J. Gray

Nosocomial infections in neonatal intensive care units in developed and developing countries: how can we narrow the gap?

Nosocomial infections are one of the leading causes of mortality and morbidity in neonatal intensive care units (NICUs). Both the incidence and causes of infections vary widely among NICUs. However, the incidence of infection is higher in developing countries, where Gram-negative bacteria are usually reported to be the predominant pathogens. The report by Abdel-Wahab et al. in this issue of the Journal of Hospital Infection exemplifies these facts, and, as the authors note, is consistent with previous reports from Egypt. Factors such as climate and cultural practices have been suggested as explanations for the differences in infections between developing and developed countries. However, there is evidence that the pattern of nosocomial infection is directly related to healthcare resources. Tosson et al. reviewed twelve studies from eight Arabic countries including 2308 newborns with culture-proven sepsis and found that Gram-negative bacteria were the predominant pathogens in Libya, Egypt, Jordan, and Iraq (65e90% of all sepsis cases), whereas in

Bacteraemia with meticillin-susceptible Staphylococcus aureus in an English children’s hospital

published hospital HAI prevalence calculated using identical methodology. In 2006, HAI prevalence was 7.2% in our hospital, 4.89% in the Republic of Ireland and 7.59% in the UK and Ireland.2,3 Although our numbers are small, to our knowledge this is the first study evaluating HAI prevalence in patients with delayed hospital discharge. Possible explanations include patient characteristics (e.g. age and HAI risk factors) and prolonged hospital stay, which in itself is a risk factor for HAI.4 The mean age of delayed discharge patients was 71.8 years, significantly older than all inpatients in our hospital in 2006 (64.4 years). Patients with HAI had at least one risk factor, the presence of which was significantly associated with HAI (P1⁄4 0.02). UTI prevalence was higher in our study when compared to 2006 (8.2% vs 1.3%, P1⁄4 0.0045), which may be due to the increased number of patients with a urinary catheter (41% vs 24%, P1⁄4 0.0079). Limitations of our study include small numbers and comparison of HAI prevalence results from two different time points (the present study and the 2006 UK and Ireland prevalence study), albeit using identical methodologies. Nearly two-thirds of patients in this study were awaiting LTC. Delayed discharge renders these medically discharged patients at risk of acquiring HAI while in hospital, resulting not only in patient morbidity but also in increased healthcare costs. The English Department of Health has estimated the cost of treating an HAI at £4,000–11,000 and the extra number of days spent in hospital by patients at 11 (‘HCAI Research Network’, details available online). With the cost of an acute hospital bed estimated at V1,917 per day in Ireland, this accounts for the bulk of the costs associated with treating an HAI (‘Irish Health’, details available online). Our study suggests that delayed discharge is associated with an increase in HAI prevalence. Many of these HAIs are associated with the presence of modifiable risk factors. In the majority of our cases the reason for prolonged hospital stay was waiting for LTC. Earlier discharge of these patients would potentially prevent HAI, reduce patient morbidity and mortality and effect significant cost savings. Larger surveys are needed to confirm our findings and to inform future health planning and HAI preventive strategies.

Casualties of war: the infection control assessment of civilians transferred from conflict zones to specialist units overseas for treatment

Summary The casualties of global conflict attract media attention and sympathy in public, governmental, and non-governmental circles. Hospitals in developed countries offering specialist reconstructive or tertiary services are not infrequently asked to accept civilian patients from overseas conflict for complex surgical procedures or rehabilitation. Concern about the infection prevention and control risks posed by these patients, and the lack of a good evidence base on which to base measured precautions, means that the precautionary principle of accepting zero risk is usually followed. The aim of this article is to highlight infection control considerations that may be required when treating casualties from overseas conflict, based partly on our own experience. Currently there is a lack of published evidence and national consensus on how to manage these patients. The precautionary principle requires that there is an ongoing search for evidence and knowledge that can be used to move towards more traditional risk management. We propose that only by gathering the experiences of the many individual hospitals that have each cared for small numbers of such patients can such evidence and knowledge be assimilated.

Specialized cleaning associated with antimicrobial coatings for reduction of hospital-acquired infection: opinion of the COST Action Network AMiCI (CA15114)

Recognized issues with poor hand hygiene compliance among healthcare workers and reports of recontamination of previously chemically disinfected surfaces through hand contact emphasize the need for novel hygiene methods in addition to those currently available. One such approach involves antimicrobial (nano) coatings (AMCs), whereby integrated active ingredients are responsible for elimination of micro-organisms that come into contact with treated surfaces. While widely studied under laboratory conditions with promising results, studies under real-life healthcare conditions are scarce. The views of 75 contributors from 30 European countries were collated regarding specialized cleaning associated with AMCs for reduction of healthcare-associated infection. There was unanimous agreement that generation of scientific guidelines for cleaning of AMCs, using traditional or new processes, is needed. Specific topics included: understanding mechanisms of action of cleaning materials and their physical interactions with conventional coatings and AMCs; that assessments mimic the life cycle of coatings to determine the impact of repetitive cleaning and other aspects of ageing (e.g. exposure to sunlight); determining concentrations of AMC-derived biocides in effluents; and development of effective de-activation and sterilization treatments for cleaning effluents. Further, the consensus opinion was that, prior to widespread implementation of AMCs, there is a need for clarification of the varying responsibilities of involved clinical, healthcare management, cleaning services and environmental safety stakeholders.

Investigation of possible routes of transmission of group B streptococci to humans outside the neonatal period

Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand * Corresponding author. Address: Mahidol Oxford Tropical Medicine Research Unit, 3rd floor, Chalermprakiat Building, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400 Thailand. Tel.: þ66 22036311; fax: þ66 23549169. E-mail address: lek@tropmedres.ac (V. Wuthiekanun).

Critical points in the pathway of antibiotic prescribing in a children’s hospital: the Antibiotic Mapping of Prescribing (ABMAP) study

BACKGROUND The World Health Organization has identified antimicrobial resistance (AMR) as one of the most significant global risks facing modern medicine. Interventions to improve antibiotic prescribing have so far had limited impact. AIM To understand the barriers to effective antibiotic prescribing. METHODS Mixed methodologies were used to investigate prescribing behaviours to identify the critical points in the antibiotic prescribing pathway for hospital inpatients. We assessed knowledge, experience or empowerment of prescribers, organizational factors, and use of the laboratory. Phase 1 was an online survey to map barriers and facilitators to antibiotic prescribing (56 participants). Phase 2 consisted of focus groups and interviews to gain more understanding of prescribing behaviours (10 participants). Phase 3 was an online survey to obtain opinions on possible solutions (22 participants). FINDINGS Barriers to prescribing were: laboratory factors 71.6%, resource issues 40%, time constraints 17.5%, pressure from others 52%. Ninety-three percent of prescribers were concerned about AMR. In three scenarios only 9% were confident not to prescribe antibiotics for a patient without bacterial infection; 53% would prescribe unnecessarily broad-spectrum antibiotics for pneumonia. Only 5% would de-escalate antibiotics in a microbiologically confirmed bacteraemia. Despite concerns about AMR, prescribers did not perceive that continuing antibiotics for individual patients might promote resistance. Prescribers were unwilling to change antibiotics out of hours and reported that they preferred professional support for antibiotic prescribing. CONCLUSION There was a marked disparity between prescribers, self-reporting of prescribing behaviour and responses to clinical scenarios. It was not clear whether training alone would change behaviours. Prescribers desired a directive mechanism to support antibiotic prescribing and stewardship.

The protected environment for high-risk haematology patients: as safe as we think?

We read with interest the report by Picot-Guéraud et al. of finding filamentous fungi, including Aspergillus spp., in air samples collected in protected rooms under laminar airflow. They suggest that defects in high-efficiency particulate air (HEPA) filters and/or deficiencies in other aspects of the ventilation system may have been the cause. Our bone marrow transplant unit (BMT) has six positivepressure single cubicles with en-suite bathrooms, with HEPAfiltered laminar airflow. Each year the unit is closed down for one week to allow planned maintenance, including testing of the ventilation system. After deep cleaning, and before reopening to patients, we undertake microbial air sampling using a Casella slit sampler. In each of the past two years postmaintenance microbial air counts have been found to be unexpectedly high, which we have related to deficiencies in the vicinity of the ceiling air-supply vents. In 2014 we found microbial counts ranging from 29 to >100 cfu/1000 L; three rooms had>50 cfu/1000 L, and in these three rooms Aspergillus spp. were also detected (1e4 cfu/ 1000 L). On investigation we observed damage to the paintwork on the ceilings, and to the seals around light fittings, in the roomswith highmicrobial air counts. Dust had collected in these defects, which were directly in the pathway of the laminar airflow supply. Swabs collected fromthese areas grewvery large numbers of bacteria (predominantly coagulase-negative staphylococci and Micrococcus spp.), but no fungi were isolated. The defects were repaired, and repeat air sampling showed <20 cfu/1000 L, with no fungi, in all rooms. This year, even higher microbial counts were recorded. Four of the six rooms had counts of>100 cfu/1000 L, including 2e5 cfu/1000 L ofAspergillus spp. This time the problemwas identified as being dust on the ceiling air-supply vents themselves, which had not been cleaned by the contractors. After cleaning, all roomswere found to have <5 cfu/1000 L, with no fungi, on repeat air sampling. In both years it is highly likely that the patients occupying these rooms before the maintenance shutdown would have beennursed in air that, althoughHEPA-filtered, had comparable