Clostridium Difficile Infection Prevention and Control - Essay Example

Assignment: Infection Control Implementation of Good Practices towards Clostridium Difficile Infection Prevention and Control Contents Introduction 3a). Description 4 3.Implementation of good practices towards C. difficile infection 6 a)Standard safety measure 6 4.General principles of infection and control of C. difficile 6 a). Methods of transmission 6 I). Contact transmission 6 II). Droplet transmission 7 III). Air born transmission 7 b). Scope of transmission 8 c).The risk management basics 9 I). Hand hygiene 10 II). Personal protective equipment 11 III). Handling and disposing of sharps 12 IV). Safe handling and disposal of chemical wastes 12 V). Routine management of the physical environment 13 VI). Reprocessing of reusable instruments and equipment 13 6. Treatment for C. difficile 14 7.Conclusion 14 8.Recommendations 15 9.Appendix 19 Introduction Clostridium difficile also known as C. difficile or C. diff, is a bacterium that infects and makes people and other animals unwell. C. diff is gradually growing to be common and its symptoms are growing more severe and harder to treat. Statistics show that hospitalized patients are more prone to the infection however, it also affects healthy individuals (Landelle et al., 2014). Every employee working under health departments has a key responsibility to ensure prevention and management of the infections. This responsibility covers entirely all health and social care organizations, regardless of the patient setting or care provider. Introduction of good health practices is geared towards prevention and management of infections related to pathogens that cause c. diff (Madan et al., 2014). There are many attributions to infection or diseases, for example, different microorganisms such as bacteria, fungi, viruses, and prions. These microorganisms result in a wide variety of infections (Beltrami, 2010). Such infections include urinary tract, wounds, respiratory, blood, bone and skin infections. To say that not all infections are transmissible will be in order, nonetheless, a majority of them such as influenza, clostridium difficile and norovirus can spread from one person to another hence end up causing transmissible infections (Artel, 2011). Health and social care facilities generate a challenging environment due to the operations undertaken on a daily basis. This environment poses as a perfect medium for transfer of the microorganisms from patient, equipment and staff. It is important to be vigilant at all times in these environments due to the vulnerability; pressure associated with opportunist pathogens and the intensity and complexity of health care environments (Angenent & Kelly, 2009). Patients with mild symptoms of c. diff may improve if they stop taking antibiotics. Those with severe symptoms need different antibiotic medication (Gomez-Simmonds et al., 2014) Clostridium difficile is an infection of the colon by the bacterium. It causes colitis by producing toxins that damage the lining of the colon. The symptoms include diarrhea, fever, and abdominal pain. It can develop into severe complications, which include dehydration, rupture of the colon, and spread of infections to the abdominal cavity or body. The most common cause of c. difficile colitis occurs in patients in the hospitals, though the number of cases out of the hospital has increased. The choice of this topic in this analysis was influenced by the responsibility burden for social care facilities and health organizations as important pillars in curbing down c. difficile infections (. As seen above, these environments are exposed to breeding grounds for the pathogens causing c. diff to grow and infect people easily due to the nature and activities (Meessen-Pinard et al., 2012). This analysis emphasizes the key roles that nursing staff and other health stakeholders have in helping to reduce the prevalence of health care associated infections. The knowledge of how microorganisms develop infections is crucial to prevention developments. The entire nursing fraternity, midwives, and other healthcare assistants carry the main role of prevention (Anderson, Mackel & Stoler, 2008). Steps such as making sure that the clinics, health centres, and social care facilities remain clean, and washing hands regularly, ensuring knowledge and skills for promotion of a clean environment contribute greatly in minimizing the risk of cross infection of c. difficile. a). Description Clostridium difficile is a bacterium related to pathogens that cause tetanus and botulism. The c. difficile bacterium has two forms. The first is an active infectious form that cannot survive in the environment for prolonged periods. The other form is non-active referred to as spore and it can survive in the environment for a longer time. Spores do not cause infections directly. However, when ingested they transform to the active form. These pathogens can be found nearly everywhere. C. difficile spores lie dormant inside the colon until a person takes an antibiotic. The antibiotic disrupts the other bacteria that live in the colon and prevent C. difficile from transforming into its active, disease causing bacterial form (Neuberger et al., 2013). As a result, C. difficile transforms into its infectious (Donskey, 2010) form and then produces toxins (chemicals) that inflame and damage the colon. The inflammation results in an influx of white blood cells to the colon. The severity of the colitis can vary. In severe cases, the toxins kill the tissue of the inner lining of the colon, causing the tissue to fall (Currie et al., 2011). The tissue that falls off is mixed with white blood cells and gives the appearance of a white, membranous patch covering the inner lining of the colon (Donskey, 2010). This severe form of C. difficile colitis is called pseudomembranous colitis because the patches appear like membranes (Aiello & Larson, 2010). Infection prevention, a standard set in the Principles of Nursing Practice, enshrined under principle C that states, “Nurses and nursing staff manage risks, are vigilant about the risks, and help to keep everyone safe in the place they receive care”. This principle plays a stirring role in exploration and analysis (Watterson et al., 2012). It helps in achieving quality nursing care and clarifying nursing contribution to improving health care outcomes and patient experiences (Currie et al., 2011). The paper further discusses and avails guidelines on the fundamental principles of infection prevention and control highlighting the importance of issues such as nutrition and hydration form the essential components complementing the nursing practice. The main agenda involves coming up with an overview of the core elements and rationale for infection prevention and related activities. The scope of application includes all nurses, midwives, and health care assistants in spite of their practice locale. Accordingly, the information within this explorational analysis is useful and at least partially applicable to all stakehoilders within the medical field (Donskey, 2010). 3. Implementation of good practices towards C. difficile infection Prevention and control a) Standard safety measure Standard safety measures are the guidelines that ensure safety for both staff and clients under a health or social care organization. If every person with or without a role in these environments follows the standards and safety measures, the objectives towards safe practice and control of c. diff infection will easily be attained. Best practice becomes natural, and the risk of infections minimized (Duckro, 2012). The objectives towards safety precaution and best practice include; i. Achieving utmost hand sanitation ii. Develop a culture of using personal protective equipment iii. Safe handling and disposal of sharps iv. Safe handling and disposal of clinical waste v. Managing blood and bodily fluids vi. Decontamination of equipment at all times vii. Retaining and maintaining a clean clinical environment viii. Appropriate use of indwelling devices ix. General Management of accidents x. Achieving good communication levels (between health care workers, patients and visitors) (Haley et al., 2014) 4. General principles of infection and control of C. difficile a). Methods of transmission I). Contact transmission The most identified means found in all the resources used in this research indicates that contact is the most common mode of c. difficile transmission (Pu et al., 2014). Most of them describe contact as either direct or indirect. Direct contact transmission is said to occur when the pathogens responsible for infection development are transferred from one person to another. For example, a patient’s blood enters a health care employee through unprotected cuts from surgical razors or needles. On the other hand, indirect conduct transmission occurs when a pathogen affects two or more people. This occurs through a contaminated intermediate object or person. For example, nurses’ hands can transmit infectious pathogens after touching an infected patient with bare hands or protective gear, but touches another patient or person with the protective gear or not washing their hands (Katzenstein, 2011). II). Droplet transmission Droplet transmission transmits c. difficile pathogens from one person to another through activities such as coughing, sneezing or talking and during the performance of certain procedures. Droplets are small c. difficile pathogenic particles that are larger than 5 microns in size (Stanley et al., 2013). They transmit infections when they travel directly from the respiratory tract of an infected person to susceptible mucosal surfaces of another person (McManus, 2010). The limitations for this transmission include gravity and distance. For instance, a person must be in close distance of a metre or less in order to catch the particles from the transmitting agent. Sometimes gravity pulls the particle down hence reducing the effects. However, the droplets can be transmitted via indirect method, especially, when they come to contact with mucosal surfaces. Examples of infectious agents that are transmitted via droplets include influence virus and meningococcal (Struelens, 2009). III). Air born transmission Airborne transmission occurs when pathogen particles hang in the air for a longer period. A person creates small particles during talking, breathing, coughing or sneezing. These particles, through evaporation, hang in the air such that if a person is infected, the pathogens will affect other persons. Infections occur during diagnostic sputum induction, bronchoscopy, airway suctioning, end tracheal intubation, positive pressure ventilation through facemasks and high frequency oscillatory ventilation (Keessen et al., 2013). The pathogens hanging in the air can travel long distances due to air current movement, hence, creating a larger contaminated environment. When a person inhales, the air passes through a mucous respiratory tract creating a breeding zone for the pathogen to build a nest. Examples of these pathogens include measles virus, chickenpox virus and tuberculosis viruses (Tuma & Sepkowitz, 2006). b). Scope of transmission CDI (Clostridium difficile infection is something that has come to negatively impact healthcare providers and patients to a greater and greater degree over the past several years. As such, the scope of infection for this disease is primarily associated with the use/overuse of certain anti-biotics. As the medical profession is already well aware of the potential risk that over-dependence upon antibiotics creates, the added risk for the potential transmission of CDI is a further complication that must be engaged. Moreover, from an analysis of the relevant and existing healthcare data, it is clear and apparent that the broad majority of new CDI infections take place in managed care facilities; such as hospitals and nursing homes (Hutin & Hauri, 2010). As such, standard precautions involve work practices that should be applied by all workers, patients and visitors within a health environment or a social care facility to prevent infections. This also ensures maximum control of infections. Taken as the first approach towards good health practices, these standard precautionary measures attain maximum prevention and control of infections. In general, they are preventive measures implemented to break the spread of infections (Duckro, 2012). c).The risk management basics In the context of this research, the term ‘risk’ means the possibility of contracting c. difficile infections to patients or health care workers from activities emanating from the healthcare environments. On the other hand, risk management is the canons for preventing and reducing harm arising from c. difficile pathogen causing infections (Duckro, 2012). Several levels for successful approaches to risk management in a health environment exist. The first level is the wide facility level where support for effective risk management is done through organizational risk management policy, staff training, follow-up of outcomes and monitoring and reporting evaluation. The other level is the word or departmental based. Inserting risk management is configured in all policies, in a view, to considering risks in all situations (Calfee, & Farr, 2011). The third is individual level, where specific procedures performed by individuals are run through a risk assessment basis and necessary precautionary measures adopted. For instance, providing education sessions on hand hygiene to all parties involved (Duckro, 2012). The standard of risk management outlines several steps or approaches that allow continuous quality improvement on risk management methods. The first step involves establishing context i.e. identifying the basic parameters that are required to manage risks. The second step is avoiding risks; it entails an establishment of whether there is a risk and if the risk is avoidable in future events (Aiello & Larson, 2010). The next step is identifying potential risks such that all potential risk is addressed during analysis and treatment. The other step is analyzing the risks such that the source of the risk, impact and likelihood of occurrence are identified. The next step encompasses risk evaluation so that priorities are identified. The last step embraces treating the risk by implementing appropriate management and control options and standards (Bhalla, 2010). Through a further examination of Table 2.0, represented within the appendix of this analysis, the reader can come to a more informed understanding with respect to the different levels and potential treatments that CDI should be engaged with; dependent upont he symptons and overall level of severity that is engenders. I). Hand hygiene Risks involve transmitting c.difficile pathogens through touch. Most of the time, hands harbour microorganisms that cause infections such that touching may bring a shifting effect of pathogens (Moehring et al., 2013). Hands are contaminated especially with respiratory fluid during events like coughing or sneezing. Struelens (2009) outline that contaminated hands lead to cross-transmission of pathogens in non-outbreak situations. Evidence based research has shown that most health workers, visitors and patients do not decontaminate their hands as often as the standard requirements dictate (Juneau et al., 2013). It also shows that the correct techniques are not observed during decontamination processes (Beltrami, 2010). The standard procedure for hand hygiene states that hands must be decontaminated through a routine hygiene procedure (Beltrami, 2010). The procedure involves several steps. These steps stipulate that hands must be decontaminated before touching a patient, before a procedure, after performing a procedure or body substance exposure risk, after touching a patient and after touching a patient’s surroundings. One of the most effective means of remediating against the potential spread of CDI is to ensure that the best practice of healthcare sanitation is practiced. Although this involves a litany of steps, proper healthcare professional hand sanitation has definitively been proven to have a direct correlation to the overall spread of this disease (Asensio & Monge, 2012). It is also important to decontaminate hands after removal of protective gloves (Aiello & Larson, 2010). It is a standard procedure to decontaminate hands after visiting the toilet, touching any equipment in the surroundings, and after hands becoming visibly soiled. Before starting or leaving work, eating or handling food and drinks, using or touching any equipment, the hands are supposed to be decontaminated (Headley, 2012). However, the research points out that evidence shows neglect in all these areas in general (Beltrami, 2010). II). Personal protective equipment Transmission of c. difficile pathogens through contact or droplet route creates several risks. Contamination can take place between the workers, patients, environment, and visitors. The facilitator of transmission is contact with mucous membrane of either of the named groups (Inns, 2013). Personal protective equipment refers to protective barriers used to isolate contact of any elements that may cause infections (Aiello & Larson, 2010). The equipment isolates mucous membrane, airways, skin and clothing from contact with infectious agents. Examples of protective gears used as part of standard precautions include aprons, gowns, gloves, surgical masks, and protective eyewear and face shields. Studies by scholars such as Ramanathan (2014) indicated that most health care employees follow the standard procedures for protection purposes. They are aware that the use of these barriers acts as a protective measure to all persons in these environments (Calfee, 2011). Several factors are considered as guidelines to the protective gear a person will use on different occasions. The first factor is the probability of exposure to blood and body substances. The second factor considers the blood substance involved. The last factor embroils route of transmission of infectious agents (Aiello & Larson, 2010). Evidence points out that not all personal preventive equipment meet therapeutic goods criteria hence putting the staff at risk. In other instances, workers neglect stipulated manufactures instructions on the use of this equipment. The risk assessment of a situation will guide on how and which protective equipment should be used (Donskey, 2010). III). Handling and disposing of sharps The risks involve exposure of health workers to sharp objects. This puts health workers at risk of injury and the potential exposure to blood borne infectious c. difficile pathogens (Toepfer et al. ,2014. Statistics containing evidence based show that injuries occur most often in the following scenarios: (Donskey, 2010) a. During use of a sharp device on a patient (41%); b. After use and before disposal of a sharp device (40%); and c. During or after appropriate or inappropriate disposal of sharp devices (15%) Sharps objects include needles, scalpels, stitch cutters, glass ampoules and all other sharp instruments. The survey shows that accidents are common in health environments showing that many nurses obtain at least one needle stick or other sharp objects injuries (Hutin & Hauri, 2010). IV). Safe handling and disposal of chemical wastes Standards provide that every work place should have a written policy on waste disposal, which provides guidance on all aspects, including special waste, such as pharmaceuticals and cytotoxic waste, segregation of waste and an audit trails (Crawford et al., 2012). Mixing immix-able wastes causes an eruption of endogenous reactions that develops pathogen. The pathogens cause infections. Evidence based findings show that many organizations do not take keen consideration of labelling their waste bags (Kundrapu et al., 2014). Some health facilities dispose of sharps with other waste products posing a risk in the collection of waste. Such sharp objects should be placed in containers that could not burst hence containing them in a safe environment (Herwaldt, 2011). V). Routine management of the physical environment Studies suggest by such researchers as Lofgren et al. (2014) indicate that there is evidence based upon the understanding that that microorganisms hide extremely well within the health facility environment. Evidence from Lofgren points to the fact that eruptions of the bacteria are suggest an association between poor environmental hygiene and the transmission of infectious pathogens in health care settings and social care settings. Transmission occurs through direct or indirect contact with contaminated equipment. In other cases, the fixtures and fittings were inappropriate hence acted as agents of pathogen harbour eventually transmitting the pathogens to people who encounter the fixtures. The principle practice of good conduct stipulates that health facilities should be patient friendly and offer a safe environment for care (Struelens, 2009). VI). Reprocessing of reusable instruments and equipment Research from Rahimi et al. (2014) shows that any infectious agent introduced into the body may result in infection. It further shows that not in all health care facilities reusable instruments and equipment are handled in a manner that will prevent patient, healthcare workers and the environmental contact from potential degeneration of infectious materials (McManus, 2010). McManus also stipulates that single-use medical devices should not be reprocessed. The facility must seek a license in case they want to start reprocessing equipment. All health centres should be open at all times for internal and external audit. All the equipment under reprocessing should undergo reprocessing - cleaning, disinfection and sterilization. The surveys conducted show that many health care workers at times do not follow standard procedure for reprocessing (McManus, 2010). 6. Treatment for C. difficile Doctors prescribe a ten day course of one of the following oral antibiotics. The first is metronidazole (flagyl). The second is dificid (fidaxomicin) and the third is vancomycin (vancocin). Flagyl is the first to be administered. After 72 hours, the patient is supposed to show improvement. However, the diarrhea may return temporarily. Other treatment modes include taking plenty of water and other fluids. A person can also get intravenous fluid to guard against dehydration (Perez et al., 2013) 7. Conclusion In general, the paper has researched on ways to cultivate good practice in the nursing profession. Many issues come up forming important aspects of strategies reliable for creating a healthy co-existence in a social care and health environment. The first aspect, highly sensitized, is hands hygiene. People should regularly clean their hands in order to minimize pathogen infection effects. After washing, hands should be dried so that the microorganisms do not get a chance to hide. Workers are provided with options of using personal protective equipment to curb infections. There are several methods of transmission that parties relevant to a health care environment should be aware. These methods include contact transmission, droplet transmission, and airborne transmission among many others. For healthy prevention and control of infection transmission, the basic factor identified is hygiene. Good practice is a responsibility bestowed to health workers, patients, and visitors. They are all responsible for maintaining a healthy environment for prevention and control of infections 8. Recommendations Hand decontamination before contact with the patient and after any activity or contact that contaminates the hands. This includes following the removal of gloves. Use quality methods to disinfect your hands such as alcohol, gels and hand rubs. The health facilities should station many washing points so that visitors and patients can wash hands regularly. Using wrong methods for drying hands may increase potentiality for pathogen transfer. Quality paper for drying should be stationed at all washing stations to facilitate quality drying. Health workers should ensure that they use personal protective equipment and follow all instructions placed by manufacturers and health standard practices. Use disposable gloves whenever there is an impending contact with body fluids and blood. Proper ways of wearing gowns and aprons should be taught to all health workers to avoid touching them at areas where they are contaminated. Health care facilities should purchase instruments that help in grasping needles, retract tissues and load/unload needles and scalpels to prevent direct contact with them and avoid accidents. Appropriate ways of disposing single-use sharps should be devised in order to avoid accidents. Label all the waste bins to avoid mixing the wastes in a way that may cause health hazards. Bibliography Aiello, E & Larson, L. (2010) What is the evidence for a causal link between hygiene and infections? Lancet Infect Dis 2(2): 103–10. Anderson, L., Mackel, D. C., & Stoler, B. S. (2008) Carpeting in hospitals: an epidemiological evaluation. J Clin Microbiol 15(3): 408–15. Angenent, L. T., & Kelley. S. T. (2009) Molecular identification of potential pathogens in water and air of a hospital therapy pool. Proc Natl Acad Sci U S A 102(13): 4860–65. Arlet, G. (2011) Measurement of bacterial and fungal air counts in two bone marrow transplant units. J Hosp Infect 13(1): 63–69. Asensio, A, & Monge, D 2012, [Epidemiology of Clostridium difficile infection in Spain], Enfermedades Infecciosas Y Microbiología Clínica, 30, 6, pp. 333-337, MEDLINE, EBSCOhost, viewed 10 March 2014. Beltrami, T. (2010) Transmission of HIV and hepatitis C virus from a nursing home patient to a health care worker. Am J Infect Control 31(3): 168–75. Bhalla, A. (2010) Acquisition of nosocomial pathogens on hands after contact with environmental surfaces near hospitalized patients. Infect Control Hosp Epidemiol 25(2): 164–67. Calfee, D. P. & Farr BM (2011) Infection control and cost control in the era of managed care. Infect Control Hosp Epidemiol 23: 407–10. Crawford, T, Huesgen, E, & Danziger, L 2012, Fidaxomicin: A novel macrocyclic antibiotic for the treatment of Clostridium difficile infection, American Journal Of Health-System Pharmacy, 69, 11, pp. 933-943, CINAHL Complete, EBSCOhost, viewed 10 March 2014. Donskey CJ (2010) The role of the intestinal tract as a reservoir and source for transmission of nosocomial pathogens. Clin Infect Dis Duckro, H. M. (2012) Transfer of vancomycin-resistant enterococci via health care worker hands. Arch Intern Med Gomez-Simmonds, A, Kubin, C, & E. Yoko, F 2014, Comparison of 3 Severity Criteria for Clostridium difficile Infection, Infection Control & Hospital Epidemiology, 35, 2, pp. 196-199, CINAHL Complete, EBSCOhost, viewed 10 March 2014. Headley, C 2012, Deadly Diarrhea: Clostridium Difficile Infection, Nephrology Nursing Journal, 39, 6, pp. 459-468, CINAHL Complete, EBSCOhost, viewed 10 March 2014. Herwaldt, L. A (2011) Control of methicillin-resistant Staphylococcus aureus in the hospital setting. Am J Med 106(5A): 11S–18S; discussion 48S–52S. Hutin, Y. & Hauri, A. (2010) Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections. Bull WHO 81(7): 491–500. Inns, G 2013, Effect of ribotype on all-cause mortality following Clostridium difficile infection, Journal Of Hospital Infection, 84, 3, pp. 235-241, CINAHL, EBSCOhost, viewed 10 March 2014. Juneau, C, P., Wagal, N, Loeffelholz, M, Savidge, T, Croisant, S, & Dann, S 2013, Community-Acquired Clostridium Difficile Infection: Awareness and Clinical Implications, Journal For Nurse Practitioners, 9, 1, pp. 1-6, CINAHL Complete, EBSCOhost, viewed 10 March 2014. Katzenstein, T. L. (2011) Nosocomial HIV-transmission in an outpatient clinic detected by epidemiological and phylogenetic analyses. AIDS 13(13): 1737–44. Keessen, E, Harmanus, C, Dohmen, W, Kuijper, E, & Lipman, L 2013, Clostridium difficile infection associated with pig farms,Emerging Infectious Diseases, 19, 6, pp. 1032-1034, MEDLINE, EBSCOhost, viewed 10 March 2014. Kellaway, C. H., McCallum, P., & Tebbutta, H. (2009) The fatalities at Bundaberg. Report of the RoyalCommission. Med J Aust ii(2): 38. Kundrapu, S, Sunkesula, V, Jury, I, Deshpande, A, & Donskey, C 2014, A Randomized Trial of Soap and Water Hand Wash Versus Alcohol Hand Rub for Removal of Clostridium difficile Spores from Hands of Patients, Infection Control & Hospital Epidemiology, 35, 2, pp. 204-206, CINAHL Complete, EBSCOhost, viewed 10 March 2014. Landelle, C, Verachten, M, Legrand, P, Girou, E, Barbut, F, & Brun Buisson, , 2014, Contamination of Healthcare Workers Hands with Clostridium difficile Spores after Caring for Patients with C. difficile Infection, Infection Control & Hospital Epidemiology, 35, 1, pp. 10-15, CINAHL Complete, EBSCOhost, viewed 10 March 2014. Lofgren, T, Moehring, R, Anderson, D, Weber, D, & Fefferman, N 2014, A Mathematical Model to Evaluate the Routine Use of Fecal Microbiota Transplantation to Prevent Incident and Recurrent Clostridium difficile Infection, Infection Control & Hospital Epidemiology, 35, 1, pp. 18-27, CINAHL Complete, EBSCOhost, viewed 10 March 2014. McManus, P. (2010) Antibiotic use in the Australian community, 1990–1995. MJA 167(3): 124–27. Meessen-Pinard, M, Sekulovic, O, & Fortier, L 2012, Evidence of in vivo prophage induction during Clostridium difficile infection,Applied And Environmental Microbiology, 78, 21, pp. 7662-7670, MEDLINE, EBSCOhost, viewed 10 March 2014. Moehring, R, Lofgren, E, & Anderson, D 2013, Impact of Change to Molecular Testing for Clostridium difficile Infection on Healthcare Facility--Associated Incidence Rates, Infection Control & Hospital Epidemiology, 34, 10, pp. 1055-1061, CINAHL Complete, EBSCOhost, viewed 10 March 2014. Neuberger, A, Saadi, T, Shetern, A, & Schwartz, E 2013, Clostridium difficile Infection in travelers--a neglected pathogen?, Journal Of Travel Medicine, 20, 1, pp. 37-43, MEDLINE, EBSCOhost, viewed 10 March 2014. Pérez, M, Hurtado, A, Couto, I, Gutiérrez, J, Seoane, L, Suárez, J, & Galeiras, R 2013, [Multidisciplinary approach of Clostridium difficile infection], Revista Chilena De Infectología: Órgano Oficial De La Sociedad Chilena De Infectología, 30, 2, pp. 165-185, MEDLINE, EBSCOhost, viewed 10 March 2014. Pu, W, Youlian, Z, Zhongqiu, W, Shan, X, Ye, C, Bo, J, Ting, Z, Minyi, L, Runhua, L, & Jiasheng, T 2014, Identification of Clostridium difficile Ribotype 027 for the First Time in Mainland China, Infection Control & Hospital Epidemiology, 35, 1, pp. 95-98, CINAHL Complete, EBSCOhost, viewed 10 March 2014. Rahimi, E, Jalali, M, & Scott Weese, J 2014, Prevalence of Clostridium difficile in raw beef, cow, sheep, goat, camel and buffalo meat in Iran, BMC Public Health, 14, 1, pp. 1-9, Academic Search Complete, EBSCOhost, viewed 10 March 2014. Ramanathan, S, Johnson, S, Burns, S, Kralovic, S, Goldstein, B, Smith, B, Gerding, D, & Evans, C 2014, Recurrence of Clostridium difficile infection among veterans with spinal cord injury and disorder, American Journal Of Infection Control, 42, 2, pp. 168-173, CINAHL, EBSCOhost, viewed 10 March 2014. Stanley, J, Bartlett, J, Dart, B, & Ashcraft, J 2013, Clostridium difficile infection, Current Problems In Surgery, 50, 7, pp. 302-337, MEDLINE, EBSCOhost, viewed 10 March 2014. Struelens MJ (2009). The epidemiology of antimicrobial resistance in hospital acquired infections: problems and possible solutions. BMJ 317(7159): 652–54. Toepfer, M, Magnusson, C, Norén, T, Hansen, I, Iveroth, P, & Offenbartl, K 2014, [Insidious and widespread outbreak of Clostridium difficile. Changed cleaning procedures and frequent evaluations cut infection rates in half], Läkartidningen, 111, 1-2, pp. 24-27, MEDLINE, EBSCOhost, viewed 10 March 2014. Tuma S & Sepkowitz (2006) Efficacy of safety-engineered device implementation in the prevention of percutaneous injuries: a reviewof published studies. Healthcare Epidemiol 42: 1159. Watterson, L, Coley, M, & Jobling, S 2012, Making Principles of Nursing Practice a reality at work, British Journal Of Healthcare Assistants, 6, 8, pp. 388-391, CINAHL Complete, EBSCOhost, viewed 10 March 2014. 9. Appendix Table 1.0 Data extraction table World health organization Guidelines on hand hygiene in health care (2010) United state centers for disease control and prevention Workbook for designing, implementing and evaluating a sharps injury prevention program (2008) Guideline for disinfection and sterilisation in healthcare facilities (2009) Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings (2007) Management of multidrug-resistant organisms in healthcare settings (2010) Guidelines for infection control in the dental setting (2008) Guidelines for environmental infection control in health-care facilities (2009) Table 2.0 Likeli- hood Consequences Negligible Minor Moderate Major Extreme Rare Low low Low Medium Very high Unlikely Low Medium Medium High Very high Possible Low Medium High Very high Very high Likely Medium High Very high Very high Extreme Almost Certain Medium Very high Very high Extreme Extreme Low risk Manage by routine procedures. Medium risk Manage by specific monitor or audit procedures High risk Very high risk Extreme risk This is serious and must be addressed immediately Read More