Our hospital experienced an outbreak of multidrug-resistant Pseudomonas aeruginosa (MDRP) in October, 2008. Environmental microorganisms testing, and bacteriological examinations of the nasal cavity, urine, and stool of our hospital patients were undertaken to assess the conditions of MDRP infection and to prevent the infection from spreading. However, our evaluation detected no MDRP, only Pseudomonas aeruginosa, Acinetobacter and Bacillus species. We then assessed microbial contamination of institutional tap water as part of our strategy for prevention of hospital infection by environmental bacteria including MDRP. The survey complied with the Water Supply Act, Japanese Pharmacopoeia and Filtration Enrichment Method on New Legionellosis Prevention Incentives. The survey found no MDRP, but heterotrophic bacteria was detected which may cause opportunistic and healthcare-associated infections by Bacillus cereus and Legionella pneumophila, which are both clinically important. This study shows that the water-supply installation should be periodically cleaned and maintained to prevent bacterial contamination.
Hospital towels must be disinfected by hot water cleaning. However, towels are sometimes contaminated with Bacillus cereus spores resistant to heat. Such contamination can cause healthcare associated infections. Thus, B. cereus contamination of hospital towels should be routinely evaluated to control infections. However, standard methods for the evaluation have not yet been established. In the present study, B. cereus contamination of hospital towels was measured using four methods; the agar contact method, the swab method, the simple shaking method, and the glass bead shaking method. The agar contact method could not quantify the towel contamination. The swab method could detect only a small number of bacteria from hospital towels. Both shaking methods could detect a large number of bacteria from hospital towels. Especially, the glass bead shaking method detected twice as many bacteria as the simple shaking method. These results indicate that the glass bead shaking method is the most suitable method for evaluating B. cereus contamination of hospital towels. In addition, our results demonstrated that B. cereus does not have uniform distribution in towels. Therefore, evaluation of B. cereus contamination must examine several test pieces of the same towel.
Hand hygiene is important as a strategy to prevent hospital infection. In particular, alcohol-containing antiseptic hand rubs (alcohol-based hand rubs) are currently essential in clinical practice due to their simplicity and potent antiseptic effects. In this study, we compared the antiseptic and prolonged effects of representative rubbing-type antiseptics routinely employed in clinical practice, such as 0.2 w/v% benzalkonium chloride alcohol preparation, 0.5 w/v% quick-drying povidone-iodine alcohol preparation, and 0.2/0.5 w/v% quick-drying chlorhexidine gluconate alcohol preparations, applied in accordance with the glove juice method at various volumes. The subjects were female pharmacy students, who operated nozzle-type containers containing these rubbing-type antiseptics to collect typical samples by pushing the nozzle, as usually used by pharmacy students for hand/finger antisepsis, and the delivered volume was measured. The bacterial reduction rate after 1, 2, or 3 mL of each preparation was rubbed into the hands/fingers 3 times. All preparations exhibited favorable antiseptic effects when the sample was 2 mL or more. In addition, the antiseptic effects persisted for 4 hours when using 2 mL of preparation 3 times. Usually, the collected volumes per push of preparations containing 0.2 w/v% benzalkonium chloride and 0.5 w/v% chlorhexidine gluconate were approximately 2 mL. However, the volumes of preparations containing 0.5 w/v% povidone-iodine and 0.2 w/v% chlorhexidine gluconate were less than 2 mL. To achieve effective hand/finger antisepsis, the volumes of antiseptics applied must be considered.
This study evaluated complications during catheter placement such as catheter-related bloodstream infections (CR-BSI) in patients receiving peripherally inserted central venous catheters (PICCs), or conventional central venous catheters (CVCs) in 8 facilities, including 277 patients receiving PICCs (PICC group), and 276 patients receiving CVCs (CVC group). The incidence of CR-BSI was 5.6 cases/1,000 catheter days for the PICC group, and 7.0 cases/1,000 catheter days for the CVC group, showing a lower incidence of CR-BSI in the PICC group. Risk analysis for CR-BSI showed using PICCs was a factor for reducing infection risk (odds ratio 0.55; p=0.019). As complications during insertions, pneumothorax or arterial puncture occurred in the CVC group, but not in the PICC group, but bleeding from the insertion site often occurred in the PICC group. As complications during placements, phlebitis was often observed in the PICC group, and fever or sepsis in the CVC group. The number of incidents of CR-BSI after insertion of PICC or CVC in 553 patients can be expected to be 59 and 98, respectively, and using PICCs would result in cost reduction of about 16 million yen for antimicrobial agents and about 820 days of total hospital stays. The use of PICCs and CVCs, and complications including CR-BSI, can be revealed by analysis of the data from multiple facilities, indicating the effectiveness of PICCs for CVCs.
This study evaluated the changes in antimicrobial use density (AUD) for injections at our hospital over 7 years (2001-2007), and investigated the factors affecting consumption and selectivity of antimicrobials. Consumption of glycopeptide antibiotic showed no increase or antimicrobial drugs with susceptibility to Pseudomonas aeruginosa decreased in 2002 and 2005, respectively. However, use of first generation cephalosporins increased after 2002. These changes depended on revised guidelines for use of antimicrobial drugs. This report was one of the few studies of long-term monitoring of use of antimicrobial drugs at medical institutions in Japan.
The effect of antimicrobial use density (AUD) of injectable carbapenems (CBPMs) was investigated on the incidence of multi-drug resistant Pseudomonas aeruginosa (MDRP) and the resistance rate of P. aeruginosa isolated from April 1, 2003 to March 31, 2008, before starting a reporting system for CBPMs. The annual rate of detection of P. aeruginosa was constantly 4.7-5.7% and that of MDRP was equal to or less than 2% until 2006, except for 4.8% in 2007. Three new strains of MDRP which produced metallobeta lactamase were detected per year, whereas strains not producing metallobeta lactamase showed a tendency to increase. During the investigation period, the resistance rate to P. aeruginosa remained with imipenem (IPM/CS)>meropenem (MEPM), and both tended to decrease with IPM/CS (27→23%), MEPM (19→15%), at the peak in 2005 when the Infection Control Team strengthened the anti-environmental infection measures for MDRP. In the same period, the total AUD of CBPMs was high at 21.1-22.5, especially 26.6 in 2007, and above 70% were IPM/CS and MPEM since 2004. In addition, the AUD was approximately constant with some increase and decrease for IPM/CS, and increased for MPEM. The study suggests that resistance in not only CBPMs but also other antimicrobial agents as well as execution of the standard precautions require attention, when starting a reporting system to decrease the resistance rate of P. aeruginosa.
The antiseptic effectiveness of a waterless method using 0.5 w/v% chlorhexidine gluconate (CHG)/ethanol preparation was compared to the conventional two-stage surgical scrub method, using 4 w/v% CHG scrub followed by application of 0.2 w/v%CHG/ethanol preparation in 30 healthcare workers. The reduction factor (RF) for bacterial counts on the subjects hands showed the two methods were not significantly different, both immediately (1.443±0.647; waterless, 1.508±0.801; two-stage, p=0.565) and after 3 hours (1.431±0.716, 1.251±0.745, p=0.173), indicating that the antiseptic effectiveness of these methods were equivalent. The waterless method, however, was more time efficient and cost effective than the conventional method. Moreover, a satisfaction survey showed a favorable response to the waterless method. The waterless method using an alcohol preparation with persistent activity agents such as CHG is acceptable for surgical hand antisepsis.
Hand-washing is one of the most important procedures for preventing the spread of infection in the community. This study investigated the effect of hand-washing on bacterial removal in elderly people washing their own hands. The hand-washing methods among elderly people were also observed. Guidance of hand-washing for elderly people was then developed. Hand-washing was performed with liquid soap and water by 17 elderly people and 15 nurses. More bacteria (620.2 CFU) were detected from the hands of elderly people than from the hands of nurses (164.1 CFU). More bacteria were detected after washing than before washing in 8 of the 17 elderly people (47%). Before guidance, half of the elderly people rubbed the palm, back of the hand and interdigital spaces, but often missed the tips of the fingers, thumbs and wrists. In addition, only a few people thoroughly rinsed their hands (23.5%) and thoroughly dried their hands (29.4%). After guidance, 64.7% of the elderly people scrubbed the tips of fingers, 76.5% scrubbed the thumbs, and 41.2% scrubbed the wrist. Furthermore, 70.0% rinsed thoroughly and 94.1% dried their hands thoroughly. Effective methods of hand-washing rather than simply recommending hand-washing are essential to prevent the spread of infection.
Therapeutic Drug Monitoring (TDM) is an important guide for the clinician to provide effective and safe drug therapy in the individual patient. However, the current state of implementation in Japan is unclear. The present study surveyed the current use of TDM, which promotes correct use of antimicrobial agents and antifungal agents, as well as Infection Control Team (ICT) activities. To compile this survey, questionnaire forms were sent to 1000 pharmacies within hospitals with beds for inpatients, and the responses of 540 pharmacies were processed and classified by size of the facilities. TDM implementation ratio varied between 38% to 92%, and was higher in large hospitals. TDM implementation ratio was also higher in hospitals with ICTs (82%) than without ICTs (46%), and this tendency was not affected by the size. TDM implementation ratio also depended on the types of antimicrobial agent, varying from 11% to 73%, with anti-MRSA agents ranking higher (vancomycin 73%, teicoplanin 57% and arbekacin 60%). However, the TDM implementation ratio was only 11% for the antifungal agent voriconazole, for which insurance recently started to cover the use of TDM. This survey indicated that TDM tended to be appropriately used for antimicrobial agents and antifungal agents in a large number of hospitals in Japan, but the implementation ratio varied with the size of the hospital.
Our hospital is a moderately-sized general hospital with 250 beds. Our Infection Control Team (ICT), which consists of an Infection Control Doctor (internist), Infection Control Nurse and bacteriological laboratory technician, has assessed the information of multiple drug-resistant strains in our hospital and made rounds every other week. Our hospital does not have a dermatology department, so when scabies was suspected in a hospitalized patient, each chief physician asked the cooperating dermatologist to visit their patients. However, we experienced an outbreak of scabies extending to 36 individuals including 5 patients, patient's family members, helpers, and staff members and their families. Analysis of the infection route suggested that a physical therapist and other staff might have been infected by the source patient and acted as the vector. Crusted scabies patients were isolated and ivermectin was administered to all infected patients. Furthermore, scrubbing with sulfureous water and standard precautions were enforced. This outbreak of scabies was attributable not to simple underdiagnosis but to the fragile informaiton system of our ICT. Information on the suspicion of scabies should be automatically delivered to the ICT through the head nurse or coordinating staff. The ICT must intervene at the stage of suspicion of scabies and prompt the chief physician to begin early treatment for scabies, especially in a hospital which has no dermatologist.