To determine the impact of total household decolonization with intranasal mupirocin and chlorhexidine gluconate body wash on recurrent methicillin-resistant Staphylococcus aureus (MRSA) infection among subjects with MRSA skin and soft-tissue infection.

Three-arm nonmasked randomized controlled trial.

Five academic medical centers in Southeastern Pennsylvania.

Adults and children presenting to ambulatory care settings with community-onset MRSA skin and soft-tissue infection (ie, index cases) and their household members.

Enrolled households were randomized to 1 of 3 intervention groups: (1) education on routine hygiene measures, (2) education plus decolonization without reminders (intranasal mupirocin ointment twice daily for 7 days and chlorhexidine gluconate on the first and last day), or (3) education plus decolonization with reminders, where subjects received daily telephone call or text message reminders.

Owing to small numbers of recurrent infections, this analysis focused on time to clearance of colonization in the index case.

Of 223 households, 73 were randomized to education-only, 76 to decolonization without reminders, 74 to decolonization with reminders. There was no significant difference in time to clearance of colonization between the education-only and decolonization groups (log-rank P=.768). In secondary analyses, compliance with decolonization was associated with decreased time to clearance (P=.018).

Total household decolonization did not result in decreased time to clearance of MRSA colonization among adults and children with MRSA skin and soft-tissue infection. However, subjects who were compliant with the protocol had more rapid clearance

Trial registration. ClinicalTrials.gov identifier: NCT00966446

Infect Control Hosp Epidemiol 2016;1–8

To identify Choosing Wisely items for the American Board of Internal Medicine Foundation.

The Society for Healthcare Epidemiology of America (SHEA) elicited potential items from a hospital epidemiology listserv, SHEA committee members, and a SHEA–Infectious Diseases Society of America compendium with SHEA Research Network members ranking items by Delphi method voting. The SHEA Guidelines Committee reviewed the top 10 items for appropriateness for Choosing Wisely. Five final recommendations were approved via individual member vote by committees and the SHEA Board.

Ninety-six items were proposed by 87 listserv members and 99 SHEA committee members. Top 40 items were ranked by 24 committee members and 64 of 226 SHEA Research Network members. The 5 final recommendations follow: 1. Don’t continue antibiotics beyond 72 hours in hospitalized patients unless patient has clear evidence of infection. 2. Avoid invasive devices (including central venous catheters, endotracheal tubes, and urinary catheters)and, if required, use no longer than necessary. They pose a major risk for infections. 3. Don’t perform urinalysis, urine culture, blood culture, or Clostridium difficile testing unless patients have signs or symptoms of infection. Tests can be falsely positive leading to overdiagnosis and overtreatment. 4. Do not use antibiotics in patients with recent C. difficile without convincing evidence of need. Antibiotics pose a high risk of C. difficile recurrence. 5. Don’t continue surgical prophylactic antibiotics after the patient has left the operating room. Five runner-up recommendations are included.

These 5 SHEA Choosing Wisely and 5 runner-up items limit medical overuse.

Infect Control Hosp Epidemiol 2016;37:755–760

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 major mechanism of fluoroquinolone (FQ) resistance in Pseudomonas aeruginosa (PSA) is modification of target proteins in DNA gyrase and topoisomerase IV, most commonly the gyrA and parC subunits. The objective of this study was to determine risk factors for PSA with and without gyrA or parC mutations.

Case-case-control study

Two adult academic acute-care hospitals

Case 1 study participants had a PSA isolate on hospital day 3 or later with any gyrA or parC mutation; case 2 study participants had a PSA isolate on hospital day 3 or later without these mutations. Controls were a random sample of all inpatients with a stay of 3 days or more.

Each case group was compared to the control group in separate multivariate models on the basis of demographics and inpatient antibiotic exposure, and risk factors were qualitatively compared.

Of 298 PSA isolates, 172 (57.7%) had at least 1 mutation. Exposure to vancomycin and other agents with extended Gram-positive activity was a risk factor for both cases (case 1 odds ratio [OR], 1.09; 95% confidence interval [CI], 1.04–1.13; OR, 1.14; 95% CI, 1.03–1.26; case 2 OR, 1.09; 95% CI, 1.03–1.14; OR, 1.13; 95% CI, 1.01–1.25, respectively).

Exposure to agents with extended Gram-positive activity is a risk factor for isolation of PSA overall but not for gyrA/parC mutations. FQ exposure is not associated with isolation of PSA with mutations.

Infect Control Hosp Epidemiol 2015;00(0): 1–7

Although prior authorization and prospective audit with feedback are both effective antimicrobial stewardship program (ASP) strategies, the relative impact of these approaches remains unclear. We compared these core ASP strategies at an academic medical center.

Quasi-experimental study.

We compared antimicrobial use during the 24 months before and after implementation of an ASP strategy change. The ASP used prior authorization alone during the preintervention period, June 2007 through May 2009. In June 2009, many antimicrobials were unrestricted and prospective audit was implemented for cefepime, piperacillin/tazobactam, and vancomycin, marking the start of the postintervention period, July 2009 through June 2011. All adult inpatients who received more than or equal to 1 dose of an antimicrobial were included. The primary end point was antimicrobial consumption in days of therapy per 1,000 patient-days (DOT/1,000-PD). Secondary end points included length of stay (LOS).

In total, 55,336 patients were included (29,660 preintervention and 25,676 postintervention). During the preintervention period, both total systemic antimicrobial use (−9.75 DOT/1,000-PD per month) and broad-spectrum anti-gram-negative antimicrobial use (−4.00 DOT/1,000-PD) declined. After the introduction of prospective audit with feedback, however, both total antimicrobial use (+9.65 DOT/1,000-PD per month; P < .001) and broad-spectrum anti-gram-negative antimicrobial use (+4.80 DOT/1,000-PD per month; P < .001) increased significantly. Use of cefepime and piperacillin/tazobactam both significantly increased after the intervention (P = .03). Hospital LOS and LOS after first antimicrobial dose also significantly increased after the intervention (P = .016 and .004, respectively).

Significant increases in antimicrobial consumption and LOS were observed after the change in ASP strategy.

Infect Control Hosp Epidemiol 2014;35(9):1092-1099

To evaluate the usability and effectiveness of a computerized clinical decision support (CDS) intervention aimed at reducing the duration of urinary tract catheterizations.

Retrospective cohort study.

Academic healthcare system.

All adult patients admitted from March 2009 through May 2012.

A CDS intervention was integrated into a commercial electronic health record. Providers were prompted at order entry to specify the indication for urinary catheter insertion. On the basis of the indication chosen, providers were alerted to reassess the need for the urinary catheter if it was not removed within the recommended time. Three time periods were examined: baseline, after implementation of the first intervention (stock reminder), and after a second iteration (homegrown reminder). The primary endpoint was the usability of the intervention as measured by the proportion of reminders through which providers submitted a remove urinary catheter order. Secondary endpoints were the urinary catheter utilization ratio and the rate of hospital-acquired catheter-associated urinary tract infections (CAUTIs).

The first intervention displayed limited usability, with 2% of reminders resulting in a remove order. Usability improved to 15% with the revised reminder. The catheter utilization ratio declined over the 3 time periods (0.22, 0.20, and 0.19, respectively; P < .001), as did CAUTIs per 1,000 patient-days (0.84, 0.70, and 0.51, respectively; P < .001).

A urinary catheter removal reminder system was successfully integrated within a healthcare system’s electronic health record. The usability of the reminder was highly dependent on its user interface, with a homegrown version of the reminder resulting in higher impact than a stock reminder.

Infect Control Hosp Epidemiol 2014;35(9):1147-1155

Infections due to fluoroquinolone-resistant Escherichia coli (FQREC) are associated with significant morbidity and mortality. Fluoroquinolone resistance likely arises at the level of gastrointestinal colonization. The objective of this study was to identify risk factors for the development of FQREC gastrointestinal tract colonization in hospitalized patients, including the impact of antibiotics prescribed during hospitalization.

A prospective cohort study was conducted from 2002 to 2004 within a university health system.

Hospitalized patients initially colonized with fluoroquinolone-susceptible E. coli were followed up with serial fecal sampling for new FQREC colonization or until hospital discharge or death. A Cox proportional hazards regression model was developed to identify risk factors for new FQREC colonization, with antibiotic exposure modeled as time-varying covariates.

Of 395 subjects, 73 (18.5%) became newly colonized with FQREC. Length of stay before sampling (hazard ratio [HR], 1.02 [95% confidence interval (CI), 1.1–1.03]; P = .003) and malignancy (HR, 0.37 [95% CI, 0.21–0.67]; P = .001) were significantly associated with the development of FQREC colonization. In addition, receipt of a first-generation cephalosporin (HR, 1.19 [95% CI, 1.10–1.29]; P<.001) or cefepime (HR, 1.05 [95% CI, 1.00–1.10]; P = .048) during hospitalization increased the risk of new FQREC colonization.

The acquisition of FQREC in the hospital setting is complex, and antimicrobial stewardship programs should take into account patterns of antibiotic use in implementing strategies to reduce the development of new FQREC colonization. Future studies are needed to identify risk factors for infection in hospitalized patients newly colonized with FQREC.

Little is known about whether those performing healthcare-associated infection (HAI) surveillance vary in their interpretations of HAI definitions developed by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN). Our primary objective was to characterize variations in these interpretations using clinical vignettes. We also describe predictors of variation in responses.

Cross-sectional study.

United States.

A sample of US-based members of the Society for Healthcare Epidemiology of America (SHEA) Research Network.

Respondents assessed whether each of 6 clinical vignettes met criteria for an NHSN-defined HAI. Individual- and institutional-level data were also gathered.

Surveys were distributed to 143 SHEA Research Network members from 126 hospitals. In total, 113 responses were obtained, representing at least 61 unique hospitals (30 respondents did not identify a hospital); 79.2% (84 of 106 nonmissing responses) were infection preventionists, and 79.4% (81 of 102 nonmissing responses) worked at academic hospitals. Among the 6 vignettes, the proportion of respondents correctly characterizing the vignettes was as low as 27.3%. Combining all 6 vignettes, the mean percentage of correct responses was 61.1% (95% confidence interval, 57.7%–63.8%). Percentage of correct responses was associated with presence of a clinical background (ie, nursing or physician degrees) but not with hospital size or infection prevention and control department characteristics.

Substantial heterogeneity exists in the application of HAI definitions in this survey of infection preventionists and hospital epidemiologists. Our data suggest a need to better clarify these definitions, especially when comparing HAI rates across institutions.

The success of central line-associated bloodstream infection (CLABSI) prevention programs in intensive care units (ICUs) has led to the expansion of surveillance at many hospitals. We sought to compare non-ICU CLABSI (nCLABSI) rates with national reports and describe methods of surveillance at several participating US institutions.

An electronic survey of several medical centers about infection surveillance practices and rate data for non-ICU Patients.

Ten tertiary care hospitals.

In March 2011, a survey was sent to 10 medical centers. The survey consisted of 12 questions regarding demographics and CLABSI surveillance methodology for non-ICU patients at each center. Participants were also asked to provide available rate and device utilization data.

Hospitals ranged in size from 238 to 1,400 total beds (median, 815). All hospitals reported using Centers for Disease Control and Prevention (CDC) definitions. Denominators were collected by different means: counting patients with central lines every day (5 hospitals), indirectly estimating on the basis of electronic orders (n = 4), or another automated method (n = 1). Rates of nCLABSI ranged from 0.2 to 4.2 infections per 1,000 catheter-days (median, 2.5). The national rate reported by the CDC using 2009 data from the National Healthcare Surveillance Network was 1.14 infections per 1,000 catheter-days.

Only 2 hospitals were below the pooled CLABSI rate for inpatient wards; all others exceeded this rate. Possible explanations include differences in average central line utilization or hospital size in the impact of certain clinical risk factors notably absent from the definition and in interpretation and reporting practices. Further investigation is necessary to determine whether the national benchmarks are low or whether the hospitals surveyed here represent a selection of outliers.

Staphylococcus aureus is a cause of community- and healthcare-acquired infections and is associated with substantial morbidity, mortality, and costs. Vancomycin minimum inhibitory concentrations (MICs) among S. aureus have increased, and reduced vancomycin susceptibility (RVS) may be associated with treatment failure. We aimed to identify clinical risk factors for RVS in S. aureus bacteremia.

Case-control.

Academic tertiary care medical center and affiliated urban community hospital.

Cases were patients with RVS S. aureus isolates (defined as vancomycin E-test MIC >1.0 μg/mL). Controls were patients with non-RVS S. aureus isolates.

Of 392 subjects, 134 (34.2%) had RVS. Fifty-eight of 202 patients (28.7%) with methicillin-susceptible S. aureus (MSSA) isolates had RVS, and 76 of 190 patients (40.0%) with methicillin-resistant S. aureus (MRSA) isolates had RVS (P = .02). In unadjusted analyses, prior vancomycin use was associated with RVS (odds ratio [OR], 2.08; 95% confidence interval [CI], 1.00–4.32; P = .046). In stratified analyses, there was significant effect modification by methicillin susceptibility on the association between vancomycin use and RVS (P = .04). In multivariate analyses, after hospital of admission and prior levofloxacin use were controlled for, the association between vancomycin use and RVS was significant for patients with MSSA infection (adjusted OR, 4.02; 95% CI, 1.11–14.50) but not MRSA infection (adjusted OR, 0.87; 95% CI, 0.36–2.13).

A substantial proportion of patients with S. aureus bacteremia had RVS. The association between prior vancomycin use and RVS was significant for patients with MSSA infection but not MRSA infection, suggesting a complex relationship between the clinical and molecular epidemiology of RVS in S. aureus.

Infect Control Hosp Epidemiol 2012;33(2):160-166

To compare use of chlorhexidine with use of iodine for preoperative skin antisepsis with respect to effectiveness in preventing surgical site infections (SSIs) and cost.

We searched the Agency for Healthcare Research and Quality website, the Cochrane Library, Medline, and EMBASE up to January 2010 for eligible studies. Included studies were systematic reviews, meta-analyses, or randomized controlled trials (RCTs) comparing preoperative skin antisepsis with chlorhexidine and with iodine and assessing for the outcomes of SSI or positive skin culture result after application. One reviewer extracted data and assessed individual study quality, quality of evidence for each outcome, and publication bias. Meta-analyses were performed using a fixed-effects model. Using results from the meta-analysis and cost data from the Hospital of the University of Pennsylvania, we developed a decision analytic cost-benefit model to compare the economic value, from the hospital perspective, of antisepsis with iodine versus antisepsis with 2 preparations of chlorhexidine (ie, 4% chlorhexidine bottle and single-use applicators of a 2% chlorhexidine gluconate [CHG] and 70% isopropyl alcohol [IPA] solution), and also performed sensitivity analyses.

Nine RCTs with a total of 3,614 patients were included in the meta-analysis. Meta-analysis revealed that chlorhexidine antisepsis was associated with significantly fewer SSIs (adjusted risk ratio, 0.64 [95% confidence interval, [0.51–0.80]) and positive skin culture results (adjusted risk ratio, 0.44 [95% confidence interval, 0.35–0.56]) than was iodine antisepsis. In the cost-benefit model baseline scenario, switching from iodine to chlorhexidine resulted in a net cost savings of $16-$26 per surgical case and $349,904–$568,594 per year for the Hospital of the University of Pennsylvania. Sensitivity analyses showed that net cost savings persisted under most circumstances.

Preoperative skin antisepsis with chlorhexidine is more effective than preoperative skin antisepsis with iodine for preventing SSI and results in cost savings.