Category Archives: infection control

Results of the National healthcare associated infection point prevalence study (CHAINS)

On behalf of everybody involved in this exciting study, I am delighted to share the main outcomes that have now been published in Antimicrobial Resistance and Infection Control. We specifically targeted this journal given its significant international status, and importantly all articles are open access. This means that it is available to everybody all the time, and also allows for a pdf download.

Some key points on the study:

  • First national study of its type in Australia for over 30 years
  • Identified that 1 in 10 adult acute inpatients has an infection as a result of their healthcare
  • Most common infections were those following surgery, urinary tract infections and pneumoniaI
  • Identified many infections that hospitals would not normally be detected in routine surveillance processes
  • 1 in 10 patients were being managed for a multi-drug resistant organism
  • Australia is one of the few OECD countries that does not have a national surveillance program
  • Data was collected from19 large hospitals across the country over four months in 2018

A major strength of the study is the use of the same trained data collectors across all sites. This ensured consistency in the application of definitions and datas collection, and also negated any subjective influences if it were data from hospital-based collectors. This is a critical difference to other international PPS and adds reliability to our study.

Importantly, we did not include smaller or specialty hospitals, private hospitals and excluded all patients under 18. Future studies should be funded to all patients across all sites.

This is the first time in 34 years we have had an estimate of HAI prevalence across Australia. In the absence of a national HAI surveillance program, we suggest data from repeated national HAI PPS in all facilities could be used to inform and drive national prevention initiatives.

To read more about the findings, we have written an article in The Conversation, and access to the journal article is here. See highlights from the study in our brief animation below.

Again, a sincere thank you to the infection prevention teams from the participating sites, your support and cooperation was crucial to the success of this study.

We will discuss implications and other outcomes from the study in future blogs

Sincere thanks to the wonderful dedicated infection prevention teams from each of the participating sites for their cooperation and hospitality.

  • Alfred Hospital, Vic
  • Bendigo Health, Vic
  • Calvary Hospital, ACT
  • Fiona Stanley Hospital, WA
  • Frankston Hospital, Vic
  • Gold Coast University Hospital, QLD
  • Hornsby Ku-ring-gai Hospital, NSW
  • Launceston General Hospital, Tas
  • North West Regional Hospital, Tas
  • Redcliffe Hospital, QLD
  • Royal Brisbane and Women’s Hospital, QLD
  • Royal North Shore Hospital, NSW
  • The Prince of Wales Hospital, NSW
  • The Queen Elizabeth Hospital, SA
  • The Royal Adelaide Hospital, SA
  • Westmead Hospital, NSW

Acknowledgements

The authors acknowledge the work of the CHAINS Project Manager, Bridey Saultry, Research Assistants Ms Stephanie Curtis and Ms Sophie Robinson, Infection Prevention teams, site investigators and key stakeholders at the participating hospitals. The Centre for Quality and Patient Safety Research, Deakin University, for supporting and administering the project. We also acknowledge Kalisvar Marimuthu, Professor Jacqui Reilly and Professor Jennie Wilson for expert advice and guidance in the planning stages of this project

National HAI PPS Update – July 2019

On behalf of the research team I am delighted to inform you that data analysis from the CHAINS project has now been completed.

We have recently submitted a manuscript for publication and look forward to sharing the primary outcomes with you, hopefully in the near future.

In April this year, I was fortunate to present some preliminary data at the 29th European Congress of Clinical Microbiology & Infectious Diseases, in Amsterdam, The Netherlands. Interestingly, I received many comments from Europeans who couldn’t believe that regular HAI point prevalent surveys are not undertaken in Australia.

I was also recently invited by Safer Care Victoria to present some data to the Infection Control Clinical Network 2019 forum.  We are in the process of planning similar updates to all jurisdictions over the next few months. I will also be presenting some findings to the Healthcare Infection Advisory Committee of the Australian Commission for Safety and Quality in Health Care later this year.

Another important part of our dissemination strategy is to provide each participating hospital with a report that will allow them to compare their own data with other (de-identified) participating sites. This report is due later in the year.

We are looking forward to providing you with more detailed updates soon.

Phil

Best article for 2018 – #blogoff

Jon Otter and I have been having a ‘blog off’, with the aim of presenting the best infection control paper for 2018 (to date). Below, I put my case forward. You can read Jon’s post here. After you read both blogs and listen to points made via Twitter, we encourage you to vote (for the article I present!). Follow more on Twitter (@1healthau) and #mitchellvsotter via this link. Results will be presented during my social media talk on Monday 1st October (& via Twitter). You can vote using this link: https://www.surveymonkey.com/r/SL23H6K

___________

My (Brett Mitchell’s) choice of article

Choosing the best article is always fraught with danger. There are so many great infection control articles in 2018, but for this blog, I have chosen something that impacts everyone working in infection control – contact precautions (CP).  The article – Impact of Discontinuing Contact Precautions for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus: An Interrupted Time Series Analysis by Bearman et al.

There are three main reasons, why I believe this article is noteworthy:

  1. Advancement of knowledge in a difficult area
  2. Sets foundation for additional studies
  3. The implications for changing practice around contact precautions are profound

What is the article about?

In this single centre quasi experimental study, seven horizontal infection control interventions were evaluated. One of these, was the discontinuation of CP for patients with MRSA and VRE. During the study period, using interrupted time-series analysis, infection rates for MRSA and VRE decreased, in addition to device associated HAIs – following discontinuation of CP. Importantly, compliance with CP was monitored prior to cessation, 94% compliance with CPs hospital wide, from nearly 2700 observations. The authors conclude with the suggestions that the discontinuation of CP for patients infected or colonized with MRSA or VRE, when combined with horizontal infection prevention measures was not associated with an increased incidence of MRSA and VRE device-associated infections. MRSA HAI decreased by 1.3 per 100,000 bed days and VRE HAI decreased by 7.5/100,000 bed days. Not statistically significant, but clinically relevant in the context of no increase or difference.

Advancement of knowledge

Evidence supporting the use of CPs is largely based on observational studies, theory and expert opinion. Undertaking RCTs in infection control is challenging and not always possible, not the least on the topic of evaluating the impact of stopping CPs.  We have seen other work which has tested the value of universal glove and gown use, but limited work on ceasing CPs. This study takes a big step forward, using a robust design. It adds to a small but growing body of evidence investigating the universal application of CP for patients with any MRO.

Sets foundation

Another important aspect of this study, is that it sets the foundation for more work. It appears that no harm was caused as a result of ceasing CPs. This evidence is critical when attempting to seek funds for future studies, convincing a hospital to attempt something similar and obtaining ethical approvals. It was ‘gutsy’ to undertake a study that ceased CP, but the pragmatic and clever approach of bundling this with other horizontal infection control initiative made this palatable, as well as being able to unpick the relative effect of ceasing CP, using interrupted time series. In so doing, the authors have taken this controversial topic forward and established platform for multi-site sites (plus or minus randomisation).

For the record, I am not suggesting we should change practice around CPs yet, nor I am suggesting CP do not work in the prevention transmission of certain organisms. Rather, I am saying we should be open to the idea and support work that helps answer this question one way or another.

Implications

Imagine the implications if CPs were not required for patients with certain organisms. As quoted in a recent paper by Prof Nick GravesBecause you exist in a world of scarce resources, the choices you make have economic consequences”. The implications regarding CPs are significant and include the (reduction) in cost of personal protection equipment to the increased availability of single rooms as a starting point. In addition, think about the time invested in

identifying patients with MROs, placing them in CPs, monitoring compliance and the associated education with staff. The freeing up of resources, where there are finite resources, is critically important and present new opportunities.

The authors are to be congratulated for tackling a vexed issue and opening the door to the next stage. We need more research in infection prevention and control, that tackles the ‘known unknowns’, so we can advance the science of the profession, have practice underpinned by strong evidence and provide optimal patient care. Where else to start, than with evidence around CPs?  Regardless of whether you are clinician, an infection control professional, policy maker or researcher, this article should be of interest to you. Let’s hope more studies can build on this in the near future.

If you are in agreement, don’t forget to vote for this article here

 

Quick insight into ECCMID 2018

After a great few days at ECCMID conference in Madrid, I thought I would give some highlights. There were many good sessions and presentations, but I have picked a few that stood out for me. To set the scene, for those who haven’t been to ECCMID, it is huge. Around 15,000 delegates and 15+ sessions going at any one time. The poster area is the size of a airport hanger. Planning is key.

Petra Gastmeier contributed to many pieces of work at the conference, but on the first day, presented on “Before an outbreak – is complete sanitation of robotic surgical instruments possible?”. She discussed two key outcomes when answering this question. First, is the instrument clean or not; second, does the instrument affects surgical site infection rates. Her talk concluded by with the concept that at present, based on literature, robotics instruments do not appear to increase SSI rates. However, a strong CSSD is required.  Maybe the reasons is that the process includes disinfection and sterilisation. The presentation can be viewed here.

 

John Rossen discussed whole genome sequencing in outbreaks. Challenges and advantanges of WHS were discussed. One issue is the cost and turnaround time. He discussed his work, which involved used WGS to develop a local PCR test – to distinguish outbreak strains from others. This overcomes the cost and timeliness issues. The presentation can be viewed here

 

Jon Otter, always great to listen to, was heavily involved in the conference. If you haven’t seen his blog, make sure you check it out (but don’t forget us). Jon always makes his work available on the blog as well.  I have picked one of Jon’s talks,” Before an outbreak – what to do after first MDR Gram-negatives enter your hospital?”. A great interactive session with live voting. There was variation from the audience, with respect to what products (chlorine or HP) are used for control CPE. A key take home from me, was that cleaning and sinks, are a key issue. There was quite a strong focus on the role of sink in MRGN control at the conference. The presentation can be viewed here.

 

Ben Cooper talking about modelling. Some key things from his talk were – ‘models help us think’. I really like that motto. Time series analysis are good, but poorly analysed. The way of the future is to use models to design high quality RCTs. His presentation can be viewed here.

 

In something close to my heart, given some studies I am involved with, was a talk by Marc Bonton (@MarcBonten) on pragmatic trial designs. Some key takes homes: consider the natural history of the disease. It is easily to find an intervention that works, if the infection rates was trending down anyway. Cluster RCTs are good, but consider selection bias and carry over effects. His presentation can be viewed here.

 

There was a session that had short presentations on current / early research findings. Many topics were covered, from hand dryers to risk factors for predicting ESBL carriers. Sessions topics and presentations are here.  One stand out me, for novelty, was a study that explored norvirus dispersal. It is worth a look.  Norovirus was spilt in a laboratory, then cleaned. Results are very interesting. The presentation by Caroline Lopes Ciofi-Silva is worth seeing as you get a real sense of what they did. I feel for those who cleaned up the norovirus – I wonder if they got sick??

 

There was also an interesting study exploring contact precautions Vs standard precautions, involving 30,000+ patient in 20 non ICUs – to determine any difference in EBSL acquisition. Findings are suggesting no difference, but the key for me, is whether the rooms were single rooms. If so, they would probably would not expect to find any difference. If the ICUs were single rooms, then I think we are none the wiser – especially as most hospitals are not 100% single rooms. If there were shared rooms, this may be the catalyst to rethink contact precautions.

 

There was also a great “Year in review” for infection control. I could never do this justice and it is worth seeing the presentations. Hilary Humphreys presented first and went through a mountain of papers. Looking forward to hearing Hilary again at ACIPC 2018 in Brisbane.

 

There is plenty I have missed. You can use the ECCMID live website to find and view other presentations. I also tweeted about other presentations. Speaking of Twitter, there were some great interactions on Twitter at the conference, including those who were not present. It is a great way to find out they key discussion points at conferences.

 

 

 

 

Con(fused)tact precautions

Whilst “festivus”1 is generally a happy time for most of us, unfortunately people still become unwell, and our hospital beds remain occupied. One of the beds in a large Australian acute care facility has accommodated a family friend who has undergone surgery and some moderate rehab after falling at home.

Given some predisposing conditions, the family friend was at risk of acquiring a HAI, and it is disappointing to report they required treatment for various types of HAIs. They were also found to have VRE, and were promptly placed into a single room, under Contact Precautions.

Puzzled Confused Lost Signpost Showing Puzzling Problem

Whilst this family has much to be sorry and concerned about, what concerns them greatly, and what they have found most upsetting, is the inconsistent information and advice they receive on a daily basis from healthcare workers on the specific precautions that they, as family visitors, must take. Gloves, no gloves, mask, no mask, cloth gown, plastic apron… they have had almost every combination of precautions recommended. They  have even been scolded by a HCW for wearing “inappropriate” attire, whilst all the time directly observing a broad array of PPE adopted by different HCWs as they enter the room. They feel confused, angry, and upset. They lack confidence in the HCW knowledge of what is required, and feel powerless in seeking clarification of what they should be doing.

I find this troubling on several fronts. First, inconsistency. If HCWs caring for patients with MROs are giving family visitors different messages on PPE, then chances are they don’t quite understand what is required to prevent spread (evident by HCW inconsistency in their own PPE). Second, why are family visitors made to feel as though they have endangered the lives of not only their relative, but also of every other patient in the hospital when they are simply doing as they are told. And third, I don’t suspect for one minute that this situation is unique to this ward, hospital, city, or country. This scenario will likely be repeated daily in all types of facilities (see also NOTE below).

As we know, HAI prevention requires multiple interventions all being applied correctly. Whilst the momentum of antimicrobial stewardship in the fight against AMR has rightly attracted much energy, and the importance of environment is emerging , a basic understanding of precautions, and consistency of PPE messaging for HCWS and visitors is surely a simple and measureable intervention we should not lose sight of.

Phil

  1. Seinfeld 1997 – Episode 10, Season 9.

NOTE – this may be due to a lack of robust evidence and debate about Contact Precautions (see here for an example), nevertheless, messages (policy) within a facility should surely be consistent.

 

Infection, prevention & control and Aboriginal and Torres Strait Islander People.

The Snake, the Staff and the Rainbow Serpent : A Call to ‘Fill the Gap’ in research relating to infection, prevention and control and Aboriginal and Torres Strait Islander People.

(Written by Victoria Gregory)1

 

Aboriginal and Torres Strait Islander people are the oldest surviving culture in the world, yet they will live approximately 10 years less than other Australians. Some contributing factors include indigenous people are at higher risk for emerging infectious diseases compared to other populations (Butler et al 2001). Examples of infectious diseases include respiratory tract infections, infections with antimicrobial-resistant organisms, and bacteremia and meningitis caused by Streptococcus pneumoniae, zoonotic diseases, viral hepatitis, Helicobacter pylori and respiratory syncytial virus infections, diseases caused by Group A and B streptococcus, tuberculosis, Haemophilus influenzae type b, and Neisseria meningitides (Butler et al 2001).

Here are some specific examples:

  • According to data from ‘healthinfonet’ between 2009 and 2013 tuberculosis notifications were 11 times higher for Indigenous people than for Australian born non-Indigenous people.
  • In 2014-15, Aboriginal and Torres Strait Islander people were three times more likely that non-indigenous people to be admitted to hospital for influenza and pneumonia.
  • In 2014, there were 170 cases of invasive meningococcal disease notified in Australia with 21 cases (12%) identified as Aboriginal; an increase from 2013 where 13 cases (8.7%) were identified as Aboriginal and one identified as Torres Strait Islander (0.7%).
  • In 2015, hepatitis C notifications were five times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people and the rate of HIV diagnosis was just over twice as high for Aboriginal and Torres Strait Islander people than non-Indigenous people. Notification rates for gonorrhoea were also 10 times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people. For syphilis, notification rates were six times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people. For chlamydia, notification rates were three times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people.
  • Skin infections are also common in Aboriginal and Torres strait Islander Communities (The Lowitja Institute).

These data paint a real and bleak picture, but there are many success stories, including:

  • An initiative by Australians for Native Title and Reconciliation group in 2007 which reported on successful Aboriginal and Torres Strait Islander health projects, such as:
    • ‘Tune into your health: Nunkawarrin Yunti Aboriginal Health Service’ where young people developed lyrics and songs about health issues affecting their community, a song called ‘It’s in your blood’ increased knowledge and awareness of Hepatitis C.
    • ‘Keeping safe with a snake: Marie Stropes International Australia’ an initiative raising awareness of sexual health.
    • ‘Mooditj: Sexual health and positive life skills’ an initiative by the Family Planning Association of Western Australia.
    • Healthworkforce Project and the Shalom Gamarada Ngiyani Yana Residential Scholarship program which has increased the numbers of Aboriginal and Torres Strait Islander students studying medicine and health at UNSW.
  • The implementation of the nationally funded Hib disease vaccination in 1993 which resulted in decrease of notifications of invasive Hib disease by more than 95%.
  • The painting above, ‘Healthcare in the Western Desert’ was created as part of an innovative project building mutual trust and respect involving Aboriginal artists from the Wankatjunka, Kakutja and Walpirri language groups and second year medical students from the University of Notre Dame during the students’ Remote Area Health Placement in the Kimberly. It highlights the 3 ‘snake and staff’ images representing the medical profession as well as symbols depicting women and children from the local communities and coloured squares representing the medical clinics and a number of circular jila (waterholes). The act of painting together transcended cultural differences and led to an evolution of knowledge and understanding for all participants.

Indigenous communities are at high risk for many infectious diseases, but there is limited research specifically relating to Indigenous health in relation to infection, prevention and control in Australia. Culturally appropriate research and ‘bottom-up’ prevention and control strategies, as well as long term commitment to their implementation is urgently required. It is our responsibility to mainstream Aboriginal and Torres Strait Islander equality in all the valuable work that we do in the infection, prevention and control sphere. This blog is a reminder of the alarming statistics around infections and a call to work on closing the gap in health outcomes in Australia.

This blog was written by Victoria Gregory.

References

  1. Australians for Native Title and Reconciliation. antar.org.au
  2. Closing the Gap Prime Minister’s Report 2017. Closing the gap.pmc.gov.au
  3. Australian Indigenous HealthInfonet.http://healthinfonet.ecu.edu.au/ Retrieved 29.11.17
  4.  Butler, J. C., Crengle, S., Cheek, J. E., Leach, A. J., Lennon, D., O’Brien, K. L., & Santosham, M. (2001). Emerging infectious diseases among indigenous peoples. Emerging infectious diseases, 7(3 Suppl), 554.
  5. The Lowitja Institute. http://www.crcah.org.au/search/site/infection
  6. The University of Notre Dame, Australia. http://www.nd.edu.au/news/media-releases/2017/077

 

 

 

Some take aways from #ACIPC17 Conference, Canberra

Congratulations to the organisers of ACIPC Conference 2017 Parliament_House_Canberra_Dusk_Panoramain Canberra. Well done to the Conference Committee and the Scientific Committee. A great program and venue adding to the always enjoyable catch up with colleagues local, national and international.

There were many highlights. Due to other commitments, I missed a few of the major plenaries. Nevertheless, I came away with some clear take home messages from those I did get to, here are just a few of them…

  1. An emerging theme from the presentations was that of public reporting and financial penalties (PR&FP) associated with healthcare associated infections (HAIs). The likelihood that Australia needs to accept that these are inevitable for a range of HAIs is clear. In case you missed it, Benjamin Magid presented an excellent talk touching on the Australian Commission for Safety and Quality in Health Care use of what are called Hospital Acquired Complications, that use administrative coding data to detect healthcare associated infections, and which I have blogged about previously.
    One of the many advantages of living and working in Australia and hosting keynotes from the US is that they often provide a window to the future. At various stages, Prof Pat Stone, A/Prof Dev Anderson and Dr Susan Huang all related stories about their experience of PR&FP. From their experience it would seem, at some point in time, the implementation of PR&FPs does eventually turn into a positive for infection prevention (and hence our patients). From what we hear, PR&FPs seem to result in a recognition of infection prevention that subsequently provide opportunities to increase resources. Thats not to say there was no pain during the “journey”, and we should be prepared for that. Although Dev Anderson did argue against the notion of PR&FPs in the final debate, he was quick to tweet afterwards that in fact he does support it! Finally on this point, we should continue to explore better use of existing data if validated, strive to minimise the burden of data collection, and consider whether current HAI definitions are suitable for the PR&FP environment.
  2. The quality of the free papers gets better every year. The addition of the quick poster presentations and the new format of the 3 minute research presentations was a celebration of the excellent research being undertaken in our field. Updates on current studies (e.g. the large and complex REACH project) further added to our awareness of exciting work being undertaken by our colleagues. The next few years will see many of these projects yield new knowledge and fill sessions of conferences to come!
  3. The consumer voice is powerful. The presentation delivered by Mathew Ames left many in the auditorium not only in tears, but also resolute about the work we undertake.
  4. Finally for now, I believe the pop up sessions during lunch were a big winner. Informal yet intimate, a great way to get close to those people who are always hard to find at conferences. A great initiative hopefully here to stay..

But thats just some of my impressions from the sessions I saw. You might have seen something completely different. If so, comment below and let us know…

Looking forward to Brisbane in 2018.

TIP: Next year, if you have trouble remembering the correct Twitter hashtag, think  character count efficiency...save the character count by dropping the “20” from “2018”

#ACIPC18

 

Phil
Disclosure – ACIPC Board member (President Elect) and member of the ACIPC Conference Scientific Committee 2017