Review of hospital isolation and infection control precautions

Antimicrobial Peptides in Infectious Diseases and Beyond-A Narrative Review

Despite recent medical research and clinical practice developments, the development of antimicrobial resistance (AMR) significantly limits therapeutics for infectious diseases. Thus, novel treatments for infectious diseases, especially in this era of increasing AMR, are urgently needed. There is ongoing research on non-classical therapies for infectious diseases utilizing alternative antimicrobial mechanisms to fight pathogens, such as bacteriophages or antimicrobial peptides (AMPs). AMPs are evolutionarily conserved molecules naturally produced by several organisms, such as plants, insects, marine organisms, and mammals, aiming to protect the host by fighting pathogenic microorganisms. There is ongoing research regarding developing AMPs for clinical use in infectious diseases. Moreover, AMPs have several other non-medical applications in the food industry, such as preservatives, animal husbandry, plant protection, and aquaculture. This review focuses on AMPs, their origins, biology, structure, mechanisms of action, non-medical applications, and clinical applications in infectious diseases.

Healthcare workers' behaviors on infection prevention and control and their determinants during the COVID-19 pandemic: a cross-sectional study based on the theoretical domains framework in Wuhan, China

Background

Infection prevention and control (IPC) measures are crucial to combat the COVID-19 pandemic. This study aimed to explore the levels and determinants of HCWs’ IPC behaviors based on the theoretical domains framework (TDF), which has been shown to be effective in guiding behavior change.

Methods

A cross-sectional survey was conducted in Wuhan, China in January 2020. Self-reported hand hygiene and droplet isolation behaviors (including the use of masks, gloves, goggles and gowns) were set as dependent variables. TDF domains and HCWs’ characteristics were independent variables. Negative binomial regression analyses were performed to explore their relationships.

Results

HCWs reported good IPC behaviors, while the compliance with goggle and gown use was relatively low (below 85%). Environmental context and resources domain was significantly related to hand hygiene (β = 0.018, p = 0.026), overall droplet isolation behaviors (β = 0.056, p = 0.001), goggle (β = 0.098, p = 0.001) and gown use (β = 0.101. p < 0.001). Knowledge domain was significantly related to goggle (β = 0.081, p = 0.005) and gown use (β = 0.053, p = 0.013). Emotion domain was a predictor of overall droplet isolation behaviors (β = 0.043, p = 0.016), goggle (β = 0.074, p = 0.026) and gown use (β = 0.106, p < 0.001). Social influences domain was a predictor of overall droplet isolation behaviors (β = 0.031, p = 0.029) and gown use (β = 0.039, p = 0.035). HCWs in high-risk departments had better behaviors of gown use (β = 0.158, p = 0.032). HCWs who had encountered confirmed or suspected patients reported worse behaviors of goggle (β = − 0.127, p = 0.050) and gown use (β = − 0.153, p = 0.003).

Conclusions

Adequate personal protective materials and human resources, education and training, as well as supervision and role model setting are necessary to improve IPC behaviors regarding the COVID-19 pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-021-00641-0.

A review of isolation practices and procedures in healthcare settings

The notion of 'isolation' in infectious diseases refers to the possibility of people known or suspected to be infected from the wider population, and has historically been used to control and prevent the spread of infectious diseases. Isolation practices in healthcare settings evolved over the 20th century resulting in a focus on the disruption of known routes of potential transmission. There was renewed attention to infection prevention and control (IPC) in the UK at the turn of the 20th century after high-profile reports acknowledged the importance of IPC as a key indicator of high-quality clinical care, and the impact of healthcare-acquired infections. There has been a shift away from isolation wards towards isolation in single rooms on general wards. For infections that are spread by the airborne, droplet or contact routes, placing the patient in single-room isolation is considered to be an important component of transmission-based precautions (TBPs). However, in practice isolation is complex and a number of challenges are involved in implementing IPC procedures.

Pitfall benchmarking of cleaning costs in hospitals

Purpose

It is typical of public real estate benchmarking reports to show only highly aggregated benchmarks based on buildings’ floor areas. They hardly provide disaggregated benchmarks for usage clusters. The aim of this study is to show the caveats from highly aggregated benchmarking without consideration of cluster-specific characteristics.

Design/methodology/approach

Based on the parameters of the German facility management association 812 standards, cleaning costs and costs for the surfaces of seven hospitals have been collected and allocated to specific room clusters. Using these basic data, a calculation and simulation conducted with the aim of simulating facilities that are comparable in the sum of costs yet feature varying sub-clusters as cost drivers. In particular, during this simulation, area ratios were varied randomly and the average cleaning costs per cluster were held constant for all hospitals. Therefore, the costs per square meter in the clusters of all simulated hospitals are identical and the full costs only depend on the area ratios.

Findings

The simulation shows that highly aggregated cleaning costs lead to large spans, and thus, to misinterpretations in the field of action. In the case, the aggregate benchmark ranges from 40.6 to 66.5 EUR/m², although, for all hospitals the same costs per square meter had been used. Thus, the bias results only from varying the share of area across the clusters. This finding is caused by a well-known statistical problem: the Simpson’s paradoxon, which currently receives little attention in real estate benchmarking.

Practical implications

The results show, that the regular benchmarking with high aggregated data, often used in practice, cannot be recommended. The author consider using a detailed benchmarking as meaningful and purposeful. To be able to make a detailed benchmarking, it is essential to identify and collect the influencing factors. Only if all important factors, in this case, the clusters will be regarded in the benchmarking, a reasonable benchmarking and useful interpretation can be given. Using a simple benchmarking to get a rough overview is refused steadfastly.

Originality/value

The study highlights that a comparison with public benchmarking reports (operation costs) must be taken with great caution. The author has quantified the bias from the aggregated benchmarking and have shown, that the Simpson’s paradox fully explains the consequences.

Infection prevention control and organisational patient safety culture within the context of isolation: study protocol

BACKGROUND

Healthcare associated infection (HCAI) is a major cause of morbidity and mortality. In recent years, there have been high profile successes in infection prevention control (IPC), such as the dramatic reductions in methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (which is viewed as one proxy indicator of overall harm) and Clostridium difficile in the UK. Nevertheless, HCAI remains a costly burden to health services, a source of concern to patients and the public and at present, is receiving priority from policy makers as it contributes to the global threat of antimicrobial resistance.

METHODS

The study involves qualitative case studies within isolation settings at two National Health Service (NHS) district general hospitals (DGHs) in Wales, in the UK. The 18-month study incorporates Manchester Patient Safety Framework (MaPSaF) workshops with health workers and other hospital staff, in depth interviews with patients and their relative / informal carer, health workers and hospital staff, and periods of hospital ward observation.

DISCUSSION

The present study aims to investigate the ways in which engagement of health workers with IPC strategies and principles, shape and inform organisational patient safety culture within the context of isolation in surgical, medical and admission hospital settings; and vice-versa. We want to understand the meaning of IPC 'ownership' for health workers; the ways in which IPC is promoted, how IPC teams operate as new challenges arise, how their effectiveness is assessed and the positioning of IPC within the broader context of organisational patient safety culture, within hospital isolation settings.

Antimicrobial activity of wild mushroom extracts against clinical isolates resistant to different antibiotics

AIMS

This work aimed to screen the antimicrobial activity of aqueous methanolic extracts of 13 mushroom species, collected in Bragança, against several clinical isolates obtained in Hospital Center of Trás-os-Montes and Alto Douro, Portugal.

METHODS AND RESULTS

Microdilution method was used to determine the minimum inhibitory concentration (MIC) and the minimum bactericidal concentration (MBC). MIC results showed that Russula delica and Fistulina hepatica extracts inhibited the growth of gram-negative (Escherichia coli, Morganella morganni and Pasteurella multocida) and gram-positive (Staphylococcus aureus, MRSA, Enterococcus faecalis, Listeria monocytogenes, Streptococcus agalactiae and Streptococcus pyogenes) bacteria. A bactericide effect of both extracts was observed in Past. multocida, Strep. agalactiae and Strep. pyogenes with MBC of 20, 10 and 5 mg ml⁻¹, respectively. Lepista nuda extract exhibited a bactericide effect upon Past. multocida at 5 mg ml⁻¹ and inhibited Proteus mirabilis at 20 mg ml⁻¹. Ramaria botrytis extract showed activity against Enterococcus faecalis and L. monocytogenes, being bactericide for Past. multocida, Strep. agalactiae (MBCs 20 mg ml⁻¹) and Strep. pyogenes (MBC 10 mg ml⁻¹). Leucopaxillus giganteus extract inhibited the growth of E. coli and Pr. mirabilis, being bactericide for Past. multocida, Strep. pyogenes and Strep. agalactiae.

CONCLUSIONS

Fistulina hepatica, R. botrytis and R. delica are the most promising species as antimicrobial agents.

SIGNIFICANCE AND IMPACT OF THE STUDY

Mushroom extracts could be an alternative as antimicrobials against pathogenic micro-organisms resistant to conventional treatments.

Patterns of antimicrobial therapy in severe nosocomial infections: empiric choices, proportion of appropriate therapy, and adaptation rates--a multicentre, observational survey in critically ill patients

This prospective, observational multicentre (n=24) study investigated relationships between antimicrobial choices and rates of empiric appropriate or adequate therapy, and subsequent adaptation of therapy in 171 ICU patients with severe nosocomial infections. Appropriate antibiotic therapy was defined as in vitro susceptibility of the causative pathogen and clinical response to the agent administered. In non-microbiologically documented infections, therapy was considered adequate in the case of favourable clinical response <5 days. Patients had pneumonia (n=127; 66 ventilator-associated), intra-abdominal infection (n=23), and bloodstream infection (n=21). Predominant pathogens were Pseudomonas aeruginosa (n=29) Escherichia coli (n=26), Staphylococcus aureus (n=22), and Enterobacter aerogenes (n=21). In 49.6% of infections multidrug-resistant (MDR) bacteria were involved, mostly extended-spectrum beta-lactamase (EBSL)-producing Enterobacteriaceae and MDR non-fermenting Gram-negative bacteria. Prior antibiotic exposure and hospitalisation in a general ward prior to ICU admission were risk factors for MDR. Empiric therapy was appropriate/adequate in 63.7% of cases. Empiric schemes were classified according to coverage of (i) ESBL-producing Enterobacteriaceae and non-fermenting Gram-negative bacteria ("meropenem-based"), (ii) non-fermenting Gram-negative bacteria (schemes with an antipseudomonal agent), and (iii) first-line agents not covering ESBL-Enterobacteriaceae nor non-fermenting Gram-negative bacteria. Meropenem-based schemes allowed for significantly higher rates of appropriate/adequate therapy (p<0.001). This benefit remained when only patients without risk factors for MDR were considered (p=0.021). In 106 patients (61%) empiric therapy was modified: in 60 cases following initial inappropriate/inadequate therapy, in 46 patients in order to refine empiric therapy. In this study reflecting real-life practice, first-line use of meropenem provided significantly higher rates of the appropriate/adequate therapy, irrespective of presence of risk factors for MDR.

Importance of environmental decontamination--a critical view

The level of evidence supporting different disinfection and cleaning procedures performed in healthcare settings worldwide is low. With respect to environmental surfaces, the final assessment of whether use of disinfectants rather than detergents alone reduces nosocomial infection rates in different clinical settings still awaits conclusive study. It must be kept in mind that the effect of surface disinfection is only transient microbial contamination will have reached its former level within a few hours. While resistance to biocides is generally not judged to be as critical as antibiotic resistance, scientific data support the need for proper use, i.e. avoidance of widespread application, especially in low concentrations and in consumer products. The decontamination ability of the substances used; prevention of resistance; and safety for patients, personnel and the environment; are the cornerstones that interact with each other. Future work should focus on this complex background. Targeted disinfection of environmental surfaces (those frequently touched) is an established component of infection control activities to prevent the spread of nosocomial (multi-resistant) pathogens, but of lesser importance than proper hand hygiene. However, since the use of disinfectants may pose a danger to staff, patients and the environment, prudent use combined with the application of proven safety precautions is important. Since emerging resistant pathogens will challenge healthcare facilities in future even more than today, well-designed studies addressing the role of disinfection in the healthcare-setting are needed.

Pseudomonas aeruginosa multiresistente em unidade de cuidados intensivos: desafios que procedem?

OBJETIVOS: Avaliar a ocorrência de infecção hospitalar por Pseudomonas aeruginosa multiresistente em pacientes hospitalizados em uma unidade de cuidados intensivos. MÉTODO: estudo retrospectivo realizado de outubro de 2003 a setembro de 2004 em um hospital de emergências. RESULTADOS: Totalizou-se 68 portadores de bactérias multiresistentes sendo 10 (14,7%) de P. aeruginosa. Destes, 8 pacientes eram do sexo masculino, as médias de idade e de internação foram respectivamente de 57 anos a média de idade, 43,7 a média de dias de internação e 7 pacientes morreram. Isolaram-se 8 cepas no sangue, cinco na urina, duas em cateteres venosos e uma no líquor, das quais sete sensíveis somente a polimixina e três ao imipenem. CONCLUSÃO: O perfil microbiológico deve ser avaliado periodicamente visto que é específico de uma unidade ou instituição, e demanda ações correlatas.

[Utilization of patient isolation in non critical units from a university hospital]

BACKGROUND AND OBJECTIVE

Correct utilization of source isolation (SI) in hospitals is important to take advantage of hospital resources. The objective of this work was to evaluate the utilization of SI considering the appropriateness of isolation length-stay.

PATIENTS AND METHOD

During a period of 19 months a prospective observational study was carried out among non-critical inpatients who underwent SI in a university hospital. The information was obtained from Admission Unit data, daily ward rounds and review of case history records.

RESULTS

A total of 239 SIs were identified, summarizing 2,589 days in isolation (median: 8 days, range: 1-56 days). These data supposed a cumulative incidence of 6.74 isolations by 1,000 admissions, and an incidence density of 1.08 isolations by 1,000 inpatient-day. 36.8% of SIs were considered incorrectly used, meaning a total of 703 inappropriate stays in isolation (27.1% of all stays carried out in SI). Surgical wound infections prompted inappropriate isolations with a greater frequency (45.2%), mainly after hip and knee prosthesis implantation interventions (42.9% and 17.9%, respectively).

CONCLUSIONS

It is necessary to develop quality criteria and indicators in order to implement quality improvement actions to optimize SI length-stay management.

Prospective evaluation of hospital isolation room capacity

Risk assessment is used to determine the need for isolation in single rooms. Limited availability of isolation rooms and/or operational needs may compromise this process. This article reports the results of a 12-month prospective observational study of every infection control request for isolation in a 1100-bed teaching hospital. In addition, four point-prevalence surveys of the usage of single rooms were carried out. Data were collected on the incidence of new clinical meticillin-resistant Staphylococcus aureus (MRSA) isolates per ward and these were correlated with rates of isolation failures for MRSA cases. There were 845 requirements for patient isolation, of which 185 (22%) could not be met (isolation failures). Three-quarters of the requirements for isolation were due to MRSA or Clostridium difficile. The proportion of isolation failures was consistent for most organisms and conditions but varied markedly between clinical specialities (0-57%). Reasons for failure to isolate included no single rooms available, all single/isolation rooms occupied (for both isolation and non-infection-control reasons), limitations on the use of single rooms in mixed-sex wards and patient-specific reasons. Only a minority of the available single rooms were occupied for infection control reasons (12-19%). There was a statistically significant correlation between isolation failures and MRSA incidence (Spearman's rho 0.596, P<0.001). In only one case where a ward had >or=30% of its beds provided in single rooms was there an instance of failure to isolate. In conclusion, insufficient capacity to isolate patients with potentially transmissible pathogens is common and may compromise infection control requirements. Either isolation capacity must be increased or evidence-based risk assessment must be applied to situations where demand for isolation exceeds availability. Further information is needed on the consequences of isolation failure.

Guidelines for the control of glycopeptide-resistant enterococci in hospitals

The increase since the mid 1980s in glycopeptide resistant enterococci (GRE) raised concerns about the limited options for antimicrobial therapy, the implications for ever-increasing numbers of immunocompromised hospitalised patients, and fuelled fears, now realised, for the transfer of glycopeptide resistance to more pathogenic bacteria, such as Staphylococcus aureus. These issues underlined the need for guidelines for the emergence and control of GRE in the hospital setting. This Hospital Infection Society (HIS) and Infection Control Nurses Association (ICNA) working party report reviews the literature relating to GRE prevention and control. It provides guidance on microbiological investigation, treatment and management, including antimicrobial prescribing and infection control measures. Evidence identified to support recommendations has been categorized. A risk assessment approach is recommended and areas for research and development identified.