend of lower CLABSI risk, than late replacement.

Conclusions: There was no cut-off duration beyond which PICC should be removed electively. Early UVC removal and replacement by PICC before day 4 could be considered.

Full reference: Sanderson, E. et al. (2017) Dwell Time and Risk of Central Line-Associated Bloodstream Infection in Neonates. The Journal of Hospital Infection. Published online: 24 June 2017

Disinfection of gloved hands for multiple activities with indicated glove use on the same patient

Most hand hygiene guidelines recommend that gloves should be changed during patient care when an indication for hand disinfection occurs | The Journal of Hospital Infection

pair-of-green-latex-gloves-361x544.jpg

Observational studies indicate that the majority of healthcare workers (HCWs) do not disinfect their hands at all during continued glove wear. The aim of this narrative review is to assess the potential benefits and risks for disinfecting gloved hands during patient care for multiple activities with indicated glove use on the same patient.

Continued glove wear for multiple activities on the same patient often results in performing procedures, including aseptic procedures with contaminated gloves, especially in a setting where there are many indications in a short time, e.g. anaesthetics or accident and emergency departments. Of further note is that hand hygiene compliance is often lower when gloves are worn. To date, three independent studies have shown that decontamination is at least as effective on gloved hands as on bare hands and that puncture rates are usually not higher after up to 10 disinfections. One study on a neonatal intensive care unit showed that promotion of disinfecting gloved hands during care on the same patient resulted in a significant reduction in the incidence of late-onset infections and of necrotizing enterocolitis.

We conclude that disinfection of gloved hands by HCWs can substantially reduce the risk of transmission when gloves are indicated for the entire episode of patient care and when performed during multiple activities on the same patient.

Full reference: Kampf, G. & Lemmen, S. (2017) Disinfection of gloved hands for multiple activities with indicated glove use on the same patient. The Journal of Hospital Infection. Published online: June 22 2017

Removal of sinks and introduction of ‘water-free’ patient care

Sinks in patient rooms are associated with hospital-acquired infections | Antimicrobial Resistance & Infection Control

tap-943297_960_720.jpg

Background: The aim of this study was to evaluate the effect of removal of sinks from the Intensive Care Unit (ICU) patient rooms and the introduction of ‘water-free’ patient care on gram-negative bacilli colonization rates.

Conclusions: Removal of sinks from patient rooms and introduction of a method of ‘water-free’ patient care is associated with a significant reduction of patient colonization with GNB, especially in patients with a longer ICU length of stay.

Full reference: Hopman, J. et al. (2017) Reduced rate of intensive care unit acquired gram-negative bacilli after removal of sinks and introduction of ‘water-free’ patient care. Antimicrobial Resistance & Infection Control. 6:59

The Scottish enhanced Staphylococcus aureus bacteraemia surveillance program

Staphylococcus aureus bacteraemia (SAB) is the second most common source of positive blood cultures after Escherichia coli (E. coli) reported within NHS Scotland. Laboratory surveillance has been mandatory in Scotland for SAB since 2001 | Journal of Hospital Infection

Aim: To gain an understanding of the epidemiology of SAB cases and associated risk factors for healthcare and true community onset. Identifying these factors and patient populations most at risk allows focused improvement plans to be developed.

Methods: All NHS Boards within NHS Scotland take part in the mandatory enhanced surveillance collecting data by trained data collectors using nationally agreed definitions.

Findings: Between 1st October 2014 and 31st March 2016, 2256 episodes of SAB in adults were identified. The blood cultures were taken in 58 hospitals and across all 15 Scottish health boards. The data demonstrated that approximately one third of all SAB cases are true community cases. Vascular access devices (VAD) continue to be the most reported entry point (25.7%) in persons who receive healthcare, whereas, skin and soft tissue risk factors are present in all origins. A significant risk factor unique to community cases are in people who inject drugs (PWID).

Conclusion: Improvement plans for reduction of SAB should be more widely targeted than solely in hospital care settings.

Full reference: Murdoch, F. et al. (2017) The Scottish enhanced Staphylococcus aureus bacteraemia surveillance program: The first 18 months data in adults. Journal of Hospital Infection. Published online: June 08, 2017

Reducing the Risk of Mouth to Mouth Transmission of Pathogens Via Parking Tickets.

In the initial phase of our study 598 staff members were observed entering the carpark. 21.6% of them put their parking ticket in their mouth | Journal of Hospital Infection

parking-825371_960_720.jpg

Using UV dye we successfully demonstrated card-to-card cross-contamination. Swabs of the ticket machine yielded commensal bacteria: coagulase negative staphylococci and a Bacillus species.

After placing a poster on the ticket-reading machine highlighting this potential infection risk, a further 1366 observations resulted in a statistically significant and persistent decline in the proportion of staff putting their carpark tickets in their mouths (p<0.001).

Full reference: Groves, J. et al. (2017) Reducing the Risk of Mouth to Mouth Transmission of Pathogens Via Reusable, Machine-read, Parking Tickets. An observational cohort study. Journal of Hospital Infection. Published online: June 08, 2017

Are alcohol-based dispensers fomites for C difficile?

The purpose of this study was to evaluate alcohol-based dispensers as potential fomites for Clostridium difficile | American Journal of Infection Control

11694-2

A convenience sample of 120 alcohol-based dispensers was evaluated for the presence of C difficile either by culture or polymerase chain reaction for C difficile toxin. The results demonstrated that C difficile was not cultured, and C difficile toxin was not detected using polymerase chain reaction; however, gram-positive rods, Clostridium perfringens, Pantoea agglomerans, coagulase-negative Staphylococcus, Peptostreptococcus, Bacillus spp, and microaerophilic Streptococcus were present within the overflow basins of the alcohol-based dispensers.

Full reference: Hall, J.A. et al. (2017) Dipping into the Clostridium difficile pool: Are alcohol-based dispensers fomites for C difficile? American Journal of Infection Control. DOI: 10.1016/j.ajic.2017.04.284