To determine the rates of surgical-site infections (SSIs) after spinal surgery and to identify the risk factors associated with infection.

SSIs had been identified by active prospective surveillance. A case-control study to identify risk factors was performed retrospectively.

University-associated, tertiary-care pediatric hospital.

All patients who underwent spinal surgery between 1994 and 1998. Cases were all patients who developed an SSI after spinal surgery. Controls were patients who did not develop an SSI, matched with the cases for the presence or absence of myelodysplasia and for the surgery date closest to that of the case.

There were 10 infections following 125 posterior spinal fusions, 4 infections after 50 combined anterior-posterior fusions, and none after 95 other operations. The infection rate was higher in patients with myelodysplasia (32 per 100 operations) than in other patients (3.4 per 100 operations; relative risk = 9.45; P < .001). Gram-negative organisms were more common in early infections and Staphylococcus aureus in later infections. Most infections occurred in fusion involving sacral vertebrae (odds ratio [OR] = 12.0; P = .019). Antibiotic prophylaxis was more frequently suboptimal in cases than in controls (OR = 5.5; P = .034). Five patients required removal of instrumentation and 4 others required surgical debridement.

Patients with myelodysplasia are at a higher risk for SSIs after spinal fusion. Optimal antibiotic prophylaxis may reduce the risk of infection, especially in high-risk patients such as those with myelodysplasia or those undergoing fusion involving the sacral area.

To evaluate the efficacy of a multifaceted hospitalwide quality improvement program that featured an intervention to remind physicians to remove unnecessary urinary catheters.

A hospitalwide preintervention-postintervention study was conducted over 2 years (July 1, 2004, through June 30, 2006). The intervention consisted of nurse-generated daily reminders that were used by an intervention team to remind physicians to remove unnecessary urinary catheters, beginning 3 days after insertion. Clinical, microbiological, pharmaceutical, and cost data were collected.

A total of 2,412 patients were enrolled in the study. No differences were found in the demographic and/or clinical characteristics of patients between the preintervention and postintervention periods. After the intervention, reductions were found in the rate of inappropriate urinary catheterization (mean rate, preintervention vs postintervention, 20.4% vs 11% [P = .04]), the rate of catheter-associated urinary tract infection (CA-UTI) (mean rate, 21.5 vs 5.2 infections per 1,000 catheter-days [P <.001]), the duration of urinary catheterization (mean, 11 vs 3 days [P < .001]), and the total length of hospitalization (mean, 16 vs 5 days [P < .001]). A linear relationship was seen between the monthly average duration of catheterization and the rate of CA-UTI (r = 0.89; P < .001). The intervention had the greatest impact on the rate of CA-UTI in the intensive care units (mean rate, preintervention vs postintervention, 23.4 vs 3.5 infections per 1,000 catheter-days [P = .01]). The monthly hospital costs for antibiotics to treat CA-UTI were reduced by 63% (mean, $3,739 vs $1,378 [P < .001]), and the hospitalization cost for each patient during the intervention was reduced by 58% (mean, $366 vs $154 [P < .001]).

This study suggests that a multifaceted intervention to remind physicians to remove unnecessary urinary catheters can significantly reduced the duration of urinary catheterization and the CA-UTI rate in a hospital in a developing country.

To evaluate the utility and impact of using a declination form in the context of an influenza immunization program for healthcare workers.

A combined form for documentation of vaccination consent, medical contraindication(s) for vaccination, or vaccination declination was used during the 2006-2007 influenza season in a healthcare system employing approximately 9,200 nonphysician employees in 3 hospitals; a skilled nursing care facility; a large, multisite, faculty-practice plan; and an administrative building. Responses were entered into a database that contained files from human resources departments, which allowed correlation with job category and work location.

The overall levels of influenza vaccination coverage of employees increased from 43% (3,892 of 9,050) during the 2005-2006 season to 66.5% (6,123 of 9,214) during the 2006-2007 season. Of 9,214 employees, 1,898 (20.6%) signed the declination statement. Among the occupation groups, nurses had the lowest rate of declining vaccination (13.2% [393 of 2,970]; P < .0001), followed by pharmacy personnel (18.1% [40 of 221]), ancillary personnel with frequent patient contact (21.9% [169 of 771), and all others (24.7% [1,296 of 5,252]). Among the employees who declined vaccination, nurses were the least likely to select the reasons “afraid of needles” (3.8% [15 of 393], vs. 9.1% [137 of 1,505] for all other groups; P < .001) and “fear of getting influenza from the vaccine” (13.5% [53 of 393], vs. 20.5% [309 of 1,505]; P = .002). Seven pregnant nurses had been advised by their obstetricians to avoid vaccination. When declination of influenza vaccination was analyzed by age, 16% of personnel (797 of 4,980) 50 years of age and older declined to be vaccinated, compared with 26% of personnel (1,101 of 4,234) younger than 50 years of age {P < .0001).

Implementing use of the declination form during the 2006-2007 influenza season was one of several measures that led to a 55% increase in the acceptance of influenza vaccination by healthcare workers in our healthcare system. Although we cannot determine to what degree use of the declination form contributed to the increased rate of vaccination, use of this form helped the vaccination program assess the reasons for declination and will help to focus future vaccination campaigns.

To evaluate the receipt of information and knowledge about influenza and vaccination, as well as influenza vaccination status and reasons for declining vaccination, among registered nurses.

Cross-sectional survey of registered nurses (RNs).

A large tertiary medical center with a long-standing, multifaceted influenza vaccination program and relatively high vaccination rates among employees overall (76.5%).

Randomly selected group of 990 RNs employed as inpatient staff nurses at the institution.

The survey was completed by 513 (51.8%) of 990 RNs. Most RNs (86.7%) had received an influenza vaccination in the past, and 331 (64.5%) intended to receive vaccination during the 2005-2006 influenza season. More than 90% of RNs acknowledged exposure to educational bulletins, and most had received information about influenza severity (383 [74.7%]), transmission (398 [77.6%]), vaccine safety (416 [81.1%]), and the time and location of free vaccination (460 [89.7%]). A majority (436 [85.0%]) felt they had received all the information they needed to make good decisions about vaccination. However, only 49 RNs (9.6%) gave correct answers to more than 85% of the knowledge questions on the survey. The reasons most frequently reported for declining vaccination were doubts about the risk of influenza and the need for vaccination, concerns about vaccine effectiveness and side effects, and dislike of injections.

RNs exposed to a longstanding, multifaceted educational program had received information about influenza vaccination, but misconceptions were common and only 331 (64.5%) intended to receive vaccination. Strategies other than educational interventions are needed to increase influenza vaccination rates and thereby to ensure healthcare worker and patient safety.

To assess the prevalence of and the clinical features associated with asymptomatic Staphylococcus aureus colonization in a healthy outpatient population, and to compare the characteristics of colonizing methicillin-resistant S. aureus (MRSA) strains with those of strains causing infection in our community and hospital.

Outpatient military clinics.

Specimens were obtained from the nares, pharynx, and axillae of 404 outpatients, and a questionnaire was administered to obtain demographic and risk factor information. MRSA strains were typed by pulsed-field gel electrophoresis (PFGE) and evaluated for antibiotic susceptibility. Antibiograms of study MRSA strains were compared with those of MRSA strains causing clinical illness during the same time period.

Methicillin-susceptible S. aureus (MSSA) colonization was present in 153 (38%) of the 404 asymptomatic outpatients, and MRSA colonization was present in 8 (2%). Detection of colonization was highest from the nares. No clinical risk factor was significantly associated with MRSA colonization; however, a tendency was noted for MRSA to be more common in men and in those who were older or who had been recently hospitalized. All colonizing MRSA strains had unique patterns on PFGE. In contrast to strains responsible for hospital infections, most colonizing isolates of MRSA were susceptible to oral antibiotics.

MRSA and MSSA colonization is common in our outpatient population. Colonization is best detected by nares cultures and most carriers of MRSA are without apparent predisposing risk factors for acquisition. Colonizing isolates of MRSA are heterogeneous and, unlike nosocomial isolates, often retain susceptibility to other non-beta-lactam antibiotics.

To describe an outbreak of hospital-acquired MRSA in a NICU and to identify the risk factors for, outcomes of, and interventions that eliminated it.

An 18-bed, level III-IV NICU in a community hospital.

Interventions to control MRSA included active surveillance, aggressive contact isolation, and cohorting and decolonization of infants and HCWs with MRSA. A case–control study was performed to compare infants with and without MRSA.

A cluster of 6 cases of MRSA infection between September and October 2001 represented an increased attack rate of 21.2% compared with 5.3% in the previous months. Active surveillance identified unsuspected MRSA colonization in 6 (21.4%) of 28 patients and 6 (5.5%) of 110 HCWs screened. They were all successfully decolonized. There was an increased risk of MRSA colonization and infection among infants with low birth weight or younger gestational age. Multiple gestation was associated with an increased risk of colonization (OR, 37.5; CI95, 3.9–363.1) and infection (OR, 5.36; CI95, 1.37–20.96). Gavage feeding (OR, 10.33; CI95, 1.28–83.37) and intubation (OR, 5.97; CI95, 1.22–29.31) were associated with increased risk of infection. Infants with MRSA infection had a significantly longer hospital stay than infants without MRSA (51.83 vs 21.46 days; P = .003). Rep-PCR with mec typing and PVL analysis confirmed the presence of a single common strain of hospital-acquired MRSA.

Active surveillance, aggressive implementation of contact isolation, cohorting, and decolonization effectively eradicated MRSA from the NICU for 2½ years following the outbreak. (Infect Control Hosp Epidemiol 2005;26:616-621)

To determine the range and the mode of germicidal activity of sterilants generated by a nonthermal plasma sterilization system for microorganisms.

Representative bacteria, spores, viruses, bacteriophages, and fungi were exposed to the plasma cycle and the residual viability was measured in vitro. To assess the mode of lethal injury, Escherichia coli, Staphylococcus aureus, Bacillus atrophaeus, and bacteriophages were exposed to the plasma cycle, and the effects of the plasma-generated sterilants on the biological parameters were determined.

There were at least 4-6 log reductions in viability for all microorganisms after 10 minutes of exposure to the plasma cycle. Electron micrographs and studies of the inhibition of bacteriophage infectivity suggested that the primary injury is to the organisms' cell envelopes. The plasma cycle also denatured isolated bacterial proteins and inactivated bacteriophages, but it had no effect on isolated DNA and bacterial proteins within exposed bacteria.

Nonthermal plasma, which is produced at atmospheric temperature and pressure, generates sterilants that kill high concentrations of microorganisms and inactivate viruses during a 10-minute exposure. The primary injury appears to be at the surface structures of the organisms. This suggests that nonthermal plasma has utility for sterilization of heat-sensitive medical materials and devices.

To identify differences between unit-specific and hospital-wide antibiograms and to determine the potential impact of these differences on selection of empirical antimicrobial therapy.

A 625-bed tertiary care medical center.

Antimicrobial susceptibility results were collected for all inpatient clinical bacterial isolates recovered over a 3-year period; isolates were categorized by the hospital location of the patient at the time of sampling and by the anatomic site from which the isolate was recovered. Antibiograms from each unit were compiled for the most commonly isolated organisms and were compared to the hospital-wide antibiogram.

A total of 9,970 bacterial isolates were evaluated in this study, including 2,646 enterococcal isolates, 2,806 S. aureus isolates, 2,795 E. coli isolates, and 1,723 Pseudomonas aeruginosa isolates. The percentages of bacterial isolates resistant to antimicrobials were significantly higher in the medical ICU and surgical ICU than the hospital-wide antibiogram would have predicted, whereas the percentages of isolates susceptible to antimicrobials were significantly higher in the non-ICU units, compared with the hospital overall. However, on general medicine units, the prevalence of susceptibility to levofloxacin was significantly lower than that for the hospital overall.

Unit-specific antibiograms are important for making informed decisions about empirical antimicrobial therapy, because the hospital-wide antibiogram may mask important differences in susceptibility rates across different units. These differences may have important implications for selecting the optimal empirical antimicrobial therapy.

To compare the microbiological efficacy of hydrogen peroxide vapor (HPV) and ultraviolet radiation (UVC) for room decontamination.

Prospective observational study.

500-bed teaching hospital.

HPV and UVC processes were performed in 15 patient rooms. Five high-touch sites were sampled before and after the processes and aerobic colony counts (ACCs) were determined. Carrier disks with ~106Clostridium difficile (CD) spores and biological indicators (BIs) with 104 and 106Geobacillus stearothermophilus spores were placed in 5 sites before decontamination. After decontamination, CD log reductions were determined and BIs were recorded as growth or no growth.

93% of ACC samples that had growth before HPV did not have growth after HPV, whereas 52% of sites that had growth before UVC did not have growth after UVC (P < .0001). The mean CD log reduction was >6 for HPV and ~2 for UVC. After HPV 100% of the 104 BIs did not grow, and 22% did not grow after UVC, with a range of 7%–53% for the 5 sites. For the 106 BIs, 99% did not grow after HPV and 0% did not grow after UVC. Sites out of direct line of sight were significantly more likely to show growth after UVC than after HPV. Mean cycle time was 153 (range, 140–177) min for HPV and 73 (range, 39–100) min for UVC (P < .0001).

Both HPV and UVC reduce bacterial contamination, including spores, in patient rooms, but HPV is significantly more effective. UVC is significantly less effective for sites that are out of direct line of sight.

To detail the activities of the Veterans Health Administration (VHA) Antimicrobial Stewardship Initiative and evaluate outcomes of the program.

Observational analysis.

The VHA is a large integrated healthcare system serving approximately 6 million individuals annually at more than 140 medical facilities.

Utilization of nationally developed resources, proportional distribution of antibiotics, changes in stewardship practices and patient safety measures were reported. In addition, inpatient antimicrobial use was evaluated before and after implementation of national stewardship activities.

Nationally developed stewardship resources were well utilized, and many stewardship practices significantly increased, including development of written stewardship policies at 92% of facilities by 2015 (P<.05). While the proportional distribution of antibiotics did not change, inpatient antibiotic use significantly decreased after VHA Antimicrobial Stewardship Initiative activities began (P<.0001). A 12% decrease in antibiotic use was noted overall. The VHA has also noted significantly declining use of antimicrobials prescribed for resistant Gram-negative organisms, including carbapenems, as well as declining hospital readmission and mortality rates. Concurrently, the VHA reported decreasing rates of Clostridium difficile infection.

The VHA National Antimicrobial Stewardship Initiative includes continuing education, disease-specific guidelines, and development of example policies in addition to other highly utilized resources. While no specific ideal level of antimicrobial utilization has been established, the VHA has shown that improving antimicrobial usage in a large healthcare system may be achieved through national guidance and resources with local implementation of antimicrobial stewardship programs.

Infect Control Hosp Epidemiol 2017;38:513–520

Research suggests that patients could improve healthcare workers' compliance with hand hygiene recommendations by reminding them to cleanse their hands.

To assess patients' perceptions of a patient-participation program to improve healthcare workers' compliance with hand hygiene.

Cross-sectional survey of patient knowledge and perceptions of healthcare-associated infections, hand hygiene, and patient participation, defined as the active involvement of patients in various aspects of their health care.

Large Swiss teaching hospital.

Of 194 patients who participated, most responded that they would not feel comfortable asking a nurse (148 respondents [76%]) or a physician (150 [77%]) to perform hand hygiene, and 57 (29%) believed that this would help prevent healthcare-associated infections. In contrast, an explicit invitation from a healthcare worker to ask about hand hygiene doubled the intention to ask a nurse (from 34% to 83% of respondents; P < .001) and to ask a physician (from 30% to 78%; P < .001). In multivariate analysis, being nonreligious, having an expansive personality, being concerned about healthcare-associated infections, and believing that patient participation would prevent healthcare-associated infections were associated with the intention to ask a nurse or a physician to perform hand hygiene (P < .05). Being of Jewish, Eastern Orthodox, or Buddhist faith was associated also with increased intention to ask a nurse (P < .05), compared with being of Christian faith.

This study identifies several sociodemographic characteristics associated with the intention to ask nurses and physicians about hand hygiene and underscores the importance of a direct invitation from healthcare workers to increase patient participation and foster patient empowerment. These findings could guide the development of future hand hygiene-promotion strategies.

Several hospitals opting not to use active surveillance cultures to identify carriers of vancomycin-resistant Enterococcus (VRE) have reported that adoption of other parts of the Centers for Disease Control and Prevention guideline for controlling VRE has had little to no impact. Because use of surveillance cultures and contact isolation controlled a large outbreak at this hospital, their costs were estimated for comparison with the excess costs of VRE bacteremias occurring at a higher rate at a hospital not employing these measures.

Two university hospitals.

Inpatients deemed high risk for VRE acquisition at this hospital underwent weekly perirectal surveillance cultures. Estimated costs of cultures and resulting isolation during a 2-year period were compared with the estimated excess costs of more frequent VRE bacteremias at another hospital of similar size and complexity not using surveillance cultures to control spread throughout the hospital.

Of 54,052 patients admitted, 10,400 had perirectal swabs taken. Cultures and isolation cost an estimated $253,099. VRE culture positivity was limited to 193 (0.38%) and VRE bacteremia to 1 (0.002%) as compared with 29 bacteremias at the comparison hospital. The estimated attributable cost of VRE bacteremia at the comparison hospital of $761,320 exceeded the cost of the control program at this hospital by threefold.

The excess costs of VRE bacteremia may justify the costs of preventive measures. The costs of VRE infections at other body sites, of deaths from untreatable infections, and of dissemination of genes for vancomycin resistance also help to justify the costs of implementing an effective control program.

The purpose of the study was to determine the incidence and risk factors for the acquisition of methicillin-resistant Staphylococcus aureus (MRSA) in our community.

This study used a cross-sectional design to assess patients colonized or infected with MRSA.

The study population consisted of residents of London, Ontario, Canada, who were identified as MRSA-positive for the first time in 1997.

All acute- and chronic-care hospitals, long-term healthcare facilities, and community physicians' offices in the city of London participated in the study.

Incidence of MRSA in the community, risk factors for acquisition, especially previous hospitalization over a defined period, and strain type were evaluated.

In 1997, 331 residents of London were newly identified as MRSA-positive, representing an annual incidence of 100/100,000 persons (95% confidence interval, 88.8-110.7). Thirty-one (9.4%) individuals were not healthcare-facility patients in the previous month, and 11 (3.3%), 10 (3.0%), and 6 (1.8%) individuals had no such contact in the previous 3, 6, and 12 months, respectively. One hundred seventy-seven strains, including five of the isolates from patients with no healthcare-facility contact in the previous year, were typed. One hundred sixty (90.3%) of these isolates, including all typed strains from patients with no healthcare facility contact, belonged to a single clone.

These findings demonstrate that the incidence of MRSA is higher than previously reported and that hospital contact is the single most important risk factor for the acquisition of MRSA in our community. Screening for MRSA in previously hospitalized patients at the time of hospitalization may reduce nosocomial spread and indirectly reduce the incidence of MRSA in the community.