The needs of developing countries and the resources required

Measuring the effectiveness of an integrated intervention package to improve the level of infection prevention and control: a multi-centre study in Bangladesh

BACKGROUND

Infection prevention and control (IPC) is a critical component of delivering safe, effective and high-quality healthcare services, and eliminating avoidable healthcare-associated infections (HAIs) in health facilities, predominantly in population-dense settings such as Bangladesh.

AIM

Our study aimed to assess the effect of an integrated intervention package in improving the IPC level of the health facilities in Bangladesh.

METHODS

We conducted a pre-post intervention study in six district hospitals (DHs) and 13 Upazila Health Complexes (UHCs) in the six districts of Bangladesh. Baseline and endline assessments were conducted between March and December 2021 using the adapted World Health Organization Infection Prevention and Control Assessment Framework (WHO-IPCAF) tool. The IPCAF score, ranging from 0-800, was calculated by adding the scores of eight components, and the IPC promotion and practice level was categorized as Inadequate (0-200), Basic (201-400), Intermediate (401-600) and Advanced (601-800). The integrated intervention package including IPC committee formation, healthcare provider training, logistics provision, necessary guidelines distribution, triage/flu corners establishment, and infrastructure development was implemented in all facilities.

RESULTS

The average IPCAF score across all the facilities showed a significant increase from 16% (95% CI: 11.5-20.65%) to 54% (95% CI: 51.4-57.1%). Overall, the IPCAF score increased by 34 percentage points (P<0.001) in DHs and 40 percentage points (P<0.001) in UHCs. Following the intervention, 12 (three DHs, nine UHCs) of 19 facilities progressed from inadequate to intermediate, and another three DHs upgraded from basic to intermediate in terms of IPC level.

CONCLUSION

The integrated intervention package improved IPCAF score in all facilities.

Institutional Factors Associated with Infection Prevention and Control Practices Globally during the Infectious Pandemics in Resource-Limited Settings

Healthcare-associated infections lead to considerable morbidity, a prolonged hospital stay, antibiotic resistance, long-term disability, mortality and increased healthcare costs. Based on the literature, some individual and socio-demographic factors including knowledge, age and length of service or work experience, gender and type of profession influence compliance with infection prevention and control procedures. In addition, organizational culture, which refers to the assumptions, values, and norms shared among colleagues, can influence an individual's thinking and healthcare workers' behavior, either positively or negatively. Infection control practices based on the perspective of patients, hospital management and healthcare workers may help develop a better understanding of the factors influencing compliance with infection prevention and control policies and guidelines.

Risk Factors for Surgical Site Infections in Pediatric General Surgery: A Case–Control Study

Objective Despite being the most common postoperative complication and having associated morbidity and mortality that increase health care costs, surgical site infection (SSI) has not received adequate attention and deserves further study. Previous reports in children were limited to SSI in certain populations. We conducted this retrospective case–control study to determine the incidence and possible risk factors for SSI following pediatric general surgical procedures.

Methods This was a retrospective case–control matched cohort study of all patients aged 0 to 14 years who underwent pediatric general surgical procedures between June 2015 and July 2018. The electronic medical records were searched for a diagnosis of SSI. Control subjects were randomly selected at a 4:1 ratio from patients who underwent identical procedures. Multiple risk factors were evaluated by bivariate analysis and multivariable conditional logistic regression.

Results A total of 1,520 patients underwent a general pediatric procedure during the study period, and of these, 47 (3.09%) developed SSIs. A bivariate analysis showed that patients with SSIs were younger, were admitted to the neonatal intensive care unit/pediatric intensive care unit (NICU/PICU) preoperatively, were more severely ill as measured by the ASA classification, underwent multiple procedures, had more surgical complications, and were transferred to the NICU/PICU postoperatively. A multivariate analysis identified four independent predictors of SSI: age, preoperative NICU/PICU admission, number of procedures, and ASA classification.

Conclusion Younger children with preoperative admission to the NICU/PICU, those who underwent multiple procedures and those who were severely ill as measured by their ASA classification were significantly more likely to develop SSIs.

Cost-effectiveness of interventions to improve hand hygiene in healthcare workers in middle-income hospital settings: a model-based analysis

BACKGROUND

Multi-modal interventions are effective in increasing hand hygiene (HH) compliance among healthcare workers, but it is not known whether such interventions are cost-effective outside high-income countries.

AIM

To evaluate the cost-effectiveness of multi-modal hospital interventions to improve HH compliance in a middle-income country.

METHODS

Using a conservative approach, a model was developed to determine whether reductions in meticillin-resistant Staphylococcus aureus bloodstream infections (MRSA-BSIs) alone would make HH interventions cost-effective in intensive care units (ICUs). Transmission dynamic and decision analytic models were combined to determine the expected impact of HH interventions on MRSA-BSI incidence and evaluate their cost-effectiveness. A series of sensitivity analyses and hypothetical scenarios making different assumptions about transmissibility were explored to generalize the findings.

FINDINGS

Interventions increasing HH compliance from a 10% baseline to ≥20% are likely to be cost-effective solely through reduced MRSA-BSI. Increasing compliance from 10% to 40% was estimated to cost US$2515 per 10,000 bed-days with 3.8 quality-adjusted life-years (QALYs) gained in a paediatric ICU (PICU) and US$1743 per 10,000 bed-days with 3.7 QALYs gained in an adult ICU. If baseline compliance is not >20%, the intervention is always cost-effective even with only a 10% compliance improvement.

CONCLUSION

Effective multi-modal HH interventions are likely to be cost-effective due to preventing MRSA-BSI alone in ICU settings in middle-income countries where baseline compliance is typically low. Where compliance is higher, the cost-effectiveness of interventions to improve it further will depend on the impact on hospital-acquired infections other than MRSA-BSI.

Case study: Reducing preventable maternal mortality in Rwandan healthcare facilities through improvements in WASH protocols

Problem

A lack of proper water, sanitation, and hygiene (WASH) infrastructure and poor hygiene practices reduce the preparedness and response of health care facilities (HCFs) in low-income countries to infection and disease outbreaks. According to a World Bank Service Provision Assessment conducted in 2007, only 28% of HCFs in Rwanda had water access throughout the year supplied by tap and 58% of HCFs provided functioning latrines. 1 This evaluation of services and infrastructure in HCFs in Rwanda indicates that targets for WASH in-country need to be enhanced.

Objectives

To present a case study of the causes and management of sepsis during delivery that led to the death of a 27-year-old woman, and propose a WASH protocol to be implemented in HCFs in Rwanda.

Methods

The state of WASH services used by staff, caregivers, and patients in HCFs was assessed in 2009 in national evaluations conducted by the Ministry of Infrastructure of Rwanda. Site selection was purposive, based on the presence of both water and power supply. Direct observation was used to assess water treatment, presence and condition of sanitation facilities and sterile equipment in the delivery room, provision of soap and water, gloves, alcohol-based hand rub, and WASH-related record keeping.

Results

All healthcare facilities met Ministry policies for water access, but WHO guidelines for environmental standards, including for water quality, were not fully satisfied.

Conclusions

The promotion and provision of low-cost technologies that enable improved WASH practices could help to reduce high rates of morbidity and mortality due to infection in low-income countries.

Reducing Hospital-acquired Infection Rate using the Six Sigma DMAIC Approach

Background:

Hospital-acquired infection (HAI) is one of the most common complications occurring in a hospital setting. Although previous studies have demonstrated the application of data-driven Six Sigma DMAIC (Define, Measure, Analyze, Improve and Control) methodology in various health-care settings, no such studies have been conducted on HAI in the Saudi Arabian context.

Objective:

The purpose of this research was to study the effect of the Six Sigma DMAIC approach in reducing the HAI rate at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia.

Methods:

Historical data on HAI reported at inpatient units of the hospital between January and December 2013 were collected, and the overall HAI rate for the year 2013 was determined. The Six Sigma DMAIC approach was then prospectively implemented between January and December 2014, and its effect in reducing the HAI rate was evaluated through five phases. The incidence of HAI in 2013 was used as the problem and a 30% reduction from 4.18 by the end of 2014 was set as the project goal. Potential causes contributing to HAI were identified by root cause analysis, following which appropriate improvement strategies were implemented and then the pre- and postintervention HAI rates were compared.

Results:

The overall HAI rate was observed as 4.18. After implementing improvement strategies, the HAI rate significantly reduced from 3.92 during the preintervention phase (first quarter of 2014) to 2.73 during the postintervention phase (third quarter of 2014) (P < 0.05). A control plan was also executed to sustain this improvement.

Conclusion:

The results show that the Six Sigma “DMAIC” approach is effective in reducing the HAI rate.

Surgical Site Infection Rate Drops to 0% Using a Vacuum-Assisted Closure in Contaminated/ Dirty Infected Laparotomy Wounds

Wound site infections increase costs, hospital stay, morbidity, and mortality. Techniques used for wounds management after laparotomy are primary, delayed primary, and vacuum-assisted closures. The objective of this study is to compare infection rates between those techniques in contaminated and dirty/ infected wounds. Eighty-one laparotomized patients with Class III or IV surgical wounds were enrolled in a three-arm randomized prospective study. Patients were allocated to each group with the software Research Randomizer® (Urbaniak, G. C, & Plous, S., Version 4.0). Presence of infection was determined by a certified board physician according to Centers for Disease Control's Criteria for Defining a Surgical Site Infection. Twenty-seven patients received primary closure, 29 delayed primary closure, and 25 vacuum-assisted closure, with no exclusions for analysis. Surgical site infection was present in 10 (37%) patients treated with primary closure, 5 (17%) with primary delayed closure, and 0 (0%) patients receiving vacuum-assisted closure. Statistical significance was found between infection rates of the vacuum-assisted group and the other two groups. No significant difference was found between the primary and primary delayed closure groups. The infection rate in contaminated/dirty-infected laparotomy wounds decreases from 37 and 17 per cent with a primary and delayed primary closures, respectively, to 0 per cent with vacuum-assisted systems.

Nosocomial infection and its molecular mechanisms of antibiotic resistance

Nosocomial infection is a kind of infection, which is spread in various hospital environments, and leads to many serious diseases (e.g. pneumonia, urinary tract infection, gastroenteritis, and puerperal fever), and causes higher mortality than community-acquired infection. Bacteria are predominant among all the nosocomial infection-associated pathogens, thus a large number of antibiotics, such as aminoglycosides, penicillins, cephalosporins, and carbapenems, are adopted in clinical treatment. However, in recent years antibiotic resistance quickly spreads worldwide and causes a critical threat to public health. The predominant bacteria include Methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, and Acinetobacter baumannii. In these bacteria, resistance emerged from antibiotic resistant genes and many of those can be exchanged between bacteria. With technical advances, molecular mechanisms of resistance have been gradually unveiled. In this review, recent advances in knowledge about mechanisms by which (i) bacteria hydrolyze antibiotics (e.g. extended spectrum β-lactamases, (ii) AmpC β-lactamases, carbapenemases), (iii) avoid antibiotic targeting (e.g. mutated vanA and mecA genes), (iv) prevent antibiotic permeation (e.g. porin deficiency), or (v) excrete intracellular antibiotics (e.g. active efflux pump) are summarized.

Diversities in perceived knowledge and practice of preoperative skin preparation in Swedish orthopaedic surgery

Preoperative skin preparations may reduce the risk of hospital-acquired infections. This cross sectional questionnaire study aimed to identify the practice and knowledge of preoperative skin preparation in Swedish orthopaedic surgery departments. One hundred and six respondents (response rate 68%) from 13 Swedish orthopaedic departments reported a diversity of current recommendations and evidence, and good knowledge of skin preparations. This study found variations in practice and deviations from recommendations, despite high levels of knowledge.

Success in the South Pacific: a case study of successful diffusion of an infection prevention and control program

INTRODUCTION

The aim of this study was to explore the role of the Diffusion of Innovations framework in adopting an infection prevention and control program (IPCP) in a low and middle income (LMI) country, the Republic of Kiribati.

METHODS

Case-study methodology was used to examine and contextualise the analysis of the Republic of Kiribati's adoption of the IPCP from 2003 to 2010. Data were collected from multiple sources including semi-structured interviews, IPCP documentation, program evaluation and a healthcare worker survey. Data were subjected to thematic analysis and descriptive statistics where relevant to the study design.

RESULTS

It was found that the self-initiated progression of activities and stimuli has resulted in the successful adoption of a comprehensive IPCP. The process followed the staged model of the classic Diffusion of Innovations process in organisations described by Everett Rogers.

CONCLUSION

This case study provides an illustration of how a comprehensive IPCP can be adopted in a LMI country setting with little involvement from external agencies. It identifies key stimuli, opportunities and activities which could be similarly adopted and implemented by other LMI countries.

Bacteriological assessment of the hospital environment in two referral hospitals in Yaoundé-Cameroon

Introduction

Many studies still show significant numbers of surgical patients contracting nosocomial infections each year globally with high morbidity and mortality. The aim of this study was to identify potential bacteria reservoirs that may be responsible for nosocomial infection in surgical services in the Yaoundé University Teaching Hospital (YUTH) and the Central Hospital Yaoundé (CHY).

Methods

A cross sectional descriptive study was conducted from June to August 2012. Air, water, and surface samples were collected from two surgical services and subjected to standard bacteriological analysis.

Results

A total of 143 surface samples were collected. Bacteria were isolated in all surfaces except from one trolley sample and a surgical cabinet sample. The predominant species in all services was coagulase negative Staphylococcus (CNS). The average number of colonies was 132. 82CFU/25cm². The bacteria isolated in the air were similar to those isolated from surfaces. From the 16 water samples cultured, an average of 50.93 CFU/100ml bacteria were isolated. The distribution of isolated species showed a predominance of Burkholderia cepacia.

Conclusion

These results showed the importance of the hospital environment as a potential reservoir and source of nosocomial infections amongst surgical patient at YUTH and CHY, thus we suggest that Public health policy makers in Cameroon must define, publish guidelines and recommendations for monitoring environmental microbiota in health facilities.

National Survey of Practices to Prevent Healthcare-Associated Infections in Thailand: The Role of Safely Culture and Collaboratives

Objective.

To evaluate hospital characteristics and practices used by Thai hospitals to prevent catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP), the 3 most common types of healthcare-associated infection (HAI) in Thailand.

Design.

Survey.

Setting.

Thai hospitals with an intensive care unit and 250 or more hospital beds

Methods.

Between January 1, 2010, and October 31, 2010, research nurses collected data from all eligible hospitals. The survey assessed hospital characteristics and practices to prevent CAUTI, CLABSI, and VAP. Ordinal logistic regression was used to assess relationships between hospital characteristics and use of prevention practices.

Results.

A total of 204 (80%) of 256 hospitals responded. Most hospitals (93%) reported regularly using alcohol-based hand rub. The most frequently reported prevention practice by infection was as follows: for CAUTI, condom catheters in men (47%); for CLABSI, avoiding routine central venous catheter changes (85%); and for VAP, semirecumbent positioning (84%). Hospitals with peripherally inserted central catheter insertion teams were more likely to regularly use elements of the CLABSI prevention bundle. Greater safety scores were associated with regular use of several VAP prevention practices. The only hospital characteristic associated with increased use of at least 1 prevention practice for each infection was membership in an HAI collaborative.

Conclusions.

While reported adherence to hand hygiene was high, many of the prevention practices for CAUTI, CLABSI, and VAP were used infrequently in Thailand. Policies and interventions emphasizing specific infection prevention practices, establishing a strong institutional safety culture, and participating in collaboratives to prevent HAI may be beneficial.

Stethoscopes as potential intrahospital carriers of pathogenic microorganisms

Stethoscopes can take part in the transmission of health care-associated infections. We cultured 112 stethoscopes by direct imprint on blood agar to estimate the prevalence of potentially pathogenic microorganisms. Forty-eight (47%) produced 50 potentially pathogenic microorganisms; from these, 43 (86%) were Staphylococcus aureus, of which 18 (42%) were methicillin-resistant S. aureus. We concluded that stethoscopes should be considered as potential fomites and must be disinfected routinely before and after each patient contact.

Evaluating infection control: a review of implementation of an infection prevention and control program in a low-income country setting

BACKGROUND

This study was conducted to review the status of the comprehensive infection prevention and control program (IPCP) established in the Republic of Kiribati in 2005, and to identify opportunities to continue and expand the integration of the IPCP into health service delivery.

METHODS

The review was conducted in 2010 using 2 empirical tools: a pilot IPCP evaluation (IPCPE) tool that evaluated the activities of the program and its implementation, and a previously validated self-administered survey that assessed health care worker (HCW) knowledge, application, and confidence in infection control principles and practice. The survey was given to all 186 clinicians at Tungaru Central Hospital; the response rate was 59.7%.

RESULTS

The Kiribati IPCP demonstrated a minimum level of compliance (75%) with the activity standards set out in the IPCPE tool. The mean scores on the HCW survey were 62% for knowledge, 63% for application, and 79% for confidence. Significant correlations were found among knowledge, application, and confidence.

CONCLUSIONS

This evaluation of the Kiribati IPCP with our IPCPE tool provides valuable insight into the status of a recently adopted comprehensive program and how it has translated into the knowledge, application, and confidence of HCWs in their clinical practice. The HCW survey provides evidence that the IPCP has translated into confidence and ability in the application of infection prevention practices.

Potential sources of transmission of hospital acquired infections in the volta regional hospital in Ghana

BACKGROUND

The study was undertaken to assess potential sources that might transmit Hospital Acquired Infections in the Volta Regional Hospital of Ghana.

METHOD

A total of 218 swabs were taken over a six month study period of two weeks sampling bi-monthly from 33 different door handles, taps, desk surfaces and lavatories and 15 different surfaces in the theatre before and after cleaning on each sampling day. The swabs were cultured on Blood, Chocolate and MacConkey agars and incubated for 24hrs at 35±2°C after which isolates were identified morphologically and biochemically.

RESULTS

A total of 187 (88.8%) bacterial isolates were obtained from the swabs (P<0.0017) made up of 55.5% non-pathogenic isolates, 33.3% pathogenic isolates and 14.2% no bacteria growth. There was significant difference between pathogenic isolates and no bacterial growth (P=0.0244). The largest pathogenic isolates were S. aureus (57.6%) and E. coli (39.4%) whilst Bacillus spp. was the only non-pathogenic isolate. Door handles of the various wards and theatre had the highest total bacterial isolates (25.7%), followed by the lavatories (24.6%); whereas the lavatories recorded the most pathogenic isolate (21), followed by taps. There was no change in S. aureus isolate numbers after cleaning whereas E. coli decreased by (26.7%) and Bacillus spp. increase by (32.7%).

CONCLUSION

The high percentage of pathogenic isolates of S. aureus and E. coli as well as Bacillus spp. on fomites at the Volta Regional Hospital indicates a high potential risk of HAI in the hospital.

Help or hindrance? Is current infection control advice applicable in low- and middle-income countries? A review of the literature

BACKGROUND

High-income countries with established infection control programs have demonstrated effective control of infection transmission in health care settings. The guidelines and advice underlying these effective control programs have been produced by high-income countries for their own social, economic, and health environments. These have also been adopted by low- and middle-income (LMI) countries, but these countries appear to have a limited ability to apply these principles using the same methods.

METHODS

A systematic search for literature published in English was conducted exploring the relationship between the available infection prevention and control advice and the capacity of LMI countries to apply this guidance in their health care settings. Articles relevant to this exploration were identified and subsequently informed further search terms and identified other significant documents.

RESULTS

Infection control guidelines designed for high-income countries are being utilized by LMI countries, with varying degrees of success mainly because of physical, environmental, and socioeconomic factors. There is a lack of published studies exploring the implementation of comprehensive infection control advice and programs, including the minimal advice, which is designed specifically for resource-limited settings.

CONCLUSION

What is evident from the literature is that there is a need for the development of infection control and prevention guidelines based on evidence but adapted to the specific needs of health care workers in LMI countries. This must be done in collaboration with those same LMI countries' health care workers. Equally, because of finance and health priorities, health care facilities should choose those interventions most relevant to the needs of their population and workers to prevent infection transmission. Opportunities for further research into application of available infection control advice in LMI countries are identified. Through such research, more appropriate advice may be devised to assist with the development of infection control programs in these settings.

Prevalence and predictors of surgical site infection in Tbilisi, Republic of Georgia

Surgical site infections (SSIs) are a serious problem worldwide. Little is known about the epidemiology of SSI in the former Soviet Union. In order to determine the prevalence and predictors of SSI in the Republic of Georgia, we undertook a multicentre observational study of SSIs in three urban hospitals in the capital, Tbilisi. Point prevalence studies (PPS) were performed every 3-5 weeks from September 2000 to January 2002 using the National Nosocomial Infections Surveillance (NNIS) System definitions. All patients who had undergone surgery and were present in participating departments at study hospitals on the day of PPS were included. Of 872 surgical procedures, 146 (16.7%) were complicated by SSI. The prevalence of SSI varied by procedure and risk category. On multivariate regression analysis, age, wound class, one hospital (B) and urological surgery were predictive of SSI. In a separate model, NNIS risk index was highly predictive of SSI. Antibiotic prophylaxis was rare (29.5% of operations), while postoperative antibiotic use was common. SSI is an important problem in the Republic of Georgia. Potential areas for intervention include antibiotic prophylaxis and shaving practices for skin preparation.

‘Clean Care is Safer Care’: the Global Patient Safety Challenge 2005–2006

BACKGROUND

Each year the treatment and care of hundreds of millions of patients worldwide is complicated by infections acquired during healthcare. The impact of healthcare-associated infection may imply prolonged stays in hospital, long-term disability, massive additional financial burden, and deaths.

ACTION

Patient safety is a global issue that affects both developed and developing countries. In October 2004, the World Health Organization launched the World Alliance for Patient Safety to co-ordinate and accelerate improvements in patient safety internationally. A core element of the Alliance is the identification of a topic to be addressed as a Global Patient Safety Challenge over a two-year cycle. The first topic chosen for 2005-2006 is healthcare-associated infection.

PERSPECTIVES

The Challenge aims at implementing several actions to tackle healthcare-associated infections worldwide, regardless of the level of development of healthcare systems and the availability of resources. Implementation strategies include the integration in different healthcare settings of multiple interventions in the areas of blood safety, injection safety, and clinical procedure safety, as well as water, sanitation, and waste management, with the promotion of hand hygiene in healthcare as the cornerstone.

Infection Control: Old Problems and New Challenges

Infection control faces radical changes at the beginning of the third millennium. The first part of this review focuses on problems not yet solved, such as 1) surveillance systems, which should be active and extremely flexible; 2) infection outbreaks in hospitals and strategies to avoid them; 3) hand washing and alternatives such as rapid hand antisepsis; 4) water and food in the hospital as potential reservoirs of nosocomial pathogens; 5) upgrading of infection control programs to turn them into systems to improve the quality of care; 6) fatal Gram-negative bacteremias in hospitals from developing countries, which can be avoided with better standards of care; 7) the elemental role of the microbiology laboratory in the prevention and control of infections; 8) the unprecedented crisis due to the emergence of specific multi-resistant pathogens; 9) the risks for healthcare workers, such as tuberculosis, hepatitis, HIV, SARS, and hemorrhagic fevers; and 10) the need for the consistent application of guidelines. The second part of this review focuses on new challenges for infection control, such as 1) the ever-growing number of immunocompromised patients and basic control measures to avoid opportunistic infections; 2) the concerns about the capacity of the public health systems to deal with terrorist acts; 3) the practice of high-risk procedures in facilities lacking trained personnel, efficient laboratories, and protective items; and 4) gene therapy and its potential infectious complications. Consideration is given to the asymmetric development of infection control globally.

Infection control practices reduce nosocomial infections and mortality in preterm infants in Bangladesh

OBJECTIVE

The skin is a potential source for invasive infections in neonates from developing countries such as Bangladesh, where the level of environmental contamination is exceedingly high. A randomized controlled trial was conducted from 1998 to 2003 in the Special Care Nursery of a tertiary hospital in Bangladesh to test the effectiveness of topical emollient therapy in enhancing the skin barrier of preterm neonates less than 33 weeks of gestational age. In the initial months of the study, the infection and mortality rates were noted to be unacceptably high. Therefore, an infection control program was introduced early in the trial to reduce the rate of nosocomial infections.

STUDY DESIGN

After a comprehensive review of neonatal care practices and equipment to identify sources of nosocomial infections, a simple but comprehensive infection control program was introduced that emphasized education of staff and caregivers about measures to decrease risk of contamination, particularly hand-washing, proper disposal of infectious waste, and strict asepsis during procedures, as well as prudent use of antibiotics.

RESULTS

Infection control efforts resulted in declines in episodes of suspected sepsis (47%), cases of culture-proven (61%) sepsis, patients with a clinical diagnosis of sepsis (79%), and deaths with clinical (82%) or culture-proven sepsis (50%).

CONCLUSION

The infection control program was shown to be a simple, low-cost, low-technology intervention to reduce substantially the incidence of septicemia and mortality in the nursery.

Hospital-acquired neonatal infections in developing countries

Hospital-born babies in developing countries are at increased risk of neonatal infections because of poor intrapartum and postnatal infection-control practices. We reviewed data from developing countries on rates of neonatal infections among hospital-born babies, range of pathogens, antimicrobial resistance, and infection-control interventions. Reported rates of neonatal infections were 3-20 times higher than those reported for hospital-born babies in industrialised countries. Klebsiella pneumoniae, other gram-negative rods (Escherichia coli, Pseudomonas spp, Acinetobacter spp), and Staphylococcus aureus were the major pathogens among 11,471 bloodstream isolates reported. These infections can often present soon after birth. About 70% would not be covered by an empiric regimen of ampicillin and gentamicin, and many might be untreatable in resource-constrained environments. The associated morbidity, mortality, costs, and adverse effect on future health-seeking behaviour by communities pose barriers to improvement of neonatal outcomes in developing countries. Low-cost, "bundled" interventions using systems quality improvement approaches for improved infection control are possible, but should be supported by evidence in developing country settings.

Standard precautions and post exposure prophylaxis for preventing infections

In health care set up, risk of acquiring infection by both patients and health care worker (HCW) from each other is fairly high. Despite progress, hospital acquired infections (HAI) are a problem in both developed and developing countries and are an important cause of death. Many different microbes cause HAI in both patients and HCW; these include various commensals, pathogenic bacteria, viruses, parasites, and fungi. Among these HIV, hepatitis B, and hepatitis C are of major significance to HCW. 'Standard precautions' have now replaced the term 'universal precautions', and are designed to reduce the risk of transmission of microorganisms in health care set-up from both recognized and unrecognized sources. Ultimate aim is to reduce the risk of disease transmission in the healthcare setting, both to the patient and the provider, and thus reduce morbidity. This applies to all patients, regardless of their diagnosis and expands the coverage of universal precautions by recognizing that any body fluid may contain contagious and harmful microorganisms. This article reviews the standard precautions and discusses current guidelines on post exposure prophylaxis (PEP).

Incidence and predictors of surgical-site infections in Vietnam

OBJECTIVE

To determine the incidence of, and risk factors for, surgical-site infections (SSIs).

DESIGN

Prospective observational study of all patients undergoing surgery during a 3-month period.

SETTING

Two urban hospitals in Hanoi, Vietnam.

PATIENTS

All 697 patients admitted for emergent and elective surgery.

METHODS

Data were collected on all patients undergoing surgery during a 3-month period at each hospital. We stratified the data by type of surgery, wound class, and Study on the Efficacy of Nosocomial Infection Control (SENIC) risk index. The analysis was done with the data sets from each hospital separately and with the combined data. The risk factors for SSI were identified using a logistic-regression model.

RESULTS

During the period of observation, 10.9% of 697 patients had SSI. The SSI rate was 8.3% for clean wounds, 8.6% for clean-contaminated, 12.2% for contaminated, and 43.9% for dirty wounds. The lowest rate of SSI (2.4%) was found in obstetric-gynecologic procedures and the highest rate (33.3%) in cardiothoracic operations. Using the SENIC risk index, the incidence of SSI in low-risk patients was 5.1%; for medium-risk patients, 13.5%, and high-risk patients, 24.2%. In a logistic-regression model, abdominal surgery (odds ratio [OR], 4.46; P<.01) and wound class IV (OR, 5.67; P<.01) were significant predictors of SSI. All patients were treated with prolonged courses of perioperative antibiotics. Overall infection control practices were poor as a result of deficient facilities, limited surgical instruments, and a lack of proper supplies for wound care and personal hygiene.

CONCLUSIONS

There was a higher incidence of SSI in low-risk patients in Vietnam compared with developed countries. Excessive reliance on antimicrobial therapy as a means to limit SSI places patients at higher risk of adverse effects from treatment and also may contribute to worsening problems with antimicrobial resistance. Establishment of an infection control program with guidelines for antimicrobial use should improve the use of prophylactic antibiotics and attention to proper surgical and wound-care techniques. These interventions also should reduce the incidence of SSI and its associated morbidity and costs.

Nosocomial Infections in a Community Hospital in Mexico

Results from prospective surveillance of nosocomial infections (NIs) in a small community hospital were evaluated, and a case-control study was conducted. The rate of 1.4 NIs per 100 discharges determined by prospective surveillance was found to be underestimated. Prematurity, pediatric service, surgery, length of stay, and age were independently associated with NI.

Nosocomial infections in a community hospital in Mexico

Results from prospective surveillance of nosocomial infections (NIs) in a small community hospital were evaluated, and a case-control study was conducted. The rate of 1.4 NIs per 100 discharges determined by prospective surveillance was found to be underestimated. Prematurity, pediatric service, surgery, length of stay, and age were independently associated with NI.

Factors associated with tuberculin reactivity in two general hospitals in Mexico

OBJECTIVE

To identify risk factors associated with tuberculin reactivity in healthcare workers (HCWs).

DESIGN

Cross-sectional survey of tuberculin reactivity (2 TU of purified protein derivative (PPD) RT23, using the Mantoux two-step test).

SETTING

Two general hospitals located in a region with a high prevalence of tuberculosis and high bacille Calmette-Guerin (BCG) coverage.

PARTICIPANTS

Volunteer sample of HCWs.

RESULTS

605 HCWs were recruited: 71.2% female; mean age, 36.4 (standard deviation [SD], 8.2) years; 48.9% nurses, 10.4% physicians, 26.8% administrative personnel; mean time of employment, 10.9 (SD, 6.7) years. PPD reactivity (> or =10 mm) was found in 390 (64.5%). Multivariate analysis revealed an association of tuberculin reactivity with occupational exposure in the hospital: participation in autopsies (odds ratio [OR], 9.3; 95% confidence interval [CI95], 2.1-40.5; P=.003.), more than 1 year of employment (OR, 2.4; CI95, 1.1-5.0; P=.02), work in the emergency or radiology departments (OR, 2.0; CI95, 1.03-3.81; P=.04), being physicians or nurses (OR, 1.5; CI95, 1.04-2.11; P=.03), age (OR, 1.04; CI95, 1.02-1.07 per year of age; P<.001), and BCG scar (OR, 2.1; CI95, 1.2-3.4; P=.005).

CONCLUSIONS

Although the studied population has a high baseline prevalence of tuberculosis infection and high coverage of BCG vaccination, nosocomial risk factors associated with PPD reactivity were identified as professional risks; strict early preventive measures must be implemented accordingly.

Molecular epidemiology of an outbreak of Enterobacter cloacae in the neonatal intensive care unit of a provincial hospital in Gauteng, South Africa

An outbreak of Enterobacter cloacae in the neonatal intensive care unit of a provincial hospital in Gauteng, South Africa, resulting in nine deaths was investigated. Macrorestriction analysis using pulsed-field gel electrophoresis revealed that three isolates of E. cloacae from blood cultures of patients, six from environmental sources, and one from the hands of a staff member belonged to the same genotypic cluster.

Incidence of nosocomial pneumonia in a medical intensive care unit and general medical ward patients in a public hospital in Bombay, India

We prospectively studied the incidence of hospital-acquired pneumonia in 1886 consecutive admissions to an 1800 bed hospital in Bombay; 991 of them to general medical wards and 895 to a 17-bed medical intensive care unit (ICU). The average bed occupancy in the general wards was 56 patients in a ward with 40 beds. Staffing in the general ward was two nurses for 56 patients, and in the ICU three nurses for 17 beds. One hundred and sixty-eight patients developed nosocomial pneumonia: 18 (1.8%) in general wards and 150 (16.7%) in the ICU. Common isolates included Pseudomonas spp (44%) and Klebsiella spp (34%). The most frequently used antibiotics were cefotaxime (34%), amikacin (25%), gentamicin (23%) and ofloxacin (13%). Crude mortality in general ward patients was 88.9 vs 14.6% in patients without pneumonia. The corresponding figures for ICU patients were 67.4 vs 37.1%; 40% of the crude mortality in ICU patients with pneumonia was attributable to the infection. Infected patients stayed an additional 5.8 days in the ICU and 6.7 days in the general ward. Costs of additional stay and antibiotics accounted for 18.6% of the ICU budget. The incidence of nosocomial pneumonia was lower than expected, despite occupancy exceeding bed capacity, low nurse:patient ratios, and extensive reuse of disposable respiratory therapy equipment. Nevertheless, nosocomial pneumonia imposes a significant financial burden on the already scarce resources available for intensive care in developing countries like India.

Disinfection and sterilization practices in Mexico

We evaluated antisepsis, disinfection, and sterilization procedures at 22 hospitals in the state of Yucatan, Mexico, which provide services for approximately 80% of the population. The percentage of hospitals that followed standard recommendations for diverse antisepsis procedures were as follows: surgical scrub, 41%; surgical site preparation, 68%; central intravenous (iv) catheters, 61%; peripheral iv catheters, 86%; urinary catheters, 41%, and umbilical cord care, 5%. Inappropriate procedures typically involved the use of benzalkonium chloride and mercury compounds. Adequate sterilization procedures were observed for sharp surgical instruments in 9%, for blunt surgical instruments in 81%; for linen in 90%; for surgical brushes in 9%; for metal prostheses in 100%; for plastic prostheses in 57%; and for disinfection of endoscopes in 30%. The most common errors were the use of too short an exposure time in steam sterilizers or dry heat sterilizers, and the use of benzalkonium chloride as a sterilizing agent. Only 14% of hospitals used commercial spore preparations for autoclave monitoring. For the reuse of disposables, 50-94% of hospitals employed inappropriate sterilization or low-level disinfection procedures. Similar conditions are likely to exist in hospitals throughout the country. The establishment of strict regulations and hospital training programmes for disinfection and sterilization procedures, and the reuse of disposable devices is urgently needed in Mexico.