To evaluate the effect of education and performance feedback regarding compliance with catheter care and handwashing on rates of catheter-associated urinary tract infection (UTI) in intensive care units (ICUs).

Two level III adult ICUs in a private healthcare facility in Argentina.

All adult patients admitted to the study units who had a urinary catheter in place for at least 24 hours.

A prospective, open trial in which rates of catheter-associated UTI determined during a baseline period of active surveillance without education and performance feedback were compared with rates of catheter-associated UTI after imple-menting education and performance feedback.

There were 1,779 catheter-days during the baseline period and 5,568 catheter-days during the intervention period. Compliance regarding prevention of compression of the tubing by a leg improved (from 83% to 96%; relative risk [RR], 1.15; 95% confidence interval [CI95], 1.03 to 1.28; P = .01) and so did compliance with handwashing (from 23.1% to 65.2%; RR, 2.82; CI95, 2.49 to 3.20; P<.0001). Catheter-associated UTI rates decreased significantly from 21.3 to 12.39 per 1,000 catheter-days (RR, 0.58; CI95, 0.39 to 0.86; P = .006).

Implementing education and performance feedback regarding catheter care measures and handwashing compliance was associated with a significant reduction in catheter-associated UTI rates. Similar programs may help reduce catheter-associated UTI rates in other Latin American hospitals.

The use of sterile gloves is part of general aseptic procedure, which aims to prevent surgical team members from transmitting infectious agents to patients during procedures performed in an operating room. In addition, surgical gloves also protect team members against patient-transmitted infectious agents. Adequate protection, however, requires that the glove material remain intact. The risk of perforations in surgical gloves is thought to correlate with the duration of wear, yet very few prospective studies have addressed this issue.

We prospectively collected 898 consecutive pairs of used surgical gloves over a 9-month period in a single institution. After surgical team members wore the gloves during surgical procedures, the gloves were examined for microperforations using the watertight test described in European Norm 455, part 1. The gloves were analyzed as a pair; if 1 glove had a perforation, the pair was considered to be perforated. In addition, we evaluated the use of a hand cream that contained a suspension of cornstarch and ethanol to determine its potential influence on the rate of microperforation.

Wearing gloves for 90 minutes or less resulted in microperforations in 46 (15.4%) of 299 pairs of gloves, whereas wearing gloves for 91-150 minutes resulted in perforation of 54 (18.1%) of 299 pairs, and 71 of (23.7%) of 300 pairs were perforated when the duration of wear was longer than 150 minutes (P = .05). Subgroup analysis revealed no significant difference in the rates of microperforation for surgeons (56 [23.0%] of 244 pairs of gloves perforated), first assistants (43 [19.0%] of 226 pairs perforated), and surgical nurses (53 [20.5%] of 259 pairs perforated). Of 171 microperforations, 114 (66.7%) were found on the left hand glove (ie, the glove on subjects' nondominant hand), predominantly on the left index finger (55 [32.3%]). The use of the hand cream had no influence on the rate of microperforation.

Because of the increase in the rate of microperforation over time, it is recommended that surgeons, first assistants, and surgical nurses directly assisting in the operating field change gloves after 90 minutes of surgery.

To describe an outbreak of serious nosocomial Burkholderia cepacia infections occurring after transrectal prostate biopsy associated with ultrasound gel intrinsically contaminated with paraben-degrading microorganisms.

A retrospective chart review prompted by a blood culture isolate of B, cepacia. Identification of microorganisms in ultrasound gel in two Canadian centers and characterization by pulsed-field gel electrophoresis and assays for paraben degradation.

Two Canadian university-affiliated, tertiary-care centers in Newfoundland and Alberta.

Six serious B. cepacia infections were identified at the two centers. Isolates of B. cepacia recovered from the blood of patients from both centers and the ultrasound gel used during the procedures were identical, confirming intrinsic contamination. Strains of Enterobacter cloacae isolated from ultrasound gel at the two centers were also identical. The ability to degrade parabens was proven for both B. cepacia and E. cloacae strains recovered from the ultrasound gel.

Ultrasound gel is a potential source of infection. Contamination occurs at the time of manufacture, with organisms that degrade parabens, which are commonly used as stabilizing agents. There are far-reaching implications for the infection control community.

To study postoperative infections in hospital and after discharge, and to identify the risk factors for such infections.

Prospective cohort study, with telephone follow-up for 1 month after hospital discharge.

The general surgery service of a tertiary hospital in Spain.

In-hospital and postdischarge surgical-site infection (SSI), always confirmed by a physician.

Of the 1,506 patients initially enrolled, 29 died during hospital stay, and 33 were lost to postdischarge follow-up. An SSI was identified prior to discharge in 123 patients and after discharge in 103. For several variables (age, serum albumin, glycemia, lengths of preoperative and postoperative hospital stay, etc), there were no differences between patients with postdischarge SSI and noninfected patients; however, there were differences detected between patients with postdischarge SSI and in-hospital SSI, as well as between patients with in-hospital SSI and noninfected patients. The analysis of risk factors showed that most predictors for in-hospital SSI did not behave in the same manner for postdischarge SSI. Stepwise logistic regression only identified chemoprophylaxis, age (advanced age was a preventive factor), and body mass index as independent risk factors for postdischarge SSI. Differences in risk factors between in-hospital and postdischarge SSIs remained even after controlling for time from operation to diagnosis.

Most predictors of in-hospital SSI were not predictors of postdischarge SSI.

Most hospitals in the United States do not perform active surveillance cultures and, thus, rely on clinical microbiological cultures (CMCs) to identify patients colonized with methicillin-resistant Staphylococcus aureus (MRSA). We sought to determine what proportion of patients who are colonized with MRSA at admission are identified by CMCs during hospitalization.

From February 1998 through November 2002, patients found to be colonized with MRSA at admission by use of active surveillance cultures were identified. The proportion of colonized patients who had a CMC that was positive for MRSA, the number of CMCs performed and their type (ie, according to the anatomical site from which specimens were obtained for culture), and the number and type of CMCs that were positive for MRSA were calculated.

Four hundred thirty-seven patients were found to be colonized with MRSA at admission, and 98 of 1,238 CMCs (7.9%; 95% confidence interval, 6.5%-9.6%) performed for 66 of these patients (15%; 95% confidence interval, 11.9%-18.8%) were positive for MRSA. The number of nonisolated days that would have occurred by relying on CMCs to identify MRSA-colonized patients was 3,247 (mean, 7.4 days per patient). Among the anatomical sites from which specimens were obtained for CMC, wounds demonstrated the highest sensitivity (30.2%) for identifying MRSA-colonized patients.

CMCs failed to identify 85% of MRSA-colonized patients, because, in part, CMCs identified only a small proportion of colonized patients. Because many studies have shown a decrease in the transmission of MRSA from colonized patients for whom contact precautions, rather than standard precautions, are used, the findings of this study suggest that failure to identify colonized patients and to use contact precautions may be an important reason for the increasing rate of nosocomial MRSA infection in hospitals in the United States.

Previous work has shown that daily skin cleansing with Chlorhexidine gluconate (CHG) is effective in preventing infection in the medical intensive care unit (MICU). A colorimetric, semiquantitative indicator was used to measure CHG concentration on skin (neck, antecubital fossae, and inguinal areas) of patients bathed daily with CHG during their MICU stay and after discharge from the MICU, when CHG bathing stopped.

MICU patients at Rush University Medical Center.

CHG concentration on skin was measured and skin sites were cultured quantitatively. The relationship between CHG concentration and microbial density on skin was explored in a mixed-effects model using gram-positive colony-forming unit (CFU) counts.

For 20 MICU patients studied (240 measurements), the lowest CHG concentrations (0–18.75 μg/mL) and the highest gram-positive CFU counts were on the neck (median, 1.07 log10 CFUs; P = .014). CHG concentration increased postbath and decreased over 24 hours (P < .001). In parallel, median log10 CFUs decreased pre- to postbath (0.78 to 0) and then increased over 24 hours to the baseline of 0.78 (P = .001). A CHG concentration above 18.75 μg/mL was associated with decreased gram-positive CFUs (P = .004). In all but 2 instances, CHG was detected on patient skin during the entire interbath (approximately 24-hour) period (18 [90%] of 20 patients). In 11 patients studied after MICU discharge (80 measurements), CHG skin concentrations fell below effective levels after 1–3 days.

In MICU patients bathed daily with CHG, CHG concentration was inversely associated with microbial density on skin; residual antimicrobial activity on skin persisted up to 24 hours. Determination of CHG concentration on the skin of patients may be useful in monitoring the adequacy of skin cleansing by healthcare workers.

To compare incidence rates of Clostridium difficile infection (CDI) during a 6-year period among 5 geographically diverse academic medical centers across the United States by use of recommended standardized surveillance definitions of CDI that incorporate recent information on healthcare facility (HCF) exposure.

Data on C. difficile toxin assay results and dates of hospital admission and discharge were collected from electronic databases. Chart review was performed for patients with a positive C. difficile toxin assay result who were identified within 48 hours after hospital admission to determine whether they had any HCF exposure during the 90 days prior to their hospital admission. CDI cases, defined as any inpatient with a stool toxin assay positive for C. difficile, were categorized into 5 surveillance definitions based on recent HCF exposure. Annual CDI rates were calculated and evaluated by use of the χ2 test for trend and the χ2 summary test.

During the study period, there were significant increases in the overall incidence rates of HCF-onset, HCF-associated CDI (from 7.0 to 8.5 cases per 10,000 patient-days; P < .001); community-onset, HCF-associated CDI attributed to a study hospital (from 1.1 to 1.3 cases per 10,000 patient-days; P = .003); and community-onset, HCF-associated CDI not attributed to a study hospital (from 0.8 to 1.5 cases per 1,000 admissions overall; P < .001). For each surveillance definition of CDI, there were significant differences in the total incidence rate between HCFs.

The increasing incidence rates of CDI over time and across healthcare institutions and the correlation of CDI incidence in different surveillance categories suggest that CDI may be a regional problem and not isolated to a single HCF within a community.

To review evidence regarding the effectiveness of control measures in reducing transmission of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals.

Literature review and surveillance cultures of hospitalized patients at high risk for MRSA colonization or infection.

A 500-bed, university-affiliated, community teaching hospital.

The percentage of nosocomial S. aureus infections caused by MRSA increased significantly between 1982 and 2002, despite the use of various isolation and barrier precaution policies. The apparent ineffectiveness of control measures may be due to several factors including the failure to identify patients colonized with MRSA For example, cultures of stool specimens submitted for Clostridium difficile toxin assays at one hospital found that 12% of patients had MRSA in their stool, and 41% of patients with unrecognized colonization were cared for without using barrier precautions. Other factors include the use of barrier precaution strategies that do not account for multiple reservoirs of MRSA, poor adherence of healthcare workers (HCWs) to recommended barrier precautions and handwashing, failure to identify and treat HCWs responsible for transmitting MRSA, and importation of MRSA by patients admitted from other facilities. Control programs that include active surveillance cultures (ASCs) of high-risk patients and use of barrier precautions have reduced MRSA prevalence rates and have been cost-effective. Using a staged approach to implementing ASCs can minimize logistic problems.

MRSA control programs are effective if they include ASCs of high-risk patients, use of barrier precautions when caring for colonized or infected patients, hand hygiene, and treating HCWs implicated in MRSA transmission.

Some policy makers have embraced public reporting of healthcare-associated infections (HAIs) as a strategy for improving patient safety and reducing healthcare costs. We compared the accuracy of 2 methods of identifying cases of HAI: review of administrative data and targeted active surveillance.

A cross-sectional prospective study was performed during a 9-month period in 2004 at the Children's Hospital of Philadelphia, a 418-bed academic pediatric hospital. “True HAI” cases were defined as those that met the definitions of the National Nosocomial Infections Surveillance System and that were detected by a trained infection control professional on review of the medical record. We examined the sensitivity and the positive and negative predictive values of identifying HAI cases by review of administrative data and by targeted active surveillance.

We found similar sensitivities for identification of HAI cases by review of administrative data (61%) and by targeted active surveillance (76%). However, the positive predictive value of identifying HAI cases by review of administrative data was poor (20%), whereas that of targeted active surveillance was 100%.

The positive predictive value of identifying HAI cases by targeted active surveillance is very high. Additional investigation is needed to define the optimal detection method for institutions that provide HAI data for comparative analysis.

To determine the costs of the interventions aimed at controlling the 4-month outbreak and to determine the attributable length of stay (LOS) associated with infection and colonization with extended-spectrum beta-lactamase-producing Klebsiella pneumoniae.

A retrospective cost analysis was conducted from the hospital perspective. A micro-costing approach was employed. The LOS of four groups of hospitalized patients were compared with each other. National Perinatal Information Center criteria were used to stratify infants for severity of risk. The LOS of each group was compared with that of a national sample of similarly stratified infants.

A level III-IV, 45-bed neonatal intensive care unit.

Infant groups were infected (n = 8), colonized (n = 14), concurrent cohort (n = 54), and prior cohort (n = 486).

The cost of the outbreak totaled $341,751. The largest proportion of costs was related to healthcare worker time providing direct patient care (2,489 hours at a cost of $146,331). Infected and colonized neonates had longer LOS than either the concurrent cohort or the prior cohort (P < .001). Compared with the national sample, infected infants had a 48.5-day longer mean LOS (95% confidence interval [CI95], 1.7 to 95.2), whereas the prior cohort's mean LOS was 6 days shorter (CI95, -9.4 to -2.9).

This study increases the understanding of the burden of these multidrug-resistant organisms. Further research is needed to estimate the societal costs of these infections and the cost-effectiveness of preventive interventions.

To describe an outbreak of imipenem-resistant Acinetobacter baumannii (IR-Ab) and the measures for its control, and to investigate risk factors for IR-Ab acquisition.

An observational and a case-control study.

A surgical intensive care unit (ICU) in a university tertiary care hospital.

After admission to the ICU of an IR-Ab-positive patient, patients were prospectively screened for IR-Ab carriage upon admission and then once a week. Environmental cleaning and barrier safety measures were used for IR-Ab carriers. A case-control study was performed to identify factors associated with IR-Ab acquisition. Cases were patients who acquired IR-Ab. Controls were patients who were hospitalized in the ICU at the same time as cases and were exposed to IR-Ab for a similar duration as cases. The following variables were investigated as potential risk factors: baseline characteristics, scores for severity of illness and therapeutic intervention, presence and duration of invasive procedures, and antimicrobial administration.

Beginning in May 1996, the outbreak involved 17 patients over 9 months, of whom 12 acquired IR-Ab (cases), 4 had IR-Ab isolates on admission to the ICU, and 1 could not be classified. Genotypic analysis identified two different IR-Ab isolates, responsible for three clusters. Ten of the 12 nosocomial cases developed infection. Control measures included reinforcement of barrier safety measures, limitation of the number of admissions, and thorough environmental cleaning. No new case was identified after January 1997. Eleven of the 12 cases could be compared to 19 controls. After adjustment for severity of illness, a high individual therapeutic intervention score appeared to be a risk factor for IR-Ab acquisition.

The outbreak ended after strict application of control measures. Our results suggest that high work load contributes to IR-Ab acquisition.

Staphylococcus aureus is an important cause of infection in intensive care unit (ICU) patients. Colonization with methicillin-resistant S. aureus (MRSA) is a risk factor for subsequent S. aureus infection. However, MRSA-colonized patients may have more comorbidities than methicillin-susceptible S. aureus (MSSA)-colonized or noncolonized patients and therefore may be more susceptible to infection on that basis.

To determine whether MRSA-colonized patients who are admitted to medical and surgical ICUs are more likely to develop any S. aureus infection in the ICU, compared with patients colonized with MSSA or not colonized with S. aureus, independent of predisposing patient risk factors.

Prospective cohort study.

A 24-bed surgical ICU and a 19-bed medical ICU of a 1,252-bed, academic hospital.

A total of 9,523 patients for whom nasal swab samples were cultured for S. aureus at ICU admission during the period from December 2002 through August 2007.

Patients in the ICU for more than 48 hours were examined for an ICU-acquired S. aureus infection, defined as development of S. aureus infection more than 48 hours after ICU admission.

S. aureus colonization was present at admission for 1,433 (27.8%) of 5,161 patients (674 [47.0%] with MRSA and 759 [53.0%] with MSSA). An ICU-acquired S. aureus infection developed in 113 (2.19%) patients, of whom 75 (66.4%) had an infection due to MRSA. Risk factors associated with an ICU-acquired S. aureus infection included MRSA colonization at admission (adjusted hazard ratio, 4.70 [95% confidence interval, 3.07-7.21]) and MSSA colonization at admission (adjusted hazard ratio, 2.47 [95% confidence interval, 1.52-4.01]).

ICU patients colonized with S. aureus were at greater risk of developing a S. aureus infection in the ICU. Even after adjusting for patient-specific risk factors, MRSA-colonized patients were more likely to develop S. aureus infection, compared with MSSA-colonized or noncolonized patients.

To perform active targeted prospective surveillance to measure device-associated infection (DAI) rates, attributable mortality due to DAI, and the microbiological and antibiotic resistance profiles of infecting pathogens at 10 intensive care units (ICUs) in 9 hospitals in Colombia, all of which are members of the International Infection Control Consortium.

We conducted prospective surveillance of healthcare-associated infection in 9 hospitals by using the definitions of the US Centers for Disease Control and Prevention National Nosocomial Surveillance System (NNIS). DAI rates were calculated as the number of infections per 100 ICU patients and per 1,000 device-days.

During the 3-year study, 2,172 patients hospitalized in an ICU for an aggregate duration of 14,603 days acquired 266 DAIs, for an overall DAI rate of 12.2%, or 18.2 DAIs per 1,000 patient-days. Central venous catheter (CVC)–related bloodstream infection (BSI) (47.4% of DAIs; 11.3 cases per 1,000 catheter-days) was the most common DAI, followed by ventilator-associated pneumonia (VAP) (32.3% of DAIs; 10.0 cases per 1,000 ventilator-days) and catheter-associated urinary tract infection (CAUTI) (20.3% of DAIs; 4.3 cases per 1,000 catheter-days). Overall, 65.4% of all Staphylococcus aureus infections were caused by methicillin-resistant strains; 40.0% of Enterobacteriaceae isolates were resistant to ceftriaxone and 28.3% were resistant to ceftazidime; and 40.0% of Pseudomonas aeruginosa isolates were resistant to fluoroquinolones, 50.0% were resistant to ceftazidime, 33.3% were resistant to piperacillin-tazobactam, and 19.0% were resistant to imipenem. The crude unadjusted attributable mortality was 16.9% among patients with VAP (relative risk [RR], 1.93; 95% confidence interval [CI], 1.24-3.00; P = .002); 18.5 among those with CVC-associated BSI (RR, 2.02; 95% CI, 1.42-2.87; P<.001); and 10.5% among those with CAUTI (RR, 1.58; 95% CI, 0.78-3.18; P = .19).

The rates of DAI in the Colombian ICUs were lower than those published in some reports from other Latin American countries and were higher than those reported in US ICUs by the NNIS. These data show the need for more-effective infection control interventions in Colombia.

To evaluate the impact of active screening for methicillin-resistant Staphylococcus aureus (MRSA) on MRSA infection rates and cost avoidance in units where the risk of MRSA transmission is high.

During a 15-month period, all patients admitted to our adult medical and surgical intensive care units (ICUs) were screened for MRSA nasal carriage on admission and weekly thereafter. The overall rates of all MRSA infections and of nosocomial MRSA infection in the 2 adult ICUs and the general wards were compared with rates during the 15-month period prior to the start of routine screening. The percentage of patients colonized or infected with MRSA on admission and the cost avoidance of the surveillance program were also assessed.

The overall rate of MRSA infections for all 3 areas combined decreased from 6.1 infections per 1,000 census-days in the preintervention period to 4.1 infections per 1,000 census-days in the postintervention period (P = .01). The decrease remained statistically significant when only nosocomial MRSA infections were examined (4.5 vs 2.8 infections per 1,000 census-days; P<.01), despite a corresponding increase during the postintervention period in the percentage of patients with onset of MRSA infection in the first 72 hours after admission to the general wards (46% to 81%; P<.005). A total of 3.7% of ICU patients were colonized or infected with MRSA on admission; MRSA would not have been detected in 91% of these patients if screening had not been performed. At a cost of $3,475/month for the program, we averted a mean of 2.5 MRSA infections/month for the ICUs combined, avoiding $19,714/month in excess cost in the ICUs.

Even in a setting of increasing community-associated MRSA, active MRSA screening as part of a multi-factorial intervention targeted to high-risk units may be an effective and cost-avoidant strategy for achieving a sustained decrease of MRSA infections throughout the hospital.

To quantify the economic burden of in-hospital surgical site infections (SSIs) at a European university hospital.

Matched case-control study nested in a prospective observational cohort study.

Basel University Hospital in Switzerland, where an average of 28,000 surgical procedures are performed per year.

All in-hospital occurrences of SSI associated with surgeries performed between January 1, 2000, and December 31, 2001, by the visceral, vascular, and traumatology divisions at Basel University Hospital were prospectively recorded. Each case patient was matched to a control patient by age, procedure code, and National Nosocomial Infection Surveillance System risk index. The case-control pairs were analyzed for differences in cost of hospital care and in provision of specialized care.

A total of 6,283 procedures were performed:187 SSIs were detected in inpatients, 168 of whom were successfully matched with a control patient. For case patients, the mean additional hospital cost was SwF19,638 (95% confidence interval [CI], SwF8,492–SwF30,784); the mean additional postoperative length of hospital stay was 16.8 days (95% CI, 13–20.6 days); and the mean additional in-hospital duration of antibiotic therapy was 7.4 days (95% CI, 5.1–9.6 days). Differences were primarily attributable to organ space SSIs (n = 76).

Ina European university hospital setting, SSIs are costly and constitute a heavy and potentially preventable burden on both patients and healthcare providers.