Comparison of surgical site infection (SSI) rates across institutions has been an effective infection control measure, but success relies on the quality of risk adjustments. This study assessed desirable risk-adjustment methodologies for use in the Japan Nosocomial Infections Surveillance (JANIS) network. Patients who underwent 1 of 6 digestive system procedures (APPY, BILI, CHOL, COLN, GAST, or REC) were included. Logistic regression analysis was performed to predict the risk of developing SSI in the following two models: (1) selected variables that consist of an NNIS Risk Index, or (2) all variables that were collected at SSI surveillance. Model performances were assessed using the c-index. Two regression models were also developed that included or excluded factors regarding surgery duration as well as laparoscopic surgery. The difference in the standardized infection ratio (SIR) in each model was then evaluated. Surveillance data were collected from a total of 37,251 procedures from 37 institutions. Odds ratios regarding the development of SSI were generally different between procedures and risk factors. Except for APPY, the c-index was statistically greater in the model with all variables than in the model including risk index factors only (p<0.001). The estimates of SIR were considerably different between models with adjustment of surgery duration and laparoscopic surgery versus models without these adjustments. The two models offered contradictory evidence regarding hospital performance. Multivariate logistic regression analyses that use all available variables from SSI surveillance were found to be superior to NNIS risk index methodology. When calculating SIR, we should consider the exclusion of surgery duration and laparoscopic surgery as risk-adjustment factors.
An original infection management system was constructed for integrated management and analysis of information related to bacteriological examination distributed in electronic clinical records. The infection management system includes functions of multi-drug resistant bacterium detection, antimicrobial susceptibility rate (antibiograms), and hospital ward map, and others. Immediate objective appreciation of the infection situation is possible using the infection management system. Moreover, infection management procedures are streamlined, making the best use of each occupational category of the ICT members, because complex clerical work can be reduced. The unique infection management system easily fulfills our intentions, and is effective for appropriate infection management.
Management of multidrug-resistant organisms in the healthcare setup remains a significant problem. Since the formation of the infection control team (ICT) at our hospital in August 2004, supportive measures for the appropriate use of antimicrobial agents are being implemented gradually. Here we describe the measures implemented and discuss the outcomes and assessments of our system. A system has been implemented for reporting the use of specific intravenous antimicrobial agents (intravenous anti-methicillin-resistant Staphylococcus aureus agents, intravenous carbapenems, and intravenous fluoroquinolones) since 2007. This system was linked to computerized ordering systems. These supportive measures were implemented gradually. The ICT antimicrobial agents monitoring program was introduced in 2010 as a method for intervening more positively in treatment. As an index of the effectiveness of these measures, changes in the amount of carbapenems used (in vials), duration of administration, proportion of carbapenem-sensitive P. aeruginosa cases, and incidence of multidrug-resistant P. aeruginosa (MDRP) were investigated. The amount of carbapenems used decreased from 1277 vials (November 2004) to 327 vials (June 2010), and the duration of carbapenem administration decreased from 8.40 days (2006) to 5.97 days (2010). In addition, the proportion of meropenem-sensitive P. aeruginosa cases increased from 72% (2008) to 90% (2011) and the annual incidence of MDRP decreased from 28 (2008) to 1 (2011). By ensuring the gradual implementation of these supportive measures, we were able to increase awareness regarding the appropriate use of antimicrobial agents among medical professionals. These measures also helped in increasing the proportion of meropenem-sensitive P. aeruginosa cases and remarkably decreased the annual incidence of MDRP. Based on these findings, we want to promote intervention for appropriate use of high quality antimicrobial agents to continuously support the effective treatment of infectious diseases.
After the Touhoku-Pacific Ocean Earthquake, an epidemic outbreak of influenza occurred in a gymnasium of a high school used as a refuge in Iwate. We report the time course of the outbreak and our intervention to prevent the infection spreading. A 60 years old woman with fever was diagnosed as influenza A first by rapid diagnosis kit on April 04, 2011. She had returned to the shelter after discharge from a regional hospital. Although quarantine treatment was started immediately using the empty classrooms, the number of patients with influenza increased every day. The patients were concentrated in a small area near the wall of the gymnasium, so we started oseltamivir prophylaxis administration according to the national insurance criteria on April 9. We also found that the dressing room next to the bathroom and the line for meals, where many people gathered in a small area, may have caused infection spreading. We checked the cleanliness of the dressing room and encouraged people to wear surgical masks in the line for meals. At the same time, we advised febrile patients to come to our temporary hospital immediately. The number of patients decreased after April 16, with no new cases after April 20, and no patient was isolated after April 24. Finally, the total number of influenza cases was 40. We were able to control the influenza outbreak to termination without experiencing severe cases. Immediate start of quarantine treatment, enforcing standard precautions, expanding the criteria for oseltamivir prophylaxis, and encouraging people with symptoms to go to our temporary hospital immediately, were considered to have contributed to the convergence of the outbreak.
Hand hygiene is recognized as one of the most important measures for preventing the spread of health care-associated infections, but there is little data regarding the actual situation of hand hygiene practice in Japan. Therefore, we undertook a questionnaire survey in Nara Prefecture to elucidate the current situation. Questionnaires were sent to 23 nurses from 23 institutions who participated at the meeting of the Nara Infection Control Network held on October 15, 2011. Eighteen institutions responded to the survey. All hospitals were equipped with liquid soap and hand hygiene antiseptics. Eight hospitals (44%) surveyed hand hygiene compliance, but only one gave the hand hygiene compliance rate. All institutions had educational programs at least once a year. The programs included instruction on hand hygiene, educational movies, and evaluation of hand hygiene practice with fluorescent powder. Most of the hospitals had adequate hand hygiene equipment and provided educational programs for hand hygiene. However, hospitals with adequate hand hygiene monitoring such as direct observation are rare.
Newborn infants are at high risk for bacterial infection transmitted via the hands of medical staff. Both standard precautions and contact precautions have been introduced in the NICU of our hospital. In this study, compliance behavior with hand hygiene precautions was observed using video taping and evaluation on the checklists entitled “Your five moments for hand hygiene (WHO)” and “Guideline for Hand Hygiene in Health-care settings (CDC)”. This study found trends of hand hygiene with correct timing and with incorrect timing, respectively. Lower rates of hand hygiene were observed after touching contaminated areas such as the pubic region and after exposure to body fluids (23.1% and 33.3%, respectively), possibly because medical staff have misconceptions regarding neonatal body fluids as clean. The rate of hand hygiene before sterile procedures was also low (41.2%), possibly because many procedures are performed in the infant incubator, such as intratracheal suctioning and drip infusion. In addition, safety management tends to take priority over hand hygiene during procedures, especially in the infant incubator. This study indicates the need for measures to improve hand hygiene compliance from the aspects of safety and infection control.
Bacterial surveillance in a hospital is important to decrease the development of healthcare-associated infection. Our past surveillance work has involved major efforts in data collection and statistical analysis for outbreak monitoring. However, we had problems including 1) delayed detection of an outbreak due to analysis being performed on a weekly or monthly basis, 2) difficulty in detecting an increase in bacteria during the period from the end of one month to the beginning of the next month, 3) difficulty in detecting an increase in bacterial species other than for the subject bacteria of the monitoring, 4) lack of a method for detecting an abnormal increase of bacteria in other departments of the hospital, and 5) difficulty in sharing the details of infection among staff members of the hospital. To solve these problems, we established an infection control support system that included real-time outbreak monitoring for unlimited bacterial species and a systematic record keeping process in 2010. A review of the subject bacterial species in outbreak monitoring and the methods used to detect an outbreak allowed identification of actual outbreaks in the hospital in real time and sharing of this information among staff members. In addition, infection control can be performed in the whole hospital based on past events, using the control function of the round records, including the details of infection control. In the future, we plan to develop the present system further to achieve more effective infection control.
Two cases of nosocomial Gram-negative bacteremia occurred following upper gastrointestinal procedures. Case1: a 55-year-old woman with esophageal cancer had undergone wire-guided intraluminal dilation of the esophageal stricture the day before the blood culture. Positive blood culture isolated Enterobacter cloacae. Case 2: a 64-year-old man with liver cirrhosis complicating esophageal varices developed laboratory-confirmed Gram-negative bacteremia twice, each episode being preceded by invasive endoscopic procedure as a treatment for esophageal varices. Positive blood culture isolated E. cloacae and Asaia lannensis, respectively. Routine antimicrobial prophylaxis is not warranted in upper GI-tract instrumentation procedures, but development of post-endoscopy nosocomial bacteremia should always be considered in immunocompromised patients.