Health education and behaviour change
“Why is it so difficult for me to get people to follow basic infection control practices?!” That question was posed by Prof. Michael A. Borg from Malta who spoke about the difficulty of effecting behaviour change. Despite the plethora of evidencebased guidelines and literature, implementation of correct infection prevention and control (IPC) procedures continued to be a challenge in healthcare settings. That meant that attempts to implement IPC measures were often suboptimal or even failed. It was difficult to change, in particular, long-established behavioural practices.
There were positive examples from industry showing how behaviour changes could be achieved. These could serve as models for effective infection control/hygiene strategies.
Health education was the focus of a talk by Charlotte Eley. The e-bug programme been major outbreaks in North America and Europe. Conversely, little was known about the C. difficile infection rates in other parts of the world – nor about important aspects of the natural and evolutionary history of C. difficile. Riley elaborated on the One Health Concept, a worldwide strategy for interdisciplinary cooperation and communication on all aspects of healthcare for humans, animals and the environment. 70% of emerging infections in recent years were vector-borne diseases or zoonoses – animal diseases transmissible to humans. Riley explained that C. difficile infections were also zoonotic diseases, in either a direct or indirect sense. C. difficile was apparently found to colonize the gastrointestinal tract of all animals during the neonatal period.
While this bacterium was unable to compete with other bacterial species, it was able to undergo rapid growth once the human intestinal flora had been eliminated through antibiotic treatment. The use of cephalosporins had exacerbated problems with C.difficile, and their use for animal production had in the meantime given rise to a massive repository of this bacterium also outside the hospital. Riley finished by drawing attention to the need for awareness and good surveillance to monitor the infection rates and prevent the emergence of antibiotic-resistant strains.
Dr Michael Weinbren, Consultant Microbiologist at Chesterfield Royal Hospital, spoke in a Meet the Expert session also about Clostridium difficile. He described its basic characteristics and transmission routes, and also gave an overview of the clinical manifestations of pseudomembranous colitis. C. difficile spores were spread to all environments and did not need moisture, pioneered by Public Health England was a community education course on antibiotics, infections and hygiene (primarily aimed at children). She explained that 80% of all antibiotics were prescribed in the community, of which some 50% were unnecessary. These insights on hygiene and self-care (hand and food hygiene, an introduction to microbes, etc.) were incorporated into a six-week course and its effectiveness verified by completing before and after knowledge questionnaires. The pilot course participants were young mothers and adults with learning difficulties. The results demonstrated an improvement in participant knowledge, in particular of microorganisms and antibiotics. Likewise, behaviour changes were reported (e.g. more frequent hand washing and tooth brushing). The speaker pointed out that the course, which could be downloaded free of charge at www.e-Bug.eu/beat-the-bugs, was suitable for promoting awareness and knowledge of hygiene among the public.
|| Clostridium difficile – current challenges
Professor Thomas V. Riley, Australia, spoke about Clostridium difficile. A significant number of infections in the western healthcare sector were attributable to C. difficile. Since the early 2000s there had been major outbreaks in North America and Europe. Conversely, little was known about the C. difficile infection rates in other parts of the world – nor about important aspects of the natural and evolutionary history of C. difficile. Riley elaborated on the One Health Concept, a worldwide strategy for interdisciplinary cooperation and communication on all aspects of healthcare for humans, animals and the environment. 70% of emerging infections in recent years were vector-borne diseases or zoonoses – animal diseases transmissible to humans. Riley explained that C. difficile infections were also zoonotic diseases, in either a direct or indirect sense. C. difficile was apparently found to colonize the gastrointestinal tract of all animals during the neonatal period.
While this bacterium was unable to compete with other bacterial species, it was able to undergo rapid growth once the human intestinal flora had been eliminated through antibiotic treatment. The use of cephalosporins had exacerbated problems with C.difficile, and their use for animal production had in the meantime given rise to a massive repository of this bacterium also outside the hospital. Riley finished by drawing attention to the need for awareness and good surveillance to monitor the infection rates and prevent the emergence of antibiotic-resistant strains.
Dr Michael Weinbren, Consultant Microbiologist at Chesterfield Royal Hospital, spoke in a Meet the Expert session also about Clostridium difficile. He described its basic haracteristics and transmission routes, and also gave an overview of the clinical manifestations of pseudomembranous colitis.C. difficile spores were spread to all environments and did not need moisture, hence cleaning was of paramount importance. There continued to be periods of increased incidence of C. difficile infections or outbreaks which could be brought under control thorough cleaning. The problem was that often accessories and items in the patient’s surroundings were not properly cleaned e.g. blood pressure cuffs. In situations where patients used their own personal appliances, e.g. wheelchairs, CPAP (continuous positive airway pressure) machines, these were often not included in the cleaning operation since there was a lack of understanding of who was responsible for that. Weinbren stated that by limiting such patient items in his own institution it had been possible to reduce the spore burden. He also stressed that effective terminal cleaning e.g. with UVC and H2O2, should be preceded by thorough precleaning, but that standardization and monitoring were often a problem.
However, C. difficile was often newly introduced from the hospital via the admission wards. Here, the standard of cleaning was frequently inadequate and items such as beds from these wards were used to transfer patients to other wards and examination rooms. That served as a vehicle spread the spores throughout the hospital. Evidence of that came to light at times, as demonstrated by Weinbren on the basis of one example. Five patients with C. difficile infections which manifested at different time points and on different wards were found to have one thing in common: they had been admitted on the same day via the same admission ward.
|| The role of the microbiome
Dr Nicola Fawcett from Oxford described the human microbiome as the “microbial armour” and reported on its role in infection prevention. There was growing evidence that the microorganisms colonizing the human body played a key role in resistance to colonization and infection by pathogenic organisms. They could do so through direct competition and interaction, or indirectly through their effects on the immune system, which was reliant on commensal microorganisms, e.g. in the intestines, to function properly. Accordingly, interventions such as the use of antibiotics or other measures that positively or negatively impacted the human microbiome had implications for infection resistance. Dr Fawcett mentioned the prospects for future interventions – research was underway to ascertain how manipulation of the microbiome could be used to improve health and infection prevention. Bloodstream infections and sepsis Professor Jacqui Reilly, Scotland, reported on the topic of bloodstream infection (BSI), its current epidemiology and on the symptoms on which diagnosis was based (positive blood cultures plus fever and hypotension). Hence, its definition was not unlike that of sepsis. Reilly presented data from Scotland; Escherichia coli was by far the most commonly implicated pathogen. 12% of all healthcare-associated (nosocomial infections) related to BSI or sepsis. 10% of all antibiotics of which 15% were broad spectrum antibiotics, were prescribed to combat these infections. She continued her lecture by addressing prevention strategies. Early detection through screening was important, as was early treatment of primary infections. There was also a need to create public awareness of the symptoms, for example temperature drop as a sign of deterioration, since 50% of BSIs occurred in the community. More rigorous measures were needed to promote personal hygiene and hand hygiene. And finally antibiotic stewto ardship played an important role. In the context of the one health concept, attention had to be also paid to animals since they served as reservoirs.
|| Isolation as a means of prevention – prospects and limits
In parallel sessions other topics were addressed in the afternoon. Brett Mitchell et al. from Australia evaluated the potential benefits of installing temporary isolation facilities to supplement the limited number of single rooms and isolation facilities available in hospitals. The portable isolation room (Redi-RoomTM) could be installed on existing wards. By direct observation, video recording and questionnaires, procedures within the isolation room were compared and evaluated versus those in a standard (control) room after 13 nurses were randomly assigned to one or the other room where they had to perform various clinical (nursing) activities over three days. A technical assessment was also undertaken by infection control professionals. The movements as well as the time needed for the activities were largely identical in both room types. The various tools used for evaluation proved to be adequate and could serve as a valuable basis for evaluation of new technologies in hospitals.
Elaine Ross and colleagues investigated whether a PCR (polymerase chain reaction) point of care testing (POCT) platform for influenza and respiratory syncytial virus (RSV) on admission could be useful to ensure that patients received correct treatment sooner and to facilitate management in periods of extreme winter bed pressures (e.g. during flu epidemics).
The PCR unit was installed in the admissions’ department and was able to confirm or rule out influenza or RSV within 30 minutes. These results could be taken into account for treatment decision-making as well as for patient placement (e.g. isolation). It was revealed that following the introduction of point of care testing no cases of healthcare-associated influenza or RSV infection occurred. POCT helped promote cohort nursing of symptomatic patients as well as optimize the use of single rooms or isolation rooms. In addition, this system contributed to standardization of influenza prophylaxis and treatment.
Lisa Ritchie from Scotland reported on the results of admission risk assessment and pre-emptive patient cohorting in the control of MRSA patients. A prospective study was carried out at two hospitals over a period of 16 months to investigate whether pre-emptive cohorting of those patients identified as at high risk for MRSA could impact the MRSA transmission rate on general wards. Screening swabs were taken from all patients on admission and discharge in order to document MRSA baseline colonization and infection contracted in the course of the study.
The study unfolded in three phases: in phase 1 patients identified as risk patients were isolated in single rooms. In the second phase the risk patients were pre-emptively cohorted, while in phase 3 the original practice from phase 1 was reinstituted. The swabbing and laboratory tests showed that 1% of the screened patients had contracted MRSA in the course of their hospital stay. The speaker pointed out that patient cohorting did not positively impact the transmission rates and on its own did not appear to be a suitable strategy for transmission prevention.
|| Vascular access – what is the best approach?
Vascular access was the focus of two lectures in the afternoon. Steve Hill from the Christie NHS Foundation Trust in Manchester used this as an example to demonstrate how clinical evidence could influence practice when introducing new devices and products. He explained that a new catheter type had been investigated in 42 patients. The parameters investigated were e.g. successful puncture on the first attempt, flow rate, infections and other complication rates. The findings were compared with those of the literature. The greatest challenge faced was catheterrelated thrombosis; in the oncology setting, in particular, this gave rise to additional costs and detracted from the quality of life. Although the new catheter scored highly for successful puncture, the higher thrombosis rate and the ensuing higher infection and complication rates meant that the catheter was not introduced for routine use Hill presented similar studies, e.g. on the alternative placement of catheters in the case if chest wall metastases, where placement in the trapezius muscle was found to be associated with fewer complications. Hill stated that the evidence collected in these cases had led to a change in practices and could be implemented in small steps. Interdisciplinary cooperation was important to see a problem from different angles and collect reliable data. Tim Jackson, Consultant Anaesthetist from Calderdale and Huddersfield, dealt with placement of vascular lines. This was undertaken in various disciplines – either in the respective department or by anaesthetists or emergency medicine physicians – using different approaches. In certain places there were “vascular access teams”, especially in oncology. That called for standardization or agreement on best practice. To cite Jackson, the overriding goal was to ensure that “the patient receives the right line and in the right time”. While an evidence-based and fundamentally standardized approach was important, that was not always the correct basis for decision-making or for all patients – in particular in oncology. At times, other approaches were more suitable for an individual patient, for whom even small changes could mean an improvement.
Central venous access devices were not as risky as commonly assumed when properly placed. These were often the best choice, especially when administering substances that caused vascular damage (e.g.vancomycin) or in patients needing frequent or numerous peripheral vascular access devices. A framework of tools had been developed to guide decision-making for the best vascular access choices (UK Vessel Health and Preservation). Implementation of the framework into the real world remained a challenge despite its benefits being acknowledged by all concerned. Here, too, it was not easy to change established practices, in particular in times of cost pressures and staff shortages. Jackson finished by pointing out that the data provided by the institutions already applying the framework were encouraging and he called for documentation of the framework measures as proof of their impact.
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Author: Gudrun Westermann
