Showing papers in "Infection Control and Hospital Epidemiology in 2008"

Antimicrobial-Resistant Pathogens Associated with Healthcare- Associated Infections: Summary of Data Reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009-2010

Abstract: Objective. To describe antimicrobial resistance patterns for healthcare-associated infections (HAIs) reported to the National Healthcare Safety Network (NHSN) during 2009-2010. Methods. Central line-associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated pneumonia, and surgical site infections were included. Pooled mean proportions of isolates interpreted as resistant (or, in some cases, nonsusceptible) to selected antimicrobial agents were calculated by type of HAI and compared to historical data. Results. Overall, 2,039 hospitals reported 1 or more HAIs; 1,749 (86%) were general acute care hospitals, and 1,143 (56%) had fewer than 200 beds. There were 69,475 HAIs and 81,139 pathogens reported. Eight pathogen groups accounted for about 80% of reported pathogens: Staphylococcus aureus (16%), Enterococcus spp. (14%), Escherichia coli (12%), coagulase-negative staphylococci (11%), Candida spp. (9%), Klebsiella pneumoniae (and Klebsiella oxytoca; 8%), Pseudomonas aeruginosa (8%), and Enterobacter spp. (5%). The percentage of resistance was similar to that reported in the previous 2-year period, with a slight decrease in the percentage of S. aureus resistant to oxacillins (MRSA). Nearly 20% of pathogens reported from all HAIs were the following multidrug-resistant phenotypes: MRSA (8.5%); vancomycin-resistant Enterococcus (3%); extended-spectrum cephalosporin-resistant K. pneumoniae and K. oxytoca (2%), E. coli (2%), and Enterobacter spp. (2%); and carbapenem-resistant P. aeruginosa (2%), K. pneumoniae/oxytoca (<1%), E, coli (<1%), and Enterobacter spp. (<1%). Among facilities reporting HAIs with 1 of the above gram-negative bacteria, 20%-40% reported at least 1 with the resistant phenotype. Conclusion. While the proportion of resistant isolates did not substantially change from that in the previous 2 years, multidrug-resistant gram-negative phenotypes were reported from a moderate proportion of facilities.

Guideline for disinfection and sterilization in healthcare facilities, 2008

Abstract: The issue of whether low-level tolerance to germicides selects for antibiotic-resistant strains is unsettled but might depend on the mechanism by which tolerance is attained. For example, changes in the permeability barrier or efflux mechanisms might affect susceptibility to both antibiotics and germicides, but specific changes to a target site might not. Some researchers have suggested that use of disinfectants or antiseptics (e.g., triclosan) could facilitate development of antibiotic-resistant microorganisms 334, 335, . Although evidence in laboratory studies indicates low-level resistance to triclosan, the concentrations of triclosan in these studies were low (generally <1 μg/mL) and dissimilar from the higher levels used in antimicrobial products (2,000–20,000 μg/mL) 364, . Thus, researchers can create laboratory-derived mutants that demonstrate reduced susceptibility to antiseptics or disinfectants. In some experiments, such bacteria have demonstrated reduced susceptibility to certain antibiotics . There is no evidence that using antiseptics or disinfectants selects for antibiotic-resistant organisms in nature or that such mutants survive in nature. ). In addition, the action of antibiotics and the action of disinfectants differ fundamentally. Antibiotics are selectively toxic and generally have a single target site in bacteria, thereby inhibiting a specific biosynthetic process. Germicides generally are considered nonspecific antimicrobials because of a multiplicity of toxic-effect mechanisms or target sites and are broader spectrum in the types of microorganisms against which they are effective 344, .

Outcomes of carbapenem-resistant Klebsiella pneumoniae infection and the impact of antimicrobial and adjunctive therapies.

Abstract: Background. Carbapenem‐resistant Klebsiella pneumoniae is an emerging healthcare‐associated pathogen. Objective. To describe the epidemiology of and clinical outcomes associated with carbapenem‐resistant K. pneumoniae infection and to identify risk factors associated with mortality among patients with this type of infection. Setting. Mount Sinai Hospital, a 1,171‐bed tertiary care teaching hospital in New York City. Design. Two matched case‐control studies. Methods. In the first matched case‐control study, case patients with carbapenem‐resistant K. pneumoniae infection were compared with control patients with carbapenem‐susceptible K. pneumoniae infection. In the second case‐control study, patients who survived carbapenem‐resistant K. pneumoniae infection were compared with those who did not survive, to identify risk factors associated with mortality among patients with carbapenem‐resistant K. pneumoniae infection. Results. There were 99 case patients and 99 control patients identified. Carbapenem‐resista...

Strategies to Prevent Surgical Site Infections in Acute Care Hospitals

Abstract: Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals to implement and prioritize their surgical site infection (SSI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.1. Burden of SSIs as complications in acute care facilities.a. SSIs occur in 2%-5% of patients undergoing inpatient surgery in the United States.b. Approximately 500,000 SSIs occur each year.2. Outcomes associated with SSIa. Each SSI is associated with approximately 7-10 additional postoperative hospital days.b. Patients with an SSI have a 2-11 times higher risk of death, compared with operative patients without an SSI.i. Seventy-seven percent of deaths among patients with SSI are direcdy attributable to SSI.c. Attributable costs of SSI vary, depending on the type of operative procedure and the type of infecting pathogen; published estimates range from $10 billion annually in healthcare expenditures.1. Definitionsa. The Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System and the National Healthcare Safety Network definitions for SSI are widely used.b. SSIs are classified as follows (Figure):i. Superficial incisional (involving only skin or subcutaneous tissue of the incision)ii. Deep incisional (involving fascia and/or muscular layers)iii. Organ/space

Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals

Abstract: Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line–associated bloodstream infection (CLABSI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.1. Patients at risk for CLABSIs in acute care facilitiesa. Intensive care unit (ICU) population: The risk of CLABSI in ICU patients is high. Reasons for this include the frequent insertion of multiple catheters, the use of specific types of catheters that are almost exclusively inserted in ICU patients and associated with substantial risk (eg, arterial catheters), and the fact that catheters are frequently placed in emergency circumstances, repeatedly accessed each day, and often needed for extended periods.b. Non-ICU population: Although the primary focus of attention over the past 2 decades has been the ICU setting, recent data suggest that the greatest numbers of patients with central lines are in hospital units outside the ICU, where there is a substantial risk of CLABSI.2. Outcomes associated with hospital-acquired CLABSIa. Increased length of hospital stayb. Increased cost; the non-inflation-adjusted attributable cost of CLABSIs has been found to vary from 29,000 per episode

Strategies to Prevent Catheter‐Associated Urinary Tract Infections in Acute Care Hospitals

Abstract: Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion. 1. Burden of CAUTIs a. Urinary tract infection is the most common hospital-acquired infection; 80% of these infections are attributable to an indwelling urethral catheter. b. Twelve to sixteen percent of hospital inpatients will have a urinary catheter at some time during their hospital stay. c. The daily risk of acquisition of urinary infection varies from 3% to 7% when an indwelling urethral catheter remains in situ. 2. Outcomes associated with CAUTI a. Urinary tract infection is the most important adverse outcome of urinary catheter use. Bacteremia and sepsis may occur in a small proportion of infected patients. b. Morbidity attributable to any single episode of catheterization is limited, but the high frequency of catheter use in hospitalized patients means that the cumulative burden of CAUTI is substantial. c. Catheter use is also associated with negative outcomes other than infection, including nonbacterial urethral inflammation, urethral strictures, and mechanical trauma.

Strategies to prevent ventilator-associated pneumonia in acute care hospitals.

Abstract: Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their ventilator-associated pneumonia (VAP) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.1. Occurrence of VAP in acute care facilities.a. VAP is one of the most common infections acquired by adults and children in intensive care units (ICUs).i. In early studies, it was reported that 10%-20% of patients undergoing ventilation developed VAP. More-recent publications report rates of VAP that range from 1 to 4 cases per 1,000 ventilator-days, but rates may exceed 10 cases per 1,000 ventilator-days in some neonatal and surgical patient populations. The results of recent quality improvement initiatives, however, suggest that many cases of VAP might be prevented by careful attention to the process of care.2. Outcomes associated with VAPa. VAP is a cause of significant patient morbidity and mortality, increased utilization of healthcare resources, and excess cost.i. The mortality attributable to VAP may exceed 10%.ii. Patients with VAP require prolonged periods of mechanical ventilation, extended hospitalizations, excess use of antimicrobial medications, and increased direct medical costs.

A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals

Abstract: Preventable healthcare-associated infections (HAIs) occur in US hospitals. Preventing these infections is a national priority, with initiatives led by healthcare organizations, professional associations, government and accrediting agencies, legislators, regulators, payers, and consumer advocacy groups. To assist acute care hospitals in focusing and prioritizing efforts to implement evidence-based practices for prevention of HAIs, the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America Standards and Practice Guidelines Committee appointed a task force to create a concise compendium of recommendations for the prevention of common HAIs. This compendium is implementation focused and differs from most previously published guidelines in that it highlights a set of basic HAI prevention strategies plus special approaches for use in locations and/or populations within the hospital when infections are not controlled by use of basic practices, recommends that accountability for implementing infection prevention practices be assigned to specific groups and individuals, and includes proposed performance measures for internal quality improvement efforts.

Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals

Abstract: Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their Clostridium difficile infection (CDI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.1. Increasing rates of CDIC. difficile now rivals methicillin-resistant Staphylococcus aureus (MRSA) as the most common organism to cause healthcare-associated infections in the United States.a. In the United States, the proportion of hospital discharges in which the patient received the International Classification of Diseases, Ninth Revision discharge diagnosis code for CDI more than doubled between 2000 and 2003, and CDI rates continued to increase in 2004 and 2005 (L. C. McDonald, MD, personal communication, July 2007). These increases have been seen in pediatric and adult populations, but elderly individuals have been disproportionately affected. CDI incidence has also increased in Canada and Europe.b. There have been numerous reports of an increase in CDI severity.c. Most reports of increases in the incidence and severity of CDI have been associated with the BI/NAP1/027 strain of C. difficile. This strain produces more toxins A and B in vitro than do many other strains of C. difficile, produces a third toxin (binary toxin), and is highly resistant to fluoroquinolones.

Impact of an Environmental Cleaning Intervention on the Presence of Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci on Surfaces in Intensive Care Unit Rooms

Abstract: Environmental contamination with pathogens commonly occurs during routine medical care. Many studies have described transmission of pathogenic organisms through contact with contaminated room surfaces.1–3 Of particular concern is the potential for transmission of multidrug-resistant organisms, such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), which are associated with healthcare-associated infections, increased lengths of stay in hospitals, increased healthcare costs, and increased mortality.4–7 Cleaning is essential to reduce environmental reservoirs of known hospital-acquired pathogens. Surfaces in rooms occupied by MRSA-positive or VRE-positive patients can contaminate the hands of healthcare workers who touch these surfaces without touching the colonized or infected patient.8–10 Both MRSA and VRE have been isolated from various fomites, including beds, linen hampers, doorknobs, and window ledges.11–16 Studies have demonstrated that these antimicrobial-resistant pathogens can persist on room surfaces even after discharge cleaning.17,18 Interventions that address the thoroughness of room cleaning have proven successful in reducing the environmental burden of such organisms.13 Although the goal of environmental cleaning and disinfection is not sterilization, adequate cleaning requires sufficient removal of pathogens to minimize patients’ risk of acquiring infections from hospital environments. This is particularly true in areas serving high-risk patients, such as intensive care units (ICUs). The Environmental Services department at Brigham and Women’s Hospital has routine cleaning policies that exceed national performance standards.19 Examples of added measures include exchanging bed curtains after discharging patients who were placed under contact precautions and using pour bottles to dispense disinfectant, which results in quantities of applied agent that are larger than those dispensed by spray bottles. In addition, all Environmental Services staff receive hands-on training in cleaning protocols and twice-monthly quality-control assessments that affect compensation. Nevertheless, we have recently shown that patients admitted to ICU rooms previously occupied by MRSA or VRE carriers are at increased risk for MRSA or VRE acquisition.18 It is possible that high-risk areas occupied by patients who are critically ill, often with wounds, medical devices, and immunocompromised states, have need of more-intensive cleaning protocols to reduce transmission of and subsequent infection due to these and other pathogens. Recently, a novel and nontoxic tracking marker that is visible only under a UV lamp (“black light”) has been developed to assess the quality of environmental cleaning. It is invisible and can be removed only with sufficient moisture.20–23 Feedback based on this evaluation system has been shown to improve cleaning technique, but it is not known whether it produces reductions in environmental contamination. We assessed whether an intervention involving improved cleaning practices, staff education, and feedback based on the black-light monitoring system would impact the thoroughness of discharge room cleaning and the environmental prevalence of MRSA and VRE in ICU rooms.

Risk of hand or glove contamination after contact with patients colonized with vancomycin-resistant enterococcus or the colonized patients' environment.

Abstract: Objective. To estimate the level of hand or glove contamination with vancomycin‐resistant enterococci (VRE) among healthcare workers (HCWs) who touch a patient colonized with VRE and/or the colonized patient’s environment during routine care. Design. Structured observational study. Setting. Medical intensive care unit of a 700‐bed, tertiary‐care teaching hospital. Participants. VRE‐colonized patients and their caregivers. Methods. We obtained samples from sites on the intact skin of 22 patients colonized with VRE and samples from sites in the patients’ rooms, before and after routine care, during 27 monitoring episodes. A total of 98 unique HCWs were observed during 131 HCW observations. Observers recorded the sites touched by HCWs. Culture samples were obtained from HCWs’ hands and gloves before and after care. Results. VRE were isolated from a mean (±SD) of \documentclass{aastex} \usepackage{amsbsy} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{bm} \usepackage{mathrsfs} \usepackage{pifont} \use...

Impact of Hydrogen Peroxide Vapor Room Decontamination on Clostridium difficile Environmental Contamination and Transmission in a Healthcare Setting

Abstract: Objective. To determine whether hydrogen peroxide vapor (HPV) decontamination can reduce environmental contamination with and nosocomial transmission of Clostridium difficile. Design. A prospective before-after intervention study. Setting. A hospital affected by an epidemic strain of C. difficile. Intervention. Intensive HPV decontamination of 5 high-incidence wards followed by hospital-wide decontamination of rooms vacated by patients with C. difficile–associated disease (CDAD). The preintervention period was June 2004 through March 2005, and the intervention period was June 2005 through March 2006. Results. Eleven (25.6%) of 43 cultures of samples collected by sponge from surfaces before HPV decontamination yielded C. difficile, compared with 0 of 37 cultures of samples obtained after HPV decontamination (P < .001). On 5 high-incidence wards, the incidence of nosocomial CDAD was significantly lower during the intervention period than during the preintervention period (1.28 vs 2.28 cases per 1,000 patien...

Improving Cleaning of the Environment Surrounding Patients in 36 Acute Care Hospitals

Abstract: objective. The prevalence of serious infections caused by multidrug-resistant pathogens transmitted in the hospital setting has reached alarming levels, despite intensified interventions. In the context of mandates that hospitals ensure compliance with disinfection procedures of surfaces in the environment surrounding the patient, we implemented a multihospital project to both evaluate and improve current cleaning practices. design. Prospective quasi-experimental, before-after, study. setting. Thirty-six acute care hospitals in the United States ranging in size from 25 to 721 beds. methods. We used a fluorescent targeting method to objectively evaluate the thoroughness of terminal room disinfection cleaning before and after structured educational and procedural interventions. results. Of 20,646 standardized environmental surfaces (14 types of objects), only 9,910 (48%) were cleaned at baseline (95% confidence interval, 43.4‐51.8). Thoroughness of cleaning at baseline correlated only with hospital expenditures for environmental services personnel ( ). After implementation of interventions and provision of objective performance feedback to the environmental services staff, it

Randomized controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia.

Abstract: Objective. To determine the effectiveness of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator‐associated pneumonia (VAP). Design. Randomized controlled trial and meta‐analysis. Setting. A tertiary care university hospital in Bangkok, Thailand. Participants. Adult patients who received mechanical ventilation and who were hospitalized in intensive care units and general medical wards. Methods. The patients were randomized to receive oral decontamination with 2% chlorhexidine solution or normal saline solution 4 times per day until their endotracheal tubes were removed. The outcome measures were the development of VAP and oropharyngeal colonization with gram‐negative bacilli. Meta‐analysis was performed by combining the results of the present study with those from another randomized controlled trial that also used a 2% chlorhexidine formulation for oral decontamination. Results. The characteristics of the patients in the chlorhexidine group ( \documentclass{aastex} \usepac...

Risk factors for surgical site infection after low transverse cesarean section.

Abstract: Background. Independent risk factors for surgical site infection (SSI) after cesarean section have not been well documented, despite the large number of cesarean sections performed and the relatively common occurrence of SSI. Objective. To determine independent risk factors for SSI after low transverse cesarean section. Design. Retrospective case-control study. Setting. Barnes-Jewish Hospital, a 1,250-bed tertiary care hospital. Patients. A total of 1,605 women who underwent low transverse cesarean section during the period from July 1999 to June 2001. Methods. Using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for SSI or wound complication and/or data on antibiotic use during the surgical hospitalization or at readmission to the hospital or emergency department, we identified potential cases of SSI in a cohort of patients who underwent a low transverse cesarean section. Cases of SSI were verified by chart review using the definitions from the Centers...

Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals .

Abstract: Objective.The quality of environmental hygiene in hospitals is under increasing scrutiny from both healthcare providers and consumers because the prevalence of serious infections due to multidrug-resistant pathogens has reached alarming levels. On the basis of the results from a small number of hospitals, we undertook a study to evaluate the thoroughness of disinfection and cleaning in the patient's immediate environment and to identify opportunities for improvement in a diverse group of acute care hospitals.Methods.Prospective multicenter study to evaluate the thoroughness of terminal room cleaning in hospitals using a novel targeting method to mimic the surface contamination of objects in the patient's immediate environment.Setting.Twenty-three acute care hospitals.Results.The overall thoroughness of terminal cleaning, expressed as a percentage of surfaces evaluated, was 49% (range for all 23 hospitals, 35%-81%). Despite the tight clustering of overall cleaning rates in 21 of the hospitals, there was marked variation within object categories, which was particularly notable with respect to the cleaning of toilet handholds, bedpan cleaners, light switches, and door knobs (mean cleaning rates, less than 30%; institutional ranges, 0%-90%). Sinks, toilet seats, and tray tables, in contrast, were consistently relatively well cleaned (mean cleaning rates, over 75%). Patient telephones, nurse call devices, and bedside rails were inconsistently cleaned.Conclusion.We identified significant opportunities in all participating hospitals to improve the cleaning of frequently touched objects in the patient's immediate environment. The information obtained from such assessments can be used to develop focused administrative and educational interventions that incorporate ongoing feedback to the environmental services staff, to improve cleaning and disinfection practices in healthcare institutions.

Strategies to Prevent Transmission of Methicillin‐Resistant Staphylococcus aureus in Acute Care Hospitals

Abstract: Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). Our intent in this document is to highlight practical recommendations in a concise format to assist acute care hospitals in their efforts to prevent transmission of methicillin-resistant Staphylococcus aureus (MRSA). Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary, Introduction, and accompanying editorial for additional discussion.1. Burden of HAIs caused by MRSA in acute care facilitiesa. In the United States, the proportion of hospital-associated S. aureus infections that are caused by strains resistant to methicillin has steadily increased. In 2004, MRSA accounted for 63% of S. aureus infections in hospitals.b. Although the proportion of S. aureus–associated HAIs among intensive care unit (ICU) patients that are due to methicillin-resistant strains has increased (a relative measure of the MRSA problem), recent data suggest that the incidence of central line–associated bloodstream infection caused by MRSA (an absolute measure of the problem) has decreased in several types of ICUs since 2001. Although these findings suggest that there has been some success in preventing nosocomial MRSA transmission and infection, many patient groups continue to be at risk for such transmission.c. MRSA has also been documented in other areas of the hospital and in other types of healthcare facilities, including those that provide long-term care.

SHEA/APIC guideline: Infection prevention and control in the long-term care facility

Abstract: Long-term care facilities (LTCFs) may be defined as institutions that provide health care to people who are unable to manage independently in the community.1 This care may be chronic care management or short-term rehabilitative services. The term nursing home is defined as a facility licensed with an organized professional staff and inpatient beds that provides continuous nursing and other services to patients who are not in the acute phase of an illness. There is considerable overlap between the 2 terms. More than 1.5 million residents reside in United States (US) nursing homes. In recent years, the acuity of illness of nursing home residents has increased. LTCF residents have a risk of developing health care-associated infection (HAI) that approaches that seen in acute care hospital patients. A great deal of information has been published concerning infections in the LTCF, and infection control programs are nearly universal in that setting. This position paper reviews the literature on infections and infection control programs in the LTCF. Recommendations are developed for long-term care (LTC) infection control programs based on interpretation of currently available evidence. The recommendations cover the structure and function of the infection control program, including surveillance, isolation precautions, outbreak control, resident care, and employee health. Infection control resources are also presented. Hospital infection control programs are well established in the US. Virtually every hospital has an infection control professional (ICP), and many larger hospitals have a consulting hospital epidemiologist. The Study on the Efficacy of Nosocomial Infection Control (SENIC) documented the effectiveness of a hospital infection control program that applies standard surveillance and control measures.2 The major elements leading to a HAI are the infectious agent, a susceptible host, and a means of transmission. These elements are present in LTCFs as well as in hospitals. It is not surprising, therefore, that almost as many HAIs occur annually in LTCFs as in hospitals in the US.3 The last 2 decades have seen increased recognition of the problem of infections in LTCFs, with subsequent widespread development of LTCF infection control programs and definition of the role of the ICP in LTCFs. An increasingly robust literature is devoted to LTC infection control issues such as the descriptive epidemiology of LTCF infections, the microbiology of LTCF infections, outbreaks, control measures, and isolation. Nevertheless, there is as yet no SENIC-equivalent study documenting the efficacy of infection control in LTCFs, and few controlled studies have analyzed the efficacy or cost-effectiveness of the specific control measures in that setting. Although hospitals and LTCFs both have closed populations of patients requiring nursing care, they are quite different. They differ with regard to payment systems, patient acuity, availability of laboratory and x-ray, and nurse-to-patient ratios. More fundamentally, the focus is different. The acute care facility focus is on providing intensive care to a patient who is generally expected to recover or improve, and high technology is integral to the process. In LTCFs, the patient population may be very heterogeneous. Most LTCFs carry out plans of care that have already been established in acute care or evaluate chronic conditions. The LTCF is functionally the home for the resident, who is usually elderly and in declining health and will often stay for years, hence comfort, dignity, and rights are paramount. It is a low-technology setting. Residents are often transferred between the acute care and the LTC setting, adding an additional dynamic to transmission and acquisition of HAIs. Application of hospital infection control guidelines to the LTCF is often unrealistic in view of the differences noted above and the different infection control resources. Standards and guidelines specific to the LTCF setting are now commonly found. The problem of developing guidelines applicable to all LTCFs is compounded by the varying levels of nursing intensity (eg, skilled nursing facility vs assisted living), LTCF size, and access to physician input and diagnostic testing. This position paper provides basic infection control recommendations that could be widely applied to LTCFs with the expectation of minimizing HAIs in LTC. The efficacy of these measures in the LTCF, in most cases, is not proven by prospective controlled studies but is based on infection control logic, adaptation of hospital experience, LTCF surveys, Centers for Disease Control and Prevention (CDC) and other guidelines containing specific recommendations for LTCFs, and field experience. Every effort will be made to address the unique concerns of LTCFs. Because facilities differ, the infection risk factors specific to the resident population, the nature of the facility, and the resources available should dictate the scope and focus of the infection control program. In a number of instances, specific hospital-oriented guidelines have been published and are referenced (eg, guidelines for prevention of intravascular (IV) device-associated infection). These guidelines are relevant, at least in part, to the LTC setting but may be adapted depending on facility size, resources, resident acuity, local regulations, local infection control issues, etc. Reworking those sources to a form applicable to all LTCFs is beyond the scope of this guideline. Any discussion of infection control issues must be made in the context of the LTCF as a community. The LTCF is a home for residents, a home in which they usually reside for months or years; comfort and infection control principles must both be addressed.

Recommendations for metrics for multidrug-resistant organisms in healthcare settings: SHEA/HICPAC Position paper

Abstract: The assessment of MDRO infection and colonization should include the identification of known carriers, the detection of hospital-specific and healthcare-associated acquisition, an estimation of the burden of serious infection, an understanding of the reservoir affecting the transmission of MDROs, and an evaluation of the effect of intervention. Several strategies can be used to obtain data that aid in this assessment. We have defined and categorized the recommended metrics for each of these aspects of measuring MDRO infection and colonization, for use by healthcare facilities. © 2008 by The Society for Healthcare Epidemiology of America. All rights reserved.

Prospective, controlled, cross-over trial of alcohol-based hand gel in critical care units .

Abstract: Background. There are limited data from prospective studies to indicate whether improvement in hand hygiene associated with the use of alcohol‐based hand hygiene products results in improved patient outcomes. Design. A 2‐year, prospective, controlled, cross‐over trial of alcohol‐based hand gel. Setting. The study was conducted in 2 medical‐surgical ICUs for adults, each with 12 beds, from August 2001 to September 2003 at a university‐associated, tertiary care teaching hospital. Methods. An alcohol‐based hand gel was provided in one critical care unit and not provided in the other. After 1 year, the assignment was reversed. The hand hygiene adherence rate and the incidence of nosocomial infection were monitored. Samples for culture were obtained from nurses' hands every 2 months. Results. During 17,994 minutes of observation, which included 3,678 opportunities for hand hygiene, adherence rates improved dramatically after the introduction of hand gel, increasing from 37% to 68% in one unit and from 38% to 6...

Case-control study of antibiotic use and subsequent Clostridium difficile-associated diarrhea in hospitalized patients.

Abstract: Objective.To determine which antibiotics increase or decrease the risk of Clostridium difficile-associated diarrhea (CDAD).Design.Retrospective case-control study.Setting.Nonprofit, integrated healthcare delivery system in Northern California.Patients.Study participants included patients with cases of hospital-acquired CDAD that occurred during the period from 1999 through 2005 (n = 1,142) and control patients (n = 3,351) matched for facility, calendar quarter during which hospitalization occurred, diagnosis related group for the index hospitalization, and length of hospital stay. All case and control patients had received antibiotics in the 60 days before the index date. For each antibiotic, the risk of CDAD was examined in relation to whether the patient received the antibiotic, after adjustment for use of other antibiotics, demographic characteristics, selected health conditions, and use of healthcare services.Results.The following antibiotics were associated with a significantly increased risk of acquiring CDAD: imipenem-cilastin (odds ratio [OR], 2.77), clindamycin (OR, 2.31), cefuroxime (OR, 2.16), moxifloxacin (OR, 1.88), ceftazidime (OR, 1.82), cefpodoxime (OR, 1.58), ceftizoxime (OR, 1.57), and ceftriaxone (OR, 1.49). Metronidazole and doxycycline were associated with a significantly reduced risk of CDAD (OR for metronidazole, 0.67; OR for doxycycline, 0.41). Other factors associated with an increased risk of CDAD were older age, longer hospital stays, use of proton pump inhibitors, prior gastrointestinal disease, and prior infection (not including C. difficile infection.)Conclusions.Some antibiotics appear to increase the risk of acquiring CDAD, notably clindamycin, third-generation cephalosporins, and carbapenems, whereas metronidazole and doxycycline appear to be protective, compared with other antibiotics.

Detection of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci on the gowns and gloves of healthcare workers.

Abstract: Objective. To assess the rate of and the risk factors for the detection of methicillin-resistant S. aureus (MRSA) and vancomycin-resistant enterococci (VRE) on the protective gowns and gloves of healthcare workers (HCWs). Methods. We observed the interactions between HCWs and patients during routine clinical activities in a 29-bed medical intensive care unit at the University of Maryland Medical Center, an urban tertiary care academic hospital. Samples for culture were obtained from HCWs' hands prior to their entering a patient's room, from HCWs' disposable gowns and gloves after they completed patient care activities, and from HCWs' hands immediately after they removed their protective gowns and gloves. Results. Of 137 HCWs caring for patients colonized or infected with MRSA and/or VRE, 24 (17.5%; 95% confidence interval, 11.6%–24.4%) acquired the organism on their gloves, gown, or both. HCW contact with the endotracheal tube or tracheostomy site of a patient (P < .05), HCW contact with the head and/or n...

Summer Peaks in the Incidences of Gram-Negative Bacterial Infection Among Hospitalized Patients

Abstract: Objective. Recognition of seasonal trends in hospital infections may improve diagnosis, use of empirical therapy, and infection prevention interventions. There are very few data available regarding the seasonal variability of these infections. We quantified the seasonal variation in the incidences of hospital infection caused by common bacterial pathogens and estimated the association between temperature changes and infection rates. Methods. A cohort of all adult patients admitted to the University of Maryland Medical Center during the period from 1998 through 2005 was analyzed. Time‐series analyses were used to estimate the association of the number of infections per month caused by Pseudomonas aeruginosa, Acinetobacter baumannii, Enterobacter cloacae, Escherichia coli, Staphylococcus aureus, and enterococci with season and temperature, while controlling for long‐term trends. Results. There were 218,594 admissions to the index hospital, and analysis of 26,624 unique clinical cultures that grew the organi...

Highly effective regimen for decolonization of methicillin-resistant Staphylococcus aureus carriers.

Abstract: OBJECTIVE: To evaluate the efficacy of a standardized regimen for decolonization of methicillin-resistant Staphylococcus aureus (MRSA) carriers and to identify factors influencing decolonization treatment failure. DESIGN: Prospective cohort study from January 2002 to April 2007, with a mean follow-up period of 36 months. SETTING: University hospital with 750 beds and 27,000 admissions/year. PATIENTS: Of 94 consecutive hospitalized patients with MRSA colonization or infection, 32 were excluded because of spontaneous loss of MRSA, contraindications, death, or refusal to participate. In 62 patients, decolonization treatment was completed. At least 6 body sites were screened for MRSA (including by use of rectal swabs) before the start of treatment. INTERVENTIONS: Standardized decolonization treatment consisted of mupirocin nasal ointment, chlorhexidine mouth rinse, and full-body wash with chlorhexidine soap for 5 days. Intestinal and urinary-tract colonization were treated with oral vancomycin and cotrimoxazole, respectively. Vaginal colonization was treated with povidone-iodine or, alternatively, with chlorhexidine ovula or octenidine solution. Other antibiotics were added to the regimen if treatment failed. Successful decolonization was considered to have been achieved if results were negative for 3 consecutive sets of cultures of more than 6 screening sites. RESULTS: The mean age (+/- standard deviation [SD]) age of the 62 patients was 66.2 +/- 19 years. The most frequent locations of MRSA colonization were the nose (42 patients [68%]), the throat (33 [53%]), perianal area (33 [53%]), rectum (36 [58%]), and inguinal area (30 [49%]). Decolonization was completed in 87% of patients after a mean (+/-SD) of 2.1 +/- 1.8 decolonization cycles (range, 1-10 cycles). Sixty-five percent of patients ultimately required peroral antibiotic treatment (vancomycin, 52%; cotrimoxazole, 27%; rifampin and fusidic acid, 18%). Decolonization was successful in 54 (87%) of the patie in the intent-to-treat analysis and in 51 (98%) of 52 patients in the on-treatment analysis. CONCLUSION: This standardized regimen for MRSA decolonization was highly effective in patients who completed the full decolonization treatment course.

Use of active surveillance cultures to detect asymptomatic colonization with carbapenem-resistant Klebsiella pneumoniae in intensive care unit patients.

Abstract: Carbapenem-resistant Klebsiella pneumoniae is emerging as a significant healthcare-associated pathogen. Clinical cultures detect only a fraction of the colonized population, and patients with asymptomatic colonization are at risk of invasive infection. Additional study of the impact of detection of asymptomatic colonization on subsequent infection and transmission is needed.

Cohort study of the pathogenesis and molecular epidemiology of catheter-related bloodstream infection in neonates with peripherally inserted central venous catheters.

Abstract: Objective.To better define the pathogenesis of catheter-related bloodstream infection (BSI) in neonates with peripherally inserted central venous catheters (PICCs) to guide the development of more effective strategies for prevention.Design.Prospective nested cohort study.Setting.Level III neonatal intensive care unit in a community hospital.Methods.During a randomized trial to assess the safety and efficacy of a prophylactic vancomycin-heparin catheter-lock solution for the prevention of catheter-related BSI in neonates with PICCs, we performed cultures of peripheral and catheter-drawn blood samples, and quantitative cultures of catheter hub samples if BSI was suspected clinically. We performed semiquantitative cultures of the catheter tip and the catheter hub and the skin at the insertion site when the catheter was removed. Molecular subtyping by pulsed-field electrophoresis was used to determine the probable pathogenesis of all BSIs due to coagulase-negative staphylococci (CoNS); for BSIs caused by other microorganisms, epidemiologic concordance was based on speciation and antibiograms. Catheter-related BSI was considered extraluminally acquired if concordance was demonstrable solely between isolates recovered from the catheter tip and the blood, independent of concordance with isolates recovered from the insertion site. Catheter-related BSI was considered intraluminally acquired if concordance was demonstrated only between isolates recovered from the catheter hub and the blood. The source of the infection was considered indeterminate if both concordance patterns were present.Results.Nosocomial BSI was identified in 23 of the 82 neonates in the cohort. Fifteen of these infections, 14 of which were caused by CoNS, were considered definite or probable catheter-related BSIs. Catheter-related BSI was intraluminally acquired in 10 (67%) of 15 patients, extraluminally acquired in 3 (20%), and indeterminate in 2 (13%).Conclusions.Most catheter-related BSIs in neonates with PICCs are caused by CoNS and derive from intraluminal contamination. Strategies for prevention of catheter-related BSI directed at this predominant mechanism of infection are most likely to be effective.

Secular trends in candidemia-related hospitalization in the United States, 2000-2005.

Abstract: In the United States, from January 1, 2000, through December 31, 2005, the incidence of candidemia-related hospitalization per 100,000 population rose by 52%, from 3.65 to 5.56 cases; and the incidence per 1,000 hospitalizations rose by 49%, from 0.28 to 0.42 cases. The proportion of all candidemia-related hospitalizations in which candidemia was the principal diagnosis remained stable at approximately 14%.

Influenza vaccination among registered nurses: information receipt, knowledge, and decision-making at an institution with a multifaceted educational program.

Abstract: Objective. To evaluate the receipt of information and knowledge about influenza and vaccination, as well as influenza vaccination status and reasons for declining vaccination, among registered nurses. Design. Cross‐sectional survey of registered nurses (RNs). Setting. A large tertiary medical center with a long‐standing, multifaceted influenza vaccination program and relatively high vaccination rates among employees overall (76.5%). Participants. Randomly selected group of 990 RNs employed as inpatient staff nurses at the institution. Results. The survey was completed by 513 (51.8%) of 990 RNs. Most RNs (86.7%) had received an influenza vaccination in the past, and 331 (64.5%) intended to receive vaccination during the 2005‐2006 influenza season. More than 90% of RNs acknowledged exposure to educational bulletins, and most had received information about influenza severity (383 [74.7%]), transmission (398 [77.6%]), vaccine safety (416 [81.1%]), and the time and location of free vaccination (460 [89.7%]). A...

Prevention of nosocomial infection and standard precautions: knowledge and source of information among healthcare students.

Abstract: Objective. To evaluate the knowledge of healthcare students after four curricula on infection control and to identify sources of information. Design. Cross-sectional study. Setting. Four healthcare schools at Rouen University (Rouen, France). Participants. Medical students, nursing students, assistant radiologist students, and physiotherapist students taking public health courses. Methods. To measure students' knowledge of infection control and their sources of information, 6 multiple-choice questions were asked about 3 specific areas: standard precautions, hand hygiene, and nosocomial infection. Each questionnaire section had 10 possible points, for an overall perfect score of 30. The sources of information for these 3 areas were also recorded: self-learning, practice training in wards, formal training in wards, and teaching during the curriculum. A logistic regression analysis was performed to identify factors associated with acceptable level of knowledge. Results. Three hundred fifty students (107 medi...

Clinical and economic consequences of failure of initial antibiotic therapy for hospitalized patients with complicated skin and skin-structure infections.

Abstract: Objective. To estimate the consequences of failure of initial antibiotic therapy for patients with complicated skin and skin‐structure infections. Design. Retrospective cohort study. Setting. Large US multihospital database. Patients. We identified a total of 47,219 patients (age 18 years or older) who were admitted to the hospital for complicated skin and skin‐structure infections from April 1, 2003, through March 31, 2004, and who received intravenous antibiotics during the first 2 hospital‐days (ie, initial antibiotic therapy). Failure of therapy was defined as drainage, debridement, or receipt of other intravenous antibiotics at any subsequent time (except for changes to narrower‐spectrum agents or any therapy change immediately before discharge). Predictors of failure of antibiotic therapy and mortality were examined using multivariate logistic regression. Analysis of covariance was used to estimate the impact of treatment failure on duration of intravenous antibiotic therapy, length of stay, and tot...