AJIC: American Journal of Infection Control

When fiction mirrors reality: 2010 Odyssey Two

Cathryn Murphy — 2010-03-01

In 2010 Odyssey Two, Arthur C. Clarke describes the adventures of a multinational crew of US and Russian space explorers working towards a better understanding of problems during a previously unsuccessful 2001 space mission. Clarke's space explorers have several other goals to achieve including the need to urgently reach Jupiter. The US/Soviet team believes their technological capability will guarantee success. In a surprise twist, they learn that another nation previously unknown for space expedition capacity has achieved remarkable growth and development and is also rapidly pursuing a landing on Jupiter.

Occupational exposures in emergency medical service providers and knowledge of and compliance with universal precautions

Shelley A. Harris, Laura Ann Nicolai — 2009-10-08

Background: Little is known about compliance with universal precautions (CUP) or occupational exposures to blood and body fluids among Emergency Medical Services (EMS) providers. The objective of this study was to obtain estimates of CUP and knowledge of universal precautions (KUP), occupational exposures, and needle and lancet sticks in the prehospital environment.Methods: A convenience sample of workers (n=311, 51% response) from 17 agencies in Virginia that provided emergency ground transportation (volunteer, commercial, government rescue squads, and fire departments) completed a questionnaire on certification and training, KUP, CUP, exposures and needlesticks, risk perceptions, and demographic variables.Results: Nearly all EMS providers reported exposures and were concerned about risk of HIV and hepatitis. Providers reported inconsistent CUP when treating patients or using needles, including failure to wear gloves (17%) and to appropriately dispose of contaminated materials (79%), including needles (87%), at all times. Certification type (advanced and basic) was related to both KUP and CUP. Of those respondents reporting current sharps use, 40% recapped needles. A lancet stick was reported by 1.4% (n=5), and 4.5% reported a needlestick (n=14).Conclusion: EMS providers working in the prehospital environment experience significant exposures but are not consistently using universal precautions.

International Nosocomial Infection Control Consortium (INICC) report, data summary for 2003-2008, issued June 2009

2010-03-01

We report the results of the International Infection Control Consortium (INICC) surveillance study from January 2003 through December 2008 in 173 intensive care units (ICUs) in Latin America, Asia, Africa, and Europe. During the 6-year study, using Centers for Disease Control and Prevention (CDC) US National Healthcare Safety Network (NHSN; formerly the National Nosocomial Infection Surveillance system [NNIS]) definitions for device-associated health care-associated infection, we collected prospective data from 155,358 patients hospitalized in the consortium's hospital ICUs for an aggregate of 923,624 days. Although device utilization in the developing countries' ICUs was remarkably similar to that reported from US ICUs in the CDC's NHSN, rates of device-associated nosocomial infection were markedly higher in the ICUs of the INICC hospitals: the pooled rate of central venous catheter (CVC)-associated bloodstream infections (BSI) in the INICC ICUs, 7.6 per 1000 CVC-days, is nearly 3-fold higher than the 2.0 per 1000 CVC-days reported from comparable US ICUs, and the overall rate of ventilator-associated pneumonia (VAP) was also far higher, 13.6 versus 3.3 per 1000 ventilator-days, respectively, as was the rate of catheter-associated urinary tract infection (CAUTI), 6.3 versus 3.3 per 1000 catheter-days, respectively. Most strikingly, the frequencies of resistance of Staphylococcus aureus isolates to methicillin (MRSA) (84.1% vs 56.8%, respectively), Klebsiella pneumoniae to ceftazidime or ceftriaxone (76.1% vs 27.1%, respectively), Acinetobacter baumannii to imipenem (46.3% vs 29.2%, respectively), and Pseudomonas aeruginosa to piperacillin (78.0% vs 20.2%, respectively) were also far higher in the consortium's ICUs, and the crude unadjusted excess mortalities of device-related infections ranged from 23.6% (CVC-associated bloodstream infections) to 29.3% (VAP).

Contact precautions for multidrug-resistant organisms: Current recommendations and actual practice

Sarah A. Clock, Bevin Cohen, Maryam Behta, Barbara Ross, Elaine L. Larson — 2009-11-13

Background: Contact precautions are recommended for interactions with patients colonized/infected with multidrug-resistant organisms; however, actual rates of implementation of contact precautions are unknown.Methods: Observers recorded the availability of supplies and staff/visitor adherence to contact precautions at rooms of patients indicated for contact precautions. Data were collected at 3 sites in a New York City hospital network.Results: Contact precautions signs were present for 85.4% of indicated patients. The largest proportions were indicated for isolation for vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus cultures. Isolation carts were available outside 93.7% to 96.7% of rooms displaying signs, and personal protective equipment was available at rates of 49.4% to 72.1% for gloves (all sizes: small, medium, and large) and 91.7% to 95.2% for gowns. Overall adherence rates on room entry and exit, respectively, were 19.4% and 48.4% for hand hygiene, 67.5% and 63.5% for gloves, and 67.9% and 77.1% for gowns. Adherence was significantly better in intensive care units (P < .05) and by patient care staff (P < .05), and patient care staff compliance with one contact precautions behavior was predictive of adherence to additional behaviors (P < .001).Conclusions: Our findings support the recommendation that methods to monitor contact precautions and identify and correct nonadherent practices should be a standard component of infection prevention and control programs.

Surgical site infections: Causative pathogens and associated outcomes

2009-11-04

Background: Surgical site infections (SSIs) are associated with substantial morbidity, mortality, and cost. Few studies have examined the causative pathogens, mortality, and economic burden among patients rehospitalized for SSIs.Methods: From 2003 to 2007, 8302 patients were readmitted to 97 US hospitals with a culture-confirmed SSI. We analyzed the causative pathogens and their associations with in-hospital mortality, length of stay (LOS), and cost.Results: The proportion of methicillin-resistant Staphylococcus aureus (MRSA) significantly increased among culture-positive SSI patients during the study period (16.1% to 20.6%, respectively, P < .0001). MRSA (compared with other) infections had higher raw mortality rates (1.4% vs 0.8%, respectively, P=.03), longer LOS (median, 6 vs 5 days, respectively, P < .0001), and higher hospital costs ($7036 vs $6134, respectively, P < .0001). The MRSA infection risk-adjusted attributable LOS increase was 0.93 days (95% confidence interval [CI]: 0.65-1.21; P < .0001), and cost increase was $1157 (95% CI: $641-$1644; P < .0001). Other significant independent risk factors increasing cost and LOS included illness severity, transfer from another health care facility, previous admission (<30 days), and other polymicrobial infections (P < .05).Conclusion: SSIs caused by MRSA increased significantly and were independently associated with economic burden. Admission illness severity, transfer from another health care setting, and recent hospitalization were associated with higher mortality, increased LOS, and cost.

Body art practices among inmates: Implications for transmission of bloodborne infections

Titilayo C. Abiona, Joseph A. Balogun, Adedeji S. Adefuye, Patricia E. Sloan — 2009-10-13

Background: Unsterile body art practices among inmates in prison have been implicated in the transmission of bloodborne viruses. The objectives of this study were to determine the prevalence of tattooing and body piercing among inmates, identify factors associated with receiving a tattoo in prison, and explore the contexts of tattooing and body piercing in prison.Methods: A cross-sectional survey was conducted among randomly selected inmates in 17 state prisons in Illinois; a convenient sample of recently released exprisoners in Chicago, IL, participated in focus group discussions (FGDs).Results: A total of 1819 (1293 men and 526 women) inmates participated in the survey, and 47 exprisoners participated in the FGDs. Sixty-seven percent of the survey sample had tattoos, and 60% had body piercings. More men (19.3%) than women (8.7%) had received tattoos in prison (odds ratio, 0.40; 95% confidence interval: 0.29-0.56); prevalence of body piercing in prison was low (1.3%) and similar for men and women. Factors associated with tattooing in prison include incarceration for 1 year or longer and having had sex in prison among both men and women; nonheterosexual identity for women only; and for men, being 30-39 years old; incarcerated 4 or more times; having a history of sharing needles, multiple vaginal sex partners, and inconsistent condom use in the 6 months before arrest. Focus groups provided information on body art practices in prison. Inmates had a variety of reasons for getting body art, equipment was often shared, and cleansing agents were not readily available.Conclusion: Tattooing and body piercing practices exist in prison and could constitute risks for transmission of bloodborne viral infections. Interventions to reduce these risks are discussed.

Bloodborne pathogen risk reduction activities in the body piercing and tattooing industry

2009-11-13

Background: This study examines how well regulations for bloodborne pathogens (BBPs), established primarily to reduce exposure risk for health care workers, are being followed by workers and employers in the tattooing and body piercing industry.Method: Twelve shops performing tattooing and/or body piercing (body art) in Pennsylvania and Texas were assessed for compliance with 5 administrative and 10 infection control standards for reducing exposure to BBPs.Results: All shops demonstrated compliance with infection control standards, but not with administrative standards, such as maintaining an exposure control plan, offering hepatitis B vaccine, and training staff. Shops staffed with members of professional body art organizations demonstrated higher compliance with the administrative standards. Shops in locations where the body art industry was regulated and shops in nonregulated locations demonstrated similar compliance, as did contractor- and employee-staffed shops.Conclusions: Regulations to control occupational exposure to BBPs have been in place since 1991. This study corroborates noncompliance with some standards within the body art industry reported by previous studies. Without notable enforcement, regulation at national, state, or local levels does not affect compliance. In this study, the factor most closely associated with compliance with administrative regulations was the artist's membership in a professional body art association.

Effect of exclusion policy on the control of outbreaks of suspected viral gastroenteritis: Analysis of outbreak investigations in care homes

Roberto Vivancos, Torbjorn Sundkvist, Deborah Barker, Janice Burton, Pat Nair — 2009-10-26

Background: Norovirus is an important cause of gastroenteritis outbreaks in care homes. Differences exist in the recommended duration of exclusion for affected staff during an outbreak.Methods: We conducted a retrospective analysis of outbreak reports in 2006 and 2007 managed by health protection staff in 2 counties with differing exclusion policies, one advising exclusion of affected staff and isolation of residents for 72hours and the other for 48hours after the resolution of symptoms. We compared attack rates and average numbers of cases in residents and staff, adjusting for type of care home and staffing rate.Results: A total of 96 outbreaks were managed, 63 with a 72-hour exclusion policy and 33 with a 48-hour exclusion policy. The longer exclusion policy resulted in lower mean number of cases among staff (6.5 vs 9.6; P=.044) and a lower overall attack rate (32.6% vs 35.1%; P=.05). No differences in the mean number of cases or the attack rate among residents were seen.Conclusion: This brief study suggests that a longer exclusion policy reduces the number of cases among staff affected with viral gastroenteritis, possibly resulting in less staff absences. This could have potential benefits, particularly when resources are limited.

Cluster of necrotizing enterocolitis in a neonatal intensive care unit: New Mexico, 2007

Aaron M. Wendelboe, Chad Smelser, Cynthia A. Lucero, L. Clifford McDonald — 2009-10-13

Background: Although the cause of necrotizing enterocolitis (NEC) is unknown, infection control practices have been shown to play an important role in containing many outbreaks. We investigated the etiology of a cluster of NEC in a level 3 neonatal intensive care unit and monitored for new cases following the implementation of enhanced infection control measures.Methods: Investigators performed a chart and laboratory review for neonates with a diagnosis of NEC during January 1, 2007, to February 13, 2007, to identify risk factors. Enhanced environmental cleaning, cohorting of infants and nurses, and increased attention to hand hygiene were instituted. Commercial feeding products in the unit were tested for bacterial contamination. Close monitoring for new cases continued for 2 months following the identification of the cluster.Results: Eleven cases of NEC were identified during the study period. Patients had a median of 5 disease risk factors (range, 3-8). Four distinct pathogens were detected in blood or stool specimens from 4 different patients. One sample of human milk fortifier (HMF) tested contained a colony count of Bacillus cereus at the US Food and Drug Administration's upper microbiologic limit for contamination. Seven (65%) patients received HMF before symptom onset, and 9 (82%) patients received 1 or more types of liquid formula. Only 1 new case was identified during the period of close monitoring.Conclusion: A microbiologic cause was not identified, and, although the cluster might have resolved spontaneously, enhanced infection control and changing batches of HMF might have played a role in controlling this outbreak.

Peripherally inserted central venous catheters in the acute care setting: A safe alternative to high-risk short-term central venous catheters

2009-10-19

Background: Peripherally inserted central venous catheters (PICCs) serve as an alternative to short-term central venous catheters (CVCs) for providing intravenous (IV) access in the hospital. It is not clear which device has a lower risk of central line–associated bloodstream infection (CLABSI). We compared CVC- and PICC-related CLABSI rates in the setting of an intervention to remove high-risk CVCs.Methods: We prospectively followed patients with CVCs in the non–intensive care units (ICUs) and those with PICCs hospital-wide. A team evaluated the need for the CVC and the risk of infection, recommended the discontinuation of unnecessary or high-risk CVCs, and suggested PICC insertion for patients requiring prolonged access. Data on age, gender, type of catheter, duration of catheter utilization, and the development of CLABSIs were obtained.Results: A total of 638 CVCs were placed for 4917 catheter-days, during which 12 patients had a CLABSI, for a rate of 2.4 per 1000 catheter-days. A total of 622 PICCs were placed for 5703 catheter-days, during which 13 patients had a CLABSI, for a rate of 2.3 per 1000 catheter-days. The median time to development of infection was significantly longer in the patients with a PICC (23 vs 13 days; P=.03).Conclusion: In the presence of active surveillance and intervention to remove unnecessary or high-risk CVCs, CVCs and PICCs had similar rates of CLABSIs. Given their longer time to the development of infection, PICCs may be a safe alternative for prolonged inpatient IV access.

Concentration of bacteria passing through puncture holes in surgical gloves

2009-10-13

Background: The reasons for gloving-up for surgery are to protect the surgical field from microorganisms on the surgeon's hands and protect the surgeon from the patient's microorganisms. This study measured the concentration of bacteria passing through glove punctures under surgical conditions.Methods: Double-layered surgical gloves were worn during visceral surgeries over a 4-month period. The study included 128 outer gloves and 122 inner gloves from 20 septic laparotomies. To measure bacterial passage though punctures, intraoperative swabs were made, yielding microorganisms that were compared with microorganisms retrieved from the inner glove layer using a modified Gaschen bag method.Results: Depending on the duration of glove wear, the microperforation rate of the outer layer averaged 15%. Approximately 82% of the perforations went unnoticed by the surgical team. Some 86% of perforations occurred in the nondominant hand, with the index finger being the most frequently punctured location (36%). Bacterial passage from the surgical site through punctures was detected in 4.7% of the investigated gloves.Conclusion: Depending on the duration of wear, surgical gloves develop microperforations not immediately recognized by staff. During surgery, such perforations allow passage of bacteria from the surgical site through the punctures. Possible strategies for preventing passage of bacteria include strengthening of glove areas prone to punctures and strict glove changing every 90 minutes.

Neonatal rates and risk factors of device-associated bloodstream infection in a tertiary care center in Saudi Arabia

2009-11-09

In a prospective surveillance study, we examine the risk of device-associated bloodstream infection (BSI) in a neonatal intensive care unit at Riyadh, Saudi Arabia, during 2006 and 2007. The incidence per 1000 device-days was 8.2 for central line-associated BSI and 10.5 for umbilical catheter-associated BSI. Both rates were higher with more umbilical catheter and less central line utilization ratios compared with those reported by the American National Healthcare Safety Network hospitals. Concurrent with implementation of more strict infection control practices, BSI rates declined over the course of the study. Prolonged device duration was an independent risk factor for device-associated BSI.

Incidence and outcomes of infections in cardiac allograft recipients: A Brazilian perspective

2010-03-01

To the Editor: Heart transplantation (HT) is an acceptable therapy for end-stage heart disease. Over the past 25 years, more than 80,000 procedures were performed worldwide with overall 5-year survival estimated at 70.0%. In Brazil, HT has been performed since 1984. The long-term results are comparable with those of European and US centers, despite regional and socioeconomic differences and the high proportion of patients with Chagas heart disease (ChD) included in the statistics. Despite many advances in transplantation medicine over this period, infectious complications (IC) influence long-term survival, and their prevention and treatment remain important medical challenges. Several factors appear to influence their incidence, including the degree of immune suppression, coinfection with immunomodulating pathogens, and the intensity of epidemiologic exposure. However, studies focusing on this issue cover only populations from Europe or North America.

Needlestick injury surveillance and underreporting in Japan

Derek R. Smith — 2010-03-01

To the Editor: I read with interest the article by Nagao et al that describes accidental exposures to blood and body fluid in operating rooms and the issue of underreporting. In their article, the authors raise some very important points regarding mucocutaneous and percutaneous exposures in Japan, as well as the critical issue of underreporting.

An increased incidence of biofilm-producing multidrug-resistant methicillin-resistant Staphylococcus aureus in a tertiary care hospital from India: A 2-year study

Nilima V. Telang, Meena G. Satpute, Krishna B. Niphadkar, Suresh G. Joshi — 2010-03-01

To the Editor: Methicillin-resistant Staphylococcus aureus (MRSA)-infected and -colonized patients in hospitals mediate the dissemination of MRSA, and hospital staff facilitate further transmission. The development of multidrug resistance and the transmission of pathogens have been recognized as major challenges. Biofilm-producing MRSA is known to be more difficult to control, providing about 1000-fold greater resistance to antibacterial agents than MRSA not embedded in biofilm. Hospital and health care workers colonized with MRSA are the major players in infection transmission. Thus, knowledge of the prevalence, current antibiogram, and relevant phenotypic properties is crucial to determining the appropriate empirical treatment for control of MRSA infections. In a recent study, we found a high prevalence of MRSA. In this prospective trial study, we analyzed the data generated over a 24-month period (January 2007 to December 2008) and assessed the antibacterial susceptibility and biofilm formation properties of MRSA isolates. A total of 16,903 clinical specimens of pus, blood, respiratory secretions, urine, body fluids, and catheter tips were collected from patients at KEM Hospital in Pune, India. A total of 117 staff members at risk for being carriers were screened for MRSA with nasal swabs; a total of 356 nasal swabs, including follow-ups, were obtained. All S aureus isolates and MRSA were confirmed by API (BioMerieux, Marcy L'Etoile, France), antibiotic susceptibility testing (AST) carried out on API and Vitek 2 Compact, and biofilm detection by established microtiter plate assays with appropriate control strains.

2010-03-01

Editorial Board

2010-03-01

APIC Masthead

2010-03-01

Information for Readers

2010-03-01

AJIC: American Journal of Infection Control

When fiction mirrors reality: 2010 Odyssey Two

Occupational exposures in emergency medical service providers and knowledge of and compliance with universal precautions

International Nosocomial Infection Control Consortium (INICC) report, data summary for 2003-2008, issued June 2009

Contact precautions for multidrug-resistant organisms: Current recommendations and actual practice

Surgical site infections: Causative pathogens and associated outcomes

Body art practices among inmates: Implications for transmission of bloodborne infections

Bloodborne pathogen risk reduction activities in the body piercing and tattooing industry

Effect of exclusion policy on the control of outbreaks of suspected viral gastroenteritis: Analysis of outbreak investigations in care homes

Cluster of necrotizing enterocolitis in a neonatal intensive care unit: New Mexico, 2007

Peripherally inserted central venous catheters in the acute care setting: A safe alternative to high-risk short-term central venous catheters

Concentration of bacteria passing through puncture holes in surgical gloves

Neonatal rates and risk factors of device-associated bloodstream infection in a tertiary care center in Saudi Arabia

Incidence and outcomes of infections in cardiac allograft recipients: A Brazilian perspective

Needlestick injury surveillance and underreporting in Japan

An increased incidence of biofilm-producing multidrug-resistant methicillin-resistant Staphylococcus aureus in a tertiary care hospital from India: A 2-year study

Table of Contents

Editorial Board

APIC Masthead

Information for Readers