Development and assessment of national performance indicators for infection prevention and control and antimicrobial stewardship in European long-term care facilities.

BACKGROUND: Healthcare-associated infections in long-term care facilities (LTCFs) are of increasing importance. AIM: To develop consensus national performance indicators (NPIs) for infection control (ICPI) and antimicrobial stewardship (ASPI) in LTCFs, and assess the performance of 32 European countries against these NPIs. METHODS: Previously established European standards were the basis for consensus and the same iterative approach with national representatives from the 32 countries. A World Health Organization scoring system recorded how close each country was to implementing each standard. FINDINGS: The 42 agreed component indicators were grouped into six NPI categories: 'national programme', 'guidelines', 'expert advice', 'IC structure' (not present in the ASPI), 'surveillance' and 'composite'. 'Guidelines' scored the highest mean total possible score (60%, range 20-100%), followed by 'composite' (53%, range 30-100%), 'expert advice' (48%, range 20-100%), 'surveillance' (47%, range 20-83%), 'national programme' (42%, range 20-100%) and 'IC structure' (39%, range 20-100%). Although several scores were low, some countries were able to implement all NPIs, indicating that this was feasible. Most NPIs were very significantly related, indicating that they were considered to be important by the countries. 'Guidelines' and 'IC structure' were significantly related to European region (P ≤ 0.05). Accreditation/inspection was not evident in seven (22%) countries, nine (28%) countries had accreditation/inspection that included IC assessments, and seven (22%) countries had accreditation/inspection that included IC and antimicrobial stewardship assessments. Multi-variable analysis found that only the NPI and the ICPI 'expert advice' were associated with accreditation/inspection which included IC and antimicrobial stewardship. CONCLUSION: The identified gaps represent significant potential patient safety issues. The NPIs should serve as a basis for monitoring improvements over the coming years.

NADH-glutamate synthase in alfalfa root nodules. Genetic regulation and cellular expression.

NADH-dependent glutamate synthase (NADH-GOGAT; EC 1.4.1.14) is a key enzyme in primary nitrogen assimilation in alfalfa (Medicago sativa L.) root nodules. Here we report that in alfalfa, a single gene, probably with multiple alleles, encodes for NADH-GOGAT. In situ hybridizations were performed to assess the location of NADH-GOGAT transcript in alfalfa root nodules. In wild-type cv Saranac nodules the NADH-GOGAT gene is predominantly expressed in infected cells. Nodules devoid of bacteroids (empty) induced by Sinorhizobium meliloti 7154 had no NADH-GOGAT transcript detectable by in situ hybridization, suggesting that the presence of the bacteroid may be important for NADH-GOGAT expression. The pattern of expression of NADH-GOGAT shifted during root nodule development. Until d 9 after planting, all infected cells appeared to express NADH-GOGAT. By d 19, a gradient of expression from high in the early symbiotic zone to low in the late symbiotic zone was observed. In 33-d-old nodules expression was seen in only a few cell layers in the early symbiotic zone. This pattern of expression was also observed for the nifH transcript but not for leghemoglobin. The promoter of NADH-GOGAT was evaluated in transgenic alfalfa plants carrying chimeric beta-glucuronidase promoter fusions. The results suggest that there are at least four regulatory elements. The region responsible for expression in the infected cell zone contains an 88-bp direct repeat.