To determine whether ambient air pollutants and meteorological variables are associated with daily COVID-19 incidence.

A retrospective cohort from January 25 to February 29, 2020.

Cities of Wuhan, Xiaogan, and Huanggang, China.

The COVID-19 cases detected each day.

We collected daily data of COVID-19 incidence, 8 ambient air pollutants (particulate matter of ≤2.5 µm [PM2.5], particulate matter ≤10 µm [PM10], sulfur dioxide [SO2], carbon monoxide [CO], nitrogen dioxide [NO2], and maximum 8-h moving average concentrations for ozone [O3-8h]) and 3 meteorological variables (temperature, relative humidity, and wind) in China’s 3 worst COVID-19–stricken cities during the study period. The multivariate Poisson regression was performed to understand their correlation.

Daily COVID-19 incidence was positively associated with PM2.5 and humidity in all cities. Specifically, the relative risk (RR) of PM2.5 for daily COVID-19 incidences were 1.036 (95% confidence interval [CI], 1.032–1.039) in Wuhan, 1.059 (95% CI, 1.046–1.072) in Xiaogan, and 1.144 (95% CI, 1.12–1.169) in Huanggang. The RR of humidity for daily COVID-19 incidence was consistently lower than that of PM2.5, and this difference ranged from 0.027 to 0.111. Moreover, PM10 and temperature also exhibited a notable correlation with daily COVID-19 incidence, but in a negative pattern The RR of PM10 for daily COVID-19 incidence ranged from 0.915 (95% CI, 0.896–0.934) to 0.961 (95% CI, 0.95–0.972, while that of temperature ranged from 0.738 (95% CI, 0.717–0.759) to 0.969 (95% CI, 0.966–0.973).

Our data show that PM2.5 and humidity are substantially associated with an increased risk of COVID-19 and that PM10 and temperature are substantially associated with a decreased risk of COVID-19.

To evaluate the effect of bathing patients with 2% chlorhexidine on the rates of central vascular catheter (CVC)–associated bloodstream infection (BSI) at a long-term acute care hospital (LTACH).

Quasi-experimental study.

A 70-bed LTACH in the greater Chicago area.

All consecutive patients admitted to the LTACH during the period from February 2006 to February 2008.

For patients at the LTACH, daily 2% chlorhexidine baths were instituted during the period from September 2006 until May 2007 (ie, the intervention period). A preintervention period (in which patients were given daily soap-and-water baths) and a postintervention period (in which patients were given daily nonmedicated baths and weekly 2% chlorhexidine baths) were also observed. The rates of CVC-associated BSI and ventilator-associated pneumonia were analyzed for the intervention period and for the pre- and postintervention periods.

The rates of CVC-associated BSI were 9.5, 3.8, and 6.4 cases per 1,000 CVC-days during the preintervention, intervention, and postintervention periods, respectively. By the end of the intervention period, there was a net reduction of 99% in the CVC-associated BSI rate. No changes were seen in the rates of ventilator-associated pneumonia during the preintervention and intervention periods.

Daily chlorhexidine baths appeared to be an effective intervention to reduce rates of CVC-associated BSI in an LTACH.

To explore current practices and decision making regarding antimicrobial prescribing among emergency department (ED) clinical providers.

We conducted a survey of ED providers recruited from 8 sites in 3 cities. Using purposeful sampling, we then recruited 21 providers for in-depth interviews. Additionally, we observed 10 patient-provider interactions at one of the ED sites. SAS 9.3 was used for descriptive and predictive statistics. Interviews were audio recorded, transcribed, and analyzed using a thematic, constructivist approach with consensus coding using NVivo 10.0. Field and interview notes collected during the observational study were aligned with themes identified through individual interviews.

Of 150 survey respondents, 76% agreed or strongly agreed that antibiotics are overused in the ED, while half believed they personally did not overprescribe. Eighty-nine percent used a smartphone or tablet in the ED for antibiotic prescribing decisions. Several significant differences were found between attending and resident physicians. Interview analysis identified 42 codes aggregated into the following themes: (1) resource and environmental factors that affect care; (2) access to and quality of care received outside of the ED consult; (3) patient-provider relationships; (4) clinical inertia; and (5) local knowledge generation. The observational study revealed limited patient understanding of antibiotic use. Providers relied heavily upon diagnostics and provided limited education to patients. Most patients denied a priori expectations of being prescribed antibiotics.

Patient, provider, and healthcare system factors should be considered when designing interventions to improve antimicrobial stewardship in the ED setting.

Infect Control Hosp Epidemiol 2014;35(9):1114-1125

To evaluate the usefulness of repeated prevalence surveys to determine trends in the rates of nosocomial infections and to detect changes in risk factors (eg, use of invasive devices) associated with nosocomial infections.

Ten annual prevalence surveys were conducted by trained infection control practitioners between 1985 and 1995 for acute-care patients on the medical, surgical, pediatric, and obstetric-gynecologic services at a 900-bed, tertiary-care, teaching hospital with 750 acute-care beds. The same methods of chart review and concurrent reporting from nursing, the microbiology and clinical laboratory, and the pharmacy were used each year to collect data on the prevalence of nosocomial infections, invasive-device utilization, and abnormal laboratory indicators. Although data were collected on a single day, a period-prevalence study approach was used, because charts were reviewed for any infection data occurring within the 7 days prior to the survey.

The hospital census for acute-care patients, as measured by the prevalence surveys, declined sharply over the 10 years, from 673 to 575 patients (P=.02). However, the medical service census increased from 150 to 188 patients (P=.01). During the same period, there was a significant decrease in the mean length of stay, from 7.3 to 6.0 days (P=.01), and a concomitant increase in the mean diagnosis-related-group case-mix index, from 1.03 to 1.24 (P=.001). Overall, nosocomial infection rates remained unchanged over the study period (mean of 9.85 infections per 100 patients), but rates of nosocomial bloodstream infection increased from 0.0% in 1985 to 2.3% in 1995 (P=.05). Nosocomial infection rates were significantly higher on the medical and surgical services than on other services (P<.001). Utilization rates increased significantly for Foley catheters (9.0% to 16.0%, P=.002) and ventilators (5.0% to 8.0%, P=.05).

Despite apparent increases in the severity of illness of our patients, overall rates of nosocomial infection remained stable during a decade of study. Rates of nosocomial bloodstream infection increased, in parallel with National Nosocomial Infection Surveillance System data. We found repeated prevalence surveys to be useful in following trends and rates of infection, device utilization, and abnormal laboratory values among patients at our institution. Such methodologies can be valuable and low-cost components of a comprehensive infection surveillance, prevention, and control program and other potential quality-improvement initiatives, because they enable better annual planning of departmental strategies to meet hospital needs

To describe the results of the first year of the Dutch national surveillance of surgical-site infections (SSIs) and risk factors, which aims to implement a standardized surveillance system in a network of Dutch hospitals, to collect comparable data on SSIs to serve as a reference, and to provide a basic infrastructure for further intervention research.

Prospective multicenter cohort study.

Acute-care hospitals in The Netherlands from June 1996 to May 1997.

38 hospitals participated, with a slight overrepresentation of larger hospitals. Following a total of 18,063 operations, 562 SSIs occurred, of which 198 were deep. Multivariate analysis of pooled procedures shows that age, preoperative length of stay, wound contamination class, anesthesia score, and duration of surgery were independent risk factors for SSI. When analyzed by procedure, the relative importance of these risk factors changed. Bacteriological documentation was available for 56% of the SSIs; 35% of all isolates were Staphylococcus aureus. Multiple regression analysis computed the mean extra postoperative length of stay associated with SSI to be 8.2 days.

The first year of national surveillance has shown that it is feasible to collect comparable data on SSI, which are already used for education, policy, and decision making in the network of participating hospitals. This gives room to effectuate the next aim, namely to use the network as an infrastructure for intervention research. Multivariate analysis shows that feedback on a procedure-specific level is important.

To compare the efficacy of a new antiseptic catheter containing silver sulfadiazine and chlorhexidine on the external surface and chlorhexidine in the lumens to an antibiotic catheter impregnated with minocycline and rifampin on its external and luminal surfaces.

Experimental trial.

Antimicrobial spectrum of catheters was determined by zones of inhibition. Resistance to luminal colonization was tested in vitro by locking catheter lumens with Staphylococcus epidermidis or Staphylococcus aureus culture after 7 days of perfusion. In vitro development of resistance to the antiseptic or antibiotic combination used in catheters was investigated. In vivo efficacy was tested (rat subcutaneous model) by challenge with sensitive or antibiotic-resistant bacteria.

Antiseptic and antibiotic catheters exhibited broad-spectrum action. However, antibiotic catheters were not effective against Candida species and Pseudomonas aeruginosa. Both catheters prevented luminal colonization. Compared to controls, both test catheters resisted colonization when challenged with S aureus 7 and 14 days' postimplant (P<.05).

Repeated in vitro exposure of S epidermidis culture to the antibiotic and antiseptic combinations led to small increases in the minimum inhibitory concentration (15 times and 2 times, respectively). Unlike the antibiotic catheter, the in vitro and in vivo activity of the antiseptic catheter was unaffected by the resistance profile of the test organism. Antiseptic catheters were more effective than antibiotic catheters in preventing colonization by rifampin-resistant S epidermidis in vivo (P<.05).

Antiseptic and antibiotic catheters exhibit similar efficacy; however, when challenged with a rifampin-resistant strain, the antibiotic catheter appeared to be more susceptible to colonization than the antiseptic device.

We introduced a long-term care facility (LTCF) infectious disease (ID) consultation service (LID service) that provides on-site consultations to residents of a Veterans Affairs (VA) LTCF. We determined the impact of the LID service on antimicrobial use and Clostridium difficile infections at the LTCF.

A 160-bed VA LTCF.

Systemic antimicrobial use and positive C. difficile tests at the LTCF were compared for the 36 months before and the 18 months after the initiation of the ID consultation service through segmented regression analysis of an interrupted time series.

Relative to that in the preintervention period, total systemic antibiotic administration decreased by 30% (P<.001), with significant reductions in both oral (32%; P<.001) and intravenous (25%; P = .008) agents. The greatest reductions were seen for tetracyclines (64%; P<.001), clindamycin (61%; P<.001), sulfamethoxazole/trimethoprim (38%; P<.001), fluoroquinolones (38%; P<.001), and β lactam/β-lactamase inhibitor combinations (28%; P<.001). The rate of positive C. difficile tests at the LTCF declined in the postintervention period relative to preintervention rates (P = .04).

Implementation of an LTCF ID service led to a significant reduction in total antimicrobial use. Bringing providers with ID expertise to the LTCF represents a new and effective means to achieve antimicrobial stewardship.

To determine risk factors for vancomycin-resistant Enterococcus (VRE) colonization during a hospital outbreak and to evaluate Centers for Disease Control and Prevention (CDC)-recommended control measures.

Epidemiological study involving prospective identification of colonization and a case-control study.

A university hospital.

Patients on eight wards involved in outbreak from late 1994 through early 1995.

Cases were matched by ward and culture date with up to two controls. Risk factors were evaluated with four multivariate models using conditional logistic regression. The first evaluated proximity to other VRE patients and isolation status. The second evaluated proximity to unisolated VRE cases and three variables independently predictive after adjustment for proximity. The third evaluated seven significant univariate predictors in addition to proximity to unisolated VRE in backward, stepwise logistic regression. The fourth assessed proximity to VRE with all other variables collected, clustered in a principal components analysis. Pulsed-field gel electrophoresis was performed to assess clonality of two outbreak strains.

The incidence of transmission declined significantly after CDC guidelines were implemented. Proximity to unisolated VRE cases during the prior week was a significant predictor of acquisition in each of four multivariate models. Other significant risk factors in multivariate models included a history of major trauma and treatment with metronidazole. Pulsed-field gel electrophoresis confirmed the clonality of two outbreak strains.

VRE was transmitted between patients during a hospital epidemic, with proximity to previously unisolated VRE patients being an important risk factor. Weekly surveillance cultures and contact isolation of colonized patients significantly reduced spread.

To determine whether there is an association between the increasing use of alcohol-based hand rubs (ABHRs) and the increased incidence of Clostridium difficile–associated disease (CDAD).

A 500-bed university-affiliated community teaching hospital.

Use of ABHRs during the period 2000-2003 was expressed as the number of liters of ABHR used per 1000 patient-days. The proportion of hand hygiene episodes performed by using an ABHR was determined by periodic observational surveys. CDAD was defined as a physician-ordered stool assay positive for C. difficile toxin A or A/B. The incidence of CDAD was expressed as the number of unique patients who had 1 or more positive CDAD test results per 1,000 patient-days.

During 2000-2003, the use of ABHR increased 10-fold, from 3 to greater than 30 L/1,000 patient-days (P< .001). The proportion of hand hygiene episodes performed using an ABHR increased from 10% to 85% (P< .001). The incidence of CDAD in 2000, 2001, 2002, and 2003 was 1.74, 2.33, 1.14, and 1.18 cases/1,000 patient-days, respectively.

Despite a significant and progressive increase in the use of ABHRs in our facility during a 3-year period, there was no evidence that the incidence of CDAD increased. These findings suggest that factors other than the increased use of ABHRs are responsible for the increasing incidence of CDAD noted since 2000 in other facilities.

To assess the duration of shedding of influenza A virus detected by polymerase chain reaction (PCR) and cell culture among patients hospitalized with influenza A virus infection.

Mayo Clinic (Rochester, Minnesota) hospitals that cater to both the community and referral populations.

Patients 18 years old and older who were hospitalized between December 1, 2004, and March 15, 2005, with a laboratory-confirmed (ie, PCR-based) diagnosis of influenza A virus infection were consecutively enrolled. Additional throat swab specimens were collected at 2, 3, 5, and 7 days after the initial specimen (if the patient was still hospitalized). All specimens were tested by PCR and culture (both conventional tube culture and shell vial assay). Information on demographic characteristics, date of symptom onset, comorbidities, immunosuppression, influenza vaccination status, and receipt of antiviral treatment was obtained by interview and medical record review. Patients were excluded if informed consent could not be obtained or if the date of symptom onset could not be ascertained.

Of 149 patients hospitalized with influenza A virus infection, 50 patients were enrolled in the study. Most patients were older (median age, 76 years), and almost all (96%) had underlying chronic medical conditions. Of 41 patients included in the final analysis, influenza A virus was detected in 22 (54%) by PCR and in 12 (29%) by culture methods at or beyond 7 days after symptom onset. All 12 patients identified by culture also had PCR results positive for influenza A virus.

Hospitalized patients with influenza A virus infection can shed detectable virus beyond the 5- to 7-day period traditionally considered the duration of infectivity. Additional research is needed to assess whether prolonging the duration of patient isolation is warranted to prevent nosocomial outbreaks during the influenza season.

To examine risk factors for surgical site infection (SSI) following spinal surgery and to analyze the associations between a surgeon's years of operating experience and surgical specialty and patients' SSI risk.

Case-control study.

A tertiary care facility and a community hospital in Durham, North Carolina.

Each case patient who developed an SSI complicating laminectomy was matched with 2 noninfected control patients by hospital, year of surgery, and National Nosocomial Infection Surveillance System risk index score.

Forty-one case patients with SSI complicating laminectomy and 82 matched control patients were analyzed. Nonwhite race, diabetes and an elevated body mass index (BMI) were more common among case patients than among control patients. Subjects with a BMI greater than 35 were more likely to undergo a prolonged procedure, compared with case patients who had a BMI of 35 or less. The SSI rate for patients operated on by neurosurgeons was 28%, compared with 43% for patients operated on by orthopedic surgeons (odds ratio [OR], 0.5; P = .12). The number of years of operating experience were not associated with SSI risk. Multivariate analysis revealed diabetes (OR, 4.2 [95% confidence interval {CI}, 1.1-16.3]; P = .04), BMI greater than 35 (OR, 7.1 [95% CI, 1.8-28.3]; P = .005), and laminectomy at a level other than cervical (OR, 6.7 [95% CI, 1.4-33.3]; P = .02) as independent risk factors for SSI following laminectomy.

Diabetes, obesity, and laminectomy at a level other than cervical are independent risk factors for SSI following laminectomy. Preoperative weight loss and tight perioperative control of blood glucose levels may reduce the risk of SSI in laminectomy patients.

Several studies demonstrating that central line–associated bloodstream infections (CLABSIs) are preventable prompted a national initiative to reduce the incidence of these infections.

We conducted a collaborative cohort study to evaluate the impact of the national “On the CUSP: Stop BSI” program on CLABSI rates among participating adult intensive care units (ICUs). The program goal was to achieve a unit-level mean CLABSI rate of less than 1 case per 1,000 catheter-days using standardized definitions from the National Healthcare Safety Network. Multilevel Poisson regression modeling compared infection rates before, during, and up to 18 months after the intervention was implemented.

A total of 1,071 ICUs from 44 states, the District of Columbia, and Puerto Rico, reporting 27,153 ICU-months and 4,454,324 catheter-days of data, were included in the analysis. The overall mean CLABSI rate significantly decreased from 1.96 cases per 1,000 catheter-days at baseline to 1.15 at 16–18 months after implementation. CLABSI rates decreased during all observation periods compared with baseline, with adjusted incidence rate ratios steadily decreasing to 0.57 (95% confidence intervals, 0.50–0.65) at 16–18 months after implementation.

Coincident with the implementation of the national “On the CUSP: Stop BSI” program was a significant and sustained decrease in CLABSIs among a large and diverse cohort of ICUs, demonstrating an overall 43% decrease and suggesting the majority of ICUs in the United States can achieve additional reductions in CLABSI rates.

To describe the epidemiology of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (ESBL-EC) and Klebsiella pneumoniae (ESBL-KP) infections

Retrospective cohort

Inpatient care at community hospitals

All patients with ESBL-EC or ESBL-KP infections

ESBL-EC and ESBL-KP infections from 26 community hospitals were prospectively entered into a centralized database from January 2009 to December 2014.

A total of 925 infections caused by ESBL-EC (10.5 infections per 100,000 patient days) and 463 infections caused by ESBL-KP (5.3 infections per 100,000 patient days) were identified during 8,791,243 patient days of surveillance. The incidence of ESBL-EC infections increased from 5.28 to 10.5 patients per 100,000 patient days during the study period (P=.006). The number of community hospitals with ESBL-EC infections increased from 17 (65%) in 2009 to 20 (77%) in 2014. The median ESBL-EC infection rates among individual hospitals with ≥1 ESBL-EC infection increased from 11.1 infections/100,000 patient days (range, 2.2–33.9 days) in 2009 to 22.1 infections per 100,000 patient days (range, 0.66–134 days) in 2014 (P=.05). The incidence of ESBL-KP infections remained constant over the study period (P=.14). Community-associated and healthcare-associated ESBL-EC infections trended upward (P=.006 and P=.02, respectively), while hospital-onset infections remained stable (P=.07). ESBL-EC infections were more common in females (54% vs 44%, P<.001) and Caucasians (50% vs 40%, P<.0001), and were more likely to be isolated from the urinary tract (61% vs 52%, P<.0001) than ESBL-KP infections.

The incidence of ESBL-EC infection has increased in community hospitals throughout the southeastern United States, while the incidence of ESBL-KP infection has remained stable. Community- and healthcare-associated ESBL-EC infections are driving the upward trend.

Infect. Control Hosp. Epidemiol. 2015;37(1):49–54

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

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

Level III NICUs at Chicago-area hospitals.

Neonates and healthcare workers associated with the level III NICUs.

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

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

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

Whole-body washing with antiseptic solution has been widely used as part of eradication treatment for colonization with methicillin-resistant Staphylococcus aureus (MRSA), but evidence for the effectiveness of this measure is limited.

To study the efficacy of whole-body washing with chlorhexidine for the control of MRSA.

Randomized, placebo-controlled, double-blinded clinical trial.

University Hospital of Heidelberg and surrounding nursing homes.

MRSA carriers who were not treated concurrently with antibiotics effective against MRSA were eligible for the study.

Five days of whole-body washing with either 4% chlorhexidine solution (treatment group) or with a placebo solution. All patients received mupirocin nasal ointment and chlorhexidine mouth rinse. The outcome was evaluated 3, 4, 5, 9, and 30 days after treatment with swab samples taken from several body sites.

Of 114 patients enrolled in the study (56 in the treatment group and 58 in the placebo group), 11 did not finish treatment (8 from the treatment group and 3 from the placebo group [P = .02]). At baseline, the groups did not differ with regard to age, sex, underlying condition, site of MRSA colonization, or history of MRSA eradication treatment. Eleven patients were MRSA-free 30 days after treatment (4 from the treatment group and 7 from the placebo group [P = .47]). Only groin-area colonization was significantly better eradicated by the use of chlorhexidine. The best predictor for total eradication was a low number of body sites positive for MRSA. Adverse effects were significantly more frequent in the treatment group than in the placebo group (any symptom, 71% vs 33%) but were reversible in most cases.

Whole-body washing can reduce skin colonization, but it appears necessary to extend eradication measures to the gastrointestinal tract, wounds, and/or other colonized body sites if complete eradication is the goal.

ClinicalTrials.gov identifier: NCT00266448.

To characterize trends in outpatient antibiotic prescriptions in the United States

Retrospective ecological and temporal trend study evaluating outpatient antibiotic prescriptions from 2013 to 2015

National administrative claims data from a pharmacy benefits manager PARTICIPANTS. Prescription pharmacy beneficiaries from Express Scripts Holding Company

Annual and seasonal percent change in antibiotic prescriptions

Approximately 98 million outpatient antibiotic prescriptions were filled by 39 million insurance beneficiaries during the 3-year study period. The most commonly prescribed antibiotics were azithromycin, amoxicillin, amoxicillin/clavulanate, ciprofloxacin, and cephalexin. No significant changes in individual or overall annual antibiotic prescribing rates were found during the study period. Significant seasonal variation was observed, with antibiotics being 42% more likely to be prescribed during February than September (peak-to-trough ratio [PTTR], 1.42; 95% confidence interval [CI], 1.39–1.61). Similar seasonal trends were found for azithromycin (PTTR, 2.46; 95% CI, 2.44–3.47), amoxicillin (PTTR, 1.52; 95% CI, 1.42–1.89), and amoxicillin/clavulanate (PTTR, 1.78; 95% CI, 1.68–2.29).

This study demonstrates that annual national outpatient antibiotic prescribing practices remained unchanged during our study period. Furthermore, seasonal peaks in antibiotics generally used to treat viral upper respiratory tract infections remained unchanged during cold and influenza season. These results suggest that inappropriate prescribing of antibiotics remains widespread, despite the concurrent release of several guideline-based best practices intended to reduce inappropriate antibiotic consumption; however, further research linking national outpatient antibiotic prescriptions to associated medical conditions is needed to confirm these findings.

Infect Control Hosp Epidemiol 2018;39:584–589

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

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

An observational study with a planned intervention.

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

Patients admitted during the study period.

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

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

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

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

Antimicrobial stewardship programs (ASPs) are recommended to optimize antimicrobial use for hospitalized patients. Although mechanisms for the implementation of ASPs have been described, data-driven approaches to prioritize specific conditions and antimicrobials for intervention have not been established. We aimed to develop a strategy for identifying high-impact targets for antimicrobial stewardship efforts.

Retrospective cross-sectional study.

Children admitted to 32 freestanding children's hospitals in the United States in 2010.

We identified the conditions with the largest proportional contribution to the total days of antibiotic therapy prescribed to all hospitalized children. For the 4 highest-using conditions, we examined variability between hospitals in antibiotic selection patterns for use of either first- or second-line therapies depending on the condition. Antibiotic use was determined using standardized probability of exposure to selected agents and standardized days of therapy per 1,000 patient-days, adjusting for patient demographics and severity of illness.

In 2010, 524,364 children received 2,082,929 days of antibiotic therapy. Surgical patients received 43% of all antibiotics. The 4 highest-using conditions—pneumonia, appendicitis, cystic fibrosis, and skin and soft-tissue infection—represent 1% of all conditions yet accounted for more than 10% of all antibiotic use. Wide variability in antibiotic use occurred for 3 of these 4 conditions.

Antibiotic use in children's hospitals varied broadly across institutions when examining diagnoses individually and adjusting for severity of illness. Identifying conditions with both frequent and variable antimicrobial use informs the prioritization of high-impact targets for future antimicrobial stewardship interventions.

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

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

An observational study with a planned intervention.

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

Patients admitted during the study period.

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

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

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

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