World wide web resources on control of nosocomial infections

Nosocomial infections are a major worldwide cause of death and disability, infection control programs are effective in limiting these infections, especially those acquired in the intensive care unit. The development of the world wide web has provided health care professionals with immediate access to continuously updated information in the field of infection control. We sought to identify websites that contain information on nosocomial infection control by using popular internet search engines, such as Google, Yahoo and AltaVista, and by reviewing relevant publications identified in the PubMed and Current Contents databases. Only those sites that were English language, open access, and developed by a government, academic institution, or national or international scientific association were eligible for inclusion. From a vast number of internet sites initially identified, we selected 49 that provide information on infection control for inclusion in our list of practical and relevant internet resources. Several sites provide general information on infection control practices, whereas others focus on one or a few specific infection(s). We provide health care professionals with a timely and succinct list of open access internet resources that contain information regarding the prevention and control of nosocomial infections in order to help in the dissemination of relevant information and so contribute to the limitation of such hazards.


Introduction
Nosocomial infections (NIs) are a major worldwide cause of death and disability, according to estimates reported by the World Health Organization [1]. Up to 15% of hospitalized patients suffer from infections associated with health care [2]. In addition, in the EPIC (European Prevalence of Infection in Intensive Care) study [3], Vincent and coworkers reported that the prevalence of NI in 1417 European intensive care units was 20.6% in 1992. Several studies focusing on the impact of NIs on health care revealed that they are responsible for increased in mortality, morbidity, and length of hospital and intensive care unit stays [4,5].
NIs appear be an unavoidable toll that we must pay while we attempt to manage patients aggressively using the latest technologies, including invasive devices. However, at least a third of NIs are preventable through infection control programs, as suggested by the SENIC (Study on the Efficacy of Nosocomial Infection Control) study from the US Centers for Disease Control and Prevention [6]. Because there is ample evidence of the effectiveness of infection control programs [6][7][8], an understanding of such programs and of their incorporation into everyday clinical practice is mandatory.
The need for education and constant updating of infection control measures may now be achieved with the use of modern technology, including the internet and world wide web. However, navigation of the world wide web to gain valuable information from reliable sources is recognized not to be easy [9]. Thus, we endeavored to identify various electronic sources on matters of prevention and control of NIs, and to compile a list of major websites as a guide for interested health care professionals.

Method
Popular internet search engines, including Google, Yahoo and AltaVista, were used to identify websites that provide information regarding the control of NIs. Broad search terms such as 'infection control' were used to identify a large number of relevant websites. The first 100 hits on each search engine were further reviewed. A number of the identified sites provided links to other sites, which are also included in this review.
PubMed and Current Contents were also extensively searched by using the following search strategy: 'infection control' AND 'world wide web'.
To be included in our list, a website had to be developed by a government, academic institution, or a national or international health care professionals' association, as a guarantee of accuracy and overall validity of the information provided; personal sites or those maintained by commercial entities were excluded. In addition, we selected only those sites that were written in English (alternative language options, if present, were mentioned, but absence of information in English was considered an exclusion criterion for the purposes of this article) and that offer free access (specifically, no paid registration is required to gain access to the full content of the site; sites requiring free registration for access were not excluded).

Results
A great many websites were initially identified using the specified search engines. In detail, the term 'infection control' yielded about 26,800,000 hits in Google, about 45,100,000 in Yahoo, and about 26,000,000 in Alta Vista. Of these we selected 44 websites; five additional sites, known to us, that were not captured through the initial internet search were added to the final list. Searches of the PubMed and Current Contents databases did not identify any additional websites.
In Table 1 we present the websites we selected based on the selection criteria outlined above. In all, our list contains 49 websites that provide information on infection control. Twenty-one of these sites were developed by governments, 15 by academic institutions, and 13 by health care professionals' associations. It is noteworthy that some interesting websites on the issue of infection control are derived from nurses' associations. The majority of the retrieved sites provide general information on infection control practices, whereas others focus on one particular infection, such as human immunodeficiency virus infection or severe acute respiratory syndrome.
We accessed each of the web addresses listed in Table 1 both to confirm accessibility and to verify that they contain accurate information on matters of infection control. Other characteristics of these resources, such as extent of content, subspecialty focus, and inclusion of specific guidelines, are summarized in the right-most column of the table.

Discussion
We attempted to provide health care professionals with a timely and succinct list of world wide web resources that contain valuable information on the prevention and control of NIs. Because websites containing information that is both accurate and accessible are considered to be the best [10], we aimed to include in our list only those websites with these features.
Our search was conducted to identify websites reporting on methods and techniques that are needed to prevent crosscontamination and to control potential sources of pathogens that could be transmitted from patient to patient or from health care professional to patient. Specifically, the listed websites include updated information on isolation, standard precautions (hand hygiene, wearing of gloves, mask and gowns, manipulation of sharp objects, and proper use of patient care equipment) and transmission-based precautions.
In addition to such measures, control of use of antimicrobial agents is a major component of hospital infection control, because antimicrobial abuse is known to enhance the development of resistant strains [11]. It was beyond the scope of this work to identify websites providing recommendations on the control of antimicrobial use. However, a good knowledge of local epidemiologic patterns and resistance profiles of prevailing pathogens is crucial to selecting appropriate antimicrobial treatment. Therefore, our research team recently reported on a collection of world wide web resources that include updated information on antimicrobial resistance patterns of clinical isolates from patients from various parts of the world [12].
One of the sites included in our list [13], developed by US Centers for Disease Control and Prevention Hospital Control Practice Advisory Committee, is worthy of particular mention because it features guidelines for the protection of health care professionals from infectious agents as well as management of postexposure care. The prevention strategies we found in this website include immunization for vaccine preventable diseases (tetanus, hepatitis B, and influenza) and isolation precautions to prevent exposure to infectious agents. Specific recommendations regarding management of health care workers who have suffered significant exposure to human immunodeficiency virus, hepatitis B and C viruses, Neisseria meningitidis, and Mycobacterium tuberculosis are also provided in this site.
We considered free access to be a prerequisite for websites to be included in our list, because the rationale of this work and of the world wide web in general is to provide information to all who are interested. In addition, need for free distribution of medical literature is widely supported, and open access journals are expected to enjoy greater increases in impact factor than are their subscription counterparts [14]. However, given that appropriate educational resources are often costly, we acknowledge that the exclusion of websites requiring paid registration might have directed our list of websites toward lower quality resources.
Although we endeavored, through our gathering strategy, to review most websites that provide information on infection control, we also recognize that some sites that offer valuable information on this issue might have been omitted. In addition, there are other potentially relevant sites that we omitted because they did not fulfil the inclusion criteria. The selection criteria were primarily aimed at avoiding the creation of an extended and impractical list, which would be of limited use to a health care worker with time constraints.

Conclusion
We provide the reader with an organized and practical list of available internet resources that contain free and accurate information on prevention and control of NIs. Given the well documented impact of such infections on morbidity and mortality, as well as the effectiveness of infection control programs, we believe that this work may help to limit NIs through broader distribution of knowledge on infection control measures.