| 1. |
- Lymer, Ulla-Britt, et al.
(författare)
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A descriptive study of blood exposure incidents among healthcare workers in a university hospital in Sweden
- 1997
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Ingår i: Journal of Hospital Infection. - 0195-6701 .- 1532-2939. ; 35:3, s. 223-235
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Tidskriftsartikel (refereegranskat)abstract
- In an attempt to document blood exposure incidents and compliance with recommended serological investigations, universal precautions and incident reporting routines, data was collected from occupational injury reports during a two-year period. In addition, a sample of healthcare workers (HCWs) answered a questionnaire about blood tests and work routines. In a third part of the study some HCWs were asked about the type and actual frequency of incidents, together with the number of reported incidents during the two-year study period. Of a total of 473 reported occupational blood exposures, the majority came from nurses and the minority from physicians. Most reported incidents occurred on hospital wards. The most common incidents were needlestick injuries, and 35% occurred when the needle was recapped. Medical laboratory technicians (MLT) reported significantly more mucocutaneous incidents than other professionals (P < 0·01). In 10% of the incidents, the patient had a known blood-borne infection. Serological investigations post-exposure varied among professional groups, and 35% were not tested. No seroconversion was shown in the HCWs tested. In the third part of the study, respondents recalled 1180 incidents, although only 9% of these had been reported. The majority occurred in operating theatres, and in connection with anaesthesia. There was a significant difference (P < 0·001) between the different professional groups with regard to the frequency of incident reporting. Physicians reported only 3% and MLTs 36% of the incidents. Eighty-one percent believed that the accident could have been avoided. Despite knowledge of universal precautions, professionals continue to behave in a risky manner, which can result in blood exposure incidents.
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| 2. |
- Samuelsson, A, et al.
(författare)
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Clustering of enterococcal infections in a general intensive care unit
- 2003
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Ingår i: Journal of Hospital Infection. - 0195-6701 .- 1532-2939. ; 54:3, s. 188-195
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Tidskriftsartikel (refereegranskat)abstract
- This is a retrospective study comparing patients' characteristics, antibiotic consumption and environmental contamination before the impact of a new regimen of intensified infection control measures in a general intensive care unit (ICU) at a university-affiliated tertiary-care teaching hospital. The new regimen consisted of (1) reorganization of patient rooms (2) improved hygienic measures including strict hygiene barrier nursing (3) more isolated patient care and (4) more restrictive use of antibiotics. The regimen was introduced after a cluster of enterococcal infections. All patients admitted to the ICU from 1 March 1995 to 28 february 1997 were included. A study period of 12 months after reorganization of the ward was compared with the 12 months immediately before it. The antibiotic consumption, the individual patient's severity of disease (APACHE score), and the extent of therapeutic interventions (TISS score) were recorded. Enterococci were typed biochemically, antibiograms were established and the relation between the isolates was investigated with pulsed-field gel electrophoresis. The bacteriological results and the patient data suggested a hospital-acquired spread as the cause of the ICU enterococcal outbreak. After implementation of the new regimen, we observed a reduction in the rate of enterococcal bloodstream infections from 3.1 to 1.8%. The consumption of antibiotics fell from 6.11 to 4.24 defined daily doses per patient.The introduction of strict hygiene and barrier nursing, more restrictive use of antibiotics, isolation of infected patients, thorough cleaning and disinfection of the unit was followed by an absence of enterococcal infection clustering and reduction in incidence of enterococcal bacteraemia. We were not able to determine whether the reduction in antibiotic consumption was due to the intervention programme. ⌐ 2003 The Hospital Infection Society. Published by Elsevier Science Ltd. All rights reserved.
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| 3. |
- Aganovic, A., et al.
(författare)
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Ventilation design conditions associated with airborne bacteria levels within the wound area during surgical procedures: a systematic review
- 2021
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Ingår i: Journal of Hospital Infection. - : Elsevier BV. - 0195-6701 .- 1532-2939. ; 113, s. 85-95
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Forskningsöversikt (refereegranskat)abstract
- Background: Without confirmation of the ventilation design conditions (typology and airflow rate), the common practice of identifying unidirectional airflow (UDAF) systems as equivalent to ultra-clean air ventilation systems may be misleading, but also any claims about the ineffectiveness of UDAF systems should be doubted. The aim of this review was to assess and compare ventilation system design conditions for which ultra-clean air (mean <10 cfu/m ) within 50 cm from the wound has been reported. Six medical databases were systematically searched to identify and select studies reporting intraoperative airborne levels expressed as cfu/m close to the wound site, and ventilation system design conditions. Available data on confounding factors such as the number of persons present in the operating room, number of door openings, and clothing material were also included. Predictors for achieving mean airborne bacteria levels within <10 cfu/m were identified using a penalized multivariate logistic regression model. Twelve studies met the eligibility criteria and were included for analysis. UDAF systems considered had significantly higher air volume flows compared with turbulent ventilation (TV) systems considered. Ultra-clean environments were reported in all UDAF-ventilated (N = 7) rooms compared with four of 11 operating rooms equipped with TV. On multivariate analysis, the total number of air exchange rates (P=0.019; odds ratio (OR) 95% confidence interval (CI): 0.66–0.96) and type of clothing material (P=0.031; OR 95% CI: 0.01–0.71) were significantly associated with achieving mean levels of airborne bacteria <10 cfu/m . High-volume UDAF systems complying with DIN 1946-4:2008 standards for the airflow rate and ceiling diffuser size unconditionally achieve ultra-clean air close to the wound site. In conclusion, the studied articles demonstrate that high-volume UDAF systems perform as ultra-clean air systems and are superior to TV systems in reducing airborne bacteria levels close to the wound site. 3 3 3 3
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| 4. |
- Aguado, J. M., et al.
(författare)
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Highlighting clinical needs in Clostridium difficile infection : the views of European healthcare professionals at the front line
- 2015
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Ingår i: Journal of Hospital Infection. - : Academic Press. - 0195-6701 .- 1532-2939. ; 90:2, s. 117-125
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Tidskriftsartikel (refereegranskat)abstract
- Background: Clostridium difficile infection (CDI) is the leading cause of infectious nosocomial diarrhoea in Europe. Despite increased focus, its incidence and severity are increasing in many European countries. Aim: We developed a series of consensus statements to identify unmet clinical needs in the recognition and management of CDI. Methods: A consortium of European experts prepared a series of 29 statements representing their collective views on the diagnosis and management of CDI in Europe. The statements were grouped into the following six broad themes: diagnosis; definitions of severity; treatment failure, recurrence and its consequences; infection prevention and control interventions; education and antimicrobial stewardship; and National CDI clinical guidance and policy. These statements were reviewed using questionnaires by 1047 clinicians involved in managing CDI, who indicated their level of agreement with each statement. Findings: Levels of agreement exceeded the 66% threshold for consensus for 27 out of 29 statements (93.1%), indicating strong support. Variance between countries and specialties was analysed and showed strong alignment with the overall consensus scores. Conclusion: Based on the consensus scores of the respondent group, recommendations are suggested for the further development of CDI services in order to reduce transmission and recurrence and to ensure that appropriate diagnosis and treatment strategies are applied across all healthcare settings.
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| 5. |
- Ahmed, Anisuddin, et al.
(författare)
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Measuring the effectiveness of an integrated intervention package to improve the level of infection prevention and control : a multi-centre study in Bangladesh
- 2024
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Ingår i: Journal of Hospital Infection. - : Elsevier. - 0195-6701 .- 1532-2939. ; 145, s. 22-33
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Tidskriftsartikel (refereegranskat)abstract
- Background: Infection prevention and control (IPC) is a critical component of delivering safe, effective and high -quality healthcare services, and eliminating avoidable healthcare -associated infections (HAIs) in health facilities, predominantly in populationdense settings such as Bangladesh.Aim: Our study aimed to assess the effect of an integrated intervention package in improving the IPC level of the health facilities in Bangladesh.Methods: We conducted a pre -post intervention study in six district hospitals (DHs) and 13 Upazila Health Complexes (UHCs) in the six districts of Bangladesh. Baseline and endline assessments were conducted between March and December 2021 using the adapted World Health Organization Infection Prevention and Control Assessment Framework (WHO-IPCAF) tool. The IPCAF score, ranging from 0-800, was calculated by adding the scores of eight components, and the IPC promotion and practice level was categorized as Inadequate (0 -200), Basic (201-400), Intermediate (401-600) and Advanced (601-800). The integrated intervention package including IPC committee formation, healthcare provider training, logistics provision, necessary guidelines distribution, triage/flu corners establishment, and infrastructure development was implemented in all facilities.Results: The average IPCAF score across all the facilities showed a significant increase from 16% (95% CI: 11.5-20.65%) to 54% (95% CI: 51.4-57.1%). Overall, the IPCAF score increased by 34 percentage points (P<0.001) in DHs and 40 percentage points (P<0.001) in UHCs. Following the intervention, 12 (three DHs, nine UHCs) of 19 facilities progressed from inadequate to intermediate, and another three DHs upgraded from basic to intermediate in terms of IPC level.Conclusion: The integrated intervention package improved IPCAF score in all facilities.
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| 6. |
- Alsved, M., et al.
(författare)
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Temperature-controlled airflow ventilation in operating rooms compared with laminar airflow and turbulent mixed airflow
- 2018
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Ingår i: Journal of Hospital Infection. - : W B SAUNDERS CO LTD. - 0195-6701 .- 1532-2939. ; 98:2, s. 181-190
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Tidskriftsartikel (refereegranskat)abstract
- Aim: To evaluate three types of ventilation systems for operating rooms with respect to air cleanliness [in colony-forming units (cfu/m(3))], energy consumption and comfort of working environment (noise and draught) as reported by surgical team members. Methods: Two commonly used ventilation systems, vertical laminar airflow (LAF) and turbulent mixed airflow (TMA), were compared with a newly developed ventilation technique, temperature-controlled airflow (T(c)AF). The cfu concentrations were measured at three locations in an operating room during 45 orthopaedic procedures: close to the wound (<40 cm), at the instrument table and peripherally in the room. The operating team evaluated the comfort of the working environment by answering a questionnaire. Findings: LAF and T(c)AF, but not TMA, resulted in less than 10 cfu/m(3) at all measurement locations in the room during surgery. Median values of cfu/m(3) close to the wound (250 samples) were 0 for LAF, 1 for T(c)AF and 10 for TMA. Peripherally in the room, the cfu concentrations were lowest for T(c)AF. The cfu concentrations did not scale proportionally with airflow rates. Compared with LAF, the power consumption of T(c)AF was 28% lower and there was significantly less disturbance from noise and draught. Conclusion: T(c)AF and LAF remove bacteria more efficiently from the air than TMA, especially close to the wound and at the instrument table. Like LAF, the new T(c)AF ventilation system maintained very low levels of cfu in the air, but T(c)AF used substantially less energy and provided a more comfortable working environment than LAF. This enables energy savings with preserved air quality.
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| 7. |
- Blomgren, Per-Ola, et al.
(författare)
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Healthcare workers' perceptions and acceptance of an electronic reminder system for hand hygiene
- 2021
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Ingår i: Journal of Hospital Infection. - : Elsevier. - 0195-6701 .- 1532-2939. ; 108, s. 197-204
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Tidskriftsartikel (refereegranskat)abstract
- Background:Healthcare-associated infections (HCAIs) have a large negative impact onmorbidity, mortality, and quality of life. Approximately 9% of all patients hospitalized inSweden suffer from HCAI. Hand hygiene plays a key role and is considered the single mostimportant measure to reduce HCAI. The hospital organization works actively to reduceHCAI. Implementing electronic systems to remind and/or notify healthcare workers raisesawareness of and adherence to hand hygiene. However, there is a paucity of studiesaddressing individuals’ perceptions of having such a system and how the organizationworks.Aim:To investigate healthcare workers’ perceptions of infection prevention in thehealthcare organization and perceptions and acceptance of an electronic reminder systemthat encourages good hand hygiene.Methods:Qualitative descriptive design with data collected in eight focus group inter-views including assistant nurses, nurses, and physicians (N¼38). Content analysis wasapplied and data were related to the Theory of Planned Behaviour.Findings:Healthcare workers perceive lack of feedback from the hospital organizationand are positive towards an electronic reminder system to increase adherence to handhygiene. The electronic reminder system should not register data at an individual levelsince it could be used as an instrument for control by the management that could bestressful for staff.Conclusion:In general, there is positive acceptance of the electronic reminder system,and the respondents perceived it as having the ability to change behaviour. However, theconcept has to be further developed to protect the individual’s integrity and needs to beused with feedback on a group level
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| 8. |
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| 9. |
- Cardell, Kristina, 1964-, et al.
(författare)
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Nosocomial hepatitis C in a thoracic surgery unit; retrospective findings generating a prospective study
- 2008
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Ingår i: Journal of Hospital Infection. - : Elsevier BV. - 0195-6701 .- 1532-2939. ; 68:4, s. 322-328
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Tidskriftsartikel (refereegranskat)abstract
- We describe the transmission of hepatitis C virus (HCV) to two patients from a thoracic surgeon who was unaware of his hepatitis C infection. By partial sequencing of the non-structural 5B gene and phylogenetic analysis, the viruses from both patients were found to be closely related to genotype la strain from the surgeon. Two further hepatitis C cases were found in relation to the thoracic clinic. Their HCV sequences were related to each other but were of genotype 2b and the source of infection was never revealed. To elucidate the magnitude of the problem, we conducted a prospective study for a period of 17 months in which patients who were about to undergo thoracic surgery were asked to participate. Blood samples were drawn prior to surgery and at least four months later. The postoperative samples were then screened for anti-HCV and, if positive, the initial sample was also analysed. The only two patients (0.4%) identified were confirmed anti-HCV positive before surgery, and none out of 456 evaluable cases seroconverted to anti-HCV during the observation period. Despite the retrospectively identified cases, nosocomial hepatitis C is rare in our thoracic unit. The study points out the risk of transmission of hepatitis C from infected personnel and reiterates the need for universal precautions.
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| 10. |
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| 11. |
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| 12. |
- Dannetun, E., et al.
(författare)
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Coverage of hepatitis B vaccination in Swedish healthcare workers
- 2006
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Ingår i: Journal of Hospital Infection. - : Elsevier BV. - 0195-6701 .- 1532-2939. ; 63:2, s. 201-204
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Tidskriftsartikel (refereegranskat)abstract
- The aim of this study was to assess how well the guidelines on vaccination against hepatitis B had been implemented among healthcare workers (HCWs) at risk for blood exposure. A point-prevalence survey was conducted in six departments of a university hospital in Sweden: the emergency room, intensive care unit, postoperative unit, surgical theatre, department of anaesthesiology and the laboratory for blood chemistry. All HCWs who worked in these departments during the 24 h of the survey were asked to complete a questionnaire. In total, 369 questionnaires were analysed. Seventy-nine percent (293/369) of HCWs had received at least one dose of vaccine, but only 40% (147/369) reported that they were fully vaccinated and 21% (76/369) had not been vaccinated at all. The majority of unvaccinated HCWs (72/76, 95%) stated that they would accept vaccination if offered. The main barrier to better compliance with the guidelines is not lack of acceptance among the employees but the failure of the employer to ensure that policies are implemented. © 2006 The Hospital Infection Society.
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| 13. |
- Darelid, Johan, 1950-, et al.
(författare)
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Control of nosocomial Legionnaires' disease by keeping the circulating hot water temperature above 55°C : experience from a 10-year surveillance programme in a district general hospital
- 2002
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Ingår i: Journal of Hospital Infection. - : Elsevier BV. - 0195-6701 .- 1532-2939. ; 50:3, s. 213-219
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Tidskriftsartikel (refereegranskat)abstract
- After a nosocomial outbreak of Legionnaires' disease in a 450-bed district general hospital in 1991, the circulating hot water temperature was kept above 55°C as the sole control measure. From 1991 to 2000, all cases of nosocomial pneumonia were clinically monitored and tested for Legionella pneumophila serogroup 1 by serology or urinary antigen detection. Water samples from peripheral tap sites were cultured for Legionella spp. twice a year. An infection with L. pneumophila serogroup 1 was diagnosed in four out of 366 (1.1%) patients treated for nosocomial pneumonia, representing one case per 26 000 admissions. All patients were cured without complications. L. pneumophila serogroup 1 was isolated in 30 of 251 (12%) cultured hospital water samples during the monitoring period. We conclude that control of nosocomial Legionnaires' disease in a primary referral hospital is possible by keeping the circulating hospital hot water temperature above 55°C, together with careful clinical surveillance. Complete eradication of Legionella spp. from the hot water system does not seem necessary.
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| 14. |
- Edner, Ann, et al.
(författare)
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Low risk of transmission of pathogenic bacteria between children and the assistance dog during animal-assisted if strict rules are followed
- 2021
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Ingår i: Journal of Hospital Infection. - : Elsevier. - 0195-6701 .- 1532-2939. ; 115, s. 5-9
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Tidskriftsartikel (refereegranskat)abstract
- This study explored the bacterial transmission between patients and dogs during dog assisted therapy (DAT). Twenty children (55% girls) with a median age of 7 years (range 3-17 years) were included. Two dogs assisted and the conditions were more restricted hygienically with dog 2. Samples from child and dog were collected and cultured before and after each DAT visit. The results showed that dog 1 transmitted bacteria repeatedly to the children. No bacteria were transmitted with dog 2. In conclusion, exchange of bacteria can occur between dog and child during DAT, but it can be reduced by simple infection control measures. (c) 2021 Published by Elsevier Ltd on behalf of The Healthcare Infection Society.
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| 15. |
- Falk-Brynhildsen, Karin, 1959-, et al.
(författare)
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Bacterial recolonization of the skin and wound contamination during cardiac surgery : a randomized controlled trial of the use of plastic adhesive drape compared with bare skin
- 2013
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Ingår i: Journal of Hospital Infection. - London, United Kingdom : Saunders Elsevier. - 0195-6701 .- 1532-2939. ; 84:2, s. 151-158
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Tidskriftsartikel (refereegranskat)abstract
- Background: Sternal wound infection after cardiac surgery is a serious complication. Various perioperative strategies, including plastic adhesive drapes, are used to reduce bacterial contamination of surgical wounds.Aim: To compare plastic adhesive drape to bare skin regarding bacterial growth in wound and time to recolonization of the adjacent skin intraoperatively, in cardiac surgery patients.Methods: This single-blinded randomized controlled trial (May 2010 to May 2011) included 140 patients scheduled for cardiac surgery via median sternotomy. The patients were randomly allocated to the adhesive drape (chest covered with plastic adhesive drape) or bare skin group. Bacterial samples were taken preoperatively and intraoperatively every hour during surgery until skin closure.Results: Disinfection with 0.5% chlorhexidine solution in 70% alcohol decreased coagulase-negative staphylococci (CoNS), while the proportion colonized with Propionibacterium acnes was not significantly reduced and was still present in more than 50% of skin samples. P. acnes was significantly more common in men than in women. Progressive bacterial recolonization of the skin occurred within 2-3 h. At 120 min there were significantly more positive cultures in the adhesive drape group versus bare skin group for P. acnes (63% vs 44%; P = 0.034) and for CoNS (45% vs 24%; P = 0.013). The only statistically significant difference in bacterial growth in the surgical wound was higher proportion of CoNS at the end of surgery in the adhesive drape group (14.7% vs 4.4%; P = 0.044).Conclusion: Plastic adhesive drape does not reduce bacterial recolonization. P. acnes colonized men more frequently, and was not decreased by disinfection with chlorhexidine solution in alcohol.
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| 16. |
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| 17. |
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| 18. |
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| 19. |
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| 20. |
- Grevskott, D. H., et al.
(författare)
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Emergence and dissemination of epidemic-causing OXA-244 carbapenemase-producing Escherichia coli ST38 through hospital sewage in Norway, 2020-2022
- 2024
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Ingår i: JOURNAL OF HOSPITAL INFECTION. - 0195-6701 .- 1532-2939. ; 145, s. 165-173
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Tidskriftsartikel (refereegranskat)abstract
- Background: Population -based sewage surveillance has emerged as a promising approach for studying the prevalence of antibiotic resistance in pathogens. Aim: To determine the temporal prevalence of cefotaxime-resistant Escherichia coli in sewage from five sewage treatment plants located in Bergen city, to determine whether ESBL- and carbapenemase-producing E. coli are consistently disseminated in the receiving environment through sewage. Method: A total of 569 cefotaxime-resistant E. coli were isolated over a period of 19 months (August 2020 to February 2022) using ECC CHROMagarTM plates from 82 samples, antibiotic sensitivity profiles were determined, using SensititreTM plates. The draft genome sequences were determined, using Illumina MiSeq-based sequencing. Complete genome sequences were determined, using Oxford Nanopore-based sequencing. Findings: All 569 strains obtained from influent (N1/4461) and effluent (N1/4108) were multidrug resistant. Most of the sequenced strains (52 of 61) carried blaCTX-M-15 (38.5%) and blaCTX-M-27 (34.6%). The most prevalent sequence types (STs) for ESBL-carrying strains were ST131 (32.8%) and ST38 (21.3%). All CTX-M-27-carrying ST131 strains belonged to clade A or C1, while CTX-M-15-harbouring strains were present in all the clades. Five OXA-244producing ST38 strains, genetically similar to epidemic -causing strains from Western Norway, France and the Netherlands, were isolated only from raw and treated sewage of the treatment plant receiving hospital sewage.
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| 21. |
- Gustavsson, Lars, et al.
(författare)
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Excess mortality following community-onset norovirus enteritis in the elderly.
- 2011
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Ingår i: The Journal of hospital infection. - : Elsevier BV. - 1532-2939 .- 0195-6701. ; 79:1, s. 27-31
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Tidskriftsartikel (refereegranskat)abstract
- Norovirus has been associated with excess deaths. A retrospective study of mortality following norovirus enteritis (NVE) was undertaken. All hospitalized adult patients with a stool sample positive for norovirus genogroup II on polymerase chain reaction, treated at Sahlgrenska University Hospital, Gothenburg, Sweden between August 2008 and June 2009, were included as cases (N=598, aged 18-101 years). Matched controls without enteritis (N=1196) were selected for comparison. Medical records were reviewed and deaths up to 90 days following positive sampling were noted, as well as comorbidities and length of hospital stay. Thirty- and 90-day survival rates were calculated. Total 30-day mortality was 7.6% and no deaths were recorded in cases aged 18-59 years. Thirty-day mortality was higher in cases with underlying medical conditions compared with those without these comorbidities (age 60-101 years: 89.5% vs 94.7% alive at Day 30, respectively; P<0.05). In cases aged >80 years, mortality was higher in those with community-onset NVE (N=64) compared with hospital-onset NVE (N=305) (81.2% vs 90.2% alive at Day 30, respectively; P<0.05), and compared with controls (N=128) (81.2% vs 91.4% alive at Day 30, respectively; P<0.05). Median length of hospital stay was 20 [interquartile range (IQR) 12-29] days for cases with hospital-onset NVE, and seven (IQR 2-13) days for controls (P<0.001). In conclusion, community-onset NVE requiring hospitalization was associated with higher mortality compared with hospital-onset NVE and matched controls in hospitalized elderly patients.
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| 22. |
- Hammarskjold, F., et al.
(författare)
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Possible transmission of Candida albicans on an intensive care unit: genotype and temporal cluster analyses
- 2013
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Ingår i: Journal of Hospital Infection. - : Elsevier BV. - 0195-6701 .- 1532-2939. ; 85:1, s. 60-65
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Tidskriftsartikel (refereegranskat)abstract
- Background: Nosocomial transmission of Candida spp. has not been fully explored and previous studies have shown conflicting results. Aim: To evaluate the possible nosocomial transmission of Candida spp. on an intensive care unit (ICU). Methods: A prospective study was conducted for a period of 19 months, including all patients on our ICU with growth of Candida spp. from surveillance and directed cultures. Molecular typing with repetitive sequence-based polymerase chain reaction was used to define genotype relationships between the Candida albicans and Candida glabrata isolates. Candida isolates obtained from blood cultures taken from patients in our county outside the ICU were used as a reference. Temporal cluster analysis was performed to evaluate genotype distribution over time. Findings: Seventy-seven patients with 78 ICU stays, representing 12% of all ICU stays, were found to harbour 180 isolates of Candida spp. Molecular typing revealed 27 C. albicans genotypes and 10 of C. glabrata. Possible clustering, indicated by overlapping stays of patients with indistinguishable candida genotypes, was observed on seven occasions with C. albicans and on two occasions with C. glabrata. Two C. albicans genotypes were found significantly more often in the ICU group compared with the reference group. Moreover, C. albicans genotypes isolated from more than one patient were significantly more often found in the ICU group. Temporal cluster analysis revealed a significantly increased number of pairs with indistinguishable genotypes at a 21-day interval, indicating clustering. Conclusion: This study indicates possible transmission of C. albicans between ICU patients based on genotyping and temporal cluster analysis.
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| 23. |
- Hammarskjöld, Fredrik, et al.
(författare)
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Low incidence of arterial catheter infections in a Swedish intensive care unit: risk factors for colonisation and infection
- 2010
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Ingår i: Journal of Hospital Infection. - : Elsevier BV. - 0195-6701 .- 1532-2939. ; 76:2, s. 130-134
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Tidskriftsartikel (refereegranskat)abstract
- There is growing concern that arterial catheters (ACs) cause catheter-related infections (CRIs). Limited data are available concerning risk factors for AC-CRI and there are no studies concerning incidence and micro-organisms from northern Europe. The aims of this study were to determine the incidence of, and micro-organisms responsible for, AC colonisation and AC-CRI in a Swedish intensive care unit (ICU), and to determine risk factors contributing to AC colonisation and AC-CRI. We prospectively studied all patients (N=539) receiving ACs (N=691) in a mixed ICU of a county hospital. Six hundred (87%) of all ACs were assessed completely. The total catheterisation time for 482 patients was 2567 days. The incidence of positive tip culture was 7.8 per 1000 catheter-days, with the predominant micro-organism being coagulase-negative staphylococci (CoNS). The incidence of AC-CRI was 2.0 per 1000 catheter-days (with no cases of bacteraemia). All AC-CRIs were caused by CoNS. Multivariate analysis revealed that immunosuppression, central venous catheter (CVC) colonisation and CVC infection were significant risk factors for AC-CRI. We conclude that AC colonisation and infection with systemic symptoms occur at a low rate in our ICU which supports our practice of basic hygiene routines for the prevention of AC-CRI. Colonisation and infection of a simultaneous CVC seem to be risk factors. The role of contemporaneous colonisation and infection of multiple bloodstream catheters has received little attention previously. Further studies are needed to verify the significance of this finding.
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| 24. |
- Hanberger, Håkan, 1954-, et al.
(författare)
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Surveillance of antibiotic resistance in European ICUs
- 2001
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Ingår i: Journal of Hospital Infection. - : Elsevier BV. - 0195-6701 .- 1532-2939. ; 48:3, s. 161-176
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Tidskriftsartikel (refereegranskat)abstract
- Antibiotic resistance among bacteria causing hospital-acquired infections poses a threat, particularly to patients in intensive care units (ICUs). In order to control the spread of resistant bacteria, local, regional and national resistance surveillance data must be used to develop efficient intervention strategies. In an attempt to identify national differences and the dynamics of antibiotic resistance in European ICUs, data have been merged from several networks of resistance surveillance performed during the 1990s. It should be stressed, however, that comparisons of results from different studies using different methods and different population samples must be made with caution. Antibiotic resistance across all species and drugs was, with some exceptions, highest in southern European countries and Russia, and lowest in Scandinavia. More effective strategies are needed to control the selection and spread of resistant organisms. Antibiotic intervention policies, efficient infection control measures and an overall awareness of the serious implications at public health level will contribute to the management of antibiotic resistance.
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| 25. |
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| 26. |
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| 27. |
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| 28. |
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| 29. |
- Knape, L., et al.
(författare)
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The adenosine triphosphate method as a quality control tool to assess 'cleanliness' of frequently touched hospital surfaces
- 2015
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Ingår i: Journal of Hospital Infection. - : Elsevier BV. - 0195-6701 .- 1532-2939. ; 91:2, s. 166-170
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Tidskriftsartikel (refereegranskat)abstract
- Background: The adenosine triphosphate (ATP) method is widely accepted as a quality control method to complement visual assessment, in the specifications of requirements, when purchasing cleaning contractors in Swedish hospitals. Aim: To examine whether the amount of biological load, as measured by ATP on frequently touched near-patient surfaces, had been reduced after an intervention; to evaluate the correlation between visual assessment and ATP levels on the same surfaces; to identify aspects of the performance of the ATP method as a tool in evaluating hospital cleanliness. Methods: A prospective intervention study in three phases was carried out in a medical ward and an intensive care unit (ICU) at a regional hospital in mid-Sweden between 2012 and 2013. Existing cleaning procedures were defined and baseline tests were sampled by visual inspection and ATP measurements of ten frequently touched surfaces in patients' rooms before and after intervention. The intervention consisted of educating nursing staff about the importance of hospital cleaning and direct feedback of ATP levels before and after cleaning. Findings: The mixed model showed a significant decrease in ATP levels after the intervention (P < 0.001). Relative light unit values were lower in the ICU. Cleanliness as judged by visual assessments improved. In the logistic regression analysis, there was a significant association between visual assessments and ATP levels. Conclusion: Direct feedback of ATP levels, together with education and introduction of written cleaning protocols, were effective tools to improve cleanliness. Visual assessment correlated with the level of ATP but the correlation was not absolute. The ATP method could serve as an educational tool for staff, but is not enough to assess hospital cleanliness in general as only a limited part of a large area is covered.
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| 30. |
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| 31. |
- Labeau, S., et al.
(författare)
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Evidence-based guidelines for the prevention of ventilator-associated pneumonia : results of a knowledge test among European intensive care nurses
- 2008
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Ingår i: Journal of Hospital Infection. - : Elsevier BV. - 0195-6701 .- 1532-2939. ; 70:2, s. 180-185
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Tidskriftsartikel (refereegranskat)abstract
- As part of a needs analysis preceding the development of an e-learning platform on infection prevention, European intensive care unit (ICU) nurses were subjected to a knowledge test on evidence-based guidelines for preventing ventilator-associated pneumonia (VAP). A validated multiple-choice questionnaire was distributed to 22 European countries between October 2006 and March 2007. Demographics included nationality, gender, ICU experience, number of ICU beds and acquisition of a specialised degree in intensive care. We collected 3329 questionnaires (response rate 69.1%). The average score was 45.1%. Fifty-five percent of respondents knew that the oral route is recommended for intubation; 35% knew that ventilator circuits should be changed for each new patient; 38% knew that heat and moisture exchangers were the recommended humidifier type, but only 21% knew that these should be changed once weekly; closed suctioning systems were recommended by 46%, and 18% knew that these must be changed for each new patient only; 51% and 57%, respectively, recognised that subglottic drainage and kinetic beds reduce VAP incidence. Most (85%) knew that semi-recumbent positioning prevents VAP. Professional seniority and number of ICU beds were shown to be independently associated with better test scores. Further research may determine whether low scores are related to a lack of knowledge, deficiencies in training, differences in what is regarded as good practice, and/or a lack of consistent policy.
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| 32. |
- Lindberg, Magnus, et al.
(författare)
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Risk behaviours for organism transmission in daily care activities : a longitudinal observational case study
- 2018
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Ingår i: Journal of Hospital Infection. - : Elsevier BV. - 0195-6701 .- 1532-2939. ; 100:3, s. e146-e150
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: To understand healthcare personnel's infection prevention behaviour has long been viewed as a key factor in preventing healthcare-associated infections. Suboptimal hand hygiene compliance and handling of materials, equipment and surfaces present the main risks for potential organism transmission. Further exploration is needed regarding the role of context-specific conditions and the infection prevention behaviours of healthcare personnel. Such knowledge could enable the development of new intervention strategies for modifying behaviour.AIM: To describe risk behaviours for organism transmission in daily care activities over time.METHODS: Unstructured observations of healthcare personnel carrying out patient related activities were performed on 12 occasions over a period of 18 months.FINDINGS: Risk behaviours for organism transmission occur frequently in daily care activities and the results shows that the occurrence is somewhat stable over time. Interruptions in care activities contribute to an increased risk for organism transmission that could lead to subsequent healthcare-associated infection.CONCLUSION: Interventions aimed at reducing the risks of healthcare-associated infections need to focus on strategies that address: hand hygiene compliance; the handling of materials, equipment, work clothes and surfaces; as well as the effects of interruptions in care activities if they are to alter healthcare personnel's infection prevention behaviour sufficiently.
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| 33. |
- Lindberg, Maria, et al.
(författare)
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Suffering from meticillin-resistant Staphylococcus aureus : experiences and understandings of colonisation
- 2009
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Ingår i: Journal of Hospital Infection. - : Elsevier BV. - 0195-6701 .- 1532-2939. ; 73:3, s. 271-277
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Tidskriftsartikel (refereegranskat)abstract
- The objective was to explore individuals' experiences and understandings of meticillin-resistant Staphylococcus aureus (MRSA) colonisation. Thirteen interviews were performed and processed using content analysis, resulting in the theme 'Invaded, insecure and alone'. The participants experienced fears and limitations in everyday life and expressed a need to protect others from contagion. Moreover, they experienced encounters with, and information from, healthcare workers differently: some were content, whereas others were discontent. The described fears, limitations and inadequate professional-patient relationship generated unacceptable distress for MRSA-colonised persons. Thus, the healthcare sector should assume responsibility for managing MRSA, and healthcare workers must improve their professionalism and information skills, so as to better meet MRSA-colonised persons' needs.
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| 34. |
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| 35. |
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| 36. |
- Lytsy, Birgitta, 1968-, et al.
(författare)
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Evaluating the effect of Novarerus NV800 air purifier units during orthopaedic surgery to reduce bioburden in the air
- 2022
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Ingår i: Journal of Hospital Infection. - : Elsevier BV. - 0195-6701 .- 1532-2939. ; 130, s. 108-111
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Tidskriftsartikel (refereegranskat)abstract
- Background: A locally installed air purifier unit (Novaerus Protect 800) has been shown to reduce the air bioburden in an intensive care unit and the incidence of healthcare-associated infections. Aim: To explore whether this type of air purifying unit could reduce bacterial concentrations in the air of an operating room (OR) during orthopaedic surgery, thereby reducing the risk of surgical site infections. Methods: In this prospective experimental study, undertaken in 2018, three air purifying units were installed in an OR in a Swedish hospital in 2018. The air was actively sampled during 11 operations by a slit-to-slit agar impactor with the air purifying units either switched on or switched off. Air movements were visualized with the aid of smoke in mock-up studies. Findings: No significant difference in bacterial concentrations in air was found between the two conditions (air purifying units switched off or on) (P=0.54). Air movements around and above the surgical wound were disordered and resembled those of dilution mixing air. Conclusion: The three air purifying units installed in the OR did not reduce the airborne bacterial levels in the critical zone during orthopaedic surgery.
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| 37. |
- Lytsy, Birgitta, 1968-, et al.
(författare)
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Hygienic interventions to decrease deep sternal wound infections following coronary artery bypass grafting
- 2015
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Ingår i: Journal of Hospital Infection. - : Elsevier BV. - 0195-6701 .- 1532-2939. ; 91:4, s. 326-331
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: The department of Cardiothoracic Surgery at Uppsala University Hospital has 25 beds in one to four patient rooms and an operating suite consisting of five operating rooms with ultraclean air. Around 700 open heart (250 isolated coronary artery bypass grafting, CABG) operations are performed annually. In 2009, the numbers of deep sternal wound infections (DSWIs) increased to unacceptable rates despite existing hygienic guidelines.AIM: To show how root cause analysis (RCA) followed by quality improvement interventions reduced the rate of DSWI after CABG surgery.METHODS: Only isolated CABG patients requiring surgical revision due to DSWI were included. Swabs and tissue biopsies were taken during surgical revision and analysed with standard methods. DSWIs were registered prospectively according to US Centers for Disease Control and Prevention definitions. RCA for infection was performed between September 2009 and April 2010. Interventions based on results of the RCA and on nationally recommended practices were concluded in April 2010, and thought to have taken full effect by July 1st, 2010. Air was actively sampled at ≤0.5m from the sternal incision.FINDINGS: DSWI incidence rates per CABG operations decreased from 5.1% pre intervention to 0.9% post intervention. Wound cultures pre intervention grew Staphylococcus aureus 27.1% and coagulase negative staphylococcus (CoNS) 47.1%, post intervention S. aureus 23.1% and CoNS 30.8%. Air counts did not exceed 5cfu/m(3).CONCLUSION: When the aetiology of an error is multifactorial, RCA engaging both the medical professions and the infection control team is a potential tool to map causes leading to adverse events such as healthcare-associated infections. A systematic quality improvement intervention based on the RCA may reduce the number of deep sternal wound infections after CABG surgery.
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| 38. |
- Lytsy, Birgitta, 1968-, et al.
(författare)
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Source strength as a measurement to define the ability of clean air suits to reduce airborne contamination in operating rooms
- 2022
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Ingår i: Journal of Hospital Infection. - : Elsevier BV. - 0195-6701 .- 1532-2939. ; 119, s. 9-15
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Tidskriftsartikel (refereegranskat)abstract
- Background: Surgical site infections after total hip and knee replacement are linked to the quality of the operating room (OR) air. Applying tight occlusive clothing, effective ventilation and correct working methods are key concepts to obtain low bacterial concentrations in the OR air. The dry penetration test referred to in European standard EN 13795-2:2019 is a screening method for materials used in surgical clothing. Source strength, defined as the dispersal of bacteria-carrying particles from persons during activity, is a functional test of clothing systems and has been calculated in a dispersal chamber and in ORs. Results from both tests can be used when comparing surgical clothing systems. Aim: This study relates results of dry penetration tests to source strength values for five surgical clothing systems available on the Swedish market. Methods: Experimental data are reported on the function of these products, expressed as source strength calculated from results in a dispersal chamber and in ORs during orthopaedic operations. Findings: All materials tested with dry penetration ≤50 colony-forming units (cfu) had source strength values <3 cfu/s for one person in the dispersal chamber, whereas the material of one product when laundered >50 times had source strength in the dispersal chamber of up to 8 cfu/s. Conclusion: The dry penetration test could predict the performance of clean air suits of the same design, but more studies are needed to obtain a more valid correlation. Requirements of source strength should be included in standards.
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| 39. |
- Nilsson, Kjell G, et al.
(författare)
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Assessment of horizontal laminar air flow instrument table for additional ultraclean space during surgery
- 2010
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Ingår i: Journal of Hospital Infection. - : Elsevier. - 0195-6701 .- 1532-2939. ; 76:3, s. 243-246
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Tidskriftsartikel (refereegranskat)abstract
- The area in a vertical ultraclean laminar air flow (LAF) theatre is usually too small to accommodate all the equipment needed for major surgery. We investigated the addition of an instrument table supplied with fixed ultraclean LAF and placed alongside the existing main LAF unit, to determine its physical and bacteriological effect on the main unit. In phase 1, with two investigators but without a patient, smoke tests showed no intrusion of air from the table into the main unit and particle counts did not show any adverse effect on the main LAF unit. In phase 2, during patients undergoing two total knee replacements, the LAF table and a table without LAF were placed alongside the main LAF unit. The tables were subjected to the activity of an extra operating room (OR) nurse working from inside the main LAF vigorously simulating handling of instruments. During this activity, the >5 μm particle counts were 275/m3 at the instrument table with LAF and 8550/m3 at the table without LAF (P < 0.0001). Also, without the OR nurse activity, the particle counts, just inside the main unit and adjacent to the LAF table, were significantly reduced (P < 0.03–0.003). Sedimentation plates on the LAF table and in the main unit registered 22 and 25 cfu/m2/h respectively compared with 45 cfu/m2/h at the instrument table without LAF. In conclusion, the results from the smoke tests, particle counts and bacteriological evaluation showed that the additional instrument table supplied with LAF is efficient and can be safely used as an extension additional to a main OR LAF unit.
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| 40. |
- Olofsson, Magnus, et al.
(författare)
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Differences in molecular epidemiology of Staphylococcus aureus and Escherichia coli in nursing home residents and people in unassisted living situations
- 2019
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Ingår i: Journal of Hospital Infection. - : W B SAUNDERS CO LTD. - 0195-6701 .- 1532-2939. ; 101:1, s. 76-83
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Tidskriftsartikel (refereegranskat)abstract
- Background: The usefulness of colonization pressure as a working model and proxy for infection transmission is limited due to the inability to grade or quantify the specific risk within environments that are subject to change. Aim: To elaborate on the colonization pressure model by comparing the molecular epidemiology of two bacteria, Staphylococcus aureus and Escherichia coli, among residents in a nursing home and people in unassisted living situations. Methods: A cross-sectional study of 73 elderly residents from a village in south-central Sweden was conducted. Of these, 35 were residents of a nursing home, and 34 lived in an own place of residence in the same geographical area. Samples of two representative bacterial species were collected from multiple body sites and analysed for molecular diversity. Findings: Combining all body sites, 47% of the participants were colonized with S. aureus and 93% with E. coli. The nursing home group, the group in unassisted living situations, and both units combined, held 16, 17, and 29 different S. aureus spa types, respectively. The corresponding numbers of different E. coli serogenotypes were 34, 28, and 48. Diabetes mellitus was associated with more frequent colonization with S. aureus. Conclusion: The molecular diversity of bacteria found within different forms of accommodation was within the same range. Hospital quality hygiene might have contributed to the absence of homogenization of the molecular diversity within the nursing home group. Diabetes mellitus might have played a role in a patient selection characterized by advanced age. (C) 2018 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
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| 41. |
- Ransjö, Ulrika, et al.
(författare)
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Hospital outbreak control requires joint efforts from hospital management, microbiology and infection control
- 2010
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Ingår i: Journal of Hospital Infection. - Amsterdam : Elsevier. - 0195-6701 .- 1532-2939. ; 76:1, s. 26-31
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Tidskriftsartikel (refereegranskat)abstract
- An outbreak of multidrug-resistant Klebsiella pneumoniae producing the extended-spectrum beta-lactamase CTX-M-15 affected 247 mainly elderly patients in more than 30 wards in a 1000-bedded Swedish teaching hospital between May 2005 and August 2007. A manual search of the hospital administrative records for possible contacts between cases in wards and outpatient settings revealed a complex chain of transmission. Faecal screening identified twice as many cases as cultures from clinical samples. Transmission occurred by direct and indirect patient-to-patient contact, facilitated by patient overcrowding. Interventions included formation of a steering group with economic power, increased bed numbers, better compliance with alcohol hand disinfection and hospital dress code, better hand hygiene for patients and improved cleaning. The cost of the interventions was estimated to be €3 million. Special infection control policies were not necessary, but resources were needed to make existing policies possible to follow, and for educational efforts to improve compliance.
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| 42. |
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| 43. |
- Samuelsson, Annika, 1964-, et al.
(författare)
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Late onset neonatal sepsis, risk factors and interventions: an analysis of recurrent outbreaks of Serratia marcescens 2006-2011
- 2014
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Ingår i: Journal of Hospital Infection. - : Elsevier. - 0195-6701 .- 1532-2939. ; 86:1, s. 57-63
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Tidskriftsartikel (refereegranskat)abstract
- Background: during the period 2006 to 2011 we observed 11 patients with Serratia marcescens sepsis, a total of 47 patients were colonised due to spread of different clones. These recurrent clusters brought about interventions to reduce spread between patients.Aim: to evaluate the effect of stepwise introduced interventions to prevent S marcescens colonisation/sepsis and to analyse risk factors for late onset sepsis (LOS).Methods: to evaluate the interventions an open retrospective observational study was performed. A retrospective case-control study was performed to analyse risk factors for LOS.Findings: main findings of this study were the decrease in S marcescens sepsis and colonisation after the stepwise adoption of hygiene interventions, as well as identifying low gestational age, low birth weight, indwelling central venous or umbilical catheter and ventilator treatment as risk factors for LOS. Compliance to basic hygiene guidelines was the only intervention continuously monitored from late 2007. Compliance increased gradually to a steady high level early 2009. There was a decrease in LOS with S marcescens (LOS-Ser) clustering after the second quarter of 2008. After the first quarter of 2009 we saw a decrease in S marcescens colonisation.Conclusion: We were not able to isolate specific effects of each intervention, but an update of our antibiotic policy probably had effect on the occurrence of LOS-ser. The delayed effect of interventions on S marcescens colonisation was probably due to the time it takes for new routines to have impact, illustrated by the gradual increase in compliance to basic hygiene guidelines.
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| 44. |
- Sandström, Nadia, 1995-, et al.
(författare)
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The presence of skin bacteria in the sternal wound and contamination of implantation materials during cardiac surgery
- 2023
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Ingår i: Journal of Hospital Infection. - : Academic Press. - 0195-6701 .- 1532-2939. ; 135, s. 145-151
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Sternal wound infections (SWI) and aortic graft infections (AGI) are serious complications after cardiac surgery. Staphylococcus aureus and coagulase-negative staphylococci are the most common causes of SWI, while AGI are less studied. AGI may occur from contamination during surgery or postoperative haematogenous spread. Skin commensals, such as Cutibacterium acnes, are present in the surgical wound; however, their ability to cause infection is debated.AIM: The aim of this study was to investigate the presence of skin bacteria in the sternal wound and to evaluate their possible ability to contaminate surgical materials.METHODS: We included 50 patients that underwent coronary artery bypass graft surgery and/or valve replacement surgery at our centre from 2020 to 2021. Cultures were collected from skin and subcutaneous tissue at two time points during surgery, and from pieces of vascular graft and felt that were pressed against subcutaneous tissue. The most common bacterial isolates were tested for antibiotic susceptibility with disk diffusion and gradient tests.FINDINGS: Cultures from skin had bacterial growth in 48% of patients at surgery start and in 78% after two hours, and cultures from subcutaneous tissue were positive in 72% and 76% of patients, respectively. The most common isolates were C. acnes and S. epidermidis. Cultures from surgical materials were positive in 80-88%. No difference in susceptibility was found for S. epidermidis isolates at surgery start compared to after two hours.CONCLUSIONS: The results suggest that skin bacteria are present in the wound and may contaminate surgical graft material during cardiac surgery.
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| 45. |
- Schönning, Caroline, et al.
(författare)
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Legionellosis acquired through a dental unit : a case study
- 2017
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Ingår i: Journal of Hospital Infection. - : Elsevier BV. - 0195-6701 .- 1532-2939. ; 96:1, s. 89-92
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Tidskriftsartikel (refereegranskat)abstract
- In 2012, an elderly immunocompromised man died from legionellosis at a hospital in Uppsala, Sweden. The patient had visited a dental ward at the hospital during the incubation period. Legionella spp. at a concentration of 2000 colony-forming units/L were isolated from the cupfiller outlet providing water for oral rinsing. Isolates from the patient and the dental unit were Legionella pneumophila serogroup 1, subgroup Knoxville and ST9. Pulsed-field gel electrophoresis and whole-genome sequencing strongly suggested that the isolates were of common origin. This report presents one of few documented cases of legionellosis acquired through a dental unit.
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| 46. |
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| 47. |
- Sendi, P, et al.
(författare)
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Group B streptococcus in prosthetic hip and knee joint-associated infections
- 2011
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Ingår i: Journal of Hospital Infection. - : Saunders Elsevier. - 0195-6701 .- 1532-2939. ; 79:1, s. 64-69
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Tidskriftsartikel (refereegranskat)abstract
- The incidence of invasive group B streptococcus (GBS) infections in non-pregnant adults is increasing. Little is known about GBS in periprosthetic joint infections (PJIs). We aimed to analyse the clinical presentation of GBS PJI and its treatment in association with the outcome. The characteristics of 36 GBS PJIs collected from 10 centres were investigated. In 34 episodes, follow-up examination of ≥ 2 years was available, allowing treatment and outcome analysis. Most infections (75%) occurred ≥ 3 months after implantation. Most patients (91%) had at least one comorbidity; 69% presented with acute symptoms and 83% with damaged periprosthetic soft tissue. In 20 of 34 episodes debridement and retention of implant was attempted, but in five of these the prosthesis was ultimately removed. Hence, in 19 (56%) episodes, the implant was removed, including 14 immediate removals. In four episodes the removal was permanent. Penicillin derivatives and clindamycin were the most common antimicrobials administered (68%). In 94% the infection was cured, and in 82% functional mobility preserved. Debridement with implant retention was successful if the duration of symptoms was short, the prosthesis stable, and the tissue damage minor (10/10 vs 3/10 episodes, P = 0.003). Surgery that complied with a published algorithm was associated with a favourable outcome (P = 0.049).
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| 48. |
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| 49. |
- Smolle, C, et al.
(författare)
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Effectiveness of automated ultraviolet-C light for decontamination of textiles inoculated with Enterococcus faecium.
- 2018
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Ingår i: Journal of Hospital Infection. - : Elsevier BV. - 0195-6701 .- 1532-2939. ; 98:1, s. 102-104
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Tidskriftsartikel (refereegranskat)abstract
- Healthcare textiles are increasingly recognized as potential vehicles for transmission of hospital-acquired infections. This study tested the ability of an automated ultraviolet-C (UV-C) room disinfection device (Tru-D Smart UV-C) to decontaminate textiles inoculated with Enterococcus faecium in a clinical setting. Contaminated polycotton (50/50 polyester/cotton) swatches were distributed to predefined locations in a ward room and exposed to UV-C light. UV-C decontamination reduced E. faecium counts by a mean log10 reduction factor of 1.37 (all P = 0.005, Wilcoxon signed rank test). UV-C decontamination may be a feasible adjunctive measure to conventional laundering to preserve the cleanliness of healthcare textiles in ward rooms.
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| 50. |
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