Changes in healthcare-associated Staphylococcus aureus bloodstream infections after the introduction of a national hand hygiene initiative

Background. Interventions that prevent healthcare-associated infection should lead to fewer deaths and shorter hospital stays. Cleaning hands (with soap or alcohol) is an effective way to prevent the transmission of organisms, but rates of compliance with hand hygiene are sometimes disappointingly low. The National Hand Hygiene Initiative in Australia aimed to improve hand hygiene compliance among healthcare workers, with the goal of reducing rates of healthcare-associated infection. Methods. We examined whether the introduction of the National Hand Hygiene Initiative was associated with a change in infection rates. Monthly infection rates for healthcare-associated Staphylococcus aureus bloodstream infections were examined in 38 Australian hospitals across 6 states. We used Poisson regression and examined 12 possible patterns of change, with the best fitting pattern chosen using the Akaike information criterion. Monthly bed-days were included to control for increased hospital use over time. Results. The National Hand Hygiene Initiative was associated with a reduction in infection rates in 4 of the 6 states studied. Two states showed an immediate reduction in rates of 17% and 28%, 2 states showed a linear decrease in rates of 8% and 11% per year, and 2 showed no change in infection rates. Conclusions. The intervention was associated with reduced infection rates in most states. The failure in 2 states may have been because those states already had effective initiatives before the national initiative’s introduction or because infection rates were already low and could not be further reduced.

Efficient parameter estimation in longitudinal data analysis using a hybrid GEE method

The method of generalized estimating equations (GEEs) provides consistent estimates of the regression parameters in a marginal regression model for longitudinal data, even when the working correlation model is misspecified (Liang and Zeger, 1986). However, the efficiency of a GEE estimate can be seriously affected by the choice of the working correlation model. This study addresses this problem by proposing a hybrid method that combines multiple GEEs based on different working correlation models, using the empirical likelihood method (Qin and Lawless, 1994). Analyses show that this hybrid method is more efficient than a GEE using a misspecified working correlation model. Furthermore, if one of the working correlation structures correctly models the within-subject correlations, then this hybrid method provides the most efficient parameter estimates. In simulations, the hybrid method's finite-sample performance is superior to a GEE under any of the commonly used working correlation models and is almost fully efficient in all scenarios studied. The hybrid method is illustrated using data from a longitudinal study of the respiratory infection rates in 275 Indonesian children.

Transmission of Japanese Encephalitis Virus from the Black Flying Fox, Pteropus alecto, to Culex annulirostris Mosquitoes, Despite the Absence of Detectable Viremia.

To determine the potential role of flying foxes in transmission cycles of Japanese encephalitis virus (JEV) in Australia, we exposed Pteropus alecto (Megachiroptera: Pteropididae) to JEV via infected Culex annulirostris mosquitoes or inoculation. No flying foxes developed symptoms consistent with JEV infection. Anti-JEV IgG antibodies developed in 6/10 flying foxes exposed to infected Cx. annulirostris and in 5/5 inoculated flying foxes. Low-level viremia was detected by real-time reverse transcriptase polymerase chain reaction in 1/5 inoculated flying foxes and this animal was able to infect recipient mosquitoes. Although viremia was not detected in any of the 10 flying foxes that were exposed to JEV by mosquito bite, two animals infected recipient mosquitoes. Likewise, an inoculated flying fox without detectable viremia infected recipient mosquitoes. Although infection rates in recipient mosquitoes were low, the high population densities in roosting camps, coupled with migratory behavior indicate that flying foxes could play a role in the dispersal of JEV.

Methods to determine resistance to anthelmintics when continuing larval development occurs

The in vivo faecal egg count reduction test (FECRT) is the most commonly used test to detect anthelmintic resistance (AR) in gastrointestinal nematodes (GIN) of ruminants in pasture based systems. However, there are several variations on the method, some more appropriate than others in specific circumstances. While in some cases labour and time can be saved by just collecting post-drench faecal worm egg counts (FEC) of treatment groups with controls, or pre- and post-drench FEC of a treatment group with no controls, there are circumstances when pre- and post-drench FEC of an untreated control group as well as from the treatment groups are necessary. Computer simulation techniques were used to determine the most appropriate of several methods for calculating AR when there is continuing larval development during the testing period, as often occurs when anthelmintic treatments against genera of GIN with high biotic potential or high re-infection rates, such as Haemonchus contortus of sheep and Cooperia punctata of cattle, are less than 100% efficacious. Three field FECRT experimental designs were investigated: (I) post-drench FEC of treatment and controls groups, (II) pre- and post-drench FEC of a treatment group only and (III) pre- and post-drench FEC of treatment and control groups. To investigate the performance of methods of indicating AR for each of these designs, simulated animal FEC were generated from negative binominal distributions with subsequent sampling from the binomial distributions to account for drench effect, with varying parameters for worm burden, larval development and drench resistance. Calculations of percent reductions and confidence limits were based on those of the Standing Committee for Agriculture (SCA) guidelines. For the two field methods with pre-drench FEC, confidence limits were also determined from cumulative inverse Beta distributions of FEC, for eggs per gram (epg) and the number of eggs counted at detection levels of 50 and 25. Two rules for determining AR: (1) %reduction (%R) < 95% and lower confidence limit <90%; and (2) upper confidence limit <95%, were also assessed. For each combination of worm burden, larval development and drench resistance parameters, 1000 simulations were run to determine the number of times the theoretical percent reduction fell within the estimated confidence limits and the number of times resistance would have been declared. When continuing larval development occurs during the testing period of the FECRT, the simulations showed AR should be calculated from pre- and post-drench worm egg counts of an untreated control group as well as from the treatment group. If the widely used resistance rule 1 is used to assess resistance, rule 2 should also be applied, especially when %R is in the range 90 to 95% and resistance is suspected.

Frequency of dressing changes for central venous access devices on catheter-related infections

Background People admitted to intensive care units and those with chronic health care problems often require long-term vascular access. Central venous access devices (CVADs) are used for administering intravenous medications and blood sampling. CVADs are covered with a dressing and secured with an adhesive or adhesive tape to protect them from infection and reduce movement. Dressings are changed when they become soiled with blood or start to come away from the skin. Repeated removal and application of dressings can cause damage to the skin. The skin is an important barrier that protects the body against infection. Less frequent dressing changes may reduce skin damage, but it is unclear whether this practice affects the frequency of catheter-related infections. Objectives To assess the effect of the frequency of CVAD dressing changes on the incidence of catheter-related infections and other outcomes including pain and skin damage. Search methods In June 2015 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We also searched clinical trials registries for registered trials. There were no restrictions with respect to language, date of publication or study setting. Selection criteria All randomised controlled trials (RCTs) evaluating the effect of the frequency of CVAD dressing changes on the incidence of catheter-related infections on all patients in any healthcare setting. Data collection and analysis We used standard Cochrane review methodology. Two review authors independently assessed studies for inclusion, performed risk of bias assessment and data extraction. We undertook meta-analysis where appropriate or otherwise synthesised data descriptively when heterogeneous. Main results We included five RCTs (2277 participants) that compared different frequencies of CVAD dressing changes. The studies were all conducted in Europe and published between 1995 and 2009. Participants were recruited from the intensive care and cancer care departments of one children's and four adult hospitals. The studies used a variety of transparent dressings and compared a longer interval between dressing changes (5 to15 days; intervention) with a shorter interval between changes (2 to 5 days; control). In each study participants were followed up until the CVAD was removed or until discharge from ICU or hospital. - Confirmed catheter-related bloodstream infection (CRBSI) One trial randomised 995 people receiving central venous catheters to a longer or shorter interval between dressing changes and measured CRBSI. It is unclear whether there is a difference in the risk of CRBSI between people having long or short intervals between dressing changes (RR 1.42, 95% confidence interval (CI) 0.40 to 4.98) (low quality evidence). - Suspected catheter-related bloodstream infection Two trials randomised a total of 151 participants to longer or shorter dressing intervals and measured suspected CRBSI. It is unclear whether there is a difference in the risk of suspected CRBSI between people having long or short intervals between dressing changes (RR 0.70, 95% CI 0.23 to 2.10) (low quality evidence). - All cause mortality Three trials randomised a total of 896 participants to longer or shorter dressing intervals and measured all cause mortality. It is unclear whether there is a difference in the risk of death from any cause between people having long or short intervals between dressing changes (RR 1.06, 95% CI 0.90 to 1.25) (low quality evidence). - Catheter-site infection Two trials randomised a total of 371 participants to longer or shorter dressing intervals and measured catheter-site infection. It is unclear whether there is a difference in risk of catheter-site infection between people having long or short intervals between dressing changes (RR 1.07, 95% CI 0.71 to 1.63) (low quality evidence). - Skin damage One small trial (112 children) and three trials (1475 adults) measured skin damage. There was very low quality evidence for the effect of long intervals between dressing changes on skin damage compared with short intervals (children: RR of scoring ≥ 2 on the skin damage scale 0.33, 95% CI 0.16 to 0.68; data for adults not pooled). - Pain Two studies involving 193 participants measured pain. It is unclear if there is a difference between long and short interval dressing changes on pain during dressing removal (RR 0.80, 95% CI 0.46 to 1.38) (low quality evidence). Authors' conclusions The best available evidence is currently inconclusive regarding whether longer intervals between CVAD dressing changes are associated with more or less catheter-related infection, mortality or pain than shorter intervals.

Mediastinitis after cardiac surgery

Mediastinitis as a complication after cardiac surgery is rare but disastrous increasing the hospital stay, hospital costs, morbidity and mortality. It occurs in 1-3 % of patients after median sternotomy. The purpose of this study was to find out the risk factors and also to investigate new ways to prevent mediastinitis. First, we assessed operating room air contamination monitoring by comparing the bacteriological technique with continuous particle counting in low level contamination achieved by ultra clean garment options in 66 coronary artery bypass grafting operations. Second, we examined surgical glove perforations and the changes in bacterial flora of surgeons' fingertips in 116 open-heart operations. Third, the effect of gentamicin-collagen sponge on preventing surgical site infections (SSI) was studied in randomized controlled study with 557 participants. Finally, incidence, outcome, and risk factors of mediastinitis were studied in over 10,000 patients. With the alternative garment and textile system (cotton group and clean air suit group), the air counts fell from 25 to 7 colony-forming units/m3 (P<0.01). The contamination of the sternal wound was reduced by 46% and that of the leg wound by >90%. In only 17% operations both gloves were found unpunctured. Frequency of glove perforations and bacteria counts of hands were found to increase with operation time. With local gentamicin prophylaxis slightly less SSIs (4.0 vs. 5.9%) and mediastinitis (1.1 vs. 1.9%) occurred. We identified 120/10713 cases of postoperative mediastinitis (1.1%). During the study period, the patient population grew significantly older, the proportion of women and patients with ASA score >3 increased significantly. In multivariate logistic regression analysis, the only significant predictor for mediastinitis was obesity. Continuous particle monitoring is a good intraoperative method to control the air contamination related to the theatre staff behavior during individual operation. When a glove puncture is detected, both gloves are to be changed. Before donning a new pair of gloves, the renewed disinfection of hands will help to keep their bacterial counts lower even towards the end of long operation. Gentamicin-collagen sponge may have beneficial effects on the prevention of SSI, but further research is needed. Mediastinitis is not diminishing. Larger populations at risk, for example proportions of overweight patients, reinforce the importance of surveillance and pose a challenge in focusing preventive measures.

Stability and mobility of sand-bed channels affected by seepage

Seepage effects on the stability, mobility, and incipient motion of sand-bed particles are experimentally investigated. Seepage through a sand bed in a downward direction (suction) reduces the stability of particles, and it can even initiate their movement. The bed erosion is increased with the increased rates of suction. Whereas the seepage in an upward direction (injection) increases the stability of bed particles, it does not aid initiating their movement. The rate of bed erosion is reduced or even stopped by the increased infection rates. Hydrodynamic conditions leading to the so-called "pseudoincipient motion'' with suction (for the initiation of particles movement that are otherwise at rest under no-seepage conditions), and with injection (for only arresting the particles movement that are otherwise moving initially) are evaluated. The conventional Shields curve cannot be used to predict such pseudoincipient motion conditions with seepage. The concepts thus developed are useful for a better understanding of the sediment transport mechanics and in the design of stable alluvial channels affected by seepage.

Executing Long-running Multi-component Applications on Batch Grids

Computational grids are increasingly being used for executing large multi-component scientific applications. The most widely reported advantages of application execution on grids are the performance benefits, in terms of speeds, problem sizes or quality of solutions, due to increased number of processors. We explore the possibility of improved performance on grids without increasing the application’s processor space. For this, we consider grids with multiple batch systems. We explore the challenges involved in and the advantages of executing long-running multi-component applications on multiple batch sites with a popular multi-component climate simulation application, CCSM, as the motivation.We have performed extensive simulation studies to estimate the single and multi-site execution rates of the applications for different system characteristics.Our experiments show that in many cases, multiple batch executions can have better execution rates than a single site execution.

Divvying up an incubator: How parasitic and mutualistic fig wasps use space within their nursery microcosm

Differential occupancy of space can lead to species coexistence. The fig-fig wasp pollination system hosts species-specific pollinating and parasitic wasps that develop within galls in a nursery comprising a closed inflorescence, the syconium. This microcosm affords excellent opportunities for investigating spatial partitioning since it harbours a closed community in which all wasp species are dependent on securing safe sites inside the syconium for their developing offspring while differing in life history, egg deposition strategies and oviposition times relative to nursery development. We determined ontogenetic changes in oviposition sites available to the seven-member fig wasp community of Ficus racemosa comprising pollinators, gallers and parasitoids. We used species distribution models (SDMs) for the first time at a microcosm scale to predict patterns of spatial occurrence of nursery occupants. SDMs gave high true-positive and low false-positive site occupancy rates for most occupants indicating species specificity in oviposition sites. The nursery microcosm itself changed with syconium development and sequential egg-laying by different wasp species. The number of sites occupied by offspring of the different wasp species was negatively related to the risk of syconium abortion by the plant host following oviposition. Since unpollinated syconia are usually aborted, parasitic wasps ovipositing into nurseries at the same time as the pollinator targeted many sites, suggesting response to lower risk of syconium abortion owing to reduced risk of pollination failure compared to those species ovipositing before pollination. Wasp life history and oviposition time relative to nursery development contributed to the co-existence of nursery occupants.

Avaliação in vitro de duas resinas macias para reembasamento de próteses modificadas pela incorporação de clorexidina

Resinas macias para reembasamento de próteses são largamente utilizadas após cirurgias para estabilizarem a prótese e condicionarem o tecido, aguardando a completa cicatrização. É importante que o material não seja facilmente colonizado por biofilme oral e se possível, evite a contaminação do sítio cirúrgico. Objetivou-se avaliar o efeito da incorporação de clorexidina às resinas acrílicas macias para o reembasamento de próteses totais, através de análises de liberação, citotoxicidade e efeito inibitório de um biofilme de C. albicans. Foram confeccionados corpos de provas (CDPs) com as resinas Trusoft e Coe-soft, com incorporação de 0%, 0,5%, 1,0% e 2,0% de clorexidina, totalizando 8 grupos. A liberação de clorexidina foi avaliada através da mensuração da mudança na densidade óptica da solução de armazenamento, na qual ficaram imersos os CDPs, por espectrometria UV, a cada 48 horas, durante 40 dias. A citotoxicidade celular foi avaliada em fibroblastos (linhagem L929), que ficaram 24 horas em contato com meio de cultura no qual os CDPs ficaram previamente imersos, pela técnica de absorção de corante vermelho neutro após 24, 48 e 72 horas e semanalmente até o 28 dia. E, por fim, a atividade antifúngica contra a C. albicans (ATCC 10231) foi avaliada de duas maneiras: (1) teste de difusão em ágar, no qual os CDPs foram colocados em placas de BHI previamente inoculadas com C. albicans, com medição do halo de inibição após 48 horas de incubação a 37C; (2) a avaliação da inibição da formação de um biofilme de C. albicans sobre a superfície dos CDPs pela quantificação por metil tetrazólio (MTT) a cada 48 horas, durante 22 dias, com leitura feita em espectrofotômetro de UV. Os dados obtidos foram inseridos no programa SigmaStat (versão 3.1, USA) para realizar as análises estatísticas. As diferenças estatísticas foram determinadas por análises de variâncias do tipo ANOVA e todos os procedimentos para comparações múltiplas pareadas foram feitos utilizando-se o método Holm-Sidak, com nível de significância global igual a 0,05. A clorexidina adicionada às resinas testadas foi capaz de ser liberada para o meio de armazenagem, proporcionalmente à quantidade de clorexidina incorporada, porém com diferentes cinéticas de liberação entre as resinas, visto que a Trusoft libera até 71% do total de clorexidina liberada nas primeiras 48 horas e a Coe-soft, até 44%. Ambas as resinas com incorporação de clorexidina apresentaram efeito citotóxico adicional, se comparadas às resinas sem clorexidina, porém para a Coe-soft não houve diferença estatística dos valores, apenas para a Trusoft (p<0,001). Ocorreu formação de halo de inibição proporcionalmente às concentrações de resinas adicionadas, com maiores halos para a resina Trusoft (p<0,001), e sem formação de halo para as resinas sem clorexidina; a inibição da formação de biofilme, realizada somente com a resina Coe-soft, mostrou total inibição durante 8, 12 e 16 dias, para a incorporação de 0,5%, 1,0% e 2,0% respectivamente, sendo uma diminuição estatisticamente significativa (p<0,001) em relação à resina sem incorporação de clorexidina, que não apresentou inibição do biofilme.

White spot syndrome virus (WSSV) infects specific hemocytes of the shrimp Penaeus merguiensis

White spot syndrome virus (WSSV) was specifically detected by PCR in Penaeus merguiensis hemocytes, hemolymph and plasma. This suggested a close association between the shrimp hemolymph and the virus. Three types of hemocyte from shrimp were isolated using flow cytometry. Dynamic changes of the hemocyte subpopulations in P. merguiensis at different times after infection were observed, indicating that the WSSV infection selectively affected specific subpopulations. Immunofluorescence assay (IFA) and a Wright-Giemsa double staining study of hemocyte types further confirmed the cellular localization of the virus in the infected hemocytes. Electron microscopy revealed virus particles in both vacuoles and the nucleus of the semigranular cells (SGC), as well as in the vacuoles of the granular cells (GC). However, no virus could be detected in the hyaline cells (HC). Our results suggest that the virus infects 2 types of shrimp hemocytes-GCs and SGCs. The SGC type contains higher virus loads and exhibits faster infection rates, and is apparently more susceptible to WSSV infection.

Host sex and ectoparasite infections of plateau pika (Ochotona curzoniae, Hodgson) on the Qinghai-Tibetan Plateau

A total of 449 plateau pika (Ochotona curzoniae Hudgson) individuals were sampled with rattraps from 21 plots (size 1 ha) randomly scattered over the area of the species distribution at the altitude 3275-4807 in a.s.l. in the Qinghai-Tibetan Plateau (West China). Two main ectoparasite species Hypoderma satyrus Brauer and Ixodes crenulatus Neumann of plateau pika were surveyed, and the relations between host sex and parasitism were analyzed. The results were: (i) although not significantly, the infection rate of female young was close to zero and lower than that of male young (6%), while the infection rate of female sub-adults (19%) was contrarily - higher than that of male sub-adults (11%); adult females had significantly higher (41%) infection rate than that of males (18%) (P<0.001); (ii) the parasite infection rates for both males and females increased with increasing age, but female age-groups had obviously steeper slope. We suggested that the differences of body mass, growth rate and home range between males and females had mainly caused the sex-biased parasitism (SBP) of plateau pika at each age stage. Also, due to the higher increases of body mass and maybe as well as of the home range differences between consecutive age-groups, the parasite infections of females became more sensitive to the influences of age than that of males.

Avaliação da qualidade do ar interior num bloco operatório e numa central de esterilização utilizando como indicador a concentração de dióxido de carbono

A população dos países mais desenvolvidos passa, em média, cerca de 90 % do seu tempo em ambientes interiores, seja em casa, no trabalho e até em actividades de lazer. Assim, é indiscutível a necessidade de manutenção de ambientes interiores saudáveis e confortáveis. este estudo teve como principal objectivo avaliar a qualidade do ar interior e a eficiência do sistema de ar condicionado das salas de operações de um bloco operatório e de uma central de esterilização de um hospital Português, utilizando como indicador as concentrações de dióxido de carbono. People of developed countries spend about 90% of their time indoor, in their houses, workplaces or in leisure time. in consequence, nowadays, it is very important to keep healthy and comfortable indoor environments. the main goal of the study was to evaluate the quality and the efficiency of the conditional air system of 6 operations room of a surgical site and a central of sterilization of a Portuguese hospital, being used as indicating the concentrations of carbon dioxide.

Infeções em Cateteres de Hemodialisados

Projeto de Pós-Graduação/Dissertação apresentado à Universidade Fernando Pessoa como parte dos requisitos para obtenção do grau de Mestre em Ciências Farmacêuticas

Optimizing perioperative analgesia for patients undergoing operative fixation of hip fractures

This PhD thesis describes work carried out on investigation of various interventions with the aim to optimise the anaesthetic management of patients scheduled to undergo operative fixation of hip fractures. We analysed the perioperative effects of continuous femoral nerve block, single preoperative dose of i.v. dexamethasone, the intention to deposit local anaesthetic in different locations around the femoral nerve during ultrasound guided femoral nerve block, continuous spinal anaesthesia and peri-surgical site infiltration with local anaesthetic after surgical fixation of hip fractures. Continuous femoral nerve block provided more effective preoperative analgesia six hours after the insertion of the perineural catheter compared to a standard opiate-based regimen in patients undergoing operative fixation of fractured hip. A single low dose of preoperative dexamethasone in the intervention group decreased pain scores by 75% six hours after the surgery. Both interventions had no major effect on the functional recovery in the first year after the surgical fixation of fractured hip. The results of the ultrasound guided femoral nerve block trial showed no clinical advantage of intending to deposit local anaesthetic circumferentially during performing femoral nerve block. Using the Dixon and Massey’s “up- and-down” method, we demonstrated that intrathecal 0.26 ml of 0.5% bupivacaine provided adequate surgical anaesthesia within 15 minutes in 50% of patients undergoing operative fixation of hip fracture. Finally, we demonstrated that local anaesthetic infiltration had no effect on pain scores 12 hours after the surgical fixation of fractured neck of femur. In addition to this original body of work, a review article was published on femoral nerve block highlighting the use of ultrasound guidance. In conclusion, the results of this thesis offer an insight into interventions aimed at optimising perioperative analgesia in patients scheduled to undergo operative fixation of hip fractures.