To evaluate the impact of postprescription review of broad-spectrum antimicrobial (study-ABX) agents on rates of antimicrobial use.

Quasi-experimental before-after study.

Five academic medical centers.

Adults receiving at least 48 hours of study-ABX.

The baseline, intervention, and follow-up periods were 6 months each in 2 units at each of 5 sites. Adults receiving at least 48 hours of study-ABX entered the cohort as case-patients. During the intervention, infectious-diseases physicians reviewed the cases after 48 hours of study-ABX. The provider was contacted with alternative recommendations if antimicrobial use was considered to be unjustified on the basis of predetermined criteria. Acceptance rates were assessed 48 hours later. The primary outcome measure was days of study-ABX per 1,000 study-patient-days in the baseline and intervention periods.

There were 1,265 patients in the baseline period and 1,163 patients in the intervention period. Study-ABX use decreased significantly during the intervention period at 2 sites: from 574.4 to 533.8 study-ABX days/1,000 patient-days (incidence rate ratio [IRR], 0.93; 95% confidence interval [CI], 0.88-0.97; P = .002) at hospital В and from 615.6 to 514.4 study-ABX days/1,000 patient-days (IRR, 0.83; 95% CI, 0.79-0.88; P < .001) at hospital D. Both had established antimicrobial stewardship programs (ASP). Study-ABX use increased at 2 sites and stayed the same at 1 site. At all institutions combined, 390 of 1,429 (27.3%) study-ABX courses were assessed as unjustified; recommendations to modify or stop therapy were accepted for 260 (66.7%) of these courses.

Postprescription review of study-ABX decreased antimicrobial utilization in some of the study hospitals and may be more effective when performed as part of an established ASP.

To evaluate the economic impact of performing rapid testing for Staphylococcus aureus colonization before admission for all inpatients who are scheduled to undergo elective surgery and providing subsequent decolonization therapy for those patients found to be colonized with S. aureus.

A budget impact model that used probabilistic sensitivity analysis to account for the uncertainties in the input variables was developed. Primary input variables included the marginal effect of S. aureus infection on patient outcomes among patients who underwent elective surgery, patient demographic characteristics, the prevalence of nasal carriage of S. aureus, the sensitivity and specificity of the rapid diagnostic test for S. aureus colonization, the efficacy of decolonization therapy for nasal carriage of S. aureus, and cost data. Data sources for the input variables included the 2003 Nationwide Inpatient Sample data and the published literature.

In 2003, there were an estimated 7,181,484 patients admitted to US hospitals for elective surgery. Our analysis indicated preadmission testing and subsequent decolonization therapy for patients colonized with S. aureus would have produced a mean annual cost savings to US hospitals of $231,538,400 (95% confidence interval [CI], -$300 million to $1.3 billion). The mean annual number of hospital-days that could have been eliminated was estimated at 364,919 days (95% CI, 67,893-926,983 days), and a mean of 935 in-hospital deaths (95% CI, 88-3,691) could have been avoided per year. Sensitivity analysis indicated a 64.5% probability that there would be cost savings to US hospitals as a result of preadmission testing and subsequent decolonization therapy.

The addition of preadmission testing and decolonization therapy to standard care would result in significant cost savings, even after accounting for variations in the model input values.

Education-based interventions can reduce the incidence of catheter-associated bloodstream infection. The generalizability of findings from single-center studies is limited.

To assess the effect of a multicenter intervention to prevent catheter-associated bloodstream infections.

An observational study with a planned intervention.

Twelve intensive care units and 1 bone marrow transplantation unit at 6 academic medical centers.

Patients admitted during the study period.

Updates of written policies, distribution of a 9-page self-study module with accompanying pretest and posttest, didactic lectures, and incorporation into practice of evidence-based guidelines regarding central venous catheter (CVC) insertion and care.

Standard data collection tools and definitions were used to measure the process of care (ie, the proportion of non-tunneled catheters inserted into the femoral vein and the condition of the CVC insertion site dressing for both tunneled and nontunneled catheters) and the incidence of catheter-associated bloodstream infection.

Between the preintervention period and the postintervention period, the percentage of CVCs inserted into the femoral vein decreased from 12.9% to 9.4% (relative ratio, 0.73; 95% confidence interval [CI], 0.61-0.88); the total proportion of catheter insertion site dressings properly dated increased from 26.6% to 34.4% (relative ratio, 1.29; 95% CI, 1.17-1.42), and the overall rate of catheter-associated bloodstream infections decreased from 11.2 to 8.9 infections per 1,000 catheter-days (relative rate, 0.79; 95% CI, 0.67-0.93). The effect of the intervention varied among individual units.

An education-based intervention that uses evidence-based practices can be successfully implemented in a diverse group of medical and surgical units and reduce catheter-associated bloodstream infection rates.

Education-based interventions can reduce the incidence of catheter-associated bloodstream infection. The generalizability of findings from single-center studies is limited.

To assess the effect of a multicenter intervention to prevent catheter-associated bloodstream infections.

An observational study with a planned intervention.

Twelve intensive care units and 1 bone marrow transplantation unit at 6 academic medical centers.

Patients admitted during the study period.

Updates of written policies, distribution of a 9-page self-study module with accompanying pretest and posttest, didactic lectures, and incorporation into practice of evidence-based guidelines regarding central venous catheter (CVC) insertion and care.

Standard data collection tools and definitions were used to measure the process of care (ie, the proportion of non-tunneled catheters inserted into the femoral vein and the condition of the CVC insertion site dressing for both tunneled and nontunneled catheters) and the incidence of catheter-associated bloodstream infection.

Between the preintervention period and the postintervention period, the percentage of CVCs inserted into the femoral vein decreased from 12.9% to 9.4% (relative ratio, 0.73; 95% confidence interval [CI], 0.61-0.88); the total proportion of catheter insertion site dressings properly dated increased from 26.6% to 34.4% (relative ratio, 1.29; 95% CI, 1.17-1.42), and the overall rate of catheter-associated bloodstream infections decreased from 11.2 to 8.9 infections per 1,000 catheter-days (relative rate, 0.79; 95% CI, 0.67-0.93). The effect of the intervention varied among individual units.

An education-based intervention that uses evidence-based practices can be successfully implemented in a diverse group of medical and surgical units and reduce catheter-associated bloodstream infection rates.

In 2002, the Chicago Department of Public Health (CDPH; Chicago, Illinois) convened the Chicago-Area Neonatal MRSA Working Group (CANMWG) to discuss and compare approaches aimed at control of methicillin-resistant Staphylococcus aureus (MRSA) in neonatal intensive care units (NICUs). To better understand these issues on a regional level, the CDPH and the Evanston Department of Health and Human Services (EDHHS; Evanston, Illinois) began an investigation.

Survey to collect demographic, clinical, microbiologic, and epidemiologic data on individual cases and clusters of MRSA infection; an additional survey collected data on infection control practices.

Level III NICUs at Chicago-area hospitals.

Neonates and healthcare workers associated with the level III NICUs.

From June 2001 through September 2002, the participating hospitals reported all clusters of MRSA infection in their respective level III NICUs to the CDPH and the EDHHS.

Thirteen clusters of MRSA infection were detected in level III NICUs, and 149 MRSA-positive infants were reported. Infection control surveys showed that hospitals took different approaches for controlling MRSA colonization and infection in NICUs.

The CANMWG developed recommendations for the prevention and control of MRSA colonization and infection in the NICU and agreed that recommendations should expand to include future data generated by further studies. Continuing partnerships between hospital infection control personnel and public health professionals will be crucial in honing appropriate guidelines for effective approaches to the management and control of MRSA colonization and infection in NICUs.

To determine the extent to which evidence-based practices for the prevention of central venous catheter (CVC)-associated bloodstream infections are incorporated into the policies and practices of academic intensive care units (ICUs) in the United States and to determine variations in the policies on CVC insertion, use, and care.

A 9-page written survey of practices and policies for nontunneled CVC insertion and care.

ICUs in 10 academic tertiary-care hospitals.

ICU medical directors and nurse managers.

Twenty-five ICUs were surveyed (1-6 ICUs per hospital). In 80% of the units, 5 separate groups of clinicians inserted 24%-50% of all nontunneled CVCs. In 56% of the units, placement of more than two-thirds of nontunneled CVCs was performed in a single location in the hospital. Twenty units (80%) had written policies for CVC insertion. Twenty-eight percent of units had a policy requiring maximal sterile-barrier precautions when CVCs were placed, and 52% of the units had formal educational programs with regard to CVC insertion. Eighty percent of the units had a policy requiring staff to perform hand hygiene before inserting CVCs, but only 36% and 60% of the units required hand hygiene before accessing a CVC and treating the exit site, respectively.

ICU policy regarding the insertion and care of CVCs varies considerably from hospital to hospital. ICUs may be able to improve patient outcome if evidence-based guidelines for CVC insertion and care are implemented.

To compare risk factors, clinical features, and outcomes in patients with Enterococcus avium, Enterococcus casseliflavus, Enterococcus durans, Enterococcus gallinarum, and Enterococcus mundtii bacteremia (cases) with those in patients with Enterococcus faecalis bacteremia (controls).

A retrospective case-control study.

A 725-bed, university-affiliated, academic medical center.

The clinical microbiology database at Northwestern Memorial Hospital from January 1994 to May 2003 was searched to identify cases; each case was matched to one control on the basis of date of admission.

Thirty-three cases were identified and matched with 33 controls. The mean duration of hospital stay was longer (29.7 vs 17.2 days; P = .03) and the mean time to acquisition of bacteremia was greater (16.5 vs 6.3 days; P = .003) for cases than controls. Cases were more likely to have underlying hematologic malignancies (P < .001), to have been treated with corticosteroids (P = .02), and to be neutropenic (P = .003). Controls were more likely to have an indwelling bladder catheter (P = .01), and cases were more likely to have the gastrointestinal tract as a source of infection (P = .007) and to have concurrent cholangitis (P = .002). There were no differences in severity of illness or in mortality rates.

Compared with patients with E. faecalis bacteremia, patients with non-E. faecalis, non-Enterococcus faecium enterococcal bacteremia were more likely to have a hematologic malignancy, prior treatment with corticosteroids, neutropenia, and cholangitis; longer duration of hospital stay was also identified as a clinical feature. However, non-E. faecalis, non-E. faecium species are not associated with any differences in mortality.

Clostridium difficile-associated diarrhea (CDAD) causes substantial healthcare-associated morbidity. Unlike other common healthcare-associated pathogens, little comparative information is available about CDAD rates in hospitalized patients.

To determine CDAD rates per 10,000 patient-days and per 1,000 hospital admissions at 7 geographically diverse tertiary-care centers from 2000 to 2003, and to survey participating centers on methods of CDAD surveillance and case definition.

Each center provided specific information for the study period, including case numbers, patient-days, and hospital characteristics. Case definitions and laboratory diagnoses of healthcare-associated CDAD were determined by each institution. Within institutions, case definitions remained consistent during the study period.

Overall, mean annual case rates of CDAD were 12.1 per 10,000 patient-days (range, 3.1 to 25.1) and 7.4 per 1,000 hospital admissions (range, 3.1 to 13.1). No significant increases were observed in CDAD case rates during the 4-year interval, either at individual centers or in the Prevention Epicenter hospitals as a whole. Prevention Epicenter hospitals differed in their CDAD case definitions. Different case definitions used by the hospitals applied to a fixed data set resulted in a 30% difference in rates. No associations were identified between diagnostic test or case definition used and the relative rate of CDAD at a specific medical center.

Rates of CDAD vary widely at tertiary-care centers across the United States. No significant increases in case rates were identified. The varying clinical and laboratory approaches to diagnosis complicated comparisons between hospitals. To facilitate benchmarking and comparisons between institutions, we recommend development of a more standardized case definition.

Nosocomial infections due to medical devices are of increasing concern to infection control practitioners. Attempts to prevent such infections have included surveillance cultures of endoscopes and bronchoscopes. In July 2002, the infectious disease consultation service was asked to see three patients with sepsis due to multidrug-resistant Pseudomonas aeruginosa after endoscopic retrograde cholangiopancreatography (ERCP).

To describe an outbreak of multidrug-resistant P. aeruginosa sepsis after ERCP at an institution that performs routine surveillance cultures of endoscopes.

A traditional outbreak investigation supplemented by pulsed-field gel electrophoresis (PFGE) was undertaken, including a case-control analysis based on the hypothesis that all infected individuals had their ERCP performed with the same endoscope.

A tertiary-care academic medical center.

The case-control analysis confirmed the hypothesis that undergoing ERCP with the implicated endoscope was associated with a culture positive for Pseudomonas (P = .01). The available strains were identical by PFGE. This outbreak occurred despite a negative surveillance culture of the implicated endoscope 1 month earlier.

Infectious morbidity can occur after endoscopy despite negative surveillance cultures. The practice of routine endoscope cultures does not prevent device-related infectious morbidity.

Investigate and control an increase in bloodstream infections (BSIs) in an outpatient hemodialysis center.

A retrospective cohort study was conducted for patients receiving dialysis at the center from February 2000 to April 2001. A case–control study compared microbiological data for all BSIs that occurred during the study period with those for BSIs that occurred during a baseline period Qanuary 1999 to January 2000). BSI rates before and after a 1-month intervention (May 2001) were assessed. A case was defined as a new BSI during the study period.

The outbreak was polymicrobial, with approximately 30 species. The baseline BSI rate was 0.7 per 100 patient-months. From February 2000 to April 2001, the BSI rate increased to 4.2 per 100 patient-months. Overall, 75% of the BSIs were associated with central venous catheters (CVCs), but CVC use did not fully explain the increase in BSIs. In January 2000, when the center changed ownership, prepackaged CVC dressing kits and biweekly infection control monitoring were discontinued. Beginning in May 2001, staff were educated on CVC care, chlorhexidine replaced povidone-iodine for cutaneous antisepsis, gauze replaced transparent dressings, antimicrobial ointments containing polyethylene glycol at CVC exit sites were discontinued, and patients with CVCs were educated on cutaneous hygiene. After the intervention period, by October 2001, rates decreased to less than 1 BSI per 100 patient-months.

Proper cutaneous antisepsis and access site care is crucial in preventing BSIs in patients receiving hemodialysis. Infection control programs, staff and patient education, and use of optimal antisepsis agents or prepackaged kits are useful toward this end.

To determine the molecular epidemiology of vancomycin-resistant enterococci (VRE) at our medical center in order to identify the extent of strain clonality and possible transmission patterns of this pathogen.

An important facet of our infection control program includes molecular typing of all clinical and surveillance isolates of VRE to determine transmission patterns in the hospital. Molecular strain typing is performed by restriction endonuclease analysis (REA) of genomic DNA. REA patterns are visually compared to categorize VRE strains into type and subtype designations.

A 588-bed, university-affiliated, tertiary-care hospital and a neighboring 155-bed rehabilitation facility.

From January 1995 through December 1996, 379 VRE isolates were collected from 197 patients. Thirty-three genotypes were determined by REA typing; 15 genotypes were implicated in 29 instances of potential nosocomial transmission. Three major clusters of VRE involving patients on multiple nursing units and two adjacent hospitals were identified. The remaining instances of nosocomial transmission occurred in small patient clusters.

In conclusion, the VRE epidemic at this medical center is polyclonal. VRE transmission patterns are complex, and, while large clusters do occur, the usual pattern of nosocomial acquisition of this pathogen occurs in the setting of “mini-clusters”.

To determine the recovery of vancomycin-resistant enterococci (VRE) on fingertips, gloved fingertips, and environmental surfaces commonly encountered in the healthcare setting, and to examine the importance of handwashing on the removal of these organisms.

Two clinical isolates of VRE (Enterococcus faecalis and Enterococcus faecium) were inoculated onto the hands of healthy human volunteers and the following environmental surfaces: countertops, bedrails, telephones, and stethoscopes. Following inoculation, samples were obtained at various time intervals to determine rates of recovery of organisms. To evaluate the effects of handwashing on enterococcal recovery, two different soap preparations were tested. Hands were washed with water alone or with one of the soaps and water. The soap and water studies were performed with a 5-second and a 30-second wash.

Both enterococcal strains survived for at least 60 minutes on gloved and ungloved fingertips. The E faecalis was recoverable from countertops for 5 days; the E faecium persisted for 7 days. For bedrails, both enterococcal species survived for 24 hours without significant reduction in colony counts. The bacteria persisted for 60 minutes on the telephone handpiece and for 30 minutes on the diaphragmatic surface of the stethoscope. A 5-second wash with water alone resulted in virtually no change in recovery of enterococci; a 30-second wash with water plus either soap was necessary to eradicate the bacteria from hands completely.

VRE are capable of prolonged survival on hands, gloves, and environmental surfaces. Hands should be washed thoroughly and gloves removed following contact with patients infected or colonized with these multidrug-resistant bacteria. Finally, environmental surfaces may serve as potential reservoirs for nosocomial transmission of VRE and need to be considered when formulating institutional infection control policies.