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The coronavirus disease 2019 (COVID-19) pandemic highlighted the importance of robust infection prevention and control (IPAC) practices to maintain patient and staff safety. However, healthcare workers (HCWs) face many barriers that affect their ability to follow these practices. We identified barriers affecting HCW adherence to IPAC practices during the pandemic in British Columbia, Canada.
Cross-sectional web-based survey.
Acute care, long-term care or assisted living, outpatient, mental health, prehospital care, and home care.
Eligible respondents included direct-care providers and IPAC professionals working in these settings in all health authorities across British Columbia.
We conducted a web-based survey from August to September 2021 to assess respondent knowledge and attitudes toward IPAC within the context of the COVID-19 pandemic. Respondents were asked to rate the extent to which various barriers affected their ability to follow IPAC practices throughout the pandemic and to make suggestions for improvement.
The final analysis included 2,488 responses; 36% of respondents worked in acute care. Overall, perceptions of IPAC practice among non-IPAC professionals were positive. The main self-perceived barriers to adherence included inadequate staffing to cover absences (58%), limited space in staff rooms (57%), multibed rooms (51%), and confusing messages about IPAC practices (51%). Common suggestions for improvement included receiving more support from IPAC leadership and clearer communication about required IPAC practices.
Our findings highlight frontline HCW perspectives regarding priority areas of improvement for IPAC practices. They will inform policy and guideline development to prevent transmission of COVID-19 and future emerging infections.
Background: Data regarding the effects of the SARS-COV-2 (COVID-19) pandemic on healthcare-associated infections (HAIs) in Canadian acute-care hospitals are limited. We examined the impact of the COVID-19 pandemic on HAIs and antimicrobial resistant organisms in hospitals participating in the Canadian Nosocomial Infection Surveillance Program. Methods: We analyzed 13,406 HAIs including adult mixed intensive care unit (ICU) central-line–associated bloodstream infections (CLABSIs), and healthcare-associated (HA) Clostridioides difficile infection (CDI), methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSI), vancomycin-resistant Enterococcus (VRE) BSI, and carbapenemase-producing Enterobacterales (CPE) infections collected using standardized case definitions and questionnaires from 29–64 hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP) from January 2018 to December 2021. We used a generalized linear mixed model with quasi-Poisson distribution to assess step and slope changes in monthly HAI rates between the pre–COVID-19 pandemic period (January 1, 2018–February 29, 2020; 26 time points) and the COVID-19 pandemic period (March 1, 2020–December 31, 2021; 22 time points). Results were reported as incidence rate ratios (IRRs) with 95% confidence intervals (CIs) and adjusted for seasonality, hospital clustering, and hospital characteristics of interest. Results: In the CNISP network, 7,352 (55%) HAIs were reported in the prepandemic period and 6,054 (45%) in the pandemic period. Median age was significantly younger during the pandemic period compared to the prepandemic period among patients with HA-CDI, HA-MRSA BSI, and adult mixed ICU CLABSIs, and more than half of cases among all reported HAIs were male (range, 52%–65%). The 30-day all-cause in-hospital mortality rate did not significantly change between the prepandemic and pandemic periods for all reported HAIs and was highest among HA-VRE BSIs (34%). Modeling results indicated that the COVID-19 pandemic was associated with an immediate increase in HA-CDI and adult mixed ICU CLABSI rates whereas HA-MRSA BSI, HA-CPE and HA-VRE BSI rates immediately decreased. However, pandemic status did not have a statistically significant lasting impact on monthly rate trends for all reported HAIs after adjusting for seasonality, clustering, and hospital covariates (Fig. 1 and 2). Adjusted IRRs for all HAIs ranged from 1.00 to 1.01 (95% CI, 0.94–0.99 to 1.01–1.05).
Conclusions: Although the COVID-19 pandemic placed a significant burden on the Canadian healthcare system, the immediate impact on monthly rates of HAIs in Canadian acute-care hospitals was not sustained over time. Understanding the epidemiological effects of the COVID-19 pandemic in the context of changing patient populations, and clinical and infection control practices, are essential to inform the continued management and prevention of HAIs in Canadian acute-care settings.
Background: The Canadian Nosocomial Infection Surveillance Program (CNISP) observed increased mortality among neonatal intensive care unit (NICU) patients with central-line–associated bloodstream infection (CLABSI) starting in 2017. In this study, we compared NICU patients with CLABSIs before and after 2017, and quantified the impact of epidemiological factors on 30-day survival. Methods: We included 1,276 NICU patients from 8–16 participating CNISP hospitals from the pre-2017 period (2009–2016) and the post-2017 period (2017–2022) using standardized definitions and questionnaires. We used Cox regression modeling to assess the impact of age at date of positive culture, sex, birthweight, CLABSI microorganism, region of the country, and surveillance period (before 2017 vs after 2017) on time to 30-day all-cause mortality from date of positive culture. Gestational age was not available for this analysis. We reported model outputs as hazard ratios with 95% CIs. Results: In total, 769 (60%) NICU CLABSIs were reported in the pre-2017 period and 507 (40%) in the post-2017 period. The 30-day all-cause mortality rate was 8% (n = 100 of 1,276) overall, and significantly higher after 2017 (12%, n = 61 of 507) than before 2017 (5%, n = 39 of 769) (P < .001).
During the post-2017 period, cases were significantly younger: 16 days (IQR, 9–33) versus 21 days (IQR, 11–49) (P = .002). Median days from ICU admission to infection were shorter: 14 (IQR, 8–31) versus 19 (IQR, 10–41) (P < .001). More gram-negative CLABSIs were identified (29% vs 24%; P = .040) and fewer gram-positive CLABSIs were identified (64% vs 72%; P = .006) compared to the pre-2017 period. Mortality was higher in CLABSIs caused by gram-negative bacteria (15%, n = 50 of 328) than gram-positive bacteria (4.4%, n = 39 of 877) (P < .001), and mortality was higher in neonates with birthweight <1,000 g (11%, n = 71 of 673) compared to those weighing ≥1,000 g (5%, n = 28 of 560) (P < .001).
Adjusting for all other factors, survival modeling indicated that NICU CLABSIs identified in the post-2017 period had 2.12 (95% CI, 1.23–3.66) times the hazard ratio of 30-day all-cause mortality compared to those before 2017 (P < .006). Those identified with a gram-positive bacterium had a 0.28 hazard ratio (95% CI, 0.12–0.65) of 30-day mortality compared to those with a gram-negative bacterium or fungus (P = .003). In the fully adjusted model, age, sex, and birthweight were not significantly associated with NICU CLABSI survival. Conclusions: NICU patients with CLABSIs had significantly higher all-cause mortality between 2017–2022 compared to 2009–2016, and those who acquired gram-positive–associated CLABSIs had improved survival compared to other organisms. Further work is needed to identify and understand factors driving the increased mortality among NICU CLABSI patients from 2017–2022.
To evaluate the change in consumption of specific antibiotics in a neonatal intensive care unit after the implementation of an antimicrobial stewardship program (ASP).
Retrospective cohort study between January 1, 2010, and December 31,2019.
The neonatal intensive care unit at British Columbia Women’s Hospital (Vancouver Canada), a tertiary-care center.
Admitted neonates prescribed antibiotics.
We implemented an ASP with an early implementation phase starting in January 2014 (period 2) and a later phase starting in January 2017 (period 3). Patient demographics were collected, including birth weight, gestational age, history of necrotizing enterocolitis (NEC), and surgical operations from existing databases. Interrupted time-series analysis was used, and comparison of antibiotic days of therapy (DOT) averages were conducted across the preimplementation period (period 1), period 2, and period 3 regarding total patients and subgroups.
We identified 4,512 infants. There was a significant decrease in DOT from 472 (95% confidence interval [CI], 431–517) in period 1 to 405 (95% CI, 367–446) in period 2 to 313 (95% CI, 280–350) in period 3. We detected a significant decrease in the use of ampicillin, aminoglycosides, cloxacillin, and linezolid but not in vancomycin or cefotaxime. Subgroup analyses of infants <1,500 g and those without NEC or surgery showed decreases in the use of cloxacillin, aminoglycosides, and linezolid.
The implementation of an ASP was associated with a significant decrease in the overall DOT and use of certain antibiotics. This study presents important targets for ongoing ASP work.
The coronavirus disease 2019 (COVID-19) pandemic has placed significant burden on healthcare systems. We compared Clostridioides difficile infection (CDI) epidemiology before and during the pandemic across 71 hospitals participating in the Canadian Nosocomial Infection Surveillance Program. Using an interrupted time series analysis, we showed that CDI rates significantly increased during the COVID-19 pandemic.
To evaluate 3 formulations of copper (Cu)-based self-sanitizing surfaces for antimicrobial efficacy and durability over 1 year in inpatient clinical areas and laboratories.
Randomized control trial.
We assessed 3 copper formulations: (1) solid alloy 80% Cu–20% Ni (integral copper), (2) spray-on 80% Cu–20% Ni (spray-on) and (3) 16% composite copper-impregnated surface (CIS). In total, 480 coupons (1 cm2) of the 3 products and control surgical grade (AISI 316) stainless steel were inserted into gaskets and affixed to clinical carts used in patient care areas (including emergency and maternity units) and on microbiology laboratory bench work spaces (n = 240). The microbial burden and assessment of resistance to wear, corrosion, and material compatibility were determined every 3 months. Participants included 3 tertiary-care Canadian adult hospital and 1 pediatric-maternity hospital.
Copper formulations used on inpatient units statistically significantly reduced bacterial bioburden compared to stainless steel at months 3 and 6. Only the integral copper product had significantly less bacteria than stainless steel at month 12. No statistically significant differences were detected in microbial burden between copper formulations and stainless-steel coupons on microbiology laboratory benches where bacterial counts were low overall. All mass changes and corrosion rates of the formulations were acceptable by engineering standards.
Copper surfaces vary in their antimicrobial efficacy after 1 year of hospital use. Frequency of cleaning and disinfection influence the impact of copper; the greatest reduction in microbial bioburden occurred in clinical areas compared to the microbiology laboratory where cleaning and disinfection were performed multiple times daily.
Background: Bloodstream infections (BSIs) due to methicillin-resistant Staphylococcus aureus (MRSA) are important causes of morbidity and mortality in hospitalized patients. Long-term national MRSA BSI surveillance establishes rates for internal and external comparison and provide insight into epidemiologic, molecular, and resistance trends. Here, we present and discuss National MRSA BSI incidence rates and trends over time in Canadian acute-care hospitals from 2008 to 2018. Methods: The Canadian Nosocomial Infection Surveillance Programme (CNISP) is a collaborative effort of the Association of Medical Microbiology and Infectious Disease Canada and the Public Health Agency of Canada. Since 1995, the CNISP has conducted hospital-based sentinel surveillance of MRSA BSIs. Data were collected using standardized definitions and forms from hospitals that participate in the CNISP (48 hospitals in 2008 to 62 hospitals in 2018). For each MRSA BSI identiﬁed, the medical record was reviewed for clinical and demographic information and when possible, 1 blood-culture isolate per patient was submitted to a central laboratory for further molecular characterization and susceptibility testing. Results: From 2008 to 2013, MRSA BSI rates per 10,000 patient days were relatively stable (0.60–0.56). Since 2014, MRSA BSI rates have gradually increased from 0.66 to 1.05 in 2018. Although healthcare-associated (HA) MRSA BSI has shown a minimal increase (0.40 in 2014 to 0.51 in 2018), community-acquired (CA) MRSA BSI has increased by 150%, from 0.20 in 2014 to 0.50 in 2018 (Fig. 1). Laboratory characterization revealed that the proportion of isolates identified as CMRSA 2 (USA 100) decreased each year, from 39% in 2015 to 28% in 2018, while CMRSA 10 (USA 300) has increased from 41% to 47%. Susceptibility testing shows a decrease in clindamycin resistance from 82% in 2013 to 41% in 2018. Conclusions: Over the last decade, ongoing prospective MRSA BSI surveillance has shown relatively stable HA-MRSA rates, while CA-MRSA BSI rates have risen substantially. The proportion of isolates most commonly associated with HA-MRSA BSI (CMRSA2/USA 100) are decreasing and, given that resistance trends are tied to the prevalence of specific epidemic types, a large decrease in clindamycin resistance has been observed. MRSA BSI surveillance has shown a changing pattern in the epidemiology and laboratory characterization of MRSA BSI. The addition of hospitals in later years that may have had higher rates of CA-MRSA BSI could be a confounding factor. Continued comprehensive national surveillance will provide valuable information to address the challenges of infection prevention and control of MRSA BSI in hospitals.
Background: Healthcare services are increasingly shifting from inpatient to outpatient settings. Outpatient settings such as emergency departments (EDs), oncology clinics, dialysis clinics, and day surgery often involve invasive procedures with the risk of acquiring healthcare-associated infections (HAIs). As a leading cause of HAI, Clostridioides difficile infection (CDI) in outpatient settings has not been sufficiently described in Canada. The Canadian Nosocomial Infection Surveillance Program (CNISP) aims to describe the epidemiology, molecular characterization, and antimicrobial susceptibility of outpatient CDI across Canada. Methods: Epidemiologic data were collected from patients diagnosed with CDI from a network of 47 adult and pediatric CNISP hospitals. Patients presenting to an outpatient setting such as the ED or outpatient clinics were considered as outpatient CDI. Cases were considered HAIs if the patient had had a healthcare intervention within the previous 4 weeks, and they were considered community-associated if there was no history of hospitalization within the previous 12 weeks. Clostridioides difficile isolates were submitted to the National Microbiology Laboratory for testing during an annual 2-month targeted surveillance period. National and regional rates of CDI were stratified by outpatient location. Results: Between January 1, 2015, and June 30, 2019, 2,691 cases of outpatient-CDI were reported, and 348 isolates were available for testing. Most cases (1,475 of 2,691, 54.8%) were identified in outpatient clinics, and 72.8% (1,960 of 2,691) were classified as community associated. CDI cases per 100,000 ED visits were highest in 2015, at 10.3, and decreased to 8.1 in 2018. Rates from outpatient clinics decreased from 3.5 in 2016 to 2.7 in 2018 (Fig. 1). Regionally, CDI rates in the ED declined in Central Canada and increased in the West after 2016. Rates in outpatient clinics were >2 times higher in the West compared to other regions. RT027 associated with NAP1 was most common among ED patients (26 of 195, 13.3%), whereas RT106 associated with NAP11 was predominant in outpatient clinics (22 of 189, 11.6%). Overall, 10.4% of isolates were resistant to moxifloxacin, 0.5% were resistant to rifampin, and 24.2% were resistant to clindamycin. No resistance was observed for metronidazole, vancomycin, or tigecycline. Compared to CNISP inpatient CDI data, outpatients with CDI were younger (51.8 ± 23.3 vs 64.2 ± 21.6; P < .001), included more females (56.4% vs 50.9%; P < .001), and were more often treated with metronidazole (63.0% vs 56.1%; P < .001). Conclusions: For the first time, CDI cases identified in outpatient settings were characterized in a Canadian context. Outpatient CDI rates are decreasing overall, but they vary by region. Predominant ribotypes vary based on outpatient location. Outpatients with CDI are younger and are more likely female than inpatients with CDI.
Disclosures: Susy Hota reports contract research for Finch Therapeutics.
Background: Carbapenemase-producing Enterobacterales (CPE) have rapidly become a global health concern and are associated with substantial morbidity and mortality due to limited treatment options. Travel to endemic areas, especially healthcare exposure in these areas, is an important risk factor for acquisition. We describe the evolving epidemiology, molecular features, and outcomes of CPE in Canada through surveillance by the Canadian Nosocomial Infection Surveillance Program (CNISP). Methods: CNISP has conducted surveillance for CPE among inpatients and outpatients of all ages since 2010. Participating acute-care facilities submit eligible specimens to the National Microbiology Laboratory for detection of carbapenemase production, and epidemiological data are collected. Incidence rates per 10,000 patient days are calculated based on inpatient data. Results: In total, 59 CNISP hospitals in 10 Canadian provinces representing 21,789 beds and 6,785,013 patient days participated in this surveillance. From 2010 to 2018, 118 (26%) CPE-infected and 547 (74%) CPE-colonized patients were identified. Few pediatric cases were identified (n = 18). Infection incidence rates remain low and stable (0.02 per 10,000 patient days in 2010 to 0.03 per 10,000 patient days in 2018), and colonization incidence rates have increased by 89% over the surveillance period. Overall, 92% of cases were acquired in a healthcare facility: 61% (n = 278) in a Canadian healthcare facility and 31% (n = 142) in a healthcare facility outside Canada. Of the 8% of cases not acquired in a healthcare facility, 50% (16 of 32) reported travel outside of Canada in the 12 months prior to positive culture. The distribution of carbapenemases varied by region; New Delhi metallo-B-lactamase (NDM) was dominant (59%) in western Canada and Klebsiella pneumoniae carbapenemase (KPC) (66%) in central Canada. NDM and class D carbapenemase OXA-48 were more commonly identified among those who traveled outside of Canada, whereas KPC was more commonly identified among patients without travel. In addition, 30-day all-cause mortality was 14% (25 of 181) among CPE infected patients and 32% (14 of 44) among those with bacteremia. Conclusions: CPE rates remain low in Canada; however, national surveillance data suggest that the increase in CPE in Canada is now being driven by local nosocomial transmission as well as travel and healthcare within endemic areas. Changes in screening practices may have contributed to the increase in colonizations; however, these data are currently lacking and will be collected moving forward. These data highlight the need to intensify surveillance and coordinate infection control measures to prevent further spread of CPE in Canadian acute-care hospitals.
Susy Hota reports contracted research for Finch Therapeutics. Allison McGeer reports funds to her institution for projects for which she is the principal investigator from Pfizer and Merck, as well as consulting fees from the following companies: Sanofi-Pasteur, Sunovion, GSK, Pfizer, and Cidara.
Background: Nosocomial central-line–associated bloodstream infections (CLABSIs) are an important cause of morbidity and mortality in hospitalized patients. CLABSI surveillance establishes rates for internal and external comparison, identifies risk factors, and allows assessment of interventions. Objectives: To determine the frequency of CLABSIs among adult patients admitted to intensive care units (ICUs) in CNISP hospitals and evaluate trends over time. Methods: CNISP is a collaborative effort of the Canadian Hospital Epidemiology Committee, the Association of Medical Microbiologists and Infectious Disease Canada and the Public Health Agency of Canada. Since 1995, CNISP has conducted hospital-based sentinel surveillance of healthcare-associated infections. Overall, 55 CNISP hospitals participated in ≥1 year of CLABSI surveillance. Adult ICUs are categorized as mixed ICUs or cardiovascular (CV) surgery ICUs. Data were collected using standardized definitions and collection forms. Line-day denominators for each participating ICU were collected. Negative-binomial regression was used to test for linear trends, with robust standard errors to account for clustering by hospital. We used the Fisher exact test to compare binary variables. Results: Each year, 28–42 adult ICUs participated in surveillance (27–37 mixed, 6–8 CV surgery). In both mixed ICUs and CV-ICUs, rates remained relatively stable between 2011 and 2018 (Fig. 1). In mixed ICUs, CLABSI rates were 1.0 per 1,000 line days in 2011, and 1.0 per 1,000 line days in 2018 (test for linear trend, P = .66). In CV-ICUs, CLABSI rates were 1.1 per 1,000 line days in 2011 and 0.8 per 1,000 line days in 2018 (P = .19). Case age and gender distributions were consistent across the surveillance period. The 30-day all-cause mortality rate was 29% in 2011 and in 2018 (annual range, 29%–35%). Between 2011 and 2018, the percentage of isolated microorganisms that were coagulase-negative staphylococci (CONS) decreased from 31% to 18% (P = .004). The percentage of other gram-positive organisms increased from 32% to 37% (P = .34); Bacillus increased from 0% to 4% of isolates and methicillin-susceptible Staphylococcus aureus from 2% to 6%). The gram-negative organisms increased from 21% to 27% (P = .19). Yeast represented 16% in 2011 and 18% in 2018; however, the percentage of yeast that were Candida albicans decreased over time (58% of yeast in 2011 and 30% in 2018; P = .04). Between 2011 and 2018, the most commonly identified species of microorganism in each year were CONS (18% in 2018) and Enterococcus spp (18% in 2018). Conclusions: Ongoing CLABSI surveillance has shown stable rates of CLABSI in adult ICUs from 2011 to 2018. The causative microorganisms have changed, with CONS decreasing from 31% to 18%.
Funding: CNISP is funded by the Public Health Agency of Canada.
Disclosures: Allison McGeer reports funds to her for studies, for which she is the principal investigator, from Pfizer and Merck, as well as consulting fees from Sanofi-Pasteur, Sunovion, GSK, Pfizer, and Cidara.
Healthcare worker hand hygiene is known to prevent healthcare-associated infections, but there are few data on patient hand hygiene despite the fact that nosocomial pathogens may be acquired by patients via their own unclean hands. The purpose of this study was to measure patient hand hygiene behavior in the hospital after visiting a bathroom, before eating, and on entering and leaving their rooms
Acute care teaching hospital in Canada.
Convenience sample of 279 adult patients admitted to 3 multiorgan transplant units between July 2012 and March 2013.
Patient use of alcohol-based hand rub and soap dispensers was measured using an ultrasound-based real-time location system during visits to bathrooms, mealtimes, kitchen visits, and on entering and leaving their rooms.
Overall, patients performed hand hygiene during 29.7% of bathroom visits, 39.1% of mealtimes, 3.3% of kitchen visits, 2.9% of room entries, and 6.7% of room exits.
Patients appear to perform hand hygiene infrequently, which may contribute to transmission of pathogens from the hospital environment via indirect contact or fecal-oral routes.
Infect Control Hosp Epidemiol 2014;35(11):1336–1341
The objective of this study was to determine the prevalence of Staphylococcus-contaminated stethoscopes belonging to emergency department (ED) staff and to identify the proportion of these that were Staphylococcus aureus or methicillin-resistant Staphylococcus aureus (MRSA).
We conducted a prospective observational cohort study of bacterial cultures from 100 ED staff members' stethoscopes at three EDs. Study participants were asked to complete a questionnaire.
Fifty-four specimens grew coagulase-negative staphylococci and one grew methicillin-susceptible S. aureus. No MRSA was cultured. Only 8% of participants, all of whom were nurses, reported cleaning their stethoscope before or after each patient assessment. Alcohol-based wipes were most commonly used to clean stethoscopes. A lack of time, being too busy, and forgetfulness were the most frequently reported reasons for not cleaning the stethoscope in the ED.
This study indicates that although stethoscope contamination rates in these EDs are high, the prevalence of S. aureus or MRSA on stethoscopes is low.
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