Nursing & Health

Background: In Australia, little is known about the risk of acquiring methicillin-resistant Staphylococcus aureus(MRSA) from prior room occupants. The aims of the study are to understand the risk ofMRSAacquisition from prior room occupants and to further extend the existing knowledge-base on the role of discharge cleaning in hospitals.

Methods: A non-concurrent cohort study was undertaken in five wards at a 250-bed general hospital in Tasmania, Australia. All admitted patients were screened for MRSA. Weekly screenings for all patients who remained in hospital were undertaken. New MRSA acquisitions were identified. The exposed group were patients whose immediate prior room occupant had MRSA, while the unexposed prior room occupant did not have MRSA.

Results: 6228 patients were at risk of acquiringMRSA,with 237 newMRSAacquisitions equating to an acquisition rate of 3.8% for each at-risk patient admission. The unadjusted odds ratio for acquiring MRSA when the prior room occupant had MRSA was 2.9 (95% CI 2.2–3.9). Using logistic regression, exposure to a prior occupant harbouring MRSA remained a significant predictor of subsequent acquisition, after controlling for variables, OR 2.7 (95% CI 2.0–3.6).

Conclusion: Admission to a room previously occupied by a person with MRSA increased the odds of acquisition for the subsequent patient, independent of other risk factors. It demonstrates the necessity of having effective discharge cleaning practices in place. We believe increased attention to discharge room cleaning in hospitals is required and the reconsideration of additional recommendations for discharge cleaning.

Objectives The impact of surface disinfection versus detergent cleaning on healthcare associated infection rates remains unresolved. We aimed to evaluate the efficacy of hydrogen peroxide (HP) decontamination against methicillin-resistant Staphylococcus aureus (MRSA).

Design Single centred retrospective before and after study design.

Setting Launceston General Hospital, Tasmania, Australia.

Participants Patients with MRSA infection or colonisation.

Interventions Rooms occupied by patients with MRSA infection or colonisation were cleaned following discharge with either detergent or HP.

Main outcome measures MRSA room contamination following cleaning; new MRSA acquisition in patients.

ResultsOver 3600 discharge cleans were completed, with more than 32 600 environmental swabs processed. MRSA was isolated from 24.7% rooms following detergent cleaning and from 18.8% of rooms after HP (p

Conclusions Use of HP disinfection led to a decrease in residual MRSA contamination in patient rooms compared with detergent. It may also have encouraged the reduction in patient MRSA acquisition despite several confounders including staff feedback on terminal cleaning, additional MRSA screening and quicker laboratory methods. Infection control is best served by concurrent interventions targeting both the patient and healthcare environment.

Background: Urinary tract infections account for ~30% of healthcare-associated infections reported by hospitals. Virtually all healthcare-associated urinary tract infections (HAUTIs) are caused by instrumentation of the urinary tract, creating an opportunity to prevent a large proportion of HAUTIs, including catheter-associated urinary tract infections (CAUTIs). In Australia, there is no specific national strategy and surveillance system in place to address HAUTIs or CAUTIs. To determine the need for prospective surveillance of HAUTIs, we propose undertaking a national point prevalence study. This paper describes the methods that could be used to undertake such a study.

Methods: A cross-sectional point prevalence design is proposed. The population is all patients hospitalised overnight in Australian hospitals, with the sample to exclude outpatients and those in emergency departments. The proposed operational definition is that used by the Health Protection Agency. A standardised training package for data collectors is recommended with standardised data collection and analysis processes described. Individual patient consent should be waived.

Discussion: Explanation of aspects of the proposed methods are provided, primarily based on findings from a pilot study that informed the development of the proposed protocol. This included development and delivery of training for data collectors and use of the Health Protection Agency HAUTI surveillance definition, rather than the Centers for Disease Control definition.

Conclusion: Conducting a national point prevalence study on HAUTIs including CAUTIs will provide evidence that can be subsequently used to debate the cost effectiveness and value of prospective surveillance. By conducting a pilot study and critically evaluating that process, we have been able to propose a method that could be used for a single hospital or national study.

Background

Evidence from a previous systematic review indicates that patients admitted to a room where the previous occupant had a multidrug-resistant bacterial infection resulted in an increased risk of subsequent colonisation and infection with the same organism for the next room occupant. In this paper, we have sought to expand and update this review.

Methods

A systematic review and meta-analysis was undertaken. A search using Medline/PubMed, Cochrane and CINHAL databases was conducted. Risk of bias was assessed by the ROB-2 tool for randomised control studies and ROBIN-I for non-randomised studies.

Results

From 5175 identified, 12 papers from 11 studies were included in the review for analysis. From 28,299 patients who were admitted into a room where the prior room occupant had any of the organisms of interest, 651 (2.3%) were shown to acquire the same species of organism. In contrast, 981,865 patients were admitted to a room where the prior occupant did not have an organism of interest, 3818 (0.39%) acquired an organism(s). The pooled acquisition odds ratio (OR) for all the organisms across all studies was 2.45 (95% CI: 1.53–3.93]. There was heterogeneity between the studies (I2 89%, P < 0.001).

Conclusion

The pooled OR for all the pathogens in this latest review has increased since the original review. Findings from our review provide some evidence to help inform a risk management approach when determining patient room allocation. The risk of pathogen acquisition appears to remain high, supporting the need for continued investment in this area.

Background

Evidence for the benefits of antiseptic meatal cleaning in reducing catheter-associated urinary tract infection (UTI) is inconclusive. We assessed the efficacy of 0·1% chlorhexidine solution compared with normal saline for meatal cleaning before urinary catheter insertion in reducing the incidence of catheter-associated asymptomatic bacteriuria and UTI.

Methods

A cross-sectional, stepped-wedge, open-label, randomised controlled trial was undertaken in Australian hospitals. Eligible hospitals were Australian public and private hospitals, with an intensive care unit and more than 30 000 hospital admissions per year. Hospitals were randomly assigned to an intervention crossover date using a computer-generated randomisation system. Crossover dates occurred every 8 weeks; during the first 8 weeks of the study, no hospitals were exposed to the intervention (control phase), after which each hospital sequentially crossed over from the control to the intervention every 8 weeks. Patients requiring a urinary cathetwer were potentially eligible for inclusion in this hospital-wide study. Participants were excluded if they were younger than 2 years, had a medical reason preventing the use of the chlorhexidine, had the catheter inserted in theatre, did not have the catheter insertion date documented, required in-and-out or suprapubic catheterisation, had symptoms and signs suggestive of UTI at the time of catheter insertion, or were currently undergoing treatment for UTI. The intervention was the use of 0·1% chlorhexidine solution for meatal cleaning before urinary catheterisation with 0·9% normal saline used in the control phase. Masking of hospitals was not possible because it was not feasible to mask staff administering the intervention. The co-primary outcomes were the number of cases of catheter-associated asymptomatic bacteriuria and UTI per 100 catheter-days and were assessed within 7 days of catheter insertion in the intention-to-treat population. This trial is registered with Australian New Zealand Clinical Trials Registry, number ACTRN12617000373370.

Findings

21 hospitals were assessed for eligibility between Jan 5, 2017, and May 1, 2017; of these, three were successfully enrolled and randomised to one of three intervention crossover dates. 1642 participants in these hospitals were included in the study between Aug 1, 2017, and March 12, 2018, 697 (42%) in the control phase and 945 (58%) in the intervention period. In the control period, 13 catheter-associated UTI and 29 catheter-associated asymptomatic bacteriuria events in 2889 catheter-days (0·45 catheter-associated UTI cases and 1·00 catheter-associated asymptomatic bacteriuria cases per 100 catheter-days) were recorded compared with four catheter-associated UTI and 16 catheter-associated asymptomatic bacteriuria events in 2338 catheter-days (0·17 catheter-associated UTI cases and 0·68 catheter-associated asymptomatic bacteriuria cases per 100 catheter-days) during the intervention period. The intervention was associated with a 74% reduction in the incidence of catheter-associated asymptomatic bacteriuria (incident rate ratio 0·26, 95% CI 0·08–0·86, p=0·026), and a 94% decrease in the incidence of catheter-associated UTI (0·06, 95% CI 0·01–0·32, p=0·00080). There were no reported adverse events.

Interpretation

The use of chlorhexidine solution for meatal cleaning before catheter insertion decreased the incidence of catheter-associated asymptomatic bacteriuria and UTI and has the potential to improve patient safety.

Background

The role of environment in infection prevention and control is being increasingly acknowledged. However, gaps remain between what is promoted as best practice in the literature and what is occurring in healthcare settings. In part, this is due to a lack of generally accepted scientific standards, further confounding the ability to demonstrate an undisputed role for the healthcare environment in healthcare-acquired infections (HAIs). Evaluating environmental cleanliness in a standardised format is required, in order to enable a framework for performance management and provide a method by which interventions can be evaluated. Standardised assessment would provide reliable data to support quality-improvement activities and to ensure that healthcare staff have relevant and useful information to inform and adapt practice.

Methods

This integrative literature reviewdescribes approaches to assessing environmental cleanliness. A search of the published literature was undertaken, in combination with a targeted review of the grey literature.

Results

Four methods for assessing environmental cleanliness were identified: visual inspection, fluorescent gel marker, adenosine triphosphate (ATP) and microbial cultures. Advantages and disadvantages for each are explored.

Conclusion

Methods that evaluate cleaning performance are useful in assessing adherence to cleaning protocols, whereas methods that sample bio-burden provide a more relevant indication of infection risk. Fast, reproducible, costeffective and reliable methods are needed for routine environmental cleaning evaluation in order to predict timely clinical risk.

A systematic review and meta-analysis was conducted to determine the risk of pathogen acquisition for patients associated with prior room occupancy. The analysis was also broadened to examine any differences in acquisition risk between Gram-positive and Gram–negative organisms. A search using MEDLINE/Pubmed, Cochrane and CINHAL yielded 2,577 citations between 1984 and 2014. Reviews were assessed in accordance with the international prospective register of systematic reviews (PROSPERO). Just seven articles met the inclusion criteria namely, (a) papers were peer reviewed, (b) pathogen acquisition prevalence rates were reported, (c) articles were written in English; and (d) had minimal or no risk of bias based on the Newcastle-Ottawa Scale (NOS). One study was an extension of a previous study and was discarded. Employing NOS provided little difference between the studies, with five studies receiving eight-star, and 2 studies receiving seven-star ratings, respectively. Overall, pooled acquisition odds ratio for study pathogens (methicillin-resistant Staphylococcus aureus; vancomycin-resistant enterococcus; Clostridium difficile; Acinetobacter; ESBL-producing coliforms; Pseudomonas) was 2.14 (95% CI = 1.65–2.77). When comparing data between Gram-positive and Gram-negative organisms, the pooled acquisition odds ratio for Gram-negatives was 2.65 (95% CI = 2.02–3.47) and 1.89 (95% CI = 1.62–2.21) for Gram-positives. The findings have important implications for infection control professionals, environmental cleaning services and patients, given that current practices fail to adequately reduce acquisition risk. While there may be non-preventable sources of acquisition, revised practices require collaborative work between all responsible staff in order to reduce this risk to a minimum.