Given recent changes in the epidemiology of Clostridioides difficile infection (CDI) and prevention efforts, we investigated temporal changes over a period of 11 years (2006–2016) in incidence and risk factors for CDI.

Retrospective matched case-control study.

Pediatric and adult inpatients (n = 694,849) discharged from 3 hospitals (tertiary and quaternary care, community, and pediatric) in a large, academic health center in New York City.

Risk factors were identified in cases and controls matched by length of stay at a ratio of 1:4. A Cochran–Armitage or Mann-Kendall test was used to investigate trends of incidence and risk factors.

Of 694,849 inpatients, 6,038 (0.87%) had CDI: 44% of these cases were hospital acquired (HA-CDI) and 56% were community acquired (CA-CDI). We observed temporal downward trends in HA-CDI (−0.03% per year) and upward trends in CA-CDI (+0.04% per year). Over time, antibiotics were administered to more patients (+3% per year); the use of high-risk antibiotics declined (–1.2% per year); and antibiotic duration increased in patients with HA-CDI (+4.4% per year). Fewer proton-pump inhibitors and more histamine-2 blockers were used (−3.8% and +7.3% per year, respectively; all Ptrend <.05).

Although the incidence of HA-CDI decreased over time, CA-CDI simultaneously increased. Continued efforts to assure judicious use of antibiotics in inpatient and community settings is clearly vital. Measuring the actual the level of exposure of an antibiotic (incidence density) should be used for ongoing surveillance and assessment.

Multidrug-resistant organisms (MDROs) cause ~5%–10% of infections in hospitalized children, leading to an increased risk of death, prolonged hospitalization, and additional costs. Antibiotic exposure is considered a driving factor of MDRO acquisition; however, consensus regarding the impact of antibiotic factors, especially in children, is lacking. We conducted a systematic review to examine the relationship between antibiotic use and subsequent healthcare-associated infection or colonization with an MDRO in children.

Systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline.

We searched PubMed and Embase for all English, peer-reviewed original research studies published before September 2018. Included studies evaluated hospitalized children, antibiotic use as an exposure, and bacterial MDRO as an outcome.

Of the 535 studies initially identified, 29 met the inclusion criteria. Overall, a positive association was identified in most studies evaluating a specific antibiotic exposure (17 of 21, 81%), duration of antibiotics (9 of 12, 75%), and number of antibiotics received (2 of 3, 67%). Those studies that evaluated any antibiotic exposure had mixed results (5 of 10, 50%). Study sites, populations, and definitions of antibiotic use and MDROs varied widely.

Published studies evaluating this relationship are limited and are of mixed quality. Limitations include observation bias in recall of antibiotic exposure, variations in case definitions, and lack of evaluation of antibiotic dosing and appropriateness. Additional studies exploring the impact of antibiotic use and MDRO acquisition may be needed to develop effective antibiotic stewardship programs for hospitalized children.

To evaluate the impact of universal contact precautions (UCP) on rates of multidrug-resistant organisms (MDROs) in intensive care units (ICUs) over 9 years

Retrospective, nonrandomized observational study

An 800-bed adult academic medical center in New York City

All patients admitted to 6 ICUs, 3 of which instituted UCP in 2007

Using a comparative effectiveness approach, we studied the longitudinal impact of UCP on MDRO incidence density rates, including methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and carbapenem-resistant Klebsiella pneumoniae. Data were extracted from a clinical research database for 2006–2014. Monthly MDRO rates were compared between the baseline period and the UCP period, utilizing time series analyses based on generalized linear models. The same models were also used to compare MDRO rates in the 3 UCP units to 3 ICUs without UCPs.

Overall, MDRO rates decreased over time, but there was no significant decrease in the trend (slope) during the UCP period compared to the baseline period for any of the 3 intervention units. Furthermore, there was no significant difference between UCP units (6.6% decrease in MDRO rates per year) and non-UCP units (6.0% decrease per year; P=.840).

The results of this 9-year study suggest that decreases in MDROs, including multidrug-resistant gram-negative bacilli, were more likely due to hospital-wide improvements in infection prevention during this period and that UCP had no detectable additional impact.

Infect Control Hosp Epidemiol 2018;39:534–540

The financial incentives for hospitals to improve care may be weaker if higher insurer payments for adverse conditions offset a portion of hospital costs. The purpose of this study was to simulate incentives for reducing hospital-acquired infections under various payment configurations by Medicare, Medicaid, and private payers.

Matched case-control study.

A large, urban hospital system with 1 community hospital and 2 tertiary-care hospitals.

All patients discharged in 2013 and 2014.

Using electronic hospital records, we identified hospital-acquired bloodstream infections (BSIs) and urinary tract infections (UTIs) with a validated algorithm. We assessed excess hospital costs, length of stay, and payments due to infection, and we compared them to those of uninfected patients matched by propensity for infection.

In most scenarios, hospitals recovered only a portion of excess HAI costs through increased payments. Patients with UTIs incurred incremental costs of $6,238 (P<.01), while payments increased $1,901 (P<.05) at public diagnosis-related group (DRG) rates. For BSIs, incremental costs were $15,367 (P<.01), while payments increased $7,895 (P<.01). If private payers reimbursed a 200% markup over Medicare DRG rates, hospitals recovered 55% of costs from BSI and UTI among private-pay patients and 54% for BSI and 33% for UTI, respectively, across all patients. Under per-diem payment for private patients with no markup, hospitals recovered 71% of excess costs of BSI and 88% for UTI. At 150% markup and per-diem payments, hospitals profited.

Hospital incentives for investing in patient safety vary by payer and payment configuration. Higher payments provide resources to improve patient safety, but current payment structures may also reduce the willingness of hospitals to invest in patient safety.

Infect Control Hosp Epidemiol 2018;39:509–515

We aimed to improve the research consenting process by developing and evaluating simplified consent forms.

Four templates written at the eighth-tenth grade reading level were developed and trialed by a group of experts in clinical research, health literacy, national regulatory requirements, and end users. Researchers from protocols which had received expedited review were surveyed at 2 time points regarding their use and assessment of the templates.

At baseline 18/86 (20.9%) responding researchers had heard of the templates and 5 (5.8%) reported that they had used them; 2 years later, 54.2% (32/59) had heard of the templates and 87.5% (28/32) had used them (p<0.001).

Consent form templates may be one mechanism to improve patient comprehension of research protocols as well as efficiency of the review process, but require considerable time for development and implementation, and one key to their success is involvement and support from the IRB and technical staff.

To describe compliance with the central line (CL) insertion bundle overall and with individual bundle elements in US adult intensive care units (ICUs) and to determine the relationship between bundle compliance and central line–associated bloodstream infection (CLABSI) rates.

Cross-sectional study.

National sample of adult ICUs participating in National Healthcare Safety Network (NHSN) surveillance.

Hospitals were surveyed to determine compliance with CL insertion bundle elements in ICUs. Corresponding NHSN ICU CLABSI rates were obtained. Multivariate Poisson regression models were used to assess associations between CL bundle compliance and CLABSI rates, controlling for hospital and ICU characteristics.

A total of 984 adult ICUs in 632 hospitals were included. Most ICUs had CL bundle policies, but only 69% reported excellent compliance (≥95%) with at least 1 element. Lower CLABSI rates were associated with compliance with just 1 element (incidence rate ratio [IRR] 0.77; 95% confidence interval [CI], 0.64–0.92); however, ≥95% compliance with all 5 elements was associated with the greatest reduction (IRR, 0.67; 95% CI, 0.59–0.77). There was no association between CLABSI rates and simply having a written CL bundle policy nor with bundle compliance <75%. Additionally, better-resourced infection prevention departments were associated with lower CLABSI rates.

Our findings demonstrate the impact of transferring infection prevention interventions to the real-world setting. Compliance with the entire bundle was most effective, although excellent compliance with even 1 bundle element was associated with lower CLABSI rates. The variability in compliance across ICUs suggests that, at the national level, there is still room for improvement in CLABSI reduction.

Infect Control Hosp Epidemiol 2016;37:805–810

To describe the use of antimicrobial stewardship policies and to investigate factors associated with implementation in a national sample of acute care hospitals.

Cross-sectional survey.

Infection Control Directors from acute care hospitals participating in the National Healthcare Safety Network (NHSN).

An online survey was conducted in the Fall of 2011. A subset of hospitals also provided access to their 2011 NHSN annual survey data.

Responses were received from 1,015 hospitals (30% response rate). The majority of hospitals (64%) reported the presence of a policy; use of antibiograms and antimicrobial restriction policies were most frequently utilized (83% and 65%, respectively). Respondents from larger, urban, teaching hospitals and those that are part of a system that shares resources were more likely to report a policy in place (P<.01). Hospitals located in California were more likely to have policy in place than in hospitals located in other states (P=.014).

This study provides a snapshot of the implementation of antimicrobial stewardship policies in place in U.S. hospitals and suggests that statewide efforts in California are achieving their intended effect. Further research is needed to identify factors that foster the adoption of these policies.

Infect Control Hosp Epidemiol 2014;00(0): 1–4

To describe the prevalence of Staphylococcus warneri on the hands of nurses and the clinical relevance of this organism among neonates in the neonatal intensive care unit (NICU).

Prospective cohort study that examined the microbial flora on the hands of nurses and clinical isolates recovered from neonates during a 23-month period (March 1, 2001, through January 31, 2003).

Two high-risk NICUs in New York City.

All neonates hospitalized in the NICUs for more than 24 hours and all full-time nurses from the same NICUs who volunteered to participate.

At baseline and then every 3 months, samples for culture were obtained from each nurse's cleaned dominant hand. Pulsed-field electrophoresis compared S. warneri isolates from neonates and staff.

Samples for culture (n = 834) were obtained from the hands of 119 nurses; 520 (44%) of the 1,195 isolates of coagulase-negative staphylococci recovered were identified as S. warneri. Of the 647 clinically relevant isolates recovered from neonates, 17 (8%) of the 202 isolates that were identified to species level were S. warneri. Pulsed-field electrophoresis revealed a common strain of S. warneri that was shared among the nurses and neonates. Furthermore, 117 (23%) of 520 S. warneri isolates from nurses' hands had minimum inhibitory concentrations for vancomycin of 4 μg/mL, which indicate decreasing susceptibility.

Our findings that S. warneri can be pathogenic in neonates, is a predominant species of coagulase-negative staphylococci cultured from the hands of nurses, and has decreased vancomycin susceptibility underscore the importance of continued surveillance for vancomycin resistance and pathogenicity in pediatric care settings.