Impact on hand hygiene compliance following migration to a new hospital with improved resources and the sequential introduction of World Health Organization recommendations.

Am J Infect Control. 2012 Jan 26;

Authors: Abela N, Borg MA

Abstract
BACKGROUND: One commonly cited reason for inadequate hand hygiene (HH) in health care facilities is lack of handwashing sinks and alcohol hand rub (AHR). METHODS: Using the World Health Organization (WHO) direct observation method, we studied HH compliance after migration from an old hospital having 1 HH station (sink and AHR) per 6 beds to a new institution with 1 per 0.85 beds. We then introduced the other WHO strategy components in a sequential manner-posters, active education, and performance feedback-and assessed the impact of the various elements over time. RESULTS: Migration from the old to the new hospital was actually accompanied by a reduction in HH from 27.3% to 14.5% (P < .01), with a 52% decline in handwashing (P = .01) after patient contact. Small group interactive teaching improved HH compliance but only reached a maximum of 33.1%. No change was seen where only posters and leaflets (without educational sessions) were adopted. Significant improvement was only obtained after a performance feedback campaign coupled with increased staff accountability, reaching an overall average of 63% (P < .001). CONCLUSION: Our results suggest that, on their own, better resources do not offer any guarantees of improved HH practices. However, once in place, audit and feedback-coupled with genuine administrative support and fostering of individual accountability-appear to be effective change tools to increase HH compliance.

PMID: 22285712 [PubMed - as supplied by publisher]

The burden of multidrug-resistant organisms on tertiary hospitals posed by patients with recent stays in long-term acute care facilities.

Am J Infect Control. 2012 Jan 26;

Authors: Marchaim D, Chopra T, Bogan C, Bheemreddy S, Sengstock D, Jagarlamudi R, Malani A, Lemanek L, Moshos J, Lephart PR, Ku K, Hasan A, Lee J, Khandker N, Blunden C, Geffert SF, Moody M, Hiro R, Wang Y, Ahmad F, Mohammadi T, Faruque O, Patel D, Pogue JM, Hayakawa K, Dhar S, Kaye KS

Abstract
BACKGROUND: Long-term acute care (LTAC) facilities admit patients with complex, advanced disease states. Study aims were to determine the burden posed on hospitals associated with LTAC exposure and analyze the differences between "present on admission" (POA) multidrug-resistant (MDR), gram-negative organisms (GNO) and POA MDR gram-positive organisms (GPO). METHODS: A multicenter retrospective study was conducted in 13 hospitals from southeast Michigan, from September 1, 2008, to August 31, 2009. Cultures obtained in the first 72 hours of hospitalization (ie, POA) of MDR-GPO and MDR-GNO were reviewed. LTAC exposures in the previous 6 months and direct admission from a LTAC were recorded. RESULTS: Overall, 5,297 patients with 7,147 MDR POA cultures were analyzed: 2,619 (36.6%) were MDR-GNO, and 4,528 (63.4%) were MDR-GPO. LTAC exposure in the past 6 months was present in 251 (5.2%) infectious episodes and was significantly more common among POA MDR-GNO than MDR-GPO (158 [8.6%] and 94 [3.1%], respectively, odds ratio, 2.87; P < .001). Recent LTAC exposure was strongly associated with both carbapenem-resistant Enterobacteriaceae (CRE) (31.6% of all CRE cases, P < .001) and Acinetobacter baumannii (14.9% of all A baumannii cases, P < .001). CONCLUSION: Nearly 10% of MDR-GNO POA had recent LTAC exposure. Hospital efforts to control the spread of MDR-GNO should focus on collaborations and communications with referring LTACs and interventions targeted towards patients with recent LTAC exposure.

PMID: 22285709 [PubMed - as supplied by publisher]

Association between risk of bloodstream infection and duration of use of totally implantable access ports and central lines: a 24-month study.

Am J Infect Control. 2011 Sep;39(7):e39-43

Authors: Yoshida J, Ishimaru T, Kikuchi T, Matsubara N, Asano I

Abstract
BACKGROUND: Prolonged use of totally implantable access ports (APs) and central lines (CLs) has been known to carry a risk of bloodstream infection (BSI), but the safe cutoff day for discontinuing use remains unknown. We performed a receiver operating characteristic (ROC) curve analysis to determine this cutoff.
METHODS: A retrospective 24-month study covered a total of 22,481 days of device use. For each day of use, the following findings were recorded: patient age and sex; presence or absence of diabetes mellitus, preexisting sepsis, and renal disease; and occurrence of device-associated BSI. BSI was defined in accordance with the Centers for Disease Control and Prevention's definition of catheter-related infection.
RESULTS: BSIs occurred in 81 patients with an AP, for a BSI rate of 2.81 cases per 1,000 days of use. Among the 896 patients with a CL, the BSI rate was 5.60 cases per 1,000 days of use. The ROC analysis found a cutoff time of 33 days for APs (median days of use, 48) and 10 days for CLs (median days of use, 20.5). For the total 22,481 days of use, the odds ratio between APs and CLs with respect to BSI was 0.556 (95% confidence interval [CI], 0.256-1.208; P = .138). Days of use beyond the cutoff had an odds ratio of 2.867 (95% CI, 1.823-4.507; P < .001). Among the risk factors, preexisting sepsis had an odds ratio of 7.843 (95% CI, 4.666-13.184; P < .001).
CONCLUSION: Use of an AP for more than 33 days and a CL for more than 10 days may carry an increased risk of device-associated BSI. These cutoff periods are longer than those expected at the time of device placement and indicate the importance of postplacement care.

PMID: 21652113 [PubMed - indexed for MEDLINE]

Evaluation of bacterial contaminants found on unused paper towels and possible postcontamination after handwashing: A pilot study.

Am J Infect Control. 2011 Dec 15;

Authors: Gendron LM, Trudel L, Moineau S, Duchaine C

Abstract
BACKGROUND: Bacterial contamination is a concern in the pulp and paper industry. Not only is the machinery contaminated but also can be the end-paper products. Bacterial transmission from unused paper towels to hands and surfaces is not well documented. METHODS: The culturable bacterial community of 6 different unused paper towel brands was determined by culture methods and by sequencing the 16S ribosomal DNA of bacterial contaminants. Next, we investigated the possible airborne and direct contact transmissions of these bacterial contaminants during hand drying after washing. RESULTS: Between 10(2) and 10(5) colony-forming units per gram of unused paper towels were isolated from the different paper towel brands. Bacteria belonging to the Bacillus genus were by far the most abundant microorganisms found (83.0%), followed by Paenibacillus (15.6%), Exiguobacterium (1.6%), and Clostridium (0.01%). Paper towels made from recycled fibers harbored between 100- to 1,000-fold more bacteria than the virgin wood pulp brand. Bacteria were easily transferred to disposable nitrile gloves when drying hands with paper towels. However, no evidence of bacterial airborne transmission was observed during paper towel dispensing. CONCLUSION: This pilot study demonstrated that a large community of culturable bacteria, including toxin producers, can be isolated from unused paper towels and that they may be transferred to individuals after handwashing. This may have implications in some industrial and clinical settings as well as in immunocompromised individuals.

PMID: 22177666 [PubMed - as supplied by publisher]

Comparison of bacteria on new, disposable, laundered, and unlaundered hospital scrubs.

Am J Infect Control. 2011 Dec 15;

Authors: Nordstrom JM, Reynolds KA, Gerba CP

Abstract
BACKGROUND: As a cost-saving measure, an increasing number of hospitals allow personnel to launder their uniforms, lab coats, and operating room scrubs at home. With rising nosocomial infection rates and increasing levels of multidrug-resistant bacteria in hospital settings, uniform contamination may be an environmental factor in the spread of infection. METHODS: We quantified the number and identity of bacteria found on swatches cut from unwashed operating room, hospital-laundered, home-laundered, new cloth, and new disposable scrubs. RESULTS: Of the 29 unwashed hospital operating room scrub swatches analyzed, 23 (79%) were positive for some type of gram-positive cocci, with 3 (10%) of those classified as Staphylococcus aureus, and 20 (69%) were positive for coliform bacteria, 3 of which were Escherichia coli. Home-laundered scrubs had a significantly higher total bacteria count than hospital-laundered scrubs (P = .016). There was no statistical difference in the bacteria counts between hospital-laundered scrubs and unused new and disposable scrubs. In the home-laundered scrubs 44% (18/41) were positive for coliform bacteria, but no isolates were Escherichia coli. CONCLUSIONS: Significantly higher bacteria counts were isolated from home-laundered scrubs and unwashed scrubs than from new, hospital-laundered, and disposable scrubs.

PMID: 22177668 [PubMed - as supplied by publisher]

Contact Precautions for methicillin-resistant Staphylococcus aureus colonization: Costly and unnecessary?

Am J Infect Control. 2011 Oct 18;

Authors: Spence MR, Dammel T, Courser S

Abstract
BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is frequently encountered in health care facilities. Many hospitals have established screening programs to identify individuals harboring the organism. Patients identified as carrying MRSA are frequently placed in Contact Precautions at time of admission. METHODS: Between January 1, 2007, and December 31, 2010, we screened a select group of patients for MRSA employing polymerase chain reaction testing. We recorded our screening results and also recorded the MRSA hospital-acquired infection (HAI) rate. In January 2010, we discontinued placing individuals, asymptomatically colonized with MRSA, in Contact Precautions. RESULTS: Between January 1, 2007, and December 31, 2010, we screened 6,712 asymptomatic patients for MRSA and found 633 (9.4%) to be positive. During this same time period, we encountered 7 MRSA HAI. There was 1 MRSA HAI in the first year and 2 in each of the last 3 years of the study period. The costs incurred for Contact Precautions for the MRSA study population averaged $8,055 per year for each of the first 3 years and $0 for 2010. CONCLUSION: Placing patients who are asymptomatically harboring MRSA in Contact Precautions did not decrease the rate of HAI caused by this organism and was relatively expensive.

PMID: 22015256 [PubMed - as supplied by publisher]

Acquisition of spores on gloved hands after contact with the skin of patients with Clostridium difficile infection and with environmental surfaces in their rooms.

Am J Infect Control. 2011 Oct 7;

Authors: Guerrero DM, Nerandzic MM, Jury LA, Jinno S, Chang S, Donskey CJ

Abstract
In a prospective study of 30 patients with Clostridium difficile infection, we found that acquisition of spores on gloved hands was as likely after contact with commonly touched environmental surfaces (ie, bed rail, bedside table, telephone, call button) as after contact with commonly examined skin sites (ie, chest, abdomen, arm, hand).

PMID: 21982209 [PubMed - as supplied by publisher]

Evaluation of screening risk and nonrisk patients for methicillin-resistant Staphylococcus aureus on admission in an acute care hospital.

Am J Infect Control. 2011 Sep 30;

Authors: Creamer E, Galvin S, Dolan A, Sherlock O, Dimitrov BD, Fitzgerald-Hughes D, Thomas T, Walsh J, Moore J, Smyth EG, Shore AC, Sullivan D, Kinnevey P, O'Lorcain P, Cunney R, Coleman DC, Humphreys H

Abstract
BACKGROUND: Screening for methicillin-resistant Staphylocccus aureus (MRSA) is advocated as part of control measures, but screening all patients on admission to hospital may not be cost-effective. OBJECTIVE: Our objective was to evaluate the additional yield of screening all patients on admission compared with only patients with risk factors and to assess cost aspects. METHODS: A prospective, nonrandomized observational study of screening nonrisk patients ?72 hours of admission compared with only screening patients with risk factors over 3 years in a tertiary referral hospital was conducted. We also assessed the costs of screening both groups. RESULTS: A total of 48 of 892 (5%) patients was MRSA positive; 28 of 314 (9%) during year 1, 12 of 257 (5%) during year 2, and 8 of 321 (2%) during year 3. There were significantly fewer MRSA-positive patients among nonrisk compared with MRSA-risk patients: 4 of 340 (1%) versus 44 of 552 (8%), P ? .0001, respectively. However, screening nonrisk patients increased the number of screening samples by 62% with a proportionate increase in the costs of screening. A backward stepwise logistic regression model identified age > 70 years, diagnosis of chronic pulmonary disease, previous MRSA infection, and admission to hospital during the previous 18 months as the most important independent predictors to discriminate between MRSA-positive and MRSA-negative patients on admission (94.3% accuracy, P < .001). CONCLUSION: Screening patients without risk factors increased the number of screenings and costs but resulted in few additional cases being detected. In a hospital where MRSA is endemic, targeted screening of at-risk patients on admission remains the most efficient strategy for the early identification of MRSA-positive patients.

PMID: 21962934 [PubMed - as supplied by publisher]

Rapid control of a scabies outbreak at a tertiary care hospital without ward closure.

Am J Infect Control. 2011 Aug 24;

Authors: Khan A, O'Grady S, Muller MP

Abstract
BACKGROUND: Although scabies outbreaks in hospitals are frequent, the optimal approach to management of these outbreaks has not yet been defined. We describe a hospital scabies outbreak that was successfully controlled without ward closure. METHODS: An outbreak of scabies at a teaching hospital and subsequent control measures were investigated. Outcomes included the number of cases affecting patients and staff, number of patients and staff requiring prophylaxis, duration of the outbreak, and cost of the outbreak. Outcomes were compared with those in a similar outbreak occurring at the same hospital 20 years earlier and with other published descriptions of hospital scabies outbreaks. RESULTS: In January 2010, a patient who had undergone renal transplantation was admitted 3 times to St. Michael's Hospital, but a diagnosis of scabies was not considered until the final admission. Widespread exposure of patients and staff on 2 wards prompted the establishment of an outbreak management team. Initial interventions focused on isolation and treatment of the index case and on contact tracing to identify and treat secondary cases and to offer prophylaxis to direct contacts. Five symptomatic staff members and 2 patient cases were quickly identified, an outbreak was declared, and mass simultaneous prophylaxis was initiated on the 2 involved wards. A single case occurred 2 weeks after the mass prophylaxis program in a staff member who had not received the prophylaxis. Six weeks after the onset of symptoms, the end of the outbreak was declared. No additional cases have been reported up to the time of publication. The total cost of the outbreak was $20,000. CONCLUSIONS: Early recognition of crusted scabies is essential to prevent outbreaks. Once an outbreak occurs, prompt control of the index patient and rapid tracing of contacts to identify secondary cases are necessary. When prolonged exposure to a case of crusted scabies results in multiple secondary cases, institution of simultaneous mass prophylaxis is the most efficient strategy for terminating the outbreak and can be implemented without ward closure.

PMID: 21868131 [PubMed - as supplied by publisher]

Nursing and physician attire as possible source of nosocomial infections.

Am J Infect Control. 2011 Sep;39(7):555-559

Authors: Wiener-Well Y, Galuty M, Rudensky B, Schlesinger Y, Attias D, Yinnon AM

Abstract
BACKGROUND: Uniforms worn by medical and nursing staff are not usually considered important in the transmission of microorganisms. We investigated the rate of potentially pathogenic bacteria present on uniforms worn by hospital staff, as well as the bacterial load of these microorganisms. METHODS: Cultures were obtained from uniforms of nurses and physicians by pressing standard blood agar plates at the abdominal zone, sleeve ends, and pockets. Each participant completed a questionnaire. RESULTS: A total of 238 samples were collected from 135 personnel, including 75 nurses (55%) and 60 physicians (45%). Of these, 79 (58%) claimed to change their uniform every day, and 104 (77%) defined the level of hygiene of their attire as fair to excellent. Potentially pathogenic bacteria were isolated from at least one site of the uniforms of 85 participants (63%) and were isolated from 119 samples (50%); 21 (14%) of the samples from nurses' gowns and 6 (6%) of the samples from physicians' gowns (P = NS) included of antibiotic-resistant bacteria. CONCLUSION: Up to 60% of hospital staff's uniforms are colonized with potentially pathogenic bacteria, including drug-resistant organisms. It remains to be determined whether these bacteria can be transferred to patients and cause clinically relevant infection.

PMID: 21864762 [PubMed - as supplied by publisher]

Do hospital visitors wash their hands? Assessing the use of alcohol-based hand sanitizer in a hospital lobby.

Am J Infect Control. 2011 Aug 22;

Authors: Birnbach DJ, Nevo I, Barnes S, Fitzpatrick M, Rosen LF, Everett-Thomas R, Sanko JS, Arheart KL

Abstract
BACKGROUND: Reports regarding hand hygiene compliance (HHC) among hospital visitors are limited. Although there is an implicit assumption that the availability of alcohol-based hand sanitizer (AHS) promotes visitor HHC, the degree of AHS use by visitors remains unclear. To assess AHS use, we observed visitor HHC and how it is affected by visual cues in a private university hospital. METHODS: Using an observational controlled study, we tested 3 interventions: a desk sign mandating all visitors to use AHS, a free-standing AHS dispenser directly in front of a security desk, and a combination of a freestanding AHS dispenser and a sign. RESULTS: HHC was 0.52% at baseline and did not improve significantly when the desk sign was provided as a cue 0.67% (P = .753). However, HHC did improve significantly with use of the freestanding AHS dispenser (9.33%) and the sign and dispenser combination (11.67%) (P < .001 for all comparisons of dispenser alone and sign and dispenser with baseline and sign alone). The degree of improvement with the sign and dispenser combination over the dispenser was not statistically significant. CONCLUSIONS: Hospital visitors represent an important factor in infection prevention. A coordinated effort is needed to increase visitor HHC, including an evaluation of the AHS placement, education of visitors on the importance of HHC, and evaluation of corresponding changes in hand hygiene behavior.

PMID: 21864941 [PubMed - as supplied by publisher]

Overview of adverse events related to invasive procedures in the intensive care unit.

Am J Infect Control. 2011 Aug 2;

Authors: Pottier V, Daubin C, Lerolle N, Gaillard C, Viquesnel G, Plaud B, Hanouz JL, Charbonneau P

BACKGROUND: This study was conducted to determine the frequency, predictors, and clinical impact of adverse events (AEs) related to invasive procedures in the intensive care unit (ICU). METHODS: This was a prospective observational study of ICUs in a university hospital. RESULTS: A total of 893 patients requiring invasive procedures were admitted over a 1-year period. Among these, 310 patients (34.7%) experienced a total of 505 AEs. The mean number of AEs per patient was 1.6 ± 1.1 (range, 1-7). Infectious AEs were significantly more frequent than mechanical AEs (60.4% vs 39.6%; P = .01). Factors independently associated with AE occurrence were isolation of multidrug-resistant bacteria at ICU admission, >5 invasive procedures, and ICU length of stay >8 days. Thirty-three AEs (6.5%) resulted in severe clinical impact, including 24 deaths. Ventilator-associated pneumonia (VAP) accounted for 62.5% of the deaths related to AEs. CONCLUSIONS: One-third of critically ill patients experienced AEs related to invasive procedures. Severe AEs were associated with 11% of all ICU deaths. VAP was the most frequent AE related to death. An improved assessment of the risk-benefit balance before each invasive procedure and increased efforts to decrease VAP prevalence are needed to reduce AE-related mortality.

PMID: 21813208 [PubMed - as supplied by publisher]

Successful control of a norovirus outbreak among attendees of a hospital teaching conference.

Am J Infect Control. 2011 Aug 3;

Authors: Vinnard C, Lee I, Linkin D

We report an outbreak of norovirus gastroenteritis after a hospital teaching conference, and describe the specific measures instituted by the infection control team. No secondary cases of norovirus infection were identified among hospital staff or patients. In a case-control study, we identified multiple food source contamination as the source of the outbreak. Our report highlights the potential success of a multifaceted infection control strategy in preventing the transmission of norovirus in health care settings.

PMID: 21816511 [PubMed - as supplied by publisher]

Epidemiology of central line-associated bloodstream infections in Quebec intensive care units: A 6-year review.

Am J Infect Control. 2011 Aug 6;

Authors: Fontela PS, Platt RW, Rocher I, Frenette C, Moore D, Fortin E, Buckeridge D, Pai M, Quach C

BACKGROUND: The burden of central line-associated bloodstream infections (CLABSI) in Canadian intensive care units (ICUs) is not well established. The present study aimed to describe CLABSI epidemiology in Quebec ICUs during 2003-2009. METHODS: The study population was a retrospective dynamic cohort of 58 ICUs that participated in the Surveillance Provinciale des Infections Nosocomiales program during 2003-2009. We calculated annual CLABSI incidence rates (IRs), central venous catheter (CVC) utilization ratios, and case-fatality proportions, and described the pathogens involved. We analyzed data using descriptive statistics and standardized incidence ratios. RESULTS: A total of 891 CLABSIs were identified during 446,137 CVC-days. In 2003-2009, CLABSI IRs were 1.67 CLABSI/1,000 CVC-days in adult ICUs, 2.20 CLABSIs/1,000 CVC-days in pediatric ICUs, and 4.40 CLABSIs/1,000 CVC-days in neonatal ICUs. Since 2007, CLABSI IRs in adult, pediatric and neonatal ICUs have decreased by 11%, 50%, and 18%, respectively. Pediatric ICUs had the highest CVC utilization ratio (median, 0.61; interquartile range, 0.57-0.66). Coagulase-negative staphylococci caused 53% of the CLABSIs. The proportion of methicillin-resistant Staphylococcus aureus declined from 70% to <40% after 2006. CONCLUSIONS: CLABSIs result in a considerable burden of illness in Quebec ICUs. However, CLABSI IRs have decreased since 2007, and the proportion of methicillin-resistant S aureus has remained <40% since 2006. Continuous surveillance is essential to determine whether these changes are sustainable.

PMID: 21824682 [PubMed - as supplied by publisher]

Antimicrobial resistance in pathogens causing nosocomial bloodstream infections in university hospitals in Egypt.

Am J Infect Control. 2011 Aug 10;

Authors: Saied T, Elkholy A, Hafez SF, Basim H, Wasfy MO, El-Shoubary W, Samir A, Pimentel G, Talaat M

BACKGROUND: Nosocomial bloodstream infections (BSIs) and antimicrobial resistance (AMR) are worldwide health care problems causing substantial patient morbidity and mortality. This study was conducted to identify bacterial pathogens isolated from nosocomial BSIs and determine their AMR patterns. METHODS: An active surveillance program for BSIs was conducted in intensive care units in 3 large university hospitals in Egypt between September 1, 2006, and June 30, 2007. Infection prevention and control teams and link nurses in collaboration with intensive care physicians were looking actively to identify patients who acquired BSIs based on Centers for Disease Control and Prevention standard case definitions. Blood cultures were obtained from patients with suspected BSIs and processed to isolate bacteria and test their antimicrobial resistance. RESULTS: During the 10-month active surveillance period, a total of 600 pathogens were isolated from blood cultures of 1,575 patients (38%). Of these 600 isolates, 386 (66%) were gram-negative, 178 (30%) were gram-positive, and 24 (4%) were budding yeasts. The gram-negative organisms included 162 (27%) Klebsiella pneumoniae and 23 (3.8%) Escherichia coli. Extended-spectrum ?-lactamase enzymes were detected in 79% of the K pneumoniae isolates and 39% of the E coli isolates. Methicillin-resistant Staphylococcus aureus accounted for 60% of S aureus infections. CONCLUSIONS: High rates of ?-lactamase resistance and methicillin-resistant S aureus were found in the 3 Egyptian university hospitals studied. This study highlights the need for strengthening infection prevention and control programs, monitoring AMR at each facility, and developing policies for antibiotic use.

PMID: 21835504 [PubMed - as supplied by publisher]