An ethical framework adapted for infection prevention and control.

OBJECTIVE: The ethical implications of infection prevention and control (IPAC) are recognized, yet a framework to guide the application of ethical principles is lacking. We adapted an ethical framework to provide a systematic approach for fair and transparent IPAC decision making. METHODS: We conducted a literature search for existing ethical frameworks in IPAC. Working with practicing healthcare ethicists, an existing ethical framework was adapted for use in IPAC. Indications were developed for application to practice, with integration of ethical principles and process conditions specifically relevant to IPAC. Practical refinements were made to the framework based on end-user feedback and application to 2 real-world situations. RESULTS: In total, 7 articles were identified that discussed ethical principles within IPAC, but none proposed a systematic framework to guide ethical decision making. The adapted framework, named the Ethical Infection Prevention and Control (EIPAC) framework, takes the user through 4 intuitive and actionable steps, centering key ethical principles that facilitate reasoned and just decision making. In applying the EIPAC framework to practice, weighing the predefined ethical principles in different scenarios was a challenge. Although no hierarchy of principles can apply to all contexts in IPAC, our experience highlighted that the equitable distribution of benefits and burdens, and the proportional impacts of options under review, are particularly important considerations for IPAC. CONCLUSIONS: The EIPAC framework can serve as an actionable ethical principles-based decision-making tool for use by IPAC professionals encountering complex situations in any healthcare context.

Impact of chlorhexidine bathing on methicillin-resistant Staphylococcus aureus incidence in an endemic chronic care setting: A randomized controlled trial.

We postulated that bathing with 2% chlorhexidine-impregnated antiseptic washcloths could reduce methicillin-resistant Staphylococcus aureus (MRSA) incidence among chronic care patients compared with nonantiseptic bathing. A total of 122 patients on 3 hospital units were enrolled in a 12-month, cluster-randomized, open-label, controlled trial, with 8 patients becoming MRSA positive. The 2% chlorhexidine-impregnated antiseptic washcloths reduced incidence by 71% (0.1 vs 0.44 cases per 1,000 patient days) (P = .14; Fisher exact). The detected difference was not statistically significant because of a low number of observed events.

Making change easy: A peer-to-peer guide on transitioning to new hand hygiene products.

This report summarizes our experiences planning and implementing the transition to a new commercial line of hand hygiene products and their dispensing systems in a large academic health care facility in Toronto, Canada. Our lessons learned are organized into a practical guide made available in 2 different formats: this article and an illustrated peer-to-peer guide (http://www.baycrest.org/wp-content/uploads/HCE-PROG-HH_HighQuality.pdf).

Distribution of outbreak reporting in health care institutions by day of the week.

BACKGROUND: The notion that outbreaks are more likely to occur on Friday is prevalent among staff in health care institutions. However, there is little evidence to support or discredit this notion. We postulated that outbreaks were no more likely to be reported on any particular day of the week. METHODS: A total of 901 institutional outbreaks in Toronto health care facilities were tabulated according to type, outbreak setting, and day of the week reported. A χ(2) goodness-of-fit test compared daily values for 7-day per week and 5-day per week periods. Post hoc partitioning was used to pinpoint specific day(s) of the week that differed significantly. RESULTS: Fewer outbreaks were reported on Saturdays and Sundays. Further analysis examined the distribution of outbreak reporting specifically focusing on the Monday to Friday weekday period. Among the weekdays, higher proportions of outbreaks were reported on Mondays and Fridays. CONCLUSION: Our null hypothesis was rejected. Overall, Mondays and Fridays had the highest occurrence of outbreak reporting. We suggest that this might be due to "deadline" and "catch-up" reporting related to the "weekend effect," whereby structural differences in weekend staffing affect detection of outbreaks. Such delays warrant reexamination of surveillance processes for timely outbreak detection independent of calendar cycle.

Polyphosphate kinase 1 is a pathogenesis determinant in Campylobacter jejuni.

Campylobacter jejuni is the leading cause of bacterial gastroenteritis in the developed world. Despite its prevalence, relatively little is known about C. jejuni's precise pathogenesis mechanisms, particularly in comparison to other well-studied enteric organisms such as Escherichia coli and Salmonella spp. Altered expression of phosphate genes in a C. jejuni stringent response mutant, together with known correlations between the stringent response, polyphosphate (poly-P), and virulence in other bacteria, led us to investigate the role of poly-P in C. jejuni stress survival and pathogenesis. All sequenced C. jejuni strains harbor a conserved putative polyphosphate kinase 1 predicted to be principally responsible for poly-P synthesis. We generated a targeted ppk1 deletion mutant (Deltappk1) in C. jejuni strain 81-176 and found that Deltappk1, as well as the DeltaspoT stringent response mutant, exhibited low levels of poly-P at all growth stages. In contrast, wild-type C. jejuni poly-P levels increased significantly as the bacteria transitioned from log to stationary phase. Phenotypic analyses revealed that the Deltappk1 mutant was defective for survival during osmotic shock and low-nutrient stress. However, certain phenotypes associated with ppk1 deletion in other bacteria (i.e., motility and oxidative stress) were unaffected in the C. jejuni Deltappk1 mutant, which also displayed an unexpected increase in biofilm formation. The C. jejuni Deltappk1 mutant was also defective for the virulence-associated phenotype of intraepithelial cell survival in a tissue culture infection model and exhibited a striking, dose-dependent chick colonization defect. These results indicate that poly-P utilization and accumulation contribute significantly to C. jejuni pathogenesis and affect its ability to adapt to specific stresses and stringencies. Furthermore, our study demonstrates that poly-P likely plays both similar and unique roles in C. jejuni compared to its roles in other bacteria and that poly-P metabolism is linked to stringent response mechanisms in C. jejuni.

Pathogen and indicator variability in a heavily impacted watershed.

Water samples were collected from 36 locations within the Grand River Watershed, in Southwestern Ontario, Canada from July 2002 to December 2003 and were analyzed for total coliforms, fecal coliforms, Escherichia coli, Escherichia coli O157:H7, and thermophilic Campylobacter spp. A subset of samples was also analyzed for Cryptosporidium spp., Giardia spp., culturable human enteric viruses, and Clostridium perfringens. Storm and snowmelt events were sampled at two locations including a drinking water intake. For the majority of the events, the Spearman rank correlation test showed a positive correlation between E. coli levels and turbidity. Peaks in pathogen numbers frequently preceded the peaks in numbers of indicator organisms and turbidity. Pathogen levels sometimes decreased to undetectable levels during an event. As pathogen peaks did not correspond to turbidity and indicator peaks, the correlations were weak. Weak correlations may be the result of differences in the sources of the pathogens, rather than differences in pathogen movement through the environment. Results from this investigation have implications for planning monitoring programs for water quality and for the development of pathogen fate and transport models to be used for source water risk assessment.