Central clinical laboratory and infection control team: an essential partnership controlling health care-associated infections

Infection Control Committee (ICC) of Akita University Hospital was established in 1980's, when methicillin-resistant Staphylococcus aureus (MRSA) spread in teaching hospitals in Japan. After 20 years from the establishment of ICC, we needed to shake up some of the outdated infection control systems. Infection Control Team (ICT) was established in 2002 to reinforce ICC. ICT was consisted of five infection control doctors (ICD), two infection control nurses (ICN), two medical technicians in bacteriological division of clinical laboratory, one pharmacist and three administrative officials in the hospital. Monitoring of multiple drug-resistant pathogens, antibiotic use, surgical site infections and bloodstream infections are mandatory. Personnel training and educational activity are also required. After the establishment of ICT, inappropriate use of antibiotics and prevalence of MRSA were dramatically decreased. The hospital saved more than 30,000,000 yen annually. However, with a great regret, we experienced an outbreak of MRSA in a department of our hospital in 2003. MRSA infection was judged as a cause of death in three patients in the outbreak. MRSA was thought to transmit via medical personnel since pulsed-field gel electrophoresis revealed common genotype in 11 out of 15 patients studied. Prevention of healthcare-associated infections is a crucial in the management of hospitals. In this paper, we verified the efforts to control the outbreak and analyzed factors interfering infection control activities. A crucial role of a clinical laboratory in controlling healthcare associated infections was also discussed.     

Hospital infection and its countermove

Actual activities of Infection Control Team (ICT) in Suzuka General Hospital is reported. Surveillance of hospital infection, feedback of actual information of infection to each fields and ward round by ICT with certified Infection Control Nurse (ICN) can lead good confidence between ICT and other departments. Participation of ICN for ICT is important due to its trans-department activities.     

Medical technologist as a member of infection control team

For the prevention of infection at institutions, an Anti-nosocomial Infection Committee or an Infection Control Team (ICT) is organized at each institution according to its scale. We report the present status of the ICT managed mainly by medical technologists engaged in microbiological examination (certified medical microbiological technologists) at Dokkyo University School of Medicine. Since this hospital is an educational hospital, the department of clinical laboratory medicine cooperates with the microbiological laboratory of the clinical laboratory in infection control education of medical workers (such as medical students, nursing students, physicians and nurses) in infection diagnosis, infection control/infection management. Since infection control is achieved by improvement in hygiene knowledge and its practice in all citizens, we also attached importance to publicity activities associated with microbiology for patients, their families, and all medical workers.     

Critical role of clinical laboratories in hospital infection control

The hospital infection control and prevention is recognized to be more and more important according to the advances in modern medical treatment and care. Clinical microbiology laboratory play critical roles in the hospital infection control as a member of infection control team (ICT). They are the first in a hospital to identify outbreak of MRSA in NICU and molecular epidemiological analysis of the isolates lead proper intervention of ICT to the concerned ward. From a viewpoint of infectious disease specialist, rapid and precise microbiological information is essential for the appropriate diagnosis and treatment of infectious diseases. Each medical technologist need to make efforts to understand the characteristics of the examinations for infectious diseases and send out information useful for clinical practices. In our hospital, with the participation of all members of medical technologists, rapid reporting system was developed for blood culture examinations, which greatly contribute to the appropriate treatment of bloodstream infections. Collaborations of clinical microbiology laboratory with other members of ICT realize high quality hospital infection control. They also need to be aware of themselves as good practitioners of infection control measures to prevent hospital infections.     

In terms of infection control team(ICT)

We think it is important to make up a medical team for the infection control in the hospital since patients admitted often turn to compromised hosts who possessed the high risk to provoke the possible transmission of nosocomial infections. Infection control team(ICT) under the infection control committee(ICC) was established in our Yamagata University Hospital at the 1994 April. Members of the ICT are composed of staffs at various sections: physicians, pharmacists, nurses, clinical laboratory staffs, a neutrionist and administration office staffs, with the aim of preventing the nosocomial infections. Twenty three staffs of ICT who are specialist at each section have practiced the round of wards, leading in hand-washing, checking of the proper use of antibiotics and disinfectants, making and revising of the infection control manual, follow-up of the route of infection, and a countermeasure of prevention for needle pad accidents, etc. Furthermore, ICT has exerted all possible efforts of various investigations for infections when it is necessary. Problems that are faced our ICT are the construction of a network an inter-net among clinical divisions, nursing, pharmacy and clinical laboratory, and a system of the centralized management is actualized thereby.     

The outbreak of acute gastroenteritis caused by Norwalk like viruses in Zadar general hospital (2007)

OBJECTIVE: Early detection of clinical signs and symptoms of acute gastroenteritis and appropriate preventive measures to stop the spread of infection. METHODS: Epidemiological inspection, clinical examination of hospitalized patients followed by standard bacteriologic and virologic analysis. Norovirus antigen was detected in stool specimen by enzyme immunoassay (EIA). RESULTS: An epidemic of acute gastroenteritis caused by Norwalk like viruses lasted for two weeks (January 26-February 9, 2007). A total of 39 cases were recorded, including 22 (56.4%) inpatients and 17 (43.6%) healthcare workers with disease symptoms. All patients (n = 22; 100%) were hospitalized at Department of Internal Medicine, Cardiology Ward; 11 (64.7%) healthcare workers were working at Cardiology Ward, 3 (17.6%) at Diagnostic Cardiology Laboratory where patients underwent their diagnostic procedures, and 1 (5.9%) healthcare worker at Department of Anesthesiology and Intensive Care was patient consultant at Cardiac Intensive Care Unit. Other healthcare workers, 1 (5.9%) from Department of Neurosurgery and Department of Pathology each, were in family contact with two health care workers employed at Cardiology Ward. DISCUSSION: The Hospital Infection Control Committee was informed about the outbreak of acute gastroenteritis on day 8 of the outbreak. Anti-epidemic measures (according to the source of infection detected and to the mechanisms of transmission) were implemented after epidemiological inspection on day 1 of event recording and continued for two more weeks after the occurrence of the disease clinical symptoms in the last patient involved. CONCLUSION: It is necessary to promptly inform the Hospital Infection Control Committee on the epidemic outbreak for effective and timely anti-epidemic measures to stop the spread of acute gastroenteritis caused by Norwalk like viruses.     

Role of medical technologists in the infection control team

The infection control team (ICT) plays important roles in many different aspects of infection control. They include (1) surveillance for hospital-acquired infection, (2) developing the infection control manual, (3) checking that the manual is followed correctly, (4) giving information about the isolation of microorganisms in the hospital, (5) educating and instructing medical staff, etc. Many data have been accumulated on a database in the microbiology laboratory. Bacterial samples are also examined in the microbiological laboratory therefore medical technologists will be the first to notice hospital-acquired infection. Offering prompt information, obtained by surveillance or routine work, greatly contributes to infection control. Furthermore, a 24hr system for the microbiological laboratory may prevent occupational infection of health care workers. The role of the medical technologist in ICT is thus important. To prevent outbreaks of infection, the regional network is also important for the collection of information about the pathogen and the susceptibility of antimicrobial agents in the region. The medical technologist should participate in and communicate with this network. As mentioned above, the inclusion of medical technologists in infection control practice is essential. To participate in the ICT, medical technologists need to have communication skills, and be recognized by other team members as an essential member.     

Desirable role of the clinical laboratory in hospital infection control

Prevention of hospital-acquired infection is the most important strategy to control infection in terms of the well being of patients and the medical economy. Infection control in hospitals is carried out by the action against hospital-based infection, for which clinical laboratory functions, such as surveillance and outbreak investigation, should be primary responsible. Therefore, it is essential for clinicians to have clinical laboratory rapidly detect pathogenic organisms and provide new and update information on appropriate antibiotics and clinical isolates. It is also desirable for clinical laboratory to collaborate with infection control team (ICT) and link nurse, and provide them with useful information on on-going infection.     

Occupational rituals in patient management

The social practices surrounding diagnosis and management decisions are analyzed from a sociological perspective as occupational rituals. These rituals are part of rounds and conferences, and they assist physicians in managing uncertainty, making treatment decisions, and evaluating outcomes. Physicians use eight key strategies to manage uncertainty: hedged assertions, probability reasoning, a focus on uncertainty as a research problem, requests for consultations, Socratic teaching, deciding not to decide, gallows humor, and hyperrealism. Clinical experience and scientific evidence are used in treatment decisions. The manner in which decisions are made at rounds allows physicians to dramatize the seriousness with which they take their responsibilities to patients. Two major rituals for evaluating outcomes of treatment decisions, grand rounds and the mortality and morbidity conference, provide a forum for dramatizing success and failure, respectively. Occupational rituals allow physicians to discuss their problems. The capacity of modern medicine to process clinical data threatens to obviate these rituals.     

Establishment of a pharmacogenomic testing system for the realization of individual pharmacotherapy

The metabolism of and sensitivity to drugs differ from individual to individual, and one base polymorphism of drug-metabolizing enzymes is known to play an important role in this difference between individuals. The genotyping of drug-metabolizing enzymes prior to drug administration would help to predict individual reactivity to drugs and possible adverse reactions that may occur, which is essential to realize tailor-made therapy for individual patients. In July 2005, the Pharmacogenomics Working Group, composed of members of the Clinical Genomic Medicine Unit, Pharmaceutical Department, Medical Informatics Department, Clinical Laboratory, Gastroenterology, Cardiovascular Medicine, and Department of Neurology, was established in our university hospital in an attempt to introduce such pharmacogenomic testing. The project was approved by the Institutional Research Ethics Committee of the Faculty of Medicine, the University of Tokyo, and, in August 2006, testing for CYP2C19*2 and CYP2C19*3, enzymes involved in the metabolism of proton pump inhibitors, was started. Furthermore, in August 2007, testing for CYP2C9*3, the enzyme involved in the metabolism of Warfarin, and vitamin K epoxidereductase1 (VKORC1) 6484 C>T was started. In the CYP2C19 genotyping, the high incidence of poor metabolizers has been demonstrated; it was speculated that the test could confirm the adverse effects of the drug, i.e., after administration of the drug to patients. Moreover, testing for CYP2C9*3 and VKORC1 6484 C>T was shown to be useful for the safe administration of warfarin. The pharmacogenomic testing system was successfully established in our university hospital, and the Pharmacogenomics Working Group is still active, playing an important role in this project.     

Comparison of Two Surveillance Methods for Detecting Nosocomial Infections in Surgical Patients

Nosocomial infections play a role in quality and cost control in health care. Surveillance of these infections is the only way to gain more insight into their frequency and causes. Since the results of surveillance may lead to changes in both patient and hospital management, which are sometimes major, it is necessary that all healthcare workers involved agree on the criteria used for the diagnosis and surveillance of these complications. In order to compare the efficacy of two surveillance methods, nosocomial infections in surgical patients were registered by both the Department of Surgery (complication surveillance [CS]) and the Department of Infection Control (nosocomial infection surveillance [NIS]) at the University Medical Center Utrecht, The Netherlands, over a 2-month period. The CS team used the national criteria of the Association of Surgeons of the Netherlands and the NIS team used the international criteria of the Centers for Disease Control and Prevention, USA, to define cases of nosocomial infection. A total of 515 patients were included in both arms of the study. The CS team diagnosed 69 infections in 49 patients, and the NIS team diagnosed 64 infections in 45 patients. Of 104 total infections, 39 were diagnosed by the CS team exclusively, 35 by the NIS team exclusively and only 30 by both. The main reasons for the inconsistent results were as follows: (i) the lack of follow-up after discharge in the NIS arm, (ii) the use of clinical criteria for the definition of a nosocomial infection in the CS arm, and (iii) the use of positive cultures as part of the criteria in the NIS arm. From the perspective of infection control, the CS system cannot be recommended for the surveillance of nosocomial infections. Electronic Publication     

Role of a clinical laboratory center as a correlational center for infection control

The prevention of hospital acquired infection is one of the most critical managements for the maintenance of high clinical quality. Surveillance such as the isolation rate of MRSA (methicillin resistant Staphylococcus aureus), MDRP (multidrug-resistant Pseudomonas aeruginosa) and catheter associated blood stream infection rate are useful tools for infection control. In these surveillances, the clinical laboratory center plays an important role in hospitals. Recent studies have shown that community-acquired MRSA has spread rapidly in the United States and clonal MDRP has also spread in Japan. In our studies, similar genotyped MDRP was isolated from several hospitals in the same region. These results suggested that infection control associated with regional hospitals is important to prevent the spread of antimicrobial resistant pathogens. The clinical laboratory center should also play an important role in regional infection control.     

Focus on: Watsonville Community Hospital Biomedical Engineering Department.

The Journal of Clinical Engineering is pleased to present this FOCUS on the Biomedical Engineering Department of Watsonville Community Hospital (Watsonville, CA). Since the Department's inception in 1983, the growth of the hospital and the surrounding area has resulted in the expansion of the Department and its duties. This paper describes the responsibilities of the two-man Biomedical Engineering Department, which serves this 130-bed hospital and oversees the preventive maintenance and repair of approximately 800 pieces of equipment. In addition, the Department is involved with staff education, equipment inventory control, new equipment purchases, technical consultations, and special projects.     

Infection control in Hamamatsu Medical Center

Since the department of Infection Control was established in Hamamatsu Medical Center, a 615-bed community teaching hospital, we have been practicing infection control program including surveillance, coping with needle stick injuries, introducing Interlink system, PPD testing and influenza vaccination to the health care workers. One of the obstacles in the practice of the hospital infection has been a cost, and the infection control does not progress as long as this can't be solved. The infection control, which we have been carrying out so far, seems to have a lot of unnecessary practices. If we stop those practices, considerable cost can be reduced because the hospital infection is achieved in the entire hospital and can be shifted to the practice which is necessary. Although identification of the unnecessary practices is very difficult, EBM (Evidence based medicine) provides us with useful information. "The re-distribution of the cost" referring to EBM seems to be very important to progress infection control.     

Covid-19 pandemic: chronicle of responses and experiences of the infection prevention and control committee at a tertiary hospital in southwest Nigeria

Since the advent of 2019-Corona virus Disease (COVID-19) in Nigeria in February 2020, the number of confirmed cases has risen astronomically to over 61,307 cases within 8 months with more than 812 healthcare workers infected and some recorded deaths within their ranks.Infection prevention and control is a key component in ensuring safety of healthcare workers in the hospital as healthcare-associated infection is one of the most common complications of healthcare management. Unbridled transmission of infection can lead to shortage of healthcare personnel, reduced system efficiency, increased morbidity and mortality among patients and in some instances, total collapse of healthcare delivery services. The Infection Prevention and Control Committee is a recognised group by the Centre for Disease Control and Prevention with their core programmes including drawing up activities, procedures and policies designed to achieve above-stated objectives before, during and after any disease outbreak, especially emerging and re-emerging ones such as the 2019 Coronavirus Disease. In this report, we highlight the roles played by the Infection Prevention and Control Committee of the University of Medical Sciences Teaching Hospital to prevent the spread of COVID-19 within and outside the hospital community and the lessons learned to date.     

2009-2011年某教学医院医院感染流行病学特征分析

目的了解某院医院感染流行特征。方法连续3年采用横断面调查的形式调查该院住院患者,对调查日的所有住院患者的医院感染情况进行床旁调查和病历调查,统一填写调查表。结果 3年医院感染率为4.70%,医院感染例次率为5.01%。3年合计,各科室感染率前3位为重症医学科（35.00%）、层流病房（31.58%）、血液科（15.95%）;感染部位构成比前3位为下呼吸道（47.43%）、泌尿道（15.81%）、血液系统（8.82%）;病原体前3位为铜绿假单胞菌（13.90%）、大肠杆菌（11.23%）、金黄色葡萄球菌（9.63%）。结论医院感染的主要科室是重症医学科、层流病房、血液科,主要部位是呼吸道、泌尿道、血液系统,病原体以铜绿假单胞菌、大肠杆菌、金黄色葡萄球菌多见。     

Interpretation of the results of blood culture and interventional role by clinical laboratory physicians

Blood culture has long been recognized as the gold standard for the definitive diagnosis of bacterial and fungal infections. However, fewer blood cultures have been tested and their results have not been fully used in Japan. Clinical laboratory physicians should play an interventional role, such as recommending blood culture tests in patients with infectious disease or fever of unknown origin. In our hospital, clinical laboratory physicians act as on-call consultants. The yearly number of consultations is between 500 and 700, and consultations concerning infectious disease have increased up to 40% in the past 5 years. As a result, the number of blood cultures and the percentage of 2-set blood collections have increased in order to increase the positivity rate and determine whether the results obtained were contaminated. However, physicians sometimes misunderstand the results of blood culture, and they assume that the identified organism was causative, or that sepsis did not exist if the culture is negative. Clinical laboratory physicians should act as consultants more frequently, concerning the interpretation of blood culture results, and the choice of antimicrobial agents, because the inappropriate use of antimicrobial agents leads to higher mortality and higher medical costs. Finally, collaboration between clinical laboratory physicians and co-medical staff such as the infection control team, nurses and pharmacists is necessary.     

Detection of drug resistant bacteria and correspondence of microbiological laboratory to clinical physicians

The world is now being faced with the battle for antimicrobial resistant organisms(ARO), such as MRSA, PRSP, ESBL producing GNR, MDRP and VRSA. These AROs are causing hospital-acquired infections(HAI) by the way of person-to-person transmission. The role of microbiological laboratories in hospitals is quite important in controlling HAI. Firstly, accurate detection of AROs is essential. They have to be proficient in both isolation and detection of AROs. Secondly, they have to return the results rapidly for not only clinicians but infection control team(ICT) to prevent more spread of HAI if an isolated organism is ARO. Thirdly, they have to report the statistical data about isolated organisms for ICT in each hospital. AROs can be isolated by three major methods, detection of responsible resistant genes or proteins and antimicrobial susceptibility tests. Most laboratories isolate AROs, using one or two of these methods. They should be prepared for and follow the most current criteria of AROs by Japanese original standard, or presented from NCCLS. Microbiological laboratories should also play a role in both hospital epidemiology and appropriate antimicrobial use by providing useful information, annual or periodical reports of antimicrobial susceptibility for isolated organisms which are relevant in their hospital. The microbiological laboratory which have good skills in detecting AROs, analyzing epidemiological data and communicating with all hospital workers, is now required from ICT in controlling HAI.     

2016～2017年泌尿系感染病原菌特征分析

目的 了解2016～2017年泌尿系感染病原菌、性别、年龄、科室分布特点,为临床泌尿系感染疾病诊断与医院感染控制提供可靠依据.方法 收集医院2016年1月至2017年12月分离的泌尿系感染病原菌1369株,细菌培养和药敏试验按《全国临床检验操作规程》(第四版)进行,采用VITEK-2 compact全自动药敏鉴定分析仪对菌株进行鉴定及药敏试验,药敏折点判断采用美国临床实验室标准化委员会(CLSI)2017版标准.采用WHONET 5.6软件和卡方检验进行数据处理和分析.结果 1369株病原菌中,分别检出革兰阴性菌778株(56.83％),革兰阳性菌303株(22.13％),真菌288株(21.04％),主要以革兰阴性菌为主.革兰阴性菌分离率前两位的病原菌分别为大肠埃希菌(28.85％)、肺炎克雷伯菌(11.91％).革兰阳性菌分离率前两位分别为屎肠球菌(11.91％)、粪肠球菌(4.53％).真菌分离率最高为白色假丝酵母菌(8.25％).男女性别占分别为男性为62.24％、女性37.76％.泌尿系感染人群占比前三位的为81 ～ 90岁(43.54％)、71 ～80岁(21.18％)、61～ 70岁(12.56％).泌尿系感染病原菌在全院各病区均有分布,病区分离率前3位分别为占ICU病区(26.52％),神经与精神病区(17.02％),急诊病区(10.52％),其中以ICU病区最多.结论 医院泌尿系感染病原菌以革兰阴性菌为主,大肠埃希菌为主要致病菌.男性患者较女性患者更容易导致泌尿系感染.泌尿系感染人群以60岁以上人群比例最多,其中81-90年龄段占比较高.ICU病区患者泌尿系感染几率最高.及时监测尿液标本临床分离株的分布情况和特征,能够帮助临床医生诊断尿路感染.     

不同条件保存24小时尿液对生化检测的影响

目的探讨24h尿在不同的保存条件下对生化项目检测结果的影响,探寻一种不影响尿液生化检测结果且留取安全简便的保存方式。方法在同一时间收集20份患者尿液,将每份尿液分装四份,使用不同方法分别处理:冷藏(2~8℃)未添加防腐剂、常温(18~25℃)未添加防腐剂、常温添加浓盐酸以及常温添加硼酸。尿液按上述方法保存24h后进行生化项目检测,包含:总蛋白、钾、钠、氯、钙、磷、尿素、尿酸及肌酐。采用单因素方差分析或Wilcoxon检验比较其他三种与冷藏保存方式间的差异。结果尿液各项生化检测结果在常温保存与冷藏保存相比差异均无统计学意义(P>0.05);使用浓盐酸保存与冷藏保存相比在总蛋白、钾、氯、尿素、尿酸及肌酐检测差异存在统计学意义(P<0.05);使用硼酸保存与冷藏保存相比在钾、尿酸、尿素及肌酐检测差异存在统计学意义(P<0.05)。结论24h尿液在留取过程中,使用常温与冷藏保存方式相比,生化检测结果无明显差异,而添加浓盐酸和硼酸保存尿液会对生化检测结果产生不同程度的影响。