La phase de primo-infection à VIH qui correspond aux premières semaines de l'infection est une phase cruciale qui détermine en partie l'évolution clinique de la maladie. La dynamique du virus et des lymphocytes T CD4+ (principale cible) durant cette phase est complexe. D'une part cette phase est asymptomatique dans plus de la moitié des cas et est semblable à un syndrome grippal; elle passe par conséquent très souvent inaperçue et peu de données sont disponibles. D'autre part la date d'infection est généralement inconnue ce qui complique l'étude de l'évolution au cours du temps des marqueurs viro-immunologiques. Les modèles dynamiques basés sur des systèmes d'équations différentielles permettent de prendre en compte l'interaction complexe et non-linéaire existant entre le VIH et le système immunitaire. De plus, leur aspect mécanistique peut être très utile pour la compréhension de la physiopathologie ou l'effet d'intervention. Cependant l'estimation de ces modèles est complexe et plusieurs méthodes sont disponibles à ce jour. Nous proposons dans cette thèse une méthode d'estimation pour des modèles dynamiques prenant en compte l'incertitude sur la date d'infection. Nous appliquons cette méthode à un jeu de données réelles de 761 séroconverteurs de la Collaboration CASCADE durant leur première année de suivi. Ces modèles possèdent un grand nombre de paramètres pouvant inclure des effets aléatoires et des variables explicatives. La sélection du meilleur modèle peut nécessiter l'estimation d'un grand nombre de modèles et peut s'avérer très longue. Nous proposons des tests du score pour sélectionner les effets aléatoires et les variables explicatives plus rapidement dans le cadre général des modèles non-linéaires à effets mixtes avec une illustration sur des modèles dynamiques. Enfin, nous proposons de comparer plusieurs modèles biologiques possibles de la primo-infection à VIH pour prédire la dynamique de la charge virale plasmatique et des CD4.

La mammite bovine à S. aureus se caractérise, dune part, par la persistance dun nombre élevé de cellules inflammatoires (principalement des neutrophiles) dans le lait, et, dautre part, par la persistance de la bactérie dans la glande mammaire. La guérison dune mammite à S. aureus repose donc sur deux facteurs étroitement liés : le retour à une concentration normale de cellules dans le lait et léradication de lorganisme pathogène. Or, laccumulation et lactivation des neutrophiles au site de linfection requiert lexpression de cytokines pro-inflammatoires, telles que lIL-8 et le GM-CSF, et la croissance intra- et extracellulaire de S. aureus est augmentée en présence de cytokines inflammatoires, telles que lIL-1b et le TNF-a. La persistance de cytokines pro-inflammatoires semble donc être défavorable à la guérison dune mammite à S. aureus. Lexpression de la plupart des cytokines pro-inflammatoires est sous la dépendance du facteur nucléaire kB (NF kB). Par conséquent, NF kB pourrait être une cible thérapeutique intéressante pour améliorer ou soigner la mammite à S. aureus. Au début de ce travail aucune étude navait été dédiée au rôle de NF kB dans la mammite. Nous avons par conséquent tenté de clarifier ce rôle, ainsi que le potentiel de NF-kB en tant que cible thérapeutique dans la mammite bovine.

Smittsamma sjukdomar kostar det svenska samhället enorma summor varje år. Behandlingen av smittade patienter har tidigare uppskattats till 5-10 miljarder svenska kronor årligen. Vidare estimeras de förebyggande åtgärderna kosta samhället runt en miljard svenska kronor. Detta betyder att det finns en ekonomisk drivkraft för att reducera antalet smittade patienter inom vården, speciellt de fall som är orsakade av resistenta bakterier. Samtidigt pågår det en debatt om resistenta bakterier och antibiotikaförbrukningen i både forskning och media. Resistenta bakterier kan bli ett hot mot vår framtid om vi inte minskar antibiotikaförbrukningen och vidtar åtgärder för att förhindra smittspridning. Om antalet personer som blir smittade av resistenta bakterier kan reduceras minskar även antibiotikaförbrukningen som i sin tur leder till att färre bakterier utvecklar ett resistensmönster för antibiotika. Detta betyder att det är viktigt att studera och effektivisera hanteringen av smittsamma patienter.   För att reducera antalet smittade patienter måste förebyggande åtgärder vidtas och smittkällan måste kartläggas vid ett upptäckt fall av en smitta. Svensk sjukvård arbetar idag aktivt med smitthantering. Detta begrepp omfattar upptäckt, kontroll och spårning av smitta. Uppdragsgivaren till detta examensarbete, Cambio Healthcare Systems, saknar en fullständig bild över hur smitthanteringen egentligen går till på ett sjukhus. Deras målsättning är att utveckla ett IT-system som kan underlätta smitthanteringsprocessen. Denna studie syftar till att kartlägga informationsflödet vid smitthanteringsprocessen och identifiera de inblandade aktörernas ansvarsområden och skyldigheter enligt regelverket. Vidare syftar arbetet till att presentera åtgärdsförslag som kan minska de identifierade riskerna och effektivisera smitthanteringsprocessen av resistenta bakterier.   För att kartlägga smitthanteringsprocessen genomfördes en fallstudie av ett svenskt universitetssjukhus under våren 2013. Aktörer som studerades var det mikrobiologiska laboratoriet, vårdhygien, smittskyddsenheten, smittskyddsinstitutet samt läkare och sjuksköterskor vid två avdelningar på sjukhuset. Datainsamlingen består av intervjuer, observationer och dokument.   Resultatet av fallstudien visade att smitthanteringsprocessen är ett komplext system med ett omfattande informationsflöde. Huvudaktörerna är vårdhygien, sjukvårdspersonalen och det mikrobiologiska laboratoriet. De är viktiga eftersom deras praktiska handlande är avgörande för att smitthanteringen genomförs. Smittskyddsenheten är inblandad till viss del, men tillhör inte huvudaktörerna. Studien visade även att smittskyddsinstitutet inte hade någon framträdande roll i smitthanteringsprocessen av resistenta bakterier på sjukhuset.   Ansvarsfördelningen är till viss del styrd av smittskyddslagen och enligt denna lag har den behandlande läkaren en central roll i processen. I verkligheten är läkarens roll mindre framträdande vid smittspårningen, vanligtvis delegerar läkaren uppgifter till sjuksköterskor eller till vårdhygien. Mycket av kommunikationen mellan aktörerna är muntlig och detta innebär att ett flertal risker kan uppstå. Vid identifieringen av risker för hela processen konstaterades det att de flesta risker kan uppstå på grund av den mänskliga faktorn, ofta i kombination med användandet av ett otillräckligt datasystem. Åtgärdsförslagen för att effektivisera processen fokuserar därför på att minimera de identifierade riskerna med hjälp av framtida IT-system.   Slutsatsen av studien är att det finns ett stort behov av IT-lösningar för att effektivisera smitthanteringsprocessen av resistenta bakterier. Min rekommendation är att Cambio Healthcare Systems AB bör fokusera på att utveckla ett system för att digitalisera arkiveringen av beläggningslistorna och spåra patientflöden tillbaka i tiden i Cosmic då detta är ett starkt önskemål från kunderna. En annan viktig åtgärd är att utveckla smittspecifika checklistor som visas på datorn i samband med att läkaren får ett positivt provsvar. Slutligen rekommenderar jag Cambio Healthcare Systems AB att utveckla ett smittlarm som kan integreras med deras befintliga whiteboardtavla som nyligen lanserades. / Infectious diseases are a major cost item for the Swedish society. The treatment of infected patients has previously been estimated to 5-10 billion SEK annually and preventive actions cost the Swedish society around one billion SEK every year. Therefore, there are strong economic incentives to reduce the number of infected patients in care, particularly cases caused by resistant bacteria. There is an ongoing debate in both media and research about bacterial resistance and antibiotic consumption. Resistant bacteria can be a threat to our future if we do not reduce the consumption of antibiotics and take measure against infection spreading. If it is possible to reduce the number of resistant bacteria infected patients in the future it enables a decline in antibiotic consumption. This in turn leads to a decreased quantity of bacteria that is able to develop a resistance pattern to antibiotic. Thus, it is highly motivated to study and streamline the process of infection control.   Preventive measures must be taken and the source of the infection must be identified in order to reduce the number of infected patients. The Swedish health care sector is currently working actively with infection control. The concept of infection control encloses the detection, the control and the tracing of the infection. The requestor of this master thesis, Cambio Healthcare Systems AB, does not have a complete picture of the process of the infection control. Their goal is to develop an IT system to facilitate the process of infection control. This study aims to map the information flow of the process and to identify the involved actors’ field of responsibility and obligations according to the law. Further, this thesis aims to present action proposals that can reduce the identified risks and streamline the infection control of resistant bacteria.   A case study of a Swedish university hospital was performed in the spring of 2013 in order to map the process of infection control. The investigated actors were the microbiological laboratory, the local health protection unit (Vårdhygien), the unit of infection control at a regional level (Smittskyddsenheten), the Swedish Institute of Infectious Disease Control (Smittskyddsinstitutet) and physicians and nurses at two hospital departments. The data collection consists of interviews, observations and documents.   The result of this case study shows that the process of infection control is a complex system with an extensive flow of information. The main actors are the local health protection unit, the microbiological laboratory and the medical staff. Their practical actions are essential for the process of infection control. The unit of infection control at a regional level is involved to some extent, but does not belong to the main actors. Furthermore, the study showed that the Swedish Institute of Infectious Disease Control does not have a prominent role in the process at the hospital.   The division of responsibilities is to some extent controlled by the law. According to the law, the physician in charge has a central role in the process of infection control. However, the physician’s role in reality is less prominent. Usually, the physician delegates the tasks to the other actors such as nurses or to the local health protection unit. The communication between the actors is mainly oral and this can cause risks. Most of the identified risks occurred due to human error, often in combination with use of an insufficient IT-system. Therefore, the proposed actions to streamline the process focus on minimizing the identified risks with help of future IT solutions.   The conclusion of this study is that there is a strong demand for IT solutions to streamline the process of infection control of resistant bacteria. My recommendation is that Cambio Healthcare Systems AB should focus on developing a system to digitalize the archiving of the occupancy lists, which also enables tracing the flow of patients back in time. This is a request from several health care professionals. Another important proposed action is to develop a checklist that is specific for every infection disease. Simultaneously as the physician receives the positive test results, this checklist will appear on the physician’s screen. Finally, I recommend Cambio Healthcare Systems AB to develop an alarm to infection diseases that can be integrated with their existing whiteboards that were recently introduced to the market.

Staphylococcus aureus is one of the most important pathogens both in community- or hospital-acquired infections. The first part of this study analyzed the similarity of molecular types of S. aureus isolates cultured from nares and blood in patients with S. aureus bacteremia (SAB) by pulse-fielded gel electrophoresis (PFGE) of digested chromosomal DNA by Sma I at Kaohsiung Veterans General Hospital from August 1, 2000 through July 31, 2001. The results showed that the PFGE types of 78 (82.1%) paired nare and blood isolates of the 95 SAB patients having nasal carriage of S. aureus were clonally identical; identical in 89.7% patients of nosocomial group and 62.9% in community-acquired group. This provides the powerful evidence in close relationship between nasal carriage of S. aureus and acquisition of it in bacteremia. The data also showed that the rate of methicillin resistance occurred in SAB patients with nasal carriage in isolates of nosocomial SAB was 85.3%, and 31.3% in community-acquired group. The second part of this study analyzed the distribution of PFGE types of 163 nosocomial SAB isolates. The most predominant type was type A and composed 51.5% (84 strains) of 163 nosocomial SAB isolates. They were further divided into 7 subtypes. The second prevailing type was type B, 6.1%(10 strains). The evidence that an endemic stain (type A) occurred in >50% of nosocomial bacteremic isolates demonstrates horizontal dissemination of a single endemic strain of S. aureus in the SAB patients was common in the hospital. These results provide support for strategies to endorse more intensive procedures in infection control and to prevent systemic S. aureus infections by eliminating S. aureus nasal carriage.

The mental and physical benefits of pet ownership are well established; however, pets can also transmit pathogens to people, with children, elderly, pregnant and immunocompromised individuals at greatest risk of disease. Little is known about the public’s knowledge and practices related to pet-associated disease. Questionnaires were distributed at two general practice physician clinics and to parents/guardians of children diagnosed with diabetes or cancer at specialty practice clinics. Pet ownership and contact were common, with 64-66% of participants having a pet in their household. Acquisition of a new pet, including high-risk pets, was common (20%) following a diagnosis of cancer in children. Pet exposure outside the home was frequently reported for individuals in pet and non-pet owning households (25-52%). Education of respondents about diseases was poor, as only approximately one-third recalled receiving pet-associated disease information. Parents of cancer patients were more likely than parents of diabetes patients to recall receiving this information, yet proportions were low in both groups (32% and 13%, respectively). Respondents’ knowledge of pet-associated pathogens was similar between the groups, with pet owners and parents of diabetic children having higher knowledge. Pet (30-36%) and non-pet (~10%) owning households reported dog/cat bites or scratches during the preceding year. Within the general practice respondents, lower-risk households did not differ from higher-risk households regarding perceived disease risk of pets, zoonotic disease knowledge, recall of being asked by their medical provider if they owned pets, or recall of having received information regarding pet-associated disease risks and preventive measures. Pet ownership, husbandry and infection control practices were similar between low- and high-risk households. Husbandry practices that increase zoonotic disease risk were frequently identified, including feeding high-risk diets, allowing children to clean up fecal material and allowing reptiles to roam through the kitchen. With few exceptions, practices were not associated with the presence of higher-risk members in the household or recall of having previously received zoonotic disease education. There is a need for improved education on zoonotic disease prevention practices for pet- and non pet-owning households, particularly those with individuals at higher risk of infection and those with high-risk species.

Emerging multidrug-resistant tuberculosis (MDR/XDR-TB) has become a major public health problem, placing millions at risk. Further, nosocomial transmission of MDR/XDR-TB places both patients and healthcare workers at an even higher risk. Effective tuberculosis (TB) infection prevention and control (IPC) policies in high-risk settings must use evidence-based science and should be customized to the setting. However, the growing incidence of MDR/XDR-TB in some global settings raises questions about whether adequate healthcare-related TB IPC policies are in place and whether they are implemented effectively. The purpose of this systematic literature review was to catalogue healthcare-related TB IPC policy research conducted in high-prevalence settings and draw a picture of existing evidence-based TB IPC policies and their implementation, with a focus on preventing and controlling nosocomial transmission of MDR/XDR-TB. Two databases (PubMed and Embase) were searched from 1990 – 2013 and outputs were categorized by region/country, income, MDR/XDR-TB incidence, level of IC intervention, and time period. None of the 20 captured research studies were conducted in TB high-prevalence, low-income settings. Most (12/20) were implemented within the Pan American Health Organization region, followed by the African (4/20) and European (4, 20%) regions. Most studies reviewed (70%) were undertaken because of an outbreak and most (70%) were published between 1990 – 2000. This systematic literature review showed a gap in research on TB IPC policies addressing nosocomial transmission of MDR/XDR-TB in high-prevalence, low-income settings. TB IPC policy development and implementation should be routinely undertaken as a part of effective and efficient public health practice. Development of TB IPC global best practices should be guaranteed and a concerted effort to promote, distribute, train, and implement these TB IPC best practices in low-resource countries would help mitigate the growing incidence of MDR/XDR-TB worldwide.

L’infection à VIH-1 est associée à une forte déplétion des lymphocytes T CD4+ à polarisation Th17 au niveau des tissus lymphoïdes associés aux muqueuses intestinales (GALT, gut-associated lymphoid tissues). Ceci conduit à la translocation microbienne, qui est une cause d’activation immunitaire chronique et de progression de la maladie. Les cellules épithéliales (CE) jouent un rôle critique dans le maintien de l’intégrité et de l’homéostasie au niveau des muqueuses intestinales via le recrutement des cellules de l’immunité innée (e.g., neutrophiles) et adaptative (e.g., cellules Th17). Les neutrophiles produisent des molécules antivirales (e.g., défensines-) et ont la capacité de limiter la réplication virale au niveau des muqueuses. Les cellules Th17 jouent un double rôle lors de l’infection à VIH. Elles contribuent d’une part à la défense contre différents pathogènes opportunistes en augmentant, via la production d’IL-17, la capacité des CE à attirer les cellules Th17 et les neutrophiles. D’autre part, les cellules Th17 jouent un rôle délétère en tant que cibles de réplication virale et sources de cytokines pro-inflammatoires. La fréquence des cellules Th17 est diminuée dans les GALT mais pas dans les poumons des patients infectés par le VIH, suggérant qu’il existe des mécanismes différents par lesquels les cellules Th17 sont recrutées vers ces sites anatomiques. Nous avons testé l’hypothèse selon laquelle le VIH interfère avec la capacité des CE intestinales et non pas pulmonaires à produire des chimiokines (CK) responsables de l’attraction des cellules Th17 et des neutrophiles. Nous avons démontré que les CE intestinales et pulmonaires produisent des CK spécifiques pour les cellules Th17 (CCL20) et les neutrophiles (CXCL8) en réponse à des stimuli pro-inflammatoires tels que l’IL-1 et le TNF-. Le TNF- agit en synergie avec l’IL-17, un « signal de danger » récemment identifié, et augmente la capacité des CE intestinales mais pas pulmonaires à produire la chimiokine CCL20. Cette synergie s’explique par l’augmentation préférentielle de l’expression du récepteur à l’IL-17 à la surface des CE intestinales suite à la stimulation par le TNF-. L’exposition au VIH n’affecte pas la production de CCL20 et de CXCL8 par les CE intestinales, mais altère la capacité des CE alvéolaires à produire ces chimiokines en accord avec la permissivité sélective de ces dernières à l’infection par le VIH. En conclusion, nos résultats démontrent que (i) le VIH n’interfère pas directement avec la capacité des CE intestinales à recruter des cellules Th17 et des neutrophils et que (ii) la production de CCL20 par ces cellules est dépendantes de la synergie entre le TNF- et l’IL-17. Ainsi, la déplétion des cellules Th17 et la pénurie en IL-17 dans les GALT des sujets infectés pourrait causer de façon préférentielle des altérations fonctionnelles au niveau des CE intestinales, se traduisant par l’altération du recrutement des cellules Th17 en réponse au CCL20. / The HIV-1 infection is associated with a severe loss of CD4+ T-cells with Th17 polarization from the gut-associated lymphoid tissues (GALT). These alterations lead to microbial translocation, which is a cause of chronic immune activation and disease progression in HIV-infected subjects. Epithelial cells (EC) play a critical role in maintaining mucosal integrity and homeostasis in the GALT by mechanisms including recruitment of innate (e.g., neutrophils) and adaptive immunity cells (e.g., Th17 cells). Neutrophils produce antiviral molecules (e.g., -defensins) that may limit HIV replication at mucosal sites. Th17 cells play a dual role in HIV pathogenesis. Th17 cells contribute to the defence against different opportunistic pathogens by increasing the ability of epithelial cells to attract neutrophils in an IL-17-dependent manner. On the other hand, Th17 cells play a deleterious role in HIV pathogenesis as they are sites of productive viral replication and a source of pro-inflammatory cytokines. The frequency of Th17 cells is decreased in the GALT but not in the lungs of HIV-infected individuals, suggesting distinct mechanisms of Th17 recruitment in these anatomic sites in the context of HIV pathogenesis. In this manuscript we tested the hypothesis that HIV differentially interfere with the ability of intestinal but not pulmonary EC to produce chemokines that attract Th17 cells and neutrophils. We demonstrated that both intestinal and pulmonary EC produce chemokines that specifically attract Th17 cells (CCL20) and neutrophils (CXCL8) upon stimulation with the pro-inflammatory cytokines IL-1 and TNF- . TNF-α acted in synergy with IL-17, a recently identified « danger signal », and increases the capacity of intestinal but not pulmonary EC to produce CCL20. This synergistic effect can be explained by the preferential upregulation of IL-17 receptor expression on intestinal EC upon TNF- stimulation. The exposure of intestinal EC to HIV did not affect their ability to produce CCL20 and CXCL8; however, exposure to HIV altered the production of these chemokines by alveolar EC, consistent with their selective permissiveness to infection. In conclusion, our results demonstrate that (i) HIV does not interfere directly with the ability of intestinal EC to attract Th17 cells and neutrophils and that (ii) the ability of intestinal EC to recruit the Th17 cells via CCL20 production is selectively dependent on the synergy between TNF- and IL-17. Thus, the depletion of Th17 cells and the shortage in IL-17 in the GALT of HIV-infected subjects may preferentially lead to functional alterations of the intestinal barrier resulting by the alteration of Th17 recruitment in response to CCL20.

The purpose of this study was to investigate the effects of three different glycemic control conditions (tight, conventional, and standard) in the intraoperative period on: 1) postoperative surgical site infections, and 2) postoperative procalcitonin, and C-reactive protein levels in patients undergoing open-heart surgery. Secondary aims of the study were to investigate the effects of the three glycemic treatment conditions on: 1) intraoperative blood glucose; 2) intraoperative glycemic stability; and 3) intensive care unit length of stay, in patients undergoing open-heart surgery. An experimental design with a multilevel, single factor, within-subjects design was utilized. Patients were nested within anesthesia provider teams. The design was counterbalanced by means of a Latin square, where each of three anesthesia provider teams dispensed each of three glycemic control conditions once. Thirty-seven participants were randomized to either tight glycemic control (n =15), which maintained blood glucose 110-149 mg/dl via continuous intravenous insulin infusion, conventional glycemic control (n = 11), which maintained blood glucose 150-180 mg/dl via continuous intravenous insulin infusion, or standard glycemic control (n =11) which maintain blood glucose 150-180 mg/dl via intravenous bolus injections of insulin. The main findings of this study were that there were no significant differences between the three glycemic interventional treatment groups in 1) thirty-day surgical site infections, 2) postoperative C-reactive protein or procalcitonin concentrations 3) intensive care unit length of stay, 4) intraoperative blood glucose levels, or 5) glycemic stability. An association between intraoperative peak blood glucose and surgical site infection was established. Participants that experienced higher peak blood glucose levels intraoperatively exhibited increased surgical site infections. Procalcitonin levels were significantly elevated in participants that experienced a surgical site infection, but C-reactive protein showed no significant difference between participants with or without a surgical site infection. Coronary artery bypass graft surgery concomitant with valve replacement surgery was associated with a higher rate of surgical site infections compared coronary artery bypass graft surgery or valve surgery independently. In conclusion, an association was found between higher peak intraoperative blood glucose levels and increased surgical site infections, therefore maintaining intraoperative blood glucose levels below 180 mg/dl via a continuous intravenous infusion of insulin, may reduce postoperative surgical site infections in the open-heart patient. The use of tight glycemic control during the intraoperative period can be achieved safely, with the use of judicious protocols, but its benefits remain unproven. Inflammatory biomarker procalcitonin was predictive of infection, where C-reactive protein was not. The addition of procalcitonin to routine postoperative blood work, in open-heart patients, may benefit providers in the diagnosis and early treatment of surgical site infections. This study was underpowered. Further studies with appropriate sample size, may be able to determine if tight glycemic control, compared to moderate glycemic control, in the intraoperative period is of benefit to patients undergoing open-heart surgery.

Introduction: Clostridium difficile infection (CDI) is a common hospital-acquired infection and a financial burden on the healthcare system. There is a need to reduce its impact on patients and the entire health system. More accurate estimates of the financial impact of CDI will assist hospitals in creating better CDI reduction strategies with limited resources. Previous research has not sufficiently accounted for the skewed nature of hospital cost data, baseline patient mortality risk, and the time-varying nature of CDI. Objective: We conducted a retrospective cohort study to estimate the cost impact of hospital-acquired CDI from the hospital perspective, using a number of analytical approaches. Method: We used clinical and administrative data for inpatients treated at The Ottawa Hospital to construct an analytical data set. Our primary outcome was direct costs and our primary exposure was hospital-acquired CDI. We performed the following analyses: Ordinary least square regression and generalized linear regression as time-fixed methods, and Kaplan-Meier survival curve and Cox regression models as time-varying methods. Results: A total of 49,888 admissions were included in this study (mean (SD) age of 64.6 ± 17.8 years, median (IQR) baseline mortality risk of 0.04 (0.01-0.14)). 360 (0.73%) patients developed CDI. Estimates of incremental cost due to CDI were substantially higher when using time-fixed methods than time-varying methods. Using methods that appropriately account for the time-varying nature of the exposure, the estimated incremental cost due to CDI was $8,997 per patient. In contrast, estimates from time-fixed methods ranged from $49,150 to $55,962: about a six fold difference. Conclusion: Estimates of hospital costs are strongly influenced by the time-varying nature of CDI as well as baseline mortality risk. If studies do not account for these factors, it is likely that the impact of hospital-acquired CDI will be overestimated.

Baggrund:Hygiejne er et nyt indsatsområde, som er skrevet ind i Sundhedsaftalerne 2011-2014. Sundhedsaftalen beskriver, at der i kommunerne er stigende behov for infektionshygiejnisk rådgivning i de kommunale institutioner. Formål:Formålet med dette studie var at undersøge, beskrive og analysere, hvordan kommuner på baggrund af Sundhedsaftalen 2011-2014arbejdermed oginterntsamarbejderom udvikling af en hygiejneorganisation. Desuden var formålet at afdække om Sundhedsstyrelsens forebyggelsespakke om hygiejne og netværksdannelsen omkring hospitalerne, havde betydning for udviklingen afhygiejneorganisation. Metode: Studiet er et kvalitativt studie,hvor det empiriske materialeblev indsamlet vedsemistrukturerede interview med medlemmer af hygiejnenetværket med hospitalet.Som analysemetode blev anvendt kvalitativ indholdsanalyse. Den teoretiske ramme for studiet er fokuseret på forskellige former for samarbejde, og styrker og svagheder ved samarbejde. Resultat:Studiet viste, at kommuner i Region Hovedstaden arbejder på forskellig vis medudvikling af en hygiejneorganisation.En afgørende faktorfor arbejdet var ledelsesforankring. Samarbejdet kompliceredes af, at kommunen blev opfattet som en stor, uoverskuelig organisation. Sundhedsaftalen, forebyggelsespakken om hygiejne og samarbejdet med hospitalet blev opfattet, som motiverende faktorer for udvikling af en hygiejneorganisation. Det blev opfattet, som en nødvendighed, at kommunen havde adgang til en hygiejnesygeplejerske, så arbejdet med hygiejne ikke kun blev baseret på interesse, men på kompetencer inden for området. Konklusion:Der er forskellige forhold, som er af afgørende betydning for samarbejde om udvikling af en kommunal hygiejneorganisation. Hygiejneorganiastionen skal være ledelsesforankret, og der skal være ledelsesgodkendte rammer for og ressourcer til arbejdet. Kommunen skal have direkte adgang til specialistviden på hygiejneområdet. / Background:Infection control isa new focus areain the intersectoral health agreements 2011-2014,which statesthat municipalities need guidance regarding infection control. Aim:The present study aimed to investigate, describe and analyze, how municipalitiesin Denmark ́s Capital Region collaborate internally while building an infection control organization. The study also aimed to determinehow hygiene suggestions from the National Board of Health and networking with hospitals affected the development of the infection control organization. Method:The empirical material of this qualitative studyincludedsemi-structured interviews with network members.Data was analyzed with qualitative content analysis. Theories supporting the study were different perspectives on collaboration. Results:The study found that municipalities in the Capital Region collaborate in different ways while developing an infection control organization. Management participationplayeda crucial role.. The municipality was considered a large confusing organization. Motivation factors included the health agreements, hygiene suggestions from the National Board of Health and networking with hospitals. Access to an infection control nurse was considered a necessary element, basing collaboration on competencies, rather than personal interest. Conclusion:Different circumstances are crucial when developing an infection control organization. Management must participate, and also must approve settings and resources. The municipality must have directaccess to expert knowledge about infection control / <p>ISBN 978-91-86739-81-2</p>