To describe the French program for the prevention of healthcare-associated infections and antibiotic resistance and provide results for some of the indicators available to evaluate the program. In addition to structures and process indicators, the 2 outcome indicators selected were the rate of surgical site infection and the proportion of methicillin-resistant Staphylococcus aureus (MRSA) isolates among the S. aureus isolates recovered.

Descriptive study of the evolution of the national structures for control of healthcare-associated infections since 1992. Through national surveillance networks, process indicators were available from 1993 to 2006, surgical site infection rates were available from 1999 to 2005, and prevalence rates for MRSA infection were available from 2001 to 2007.

A comprehensive national program has gradually been set up in France during the period from 1993 to 2004, which included strengthening of organized infection control activities at the local, regional, and national levels and developing large networks for surveillance of specific infections and antibiotic resistance. These achievements were complemented by instituting mandatory notification for unusual nosocomial events, especially outbreaks. The second phase of the program involved the implementation of 5 national quality indicators with public reporting. Surgical site infection rates decreased by 25% over a 6-year period. In France, the median proportion of MRSA among S. aureus isolates recovered from patients with bacteremia decreased from 33.4% to 25.7% during the period from 2001 to 2007, whereas this proportion increased in many other European countries.

Very few national programs have been evaluated since the Study on the Efficacy of Nosocomial Infection Control. Although continuing efforts are required, the French program appears to have been effective at reducing infection rates.

The presence of methicillin-resistant Staphylococcus aureus (MRSA) and glycopeptide-intermediate S. aureus (GISA) in hospitals poses a significant challenge to hospital infection control teams. The use of disinfectants for both surface and hand cleaning is an essential part of the infection control measures.

To evaluate the effectiveness of common hospital hand disinfectants against MRSA, GISA, and heterogeneous GISA (hGISA).

For methicillin-susceptible S. aureus (MSSA), MRSA, GISA, and hGISA, the levels of susceptibility to hand disinfectants and their active ingredients were determined. Suspension tests were performed on commercial handwashing products.

Minimum inhibitory concentrations (MICs) of 2-propanol, Chlorhexidine, and hexachlorophene were similar for all phenotypes. The MICs of cetrimide and triclosan were higher for the MRSA, GISA, and hGISA strains than for the MSSA strain. The MICs for the chlorhexidine-containing agents Hibisol and Hibiscrub (AstraZeneca) and for the propanol-containing agent Sterillium (Medline) were 1-2-fold lower for the MSSA strains than for the MRSA, GISA, and hGISA strains. Suspension tests showed that the GISA and hGISA strains were less susceptible to the triclosan-containing agent Aquasept (SSL) than were the MRSA and MSSA strains, with resistance increasing with glycopeptide resistance. Products containing Betadine (Purdue) were more effective against the GISA and hGISA strains than against the MRSA and MSSA strains, especially after the strain was exposed to the product for 30 seconds.

Using the EN 1040 standard criteria for the performance of disinfectants, we determined that all agents, except 50% Aquasept for hGISA and 0.33% hexachlorophene for GISA, performed effectively. However, the GISA and hGISA strains were less susceptible to triclosan-containing products, compared with the MRSA stains, but were more susceptible to products containing Betadine.

To evaluate the effectiveness of the oral application of a 0.12% solution of Chlorhexidine for prevention of respiratory tract infections among intensive care unit (ICU) patients.

The study design was a double-blind, randomized, placebo-controlled trial.

The study was performed in an ICU in a tertiary care hospital at a public university.

Study participants comprised 194 patients admitted to the ICU with a prospective length of stay greater than 48 hours, randomized into 2 groups: those who received Chlorhexidine (n = 98) and those who received a placebo (n = 96).

Oral rinses with Chlorhexidine or a placebo were performed 3 times a day throughout the duration of the patient's stay in the ICU. Clinical data were collected prospectively.

Both groups displayed similar baseline clinical features. The overall incidence of respiratory tract infections (RR, 1.0 [95% confidence interval [CI], 0.63-1.60]) and the rates of ventilator-associated pneumonia per 1,000 ventilator-days were similar in both experimental and control groups (22.6 vs 22.3; P = .95). Respiratory tract infection-free survival time (7.8 vs 6.9 days; P = .61), duration of mechanical ventilation (11.1 vs 11.0 days; P = .61), and length of stay (9.7 vs 10.4 days; P = .67) did not differ between the Chlorhexidine and placebo groups. However, patients in the Chlorhexidine group exhibited a larger interval between ICU admission and onset of the first respiratory tract infection (11.3 vs 7.6 days; P = .05). The chances of surviving the ICU stay were similar (RR, 1.08 [95% CI, 0.72-1.63]).

Oral application of a 0.12% solution of Chlorhexidine does not prevent respiratory tract infections among ICU patients, although it may retard their onset.

Oral metronidazole has been recommended for treatment of mild-to-moderate Clostridium difficile–associated disease (CDAD), in part because of concern that use of vancomycin may be more likely to promote colonization and transmission of vancomycin-resistant enterococci (VRE). The objective of our study was to compare the frequency of skin and environmental VRE contamination associated with metronidazole treatment for CDAD with such frequency associated with vancomycin treatment for CDAD.

Prospective, observational study. This study was performed at the Cleveland Veterans Affairs Medical Center (Cleveland, OH). For patients with CDAD who had concurrent VRE colonization, stool, skin, and environmental samples were cultured for VRE before, during, and up to 3 weeks after therapy with metronidazole or vancomycin. The proportions of skin and environmental contamination were compared before and after resolution of diarrhea and during treatment with metronidazole or vancomycin.

Of the 34 patients, 17 were treated with vancomycin and 17 were treated with metronidazole. The proportion of environmental cultures that were positive for VRE was significantly higher during resolution of diarrhea than it was after resolution of diarrhea (38% vs 28%; P = .025), whereas the proportion of skin cultures positive was not different during and after resolution of diarrhea (78% vs 71%; P = .60). There were no differences between patients who received metronidazole and patients who received vancomycin in the proportions of skin culture results (73% vs 77%; P = .80) or environmental culture results (37% vs 32%; P = .359) that were positive for VRE. Eleven patients (32%) had chronic fecal incontinence, and 28 (82%) had incontinence at least once during their CDAD episode.

In VRE-colonized patients with CDAD who experienced frequent fecal incontinence, skin and environmental VRE contamination was common during and after resolution of diarrhea. The frequency of VRE contamination was similar between patients treated with metronidazole and patients treated with vancomycin.

We investigated a cluster of cases of bloodstream infection (BSI) due to the mold Phialemonium at a hemodialysis center in Illinois and conducted a cohort study to identify risk factors.

Environmental assessment and cohort study.

A hemodialysis center in a tertiary care hospital.

A case patient was defined as a person who underwent dialysis at the center and had a blood sample that tested positive for Phialemonium curvatum on culture. We reviewed microbiology and medical records and tested water, surface, and dialysate samples by culture. Molds isolated from environmental and clinical specimens were identified by their morphological features and confirmed by sequencing DNA.

We identified 2 case patients with BSI due to P. curvatum. Both became febrile and hypotensive while undergoing dialysis on the same machine at the same treatment station, although on different days. Dialysis machines were equipped with waste handling option ports that are used to discard dialyzer priming fluid. We isolated P. curvatum from the product water (ie, water used for dialysis purposes) at 2 of 19 treatment stations, one of which was the implicated station.

The source of P. curvatum was likely the water distribution system. To our knowledge, this is the first report of patients acquiring a mold BSI from contaminated product water. The route of exposure in these cases of BSI due to P. curvatum may be related to the malfunction and improper maintenance of the waste handling option ports. Waste handling option ports have been previously implicated as the source of bacterial BSI due to the backflow of waste fluid into a patient's blood line. No additional cases of infection were noted after remediation of the water distribution system and after discontinuing use of waste handling option ports at the facility.

Healthcare-associated, community-acquired bacteremia is a subcategory of community-acquired bacteremia distinguished by recent exposure of the patient to the healthcare system before hospital admission. Our objective was to apply this category to a prospective cohort of hospitalized patients with gram-negative bacteremia to determine differences in the epidemiological characteristics, treatment, and outcome of community-acquired bacteremia; healthcare-associated, community-acquired bacteremia; and hospital-acquired bacteremia.

A 6-month prospective cohort study.

A 1,250-bed tertiary care hospital.

Adults hospitalized with gram-negative bacteremia.

Among 250 patients, 160 (64.0%) had bacteremia within 48 hours after admission; 132 (82.5%) of these were considered to have healthcare-associated, community-acquired bacteremia, according to previously published criteria. For patients with healthcare-associated, community-acquired bacteremia, compared with patients with community-acquired bacteremia, malignancies (59 [44.7%] of 132 patients vs 3 [10.7%] of 28 patients; P = .001), open wounds at admission (42 [31.8%] vs 3 [10.7%]; P = .02), and intravascular catheter-related infections (26 [19.7%] vs 0; P = .009) were more frequent and Escherichia coli as a causative agent was less frequent (16 [57.1%] vs 33 [25.0%]; P = .001). There was no difference between these 2 groups in inadequate empirical antibiotic treatment (36 [27.3%] vs 6 [21.4%]; P = .5) and hospital mortality (18 [13.6%] vs 2 [[7.1%]; P = .5). Compared with 90 patients with hospital-acquired bacteremia, patients with healthcare-associated, community-acquired bacteremia had a higher Charlson score (odds ratio [OR], 1.31 [95% confidence interval (CI), 1.14–1.49]) but were less likely to have lymphoma (OR, 0.07 [95% CI, 0.01–0.51]), neutropenia (OR, 0.21 [95% CI, 0.07–0.61]), a removable foreign body (OR, 0.08 [95% CI, 0.03–0.20]), or Klebsiella pneumoniae infection (OR, 0.26 [95% CI, 0.11–0.62]).

Many cases of gram-negative bacteremia that occurred in hospitalized patients were healthcare associated. The patients differed in some aspects from patients with community-acquired bacteremia and from those with hospital-acquired bacteremia, but not in mortality.

To characterize practices related to measuring influenza vaccination rates among healthcare personnel in US hospitals.

Descriptive survey.

Nonfederal, short-stay hospitals that provide general medical and surgical services, identified by use of the 2004 American Hospital Association Annual Survey Database.

Healthcare personnel from 996 randomly sampled US hospitals stratified by region and bed size.

A self-administered questionnaire was distributed in 2006 to infection control coordinators to gather data on policies and practices related to the provision of the influenza vaccine and on the measurement and reporting of influenza vaccination rates. Descriptive statistics and associations were calculated, and logistic regression was conducted.

The response rate was 56% (ie, 555 of 996 US hospitals responded to the questionnaire). Weighting accounted for sampling design and nonresponse. Most hospitals provided the influenza vaccine to employees (100%), credentialed medical staff (ie, independent practitioners; 94%), volunteers (86%), and contract staff (83%); provision for students and residents was less frequent (58%). Only 69% of hospitals measured vaccination rates (mean coverage rate, 55%). Most hospitals that measured coverage included employees (98%) in the vaccination rates, whereas contract staff (53%), credentialed medical staff (56%), volunteers (56%), and students and residents (30%) were less commonly included. Among hospitals measuring coverage, 44% included persons for which vaccine was contraindicated, and 51% included persons who refused vaccination. After adjustment for region and size, hospitals with vaccination plans written into policy (odds ratio, 2.0 [95% confidence interval, 1.22–7.67]) or that addressed internally reporting coverage (odds ratio, 4.8 [95% confidence interval, 2.97–7.66]) were more likely to measure coverage than were hospitals without such plans.

Hospitals vary in terms of the groups of individuals included in influenza vaccination coverage measurements. Standardized measures may improve comparability of hospital-reported vaccination rates. Measuring coverage in a manner that facilitates identification of occupational groups with low vaccination rates may inform development of targeted interventions.

To evaluate the impact of methicillin-resistant Staphylococcus aureus on the prevalence of S. aureus bloodstream infection among children.

Retrospective analysis of demographic data, risk factors for infection, and clinical outcomes for children (age, less than 18 years) with S. aureus bacteremia hospitalized at a children's hospital during 2001–2006.

We identified 164 episodes of S. aureus bacteremia among 151 children. The prevalence of bacteremia due to methicillin-susceptible S. aureus during 2001–2003 was approximately the same as that during 2004–2006 (29 and 30 cases, respectively, per 10,000 hospitalized children [hereafter, “per 10,000 hospitalizations”]), but the prevalence of bacteremia due to methicillin-resistant S. aureus increased from 4 to 11 cases, respectively, per 10,000 hospitalizations (P = .015). A total of 48% of infections involved children who had S. aureus-positive blood cultures less than 3 days after hospital admission. Seventy-four percent of these children had a preexisting comorbidity. When the prevalence of S. aureus bacteremia was stratified by race, sex, or age, neonates hospitalized at birth and Hispanic children had significantly reduced risks of infection. Children younger than 1 year of age (excluding neonates hospitalized at birth) had an increased prevalence of hospital-onset S. aureus bacteremia. There was a disproportionate increase in the risk of S. aureus bacteremia for each additional week of hospitalization among children with hospital-onset S. aureus bacteremia. Children with methicillin-resistant S. aureus bacteremia had a longer hospital stay, were transferred to another facility at a greater rate than they were discharged home, and had a greater mortality rate, compared with children with methicillin-susceptible S. aureus bacteremia.

This study documents the prevalence of S. aureus bacteremia among children with a high risk for acquiring this infection, and it describes populations of children who are at higher risk for bacteremia due to either methicillin-susceptible or methicillin-resistant S. aureus. Methods to improve prevention of S. aureus bacteremia are needed for children with healthcare-associated risk factors for S. aureus bacteremia.

To investigate a pseudo-outbreak of “Mycobacterium paraffinicum” (unofficial taxon) infection and/or colonization, using isolates recovered from clinical and environmental specimens.

Outbreak investigation.

University-affiliated, tertiary-care hospital.

M. paraffinicum, a slow-growing, nontuberculous species of mycobacteria, was recovered from 21 patients and an ice machine on a single patient care unit over a 2.5-year period. The clinical, epidemiological, and environmental investigation of this pseudo-outbreak is described.

Twenty-one patients with pulmonary symptoms and possible risk factors for tuberculosis were admitted to inpatient rooms that provided airborne isolation conditions in 2 adjacent hospital buildings. In addition, 1 outpatient had induced sputum cultured for mycobacteria in the pulmonary function laboratory. Of the samples obtained from these 21 patients, 26 isolates from respiratory samples and 1 isolate from a stool sample were identified as M. paraffinicum. Environmental isolates obtained from an ice machine in the patient care unit where the majority of the patients were admitted were also identified as M. paraffinicum.

An epidemiological investigation that used molecular tools confirmed the suspicion of a pseudo-outbreak of M. paraffinicum infection and/or colonization. The hospital water system was identified as the source of contamination.

Methicillin-resistant Staphylococcus aureus (MRSA) can cause severe infection in patients who are undergoing vascular surgical operations. Testing all vascular surgery patients preoperatively for MRSA and attempting to decolonize those who have positive results may be a strategy to prevent MRSA infection. The economic value of such a strategy has not yet been determined.

We developed a decision-analytic computer simulation model to determine the economic value of using such a strategy before all vascular surgical procedures from the societal and third-party payer perspectives at different MRSA prevalence and decolonization success rates.

The model showed preoperative MRSA testing to be cost-effective (incremental cost-effectiveness ratio, <$50,000 per quality-adjusted life year) when the MRSA prevalence is ≥0.01 and the decolonization success rate is ≥0.25. In fact, this strategy was dominant (ie, less costly and more effective) at the following thresholds: MRSA prevalence ≥0.01 and decolonization success rate ≥0.5, and MRSA prevalence ≥0.025 and decolonization success rate ≥0.25.

Testing and decolonizing patients for MRSA before vascular surgery may be a cost-effective strategy over a wide range of MRSA prevalence and decolonization success rates.

Controlled studies that took place in medical intensive care units (MICUs) have demonstrated that bathing patients with Chlorhexidine gluconate (CHG) can reduce skin colonization with potential pathogens and can lessen the risk of central venous catheter (CVC)-associated bloodstream infection (BSI).

TO examine, without oversight of practice by research study staff, the effectiveness or real-world effect of patient cleansing with CHG on rates of CVC-associated BSI.

In the fall of 2005, the MICU at Rush University Medical Center discontinued bathing patients daily with soap and water and substituted skin cleansing with no-rinse, 2% CHG-impregnated cloths. This change was a clinical management decision without research input.

A 21-bed MICU at Rush University Medical Center.

Patients hospitalized in the MICU during the period from September 2004 through October 2006.

In a pre-post study design, we gathered data from administrative and laboratory databases, infection control practitioner logs, and patient medical charts to compare rates of CVC-associated BSI and blood culture contamination between the baseline soap-and-water bathing period (September 2004-October 2005) and the CHG bathing period (November 2005-October 2006). Rates of secondary BSI, Clostridium difficile infection (CDI), ventilator-associated pneumonia (VAP), and urinary tract infection (UTI) served as control variables that were not expected to be affected by CHG bathing.

Bathing with CHG was associated with a statistically significant decrease in the rate of CVC-associated BSI (from 5.31 to 0.69 cases per 1,000 CVC-days; P = .006) and in the rate of blood culture contamination (from 6.99 to 4.1 cases per 1,000 patient-days; P = .04). Rates of secondary BSI, CDI, VAP, and UTI did not change significantly.

In our analysis of real-world practice, daily bathing of MICU patients with CHG was effective at reducing rates of CVC-associated BSI and blood culture contamination. Controlled studies are needed to determine whether these beneficial effects extend outside the MICU.

The goal of this effort was to reduce central venous catheter (CVC)-associated bloodstream infections (BSIs) in pediatric intensive care unit (ICU) patients by means of a multicenter evidence-based intervention.

An observational study was conducted in 26 freestanding children's hospitals with pediatric or cardiac ICUs that joined a Child Health Corporation of America collaborative. CVC-associated BSI protocols were implemented using a collaborative process that included catheter insertion and maintenance bundles, daily review of CVC necessity, and daily goals. The primary goal was either a 50% reduction in the CVC-associated BSI rate or a rate of 1.5 CVC-associated BSIs per 1,000 CVC-days in each ICU at the end of a 9-month improvement period. A 12-month sustain period followed the initial improvement period, with the primary goal of maintaining the improvements achieved.

The collaborative median CVC-associated BSI rate decreased from 6.3 CVC-associated BSIs per 1,000 CVC-days at the start of the collaborative to 4.3 CVC-associated BSIs per 1,000 CVC-days at the end of the collaborative. Sixty-five percent of all participants documented a decrease in their CVC-associated BSI rate. Sixty-nine CVC-associated BSIs were prevented across all teams, with an estimated cost avoidance of $2.9 million. Hospitals were able to sustain their improvements during a 12-month sustain period and prevent another 198 infections.

We conclude that our collaborative quality improvement project demonstrated that significant reduction in CVC-associated BSI rates and related costs can be realized by means of evidence-based prevention interventions, enhanced communication among caregivers, standardization of CVC insertion and maintenance processes, enhanced measurement, and empowerment of team members to enforce adherence to best practices.

To describe the epidemiology of bloodstream infection caused by USA300 strains of methicillin-resistant Staphylococcus aureus (MRSA), which are traditionally associated with cases of community-acquired infection, in the healthcare setting.

Retrospective cohort study.

Three academically affiliated hospitals in Denver, Colorado.

Review of cases of S. aureus bloodstream infection during the period from 2003 through 2007. Polymerase chain reaction was used to identify MRSA USA300 isolates.

A total of 330 cases of MRSA bloodstream infection occurred during the study period, of which 286 (87%) were healthcare-associated. The rates of methicillin resistance among the S. aureus isolates recovered did not vary during the study period and were similar among the 3 hospitals. However, the percentages of cases of healthcare-associated MRSA bloodstream infection due to USA300 strains varied substantially among the 3 hospitals: 62%, 19%, and 36% (P < .001) for community-onset cases and 33%, 3%, and 33% (P = .005) for hospital-onset cases, in hospitals A, B, and C, respectively. In addition, the number of cases of healthcare-associated MRSA bloodstream infection caused by USA300 strains increased during the study period at 2 of the 3 hospitals. At each hospital, USA300 strains were most common among cases of community-associated infection and were least common among cases of hospital-onset infection. Admission to hospital A (a safety-net hospital), injection drug use, and human immunodeficiency virus infection were independent risk factors for healthcare-associated MRSA bloodstream infection due to USA300 strains.

The prevalence of USA300 strains among cases of healthcare-associated MRSA bloodstream infection varied dramatically among geographically clustered hospitals. USA300 strains are replacing traditional healthcare-related strains of MRSA in some healthcare settings. Our data suggest that the prevalence of USA300 strains in the community is the dominant factor affecting the prevalence of this strain type in the healthcare setting.

To identify risk factors associated with nosocomial bloodstream infections caused by multiple clones of the staphylococcal cassette chromosome mec (SCCmec) type IV strain of methicillin-resistant Staphylococcus aureus (MRSA).

An unmatched case-control study (at a ratio of 1:2) performed during the period from October 2002 through September 2003.

A 2,000-bed tertiary care teaching hospital affiliated with the University of São Paulo in São Paulo, Brazil.

Case patients (n = 30) were defined either as patients who had a bloodstream infection due to SCCmec type IV MRSA diagnosed at least 48 hours after hospital admission or as neonates with the infection who were born in the hospital. Control patients (n = 60) were defined as patients with SCCmec type III MRSA infection diagnosed at least 48 hours after hospital admission. Genes encoding virulence factors were studied in the isolates recovered from case patients, and molecular typing of the SCCmec type IV MRSA isolates was also done by pulsed-field gel electrophoresis and multilocus sequence typing.

In multivariate analysis, the following 3 variables were significantly associated with having a nosocomial bloodstream infection caused by SCCmec type IV strains of MRSA: an age of less than 1 year, less frequent use of a central venous catheter (odds ratio [OR], 0.07 [95% confidence interval {CI}, 0.02–0.28]; P = .001), and female sex. A second analysis was performed that excluded the case and control patients from the neonatal unit, and, in multivariate analysis, the following variables were significantly associated with having a nosocomial bloodstream infection caused by SCCmec type IV strains of MRSA: less frequent use of a central venous catheter (OR, 0.12 [95% CI, 0.03–0.55]; P = .007), lower Acute Physiology and Chronic Health Evaluation II score on admission (OR, 0.14 [95% CI, 0.03–.61]; P = .009), less frequent surgery (OR, 0.21 [95% CI, 0.06–0.83]; P = .025), and female sex (OR, 5.70 [95% CI, 1.32–24.66]; P = .020). Of the 29 SCCmec type IV MRSA isolates recovered from case patients, none contained the Panton-Valentine leukocidin, λ-hemolysin, enterotoxin B or C, or toxic shock syndrome toxin-1. All of the isolates contained genes for the LukE-LukD leukocidin and α-hemolysin. Genes for enterotoxin A were present in 1 isolate, and genes for β-hemolysin were present in 3 isolates.

“Classical” risk factors do not apply to patients infected with the SCCmec type IV strain of MRSA, which is an important cause of nosocomial bacteremia. This strain infects a patient population that is less ill and has had less frequent invasive procedures than a patient population infected with the multidrug-resistant strain of SCCmec type III MRSA. We found that virulence factors were rare and that Panton-Valentine leukocidin was absent. There were multiple clones of the SCCmec type IV strain in our hospital. Children under 1 year of age were at a higher risk. There was a predominant clone (sequence type 5) in this patient population.

Despite the high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infection in the hospital, the proportion of patients with MRSA bacteremia who receive appropriate empirical therapy remains suboptimal.

To investigate the proportion of patients with MRSA bloodstream infection (BSI) who received appropriate empirical antibiotic therapy and to identify risk factors associated with receipt of appropriate empirical therapy.

We studied a cohort of patients from 10 hospitals. The primary outcome was the proportion of patients who received appropriate empirical antibiotic therapy for MRSA BSI. Appropriate therapy was defined as receipt of daptomycin, linezolid, quinupristin-dalfopristin, or vancomycin within 1 calendar day after the first blood culture result positive for S. aureus (ie, before antimicrobial susceptibilities were known). Multivariable logistic regression was used to determine variables associated with receipt of appropriate empirical therapy.

The study included 562 patients with MRSA BSI. The mean (± standard deviation) age of the patients was 64 ± 16 years, and 288 (51.2%) were male. Only 291 (51.8%) patients received appropriate empirical therapy. Patients were more likely to receive appropriate therapy if they required hemodialysis (odds ratio [OR], 1.36 [95% confidence interval {CI}, 1.00–1.85]), had undergone knee or hip arthroplasty (OR, 3.04 [95% CI, 1.21–7.6]), had a central venous catheter at admission (OR, 1.72 [95% CI, 1.01–2.93]), or had a McCabe score of 1 at admission (OR, 1.83 [95% CI, 1.16–2.83]). Bowel incontinence (OR, 0.41 [95% CI, 0.19–0.92]) and BSIs categorized as primary (OR, 0.41 [95% CI, 0.27–0.63]) were associated with a decreased likelihood of receiving appropriate empirical therapy.

Only half of patients with MRSA BSI received appropriate empirical therapy. Factors associated with receiving appropriate empirical antibiotics included the presence of a central venous catheter at admission and a history of joint arthroplasty. Surprisingly, prior MRSA infection was not predictive of receipt of appropriate antimicrobial therapy.

We examined the usefulness of a simple method to account for incomplete postdischarge follow-up during surveillance of surgical site infection (SSI) by use of the National Nosocomial Infections Surveillance (NNIS) system's risk index.

Retrospective cohort study that used data prospectively collected from 1993 through 2006.

Five private, nonuniversity healthcare facilities in Belo Horizonte, Brazil.

Consecutive patients undergoing the following NNIS operative procedures: 20,981 operations on the genitourinary system, 11,930 abdominal hysterectomies, 7,696 herniorraphies, 6,002 cholecystectomies, and 6,892 laparotomies.

For each operative procedure category, 2 SSI risk models were specified. First, a model based on the NNIS system's risk index variables was specified (hereafter referred to as the NNIS-based model). Second, a modified model (hereafter referred to as the modified NNIS-based model), which was also based on the NNIS system's risk index, was specified with a postdischarge surveillance indicator, which was assigned the value of 1 if the patient could be reached during follow-up and a value of 0 if the patient could not be reached. A formal comparison of the capabilities of the 2 models to assess the risk of SSI was conducted using measures of calibration (by use of the Pearson goodness-of-fit test) and discrimination (by use of receiver operating characteristic curves). Goodman-Kruskal correlations (G) were also calculated.

The rate of incomplete postdischarge follow-up varied between 29.8% for abdominal hysterectomies and 50.5% for cholecystectomies. The modified NNIS-based model for laparotomy did not show any significant benefit over the NNIS-based model in any measure. For all other operative procedures, the modified NNIS-based model showed a significantly improved discriminatory ability and higher G statistics, compared with the NNIS-based model, with no significant impairment in calibration, except if used to assess the risk of SSI after operations on the genitourinary system or after a cholecystectomy.

Compared with the NNIS-based model, the modified NNIS-based model added potentially useful clinical information regarding most of the operative procedures. Further work is warranted to evaluate this method for accounting for incomplete postdischarge follow-up during surveillance of SSI.

The prevalence of fluoroquinolone (FQ) resistance in Escherichia coli has increased markedly in recent years. Despite the important role of gastrointestinal tract colonization with FQ-resistant E. coli (FQREC), the prevalence of and risk factors for FQREC colonization among the general hospitalized patient population have not been described, to our knowledge. The objective of this study was to identify the prevalence of and risk factors for FQREC colonization among hospitalized patients.

Three-year case-control study. Case patients (ie, all subjects with FQREC colonization) were compared with control patients (ie, all subjects without FQREC colonization).

Two large medical centers within an academic health system.

All patients hospitalized at the 2 study hospitals.

Three annual fecal surveillance surveys were conducted. All patients colonized with FQREC (levofloxacin minimum inhibitory concentration, ≥ 8 μg/mL) were identified.

Of the 774 subjects, 89 (11.5%) were colonized with FQREC. Although there was a significant association between prior FQ use and FQREC colonization on bivariable analysis (odds ratio [OR], 2.02 [95% confidence interval {CI}, 1.14–3.46]; P = .01), there was statistically significant effect modification by year of study (P = .005). In multivariable analyses, after controlling for the hospital and for the duration of hospitalization prior to sampling, the association between FQ use and FQREC colonization was as follows: adjusted OR (aOR), 0.97 (95% CI, 0.29–3.23) in 2002; aOR, 1.41 (95% CI, 0.57–3.50) in 2003; and aOR, 9.87 (95% CI, 3.67–26.55) in 2004.

The association between prior FQ use and FQREC colonization varied significantly by study year, suggesting that the clinical epidemiology of resistant organisms may change over time. Furthermore, in the context of recent work showing significant changes in FQREC prevalence as well as changes in FQ resistance mechanisms (specifically, efflux overexpression) over the same time period, these results suggest a previously unrecognized complexity in the relationship between the clinical and molecular epidemiology of FQ resistance.

To detect the burden of vancomycin-resistant Enterococcus (VRE) colonization among pediatric oncology patients and to determine risk factors for VRE acquisition.

Retrospective case-control study.

The Children's Hospital of Philadelphia.

Pediatric oncology patients hospitalized from June 2006 through December 2007.

Prevalence surveys revealed an increased VRE burden among pediatric oncology patients. For the case-control study, the 16 case patients were pediatric oncology patients who had 1 stool sample negative for VRE at screening before having a stool sample positive for VRE at screening; the 62 control patients had 2 consecutive screenings in which stool samples were negative for VRE. Case and control patients were matched on the duration of the interval between screens. Analyses were performed to determine the association between multiple exposures and VRE acquisition.

The prevalence survey revealed that 5 (9.6%) of 52 patients had unsuspected VRE colonization at the time of hospitalization. Multivariate analysis identified a lack of empirical contact precautions (odds ratio [OR], 17.16 [95% confidence interval {CI}, 1.49–198.21]; P = .02) and the presence of a gastrointestinal device (OR, 4.03 [95% CI, 1.04–15.56]; P = .04) as significant risk factors for acquisition of VRE. Observations in the interventional radiology department revealed that staff could not access the portions of the electronic medical record in which isolation precautions were documented. Simple interventions that granted access and that trained interventional radiology staff to review the need for precautions, coupled with enhanced infection control practices, interrupted ongoing transmission and reduced the proportion of VRE screens that were positive to 15 (1.2%) of 1,270.

Inadequate communication with regard to infection control precautions can increase the risk of transmission of epidemiologically important organisms, particularly when patients receive care at multiple clinic locations. Adherence to infection control practices across the spectrum of care may limit the spread of resistant organisms.

To determine the rates of and risk factors for carriage and acquisition of extended-spectrum (β-lactamase (ESBL)-producing Enterobacteriaceae during hospitalization.

Cohort study.

Shaare Zedek Medical Center, a 550-bed teaching hospital.

During a 5-month period (February 1-June 30, 2004), 167 (8%) of 1,985 newly admitted general medical patients were enrolled in our study. Nasal, oropharyngeal, and rectal swab specimens were obtained at admission and every 2-3 days until hospital discharge or death. Enterobacteriaceae isolates were tested for ESBL, and Staphylococcus aureus isolates were tested for methicillin resistance.

Of the 167 patients enrolled in our study, 15 (9%) were identified as nasal carriers of methicillin-resistant S. aureus (MRSA) at admission, and 13 (8%) were rectal carriers of ESBL-producing Enterobacteriaceae at admission. Univariate risk factors for rectal carriage of ESBL-producing Enterobacteriaceae included female sex (odds ratio [OR], 11 [95% confidence interval {CI}, 1.4—238]; P < .05), nursing home residence (OR, 6.9 [95% CI, 1.8-27]; P < .01), recent antibiotic treatment (OR, 9.8 [95% CI, 1.7-74]; P < .05), and concomitant nasal carriage of MRSA and/or ESBL-producing Enterobacteriaceae (OR, 5.8 [95% CI, 1.2-26]; P < .01). Multivariate risk factors were female sex and recent antibiotic treatment. During hospitalization, 35 (21%) of 167 patients had acquired rectal carriage of ESBL-producing Enterobacteriaceae (P = .002, for trend analysis). Of the 12 patients who were still in the hospital 2 weeks after admission, 4 (33%) were carriers of ESBL-producing Enterobacteriaceae. Univariate risk factors for acquisition included an age of older than 65 years (P < .005), nursing home residence (OR 2.6, [95% CI, 0.98-2.6]), impaired cognition (OR, 4.8 [95% CI, 1.9-12]), recent antibiotic treatment (OR, 2.7 [95% CI, 0.9-8.3]), respiratory assistance (OR, 4.2 [95% CI, 1.2-14]), and prolonged hospitalization. Multivariate risk factors were an age of older than 65 years and broad-spectrum antibiotic therapy.

Rectal carriage of ESBL-producing Enterobacteriaceae occurred in 13 (8%) of 167 patients at admission to the medical departments of our hospital and in 4 (33%) of 12 patients still remaining in our hospital after 2 weeks.

To determine risk factors and outcomes for patients with meropenem high–level-resistant Pseudomonas aeruginosa (MRPA) (minimum inhibitory concentration [MIC] ≥ 32 μg/mL).

Case-control-control.

An 867-bed urban, teaching hospital.

Fifty-eight MRPA case patients identified from an earlier P. aeruginosa study; 125 randomly selected control patients with meropenem-susceptible P. aeruginosa (MSPA) (MIC ≤ 4 μg/mL), and 57 control patients without P. aeruginosa (sampled by case date/location).

Patient data, outcomes, and costs were obtained via administrative database. Cases were compared to each control group while controlling for time at risk (days between admission and culture, or entire length of stay [LOS] for patients without P. aeruginosa).

A multivariable model predicted risks for MRPA versus MSPA (odds ratio [95% confidence interval]): more admissions (in the prior 12 months) (1.41 [1.15, 1.74]), congestive heart failure (2.19 [1.03, 4.68]), and Foley catheter (2.53 [1.18, 5.45]) (adj. R2 = 0.28). For MRPA versus no P. aeruginosa, risks were age (in 5-year increments) (1.17 [1.03, 1.33]), more prior admissions (1.40 [1.08, 1.81]), and more days in the intensive care unit (1.10 [1.03, 1.18]) (adj. R2 = 0.32). Other invasive devices (including mechanical ventilation) and previous antibiotic use (including carbapenems) were nonsignificant. MRPA mortality (31%) did not differ from that of MSPA (15%) when adjusted for time at risk (P = .15) but did from mortality without P. aeruginosa (9%) (P = .01 ). Median LOS and costs were greater for MRPA patients versus MSPA patients and patients without P. aeruginosa: 30 days versus 16 and 10 (P < .01 ) and $88,425 versus $28,620 and $22,605 (P <.01).

Although antibiotic use has been shown to promote resistance, our data found that prior antibiotic use was not associated with MRPA acquisition. However, admission frequency and Foley catheters were, suggesting that infection control measures are essential to reducing MRPA transmission.