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A cost-benefit analysis of gown use in controlling vancomycin-resistant Enterococcus transmission: is it worth the price?

01 May 2004-Infection Control and Hospital Epidemiology (Infect Control Hosp Epidemiol)-Vol. 25, Iss: 5, pp 418-424
TL;DR: Infection control policies (eg, gown use) initially increase the cost of health services delivery, however, such policies can be cost saving by averting nosocomial infections and the associated costs of treatment.
Abstract: Objective:To determine the net benefit and costs associated with gown use in preventing transmission of van-comycin-resistant Enterococcus (VRE).Design:A cost-benefit analysis measuring the net benefit of gowns was performed. Benefits, defined as averted costs from reduced VRE colonization and infection, were estimated using a matched cohort study. Data sources included a step-down cost allocation system, hospital informatics, and microbiology databases.Setting:The medical intensive care unit (MICU) at Barnes-Jewish Hospital, St. Louis, Missouri.Patients:Patients admitted to the MICU for more than 24 hours from July 1, 1997, to December 31, 1999.Interventions:Alternating periods when all healthcare workers and visitors were required to wear gowns and gloves versus gloves alone on entry to the rooms of patients colonized or infected with VRE.Results:On base-case analysis, 58 VRE cases were averted with gown use during 18 months. The annual net benefit of the gown policy was 1,897. The analysis was most sensitive to the level of VRE transmission.Conclusions:Infection control policies (eg, gown use) initially increase the cost of health services delivery. However, such policies can be cost saving by averting nosocomial infections and the associated costs of treatment. The cost savings to the hospital plus the benefits to patients and their families of avoiding nosocomial infections make effective infection control policies a good investment.

Summary (2 min read)

Study Population

  • During the 12 months between these two periods, gowns were not required.
  • The institutional review board committees of Saint Louis University and Washington University approved this study.
  • During the entire study period, all patients were actively screened for VRE by collection of stool for cultures or rectal swabs on admission, every 7 days, and at discharge from the MICU.
  • Two patients without VRE were randomly selected, using the same matching criteria, for each patient with VRE bacteremia.

Costs

  • Overall costs for the VRE surveillance and infection control program were estimated using the hospital’s step- down cost allocation system, which recorded line-item cost data per resource consumed and total cost per hospital admission.
  • The cost for each isolation cart included all initial supplies.
  • Observational time trials were used to estimate the time required for healthcare workers to retrieve, don, doff, and properly dispose of gowns.
  • 18 To estimate the cost associated with excess workload per VRE patient contact, the average time was multiplied by the average registered nurse salary (excluding fringe benefits).
  • Microbiology costs for each patient were obtained from line-item reports from the hospital’s microbiology database.

Decision Analysis

  • The costs, benefits, and net benefit for the enhanced infection control and VRE surveillance programs are listed in Table 3.
  • The incremental cost per case of VRE colonization averted was $1,897.

Sensitivity Analysis

  • Several parameters were changed to determine the impact of their four main assumptions on the net benefit of gowns.
  • The results were most sensitive to the probability of acquiring enteric VRE.
  • Specifically, gowns are more likely to impact transmission when there are high rates of VRE colonization compared with when there are low rates.

Statistical Analysis

  • Univariate statistics were obtained using SPSS software (version 10.0; SPSS, Inc., Chicago, IL).
  • Differences in characteristics between patients with and patients without VRE were identified using t tests for continuous covariates and chi-square tests for categorical covariates.
  • A Decision Tree Add-In for Microsoft Excel was used for the decision analysis (TreePlan, version 1.62; Microsoft Corp., Redmond, WA).

Matched Cohort

  • Based on the matching criteria, patients with and patients without VRE were closely matched.
  • The mean APACHE II scores were similar between patients colonized with VRE and their matched controls and between patients with VRE bacteremia and their matched controls (22.0 vs 21.8 and 26.5 vs 26.3, respectively), as were the mean ages (62.3 vs 62.2 years and 65.4 vs 64.0 years, respectively).
  • An event pathway showing vancomycin-resistant enterococci (VRE) colonization and infection rates from July 1, 1997, to December 31, 1999, for patients in the medical intensive care unit.

Primary Outcomes

  • The length of MICU stay, length of hospital stay, MICU costs, and hospital costs attributable to VRE were less for patients colonized with VRE than for patients with VRE bacteremia (Table 2).
  • Five patients in the latter group died while hospitalized.

DISCUSSION

  • The results of this cost–benefit analysis provide evidence that gown use adds costs to the delivery of health services in a MICU setting, but the benefits from averting enteric VRE transmission outweigh those costs.
  • The increased cost associated with gown use needs to be considered relative to the attributable length of stay, mortality, and costs associated with VRE acquisition.
  • There are several limitations to this study.
  • The limitation that biases the study toward finding gowns to be cost-saving relates to the fact that the infection control protocols for this study were already in place at this insti- tution prior to the start of the study.
  • The authors would have been potentially able to determine the number of secondary cases of VRE generated from a primary case of VRE and more accurately quantify the number of VRE cases averted.

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A Cost–Benefit Analysis of Gown Use in Controlling Vancomycin‐Resistant Enterococcus
Transmission: Is It Worth the Price?• 
Author(s): Laura A. Puzniak , PhD, Kathleen N. Gillespie , PhD, Terry Leet , PhD, Marin Kollef
, MD, Linda M. Mundy , MD
Reviewed work(s):
Source:
Infection Control and Hospital Epidemiology,
Vol. 25, No. 5 (May 2004), pp. 418-424
Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of
America
Stable URL: http://www.jstor.org/stable/10.1086/502416 .
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418 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY May 2004
A C
OST–BENEFIT ANALYSIS OF GOWN USE IN
C
ONTROLLING VANCOMYCIN-RESISTANT
E
NTEROCOCCUS
TRANSMISSION: IS IT WORTH THE PRICE?
Laura A. Puzniak, PhD; Kathleen N. Gillespie, PhD; Terry Leet, PhD; Marin Kollef, MD; Linda M. Mundy, MD
Enterococci are the third most common pathogen
associated with nosocomial infections, accounting for 12%
of intensive care unit infections.
1
The increasing preva-
lence of enterococcal infections is problematic due to lim-
ited treatment and eradication strategies. Furthermore,
the public health threat from vancomycin-resistant ente-
rococci (VRE) is more imminent given the recent detec-
tion of vancomycin-resistant Staphylococcus aureus
(VRSA).
2-4
The presence of vanA in a clinical isolate of
VRSA from a host colonized with VRE suggests exchange
of genetic material between these gram-positive
pathogens.
2
Hospital Infection Control Practices Advisory
Committee guidelines for controlling VRE include screen-
ing high-risk populations, using vancomycin appropriately,
educating medical staff, and implementing infection con-
trol procedures.
5
Recommended infection control prac-
tices include the use of gloves and gowns with patients col-
onized or infected with drug-resistant pathogens.
5
Despite
encouraging results for the efficacy of gown use, there is
ongoing debate over the cost versus benefit of requiring
gown use to prevent VRE transmission.
6-15
Few studies have assessed the costs and benefits
associated with gown use.
11-13
One study reported an
annual cost increase of $11,303 for gowns and gloves after
a VRE epidemic began.
12
The authors concluded that pre-
venting a case of VRE bacteremia was worth the addition-
al cost for implementing isolation precautions. In contrast,
a study in a bone marrow transplant unit reported that dis-
continuing the use of gowns and shoe covers created a
$70,000 savings for the unit with no increase in infection
rates.
11
Our prior work showed that requiring healthcare
workers and visitors to wear gowns when entering the
rooms of patients in a medical intensive care unit (MICU)
reduced the patients’ risk of VRE acquisition during peri-
ods of high VRE colonization pressure.
13
The purpose of
this study was to determine the costs and benefits of this
enhanced infection control program aimed at reducing
VRE transmission.
Drs. Puzniak, Leet, and Mundy are from the Department of Community Health and Dr. Gillespie is from the Department of Health
Management and Policy, Saint Louis University School of Public Health, St. Louis, Missouri. Drs. Kollef and Mundy are from the Department of
Medicine, Washington University School of Medicine, St. Louis, Missouri.
Address reprint requests to Linda M. Mundy, MD, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8051, St.
Louis, MO 63110.
The authors thank the 65 members of the medical intensive care unit, the Barnes–Jewish Hospital medicine residents, and the Washington
University faculty who participated in the care of these patients; Donna Prentice and Jennie Mayfield for managing the VRE surveillance program;
Joan Hoppe-Bauer for providing microbiology data; and Dr. Brooke Shadel for her insightful comments during manuscript review.
OBJECTIVE: To determine the net benefit and costs
associated with gown use in preventing transmission of van-
comycin-resistant Enterococcus (VRE).
DESIGN: A cost–benefit analysis measuring the net ben-
efit of gowns was performed. Benefits, defined as averted costs
from reduced VRE colonization and infection, were estimated
using a matched cohort study. Data sources included a step-down
cost allocation system, hospital informatics, and microbiology
databases.
SETTING: The medical intensive care unit (MICU) at
Barnes–Jewish Hospital, St. Louis, Missouri.
PATIENTS: Patients admitted to the MICU for more than
24 hours from July 1, 1997, to December 31, 1999.
INTERVENTIONS: Alternating periods when all health-
care workers and visitors were required to wear gowns and
gloves versus gloves alone on entry to the rooms of patients col-
onized or infected with VRE.
RESULTS: On base-case analysis, 58 VRE cases were
averted with gown use during 18 months. The annual net benefit
of the gown policy was $419,346 and the cost per case averted of
VRE was $1,897. The analysis was most sensitive to the level of
VRE transmission.
CONCLUSIONS: Infection control policies (eg, gown
use) initially increase the cost of health services delivery.
However, such policies can be cost saving by averting nosocomi-
al infections and the associated costs of treatment. The cost sav-
ings to the hospital plus the benefits to patients and their families
of avoiding nosocomial infections make effective infection con-
trol policies a good investment (Infect Control Hosp Epidemiol
2004;25:418-424).
ABSTRACT

Vol. 25 No. 5 COST–BENEFIT ANALYSIS OF GOWNS 419
METHODS
Study Population
All patients staying more than 24 hours in a 19-bed
MICU at Barnes–Jewish Hospital from July 1, 1997, to
December 31, 1999, were eligible. All healthcare workers
and visitors were required to wear gowns and gloves on
entry into the rooms of patients colonized or infected with
VRE from July, 1, 1997, to June 30, 1998, and from July 1,
1999, to December 31, 1999. During the 12 months
between these two periods, gowns were not required. The
institutional review board committees of Saint Louis
University and Washington University approved this
study.
During the entire study period, all patients were
actively screened for VRE by collection of stool for cul-
tures or rectal swabs on admission, every 7 days, and at
discharge from the MICU. Per hospital protocol, stool
specimens sent for the detection of Clostridium difficile
toxin were also screened for VRE. For each patient with
VRE, a sign requiring contact precautions and an isolation
cart containing a dedicated stethoscope, a glass ther-
mometer, and gloves were placed at the entrance to the
patient’s room. Contact precautions were continued
unless a patient had two subsequent consecutive stool
surveillance specimens that tested negative. Gowns that
were fluid resistant and laundered after each use were
added to the isolation cart during the designated gown
periods.
A matched cohort study design was used to deter-
mine the attributable cost of VRE. Patients without VRE
from the same MICU population were matched to patients
with VRE by diagnosis-related group (DRG) code, Acute
Physiology and Chronic Health Evaluation (APACHE) II
16
severity of illness score (± 2 points), and age (± 5 years).
17
One patient without VRE was randomly selected for each
patient colonized with VRE when there were multiple
patients without VRE with the same matching criteria.
Two patients without VRE were randomly selected, using
the same matching criteria, for each patient with VRE bac-
teremia. Two matched controls were used to increase sta-
tistical power due to the small number of patients with
VRE bacteremia. Four patients colonized with VRE and
two patients with VRE bacteremia were excluded from the
study population because there was not a match of a
patient without VRE.
Clinical endpoints were obtained from the hospital’s
informatics system. These included MICU and hospital
lengths of stay, presence of nosocomial bacteremia due to
oxacillin-resistant S. aureus (ORSA) or Pseudomonas
aeruginosa, and presence of colitis or diarrhea associated
with C. difficile toxin. The three nosocomial pathogens
were used to determine whether the frequency of co-
infections was similar between patients with and patients
without VRE.
Costs
Overall costs for the VRE surveillance and infection
control program were estimated using the hospital’s step-
down cost allocation system, which recorded line-item
cost data per resource consumed and total cost per hospi-
tal admission. MICU costs were estimated from these
data by dividing the patient’s total hospitalization cost by
total days of hospitalization and then multiplying the quo-
tient by the patient’s total MICU-days. This data system
also provided hospital reimbursement data, type of insur-
ance, case mix index, and DRG. Medicare patients from
the study population were used to determine the average
non-reimbursed hospitalization cost by VRE status.
The cost for each isolation cart included all initial
supplies. In addition to the costs for gowns, the costs
resulting from staff time to comply with gown use were
estimated. Observational time trials were used to estimate
the time required for healthcare workers to retrieve, don,
doff, and properly dispose of gowns. On three separate
occasions, two unobtrusive observers measured the
amount of time required by 128 healthcare workers to
comply with the gown policy. Our observations showed
that the average worker needed 60 seconds (range, 35 to
95 seconds) to don and doff gowns, which was similar to
the amount of time needed for the same activities in anoth-
er study.
18
To estimate the cost associated with excess
workload per VRE patient contact, the average time was
multiplied by the average registered nurse salary (exclud-
ing fringe benefits). Because a range of healthcare work-
ers entered a patient’s room, the average registered
nurse’s salary was used to approximate this cost.
Microbiology costs for each patient were obtained
from line-item reports from the hospital’s microbiology
database. Microbiology costs were inclusive of all related
testing costs (ie, materials, technician time, nursing time
for culture procurement, and overhead). Individualized
costs associated with contact precautions and surveil-
lance are listed in Table 1. All costs were reported in U.S.
dollars.
Decision Analysis
An event pathway of the study was constructed
showing VRE colonization and infection rates during this
30-month study period (Figure).
13
Costs were allocated to
each arm based on actual resources consumed per
patient. Each patient with VRE, regardless of study peri-
od, was charged the costs for a cart, gloves, and hand
hygiene. During the gown period, patients with VRE were
charged additional costs for gowns and nursing time to
comply with the gown policy.
Benefits were measured as the number of VRE
cases and the MICU costs averted. The number of VRE
cases averted was estimated by multiplying the difference
in the VRE rates between the study periods by the num-
ber of patients in the gown period. The number of VRE
cases averted per 1,000 MICU-days was calculated by tak-
ing the number of cases averted and dividing it by the
total number of MICU patient-days in the gown period and
multiplying by 1,000. Averted attributable cost for the
gown period and net benefit of the gown policy
19
were
computed as shown in equations 1 and 2, respectively.

420 INFECTION
CONTROL AND H
OSPITAL
EPIDEMIOLOGY
May 2004
(1) averted attributable cost
gown
= (attributable cost
of VRE colonization annualized number of VRE colo-
nized cases averted) + (weighted mean attributable cost
of both diagnostic criteria of VRE bacteremia annual-
ized number of VRE bacteremic cases averted)
(2) net benefit = averted attributable cost
gown
-
(annualized isolation/surveillance cost
gown
- isolation/sur-
veillance cost
no-gown
)
The latter term in equation 2 measured the incre-
mental costs of the gown policy. Costs and benefits in the
gown period were annualized because the gown period
was 6 months longer than the no-gown period.
Sensitivity Analysis
A sensitivity analysis was performed varying sever-
al parameters related to the assumptions regarding the
number of gowns used, time required to don and doff
gowns, VRE transmission rates for this analysis, and cost
of materials. Our baseline estimate for the number of
gowns used was 100 gowns per patient per day. We used
the previously reported value of 60 contacts per day
18
for
the lower limit and an equivalent difference, 140 contacts
per day, for the upper limit. The average number of VRE
cultures performed during the study was 2 per patient per
MICU stay. To adjust for variation in surveillance mecha-
nisms,
20-23
we used 2 cultures as the baseline measure and
varied this measure between 1 and 4 cultures per MICU
stay. Because there were differences in cost between pos-
itive and negative cultures, we used the same proportion
of positive cultures as the original analyses when the para-
meter was changed to 4 cultures per patient. Because the
costs of isolation materials and laboratory testing can dif-
fer between hospitals and can increase due to inflation, we
altered the costs for these items by 20% in both directions.
As shown in the figure, the risks of both acquiring VRE
and developing bacteremia were lower in the gown peri-
od; therefore, we altered the probability of acquiring VRE
in the gown period from 40% to 100% of the probability of
acquiring VRE in the no-gown period to determine the net
benefit at varying levels of VRE transmission.
Statistical Analysis
Univariate statistics were obtained using SPSS soft-
ware (version 10.0; SPSS, Inc., Chicago, IL). Differences
in characteristics between patients with and patients with-
out VRE were identified using t tests for continuous
covariates and chi-square tests for categorical covariates.
A Decision Tree Add-In for Microsoft Excel was used for
the decision analysis (TreePlan, version 1.62; Microsoft
Corp., Redmond, WA).
RESULTS
Matched Cohort
Based on the matching criteria, patients with and
patients without VRE were closely matched. The mean
APACHE II scores were similar between patients colo-
nized with VRE and their matched controls and between
patients with VRE bacteremia and their matched controls
(22.0 vs 21.8 and 26.5 vs 26.3, respectively), as were the
mean ages (62.3 vs 62.2 years and 65.4 vs 64.0 years,
respectively). In addition, there were no significant differ-
ences in the frequency of co-infections between patients
TABLE 1
INDIVIDUALIZED
COSTS ASSOCIATED WITH CONTACT PRECAUTIONS
AND VANCOMYCIN-RESISTANT ENTEROCOCCI SURVEILLANCE IN THE
M
EDICAL INTENSIVE CARE UNIT
Cost
Variable Cost per Day
Gown $0.75 each $75.00
Gloves $0.07/pair $7.00
Hand hygiene $0.10/use $10.00
Nursing time to don and doff gowns $27.00/hour $45.00
Isolation cart set up (cost of initial $18.00 One-time
cart set up—bag of gowns, cost
stethoscope, thermometer, and
box of gloves)
VRE-negative test $12.13 Varies
VRE-positive test $24.29 Varies
VRE = vancomycin-resistant enterococci.
89
VRE colonization from admission culture
94 95%
VRE + on admission
8%
5
VRE infection from admission culture
5%
1164
Admission gown period
62%
1011
No acquisition
94%
1070
VRE - admission 55
VRE acquired colonization
92%
59 93%
VRE acquisition
6%
4
1872 VRE acquired infection
Enter
1 7%
79
VRE colonization from admission culture
88 90%
VRE + on admission
12%
9
VRE infection from admission culture
10%
708
Admission no gown period
38%
552
No acquisition
89%
620
VRE - admission 62
VRE acquired colonization
88%
68 91%
VRE acquisition
11%
6
VRE acquired infection
9%
FIGURE. An event pathway showing vancomycin-resistant enterococci
(VRE) colonization and infection rates from July 1, 1997, to December 31,
1999, for patients in the medical intensive care unit.

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914 citations

Journal ArticleDOI
TL;DR: The attributable mortality from nosocomial bloodstream infection is high in critically ill patients and is associated with a doubling of the SICU stay, an excess length of hospital stay of 24 days in survivors, and a significant economic burden.
Abstract: OBJECTIVE To determine the excess length of stay, extra costs, and mortality attributable to nosocomial bloodstream infection in critically ill patients. DESIGN Pairwise-matched (1:1) case-control study. SETTING Surgical intensive care unit (SICU) in a tertiary health care institution. PATIENTS All patients admitted in the SICU between July 1, 1988, and June 30, 1990, were eligible. Cases were defined as patients with nosocomial bloodstream infection; controls were selected according to matching variables in a stepwise fashion. METHODS Matching variables were primary diagnosis for admission, age, sex, length of stay before the day of infection in cases, and total number of discharge diagnoses. Matching was successful for 89% of the cohort; 86 matched case-control pairs were studied. MAIN OUTCOME MEASURES Crude and attributable mortality, excess length of hospital and SICU stay, and overall costs. RESULTS Nosocomial bloodstream infection complicated 2.67 per 100 admissions to the SICU during the study period. The crude mortality rates from cases and controls were 50% and 15%, respectively (P < .01); thus, the estimated attributable mortality rate was 35% (95% confidence interval, 25% to 45%). The median length of hospital stay significantly differed between cases and controls (40 vs 26 days, respectively; P < .01). When only matched pairs who survived bloodstream infection were considered (n = 41), cases stayed in the hospital a median of 54 days vs 30 days for controls (P < .01), and cases stayed in the SICU a median of 15 days vs 7 days for controls (P < .01). Thus, extra hospital and SICU length of stay attributable to bloodstream infection was 24 and 8 days, respectively. Extra costs attributable to the infection averaged $40,000 per survivor. CONCLUSIONS The attributable mortality from nosocomial bloodstream infection is high in critically ill patients. The infection is associated with a doubling of the SICU stay, an excess length of hospital stay of 24 days in survivors, and a significant economic burden.

816 citations

Journal Article
TL;DR: Routine surveillance of VAPs is mandatory, and high-risk patients, especially those with prolonged granulocytopenia or organ transplants, should be cared for in hospital units with high-efficiency-particulate-arrestor filtered air.
Abstract: Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in the intensive care unit and is associated with major morbidity and attributable mortality. Strategies to prevent VAP are likely to be successful only if based upon a sound understanding of pathogenesis and epidemiology. The major route for acquiring endemic VAP is oropharyngeal colonization by the endogenous flora or by pathogens acquired exogenously from the intensive care unit environment, especially the hands or apparel of health-care workers, contaminated respiratory equipment, hospital water, or air. The stomach represents a potential site of secondary colonization and reservoir of nosocomial Gram-negative bacilli. Endotracheal-tube biofilm formation may play a contributory role in sustaining tracheal colonization and also have an important role in late-onset VAP caused by resistant organisms. Aspiration of microbe-laden oropharyngeal, gastric, or tracheal secretions around the cuffed endotracheal tube into the normally sterile lower respiratory tract results in most cases of endemic VAP. In contrast, epidemic VAP is most often caused by contamination of respiratory therapy equipment, bronchoscopes, medical aerosols, water (eg, Legionella) or air (eg, Aspergillus or the severe acute respiratory syndrome virus). Strategies to eradicate oropharyngeal and/or intestinal microbial colonization, such as with chlorhexidine oral care, prophylactic aerosolization of antimicrobials, selective aerodigestive mucosal antimicrobial decontamination, or the use of sucralfate rather than H(2) antagonists for stress ulcer prophylaxis, and measures to prevent aspiration, such as semirecumbent positioning or continuous subglottic suctioning, have all been shown to reduce the risk of VAP. Measures to prevent epidemic VAP include rigorous disinfection of respiratory equipment and bronchoscopes, and infection-control measures to prevent contamination of medical aerosols. Hospital water should be Legionella-free, and high-risk patients, especially those with prolonged granulocytopenia or organ transplants, should be cared for in hospital units with high-efficiency-particulate-arrestor (HEPA) filtered air. Routine surveillance of VAP, to track endemic VAPs and facilitate early detection of outbreaks, is mandatory.

420 citations


Cites background from "A cost-benefit analysis of gown use..."

  • ...133 Infection control practices to prevent nosocomial spread of respiratory viral infections include: (1) a high level of immunization of patients and staff against influenza; (2) prevention of patient contact with persons (friends, family, and health-care staff) who have active respiratory symptoms; (3) use of rapid diagnostic tests to quickly identify symptomatic patients with potentially transmissible viral pathogens, to facilitate early implementation of isolation precautions; (4) cohorting patients with confirmed infection when single rooms are not available; and (5) placement of patients with suspected community-acquired respiratory viral infections in droplet isolation precautions....

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  • ...1): (1) by aspiration of microbeladen secretions, either from the oropharynx directly or, secondarily, by reflux from the stomach into the oropharynx, then into the lower respiratory tract;37–39 (2) by direct extension of a contiguous infection, such as a pleuralspace infection;40 (3) through inhalation of contaminated air or medical aerosols;41 or (4) by hematogenous carriage of microorganisms to the lung from remote sites of local infection, such as vascular or urinary catheter-related bloodstream infection....

    [...]

References
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Journal ArticleDOI
TL;DR: The incidence of transmission of vancomycin-resistant Enterococcus (VRE) colonization during a hospital outbreak declined significantly after CDC guidelines were implemented and risk factors including a history of major trauma and treatment with metronidazole were evaluated.
Abstract: OBJECTIVE: To determine risk factors for vancomycin-resistant Enterococcus (VRE) colonization during a hospital outbreak and to evaluate Centers for Disease Control and Prevention (CDC)-recommended control measures. DESIGN: Epidemiological study involving prospective identification of colonization and a case-control study. SETTING: A university hospital. PARTICIPANTS: Patients on eight wards involved in outbreak from late 1994 through early 1995. METHODS: Cases were matched by ward and culture date with up to two controls. Risk factors were evaluated with four multivariate models using conditional logistic regression. The first evaluated proximity to other VRE patients and isolation status. The second evaluated proximity to unisolated VRE cases and three variables independently predictive after adjustment for proximity. The third evaluated seven significant univariate predictors in addition to proximity to unisolated VRE in backward, stepwise logistic regression. The fourth assessed proximity to VRE with all other variables collected, clustered in a principal components analysis. Pulsed-field gel electrophoresis was performed to assess clonality of two outbreak strains. RESULTS: The incidence of transmission declined significantly after CDC guidelines were implemented. Proximity to unisolated VRE cases during the prior week was a significant predictor of acquisition in each of four multivariate models. Other significant risk factors in multivariate models included a history of major trauma and treatment with metronidazole. Pulsed-field gel electrophoresis confirmed the clonality of two outbreak strains. CONCLUSIONS: VRE was transmitted between patients during a hospital epidemic, with proximity to previously unisolated VRE patients being an important risk factor. Weekly surveillance cultures and contact isolation of colonized patients significantly reduced spread (Infect Control Hosp Epidemiol 2001;22:140-147).

133 citations


"A cost-benefit analysis of gown use..." refers background in this paper

  • ...The increased cost associated with gown use needs to be considered relative to the attributable length of stay, mortality, and costs associated with VRE acquisition.(29)"(40)...

    [...]

Journal ArticleDOI
TL;DR: Stepwise discriminant function analysis indicated that the use of vascular catheters and renal dialysis and the presence of immune deficiency were predictors of fatal outcome in cases and enterococcal bacteremia has become a prominent nosocomial pathogen.

133 citations

Journal ArticleDOI
TL;DR: The adjusted risk estimate indicated that gowns were protective in reducing VRE acquisition in an MICU with high VRE colonization pressure.
Abstract: Infection-control recommendations include the use of gowns and gloves to prevent horizontal transmission of vancomycin-resistant enterococci (VRE). This study sought to determine whether the use of a gown and gloves gives greater protection than glove use alone against VRE transmission in a medical intensive care unit (MICU). From 1 July 1997 through 30 June 1998 and from 1 July 1999 through 31 December 1999, health care personnel and visitors were required to don gloves and gowns upon entry into rooms where there were patients infected with nosocomial pathogens. From 1 July 1998 through 30 June 1999, only gloves were required under these same circumstances. During the gown period, 59 patients acquired VRE (9.1 cases per 1000 MICU-days), and 73 patients acquired VRE during the no-gown period (19.6 cases per 1000 MICU-days; P<.01). The adjusted risk estimate indicated that gowns were protective in reducing VRE acquisition in an MICU with high VRE colonization pressure.

121 citations

Journal ArticleDOI
TL;DR: Authors of CEAs are more likely to support strategies requiring additional expenditure than the low-cost alternative, and concerns about funding source seem to be warranted.
Abstract: OBEJCTIVE: Although cost-effectiveness analyses (CEAs) have been advocated as a tool to critically appraise the value of health expenditures, it has been widely hoped that they might also help contain health care costs. To determine how often they discourage additional expenditures, we reviewed the conclusions of recently published CEAs.

116 citations

Journal ArticleDOI
TL;DR: Implementation of the various infection control measures did not eradicate VRE cases from the hospital, and rectal cultures were more useful than pharyngeal cultures for surveillance of VRE.
Abstract: OBJECTIVE To describe the effect of infection control interventions on the incidence of vancomycin-resistant enterococci (VRE), the utility of pharyngeal cultures for surveillance for VRE colonization, and the cost of barrier precautions. DESIGN Evaluation of the occurrence of VRE infection or colonization, rates of vancomycin use, results of surveillance cultures before and after interventions, and the cost of increased barrier precautions. SETTING University of Massachusetts Medical Center, a 347-bed tertiary-care teaching hospital with eight intensive-care units, one burn unit, and one bone marrow transplant unit. PARTICIPANTS Patients in the intensive-care units and staff who were involved with patients colonized or infected with VRE. METHODS Infection control interventions included placement of patients with VRE in private rooms, strict contact isolation, cohorting of patient and nursing staff, prohibiting of equipment sharing, and monitoring of compliance with the vancomycin restriction policy, with hand washing, and of the adequacy of environmental cleaning. Both rectal and pharyngeal cultures were obtained from patients at the beginning of the outbreak, and the utility of pharyngeal cultures was evaluated. The cost of barrier precautions was estimated by comparing the cost of glove and gown use before and after the outbreak began. RESULTS The interventions decreased the number of new cases of VRE, but total eradication of VRE was not achieved. Compliance with the room-cleaning protocol was 91% (141/155 observations). Hand washing following interaction with patients who were not in isolation was 51%, vs 100% for patients in isolation. Overall, handwashing compliance was 71% (319/449): 56% (130/231) for physicians and 86% (187/218) for nurses (P<.0001). The mean number of doses of vancomycin dispensed per 1,000 patient days decreased from 145 to 114 per 1,000 patient days (P<.001). Compliance with vancomycin-use guidelines was 85%. Forty-six (77%) of 60 surveillance rectal swabs yielded enterococci, as compared to only 4 (11%) of 36 pharyngeal cultures (P<.0001). Expenses on glove and gowns alone increased by over $11,000 per year since the epidemic began. CONCLUSIONS Implementation of the various infection control measures did not eradicate VRE cases from the hospital. Rectal cultures were more useful than pharyngeal cultures for surveillance of VRE. Controlling VRE epidemics can be costly.

102 citations

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