We introduced a long-term care facility (LTCF) infectious disease (ID) consultation service (LID service) that provides on-site consultations to residents of a Veterans Affairs (VA) LTCF. We determined the impact of the LID service on antimicrobial use and Clostridium difficile infections at the LTCF.

A 160-bed VA LTCF.

Systemic antimicrobial use and positive C. difficile tests at the LTCF were compared for the 36 months before and the 18 months after the initiation of the ID consultation service through segmented regression analysis of an interrupted time series.

Relative to that in the preintervention period, total systemic antibiotic administration decreased by 30% (P<.001), with significant reductions in both oral (32%; P<.001) and intravenous (25%; P = .008) agents. The greatest reductions were seen for tetracyclines (64%; P<.001), clindamycin (61%; P<.001), sulfamethoxazole/trimethoprim (38%; P<.001), fluoroquinolones (38%; P<.001), and β lactam/β-lactamase inhibitor combinations (28%; P<.001). The rate of positive C. difficile tests at the LTCF declined in the postintervention period relative to preintervention rates (P = .04).

Implementation of an LTCF ID service led to a significant reduction in total antimicrobial use. Bringing providers with ID expertise to the LTCF represents a new and effective means to achieve antimicrobial stewardship.

Hospital readmissions are a current target of initiatives to reduce healthcare costs. This study quantified the association between having a clinical culture positive for 1 of 3 prevalent hospital-associated organisms and time to hospital readmission.

Retrospective cohort study.

Adults admitted to an academic, tertiary care referral center from January 1, 2001, through December 31, 2008.

The primary exposure of interest was a clinical culture positive for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), or Clostridium difficile obtained more than 48 hours after hospital admission during the index hospital stay. The primary outcome of interest was time to readmission to the index facility. Multivariable Cox proportional hazards models were used to model the adjusted association between positive clinical culture result and time to readmission and to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).

Among 136,513 index admissions, the prevalence of hospital-associated positive clinical culture result for 1 of the 3 organisms of interest was 3%, and 35% of patients were readmitted to the index facility within 1 year after discharge. Patients with a positive clinical culture obtained more than 48 hours after hospital admission had an increased hazard of readmission (HR, 1.40; 95% CI, 1.33–1.46) after adjusting for age, sex, index admission length of stay, intensive care unit stay, Charlson comorbidity index, and year of hospital admission.

Patients with healthcare-associated infections may be at increased risk of hospital readmission. These findings may be used to impact health outcomes after discharge from the hospital and to encourage better infection prevention efforts.

Mandatory reporting of healthcare-associated infections is common, but underreporting by hospitals limits meaningful interpretation.

To validate mandatory intensive care unit (ICU) central line–associated bloodstream infection (CLABSI) reporting by Oregon hospitals.

Blinded comparison of ICU CLABSI determination by hospitals and health department–based external reviewers with group adjudication.

Forty-four Oregon hospitals required by state law to report ICU CLABSIs.

Seventy-six patients with ICU CLABSIs and a systematic sample of 741 other patients with ICU-related bacteremia episodes.

External reviewers examined medical records and determined CLABSI status. All cases with CLABSI determinations discordant from hospital reporting were adjudicated through formal discussion with hospital staff, a process novel to validation of CLABSI reporting.

Hospital representatives and external reviewers agreed on CLABSI status in 782 (96%) of 817 bacteremia episodes (k = 0.77 [95% confidence interval (CI), 0.70-0.84]). Among the 27 episodes identified as CLABSIs by external reviewers but not reported by hospitals, the final status was CLABSI in 16 (59%). The measured sensitivities of hospital ICU CLABSI reporting were 72% (95% CI, 62%-81%) with adjudicated CLABSI determination as the reference standard and 60% (95% CI, 51%-69%) with external review alone as the reference standard (P = .07). Validation increased the statewide ICU CLABSI rate from 1.21 (95% CI, 0.95-1.51) to 1.54 (95% CI, 1.25-1.88) CLABSIs/1,000 central line–days; ICU CLABSI rates increased by more than 1.00 CLABSI/1,000 central line–days in 6 (14%) hospitals.

Validating hospital CLABSI reporting improves accuracy of hospital-based CLABSI surveillance. Discussing discordant findings improves the quality of validation.

To determine whether improper high-level disinfection practices during endoscopy procedures resulted in bloodborne viral infection transmission.

Retrospective cohort study.

Four Veterans Affairs medical centers (VAMCs).

Veterans who underwent colonoscopy and laryngoscopy (ear, nose, and throat [ENT]) procedures from 2003 to 2009.

Patients were identified through electronic health record searches and serotested for human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B virus (HBV). Newly discovered case patients were linked to a potential source with known identical infection, whose procedure occurred no more than 1 day prior to the case patient's procedure. Viral genetic testing was performed for case/proximate pairs to determine relatedness.

Of 10,737 veterans who underwent endoscopy at 4 VAMCs, 9,879 patients agreed to viral testing. Of these, 90 patients were newly diagnosed with 1 or more viral bloodborne pathogens (BBPs). There were no case/proximate pairings found for patients with either HIV or HBV; 24 HCV case/proximate pairings were found, of which 7 case patients and 8 proximate patients had sufficient viral load for further genetic testing. Only 2 of these cases, both of whom underwent laryngoscopy, and their 4 proximates agreed to further testing. None of the 4 remaining proximate patients who underwent colonoscopy agreed to further testing. Mean genetic distance between the 2 case patients and 4 proximate patients ranged from 13.5% to 19.1%.

Our investigation revealed that exposure to improperly reprocessed ENT endoscopes did not result in viral transmission in those patients who had viral genetic analysis performed. Any potential transmission of BBPs from colonoscopy remains unknown.

To develop a modified surveillance definition of central line-associated bloodstream infection (mCLABSI) specific for our population of patients with hematologic malignancies to better support ongoing improvement efforts at our hospital.

Retrospective cohort study.

Hematologic malignancies population in a 1,200-bed tertiary care hospital on a 22-bed bone marrow transplant (BMT) unit and a 22-bed leukemia unit.

An mCLABSI definition was developed, and pathogens and rates were compared against those determined using the National Healthcare Safety Network (NHSN) definition.

By the NHSN definition the CLABSI rate on the BMT unit was 6.0 per 1,000 central line-days, and by the mCLABSI definition the rate was 2.0 per 1,000 line-days (P < .001). On the leukemia unit, the NHSN CLABSI rate was 14.4 per 1,000 line-days, and the mCLABSI rate was 8.2 per 1,000 line-days (P = .009). The top 3 CLABSI pathogens by the NHSN definition were Enterococcus species, Klebsiella species, and Escherichia coli. The top 3 CLABSI pathogens by the mCLABSI definition were coagulase-negative Staphylococcus (CONS), Pseudomonas aeruginosa, and Staphylococcus aureus. The difference in the incidence of CONS as a cause of CLABSI under the 2 definitions was statistically significant (P < .001).

A modified surveillance definition of CLABSI was associated with an increase in the identification of staphylococci as the cause of CLABSIs, as opposed to enteric pathogens, and a decrease in CLABSI rates.

In Pennsylvania, reporting of healthcare-associated infections (HAIs) was mandated in 2007, and hospitals were encouraged to implement qualified electronic surveillance (QES) systems to assist HAI detection. This study evaluated the usefulness of these systems in reducing HAIs.

Online survey and retrospective cohort study. Eligible facilities had a QES or manual system in place for the entire study period and sufficient data in selected hospital units.

Surveys were sent to infection preventionists (IPs) in all Pennsylvania hospitals to gather qualitative information about their systems. National Healthcare Safety Network data from Pennsylvania hospitals for July 2008 through June 2010 were used to compare catheter-associated urinary tract infection (CAUTI) rates in facilities with and without a QES system.

IPs from 174 facilities responded to the survey. Data from 119 of 234 hospitals were analyzed.

IPs in facilities with a QES system reported spending as much time on data management and education as IPs in hospitals with manual surveillance. Significant interaction was observed in CAUTI rates over time between groups of facilities with and without a QES system after controlling for device-utilization ratio, location within hospital, and licensed bed size (P< .01). QES hospitals showed a significant decline in CAUTI rates (P< .01); manual surveillance facilities showed no change in rates (P> .05).

Over the 2-year period, a significant decline in CAUTI rates was observed in facilities with a QES system. This suggests that electronic systems may aid in reducing HAI rates. Additional data are needed to see whether these improvements and trends persist.

Infect Control Hosp Epidemiol 2012;33(2):105-111

Despite a proliferation of phlebotomy devices with engineered sharps injury protection (ESIP), the impact of various winged device designs on blood splatter occurring during venipuncture procedures has not been explored.

To evaluate the potential for blood splatter of 6 designs of winged phlebotomy devices.

A laboratory-based device evaluation without human subjects, using a simulated patient venous system.

We evaluated 18 winged phlebotomy devices of 6 device designs by Terumo, BD Vacutainer (2 designs), Greiner, Smith Medical, and Kendall (designated A-F, respectively). Scientific filters were positioned around the devices and weighed before and after venipuncture was performed. Visible blood on filters, exam gloves, and devices and measurable blood splatter were the primary units of analysis.

The percentages of devices and gloves with visible blood on them and filters with measurable blood splatter ranged from 0% to 20%. There was a statistically significant association between device design and visible blood on devices (P< .0001) and between device design and filters with measurable blood splatter (P< .0001), but not between device design and visible blood on gloves. A wide range of associations were demonstrated between device design and visible blood on gloves or devices and incidence of blood splatter.

The results of this evaluation suggest that winged phlebotomy devices with ESIP may produce blood splatter during venipuncture. Reinforcing the importance of eye protection and developing a methodology to assess ocular exposure to blood splatter are major implications for healthcare personnel who use these devices. Future studies should focus on evaluating different designs of intravascular devices (intravenous catheters, other phlebotomy devices) for blood splatter.

To measure support for seasonal influenza vaccination requirements among US healthcare personnel (HCP) and its associations with attitudes regarding influenza and influenza vaccination and self-reported coverage by existing vaccination requirements.

Between lune 1 and June 30, 2010, we surveyed a sample of US HCP (n = 1,664) recruited using an existing probability-based online research panel of participants representing the US general population as a sampling frame.

General community.

Eligible HCP who (1) reported having worked as medical doctors, health technologists, healthcare support staff, or other health practitioners or who (2) reported having worked in hospitals, ambulatory care facilities, long-term care facilities, or other health-related settings.

We analyzed support for seasonal influenza vaccination requirements for HCP using proportion estimation and multivariable probit models.

A total of 57.4% (95% confidence interval, 53.3%–61.5%) of US HCP agreed that HCP should be required to be vaccinated for seasonal influenza. Support for mandatory vaccination was statistically significantly higher among HCP who were subject to employer-based influenza vaccination requirements, who considered influenza to be a serious disease, and who agreed that influenza vaccine was safe and effective.

A majority of HCP support influenza vaccination requirements. Moreover, providing HCP with information about the safety of influenza vaccination and communicating that immunization of HCP is a patient safety issue may be important for generating staff support for influenza vaccination requirements.

Infect Control Hosp Epidemiol 2012;33(3):213-221

To determine the effectiveness of World Health Organization (WHO) multimodal strategy in promoting hand hygiene (HH) among healthcare workers (HCWs) in long-term care facilities (LTCFs).

Cluster-randomized controlled trial.

Eighteen homes for the elderly in Hong Kong were randomly allocated to 2 intervention arms and a control arm. Direct observation of HH practice was conducted by trained nurses. Either handrubbing with alcohol-based handrub (ABHR) or handwashing with liquid soap and water was counted as a compliant action. Disease notification data during 2007–2010 were used to calculate incidence rate ratio (IRR).

Managers and HCWs of the participating homes.

The WHO multimodal strategy was employed. All intervention homes were supplied with ABHR (WHO formulation I), ABHR racks, pull reels, HH posters and reminders, a health talk, video clips, training materials, and performance feedback. The only difference was that intervention arms 1 and 2 were provided with slightly powdered and powderless gloves, respectively.

A total of 11,669 HH opportunities were observed. HH compliance increased from 27.0% to 60.6% and from 22.2% to 48.6% in intervention arms 1 and 2, respectively. Both intervention arms showed increased HH compliance after intervention compared to controls, at 21.6% compliance (both P < .001). Provision of slightly powdered versus powderless gloves did not have any significant impact on ABHR usage. Respiratory outbreaks (IRR, 0.12; 95% confidence interval [CI], 0.01–0.93; P = .04) and methicillin-resistant Staphylococcus aureus infections requiring hospital admission (IRR, 0.61; 95% CI, 0.38–0.97; P = .04) were reduced after intervention.

A promotion program applying the WHO multimodal strategy was effective in improving HH among HCWs in LTCFs.

To evaluate the use of inpatient pharmacy and administrative data to detect surgical site infections (SSIs) following hysterectomy and colorectal and vascular surgery.

Retrospective cohort study.

Five hospitals affiliated with academic medical centers.

Adults who underwent abdominal or vaginal hysterectomy, colorectal surgery, or vascular surgery procedures between July 1, 2003, and June 30, 2005.

We reviewed the medical records of weighted, random samples drawn from 3,079 abdominal and vaginal hysterectomy, 4,748 colorectal surgery, and 3,332 vascular surgery procedures. We compared routine surveillance with screening of inpatient pharmacy data and diagnosis codes and then performed medical record review to confirm SSI status.

Medical records from 823 hysterectomy, 736 colorectal surgery, and 680 vascular surgery procedures were reviewed. SSI rates determined by antimicrobial- and/or diagnosis code-based screening followed by medical record review (enhanced surveillance) were substantially higher than rates determined by routine surveillance (4.3% [95% confidence interval, 3.6%—5.1%] vs 2.7% for hysterectomies, 7.1% [95% confidence interval, 6.7%–8.2%] vs 2.0% for colorectal procedures, and 2.3% [95% confidence interval, 1.9%–2.9%] vs 1.4% for vascular procedures). Enhanced surveillance had substantially higher sensitivity than did routine surveillance to detect SSI (92% vs 59% for hysterectomies, 88% vs 22% for colorectal procedures, and 72% vs 43% for vascular procedures). A review of medical records confirmed SSI for 31% of hysterectomies, 20% of colorectal procedures, and 31% of vascular procedures that met the enhanced screening criteria.

Antimicrobial- and diagnosis code-based screening may be a useful method for enhancing and streamlining SSI surveillance for a variety of surgical procedures, including those procedures targeted by the Centers for Medicare and Medicaid Services.

To determine whether transfer from a long-term care facility (LTCF) is a risk factor for colonization with Klebsiella pneumoniae carbapenemase (KPC)–producing Enterobacteriaceae upon acute care hospital admission.

Microbiologic survey and nested case-control study.

Four hospitals in a metropolitan area (Chicago) with an early KPC epidemic.

Hospitalized adults.

Patients transferred from LTCFs were matched 1 : 1 to patients admitted from the community by age (± 10 years), admitting clinical service, and admission date (± 2 weeks). Rectal swab specimens were collected within 3 days after admission and tested for KPC-producing Enterobacteriaceae. Demographic and clinical information was extracted from medical records.

One hundred eighty patients from LTCFs were matched to 180 community patients. KPC-producing Enterobacteriaceae colonization was detected in 15 (8.3%) of the LTCF patients and 0 (0%) of the community patients (P<.001). Prevalence of carriage differed by LTCF subtype: 2 of 135 (1.5%) patients from skilled nursing facilities without ventilator care (SNFs) were colonized upon admission, compared to 9 of 33 (27.3%) patients from skilled nursing facilities with ventilator care (VSNFs) and 4 of 12 (33.3%) patients from long-term acute care hospitals (LTACHs; P<.001). In a multivariable logistic regression model adjusted for a propensity score that predicted LTCF subtype, patients admitted from VSNFs or LTACHs had 7.0-fold greater odds of colonization (ie, odds ratio; 95% confidence interval, 1.3–42; P = .022) with KPC-producing Enterobacteriaceae than patients from an SNF.

Patients admitted to acute care hospitals from high-acuity LTCFs (ie, VSNFs and LTACHs) were more likely to be colonized with KPC-producing Enterobacteriaceae than were patients admitted from the community. Identification of healthcare facilities with a high prevalence of colonized patients presents an opportunity for focused interventions that may aid regional control efforts.

The inanimate hospital environment has emerged as an important reservoir of nosocomial pathogens. In particular, multidrug-resistant pathogens, such as methicillin-resistant Staphylococcus aureus, Acinetobacter species, and Clostridium difficile, play a major role in the transmission of hospital-acquired infections. In Europe, aldehydes, chlorine, and quaternary ammonium compounds have been commonly used for environmental disinfection. Glucoprotamin, a newer active compound for disinfectants, has been clinically tested for disinfection of instruments but not for environmental disinfection.

This study evaluated the antimicrobial effectiveness of a glucoprotamin-containing product (Incidin) compared with that of an aldehyde-containing product (Deconex), the current standard at our institution.

This prospective crossover study was conducted in our access-restricted hematologic transplant unit. A total of 3,086 samples from the environment were processed and examined for overall bacterial burden as well as selectively for S. aureus, C. difficile, and gram-negative bacteria.

There was no significant difference in residual bacteria after disinfection between the 2 products in terms of overall burden and selected pathogens. Enterococci were the predominant pathogens recovered from surfaces, but no vancomycin-resistant enterococci were recovered. Similarly, C. difficile could not be found in the patients' environment, even in rooms, despite the use of selective media.

The aldehyde-containing product (Deconex) and the glucoprotamin-containing product (Incidin) demonstrated similar efficacy against environmental contamination in a hematologic transplant unit with the application of selective media for C. difficile, S. aureus, and gram-negative bacteria in addition to standard medium.

Viral respiratory pathogens cause outbreaks in pediatric long-term care facilities (LTCFs), but few studies have used viral diagnostic testing to identify the causative pathogens. We describe the use of such testing during a prolonged period of respiratory illness and elucidate the epidemiology of human metapneumovirus (hMPV) at our LTCF.

Retrospective study of influenza-like illness (ILI).

A 136-bed pediatric LTCF from January 1 through April 30, 2010.

The ILI case definition included fever, cough, change in oropharyngeal secretions, increase in oxygen requirement, and/or wheezing.

During the study period, 69 episodes of ILI occurred in 61 (41%) of 150 residents. A viral pathogen was detected in 27 (39%) of the episodes, including respiratory syncytial virus (RSV) (n = 3), influenza A virus (not typed; n = 2), parainfluenza virus (n = 2), adenovirus (n = 1), and hMPV (n = 19). Twenty-seven of the residents with ILI (44%) required transfer to acute care hospitals (mean length of hospitalization, 12 days; range, 3–47 days). Residents with tracheostomies were more likely to have ILI (adjusted odds ratio [OR], 3.99 [95% confidence interval {CI}, 1.87–8.53]; P = .0004). The mortality rate for residents with ILI was 1.6%. Residents with hMPV were younger (P = .03), more likely to be transferred to an acute care facility (OR, 3.73 [95% CI, 1.17–11.95]; P = .02), and less likely to have a tracheostomy (adjusted OR, 0.19 [95% CI, 0.047–0.757]; P = .02).

Diverse pathogens, most notably hMPV, caused ILI in our pediatric LTCF during a prolonged period of time. Viral testing was helpful in characterizing the epidemiology of ILI in this population.

The success of central line-associated bloodstream infection (CLABSI) prevention programs in intensive care units (ICUs) has led to the expansion of surveillance at many hospitals. We sought to compare non-ICU CLABSI (nCLABSI) rates with national reports and describe methods of surveillance at several participating US institutions.

An electronic survey of several medical centers about infection surveillance practices and rate data for non-ICU Patients.

Ten tertiary care hospitals.

In March 2011, a survey was sent to 10 medical centers. The survey consisted of 12 questions regarding demographics and CLABSI surveillance methodology for non-ICU patients at each center. Participants were also asked to provide available rate and device utilization data.

Hospitals ranged in size from 238 to 1,400 total beds (median, 815). All hospitals reported using Centers for Disease Control and Prevention (CDC) definitions. Denominators were collected by different means: counting patients with central lines every day (5 hospitals), indirectly estimating on the basis of electronic orders (n = 4), or another automated method (n = 1). Rates of nCLABSI ranged from 0.2 to 4.2 infections per 1,000 catheter-days (median, 2.5). The national rate reported by the CDC using 2009 data from the National Healthcare Surveillance Network was 1.14 infections per 1,000 catheter-days.

Only 2 hospitals were below the pooled CLABSI rate for inpatient wards; all others exceeded this rate. Possible explanations include differences in average central line utilization or hospital size in the impact of certain clinical risk factors notably absent from the definition and in interpretation and reporting practices. Further investigation is necessary to determine whether the national benchmarks are low or whether the hospitals surveyed here represent a selection of outliers.