To identify Choosing Wisely items for the American Board of Internal Medicine Foundation.

The Society for Healthcare Epidemiology of America (SHEA) elicited potential items from a hospital epidemiology listserv, SHEA committee members, and a SHEA–Infectious Diseases Society of America compendium with SHEA Research Network members ranking items by Delphi method voting. The SHEA Guidelines Committee reviewed the top 10 items for appropriateness for Choosing Wisely. Five final recommendations were approved via individual member vote by committees and the SHEA Board.

Ninety-six items were proposed by 87 listserv members and 99 SHEA committee members. Top 40 items were ranked by 24 committee members and 64 of 226 SHEA Research Network members. The 5 final recommendations follow: 1. Don’t continue antibiotics beyond 72 hours in hospitalized patients unless patient has clear evidence of infection. 2. Avoid invasive devices (including central venous catheters, endotracheal tubes, and urinary catheters)and, if required, use no longer than necessary. They pose a major risk for infections. 3. Don’t perform urinalysis, urine culture, blood culture, or Clostridium difficile testing unless patients have signs or symptoms of infection. Tests can be falsely positive leading to overdiagnosis and overtreatment. 4. Do not use antibiotics in patients with recent C. difficile without convincing evidence of need. Antibiotics pose a high risk of C. difficile recurrence. 5. Don’t continue surgical prophylactic antibiotics after the patient has left the operating room. Five runner-up recommendations are included.

These 5 SHEA Choosing Wisely and 5 runner-up items limit medical overuse.

Infect Control Hosp Epidemiol 2016;37:755–760

Recerntly, the role of the healthcare network, defined as a set of hospitals linked by patient transfers, has been increasingly considered in the control of antimicrobial resistance. Here, we investigate the potential impact of nursing homes on the spread of antimicrobial-resistant pathogens across the healthcare network and its importance for control strategies.

Based on patient transfer data, we designed a network model representing the Dutch healthcare system of hospitals and nursing homes. We simulated the spread of an antimicrobial-resistant pathogen across the healthcare network, and we modeled transmission within institutions using a stochastic susceptible–infected–susceptible (SIS) epidemic model. Transmission between institutions followed transfers. We identified the contribution of nursing homes to the dispersal of the pathogen by comparing simulations of the network with and without nursing homes.

Our results strongly suggest that nursing homes in the Netherlands have the potential to drive and sustain epidemics across the healthcare network. Even when the daily probability of transmission in nursing homes is much lower than in hospitals, transmission of resistance can be more effective because of the much longer length of stay of patients in nursing homes.

If an antimicrobial-resistant pathogen emerges that spreads easily within nursing homes, control efforts aimed at hospitals may no longer be effective in preventing nationwide outbreaks. It is important to consider nursing homes in planning regional and national infection control and in implementing surveillance systems that monitor the spread of antimicrobial resistance.

Infect Control Hosp Epidemiol 2016;37:761–767

To describe the burden of extended-spectrum β-lactamase (ESBL) Enterobacteriaceae in veterans with spinal cord injury or disorder (SCI/D), to identify risk factors for ESBL acquisition, and to assess impact on clinical outcomes

Retrospective case-case-control study

Veterans with SCI/D and utilization at a Veterans’ Affairs medical center from January 1, 2012, to December 31, 2013.

Patients with a positive culture for ESBL Klebsiella pneumoniae, Escherichia coli, or Proteus mirabilis were matched with patients with non-ESBL organisms by organism, facility, and level of care and to uninfected controls by facility and level of care. Inpatients were also matched by time at risk. Univariate and multivariate matched models were assessed for differences in risk factors and outcomes.

A total of 492 cases (62.6% outpatients) were matched 1:1 with each comparison group. Recent prior use of fluoroquinolones and prior use of third- and fourth-generation cephalosporins were independently associated with ESBL compared to the non-ESBL group (adjusted odds ratio [aOR], 2.61; 95% confidence interval [CI], 1.77–3.84; P<.001 for fluoroquinolones and aOR, 3.86; 95% CI, 2.06–7.25; P<.001 for third- and fourth-generation cephalosporins) and the control group (aOR, 2.10; 95% CI, 1.29–3.43; P = .003 for fluoroquinolones; and aOR, 3.31; 95% CI, 1.56–7.06; P=.002 for third- and fourth-generation cephalosporins). Although there were no differences in mortality rate, the ESBL group had a longer post-culture length of stay (LOS) than the non-ESBL group (incidence rate ratio, 1.36; 95% CI, 1.13–1.63; P=.001).

All SCI/D patients with ESBL were more likely to have had recent exposure to fluoroquinolones or third- and fourth-generation cephalosporins, and hospitalized patients were more likely to have increased post-culture LOS. Programs targeted toward reduced antibiotic use in SCI/D patients may prevent subsequent ESBL acquisition.

Infect Control Hosp Epidemiol 2016;37:768–776

To concomitantly determine the differential degrees of air and environmental contamination by Acinetobacter baumannii based on anatomic source of colonization and type of ICU layout (single-occupancy vs open layout).

Longitudinal prospective surveillance study of air and environmental surfaces in patient rooms.

A 1,500-bed public teaching hospital in Miami, Florida.

Consecutive A. baumannii–colonized patients admitted to our ICUs between October 2013 and February 2014.

Air and environmental surfaces of the rooms of A. baumannii–colonized patients were sampled daily for up to 10 days. Pulsed-field gel electrophoresis (PFGE) was used to type and match the matching air, environmental, and clinical A. baumannii isolates.

A total of 25 A. baumannii–colonized patients were identified during the study period; 17 were colonized in the respiratory tract and 8 were colonized in the rectum. In rooms with rectally colonized patients, 38.3% of air samples were positive for A. baumannii; in rooms of patients with respiratory colonization, 13.1% of air samples were positive (P=.0001). In rooms with rectally colonized patients, 15.5% of environmental samples were positive for A. baumannii; in rooms of patients with respiratory colonization, 9.5% of environmental samples were positive (P=.02). The rates of air contamination in the open-layout and single-occupancy ICUs were 17.9% and 21.8%, respectively (P=.5). Environmental surfaces were positive in 9.5% of instances in open-layout ICUs versus 13.4% in single-occupancy ICUs (P=.09).

Air and environmental surface contaminations were significantly greater among rectally colonized patients; however, ICU layout did not influence the rate of contamination.

Infect Control Hosp Epidemiol 2016;37:777–781

To determine the impact of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus (MRSA/VRE) designations, or flags, on selected hospital operational outcomes.

Retrospective cohort study of inpatients admitted to the Massachusetts General Hospital during 2010–2011.

Operational outcomes were time to bed arrival, acuity-unrelated within-hospital transfers, and length of stay. Covariates considered included demographic and clinical characteristics: age, gender, severity of illness on admission, admit day of week, residence prior to admission, hospitalization within the prior 30 days, clinical service, and discharge destination.

Overall, 81,288 admissions were included. After adjusting for covariates, patients with a MRSA/VRE flag at the time of admission experienced a mean delay in time to bed arrival of 1.03 hours (9.63 hours [95% CI, 9.39–9.88] vs 8.60 hours [95% CI, 8.47–8.73]). These patients had 1.19 times the odds of experiencing an acuity-unrelated within-hospital transfer [95% CI, 1.13–1.26] and a mean length of stay 1.76 days longer (7.03 days [95% CI, 6.82–7.24] vs 5.27 days [95% CI, 5.15–5.38]) than patients with no MRSA/VRE flag.

MRSA/VRE designation was associated with delays in time to bed arrival, increased likelihood of acuity-unrelated within-hospital transfers and extended length of stay. Efforts to identify patients who have cleared MRSA/VRE colonization are critically important to mitigate inefficient use of resources and to improve inpatient flow.

Infect Control Hosp Epidemiol 2016;37:782–790

To determine whether daily chlorhexidine gluconate (CHG) bathing of intensive care unit (ICU) patients leads to a decrease in hospital-acquired infections (HAIs), particularly infections caused by methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE).

Interrupted time series analysis.

The study included 33 community hospitals participating in the Duke Infection Control Outreach Network from January 2008 through December 2013.

All ICU patients at study hospitals during the study period.

Of the 33 hospitals, 17 hospitals implemented CHG bathing during the study period, and 16 hospitals that did not perform CHG bathing served as controls. Primary pre-specified outcomes included ICU central-line–associated bloodstream infections (CLABSIs), primary bloodstream infections (BSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infections (CAUTIs). MRSA and VRE HAIs were also evaluated.

Chlorhexidine gluconate (CHG) bathing was associated with a significant downward trend in incidence rates of ICU CLABSI (incidence rate ratio [IRR], 0.96; 95% confidence interval [CI], 0.93–0.99), ICU primary BSI (IRR, 0.96; 95% CI, 0.94–0.99), VRE CLABSIs (IRR, 0.97; 95% CI, 0.97–0.98), and all combined VRE infections (IRR, 0.96; 95% CI, 0.93–1.00). No significant trend in MRSA infection incidence rates was identified prior to or following the implementation of CHG bathing.

In this multicenter, real-world analysis of the impact of CHG bathing, hospitals that implemented CHG bathing attained a decrease in ICU CLABSIs, ICU primary BSIs, and VRE CLABSIs. CHG bathing did not affect rates of specific or overall infections due to MRSA. Our findings support daily CHG bathing of ICU patients.

Infect Control Hosp Epidemiol 2016;37:791–797

To improve the patient safety of very-low-birthweight infants in neonatal departments in Germany.

Multicenter cohort study with a baseline (24 months), an intervention (12 months), and a postinterventional follow-up period (12 months) and time series analysis.

Very-low-birthweight patients from 32 neonatal departments in Germany.

Neonatal departments showing a standardized infection ratio of bloodstream infection 10% higher than the expected number (standardized infection ratio ≥1.1) were invited to participate in the study. To reduce the occurrence of primary bloodstream infections, evidence-based bundles to improve catheter maintenance routines, insertion practice, and hand-hygiene compliance were implemented in the participating infirmaries.

Thirty-four departments participated in the study and 32 reported data. In total, 6,222 very-low-birthweight infants with 231,868 patient-days and 1,405 cases of bloodstream infections were analyzed. In the baseline period the pooled mean bloodstream infection rate was 6.63 (95% CI, 6.17–7.12) per 1,000 patient-days. The bloodstream infection rate decreased in the intervention period to 5.68 (relative risk, 0.86 [95% CI, 0.76–0.97]) and in the 1-year follow-up period to 5.31 per 1,000 patient-days (relative risk, 0.80 [95% CI, 0.70–0.92]). The multivariable time series analysis of monthly aggregated data showed a significant change in the slope for the frequency of bloodstream infections from the start to the end of the intervention (change in slope incidence rate ratio, 0.97; P=.001).

The implementation of an intervention bundle is feasible and can reduce bloodstream infections in neonatal departments.

Infect Control Hosp Epidemiol 2016;37:798–804

To describe compliance with the central line (CL) insertion bundle overall and with individual bundle elements in US adult intensive care units (ICUs) and to determine the relationship between bundle compliance and central line–associated bloodstream infection (CLABSI) rates.

Cross-sectional study.

National sample of adult ICUs participating in National Healthcare Safety Network (NHSN) surveillance.

Hospitals were surveyed to determine compliance with CL insertion bundle elements in ICUs. Corresponding NHSN ICU CLABSI rates were obtained. Multivariate Poisson regression models were used to assess associations between CL bundle compliance and CLABSI rates, controlling for hospital and ICU characteristics.

A total of 984 adult ICUs in 632 hospitals were included. Most ICUs had CL bundle policies, but only 69% reported excellent compliance (≥95%) with at least 1 element. Lower CLABSI rates were associated with compliance with just 1 element (incidence rate ratio [IRR] 0.77; 95% confidence interval [CI], 0.64–0.92); however, ≥95% compliance with all 5 elements was associated with the greatest reduction (IRR, 0.67; 95% CI, 0.59–0.77). There was no association between CLABSI rates and simply having a written CL bundle policy nor with bundle compliance <75%. Additionally, better-resourced infection prevention departments were associated with lower CLABSI rates.

Our findings demonstrate the impact of transferring infection prevention interventions to the real-world setting. Compliance with the entire bundle was most effective, although excellent compliance with even 1 bundle element was associated with lower CLABSI rates. The variability in compliance across ICUs suggests that, at the national level, there is still room for improvement in CLABSI reduction.

Infect Control Hosp Epidemiol 2016;37:805–810

The number of peripherally inserted central catheter (PICC) lumens is associated with thrombotic and infectious complications. Because multilumen PICCs are not necessary in all patients, policies that limit their use may improve safety and cost.

To design a simulation-based analysis to estimate outcomes and cost associated with a policy that encourages single-lumen PICC use.

Model inputs, including risk of complications and costs associated with single- and multilumen PICCs, were obtained from available literature and a multihospital collaborative quality improvement project. Cost savings and reduction in central line–associated bloodstream infection and deep vein thrombosis events from institution of a single-lumen PICC default policy were reported.

According to our model, a hospital that places 1,000 PICCs per year (25% of which are single-lumen and 75% multilumen) experiences annual PICC-related maintenance and complication costs of $1,228,598 (95% CI, $1,053,175–$1,430,958). In such facilities, every 5% increase in single-lumen PICC use would prevent 0.5 PICC-related central line-associated bloodstream infections and 0.5 PICC-related deep vein thrombosis events, while saving $23,500. Moving from 25% to 50% single-lumen PICC utilization would result in total savings of $119,283 (95% CI, $74,030–$184,170) per year. Regardless of baseline prevalence, a single-lumen default PICC policy would be associated with approximately 10% cost savings. Findings remained robust in multiway sensitivity analyses.

Hospital policies that limit the number of PICC lumens may enhance patient safety and reduce healthcare costs. Studies measuring intended and unintended consequences of this approach, followed by rapid adoption, appear necessary.

Infect Control Hosp Epidemiol 2016;37:811–817

To determine the clinical diagnoses associated with the National Healthcare Safety Network (NHSN) pneumonia (PNEU) or lower respiratory infection (LRI) surveillance events

Retrospective chart review

A convenience sample of 8 acute-care hospitals in Pennsylvania

All patients hospitalized during 2011–2012

Medical records were reviewed from a random sample of patients reported to the NHSN to have PNEU or LRI, excluding adults with ventilator-associated PNEU. Documented clinical diagnoses corresponding temporally to the PNEU and LRI events were recorded.

We reviewed 250 (30%) of 838 eligible PNEU and LRI events reported to the NHSN; 29 reported events (12%) fulfilled neither PNEU nor LRI case criteria. Differences interpreting radiology reports accounted for most misclassifications. Of 81 PNEU events in adults not on mechanical ventilation, 84% had clinician-diagnosed pneumonia; of these, 25% were attributed to aspiration. Of 43 adult LRI, 88% were in mechanically ventilated patients and 35% had no corresponding clinical diagnosis (infectious or noninfectious) documented at the time of LRI. Of 36 pediatric PNEU events, 72% were ventilator associated, and 70% corresponded to a clinical pneumonia diagnosis. Of 61 pediatric LRI patients, 84% were mechanically ventilated and 21% had no corresponding clinical diagnosis documented.

In adults not on mechanical ventilation and in children, most NHSN-defined PNEU events corresponded with compatible clinical conditions documented in the medical record. In contrast, NHSN LRI events often did not. As a result, substantial modifications to the LRI definitions were implemented in 2015.

Infect Control Hosp Epidemiol 2016;37:818–824

To determine the effect of graft choice (allograft, bone-patellar tendon-bone autograft, or hamstring autograft) on deep tissue infections following anterior cruciate ligament (ACL) reconstructions.

Retrospective cohort study.

Patients from 6 US health plans who underwent ACL reconstruction from January 1, 2000, through December 31, 2008.

We identified ACL reconstructions and potential postoperative infections using claims data. A hierarchical stratified sampling strategy was used to identify patients for medical record review to confirm ACL reconstructions and to determine allograft vs autograft tissue implanted, clinical characteristics, and infection status. We estimated infection rates overall and by graft type. We used logistic regression to assess the association between infections and patients’ demographic characteristics, comorbidities, and choice of graft.

On review of 1,452 medical records, we found 55 deep wound infections. With correction for sampling weights, infection rates varied by graft type: 0.5% (95% CI, 0.3%-0.8%) with allografts, 0.6% (0.1%–1.5%) with bone-patellar tendon-bone autografts, and 2.5% (1.9%–3.1%) with hamstring autograft. After adjusting for potential confounders, we found an increased infection risk with hamstring autografts compared with allografts (odds ratio, 5.9; 95% CI, 2.8–12.8). However, there was no difference in infection risk among bone-patellar tendon-bone autografts vs allografts (odds ratio, 1.2; 95% CI, 0.3–4.8).

The overall risk for deep wound infections following ACL reconstruction is low but it does vary by graft type. Infection risk was highest in hamstring autograft recipients compared with allograft recipients and bone-patellar tendon-bone autograft recipients.

Infect Control Hosp Epidemiol 2016;37:827–833

To improve hand hygiene (HH) compliance among physicians and nurses in a rural hospital in sub-Saharan Africa (SSA) using the World Health Organization’s (WHO’s) Guidelines on Hand Hygiene in Health Care.

This study was a quasi-experimental design divided into 4 phases: (1) preparation of materials and acquisition of the hospital administration’s support, (2) baseline evaluation, (3) intervention, and (4) follow-up evaluation.

A 160-bed, non-referral hospital in Gitwe, Rwanda

A total of 12 physicians and 54 nurses participated in this study.

The intervention consisted of introducing locally produced alcohol-based hand rub (ABHR); educating healthcare workers (HCWs) on proper HH practice; providing pocket-sized ABHR bottles for HCWs; placing HH reminders in the workplace; and surveying HCWs at surrounding health centers regarding HH compliance barriers. Hand hygiene infrastructure, compliance, and knowledge were assessed among physicians and nurses using baseline observations and a follow-up evaluation survey.

Overall, HH compliance improved from 34.1% at baseline to 68.9% post intervention (P<.001), and HH knowledge was significantly enhanced (P<.001). The 3 departments included in this study had only 1 sink for 29 patient rooms, and 100% of HH opportunities used ABHR. Hand hygiene compliance was significantly higher among physicians than nurses both before and after the intervention. All measures of HH compliance improved except for “after body fluid exposure,” which was 51.7% before intervention and 52.8% after intervention (P>.05).

Hand hygiene campaigns using WHO methods in SSA have been implemented exclusively in large, referral hospitals. This study shows that an HH program using the WHO tools successfully improved HH in a low-income, rural hospital in SSA.

Infect Control Hosp Epidemiol 2016;37:834–839

To evaluate the effect of healthcare worker (HCW) influenza vaccination on the incidence of nosocomial influenza

Retrospective cross-sectional study

A 550-bed tertiary-care academic medical center

All admitted patients with a direct fluorescent antibody (DFA) or polymerase chain reaction (PCR) assay positive for influenza ordered between October 1 and May 31 from 2010 to 2015 were eligible for inclusion. Nosocomial influenza was defined as a positive influenza test collected ≥48 hours after admission in patients without influenza-like illness present within 24 hours of admission. Relative nosocomial influenza frequency was calculated by dividing the number of nosocomial cases by the total number of admitted patients with influenza for each season. A univariate logistic regression was used to determine the association between HCW influenza vaccination coverage and nosocomial influenza.

Over 5 seasons, 533 patients had positive influenza tests during their hospitalization; 29 of these patients (5.4%) acquired influenza during their hospitalization. HCW vaccination coverage increased over the 5 seasons from 47% to 90% (P<.001). Despite an initial decrease in relative nosocomial influenza frequency during the first year (9% to 4.9%), subsequent seasons failed to show an additional decrease in nosocomial infections (4.3%, 5.2%, and 4.8%, respectively); the overall decrease in nosocomial influenza from the first season to the final season was not significant (P=.282). No association was detected between HCW vaccination coverage and nosocomial influenza (odds ratio [OR], 0.990; 95% confidence interval [CI], 0.970–1.011).

HCW vaccination >50% may not have a significant effect on nosocomial influenza.

Infect Control Hosp Epidemiol 2016;37:840–844

Invasive aspergillosis (IA) is a rare but severe infection caused by Aspergillus spp. that often develops in immunocompromised patients. Lethality remains high in this population. Therefore, preventive strategies are of key importance. The impact of a mobile air decontamination system (Plasmair, AirInSpace, Montigny-le-Bretonneux, France) on the incidence of IA in neutropenic patients was evaluated in this study.

Retrospective cohort study

Patients with chemotherapy-induced neutropenia lasting 7 days or more were included over a 2-year period. Cases of IA were confirmed using the revised European Organization for Research and Treatment of Cancer (EORTC) criteria. We took advantage of a partial installation of Plasmair systems in the hematology intensive care unit during this period to compare patients treated in Plasmair-equipped versus non-equipped rooms. Patients were assigned to Plasmair-equipped or non-equipped rooms depending only on bed availability. Differences in IA incidence in both groups were compared using Fisher’s exact test, and a multivariate analysis was performed to take into account potential confounding factors.

Data from 156 evaluable patients were available. Both groups were homogenous in terms of age, gender, hematological diagnosis, duration of neutropenia, and prophylaxis. A total of 11 cases of probable IA were diagnosed: 10 in patients in non-equipped rooms and only 1 patient in a Plasmair-equipped room. The odds of developing IA were much lower for patients hospitalized in Plasmair-equipped rooms than for patients in non-equipped rooms (P=.02; odds ratio [OR] =0.11; 95% confidence interval [CI], 0.00–0.84).

In this study, Plasmair demonstrated a major impact in reducing the incidence of IA in neutropenic patients with hematologic malignancies.

Infect Control Hosp Epidemiol 2016;37:845–851