Implementation of a quality improvement project using the patient as the observer to improve hand hygiene compliance in ambulatory care practices.

BACKGROUND: Monitoring hand hygiene compliance in the ambulatory setting remains a challenge because a healthcare trained observer loses line of sight once the examination room door closes. This quality improvement project focused on the implementation of a hand hygiene compliance improvement programme that is amenable to the routines and work flows of the ambulatory setting. METHODS: After a review of the literature, nursing leadership and infection prevention implemented the 'patient as the observer' hand hygiene programme across 32 ambulatory practices. RESULTS: Patients completed 281,000 observations with an overall compliance rate of ≥90%. The average overall compliance rate by role was 91% for providers, 89% for nurses, and 91% for medical assistants/technicians/others. A 92% compliance average was noted 'before caring for you' and 89% 'after caring for you' for providers, 90% and 87% for nurses, and 92% and 89% for medical assistants/technicians/others. DISCUSSION: This study demonstrated that the implementation of a hand hygiene compliance improvement programme using the patient as the observer can be adopted successfully in the ambulatory setting. CONCLUSION: Hand hygiene compliance can be monitored effectively in the ambulatory setting with the involvement of the patient as the observer.

Deltamethrin resistant alleles predominate in Rhipicephalus sanguineus sensu lato in South India.

Brown dog tick, Rhipicephalus sanguineus sensu lato, an important ectoparasite transmitting several pathogens, is the most common tick species infesting dogs. Control of ticks being central to the control of fatal tick-borne diseases, this study attempted to assess the susceptibility/resistance of brown dog ticks to synthetic pyrethroids, the commonly used acaricides against ticks. Larval packet assay revealed 60% of isolates tested to be resistant and tolerant to deltamethrin as per the resistance factor that ranged from 1 to 53.7. Sequence analysis of the PCR amplified product of domain II S4-5 linker of sodium channel gene in R. sanguineus revealed novel polymorphisms, viz., C190A, G215T and T270C. In domain III S6 region of the gene, a T2134C mutation was observed. Genotyping with allele-specific PCR targeting domain II S4-5 linker region using single larvae revealed that most R. sanguineus larvae in the study population were homozygous resistant (RR) genotypes, followed by heterozygous (RS) and homozygous susceptible (SS) genotypes. A higher proportion of RS genotypes was also observed in domain III S6 region. This first report of genotyping of Indian R. sanguineus to analyse synthetic pyrethroid resistance highlights the need to devise alternate control strategies to reduce the brown dog tick population.

Genotyping of Deltamethrin Resistance in Rhipicephalus (Boophilus) microplus Population in Kerala, South India.

PURPOSE: Genotyping of Rhipicephalus (Boophilus) microplus for polymorphisms in deltamethrin-resistant loci of sodium channel gene by allele-specific PCR (AS-PCR). METHODS: Adult R. (B.) microplus ticks were collected from naturally infested cattle in Kerala. The larval packet test (LPT) was performed with deltamethrin and dose response data were analysed by probit method. Adult and larval tick DNA were amplified by PCR and later sequenced to identify mutations, if any, in the domain II S4-5 linker and domain III S6 regions in para voltage-gated sodium channel gene, at loci that were previously documented to be associated with deltamethrin resistance. Allele-specific PCR was performed for the amplification of target gene locus (C190A and T2134C) to genotype 1000 larvae each, at these loci. Genotype frequency was statistically analysed by Chi-square test. RESULTS: Bioassay using LPT revealed that LC50 and LC95 values of all the R. (B.) microplus isolates in this study were more than double the reported values of reference susceptible strain. Sequence analysis of the PCR amplicons of domain II S4-5 linker of voltage-gated sodium channel gene revealed C190A mutation, A271G mutation as well as A-G mutation at 217th position. AS-PCR done to genotype C190A mutations revealed a frequency of 6%, 15% and 64%, respectively for homozygous-susceptible (SS), heterozygous (RS) and homozygous-resistant (RR) genotypes. In domain III S6 region of the gene, C2121T and A2102T mutations were observed. AS-PCR to genotype the previously reported T2134C mutation revealed 100% SS genotype in R. (B.) microplus isolates of Kerala. CONCLUSIONS: Genotyping of R. (B.) microplus isolates of Kerala for target site mutations reportedly associated with deltamethrin resistance revealed a significantly high frequency of resistant genotypes at II S4-5 linker of voltage-gated sodium channel gene. This study forms the first report of such mutations in Kerala, south India and demands serious attention in the light of increased prevalence of tick-borne haemoparasitic infection.

Utility of recombinant LipL41 based IgM and IgG ELISA in diagnosis of canine leptospirosis in an endemic area - a study from Kerala, India.

A study was undertaken to evaluate the relevance of detecting IgM and IgG antibodies in diagnosis of canine leptospirosis in Kerala, a southern state of India, which is endemic for the disease. A total of 205 blood (35 from healthy vaccinated, 30 from healthy unvaccinated and 140 from diseased dogs) and 151 urine samples (11 from healthy vaccinated and 140 from diseased dogs) were collected from three districts of Kerala, Thrissur, Palakkad and Kozhikode with high incidence of leptospirosis. Recombinant LipL41 protein was used as antigen and IgG and IgM based ELISAs were standardized. The results were compared with the gold standard test, microscopic agglutination test (MAT). The MAT positive samples (146 samples) were divided into those having titre >1:800 and those between 1:100 and 1:400 in view that the former constituted the acute cases. It was found that IgM ELISA was more specific and sensitive in detecting acute cases (MAT >1:800) whereas IgG ELISA was less specific. In case of seroprevalence studies (MAT titre 1:100 to 1: 400), IgG ELISA was found to be more sensitive and specific than IgM ELISA. Receiver operating characteristic curves when plotted, revealed the accuracy of IgM ELISA in acute leptospirosis. Many samples were positive for both IgG and IgM antibodies. Polymerase Chain Reaction (PCR) targeting lipl41 gene was standardized and urine and blood samples from the same dogs were tested. PCR was found to be the specific test for the early detection of leptospires in blood even before seroconversion. However, PCR analysis of the urine samples was found to be insensitive. Hence, it can be concluded that the diagnostic strategies should be modified, and a combination of serological and molecular tests is recommended in endemic areas rather than simple detection of IgM or IgG antibodies, for the early detection of acute clinical cases of leptospirosis.

Utility of recombinant LipL41 based IgM and IgG ELISA in diagnosis of canine leptospirosis in an endemic area – a study from Kerala, India

@#A study was undertaken to evaluate the relevance of detecting IgM and IgG antibodies in diagnosis of canine leptospirosis in Kerala, a southern state of India, which is endemic for the disease. A total of 205 blood (35 from healthy vaccinated, 30 from healthy unvaccinated and 140 from diseased dogs) and 151 urine samples (11 from healthy vaccinated and 140 from diseased dogs) were collected from three districts of Kerala, Thrissur, Palakkad and Kozhikode with high incidence of leptospirosis. Recombinant LipL41 protein was used as antigen and IgG and IgM based ELISAs were standardized. The results were compared with the gold standard test, microscopic agglutination test (MAT). The MAT positive samples (146 samples) were divided into those having titre >1:800 and those between 1:100 and 1:400 in view that the former constituted the acute cases. It was found that IgM ELISA was more specific and sensitive in detecting acute cases (MAT >1:800) whereas IgG ELISA was less specific. In case of seroprevalence studies (MAT titre 1:100 to 1: 400), IgG ELISA was found to be more sensitive and specific than IgM ELISA. Receiver operating characteristic curves when plotted, revealed the accuracy of IgM ELISA in acute leptospirosis. Many samples were positive for both IgG and IgM antibodies. Polymerase Chain Reaction (PCR) targeting lipl41 gene was standardized and urine and blood samples from the same dogs were tested. PCR was found to be the specific test for the early detection of leptospires in blood even before seroconversion. However, PCR analysis of the urine samples was found to be insensitive. Hence, it can be concluded that the diagnostic strategies should be modified, and a combination of serological and molecular tests is recommended in endemic areas rather than simple detection of IgM or IgG antibodies, for the early detection of acute clinical cases of leptospirosis.