Implementation of tailored interventions in a statewide programme to reduce central line-associated bloodstream infections

BACKGROUND

There have been few studies exploring implementation strategies to central line-associated bloodstream infections (CLABSIs) in low- or middle-income countries.

AIM

To implement tailored interventions to reduce CLABSI rates in adult intensive care units.

METHODS

The implementation strategy of the State Health Department was performed in São Paulo State, Brazil, over two cycles. Cycle 1 (56 hospitals) was exploratory and cycle 2 (77 hospitals) was designed to confirm the hypothesis generated by the first cycle, with three phases each (pre-intervention, intervention, post-intervention). Cycles included: evaluation of healthcare workers' knowledge, observation of practices, and CLABSI rates monthly report. In cycle 1, a log-normal mixed model was used to select variables significantly associated with the reduction of CLABSI. In cycle 2, CLABSI rates were evaluated.

FINDINGS

Healthcare workers' practices improved after intervention. In cycle 1, reduction of CLABSI rates was more pronounced in hospitals with initial CLABSI rates >7.4 per 1000 catheter-days (P < 0.001) and those that introduced the use of peripherally inserted central catheters (P = 0.01). For hospitals with high CLABSI initial rates, simulation demonstrated that the rates were expected to decrease by 36% (95% CI: 9-63), no matter the type of intervention. In cycle 2, there was an overall decrease in CLABSI rates during the intervention period; whereas the mean rate fell further post-intervention, rates at the 90^th percentile increased.

CONCLUSION

The implementation strategy may have had an effect on infection rates independently of the specific interventions implemented; however, the sustainability of reduction in the post-intervention period remains a challenge.

Candida colonisation as a source for candidaemia

Candida spp. are important healthcare-associated pathogens. Identifying the source of infection is important for prevention and control strategies. The objective of this study was to evaluate candida colonisation sites as potential sources for candidaemia. Sixty-three consecutive patients with a positive blood culture for candida were included. Surveillance cultures were collected from urine, rectum, oropharynx, skin, intravascular catheter tip and skin around catheter. Molecular typing was performed when the same species of candida was isolated from blood and surveillance sites of a patient. C. albicans was associated with 42% of candidaemias, C. parapsilosis 33%, C. tropicalis 16% and C. guilliermondii, C. krusei, C. glabrata, C. holmii and C. metapsilosis were all 2% each. Six of 10 C. parapsilosis catheter tip isolates were indistinguishable from corresponding blood isolates (all in neonates). C. albicans isolates from blood were indistinguishable from corresponding gastrointestinal tract isolates in 13 of 26 patients and from catheter tip isolates in two patients. In conclusion, the results suggest that gastrointestinal colonisation is the probable source of C. albicans candidaemia and C. parapsilosis is exogenous.

Disconnecting central hot water and using electric showers to avoid colonization of the water system by Legionella pneumophila: an 11-year study

Legionella spp. can be difficult to control in hospitals. The objective of this study was to describe an 11-year experience with the use of electric showers in the control of Legionella pneumophila. From June 1989 to March 1990 there was an outbreak of pneumonia caused by L. pneumophila in a 20-bed renal transplant unit in a university-associated tertiary-care hospital. Control measures included hyperchlorination, heating and flushing of the water system with limited results. In November 1993 the central hot water was disconnected and water for bathing was heated using electric showers. From January 1992 to June 1995 water was collected from showers and water faucets and cultured for L. pneumophila every two weeks. Surveillance cultures were then collected every month until May 1999. During this seven-year surveillance period, 1115 samples of water were cultured. Water cultures were positive on 24 of 429 occasions (without cases of legionellosis) during the pre-shower period (22 months). In the post-shower period (67 months) only one of 686 cultures was positive. Subsequently there have been no new cases of nosocomial pneumonia by L. pneumophila although surveillance continues. In conclusion, disconnecting the central hot water was effective in avoiding colonization of the water system by L. pneumophila. Heating was possible by using electric showers, which are effective, easy to maintain and cheap.