To get us in the mood for Dr Nneoma Okeke’s Journal Club tomorrow (register here!), I’ve been reading the paper that will be covered. Over the past two decades, a huge population-based study in Queensland, Australia sheds light on the evolving landscape of Candida and Candida-like species bloodstream infections. This analysis, including 2,586 episodes across 2,420 patients, reveals critical trends in species prevalence, resistance patterns, gender differences, and clinical outcomes that have significant implications for healthcare practices.
Continue readingVancomycin to prevent recurrent CDI? On yer bike…
After our summer break, I’m looking forward to our first Journal Club of the Autumn tomorrow (register here). I’ve written this post in preparation for the Journal Club, which is hosted by IPC Partners in partnership with IPC Launch, ID Watch, and the Healthcare Hygiene magazine on the topic “Optimizing prevention and treatment of gastrointestinal and urinary tract infections”. The paper that I’ll be covering is a randomised controlled trial of oral vancomycin to prevent recurrent C. difficile infection.
Continue readingMaking IPC live for frontline healthcare workers – part 2
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?
Making IPC live for frontline healthcare workers
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!) The paper that I have chosen for the Journal Club is this one in the Journal of Infection Prevention, exploring infection prevention behaviour in hospital nursing staff.
Continue readingS. aureus and SSI: all roads point to nasal colonisation
I’ve written this post in preparation for tomorrow’s Journal Club, which will be about this paper on S. aureus colonisation and SSI (register here). Having not written or reviewed much on S. aureus for quite a while, I’m reading my second S. aureus paper in two weeks, following last week’s blog on a paper from the Healthcare Infection Society special on “MRSA: the enduring foe“!
Continue readingAssessing the prevalence of MRSA and VRSA in Ethiopia
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).
MRSA admission screening – does it work and is it cost-effective?
I’ve written this post in preparation for next week’s Journal Club in partnership with the Healthcare Infection Society themed around their MRSA article collection: “MRSA: the enduring foe”. Having spent a fair bit of time this week looking at post-infection reviews related to MRSA bloodstream infections, I can vouch for how well this particular foe has endured, even in a relatively low prevalence setting!
Continue readingUsing whole genome sequencing to investigate a Burkholderia ICU outbreak
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
“It might be gloves; it’s always hand hygiene”
Yesterday was World Hand Hygiene Day 2025! Look out for a World Hand Hygiene Day 2025 themed Journal Club tomorrow, where we will be discussing this paper. You can register for Journal Club here.
Continue readingIPS Journal Club: A real time intervention to increase CHG bathing and reduce CLABSIs
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
Reflections on Infection Prevention and Control 