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Background Faecal haemoglobin concentration (f-Hb), estimated using a faecal immunochemical test, can be safely implemented in primary care to assess risk of colorectal cancer (CRC). Clinical outcomes of patients presenting with symptoms of lower gastrointestinal disease were examined using an extensive range of f-Hb thresholds to decide on reassurance or referral for further investigation. Methods All patients who attended primary care and submitted a single faecal specimen faecal immunochemical test in the first year of the routine service had f-Hb estimated using HM-JACKarc: f-Hb thresholds from Results Low f-Hb thresholds of 400 µg/g, ≥200 µg/g and ≥100 µg/g. However, patients with a f-Hb concentration of Conclusions In primary care, f-Hb, in conjunction with clinical assessment, can safely and objectively determine individual risk of CRC and decide on simple reassurance or urgent, or routine referral.

Background Current guidelines document persistent rectal bleeding as an alarm symptom in patients presenting to primary care. We studied whether a faecal immunochemical test could assist in their assessment. Methods From December 2015, faecal immunochemical tests were routinely available to primary care when assessing patients with new-onset bowel symptoms: general practitioners were encouraged to include faecal haemoglobin concentration (f-Hb) within any referral to secondary care. Results with f-Hb ≥10 μg Hb/g faeces were defined as positive. The incidence of significant bowel disease (SBD: colorectal cancer [CRC], higher-risk adenoma [HRA: any ≥1 cm, or three or more] and inflammatory bowel disease [IBD]) at subsequent colonoscopy, referred symptoms and f-Hb were recorded. Results Of 1447 patients with a faecal immunochemical test result and colonoscopy outcome, SBD was diagnosed in 296 patients (20.5%; 95 with CRC, 133 with HRA, and 68 with IBD). Four hundred and sixty-two patients (31.9%) reported rectal bleeding: 294 had f-Hb ≥10 μg Hb/g faeces. At colonoscopy, 105/294 had SBD versus 14/168 with rectal bleeding and f-Hb Conclusion Patients with rectal bleeding and f-Hb

Summary Background Surveillance of surgical site infections (SSIs) is a core component of effective infection control practices, though its impact has not been quantified on a large scale. Aim To determine the time-trend of SSI rates in surveillance networks. Methods SSI surveillance networks provided procedure-specific data on numbers of SSIs and operations, stratified by hospitals' year of participation in the surveillance, to capture length of participation as an exposure. Pooled and procedure-specific random-effects Poisson regression was performed to obtain yearly rate ratios (RRs) with 95% confidence intervals (CIs), and including surveillance network as random intercept. Findings Of 36 invited networks, 17 networks from 15 high-income countries across Asia, Australia and Europe participated in the study. Aggregated data on 17 surgical procedures (cardiovascular, digestive, gynaecological-obstetrical, neurosurgical, and orthopaedic) were collected, resulting in data concerning 5,831,737 operations and 113,166 SSIs. There was a significant decrease in overall SSI rates over surveillance time, resulting in a 35% reduction at the ninth (final) included year of surveillance (RR: 0.65; 95% CI: 0.63–0.67). There were large variations across procedure-specific trends, but strong consistent decreases were observed for colorectal surgery, herniorrhaphy, caesarean section, hip prosthesis, and knee prosthesis. Conclusion In this large, international cohort study, pooled SSI rates were associated with a stable and sustainable decrease after joining an SSI surveillance network; a causal relationship is possible, although unproven. There was heterogeneity in procedure-specific trends. These findings support the pivotal role of surveillance in reducing infection rates and call for widespread implementation of hospital-based SSI surveillance in high-income countries.

ObjectiveTo determine whether a faecal immunochemical test (FIT) for faecal haemoglobin concentration (f-Hb) can be safely implemented in primary care as a rule-out test for significant bowel disease (SBD) (colorectal cancer (CRC), higher risk adenoma (HRA) and inflammatory bowel disease (IBD)) when used as an adjunct to the clinical assessment of new bowel symptoms.DesignSingle-centre prospective cohort study of all patients who attended primary care and submitted a FIT in the first calendar year of the service beginning December 2015. f-Hb was estimated using HM-JACKarc (Kyowa Medex) with a clinical cut-off of ≥10 µg Hb/g faeces. Incident cases of CRC were verified via anonymised record linkage to the Scottish Cancer Registry.Results5422 patients submitted 5660 FIT specimens, of which 5372 were analysed (positivity: 21.9%). 2848 patients were referred immediately to secondary care and three with f-Hb ConclusionIn primary care, measurement of f-Hb, in conjunction with clinical assessment, can safely and objectively determine a patient’s risk of SBD.

Background Faecal immunochemical tests for haemoglobin have been recommended to assist in assessment of patients presenting in primary care with lower bowel symptoms. The aim was to assess if, and which, additional variables might enhance this use of faecal immunochemical tests. Methods Faecal immunochemical test analysis has been a NHS Tayside investigation since December 2015. During the first year, 993 patients attending colonoscopy were invited to complete a detailed questionnaire on demographic background, symptoms, smoking status, alcohol use, dietary fibre, red and processed meat intake, physical activity, sitting time, dietary supplement use, family history of colorectal cancer, adenoma, inflammatory bowel disease and diabetes. Significant bowel disease was classified as colorectal cancer, advanced adenoma or inflammatory bowel disease. Results A total of 470 (47.3%) invitees agreed to complete the questionnaire and 408 (41.1%) did. Unadjusted odds ratios for the presence of significant bowel disease compared with undetectable faecal haemoglobin increased with increasing faecal haemoglobin and for faecal haemoglobin 10–49, 50–199, 200–399 and ⩾400 μg Hb/g faeces were 0.95 (95% CI: 0.16–5.63), 2.47 (0.55–1.03), 6.30 (1.08–36.65) and 18.90 (4.22–84.62), respectively. Rectal bleeding and family history of polyps were the only other variables with statistically significant ( P Conclusions Faecal haemoglobin is the most important factor to be considered when deciding which patients presenting in primary care with lower bowel symptoms would benefit most from referral for colonoscopy.

Clostridium difficile, the most common cause of hospital-associated diarrhoea in developed countries, presents major public health challenges. The high clinical and economic burden fromC. difficileinfection (CDI) relates to the high frequency of recurrent infections caused by either the same or different strains ofC. difficile. An interval of 8 weeks after index infection is commonly used to classify recurrent CDI episodes. We assessed strains ofC. difficilein a sample of patients with recurrent CDI in Western Australia from October 2011 to July 2017. The performance of different intervals between initial and subsequent episodes of CDI was investigated. Of 4612 patients with CDI, 1471 (32%) were identified with recurrence. PCR ribotyping data were available for initial and recurrent episodes for 551 patients. Relapse (recurrence with same ribotype (RT) as index episode) was found in 350 (64%) patients and reinfection (recurrence with new RT) in 201 (36%) patients. Our analysis indicates that 8- and 20-week intervals failed to adequately distinguish reinfection from relapse. In addition, living in a non-metropolitan area modified the effect of age on the risk of relapse. Where molecular epidemiological data are not available, we suggest that applying an 8-week interval to define recurrent CDI requires more consideration.

There have been efforts worldwide to reduce the incidence of hospital-onset Staphylococcus aureus bacteremia (SAB). This longitudinal study demonstrates a nationwide reduction in both methicillin-resistant and methicillin-susceptible SAB in Australia. Background. Staphylococcus aureus bacteremia (SAB) is a serious cause of morbidity and mortality. This longitudinal study describes significant reductions in hospital-onset SAB (HO-SAB) in Australian hospitals over the past 12 years. Methods. An observational cohort study design was used. Prospective surveillance of HO-SAB in 132 hospitals in Australia was undertaken. Aggregated data from all patients who acquired HO-SAB was collected (defined as 1 or more blood cultures positive for S. aureus taken from a patient who had been admitted to hospital for >48 hours). The primary outcome was the incidence of HO-SAB, including both methicillin-resistant (MRSA) and methicillin-susceptible (MSSA) S. aureus strains. Results. A total of 2733 HO-SAB cases were identified over the study period, giving an aggregate incidence of 0.90 per 10 000 patient-days (PDs) (95% confidence interval [CI], .86–.93). There was a 63% decrease in the annual incidence, from 1.72 per 10 000 PDs in 2002 (95% CI, 1.50–1.97) to 0.64 per 10 000 PDs (95% CI, .53–.76) in 2013. The mean reduction per year was 9.4% (95% CI, −8.1% to −10.7%). Significant reductions in both HO-MRSA (from 0.77 to 0.18 per 10 000 PDs) and HO-MSSA (from 1.71 to 0.64 per 10 000 PDs) bacteremia were observed. Conclusions. There was a major and significant reduction in incidence of HO-SAB caused by both MRSA and MSSA in Australian hospitals since 2002. This reduction coincided with a range of infection prevention and control activities implemented during this time. It suggests that national and local efforts to reduce the burden of healthcare-associated infections have been very successful.

Objective: To report outcomes from the first 2 years of the National Hand Hygiene Initiative (NHHI), a hand hygiene (HH) culture-change program implemented in all Australian hospitals to improve health care workers’ HH compliance, increase use of alcohol-based hand rub and reduce the risk of health care-associated infections. Design and setting: The HH program was based on the World Health Organization 5 Moments for Hand Hygiene program, and included standardised educational materials and a regular audit system of HH compliance. The NHHI was implemented in January 2009. Main outcome measures: HH compliance and Staphylococcus aureus bacteraemia (SAB) incidence rates 2 years after NHHI implementation. Results: In late 2010, the overall national HH compliance rate in 521 hospitals was 68.3% (168 641/246 931 moments), but HH compliance before patient contact was 10%–15% lower than after patient contact. Among sites new to the 5 Moments audit tool, HH compliance improved from 43.6% (6431/14 740) at baseline to 67.8% (106 851/157 708) (P < 0.001). HH compliance was highest among nursing staff (73.6%; 116 851/158 732) and worst among medical staff (52.3%; 17 897/34 224) after 2 years. National incidence rates of methicillin-resistant SAB were stable for the 18 months before the NHHI (July 2007–2008; P = 0.366), but declined after implementation (2009–2010; P = 0.008). Annual national rates of hospital-onset SAB per 10 000 patient-days were 1.004 and 0.995 in 2009 and 2010, respectively, of which about 75% were due to methicillin-susceptible S. aureus. Conclusions: The NHHI was associated with widespread sustained improvements in HH compliance among Australian health care workers. Although specific linking of SAB rate changes to the NHHI was not possible, further declines in national SAB rates are expected.

The rate of healthcare-associated Staphylococcus aureus bacteraemia (HA-SAB) is one outcome measure utilised to assess the quality and safety of care provided in hospitals. It has been accepted for use for this purpose by the Australian Health Ministers Council and has been incorporated as an indicator into the National Healthcare Agreement. To ensure such data is credible, it is critical that all organisations with responsibility for collating and analysing HA-SAB rates have systems in place to support accurate data collection at the hospital level, regularly review and improve these systems, and perform quality assurance of the data they receive and submit to the Commonwealth. To assess the quality of data being submitted to Healthcare Infection Surveillance Western Australian (HISWA), a retrospective audit was performed to validate 2008 HA-SAB data submitted by Western Australian public hospitals. The sensitivity of HISWA HA-SAB surveillance was 77% and the specificity was 99.6%. Hospitals without on-site clinical microbiologists performed relatively poorly. Discharge coding was not an accurate reflection of SAB rates.

There is marked variation in the rate of surgical site infections (SSIs) following total hip and knee replacements reported by hospitals submitting data to the Healthcare Infection Surveillance Western Australia. Ablinded retrospective case review was performed in order to determine if the differences were due to varying surveillance and reporting effectiveness. To further assess the quality of surveillance methodology the infection control professional at each site completed a paper-based, structured interview. A total of 444 patient charts were reviewed. Overall, the sensitivity of routine surveillance was 83%, the specificity 99%, the positive predictive value 94% and the negative predictive value 97%. The sensitivity varied between hospitals, ranging from 20 to 100%. The results of the methodology survey revealed fairly comparable surveillance practices at nine of the 10 hospitals. The hospitals with the lowest SSI rates were also those with the highest sensitivity to detect an SSI, suggesting that the difference in the quality of surveillance and reporting by each hospital is not responsible for the variation in SSI rates. The results of this study support the notion that those hospitals reporting the lowest SSI rates demonstrate high performance in both detection and prevention of SSI following hip and knee replacement surgery.

Objectives: To report the quarterly incidence of hospital-identified Clostridium difficile infection (HI-CDI) in Australia, and to estimate the burden ascribed to hospital-associated (HA) and community-associated (CA) infections. Design, setting and patients: Prospective surveillance of all cases of CDI diagnosed in hospital patients from 1 January 2011 to 31 December 2012 in 450 public hospitals in all Australian states and the Australian Capital Territory. All patients admitted to inpatient wards or units in acute public hospitals, including psychiatry, rehabilitation and aged care, were included, as well as those attending emergency departments and outpatient clinics. Main outcome measures: Incidence of HI-CDI (primary outcome); proportion and incidence of HA-CDI and CA-CDI (secondary outcomes). Results: The annual incidence of HI-CDI increased from 3.25/10 000 patient-days (PD) in 2011 to 4.03/10 000 PD in 2012. Poisson regression modelling demonstrated a 29% increase (95% CI, 25% to 34%) per quarter between April and December 2011, with a peak of 4.49/10 000 PD in the October-December quarter. The incidence plateaued in January-March 2012 and then declined by 8% (95% CI, - 11% to - 5%) per quarter to 3.76/10 000 PD in July-September 2012, after which the rate rose again by 11% (95% CI, 4% to 19%) per quarter to 4.09/10 000 PD in October-December 2012. Trends were similar for HA-CDI and CA-CDI. A subgroup analysis determined that 26% of cases were CA-CDI. Conclusions: A significant increase in both HA-CDI and CA-CDI identified through hospital surveillance occurred in Australia during 2011-2012. Studies are required to further characterise the epidemiology of CDI in Australia.

To the Editor—We thank Worth and colleagues [1] for reflecting on some important points related to our recent study where we reported a 63% reduction in hospital-onset (HO) Staphylococcus aureus bacteremia (SAB) in Australia [2]. We agree that the HO-SAB definition used in our study is not the national definition currently used for healthcare-associated (HCA) SAB surveillance in Australian hospitals. We commented on this in the discussion. Authors of our study have previously made similar comments to those made by Worth and colleagues [3–8]. For the purposes of benchmarking Australia internationally, we believe a HO-SAB definition is a robust and accurate approach to identify any real reduction in SAB—the aim of the paper. Capturing all HCA-SAB cases requires much more additional work by infection control professionals and infectious diseases physicians at a local level. In addition, collecting such additional surveillance requires validation [9, 10], potentially lacking in parts of Australia. However, there are 2 important reasons why we used only a HO-SAB definition in our study. First, we wanted to report data over a long time frame, 12 years of data. The HCA-SAB definition was not agreed upon by Health Ministers until 2008 in Australia, meaning previous longitudinal prospective data were not collected consistently. Retrospective analysis would have been very difficult and likely subject to bias. Second, the HO-SAB definition allows for international comparisons, whereas the HCA-SAB definition does not. Without using a HO-SAB definition, we would not have been able to undertake the comparisons outlined in our discussion. We fully support the use of HCA-SAB surveillance definition and hope that many other countries move to such a definition for the reasons described by Worth and colleagues. We believe that when data are presented, HO-SAB should be presented as a subset of the total HCA-SAB numbers where possible. Comparisons can then be made with studies that have not used the more inclusive definition. The conclusions in our study are consistent with the definitional approach we used. We never stated or implied that we tried to measure and report all cases of HCA-SAB. We acknowledge the point made by Worth and colleagues regarding data analysis and model adjustment for heterogeneity and multistate frailty. We are not convinced that this extra complexity in analysis is needed to demonstrate the points made. Regardless, under the agreements with those providing data for our study, only aggregated hospital data were to be analyzed and published, so the proposed analysis was not possible. What our data showed was a major and significant reduction in incidence of HO-SAB over a 12-year period caused by both methicillin-resistant and methicillin-sensitive S. aureus in Australian hospitals since 2002. This reduction coincided with a range of infection prevention and control activities implemented during this time [2]. It suggests that national and local efforts to reduce the burden have been very successful. As we commented, there are many potential reasons for the reductions in HO-SAB observed in our study, and Worth and colleagues are correct in acknowledging the important role that surveillance and multiple interventions play [11, 12].

We wish to update the information presented by Murphy in her 2007 surveywith the inclusion of occupational exposure rates from the Western Australian healthcare-associated infection surveillance program (HISWA). Since January 2008 quarterly submission of occupational exposure event rates (percutaneous and non-percutaneous) as a proportion of occupied bed days has been a mandatory reporting requirement for all public hospitals in WA. In addition, fiveprivate hospitals voluntarily submit this same data. The Australian Council of Healthcare Standards definitions are applied and rates of occupational exposure are reported each quarter by the contributing hospitals. TheWAaggregated rates are subsequently published on the HISWA website.

We describe an Australia-wide Clostridium difficile outbreak in 2011 and 2012 involving the previously uncommon ribotype 244. In Western Australia, 14 of 25 cases were community-associated, 11 were detected in patients younger than?65 years, 14 presented to emergency/outpatient departments, and 14 to non-tertiary/community hospitals. Using whole genome sequencing, we confirm ribotype 244 is from the same C. difficile clade as the epidemic ribotype 027. Like ribotype 027, it produces toxins A, B, and binary toxin, however it is fluoroquinolone-susceptible and thousands of single nucleotide variants distinct from ribotype 027. Fifteen outbreak isolates from across Australia were sequenced. Despite their geographic separation, all were genetically highly related without evidence of geographic clustering, consistent with a point source, for example affecting the national food chain. Comparison with reference laboratory strains revealed the outbreak clone shared a common ancestor with isolates from the United States and United Kingdom (UK). A strain obtained in the UK was phylogenetically related to our outbreak. Follow-up of that case revealed the patient had recently returned from Australia. Our data demonstrate new C. difficile strains are an on-going threat, with potential for rapid spread. Active surveillance is needed to identify and control emerging lineages.