To evaluate the efficacy of copper-coating in reducing environmental colonization in an intensive-care unit (ICU) with multidrug-resistant-organism (MDRO) endemicity

Interventional, comparative crossover trial

The general ICU of Attikon University hospital in Athens, Greece

Those admitted to ICU compartments A and B during the study period

Before any intervention (phase 1), the optimum sampling method using 2 nylon swabs was validated. In phase 2, 6 copper-coated beds (ie, with coated upper, lower, and side rails) and accessories (ie, coated side table, intravenous [i.v.] pole stands, side-cart handles, and manual antiseptic dispenser cover) were introduced as follows: During phase 2a (September 2011 to February 2012), coated items were placed next to noncoated ones (controls) in both compartments A and B; during phase 2b (May 2012 to January 2013), all copper-coated items were placed in compartment A, and all noncoated ones (controls) in compartment B. Patients were randomly assigned to available beds. Environmental samples were cultured quantitatively for clinically important bacteria. Clinical and demographic data were collected from medical records.

Copper coating significantly reduced the percentage of colonized surfaces (55.6% vs 72.5%; P<.0001), the percentage of surfaces colonized by MDR gram-negative bacteria (13.8% vs 22.7%; P=.003) or by enterococci (4% vs 17%; P=.014), the total bioburden (2,858 vs 7,631 cfu/100 cm2; P=.008), and the bioburden of gram-negative isolates, specifically (261 vs 1,266 cfu/100 cm2; P=.049). This effect was more pronounced when the ratio of coated surfaces around the patient was increased (phase 2b).

Copper-coated items in an ICU setting with endemic high antimicrobial resistance reduced environmental colonization by MDROs.

Infect Control Hosp Epidemiol 2017;38:765–771

To determine the impact of an environmental disinfection intervention on the incidence of healthcare-associated Clostridium difficile infection (CDI).

A multicenter randomized trial.

In total,16 acute-care hospitals in northeastern Ohio participated in the study.

We conducted a 12-month randomized trial to compare standard cleaning to enhanced cleaning that included monitoring of environmental services (EVS) personnel performance with feedback to EVS and infection control staff. We assessed the thoroughness of cleaning based on fluorescent marker removal from high-touch surfaces and the effectiveness of disinfection based on environmental cultures for C. difficile. A linear mixed model was used to compare CDI rates in the intervention and postintervention periods for control and intervention hospitals. The primary outcome was the incidence of healthcare-associated CDI.

Overall, 7 intervention hospitals and 8 control hospitals completed the study. The intervention resulted in significantly increased fluorescent marker removal in CDI and non-CDI rooms and decreased recovery of C. difficile from high-touch surfaces in CDI rooms. However, no reduction was observed in the incidence of healthcare-associated CDI in the intervention hospitals during the intervention and postintervention periods. Moreover, there was no correlation between the percentage of positive cultures after cleaning of CDI or non-CDI rooms and the incidence of healthcare-associated CDI.

An environmental disinfection intervention improved the thoroughness and effectiveness of cleaning but did not reduce the incidence of healthcare-associated CDI. Thus, interventions that focus only on improving cleaning may not be sufficient to control healthcare-associated CDI.

Infect Control Hosp Epidemiol 2017;38:777–783

Activated alkaline glutaraldehyde (GTA) remains one of the most widely used high-level disinfectants worldwide. However, several reports have highlighted the potential for nontuberculous mycobacteria to develop high-level resistance to this product. Because aldehyde resistance may lead to cross-resistance to other biocides, we investigated the susceptibility profile of GTA-resistant Mycobacterium chelonae and M. abscessus isolates to various disinfectant chemistries.

High-level disinfectants commonly used in the reprocessing of endoscopes and other heat-sensitive, semicritical medical equipment, including different formulations of aldehyde-based products and oxidizing agents, were tested against 10 slow- and fast-growing, GTA-susceptible and GTA-resistant, Mycobacterium isolates in suspension tests and carrier tests at different temperatures.

While peracetic acid– and hydrogen peroxide–based disinfectants (S40, Resert XL, Reliance DG) efficiently killed all of the Mycobacterium isolates, GTA- and ortho-phthalaldehyde-based products (ie, Cidex, Aldahol, Cidex OPA) showed variable efficacy against GTA-resistant strains despite the ability of some formulations (Aldahol) to overcome the resistance of some of these isolates, especially when the temperature was increased from 20°C to 25°C.

Application permitting, oxidizing chemistries may provide a safe alternative to aldehyde-based products, particularly in GTA-resistant mycobacterial outbreaks.

Infect Control Hosp Epidemiol 2017;38:784–791

In 2011, pediatric hematopoietic stem cell transplant (HSCT) patients were moved from an older hospital to a new children’s hospital. To minimize bacterial growth in the new hospital’s water during construction, the plumbing system was flushed and disinfected before occupancy. However, 6 months after occupancy, an increased incidence of rapidly growing mycobacteria (RGM) was detected in clinical cultures. Over 10 months, 15 pediatric HSCT patients were infected, while no pediatric HSCT patients had been infected in the preceding 12 months.

To determine the cause of the outbreak and to interrupt patient acquisition of RGM.

Water samples were collected from water entering the hospital and from drinking water and ice machines (DWIMs) from the old and new hospitals. Total heterotrophic plate counts (HPCs, CFU/mL) of water were undertaken, and select isolates were identified as RGM.

The cause of the outbreak was increased bacterial levels in the water (including RGM) in the DWIMs in the new (2011) hospital. Tests revealed higher HPCs in drinking water and ice from the DWIMs in the new hospital than in the DWIMs in the old hospital. Ultimately, HPCs were reduced by several different interventions.

In response to an RGM outbreak, HSCT patients were banned from ingesting DWIM ice and water and bottled water was provided. Since this interverntion 4 years ago, no additional RGM isolates have been identified in HSCT patient cultures. Our measures to reduce HPCs to goal levels in drinking water from DWIMs were successful, but the HPCs for ice have not consistently reached the goal of <500 CFU/mL.

Infect Control Hosp Epidemiol 2017;38:792–800

To investigate an outbreak of Pseudomonas aeruginosa infections and colonization in a neonatal intensive care unit.

Infection control assessment, environmental evaluation, and case-control study.

Newly built community-based hospital, 28-bed neonatal intensive care unit.

Neonatal intensive care unit patients receiving care between June 1, 2013, and September 30, 2014.

Case finding was performed through microbiology record review. Infection control observations, interviews, and environmental assessment were performed. A matched case-control study was conducted to identify risk factors for P. aeruginosa infection. Patient and environmental isolates were collected for pulsed-field gel electrophoresis to determine strain relatedness.

In total, 31 cases were identified. Case clusters were temporally associated with absence of point-of-use filters on faucets in patient rooms. After adjusting for gestational age, case patients were more likely to have been in a room without a point-of-use filter (odds ratio [OR], 37.55; 95% confidence interval [CI], 7.16–∞). Case patients had higher odds of exposure to peripherally inserted central catheters (OR, 7.20; 95% CI, 1.75–37.30) and invasive ventilation (OR, 5.79; 95% CI, 1.39–30.62). Of 42 environmental samples, 28 (67%) grew P. aeruginosa. Isolates from the 2 most recent case patients were indistinguishable by pulsed-field gel electrophoresis from water-related samples obtained from these case-patient rooms.

This outbreak was attributed to contaminated water. Interruption of the outbreak with point-of-use filters provided a short-term solution; however, eradication of P. aeruginosa in water and fixtures was necessary to protect patients. This outbreak highlights the importance of understanding the risks of stagnant water in healthcare facilities.

Infect Control Hosp Epidemiol 2017;38:801–808

To determine whether the seasonality of surgical site infections (SSIs) can be explained by changes in temperature.

Retrospective cohort analysis.

The National Inpatient Sample database.

All hospital discharges with a primary diagnosis of SSI from 1998 to 2011 were considered cases. Discharges with a primary or secondary diagnoses of specific surgeries commonly associated with SSIs from the previous and current month served as our “at risk” cohort.

We modeled the national monthly count of SSI cases both nationally and stratified by region, sex, age, and type of institution. We used data from the National Climatic Data Center to estimate the monthly average temperatures for all hospital locations. We modeled the odds of having a primary diagnosis of SSI as a function of demographics, payer, location, patient severity, admission month, year, and the average temperature in the month of admission.

SSI incidence is highly seasonal, with the highest SSI incidence in August and the lowest in January. During the study period, there were 26.5% more cases in August than in January (95% CI, 23.3–29.7). Controlling for demographic and hospital-level characteristics, the odds of a primary SSI admission increased by roughly 2.1% per 2.8°C (5°F) increase in the average monthly temperature. Specifically, the highest temperature group, >32.2°C (>90°F), was associated with an increase in the odds of an SSI admission of 28.9% (95% CI, 20.2–38.3) compared to temperatures <4.4°C (<40°F).

At population level, SSI risk is highly seasonal and is associated with warmer weather.

Infect Control Hosp Epidemiol 2017;38:809–816

Orthopedic procedures are an important focus in efforts to reduce surgical site infections (SSIs). In 2008, the Centers for Medicare and Medicaid (CMS) stopped reimbursements for additional charges associated with serious hospital-acquired conditions, including SSI following certain orthopedic procedures. We aimed to evaluate the CMS policy’s effect on rates of targeted orthopedic SSIs among the Medicare population.

We examined SSI rates following orthopedic procedures among the Medicare population before and after policy implementation compared to a similarly aged control group. Using the Nationwide Inpatient Sample database for 2000–2013, we estimated rate ratios (RRs) of orthopedic SSIs among Medicare and non-Medicare patients using a difference-in-differences approach.

Following policy implementation, SSIs significantly decreased among both the Medicare and non-Medicare populations (RR, 0.7; 95% confidence interval [CI], 0.6–0.8) and RR, 0.8l; 95% CI, 0.7–0.9), respectively. However, the estimated decrease among the Medicare population was not significantly greater than the decrease among the control population (RR, 0.9; 95% CI, 0.8–1.1).

While SSI rates decreased significantly following the implementation of the CMS nonpayment policy, this trend was not associated with policy intervention but rather larger secular trends that likely contributed to decreasing SSI rates over time.

Infect Control Hosp Epidemiol 2017;38:817–822

Appropriate use of surgical antibiotic prophylaxis (SAP) reduces intraoperative wound contamination in pediatric surgery, thus minimizing the risk of surgical site infection (SSIs). Conversely, inappropriate use of SAP exposes patients to the risk of antibiotic side effects and contributes to the emergence of antimicrobial resistance. Our aims were to describe SAP administration and to analyze factors associated with nonadherence in pediatric patients.

Descriptive study.

Overall, 955 pediatric patients underwent 1,038 surgical procedures.

We assessed adherence to SAP international guidelines for surgical procedures performed on children aged <18 years in 2015 in 4 randomly selected hospitals in Calabria (Italy). The clinical records of these patients were retrospectively reviewed.

Appropriate SAP administration or nonadministration pertained to 754 surgical procedures (72.6%). Surgical antibiotic prophylaxis was administered in 88.5% of 358 procedures with an SAP indication. Adherence to guidelines for appropriate drug choice were followed in 5.7% of cases, for route of administration in 76.7% of cases, for timing in 48.6% of cases, for duration in 14.5% of cases, and for dose in 91.5% of cases, and for all components in only 5 cases (1.6%). Among 680 procedures without SAP indication, 35.7% case patients received antibiotics. Inappropriate administration of antibiotics in procedures without SAP indication was associated with surgical specialty wards (P=.008), ordinary admission (P<.001), head and neck surgical procedures (P=.020), clean surgery (P=.017), and surgical duration (P=.010).

Discrepancies between SAP guidelines and actual practice behavior more frequently indicate excessive use of antibiotics than underuse. Increased awareness of SAP guidelines is required.

Infect Control Hosp Epidemiol 2017;38:823–831

To analyze influential infectious diseases, antimicrobial stewardship, infection control, or medical microbiology blogs and bloggers

World wide web

We conducted a systematic search for blogs in accordance with the PRISMA guidelines in September 2015.

A snowball sampling approach was applied to identify blogs using various search engines. Blogs were eligible if they (1) focused on infectious diseases, antimicrobial stewardship, infection control, or medical microbiology; (2) were intended for health professionals; and (3) were written in English and (4) were updated regularly. We mapped blog and blogger characteristics and used an innovative tool to assess the architecture and content of the included blogs. The motivations and perceptions of bloggers and readers were also assessed.

A total of 88 blogs were identified. Moreover, 28 blogs (32%) focused on infectious diseases, 46 (52%) focused on medical microbiology, and 14 (16%) focused on infection control or antimicrobial stewardship. Bloggers were mainly male with medical doctorates and/or PhDs; 32 bloggers (36%) posted at least weekly; and 51 (58%) had a research purpose. The aims were considered clear for 23 blogs (26%), and the field covered was considered broad for 25 blogs (28%). Presentation was considered good for 22 blogs (25%), 51 blogs (58%) were easy to read, and 46 blogs (52%) included expert interpretation. Among the top 10 blogs, 3 focused on infectious diseases, 6 focused on medical microbiology, and 2 focused on infection control (2 were equally ranked). The bloggers we questioned were motivated to share their independent expertise and opinions. Readers appreciated the concise messages on scientific topics and practical updates.

This study describes high-level blogs in the fields of infectious diseases, infection control, and medical microbiology. Our findings suggest ways in which bloggers should build/orientate blogs for readers, and we have highlighted current gaps in blog topics such as antimicrobial stewardship.

Infect. Control Hosp. Epidemiol 2017;38:832–839

We examined the impact of methicillin-resistant Staphylococcus aureus (MRSA) guidelines in Québec adult hospitals from January 1, 2006, to March 31, 2015, by examining the incidence rate reduction (IRR) in healthcare-associated MRSA bloodstream infections (HA-MRSA), using central-line associated bloodstream infections (CLABSIs) as a comparator.

In this study, we utilized a quasi-experimental design with Poisson segmented regression to model HA-MRSA and CLABSI incidence for successive 4-week surveillance segments, stratified by teaching status. We used 3 distinct periods with 2 break points (April 1, 2007, and January 3, 2010) corresponding to major MRSA guideline publications and updates.

Over the study period, HA-MRSA incidence decreased significantly in adult teaching facilities but not in nonteaching facilities. Prior to MRSA guideline publication (2006–2007), HA-MRSA incidence decrease was not significant (P=.89), while CLABSI incidence decreased by 4% per 4-week period (P=.05). After the publication of guidelines (2007–2009), HA-MRSA incidence decreased significantly by 1% (P=.04), while no significant decrease in CLABSI incidence was observed (P=.75). HA-MRSA and CLABSI decreases were both significant at 1% for 2010–2015 (P<.001 and P=.01, respectively). These decreases were gradual rather than sudden; break points were not significant. Teaching facilities drove these decreases.

During the study period, HA-MRSA and CLABSI rates decreased significantly. In 2007–2009, the significant decrease in HA-MRSA rates with stable CLABSI rates suggests an impact from MRSA-specific guidelines. In 2010–2015, significant and equal IRRs for HA-MRSA and CLABSI may be due to the continuing impact of MRSA guidelines, to the impact of new interventions targeting device-associated infections in general by the 2010–2015 Action Plan, or to a combination of factors.

Infect Control Hosp Epidemiol 2017;38:840–847

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