Search

Background Tertiary referral health service. Intervention(s) An approach to hospital based contact tracing is described along with tools employed to streamline the process and including the development of an outbreak management team (OMT) for each contact trace. Results Forty-one OMTs occurred, involving 23 HCW and 18 patient index cases. The total furloughed HCWs arising from these contact traces was 383, with individual contact traces furloughing a mean (range) of 10 (0–80) HCWs. Importantly, 15 furloughed HCWs subsequently became COVID-19 positive during their 14-day isolation period, showing the importance of the contact tracing process and the ability to remove workers from the workplace before they become infectious. Conclusions A standardised, streamlined contact tracing procedure in healthcare settings ensures any impacts of COVID-19 positive cases are consistently managed. This response framework may be of use to other health services and help reduce the transmission of COVID-19 in the workplace., Highlights The Known • Test, trace and isolate are well known strategies for COVID-19 control. The New • We describe an outbreak management framework in a tertiary hospital during COVID-19. The Implications • This framework will aid health services dealing with COVID-19 outbreaks.

Background: It has been noted that olfactory and gustatory disturbances may precede or accompany the typical features of COVID-19, such as fever and cough. Hence, a high index of suspicion is required when patients report sudden loss of smell or taste, in order to facilitate timely diagnosis and isolation.Aims/objectives: The aim of this study was to assess the frequency of olfactory and gustatory disturbances in COVID-19 positive patients from a cohort representative of Melbourne, Australia.Methods: A retrospective descriptive study was conducted on patients who tested positive for COVID-19. Standardised phone consultations and online follow-up questionnaires were performed to assess clinical features of COVID-19, with a focus on smell and taste disorders.Results: The most frequent symptoms experienced were taste and smell disturbances with 74% experiencing either smell or taste disturbance or both. Post-recovery, 34% of patients continued to experience ongoing hyposmia and 2% anosmia, whereas 28% continued to suffer from hypogeusia or ageusia.Conclusion and significance: This study presents the high rates of improvement of both olfactory and gustatory disturbance in a short-lived period. It also highlights the importance of these symptoms in prompting appropriate testing, quarantine precautions, initiate early olfactory retraining and the potential for continued sensory disturbance.

Objective: the COVID-19 pandemic has incurred psychological risks for healthcare workers (HCWs). We established a Victorian HCW cohort (the Coronavirus in Victorian Healthcare and Aged-Care Workers (COVIC-HA) cohort study) to examine COVID-19 impacts on HCWs and assess organisational responses over time. Methods: mixed-methods cohort study, with baseline data collected via an online survey (7 May–18 July 2021) across four healthcare settings: ambulance, hospitals, primary care, and residential aged-care. Outcomes included self-reported symptoms of depression, anxiety, post-traumatic stress (PTS), wellbeing, burnout, and resilience, measured using validated tools. Work and home-related COVID-19 impacts and perceptions of workplace responses were also captured. Results: among 984 HCWs, symptoms of clinically significant depression, anxiety, and PTS were reported by 22.5%, 14.0%, and 20.4%, respectively, highest among paramedics and nurses. Emotional exhaustion reflecting moderate–severe burnout was reported by 65.1%. Concerns about contracting COVID-19 at work and transmitting COVID-19 were common, but 91.2% felt well-informed on workplace changes and 78.3% reported that support services were available. Conclusions: Australian HCWs employed during 2021 experienced adverse mental health outcomes, with prevalence differences observed according to occupation. Longitudinal evidence is needed to inform workplace strategies that support the physical and mental wellbeing of HCWs at organisational and state policy levels.

Summary Background Decades of studies document an association between Gammaproteobacteria in sink drains and hospital-acquired infections, but the evidence for causality is unclear. Aim We aimed to develop a tool to assess the quality of evidence for causality in research studies that implicate sink drains as reservoirs for hospital-acquired Gammaproteobacterial infections. Methods We used a modified Delphi process with recruited experts in hospital epidemiology to develop this tool from a pre-existing causal assessment application. Findings Through four rounds of feedback and revision we developed the ‘Modified CADDIS Tool for Causality Assessment of Sink Drains as a Reservoir for Hospital-Acquired Gammaproteobacterial Infection or Colonization’. In tests of tool application to published literature during development, mean percent agreement ranged from 46.7% to 87.5%, and the Gwet's AC1 statistic (adjusting for chance agreement) ranged from 0.13 to 1.0 (median 68.1). Areas of disagreement were felt to result from lack of a priori knowledge of causal pathways from sink drains to patients and uncertain influence of co-interventions to prevent organism acquisition. Modifications were made until consensus was achieved that further iterations would not improve the tool. When the tool was applied to 44 articles by two independent reviewers in an ongoing systematic review, percent agreement ranged from 93% to 98%, and the Gwet's AC1 statistic was 0.91–0.97. Conclusion The modified causality tool was useful for evaluating studies that implicate sink drains as reservoirs for hospital-acquired infections and may help guide the conduct and reporting of future research.

BACKGROUND Infective endocarditis (IE) results in substantial morbidity and mortality in people who inject drugs (PWID). AIMS To describe the burden of IE and its outcomes in PWID. METHODS Retrospective cohort study of adults admitted to a tertiary referral centre in Melbourne, Australia, with IE due to injection drug use from 1997 to 2015. RESULTS Ninety-seven PWID with 127 episodes of IE were identified with a median acute inpatient stay of 37 days (1-84). Admission to an intensive care unit was required in 67/127 (53%) episodes. Twenty-seven percent (34/127) of episodes occurred in patients with a previous episode of endocarditis. One third (43/127, 34%) of episodes involved left-sided cardiac valves. Antimicrobial treatment was completed in 88 (70%) episodes. Valve surgery was performed in 25/127 (20%) episodes. Predictors of surgery in univariable analysis were left-sided cardiac involvement (risk ratio (RR) 6.0), severe valvular regurgitation (RR 2.6) and cardiac failure (RR 2.2) (all P

Healthcare workers are at increased risk of occupational transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We report 2 instances of healthcare workers contracting SARS-CoV-2 despite no known breach of personal protective equipment. Additional specific equipment cleaning was initiated. Viral genomic sequencing supported this transmission hypothesis and our subsequent response.

Antimicrobial stewardship (AMS) in Australia is supported by a number of factors, including enabling national policies, sectoral clinical governance frameworks and surveillance programmes, clinician-led educational initiatives and health services research. A One Health research programme undertaken by the National Centre for Antimicrobial Stewardship (NCAS) in Australia has combined antimicrobial prescribing surveillance with qualitative research focused on developing antimicrobial use-related situational analyses and scoping AMS implementation options across healthcare settings, including metropolitan hospitals, regional and rural hospitals, aged care homes, general practice clinics and companion animal and agricultural veterinary practices. Qualitative research involving clinicians across these diverse settings in Australia has contributed to improved understanding of contextual factors that influence antimicrobial prescribing, and barriers and facilitators of AMS implementation. This body of research has been underpinned by a commitment to supplementing ‘big data’ on antimicrobial prescribing practices, where available, with knowledge of the sociocultural, technical, environmental and other factors that shape prescribing behaviours. NCAS provided a unique opportunity for exchange and cross-pollination across the human and animal health programme domains. It has facilitated synergistic approaches to AMS research and education, and implementation of resources and stewardship activities. The NCAS programme aimed to synergistically combine quantitative and qualitative approaches to AMS research. In this article, we describe the qualitative findings of the first 5 years.

BackgroundCOVID-19 has resulted in many infections in healthcare workers (HCWs) globally. We performed state-wide SARS-CoV-2 genomic epidemiological investigations to identify HCW transmission dynamics and provide recommendations to optimise healthcare system preparedness for future outbreaks.MethodsGenome sequencing was attempted on all COVID-19 cases in Victoria, Australia. We combined genomic and epidemiologic data to investigate the source of HCW infections across multiple healthcare facilities (HCFs) in the state. Phylogenetic analysis and fine-scale hierarchical clustering were performed for the entire Victorian dataset including community and healthcare cases. Facilities provided standardised epidemiological data and putative transmission links.FindingsBetween March and October 2020, approximately 1,240 HCW COVID-19 infection cases were identified; 765 are included here. Genomic sequencing was successful for 612 (80%) cases. Thirty-six investigations were undertaken across 12 HCFs. Genomic analysis revealed that multiple introductions of COVID-19 into facilities (31/36) were more common than single introductions (5/36). Major contributors to HCW acquisitions included mobility of staff and patients between wards and facilities, and characteristics and behaviours of individual patients including super-spreading events. Key limitations at the HCF level were identified.InterpretationGenomic epidemiological analyses enhanced understanding of HCW infections, revealing unsuspected clusters and transmission networks. Combined analysis of all HCWs and patients in a HCF should be conducted, supported by high rates of sequencing coverage for all cases in the population. Established systems for integrated genomic epidemiological investigations in healthcare settings will improve HCW safety in future pandemics.FundingThe Victorian Government, the National Health and Medical Research Council Australia, and the Medical Research Future Fund.

Background Universal screening has been proposed as a strategy to identify asymptomatic individuals infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and mitigate transmission. Aim To investigate the rate of positive tests among pregnant women in Melbourne, Australia. Methods We performed a cross-sectional prevalence study at three maternity hospitals (one tertiary referral hospital and two secondary maternities) in Melbourne, Australia. SARS-CoV-2 testing was offered to all pregnant women attending face-to-face antenatal visits and to those attending the hospital with symptoms of possible coronavirus disease, between 6th and 19th of May 2020. Testing was performed by multiplex-tandem polymerase chain reaction (PCR) on combined oropharyngeal and nasopharyngeal swabs. The primary outcome was the proportion of positive SARS-CoV-2 tests. Findings SARS-CoV-2 testing was performed in 350 women, of whom 19 had symptoms of possible COVID-19. The median maternal age was 32 years (IQR 28–35 years), and the median gestational age at testing was 33 weeks and four days (IQR 28 weeks to 36 weeks and two days). All 350 tests returned negative results (p = 0%, 95% CI 0–1.0%). Conclusion In a two-week period of low disease prevalence, the rate of asymptomatic coronavirus infection among pregnant women in Australia during the study period was negligible, reflecting low levels of community transmission.

The annual Aged Care National Antimicrobial Prescribing Survey aims to identify local and national prescribing issues and guide antimicrobial stewardship goals In the 2018 point prevalence survey, medication charts of over 20,000 residents were reviewed from 407 participating facilities across Australia On the day of the survey, almost 10% of residents were prescribed an antimicrobial Nearly two-thirds of recently prescribed antimicrobials were for residents who had no documented signs or symptoms of infection Over a quarter of antimicrobials had been prescribed for longer than six months Incomplete documentation was a prominent barrier to proper review of antimicrobial therapy, with the indication, review date or stop date not documented for many prescriptions Recommendations include using appropriate microbiological testing to guide prescribing, following national antimicrobial prescribing guidelines, documenting the indication for the antimicrobial, and its start, stop and review dates, and monitoring and re-evaluating long-term antimicrobial use Keywords: aged, antibiotic prophylaxis, antibiotics, antimicrobial stewardship, homes for the aged, infection Introduction Residents of aged-care homes are especially vulnerable to infection.1 Lack of diagnostic certainty can compound the complexity of decision making around antimicrobial use.2 In aged-care homes, antimicrobial use takes place within a context of heightened risk and vigilance due to the potential for complications and clinical deterioration. Overuse and inappropriate use of antimicrobials, however, can accelerate antimicrobial resistance and increase morbidity and mortality from drug-resistant infections. Inappropriate use of antimicrobials can directly and indirectly harm residents,3 and aged-care homes can serve as reservoirs and sites of transmission of drug-resistant organisms.4,5 Aged-care homes play an important role in community– hospital transmission of drug-resistant organisms,6 so prudent use of antimicrobials is a necessity. Surveillance of antimicrobial use can guide improved prescribing practices.

Objective:To describe an outbreak of bacteremia caused by vancomycin-sensitive Enterococcus faecalis (VSEfe).Design:An investigation by retrospective case control and molecular typing by whole-genome sequencing (WGS).Setting:A tertiary-care neonatal unit in Melbourne, Australia.Methods:Risk factors for 30 consecutive neonates with VSEfe bacteremia from June 2011 to December 2014 were analyzed using a case control study. Controls were neonates matched for gestational age, birth weight, and year of birth. Isolates were typed using WGS, and multilocus sequence typing (MLST) was determined.Results:Bacteremia for case patients occurred at a median time after delivery of 23.5 days (interquartile range, 14.9–35.8). Previous described risk factors for nosocomial bacteremia did not contribute to excess risk for VSEfe. WGS typing results designated 43% ST179 as well as 14 other sequence types, indicating a polyclonal outbreak. A multimodal intervention that included education, insertion checklists, guidelines on maintenance and access of central lines, adjustments to the late onset sepsis antibiotic treatment, and the introduction of diaper bags for disposal of soiled diapers after being handled inside the bed, led to termination of the outbreak.Conclusions:Typing using WGS identified this outbreak as predominately nonclonal and therefore not due to cross transmission. A multimodal approach was then sought to reduce the incidence of VSEfe bacteremia.

Background Health service hand hygiene programs have seen widespread use of chlorhexidine solutions. Reports of both immediate and delayed hypersensitivity to chlorhexidine are increasing among health care workers. This study examined the prevalence of self-reported symptoms of sensitivity to chlorhexidine solutions among health care workers. Methods This study was a cross-sectional online anonymous survey of all workers at a single health service. Results Of the 1,050 completed responses, 76.3% were female, 35.3% were nurses and midwives, 28% were medical staff, and 8.7% were working in nonclinical areas. Over 95% used chlorhexidine-based hand hygiene products in their workplace. Nurses and midwives most frequently reported asthma (13.7%), contact dermatitis (27.8%), and previous testing for allergy to chlorhexidine (4.9%). There was a correlation between both the presence of atopy, eczema, or dermatitis and the self-reporting of dry skin, eczema, or dermatitis attributed to chlorhexidine use. Discussion Occupational chlorhexidine allergy is an important risk to health care workers. Self-reported symptoms of sensitivity to chlorhexidine solutions revealed high reported use and presence of skin symptoms among health care workers. Conclusions Screening programs need to identify nurses who develop chlorhexidine sensitivity due to occupational exposure. Strategies to mitigate risk should provide alternatives for those with sensitization.

Background: Physical removal of soil rather than biocidal activity is the focus for this safer cleaning method. Methods: We compared 11 years of Victorian healthcare norovirus and suspected viral gastroenteritis outbreak data. Results: Improvements in infection control practice, including the Victorian hand hygiene program corresponds with reduced illness across Victoria during that time. Monash Health reductions are statistically significant and coincide with the implementation of a novel cleaning methodology. Conclusion: Cleaning without chemicals has not increased the risk of norovirus or suspected viral gastroenteritis illness at Monash Health.

Highlights • Nurse-initiated polymerase chain reaction testing is feasible in nursing homes. • Viruses are common among nursing home residents. • Nurse-initiated respiratory specimen testing is useful for infection prevention. • Further resources are required to impact antibiotic prescribing., Background Diagnostic testing using polymerase chain reaction (PCR) is infrequently initiated for diagnosis of respiratory tract infections (RTIs) in nursing homes. The objectives of this study were to determine the feasibility of implementing nurse-initiated PCR testing of respiratory specimens in nursing home settings and to compare antibiotic prescribing prior to and during the implementation. Methods This was a pragmatic, historically controlled study in 3 nursing homes (181 total beds) in Melbourne, Australia. Results The number of PCR tests of respiratory specimens (over 12 months) increased from 5 to 67 when nurses could initiate the tests. Residents with RTI symptoms had a virus identified by PCR in 50.7% of tests, including 14 positive for influenza. Six outbreaks were identified. When clustering was taken into consideration, incidence rates of antibiotic days of therapy did not change (incidence rate ratio = 0.94, 95% confidence interval, 0.25-3.35, P = .92) despite identification of more viral pathogens. Conclusions In nursing homes, nurse-initiated PCR testing of respiratory specimens is feasible and useful in terms of identifying the cause of many RTIs and outbreaks, and viruses are common in this context. However, the current study suggests the availability of these test results alone does not impact antibiotic prescribing.

The aim of this study was to determine if natural killer cell number (CD3- /CD16± /CD56± ) and cytotoxic killing function predicts severity and frequency of infection in kidney transplant recipients. A cohort of 168 kidney transplant recipients with stable graft function underwent assessment of natural killer cell number and functional killing capacity immediately prior to entry into this prospective study. Participants were followed for 2 years for development of severe infection, defined as hospitalization for infection. Area under receiver operating characteristic (AUROC) curves were used to evaluate the accuracy of natural killer cell number and function for predicting severe infection. Adjusted odds ratios were determined by logistic regression. Fifty-nine kidney transplant recipients (35%) developed severe infection and 7 (4%) died. Natural killer cell function was a better predictor of severe infection than natural killer cell number: AUROC 0.84 and 0.75, respectively (P = .018). Logistic regression demonstrated that after adjustment for age, transplant function, transplant duration, mycophenolate use, and increasing natural killer function (odds ratio [OR] 0.82, 95% confidence interval [CI] 0.74-0.90; P

Purpose The aim of this study was to determine if measurement of B cell protective immunity was associated with susceptibility to sinopulmonary infection in kidney transplant recipients. Methods and Materials A prospective cohort of 168 patients with stable graft function (median 4.1 years) underwent assessment of B-lymphocyte antigen CD19 (CD19+) cell number, immunoglobulin G concentration, and seroresponses to influenza vaccination upon study entry. Patients received a single dose of a trivalent, seasonal influenza vaccine. Results After 2 years follow-up, 31 patients (18%) developed sinopulmonary infection. CD19+ cell number was strongly associated with future sinopulmonary infection. A higher proportion of patients with CD19+ cell counts below the fifth percentile for controls developed sinopulmonary infections than those above the fifth percentile, 30% (23 of 77 patients) compared with 9% (7 of 79 patients; P = .001). There was a trend toward a higher proportion of patients with reduced immunoglobulin G concentrations developing infections than in the normal range for controls, 29% (14 of 48 patients) compared with 15% (16 of 108 patients; P = .060). Influenza vaccination seroresponses were poor in patients and controls such that they could not be used to identify a subgroup of patients at high risk for the development of severe pulmonary infection. Conclusions Monitoring B-cell numbers represents a simple, inexpensive means of stratifying transplant recipients' risk of sinopulmonary infection.

Objectives:To conduct a pilot study implementing combined genomic and epidemiologic surveillance for hospital-acquired multidrug-resistant organisms (MDROs) to predict transmission between patients and to estimate the local burden of MDRO transmission.Design:Pilot prospective multicenter surveillance study.Setting:The study was conducted in 8 university hospitals (2,800 beds total) in Melbourne, Australia (population 4.8 million), including 4 acute-care, 1 specialist cancer care, and 3 subacute-care hospitals.Methods:All clinical and screening isolates from hospital inpatients (April 24 to June 18, 2017) were collected for 6 MDROs: vanA VRE, MRSA, ESBL Escherichia coli (ESBL-Ec) and Klebsiella pneumoniae (ESBL-Kp), and carbapenem-resistant Pseudomonas aeruginosa (CRPa) and Acinetobacter baumannii (CRAb). Isolates were analyzed and reported as routine by hospital laboratories, underwent whole-genome sequencing at the central laboratory, and were analyzed using open-source bioinformatic tools. MDRO burden and transmission were assessed using combined genomic and epidemiologic data.Results:In total, 408 isolates were collected from 358 patients; 47.5% were screening isolates. ESBL-Ec was most common (52.5%), then MRSA (21.6%), vanA VRE (15.7%), and ESBL-Kp (7.6%). Most MDROs (88.3%) were isolated from patients with recent healthcare exposure.Combining genomics and epidemiology identified that at least 27.1% of MDROs were likely acquired in a hospital; most of these transmission events would not have been detected without genomics. The highest proportion of transmission occurred with vanA VRE (88.4% of patients).Conclusions:Genomic and epidemiologic data from multiple institutions can feasibly be combined prospectively, providing substantial insights into the burden and distribution of MDROs, including in-hospital transmission. This analysis enables infection control teams to target interventions more effectively.

We present a case of late symptom onset of COVID-19 infection 72 days after initial diagnosis in an immunocompromised 53-year-old man. SARS-CoV-2 was cultured from his sputum sample at this time, and genomic sequencing suggested reinfection was unlikely. After receipt of convalescent plasma, SARS-CoV-2 became undetectable by PCR 111 days after diagnosis, although SARS-CoV-2 antibodies remained not detectable. This case posed difficult public health management issues in a low prevalence COVID-19 setting as the person required extended home isolation given his prolonged SARS-CoV-2 PCR detection.

Background On 31 December 2019, the World Health Organization recognised clusters of pneumonia‐like cases due to a novel coronavirus disease (COVID‐19). COVID‐19 became a pandemic 71 days later. Aim To report the clinical and epidemiological features, laboratory data and outcomes of the first group of 11 returned travellers with COVID‐19 in Australia. Methods This is a retrospective, multi‐centre case series. All patients with confirmed COVID‐19 infection were admitted to tertiary referral hospitals in New South Wales, Queensland, Victoria and South Australia. Results The median age of our patient cohort was 42 years (IQR, 24–53 years) with six men and five women. Eight patients (72.7%) had returned from Wuhan, one from Shenzhen, one from Japan, and one from Europe. Possible human‐to‐human transmission from close family contacts in gatherings overseas occurred in two cases. Symptoms on admission were fever, cough and sore throat (n = 9, 81.8%). Co‐morbidities included hypertension (n = 3, 27.3%) and hypercholesterolaemia (n = 2, 18.2%). No patients developed severe acute respiratory distress nor required intensive care unit admission or mechanical ventilation. After a median hospital stay of 14.5 days (IQR, 6.75–21), all patients were discharged. Conclusions This is a historical record of the first COVID‐19 cases in Australia during the early biocontainment phase of the national response. These findings were invaluable for establishing early inpatient and outpatient COVID‐19 models of care and informing the management of COVID‐19 overtime as the outbreak evolved. Future research should extend this Australian case series to examine global epidemiological variation of this novel infection. This article is protected by copyright. All rights reserved.

Hospital-acquired Staphylococcus aureus bacteremia (SAB) is a significant cause of morbidity and mortality worldwide.1 Serious clinical outcomes (e.g. septic shock, localized infection, and infective endocarditis) contribute to the healthcare burden at the individual, health service and national level.2,3.

Rapid detection and isolation of coronavirus disease 2019 (COVID-19) patients is the only means of reducing hospital transmission. We describe the impact of implementation of on-site severe acute respiratory coronavirus virus 2 (SARS-CoV-2) reverse-transcription polymerase chain reaction (RT-PCR) testing on reducing turnaround time, isolation duration, pathology test ordering, and antibiotic use in patients who do not have COVID-19.

BackgroundHealthcare workers (HCWs) are at particular risk during pandemics and epidemics of highly virulent diseases with significant morbidity and case fatality rate. These diseases include severe acute respiratory syndrome coronaviruses, SARS-CoV-1 and SARS-CoV-2, Middle Eastern Respiratory Syndrome (MERS), and Ebola. With the current (SARS-CoV-2) global pandemic, it is critical to delineate appropriate contextual respiratory protection for HCWs. The aim of this systematic review was to evaluate the effect of powered air-purifying respirators (PAPRs) as part of respiratory protection versus another device (egN95/FFP2) on HCW infection rates and contamination.MethodsOur primary outcomes included HCW infection rates with SARS-CoV-2, SARS-CoV-1, Ebola, or MERS when utilizing PAPR. We included randomized controlled trials, non-randomized controlled trials, and observational studies. We searched the following databases: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two reviewers independently screened all citations, full-text articles, and abstracted data. Due to clinical and methodological heterogeneity, we did not conduct a meta-analysis. Where applicable, we constructed evidence profile (EP) tables for each individual outcome. Confidence in cumulative evidence for each outcome was classified according to the GRADE system.ResultsWe identified 689 studies during literature searches. We included 10 full-text studies. A narrative synthesis was provided. Two on-field studies reported no difference in the rates of healthcare workers performing airway procedures during the care of critical patients with SARS-CoV-2. A single simulation trial reported a lower level of cross-contamination of participants using PAPR compared to alternative respiratory protection. There is moderate quality evidence that PAPR use is associated with greater heat tolerance but lower scores for mobility and communication ability. We identified a trend towards greater self-reported wearer comfort with PAPR technology in low-quality observational simulation studies.ConclusionField observational studies do not indicate a difference in healthcare worker infection utilizing PAPR devices versus other compliant respiratory equipment. Greater heat tolerance accompanied by lower scores of mobility and audibility in PAPR was identified. Further pragmatic studies are needed in order to delineate actual effectiveness and provider satisfaction with PAPR technology.Systematic review registrationThe protocol for this review was prospectively registered with the International Register of Systematic Reviews identification numberCRD42020184724.

BackgroundHealthcare workers (HCWs) are at particular risk during pandemics and epidemics of highly virulent diseases with significant morbidity and case fatality rate. These diseases include Severe Acute Respiratory Syndrome Coronaviruses, SARS-CoV-1 and SARS-CoV-2, Middle Eastern Respiratory Syndrome (MERS) and Ebola. With the current (SARS-CoV-2) global pandemic, it is critical to delineate appropriate contextual respiratory protection for HCWs. The aim of this systematic review was to evaluate the effect of Powered Air Purifying Respirators (PAPR’s) as part of respiratory protection versus another device (egN95/FFP2) on HCW infection rates and contamination.MethodsOur primary outcomes included HCW infection rates with SARS-CoV-2, SARS-CoV-1, Ebola or MERS when utilizing PAPR. We included randomized controlled trials, non-randomized controlled trials, and observational studies. We searched the following databases: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two reviewers independently screened all citations, full-text articles, and abstracted data. Due to clinical and methodological heterogeneity, we did not conduct a meta-analysis. Where applicable, we constructed Evidence Profile (EP) tables for each individual outcome. Confidence in cumulative evidence for each outcome was classified according to the GRADE system.ResultsWe identified 689 studies during literature searches. We included 10 full text studies. A narrative synthesis was provided. Two on-field studies reported no difference in the rates of healthcare workers performing airway procedures during care of critical patients with SARS-CoV-2. A single simulation trial reported a lower level of cross-contamination of participants using PAPR compared to alternative respiratory protection. There is moderate quality evidence that PAPR use is associated with greater heat tolerance but lower scores for mobility and communication ability. We identified a trend toward greater self-reported wearer comfort with PAPR technology in low quality observational simulation studies.ConclusionField observational studies do not indicate a difference in healthcare worker infection utilizing PAPR devices versus other compliant respiratory equipment. Greater heat tolerance accompanied by lower scores of mobility and audibility in PAPR were identified. Further pragmatic studies are needed in order to delineate actual effectiveness and provider satisfaction with PAPR technology.Please note: Protocol for this review was prospectively registered with the International Register of Systematic Reviews identification number CRD42020184724.

Background Multiresistant organisms (MROs) pose a critical threat to public health. Population-based programs for control of MROs such as carbapenemase-producing Enterobacterales (CPE) have emerged and evaluation is needed. We assessed the feasibility and impact of a statewide CPE surveillance and response program deployed across Victoria, Australia (population 6.5 million). Methods A prospective multimodal intervention including active screening, carrier isolation, centralized case investigation, and comparative pathogen genomics was implemented. We analyzed trends in CPE incidence and clinical presentation, risk factors, and local transmission over the program’s first 3 years (2016–2018). Results CPE case ascertainment increased over the study period to 1.42 cases/100 000 population, linked to increased screening without a concomitant rise in active clinical infections (0.45–0.60 infections/100 000 population, P = .640). KPC-2 infection decreased from 0.29 infections/100 000 population prior to intervention to 0.03 infections/100 000 population in 2018 (P = .003). Comprehensive case investigation identified instances of overseas community acquisition. Median time between isolate referral and genomic and epidemiological assessment for local transmission was 11 days (IQR, 9–14). Prospective surveillance identified numerous small transmission networks (median, 2; range, 1–19 cases), predominantly IMP and KPC, with median pairwise distance of 8 (IQR, 4–13) single nucleotide polymorphisms; low diversity between clusters of the same sequence type suggested genomic cluster definitions alone are insufficient for targeted response. Conclusions We demonstrate the value of centralized CPE control programs to increase case ascertainment, resolve risk factors, and identify local transmission through prospective genomic and epidemiological surveillance; methodologies are transferable to low-prevalence settings and MROs globally., A statewide multimodal intervention for the control of carbapenemase-producing Enterobacterales was associated with a significant increase in case ascertainment, with no rise in clinical infections. Timely prospective epidemiological and genomic surveillance identified numerous small local transmission networks permitting rapid response.

Background: Multi-resistant organisms (MROs) pose a critical threat to public health. Recently, population-based systems for surveillance and control of MROs such as Carbapenemase-producing Enterobacterales (CPE) have emerged globally and evaluation is needed. In this study, we assess the feasibility and impact of a state-wide CPE surveillance and response program deployed in December 2015 across Victoria, Australia (population 6·5 million). Methods: A prospective population-based multi-modal intervention, including active screening, carrier isolation, centralised case investigation and comparative pathogen genomics was implemented. We assess impact by analysing trend in CPE incidence and clinical presentation, risk factors for acquisition and local transmission, using data from the first three years of implementation (January 2016 to December 2018). Findings: CPE case ascertainment increased over the study period to 1·42 cases/100,000 population, linked to increased screening without a concomitant rise in active clinical infections (0·45-0·60 infections/100,000 population, p=0·640). Occurrence of KPC-2 infection decreased from 0·29 infections/100,000 population prior to intervention to 0·03 infections/100,000 population in 2018 (p=0·003). Comprehensive case investigation enabled identification of novel risk factors, including non-healthcare-related overseas acquisition. Median time between isolate referral and initial centralised genomic and epidemiological assessment for local transmission was 11 days (IQR 9-14). Prospective surveillance identified numerous small transmission networks (median 2, range 1-19 cases), predominantly IMP- and KPC-producing organisms. Genomic and epidemiologically defined clusters had a median pairwise distance of 8 (IQR 4-13) single nucleotide polymorphisms, however low diversity between clusters of the same sequence type suggested genomic cluster definitions alone are insufficient for targeted control measures. Interpretation: Our results demonstrate the value of centralised CPE surveillance and control programs to increase case ascertainment, resolve risk factors and identify putative local transmission through combined genomic and epidemiological surveillance; methodologies are transferable to other low-prevalence settings and MROs globally. Funding Statement: National Health and Medical Research Council (NHMRC) partnership grant (GNT1149991) and the Victorian Government. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: All data were collected in accordance with the Victorian Public Health and Wellbeing Act 2008. Ethical approval was obtained from the Human Ethics Advisory Group of the School of Biomedical Sciences, University of Melbourne (Ethics ID 1954615.2).

In Australia and New Zealand, >50% of people with cystic fibrosis (CF) are adults and many of these people are pursuing vocational training and undertaking paid employment. More than 6% of adults with CF are working in health care. There is limited guidance in literature to support health care workers with CF (HCWcf) in training and in employment to support safe practice and to provide protection for themselves and their patients from the acquisition of health care associated infection. A multidisciplinary team of CF and Infectious Disease Clinicians, Infection Prevention and Control Practitioners, HCWcf, academic experts in medical ethics and representatives from universities, appraised the available evidence on the risk posed to and by HCWcf. Specific recommendations were made for HCWcf, CF health care teams, hospitals and universities to support the safe practice and appropriate support for HCWcf.

Objective Our objective was to examine the impact of a human factor-designed multimodal intervention on the proportion of unused peripheral i.v. cannula (PIVC) insertion in our ED. Methods A pre- and post-multimodal intervention retrospective cohort study was conducted using a structured electronic medical record review within a single adult tertiary ED in Australia. Pre-intervention data was collected 30 days prior to the multimodal intervention, with 30 day post-intervention data collected 3 months after the intervention commenced. The rates of PIVC inserted, the unused rate and the unused but appropriately inserted cannulas were the main outcome measures. Results Intravenous cannula insertion rates decreased by 12.9% (95% confidence interval [CI] 12.19-13.61) between the pre-intervention (1413/4167 [33.9%]; 95% CI 32.5-35.4) and post-intervention cohort (928/4421 [21.0%]; 95% CI 19.8-22.2). An analysis of 754 cases (376 pre-intervention and 378 post-intervention) showed that 139 of 376 (37.0%; 95% CI 32.1-42.1) i.v. cannulas were unused pre-intervention, while 73 of 378 (19.3%; 95% CI 15.4-23.7) was unused post-intervention; an absolute reduction of 17.7% (95% CI 14.98-20.42). The relative risk of an unused i.v. cannula was 0.52 (95% CI 0.41-0.67). The proportion of unused but appropriately inserted i.v. cannulas remained unchanged in both cohorts, with a relative risk of 0.91 (95% CI 0.58-1.42). Conclusion Our multimodal intervention successfully reduced the number of unused PIVCs inserted in the ED, with a reduction in overall and unused PIVC insertions without any change in appropriate insertions.

Objectives The aim of this research was to determine the prevalence of urinary tract infections (UTIs) in 2 aged care homes (ACHs) and examine the extent to which presumed UTIs met the 2012 McGeer infection surveillance definitions. Design Retrospective observational study. Setting Two ACHs: a 30-bed facility and a 100-bed facility Participants Residents of the 2 ACHs diagnosed with UTI. Methods A retrospective review was conducted of UTIs clinically diagnosed at the 2 facilities over a 16-month period, utilizing surveillance and microbiologic data, resident progress notes, and medication charts. This data was reviewed to determine how many diagnosed UTIs met the revised McGeer definitions. Results Overall, 119 UTIs were diagnosed in 57 residents over 16 months. Only 7 of the diagnosed UTIs met the McGeer definitions. Forty-seven did not meet the clinical evidence, 17 did not meet the microbiologic evidence, and 48 did not meet either surveillance criteria. Conclusions This study demonstrated the disparity between the clinical diagnosis of UTI and the surveillance definitions for UTI, and highlights the limitations of the McGeer definitions in those with cognitive or communication deficits. There is an urgent need for antimicrobial stewardship programs and education in the ACH setting.

Gram-negative bacteria that are resistant to antimicrobials, including carbapenems, have emerged as a significant global public health threat. Multidrug-resistant gram-negative bacteria, including carbapenemase-producing Enterobacteriaceae (CPE), place patients at risk of potentially untreatable infection. Australia has not reported a large number of CPE cases compared to Europe, North America, and the Middle East, creating an opportunity to prevent CPE from becoming established in Australia. An outbreak of Klebsiella pneumoniae carbapenemase in 2014 demonstrated there was variable testing, reporting, response to and communication of CPE. In response, the Australian Commission on Safety and Quality in Health Care formed a taskforce to assist health facilities to respond to the threat of CPE. Recommendations for state and territory health departments include coordinating a risk assessment, undertaking epidemiological and microbiological investigations, determining the requirement for control measures, and coordinating risk-communication activities. The response should take advice from experts in infectious diseases, microbiology, public health, infection prevention and control and epidemiologists. The guide aims to: •Alert healthcare professionals, health departments and hospital executives to the emerging threat of CPE in Australia •Recommend strategies to prevent, detect and contain CPE •Provide information and resources for hospital executives, healthcare professionals and consumers •Recommend laboratory screening and confirmation methods. The recommendations with rationale and commentary have been structured into sections depending on the burden of CPE in the health facility. The sections include: planning, preparing and prevention; CPE screening and surveillance; strategies to reduce CPE transmission; outbreak management; laboratory screening and confirmation methods.

Mycobacterium chimaera infection in patients who have had cardiac bypass surgery has recently been associated with contamination of water in heater cooler units. Those responsible for infection prevention and control programs face the challenge of responding to this rare but potentially life-threatening and avoidable healthcare-associated infection. Infection control professionals need to be aware of this issue and take an active role in formulating hospital responses. Policies should be rational and appropriate to the level of risk, should minimise service disruption and costs, and recognise that evidence about risk mitigation measures is still emerging. This paper provides background information to the topic and proposes a risk management based approach to heater cooler units in hospitals that perform cardiac bypass surgery, so that infection control professionals can develop a local, tailored response.

BackgroundMultidrug-resistant organisms (MDROs) disproportionately affect hospitalized patients due to the combination of comorbidities, frequent antimicrobial use, and in-hospital MDRO transmission. Identification of MDRO transmission by hospital microbiology laboratories is difficult due to limitations of existing typing methods.MethodsWe conducted a prospective multicenter genomics implementation study (8 hospitals, 2800 beds) from 24thApril to 18thJune 2017 in Melbourne, Australia. Clinical and screening isolates from hospital inpatients were collected for six MDROs (vanAVRE, MRSA, ESBLE. coli[ESBL-Ec] andKlebsiella pneumoniae[ESBL-Kp], and carbapenem-resistantPseudomonas aeruginosa[CRPa] andAcinetobacter baumannii[CRAb]), sequenced (Illumina NextSeq) and analyzed using open-source tools. MDRO transmission was assessed by genomics (core SNP phylogeny, grouped by species and ST) and compared to epidemiologic data.Results408 isolates were collected from 358 patients; 47.5% were screening isolates. ESBL-Ec was most common (52.5%), then MRSA (21.6%),vanAVRE (15.7%) and ESBL-Kp (7.6%).We define the transmission rate for each MDRO by genomics and epidemiology; 31.6% of all study patients had potential genomic links to other study isolates; 86% of these were confirmed by epidemiologic links (probable or possible transmission). The highest transmission rates occurred withvanA VRE (88.4% of patients).ConclusionsCombining genomics with high-quality epidemiologic data gives substantial insights into the burden and distribution of critical MDROs in hospitals, including in-hospital transmission. By defining transmission rates by genomics, we hope to enable comparisons over time and between sites, and introduce this as a new outcome measure to assess the efficacy of infection control interventions.

Background The objective of this study was to understand how aged care home health professionals perceive antimicrobial use near the end of life and how they perceive potential antimicrobial stewardship activities near the end of life in aged care homes. Methods Qualitative semi-structured interviews were undertaken with general practitioners, nurses, and pharmacists who provide routine care in aged care homes in Victoria, Australia. Interviews were coded using frameworks for understanding behavior change. Results Themes were established within 14 interviews, and an additional 6 interviews were undertaken to ensure thematic saturation. Two major themes emerged: (i) Antimicrobial stewardship activities near the end of life in aged care homes need to enable aged care home nurses to make decisions substantiated by evidence-based clinical knowledge. Antimicrobial stewardship should clearly be part of an aged care home nurse's role, and accreditation standards provide powerful motivation for behavior change. (ii) Antimicrobial stewardship activities near the end of life in aged care homes must address family confidence in resident wellbeing. Antimicrobial stewardship activities should be inclusive of family involvement, and messages should highlight the point that antimicrobial stewardship improves care. Conclusions Antimicrobial stewardship activities that reinforce evidence-based clinical decision-making by aged care home nurses and address family confidence in resident wellbeing are required near the end of life in aged care homes. Accreditation standards are important motivators for behavior change in aged care homes.

IntroductionMultimodal interventions (MMI) are frequently used in various healthcare settings to encourage change in healthcare personnel practices and improve patient safety. In 2013, an MMI conducted in an Australian metropolitan ED used clinician champions, guidelines, education sessions and promotional materials to encourage a reduction in unused and inappropriate peripheral intravenous cannulas (PIVC). A 60-day postintervention demonstrated a successful reduction in the number of unused PIVCs without changes in appropriate insertions. We aimed to investigate if this MMI produced a sustained effect in reducing the frequency of unused PIVCs inserted in this ED.MethodsA single-centre retrospective cohort study of adult patients presenting to the above ED in Victoria, Australia, was conducted in April 2018. A random sample of 380 patients with a PIVC inserted in ED was assessed to determine if the PIVC was used (termed ‘Long-term follow-up’). The appropriateness of unused PIVCs was assessed. Our findings were compared with previously collected data in 2013 (‘Pre-Intervention’ and ‘Immediately Post-Intervention’) to determine a sustained reduction in the frequency of unused PIVC insertions was achieved. Long-term analysis of the MMI, including the overall frequency of PIVC insertions in ED before and after the MMI, was also collected.ResultsIn our Long-term follow-up cohort, 101 of 373 (27.1%, 95% CI 22.6% to 31.9%) PIVCs were unused (seven cases excluded). This was significantly lower than the Pre-Intervention cohort (139/376, 37.0%, 95% CI 32.1% to 42.1%). While not significant, the frequency of unused PIVCs in the Post-Intervention cohort was lower in comparison (73/378, 19.3%, 95% CI 15.4% to 23.7%). No significant change in the appropriateness of unused PIVCs was observed between the Post-Intervention and Long-term follow-up. The overall proportion of patients receiving a PIVC has remained low since the MMI.ConclusionAn MMI aimed at reducing unused PIVC insertions in ED has been effective in eliciting sustained change. Unused but appropriately inserted PIVCs seem unaffected by the intervention.

Background The excessive use of antimicrobials in aged-care homes is a widely recognised phenomenon. This is problematic because it can harm residents, and is detrimental to public health. Residents in the final month of life are increasingly likely to be prescribed an antimicrobial, commonly without having signs and symptoms of infection that support antimicrobial use. Objectives We aimed to describe the perspectives of health professionals on antimicrobial use near the end of life in aged-care homes and investigate the potential opportunities for nurses to undertake antimicrobial stewardship activities near the end of life in aged-care homes. Design One-on-one, semi-structured, qualitative interviews. Settings and participants Twelve nurses, six general practitioners and two pharmacists providing routine care to residents of aged-care homes in Victoria, Australia were interviewed. Diversity in terms of years of experience, aged-care funding type (government, private-for-profits and not-for-profits) and location (metropolitan and regional) were sought. Methods Interviews were transcribed and open coded in a descriptive manner using validated frameworks for understanding behaviour change. The descriptive code was then used to build an interpretive code structure based on questions founded in grounded theory. Results Thematic saturation was reached after fourteen interviews, and an additional six interviews were conducted to ensure emergent themes were consistent and definitive. There are opportunities for aged-care home nurses to undertake antimicrobial stewardship activities near the end of life in the provision of routine care. Aged-care home nurses are influential in antimicrobial decisions near the end of life in routine care because of their leadership in advance care planning, care co-ordination and care provision in an environment with stopgap and visiting medical resources. Nurses also have social influence among residents, families and medical professionals during critical conversations near the end of life. Past negative social interactions within the aged-care home environment between nurses and families can result in ‘fear-based’ social influences on antimicrobial prescribing. Conclusions The work of facilitating advance care planning, care coordination, care delivery, and communicating with families and medical professionals provide important opportunities for aged-care home nurses to lead appropriate antimicrobial stewardship activities near the end of life.

Background Since 2015 the Aged Care National Antimicrobial Prescribing Survey has collected and reported data on antibiotic use in Australian aged care homes (ACHs) as part of the Australian Commission on Safety and Quality in Health Care's Antimicrobial Use and Resistance in Australia project. The objective of this study was to analyze this data source with regards to prescribing for urinary tract infections (UTIs) to improve the use of antibiotics. Methods This cross-sectional study analyzed the 2016 and 2017 survey data. Antibiotic prescribing for urinary tract indications was compared with national guideline recommendations. Results A total of 662 antibiotic prescriptions from 247 ACHs were analyzed. For all prophylactic antibiotics for UTI, 51.8% were prescribed for longer than 6 months, contrary to the guideline recommendation. Most antibiotics prescribed for treatment (71.6%) were for cystitis. Cefalexin was most frequently selected for treatment of cystitis, with 10.4% of these prescriptions being concordant with the recommendations. Prescribing additional daily doses of cefalexin occurred in 63.2% of prescriptions. Conclusions Antimicrobial stewardship activities targeting UTI prophylaxis for durations longer than 6 months, and excessive daily doses of cefalexin to treat cystitis could yield significant reductions in unnecessary antibiotic consumption among Australian residents of ACHs.

Aim There is no national consensus on infection control in haemodialysis units in Australia and New Zealand. The primary aim of this guideline was to provide recommendations on screening for blood-borne viruses and multi-resistant organisms for dialysis units based on the available evidence. Methods The Kidney Health Australia Caring for Australasians with Renal Impairment guidelines, overall approach to guideline development follows the GRADE framework. A facilitated workshop was conducted to ensure that patient and caregiver concerns were considered. The evidence from relevant medical databases on the impact of screening on detection and transmission rates, hospitalization, mortality and psychosocial care, was reviewed and critically appraised. The guideline group made recommendations from the evidence available. Results The main guideline recommendations are: Dialysis units adopt a comprehensive approach that encompasses standard infection control precautions. Conduct routine surveillance for key blood-borne viruses and methicillin-resistant Staphylococcus aureus. Conduct routine surveillance of individual levels of protection against hepatitis B for patients on haemodialysis. Use dedicated dialysis machines for HBV-infected patients. The evidence in totality was not found to support routine surveillance of vancomycin-resistant Enterococci . Enhanced surveillance in light of the local risk of transmittable infectious agents should be considered by dialysis units. Very few studies have reported on the potential adverse effects of screening and associated practices. Conclusions Future research should focus on the potential benefits and adverse effects of screening and associated practices on clinical outcomes including infections prevented and health service delivery, and psychosocial domains for patients. Given the results of trials in the critical setting, the effectiveness of methicillin-resistant Staphylococcus aureus decolonization in people receiving dialysis therapy warrants further research.

© 2019 Chen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Background Widespread use of antibiotics has led to the development of antibiotic resistance. However, there are limited data describing antibiotic use in the community setting, and examining factors associated with greater use. Our study aimed to quantify antibiotic dispensing in older adults in the community according to socio-demographics and health services use. Methods Prospective analysis of a population-based cohort study of 239,981 adults aged 45 years in Australia (the Sax Institute’s 45 and Up Study). Data on socio-demographics and health from a questionnaire, were linked to 2015 antibiotic dispensing data from the Pharmaceutical Benefits Scheme (PBS), as well as other administrative health databases. We estimated the Defined Daily Dose (DDD) of systemic antibiotics dispensed, defined by an Anatomic Therapeutic Classification code beginning with J01, in 2015. We also conducted Poisson regression with robust standard errors to identify factors associated with antibiotic dispensing. Results Overall, 49.3% of 45 and Up Study participants had at least one systemic antibiotic dispensed in 2015 with a total of 392,856 prescriptions dispensed and an average of 36.5 DDDs/1000-persons/day in the study population. The quantity of antibiotics dispensed increased with increasing age (25.6 DDDs/1000/day in 15 general practitioner consultations in the last year (80.5 and 88.3 DDDs/1000/day, respectively). These factors remained strongly associated with greater antibiotic dispensing after adjusting for age, sex, education, income, area of residence and co-morbidities. Conclusions Residence in aged care facilities and high GP visits are associated with greater antibiotic dispensing. This study provides important evidence regarding high use groups for antimicrobial stewardship.

Background Antimicrobial stewardship teams play an important role in assisting with the optimization of antimicrobial use in acute care settings. We aimed to determine whether a rapid review by a multidisciplinary antimicrobial stewardship team would improve the timeliness of optimal antimicrobial therapy for patients with positive blood cultures. Methods This prospective randomized controlled trial was undertaken in two Australian hospitals. Patients received either standard care (a clinical microbiologist, registrar or laboratory scientist communicating the positive blood culture by phone to the treating doctor) or intervention (standard care plus rapid review by a multidisciplinary antimicrobial stewardship team). Outcomes included time to appropriate and/or active antimicrobial therapy and in-hospital mortality. The trial was registered on the Australian New Zealand Clinical Trials Registry (ACTRN12614000258651). Results A total of 160 patients were enrolled in this study: 81 in the standard care arm and 79 in the intervention arm. Patients in the intervention arm were commenced earlier on active (HR 8.02, 95% CI: 2.15-29.91) and appropriate antimicrobials (HR 1.95, 95% CI: 1.13-3.38), with a higher proportion of patients allocated to the intervention arm receiving active therapy at 48 h (96% versus 82%) and appropriate therapy at 72 h (70% versus 54%). The majority of patients where the blood culture was a contaminant were not started on antimicrobial therapy, and there were no significant differences in time to cessation of antimicrobial therapy. Conclusions Antimicrobial stewardship team review of patients with pathogenic positive blood cultures improved the time to both active and appropriate antimicrobial therapy.