Our aim was to evaluate the impact of aerators on water microbiological contamination in at-risk hospital departments, with a view to quantifying the possible risk of patient exposure to waterborne microorganisms.

We analyzed the microbiological and chemical-physical characteristics of hot and cold water in some critical hospital departments.

Two hospitals in northern Italy.

We took 304 water samples over a 1-year period, at 3-month intervals, from taps used by healthcare personnel for handwashing, surgical washing, and the washing of medical equipment. We analyzed heterotrophic plate counts (HPCs) at 36°C and 22°C, nonfastidious gram-negative bacteria (GNB-NE), and Legionella pneumophila.

The percentages of positivity and mean values of HPCs at 22°C, HPCs at 36°C, and GNB-NE loads were significantly higher at outlet points than in the plumbing system. In particular, GNB-NE positivity was higher at outlet points than in the plumbing system in both the cold water (31.58% vs 6.58% of samples were positive) and hot water (21.05% vs 3.95%) supplies. Our results also revealed contamination by L. pneumophila both in the plumbing system and at outlet points, with percentages of positive samples varying according to the serogroup examined (serogroups 1 and 2-14). The mean concentrations displayed statistically significant (P < .001) differences between the outlet points (27,382.89 ± 42,245.33 colony-forming units [cfu]/L) and the plumbing system (19,461.84 ± 29,982.11 cfu/L).

These results reveal a high level of contamination of aerators by various species of gram-negative opportunists that are potentially very dangerous for immunocompromised patients and, therefore, the need to improve the management of these devices.

Overutilization of antimicrobial therapy places patients at risk for harm and contributes to antimicrobial resistance and escalating healthcare costs. Focusing on redundant or duplicate antimicrobial therapy is 1 recommended strategy to reduce overutilization and its attendant effects on patient safety and hospital costs

This study explored the incidence and economic impact of potentially redundant antimicrobial therapy.

We conducted a retrospective analysis of inpatient administrative data drawn from 505 nonfederal US hospitals. All hospitalized patients discharged between January 1, 2008, and December 31, 2011, were eligible for study inclusion. Potentially redundant antimicrobial therapy was identified from pharmacy records and was defined as patients receiving treatment with overlapping antibiotic spectra for 2 or more consecutive days.

We found evidence of potentially inappropriate, redundant antimicrobial coverage for 23 different antimicrobial combinations in 394 of the 505 (78%) hospitals, representing a total of 32,507 cases. High-frequency redundancies were observed in 3 antianaerobic regimens, accounting for 22,701 (70%) of the cases. Of these, metronidazole and piperacillin-tazobactam accounted for 53% (n = 17,326) of all potentially redundant cases. Days of redundant therapy totaled 148,589, representing greater than $12 million in potentially avoidable healthcare costs.

Our study suggests that there may be pervasive use of redundant antimicrobial therapy within US hospitals. Appropriate use of antimicrobials may reduce the risk of harm to patients and lower healthcare costs.

Although prior authorization and prospective audit with feedback are both effective antimicrobial stewardship program (ASP) strategies, the relative impact of these approaches remains unclear. We compared these core ASP strategies at an academic medical center.

Quasi-experimental study.

We compared antimicrobial use during the 24 months before and after implementation of an ASP strategy change. The ASP used prior authorization alone during the preintervention period, June 2007 through May 2009. In June 2009, many antimicrobials were unrestricted and prospective audit was implemented for cefepime, piperacillin/tazobactam, and vancomycin, marking the start of the postintervention period, July 2009 through June 2011. All adult inpatients who received more than or equal to 1 dose of an antimicrobial were included. The primary end point was antimicrobial consumption in days of therapy per 1,000 patient-days (DOT/1,000-PD). Secondary end points included length of stay (LOS).

In total, 55,336 patients were included (29,660 preintervention and 25,676 postintervention). During the preintervention period, both total systemic antimicrobial use (−9.75 DOT/1,000-PD per month) and broad-spectrum anti-gram-negative antimicrobial use (−4.00 DOT/1,000-PD) declined. After the introduction of prospective audit with feedback, however, both total antimicrobial use (+9.65 DOT/1,000-PD per month; P < .001) and broad-spectrum anti-gram-negative antimicrobial use (+4.80 DOT/1,000-PD per month; P < .001) increased significantly. Use of cefepime and piperacillin/tazobactam both significantly increased after the intervention (P = .03). Hospital LOS and LOS after first antimicrobial dose also significantly increased after the intervention (P = .016 and .004, respectively).

Significant increases in antimicrobial consumption and LOS were observed after the change in ASP strategy.

Infect Control Hosp Epidemiol 2014;35(9):1092-1099

We determined the percentage of healthcare workers' (HCWs') hands contaminated with Clostridium difficile spores after caring for patients with C. difficile infection (CDI) and risk factors associated with contamination.

Prospective study.

A French university hospital.

We compared the hand contamination rate among HCWs caring for patients with CDI (exposed group; n = 66) with that among an unexposed group (n = 44). Spores of C. difficile were recovered from the hands of HCWs after rubbing their fingers and palms in alcohol shortly after patient care. Associations between hand contamination and HCW category, type (patient or environment), and risk level (high or low risk) of HCW contacts and their respective duration as well as use of gloves were analyzed by bivariate and multivariate analysis.

C. difficile spores were detected on 24% of HCWs' hands in the exposed group and on 0% in the unexposed group (P < .001). In the exposed group, logistic regression, which adjusted for high-risk contact (ie, exposure to fecal soiling), contact with the environment, and contact with or without use of gloves, revealed that high-risk contact (adjusted odds ratio [aOR] per 1 contact increment, 2.78; 95% confidence interval [CI], 1.42–5.45; P = .003) and at least 1 contact without use of gloves (aOR, 6.26; 95% CI, 1.27–30.78; P = .02) were independently associated with HCW hand contamination by C. difficile spores.

Nearly one-quarter of HCWs have hands contaminated with C. difficile spores after routine care of patients with CDI. Hand contamination is positively associated with exposure to fecal soiling and lack of glove use.

Carbapenem-resistant Enterobacteriaceae (CRE) are clinically challenging, threaten patient safety, and represent an emerging public health issue. CRE reporting is not mandated in Michigan.

The Michigan Department of Community Health–led CRE Surveillance and Prevention Initiative enrolled 21 facilities (17 acute care and 4 long-term acute care facilities) across the state. Baseline data collection began September 1, 2012, and ended February 28, 2013 (duration, 6 months). Enrolled facilities voluntarily reported cases of Klebsiella pneumoniae and Escherichia coli according to the surveillance algorithm. Patient demographic characteristics, laboratory testing, microbiology, clinical, and antimicrobial information were captured via standardized data collection forms. Facilities reported admissions and patient-days each month.

One-hundred two cases over 957,220 patient-days were reported, resulting in a crude incidence rate of 1.07 cases per 10,000 patient-days. Eighty-nine case patients had test results positive for K. pneumoniae, whereas 13 had results positive for E. coli. CRE case patients had a mean age of 63 years, and 51% were male. Urine cultures (61%) were the most frequently reported specimen source. Thirty-five percent of cases were hospital onset; sixty-five percent were community onset (CO), although 75% of CO case patients reported healthcare exposure within the previous 90 days. Cardiovascular disease, renal failure, and diabetes mellitus were the most frequently reported comorbid conditions. Common ris k factors included surgery within the previous 90 days, recent infection or colonization with a multidrug-resistant organism, and recent exposures to antimicrobials, especially third- or fourth-generation cephalosporins.

CRE are found throughout Michigan healthcare facilities. Implementing a regional, coordinated surveillance and prevention initiative may prevent CRE from becoming hyperendemic in Michigan.

Healthcare worker hand hygiene is known to prevent healthcare-associated infections, but there are few data on patient hand hygiene despite the fact that nosocomial pathogens may be acquired by patients via their own unclean hands. The purpose of this study was to measure patient hand hygiene behavior in the hospital after visiting a bathroom, before eating, and on entering and leaving their rooms

Cross-sectional study.

Acute care teaching hospital in Canada.

Convenience sample of 279 adult patients admitted to 3 multiorgan transplant units between July 2012 and March 2013.

Patient use of alcohol-based hand rub and soap dispensers was measured using an ultrasound-based real-time location system during visits to bathrooms, mealtimes, kitchen visits, and on entering and leaving their rooms.

Overall, patients performed hand hygiene during 29.7% of bathroom visits, 39.1% of mealtimes, 3.3% of kitchen visits, 2.9% of room entries, and 6.7% of room exits.

Patients appear to perform hand hygiene infrequently, which may contribute to transmission of pathogens from the hospital environment via indirect contact or fecal-oral routes.

Infect Control Hosp Epidemiol 2014;35(11):1336–1341

Describe the epidemiology of healthcare-related (ie, healthcare-associated and hospital-acquired) pneumonia due to methicillin-resistant Staphylococcus aureus (MRSA) among hospitalized patients in community hospitals.

Retrospective cohort study.

Twenty-four community hospitals in the southeastern United States affiliated with the Duke Infection Control Outreach Network (median size, 211 beds; range, 103–658 beds).

Adult patients with healthcare-related MRSA pneumonia admitted to study hospitals from January 1, 2008, to December 31, 2012, were identified using surveillance data. Seasonal and annual incidence rates (cases per 100,000 patient-days) were estimated using generalized estimating equation models. Characteristics of community-onset and hospital-onset cases were compared.

A total of 1,048 cases of healthcare-related pneumonia due to MRSA were observed during 5,863,941 patient-days. The annual incidence rate of healthcare-related MRSA pneumonia increased from 11.3 cases per 100,000 patient-days (95% confidence interval [CI], 6.8–18.7) in 2008 to 15.5 cases per 100,000 patient-days (95% CI, 8.4–28.5) in 2012 (P = .055). The incidence rate was highest in winter months and lowest in summer months (15.4 vs 11.1 cases per 100,000 patient-days; incidence rate ratio, 1.39 [95% CI, 1.06–1.82]; P = .016). A total of 814 cases (77.7%) were community-onset healthcare-associated pneumonia cases; only 49 cases (4.7%) were ventilator-associated cases. Of 811 patients whose disposition was known, 240 (29.6%) died during hospitalization or were discharged to hospice.

From 2008 through 2012, the incidence of healthcare-related MRSA pneumonia among patients who were admitted to a large network of community hospitals increased, despite the decreasing incidence of invasive MRSA infections nationwide. Additional study is warranted to evaluate trends in this important and potentially modifiable public health problem.

Infect Control Hosp Epidemiol 2014;35(12):1452–1457

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.

Appropriate use of antimicrobials for surgical prophylaxis is an important patient safety issue. Antimicrobial levels should be present during the duration of the surgical procedure until incision site closure. For prolonged surgical procedures in which the tissue concentration of the prophylactic antimicrobial may decrease to below the necessary minimum inhibitory concentration, intraoperative redosing of antimicrobials may be crucial

To evaluate compliance of appropriate intraoperative antimicrobial surgical prophylaxis using real-time intraoperative antimicrobial dosing reminders at a large teaching hospital.

A retrospective review of electronic records (March 2009–October 2012) was performed. Patients were included if they were at least 18 years of age and underwent a procedure requiring antimicrobial surgical prophylaxis. Compliance was determined by comparing 3 time intervals: baseline (March 2009–March 2010); intervention period 1 (IP-1; April 1, 2010–April 30, 2012), and intervention period 2 (IP-2; May 1, 2012–October 31, 2012). Interventions included a hospital-wide standardized protocol comprising an automated intraoperative paging system to notify when antimicrobials should be redosed.

A total of 7,461 of 75,230 surgical procedures required intraoperative redosing of antimicrobials and were analyzed. Patient mean age (± standard deviation) was 45 ± 19 years, and 62.6% were female. The most common procedures that required prophylaxis were solid organ transplantation, neurosurgical procedures, and orthopedic procedures. Baseline compliance (n = 2,183) was 15.8%; compliance significantly improved to 65.3% during IP-1 (n = 4,486; P < .001). The compliance rate improved to 76.7% during IP-2 (P > .001 compared with no reminder).

Compliance with redosing of intraoperative antimicrobials was improved with the combined approach of guidelines, education to healthcare providers, and real-time automated paging system.