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To evaluate the impact of a standardized, process-validated intervention utilizing daily hospital-wide patient-zone sporicidal disinfectant cleaning on incidence density of healthcare-onset Clostridioides difficile infection (HO-CDI) standardized infection ratios (SIRs).
Multi-site, quasi-experimental study, with control hospitals and a nonequivalent dependent variable.
The study was conducted across 8 acute-care hospitals in 6 states with stable endemic HO-CDI SIRs.
Following an 18-month preintervention control period, each site implemented a program of daily hospital-wide sporicidal disinfectant patient zone cleaning. After a wash-in period, thoroughness of disinfection cleaning (TDC) was monitored prospectively and optimized with performance feedback utilizing a previously validated process improvement program. Mean HO-CDI SIRs were calculated by quarter for the pre- and postintervention periods for both the intervention and control hospitals. We used a difference-in-differences analysis to estimate the change in the average HO-CDI SIR and HO-CAUTI SIR for the pre- and postintervention periods.
Following the wash-in period, the TDC improved steadily for all sites and by 18 months was 93.6% for the group. The mean HO-CDI SIRs decreased from 1.03 to 0.6 (95% CI, 0.13–0.75; P = .009). In the adjusted difference-in-differences analysis in comparison to controls, there was a 0.55 reduction (95% CI, −0.77 to −0.32) in HO-CDI (P < .001) or a 50% relative decrease from baseline.
This study represents the first multiple-site, quasi-experimental study with control hospitals and a nonequivalent dependent variable to evaluate a 4-component intervention on HO-CDI. Following ongoing improvement in cleaning thoroughness, there was a sustained 50% decrease in HO-CDI SIRs compared to controls.
Background: Sink drainage systems are a potential reservoir for the dissemination of gram-negative bacilli but are not amenable to standard methods of cleaning and disinfection. Pouring liquid disinfectants down drains has only a limited and transient effect on drain colonization, presumably due to inadequate disinfectant contact time and suboptimal penetration into areas harboring biofilm-associated organisms. Methods: We compared the antimicrobial efficacy of 2 novel sink disinfection methods intended to enhance disinfectant contact time and penetration. Healthcare facility sinks were randomly assigned to disinfection with 300 mL hydrogen peroxide-based disinfectant applied either as a foam (N = 13 sinks) or instilled for 30 minutes behind a temporary obstruction created by an inflated urinary catheter balloon (N = 12 sinks). Swabs were used to collect quantitative cultures from the proximal sink drain to depth of 2.5 cm (1 inch) below the strainer before treatment and at 15 minutes and 1, 2, 3, 5, and 7 days after treatment. Repeated measures analysis of variance was performed to compare the efficacy of the 2 treatments. Results: As shown in Fig. 1, both methods yielded an initial reduction of >3 log10 CFU of gram-negative bacilli. Over the 7-day follow-up period, disinfectant instillation resulted in significantly greater reduction than the foam application (P < .01). Recovery of sink colonization to >2 log per swab occurred at day 3 for both treatments, whereas recovery to >3 log per swab occurred on day 3 for the foam treatment versus day 7 for disinfectant instillation. Conclusions: Two novel disinfection methods were effective in reducing sink drain colonization for several days. The instillation method was more effective than the foam method in maintaining reductions over 7 days.
Background: Despite ongoing efforts over the past 3 decades, hospital-onset Clostridioides difficile infection (HO-CDI) continues to challenge interventions aimed at its prevention and control. We describe the impact of a model environmental services (EVS) program on the incidence of HO-CDI across 8 hospitals that are part of a nationwide integrated health system. Methods: Eight acute-care hospitals with 44–532 beds (mean, 263 beds) in 6 states with stable endemic HO-CDI incidence densities independently implemented identical sporicidal environmental hygiene interventions in 2017. The program combined the use of a hydrogen peroxide/peroxyacetic acid surface disinfectant for all patient-zone hygienic cleaning combined with a structured model EVS cleaning program that included optimized cleaning and disinfection technique, staff training, and auditing with objective performance feedback, which aligned with 2008 HICPAC/CDC categories I and II as well as 2010 CDC Guidance Level II monitoring program recommendations. After a 3-month phase-in, we compared NHSN-reported LabID HO-CDI SIRs for 18 months before and 12 months after implementation of the program. Results were not shared between sites and data were not collated by the authors until a year after the postintervention results were initially available. Multiple possible confounding factors were evaluated and determined not to have identifiably affected the outcome. Results: Mean preintervention HO-CDI SIRs over the 18 months measured ranged from 0.5 to 1.4 (mean, 1.0 for the group). Following the wash-in period, SIRs decreased precipitously in all sites to a mean of 0.42 for the group by the end of 12 months of the intervention. (P < .0001) (Fig. 1). Individual site improvement ranged from 20% to 92% (mean, 57%) (Fig. 2.) Conclusions: Overall, HO-CDI SIRs decreased almost 60% in the study hospitals following daily sporicidal disinfection cleaning of all patient-zone surfaces in association with ongoing programmatic optimization of cleaning practice. As predicted by earlier single-site studies reporting a favorable impact of sporicidal disinfectant cleaning in outbreak settings, this multisite quasi-experimental study has illustrated the substantial potential impact of hospital-wide sporicidal disinfection integrated with objectively sustained optimized thoroughness of cleaning to decrease the incidence of HO-CDI.
For many years, patient-area wastewater drains (ie, sink and shower drains) have been considered a potential source of bacterial pathogens that can be transmitted to patients. Recently, evolving genomic epidemiology tools combined with new insights into the ecology of wastewater drain (WWD) biofilm have provided new perspectives on the clinical relevance and hospital-associated infection (HAI) transmission risks related to these fixtures. To further clarify the clinical relevance of WWD-associated pathogen transmission, reports of outbreaks attributed to WWDs were selected for review that (1) investigated the outbreak epidemiology of WWD-associated transmission of bacterial pathogens, (2) utilized advanced microbiologic methods to establish clonality of outbreak pathogens and/or resistance genes, or (3) described interventions implemented to mitigate transmission of the outbreak pathogens from WWDs. These reports were collated, compared, and analyzed, and the results are presented here.
This online resource answers the key questions that any clinician encounters with a high-risk pregnancy: what are the risks for the woman and/or the baby with this condition? How do I manage a pregnancy complicated by this condition? How do I perform this procedure (e.g. amniocentesis, cesarean section)? All the chapters are newly written or updated to reflect current, evidence-based management and changes in practice. The 'Normal Values' section, a hugely popular reference source, is included. Over half of the chapters have new authors. New chapters have also been added to keep the content up to date with modern developments. This comprehensive online resource provides links to key websites (e.g. National Clinical Guidelines), video recordings - especially of procedures - and additional images and all content will be reviewed annually and updated as necessary.
“Normal” has different meanings. In the context of physical or laboratory measurements, “normal” may mean “average,” “disease-free,” or “within a given statistical range.” However, it is important to know the characteristics of the population yielding “normal” values before deciding whether these values provide an appropriate reference range with which to compare an individual test result. Many laboratories now print reference ranges on their reports and highlight test values that fall outside these values as “abnormal.” When the test subject is a pregnant woman, a fetus, or a newborn, and the reference population is composed predominantly of middle-aged men, then comparisons are patently inappropriate. It is important to understand how the physiologic changes of pregnancy affect the results of various tests and measurements before deciding whether an out-of-range result is actually abnormal.
Modern antenatal care aims to optimize both maternal and fetal outcomes. The various methods of prenatal fetal surveillance are directed towards early detection and, sometimes, prevention of chronic fetal hypoxia. The fetal response to acute or chronic hypoxia varies and is modified by the preceding fetal condition. Prenatal fetal surveillance tools are useful in pregnancies that are at high risk of developing chronic fetal hypoxia, but less so for acute events (e.g., placental abruption). There is evidence that fetal surveillance in unselected low-risk population is not cost-effective and leads to unnecessary interventions. Therefore routine prenatal fetal surveillance techniques or tests are not universally adopted in this group.
Intra-amniotic infection/inflammation (IAI) is a frequent and important cause of spontaneous preterm labor and delivery. Indeed, it is the only pathologic process for which both a causal link with spontaneous preterm birth has been established and a molecular pathophysiology defined. Fetal infection/inflammation has been implicated in the genesis of fetal and neonatal injury leading to cerebral palsy (CP) and chronic lung disease. Pathologic intra-amniotic inflammation can occur in the absence of detectable microorganisms, upon analysis by cultivation and/or molecular microbiologic techniques. This condition is known as sterile intra-amniotic inflammation and has been observed in patients with preterm labor and intact membranes, preterm prelabor rupture of the membranes (PPROM), and a short cervix. A mild sterile inflammatory process also participates in spontaneous labor at term, but this is considered to be an example of physiologic inflammation similar to that implicated in other important events in reproductive physiology, such as ovulation and implantation.
Complications arise more frequently during the first trimester than at any other stage of pregnancy. Most present with bleeding, pain, or both. Vaginal bleeding occurs in about 20% of clinically diagnosed pregnancies. It causes considerable anxiety for the woman and her partner. In the vast majority of cases, no intervention alters the outcome. The main aim of clinical management is a prompt and accurate diagnosis, with reassurance if the pregnancy is appropriately developed and viable, or appropriate intervention if not. This chapter focuses on the principles of diagnosis and management and three principal diagnoses: miscarriage, ectopic pregnancy, and gestational trophoblastic disease. The other differential diagnoses are shown in Table 5.1.
Imagine asking yourself the question, “How would I describe a typical pregnant woman who uses drugs?” You might reply that she comes from a different social class, cannot think beyond the pregnancy, uses jargon, and doesn’t listen or care about the welfare of the child. However, my experience when asking drug-using women what they thought about the typical obstetrician is that they say the doctor was from a different social class, could not think beyond the pregnancy, used jargon, and didn’t listen or care about the welfare of the child.