Because patients with vancomycin-resistant Enterococcus bacteremia (VREB) usually have a higher severity of illness, it has been unclear whether VREB is worse than vancomycin-susceptible Enterococcus bacteremia (VSEB).

Data on morbidity and case fatality rates and costs were pooled from studies comparing VREB and VSEB, identified by Medline (January 1986 to April 2002) and meeting abstracts. Heterogeneity across studies was assessed with contingency table chi-square. Multivariate analyses (MVAs) controlling for other predictors were evaluated.

Thirteen studies compared case-fatality rates of VREB and VSEB. VREB case fatality was significantly higher (48.9% vs 19%; RR, 2.57; CI95, 2.27 to 2.91; attributable mortality = 30%). Five studies compared VREB with VSEB when bacteremia was the direct cause of death; VREB case fatality was significantly higher (39.1% vs 21.8%; RR, 1.79; CI95, 1.28 to 2.5; attributable mortality = 17%). Four MVAs found significant increases in case-fatality rates (OR 2.10 to 4.0), 3 showed trends toward increase (OR, 1.74 to 3.34 with wide confidence intervals), and 3 with low statistical power found no difference. VREB recurred in 16.9% versus 3.7% with VSEB (P < .0001). Three studies reported significant increases in LOS, costs, or both with VREB.

Most studies have had inadequate sample size, inadequate adjustment for other predictors of adverse outcomes, or both, but available data suggest that VREB is associated with higher recurrence, mortality, and excess costs than VSEB including multiple studies adjusting for severity of illness.

In the current absence of a vaccine for COVID-19, public health responses aim to break the chain of infection by focusing on the mode of transmission. We reviewed the current evidence on the transmission dynamics and on pathogenic and clinical features of COVID-19 to critically identify any gaps in the current infection prevention and control (IPC) guidelines.

In this study, we reviewed global COVID-19 IPC guidelines by organizations such as the World Health Organization (WHO), the US Centers for Disease Control and Prevention (CDC), and the European Centre for Disease Prevention and Control (ECDC). Guidelines from 2 high-income countries (Australia and United Kingdom) and from 1 middle-income country (China) were also reviewed. We searched publications in English on ‘PubMed’ and Google Scholar. We extracted information related to COVID-19 transmission dynamics, clinical presentations, and exposures that may facilitate transmission. We then compared these findings with the recommended IPC measures.

Nosocomial transmission of SARS-CoV-2 in healthcare settings occurs through droplets, aerosols, and the oral–fecal or fecal–droplet route. However, the IPC guidelines fail to cover all transmission modes, and the recommendations also conflict with each other. Most guidelines recommend surgical masks for healthcare providers during routine care and N95 respirators for aerosol-generating procedures. However, recommendations regarding the type of face mask varied, and the CDC recommends cloth masks when surgical masks are unavailable.

IPC strategies should consider all the possible routes of transmission and should target all patient care activities involving risk of person-to-person transmission. This review may assist international health agencies in updating their guidelines.

The Victorian Infection Control Surveillance Project (VICSP) is a multicenter collaborative surveillance project established by infection control practitioners. Five public hospitals contributed data for patients undergoing coronary artery bypass graft (CABG) surgery.

To determine the aggregate and comparative interhospital surgical-site infection (SSI) rates for patients undergoing CABG surgery and the risk factors for SSI in this patient group.

Each institution used standardized definitions of SSI, risk adjustment, and reporting methodology according to the National Nosocomial Infections Surveillance System of the Centers for Disease Control and Prevention. Data on potential risk factors were prospectively collected.

For 4,474 patients undergoing CABG surgery, the aggregate SSI rate was 7.8 infections per 100 procedures (95% confidence interval [CI95], 7.0-8.5), with individual institutions ranging between 4.5 and 10.7 infections per 100 procedures. Multivariate risk factor analysis demonstrated age (odds ratio [OR], 1.02; CI95, 1.01-1.04; P < .001), obesity (OR, 1.8; CI95, 1.4-2.3; P < .001), and diabetes mellitus (OR, 1.6; CI95, 1.2-2.1; P < .001) as independent predictors of SSI. Three hundred thirty-four organisms were isolated from 296 SSIs. Of the total SSIs, methicillin-resistant Staphylococcus aureus was isolated from 32%, methicillin-sensitive S. aureus from 24%, gram-negative bacilli (eg, Enterobacter and Escherichia colt) from 18%, and miscellaneous organisms from the remainder.

We documented aggregate and comparative SSI rates among five Victorian public hospitals performing CABG surgery and defined specific independent risk factors for SSI. VICSP data offer opportunities for targeted interventions to reduce SSI following cardiac surgery.

Indwelling urinary catheters are the most common source of infections in intensive care units (ICUs). The aim of this study was to evaluate the efficacy of nurse-generated daily reminders to physicians to remove unnecessary urinary catheters 5 days after insertion.

A time-sequence nonrandomized intervention study.

Adult ICUs (medical, surgical, cardiovascular surgical, neurosurgical, and coronary care) of a tertiary-care university medical center.

All patients admitted to the adult ICUs during a 2-year period. The study consisted of a 12-month observational phase (15,960 patient-days) followed by a 12-month intervention phase (15,525 patient-days).

Daily reminders to physicians from the nursing staff to remove unnecessary urinary catheters 5 days after insertion.

The duration of urinary catheterization was significantly reduced during the intervention phase (from 7.0 ± 1.1 days to 4.6 ± 0.7 days; P < .001). The rate of catheter-associated urinary tract infection (CAUTI) was also significantly reduced (from 11.5 ± 3.1 to 8.3 ± 2.5 patients with CAUTI per 1,000 catheter-days; P = .009). There was a linear relationship between the monthly average duration of catheterization and the rate of CAUTI (r = 0.50; P = .01). The excess monthly cost of antibiotics for CAUTI was reduced by 69% (from $4,021 ± $1,800 to $1,220 ± $941; P = .004).

This study demonstrated that a simple measure instituted as part of a continuous quality improvement program significantly reduced the duration of urinary catheterization, rate of CAUTI, and additional costs of antibiotics to manage CAUTI.

Healthcare-associated infection (HAI) is costly and causes substantial morbidity. We sought to understand why some hospitals were engaged in HAI prevention activities while others were not. Because preliminary data indicated that hospital leadership played an important role, we sought better to understand which behaviors are exhibited by leaders who are successful at implementing HAI prevention practices in US hospitals.

We report phases 2 and 3 of a 3-phase study. In phase 2, 14 purposefully sampled US hospitals were selected from among the 72% of 700 invited hospitals whose lead infection preventionist had completed a quantitative survey on HAI prevention during phase 1. Qualitative data were collected during 38 semistructured phone interviews with key personnel at the 14 hospitals. During phase 3, we conducted 48 interviews during 6 in-person site visits to identify recurrent and unifying themes that characterize behaviors of successful leaders.

We found that successful leaders (1) cultivated a culture of clinical excellence and effectively communicated it to staff; (2) focused on overcoming barriers and dealt directly with resistant staff or process issues that impeded prevention of HAI; (3) inspired their employees; and (4) thought strategically while acting locally, which involved politicking before crucial committee votes, leveraging personal prestige to move initiatives forward, and forming partnerships across disciplines. Hospital epidemiologists and infection preventionists often played more important leadership roles in their hospital's patient safety activities than did senior executives.

Leadership plays an important role in infection prevention activities. The behaviors of successful leaders could be adopted by others who seek to prevent HAI.

To evaluate healthcare worker (HCW) risk of self-contamination when donning and doffing personal protective equipment (PPE) using fluorescence and MS2 bacteriophage.

Prospective pilot study.

Tertiary-care hospital.

A total of 36 HCWs were included in this study: 18 donned/doffed contact precaution (CP) PPE and 18 donned/doffed Ebola virus disease (EVD) PPE.

HCWs donned PPE according to standard protocols. Fluorescent liquid and MS2 bacteriophage were applied to HCWs. HCWs then doffed their PPE. After doffing, HCWs were scanned for fluorescence and swabbed for MS2. MS2 detection was performed using reverse transcriptase PCR. The donning and doffing processes were videotaped, and protocol deviations were recorded.

Overall, 27% of EVD PPE HCWs and 50% of CP PPE HCWs made ≥1 protocol deviation while donning, and 100% of EVD PPE HCWs and 67% of CP PPE HCWs made ≥1 protocol deviation while doffing (P=.02). The median number of doffing protocol deviations among EVD PPE HCWs was 4, versus 1 among CP PPE HCWs. Also, 15 EVD PPE protocol deviations were committed by doffing assistants and/or trained observers. Fluorescence was detected on 8 EVD PPE HCWs (44%) and 5 CP PPE HCWs (28%), most commonly on hands. MS2 was recovered from 2 EVD PPE HCWs (11%) and 3 CP PPE HCWs (17%).

Protocol deviations were common during both EVD and CP PPE doffing, and some deviations during EVD PPE doffing were committed by the HCW doffing assistant and/or the trained observer. Self-contamination was common. PPE donning/doffing are complex and deserve additional study.

Infect Control Hosp Epidemiol 2017;38:1077–1083

To determine differences in healthcare costs between cases of methicillin-susceptible Staphylococcus aureus (MSSA) infection and methicillin-resistant S. aureus (MRSA) infection in adults.

Retrospective study of all cases of S. aureus infection.

Department of Veterans Affairs hospital and associated clinics.

There were 390 patients with MSSA infections and 335 patients with MRSA infections.

We used medical records, accounting systems, and interviews to identify services rendered and costs for Minneapolis Veterans Affairs Medical Center patients with S. aureus infection with onset during the period from January 1, 2004, through June 30, 2006. We used regression analysis to adjust for patient characteristics.

Median 6-month unadjusted costs for patients infected with MRSA were $34,657, compared with $15,923 for patients infected with MSSA. Patients with MRSA infection had more comorbidities than patients with MSSA infection (mean Charlson index 4.3 vs 3.2; P < .001). For patients with Charlson indices of 3 or less, mean adjusted 6-month costs derived from multivariate analysis were $51,252 (95% CI, $46,041–$56,464) for MRSA infection and $30,158 (95% CI, $27,092–$33,225) for MSSA infection. For patients with Charlson indices of 4 or more, mean adjusted costs were $84,436 (95% CI, $79,843–$89,029) for MRSA infection and $59,245 (95% CI, $56,016–$62,473) for MSSA infection. Patients with MRSA infection were also more likely to die than were patients with MSSA infection (23.6% vs 11.5%; P < .001). MRSA infection was more likely to involve the lungs, bloodstream, and urinary tract, while MSSA infection was more likely to involve bones or joints; eyes, ears, nose, or throat; surgical sites; and skin or soft tissue (P < .001).

Resistance to methicillin in S. aureus was independently associated with increased costs. Effective antimicrobial stewardship and infection prevention programs are needed to prevent these costly infections.

Investigation of an outbreak of influenza A in a neonatal intensive care unit (NICU) with examination of risk factors for infection and outcomes.

Retrospective cohort study of infants admitted to the unit during the outbreak period. Prospective survey of NICU staff and mothers of infants in the cohort study.

Level III nursery in a university-affiliated tertiary referral center.

Nineteen infants in the NICU were infected with influenza A. There were six symptomatic cases and one death who had evidence of virus-associated hemophagocytic syndrome at autopsy. Amantadine prophylaxis was offered to the NICU staff, and amantadine therapy was given to five of the six symptomatic infants. Mechanical ventilation, gestational age, birth weight, Clinical Risk Index for Babies score, and twin pregnancy were associated with acquisition of influenza A on univariate analysis. Mechanical ventilation (odds ratio [OR], 6.2; P=.02) and twin pregnancy (OR, 7.0; P=.04) remained as significant risk factors for infection on multiple logistic regression analysis. Only 15% of respondents to the NICU staff survey were vaccinated against influenza. There was no association between a history of an influenza-like illness during pregnancy and acquisition of influenza A by infants of mothers who responded to the maternal survey (OR, 0.91; P=1.0).

Influenza A is an important pathogen in the neonatal population and is readily transmissible in the NICU setting.

Despite a reported worldwide increase, the incidence of extended-spectrum β-lactamase (ESBL) Escherichia coli and Klebsiella infections in the United States is unknown. Understanding the incidence and trends of ESBL infections will aid in directing research and prevention efforts.

To perform a literature review to identify the incidence of ESBL-producing E. coli and Klebsiella infections in the United States.

Systematic literature review.

MEDLINE via Ovid, CINAHL, Cochrane library, NHS Economic Evaluation Database, Web of Science, and Scopus were searched for multicenter (≥2 sites), US studies published between 2000 and 2015 that evaluated the incidence of ESBL-E. coli or ESBL-Klebsiella infections. We excluded studies that examined resistance rates alone or did not have a denominator that included uninfected patients such as patient days, device days, number of admissions, or number of discharges. Additionally, articles that were not written in English, contained duplicated data, or pertained to ESBL organisms from food, animals, or the environment were excluded.

Among 51,419 studies examined, 9 were included for review. Incidence rates differed by patient population, time, and ESBL definition and ranged from 0 infections per 100,000 patient days to 16.64 infections per 10,000 discharges and incidence rates increased over time from 1997 to 2011. Rates were slightly higher for ESBL-Klebsiella infections than for ESBL-E. coli infections.

The incidence of ESBL-E. coli and ESBL-Klebsiella infections in the United States has increased, with slightly higher rates of ESBL-Klebsiella infections. Appropriate estimates of ESBL infections when coupled with other mechanisms of resistance will allow for the appropriate targeting of resources toward research, drug discovery, antimicrobial stewardship, and infection prevention.

Infect Control Hosp Epidemiol 2017;38:1209–1215

To identify risk factors associated with surgical site infection (SSI) after pediatric posterior spinal fusion procedure by examining characteristics related to the patient, the surgical procedure, and tissue hypoxia.

Retrospective case-control study nested in a hospital cohort study.

A 475-bed, tertiary care children's hospital.

All patients who underwent a spinal fusion procedure during the period from January 1995 through December 2006 were included. SSI cases were identified by means of prospective surveillance using National Nosocomial Infection Surveillance system definitions. Forty-four case patients who underwent a posterior spinal fusion procedure and developed an SSI were identified and evaluated. Each case patient was matched (on the basis of date of surgery, ± 3 months) to 3 control patients who underwent a posterior spinal fusion procedure but did not develop an SSI. Risk factors for SSI were evaluated by univariate analysis and multivariable conditional logistic regression. Odds ratios (ORs), with 95% confidence intervals (CIs) and P values, were calculated.

From 1995 to 2006, the mean annual rate of SSI after posterior spinal fusion procedure was 4.4% (range, 1.1%—6.7%). Significant risk factors associated with SSI in the univariate analysis included the following: a body mass index (BMI) greater than the 95th percentile (OR, 3.5 [95% CI, 1.5–8.3]); antibiotic prophylaxis with clindamycin, compared with other antibiotics (OR, 3.5 [95% CI, 1.2 10.0]); inappropriately low dose of antibiotic (OR, 2.6 [95% CI, 1.0–6.6]); and a longer duration of hypothermia (ie, a core body temperature of less than 35.5°C) during surgery (OR, 0.4 [95% CI, 0.2–0.9]). An American Society of Anesthesiologists (ASA) score of greater than 2, obesity (ie, a BMI greater than the 95th percentile), antibiotic prophylaxis with clindamycin, and hypothermia were statistically significant in the multivariable model.

An ASA score greater than 2, obesity, and antibiotic prophylaxis with clindamycin were independent risk factors for SSI. Hypothermia during surgery appears to provide protection against SSI in this patient population.

To compare the public's knowledge and perception of SARS and the extent to which various precautionary measures were adopted in Hong Kong and Singapore.

Cross-sectional telephone survey of 705 Hong Kong and 1,201 Singapore adults selected by random-digit dialing.

Hong Kong respondents had significantly higher anxiety than Singapore respondents (State Trait Anxiety Inventory [STAI] score, 2.06 vs 1.77; P < .001). The former group also reported more frequent headaches, difficulty breathing, dizziness, rhinorrhea, and sore throat. More than 90% in both cities were willing to be quarantined if they had close contact with a SARS case, and 70% or more would be compliant for social contacts. Most respondents (86.7% in Hong Kong vs 71.4% in Singapore; P < .001) knew that SARS could be transmitted via respiratory droplets, although fewer (75.8% in Hong Kong vs 62.1% in Singapore; P < .001) knew that fomites were also a possible transmission source. Twenty-three percent of Hong Kong and 11.9% of Singapore respondents believed that they were “very likely” or “somewhat likely” to contract SARS during the current outbreak (P < .001). There were large differences between Hong Kong and Singapore in the adoption of personal precautionary measures. Respondents with higher levels of anxiety, better knowledge about SARS, and greater risk perceptions were more likely to take comprehensive precautionary measures against the infection, as were older, female, and more educated individuals.

Comparative psychobehavioral surveillance and analysis could yield important insights into generic versus population-specific issues that could be used to inform, design, and evaluate public health infection control policy measures.

To identify risk factors associated with the development of surgical-site infection (SSI) following total knee arthroplasty (TKA).

A case-control study.

A 1,100-bed, university-affiliated, tertiary-care teaching hospital.

Case-patients with SSI occurring up to 1 year following primary TKA performed between January 1999 and December 2001 were identified prospectively by infection control practitioners using National Nosocomial Infections Surveillance (NNIS) System methods. Three control-patients were selected for each case-patient, matched by date of surgery. Stepwise logistic regression analysis was used to determine the relation of potential risk factors to the development of infection.

Twenty-two patients with infections (6 superficial and 16 deep) were identified. Infection rates per year were 0.95%, 1.07%, and 1.19% in 1999, 2000, and 2001, respectively. Logistic regression analysis identified two variables independently associated with the development of infection: the use of closed suction drainage (odds ratio [OR], 7.0; 95% confidence interval [CI95], 2.1-25.0; P = .0015) and increased international normalized ratio (INR) (OR, 2.4; CI95, 1.1-5.7; P = .035). Factors not statistically associated with the development of infection included age, NNIS System risk index score, presence of various comorbidities, surgeon, duration of procedure or tourniquet time, type of bone cement or prosthesis used, or receipt of blood product transfusions.

The use of closed suction drainage and a high postoperative INR were associated with the development of SSI following TKA. Avoiding the use of surgical drains and careful monitoring of anticoagulant prophylaxis in patients undergoing TKA should reduce the risk of infection.

To review the evidence evaluating perioperative intranasal mupirocin for the prevention of surgical-site infections according to type of surgical procedure.

Systematic review and meta-analysis of published clinical trials.

Studies included were either randomized clinical trial or prospective trials at a single institution that measured outcomes both before and after an institution-wide intervention (before-after trial). In all studies, intervention and control groups differed only by the use of perioperative intranasal mupirocin in the intervention group.

Patients undergoing general or nongeneral surgery (eg, cardiothoracic surgery, orthopedic surgery, and neurosurgery).

Risk of surgical-site infection following perioperative intranasal mupirocin versus usual care.

Three randomized and four before-after trials met the inclusion criteria. No reduction in surgical-site infection rate was seen in randomized general surgery trials (summary estimates: 8.4% in the mupirocin group and 8.1% in the control group; relative risk [RR], 1.04; 95% confidence interval [CI95], 0.81 to 1.33). In nongeneral surgery, the use of mupirocin was associated with a reduction in surgical-site infection in randomized trials (summary estimates: 6.0% in the mupirocin group and 7.6% in the control group; RR, 0.80; CI95, 0.58 to 1.10) and in before-after trials (summary estimates: 1.7% in the mupirocin group and 4.1% in the control group; RR, 0.40; CI95, 0.29 to 0.56).

Perioperative intranasal mupirocin appears to decrease the incidence of surgical-site infection when used as prophylaxis in nongeneral surgery. Given its low risk and low cost, use of perioperative intranasal mupirocin should be considered in these settings.

Wearing of gloves reduces transmission of organisms by healthcare workers' hands but is not a substitute for hand hygiene. Results of previous studies have varied as to whether hand hygiene is worse when gloves are worn. Most studies have been small and used nonstandardized assessments of glove use and hand hygiene. We sought to observe whether gloves were worn when appropriate and whether hand hygiene compliance differed when gloves were worn.

Observational study.

Healthcare workers in 56 medical or care of the elderly wards and intensive care units in 15 hospitals across England and Wales.

We observed hand hygiene and glove usage (7,578 moments for hand hygiene) during 249 one-hour sessions. Observers also recorded whether gloves were or were not worn for individual contacts.

Gloves were used in 1,983 (26.2%) of the 7,578 moments for hand hygiene and in 551 (16.7%) of 3,292 low-risk contacts; gloves were not used in 141 (21.1%) of 669 high-risk contacts. The rate of hand hygiene compliance with glove use was 41.4% (415 of 1,002 moments), and the rate without glove use was 50.0% (1,344 of 2,686 moments). After adjusting for ward, healthcare worker type, contact risk level, and whether the hand hygiene opportunity occurred before or after a patient contact, glove use was strongly associated with lower levels of hand hygiene (adjusted odds ratio, 0.65 [95% confidence interval, 0.54-0.79]; P<.0001).

The rate of glove usage is lower than previously reported. Gloves are often worn when not indicated and vice versa. The rate of compliance with hand hygiene was significantly lower when gloves were worn. Hand hygiene campaigns should consider placing greater emphasis on the World Health Organization indications for gloving and associated hand hygiene.

National Research Register N0256159318.

To determine which antibiotics increase or decrease the risk of Clostridium difficile-associated diarrhea (CDAD).

Retrospective case-control study.

Nonprofit, integrated healthcare delivery system in Northern California.

Study participants included patients with cases of hospital-acquired CDAD that occurred during the period from 1999 through 2005 (n = 1,142) and control patients (n = 3,351) matched for facility, calendar quarter during which hospitalization occurred, diagnosis related group for the index hospitalization, and length of hospital stay. All case and control patients had received antibiotics in the 60 days before the index date. For each antibiotic, the risk of CDAD was examined in relation to whether the patient received the antibiotic, after adjustment for use of other antibiotics, demographic characteristics, selected health conditions, and use of healthcare services.

The following antibiotics were associated with a significantly increased risk of acquiring CDAD: imipenem-cilastin (odds ratio [OR], 2.77), clindamycin (OR, 2.31), cefuroxime (OR, 2.16), moxifloxacin (OR, 1.88), ceftazidime (OR, 1.82), cefpodoxime (OR, 1.58), ceftizoxime (OR, 1.57), and ceftriaxone (OR, 1.49). Metronidazole and doxycycline were associated with a significantly reduced risk of CDAD (OR for metronidazole, 0.67; OR for doxycycline, 0.41). Other factors associated with an increased risk of CDAD were older age, longer hospital stays, use of proton pump inhibitors, prior gastrointestinal disease, and prior infection (not including C. difficile infection.)

Some antibiotics appear to increase the risk of acquiring CDAD, notably clindamycin, third-generation cephalosporins, and carbapenems, whereas metronidazole and doxycycline appear to be protective, compared with other antibiotics.