Showing papers in "Infection Control and Hospital Epidemiology in 2009"

The World Health Organization Guidelines on Hand Hygiene in Health Care and Their Consensus Recommendations

Abstract: The World Health Organization's Guidelines on Hand Hygiene in Health Care have been issued by WHO Patient Safety on 5 May 2009 on the occasion of the launch of the Save Lives: Clean Your Hands initiative. The Guidelines represent the contribution of more than 100 international experts and provide a comprehensive overview of essential aspects of hand hygiene in health care, evidence- and consensus-based recommendations, and lessons learned from testing their Advanced Draft and related implementation tools.

Attributable mortality rate for carbapenem-resistant Klebsiella pneumoniae bacteremia.

Abstract: Objective.To determine the attributable (direct) mortality and morbidity caused by carbapenem-resistant Klebsiella pneumoniae bacteremia.Design.A matched retrospective, historical cohort design, using a stepwise procedure to stringendy match the best control subjects to the best case subjects.Setting.A 1,000-bed tertiary-care university teaching hospital.Patients.Case subjects were defined as adult patients with carbapenem-resistant K. pneumoniae bacteremia during the period from October 2005 through October 2008. Control subjects were defined as patients who were very similar to case subjects except that they did not have bacteremia.Methods.Matching potential control subjects to case subjects was performed at a 1:1 ratio using a computerized record system. The criteria used included same hospitalization period, similar Charlson comorbidity index, same underlying disease, same age within 10 years, and same sex. Demographic and clinical characteristics were collected from medical records.Results.During the study period, 319 patients developed an infection due to carbapenem-resistant K. pneumoniae. Of these 319 patients, 39 (12.2%) developed a bloodstream infection, for an overall rate of 0.59 episodes of carbapenem-resistant K. pneumoniae bacteremia per 10,000 patient-days. We excluded 7 patients from our study, leaving a total of 32 case subjects in our cohort. Case subjects were significandy more likely than control subjects (n = 32) to require care in an intensive care unit (12 case subjects [37.5%] vs 3 control subjects [9.4%]), ventilator support (17 case subjects [53.1%] vs 8 control subjects [25%]), and use of a central venous catheter (19 case subjects [59.4%] vs 9 control subjects [28.1%]). For case subjects, the crude mortality rate was 71.9% (ie, 23 of the 32 case subjects died); for control subjects, the crude mortality rate was 21.9% (ie, 7 of the 32 control subjects died) (P < .001. For case subjects, the attributable mortality was 50% (95% confidence interval [CI], 15.3%-98.6%). A mortality risk ratio of 3.3 (95% CI, 2.9-28.5) was found for case subjects with carbapenem-resistant K. pneumoniae bacteremia.Conclusions.Patients with carbapenem-resistant K. pneumoniae require more intensive and invasive care. We have shown that the crude and attributable mortality rates associated with carbapenem-resistant K. pneumoniae bacteremia were striking.

Outbreak of Multidrug-Resistant Pseudomonas aeruginosa Colonization and Infection Secondary to Imperfect Intensive Care Unit Room Design

Abstract: Background. Pseudomonas aeruginosa has been increasingly recognized for its ability to cause significant hospital‐associated outbreaks, particularly since the emergence of multidrug‐resistant strains. Biofilm formation allows the pathogen to persist in environmental reservoirs. Thus, multiple hospital room design elements, including sink placement and design, can impact nosocomial transmission of P. aeruginosa and other pathogens. Methods. From December 2004 through March 2006, 36 patients exposed to the intensive care unit or transplant units of a tertiary care hospital were infected with a multidrug‐resistant strain of P. aeruginosa. All phenotypically similar isolates were examined for genetic relatedness by means of pulsed‐field gel electrophoresis. Clinical characteristics of the affected patients were collected, and a detailed epidemiological and environmental investigation of potential sources was carried out. Results. Seventeen of the infected patients died within 3 months; for 12 (71%) of these p...

Risk Factors and Clinical Impact of Klebsiella pneumoniae Carbapenemase–Producing K. pneumoniae

Abstract: BACKGROUND Klebsiella pneumoniae carbapenemase (KPC)–producing K. pneumoniae is an emerging pathogen with serious clinical and infection control implications. To our knowledge, no study has specifically examined risk factors for KPC-producing K. pneumoniae or its impact on mortality.

A Qualitative Exploration of Reasons for Poor Hand Hygiene Among Hospital Workers: Lack of Positive Role Models and of Convincing Evidence That Hand Hygiene Prevents Cross-Infection

Abstract: Objective. To study potential determinants of hand hygiene compliance among healthcare workers in the hospital setting. Design. A qualitative study based on structured‐interview guidelines, consisting of 9 focus group interviews involving 58 persons and 7 individual interviews. Interview transcripts were subjected to content analysis. Setting. Intensive care units and surgical departments of 5 hospitals of varying size in the Netherlands. Participants. A total of 65 nurses, attending physicians, medical residents, and medical students. Results. Nurses and medical students expressed the importance of hand hygiene for preventing of cross‐infection among patients and themselves. Physicians expressed the importance of hand hygiene for self‐protection, but they perceived that there is a lack of evidence that handwashing is effective in preventing cross‐infection. All participants stated that personal beliefs about the efficacy of hand hygiene and examples and norms provided by senior hospital staff are of majo...

Monitoring the effectiveness of hospital cleaning practices by use of an adenosine triphosphate bioluminescence assay.

Abstract: Objective. To evaluate the usefulness of an adenosine triphosphate (ATP) bioluminescence assay for assessing the efficacy of daily hospital cleaning practices. Design. A 2‐phase prospective intervention study. Setting. A university‐affiliated community teaching hospital. Methods. During phase I of our study, 5 high‐touch surfaces in 20 patient rooms were sampled before and after daily cleaning. Moistened swabs were used to sample these surfaces and were then plated onto routine and selective media, and aerobic colony counts were determined after 48 hours of incubation. Specialized ATP swabs were used to sample the same high‐touch surfaces in the 20 patient rooms and were then placed in luminometers, and the amount of ATP present was expressed as relative light units. During phase II of our study, after in‐service housekeeper educational sessions were given, the housekeepers were told in advance when ATP readings would be taken before and after cleaning. Results. During phase I, the colony counts revealed ...

Effects of Preoperative Skin Preparation on Postoperative Wound Infection Rates: A Prospective Study of 3 Skin Preparation Protocols

Abstract: Objective. To compare the effects of different skin preparation solutions on surgical‐site infection rates. Design. Three skin preparations were compared by means of a sequential implementation design. Each agent was adopted as the preferred modality for a 6‐month period for all general surgery cases. Period 1 used a povidone‐iodine scrub‐paint combination (Betadine) with an isopropyl alcohol application between these steps, period 2 used 2% chlorhexidine and 70% isopropyl alcohol (ChloraPrep), and period 3 used iodine povacrylex in isopropyl alcohol (DuraPrep). Surgical‐site infections were tracked for 30 days as part of ongoing data collection for the National Surgical Quality Improvement Project initiative. The primary outcome was the overall rate of surgical‐site infection by 6‐month period performed in an intent‐to‐treat manner. Setting. Single large academic medical center. Patients. All adult general surgery patients. Results. The study comprised 3,209 operations. The lowest infection rate was seen...

Carbapenem Resistance Among Klebsiella pneumoniae Isolates Risk Factors, Molecular Characteristics, and Susceptibility Patterns

Abstract: Background. Carbapenem resistance among isolates of Klebsiella pneumoniae has been unusual. Objectives. To identify risk factors for infection with carbapenem‐resistant K. pneumoniae (CRKP) and to characterize microbiological aspects of isolates associated with these infections. Design. Retrospective case‐control study. Setting. A 900‐bed tertiary care hospital. Results. From January 2006 through April 2007, K. pneumoniae was isolated from 461 inpatients; 88 had CRKP infection (case patients), whereas 373 had carbapenem‐susceptible K. pneumoniae infection (control subjects). The independent risk factors for infection with CRKP were prior fluoroquinolone use (odds ratio [OR], 1.87 [95% confidence interval {CI}, 1.07–3.26]; \documentclass{aastex} \usepackage{amsbsy} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{bm} \usepackage{mathrsfs} \usepackage{pifont} \usepackage{stmaryrd} \usepackage{textcomp} \usepackage{portland,xspace} \usepackage{amsmath,amsxtra} \usepackage[OT2,OT1]{fontenc} ewcommand\...

Nosocomial outbreak of infection with pan-drug-resistant Acinetobacter baumannii in a tertiary care university hospital.

Abstract: Objective. To describe what is, to our knowledge, the first nosocomial outbreak of infection with pan–drug‐resistant (including colistin‐resistant) Acinetobacter baumannii, to determine the risk factors associated with these types of infections, and to determine their clinical impact. Design. Nested case‐control cohort study and a clinical‐microbiological study. Setting. A 1,521‐bed tertiary care university hospital in Seville, Spain. Patients. Case patients were inpatients who had a pan–drug‐resistant A. baumannii isolate recovered from a clinical or surveillance sample obtained at least 48 hours after admission to an intensive care unit (ICU) during the time of the epidemic outbreak. Control patients were patients who were admitted to any of the “boxes” (ie, rooms that partition off a distinct area for a patient's bed and the equipment needed to care for the patient) of an ICU for at least 48 hours during the time of the epidemic outbreak. Results. All the clinical isolates had similar antibiotic suscep...

Review of current literature on the economic burden of Clostridium difficile infection.

Abstract: Clostridium difficile is well recognized as the most common infectious cause of healthcare-associated diarrhea. Since 2000, this pathogen has demonstrated an increased propensity to cause more frequent and virulent illness that is often refractory to treatment. An analysis by the Centers for Disease Control and Prevention revealed that, in the United States, the number of patients discharged from hospitals who received the International Classification of Diseases, Ninth Revision discharge diagnosis code for C. difficile infection (CDI) more than doubled from 2000 to 2003. Unpublished data indicate that this trend has continued and that more than 250,000 US hospitalizations were associated with CDI in 2005. A previously uncommon hypervirulent strain of C. difficile is thought to contribute, in part, to the dramatic increase in the incidence and severity of the infection. Although the economic impact of the disease is believed to be profound and is expected to increase, data on the costs associated with CDI are scarce. To more completely assess its economic burden, we performed a review of available literature that reported costs associated with the infection.

Hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile.

Abstract: objective. To evaluate common hand hygiene methods for efficacy in removing Clostridium difficile. design. Randomized crossover comparison among 10 volunteers with hands experimentally contaminated by nontoxigenic C. difficile. methods. Interventions included warm water with plain soap, cold water with plain soap, warm water with antibacterial soap, antiseptic hand wipes, alcohol-based handrub, and a control involving no intervention. All interventions were evaluated for mean reduction in colonyforming units (CFUs) under 2 contamination protocols: “whole hand” and “palmar surface.” Results were analyzed according to a Bayesian approach, by using hierarchical models adjusted for multiple observations. results. Under the whole-hand protocol, the greatest adjusted mean reductions were achieved by warm water with plain soap (2.14 log10 CFU/mL [95% credible interval (CrI), 1.74‐2.54 log10 CFU/mL]), cold water with plain soap (1.88 log10 CFU/mL [95% CrI, 1.48‐2.28 log10 CFU/mL), and warm water with antibacterial soap (1.51 log10 CFU/mL [95% CrI, 1.12‐1.91 log10 CFU/mL]), followed by antiseptic hand wipes (0.57 log10 CFU/mL [95% CrI, 0.17‐0.96 log10 CFU/mL]). Alcohol-based handrub (0.06 log10 CFU/mL [95% CrI, 0.34 to 0.45 log10 CFU/mL]) was equivalent to no intervention. Under the palmar surface protocol, warm water with plain soap, cold water with plain soap, and warm water with antibacterial soap again yielded the greatest mean reductions, followed by antiseptic hand wipes (26.6, 26.6, 26.6, and 21.9 CFUs per plate, respectively), when compared with alcohol-based handrub. Hypothenar (odds ratio, 10.98 [95% CrI, 1.96‐37.65]) and thenar (odds ratio, 6.99 [95% CrI, 1.25‐23.41]) surfaces were more likely than fingertips to remain heavily contaminated after handwashing. conclusions. Handwashing with soap and water showed the greatest efficacy in removing C. difficile and should be performed preferentially over the use of alcohol-based handrubs when contact with C. difficile is suspected or likely.

Success of an Infection Control Program to Reduce the Spread of Carbapenem-Resistant Klebsiella pneumoniae

Abstract: Objective. To assess the effect of enhanced infection control measures with screening for gastrointestinal colonization on limiting the spread of carbapenem‐resistant Klebsiella pneumoniae in a New York City hospital endemic for this pathogen. Design. Retrospective observational study with pre‐ and postinterventional phases. Methods. Beginning in 2006, a comprehensive infection control program was instituted in a 10‐bed medical and surgical intensive care unit at a university‐based medical center. In addition to being placed in contact isolation, all patients colonized or infected with carbapenem‐resistant gram‐negative bacilli, vancomycin‐resistant Enterococcus, or methicillin‐resistant Staphylococcus aureus were cohorted to one end of the unit. Improved decontamination of hands and environmental surfaces was encouraged. In addition, routine rectal surveillance cultures were screened for the presence of carbapenem‐resistant pathogens. The number of patients per quarter with clinical cultures positive for...

Variability in the hawthorne effect with regard to hand hygiene performance in high- and low-performing inpatient care units.

Abstract: Objective. To determine the impact of known observers on hand hygiene performance in inpatient care units with differing baseline levels of hand hygiene compliance. Design. Observational study. Setting. Three inpatient care units, selected on the basis of past hand hygiene performance, in a hospital where hand hygiene observation and feedback are routine. Participants. Three infection control practitioners (ICPs) and a student intern observed hospital staff. Methods. Beginning in late 2005, the 3 ICPs, who were well known to the hospital staff, performed frequent, regular observations of hand hygiene in all 3 inpatient care units of the hospital, as part of routine surveillance. During the study period (January–May 2007), a student intern who was unknown to the hospital staff also performed observations of hand hygiene in the 3 inpatient care units. The rates of hand hygiene compliance observed by the 3 ICPs were compared with those observed by the student intern. Results. The 3 ICPs observed 332 opportun...

Comparison of the Efficacy of a Hydrogen Peroxide Dry-Mist Disinfection System and Sodium Hypochlorite Solution for Eradication of Clostridium difficile Spores

Abstract: Objective. To compare a hydrogen peroxide dry‐mist system and a 0.5% hypochlorite solution with respect to their ability to disinfect Clostridium difficile–contaminated surfaces in vitro and in situ. Design. Prospective, randomized, before‐after trial. Setting. Two French hospitals affected by C. difficile. Intervention. In situ efficacy of disinfectants was assessed in rooms that had housed patients with C. difficile infection. A prospective study was performed at 2 hospitals that involved randomization of disinfection processes. When a patient with C. difficile infection was discharged, environmental contamination in the patient's room was evaluated before and after disinfection. Environmental surfaces were sampled for C. difficile by use of moistened swabs; swab samples were cultured on selective plates and in broth. Both disinfectants were tested in vitro with a spore‐carrier test; in this test, 2 types of material, vinyl polychloride (representative of the room's floor) and laminate (representative o...

Effectiveness of routine patient cleansing with chlorhexidine gluconate for infection prevention in the medical intensive care unit.

Abstract: Background. Controlled studies that took place in medical intensive care units (MICUs) have demonstrated that bathing patients with chlorhexidine gluconate (CHG) can reduce skin colonization with potential pathogens and can lessen the risk of central venous catheter (CVC)–associated bloodstream infection (BSI). Objective. To examine, without oversight of practice by research study staff, the effectiveness or real‐world effect of patient cleansing with CHG on rates of CVC‐associated BSI. Design. In the fall of 2005, the MICU at Rush University Medical Center discontinued bathing patients daily with soap and water and substituted skin cleansing with no‐rinse, 2% CHG‐impregnated cloths. This change was a clinical management decision without research input. Setting. A 21‐bed MICU at Rush University Medical Center. Patients. Patients hospitalized in the MICU during the period from September 2004 through October 2006. Methods. In a pre‐post study design, we gathered data from administrative and laboratory datab...

Risk factors associated with surgical site infection after pediatric posterior spinal fusion procedure.

Abstract: objective. To identify risk factors associated with surgical site infection (SSI) after pediatric posterior spinal fusion procedure by examining characteristics related to the patient, the surgical procedure, and tissue hypoxia. design. Retrospective case-control study nested in a hospital cohort study. setting. A 475-bed, tertiary care children’s hospital. methods. All patients who underwent a spinal fusion procedure during the period from January 1995 through December 2006 were included. SSI cases were identified by means of prospective surveillance using National Nosocomial Infection Surveillance system definitions. Forty-four case patients who underwent a posterior spinal fusion procedure and developed an SSI were identified and evaluated. Each case patient was matched (on the basis of date of surgery, 3 months) to 3 control patients who underwent a posterior spinal fusion procedure but did not develop an SSI. Risk factors for SSI were evaluated by univariate analysis and multivariable conditional logistic regression. Odds ratios (ORs), with 95% confidence intervals (CIs) and P values, were calculated. results. From 1995 to 2006, the mean annual rate of SSI after posterior spinal fusion procedure was 4.4% (range, 1.1%–6.7%). Significant risk factors associated with SSI in the univariate analysis included the following: a body mass index (BMI) greater than the 95th percentile (OR, 3.5 [95% CI, 1.5–8.3]); antibiotic prophylaxis with clindamycin, compared with other antibiotics (OR, 3.5 [95% CI, 1.2– 10.0]); inappropriately low dose of antibiotic (OR, 2.6 [95% CI, 1.0–6.6]); and a longer duration of hypothermia (ie, a core body temperature of less than 35.5C) during surgery (OR, 0.4 [95% CI, 0.2–0.9]). An American Society of Anesthesiologists (ASA) score of greater than 2, obesity (ie, a BMI greater than the 95th percentile), antibiotic prophylaxis with clindamycin, and hypothermia were statistically significant in the multivariable model. conclusion. An ASA score greater than 2, obesity, and antibiotic prophylaxis with clindamycin were independent risk factors for SSI. Hypothermia during surgery appears to provide protection against SSI in this patient population.

Impact of an antimicrobial utilization program on antimicrobial use at a large teaching hospital: a randomized controlled trial.

Abstract: Background Multidisciplinary antimicrobial utilization teams (AUTs) have been proposed as a mechanism for improving antimicrobial use, but data on their efficacy remain limited. Objective To determine the impact of an AUT on antimicrobial use at a teaching hospital. Design Randomized controlled intervention trial. Setting A 953-bed, public, university-affiliated, urban teaching hospital. Patients Patients who were given selected antimicrobial agents (piperacillin-tazobactam, levofloxacin, or vancomycin) by internal medicine ward teams. Intervention Twelve internal medicine teams were randomly assigned monthly: 6 teams to an intervention group (academic detailing by the AUT) and 6 teams to a control group that was given indication-based guidelines for prescription of broad-spectrum antimicrobials (standard of care), during a 10-month study period. Measurements Proportion of appropriate empirical, definitive (therapeutic), and end (overall) antimicrobial usage. Results A total of 784 new prescriptions of piperacillin-tazobactam, levofloxacin, and vancomycin were reviewed. The proportion of antimicrobial prescriptions written by the intervention teams that was considered to be appropriate was significantly higher than the proportion of antimicrobial prescriptions written by the control teams that was considered to be appropriate: 82% versus 73% for empirical (risk ratio [RR], 1.14; 95% confidence interval [CI], 1.04-1.24), 82% versus 43% for definitive (RR, 1.89; 95% CI, 1.53-2.33), and 94% versus 70% for end antimicrobial usage (RR, 1.34; 95% CI, 1.25-1.43). In multivariate analysis, teams that received feedback from the AUT alone (adjusted RR, 1.37; 95% CI, 1.27-1.48) or from both the AUT and the infectious diseases consultation service (adjusted RR, 2.28; 95% CI, 1.64-3.19) were significantly more likely to prescribe end antimicrobial usage appropriately, compared with control teams. Conclusions A multidisciplinary AUT that provides feedback to prescribing physicians was an effective method in improving antimicrobial use. Trial registration. ClinicalTrials.gov identifier: NCT00552838.

Prospective Evaluation of Colonization with Extended‐Spectrum β‐Lactamase (ESBL)–Producing Enterobacteriaceae Among Patients at Hospital Admission and of Subsequent Colonization with ESBL‐Producing Enterobacteriaceae Among Patients During Hospitalization

Abstract: Objective.To determine the rates of and risk factors for carriage and acquisition of extended-spectrum (β-lactamase (ESBL)-producing Enterobacteriaceae during hospitalization.Design.Cohort study.Setting.Shaare Zedek Medical Center, a 550-bed teaching hospital.Methods.During a 5-month period (February 1-June 30, 2004), 167 (8%) of 1,985 newly admitted general medical patients were enrolled in our study. Nasal, oropharyngeal, and rectal swab specimens were obtained at admission and every 2-3 days until hospital discharge or death. Enterobacteriaceae isolates were tested for ESBL, and Staphylococcus aureus isolates were tested for methicillin resistance.Results.Of the 167 patients enrolled in our study, 15 (9%) were identified as nasal carriers of methicillin-resistant S. aureus (MRSA) at admission, and 13 (8%) were rectal carriers of ESBL-producing Enterobacteriaceae at admission. Univariate risk factors for rectal carriage of ESBL-producing Enterobacteriaceae included female sex (odds ratio [OR], 11 [95% confidence interval {CI}, 1.4—238]; P < .05), nursing home residence (OR, 6.9 [95% CI, 1.8-27]; P < .01), recent antibiotic treatment (OR, 9.8 [95% CI, 1.7-74]; P < .05), and concomitant nasal carriage of MRSA and/or ESBL-producing Enterobacteriaceae (OR, 5.8 [95% CI, 1.2-26]; P < .01). Multivariate risk factors were female sex and recent antibiotic treatment. During hospitalization, 35 (21%) of 167 patients had acquired rectal carriage of ESBL-producing Enterobacteriaceae (P = .002, for trend analysis). Of the 12 patients who were still in the hospital 2 weeks after admission, 4 (33%) were carriers of ESBL-producing Enterobacteriaceae. Univariate risk factors for acquisition included an age of older than 65 years (P < .005), nursing home residence (OR 2.6, [95% CI, 0.98-2.6]), impaired cognition (OR, 4.8 [95% CI, 1.9-12]), recent antibiotic treatment (OR, 2.7 [95% CI, 0.9-8.3]), respiratory assistance (OR, 4.2 [95% CI, 1.2-14]), and prolonged hospitalization. Multivariate risk factors were an age of older than 65 years and broad-spectrum antibiotic therapy.Conclusions.Rectal carriage of ESBL-producing Enterobacteriaceae occurred in 13 (8%) of 167 patients at admission to the medical departments of our hospital and in 4 (33%) of 12 patients still remaining in our hospital after 2 weeks.

Epidemiology and Impact of Imipenem Resistance in Acinetobacter baumannii

Abstract: Background. Acinetobacter baumannii is an emerging gram‐negative pathogen that can cause healthcare‐acquired infections among patients. Treatment is complicated for cases of healthcare‐acquired infection with A. baumannii resistant to imipenem. Objective. To elucidate the risk factors for imipenem‐resistant A. baumannii (IRAB) infection or colonization and to identify the effect of resistance on clinical and economic outcomes. Methods. We analyzed data from 2 medical centers of the University of Pennsylvania. Longitudinal trends in the prevalence of IRAB clinical isolates were characterized during the period from 1989 through 2004. For A. baumannii isolates obtained from 2001 through 2006, a case‐control study was conducted to investigate the association between prior carbapenem use and IRAB infection or colonization, and a cohort study was performed to identify the effect of IRAB infection or colonization on mortality, length of stay after culture, and hospital cost after culture. Results. From 1989 thro...

Prevention of central venous catheter-associated bloodstream infections in pediatric intensive care units: a performance improvement collaborative.

Abstract: objective The goal of this effort was to reduce central venous catheter (CVC)–associated bloodstream infections (BSIs) in pediatric intensive care unit (ICU) patients by means of a multicenter evidence-based intervention methods An observational study was conducted in 26 freestanding children’s hospitals with pediatric or cardiac ICUs that joined a Child Health Corporation of America collaborative CVC-associated BSI protocols were implemented using a collaborative process that included catheter insertion and maintenance bundles, daily review of CVC necessity, and daily goals The primary goal was either a 50% reduction in the CVC-associated BSI rate or a rate of 15 CVC-associated BSIs per 1,000 CVC-days in each ICU at the end of a 9-month improvement period A 12-month sustain period followed the initial improvement period, with the primary goal of maintaining the improvements achieved results The collaborative median CVC-associated BSI rate decreased from 63 CVC-associated BSIs per 1,000 CVC-days at the start of the collaborative to 43 CVC-associated BSIs per 1,000 CVC-days at the end of the collaborative Sixty-five percent of all participants documented a decrease in their CVC-associated BSI rate Sixty-nine CVC-associated BSIs were prevented across all teams, with an estimated cost avoidance of $29 million Hospitals were able to sustain their improvements during a 12-month sustain period and prevent another 198 infections conclusions We conclude that our collaborative quality improvement project demonstrated that significant reduction in CVC-associated BSI rates and related costs can be realized by means of evidence-based prevention interventions, enhanced communication among caregivers, standardization of CVC insertion and maintenance processes, enhanced measurement, and empowerment of team members to enforce adherence to best practices Infect Control Hosp Epidemiol 2009; 30:645-651

5 Years of Experience Implementing a Methicillin-Resistant Staphylococcus aureus Search and Destroy Policy at the Largest University Medical Center in the Netherlands

Abstract: objective. To evaluate the effectiveness of a rigorous search and destroy policy for controlling methicillin-resistant Staphylococcus aureus (MRSA) infection or colonization. design. Hospital-based observational follow-up study. setting. Erasmus University Medical Center Rotterdam, a 1,200-bed tertiary care center in Rotterdam, the Netherlands. methods. Outbreak control was accomplished by the use of active surveillance cultures for persons at risk, by the preemptive isolation of patients at risk, and by the strict isolation of known MRSA carriers and the eradication of MRSA carriage. For unexpected cases of MRSA colonization or infection, patients placed in strict isolation or contact isolation and healthcare workers (HCWs) were screened. We collected data from 2000–2004. results. During the 5-year study period, 51,907 MRSA screening cultures were performed for 21,598 persons at risk (8,403 patients and 13,195 HCWs). By screening, it was determined that 123 (1.5%) of 8,403 patients and 31 (0.2%) of 13,195 HCWs were MRSA carriers. From the performance of clinical cultures, it was determined that 54 additional patients were MRSA carriers, resulting in a total of 177 patients carrying MRSA. Of the 177 patients carrying MRSA, 144 (81%) were primary patients, and 33 (19%) secondary patients. The average number of nosocomial transmissions was 6.7 per year. The cumulative incidence of MRSA colonization among this group of patients was 0.10 cases per 100 admissions. Of 156 cases of MRSA colonization, 44 (28%) were acquired in a foreign healthcare institution, and 45 (29%) were acquired in other Dutch hospitals, 22 (47%) of which were acquired in a single hospital in our region. There were 16 cases (10%) that occurred in a nursing home and another 16 cases (10%) that fulfilled our definition of community-acquired MRSA colonization; there were 4 cases (3%) categorized as “other” and 31 cases (20%) for which the source of MRSA acquisition remained unknown. The basic reproduction rate was 10-fold less for patients isolated on admission, compared with those who were not. During the 5-year study period, 5 episodes of MRSA bacteremia occurred in which 4 patients died, an incidence rate of 0.28 cases of infection per 100,000 patient-days per year. conclusion. Our results show that, during a rigorous search and destroy policy, a low incidence of MRSA in our medical center was continuously observed and that this policy most likely contributed to a very low nosocomial transmission rate.

Prevention of bloodstream infections by use of daily chlorhexidine baths for patients at a long-term acute care hospital

Abstract: Objective. To evaluate the effect of bathing patients with 2% chlorhexidine on the rates of central vascular catheter (CVC)–associated bloodstream infection (BSI) at a long‐term acute care hospital (LTACH). Design. Quasi‐experimental study Setting. A 70‐bed LTACH in the greater Chicago area. Patients. All consecutive patients admitted to the LTACH during the period from February 2006 to February 2008. Methods. For patients at the LTACH, daily 2% chlorhexidine baths were instituted during the period from September 2006 until May 2007 (ie, the intervention period). A preintervention period (in which patients were given daily soap‐and‐water baths) and a postintervention period (in which patients were given daily nonmedicated baths and weekly 2% chlorhexidine baths) were also observed. The rates of CVC‐associated BSI and ventilator‐associated pneumonia were analyzed for the intervention period and for the pre‐ and postintervention periods. Results. The rates of CVC‐associated BSI were 9.5, 3.8, and 6.4 cases ...

Secular trends of hospitalization with vancomycin-resistant enterococcus infection in the United States, 2000-2006.

Abstract: Although the incidence of hospitalizations with infection due to vancomycin-resistant pathogens in the United States remained stable during 2000-2003, it increased from 4.60 to 9.48 hospitalizations per 100,000 population during 2003-2006. Hospitalizations with infection due to vancomycin-resistant pathogens also increased as a proportion of all US hospitalizations, from 3.16 to 6.51 hospitalizations with VRE infection per 10,000 total hospitalizations during 2003-2006. The number of hospitalizations with infection due to vancomycin-resistant pathogens is increasing in the United States. Because infection due to vancomycin-resistant organisms is associated with poor outcomes, the epidemiology of this trend needs further exploration.

Clostridium difficile infection in Ohio hospitals and nursing homes during 2006.

Abstract: context. Healthcare data suggest that the incidence and severity of Clostridium difficile infection (CDI) in hospitals are increasing. However, the overall burden of disease and the mortality rate associated with CDI, including the contribution from cases of infection that occur in nursing homes, are poorly understood. objective. To describe the epidemiology, disease burden, and mortality rate of healthcare-onset CDI. methods. In 2006, active public reporting of healthcare-onset CDI, using standardized case definitions, was mandated for all Ohio hospitals and nursing homes. Incidence rates were determined and stratified according to healthcare facility characteristics. Death certificates that listed CDI were analyzed for trends. results. There were 14,329 CDI cases reported, including 6,376 cases at 210 hospitals (5,217 initial cases [ie, cases identified more than 48 hours after admission to a healthcare facility in patients who had not had CDI during the previous 6 months] and 1,159 recurrent cases [ie, cases involving patients who had had CDI during the previous 6 months]) and 7,953 cases at 955 nursing homes (4,880 initial and 3,073 recurrent cases) . After adjusting for missing data, the estimated total was 18,200 cases of CDI, which included 7,000 hospital cases (5,700 initial and 1,300 recurrent cases) and 11,200 nursing homes cases (6,900 initial and 4,300 recurrent cases). The rate for initial cases was 6.4–7.9 cases/10,000 patient-days for hospitals and 1.7–2.9 cases/10,000 patient-days for nursing homes. The rate for initial cases in nursing homes decreased during the study ( P ! .001 ). Nonpediatric hospital status ( P p .011 ), a smaller number of beds ( P p .003), and location in the eastern or northeastern region of the state ( P p .011 ) were each independently associated with a higher rate of initial cases in hospitals. Death certificates for 2006 listed CDI among the causes of death for 893 Ohio residents; between 2000 and 2006, this number increased more than 4-fold.

Topical Therapy for Methicillin‐Resistant Staphylococcus aureus Colonization: Impact on Infection Risk

Abstract: Objective. We evaluated the usefulness of topical decolonization therapy for reducing the risk of methicillin‐resistant Staphylococcus aureus (MRSA) infection among MRSA‐colonized inpatients. Design. Retrospective cohort study. Setting and intervention. Three hospitals with universal surveillance for MRSA; at their physician's discretion, colonized patients could be treated with a 5‐day course of nasal mupirocin calcium 2%, twice daily, plus chlorhexidine gluconate 4% every second day. Patients and methods. MRSA carriers were later retested for colonization (407 subjects; study 1) or followed up for development of MRSA infection (933 subjects; study 2). Multivariable methods were used to determine the impact of decolonization therapy on the risks of sustained colonization (in study 1) and MRSA infection (in study 2). Results. Independent risk factors for sustained colonization included residence in a long‐term care facility (odds ratio [OR], 1.8 [95% confidence interval {CI}, 1.1–3.2]) and a pressure ulce...

Two time-series analyses of the impact of antibiotic consumption and alcohol-based hand disinfection on the incidences of nosocomial methicillin-resistant Staphylococcus aureus infection and Clostridium difficile infection.

Abstract: Objective. To determine the impact of antibiotic consumption and alcohol‐based hand disinfection on the incidences of nosocomial methicillin‐resistant Staphylococcus aureus (MRSA) infection and Clostridium difficile infection (CDI). Methods. Two multivariate time‐series analyses were performed that used as dependent variables the monthly incidences of nosocomial MRSA infection and CDI at the Freiburg University Medical Center during the period January 2003 through October 2007. The volume of alcohol‐based hand rub solution used per month was quantified in liters per 1,000 patient‐days. Antibiotic consumption was calculated in terms of the number of defined daily doses per 1,000 patient‐days per month. Results. The use of alcohol‐based hand rub was found to have a significant impact on the incidence of nosocomial MRSA infection ( \documentclass{aastex} \usepackage{amsbsy} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{bm} \usepackage{mathrsfs} \usepackage{pifont} \usepackage{stmaryrd} \usepackage{t...

A cluster of cases of nosocomial legionnaires disease linked to a contaminated hospital decorative water fountain.

Abstract: Background—Nosocomial outbreaks of Legionnaire’s disease have been linked to contaminated water in hospitals. Immunocompromised patients are particularly vulnerable and, when infected, have a high mortality rate. We report the investigation of a cluster of nosocomial pneumonia due to Legionella pneumophila serogroup 1 that occurred among patients on our stem cell transplantation unit. Methods—We conducted a record review to identify common points of potential exposure, followed by environmental and water sampling for Legionella spp. from those sources. We used an air sampler in an attempt to detect aerosolized Legionella, and pulsed-field gel electrophoresis to compare clinical and environmental isolates. Results—The most likely sources identified were the water supply in the patients’ rooms and a decorative fountain in the radiation oncology suite. Samples from the patients’ rooms did not grow Legionella species. Cultures of the fountain, which had been restarted 4 months earlier after being shut off for 5 months, yielded L. pneumophila serogroup 1. The isolates from both patients and the fountain were identical by pulsed-field gel electrophoresis. Both patients developed pneumonia within 10 days of completing radiation therapy, and each reported having observed the fountain at close range. Both patients’ infections were identified early and treated promptly, and both recovered. Conclusions—This cluster was caused by contamination of a decorative fountain despite its being equipped with a filter and ozone generator. Fountains are a potential source of nosocomial Legionnaire’s disease despite standard maintenance and sanitizing measures. In our opinion, fountains present unacceptable risk in hospitals serving immunocompromised patients.

Incidence of microperforation for surgical gloves depends on duration of wear

Abstract: background. The use of sterile gloves is part of general aseptic procedure, which aims to prevent surgical team members from transmitting infectious agents to patients during procedures performed in an operating room. In addition, surgical gloves also protect team members against patient-transmitted infectious agents. Adequate protection, however, requires that the glove material remain intact. The risk of perforations in surgical gloves is thought to correlate with the duration of wear, yet very few prospective studies have addressed this issue. methods. We prospectively collected 898 consecutive pairs of used surgical gloves over a 9-month period in a single institution. After surgical team members wore the gloves during surgical procedures, the gloves were examined for microperforations using the watertight test described in European Norm 455, part 1. The gloves were analyzed as a pair; if 1 glove had a perforation, the pair was considered to be perforated. In addition, we evaluated the use of a hand cream that contained a suspension of cornstarch and ethanol to determine its potential influence on the rate of microperforation. results. Wearing gloves for 90 minutes or less resulted in microperforations in 46 (15.4%) of 299 pairs of gloves, whereas wearing gloves for 91‐150 minutes resulted in perforation of 54 (18.1%) of 299 pairs, and 71 of (23.7%) of 300 pairs were perforated when the duration of wear was longer than 150 minutes ( ). Subgroup analysis revealed no significant difference in the rates of microperforation P p .05 for surgeons (56 [23.0%] of 244 pairs of gloves perforated), first assistants (43 [19.0%] of 226 pairs perforated), and surgical nurses (53 [20.5%] of 259 pairs perforated). Of 171 microperforations, 114 (66.7%) were found on the left hand glove (ie, the glove on subjects’ nondominant hand), predominantly on the left index finger (55 [32.3%]). The use of the hand cream had no influence on the rate of microperforation. conclusion. Because of the increase in the rate of microperforation over time, it is recommended that surgeons, first assistants, and surgical nurses directly assisting in the operating field change gloves after 90 minutes of surgery. Infect Control Hosp Epidemiol 2009; 30:409-414

Results of survey on implementation of Infectious Diseases Society of America and Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship

Abstract: It has been recognized for several decades that as much as 50% of antimicrobial use is inappropriate, which leads to considerable costs and increased selection for resistant pathogens. Antimicrobial stewardship guidelines were published in 2007 by the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA), with the primary goal of optimizing clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms (such as Clostridium difficile), and the emergence of resistance. We performed a survey to determine the prevalence of and components of antimicrobial stewardship programs in US hospitals.

Patients' beliefs and perceptions of their participation to increase healthcare worker compliance with hand hygiene

Abstract: background. Research suggests that patients could improve healthcare workers’ compliance with hand hygiene recommendations by reminding them to cleanse their hands. objective. To assess patients’ perceptions of a patient-participation program to improve healthcare workers’ compliance with hand hygiene. design. Cross-sectional survey of patient knowledge and perceptions of healthcare-associated infections, hand hygiene, and patient participation, defined as the active involvement of patients in various aspects of their health care. setting. Large Swiss teaching hospital. results. Of 194 patients who participated, most responded that they would not feel comfortable asking a nurse (148 respondents [76%]) or a physician (150 [77%]) to perform hand hygiene, and 57 (29%) believed that this would help prevent healthcare-associated infections. In contrast, an explicit invitation from a healthcare worker to ask about hand hygiene doubled the intention to ask a nurse (from 34% to 83% of respondents; ) and to ask a physician (from 30% to 78%; ). In multivariate analysis, being nonreligious, having P ! .001 P ! .001 an expansive personality, being concerned about healthcare-associated infections, and believing that patient participation would prevent healthcare-associated infections were associated with the intention to ask a nurse or a physician to perform hand hygiene ( ). Being P ! .05 of Jewish, Eastern Orthodox, or Buddhist faith was associated also with increased intention to ask a nurse ( ), compared with being P ! .05 of Christian faith. conclusions. This study identifies several sociodemographic characteristics associated with the intention to ask nurses and physicians about hand hygiene and underscores the importance of a direct invitation from healthcare workers to increase patient participation and foster patient empowerment. These findings could guide the development of future hand hygiene–promotion strategies. Infect Control Hosp Epidemiol 2009; 30:830-839