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Time to react\" [4] in 2009. Because the model estimates reported in the AMR Review [1] are partly based on the ECDC [4] methodology, we will discuss both reports, which estimated the burden of AMR in Europe and the world, respectively. [...]overlapping catchment areas between hospitals and uncertainty in catchment population estimates are ignored.\\n Scientific Scrutiny Although the results from these burden reports are often cited, none of these burden estimates themselves have been published in peer-reviewed literature.

Background. Despite the high prevalence of patient-reported antibiotic allergy (so-called antibiotic allergy labels [AALs]) and their impact on antibiotic prescribing, incorporation of antibiotic allergy testing (AAT) into antimicrobial stewardship (AMS) programs (AAT-AMS) is not widespread. We aimed to evaluate the impact of an AAT-AMS program on AAL prevalence, antibiotic usage, and appropriateness of prescribing. Methods. AAT-AMS was implemented at two large Australian hospitals during a 14-month period beginning May 2015. Baseline demographics, AAL history, age-adjusted Charlson comorbidity index, infection history, and antibiotic usage for 12 months prior to testing (pre–AAT-AMS) and 3 months following testing (post–AAT-AMS) were recorded for each participant. Study outcomes included the proportion of patients who were \"de-labeled\" of their AAL, spectrum of antibiotic courses pre– and post–AAT-AMS, and antibiotic appropriateness (using standard definitions). Results. From the 118 antibiotic allergy—tested patients, 226 AALs were reported (mean, 1.91/patient), with 53.6% involving 1 or more penicillin class drug. AAT-AMS allowed AAL de-labeling in 98 (83%) patients–56% (55/98) with all AALs removed. Post– AAT, prescribing of narrow-spectrum penicillins was more likely (adjusted odds ratio [aOR], 2.81, 95% confidence interval [CI], 1.45–5.42), as was narrow-spectrum β-lactams (aOR, 3.54; 95% CI, 1.98–6.33), and appropriate antibiotics (aOR, 12.27; 95% CI, 5.00–30.09); and less likely for restricted antibiotics (aOR, 0.16; 95% CI, 09–.29), after adjusting for indication, Charlson comorbidity index, and care setting. Conclusions. An integrated AAT-AMS program was effective in both de-labeling of AALs and promotion of improved antibiotic usage and appropriateness, supporting the routine incorporation of AAT into AMS programs.

Background Australia does not have a national healthcare associated infection (HAI) surveillance program. Only one HAI point prevalence study has been undertaken in 1984. The objective of this study was to estimate the burden of healthcare associated infection (HAI) in acute adult inpatients in Australia. Methods A cross sectional point prevalence study (PPS) was conducted in a sample of large acute care hospitals. All data were collected by two trained Research Assistants. Surveillance methodology was based on the European Centre for Disease Prevention and Control (ECDC) PPS Protocol with variation in the sampling method in that only acute inpatients ≥ 18 years old were included. ECDC HAI definitions were applied. Results Data was collected between August and November 2018. A total of 2767 patients from 19 hospitals were included in the study. The median age of patients was 67, and 52.9% of the sample were male. Presence of a multi-drug resistant organism was documented for 10.3% of the patients. There were 363 HAIs present in 273 patients. The prevalence of patients with a HAI was 9.9% (95%CI: 8.8–11.0). Hospital prevalence rates ranged from 5.7% (95%CI:2.9–11.0) to 17.0% (95%CI:10.7–26.1). The most common HAIs were surgical site infection, pneumonia and urinary tract infection, comprising 64% of all HAIs identified. Conclusion This is the first HAI PPS to be conducted in Australia in 34 years. The prevalence rate is higher than the previous Australian study and that reported by the ECDC, however differences in methodology limit comparison. Regular, large scale HAI PPS should be undertaken to generate national HAI data to inform and drive national interventions.

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.

Hand hygiene is a key component of infection control in healthcare. WHO recommends that healthcare workers perform six specific poses during each hand hygiene action. SureWash (Glanta Ltd, Dublin, Ireland) is a novel device that uses video-measurement technology and immediate feedback to teach this technique. We assessed the impact of self-directed SureWash use on healthcare worker hand hygiene technique and evaluated the device's diagnostic capacity. A controlled before-after study: subjects in Group A were exposed to the SureWash for four weeks followed by Group B for 12 weeks. Each subject's hand hygiene technique was assessed by blinded observers at baseline (T0) and following intervention periods (T1 and T2). Primary outcome was performance of a complete hand hygiene action, requiring all six poses during an action lasting ≥20 seconds. The number of poses per hand hygiene action (maximum 6) was assessed in a post-hoc analysis. SureWash's diagnostic capacity compared to human observers was assessed using ROC curve analysis. Thirty-four and 29 healthcare workers were recruited to groups A and B, respectively. No participants performed a complete action at baseline. At T1, one Group A participant and no Group B participants performed a complete action. At baseline, the median number of poses performed per action was 2.0 and 1.0 in Groups A and B, respectively (p = 0.12). At T1, the number of poses per action was greater in Group A (post-intervention) than Group B (control): median 3.8 and 2.0, respectively (p<0.001). In Group A, the number of poses performed twelve weeks post-intervention (median 3.0) remained higher than baseline (p<0.001). The area under the ROC curves for the 6 poses ranged from 0.59 to 0.88. While no impact on complete actions was demonstrated, SureWash significantly increased the number of poses per hand hygiene action and demonstrated good diagnostic capacity.

Background Multidrug resistant organisms (MDROs) occur more commonly in burns patients than in other hospital patients and are an increasingly frequent cause of burn-related mortality. We examined the incidence, trends and risk factors for MDRO acquisition in a specialist burns service housed in an open general surgical ward, and general intensive care unit. Methods We performed a retrospective study of adult patients admitted with an acute burn injury to our specialist statewide tertiary burns service between July 2014 and October 2020. We linked patient demographics, injury, treatment, and outcome details from our prospective burns service registry to microbiology and antimicrobial prescribing data. The outcome of interest was first MDRO detection, stratified into the following groups of interest: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), two groups of Pseudomonas (carbapenem resistant, and piperacillin-tazobactam or cefepime resistant), carbapenem-resistant Acinetobacter species, Stenotrophomonas maltophilia , carbapenem-resistant Enterobacteriaceae (CRE), and extended-spectrum beta-lactamase producing Enterobacteriaceae (ESBL-PE). We used a Cox proportional hazards model to evaluate the association between antibiotic exposure and MDRO acquisition. Results There were 2,036 acute admissions, of which 230 (11.3%) had at least one MDRO isolated from clinical specimens, most frequently wound swabs. While acquisition rates of individual MDRO groups varied over the study period, acquisition rate of any MDRO was reasonably stable over time. Carbapenem-resistant Pseudomonas was acquired at the highest rate over the study period (3.5/1000 patient days). The 12.8% (29/226) of MDROs isolated within 48 h were predominantly MRSA and Stenotrophomonas. Median (IQR) time from admission to MDRO detection was 10.9 (5.6–20.5) days, ranging from 9.8 (2.7–24.2) for MRSA to 23.6 (15.7–36.0) for carbapenem-resistant P. aeruginosa . Patients with MDROs were older, had more extensive burns, longer length of stay, and were more likely to have operative burn management. We were unable to detect a relationship between antibiotic exposure and emergence of MDROs. Conclusions MDROs are a common and consistent presence in our burns unit. The pattern of acquisition suggests various causes, including introduction from the community and nosocomial spread. More regular surveillance of incidence and targeted interventions may decrease their prevalence, and limit the development of invasive infection.

Aminoglycosides are commonly prescribed to children with febrile neutropenia (FN) but their impact on clinical outcomes is uncertain and extent of guideline compliance is unknown. We aimed to review aminoglycoside prescription and additional antibiotic prescribing, guideline compliance and outcomes for children with FN. We analysed data from the Australian Predicting Infectious ComplicatioNs in Children with Cancer (PICNICC) prospective multicentre cohort study, in children <18 years with FN between November 2016 and January 2018. Impact of aminoglycoside use in the first 12 hours of FN on composite unfavourable outcome of death, ICU admission, relapse of infection or late-onset sepsis was assessed using multivariable Cox regression. The study was conducted in Australia where antimicrobial resistance among gram negative organisms is relatively low. Data from 858 episodes of FN in 462 children from 8 centres were assessed, median age 5.8 years (IQR 3.5-10.8 years). Early empiric aminoglycosides were prescribed in 255 episodes (29.7%). Guideline non-compliance was common: in 46% (184/400) of eligible episodes, patients did not receive aminoglycosides, while aminoglycosides were prescribed in 9% (39/458) of guideline-ineligible episodes. Adjusted hazard of the composite unfavourable outcome was 3.81 times higher among patients prescribed empiric aminoglycosides than among those who weren't (95% confidence interval, 1.89-7.67), with no increased risk of unfavourable outcome in eligible patients who did not receive aminoglycosides. In a large paediatric FN cohort, aminoglycoside prescription was common and was often non-compliant with guidelines. There was no evidence for improved outcome with aminoglycosides, even in those who met guideline criteria, within a low-resistance setting. Empiric aminoglycoside prescription for children with FN requires urgent review in guidelines and in national practice.

Buruli ulcer (BU), caused by Mycobacterium ulcerans, is increasing in incidence in Victoria, Australia. To improve understanding of disease transmission, we aimed to map the location of BU lesions on the human body. Using notification data and clinical records review, we conducted a retrospective observational study of patients diagnosed with BU in Victoria from 1998-2015. We created electronic density maps of lesion locations using spatial analysis software and compared lesion distribution by age, gender, presence of multiple lesions and month of infection. We examined 579 patients with 649 lesions; 32 (5.5%) patients had multiple lesions. Lesions were predominantly located on lower (70.0%) and upper (27.1%) limbs, and showed a non-random distribution with strong predilection for the ankles, elbows and calves. When stratified by gender, upper limb lesions were more common (OR 1·97, 95% CI 1·38-2·82, p<0·001) while lower limb lesions were less common in men than in women (OR 0·48, 95% CI 0·34-0·68, p<0·001). Patients aged ≥ 65 years (OR 3·13, 95% CI 1·52-6·43, p = 0·001) and those with a lesion on the ankle (OR 2·49, 95% CI 1·14-5·43, p = 0·02) were more likely to have multiple lesions. Most infections (71.3%) were likely acquired in the warmer 6 months of the year. Comparison with published work in Cameroon, Africa, showed similar lesion distribution and suggests the mode of M. ulcerans transmission may be the same across the globe. Our findings also aid clinical diagnosis and provide quantitative background information for further research investigating disease transmission.

Background Ceftriaxone-resistant Enterobacteriaceae are priority pathogens of critical importance. Escherichia coli is the most commonly isolated Enterobacteriaceae. There are few data regarding non-invasive ceftriaxone-resistant E. coli (CR-EC) isolates in the Australian community. We aimed to describe the prevalence, phenotype, geographic variation, and sociodemographic predictors of ceftriaxone-resistance among E. coli isolates recovered from urine specimens. Methods In August 2017, we prospectively analysed E. coli isolates recovered from urine specimens submitted to Dorevitch Pathology (Victoria, Australia), a laboratory that services patients in the community and hospitals. In addition to patient-level predictors of ceftriaxone resistance, we mapped patient postcodes to community-level indicators including Index of Relative Socioeconomic Deprivation, remoteness, and proportion of residents born overseas. We used Poisson regression with log link and robust standard errors to quantify the association between ceftriaxone resistance and patient- and community-level factors. Results We included 6732 non-duplicate E. coli isolates. Most (89.2%, 6008/6732) were obtained from female patients. Median age was 56 years (IQR, 32–74). Most patients (90.5%, 5789/6732) were neither referred from a hospital nor residing in a residential aged care facility (RACF). Among the 6732 isolates, 5.7% (382) were CR-EC, ranging from 3.5% (44/1268) in inner regional areas to 6.3% (330/5267) in major cities. Extended spectrum ß–lactamase (ESBL) -production was the most common mechanism for ceftriaxone resistance (89%, 341/382). Nitrofurantoin was the most active oral agent against CR-EC. Eight CR-EC isolates (2.4%) were susceptible only to amikacin, meropenem and nitrofurantoin. None were resistant to meropenem. On multivariable analysis, ceftriaxone resistance was associated with age, residence in a RACF (adjusted relative risk [aRR] 2.94, 95% confidence interval [CI] 2.10–4.13), specimen referral from hospital (aRR 2.05, 95% CI 1.45–2.9), and the proportion of residents born in North Africa and the Middle East (aRR 1.30 for each 5% absolute increase, 95% CI 1.09–1.54), South-East Asia (aRR 1.14, 95% CI 1.02–1.27), and Southern and Central Asia (aRR 1.16, 95% CI 1.04–1.28). Conclusions These results provide insights into sociodemographic variation in CR-EC in the community. A better understanding of this variation may inform empiric treatment guidelines and strategies to reduce community dissemination of CR-EC.

Buruli ulcer is a necrotising infection of skin and soft tissue caused by Mycobacterium ulcerans (M. ulcerans). Buruli ulcer most often occurs on limbs, and it is hypothesized this is explained by direct exposure to the environment. However, even on exposed areas Buruli ulcer is not randomly distributed. M. ulcerans prefers an in vitro temperature of 30-33°C and growth is inhibited at higher temperatures. This study investigated whether variations in skin surface temperature distribution in healthy volunteers could partly account for Buruli ulcer lesion distribution. In this observational study, a thermal camera (FLIR E8) was used to measure skin surface temperature at the sternal notch and at 44 predetermined locations on the limbs of 18 human participants. Body locations of high, middle and low Buruli ulcer incidence were identified from existing density maps of lesion distribution. Skin temperature of the three incidence location groups were compared, and differences in age and sex groups were also analysed. We found an inverse relationship between skin temperature and lesion distribution, where high incidence locations were significantly cooler and low incidence locations significantly warmer (Kruskal-Wallis test p<0.0001). Linear mixed effects regression analysis estimated that skin surface temperature accounts for 22.0% of the variance in Buruli ulcer lesion distribution (marginal R-squared = 0.219) in the anterior location group, and 0.6% in the posterior group (marginal R-squared 0.006). Men had warmer upper and lower limbs than females (Mann-Whitney U test p = 0.0003 and p<0.0001 respectively). We have found an inverse relationship between skin temperature and Buruli ulcer lesion distribution, however this association is weak. Additional unknown factors are likely to be involved that explain the majority of the variation in Buruli lesion distribution.