AJIC: American Journal of Infection Control - Articles in Press

The short-term and long-term effectiveness of a multidisciplinary hand hygiene improvement program - Corrected Proof

2012-01-30

Background: Although hand hygiene (HH) compliance has been an important issue for years, the compliance rate is still a problem in health care today.Methods: This was an observational, prospective, before-and-after study. We measured HH knowledge and HH compliance before (baseline), directly after (poststrategy), and 6 months after the performance of HH team strategies (follow-up). The study was composed of employed nurses and physicians working in the department of internal medicine of a university hospital. We performed a multifaceted improvement program including HH education, feedback, reminders, social influence activities including the use of role models, and improvement of HH facilities.Results: Ninety-two nurses and physicians were included. Compared with baseline, there was a significant improvement in the overall mean HH knowledge score at poststrategy (from 7.4 to 8.4) and follow-up (from 7.4 to 8.3). The overall HH compliance was 27% at baseline, 83% at poststrategy, and 75% at follow-up. At baseline, the compliance rate was 17% in nurses and 43% in physicians and significantly improved to 63% in nurses and 91% in physicians at follow-up.Conclusion: Our multifaceted HH improvement program resulted in a sustained improvement of HH knowledge and compliance in nurses as well as physicians.

Assessing colectomies due to Clostridium difficile infection: Increases in the community, but not in the referral center - Corrected Proof

2012-01-30

To investigate an increase in CDI-related colectomies, electronically available data were used to identify patients who underwent colectomy and were diagnosed with Clostridium difficile infection (CDI), with chart review to determine whether the colectomy was for CDI. The investigation found an increase in CDI-related colectomies for CDI not associated with the study institution. Electronically available data facilitated surveillance for severe CDI.

The burden of multidrug-resistant organisms on tertiary hospitals posed by patients with recent stays in long-term acute care facilities - Corrected Proof

2012-01-30

Background: Long-term acute care (LTAC) facilities admit patients with complex, advanced disease states. Study aims were to determine the burden posed on hospitals associated with LTAC exposure and analyze the differences between “present on admission” (POA) multidrug-resistant (MDR), gram-negative organisms (GNO) and POA MDR gram-positive organisms (GPO).Methods: A multicenter retrospective study was conducted in 13 hospitals from southeast Michigan, from September 1, 2008, to August 31, 2009. Cultures obtained in the first 72 hours of hospitalization (ie, POA) of MDR-GPO and MDR-GNO were reviewed. LTAC exposures in the previous 6 months and direct admission from a LTAC were recorded.Results: Overall, 5,297 patients with 7,147 MDR POA cultures were analyzed: 2,619 (36.6%) were MDR-GNO, and 4,528 (63.4%) were MDR-GPO. LTAC exposure in the past 6 months was present in 251 (5.2%) infectious episodes and was significantly more common among POA MDR-GNO than MDR-GPO (158 [8.6%] and 94 [3.1%], respectively, odds ratio, 2.87; P < .001). Recent LTAC exposure was strongly associated with both carbapenem-resistant Enterobacteriaceae (CRE) (31.6% of all CRE cases, P < .001) and Acinetobacter baumannii (14.9% of all A baumannii cases, P < .001).Conclusion: Nearly 10% of MDR-GNO POA had recent LTAC exposure. Hospital efforts to control the spread of MDR-GNO should focus on collaborations and communications with referring LTACs and interventions targeted towards patients with recent LTAC exposure.

Impact on hand hygiene compliance following migration to a new hospital with improved resources and the sequential introduction of World Health Organization recommendations - Corrected Proof

Noel Abela, Michael A. Borg — 2012-01-30

Background: One commonly cited reason for inadequate hand hygiene (HH) in health care facilities is lack of handwashing sinks and alcohol hand rub (AHR).Methods: Using the World Health Organization (WHO) direct observation method, we studied HH compliance after migration from an old hospital having 1 HH station (sink and AHR) per 6 beds to a new institution with 1 per 0.85 beds. We then introduced the other WHO strategy components in a sequential manner—posters, active education, and performance feedback—and assessed the impact of the various elements over time.Results: Migration from the old to the new hospital was actually accompanied by a reduction in HH from 27.3% to 14.5% (P < .01), with a 52% decline in handwashing (P = .01) after patient contact. Small group interactive teaching improved HH compliance but only reached a maximum of 33.1%. No change was seen where only posters and leaflets (without educational sessions) were adopted. Significant improvement was only obtained after a performance feedback campaign coupled with increased staff accountability, reaching an overall average of 63% (P < .001).Conclusion: Our results suggest that, on their own, better resources do not offer any guarantees of improved HH practices. However, once in place, audit and feedback—coupled with genuine administrative support and fostering of individual accountability—appear to be effective change tools to increase HH compliance.

Traffic flow in the operating room: An explorative and descriptive study on air quality during orthopedic trauma implant surgery - Corrected Proof

2012-01-30

Background: Understanding the protective potential of operating room (OR) ventilation under different conditions is crucial to optimizing the surgical environment. This study investigated the air quality, expressed as colony-forming units (CFU)/m3, during orthopedic trauma surgery in a displacement-ventilated OR; explored how traffic flow and the number of persons present in the OR affects the air contamination rate in the vicinity of surgical wounds; and identified reasons for door openings in the OR.Methods: Data collection, consisting of active air sampling and observations, was performed during 30 orthopedic procedures.Results: In 52 of the 91 air samples collected (57%), the CFU/m3 values exceeded the recommended level of <10 CFU/m3. In addition, the data showed a strongly positive correlation between the total CFU/m3 per operation and total traffic flow per operation (r = 0.74; P = .001; n = 24), after controlling for duration of surgery. A weaker, yet still positive correlation between CFU/m3 and the number of persons present in the OR (r = 0.22; P = .04; n = 82) was also found. Traffic flow, number of persons present, and duration of surgery explained 68% of the variance in total CFU/m3 (P = .001).Conclusions: Traffic flow has a strong negative impact on the OR environment. The results of this study support interventions aimed at preventing surgical site infections by reducing traffic flow in the OR.

Transmission of hepatitis B virus associated with assisted monitoring of blood glucose at an assisted living facility in New York State - Corrected Proof

2012-01-27

Background: Hepatitis B virus (HBV) transmission has been reported after patient-to-patient blood exposure during assisted monitoring of blood glucose (AMBG). Three assisted-living facility (ALF) residents who underwent AMBG developed acute HBV infection (HBVI) within 10 days. We investigated HBV transmission and implemented preventive measures.Methods: A retrospective cohort study was conducted. Infection control practices were assessed. HBVI screening was conducted for all staff and epidemiologically linked residents. Viral DNA sequences were compared for a subset of isolates.Results: Lancing devices and glucometers were shared among residents without proper sanitization. Serologic testing of all 34 residents with diabetes and 12 epidemiologically linked residents present during the exposure period detected 6 residents with diabetes with current HBVI and 4 residents with diabetes and 1 epidemiologically linked resident with previous HBVI. A cohort study of 32 individuals with diabetes identified AMBG as a significant risk factor for HBVI (relative risk, 6.7; 95% confidence interval, 1.7-26.3). Viral DNA sequences for 5 AMBG-exposed residents’ isolates were identical, suggesting a common source.Conclusions: AMBG was significantly associated with HBVI in ALF residents with diabetes. Despite clear preventive recommendations, bloodborne pathogen transmission continues to occur in the setting of AMBG. Strengthening direct care provider, infection preventionist, and health department partnerships with ALFs is crucial to ensure safe AMBG practices and prevent HBV transmission.

Self-reported reasons for hand hygiene in 3 groups of health care workers - Corrected Proof

Anne Collins McLaughlin, Fran Walsh — 2012-01-24

Background: The hands of health care workers continue to be the main vector for nosocomial infection in hospitals. The purpose of the current research was to capture the health beliefs and self-reported behaviors of US health care workers to better understand why workers avoid hand hygiene and what prompts them to wash.Methods: An online survey of health care workers assessed their reasons for washing their hands, reasons for not washing, and what cues prompted the decision to wash or not wash in a variety of locations.Results: The findings were that hand hygiene could be cued by an external situation but tended to be motivated internally. Hand hygiene was avoided because of situational barriers.Conclusion: The reasons for performing hand hygiene can be situated in the internally motivated Theory of Planned Behavior; however, the reasons for not performing hand hygiene tend to be situational and affected by the environment. The results may be used to design programs, products, and systems that promote appropriate hand hygiene practices. Principles for design of these programs and products are provided.

Comparative efficacy of commercially available alcohol-based hand rubs and World Health Organization-recommended hand rubs: Formulation matters - Corrected Proof

2012-01-24

Background: Use of alcohol-based hand rubs (ABHRs) effectively reduces transmission of pathogenic microorganisms. However, the impact of alcohol concentration and format on product efficacy is currently being debated.Methods: Two novel ABHR formulations containing 70% ethanol were evaluated according to American Society for Testing and Materials E1174 (Health Care Personnel Handwash [HCPHW]) and European Norm (EN) 1500 global standards. Additionally, using E1174, the efficacy of these formulations was compared head-to-head against 7 representative commercially available ABHRs and 2 World Health Organization recommended formulations containing alcohol concentrations of 60% to 90%.Results: The novel ABHR formulations met efficacy requirements for both HCPHW and EN 1500 when tested at application volumes typically used in these methods. Moreover, these formulations met HCPHW requirements when tested at a more realistic 2-mL product application. In contrast, the commercial ABHRs and World Health Organization formulations failed to meet HCPHW requirements using a 2-mL application. Importantly, product performance did not correlate with alcohol concentration.Conclusion: Product formulation can greatly influence the overall antimicrobial efficacy of ABHRs and is a more important factor than alcohol concentration alone. Two novel ABHRs based on 70% ethanol have been formulated to meet global efficacy standards when tested at volumes more representative of normal product use in health care environments.

Consecutive Serratia marcescens multiclone outbreaks in a neonatal intensive care unit - Corrected Proof

2012-01-24

Background: This report describes 3 consecutive outbreaks caused by genetically unrelated Serratia marcescens clones that occurred in a neonatal intensive care unit (NICU) over a 35-month period.Methods: Carriage testing in neonates and health care workers and environmental investigation were performed. An unmatched case-control study was conducted to identify risk factors for S marcescens isolation.Results: During the 35-month period, there were 57 neonates with S marcescens isolation in the NICU, including 37 carriers and 20 infected neonates. The prevalence rate of S marcescens isolation was 12.3% in outbreak 1, 47.4% in outbreak 2, and 42% in outbreak 3. Nine of the 20 infected neonates died (45% case fatality rate). A total of 10 pulsed field gel electrophoresis types were introduced in the NICU in various times; 4 of these types accounted for the 9 fatal cases. During outbreak 3, a type VIII S marcescens strain, the prevalent clinical clone during this period, was detected in the milk kitchen sink drain. Multiple logistic regression revealed that the only statistically significant factor for S marcencens isolation was the administration of total parenteral nutrition.Conclusions: Total parenteral nutrition solution might constitute a possible route for the introduction of microorganisms in the NICU. Gaps in infection control should be identified and strict measures implemented to ensure patient safety.

Appropriate time-interval application of alcohol hand gel on reducing influenza-like illness among preschool children: A randomized, controlled trial - Corrected Proof

2012-01-24

Background: We studied the efficacy of different time-interval applications of alcohol hand gel as a strategy for the prevention of influenza-like illness (ILI) in preschool-age children.Methods: We performed a classroom-based cluster randomization at a kindergarten school in Bangkok, Thailand. A total of 1437 children were placed into 3 test groups, based on the frequency of alcohol hand gel use for hand hygiene: only before lunch (q lunch), every 120 minutes (q 120), and every 60 minutes (q 60). The primary outcome was a change in the school absenteeism rate caused by ILI.Results: The rates of absenteeism from confirmed ILI (sick days/present days) were 0.026 in the q lunch group, 0.025 in the q 120 group, and 0.017 in the q 60 group. Significant reductions in absenteeism rates were seen when comparing the q 60 group with the q 120 group (rate difference, 0.009; 95% confidence interval [CI], −0.002 to 0.015; P = .008) and comparing the q 60 group with the q lunch group (rate difference, 0.0096; 95% CI, 0.004-0.016; P = .002). No such differences were detected between the q 120 and q lunch groups (rate difference, 0.001; 95% CI, 0.005-0.007; P = .743).Conclusions: The compulsory hourly use of alcohol gel as classroom hand disinfection could significantly reduce the rate of absenteeism from ILI in preschool-age children.

Survival of influenza virus on hands and fomites in community and laboratory settings - Corrected Proof

2012-01-24

Background: Transmission dynamics modeling provides a practical method for virtual evaluation of the impact of public health interventions in response to prospective influenza pandemics and also may help determine the relative contribution of different modes of transmission to overall infection rates. Accurate estimates of longevity for all forms of viral particles are needed for such models to be useful.Methods: We conducted a time course study to determine the viability and longevity of H1N1 virus on naturally contaminated hands and household surfaces of 20 individuals with laboratory-confirmed infection. Participants coughed or sneezed into their hands, which were sampled immediately and again after 5, 10, and 30 minutes. Samples also were obtained from household surfaces handled by the participants immediately after coughing/sneezing. Clinically obtained H1N1 isolates were used to assess the viability and longevity of the virus on various artificially inoculated common household surfaces and human hands in a controlled laboratory setting. Viral detection was achieved by culture and real-time reverse-transcriptase polymerase chain reaction.Results: The results suggest that H1N1 does not survive long on naturally contaminated skin and fomites, and that secretions deposited on hands by coughing or sneezing have a concentration of <2.15 × 10 to 2.94 × 10 TCID50/mL.Conclusions: These data can be used to estimate the relative contribution of direct and indirect contact transmission on overall infection rates.

A public health initiative to increase annual influenza immunization among hospital health care personnel: The San Diego Hospital Influenza Immunization Partnership - Corrected Proof

2012-01-24

Background: A public health department–supported intervention to increase influenza immunization among hospital-based health care practitioners (HCPs) in San Diego County took place between 2005 and 2008. The study included all major hospitals in the county, with a population of approximately 3.5 million.Methods: Information on hospital activities was collected from before, during and after initiative activities. Vaccination status and demographics were collected directly from HCP using hospital-based and random-dialed telephone surveys.Results: Between 2006 and 2008, hospitals increased promotion activities and reported increases in vaccination rates. Based on the random-dialed surveys, HCP influenza vaccination coverage rates did not increase significantly. Vaccination rates were significantly higher in HCPs who reported that employers provided free vaccination and those who believed that their employers mandated influenza vaccination.Conclusions: This local public health initiative and concurrent state legislation were effective in increasing employer efforts to promote influenza vaccination; however, population-based surveys of HCPs did not show significant increases in influenza vaccination. Overall, this study suggests that public health leadership, intensive employer promotion activities, and state-required declinations alone were not sufficient to significantly increase HCP influenza vaccination. Policymakers and employers should consider mandates to achieve optimal influenza vaccination among HCPs.

Use of the point of origin code from a universal billing form, UB-04, to efficiently identify hospitalized patients admitted from other health care facilities - Corrected Proof

2012-01-16

Background: Recent exposure to health care facilities is a risk factor for carriage of multidrug-resistant organisms, but identification of hospitalized patients admitted from other health care facilities is often inefficient.Methods: At an acute care hospital, we utilized a standard point of origin code from a universal billing form (UB-04) to categorize hospitalized patients as admitted from any health care facility (long-term care facility vs acute care facility). In a prospective study, the point of origin code and information obtained from physician-documented history were validated against patient self-report.Results: Admission source for 523 patients was assessed. For identifying admission from any health care facility, the point of origin code had 86% sensitivity (95% confidence interval [CI]: 77-92) and 98% specificity (95% CI: 97-99). Physician-documented history had 75% sensitivity (95% CI: 65-84) and 98% specificity (95% CI: 96-99). For identifying patients from long-term care facilities, the sensitivities of the point of origin code and physician history were 50% (95% CI: 23-77) and 71% (95% CI: 42-92), respectively. For identifying patients admitted from acute care facilities, the sensitivities of the point of origin code and physician history were 93% (95% CI: 84-98) and 76% (95% CI: 64-85), respectively.Conclusion: The point of origin code is an accurate method of identifying patients admitted from another health care facility that is comparable with physician-documented history.

Multidrug-resistant organisms in a community living facility: Tracking patient interactions and time spent in common areas - Corrected Proof

2012-01-16

Contact precautions in community living facilities (CLF) are used to reduce the transmission of multidrug-resistant organisms (MDRO). However, this policy does not address the contamination of shared spaces, devices (eg, wheelchairs), and interactions with other patients. Using a real-time surveillance system, this study examines the time MDRO-positive patients spend interacting with others in communal areas. The findings from this study may be used to tailor MDRO policies and practices to the specific needs of CLF.

Impact of clinical severity index, infective pathogens, and initial empiric antibiotic use on hospital mortality in patients with ventilator-associated pneumonia - Corrected Proof

2012-01-16

Background: The prompt initial use of appropriate antibiotics should improve mortality rates in adults with ventilator-associated pneumonia (VAP). However, the incidence of multidrug-resistant (MDR) pathogen infections is on the rise, and the choice of the initial empiric antibiotic may be challenging. We investigated whether appropriate initial antibiotic therapy, infective pathogens, and the clinical severity index influence hospital mortality in patients with VAP and determined independent risk factors for the same.Methods: This study evaluated 163 adult patients (aged ≥ 18 years) at Chang Gung Memorial Hospital, Kaohsiung, Taiwan, from January 1, 2007, to January 31, 2008. Eligibility was evaluated based on criteria for VAP. Sequential Organ Failure Assessment (SOFA) scores, Acute Physiological Assessment and Chronic Health Evaluation II (APACHE II) scores, oxygenation index, underlying comorbidities, septic shock status, previous tracheostomy status, and factors related to pneumonia were collected for analysis.Results: Ninety-two patients survived from a total 163 patients with VAP during the course of their confinement in the intensive care unit. Multivariable logistic regression analysis identified that a pre-existing Charlson Comorbidity Index score (P = .011), initial oxygenation index (P = .025), SOFA score (P = .043), VAP caused by Acinetobacter baumanii (P = .030), and infection with MDR pathogens (P = .003) were independent risk factors for hospital mortality in patients with VAP.Conclusion: High Charlson Comorbidity Index score, high initial oxygenation index, high SOFA score, and infection with Acinetobacter baumannii or MDR pathogens significantly affect hospital mortality in patients with VAP.

Investigating Jordanian nurses’ handwashing beliefs, attitudes, and compliance - Corrected Proof

Muhammad W. Darawad, Mahmoud Al-Hussami, Iyad I. Almhairat, Manal Al-Sutari — 2012-01-16

Background: Low rates of handwashing compliance among nurses are still reported in literature. Handwashing beliefs and attitudes were found to correlate and predict handwashing practices. However, such an important field is not fully explored in Jordan.Objectives: This study aims at exploring Jordanian nurses’ handwashing beliefs, attitudes, and compliance and examining the predictors of their handwashing compliance.Methods: A cross-sectional multicenter survey design was used to collect data from registered nurses and nursing assistants (N = 198) who were providing care to patients in governmental hospitals in Jordan. Data collection took place over 3 months during the period of February 2011 to April 2011 using the Handwashing Assessment Inventory.Results: Participants’ mean score of handwashing compliance was 74.29%. They showed positive attitudes but seemed to lack knowledge concerning handwashing. Analysis revealed a 5-predictor model, which accounted for 37.5% of the variance in nurses’ handwashing compliance. Nurses’ beliefs relatively had the highest prediction effects (β = .309, P < .01), followed by skin assessment (β = .290, P < .01).Conclusion: Jordanian nurses reported moderate handwashing compliance and were found to lack knowledge concerning handwashing protocols, for which education programs are recommended. This study raised the awareness regarding the importance of complying with handwashing protocols.

Evaluation of bacterial contaminants found on unused paper towels and possible postcontamination after handwashing: A pilot study - Corrected Proof

Louis McCusky Gendron, Luc Trudel, Sylvain Moineau, Caroline Duchaine — 2011-12-19

Background: Bacterial contamination is a concern in the pulp and paper industry. Not only is the machinery contaminated but also can be the end-paper products. Bacterial transmission from unused paper towels to hands and surfaces is not well documented.Methods: The culturable bacterial community of 6 different unused paper towel brands was determined by culture methods and by sequencing the 16S ribosomal DNA of bacterial contaminants. Next, we investigated the possible airborne and direct contact transmissions of these bacterial contaminants during hand drying after washing.Results: Between 102 and 105 colony-forming units per gram of unused paper towels were isolated from the different paper towel brands. Bacteria belonging to the Bacillus genus were by far the most abundant microorganisms found (83.0%), followed by Paenibacillus (15.6%), Exiguobacterium (1.6%), and Clostridium (0.01%). Paper towels made from recycled fibers harbored between 100- to 1,000-fold more bacteria than the virgin wood pulp brand. Bacteria were easily transferred to disposable nitrile gloves when drying hands with paper towels. However, no evidence of bacterial airborne transmission was observed during paper towel dispensing.Conclusion: This pilot study demonstrated that a large community of culturable bacteria, including toxin producers, can be isolated from unused paper towels and that they may be transferred to individuals after handwashing. This may have implications in some industrial and clinical settings as well as in immunocompromised individuals.

Hospital bath basins are frequently contaminated with multidrug-resistant human pathogens - Corrected Proof

2011-12-19

The hospital environment is increasingly recognized as a reservoir for hospital-acquired pathogens. During a 44-month study period, a total of 1,103 basins from 88 hospitals in the United States and Canada were sampled. Overall, 62.2% of the basins (at least 1 basin at each hospital) were contaminated with commonly encountered hospital-acquired pathogens.

Comparison of bacteria on new, disposable, laundered, and unlaundered hospital scrubs - Corrected Proof

Jeanne M. Nordstrom, Kelly A. Reynolds, Charles P. Gerba — 2011-12-19

Background: As a cost-saving measure, an increasing number of hospitals allow personnel to launder their uniforms, lab coats, and operating room scrubs at home. With rising nosocomial infection rates and increasing levels of multidrug-resistant bacteria in hospital settings, uniform contamination may be an environmental factor in the spread of infection.Methods: We quantified the number and identity of bacteria found on swatches cut from unwashed operating room, hospital-laundered, home-laundered, new cloth, and new disposable scrubs.Results: Of the 29 unwashed hospital operating room scrub swatches analyzed, 23 (79%) were positive for some type of gram-positive cocci, with 3 (10%) of those classified as Staphylococcus aureus, and 20 (69%) were positive for coliform bacteria, 3 of which were Escherichia coli. Home-laundered scrubs had a significantly higher total bacteria count than hospital-laundered scrubs (P = .016). There was no statistical difference in the bacteria counts between hospital-laundered scrubs and unused new and disposable scrubs. In the home-laundered scrubs 44% (18/41) were positive for coliform bacteria, but no isolates were Escherichia coli.Conclusions: Significantly higher bacteria counts were isolated from home-laundered scrubs and unwashed scrubs than from new, hospital-laundered, and disposable scrubs.

Real-time polymerase chain reaction testing for Clostridium difficile reduces isolation time and improves patient management in a small community hospital - Corrected Proof

Mary Catanzaro, Justin Cirone — 2011-12-08

Background: The impact of a switch from a toxin A/B enzyme immunoassay (EIA) to a polymerase chain reaction (PCR) method for detection of toxigenic Clostridium difficile was assessed for C difficile infection (CDI) rates, patient isolation-days, and CDI-related treatment.Methods: A 6-month retrospective study was done on symptomatic patients tested by the toxin A/B EIA and PCR assays. Data on the number of C difficile tests ordered, patient isolation-days, and treatment with metronidazole or vancomycin were collected. CDI rates were reported as cases per 10,000 patient-days, and differences between both groups were compared by χ2 and Z-test analysis.Results: The CDI incidence was 11.2 and 12.7/10,000 patient-days in the EIA and PCR test periods, respectively (P = .36). Health care-associated CDI decreased from 4.4 per 10,000 patient-days during EIA testing to 0.9 per 10,000 patient-days during PCR testing (P = .02). A significant decrease in patient isolation-days (P < .00001), tests ordered (P = .002), and metronidazole treatment for patients with a negative C difficile test (P = .02) was observed with PCR testing.Conclusion: PCR testing is a viable option for small community hospitals, providing accurate and timely results for patient management and infection control. This can potentially lead to improved outcomes, increased patient satisfaction, and significant hospital cost savings.

Testing of the World Health Organization recommended formulations in their application as hygienic hand rubs and proposals for increased efficacy - Corrected Proof

2011-12-02

Background: In Central Europe, alcohol-based hand rubs have been the preferred choice for hand hygiene, whereas, in other countries, other preparations have been used that are based on other active agents. Recently, a move towards alcohol-based hand rubs has begun, but they may be costly and unaffordable to some. Therefore, the World Health Organization (WHO) has recommended 2 hand rub formulations (WHO I and WHO II) for local production in health care settings where commercial products are not available or are too expensive.Objectives: WHO I, based on ethanol 80% (vol/vol), and WHO II, based on isopropanol 75% (vol/vol), were investigated for their bactericidal efficacy in their application as hygienic hand rubs.Methods: The investigation took place at the Institute for Hygiene and Applied Immunology, Medical University Vienna, Austria, as a prospective, randomized, in vivo laboratory study, comparative in crossover design. Both formulations were tested according to the European Standard EN 1500 in 2 applications (1 × 3 mL/30 seconds or 2 × 3 mL/2 × 30 seconds). Additionally, modifications with increased alcohol concentrations (weight instead of volume percent) were tested in the short application. Bactericidal efficacies were compared with those of the respective reference procedure “R,” ie, rubbing 2 × 3 mL 60% vol/vol isopropanol for 2 × 30 seconds onto hands artificially contaminated with Escherichia coli K12.Results: The short application of either WHO formulation resulted in bacterial reductions significantly inferior to the respective ones of R. However, prolonging the contact time to 60 seconds or increasing the alcohol content produced reductions similar to those of R.Conclusion: Both WHO-recommended formulations meet the efficacy requirements of EN 1500 within 60 seconds but not within 30 seconds. Increasing the respective alcohol concentrations from 80% vol/vol to 80% wt/wt and 75% vol/vol to 75% wt/wt renders the formulations sufficiently active to conform to the norm also within 30 sections.

A point prevalence survey of health care-associated infections in Canadian pediatric inpatients - Corrected Proof

2011-11-14

Background: Health care-associated infections (HAIs) cause considerable morbidity and mortality to hospitalized patients. The objective of this point prevalence study was to assess the burden of HAIs in the Canadian pediatric population, updating results reported from a similar study conducted in 2002.Methods: A point prevalence survey of pediatric inpatients was conducted in February 2009 in 30 pediatric or combined adult/pediatric hospitals. Data pertaining to one 24-hour period were collected, including information on HAIs, microorganisms isolated, antimicrobials prescribed, and use of additional (transmission based) precautions. The following prevalent infections were included: pneumonia, urinary tract infection, bloodstream infection, surgical site infection, viral respiratory infection, Clostridium difficile infection, viral gastroenteritis, and necrotizing enterocolitis.Results: One hundred eighteen patients had 1 or more HAI, corresponding to a prevalence of 8.7% (n = 118 of 1353, 95% confidence interval: 7.2-10.2). Six patients had 2 infections. Bloodstream infections were the most frequent infection in neonates (3.0%), infants (3.1%), and children (3.5%). Among all patients surveyed, 16.3% were on additional precautions, and 40.1% were on antimicrobial agents, whereas 40.7% of patients with a HAI were on additional precautions, and 89.0% were on antimicrobial agents.Conclusion: Overall prevalence of HAI in 2009 has remained similar to the prevalence reported from 2002. The unchanged prevalence of these infections nonetheless warrants continued vigilance on their prevention and control.

Nosocomial infections in a pediatric residential care facility - Corrected Proof

Amir Abdolahi, Susan G. Fisher, Carla Aquino, Hind A. Beydoun — 2011-11-07

Background: Nosocomial infections have rarely been characterized in pediatric residential care facilities. The purpose of this study is to assess the frequency of and risk factors for infectious diseases in pediatric residential care facilities over a 1-year period and to contrast them with other pediatric extended care facilities.Methods: A retrospective chart review was performed at a pediatric residential care facility dedicated exclusively to children with severe physical and mental disabilities. Incidence rates of infection were collected on a census of 109 residents from January 1 through December 31, 2009. Infectious diseases were classified using ICD-9-CM codes. PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched to identify similar studies.Results: In 2009, the overall incidence rate of infection was 6.21 per 1,000 resident-days of care, with the most frequent being streptococcal or staphylococcal skin infections (1.11 per 1,000 resident-days) and the least frequent being conjunctivitis (0.16 per 1,000 resident-days). Extensive literature reviews yielded 2 published studies that evaluated infections in pediatric extended care facilities; these studies exhibited distinct prevalences of infectious diseases when compared with the current study.Conclusion: Studies examining nosocomial infections should not consider pediatric extended care facilities as 1 single entity given the heterogeneity among these facilities.

Effectiveness of a multidimensional approach to reduce ventilator-associated pneumonia in pediatric intensive care units of 5 developing countries: International Nosocomial Infection Control Consortium findings - Corrected Proof

2011-11-04

Background: Ventilator-associated pneumonia (VAP) is one of the most common health care–associated infections in pediatric intensive care units (PICUs). Practice bundles have been shown to reduce VAP rates in PICUs in developed countries; however, the impact of a multidimensional approach, including a bundle, has not been analyzed in PICUs from developing countries.Methods: This was a before-after study to determine rates of VAP during a period of active surveillance without the implementation of the multidimensional infection control program (phase 1) to be compared with rates of VAP after implementing such a program, which included the following: bundle of infection control interventions, education, outcome surveillance, process surveillance, feedback on VAP rates, and performance feedback on infection control practices (phase 2). This study was conducted by infection control professionals applying the National Health Safety Network's definitions of health care—associated infections and the International Nosocomial Infection Control Consortium's surveillance methodology.Results: During the baseline period, we recorded a total of 5,212 mechanical ventilator (MV)-days, and during implementation of the intervention bundle, we recorded 9,894 MV-days. The VAP rate was 11.7 per 1,000 MV-days during the baseline period and 8.1 per 1,000 MV-days during the intervention period (relative risk, 0.69; 95% confidence interval, 0.5-0.96; P = .02), demonstrating a 31% reduction in VAP rate.Conclusions: Our results show that implementation of the International Nosocomial Infection Control Consortium's multidimensional program was associated with a significant reduction in VAP rate in PICUs of developing countries.

Comparison of bacterial contamination of blood conservation system and stopcock system arterial sampling lines used in critically ill patients - Corrected Proof

2011-11-04

Background: Commonly placed to monitor blood pressure and to aspirate blood, arterial lines frequently cause complications. The blood conservation system (BCS) forms a closed infusion line and may be expected to reduce complications caused by intraluminal contamination. We compared microbial contamination resulting from use of BCS and 3-way stopcock catheterization.Methods: Patients who required arterial catheterization for at least 24 hours in our intensive care unit were randomly assigned to receive an arterial pressure monitoring system either with the BCS (test group) or with a 3-way stopcock (comparator group). To evaluate arterial line contamination, we qualitatively assessed the contamination of the catheter tip and intraluminal fluid.Results: We analyzed microbial contamination for a total of 216 arterial catheters: 109 in the test group and 107 in the comparator group. We found no difference in the incidence of catheter tip colonization in the 2 groups (test group, 8/109 vs comparator group, 11/107; P = .48). There was a statistically significant correlation between catheter tip colonization and duration of arterial line utilization. We found statistically significantly lower intraluminal fluid contamination in the test group (test group, 2/109 vs comparator group, 9/107; P = .03). There was no relationship between intraluminal fluid contamination and catheter tip contamination.Conclusion: There was less microbial contamination of intraluminal fluid when BCS was used for arterial catheterization.

Nurse-directed interventions to reduce catheter-associated urinary tract infections - Corrected Proof

2011-11-03

Background: Catheter-associated urinary tract infections (CAUTIs) are common, morbid, and costly. Nearly 25% of hospitalized patients are catheterized yearly, and 10% develop urinary tract infections. Evidence-based guidelines exist for indwelling urinary catheter management but are not consistently followed.Methods: A pre/post intervention design was used in this quality improvement project to test the impact of nurse-driven interventions based on current evidence to reduce CAUTIs in hospitalized patients on 2 medical/surgical units. Interventions consisted of hospital-wide strategies including policy and product improvements and unit-specific strategies that focused on a review of current evidence to guide practice.Results: The number of catheter days decreased from 3.01 to 2.2 (P = .018) on the surgery unit and from 3.53 to 2.7 (P = .076) on the medical unit. CAUTI rates were too low to achieve significant reduction. Product cost savings were estimated at $52,000/year.Conclusion: Guidelines derived from research and other sources of evidence can successfully improve patient outcomes. Nurse-driven interventions, combined with system-wide product changes, and patient and family involvement may be effective strategies that reduce CAUTI.

Successful control of vancomycin-resistant Enterococcus faecium nosocomial outbreak in a teaching hospital in China - Corrected Proof

Yingmei Liu, Bin Cao, Li Gu, Kun Liu, Zhe Feng — 2011-10-31

In 2008, a vancomycin-resistant enterococci outbreak occurred across 2 intensive care units in our hospital. This outbreak prompted us to implement intensified control measures. We describe the molecular epidemiology of the outbreak, as well as the intervention strategies that resulted in successful control of the outbreak.

Group A rotavirus detection on environmental surfaces in a hospital intensive care unit - Corrected Proof

2011-10-24

Background: Environmental surfaces can play a role in the spread of pathogens, such as enteric viruses, within a hospital. This study assessed the level of contamination of group A rotavirus (RV-A) on environmental surfaces samples from an adult intensive care unit in a hospital in Rio de Janeiro, Brazil.Methods: A total of 504 environmental surface samples were obtained from multiple sites in the intensive care unit, including flushing buttons, telephones, and alcohol gel supports. Nested and quantitative reverse-transcriptase polymerase chain reaction (RT-PCR) were used to detect and quantify RV-A levels through partial amplification of VP6 and NSP3 genes, respectively, and the viability of the viruses detected was assessed by MA-104 cell integrated cell culture/RT-PCR.Results: RV-A was detected by nested RT-PCR in 14% of the samples (73 of 504), with viral loads ranging from 3.4 genomic copies/mL to 2.9 × 103 genomic copies/mL. The nucleotide sequence of the amplicons obtained from nested RT-PCR confirmed that the positive samples were RV-A. Moreover, 3 of 10 strains investigated demonstrated viability by integrated cell culture/RT-PCR.Conclusion: The detection of RV-A on environmental surface samples indicates a need for improvements to hospital cleaning procedures to reduce viral contamination, and suggests, as reported previously, that RV-A can be used as a biomarker to assess contamination in hospitals.

Contact Precautions for methicillin-resistant Staphylococcus aureus colonization: Costly and unnecessary? - Corrected Proof

Michael R. Spence, Tereal Dammel, Shari Courser — 2011-10-19

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is frequently encountered in health care facilities. Many hospitals have established screening programs to identify individuals harboring the organism. Patients identified as carrying MRSA are frequently placed in Contact Precautions at time of admission.Methods: Between January 1, 2007, and December 31, 2010, we screened a select group of patients for MRSA employing polymerase chain reaction testing. We recorded our screening results and also recorded the MRSA hospital-acquired infection (HAI) rate. In January 2010, we discontinued placing individuals, asymptomatically colonized with MRSA, in Contact Precautions.Results: Between January 1, 2007, and December 31, 2010, we screened 6,712 asymptomatic patients for MRSA and found 633 (9.4%) to be positive. During this same time period, we encountered 7 MRSA HAI. There was 1 MRSA HAI in the first year and 2 in each of the last 3 years of the study period. The costs incurred for Contact Precautions for the MRSA study population averaged $8,055 per year for each of the first 3 years and $0 for 2010.Conclusion: Placing patients who are asymptomatically harboring MRSA in Contact Precautions did not decrease the rate of HAI caused by this organism and was relatively expensive.

Acquisition of spores on gloved hands after contact with the skin of patients with Clostridium difficile infection and with environmental surfaces in their rooms - Corrected Proof

2011-10-10

In a prospective study of 30 patients with Clostridium difficile infection, we found that acquisition of spores on gloved hands was as likely after contact with commonly touched environmental surfaces (ie, bed rail, bedside table, telephone, call button) as after contact with commonly examined skin sites (ie, chest, abdomen, arm, hand).

Patient environment microbial burden reduction: A pilot study comparison of 2 terminal cleaning methods - Corrected Proof

2011-10-07

Effective cleaning of the patient environment has been advocated to reduce the risk for nosocomial infection. This pilot study compared 2 terminal cleaning methods, a traditional method in which a disinfectant was applied with a wetted cloth and an alternative method in which the disinfectant was applied using the PureMist system (PureCart Systems, Green Bay, WI). There was no difference in effectiveness, with a mean relative reduction of microbial burden of 84% for the traditional method versus 88% for the PureMist method.

Evaluation of screening risk and nonrisk patients for methicillin-resistant Staphylococcus aureus on admission in an acute care hospital - Corrected Proof

2011-10-03

Background: Screening for methicillin-resistant Staphylocccus aureus (MRSA) is advocated as part of control measures, but screening all patients on admission to hospital may not be cost-effective.Objective: Our objective was to evaluate the additional yield of screening all patients on admission compared with only patients with risk factors and to assess cost aspects.Methods: A prospective, nonrandomized observational study of screening nonrisk patients ≤72 hours of admission compared with only screening patients with risk factors over 3 years in a tertiary referral hospital was conducted. We also assessed the costs of screening both groups.Results: A total of 48 of 892 (5%) patients was MRSA positive; 28 of 314 (9%) during year 1, 12 of 257 (5%) during year 2, and 8 of 321 (2%) during year 3. There were significantly fewer MRSA-positive patients among nonrisk compared with MRSA-risk patients: 4 of 340 (1%) versus 44 of 552 (8%), P ≤ .0001, respectively. However, screening nonrisk patients increased the number of screening samples by 62% with a proportionate increase in the costs of screening. A backward stepwise logistic regression model identified age > 70 years, diagnosis of chronic pulmonary disease, previous MRSA infection, and admission to hospital during the previous 18 months as the most important independent predictors to discriminate between MRSA-positive and MRSA-negative patients on admission (94.3% accuracy, P < .001).Conclusion: Screening patients without risk factors increased the number of screenings and costs but resulted in few additional cases being detected. In a hospital where MRSA is endemic, targeted screening of at-risk patients on admission remains the most efficient strategy for the early identification of MRSA-positive patients.

Evaluation of contact precautions discharges in an acute care setting - Corrected Proof

Janet P. Haas, Peter Shupper, Paul Visintainer, Marisa A. Montecalvo — 2011-10-03

The health care environment is increasingly discussed as a source of health care-associated infections. We evaluated patterns of discharges among patients on contact precautions (CP) and assessed correlation of CP discharges with health care acquisition of organisms requiring CP and evaluated the feasibility of targeting CP discharges for additional monitoring.

Screening for tuberculosis among homeless shelter staff - Corrected Proof

2011-09-29

The prevalence of tuberculosis (TB) among homeless shelter staff was assessed using the tuberculin skin test (TST) and the Quantiferon TB-Gold in tube interferon-γ release assay (QFT-TB). Investigation of 51 participants for whom both QFT-TB and TST results were available showed 47.1% and 43.1% positivity, respectively, with excellent (92%) concordance between the 2 tests. The high risk for acquiring occupational TB necessitates the development of TB surveillance protocols for homeless shelter staff in Italy.

Relative frequency of health care-associated pathogens by infection site at a university hospital from 1980 to 2008 - Corrected Proof

2011-09-26

Background: We describe the relative frequency of health care-associated pathogens by infection site over 29 years using hospital-wide surveillance data from a large academic hospital.Methods: Comprehensive hospital-wide surveillance was provided by trained infection preventionists using Centers for Disease Control and Prevention definitions. Five 5-year blocks and one 4-year block were created for each site: bloodstream infections (BSI), urinary tract infections (UTI), respiratory tract infections (RTI), and surgical site infections (SSI). The blocks of relative frequency of health care-associated pathogens were compared by χ2 analysis, and trends for each pathogen were estimated by regression analysis.Results: At least 1 pathogen was isolated from 28,208 (83.5%) of 33,797 health care-associated infections (HAI). Staphylococcus aureus, coagulase-negative staphylococci (CoNS), Enterococcus species, and Clostridium difficile and other anaerobes significantly increased, whereas Escherichia coli, Pseudomonas aeruginosa, Klebsiella species, Enterobacter species, and other streptococci significantly decreased in the relative proportion of pathogens during the study period. By infection site, results showed significant increasing trends of S aureus in UTI, RTI, and SSI; CoNS in BSI and SSI; Candida in SSI; and Enterococcus in BSI and UTI.Conclusion: Significant changes in relative frequency of health care-associated pathogens by infection site occurred over the 29-year period. These findings have implications for implementation of infection prevention strategies.

Incidence and modifiable risk factors of surveillance of surgical site infections in Egypt: A prospective study - Corrected Proof

2011-09-26

Background: Surgical site infections (SSIs) contribute significantly to patient morbidity and mortality and exhaust health care system resources. The main objectives of the study were to describe the incidence rates of SSIs among patients undergoing urologic or cardiothoracic surgeries, the associated risk factors, and the common causative etiologies found at Alexandria University Hospital in Egypt.Methods: A prospective active surveillance study for patients undergoing urologic and cardiothoracic surgeries was implemented from July 2009 to December 2010. Patients were inspected daily for developing SSIs and with a 30-day postoperative follow-up. Wound swabs were obtained from patients who had clinical signs suggestive of infection. Swabs were cultured for bacterial identification and tested for antimicrobial sensitivity. Standard Centers for Disease Control and Prevention National Health Safety Network case definitions were used.Results: SSIs occurred in 187 (17%) of patients with complete follow-up (n = 1,062), of which 106 (57%) occurred in-hospital and 81 (43%) occurred after discharge. Higher SSI rates were observed in cardiothoracic surgeries (23.3%), compared with urologic surgeries (9%) (P < .001). A stepwise logistic model identified an increased risk of SSI for those who underwent cardiothoracic surgeries (odds ratio [OR], 4.7; 95% confidence interval [CI], 2.2-11.1), those aged >45 years (OR, 2.32; 95% CI, 1.35-4.01), increased duration of hospital stay before (OR, 1.03; 95% CI, 1.01-1.05) and after (OR, 1.07; 95% CI, 1.04-1.09) surgery, antibiotics ≤24 hours before surgery (OR, 2.54; 95% CI, 1.63-3.94), and dirty wounds (OR, 4.09; 95% CI, 1.60-10.43).Conclusions: Measures to reduce the high rates of SSI need to be instituted through a multidisciplinary effort including infection control education and specific SSI prevention activities at Alexandria University Hospital.

Vancomycin-resistant Enterococcus faecium outbreak caused by patient transfer in 2 separate intensive care units - Corrected Proof

2011-09-26

This report describes an outbreak involving vancomycin-resistant Enterococcus faecium colonization in 2 separate intensive care units (ICUs). Outbreak investigation including pulsed-field gel electrophoresis demonstrated that transfer of a vancomycin-resistant Enterococcus faecium colonized patient between ICUs contributed to the outbreaks that occurred simultaneously in 2 separate ICUs.

An alternative methodology for interpretation and reporting of hand hygiene compliance data - Corrected Proof

Giulio DiDiodato — 2011-09-26

Background: Since 2009, all hospitals in Ontario have been mandated to publicly report health care provider compliance with hand hygiene opportunities (http://www.health.gov.on.ca/patient_safety/index.html). Hand hygiene compliance (HHC) is reported for 2 of the 4 moments during the health care provider-patient encounter. This study analyzes the HHC data by using an alternative methodology for interpretation and reporting.Methods: Annualized HHC data were available for fiscal years 2009 and 2010 for each of the 5 hospital corporations (6 sites) in the North Simcoe Muskoka Local Health Integration Network. The weighted average for HHC was used to estimate the overall observed rate for HHC for each hospital and reporting period. Using Bayes' probability theorem, this estimate was used to predict the probability that any patient would experience HHC for at least 75% of hand hygiene moments. This probability was categorized as excellent (≥75%), above average (50%-74%), below average (25%-49%), or poor (<25%). The results were reported using a balanced scorecard display.Results: The overall observed rates for HHC ranged from 50% to 87% (mean, 75% ± 11%, P = .079). Using the alternative methodology for reporting, 6 of the 12 reporting periods would be categorized as excellent, 1 as above average, 2 as below average, and 3 as poor.Conclusion: Population-level HHC data can be converted to patient-level risk information. Reporting this information to the public may increase the value and understandability of this patient safety indicator.

Eight initiatives that misleadingly lower ventilator-associated pneumonia rates - Corrected Proof

Michael Klompas — 2011-09-26

Hospitals are likely to re-examine their ventilator-associated pneumonia (VAP) prevention and surveillance programs in the coming months in light of The Joint Commission's proposal to make VAP prevention a National Patient Safety Goal for 2012. Ideally, the Commission's proposal will trigger broader and more rigorous VAP prevention efforts nationwide. There is some risk, however, that efforts to enhance the rigor of VAP surveillance may undermine some of the momentum for prevention. This is because increasing the rigor of surveillance almost inevitably lowers VAP rates in and of itself despite being independent of patient care. These misleading decreases in VAP rates may lull hospitals into a false sense of complacency that could undermine motivation to enhance prevention. We describe 8 initiatives that well-intentioned hospitals might be considering to make VAP surveillance more rigorous. Each of these initiatives will lower apparent VAP rates despite not materially improving patient care.

Pilot study to measure cleaning effectiveness in health care - Corrected Proof

Elizabeth E. Gillespie, Carmel Scott, Jill Wilson, Rhonda Stuart — 2011-09-22

Environmental surfaces are likely to contribute to the transmission of health care–associated pathogens. The present study aimed to determine the most effective regimen or product for removing bioburden. An adenosine triphosphate assessment technique was used to compare cleaning methods and products for removing bioburden from soiled surfaces. Of the regimens or products tested, 2-step cleaning most thoroughly removed bioburden. The 2-in-1 products were no more effective in removing bioburden than a 1-step clean using a neutral detergent.

Prospective audit for antimicrobial stewardship in intensive care: Impact on resistance and clinical outcomes - Corrected Proof

Carlos A. DiazGranados — 2011-09-22

Background: The impact of antimicrobial audit and feedback on outcomes of critically ill adults is unclear.Methods: A prospective study was performed in the intensive care units (ICU) of a public hospital in Atlanta, GA. Critically ill adults receiving empiric imipenem or piperacillin-tazobactam were eligible. Outcomes for 3 periods were compared: baseline (B, February to May 2006), model 1 (M1, October 2006 to July 2008), and model 2 (M2, September 2008 to February 2009). No audit was performed during B. During M1, an infectious diseases physician evaluated patients, and a critical care pharmacist communicated recommendations to the treating team. During M2, an infectious diseases physician directly participated in interdisciplinary rounds with the medical ICU team.Results: One hundred ninety-four patients were included during B, 415 during M1, and 83 during M2. M1 and M2 were associated with appropriate antimicrobial selection (B, 70%; M1, 78%; M2, 82%; P = .042) and with lower rates of resistance (B, 31%; M1, 25%; M2, 17%; P = .033). Logistic regression analysis confirmed that audit and feedback were independently associated with appropriate antimicrobial selection and prevention of resistance. The association remained strongest for M2.Conclusion: Audit and feedback had an influence on antimicrobial prescription patterns in the ICU with a favorable impact on the emergence of resistance.

Diagnostic accuracy of surveillance cultures to detect gastrointestinal colonization with multidrug-resistant gram-negative bacteria - Corrected Proof

Graham M. Snyder, Erika M.C. D’Agata — 2011-09-20

To quantify the sensitivity of surveillance cultures for the detection of multidrug-resistant gram-negative (MDRGN) bacteria, perianal/rectal swabs were collected from patients with positive clinical cultures for MDRGN species. Surveillance cultures identified colonization with the same genetically related MDRGN species in 29 of 37 MDRGN clinical culture isolates (78%). There was a trend toward less antimicrobial exposure among patients with false-negative surveillance culture results (P = .06).

Effectiveness of an audible reminder on hand hygiene adherence - Corrected Proof

Morkos Fakhry, George B. Hanna, Oliver Anderson, Alison Holmes, Dinesh Nathwani — 2011-09-16

Background: Multimodal interventions aim to improve health care workers’ adherence to hand hygiene guidelines. Visitors are not primarily targeted, but may spread epidemic infections. Effective interventions that improve the adherence of visitors to hand hygiene guidelines are needed to prevent the transmission of epidemic infections to or from health care environments.Methods: An electronic motion sensor–triggered audible hand hygiene reminder was installed at hospital ward entrances. An 8-month preinterventional and postinterventional study was carried out to measure the adherence of hospital visitors and staff to hand hygiene guidelines.Results: Overall hand hygiene adherence increased from 7.6% to 49.9% (P < .001). The adherence of visitors and nonclinical staff increased immediately from 10.6% to 63.7% and from 5.3% to 34.8%, respectively (P < .001). Adherence of doctors, nurses, and physiotherapists increased gradually from 4.5% to 38.3%, from 5.4% to 43.4%, and from 8.7% to 49.5%, respectively (P < .001). Improved adherence was sustained among visitors and clinical staff (P < .001), but not among nonclinical staff (P = .341).Conclusions: The electronic motion sensor–triggered audible reminder immediately and significantly improved and sustained greater adherence of hospital visitors and clinical staff to hand hygiene guidelines. This is an effective addition to multimodal hand hygiene interventions and may help control epidemic infections.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 36 countries, for 2004-2009 - Corrected Proof

2011-09-12

The results of a surveillance study conducted by the International Nosocomial Infection Control Consortium (INICC) from January 2004 through December 2009 in 422 intensive care units (ICUs) of 36 countries in Latin America, Asia, Africa, and Europe are reported. During the 6-year study period, using Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN; formerly the National Nosocomial Infection Surveillance system [NNIS]) definitions for device-associated health care-associated infections, we gathered prospective data from 313,008 patients hospitalized in the consortium’s ICUs for an aggregate of 2,194,897 ICU bed-days. Despite the fact that the use of devices in the developing countries’ ICUs was remarkably similar to that reported in US ICUs in the CDC’s NHSN, rates of device-associated nosocomial infection were significantly higher in the ICUs of the INICC hospitals; the pooled rate of central line-associated bloodstream infection in the INICC ICUs of 6.8 per 1,000 central line-days was more than 3-fold higher than the 2.0 per 1,000 central line-days reported in comparable US ICUs. The overall rate of ventilator-associated pneumonia also was far higher (15.8 vs 3.3 per 1,000 ventilator-days), as was the rate of catheter-associated urinary tract infection (6.3 vs. 3.3 per 1,000 catheter-days). Notably, the frequencies of resistance of Pseudomonas aeruginosa isolates to imipenem (47.2% vs 23.0%), Klebsiella pneumoniae isolates to ceftazidime (76.3% vs 27.1%), Escherichia coli isolates to ceftazidime (66.7% vs 8.1%), Staphylococcus aureus isolates to methicillin (84.4% vs 56.8%), were also higher in the consortium’s ICUs, and the crude unadjusted excess mortalities of device-related infections ranged from 7.3% (for catheter-associated urinary tract infection) to 15.2% (for ventilator-associated pneumonia).

Risk of rabies transmission and adverse effects of postexposure prophylaxis in health care workers exposed to a fatal case of human rabies - Corrected Proof

2011-09-12

On May 27, 2008, a patient died from rabies at the Cayenne Hospital in French Guiana. Postexposure prophylaxis vaccination was implemented for all health care workers exposed to this patient. Examining the management of such a rare risk reveals important factors in the education of personnel who may have contact with a patient with rabies, to permit appropriate risk assessment and reduce unnecessary postexposure prophylaxis, taking into account the risks and costs of adverse events.

Risk factors for developing clinical infection with carbapenem-resistant Klebsiella pneumoniae in hospital patients initially only colonized with carbapenem-resistant K pneumoniae - Corrected Proof

2011-09-12

Background: This study examined predictors of carbapenem-resistant Klebsiella pneumoniae (CRKP) colonization and risk factors for the development of CRKP infection in patients initially only colonized with CRKP.Methods: A total of 464 patients with CRKP rectal colonization (CRKP-RC) were identified. Two case-control studies were performed, one comparing risk factors for CRKP-RC in patients who did not develop CRKP infection (CRKP-IN) versus patients without CRKP-RC and CRKP-IN, and the other comparing CRKP-RC patients who did not develop CRKP-IN with those who did.Results: Forty-two of the 464 colonized patients developed CRKP-IN. Multivariate analysis identified the following predictors for CRKP-RC: antibiotic therapy (odds ratio [OR], 5.76; P ≤ .0001), aminopenicillin therapy (OR, 7.753; P = .004), bedridden (OR, 3.09; P = .021), and nursing home residency (OR, 3.09; P = .013). Risk factors for CRKP-IN in initially CRKP-RC–positive patients were previous invasive procedure (OR, 5.737; P = .021), diabetes mellitus (OR, 4.362; P = .017), solid tumor (OR, 3.422; P = .025), tracheostomy (OR, 4.978; P = .042), urinary catheter insertion (OR, 4.696; P = .037), and antipseudomonal penicillin (OR, 23.09; P ≤ .0001).Conclusions: We suggest that in patients with CRKP-RC, a strategy for preventing CRKP-IN might include limiting antipseudomonal penicillin and carbapenem use and preventing infections by closely following compliance with infection control bundles.

Long-term care facilities in Utah: A description of human and information technology resources applied to infection control practice - Corrected Proof

Makoto Jones, Matthew H. Samore, Marjorie Carter, Michael A. Rubin — 2011-09-12

Background: Little is known about the implementation of infection control (IC) programs and information technology (IT) infrastructure in long-term care facilities (LTCFs). We assessed the IC human resources, IT infrastructure, and IC scope of practice at LTCFs in Utah.Methods: All LTCFs throughout Utah (n = 80) were invited to complete a written survey in 2005 regarding IC staffing, policies and practices, and IT infrastructure and capacity.Results: Responses were received from 62 facilities (77.5%). Most infection preventionists (IPs) were registered nurses (71%) with on-the-job training (81.7%). Most had other duties besides their IC work (93.5%), which took up the majority of their time. Most facilities provided desktop computers (96.8%) and all provided Internet access, but some of the infrastructure was not current. A minority (14.5%) used sophisticated software packages to support their IC activities. Less than 20% of the facilities had integrated radiology, diagnostic laboratory, or microbiology data with their facility computer system. The Internet was used primarily as a reference tool (77.4%). Most IPs reported taking responsibility for routine surveillance and monitoring tasks, but a substantial number did not perform all queried tasks. They may have difficulty with feedback of specific unit and physician infection rates (43.2% and 67.7%, respectively).Conclusions: Our findings underscore what has previously been reported about LTCFs’ IC human resources and IP scope of practice. We also found that some IT infrastructure was outdated, and that existing resources were underutilized for IC purposes.

Preventive strategies for central line–associated bloodstream infections in pediatric hematopoietic stem cell transplant recipients - Corrected Proof

2011-09-12

Background: Few studies have described preventive strategies for central line–associated bloodstream infections (CLABSIs) in pediatric hematopoietic stem cell transplantation (HSCT) recipients.Methods: We performed a pilot intervention study in our pediatric HSCT population in 2006-2008 and compared CLABSI rates before and after implementation of preventive strategies (ie, training staff and caregivers in procedures for dressing changes and drawing blood) in the inpatient, outpatient, and non–health care (ie, home) settings. We also studied the pathogens associated with hospital-onset versus community-onset CLABSIs.Results: During the study period, 90 children (median age, 10 years) underwent HSCT. Fifty-nine children (66%) developed a CLABSI; 18 in the hospital, 27 in the community, and 14 in both settings. After implementation of central line (CL) maintenance care strategies, the overall CLABSI rate declined from 10.03 to 3.00 CLABSIs per 1,000 CL-days (rate ratio, 0.3; 95% confidence interval, 0.2-0.5, P < .0001) and rates declined for both hospital- and community-onset CLABSIs. Gram negative pathogens caused more community-onset (45/65, 69%) than hospital-onset (22/46, 48%) CLABSIs (odds ratio, 2.5; 95% confidence interval, 1.1-5.4; P = .02).Conclusions: Standardization of care practices for CL maintenance was associated with a reduction of CLABSIs in our pediatric HSCT population. A multicenter study is needed to confirm these observations.

A multifaceted pilot program to promote hand hygiene at a suburban fire department - Corrected Proof

Christine McGuire-Wolfe, Donna Haiduven, C. Duncan Hitchcock — 2011-09-12

Background: Firefighters (FFs) and Emergency Medical Services (EMS) personnel provide care in uncontrolled settings, where the risk of hand contamination is great and opportunities for handwashing are few. Knowledge, attitudes, and beliefs about hand hygiene in this group have not been well reported.Methods: Written surveys were administered to FFs and EMS personnel to assess their practices, attitudes, and beliefs before and after installation of alcohol hand gel dispensers, hanging of reminder posters, and completion of PowerPoint training.Results: A majority of the participants (n = 131; 58.5%) indicated they had not received any training on hand hygiene from the fire department before the intervention. Responses to Likert scale questions about attitudes, practices, and beliefs regarding handwashing did not reveal any statistically significant differences between preintervention and postintervention surveys; however, responses to direct questions about the impact of the intervention were more promising.Conclusions: Implementation and evaluation of an intervention to target groups of EMS personnel and FFs can guide future efforts to improve hand hygiene practices in this distinctive group.

Epidemiology of respiratory viruses in children admitted to an infant/toddler unit - Corrected Proof

Aaron M. Milstone, Trish M. Perl, Alexandra Valsamakis — 2011-09-12

This study examined the prevalence of common respiratory viruses in an infant/toddler cohort tested as part of a comprehensive strategy to prevent nosocomial respiratory virus transmission and measured the unrecognized reservoir of viruses in children without common respiratory virus symptoms.