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- Lindqvist, Maria, 1983-
(author)
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Epidemiological and molecular biological studies of multi-resistant methicillin-susceptible Staphylococcus aureus
- 2014
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Doctoral thesis (other academic/artistic)abstract
- Antibiotic resistance is increasingly recognised as a major problem and threat. During the last decades Gram-positive bacteria in general, and methicillin-resistant Staphylococcus aureus (MRSA) in particular, have been in focus both concerning matters of antibiotic resistance and as pathogens causing health care-associated (nosocomial) infections. In contrast to MRSA, studies on clonal distribution of methicillin-susceptible S. aureus (MSSA) are scarce. However, interest in MSSA has increased since it was shown that MRSA emerges from susceptible backgrounds by acquisition of a staphylococcal cassette chromosome element, carrying the mecA gene encoding methicillin-resistance (SCCmec).In an outbreak investigation of MRSA in Östergötland County, Sweden, in 2005, a high incidence of MSSA isolates with concomitant resistance to erythromycin, clindamycin and tobramycin (ECT-R) was detected. Analysis showed that 91 % of the investigated isolates were genetically related (clonal). The ECT-R clone was divided into four different but closely related patterns with pulsed-field gel electrophoresis (PFGE), and was designated spa type t002. Whole genome sequencing revealed that the ECT-R clone carried a pseudo-SCC element estimated to be 12 kb in size, showing a resemblance of more than 99 % with the SCCmec type II element of MRSA strain N315 (New York/Japan clone). This suggested a probable derivation from a highly successful MRSA strain, which had partially excised its SCCmec. The clonal outbreak was concentrated in eight hospital departments and two primary care centres, all located in the city of Linköping. Despite a high exchange of patients with the hospitals in the neighbouring counties in southeast Sweden (Jönköping- and Kalmar County), the ECT-R clone seemed to be limited to Östergötland County. However, a tobramycin-resistant clone predominated by isolates of spa type t084 was found in all three counties in southeast Sweden, and in particular among newborns, suggesting inter-hospital transmission.The ECT-R clone has survived as an abundant MSSA clone for a decade in Östergötland County, which indicates an insufficiency in the maintenance of basic hygiene guidelines, and that the clone probably possesses mechanisms of virulence and transmission that are yet to be discovered.
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| 2. |
- Lymer, Ulla-Britt, 1943-
(author)
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Blood exposure in health care : health care workers' and patients' experiences
- 2004
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Doctoral thesis (other academic/artistic)abstract
- The general aim of this thesis was to describe and analyse health care workers' blood-exposure incidents, protective measures, and the motives behind decision making about risks and protective measures. The aim was also to procure knowledge about patients' conceptions about their care, and if precautions taken by the health care workers were included in quaiity care. The methods used were: in study I quantitative method, in studies II and III grounded theory method, and in study IV phenomenographic method.The aims of study I were to describe and analyse blood-exposure incidents and compliance in relation to recommended serological investigations, universal precautions and incident reporting routines and also to follow up a campaign against blood-exposure. Instruments used were incident report forms (n=473) and questionnaires (n=132), (n=108), (n=517). The majority of the 473 reported blood-exposure incidents came from nurses and the minority from physicians. Incidents occurred most often on hospital wards, the most commonly reported incident being needle-stick injuries, 35% ofwhich occurred during recapping the needle. Medicallaboratory technicians reported significantIy more mucocutaneous incidents than other professionaIs (P<0,01). Serological investigations post-exposure varied and 35% of individuaIs were not tested. In an anonymous questionnaire, the respondents recalled 1180 incidents, although onIy 9% of these were reported. Physicians reported onIy 3% of these, medical laboratory technicians reporting 36%. The under reporting was most common in operation theatres and in anaesthesia. Eighty-one percent believed that the accident could have been avoided if they had followed the recommended clinical practice. Despite knowledge of universal precautions, professionaIs continue to behave in a risky manner, which can result in blood exposure incidents and possibly a blood-borne viral infection.The aim of study II was to identify factors that influenced health care workers' actions in situations involving a risk of blood-exposure. Nurses and assistant nurses were interviewed (n=15). The analysis showed that there was a conflict between different demands involving protecting the patient's privacy, protecting themselves from being infected and respecting the norms of the department. The process of managing this conflict was labelled 'balancing', which most often resulted in the choice of a diagnosis-related strategy, i.e. a non-compliant behaviour. The underlying causes of how patterns of action are formed by individual and socio-cultural forces resulted in five categories, which were seen as forces that could underrnine compliance.The aim of study III was to describe and analyse different forces that promote adherence to universal precautions. Nurses and assistant nurses were interviewed (n=15, the same as in study II). The charge nurse, informal leaders, students, infection controi nurses, type of work., availability of equipment, blood-exposure incidents and media-coverage of viral blood-borne infections were described as potentially irnportant for compliance. The properties these agents must possess in order to be influential were also described. The results irnply that information about safe practices alone is insufficient to achieve that goal. All factors of importance for compliance must be taken into consideration in clinical work and in education.The aim in study IV was to identify and describe patients' conceptions of quality care and of barrier care. The patients (n=14) were adult and treated for orthopaedic reasons. Included in their conceptions of quality care were: Nice manners, mutual achievement, being involved, being cured, being cared for, and having safe care. When comparing these conceptions with previous research about patients' views of quaIity care, the findings confirmed, to a large extent, the findings from other studies. Included in patients' conceptions of barrier care were: Regular use of gloves, regular use of masks and eye-shields, use of gloves in special situations, use of masks and eye-shields in special situations, and keeping clean. The conceptions were of an interpersonal, as well as of a medical-technical nature. Patients' conceptions of barrier care could be included in the category: Having safe care. The frequentIy expressed opinion, among nurses and assistant nurses, that patients may be offended by the use of protective equipment could be refuted.This thesis has contributed to an improved understanding of the occurrence and handling of blood-exposure incidents. The dynamics of compliance and non-compliance with universal precautions have also been described by means of an attempt to uncover the interplay between deactivators and re-activators in the safety culture on wards. Patients' conceptions about barrier care were shown to be an integrated part of quality care.
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| 3. |
- Samuelsson, Annika, 1964-
(author)
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The faecal flora : a source of healthcare-associated infections and antibiotic resistance
- 2013
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Doctoral thesis (other academic/artistic)abstract
- Healthcare-associated infections (HAI) are important causes of mortality and morbidity, and antibiotic treatment is often necessary. Development and availability of new antibiotics are closely followed by development of resistance among microorganisms. During antibiotic therapy, a fraction of the antibiotic given is found in the gut. The human gut is an important reservoir of bacteria. Microorganisms residing or passing the gut is referred to as the gut flora or microbiota. The results of this thesis showed spread of Enterococcus spp between patients on a general intensive care unit, causing septicaemia. After improved hygiene, reorganisation of rooms and thorough cleaning of the unit, together with revision of antibiotic strategy, the incidence of septicaemia with Enterococcus spp fell. Investigation of patients treated for acute intra-abdominal infections showed a shift in the aerobic faecal flora from antibiotic-susceptible Enterobacteriaceae spp towards Enterococcus faecium, yeasts and species of Enterobacteriaceae more resistant to antibiotics, after antibiotic treatment and hospital care. Investigation of recurrent outbreaks of Serratia marcescens sepsis in patients admitted to a neonatal intensive care unit showed different clones with each outbreak. Multiple hygiene interventions and revision of antibiotic strategy subsequently obviated recurrent outbreaks of sepsis, but spread of S. marcescens was not reduced until compliance with basic hygiene guidelines remained stable above 80%. We also found that low gestational age at birth, ventilator treatment and central venous or umbilical catheters are independent risk factors for late onset sepsis. Investigation of the faecal microbiota in patients with acute appendicitis or diverticulitis revealed that disturbance of the faecal microbiota already existed on admission, with higher numbers of Enterobacteriaceae and less Bacteroides, Faecalibacterium, Ruminococcus and Prevotella prior to antibiotic treatment and hospitalisation, than the control population. After treatment and hospitalisation diversity increased significantly in the diverticulitis group, approaching the healthy controls in composition.
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