American Journal of Infection Control 43 (2015) 418-21
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Letters to the Editor
Patients’ perceptions of hospital-acquired infections in northern Queensland, Australia: A pilot study To the Editor: We aimed to study the knowledge of health care acquired infections (HAIs) held by patients in Australian hospitals. Studies of patients’ beliefs about HAIs exist,1-3 but none have specifically assessed the beliefs of an Australian population. We piloted a British questionnaire3 in 2 North Queensland hospitals: 1 large tertiary-level facility and 1 small, remote facility. After ethics approvals (HREC/13/QTHS/29) were secured, we recruited a small convenience sample of adult surgical inpatients, including Torres Strait Islander people, in the small hospital. The large hospital’s culturally diverse population was appropriate and expected for Australian city hospitals. The questionnaire was left with participants, and if required, we read the questions and assisted in recording responses. In the large hospital, questionnaires were distributed during a 4-week period during April 2013; in the remote facility, questionnaires were distributed between April 2013 and April 2014 whenever surgical patients were present. Information regarding nonparticipation was not collected. Twenty-nine men and 22 women responded: 42 participants (82.4%) were from the large hospital (average age 56 years [range, 20-92 years]. Retired persons made up 27.5% of the respondents. Most (n ¼ 32; 62.8%) had been an inpatient within the previous 2 years and were aware of the risk of HAIs (n ¼ 42; 82.4%). They reported having accessed multiple sources of informationdseveral mentioned nurse friends or family as information sources and 2 mentioned the Internet. Most reported they had enough information (n ¼ 36; 70.6%) and enough understanding (n ¼ 41; 80.4%), about HAIs. Thirty-three (64.7%) believed the media did not portray HAIs accurately and 8 (15.7%) did not answer this question. When asked if HAIs were preventable, responses were mixed: 21 (41.1%) replied “yes,” 25 (49.0%) replied “no,” 1 replied “unsure,” 1 replied “both,” and 3 (5.9%) did not answer. Participants mentioned options for decreasing the risk of contracting an HAI. The use of alcoholbased handrub for visitors (n ¼ 34; 67%) and staff (n ¼ 33; 65%), involving patients more in their own care (n ¼ 33, 65%), increase domestic/cleaning staff (n ¼ 28; 55%), better staff compliance with infection control measures (n ¼ 27; 53%), stop the movement of patients from ward to ward (n ¼ 23; 45%), and restrict the number of visitors (n ¼ 9; 18%) were all suggested. Respondents listed specific bacteria-causing HAIs, including Staphylococcus (“MRSA,” “staph,” and “golden staph”) (n ¼ 8; 15.7%) and Legionella (n ¼ 3; 5.9%). Of the 15 participants (29.4%) who were unable to name any bacteria, 6 stated “staph,”
“septicemia,” “bruising at this time,” “coughing,” or “no handwashing” as contributors to HAI. Thirty-one participants (60.8%) stated they understood how microorganisms spread in hospital settings, and provided examples: “lack of handwashing,” “poor hygiene,” “infected surgical instruments,” and “coughing.” Almost two-thirds (n ¼ 33; 64.7%) were satisfied that all infection control measures were being taken. Respondents were satisfied with the amount of information they had about HAIs, and saw the need for all to be involved in minimizing HAIs. No single source of information about HAIs was as important as the media was in the UK study.3 The importance of using the provided alcohol handrub was understood. Assisting patients to complete the survey was essential. For some, English was not their first language, and this will be incorporated into the proposed nationwide study. We determined that the study is feasible to conduct across Australia and large-scale funding is being sought, with the ultimate aim of developing appropriate interventions to minimize the spread of HAIs among the general public. We planned to trial the questionnaire in more than 2 facilities but encountered difficulties in acquiring ethics/governance approvals. The cancellation of surgical lists at the small, remote facility affected the number of questionnaires distributed and lengthened data collection. Nurses’ workloads at the large hospital affected their availability to distribute the questionnaires. Surgical patients experience HAIs,4 and research has been done to develop ways to prevent the spread of infection.1-3 Little is known about patients’ perceptions and knowledge of HAIs, especially in Australia. This pilot study provided no conclusive results, but showed the UK questionnaire to be useful and appropriate for an Australian population. Acknowledgments The authors thank Dr Maurice Madeo for permission to use the questionnaire and the Far North Queensland Hospital Foundatione Research Award 2012. References 1. Landers T, Abusalem S, Coty M, Bingham J. Patient-centered hand hygiene: the next step in infection prevention. Am J Infect Control 2012;40:S11-7. 2. Ottum A, Sethi AK, Jacobs E, Zerbel S, Gaines ME, Safdar N. Engaging patients in the prevention of health care-associated infections: a survey of patients’ awareness, knowledge, and perceptions regarding the risks and consequences of infection with methicillin-resistant Staphylococcus aureus and Clostridium difficile. Am J Infect Control 2013;41:322-6. 3. Madeo M, Shields L, Owen E. A pilot study to investigate patients reported knowledge, awareness, and beliefs on health care-associated infection. Am J Infect Control 2008;36:63-9. 4. Roberts RR, Scott RD, Hota B, Kampe LM, Abbasi F, Schabowski S, et al. Costs attributable to healthcare-acquired infection in hospitalized adults and a comparison of economic methods. Med Care 2010;48:1026-35. Conflicts of interest: None to report.
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Letters to the Editor / American Journal of Infection Control 43 (2015) 418-21
Wendy Smyth, PhD Tropical Health Research Unit The Townsville Hospital, Townsville Queensland, Australia College of Healthcare Sciences James Cook University, Townsville Queensland, Australia Gail Abernethy, BHealth Tropical Health Research Unit The Townsville Hospital, Townsville Queensland, Australia Matthew Mason, MAdvPrac School of Nursing and Midwifery University of the Sunshine Coast Queensland, Australia Janine Carrucan Tropical Health Research Unit The Townsville Hospital, Townsville Queensland, Australia Megan Hayes Tropical Health Research Unit The Townsville Hospital, Townsville Queensland, Australia College of Healthcare Sciences James Cook University, Townsville Queensland, Australia Linda Shields, MD, PhD* Tropical Health Research Unit The Townsville Hospital, Townsville Queensland, Australia College of Healthcare Sciences James Cook University, Townsville Queensland, Australia School of Medicine The University of Queensland, Brisbane Queensland, Australia *
Address correspondence to Linda Shields, MD, PhD, Tropical Health Research Unit, The Townsville Hospital, Townsville, Qld 4810, Australia. E-mail address: [email protected] (L. Shields). http://dx.doi.org/10.1016/j.ajic.2015.01.008
Evolution of antibiotic resistance in bacteria involved in urinary tract infections: A 3-year London experience To the Editor: We read with interest the work by Sorlozano et al1 analyzing their 7-year surveillance of prevailing antimicrobial resistance among 31,758 uropathogen isolates from community and hospital
419
patients. We support this focus on a noninvasive sample type to inform empiric antimicrobial policy; typically, such discussions are dictated solely by invasive samples such as blood cultures acknowledged to represent only a small proportion of all of the antimicrobial susceptibility data available.2 We also applaud the construction of combined all-uropathogen antibiograms. Antibiograms are all too frequently displayed per-pathogen and as such are of limited use to frontline clinicians where disease processes can be caused by numerous pathogens. Using the method and assumptions set out by Sorlozano et al1 we constructed similar antibiograms for our London cohort and are able to draw several comparisons. We retrospectively analyzed the antimicrobial susceptibility patterns of 70,313 uropathogen isolates from primary care (38,768 isolates submitted from patients attending more than 100 community practices) and secondary care (31,545 isolates submitted from patients attending 4 teaching hospitals; 1,600 beds total) across West London between April 2009 and March 2012 (fiscal years). Isolates were identified from urine samples submitted on clinical suspicion of a urinary tract infection, and laboratory investigation followed national standard operating procedures.3 Briefly: 1 mL loop culture on commercial selective chromogenic agar (Brilliance; Oxoid, Basingstoke, United Kingdom) and culture at 18-24 hours at 37 C in air, organisms with > 104 CFU had susceptibility testing through disc diffusion methods using accepted breakpoints.4 First-line agents tested were amoxicillin-clavulanic acid, gentamicin, cephalexin, nitrofurantoin, ciprofloxacin, and trimethoprim. Across all three years in our London cohort, similar to Sorlozano et al,1 we found Escherichia coli to be the predominating uropathogen (accounting for 60.2% of primary care and 47.7% of secondary care isolates), with non-E coli Enterobacteriaceae also frequent causative organisms (16.4% and 19.6%), and enterococci (9.4% and 12.3%) and other organisms (14.0% and 20.4%) less so. In considering all-uropathogen susceptibility rates, significant variation between the findings of Sorlozano et al1 and our data can be seen. For amoxicillin-clavulanic acid, Sorlozano et al1 report a significant decrease in uropathogen susceptibility over the 7-year period; we observed a similar fall in susceptibility from 2009-2010 to 20102011, but this was followed by some recovery in susceptibility the following year (primary care 94% in 2009-2010, 86% in 2010-2011, and 90% in 2011-2012; secondary care 91% in 2009-2010, 82% in 2010-2011, and 87% in 2011-2012). Such year-on-year variation among both community and secondary care patients warrants further investigation, particularly whether hitherto undetected minioutbreaks may be contributing to the fluctuations. Although the excess resistance in secondary care over primary care in our data mirrors the data in Sorlozano et al,1 what is also clear is the excess resistance seen in their regional patient cohort compared with our London patient group, where amoxicillin-clavulanic acid susceptibility rates remained 10%-15% higher. A similar excess of resistance among isolates from the Sorlozano et al1 cohort can be seen for ciprofloxacin (60%-70% susceptibility vs a 3-year London average susceptibility of 86% in primary care and 79% in secondary care), cephalosporins (60% susceptibility [to cefuroxime] vs 81% susceptibility [to cephalexin] in the community and 74% in secondary care), folate synthesis inhibitors (45%-60% susceptibility [to co-trimoxazole] vs 67% susceptibility [to trimethoprim]) in the community and 65% in secondary care), gentamicin (75% susceptibility vs 88% susceptibility in the community and 82% in secondary care), and nitrofurantoin (80%-90% susceptibility vs 94% in the community and 92% in secondary care). These findings have significant connotations for antimicrobial policies and for potential use as proxy indicators for antimicrobial consumption and policy adherence. First, with UK national
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Letters to the Editor
Patients’ perceptions of hospital-acquired infections in northern Queensland, Australia: A pilot study To the Editor: We aimed to study the knowledge of health care acquired infections (HAIs) held by patients in Australian hospitals. Studies of patients’ beliefs about HAIs exist,1-3 but none have specifically assessed the beliefs of an Australian population. We piloted a British questionnaire3 in 2 North Queensland hospitals: 1 large tertiary-level facility and 1 small, remote facility. After ethics approvals (HREC/13/QTHS/29) were secured, we recruited a small convenience sample of adult surgical inpatients, including Torres Strait Islander people, in the small hospital. The large hospital’s culturally diverse population was appropriate and expected for Australian city hospitals. The questionnaire was left with participants, and if required, we read the questions and assisted in recording responses. In the large hospital, questionnaires were distributed during a 4-week period during April 2013; in the remote facility, questionnaires were distributed between April 2013 and April 2014 whenever surgical patients were present. Information regarding nonparticipation was not collected. Twenty-nine men and 22 women responded: 42 participants (82.4%) were from the large hospital (average age 56 years [range, 20-92 years]. Retired persons made up 27.5% of the respondents. Most (n ¼ 32; 62.8%) had been an inpatient within the previous 2 years and were aware of the risk of HAIs (n ¼ 42; 82.4%). They reported having accessed multiple sources of informationdseveral mentioned nurse friends or family as information sources and 2 mentioned the Internet. Most reported they had enough information (n ¼ 36; 70.6%) and enough understanding (n ¼ 41; 80.4%), about HAIs. Thirty-three (64.7%) believed the media did not portray HAIs accurately and 8 (15.7%) did not answer this question. When asked if HAIs were preventable, responses were mixed: 21 (41.1%) replied “yes,” 25 (49.0%) replied “no,” 1 replied “unsure,” 1 replied “both,” and 3 (5.9%) did not answer. Participants mentioned options for decreasing the risk of contracting an HAI. The use of alcoholbased handrub for visitors (n ¼ 34; 67%) and staff (n ¼ 33; 65%), involving patients more in their own care (n ¼ 33, 65%), increase domestic/cleaning staff (n ¼ 28; 55%), better staff compliance with infection control measures (n ¼ 27; 53%), stop the movement of patients from ward to ward (n ¼ 23; 45%), and restrict the number of visitors (n ¼ 9; 18%) were all suggested. Respondents listed specific bacteria-causing HAIs, including Staphylococcus (“MRSA,” “staph,” and “golden staph”) (n ¼ 8; 15.7%) and Legionella (n ¼ 3; 5.9%). Of the 15 participants (29.4%) who were unable to name any bacteria, 6 stated “staph,”
“septicemia,” “bruising at this time,” “coughing,” or “no handwashing” as contributors to HAI. Thirty-one participants (60.8%) stated they understood how microorganisms spread in hospital settings, and provided examples: “lack of handwashing,” “poor hygiene,” “infected surgical instruments,” and “coughing.” Almost two-thirds (n ¼ 33; 64.7%) were satisfied that all infection control measures were being taken. Respondents were satisfied with the amount of information they had about HAIs, and saw the need for all to be involved in minimizing HAIs. No single source of information about HAIs was as important as the media was in the UK study.3 The importance of using the provided alcohol handrub was understood. Assisting patients to complete the survey was essential. For some, English was not their first language, and this will be incorporated into the proposed nationwide study. We determined that the study is feasible to conduct across Australia and large-scale funding is being sought, with the ultimate aim of developing appropriate interventions to minimize the spread of HAIs among the general public. We planned to trial the questionnaire in more than 2 facilities but encountered difficulties in acquiring ethics/governance approvals. The cancellation of surgical lists at the small, remote facility affected the number of questionnaires distributed and lengthened data collection. Nurses’ workloads at the large hospital affected their availability to distribute the questionnaires. Surgical patients experience HAIs,4 and research has been done to develop ways to prevent the spread of infection.1-3 Little is known about patients’ perceptions and knowledge of HAIs, especially in Australia. This pilot study provided no conclusive results, but showed the UK questionnaire to be useful and appropriate for an Australian population. Acknowledgments The authors thank Dr Maurice Madeo for permission to use the questionnaire and the Far North Queensland Hospital Foundatione Research Award 2012. References 1. Landers T, Abusalem S, Coty M, Bingham J. Patient-centered hand hygiene: the next step in infection prevention. Am J Infect Control 2012;40:S11-7. 2. Ottum A, Sethi AK, Jacobs E, Zerbel S, Gaines ME, Safdar N. Engaging patients in the prevention of health care-associated infections: a survey of patients’ awareness, knowledge, and perceptions regarding the risks and consequences of infection with methicillin-resistant Staphylococcus aureus and Clostridium difficile. Am J Infect Control 2013;41:322-6. 3. Madeo M, Shields L, Owen E. A pilot study to investigate patients reported knowledge, awareness, and beliefs on health care-associated infection. Am J Infect Control 2008;36:63-9. 4. Roberts RR, Scott RD, Hota B, Kampe LM, Abbasi F, Schabowski S, et al. Costs attributable to healthcare-acquired infection in hospitalized adults and a comparison of economic methods. Med Care 2010;48:1026-35. Conflicts of interest: None to report.
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Letters to the Editor / American Journal of Infection Control 43 (2015) 418-21
Wendy Smyth, PhD Tropical Health Research Unit The Townsville Hospital, Townsville Queensland, Australia College of Healthcare Sciences James Cook University, Townsville Queensland, Australia Gail Abernethy, BHealth Tropical Health Research Unit The Townsville Hospital, Townsville Queensland, Australia Matthew Mason, MAdvPrac School of Nursing and Midwifery University of the Sunshine Coast Queensland, Australia Janine Carrucan Tropical Health Research Unit The Townsville Hospital, Townsville Queensland, Australia Megan Hayes Tropical Health Research Unit The Townsville Hospital, Townsville Queensland, Australia College of Healthcare Sciences James Cook University, Townsville Queensland, Australia Linda Shields, MD, PhD* Tropical Health Research Unit The Townsville Hospital, Townsville Queensland, Australia College of Healthcare Sciences James Cook University, Townsville Queensland, Australia School of Medicine The University of Queensland, Brisbane Queensland, Australia *
Address correspondence to Linda Shields, MD, PhD, Tropical Health Research Unit, The Townsville Hospital, Townsville, Qld 4810, Australia. E-mail address: [email protected] (L. Shields). http://dx.doi.org/10.1016/j.ajic.2015.01.008
Evolution of antibiotic resistance in bacteria involved in urinary tract infections: A 3-year London experience To the Editor: We read with interest the work by Sorlozano et al1 analyzing their 7-year surveillance of prevailing antimicrobial resistance among 31,758 uropathogen isolates from community and hospital
419
patients. We support this focus on a noninvasive sample type to inform empiric antimicrobial policy; typically, such discussions are dictated solely by invasive samples such as blood cultures acknowledged to represent only a small proportion of all of the antimicrobial susceptibility data available.2 We also applaud the construction of combined all-uropathogen antibiograms. Antibiograms are all too frequently displayed per-pathogen and as such are of limited use to frontline clinicians where disease processes can be caused by numerous pathogens. Using the method and assumptions set out by Sorlozano et al1 we constructed similar antibiograms for our London cohort and are able to draw several comparisons. We retrospectively analyzed the antimicrobial susceptibility patterns of 70,313 uropathogen isolates from primary care (38,768 isolates submitted from patients attending more than 100 community practices) and secondary care (31,545 isolates submitted from patients attending 4 teaching hospitals; 1,600 beds total) across West London between April 2009 and March 2012 (fiscal years). Isolates were identified from urine samples submitted on clinical suspicion of a urinary tract infection, and laboratory investigation followed national standard operating procedures.3 Briefly: 1 mL loop culture on commercial selective chromogenic agar (Brilliance; Oxoid, Basingstoke, United Kingdom) and culture at 18-24 hours at 37 C in air, organisms with > 104 CFU had susceptibility testing through disc diffusion methods using accepted breakpoints.4 First-line agents tested were amoxicillin-clavulanic acid, gentamicin, cephalexin, nitrofurantoin, ciprofloxacin, and trimethoprim. Across all three years in our London cohort, similar to Sorlozano et al,1 we found Escherichia coli to be the predominating uropathogen (accounting for 60.2% of primary care and 47.7% of secondary care isolates), with non-E coli Enterobacteriaceae also frequent causative organisms (16.4% and 19.6%), and enterococci (9.4% and 12.3%) and other organisms (14.0% and 20.4%) less so. In considering all-uropathogen susceptibility rates, significant variation between the findings of Sorlozano et al1 and our data can be seen. For amoxicillin-clavulanic acid, Sorlozano et al1 report a significant decrease in uropathogen susceptibility over the 7-year period; we observed a similar fall in susceptibility from 2009-2010 to 20102011, but this was followed by some recovery in susceptibility the following year (primary care 94% in 2009-2010, 86% in 2010-2011, and 90% in 2011-2012; secondary care 91% in 2009-2010, 82% in 2010-2011, and 87% in 2011-2012). Such year-on-year variation among both community and secondary care patients warrants further investigation, particularly whether hitherto undetected minioutbreaks may be contributing to the fluctuations. Although the excess resistance in secondary care over primary care in our data mirrors the data in Sorlozano et al,1 what is also clear is the excess resistance seen in their regional patient cohort compared with our London patient group, where amoxicillin-clavulanic acid susceptibility rates remained 10%-15% higher. A similar excess of resistance among isolates from the Sorlozano et al1 cohort can be seen for ciprofloxacin (60%-70% susceptibility vs a 3-year London average susceptibility of 86% in primary care and 79% in secondary care), cephalosporins (60% susceptibility [to cefuroxime] vs 81% susceptibility [to cephalexin] in the community and 74% in secondary care), folate synthesis inhibitors (45%-60% susceptibility [to co-trimoxazole] vs 67% susceptibility [to trimethoprim]) in the community and 65% in secondary care), gentamicin (75% susceptibility vs 88% susceptibility in the community and 82% in secondary care), and nitrofurantoin (80%-90% susceptibility vs 94% in the community and 92% in secondary care). These findings have significant connotations for antimicrobial policies and for potential use as proxy indicators for antimicrobial consumption and policy adherence. First, with UK national
