We evaluated the clinical and molecular epidemiology of bloodstream infections (BSIs) due to methicillin-resistant Staphylococcus aureus (MRSA) in older versus younger patients treated with vancomycin, determining the independent effect of increased age on outcomes.

Observational retrospective cohort study.

Detroit Medical Center, level I trauma center.

Adult older (65 years and older) and younger (younger than 65 years) patients with documented BSIs due to MRSA treated with vancomycin (2005–2010).

Collected demographics, comorbidities, microbiology, treatment, outcomes. Multivariable model used to generate propensity score for each patient on the basis of the probability of being 65 years of age or older.

Three hundred twenty patients were eligible (69 patients 65 years and older; 251 patients younger than 65 years). Catheter-related infections and endocarditis were the most common sites of infection for older (20.3%) and younger (19.1%) adults, respectively. Median first total 24-hour vancomycin dose (1,000 vs 2,000 mg; P< .001) and initial trough (13.1 vs 15.0 mg/L; P = .043) was significantly lower in older versus younger patients. Vancomycin treatment failure rates were similar among older and younger patients (49.3% vs 53.4%; P = .545). In multivariable analysis of outcomes, after controlling for predictors of older age, there was no difference in clinical outcomes between older and younger adults.

After accounting for confounders associated with increased age, failure rate of patients with BSIs due to MRSA treated with vancomycin was similar between older and younger patients. Older adults were less likely to have optimal vancomycin dosing and initial trough levels than younger patients. Efforts should be made to optimize dosing of medications such as vancomycin in older adults.

Central line-associated bloodstream infection (CLABSI) is a national target for mandatory reporting and a Centers for Medicare and Medicaid Services target for value-based purchasing. Differences in chart review versus claims-based metrics used by national agencies and groups raise concerns about the validity of these measures.

Evaluate consistency and reasons for discordance among chart review and claims-based CLABSI events.

We conducted 2 multicenter retrospective cohort studies within 6 academic institutions. A total of 150 consecutive patients were identified with CLABSI on the basis of National Healthcare Safety Network (NHSN) criteria (NHSN cohort), and an additional 150 consecutive patients were identified with CLABSI on the basis of claims codes (claims cohort). Ail events had full-text medical record reviews and were identified as concordant or discordant with the other metric.

In the NHSN cohort, there were 152 CLABSIs among 150 patients, and 73.0% of these cases were discordant with claims data. Common reasons for the lack of associated claims codes included coding omission and lack of physician documentation of bacteremia cause. In the claims cohort, there were 150 CLABSIs among 150 patients, and 65.3% of these cases were discordant with NHSN criteria. Common reasons for the lack of NHSN reporting were identification of non-CLABSI with bacteremia meeting Centers for Disease Control and Prevention (CDC) criteria for an alternative infection source.

Substantial discordance between NHSN and claims-based CLABSI indicators persists. Compared with standardized CDC chart review criteria, claims data often had both coding omissions and misclassification of non-CLABSI infections as CLABSI. Additionally, claims did not identify any additional CLABSIs for CDC reporting. NHSN criteria are a more consistent interhospital standard for CLABSI reporting.

Occupational exposures to blood and other bodily fluids occur in approximately 5 per 100 persons every year in US hospitals. Since the provision of health care in the deployed environment poses unique challenges to hospital personnel, it is important to characterize the rates of occupational exposures and understand the prevalence of blood-borne pathogens (BBPs) in host nations.

A retrospective review of public health and laboratory records at a US military trauma center in Afghanistan from October 1, 2010, to March 31, 2012.

A total of 65 occupational exposures were reported, including 47 (72%) percutaneous and 18 (28%) mucocutaneous, with a yearly rate of 8.6 exposures per 100 persons. During 6-month deployment cycles, the majority of exposures (46.2%) occurred in the first 2 months after arrival in Afghanistan. Physicians reported the most exposures (26%), and the operating room (48%) was the most common hospital location. The prevalence of hepatitis B and hepatitis C among local national source patients (n = 59 ) was 8.9% and 2.3%, respectively, with no cases of HIV or syphilis detected. In contrast, there were no BBPs detected in coalition source (n = 12) or exposed (n = 57) patients.

The characteristics of occupational exposures in this deployed environment were comparable to those of US-based hospitals. Standard practices used to reduce occupational exposures, such as use of personal protective equipment and safety devices, should continue to be prioritized in the deployed setting. Although BBP rates are not well defined in Afghanistan, our results were consistent with those of prior epidemiologic studies.

To investigate the simultaneous occurrence of more than 1 Clostridium difficile ribotype in patients' stool samples at the time of diagnostic testing.

Stool samples submitted for diagnostic testing for the presence of toxigenic C. difficile were obtained for 102 unique patients. A total of 95 single colonies of C. difficile per stool sample were isolated on selective media, subcultured alongside negative (uninoculated) controls, and polymerase chain reaction (PCR) ribotyped using capillary gel electrophoresis.

Capillary-based PCR ribotyping was successful for 9,335 C. difficile isolates, yielding a median of 93 characterized isolates per stool sample (range, 69-95). More than 1 C. difficile ribotype was present in 16 of 102 (16%) C. difficile infection (CDI) cases; 2 of the 16 mixtures were composed of at least 3 ribotypes, while the remaining 14 were composed of at least 2.

Deep sampling of patient stool samples coupled with capillary-based PCR ribotyping identified a high rate of mixed CDI cases compared with previous estimates. Studies seeking to quantify the clinical significance of particular C. difficile ribotypes should account for mixed cases of disease.

Examine the use of airborne isolation by identifying reasons for nontimely discontinuation and predictors of compliance with Centers for Disease Control and Prevention (CDC) guidelines. Compliance with guidelines should result in timely (within 48 hours) discontinuation of isolation in patients without infectious pulmonary tuberculosis (TB).

Retrospective, observational study.

A private, university-affiliated, tertiary-care medical center.

All patients in airborne isolation for suspected pulmonary TB from June through December 2011.

Chart reviews were performed to identify airborne isolation practices and delayed (greater than 48 hours) or very delayed (greater than 72 hours) discontinuation. We used descriptive statistics and logistic regression to determine independent predictors of nontimely discontinuation of isolation.

We identified 113 patients (mean age ± standard deviation, 59.8 ± 17.7 years; male sex, 75.2%; white race, 15.9%; mean collection interval ± standard deviation, 21.4 ± 12.9 hours). Delayed and very delayed isolation discontinuation was noted in 81% and 49% of patients, respectively. No significant differences in demographic characteristics and clinical characteristics were identified between groups. Predictors of timely (within 48 hours) airborne isolation discontinuation included use of alternate diagnosis for discontinuation of isolation (P = .02), early infectious diseases (ID) consultation (P = .03), pulmonary consultation (P = .02), average sputum collection interval less than 24 hours (P = .03), and need for more than 1 induced sputum specimen (P = .05). Adjusting for potential confounders, pulmonary consultation (odds ratio [OR] [95% confidence interval (CI)], 0.14 [0.03-0.58]), alternate diagnosis for discontinuation of isolation (OR [95% CI], 4.5 [1.3-15.8]), and early ID consultation (OR [95% CI], 4.0 [1.1-14.8]) were independently associated with timely discontinuation.

Timely airborne isolation discontinuation occurs in only 18.6% of cases and is an opportunity for cost savings, improved efficiency, and potentially patient safety and satisfaction.

To determine the patient- and device-specific risk factors for hospital-acquired peripherally inserted central venous catheter–related bloodstream infections (PICC BSIs) in adult patients.

Nested case-control study.

Barnes-Jewish Hospital, a 1,252-bed tertiary care teaching hospital.

Adult patients with PICCs placed from January 1, 2006, through July 31, 2008.

PICC BSI cases were identified using the National Healthcare Safety Network definition. Uninfected control patients with PICCs in place were randomly selected at a 3: 1 ratio. Patient- and device-related variables were examined using multivariate analysis.

The overall PICC BSI rate was 3.13 per 1,000 catheter-days. Independent risk factors for PICC BSIs included congestive heart failure (odds ratio [OR], 2.0 [95% confidence interval (CI), 1.26–3.17]; P = .003), intra-abdominal perforation (OR, 5.66 [95% CI, 1.76–18.19]; P = .004), Clostidium difficile infection (OR, 2.25 [95% CI, 1.17–4.33]; P = .02), recent chemotherapy (OR, 3.36 [95% CI, 1.15–9.78]; P = .03), presence of tracheostomy (OR, 5.88 [95% CI, 2.99–11.55]; P < .001), and type of catheter (OR for double lumen, 1.89 [95% CI, 1.15–3.10]; P = .01; OR for triple lumen, 2.87 [95% CI, 1.39–5.92]; P = .004). Underlying chronic obstructive pulmonary disease (OR, 0.48 [95% CI, 0.29–0.78]; P = .03) and admission to surgical (OR, 0.43 [95% CI, 0.24–0.79]; P = .006) or oncology and orthopedic (OR, 0.35 [95% CI, 0.13–0.99]; P = .05) services were less likely to be associated with having a PICC BSI.

We identified several novel factors related to PICC BSIs. These factors may inform preventive measures.