Showing papers in "Infection Control and Hospital Epidemiology in 2003"
TL;DR: Active surveillance cultures are essential to identify the reservoir for spread of MRSA and VRE infections and make control possible using the CDC's long-recommended contact precautions, demonstrating consistency of evidence, high strength of association, reversibility, dose gradient, and specificity for control with this approach.
Abstract: patients with MRSA or VRE usually acquire it via spread. The CDC has long-recommended contact precautions for patients colonized or infected with such pathogens. Most facilities have required this as policy, but have not actively identified colonized patients with sur veillance cultures, leaving most colonized patients undetected and unisolated. Many studies have shown control of endemic and/or epidemic MRSA and VRE infections using surveillance cultures and contact precautions, demonstrating consistency of evidence, high strength of association, reversibility, a dose gradient, and specificity for control with this approach. Adjunctive control measures are also discussed. CONCLUSION: Active surveillance cultures are essential to identify the reservoir for spread of MRSA and VRE infections and make control possible using the CDC’s long-recommended contact precautions (Infect Control Hosp Epidemiol 2003;24:362-386).
1,432 citations
TL;DR: It is suggested that an ongoing multidisciplinary antibiotic management program may have a sustained beneficial impact on both expenditures for antibiotics and the incidence of nosocomial infection by C. difficile and resistant bacterial pathogens.
Abstract: Objective:To evaluate the impact of an interventional multidisciplinary antibiotic management program on expenditures for antibiotics and on the incidence of nosocomial infections caused by Clostridium difficile and antibiotic-resistant pathogens during 7 years.Design:Prospective study with comparison with preintervention trends.Setting:University-affiliated teaching hospital.Patients:All adult inpatients.Intervention:A multidisciplinary antibiotic management program to minimize the inappropriate use of third-generation cephalosporins was implemented in 1991. Its impact was evaluated prospectively. The incidence of nosocomial C. difficile and resistant Enterobacteriaceae infections as well as the rate of vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) were compared with those of National Nosocomial Infections Surveillance System hospitals of similar size.Results:Following implementation of the program, there was a 22% decrease in the use of parenteral broad-spectrum antibiotics (P < .0001) despite a 15% increase in acuity of patient care during the following 7 years. Concomitantly, there was a significant (P= .002) decrease in nosocomial infections caused by C. difficile and a significant (P = .02) decrease in nosocomial infections caused by resistant Enterobacteriaceae. The program also appeared to have a favorable impact on VRE rates without a sustained impact on MRSA rates.Conclusion:These results suggest that an ongoing multidisciplinary antibiotic management program may have a sustained beneficial impact on both expenditures for antibiotics and the incidence of nosocomial infection by C. difficile and resistant bacterial pathogens.
410 citations
TL;DR: A review of Acinetobacter outbreaks summarizes factors related to the presence and recognition of organism transmission and describes the implementation of control and prevention measures directed at limiting spread of infection as mentioned in this paper.
Abstract: This review of Acinetobacter outbreaks summarizes factors related to the presence and recognition of organism transmission and describes the implementation of control and prevention measures directed at limiting spread. Exogenous transmission of Acinetobacter should be considered when infections are endemic and when case rates increase. Increasing or new antimicrobial resistances in a collection of isolates also suggest transmission, and transmission can be definitively confirmed when isolates are found to be indistinguishable from or related to one another by a discriminatory genotyping test. An investigation for a common source should be conducted. When a common source cannot be found and eliminated, or once an endemically transmitted organism is established, containment or prevention efforts may require aggressive interventions, complex interventions, or both. Colonization at multiple sites, the relative ease of induction of antibiotic resistance in the organism following patient exposure to multiple drugs, and long-term environmental survival provide enhanced opportunities for the transmission of Acinetobacter between and among patients. New approaches and interventional trials are needed to define effective measures for the prevention and control of Acinobacter infections.
395 citations
TL;DR: Belief in commonly held influenza vaccine misconceptions was significantly associated with influenza vaccine declination among nursing staff and may act as a barrier to greater rates of influenza vaccination.
Abstract: Objective: Influenza vaccine receipt by healthcare workers (HCWs) is important because HCWs are at risk for occupational exposure to influenza and may act as vectors in the nosocomial transmission of influenza. HCWs were surveyed to determine whether belief in commonly held influenza vaccine misconceptions was associated with influenza vaccine acceptance. Design: Cross-sectional study. Setting: A large urban teaching hospital. Method: A self-administered survey was used to assess nursing and physician staff influenza vaccine knowledge, current vaccination status, and potential reasons for vaccine declination. Results: Two hundred twelve of 215 surveys were completed. The overall influenza vaccination rate was 73%. Physician staff were significantly more likely to have been vaccinated compared with nursing staff (82% vs 62%, respectively; P = .0009). HCWs answering the 5 influenza vaccine basic knowledge questions correctly were significantly more likely to have been vaccinated than those responding incorrectly to any question (84% vs 64%, respectively; P = .002). This association was present in the nursing group where 80% of those answering the knowledge questions correctly were vaccinated, but only 49% of those answering incorrectly were vaccinated (P = .000005). However, in the physician group, there was no significant difference in the influenza vaccination rates between those answering correctly and those answering incorrectly (P = .459). Conclusion: Belief in commonly held influenza vaccine misconceptions was significantly associated with influenza vaccine declination among nursing staff and may act as a barrier to greater rates of influenza vaccination. Reasons for influenza vaccine nonreceipt may differ between nursing and physician staff.
229 citations
TL;DR: Prevention strategies for occupationally acquired HIV infection should continue to emphasize avoiding blood exposures, and healthcare workers should be educated about both the benefits and the limitations of PEP, which does not always prevent HIV infection following an exposure.
Abstract: OBJECTIVE: To characterize occupationally acquired human immunodeficiency virus (HIV) infection detected through case surveillance efforts in the United States. DESIGN: National surveillance systems, based on volun- tary case reporting. SETTING: Healthcare or laboratory (clinical or research) settings. PATIENTS: Healthcare workers, defined as individuals employed in healthcare or laboratory settings (including students and trainees), who are infected with HIV. METHODS: Review of data reported through December 2001 in the HIV/AIDS Reporting System and the National Surveillance for Occupationally Acquired HIV Infection. RESULTS: Of 57 healthcare workers with documented occupationally acquired HIV infection, most (86%) were exposed to blood, and most (88%) had percutaneous injuries. The circum- stances varied among 51 percutaneous injuries, with the largest proportion (41%) occurring after a procedure, 35% occurring dur- ing a procedure, and 20% occurring during disposal of sharp objects. Unexpected circumstances difficult to anticipate during or after procedures accounted for 20% of all injuries. Of 55 known source patients, most (69%) had acquired immunodeficiency syn- drome (AIDS) at the time of occupational exposure, but some (11%) had asymptomatic HIV infection. Eight (14%) of the health- care workers were infected despite receiving postexposure pro- phylaxis (PEP). CONCLUSIONS: Prevention strategies for occupationally acquired HIV infection should continue to emphasize avoiding blood exposures. Healthcare workers should be educated about both the benefits and the limitations of PEP, which does not always prevent HIV infection following an exposure. Technologic advances (eg, safety-engineered devices) may further enhance safety in the healthcare workplace (Infect Control Hosp Epidemiol 2003;24:86-96). ABSTRACT
225 citations
TL;DR: The genome sequence of the prototypic CA- MRSA strain, MW2, revealed the presence of additional virulence factors not commonly present in other S. aureus strains, and the genetic relatedness of 30 geographically diverse CA-MRSA isolates clustered based on SCCmec type IV was determined.
Abstract: The prevalence of MRSA in the nosocomial setting has been well studied, and its control remains a challenge for infection control professionals Complicating this problem is the increasing number of reports on the spread of community-acquired MRSA (CA-MRSA) CA-MRSA strains differ from hospital-acquired MRSA (HA-MRSA) strains in that they are generally susceptible to most antibiotics These strains share the presence of staphylococcal cassette chromosome mec (SCCmec) type IV in their genomes, are frequently virulent, and predominantly cause skin and soft tissue infections The genome sequence of the prototypic CA-MRSA strain, MW2, revealed the presence of additional virulence factors not commonly present in other S aureus strains We determined the genetic relatedness of 30 geographically diverse CA-MRSA isolates clustered based on SCCmec type IV by sequence analysis of the polymorphic repeat region of the protein A gene (spa typing) These results indicated that most strains shared a common spa type (131), identical to MW2 Because this group tends to infect healthy individuals with no known risk factors for nosocomial acquisition of MRSA, we refer to it as CA-MRSA without risk factors A second group, CA-MRSA with risk factors, consists of two related genotypes, spa types 1 and 7, which differ by one nucleotide change These strains have caused severe infections in HIV-positive patients in Los Angeles and New York Although CA-MRSA strains share genetic determinants, they are not clonal but rather are derived from different genetic backgrounds The genetic characteristics and the epidemiology of CA-MRSA with and without risk factors are discussed
220 citations
TL;DR: This consensus document presents background data and evidence-based recommendations for practices that are intended to decrease the risk of transmission of respiratory pathogens among CF patients from contaminated respiratory therapy equipment or the contaminated environment and thereby reduce the burden of respiratory illness.
Abstract: Infection Control Recommendations for Patients With Cystic Fibrosis: Microbiology, Important Pathogens, and Infection Control Practices to Prevent Patient-to-Patient Transmission updates, expands, and replaces the consensus statement, Microbiology and Infectious Disease in Cystic Fibrosis published in 1994. This consensus document presents background data and evidence-based recommendations for practices that are intended to decrease the risk of transmission of respiratory pathogens among CF patients from contaminated respiratory therapy equipment or the contaminated environment and thereby reduce the burden of respiratory illness. Included are recommendations applicable in the acute care hospital, ambulatory, home care, and selected non-healthcare settings. The target audience includes all healthcare workers who provide care to CF patients. Antimicrobial management is beyond the scope of this document.
210 citations
TL;DR: Concern over the potential for pathogen transmission during endoscopy has raised questions about the best methods for disinfection or sterilization of these devices between patient uses.
Abstract: Flexible gastrointestinal endoscopy is a valuable diagnostic and therapeutic tool for the care of patients with gastrointestinal and pancreaticobiliary disorders. Compliance with accepted guidelines for the reprocessing of gastrointestinal endoscopes between patients is critical to the safety and success of their use. When these guidelines are followed, pathogen transmission can be effectively prevented. Increased efforts and resources should be directed to improve compliance with these guidelines. Further research in the area of gastrointestinal endoscope reprocessing should be encouraged. The organizations that endorsed this guideline are committed to assisting the FDA and manufacturers in addressing critical infection control issues in gastrointestinal device reprocessing.
199 citations
TL;DR: Antimicrobial-impregnated CVCs reduced the risk of CVC-associated BSI by 66% in patients receiving TPN, and peripherally inserted central catheters (PICCs) were associated with a lower risk.
Abstract: Background Defining risk factors for central venous catheter (CVC)-associated bloodstream infections (BSIs) is critical to establishing prevention measures, especially for factors such as nurse staffing and antimicrobial-impregnated CVCs. Methods We prospectively monitored CVCs, nurse staffing, and patient-related variables for CVC-associated BSIs among adults admitted to eight ICUs during 2 years. Results A total of 240 CVC-associated BSIs (2.8%) were identified among 4,535 patients, representing 8,593 CVCs. Antimicrobial-impregnated CVCs reduced the risk for CVC-associated BSI only among patients whose CVC was used to administer total parenteral nutrition (TPN, 2.6 CVC-associated BSIs per 1,000 CVC-days vs no TPN, 7.5 CVC-associated BSIs per 1,000 CVC-days; P = .006). Among patients not receiving TPN, there was an increase in the risk of CVC-associated BSI in patients cared for by "float" nurses for more than 60% of the duration of the CVC. In multivariable analysis, risk factors for CVC-associated BSIs were the use of TPN in non-antimicrobial-impregnated CVCs (P = .0001), patient cared for by a float nurse for more than 60% of CVC-days (P = .0019), no antibiotics administered to the patient within 48 hours of insertion (P = .0001), and patient unarousable for 70% or more of the duration of the CVC (P = .0001). Peripherally inserted central catheters (PICCs) were associated with a lower risk for CVC-associated BSI (P = .0001). Conclusions Antimicrobial-impregnated CVCs reduced the risk of CVC-associated BSI by 66% in patients receiving TPN. Limiting the use of float nurses for ICU patients with CVCs and the use of PICCs may also reduce the risk of CVC-associated BSI.
175 citations
TL;DR: Most studies have had inadequate sample size, inadequate adjustment for other predictors of adverse outcomes, or both, but available data suggest that VREB is associated with higher recurrence, mortality, and excess costs than VSEB including multiple studies adjusting for severity of illness.
Abstract: Background:Because patients with vancomycin-resistant Enterococcus bacteremia (VREB) usually have a higher severity of illness, it has been unclear whether VREB is worse than vancomycin-susceptible Enterococcus bacteremia (VSEB).Methods:Data on morbidity and case fatality rates and costs were pooled from studies comparing VREB and VSEB, identified by Medline (January 1986 to April 2002) and meeting abstracts. Heterogeneity across studies was assessed with contingency table chi-square. Multivariate analyses (MVAs) controlling for other predictors were evaluated.Results:Thirteen studies compared case-fatality rates of VREB and VSEB. VREB case fatality was significantly higher (48.9% vs 19%; RR, 2.57; CI95, 2.27 to 2.91; attributable mortality = 30%). Five studies compared VREB with VSEB when bacteremia was the direct cause of death; VREB case fatality was significantly higher (39.1% vs 21.8%; RR, 1.79; CI95, 1.28 to 2.5; attributable mortality = 17%). Four MVAs found significant increases in case-fatality rates (OR 2.10 to 4.0), 3 showed trends toward increase (OR, 1.74 to 3.34 with wide confidence intervals), and 3 with low statistical power found no difference. VREB recurred in 16.9% versus 3.7% with VSEB (P < .0001). Three studies reported significant increases in LOS, costs, or both with VREB.Conclusion:Most studies have had inadequate sample size, inadequate adjustment for other predictors of adverse outcomes, or both, but available data suggest that VREB is associated with higher recurrence, mortality, and excess costs than VSEB including multiple studies adjusting for severity of illness.
163 citations
TL;DR: The epidemiologic and molecular investigations that successfully contained an outbreak of methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit (NICU) were described and a possible route of MRSA transmission was elucidated by molecular typing.
Abstract: OBJECTIVE: To describe the epidemiologic and molecular investigations that successfully contained an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) in a neonatal intensive care unit (NICU). DESIGN: Isolates of MRSA were typed by pulsed-field gel electrophoresis (PFGE) and S. aureus protein A (spa). SETTING: A level III-IV, 45-bed NICU located in a children's hospital within a medical center. PATIENTS: Incident cases had MRSA isolated from clinical cultures (eg, blood) or surveillance cultures (ie, anterior nares). INTERVENTIONS: Infected and colonized infants were placed on contact precautions, cohorted, and treated with mupirocin. Surveillance cultures were performed for healthcare workers (HCWs). Colonized HCWs were treated with topical mupirocin and hexachlorophene showers. RESULTS: From January to March 2001, the outbreak strain of MRSA, PFGE clone B, was harbored by 13 infants. Three (1.3%) of 235 HCWs were colonized with MRSA. Two HCWs, who rotated between the adult and the pediatric facility, harbored clone C. One HCW, who exclusively worked in the children's hospital, was colonized with clone B. From January 1999 to November 2000, 22 patients hospitalized in the adult facility were infected or colonized with clone B. Spa typing and PFGE yielded concordant results. PFGE clone B was identified as spa type 16, associated with outbreaks in Brazil and Hungary. CONCLUSIONS: A possible route of MRSA transmission was elucidated by molecular typing. MRSA appears to have been transferred from our adult facility to our pediatric facility by a rotating HCW. Spa typing allowed comparison of our institution's MRSA strains with previously characterized outbreak clones.
TL;DR: Copper-silver ionization is now the only disinfection modality to have fulfilled all four evaluation criteria and no cases of hospital-acquired legionnaires' disease have occurred in any hospital since 1995.
Abstract: Background and Objectives:Hospital-acquired legionnaires' disease can be prevented by disinfection of hospital water systems This study assessed the long-term efficacy of copper-silver ionization as a disinfection method in controlling Legionella in hospital water systems and reducing the incidence of hospital-acquired legionnaires' disease A standardized, evidence-based approach to assist hospitals with decision making concerning the possible purchase of a disinfection system is presentedDesign:The first 16 hospitals to install copper-silver ionization systems for Legionella disinfection were surveyed Surveys conducted in 1995 and 2000 documented the experiences of the hospitals with maintenance of the system, contamination of water with Legionella, and occurrence of hospital-acquired legionnaires' disease All were acute care hospitals with a mean of 435 bedsResults:All 16 hospitals reported cases of hospital-acquired legionnaires' disease prior to installing the copper-silver ionization system Seventy-five percent had previously attempted other disinfection methods including superheat and flush, ultraviolet light, and hyperchlorination By 2000, the ionization systems had been operational from 5 to 11 years Prior to installation, 47% of the hospitals reported that more than 30% of distal water sites yielded Legionella In 1995, after installation, 50% of the hospitals reported 0% positivity, and 43% still reported 0% in 2000 Moreover, no cases of hospital-acquired legionnaires' disease have occurred in any hospital since 1995Conclusions:This study represents the final step in a proposed 4-step evaluation process of disinfection systems that includes (1) demonstrated efficacy of Legionella eradication in vitro using laboratory assays, (2) anecdotal experiences in preventing legionnaires' disease in individual hospitals, (3) controlled studies in individual hospitals, and (4) validation in confirmatory reports from multiple hospitals during a prolonged time (5 to 11 years in this study) Copper-silver ionization is now the only disinfection modality to have fulfilled all four evaluation criteria
TL;DR: The findings indicate that the epidemiology of MRSA in rural southwestern Alaska has changed and suggest that the emergence of community-onsetMRSA in this region was not related to spread of a hospital organism.
Abstract: Objective We investigated a large outbreak of community-onset methicillin-resistant Staphylococcus aureus (MRSA) infections in southwestern Alaska to determine the extent of these infections and whether MRSA isolates were likely community acquired. Design Retrospective cohort study. Setting Rural southwestern Alaska. Patients All patients with a history of culture-confirmed S. aureus infection from March 1, 1999, through August 10, 2000. Results More than 80% of culture-confirmed S. aureus infections were methicillin resistant, and 84% of MRSA infections involved skin or soft tissue; invasive disease was rare. Most (77%) of the patients with MRSA skin infections had community-acquired MRSA (no hospitalization, surgery, dialysis, indwelling line or catheter, or admission to a long-term-care facility in the 12 months before infection). Patients with MRSA skin infections were more likely to have received a prescription for an antimicrobial agent in the 180 days before infection than were patients with methicillin-susceptible S. aureus skin infections. Conclusions Our findings indicate that the epidemiology of MRSA in rural southwestern Alaska has changed and suggest that the emergence of community-onset MRSA in this region was not related to spread of a hospital organism. Treatment guidelines were developed recommending that beta-lactam antimicrobial agents not be used as a first-line therapy for suspected S. aureus infections.
TL;DR: Computer equipment must be kept clean so it does not become another vehicle for transmission of pathogens to patients.
Abstract: We tested 100 keyboards in 29 clinical areas for bacterial contamination. Ninety five were positive for microorganisms. Streptococcus, Clostridium perfringens, Enterococcus (including one vancomycin-resistant Enterococcus), Staphylococcus aureus, fungi, and gram-negative organisms were isolated. Computer equipment must be kept clean so it does not become another vehicle for transmission of pathogens to patients.
TL;DR: The Charlson WIC is a good predictor of mortality in this population of patients with SAB and may be a useful instrument to control comorbidity in studies aiming to investigate risk factors for death due to bacteremia.
Abstract: Objective:To demonstrate the effectiveness of the Charlson weighted index of comorbidity (WIC) for controlling comorbidity in prospective studies focusing on mortality in patients with Staphylococcus aureus bacteremia (SAB).Design:Cohort study.Setting:Two tertiary-care, university-affiliated hospitals in France.Patients:One hundred sixty-six inpatients 18 years or older consecutively diagnosed with SAB from May 15, 2001, to May 15, 2002.Methods:Patients were prospectively assessed and cases were followed by the infectious diseases consult service at least 3 months after effective antibiotic therapy completion. The Charlson WIC was computed and dichotomized into scores of fewer than 3 points and 3 or more points. Bacteremia source, acute complication due to SAB acquisition in the ICU, and inappropriate empiric antibiotic therapy were recorded. The endpoint was death due to SAB and overall mortality.Results:In univariate analysis, the Charlson WIC was able to predict overall mortality and S. aureus-related death. The following variables were found to be independently predictive of mortality due to SAB using the Cox model: an acute complication due to S. aureus (OR, 8.9; CI95, 4 to 19.7; P < .001), a Charlson WIC score of 3 or more (OR, 3; CI95, 1.3 to 5.5; P = .006), and age (OR, 1.04; CI95, 1.009 to 1.07; P < .01).Conclusions:Comorbidity contributes to death in patients with SAB. The Charlson WIC is a good predictor of mortality in this population and may be a useful instrument to control comorbidity in studies aiming to investigate risk factors for death due to bacteremia.
TL;DR: House staff tended to work through their illnesses, potentially putting patients at risk, and thought the vaccine should be mandatory, despite busy schedules and an unfounded fear of getting influenza symptoms from the vaccine.
Abstract: Objective: To determine influenza vaccination rates, vaccine effectiveness, and factors influencing vaccination decisions among house staff. Design: Cross-sectional survey. Setting and Participants: All residents registered at the University of Toronto were surveyed after the 1999-2000 influenza season. Of the 1,159 questionnaires mailed, 670 (58%) could be evaluated. Results: Influenza-like illnesses were reported by 36% of house staff. The vaccination rate was 51% among respondents, being highest for community and occupational medicine and pediatric staff (77% and 75%) and lowest for psychiatry, surgery, and radiology staff (32%, 36%, and 36%). Vaccinees reported significantly fewer episodes of illness (42 vs 54 per 100 subjects; P = .03) and fewer days of illness (272 vs 374 per 100 subjects; P = .02); absenteeism was not different (63 vs 69 per 100 subjects; P = .69). Self-protection was the most common reason for vaccination. Vaccinees believed the vaccine was more effective than did non-vaccinees (P < .01). Non-vaccinees considered influenza-like symptoms the most important side effect of the vaccine. Busy schedules and inconvenience were the most common reasons for not getting vaccinated. Overall, 44% of house staff believed the influenza vaccine should be mandatory. Conclusions: Influenza-like illness was common among house staff. They tended to work through their illnesses, potentially putting patients at risk. They were motivated mostly by self-protection and did report a benefit. Despite busy schedules and an unfounded fear of getting influenza symptoms from the vaccine, many thought the vaccine should be mandatory.
TL;DR: Mupirocin was effective in eradicating MS MRSA, but strains of MR MRSA often persisted after treatment, which appeared to reflect treatment failure rather than exogenous recolonization.
Abstract: Objective:To determine the efficacy of mupirocin ointment in reducing nasal colonization with mupirocin-susceptible, methicillin-resistant Staphylococcus aureus (MS MRSA) as well as mupirocin-resistant MRSA (MR MRSA).Design:Prospective evaluation in which patients colonized with MRSA were treated twice daily with 2% topical mupirocin ointment for 5 days.Setting:James H. Quillen Veterans' Affairs Medical Center.Patients:Forty hospitalized patients with two anterior nares cultures positive for MRSA within a 7-day period.Methods:Treated patients had post-treatment cultures at day 3 and weeks 1,2, and 4. Isolates underwent mupirocin-susceptibility testing and DNA typing. MRSA clearance and type turnover were assessed for isolates that were mupirocin-susceptible, low-level (LL) MR MRSA and high-level (HL) MR MRSA.Results:Post-treatment nares cultures on day 3 were negative for 78.5%, 80%, and 27.7% of patients with MS MRSA, LL-MR MRSA, and HL-MR MRSA, respectively. Sustained culture negativity at 1 to 4 weeks was more common in the MS MRSA group (91%) than in the LL-MR MRSA group (25%) or the HL-MR MRSA group (25%). Positive post-treatment cultures usually showed the same DNA pattern relative to baseline. Plasmid curing of 18 HL-MR MRSA resulted in 15 MS MRSA and 3 LL-MR MRSA.Conclusions:Mupirocin was effective in eradicating MS MRSA, but strains of MR MRSA often persisted after treatment. This appeared to reflect treatment failure rather than exogenous recolonization. MR MRSA is now more prevalent and it is appropriate to sample MRSA populations for mupirocin susceptibility prior to incorporating mupirocin into infection control programs.
TL;DR: Current surveillance and infection control efforts to reduce morbidity and mortality associated with bloodstream infections concentrate on the high-risk ICU patients with CVCs, but a 1-day prevalence survey of CVC use among adult inpatients at six medical centers participating in the Prevention Epicenter Program of the CDC suggests that more efforts should be directed to patients withCVCs who are outside the ICU.
Abstract: Objective:To determine the prevalence of central venous catheter (CVC) use among patients both within and outside the ICU setting.Design:A 1-day prevalence survey of CVC use among adult inpatients at six medical centers participating in the Prevention Epicenter Program of the CDC. Using a standardized form, observers at each Epicenter performed a hospital-wide survey, collecting data on CVC use.Setting:Inpatient wards and ICUs of six large urban teaching hospitals.Results:At the six medical centers, 2,459 patients were surveyed; 29% had CVCs. Among the hospitals, from 43% to 80% (mean, 59.3%) of ICU patients and from 7% to 39% (mean, 23.7%) of non-ICU patients had CVCs. Despite the lower rate of CVC use on non-ICU wards, the actual number of CVCs outside the ICUs exceeded that of the ICUs. Most catheters were inserted in the subclavian (55%) or jugular (22%) site, with femoral (6%) and peripheral (15%) sites less commonly used. The jugular (33.0% vs 16.6%; P < .001) and femoral (13.8% vs 2.7%; P < .001) sites were more frequently used in ICU patients, whereas peripherally inserted (19.9% vs 5.9%; P < .001) and subclavian (60.7% vs 47.3%; P < .001) catheters were more commonly used in non-ICU patients.Conclusions:Current surveillance and infection control efforts to reduce morbidity and mortality associated with bloodstream infections concentrate on the high-risk ICU patients with CVCs. Our survey demonstrated that two-thirds of identified CVCs were not in ICU patients and suggests that more efforts should be directed to patients with CVCs who are outside the ICU.
TL;DR: It is suggested that transmission of nosocomially acquired MRSA outside of the healthcare setting may be a substantial source of MRSA colonization and infection in the community.
Abstract: OBJECTIVE: To determine the frequency with which methicillin-resistant Staphylococcus aureus (MRSA) is spread from colonized or infected patients to their household and community contacts. DESIGN: Retrospective cohort study. SETTING: University hospital. PARTICIPANTS: Household and community contacts of MRSA-colonized or -infected patients for whom MRSA screening cultures were performed. RESULTS: MRSA was isolated from 25 (14.5%) of 172 individuals. Among the contacts of index patients who had at least one MRSA-colonized contact, those with close contact to the index patient were 7.5 times more likely to be colonized (53% vs 7%; 95% confidence interval, 1.1 to 50.3; P =.002). An analysis of antimicrobial susceptibility and DNA fingerprint patterns suggested person-to-person spread. CONCLUSIONS: MRSA colonization occurs frequently among household and community contacts of patients with nosocomially acquired MRSA, suggesting that transmission of nosocomially acquired MRSA outside of the healthcare setting may be a substantial source of MRSA colonization and infection in the community.
TL;DR: Postexposure screening of HCWs allowed early detection of MRSA carriage and prevention of subsequent transmission to patients in settings where the MRSA prevalence is higher, and an adapted version of the program could help prevent dissemination.
Abstract: Background and objective The benefit of screening healthcare workers (HCWs) at risk for methicillin-resistant Staphylococcus aureus (MRSA) carriage and furloughing MRSA-positive HCWs to prevent spread to patients is controversial. We evaluated our MRSA program for HCWs between 1992 and 2002. Setting A university medical center in The Netherlands, where methicillin resistance has been kept below 0.5% of all nosocomial S. aureus infections using active surveillance cultures and isolation of colonized patients. Design HCWs caring for MRSA-positive patients or patients in foreign hospitals were screened for MRSA. MRSA-positive HCWs had additional cultures, temporary exclusion from patient-related work, assessment of risk factors for persisting carriage, decolonization therapy with mupirocin intranasally and chlorhexidine baths for skin and hair, and follow-up cultures. Results Fifty-nine HCWs were colonized with MRSA. Seven of 840 screened employees contracted MRSA in foreign hospitals; 36 acquired MRSA after contact with MRSA-positive patients despite isolation precautions (attack rate per outbreak varied from less than 1% to 15%). Our hospital experienced 17 MRSA outbreaks, including 13 episodes in which HCWs were involved. HCWs were index cases of at least 4 outbreaks. In 8 outbreaks, HCWs acquired MRSA after caring for MRSA-positive patients despite isolation precautions. Conclusion Postexposure screening of HCWs allowed early detection of MRSA carriage and prevention of subsequent transmission to patients. Where the MRSA prevalence is higher, the role of HCWs may be greater. In such settings, an adapted version of our program could help prevent dissemination.
TL;DR: There was no evidence that MRSA colonization occurs commonly among low-risk individuals in this community, and data suggest that evaluation of recent healthcare exposures is essential if true community acquisition of MRSA is to be confirmed.
Abstract: Objectives To determine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization among patients presenting for hospital admission and to identify risk factors for MRSA colonization. Design Surveillance cultures were performed at the time of hospital admission to identify patients colonized with S. aureus. A case-control study was performed to identify risk factors for MRSA colonization. Setting A tertiary-care academic medical center. Patients Adults presenting for hospital admission (N = 974). Results S. aureus was isolated from 205 (21%) of the patients for whom cultures were performed. Methicillin-sensitive S. aureus was isolated from 179 (18.4%) of the patients, and MRSA was isolated from 26 (2.7%) of the patients. All 26 MRSA-colonized patients had been admitted to a healthcare facility in the preceding year, had at least one chronic illness, or both. In multivariate analyses comparing MRSA-colonized patients with control-patients, admission to a nursing home (odds ratio [OR], 16.5; 95% confidence interval [CI95], 1.4 to 192.1; P = .025) or a hospitalization of 5 days or longer during the preceding year (OR, 3.91; CI95, 1.1 to 13.9; P = .035) were independent predictors of MRSA colonization. Conclusions Patients colonized with MRSA admitted to this hospital likely acquired the organism during previous encounters with healthcare facilities. There was no evidence that MRSA colonization occurs commonly among low-risk individuals in this community. These data suggest that evaluation of recent healthcare exposures is essential if true community acquisition of MRSA is to be confirmed.
TL;DR: Vancomycin-resistant enterococcal bacteremia contributes significantly to excess mortality and economic loss, once severity of illness is considered and efforts to prevent these infections will likely be cost-effective.
Abstract: OBJECTIVE: To determine the impact of vancomycinresistant enterococcal bacteremia on patient outcomes and costs by assessing mortality, excess length of stay, and charges attributable to it. DESIGN: A population-based, matched, historical cohort study. SETTING: A 1,025-bed, university-based teaching facility and referral hospital. PATIENTS: Two hundred seventy-seven vancomycinresistant enterococcal bacteremia case-patients and 277 matched control-patients identified between 1993 and 2000. RESULTS: The crude mortality rate was 50.2% and 19.9% for case-patients and control-patients, respectively, yielding a mortality rate of 30.3% attributable to vancomycin-resistant enterococcal bacteremia. The excess length of hospital stay attributable to vancomycin-resistant enterococcal bacteremia was 17 days, of which 12 days were spent in intensive care units. On average, $77,558 in extra charges was attributable to each vancomycin-resistant enterococcal bacteremia. To adjust for severity of illness, 159 pairs of case-patients and control-patients, who had the same severity of illness (All Patient Refined-Diagnosis Related Group complexity level), were further analyzed. When patients were stratified by severity of illness, the crude mortality rate was 50.3% among case-patients compared with 27.7% among control-patients, accounting for an attributable mortality rate of 22.6%. Attributable excess length of stay and charges were 17 days and $81,208, respectively. CONCLUSION: Vancomycin-resistant enterococcal bacteremia contributes significantly to excess mortality and economic loss, once severity of illness is considered. Efforts to prevent these infections will likely be cost-effective (Infect Control Hosp Epidemiol 2003;24:251-256).
TL;DR: In this article, the authors compared the characteristics of colonizing methicillin-resistant S. aureus (MRSA) strains with those of strains causing infection in our community and hospital.
Abstract: OBJECTIVES: To assess the prevalence of and the clinical features associated with asymptomatic Staphylococcus aureus colonization in a healthy outpatient population, and to compare the characteristics of colonizing methicillin-resistant S. aureus (MRSA) strains with those of strains causing infection in our community and hospital. SETTING: Outpatient military clinics. METHODS: Specimens were obtained from the nares, pharynx, and axillae of 404 outpatients, and a questionnaire was administered to obtain demographic and risk factor information. MRSA strains were typed by pulsed-field gel electrophoresis (PFGE) and evaluated for antibiotic susceptibility. Antibiograms of study MRSA strains were compared with those of MRSA strains causing clinical illness during the same time period. RESULTS: Methicillin-susceptible S. aureus (MSSA) colonization was present in 153 (38%) of the 404 asymptomatic outpatients, and MRSA colonization was present in 8 (2%). Detection of colonization was highest from the nares. No clinical risk factor was significantly associated with MRSA colonization; however, a tendency was noted for MRSA to be more common in men and in those who were older or who had been recently hospitalized. All colonizing MRSA strains had unique patterns on PFGE. In contrast to strains responsible for hospital infections, most colonizing isolates of MRSA were susceptible to oral antibiotics. CONCLUSIONS: MRSA and MSSA colonization is common in our outpatient population. Colonization is best detected by nares cultures and most carriers of MRSA are without apparent predisposing risk factors for acquisition. Colonizing isolates of MRSA are heterogeneous and, unlike nosocomial isolates, often retain susceptibility to other non–beta-lactam antibiotics (Infect Control Hosp Epidemiol 2003;24:439-444).
TL;DR: Recommendations for the diagnosis and treatment of skin infections in the jail are issued and LACDHS is working with the Los Angeles County Sheriffs Department to review policies and procedures on laundry, showers, environmental cleaning, skin care, and control of person-to-person transmission.
Abstract: Outbreaks of Community-Associated Methicillin-Resistant Staphylococcus aureus Skin Infections Methicillin-resistant Staphylococcus aureus (MRSA) has commonly occurred in healthcare settings; however, recent investigations of community-associated MRSA (CAMRSA) have identified infection in various settings, including correctional facilities, athletic teams, and others. During 2002, the Los Angeles County Department of Health Services (LACDHS) investigated three community outbreaks of skin infections associated with MRSA In September 2002, LACDHS investigated cases of MRSA infection in two athletes on the same team who were hospitalized with MRSA within the same week. No additional cases of MRSA have been identified. The source of MRSA infection for these patients has not been determined. On November 22, 2002, physicians from two large infectious disease clinical practices notified LACDHS of MRSA skin infections among men who have sex with men (MSM). LACDHS has increased surveillance in selected clinics serving MSM and has begun a study of risk factors for infection among this population. In February 2003, LACDHS investigated an outbreak in the Los Angeles County Jail, in which 928 inmates had MRSA wound infections diagnosed in 2002. Patients were reported as having spider bites but subsequently were found to be infected with MRSA Review of the medical charts of 39 of the 66 inmates hospitalized with these infections indicated that all initially had skin infections, but 10 later had invasive disease, including bacteremia, endocarditis, or osteomyelitis. The Los Angeles County Jail is the largest jail system in the United States; 165,000 individuals are incarcerated in the jail each year. LACDHS issued recommendations for the diagnosis and treatment of skin infections in the jail and is working with the Los Angeles County Sheriffs Department to review policies and procedures on laundry, showers, environmental cleaning, skin care, and control of person-to-person transmission.
TL;DR: This study increases the understanding of the burden of these multidrug-resistant organisms and estimates the societal costs of these infections and the cost-effectiveness of preventive interventions.
Abstract: OBJECTIVES To determine the costs of the interventions aimed at controlling the 4-month outbreak and to determine the attributable length of stay (LOS) associated with infection and colonization with extended-spectrum beta-lactamase-producing Klebsiella pneumoniae. DESIGN A retrospective cost analysis was conducted from the hospital perspective. A micro-costing approach was employed. The LOS of four groups of hospitalized patients were compared with each other. National Perinatal Information Center criteria were used to stratify infants for severity of risk. The LOS of each group was compared with that of a national sample of similarly stratified infants. SETTING A level III-IV, 45-bed neonatal intensive care unit. PATIENTS Infant groups were infected (n = 8), colonized (n = 14), concurrent cohort (n = 54), and prior cohort (n = 486). RESULTS The cost of the outbreak totaled 341,751 dollars. The largest proportion of costs was related to healthcare worker time providing direct patient care (2,489 hours at a cost of 146,331 dollars). Infected and colonized neonates had longer LOS than either the concurrent cohort or the prior cohort (P < .001). Compared with the national sample, infected infants had a 48.5-day longer mean LOS (95% confidence interval [CI95], 1.7 to 95.2), whereas the prior cohort's mean LOS was 6 days shorter (CI95, -9.4 to -2.9). CONCLUSIONS This study increases the understanding of the burden of these multidrug-resistant organisms. Further research is needed to estimate the societal costs of these infections and the cost-effectiveness of preventive interventions.
TL;DR: This outbreak of HCV probably occurred when a multidose saline vial was contaminated with blood from an HCV-infected patient, and hospitals should emphasize adherence to standard procedures to prevent blood-borne infections.
Abstract: Objective:To identify the source of an outbreak of acute hepatitis C virus (HCV) infection among 3 patients occurring within 8 weeks of hospitalization in the same ward of a Florida hospital during November 1998.Design:A retrospective cohort study was conducted among 41 patients hospitalized between November 11 and 19, 1998. Patients' blood was tested for antibodies to HCV, and HCV RNA-positive samples were genotyped and sequenced.Results:Of the 41 patients, 24 (59%) participated in the study. HCV genotype 1b infections were found in 5 patients. Three of 4 patients who received saline flushes from a multidose saline vial on November 16 had acute HCV infection, whereas none of the 9 patients who did not receive saline flushes had HCV infection (P = .01). No other significant exposures were identified. The HCV sequence was available for 1 case of acute HCV and differed by a single nucleotide (0.3%) from that of the indeterminate case.Conclusion:This outbreak of HCV probably occurred when a multidose saline vial was contaminated with blood from an HCV-infected patient. Hospitals should emphasize adherence to standard procedures to prevent blood-borne infections. In addition, the use of single-dose vials or prefilled saline syringes might further reduce the risk for nosocomial transmission of blood-borne pathogens.
TL;DR: Cidal activity was shown against C. difficile spores by glutaraldehyde, peracetyl ions, and acidified nitrite, and these agents seem well suited for the disinfection of C. diffuse spores in the hospital environment.
Abstract: Objective:To identify environmentally safe, rapidly acting agents for killing spores of Clostridium difficile in the hospital environment.Design:Three classic disinfectants (2% glutaraldehyde, 1.6% peracetyl ions, and 70% isopropanol) and acidified nitrite were compared for activity against C. difficile spores. Four strains of C. difficile belonging to different serogroups were tested using a dilution–neutralization method according to preliminary European Standard prEN 14347. For peracetyl ions and acidified nitrite, the subjective cleaning effect and the sporicidal activity was also tested in the presence of organic load.Results:Peracetyl ions were highly sporicidal and yielded a minimum 4 log10 reduction of germinating spores already at short exposure times, independent of organic load conditions. Isopropanol 70% showed low or no inactivation at all exposure times, whereas glutaraldehyde and acidified nitrite each resulted in an increasing inactivation factor (IF) over time, from an IF greater than 1.4 at 5 minutes of exposure time to greater than 4.1 at 30 minutes. Soiling conditions did not influence the effect of acidified nitrite. There was no difference in the IF among the 4 strains tested for any of the investigated agents. Acidified nitrite demonstrated a good subjective cleaning effect and peracetyl ions demonstrated a satisfactory effect.Conclusions:Cidal activity was shown against C. difficile spores by glutaraldehyde, peracetyl ions, and acidified nitrite. As acidified nitrite and peracetyl ions are considered to be environmentally safe chemicals, these agents seem well suited for the disinfection of C. difficile spores in the hospital environment.
TL;DR: Optimal antibiotic prophylaxis may reduce the risk of infection, especially in high-risk patients such as those with myelodysplasia or those undergoing fusion involving the sacral area.
Abstract: OBJECTIVES: To determine the rates of surgical-site infections (SSIs) after spinal surgery and to identify the risk factors associated with infection. DESIGN: SSIs had been identified by active prospective surveillance. A case-control study to identify risk factors was performed retrospectively. SETTING: University-associated, tertiary-care pediatric hospital. PATIENTS: All patients who underwent spinal surgery between 1994 and 1998. Cases were all patients who developed an SSI after spinal surgery. Controls were patients who did not develop an SSI, matched with the cases for the presence or absence of myelodysplasia and for the surgery date closest to that of the case. RESULTS: There were 10 infections following 125 posterior spinal fusions, 4 infections after 50 combined anterior-posterior fusions, and none after 95 other operations. The infection rate was higher in patients with myelodysplasia (32 per 100 operations) than in other patients (3.4 per 100 operations; relative risk = 9.45; P <.001). Gram-negative organisms were more common in early infections and Staphylococcus aureus in later infections. Most infections occurred in fusion involving sacral vertebrae (odds ratio [OR] = 12.0; P =.019). Antibiotic prophylaxis was more frequently suboptimal in cases than in controls (OR = 5.5; P =.034). Five patients required removal of instrumentation and 4 others required surgical debridement. CONCLUSIONS: Patients with myelodysplasia are at a higher risk for SSIs after spinal fusion. Optimal antibiotic prophylaxis may reduce the risk of infection, especially in high-risk patients such as those with myelodysplasia or those undergoing fusion involving the sacral area.
TL;DR: Infliximab is a chimeric monoclonal antibody against tumor necrosis factor (TNF)-alpha, used for the treatment of Crohn's disease and rheumatoid arthritis.
Abstract: Background:Infliximab is a chimeric monoclonal antibody against tumor necrosis factor (TNF)-alpha, used for the treatment of Crohn's disease and rheumatoid arthritis. Recently, an increased risk of infection due to Mycobacterium tuberculosis and rare cases of invasive fungal disease have been reported following infliximab therapy.Case Report:A 73-year-old woman with chronic rheumatoid arthritis who had been treated with methotrexate, leflunomide, and prednisone was given the first of three doses of infliximab in June 2001. In July 2001, she presented with cough, and in August, she had a right upper lobe infiltrate that was treated with levofloxacin without improvement. In October, the patient had right upper and middle lobe infiltrates on a chest x-ray and computed tomography scan. At bronchoscopy, an endobronchial mass was biopsied, which demonstrated Aspergillus fumigatus. Our patient had frequently accompanied her daughter on visits to another medical center following a stem cell transplant, where her daughter was instructed to wear a mask during all visits because of extensive building construction. We postulate that our patient may have acquired pulmonary aspergillosis during this period. Literature reviews on granulomatous diseases following infliximab therapy and hospital-acquired aspergillosis are presented.Conclusion:The temporal relationship between the administration of infliximab and A. fumigatus infection in this patient suggests a causal relationship and possible healthcare-associated acquisition. These data underscore the importance of both patient and family education on prevention strategies when potent immune-modulating medications such as infliximab have been prescribed (Infect Control Hosp Epidemiol 2003;24:477-482)
TL;DR: Most suspected EOS infants with NegBCs are given antibiotics, but no antepartum historical risk factors or neonatal clinical signs explained prolonged administration, so discontinuing empiric antibiotics when BCs are negative in asymptomatic ELBW infants can reduce antimicrobial exposure without compromising clinical outcome.
Abstract: OBJECTIVES: To study multicenter antibiotic practices for suspected early-onset sepsis (EOS) with negative blood cultures (NegBCs) and to identify opportunities for reduction of antimicrobial exposure. DESIGN: Retrospective study. SETTING: Thirty academic hospitals (University HealthSystem Consortium) located in 24 states. METHODS: Data were from a survey of 790 extremely low birth weight (ELBW) infants. Total antibiotic exposures (antibiotic-days per patient) were calculated. RESULTS: On admission to the NICU, 94% of 790 ELBW infants had BCs performed and empiric antibiotics initiated. When PosBC and NegBC infants were compared, 47 patients with PosBCs were similar to 695 with NegBCs in birth weight, gestational age (GA), and mortality. Patients with suspected EOS but NegBCs given ampicillin/aminoglycosides were grouped by length of administration and GA. For GA of 26 weeks or younger, 170 infants given a short (≤ 3 days) and 157 given a long (≤ 7 days) course were similar regarding birth weight, mortality, antepartum history, and CRIB scores, but were different (P <.01) in number receiving a third antimicrobial (3% and 17%) and antibiotic-days (23 and 38). For GA of 27 weeks or older, 113 infants given a short and 77 given a long course differed (P <.01) in number receiving a third antimicrobial (2% and 23%) and antibiotic-days (19 and 30). CONCLUSIONS: Most suspected EOS infants with NegBCs are given antibiotics, but no antepartum historical risk factors or neonatal clinical signs explained prolonged administration. Discontinuing empiric antibiotics when BCs are negative in asymptomatic ELBW infants can reduce antimicrobial exposure without compromising clinical outcome.