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Awareness, perceived relevance, and acceptance of large animal hospital surveillance and infection control practices by referring veterinarians and clients
Abstract
Objective:
To assess awareness, perceived relevance, and acceptance of surveillance and infection control practices at a large animal referral hospital among referring veterinarians and clients who sent horses to the facility for veterinary care.
Design:
Survey.
Sample:
57 referring veterinarians and 594 clients.
Procedures:
A 15-question survey targeting Salmonella enterica as an important pathogen of interest in horses was sent to clients who sent ≥ 1 horse to the University of Florida Large Animal Hospital for veterinary care during July 1, 2007, through July 1, 2011, and to veterinarians who had referred horses to the same hospital prior to July 1, 2011. Responses were summarized with descriptive statistics. The χ(2) test and the Wilcoxon rank sum test were used to examine associations among variables of interest.
Results:
Survey response rates were low (57/467 [12%] for veterinarians and 594/3,095 [19%] for clients). Significantly more (35/56 [63%]) veterinarians than clients (227/585 [39%]) were aware that the hospital operates a surveillance and infection control program. Most veterinarians (56/57 [98%]) and clients (554/574 [97%]) indicated that sampling and testing of horses to detect Salmonella shedding in feces at admission and during hospitalization was justified. In addition, on a scale of 1 (not important) to 10 (very important), veterinarians and clients indicated it was very important (median score, 10 [interquartile range, 8 to 10] for both groups) that a referral hospital operates a surveillance and infection control program.
Conclusions and clinical relevance:
Survey results indicated that awareness of hospital surveillance and infection control practices was higher among veterinarians than clients, and these practices were considered relevant and well-accepted among participant veterinarians and clients.
When dealing with horses suffering from gastrointestinal disease, one must remain constantly vigilant both for the potential role of infectious etiologies and for the risk of infectious complications in these patients. The development and diligent implementation of infection control practices and surveillance are required in order to minimize the risk of nosocomial infections, and to minimize their severity and dissemination when they do occur. Although the responsibility for effective implementation rests with all staff members, the designation of specific individuals with responsibility for oversight and maintenance of standards can be extremely helpful in ensuring the effectiveness of the biosecurity program. Ongoing training of all caregivers regarding both the underlying concepts and the practices involved in biosecurity is essential in this process.
Reasons for performing studyEquine Recurrent Uveitis (ERU) is a leading cause of vision loss in horses.Objectives
To assess the prognosis and impact of ERU on affected horses and their owners by evaluating the signalment, treatment, and outcome (including the loss of use, vision assessment, and economic loss).Study DesignRetrospective impact study.Methods
Medical records of horses presenting to the NCSU-VHC with ERU between 1999 and 2014 were reviewed. Signalment, clinical signs, ophthalmic examination findings, treatments, and outcomes were evaluated. Owner questionnaires were completed regarding vision, job/role, monetary value, diagnostic and treatment costs, concurrent illness, and outcomes.ResultsRecords of 224 horses (338 eyes) with ERU were reviewed. There was an over-representation of Appaloosas (54; 24.1%), Hanoverians (11; 5.0%), and other Warmbloods (13; 5.8%). Ninety-six eyes (28.4%) were diagnosed as blind and 35 eyes (10.4%) with glaucoma on initial evaluation. Leptospirosis titers of serum and/or aqueous humor were obtained in 88 horses and were positive in 40 horses (45.5%), with L. pomona being the most frequently isolated serovar. Globe loss at the NCSU-VHC occurred in 41 ERU eyes (12.1% of total). Owner questionnaires were evaluated in 194 horses (86.6%) and 91 horses (46.9%) were reported blind in the affected eye (s). Fifty-seven horses (29.4%) did not return to their previous role, while 61 (31.4%) performed at a reduced level. ERU decreased the monetary value of 164 horses. Twenty-nine horses (14.9%) were euthanised and 37 (19.1%) underwent change in ownership as a direct result of ERU.Conclusions
The impact of ERU is attributed to the high frequency of blindness, globe loss, and loss of function. Euthanasia and change of ownership are common sequelae to the progressive nature of ERU. These factors, along with financial costs of the disease, have a significant impact on affected horses and their owners.This article is protected by copyright. All rights reserved.
Hospital-associated infections, including those caused by zoonotic agents, represent an increasing concern in veterinary practice. Veterinarians and hospital staff are obligated and expected to provide education about and protection from transmission of pathogens among animal patients and between animal patients and human beings (eg, veterinary staff, volunteers, owners) who come into contact with infected animals. Patient management involves assessing risks of pathogen transmission, identification of animals either suspected of or proved to be infected with a transmissible infectious disease agent, and the implementation of measures that minimize the likelihood of transmission of the infectious agent.
Copyright © 2015 Elsevier Inc. All rights reserved.
To identify risk factors for nosocomial Salmonella infections among hospitalized horses.
Longitudinal study.
1,583 horses hospitalized in an intensive care unit between January 1992 and June 1996.
Survivor functions were used to estimate time to shedding salmonellae for various Salmonella serotypes. Survival analysis was then used to determine how variables associated with patient management, environmental conditions, hospital conditions, and other disease processes affected the risk of nosocomial Salmonella infection.
78 horses shed Salmonella organisms: 35 shed Salmonella krefeld, 26 shed S typhimurium, and 17 shed other Salmonella serotypes. Mean time from admission to shedding was significantly longer for horses shedding S krefeld or S typhimurium than for horses shedding other Salmonella serotypes. Therefore, infection with S krefeld or S typhimurium was considered nosocomial. Seven variables were found to be significantly associated with risk of nosocomial Salmonella infection: mean number of horses in the hospital shedding S krefeld during the 4 days prior to and the day of admission, mean number of horses shedding S typhimurium during this period, a diagnosis of large colon impaction, withholding feed, number of days fed bran mash, duration of treatment with potassium penicillin G, and mean daily ambient temperature.
Results suggest that risk of nosocomial Salmonella infections is greater for horses with large colon impactions. In addition to implementing hospital protocols that minimize cross contamination between patients, strategies to reduce the risk of nosocomial Salmonella infection should include minimizing use of potassium penicillin G and regulation of environmental temperature in the hospital.
An outbreak of salmonellosis in a population of hospitalized horses resulted in the closure of a teaching hospital for a period of 10 weeks. Fecal samples were collected from suspected cases and cultured for Salmonella. Salmonella isolates were characterized using antimicrobial susceptibility testing, pulsed-field gel electrophoresis (PFGE) and phage typing. Thirty-three cases of infection by a multidrug-resistant strain of S. typhimurium were detected. The index case was admitted on 26 August 1999. Fifteen (45%) cases occurred between April and June 2000. PFGE results suggested that this strain of S. typhimurium might have been introduced into the hospital environment by a foal presenting with diarrhea. The hospital was closed on June 13, and intensive environmental cleaning and disinfection were completed. Enforcement of infectious disease control protocols in hospitals and environmental and patient surveillance is needed to prevent outbreaks of salmonellosis.
Outbreaks of nosocomial Salmonella infections in hospitalised horses can occur when surveillance and infection control protocols are not in place, or not well structured and enforced. The aim of this article is to present a review of published studies that have contributed to the literature of the epidemiology and infection control aspects of nosocomial Salmonella infections in hospitalised horses. The review highlights important elements that must be taken into consideration during the formulation, implementation and evaluation of a hospital surveillance and infection control programme designed to reduce the risk of an outbreak of nosocomial Salmonella infection in hospitalised horses.
To evaluate the potential association between Salmonella enterica shedding in hospitalized horses and the risk of diarrhea among stablemates, and to characterize gastrointestinal-related illness and death following discharge among horses that shed S. enterica while hospitalized.
Retrospective cohort study [corrected].
221 horses (59 that shed S. enterica during hospitalization and 162 that tested negative for S. enterica shedding ≥ 3 times during hospitalization).
Information from medical records (signalment, results of microbial culture of fecal samples, clinical status at the time of culture, and treatment history) was combined with data collected through interviews with horse owners regarding formerly hospitalized horses and their stablemates. Data were analyzed to investigate risk factors for death and diarrhea.
Occurrence of diarrhea among stablemates of formerly hospitalized horses was not associated with S. enterica shedding in hospitalized horses but was associated with oral treatment with antimicrobials during hospitalization. Salmonella enterica shedding during hospitalization was not associated with risk of death or gastrointestinal-related illness in study horses ≤ 6 months after discharge, but shedding status and history of gastrointestinal illness were associated with increased risk of death during the preinterview period.
Stablemates of horses that shed S. enterica during hospitalization did not appear to have an increased risk for diarrhea, but comingling with horses that receive orally administered antimicrobials may affect this risk. Salmonella enterica shedding during hospitalization may be a marker of increased long-term risk of death after discharge. Risks are likely influenced by the S enterica strain involved and biosecurity procedures used.
Nosocomial salmonellosis is an important problem for large animal veterinary teaching hospitals (VTHs).
To describe failure of an Infection Control Program (ICP) that resulted in an outbreak of salmonellosis caused by Salmonella Newport multidrug resistant (MDR)-AmpC at a large animal VTH.
Sixty-one animals identified with the outbreak strain of Salmonella.
Retrospective study: Data collected included signalment, presenting complaint, duration of hospitalization, discharge status, and financial information. Phenotypic and genotypic characterization was performed on Salmonella isolates.
The outbreak occurred despite an existing ICP; the ICP was reviewed and weaknesses identified. Routine patient surveillance was not performed before or during the outbreak; fecal sampling was triggered only by a patient algorithm based on clinical signs. Sixty-one animals were infected with the outbreak strain of S. Newport, and the majority were horses (n = 54). Case fatality rate was 36.1%. S. Newport isolates demonstrated high genetic similarity (Dice ≥ 0.96), and all had the MDR-AmpC phenotype. Environmental persistence of the organism necessitated complete hospital closure, extensive decontamination, and remediation of the facility. A paradigm shift in the relevance of biosecurity in a VTH and the establishment of a stringent ICP were integral components of successful hospital reopening.
An ineffective ICP resulted in a nosocomial outbreak caused by a MDR S. Newport in a VTH. Closure of a VTH affected all missions of the institution and had substantial financial impact (US$4.12 million).
Nosocomial salmonellosis is often assumed to occur because infection control and surveillance practices are inadequate, but published evidence is lacking to support the related contention that rigorous application of these practices can impact the severity of outbreaks.
Describe active surveillance, early recognition, and intensive mitigation efforts used in an effort to control an outbreak of nosocomial Salmonella enterica serotype Newport infections without hospital closure.
Large animals hospitalized at a referral hospital.
This prospective outbreak investigation was initiated when Salmonella Newport infections were detected among hospitalized animals by active surveillance. Data were analyzed to identify temporal and spatial patterns for epidemic spread of Salmonella in the hospital. Mitigation efforts were aggressively adjusted in response to surveillance data. Genetic relatedness of isolates was investigated by pulsed-field gel electrophoresis.
Of 145 large animals sampled, 8 (5.6%) were infected with the Salmonella strain associated with this outbreak, and all but 1 shed Salmonella in the absence of or before the onset of disease. This strain was recovered from 14.2% (42/295) of environmental samples (ENV samples), indicating that widespread environmental contamination had occurred. Isolates of Salmonella Newport obtained from infected animals and the environment were genetically indistinguishable, confirming clonal dissemination.
Active surveillance allowed early detection of nosocomial Salmonella transmission and hospital contamination. Use of aggressive interventions was followed by cessation of transmission. Active surveillance can allow earlier recognition and mitigation compared with programs by only sampling of clinically affected animals.
To examine the relationship between abdominal surgery and nosocomial Salmonella infections and the relationship between high caseload in combination with abdominal surgery and nosocomial Salmonella infections in hospitalized horses with signs of gastrointestinal tract disease.
140 horses.
Case-control study.
To accomplish the first objective, 1 to 4 control horses were matched with each nosocomial case horse on the basis of admission date of a primary case horse. The frequency of abdominal surgery and other investigated exposure factors were compared between nosocomial case horses and control horses. For the second objective, 4 control horses were matched with each nosocomial case horse on the basis of year of admission. The frequency of high caseload (>or=26 inpatients), abdominal surgery, and other factors was compared between nosocomial case horses and control horses.
The odds of nosocomial Salmonella infection were 8 times as high (odds ratio=8.2; 95% confidence interval=1.11, 60.24) in horses that underwent abdominal surgery, compared with the odds for horses that did not undergo surgery. High caseload alone or in combination with abdominal surgery was not associated with increased risk of nosocomial Salmonella infection.
Abdominal surgery was identified as a risk factor for nosocomial Salmonella infections in horses. Horses that undergo abdominal surgery require enhanced infection control and preventative care. Risk of nosocomial Salmonella infections may be reduced by implementation of biosecurity measures (such as the use of plastic boots, gloves, and footbaths) immediately after surgery.
To determine sources of Salmonella organisms in a veterinary teaching hospital, compare bacterial culture with polymerase chain reaction (PCR) testing for detection of Salmonella organisms in environmental samples, and evaluate the effects of various disinfectants on detection of Salmonella organisms on surface materials.
Prospective study.
Fecal samples from 638 hospitalized horses and 783 environmental samples.
Standard bacterial culture techniques were used; the PCR test amplified a segment of the Salmonella DNA. Five disinfectants were mixed with Salmonella suspensions, and bacterial culture was performed. Swab samples were collected from 7 surface materials after inoculation of the surfaces with Salmonella Typhimurium, with or without addition of a disinfectant, and submitted for bacterial culture and PCR testing.
Salmonella organisms were detected in fecal samples from 35 (5.5%) horses. For environmental samples, the proportion of positive bacterial culture results (1/783) was significantly less than the proportion of positive PCR test results (110/783), probably because of detection of nonviable DNA by the PCR test. Detection of Salmonella organisms varied with the surface material tested, the method of detection (bacterial culture vs PCR testing), and the presence and type of disinfectant.
Results of the present study suggested that Salmonella organisms can be isolated from feces of hospitalized horses and a variety of environmental surfaces in a large animal hospital. Although recovery of Salmonella organisms was affected by surface material and disinfectant, bleach was the most effective disinfectant on the largest number of surfaces tested.
Hospitalization of sick animals tremendously increases their risk of acquiring infections as this congregates animals that are most likely to be shedding infectious agents with animals that often have enhanced susceptibility. In order to provide the best veterinary care possible, veterinarians have an underlying responsibility to minimize the risk of additional harm that might unintentionally befall a patient because of their interventions. This includes minimizing the risk of exposing patients to infectious agents. It is therefore incumbent upon veterinarians to actively manage the risk of nosocomial infections. Nosocomial infections in veterinary hospitals are not solely a patient-care concern; the spread of infectious agents can also significantly impact normal hospital operations, revenue, client confidence, public image, and can even affect the morale of hospital personnel. In some cases nosocomial agents can also be zoonotic. This paper discusses the need for biosecurity programs in veterinary practices, and describes a practical approach for developing biosecurity practices that are tailored to individual facilities.
Surveillance for nosocomial infection and disease is a critical component in an integrated and highly effective infection control program. Surveillance activities provide a sensory role to guide ongoing control practices so that they are focused and efficient. Without input from surveillance results, infection control practices are likely to be guided more by emotion and opinion than by data and evidence. This article discusses issues to be considered when developing effective nosocomial infection surveillance programs as well as the historical perspective of surveillance efforts for nosocomial infection in human health care settings.
The science of control of infectious diseases in hospitals was born in 1847 when Semmelweis, a physician, ordered his medical students to scrub their hands in chlorinated lime water between patients and demonstrated that this simple procedure resulted ina dramatic decline in patient morbidity and mortality. In the late nineteenth century came huge breakthroughs in the understanding that microorganisms cause many disorders, and methods to eliminate and control these microorganisms were attempted. By 1910, sterile instruments, gowns, masks, and gloves had become standard for surgical procedures in large university human hospitals, and isolation of human and veterinary patients with contagious diseases became standard. With the advent of vaccines, many epidemic viral diseases could be controlled, and antimicrobial drugs allowed many previously devastating bacterial diseases to be treated effectively. Before long, however, bacterial resistance became an important issue and remains so today, particularly for Salmonella and Staphylococcus aureus in horses. Vaccination has decreased the number of animals susceptible to equine influenza and equine herpesvirus 1, yet these contagious diseases still pose a serious issue in large equine veterinary hospitals. The development of equine isolation facilities and improved methods of barn cleaning; mandatory application of procedures, such as handwashing or use of disinfectant hand wipes, to prevent the spread of infectious diseases; and monitoring of antimicrobial resistance and use of restricted antimicrobial drugs were driven by recognition and necessity and have given rise to current equine infection control programs.
Infection control entails preventing or minimizing exposure to infectious agents or optimizing resistance to infection at the individual and population levels should exposure occur. The degree to which each of these strategies is applied varies according to the attributes of the disease agent and the population at risk. In developing an infection control, biosecurity, or biocontainment plan, it is important to decide which agent or agents are to be controlled, the method by which they might be introduced to the individual or population, and methods by which they might spread once at a farm or veterinary clinic.