In recent years, the number of legal trials involving the legal responsibility of a hospital for the occurrence of nosocomial infection has been increasing, and hospitals have been required to pay large amounts of compensation. Precedents concerning the nosocomial infection of methicillin-resistant Staphylococcus aureus (MRSA) were analyzed during the past 12 years with a computer precedent search system, to identify only trials in which the nosocomial infection of the MRSA became a direct issue of the responsibility. Among the 23 precedents, 22 trials could be evaluated. Fault of a medical worker was involved in 13 cases, and the remaining nine cases were dismissed. MRSA infectious disease were closely related in ten of the 13 cases. MRSA nosocomial infection was considered to be the responsibility of the medical worker in a few cases, most related to the responsibility of early diagnosis and early adequate treatment of MRSA infections.
Nosocomial transmission of vancomycin-resistant Enterococci (VRE) occurred in Kyushu University Hospital in March 2004. A strain of E. faecium of the Van B type was isolated from a stool sample of a patient, after which VRE was detected from other five patients in the same ward up to August 2004. Correct infection control for VRE was not initially performed because the strain was misidentified as E. casseliflavus. Pulsed-field gel electrophoresis (PFGE) revealed that all the VRE strains were closely related, so transmission was considered to be nosocomial. All six patients colonized with VRE were female and were comparatively active. They used shared bathrooms. None of the patients shared a room with any of the other patients colonized with VRE. Therefore, we speculate that a contaminated toilet seat was the probable route of transmission. Our strategy of care to prevent contact with possible sites of infection, cleaning susceptible environments, especially the bathrooms, and strengthening hand hygiene adherence successfully led to the end of the outbreak.
Pseudomonas aeruginosa is a Gram-negative bacterium and is clinically significant for opportunistic infections propagated within the hospital environment. In particular, these bacteria are easy to isolate from water-supply environments (e.g. tap, sink). Bactericidal conditions using hot water against three P. aeruginosa clinical isolates, including MDRP and biofilm-forming strain, were assessed. Furthermore, the efficacy of eradication, using hot water, was investigated for P. aeruginosa on the surfaces of water supply environments in hot-spring facilities, a hospital, and a nursing home. All three strains became extinct in contact with hot water at more than 70°C for 5 seconds or more. P. aeruginosa on the water supply environmental surfaces was eradicated by this condition except for two taps in hot-spring facilities. These two taps were of complicated shape, which was thought to be the major cause of eradication failure. The results suggest that hot water eradication should be considered as an option for P. aeruginosa eradication on environmental surfaces in hospitals or nursing homes.
The knowledge, attitudes, and practices of nurses regarding these standard precautions were studied, the levels and correlations of these areas, and specific precautions among the standard precautions were analyzed. The investigation targeted 590 nurses at three institutions that are operated by different entities in Nagasaki prefecture, using questionnaires regarding their knowledge, attitudes, and practices with regard to standard precautions, and further analyzing answers according to the basic attributes. The results found no correlation between score and attitude scores (rs=0.17, p<0.01), or between knowledge and practice scores (rs=0.057, p>0.05). A correlation was observed between the attitude and practice scores (rs=0.412, p<0.01), suggesting that having a good attitude is an important factor for achieving better practice results. The knowledge scores were mean 8.9 (SD1.5), the attitude scores were median 92 (87∼97), and the practice scores were median 84.5 (78∼91). The practice scores were lower than the attitude scores for standard precautions. We believe that simply acquiring knowledge and a good attitude does not always lead to good practice. In the analysis according to the basic attributes, nurses with more experience and who were older tended to have better scores for attitude and practice. Consequently, we believe that it is effective to educate and train nurses according to their level of experience and age. In addition, assistant head nurses or nurses who belonged to infection control committees had higher scores for attitude (p<0.01), and practice (p<0.01), and we believe that job titles and memberships in committees may affect the attitudes (p<0.01), and practices (p<0.01) of nurses regarding the standard precautions. Nurses who had undergone appropriate training also had higher scores for knowledge (p<0.01), attitude (p<0.01), and practice (p<0.01), thus indicating the importance of practical training.
The present situation of infection control strategies in home visit nursing care stations was evaluated using questionnaires at home visit nursing care stations in Tokyo in 2004, and stations in areas outside Tokyo in 2005. Answers were recovered from 134 stations in Tokyo and 523 stations in other areas of Japan outside Tokyo. The results were as follows. 1) Infection control manuals were used at 65.7% of stations in Tokyo and at 77.1% in other areas, and infection control training was given to nurses at 54.5% of stations in Tokyo and at 70.9% in other areas. 2) Nurses were recommended to wash their hands at 74.6% of stations in Tokyo and 72.5% in other areas. Hand washing with running tap water and soap was the most frequently recommended method, followed by waterless hand-washing products. 3) Vaccination was recommended to visiting nurses at 85.8% of stations in Tokyo and at 86.0% in other areas, and most of them recommended influenza vaccine. 4) Half of stations reported that information about infectious disease was not included in their medical instructions. 5) Some stations had users suffering from infections, so were maintaining manuals for infection control and made attempts to study prevention against infection. Home visit type services are increasing more and more in Japan, so both nurses and other personnel relating to home visit care should cooperate and should receive systematic infection control education
Outbreaks of Bacillus cereus attributable to hot towels (heated moist towels for body cleaning) continue to be reported, so microbial control and correct handling of hot towels are important issues. Our institution experienced an outbreak of B. cereus in 2003, which was believed to have originated from contaminated hot towels and improper handling of a body-cleaning towel cart. To comply with a request for resumption of use of hot towels for cleaning patients, the hot towels were evaluated in an effort to define operating instructions for the body-cleaning towel cart. Hot towels provided for patients were rented and delivered in a washed and dry condition. The towels were moistened in the facility and heated/warmed in the body-cleaning towel cart to be used for care of patients. The used towels were collected and retreated by the supplier for the next rental use. Towels prepared in this way were analyzed. The total number of contaminating microorganisms detected from these dry towels was about 106 cfu/towel and remained stable during a certain storage period. The D values for B. cereus in the microbial suspension taken from the towels were 100 min at 80°C and 10 min at 100°C. To determine the microbiocidal effect of the towel warming process in the body-cleaning towel cart, the Biological Indicator containing Bacillus spores (NAMSA) used for control of sterilization processes was inserted among the towels and treated in the usual way. Strains such as B. subtilis, B. pumilus and B. cereus excluding Geobacillus stearothermophilus were killed in this process. Therefore, use of the body-cleaning towel cart requires properly cleaned towels and heat treatment of towels containing a minimum amount of water to effectively control contamination of the hot towels.
Inappropriate use of antimicrobial agents causes unnecessary patient exposure to medication and emergence of antibiotic resistance. Our institution started to use a notification policy for various classes of antimicrobial agents (carbapenems, fourth-generation cephalosporins and quinolones, ceftazidimes, and antimethicillin-resistant Staphylococcus aureus (MRSA) agents) from November 2005. In this study, consumption of the antimicrobial agents for every half year and the trends of antimicrobial resistance were verified before and after the introduction of the notification policy, and the system was evaluated. Total antimicrobial usage density (AUD) of broad-spectrum antimicrobial agents (i.e. carbapenems, fourth-generation cephalosporins and quinolones) was decreased from 34.1 to 16.0 (p<0.01). The incidence of Pseudomonas aeruginosa isolates resistant to imipenem/cilastatin (IPM/CS) and levofloxacin (LVFX) showed decreasing trends. The detection rate of MRSA was significantly decreased (p<0.05). Multidrug-resistant Pseudomonas aeruginosa (MDRP) and extended-spectrum beta-lactamase (ESBLs) producing enterobacteria were not detected. In contrast, the AUD of anti-MRSA agents was not changed. Education about the effectiveness and appropriate use of anti-MRSA agents was given before the introduction of the notification policy. Therefore, the notification policy for agents to prevent the emergence of resistance may be ineffective. The present study indicates that our notification policy for various classes of antibiotics is effective for reducing excessive broad-spectrum antibiotic use, and control over nosocomial infections in the settings of antimicrobial agents was not used appropriately.
Our hospital Infection Control Team (ICT) has managed the use of anti-methicillin-resistant Staphylococcus aureus (MRSA) drugs [vancomycin (VCM), arbekacin (ABK), and teicoplanin (TEIC)] since 2000. The present study evaluated the effect of intervention by the ICT on the following: Annual total amount of anti-MRSA drugs used; number of patients treated with anti-MRSA drugs and duration of treatment with anti-MRSA drugs. The frequencies of therapeutic drug monitoring (TDM) of anti-MRSA drugs and loading administration of TEIC were also assessed. The total amount of anti-MRSA drugs used in our hospital has tended to decrease since 2000. The mean duration of VCM treatment significantly decreased from 13.7±14.2 days (N=172) in 2000 to 8.2±11.1 days (N=299) in 2006 (p=0.0001). The frequency of TDM for VCM significantly increased from 33.3% in 2000 to 70.6% in 2006 (p<0.001), and the total frequency of TDM for anti-MRSA drugs also significantly increased from 29.7% to 63.4%, respectively (p<0.001). The frequency of loading administration of TEIC in 2006 was higher than that in 2000. These findings suggest that intervention by the ICT promotes the appropriate use of anti-MRSA drugs.