Professor Brett Mitchell

Background: ¿Contact precautions,¿ are recommended for hospitalised patients with known methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) colonisation. Despite increasing observational evidence suggesting that gowns and gloves are of no added benefit over hand hygiene and environmental cleaning, guidelines continue to recommend them. Methods: A cross-sectional online survey of infection prevention professionals, infectious diseases physicians and microbiologists in Australian and New Zealand hospitals was conducted. The purpose was to explore variations in current approaches to known MRSA and VRE colonisation, and determine clinical equipoise for a proposed randomised control trial (RCT) to withdraw the use of gowns and gloves in this setting. Results: 226 responses from 122 hospitals across all Australian jurisdiction and multiple regions of New Zealand were received. While most hospitals implement contact precautions for MRSA (86%) and VRE (92%), variations based on MRSA and VRE subtypes are common. There was strong interest in removing glove and gown use for MRSA (72% and 73%, respectively) and VRE (70% and 68%, respectively). 62% of surveyed hospitals expressed interest in participating in a proposed cluster RCT comparing discontinuation of gown and glove use as part of contact precautions for MRSA and VRE, with their ongoing use. Conclusion: The mandated use of PPE in the context of MRSA and VRE colonisation warrants further examination. An RCT is needed to definitively address this issue and to promote a widespread change in practice, if warranted.

Background: Healthcare-associated infections (HAIs) are a common, costly, yet largely preventable complication impacting patients in healthcare settings globally. Improving routine cleaning and disinfection of the hospital environment has been shown to reduce the risk of HAI. Contaminated shared medical equipment presents a primary transmission route for infectious pathogens, yet is rarely studied. The CLEEN study will assess how enhanced cleaning and disinfection of shared medical equipment affects the rate of HAIs in a tertiary hospital setting. The initiative is an evidence-based approach combining staff training, auditing and feedback to environmental services staff to enhance cleaning and disinfection practices. Methods: The CLEEN study will use a stepped wedge randomised controlled design in 10 wards of one large Australian hospital over 36¿weeks. The intervention will consist of 3 additional hours per weekday for the dedicated cleaning and disinfection of shared medical equipment on each ward. The primary outcome is to demonstrate the effectiveness of improving the quality and frequency of cleaning shared medical equipment in reducing HAIs, as measured by a HAI point prevalence study (PPS). The secondary outcomes include the thoroughness of equipment cleaning assessed using fluorescent marker technology and the cost-effectiveness of the intervention. Discussion: Evidence from the CLEEN study will contribute to future policy and practice guidelines about the cleaning and disinfection of shared medical equipment. It will be used by healthcare leaders and clinicians to inform decision-making and implementation of best-practice infection prevention strategies to reduce HAIs in healthcare facilities. Trial registration: Australia New Zealand Clinical Trial Registry ACTRN12622001143718.

Infection transmission in healthcare is multifaceted and by in large involves the complex interplay between a pathogen, a host and their environment. To prevent transmission, infection prevention strategies must also consider these complexities and incorporate targeted interventions aimed at all possible transmission pathways. One strategy to prevent and control infection is environmental cleaning. There are many aspects to an environmental cleaning strategy. We believe the key to successfully reducing the risk of healthcare-associated infections through the environment, is to design and implement a multimodal intervention. This paper aims to provide an overview of important considerations for designing a meaningful and sustainable environmental program for healthcare facilities.

Background: The cost-effectiveness of patient isolation as part of an infection prevention effort is poorly understood. The potential to reduce risks of transmission saving costs and improving health outcomes is strong, yet up front investments in patient isolation are required. We report a cost-effectiveness model to inform adoption of a portable single isolation rooms into Australian publicly funded acute hospitals. Methods: Information is harvested from a range of contemporary sources to reveal the expected changes to total costs and total health benefits measured by life years gain. An Incremental cost-effectiveness ratio is estimated with uncertainty in all model parameters included by probabilistic sensitivity analysis. Results: The adoption decision was found to change total costs per 100,000 occupied bed-days by $1,429,011 and generate health benefits of 436 life years. The mean cost per life year gained is $3278. The probability an adoption decision is cost saving is 2.1%. Conclusion: There is some evidence that adoption of rediroom is likely to be a cost-effective solution for Australian hospitals. Important caveats and assumptions need to be considered when interpreting this conclusion.

Background: Millions of people have acquired and died from SARS-CoV-2 infection during the COVID-19 pandemic. Healthcare workers (HCWs) are required to wear personal protective equipment (PPE), including surgical masks and P2/N95 respirators, to prevent infection while treating patients. However, the comparative effectiveness of respirators and masks in preventing SARS-CoV-2 infection and the likelihood of experiencing adverse events (AEs) with wear are unclear. Methods: Searches were carried out in PubMed, Europe PMC and the Cochrane COVID-19 Study Register to 14 June 2021. A systematic review of comparative epidemiological studies examining SARS-CoV-2 infection or AE incidence in HCWs wearing P2/N95 (or equivalent) respirators and surgical masks was performed. Article screening, risk of bias assessment and data extraction were duplicated. Meta-analysis of extracted data was carried out in RevMan. Results: Twenty-one studies were included, with most having high risk of bias. There was no statistically significant difference in respirator or surgical mask effectiveness in preventing SARS-CoV-2 infection (OR 0.85, [95%CI 0.72, 1.01]). Healthcare workers experienced significantly more headaches (OR 2.62, [95%CI 1.18, 5.81]), respiratory distress (OR 4.21, [95%CI 1.46, 12.13]), facial irritation (OR 1.80, [95%CI 1.03, 3.14]) and pressure-related injuries (OR 4.39, [95%CI 2.37, 8.15]) when wearing respirators compared to surgical masks. Conclusion: The existing epidemiological evidence does not enable definitive assessment of the effectiveness of respirators compared to surgical masks in preventing infection. Healthcare workers wearing respirators may be more likely to experience AEs. Effective mitigation strategies are important to ensure the uptake and correct use of respirators by HCWs.

Background: As frontline providers of care, nurses and midwives play a critical role in controlling infections such as COVID-19, influenza, multi-drug resistant organisms and health care associated infections. Improved cleaning can reduce the incidence of infection and is cost effective but relies on healthcare personnel to correctly apply cleaning measures. As nurses and midwives have the most contact with patients and as an important first step in improving compliance, this study sought to explore nurses' and midwives¿ knowledge on the role of the environment in infection prevention and control and identify challenges in maintaining clean patient environments. Methods: Cross-sectional online survey of 96 nurses (RN/EN) and midwives (RW) employed in clinical settings (e.g. hospital, aged care, medical centre, clinic) in Australia. Results: Nurses and midwives broadly stated that they understood the importance of cleaning. However, cleaning responsibilities varied and there was confusion regarding the application of different disinfectants when cleaning after patients with a suspected or diagnosed infection post-discharge. Most would not be confident being placed in a room where a previous patient had a diagnosed infection such as multi-drug resistant organism. Conclusion: Greater organisational support and improving applied knowledge about infection control procedures is needed. This includes correct use of disinfectants, which disinfectant to use for various situations, and cleaning effectively following discharge of a patient with known infection. The cleanliness of shared medical equipment may also pose current risk due to lack of cleaning.

Objective To predict the cost and health effects of routine use of whole-genome sequencing (WGS) of bacterial pathogens compared with those of standard of care. Design Budget impact analysis was performed over the following 5 years. Data were primarily from sequencing results on clusters of multidrug-resistant organisms across 27 hospitals. Model inputs were derived from hospitalisation and sequencing data, and epidemiological and costing reports, and included multidrug resistance rates and their trends. Setting Queensland, Australia. Participants Hospitalised patients. Interventions WGS surveillance of six common multidrug-resistant organisms (Staphylococcus aureus, Escherichia coli, Enterococcus faecium, Klebsiella pneumoniae, Enterobacter sp and Acinetobacter baumannii) compared with standard of care or routine microbiology testing. Primary and secondary outcomes Expected hospital costs, counts of patient infections and colonisations, and deaths from bloodstream infections. Results In 2021, 97 539 patients in Queensland are expected to be infected or colonised with one of six multidrug-resistant organisms with standard of care testing. WGS surveillance strategy and earlier infection control measures could avoid 36 726 infected or colonised patients and avoid 650 deaths. The total cost under standard of care was A170.8 million in 2021. WGS surveillance costs an additional A26.8 million but was offset by fewer costs for cleaning, nursing, personal protective equipment, shorter hospital stays and antimicrobials to produce an overall cost savings of 30.9 million in 2021. Sensitivity analyses showed cost savings remained when input values were varied at 95% confidence limits. Conclusions Compared with standard of care, WGS surveillance at a state-wide level could prevent a substantial number of hospital patients infected with multidrug-resistant organisms and related deaths and save healthcare costs. Primary prevention through routine use of WGS is an investment priority for the control of serious hospital-associated infections.

Objective A systematic review on meatal cleaning prior to urinary catheterisation and post catheterisation and reduces the risk catheter-associated urinary tract infections (CAUTIs) and bacteriuria was published in 2017, with further studies undertaken since this time. The objective of this paper is to present an updated systematic review on the effectiveness of antiseptic cleaning of the meatal area for the prevention of CAUTIs and bacteriuria in patients who receive a urinary catheter. Design Systematic review. Data sources Electronic databases Cochrane Library, PubMed, Embase, The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline and Academic Search Complete were searched from 1 January 2016 and 29 February 2020. Eligibility criteria Randomised controlled trials (RCTs) and quasi-experimental studies evaluating the use of antiseptic, antibacterial or non-medicated agents for cleaning the meatal, periurethral or perineal areas before indwelling catheter insertion or intermittent catheterisation or during routine meatal care. Data extraction and synthesis Data were extracted using the Cochrane Collaboration's data collection form for RCTs and non-RCTs. Data were extracted by one researcher and then checked for accuracy by a second researcher. Results A total of 18 studies were included. Some potential benefit of using antiseptics, compared with non-antiseptics for meatal cleaning to prevent bacteriuria and or CAUTI was identified (OR 0.84, 95% CI 0.69 to 1.02; p=0.071). Antiseptics (chlorhexidine or povidine-iodine) may be of value for meatal cleaning on the incidence of CAUTI, compared with comparator agents (saline, soap or antimicrobial cloths) (OR=0.65, 95% CI 0.42 to 0.99; p=0.047). Conclusion There is emerging evidence of the role of some specific antiseptics (chlorhexidine) prior to urinary catheterisation, in reducing CAUTIs, and some potential benefit to the role of antiseptics more generally in reducing bacteriuria. PROSPERO registration number CRD42015023741.

Background: COVID-19 has placed unprecedented demands on infection control professionals (ICPs) and infectious disease (ID) physicians. This study examined their knowledge, preparedness, and experiences managing COVID-19 in the Australian healthcare settings. Methods: A cross-sectional study of ICPs and ID physician members of the Australasian College for Infection Prevention and Control (ACIPC) and the Australasian Society for Infectious Diseases (ASID) was conducted using an online survey. Descriptive statistics were used to summarise and report data. Results: A total of 103 survey responses were included in the analysis for ICPs and 45 for ID physicians. A majority of ICPs (78.7%) and ID physicians (77.8%) indicated having ¿very good¿ or ¿good¿ level of knowledge of COVID-19. Almost all ICPs (94.2%) relied on state or territory's department of health websites to source up-to-date information While most ID physicians (84.4%) used scientific literature and journals. A majority of ICPs (96%) and ID physicians (73.3%) reported feeling ¿moderately prepared¿ or ¿extremely prepared¿ for managing COVID-19. Most respondents had received specific training about COVID-19 within their workplace (ICPs: 75%; ID physicians: 66.7%), particularly training/certification in PPE use, which made them feel ¿mostly or entirely confident¿ in using it. Most ICPs (84.5%) and ID physicians (76.2%) reported having ¿considerably¿ or ¿moderately more¿ work added to their daily duties. Their biggest concerns included the uncertainties under a rapidly changing landscape, PPE availability, and the community's compliance. Conclusion: Harmonised information, specific COVID-19 training and education, and adequate support for front-line workers are key to successfully managing COVID-19 and other future outbreaks.

Background. Healthcare-associated infections (HAIs) remain a significant patient safety issue, with point prevalence estimates being ~5% in high-income countries. In 2016-2017, the Researching Effective Approaches to Cleaning in Hospitals (REACH) study implemented an environmental cleaning bundle targeting communication, staff training, improved cleaning technique, product use, and audit of frequent touch-point cleaning. This study evaluates the cost-effectiveness of the environmental cleaning bundle for reducing the incidence of HAIs. Methods. A stepped-wedge, cluster-randomized trial was conducted in 11 hospitals recruited from 6 Australian states and territories. Bundle effectiveness was measured by the numbers of Staphylococcus aureus bacteremia, Clostridium difficile infection, and vancomycin-resistant enterococci infections prevented in the intervention phase based on estimated reductions in the relative risk of infection. Changes to costs were defined as the cost of implementing the bundle minus cost savings from fewer infections. Health benefits gained from fewer infections were measured in quality-adjusted life-years (QALYs). Cost-effectiveness was evaluated using the incremental cost-effectiveness ratio and net monetary benefit of adopting the cleaning bundle over existing hospital cleaning practices. Results. Implementing the cleaning bundle cost $349 000 Australian dollars (AUD) and generated AUD$147 500 in cost savings. Infections prevented under the cleaning bundle returned a net monetary benefit of AUD$1.02 million and an incremental cost-effectiveness ratio of $4684 per QALY gained. There was an 86% chance that the bundle was cost-effective compared with existing hospital cleaning practices. Conclusions. A bundled, evidence-based approach to improving hospital cleaning is a cost-effective intervention for reducing the incidence of HAIs.

Background: The use of invasive devices increases the risk of healthcare associated infections (HAI). The recent national HAI point prevalence survey secondary outcomes aimed to estimate the prevalence of patients with an indwelling urinary catheter device and vascular access devices; and also identify prevalence of those managed under transmission based precautions (TBP); and those colonised or infected with a multi drug resistant organism (MDRO). Methods: A point prevalence study was conducted in large acute care Australian public hospitals. All data were collected by two trained Research Assistants. Surveillance methodology was based on the European Centre for Disease Prevention and Control PPS Protocol. Data was also collected on prevalence of TBPs and MDROs. Results: A total of 2767 acute adult inpatients were sampled across 19 hospitals. The prevalence of peripheral vascular, central vascular and urinary catheters devices was 55.2% (95%CI: 53.3%¿57.1%), 14.8% (95%CI: 13.5%¿16.1%) and 20.7% (95%CI: 19.2%¿22.3%) respectively. Of the 2767 patients sampled 285 (10.3%, 95%CI: 9.2%¿11.5%) were documented as either being infected or colonised with a MDRO, and 781 (11.8%) patients were being managed under the hospital TBP policy. Conclusion: This is the first national study to describe the prevalence of devices, TBPs and MDROs in Australian healthcare settings. In an era where device use should be constantly reviewed to minimise risk of HAI, and the increasing challenges of managing patients with MDROs, this data can serve as a benchmark for future studies.

Objective: To examine the global burden, associated point sources, and successful prevention and control measures for documented outbreaks of Burkholderia cepacia healthcare-associated infections (HAIs).Design: Integrative review.Methods: A review of all outbreaks of Burkholderia cepacia HAIs published in the peer-reviewed literature between January 1970 and October 2019 was conducted to identify the global burden, associated point sources, and successful prevention and control measures using the Guidelines for Outbreak Reports and Intervention Studies of Nosocomial Infections (ORION).Results: In total, we reviewed 125 documented outbreaks of Burkholderia cepacia-related HAIs worldwide. The reported B. cepacia HAIs for this period involved 3,287 patients. The point sources were identified in most outbreaks of B. cepacia HAIs (n = 93; 74.4%); they included medication vials, disinfectants, and antiseptics. Moreover, 95 of the outbreak reports (76%) described effective prevention and control measures, but only 33 reports indicated the use of a combination of environment-, patient- and staff-related measures. None of the outbreak reports used the ORION guidelines.Conclusions: Outbreaks of Burkholderia cepacia HAIs are an ongoing challenge. They are often associated with immunocompromised patients who acquire the infection from exposure to contaminated medications, products, and equipment. These outbreaks are not infrequent, and a range of infection prevention and control measures have been effective in arresting spread. The use of ORION guidelines for outbreak reporting would improve the quality of information and data to generate evidence for translation into practice.

Background: The environment has an important role in the transmission of healthcare associated infections. This has encouraged interest in novel methods to improve hygiene in hospitals. One such technology is the use of hydrogen peroxide to decontaminate rooms and equipment; there are, however, few studies that have investigated the effect of continuous dilute hydrogen peroxide (DHP) in the clinical environment. The aim of this study was to examine the use of dilute hydrogen peroxide (DHP) in a critical care unit and measure the microbiological impact on surface contamination. Methods: We conducted a prospective observational cross-over study in a ten-bed critical care unit in one rural Australian hospital. Selected high-touch sites were screened using dipslides across three study phases: baseline; continuous DHP; and no DHP (control). Quantitative aerobic colony counts (ACC) were assessed against a benchmark standard of ACC >2.5 cfu/cm2 to indicate hygiene failure. Results: There were low levels of microbial contamination in the unit for baseline; DHP; and no DHP phases: 2.2% (95% CI 0.7¿5.4%) vs 7.7% (95% CI 4.3¿13.0%) vs 6% (95% CI 3.2¿10.4%) hygiene failures, respectively. Significant reduction in ACCs did not occur when the DHP was operating compared with baseline and control phases. Conclusion: Further work is needed to determine whether continuous DHP technology has a role in decontamination for healthcare settings.

Nurses and midwives of Australia now is the time for change! As powerfully placed, Indigenous and non-Indigenous nursing and midwifery professionals, together we can ensure an effective and robust Indigenous curriculum in our nursing and midwifery schools of education. Today, Australia finds itself in a shifting tide of social change, where the voices for better and safer health care ring out loud. Voices for justice, equity and equality reverberate across our cities, our streets, homes, and institutions of learning. It is a call for new songlines of reform. The need to embed meaningful Indigenous health curricula is stronger now than it ever was for Australian nursing and midwifery. It is essential that nursing and midwifery leadership continue to build an authentic collaborative environment for Indigenous curriculum development. Bipartisan alliance is imperative for all academic staff to be confident in their teaching and learning experiences with Indigenous health syllabus. This paper is a call out. Now is the time for Indigenous and non-Indigenous nurses and midwives to make a stand together, for justice and equity in our teaching, learning, and practice. Together we will dismantle systems, policy, and practices in health that oppress. The Black Lives Matter movement provides us with a ¿now window¿ of accepted dialogue to build a better, culturally safe Australian nursing and midwifery workforce, ensuring that Black Lives Matter in all aspects of health care.

Background: Environmental cleaning is an important approach to reducing healthcare-associated infection. The aim of this short research paper is to describe changes in the efficacy of post-discharge cleaning by examining the amount of bio-burden on frequent touch points (FTPs) in patient areas, using a validated Adenosine Triphosphate (ATP) bioluminescence sampling method. In so doing, we present findings from a secondary outcome of a recent trial, the Researching Effective Approaches to Cleaning in Hospitals (REACH) study. Methods: The REACH study used a prospective, stepped-wedge randomised cluster design. Cross sectional ATP sampling was conducted at three of the 11 participating hospitals. At each hospital, during the control and intervention phase of the study, six Frequent Touch Points (FTPs) were sampled: toilet flush, bathroom tap, inside bathroom door handle, patient call button, over bed tray table, and bed rails. Results: Across the three hospitals, 519 surfaces in 49 rooms (control phase) and 2856 surfaces in 251 rooms (intervention phase) were sampled. Bedroom FTP cleaning improved across all three hospitals. The cleaning of bathroom FTPs was generally high from the outset and remained consistent throughout the whole study period. Average cleaning outcomes for bathroom FTPs were consistently high during the control period however outcomes varied between individual FTP. Changes in cleaning performance over time reflected variation in intervention effectiveness at the hospital level. Conclusion: Findings confirm improvement in cleaning in the FTPs in bedrooms, demonstrating improvements in discharge cleaning aligned with the improvements seen when using fluorescent marking technology as a marker of performance.

An important aspect of safety and quality in healthcare is the implementation of infection prevention and control guidelines. However, little is known regarding the strength of evidence on which recommendations for such guidelines are based. This study aimed to describe the strength of recommendations of infection prevention and control guidelines published in the last 10 years. For this review, the websites of government and professional organizations for national and international infection prevention and control clinical guidelines were purposively searched. The search was limited to publications between January 2009 and April 2019, and those with a formal grading system were used to determine the strength of the evidence underpinning the recommendations. Recommendations from guidelines were categorized into 21 infection control categories. A descriptive synthesis of the data was undertaken. A total of 31 guidelines comprising 1855 recommendations were included. Guidelines were mainly developed in the USA (N = 11, 35.5%) and Canada (N = 9, 29.0%). Most guidelines used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach (N = 6, 19.4%. The majority of the guidelines contained recommendations categorized under the themes of devices (N = 316, 16.9%) and transmission-based precautions (N = 315, 16.8%). Most recommendations (N = 769, 41.5%) were graded as using evidence from descriptive studies, expert opinion and low-quality evidence. There are a vast number of infection prevention and control guidelines developed by national and international government or professional organizations, many without a strong evidence base. This presents multiple research opportunities that should prioritize common prevention activities that currently have a low evidence base.

Background: Healthcare-associated infections are serious and significant complications present across healthcare services, including residential aged care facilities. Although ensuring high quality personal and clinical care delivered to older people residing in these facilities is a high national priority, there is a paucity of evidence published about outbreaks, governance and education programs held for healthcare workers within Australian residential aged care facilities. The aim of this study is to examine the scope of practice of Infection Prevention and Control professionals within Australian residential aged care facilities and the types of infection prevention and control education and training delivered. Methods: A cross-sectional study was conducted inviting all Australian residential aged care facilities to participate in an online survey. Results: A total of 134 residential aged care facilities completed the survey. The majority (88.1%) reported having a designated Infection Prevention and Control professional responsible for surveillance and educational activities. Hand hygiene (94%), personal protective equipment (PPE) (79.9%) and environmental cleaning (70.1%) were some of the available Infection Prevention and Control programs. The lack of access to Infection Prevention and Control education (69.5%) and lack of Infection Prevention and Control expert advice (67.2%) were also reported by some Residential aged care facilities. Conclusion: Australian residential aged care facilities recognise the importance of Infection Prevention and Control training programs to manage infection surveillance and outbreaks. Considerable activities are carried out to increase knowledge on breaking the chain of infection. Yet, more support and resources are needed to assist these efforts.

Background: Non-antibiotic interventions for urinary tract infection (UTI) prevention have been investigated as a strategy to reduce antibiotic prescribing for UTI and subsequent antibiotic resistance. Increased hydration is widely advocated for preventing UTI; however, evidence for its effectiveness is unknown. Aim: To systematically review the published literature on the effectiveness of increased fluid intake as a preventive intervention for UTI in adults and children in any setting. Methods: Five electronic databases were searched from inception to February 2019 to identify published randomized controlled trials (RCTs) and quasi-experimental studies evaluating the effectiveness of high (=1.5 L/24 h) versus normal/low (<1.5 L/24 h) fluid intake for UTI prevention. The outcome was UTI incidence. Risk of bias was assessed using the Cochrane Collaboration's tool. Due to the small number of studies identified, meta-analysis was not possible. Hence a narrative synthesis was undertaken. Findings: Of the 2822 potentially relevant papers, two were eligible for inclusion: an RCT (individual randomization) and a cluster-RCT. Both studies differed regarding participants, setting, sample size, UTI definition, and intervention. The RCT was assessed as having a low risk of bias whereas the cluster-RCT had a high risk of bias. Only the RCT, which included healthy premenopausal women visiting primary care clinics, demonstrated statistical significance for the effect of high fluid intake for UTI prevention. Conclusion: The lack of enough adequately powered and robust RCTs highlights the need for further research on the effectiveness of this intervention for UTI prevention.

Background: Individuals in residential and aged care facilities (RACFs) are at risk of developing health care-associated infections (HAIs) due to factors such as age-related changes in physiology, immunity, comorbid illness and functional disability. The recent establishment of an Australian Royal Commission into the Quality of Residential and Aged Care Services highlights the challenges of providing care in this sector. This national study identified infection prevention and control (IPC) services, practice and priorities in Australian RACFs. Methods: A cross-sectional study of 158 Australian RACFs comprising a 42-question survey incorporating five key domains relating to IPC namely governance, education, practice, surveillance, competency and capability was undertaken in 2018. Results: Of the 131 respondents, the majority 92.4% of respondents reported having a documented IPC program, 22.9% (n = 30) operated with a dedicated infection control committee The majority of RACFs reported lacking specialist and qualified experienced IPC professionals (n = 67). The majority of RACFs (90.1%, n = 118) reported the existence of a designated employee with IPC responsibilities. Of these 118 staff members with IPC responsibilities, 42.5% had a qualification in IPC. The reported average funded hours per month for IPC professional or an external provider of IPC activities was 14 (95% CI 9.6¿18.9 h). Conclusion: The overwhelming majority of RACFs deliver IPC services and report doing so in ways that meet the needs of their own specific contexts in the absence of the lack of formal guidelines when compared to the hospital sector. Quality residential and aged care free from HAIs requires formal structure and organization strategies.

Background: Point prevalence studies identify that pneumonia is the most common healthcare associated infection. However, non-ventilator associated healthcare associated pneumonia (NV-HAP) is both underreported and understudied. Most research conducted to date, focuses on ventilator associated pneumonia. We conducted a systematic review, to provide the latest evidence for strategies to reduce NV-HAP and describe the methodological approaches used. Methods: We performed a systematic search to identify research exploring and evaluating NV-HAP preventive measures in hospitals and aged-care facilities. The electronic database Medline was searched, for peer-reviewed articles published between 1st January 1998 and 31st August 2018. An assessment of the study quality and risk of bias of included articles was conducted using the Newcastle¿Ottawa Scale. Results: The literature search yielded 1551 articles, with 15 articles meeting the inclusion criteria. The majority of strategies for NV-HAP prevention focussed on oral care (n = 9). Three studies evaluated a form of physical activity, such as passive movements, two studies used dysphagia screening and management; and another study evaluated prophylactic antibiotics. Most studies (n = 12) were conducted in a hospital setting. Six of the fifteen studies were randomised controlled trials. Conclusion: There was considerable heterogeneity in the included studies, including the type of intervention, study design, methods and definitions used to diagnose the NV-HAP. To date, interventions to reduce NV-HAP appear to be based broadly on the themes of improving oral care, increased mobility or movement and dysphagia management.

Objective: To determine the effectiveness and ease of use of an electronic reminder device in reducing urinary catheterization duration.Design: A randomized controlled trial with a cross-sectional anonymous online survey and focus group.Setting: Ten wards in an Australian hospital.Participants: All hospitalized patients with a urinary catheter.Intervention: An electronic reminder system, the CATH TAG, applied to urinary catheter bags to prompt removal of urinary catheters.Outcomes: Catheterization duration and perceptions of nurses about the ease of use.Methods: A Cox proportional hazards model was used to assess the rate of removal of catheters. A phenomenological approach underpinned data collection and analysis methods associated with the focus group.Results: In total, 1,167 patients with a urinary catheter were included. The mean durations in control and intervention phases were 5.51 days (95% confidence interval [CI], 4.9-6.2) and 5.08 days (95% CI, 4.6-5.6), respectively. For patients who had a CATH TAG applied, the hazard ratio (HR) was 1.02 (95% CI, 0.91-1.14; P =.75). A subgroup analysis excluded patients in an intensive care unit (ICU), and the use of the CATH TAG was associated with a 23% decrease in the mean, from 5.00 days (95% CI, 4.44-5.56) to 3.84 days (95% CI, 3.47-4.21). Overall, 82 nurses completed a survey and 5 nurses participated in a focus group. Responses regarding the device were largely positive, and benefits for patient care were identified.Conclusion: The CATH TAG did not reduce the duration of catheterization, but potential benefits in patients outside the ICU were identified. Electronic reminders may be useful to aid prompt removal of urinary catheters in the non-ICU hospital setting.

Background: The hospital environment is a reservoir for the transmission of microorganisms. The effect of improved cleaning on patient-centred outcomes remains unclear. We aimed to evaluate the effectiveness of an environmental cleaning bundle to reduce health care-associated infections in hospitals. Methods: The REACH study was a pragmatic, multicentre, randomised trial done in 11 acute care hospitals in Australia. Eligible hospitals had an intensive care unit, were classified by the National Health Performance Authority as a major hospital (public hospitals) or having more than 200 inpatient beds (private hospitals), and had a health-care-associated infection surveillance programme. The stepped-wedge design meant intervention periods varied from 20 weeks to 50 weeks. We introduced the REACH cleaning bundle, a multimodal intervention, focusing on optimising product use, technique, staff training, auditing with feedback, and communication, for routine cleaning. The primary outcomes were incidences of health-care-associated Staphylococcus aureus bacteraemia, Clostridium difficile infection, and vancomycin-resistant enterococci infection. The secondary outcome was the thoroughness of cleaning of frequent touch points, assessed by a fluorescent marking gel. This study is registered with the Australian and New Zealand Clinical Trial Registry, number ACTRN12615000325505. Findings: Between May 9, 2016, and July 30, 2017, we implemented the cleaning bundle in 11 hospitals. In the pre-intervention phase, there were 230 cases of vancomycin-resistant enterococci infection, 362 of S aureus bacteraemia, and 968 C difficile infections, for 3 534 439 occupied bed-days. During intervention, there were 50 cases of vancomycin-resistant enterococci infection, 109 of S aureus bacteraemia, and 278 C difficile infections, for 1 267 134 occupied bed-days. After the intervention, vancomycin-resistant enterococci infections reduced from 0·35 to 0·22 per 10 000 occupied bed-days (relative risk 0·63, 95% CI 0·41¿0·97, p=0·0340). The incidences of S aureus bacteraemia (0·97 to 0·80 per 10 000 occupied bed-days; 0·82, 0·60¿1·12, p=0·2180) and C difficile infections (2·34 to 2·52 per 10 000 occupied bed-days; 1·07, 0·88¿1·30, p=0·4655) did not change significantly. The intervention increased the percentage of frequent touch points cleaned in bathrooms from 55% to 76% (odds ratio 2·07, 1·83¿2·34, p<0·0001) and bedrooms from 64% to 86% (1·87, 1·68¿2·09, p<0·0001). Interpretation: The REACH cleaning bundle was successful at improving cleaning thoroughness and showed great promise in reducing vancomycin-resistant enterococci infections. Our work will inform hospital cleaning policy and practice, highlighting the value of investment in both routine and discharge cleaning practice. Funding: National Health and Medical Research Council (Australia).

Background: Catheter associated urinary tract infections are one of the most common infections acquired in hospital. A recent randomised control study demonstrated the benefit of using chlorhexidine (0.1%) for meatal cleaning prior to urinary catheter insertion, by reducing both catheter associated asymptomatic bacteriuria and infection. These findings raise the important question of whether a decision to switch from saline to chlorhexidine was likely to be cost-effective. The aim of this paper was to evaluate the cost-effectiveness of adopting routine use of chlorhexidine for meatal cleaning prior to urinary catheter insertion Methods: The outcomes of this cost-effectiveness study are changes to health service costs in $AUD and changes to quality adjusted life years from a decision to adopt 0.1% chlorhexidine for meatal cleaning prior to urinary catheter insertion as compared to saline. Effectiveness outcomes for this study were taken from a 32 week stepped wedge randomised controlled study conducted in three Australian hospitals. Results: The changes in health costs from switching from saline to 0.1% chlorhexidine per 100,000 catheterisations would save hospitals AUD$387,909 per 100,000 catherisations, prevent 70 cases of catheter associated urinary tract infections, release 282 bed days and provide a small improvement in health benefits of 1.43 quality adjusted life years. Using a maximum willingness to pay for a marginal quality adjusted life year threshold of AUD$28,000 per 100,000 catherisations, suggests that adopting chlorhexidine would be cost effective and potentially cost-saving. Conclusion: The findings from our work provide evidence to health system administrators and those responsible for drafting catheter associated urinary tract infections prevention guidelines that investing in switching from saline to chlorhexidine is not only clinically effective but also a sensible decision in the context of allocating finite healthcare resources.

Background: Evidence for the benefits of antiseptic meatal cleaning in reducing catheter-associated urinary tract infection (UTI) is inconclusive. We assessed the efficacy of 0·1% chlorhexidine solution compared with normal saline for meatal cleaning before urinary catheter insertion in reducing the incidence of catheter-associated asymptomatic bacteriuria and UTI. Methods: A cross-sectional, stepped-wedge, open-label, randomised controlled trial was undertaken in Australian hospitals. Eligible hospitals were Australian public and private hospitals, with an intensive care unit and more than 30 000 hospital admissions per year. Hospitals were randomly assigned to an intervention crossover date using a computer-generated randomisation system. Crossover dates occurred every 8 weeks; during the first 8 weeks of the study, no hospitals were exposed to the intervention (control phase), after which each hospital sequentially crossed over from the control to the intervention every 8 weeks. Patients requiring a urinary cathetwer were potentially eligible for inclusion in this hospital-wide study. Participants were excluded if they were younger than 2 years, had a medical reason preventing the use of the chlorhexidine, had the catheter inserted in theatre, did not have the catheter insertion date documented, required in-and-out or suprapubic catheterisation, had symptoms and signs suggestive of UTI at the time of catheter insertion, or were currently undergoing treatment for UTI. The intervention was the use of 0·1% chlorhexidine solution for meatal cleaning before urinary catheterisation with 0·9% normal saline used in the control phase. Masking of hospitals was not possible because it was not feasible to mask staff administering the intervention. The co-primary outcomes were the number of cases of catheter-associated asymptomatic bacteriuria and UTI per 100 catheter-days and were assessed within 7 days of catheter insertion in the intention-to-treat population. This trial is registered with Australian New Zealand Clinical Trials Registry, number ACTRN12617000373370. Findings: 21 hospitals were assessed for eligibility between Jan 5, 2017, and May 1, 2017; of these, three were successfully enrolled and randomised to one of three intervention crossover dates. 1642 participants in these hospitals were included in the study between Aug 1, 2017, and March 12, 2018, 697 (42%) in the control phase and 945 (58%) in the intervention period. In the control period, 13 catheter-associated UTI and 29 catheter-associated asymptomatic bacteriuria events in 2889 catheter-days (0·45 catheter-associated UTI cases and 1·00 catheter-associated asymptomatic bacteriuria cases per 100 catheter-days) were recorded compared with four catheter-associated UTI and 16 catheter-associated asymptomatic bacteriuria events in 2338 catheter-days (0·17 catheter-associated UTI cases and 0·68 catheter-associated asymptomatic bacteriuria cases per 100 catheter-days) during the intervention period. The intervention was associated with a 74% reduction in the incidence of catheter-associated asymptomatic bacteriuria (incident rate ratio 0·26, 95% CI 0·08¿0·86, p=0·026), and a 94% decrease in the incidence of catheter-associated UTI (0·06, 95% CI 0·01¿0·32, p=0·00080). There were no reported adverse events. Interpretation: The use of chlorhexidine solution for meatal cleaning before catheter insertion decreased the incidence of catheter-associated asymptomatic bacteriuria and UTI and has the potential to improve patient safety. Funding: HCF Research Foundation.

The onset of type 2 diabetes mellitus is associated with various modifiable and non-modifiable risk factors, including lifestyle factors. Obesity is the principal lifestyle factor associated with an increased risk of developing type 2 diabetes. It is essential for nurses to have an understanding of the pathophysiology associated with factors that contribute to an increased risk of type 2 diabetes, particularly those associated with obesity. Nurses who have an understanding of the interaction between obesity and the onset of type 2 diabetes are better equipped to discuss the importance of weight loss and other necessary lifestyle adjustments in the prevention and management of obesity and diabetes associated with obesity, to implement evidence-based practice and to support patients to manage their health effectively.

Australia does not have a national healthcare-associated infection (HAI) surveillance program. Without national surveillance, we do not understand the burden of HAIs, nor can we accurately assess the effects of national infection prevention initiatives. Recent research has demonstrated disparity between existing jurisdictional-based HAI surveillance activity while also identifying broad key stakeholder support for the establishment of a national program. A uniform surveillance program will also address growing concerns about hospital performance measurements and enable public reporting of hospital data.

Background Catheter-associated urinary tract infections (CAUTIs) are among the most common healthcare-associated infections. Antiseptic cleaning of the meatal area before and during catheter use may reduce the risk of CAUTIs. Aim To undertake a systematic review of the literature and meta-analysis of studies investigating the effectiveness of antiseptic cleaning before urinary catheter insertion and during catheter use for prevention of CAUTIs. Methods Electronic databases were searched to identify randomized controlled trials. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated and compared across intervention and control groups using DerSimonian¿Laird random-effects model. Subgroup analyses were performed. Heterogeneity was estimated using the I2 statistic. Findings In total, 2665 potential papers were identified; of these, 14 studies were eligible for inclusion. There was no difference in the incidence of CAUTIs when comparing antiseptic and non-antiseptic agents (pooled OR 0.90, 95% CI 0.73¿1.10; P=0.31), or when comparing different agents: povidone-iodine vs routine care; povidone-iodine vs soap and water; chlorhexidine vs water; povidone-iodine vs saline; povidone-iodine vs water; and green soap and water vs routine care (P>0.05 for all). Comparison of an antibacterial agent with routine care indicated near significance (P=0.06). There was no evidence of heterogeneity (I2=0%; P>0.05). Subgroup analyses showed no difference in the incidence of CAUTIs in terms of country, setting, risk of bias, sex and frequency of administration. Conclusions There were no differences in CAUTI rates, although methodological issues hamper generalizability of this finding. Antibacterial agents may prove to be significant in a well-conducted study. The present results provide good evidence to inform infection control guidelines in catheter management.

Background Effective clinical governance is necessary to support improvements in infection control. Historically, the focus has been on ensuring that infection control practice and policy is based on evidence, and that there is use of surveillance and auditing for self-regulation and performance feedback. There has been less exploration of how contextual and organizational factors mediate an infection preventionists (IP's) ability to engage with evidence-based practice and enact good clinical governance. Methods A cross sectional Web-based survey of IPs in Australia and New Zealand was undertaken. Questions focused on engagement in evidence-based practice and perceptions about the context, culture, and leadership within the infection control team and organization. Responses were mapped against dimensions of Scally and Donaldson's clinical governance framework. Results Three hundred surveys were returned. IPs appear well equipped at an individual level to undertake evidence-based practice. The most serious set of perceived challenges to good clinical governance related to a lack of leadership or active resistance to infection control within the organization. Additional challenges included lack of information technology solutions and poor access to specialist expertise and financial resources. Conclusions Focusing on strengthening contextual factors at the organizational level that otherwise undermine capacity to implement evidence-based practice is key to sustaining current infection control successes and promoting further practice improvements.

Background Challenges with limited single rooms and isolation facilities in hospitals have created an opportunity for temporary, portable isolation technology. This article describes the process used to evaluate the prototype of a new isolation room (RediRoom; CareStrategic Ltd, Brisbane, Queensland, Australia) that can be installed in existing hospital ward areas. Our aim is to assess the functionality of this new room, and in so doing, to evaluate the methods used. Methods We employed a mixed-methods approach involving video recording, interviews, and objective temperature and humidity measurements within a crossover interventional study. Participants completed a range of clinical activities in the RediRoom and a control. The setting for the study was a clinical ward environment at an Australian higher education institution. Results There were similarities between the RediRoom and the control using a range of measures. The time taken to complete a range of clinical activities in both rooms was broadly consistent. Network analysis also suggested broad similarities in the movement of nurses undertaking activities in both rooms. Conclusion Our study attempted to simulate a clinical environment and clinical activities and provide the best possible comparison by completing activities sequentially, with immediate feedback to researchers. Video recording added significant value to the process because it provided some objectivity. A form of reflexive ethnography with participants could be of value in similar studies in the future.

OBJECTIVE To explore the trends in infection control peer-reviewed journals, mainstream media, and blogs written by infection control professionals DESIGN Narrative and scoping reviews METHODS Narrative and scoping reviews were performed to identify trending infection prevention and control topics from international journals, national news websites, newspapers, and so-called grey literature throughout 2015. Data were analyzed using word frequencies, and results are displayed in word clouds. RESULTS For 2015, our search identified 6 news websites with a total of published 116 articles, 71 articles from selected newspapers, and 214 publications from infection control websites. In total, 1,059 journal articles were initially identified; 98 articles were anonymous and thus were excluded, leaving 961 articles in the reviews. The terms 'superbug' and 'antibiotics' were most commonly used in titles of news websites and newspapers, whereas the terms 'infection' and 'prevention' were most commonly used in infection control websites or blogs. The word frequency differences among the 4 selected journals reflected their respective specialties. CONCLUSION In infection prevention and control, the integration of a range of mediums is necessary to best serve public interests. Whether the aim is advocacy, general health information dissemination, or warnings of imminent risk, health researchers have access to multiple forums with different strengths through which to influence public risk perceptions and responses. Infect Control Hosp Epidemiol 2017;38:1098-1102.

OBJECTIVE To examine tweeting activity, networks, and common topics mentioned on Twitter at 4 international infection control and infectious disease conferences. DESIGN A cross-sectional study. METHODS An independent company was commissioned to undertake a Twitter 'trawl' each month between July 1, 2016, and November 31, 2016. The trawl identified any tweets that contained the official hashtags of the conferences for (1) the UK Infection Prevention Society, (2) IDWeek 2016, (3) the Federation of Infectious Society/Hospital Infection Society, and (4) the Australasian College for Infection Prevention and Control. Topics from each tweet were identified, and an examination of the frequency and timing of tweets was performed. A social network analysis was performed to illustrate connections between users. A multivariate binary logistic regression model was developed to explore the predictors of 'retweets.' RESULTS In total, 23,718 tweets were identified as using 1 of the 2 hashtags of interest. The results demonstrated that the most tweets were posted during the conferences. Network analysis demonstrated a diversity of twitter networks. A link to a web address was a significant predictor of whether a tweet would be retweeted (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.9-2.1). Other significant factors predicting a retweet included tweeting on topics such as Clostridium difficile (OR, 2.0; 95% CI, 1.7-2.4) and the media (OR, 1.8; 95% CI, 1.6-2.0). Tweets that contained a picture were significantly less likely to be retweeted (OR, 0.06; 95% CI, 0.05-0.08). CONCLUSION Twitter is a useful tool for information sharing and networking at infection control conferences.

Lifestyle medicine interventions are typically intensive by design. This study explored the optimal ¿dosage¿ of a well-known lifestyle medicine intervention¿the Complete Health Improvement Program (CHIP). A total of 2383 individuals (mean age = 61.0 ± 9.2 years; 34% males) participated in either an 8-session (N = 448) or 16-session (N = 1935) version of the CHIP intervention conducted over 4 weeks in community settings throughout North America. Both the 8- and 16-session groups experienced significant improvements in all the chronic disease risk factors measured. There was no difference between the changes experienced by the 8- and 16-session groups in lipid profile, fasting plasma glucose, or systolic blood pressure. The 8-session group experienced a significantly greater reduction in body mass (0.3 percentage points or 0.8 lbs, P <.01), but the 16-session group recorded a significantly greater reduction in diastolic blood pressure (2.8 percentage points or 2.2 mm Hg, P <.01). There was no clear difference between the outcomes achieved in 4 weeks by the 8- and 16-session versions of the CHIP lifestyle medicine intervention. This study suggests that the short-term outcomes achieved by a 16-session CHIP intervention can be achieved in half the number of sessions, which has implications from a resourcing and cost-effectiveness perspective.

Background Infection control professionals (ICPs) are critical in maintaining high standards of quality patient care. Until recently, little was known about the scope of practice, structures, resources and priorities for ICPs and infection control units more generally. Over the past three years we have undertaken a program of work to explore these issues. The purpose of this discussion paper is to synthesise these results and outline implications for the Australian infection control community. Methods We undertook a survey of individual ICPs in Australian and New Zealand and a survey of hospital infection control units within Australia. To understand how our research program could be used to inform and be of value, we also convened a stakeholder workshop to discuss how data from our studies could be translated into meaningfully constructed findings. A synthesis of the findings from the two surveys and the workshop was undertaken and this formed the basis of this discussion paper. Results We were able for the first time, to comprehensively report on infection control staffing levels, priorities and barriers within Australia. We identified considerable variability in the scope, experience and expertise of ICPs and the potential value that credentialing has with respect to effective infection control programs. We were however, unable to develop recommendations with respect to staffing. Conclusion The findings of our work may be used in designing and justifying business cases for infection prevention and control resources. There is also a need to undertake a similar study in settings other than hospitals.

Introduction Assessing the functionality and infection control implications of new technologies presents significant challenges. In this discussion paper, we present our approach to assessing infection control aspects of a new isolation room, the RediRoom¿ (prototype). We report how we evaluated this room, lessons learnt and suggestions for future evaluations in this area. Methods There is no documented method for evaluating a novel temporary isolation room. We combined a range of existing tools to undertake a technical assessment. Three approaches were used, an assessment against standards or guidelines; professional assessment; and a cleaning assessment. Results To assess compliance against existing recommendations related to the built environment and isolation rooms, elements contained within Australasian and United Kingdom guidelines were used. We were able to identify which elements in these guidelines were of the most value and relevance. An ultraviolet (UV) solution with fluorescent light assessment was used to assess the ability to clean surfaces. This approach was a useful objective measure. A professional assessment is potentially subjective, but provides an opportunity to identify other potential issues and benefits. In this study, the RediRoom¿ performed well against all three approaches. We identified limitations in using existing guidelines for a temporary isolation room. Conclusion In our study, the use of video and video reflexive ethnography for the professional assessment would have been useful. We propose a revised list of assessment against which new isolation solutions or technologies could be assessed, with the view of others continuing to build on this.

Introduction Central to all efforts to control and prevent healthcare associated infections (HAIs) is the inherent need to measure the burden of infection and disease, classically referred to as surveillance. Australia does not have a national HAI surveillance system making it very difficult to systematically assess and report on the burden of hospital-acquired HAIs. This systematic review reports the incidence burden of HAIs in Australian hospitals as reported in the peer-reviewed literature from 2010 to 2016. Methods Systematic review of the peer-reviewed literature reporting the incidence of HAIs in Australian hospitals between from 2010 to 2016 was identified using MEDLINE and CINAHL databases. The study protocol is registered with PROSPERO (registration number: CRD42016052997). Results Of the 844 articles identified in the search, 24 articles were included in this review. Overall, these data suggest 83,096 HAIs per year in Australia, comprising 71,186 urinary tract infections, 4902 Clostridium difficile infections, 3946 surgical site infections, 1962 respiratory infections in acute stroke patients and 1100 hospital-onset Staphylococcus aureus bacteraemia. This is very large underestimate given the lack of or incomplete data on common infections such as pneumonia, gastroenterological and bloodstream infection, thus potentially missing up to 50%¿60% of infections. If that is the case, the incidence of HAIs in Australia may be closer to 165,000 per year. Conclusion There is a dearth of peer-reviewed literature reporting the incidence of HAIs in Australian hospitals, making it very difficult to an accurate burden of infection. On the eve of a global ¿post antibiotic era¿, the need for national consensus on definitions, surveillance methodology and reporting is paramount.

Objective To describe the development, pilot testing and evaluation of face-to-face and online educational training packages for healthcare staff undertaking point prevalence surveys (PPS) of healthcare-associated urinary tract infections (HAUTIs) in Australian hospitals and aged care facilities. Methods The study involved two phases. A face-to-face educational training package was developed and used in Phase I of the HAUTI PPS data collection conducted in six hospitals. In Phase II, the training package was expanded and modified for online use by healthcare staff in 82 hospitals and 17 aged care facilities. Ten staff evaluated the face-to-face training package in Phase I. For Phase II, 38 staff evaluated the online training package. After each phase, staff completed an online evaluation survey about the usefulness of the training package and ease of data collection. Results For Phase I, usefulness of the training package was rated highly (100%, n = 10) with all respondents rating the training useful in preparing for data collection. Staff in Phase II also reported the online training useful in preparing for data collection and was rated very useful by 21% (n = 8) of respondents and useful by 66% (n = 25). Some respondents (Phase I, n = 4 and Phase II, n = 25) provided small amount of text data that was triangulated with quantitative data. Qualitative feedback reinforced quantitative ranking of usefulness of the training package. Conclusion The training packages were sufficient to train healthcare staff with varying levels of knowledge and skills in undertaking HAUTI PPS in hospitals and/or aged care facilities.

Background The purpose of this paper is to highlight the range of cleaning practices and processes in 11 Australian hospitals and to discuss the challenges this variation poses to the implementation of clinical trials or changes to hospital cleaning practices. Methods A cross-sectional study design was used to determine cleaning practices and processes in hospitals participating in the ¿Researching Effective Approaches to Cleaning in Hospitals¿ (REACH) study. A standardised template and approach was used to collect information. Data collection activities included structured on-site discussions, a review of hospital practices and a document review of policy and procedural documents related to cleaning. Results Variations in the auditing process used to evaluate environmental cleanliness, cleaning practices, product use, training and communication pathways available to cleaning staff were identified. There was also variation in workforce structure and responsibilities for cleaning. Conclusion This paper is the first to describe the differences in cleaning practices between Australian hospitals. The variations identified present a number of challenges for the conduct of research and have important implications for both monitoring of and standards for cleanliness. These challenges include implementing a practice change or cleaning study where hospitals have different processes, practices and structures.

Background: The emergence of antimicrobial resistance is of particular concern with respect to urinary tract infections, since the majority of causative agents are Gram-negative bacteria. Healthcare-associated urinary tract infections (HAUTIs) are frequently associated with instrumentation of the urinary tract, specifically with indwelling catheters. Aim: To evaluate the current incidence, mortality, and length of hospital stay associated with HAUTIs. Methods: A non-concurrent cohort study design was used, conducted between January 1st, 2010 and June 30th, 2014. All patients admitted to one of the eight participating Australian hospitals and who were hospitalized for more than two days were included. The primary outcome measures were the incidence, mortality, and excess length of stay associated with HAUTIs. Findings: From 162,503 patient admissions, 1.73% [95% confidence interval (CI): 1.67-1.80] of admitted patients acquired a HAUTI. Using a multi-state model, the expected extra length of stay due to HAUTI was four days (95% CI: 3.1-5.0 days). Using a Cox regression model, infection significantly reduced the rate of discharge (hazard ratio: 0.78; 95% CI: 0.73-0.83). Women were less likely to die (0.71; 0.66-0.75), whereas older patients were more likely to die (1.40; 1.38-1.43). Death was rarer in a tertiary referral hospital compared to other hospitals, after adjusting for age and sex (0.74; 0.69-0.78). Conclusion: This study is the first to explore the burden of HAUTIs in hospitals using appropriate statistical methods in a developed country. Our study indicates that the incidence of HAUTI, in addition to its associated extra length of stay in hospital, presents a burden to the hospital system. With increasing incidence of UTI due to antimicrobial-resistant organisms, surveillance and interventions to reduce the incidence of HAUTI are required.

Introduction Given the trends in antimicrobial resistance, particularly for Gram-negative organisms, the surveillance of urinary tract infections (UTIs) has the potential to become increasingly important in the future. Whilst considering accuracy and efficiency, we undertook a cohort study in a large Australian health district to inform future discussions around surveillance approaches to healthcare-associated UTIs (HAUTI). Methods A retrospective cohort study in eight hospitals was conducted to examine the clinical coding data of all patients hospitalised for more than two days over a four-and-half-year period. These data were compared to a conservative laboratory-based HAUTI definition. Results The data from 162,503 patient admissions were examined. During the study period, 2821 of the admitted patients acquired a HAUTI. Of those patients identified as having a laboratory-diagnosed HAUTI, 29.3% had a clinical code relating to a UTI. Conclusion The clinical coding data used to identify cases of HAUTI is very unreliable as a significant proportion of cases were not identified. To ensure the efficient and effective use of resources, a range of approaches should be considered in the event of HAUTI surveillance being required.

Background Despite evidence from overseas that certification and credentialing of infection control professionals (ICPs) is important to patient outcomes, there are no standardized requirements for the education and preparation of ICPs in Australia. A credentialing process (now managed by the Australasian College of Infection Prevention and Control) has been in existence since 2000; however, no evaluation has occurred. Methods A cross-sectional study design was used to identify the perceived barriers to credentialing and the characteristics of credentialed ICPs. Results There were 300 responses received; 45 (15%) of participants were credentialed. Noncredentialed ICPs identified barriers to credentialing as no employer requirement and no associated remuneration. Generally credentialed ICPs were more likely to hold higher degrees and have more infection control experience than their noncredentialed colleagues. Conclusions The credentialing process itself may assist in supporting ICP development by providing an opportunity for reflection and feedback from peer review. Further, the process may assist ICPs in being flexible and adaptable to the challenging and ever-changing environment that is infection control.

Background There is limited contemporary information on how infection control professionals (ICPs) in hospitals utilise their time, with even less providing any specific data on time taken to undertake HAI surveillance. HAI surveillance is a critical component of any infection control program. Methods An anonymous online web-based survey was used to conduct a cross-sectional study of infection control units in public and private Australian hospitals. Participants were asked demographic information and time spent undertaking infection control activities, including surveillance. Results Forty infection control units, responsible for providing services to 138 hospitals completed the survey. The percentage of time spent undertaking HAI surveillance activities by members of the infection control units was 1675¿h or 36.0% (95% CI 34.3%¿37.8%; range 17%¿61%) of all contracted infection control professionals time (4653¿h). Of the time spent undertaking HAI surveillance, 56% was spent collecting data, 27% collecting data on compliance with infection control activities and 17% feeding HAI data back to clinicians and management. There was no difference in the proportion of time spent undertaking HAI surveillance between public and privately funded hospitals or infection control units led by a credentialed ICP. Infection control units with a form of electronic surveillance dedicated more time to surveillance, compared to units that did not use such a system. Demands for surveillance increased with larger number of hospitals beds. Conclusion The costs of undertaking HAI surveillance and collecting data can be considerable. The efficiency of undertaking surveillance should be considered, weighing investment against the likely improvement in infection rates and patient quality of life.

Objectives Surveillance of healthcare associated urinary tract infections (HAUTIs) in Australian acute and aged care facilities is lacking. Therefore, to provide the foundation for a national point prevalence study of HAUTIs and catheter associated urinary tract infection (CAUTIs), a three phase project was developed with recent completion of the second phase. The objectives of Phase II were to (1) develop a website incorporating tools for conducting point prevalence of HAUTIs and CAUTIs, (2) pilot an online process and database for conducting point prevalence of HAUTIs and CAUTIs and (3) determine the point prevalence of HAUTIs and CAUTIs in acute and aged care facilities. This paper reports on the third objective. Methods Point prevalence of HAUTIs and CAUTIs were assessed in 82 acute care and 17 aged care facilities within four Australian jurisdictions using an online survey. Results The study included 1320 patients and 663 residents from acute and aged care facilities respectively. HAUTI prevalence was 1.4% (95% CI 0.8¿2.2%) in acute care and 1.5% (95% CI 0.8¿2.6%) in aged care. Catheter use in acute care (9.3%) was three times greater than aged care (3.3%). Conclusion Given the relative frequency with which HAUTI occurs, associations with addition length of stay in hospital and risk of systemic sepsis from these infections, efforts should be made to further minimise HAUTI prevalence. There is also a need to develop targeted interventions for catheter use especially in acute care because inappropriate and/or excessive catheter use has implications for the risk of CAUTIs and adds consumable costs.

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.

This study describes the antimicrobial resistance temporal trends and seasonal variation of Escherichia coli (E. coli) urinary tract infections (UTIs) over five years, from 2009 to 2013, and compares prevalence of resistance in hospital- and community-acquired E. coli UTI. A cross sectional study of E. coli UTIs from patients attending a tertiary referral hospital in Canberra, Australia was undertaken. Time series analysis was performed to illustrate resistance trends. Only the first positive E. coli UTI per patient per year was included in the analysis. A total of 15,022 positive cultures from 8724 patients were identified. Results are based on 5333 first E. coli UTIs, from 4732 patients, of which 84.2% were communityacquired. Five-year hospital and community resistance rates were highest for ampicillin (41.9%) and trimethoprim (20.7%). Resistance was lowest for meropenem (0.0%), nitrofurantoin (2.7%), piperacillin-tazobactam (2.9%) and ciprofloxacin (6.5%). Resistance to amoxycillin-clavulanate, cefazolin, gentamicin and piperacillin-tazobactam were significantly higher in hospital- compared to community-acquired UTIs (9.3% versus 6.2%; 15.4% versus 9.7%; 5.2% versus 3.7% and 5.2% versus 2.5%, respectively). Trend analysis showed significant increases in resistance over five years for amoxycillin-clavulanate, trimethoprim, ciprofloxacin, nitrofurantoin, trimethoprim-sulphamethoxazole, cefazolin, ceftriaxone and gentamicin (P<0.05, for all) with seasonal pattern observed for trimethoprim resistance (augmented Dickey-Fuller statistic = 4.136; P = 0.006). An association between ciprofloxacin resistance, cefazolin resistance and ceftriaxone resistance with older age was noted. Given the relatively high resistance rates for ampicillin and trimethoprim, these antimicrobials should be reconsidered for empirical treatment of UTIs in this patient population. Our findings have important implications for UTI treatment based on setting of acquisition.

A systematic review and meta-analysis was conducted to determine the risk of pathogen acquisition for patients associated with prior room occupancy. The analysis was also broadened to examine any differences in acquisition risk between Gram-positive and Gram-negative organisms. A search using Medline/PubMed, Cochrane and CINHAL yielded 2577 citations between 1984 and 2014. Reviews were assessed in accordance with the international prospective register of systematic reviews (PROSPERO). Just seven articles met the inclusion criteria, namely: (a) papers were peer reviewed, (b) pathogen acquisition prevalence rates were reported, (c) articles were written in English; and (d) had minimal or no risk of bias based on the Newcastle-Ottawa Scale (NOS). One study was an extension of a previous study and was discarded. Employing NOS provided little difference between the studies, with five studies receiving eight-star and two studies receiving seven-star ratings, respectively. Overall, pooled acquisition odds ratio for study pathogens (meticillin-resistant Staphylococcus aureus; vancomycin-resistant enterococcus; Clostridium difficile; acinetobacter; extended-spectrum ß-lactamase-producing coliforms; pseudomonas) was 2.14 [95% confidence interval (CI): 1.65-2.77]. When comparing data between Gram-positive and Gram-negative organisms, the pooled acquisition odds ratio for Gram-negatives was 2.65 (95% CI: 2.02-3.47) and 1.89 (95% CI: 1.62-2.21) for Gram positives. The findings have important implications for infection control professionals, environmental cleaning services and patients, since current practices fail to adequately reduce acquisition risk. Although there may be non-preventable sources of acquisition, revised practices require collaborative work between all responsible staff in order to reduce this risk to a minimum.

Background This article describes infection prevention and control professionals' (ICPs') staffing levels, patient outcomes, and costs associated with the provision of infection prevention and control services in Australian hospitals. A secondary objective was to determine the priorities for infection control units. Methods A cross-sectional study design was used. Infection control units in Australian public and private hospitals completed a Web-based anonymous survey. Data collected included details about the respondent; hospital demographics; details and services of the infection control unit; and a description of infection prevention and control-related outputs, patient outcomes, and infection control priorities. Results Forty-nine surveys were undertaken, accounting for 152 Australian hospitals. The mean number of ICPs was 0.66 per 100 overnight beds (95% confidence interval, 0.55-0.77). Privately funded hospitals have significantly fewer ICPs per 100 overnight beds compared with publicly funded hospitals (P <.01). Staffing costs for nursing staff in infection control units in this study totaled $16,364,392 (mean, $380,566). Infection control units managing smaller hospitals (<270 beds) identified the need for increased access to infectious diseases or microbiology support. Conclusion This study provides valuable information to support future decisions by funders, hospital administrators, and ICPs on service delivery models for infection prevention and control. Further, it is the first to provide estimates of the resourcing and cost of staffing infection control in hospitals at a national level.

This study assessed urinary Escherichia coli antibiotic susceptibility patterns in Tasmania, Australia, andexamined their association with community antibiotic use. The susceptibility profiles of all urinary E. coliisolates collected in Tasmania between January 2010 and December 2012 were included. The amount ofPharmaceutical Benefits Scheme (PBS)-subsidised use of amoxicillin, amoxicillin/clavulanic acid (AMC),cefalexin, norfloxacin, ciprofloxacin and trimethoprim was retrieved (at the Tasmanian population level)and the number of defined daily doses per 1000 population per day in Tasmania for these antibiotics wascalculated for each month during the study period. Antimicrobial susceptibility data were assessed forchanges over time in the 3-year study period. Antimicrobial use and susceptibility data were assessedfor seasonal differences and lag in resistance following antibiotic use. Excluding duplicates, 28 145 E. coliisolates were included. Resistance levels were low; 35% of isolates were non-susceptible to amoxicillin,14% were non-susceptible to trimethoprim and <5% were non-susceptible to AMC, cefalexin, gentamicinand norfloxacin. Amoxicillin use increased by 35% during winter/spring compared with summer/autumn,and AMC use increased by 21%. No seasonal variation in quinolone use or resistance was detected. Thelow levels of antimicrobial resistance identified may relate to Tasmania's isolated geographical location.Significant seasonal variation in amoxicillin and AMC use is likely to be due to increased use of theseantibiotics for treatment of respiratory tract infections in winter. Quinolone use is restricted by the PBSin Australia, which is the likely explanation for the low levels of quinolone use and resistance identified.

Background In the past decade the policy and practice context for infection control in Australia and New Zealand has changed, with infection control professionals (ICPs) now involved in the implementation of a large number of national strategies. Little is known about the current ICP workforce and what they do in their day-to-day positions. The aim of this study was to describe the ICP workforce in Australia and New Zealand with a focus on roles, responsibilities, and scope of practice. Methods A cross-sectional design using snowball recruitment was employed. ICPs completed an anonymous web-based survey with questions on demographics; qualifications held; level of experience; workplace characteristics; and roles and responsibilities. Chi-squared tests were used to determine if any factors were associated with how often activities were undertaken. Results A total of 300 ICPs from all Australian states and territories and New Zealand participated. Most ICPs were female (94%); 53% were aged over 50, and 93% were employed in registered nursing roles. Scope of practice was diverse: all ICPs indicated they undertook a large number and variety of activities as part of their roles. Some activities were undertaken on a less frequent basis by sole practitioners and ICPs in small teams. Conclusion This survey provides useful information on the current education, experience levels and scope of practice of ICPs in Australia and New Zealand. Work is now required to establish the best mechanisms to support and potentially streamline scope of practice, so that infection-control practice is optimised.

Background Healthcare Infection, the official publication of the Australasian College for Infection Prevention Control, is an international, peer-reviewed journal. This paper presents an analysis of the publication scholarship trends of articles published within Healthcare Infection, providing insight into future publication trends. Methods A cross-sectional study design was used to explore published articles over a 12-year period, between 2002 and 2015. A content analysis was performed to examine the key thematic characteristics of all published articles. Citation data from articles published between 2011 and 2015 were extracted from Scopus. Results A total of 345 articles were published in Healthcare Infection during this time. The topics and content of the publications varied considerably. Approximately half the published articles were original research of which the majority were low level evidence. Other articles comprised discussion papers, review articles and editorials. Conclusion In recent years, there has been an increase in international collaborations and diversification of topics published, including urinary tract infection, sharps injuries, health economics, and antibiotic resistance and stewardship.

Introduction A standardised approach to evaluating environmental cleanliness is important to ensure consistency of assessor training, allow benchmarking of results between facilities, ensure consistency of the assessment of the environment and assist in meeting national accreditation standards. This paper describes the development process and the findings of the first 12 months of data following the introduction of a standardised program for evaluating environmental cleanliness within Tasmanian healthcare facilities using two different evaluation methods. Methods Evaluation of environmental cleanliness was undertaken as part of a structured program and involved the use of an ultraviolet solution and fluorescent light in addition to a visual assessment. Twelve Tasmanian hospitals participated in this study. Results A total of 290 fluorescent light assessments and 232 visual inspections were conducted. Using the fluorescent light assessment, the percentage of correctly cleaned items increased from a baseline of 82.3% to 85.4% over the 12-month study period. Using the visual assessment, 92.5% of items were deemed acceptable during the study period. Conclusions Our multi-centred study identified a high baseline level of cleanliness using a fluorescent light. We identified that objects were frequently deemed to be visually acceptable, yet may not have been cleaned. The project was supported by a range of online tools for data submission, training tools and a formal assessment of auditors.

Background: During the last decade the resistance rate of urinary Escherichia coli (E. coli) to fluoroquinolones such as ciprofloxacin has increased. Systematic reviews of studies investigating ciprofloxacin resistance in community- and hospital-acquired E. coli urinary tract infections (UTI) are absent. This study systematically reviewed the literature and where appropriate, meta-analysed studies investigating ciprofloxacin resistance in community- and hospital-acquired E. coli UTIs. Methods: Observational studies published between 2004 and 2014 were identified through Medline, PubMed, Embase, Cochrane, Scopus and Cinahl searches. Overall and sub-group pooled estimates of ciprofloxacin resistance were evaluated using DerSimonian-Laird random-effects models. The I2 statistic was calculated to demonstrate the degree of heterogeneity. Risk of bias among included studies was also investigated. Results: Of the identified 1134 papers, 53 were eligible for inclusion, providing 54 studies for analysis with one paper presenting both community and hospital studies. Compared to the community setting, resistance to ciprofloxacin was significantly higher in the hospital setting (pooled resistance 0.38, 95 % CI 0.36-0.41 versus 0.27, 95 % CI 0.24-0.31 in community-acquired UTIs, P < 0.001). Resistance significantly varied by region and country with the highest resistance observed in developing countries. Similarly, a significant rise in resistance over time was seen in studies reporting on community-acquired E. coli UTI. Conclusions: Ciprofloxacin resistance in E. coli UTI is increasing and the use of this antimicrobial agent as empirical therapy for UTI should be reconsidered. Policy restrictions on ciprofloxacin use should be enhanced especially in developing countries without current regulations.

Surveillance of healthcare-associated infections is central to healthcare epidemiology and infection control programmes and a critical factor in the prevention of these infections. By definition, the term 'infection prevention' implies that healthcare-associated infections may be preventable. The purpose of surveillance is to provide quality data that can be used in an effective monitoring and alert system and to reduce the incidence of preventable healthcare-associated infections. This article examines the purpose of surveillance, explains key epidemiological terms, provides an overview of approaches to surveillance and discusses the importance of validation.

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.

Reliable surveillance data and continuous monitoring can provide useful information for clinicians and patients alike, by identifying areas needing improvement and demonstrating the effectiveness of interventions. Improving the rigor of health care-associated infection surveillance makes it possible to provide more valid and reliable information. We propose a model that can be used by infection control preventionists, researchers, and health planners and can serve as a trigger for understanding the influences on reliable and valid health care-associated infection data.

Background Clostridium difficile infection (CDI) possibly extends hospital length of stay (LOS); however, the current evidence does not account for the time-dependent bias, ie, when infection is incorrectly analyzed as a baseline covariate. The aim of this study was to determine whether CDI increases LOS after managing this bias. Methods We examined the estimated extra LOS because of CDI using a multistate model. Data from all persons hospitalized >48 hours over 4 years in a tertiary hospital in Australia were analyzed. Persons with health care-associated CDIs were identified. Cox proportional hazards models were applied together with multistate modeling. Results One hundred fifty-eight of 58,942 admissions examined had CDI. The mean extra LOS because of infection was 0.9 days (95% confidence interval: -1.8 to 3.6 days, P =.51) when a multistate model was applied. The hazard of discharge was lower in persons who had CDI (adjusted hazard ratio, 0.42; P <.001) when a Cox proportional hazard model was applied. Conclusion This study is the first to use multistate models to determine the extra LOS because of CDI. Results suggest CDI does not significantly contribute to hospital LOS, contradicting findings published elsewhere. Conversely, when methods prone to result in time-dependent bias were applied to the data, the hazard of discharge significantly increased. These findings contribute to discussion on methods used to evaluate LOS and health care-associated infections.

Aim: To present a discussion on theoretical frameworks in infection prevention and control. Background: Infection prevention and control programmes have been in place for several years in response to the incidence of healthcare-associated infections and their associated morbidity and mortality. Theoretical frameworks play an important role in formalizing the understanding of infection prevention activities. Design: Discussion paper. Data sources: A literature search using electronic databases was conducted for published articles in English addressing theoretical frameworks in infection prevention and control between 1980-2012. Results: Nineteen papers that included a reference to frameworks were identified in the review. A narrative analysis of these papers was completed. Two models were identified and neither included the role of surveillance. Discussion: To reduce the risk of acquiring a healthcare-associated infection, a multifaceted approach to infection prevention is required. One key component in this approach is surveillance. The review identified two infection prevention and control frameworks, yet these are rarely applied in infection prevention and control programmes. Only one framework considered the multifaceted approach required for infection prevention. It did not, however, incorporate the role of surveillance. We present a framework that incorporates the role of surveillance into a biopsychosocial approach to infection prevention and control. Conclusion: Infection prevention and control programmes and associated research are led primarily by nurses. There is a need for an explicit infection prevention and control framework incorporating the important role that surveillance has in infection prevention activities. This study presents one framework for further critique and discussion. © 2013 John Wiley & Sons Ltd.

Issue addressed Complete Health Improvement Program (CHIP) is a lifestyle modification program that promotes healthy diet, physical activity and stress management techniques. Among US CHIP participants, differences in gender responsiveness to improvements in chronic disease risk factors were demonstrated. This study examined gender differences in outcomes to the CHIP intervention in Australasia. Methods Changes in body weight, blood pressure (BP), blood lipid profile and fasting plasma glucose (FPG) were assessed in 925 participants (34.3% men, mean age=56.0±12.5 years; 65.7% women, mean age=54.4±13.5 years) 30 days after program commencement. Results Significant reductions (P<0.001) in all biometrics measured were found for men and women but were greater among men for total (TC) and low-density lipoprotein cholesterol (LDL), triglycerides (TG), FPG, body mass index (BMI) and TC/high-density lipoprotein cholesterol (HDL) ratio. Participants with highest baseline classifications of BMI, systolic BP, blood lipids and FPG showed greatest reductions in 30 days. Conclusions CHIP more effectively reduced chronic disease risk factors among men than women. All participants, but particularly men, entering the program with the greatest risk achieved the largest reductions. Possible physiological or behavioural factors include food preferences, making commitments and differential support modes. So what? Developers of lifestyle intervention programs should consider gender differences in physiological and behavioural factors when planning interventions. In particular, developers should manage expectations of people entering lifestyle interventions to increase awareness that men tend to respond better than women. In addition, this is a call for further research to identify the underlying mechanisms responsible for the disproportionate responsiveness of males.

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 methicillinsusceptible (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 healthcareassociated infections have been very successful.

Background Urinary tract infections account for ~30% of healthcare-associated infections reported by hospitals. Virtually all healthcare-associated urinary tract infections (HAUTIs) are caused by instrumentation of the urinary tract, creating an opportunity to prevent a large proportion of HAUTIs, including catheter-associated urinary tract infections (CAUTIs). In Australia, there is no specific national strategy and surveillance system in place to address HAUTIs or CAUTIs. To determine the need for prospective surveillance of HAUTIs, we propose undertaking a national point prevalence study. This paper describes the methods that could be used to undertake such a study. Methods A cross-sectional point prevalence design is proposed. The population is all patients hospitalised overnight in Australian hospitals, with the sample to exclude outpatients and those in emergency departments. The proposed operational definition is that used by the Health Protection Agency. A standardised training package for data collectors is recommended with standardised data collection and analysis processes described. Individual patient consent should be waived. Discussion Explanation of aspects of the proposed methods are provided, primarily based on findings from a pilot study that informed the development of the proposed protocol. This included development and delivery of training for data collectors and use of the Health Protection Agency HAUTI surveillance definition, rather than the Centers for Disease Control definition. Conclusion Conducting a national point prevalence study on HAUTIs including CAUTIs will provide evidence that can be subsequently used to debate the cost effectiveness and value of prospective surveillance. By conducting a pilot study and critically evaluating that process, we have been able to propose a method that could be used for a single hospital or national study. © 2014 Australasian College for Infection Prevention and Control.

Purpose The aim of this study is to determine the incidence of Clostridium difficile infection (CDI) in an Australian hospital and highlight considerations for other Asian countries that are considering establishing or modifying existing CDI surveillance programs.

Background: In recent year, national bodies have been actively addressing the increasing concern on the spread of healthcare-associated infections (HAIs). The current study measures the knowledge, intentions and beliefs of third-year Australian nursing students on key infection prevention and control (IPC) concepts. Methods: A cross-sectional study of final-year undergraduate nursing students from Schools of Nursing at six Australian universities was undertaken. Students were asked to participate in an anonymous survey. The survey explored knowledge of standard precautions and transmission based precautions. In addition intentions and beliefs towards IPC were explored. Results: 349 students from six universities completed the study. 59.8% (95% CI 58.8-60.8%) of questions were answered correctly. Significantly more standard precaution questions were correctly answered than transmission-based precaution questions (p < 0.001). No association was found between self-reported compliance with IPC activities and gender or age. Certain infection control issues were correlated with the percentage of correctly answered transmission-based precaution questions. The participants were most likely to seek infection control information from an infection control professional. Conclusion: Knowledge on transmission-based precautions was substandard. As transmission-based precautions are the foundation of IPC for serious organisms and infections, education institutions should reflect on the content and style of educational delivery on this topic.

Objectives: The impact of surface disinfection versus detergent cleaning on healthcare associated infection rates remains unresolved. We aimed to evaluate the efficacy of hydrogen peroxide (HP) decontamination against methicillin-resistant Staphylococcus aureus (MRSA). Design: Single centred retrospective before and after study design. Setting: Launceston General Hospital, Tasmania, Australia. Participants: Patients with MRSA infection or colonisation. Interventions: Rooms occupied by patients with MRSA infection or colonisation were cleaned following discharge with either detergent or HP. Main outcome measures: MRSA room contamination following cleaning; new MRSA acquisition in patients. Results: Over 3600 discharge cleans were completed, with more than 32 600 environmental swabs processed. MRSA was isolated from 24.7% rooms following detergent cleaning and from 18.8% of rooms after HP (p<0.001). The incidence of MRSA acquisition reduced from 9.0 to 5.3 per 10 000 patient days in detergent and disinfectant arms, respectively (p<0.001). Conclusions: Use of HP disinfection led to a decrease in residual MRSA contamination in patient rooms compared with detergent. It may also have encouraged the reduction in patient MRSA acquisition despite several confounders including staff feedback on terminal cleaning, additional MRSA screening and quicker laboratory methods. Infection control is best served by concurrent interventions targeting both the patient and healthcare environment.

Objectives: Urinary tract infections (UTIs) account for over 30% of healthcare-associated infections. The aim of this study was to determine healthcare-associated UTI (HAUTI) and catheter-associated UTI (CAUTI) point prevalence in six Australian hospitals to inform a national point prevalence process and compare two internationally accepted HAUTI definitions. We also described the level and comprehensiveness of clinical record documentation, microbiology laboratory and coding data at identifying HAUTIs and CAUTIs. Setting: Data were collected from three public and three private Australian hospitals over the first 6 months of 2013. Participants: A total of 1109 patients were surveyed. Records of patients of all ages, hospitalised on the day of the point prevalence at the study sites, were eligible for inclusion. Outpatients, patients in adult mental health units, patients categorised as maintenance care type (ie, patients waiting to be transferred to a long-term care facility) and those in the emergency department during the duration of the survey were excluded. Outcome measures: The primary outcome measures were the HAUTI and CAUTI point prevalence. Results: Overall HAUTI and CAUTI prevalence was 1.4% (15/1109) and 0.9% (10/1109), respectively. Staphylococcus aureus and Candida species were the most common pathogens. One-quarter (26.3%) of patients had a urinary catheter and fewer than half had appropriate documentation. Eight of the 15 patients ascertained to have a HAUTI based on clinical records (6 being CAUTI) were coded by the medical records department with an International Classification of Diseases (ICD)-10 code for UTI diagnosis. The Health Protection Agency Surveillance definition had a positive predictive value of 91.67% (CI 64.61 to 98.51) compared against the Centers for Disease Control and Prevention definition. Conclusions: These study results provide a foundation for a national Australian point prevalence study and inform the development and implementation of targeted healthcare-associated infection surveillance more broadly.

Clostridium difficile is a bacterium which commonly causes diarrhoea in inpatients. C. difficile affects hospitalised patients worldwide and can pose a significant risk to patients. This article explores the transmission and risk factors for C. difficile infection (CDI). There are many aspects to the prevention and control of CDI: appropriate antibiotic use, early instigation and maintenance of prevention and control strategies, and high standards of environmental cleanliness, education, and surveillance. This article discusses the role of the nurse in each of these prevention and control activities.

Background In Australia, little is known about the risk of acquiring methicillin-resistant Staphylococcus aureus (MRSA) from prior room occupants. The aims of the study are to understand the risk of MRSA acquisition from prior room occupants and to further extend the existing knowledge-base on the role of discharge cleaning in hospitals. Methods A non-concurrent cohort study was undertaken in five wards at a 250-bed general hospital in Tasmania, Australia. All admitted patients were screened for MRSA. Weekly screenings for all patients who remained in hospital were undertaken. New MRSA acquisitions were identified. The exposed group were patients whose immediate prior room occupant had MRSA, while the unexposed prior room occupant did not have MRSA. Results 6228 patients were at risk of acquiring MRSA, with 237 new MRSA acquisitions equating to an acquisition rate of 3.8% for each at-risk patient admission. The unadjusted odds ratio for acquiring MRSA when the prior room occupant had MRSA was 2.9 (95% CI 2.2-3.9). Using logistic regression, exposure to a prior occupant harbouring MRSA remained a significant predictor of subsequent acquisition, after controlling for variables, OR 2.7 (95% CI 2.0-3.6). Conclusion Admission to a room previously occupied by a person with MRSA increased the odds of acquisition for the subsequent patient, independent of other risk factors. It demonstrates the necessity of having effective discharge cleaning practices in place. We believe increased attention to discharge room cleaning in hospitals is required and the reconsideration of additional recommendations for discharge cleaning.

Aim: To quantify the risk of death associated with Clostridium difficile infection, in an Australian tertiary hospital. Background: Two reviews examining Clostridium difficile infection and mortality indicate that Clostridium difficile infection is associated with increased mortality in hospitalized patients. Studies investigating the mortality of Clostridium difficile infection in settings outside of Europe and North America are required, so that the epidemiology of Clostridium difficile infection in these regions can be understood and appropriate prevention strategies made. Design: An observational non-concurrent cohort study design was used. Methods: Data from all persons who had (exposed) and a matched sample of persons who did not have Clostridium difficile infection, for the calendar years 2007-2010, were analysed. The risk of dying within 30, 60, 90 and 180 days was compared using the two groups. Kaplan-Meier survival analysis and conditional logistic regression models were applied to the data to examine time to death and mortality risk adjusted for comorbidities using the Charlson Comorbidity Index. Results: One hundred and fifty-eight cases of infection were identified. A statistically significant difference in all-cause mortality was identified between exposed and non-exposed groups at 60 and 180 days. In a conditional regression model, mortality in the exposed group was significantly higher at 180 days. Conclusion: In this Australian study, Clostridium difficile infection was associated with increased mortality. In doing so, it highlights the need for nurses to immediately instigate contact precautions for persons suspected of having Clostridium difficile infection and to facilitate a timely faecal collection for testing. Our findings support ongoing surveillance of Clostridium difficile infection and associated prevention and control activities. © 2013 Blackwell Publishing Ltd.

Background The role of environment in infection prevention and control is being increasingly acknowledged. However, gaps remain between what is promoted as best practice in the literature and what is occurring in healthcare settings. In part, this is due to a lack of generally accepted scientific standards, further confounding the ability to demonstrate an undisputed role for the healthcare environment in healthcare-acquired infections (HAIs). Evaluating environmental cleanliness in a standardised format is required, in order to enable a framework for performance management and provide a method by which interventions can be evaluated. Standardised assessment would provide reliable data to support quality-improvement activities and to ensure that healthcare staff have relevant and useful information to inform and adapt practice. Methods This integrative literature review describes approaches to assessing environmental cleanliness. A search of the published literature was undertaken, in combination with a targeted review of the grey literature. Results Four methods for assessing environmental cleanliness were identified: visual inspection, fluorescent gel marker, adenosine triphosphate (ATP) and microbial cultures. Advantages and disadvantages for each are explored. Conclusion Methods that evaluate cleaning performance are useful in assessing adherence to cleaning protocols, whereas methods that sample bio-burden provide a more relevant indication of infection risk. Fast, reproducible, cost-effective and reliable methods are needed for routine environmental cleaning evaluation in order to predict timely clinical risk. © Australasian College for Infection Prevention and Control 2013.