Seamus Mark McHugh

High prevalence of non-albicans yeasts and detection of anti-fungal resistance in the oral flora of patients with advanced cancer

Oral fungal infections frequently develop in individuals with advanced cancer. This study examined the oral mycological flora of 207 patients receiving palliative care for advanced malignant disease. Demographic details and a clinical history were documented from each participant. A tongue swab was collected and cultured on CHROMAgar Candida® (CHROMAgar Paris, France). All yeasts were identified by germ tube test, API ID 32C profiles and, for Candida dubliniensis, by species-specific PCR. Susceptibility to fluconazole and itraconazole was determined by a broth microdilution assay according to the National Committee for Clinical Laboratory Standards (NCCLS). At time of sampling, 54 (26%) of the 207 subjects had clinical evidence of a fungal infection and yeasts were isolated from 139 (67%) individuals. In total, 194 yeasts were isolated, of which 95 (49%) were Candida albicans. There was a high prevalence of Candidia glabrata (47 isolates) of which 34 (72%) were resistant to both fluconazole and itraconazole. All nine isolates of C. dubliniensis recovered were susceptible to both azoles. No relationship was established between anti-fungal usage in the preceding three months and the presence of azole resistant yeasts. This study of patients with advanced cancer has demonstrated a high incidence of oral colonization with non-C. albicans yeasts, many of which had reduced susceptibility to fluconazole and itraconazole. The role of improved oral care regimes and novel anti-fungal drugs merits further attention, to reduce the occurrence of fungal infection in these patients.

Intraoperative technique as a factor in the prevention of surgical site infection.

Approximately five percent of patients who undergo surgery develop surgical site infections (SSIs) which are associated with an extra seven days as an inpatient and with increased postoperative mortality. The competence and technique of the surgeon is considered important in preventing SSI. We have reviewed the evidence on different aspects of surgical technique and its role in preventing SSI. The most recent guidelines from the National Institute for Health and Clinical Excellence in the UK recommend avoiding diathermy for skin incision even though this reduces incision time and blood loss, both associated with lower infection rates. Studies comparing different closure techniques, i.e. continuous versus interrupted sutures, have not found a statistically significant difference in the SSI rate, but using continuous sutures is quicker. For contaminated wounds, the surgical site should be left open for four days to allow for treatment of local infection before subsequent healing by primary intention. Surgical drains should be placed through separate incisions, closed suction drains are preferable to open drains, and all drains should be removed as soon as possible. There are relatively few large studies on the impact of surgical techniques on SSI rates. Larger multicentre prospective studies are required to define what aspects of surgical technique impact on SSI, to better inform surgical practice and support education programmes for surgical trainees.

Air and surface contamination patterns of meticillin-resistant Staphylococcus aureus on eight acute hospital wards.

BACKGROUND Meticillin-resistant Staphylococcus aureus (MRSA) can be recovered from hospital air and from environmental surfaces. This poses a potential risk of transmission to patients. AIM To investigate associations between MRSA isolates recovered from air and environmental surfaces with those from patients when undertaking extensive patient and environmental sampling. METHODS This was a prospective observational study of patients and their environment in eight wards of a 700-bed tertiary care hospital during 2010 and 2011. Sampling of patients, air and surfaces was carried out on all ward bays, with more extended environmental sampling in ward high-dependency bays and at particular times of the day. The genetic relatedness of isolates was determined by DNA microarray profiling and spa typing. FINDINGS MRSA was recovered from 30/706 (4.3%) patients and from 19/132 (14.4%) air samples. On 9/132 (6.8%) occasions both patient and air samples yielded MRSA. In 32 high-dependency bays, MRSA was recovered from 12/161 (7.4%) patients, 8/32 (25%) air samples, and 21/644 (3.3%) environmental surface samples. On 10/132 (7.6%) occasions, MRSA was isolated from air in the absence of MRSA-positive patients. Patient demographic data combined with spa typing and DNA microarray profiling revealed four likely transmission clusters, where patient and environmental isolates were deemed to be very closely related. CONCLUSION Air sampling yielded MRSA on frequent occasions, especially in high-dependency bays. Environmental and air sampling combined with patient demographic data, spa typing and DNA microarray profiling indicated the presence of clusters that were not otherwise apparent.

Surgical attire, practices and their perception in the prevention of surgical site infection.

INTRODUCTION Clean surgical scrubs, surgical gowns and headgear are worn by operative teams to decrease bacterial contamination and lower surgical site infection (SSI) rates. METHODS A detailed review was undertaken of peer-reviewed publications and other sources of material in the English language over the last 50 years included. RESULTS Surgical scrubs should be clean and made of tightly woven material. Studies investigating single-use gowns and drapes versus reusable gowns report conflicting evidence. Double gloving may reduce SSI rates in procedures where no antibiotic prophylaxis was administered. Bacterial contamination of the operative field has been shown to be decreased by the wearing of surgical headgear by the operating team. CONCLUSIONS Further consideration and better trials are required to determine the impact of different theatre clothing on SSI rates.

A targeted e-learning program for surgical trainees to enhance patient safety in preventing surgical infection.

Introduction Surgical site infection accounts for 20% of all health care–associated infections (HCAIs); however, a program incorporating the education of surgeons has yet to be established across the specialty. Methods An audit of surgical practice in infection prevention was carried out in Beaumont Hospital from July to November 2009. An educational Web site was developed targeting deficiencies highlighted in the audit. Interactive clinical cases were constructed using PHP coding, an HTML‐embedded language, and then linked to a MySQL relational database. PowerPoint tutorials were produced as online Flash audiovisual movies. An online repository of streaming videos demonstrating best practice was made available, and weekly podcasts were made available on the iTunes© store for free download. Usage of the e‐learning program was assessed quantitatively over 6 weeks in May and June 2010 using the commercial company Hitslink. Results During the 5‐month audit, deficiencies in practice were highlighted, including the timing of surgical prophylaxis (33% noncompliance) and intravascular catheter care in surgical patients (38% noncompliance regarding necessity). Over the 6‐week assessment of the educational material, the SurgInfection.com Web pages were accessed more than 8000 times; 77.9% of the visitors were from Ireland. The most commonly accessed modality was the repository with interactive clinical cases, accounting for 3463 (43%) of the Web site visits. The average user spent 57 minutes per visit, with 30% of them visiting the Web site multiple times. Discussion Interactive virtual cases mirroring real‐life clinical scenarios are likely to be successful as an e‐learning modality. User‐friendly interfaces and 24‐hour accessibility will increases uptake by surgical trainees.

Preventing infection in general surgery: improvements through education of surgeons by surgeons

Surgical patients are at particular risk of healthcare-associated infection (HCAI) due to the presence of a surgical site leading to surgical site infection (SSI), and because of the need for intravascular access resulting in catheter-related bloodstream infection (CRBSI). A two-year initiative commenced with an initial audit of surgical practice; this was used to inform the development of a targeted educational initiative by surgeons specifically for surgical trainees. Parameters assessed during the initial audit and a further audit after the educational initiative were related to intra- and postoperative aspects of the prevention of SSIs, as well as care of peripheral venous catheters (PVCs) in surgical patients. The proportion of prophylactic antibiotics administered prior to incision across 360 operations increased from 30.0% to 59.1% (P<0.001). Surgical site dressings were observed in 234 patients, and a significant decrease was found in the percentage of dressings that were tampered with during the initial 48h after surgery (16.5% vs 6.2%, P=0.030). In total, 574 PVCs were assessed over the two-year period. Improvements were found in the proportion of unnecessary PVCs in situ (37.9% vs 24.4%, P<0.001), PVCs in situ for >72h (10.6% vs 3.1%, P<0.001) and PVCs covered with clean and intact dressings (87.3% vs 97.6%, P<0.001). Significant improvements in surgical practice were established for the prevention of SSI and CRBSI through a focused educational programme developed by and for surgeons. Potentially, other specific measures may also be warranted to achieve further improvements in infection prevention in surgical practice.

Preventing healthcare-associated infection through education: Have surgeons been overlooked?

BACKGROUND/AIMS Some 20-30% of HCAI are considered to be preventable through an extensive infection prevention and control programme. Through an extensive literature review we aim to critically appraise studies which have utilised education initiatives to decrease HCAI. METHODS An extensive review of the literature was carried out in both online medical journals and through the Royal College of Surgeons in Ireland library. FINDINGS Many studies over the last 10 years have demonstrated success in educating nursing staff, critical care healthcare workers as well as medical students and junior doctors in the infection prevention and control of infection. Comparatively few have focussed on surgical trainees. A blended learning approach, with particular focus on the small group format is important. Interventions involving web-based learning in combination with established education formats are proving successful in changing behaviour. CONCLUSIONS The development of an educational strategy for surgical trainees focussing on infection prevention and control is overdue. Such a programme would have far reaching benefits for individual patients, contribute to significant economic savings within health services and enhance the quality and safety of patient care.

Role of patient awareness in prevention of peripheral vascular catheter-related bloodstream infection.

Infection • Author(s): Seamus Mark McHugh , MB, BCh, BAO, MRCSI, Mark Anthony Corrigan , MD, MRCSI, Borislav D. Dimitrov , PhD, Margaret Morris‐Downes , PhD, Fidelma Fitzpatrick , MD, Seamus Cowman , MSc, PhD, Sean Tierney , BSc, MCh, FRCSI, Arnold D. K. Hill , MCh, FRCSI, Hilary Humphreys , MD, FRCPI Source: Infection Control and Hospital Epidemiology, Vol. 32, No. 1 (January 2011), pp. 95-96 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/657630 . Accessed: 11/01/2011 10:59

Improving surgical outpatient efficiency through mobile phone text messaging.

Introduction. Currently, 175 000 people are on outpatient waiting lists in Irish hospitals. Many clinic slots are taken by patients returning for routine review postoperatively. Methods. A Nokia mobile phone was used to send an outpatient text (OPT) to patients 2 weeks postdischarge. Patients replying that they were well were discharged. If no reply after 2 attempts was received, they were scheduled for the next outpatient clinic. Results. Overall, 55 patients were offered the service over a 4-month period. Of these, 74.5% of patients were discharged from follow-up using text message surveillance. Patients were surveyed regarding their perception of the surveillance model, with all respondents ranking OPT surveillance as their preferred method of follow-up. There was a 13.6% decrease in outpatient visits over the study period. In addition, 6 emergency department visits were also avoided. Conclusion. Text message surveillance decreases outpatient waiting times and increases quality of care.

Surgent University: the establishment and evaluation of a national online clinical teaching repository for surgical trainees and students.

Introduction. The aim of this study was to develop a new teaching strategy for medical students while creating a national online repository system (Surgent University). Then, the potential of this e-learning modality to facilitate learning of clinical surgery was evaluated. Methods. An online repository and Internet-based interface was designed and hosted on the medical education Web site, www.surgent.ie. Participation was by medical students across 3 Irish universities. Student use of the repository was quantitatively assessed over an 8-week period. They were then invited to complete an anonymous survey assessing the effectiveness of the online repository. Statistical analysis was performed using SPSS version 15, with P < .05 considered significant. Results. Over the study period, the online repository received 6105 uploaded facts by 182 final-year medical students from 3 different universities. The repository Web pages were accessed 54 061 times with 4609 individual searches of the repository. Of the 60 participating students invited to provide survey-based feedback, there were 40 respondents, giving a 66.7% response rate. Of those surveyed, 70% (n = 28) rated the online repository as highly beneficial and 75% (n = 30) as highly relevant. Overall, 87.5% (n = 35) felt that it should be continued, and 70% (n = 28) felt that it should be expanded beyond surgery to include other hospital specialties. Those finding the program interface user-friendly were more likely to find it beneficial (P = .031) and relevant to their ongoing education (P = .002). Conclusions. A user-friendly interface allows for high levels of usage, whereas a “student-centered” structure ensures that the facts uploaded are beneficial and relevant to medical students’ education.