Some policy makers have embraced public reporting of healthcare-associated infections (HAIs) as a strategy for improving patient safety and reducing healthcare costs. We compared the accuracy of 2 methods of identifying cases of HAI: review of administrative data and targeted active surveillance.

A cross-sectional prospective study was performed during a 9-month period in 2004 at the Children's Hospital of Philadelphia, a 418-bed academic pediatric hospital. “True HAI” cases were defined as those that met the definitions of the National Nosocomial Infections Surveillance System and that were detected by a trained infection control professional on review of the medical record. We examined the sensitivity and the positive and negative predictive values of identifying HAI cases by review of administrative data and by targeted active surveillance.

We found similar sensitivities for identification of HAI cases by review of administrative data (61%) and by targeted active surveillance (76%). However, the positive predictive value of identifying HAI cases by review of administrative data was poor (20%), whereas that of targeted active surveillance was 100%.

The positive predictive value of identifying HAI cases by targeted active surveillance is very high. Additional investigation is needed to define the optimal detection method for institutions that provide HAI data for comparative analysis.

To determine the feasibility of estimating the number of central line-days at a hospital from a sample of months or individual days in a year, for surveillance of healthcare-associated bloodstream infections.

We used data reported to the National Nosocomial Infections Surveillance system in the adult and pediatric intensive care unit component for 1995-2003 and data from a sample of hospitals' daily counts of device use for 12 consecutive months. We calculated the percentile error as the central line-associated bloodstream infection percentile based on rates per line-days minus the percentile based on rates per estimated line-days.

A total of 247 hospitals were used for sampling whole months and 12 hospitals were used for sampling individual days.

For a 1-month sample of central line–days data, the median percentile error was 3.3 (75th percentile, 7.9; 90th percentile, 15.4). The percentile error decreased with an increase in the number of months sampled. For a 3-month sample, the median percentile error was 1.4 (75th percentile, 4.3; 95th percentile, 8.3). Sampling individual days throughout the year yielded lower percentile errors than sampling an equivalent fraction of whole months. With 1 weekday sampled per week, the median percentile error ranged from 0.65 to 1.40, and the 90th percentile ranged from 2.8 to 5.0. Thus, for 90% of units, collecting data on line-days once a week provides an estimate within ± 5 percentile points of the true line-day rate.

Sample-based estimates of central line-days can yield results that are acceptable for surveillance of healthcare-associated bloodstream infections.

To describe the incidence of device-associated nosocomial infections in medical-surgical intensive care units (MS ICUs) in a university hospital in Turkey and compare it with National Nosocomial Infections Surveillance (NNIS) system rates.

Prospective surveillance study during a period of 27 months. Device utilization ratios and device-associated infection rates were calculated using US Centers for Disease Control and Prevention and NNIS definitions.

Two separate MS ICUs at Akdeniz University Hospital, Antalya, Turkey.

All patients were included who presented with no signs and symptoms of infection within the first 48 hours after admission.

Data on 1,985 patients with a total of 16,892 patient-days were analyzed. The mean overall infection rate per 100 patients was 29.1 infections, and the mean infection rate per 1,000 patient-days was 34.2 infections. The rate of ventilator-associated pneumonia was 20.76 infections per 1,000 ventilator-days, the rate of catheter-associated urinary tract infection was 13.63 infections per 1,000 urinary catheter–days, and the rate of catheter-associated bloodstream infection was 9.69 infections per 1,000 central line–days. The most frequently isolated pathogens were Pseudomonas species among patients with ventilator-associated pneumonias (35.8% of cases), Candida species among patients with catheter-associated urinary tract infections (37.1% of cases), and coagulase-negative staphylococci among patients with catheter-associated bloodstream infections (20.0% of cases).

We found both higher device-associated infection rates and higher device utilization ratios in our MS ICUs than those reported by the NNIS system. To reduce the rate of infection, implementation of infection control practices and comprehensive education are required, and an appropriate nationwide nosocomial infection and control system is needed in Turkey.

To perform active targeted prospective surveillance to measure device-associated infection (DAI) rates, attributable mortality due to DAI, and the microbiological and antibiotic resistance profiles of infecting pathogens at 10 intensive care units (ICUs) in 9 hospitals in Colombia, all of which are members of the International Infection Control Consortium.

We conducted prospective surveillance of healthcare-associated infection in 9 hospitals by using the definitions of the US Centers for Disease Control and Prevention National Nosocomial Surveillance System (NNIS). DAI rates were calculated as the number of infections per 100 ICU patients and per 1,000 device-days.

During the 3-year study, 2,172 patients hospitalized in an ICU for an aggregate duration of 14,603 days acquired 266 DAIs, for an overall DAI rate of 12.2%, or 18.2 DAIs per 1,000 patient-days. Central venous catheter (CVC)–related bloodstream infection (BSI) (47.4% of DAIs; 11.3 cases per 1,000 catheter-days) was the most common DAI, followed by ventilator-associated pneumonia (VAP) (32.3% of DAIs; 10.0 cases per 1,000 ventilator-days) and catheter-associated urinary tract infection (CAUTI) (20.3% of DAIs; 4.3 cases per 1,000 catheter-days). Overall, 65.4% of all Staphylococcus aureus infections were caused by methicillin-resistant strains; 40.0% of Enterobacteriaceae isolates were resistant to ceftriaxone and 28.3% were resistant to ceftazidime; and 40.0% of Pseudomonas aeruginosa isolates were resistant to fluoroquinolones, 50.0% were resistant to ceftazidime, 33.3% were resistant to piperacillin-tazobactam, and 19.0% were resistant to imipenem. The crude unadjusted attributable mortality was 16.9% among patients with VAP (relative risk [RR], 1.93; 95% confidence interval [CI], 1.24-3.00; P = .002); 18.5 among those with CVC-associated BSI (RR, 2.02; 95% CI, 1.42-2.87; P<.001); and 10.5% among those with CAUTI (RR, 1.58; 95% CI, 0.78-3.18; P = .19).

The rates of DAI in the Colombian ICUs were lower than those published in some reports from other Latin American countries and were higher than those reported in US ICUs by the NNIS. These data show the need for more-effective infection control interventions in Colombia.

Reference data from intensive care units (ICUs) are not applicable to non-ICU patients because of the differences in device use rates, length of stay, and severity of underlying diseases among the patient populations. In contrast to the huge amount of data available for ICU patients, appropriate surveillance data for non-ICU patients have been missing in Germany.

To establish a new module (“DEVICE-KISS”) of the German Nosocomial Infection Surveillance System for generating stratified reference data for non-ICU wards.

Non-ICU patients from 42 German hospitals.

Monthly patient-days, device-days and nosocomial infections (NIs) (using Centers for Disease Control and Prevention definitions) were counted. Device use rates were calculated, and NI rates were stratified by different medical specialities.

From July 2002 through June 2004, among the 77 wards, there were a total of 536,955 patient-days and 74,188 device-days (for CVC-associated primary bloodstream infections, there were 181,401 patient-days and 8,317 central vascular catheter [CVC]-days in 29 wards; for urinary catheter–associated urinary tract infections, there were 445,536 patient-days and 65,871 urinary catheter–days in 65 wards) and 483 NIs (36 bloodstream infections and 447 urinary tract infections). The mean device use rates were 4.6 device-days per 100 patient-days for CVCs (29 wards) and 14.8 device-days per 100 patient-days for urinary catheters (65 wards), respectively. Mean device-associated NI rates were 4.3 infections per 1,000 CVC-days for CVC-associated bloodstream infections and 6.8 infections per 1,000 urinary catheter–days for catheter-associated urinary tract infections.

DEVICE-KISS allows non-ICUs to recognize an outlier position with regard to NIs by providing well-founded reference data for non-ICU patients.

To determine whether contaminated ultrasound gel is the source of intermittent outbreaks of nosocomial infection due to Burkholderia cepacia complex in patients without cystic fibrosis since 1992.

A prospective clinical and in vitro study of all in-use bottles of ultrasound gel, as well as a retrospective analysis of archived bacterial strains, were performed. Handling of gel for clinical purposes throughout the hospital was evaluated. Gel and archived clinical isolates of B. cepacia complex were speciated to genomovar level and characterized by pulsed-field gel electrophoresis, and the pulsed-field gel electrophoresis patterns were compared.

The Hospital for Sick Children, a 300-bed, tertiary care, pediatric academic health sciences center in Toronto, Canada.

All patients without cystic fibrosis from whom B. cepacia complex was recovered at the Hospital for Sick Children since 1992.

No standardized protocol for storage or handling of ultrasound gel was found. Gel from 39% of bottles grew either B. cepacia (genomovar I) or Burkholderia stabilis (genomovar IV). These isolates had pulsed-field gel electrophoresis patterns identical to 2 of the 7 clinical pulsed-field gel electrophoresis types that are responsible for 88% of clinical isolates.

Contaminated ultrasound gel contributed to nosocomial infection due to B. cepacia complex in this institution over the course of 10 years. Suggested guidelines for the handling of ultrasound gel are provided.

We developed a microbiological test to detect the penetration of airborne microorganisms through the packaging of medical products after sterilization, to meet the requirements of European standard EN 556. We applied this test method to transparent pouches.

The microbial-barrier properties of the transparent pouches were determined using the microbial challenge test, in which the package was placed inside an exposure chamber and exposed to a defined aerosol of Saccharomyces cerevisiae. The atmospheric pressure in the chamber was periodically reduced by 0-75 millibars, to simulate weather-dependent pressure changes. Thermoresistant petri dishes filled with nutrient agar were integrated into the transparent pouches before sterilization. The packages were incubated after exposure. They were then opened and examined for colony growth.

The number of recontaminated packages per test group (n = 50) depended on the microbial bioload (defined as the number of colony-forming units per plate) to which the packages were exposed and on the size and number of decreases in atmospheric pressure. Results of multiple regression analysis showed a significant increase in the number of recontaminated packages in correlation with the product of the values for microbial bioload and the size and number of decreases in atmospheric pressure. When we analyzed the probability of recontamination of wrapped medical devices after 2 reductions in atmospheric pressure (30 millibars each) and with a surface microbial load of 10 colony-forming units per 64 cm2, we estimated that the frequency of recontamination was 1: 100,000.

Multiple regression analysis showed that the proposed microbial challenge test is suitable to determine the probability of package recontamination at the 1: 1,000,000 level.

Computers are ubiquitous in the healthcare setting and have been shown to be contaminated with potentially pathogenic microorganisms. This study was performed to determine the degree of microbial contamination, the efficacy of different disinfectants, and the cosmetic and functional effects of the disinfectants on the computer keyboards.

We assessed the effectiveness of 6 different disinfectants (1 each containing chlorine, alcohol, or phenol and 3 containing quaternary ammonium) against 3 test organisms (oxacillin-resistant Staphylococcus aureus [ORSA], Pseudomonas aeruginosa, and vancomycin-resistant Enterococcus species) inoculated onto study computer keyboards. We also assessed the computer keyboards for functional and cosmetic damage after disinfectant use.

Potential pathogens cultured from more than 50% of the computers included coagulase-negative staphylococci (100% of keyboards), diphtheroids (80%), Micrococcus species (72%), and Bacillus species (64%). Other pathogens cultured included ORSA (4% of keyboards), OSSA (4%), vancomycin-susceptible Enterococcus species (12%), and nonfermentative gram-negative rods (36%). All disinfectants, as well as the sterile water control, were effective at removing or inactivating more than 95% of the test bacteria. No functional or cosmetic damage to the computer keyboards was observed after 300 disinfection cycles.

Our data suggest that microbial contamination of keyboards is prevalent and that keyboards may be successfully decontaminated with disinfectants. Keyboards should be disinfected daily or when visibly soiled or if they become contaminated with blood.

To determine whether feedback on antimicrobial use improves physician compliance with local hospital guidelines on antimicrobial prescribing.

In this time series analysis, in which a historical control period was compared with an intervention period, all orders for antimicrobials (except those for surgical prophylaxis) placed from November 1, 2002, through April 30, 2004, were prospectively evaluated by an antimicrobial management team (AMT) for compliance with local hospital guidelines. During the control period, orders were evaluated to determine compliance with hospital guidelines before and after recommendations by the AMT were provided to physicians. Feedback was given for the second 9-month period in the form of a weekly report to prescribing physicians, a monthly hospital newsletter, and a quarterly report to various hospital committees. During the intervention period, orders were evaluated to determine compliance with hospital guidelines before and after recommendations by the AMT were provided to physicians.

The Veterans Affairs Medical Center, a 110-bed facility, in Louisville, Kentucky.

Internal medicine physicians and general surgeons.

A total of 2,807 antimicrobial courses were evaluated. Compliance with hospital guidelines before AMT recommendations was 70% during the control period and 74% during the intervention period (P = .02). Compliance after AMT recommendations was 90% during the control period and 93% during the intervention period (P ≤ .01).

The use of feedback had a significantly favorable impact on physician compliance with the hospital's guidelines on antimicrobial prescribing. Use of feedback should be added to the list of interventions that promote appropriate antimicrobial use in the hospital setting.

To assess the response of long-term care facilities (LTCFs) to the 2004-2005 influenza vaccine shortage and the impact on resident and healthcare worker (HCW) immunization rates.

A 12-item questionnaire was sent to 824 randomly selected LTCFs in December 2004. The following 2 open-ended questions were also asked: “How did you cope with the vaccine shortage?” and “Who helped you get your supply?” Immunization rates reported by LTCF administrators for 2003-2003 and 2003-2004 were compared with those for 2004-2005. Immunization rates were defined as the proportion of all eligible residents and HCWs who received influenza vaccine.

Responses were received from 380 LTCFs (46.3%), which had a total of 38,447 beds. Resident mean influenza immunization rates (±SD) decreased from 85% ± 15.3% in 2002-2003 and 85.1% ± 15.3% in 2003-2004 to 81.9% ± 19.4% in the 2004-2005 influenza season (P = .025). The immunization rates among HCWs also decreased from 51% in 2002-2003 and 2003-2004 to 38.4% in 2004-2005 (P<.001). In response to one of the open-ended questions, 96 facilities (25.3%) reported that they obtained vaccine from 2 or more sources. Eight percent commented on specific intensified infection control efforts, and only 2.3% commented on emergency preparedness.

The influenza vaccine shortage in 2004-2005 impacted immunization practices of LTCFs across the United States, leading to decreases in both resident and HCW vaccination rates. The significant decrease in vaccination rates in LTCFs is of concern and has broad implications for policy makers working on emergency preparedness for a possible pandemic of influenza.

To identify nursing home resident and facility characteristics associated with patients not receiving influenza immunization and having unknown immunization status.

Secondary data analysis using multinomial logistic regression of data from the National Nursing Home Survey, a nationally representative establishment-based survey.

A total of 1,423 nursing facilities of all ownerships and certifications systematically sampled with probability proportional to number of beds.

A total of 7,350 randomly sampled people aged 65 years or older residing in nursing homes between July and December 1999 (approximately 6 per facility).

Immunization status of residents.

Fifteen percent of residents were not immunized and 19% had unknown immunization status. In multivariate analysis, lack of immunization and unknown immunization status were each separately associated with being newly admitted, with no or unknown pneumococcal immunization, and with facility failures to screen for immunization and to record inoculation in the medical record. High-risk status and staff immunization requirements had no effect. Separate analyses showed that residents with unknown immunization status are statistically significantly different from both those vaccinated and those not vaccinated.

This study indicates that both resident and facility characteristics are associated with failure to be immunized for influenza. Facilities should consider targeting younger, newly admitted, and residential care residents for influenza immunization, since they are more likely to be missed. Further research into the barriers to immunization specific to nursing home resident choice or opportunity may be warranted.

To investigate a nosocomial outbreak of infection with Acinetobacter strain RUH 1139, in the unit of high neonatal risk at University Hospital of The Andes (Mérida, Venezuela).

Twenty-eight Acinetobacter strains were detected by biochemical testing and further identified to the species level by examination of the gene encoding 16S ribosomal DNA, using restriction analysis and gene sequencing. The epidemiological relationship between the strains was established by means of repetitive extragenic palindromic polymerase chain reaction (REP-PCR) and pulsed-field gel electrophoresis (PFGE), and antimicrobial susceptibilities were determined by disk diffusion.

The spread of an epidemic strain of Acinetobacter RUH 1139 among 16 patients over a period of 3 months was demonstrated using antimicrobial susceptibility testing, PFGE, and REP-PCR. The epidemic strain was also isolated in 2 of the sampled parenteral nutrition solutions. All the patients involved in the infection outbreak had received parenteral solution. Moreover, strains of Acinetobacter RUH 1139 with another PFGE pattern and of A. baumannii were sporadically isolated before and during the outbreak.

This is the first description of an outbreak of infection with this genospecies of Acinetobacter in which parenteral nutrition solution was potentially the infection source.

Molecular epidemiologic surveillance of Acinetobacter baumannii by polymerase chain reaction-randomly amplified polymorphic DNA analysis in a university hospital for 3 consecutive study periods.

Twelve different Acinetobacter baumannii genotypes (A-L) were detected. Although only 2 genotypes were detected during the first period and genotype A appeared to be the most common genotype, genotype D was included in these genotypes during the second study period. Genotype A completely disappeared during the third period. Although the presence of genotype C and the genotype D continued during the third period, 9 new genotypes were detected during this period. Genotype A appeared to be the most common genotype in the hospital (detected in 19 different clinics). The distribution of genotypes in clinical samples correlated with patient traffic between them. Some genotypes were found in both clinical and environmental samples. Seventeen different antibiotypes were detected, according to antibiotic susceptibility profiles.

Environmental contamination, airborne transmission, patient transfer, and cross-contamination play important roles in epidemics caused by A. baumannii in our hospital. The distribution of genotypes can change over time, so antibiotyping is not appropriate for the epidemiological analysis of A. baumanii infection.