AJIC: American Journal of Infection Control - Articles in Press

Clinical and economic outcomes from a community hospital's antimicrobial stewardship program - Corrected Proof

2012-05-14

Background: Data from community antimicrobial stewardship programs (ASPs) are limited. We describe clinical and economic outcomes from the first year of our hospital's ASP.Methods: The ASP team comprised 2 infectious disease physicians and 3 intensive care unit pharmacists. The team prospectively audited the new starts and weekly use of 8 target antimicrobials: aztreonam, caspofungin, daptomycin, ertapenem, linezolid, meropenem, tigecycline, and voriconazole. Using administrative data, outcomes from the first year of the program, including death within 30 days of hospitalization, readmission within 30 days of discharge, and development of Clostridium difficile infection (CDI), were compared with outcomes from a similar period before institution of the program.Results: A total of 510 antimicrobial orders were reviewed, of which 323 (63%) were appropriate, 94 (18%) prompted deescalation, 61 (12%) were denied, and 27 (5%) led to formal consultation with an infectious disease physician. On multivariate analysis, implementation of the ASP was associated with an approximate 50% reduction in the odds of developing CDI (odds ratio, 0.46; 95% confidence interval, 0.25-0.82). The ASP was not associated with decreased mortality at 30 days after discharge or readmission rate. The antimicrobial cost per patient-day decreased by 13.3%, from $10.16 to $8.81. The antimicrobial budget decreased by 15.2%, resulting in a total savings of $228,911. There was a 25.4% decrease in defined daily doses of the target antimicrobials.Conclusions: Implementation of the ASP was associated with significant reductions in CDI rate, antimicrobial use, and pharmacy costs.

Impact of the 2009 influenza A (H1N1) pandemic on Canadian health care workers: A survey on vaccination, illness, absenteeism, and personal protective equipment - Corrected Proof

2012-05-11

Background: Data are limited on the impact of the 2009 H1N1 influenza A pandemic on health care worker (HCW) vaccination, illness, absenteeism, and personal protective equipment (PPE) use.Methods: A survey was completed by HCWs from 14 hospitals participating in the Canadian Nosocomial Infection Surveillance Program who provided direct care to patients with pH1N1 influenza in high-risk units between September and December 2009.Results: Surveys were returned from 986 HCWs (80% nurses, 14% respiratory therapists, and 6% physicians). HCWs working in an intensive care unit (78%) or a designated influenza ward (67%) were more compliant with wearing an N95 respirator for aerosol-generating medical procedures than those working in an emergency department (47%; P < .001). HCWs who worked in health care for >11 years were more compliant with wearing protective eyewear than those who worked for ≤11 years (69% vs 54%; P < .001). A total of 815 HCWs (83%) reported having received the pH1N1 influenza vaccine, and 372 (38%) reported having received the 2009-2010 seasonal influenza vaccine. Influenza-like illness was reported by 236 (24%) HCWs, 170 of whom (72%) reported missing work.Conclusions: Experience working in health care improves PPE use and HCWs in emergency departments should be targeted for interventions to improve PPE compliance. pH1N1 influenza vaccine coverage was high, but seasonal influenza vaccine coverage was low, and significant HCW illness and absenteeism were reported.

Impact of alcohol-impregnated port protectors and needleless neutral pressure connectors on central line–associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit - Corrected Proof

Michael A. Sweet, Aaron Cumpston, Frank Briggs, Michael Craig, Mehdi Hamadani — 2012-05-10

Background: A major risk factor for the development of bloodstream infection is the presence of a central venous catheter (CVC), especially in immunocompromised patients. CVC hub contamination is a risk factor for central line–associated bloodstream infection (CLABSI).Methods: This observational before–after trial in a tertiary care hospital's oncology unit included adult patients with a CVC. During the intervention period, the practice of central line hub care was changed from cleaning with alcohol wipes to using alcohol-impregnated port protectors. To accommodate the protectors, the needless hubs were changed to a neutral pressure connector. The intervention period (January-July 2010) was compared with a historical control (January-December 2009).Results: A total of 3,005 central line-days and 1 CLABSI (a rate of 0.3 infections/1,000 central line-days) were documented during the intervention period, compared with 6,851 central line-days and 16 CLABSIs (2.3 infections/1,000 central line-days) during the control period (relative risk, 0.14; 95% confidence interval [CI], 0.02-1.07; P = .03). The rate of contaminated blood cultures (CBCs) from central lines was 2.5% (17 of 692) during the control period, but only 0.2% (1 of 470) during the intervention period (relative risk, 0.09; 95% CI, 0.01-0.65; P = .002).Conclusions: The implementation of alcohol-impregnated port protectors and needleless neutral pressure connectors significantly reduced the rates of CLABSIs and CBCs in our oncology patient population.

Absence of Clostridium difficile in asymptomatic hospital staff - Corrected Proof

2012-05-09

Clostridium difficile is considered a leading cause of hospital-acquired diarrhea. To evaluate the prevalence of asymptomatic C difficile stool carriage among hospital staff, we tested stool samples from 112 volunteers for toxigenic C difficile.

Bacterial burden in the operating room: Impact of airflow systems - Corrected Proof

2012-04-30

Background: Wound infections present one of the most prevalent and frequent complications associated with surgical procedures. This study analyzes the impact of currently used ventilation systems in the operating room to reduce bacterial contamination during surgical procedures.Methods: Four ventilation systems (window-based ventilation, supported air nozzle canopy, low-turbulence displacement airflow, and low-turbulence displacement airflow with flow stabilizer) were analyzed. Two hundred seventy-seven surgical procedures in 6 operating rooms of 5 different hospitals were analyzed for this study.Results: Window-based ventilation showed the highest intraoperative contamination (13.3 colony-forming units [CFU]/h) followed by supported air nozzle canopy (6.4 CFU/h; P = .001 vs window-based ventilation) and low-turbulence displacement airflow (3.4 and 0.8 CFU/h; P < .001 vs window-based ventilation and supported air nozzle canopy). The highest protection was provided by the low-turbulence displacement airflow with flow stabilizer (0.7 CFU/h), which showed a highly significant difference compared with the best supported air nozzle canopy theatre (3.9 CFU/h; P < .001). Furthermore, this system showed no increase of contamination in prolonged durations of surgical procedures.Conclusion: This study shows that intraoperative contamination can be significantly reduced by the use of adequate ventilation systems.

Distribution of outbreak reporting in health care institutions by day of the week - Corrected Proof

2012-04-16

Background: The notion that outbreaks are more likely to occur on Friday is prevalent among staff in health care institutions. However, there is little evidence to support or discredit this notion. We postulated that outbreaks were no more likely to be reported on any particular day of the week.Methods: A total of 901 institutional outbreaks in Toronto health care facilities were tabulated according to type, outbreak setting, and day of the week reported. A χ2 goodness-of-fit test compared daily values for 7-day per week and 5-day per week periods. Post hoc partitioning was used to pinpoint specific day(s) of the week that differed significantly.Results: Fewer outbreaks were reported on Saturdays and Sundays. Further analysis examined the distribution of outbreak reporting specifically focusing on the Monday to Friday weekday period. Among the weekdays, higher proportions of outbreaks were reported on Mondays and Fridays.Conclusion: Our null hypothesis was rejected. Overall, Mondays and Fridays had the highest occurrence of outbreak reporting. We suggest that this might be due to “deadline” and “catch-up” reporting related to the “weekend effect,” whereby structural differences in weekend staffing affect detection of outbreaks. Such delays warrant reexamination of surveillance processes for timely outbreak detection independent of calendar cycle.

Respiratory hygiene in emergency departments: Compliance, beliefs, and perceptions - Corrected Proof

2012-04-16

Background: Low respiratory hygiene compliance among health care workers of emergency departments has become a major concern in the spread of respiratory infections. Our objective was to determine the compliance with respiratory hygiene of triage nurses at 2 university hospital centers and to identify factors influencing compliance to the respiratory hygiene principles of emergency health care workers.Methods: A 2-part, cross-sectional, descriptive study was conducted at 2 training centers. An anonymous observation of compliance with respiratory hygiene by triage emergency nurses was performed. A self-administered, voluntary questionnaire on attitudes, perceptions, and knowledge of respiratory hygiene guidelines was distributed to the health care workers at the emergency department of the 2 hospital sites.Results: Median objective compliance with respiratory hygiene measures of triage nurses was 22% (interquartile range [IQR], 11%-33%). Median perceived compliance of the health care workers was 68% (IQR, 61%-79%). Median actual knowledge score was 75% (IQR, 75%-100%). Overall, 91.9% of respondents believed that the mask was an effective preventive measure. The main obstacles toward mask wearing by the health care worker were “tendency to forget” (37.8%) and “discomfort” (35.1%).Conclusion: The compliance rate at our institution is very low. We identified a few factors affecting adherence to respiratory hygiene measures that are of potential use in targeting groups and formulating recommendations.

A pilot study on the use of geometrically accurate face models to replicate ex vivo N95 mask fit - Corrected Proof

Laleh Golshahi, Karla Telidetzki, Ben King, Diana Shaw, Warren H. Finlay — 2012-04-16

To test the feasibility of replicating a face mask seal in vitro, we created 5 geometrically accurate reconstructions of the head and neck of an adult human subject using different materials. Three breathing patterns were simulated with each replica and an attached N95 mask. Quantitative fit testing on the subject and the replicas showed that none of the 5 isotropic materials used allowed duplication of the ex vivo mask seal for the specific mask–face combination studied.

Risk factors for vancomycin-resistant enterococci infection and mortality in colonized patients on intensive care unit admission - Corrected Proof

2012-04-09

This study examined the incidence of and risk factors for development of vancomycin-resistant enterococci (VRE) infection and death in VRE-colonized patients in a medical intensive care unit. VRE colonization was identified in 184 patients (17.6%) in whom VRE perianal swab cultures were obtained. Of these, 28 (11.9%) developed VRE infection. Control of infectious sources is crucial to decrease development of VRE infections and optimize the survival of VRE-colonized patients.

Performance evaluation of filtering facepiece respirators using virus aerosols - Corrected Proof

Zhili Zuo, Thomas H. Kuehn, David Y.H. Pui — 2012-04-09

Physical penetration and infectivity penetration of adenovirus and influenza virus aerosols through respirators were measured to better characterize the effectiveness of filtering facepiece respirators against airborne virus. A physical penetration of 2%-5% was found. However, large sample-to-sample variation made it difficult to quantify the difference in physical penetration caused by the different virus aerosols. Infectivity penetration of adenovirus was much lower than physical penetration, indicating that the latter provides a conservative estimate for respirator performance.

Polymerase chain reaction testing for Clostridium difficile - Corrected Proof

Mary Catanzaro, Justin Cirone — 2012-04-05

We believe the conclusion that polymerase chain reaction detection of toxigenic Clostridium difficile is viable for a small community hospital is accurate because it was successfully implemented in our setting and resulted in benefits including decreased length of stay in isolation, tests ordered, and empiric antimicrobial therapy. We acknowledge that a formal cost analysis was beyond the scope of the study and, therefore, that our results may not be generalized to all small community hospitals.

Predictors of stethoscope disinfection among pediatric health care providers - Corrected Proof

2012-04-05

Background: Stethoscopes are contaminated with bacteria, but predictors of stethoscope disinfection frequency are unknown. We sought to describe health care provider stethoscope disinfection attitudes and practices and determine predictors of frequent disinfection.Methods: We used an anonymous online survey of nurses, nurse practitioners, and physicians at a pediatric hospital. We assessed frequency and methods of disinfection, perceptions of contamination, and barriers to disinfection. Multivariate logistic regression models were used to identify independent predictors of disinfecting after every use.Results: One thousand four hundred one respondents completed the survey: 76% believed that infection transmission occurs via stethoscopes, but only 24% reported disinfecting after every use. In multivariate analyses, belief that infection transmission occurs via stethoscopes significantly increased the odds of disinfection after every use (odds ratio [OR], 2.06 [95% confidence interval (CI): 1.38-3.06]). The odds of disinfection after every use were significantly decreased in those who perceived the following barriers: lack of time (OR, 0.31 [95% CI: 0.18-0.54]), lack of access to disinfection material (OR, 0.41 [95% CI: 0.29-0.57]), or lack of visual reminders to disinfect (OR, 0.22 [95% CI: 0.14-0.34]).Conclusion: Only a minority of pediatric health care providers reported disinfecting their stethoscopes after every use. Increasing access to disinfection materials and visual reminders in health care facilities may improve stethoscope disinfection practices.

Behind the mask: Determinants of nurse's adherence to facial protective equipment - Corrected Proof

2012-04-05

Background: As the predominant occupation in the health sector and as the health worker with the most patient interaction, nurses are at high risk for occupational transmission of communicable respiratory illness. The use of facial protective equipment (FPE) is an important strategy to prevent occupational transmission.Methods: A 2-phased study was conducted to examine nurse's adherence to recommended use of FPE. Phase 1 was a cross-sectional survey of nurses in selected units of 6 acute care hospitals in Toronto, Canada. Phase 2 was a direct observational study of critical care nurses.Results: Of the 1,074 nurses who completed surveys (82% response rate), 44% reported adherence to recommended use of FPE. Multivariable analysis revealed 6 predictors of adherence: unit type, frequency of equipment use, equipment availability, training, organizational support, and communication. Following the survey, 100 observations in 14 intensive care units were conducted that revealed a 44% competence rate with proper use of N95 respirators and knowledge as a significant predictor of competence.Conclusion: Whereas increasing knowledge should enhance competence, strategies to improve adherence to recommended use of FPE in a busy and complex health care setting should focus on ready availability of equipment, training and fit testing, organizational support for worker health and safety, and good communication practices.

Determinants of personal and household hygiene among college students in New York City, 2011 - Corrected Proof

2012-04-01

Background: Although several studies have characterized the hygiene habits of college students, few have assessed the determinants underlying such behaviors.Objectives: Our study sought to describe students’ knowledge, practices, and beliefs about hygiene and determine whether there is an association between reported behaviors and frequency of illness.Methods: A sample of 299 undergraduate students completed a questionnaire assessing demographics, personal and household hygiene behaviors, beliefs and knowledge about hygiene, and general health status.Results: Variation in reported hygiene habits was noted across several demographic factors. Women reported “always” washing their hands after using the toilet (87.1%) more than men (65.3%, P = .001). Similarly, freshmen reported such behavior (80.4%) more than sophomores (71.9%), juniors (67.7%), or seniors (50%, P = .011). Whereas 96.6% of participants thought that handwashing was either “very important” or “somewhat important” for preventing disease, smaller proportions thought it could prevent upper respiratory infections (85.1%) or gastroenteritis (48.3%), specifically. There was no significant relationship between reported behaviors and self-reported health status.Conclusion: The hygiene habits of college students may be motivated by perceptions of socially acceptable behavior rather than scientific knowledge. Interventions targeting the social norms of incoming and continuing students may be effective in improving hygiene determinants and ultimately hygiene practices.

Seasonal and H1N1 influenza vaccine compliance and intent to be vaccinated among emergency medical services personnel - Corrected Proof

2012-04-01

Background: Only limited data are available on emergency medical technicians’ (EMT) influenza vaccination compliance.Methods: A questionnaire was administered to St Louis EMTs during March to June 2011 to assess compliance with the 2010/2011 and 2009/2010 seasonal and pandemic H1N1 influenza vaccinations, factors that predicted uptake of 2010/2011 seasonal influenza vaccine, and intent to be vaccinated.Results: In all, 265 EMTs participated. EMTs’ attitudes and beliefs toward influenza vaccines differed significantly when comparing vaccinated to nonvaccinated EMTs. EMTs whose employer had a mandatory vaccination policy were significantly more likely to receive the seasonal influenza vaccine (100% vs 75.6%, respectively) or the H1N1 vaccine (100% vs 66.8%, respectively) compared with those without such a policy (χ2 = 8.8, P < .001 and χ2 = 6.7, P < .01, respectively). In logistic regression controlling for demographics, determinants of 2010/2011 seasonal influenza vaccination included belief that EMTs should be vaccinated every year, perceived importance of vaccination, perception that influenza vaccine has few adverse effects, and past vaccine-seeking behavior. In logistic regression controlling for demographics, determinants of intent to be vaccinated included having the vaccine available on-site and free of charge and belief that EMTs should be vaccinated every year.Conclusion: EMT-targeted interventions should be used to increase vaccine compliance, including implementing a mandatory vaccination policy and addressing EMTs’ beliefs and attitudes about vaccine in an education campaign.

Hospital privacy curtains are frequently and rapidly contaminated with potentially pathogenic bacteria - Corrected Proof

2012-04-01

Background: Privacy curtains are a potentially important site of bacterial contamination in hospitals. We performed a longitudinal study to determine the prevalence and time course of bacterial contamination on privacy curtains.Methods: Over a 3-week period, swab cultures (n = 180) were obtained twice weekly from the leading edge of 43 curtains in 30 rooms in 2 intensive care units and a medical ward. Curtains were marked to determine when they were changed. Contamination with Staphylococcus aureus, methicillin-resistant S aureus (MRSA), Enterococcus spp, vancomycin-resistant enterococcus (VRE), or aerobic gram-negative rods was determined by standard microbiologic methods. To distinguish persistence of pathogens on curtains from recontamination, all VRE and MRSA were typed using pulsed-field gel electrophoresis.Results: Twelve of 13 curtains (92%) placed during the study showed contamination within 1 week. Forty-one of 43 curtains (95%) demonstrated contamination on at least 1 occasion, including 21% with MRSA and 42% with VRE. Eight curtains yielded VRE at multiple time points: 3 with persistence of a single isolate type and 5 with different types, suggesting frequent recontamination.Conclusion: Privacy curtains are rapidly contaminated with potentially pathogenic bacteria. Further studies should investigate the role of privacy curtains in pathogen transmission and provide interventions to reduce curtain contamination.

Polymerase chain reaction testing for Clostridium difficile - Corrected Proof

Beuy Joob, Viroj Wiwanitkit — 2012-03-30

The publication in testing for Clostridium difficile is very interesting. Catanzaro and Cirone concluded that “PCR testing is a viable option for small community hospitals, providing accurate and timely results for patient management and infection control.” This conclusion might or might not be correct. It is no doubt that polymerase chain reaction (PCR) testing can reduce the turnaround time, but its cost is very high compared with standard testing. Based on this testing, there is no cost identification, and there is also no cost-utility analysis. Although there is no previous medical economic analysis on PCR testing for C difficile, a recent publication showed that it is still doubtful that PCR testing for Clostridium perfringens in disease control is cost-effective.

Oseltamivir adherence and tolerability in health care workers treated prophylactically after occupational influenza exposure - Corrected Proof

Lydia M. Upjohn, Andrew J. Stewardson, Caroline Marshall — 2012-03-23

This survey of health care workers who were prescribed oseltamivir prophylaxis after occupational exposure to 2009 pandemic influenza A (H1N1) documents their adherence, adverse effects, development of influenza-like illness, and knowledge and beliefs about the treatment and transmission of influenza. Adverse effects occurred in 15 of 36 participants evaluated (41.6%). The majority of the participants understood that influenza is highly infective and would take oseltamivir again, although 40.5% (15 of 37) thought they had not been given sufficient information about adverse effects.

Compliance with hand hygiene and glove change in a general hospital, Mashhad, Iran: An observational study - Corrected Proof

HamidReza Naderi, Fereshte Sheybani, Irandokht Mostafavi, Nasrin Khosravi — 2012-03-23

Background: Hand hygiene is the single most important element of strategies to prevent health care-associated infections. However, handwashing rates among health care workers have ranged from 9% to 50%. This observation took place as a structured, overt strategy to assess the hospital staff’s hand hygiene compliance. The study was carried out in Imam Reza General Hospital, Mashhad, Iran.Methods: All hospital staff, including physicians, nurses, and unlicensed assistive personnel in 4 randomly selected wards, were observed by 2 infection control nurse specialists for 5 observation periods on each ward. The observation was overt, and observers compiled data by filling out 2 checklists. All staff knew that they were being observed, and the observers made no interventions.Results: The overall compliance with hand hygiene activities was 47.9% (438 episodes out of 913 potential opportunities) and, with sole emphasis on handwashing, was only 8.5%.Conclusion: Inappropriate glove use might be a component of poor hand hygiene compliance. Training campaigns should be implanted for health care personnel and all hospital staff to re-emphasize the importance of adherence to hand hygiene protocols.

Designing a protocol to reduce catheter-associated urinary tract infections among hospitalized patients - Corrected Proof

2012-03-23

Hospital-acquired urinary tract infections comprise 40% of hospital-acquired infections with over 80% of these hospital-acquired urinary tract infections associated with the use of urinary catheters. The process that was used to establish a new hospital protocol using the “IAIMS” (identifying, assessing, implementing, modifying/maintaining, spread/surveillance) model to reduce the incidence of catheter-associated urinary tract infections is described. The example is intended to serve as a framework for the development of protocols to address other hospital-acquired infections.

Retrospective evaluation of colistin versus tigecycline for the treatment of Acinetobacter baumannii and/or carbapenem-resistant Enterobacteriaceae infections - Corrected Proof

2012-03-23

Backgound: Therapeutic options are limited for infections because of Acinetobacter baumannii and carbapenem-resistant Enterobacteriaceae (CRE). Study aim was to compare the efficacy of colistin to tigecycline for the treatment of these types of infections.Methods: A retrospective study was conducted at the Detroit Medical Center. Adult patients with infections because of A baumannii or CRE in 2009 who received ≥2 doses of colistin or tigecycline were studied. Risk factors, outcomes, and costs were analyzed.Results: There were 82 patients with infections because of A baumannii, 12 with CRE, and 12 with A baumannii and CRE coinfection. Seventy-one patients received colistin, 16 received tigecycline, and 19 received both colistin and tigecycline. Seven isolates were nonsusceptible to colistin and 79 to tigecycline. Patients receiving colistin alone or in combination were more likely to die during their hospitalization than patients receiving only tigecycline (P = .002). However, patients receiving colistin had higher severity of acute illness and had notable delays in initiation of effective antimicrobial therapy (P < .001).Conclusion: Compared with patients who received tigecycline alone, patients who received colistin alone or in combination had a higher severity of acute illness indices and delays in initiation of effective therapy. This increased severity of illness contributed to the increased rate of mortality among patients treated with colistin for A baumannii or CRE infections.

High fecal hand contamination among wilderness hikers - Corrected Proof

2012-03-15

Information about hand hygiene and fecal hand contamination among the general public is limited. Hands are an important vector in transmission of various pathogenic bacteria. We found high (31%) prevalence of fecal hand contamination among healthy adults engaged in hiking.

Utility of a focused vancomycin-resistant enterococci screening protocol to identify colonization in hospitalized children - Corrected Proof

Gina Weddle, Mary Anne Jackson, Rangaraj Selvarangan — 2012-03-15

Screening for vancomycin-resistant enterococci (VRE) is controversial, and disagreement exists on policy implementation. This study investigated the likelihood of a positive test using 1, 2, or 3 rectal screenings for VRE colonization. In this descriptive study of positive VRE screening cultures, a total of 1211 VRE screens identified 41 positive results. The mean age of these positive patients was 5.7 years. Thirty-nine of the 41 had a chronic illness, and only 2 were healthy. Diagnoses included pulmonary disease in 11 patients and chronic gastrointestinal abnormality in 7. Six patients had been born preterm, and 12 had been treated in a neonatal intensive care unit within the previous 6 months. Thirty-six of the 41 positive results were identified on the first screen. The likelihood of subsequently having a positive screen after a negative screen was 0.43% (95% confidence interval, 0.15%-1.02%). The cost of cultures plus isolation was $50,000 for the study period. Our data show that the likelihood of detecting a positive VRE culture after an initial negative was low, particularly in otherwise healthy children.

Positive deviance: Using a nurse call system to evaluate hand hygiene practices - Corrected Proof

2012-03-14

Background: Many approaches have been taken to increase compliance with hand hygiene by health care professionals. We evaluated a nurse call system used as a tool in a positive deviance (PD) approach to improving compliance.Methods: We conducted a quasi-experimental study between September 2008 and December 2010 in 2 step-down units (SDUs). The consumption of alcohol-based sanitizers for hand hygiene was monitored by electronic handwash counters installed in each room as of January 2009. The number of nurse visits to patient rooms was measured by the nurse call system, which provides information on each instance of nursing care provided to the patients.Results: The use of alcohol hand rubs was increased in both units after implementation of the PD approach, with higher rates sustained for more than 2 years. The rate of device-related infections showed a decreasing trend, especially for catheter-associated urinary infection in the east SDU. In both units, the ratio of alcohol hand rub uses to nurse visits was >2.5, indicating increased use of alcohol rubs, especially in the east SDU, which had a ratio of 3 for 2010.Conclusions: The PD approach to hand hygiene produced increased compliance, as measured by increased consumption of alcohol hand sanitizer, an improved ratio of alcohol hand rub uses to nurse visits, and a reduced rate of device-related infections, with results sustained over 2 years.

Adherence to international and national recommendations for the prevention of surgical site infections in Italy: Results from an observational prospective study in elective surgery - Corrected Proof

2012-03-14

Background: An observational prospective study of the perioperative procedures for prevention of surgical site infections (SSIs) was carried out in a tertiary referral teaching hospital in Liguria, Italy, to evaluate their adherence to international and national standards.Methods: A 1-month survey was performed in all surgical departments, monitored by turns by trained survey teams. Data regarding presurgical patient preparation and intraoperative infection control practices were collected.Results: A total of 717 elective interventions were actively monitored in 703 patients who underwent surgery. Hair-shaving was performed mainly using a razor (92%) by the nurses (72.8%) on the day before the operation (83.5%). All of the patients showered, either with a common detergent (87%) or with an antiseptic solution (13%). Antimicrobial prophylaxis was administered properly in 75.7% of the patients at induction of anaesthesia; however, according to current Italian guidelines, inappropriate prophylaxis was provided in 55.2% patients. Appropriate antisepsis of the incision area was done in 97.4% of the operations, and nearly 90% of the interventions lasted less than the respective 75th percentile. The doors of the operating theatres were mostly open during the duration of the operation in 36.3% of the cases.Conclusions: This review of infection control policies identified significant opportunities for improving the safety and the quality of routine surgical practice.

Molecular and epidemiologic predictors of Staphylococcus aureus colonization site in a population with limited nosocomial exposure - Corrected Proof

2012-03-14

Background: The anterior naris has been considered the most consistent location of asymptomatic Staphylococcus aureus colonization. However, recent studies have shown that a substantial number of individuals, ranging from 7% to 32% of colonized individuals, are exclusive throat carriers. Most of these studies have been carried out in a health care setting, limiting their generalizability to nonhospitalized populations.Methods: To evaluate anatomic carriage sites of S aureus in individuals outside of a health care setting, we combined the results of 2 cross-sectional studies conducted in Iowa.Results: S aureus was carried by 103 of 340 individuals (30.3%), including 31 (30.1%) exclusive throat carriers, 44 (42.7%) exclusive nose carriers, and 28 (27.2%) colonized in both sites. Nonwhite race (adjusted odds ratio [OR], 4.91; 95% confidence interval [CI], 1.26-18.3) and younger age (≥30 years: OR, 0.23; 95% CI, 0.10-0.54) were associated with increased odds of exclusive throat carriage, whereas nonwhite race (OR, 5.14; 95% CI, 1.62-16.3) and spring or summer sampling season (OR, 2.62; 95% CI, 1.32-5.18) were associated with increased odds of exclusive nasal carriage.Conclusions: These findings suggest that including a throat swab in addition to a nasal swab could play an important role in the success of surveillance programs, particularly among younger adults.

Computer screen saver hand hygiene information curbs a negative trend in hand hygiene behavior - Corrected Proof

2012-03-14

Background: Appropriate hand hygiene among health care workers is the most important infection prevention measure; however, compliance is generally low. Gain-framed messages (ie, messages that emphasize the benefits of hand hygiene rather than the risks of noncompliance) may be most effective, but have not been tested.Methods: The study was conducted in a 27-bed neonatal intensive care unit. We performed an interrupted time series analysis of objectively measured hand disinfection events. We used electronic devices in hand alcohol dispensers, which continuously documented the frequency of hand disinfection events. In addition, hand hygiene compliance before and after the intervention period were directly observed.Results: The negative trend in hand hygiene events per patient-day before the intervention (decrease by 2.3 [standard error, 0.5] per week) changed to a significant positive trend (increase of 1.5 [0.5] per week) after the intervention (P < .001). The direct observations confirmed these results, showing a significant improvement in hand hygiene compliance from 193 of 303 (63.6%) observed hand hygiene events at pretest to 201 of 281 (71.5%) at posttest.Conclusions: We conclude that gain-framed messages concerning hand hygiene presented on screen savers may improve hand hygiene compliance.

Point of care experience with pneumococcal and influenza vaccine documentation among persons aged ≥65 years: High refusal rates and missing information - Corrected Proof

2012-03-14

Missed opportunities to vaccinate and refusal of vaccine by patients have hindered the achievement of national health care goals. The meaningful use of electronic medical records should improve vaccination rates, but few studies have examined the content of these records. In our vaccine intervention program using an electronic record with physician prompts, paper prompts, and nursing standing orders, we were unable to achieve national vaccine goals, due in large part to missing information and patient refusal.

Effect of a multidisciplinary intervention on central line utilization in an acute care hospital - Corrected Proof

2012-03-14

Background: Many institutions that have adopted evidence-based infection prevention practices have achieved reductions in the rate of central line-associated bloodstream infection (CLABSI) in their intensive care units (ICUs). Few studies have investigated the impact of CLABSI prevention strategies in non-ICU settings, however. This study was conducted to assess whether a multifaceted educational initiative significantly improved health care workers’ adherence to clinical practices that have been demonstrated to reduce CLABSI rates.Methods: This prospective interventional study compared central line utilization and other variables in medical ICU (MICU) and non-ICU settings at an inner city community teaching hospital. The study included 3 phases: preintervention, intervention, and postintervention.Results: A total of 128 central venous catheter (CVC) placements were reviewed. After the intervention, the proportion of patients transferred out of the MICU with a CVC in place decreased significantly (P = .05), and the percentage of patients transitioned from a CVC to a peripherally inserted venous catheter increased (P = .004). The mean duration of CVC use decreased from 8.2 days to 5.7 days (P = .004), which was confirmed by linear regression (P = .003).Conclusions: Our data indicate that multidisciplinary, evidenced-based educational interventions can significantly improve targeted measures of CVC use. Our program was successfully implemented with limited resources and should be reproducible at other hospitals.

Infection preventionists’ job descriptions: Do they reflect expanded roles and responsibilities? - Corrected Proof

Mary Lou Manning, Dorothy L. Borton, Dawn Marie Rumovitz — 2012-03-14

In the last decade, the scope of practice of infection preventionists has expanded beyond the traditional roles of solo practitioner and expert data collectors to roles of interventionists and crucial leaders in successful patient safety initiatives. We examined the job descriptions of a small group of practicing infection preventionists to determine whether they reflected this expanded scope and responsibilities.

Local influenza-like illness surveillance at a university health system during the 2009 H1N1 influenza pandemic - Corrected Proof

Arthur W. Baker, Kyle Enfield, Beth Mehring, James C. Turner, Costi D. Sifri — 2012-03-14

Background: The 2009 novel H1N1 influenza epidemic generated interest in regional and national influenza surveillance methods. Some systems revamped traditional syndromic and laboratory surveillance techniques, whereas others tracked influenza by Internet-based searches or other unique methods. We hypothesized that an influenza-like illness (ILI) surveillance system at a single university hospital would be accurate and useful for monitoring local influenza activity and impact.Methods: We developed a system of ILI surveillance at 8 sentinel sites associated with a university health care system before the pandemic 2009-10 influenza season. Most sentinel sites used a symptom-based definition of ILI, whereas others used electronic medical records-based definitions.Results: Results of the local ILI surveillance network correlated well with the onset and peak of the influenza season compared with state and regional ILI data, closely approximated cases of microbiologically confirmed influenza, demonstrated early onset of illness in one site in the sentinel site network, and were available several days sooner than data from existing surveillance systems.Conclusions: Local influenza surveillance at a single-institution level provided timely, useful, and accurate information, which helped guide resource utilization during the pandemic influenza season. The system was an important supplement to state and regional influenza surveillance.

Device-associated nosocomial infection rates in intensive care units at Cairo University hospitals: First step toward initiating surveillance programs in a resource-limited country - Corrected Proof

2012-03-14

Background: Device associated infections (DAIs) have major impact on patient morbidity and mortality.Methods: This study involved active prospective surveillance to measure the incidence of DAIs, evaluate microbiological profiles, and investigate excessive mortality in intensive care units (ICUs) in 3 hospitals of Cairo University applying the US Centers for Disease Control and Prevention’s National Healthcare Safety Network case definitions for ventilator-associated pneumonia (VAP), catheter-associated urinary tract infection (CAUTI), and central-line associated bloodstream infection (CLABSI). Data were collected between March 2009 and May 2010.Results: A total of 1,101 patients were hospitalized for a total of 10,869 days, had 4,734 device-days, and acquired 97 DAIs, with an overall rate of 20.5/1,000 ICU days. VAP was the most commonly identified infection (88.7%); followed by CLABSI (8.2%) and CAUTI (3.1%). Excess mortality was 48% (relative risk, 1.9; P < .001) for CAUTI, 12.9% (relative risk, 1.2; 95% confidence interval, 1.1-1.4; P < .05) for VAP, and 45.7% for CLABSI. Acinetobacter baumannii was the most frequently isolated pathogen (36.1%), followed by Klebsiella pneumoniae (29.2%) and Pseudomonas aeruginosa (22.2%). High antimicrobial resistance was identified, with 85% of A baumannii isolates resistant to ciprofloxacin and imipenem, 76% of K pneumoniae isolates were extended-spectrum β-lactamase producers, and 56.3% P aeruginosa isolates resistant to imipenem (56.3%).Conclusion: High rates of DAI and antimicrobial resistance require strengthening infection control, instituting surveillance systems, and implementing evidence-based preventive strategies.

Reduction of surgical site infections in low transverse cesarean section at a university hospital - Corrected Proof

2012-03-14

Background: We implemented evidence-based interventions to reduce risk of surgical site infection (SSI) following low transverse cesarean section (LTCS).Methods: An observational study was conducted to determine LTCS SSI rates and the impact of infection control interventions at an academic teaching hospital during the period October 2005 to December 2008, including the use of 2% chlorhexidine gluconate (CHG) for surgical skin preparation before LTCS and no-rinse CHG cloths for preoperative skin cleansing. We compared overall and risk strata specific SSI rates and standardized incidence ratios during 4 study periods and estimated cost savings.Results: Of 1,844 LTCSs performed, 99 patients were identified with SSI. SSI rates per 100 LTCS declined from 6.27 at baseline and 10.84 during the outbreak period to 5.92 in intervention 1 period and 2.29 in intervention 2 period. Overall, a 63.5% reduction in SSI rate from baseline was achieved by ensuring compliance with SSI prevention guidelines and improving skin antisepsis (P = .003). In intervention 2 period, the standardized incidence ratio was 0.99 compared with 2.64 at baseline and 4.50 during the outbreak period.Conclusion: A multidisciplinary approach including evidence-based SSI prevention practices, effective infection prevention products, and staff and patient engagement substantially reduced infection risk and improved patient safety following LTCS.

Biofilms on environmental surfaces: Evaluation of the disinfection efficacy of a novel steam vapor system - Corrected Proof

Liyan Song, Jianfeng Wu, Chuanwu Xi — 2012-03-13

Background: Environmental surfaces in health care settings are often contaminated by microorganisms, and biofilms can develop on the surfaces in these settings. Steam vapor technology is of potential use for disinfection of biofilms on the environmental surfaces.Methods: We tested the disinfection efficacy of a thermal-accelerated nanocrystal sanitation (TANCS)-equipped steam vapor technology against biofilms through disinfecting biofilms developed by 4 bacterial strains—Escherichia coli, Acinetobacter baumannii, Pseudomonas aeruginosa, and Staphylococcus aureus—on an identical test surface (ie, polycarbonate) and biofilms developed by E coli on 4 different test surfaces: polycarbonate, rubber, stainless steel, and ceramics.Results: Our data show that a 3-second steam treatment rapidly killed each biofilm tested (>99.95 % killing efficiency). For biofilms developed on different surfaces, 3-second steam treatment achieved 99.95% killing of E coli biofilms developed on different surfaces. Compared with chemical disinfection, steam treatment for <1 second a similar level of biofilm disinfection as provided by incubation with 10-ppm sodium hypochlorite (bleach) for 10-20 minutes of contact time.Conclusions: Our data suggest that the TANCS-equipped steam vapor disinfection is an emerging and potentially useful technology for disinfecting biofilms on environmental surfaces.

An outbreak of human parainfluenza virus 3 infection in an outpatient hematopoietic stem cell transplantation clinic - Corrected Proof

2012-03-12

Background: Parainfluenza viruses cause respiratory tract infections in adults and children, with peak activity during the spring and summer months. Human parainfluenza virus type 3 (hPIV-3) can contribute to significant morbidity and mortality in patients undergoing hematopoietic stem cell transplantation (HSCT).Methods: Automated surveillance software was used to identify an hPIV-3 outbreak in an HSCT clinic. Active surveillance for respiratory illness and infection control measures were instituted. A retrospective molecular investigation of outbreak viral strains was performed by direct sequencing.Results: Twelve of 196 HSCT recipients attending the clinic during the outbreak period had hPIV-3; one of these patients died. Sequencing demonstrated highly related strains in 9 of 10 patients studied. Despite the ongoing presence of hPIV-3 outside the inpatient/outpatient care continuum clinic, only 2 cases were observed after institution of respiratory season infection control measures.Conclusions: This investigation demonstrates the utility of surveillance software in the identification of respiratory virus outbreaks and the importance of rapid implementation of infection control/prevention measures for containment of outbreaks.

Estimating the volume of alcohol-based hand rub required for a hand hygiene program - Corrected Proof

Silvana Sicoli, Linda Hunter, Josée Shymanski, Kathryn Suh, Virginia R. Roth — 2012-03-05

Background: Providing alcohol-based hand rub (ABHR) at the point of care is a key success factor in enabling health care providers to achieve optimal hand hygiene practices. There are few tools available for health care organizations to assess the number of points of care, estimate the number of hand hygiene indications at each point of care, and estimate the anticipated volume of ABHR required to support a hand hygiene program.Methods: We developed an assessment tool to systematically evaluate the environmental hand hygiene needs in diverse care settings across a multisite health care organization.Results: We identified 1,103 points of care in 34 clinical units, of which only 53% had ABHR at point of care. There are an estimated 171,468,240 (95% confidence interval: 146,844,406-191,871,179) hand hygiene indications per year in our in-patient and emergency areas. If 100% compliance with hand hygiene is achieved, 240,056 L of ABHR will be required each year.Conclusions: Our environmental assessment was invaluable in estimating the number of hand hygiene indications by unit and the logistical and financial requirements to implement a hand hygiene program. Other health care organizations may find this a useful framework to estimate their own environmental hand hygiene needs.

Decreasing ventilator-associated pneumonia in the intensive care unit: A sustainable comprehensive quality improvement program - Corrected Proof

Kara Heck — 2012-03-05

An intensive care unit implemented an oral care bundle to decrease ventilator-associated pneumonia (VAP). A retrospective analysis comparing like time periods revealed the VAP rate per 1,000 ventilator-days dropped significantly from 10.5 to 0 (P = .016). The oral care bundle remains in place as of end of May 2011 and has proven to be a sustainable method for VAP prevention.

Prevalence of susceptibility to tetanus and diphtheria in health care workers in Catalonia - Corrected Proof

2012-03-05

A seroprevalence study of tetanus and diphtheria was carried out in a sample of 537 health care workers in Catalonia. The prevalence of protective antibodies against tetanus was 93.9% (95% confidence interval: 91.5-95.7). The prevalence of protective antibodies against diphtheria was 46.4% (95% confidence interval: 42.1-50.7). Tetanus protection should be improved in health care workers born before 1975. The immune status against diphtheria was poor, with less than half of people born before 1975 correctly immunized.

An evaluation of immediate-use steam sterilization practices in adult knee and hip arthroplasty procedures - Corrected Proof

Scott L. Zuckerman, Ravi Parikh, David C. Moore, Thomas R. Talbot — 2012-02-27

Background: Immediate-use steam sterilization (IUSS) is a safe method to sterilize emergently contaminated instruments, but inappropriate use may lead to an increased risk for surgical site infection. This study aimed to identify risk factors, rationale, and variability in procedural adherence in cases of IUSS.Methods: This retrospective, case-control study compared adult patients undergoing hip and knee arthroplasty in which IUSS was (n = 104) and was not (n = 81) performed.Results: Multivariate analysis revealed 4 predictive risk factors for IUSS: history of malignancy (odds ratio [OR], 3.2 [95% confidence interval (CI) 1.1-9.3]), obesity (OR, 2.3 [95% CI: 1.02-5.2]), procedure performed in operating room 13 (OR, 2.5 [95% CI: 1.2-5.4]), and Monday procedure (OR, 3.6 [95% CI: 1.4-9.1]). The only factor that protected against IUSS was performing the procedure in the morning (OR, 0.4 [95% CI: 0.2-0.96]). Only 9.5% of cases of IUSS involved an acceptable indication. Documented adherence to core practices was also variable.Conclusion: Several patient- and case-specific factors can help predict the incidence of IUSS. Furthermore, practices should be hardwired to ensure IUSS is utilized for the correct indication. Documentation must be improved to allow institutions to accurately track IUSS.

Too close for comfort: Screening strategy to detect methicillin-resistant Staphylococcus aureus conversion in exposed roommates - Corrected Proof

Wil Ng, Kalpana George, Nurun Muhammed, Joanne Tomassi, Kevin C. Katz — 2012-02-27

All 899 roommates exposed to methicillin-resistant Staphylococcus aureus (MRSA) index cases were studied over 57 months. MRSA detection is better at approximately 3 days (50%-55%) or 7 days (56%) after contact has been broken than day 0 (30%). Polymerase chain reaction testing at day 3 performs similarly to culture at day 7. Nasal/rectal screening provides superior detection than nasal alone. Those exposed >48 hours are at significantly greater risk of colonization.

Long-term survival curve of methicillin-resistant Staphylococcus aureus on clinical contact surfaces in natural-like conditions - Corrected Proof

Stefano Petti, Maria De Giusti, Catia Moroni, Antonella Polimeni — 2012-02-27

We investigated methicillin-resistant Staphylococcus aureus (MRSA) survival on a noncritical environmental surface in real-life conditions (dental chair located in a box of a Dentistry Department, subjected to microclimate variations and presence of people) and with a plausible baseline inoculum (5-log colony-forming units) in contrast to survival that has been frequently tested in laboratory conditions and/or using high baseline levels. We tested 5 freshly isolated sporadic strains and observed a drastic MRSA fall (>90%) 15 minutes after exposure to the environment. After 4 months, we detected MRSA at very low levels in 9 out of 25 tests. The MRSA survival curve showed that the velocity of log count decrease, highest soon after exposure, tended to decrease progressively. Thus, whereas the risk for infection through shared surfaces is probably minimal, the risk for MRSA diffusion in the community is high.

Risk factors associated with linezolid-nonsusceptible enterococcal infections - Corrected Proof

2012-02-24

Linezolid is one of few treatment options available for vancomycin-resistant enterococci. The present study investigated risk factors for linezolid-nonsusceptible enterococci using a case-control study of 15 cases and 60 control patients. Previous hospitalization, admission to a medical service, comorbidity, and linezolid and sulfonamide therapy were identified as risk factors.

Disparity in infection control practices for multidrug-resistant Enterobacteriaceae - Corrected Proof

2012-02-24

Background: There is a lack of empiric evidence regarding the optimal approach to controlling the transmission of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) and carbapenem-resistant Enterobacteriaceae (CRE). In this context, we expect that infection control practices for these organisms vary widely between hospitals.Methods: A survey examining infection control practices for ESBL-E and CRE was distributed to 6 academic and 9 community hospitals in Toronto, Canada.Results: All hospitals responded to the survey. Among 15 hospitals in 1 geographic area, 8 different approaches to the management of ESBL-E were utilized. There was wide variation in the use infection control practices including admission screening (53% and 53%), contact precautions (53% and 100%), and isolation (60% and 100%) for ESBL-E and CRE, respectively. Of hospitals performing admission screening, 75% used risk factor-based screening for ESBL-E and CRE.Conclusion: Even within a single geographic area, there is wide variation in infection control strategies to contain or control ESBL-E and CRE. These results are concerning given evidence that a coordinated approach may be required to prevent or limit the emergence of CRE.

Intrinsic bacterial burden associated with intensive care unit hospital beds: Effects of disinfection on population recovery and mitigation of potential infection risk - Corrected Proof

2012-02-24

Background: Commonly touched items are likely reservoirs from which patients, health care workers, and visitors may encounter and transfer microbes. A quantitative assessment was conducted of the risk represented by the intrinsic bacterial burden associated with bed rails in a medical intensive care unit (MICU), and how disinfection might mitigate this risk.Methods: Bacteria present on the rails from 36 patient beds in the MICU were sampled immediately before cleaning and at 0.5, 2.5, 4.5, and 6.5 hours after cleaning. Beds were sanitized with either a bottled disinfectant (BD; CaviCide) or an automated bulk-diluted disinfectant (ABDD; Virex II 256).Results: The majority of bacteria recovered from the bed rails in the MICU were staphylococci, but not methicillin-resistant Staphylococcus aureus. Vancomycin-resistant enterococci were recovered from 3 beds. Bottled disinfectant reduced the average bacterial burden on the rails by 99%. However, the burden rebounded to 30% of that found before disinfection by 6.5 hours after disinfection. ABDD reduced the burden by an average of 45%, but levels rebounded within 2.5 hours. The effectiveness of both disinfectants was reflected in median reductions to burden of 98% for BD and 95% for ABDD.Conclusions: Cleaning with hospital-approved disinfectants reduced the intrinsic bacterial burden on bed rail surfaces by up to 99%, although the population, principally staphylococci, rebounded quickly to predisinfection levels.

Antibiotic use in Vietnamese hospitals: A multicenter point-prevalence study - Corrected Proof

2012-02-20

Background: Inappropriate antibiotic prescribing appears to be common worldwide and is contributing to the selection of resistant organisms. This study examined the prevalence of antibiotic prescription and the appropriateness of indications for these prescriptions in 36 representative general hospitals across Vietnam.Methods: A point-prevalence study was performed between February and December 2008. All inpatients on the day of the survey were included in the analysis. Standard published guidelines were used to evaluate the appropriateness of indications for antibiotic prescription.Results: On the day of the study, 5,104 of 7,571 patients (67.4%) were receiving antibiotic therapy. The antibiotic prescription rate was highest in surgery wards (93.2%) and lowest in medical wards (48.2%). Of the 5,104 patients receiving antibiotics, the most commonly prescribed agents were cephalosporins (70.2%), penicillins (21.6%), and aminoglycosides (18.9%). Approximately one-third of the patients (1,573 of 5,104) had an inappropriate indication for prescription. Risk factors independently associated with inappropriate indication for antibiotic prescription were seen in hospitals at the national level, obstetrics and gynecology departments, and surgical wards.Conclusions: Our data indicate a high rate of antibiotic use in Vietnamese hospitals, and also a high prevalence of inappropriate indications for antibiotic prescriptions. These findings suggest important areas for intervention and implementation of antibiotic stewardship policies in Vietnamese hospitals.

Comparison of the efficiency of nail pick and brush used for nail cleaning during surgical scrub on reducing bacterial counts - Corrected Proof

Aliye Okgün Alcan, Fatma Demir Korkmaz — 2012-02-20

Background: Although the surgical scrub is a mandatory and routine procedure, there is no standard recommendation for nail cleaning during the scrub. This study compared the efficacy of nail picks and brushes used for nail cleaning during the surgical scrub in reducing bacterial counts.Methods: Sixty circulatory nurses were included in the survey. The nurses were randomized to undertake 1 of 3 surgical hand scrub protocols: using surgical scrub alone (control group), using a nail pick during the surgical scrub, or using a brush during the surgical scrub. Bacterial counts were measured on the dominant hand immediately before the scrub and 1 hour after the scrub using the glove juice method.Results: The bacterial counts at 1 hour after the surgical scrub were lower in the control group than in the 2 intervention groups, and there was no significant difference between the 2 intervention groups (F = 2.063; P = .136; P > .05).Conclusion: Using nail picks and brushes on nails during the surgical scrub does not provide additional decontamination.

A multilevel model of methicillin-resistant Staphylococcus aureus acquisition within the hierarchy of an Australian tertiary hospital - Corrected Proof

Fiona Kong, David L. Paterson, Michael Coory, Archie C.A. Clements — 2012-02-15

Hospitals without universal single room accommodations typically contain multibed cubicles within wards. In this study, we examined whether the variation in a patient’s risk for acquiring methicillin-resistant Staphylococcus aureus (MRSA) in a major tertiary hospital was greatest at the bed, cubicle, or ward level, and quantified the risk of MRSA acquisition associated with exposure to MRSA-colonized/infected patients within the same bed, cubicle, and ward at differently distributed lag times. Nested tri-level hierarchical logistic regression models with random effects were used for non-multiresistant MRSA (nmMRSA) and multiresistant MRSA (mMRSA). The models were internally validated. Receiver operating characteristic curves were used to compare the models’ predictive capability The odds of new nmMRSA acquisition were 6.06-fold (95% credible intervals [CrI], 3.93- to 9.34-fold) greater in bed-weeks when a nmMRSA-colonized/infected patient was in the same cubicle 2 weeks earlier. The odds of mMRSA acquisition were 5.12-fold (95% CrI, 4.02- to 6.51-fold) greater in bed-weeks when a colonized/infected patient was in the same ward 2 weeks earlier. The between-cluster variance was highest at the ward level. Patients were at greater risk if there was a colonized/infected patient in the same cubicle or ward 2 weeks earlier. Our findings indicate that focusing on the relevant cubicles and wards during this high-risk period can help target infection control resources more efficiently.

Alcohol handrubbing and chlorhexidine handwashing protocols for routine hospital practice: A randomized clinical trial of protocol efficacy and time effectiveness - Corrected Proof

2012-02-13

Background: The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) recommend the use of alcohol handrubs to prevent health care-associated infections. However, the efficacy and time effectiveness of different alcohol handrubbing protocols have yet to be evaluated.Methods: We conducted a randomized controlled trial in the general wards of a 1,300-bed, acute, tertiary care hospital to compare the effectiveness of 3 hand hygiene protocols during routine inpatient care: (1) handrubbing with alcohol covering all hand surfaces, (2) handrubbing with alcohol using the standard 7-step technique, and (3) handwashing with chlorhexidine using the standard 7-step technique. Hand samples were obtained from 60 medical and 60 nursing staff, before and after hand hygiene. Quantitative and qualitative bacterial evaluations were carried out by microbiologists blinded to the protocol.Results: All 3 protocols were effective in reducing hand bacterial load (P < .01). During routine patient care, alcohol handrubbing covering all hand surfaces required less time (median, 26.0 seconds) than alcohol handrubbing using the 7-step technique (median 38.5 seconds; P = .04) and chlorhexidine handwashing (median, 75.5 seconds; P < .001).Conclusion: Alcohol handrubbing protocols are as efficacious as chlorhexidine handwashing. Alcohol handrubbing covering all hand surfaces is the most time-effective protocol for routine patient care activities in busy general wards.

Environmental contamination with extended-spectrum β-lactamases: Is there any difference between Escherichia coli and Klebsiella spp? - Corrected Proof

2012-02-13

Background: The hospital environment contributes to the spread of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae (ESBL-PE) during outbreaks. We aimed to assess the rate of environmental contamination in rooms occupied by ESBL carriers or infected children and to identify risk factors associated with contamination.Methods: Five environmental surface samples were systematically performed in rooms occupied by ESBL-PE carrier or infected children.Results: Forty-six Escherichia coli and 48 Klebsiella infected/carrier patients were included in the study. Nineteen (4%) of the 470 environmental samples performed yielded ESBL-PE. Klebsiella spp was the most frequent species isolated (16, 89%), whereas E coli and Citrobacter freundii were reported twice and once, respectively. Ten of the 19 (52%) isolates were identical to the corresponding strains isolated from children. Multivariate analysis highlighted ESBL-producing Klebsiella carriage/infection as the only risk factor significantly associated with surface contamination (P = .024).Conclusion: Our data suggest that hospital environmental contamination is more frequent in instances of fecal carriage or infection with ESBL-producing Klebsiella than ESBL-producing E coli. Reinforcing hygiene measures around ESBL-producing Klebsiella might be necessary to reduce the spread of ESBL-PE in hospital environments.

Quantification of anesthesia providers’ hand hygiene in a busy metropolitan operating room: What would Semmelweis think? - Corrected Proof

Chuck Biddle, Jagdip Shah — 2012-02-13

Background: Hand hygiene (HH) is poor in the health care environment representing a major public health concern. HH compliance is poorly studied in anesthesia providers who contribute extensively to nosocomial infection. The rate of HH opportunities and compliance by these providers was studied using embedded, clandestine observers. We aimed to quantify HH behaviors and taxonomize failures.Methods: Following intensive training, 5 observers masquerading as nursing staff in an academic center, observed the HH of anesthesia providers over a 4-week period throughout the perioperative period using a World Health Organization tool. HH opportunities and HH failures were recorded and categorized using a qualitative content analysis.Results: Nearly 8,000 HH opportunities were observed. HH opportunities averaged 34 to 41/hour and peaked several times at 54/hour. Aggregate failure rate was 82% with a range of 64% to 93% by provider group.Conclusion: HH was very poor among anesthesia providers. The task density of anesthesia care may conspire with an intrinsic HH failure rate to create great opportunity for horizontal and vertical vectors for nosocomial infection. Our observations have led to aggressive educational and ergonomic interventions at our facility. Given the task density of anesthesia care, and the observed failure rates, novel approaches to HH should be investigated.