To evaluate three different DNA techniques for typing nonfermentative gram-negative bacilli isolated from Latin American hospitals.

One hundred twenty-six nonfermentative gram-negative bacilli were typed.

Pseudomonas aeruginosa (n = 64) and Acinetobacter baumannii (n = 42) samples were obtained from blood cultures of patients admitted to 10 medical centers in Latin America during 1998 and Stenotrophomonas maltophilia (n = 20) samples were obtained from patients admitted to the Hospital São Paulo between 1999 and 2001.

All samples were typed using automated ribotyping, PFGE, and ERIC-PCR. The discriminatory power for each technique was calculated using Hunter's generalized formula.

All strains could be typed by automated ribotyping and ERIC-PCR, but two strains (1.6%) were not typeable by PFGE. All three techniques showed 100% reproducibility. The time to obtain the results was shorter for automated ribotyping and ERIC-PCR compared with PFGE. Likewise, the costs for ERIC-PCR and PFGE were lower than those for automated ribotyping. The interpretation of results was more complicated and more difficult with ERIC-PCR than with both PFGE and automated ribotyping. All techniques presented excellent discriminatory power for P. aeruginosa (0.98). PFGE presented the highest discriminatory power (0.94) for A. baumannii, and both PFGE and ERIC-PCR showed higher discriminatory power (0.90 for both) than automated ribotyping (0.82) for S. maltophilia.

PFGE showed the highest discriminatory power for typing these nonfermentative gram-negative bacilli. However, automated ribotyping and ERIC-PCR can provide results in a shorter time period with similar discriminatory power.

Limited data on the risk of peripherally inserted central venous catheter-associated bloodstream infections (PICC BSIs) in hospitalized patients are available. In 2007, dedicated intravenous therapy nurses were no longer available to place difficult peripheral intravenous catheters or provide PICC care Barnes-Jewish Hospital.

To determine the hospital-wide incidence of PICC BSIs and to assess the effect of discontinuing intravenous therapy service on PICC use and PICC BSI rates.

A 1,252-bed tertiary care teaching hospital.

A 31-month retrospective cohort study was performed. PICC BSIs were defined using National Healthcare Safety Network criteria.

In total, 163 PICC BSIs were identified (3.13 BSIs per 1,000 catheter-days). PICC use was higher in intensive care units (ICUs) than non-ICU areas (PICC utilization ratio, 0.109 vs 0.059 catheter-days per patient-day for ICU vs non-ICU; rate ratio [RR], 1.84 [95% confidence interval {CI}, 1.78-1.91]). PICC BSI rates were higher in ICUs (4.79 vs 2.79 episodes per 1,000 catheter-days; RR, 1.7 [95% CI, 1.10-2.61]). PICC use increased hospital-wide after the intravenous therapy service was discontinued (0.049 vs 0.097 catheter-days per patient-day; P = .01), but PICC BSI rates did not change (2.68 vs 3.63 episodes per 1,000 catheter-days; P = .06). Of PICC BSIs, 73% occurred in non-ICU patients.

PICC use and PICC BSI rates were higher in ICUs; however, most of the PICC BSIs occurred in non-ICU areas. Reduction in intravenous therapy services was associated with increased PICC use across the hospital, but PICC BSI rates did not increase.

Clostridium difficile infection (CDI) places a high burden on the US healthcare system. Recurrent CDI (RCDI) occurs frequently. Recently proposed guidelines from the American College of Gastroenterology (ACG) and the American Gastroenterology Association (AGA) include fecal microbiota transplantation (FMT) as a therapeutic option for RCDI. The purpose of this study was to estimate the cost-effectiveness of FMT compared with vancomycin for the treatment of RCDI in adults, specifically following guidelines proposed by the ACG and AGA.

We constructed a decision-analytic computer simulation using inputs from the published literature to compare the standard approach using tapered vancomycin to FMT for RCDI from the third-party payer perspective. Our effectiveness measure was quality-adjusted life years (QALYs). Because simulated patients were followed for 90 days, discounting was not necessary. One-way and probabilistic sensitivity analyses were performed.

Base-case analysis showed that FMT was less costly ($1,669 vs $3,788) and more effective (0.242 QALYs vs 0.235 QALYs) than vancomycin for RCDI. One-way sensitivity analyses showed that FMT was the dominant strategy (both less expensive and more effective) if cure rates for FMT and vancomycin were ≥70% and <91%, respectively, and if the cost of FMT was <$3,206. Probabilistic sensitivity analysis, varying all parameters simultaneously, showed that FMT was the dominant strategy over 10, 000 second-order Monte Carlo simulations.

Our results suggest that FMT may be a cost-saving intervention in managing RCDI. Implementation of FMT for RCDI may help decrease the economic burden to the healthcare system.

Infect Control Hosp Epidemiol 2014;00(0): 1–7

Hand hygiene is the core element of infection prevention and control. The optimal hand-hygiene gesture, however, remains poorly defined.

We aimed to evaluate the influence of hand-rubbing duration on the reduction of bacterial counts on the hands of healthcare personnel (HCP).

We performed an experimental study based on the European Norm 1500. Hand rubbing was performed for 10, 15, 20, 30, 45, or 60 seconds, according to the WHO technique using 3 mL alcohol-based hand rub. Hand contamination with E. coli ATCC 10536 was followed by hand rubbing and sampling. A generalized linear mixed model with a random effect on the subject adjusted for hand size and gender was used to analyze the reduction in bacterial counts after each hand-rubbing action. In addition, hand-rubbing durations of 15 and 30 seconds were compared to assert non-inferiority (0.6 log10).

In total, 32 HCP performed 123 trials. All durations of hand rubbing led to significant reductions in bacterial counts (P<.001). Reductions achieved after 10, 15, or 20 seconds of hand rubbing were not significantly different from those obtained after 30 seconds. The mean bacterial reduction after 15 seconds of hand rubbing was 0.11 log10 lower (95% CI, −0.46 to 0.24) than after 30 seconds, demonstrating non-inferiority.

Hand rubbing for 15 seconds was not inferior to 30 seconds in reducing bacterial counts on hands under the described experimental conditions. There was no gain in reducing bacterial counts from hand rubbing longer than 30 seconds. Further studies are needed to assess the clinical significance of our findings.

Infect Control Hosp Epidemiol 2017;38:547–552

Antimicrobial use in hospitalized children has not been well described. To identify targets for antimicrobial stewardship interventions, we retrospectively examined pediatric utilization rates for 48 antimicrobials from 2007 to 2010 as well as appropriateness of vancomycin and cefepime use in 2010.

All children hospitalized between 2007 and 2010 at the Mayo Clinic Children's Hospital, a 120-bed facility within a larger adult hospital in Rochester, Minnesota.

We calculated antimicrobial utilization rates in days of therapy per 1,000 patient-days. Details of vancomycin and cefepime use in 2010 were abstracted by chart review. Two pediatric infectious disease physicians independently assessed appropriateness of antibiotic use.

From 2007 to 2010, 9,880 of 17,242 (57%) hospitalized children received 1 or more antimicrobials. Antimicrobials (days of therapy per 1,000 patient-days) used most frequently in 2010 were cefazolin (97.8), vancomycin (97.1), fluconazole (76.4), piperacillin-tazobactam (70.7), and cefepime (67.6). Utilization rates increased significantly from 2007 to 2010 for 10 antimicrobials, including vancomycin, fluconazole, piperacillin-tazobactam, cefepime, trimethoprim-sulfamethoxazole, caspofungin, and cefotaxime. In 2010, inappropriate use of vancomycin and cefepime was greater in the pediatric intensive care unit than ward (vancomycin: 17.8% vs 6.4%, P = .001; cefepime: 9.2% vs 3.9%, P = .142) and on surgical versus medical services (vancomycin: 20.5% vs 8.0%, P = .001; cefepime: 19.4% vs 3.4%, P ≤ .001). The most common reason for inappropriate antibiotic use was failure to discontinue or de-escalate therapy.

In our children's hospital, use of 10 antimicrobials increased during the study period. Inappropriate use of vancomycin and cefepime was greatest on the critical care and surgical services, largely as a result of failure to de-escalate therapy, suggesting targets for future antimicrobial stewardship interventions.

To evaluate antimicrobial utilization and prescription practices in a neonatal intensive care unit (NICU) after implementation of an antimicrobial stewardship program (ASP).

Quasi-experimental, interrupted time-series study.

A 54-bed, level IV NICU in a regional academic and tertiary referral center.

All neonates prescribed antimicrobials from January 1, 2011, to June 30, 2016, were eligible for inclusion.

Implementation of a NICU-specific ASP beginning July 2012.

We convened a multidisciplinary team and developed guidelines for common infections, with a focus on prescriber audit and feedback. We conducted an interrupted time-series analysis to evaluate the effects of our ASP. Our primary outcome measure was days of antibiotic therapy (DOT) per 1,000 patient days for all and for select antimicrobials. Secondary outcomes included provider-specific antimicrobial prescription events for suspected late-onset sepsis (blood or cerebrospinal fluid infection at >72 hours of life) and guideline compliance.

Antibiotic utilization decreased by 14.7 DOT per 1,000 patient days during the stewardship period, although this decrease was not statistically significant (P=.669). Use of ampicillin, the most commonly antimicrobial prescribed in our NICU, decreased significantly, declining by 22.5 DOT per 1,000 patient days (P=.037). Late-onset sepsis evaluation and prescription events per 100 NICU days of clinical service decreased significantly (P<.0001), with an average reduction of 2.65 evaluations per year per provider. Clinical guidelines were adhered to 98.75% of the time.

Implementation of a NICU-specific antimicrobial stewardship program is feasible and can improve antibiotic prescribing practices.

Infect Control Hosp Epidemiol 2017;38:1137–1143

To evaluate the use of routinely collected electronic health data in Medicare claims to identify surgical site infections (SSIs) following hip arthroplasty, knee arthroplasty, and vascular surgery.

Retrospective cohort study.

Four academic hospitals that perform prospective SSI surveillance.

We developed lists of International Classification of Diseases, Ninth Revision, and Current Procedural Terminology diagnosis and procedure codes to identify potential SSIs. We then screened for these codes in Medicare claims submitted by each hospital on patients older than 65 years of age who had undergone 1 of the study procedures during 2007. Each site reviewed medical records of patients identified by either claims codes or traditional infection control surveillance to confirm SSI using Centers for Disease Control and Prevention/ National Healthcare Safety Network criteria. We assessed the performance of both methods against all chart-confirmed SSIs identified by either method.

Claims-based surveillance detected 1.8–4.7-fold more SSIs than traditional surveillance, including detection of all previously identified cases. For hip and vascular surgery, there was a 5-fold and 1.6-fold increase in detection of deep and organ/space infections, respectively, with no increased detection of deep and organ/space infections following knee surgery. Use of claims to trigger chart review led to confirmation of SSI in 1 out of 3 charts for hip arthroplasty, 1 out of 5 charts for knee arthroplasty, and 1 out of 2 charts for vascular surgery.

Claims-based SSI surveillance markedly increased the number of SSIs detected following hip arthroplasty, knee arthroplasty, and vascular surgery. It deserves consideration as a more effective approach to target chart reviews for identifying SSIs.

Infect Control Hosp Epidemiol 2012;33(1):40-49

To examine the relationship between nurse staffing levels and the rate of nosocomial viral gastrointestinal infections (NVGIs) in a general pediatrics population.

Retrospective descriptive study.

A general pediatrics ward at The Hospital for Sick Children in Toronto, Ontario, Canada, a 320-bed, tertiary-care pediatric institution.

Forty-three NVGIs were detected in 37 patients of 2,929 admissions (1.3%). The monthly NVGI rate correlated significantly with the monthly night patient-to-nurse ratio (r = 0.56) and the monthly day patient-to-nurse ratio (r = 0.50). The nursing hours per patient-day during the preinfection period (PIP) were significantly lower than those during the nonpreinfection period (NPIP; 12.5 vs 13.0). There was no difference between the PIP and the NPIP day patient-to-nurse ratios (3.31 vs 3.32), but there was a significant difference between the PIP and the NPIP night patient-to-nurse ratios (3.26 vs 3.16). The incidence of NVGIs in the 72-hour period after any day when the nursing hours per patient-day were less than 10.5 was 6.39 infections per 1,000 patient-days, compared with 2.17 infections per 1,000 patient-days in periods with more than 10.5 nursing hours per patient-day (rate ratio, 2.94; 95% confidence interval, 2.16 to 4.01).

Nurse understaffing contributed to an increased NVGI rate in our general pediatrics population, and should be assessed as a risk factor in outbreak investigations.

TO apply interim surveillance definitions of Clostridium difficile infection (CDI) cases to 1 year of data from the provincewide surveillance system of Manitoba, Canada, to determine the epidemiology of CDI incident cases in a population.

CDI cases were categorized with interim surveillance definitions developed by an ad hoc C. difficile surveillance working group. Incident cases recorded in the provincial CDI database between July 2005 and June 2006 were linked to the provincial hospitalization and nursing home databases and analyzed.

One thousand six incident cases were identified over 1 year. Five hundred fifteen (51%) cases were associated with and began in a healthcare facility (HCF), whereas 275 (27%) were associated with and began in the community. An additional 131 (13%) cases were HCF associated but began in the community, while 85 (8%) were of indeterminate origin. Cases of HCF-associated CDI occurred in patients who were older than did cases of community-associated CDI (P < .0001). The provincial rate of community-onset cases was 23.4 per 100,000 person-years, and rates varied among geographic areas. HCF-associated CDI rates among the 10 largest hospitals varied from 0.5 to 8.4 per 10,000 patient-days. The time to CDI onset after hospital admission indicated that 25% of nosocomial cases began by the 8th day, and 50% began by the 17th day.

Although the majority of CDI cases were associated with exposure to a HCF, 40% of incident CDI began in the community. Populations with HCF- and community-associated CDI demonstrated significantly different age distributions. The wide variation of rates among HCFs requires explanation. The high percentage of incident cases in the community warrants increased study.

To determine trends, patient characteristics, and outcome of patients with healthcare-associated influenza in Canadian hospitals.

Prospective surveillance of laboratory-confirmed influenza among hospitalized adults was conducted from 2006 to 2012. Adults with positive test results at or after admission to the hospital were assessed. Influenza was considered to be healthcare associated if symptom onset was equal to or more than 96 hours after admission to a facility or if a patient was readmitted less than 96 hours after discharge or admitted less than 96 hours after transfer from another facility. Baseline characteristics of influenza patients were collected. Patients were reassessed at 30 days to determine the outcome.

Acute care hospitals participating in the Canadian Nosocomial Infection Surveillance Program.

A total of 570 (17.3%) of 3,299 influenza cases were healthcare associated; 345 (60.5%) were acquired in a long-term care facility (LTCF), and 225 (39.5%) were acquired in an acute care facility (ACF). There was year-to-year variability in the rate and proportion of cases that were healthcare associated and variability in the proportion that were acquired in a LTCF versus an ACF. Patients with LTCF-associated cases were older, had a higher proportion of chronic heart disease, and were less likely to be immunocompromised compared with patients with ACF-associated cases; there was no significant difference in 30-day all-cause and influenza-specific mortality.

Healthcare-associated influenza is a major component of the burden of disease from influenza in hospitals, but the proportion of cases that are healthcare associated varies markedly from year to year, as does the proportion of healthcare-associated infections that are acquired in an ACF versus an LTCF.

Diagnosing ventilator-associated pneumonia (VAP) is difficult, and misdiagnosis can lead to unnecessary and prolonged antibiotic treatment. We sought to quantify and characterize unjustified antimicrobial use for VAP and identify risk factors for continuation of antibiotics in patients without VAP after 3 days.

Patients suspected of having VAP were identified in 6 adult intensive care units (ICUs) over 1 year. A multidisciplinary adjudication committee determined whether the ICU team's VAP diagnosis and therapy were justified, using clinical, microbiologic, and radiographic data at diagnosis and on day 3. Outcomes included the proportion of VAP events misdiagnosed as and treated for VAP on days 1 and 3 and risk factors for the continuation of antibiotics in patients without VAP after day 3.

Two hundred thirty-one events were identified as possible VAP by the ICUs. On day 1, 135 (58.4%) of them were determined to not have VAP by the committee. Antibiotics were continued for 120 (76%) of 158 events without VAP on day 3. After adjusting for acute physiology and chronic health evaluation II score and requiring vasopressors on day 1, sputum culture collection on day 3 was significantly associated with antibiotic continuation in patients without VAP. Patients without VAP or other infection received 1,183 excess days of antibiotics during the study.

Overdiagnosis and treatment of VAP was common in this study and led to 1,183 excess days of antibiotics in patients with no indication for antibiotics. Clinical differences between non-VAP patients who had antibiotics continued or discontinued were minimal, suggesting that clinician preferences and behaviors contribute to unnecessary prescribing.

We describe the efficacy of enhanced infection control measures, including those recommended in the Centers for Disease Control and Prevention’s 2012 carbapenem-resistant Enterobacteriaceae (CRE) toolkit, to control concurrent outbreaks of carbapenemase-producing Enterobacteriaceae (CPE) and extensively drug-resistant Acinetobacter baumannii (XDR-AB).

Before-after intervention study.

Fifteen-bed surgical trauma intensive care unit (ICU).

We investigated the impact of enhanced infection control measures in response to clusters of CPE and XDR-AB infections in an ICU from April 2009 to March 2010. Polymerase chain reaction was used to detect the presence of blaKPC and resistance plasmids in CRE. Pulsed-field gel electrophoresis was performed to assess XDR-AB clonality. Enhanced infection-control measures were implemented in response to ongoing transmission of CPE and a new outbreak of XDR-AB. Efficacy was evaluated by comparing the incidence rate (IR) of CPE and XDR-AB before and after the implementation of these measures.

The IR of CPE for the 12 months before the implementation of enhanced measures was 7.77 cases per 1,000 patient-days, whereas the IR of XDR-AB for the 3 months before implementation was 6.79 cases per 1,000 patient-days. All examined CPE shared endemic blaKPC resistance plasmids, and 6 of the 7 XDR-AB isolates were clonal. Following institution of enhanced infection control measures, the CPE IR decreased to 1.22 cases per 1,000 patient-days (P = .001), and no more cases of XDR-AB were identified.

Use of infection control measures described in the Centers for Disease Control and Prevention’s 2012 CRE toolkit was associated with a reduction in the IR of CPE and an interruption in XDR-AB transmission.

The spread of antibiotic-resistant pathogens represents an increasing threat in healthcare facilities. Concern has been expressed that the use of surface disinfectants and antiseptics may select for antibiotic-resistant pathogens.

To review the scientific literature on whether there is a link between use of germicides (ie, disinfectants and antiseptics) and bacterial resistance to antibiotics. In addition, we will review whether antibiotic-resistant bacteria exhibit altered susceptibility to germicides that are recommended for use as disinfectants or antiseptics.

A review of the appropriate scientific literature.

In the laboratory, it has been possible to develop bacterial mutants with reduced susceptibility to disinfectants and antiseptics that also demonstrate decreased susceptibility to antibiotics. However, the antibiotic resistance described was not clinically relevant because the test organism was rarely a human pathogen, the altered level of antimicrobial susceptibility was within achievable serum levels for the antibiotic, or the antibiotic tested was not clinically used to treat the study pathogen. Similarly, wild-type strains with reduced susceptibility to disinfectants (principally, quaternary ammonium compounds) and antiseptics (principally, triclosan) have been reported. However, because the concentration of disinfectants used in the healthcare setting greatly exceeds the concentration required to kill strains with reduced susceptibility to disinfectants, the clinical relevance of these observations is questionable.

To date, there is no evidence that using recommended antiseptics or disinfectants selects for antibiotic-resistant organisms in nature. Disinfectants and antiseptics should be used when there are scientific studies demonstrating benefit or when there is a strong theoretical rationale for using germicides.

To validate the utility of a previously published scoring model (Italian) to identify patients infected with community-onset extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-EKP) and develop a new model (Duke) based on local epidemiology.

This case-control study included patients 18 years of age or more admitted to Duke University Hospital between January 1, 2008, and December 31, 2010, with culture-confirmed infection due to an ESBL-EKP (cases). Uninfected controls were matched to cases (3 : 1). The Italian model was applied to our patient population for validation. The Duke model was developed through logistic-regression-based prediction scores calculated on variables independently associated with ESBL-EKP isolation. Sensitivities and specificities at various point cutoffs were determined, and determination of the area under the receiver operating characteristic curve (ROC AUC) was performed.

A total of 123 cases and 375 controls were identified. Adjusted odds ratios and 95% confidence intervals for variables previously identified in the Italian model were as follows: hospitalization (3.20 [1.62–6.55]), transfer (4.31 [2.15–8.78]), urinary catheterization (5.92 [3.09–11.60]), β-lactam and/or fluoroquinolone therapy (3.76 [2.06–6.95]), age 70 years or more (1.55 [0.79–3.01]), and Charlson Comorbidity Score of 4 or above (1.06 [0.55–2.01]). Sensitivity and specificity were, respectively, more than or equal to 95% and less than or equal to 47% for scores 3 or below and were less than or equal to 50% and more than or equal to 96% for scores 8 or above. The ROC AUC was 0.88. Variables identified in the Duke model were as follows: hospitalization (2.63 [1.32–5.41]), transfer (5.30 [2.67–10.71]), urinary catheterization (6.89 [3.62–13.38]), β-lactam and/or fluoroquinolone therapy (3.47 [1.91–6.41]), and immunosuppression (2.34 [1.14–4.80]). Sensitivity and specificity were, respectively, more than or equal to 94% and less than or equal to 65% for scores 3 or below and were less than or equal to 58% and more than or equal to 95% for scores 8 or above. The ROC AUC was 0.89.

While the previously reported model was an excellent predictor of community-onset ESBL-EKP infection, models utilizing factors based on local epidemiology may be associated with improved performance.

To investigate the potential reservoir and mode of transmission of pandrug-resistant (PDR) Acinetobacter baumannii in a 7-day-old neonate who developed PDR A. baumannii bacteremia that was presumed to be the iceberg of a potential outbreak.

Outbreak investigation based on a program of prospective hospital-wide surveillance for nosocomial infection.

A 24-bed neonatal intensive care unit in a 2,200-bed major teaching hospital in Taiwan that provides care for critically ill neonates born in this hospital and those transferred from other hospitals.

Samples from 33 healthcare workers' hands and 40 samples from the environment were cultured. Surveillance cultures of anal swab specimens and sputum samples were performed for neonates on admission to the neonatal intensive care unit and every 2 weeks until discharge. The PDR A. baumannii isolates, defined as isolates resistant to all currently available systemic antimicrobials except polymyxin B, were analyzed by pulsed-field gel electrophoresis. Control measures consisted of implementing contact isolation, reinforcing hand hygiene adherence, cohorting of nurses, and environmental cleaning.

One culture of an environmental sample and no cultures of samples from healthcare workers' hands grew PDR A. baumannii. The positive culture result involved a sample obtained from a ventilation tube used by the index patient. During the following 2 months, active surveillance identified PDR A. baumannii in 8 additional neonates, and isolates from 7 had the same electrokaryotype. Of the 9 neonates colonized or infected with PDR A. baumannii, 1 died from an unrelated condition. Reinforcement of infection control measures resulted in 100% adherence to proper hand hygiene protocol. The outbreak was stopped without compromising patient care.

In the absence of environmental contamination, transient hand carriage by personnel who cared for neonates colonized or infected with PDR A. baumannii was suspected to be the mode of transmission. Vigilance, prompt intervention and strict adherence to hand hygiene protocol were the key factors that led to the successful control of this outbreak. Active surveillance appears to be an effective measure to identify potential transmitters and reservoirs of PDR A. baumannii.