AJIC: American Journal of Infection Control - Articles in Press

A matched prospective cohort study on Staphylococcus aureus and Escherichia coli bloodstream infections: Extended perspectives beyond resistance - Corrected Proof

2010-07-23

Background: Bacteremias caused by Staphylococcus aureus and Escherichia coli are among the most common bloodstream infections (BSIs) in adults. The aim of the study was to investigate risk factors for infection and clinical outcomes of bacteremias caused by S aureus or E coli.Methods: We conducted a 1-year matched prospective cohort study including 150 patients with BSI caused by susceptible or resistant S aureus or E coli and 300 controls without BSI caused by these organisms.Results: Of the 150 episodes of bacteremia, 37% were caused by S aureus (including 5 cases of methicillin-resistant S aureus [MRSA]) and 63% were caused by E coli (including 9 cases of extended-spectrum beta lactamase [ESBL]-producing E coli). We identified 4 independent risk factors for acquisition of S aureus bacteremia (emergency, peripheral or central vascular catheter, renal disease) and 6 risk factors for E coli bacteremia (emergency, peripheral or central vascular catheter, malignancy, cytoreductive or immunosuppressive therapy). Both types of bacteremia were associated with an increased length of hospital stay compared with controls. We observed a 5-fold increase in the 30-day mortality rate for bacteremias due to S aureus, and a 2-fold increase in BSI caused by E coli. The in-hospital mortality rate was increased by 6-fold for S aureus and by 3-fold for E coli.Conclusion: Longer hospitalization periods and increased mortality of bacteremias caused by S aureus or E coli, irrespective of susceptibility, implicate controlling for risk factors at an early stage.

A prospective multicenter study evaluating skin tolerance to standard hand hygiene techniques - Corrected Proof

2010-07-22

We performed a prospective multicenter study to assess the dryness and irritation of the hands in health care facilities, and to evaluate whether that disinfection with an alcohol-based hand rub (ABHR) is better tolerated than classic handwashing with mild soap and water. Our study was conducted in 9 sites in the summer and winter. A team of investigators evaluated dryness and irritation. This study takes into account most of the individual and environmental risk factors (age, sex, use of a protective agent, constitutional factors, personal factors, external factors, institution, function, and number of consecutive working days). The results from the 1932 assessments collected show that traditional handwashing is a risk factor for dryness and irritation, whereas the use of ABHR causes no skin deterioration and might have a protective effect, particularly in intensive use. These results provide a strong argument to counter the rear-guard resistance to the use of ABHRs.

Stopcock lumen contamination does not reflect the full burden of bacterial intravenous tubing contamination: Analysis using a novel injection port - Corrected Proof

Matthew K. Muffly, Michael L. Beach, Yi Cai Isaac Tong, Mark P. Yeager — 2010-07-15

Background: Prior clinical studies have used injection port lumen culture as a marker of intravenous (IV) fluid system contamination. We hypothesized that culturing injected saline (effluent) is a more sensitive method of detecting IV fluid system bacterial contamination than lumen culture. To test this hypothesis, we compared the incidence of lumen contamination with effluent contamination in a simulated setting. We also measured the effect of a novel injection port protective device (Port Guide; Matrix Tooling, Inc, Wood Dale, IL) on contamination.Methods: In this ex vivo study, 33 providers performed 5 injections of 1 mL sterile saline into each of 4 injection port designs: (1) stopcock, (2) stopcock with Port Guide, (3) stopcock with disinfectable needleless closed connector (DNCC), and (4) stopcock with DNCC and Port Guide. The primary outcome was the rate of effluent contamination with simultaneously contaminated injection port lumen.Results: Bacterial organisms were recovered from the effluent in 17 of the 132 injection ports evaluated. Of those 17 injection ports with contaminated effluent, 4 injection port lumens were simultaneously contaminated (24%). Additionally, use of the stopcock with Port Guide significantly reduced effluent contamination.Conclusion: Effluent culture is a more sensitive marker of IV fluid system contamination than injection port lumen culture. A novel protective device on the stopcock (Port Guide) significantly reduced IV fluid system bacterial contamination.

Infection control hazards and near misses reported by nursing students - Corrected Proof

2010-07-12

Background: Hazard and near-miss reporting has been integrated into the curriculum for postbaccalaureate bachelor of science in nursing/master of science in nursing degree students at our institution through a Web-based reporting system since 2006. The system is used during their 25-week clinical rotations of 2 days per week in community, medical-surgical, obstetrics, pediatrics, and psychiatric settings. The purpose of this article is to describe the frequency and types of hazard and near-miss comments about infection control issues over 3 years of data collection.Methods: For each clinical rotation, students were required to complete 2 entries per week into a structured electronic hazard and near-miss reporting system. Three years worth of comments associated with these reports (2006-2009) were extracted and analyzed by 3 independent reviewers (κ statistic = 0.85). Seven categories of infection control problems were identified.Results: Five hundred nursing students submitted 3492 comments related to hazards and near misses. Of these, 886 responses (25.4%) were related to infection control practices. The most common category was nonadherence to isolation precautions (27.6%), followed by contamination of the environment or equipment (18.5%), breaks in aseptic technique (17.2%), hand hygiene (15.9%) or gloving failures (11.5%), and occupational risks (8.2%).Conclusion: Infection control hazards and near misses were commonly reported across clinical settings by nursing students. Awareness of such problems among clinicians is necessary before work flow process changes can be made, but clinical change require systems-level change. To be effective and sustainable, reporting methods must be easy to use and available in real time.

Health care-associated infections studies project: Case 2 - Corrected Proof

2010-07-12

Welcome to the second publication of a joint effort between the American Journal of Infection Control and the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN). This collaboration is a series of case studies representing surveillance scenarios faced everyday by infection preventionists (IPs) using NHSN definitions. Please refer to the June 2010 issue for more information.

Awareness of government seasonal and 2009 H1N1 influenza vaccination recommendations among targeted US adults: The role of provider interactions - Corrected Proof

Jürgen Maurer, Lori Uscher-Pines, Katherine M. Harris — 2010-07-02

We present nationally representative estimates regarding awareness of government vaccination recommendations for seasonal and 2009 H1N1 influenza among US adults for whom such vaccinations are specifically recommended. We also show how awareness varies based on interactions with health care providers. Despite comprehensive media coverage of the H1N1 pandemic, awareness of government influenza vaccination recommendations among adults is low. Provider-based vaccination counseling may help increase adults' awareness of federal vaccination recommendations.

Diurnal variation in hand hygiene compliance in a tertiary level multidisciplinary intensive care unit - Corrected Proof

Sandeep Sahay, Sauren Panja, Sumit Ray, B.K. Rao — 2010-06-28

Background: Hand hygiene compliance among health care providers is considered to be the single most effective factor to reduce hospital acquired infections. Despite continuous education and awareness, compliance with hand hygiene guidelines has remained low, particularly during evening shifts.Objective: Our objective was to determine the compliance with hand hygiene guidelines among doctors, nurses, and paramedical staff during day and night duties in a multidisciplinary intensive care unit (ICU).Methods: We used a prospective, observational, 6-month study conducted in a 34-bed ICU within a tertiary care teaching hospital. All doctors, nurses, and paramedical staff in the ICU were included. An investigator, placed within the ICU setting, observed the hand hygiene practices during day and night. Day and night shift change times were 08:00 and 20:00 hours, respectively.Results: Of the 5639 opportunities for hand hygiene, 3383 (59.9%) were properly performed. Overall rates of compliance were 66.1% for doctors, 60.7% for nurses, and 38.6% for paramedical staff. Hand hygiene compliance dropped during the night for doctors (81% vs 46%, respectively, P < .001), for nurses (64% vs 55%, respectively, P = .02), and for paramedical staff (44% vs 31%, respectively, P = .01). Characterization of noncompliance is as follows: “No handwashing after procedure” in 41%, “improper duration of handwashing” in 32%, and “no handwashing done at all” in 27% of the events. “No handwashing done at all” occurred in 55% of the time at night with doctors having the highest rate of noncompliance, making 163 (34%) contacts without handwashing.Conclusion: Whereas compliance with hand hygiene guidelines was lower at night compared with day, irrespective of discipline in all 3 groups of health care providers, both periods of compliance would benefit from additional training focusing on the importance of hand hygiene around the clock.

Assessing specific secondary ICD-9-CM codes as potential predictors of surgical site infections - Corrected Proof

Jessica West, Yosef Khan, David M. Murray, Kurt B. Stevenson — 2010-06-28

Background: Public reporting and reduced Medicare payments because of health care-associated infections have resulted in the consideration of administrative discharge codes as markers of health care-associated infections. This study aims to determine whether specific secondary ICD-9-CM infection codes linked to cases from a large data set of surgical procedures are predictors of surgical site infections (SSIs).Methods: All patients undergoing 1 of 9 surgical procedures from January 1, 2005, through December 31, 2005, at a large academic medical center and who were assigned a secondary ICD-9-CM infection code at discharge were eligible for study inclusion. All cases were reviewed to determine the presence of SSIs. Logistic regression was used to determine which secondary codes were predictors of SSIs.Results: Among 75 secondary infection codes applied at discharge to 454 patients, only 1 code (998.59) appeared to be reliably associated with SSIs. Two other general infection codes (996.63 and 996.67) and 1 specific infection code (320.3) may also have utility.Conclusion: Administrative coding data do not perform well to identify SSIs. Some general secondary infection codes, however, may have the potential to be utilized in screening algorithms of electronic health data to assist in SSI surveillance.

Exploring determinants of acceptance of the pandemic influenza A (H1N1) 2009 vaccination in nurses - Corrected Proof

Kin-Wang To, Sing Lee, Tat-On Chan, Shui-Shan Lee — 2010-06-21

This study investigated the anticipated vaccination rate against pandemic human influenza A (H1N1) 2009 in the health care setting. Self-administered questionnaires were used to assess nurses' acceptance of vaccination against seasonal flu and H1N1. They were sent to nurses by post through various nurses' unions before initiation of the vaccination program. Only 13.3% of the respondents planned to receive the H1N1 vaccine, compared with 37.5% for the seasonal influenza vaccine. Vaccination against seasonal influenza in the preceding season strongly predicted the likelihood of H1N1 vaccination. The main reason cited for H1N1 vaccination was self-protection, and reasons for rejecting vaccination included possible side effects, ineffectiveness of the vaccine, and the mild nature of the disease. Personal contact with patients with H1N1 or severe acute respiratory syndrome at work did not significantly increase the likelihood of receiving the H1N1 vaccine. More than 40% of the respondents were undecided at the time of the survey. The promotion of vaccination against seasonal influenza may play a role in improving H1N1 vaccination coverage. Efforts are needed to address concerns about vaccination risk and to incorporate H1N1 vaccination in standard infection control practice with policy support.

Clinical and economic outcomes of decreased fluconazole susceptibility in patients with Candida glabrata bloodstream infections - Corrected Proof

2010-06-14

Background: The impact of reduced fluconazole susceptibility on clinical and economic outcomes in patients with Candida glabrata bloodstream infections (BSI) is unknown.Methods: A retrospective cohort study was conducted to evaluate 30-day inpatient mortality and postculture hospital charges in patients with C glabrata BSI with decreased fluconazole susceptibility (minimum inhibitory concentration [MIC] ≥ 16 μg/mL) versus fluconazole-susceptible C glabrata BSI (MIC ≤ 8 μg/mL). These analyses were adjusted for demographics, comorbidities, and time at risk. Secondary analyses limited the C glabrata group with decreased fluconazole susceptibility to MIC ≥ 64 μg/mL.Results: There were 45 (31%) deaths among 144 enrolled patients: 19 deaths (25%) among 76 patients with C glabrata BSI with decreased fluconazole susceptibility and 26 deaths (38%) among 68 patients with fluconazole-susceptible C glabrata BSI. Decreased fluconazole susceptibility was not independently associated with increased 30-day inpatient mortality (adjusted odds ratio, .60; 95% confidence interval (CI): 0.26-1.35; P = 0.22) or hospital charges (multiplicative change in hospital charges, .93; 95% CI: 0.60-1.43; P = 0.73). Older age was associated with increased mortality and increased time at risk was associated with increased hospital charges.Conclusion: Crude mortality rates remain high in patients with C glabrata BSI. However, decreased fluconazole susceptibility was not associated with increased mortality or hospital charges.

Defining the configuration of a hand hygiene monitoring system - Corrected Proof

Veronique M. Boscart, Alexander I. Levchenko, Geoff R. Fernie — 2010-06-07

Background: Inadequate hand hygiene (HH) by staff leads to hospital-acquired infections, high morbidity, and mortality rates for patients and a growing economic impact. The Toronto Rehabilitation Institute developed a different approach to measure and increase HH frequency, that is, a monitoring system that automatically detects HH opportunities associated with approaching and leaving patient areas. The aim of this study was to collect and classify data on HH opportunities to (1) evaluate the percentage of opportunities that the system could detect and (2) identify the system configuration.Methods: An observational study collected time-stamped data on HH opportunities and methods of nurses on a complex care unit. Data were processed according to the Ministry of Health of Ontario, Canada. The data were subsequently classified corresponding to the motion patterns of nurses to identify areas that need to be controlled by the system.Results: A total of 1093 HH opportunities were recorded over 94 hours from 15 nurses, with 919 opportunities associated with entering or leaving patient environments.Conclusion: The monitoring system would be able to detect and process 85% of HH opportunities in a complex care setting. To process these opportunities, the system configuration should include monitoring of patient room entrances, individual patient environments in multibed rooms, and shared ensuite bathrooms.

The use of adenosine triphosphate bioluminescence to assess the efficacy of a modified cleaning program implemented within an intensive care setting - Corrected Proof

Ginny Moore, Debbie Smyth, Julie Singleton, Peter Wilson — 2010-06-07

Background: A total environmental cleaning system based on microfiber technology was implemented within 2 intensive care units (ICUs). The efficacy of this modified cleaning program was assessed using adenosine triphosphate (ATP) bioluminescence.Methods: A team of trained hygiene technicians cleaned all near-patient furniture and equipment twice a day using ultramicrofiber cloths. Every week for 40 weeks, 10 surfaces within a randomly selected bed area were sampled using the 3M Clean-Trace Clinical Hygiene Monitoring System (3M Health Care Ltd, Loughborough, United Kingdom). The ability of the modified cleaning program to reduce surface contamination to “acceptable” levels was measured against previously proposed benchmark ATP values.Results: In comparison with normal cleaning procedures routinely carried out by the nurses, the modified cleaning program significantly reduced (P < .001) the ATP readings obtained from surfaces within the near-patient environment. In both ICUs, 95% of surfaces sampled after modified cleaning had relative light unit values of <500 and were deemed “clean.” Almost 90% of the surfaces could also be “passed” using the more stringent benchmark value of 250 relative light units. However, regardless of benchmark value used, the majority of surfaces sampled could also be considered adequately clean prior to them being cleaned by the hygiene technicians.Conclusion: The use of ATP bioluminescence has been proposed as a means to improve the management of hospital cleaning. Use of benchmark values can help continually monitor the efficacy of existing cleaning programs. However, when evaluating novel or new cleaning practices, baseline cleanliness (ie, the level of cleanliness routinely achieved using normal cleaning procedures) must also be taken into consideration, or the efficacy of modified cleaning will be overestimated.

A cluster of Listeria monocytogenes infections in hospitalized adults - Corrected Proof

2010-06-07

Background: Listeriosis occurs mainly in persons at extremes of age and with immunocompromising conditions. It is believed that most cases of listeriosis are acquired in the community. A cluster of listeriosis in hospitalized patients prompted the present investigation.Methods: We conducted a case series study of listeriosis from August 21, 2006, to June 1, 2007, in a hospital in the city of Rio de Janeiro, Brazil.Results: Six patients with Listeria monocytogenes infection were identified: 5 during hospitalization and 1 at a day clinic. By the time the infection was diagnosed, 5 patients had been in the hospital for a mean of 9 days. All patients were elderly (median age, 80 years) and had immunocompromising conditions. Five (83%) patients died. Four patients developed bloodstream infections, 3 caused by serotype 1/2b. Two patients had peritonitis: one caused by serotype 3b and another by serotype 1/2b. Four L monocytogenes isolates belonged to a single pulse-field gel electrophoresis genotype, suggesting a common source. An epidemiologic investigation pointed to the hospital kitchen as the possible contamination.Conclusion: Data suggest a health care-associated outbreak of listeriosis and highlight the importance of developing guidelines for prevention and treatment of health care-associated foodborne diseases, especially in hospitals with immunocompromised adult patients.

Real-time validation and presentation of the cumulative antibiogram and implications of presenting a standard format using a novel in-house software: ABSOFT - Corrected Proof

Godwin Wilson, Shaherudeen Badarudeen, Angela Godwin — 2010-06-07

Background: Antibiograms must use a standard format to present microbiologic data.Objective: When antibacterials are selected for the treatment of infections, knowledge of the locally most likely causative organisms and the prevalence of resistant pathogens to antibacterial agents are essential. This involves generating a cumulative antibiogram. We designed an in-house novel software to prepare our antibiogram, validate data, and analyze results and assessed the performance of this technology. It should be noted that analysis of specific antibiotic resistance patterns were not a focus of this study.Setting: The study was conducted at Al Khor Hospital, Hamad Medical Corporation, a 110-bed acute care hospital that serves patients in the northern area of Qatar. Positive microbiology cultures excluding surveillance samples, isolated in the microbiology laboratory from January 2008 to December 2008, were entered into an in-house software, ABSOFT, designed by one of the authors.Results: The software produced the antibiogram in a fixed format. Epidemiologic data and comparison of our data to the National Nosocomial Infection Surveillance benchmark for multidrug-resistant organism distribution were also presented real time. Automatic color-coded results in tabular format were printed instantaneously without errors, thus eliminating the need to be reviewed.Conclusion: The paper highlights real-time validation and presentation of the cumulative antibiogram, additionally suggesting the format for reporting using a novel in-house software ABSOFT. This technology provided us an accurate, simple, cost-effective solution to present validated data real-time in a transparent and consistent manner. To our knowledge to date, no uniform format has been recommended for the presentation of cumulative antibiograms.

Patients with Acinetobacter baumannii bloodstream infections are colonized in the gastrointestinal tract with identical strains - Corrected Proof

2010-06-07

In this study, we identified critically ill patients with Acinetobacter baumannii bacteremia and examined perirectal surveillance cultures for the presence of genetically related A baumannii strains using pulsed-field gel electrophoresis to determine whether gut colonization preceded clinical infection. Seven patients with imipenem-resistant A baumannii bacteremia were identified from January to June of 2008. Six of 7 (86%) patients were colonized in the gastrointestinal tract with genetically similar strains preceding their bacteremia.

A stepwise approach to control an outbreak and ongoing transmission of methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit - Corrected Proof

2010-06-07

Background: Preventing methicillin-resistant Staphylococcus aureus (MRSA) transmission in health care facilities where MRSA is endemic is challenging yet critical.Objective: We sought to determine the effectiveness of 2 bundles of interventions for preventing MRSA transmission in a neonatal intensive care unit (NICU).Methods: This retrospective cohort study included infants admitted to our NICU between September 1, 2004, and March 31, 2009. Following a MRSA outbreak between September 2004 and September 2005, preventing ongoing MRSA transmission remained a challenge. In July 2006, bundle-I, including culture-based active surveillance, preemptive contact precaution for up to 72 hours for new admissions, and cohorting assignment of direct caregivers was introduced for eradicating MRSA transmission. Bundle-II began in April 2007 and included bundle-1 measures except that the real-time polymerase chain reaction test replaced culture for the detection of MRSA.Results: This study identified 218 infants who developed MRSA infection or colonization and 151 instances of MRSA transmission during the study period. After instituting bundle-II, the transmission rate declined from 2.9 to 2.1 per 1000 patient-days-at-risk (incidence rate ratio, 1.4; 95% confidence interval: 0.9-2.2), and hospital-acquired MRSA infections declined from 1.3 to 0.5 per 1000 patient-days-at-risk (incidence rate ratio, 2.5; 95% confidence interval: 1.1-5.8).Conclusion: Despite an increasing incidence of MRSA in community settings, preventing MRSA transmission within a NICU is achievable through implementation of optimal intervention strategies.

Barriers to implementing infection prevention and control guidelines during crises: Experiences of health care professionals - Corrected Proof

2010-06-07

Background: Communicable disease crises can endanger the health care system and often require special guidelines. Understanding reasons for nonadherence to crisis guidelines is needed to improve crisis management. We identified and measured barriers and conditions for optimal adherence as perceived by 4 categories of health care professionals.Methods: In-depth interviews were performed (n = 26) to develop a questionnaire for a cross-sectional survey of microbiologists (100% response), infection preventionists (74% response), public health physicians (96% response), and public health nurses (82% response). The groups were asked to appraise barriers encountered during 4 outbreaks (severe acute respiratory syndrome [SARS], Clostridium difficile ribotype 027, rubella, and avian influenza) according to a 5-point Likert scale. When at least 33% of the participants responded “strongly agree,” “agree,” or “rather agree than disagree,” a barrier was defined as “often experienced.” The common (“generic”) barriers were included in a univariate and multivariate model. Barriers specific to the various groups were studied as well.Results: Crisis guidelines were found to have 4 generic barriers to adherence: (1) lack of imperative or precise wording, (2) lack of easily identifiable instructions specific to each profession, (3) lack of concrete performance targets, and (4) lack of timely and adequate guidance on personal protective equipment and other safety measures. The cross-sectional study also yielded profession-specific sets of often-experienced barriers.Conclusions: To improve adherence to crisis guidelines, the generic barriers should be addressed when developing guidelines, irrespective of the infectious agent. Profession-specific barriers require profession-specific strategies to change attitudes, ensure organizational facilities, and provide an adequate setting for crisis management.

Reduction in central line-associated bloodstream infections by implementation of a postinsertion care bundle - Corrected Proof

Karen Guerin, Julia Wagner, Keith Rains, Mary Bessesen — 2010-06-07

Background: Central line-associated bloodstream infections (CLABSIs) cause substantial morbidity and incur excess costs. The use of a central line insertion bundle has been shown to reduce the incidence of CLABSI. Postinsertion care has been included in some studies of CLABSI, but this has not been studied independently of other interventions.Methods: Surveillance for CLABSI was conducted by trained infection preventionists using National Health Safety Network case definitions and device-day measurement methods. During the intervention period, nursing staff used a postinsertion care bundle consisting of daily inspection of the insertion site; site care if the dressing was wet, soiled, or had not been changed for 7 days; documentation of ongoing need for the catheter; proper application of a chlorohexidine gluconate-impregnated sponge at the insertion site; performance of hand hygiene before handling the intravenous system; and application of an alcohol scrub to the infusion hub for 15 seconds before each entry.Results: During the preintervention period, there were 4415 documented catheter-days and 25 CLABSIs, for an incidence density of 5.7 CLABSIs per 1000 catheter-days. After implementation of the interventions, there were 2825 catheter-days and 3 CLABSIs, for an incidence density of 1.1 per 1000 catheter-days. The relative risk for a CLABSI occurring during the postintervention period compared with the preintervention period was 0.19 (95% confidence interval, 0.06-0.63; P = .004).Conclusions: This study demonstrates that implementation of a central venous catheter postinsertion care bundle was associated with a significant reduction in CLABSI in a setting where compliance with the central line insertion bundle was already high.

How much time should long-term care and geriatric rehabilitation facilities (nursing homes) spend on infection control? - Corrected Proof

Peterhans J. van den Broek, Herman J.M. Cools, Mireille Wulf, Philo H.A.C. Das — 2010-06-07

Background: For hospitals, standards for the required number of infection control personnel are outdated and disputed. Such standards are not even available for long-term care and geriatric rehabilitation facilities (ie, nursing homes). This study addressed the question of how much time nursing homes should spend on infection control.Methods: Through group discussions and individual sessions, experienced infection control practitioners, medical microbiologists, and nursing home doctors evaluated the time needed to perform infection control activities in a model nursing home.Results: The number of hours needed was estimated as 513 per 100 beds, or 154 per 10,000 care-days per year.Conclusions: Given that significant differences can be expected among the various facilities identified as nursing homes, long-term care facilities, or geriatric rehabilitation centers, as well as among countries, the standard that we propose for The Netherlands will not be generally applicable. However, the method we have used to determine this standard can be easily applied in other countries and settings.

Risk factors and risk adjustment for surgical site infections in pediatric cardiothoracic surgery patients - Corrected Proof

2010-06-07

Background: The complexity of congenital cardiac defects and the aggressive medical management required to support patients through their recovery place children at high risk for surgical site infection (SSI).Methods: We conducted a retrospective review of children undergoing cardiothoracic surgery at a tertiary care referral center between January 1, 2000, and June 30, 2001. Preoperative, intraoperative, and postoperative data were assessed by multivariate analysis.Results: Of 726 surgical procedures performed in 626 patients, SSIs occurred after 46 procedures performed in 46 patients (6.3%). Infections were superficial (n = 22; 47.8%), deep tissue (n = 7; 15.2%), or organ space (n = 17; 37.0%), including 5 episodes of mediastinitis. Median time to SSI was 10 days; 36% of the infections were identified after discharge. On multivariate analysis, children with SSIs were more likely to have been <30 days old (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.2-70), to have a perioperative medical device, and to use parenteral nutrition (OR, 3.3; 95% CI, 1.4-7.9). Multiple severity of illness scores, the Risk Adjustment for Congenital Heart Surgery (RACHS-1) category, and longer duration of postoperative antimicrobials were not associated with SSI.Conclusions: The use of perioperative medical interventions increases the risk of SSI in young children after cardiac surgery. Prolonged postoperative courses of antimicrobials should be avoided in the absence of documented infection.

Hydrogen peroxide vapor decontamination of an intensive care unit to remove environmental reservoirs of multidrug-resistant gram-negative rods during an outbreak - Corrected Proof

2010-06-07

Multidrug-resistant gram-negative rods (MDR-GNR) are an increasing cause for concern in intensive care units (ICUs). We used hydrogen peroxide vapor (HPV) to decontaminate our entire ICU in an attempt to eradicate undetected environmental contamination during outbreaks of MDR-GNR. Surface sampling identified GNR, including MDR strains, on 10 (48%) of 21 areas cultured after intensive cleaning but before decontamination with HPV, and on no areas after HPV. No new cases of Acinetobacter were identified for approximately 3 months after HPV.

Foley catheter practices and knowledge among Minnesota physicians - Corrected Proof

Dimitri M. Drekonja, Michael A. Kuskowski, James R. Johnson — 2010-06-07

Background: Urinary catheter use is common, and physicians are often unaware of the presence of a catheter in a patient. Despite this, and despite a recent policy change classifying catheter-associated urinary tract infection (CAUTI) as nonreimbursable, little is known regarding physicians' knowledge and attitudes regarding catheters, or their responses to the policy change.Methods: Licensed Minnesota physicians were sent an Internet-based survey regarding indications for Foley catheter placement, effectiveness of interventions for preventing CAUTI, and knowledge of and response to the changed reimbursement policy.Results: Overall, respondents exhibited good knowledge regarding indications for catheterization, with the 2 indications most widely accepted as being valid (critical illness with tenuous volume status and urinary obstruction) receiving the highest appropriateness scores. Most respondents reported awareness of the changed reimbursement policy for CAUTI; fully one-third indicated that because of this change, they now removed catheters earlier than previously. The responses from primary care physicians and surgeons differed significantly in terms of indications for catheterization, methods to prevent CAUTI, and the impact of the policy change on their practice patterns.Conclusions: Respondents demonstrated relatively good knowledge regarding Foley catheter use, and most were aware of the changed CAUTI reimbursement policy. Surgeons and primary care physicians may have different approaches to catheter management. Efforts are needed to translate catheter-related knowledge into good clinical practice.

Can we reduce the spread of influenza in schools with face masks? - Corrected Proof

Sara Y. Del Valle, Raymond Tellier, Gary S. Settles, Julian W. Tang — 2010-06-07

There is sufficient evidence indicating that masks, if worn properly and consistently, are an effective nonpharmaceutical intervention in the control of disease spread. The use of masks during a pandemic can minimize the spread of influenza and its economic impact, yet mask-wearing compliance in adults is often poor. Educating the public on the effectiveness of masks can increase compliance whilst reducing morbidity and mortality. With targeted campaigns and the help of the fashion industry, masks may become a popular accessory amongst school children. As children are effective source-transmitters of infection, encouraging a trend toward such increased mask-wearing could result in a significant, self-perpetuating reduction mechanism for limiting influenza transmission in schools during a pandemic.

Prospective study of colonization and infection because of Pseudomonas aeruginosa in mechanically ventilated patients at a neonatal intensive care unit in China - Corrected Proof

Hong-bo Hu, Han-ju Huang, Qiao-ying Peng, Jia Lu, Xing-yun Lei — 2010-06-04

Background: Ventilator-associated pneumonia (VAP) is an important nosocomial infection at neonatal intensive care units (NICU), frequently caused by Pseudomonas aeruginosa. A 6-month prospective study from January 2009 through June 2009 was performed to investigate the respective contribution of endogenous and exogenous transmission of P aeruginosa in the respiratory colonization or/and infection in the mechanically ventilated patients at a NICU to identify routes of lung infection with P aeruginosa and to assess risk factors for colonization or respiratory infection with P aeruginosa.Methods: Samples from oropharyngeal swab, tracheobronchial aspirates, gastric aspirate, and rectal swab were obtained in each patient after intubation and then twice a week. Surveillance cultures for the presence of P aeruginosa from environmental surfaces of the ICU were taken once every 5 days during the study period. Pulsed-field gel electrophoresis was used to characterize the clonal relatedness of the strains by SpeI-digested genomic DNA.Results: Eighteen patients (78.3%) had colonization of the upper respiratory tract. Sixteen (69.6%) patients with colonization of the respiratory tract were infected from other patients or environmental surfaces, which was considered exogenous, and, among strains causing pulmonary infection, there were 4 (50%) patients with exogenous infection. Eight of these developed VAP after a mean of 9 ± 3.4 days. The incidence of P aeruginosa VAP on the unit was 6.2%. The respiratory tract was the earliest site of colonization in all patients of VAP. Low birth weight, duration of mechanical ventilation, previous ampicillin group use, and previous second-generation cephalosporins use were independently associated with patient-related acquisition of P aeruginosa.Conclusion: Our results confirm that the upper respiratory tract acts as an important reservoir of P aeruginosa colonization and infection in the mechanically ventilated patients and emphasize the importance of exogenous acquisition of P aeruginosa. A combination of early identification and eradication of airways colonization by P aeruginosa plus infection control measures may be the basis to prevent pulmonary infection.

Post-cesarean delivery infectious morbidity: Focus on preoperative antibiotics and methicillin-resistant Staphylococcus aureus - Corrected Proof

Andrea Ries Thurman, Yadira Anca, Cassandra A. White, David E. Soper — 2010-06-04

Background: Randomized controlled trials show that administering preoperative antibiotics prior to cesarean delivery (CD) significantly reduces the incidence of post-CD infectious morbidity. Methicillin-resistant Staphylococcus aureus (MRSA) has become prevalent in obstetrics and gynecology. The objective of this trial is to examine infectious morbidity in a clinical setting before versus after implementation of a preoperative antibiotic policy and, further, to describe the organisms cultured from CD wound infections.Methods: We used a retrospective chart review of women delivering by CD before and after implementation of preoperative antibiotic policy.Results: Prior to instituting the preoperative antibiotic policy, the incidence of post-CD infectious morbidity was 20.7% and dropped to 8.5% after the policy was established (P < .001). Study cohorts were similar (P > .05) in several risk factors for infection. MRSA was the most common organism isolated from post-CD wound infections (18/34, 53%). Endomyometritis accounted for the majority of post-CD infections (143/191, 74.9%), and most infections occurred within 7 days of CD (170/191, 89.0%).Conclusion: The incidence of post-CD infectious complications decreased after a policy of administering preoperative antibiotics was instituted. MRSA was the most common organism isolated from post-CD wound infections. Further studies into the benefit of MRSA coverage in CD preoperative antibiotic regimens are needed.

Hospital methicillin-resistant Staphylococcus aureus active surveillance practices in Los Angeles County: Implications of legislation-based infection control, 2008 - Corrected Proof

2010-05-17

Pending California legislation prompted an on-line survey of methicillin-resistant Staphylococcus aureus (MRSA) active surveillance practices administered to infection preventionists of all 102 acute care licensed hospitals in Los Angeles County. We describe reported surveillance methods. Ninety-six hospitals responded with 41% performing MRSA active surveillance. Comments indicated resistance to implementation of active surveillance because its benefits remain controversial.

Predictors of mortality of Acinetobacter baumannii infections: A 2-year prospective study in a Greek surgical intensive care unit - Corrected Proof

2010-05-17

Background: Nosocomial infections are a frequent and continuously increasing problem worldwide, have a rapidly increasing multidrug resistance to antibiotics, and are associated with significant morbidity and mortality.Objective: Our objectives were to evaluate Acinetobacter baumannii infection incidence in our surgical intensive care unit (SICU), the clinical features and outcome of these patients, and, particularly, to investigate predictors of A baumannii infection-related mortality.Methods: Ours was a prospective study of all patients with ICU-acquired A baumannii infection from January 1, 2006, to December 31, 2007.Results: Among 680 patients, 60 (8.8%) sustained A baumannii infection. Mean age was 68.4 ± 6.2 years, Acute Physiology and Chronic Health Evaluation (APACHE) II score on SICU admission 20.6 ± 8.1 and Sequential Organ Failure Assessment (SOFA) score on infection day 9.5 ± 4.2 (women: 50%). Multidrug resistance, morbidity, and mortality were 45%, 65%, and 46.6% (n = 28), respectively. In multivariate analysis, age (P = .03; odds ratio [OR], 1.13; 95% confidence interval [CI]: 1.018-1.259), acute renal failure (P = .001; OR, 17.9; 95% CI: 6.628-75.565), and thrombocytopenia (P = .03; OR, 26.4; 95% CI: 1.234-56.926) complicating the infection and subsequent Enterococcus faecium bacteremia (P = .01; OR, 3.5; 95% CI: 1.84-6.95) were mortality predictors.Conclusion: A baumannii infections are frequent and associated with high drug multiresistance, morbidity, and mortality. Age, renal failure, thrombocytopenia, and subsequent E faecium bacteremia were predictors of A baumannii infection-associated mortality.

A preliminary assessment of the occupational risk of acquiring Legionnaires' disease for people working in telephone manholes, a new workplace environment for Legionella growth - Corrected Proof

2010-05-17

Background: Telephone manholes (TMs) are underground wells, used in Italy by the telecommunication companies to locate telephone networks. Following a fatal case of Legionnaires' disease (LD), acquired during working activity in a TM, we investigated whether Legionella was present in TMs and could be a risk for manhole workers (MWs).Methods: Three hundred fifty-three environmental samples were collected from 100 TMs, and serum antibody titer against Legionella pneumophila and Legionella species non-pneumophila was determined from both MWs and control non-manhole workers.Results: L pneumophila and Legionella species non-pneumophila were detected in 28% of water samples, in 8% of the biofilm, and in 6% of sediment matrices taken in TMs, in a concentration range of 102 to 104 colony-forming units/L. No Legionella was found in TM air samples. Although there was a statistically significant difference (P = .027) in antibody titer to L pneumophila serogroup 1 (Lp1) between MWs and non-manhole workers, a multivariate logistic regression analysis showed a significant association between antibody against Lp1 and both age group and the practice of aquatic sports.Conclusion: Although further investigations will be performed to quantify the risk of acquiring legionellosis, this preliminary study demonstrates for the first time the presence of Legionella, including human pathogenic species, in a working environment such as TM.

Role of nasal methicillin-resistant Staphylococcus aureus screening in the management of skin and soft tissue infections - Corrected Proof

Anneliese M. Schleyer, Kenneth M. Jarman, Jeannie D. Chan, Timothy H. Dellit — 2010-04-26

We set out to determine whether nasal swab isolates can identify methicillin-resistant Staphylococcus aureus (MRSA) colonization and guide therapy in skin and soft tissue infections (SSTI). Among hospitalized patients admitted to a general medicine service with SSTI, specificity and positive predictive value for MRSA in nasal swab isolates were 100%; sensitivity was 55%. Thus, positive nasal swab cultures may help identify MRSA colonization and guide antimicrobial therapy for SSTI when wound cultures cannot be obtained.

New interventions to increase influenza vaccination rates in health care workers - Corrected Proof

2010-04-26

Background: The most effective strategy for avoiding nosocomial influenza outbreaks is through vaccination of health care workers (HCWs). In Spain, HCW vaccination coverage rarely exceeds 25%. The objective of this study was to determine whether an active vaccination campaign promoting communication among HCWs increased influenza vaccination coverage rates and permitted a shorter campaign.Methods: This was a before-after trial, comparing free mobile vaccination teams without and with strategies promoting HCW involvement by means of weekly educational and promotional messages through electronic mail, including 2 prize draws for vaccinated HCWs and a Web page including pictures of vaccinated HCWs and all senior hospital management. Weekly coverages were publicized, the staff of mobile units was increased, and their routes in the hospital were advertised. The study population was >4500 HCWs (permanent and temporary staff) at a Spanish university hospital during the 2007-08 and 2008-09 influenza seasons.Results: Coverage was 23% (95% confidence interval [CI], 22.5%-24.9%) in the 2007-08 season and 37% (95% CI, 34.7%-37.4%) in 2008-09 season. The vaccination rate was highest in HCWs aged ≥65 years and in physicians. The weekly vaccination rates were significantly higher for the 2008-09 season compared with the 2007-08 season except for the first and third weeks; for example, in week 2, the rate was 1.7 HCWs per 100 persons-week (95% CI, 1.3-2.1) in 2007-08, compared with 3.7 HCWs per 100 persons-week (95% CI, 3.2-4.4) in 2009-09. Rate increases were concentrated in the first weeks of the program, with a peak occurring in week 3 during the 2007-08 season and in week 2 during the 2008-09 season.Conclusion: This intervention improved influenza vaccination coverage of HCWs and allowed more rapid achievement of higher coverage.

Changing the culture of hand hygiene compliance using a bundle that includes a violation letter - Corrected Proof

Teresa Chou, James Kerridge, Mandavi Kulkarni, Katie Wickman, James Malow — 2010-04-26

Hand hygiene is the best method of preventing transmission of infections in health care, but compliance is usually suboptimal. In one hospital, compliance with hand hygiene was improved and sustained using a multifaceted bundle approach. A unique aspect of the bundle was the creation of a violation letter that was sent to and enforced by managers of noncompliant personnel. The letter appeared to be the major factor in raising the hand hygiene compliance rate from 34% to >90% in a 2-year period.

Provision and use of safety-engineered medical devices among home care and hospice nurses in North Carolina - Corrected Proof

Jack K. Leiss — 2010-04-26

Background: Nurses who provide care in the home are at risk of blood exposure from needlesticks. Using safety-engineered medical devices reduces the risk of needlestick. The objectives of this study were to assess provision of safety devices by home care and hospice agencies as well as the use of these devices by home care and hospice nurses in North Carolina, and to examine the association between provision and use.Methods: A mail survey was conducted among North Carolina home care and hospice nurses in 2006.Results: The adjusted response rate was 69% (n = 833). The percentage of nurses who were always provided with safety devices ranged from 51% (blood tube holders) to 83% (winged steel needles). Ninety-five percent of nurses who were always provided with safety devices, but only 15%-50% of nurses who were not always provided with safety devices, used a safety device the last time they used that general type of device. Among nurses who did not use a safety device on that occasion, 60%-80% did not use it because it was not provided by the agency.Conclusion: This study suggests that limited access is the primary reason for home care/hospice nurses' failure to use safety devices. The policy goal of providing safety devices to health care workers in all situations in which such devices could reduce their risk of needlestick is not being achieved for home care nurses in North Carolina.

Mild form of 2009 H1N1 influenza infection detected by active surveillance: Implications for infection control - Corrected Proof

Ina Jeong, Chang-hoon Lee, Deog Kyeom Kim, Hee Soon Chung, Sang Won Park — 2010-04-26

Background: Screening patients with suspected influenza is a key step for infection control within communities and institutions. By analyzing the clinical characteristics of mild 2009 H1N1 influenza cases detected by active surveillance, we assessed the utility of the commonly used influenza case definition.Methods: We retrospectively reviewed medical records of 44 patients who were hospitalized and quarantined and who tested positive for the 2009 H1N1 virus using real-time reverse-transcriptase polymerase chain reaction between May 29 and July 28, 2009.Results: Patient median age was 17 years (range, 8-79 years), and 37 patients were male (84%). Common symptoms included cough (34/44; 77.3%), subjective fever (23/44; 52.3%), rhinorrhea or nasal congestion (22/44; 50%), sore throat (19/44; 43.2%), and diarrhea (7/44; 15.9%). All patients were treated with oseltamivir after the onset of initial symptoms (mean, 2.6 days). Common laboratory test results included leucopenia (23/44; 52.3%) and mildly elevated C-reactive protein (26/44; 59.1%).Conclusion: There were many mild afebrile cases of the 2009 pandemic H1N1 influenza. Cough, mild leukopenia, and mildly elevated C-reactive protein were relatively common clinical manifestations. Thus, case-based surveillance for the index cluster of 2009 pandemic influenza is not an effective method for infection control in communities or hospital settings.

Health-associated infections in a pediatric nephrology unit in China - Corrected Proof

Qingli Zhang, Xiaonan Xu, Joanne M. Langley, Baoquan Zhu, Ni Zhang, Yuying Tang — 2010-04-23

Background: Health care-associated infection (HAI) in children is associated with morbidity and mortality, prolonged hospital stay, and increased health care costs. We report the prevalence of HAIs in children admitted to the pediatric nephrology unit of a large tertiary care pediatric hospital in China between 2000 and 2008.Methods: A prospective infection control surveillance program led by physicians identified HAIs in admitted patients and sent monthly summary data to the hospital's Nosocomial Infections Committee. Infections at any body site meeting the Center for Disease Control and Prevention's former National Nosocomial Infection Surveillance System definitions were eligible for inclusion. Over the study period, various infection prevention and control strategies were introduced, including education on hand hygiene, measures to ensure appropriate antimicrobial prophylaxis for patients, and a guideline for antibiotic use.Results: Of the 971 patients admitted, 81 had a total of 89 episodes of HAI (9.16%; 89/971); 75 patients (92.6%) had one HAI. The percentage of children acquiring HAI decreased from 12% to 6% over the observation period, representing a statistically significant linear trend. The most common type of HAI was respiratory tract infection (65.16%; n = 58), followed by gastrointestinal tract infection (11.24%; n = 10), skin and soft tissue infection (8.99% (n = 8), bloodstream infection (7.87%; n = 7), and urinary tract infection (6.74%; n = 6).Conclusions: The incidence of HAI in a pediatric nephrology ward decreased over an 8-year period, associated with a surveillance program and education directed at hand hygiene and appropriate antibiotic use. Despite a strict visitor policy, respiratory tract infection was the most common HAI seen.

Health care-associated and community-associated methicillin-resistant Staphylococcus aureus infections: A comparison of definitions - Corrected Proof

Natalie L. McCarthy, Patrick S. Sullivan, Robert Gaynes, David Rimland — 2010-04-23

Background: Different approaches are used to classify methicillin-resistant Staphylococcus aureus (MRSA) infections as either community-acquired (CA-MRSA) or health care-associated MRSA (HA-MRSA).Methods: We collected information on patients seen at the Atlanta Veterans Affairs Medical Center with MRSA infections from June 2007 through May 2008. We classified MRSA infections as either HA or CA using an epidemiologic definition and an antibiotic susceptibility phenotype rule. We used multivariate logistic regression to describe factors significantly associated with HA-MRSA infections compared with CA-MRSA infections.Results: Using the epidemiologic definition to classify infections, we found white race (odds ratio [OR], 3.2; 95% confidence interval [CI]: 2.0-5.2), oral antibiotics in the 3 months prior (OR, 4.0; 95% CI: 1.5-10.4), and endoscopy in the past year (OR, 3.8; 95% CI: 1.8-8.0) were significantly associated with health care-associated infections. When classifying by the resistance phenotype rule, we found hospitalization in the past year (OR: 1.8; 95% CI: 1.1-3.1) and an indwelling device in the past year (OR: 6.3; 95% CI: 2.5-15.8) were significantly associated with health care-associated infections.Conclusion: We found few differences between CA- and HA-MRSA infections, regardless of how health care-association was defined. We believe that the migration of CA-MRSA into health care settings and the recent increasing antibiotic resistance of CA-MRSA strains contribute to the lack of factors associated with HA (vs CA) MRSA.

Molecular surveillance of Staphylococcus aureus colonization in a neonatal intensive care unit - Corrected Proof

Kanokporn Mongkolrattanothai, Peggy Mankin, Joanna Cranston, Barry M. Gray — 2010-04-23

In a survey of staphylococcal colonization, Staphylococcus aureus was detected in 7 of 67 infants (10%). Two of the infants (3%) carried methicillin-resistant S aureus (MRSA), revealing an unsuspected transmission of MRSA within the neonatal intensive care unit. Molecular surveillance of S aureus provided useful information to improve infection control practices.

Seroprevalence of hepatitis C and B among blood donors in Egypt: Minya Governorate, 2000-2008 - Corrected Proof

Mahmoud Aboelneen Khattab, Mohammed Eslam, Mohammed Ahmed Sharwae, Lamia Hamdy — 2010-04-19

It is an interesting issue to study the prevalence of hepatitis C and B viruses in Egypt in the last decade. In this study, the overall hepatitis B surface antigen and antibody to hepatitis C virus prevalence were 1.65% and 9.02%, respectively. Antibody to hepatitis C virus and hepatitis B surface antigen prevalence estimates dropped from 11.06% to 6.3% (P = .001) and 1.24% to 1.17% (P = .2), respectively.

Decreasing ventilator-associated pneumonia in adult intensive care units using the Institute for Healthcare Improvement bundle - Corrected Proof

Jaffar A. Al-Tawfiq, Mahmoud S. Abed — 2010-04-19

Background: Ventilator-associated pneumonia (VAP) increases in-hospital mortality of ventilated patients to 46%, compared with 32% for ventilated patients who do not develop VAP. In addition, VAP prolongs time spent on the ventilator, length of intensive care unit (ICU) stay, and length of hospital stay.Methods: In this study, we implemented VAP bundle to decrease the rate of VAP infection. This is a pre- and postintervention trial beginning in 2006 to decrease the rate of VAP in adult ICUs after initiation of the Institute for Healthcare Improvement (IHI) VAP bundle compared with the VAP rate for the preceding 12 months. The study was conducted at a private general hospital in Saudi Arabia. The study included all adult patients who were on mechanical ventilation from 2006 to 2008. An interdisciplinary performance improvement team was formed. The team implemented an evidence-based VAP bundle adopted from the IHI.Results: The implementation of the VAP prevention bundle resulted in the reduction of VAP rates from a mean of 9.3 cases per 1000 ventilator-days in fiscal year 2006 to 2.3 cases per 1000 ventilator-days in 2007 and to 2.2 in 2008 (P < .001). It is estimated that each VAP case increases the hospital length of stay attributable by 10 days and the mean hospital cost by $40,000. Thus, the potential decrease in hospital cost is $780,000 annually.Conclusion: Implementing the IHI VAP bundle significantly resulted in the reduction of the VAP rate with potential great cost avoidance.

Clostridium difficile colitis: A retrospective study of incidence and severity before and after institution of an alcohol-based hand rub policy - Corrected Proof

2010-04-14

Background: Clostridium difficile‒associated diarrhea is a leading cause of hospital-acquired diarrhea. We sought to determine whether the institution of a hospital-wide alcohol-based hand rub (ABHR) policy was associated with an increase in the incidence and/or severity of health care facility‒onset, health care facility‒associated C difficile diarrhea (CDAD).Methods: We used a retrospective chart review analysis to compare incidence rates of CDAD before and after implementation of the ABHR policy. We also compared rates of sepsis, colectomy, and death in patients with CDAD before and after implementation of the ABHR policy.Results: The incidence rate of CDAD was 3.98 per 10,000 patient-days after implementation of the ABHR policy, compared with 4.96 per 10,000 patient-days before implementation (P = .0036). The crude mortality rate in patients diagnosed with CDAD was 10.7% after implementation, compared with 13.3% before implementation (P = .275). The rate of sepsis in patients diagnosed with CDAD was 19.6% after implementation, compared with 5.2% before implementation (P < .0001).Conclusion: Our data provide no evidence of an increased CDAD rate after implementation of an ABHR policy at our institution. The rate of sepsis in patients diagnosed with CDAD did rise, indicating increased severity of illness in patients with C difficile infection.

Hospital-acquired conjunctivitis in a neonatal intensive care unit: Bacterial etiology and susceptibility patterns - Corrected Proof

2010-04-14

Our study investigates the causative pathogens of hospital-acquired conjunctivitis in our neonatal intensive care unit and their susceptibility patterns. Coagulase-negative Staphylococcus was the most common bacterium, 22.1% of all isolates. The frequency of the pathogens changed during neonates' stay; Klebsiella pneumoniae (from 18% to 6.9%) and Escherichia coli (from 16% to 4.8%) decreased, whereas methicillin-susceptible Staphylococcus aureus (from 4% to 12.7%) and Enterococcus spp (from 1% to 5.3%) increased. Gram-positive cocci showed high resistant patterns. Our study indicates that the distribution of bacteria causing hospital-acquired conjunctivitis in our neonates shifted from gram-negative to gram-positive microorganisms during their neonatal intensive care unit stay. The resistance patterns are worrisome among gram-positive cocci.

Spreading the handwashing message: An alternative to traditional media campaigns - Corrected Proof

2010-04-12

Schools are a natural place from which to disseminate health messages to the community. Sending an entertaining handwashing video home with preschoolers as a component of a school-based program yielded impressive degrees of penetration and reach among families; consequently, this strategy offers a promising alternative to traditional media campaigns.

A program to limit urinary catheter use at an acute care hospital - Corrected Proof

Alan F. Rothfeld, Avelyne Stickley — 2010-04-12

Background: Urinary catheters are the major cause of catheter-associated urinary tract infections (CAUTIs) and often may be unnecessary. We attempted to reduce the number of CAUTIs by limiting the use of urinary catheters.Methods: The number of catheters and CAUTIs were recorded during a control period of 7 months. A program was implemented limiting these catheters to patients who had urinary tract obstruction, orders for hourly output measurements, breakdown of skin in areas exposed to urine in patients with documented urinary tract infections, or urine- associated skin irritation that was unresponsive to barrier measures. In patients who did not meet these criteria, the physician was asked for a catheter removal order, and superabsorbent pads or diapers were used. Urinary catheter use and CAUTIs were then recorded during a subsequent 5-month intervention period. Nursing personnel were queried regarding their experience after 4 months of the intervention period.Results: Urinary catheter use decreased by 42% (P <.01), and the incidence of CAUTIs decreased by 57% (P <.05). There was some improvement in nursing satisfaction.Conclusion: Limiting urinary catheter use can reduce the incidence of CAUTI with no deterioration in nursing satisfaction.

The value of multiple surveillance cultures for methicillin-resistant Staphylococcus aureus - Corrected Proof

Kevin R. Forward — 2010-04-09

Background: We evaluated our experience in a low prevalence setting to determine the extent to which multiple swabs increased detection rates and the incremental costs of doing so.Methods: Nasal and groin swabs submitted in pairs were cultured onto a single plate (Oxoid MRSA Denim Blue Agar; Oxoid Company, Napean, ON, Canada). We determined whether MRSA was detected when swabs submitted in the preceding 3 days were negative. We explored the costs associated with screening and of each additional colonized patient detected.Results: In all, 60,049 paired nose and perineal swabs were submitted from 21,599 patients. In all, there were 12,750 duplicate, 1437 triplicate, and 112 instances when >4 swabs were processed within 3 days. The first culture was positive in 106 of 12,750 (0.83%%), 42 of 12,750 (0.33%) on the second when the first was negative, 7 of 1642 (0.43%) on the third or subsequent swab pair when the preceding 2 were negative.Conclusion: Overall, the sensitivity of the first of multiple cultures of a set was 74.3%. Had the 14,392 multiple samples not been submitted, 49 colonized patients would not have been identified. Additional laboratory costs associated with multiple samples equaled $2088 per patient identified.

Risk factors for fluconazole resistance in patients with Candida glabrata bloodstream infection: Potential impact of control group selection on characterizing the association between previous fluconazole use and fluconazole resistance - Corrected Proof

2010-04-05

Background: Although Candida glabrata is an emerging infection, risk factors for fluconazole resistance in patients with C glabrata bloodstram infection (BSI) have not been well elucidated.Methods: A case-control study was conducted to evaluate the primary risk factor of interest, previous fluconazole use, adjusting for demographics, comorbidities, time at risk, and antimicrobial exposure and assessing for effect modification. Secondary analyses were performed limiting the case group to C glabrata BSIs with a minimum inhibitory concentration (MIC) ≥64 μg/mL.Results: Previous fluconazole use was not a significant risk factor for fluconazole-resistant C glabrata BSI in primary analysis (adjusted odds ratio [aOR], 1.5; 95% confidence interval [CI], 0.7-3.2) but was borderline significant in secondary analysis (aOR, 3.2; 95% CI, 0.9-11.3). Increased time at risk was an independent risk factor in primary (aOR, 1.02; 95% CI, 1.002-1.04) and secondary analyses (aOR, 1.03; 95% CI, 1.004-1.06).Conclusions: Increased time at risk was the only significant risk factor for fluconazole resistance. Future studies are needed to further evaluate the relationship between previous fluconazole use and fluconazole-resistant C glabrata BSI isolates with MIC ≥64 μg/mL.

Increased use of alcohol-based hand sanitizers and successful eradication of methicillin-resistant Staphylococcus aureus from a neonatal intensive care unit: A multivariate time series analysis - Corrected Proof

Fumie Sakamoto, Hiroko Yamada, Chieko Suzuki, Hideko Sugiura, Yasuharu Tokuda — 2010-04-05

Background: We analyzed time series data to investigate factors that contributed to the gradual decrease and eventual eradication of methicillin-resistant Staphylococcus aureus (MRSA) from our neonatal intensive care unit (NICU).Methods: A multivariate adjusted autoregressive integrated moving average (ARIMA) model was used for time series analyses of monthly MRSA incidence density rates and their predictors in the NICU from July 2003 to July 2009.Results: Based on our ARIMA (0,1,1), which is a nonseasonal and nonstationary moving average model, the monthly pooled mean of the amount of alcohol-based hand sanitizer used for 1 patient per day (lag time, 0 month; P = .011) was the only factor significantly associated with the MRSA incidence density rates. MRSA colonization pressure, patient-to-nurse ratios, and bed occupancy rates were not associated with MRSA acquisition in the NICU. Active surveillance, which had been practiced since the late 1980s, alone was not sufficient to control the spread of MRSA until it was accompanied by enhanced hand hygiene.Conclusion: Increasing the use of alcohol-based hand sanitizers by improving accessibility and providing periodic hand hygiene training sessions to health care workers is strongly recommended for decreasing the risk of MRSA acquisition among neonates in NICU settings.

Investigation of Panton-Valentine leukocidin expressing Staphylococcus aureus colonization among children in a child care center - Corrected Proof

2010-04-05

The presence of Panton-Valentine leukocidin expressing Staphylococcus aureus colonization was investigated with a qualitative nucleic acid hybridization assay among 122 children and 19 staff in a child care center. Genotyping of 5 Panton-Valentine leukocidin-positive isolates by pulsed-field gel electrophoresis revealed that one child and a teacher from the same class were colonized with the clonally related strains. This finding allowed us to suggest that close contact with colonized people is a risk factor for being colonized.

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

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

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

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

2010-03-15

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

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

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

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

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

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

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