Products containing alcohol are commonly used with intravascular devices at insertion, to remove lipids from occluded intravascular devices used during parenteral nutrition, and increasingly for the prevention and treatment of intravascular device-related bloodstream infection. The effects of alcohol on the integrity of intravascular devices remain unknown.

Two types of widely used commercial peripherally inserted central catheters, one made of polyether-urethane and one made of silicone, were exposed to a 70% etha-nol lock solution for up to 10 weeks. Mechanical testing was performed to identify force-at-break, stress, strain, modulus of elasticity, modulus of toughness, and wall area of ethanol-exposed and control catheters.

No significant differences between exposed and unexposed catheters were identified for any of the mechanical parameters tested except for a marginal reduction in the modulus of elasticity for both polyetherurethane and silicone catheters and minor increases in the wall area of polyetherurethane catheters.

These data indicate that exposure to a 70% ethanol lock solution does not appreciably alter the integrity of selected commercial polyetherurethane and silicone catheters. Given the greatly expanded use of alcoholic solutions with intravascular devices of all types, we believe that manufacturers would be well advised to subject their catheters and other intravascular devices to formal testing of the type employed in this study.

To determine the efficacy of mupirocin ointment in reducing nasal colonization with mupirocin-susceptible, methicillin-resistant Staphylococcus aureus (MS MRSA) as well as mupirocin-resistant MRSA (MR MRSA).

Prospective evaluation in which patients colonized with MRSA were treated twice daily with 2% topical mupirocin ointment for 5 days.

James H. Quillen Veterans' Affairs Medical Center.

Forty hospitalized patients with two anterior nares cultures positive for MRSA within a 7-day period.

Treated patients had post-treatment cultures at day 3 and weeks 1,2, and 4. Isolates underwent mupirocin-susceptibility testing and DNA typing. MRSA clearance and type turnover were assessed for isolates that were mupirocin-susceptible, low-level (LL) MR MRSA and high-level (HL) MR MRSA.

Post-treatment nares cultures on day 3 were negative for 78.5%, 80%, and 27.7% of patients with MS MRSA, LL-MR MRSA, and HL-MR MRSA, respectively. Sustained culture negativity at 1 to 4 weeks was more common in the MS MRSA group (91%) than in the LL-MR MRSA group (25%) or the HL-MR MRSA group (25%). Positive post-treatment cultures usually showed the same DNA pattern relative to baseline. Plasmid curing of 18 HL-MR MRSA resulted in 15 MS MRSA and 3 LL-MR MRSA.

Mupirocin was effective in eradicating MS MRSA, but strains of MR MRSA often persisted after treatment. This appeared to reflect treatment failure rather than exogenous recolonization. MR MRSA is now more prevalent and it is appropriate to sample MRSA populations for mupirocin susceptibility prior to incorporating mupirocin into infection control programs.

To reduce the rate of late-onset sepsis in a neonatal intensive care unit (NICU) by decreasing the rate of central line–associated bloodstream infection (CLABSI).

We conducted a quasi-experimental study of an educational intervention designed to improve the quality of clinical practice in an NICU. Participants included all NICU patients with a central venous catheter (CVC). Data were collected during the period from July 1, 2005, to June 30, 2007, to document existing CLABSI rates and CVC-related practices. A multidisciplinary quality improvement committee was established to review these and published data and to create guidelines for CVC placement and management. Educational efforts were conducted to implement these practices. Postintervention CLABSI rates were collected during the period from January 1, 2008, through March 31, 2009, and compared with preintervention data and with benchmark data from the National Healthcare Safety Network (NHSN).

The rate of CLABSI in the NICU decreased from 8.40 to 1.28 cases per 1,000 central line–days (adjusted rate ratio, 0.19 [95% confidence interval, 0.08–0.45]). This rate was lower than the NHSN benchmark rate for level III NICUs. The overall rate of late-onset sepsis was reduced from 5.84 to 1.42 cases per 1,000 patient-days (rate difference, −4.42 cases per 1,000 patient-days [95% confidence interval, −5.55 to −3.30 cases per 1,000 patient-days]).

It is possible to reduce the rate of CLABSI, and therefore the rate of late-onset sepsis, by establishing and adhering to evidence-based guidelines. Sustainability depends on continued data surveillance, knowledge of medical and nursing literature, and timely feedback to the staff. The techniques established are applicable to other populations and areas of inpatient care.

To evaluate efficacy of laminar airflow facilities plus high-efficiency particulate air (HEPA) filtration and HEPA filtration alone in preventing environmental Aspergillus contamination during hospital renovation. To show the usefulness of environmental surveillance to facilitate protection of patients at risk for invasive pulmonary aspergillosis.

Prospective sampling of air and surfaces for Aspergillus conidia during 2-year period.

A hematological department adjacent to building renovation at a university hospital.

1,047 air samples and 1,178 surface samples were collected from January 1996 to December 1997. Significantly more air samples were positive for Aspergillus species during the period of building renovation than during the periods before and after renovation in a unit without a protected air supply adjacent to the building work area (51.5% vs 31.7%; odds ratio [OR], 2.3; 95% confidence interval [CI95, 1.4-3.7; P<.001). A major increase in the frequency of positive air samples was also found in another adjacent unit that was protected with HEPA filtration alone (from 1.8% to 47.5%; OR, 48.9; CI95,12-229; P<10-7). In addition, in this unit, the mean count of Aspergillus conidia in positive air samples increased significantly during construction (4 colony-forming units [CFU]/m3 to 24.7 CFU/m3; P=.04) and the proportion of positive surface samples showed a significant increase during renovation (from 0.4% to 9.7%; OR, 28.3; CI95, 3.4-623; P=104). However, none of 142 air samples collected during renovation in the area protected with laminar airflow plus HEPA filtration showed Aspergillus conidia. In a unit distant from the building renovation site, the results of air and surface samples were not affected by renovation.

This study showed a strong association between building renovation and an increase in environmental Aspergillus contamination. Results confirmed the high efficacy of laminar airflow plus HEPA filtration and a high air-change rate. Although filtration with HEPA was effective during normal conditions, it alone was unable to prevent the rise of Aspergillus contamination related to building renovation. This study emphasized the necessity of an environmental survey of airborne contamination related to construction, to facilitate prevention of nosocomial aspergillosis outbreaks. A standardized protocol for aerobiological surveillance is needed.

To determine the prevalence of central venous catheter (CVC) use among patients both within and outside the ICU setting.

A 1-day prevalence survey of CVC use among adult inpatients at six medical centers participating in the Prevention Epicenter Program of the CDC. Using a standardized form, observers at each Epicenter performed a hospital-wide survey, collecting data on CVC use.

Inpatient wards and ICUs of six large urban teaching hospitals.

At the six medical centers, 2,459 patients were surveyed; 29% had CVCs. Among the hospitals, from 43% to 80% (mean, 59.3%) of ICU patients and from 7% to 39% (mean, 23.7%) of non-ICU patients had CVCs. Despite the lower rate of CVC use on non-ICU wards, the actual number of CVCs outside the ICUs exceeded that of the ICUs. Most catheters were inserted in the subclavian (55%) or jugular (22%) site, with femoral (6%) and peripheral (15%) sites less commonly used. The jugular (33.0% vs 16.6%; P < .001) and femoral (13.8% vs 2.7%; P < .001) sites were more frequently used in ICU patients, whereas peripherally inserted (19.9% vs 5.9%; P < .001) and subclavian (60.7% vs 47.3%; P < .001) catheters were more commonly used in non-ICU patients.

Current surveillance and infection control efforts to reduce morbidity and mortality associated with bloodstream infections concentrate on the high-risk ICU patients with CVCs. Our survey demonstrated that two-thirds of identified CVCs were not in ICU patients and suggests that more efforts should be directed to patients with CVCs who are outside the ICU.

Computers are ubiquitous in the healthcare setting and have been shown to be contaminated with potentially pathogenic microorganisms. This study was performed to determine the degree of microbial contamination, the efficacy of different disinfectants, and the cosmetic and functional effects of the disinfectants on the computer keyboards.

We assessed the effectiveness of 6 different disinfectants (1 each containing chlorine, alcohol, or phenol and 3 containing quaternary ammonium) against 3 test organisms (oxacillin-resistant Staphylococcus aureus [ORSA], Pseudomonas aeruginosa, and vancomycin-resistant Enterococcus species) inoculated onto study computer keyboards. We also assessed the computer keyboards for functional and cosmetic damage after disinfectant use.

Potential pathogens cultured from more than 50% of the computers included coagulase-negative staphylococci (100% of keyboards), diphtheroids (80%), Micrococcus species (72%), and Bacillus species (64%). Other pathogens cultured included ORSA (4% of keyboards), OSSA (4%), vancomycin-susceptible Enterococcus species (12%), and nonfermentative gram-negative rods (36%). All disinfectants, as well as the sterile water control, were effective at removing or inactivating more than 95% of the test bacteria. No functional or cosmetic damage to the computer keyboards was observed after 300 disinfection cycles.

Our data suggest that microbial contamination of keyboards is prevalent and that keyboards may be successfully decontaminated with disinfectants. Keyboards should be disinfected daily or when visibly soiled or if they become contaminated with blood.

To determine whether the use of chlorhexidine bathing and intranasal mupirocin therapy among patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) would decrease the incidence of MRSA colonization and infection among intensive care unit (ICU) patients.

After a 9-month baseline period (January 13, 2003, through October 12, 2003) during which all incident cases of MRSA colonization or infection were identified through the use of active-surveillance cultures in a combined medical-coronary ICU, all patients colonized with MRSA were treated with intranasal mupirocin and underwent daily chlorhexidine bathing.

After the intervention, incident cases of MRSA colonization or infection decreased 52% (incidence density, 8.45 vs 4.05 cases per 1,000 patient-days; P = .048). All MRSA isolates remained susceptible to chlorhexidine; the overall rate of mupirocin resistance was low (4.4%) among isolates identified by surveillance cultures and did not increase during the intervention period.

We conclude that the selective use of intranasal mupirocin and daily chlorhexidine bathing for patients colonized with MRSA reduced the incidence of MRSA colonization and infection and contributed to reductions identified by active-surveillance cultures. This finding suggests that additional strategies to reduce the incidence of MRSA infection and colonization—beyond expanded surveillance—may be needed.

To investigate the clinical features and the epidemiology of Acinetobacter baumannii in Spanish hospitals.

Prospective multicenter cohort study.

Twenty-seven general hospitals and one paraplegic center in Spain.

All cases of A. baumannii colonization or infection detected by clinical samples during November 2000 were included. Isolates were identified using phenotypic and genotypic methods. The molecular relatedness of the isolates was assessed by pulsed-field gel electrophoresis.

Twenty-five (89%) of the hospitals had 221 cases (pooled rate in general hospitals, 0.39 case per 1,000 patient-days; range, 0 to 1.17). The rate was highest in intensive care units (ICUs). Only 3 cases were pediatric. The mean age of the patients in the general hospitals was 63 years; 69% had a chronic underlying disease and 80% had previously received antimicrobial treatment. Fifty-three percent of the patients had an infection (respiratory tract, 51%; surgical site, 16%; and urinary tract, 11%). Crude mortality was higher in infected than in colonized patients (27% vs 10%; relative risk, 1.56; 95% confidence interval, 1.2 to 2.0; P = .003). Molecular analysis disclosed 79 different clones. In most hospitals, a predominant epidemic clone coexisted with other sporadic clones. Imipenem resistance was present in 39% of the hospitals.

A. baumannii was present in most participating Spanish hospitals (particularly in ICUs) with different rates among them. The organisms mainly affected predisposed patients; half of them were only colonized. Epidemic and sporadic clones coexisted in many centers.

To understand the professional and psychosocial factors that influence physician antibiotic prescribing habits in the inpatient setting.

We conducted semi-structured interviews with 30 inpatient physicians. Interviews consisted of open-ended questions and flexible probes based on participant responses. Interviews were audio recorded, transcribed, de-identified, and reviewed for accuracy and completeness. Data were analyzed using emergent thematic analysis.

Two teaching hospitals in Indianapolis, Indiana

A total of 30 inpatient physicians (10 physicians-in-training, 20 supervising staff) were enrolled in this study.

Participants recognized that antibiotics are overused, and many admitted to prescribing antibiotics even when the clinical evidence of infection was uncertain. Overprescription was largely driven by anxiety about missing an infection, whereas potential adverse effects of antibiotics did not strongly influence decision making. Participants did not routinely disclose potential adverse effects of antibiotics to inpatients. Physicians-in-training were strongly influenced by the antibiotic prescribing behavior of their supervising staff physicians. Participants sometimes questioned their colleagues’ antibiotic prescribing decisions, but they frequently avoided providing direct feedback or critique. These physicians cited obstacles of hierarchy, infrequent face-to-face encounters, and the awkwardness of these conversations.

A physician-based culture of prescribing antibiotics involves overusing antibiotics and not challenging the decisions of colleagues. The potential adverse effects of antibiotics did not strongly influence decision making in this sample. A better understanding of these factors could be leveraged in future efforts to improve antibiotic prescribing practices in the inpatient setting.

Infect. Control Hosp. Epidemiol. 2015;36(9):1065–1072

To evaluate the efficacy of a standardized regimen for decolonization of methicillin-resistant Staphylococcus aureus (MRSA) carriers and to identify factors influencing decolonization treatment failure.

Prospective cohort study from January 2002 to April 2007, with a mean follow-up period of 36 months.

University hospital with 750 beds and 27,000 admissions/year.

Of 94 consecutive hospitalized patients with MRSA colonization or infection, 32 were excluded because of spontaneous loss of MRSA, contraindications, death, or refusal to participate. In 62 patients, decolonization treatment was completed. At least 6 body sites were screened for MRSA (including by use of rectal swabs) before the start of treatment.

Standardized decolonization treatment consisted of mupirocin nasal ointment, chlorhexidine mouth rinse, and full-body wash with chlorhexidine soap for 5 days. Intestinal and urinary-tract colonization were treated with oral vancomycin and cotrimoxazole, respectively. Vaginal colonization was treated with povidone-iodine or, alternatively, with chlorhexidine ovula or octenidine solution. Other antibiotics were added to the regimen if treatment failed. Successful decolonization was considered to have been achieved if results were negative for 3 consecutive sets of cultures of more than 6 screening sites.

The mean age (± standard deviation [SD]) age of the 62 patients was 66.2 ± 19 years. The most frequent locations of MRSA colonization were the nose (42 patients [68%]), the throat (33 [53%]), perianal area (33 [53%]), rectum (36 [58%]), and inguinal area (30 [49%]). Decolonization was completed in 87% of patients after a mean (±SD) of 2.1 ± 1.8 decolonization cycles (range, 1-10 cycles). Sixty-five percent of patients ultimately required peroral antibiotic treatment (vancomycin, 52%; cotrimoxazole, 27%; rifampin and fusidic acid, 18%). Decolonization was successful in 54 (87%) of the patients in the intent-to-treat analysis and in 51 (98%) of 52 patients in the on-treatment analysis.

This standardized regimen for MRSA decolonization was highly effective in patients who completed the full decolonization treatment course.

Patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) may contaminate their immediate environment with this organism. However, the extent to which gastrointestinal colonization with MRSA affects environmental contamination is not known. We investigated the frequency of environmental contamination in the rooms of patients with diarrheal stools and heavy gastro-intestinal colonization with MRSA.

Prospective observational study.

A 500-bed teaching hospital.

Stool specimens submitted for Clostridium difficile toxin assays were inoculated onto colistin-naladixic acid agar. MRSA was identified with standard methods. Samples from a standardized list of 10 environmental surfaces were cultured, from the rooms of 8 patients who had diarrhea that yielded heavy growth of MRSA (case patients) and from the rooms of 6 MRSA-positive patients with stool cultures negative for MRSA (control patients). MRSA isolates from 13 patients (8 case patients and 5 control patients) and 64 of the environmental isolates recovered from their rooms were compared by pulsed-field gel electrophoresis (PFGE). One clinical isolate from a control patient was excluded because there was no corresponding environmental MRSA isolate with which to compare it.

Overall, MRSA were recovered from 47 (58.8%) of 80 surfaces in the rooms of case patients, compared with 14 (23.3%) of 60 surfaces in the rooms of control patients (58.8% [95% CI, 47.8-68.9] vs 23.3% [95% CI, 14.3-35.5];P<.0001). The items most commonly contaminated were bedside rails, blood pressure cuffs, television remote controls, and toilet seats. Seventy-eight percent of the environmental isolates in patients' rooms had PFGE types that were indistinguishable or closely related to those recovered from the patients' clinical specimens.

Patients who have diarrheal stools and heavy gastrointestinal colonization with MRSA are associated with significantly greater environmental MRSA contamination than patients without MRSA in their stool, and they are likely to be the source of that contamination.

To evaluate the economic and clinical impact of infection with extended-spectrum β-lactamase (ESBL)-producing Escherichia coli and Klebsiella species (ESBL-EK).

A matched-cohort analysis of the cost of illness.

An 810-bed, urban, community hospital in Hartford, Connecticut.

Twenty-one case patients infected with ESBL-EK at a site other than the urinary tract were matched with 21 control subjects infected with a non–ESBL-producing organism on the basis of pathogen species, age, anatomic site of infection, hospitalization in the intensive care unit (ICU) during the time of infection, date of hospitalization, and initial antibiotics received.

Mean infection-related costs per patient were significantly greater for case patients than for control patients ($41,353 vs $24,902; P = .034). Infection-related length of stay was the main driver of cost, which was prolonged for case patients, compared with control patients (21 vs 11 days; mean difference, 9.7 days [95% confidence interval {CI}, 3.2-14.6 days] P = .006). The additional cost attributed to the presence of an ESBL-EK infection was $16,450 per patient (95% CI, $965-$31,937). Case patients were more likely than control patients to have clinical failure (P = .027), and the rate of treatment success for case patients whose initial treatment involved antibiotics other than carbapenems was lower than that for their matched control patients (39% vs 83%; P = .013). Treatment was successful in patients for whom initial treatment was with a carbapenem, regardless of the ESBL status of the pathogen.

The cost of non–urinary tract infections caused by ESBL-EK was 1.7 times the cost of non–urinary tract infections caused by non-ESBL producers. Prompt recognition and appropriate antimicrobial selection may minimize this ESBL-related impact on hospital costs.

To determine prevalence, predictors, and outcomes of infection due to Escherichia coli sequence type ST131.

Retrospective cohort.

All healthcare settings in Olmsted County, Minnesota (eg, community hospital, tertiary care center, long-term care facilities, and ambulatory clinics).

Ambulatory and hospitalized children and adults with extraintestinal E. coli isolates.

We analyzed 299 consecutive, nonduplicate extraintestinal E. coli isolates submitted to Olmsted County laboratories in February and March 2011. ST131 was identified using single-nucleotide polymorphism polymerase chain reaction and further evaluated through pulsed-field gel electrophoresis. Associated clinical data were abstracted through medical record review.

Most isolates were from urine specimens (90%), outpatients (68%), and community-associated infections (61%). ST131 accounted for 27% of isolates overall and for a larger proportion of those isolates resistant to fluoroquinolones (81%), trimethoprim-sulfamethoxazole (42%), gentamicin (79%), and ceftriaxone (50%). The prevalence of ST131 increased with age (accounting for 5% of isolates from those 11–20 years of age, 26% of isolates from those 51–60 years of age, and 50% of isolates from those 91–100 years of age). ST131 accounted for a greater proportion of healthcare-associated isolates (49%) than community-associated isolates (15%) and for fully 76% of E. coli isolates from long-term care facility (LTCF) residents. Multivariable predictors of ST131 carriage included older age, LTCF residence, previous urinary tract infection, high-complexity infection, and previous use of fluoroquinolones, macrolides, and extended-spectrum cephalosporins. With multivariable adjustment, ST131-associated infection outcomes included receipt of more than 1 antibiotic (odds ratio [OR], 2.54 [95% confidence interval (CI), 1.25–5.17]) and persistent or recurrent symptoms (OR, 2.53 [95% CI, 1.08–5.96]). Two globally predominant ST131 pulsotypes accounted for 45% of STB 1 isolates.

ST131isa dominant, antimicrobial-resistant clonal group associated with healthcare settings, elderly hosts, and persistent or recurrent symptoms.

Hospital-acquired legionnaires' disease can be prevented by disinfection of hospital water systems. This study assessed the long-term efficacy of copper-silver ionization as a disinfection method in controlling Legionella in hospital water systems and reducing the incidence of hospital-acquired legionnaires' disease. A standardized, evidence-based approach to assist hospitals with decision making concerning the possible purchase of a disinfection system is presented.

The first 16 hospitals to install copper-silver ionization systems for Legionella disinfection were surveyed. Surveys conducted in 1995 and 2000 documented the experiences of the hospitals with maintenance of the system, contamination of water with Legionella, and occurrence of hospital-acquired legionnaires' disease. All were acute care hospitals with a mean of 435 beds.

All 16 hospitals reported cases of hospital-acquired legionnaires' disease prior to installing the copper-silver ionization system. Seventy-five percent had previously attempted other disinfection methods including superheat and flush, ultraviolet light, and hyperchlorination. By 2000, the ionization systems had been operational from 5 to 11 years. Prior to installation, 47% of the hospitals reported that more than 30% of distal water sites yielded Legionella. In 1995, after installation, 50% of the hospitals reported 0% positivity, and 43% still reported 0% in 2000. Moreover, no cases of hospital-acquired legionnaires' disease have occurred in any hospital since 1995.

This study represents the final step in a proposed 4-step evaluation process of disinfection systems that includes (1) demonstrated efficacy of Legionella eradication in vitro using laboratory assays, (2) anecdotal experiences in preventing legionnaires' disease in individual hospitals, (3) controlled studies in individual hospitals, and (4) validation in confirmatory reports from multiple hospitals during a prolonged time (5 to 11 years in this study). Copper-silver ionization is now the only disinfection modality to have fulfilled all four evaluation criteria.

Reliable data on the costs attributable to nosocomial infection (NI) are crucial to demonstrating the real cost-effectiveness of infection control measures. Several studies investigating this issue with regard to intensive care unit (ICU) patients have probably overestimated, as a result of inappropriate study methods, the part played by NIs in prolonging the length of stay.

Data from a prospective study of the incidence of NI in 5 ICUs over a period of 18 months formed the basis of this analysis. For describing the temporal dynamics of the data, a multistate model was used. Thus, ICU patients were counted as case patients as soon as an NI was ascertained on any particular day. All patients were then regarded as control subjects as long as they remained free of NI (time-to-event data analysis technique).

Admitted patients (n = 1,876) were observed for the development of NI over a period of 28,498 patient-days. In total, 431 NIs were ascertained during the study period (incidence density, 15.1 NIs per 1,000 patient-days). The influence of NI as a time-dependent covariate in a proportional hazards model was highly significant (P< .0001, Wald test). NI significantly reduced the discharge hazard (hazard ratio, 0.72 [95% confidence interval, 0.63-0.82])—that is, it prolonged the ICU stay. The mean prolongation of ICU length of stay due to NI ( ± standard error) was estimated to be 5.3 ± 1.6 days.

Further studies are required to enable comparison of data on prolongation of ICU length of stay with the results of various study methods.