Reliability of nonlocalizing signs and symptoms as indicators of the presence of infection in nursing-home residents.

Antibiotics are among the most common medications prescribed in nursing homes. The annual prevalence of antibiotic use in residents of nursing homes ranges from 47% to 79%, and more than half of antibiotic courses initiated in nursing-home settings are unnecessary or prescribed inappropriately (wrong drug, dose, or duration). Inappropriate antibiotic use is associated with a variety of negative consequences including Clostridioides difficile infection (CDI), adverse drug effects, drug-drug interactions, and antimicrobial resistance. In response to this problem, public health authorities have called for efforts to improve the quality of antibiotic prescribing in nursing homes.

Estágio sanduiche na Noruega: relato de experiência / Sandwich stage in Norway: experience report

O Programa de Doutorado no Brasil com Estágio no Exterior, conhecido como Doutorado Sanduíche, visa a contribuir para intercâmbios dos cursos de Pós-Graduação no País com seus congêneres no exterior. O objetivo deste artigo foi relatar a experiência vivida durante o estágio realizado na Noruega, em unidades hospitalares, laboratórios de microbiologia, órgãos federais e serviços de saúde de Oslo e Região Metropolitana. Foram desenvolvidas atividades de vigilância epidemiológica, técnicas laboratoriais de identificação e tipagem molecular de Staphylococcus aureus e políticas públicas e institucionais de prevenção e controle dessas bactérias, quando multirresistentes. O estágio, além de subsidiar e fortalecer a análise dos dados do projeto da tese, permitiu refletir sobre a importância de políticas públicas e diretrizes definidas, e fornecer condições para ações de prevenção e controle de agravos, tendo a saúde e o bem-estar da pessoa como valores de Estado.

The Doctoral Program in Brazil, with the Internship Abroad known as the Sandwich Ph.D., aims to contribute to exchanges of graduate courses in the country with counterparts abroad. The objective of this article was to report the lived experience during an internship in Norway, in hospital units, microbiology laboratories, federal agencies and health services in Oslo and the metropolitan region. Activities were developed for epidemiological surveillance, laboratory techniques for identification and molecular typing of Staphylococcus aureus, and public and institutional policies for prevention and control of these bacteria, when multiresistant. The Sandwich stage in addition to supporting and strengthening the analysis of project data of the thesis, permitted the reflection on the importance of established public policies and guidelines, and conditions provided for prevention and control of diseases, and health and welfare of the person as values of the state.

El Programa de Doctorado en el Brasil con Prácticas en el Exterior, conocido como Doctorado Sandwich, visa contribuir a los intercambios de los cursos de Postgrado en el País con sus congéneres en el exterior. El objetivo de este artículo fue relatar la experiencia vivida durante las prácticas realizadas en Noruega, en unidades hospitalarias, laboratorios de microbiologia, órganos federales y servicios de salud de Oslo y Región Metropolitana. Se desarrollaron actividades de vigilancia epidemiológica, técnicas de laboratorio de identificación y tipaje molecular de Staphylococcus aureus y políticas públicas e institucionales de prevención y control de esas bacterias, multiresistentes. La práctica, además de ofrecer subsídios y fortalecer al análisis de los datos del proyecto de la tesis, permitió reflexionar sobre la importancia de las políticas públicas y directivas definidas, y dar las condiciones para acciones de prevención y control de agravios, teniendo a la salud y al bienestar de la persona como valores de Estado.

Lessons to learn with the methicillin-resistant Staphylococcus aureus control in Norway

The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in Norway is low, compared to other European and American countries. The health system includes mandatory case reporting and has written guidelines for prevention and control. This communication describes the national public policies related to MRSA obtained from documents and academic experience gained during a doctoral fellowship in Oslo, Norway. The painstaking procedures used for investigating suspected cases, including health professionals, decolonization and case monitoring, could be important tools to be used by countries with a high prevalence of MRSA.

Lessons to learn with the methicillin-resistant Staphylococcus aureus control in Norway.

The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in Norway is low, compared to other European and American countries. The health system includes mandatory case reporting and has written guidelines for prevention and control. This communication describes the national public policies related to MRSA obtained from documents and academic experience gained during a doctoral fellowship in Oslo, Norway. The painstaking procedures used for investigating suspected cases, including health professionals, decolonization and case monitoring, could be important tools to be used by countries with a high prevalence of MRSA.

A multidrug-resistant, methicillin-susceptible strain of Staphylococcus aureus from a neonatal intensive care unit in Oslo, Norway.

Over a 6-month period in 2008, approximately 15% of all Staphylococcus aureus isolates from our neonatal intensive care unit were resistant to penicillin, gentamicin, erythromycin and clindamycin. Extended antibiotic susceptibility testing and molecular profiling revealed an outbreak of an S. aureus strain with a rare susceptibility pattern for a Scandinavian setting.

Hospital-acquired infections before and after healthcare reorganization in a tertiary university hospital in Norway.

BACKGROUND: To evaluate hospital-acquired infections (HAIs) in somatic (all admissions other than psychiatric) and psychiatric patients admitted to a tertiary university hospital in Oslo, before and after reorganization of the Norwegian healthcare system in 2002. METHODS: Point prevalence studies were conducted four times per annum and over the period from 1995 to 2007. RESULTS: A total of 57,360 patients were studied over the whole time period: 80.5% in somatic wards and 19.5% in psychiatric wards. The HAI rate was 6.9%, of which 8.1% were somatic and 1.9% psychiatric. 13.4% of operated patients had HAI, including 6.2% due to surgical wound infections. In somatic wards, 0.6-1% were re-admitted with HAI, 15.2-23% had infections and 18-23% used antibiotics. There was a reduction in HAI until 2002. From 2003 on, HAI increased (P = 0.010) in somatic wards (P = 0.002), in non-operated patients (P = 0.024) and in extra costs. In 2002, the Norwegian healthcare system was reorganized. This reorganization led to a 30% increase in somatic patients treated from 2003 to 2007 (P = 0.054), 27% increase in the total workload per work position (P = 0.024) and 23.5% decrease in internal service work. CONCLUSION: A declining trend of HAI was observed from 1995 to 2002 at the tertiary university hospital in Norway. In 2002, the Norwegian healthcare system was reorganized. From 2003 to 2007, HAI increased significantly as did the number of somatic patients and workload at our hospital.

[An outbreak of MRSA in a nursing home in Oslo]. / Et MRSA-utbrudd i et sykehjem i Oslo.

BACKGROUND: Infections caused by methicillin-resistant Staphylococcus aureus (MRSA) represent an increasing problem in Norway, also in nursing homes and other institutions for long-term care. We describe an outbreak of MRSA in a nursing home in Oslo 2004-5. MATERIAL AND METHODS: The nursing home has six wards with 185 beds. The building is old, all rooms have toilets and sinks, but showers are shared. Standard screening procedures were carried out according to the national MRSA guide and by using the nursing home's infection control programme. Later on we used more extensive screening of staff and patients. RESULTS: The outbreak started in a ward for short-term care, but spread to a ward for patients with dementia after some months. Ten patients, seven staff members and two relatives of infected persons were diagnosed with MRSA. All bacteria probably belonged to the same strain. Four staff members and five patients who were infected had pre-existing wounds or eczema. The nursing home was declared free of MRSA 20 months after the outbreak started, but one member of staff remained a carrier for two years, and one patient became a chronic carrier of MRSA. During the first six months, infected patients were restricted to their rooms, and standard eradication procedures were carried out for five days. Later on, we introduced cohort isolation for infected, exposed and recently treated patients, a different screening routine, a prolonged eradication procedure, restrictions on staff working elsewhere and more stringent precautions for visitors. INTERPRETATION: An old building and insufficient isolation procedures during the first phase of the outbreak contributed to spreading MRSA and prolonging the outbreak. Cohort isolation seemed to be the most important measure to control the outbreak. All nursing homes should have a designated single patient room for contact precautions. Long-term carriers of MRSA in nursing homes represent a big challenge.

[Infection control and hand hygiene in nursing homes in Oslo]. / Infeksjonskontroll og håndhygiene ved sykehjem i Oslo.

BACKGROUND: Nosocomial infections and transmission can be substantially reduced by good infection control. The laws and regulations for infection control in heath care institutions emphasize establishment of infection control programs and improved hand hygiene. Our study reviews some factors that are important for practicing adequate hand hygiene (knowledge about infection control and hand-washing facilities). MATERIAL AND METHODS: Health care workers (HCW) in nursing homes in Oslo participated in this study in 2006-2007. A questionnaire was made and SPSS was used to analyse the data . RESULTS: 70.7% of 324 HCW (in 42 nursing homes) answered the questionnaires. Nearly all of the respondents (95.6%) knew about the written procedures for hygiene and infection control; 88.5% knew that an infection control program was in place and about 50% had received information through internal education. Three of four had read the National guidelines for hand hygiene, 77.5% thought that hand disinfection was more effective than hand washing, and 97% reported hand hygiene after contact with a patient having an infection. Dispensers for hand disinfection were situated at central work places. At the same time, 17.9% informed that they worked in more than one place at the same time. INTERPRETATION: This study confirms that most nursing homes in Oslo have an infection control program and training that improves the knowledge and awareness of hand hygiene among HCWs. However, the fact that nursing homes in Oslo have the resources, knowledge and education, is not the same as compliance.

Is an increase of MRSA in Oslo, Norway, associated with changed infection control policy?

OBJECTIVES: The objective was to describe the prevalence of MRSA in Oslo, Norway, before and after introduction of a new National MRSA Control Guideline. METHODS: From 1993 to 2006, we prospectively collected clinical and microbiological data on all MRSA cases in Oslo, Norway. Two MRSA guidelines; a strict Ullevål Standard MRSA Guideline and a less strict National MRSA Control Guideline were compared. RESULTS: During 1993-2006, 358 MRSA cases were registered in Oslo; 43.9% detected in Ullevål University Hospital, 21.2% in nursing homes, and 18.7% in primary healthcare. One out of three (30.4%) were import-associated, and one out of ten (11.2%) were healthcare personnel. From 2004 on, a new National MRSA Control Guideline was introduced in primary healthcare, served by the community infection control. From 2004 on, there was a 4-6-fold increase of MRSA in primary healthcare (p = 0.038) and nursing homes (p = 0.005). Increase of MRSA cases at Ullevål (p < 0.001) was import-associated or from outbreaks in primary healthcare. There was no increase of internal spread in the hospital. CONCLUSION: These data indicate that perhaps a less strict national MRSA infection control guideline in Norway may be associated with the 4-6-fold increase of MRSA cases in the community after 2003.

[Changes in antibiotic consumption among day-care children in Oslo]. / Endringer i antibiotikaforbruk hos barnehagebarn i Oslo.

BACKGROUND: Day-care children in Oslo had a high proportion of infections (97 %) and a high consumption of antibiotics (65 %) in 2000. The study from 2000 was repeated in 2006 to see if prescriptions for antibiotics had changed. MATERIAL AND METHODS: Parents in 22 randomly chosen day-care centres in Oslo answered a questionnaire about their children (concerning infections, contact with physicians and antibiotic treatment). RESULTS: 605 parents (53 %) participated. The proportion of children treated for infections was reduced from 65 % (95 % confidence interval 61 - 69 %) in 2006 to 50 (46 - 54) % in 2000 and infections treated were reduced from 29 (26 - 32) % to 20 (17 - 23) %. Ear infections were treated in 62 % of the children in 2006 (75 % in 2000) and throat infections in 53 % (85 % in 2000) of the cases. Medical consultations resulted in prescription in 50 % of the cases in 2006 and 80 % in 2000. INTERPRETATION: Day-care children in Oslo used significantly less antibiotics and had significantly fewer medical consultations in 2006 than in 2000.

[Parents' attitudes to the prescription of antibiotics to children]. / Foreldres syn på bruk av antibiotika hos barn.

BACKGROUND: Most children in day care get infections and are prescribed antibiotics. We studied parents' attitude towards such prescription. MATERIAL AND METHODS: Parents (563 out of 1126 surveyed) in 22 day care centres returned a questionnaire on factors in their own situation and in their day care centre with impact on the use of antibiotics. RESULTS: Parents above 30 years of age, well educated and knowledgeable about antibiotics were the most sceptical of such treatment. A negative attitude on the part of employers and colleagues towards absence from work led to more use of antibiotics (p < 0.01). Children in single-parent homes were given more antibiotics than those in two-parent homes (p < 0.05). Help from relatives led to less use of antibiotics (p < 0.01). Sick children went to day care in 16% of cases; 57% of those taking antibiotics still went to day care. INTERPRETATION: Parents' situation may influence the use of antibiotics in children. Too many children are taking antibiotics and still go to day care. Support in the workplace, from relatives and from friends may give parents a better chance of staying at home with a sick child, thus preventing the spread of infections and cut down on the use of antibiotics.

[Parents' attitude to physician's role in the prescription of antibiotics to their children]. / Foreldres syn på legens rolle ved antibiotikabruk hos barna.

BACKGROUND: Most children in day care get infections and are given antibiotics. In physicians' view, the main reason for excessive use is pressure exerted on them by anxious parents. We studied parents' view of physicians' influence on the use of antibiotics. MATERIAL AND METHOD: 563 parents (50%) in 22 day care centers returned a questionnaire about their children's infections, use of antibiotics, and their experience with the doctors treating their child. RESULTS: 70% of parents had confidence in physicians' decisions. Confidence was significantly higher in doctors that they regularly consulted than in others (p = 0.001). 33% had moved on to a new physician on account of too much use of antibiotics (p < 0.05); these parents' children had received more antibiotics than other children (p < 0.05). Parents were dissatisfied with the time set aside for the consultation and with doctors' information and follow up. They expected advice and guidance, not necessarily a prescription. 47% thought that too much antibiotics are prescribed. Satisfaction was associated with less antibiotics for their own child (p < 0.001). Some parents regarded the prescription of antibiotics as doctors' way of saving time and bringing the consultation to an end. INTERPRETATION: Parents are sceptical of the use of antibiotics in children. More time set aside for the consultation is significantly associated with less use of antibiotics. Better doctor-parent communication may reduce excessive use.

[Nosocomial infections in nursing homes in Oslo]. / Nosokomiale infeksjoner i sykehjem i Oslo.

BACKGROUND: Residents of long-term care facilities are at risk of infection and may deliver resistant microbes to hospitals. MATERIAL AND METHODS: A point prevalence study was performed, including 3,474 residents in 2000 and 4,650 in 2001. RESULTS: The infection rate increased from 5.6% in 2000 to 7.5% in 2001 (p < 0.001). Urinary tract infections predominated. Pneumonia increased from 2000 to 2001 (0.7%-1.4%; p < 0.01), as did the rate of operated patients (2.9%-6.5%, p < 0.001), while postoperative wound infections was reduced (p = 0.02). Antibiotics were given to 5.8% in 2000 and 6.1% in 2001. Microbiological assessments were available from 29.6% infections in 2000 and 21.4% in 2001. Staphylococcus aureus and Escherichia coli predominated. Methicillin-resistant S aureus was found in only two patients. INTERPRETATION: The increased burden of operated patients in understaffed long-term care facilities may have caused an increasing rate of infections. Staffing with sufficient and competent personnel and intensified infection control work is needed.

[Control of imported infections in nursing homes]. / Kontroll av importinfeksjoner ved sykehjem.

BACKGROUND: Nursing home residents and accompanying staff often go on stays i Norwegian-owned health institutions in southern Europe and may bring infections back with them. MATERIAL AND METHODS: We studied infection control routines for residents and staff returning home from health institutions abroad as well as isolation capacity by an anonymous questionnaire to 59 nursing homes with a total of 4,409 residents. RESULTS: 21 nursing homes (36%) sent their residents and staff members to health institutions abroad. Testing for methicillin resistant Staphylococcus aureus (MRSA) was performed upon return by 4 out of 21 nursing homes for residents and 3 out of 21 for staff members. 22% of the 59 nursing homes had routines for infection screening of staff members working abroad. 14% would perform MRSA tests on all staff members giving such information. The nursing homes had a total of 4,409 beds, 66% of them in single rooms. There were a total of eight (0.2%) contact infection isolates but no isolate for airborne infections. INTERPRETATION: Resistant bacteria may be imported and spread through lack of infection controls of residents and staff members returning home from health care institutions abroad. The lack of isolation facilities make matters worse.

Preoperative hair removal--a systematic literature review.

This article describes a systematic literature review on whether, how, and when to perform preoperative hair removal. By searching electronic databases and reference lists of relevant articles, team members identified 20 clinical studies that deal with preoperative hair removal. No strong evidence was found to advocate against preoperative hair removal. Furthermore, there was strong evidence to recommend that when hair removal is considered necessary, shaving should not be performed. Instead a depilatory or electric clipping, preferably immediately before surgery, should be used.