Relationship between outcome of written and clinical parts in internal medicine board certifying examination.

Objective: To assess the correlation between written and clinical scores of the Thai Board of Internal Medicine certification examination in different academic years. Methods: Data from 585 internal medicine residents who passed both written and clinical parts of the board certifying examination in the first attempt during the academic year 2005-2007 were collected. Correlation between scores from both parts in each year were then examined. Results: Modest positive linear correlation was found between the written and clinical examination scores in overall (r = 0.57, 0.55, and 0.38, p <0.001 in 2005-2007 respectively). When considered for the subpart of clinical examination scores, the correlation with the section of laboratory interpretation was highest (r = 0.52, 0.54, and 0.33, p <0.001 in 2005-2007 respectively). Conclusion: The outcome of written and clinical parts of certification examination for Thai Board of Internal Medicine had a modest relationship.

Prevalence of nosocomial infection in Thailand 2006.

OBJECTIVE: To study the prevalence of nosocomial infection (NI). MATERIAL AND METHOD: A point prevalence study was done in 20 hospitals across the country in August 2006. RESULTS: The present study was done in 20 hospitals: three university, five regional, five provincial, and seven other hospitals. 9,865 patients were included Male and female patients were almost equal in number with an average age of 42.7 years. The NI proportion was 6.5%, 7.0% in male and 5.9% in female patients. The prevalence rate of NI was highest in university and other hospitals (7.6%), followed by provincial (6.0%), and regional hospital (4.9%). There were two hospitals, one regional and one other hospital with NI prevalence rates over 10%. All three university hospitals had NI exceeding 7%. The infection rate was highest in ICU (22.6%), followed by surgical (6.8%), medical and orthopedic (6.7% each) departments. The commonest site of NI was lower respiratory tract (36.1%) followed by urinary tract (25.5%). Causative organisms were identified in 70.8% of all sites of infection and over 63% were by bacteria. Gram-negative bacteria were responsible for 70.2% and gram-positive bacteria for 19.9% of all pathogens. Pseudomonas aeruginosa, Klebsiella spp., Acinetobacter baumannii, MRSA, and enterococci were the leading bacterial isolates. At the time of the present study, 47.0% of patients were receiving antimicrobials. Cephalosporins, penicillins, and aminoglycosides were most commonly used CONCLUSION: The prevalence rate of NI in Thailand in 2006 was 6.5%, similar to previous studies. Changes in NI rates in certain hospitals, even though subtle, need additional studies to improve the efficacy of NI control.

Risk factors for multi-drug resistant Acinetobacter baumannii nosocomial infection.

OBJECTIVE: To assess factors associated with multi-drug resistant Acinetobacter baumannii (MDR-AB) nosocomial infection. MATERIAL AND METHOD: This hospital-based case-control study was conducted in patients admitted to Siriraj Hospital, Bangkok, Thailand between January 1, 2005 and December 31, 2005. The study population consisted of 155 cases with MDR-AB nosocomial infection and 310 controls without nosocomial infection. The cases were matched with controls by age and ward of admission with a ratio of 1:2. RESULTS: The average age of the present study population was 63.5 +/- 18.7 years among cases and 62.9 +/- 18.2 years among controls. The mean of length of stay in hospital among cases was 4.9 +/- 1.4 weeks and controls 1.8 +/- 1.0 weeks. The most common site of MDR-AB nosocomial infection was lower respiratory tract (74.8%). The antimicrobial susceptibility of MDR-AB was 3.9% to cetriaxone and 42.1% to cefoperazone/sulbactam. Multiple logistic regression analysis showed the following associated factors with MDR-AB nosocomial infection: duration of admission prior to MDR-AB nosocomial infection > 1 week (OR = 2.06; 95% CI 1.09-3.89), indwelling urinary catheter > 1 week (OR = 8.24; 95% CI 3.81-17.82), mechanical ventilation > 1 week (OR = 5.73; 95% CI 2.96-11.10), central venous line > 1 week (OR = 3.29; 95% CI 1.48-7.31), nasogastric intubation > 1 week (OR = 6.22; 95% CI 3.24-11.93), prior administration of 3rd-4th generation cephalosporins (OR = 1.80; 95% CI 1.04-3.13), metrodazole (OR = 2.59; 95% CI 1.21-5.56), and piperacillin-tazobactam (OR = 4.68; 95% CI 1.93-11.32). CONCLUSION: A case-control study in medical and surgical patients in Siriraj Hospital in 2005 revealed risk factors for AB nosocomial infection. Prolonged admission of more than 2 weeks, use of devices, and prior treatment with certain antimicrobials were found to be significant risk factors for the infection. To reduce the infection, strict infection control measures must be applied to the patients with these risk factors. Education to medical personnel and enforcement of infection control practices are all needed to reduce antimicrobial resistant bacterial nosocomial infection.

Discriminatory powers of molecular typing techniques for methicillin-resistant Staphylococcus aureus in a university hospital, Thailand.

Discriminatory powers of various molecular techniques were evaluated for typing of methicillin-resistant Staphylococcus aureus (MRSA) isolated in Siriraj Hospital, Bangkok, Thailand. Thirty MRSA isolates were randomly selected in this study. They were characterized by pulsed-field gel electrophoresis, Clal-mecA and Clal-Tn554 polymorphisms, ribotyping, and PCR-based methods including SCCmec typing, spa and coa gene polymorphism, and repeat units in hypervariable region downstream of mecA. Individual molecular typing technique distinguished those MRSA isolates into 2 to 5 types. Eleven genetic backgrounds of MRSA isolates were elucidated by combination of typing methods with trimethoprim/sulfamethoxazole (TMP/SXT) susceptibility. Combination of all typing methods including TMP/SXT susceptibility yielded a discriminatory index of 0.94. Combination of PCR-based methods and TMP/SXT susceptibility, with the discriminatory index of 0.89, is a practical typing approach suitable for rapid epidemiological investigation of MRSA isolates in a hospital setting.

Evaluation of a training course in infection control for nurses.

OBJECTIVE: To evaluate the effectiveness of a training course in infection control for nurses. MATERIAL AND METHODS: A quasi-experimental study was performed from November 1, 2001 to December 31, 2002. The study was divided into three phases; 1) pre-intervention (November 1-30, 2001) to survey baseline data among participants, 2) intervention (January 1-31, 2002) to establish, develop and conduct the training course, 3) post-intervention (February 1, 2002 to December 31, 2002) to evaluate the effectiveness of the training program, and conduct a workshop for infection control project presentations. The research instruments consisted of questionaires and a focus group discussion guide. RESULTS: Forty-six nurses who had experience of working as infection control nurses (ICN) for more than one year and 46 hospital administrators were enrolled in the pre-interventional phase. Major problems identified among ICNs were inadequate knowledge, multiple simultaneous job descriptions, overwork and lack of collaboration from colleagues. After intervention, significant improvement was observed on their knowledge and confidence among ICNs (rating scale, 4.09 vs. 3.43; p< 0.001). All administrators agreed that the training course was beneficial to ICNs and believed that the problems in practices of IC would be solved. More satisfaction of ICNs among hospital administrators was also observed (97.7% vs. 28.3%; p< 0.001). CONCLUSION: The present study suggested that the training course to provide practical knowledge for ICNs be effective and should be conducted periodically to keep up with the advance in medical technology. An ICN network with other academic institutions should be established.

Bacterial contamination of vegetables served in hospitals.

OBJECTIVES: To study bacterial contamination of fresh vegetables before cleaning and before serving to patients in 14 hospitals. MATERIAL AND METHOD: Aerobic plate count was performed and emphasized on total viable aerobic bacteria, fecal coliform, fecal Escherichia coli and enteric pathogens in fresh vegetables including romaine lettuce, onion, parsley, celery and tomato before cleaning and before serving. Hospital nutrition officers who were involved in food purchasing and processing were interviewed. RESULTS: One hundred and six of 403 of fresh vegetable samples (26.3%) before cleaning were contaminated with > 10(7) colony forming unit per gram (CFU/gram) of viable aerobic bacteria, 106 of 178 samples (59.6%) contained MPN/fecal coliform >1,100 /gram, 78 samples (43.8%) contained MPN fecal E. coli >10/gram. Enteric bacteria were isolated from 7.2% of the total 304 samples including non typhoid Salmonella (1 sample), Vibrio cholerae non O1/O139 (7 samples) and Aeromonas species (14 samples). Forty of 396 ready to serve vegetable samples (10.1%) contained > 10(7) CFU/gram of viable aerobic bacteria. Seventy five of 183 (40.9%) samples contained >1,100 MPN fecal coliform/gram and 43 (23.5%) contained >10 MPN fecal E. coli/gram. Enteric bacteria were also detected in 7.6% of the samples including V. cholerae non O1/O139 (6 samples) and Aeromonas species (17 samples). There were three different ways in obtaining fresh vegetables to the hospitals: by auction (50%), wholesalers (21.4%) and retailers (14.2%). There were also different standards of transportation, packaging, delivery and food processing, particularly cleaning methods. CONCLUSION: Ready-to-eat fresh vegetables were contaminated in high percentages with microorganisms in the number that exceeded the standard. Better management is required to safeguard patients.

Quality of nosocomial infection control in Thailand.

OBJECTIVE: To study the quality of nosocomial infection control with respect to structure and process. MATERIAL AND METHOD: Data collection by questionnaire and interview administrators and medical personnel in 57 hospitals in Thailand in 2002. RESULTS: Nosocomial infection control was implemented in all 57 hospitals. In every hospital, there was an infection control committee (ICC) and at least 1 infection control nurse (ICN). The quality of ICNs regarding knowledge, skill and time available for infection control needed to be improved. Surveillance methods of NI were not appropriate in many hospitals. Doctors were not interested in NI control and supply of certain materials was not adequate. Lack of support and co-operation of doctors and nurses was found. Service of certain departments needed to be revised in over 50%. Doctors and nurses not directly involved in NI controlled were not satisfied with current practices. CONCLUSION: Quality of NI control in Thailand has yet to be improved regarding structure and process. Better cooperation between NI control team and healthcare personnel needs to be developed.

Program on nosocomial infection in the curricula of medicine, dentistry, nursing and medical technology in Thailand.

OBJECTIVES: To identify defects in the program on NI in curricula of medical, dental, medical technology and nursing schools. Impacts of the results of the study on the changes of the program were also evaluated MATERIAL AND METHOD: Questionnaires study of all 12, 8, 9 medical, dental, medical technology and 20 of 62 nursing schools. Data were collected and analyzed. Defects in the program of NI were identified and recommendation for improving was drafted in a workshop participated by curriculum directors and researchers. Results of the study were fedback to the schools enrolled. Changes of the program were later followed.. RESULTS: Program on NI was present in the curricula of 11 of 12 medical, some dental and medical technology but in none of the nursing schools. Education program varied in methods of teaching, hours and years of students. A few schools modified the program in their curricula by the results of the study and recommendation of a workshop participated in by researchers and program directors. CONCLUSION: Program on NI in the curricula of medical, dental, medical technology and nursing schools in Thailand varied in education methods, teaching hours and in student years. The present study results had little impact on changing the program. An evidence-based program on NI in medical, dentistry, medical technology and nursing is urgently needed.

Development of quality indicators for sterilization practices of the central sterile supply department.

OBJECTIVE: To develop quality indicators for assessing the performance of central sterile supply department. (CSSD). MATERIAL AND METHOD: Quality indicators for sterilization in CSSD were searched by literature review and by current situation analysis by 79 infection control nurses (ICNs) and 83 heads of CSSD. Quality indicators were drafted and subsequently validated by 5 experts. The feasibility and applicability of the quality indicators were tested in 37 ICNs and 34 heads of CSSD. The quality indicators were finally refined by a forum of 5 experts and 5 representatives from CSSD. RESULTS: A total of 30 quality indicators were developed. These include 9 indicators for structure, 12 for process and 9 for output of CSSD. The quality indicators were deemed appropriate for the assessment of the quality of CSSD in Thailand. CONCLUSION: Thirty indicators were developed for assessing the quality of CSSD.

Roles of infection control nurses in university hospitals.

OBJECTIVE: To evaluate the roles of infection control nurses (ICNs) in university hospitals. MATERIAL AND METHOD: Interviewing 23 ICNs in 6 university hospitals applying for hospital accreditation during March and April 2002. RESULTS: The ICNs had an average work experience of 11.3 years. The roles relatively well carried out by the ICNs were: administration, outbreak investigation, personnel health, education, consultation. Better performance was needed in the roles of presenting surveillance data to infection control committee, research and analyzing the needs and expectation of patients related to IC. CONCLUSION: Infection control nurses in university hospitals could perform their roles relatively well. However, better roles in surveillance, research and quality improvement need to be developed.

Catheter-associated urinary tract infection.

OBJECTIVES: To study the incidence, risk factors, clinical outcomes and antibiotic costs of catheter-associated urinary tract infections (CAUTI) in patients with indwelling urinary catheter for one week and longer MATERIAL AND METHOD: Patients in neurology and neurosurgery wards in a teaching hospital were studied. Patients with UTI before catheterization and in whom the catheter was removed before one week were excluded. Urine cultures were done immediately after catheterization and 3 times a week there after. Patients were followed for symptoms of UTI for 1 week after catheter removal, for 4 weeks without evidence of UTI or until discharge. RESULTS: One hundred and one patients met the inclusion criteria. The incidence of CA UTI was 73.3%. High incidence of CAUTI was found in the first 2 weeks after catheterization. About one-half of the patients with CAUTI had a single episode and were symptomatic. None of the 132 episodes of CAUTI were associated with secondary bacteremia. Risk factors for CAUTI identified were prolonged catheterization and change of the catheter Nosocomial pathogens were found in urine and yeast was the commonest. Eleven patients (14.9%) with CAUTI died and only in 2, CAUTI was considered a contributory factor for mortality. The cost of antimicrobials for treating one episode of CAUTI was 8,180 baht and this rose to 49,983 baht for CAUTI associated with concurrent infections at other sites. CONCLUSION: Catheter-associated urinary tract infection was common. Uropathogens were nosocomial micro-organisms with high incidence of resistance to antimicrobials. Impacts on morbidity, mortality and costs were substantial. Better management of urinary catheter is to be explored and implemented.

Roles of infection control nurses in regional hospitals.

OBJECTIVES: To evaluate the roles of infection control nurses (ICNs) in regional hospitals and to detect problems, obstacles in practice and needs for support. MATERIAL AND METHOD: A descriptive study by interview and questionnaire survey of 16 ICNs from regional hospitals appling for HA. RESULTS: From February to April 2002, a study by interview and questionnaires was done in 16 ICNs from 10 regional hospitals applying for HA. Most of the ICNs practised IC roles according to HA criteria except for hospital employee health, NI surveillance and research. The major problems and obstacles included the lack of IC positions, inadequate ICNs, lack of support from hospital administrative personnel, too heavy work load, lack of: IC experts, budget for IC, equipment, IC research data and education material. CONCLUSION: The present study suggested that roles of ICNs in hospital employee health, NI surveillance and research were inadequate because of the lack of full time ICNs, too heavy a work load, lack of: IC consultants supply and administrative support.

Nosocomial infection control in district hospitals in northern Thailand.

OBJECTIVE: To study the practice of nosocomial infection (NI) control in district hospitals. MATERIAL AND METHOD: Descriptive study using questionnaires and group discussion. RESULTS: From February-March 2002, five district hospitals in the northern region of Thailand were randomly enrolled. All members of the infection control committee (ICC) were included and data were available from 71 members (85.0%). Infection control activities were done by members of the ICC. The NI control program was designed by the Ministry of Public Health. Due to limited resources and suboptimal implementation, several defects in key elements for infection control were identified. Lack of competent personnel, inappropriate practices and lack of administrative support were the important barriers to good practice. CONCLUSION: Lack of competent personnel and inappropriate work instructions were identified. A review of a NI control program in district hospitals is needed.

Bacterial flora--A potential source of endophthalmitis after cataract surgery.

OBJECTIVES: To study bacteria from eye lids and conjunctival sac of patients undergoing cataract surgery before and after the application of antiseptics. MATERIAL AND METHOD: Patients undergoing elective cataract extraction in one university hospital were randomly enrolled. Cultures for bacteria and candida were done by swabbing the eye lids before and after cleaning with 4% chlorhexidine gluconate. Subsequently 10% povidone iodine was applied on eye lids and conjunctival sacs. Cultures of specimens from eye lids and conjunctival sac were taken after the application of 10% povidone iodine and at the end of the operation. RESULTS: Fifty-one patients were enrolled. Positive cultures were found in 90.2% and 82.4% before and after cleaning the face with 4% chlorhexidine. After topical application of 10% povidone iodine, only 19.6% had positive cultures from eye lids and conjunctival sac; a significant reduction (p=0.001). At the end of the operation, positive cultures were found from eye lids in 10 patients and from the conjunctival sac in 4 patients. Isolates were skin flora and candida species in 2 patients. None of the patients had endophthalmitis. CONCLUSION: Cleaning eye lids with 4% chlorhexidine followed by applying 10% povidone iodine was effective in decreasing skin flora in cataract surgery. The organisms were not completely eliminated. Postoperative follow-up to detect infectious complications is warranted.

Development of national guidelines for the prevention and control of nosocomial infections.

OBJECTIVE: To develop a national evidence-based guidelines for the prevention and control of nosocomial infection. MATERIAL AND METHOD: Draft guidelines for the prevention and control of nosocomial infection were developed by the researchers and reviewed by a 10 member panel of experts. The guidelines were modified by brainstorming of 55 practitioners in July 2002. The guidelines were tested for their applicability in 20 hospitals across the country in 2002. The participants gave suggestions on the guidelines which were modified accordingly. The guidelines were finalized by brainstorming of the 55 practitioners in August 2003. RESULTS: National guidelines for the prevention and control of nosocomial infections were developed. Twenty-one topics were included. Modifications of the drafted guidelines were made four times according to the opinions of 10 experts, twice by brainstorming of 55 practitioners and by the suggestions of participants from 20 hospitals where they were tested. The practices in hospitals with different facilities were also suggested in the guidelines. CONCLUSION: National guidelines for prevention and control of nosocomial infection were formulated. Their application for use in every hospital and periodic reviews are expected.

Effect of an education program on the prevention of ventilator-associated pneumonia: A multicenter study.

OBJECTIVE: To evaluate the effect of an educational program targeted on modifiable risk factors on ventilator-associated pneumonia (VAP) rates. MATERIAL AND METHOD: After a preliminary study on VAP risk factors was conducted at one teaching hospital, a pre- and post-interventional study was then performed on 12 hospitals in Thailand from January 1, 2002 to June 30, 2003. Each hospital randomly selected 20 patients, who were on mechanical ventilation to be enrolled The study was divided into two phases; 1) pre-intervention, 2) post-intervention. Data collected included patients 'demography and risk factors for VAP During pre-interventional phase, data on risk factors for VAP was analyzed and fedback to healthcare providers in the wards by an infection control nurse (ICN) of the individual hospital. An educational programme on the prevention of VAP was introduced by the ICN. Ventilator-associated pneumonia rates and their risk factors were continuously monitored during the post-interventionl phase. RESULTS: Two hundred and forty four patients in the pre-interventional phase and 254 patients in the post-interventional phase were included. There was no significant difference in the demography between these two patient populations. After the intervetion, there was a significant improvement in hand-hygiene practices (p<0.001) among healthcare providers and increased use of sucralfate (p=0.05) for stress ulcer prophylaxis. Ventilation-associated pneumonia rate (40.5% vs. 24%; p<0.001) and crude mortality rate associated with VAP (12.3% vs. 8.7%; p<0.001) were also reduced CONCLUSION: The educational programme targeted on modifiable risk factors for prevention of VAP was effective and should be considered as an intervention to reduce VAP rates in developing countries.

Microbial and heavy metal contamination of treated hospital wastewater in Thailand.

OBJECTIVES: To determine the microbial and heavy metal contamination of treated hospital wastewater MATERIAL AND METHOD: Methods of treating wastewater were acquired by questionnaires. Chlorine concentration, pH, bacteria and parasites in treated wastewater were tested in the individual hospitals. Heavy metal concentrations were measured by atomic absorption spectrophotometry. RESULTS: In 2002, 72 hospitals were included in the present study. The common methods of treating wastewater were activated sludge and oxidation ditch. Bacteria exceeded standard numbers, pathogenic bacteria and parasites were found in two-thirds of the hospitals. Heavy metals, namely lead, chromium and cadmium, in the hospital effluent did not exceed standard concentrations. CONCLUSION: Micro-organisms exceeding standard levels were found in treated wastewater in two-thirds of the hospitals. Lead, chromium and cadmium levels in hospital effluent were in an acceptable range.

Impacts of nosocomial infection among elderly patients in Inburi Hospital.

OBJECTIVES: To evaluate the length of stay, total medical expenditure, cost of antibiotics for nosocomial infections (NIs) and NI fatality rate of elderly patients admitted to Inburi Hospital. MATERIAL AND METHOD: A descriptive study, data from analyzing NI surveillance forms of 50 elderly patients admitted to Inburi Hospital with NI from February to May 2002. RESULTS: The average length of stay of the samples was 22.9 days, medical expenditure was 67,265 baht per patient, cost of antimicrobial drugs was 9,128.90 baht per patient and case fatality rate was 42%. CONCLUSION: The study revealed that NI in the elderly were associated with increased length of stay, costs of antimicrobial agents, total medical expenditure and a high case fatality rate.

Persistence of antimicrobial effect of antiseptics in surgical hand hygiene regimens.

OBJECTIVES: To determine the persistence of antimicrobial effect of antiseptic solutions used in surgical hand hygiene procedure, and the in-house preparation was compared to the commercial solution for its efficacy. MATERIAL AND METHOD: The present study was performed in a 150-bed hospital involving 19 staff from general, orthopedics, KUB, and OB-GYN surgical teams in 48 operations. The antimicrobial effects from 4 different solutions were determined and compared. RESULTS: The study showed that the commercial alcohol-based antiseptic solution was equally or more effective than long-time accepted povidone-iodine or chlorhexidine gluconate solutions and had better persistent effect. The in-house preparation was effective comparable to the commercial solution. CONCLUSION: The commercial alcohol-based antiseptic solution had better persistence of antimicrobial effects compared to the in-house alcohol-based hand rub, povidone iodine and chlorhexidine gluconate.

Cost-effectiveness and safety of reusable tracheal suction tubes.

OBJECTIVES: To evaluate whether the repetitive use of disposable tracheal suction tubes is cost-effective and safe over the single use. MATERIAL AND METHOD: The cost intrinsic to the washing, cleaning, re-sterilization by ethylene oxide gas, and processing was determined and compared to the cost generated by disposable tubes. The reused disposable suction tubes were also determined for their properties in physical characters and probable contamination and damages. RESULTS: The evaluation showed that cost from single-use disposable suction tubes (8.66 baht) was cheaper than expenses generated from processing steps for recycling of disposable tubes (9.92 baht). The use of a disposable tube only once should minimize the risks posed by the use of the potentially unsafe reused disposable tubes both to the patients and health care workers. CONCLUSION: Recycling of tracheal suction tubes was neither cost-effective nor safe.