Peripherally inserted central catheters (PICCs) are associated with central-line–associated bloodstream infections (CLABSIs). However, no tools to predict risk of PICC-CLABSI have been developed.

To operationalize or prioritize CLABSI risk factors when making decisions regarding the use of PICCs using a risk model to estimate an individual’s risk of PICC-CLABSI prior to device placement.

Using data from the Michigan Hospital Medicine Safety consortium, patients that experienced PICC-CLABSI between January 2013 and October 2016 were identified. A Cox proportional hazards model with robust sandwich standard error estimates was then used to identify factors associated with PICC-CLABSI. Based on regression coefficients, points were assigned to each predictor and summed for each patient to create the Michigan PICC-CLABSI (MPC) score. The predictive performance of the score was assessed using time-dependent area-under-the-curve (AUC) values.

Of 23,088 patients that received PICCs during the study period, 249 patients (1.1%) developed a CLABSI. Significant risk factors associated with PICC-CLABSI included hematological cancer (3 points), CLABSI within 3 months of PICC insertion (2 points), multilumen PICC (2 points), solid cancers with ongoing chemotherapy (2 points), receipt of total parenteral nutrition (TPN) through the PICC (1 point), and presence of another central venous catheter (CVC) at the time of PICC placement (1 point). The MPC score was significantly associated with risk of CLABSI (P<.0001). For every point increase, the hazard ratio of CLABSI increased by 1.63 (95% confidence interval, 1.56–1.71). The area under the receiver-operating-characteristics curve was 0.67 to 0.77 for PICC dwell times of 6 to 40 days, which indicates good model calibration.

The MPC score offers a novel way to inform decisions regarding PICC use, surveillance of high-risk cohorts, and utility of blood cultures when PICC-CLABSI is suspected. Future studies validating the score are necessary.

Infect Control Hosp Epidemiol 2017;38:1155–1166

Inappropriate treatment of asymptomatic bacteriuria (ASB) in the hospital setting is common. We sought to evaluate the treatment rate of ASB at the 3 hospitals and assess the impact of a hospitalist-focused improvement intervention.

Prospective, interventional trial.

Two community hospitals and a tertiary-care academic center.

Adult patients with a positive urine culture admitted to hospitalist services were included in this study. Exclusions included pregnancy, intensive care unit admission, history of a major urinary procedure, and actively being treated for a urinary tract infection (UTI) at the time of admission or >48 hours prior to urine collection.

An educational intervention using a pocket card was implemented at all sites followed by a pharmacist-based intervention at the academic center. Medical records of the first 50 eligible patients at each site were reviewed at baseline and after each intervention for signs and symptoms of UTI, microbiological results, antimicrobials used, and duration of treatment for positive urine cultures. Diagnosis of ASB was determined through adjudication by 2 hospitalists and 2 infectious diseases physicians.

Treatment rates of ASB decreased (23.5%; P=.001) after the educational intervention. Reductions in treatment rates for ASB differed by site and were greatest in patients without classic signs and symptoms of UTI (34.1%; P<.001) or urinary catheters (31.2%; P<.001). The pharmacist-based intervention was most effective at reducing ASB treatment rates in catheterized patients.

A hospitalist-focused educational intervention significantly reduced ASB treatment rates. The impact varied across sites and by patient characteristics, suggesting that a tailored approach may be useful.

Infect Control Hosp Epidemiol 2016;37:1044–1051

Carbapenem-resistant Enterobacteriaceae (CRE) are clinically challenging, threaten patient safety, and represent an emerging public health issue. CRE reporting is not mandated in Michigan.

The Michigan Department of Community Health–led CRE Surveillance and Prevention Initiative enrolled 21 facilities (17 acute care and 4 long-term acute care facilities) across the state. Baseline data collection began September 1, 2012, and ended February 28, 2013 (duration, 6 months). Enrolled facilities voluntarily reported cases of Klebsiella pneumoniae and Escherichia coli according to the surveillance algorithm. Patient demographic characteristics, laboratory testing, microbiology, clinical, and antimicrobial information were captured via standardized data collection forms. Facilities reported admissions and patient-days each month.

One-hundred two cases over 957,220 patient-days were reported, resulting in a crude incidence rate of 1.07 cases per 10,000 patient-days. Eighty-nine case patients had test results positive for K. pneumoniae, whereas 13 had results positive for E. coli. CRE case patients had a mean age of 63 years, and 51% were male. Urine cultures (61%) were the most frequently reported specimen source. Thirty-five percent of cases were hospital onset; sixty-five percent were community onset (CO), although 75% of CO case patients reported healthcare exposure within the previous 90 days. Cardiovascular disease, renal failure, and diabetes mellitus were the most frequently reported comorbid conditions. Common ris k factors included surgery within the previous 90 days, recent infection or colonization with a multidrug-resistant organism, and recent exposures to antimicrobials, especially third- or fourth-generation cephalosporins.

CRE are found throughout Michigan healthcare facilities. Implementing a regional, coordinated surveillance and prevention initiative may prevent CRE from becoming hyperendemic in Michigan.

To determine relative rates of blood culture contamination for 3 skin antisepsis interventions—10% povidone iodine aqueous solution (PI), 2% iodine tincture (IT), and 2% chlorhexidine gluconate in 70% isopropyl alcohol (CHG)—when used by dedicated phlebotomy teams to obtain peripheral blood cultures.

Randomized crossover trial with hospital floor as the unit of randomization.

Teaching hospital with 885 beds.

All adult patients undergoing peripheral blood culture collection on 3 medical-surgical floors from May 2009 through September 2009.

Each antisepsis intervention was used for 5 months on each study floor, with random crossover after a 1-month washout period. Phlebotomy teams collected all peripheral blood cultures. Each positive blood culture was adjudicated by physicians blinded to the intervention and scored as a true positive or contaminated blood culture. The primary outcome was the rate of blood culture contamination for each antisepsis agent.

In total, 12,904 peripheral blood culture sets were evaluated, of which 735 (5.7%) were positive. There were 98 contaminated cultures, representing 13.3% of all positive cultures. The overall blood culture contamination rate for the study population was 0.76%. Intent-to-treat rates of contaminated blood cultures were not significantly different among the 3 antiseptics (P = .18), yielding 0.58% with PI (95% confidence interval [CI], 0.38%-0.86%), 0.76% with IT (95% CI, 0.52%-1.07%), and 0.93% with CHG (95% CI, 0.67%-1.27%).

Choice of antiseptic agent does not impact contamination rates when blood cultures are obtained by a phlebotomy team and should, therefore, be based on costs or preference.

ClinicalTrials.gov identifier: NCT01216761.

To describe the rate of infection, associated organisms, and potential risk factors for ventilator-associated pneumonia (VAP) in patients receiving mechanical ventilation at home.

Retrospective cohort study.

University-affiliated home care service.

Patients receiving mechanical ventilation at home from June 1995 through December 2001.

Fifty-seven patients underwent ventilation at home for a total of 50,762 ventilator-days (mean ± SD, 890.6 ± 644.43 days; range, 76-2,458 days). Seventy-nine episodes of VAP occurred in 27 patients (rate, 1.55 episodes per 1,000 ventilator-days). The first episode of VAP occurred after a mean (±SD) of 245 ± 318.07 ventilator-days. VAP was most common during the first 500 days of ventilation. Rates of VAP were higher among patients who required ventilation for longer daily durations, compared with those who required it for shorter daily durations. There was no association of VAP with age, sex, underlying disease, reason for ventilation, antacid therapy, or steroid use. Microorganisms isolated from 33 episodes of VAP with available culture results included Pseudomonas species (17 isolates), Staphylococcus aureus (11), Serratia species (7), and Stenotrophomonas species (5). Eight patients died during the study; no deaths were attributed to pneumonia.

Although the organisms associated with VAP in the home setting are similar to those associated with hospital-acquired VAP, the incidence and mortality is much lower in the home care setting. Interventions to reduce the risk of VAP among patients receiving home care should be focused on patients who require ventilation for longer daily durations or who are new to receiving mechanical ventilation at home.