Author: norvillephillip

Making IPC live for frontline healthcare workers – part 2

norvillephillip Uncategorized , ,

I’ve written this post in preparation for next Wednesday’s IPS Journal Club in partnership with the Infection Prevention Society (register here). (Please note, it will be a little earlier in the day than most previous Journal Clubs, so don’t miss it, and yes I stole this paragraph from Jon). 

The paper that I have chosen for the Journal Club is this one  in the Journal of Infection Prevention, exploring infection prevention behaviour in midwifery staff. 

Kerry, Jon and I had an interesting discussion last week about which ‘live’ we use for this journal club. I think I am an advocate for both and will remain rooted to the fence! Why? We are bringing the journal club to you live and also we want everyone to live Infection Prevention and Control! 

Why did I choose this article? 

  • This is a qualitative study which I am reading more and more of as I try to understand and unpick the human behaviour and perception elements of IPC. In my opinion understanding these better can help support optimal delivery of IPC and patient care 
  • The research was conducted amongst midwives which I was interested to read more about given the high demands on midwifery services and some of the negative press midwifery services have faced in recent years 
  • I am big fan of ‘thematic analysis’ which was framework used for the analysis of the different themes arising from the semi structured interviews with midwives 

Design and methods 

  • To aim was to understand midwives’ experiences of the barriers and facilitators when adhering to infection prevention and control guidelines
  • Semi-structured interviews were conducted with 10 midwives working at a University Hospital in Ireland,  to form a qualitative descriptive study
  • A range of experience levels among participants were sort, including registration with the national nursing and midwifery board and at least 1 year of experience
  • Interviews were audio recorded, transcribed verbatim, and analysed utilising Braun and Clarke’s thematic analysis framework

Key findings 

  • Two themes were identified from the data analysis; (1) the seesaw for equilibrium; and (2) back to basics: learning on your feet.

Seesaw for equilibrium

  • Participants identified the need to find a balance between the demands and uncertainty of everyday practice and the desire to practice safely
  • Participants expressed a difficulty in balancing the ability to adhere to IPC guidelines when performing night duty or working long days as well as the physical demands of the participants’ work
  • Dealing with the effect of one’s workload and balancing workloads contributed to behaviours deviating from the IPC guidelines in the clinical practice setting.

Back to basics: Learning on your feet

  • Participants expressed frustration in having to deal with other disciplines who appeared to adopt a culture of ‘blame the midwife’ when matters relating to IPC were not put in place
  • At an environmental level, the ‘old’ and ‘not fit for purpose’ building infrastructure, physical layout and facilities of wards affected the participant’s ability to adhere to IPC guidelines
  • Some participants felt there was an overuse of posters (such as poster promoting hand washing), and the behavioural prompter was lost 
  • Participants experienced a ‘reactive rather than proactive’ approach from hospital management when there was an IPC issue

Strengths and limitations

  • The number of participants was 10 and only represents a handful of views 
  • All the participants were from the same hospital so it would be interesting to extend this out to others to see if the findings are generalizable 

Points for discussion 

  • There are clearly challenges in the delivery of safe maternity care whilst trying to maintain IPC guidelines and factors such as work patterns, environment, and resource availability impact guideline adherence
  • Do we need to reconsider visual overload? Do we have too many visual cues which confuse the messaging? How can we make our messaging more concise? 
  • Strategies like the buddy system, huddle, ISBAR, and behaviour-focused education, along with management support, are crucial.
  • There was a narrow focus on certain aspects of standard IPC precautions during the COVID-19 pandemic which led to neglect of other IPC elements. Do we need to revisit IPC guidelines post COVID? 
  • How do we strike a balance between delivering IPC safe care whilst dealing with the challenges of a busy, emotionally charged and often stressful working environment?

What does this mean for IPC? 

  • Fear, anxiety, professional integrity, and protection were key motivators for guideline adherence. How can we tackle these perceptions to make IPC guidelines less scary and more deliverable? 
  • Rapid guideline changes around COVID led to confusion and frustration so do we need to rethink IPC guidance post COVID? Could a refresh help?

Assessing the prevalence of MRSA and VRSA in Ethiopia

norvillephillip Uncategorized , , , , ,

I’ve written this post in preparation for this week’s Journal Club in partnership with the Healthcare Infection Society themed around their MRSA article collection: “‘MRSA The Enduring Foe”. Having spent a lot of time working on MRSA as part of my PhD and it regularly cropping up as an organism of concern in IPC I was interested to read about the author’s experience, particularly in a less economically developed country. 

Why I chose this article:

  • I agree with Jon from his blog last week that MRSA isn’t the foe that it once was, but it is still highly relevant and topical, especially from a global health perspective.
  • It’s less frequent to encounter vancomycin-resistant Staphylococcus aureus (VRSA) so I was interested in prevalence of VRSA.
  • I was interested to read about the prevalence of MRSA and VRSA in wound infections in a less economically developed country. 
  • MRSA has been reported at very high prevalence levels in Africa previously so I was interested if this study was comparable.

Design and methods:

  • The study was undertaken at Nekemte Specialized Hospital in Western Ethiopia. 
  • Over a six month period swabs were taken from patients presenting with wound infections and 384 wound swabs (from 384 patients) were taken. 
  • Wound swabs were plated onto chromogenic agar and antibiotic susceptibility to vancomycin and cefoxitin was assessed using disc diffusion.

Key findings:

  • The majority of wounds (63%) were deep wounds and 30.7% of study subjects had wound infections on their legs, followed by 20.6% on their feet and 16% on their hands. 
  • S. aureus was isolated from 28.4% of wounds.
  • 6.4% of S. aureus isolates were sensitive to all antibiotics tested. 
  • The prevalence of MRSA and VRSA among the isolates was 40.4% and 7.3% respectively.
  • From a total of 44 MRSA isolates, 72.7% of them showed multidrug resistance.
  • MRSA resistance against other antibiotics was also shown in the present for ciprofloxacin (45.5%), cotrimoxazole (40.9%), gentamicin (36.4%), chloramphenicol (34%), clindamycin (25%), erythromycin (15.9%), and vancomycin (9.1%).
  • Age, sex, educational level, and marital status were not predictors for the prevalence of MRSA.
  • The depth of the wound, history of wound infection, and history of antibiotic use in the last 6 months was significantly associated with the prevalence of MRSA. 

Points for discussion:

  • The prevalence of S. aureus wound infection is consistent when compared to similar geographical regions but lower than the pooled national prevalence estimate. The rates of S. aureus wound infection reported in this study seem to be quite comparable with UK data.
  • The high prevalence of multidrug resistance in the MRSA isolates is concerning! 
  • What is the correct method to detect VRSA? Disc diffusion is not recommended by CDC.  
  • What are the treatment options given the resistance to multiple antibiotics observed in the MRSA isolates?  
  • What are the best options for decolonisation of S. aureus prior to surgery given the incidence of study participants who developed wound infections following surgery. 
  • Some of the prevalence rates of MRSA referenced in this study were truly staggering! 86% of all S.aureus isolate were MRSA in this study from Nigeria! 
  • The prevalence of VRSA (7.3%)  was significantly higher than other studies.  
  • What do these results mean in the context of the antimicrobial resistance (AMR) pandemic? 

What this means for IPC

  • Depth of the wound, the patient’s setting, previous wound infections, and antibiotic treatment in the previous six months were significantly associated with MRSA wound infection so should be considered as risk factors.
  • Prevention is better than cure, given the limited treatment options when resistance to multiple antibiotics is reported. 

Finally, I hope you can join us for Journal Club Wednesday (register here).

Using whole genome sequencing to investigate a Burkholderia ICU outbreak

norvillephillip Uncategorized , , ,

I’ve written this post in preparation for Wednesday’s Journal Club (register here) in collaboration with IPC Partners

Burkholderia are fascinating genus of bacteria which I had the pleasure of doing some post doctoral work on. The ability of the species to innately resist antibiotics and preservatives, as well as prolonged persistence in the environment means the organisms can cause challenges for healthcare organisations and infection prevention and control. I have seen an increasing number of publications in recent years linking outbreaks to contaminated medical devices and even disinfectants (good systematic review here). Therefore this paper published in The Journal of Hospital Infection investigating a Burkholderia cenocepacia outbreak using whole genome sequencing (WGS) grabbed my interest. I have also been interested in the role of WGS in detection and prevention of outbreaks (see a previous IPC Partners by Dr Alex Sundermann) and the potential benefits.  

Design and methods 

  • The outbreak took place in an intensive care unit in Vietnam between May and August 2023 affecting 19 patients 
  • Environmental sampling of high touch surfaces, fluid samples and medical devices was performed 
  • WGS was performed on all available B. cenocepacia complex (Bcc) isolates using Illumina Hiseq platform. In total WGS was performed on 20 clinical isolates and 3 environmental isolates (from used syringes)
  • Prior to investigating with WGS it had been suspected that positive clinical Bcc samples were the result of blood culture contaminants

Key findings

  • Environmental sampling identified 3 B. cenocepacia isolates from separate syringes using to deliver IV fluids 
  • No growth of microorganisms was detected in samples of skin antiseptics, hand sanitizers and ultrasound gel (surprising to me!)
  • WGS confirmed that all B. cenocepacia isolates from clinical and environmental samples belonged to the same sequence type 
  • The isolates carried an array of acquired antimicrobial resistance genes predicted to confer resistance to carbapenems, sulfonamide, and tetracycline
  • The source of the outbreak was not identified but limitations in the preparation and administration of IV fluids were identified 

What this means for IPC

  • WGS can successfully be used to aid hospital outbreak investigation which is particularly relevant for complex bacteria such as Burkholderia, in which traditional detection and typing methods often have low sensitivity
  • WGS can be implemented successfully in low and medium income countries such as Vietnam but requires strong collaboration between IPC, clinical microbiologists and molecular biologists 
  • WGS allowed species identification which is important in this context, as the Bcc complex comprises of more than 22 different species, exhibiting differing epidemiological and pathologic features, and varying susceptibility to antibiotics both in vitro and in vivo. Misidentification may lead to inappropriate antimicrobial therapy. 
  • The study highlights the importance of following aseptic practices and procedures in handling and administration of intravenous medications to avoid bacterial contamination and prevent infection

IPS Journal Club: A real time intervention to increase CHG bathing and reduce CLABSIs

norvillephillip Uncategorized , , ,

I’ve written this post in preparation for Wednesday’s IPS Journal Club (register here) in collaboration with IPC Partners

The paper that I have chosen for the Journal Club is this one in the Journal of Infection Prevention, describing a real time intervention to increase chlorhexidine (CHG) bathing to reduce central line-associated blood stream infections (CLABSIs).

Why I choose this paper?

  • CHG bathing has shown promise in reducing various infections (such as CLABSIs) therefore evidence demonstrating the effect on infections is welcome
  • A recent estimate of the cost of CLABSIs is extremely high – $48,108 for every case according to the Agency for Healthcare Research and Quality
  • I was really interested in the use of a ‘real time intervention’ given the challenges which are faced around effective implementation of interventions

Design and methods

  • The study was a quality improvement project (QIP) which aimed to increase the rate of daily CHG bathing adherence for patients
  • The QIP was conducted at a 166-bed acute care community hospital in the US over 4 months
  • A Fishbone Diagram and an Impact Effort Matrix were used to identify barriers. Barriers identified included difficulty in identifying CHG documentation, as well difficulties in identifying patients that are due for CHG bathing
  • This led to the development of a ‘Time Since Bathing Column’ to make identification of missing CHG bathing opportunities more apparent within the Electronic Health Record (EHR). This allowed the hospital IPC team to provide real-time feedback when CHG bathing was overdue for a specific patient
  • A consistent message and message platform within the EHR allowed standardisation of the message content and the method of delivery
  • A sustainability plan was introduced using tools and dashboards to create individual plans focusing on ownership and empowerment of frontline staff to ensure frontline bathing  

Key findings

  • Prior to the intervention CHG bathing rate adherence was 94.9% (already very impressive) with a CLABI rate of 1.89
  • Following the implementation of the real intervention a 0.42% increase in CHG bathing adherence was detected (which was not significantly significant)
  • When including weekend CHG adherence rates in the analysis, a 2.8% increase in CHG adherence was detected (97.6%), which was statistically significant (the QIP identified that CHG bathing adherence was low on weekends)
  • No CLABSIs were identified in the 3-month study period, and 12-month CLABSI rolling rate decreased from 1.78 to 1.07 (however the sample size was too small to perform statistical analysis)

Strengths and limitations

  • CHG adherence was already extremely high, so challenges in a detecting a significant change however the QIP identified reduced CHG adherence over weekend periods
  • Although CLABSIs rate decreased the sample size was too small to identify any statistical significance  

What does this mean for IPC?

  • Cross functional working with informatic and digital teams can improve CHG adherence and potentially reduce CLABSI rates
  • Real time interventions can identify falls in CHG adherence at times where staffing levels are low, such as weekends
  • Real time feedback accompanied by multidisciplinary team engagement with clinicians were important success factors
  • Outreach and reminders effectively improved CHG bathing adherence by emphasizing the importance of consistent communication and follow-up

Water-free patient care: a narrative review of the literature

norvillephillip Uncategorized , , , ,

In preparation for today’s Journal Club in partnership with the Healthcare Infection Society around water hygiene (details and registration here), I’ve reviewed this article in the Journal of Hospital Infection.

Why I choose this article?

Waterborne healthcare associated infections (and the prevention of), have always been an area of interest for me. Papers and evidence identifying the significance of the risk (particularly in the intensive care setting), and the challenges posed by outlets other than sinks and showers, such as toilets (read related blog here) have increased significantly.

This has resulted in novel ways of reducing the risks posed by waterborne infections being explored, including the concept of water-free or water light patient care. With that in mind I was really interested to read this article by Teresa Inkster  and colleagues. What better way than a narrative review from some of the world’s leading authorities on water, to examine if there really is a benefit to implementing water-free care?

Using a defined search criterion, the narrative review identified seven papers, the majority of which focused on implementing water-free care in the intensive care unit (ICU) setting. 

Key findings

  • Water-free care was largely instigated in response to outbreaks by Gram-negative bacteria (GNB)
  • 2 of the papers reported outbreaks of multidrug resistant Pseudomonas aeruginosa. In both papers removal or limiting use of sinks and implementing water-free alternatives resulted in the termination of outbreaks.
  • 2 papers reported outbreaks in neonatal intensive care. One the studies conducted in Australia, showed that complete removal of sinks (apart for one sink for hand washing at entry and exit points) result in decreased colonisation of neonates with GNB and the unit reporting no outbreaks (traceable to water systems) for over 10 years!
  • 2 quasi experimental studies both conducted in ICU settings reported benefits when implementing water-free care. One of the studies showed an overall decrease in GNB colonisation rates. The other study showed a reduction in the incidence of MDR GNB infection, with the greatest impact observed on reducing new cases of Klebsiella pneumoniae.

Limitations of the study

The studies identified in the narrative review are weakly powered. Further research should focus on higher powered studies which focus on water-free care as the sole intervention. We can also aspire to a randomised controlled trial to hopefully provide unequivocal evidence. There are also questions to be answered on the methodology we use to sample a sink (something Jon Otter and I wrote about recently). Where and how do we sample? Can we employ whole genome sequencing more effectively?

What strategies should be adopted by healthcare providers?

Terminating outbreaks and reducing colonisation of GNB are clear benefits when implementing water-free care. The authors helpfully set out challenges which need to be addressed before healthcare providers can consider the implementation of water-free strategies. These challenges include:

  • ‘Water-free’ being a confusing term which can be a barrier in itself
  • Risk from water and wastewater systems are not appropriately risk assessed in terms of risk to vulnerable patients
  • Surveillance methods often lack sensitivity
  • Standard IPC precautions are designed to be ‘catch all’ so lack effectiveness in preventing water and wastewater transmission events

Requirement for change

The article highlights the looming global antimicrobial resistance (AMR) crisis and considers the current strategy of infection control, antimicrobial stewardship and development of new antibiotics, being largely ‘oblivious’ to the built environment. The authors make an excellent point that through improved design, installation and commission/maintenance the built environment provides an excellent opportunity to tackle the AMR crisis head on. The authors go on to emphasise how the UK New Hospital Programme  (NHP) provides an opportunity to develop solutions to implement optimal water-free care. I couldn’t agree more!

As part of the requirement for change the authors also highlight why the move to water-free care has been relatively slow. These factors include lack of awareness and recognition of risks, low sensitivity of surveillance, concerns of risk to patient safety when removing clinical hand wash basins and an increase in skin related conditions (associated with increased alcohol-based sanitisers). 

What this means for IPC?

Clearly the evidence surrounding the reduction in risk and transmission of healthcare associated infections when adopting water-free care is gathering traction. There is work to do to overcome the challenges, but also opportunities via the NHP. The authors call for empowerment of clinical staff, followed by ownership to support the successful implementation of water-free care. However, this requires support and guidance from organisations such as the Department of Health (in England).

Collaboration between IPC and estates and facilities staff, as well as executive buy in and engagement with front line staff is required to reduce the risks associated with water and wastewater. Overcoming barriers to implement water-free care will rely on a change in culture and financial investment to support its successful adoption and for the benefits to be realised. Finally with the looming AMR crisis, prevention is always better than cure, especially as we are running out of options for the cure (antibiotics)!  

Collateral damage in a waterless ICU!

norvillephillip Water , , ,

In recent months I’ve read a lot about the infection risks associated with sinks and drains in areas of healthcare organisations which house some of our most sick and vulnerable patients. The retrospective study carried out in Germany, comparing hospital acquired infection (HAI) rates in 552 intensive Care Units (ICUs) with and without sinks was perhaps the most compelling, concluding that ICU rooms with sinks were associated with a higher rate of HAIs (in comparison to those without sinks). I’ve also read with interest how many healthcare organisations have tackled the infection risk posed by sinks and water through the implementation of water-free or water light (which I personally prefer) systems. More and more evidence is emerging that this approach has merit in reducing the transmission of HAIs in ICUs, with a recent systematic review  suggesting that sink removal and other water-free interventions in ICUs, helped terminate infection outbreaks.

Continue reading →

Biofilms…the gift that keeps on giving!

norvillephillip Biofilm , ,

Last week I spent some time at the Infection Prevention Society (IPS) annual conference in Birmingham which provided a fantastic selection of talks and discussions on current and emerging IPC challenges. One topic which came up time and time again was biofilms…. for example, whether the presence of biofilms provide Candida auris with the ability to persist in the clinical environment for prolonged periods, through to the role of biofilms in reduced susceptibility to disinfectants and antibiotics. It made me revisit an excellent recent review published in Antimicrobial Resistance and Infection Control, which is the topic of today’s blog and tomorrow’s IPC Journal Club (register here).

Continue reading →

How much of a drain are sinks on our healthcare organisations?

norvillephillip Water , , ,

The role of wastewater systems in the transmission of healthcare associated infections (HCAIs) has been an interest of mine for several years but it was this paper published in JHI last year which highlighted just how big their contribution could be.  

Papers keep coming to support the link between sinks and HCAIs. This recent paper in JHI, examined rates of HCAIs caused by Pseudomonas aeruginosa in six intensive care units (ICUs) in Ontario, Canada. Specifically, the authors investigated the role of sinks in the transmission of P. aeruginosa HCAIs.

The paper was an enjoyable read as there was real rigor in the methodology relating to the microbiological analysis of the ICU sinks, something which Dr Jon Otter and I have discussed the importance of previously. The study used a combination of microbiological sampling and whole genome sequencing as part of prospective cohort study to investigate transmission. I also really liked how the authors defined important terminology used in the analysis, providing clear differentiation between ICU acquired infections and sink acquired infections.

Over the 10-month study there were 4,263 admissions to the six ICUs involved, and 72 (1.4%) P. aeruginosa HCAIs were identified. Unsurprisingly patients who were colonised with P. aeruginosa were more likely to develop and infection and infected patients spent longer in ICU. Analysis of P. aeruginosa HCAIs found that 5-7% of infections came from a sink reservoir. The authors concluded that this rate of infection was likely to be underestimated due to challenges with sampling of the environment and when assessing patient acquisition. The authors also point out that toilets were not included in their sampling analysis, something which I blogged about the risk of recently.  I tend to agree with the authors that this infection rate is underestimated given other studies have reported higher infection rates.

To conclude we have another paper which confirms the role of sinks in the transmission of infections. We need to do more to reduce the risk of these transmissions given the burden to patients and the drain on our healthcare organisations. An additional day stay in ICU has been estimated to cost £1621. We need more research into cost effective interventions to reduce the risk of transmission to reduce the sink and infection burden on our healthcare organisations.