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To examine the prevalence of healthcare-associated pathogens and the infection control policies and practices in a national sample of nursing homes (NHs).
In 2012, we conducted a national survey about the extent to which NHs follow suggested infection control practices with regard to 3 common healthcare-associated pathogens: methicillin-resistant Staphylococcus aureus, Clostridium difficile, and extended-spectrum β-lactamase producers, and their prevalence in NHs. We adapted a previously used and validated NH infection control survey, including questions on prevalence, admission and screening policies, contact precautions, decolonization, and cleaning practices.
A total of 1,002 surveys were returned. Of the responding NHs, 14.2% were less likely to accept residents with methicillin-resistant Staphylococcus aureus, with the principal reason being lack of single or cohort rooms. NHs do not routinely perform admission screening (96.4%) because it is not required by regulation (56.2%) and would not change care provision (30.7%). Isolation strategies vary substantially, with gloves being most commonly used. Most NHs (75.1%) do not decolonize carriers of methicillin-resistant Staphylococcus aureus, but some (10.6%) decolonize more than 90% of residents. Despite no guidance on how resident rooms on contact precautions should be cleaned, 59.3% of NHs report enhanced cleaning for such rooms.
Overall, NHs tend to follow voluntary infection control guidelines only if doing so does not require substantial financial investment in new or dedicated staff or infrastructure.
Staphylococcus aureus carriage among healthcare workers (HCWs) is a concern in hospital settings, where it may provide a reservoir for later infections in both patients and staff. Earlier studies have shown that the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) carriage in HCWs is highly variable, depending notably on location, hospital department type, MRSA prevalence among patients, and type of contacts with patients. However, MRSA incidence in HCWs and its occupational determinants have seldom been studied.
A prospective, observational cohort study was conducted between May and October 2009 in a French rehabilitation center hospital. HCWs and patients were screened weekly for S. aureus nasal carriage. Methicillin-susceptible S. aureus and MRSA prevalence and incidence were estimated and factors associated with MRSA acquisition were identified using generalized estimating equation regression methods.
Among 343 HCWs included in the analysis, the average prevalence was 27% (95% CI, 24%–29%) for methicillin-susceptible S. aureus and 10% (8%–11%) for MRSA. We observed 129 MRSA colonization events. According to the multivariable analysis, high MRSA prevalence level among patients and HCW occupation were significantly associated with MRSA acquisition in HCWs, with assistant nurses being more at risk than nurses (odds ratio, 2.2; 95% CI, 1.4–3.6).
Our findings may help further our understanding of the transmission dynamics of MRSA carriage acquisition in HCWs, suggesting that it is notably driven by carriage among patients and by the type of contact with patients.
Infants in the neonatal intensive care unit (NICU) are at increased risk for methicillin-resistant Staphylococcus aureus (MRSA) acquisition. Outbreaks may be difficult to identify due in part to limitations in current molecular genotyping available in clinical practice. Comparison of genome-wide single nucleotide polymorphisms (SNPs) may identify epidemiologically distinct isolates among a population sample that appears homogenous when evaluated using conventional typing methods.
To investigate a putative MRSA outbreak in a NICU utilizing whole-genome sequencing and phylogenetic analysis to identify recent transmission events.
Clinical and surveillance specimens collected during clinical care and outbreak investigation.
A total of 17 neonates hospitalized in a 43-bed level III NICU in northeastern Florida from December 2010 to October 2011 were included in this study.
We assessed epidemiological data in conjunction with 4 typing methods: antibiograms, PFGE, spa types, and phylogenetic analysis of genome-wide SNPs.
Among the 17 type USA300 isolates, 4 different spa types were identified using pulsed-field gel electrophoresis. Phylogenetic analysis identified 5 infants as belonging to 2 clusters of epidemiologically linked cases and excluded 10 unlinked cases from putative transmission events. The availability of these results during the initial investigation would have improved infection control interventions.
Whole-genome sequencing and phylogenetic analysis are invaluable tools for epidemic investigation; they identify transmission events and exclude cases mistakenly implicated by traditional typing methods. When routinely applied to surveillance and investigation in the clinical setting, this approach may provide actionable intelligence for measured, appropriate, and effective interventions.
Infect. Control Hosp. Epidemiol. 2015;36(7):777–785
To identify risk factors for recurrent methicillin-resistant Staphylococcus aureus (MRSA) colonization.
Prospective cohort study conducted from January 1, 2010, through December 31, 2012.
Five adult and pediatric academic medical centers.
Subjects (ie, index cases) who presented with acute community-onset MRSA skin and soft-tissue infection.
Index cases and all household members performed self-sampling for MRSA colonization every 2 weeks for 6 months. Clearance of colonization was defined as 2 consecutive sampling periods with negative surveillance cultures. Recurrent colonization was defined as any positive MRSA surveillance culture after clearance. Index cases with recurrent MRSA colonization were compared with those without recurrence on the basis of antibiotic exposure, household demographic characteristics, and presence of MRSA colonization in household members.
The study cohort comprised 195 index cases; recurrent MRSA colonization occurred in 85 (43.6%). Median time to recurrence was 53 days (interquartile range, 36–84 days). Treatment with clindamycin was associated with lower risk of recurrence (odds ratio, 0.52; 95% CI, 0.29–0.93). Higher percentage of household members younger than 18 was associated with increased risk of recurrence (odds ratio, 1.01; 95% CI, 1.00–1.02). The association between MRSA colonization in household members and recurrent colonization in index cases did not reach statistical significance in primary analyses.
A large proportion of patients initially presenting with MRSA skin and soft-tissue infection will have recurrent colonization after clearance. The reduced rate of recurrent colonization associated with clindamycin may indicate a unique role for this antibiotic in the treatment of such infection.
Infect. Control Hosp. Epidemiol. 2015;36(7):786–793
The incidence of Clostridium difficile infection (CDI) has increased among hospitalized patients and is a common complication of leukemia. We investigated the risks for and outcomes of CDI in hospitalized leukemia patients.
Adults with a primary diagnosis of leukemia were extracted from the United States Nationwide Inpatient Sample database, 2005–2011. The primary outcomes of interest were CDI incidence, CDI-associated mortality, length of stay (LOS), and charges. In a secondary analysis, we sought to identify independent risk factors for CDI in leukemia patients. Logistic regression was used to derive odds ratios (ORs) adjusted for potential confounders.
A total of 1,243,107 leukemia hospitalizations were identified. Overall CDI incidence was 3.4% and increased from 3.0% to 3.5% during the 7-year study period. Leukemia patients had 2.6-fold higher risk for CDI than non-leukemia patients, adjusted for LOS. CDI was associated with a 20% increase in mortality of leukemia patients, as well as 2.6 times prolonged LOS and higher hospital charges. Multivariate analysis revealed that age >65 years (OR, 1.13), male gender (OR, 1.14), prolonged LOS, admission to teaching hospital (OR, 1.16), complications of sepsis (OR, 1.83), neutropenia (OR, 1.35), renal failure (OR, 1.18), and bone marrow or stem cell transplantation (OR, 1.27) were significantly associated with CDI occurrence.
Hospitalized leukemia patients have greater than twice the risk of CDI than non-leukemia patients. The incidence of CDI in this population increased 16.7% from 2005 to 2011. Development of CDI in leukemia patients was associated with increased mortality, longer LOS, and higher hospital charges.
To observe patient care across hemodialysis facilities enrolled in the National Opportunity to Improve Infection Control in ESRD (end-stage renal disease) (NOTICE) project in order to evaluate adherence to evidence-based practices aimed at prevention of infection.
SETTING AND PARTICIPANTS
Thirty-four hemodialysis facilities were randomly selected from among 772 facilities in 4 end-stage renal disease participating networks. Facility selection was stratified on dialysis organization affiliation, size, socioeconomic status, and urban/rural status.
Trained infection control evaluators used an infection control worksheet to observe 73 distinct infection control practices at the hemodialysis facilities, from October 1, 2011, through January 31, 2012.
There was considerable variation in infection control practices across enrolled facilities. Overall adherence to recommended practices was 68% (range, 45%–92%) across all facilities. Overall adherence to expected hand hygiene practice was 72% (range, 10%–100%). Compliance to hand hygiene before and after procedures was high; however, during procedures hand hygiene compliance averaged 58%. Use of chlorhexidine as the specific agent for exit site care was 19% overall but varied from 0% to 35% by facility type. The 8 checklists varied in the frequency of perfect performance from 0% for meeting every item on the checklist for disinfection practices to 22% on the arteriovenous access practices at initiation.
Our findings suggest that there are many areas for improvement in hand hygiene and other infection prevention practices in end-stage renal disease. These NOTICE project findings will help inform the development of a larger quality improvement initiative at dialysis facilities.
Valid comparison between hospitals for benchmarking or pay-for-performance incentives requires accurate correction for underlying disease severity (case-mix). However, existing models are either very simplistic or require extensive manual data collection.
To develop a disease severity prediction model based solely on data routinely available in electronic health records for risk-adjustment in mechanically ventilated patients.
Retrospective cohort study.
Mechanically ventilated patients from a single tertiary medical center (2006–2012).
Predictors were extracted from electronic data repositories (demographic characteristics, laboratory tests, medications, microbiology results, procedure codes, and comorbidities) and assessed for feasibility and generalizability of data collection. Models for in-hospital mortality of increasing complexity were built using logistic regression. Estimated disease severity from these models was linked to rates of ventilator-associated events.
A total of 20,028 patients were initiated on mechanical ventilation, of whom 3,027 deceased in hospital. For models of incremental complexity, area under the receiver operating characteristic curve ranged from 0.83 to 0.88. A simple model including demographic characteristics, type of intensive care unit, time to intubation, blood culture sampling, 8 common laboratory tests, and surgical status achieved an area under the receiver operating characteristic curve of 0.87 (95% CI, 0.86–0.88) with adequate calibration. The estimated disease severity was associated with occurrence of ventilator-associated events.
Accurate estimation of disease severity in ventilated patients using electronic, routine care data was feasible using simple models. These estimates may be useful for risk-adjustment in ventilated patients. Additional research is necessary to validate and refine these models.
Infect. Control Hosp. Epidemiol. 2015;36(7):807–815
To determine whether implementation of a multifaceted intervention would significantly reduce the incidence of central line–associated bloodstream infections.
Prospective cohort collaborative.
SETTING AND PARTICIPANTS
Intensive care units of the Abu Dhabi Health Services Company hospitals in the Emirate of Abu Dhabi.
A bundled intervention consisting of 3 components was implemented as part of the program. It consisted of a multifaceted approach that targeted clinician use of evidence-based infection prevention recommendations, tools that supported the identification of local barriers to these practices, and implementation ideas to help ensure patients received the practices. Comprehensive unit-based safety teams were created to improve safety culture and teamwork. Finally, the measurement and feedback of monthly infection rate data to safety teams, senior leaders, and staff in participating intensive care units was encouraged. The main outcome measure was the quarterly rate of central line–associated bloodstream infections.
Eighteen intensive care units from 7 hospitals in Abu Dhabi implemented the program and achieved an overall 38% reduction in their central line–associated bloodstream infection rate, adjusted at the hospital and unit level. The number of units with a quarterly central line–associated bloodstream infection rate of less than 1 infection per 1,000 catheter-days increased by almost 40% between the baseline and postintervention periods.
A significant reduction in the global morbidity and mortality associated with central line–associated bloodstream infections is possible across intensive care units in disparate settings using a multifaceted intervention.
Infect. Control Hosp. Epidemiol. 2015;36(7):816–822
To estimate the summary effectiveness of different needle-stick injury (NSI)-prevention interventions.
We conducted a meta-analysis of English-language articles evaluating methods for reducing needle stick, sharp, or percutaneous injuries published from 2002 to 2012 identified using PubMed and Medline EBSCO databases. Data were extracted using a standardized instrument. Random effects models were used to estimate the summary effectiveness of 3 interventions: training alone, safety-engineered devices (SEDs) alone, and the combination of training and SEDs.
Healthcare facilities, mainly hospitals
Healthcare workers including physicians, midwives, and nurses
From an initial pool of 250 potentially relevant studies, 17 studies met our inclusion criteria. Six eligible studies evaluated the effectiveness of training interventions, and the summary effect of the training intervention was 0.66 (95% CI, 0.50–0.89). The summary effect across the 5 studies that assessed the efficacy of SEDs was 0.51 (95% CI, 0.40–0.64). A total of 8 studies evaluated the effectiveness of training plus SEDs, with a summary effect of 0.38 (95% CI, 0.28–0.50).
Training combined with SEDs can substantially reduce the risk of NSIs.
Using a validated air sampling method we found Acinetobacter baumannii in the air surrounding only 1 of 12 patients known to be colonized or infected with A. baumannii. Patients’ closed-circuit ventilator status, frequent air exchanges in patient rooms, and short sampling time may have contributed to this low burden.
An accepted practice for patients colonized with multidrug-resistant organisms is to discontinue contact precautions following 3 consecutive negative surveillance cultures. Our experience with surveillance cultures to detect persistent carbapenemase-producing Enterobacteriaceae (CPE) colonization suggests that extrapolation of this practice to CPE-colonized patients may not be appropriate.
The performance of a hospital- and community-onset Clostridium difficile infection definition using administrative data with a present-on-admission indicator was compared with definitions using clinical surveillance. For hospital-onset C. difficile infection, there was moderate sensitivity (68%) and high specificity (93%); for community-onset, sensitivity and specificity were high (both 85%).
We assessed frequency and predictors of seasonal influenza vaccination acceptance among inpatients at a large tertiary referral hospital, as well as reasons for vaccination refusal. Over 5 seasons, >60% of patients unvaccinated on admission refused influenza vaccination while hospitalized; “believes not at risk” was the reason most commonly given.
Potential Creutzfeldt-Jakob disease instrument-contamination events continue to occur, causing widespread hospital and patient concern. We propose the use of a combination of diagnostic tests (ie, spinal fluid for 14-3-3 protein or nasal brushing for misfolded prion protein) and instrument handling procedures (ie, using a regional set of dedicated instruments), which if applied to all patients admitted with symptoms of either dementia or cerebellar disease, should eliminate the risk of iatrogenic instrument infection.