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infection control

An innovative solution providing cost-effective cleansing and prevention of healthcare-associated infections (HAI)

‘Primum non nocere’

In relation to infection control the word prevention has not been added to the lexicon of healthcare professionals (HCPs). Despite the plethora of literature, evidence, mandatory guidance, and the basic tenant of care espoused by Nightingale that “The very first requirement in a hospital is that it should do the sick no harm.” (1), HCPs often fail to adhere to simple hand-washing and other infection prevention actions. Consequently, healthcare-associated infections (HAIs) continue to develop either as a direct result of healthcare intervention or from being in contact with a healthcare setting (2).

Healthcare-associated infections (HAIs) result in a large health and cost burden worldwide (3, 4). The demand on NHS resources comes from an increasing number of antibiotic-resistant strains of bacteria and from an increasing number of chronically ill or immunologically compromised patients who are susceptible to hospital associated ‘opportunistic’ infections(5). Between 20% and 30% of all HAIs are preventable by improved infection control measures (6,7).

HCPs lack of engagement in prevention are not well explored, but are thought to include:

  • Motivational factors – related to behaviourism (8), and ‘guideline fatigue’, whereby new guidance is either ignored or inexpertly implemented, and HCPs no longer explore new ways of working.
  • Structural empowerment – the way in which employees perceive their work environment (8); facilities not readily/easily available, ‘make do and mend’ mentality.

Preventing cross infection in leg ulcer care

According to a recent NICE Clinical Knowledge Summary (9), Ensure the ulcer is irrigated at each dressing change with warm tap water or saline, then dried. Strict aseptic technique is not required, as the aim is not to remove surface bacteria, but rather to avoid cross-infection from contamination.

Previously, buckets or cleansing with swabs/cloths have been used to achieve this. However, if not properly decontaminated after use, buckets have the potential to facilitate cross infection. The innovative PathAguard® range of antimicrobial products facilitate a reduction in cross-infection potential. The range includes:

  • The PathAguard® ABLiS® (Antimicrobial Basin Liner System): In an era which has seen the emergence of highly resistant pathogenic and persistent microbes, CMC Hygea Ltd. have developed a polypropylene utility basin system for patient hygiene activities in a clinical setting. The system is designed for use with a fitted disposable inner liner. Both PathAguard® ABLiS® and liner are treated with pathogen protection agents designed to reduce infectious risk from cross-contamination, handling and repeated use. It is a simple combination of a basin with a disposable liner both of which are impregnated with Silver Ion Technology. This has a proven kill rate of 99.99% against commonly occurring problematic species of pathogenic bacteria including E. coli, Staph aureus, Pseudomonas aeruginosa, MRSA, VRE and Klebsiella pneumoniae. The design of the system by using a liner reduces patient exposure to cross-infection from reused basins and contributes to overall infection control strategy in any healthcare setting
  • The PathAguard® Luca® Single-Use Antimicrobial Leg Ulcer Cleaning Aid (Figure 1). The leg is placed into the sleeve, the cleansing liquid is added and then the sleeve is secured around the leg. The system offers antimicrobial pathogen protection, is safe, hygienic and cost effective, is versatile and can appropriately be used in both the home and healthcare settings

Laboratory results

Both products have undergone extensive laboratory and clinical testing. Those involved in the study share their findings.

R.J. Russell BA Mod, Ph.D. (Associate Professor of Microbiology. Microbiological Test Report – 20/11/14
The results clearly show that there is little, if any, reduction in bacterial counts on standard polypropylene for any of the bacterial species tested. E.coli and Pseudomonas aeruginosa counts were seen to increase slightly but not to any significant degree. This shows that under the ISO 22196 test conditions, high counts of bacteria were able to survive in viable form and were recoverable from standard polypropylene surfaces after 3 days.

Results recorded for the PathAguard® ABLiS® devices showed a marked contrast to those recorded for polypropylene. The survival rates for all bacterial species tested were very significantly less than on polypropylene and this was regardless of whether the bacteria were in contact for 24 hours or 72 hours.

There was no significant difference between the PathAguard® ABLiS® device antibacterial performance if in new and unused state or after 5 months in use.

All PathAguard® ABLiS® device samples were capable of reducing challenge bacterial counts by greater than 99% at 24 hours and by 99.99% at 72 hours.

This antibacterial performance of the PathAguard® ABLiS® device shows definite potential for infection control in clinical usage.

Debra Johnson MPH, BSN, RN, OCN, CIC, Infection Control & Prevention Specialist (US)
We conclude that bath basins are a reservoir for bacteria and that further investigations into bath basins as a potential source of transmissions of HAI are warranted. Increased awareness of bath basins as a possible source of bacterial cross-contamination is necessary, particularly in high-risk patients. In addition, alternative bathing methods should be investigated. Our findings are a call to action to healthcare providers to develop and implement protocols for patients’ exposure to pathogens. I have not changed my mind on bath basins, with the exception of PathAguard® ABLiS®. I am excited to see what it will bring back to patient care in the US.

Dr Roy Sleator BSc, MA, PhD, CBiol, FRSB. Senior Lecturer, Department of Biological Sciences, Cork Institute of Technology, Ireland.
The rise of antibiotic resistant ‘superbugs’, coupled with increasing incidence of nosocomial infections, continues to put significant strain on hospital infection control measures. The single use disposable liner limits exposure of the basin to potentially infective material and also provides an extra physical barrier between the healthcare professional and potentially infective material. This makes decontamination easier by significantly reducing the potential for reusable basins to act as vehicles for the inadvertent transfer of infective agents. The liner also facilitates clean and easy disposal of contaminated materials; significantly reducing the possibility of sloshing and aerosol formation as the basin is transported within the healthcare facility and subsequently when the basin is sanitized. Aerosol formation is a significant cause of infectious disease transmission in health care facilities.

In my estimation, the PathAguard® ABLiS® represents the cleanest, safest, and most effective approach to protecting against healthcare associated infection during hygiene activity.

Conclusion

Strict adherence to infection prevention practices are often compromised by human and environmental factors. Incorporating, this innovative system which reduces possible cross contamination in a twofold manner and (integral antimicrobial action and single use) eliminates many human and environmental factors.

Pentland Medical will be exhibiting the PathAguard® Luca® Leg Ulcer Cleaning Aid and PathAguard® ABLiS® (Antimicrobial Basin Liner System) at the Sepsis trust meeting in Brighton in September.

 

References

  1. Nightingale F. Notes on Nursing: What It Is, and What It Is Not. Dover Publications, England
  2. National Institute for Health and Care Excellence (NICE). Infection prevention and control. NICE quality standard [QS61]. Available at: https://www.nice.org.uk/guidance/qs61/chapter/introduction
  3. Stone PW, Braccia D, Larson E. Systematic review of economic analyses of health care-associated infections. Am J Infect Control. 2005; 33: 501–509. http://www.ajicjournal.org/article/S0196-6553(05)00522-5/abstract
  4. McNamara L. Health Care-Associated Infection. Am J Crit Care 2009;18:41. http://ajcc.aacnjournals.org/content/18/1/41.full
  5. Public Health England. Healthcare associated infections (HCAI): guidance, data and analysis. March 2016 https://www.gov.uk/government/collections/healthcare-associated-infections-hcai-guidance-data-and-analysis
  6. Council of the European Union. Council recommendation of 9 June 2009 on patient safety, including the prevention and control of healthcare-associated infections (2009/C151/01). Official Journal of the European Union. 3 Jul 2009. Available from: http://ec.europa.eu/health/patient_safety/docs/council_2009_en.pdf
  7. European Centre for Disease Prevention and Control/European Medicines Agency (ECDC/EMEA). Joint technical report: The bacterial challenge: time to react. Stockholm:ECDC/EMEA; 2009. Available from: http://ecdc.europa.eu/en/publications/Publications/0909_TER_The_Bacterial_Challenge_Time_to_React.pdf
  8. Smiddy MP, O’Connell R, Creedon SA. Systematic qualitative literature review of health care workers’ compliance with hand hygiene guidelines. Am J Inf Control. 2015. 43(3);269-274
  9. NICE. Clinical Knowledge Summaries. Leg Ulcer-Venous. 2016. Available at: http://cks.nice.org.uk/leg-ulcer-venous#!scenarioclarification

Image: ©Pentland Medical

Inadvertent peri-operative hypothermia (IPH) is a common but preventable complication associated with poor outcomes for patients, including poor wound healing, increase in blood loss, impaired wound healing, and an increased risk of surgical site infection [1,2]. Crystaline temperature strips (Sharn Anesthesia Inc USA, distributed by Pentland Medical UK) offer a range of benefits in addition to accurate temperature recording.

Hypothermia is defined by the National Institute for Health and Care Excellence (NICE) as ‘a patient core temperature of below 36.0°C’ [3]. According to Berger & Fitzpatrick [1], approximately 70% of patients experience IPH, although Hart et al [2] suggest this number is 20%. Unfortunately, the combination of cool operating theatres (typically below 23°C (73.4°F) [2], the fact that the patient cannot physically move elsewhere, and the physiological effects of anaesthesia (altered thermoregulatory mechanisms), can cause core temperature to drop rapidly.

Core temperature is that relating to the deep thoracic, abdominal, and central nervous system tissues [2], and is 2-4°C (3.6-7.2°F) warmer than skin temperature. It is usually measured at the distal oesophagus, pulmonary artery, or nasopharynx.

NICE Guidance in IPH
NICE has provided guidance on the prevention of IPH for the entire peri-operative period, which makes reference to the use of temperature monitoring devices [3]:

When using any temperature recording…device, healthcare professionals should:

  • be trained in their use
  • maintain them in accordance with manufacturers’ and suppliers’ instructions
  • comply with local infection control policies
  • be aware of, and carry out, any adjustments that need to be made in order to obtain an estimate of core temperature from that recorded at the site of measurement
  • be aware of any such adjustments that are made automatically by the device used

During the intra-operative phase, Nice recommends that the patient’s temperature should be measured and documented before induction of anaesthesia and then every 30 minutes until the end of surgery. Post-operatively, it should be taken and documented on admission to recovery and every 15 minutes thereafter until transfer to the ward. Here, temperature should be measured 4 hourly for 24 hours.

Temperature monitoring devices

Oral, rectal, bladder, axillary, groin, skin, and tympanic membrane measurements are also used to measure near-core temperature (which indicates core temperature). A number of products are used, including infra-red probes and tympanic devices. However, many of these do not allow continuous monitoring, rather the machine has to be activated and a reading taken and recorded at certain times points. Regardless of the interval between measurements, such devices do not allow early warning of change.

In addition, these devices carry a cost; tympanic devices for example, use disposable caps for each reading, so the cost of purchasing the machine, calibration and servicing costs, and the on-going cost of accessories need to be taken into account.  They are often lost, broken or ‘borrowed’, so replacement costs can be high.

All types of measuring devices of this nature can carry cross contamination risk between users.

Crystaline temperature strips

A non-invasive method of continuous temperature monitoring is the use of Crystaline liquid crystal core temperature strips. The strip continuously monitors a mathematically equivalent correspondent of oesophageal core, and is more effective so than rectal or axillary skin alternatives [4]. They will accurately track patient temperature trend relative to oesophageal core; the green line shown on the strip represents the equivalent oesophogeal core temperature (Figure 1). If the strip indicates a change, an oesophageal core measurement should be taken.

Figure 1: Example Crystaline Temperature Strip

Image: ©Pentland Medical
Image: ©Pentland Medical

As well as being accurate, reliable, and low cost, they are ideally suited to facilitate adherence to the Nice guidance on IPH temperature monitoring regimens [3], making them an extremely viable alternative to other forms of temperature monitoring.

The Crystaline temperature strip is placed on the patient from admission to recovery (sometimes 24 hours or longer), so it doesn’t come into contact with anything else, significantly reducing both the contamination risk from other equipment and cross-infection. In contrast, any equipment that must be handled (in order to monitor temperature) or repeatedly applied and removed carries a much greater contamination risk.

Conclusion

Over three million Crystaline strips are used annually in the USA alone. While they do not replace the need to use oesophageal core temperature, they do provide the most cost effective, reliable, proven method of continuous temperature monitoring in compliance with Nice guidance. Crystaline provides an alternative to the tympanic and infra-red thermometers that are prone to human and physiological errors.

Shouldn’t your organisation consider these in order to comply with Nice guidance?

 

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

 

References

  1. Berger L, Fitzpatrick J. Prevention of inadvertent perioperative hypothermia. BJN.  2009. DOI: http://dx.doi.org/10.12968/bjon.2009.18.18.44553
  2. Hart SR, Bordes B, Hart J, Corsino D, et al. Unintended Perioperative Hypothermia. The Ochsner Journal. 2011. 11; 3:259-270. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3179201/ Accessed August 2015
  3. National Institute for Health and Care Excellence (NICE). NICE Guideline CG65: Inadvertent perio-perative hypothermia: The management of inadvertent perio-perative hypothermia in adults. 2008. https://www.nice.org.uk/guidance/cg65/chapter/1-Guidance Accessed August 2015
  4. Allen G, Horrow JC, Rosenberg H. Does forehead liquid crystal temperature accurately reflect ‘core’ temperature? Can J Anaesth. 1990. 37; 6:659-662. http://www.infiniti.se/upload/Studier/Sharn/LC%20and%20Core%20Temp.pdf  Accessed August 2015

An innovative bed-bathing system providing cost-effective comfort and prevention of healthcare-associated infection (HAI)

Image: ©Pentland Medical

_MG_6725

You can find out more about this product at Pentland Medical (UK Distributor)

Introduction

The PathAguard® ABLiS™ antimicrobial basin and liner system has been developed and patented by CMC Hygea Limited of Waterford, Ireland (1). The device consists of an antimicrobial-impregnated, reusable wash basin and a single-use antimicrobial liner. This device delivers safe, comfortable and effective bed bathing with cost-savings. Pentland Medical is marketing this system as ABLiS™ (2).

When used with recommended infection control procedures, ABLiS™ can reduce the risk of cross-infection when patient-assisted washing is being performed.

There is published data to support the problems of healthcare and hospital acquired infections (HAI) associated with ‘traditional’ hospital basin bathing equipment. The ABLiS™ provides a cost-effective, practical way of ensuring infection control in hospitals, nursing homes and home environments.

The Health Burden of Healthcare-Associated Infections (HAIs)

Healthcare-associated infections (HAIs) result in a large health- and cost-burden worldwide (3, 4). The demand on NHS resources comes from an increasing number of antibiotic-resistant strains of bacteria and from an increasing number of chronically ill or immunologically compromised patients who are susceptible to hospital-acquired ‘opportunistic’ infections (5).

As an example of this dual problem, the impact of methicillin-resistant Staphylococcus aureus (MRSA) on health costs and morbidity and mortality in hospital patients in the UK is well documented. In 2008, the Royal College of Physicians commissioned a financial risk management analysis that showed that during that year, 5,000 people in England were infected with MRSA (6). In 2008, the treatment of MRSA cost the NHS more than £45-million, with the estimate that every new case of MRSA cost the NHS £9,000 (6). In 2011, the National Institute for Health and Clinical Excellence (NICE) published its reported data on MRSA and Clostridium difficile, with recommendations for infection prevention (7). In 2012, the Department of Health Policy Research Programme commissioned a report on the economic burden of antimicrobial resistance with the focus on opportunistic bacteria acquired within hospital (8).

The European Centre for Disease Prevention and Control (ECDC) have estimated that between 8% and 12% of patients now admitted to hospitals in European countries suffer from healthcare-associated adverse events, with HAIs being the most prominent of them (9). HAIs now affect more than 4 million patients annually in the European Union (EU) Member States and these infections result in approximately 37,000 deaths per year (9). The Council of the EU has recently launched a recommendation to the Member States and the Commission to prevent HAIs and to promote patient safety by institutional, community, and national action plans (9). Between 20% and 30% of all HAIs are preventable by improved infection control measures (9, 10).

Bath Basins as a Potential Source of Healthcare-Associated Infections (HAI)

There are two types of bed baths used in hospitals, nursing homes and community care: the traditional basin which uses soap and water, and the disposable bath which is pre-packed in single-use units and which is usually heated before use. Bath basins can be a reservoir for bacteria and may be a source of transmission of HAIs (4, 11).

In 2015, a study of 58 patients compared the traditional basin bed bath to a disposable bed bath (12). In this study, four factors were considered: duration and quality of the bath; cost; nurse satisfaction and patient satisfaction (12). The nurses in this study clearly preferred the disposable baths, and so did the majority of patients (12). In the case of disposable baths, the costs were lower as significantly less time was used in bathing (12). The decision of the authors of this study was that nurses should inform patients about the two methods and involve patients in the decision about which method to use (12).

The Advantage of the ABLiS™ – Antimicrobial Basin and Liner System

The ABLiS™ system is latex-free, basin washer compatible, ergonomically designed and has an anti-microbial disposable liner system. The ABLiS™ system is impregnated with a combination of proven, effective antimicrobial agents.

Cost is minimal: the basin is priced at circa £8.00, with the cost of the liner and dispenser being a matter of pence, but dependent on quantity.

Conclusion

With the increasing awareness of infection control, from recent findings of nurse and patient preference, and in keeping with UK and European guidelines on prevention of healthcare-acquired infection (HAI), the ABLiS™ system is recommended for patient bathing (8-12).

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

  1. The PathAguard® ABLiS™ system is a practical solution to reduce the spread of Hospital Acquired Infections (HAI) in a healthcare environment. Product information. http://www.cmchygea.net/pathaguardreg-ablistrade.html Accessed July 13, 2015
  2. Pentland Medical Product Information website. http://www.pentlandmedical.co.uk/index.php/products/infection-prevention/pail-bath-basin-fluid-management-system/ Accessed July 13, 2015
  3. Stone PW, Braccia D, Larson E. Systematic review of economic analyses of health care-associated infections. Am J Infect Control. 2005; 33: 501–509. http://www.ajicjournal.org/article/S0196-6553(05)00522-5/abstract Accessed July 13, 2015
  4. McNamara L. Health Care-Associated Infection. Am J Crit Care 2009;18:41. http://ajcc.aacnjournals.org/content/18/1/41.full Accessed July 13, 2015
  5. Public Health England. Healthcare associated infections (HCAI): guidance, data and analysis. Published July 31, 2015. https://www.gov.uk/government/collections/healthcare-associated-infections-hcai-guidance-data-and-analysis Accessed July 13, 2015
  6. Devlin K. Every MRSA case costs NHS an extra £9,000. The Telegraph. June 25 2008.http://www.telegraph.co.uk/news/uknews/2194132/Every-MRSA-case-costs-NHS-an-extra-9000.html Accessed July 13, 2015
  7. National Institute for Health and Clinical Excellence (NICE). Public Health Guidance 36. Quality Improvement Guide. Prevention and Control of Healthcare-Associated Infections. Costing Report. 2011. http://www.nice.org.uk/guidance/ph36/resources/ph36-prevention-and-control-of-healthcareassociated-infections-costing-report2 Accessed July 13, 2015
  8. Smith RD, Coast J. The economic burden of antimicrobial resistance: Why it is more serious than current studies suggest. Independent research report commissioned and funded by the Department of Health Policy Research Programme (Economic burden of antimicrobial resistance: a rapid paper, 0410035). 2012. http://www.lshtm.ac.uk/php/economics/assets/dh_amr_report.pdf Accessed July 13, 2015
  9. Council of the European Union. Council recommendation of 9 June 2009 on patient safety, including the prevention and control of healthcare-associated infections (2009/C151/01). Official Journal of the European Union. 3 Jul 2009. Available from: http://ec.europa.eu/health/patient_safety/docs/council_2009_en.pdf Accessed July 13, 2015
  10. European Centre for Disease Prevention and Control/European Medicines Agency (ECDC/EMEA). Joint technical report The bacterial challenge: time to react. Stockholm:ECDC/EMEA; 2009. Available from: http://www.ecdc.europa.eu/en/publications/Publications/0909_TER_The_Bacterial_Challenge_Time_to_React.pdf Accessed July 13, 2015
  11. Johnson D, Lineweaver L, Maze LM. Patients’ Bath Basins as Potential Sources of Infection: A Multicenter Sampling Study. Am J Crit Care 2009;18:31-40 http://ajcc.aacnjournals.org/content/18/1/31.full Accessed July 13, 2015
  12. Noddeskou LH, Hemmingsen LE, Hordam B. Elderly patients’ and nurses’ assessment of traditional bed bath compared to prepacked single units – randomised controlled trial. Scand J Caring Sci. 2015;29(2):347-52. http://onlinelibrary.wiley.com/doi/10.1111/scs.12170/abstract Accessed July 13, 2015

Antimicrobial Research Collaborative (ARC) recommends CRE screening as a priority for admissions to high-risk specialities

Image: ©nata-lunata/Shutterstock #220986358

The Gram-negative bacterial family of Enterobacteriaceae, includes the species Klebsiella, Enterobacter, and Escherichia. These bacteria can cause opportunistic wound infections, gastroenteritis, pneumonia and septicaemia, particularly in hospital patients, including post-operative patients. Carbapenem-resistant Enterobacteriaceae (CRE) is now a serious concern for the NHS (1).

In 2009, reports first emerged from the USA that these new hospital-acquired, antibiotic-resistant bacteria, had caused death in hospital patients. A prediction was made at this time that CRE could be even harder to eradicate than methicillin-resistant Staphylococcus aureus (MRSA) or antibiotic-resistant Clostridium difficile.

Following reports of cases of CRE in more than a dozen hospitals in England and Scotland in 2009, the then Health Protection Agency (HPA) (now Public Health England) issued a warning about what it called, ‘a notable public health risk’(1). Initially, CRE was thought to be imported from patients having had surgery in India and CRE was considered to be a consequence of the increasing number of UK patients travelling abroad for surgery each year (> 100,000 in 2013) (2).

In 2015, a joint collaboration between Imperial College Healthcare NHS Trust, Imperial College Academic Health Sciences Centre (AHSC) and Imperial College London has created a new multidisciplinary research group, the Antimicrobial Research Collaborative (ARC) (3,4). The aim of the ARC is to translate research findings into new infection prevention strategies. This initiative will have an important role in addressing the problem of antimicrobial resistance (AMR).

As part of the ARC collaboration, in April 2015 researchers lead by Professor Alison Holmes, Director of the National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU), Imperial College London, published their review of current CRE screening strategies in the Journal of Infection(5,6). Among the findings of this study, they noted that admissions to high-risk specialties were likely to have higher CRE prevalence rates and that the higher prevalence of CRE resulted in higher detection rates and lower false-positivity rates (6). These researchers have recommended that CRE screening should be prioritised for hospital admissions to high-risk specialties (6).

The CRE strains are resistant to all the standard antibiotics now used in the NHS. Furthermore, some of these resistant bacteria have been shown to survive in hospital environments, such as table surfaces and door handles.

In May 2015, a publication by Weber and colleagues in the US, in the journal Infection Control & Hospital Epidemiology (ICHE) (published online in Feb 2015), reported that CRE-infected patients contaminated the environmental surfaces of hospital rooms in 8.4% of cases, but at low levels (7). Three species of CRE, Enterobacter, Klebsiella, and Escherichia, survived poorly, with 15% survival after 24 hours and 0% survival after 72 hours (7).

The survival of enteric organisms, such as CRE, is likely to be less than the survival of MRSA on hospital surfaces, due to differences in the structure of the bacterial cell capsule. The ICHE study shows that the levels of contamination and survival are high enough to be important in terms of CRE transmission (7).

In conclusion, carbapenem-resistant Enterobacteriaceae (CRE) are an important group of infections for the new multidisciplinary antimicrobial resistance (AMR) teams to target. Despite their reported limited growth and survival on hospital surfaces, the increasing number of reported cases supports the view that now is not the time to be complacent about hospital infection control.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

(1) Public Health England. https://www.gov.uk/government/organisations/public-health-england Accessed June 16, 2015

(2) Office for National Statistics, Travel Tends 2013. http://www.ons.gov.uk/ons/dcp171776_361237.pdf Accessed June 16, 2015

(3) Imperial College Healthcare NHS Trust. http://www.imperial.nhs.uk Accessed June 16, 2015

(4) The Antimicrobial Research Collaborative (ARC), Imperial College, London. http://www.imperial.ac.uk/arc Accessed June 16, 2015

(5) The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London. http://www1.imperial.ac.uk/hpruantimicrobialresistance/ Accessed June 16, 2015

(6) Venanzio V, Gharbi M, Moore LS, Robotham J, Davies F, Brannigan E, Galletly T, Holmes AH. Screening suspected cases for carbapenemase-producing Enterobacteriaceae, inclusion criteria and demand. J Inf 2015;pii:S0163-4453(15)00197-8. http://www.ncbi.nlm.nih.gov/pubmed/26070742 Accessed June 16, 2015

(7) Weber DJ, Rutala WA, Kanamori H, Gergen MF, Sickbert-Bennett EE. Carbapenem-resistant Enterobacteriaceae: frequency of hospital room contamination and survival on various inoculated surfaces. Infect Control Hosp Epidemiol. 2015;36(5):590-3. http://www.ncbi.nlm.nih.gov/pubmed/25661968 Accessed June 16, 2015

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