An outbreak of multi-drug-resistant Acinetobacter baumannii on a burns ICU and its control with multi-faceted containment measures.

BACKGROUND: Patients in burns centres are at high risk of acquiring multi-drug-resistant organisms (MDROs) due to the reduced skin barrier and long hospital stay. METHODS: This study reports the investigation and control of an outbreak of MDR Acinetobacter baumannii in a burns centre. The 27 patients hospitalized in the centre during the outbreak were screened regularly, and a total of 132 environmental samples were analysed to identify a potential source. Fourier-transform infra-red (FT-IR) spectroscopy and multi-locus sequence typing were applied to characterize the outbreak strain. RESULTS: Between August and November 2022, the outbreak affected eight patients, with 11 infections and three potentially related fatal outcomes. An interdisciplinary and multi-professional outbreak team implemented a bundle strategy with repetitive admission stops, isolation precaution measures, patient screenings, enhanced cleaning and disinfection, and staff education. FT-IR spectroscopy suggested that the outbreak started from a patient who had been repatriated 1 month previously from a country with high prevalence of MDR A. baumannii. Environmental sampling did not identify a common source. Acquisition of the outbreak strain was associated with a higher percentage of body surface area with burn lesions ≥2a [per percent increase: odds ratio (OR) 1.05, 95% confidence interval (CI) 0.99-1.12; P=0.09], and inversely associated with a higher nurse-to-patient ratio (per 0.1 increase: OR 0.34, 95% CI 0.10-1.12; P=0.06). CONCLUSIONS: Burn patients with a higher percentage of body surface area with burn lesions ≥2a are at high risk of colonization and infection due to MDROs, particularly during periods of high workload. A multi-faceted containment strategy can successfully control outbreaks due to MDR A. baumannii in a burns centre.

Fourier-transform infrared spectroscopy for typing of vancomycin-resistant Enterococcus faecium: performance analysis and outbreak investigation.

Vancomycin-resistant Enterococci, mainly Enterococcus faecium (VREfm), are causing nosocomial infections and outbreaks. Bacterial typing methods are used to assist in outbreak investigations. Most of them, especially genotypic methods like multi-locus sequence typing (MLST), whole genome sequencing (WGS), or pulsed-field gel electrophoresis, are quite expensive and time-consuming. Fourier-transform infrared (FT-IR) spectroscopy assesses the biochemical composition of bacteria, such as carboxyl groups in polysaccharides. It is an affordable technique and has a faster turnaround time. Thus, the aim of this study was to evaluate FT-IR spectroscopy for VREfm outbreak investigations. Basic performance requirements like reproducibility and the effects of incubation time were assessed in distinct sample sets. After determining a FT-IR spectroscopy cut-off range, the clustering agreement between FT-IR and WGS within a retrospective (n: 92 isolates) and a prospective outbreak (n: 15 isolates) was investigated. For WGS an average nucleotide identity (ANI) cut-off score of 0.999 was used. Basic performance analysis showed reproducible results. Moreover, FT-IR spectroscopy readouts showed a high agreement with WGS-ANI analysis in clinical outbreak investigations (V-measure 0.772 for the retrospective and 1.000 for the prospective outbreak). FT-IR spectroscopy had a higher discriminatory power than MLST in the outbreak investigations. After determining cut-off values to achieve optimal resolution, FT-IR spectroscopy is a promising technique to assist in outbreak investigation as an affordable, easy-to-use tool with a turnaround time of less than one day. IMPORTANCE Vancomycin-resistant Enterococci, mainly Enterococcus faecium (VREfm), are a frequent cause of nosocomial outbreaks. Several bacterial typing methods are used to track transmissions and investigate outbreaks, whereby genome-based techniques are used as a gold standard. Current methods are either expensive, time-consuming, or both. Additionally, often, specifically trained staff needs to be available. This study provides insight into the use of Fourier-transform infrared (FT-IR) spectroscopy, an affordable, easy-to-use tool with a short turnaround time as a typing method for VREfm. By assessing clinical samples, this work demonstrates promising results for species discrimination and reproducibility. FT-IR spectrosopy shows a high level of agreement in the analysis of VREfm outbreaks in comparison with whole genome sequencing-based methods.

Longitudinal increase in the detection rate of Mycobacterium chimaera in heater-cooler device-derived water samples.

BACKGROUND: Colonization with Mycobacterium chimaera and other non-tuberculous mycobacteria (NTM) has been reported for heater-cooler devices (HCDs) produced by several manufacturers. Up until now, exclusively LivaNova (London, UK) HCDs have been associated with M. chimaera infections after cardiac surgery. The vast majority of studies on HCD colonization were cross-sectional. AIM: We were interested in longitudinal dynamics of mycobacterial growth in HCD water samples and analysed data of a prospective mycobacterial surveillance of five LivaNova 3T HCDs. METHODS: Five LivaNova HCDs were subjected to prospective mycobacterial surveillance. For each HCD and the total of HCDs, results of mycobacterial detection were analyzed. Logistic regression was applied to model the association between growth of any NTM or M. chimaera and duration of HCD use. RESULTS: Non-tuberculous mycobacteria were isolated in 319 (48.0%, 21 water samples grew more than one mycobacterial species) of a total of 665 water samples. The most frequently detected species were M. chimaera (N = 247/319, 77.4%), Mycobacterium gordonae (46/319, 14.4%) and Mycobacterium paragordonae (34/319, 10.7%). Detection rates increased prospectively for any NTM (odds ratio (OR) per year in use: 1.60, 95% confidence interval (CI) 1.17-2.24, P<0.001) and for M. chimaera (OR per year in use: 1.67, 95% CI 1.11-2.57, P<0.01). CONCLUSION: Longer duration of HCD use was associated with higher detection rates for any NTM and M. chimaera, respectively.

Explosive nosocomial outbreak of SARS-CoV-2 in a rehabilitation clinic: the limits of genomics for outbreak reconstruction.

BACKGROUND: Nosocomial outbreaks of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) are frequent despite implementation of conventional infection control measures. An outbreak investigation was undertaken using advanced genomic and statistical techniques to reconstruct likely transmission chains and assess the role of healthcare workers (HCWs) in SARS-CoV-2 transmission. METHODS: A nosocomial SARS-CoV-2 outbreak in a university-affiliated rehabilitation clinic was investigated, involving patients and HCWs, with high coverage of pathogen whole-genome sequences (WGS). The time-varying reproduction number from epidemiological data (Rt) was estimated, and maximum likelihood phylogeny was used to assess genetic diversity of the pathogen. Genomic and epidemiological data were combined into a Bayesian framework to model the directionality of transmission, and a case-control study was performed to investigate risk factors for nosocomial SARS-CoV-2 acquisition in patients. FINDINGS: The outbreak lasted from 14th March to 12th April 2020, and involved 37 patients (31 with WGS) and 39 employees (31 with WGS), 37 of whom were HCWs. Peak Rt was estimated to be between 2.2 and 3.6. The phylogenetic tree showed very limited genetic diversity, with 60 of 62 (96.7%) isolates forming one large cluster of identical genomes. Despite the resulting uncertainty in reconstructed transmission events, the analyses suggest that HCWs (one of whom was the index case) played an essential role in cross-transmission, with a significantly greater fraction of infections (P<2.2e-16) attributable to HCWs (70.7%) than expected given the number of HCW cases (46.7%). The excess of transmission from HCWs was higher when considering infection of patients [79.0%; 95% confidence interval (CI) 78.5-79.5%] and frail patients (Clinical Frailty Scale score >5; 82.3%; 95% CI 81.8-83.4%). Furthermore, frail patients were found to be at greater risk for nosocomial COVID-19 than other patients (adjusted odds ratio 6.94, 95% CI 2.13-22.57). INTERPRETATION: This outbreak report highlights the essential role of HCWs in SARS-CoV-2 transmission dynamics in healthcare settings. Limited genetic diversity in pathogen genomes hampered the reconstruction of individual transmission events, resulting in substantial uncertainty in who infected whom. However, this study shows that despite such uncertainty, significant transmission patterns can be observed.

Implementation of the infection prevention and control core components at the national level: a global situational analysis.

BACKGROUND: Strengthening infection prevention and control (IPC) is essential to combat healthcare-associated infections, antimicrobial resistance, and to prevent and respond to outbreaks. AIM: To assess national IPC programmes worldwide according to the World Health Organization (WHO) IPC core components. METHODS: Between June 1st, 2017 and November 30th, 2018, a multi-country, cross-sectional study was conducted, based on semi-structured interviews with national IPC focal points of countries that pledged to the WHO 'Clean Care is Safer Care' challenge. Results and differences between regions and national income levels were summarized using descriptive statistics. FINDINGS: Eighty-eight of 103 (85.4%) eligible countries participated; 22.7% were low-income, 19.3% lower-middle-income, 23.9% upper-middle-income, and 34.1% high-income economies. A national IPC programme existed in 62.5%, but only 26.1% had a dedicated budget. National guidelines were available in 67.0%, but only 36.4% and 21.6% of countries had an implementation strategy and evaluated compliance with guidelines, respectively. Undergraduate IPC curriculum and in-service and postgraduate IPC training were reported by 35.2%, 54.5%, and 42% of countries, respectively. Healthcare-associated infection surveillance was reported by 46.6% of countries, with significant differences ranging from 83.3% (high-income) to zero (low-income) (P < 0.001); monitoring and feedback of IPC indicators was reported by 65.9%. Only 12.5% of countries had all core components in place. CONCLUSION: Most countries have IPC programme and guidelines, but many less have invested adequate resources and translated them in implementation and monitoring, particularly in low-income countries. Leadership support at the national and global level is needed to achieve implementation of the core components in all countries.

Antimicrobial resistance in southern China: results of prospective surveillance in Dongguan city, 2017.

BACKGROUND: Few studies have estimated the burden of infections due to antimicrobial-resistant (AMR) pathogens in China. AIM: To summarize antimicrobial resistance and assess the frequency of community-associated infections (CAIs) and healthcare-associated infections (HCAIs) due to AMR pathogens in Dongguan city, China. METHODS: Seven acute care hospitals provided antimicrobial susceptibility data for 2017, from which 'bug-drug' combinations were analysed. To calculate incidence proportions of CAI and incidence densities of HCAI, data from three tertiary care hospitals were merged with patient data, obtained from the Dongguan Nosocomial Infection Surveillance System. FINDINGS: A total of 16,548 pathogens were analysed. Non-susceptibility to third-generation cephalosporins (3GCs) in Escherichia coli and Klebsiella pneumoniae was 43.9% and 30.2%, respectively. Non-susceptibility to carbapenems in Pseudomonas aeruginosa and Acinetobacter baumannii was 29.5% and 50.9%, respectively. A quarter of Staphylococcus aureus (26.3%) were non-susceptible to oxacillin. The incidence density of HCAI due to E. coli non-susceptible to 3GCs and fluoroquinolones combined was 0.09 (95% confidence interval: 0.07-0.11) per 1000 patient-days. Both E. coli and K. pneumoniae were the predominant pathogens isolated from blood. Compared with the 2017 European Antimicrobial Resistance Surveillance Network report, the incidence proportion of bloodstream infections due to multidrug-resistant E. coli was significantly higher (14.9% and 4.6%, respectively). CONCLUSION: The incidence of non-susceptible bug-drug combinations in Dongguan city was lower compared with China as a whole. Non-susceptible bug-drug combinations were significantly more frequent in HCAI compared with CAI. The incidence proportion of bloodstream infections due to multidrug-resistant pathogens in Dongguan City was higher compared with Europe.

Interventions to prevent urinary catheter-associated infections in children and neonates: a systematic review.

INTRODUCTION: Few data are available to inform strategies for the prevention of catheter-associated urinary tract infection (CAUTI) in children and neonates. Many recommendations are derived from studies in adults and cannot be applied to the paediatric population. OBJECTIVE: This study was aimed to identify all studies that measured the efficacy of an intervention for the prevention of CAUTI in children and neonates. METHODS: A systematic review using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) was conducted. Eligible studies published between January 1st, 1995 and December 31st, 2017, were identified in PubMed, the Cochrane Database of Systematic Reviews, LILACS, SciELO and DOAJ if applying an intervention with the aim of CAUTI prevention in inpatient children, infants or neonates. The following study designs were included: controlled and non-controlled before-and-after studies, (controlled) interrupted time series analyses and randomized controlled trials. Quantitative or qualitative studies on interventions in both adults and children were eligible if data on children could be extracted. Reviews, case series, letters, notes, conference abstracts and opinion articles were excluded. RESULTS: Of 99 articles identified, six were included in the final analysis, after consensus from three independent investigators. Four studies used a multimodal strategy (using at least four or more different components at the same time) as follows: aseptic rules during catheter insertion and removal; cleaning the urethral meatus with sterile water; use of a new silicone catheter per insertion with a closed sterile drainage system by a sterile technique; daily evaluation of catheter requirement; placement of indwelling urinary catheters only for approved indications; reducing of urinary catheter days and positioning of the patient and collection device to assist in urine drainage. One study tested periurethral cleaning intervention to reduce CAUTI. One study described the association of the presence of a physician safety champion with urinary catheter device utilization ratios. Catheter-associated UTI reduction rates were reported in four studies; three achieved statistically significant decreases in CAUTI rates. Positive results were achieved only when a multimodal strategy was used with at least four or more components. This strategy could be adopted for paediatric healthcare institutions to reduce CAUTI rates in children and neonates. CONCLUSION: Evidence exists to support the use of a multimodal strategy for CAUTI reduction in hospitalized children and neonates.

Role of antimicrobial stewardship programmes in children: a systematic review.

The United Nations and the World Health Organization have designated antimicrobial resistance (AMR) as a major health priority and developed action plans to reduce AMR in all healthcare settings. Establishment of institutional antimicrobial stewardship programmes (ASPs) is advocated as a key intervention to reduce antibiotic consumption in hospitals and address high rates of multi-drug-resistant (MDR) bacteria. PUBMED and the Cochrane Database of Systematic Reviews (January 2007-March 2017) were searched to identify studies reporting the effectiveness of ASPs in general paediatric wards and paediatric intensive care units (PICUs) for reducing antibiotic consumption, use of broad-spectrum/restricted antibiotics, and antibiotic resistance and healthcare-associated infections (HAIs). Neonatal units and antifungal agents were excluded. Of 2509 titles and abstracts, nine articles were eligible for inclusion in the final analysis. All studies reported a reduction in the use of broad-spectrum/restricted antibiotics or antibiotic consumption. One study reported a reduction in HAIs in a PICU, and another study evaluated bacterial resistance, showing no effect following ASP implementation. Prospective audit on antibiotic use was the most common ASP core component (eight of nine studies). Antibiotic pre-authorization was described in two studies. Other described interventions were the provision of guidelines or written information (five of nine studies), and training of healthcare professionals (one study). There is limited evidence for a reduction in antibiotic consumption and use of broad-spectrum/restricted agents following ASP implementation specifically in PICUs. Data evaluating the impact of ASPs on HAIs and AMR in PICUs are lacking. In addition, there is limited information on effective components of a successful ASP in PICUs.

Association of national and hospital factors to hospitals' alcohol-based handrub consumption in Europe: results of the European PROHIBIT study.

OBJECTIVES: Hand hygiene is considered the most effective way to reduce the transmission of (multidrug-resistant) organisms and to prevent healthcare-associated infections. Hand rubbing with alcohol-based handrub (AHR) has become the reference standard for hand hygiene. Data on AHR consumption are easy to obtain and can serve as an approximation for hand hygiene compliance. As described earlier, AHR consumption varies among European hospitals. In the current study the role of various hospital and country indicators for AHR consumption is analysed. METHODS: As part of the European Prevention of Hospital Infections by Intervention and Training (PROHIBIT) project hospital-based data on infection prevention and control (IPC) structure and organization and hospital-wide AHR consumption were obtained from acute care hospitals. National indicators such as income, public health expenditure, national hand hygiene campaigns, IPC training and the six Hofstede dimensions were identified. Univariable and multivariable linear regression analyses using generalized linear models were performed to estimate the association between AHR consumption and indicators at both hospital and country levels. RESULTS: Data from 232 hospitals from 22 European countries were analysed. Multivariate risk factor analysis showed independent associations between AHR consumption and private and university-affiliated hospitals (multiplicative effect, 95% CI: 1.76, 1.21-2.55; and 1.39, 1.17-1.64, respectively), high-income countries (3.61, 2.94-4.43), and countries offering national curricula for the training of IPC nurses (3.77, 2.32-6.13). However, no cultural dimension was independently associated with AHR consumption. CONCLUSION: Country indicators such as high-income, national training on IPC, and hospital type and status are positively associated with AHR consumption in Europe.

Burden of healthcare-associated infections in China: results of the 2015 point prevalence survey in Dong Guan City.

BACKGROUND: Healthcare-associated infections (HCAIs) are a major health threat. There are few data about HCAI and antibiotic use in the People's Republic of China in the English literature. AIM: To describe and discuss the prevalence of HCAI and antibiotic use from the 2015 point prevalence survey (PPS) in Dong Guan City. METHODS: In 2015, the Dong Guan (City) Nosocomial Infection Control and Quality Improvement Centre organized its yearly PPS in the secondary and tertiary care hospitals of Dong Guan City. The survey was performed on one single calendar day. FINDINGS: Thirty-seven secondary and 14 tertiary care hospitals assessed 9679 and 11,641 patients, respectively. A total of 616 patients had 681 HCAIs. The pooled HCAI prevalence (95% confidence interval) in secondary care, tertiary care, and all hospitals together was 2.3% (2.0-2.6), 3.4% (3.0-3.7), and 2.9% (2.6-3.1), respectively. Lower respiratory tract infection (LRTI), urinary tract infection (UTI), surgical site infection (SSI), and bloodstream infection together accounted for 73.1% of HCAIs. LRTI was the most frequently diagnosed HCAI (35.5%), followed by UTI (17.0%), and SSI (15.1%). Gram-negative bacteria were most frequently isolated (68.1%), followed by Gram-positive bacteria (19.3%), and fungi (10.9%). Escherichia coli was the most frequent pathogen (14.8%), and Acinetobacter baumannii accounted for 10.9%. A total of 34.8% of the patients received one or more antimicrobials. CONCLUSION: The pooled prevalence is in the range of other recent Chinese studies, but lower compared to previous reports in Europe, and the USA. The use of antimicrobials for therapeutic purposes is similar to that in Europe, but lower than previous Chinese reports, and lower than in the USA.

Most international guidelines on prevention of healthcare-associated infection lack comprehensive recommendations for neonates and children.

International infection prevention and control (IPC) guidelines provide standardized recommendations for healthcare-associated infection (HCAI) prevention in adults, but often lack specific information about neonates and children. We reviewed ten international IPC/HCAI guidelines to identify paediatric-specific recommendations for HCAI prevention. Hand hygiene, bloodstream infection, ventilator-associated pneumonia, environmental control and outbreak management were frequently reported with recommendations applicable to children and newborns, but documents on catheter-associated urinary tract infection and surgical site infection were lacking.

Role of parents in the promotion of hand hygiene in the paediatric setting: a systematic literature review.

BACKGROUND: When a child is hospitalized, parents have to share their role to protect the child with the hospital, and establish a partnership with healthcare workers to deliver safe care to the child, including undertaking good hand hygiene practices. AIM: To review the scientific evidence about the participation of parents in the promotion of hand hygiene in paediatric settings. METHODS: A systematic search of MEDLINE, EMBASE and SciELO databases was undertaken using the following terms: ('hand hygiene'[MeSH] OR 'hand hygiene' OR 'hand disinfection'[MeSH] OR hand disinf* OR hand wash* OR handwash* OR hand antisep*) AND (parent OR caregiver OR mother OR father OR family OR families OR relatives). The Integrated Quality Criteria for Review of Multiple Study Designs tool was used for quality assessment. FINDINGS: The literature search yielded 1645 articles, and 11 studies met the inclusion criteria for the final analysis. Most studies were observational, and were based on questionnaires or interviews. Most parents had little knowledge about the indications to perform hand hygiene, but recognized hand hygiene as a relevant tool for the prevention of healthcare-associated infections. Their willingness to remind healthcare workers about a failed opportunity to perform hand hygiene was variable and, overall, rather low. Parents felt more comfortable about reminding healthcare workers about hand hygiene if they had previously been invited to do so. CONCLUSIONS: Literature on the subject is scarce. The promotion of hand hygiene by parents should be further explored by research as a potential intervention for enhancing patient safety in paediatric settings.

Defining the user role in infection control.

BACKGROUND: Health policy initiatives continue to recognize the valuable role of patients and the public in improving safety, advocating the availability of information as well as involvement at the point of care. In infection control, there is a limited understanding of how users interpret the plethora of publicly available information about hospital performance, and little evidence to support strategies that include reminding healthcare staff to adhere to hand hygiene practices. AIM: To understand how users define their own role in patient safety, specifically in infection control. METHODS: Through group interviews, self-completed questionnaires and scenario evaluation, user views of 41 participants (15 carers and 26 patients with recent experience of inpatient hospital care in London, UK) were collected and analysed. In addition, the project's patient representative performed direct observation of the research event to offer inter-rater reliability of the qualitative analysis. FINDINGS: Users considered evidence of systemic safety-related failings when presented with hospital choices, and did not discount hospitals with high ('red' flagged) rates of meticillin-resistant Staphylococcus aureus. Further, users considered staff satisfaction within the workplace over and above user satisfaction. Those most dissatisfied with the care they received were unlikely to ask staff, 'Have you washed your hands?' CONCLUSION: This in-depth qualitative analysis of views from a relatively informed user sample shows 'what matters', and provides new avenues for improvement initiatives. It is encouraging that users appear to take a holistic view of indicators. There is a need for strategies to improve dimensions of staff satisfaction, along with understanding the implications of patient satisfaction.

Innovative tools for quality assessment: integrated quality criteria for review of multiple study designs (ICROMS).

OBJECTIVES: With the aim to facilitate a more comprehensive review process in public health including patient safety, we established a tool that we have termed ICROMS (Integrated quality Criteria for the Review Of Multiple Study designs), which unifies, integrates and refines current quality criteria for a large range of study designs including qualitative research. STUDY DESIGN: Review, pilot testing and expert consensus. METHODS: The tool is the result of an iterative four phase process over two years: 1) gathering of established criteria for assessing controlled, non-controlled and qualitative study designs; 2) pilot testing of a first version in two systematic reviews on behavioural change in infection prevention and control and in antibiotic prescribing; 3) further refinement and adding of additional study designs in the context of the European Centre for Disease Prevention and Control funded project 'Systematic review and evidence-based guidance on organisation of hospital infection control programmes' (SIGHT); 4) scrutiny by the pan-European expert panel of the SIGHT project, which had the objective of ensuring robustness of the systematic review. RESULTS: ICROMS includes established quality criteria for randomised studies, controlled before-and-after studies and interrupted time series, and incorporates criteria for non-controlled before-and-after studies, cohort studies and qualitative studies. The tool consists of two parts: 1) a list of quality criteria specific for each study design, as well as criteria applicable across all study designs by using a scoring system; 2) a 'decision matrix', which specifies the robustness of the study by identifying minimum requirements according to the study type and the relevance of the study to the review question. The decision matrix directly determines inclusion or exclusion of a study in the review. ICROMS was applied to a series of systematic reviews to test its feasibility and usefulness in the appraisal of multiple study designs. The tool was applicable across a wide range of study designs and outcome measures. CONCLUSION: ICROMS is a comprehensive yet feasible appraisal of a large range of study designs to be included in systematic reviews addressing behaviour change studies in patient safety and public health. The tool is sufficiently flexible to be applied to a variety of other domains in health-related research. Beyond its application to systematic reviews, we envisage that ICROMS can have a positive effect on researchers to be more rigorous in their study design and more diligent in their reporting.

Organization of infection control in European hospitals.

BACKGROUND: The Prevention of Hospital Infections by Intervention and Training (PROHIBIT) survey was initiated to investigate the status of healthcare-associated infection (HCAI) prevention across Europe. AIM: This paper presents the methodology of the quantitative PROHIBIT survey and outlines the findings on infection control (IC) structure and organization including management's support at the hospital level. METHODS: Hospitals in 34 countries were invited to participate between September 2011 and March 2012. Respondents included IC personnel and hospital management. FINDINGS: Data from 309 hospitals in 24 countries were analysed. Hospitals had a median (interquartile range) of four IC nurses (2-6) and one IC doctor (0-2) per 1000 beds. Almost all hospitals (96%) had defined IC objectives, which mainly addressed hand hygiene (87%), healthcare-associated infection reduction (84%), and antibiotic stewardship (66%). Senior management provided leadership walk rounds in about half of hospitals, most often in Eastern and Northern Europe, 65% and 64%, respectively. In the majority of hospitals (71%), sanctions were not employed for repeated violations of IC practices. Use of sanctions varied significantly by region (P < 0.001), but not by countries' healthcare expenditure. CONCLUSION: There is great variance in IC staffing and policies across Europe. Some areas of practice, such as hand hygiene, seem to receive considerably more attention than others that are equally important, such as antibiotic stewardship. Programmes in IC suffer from deficiencies in human resources and local policies, ubiquitous factors that negatively impact on IC effectiveness. Strengthening of IC policies in European hospitals should be a public health priority.

Education in infection control: A need for European certification.

Healthcare-associated infections are common adverse events in acute-care medicine, causing significant morbidity and mortality. There has been a significant increase in the commitment to infection prevention and control (IPC) among European countries in recent years. However, there is still heterogeneity in training opportunities and IPC qualifications. The European Union promotes the harmonization of IPC strategies among member states. The European Centre for Disease Prevention and Control (ECDC)-commissioned Training in Infection Control in Europe project sets the stage for harmonization of IPC activities in Europe by issuing a list of core competencies for IPC professionals. European certification of IPC training and professionals would be the next logical step, which must be achieved by close collaboration between different stakeholders in Europe such as the ECDC, the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), the European Union of Medical Specialities, and the national IPC societies. Therefore, the ESCMID has launched the new European Committee on Infection Control to take the lead in the implementation of a European (board) certificate for IPC professionals.

Provision and consumption of alcohol-based hand rubs in European hospitals.

Hand hygiene is considered to be the most effective way of preventing microbial transmission and healthcare-associated infections. The use of alcohol-based hand rubs (AHRs) is the reference standard for effective hand hygiene. AHR consumption is a valuable surrogate parameter for hand hygiene performance, and it can be easily tracked in the healthcare setting. AHR availability at the point of care ensures access to optimal agents, and makes hand hygiene easier by overcoming barriers such as lack of AHRs or inconvenient dispenser locations. Data on AHR consumption and availability at the point of care in European hospitals were obtained as part of the Prevention of Hospital Infections by Intervention and Training (PROHIBIT) study, a framework 7 project funded by the European Commission. Data on AHR consumption were provided by 232 hospitals, and showed median usage of 21 mL (interquartile range (IQR) 9-37 mL) per patient-day (PD) at the hospital level, 66 mL/PD (IQR 33-103 mL/PD) at the intensive-care unit (ICU) level, and 13 mL/PD (IQR 6-25 mL/PD) at the non-ICU level. Consumption varied by country and hospital type. Most ICUs (86%) had AHRs available at 76-100% of points of care, but only approximately two-thirds (65%) of non-ICUs did. The availability of wall-mounted and bed-mounted AHR dispensers was significantly associated with AHR consumption in both ICUs and non-ICUs. The data show that further improvement in hand hygiene behaviour is needed in Europe. To what extent factors at the national, hospital and ward levels influence AHR consumption must be explored further.