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

Prospective cohort study from February 2009 to October 2009.

Eleven teaching hospitals.

HCWs.

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

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

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

Identify factors affecting the rate of hand hygiene opportunities in an acute care hospital.

Prospective observational study.

Medical and surgical in-patient units, medical-surgical intensive care unit (MSICU), neonatal intensive care unit (NICU), and emergency department (ED) of an academic acute care hospital from May to August, 2012.

Healthcare workers.

One-hour patient-based observations measured patient interactions and hand hygiene opportunities as defined by the “Four Moments for Hand Hygiene.” Rates of patient interactions and hand hygiene opportunities per patient-hour were calculated, examining variation by room type, healthcare worker type, and time of day.

During 257 hours of observation, 948 healthcare worker-patient interactions and 1,605 hand hygiene opportunities were identified. Moments 1, 2, 3, and 4 comprised 42%, 10%, 9%, and 39% of hand hygiene opportunities. Nurses contributed 77% of opportunities, physicians contributed 8%, other healthcare workers contributed 11%, and housekeeping contributed 4%. The mean rate of hand hygiene opportunities per patient-hour was 4.2 for surgical units, 4.5 for medical units, 5.2 for ED, 10.4 for NICU, and 13.2 for MSICU (P < .001). In non-ICU settings, rates of hand hygiene opportunities decreased over the course of the day. Patients with transmission-based precautions had approximately half as many interactions (rate ratio [RR], 0.55 [95% confidence interval (CI), 0.37-0.80]) and hand hygiene opportunities per hour (RR, 0.47 [95% CI, 0.29-0.77]) as did patients without precautions.

Measuring hand hygiene opportunities across clinical settings lays the groundwork for product use-based hand hygiene measurement. Additional work is needed to assess factors affecting rates in other hospitals and health care settings.

Coronary artery bypass graft (CABG) and primary arthroplasty surgical site infection (SSI) rates are declining slower than other healthcare-associated infection rates. We examined antimicrobial prophylaxis (AMP) regimens used for these operations and compared their spectrum of activity against reported SSI pathogens.

Pathogen distributions of CABG and hip/knee arthroplasty complex SSIs (deep and organ/space) reported to the National Healthcare Safety Network (NHSN) from 2006 through 2009 and AMP regimens (same procedures and time period) reported to the Surgical Care Improvement Project (SCIP) were analyzed. Regimens were categorized as standard (cefazolin or cefuroxime), β-lactam allergy (vancomycin or clindamycin with or without an aminoglycoside), and extended spectrum (vancomycin and/or an aminoglycoside with cefazolin or cefuroxime). AMP activity of each regimen was predicted on the basis of pathogen susceptibility reports and published spectra of antimicrobial activity.

There were 6,263 CABG and arthroplasty complex SSIs reported (680,489 procedures; 880 NHSN hospitals). Among 6,574 pathogens reported, methicillin-sensitive Staphylococcus aureus (23%), methicillin-resistant S. aureus (18%), coagulase-negative staphylococci (17%), and Enterococcus species (7%) were most common. AMP regimens for 2,435,703 CABG and arthroplasty procedures from 3,330 SCIP hospitals were analyzed. The proportion of pathogens predictably susceptible to standard (used in 75% of procedures), β-lactam (12%), and extended-spectrum (8%) regimens was 41%–45%, 47%–96%, and 81%—96%, respectively.

Standard AMP, used in three-quarters of CABG and primary arthroplasty procedures, has inadequate activity against more than half of SSI pathogens reported. Alternative strategies may be needed to prevent SSIs caused by pathogens resistant to standard AMP regimens.

Determine whether daily bathing with chlorhexidine-based soap decreased methicillin-resistant Staphylococcus aureus (MRSA) transmission and intensive care unit (ICU)-acquired S. aureus infection among ICU patients.

Prospective pre-post-intervention study with control unit.

A 1,250-bed tertiary care teaching hospital.

Medical and surgical ICU patients.

Active surveillance for MRSA colonization was performed in both ICUs. In June 2005, a chlorhexidine bathing protocol was implemented in the surgical ICU. Changes in S. aureus transmission and infection rate before and after implementation were analyzed using time-series methodology.

The intervention unit had a 20.68% decrease in MRSA acquisition after institution of the bathing protocol (12.64 cases per 1,000 patient-days at risk before the intervention vs 10.03 cases per 1,000 patient-days at risk after the intervention; β, −2.62 [95% confidence interval (CI), −5.19 to −0.04]; P = .046). There was no significant change in MRSA acquisition in the control ICU during the study period (10.97 cases per 1,000 patient-days at risk before June 2005 vs 11.33 cases per 1,000 patient-days at risk after June 2005; β, −11.10 [95% CI, −37.40 to 15.19]; P = .40). There was a 20.77% decrease in all S. aureus (including MRSA) acquisition in the intervention ICU from 2002 through 2007 (19.73 cases per 1,000 patient-days at risk before the intervention to 15.63 cases per 1,000 patient-days at risk after the intervention [95% CI, −7.25 to −0.95]; P = .012)]. The incidence of ICU-acquired MRSA infections decreased by 41.37% in the intervention ICU (1.96 infections per 1,000 patient-days at risk before the intervention vs 1.15 infections per 1,000 patient-days at risk after the intervention; P = .001).

Institution of daily chlorhexidine bathing in an ICU resulted in a decrease in the transmission of S. aureus, including MRSA. These data support the use of routine daily chlorhexidine baths to decrease rates of S. aureus transmission and infection.

To determine whether well-child visits are a risk factor for subsequent influenza-like illness (ILI) visits within a child's family. DESIGN. Retrospective cohort.

Using data from the Medical Expenditure Panel Survey from the years 1996-2008, we identified 84,595 families. For each family, we determined those weeks in which a well-child visit or an ILI visit occurred. We identified 23,776 well-child-visit weeks and 97,250 ILI-visit weeks. We fitted a logistic regression model, where the binary dependent variable indicated an ILI clinic visit in a particular week. Independent variables included binary indicators to denote a well-child visit in the concurrent week or one of the previous 2 weeks, the occurrence of the ILI visit during the influenza season, and the presence of children in the family in each of the age groups 0–3, 4–7, and 8–17 years. Socioeconomic variables were also included. We also estimated the overall cost of well-child-exam-related ILI using data from 2008.

We found that an ILI office visit by a family member was positively associated with a well-child visit in the same or one of the previous 2 weeks (odds ratio, 1.54). This additional risk translates to potentially 778,974 excess cases of ILI per year in the United States, with a cost of $500 million annually.

Our results should encourage ambulatory clinics to strictly enforce infection control recommendations. In addition, clinics could consider time-shifting of well-child visits so as not to coincide with the peak of the influenza season.

To explore the range of hospital policies for visitor use of personal protective equipment (PPE) when entering the room of patients under isolation precautions.

Survey using an online questionnaire.

Acute care hospitals registered in the North Carolina Statewide Program for Infection Control and Epidemiology (SPICE).

A total of 136 North Carolina hospitals were invited to participate in an online survey. The survey questionnaire was developed, reviewed, and pilot tested, and then it was distributed through SPICE listserv registered e-mail addresses. The survey was conducted from February 6 to March 30, 2012.

Among 93 respondent hospitals (response rate, 68.4%), 82 acute care hospitals (60.3%) were included in the analyses. Substantial variation was observed with regard to hospital policies for visitor PPE use when visiting patients under isolation precautions. A total of 71% of hospitals had a hospital visitor policy, and 96% of respondents agreed that hospitals should have a visitor policy. Only 14% of hospitals monitored visitor compliance with PPE. Reported compliance rates varied from “very low” to 97%. Many hospitals (28%) reported difficulties related to visitor compliance with isolation precautions, including hostility and refusal to comply.

Our study results illuminated hospital policy variations for visitor isolation precautions. Reported problems with hospital visitor policies (eg, different policies across departments or facilities) suggest the need for standard guidelines and for enhanced public awareness about the importance of visitor compliance with isolation precautions.

Antimicrobial stewardship programs (ASPs) are a mechanism to ensure the appropriate use of antimicrobials. The extent to which ASPs are formally implemented in freestanding children's hospitals is unknown. The objective of this study was to determine the prevalence and characteristics of ASPs in freestanding children's hospitals.

We conducted an electronic survey of 42 freestanding children's hospitals that are members of the Children's Hospital Association to determine the presence and characteristics of their ASPs. For hospitals without an ASP, we determined whether stewardship strategies were in place and whether there were barriers to implementing a formal ASP.

We received responses from 38 (91%) of 42. Among responding institutions, 16 (38%) had a formal ASP, and 15 (36%) were in the process of implementing a program. Most ASPs (13 [81%] of 16) were started after 2007. The median number of full-time equivalents dedicated to ASPs was 0.63 (range, 0.1–1.8). The most common antimicrobials monitored by ASPs were linezolid, vancomycin, and carbapenems. Many hospitals without a formal ASP were performing stewardship activities, including elements of prospective audit and feedback (9 [41%] of 22), formulary restriction (9 [41%] of 22), and use of clinical guidelines (17 [77%] of 22). Antimicrobial outcomes were more likely to be monitored by hospitals with ASPs (100% vs 68%; P = .01), although only 1 program provided support for a data analyst.

Most freestanding children's hospitals have implemented or are developing an ASP. These programs differ in structure and function, and more data are needed to identify program characteristics that have the greatest impact.

Evaluate antimicrobial stewardship interventions targeted to reduce highly active antiretroviral therapy (HAART)– or opportunistic infection (Ol)–related medication errors and increase error resolution.

Retrospective before-after study.

Academic medical center.

Inpatients who were prescribed antiretroviral therapy before the intervention (January 1, 2011, to October 31, 2011) and after the intervention (July 1, 2012, to December 31, 2012). Patients treated with lamivudine or tenofovir monotherapy for hepatitis B were excluded.

Antimicrobial stewardship interventions included education, modification of electronic medication records, collaboration with the infectious diseases (ID) department, and prospective audit and review of HAART and OI regimens by an ID clinical pharmacist.

Data for 162 admissions from the preintervention period and 110 admissions from the postintervention period were included. The number of admissions with a medication error was significantly reduced after the intervention (81 [50%] of 162 admissions vs 37 (34%) of 110 admissions; P < .00)1. A total of 124 errors occurred in the preintervention group (mean no. of errors, 1.5 per admission), and 43 errors occurred in the postintervention group (mean no. of errors, 1.2 per admission). The most common error types were major drug interactions and dosing in the preintervention group and renal adjustment and OI-related errors in the postintervention group. A significantly higher error resolution rate was observed in the postintervention group (36% vs 74%; P < .001). After adjustment for potential confounders with logistic regression, admission in the postintervention group was independently associated with fewer medication errors (odds ratio, 0.4 [95% confidence interval, 0.24-0.77]; P = .005). Overall, presence of an ID consultant demonstrated a higher error resolution rate (32% without a consultation vs 68% with a consultation; P = .002).

Multifaceted, multidisciplinary stewardship efforts reduced the rate and increased the overall resolution of HAART-related medication errors.

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.

The epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) is changing, with USA300 emerging first in community and then in healthcare settings. We performed nationwide surveillance to assess recent trends in the molecular epidemiology of MRSA.

One hundred consecutive unique clinically significant S. aureus isolates were recovered from patients at each of 43 US centers between July 1, 2011, and December 31, 2011. Susceptibility testing, pulsed-field gel electrophoresis (PFGE), staphylococcal protein A gene (spa) and staphylococcal cassette chromosome mec typing, and Panton-Valentine leukocidin detection were performed on all MRSA isolates.

Of 4,131 isolates collected, 2,093 (51%) were MRSA. Specimen sources of MRSA isolates included wound or abscess (54%), blood (24%), lower respiratory tract (11%), and other sterile site (10%). Thirty percent were isolated more than 48 hours after hospital admission (ie, were associated with nosocomial acquisition of infection). USA300 was the most common PFGE type (1,269 isolates; 61%), overall and in all regions, followed by USA100 (368 isolates; 18%). Among 173 spa types found, the most common were t008 (51%) and t002 (18%); no other spa type accounted for more than 2% of isolates. One strain type (USA300/t008/IV) constituted almost half of all MRSA isolates (1,005 isolates; 48%) and was the most common at all body sites, causing 37% of MRSA bloodstream infections (BSIs) and 38% of nosocomial MRSA infections. Multidrug-resistant phenotypes were found among 34 USA300 isolates (3%) from 18 states.

The USA300 PFGE type continues to advance nationwide. A single strain type (USA300/t008/IV) predominates in all regions and infection sites and is now more common than USA 100 as a cause of MRSA BSI and nosocomial infections. Although most USA300 retain typical susceptibility profiles, multidrug-resistant phenotypes are emerging.

Legionella control still remains a critical issue in healthcare settings where the preferred approach to health risk assessment and management is to develop a water safety plan. We report the experience of a university hospital, where a water safety plan has been applied since 2002, and the results obtained with the application of different methods for disinfecting hot water distribution systems in order to provide guidance for the management of water risk.

The disinfection procedures included continuous chlorination with chlorine dioxide (0.4–0.6 mg/L in recirculation loops) reinforced by endpoint filtration in critical areas and a water treatment based on monochloramine (2-3 mg/L). Real-time polymerase chain reaction and a new immunoseparation and adenosine triphosphate bioluminescence analysis were applied in environmental monitoring.

After 9 years, the integrated disinfection-filtration strategy significantly reduced positive sites by 55% and the mean count by 78% (P < .05); however, the high costs and the occurrence of a chlorine-tolerant clone belonging to Legionella pneumophila ST269 prompted us to test a new disinfectant. The shift to monochloramine allowed us to eliminate planktonic Legionella and did not require additional endpoint filtration; however, nontuberculous mycobacteria were isolated more frequently as long as the monochloramine concentration was 2 mg/L; their cultivability was never regained by increasing the concentration up to 3 mg/L.

Any disinfection method needs to be adjusted/fine-tuned in individual hospitals in order to maintain satisfactory results over time, and only a locally adapted evidence-based approach allows assessment of the efficacy and disadvantages of the control measures.

To determine the source and identify control measures of an outbreak of Tsukamurella species bloodstream infections at an outpatient oncology facility.

Epidemiologic investigation of the outbreak with a case-control study.

A case was an infection in which Tsukamurella species was isolated from a blood or catheter tip culture during the period January 2011 through June 2012 from a patient of the oncology clinic. Laboratory records of area hospitals and patient charts were reviewed. A case-control study was conducted among clinic patients to identify risk factors for Tsukamurella species bloodstream infection. Clinic staff were interviewed, and infection control practices were assessed.

Fifteen cases of Tsukamurella (Tsukamurella pulmonis or Tsukamurella tyrosinosolvens) bloodstream infection were identified, all in patients with underlying malignancy and indwelling central lines. The median age of case patients was 68 years; 47% were male. The only significant risk factor for infection was receipt of saline flush from the clinic during the period September–October 2011 (P = .03), when the clinic had been preparing saline flush from a common-source bag of saline. Other infection control deficiencies that were identified at the clinic included suboptimal procedures for central line access and preparation of chemotherapy.

Although multiple infection control lapses were identified, the outbreak was likely caused by improper preparation of saline flush syringes by the clinic. The outbreak demonstrates that bloodstream infections among oncology patients can result from improper infection control practices and highlights the critical need for increased attention to and oversight of infection control in outpatient oncology settings.