bluuebunny/crossref_metadata_2025 huggingface dataset:
Timing of Intravenous Administration Set Changes: A Systematic Review
Authors: Gillies Donna , O'Riordan Libba , Wallen Margaret , Rankin Karen , Morrison Anne , Nagy Sue
Published: April 2006

Objective:

To determine the optimal time interval for the routine replacement of intravenous administration sets when crystalloids or parenteral nutrition are administered via a central or peripheral catheter in an acute care setting.

Design:

Systematic review of all randomized or systematically allocated controlled trials addressing the frequency of replacing intravenous administration sets.

Methods:

The Cochrane Controlled Trials Register (June 2001) and the Ovid databases (Medline, CINAHL, and CancerLit-July 2001) were searched. Bibliographies, relevant conference proceedings, and any product information were also checked for references.

Results:

Eighteen studies were selected for review. The 12 included studies were separated into 3 intravenous administration set change comparisons; 24 hours versus 48 hours or more; 48 hours versus 72 hours or more; and 72 hours versus 96 hours or more. There was good evidence that changing intravenous administration sets every 72 hours or more does not increase the risk of infusate-related bloodstream infection (BSI) in patients with central or peripheral catheters and a fair level of evidence that it does not increase the risk of catheter-related BSI. There were insufficient data regarding the incidence of BSI among patients receiving parenteral nutrition, particularly lipid-containing parenteral nutrition.

Conclusions:

It appears that intravenous administration sets containing crystalloids can be changed in patients with central or peripheral catheters every 72 hours or more without increasing the risk of BSI. However, it is not possible to conclude that intravenous administration sets containing parenteral nutrition, particularly lipid-containing parenteral nutrition, can be changed at this interval.
Infectivity of Prion Protein Bound to Stainless Steel Wires: A Model for Testing Decontamination Procedures for Transmissible Spongiform Encephalopathies
Authors: Yan Zheng-xin , Stitz Lothar , Heeg Peter , Pfaff Eberhard , Roth Klaus
Published: April 2006

Objectives:

To establish an animal model to study transmissible spongiform encephalopathy using hamsters and steel wires contaminated with infectious brain materials as transfer vehicles, and, based on this model, to test decontamination procedures against the infectious prion proteins on the steel wires as a near real situation bioassay.

Design:

Infectious brain materials were given to healthy hamsters intracerebrally either as a suspension or as dried materials on the surface of steel wires. The animals were observed for 18 months. During this period, animals showing definitive clinical signs were euthanized. Decontamination studies were performed by reprocessing contaminated steel wires with different disinfection agents and procedures before implantation.

Results:

Pathological prion proteins were able to bind to the steel wires and caused disease after the contaminated wires were implanted in the brains of hamsters. When the contaminated wires were treated with different reprocessing procedures before implantation, infectivity was reduced, which was manifested directly by prolonged survival time of the test animals. These results show that this model can be used as a bioassay to validate reprocessing procedures for surgical instruments.

Conclusions:

At the time of submission of this article, only the group of hamsters incubated with wires reprocessed with an alkaline detergent, followed by sterilization with a modified cycle in a hydrogen peroxide gas plasma sterilizer (4 injections), showed no clinical signs of disease and remained alive. Two animals from the group receiving sodium hydroxide followed by autoclaving (at 134° C for 18 minutes) died. Furthermore, the tested enzymatic cleaning agent seemed to have no positive effect.
Compliance with Local Guidelines for Antibiotic Prophylaxis in Surgery
Authors: Pons-Busom Montserrat , Aguas-Compaired Margarita , Delás Jordi , Eguileor-Partearroyo Begoña
Published: April 2006

Objectives:

To describe the development and implementation of a local protocol for antibiotic prophylaxis in surgery and to assess compliance with these guidelines using a computer-based system.

Design:

One 5-week prospective period (phase 1) followed by three 1-week, cross-sectional assessments (phases 2, 3, and 4).

Setting:

Pharmacy of a 350-bed acute care teaching hospital in Barcelona, Spain.

Methods:

In phase 1, 395 forms for antibiotic prescribing delivered to the pharmacy were reviewed. Nonadherence was defined as the prescription of an antibiotic (or doses) different from what the protocol specified. In phases 2, 3, and 4, antibiotic prescribing forms for all elective procedures (630 patients) performed during 1-week periods were analyzed.

Results:

A total of 1,047 patients (mean age, 58.9 ± 17.3 years) were included. Cefazolin was administered in 41% of procedures. Overall compliance with antibiotic prescribing forms was 83.3%. There was a statistically significant increase in compliance with guidelines throughout the four phases of the study, from 80.3% in phase 1 to 87.8% in phase 4 (P < .042), as well as adherence to completing forms for surgical procedures, from 51% in phase 2 to 77.6% in phase 4 (P < .001). The main reason for non-adherence was that some procedures had not been included in the protocol in phase 2.

Conclusion:

Surgeons sensitized to the implementation of local antibiotic prophylaxis guidelines showed a high degree of compliance with them, using both the procedure established for antibiotic prescribing and the antimicrobials recommended for particular operations.
Finding a Method for Optimizing Risk Adjustment When Comparing Surgical-Site Infection Rates
Authors: Brandt Christian , Hansen Sonja , Sohr Dorit , Daschner Franz , Rüden Henning , Gastmeier Petra
Published: April 2006

Objective:

To investigate whether stratification of the risk of developing a surgical-site infection (SSI) is improved when a logistic regression model is used to weight the risk factors for each procedure category individually instead of the modified NNIS System risk index.

Design and Setting:

The German Nosocomial Infection Surveillance System, based on NNIS System methodology, has 273 acute care surgical departments participating voluntarily. Data on 9 procedure categories were included (214,271 operations).

Methods:

For each of the procedure categories, the significant risk factors from the available data (NNIS System risk index variables of ASA score, wound class, duration of operation, and endoscope use, as well as gender and age) were identified by multiple logistic regression analyses with stepwise variable selection. The area under the receiver operating characteristic (ROC) curve resulting from these analyses was used to evaluate the predictive power of logistic regression models.

Results:

For most procedures, at least two of the three variables contributing to the NNIS System risk index were shown to be independent risk factors (appendectomy, knee arthroscopy, cholecystectomy, colon surgery, herniorrhaphy, hip prosthesis, knee prosthesis, and vascular surgery). The predictive power of logistic regression models (including age and gender, when appropriate) was low (between 0.55 and 0.71) and for most procedures only slightly better than that of the NNIS System risk index.

Conclusion:

Without the inclusion of additional procedure-specific variables, logistic regression models do not improve the comparison of SSI rates from various hospitals.
Preliminary Assessment of an Automated Surveillance System for Infection Control
Authors: Wright Marc-Oliver , Perencevich Eli N. , Novak Christopher , Hebden Joan N. , Standiford Harold C. , Harris Anthony D.
Published: April 2006

Background and Objective:

Rapid identification and investigation of potential outbreaks is key to limiting transmission in the healthcare setting. Manual review of laboratory results remains a cumbersome, time-consuming task for infection control practitioners (ICPs). Computer-automated techniques have shown promise for improving the efficiency and accuracy of surveillance. We examined the use of automated control charts, provided by an automated surveillance system, for detection of potential outbreaks.

Setting:

A 656-bed academic medical center.

Methods:

We retrospectively reviewed 13 months (November 2001 through November 2002) of laboratory-patient data, comparing an automated surveillance application with standard infection control practices. We evaluated positive predictive value, sensitivity, and time required to investigate the alerts. An ICP created 75 control charts. A standardized case investigation form was developed to evaluate each alert for the likelihood of nosocomial transmission based on temporal and spatial overlap and culture results.

Results:

The 75 control charts were created in 75 minutes and 18 alerts fired above the 3-sigma level. These were independently reviewed by an ICP and associate hospital epidemiologist. The review process required an average of 20 minutes per alert and the kappa score between the reviewers was 0.82. Eleven of the 18 alerts were determined to be potential outbreaks, yielding a positive predictive value of 0.61. Routine surveillance identified 5 of these 11 alerts during this time period.

Conclusion:

Automated surveillance with user-definable control charts for cluster identification was more sensitive than routine methods and is capable of operating with high specificity and positive predictive value in a time-efficient manner.
Bone Wax as a Risk Factor for Surgical-Site Infection Following Neurospinal Surgery
Authors: Gibbs Laurel , Kakis Anthony , Weinstein Philip , Conte John E.
Published: April 2006

Surgical-site infection occurred in 6 of 42 neurospinal cases in which bone wax was used and in 1 of 72 cases in which it was not used during a 3-month period (P < .01). Increased risk of infection should be considered when using bone wax as a hemostatic agent.
Effect of the Increasing Use of Piperacillin/Tazobactam on the Incidence of Vancomycin-Resistant Enterococci in Four Academic Medical Centers
Authors: Stiefel Usha , Paterson David L. , Pultz Nicole J. , Gordon Steven M. , Aron David C. , Donskey Curtis J.
Published: April 2006

Background:

The substitution of piperacillin/tazobactam, ampicillin/sulbactam, or both for third-generation cephalosporins has been associated with reduced vancomycin-resistant enterococci (VRE). However, piperacillin/tazobactam came into widespread use during a period in which the prevalence of VRE increased. We hypothesized that the increasing use of piperacillin/tazobactam and other agents with relatively enhanced anti-enterococcal activity (ie, piperacillin, ampicillin/sulbactam, and ampicillin) has been associated with increased or unchanged rates of VRE in some hospitals.

Design:

We retrospectively evaluated the correlation between hospital antibiotic use (defined daily doses per 10,000 patient-days of care) and incidence of stool or non-stool VRE isolation. We assessed whether a high or increasing proportion of use of beta-lactam agents with relatively enhanced versus minimal (ie, third-generation cephalosporins and ticarcillin/clavulanate) anti-enterococcal activity would prevent increased VRE.

Setting:

Four academic medical centers.

Results:

With the increasing use of piperacillin/tazobactam, the use of beta-lactam agents with enhanced activity against enterococci surpassed the combined use of third-generation cephalosporins and ticarcillin/clavulanate in each hospital. In one hospital, the incidence of VRE was positively correlated with the use of piperacillin/tazobactam or beta-lactam agents with enhanced anti-enterococcal activity (P< .0001). The incidence of VRE rose steadily in another hospital despite relatively high use of beta-lactam agents with enhanced versus minimal anti-enterococcal activity. A negative correlation between VRE and piperacillin/tazobactam or beta-lactam agents with enhanced anti-enterococcal activity was observed in one hospital, but this correlation was not statistically significant.

Conclusion:

Increasing the hospital use of piperacillin/tazobactam and other beta-lactams with relatively enhanced anti-enterococcal activity may not be an effective control measure for VRE.
Do Infection Control Measures Work for Methicillin-Resistant Staphylococcus aureus?
Authors: Boyce John M. , Havill Nancy L. , Kohan Cynthia , Dumigan Diane G. , Ligi Catherine E.
Published: April 2006

Objective:

To review evidence regarding the effectiveness of control measures in reducing transmission of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals.

Design:

Literature review and surveillance cultures of hospitalized patients at high risk for MRSA colonization or infection.

Setting:

A 500-bed, university-affiliated, community teaching hospital.

Results:

The percentage of nosocomial S. aureus infections caused by MRSA increased significantly between 1982 and 2002, despite the use of various isolation and barrier precaution policies. The apparent ineffectiveness of control measures may be due to several factors including the failure to identify patients colonized with MRSA For example, cultures of stool specimens submitted for Clostridium difficile toxin assays at one hospital found that 12% of patients had MRSA in their stool, and 41% of patients with unrecognized colonization were cared for without using barrier precautions. Other factors include the use of barrier precaution strategies that do not account for multiple reservoirs of MRSA, poor adherence of healthcare workers (HCWs) to recommended barrier precautions and handwashing, failure to identify and treat HCWs responsible for transmitting MRSA, and importation of MRSA by patients admitted from other facilities. Control programs that include active surveillance cultures (ASCs) of high-risk patients and use of barrier precautions have reduced MRSA prevalence rates and have been cost-effective. Using a staged approach to implementing ASCs can minimize logistic problems.

Conclusion:

MRSA control programs are effective if they include ASCs of high-risk patients, use of barrier precautions when caring for colonized or infected patients, hand hygiene, and treating HCWs implicated in MRSA transmission.
Risk Factors and Costs Associated With Methicillin-Resistant Staphylococcus aureus Bloodstream Infections
Authors: McHugh Carolyn Guertin , Riley Lee W.
Published: April 2006

Objectives:

To compare the cost of hospitalization of patients with methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI) versus patients with methicillin-sensitive S. aureus (MSSA) BSI, controlling for severity of underlying illness; and to identify risk factors associated with MRSA BSI.

Design:

Retrospective case-control study based on medical chart review.

Setting:

A 640-bed, tertiary-care hospital in Seattle, Washington.

Patients:

All patients admitted to the hospital between January 1,1997, and December 31,1999, with S. aureus BSI confirmed by culture.

Results:

Twenty patients with MRSA BSI were compared with 40 patients with MSSA BSI. Univariate analysis identified 5 risk factors associated with MRSA BSI. Recent hospital admission (P = .006) and assisted living (P = .004) remained significant in a multivariate model. Costs were significantly higher per patient-day of hospitalization for MRSA BSI than for MSSA BSI ($5,878 vs $2,073; P = .003). When patients were stratified according to severity of illness as measured by the case mix index, a difference of $5,302 per patient-day was found between the two groups for all patients with a case mix index greater than 2(P<.001).

Conclusion:

These observations suggest that MRSA BSI significantly increases hospitalization costs compared with MSSA BSI, even when controlling for the severity of the patient's underlying illness. As MRSA BSI was also found to be significantly associated with a group of patients who have repeated hospitalizations, such infections contribute substantially to the increasing cost of medical care.
Sternal Surgical-Site Infection Following Coronary Artery Bypass Graft Prevalence, Microbiology, and Complications During a 42-Month Period
Authors: Sharma Mamta , Berriel-Cass Dorine , Baran Joseph
Published: April 2006

Objective:

Surgical-site infection (SSI) is a serious and costly complication following coronary artery bypass graft (CABG). We analyzed surgical factors, microbiology, and complications at a 608-bed community teaching hospital to identify opportunities for prevention.

Methods:

All patients undergoing CABG procedures from June 1997 through December 2000 were analyzed. Hospital records and postdischarge surveillance data were reviewed for demographics, surgical information, timing and classification of infection, microbiology, and bacteremic events.

Results:

Of 3,443 patients undergoing CABG, sternal SSI developed in 122 (3.5%); 71 (58.2%) were classified as superficial SSI and 51 (41.8%) as deep SSI. Surgical antimicrobial prophylaxis was employed in all cases. On average, infection occurred 21.5 days (range, 4 to 315) after CABG. Most cases were diagnosed on readmission (59%); 20 cases (16%) were identified by postdischarge surveillance. Microbiological data were positive in 109 (89.3%), with a single pathogen implicated in most (86.2%). Gram-positive cocci were most frequently recovered (81%); gram-negative bacilli (17%), gram-positive bacilli (1%), and yeast (1%) were less common. Staphylococcus aureus was the most frequently isolated pathogen (49%). Bacteremia was noted in 22 instances (18%). It was significantly associated with deep SSI (P =. 002) and identified only in S. aureus cases.

Conclusions:

SSI complicated 3.5% of the procedures. S. aureus was implicated in most of the cases and was significantly associated with deep SSI. It was the only pathogen associated with secondary bacteremia. In addition to standard guidelines, targeted methods against S. aureus should help reduce the overall rate of SSI.
Effect of Implementing Safety-Engineered Devices on Percutaneous Injury Epidemiology
Authors: Sohn SeJean , Eagan Janet , Sepkowitz Kent A. , Zuccotti Gianna
Published: April 2006

Objective:

To assess the effect of implementing safety-engineered devices on percutaneous injury epidemiology, specifically on percutaneous injuries associated with a higher risk of blood-borne pathogen exposure.

Design:

Before-and-after intervention trial comparing 3-year preintervention (1998–2000) and 1-year postintervention (2001–2002) periods. Percutaneous injury data have been entered prospectively into CDC NaSH software since 1998.

Setting:

A 427-bed, tertiary-care hospital in Manhattan.

Participants:

All employees who reported percutaneous injuries during the study period.

Intervention:

A “safer-needle system,” composed of a variety of safety-engineered devices to allow for needle-safe IV delivery, blood collection, IV insertion, and intramuscular and subcutaneous injection, was implemented in February 2001.

Results:

The mean annual incidence of percutaneous injuries decreased from 34.08 per 1,000 full-time–equivalent employees preintervention to 14.25 postintervention (P < .001). Reductions in the average monthly number of percutaneous injuries resulting from both low-risk (P < .01) and high-risk (P was not significant) activities were observed. Nurses experienced the greatest decrease (74.5%, P < .001), followed by ancillary staff (61.5%, P = .03). Significant rate reductions were observed for the following activities: manipulating patients or sharps (83.5%, P < .001), collisions or contact with sharps (73.0%, P = .01), disposal-related injuries (21.41%, P = .001), and catheter insertions (88.2%, P < .001). Injury rates involving hollow-bore needles also decreased (70.6%, P < .001).

Conclusions:

The implementation of safety-engineered devices reduced percutaneous injury rates across occupations, activities, times of injury, and devices. Moreover, intervention impact was observed when stratified by risk for blood-borne pathogen transmission.
Cost–Benefit Analysis of Chlorhexidine Gluconate Dressing in the Prevention of Catheter-Related Bloodstream Infections
Authors: Crawford Albert G. , Fuhr Joseph P. , Rao Bhaskar
Published: April 2006

Objectives:

To compare the costs with the benefits of using chlorhexidine gluconate dressings on central venous catheters and to determine the effectiveness of these dressings in reducing local infections and catheter-related bloodstream infections (CRBSIs), costs, and mortality.

Design:

Cost–benefit analysis using randomized, controlled trial data on chlorhexidine dressing prevention of local infection and CRBSI, data on cost of chlorhexidine dressing versus standard treatment, data on averted cost of treating local infection and CRBSI, and data on mortality attributable to CRBSI. Decision analysis evaluated averted CRBSI treatment cost per patient resulting from chlorhexidine dressing use. Sensitivity analyses demonstrated net benefit of chlorhexidine dressing, varying baseline rate of CRBSI, incremental cost of treating CRBSI, and number of catheters, and evaluated mortality preventable through chlorhexidine dressing use, varying baseline rate of CRBSI, number of catheters, and mortality attributable to CRBSI.

Patients and Setting:

Patients of all Philadelphia area hospitals and one Philadelphia academic medical center.

Results:

Estimated potential annual U.S. net benefits from chlorhexidine dressing use ranged from $275 million to approximately $1.97 billion. Cost–benefit findings persisted in sensitivity analyses varying baseline rate of CRBSI, incremental cost of treating CRBSI, and overall number of catheters used. Preventable mortality analyses showed potential decreases of between 329 and 3,906 U.S. deaths annually as a result of nationwide use of chlorhexidine dressing.

Conclusions:

Chlorhexidine dressings would reduce costs, local infections and CRBSIs, and deaths. Use of chlorhexidine dressings should be considered to prevent infections among patients with catheters.
Clustering of Serratia marcescens Infections in a Neonatal Intensive Care Unit
Authors: Sarvikivi Emmi , Lyytikäinen Outi , Salmenlinna Saara , Vuopio-Varkila Jaana , Luukkainen Päivi , Tarkka Eveliina , Saxén Harri
Published: April 2006

Objectives:

To study clusters of infections caused by Serratia marcescens in a neonatal intensive care unit (NICU) and to determine risk factors for S. marcescens infection or colonization.

Design:

Genotyping of S. marcescens isolates was performed by pulsed-field gel electrophoresis (PFGE). A retrospective case-control study was conducted.

Setting:

A tertiary-care pediatric hospital with a 16-bed NICU.

Patients:

All neonates with at least one culture positive for S. marcescens in the NICU during December 1999 to July 2002. Case-patients (n = 11) treated in the NICU during December 1999 to February 2000 were included in the case-control study. Neonates treated in the NICU for at least 72 hours during the same period with cultures negative for S. marcescens were used as control-patients (n = 27).

Results:

S. marcescens was cultured from 19 neonates; 9 were infected and 10 were colonized. PFGE analysis identified three epidemic strains; each cluster consisted of identical isolates, except one isolate in the first cluster that was different. The risk factors identified were low birth weight, prematurity, prolonged respiratory therapy, prolonged use of antibiotics, and maternal infection prior to delivery. Overcrowding and understaffing were recorded simultaneously with the clusters.

Conclusions:

PFGE analysis showed three independent clusters. Several factors contributed to spread of the epidemic strains: (1) there were many severely premature and susceptible neonates, (2) the NICU was overcrowded during the clusters, and (3) transmission was likely to occur via the hands of staff. Cohorting and improvement of routine infection control measures led to the cessation of each cluster.
Rapid Eradication of a Cluster of Serratia marcescens in a Neonatal Intensive Care Unit: Use of Epidemiologic Chromosome Profiling by Pulsed-Field Gel Electrophoresis
Authors: Lai Kwan Kew , Baker Stephen P. , Fontecchio Sally A.
Published: April 2006

Objective:

To investigate a cluster of patients infected and colonized with Serratia marcescens in a neonatal intensive care unit (NICU).

Methods:

In June 2001, two neonates in the NICU had clinical infections with S. marcescens and one died. Infection control surveillance data for the NICU revealed that S. marcescens was rarely isolated from clinical specimens. Surveillance and environmental cultures were performed and isolates were typed using pulsed-field gel electrophoresis. Staff and neonates were cohorted and a waterless, alcohol-based handwashing agent was introduced. A case-control study was performed.

Results:

From June 2 through August 20, 2001, 11 neonates with S. marcescens infection and colonization were identified. The incidence of S. marcescens infections increased from 0.19 per 1,000 patient-days in 2000 to 0.52 per 1,000 patient-days in 2001 (P < .0001). In the first 3 weeks of the investigation, there were 2 sets of patients and sinks with indistinguishable strains; however, in subsequent weeks, all isolates were of unique strains, signifying no further transmission of the two initial predominant strains. Neonates with S. marcescens were more likely to have a lower gestational age and birth weight. There was no association between cases and healthcare workers (HCWs).

Conclusions:

A cluster of S. marcescens was quickly terminated after the introduction of preventive measures including cohorting of infected and colonized neonates and HCWs, contact precautions, surveillance cultures, and a waterless, alcohol-based hand antiseptic. Chromosomal typing determined that strains with an indistinguishable pattern were no longer present in the unit after control measures were implemented.
Ventilator-Associated Pneumonia in a Pediatric Intensive Care Unit in Saudi Arabia: A 30-Month Prospective Surveillance
Authors: Almuneef Maha , Memish Ziad A. , Balkhy Hanan H. , Alalem Hala , Abutaleb Abdulrahman
Published: April 2006

Objective:

To describe the rate, risk factors, and outcome of ventilator-associated pneumonia (VAP) in pediatric patients.

Methods:

This prospective surveillance study of VAP among all patients receiving mechanical ventilation for 48 hours or more admitted to a pediatric intensive care unit (PICU) in Saudi Arabia from May 2000 to November 2002 used National Nosocomial Infections Surveillance (NNIS) System definitions.

Results:

Three hundred sixty-one eligible patients were enrolled. Most were Saudi with a mean age of 28.6 months. Thirty-seven developed VAP. The mean VAP rate was 8.87 per 1,000 ventilation-days with a ventilation utilization rate of 47%. The mean duration of mechanical ventilation was 21 days for VAP patients and 10 days for non-VAP patients. The mean PICU stay was 34 days for VAP patients and 15 days for non-VAP patients. Among VAP patients, Pseudomonas aeruginosa was the most common organism, followed by Staphylococcus aureus. Other gram-negative organisms were also encountered. There was no significant difference between VAP and non-VAP patients regarding mortality rate. Witnessed aspiration, reintubation, prior antibiotic therapy, continuous enteral feeding, and bronchoscopy were associated with VAP. On multiple logistic regression analysis, only prior antibiotic therapy, continuous enteral feeding, and bronchoscopy were independent predictors of VAP.

Conclusions:

The mean VAP rate in this hospital was higher than that reported by NNIS System surveillance of PICUs. This study has established a benchmark for future studies of VAP in the pediatric intensive care population in Saudi Arabia. Additional studies from the region are necessary for comparison and development of preventive measures.
Transmission of Methicillin-Resistant Staphylococcus aureus to Preterm Infants Through Breast Milk
Authors: Behari Priya , Englund Janet , Alcasid Grace , Garcia-Houchins Sylvia , Weber Stephen G.
Published: April 2006

Objective:

To determine a potential source of MRSA colonization and infection among preterm infants in a neonatal intensive care unit (NICU) using molecular analysis of breast milk samples.

Design:

Case report, outbreak investigation.

Results:

Preterm triplets were delivered at 26 weeks' gestation via cesarean section when routine active surveillance for MRSA was performed for all infants in a NICU. Surveillance consisted of swabbing the throat, nose, and umbilicus (TNU) weekly. Although infants A and B initially had negative TNU swabs, repeat cultures were positive for MRSA on day of life (DOL) 10 and DOL 18, respectively. Surveillance and clinical cultures for infant C were negative. Infant A developed sepsis, and multiple blood cultures were positive for MRSA beginning on DOL 14. Infant B developed conjunctivitis and a conjunctival exudate culture was positive for MRSA on DOL 70. Both infants were fed breast milk via nasogastric tube. Cultures of breast milk samples for infants A and B dated prior to either infant's first positive surveillance culture were positive for MRSA. All MRSA isolates had identical results on antibiotic susceptibility testing. PFGE demonstrated identical banding patterns for the MRSA isolates from the blood culture of infant A, breast milk for infants A and B, and a surveillance swab from infant B. At no time did the mother develop evidence of mastitis or other local breast infection.

Conclusions:

MRSA can be passed from mother to preterm infant through contaminated breast milk, even in the absence of maternal infection. Colonization and clinical disease can result.
Variation in the Use of Procedures to Monitor Antimicrobial Resistance in U.S. Hospitals
Authors: Flach Stephen D. , Diekema Daniel J. , Yankey Jon W. , BootsMiller Bonnie J. , Vaughn Thomas E. , Ernst Erika J. , Ward Marcia M. , Doebbeling Bradley N.
Published: April 2006

Background:

Antimicrobial resistance is a growing clinical and public health crisis. Experts have recommended measures to monitor antimicrobial resistance; however, little is known regarding their use.

Objective:

We describe the use of procedures to detect and report antimicrobial resistance in U.S. hospitals and the organizational and epidemiologic factors associated with their use.

Methods:

In 2001, we surveyed laboratory directors (n = 108) from a random national sample of hospitals. We studied five procedures to monitor antimicrobial resistance: (1) disseminating antibiograms to physicians at least annually, (2) notifying physicians of antimicrobial-resistant infections, (3) reporting susceptibility results within 24 hours, (4) using automated testing procedures, and (5) offering molecular typing. Explanatory variables included organizational characteristics and patterns of antimicrobial resistance for oxacillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, quinolone-resistant Escherichia coli, and extended-spectrum beta-lactamase-producing Klebsiella species. Generalized estimating equations accounting for the correlation among outcomes at the facility level were used to identify predictors of the five outcomes.

Results:

Use of the procedures ranged from 85% (automated testing) to 33% (offering molecular typing) and was related to teaching hospital status (OR, 3.1; CI95, 1.5–6.5), participation of laboratory directors on the infection control committee (OR, 1.7; CI95, 1.1–2.8), and having at least one antimicrobial-resistant pathogen with a prevalence greater than 10% (OR, 2.2; CI95, 1.4–3.3).

Conclusion:

U.S. hospitals underutilize procedures to monitor the spread of antimicrobial resistance. Use of these procedures varies and is related to organizational and epidemiologic factors. Further efforts are needed to increase their use by hospitals.
Evaluating Vancomycin Use at a Pediatric Hospital: New Approaches and Insights
Authors: Bolon Maureen K. , Arnold Alana D. , Feldman Henry A. , Rehkopf David H. , Strong Emily F. , Goldmann Donald A. , Wright Sharon B.
Published: April 2006

Objectives:

To characterize vancomycin use at a pediatric tertiary-care hospital, to discriminate between initial (≤ 72 hours) and prolonged (> 72 hours) inappropriate use, and to define patient characteristics associated with inappropriate use.

Design:

Vancomycin courses were retrospectively reviewed using an algorithm modeled on HICPAC guidelines. Data were collected regarding patient demographics, comorbidities, other medication use, and nosocomial infections. The association between each variable and the outcome of inappropriate use was determined by longitudinal regression analysis. A multi-variable model was constructed to assess risk factors for inappropriate initial and prolonged vancomycin use.

Setting:

A pediatric tertiary-care medical center.

Patients:

Children older than 1 year who received intravenous vancomycin from November 2000 to June 2001.

Results:

Three hundred twenty-seven vancomycin courses administered to 260 patients were evaluated for appropriateness. Of initial courses, 114 (35%) were considered inappropriate. Of 143 prolonged courses, 103 (72%) were considered inappropriate. Multivariable risk factor analysis identified the following variables as significantly associated with inappropriate initial use: admission to the surgery service, having a malignancy, receipt of a stem cell transplant, and having received a prior inappropriate course of vancomycin. No variables were identified as significant risk factors for inappropriate prolonged use.

Conclusions:

Substantial inappropriate use of vancomycin was identified. Prolonged inappropriate use was a particular problem. This risk factor analysis suggests that interventions targeting patients admitted to certain services or receiving multiple courses of vancomycin could reduce inappropriate use.
Increased Mortality Associated With a Clonal Outbreak of Ceftazidime-ResistantKlebsiella pneumoniae: A Case–Control Study
Authors: Qavi Abdul , Segal-Maurer Sorana , Mariano Noriel , Urban Carl , Rosenberg Carl , Burns Janice , Chiang Tom , Maurer James , Rahal James J.
Published: April 2006

Objectives:

To determine risk factors for ceftazidime-resistantKlebsiella pneumoniaeinfection and the effect of cef-tazidime-resistantK. pneumoniaeinfection on mortality during an isolated outbreak.

Design:

Case–control investigation using clinical and molecular epidemiology and prospective analysis of infection control interventions.

Setting:

Surgical intensive care unit of a university-affiliated community hospital.

Patients:

Fourteen case-patients infected with ceftazidime-resistantK. pneumoniaeand 14 control-patients.

Results:

Ten of 14 case-patients had identical strains by pulsed-field gel electrophoresis. Broad-spectrum antibiotic therapy before admission to the unit was strongly predictive of subsequent ceftazidime-resistantK. pneumoniaeinfection. In addition, patients with ceftazidime-resistantK. pneumoniaeinfection experienced increased mortality (odds ratio, 3.77).

Conclusions:

Cephalosporin restriction has been shown to decrease the incidence of nosocomial ceftazidime-resistantK. pneumoniae. However, isolated clonal outbreaks may occur due to lapses in infection control practices. Reinstatement of strict handwashing, thorough environmental cleaning, and repeat education led to termination of the outbreak. A distinct correlation between ceftazidime-resistantK. pneumoniaeinfection and mortality supports the important influence of antibiotic resistance on the outcome of serious bacterial infections.
Spread of a Methicillin-Resistant Staphylococcus aureus ST80-IV Clone in a Danish Community
Authors: Urth Tinna , Juul Gitte , Skov Robert , Schønheyder Henrik C.
Published: April 2006

Objective:

We report a community cluster of methicillin-resistant Staphylococcus aureus (MRSA) in Denmark with emphasis on routes of transmission and infection control measures. The objective is to extend knowledge of MRSA in a community setting where a nosocomial link could effectively be ruled out.

Design:

Population-based observational study from November 1997 until June 2003.

Setting:

North Jutland County, with approximately 495,000 inhabitants.

Subjects:

The cluster encompassed 46 individuals and 26 households.

Interventions:

Infection control measures included repeated visits to affected households by an infection control nurse who undertook screening for carriage among all household members and provided a program for decolonization.

Results:

The causal strain was identical to a newly described international clone, ST80; SSCmec type IV; and Panton–Valentine leukocidin positive. Plausible routes of transmission included household contact and contact at work, kindergarten, and school. We did not detect a nosocomial source or any secondary cases in hospitals. Transmission by healthcare contact outside the hospital was plausible for three cases. We found evidence that the clone was introduced on more than one occasion to immigrant families from the Middle East. A 5-day decolonization program was successful at first attempt in 15 of 16 households that could be evaluated.

Conclusions:

Despite the described infection control measures, we continued to see new cases, underlining a need for a national policy to contain MRSA in the community.
Prevalence and Nosocomial Spread of Methicillin-ResistantStaphylococcus aureusin a Long-Term-Care Facility in Slovenia
Authors: Cretnik Tjasa Zohar , Vovko Petra , Retelj Matjaz , Jutersek Borut , Harlander Tatjana , Kolman Jana , Gubina Marija
Published: April 2006

Objectives:

To determine the prevalence and incidence of methicillin-resistantStaphylococcus aureus(MRSA) colonization among residents and healthcare workers (HCWs) of a long-term-care facility (LTCF), to assess possible routes of nosocomial spread, and to determine genetic relatedness of the isolates.

Setting:

A 351-bed community LTCF for the elderly.

Design and Participants:

Study investigators made two visits, approximately 3 months apart, to the facility. Samples for cultures were obtained from 107 residents during the first visit, 91 residents during the second visit, and 38 HCWs.

Results:

The prevalence of MRSA colonization among residents was 9.3% during the first visit and 8.8% during the second visit. During the first visit, two HCWs were colonized. During the second visit, no HCWs were colonized. The colonization of HCWs suggested a potential role in the transmission of MRSA. Molecular typing showed that two of three roommates in one room had the same strain, whereas two in another room differed from one another. All isolates, except one, belonged to two related clonal groups. It seems that the clonal group to which most isolates belonged had the greatest potential for spreading among both residents and HCWs.

Conclusions:

Similar prevalence rates of MRSA colonization have been found in other European countries, but such studies have usually involved residents with better functional status than that of the participants in this study. Nosocomial spread of MRSA occurred in the facility examined, but not frequently. More attention should be focused on the hand hygiene of HCWs.
A Large Outbreak ofClostridium difficile–Associated Disease with an Unexpected Proportion of Deaths and Colectomies at a Teaching Hospital Following Increased Fluoroquinolone Use
Authors: Muto Carlene A. , Pokrywka Marian , Shutt Kathleen , Mendelsohn Aaron B. , Nouri Kathy , Posey Kathy , Roberts Terri , Croyle Karen , Krystoflak Sharon , Patel-Brown Sujata , Pasculle A. William , Paterson David L. , Saul Melissa , Harrison Lee H.
Published: April 2006

Background and Objective:

Fluoroquinolones have not been frequently implicated as a cause ofClostridium difficileoutbreaks. NosocomialC. difficileinfections increased from 2.7 to 6.8 cases per 1,000 discharges (P< .001). During the first 2 years of the outbreak, there were 253 nosocomialC. difficileinfections; of these, 26 resulted in colectomy and 18 resulted in death. We conducted an investigation of a largeC. difficileoutbreak in our hospital to identify risk factors and characterize the outbreak.

Methods:

A retrospective case-control study of case-patients withC. difficileinfection from January 2000 through April 2001 and control-patients matched by date of hospital admission, type of medical service, and length of stay; an analysis of inpatient antibiotic use; and antibiotic susceptibility testing and molecular subtyping of isolates were performed.

Results:

On logistic regression analysis, clindamycin (odds ratio [OR], 4.8; 95% confidence interval [CI95], 1.9-12.0), ceftriaxone (OR, 5.4; CI95, 1.8-15.8), and levofloxacin (OR, 2.0; CI95, 1.2-3.3) were independently associated with infection. The etiologic fractions for these three agents were 10.0%, 6.7%, and 30.8%, respectively. Fluoroquinolone use increased before the onset of the outbreak (P< .001); 59% of case-patients and 41% of control-patients had received this antibiotic class. The outbreak was polyclonal, although 52% of isolates belonged to two highly related molecular subtypes.

Conclusions:

Exposure to levofloxacin was an independent risk factor forC. difficile-associateddiarrhea and appeared to contribute substantially to the outbreak. Restricted use of levofloxacin and the other implicated antibiotics may be required to control the outbreak.
How Outbreaks Can Contribute to Prevention of Nosocomial Infection: Analysis of 1,022 Outbreaks
Authors: Gastmeier Petra , Stamm-Balderjahn Sabine , Hansen Sonja , Nitzschke-Tiemann Frauke , Zuschneid Irina , Groneberg Katrin , Rüden Henning
Published: April 2006

Objective:

To describe the epidemiology of nosocomial outbreaks published in the scientific literature.

Design:

Descriptive information was obtained from a sample of 1,022 published nosocomial outbreaks from 1966 to 2002.

Methods:

Published nosocomial outbreaks of the most important nosocomial pathogens were included in the database. A structured questionnaire was devised to extract information in a systematic manner on nosocomial outbreaks published in the literature. The following items were used: the reference, type of study (case reports or studies applying epidemiologic or fingerprinting methods), type of microorganism, setting, patients and personnel involved, type of infection, source of infection, mode of transmission, risk factors identified, and preventive measures applied.

Results:

Bloodstream infection was the most frequently identified type of infection (37.0%), followed by gastrointestinal infection (28.5%) and pneumonia (22.9%). In 37% of the outbreaks, the authors were not able to identify the sources. The most frequent sources were patients (25.7%), followed by medical equipment or devices (11.9%), the environment (11.6%), and the staff (10.9%). The mode of transmission remained unclear in 28.3% of the outbreaks. Transmission was by contact in 45.3%, by invasive technique in 16.1%, and through the air in 15.0%. The percentage of outbreaks investigated by case-control studies or cohort studies over the years was small (21% and 9%, respectively, for the whole time period).

Conclusion:

Outbreak reports in the literature are a valuable resource and should be used for educational purposes as well as for preparing outbreak investigations.
Estimation of the Cumulative Incidence of Hospital-Acquired Bacteremia From Prevalence Data: A Formula
Authors: Haore Houssein Gbaguidi , Muller Arno , Talon Daniel , Bertrand Xavier
Published: April 2006

We evaluated the validity of the formula of Rhame and Sudderth to estimate the cumulative incidence of nosocomial bacteremia from prevalence studies. The observed cumulative incidence was threefold higher than the calculated cumulative incidence. We do not recommend converting prevalence into incidence data for nosocomial bloodstream infections.
Medical Errors Detected and Corrected by a Pediatric Infectious Diseases Consultation Service
Authors: Sandora Thomas J. , Goldmann Donald A.
Published: April 2006

Errors occur frequently in healthcare and can adversely affect outcomes. This prospective study demonstrates that pediatric consultants can detect a broad range of errors in the course of routine work. Many of these errors have the potential to cause harm and can be corrected by the intervention of an infectious diseases consultant.
Hospital-Related Determinants For Surgical-Site Infection Following Hip Arthroplasty
Authors: Geubbels Eveline L. P. E. , Wille Jan C. , Nagelkerke Nico J. D. , Vandenbroucke-Grauls Christina M. J. E. , Grobbee Diederick E. , de Boer Annette S.
Published: April 2006

Objective:

To determine hospital-related risk factors for surgical-site infection (SSI) following hip arthroplasty.

Design:

Prospective, multicenter cohort study based on surveillance data and data collected through a structured telephone interview. With the use of multilevel logistic regression, the independent effect of hospital-related characteristics on SSI was assessed.

Setting:

Thirty-six acute care hospitals in the Dutch surveillance network for nosocomial infections (PREZIES), from 1996 to 2000.

Patients:

Thirteen thousand six hundred eighty patients who underwent total or partial hip arthroplasty.

Results:

A high annual volume of operations was associated with a reduced risk of SSI (risk-adjusted risk ratio [RR] per 50 extra operations, 0.85; 95% confidence interval [CI95], 0.74–0.97). With each extra full-time–equivalent infection control staff member per 250 beds available for prevention of SSI, the risk for SSI was decreased (RR, 0.48; CI95, 0.16–1.44), although the decrease was not statistically significant. Hospital size, teaching status, university affiliation, and number of surgeons and their years of experience showed no important association with the risk of SSI.

Conclusion:

Undergoing surgery in a hospital with a low volume of operations increases a patient's risk of SSI.
Rates of Surgical-Site Infection: An International Comparison
Authors: Moro Maria Luisa , Morsillo Filomena , Tangenti Marilena , Mongardi Maria , Pirazzini Maria Cristina , Ragni Pietro ,   ICN Regional Group
Published: April 2006

Objectives:

To quantify the occurrence of surgical-site infections (SSIs) in an Italian region and to estimate the proportion of potentially avoidable infections through benchmarking comparison.

Design:

Prospective study during 1 month based on a convenience sample of surgical patients admitted to 31 public hospitals. All of the patients undergoing an intervention included among the 44 operative procedures of the National Nosocomial Infections Surveillance (NNIS) System were enrolled. Ninety-five percent of the patients were actively observed after discharge for up to 30 days for all of the operations and for up to 1 year for operations involving implantation.

Results:

Among the 6,167 operative procedures studied, 290 infections were recorded (4.7 per 100 procedures), 206 (71%) of which were SSIs (3.3 per 100 procedures; 95% confidence interval, 2.9–3.9). One hundred thirty-five SSIs (65.5%) were superficial infections, 53 (25.7%) were deep infections, and 12 (5.8%) were organ–space infections; in 6 cases (2.9%), the type of SSI was not recorded. The frequency of SSIs observed in this study was significantly higher for several procedures than that expected when the NNIS System rates (standardized infection ratio [SIR] ranging from 1.77 to 6.42) or the Hungarian rates (SIR ranging from 1.28 to 3.04) were applied to the study population.

Conclusions:

The high intensity of postdischarge surveillance can in part explain the differences observed. To allow for meaningful benchmarking comparison, in addition to intrinsic patient risk, data on the intensity of postdischarge surveillance should be included in published reports.