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As children get ready to return to school, pediatric health care providers may start seeing more of this condition in their offices. Here is what you should know.

The Dx and Rx of Head Lice

's) Editorial Board members—a diverse group of professionals dedicated to advancing infection prevention and control practices. This series highlights each member's unique expertise and contributions to the field.

From groundbreaking research to innovative strategies, these experts are at the forefront of enhancing health care safety. Join us as we learn their insights, experiences, and visions for the future, providing valuable knowledge and inspiration to elevate infection control protocols.

In this installment, we hear from Tabrikah Mohammed, MSc, BSN, CIC, CPHQ, FAPIC, senior infection control officer, MSc, BSN, TQM, CIC, CPHQ, FAPIC. 

Tabrikah Mohammed, MSc, BSN, CIC, CPHQ, FAPIC, is an accomplished nursing professional with a diverse educational background and vast experience in infection control. She obtained a bachelor of nursing degree from Sharjah University in 2011 and a master of health care administration from the Royal College of Surgeon Ireland in 2013.

Tabrikah has furthered her expertise by obtaining certification as a CIC in 2018 and a CPHQ in 2021. She is also the founder of the IPQ Academy, where she imparts her knowledge and experience to other health care professionals. As the cofounder, head of the scientific committee, and infection control expert at the 

Middle East North Africa Federation for Hospital Sterilization Sciences

 (MENA FHSS), she has significantly contributed to the healthcare sector.

Emirates Infection Prevention and Sterilization Society

 (EIPSS), a nonprofit organization dedicated to advancing knowledge in infection prevention and sterilization practices in the United Arab Emirates. EIPSS operates under the 

Currently, Tabrikah serves as a senior infection control officer in 

, where she applies her skills and knowledge to ensure the safety of patients and healthcare workers. She is also a member of the 2023 editorial advisory board for 

, a testament to her reputation as an expert in infection control.

Tabrikah's contributions to infection control have been recognized through several awards, including the 

IP Idol from Certification Board of Infection Control and Epidemiology, Inc

 by Saudi Society for Infection Prevention and Control in 2023. She is also an international speaker at various conferences and conducts workshops.

Tabrikah sees these topics as trending right now:

These programs aim to optimize the use of antibiotics to combat antibiotic resistance. They involve the proper selection, dosage, and duration of antibiotic treatment to minimize resistance and adverse effects.

: Real-time data and advanced analytics track infection trends and outbreaks within healthcare facilities, allowing quicker and more effective responses.

Artificial intelligence and machine learning

: These technologies are applied to predict outbreaks and optimize infection control strategies.

Personal Protective Equipment (PPE) Innovation

: PPE is continually being innovated, with improvements in comfort, durability, and protection levels. Reusable PPE is also being developed to address supply chain issues and sustainability concerns.

Infection Control in Nonhospital Settings

: Infection prevention in long-term care facilities has become a major focus, particularly due to residents' vulnerability to infections like COVID-19 and influenza.

: There’s increased attention to infection prevention in schools, workplaces, and other community settings.

: Online platforms for infection prevention training have expanded, making education more accessible and scalable.

: There’s a growing emphasis on interprofessional education and collaboration in infection prevention, recognizing that effective infection control requires teamwork across various healthcare disciplines.

: Educating patients and their families on infection prevention practices, such as hand hygiene and recognizing signs of infection, is becoming more prevalent.

: There is a trend towards involving patients in their care, including infection prevention measures, to improve outcomes.

: There is an increasing focus on sustainable practices in infection prevention, such as reducing single-use plastics and developing environmentally friendly disinfectants.

Infection Prevention in Nonhospital Settings:

There is a growing focus on infection prevention in long-term care facilities, outpatient clinics, and community settings. Tailored infection control measures are being developed for these environments.

Telehealth services have expanded significantly, reducing the need for in-person visits and thereby lowering the risk of infection transmission. Remote monitoring of patients helps in managing infections and chronic conditions more effectively.

could focus on a range of timely and impactful topics. Here are her suggestions:

1. Emerging Infectious Diseases and Global Threats

 Coverage of the latest research and developments regarding new viruses or bacteria, particularly those with pandemic potential.

 Updates on global efforts to prevent and control infectious diseases, including responses to outbreaks and lessons learned from recent events.

 New technologies, treatments, and policies to mitigate the rise of drug-resistant infections.

 Strategies for improving AMR monitoring in healthcare settings.

3. Infection Control in Special Populations

 Best practices for preventing infections in nursing homes and other long-term care settings.

 Specialized approaches to infection control in pediatric units.

4. Health Care-Associated Infections (HAIs)

 Latest strategies, protocols, and technologies for preventing HAIs, with a focus on surgical site infections, catheter-associated infections, and ventilator-associated pneumonia.

 Case studies and lessons learned from recent HAI outbreaks.

5. Environmental Hygiene and Disinfection

 New products, technologies, and practices in environmental cleaning and disinfection.

Role of air quality in infection control:

 Research on the impact of ventilation and air purification in preventing the spread of infections.

 Strategies for healthcare professionals to address vaccine hesitancy and counter misinformation.

 Updates on new vaccines and vaccine delivery methods.

7. Technology and Digital Health in Infection Control

AI and machine learning in infection prevention:

 How artificial intelligence predicts and prevents outbreaks in healthcare settings.

 The role of telehealth in infection control, especially in managing patients with infectious diseases remotely.

 How the pandemic has changed infection control practices permanently.

 Future-proofing infection control protocols.

9. Infection Control in Nonhospital Settings

Infection prevention in outpatient clinics:

 Best practices for clinics, dental offices, and other non-hospital healthcare settings.

 Strategies for preventing infections in schools and workplaces, especially with the increasing focus on respiratory illnesses.

Continuing education for healthcare workers:

 New programs, tools, and certifications in infection prevention.

 How to involve patients and their families in infection prevention efforts.

Meet the experts shaping infection prevention: Infection Control Today's Editorial Board members share insights, experiences, and cutting-edge strategies to enhance health care safety and quality. Meet Tabrikah Mohammed, MSc, BSN, CIC, CPHQ, FAPIC.

Meet Infection Control Today's Editorial Board Member: Tabrikah Mohammed, MSc, BSN, CIC, CPHQ, FAPIC

Outsourcing is often cited as a problem in ensuring health care facilities’ ability to provide quality environmental hygiene. However, it's becoming increasingly common in many regions.

If a health care facility lacks specialized in-house knowledge about environmental hygiene or the capacity to spend time finding, hiring, and training environmental service workers. In that case, outsourcing can address a significant need, especially considering the high turnover rate in environmental hygiene positions. The job is generally not a very attractive one; it’s physically demanding and requires long hours and repetitive movements around sick people and a variety of chemicals for relatively low pay.

The concept makes sense: specialized companies with the staff and knowledge to train them to your healthcare facility’s needs and specifications can provide a flexible and agile workforce at a cost generally lower than developing the same in-house workforce. Unfortunately, the services often delivered to health care facilities don’t correspond to the quality needed for those facilities to provide safe patient care.

We all know the outbreaks are expensive in terms of the monetary cost to a health care system, the human cost, the increased use of antibiotics, and the associated issues concerning antimicrobial resistance. Although there's still a lot of research to be done to quantify the full extent of the role of the health care environment, we are learning more and more about how a well-managed health care environment prevents disease transmission. One large-scale multicenter randomized controlled trial focusing on improvements in terminal room disinfection estimated that 10 to 30% of all MDROs are transmitted to people from the health care environment.

When health care facilities outsource their environmental services, they mainly do so because the in-house staff is more expensive to train and maintain. Outsourced contracts guarantee a steady supply of a workforce that has theoretically been trained to a “professional level” (although sometimes we are left wondering exactly what that means). The truth is that many external service providers can provide quality environmental hygiene services, so why are there often so many quality issues? The blame falls largely on the health care facilities themselves.

Health care environmental hygiene (HEH) programs are often victims of limited resources. They've been easy targets for hospitals to cut budgets without immediate fallout. Even if hospital outbreaks are expensive, hospitals tend not to calculate budgets for averted infections or reduced patient bed days.

There are 2 main reasons for this: Either hospital administrations still don’t appreciate the importance of environmental hygiene to infection prevention and control (IPC), or they are aware but simply don’t think that it is an issue in their facilities, even though every study that I am aware of which looks at how often or how well high touch points are cleaned and disinfected shows shockingly low adherence (there are more, but here are a few of the more recent ones).

I have visited more than 1 hospital where eadership told me that they either didn’t have any health care-associated infections (HAIs) or that there were so few that their current systems were more than sufficient. Having seen the inner workings of the HEH programs of the hospitals mentioned above, I can assure you that there was an extremely low likelihood that this was the case. However, until there is a widespread paradigm shift in how health care facilities view and approach environmental hygiene, it will be impossible to address the current challenges associated with outsourcing.

Although we don’t have much data on this, outsourcing seems to be mainly concentrated in high-income economies.4 It’s almost ironic that more straightforward HEH programs with fewer options can be better from a human factors point of view. An experience that left a lasting impression on me was a visit to a small rural hospital in Türkiye. The director showed me around and allowed me to observe how the rooms were cleaned and ask questions about how the HEH program was implemented.

What stayed with me wasn’t how the training was conducted or what products they were using; it was that the hospital director knew the EVS staff by name and asked the worker who showed me around how her children were and other personal information. When I asked him about it, he said that at the hospital, they were like a family and that they had been working together for well over a decade. This is a far cry from the environment we see in many far wealthier hospitals, where, ultimately, the bottom line trumps any other considerations.

An EVS workforce’s performance can only be as good if staff can be trained, motivated, and monitored. Health care facilities’ HEH and IPC departments must be the ones to decide on the products, processes, and microbiological standards that are implemented by the workforce, even if it’s outsourced. If facilities cannot measure quality (let alone ensure it!), then they cannot provide safe care to their patients.

At the very least, when HEH staff is outsourced, the hospital should employ someone who ensures that the workforce is adequately trained to the same standards as an internal workforce, in compliance with internal IPC recommendations, and given sufficient time and resources to do their jobs well.

This last item on the list is a big sticking point because it comes back to the issue of the constant cost-cutting in HEH. When hospitals are putting out tenders for external companies, they must evaluate the relationship between the price, quality of the workforce, relationship with current suppliers, quality and scope of the proposed service, etc. If over a third of a facility’s purchasing decision is based on the price of the outsourcing, price will always be the deciding factor, to the detriment of quality.

So, yes, currently, there are many issues with outsourcing, but there don’t necessarily have to be. If there is a single takeaway I can offer from this conversation, it is that you usually get what you pay for.

1. Xie A, Carayon P, Cox ED, et al. Improving daily patient room cleaning: an observational study using a human factors and systems engineering approach. 

2. Ramphal L, Suzuki S, McCracken IM, Addai A. Improving hospital staff compliance with environmental cleaning behavior. 

3. Fram DS, Wendt R, Gouker A, et al. High-touch surfaces disinfection compliance in a COVID-19 intensive care unit. 

4. Peters A, Schmid MN, de Kraker MEA, Parneix P, Pittet D. Results of an international pilot survey on health care environmental hygiene at the facility level. 

5. Chen LF, Knelson LP, Gergen MF, et al. A prospective study of transmission of multidrug-resistant organisms (MDROs) between environmental sites and hospitalized patients—the TransFER study. 

Outsourcing environmental hygiene in health care facilities offers cost benefits but often compromises quality. Effective oversight, training, and standards are essential for ensuring patient safety.

Clean Hospitals Corner With Alexandra Peters, PhD: The Issues Around Outsourcing

As doctors tried to find a way to treat bacterial infections more than a century ago, Félix d’Herelle proposed using bacteriophages against bacterial infections. Although this idea sparked interest, the discovery of the world’s first antibiotic, penicillin, in 1928 by Alexander Fleming pushed phage therapy to the sidelines.

Almost a century later, the threat of rising antibiotic resistance means the world desperately needs new therapies against bacterial infections. According to the CDC, treating 6 of the 18 most alarming antibiotic resistance threats contributes to more than $4.6 billion in annual health care costs.

Why Are Antibiotics Not Effective Anymore?

Antibiotics were once a powerful treatment option against bacterial infections. Today, they do not even work in certain cases for a simple reason—resistance against them, something Fleming warned about.

Antibiotic tolerance occurs when bacteria susceptible to antibiotics survive an antibiotic regimen.

 There are 3 main molecular mechanisms of resistance—inactivation of antibiotics, modification of the antibiotic target on the bacteria, and reduction of intracellular antibiotic concentrations. Bacteria that survive an antibiotic challenge constitute a significant threat to modern health care. It was noticed that antibiotic tolerance precedes antibiotic resistance and can push toward rapid antibiotic resistance.

Patients’ and physicians’ misuse and overuse of antibiotics are major causes of antibiotic resistance. The lack of new antibiotics in the past 50 years has played a role in this silent pandemic. Pharmaceutical companies have moved from developing new antibiotics to producing more profitable medications for chronic conditions.

Phage therapy was first proposed by d’Herelle1 after he successfully used phages to treat children suffering from bacterial dysentery.

 Despite not gaining popularity in the West, phage therapy was widely used in the Soviet Union, especially Georgia, due to d’Herelle’s collaboration with Georgian scientists. Russian studies of the time show that phage therapy was used in ophthalmology, pediatrics, surgery, dermatology, and other specialties.

Naturally occurring or environmental phages can be found virtually anywhere bacteria are found. This includes water bodies, soil, animals, and plants. Water and soil samples of interest are usually passed through 0.22-μm filters, and filtrates are added onto plates with lawns of bacteria to check for lysis.

 Although the idea of using phages is more than a century old, current research has been focusing on using phage lysins as a therapeutic option.

Renewed interest in phage therapy due to rising anti­bacterial resistance has led to several clinical trials. Even though phage therapy was extensively used in the Soviet Union, Russian literature published on phage therapy cannot be taken as it is today. Poor study designs, unspecified phage titers and methods, lack of control groups, and other factors make these studies unusable.

The treatment for one of the world’s top infectious killers has changed from 2 injections of streptomycin to a multi­drug regimen today. Most cases of tuberculosis today are drug-resistant, with some patients infected with totally drug-resistant tuberculosis.

found 2 bacteriophages (D29 and DS6A) capable of lysing 

) (Figure 6). However, researchers found that D29 could not kill 

in broth culture even at the highest multiplicity of infection (ratio of bacteriophage to bacteria), although it could do so in solid culture. This may be due to 

rapidly developing resistance to the phage and replacing D29-susceptible bacteria with resistant ones. DS6A, on the other hand, was found to kill 

Sepsis is a major health risk and can be fatal. Researchers looked at phage therapy against extensively drug-resistant 

sepsis, for which very few drugs are available.

They used φkm18p, a phage isolated from hospital sewage, against KM18, a bacterial isolate of 

that has shown resistance to all antibiotics except tigecycline and polymyxins. They found that the bacterial loads were significantly lower in mice receiving immediate and delayed phage therapy. However, they could also isolate phage-resistant bacteria from the mice.

A single-arm Australian study (NCT03395769) injected 12 patients suffering from severe 

infections with 3 bacteriophages named AB-SA01 as an adjunctive therapy. None of the patients experienced adverse effects, and phage resistance was not seen.

causes one of the most severe forms of sight-threatening intraocular infections. This organism is inherently resistant to β-lactamase; other antibiotics are not enough to treat these infections.

A recent study explored the possibility of using bacterio­phages in B cereus infections. Researchers used PlyB, a phage lysin, in various mediums. They found that PlyB acted as a bac­tericidal agent against B cereus, killing the vegetative bacteria but not its spores. PlyB is a highly group-specific phage lysin that killed the bacteria in multiple growth mediums, including ex vivo rabbit vitreous humor. It also reduced bacterial counts in keratitis and endophthalmitis models, prevent­ing complications related to these infections. An in vivo mouse model also showed the efficacy of this phage lysin.9 Moreover, it was shown to be safe against human retinal cells and macrophages, making it a strong con­tender for future phage therapies.

Phage therapy against Pseudomonas aeruginosa

is a dangerous bacteria with a high mortality rate. The main factor in infections by this organism is the biofilm it secretes.

were discovered decades ago. Since then, multiple phages have been discovered that act against it. A bacteriophage cocktail, especially, has proved to be more effective against the biofilm. A cocktail may increase activity due to an increased number of hosts and may prevent resistance against bacteriophages.

Phages MAG1 and MAG4 individually affected 50% of carbapenem-resistant bacterial isolates, but when used in a combination cocktail, the anti-biofilm activity rose to 72.9%. Another cocktail of Pa193, Pa204, Pa222, and Pa223 significantly reduced the rate of biofilm production by 89% in patients with chronic rhinosinusitis. Individually they had reduced the rate by 53-73%. Phage AZ1 inhibited and destroyed the planktonic form of 

Can we use phage therapy along with antibiotics?

Current studies have used a combination of antibiotics and phage therapy, and old Russian studies used phage therapies after unsuccessful antibiotic therapies.

Researchers to find a suitable phage-derived peptide against 

found that the peptides AK15 and its isomer AK15-6 showed synergistic effects along with Rifampicin.11 Phages were also used in combination with antibiotics against 

What advantage does phage therapy have over antibiotics?

As of now, the biggest advantage of phage therapy is its ability to be used as an alternative treatment option against antibiotic-resistant bacterial infections or infections in which the currently available antibiotics are of little to no use.

Regulatory approval of phage-encoded proteins would follow the same procedure as other regulatory proteins, making it a much shorter procedure than the one used for antibiotics.

 Once the safety and regulatory concerns are cleared, phage preparations take relatively less time to prepare, giving doctors the option to order customized phage cocktails for their patients. With personalized medicine already gaining momentum in mainstream healthcare, customizing phage cocktails suited for every individual patient may become more common. This may also help in preventing misuse of phage therapy by the public, which has caused the rise of antibiotic resistance in the first place.

Bacteriophages have an advantage over antibiotics in infections caused by bacterial biofilm as they can penetrate the inner layer, unlike antibiotics, which only attack the surface. Cocktails, in particular, can increase antifilm activity and prevent resistance to phages. However, they do not seem to work as efficiently against high-density biofilms but can prevent further accumulation and diffusion of these films by reducing migratory bacteria. Large production of mature or alginate biofilms can inhibit the function of bacteriophages.

What challenges are we likely to face while developing phage therapy?

While phage therapy looks like a promising alternative to antibiotics, it has its own limitations.

The development of phage-encoded proteins depends upon therapeutic safety, cell toxicity, and immunogenicity.

 Bacterio­phages contain endotoxins with high immunogenicity, making safety a huge problem when it comes to commercial use of phages. Bacteriophage preparations must undergo extensive purification to make them safe for human consumption.

Phage preparations, like other therapies, will need to undergo extensive regulation, starting from the selection of hosts to the removal of endotoxins.12 This may make it a lengthy process that pharmaceutical companies may not be willing to undertake.

can evade phages and seek protection inside the cell. To try and combat this, we can investigate combining phages with lytic enzymes with cell-penetrating peptides.

As already seen in the above experimental models, bacteria can develop resistance to phages. This means that we may face new challenges in developing phage therapies.

As the world grapples with the rising burden of antibiotic-resistant infections, researchers need to seriously look into other therapeutic options, especially phage therapy, considering that we have seen some level of effectiveness in old Russian trials and modern-day studies. Though there is a risk of bacteria becoming resistant to commercially available phage therapies, the wide variety of available phages and relatively shorter regulatory and approval time may mean that we can produce new therapies at a much faster rate.

Rising antibiotic resistance rates have led researchers to reconsider phage therapy. Although multiple clinical trials have been conducted, phage therapy is not widely available in most countries. Phage therapy, like other forms of treatment, has its challenges, one being resistance to phages. Regulation of phages, safety, and efficacy are other problems researchers may encounter while developing new treatment options against drug-resistant bacteria.

CDC partners estimate healthcare cost of antimicrobial-resistant infections. CDC. Published April 22, 2024. https://www.cdc.gov/antimicrobial-resistance/stories/ partner-estimates.html

Rising antibiotic resistance necessitates exploring phage therapy as an alternative. Despite historical sidelining, phages show promise in treating various infections, but regulatory, safety, and resistance challenges remain.

Muhammad Aamir Anees

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