AJIC: American Journal of Infection Control - Articles in Press

Research findings from nonpharmaceutical intervention studies for pandemic influenza and current gaps in the research - Corrected Proof

2010-03-15

In June 2006, the Centers for Disease Control and Prevention released a request for applications to identify, improve, and evaluate the effectiveness of nonpharmaceutical interventions (NPIs)—strategies other than vaccines and antiviral medications—to mitigate the spread of pandemic influenza within communities and across international borders (RFA-CI06-010). These studies have provided major contributions to seasonal and pandemic influenza knowledge. Nonetheless, key concerns were identified related to the acceptability and protective efficacy of NPIs. Large-scale intervention studies conducted over multiple influenza epidemics, as well as smaller studies in controlled laboratory settings, are needed to address the gaps in the research on transmission and mitigation of influenza in the community setting. The current novel influenza A (H1N1) pandemic underscores the importance of influenza research.

Postdischarge surveillance following cesarean section: The incidence of surgical site infection and associated factors - Corrected Proof

Meire Celeste Cardoso Del Monte, Aarão Mendes Pinto Neto — 2010-03-15

Background: The rate of surgical site infections (SSI) and their associated risk factors was identified by performing postdischarge surveillance following cesarean section at a public university teaching hospital in Brazil.Methods: The study was conducted at the Center for Women's Integrated Health Care in Brazil between May 2008 and March 2009. Women were contacted by telephone 15 and 30 days after cesarean section. During hospitalization, a form was completed on factors associated with post-cesarean SSI. The χ2 test and Fisher exact test were used to analyze categorical variables and the Mann-Whitney test for numerical variables. Relative risks (RR) and their respective 95% confidence intervals (95% CI) were calculated for factors associated with SSI. P values < .05 were considered significant.Results: The final sample consisted of 187 women. SSI was detected in 44 cases (23.5%). In 42 of 44 women (95%), SSI appeared following discharge from hospital, becoming evident within the first 15 days following surgery. Number of prenatal consultations ≤7 (RR, 2.09; 95% CI: 1.26-3.48) and hypertension (RR, 2.07; 95% CI: 1.25-3.43) were significantly associated with SSI in the bivariate analysis. In the multivariate analysis, only hypertension (RR, 2.47; 95% CI: 1.21-5.04) remained significant.Conclusion: Postdischarge surveillance is essential for ensuring accurate estimates of post-cesarean section SSI. A 15-day postdischarge follow-up was shown to be sufficient. Hypertension was a factor associated with SSI.

Knowledge about and attitude towards enterovirus 71 infections: A survey of parents and teachers at kindergartens in Taiwan - Corrected Proof

2010-03-15

In 2008, we surveyed 690 parents and 104 teachers at kindergartens in Taiwan about their knowledge of and attitude towards enterovirus 71 infections. The accurate response rate for enterovirus infection characteristics was greater than 80% for specific symptoms, prevalent age group, and predominant infection season. Parents and teachers felt great anxiety and even panic about infection. Both groups perceived the impact of enterovirus infection to be worse than that of influenza.

Evaluation of biologic occupational risk control practices: Quality indicators development and validation - Corrected Proof

2010-03-15

Background: There is growing demand for the adoption of qualification systems for health care practices. This study is aimed at describing the development and validation of indicators for evaluation of biologic occupational risk control programs.Methods: The study involved 3 stages: (1) setting up a research team, (2) development of indicators, and (3) validation of the indicators by a team of specialists recruited to validate each attribute of the developed indicators. The content validation method was used for the validation, and a psychometric scale was developed for the specialists' assessment. A consensus technique was used, and every attribute that obtained a Content Validity Index of at least 0.75 was approved.Results: Eight indicators were developed for the evaluation of the biologic occupational risk prevention program, with emphasis on accidents caused by sharp instruments and occupational tuberculosis prevention. The indicators included evaluation of the structure, process, and results at the prevention and biologic risk control levels. The majority of indicators achieved a favorable consensus regarding all validated attributes.Conclusion: The developed indicators were considered validated, and the method used for construction and validation proved to be effective.

Rural Indonesian health care workers' constructs of infection prevention and control knowledge - Corrected Proof

Brahmaputra Marjadi, Mary-Louise McLaws — 2010-03-15

Background: Understanding the constructs of knowledge behind clinical practices in low-resource rural health care settings with limited laboratory facilities and surveillance programs may help in designing resource-appropriate infection prevention and control education.Methods: Multiple qualitative methods of direct observations, individual and group focus discussions, and document analysis were used to examine health care workers' knowledge of infection prevention and control practices in intravenous therapy, antibiotic therapy, instrument reprocessing, and hand hygiene in 10 rural Indonesian health care facilities.Results: Awareness of health care-associated infections was low. Protocols were in the main based on verbal instructions handed down through the ranks of health care workers. The evidence-based knowledge gained across professional training was overridden by empiricism, nonscientific modifications, and organizational and societal cultures when resources were restricted or patients demanded inappropriate therapies. This phenomenon remained undetected by accreditation systems and clinical educators.Conclusion: Rural Indonesian health care workers would benefit from a formal introduction to evidence-based practice that would deconstruct individual protocols that include nonscientific knowledge. To achieve levels of acceptable patient safety, protocols would have to be both evidence-based and resource-appropriate.

Impact of a program to prevent central line-associated bloodstream infection in the zero tolerance era - Corrected Proof

2010-03-15

Background: Central line-associated bloodstream infection (CLABSI) is one of the most important health care-associated infections in the critical care setting.Methods: A quasiexperimental study involving multiple interventions to reduce the incidence of CLABSI was conducted in a medical-surgical intensive care unit (ICU) and in 2 step-down units (SDUs). From March 2005 to March 2007 (phase 1 [P1]), some Centers for Disease Control and Prevention evidence-based practices were implemented. From April 2007 to April 2009 (P2), we intervened in these processes at the same time that performance monitoring was occurring at the bedside, and we implemented the Institute for Healthcare Improvement central line bundle for all ICU and SDU patients requiring central venous lines.Results: The mean incidence density of CLABSI per 1000 catheter-days in the ICU was 6.4 in phase 1 and 3.2 in phase 2, P < .001. The mean incidence density of CLABSI per 1000 catheter-days in the SDUs was 4.1 in phase 1 and 1.6 in phase 2, P = .005.Conclusion: These results suggest that reducing CLABSI rates in an ICU setting is a complex process that involves multiple performance measures and interventions that can also be applied to SDU settings.

Are short training sessions on hand hygiene effective in preventing hospital-acquired MRSA? A time-series analysis - Corrected Proof

Andreas Conrad, Klaus Kaier, Uwe Frank, Markus Dettenkofer — 2010-03-15

We tested the impact of short hand hygiene training sessions and bed occupancy rates on the spread of hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) using a multivariate time-series analysis. According to our model, bed occupancy rates within general ward and intensive care unit settings correlated positively with the incidence of hospital-acquired MRSA, whereas alcohol-based hand rub use and MRSA showed a negative correlation. Furthermore, our model shows that 2 hand hygiene campaigns based on short training sessions effected a long-run reduction in the incidence of hospital-acquired MRSA.

Eight years of active proposal of pneumococcal 23-valent polysaccharide vaccine: Survey on coverage rate among elderly and chronic patients - Corrected Proof

2010-03-08

Background: Streptococcus pneumoniae, lancet-shaped, gram-positive, facultative anaerobic organisms, are common inhabitants of the respiratory tract and may be isolated from the nasopharynx of 5% to 70% of healthy adults.Objective: The aims of the study were to estimate the vaccination coverage for pneumococcal 23-valent polysaccharide vaccine and to assess the impact its introduction in the Italian region of Puglia, where a program to provide this vaccination has been operative since 2000.Methods: Estimation of the coverage for pneumococcal 23-valent polysaccharide vaccine was implemented by a 2-step study consisting of data collection from local health unit vaccination registers between 2000 and 2008 in Puglia and of a cluster sampling study among general practitioners to validate routine data collected during the first step. Moreover, hospitalization for invasive pneumococcal diseases was studied.Results: From 2000 to 2004, among individuals ≥65 years, the overall coverage rate estimated by routine data amounted to 26.3%; between 2005 and 2007, annual coverage rates did not exceed 8%/year. Between 2002 and 2007, the overall coverage rate estimated by interviewing general practitioners was 46.6% (95% confidence interval: 39.9-53.4). The coverage rate in chronic patients by routine data was approximately 23%, whereas the rate provided by general practitioners was 17.6% (95% confidence interval: 12.5-22.8). From 2001 to 2007, hospitalization data did not show a reduction in invasive pneumococcal disease trends among the elderly population in Puglia.Conclusion: The results of this study demonstrate the need for improving vaccine coverage and implementing new immunization strategies and practices.

Reducing the risk of infection in vascular access patients: An in vitro evaluation of an antimicrobial silver nanotechnology luer activated device - Corrected Proof

Charles E. Edmiston, Vera Markina — 2010-03-02

Background: Luer-activated devices (LAD) have been designed to reduce the risk of sharps injury; however, published reports suggest that internal fluid path contamination occurs in selected devices. The present in vitro study compares the antimicrobial property of a silver-nanotechnology LAD to 8 nonantimicrobial LADs.Methods: A laboratory reference strain of methicillin-resistant Staphylococcus aureus (MRSA) (ATCC 33592) was used to prepare a standardized microbial challenge, 3.73- to 3.86-log10 colony-forming units (cfu)/mL, adjusted for fluid path volume for 9 commercially available LAD (1 sliver nanotechnology LAD and 8 non-antimicrobial LADs). Following incubation (15 hours at 30°C), each device was flushed, serially diluted, and plated in triplicate to trypticase soy agar for microbial recovery, expressed as log10 cfu/mL.Results: Comparison of fluid path volumes documented a wide variation between the 9 commercial devices (range, 0.025-0.359 mL). Log10 microbial recovery were shown to increase on average 1.5 to 3.0 logs in the 8 non-antimicrobial LADs, whereas S aureus recovery in the silver-nanoparticle LAD demonstrated a 2.6-log decrease following incubation (P ≤ .05).Conclusion: These findings suggest that, under in vitro conditions, a silver nanotechnology was effective in reducing the risk of fluid path colonization when the LAD was challenged using a standardized inoculum of a laboratory reference strain of MRSA. Further studies are warranted to assess the clinical efficacy of an antimicrobial LAD technology for reducing the risk of vascular access (catheter associated) infections.

Technical note: Assessment of blinding of hand hygiene observers in randomized controlled trials of hand hygiene interventions - Corrected Proof

2010-03-02

Trials evaluating interventions to improve health care workers' hand hygiene compliance use directly observed compliance as a primary outcome measure. Observers should be blinded to the intervention and the effectiveness of blinding assessed to prevent systematic bias. The literature has not addressed this issue, and this study describes a robust and pragmatic method for assessing the adequacy of blinding in hand hygiene intervention trials.

Low prevalence of Acinetobacter baumannii colonization on hospital admission - Corrected Proof

Kerri A. Thom, Anthony D. Harris, Judith A. Johnson, Jon P. Furuno — 2010-03-02

We conducted a prospective cohort study of non–critically ill patients admitted to a tertiary care center between December 2003 and September 2004 and obtained perirectal samples at hospital admission to determine the prevalence of Acinetobacter baumannii. A baumannii was isolated from 1 of 555 cultures (0.18%); no multidrug-resistant A baumannii was identified. Interventions aimed at early identification of A baumannii–colonized patients may not benefit by widely targeting non–critically ill patients on hospital admission.

Active surveillance testing and decontamination strategies in intensive care units to reduce methicillin-resistant Staphylococcus aureus infections - Corrected Proof

2010-03-02

Background: Active surveillance testing (AST) and decontamination strategies (DS) using a topical methicillin-resistant Staphylococcus aureus (MRSA) cleansing agent was introduced in July 2007 in a medical intensive care unit (MICU) and a surgical ICU (SICU) of a tertiary care hospital to reduce the incidence of MRSA infection.Methods: Data on ICU admissions between July 1, 2007, and June 30, 2008, was analyzed. All subjects, excluding known MRSA status, had an ICU length of stay (LOS) of more than 24 hours and nasal swabs performed on ICU admission, every 7 days during the ICU stay, and on discharge. MICU and SICU specimens were sent for culture and in-house real-time polymerase chain reaction, respectively. MRSA-colonized (MRSAc) patients were subjected to contact isolation precautions and DS for 5 days or until ICU discharge. Data recorded included demographics, LOS, and antibiotic use. Results were analyzed using SPSS. Control charts were used to determine special cause variation.Results: Of 653 eligible patients admitted to the ICU, 85 (13%) were determined to be MRSAc on ICU admission. A further 15% (52 of 351) were determined to be MRSAc during the ICU stay or at discharge. Thus, AST detected MRSA in at least 137 of the 653 patients (21.0%). In contrast, clinical cultures for MRSA were positive in only 12 patients (1.8%). Compared with noncolonized patients, MRSAc patients at any screening point had a longer pre-ICU LOS (P =.001), received more antibiotics (P = .004), and had a longer ICU LOS (P = .003). Compared with the preintervention period of July 2006 to June 2007, there was no significant reduction in mean MRSA infection incidence rate in both ICUs (3.8 to 3.0 per 1000 patient-days [P = .057] in the SICU and 1.4 to 1.7 per 1000 patient-days in the MICU) following intervention.Conclusions: In ICUs, AST detected 11 times more MRSA than clinical cultures. The lack of reduction in MRSA infection rates in the ICUs does not negate the roles of AST and DS, but does argue for better study design and outcome measures like MRSA transmission incidence, which perhaps would have demonstrated a true benefit of AST and DS.

Does hand hygiene compliance among health care workers change when patients are in contact precaution rooms in ICUs? - Corrected Proof

Kirven Gilbert, Cortney Stafford, Kali Crosby, Edna Fleming, Robert Gaynes — 2010-03-02

Background: Hand hygiene compliance rates among health care workers (HCW) rarely exceed 50%. Contact precautions are thought to increase HCWs' hand hygiene awareness. We sought to determine any differences in hand hygiene compliance rates for HCW between patients in contact precaution and those not in any isolation.Methods: In a hospital's medical (MICU) and surgical (SICU) intensive care units, a trained observer directly observed hand hygiene by the type of room (contact precaution or noncontact precaution) and the type of HCW (nurse or doctor).Results: The SICU had similar compliance rates (36/75 [50.7%] in contact precaution rooms vs 223/431 [51.7%] compliance in noncontact precaution rooms, P > .5); the MICU also had similar hand hygiene compliance rates (67/132 [45.1%] in contact precaution rooms vs 96/213 [50.8%] in noncontact precaution rooms, P > .10). Hand hygiene compliance rates stratified by HCW were similar with 1 exception. The MICU nurses had a higher rate of hand hygiene compliance in contact precaution rooms than in rooms with noncontact precautions (66.7% vs 51.6%, respectively).Conclusion: Compliance with hand hygiene among HCWs did not differ between contact precaution rooms and rooms with noncontact precautions with the exception of the nurses in the MICU.

Reusable elastomeric air-purifying respirators: Physiologic impact on health care workers - Corrected Proof

2010-03-02

Background: Elastomeric air-purifying respirators offer the benefit of reusability, but their physiological impact on health care workers is unknown.Methods: Ten health care workers exercised at 2 health care-associated work rates wearing an elastomeric air-purifying respirator. Mixed inhalation/exhalation respirator dead space gases (oxygen, carbon dioxide) were sampled, and physiological parameters were monitored (heart rate, breathing rate, tidal volume, minute volume, oxygen saturation, transcutaneous carbon dioxide). Numerical rating scales were used to evaluate comfort and exertion.Results: Compared with controls (no respirator), significant decreases in the breathing rate at both work rates (P < .05) and increases in tidal volume at the lower work rate (P < .01) were noted with respirator use. Approximately half the subjects had transcutaneous carbon dioxide levels above the upper limit of normal after 1 hour of use. Although well tolerated, comfort was negatively impacted by elastomeric air-purifying respirators wear.Conclusion: Reusable elastomeric air-purifying respirators impose little additional physiological burden over the course of 1 hour at usual health care work rates. However, the potential for carbon dioxide retention in a significant proportion of users exists and requires further investigation.

Interobserver variability in ventilator-associated pneumonia surveillance - Corrected Proof

Michael Klompas — 2010-02-22

Three infection control personnel and 1 physician independently evaluated 50 ventilated patients for ventilator-associated pneumonia through retrospective chart reviews. The infection control reviewers used Centers for Disease Control and Prevention criteria; the physician used clinical judgment. Infection control personnel labelled between 11 and 20 patients with VAP (κ = 0.40). The physician diagnosed 7 cases. Interobserver variability in the assessment of ventilator-associated pneumonia is high.

Educational intervention, revised instrument sterilization methods, and comprehensive preoperative skin preparation protocol reduce cesarean section surgical site infections - Corrected Proof

Phillip N. Rauk — 2010-02-22

Background: In 2005, of the approximately 4 million births in the United States, 30% were by cesarean section (C-section) delivery, which translates to roughly over 1 million C-sections in 2005 alone. C-section is associated with higher morbidity than vaginal delivery. Women who undergo C-section are 5 times more likely to develop a postpartum infection after delivery than women who undergo vaginal delivery.Objective: Estimates of surgical site infection (SSI) after C-section range from 1.50 to 2.64. A quality improvement initiative was implemented at the University of Minnesota Medical School to reduce rates of SSI using changes based on recommended care initiatives.Methods: The multidisciplinary team developed a comprehensive staff education and training program, added a preoperative skin preparation protocol using chlorhexidine gluconate (CHG) no-rinse cloths, added CHG with alcohol for interoperative skin preparation, and modified instrument sterilization techniques.Results: Data analysis revealed a statistically significant reduction in the overall SSI rate from 7.5% (33/441) in January-July 2006 to 1.2% (5/436) in January-July 2007 (χ2 test statistic, 21.2; P < .001; relative reduction of 84%).Conclusion: Interventions, including staff education, use of CHG no-rinse cloths for preoperative skin prep, CHG with alcohol for intraoperative skin prep, and appropriate instrument sterilization management led to reductions in SSI rates in patients undergoing C-section at our institution. Rates of endometritis were also noted to be lower after implementation of the interventions.

Improving hand hygiene compliance: A multidisciplinary approach - Corrected Proof

Brenda Helms, Sue Dorval, Paul St. Laurent, Melissa Winter — 2010-02-22

Abstract: This article focuses on improving hand hygiene compliance using a multidisciplinary approach. Historically, hand hygiene compliance among health care workers and physicians has been far below an acceptable level. The facility discussed in this article uses an ongoing “Hand Hygiene” campaign, which is multidisciplinary and addresses numerous barriers to compliance.

Electronic surveillance systems in infection prevention: Organizational support, program characteristics, and user satisfaction - Corrected Proof

2010-02-22

Background: The use of electronic surveillance systems (ESSs) is gradually increasing in infection prevention and control programs. Little is known about the characteristics of hospitals that have a ESS, user satisfaction with ESSs, and organizational support for implementation of ESSs.Methods: A total of 350 acute care hospitals in California were invited to participate in a Web-based survey; 207 hospitals (59%) agreed to participate. The survey included a description of infection prevention and control department staff, where and how they spent their time, a measure of organizational support for infection prevention and control, and reported experience with ESSs.Results: Only 23% (44/192) of responding infection prevention and control departments had an ESS. No statistically significant difference was seen in how and where infection preventionists (IPs) who used an ESS and those who did not spend their time. The 2 significant predictors of whether an ESS was present were score on the Organizational Support Scale (odds ratio [OR], 1.10; 95% confidence interval [CI], 1.02-1.18) and hospital bed size (OR, 1.004; 95% CI, 1.00-1.007). Organizational support also was positively correlated with IP satisfaction with the ESS, as measured on the Computer Usability Scale (P = .02).Conclusion: Despite evidence that such systems may improve efficiency of data collection and potentially improve patient outcomes, ESSs remain relatively uncommon in infection prevention and control programs. Based on our findings, organizational support appears to be a major predictor of the presence, use, and satisfaction with ESSs in infection prevention and control programs.

Influenza vaccination and sick leave practices and perceptions reported by health care workers in ambulatory care settings - Corrected Proof

Wayne Turnberg, William Daniell, Jeffrey Duchin — 2010-02-22

We examined annual influenza vaccination and sick leave practices and perceptions among 627 health care workers (HCWs) in ambulatory care settings in King County, Washington using a self-report questionnaire. Most medical practitioners (85%), but fewer other HCWs (nurses, nurse's aides, allied health professionals, administrative; 55%-64%) reported receiving an annual influenza vaccination; only 31% of HCWs reported routinely taking sick leave for influenza-like illness.

Survey of employee knowledge and attitudes before and after a multicenter Veterans' Administration quality improvement initiative to reduce nosocomial methicillin-resistant Staphylococcus aureus infections - Corrected Proof

2010-02-05

Background: Although guidelines currently recommend prevention practices to decrease in-hospital transmission of infections, increasing adherence to the practices remains a challenge. This study assessed the effect of a multicenter methicillin-resistant Staphylococcus aureus (MRSA) prevention initiative on changes in employees' knowledge, attitudes, and practices.Methods: Two cross-sectional surveys were distributed at baseline (October 2006) and follow-up (July 2007) at 17 medical centers participating in the Veterans' Administration (VA) MRSA initiative.Results: Surveys were completed by 1362 employees at baseline and 952 employees at follow-up (representing 57% and 56% of eligible respondents, respectively). Respondents included physicians (9%), nurses (38%), allied health professionals (30%), and other support staff (24%). Of the 5 knowledge items, the mean proportion answered correctly increased slightly from baseline to follow-up (from 71% to 73%; P = .07). The percentage of respondents who believed that MRSA was a problem on their unit increased over time (from 56% to 65%; P < .001). Respondents also reported increased comfort with reminding other staff about proper hand hygiene (from 61% to 70%; P < .001) and contact precautions (from 63% to 70%; P < .002). The percentage of respondents reporting at least one barrier to proper hand hygiene decreased over time (from 25% to 20%; P = .003).Conclusions: In this multicenter study of VA employees, implementation of a MRSA quality improvement initiative was associated with temporal improvements in knowledge and perceptions regarding MRSA prevention.

A multimodal approach to central venous catheter hub care can decrease catheter-related bloodstream infection - Corrected Proof

Sulaiman Sannoh, Barbara Clones, Jose Munoz, Marisa Montecalvo, Boriana Parvez — 2010-02-05

Background: This study was conducted to investigate decreases in catheter-related bloodstream infections (CRBSIs) through an evidence-based multimodal intervention.Methods: This was a prospective interventional study of neonates with a central venous catheter (CVC) from a neonatal intensive care unit database, involving implementation of a multimodal approach to central venous catheter hub care using 2% chlorhexidine in 70% isopropyl alcohol and education of medical staff by audiovisual presentations. CRBSI rates in the pre-intervention period and postintervention period were compared.Results: A total of 373 patients with a CVC (163 in the preintervention period and 210 in the postintervention period) were studied. Patient demographic and clinical characteristics were similar in the 2 periods. Extremely low birth weight infants constituted 40% of the cohort in the preintervention period and 38% of the cohort in the postintervention period. The CRBSI rate in patients with a umbilical artery catheter and an umbilical vein catheter decreased from 15/1000 catheter-days to 10/1000 catheter-days (odds ratio [OR], 0.47; 95% confidence interval [CI], 0.17-0.91). The CRBSI rate in patients with a peripherally inserted central catheter decreased from 23/1000 catheter-days to 10/1000 catheter-days (OR, 0.33; 95% CI, 0.12-0.91). These decreased CRBSI rates were sustained despite high device utilization. The incidence of gram-negative septicemia also decreased. Ten CRBSIs were prevented by this multimodal approach, representing significant health care cost savings.Conclusions: This study demonstrates significant decreases in CRBSI rate for all catheter types and birth weight categories associated with the multimodal intervention. Audiovisual education is an effective tool for practice change. Reeducation and compliance monitoring should be part of all nosocomial infection prevention strategies, resulting in significant savings in health care costs.

The impact of portable high-efficiency particulate air filters on the incidence of invasive aspergillosis in a large acute tertiary-care hospital - Corrected Proof

Zakir-Hussain Abdul Salam, Rubiyah Binte Karlin, Moi Lin Ling, Kok Soong Yang — 2010-02-03

Background: Worldwide, the frequency of invasive fungal infections has been increasing, with a corresponding increase in the numbers of high-risk patients. Exposure reduction through the use of high-efficiency particulate air (HEPA) filters has been the preferred primary preventive strategy for these high-risk patients. Although the efficiency and benefits of fixed HEPA filters is well proven, the benefits of portable HEPA filters are still inconclusive.Methods: This was a retrospective study to assess the impact of 48 portable HEPA filter units deployed in selected wards in Singapore General Hospital, an acute tertiary-care hospital in Singapore. Data were extracted between December 2005 and June 2008 on the diagnoses at discharge and microbiological and histological laboratory findings. All patients with possible, probable, or proven invasive aspergillosis (IA) were included.Results: In wards with portable HEPA filters, the incidence rate of IA of 34.61/100,000 patient-days in the preinstallation period was reduced to 17.51/100,000 patient-days in the postinstallation period (P = .01), for an incidence rate ratio of 1.98 (95% confidence interval [CI], 1.10-2.97). In wards with no HEPA filters, there was no significant change in the incidence rate during the study period. Portable HEPA filters were associated with an adjusted odds ratio of 0.49 (95% CI, 0.28-0.85; P = .01), adjusted for diagnosis and length of hospital stay.Conclusions: Portable HEPA filters are effective in the prevention of IA. The cost of widespread portable HEPA filtration in hospitals will be more than offset by the decreases in nosocomial infections in general and in IA in particular.

A 1-m distance is not safe for children with cystic fibrosis at risk for cross-infection with Pseudomonas aeruginosa - Corrected Proof

2010-02-03

Although maintaining a distance of 1 m between persons with cystic fibrosis (CF) is a universal recommendation to prevent respiratory cross-infections such as Pseudomonas aeruginosa, evidence supporting this preventive measure is scarce. Examining 336 samples from 42 patients with CF collected experimentally from sterile surfaces after speaking and coughing, we found that transmission of P aeruginosa beyond 1 m is possible during both talking and coughing, although the probability is low (1.7%).

Evaluation of the decontamination efficacy of new and reprocessed microfiber cleaning cloth compared with other commonly used cleaning cloths in the hospital - Corrected Proof

2010-02-02

Background: The aim of this study was to investigate the decontamination capacity of 4 different types of cleaning cloths (microfiber cleaning cloth, cotton cloth, sponge cloth, and disposable paper towels) commonly used in hospital in their ability to reduce microbial loads from a surface used dry or wet in new condition. All of the cloths except disposable paper towels were also compared after 10 and 20 times of reprocessing, respectively, at 90°C for 5minutes in a washing machine.Methods: Stappylococcus aureus (ATCC 6538) and Escherichia coli (ATCC 8739) were used as test organisms. Test organisms were then added to a test soil (6% bovine serum albumin and 0.6% sheep erythrocytes) resulting in a controlled concentration of 5×107 colony-forming units per milliliter in the final test suspension. Standardized tiles measuring 5×5cm were used as test surface.Results: Microfiber cloths showed the best results when being used in new condition. However, after multiple reprocessing, cotton cloth showed the best overall efficacy.Conclusion: We therefore suggest that the choice of the cleaning utilities should be based on their decontamination efficacy after several reprocessings and recommend the establishment of strict and well-defined cleaning and disinfection protocols.

Significant impact of terminal room cleaning with bleach on reducing nosocomial Clostridium difficile - Corrected Proof

2010-02-02

Background: We were alerted to increased rates of Clostridium difficile-positive tests at all 3 hospitals in our health care system by MedMined Data Mining Surveillance Service, CareFusion (San Diego, CA). In response, an intervention of terminal room cleaning with dilute bleach was instituted to decrease the amount of C difficile environmental spore contamination from patients with C difficile infection (CDI).Methods: The intervention consisted of replacing quaternary ammonium compound as a room cleaning agent with dilute bleach to disinfect rooms of patients with CDI upon discharge. All surfaces, floor to ceiling were wiped with dilute bleach applied with towels to thoroughly wet the surfaces. Daily room cleaning remained unchanged. Patients remained on C difficile contact isolation precautions until discharge. To determine the effectiveness of this program, rates of nosocomial CDI for all 3 hospitals were determined using the MedMined Virtual Surveillance Interface for 10 months prior to and 2 years after the cleaning intervention. Statistical significance was determined using Poisson regression analysis.Results: There was a 48% reduction in the prevalence density of C difficile after the bleaching intervention (95% confidence interval: 36%-58%, P < .0001).Conclusion: The implementation of a thorough, all-surface terminal bleach cleaning program in the rooms of patients with CDI has made a sustained, significant impact on reducing the rate of nosocomial CDI in our health care system.

Temporal evolution of carbapenem-resistant Acinetobacter baumannii in Curitiba, southern Brazil - Corrected Proof

2010-02-02

Background: In the last few years, carbapenem-resistant Acinetobacter baumannii isolates (CR-AB) have been identified worldwide. The first description of OXA-23–producing A baumannii in Brazil was from the city of Curitiba in 2003. The aim of the present study was to evaluate the persistence and dissemination of the first OXA-23–producing A baumannii clone isolated from patients in Hospital de Clinicas, Curitiba, Brazil.Methods: An antimicrobial susceptibility profile of the isolates was determined by the standard agar dilution method. Molecular detection of β-lactamase genes was done by polymerase chain reaction. The clonal relationship of the isolates was analyzed by pulsed-field gel electrophoresis (PFGE). Epidemiologic and clinical features were evaluated as well.Results: Genotypic analysis of 172 CR-AB isolates by PFGE identified 3 distinct major PFGE clusters (A, B, and C, accounting for 36, 69, and 65 isolates, respectively). All isolates carried the blaOXA-23–like gene and were multidrug-resistant, but were susceptible to tigecycline and polymixin B. The mortality rate related to CR-AB infection was 45.4%, and ventilator-associated pneumonia and bloodstream infections were the most frequent clinical manifestations.Conclusions: The presence of 3 clones among the CR-AB isolates suggests that cross-transmission was the main mechanism responsible for dissemination of OXA-23 producers. PFGE pattern A was genotypically similar to that of the first OXA-23–producing A baumannii clone identified in Curitiba in 1999. This clone persisted in the same hospital until April 2004. The presence of the blaOXA-23–like gene was the main mechanism associated with carbapenem resistance among the isolates studied.

Evaluation of interventions to reduce catheter-associated bloodstream infection: Continuous tailored education versus one basic lecture - Corrected Proof

2010-02-02

Background: This study evaluated the impact of 2 models of educational intervention on rates of central venous catheter–associated bloodstream infections (CVC-BSIs).Methods: This was a prospective observational study conducted between January 2005 and June 2007 in 2 medical intensive care units (designated ICU A and ICU B) in a large teaching hospital. The study was divided into in 3 periods: baseline (only rates were evaluated), preintervention (questionnaire to evaluate knowledge of health care workers [HCWs] and observation of CVC care in both ICUs), and intervention (in ICU A, tailored, continuous intervention; in ICU B, a single lecture). The preintervention and intervention periods for each ICU were compared.Results: During the preintervention period, 940 CVC-days were evaluated in ICU A and 843 CVC-days were evaluated in ICU B. During the intervention period, 2175 CVC-days were evaluated in ICU A and 1694 CVC-days were evaluated in ICU B. Questions regarding CVC insertion, disinfection during catheter manipulation, and use of an alcohol-based product during dressing application were answered correctly by 70%-100% HCWs. Nevertheless, HCWs' adherence to these practices in the preintervention period was low for CVC handling and dressing, hand hygiene (6%-35%), and catheter hub disinfection (45%-68%). During the intervention period, HCWs' adherence to hand hygiene was 48%-98%, and adherence to hub disinfection was 82%-97%. CVC-BSI rates declined in both units. In ICU A, this decrease was progressive and sustained, from 12 CVC-BSIs/1000 CVC-days at baseline to 0 after 9 months. In ICU B, the rate initially dropped from 16.2 to 0 CVC-BSIs/1000 CVC-days, but then increased to 13.7 CVC-BSIs/1000 CVC-days.Conclusions: Personal customized, continuous intervention seems to develop a “culture of prevention” and is more effective than single intervention, leading to a sustained reduction of infection rates.

How to educate health care professionals in developing countries? A Brazilian experience - Corrected Proof

2010-01-29

E-learning is an important tool to bring health care professionals updated information, especially in a large, developing country like Brazil, where teaching resources are limited. It allows the exchange of experiences between professionals, promotes simultaneous knowledge acquisition by a large number of participants, and reaches some remote areas.

Updating the guideline development methodology of the Healthcare Infection Control Practices Advisory Committee (HICPAC) - Corrected Proof

2010-01-29

This article describes the recent update to the guideline development methodology of the Healthcare Infection Control Practices Advisory Committee (HICPAC). These methods are being used to develop future HICPAC guidelines, beginning with the guideline on preventing catheter-associated urinary tract infections released in 2009. The article includes a background on HICPAC, the strengths and limitations of the methods it's used over the last two decades, and the rationale behind these recent updates. In addition, we describe the new infrastructure used to develop guidelines at HICPAC, key changes in methodology, and new elements of HICPAC guidelines, like the implementation and audit section. We also describe current challenges to the development of infection control guidelines. The current update builds on past strengths and current advances in guideline development and implementation, and enables HICPAC to improve the validity and usability of its guidelines while also addressing emerging challenges in guideline development in the area of infection prevention and control.

Control of methicillin-resistant Staphylococcus aureus in planktonic form and biofilms: A biocidal efficacy study of nonthermal dielectric-barrier discharge plasma - Corrected Proof

2010-01-20

Background: Bacterial contamination of surfaces with methicillin-resistant Staphylococcus aureus (MRSA) is a serious problem in the hospital environment and is responsible for significant nosocomial infections. The pathogenic contaminants form biofilms, which are difficult to treat with routine biocides. Thus, a continuous search for novel disinfection methods is essential for effective infection control measures. This demonstration of a novel technique for the control of virulent pathogens in planktonic form as well as in established biofilms may provide a progressive alternative to standard methodology.Methods: We evaluated a novel technique of normal atmospheric nonthermal plasma known as floating-electrode dielectric-barrier discharge (FE-DBD) plasma against a control of planktonic and biofilm forms of Escherichia coli, S aureus, multidrug-resistant methicillin-resistant S aureus (MRSA) -95 (clinical isolate), -USA300, and -USA400, using widely accepted techniques such as colony count assay, LIVE/DEAD BacLight Bacterial Viability assay, and XTT (2,3-Bis(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide) assay.Results: Exposure of free living planktonic forms of E coli, S aureus, and MRSA were rapidly inactivated by DBD plasma. Approximately 107 bacterial cells were completely (100%) killed, whereas 108 and 109 were reduced by approximately 90% to 95% and 40% to 45%, respectively, in less than 60 seconds (7.8 J/cm2) and completely disinfected in ≤120 seconds. In established biofilms, the susceptibility of MRSA USA400 was comparable with USA300 but less susceptible than MRSA95 (clinical isolate), S aureus, and E coli (P < .05) to FE-DBD plasma, and plasma was able to kill MRSA more than 60% within 15 seconds (1.95 J/cm2). The killing responses were plasma exposure-time dependent, and cell density dependent. The plasma was able disinfect surfaces in a less than 120 seconds.Conclusion: Application of DBD plasma can be a valuable decontamination technique for the removal of planktonic and biofilm-embedded bacteria such as MRSA -USA 300, -USA 400, methicillin-sensitive S aureus (MSSA), and E coli, the more common hospital contaminants. Of interest, E coli was more resistant than S aureus phenotypes.

Evaluation of an alcohol-based power sanitizing system for decontamination of hospital rooms of patients with methicillin-resistant Staphylococcus aureus carriage - Corrected Proof

2010-01-20

A power sanitizing system that delivers a sanitizing mist of alcohol, rendered nonflammable by a carbon dioxide carrier, and a low concentration of quaternary ammonium compound, was easy to use, provided thorough coverage of surfaces, and significantly reduced vancomycin-resistant Enterococcus and methicillin-resistant Staphylococcus aureus contamination on commonly touched hospital surfaces. However, it was not as consistently effective for elimination of pathogens as 10% bleach solution.

Lessons learned from the anti-SARS quarantine experience in a hospital-based fever screening station in Taiwan - Corrected Proof

Esther Ching Lan Lin, Yih Chi Peng, Jeffrey Che Hung Tsai — 2010-01-18

Background: Severe acute respiratory syndrome (SARS) was the first major novel infectious disease to hit the international community in the 21st century. While SARS was sweeping over almost 30 countries, most hospitals in Taiwan instituted mandatory quarantine measures, one of the most effective public health strategies for preventing disease transmission. We explored the anti-SARS quarantine experience of patients in a hospital-based fever screening station.Methods: We conducted a phenomenologic, qualitative study using semistructured telephone interviews during the SARS outbreak in Taiwan. Seventeen patients with fever who were quarantined in the fever screening station of a hospital emergency department for at least 2hours were recruited into this study.Results: Data analysis using Collaizi's 9 steps revealed 2 categories—external burden and internal struggle—and 6 themes regarding patients' quarantine experience. External burden included 3 themes: (1) bearing the uncomfortable surroundings, (2) facing discrimination, and (3) lacking in-person family support. Internal struggle consisted of 3 themes: (1) struggle with being quarantined, (2) struggle with emotional turmoil, and (3) struggle with possible SARS diagnosis.Conclusion: These results will contribute to sensitizing health care professionals to empathize with quarantined persons while providing quality quarantine care and other infection control measures.

Effective environmental sampling strategies for monitoring Legionella spp contamination in hot water systems - Corrected Proof

2010-01-18

Background: The prevention and control of legionellosis in hospital settings involves environmental sampling, among other measures. The data yielded by sampling constitute an important means of risk assessment and provide a valid basis on which to plan remedial (cleansing and disinfection) and preventive (maintenance) interventions. This retrospective study had 2 objectives: (1) to evaluate the utility of biofilm sampling at distal sites and (2) to identify an efficient environmental sampling strategy.Methods: Samples of hot water and biofilm were collected between June 1999 and March 2008 from 41 hospitals in Italy's Piemonte region. We analyzed results of the samples (water and biofilm) taken from the same site and results of the water samples taken from the recirculation loop and water samples taken from the distal sites during the same sampling run.Results: Microbiological analysis was performed on 3910 pairs of samples (water/biofilm). In 81% of the pairs, the results were concordant; in 17% of the pairs, Legionella was isolated only from the water samples, and in only 2% of the pairs was Legionella isolated from the biofilm sample alone. Data from 299 sampling runs show that 79% (236) of results from the water samples taken from the recirculation loop and water samples taken from the distal sites during the same sampling run were concordant, and 21% (63) were discordant.Conclusions: Our findings suggest that hospitals could safely adopt a simpler (water sampling only without biofilm sampling) and more efficient (monitoring of the entire system through sampling of recirculation loop water) environmental sampling policy.

Nosocomial infections caused by community-associated methicillin-resistant Staphylococcus aureus in Colombia - Corrected Proof

2009-12-31

Background: Community-associated methicillin-resistant Staphylococcus aureus strains (CA-MRSA) have emerged as the causative agent of health care-associated infections.Methods: An observational and prospective study was carried out in 5 hospitals in Bogotá, Colombia; severe MRSA infections were identified, and their origin led to classification as health care-associated (HA-MRSA), community-associated, or nosocomial infections. MRSA isolates were analyzed by SCCmec, pulsed-field gel electrophoresis, multilocus sequence typing, and virulence factors.Results: Twenty-six (10.4%) CA-MRSA nosocomial infection-causing strains (eg, USA300) were detected in 250 MRSA infection isolates in mainly primary bacteremia and surgical site infections. The mortality related to nosocomial infection by CA-MRSA was 27%.Conclusion: The presence of nosocomial infection by CA-MRSA in Colombia was confirmed.

Contamination of intravenous fluids: A continuing cause of hospital bacteremia - Corrected Proof

2009-12-23

Background: Nosocomial bacteremia caused by the contamination of intravenous (IV) infusates is considered rare. Unfortunately, this problem has been underestimated because its identification requires culturing infusates, a procedure not performed routinely.Methods: This study was conducted in a referral hospital where IV infusates are admixed in nursing areas. The aim was to determine the prevalence of infusate contamination in adult patients with gram-negative rod (GNR) bacteremia. Over a period of 32 months, a specimen of infusate was drawn for culture from each patient recruited after the laboratory reported a GNR in the blood.Results: A total of 384 infusates were cultured from 384 patients who had been diagnosed with GNR bacteremia. Seven infusates grew a GNR in culture, for a contamination rate of 2% (7/384; 95% confidence interval [CI] = 1% to 3%). In all cases, the infectious organism was the same as the organism isolated from the blood. Infusate contamination was responsible for 7% (7/108; 95% CI = 2% to 11%) of all primary bloodstream infections and 11% (7/62; 95% CI = 2% to 22%) of all primary bloodstream infections not associated with central venous catheter infection.Conclusions: For patients in hospitals where IV drugs are admixed in nursing units, we recommend instituting infusate culture as routine practice following the diagnosis of a GNR in the blood.

Notifiable infectious disease reporting awareness among physicians and registered nurses in primary care and emergency department settings - Corrected Proof

Wayne Turnberg, William Daniell, Jeffrey Duchin — 2009-12-23

This study examined knowledge about notifiable infectious disease reporting among physicians and registered nurses (RNs) in primary care and emergency department settings in King County, Washington. In 2005, a total of 165 physicians and 170 RNs completed a questionnaire to assess knowledge, training and feedback regarding notifiable infectious disease reporting. Only 55% of the physicians and 63% of the RNs were aware of reporting procedures within their institution. Awareness was higher when employer-provided training had been provided. Our findings indicate that employer training can improve reporting knowledge.

Outbreak of late-onset group B Streptococcus in a neonatal intensive care unit - Corrected Proof

2009-12-21

Background: In September 2007, the Tennessee Department of Health was notified of a cluster of late-onset group B streptococcal (GBS) infections in a neonatal intensive care unit (NICU). Outbreaks of late-onset GBS are rare.Methods: A case was defined as culture-confirmed invasive GBS infection in a neonate aged ≥7 days, identified in hospital A during August 23 to September 6, 2007. We reviewed medical records; examined NICU microbiology reports; and performed serotyping, pulsed-field gel electrophoresis (PFGE), and multilocus sequence typing (MLST) on invasive isolates. Maternal GBS screening, prophylaxis, and infection control policies were reviewed and staff practices observed.Results: Five cases of late-onset GBS were identified. None of the mothers of the infants received optimal GBS prophylaxis. Patient isolates were of 2 serotypes, 3 PFGE patterns, and 2 MLST patterns. Three isolates were indistinguishable on subtyping. These 3 cases were clustered in time. No common health care providers were identified. Infection control deviations in the NICU were observed.Conclusion: We identified a multiclonal cluster of 5 late-onset GBS cases. Multiple factors likely contributed to the outbreak, including nosocomial transmission of GBS. Further efforts to prevent late-onset GBS disease are necessary.

Evaluating the impact of a hand hygiene campaign on improving adherence - Corrected Proof

2009-12-21

We monitored compliance with hand hygiene (HH) by direct observation in 3 hospitals in Cantabria, Spain before and after implementation of an HH informational campaign, separately analyzing the effect of a training program. We report that training plus an informational campaign doubled the probability of HH, whereas the informational campaign without training decreased adherence, acting as a deleterious factor in HH adherence.

Exposure to hospital roommates as a risk factor for health care–associated infection - Corrected Proof

Meghan Hamel, Dick Zoutman, Chris O'Callaghan — 2009-12-21

Background: Numerous patient- and hospital-level characteristics have been established as risk factors for the transmission of health care–associated infections (HAIs). Few studies have quantitatively assessed the impact of exposure to hospital roommates on the acquisition of infections. This study evaluated the association between roommate exposures and the risk of HAIs.Methods: A retrospective cohort of adult patients admitted to a Canadian teaching hospital between June 30, 2001, and December 31, 2005, was studied. Exposures were characterized as total daily roommate exposures and daily unique roommate exposures. Outcomes examined were methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and Clostridium difficile.Results: The number of roommate exposures per day was significantly associated with MRSA and VRE infection or colonization (MRSA: hazard ratio [HR] = 1.10, 95% confidence interval [CI] = 1.05 to 1.15; VRE: HR = 1.11, 95% CI = 1.02 to 1.21), and with C difficile infection (HR = 1.11, 95% CI = 1.03 to 1.19). A significant association also was found for number of unique roommate exposures per day and VRE (HR = 1.15, 95% CI = 1.02 to 1.28).Conclusions: The significant associations found between daily roommate exposures and the infection outcomes suggest a possible role for limiting patient-to-patient contact in an infection prevention and control program in this facility. These findings have implications for the deployment and design of acute care hospitals.

Infection control nurse specialist education in Korea - Corrected Proof

Kyung Mi Kim, Jae Sim Jeong, Ho Ran Park — 2009-12-21

With the amendment of the Medical Service Act in 2003, the infection control nurse specialist system was launched as one of several specialties for nursing in Korea. Nurse specialists are certified through the national qualifying examination after graduating from a specialist nursing program with core and specialty courses at a graduate school approved by the Ministry of Health and Welfare. This article describes graduate preparation and certification for infection control nurse specialists in Korea.

Outbreak of vancomycin-resistant enterococci in a tertiary hospital: The lack of effect of measures directed mainly by surveillance cultures and differences in response between Enterococcus faecium and Enterococcus faecalis - Corrected Proof

2009-12-14

To describe the effect of active surveillance to control vancomycin-resistant enterococci (VRE) after an outbreak, 549 surveillance rectal cultures were performed in 308 patients (35% positive). An educational intervention to prevent transmission was implemented. Infection and colonization by VR- Enterococcus faecalis decreased, but Enterococcus faecium persisted despite control measures. Infections by VR-E faecalis fell to zero in 2008. We observed difficulties in controlling colonization with measures directed mainly by surveillance cultures and differences between responses of E faecium and E faecalis.

Effect of surfactants, temperature, and sonication on the virucidal activity of polyhexamethylene biguanide against the bacteriophage MS2 - Corrected Proof

Federica Pinto, Jean-Yves Maillard, Stephen P. Denyer — 2009-12-14

Background: Virucidal compounds are essential in preventing the transmission of viral infection in the health care environment. Understanding their mechanisms of action is necessary to improve their efficacy. Inactivation of viruses is less documented than that of bacteria notably because different types of virus have diverse response to microbicides, making difficult to establish an inactivation pattern.Methods: The effect of viral aggregates on the virucidal activity of polyhexamethylene biguanide-based microbicide VANTOCILTM TG (Arch Chemicals, Manchester, UK) against the bacteriophage MS2 was investigated by using in combination a standard suspension efficacy test under different conditions and dynamic light scattering measuring the presence and size of aggregates.Results: Temperature had a key role in increasing significantly the virucidal activity of VANTOCILTM TG, reducing virus concentration by 4-log10 within 10minutes at 40°C. The high temperature was linked to a reduction of viral aggregates despite the exposure to the biguanide. In addition, the viral inactivation kinetic became significantly more linear at 30°C and 40°C. Such results were also observed with sonication during treatment, where a first-order kinetic was observed. However, the addition of surfactants, even though there was evidence of a decrease in viral clumps, did not enhance the virucidal activity of polyhexamethylene biguanide.Conclusion: The presence of viral aggregates was an important factor in the virucidal efficacy of the biguanide as demonstrated by the correlation among high temperature, decrease in aggregates, and increase in activity, although it is possible that high temperatures might also cause conformational changes of the viral capsid, increasing the sensitivity of virions to the microbicide.

Effectiveness of a catheter-associated bloodstream infection bundle in a Thai tertiary care center: A 3-year study - Corrected Proof

2009-12-14

Background: We sought to determine the long-term impact of “bundled” infection control interventions on the rates of catheter-associated bloodstream infection (CA-BSI) in a middle-income country.Setting: A 500-bed tertiary care center in Thailand.Methods: A 3-year, hospital-wide, prospective quasi-experimental study was conducted for 1 year before the intervention (period 1), 1 year after implementation of the CA-BSI bundle (period 2), and at a 1-year follow-up after the intervention with intensified hand hygiene promotion (period 3).Results: In period 1, 88 episodes of CA-BSI (14 cases per 1000 catheter-days) were recorded. During period 2, the CA-BSI rate decreased by 54.1 % (6.4 cases per 1000 catheter-days; P <.001). Compared with period 1 (8% adherence), hand hygiene adherence was improved in period 2 (24%; P <.001) and period 3 (54%; P <.001). The CA-BSI rate was further decreased by 78% (1.4 cases per 1000 catheter-days; P <.001) during period 3. Notably, no CA-BSIs were seen in 6 of the 12 months (50%) of period 3. Compared with period 1, the mean number of catheter-days was significantly reduced in period 2 (4.9 ± 1.5 days; P <.001) and period 3 (4.1 ± 1.1 days; P <.001).Conclusion: Bundled infection control practices are feasible and effective in sustaining reduced incidence of CA-BSI in patients with central venous catheters in a resource-limited setting.

Airborne Aspergillus contamination during hospital construction works: Efficacy of protective measures - Corrected Proof

2009-11-18

Background: The Dijon University Hospital in Dijon, France is involved in a large construction program with heavy truck traffic and a very dusty environment. This study aimed to assess the impact of outdoor hospital construction work on Aspergillus air contamination in the immediate environment of patients at high risk for aspergillosis in the presence of protective measures.Methods: Prospective air and surface sampling (n=1301) was performed in 3 hospital units over a 30-month period. Generalized estimating equations were used to test the relationship between Aspergillus air contamination and the different variables (construction period, air treatment system, and surface contamination).Results: Positivity rates of Aspergillus spp varied from 21.1% before construction work to 16.9% during work for air samples (P=.07), and the associated mean fungal load varied from 1.21 colony-forming units (CFU)/m3 to 0.64 CFU/m3 (P=.04). In multivariate analysis, only the use of an air treatment system was associated with decreased airborne Aspergillus contamination (P < .0001). No significant difference was observed between the presence or absence of construction work and the proportion of airborne Aspergillus contamination (P=.91) or the Aspergillus fungal load (P=.10).Conclusions: No influence of hospital construction work on airborne Aspergillus contamination was demonstrated when protective measures were taken, including reinforcement of the importance of environmental cleaning.

Analysis of the microbial load in instruments used in orthopedic surgeries - Corrected Proof

2009-11-13

Background: Because of advances in technology, the number of orthopedic surgeries, mainly hip and knee replacement surgeries, has increased, with a total of 150,000 prosthetic surgeries estimated per year in the United States and 400,000 worldwide.Methods: We used an exploratory cross-sectional study, with a quantitative approach to determine the microbial load in instruments used in orthopedic surgeries, quantifying and identifying the microbial growth genus and species, according to the surgical potential of contamination that characterizes the challenge faced by the Material and Sterilization Center at the Institute of Orthopedics and Traumatology of Hospital das Clinicas of the School of Medicine of the University of Sao Paulo, Brazil.The orthopedic surgical instruments were immersed, after their use, in sterilized distilled water, sonicated in an ultrasonic washer, and posteriorly agitated. Subsequently, the wash was filtrated through a 0.45-μm membrane and incubated in aerobic and anaerobic mediums and in medium for fungi and yeasts.Results: In clean surgeries, 47% of the instruments were contaminated; in contaminated surgeries, 70%; and, in infected surgeries, 80%. Regardless of the contamination potential of the surgeries, the highest quantitative incidence of microorganism recovery was located in the 1 to 100 colony-forming unit range, and 13 samples presented a microbial growth potential >300 colony-forming units. Regardless of the contamination potential of the surgeries, there was a convergence in the incidence of negative-coagulase Staphylococcus growth (28%, clean surgeries; 32%, contaminated surgeries; and 29%, infected surgeries) and Staphylococcus aureus (28%, contaminated surgeries; and 43%, infected surgeries).Conclusion: Most of the microorganisms recovered from the analyzed instruments (78%) were vegetative bacteria that presented their death curve at around 80°C, characterizing a low challenge considering the processes of cleaning and sterilization currently employed by the Material and Sterilization Center. Fewer microorganisms were recovered from instruments used in clean surgeries in comparison with those used in contaminated and infected surgeries.

Predicting bacterial populations based on airborne particulates: A study performed in nonlaminar flow operating rooms during joint arthroplasty surgery - Corrected Proof

2009-11-13

Background: Prevention of postsurgical infection is preferable to treatment. Prevention requires identification and control of the potential sources of microbial contamination. This study investigated whether the density of airborne particulates can predict the density of viable airborne bacteria at the surgery site.Methods: A standard particle analyzer was used to measure the number and diameter of airborne particulates during 22 joint arthroplasty surgeries. An impact air sampler and standard culture plates were used to identify and count colony-forming units (CFU).Results: Particulate density averaged >500,000 particles/m3 per 10-minute interval, and 1786 CFU were identified, primarily gram-positive cocci. A particle density≥10μm explained 41% of the variation in CFU density. Particle and CFU density increased with longer surgery duration and higher staff counts.Conclusions: These findings support the use of environmental controls that isolate and protect the surgical site from airborne particulates and contamination.

Antibiotic consumption as a driver for resistance in Staphylococcus aureus and Escherichia coli within a developing region - Corrected Proof

2009-11-09

Background: This study aimed to provide insight into possible antibiotic drivers of methicillin-resistant Staphylococcus aureus (MRSA) and Escherichia coli resistant to third-generation cephalosporins (3GCREC) in southern and eastern Mediterranean institutions.Methods: MRSA and 3GCREC susceptibility proportions from 19 regional hospitals, previously published by the ARMed project, were correlated with antibiotic use data from the same institutions.Results: Hospitals reporting below-median MRSA proportions had significantly lower total antibiotic use. MRSA proportions increased with greater use of carbapenems (P=.04). In multivariate analysis, a positive correlation was identified with the use of carbapenems (P=.002), combination penicillins (P=.018), and aminoglycosides (P=.014). No difference was ascertained between 3GCREC proportions and total antibiotic use. In multivariate linear regression, a correlation was identified only for 3GCREC (P=.005), but a negative association was evident for beta-lactamase–resistant penicillins (P=.010) and first-generation cephalosporins (P=.012).Conclusions: The results suggest an association between resistance and antibiotic use, especially for carbapenems and third-generation cephalosporins. These data support the urgent implementation of antibiotic stewardship initiatives in hospitals in developing countries that focus on more judicious use of broad-spectrum formulations.

Management of a multidrug-resistant Acinetobacter baumannii outbreak in an intensive care unit using novel environmental disinfection: A 38-month report - Corrected Proof

2009-11-09

Background: Between June 1, 2004, and March 14, 2005, 16 patients in the surgical/medical intensive care unit (ICU) were infected and another 2 were colonized with multidrug-resistant (MDR) Acinetobacter baumannii. We describe the systematic investigation initiated to discover an environmental reservoir and a novel measure taken to terminate the outbreak.Methods: Cultures were taken from moist areas in the ICU, including sink traps, sink and counter surfaces, drains, and faucets. Strains were characterized using restriction endonuclease analysis. A weekly full drainpipe chase cleansing protocol with sodium hypochlorite (bleach) solution for all 24 ICU and waiting room area sinks connected by common plumbing was initiated in March 2005.Results: Eleven of 16 infected patients (69%) had a clonal MDR strain, 1 patient (6%) was infected with an unrelated strain, and in 4 patients (25%) strains were not available for typing. The reservoir for the A baumannii clone was detected in a sink trap within one of the ICU patient rooms that likely represented contamination of the entire horizontal drainage system. The bleaching protocol initiated in March 2005 successfully decontaminated the reservoir and eliminated the MDR A baumannii infections.Conclusion: A systematic search for an environmental reservoir followed by decontamination significantly reduced (P < .01) the incidence of MDR A baumannii infection.

Aldahol high-level disinfectant - Corrected Proof

Norman Miner, Valerie Harris, Thuy Dung Cao, Towanda Ebron, Natalie Lukomski — 2009-11-09

Background: Glutaraldehyde and ortho-phthalaldehyde (OPA) are widely used as the active ingredients of high level disinfectants for heat-sensitive, semicritical medical instruments. However, both of these chemicals have limitations in their spectrum of antimicrobial activity. Glutaraldehyde disinfectants are poorly mycobactericidal, and require impractically long exposure times to kill spore-forming bacteria. OPA disinfectants kill many types of mycobacteria in practical exposure times, but require 32hours to pass the Association of Official Analytical Chemists (AOAC) sporicidal test, and do not claim to be sterilants. These could be serious limitations that contribute to the formation of biofilms in endoscopes, after which the endoscopes are difficult to disinfect. The objective of our research was to discover a disinfectant formulation, based on aldehydes, that killed mycobacteria and spore-forming bacteria in a practical exposure time and temperature.Methods: Solutions of glutaraldehyde or OPA were prepared with various concentrations of alcohols, sodium and potassium salts, chelating agents, and detergents at alkaline pH values, and tested against cultures of mycobacteria and spore-forming bacteria to find a formulation that would kill these bacteria in practical exposure times at 20°C or 25°C.Results: Concentrations of≤20% w/w isopropanol and≤8% potassium acetate in combination with≤3.5% w/w glutaraldehyde at alkaline pH values killed 6log10 of mycobacteria within 10minutes at 20°C. Similar combinations killed 6log10 of Bacillus subtilis in suspension within 30minutes at 25°C, and B subtilis within 60minutes at 20°C. The sporicidal activity of OPA was not increased by combination with isopropanol and potassium acetate salts.Conclusions: Aldahol high-level disinfectant (US FDA K041360), a formulation of 3.5% glutaraldehyde in combination with 20% w/w isopropanol and 8% potassium acetate, kills mycobacteria within 10minutes at 20°C and kills 6log10 of cultures of the spore-forming bacteria B subtilis within 60minutes at 20°C.

Detection of Aspergillus fumigatus by quantitative polymerase chain reaction in air samples impacted on low-melt agar - Corrected Proof

2009-11-06

Background: The standard procedure for routine environmental sampling for the prevention of invasive aspergillosis outbreaks is culturing of Aspergillus fumigatus after impaction of air. Time to results is usually 7 days. A preliminary study was carried out to compare the time to results and sensitivity of culturing and quantitative polymerase chain reaction (QPCR) in the detection of airborne A fumigatus.Methods: Fungal DNA was extracted from 43 samples of impacted low-melt agar by a 3-step extraction method and amplified by QPCR. Identification was made using a specific A fumigatus probe.Results: With QPCR, 19 of the 43 samples were positive for A fumigatus; with culturing, 7 of these 19 samples were positive, and 12 were negative. The cycle threshold (Ct) values for the 12 culture-negative samples were between 39 and 43 cycles, and the Ct values for 6 of the 7 culture-positive samples were <38 cycles, suggesting that the amount of DNA detected by QPCR was higher in the presence of viable conidia.Conclusion: QPCR detection of airborne A fumigatus in impacted low-melt agar significantly reduces the period of time between sample collection and results (48 hours), suggesting that this new approach can be beneficial for routine environmental sampling.