Cluster randomised controlled trial of an infection control education and training intervention programme focusing on meticillin-resistant Staphylococcus aureus in nursing homes for older people. Effect of a comprehensive infection control program on the incidence of infections in long-term care facilities. The use of a ward-based educational teaching package to enhance nurses' compliance with infection control procedures. Results of a multicentre randomised controlled trial of statistical process control charts and structured diagnostic tools to reduce ward-acquired meticillin-resistant Staphylococcus aureus: the CHART Project. Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years. Cluster randomised controlled trial of tailored interventions to improve the management of urinary tract infections in women and sore throat. Impact of an infection control program in a specialized preschool. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. Impact of oral antimicrobial prophylaxis on surgical site infection and methicillin-resistant Staphylococcus aureus infection after elective colorectal surgery. Results of a prospective randomized trial.
The aim of this cluster randomised controlled trial was to test the impact of an infection control education and training programme on meticillin-resistant Staphylococcus aureus (MRSA) prevalence in nursing homes. Nursing homes were randomised to intervention (infection control education and training programme; N=16) or control (usual practice continued; N=16). Staff in intervention homes were educated and trained (0, 3 and 6 months) in the principles and implementation of good infection control practice with infection control audits conducted in all sites (0, 3, 6 and 12 months) to assess compliance with good practice. Audit scores were fed back to nursing home managers in intervention homes, together with a written report indicating where practice could be improved. Nasal swabs were taken from all consenting residents and staff at 0, 3, 6 and 12 months. The primary outcome was MRSA prevalence in residents and staff, and the secondary outcome was a change in infection control audit scores. In all, 793 residents and 338 staff were recruited at baseline. MRSA prevalence did not change during the study in residents or staff. The relative risk of a resident being colonised with MRSA in an intervention home compared with a control home at 12 months was 0.99 (95% confidence interval: 0.69, 1.42) after adjustment for clustering. Mean infection control audit scores were significantly higher in the intervention homes (82%) compared with the control homes (64%) at 12 months (P<0.0001). Consideration should be given to other approaches which may help to reduce MRSA in this setting.
                Copyright 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. Control of infection within the long-term care facility is a daunting problem. Elderly patients are at high risk for contracting infection because of reduced innate immunity, malnutrition, and the presence of chronic medical conditions. This small study tested the effect of developing and implementing a comprehensive preventive infection control program in the long-term care setting and examined the resultant incidence of infections.
                Eight private, freestanding, long-term care facilities in urban and suburban settings were selected for the study. The 4 test sites had a total of 443 beds; there were 447 beds in 4 matched control sites. Data on infection rates were accrued in both preintervention and intervention years. The control homes maintained their existing infection control policies and procedures. The test homes were provided with an infection control educational program and replaced all currently used germicidal products with single-branded products for a 12-month period. A criteria-based standardized infection control surveillance system was used to monitor and report infections in all facilities.
                In the preintervention year, the test sites experienced 743 infections (incidence density rate, 6.33) and the control homes experienced 614 infections (incidence density rate, 3.39). In the intervention year, the test homes reported 621 infections, a decrease of 122 infections (incidence density rate, 4.15); in the control homes, the number of infections increased slightly, to 626 (incidence density rate, 3.15). The greatest reduction in infections in the test homes was in upper respiratory infections (P =.06).
                This study provides additional evidence that a comprehensive infection control program that includes handwashing and environmental cleaning and disinfecting may help reduce infections among the elderly residing in long-term care settings. Obtaining study leave is becoming difficult for clinical nurses in the current economic climate, but the need to develop new clinical skills and to maintain existing good practice remains of prime importance to patient care and will become mandatory with the advent of post-registration education and practice (PREP) in the UK. The ward is widely acknowledged as the best venue for learning clinical skills by nurse educationalists and for many nurses is the preferred learning environment. The feasibility of using a ward-based teaching package to enhance nurses' compliance with key infection control precautions (hand decontamination, the use of gloves and the safe handling and disposal of sharp instruments) was tested in a quasi-experimental research study conducted on matched surgical wards in a teaching hospital, controlling for variables likely to influence performance (knowledge, availability of resources to perform infection control, previous opportunity to develop infection control expertise and nursing workload). Nurses on two wards received the intervention (experimental group). The remaining wards, which received no intervention, operated as controls. The ward-based sessions consisted of a carefully planned sequence of theory and practical demonstration delivered to qualified nurses in the clinical environment at convenient times selected by the ward managers. Performance of infection control precautions was audited before the intervention and 3 months afterwards. The sessions were well evaluated and the clinical environment was considered suitable for teaching by the nurses, but heavy and unpredictable workload prevented the teaching programme from being implemented as planned. The analysis of covariance failed to detect any changes in performance between nurses in the control and experimental groups. The implications of the study findings are discussed to help develop creative new ways of strengthening ward-based educational programmes. Statistical process control (SPC) charts have previously been advocated for infection control quality improvement. To determine their effectiveness, a multicentre randomised controlled trial was undertaken to explore whether monthly SPC feedback from infection control nurses (ICNs) to healthcare workers of ward-acquired meticillin-resistant Staphylococcus aureus (WA-MRSA) colonisation or infection rates would produce any reductions in incidence. Seventy-five wards in 24 hospitals in the UK were randomised into three arms: (1) wards receiving SPC chart feedback; (2) wards receiving SPC chart feedback in conjunction with structured diagnostic tools; and (3) control wards receiving neither type of feedback. Twenty-five months of pre-intervention WA-MRSA data were compared with 24 months of post-intervention data. Statistically significant and sustained decreases in WA-MRSA rates were identified in all three arms (P<0.001; P=0.015; P<0.001). The mean percentage reduction was 32.3% for wards receiving SPC feedback, 19.6% for wards receiving SPC and diagnostic feedback, and 23.1% for control wards, but with no significant difference between the control and intervention arms (P=0.23). There were significantly more post-intervention 'out-of-control' episodes (P=0.021) in the control arm (averages of 0.60, 0.28, and 0.28 for Control, SPC and SPC+Tools wards, respectively). Participants identified SPC charts as an effective communication tool and valuable for disseminating WA-MRSA data. To evaluate the impact of an interventional multidisciplinary antibiotic management program on expenditures for antibiotics and on the incidence of nosocomial infections caused by Clostridium difficile and antibiotic-resistant pathogens during 7 years.
                Prospective study with comparison with preintervention trends.
                University-affiliated teaching hospital.
                All adult inpatients.
                A multidisciplinary antibiotic management program to minimize the inappropriate use of third-generation cephalosporins was implemented in 1991. Its impact was evaluated prospectively. The incidence of nosocomial C. difficile and resistant Enterobacteriaceae infections as well as the rate of vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) were compared with those of National Nosocomial Infections Surveillance System hospitals of similar size.
                Following implementation of the program, there was a 22% decrease in the use of parenteral broad-spectrum antibiotics (P < .0001) despite a 15% increase in acuity of patient care during the following 7 years. Concomitantly, there was a significant (P = .002) decrease in nosocomial infections caused by C. difficile and a significant (P = .02) decrease in nosocomial infections caused by resistant Enterobacteriaceae. The program also appeared to have a favorable impact on VRE rates without a sustained impact on MRSA rates.
                These results suggest that an ongoing multidisciplinary antibiotic management program may have a sustained beneficial impact on both expenditures for antibiotics and the incidence of nosocomial infection by C. difficile and resistant bacterial pathogens. To assess the effectiveness of tailored interventions to implement guidelines for urinary tract infections in women and sore throat.
                Unblinded, cluster randomised pretest-post-test trial.
                142 general practices in Norway.
                72 practices received interventions to implement guidelines for urinary tract infection and 70 practices received interventions to implement guidelines for sore throat, serving as controls for each other. 59 practices in the urinary tract infection group and 61 practices in the sore throat group completed the study. Outcomes were measured in 16 939 consultations for sore throat and 9887 consultations for urinary tract infection.
                Interventions were developed to overcome identified barriers to implementing the guidelines. The main components of the tailored interventions were patient educational material, computer based decision support and reminders, an increase in the fee for telephone consultations, and interactive courses for general practitioners and practice assistants.
                Changes in rates of use of antibiotics, laboratory tests, and telephone consultations. Results: Patients in the sore throat group were 3% less likely to receive antibiotics after the intervention. Women with symptoms of urinary tract infection in the intervention group were 5.1% less likely to have a laboratory test ordered. No significant differences were found between the groups for the other outcomes. Large variation was found across the included practices in the rates of antibiotic prescription, use of laboratory tests and telephone consultations, and in the extent of change for all three outcome measures.
                Passively delivered, complex interventions targeted at identified barriers to change had little effect in changing practice. The purpose of this study was to design and implement a comprehensive infection control program and measure its effects on the number and types of infectious illnesses experienced by children attending a specialized preschool program.
                Participants in the study were children with Down syndrome enrolled in a school-based early intervention program. The ages of the children ranged from 6 weeks to 5 years. Through a series of parental questionnaires, the number and types of infections in the children were chronicled for a year before and a year after the implementation of an infection control intervention program. Interventions included infection control lectures, handouts, posters, and attention to environmental cleaning and disinfection, with an emphasis on toys. Compliance with these measures was monitored and recorded.
                During the interventional year the median number of total illnesses/child/month decreased significantly from the baseline year (0.70 vs 0.53, p < 0.05), with a trend toward a decrease in the number of respiratory illnesses (0.67 vs 0.42, p < 0.07). Significant decreases were also seen for the median number of physician visits (0.50 vs 0.33, p < 0.05), courses of antibiotics administered (0.33 vs 0.28, p < 0.05), and days of school missed as a result of respiratory illness (0.75 vs 0.40, p < 0.05).
                This study demonstrates a decrease in infection rates with the implementation of a comprehensive educational and environmental infection control program in a day care setting. To assess whether a multifaceted intervention can reduce the number of prescriptions for antimicrobials for suspected urinary tract infections in residents of nursing homes.
                Cluster randomised controlled trial.
                24 nursing homes in Ontario, Canada, and Idaho, United States.
                12 nursing homes allocated to a multifaceted intervention and 12 allocated to usual care. Outcomes were measured in 4217 residents.
                Diagnostic and treatment algorithm for urinary tract infections implemented at the nursing home level using a multifaceted approach--small group interactive sessions for nurses, videotapes, written material, outreach visits, and one on one interviews with physicians.
                Number of antimicrobials prescribed for suspected urinary tract infections, total use of antimicrobials, admissions to hospital, and deaths.
                Fewer courses of antimicrobials for suspected urinary tract infections per 1000 resident days were prescribed in the intervention nursing homes than in the usual care homes (1.17 v 1.59 courses; weighted mean difference -0.49, 95% confidence intervals -0.93 to -0.06). Antimicrobials for suspected urinary tract infection represented 28.4% of all courses of drugs prescribed in the intervention nursing homes compared with 38.6% prescribed in the usual care homes (weighted mean difference -9.6%, -16.9% to -2.4%). The difference in total antimicrobial use per 1000 resident days between intervention and usual care groups was not significantly different (3.52 v 3.93; weighted mean difference -0.37, -1.17 to 0.44). No significant difference was found in admissions to hospital or mortality between the study arms.
                A multifaceted intervention using algorithms can reduce the number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes. The impact of oral antimicrobial prophylaxis on the surgical site infection and methicillin-resistant Staphylococcus aureus (MRSA) infection after elective colorectal surgery was evaluated by a prospective randomized single-blind study. The patients were randomly allocated to receive either mechanical bowel cleansing with polyethylene glycol alone (group 1) or mechanical cleansing plus oral antimicrobial prophylaxis with kanamycin and erythromycin for 2 days prior to surgery (group 2). In both groups, cefotiam was intravenously given twice a day for 3 days. A total of 143 patients (71 for group 1 and 72 for group 2) were eligible. The incidence of a surgical site infection was 23.9% in group 1 and 11.1% in group 2 (P = 0.04). The incidence of MRSA infection including at surgical and remote sites was 11.1% in group 1 and 5.6% in group 2 (P = 0.19). A multivariate logistic regression analysis showed that the risk of surgical site infection was influenced by the choice of the chemical bowel preparation (P = 0.03) and blood loss (P < 0.01), while an MRSA infection was predominantly influenced by blood loss (P < 0.01) followed by coexisting underlying diseases (P = 0.07). These results suggest that preoperative antimicrobial prophylaxis would be useful for reducing the incidence of a surgical site infection without increasing the risk of an MRSA infection following elective colorectal surgery.
There is a lack of research evaluating the effects on MRSA transmission of infection prevention and control strategies in nursing homes. Rigorous studies should be conducted in nursing homes, to test interventions that have been specifically designed for this unique environment.