To determine whether increases in contact isolation precautions are associated with decreased adherence to isolation practices among healthcare workers (HCWs).

Prospective cohort study from February 2009 to October 2009.

Eleven teaching hospitals.

HCWs.

One thousand thirteen observations conducted on HCWs. Additional data included the number of persons in isolation, types of HCWs, and hospital-specific contact precaution practices. Main outcome measures included compliance with individual components of contact isolation precautions (hand hygiene before and after patient encounter, donning of gown and glove upon entering a patient room, and doffing upon exiting) and overall compliance (all 5 measures together) during varying burdens of isolation.

Compliance with hand hygiene was as follows: prior to donning gowns/gloves, 37.2%; gowning, 74.3%; gloving, 80.1%; doffing of gowns/gloves, 80.1%; after gown/glove removal, 61%. Compliance with all components was 28.9%. As the burden of isolation increased (20% or less to greater than 60%), a decrease in compliance with hand hygiene (43.6%—4.9%) and with all 5 components (31.5%—6.5%) was observed. In multivariable analysis, there was an increase in noncompliance with all 5 components of the contact isolation precautions bundle (odds ratio [OR], 6.6 [95% confidence interval (CI), 1.15-37.44]; P = .03) and in noncompliance with hand hygiene prior to donning gowns and gloves (OR, 10.1 [95% CI, 1.84—55.54]; P = .008) associated with increasing burden of isolation.

As the proportion of patients in contact isolation increases, compliance with contact isolation precautions decreases. Placing 40% of patients under contact precautions represents a tipping point for noncompliance with contact isolation precautions measures.

An estimated 293,300 healthcare-associated cases of Clostridium difficile infection (CDI) occur annually in the United States. To date, research has focused on developing risk prediction models for CDI that work well across institutions. However, this one-size-fits-all approach ignores important hospital-specific factors. We focus on a generalizable method for building facility-specific models. We demonstrate the applicability of the approach using electronic health records (EHR) from the University of Michigan Hospitals (UM) and the Massachusetts General Hospital (MGH).

We utilized EHR data from 191,014 adult admissions to UM and 65,718 adult admissions to MGH. We extracted patient demographics, admission details, patient history, and daily hospitalization details, resulting in 4,836 features from patients at UM and 1,837 from patients at MGH. We used L2 regularized logistic regression to learn the models, and we measured the discriminative performance of the models on held-out data from each hospital.

Using the UM and MGH test data, the models achieved area under the receiver operating characteristic curve (AUROC) values of 0.82 (95% confidence interval [CI], 0.80–0.84) and 0.75 ( 95% CI, 0.73–0.78), respectively. Some predictive factors were shared between the 2 models, but many of the top predictive factors differed between facilities.

A data-driven approach to building models for estimating daily patient risk for CDI was used to build institution-specific models at 2 large hospitals with different patient populations and EHR systems. In contrast to traditional approaches that focus on developing models that apply across hospitals, our generalizable approach yields risk-stratification models tailored to an institution. These hospital-specific models allow for earlier and more accurate identification of high-risk patients and better targeting of infection prevention strategies.

Infect Control Hosp Epidemiol 2018;39:425–433

To determine the effectiveness of a pulsed xenon ultraviolet (PX-UV) disinfection device for reduction in recovery of healthcare-associated pathogens.

Two acute-care hospitals.

We examined the effectiveness of PX-UV for killing of Clostridium difficile spores, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus (VRE) on glass carriers and evaluated the impact of pathogen concentration, distance from the device, organic load, and shading from the direct field of radiation on killing efficacy. We compared the effectiveness of PX-UV and ultraviolet-C (UV-C) irradiation, each delivered for 10 minutes at 4 feet. In hospital rooms, the frequency of native pathogen contamination on high-touch surfaces was assessed before and after 10 minutes of PX-UV irradiation.

On carriers, irradiation delivered for 10 minutes at 4 feet from the PX-UV device reduced recovery of C. difficile spores, MRSA, and VRE by 0.55±0.34, 1.85±0.49, and 0.6±0.25 log10 colony-forming units (CFU)/cm2, respectively. Increasing distance from the PX-UV device dramatically reduced killing efficacy, whereas pathogen concentration, organic load, and shading did not. Continuous UV-C achieved significantly greater log10CFU reductions than PX-UV irradiation on glass carriers. On frequently touched surfaces, PX-UV significantly reduced the frequency of positive C. difficile, VRE, and MRSA culture results.

The PX-UV device reduced recovery of MRSA, C. difficile, and VRE on glass carriers and on frequently touched surfaces in hospital rooms with a 10-minute UV exposure time. PX-UV was not more effective than continuous UV-C in reducing pathogen recovery on glass slides, suggesting that both forms of UV have some effectiveness at relatively short exposure times.

Infect Control Hosp Epidemiol 2014;00(0): 1–6

Endonasal endoscopic skull base surgery (ESBS) is perceived as having a high risk of infection because it is performed through the sinuses, which are not sterile.

To identify the bacteriological characteristics, incidence, mortality, and risk factors for intracranial infection after ESBS.

A retrospective analysis of the first 1,000 ESBS procedures performed at the University of Pittsburgh Medical Center from 1998 to 2008.

In 18 cases (1.8%), the patient developed meningitis. In 2 cases, the patient died within 2 months after surgery, of noninfectious causes. In 11 cases, cerebrospinal fluid (CSF) cultures had positive results. There were no predominant pathogens. Male sex (odds ratio [OR], 3.97 [95% confidence interval {CI}, 1.21-13.03]; P = .02), history of a craniotomy or endonasal surgery (OR, 4.77 [95% CI, 1.68-13.56];P = .003), surgerywith higher levels of complexity (OR, 6.60 [95% CI, 1.77-24.70];P = .005), the presence of an external ventricular drain or ventriculoperitoneal shunt at the time of surgery (OR, 6.38 [95% CI, 1.07-38.09]; P = .04), and postoperative CSF leak (OR, 12.99 [95% CI, 4.24-39.82]; P<.001) were risk factors for infection.

The incidence of infection of 1.8% in ESBS is comparable to that in open craniotomy. The most important risk factor was a postoperative CSF leak. All patients recovered from their infection.

To understand the behavioral determinants of hand hygiene in our hospital.

Qualitative study based on 17 focus groups.

Mount Sinai Hospital, an acute care tertiary hospital affiliated with the University of Toronto.

We recruited 153 healthcare workers (HCWs) representing all major patient care job categories.

Focus group discussions were transcribed verbatim. Thematic analysis was independently conducted by 3 investigators.

Participants reported that the realities of their workload (eg, urgent care and interruptions) make complete adherence to hand hygiene impossible. The guidelines were described as overly conservative, and participants expressed that their judgement is adequate to determine when to perform hand hygiene. Discussions revealed gaps in knowledge among participants; most participants expressed interest in more information and education. Participants reported self-protection as the primary reason for the performance of hand hygiene, and many admitted to prolonged glove use because it gave them a sense of protection. Limited access to hand hygiene products was a source of frustration, as was confusion related to hospital equipment as potential vehicles for transmission of infection. Participants said that they noticed other HCWs' adherence and reported that others HCWs' hygiene practices influenced their own attitudes and practices. In particular, HCWs perceive physicians as role models; physicians, however, do not see themselves as such.

Our results confirm previous findings that hand hygiene is practiced for personal protection, that limited access to supplies is a barrier, and that role models and a sense of team effort encourage hand hygiene. Educating HCWs on how to manage workload with guideline adherence and addressing contaminated hospital equipment may improve compliance.

Screening for methicillin-resistant Staphylococcus aureus (MRSA) in high-risk patients is a legislative mandate in 9 US states and has been adopted by many hospitals. Definitions of high risk differ among hospitals and state laws. A systematic evaluation of factors associated with colonization is lacking. We performed a systematic review of the literature to assess factors associated with MRSA colonization at hospital admission.

We searched MEDLINE from 1966 to 2012 for articles comparing MRSA colonized and noncolonized patients on hospital or intensive care unit (ICU) admission. Data were extracted using a standardized instrument. Meta-analyses were performed to identify factors associated with MRSA colonization.

We reviewed 4,381 abstracts; 29 articles met inclusion criteria (n = 76,913 patients). MRSA colonization at hospital admission was associated with recent prior hospitalization (odds ratio [OR], 2.4 [95% confidence interval (CI), 1.3–4.7]; P<.01), nursing home exposure (OR, 3.8 [95% CI, 2.3–6.3]; P< .01), and history of exposure to healthcare-associated pathogens (MRSA carriage: OR, 8.0 [95% CI, 4.2–15.1]; Clostridium difficile infection: OR, 3.4 [95% CI, 2.2–5.3]; vancomycin-resistant Enterococci carriage: OR, 3.1 [95% CI, 2.5–4.0]; P< .01 for all). Select comorbidities were associated with MRSA colonization (congestive heart failure, diabetes, pulmonary disease, immunosuppression, and renal failure; P< .01 for all), while others were not (human immunodeficiency virus, cirrhosis, and malignancy). ICU admission was not associated with an increased risk of MRSA colonization (OR, 1.1 [95% CI, 0.6–1.8]; P = .87).

MRSA colonization on hospital admission was associated with healthcare contact, previous healthcare-associated pathogens, and select comorbid conditions. ICU admission was not associated with MRSA colonization, although this is commonly used in state mandates for MRSA screening. Infection prevention programs utilizing targeted MRSA screening may consider our results to define patients likely to have MRSA colonization.

To determine whether copper incorporated into hospital ward furnishings and equipment can reduce their surface microbial load.

A crossover study.

Acute care medical ward with 19 beds at a large university hospital.

Fourteen types of frequent-touch items made of copper alloy were installed in various locations on an acute care medical ward. These included door handles and push plates, toilet seats and flush handles, grab rails, light switches and pull cord toggles, sockets, overbed tables, dressing trolleys, commodes, taps, and sink fittings. Their surfaces and those of equivalent standard items on the same ward were sampled once weekly for 24 weeks. The copper and standard items were switched over after 12 weeks of sampling to reduce bias in usage patterns. The total aerobic microbial counts and the presence of indicator microorganisms were determined.

Eight of the 14 copper item types had microbial counts on their surfaces that were significantly lower than counts on standard materials. The other 6 copper item types had reduced microbial numbers on their surfaces, compared with microbial counts on standard items, but the reduction did not reach statistical significance. Indicator microorganisms were recovered from both types of surfaces; however, significantly fewer copper surfaces were contaminated with vancomycin-resistant enterococci, methicillin-susceptible Staphylococcus aureus, and coliforms, compared with standard surfaces.

Copper alloys (greater than or equal to 58% copper), when incorporated into various hospital furnishings and fittings, reduce the surface microorganisms. The use of copper in combination with optimal infection-prevention strategies may therefore further reduce the risk that patients will acquire infection in healthcare environments.

Infect Control Hosp Epidemiol 2012;33(1):3-9

Early recognition of influenza virus infection in hospitalized patients can prevent nosocomial transmission.

To determine the clinical presentation of influenza in hospitalized patients.

Case series. Data were collected retrospectively from medical records and included demographic information, comorbidities, clinical symptoms and signs, microbiologic test results, and outcomes (including pneumonia and intensive care unit [ICU] admission).

A 1,400-bed teaching hospital.

A total of 207 inpatients who received a diagnosis of influenza virus infection during 3 seasons from 2000 to 2003.

Over the course of 3 seasons, 207 patients received a diagnosis of influenza (186 were infected with influenza A virus, and 21 were infected with influenza B virus). The most commonly reported symptoms were cough (186 patients [90%]) and subjective fever (137 patients [66%]); 124 patients (60%) had a documented temperature of 37.8°C or greater before influenza was diagnosed. Sore throat was uncommon (44 patients [21%]). Centers for Disease Control and Prevention (CDC) criteria for influenza-like illness (ILI)–temperature 37.8°C or greater and either cough or sore throat–were met by 107 patients (51%). There were no differences in the proportion of patients who met ILI criteria with respect to age, sex, season, influenza virus type, or time to diagnosis in the hospital. Most patients (150 [72%]) received acetaminophen. Only 41 patients (20%) had positive results of clinical cultures; 178 patients (86%) received antibiotic therapy. Fifty-six patients (27%) had pneumonia: 36 (17%) required admission to the ICU, and 25 (12%) required ventilatory support. Patients with pulmonary disease were more likely to require ventilatory support (12 [26%] vs 13 [8%]; P = .003).

Only half of hospitalized patients with influenza met CDC criteria for ILI. These criteria may be more appropriate in outpatient settings. A high index of suspicion is needed to recognize influenza in hospitalized patients.

To describe the prevalence and characteristics of antimicrobial stewardship programs (ASPs) in hospitals across the United States and to describe financial support provided for these programs.

Electronic and paper 14-question survey of infectious diseases physician members of the Infectious Diseases Society of America Emerging Infections Network (IDSA EIN).

All 1,044 IDSA EIN members who care for adult patients were invited to participate.

Five hundred twenty-two (50%) members responded. Seventy-three percent of respondents reported that their institutions had or were planning an ASP, compared with 50% reporting the same thing in an EIN survey 10 years before. A shift was noted from formulary restriction alone to use of a set of tailored strategies designed to provide information and feedback to prescribers, particularly in community hospitals. Lack of funding and lack of personnel were reported as major barriers to implementing a program. Fifty-two percent of respondents with an ASP reported that infectious diseases physicians do not receive direct compensation for their participation in the ASP, compared with 18% 10 years ago.

The percentage of institutions reporting ASPs has increased over the last decade, although small community hospitals were least likely to have these programs. In addition, ASP strategies have shifted dramatically. Lack of funding remains a key barrier for ASPs, and administrators need additional cost savings data in order to support ASPs. Interestingly, while guidelines and editorials regard compensated participation by an infectious diseases physician in these programs as critical, we found that more than half of the respondents reported no direct compensation for ASP activities.

Preventing hospital falls and injuries requires knowledge of fall and injury circumstances. Our objectives were to determine whether reported fall circumstances differ among hospitals and to identify predictors of fall-related injury.

Retrospective cohort study. Adverse event data on falls were compared according to hospital characteristics. Logistic regression was used to determine adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for risk factors for fall-related injury.

Nine hospitals in a Midwestern healthcare system.

Inpatients who fell during 2001-2003.

The 9 hospitals reported 8,974 falls that occurred in patient care areas, involving 7,082 patients; 7,082 falls were included in our analysis. Assisted falls (which accounted for 13.3% of falls in the academic hospital and 9.8% of falls in the nonacademic hospitals; P <.001) and serious fall-related injuries (which accounted for 3.7% of fall-related injuries in the academic hospital and 2.2% of fall-related injuries in the nonacademic hospitals; P <.001) differed by hospital type. In multivariate analysis for the academic hospital, increased age (aOR, 1.006 [95% CI, 1.000-1.012]), falls in locations other than patient rooms (aOR, 1.53 [95% CI, 1.03-2.27]), and unassisted falls (aOR, 1.70 [95% CI, 1.23-2.36]) were associated with increased injury risk. Altered mental status was associated with a decreased injury risk (aOR, 0.72 [95% CI, 0.58-0.89]). In multivariate analysis for the nonacademic hospitals, increased age (aOR, 1.007 [95% CI, 1.002-1.013]), falls in the bathroom (aOR, 1.46 [95% CI, 1.06-2.01]), and unassisted falls (aOR, 1.83 [95% CI, 1.37-2.43]) were associated with injury. Female sex (aOR, 0.83 [95% CI, 0.71-0.97]) was associated with a decreased risk of injury.

Some fall characteristics differed by hospital type. Further research is necessary to determine whether differences reflect true differences or merely differences in reporting practices. Fall prevention programs should target falls involving older patients, unassisted falls, and falls that occur in the patient's bathroom and in patient care areas outside of the patient's room to reduce injuries.

Multidisciplinary antimicrobial utilization teams (AUTs) have been proposed as a mechanism for improving antimicrobial use, but data on their efficacy remain limited.

To determine the impact of an AUT on antimicrobial use at a teaching hospital.

Randomized controlled intervention trial.

A 953-bed, public, university-affiliated, urban teaching hospital.

Patients who were given selected antimicrobial agents (piperacillin-tazobactam, levofloxacin, or vancomycin) by internal medicine ward teams.

Twelve internal medicine teams were randomly assigned monthly: 6 teams to an intervention group (academic detailing by the AUT) and 6 teams to a control group that was given indication-based guidelines for prescription of broad-spectrum antimicrobials (standard of care), during a 10-month study period.

Proportion of appropriate empirical, definitive (therapeutic), and end (overall) antimicrobial usage.

A total of 784 new prescriptions of piperacillin-tazobactam, levofloxacin, and vancomycin were reviewed. The proportion of antimicrobial prescriptions written by the intervention teams that was considered to be appropriate was significantly higher than the proportion of antimicrobial prescriptions written by the control teams that was considered to be appropriate: 82% versus 73% for empirical (risk ratio [RR], 1.14; 95% confidence interval [CI], 1.04-1.24), 82% versus 43% for definitive (RR, 1.89; 95% CI, 1.53-2.33), and 94% versus 70% for end antimicrobial usage (RR, 1.34; 95% CI, 1.25-1.43). In multivariate analysis, teams that received feedback from the AUT alone (adjusted RR, 1.37; 95% CI, 1.27-1.48) or from both the AUT and the infectious diseases consultation service (adjusted RR, 2.28; 95% CI, 1.64-3.19) were significantiy more likely to prescribe end antimicrobial usage appropriately, compared with control teams.

A multidisciplinary AUT that provides feedback to prescribing physicians was an effective method in improving antimicrobial use.

ClinicalTrials.gov identifier: NCT00552838.

Whether contact precautions (CP) are required to control the endemic transmission of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) in acute care hospitals is controversial in light of improvements in hand hygiene, MRSA decolonization, environmental cleaning and disinfection, fomite elimination, and chlorhexidine bathing.

To provide a framework for decision making around use of CP for endemic MRSA and VRE based on a summary of evidence related to use of CP, including impact on patients and patient care processes, and current practices in use of CP for MRSA and VRE in US hospitals.

A literature review, a survey of Society for Healthcare Epidemiology of America Research Network members on use of CP, and a detailed examination of the experience of a convenience sample of hospitals not using CP for MRSA or VRE.

Hospital epidemiologists and infection prevention experts.

No high quality data support or reject use of CP for endemic MRSA or VRE. Our survey found more than 90% of responding hospitals currently use CP for MRSA and VRE, but approximately 60% are interested in using CP in a different manner. More than 30 US hospitals do not use CP for control of endemic MRSA or VRE.

Higher quality research on the benefits and harms of CP in the control of endemic MRSA and VRE is needed. Until more definitive data are available, the use of CP for endemic MRSA or VRE in acute care hospitals should be guided by local needs and resources.

Infect Control Hosp Epidemiol 2015;36(10):1163–1172

Carbapenem-resistant Enterobacteriaceae (CRE) are rapidly emerging worldwide. Control group selection is critically important when analyzing predictors of antimicrobial resistance. Focusing on modifiable risk factors can optimize prevention and resource expenditures. To identify specific predictors of CRE, patients with CRE were compared with 3 control groups: (1) patients with extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, (2) patients with non-ESBL-containing Enterobacteriaceae, and (3) uninfected controls.

Matched multivariable analyses.

Patients possessing CRE that were isolated at Detroit Medical Center from September 1, 2008, to August 31, 2009.

Patients were matched (1:1 ratio) to the 3 sets of controls. Matching parameters included (1) bacteria type, (2) hospital/ facility, (3) unit/clinic, (4) calendar year, and (5) time at risk (ie, from admission to culture). Matched multivariable analyses were conducted between uninfected controls and patients with CRE, ESBL, and non-ESBL Enterobacteriaceae. Models were also designed comparing patients with CRE to patients with ESBL, patients with non-ESBL Enterobacteriaceae, and all 3 non-CRE groups combined.

Ninety-one unique patients with CRE were identified, and 6 matched models were constructed. Recent (less than 3 months) exposure to antibiotics was the only parameter that was consistently associated with CRE, regardless of the group to which CRE was compared, and was not independently associated with isolation of ESBL or non-ESBL Enterobacteriaceae.

Exposure to antibiotics within 3 months was an independent predictor that characterized patients with CRE isolation. As a result, antimicrobial stewardship efforts need to become a major focus of preventive Interventions. Regulatory focus regarding appropriate antimicrobial use might decrease the detrimental effects of antibiotic misuse and spread of CRE.

To assess the efficacy of both natural products (vinegar, baking soda) and common commercial disinfectants (Vesphene Ilse, TBQ, Clorox, Lysol Disinfectant Spray, Lysol Antibacterial Kitchen Cleaner, Mr. Clean Ultra, ethanol) designed for home or institutional use against potential human pathogens, including selected antibiotic-resistant bacteria.

A quantitative suspension test was used to assess the efficacy of selected disinfectants following exposure times of 30 seconds and 5 minutes. Activity was assessed against Staphylococcus aureus, Salmonella choleraesuis, Escherichia coli 0157:H7, and Pseudomonas aeruginosa. Selected disinfectants were also tested against poliovirus, vancomycin-susceptible and -resistant Enterococcus species, and methicillin-susceptible and -resistant S aureus.

The following compounds demonstrated excellent antimicrobial activity (>5.6-8.2 log10 reduction) at both exposure times: TBQ, Vesphene, Clorox, ethanol, and Lysol Antibacterial Kitchen Cleaner. Mr. Clean eliminated 4 to >6 logs10 and Lysol Disinfectant ~4 logs10 of pathogenic microorganisms at both exposure times. Vinegar eliminated <3 logs10 of S aureus and E coli, and baking soda <3 logs10 of all test pathogens. All tested chemical disinfectants completely inactivated both antibiotic-resistant and -susceptible bacteria at both exposure times. Only two disinfectants, Clorox and Lysol, demonstrated excellent activity (>3 log10 reduction) against poliovirus.

A variety of commercial household disinfectants were highly effective against potential bacterial pathogens. The natural products were less effective than commercial household disinfectants. Only Clorox and Lysol disinfectant were effective against poliovirus

To determine the effectiveness of an automated ultraviolet-C (UV-C) emitter against vancomycin-resistant enterococci (VRE), Clostridium difficile, and Acinetobacter spp. in patient rooms.

Prospective cohort study.

Two tertiary care hospitals.

Convenience sample of 39 patient rooms from which a patient infected or colonized with 1 of the 3 targeted pathogens had been discharged.

Environmental sites were cultured before and after use of an automated UV-C-emitting device in targeted rooms but before standard terminal room disinfection by environmental services.

In total, 142 samples were obtained from 27 rooms of patients who were colonized or infected with VRE, 77 samples were obtained from 10 rooms of patients with C. difficile infection, and 10 samples were obtained from 2 rooms of patients with infections due to Acinetobacter. Use of an automated UV-C-emitting device led to a significant decrease in the total number of colony-forming units (CFUs) of any type of organism (1.07 log10 reduction; P < .0001), CFUs of target pathogens (1.35 log10 reduction; P < .0001), VRE CFUs (1.68 log10 reduction; P < .0001), and C. difficile CFUs (1.16 log10 reduction; P < .0001). CFUs of Acinetobacter also decreased (1.71 log10 reduction), but the trend was not statistically significant P = .25). CFUs were reduced at all 9 of the environmental sites tested. Reductions similarly occurred in direct and indirect line of sight.

Our data confirm that automated UV-C-emitting devices can decrease the bioburden of important pathogens in real-world settings such as hospital rooms.