Observational surveys of hand hygiene compliance are time consuming. Measuring the use of a hand hygiene product is a less time-consuming method of monitoring the frequency of hand hygiene performance.

To evaluate the usefulness of electronic devices for monitoring alcohol-based hand rub use.

Prospective observational trial.

A university-affiliated teaching hospital.

Prototypes of an electronic device designed to record each time a dispenser is used (hereafter referred to as a hand hygiene event) were placed in alcohol-based hand rub dispensers on the general medical ward and in the surgical intensive care unit. Data were downloaded wirelessly to a data logger and then uploaded to a dedicated Web site for analysis. Alcohol-based hand rub dispensers were located in patient rooms and in corridors.

During a 6-month trial, 105,462 hand hygiene events occurred in the surgical intensive care unit, and 44,845 events occurred on the general medical ward. The dispensers located in patient rooms accounted for 47% of the hand hygiene events performed in the surgical intensive care unit but for only 36% of events on the general medical ward (P<.001). The dispensers most often used were located in corridors. Hand hygiene events were most common on Tuesdays, Wednesdays, and Thursdays, between 7:00 AM and 11:00 AM.

The use of these electronic devices provided an efficient and accurate method of monitoring the frequency of alcohol-based hand rub performance on the general medical ward and in the surgical intensive care unit, and yielded more detailed information on usage patterns than did expressing use as liters per 1,000 patient-days. The wireless downloading of data from dispensers required a limited amount of time, and the dedicated Web site facilitated data analysis. Such devices should prove useful in monitoring the impact of various interventions on the frequency of hand hygiene performance.

To investigate whether stratification of the risk of developing a surgical-site infection (SSI) is improved when a logistic regression model is used to weight the risk factors for each procedure category individually instead of the modified NNIS System risk index.

The German Nosocomial Infection Surveillance System, based on NNIS System methodology, has 273 acute care surgical departments participating voluntarily. Data on 9 procedure categories were included (214,271 operations).

For each of the procedure categories, the significant risk factors from the available data (NNIS System risk index variables of ASA score, wound class, duration of operation, and endoscope use, as well as gender and age) were identified by multiple logistic regression analyses with stepwise variable selection. The area under the receiver operating characteristic (ROC) curve resulting from these analyses was used to evaluate the predictive power of logistic regression models.

For most procedures, at least two of the three variables contributing to the NNIS System risk index were shown to be independent risk factors (appendectomy, knee arthroscopy, cholecystectomy, colon surgery, herniorrhaphy, hip prosthesis, knee prosthesis, and vascular surgery). The predictive power of logistic regression models (including age and gender, when appropriate) was low (between 0.55 and 0.71) and for most procedures only slightly better than that of the NNIS System risk index.

Without the inclusion of additional procedure-specific variables, logistic regression models do not improve the comparison of SSI rates from various hospitals.

To determine the frequency, risk factors, and outcomes for vancomycin-resistant Enterococcus (VRE) colonization and infection in patients with newly diagnosed acute leukemia.

Retrospective clinical study with VRE molecular strain typing.

A regional referral center for acute leukemia.

Two hundred fourteen consecutive patients with newly diagnosed acute leukemia between 2006 and 2012.

All patients had a culture of first stool and weekly surveillance for VRE. Clinical data were abstracted from the Intermountain Healthcare electronic data warehouse. VRE molecular typing was performed utilizing the semi-automated DiversiLab System.

The rate of VRE colonization was directly proportional to length of stay and was higher in patients with acute lymphoblastic leukemia. Risk factors associated with colonization include administration of corticosteroids (P=0.004) and carbapenems (P=0.009). Neither a colonized prior room occupant nor an increased unit colonization pressure affected colonization risk. Colonized patients with acute myelogenous leukemia had an increased risk of VRE bloodstream infection (BSI, P=0.002). Other risk factors for VRE BSI include severe neutropenia (P=0.04) and diarrhea (P=0.008). Fifty-eight percent of BSI isolates were identical or related by molecular typing. Eighty-nine percent of bloodstream isolates were identical or related to stool isolates identified by surveillance cultures. VRE BSI was associated with increased costs (P=0.0003) and possibly mortality.

VRE colonization has important consequences for patients with acute myelogenous leukemia undergoing induction therapy. For febrile neutropenic patients with acute myelogenous leukemia, use of empirical antibiotic regimens that avoid carbapenems and include VRE coverage may be helpful in decreasing the risks associated with VRE BSI.

Infect Control Hosp Epidemiol 2015;36(1): 47–53

Staphylococcus aureus nasal carriage is a risk factor for surgical-site infections (SSIs) caused by S. aureus, and eradication of carriage reduces postoperative nosocomial infections caused by it. No study has compared large groups of preoperative carriers and non-carriers to identify factors that are linked to S. aureus nasal carriage.

While conducting a clinical trial evaluating whether mupirocin prevented S. aureus SSIs, we prospectively collected data on 70 patient characteristics that might be associated with S. aureus carriage. We performed stepwise logistic regression analysis.

Of the 4,030 patients, 891 (22%) carried S. aureus. Independent risk factors for S. aureus nasal carriage were obesity (odds ratio [OR], 1.29; 95% confidence interval [CI95], 1.11-1.50), male gender (OR, 1.29; CI95,1.11-1.51), and a history of a cerebrovascular accident (OR, 1.53; CI95, 1.03-2.25) for all patients. Factors associated with nasal carriage varied somewhat by surgical specialty. In all groups, preoperative use of antimicrobial agents was independently associated with a lower risk of carrying S. aureus in the nares. Previously identified risk factors were not significantly associated with S. aureus nasal carriage in this large group of surgical patients.

Male gender, obesity, and a history of a cerebrovascular accident were identified as risk factors for S. aureus nasal carriage. It remains to be seen whether preoperative weight loss would reduce the rate of nasal carriage. In addition, the value of screening this patient population for S. aureus nasal carriage merits further investigation.

Modified contact precautions (MCP), defined as routine donning of isolation gowns (along with routine gloving) on entry into the rooms of patients under contact precautions, regardless of the likelihood of direct exposure to the patient or their immediate environment, were instituted at our medical center to reduce nosocomial transmission of common hospital pathogens.

To study compliance with MCP policy regarding routine gowning in intensive care units (ICUs) and general wards and to determine the relationship between gown and glove use in the care of patients under MCP in ICUs.

Prospective observational study from February 20, 2004, through January 8, 2005, involving 2,110 persons (1,504 healthcare workers [HCWs] and 606 non-HCW visitors).

A 900-bed tertiary care teaching community hospital.

Overall compliance with routine gown use was observed for 1,542 persons (73%), including 1,150 HCWs (76%) and 392 visitors (65%) (odds ratio [OR], 1.8 [95% confidence interval {CI}, 1.4-2.2]; P < .001). Visitors in the ICUs (186 [91%] of 204) were more likely than visitors in the general wards (202 [51%] of 398) to comply with gown use (OR, 10 [95% CI, 6.0-17.0]; P < .001). In logistic regression analysis, independent predictors of gown compliance among HCWs were female sex (OR, 2.3 [95% CI, 1.8-3.0]; P < .001) and ICU setting (OR, 2.2 [95% CI, 1.7-2.9]; P < .001). In the ICUs, gown use was highly predictive of glove use among HCWs (positive predictive value, 95%).

Improvement in compliance with gown use at our medical center will require more-intensive educational efforts targeted at male HCWs and at HCWs and visitors on general wards. In the care of ICU patients under MCP, HCW compliance with gown use may be used as a proxy for their compliance with glove use.

To assess the prevalence of healthcare-associated infections (HAIs) in mainland China.

Systematic review and meta-analysis.

Adults and children from secondary and tertiary acute-care hospitals in mainland China.

We searched PubMed, the China National Knowledge Infrastructure, and Wan Fang for multicenter point-prevalence surveys of acute-care hospitals in mainland China from January 2006 to August 2016. All reports related to HAI, using a point-prevalence methodology and published either in English or Chinese were eligible.

In total, 3,021 publications were identified; 115 were eligible for quality assessment and data abstraction. The weighted HAI prevalence (95% confidence interval [CI]) overall, in general hospitals, children’s hospitals, maternal and child health hospitals, and oncology hospitals were 3.12% (95% CI, 2.94%–3.29%), 3.02% (95% CI, 2.79%–3.26%), 4.43% (95% CI, 3.39%–5.47%), 1.88% (95% CI, 1.47%–2.29%), and 3.96% (95% CI, 3.12%–4.79%), respectively. In general hospitals, prevalence was highest in adult intensive care units (26.07%; 95% CI, 23.03%–29.12%), followed by surgery (3.26%; 95% CI, 2.96%–3.57%), and internal medicine (3.06%; 95% CI, 2.67%–3.46%). Overall, lower respiratory tract infection was the most frequent HAI (24,185, 47.28%), followed by urinary tract infection (5,773, 11.29%) and upper respiratory tract infection (5,194, 10.15%). Gram-negative bacilli were the most frequently isolated pathogens, and Pseudomonas aeruginosa (3,395, 14.91%), and Escherichia coli (2,918, 12.82%) were the most common single microorganisms.

This study is the largest systematic review on the prevalence of HAI in mainland China. These results provide a benchmark for future PPSs and a reference for infection prevention and control strategies in mainland China.

Infect Control Hosp Epidemiol 2018;39:701–709

Pertussis outbreaks in healthcare settings result in resource-intensive control activities, but studies have rarely evaluated the associated costs. We describe and estimate costs associated with 2 nosocomial pertussis outbreaks in King County, Washington, during the period from July 25 to September 15, 2004. One outbreak occurred at a 500-bed tertiary care hospital (hospital A), and the other occurred at a 250-bed pediatric hospital (hospital B).

We estimated the costs of each outbreak from the hospitals' perspective through standardized interviews with hospital staff and review of contact tracing logs. Direct costs included personnel time and laboratory and medication costs, whereas indirect costs were those resulting from hospital staff furloughs.

Hospital A incurred direct costs of $195,342 and indirect costs of $68,015; hospital B incurred direct costs of $71,130 and indirect costs of $50,000. Cost differences resulted primarily from higher personnel costs at hospital A ($134,536), compared with hospital B ($21,645). Total cost per pertussis case was $43,893 for hospital A (6 cases) and $30,282 for hospital B (4 cases). Total cost per person exposed to a pertussis patient were $357 for hospital A (738 exposures) and $164 for hospital B (737 exposures).

Nosocomial pertussis outbreaks result in substantial costs to hospitals, even when the number of pertussis cases is low. The cost-effectiveness of strategies to prevent nosocomial pertussis outbreaks, including vaccination of healthcare workers, should be evaluated.

To assess the prevalence of gram-positive coccal (GPC), gram-negative bacillary (GNB), and fungal bloodstream infections (BSIs) during a 12-year period in which a consistent antibiotic treatment protocol was in place; to evaluate the efficacy of these antibiotic policies in relation to treatment, to the emergence of bacterial or fungal resistance, and to the occurrence of infection outbreaks or epidemics.

Case series.

Demographic, clinical, and bacteriological information from 363 infants born during 1986 through 1991 and 1992 through 1997 who developed 433 blood-culture-proven BSIs was analyzed. Early-onset BSIs were defined as those infections discovered within 48 hours of birth, and late-onset BSIs as those that occurred thereafter. Suspected early-onset BSIs were treated with ampicillin and gentamicin, and suspected late-onset BSIs with vancomycin and gentamicin. Antibiotics were changed on the basis of organism antimicrobial susceptibility.

Early-onset BSIs were noted in 52 of 21,336 live births and 40 of 20,402 live births during 1986 through 1991 and 1992 through 1997, respectively. GPC (83% due to group B streptococcus [GBS]) accounted for approximately one half of early-onset BSI cases and GNB (68% Enterobacteriaceae) for the remainder. Early-onset GBS declined from 24 to 11 cases (P =.04) and late-onset BSI increased from 111 to 230 cases (P<.01) from the first to the last study period. Sixty-eight percent of late-onset BSIs were due to GPC (primarily coagulase-negative Staphylococcus), 18% to GNB, and 14% to fungus. Over the study period, Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, and Pseudomonas aeruginosa isolated from the newborn intensive-care unit (unlike those strains from other hospital units) remained fully susceptible to ceftazidime and gentamicin. Although the hospitalwide prevalence of methicillin-resistant Staphylococcus aureus increased, all 17 newborn BSI cases were due to methicillin-sensitive strains. Prevalence of methicillin-resistant coagulase-negative Staphylococcus increased, although all strains remained vancomycin-susceptible, as did the 16 Enterococcus faecalis isolates. All fungi recovered (from 48 patients) were susceptible to amphotericin.

We observed a decrease in the prevalence of early-onset BSIs due to GBS and an increase in late-onset BSIs due to GPC, GNB, and fungi. The combination of ampicillin and gentamicin for suspected early-onset BSIs and vancomycin and gentamicin for late-onset BSIs has been successful for treatment of individual patients without the occurrence of infection outbreaks or the emergence of resistance. Controlled antibiotic programs and periodic evaluations based on individual unit and not on hospitalwide antibiograms are advisable.

To evaluate time trends in surgical site infection (SSI) rates and SSI pathogens in Australia.

Prospective multicenter observational cohort study.

A group of 81 Australian healthcare facilities participating in the Victorian Healthcare Associated Infection Surveillance System (VICNISS).

All patients underwent surgeries performed between October 1, 2002, and June 30, 2013. National Healthcare Safety Network SSI surveillance methods were employed by the infection prevention staff at the participating hospitals.

Procedure-specific risk-adjusted SSI rates were calculated. Pathogen-specific and antimicrobial-resistant (AMR) infections were modeled using multilevel mixed-effects Poisson regression.

A total of 183,625 procedures were monitored, and 5,123 SSIs were reported. Each year of observation was associated with 11% risk reduction for superficial SSI (risk ratio [RR], 0.89; 95% confidence interval [CI], 0.88–0.90), 9% risk reduction for deep SSI (RR, 0.91; 95% CI, 0.90–0.93), and 5% risk reduction for organ/space SSI (RR, 0.95; 95% CI, 0.93–0.97). Overall, 3,318 microbiologically confirmed SSIs were reported. Of these SSIs, 1,174 (35.4%) were associated with orthopedic surgery, 827 (24.9%) with coronary artery bypass surgery, 490 (14.8%) with Caesarean sections, and 414 (12.5%) with colorectal procedures. Staphylococcus aureus was the most frequently identified pathogen, and a statistically significant increase in infections due to ceftriaxone-resistant Escherichia coli was observed (RR, 1.37; 95% CI, 1.10–1.70).

Standardized SSI surveillance methods have been implemented in Victoria, Australia. Over an 11-year period, diminishing rates of SSIs have been observed, although AMR infections increased significantly. Our findings facilitate the refinement of recommended surgical antibiotic prophylaxis regimens and highlight the need for a more expansive national surveillance strategy to identify changes in epidemiology.

Infect Control Hosp Epidemiol 2015;00(0): 1–8

To examine the clinical and epidemiologic features, excess length of stay, extra costs, and mortality attributable to bloodstream infection (BSI) in neutropenic patients with hematologic malignancies.

Prospective cohort and matched case-control study.

All adult neutropenic patients with hematologic malignancies admitted to Cologne University Hospital between May 1, 1997, and April 30, 1998, were prospectively observed. Case-patients were defined as patients with nosocomial BSI; control-patients were selected among patients without BSI.

During the study period, the BSI rate in neutropenic patients was 14.3 per 100 neutropenic episodes. Eighty-four case-patients were included. Matching was successful for 96% of the cohort; 81 matched pairs were studied. The mean total length of stay was significantly longer for patients with BSI than for control-patients (37 vs 29 days; P = .002). Extra costs attributable to the infection averaged $3,200 (U.S.) per patient. The crude mortality rates of case-patients and control-patients were 16% and 4%, respectively (P = .013), with an attributable mortality of 12% (odds ratio, 11). Eighty-seven percent of patients met the criteria for sepsis according to the American College of Chest Physicians/Society of Critical Care Medicine. Severe sepsis or septic shock occurred in 13% of patients and was correlated with mortality (55% vs 10% in patients without severe sepsis or septic shock; P =.01).

Nosocomial BSI in neutropenic patients is significantly associated with an excess length of hospital stay, extra costs, and excess mortality. Severe sepsis and septic shock are closely correlated with an adverse outcome.

To identify avoidable risk factors for central venous catheter (CVC) infections in patients undergoing short-term catheterization.

Prospective multicenter cohort study.

Two university teaching hospitals and five large nonteaching hospitals.

Patients admitted to intensive care units or surgical units and exposed to short-term CVCs.

Of 623 catheterization episodes, 9.3% were associated with catheter-related infections (CRI). The skin at the catheter site was frequently colonized (16.2%) and was the potential source of infection in 56.1% of the cases, mostly local infections. The hub was colonized less frequently (3.5%) but was responsible for systemic infections more frequently

The following variables were independently associated with CRI: duration of catheterization (for 7 to 14 days, odds ratio [OR], 3.9; 95% confidence interval [CI]95, 1.4 to 10.7; and for >14 days, OR, 5.1; CI95, 1.7 to 15.4), coronary care unit service (OR, 6.7; CI95, 1.1 to 42.9) or surgery service (OR, 4.4; CI95, 1.03 to 18.5), second episode of catheterization (OR, 7.6; CI95, 1.8 to 32.3), skin colonization at the insertion site (OR, 56.5; CI95, 10.8 to 296), and hub colonization (OR, 17.9; CI95, 2.4 to 132).

The risk associated with skin colonization varied with use of jugular access or simultaneous colonization of the hub. When only symptomatic CRI was considered, the risk associated with hub colonization was consistently higher (OR, 36.6; 7 to 190) than that associated with skin colonization (OR, 3.2; CI95, 0.7 to 14).

Age, transparent dressing, jugular insertion, male gender, duration of catheterization, and hub colonization were independent risk factors for skin colonization. The effect of age varied by type of dressing and vice versa; the effect of jugular access varied by sex; and the effect of transparent dressing varied by length of catheter-ization and vice versa.

Total parenteral nutrition and skin colonization were independently associated with an increased risk of hub colonization.

Skin and hub colonization are the two major determinants for endemic CRIs; colonization of the hub, however, is more frequently associated with more severe infections. In order to reduce CRIs, more efforts should be focused on understanding which factors increase the risk of colonization both of the skin and of the hub.

To investigate and control a biphasic outbreak of Serratia marcescens in a neonatal intensive care unit (NICU).

Epidemiological and laboratory investigation of the outbreak.

The NICU of the 1,470-bed teaching hospital of the University “Federico II,” Naples, Italy.

The outbreak involved 56 cases of colonization by S marcescens over a 15-month period, with two epidemic peaks of 6 and 3 months, respectively. Fourteen (25%) of the 56 colonized infants developed clinical infections, 50% of which were major (sepsis, meningitis, or pneumonia).

Epidemiological and microbiological investigations, analysis of macrorestriction pattern of genomic DNA through pulsed-field gel electrophoresis (PFGE) of clinical and environmental isolates, and institution of infection control measures.

Analysis of macrorestriction patterns of genomic DNA by PFGE demonstrated that the vast majority of S marcescens isolates, including three environmental strains isolated from two handwashing disinfectants and the hands of a nurse, were of the same clonal type. The successful control of the outbreak was achieved through cohorting of noncolonized infants, isolation of S marcescens-infected and -colonized infants, and an intense educational program that emphasized the need for adherence to glove use and handwashing policies. The NICU remained open to new admissions.

Outbreaks caused by S marcescens are very difficult to eradicate. An infection control program that includes molecular typing of microorganisms and the proper dissemination among staff members of the typing results is likely to be very effective in reducing NICU-acquired infections and in controlling outbreaks caused by S marcescens, as well as other multiresistant bacteria.

At the end of 2002, a new, more virulent strain of Clostridium difficile, designated BI/NAP1, was the cause of a massive outbreak of infection in the province of Quebec. This particular strain was associated with a dramatic increase in morbidity and mortality among affected patients in 2003–2004. We tested and implemented a multipronged infection control approach to curtail the rate of C. difficile infection (CDI).

Five-year observational study.

A 554-bed, acute care tertiary hospital, the largest single medical center in Quebec, Canada.

To curtail the magnitude of the outbreak, we implemented a global strategy consisting of rapid C. difficile testing for all hospitalized patients who had at least 1 occurrence of liquid stool, the rapid isolation of patients infected with C. difficile in a dedicated ward with a specially trained housekeeping team, a global hand hygiene program, and the hiring of infection control practitioners. Antibiotic consumption at the institutional level was also monitored during the 5-year surveillance period. Cases of hospital-acquired CDI per 1,000 admissions were continuously monitored on a monthly basis during the entire surveillance period.

The highest recorded CDI rate was 42 cases per 1,000 admissions in January 2004. Once additional infection control resources were put in place, the rate descreased significantly during the period from April 2005 to March 2007. During the 2003–2004 period, there were 762 cases of CDI (mean annual rate, 37.28 cases per 1,000 admissions) recorded in our study, compared with 292 cases of CDI (14.48 cases per 1,000 admissions) during the 2006–2007 period (OR, 0.379 [95% CI, 0.331–0.435]; P < .001 ), a 61% reduction. In March 2007, the equivalent of 4 full-time equivalent infection control practitioners were in place, which gave a ratio of 0.96 infection control practitioners per 133 beds in use, compared with the ratio of 0.24 infection control practitioners per 133 beds in use in 2003, and the total number of hours dedicated to cleaning and housekeeping increased by 26.2%. The total amount of antibiotics used in the hospital did not vary significantly from 2002 to 2007, although there were changes in the classes antibiotic used.

The implementation of a multipronged intervention strategy to control the outbreak of CDI significantly improved the overall situation at the hospital and underlined the importance of investing in stringent infection control practices.

The purpose of this study was to quantify the effect of multidrug-resistant (MDR) gram-negative bacteria and methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections (HAIs) on mortality following infection, regardless of patient location.

We conducted a retrospective cohort study of patients with an inpatient admission in the US Department of Veterans Affairs (VA) system between October 1, 2007, and November 30, 2010. We constructed multivariate log-binomial regressions to assess the impact of a positive culture on mortality in the 30- and 90-day periods following the first positive culture, using a propensity-score–matched subsample.

Patients identified with positive cultures due to MDR Acinetobacter (n=218), MDR Pseudomonas aeruginosa (n=1,026), and MDR Enterobacteriaceae (n=3,498) were propensity-score matched to 14,591 patients without positive cultures due to these organisms. In addition, 3,471 patients with positive cultures due to MRSA were propensity-score matched to 12,499 patients without positive MRSA cultures. Multidrug-resistant gram-negative bacteria were associated with a significantly elevated risk of mortality both for invasive (RR, 2.32; 95% CI, 1.85–2.92) and noninvasive cultures (RR, 1.33; 95% CI, 1.22–1.44) during the 30-day period. Similarly, patients with MRSA HAIs (RR, 2.77; 95% CI, 2.39–3.21) and colonizations (RR, 1.32; 95% CI, 1.22–1.50) had an increased risk of death at 30 days.

We found that HAIs due to gram-negative bacteria and MRSA conferred significantly elevated 30- and 90-day risks of mortality. This finding held true both for invasive cultures, which are likely to be true infections, and noninvasive infections, which are possibly colonizations.

Infect Control Hosp Epidemiol 2017;38:848–856