- Email: [email protected]
Minimum requirements in infection control
Accepted Manuscript Minimum requirements in infection control Jesús Rodríguez-Baño, María Dolores del Toro, Julio López-Delgado, Nico T. Mutters, Alvaro Pascual PII:
S1198-743X(15)00811-3
DOI:
10.1016/j.cmi.2015.08.025
Reference:
CMI 368
To appear in:
Clinical Microbiology and Infection
Received Date: 13 June 2015 Revised Date:
17 August 2015
Accepted Date: 31 August 2015
Please cite this article as: Rodríguez-Baño J, Toro MDd, López-Delgado J, Mutters NT, Pascual A, Minimum requirements in infection control, Clinical Microbiology and Infection (2015), doi: 10.1016/ j.cmi.2015.08.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
INVITED REVIEW FOR SPECIAL ISSUE ON INFECTION CONTROL
2 Minimum requirements in infection control
4
Jesús Rodríguez-Baño,1,2 María Dolores del Toro,1,2 Julio López-Delgado,1,3 Nico T. Mutters,4
5
Alvaro Pascual.1,5
6
Affiliation:
7
1. Unidad Clínica Intercentros de Enfermedades Infecciosas, Microbiología y Medicina
8
Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío. Seville, Spain.
9
2. Departamento de Medicina, Universidad de Sevilla. Seville, Spain.
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3
3. Departamento de Medicina Preventiva y Salud Pública, Universidad de Sevilla, Seville, Spain.
11
4. Heidelberg University Hospital, Department of Infectious Diseases, Heidelberg, Germany.
12
5. Departamento de Microbiología, Universidad de Sevilla. Seville, Spain.
13
Author for correspondence:
14
Jesús Rodríguez-Baño, Unidad de Enfermedades Infecciosas, Hospital Universitario Virgen
15
Macarena, Avda Dr Fedriani 3, 41009 Sevilla, Spain.
16
Email: [email protected]
17
Word count: 1685.
18
Keywords: Infection control, cross infections, competencies, healthcare workers, quality
19
assessment, staffing
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1
ACCEPTED MANUSCRIPT Abstract
22
While infection control (IC) activities are facing new challenges, dedication of resources to IC
23
are too frequently insufficient. Heterogeneity of resources among centres and countries are
24
huge, a fact that at least partly explains the differences in the results obtained. In this article,
25
we review and discuss the available recommendations on minimum requirements in IC related
26
to organisational aspect, IC staffing and their training, ward staffing, structural issues, and
27
microbiological support. A professional-based consensus about the minimum requirement for
28
IC in European centres based on present challenges and society demands is needed.
SC
RI PT
21
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2
ACCEPTED MANUSCRIPT Challenges to infection control (IC) in the XXI century are huge. The evolution towards
31
benchmarking, lack of reimbursement for specific healthcare-associated infections (HAI) or the
32
increasing pressure for public reporting of surveillance data [1] are completely changing the
33
public relevance of IC activities. Additionally, it is now clear that simplistic approaches are not
34
effective against some complex present problems, such as antimicrobial resistance [2]. Finally,
35
innovative methods applying concepts from other areas of quality control and behavioural
36
sciences are proving to be effective in achieving sustainable improvement in adherence to
37
adequate practices [3]. Curiously enough, in the above context and the era of patient safety
38
and quality control in healthcare, managers and administrators too frequently avoid dedicating
39
enough resources to IC programmes; the situation may have worsened in some countries
40
during the present economic crisis [4]. Beyond their impact in term of morbidity and mortality,
41
the HAI-associated costs are enormous [5]; although more research in this field is needed and
42
welcome, there is little doubt that investment in prevention is cost-effective [6]. However,
43
methodologies and resources dedicated to IC in different centres, healthcare systems and
44
countries are heterogeneous [7, 8]. While cultural, social, professional and economical
45
differences across countries in Europe are obviously important, there should be an agreement
46
about the minimum requirements needed to achieve adequate results in IC. This is one of the
47
many aims and tasks of the European Committee of Infection Control (EUCIC) from the
48
European Society of Clinical Microbiology and Infectious Diseases (ESCMID). We will briefly
49
review the recommendations regarding minimum requirements for IC in healthcare centres
50
according to present needs (Table).
SC
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Organisational aspects and IC staff
53
Multidisciplinary Infection Control Committees are apparently generalised in Europe; 91% of
54
participating centres in a recent survey had one [7]. The IC Committee is responsible for the
3
ACCEPTED MANUSCRIPT design and follow-up of the IC Programme, which should include the objectives and the
56
indicators to be measured and evaluated periodically. However, their existence does not
57
guarantee their functionality or adequate IC practices.
58
In the level of healthcare administrators and managers IC should be considered, as other
59
activities related to patients’ safety, as an institutional priority. Healthcare systems must
60
include IC-related indicators in their agreements with the specific healthcare centres.
61
It has been well accepted for more than 30 years that specific, dedicated IC staff is needed to
62
improve infection rates in hospitals [9]. A recent systematic review identified that an effective
63
infection-control programme in an acute care hospital must include as a minimum standard at
64
least one full-time specifically trained infection-control nurse per up to 250 beds, a dedicated
65
physician trained in infection control, microbiological support, and data management support
66
[10]. Considering all the activities and indicators identified in the systematic review, that figure
67
is clearly obsolete at least for tertiary and university hospitals, in which all the activities cannot
68
be assumed with such resources. It is clear that the composition of the teams must be
69
multidisciplinary and include trained nurses and at least specialists from the areas of
70
epidemiology, infectious diseases and microbiology [11]. Liaison with leaders from specific
71
services and wards such as intensive care specialists, surgeons, etc. is also needed. While a
72
ratio of one dedicated nurse per 250 beds was appropriate 30 years ago, changes in healthcare
73
system (with increasing invasive and specialised ambulatory practices, which need to be
74
addressed, and the higher severity of admitted patients) and the increasingly demanding
75
environment make it necessary to adapt the recommended ratio. The tasks to be performed
76
by the infection control practitioners are huge, including education (which is particularly
77
challenging in teaching hospitals), continuous surveillance of HCA infections and organisms,
78
compliance monitoring (hand hygiene, transmission-related precautions, isolation, infection-
79
specific bundles, disinfection and sterilisation procedures, checklists), coordinating screening
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ACCEPTED MANUSCRIPT and environmental sampling, preparing reports, writing and updating protocols, working on
81
outbreaks, etc. Therefore, one dedicated nurse per 100 beds in acute care centres and one per
82
150-250 beds in long-term care facilities are reasonable requirements [10-14]. While this
83
requirement may be difficult to accomplish for many centres, this should be a goal to achieve
84
in the mid-term.
85
Computerized systems are important for surveillance of HAI, for the investigation of outbreaks
86
and for interventions [15]. Again there are important differences among centres in the access
87
to electronic charts and tools. This is an area where consensus about minimum requirements
88
must be addressed.
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Training and accreditation of IC professionals
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As stated above, the activities to be performed in IC are numerous, varied and complex, and
92
need specialised training and competencies. Professionals working in infection control were
93
mainly trained as nurses, infectious diseases specialists, hospital hygienists, hospital
94
epidemiologists, and medical microbiologists. Training programmes in IC are heterogeneous
95
across Europe, from non-existent as differentiated programmes to full structured ones [16,
96
17]. Initiatives to define the core competencies for IC professionals are being developed in
97
Europe and the USA [16-19]. In Europe, the European Centre for Disease Prevention and
98
Control (ECDC) started the TRICE initiative in which competencies are classified in four areas
99
including programme management, quality improvement, surveillance and investigation of
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HAI, and infection control activities [16, 18]. A recently published document of the Society for
101
Healthcare Epidemiology of America (SHEA) includes different roles (hospital epidemiologist,
102
subject matter expert, healthcare administrator, outcomes assessment evaluator and
103
researcher, regulatory and public health liaison, and educator/teacher), each one with specific
104
competency areas [19]. The expected outcome of these initiatives are to harmonise the 5
ACCEPTED MANUSCRIPT training programmes for the new IC professionals across the countries but will also provide a
106
useful tool for IC teams to understand in which areas their members should emphasize their
107
training or contemplate incorporating new members fulfilling the gaps.
108
Accreditation of professionals and IC programmes are not a requirement nowadays, but
109
development of specific accreditation projects with common requirements and indicators,
110
adapted to the different types of centres and epidemiological situations is a reasonable
111
objective for the near future.
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112 Structural requirements
114
Most hospitals have important structural problems in regards to infection control issues. While
115
adequate structures (individual rooms and bathrooms for patients in all wards, available hand
116
washing points, adequate clean-dirty circuits in surgical areas and high-risk wards, appropriate
117
plumbing and air-conditioned installations and systems, etc.) should be demanded and
118
considered as requirements for all new constructions, hospitals must continue developing
119
their activity with their present structure. The minimum requirements therefore include a local
120
adaptation of IC protocols considering the structural situation (e.g., granting appropriate
121
separation between beds in open structure rooms, adequate cohorting when isolation is not
122
possible, etc.); and a prioritised list of structural problems agreed with the hospital
123
management so that some these would be solved by appropriate remodelling. Additionally, it
124
is important to remind that any remodelling activity should require the approval of the IC
125
committee.
126
Appropriate environmental cleaning services and disinfection/sterilization procedures are key
127
aspects of IC. Nevertheless, environmental cleaning is frequently substandard according to
128
present demands, and specific recommendations for minimal requirements in this area are
129
needed.
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ACCEPTED MANUSCRIPT 130 Ward staffing
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Reduction in the number of front-line doctors and (especially) nurses have been associated
133
with increased risk of transmission and lower adherence to adequate procedures [10].
134
Therfore, adequate ratios of doctors and nurses must be accomplished within all healthcare
135
centres. Also, the number of pool nurses should be kept to a minimum [10], particularly in high
136
risk units like intensive care wards, neonatal units, operating theatres and haemodialysis
137
services. Additionally, education programmes including the local adaptations of IC protocols
138
and basic measures should be regularly provided for all staff, and as a welcome to new
139
healthcare workers.
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140 Microbiological support
142
Without adequate support from the microbiological laboratory, successful IC will always be
143
hampered. Fast and reliable microbiological results are providing essential information about
144
pathogens causing HAI and therefore form a basic requirement for the IC team.
145
Microbiological results are needed to initiate or adapt the treatment regimen based on
146
identification and susceptibility results of the causing pathogen and also for typing of isolates
147
helping in deciphering transmission and suspected outbreaks. Minimum requirements include
148
appropriate pathogen identification methods and susceptibility testing for clinical and
149
screening samples, rapid reporting of results to clinicians, real-time review of specific
150
pathogens and resistance patterns of interest for IC purposes, ability to preserve potentially
151
important isolates and access to molecular typing methods when needed.
152
More rapid identification of infectious agents offers the possibility to avoid unnecessary
153
administration of antibiotics as well as starting targeted antibiotic therapy earlier in bacterial
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ACCEPTED MANUSCRIPT infections. This potentially benefits clinical care and prevents the emergence of antimicrobial
155
resistance by faster optimization of antibiotic therapy [20]. Recently, the face of clinical
156
microbiological laboratories has been changed by new advancing technologies allowing faster
157
identification and susceptibility testing. Matrix-assisted laser desorption ionization time-of-
158
flight mass spectrometry (MS) and other rapid methods allows rapid and reliable pathogen
159
identification and has significantly decreased the time of identification of bacteria [20, 21]. MS
160
might also become useful in routine detection of bacterial resistance mechanisms in the future
161
[22]. Additionally, the increasing implementation of total laboratory automation systems offers
162
the opportunity to optimise workflow, reduce costs and further accelerate microbiological
163
diagnostics [23,24]. On the other hand, external or centralised laboratories may negatively
164
affect the relevance of microbiological data on infection control activities because of delays in
165
results reporting and lack of contact with the hospital problems.
166
Whole genome sequencing (WGS) techniques can now be routinely used for detection of
167
resistance and especially for typing of organisms [25, 26]. WGS can allow identification of
168
unexpected modes of transmission and can distinguish between alternative transmission
169
scenarios which can be critical for the IC team to control outbreaks. WGS furthermore can be
170
used to link environmental isolates and thus help understanding how and when contamination
171
occurred. It may also provide new insights in bacterial population dynamics and evolution of
172
resistance. However, not all issues regarding the analysis, processing and storage of the huge
173
amount of data WGS creates, so called big data, are yet solved [27]. Nevertheless, WGS is
174
expected to change healthcare epidemiology and public health if costs decrease, data
175
interpretation is automated, and WGS data are sufficiently validated against current methods.
176
Access to this technology through adequate nets or reference laboratories should be desirable.
177
Since the access to new technologies differs across the different European countries, the
178
importance of availability to more “classic” technologies for epidemiological typing, such as
179
pulsed field gel electrophoresis (PFGE) should not be ignored.
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ACCEPTED MANUSCRIPT As a summary, microbiological support is of high importance for the IC team in many aspects.
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Antibiotic therapy can be adapted based on susceptibility results, empiric treatments can be
182
defined by analysis of local epidemiology of pathogens causing HAI, IC measures can be better
183
coordinated based on surveillance data and outcome indicators such as incidence rates or
184
bacteraemia rates, and finally, microbiological support is often crucial to control outbreaks and
185
to identify transmission dynamics.
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186 Conclusion
188
There is little doubt that the higher the demand for IC success, the higher the requirements
189
that IC activities need to accomplish the objectives. However, resources for IC are
190
heterogeneous in Europe. A professional-based consensus about the minimum requirement
191
for IC in European centres based on present challenges and society demands is needed.
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ACCEPTED MANUSCRIPT Acknowledgements
194
The authors have no conflict of interest to disclose for this paper. MDT, AP and JRB received
195
funding for research from Ministerio de Economía y Competitividad, Instituto de Salud Carlos
196
III - co-financed by European Development Regional Fund "A way to achieve Europe" ERDF,
197
Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), and the
198
Innovatives Medicine Initiative (IMI), European Union's Seventh Framework Programme
199
(FP7/2007-2013) and EFPIA companies’ in kind contribution, COMBACTE (grant agreement
200
115523), COMBACTE –CARE (grant agreement 115620), and COMBACTE-MAGNET (grant
201
agreement 115737).
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202 203
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8. Martin M, Conrad A, Zingg W, et al. Assessment of European practices in infection control. First results from PROHIBIT. 21st ECCMID 2011, Milan, Italy.
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11. Pittet D. Infection control and quality health care in the new millennium. Am J Infect Control 2005; 33: 258-267.
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13. Venberghe A, Laterre P, Goenen M, et al. Surveillance of hospital acquired infections in
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control nurse. J Hosp Infect 2002; 52: 56–59.
14. Morrison J; Health Canada, Nosocomial and Occupational Infections Section. Development of a resource model for infection prevention and control programs in
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acute, long term, and home care settings: conference proceedings of the Infection
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15. de Bruin JS, Seeling W, Schuh C. Data use and effectiveness in electronic surveillance of
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16. Brusaferro S, Cookson B, Kalenic S, et al. Training infection control and hospital hygiene professionals in Europe, 2010: agreed core competencies among 33 European
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18. European Centre for Disease Prevention and Control. Core competencies for infection control and hospital hygiene professionals in the European Union. Stockholm: ECDC;
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19. Kaye KS, Anderson DJ, Cook E, et al. Guidance for Infection Prevention and Healthcare
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20. Huang AM, Newton D, Kunapuli A, et al. Impact of rapid organism identification via matrix-assisted laser desorp- tion/ionization time-of-flight combined with
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23. Greub G, Prod’hom G: Automation in clinical bacteriology: what system to choose? Clin Microbiol Infect. 2011; 17: 655-660. 12
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24. Mutters NT, Hodiamont CJ, de Jong MD, Overmeijer HP, van den Boogaard M, Visser
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CE. Performance of Kiestra Total Laboratory Automation combined with MS in clinical
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microbiology practice. Ann Lab Med 2014; 34: 111-117. 25. Gordon NC, Price JR, Cole K, et al. Prediction of Staphylococcus aureus antimicrobial
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resistance by whole-genome sequencing. J Clin Microbiol 2014; 52: 1182-1191.
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26. Köser CU, Holden MT, Ellington MJ, et al. Rapid whole-genome sequencing for
investigation of a neonatal MRSA outbreak. N Engl J Med 2012; 366: 2267-2275
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27. Binder H, Blettner M. Big data in medical science—a biostatistical view. Part 21 of a
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Table. Summary of minimum requirements in infection control. For details, see the text. -
Infection control is considered an institutional priority.
-
Multidisciplinary Infection Control Committee.
-
Infection Control Programme including objectives and indicators, with periodical
-
RI PT
evaluations.
Multidisciplinary Infection Control teams, including at least epidemiologists,
infectious disease specialists, microbiologists and infection control nurses, and
SC
liaisons with other key actors like intensive care or surgical specialties. These teams must be share members and be closely coordinated with the Antimicrobial
-
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Stewardship team, in which pharmacists are also key members.
One full-time or equivalent infection control nurse per 100 beds in acute care centres and per 150-205 beds in long-term care facilities, according to complexity.
-
Definition of competencies for infection control team components, and specific
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accredited training according to those competencies. Access to electronic charts and tools.
-
Appropriate cleaning and disinfection/sterilization services
-
Appropriate ward staffing levels, and education for ward staff in infection control-
EP
-
related issues.
Appropriate architectonic structure and related aspects (such as enough individual
AC C
-
rooms, clean-dirty circuits where needed, access to hand hygiene points, etc.)
-
Access to appropriate microbiological support and tools, both for rapid
identification and susceptibility of pathogens causing infections and for molecular typing of isolates whenever needed in a timely manner.
279
14
S1198-743X(15)00811-3
DOI:
10.1016/j.cmi.2015.08.025
Reference:
CMI 368
To appear in:
Clinical Microbiology and Infection
Received Date: 13 June 2015 Revised Date:
17 August 2015
Accepted Date: 31 August 2015
Please cite this article as: Rodríguez-Baño J, Toro MDd, López-Delgado J, Mutters NT, Pascual A, Minimum requirements in infection control, Clinical Microbiology and Infection (2015), doi: 10.1016/ j.cmi.2015.08.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
INVITED REVIEW FOR SPECIAL ISSUE ON INFECTION CONTROL
2 Minimum requirements in infection control
4
Jesús Rodríguez-Baño,1,2 María Dolores del Toro,1,2 Julio López-Delgado,1,3 Nico T. Mutters,4
5
Alvaro Pascual.1,5
6
Affiliation:
7
1. Unidad Clínica Intercentros de Enfermedades Infecciosas, Microbiología y Medicina
8
Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío. Seville, Spain.
9
2. Departamento de Medicina, Universidad de Sevilla. Seville, Spain.
M AN U
SC
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3
3. Departamento de Medicina Preventiva y Salud Pública, Universidad de Sevilla, Seville, Spain.
11
4. Heidelberg University Hospital, Department of Infectious Diseases, Heidelberg, Germany.
12
5. Departamento de Microbiología, Universidad de Sevilla. Seville, Spain.
13
Author for correspondence:
14
Jesús Rodríguez-Baño, Unidad de Enfermedades Infecciosas, Hospital Universitario Virgen
15
Macarena, Avda Dr Fedriani 3, 41009 Sevilla, Spain.
16
Email: [email protected]
17
Word count: 1685.
18
Keywords: Infection control, cross infections, competencies, healthcare workers, quality
19
assessment, staffing
AC C
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10
20
1
ACCEPTED MANUSCRIPT Abstract
22
While infection control (IC) activities are facing new challenges, dedication of resources to IC
23
are too frequently insufficient. Heterogeneity of resources among centres and countries are
24
huge, a fact that at least partly explains the differences in the results obtained. In this article,
25
we review and discuss the available recommendations on minimum requirements in IC related
26
to organisational aspect, IC staffing and their training, ward staffing, structural issues, and
27
microbiological support. A professional-based consensus about the minimum requirement for
28
IC in European centres based on present challenges and society demands is needed.
SC
RI PT
21
AC C
EP
TE D
M AN U
29
2
ACCEPTED MANUSCRIPT Challenges to infection control (IC) in the XXI century are huge. The evolution towards
31
benchmarking, lack of reimbursement for specific healthcare-associated infections (HAI) or the
32
increasing pressure for public reporting of surveillance data [1] are completely changing the
33
public relevance of IC activities. Additionally, it is now clear that simplistic approaches are not
34
effective against some complex present problems, such as antimicrobial resistance [2]. Finally,
35
innovative methods applying concepts from other areas of quality control and behavioural
36
sciences are proving to be effective in achieving sustainable improvement in adherence to
37
adequate practices [3]. Curiously enough, in the above context and the era of patient safety
38
and quality control in healthcare, managers and administrators too frequently avoid dedicating
39
enough resources to IC programmes; the situation may have worsened in some countries
40
during the present economic crisis [4]. Beyond their impact in term of morbidity and mortality,
41
the HAI-associated costs are enormous [5]; although more research in this field is needed and
42
welcome, there is little doubt that investment in prevention is cost-effective [6]. However,
43
methodologies and resources dedicated to IC in different centres, healthcare systems and
44
countries are heterogeneous [7, 8]. While cultural, social, professional and economical
45
differences across countries in Europe are obviously important, there should be an agreement
46
about the minimum requirements needed to achieve adequate results in IC. This is one of the
47
many aims and tasks of the European Committee of Infection Control (EUCIC) from the
48
European Society of Clinical Microbiology and Infectious Diseases (ESCMID). We will briefly
49
review the recommendations regarding minimum requirements for IC in healthcare centres
50
according to present needs (Table).
SC
M AN U
TE D
EP
AC C
51
RI PT
30
52
Organisational aspects and IC staff
53
Multidisciplinary Infection Control Committees are apparently generalised in Europe; 91% of
54
participating centres in a recent survey had one [7]. The IC Committee is responsible for the
3
ACCEPTED MANUSCRIPT design and follow-up of the IC Programme, which should include the objectives and the
56
indicators to be measured and evaluated periodically. However, their existence does not
57
guarantee their functionality or adequate IC practices.
58
In the level of healthcare administrators and managers IC should be considered, as other
59
activities related to patients’ safety, as an institutional priority. Healthcare systems must
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include IC-related indicators in their agreements with the specific healthcare centres.
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It has been well accepted for more than 30 years that specific, dedicated IC staff is needed to
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improve infection rates in hospitals [9]. A recent systematic review identified that an effective
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infection-control programme in an acute care hospital must include as a minimum standard at
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least one full-time specifically trained infection-control nurse per up to 250 beds, a dedicated
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physician trained in infection control, microbiological support, and data management support
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[10]. Considering all the activities and indicators identified in the systematic review, that figure
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is clearly obsolete at least for tertiary and university hospitals, in which all the activities cannot
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be assumed with such resources. It is clear that the composition of the teams must be
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multidisciplinary and include trained nurses and at least specialists from the areas of
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epidemiology, infectious diseases and microbiology [11]. Liaison with leaders from specific
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services and wards such as intensive care specialists, surgeons, etc. is also needed. While a
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ratio of one dedicated nurse per 250 beds was appropriate 30 years ago, changes in healthcare
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system (with increasing invasive and specialised ambulatory practices, which need to be
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addressed, and the higher severity of admitted patients) and the increasingly demanding
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environment make it necessary to adapt the recommended ratio. The tasks to be performed
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by the infection control practitioners are huge, including education (which is particularly
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challenging in teaching hospitals), continuous surveillance of HCA infections and organisms,
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compliance monitoring (hand hygiene, transmission-related precautions, isolation, infection-
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specific bundles, disinfection and sterilisation procedures, checklists), coordinating screening
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outbreaks, etc. Therefore, one dedicated nurse per 100 beds in acute care centres and one per
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150-250 beds in long-term care facilities are reasonable requirements [10-14]. While this
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requirement may be difficult to accomplish for many centres, this should be a goal to achieve
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in the mid-term.
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Computerized systems are important for surveillance of HAI, for the investigation of outbreaks
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and for interventions [15]. Again there are important differences among centres in the access
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to electronic charts and tools. This is an area where consensus about minimum requirements
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must be addressed.
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Training and accreditation of IC professionals
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As stated above, the activities to be performed in IC are numerous, varied and complex, and
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need specialised training and competencies. Professionals working in infection control were
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mainly trained as nurses, infectious diseases specialists, hospital hygienists, hospital
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epidemiologists, and medical microbiologists. Training programmes in IC are heterogeneous
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across Europe, from non-existent as differentiated programmes to full structured ones [16,
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17]. Initiatives to define the core competencies for IC professionals are being developed in
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Europe and the USA [16-19]. In Europe, the European Centre for Disease Prevention and
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Control (ECDC) started the TRICE initiative in which competencies are classified in four areas
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including programme management, quality improvement, surveillance and investigation of
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HAI, and infection control activities [16, 18]. A recently published document of the Society for
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Healthcare Epidemiology of America (SHEA) includes different roles (hospital epidemiologist,
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subject matter expert, healthcare administrator, outcomes assessment evaluator and
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researcher, regulatory and public health liaison, and educator/teacher), each one with specific
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competency areas [19]. The expected outcome of these initiatives are to harmonise the 5
ACCEPTED MANUSCRIPT training programmes for the new IC professionals across the countries but will also provide a
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useful tool for IC teams to understand in which areas their members should emphasize their
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training or contemplate incorporating new members fulfilling the gaps.
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Accreditation of professionals and IC programmes are not a requirement nowadays, but
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development of specific accreditation projects with common requirements and indicators,
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adapted to the different types of centres and epidemiological situations is a reasonable
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objective for the near future.
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112 Structural requirements
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Most hospitals have important structural problems in regards to infection control issues. While
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adequate structures (individual rooms and bathrooms for patients in all wards, available hand
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washing points, adequate clean-dirty circuits in surgical areas and high-risk wards, appropriate
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plumbing and air-conditioned installations and systems, etc.) should be demanded and
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considered as requirements for all new constructions, hospitals must continue developing
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their activity with their present structure. The minimum requirements therefore include a local
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adaptation of IC protocols considering the structural situation (e.g., granting appropriate
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separation between beds in open structure rooms, adequate cohorting when isolation is not
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possible, etc.); and a prioritised list of structural problems agreed with the hospital
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management so that some these would be solved by appropriate remodelling. Additionally, it
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is important to remind that any remodelling activity should require the approval of the IC
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committee.
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Appropriate environmental cleaning services and disinfection/sterilization procedures are key
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aspects of IC. Nevertheless, environmental cleaning is frequently substandard according to
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present demands, and specific recommendations for minimal requirements in this area are
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needed.
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ACCEPTED MANUSCRIPT 130 Ward staffing
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Reduction in the number of front-line doctors and (especially) nurses have been associated
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with increased risk of transmission and lower adherence to adequate procedures [10].
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Therfore, adequate ratios of doctors and nurses must be accomplished within all healthcare
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centres. Also, the number of pool nurses should be kept to a minimum [10], particularly in high
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risk units like intensive care wards, neonatal units, operating theatres and haemodialysis
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services. Additionally, education programmes including the local adaptations of IC protocols
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and basic measures should be regularly provided for all staff, and as a welcome to new
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healthcare workers.
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140 Microbiological support
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Without adequate support from the microbiological laboratory, successful IC will always be
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hampered. Fast and reliable microbiological results are providing essential information about
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pathogens causing HAI and therefore form a basic requirement for the IC team.
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Microbiological results are needed to initiate or adapt the treatment regimen based on
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identification and susceptibility results of the causing pathogen and also for typing of isolates
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helping in deciphering transmission and suspected outbreaks. Minimum requirements include
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appropriate pathogen identification methods and susceptibility testing for clinical and
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screening samples, rapid reporting of results to clinicians, real-time review of specific
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pathogens and resistance patterns of interest for IC purposes, ability to preserve potentially
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important isolates and access to molecular typing methods when needed.
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More rapid identification of infectious agents offers the possibility to avoid unnecessary
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administration of antibiotics as well as starting targeted antibiotic therapy earlier in bacterial
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resistance by faster optimization of antibiotic therapy [20]. Recently, the face of clinical
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microbiological laboratories has been changed by new advancing technologies allowing faster
157
identification and susceptibility testing. Matrix-assisted laser desorption ionization time-of-
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flight mass spectrometry (MS) and other rapid methods allows rapid and reliable pathogen
159
identification and has significantly decreased the time of identification of bacteria [20, 21]. MS
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might also become useful in routine detection of bacterial resistance mechanisms in the future
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[22]. Additionally, the increasing implementation of total laboratory automation systems offers
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the opportunity to optimise workflow, reduce costs and further accelerate microbiological
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diagnostics [23,24]. On the other hand, external or centralised laboratories may negatively
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affect the relevance of microbiological data on infection control activities because of delays in
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results reporting and lack of contact with the hospital problems.
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Whole genome sequencing (WGS) techniques can now be routinely used for detection of
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resistance and especially for typing of organisms [25, 26]. WGS can allow identification of
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unexpected modes of transmission and can distinguish between alternative transmission
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scenarios which can be critical for the IC team to control outbreaks. WGS furthermore can be
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used to link environmental isolates and thus help understanding how and when contamination
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occurred. It may also provide new insights in bacterial population dynamics and evolution of
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resistance. However, not all issues regarding the analysis, processing and storage of the huge
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amount of data WGS creates, so called big data, are yet solved [27]. Nevertheless, WGS is
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expected to change healthcare epidemiology and public health if costs decrease, data
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interpretation is automated, and WGS data are sufficiently validated against current methods.
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Access to this technology through adequate nets or reference laboratories should be desirable.
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Since the access to new technologies differs across the different European countries, the
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importance of availability to more “classic” technologies for epidemiological typing, such as
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pulsed field gel electrophoresis (PFGE) should not be ignored.
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ACCEPTED MANUSCRIPT As a summary, microbiological support is of high importance for the IC team in many aspects.
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Antibiotic therapy can be adapted based on susceptibility results, empiric treatments can be
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defined by analysis of local epidemiology of pathogens causing HAI, IC measures can be better
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coordinated based on surveillance data and outcome indicators such as incidence rates or
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bacteraemia rates, and finally, microbiological support is often crucial to control outbreaks and
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to identify transmission dynamics.
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186 Conclusion
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There is little doubt that the higher the demand for IC success, the higher the requirements
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that IC activities need to accomplish the objectives. However, resources for IC are
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heterogeneous in Europe. A professional-based consensus about the minimum requirement
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for IC in European centres based on present challenges and society demands is needed.
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ACCEPTED MANUSCRIPT Acknowledgements
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The authors have no conflict of interest to disclose for this paper. MDT, AP and JRB received
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funding for research from Ministerio de Economía y Competitividad, Instituto de Salud Carlos
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III - co-financed by European Development Regional Fund "A way to achieve Europe" ERDF,
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Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), and the
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Innovatives Medicine Initiative (IMI), European Union's Seventh Framework Programme
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(FP7/2007-2013) and EFPIA companies’ in kind contribution, COMBACTE (grant agreement
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115523), COMBACTE –CARE (grant agreement 115620), and COMBACTE-MAGNET (grant
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agreement 115737).
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Table. Summary of minimum requirements in infection control. For details, see the text. -
Infection control is considered an institutional priority.
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Multidisciplinary Infection Control Committee.
-
Infection Control Programme including objectives and indicators, with periodical
-
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evaluations.
Multidisciplinary Infection Control teams, including at least epidemiologists,
infectious disease specialists, microbiologists and infection control nurses, and
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liaisons with other key actors like intensive care or surgical specialties. These teams must be share members and be closely coordinated with the Antimicrobial
-
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Stewardship team, in which pharmacists are also key members.
One full-time or equivalent infection control nurse per 100 beds in acute care centres and per 150-205 beds in long-term care facilities, according to complexity.
-
Definition of competencies for infection control team components, and specific
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accredited training according to those competencies. Access to electronic charts and tools.
-
Appropriate cleaning and disinfection/sterilization services
-
Appropriate ward staffing levels, and education for ward staff in infection control-
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related issues.
Appropriate architectonic structure and related aspects (such as enough individual
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rooms, clean-dirty circuits where needed, access to hand hygiene points, etc.)
-
Access to appropriate microbiological support and tools, both for rapid
identification and susceptibility of pathogens causing infections and for molecular typing of isolates whenever needed in a timely manner.
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