Barriers to healthcare-worker adherence to infection prevention and control practices in British Columbia during the coronavirus disease 2019 (COVID-19) pandemic: A cross-sectional study

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic highlighted the importance of robust infection prevention and control (IPAC) practices to maintain patient and staff safety. However, healthcare workers (HCWs) face many barriers that affect their ability to follow these practices. We identified barriers affecting HCW adherence to IPAC practices during the pandemic in British Columbia, Canada.

DESIGN

Cross-sectional web-based survey.

SETTING

Acute care, long-term care or assisted living, outpatient, mental health, prehospital care, and home care.

PARTICIPANTS

Eligible respondents included direct-care providers and IPAC professionals working in these settings in all health authorities across British Columbia.

METHODS

We conducted a web-based survey from August to September 2021 to assess respondent knowledge and attitudes toward IPAC within the context of the COVID-19 pandemic. Respondents were asked to rate the extent to which various barriers affected their ability to follow IPAC practices throughout the pandemic and to make suggestions for improvement.

RESULTS

The final analysis included 2,488 responses; 36% of respondents worked in acute care. Overall, perceptions of IPAC practice among non-IPAC professionals were positive. The main self-perceived barriers to adherence included inadequate staffing to cover absences (58%), limited space in staff rooms (57%), multibed rooms (51%), and confusing messages about IPAC practices (51%). Common suggestions for improvement included receiving more support from IPAC leadership and clearer communication about required IPAC practices.

CONCLUSIONS

Our findings highlight frontline HCW perspectives regarding priority areas of improvement for IPAC practices. They will inform policy and guideline development to prevent transmission of COVID-19 and future emerging infections.

Association of cerebrospinal fluid parameters with treatment and complications among children with cerebrospinal fluid shunt infections: a multicenter study

OBJECTIVE

Cerebrospinal fluid (CSF) white blood cell (WBC) count, neutrophil percentage, protein concentration, and glucose level are typically measured at diagnosis and serially during the treatment of CSF shunt infections. The objective of this retrospective cohort study was to describe the longitudinal profile of CSF parameters in children with CSF shunt infections and assess their association with treatment and outcome.

METHODS

Participants were children treated at 11 tertiary pediatric hospitals in Canada and the United States for CSF shunt infection, from July 1, 2013, through June 30, 2019, with hardware removal, external ventricular drain placement, intravenous antibiotics, and subsequent permanent shunt reinsertion. The relationship between CSF parameters and a complicated course (a composite outcome representing children with at least one of the following: contiguous soft-tissue infection, worsening hydrocephalus, CSF leak, intracranial bleed, brain abscess, venous thrombosis, reinfection after insertion of the new shunt, other complication, ICU admission, or death) was analyzed.

RESULTS

A total of 109 children (median age 2.8 years, 44% female) were included in this study. CSF pleocytosis, elevated protein, and hypoglycorrhachia had sensitivities of 69%, 47%, and 38% for the diagnosis of culture-confirmed CSF shunt infection, respectively. The longitudinal profile of the neutrophil percentage followed a monotonic trend, decreasing by 1.5% (95% CI 1.0%-2.0%, p < 0.0001) per day over the course of treatment. The initial WBC count differed significantly between pathogens (p = 0.011), but the proportion of neutrophils, protein concentration, and glucose level did not, and was lowest with Cutibacterium acnes. The duration of antibiotic treatment and the time to shunt reinsertion were longer in patients with a higher initial neutrophil percentage. Fifty-eight patients (53%) had one or more complications during their admission. A neutrophil percentage > 44% (Youden index) in the initial CSF sample was associated with a 1.8-fold (95% CI 1.2- to 2.8-fold) higher relative risk of a complicated course. In a random-intercept, random-slope linear mixed-effects model, the longitudinal neutrophil trajectory differed significantly between patients with and without complications (p = 0.030).

CONCLUSIONS

A higher proportion of neutrophils in the CSF at diagnosis was associated with a complicated clinical course. Other CSF parameters were associated with treatment and outcome; however, wide variability in values may limit their clinical utility.

Plasmid genomic epidemiology of blaKPC carbapenemase-producing Enterobacterales in Canada, 2010-2021

Carbapenems are considered last-resort antibiotics for the treatment of infections caused by multidrug-resistant Enterobacterales, but carbapenem resistance due to acquisition of carbapenemase genes is a growing threat that has been reported worldwide. Klebsiella pneumoniae carbapenemase (blaKPC) is the most common type of carbapenemase in Canada and elsewhere; it can hydrolyze penicillins, cephalosporins, aztreonam, and carbapenems and is frequently found on mobile plasmids in the Tn4401 transposon. This means that alongside clonal expansion, blaKPC can disseminate through plasmid- and transposon-mediated horizontal gene transfer. We applied whole genome sequencing to characterize the molecular epidemiology of 829 blaKPC carbapenemase-producing isolates collected by the Canadian Nosocomial Infection Surveillance Program from 2010 to 2021. Using a combination of short-read and long-read sequencing, we obtained 202 complete and circular blaKPC-encoding plasmids. Using MOB-suite, 10 major plasmid clusters were identified from this data set which represented 87% (175/202) of the Canadian blaKPC-encoding plasmids. We further estimated the genomic location of incomplete blaKPC-encoding contigs and predicted a plasmid cluster for 95% (603/635) of these. We identified different patterns of carbapenemase mobilization across Canada related to different plasmid clusters, including clonal transmission of IncF-type plasmids (108/829, 13%) in K. pneumoniae clonal complex 258 and novel repE(pEh60-7) plasmids (44/829, 5%) in Enterobacter hormaechei ST316, and horizontal transmission of IncL/M (142/829, 17%) and IncN-type plasmids (149/829, 18%) across multiple genera. Our findings highlight the diversity of blaKPC genomic loci and indicate that multiple, distinct plasmid clusters have contributed to blaKPC spread and persistence in Canada.

Respiratory syncytial virus epidemiology and clinical severity before and during the COVID-19 pandemic in British Columbia, Canada: a retrospective observational study

Background

The COVID-19 pandemic has perturbed the seasonality of respiratory syncytial virus (RSV) infections. However, we lack data on how this impacted the severity of paediatric RSV cases. The objective of this study was to describe the clinical severity of RSV cases before, during and after pandemic measures in British Columbia (BC), Canada.

Methods

Retrospective study of RSV cases from September 1st, 2017 to May 15th, 2023, with a review of RSV outcomes in children below 18 years old at BC's paediatric hospital. Temporal changes in RSV cases and hospitalisations were quantified using interrupted time series.

Findings

BC experienced only 11 RSV cases (from 95,266 tests) between September 2020 and August 2021. This was followed by a resurgence of 9,529 RSV cases (219,566 tests [4.3% positive tests]) in 2021-22 and 8,215 cases (124,449 tests [6.6% positive tests]) in 2022-23, increased compared to 1,750 cases (48,664 tests [3.6% positive tests]) per corresponding yearly period in 2017-20. From September 2017 to May 2023, the median age of children with RSV at BC Children's Hospital increased from 8.7 [IQR: 2.0-26.0] to 19.6 [3.9-43.7] months per yearly period. More children were hospitalised in 2022-23 (n = 360), compared to 2017-20 (n = 168 per period) and 2021-22 (n = 172). However, we detected no increase in hospitalisations or ICU admissions in children born prematurely or with chronic cardiorespiratory conditions.

Interpretation

The increased detection of symptomatic RSV cases in older children in 2021-22 and increased RSV-related hospitalisations in 2022-23 suggest a gradual increase in the pool of immunologically vulnerable children due to a prolonged lack of viral exposure.

Funding

Government of Canada via its COVID-19 Immunity Task Force.

Novel hand hygiene promotion method in a pediatric and maternity hospital: A quality improvement pilot project using auditory feedback

A pilot quality improvement project was conducted to examine the effect of playing an applause sound effect at a busy hospital concourse for three consecutive days whenever hand hygiene behavior was observed. The immediate effect was documented. The project demonstrated observable interest among people passing by, and hand hygiene events triggered by the sound effect represented 10.1% of all hand hygiene events documented. This supports the possible utility of this intervention in generating public awareness and increasing hand hygiene behavior and demonstrates the feasibility of a longer trial utilizing audio devices.

Barriers to infection prevention and control in long-term care/assisted living settings in British Columbia during the COVID-19 pandemic: a cross-sectional survey

BACKGROUND

The COVID-19 pandemic disproportionately impacted long-term care and assisted living (LTC/AL) facilities in Canada, where infection prevention and control (IPAC) programs had been suboptimal. We aimed to identify barriers affecting healthcare workers' (HCW) adherence to IPAC practices during the pandemic in British Columbia in LTC/AL compared to acute care settings.

METHODS

We conducted a web-based survey of direct care providers and IPAC professionals across BC from August to September 2021, focused on knowledge and attitudes toward IPAC within the context of the COVID-19 pandemic, and barriers that affected respondents' abilities to follow IPAC practices throughout the pandemic.

RESULTS

The final analysis included 896 acute care respondents and 441 from LTC/AL. More LTC/AL respondents reported experiencing the following barriers: following IPAC guidance was of lower priority compared to other tasks (29.1% vs. 14.7%, FDR = 0.001) and not their responsibility (28.0% vs. 11.2%, FDR = 0.001); limited supplies for personal protective equipment (PPE) (49.0% vs. 33.6%, FDR = 0.001), hand hygiene products (42.2% vs. 28.8%, FDR = 0.001), and cleaning/disinfection products (44.1% vs. 30.3%, FDR = 0.001); deficits in IPAC leadership support (46.2% vs. 38.9%, FDR = 0.012), IPAC education and training (46.9% vs. 32.0%, FDR = 0.001), and patient care knowledge for managing COVID-19 infections (46.6% vs. 36.0%, FDR = 0.001).

CONCLUSIONS

This survey found that barriers to HCWs' adherence to IPAC practices during the COVID-19 pandemic were different in LTC/AL settings compared to acute care. Improvement efforts should focus on strengthening IPAC programs in LTC/AL, particularly enhanced IPAC staffing/leadership, increased training and education, and improving access to PPE, hand hygiene, and cleaning products.

Vaccination, time lost from work, and COVID-19 infections: a Canadian healthcare worker retrospective cohort study

The COVID-19 pandemic highlighted hurdles for healthcare delivery and personnel globally. Vaccination has been an important tool for preventing severe illness and death in healthcare workers (HCWs) as well as the public at large. However, vaccination has resulted in some HCWs requiring time off work post-vaccination to recover from adverse events. We aimed to understand which HCWs needed to take time off work post-vaccination, for which vaccine types and sequence, and how post-vaccination absence impacted uptake of booster doses in a cohort of 26,267 Canadian HCWs. By March 31, 2022, more than 98% had received at least two doses of the approved COVID-19 vaccines, following a two-dose mandate. We found that recent vaccination and longer intervals between doses were associated with significantly higher odds of time-loss, whereas being a medical resident and receiving the BNT162b2 vaccine were associated with lower odds. A history of lab-confirmed SARS-CoV-2 infection was associated with lower odds of receiving a booster dose compared with no documented infection, aOR 0.61 (95% CI: 0.55, 0.68). Similarly, taking sick time following the first or second dose was associated with lower odds of receiving a booster dose, aOR 0.83 (95% CI: 0.75, 0.90). As SARS-CoV-2 becomes endemic, the number and timing of additional doses for HCWs requires consideration of prevention of illness as well as service disruption from post-vaccination time-loss. Care should be taken to ensure adequate staffing if many HCWs are being vaccinated, especially for coverage for those who are more likely to need time off to recover.

Trends in Clostridioides difficile infection rates in Canadian hospitals during the coronavirus disease 2019 (COVID-19) pandemic

The coronavirus disease 2019 (COVID-19) pandemic has placed significant burden on healthcare systems. We compared Clostridioides difficile infection (CDI) epidemiology before and during the pandemic across 71 hospitals participating in the Canadian Nosocomial Infection Surveillance Program. Using an interrupted time series analysis, we showed that CDI rates significantly increased during the COVID-19 pandemic.

Blood culture collection practices in NICU; A national survey

Background

Sepsis is the leading cause of mortality and morbidity in neonates. Blood cultures are the gold standard in diagnosing neonatal sepsis; however, there are currently no consensus guidelines for blood culture collection in neonates and significant practice variation exists in Neonatal Intensive Care Units (NICUs) globally.

Objective

To examine current practices in obtaining blood cultures in the evaluation of neonatal sepsis in NICUs across Canada.

Methods

A nine-item electronic survey was sent to each of the 29 level-3 NICUs in Canada, which are equipped to provide highly specialized care for newborns.

Results

Responses were received from 90% (26/29) of sites. Sixty-five percent (17/26) of sites have blood culture collection guidelines for the investigation of neonatal sepsis. Forty-eight percent (12/25) of sites routinely target 1.0 mL per culture bottle. In late-onset sepsis (LOS), 58% (15/26) of sites process one aerobic culture bottle, whereas four sites routinely add anaerobic culture bottles. In early-onset sepsis (EOS) in very low birth weight infants (BW <1.5 kg), 73% (19/26) of sites use umbilical cord blood, and 72% (18/25) use peripheral venipuncture. Two sites routinely collect cord blood for culture in EOS. Only one site applies the concept of differential time-to-positivity to diagnose central-line-associated bloodstream infection.

Conclusions

There is significant practice variation in methods used to obtain blood cultures in level-3 NICUs across Canada. Standardization of blood culture collection practices can provide reliable estimates of the true incidence of neonatal sepsis and help to develop appropriate antimicrobial stewardship strategies.

Trends in Severe Outcomes Among Adult and Pediatric Patients Hospitalized With COVID-19 in the Canadian Nosocomial Infection Surveillance Program, March 2020 to May 2022

Importance

Trends in COVID-19 severe outcomes have significant implications for the health care system and are key to informing public health measures. However, data summarizing trends in severe outcomes among patients hospitalized with COVID-19 in Canada are not well described.

Objective

To describe trends in severe outcomes among patients hospitalized with COVID-19 during the first 2 years of the COVID-19 pandemic.

Design, Setting, and Participants

Active prospective surveillance in this cohort study was conducted from March 15, 2020, to May 28, 2022, at a sentinel network of 155 acute care hospitals across Canada. Participants included adult (aged ≥18 years) and pediatric (aged 0-17 years) patients hospitalized with laboratory-confirmed COVID-19 at a Canadian Nosocomial Infection Surveillance Program (CNISP)-participating hospital.

Exposures

COVID-19 waves, COVID-19 vaccination status, and age group.

Main Outcomes and Measures

The CNISP collected weekly aggregate data on the following severe outcomes: hospitalization, admission to an intensive care unit (ICU), receipt of mechanical ventilation, receipt of extracorporeal membrane oxygenation, and all-cause in-hospital death.

Results

Among 1 513 065 admissions, the proportion of adult (n = 51 679) and pediatric (n = 4035) patients hospitalized with laboratory-confirmed COVID-19 was highest in waves 5 and 6 of the pandemic compared with waves 1 to 4 (77.3 vs 24.7 per 1000 patient admissions). Despite this, the proportion of patients with positive test results for COVID-19 who were admitted to an ICU, received mechanical ventilation, received extracorporeal membrane oxygenation, and died were each significantly lower in waves 5 and 6 when compared with waves 1 through 4. Admission to the ICU and in-hospital all-cause death rates were significantly higher among those who were unvaccinated against COVID-19 when compared with those who were fully vaccinated (incidence rate ratio, 4.3 and 3.9, respectively) or fully vaccinated with an additional dose (incidence rate ratio, 12.2 and 15.1, respectively).

Conclusions and Relevance

The findings of this cohort study of patients hospitalized with laboratory-confirmed COVID-19 suggest that COVID-19 vaccination is important to reduce the burden on the Canadian health care system as well as severe outcomes associated with COVID-19.

Extraction-free clinical detection of SARS-CoV-2 virus from saline gargle samples using Hamilton STARlet liquid handler

As part of the COVID-19 pandemic, clinical laboratories have been faced with massive increases in testing, resulting in sample collection systems, reagent, and staff shortages. We utilized self-collected saline gargle samples to optimize high throughput SARS-CoV-2 multiplex polymerase chain reaction (PCR) testing in order to minimize cost and technologist time. This was achieved through elimination of nucleic acid extraction and automation of sample handling on a widely available robotic liquid handler, Hamilton STARlet. A customized barcode scanning script for reading the sample ID by the Hamilton STARlet's software system was developed to allow primary tube sampling. Use of pre-frozen SARS-CoV-2 assay reaction mixtures reduced assay setup time. In both validation and live testing, the assay produced no false positive or false negative results. Of the 1060 samples tested during validation, 3.6% (39/1060) of samples required retesting as they were either single gene positive, had internal control failure or liquid aspiration error. Although the overall turnaround time was only slightly faster in the automated workflow (185 min vs 200 min), there was a 76% reduction in hands-on time, potentially reducing staff fatigue and burnout. This described process from sample self-collection to automated direct PCR testing significantly reduces the total burden on healthcare systems in terms of human resources and reagent requirements.

Effectiveness of a neonatal intensive care unit-specific antimicrobial stewardship program: A ten-year review

OBJECTIVE

To evaluate the change in consumption of specific antibiotics in a neonatal intensive care unit after the implementation of an antimicrobial stewardship program (ASP).

DESIGN

Retrospective cohort study between January 1, 2010, and December 31,2019.

SETTING

The neonatal intensive care unit at British Columbia Women's Hospital (Vancouver Canada), a tertiary-care center.

PATIENTS

Admitted neonates prescribed antibiotics.

METHODS

We implemented an ASP with an early implementation phase starting in January 2014 (period 2) and a later phase starting in January 2017 (period 3). Patient demographics were collected, including birth weight, gestational age, history of necrotizing enterocolitis (NEC), and surgical operations from existing databases. Interrupted time-series analysis was used, and comparison of antibiotic days of therapy (DOT) averages were conducted across the preimplementation period (period 1), period 2, and period 3 regarding total patients and subgroups.

RESULTS

We identified 4,512 infants. There was a significant decrease in DOT from 472 (95% confidence interval [CI], 431-517) in period 1 to 405 (95% CI, 367-446) in period 2 to 313 (95% CI, 280-350) in period 3. We detected a significant decrease in the use of ampicillin, aminoglycosides, cloxacillin, and linezolid but not in vancomycin or cefotaxime. Subgroup analyses of infants <1,500 g and those without NEC or surgery showed decreases in the use of cloxacillin, aminoglycosides, and linezolid.

CONCLUSIONS

The implementation of an ASP was associated with a significant decrease in the overall DOT and use of certain antibiotics. This study presents important targets for ongoing ASP work.

Epidemiology of primary and recurrent healthcare-associated and community-associated pediatric Clostridioides difficile infection in Canada, 2015-2020

Clostridioides difficile infection (CDI) among children remains a concerning cause of morbidity in hospital settings. We present epidemiological and molecular trends in healthcare- and community-associated CDI among children in Canadian inpatient and outpatient settings, including those who experienced recurrent infections.

Duration of Antibiotic Therapy and Timing of Shunt Reimplantation in Pediatric CSF Shunt Infections: A Retrospective Multicenter Case Series

In this retrospective multicenter series of 154 children with cerebrospinal fluid shunt infections, the median (interquartile range) duration of antibiotic therapy was 18 (14-26) days. The time to shunt replacement was 14 (10-19) days. Management appeared to potentially differ according to the targeted pathogen and site.

Cerebrospinal Fluid Shunt Infections: A Multicenter Pediatric Study

BACKGROUND

Infections complicate 5%-10% of cerebrospinal fluid (CSF) shunts. We aimed to describe the characteristics and contemporary pathogens of shunt infections in children in Canada and the United States.

METHODS

Descriptive case series at tertiary care hospitals in Canada (N = 8) and the United States (N = 3) of children up to 18 years of age with CSF shunt infections from July 1, 2013, through June 30, 2019.

RESULTS

There were 154 children (43% female, median age 2.7 years, 50% premature) with ≥1 CSF shunt infections. Median time between shunt placement and infection was 54 days (interquartile range, 24 days-2.3 years). Common pathogens were coagulase-negative staphylococci (N = 42; 28%), methicillin-susceptible Staphylococcus aureus (N = 24; 16%), methicillin-resistant S. aureus (N = 9; 5.9%), Pseudomonas aeruginosa (N = 9; 5.9%) and other Gram-negative bacilli (N = 14; 9.0%). Significant differences between pathogens were observed, including timing of infection (P = 0.023) and CSF leukocyte count (P = 0.0019); however, differences were not sufficient to reliably predict the causative organism based on the timing of infection or discriminate P. aeruginosa from other pathogens based on clinical features. Empiric antibiotic regimens, which included vancomycin (71%), cefotaxime or ceftriaxone (29%) and antipseudomonal beta-lactams (33%), were discordant with the pathogen isolated in five cases. There was variability between sites in the distribution of pathogens and choice of empiric antibiotics. Nine children died; 4 (44%) deaths were attributed to shunt infection.

CONCLUSIONS

Staphylococci remain the most common cause of CSF shunt infections, although antibiotic resistant Gram-negative bacilli occur and cannot be reliably predicted based on clinical characteristics.

Characterization of Healthcare-Associated and Community-Associated Clostridioides difficile Infections among Adults, Canada, 2015-2019

We investigated epidemiologic and molecular characteristics of healthcare-associated (HA) and community-associated (CA) Clostridioides difficile infection (CDI) among adult patients in Canadian Nosocomial Infection Surveillance Program hospitals during 2015–2019. The study encompassed 18,455 CDI cases, 13,735 (74.4%) HA and 4,720 (25.6%) CA. During 2015–2019, HA CDI rates decreased by 23.8%, whereas CA decreased by 18.8%. HA CDI was significantly associated with increased 30-day all-cause mortality as compared with CA CDI (p<0.01). Of 2,506 isolates analyzed, the most common ribotypes (RTs) were RT027, RT106, RT014, and RT020. RT027 was more often associated with CDI-attributable death than was non-RT027, regardless of acquisition type. Overall resistance C. difficile rates were similar for all drugs tested except moxifloxacin. Adult HA and CA CDI rates have declined, coinciding with changes in prevalence of RT027 and RT106. Infection prevention and control and continued national surveillance are integral to clarifying CDI epidemiology, investigation, and control.

Evaluation of observed and unobserved self-collection of saline gargle samples for the detection of SARS-CoV-2 in outpatients

The diagnostic sensitivity of observed and unobserved self-collected saline gargle samples for the molecular detection of SARS-CoV-2 in adults and school-aged children was evaluated against a reference standard of health care worker collected nasopharyngeal flocked swab.

A total of 46 participants had a positive nasopharyngeal swab sample; of these, 10 were in the observed phase and 36 were in the unobserved phase. Only one matching saline gargle sample tested negative and this was in the unobserved phase, giving an overall sensitivity of 98%. Average viral target Ct values were higher in the saline gargle samples. RNaseP Ct values were lower in unobserved collected samples compared to observed collected samples.

Unobserved self-collection of saline gargle samples is a promising outpatient testing method for COVID-19 diagnosis. The self-collection method has potential to simplify the diagnostic cycle and facilitate implementation of COVID-19 testing, particularly in settings with limited access to health care workers.

Patient, family, and visitor hand hygiene knowledge, attitudes, and practices at pediatric and maternity hospitals: A descriptive study

BACKGROUND

Patient, family, and visitor hand hygiene can prevent health care-associated infections, but little is known about their hand hygiene knowledge, attitudes, and practices. We aimed to assess patient, family, and visitor hand hygiene knowledge, attitudes, and practices at a pediatric and maternity hospital in Vancouver, British Columbia, Canada.

METHODS

Surveys based on the Theoretical Domains Framework were distributed to patients, families, and visitors to provide cross-sectional qualitative and quantitative data. This was supplemented with covert observations by trained medical students to determine patient, family, and visitor hand hygiene rates.

RESULTS

Of 348 survey respondents, there was a clear preference for hand washing with soap and water over use of alcohol-based hand rub. Beliefs about consequences were the main driver for hand hygiene. Self-reported hand hygiene rates were higher than observed rates. The overall hand hygiene rate was observed to be 10.3% (72/701), with soap and water used for 75% of hand hygiene events.

CONCLUSION

There are misconceptions regarding hand hygiene practices and low hand hygiene rates among patients, families, and visitors. Development of interventions to improve hand hygiene should focus on correcting misconceptions and emphasizing consequences of failing to perform hand hygiene in the health care setting.

Development and validation of a new triplex real-time quantitative reverse Transcriptase-PCR assay for the clinical detection of SARS-CoV-2

To increase the repertoire of PCR based laboratory developed tests (LDTs) for the detection of SARS-CoV-2, we describe a new multiplex assay (SORP), targeting the SARS-CoV-2's, Spike and ORF8 genes. The widely used human RNaseP internal control was modified to specifically co-amplify the RNaseP mRNA. The SORP triplex assay was tested on a cohort (n = 372; POS = 144/NEG = 228) of nasopharyngeal flocked swab (NPFS) specimens, previously tested for the presence of SARS-CoV-2 using a PCR assay targeting E and RdRp genes. The overall sensitivity and specificity of the SORP assay was: 99.31% (95% CI: 96.22–99.98%), 100.0% (95% CI: 98.4–100%) respectively. The SORP assay could also detect a panel of variants of concern (VOC) from the B1.1.7 (UK) and B1.351 (SA) lineage. In summary, access to a repertoire of new SARS-CoV-2 LDT's would assist diagnostic laboratories in developing strategies to overcome some of the testing issues encountered during high-throughput SARS-CoV-2 testing.

Matrix-assisted laser desorption/ionization time-of-flight MS for the accurate identification of Burkholderia cepacia complex and Burkholderia gladioli in the clinical microbiology laboratory

Introduction. Burkholderia cepacia complex (Bcc) bacteria, currently consisting of 23 closely related species, and Burkholderia gladioli, can cause serious and difficult-to-treat infections in people with cystic fibrosis. Identifying Burkholderia bacteria to the species level is considered important for understanding epidemiology and infection control, and predicting clinical outcomes. Matrix-assisted laser desorption/ionization time-of-flight MS (MALDI-TOF) is a rapid method recently introduced in clinical laboratories for bacterial species-level identification. However, reports on the ability of MALDI-TOF to accurately identify Bcc to the species level are mixed.Aim. The aim of this project was to evaluate the accuracy of MALDI-TOF using the Biotyper and VITEK MS systems in identifying isolates from 22 different Bcc species and B. gladioli compared to recA gene sequencing, which is considered the current gold standard for Bcc.Methodology. To capture maximum intra-species variation, phylogenetic trees were constructed from concatenated multi-locus sequence typing alleles and clustered with a novel k-medoids approach. One hundred isolates representing 22 Bcc species, plus B. gladioli, were assessed for bacterial identifications using the two MALDI-TOF systems.Results. At the genus level, 100 and 97.0 % of isolates were confidently identified as Burkholderia by the Biotyper and VITEK MS systems, respectively; moreover, 26.0 and 67.0 % of the isolates were correctly identified to the species level, respectively. In many, but not all, cases of species misidentification or failed identification, a representative library for that species was lacking.Conclusion. Currently available MALDI-TOF systems frequently do not accurately identify Bcc bacteria to the species level.

Hand hygiene knowledge, attitudes, and practices among hospital inpatients: A descriptive study

BACKGROUND

Pathogens may be transmitted in hospitals via patients' own hands, but little is known about the facilitators and barriers of hand hygiene among inpatients. This study aimed to assess the hand hygiene knowledge, attitudes, and practices of adult inpatients at 5 hospitals.

METHODS

The study consisted of a cross-sectional survey distributed followed by structured interviews with randomly selected inpatients. Qualitative data were analyzed independently by 2 researchers using the Theoretical Domains Framework.

RESULTS

A total of 268 surveys were completed, with 66.4% of patients reporting always performing hand hygiene after toileting and 49.2% before eating. The majority of patients (74.6%) stated that they did not want to receive more information about hand hygiene while in the hospital. Key themes identified from 23 interviews include knowledge; environmental context and resources; memory, attention, and decision processes; and social influences.

CONCLUSIONS

Self-reported patient hand hygiene rates are suboptimal and there are knowledge gaps among patients as to when to perform hand hygiene, but patients are not receptive to receiving traditional educational interventions. Future interventions to improve patient hand hygiene should focus on other behavior change domains, including environmental context and resources (eg, access to hand sanitizer at the bedside), memory, attention, and decision processes (eg, posters or other reminders), and social influences (eg, role modeling).

Impact of patient and visitor hand hygiene interventions at a pediatric hospital: A stepped wedge cluster randomized controlled trial

BACKGROUND

Patient and visitor hand hygiene has the potential to prevent health care-associated infections, but there are few data on the efficacy of interventions to improve patient/visitor hand hygiene.

OBJECTIVE

To determine whether conventional and front-line ownership (FLO) patient/visitor hand hygiene interventions improve patient/visitor and health care worker (HCW) hand hygiene rates.

METHODS

A stepped wedge cluster randomized controlled trial was conducted on inpatient units and the emergency department. A conventional intervention included pediatric-focused posters, which also served as reminders for HCWs. This was compared to a FLO intervention aimed at finding "positive deviants," staff who were already taking steps to improve patient/visitor hand hygiene. Patient/visitor and HCW hand hygiene rates were measured covertly by trained medical students.

RESULTS

Patient/visitor hand hygiene rates increased from 9.2% at baseline to 13.9% in the post-intervention period. Hand hygiene rates on units randomized to the standard intervention changed from 7.3% to 10.9% (P = .46), but FLO intervention units significantly changed from 14.3% to 25% (P = .03). The baseline HCW hand hygiene rate was 68.2%, which increased to a greater extent in the FLO group (79.1%) than in the standard intervention (73.1%), but the change was not statistically significant for either intervention compared to control (P = .18 and P = .64, respectively).

CONCLUSIONS

Hand hygiene interventions in hospitals can improve patient/visitor and HCW hand hygiene rates, and a FLO intervention appears to be more effective than a conventional intervention.

Risk factors for cerebrospinal fluid shunt infections during an outbreak: a case-control study

BACKGROUND

There are few published reports of cerebrospinal fluid (CSF) shunt infection outbreaks. In 2017-2018, British Columbia Children's Hospital (BCCH) experienced an increase in CSF shunt infections co-incident with a move to new operating rooms and a change in shunt catheters used.

AIMS

To describe how an outbreak was detected, investigations were undertaken to determine the cause, risk factors associated with CSF shunt infection during the outbreak, and changes implemented to attempt to control the outbreak.

METHODS

Retrospective case-control study. Population included patients who underwent new shunt insertion or revision. Univariate logistic regression models were fitted for each of the variables. Associations with P-values <0.2 were considered of potential interest for further investigation.

FINDINGS

There were six cases of CSF shunt infection and 19 controls. The causative organism was different in each case. The only risk factors that met the criteria for further investigation were being a neonate at the time of surgery [odds ratio (OR) 9.0, 95% confidence interval (CI) 0.7-125.3, P=0.10] and the presence of gastrointestinal disease (OR 3.8, 95% CI 0.5-26.2, P=0.18). No association was found with the operating room used or the surgical staff. In response to the outbreak, human traffic through the operating rooms was limited, rigid adherence to the wearing of surgical masks was enforced, and return to the previous CSF shunt catheters used was implemented.

CONCLUSION

No modifiable risk factors were associated with CSF shunt infection. After implementation of surgical protocol changes, no further cases of CSF shunt infection linked to the outbreak were identified.

Prevalence and clinical impact of methicillin-resistant Staphylococcus aureus colonization among infants at a level III neonatal intensive care unit

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is a well-known nosocomial pathogen in neonatal intensive care unit (NICU) patients. Studies on the impact of MRSA colonization on neonatal morbidities are scarce.

METHODS

We conducted a 1:3 matched cohort study among infants with and without MRSA colonization, born between January 2010 and June 2014, in a tertiary NICU to review their demographic characteristics and outcomes.

RESULTS

During the study period, rates of MRSA colonization and bacteremia were found to be 0.68% and 0.10%, respectively. No differences in demographic characteristics, mortality, and major morbidities were identified among infants with and without MRSA colonization.

CONCLUSIONS

We reported a low rate of MRSA colonization in infants admitted to our NICU, without impact on mortality and inhospital morbidity. Further large-scale studies are needed to understand the implications and cost-effectiveness of active MRSA surveillance.

Postexposure management of infectious diseases

Anyone exposed to an infectious disease--whether a healthcare provider, patient, or contact of a patient--should be evaluated promptly and the source of the infection identified. A systematic response entails postexposure prophylactic therapy if available and indicated, infection control measures to prevent further transmission, counseling and educating those involved, and assessing those who may require work restriction or modification.

Herd effect from influenza vaccination in non-healthcare settings: a systematic review of randomised controlled trials and observational studies

Influenza vaccination programmes are assumed to have a herd effect and protect contacts of vaccinated persons from influenza virus infection. We searched MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Global Health and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to March 2014 for studies assessing the protective effect of influenza vaccination vs no vaccination on influenza virus infections in contacts. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using a random-effects model. Of 43,082 screened articles, nine randomised controlled trials (RCTs) and four observational studies were eligible. Among the RCTs, no statistically significant herd effect on the occurrence of influenza in contacts could be found (OR: 0.62; 95% CI: 0.34–1.12). The one RCT conducted in a community setting, however, showed a significant effect (OR: 0.39; 95% CI: 0.26–0.57), as did the observational studies (OR: 0.57; 95% CI: 0.43–0.77). We found only a few studies that quantified the herd effect of vaccination, all studies except one were conducted in children, and the overall evidence was graded as low. The evidence is too limited to conclude in what setting(s) a herd effect may or may not be achieved.

Measurement of Patient Hand Hygiene in Multiorgan Transplant Units Using a Novel Technology: An Observational Study

Objective.

Healthcare worker hand hygiene is known to prevent healthcare-associated infections, but there are few data on patient hand hygiene despite the fact that nosocomial pathogens may be acquired by patients via their own unclean hands. The purpose of this study was to measure patient hand hygiene behavior in the hospital after visiting a bathroom, before eating, and on entering and leaving their rooms

Design.

Cross-sectional study.

Setting.

Acute care teaching hospital in Canada.

Patients.

Convenience sample of 279 adult patients admitted to 3 multiorgan transplant units between July 2012 and March 2013.

Methods.

Patient use of alcohol-based hand rub and soap dispensers was measured using an ultrasound-based real-time location system during visits to bathrooms, mealtimes, kitchen visits, and on entering and leaving their rooms.

Results.

Overall, patients performed hand hygiene during 29.7% of bathroom visits, 39.1% of mealtimes, 3.3% of kitchen visits, 2.9% of room entries, and 6.7% of room exits.

Conclusions.

Patients appear to perform hand hygiene infrequently, which may contribute to transmission of pathogens from the hospital environment via indirect contact or fecal-oral routes.

Infect Control Hosp Epidemiol 2014;35(11):1336–1341

Interventions to improve patient hand hygiene: a systematic review

Nosocomial pathogens may be acquired by patients via their own unclean hands, but there has been relatively little emphasis on patient hand hygiene as a tool for preventing healthcare-associated infections (HCAIs). The aim of this systematic review was to determine the efficacy of patient hand hygiene interventions in reducing HCAIs and improving patient hand hygiene rates compared to usual care. Electronic databases and grey literature were searched to August 2014. Experimental and quasi-experimental studies were included if they evaluated a patient hand hygiene intervention conducted in an acute or chronic healthcare facility and included HCAI incidence and/or patient hand hygiene rates as an outcome. All steps were performed independently by two investigators. Ten studies were included, most of which were uncontrolled before-after studies (N=8). The majority of interventions (N=7) were multi-modal, with components similar to healthcare worker hand hygiene programmes, including education, reminders, audit and feedback, and provision of hand hygiene products. Six studies reported HCAI outcomes and four studies assessed patient hand hygiene rates; all demonstrated improvements but were at moderate to high risk of bias. In conclusion, interventions to improve patient hand hygiene may reduce the incidence of HCAIs and improve hand hygiene rates, but the quality of evidence is low. Future studies should use stronger designs and be more selective in their choice of outcomes.

Applying psychological frameworks of behaviour change to improve healthcare worker hand hygiene: a systematic review

BACKGROUND

Despite the importance of hand hygiene in preventing transmission of healthcare-associated infections, compliance rates are suboptimal. Hand hygiene is a complex behaviour and psychological frameworks are promising tools to influence healthcare worker (HCW) behaviour.

AIM

(i) To review the effectiveness of interventions based on psychological theories of behaviour change to improve HCW hand hygiene compliance; (ii) to determine which frameworks have been used to predict HCW hand hygiene compliance.

METHODS

Multiple databases and reference lists of included studies were searched for studies that applied psychological theories to improve and/or predict HCW hand hygiene. All steps in selection, data extraction, and quality assessment were performed independently by two reviewers.

FINDINGS

The search yielded 918 citations; seven met eligibility criteria. Four studies evaluated hand hygiene interventions based on psychological frameworks. Interventions were informed by goal setting, control theory, operant learning, positive reinforcement, change theory, the theory of planned behaviour, and the transtheoretical model. Three predictive studies employed the theory of planned behaviour, the transtheoretical model, and the theoretical domains framework. Interventions to improve hand hygiene adherence demonstrated efficacy but studies were at moderate to high risk of bias. For many studies, it was unclear how theories of behaviour change were used to inform the interventions. Predictive studies had mixed results.

CONCLUSION

Behaviour change theory is a promising tool for improving hand hygiene; however, these theories have not been extensively examined. Our review reveals a significant gap in the literature and indicates possible avenues for novel research.

Examination of staphylococcal stethoscope contamination in the emergency department (pilot) study (EXSSCITED pilot study)

Introduction:

The objective of this study was to determine the prevalence of Staphylococcus-contaminated stethoscopes belonging to emergency department (ED) staff and to identify the proportion of these that were Staphylococcus aureus or methicillin-resistant Staphylococcus aureus (MRSA).

Methods:

We conducted a prospective observational cohort study of bacterial cultures from 100 ED staff members' stethoscopes at three EDs. Study participants were asked to complete a questionnaire.

Results:

Fifty-four specimens grew coagulase-negative staphylococci and one grew methicillin-susceptible S. aureus. No MRSA was cultured. Only 8% of participants, all of whom were nurses, reported cleaning their stethoscope before or after each patient assessment. Alcohol-based wipes were most commonly used to clean stethoscopes. A lack of time, being too busy, and forgetfulness were the most frequently reported reasons for not cleaning the stethoscope in the ED.

Conclusions:

This study indicates that although stethoscope contamination rates in these EDs are high, the prevalence of S. aureus or MRSA on stethoscopes is low.

Postexposure management of healthcare personnel to infectious diseases

Healthcare personnel (HCP) are at risk of exposure to various pathogens through their daily tasks and may serve as a reservoir for ongoing disease transmission in the healthcare setting. Management of HCP exposed to infectious agents can be disruptive to patient care, time-consuming, and costly. Exposure of HCP to an infectious source should be considered an urgent medical concern to ensure timely management and administration of postexposure prophylaxis, if available and indicated. Infection control and occupational health departments should be notified for management of exposed HCP, identification of all contacts of the index case, and application of immediate infection control measures for the index case and exposed HCP, if indicated. This article reviews the main principles of postexposure management of HCP to infectious diseases, in general, and to certain common infections, in particular, categorized by their route of transmission, in addition to primary prevention of these infections.

Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study

Background

The Hawthorne effect, or behaviour change due to awareness of being observed, is assumed to inflate hand hygiene compliance rates as measured by direct observation but there are limited data to support this.

Objective

To determine whether the presence of hand hygiene auditors was associated with an increase in hand hygiene events as measured by a real-time location system (RTLS).

Methods

The RTLS recorded all uses of alcohol-based hand rub and soap for 8 months in two units in an academic acute care hospital. The RTLS also tracked the movement of hospital hand hygiene auditors. Rates of hand hygiene events per dispenser per hour as measured by the RTLS were compared for dispensers within sight of auditors and those not exposed to auditors.

Results

The hand hygiene event rate in dispensers visible to auditors (3.75/dispenser/h) was significantly higher than in dispensers not visible to the auditors at the same time (1.48; p=0.001) and in the same dispensers during the week prior (1.07; p<0.001). The rate increased significantly when auditors were present compared with 1–5 min prior to the auditors’ arrival (1.50; p=0.009). There were no significant changes inside patient rooms.

Conclusions

Hand hygiene event rates were approximately threefold higher in hallways within eyesight of an auditor compared with when no auditor was visible and the increase occurred after the auditors’ arrival. This is consistent with the existence of a Hawthorne effect localised to areas where the auditor is visible and calls into question the accuracy of publicly reported hospital hand hygiene compliance rates.

Hand hygiene monitoring technology: protocol for a systematic review

BACKGROUND

Healthcare worker hand hygiene is thought to be one of the most important strategies to prevent healthcare-associated infections, but compliance is generally poor. Hand hygiene improvement interventions must include audits of compliance (almost always with feedback), which are most often done by direct observation - a method that is expensive, subjective, and prone to bias. New technologies, including electronic and video hand hygiene monitoring systems, have the potential to provide continuous and objective monitoring of hand hygiene, regular feedback, and for some systems, real-time reminders. We propose a systematic review of the evidence supporting the effectiveness of these systems. The primary objective is to determine whether hand hygiene monitoring systems yield sustainable improvements in hand hygiene compliance when compared to usual care.

METHODS/DESIGN

MEDLINE, EMBASE, CINAHL, and other relevant databases will be searched for randomized control studies and quasi-experimental studies evaluating a video or electronic hand hygiene monitoring system. A standard data collection form will be used to abstract relevant information from included studies. Bias will be assessed using the Cochrane Effective Practice and Organization of Care Group Risk of Bias Assessment Tool. Studies will be reviewed independently by two reviewers, with disputes resolved by a third reviewer. The primary outcome is directly observed hand hygiene compliance. Secondary outcomes include healthcare-associated infection incidence and improvements in hand hygiene compliance as measured by alternative metrics. Results will be qualitatively summarized with comparisons made between study quality, the measured outcome, and study-specific factors that may be expected to affect outcome (for example, study duration, frequency of feedback, use of real-time reminders). Meta-analysis will be performed if there is more than one study of similar systems with comparable outcome definitions.

DISCUSSION

Electronic and video monitoring systems have the potential to improve hand hygiene compliance and prevent healthcare-associated infection, but are expensive, difficult to install and maintain, and may not be accepted by all healthcare workers. This review will assess the current evidence of effectiveness of these systems before their widespread adoption.

STUDY REGISTRATION

PROSPERO registration number: CRD42013004519.

Inappropriate use of antibiotics and Clostridium difficile infection

We assessed appropriateness of preceding and concurrent antibiotics in 126 consecutive patients with hospital-associated Clostridium difficile infection. In 93 (73.8%) episodes, at least 1 preceding course of antibiotics was inappropriate. We provided feedback on concurrent antibiotics on the day of diagnosis during the final 8 months: 17 of 74 (23.0%) patients were on inappropriate antibiotics. Our recommendations were well received. Reviewing C difficile-infected patients allowed for identification of opportunities to improve antibiotic utilization and potentially improved patient outcomes.

Sudden death with clinically undiagnosed pulmonary hypertension

Four cases of sudden unexpected death associated with pulmonary hypertension are described. In all cases, the presence of pulmonary hypertension had not been clinically detected. In each case, the underlying etiology of the pulmonary hypertension was different with one case each of occult adult congenital heart disease, pulmonary sarcoidosis, pulmonary tumour microembolism from gastric adenocarcinoma, and familial primary pulmonary hypertension. These cases indicate that the forensic pathologist must be aware of occult pulmonary hypertension as a cause of sudden unexpected death in a variety of age groups.