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Background: Data regarding the effects of the SARS-COV-2 (COVID-19) pandemic on healthcare-associated infections (HAIs) in Canadian acute-care hospitals are limited. We examined the impact of the COVID-19 pandemic on HAIs and antimicrobial resistant organisms in hospitals participating in the Canadian Nosocomial Infection Surveillance Program. Methods: We analyzed 13,406 HAIs including adult mixed intensive care unit (ICU) central-line–associated bloodstream infections (CLABSIs), and healthcare-associated (HA) Clostridioides difficile infection (CDI), methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSI), vancomycin-resistant Enterococcus (VRE) BSI, and carbapenemase-producing Enterobacterales (CPE) infections collected using standardized case definitions and questionnaires from 29–64 hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP) from January 2018 to December 2021. We used a generalized linear mixed model with quasi-Poisson distribution to assess step and slope changes in monthly HAI rates between the pre–COVID-19 pandemic period (January 1, 2018–February 29, 2020; 26 time points) and the COVID-19 pandemic period (March 1, 2020–December 31, 2021; 22 time points). Results were reported as incidence rate ratios (IRRs) with 95% confidence intervals (CIs) and adjusted for seasonality, hospital clustering, and hospital characteristics of interest. Results: In the CNISP network, 7,352 (55%) HAIs were reported in the prepandemic period and 6,054 (45%) in the pandemic period. Median age was significantly younger during the pandemic period compared to the prepandemic period among patients with HA-CDI, HA-MRSA BSI, and adult mixed ICU CLABSIs, and more than half of cases among all reported HAIs were male (range, 52%–65%). The 30-day all-cause in-hospital mortality rate did not significantly change between the prepandemic and pandemic periods for all reported HAIs and was highest among HA-VRE BSIs (34%). Modeling results indicated that the COVID-19 pandemic was associated with an immediate increase in HA-CDI and adult mixed ICU CLABSI rates whereas HA-MRSA BSI, HA-CPE and HA-VRE BSI rates immediately decreased. However, pandemic status did not have a statistically significant lasting impact on monthly rate trends for all reported HAIs after adjusting for seasonality, clustering, and hospital covariates (Fig. 1 and 2). Adjusted IRRs for all HAIs ranged from 1.00 to 1.01 (95% CI, 0.94–0.99 to 1.01–1.05).
Conclusions: Although the COVID-19 pandemic placed a significant burden on the Canadian healthcare system, the immediate impact on monthly rates of HAIs in Canadian acute-care hospitals was not sustained over time. Understanding the epidemiological effects of the COVID-19 pandemic in the context of changing patient populations, and clinical and infection control practices, are essential to inform the continued management and prevention of HAIs in Canadian acute-care settings.
A multisite research team proposed a survey to assess burnout among healthcare epidemiologists. Anonymous surveys were disseminated to eligible staff at SRN facilities. Half of the respondents were experiencing burnout. Staffing shortages were a key stressor. Allowing healthcare epidemiologists to provide guidance without directly enforcing policies may improve burnout.
Mental fatigue and burnout are concerns for healthcare organizations, but their effects on leaders have not been thoroughly studied. Infectious diseases teams and leaders are at risk for mental fatigue and burnout due to the increased demands from the coronavirus disease 2019 (COVID-19) pandemic, additive effects of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) (omicron) and δ (delta) variant surges, and unique pre-existing pressures. No single intervention can reduce stress and burnout in healthcare workers. Work-hour limitations may have the biggest impact in physician burnout mitigation. Institutional and individual programs focused on mindfulness may improve well-being in the workplace. Leading during times of stress requires a multimodal approach and an understanding of goals and priorities. Greater awareness of burnout and fatigue across the healthcare spectrum and continued research are required to advance healthcare worker well-being.
Extracorporeal membrane oxygenation (ECMO) has been widely used in the care of patients with respiratory failure from coronavirus disease 2019 (COVID-19). We characterized bloodstream infections (BSIs) and ventilator-associated pneumonias (VAPs) in COVID-19 patients supported with ECMO, and we investigated their impact on patient outcomes.
Retrospective cohort study from March 1, 2020, to June 30, 2021.
Academic tertiary-care referral center.
Consecutive adult patients admitted for COVID-19 who received ECMO.
We identified BSIs and VAPs and described their epidemiology and microbiology. Cumulative antimicrobial use and the specific management of BSIs were determined. Multivariate time-dependent Cox proportional hazards models were constructed to evaluate the impact of BSIs and VAPs on mortality, controlling for age, receipt of COVID-19–specific therapeutics, and new renal replacement therapy.
We identified 136 patients who received ECMO for COVID-19 pneumonia during the study period. BSIs and VAPs occurred in 81 patients (59.6%) and 93 patients (68.4%), respectively. The incidence of BSIs was 29.5 per 1,000 ECMO days and increased with duration of ECMO cannulation. Enterococci, Enterobacterales, and Staphylococcus aureus were the most common causes of BSIs, whereas S. aureus, Klebsiella species, and Pseudomonas aeruginosa comprised the majority of VAPs. Mean antibiotic use comprised 1,031 days of therapy per 1,000 ECMO days (SD, 496). We did not detect an association between BSIs or VAPs and mortality.
BSIs and VAPs are common in COVID-19 ECMO-supported patients. Efforts to optimize their diagnosis, prevention, and management should be prioritized.
The coronavirus disease 2019 (COVID-19) pandemic has placed significant burden on healthcare systems. We compared Clostridioides difficile infection (CDI) epidemiology before and during the pandemic across 71 hospitals participating in the Canadian Nosocomial Infection Surveillance Program. Using an interrupted time series analysis, we showed that CDI rates significantly increased during the COVID-19 pandemic.
To analyze the spread of a novel sequence type (ST1478) of vancomycin-resistant Enterococcus faecium across Canadian hospitals.
Retrospective chart review of patients identified as having ST1478 VRE bloodstream infection.
Canadian hospitals that participate in the Canadian Nosocomial Infection Surveillance Program (CNISP).
From 2013 to 2018, VRE bloodstream isolates collected from participating CNISP hospitals were sent to the National Microbiology Laboratory (NML). ST1478 isolates were identified using multilocus sequence typing, and whole-genome sequencing was performed. Patient characteristics and location data were collected for patients with ST1478 bloodstream infection (BSI). The sequence and patient location information were used to generate clusters of infections and assess for intrahospital and interhospital spread.
ST1478 VRE BSI occurred predominantly in a small number of hospitals in central and western Canada. Within these hospitals, infections were clustered on certain wards, and isolates often had <20 single-nucleotide variants (SNV) differences from one another, suggesting a large component of intrahospital spread. Furthermore, some patients with bloodstream infections were identified as moving from one hospital to another, potentially having led to interhospital spread. Genomic analysis of all isolates revealed close relatedness between isolates at multiple different hospitals (<20 SNV) not predicted from our epidemiologic data.
Both intrahospital and regional interhospital spread have contributed to the emergence of VRE ST1478 infections across Canada. Whole-genome sequencing provides evidence of spread that might be missed with epidemiologic investigation alone.
The severe acute respiratory coronavirus virus 2 (SARS-CoV-2) delta variant is highly transmissible, and current vaccines may have reduced effectiveness in preventing symptomatic infection. Using epidemiological and genomic analyses, we investigated an outbreak of the variant in an acute-care setting among partially and fully vaccinated individuals. Effective outbreak control was achieved using standard measures.
An accurate estimate of the average number of hand hygiene opportunities per patient hour (HHO rate) is required to implement group electronic hand hygiene monitoring systems (GEHHMSs). We sought to identify predictors of HHOs to validate and implement a GEHHMS across a network of critical care units.
Multicenter, observational study (10 hospitals) followed by quality improvement intervention involving 24 critical care units across 12 hospitals in Ontario, Canada.
Critical care patient beds were randomized to receive 1 hour of continuous direct observation to determine the HHO rate. A Poisson regression model determined unit-level predictors of HHOs. Estimates of average HHO rates across different types of critical care units were derived and used to implement and evaluate use of GEHHMS.
During 2,812 hours of observation, we identified 25,417 HHOs. There was significant variability in HHO rate across critical care units. Time of day, day of the week, unit acuity, patient acuity, patient population and use of transmission-based precautions were significantly associated with HHO rate. Using unit-specific estimates of average HHO rate, aggregate HH adherence was 30.0% (1,084,329 of 3,614,908) at baseline with GEHHMS and improved to 38.5% (740,660 of 1,921,656) within 2 months of continuous feedback to units (P < .0001).
Unit-specific estimates based on known predictors of HHO rate enabled broad implementation of GEHHMS. Further longitudinal quality improvement efforts using this system are required to assess the impact of GEHHMS on both HH adherence and clinical outcomes within critically ill patient populations.
Background:Candida auris is an emerging pathogen that has recently disseminated globally and caused challenging outbreaks in healthcare facilities (HCFs), in part because it is commonly multidrug-resistant. Candida auris remains rare in Canada, with ~20 known cases to date. We describe the emergence of a novel subclade of C. auris in Ontario, Canada, using whole-genome sequencing (WGS). Methods: In Ontario, many HCFs submit yeast isolates from sterile sites requiring species-level characterization and antifungal susceptibility testing (AFST) to the provincial reference laboratory. Yeasts were identified using a combination of standard methods (morphology, API 20C, MALDI-ToF MS) including ITS2 sequencing. Sensititre YO9 panels were used for AFST. Genomic analysis of C. auris was performed using an Illumina HiSeq platform with at least 50× coverage; variants were called against the reference genome by using the previously published North Arizona SNP pipeline (NASP). Phylogenetic trees were produced by maximum parsimony method (MEGA7.0). Results: Between 2014 and 2018, yeast isolates from 5 different patients from 4 HCFs in the same region of Ontario were confirmed to be C. auris by ITS2 PCR and sequence analysis (Table 1). Based on interim CDC criteria for antifungal drug break points, all isolates were pansusceptible to common antifungals. WGS analysis demonstrated that the C. auris isolates were part of the South American clade (IV) and formed an isolated subclade that is well supported by bootstrap analysis, indicating clonal relationships among these isolates (Fig. 1). Conclusions: Although C. auris isolates are usually drug resistant, all 5 initial Ontario isolates were pansusceptible. WGS determined that these isolates clustered within clade IV and were clonal. This cluster of C. auris appears to represent a new subclade of the South American clade that has been transmitted among patients within a region of Ontario. C. auris may have been present in Ontario for some time, escaping earlier detection due to lack of screening programs in HCFs, historical challenges with microbiologic detection of C. auris, and the antifungal susceptibility of the circulating isolates. Investigations are underway to determine clinical features and epidemiologic relatedness among patients in this cluster.
Disclosures: Susy Hota, Contracted Research - Finch Therapeutics
Background: Healthcare services are increasingly shifting from inpatient to outpatient settings. Outpatient settings such as emergency departments (EDs), oncology clinics, dialysis clinics, and day surgery often involve invasive procedures with the risk of acquiring healthcare-associated infections (HAIs). As a leading cause of HAI, Clostridioides difficile infection (CDI) in outpatient settings has not been sufficiently described in Canada. The Canadian Nosocomial Infection Surveillance Program (CNISP) aims to describe the epidemiology, molecular characterization, and antimicrobial susceptibility of outpatient CDI across Canada. Methods: Epidemiologic data were collected from patients diagnosed with CDI from a network of 47 adult and pediatric CNISP hospitals. Patients presenting to an outpatient setting such as the ED or outpatient clinics were considered as outpatient CDI. Cases were considered HAIs if the patient had had a healthcare intervention within the previous 4 weeks, and they were considered community-associated if there was no history of hospitalization within the previous 12 weeks. Clostridioides difficile isolates were submitted to the National Microbiology Laboratory for testing during an annual 2-month targeted surveillance period. National and regional rates of CDI were stratified by outpatient location. Results: Between January 1, 2015, and June 30, 2019, 2,691 cases of outpatient-CDI were reported, and 348 isolates were available for testing. Most cases (1,475 of 2,691, 54.8%) were identified in outpatient clinics, and 72.8% (1,960 of 2,691) were classified as community associated. CDI cases per 100,000 ED visits were highest in 2015, at 10.3, and decreased to 8.1 in 2018. Rates from outpatient clinics decreased from 3.5 in 2016 to 2.7 in 2018 (Fig. 1). Regionally, CDI rates in the ED declined in Central Canada and increased in the West after 2016. Rates in outpatient clinics were >2 times higher in the West compared to other regions. RT027 associated with NAP1 was most common among ED patients (26 of 195, 13.3%), whereas RT106 associated with NAP11 was predominant in outpatient clinics (22 of 189, 11.6%). Overall, 10.4% of isolates were resistant to moxifloxacin, 0.5% were resistant to rifampin, and 24.2% were resistant to clindamycin. No resistance was observed for metronidazole, vancomycin, or tigecycline. Compared to CNISP inpatient CDI data, outpatients with CDI were younger (51.8 ± 23.3 vs 64.2 ± 21.6; P < .001), included more females (56.4% vs 50.9%; P < .001), and were more often treated with metronidazole (63.0% vs 56.1%; P < .001). Conclusions: For the first time, CDI cases identified in outpatient settings were characterized in a Canadian context. Outpatient CDI rates are decreasing overall, but they vary by region. Predominant ribotypes vary based on outpatient location. Outpatients with CDI are younger and are more likely female than inpatients with CDI.
Disclosures: Susy Hota reports contract research for Finch Therapeutics.
Background: Patients with hematologic malignancies are at increased risk for respiratory virus infections (RVIs) and may experience prolonged asymptomatic viral shedding contributing to transmission. In response to 2 extensive RVI outbreaks in our adult cancer center, a universal masking policy was implemented whereby inpatients on malignant hematology units and their visitors were required to wear procedure masks whenever they were walking outside their rooms. Visitors were required to mask when inside patient rooms. Staff were not included in the policy. Here, we describe the impact of universal masking on the incidence of nosocomial RVI in malignant hematology patients. Methods: In this before-and-after study, we examined the effects of universal masking in malignant hematology units of a 170-bed adult cancer hospital in Toronto, Canada, between January 1, 2015, and September 30, 2019. Nosocomial RVI incidence, RVI outbreak descriptions, and hand hygiene compliance rates were collected from hospital infection control databases. Mask utilization was extracted from hospital purchasing records. Staff influenza vaccination rates were obtained from occupational health records. RVI incidence rates before and after the intervention were compared using Wilcoxon rank-sum test. Results: The preimplementation phase ran from January 1, 2015, to February 28, 2017, and the postimplementation phase spanned March 1, 2017, to September 30, 2019. Monthly mask utilization on malignant hematology units increased by 105% after implementing the universal masking policy. Nosocomial RVI incidence decreased significantly after implementing the universal masking policy, and the number of cases involved in RVI outbreaks also decreased (Table 1). There was a 14% increase in nasopharyngeal swab orders after implementation. Staff influenza vaccination rates, hand hygiene compliance and infection control policies remained stable throughout the study. Conclusions: A reduction in the incidence of nosocomial RVI and number of RVI cases in outbreaks was observed after implementing the universal masking policy. Although we were unable to directly measure compliance with the intervention, increased mask utilization after the intervention implied adherence to the policy. Our experience suggests that universal masking in malignant hematology inpatients may be an effective RVI prevention strategy. Further rigorous study is warranted.
Disclosures: Susy Hota reports contract research for Finch Therapeutics.
Background: Carbapenemase-producing Enterobacterales (CPE) have rapidly become a global health concern and are associated with substantial morbidity and mortality due to limited treatment options. Travel to endemic areas, especially healthcare exposure in these areas, is an important risk factor for acquisition. We describe the evolving epidemiology, molecular features, and outcomes of CPE in Canada through surveillance by the Canadian Nosocomial Infection Surveillance Program (CNISP). Methods: CNISP has conducted surveillance for CPE among inpatients and outpatients of all ages since 2010. Participating acute-care facilities submit eligible specimens to the National Microbiology Laboratory for detection of carbapenemase production, and epidemiological data are collected. Incidence rates per 10,000 patient days are calculated based on inpatient data. Results: In total, 59 CNISP hospitals in 10 Canadian provinces representing 21,789 beds and 6,785,013 patient days participated in this surveillance. From 2010 to 2018, 118 (26%) CPE-infected and 547 (74%) CPE-colonized patients were identified. Few pediatric cases were identified (n = 18). Infection incidence rates remain low and stable (0.02 per 10,000 patient days in 2010 to 0.03 per 10,000 patient days in 2018), and colonization incidence rates have increased by 89% over the surveillance period. Overall, 92% of cases were acquired in a healthcare facility: 61% (n = 278) in a Canadian healthcare facility and 31% (n = 142) in a healthcare facility outside Canada. Of the 8% of cases not acquired in a healthcare facility, 50% (16 of 32) reported travel outside of Canada in the 12 months prior to positive culture. The distribution of carbapenemases varied by region; New Delhi metallo-B-lactamase (NDM) was dominant (59%) in western Canada and Klebsiella pneumoniae carbapenemase (KPC) (66%) in central Canada. NDM and class D carbapenemase OXA-48 were more commonly identified among those who traveled outside of Canada, whereas KPC was more commonly identified among patients without travel. In addition, 30-day all-cause mortality was 14% (25 of 181) among CPE infected patients and 32% (14 of 44) among those with bacteremia. Conclusions: CPE rates remain low in Canada; however, national surveillance data suggest that the increase in CPE in Canada is now being driven by local nosocomial transmission as well as travel and healthcare within endemic areas. Changes in screening practices may have contributed to the increase in colonizations; however, these data are currently lacking and will be collected moving forward. These data highlight the need to intensify surveillance and coordinate infection control measures to prevent further spread of CPE in Canadian acute-care hospitals.
Susy Hota reports contracted research for Finch Therapeutics. Allison McGeer reports funds to her institution for projects for which she is the principal investigator from Pfizer and Merck, as well as consulting fees from the following companies: Sanofi-Pasteur, Sunovion, GSK, Pfizer, and Cidara.
The University Health Network (UHN) is a multisite, academic health sciences center in Toronto, Canada, with 1,300 inpatient beds and ∼126,000 emergency department visits annually. Clinical services include a transplant program, cancer center, dialysis units, and rehabilitation sites. Currently, ∼0.83 km2 (>9 million ft2) of UHN real estate, ∼200 construction, renovation and maintenance projects are underway. The UHN Construction Infection Control Program (CICP) was created in 2012 and has expanded to include 3.5 FTEs to meet the needs of infection prevention oversight during these activities. We describe the performance indicators for the UHN CICP between May 2016 and December 2018 that have informed productivity and resource needs. Methods: Since 2016, construction infection preventionists (CIPs) have prospectively collected data on the frequency of activities reflecting CIP productivity and core job functions: number of meetings (attended and missed), site inspections, responses to breaches in control measures, education hours delivered, urgent requests, and after-hours work. Annual activity rates (frequency of activity divided by CIP months) were analyzed for trends, accounting for additions in CICP personnel over time. Results: Human resources and activities performed in the CICP from 2016 to 2018 are outlined in Table 1. As CICP human resources increased, the number of initiatives supported by the CICP team rose. Activity rates for attended meetings, inspections and hours of education provided increased with higher CIP resources, suggesting an improvement in individual productivity of each CIP (Fig. 1). Concurrently, the rate of missed meetings declined and after-hour requests and breach responses remained stable. Conclusions: An appropriately staffed CICP for the volume and risk level of organization-wide construction, renovation, and maintenance activities is crucial to infection prevention. We developed performance indicators based upon key functions of CIPs to evaluate the productivity of our team and ensure we had adequate human resources to maintain patient safety through our evolving needs.
Disclosures: Susy Hota reports contract research for Finch Therapeutics.
Background: Stethoscopes are known to be highly contaminated by a multitude of bacteria and therefore carry the potential to transmit pathogens within hospitals. North American infection prevention groups recommend low-level disinfection of stethoscopes for bioburden reduction between patients; however, adherence remains low in inpatient settings. Given that the lack of access to disinfection materials is the most commonly reported barrier to stethoscope hygiene, we studied an intervention using a point-of-care approach to increase stethoscope hygiene compliance among healthcare workers in critical care units. Methods: This quality improvement study was conducted in 2 critical-care units of a quaternary-care, academic, health sciences center in Toronto, Canada. We designed novel stethoscope hygiene stations consisting of a wall-mounted board with alcohol wipes, hooks for drying, and hand sanitizer dispensers to combine stethoscope and hand hygiene. Observations of stethoscope disinfection events per opportunity were collected by trained human auditors before and after the multimodal intervention, which consisted of the installation of 14 stations at the entrances of single-patient ICU rooms, accompanied by educational lectures and infographic dissemination. Anonymous feedback forms were used to gather information on healthcare workers’ stethoscope hygiene knowledge and behavior before and after the intervention. Results: In total, 124 observations were collected using convenience sampling between February and July 2019. Overall stethoscope hygiene compliance increased significantly from a baseline of 38% to 62% (P = .0316) (Fig. 1). Physician adherence to stethoscope disinfection increased by 22%. During the study period, hand hygiene compliance remained unchanged at 75%. Also, 74 healthcare providers completed feedback forms; they revealed an increase in awareness of stethoscope hygiene policies and/or recommendations (9% to 41%) and self reports of stethoscope hygiene compliance (28% to 44%). Conclusions: The implementation of stethoscope hygiene stations, coupled with an educational initiative, lead to a significant increase in overall stethoscope hygiene compliance among healthcare workers. Future quality improvement initiatives can adapt this strategy to promote disinfection and reduce pathogen burden of other personal and multiuse medical equipment.
Disclosures: Susy Hota reports contract research for Finch Therapeutics.
Background: The need for screening and isolation for patients colonized with vancomycin-resistant Enterococcus (VRE) remains controversial. In this study, we examined the effects of discontinuation and reinstatement of these practices on VRE infection and colonization incidence within a multisite, tertiary-care hospital center, including its effects on specific at-risk groups. Methods: We retrospective analyzed VRE clinical isolate, infection, and bacteremia incidence rates at our hospital (1) prior to discontinuation of universal screening and isolation (January 2010–June 2012), (2) during discontinuation (July 2012–April 2017), and (3) after reinstatement of screening and isolation in high-risk wards (intensive care and multiple-organ transplant units, June 2017–April 2019). Monthly incidence rates were calculated for each of 3 sites at our tertiary-care hospital: site A, which includes the transplant program, site B, an adult cancer hospital, and site C, which includes orthopedic and neurology programs. To understand the differential effect of screening and isolation on various risk groups, incidence rates were also calculated for individual programs within our hospital, including medicine, surgery, intensive care, oncology, and transplant programs. Results: During the period of study, 3,167 cases of VRE isolates were identified. Patient colonizations of VRE across the institution increased throughout the study period, with the monthly number of newly colonized patients increasing from 10.4 in the first period of study to 20.6 in the last period. The overall VRE clinical isolate, infection, and bacteremia incidence rates did not increase following the cessation of VRE screening and isolation precautions; however, a significant increase was seen among the patients at site B (Fig. 1, infection rates). Furthermore, there was a significant decrease in VRE clinical isolate, infection, and bacteremia incidence following the reinstatement of screening in the ICU and transplant programs at site A, but no effect was seen in the other programs (Fig. 2, infection rates). Conclusions: The risk associated with discontinuing VRE screening and isolation measures appears depend on the subgroup of patients within a hospital environment. Furthermore, risk-based or unit-based VRE screening and isolation appears to be effective at controlling VRE incidence, even after measures had previously been discontinued. Additional study of other inpatient settings is warranted to determine the effects of screening and isolation for VRE on other patient subgroups.
Disclosures: Susy Hota reports contract research for Finch Therapeutics.
Canadian hospitals were made aware of the risk of Mycobacterium chimaera infection associated with heater-cooler units (HCUs) through alerts issued by the US food and Drug Administration (FDA) and the US Centers for Disease Control and Prevention (CDC). In response, most hospitals conducted retrospective reviews for infections, informed exposed patients, and initiated a requirement for informed consent with HCU use.
To assess clinically relevant outcomes after complete cessation of control measures for vancomycin-resistant enterococci (VRE).
Quasi-experimental ecological study over 3.5 years.
All VRE screening and isolation practices at 4 large academic hospitals in Ontario, Canada, were stopped on July 1, 2012. In total, 618 anonymized abstracted charts of patients with VRE-positive clinical isolates identified between July 1, 2010, and December 31, 2013, were reviewed to determine whether the case was a true VRE infection, a VRE colonization or contaminant, or a true VRE bacteremia. All deaths within 30 days of the last VRE infection were also reviewed to determine whether the death was fully or partially attributable to VRE. All-cause mortality was evaluated over the study period. Generalized estimating equation methods were used to cluster outcome rates within hospitals, and negative binomial models were created for each outcome.
The incidence rate ratio (IRR) for VRE infections was 0.59 and the associated P value was .34. For VRE bacteremias, the IRR was 0.54 and P=.38; for all-cause mortality the IRR was 0.70 and P=.66; and for VRE attributable death, the IRR was 0.35 and P=.49. VRE control measures were not significantly associated with any of the outcomes. Rates of all outcomes appeared to increase during the 18-month period after cessation of VRE control measures, but none reached statistical significance.
Clinically significant VRE outcomes remain rare. Cessation of all control measures for VRE had no significant attributable adverse clinical impact.
To identify issues during donning and doffing of personal protective equipment (PPE) for infectious diseases and to inform PPE procurement criteria and design.
A mixed methods approach was used. Usability testing assessed the appropriateness, potential for errors, and ease of use of various combinations of PPE. A qualitative constructivist approach was used to analyze participant feedback.
Four academic health sciences centers: 2 adult hospitals, 1 trauma center, and 1 pediatric hospital, in Toronto, Canada.
Participants (n=82) were representative of the potential users of PPE within Western healthcare institutions.
None of the tested combinations provided a complete solution for PPE. Environmental factors, such as anteroom layout, and the design of protocols and instructional material were also found to impact safety. The study identified the need to design PPE as a complete system, rather than mixing and matching components.
Healthcare institutions are encouraged to use human factors methods to identify risk and failure points with the usage of their selected PPE, and to modify on the basis of iterative evaluations with representative end users. Manufacturers of PPE should consider usability when designing the next generation of PPE.
Pseudomonas aeruginosa has been increasingly recognized for its ability to cause significant hospital-associated outbreaks, particularly since the emergence of multidrug-resistant strains. Biofilm formation allows the pathogen to persist in environmental reservoirs. Thus, multiple hospital room design elements, including sink placement and design, can impact nosocomial transmission of P. aeruginosa and other pathogens.
From December 2004 through March 2006, 36 patients exposed to the intensive care unit or transplant units of a tertiary care hospital were infected with a multidrug-resistant strain of P. aeruginosa. All phenotypically similar isolates were examined for genetic relatedness by means of pulsed-field gel electrophoresis. Clinical characteristics of the affected patients were collected, and a detailed epidemiological and environmental investigation of potential sources was carried out.
Seventeen of the infected patients died within 3 months; for 12 (71%) of these patients, infection with the outbreak organism contributed to or directly caused death. The source of the outbreak was traced to hand hygiene sink drains, where biofilms containing viable organisms were found. Testing by use of a commercial fluorescent marker demonstrated that when the sink was used for handwashing, drain contents splashed at least 1 meter from the sink. Various attempts were made to disinfect the drains, but it was only when the sinks were renovated to prevent splashing onto surrounding areas that the outbreak was terminated.
This report highlights the importance of biofilms and of sink and patient room design in the propagation of an outbreak and suggests some strategies to reduce the risks associated with hospital sinks.
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