Clinical and economic outcomes from a community hospital's antimicrobial stewardship program.

Am J Infect Control. 2012 May 9;

Authors: Malani AN, Richards PG, Kapila S, Otto MH, Czerwinski J, Singal B

Abstract
BACKGROUND: Data from community antimicrobial stewardship programs (ASPs) are limited. We describe clinical and economic outcomes from the first year of our hospital's ASP. METHODS: The ASP team comprised 2 infectious disease physicians and 3 intensive care unit pharmacists. The team prospectively audited the new starts and weekly use of 8 target antimicrobials: aztreonam, caspofungin, daptomycin, ertapenem, linezolid, meropenem, tigecycline, and voriconazole. Using administrative data, outcomes from the first year of the program, including death within 30 days of hospitalization, readmission within 30 days of discharge, and development of Clostridium difficile infection (CDI), were compared with outcomes from a similar period before institution of the program. RESULTS: A total of 510 antimicrobial orders were reviewed, of which 323 (63%) were appropriate, 94 (18%) prompted deescalation, 61 (12%) were denied, and 27 (5%) led to formal consultation with an infectious disease physician. On multivariate analysis, implementation of the ASP was associated with an approximate 50% reduction in the odds of developing CDI (odds ratio, 0.46; 95% confidence interval, 0.25-0.82). The ASP was not associated with decreased mortality at 30 days after discharge or readmission rate. The antimicrobial cost per patient-day decreased by 13.3%, from $10.16 to $8.81. The antimicrobial budget decreased by 15.2%, resulting in a total savings of $228,911. There was a 25.4% decrease in defined daily doses of the target antimicrobials. CONCLUSIONS: Implementation of the ASP was associated with significant reductions in CDI rate, antimicrobial use, and pharmacy costs.

PMID: 22579261 [PubMed - as supplied by publisher]

Point-of-care hand hygiene: Preventing infection behind the curtain.

Am J Infect Control. 2012 May;40(4 Suppl 1):S3-S10

Authors: Kendall A, Landers T, Kirk J, Young E

Abstract
Best practices for hand hygiene provide indications for performance of hand hygiene at specific points in time during patient care. For hand hygiene to prevent infections, hand hygiene resources must be readily available to health care workers whenever required. This article reviews practices and recommendations intended to facilitate hand hygiene behavior at the point of care (POC) within the health care setting. Key aspects of POC hand hygiene include the provision of alcohol-based hand rub products, integration of dispensing solutions within the patient zone, consideration of patient care workflow, and dispenser designs that optimize acceptance and usage.

PMID: 22546271 [PubMed - in process]

Bundling hand hygiene interventions and measurement to decrease health care-associated infections.

Am J Infect Control. 2012 May;40(4 Suppl 1):S18-27

Authors: Pincock T, Bernstein P, Warthman S, Holst E

Abstract
Proper performance of hand hygiene at key moments during patient care is the most important means of preventing health care-associated infections (HAIs). With increasing awareness of the cost and societal impact caused by HAIs has come the realization that hand hygiene improvement initiatives are crucial to reducing the burden of HAIs. Multimodal strategies have emerged as the best approach to improving hand hygiene compliance. These strategies use a variety of intervention components intended to address obstacles to complying with good hand hygiene practices, and to reinforce behavioral change. Although research has substantiated the effectiveness of the multimodal design, challenges remain in promoting widespread adoption and implementation of a coordinated approach. This article reviews elements of a multimodal approach to improve hand hygiene and advocates the use of a "bundled" strategy. Eight key components of this bundle are proposed as a cohesive program to enable the deployment of synergistic, coordinated efforts to promote good hand hygiene practice. A consistent, bundled methodology implemented at multiple study centers would standardize processes and allow comparison of outcomes, validation of the methodology, and benchmarking. Most important, a bundled approach can lead to sustained infection reduction.

PMID: 22546269 [PubMed - in process]

Patient-centered hand hygiene: The next step in infection prevention.

Am J Infect Control. 2012 May;40(4 Suppl 1):S11-7

Authors: Landers T, Abusalem S, Coty MB, Bingham J

Abstract
Hand hygiene has been recognized as the most important means of preventing the transmission of infection, and great emphasis has been placed on ways to improve hand hygiene compliance by health care workers (HCWs). Despite increasing evidence that patients' flora and the hospital environment are the primary source of many infections, little effort has been directed toward involving patients in their own hand hygiene. Most previous work involving patients has included patients as monitors or auditors of hand hygiene practices by their HCWs. This article reviews the evidence on the benefits of including patients more directly in hand hygiene initiatives, and uses the framework of patient-centered safety initiatives to provide recommendations for the timing and implementation of patient hand hygiene protocols. It also addresses key areas for further research, practice guideline development, and implications for training of HCWs.

PMID: 22546268 [PubMed - in process]

Hospital privacy curtains are frequently and rapidly contaminated with potentially pathogenic bacteria.

Am J Infect Control. 2012 Mar 29;

Authors: Ohl M, Schweizer M, Graham M, Heilmann K, Boyken L, Diekema D

Abstract
BACKGROUND: Privacy curtains are a potentially important site of bacterial contamination in hospitals. We performed a longitudinal study to determine the prevalence and time course of bacterial contamination on privacy curtains. METHODS: Over a 3-week period, swab cultures (n = 180) were obtained twice weekly from the leading edge of 43 curtains in 30 rooms in 2 intensive care units and a medical ward. Curtains were marked to determine when they were changed. Contamination with Staphylococcus aureus, methicillin-resistant S aureus (MRSA), Enterococcus spp, vancomycin-resistant enterococcus (VRE), or aerobic gram-negative rods was determined by standard microbiologic methods. To distinguish persistence of pathogens on curtains from recontamination, all VRE and MRSA were typed using pulsed-field gel electrophoresis. RESULTS: Twelve of 13 curtains (92%) placed during the study showed contamination within 1 week. Forty-one of 43 curtains (95%) demonstrated contamination on at least 1 occasion, including 21% with MRSA and 42% with VRE. Eight curtains yielded VRE at multiple time points: 3 with persistence of a single isolate type and 5 with different types, suggesting frequent recontamination. CONCLUSION: Privacy curtains are rapidly contaminated with potentially pathogenic bacteria. Further studies should investigate the role of privacy curtains in pathogen transmission and provide interventions to reduce curtain contamination.

PMID: 22464039 [PubMed - as supplied by publisher]

Effect of a multidisciplinary intervention on central line utilization in an acute care hospital.

Am J Infect Control. 2012 Mar 13;

Authors: Faruqi A, Medefindt J, Dutta G, Philip SA, Tompkins D, Carey J

Abstract
BACKGROUND: Many institutions that have adopted evidence-based infection prevention practices have achieved reductions in the rate of central line-associated bloodstream infection (CLABSI) in their intensive care units (ICUs). Few studies have investigated the impact of CLABSI prevention strategies in non-ICU settings, however. This study was conducted to assess whether a multifaceted educational initiative significantly improved health care workers' adherence to clinical practices that have been demonstrated to reduce CLABSI rates. METHODS: This prospective interventional study compared central line utilization and other variables in medical ICU (MICU) and non-ICU settings at an inner city community teaching hospital. The study included 3 phases: preintervention, intervention, and postintervention. RESULTS: A total of 128 central venous catheter (CVC) placements were reviewed. After the intervention, the proportion of patients transferred out of the MICU with a CVC in place decreased significantly (P = .05), and the percentage of patients transitioned from a CVC to a peripherally inserted venous catheter increased (P = .004). The mean duration of CVC use decreased from 8.2 days to 5.7 days (P = .004), which was confirmed by linear regression (P = .003). CONCLUSIONS: Our data indicate that multidisciplinary, evidenced-based educational interventions can significantly improve targeted measures of CVC use. Our program was successfully implemented with limited resources and should be reproducible at other hospitals.

PMID: 22418611 [PubMed - as supplied by publisher]

Antibiotic use in Vietnamese hospitals: A multicenter point-prevalence study.

Am J Infect Control. 2012 Feb 16;

Authors: Thu TA, Rahman M, Coffin S, Harun-Or-Rashid M, Sakamoto J, Hung NV

Abstract
BACKGROUND: Inappropriate antibiotic prescribing appears to be common worldwide and is contributing to the selection of resistant organisms. This study examined the prevalence of antibiotic prescription and the appropriateness of indications for these prescriptions in 36 representative general hospitals across Vietnam. METHODS: A point-prevalence study was performed between February and December 2008. All inpatients on the day of the survey were included in the analysis. Standard published guidelines were used to evaluate the appropriateness of indications for antibiotic prescription. RESULTS: On the day of the study, 5,104 of 7,571 patients (67.4%) were receiving antibiotic therapy. The antibiotic prescription rate was highest in surgery wards (93.2%) and lowest in medical wards (48.2%). Of the 5,104 patients receiving antibiotics, the most commonly prescribed agents were cephalosporins (70.2%), penicillins (21.6%), and aminoglycosides (18.9%). Approximately one-third of the patients (1,573 of 5,104) had an inappropriate indication for prescription. Risk factors independently associated with inappropriate indication for antibiotic prescription were seen in hospitals at the national level, obstetrics and gynecology departments, and surgical wards. CONCLUSIONS: Our data indicate a high rate of antibiotic use in Vietnamese hospitals, and also a high prevalence of inappropriate indications for antibiotic prescriptions. These findings suggest important areas for intervention and implementation of antibiotic stewardship policies in Vietnamese hospitals.

PMID: 22341530 [PubMed - as supplied by publisher]

A negative nares screen in combination with absence of clinical risk factors can be used to identify patients with very low likelihood of methicillin-resistant Staphylococcus aureus infection in a Veterans Affairs hospital.

Am J Infect Control. 2012 Feb 9;

Authors: Jinno S, Chang S, Donskey CJ

Abstract
BACKGROUND: Screening for nares carriage of methicillin-resistant Staphylococcus aureus (MRSA) could be used to identify patients at reduced risk for MRSA infection. However, recent studies suggest that negative results of nares surveillance testing are not reliable to predict a low risk for MRSA infection. METHODS: To derive a clinical prediction rule, logistic regression was performed to identify predictors of MRSA infection in patients with negative nares surveillance results. To validate the prediction rule and modifications of the rule, the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated in a prospective cohort of inpatients receiving empiric vancomycin. RESULTS: A prediction rule that included 8 clinical risk factors and nares surveillance results was sensitive with NPV of 99.9%. In the validation cohort, 43 of 451 (10%) patients receiving empiric vancomycin had MRSA infection. In comparison with nares surveillance results (sensitivity, 72%; NPV, 96%), the prediction rule was more reliable for prediction of low risk for MRSA infection (sensitivity, 93%; NPV, 98%). A modified rule that included additional indications for empiric MRSA coverage based on practice guidelines reliably predicted MRSA infection (sensitivity, 100%) while excluding those at low risk (NPV, 100%). CONCLUSION: Negative nares screening results in combination with absence of certain clinical risk factors or syndromes could provide a useful strategy to predict patients with low likelihood of MRSA infection.

PMID: 22325726 [PubMed - as supplied by publisher]

Adoption of policies to prevent catheter-associated urinary tract infections in United States intensive care units.

Am J Infect Control. 2012 Feb 6;

Authors: Conway LJ, Pogorzelska M, Larson E, Stone PW

Abstract
BACKGROUND: Little is known about whether recommended strategies to prevent catheter-associated urinary tract infection (CAUTI) are being implemented in intensive care units (ICU) in the United States. OBJECTIVES: Our objectives were to describe the presence of and adherence to CAUTI prevention policies in ICUs, to identify variations in policies based on organizational characteristics, and to determine whether a relationship exists between prevention policies and CAUTI incidence rates. METHODS: Four hundred forty-one hospitals that participate in the National Healthcare Safety Network were surveyed in spring 2008. RESULTS: Two hundred fifty hospitals provided information for 415 ICUs (response rate, 57%). A small proportion of ICUs surveyed had policies supporting bladder ultrasound (26%, n = 106), condom catheters (20%, n = 82), catheter removal reminders (12%, n = 51), or nurse-initiated catheter discontinuation (10%, n = 39). ICUs in hospitals with ? 500 beds were half as likely as those in smaller hospitals to have adopted at least 1 CAUTI prevention policy (odds ratio, 0.52; 95% confidence interval: 0.33-0.86), and ICUs in hospitals where the infection control director reported always having access to key decision makers for planning were more than twice as likely as those with less access to have adopted a policy (odds ratio, 2.41; 95% confidence interval: 1.56-3.72). CONCLUSION: Little attention is currently placed on CAUTI prevention in ICUs in the United States. Further research is needed to elucidate relationships between adherence to CAUTI prevention recommendations and CAUTI incidence rates.

PMID: 22317857 [PubMed - as supplied by publisher]

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]