Identify changes in the prevalence and antimicrobial resistance patterns of potentially pathogenic bacteria in urine cultures during a 2-year antimicrobial stewardship intervention program in nursing homes (NHs).

Before-and-after intervention study.

The study included 27 NHs in North Carolina.

We audited all urine cultures ordered before and during an antimicrobial stewardship intervention. Analyses compared culture rates, culture positive rates, and pathogen antimicrobial resistance patterns.

Of 6,718 total urine cultures collected, 68% were positive for potentially pathogenic bacteria. During the intervention, significant reductions in the urine culture and positive culture rates were observed (P = .014). Most of the identified potentially uropathogenic isolates were Escherichia coli (38%), Proteus spp (13%), and Klebsiella pneumoniae (12%). A significant decrease was observed during the intervention period in nitrofurantoin resistance among E. coli (P ≤ .001) and ciprofloxacin resistance among Proteus spp (P ≤ .001); however carbapenem resistance increased for Proteus spp (P ≤ .001). Multidrug resistance also increased for Proteus spp compared to the baseline. The high baseline resistance of E. coli to the commonly prescribed antimicrobials ciprofloxacin and trimethoprim-sulfamethoxazole (TMP/SMX) did not change during the intervention.

The antimicrobial stewardship intervention program significantly reduced urine culture and culture-positive rates. Overall, very high proportions of antimicrobial resistance were observed among common pathogens; however, antimicrobial resistance trended downward but reductions were too small and scattered to conclude that the intervention significantly changed antimicrobial resistance. Longer intervention periods may be needed to effect change in resistance patterns.

To describe current practice around urine testing and identify factors leading to overtreatment of asymptomatic bacteriuria in community nursing homes (NHs)

Observational study of a stratified random sample of NH patients who had urine cultures ordered in NHs within a 1-month study period

31 NHs in North Carolina

254 NH residents who had a urine culture ordered within the 1-month study period

We conducted an NH record audit of clinical and laboratory information during the 2 days before and 7 days after a urine culture was ordered. We compared these results with the urine antibiogram from the 31 NHs.

Empirical treatment was started in 30% of cases. When cultures were reported, previously untreated cases received antibiotics 89% of the time for colony counts of ≥100,000 CFU/mL and in 35% of cases with colony counts of 10,000–99,000 CFU/mL. Due to the high rate of prescribing when culture results returned, 74% of these patients ultimately received a full course of antibiotics. Treated and untreated patients did not significantly differ in temperature, frequency of urinary signs and symptoms, or presence of Loeb criteria for antibiotic initiation. Factors most commonly associated with urine culture ordering were acute mental status changes (32%); change in the urine color, odor, or sediment (17%); and dysuria (15%).

Urine cultures play a significant role in antibiotic overprescribing. Antibiotic stewardship efforts in NHs should include reduction in culture ordering for factors not associated with infection-related morbidity as well as more scrutiny of patient condition when results become available.

Infect Control Hosp Epidemiol 2017;38:524–531

To study the epidemiology and preventability of blood contact with skin and mucous membranes during surgical procedures.

Observers present at 1,382 surgical procedures recorded information about the procedure, the personnel present, and the contacts that occurred.

Four US teaching hospitals during 1990.

Operating room personnel in five surgical specialties.

Numbers and circumstances of contact between the patient's blood (or other infective fluids) and surgical personnel's mucous membranes (mucous membrane contacts) or skin (skin contacts, excluding percutaneous injuries).

A total of 1,069 skin (including 620 hand, 258 body, and 172 face) and 32 mucous membrane (all affecting eyes) contacts were observed. Surgeons sustained most contacts (19% had ≥1 skin contact and 0.5% had ≥1 mucous membrane-eye contact). Hand contacts were 72% lower among surgeons who double gloved, and face contacts were prevented reliably by face shields. Mucous membrane-eye contacts were significantly less frequent in surgeons wearing eyeglasses and were absent in surgeons wearing goggles or face shields. Among surgeons, risk factors for skin contact depended on the area of contact: hand contacts were associated most closely with procedure duration (adjusted odds ratio [OR], 9.4; ≥4 versus <1 hour); body contacts (arms, legs, and torso) with estimated blood losses (adjusted OR, 8.4; ≥1,000 versus <100 mL); and face contacts, with orthopedic service (adjusted OR, 7.5 compared with general surgery).

Skin and mucous membrane contacts are preventable by appropriate barrier precautions, yet occur commonly during surgery. Surgeons who perform procedures similar to those included in this study should strongly consider double gloving, changing gloves routinely during surgery, or both.