Ability of an Antibiogram to Predict Pseudomonas aeruginosa Susceptibility to Targeted Antimicrobials Based on Hospital Day of Isolation.

Infect Control Hosp Epidemiol. 2012 Jun;33(6):589-93

Authors: Anderson DJ, Miller B, Marfatia R, Drew R

Abstract
Objective.?To determine the utility of an antibiogram in predicting the susceptibility of Pseudomonas aeruginosa isolates to targeted antimicrobial agents based on the day of hospitalization the specimen was collected. Design.?Single-center retrospective cohort study. Setting.?A 750-bed tertiary care medical center. Patients and Methods.?Isolates from consecutive patients with at least 1 clinical culture positive for P. aeruginosa from January 1, 2000, to June 30, 2007, were included. A study antibiogram was created by determining the overall percentages of P. aeruginosa isolates susceptible to amikacin, ceftazidime, ciprofloxacin, gentamicin, imipenem-cilastin, piperacillin-tazobactam, and tobramycin during the study period. Individual logistic regression models were created to determine the day of infection after which the study antibiogram no longer predicted susceptibility to each antibiotic. Results.?A total of 3,393 isolates were included. The antibiogram became unreliable as a predictor of susceptibility to ceftazidime, imipenem-cilastin, piperacillin-tazobactam, and tobramycin after day 10 and ciprofloxacin after day 15 but longer for gentamicin (day 21) and amikacin (day 28). Time to unreliability of the antibiogram varied for antibiotics based on location of isolation. For example, the time to unreliability of the antibiogram for ceftazidime was 5 days (95% confidence interval [CI], <1-8) in the intensive care unit (ICU) and 12 days (95% CI, 7-21) in non-ICU hospital wards ([Formula: see text]). Conclusions.?The ability of the antibiogram to predict susceptibility of P. aeruginosa decreases as duration of hospitalization increases.

PMID: 22561714 [PubMed - in process]

Trends in Aminoglycoside Use and Gentamicin-Resistant Gram-Negative Clinical Isolates in US Academic Medical Centers: Implications for Antimicrobial Stewardship.

Infect Control Hosp Epidemiol. 2012 Jun;33(6):594-601

Authors: Ababneh M, Harpe S, Oinonen M, Polk RE

Abstract
Objective.?To measure trends in aminoglycoside antibiotic use and gentamicin-resistant clinical isolates across a network of hospitals and compare network-level relationships with those of individual hospitals. Design.?Longitudinal observational investigation. Setting.?US academic medical centers. Participants.?Adult inpatients. Methods.?Adult aminoglycoside use was measured from 2002 or 2003 through 2009 in 29 hospitals. Hospital-wide antibiograms assessed gentamicin resistance by proportions and incidence rates for Pseudomonas aeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae, and Escherichia coli. Mixed-effects analysis of variance was used to assess the significance of changes in aminoglycoside use and changes in resistance rates and proportions. Generalized estimating equations were used to assess the relationship between aminoglycoside use and resistance. Results.?Mean aminoglycoside use declined by 41%, reflecting reduced gentamicin ([Formula: see text]) and tobramycin ([Formula: see text]) use; amikacin use did not change. The rate and proportion of gentamicin-resistant P. aeruginosa decreased by 48% ([Formula: see text]) and 31% ([Formula: see text]), respectively. The rate and proportion of gentamicin-resistant E. coli increased by 166% and 124%, respectively ([Formula: see text]), and they were related to increasing quinolone resistance in E. coli. Resistance among K. pneumoniae and A. baumannii did not change. Relationships between aminoglycoside use and resistance at the network level were highly variable at the individual hospital level. Conclusions.?Mean aminoglycoside use declined in this network of US hospitals and was associated with significant and opposite changes in rates of resistance for some organisms and no change for others. At the individual hospital level, antibiograms appear to be an unreliable reflection of antibiotic use, at least for aminoglycosides.

PMID: 22561715 [PubMed - in process]

Antimicrobial stewardship at transition of care from hospital to community.

Infect Control Hosp Epidemiol. 2012 Apr;33(4):401-4

Authors: Shrestha NK, Bhaskaran A, Scalera NM, Schmitt SK, Rehm SJ, Gordon SM

Abstract
Mandatory infectious disease consultation for parenteral antimicrobials at hospital discharge resulted in avoiding postdischarge parenteral antimicrobials in 28% of patients. No emergency department visit or rehospitalization within 30 days for these patients was a consequence of parenteral antimicrobial avoidance. Antimicrobial stewardship at transition of care is effective in reducing unnecessary antimicrobial use.

PMID: 22418637 [PubMed - in process]

Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program.

Infect Control Hosp Epidemiol. 2012 Apr;33(4):338-45

Authors: Standiford HC, Chan S, Tripoli M, Weekes E, Forrest GN

Abstract
Background.?An antimicrobial stewardship program was fully implemented at the University of Maryland Medical Center in July 2001 (beginning of fiscal year [FY] 2002). Essential to the program was an antimicrobial monitoring team (AMT) consisting of an infectious diseases-trained clinical pharmacist and a part-time infectious diseases physician that provided real-time monitoring of antimicrobial orders and active intervention and education when necessary. The program continued for 7 years and was terminated in order to use the resources to increase infectious diseases consults throughout the medical center as an alternative mode of stewardship. Design.?A descriptive cost analysis before, during, and after the program. Patients/setting.?A large tertiary care teaching medical center. Methods.?Monitoring the utilization (dispensing) costs of the antimicrobial agents quarterly for each FY. Results.?The utilization costs decreased from $44,181 per 1,000 patient-days at baseline prior to the full implementation of the program (FY 2001) to $23,933 (a 45.8% decrease) by the end of the program (FY 2008). There was a reduction of approximately $3 million within the first 3 years, much of which was the result of a decrease in the use of antifungal agents in the cancer center. After the program was discontinued at the end of FY 2008, antimicrobial costs increased from $23,933 to $31,653 per 1,000 patient-days, a 32.3% increase within 2 years that is equivalent to a $2 million increase for the medical center, mostly in the antibacterial category. Conclusions.?The antimicrobial stewardship program, using an antimicrobial monitoring team, was extremely cost effective over this 7-year period.

PMID: 22418628 [PubMed - in process]

Impact of the use of procalcitonin assay in hospitalized adult patients with pneumonia at a community acute care hospital.

Infect Control Hosp Epidemiol. 2012 Apr;33(4):424-6

Authors: Kook JL, Chao SR, Le J, Robinson PA

Abstract
A retrospective, quasi-experimental cohort study compared antibiotic use before and after implementation of a procalcitonin assay at a community acute care hospital. This study demonstrated that the implementation of the procalcitonin assay was associated with a decrease in antibiotic days of therapy in adult patients with pneumonia.

PMID: 22418643 [PubMed - in process]

A Crossover Trial of Antimicrobial Scrubs to ReduceMethicillin-Resistant Staphylococcus aureus Burden on Healthcare Worker Apparel.

Infect Control Hosp Epidemiol. 2012 Mar;33(3):268-75

Authors: Bearman GM, Rosato A, Elam K, Sanogo K, Stevens MP, Sessler CN, Wenzel RP

Abstract
Background.?The impact of antimicrobial scrubs on healthcare worker (HCW) bacterial burden is unknown. Objective.?To determine the effectiveness of antimicrobial scrubs on hand and apparel bacterial burden. Design.?Prospective, crossover trial. Setting and Participants.?Thirty HCWs randomized to study versus control scrubs in an intensive care unit. Methods.?Weekly microbiology samples were obtained from scrub abdominal area, cargo pocket, and hands. Mean log colony-forming unit (CFU) counts were calculated. Compliance with hand hygiene practices was measured. Apparel and hand mean log CFU counts were compared. Results.?Adherence measures were 78% (910/1,173) for hand hygiene and 82% (223/273) for scrubs. Culture compliance was 67% (306/460). No differences were observed in bacterial hand burden or in HCWs with unique positive scrub cultures. No difference in vancomycin-resistant enterococci (VRE) and gram-negative rod (GNR) burden was observed. A difference in mean log methicillin-resistant Staphylococcus aureus (MRSA) CFU count was found between study and control scrubs for leg cargo pocket (mean log CFUs, 11.84 control scrub vs 6.71 study scrub; [Formula: see text]), abdominal area (mean log CFUs, 11.35 control scrub vs 7.54 study scrub; [Formula: see text]), leg cargo pocket at the beginning of shift (mean log CFUs, 11.96 control scrub vs 4.87 study scrub; [Formula: see text]), and abdominal area pocket at the end of shift (mean log CFUs, 12.14 control scrubs vs 8.22 study scrub; [Formula: see text]). Conclusions.?Study scrubs were associated with a 4-7 mean log reduction in MRSA burden but not VRE or GNRs. A prospective trial is needed to measure the impact of antimicrobial impregnated apparel on MRSA transmission rates.

PMID: 22314064 [PubMed - in process]

Electronic-eye faucets: legionella species contamination in healthcare settings.

Infect Control Hosp Epidemiol. 2012 Mar;33(3):235-40

Authors: Sydnor ER, Bova G, Gimburg A, Cosgrove SE, Perl TM, Maragakis LL

Abstract
Objective.?To compare heterotrophic plate counts (HPCs) and Legionella species growth from electronic and manual faucet water samples. Design.?Proportions of water samples with growth and colony-forming units were compared using Fisher's exact test and the Wilcoxon rank-sum test, respectively. Setting.?Two psychiatric units and 1 medical unit in a 1,000-bed university hospital. Methods.?Water samples were collected from 20 newly installed electronic faucets and 20 existing manual faucets in 3 hospital units. Manual faucets were located in rooms adjacent to the electronic faucets and received water from the same source. Water samples were collected between December 15, 2008, and January 29, 2009. Four electronic faucets were dismantled, and faucet components were cultured. Legionella species and HPC cultures were performed using standard methods. Results.?Nearly all electronic faucets (19/20 [95%]) grew Legionella species from at least 1 water sample, compared with less than half (9/20 [45%]) of manual faucets ([Formula: see text]). Fifty-four (50%) of 108 electronic faucet water cultures grew Legionella species, compared with 11 (15%) of 75 manual faucet water cultures ([Formula: see text]). After chlorine dioxide remediation, 4 (14%) of 28 electronic faucet and 1 (3%) of 30 manual faucet water cultures grew Legionella species ([Formula: see text]), and 8 (29%) electronic faucet and 2 (7%) manual faucet cultures had significant HPC growth ([Formula: see text]). All 12 (100%) of the internal faucet components from 2 electronic faucets grew Legionella species. Conclusions.?Electronic faucets were more commonly contaminated with Legionella species and other bacteria and were less likely to be disinfected after chlorine dioxide remediation. Electronic faucet components may provide points of concentrated bacterial growth.

PMID: 22314059 [PubMed - in process]

Pandemic Influenza A(H1N1)2009 in Hospital Healthcare Workers in New Zealand.

Infect Control Hosp Epidemiol. 2012 Feb;33(2):196-9

Authors: Raymond NJ, Berry N, Blackmore TK, Jefferies S, Norton K, Perrin K, Beasley R

Abstract
We evaluated A/H1N1 influenza in healthcare workers (HCWs) and in a flu room during the 2009 pandemic. The flu room aided HCW care and management by facilitating rapid diagnosis and treatment. Absence of fever was common, and symptoms were nonspecific. A higher rate of H1N1 occurred in HCWs deployed in acute services.

PMID: 22227991 [PubMed - in process]

Infection Prevention Promotion Program Based on the PRECEDE Model: Improving Hand Hygiene Behaviors among Healthcare Personnel.

Infect Control Hosp Epidemiol. 2012 Feb;33(2):144-51

Authors: Aboumatar H, Ristaino P, Davis RO, Thompson CB, Maragakis L, Cosgrove S, Rosenstein B, Perl TM

Abstract
Background.?Healthcare-associated infections (HAIs) result in significant morbidity and mortality. Hand hygiene remains a cornerstone intervention for preventing HAIs. Unfortunately, adherence to hand hygiene guidelines among healthcare personnel is poor. Objective.?To assess short- and long-term effects of an infection prevention promotion program on healthcare personnel hand hygiene behaviors. Design.?Time series design. Setting?Our study was conducted at a tertiary care academic center. Participants.?Hospital healthcare personnel. Methods.?We developed a multimodal program that included a multimedia communications campaign, education, leadership engagement, environment modification, team performance measurement, and feedback. Healthcare personnel hand hygiene practices were measured via direct observations over a 3-year period by "undercover" observers. Results.?Overall hand hygiene compliance increased by 2-fold after full program implementation ([Formula: see text]), and this increase was sustained over a 20-month follow-up period ([Formula: see text]). The odds for compliance with hand hygiene increased by 3.8-fold in the 6 months after full program implementation (95% confidence interval, 3.53-4.23; [Formula: see text]), and this increase was sustained. There was even a modest increase at 20 months of follow up. Hand hygiene compliance increased among all disciplines and hospital units. Hand hygiene compliance increased from 35% in the first 6 months after program initiation to 77% in the last 6 months of the study period among nursing providers ([Formula: see text]), from 38% to 62% among medical providers ([Formula: see text]), and from 27% to 75% among environmental services staff ([Formula: see text]). Conclusions.?Implementation of the infection prevention promotion program was associated with a significant and sustained increase in hand hygiene practices among healthcare personnel of various disciplines.

PMID: 22227983 [PubMed - in process]

Prior Vancomycin Use Is a Risk Factor for Reduced Vancomycin Susceptibility in Methicillin-Susceptible but Not Methicillin-Resistant Staphylococcus aureus Bacteremia.

Infect Control Hosp Epidemiol. 2012 Feb;33(2):160-6

Authors: Mascitti KB, Edelstein PH, Fishman NO, Morales KH, Baltus AJ, Lautenbach E

Abstract
Objective.?Staphylococcus aureus is a cause of community- and healthcare-acquired infections and is associated with substantial morbidity, mortality, and costs. Vancomycin minimum inhibitory concentrations (MICs) among S. aureus have increased, and reduced vancomycin susceptibility (RVS) may be associated with treatment failure. We aimed to identify clinical risk factors for RVS in S. aureus bacteremia. Design.?Case-control. Setting.?Academic tertiary care medical center and affiliated urban community hospital. Patients.?Cases were patients with RVS S. aureus isolates (defined as vancomycin E-test MIC >1.0 ?g/mL). Controls were patients with non-RVS S. aureus isolates. Results.?Of 392 subjects, 134 (34.2%) had RVS. Fifty-eight of 202 patients (28.7%) with methicillin-susceptible S. aureus (MSSA) isolates had RVS, and 76 of 190 patients (40.0%) with methicillin-resistant S. aureus (MRSA) isolates had RVS ([Formula: see text]). In unadjusted analyses, prior vancomycin use was associated with RVS (odds ratio [OR], 2.08; 95% confidence interval [CI], 1.00-4.32; [Formula: see text]). In stratified analyses, there was significant effect modification by methicillin susceptibility on the association between vancomycin use and RVS ([Formula: see text]). In multivariable analyses, after hospital of admission and prior levofloxacin use were controlled for, the association between vancomycin use and RVS was significant for patients with MSSA infection (adjusted OR, 4.02; 95% CI, 1.11-14.50) but not MRSA infection (adjusted OR, 0.87; 95% CI, 0.36-2.13). Conclusions.?A substantial proportion of patients with S. aureus bacteremia had RVS. The association between prior vancomycin use and RVS was significant for patients with MSSA infection but not MRSA infection, suggesting a complex relationship between the clinical and molecular epidemiology of RVS in S. aureus.

PMID: 22227985 [PubMed - in process]

Temporary central venous catheter utilization patterns in a large tertiary care center: tracking the "idle central venous catheter".

Infect Control Hosp Epidemiol. 2012 Jan;33(1):50-7

Authors: Chernetsky Tejedor S, Tong D, Stein J, Payne C, Dressler D, Xue W, Steinberg JP

Abstract
Objectives.?Although central venous catheter (CVC) dwell time is a major risk factor for catheter-related bloodstream infections (CR-BSIs), few studies reveal how often CVCs are retained when not needed ("idle"). We describe use patterns for temporary CVCs, including peripherally inserted central catheters (PICCs), on non-ICU wards. Design.?A retrospective observational study. Setting.?A 579-bed acute care, academic tertiary care facility. Methods.?A retrospective observational study of a random sample of patients on hospital wards who have a temporary, nonimplanted CVC, with a focus on on daily ward CVC justification. A uniform definition of idle CVC-days was used. Results.?We analyzed 89 patients with 146 CVCs (56% of which were PICCs); of 1,433 ward CVC-days, 361 (25.2%) were idle. At least 1 idle day was observed for 63% of patients. Patients had a mean of 4.1 idle days and a mean of 3.4 days with both a CVC and a peripheral intravenous catheter (PIV). After adjusting for ward length of stay, mean CVC dwell time was 14.4 days for patients with PICCs versus 9.0 days for patients with non-PICC temporary CVCs (other CVCs; [Formula: see text]). Patients with a PICC had 5.4 days in which they also had a PIV, compared with 10 days in other CVC patients ([Formula: see text]). Patients with PICCs had more days in which the only justification for the CVC was intravenous administration of antimicrobial agents (8.5 vs 1.6 days; [Formula: see text]). Conclusions.?Significant proportions of ward CVC-days were unjustified. Reducing "idle CVC-days" and facilitating the appropriate use of PIVs may reduce CVC-days and CR-BSI risk.

PMID: 22173522 [PubMed - in process]

Association between Contact Precautions and Delirium at a Tertiary Care Center.

Infect Control Hosp Epidemiol. 2012 Jan;33(1):34-9

Authors: Day HR, Perencevich EN, Harris AD, Gruber-Baldini AL, Himelhoch SS, Brown CH, Dotter E, Morgan DJ

Abstract
Objective.?To investigate the relationship between contact precautions and delirium among inpatients, adjusting for other factors. Design.?Retrospective cohort study. Setting.?A 662-bed tertiary care center. Patients.?All nonpyschiatric adult patients admitted to a tertiary care center from 2007 through 2009. Methods.?Generalized estimating equations were used to estimate the association between contact precautions and delirium in a retrospective cohort of 2 years of admissions to a tertiary care center. Results.?During the 2-year period, 60,151 admissions occurred in 45,266 unique nonpsychiatric patients. After adjusting for comorbid conditions, age, sex, intensive care unit status, and length of hospitalization, contact precautions were significantly associated with delirium (as defined by International Classification of Diseases, Ninth Revision), medication, or restraint exposure (adjusted odds ratio [OR], 1.40 [95% confidence interval {CI}, 1.24-1.51]). The association between contact precautions and delirium was seen only in patients who were newly placed under contact precautions during the course of their stay (adjusted OR, 1.75 [95% CI, 1.60-1.92]; [Formula: see text]) and was not seen in patients who were already under contact precautions at admission (adjusted OR, 0.97 [95% CI, 0.86-1.09]; [Formula: see text]). Conclusions.?Although delirium was more common in patients who were newly placed under contact precautions during the course of their hospital admission, delirium was not associated with contact precautions started at hospital admission. Patients newly placed under contact precautions after admission but during hospitalization appear to be at a higher risk and may benefit from proven delirium-prevention strategies.

PMID: 22173520 [PubMed - in process]

Frequent Hospital Readmissions for Clostridium difficile Infection and the Impact on Estimates of Hospital-Associated C. difficile Burden.

Infect Control Hosp Epidemiol. 2012 Jan;33(1):20-8

Authors: Murphy CR, Avery TR, Dubberke ER, Huang SS

Abstract
Objective.?Clostridium difficile infection (CDI) is associated with hospitalization and may cause readmission following admission for any reason. We aimed to measure the incidence of readmissions due to CDI. Design.?Retrospective cohort study. Patients.?Adult inpatients in Orange County, California, who presented with new-onset CDI within 12 weeks of discharge. Methods.?We assessed mandatory 2000-2007 hospital discharge data for trends in hospital-associated CDI (HA-CDI) incidence, with and without inclusion of postdischarge CDI (PD-CDI) events resulting in rehospitalization within 12 weeks of discharge. We measured the effect of including PD-CDI events on hospital-specific CDI incidence, a mandatory reporting measure in California, and on relative hospital ranks by CDI incidence. Results.?From 2000 to 2007, countywide hospital-onset CDI (HO-CDI) incidence increased from 15 per 10,000 to 22 per 10,000 admissions. When including PD-CDI events, HA-CDI incidence doubled (29 per 10,000 in 2000 and 52 per 10,000 in 2007). Overall, including PD-CDI events resulted in significantly higher hospital-specific CDI incidence, although hospitals had disproportionate amounts of HA-CDI occurring postdischarge. This resulted in substantial shifts in some hospitals' rankings by CDI incidence. In multivariate models, both HO and PD-CDI were associated with increasing age, higher length of stay, and select comorbidities. Race and Hispanic ethnicity were predictive of PD-CDI but not HO-CDI. Conclusions.?PD-CDI events associated with rehospitalization are increasingly common. The majority of HA-CDI cases may be occurring postdischarge, raising important questions about both accurate reporting and effective prevention strategies. Some risk factors for PD-CDI may be different than those for HO-CDI, allowing additional identification of high-risk groups before discharge.

PMID: 22173518 [PubMed - in process]

A real-life snapshot of the use and abuse of urinary catheters on general medical wards.

Infect Control Hosp Epidemiol. 2011 Dec;32(12):1216-8

Authors: Harley G, Yeo AL, Stuart RL, Dendle C

Abstract
An observational study was performed on 2 wards in a tertiary hospital to determine staff awareness, knowledge, and documentation of catheter use and the effects these have on duration of catheterization. Overall, there was poor knowledge of the indications and date of catheterization. Doctor awareness decreases duration of catheterization.

PMID: 22080662 [PubMed - in process]

"The dirty hand in the latex glove": a study of hand hygiene compliance when gloves are worn.

Infect Control Hosp Epidemiol. 2011 Dec;32(12):1194-9

Authors: Fuller C, Savage J, Besser S, Hayward A, Cookson B, Cooper B, Stone S

Abstract
Background and objective.?Wearing of gloves reduces transmission of organisms by healthcare workers' hands but is not a substitute for hand hygiene. Results of previous studies have varied as to whether hand hygiene is worse when gloves are worn. Most studies have been small and used nonstandardized assessments of glove use and hand hygiene. We sought to observe whether gloves were worn when appropriate and whether hand hygiene compliance differed when gloves were worn. Design.?Observational study. Participants and setting.?Healthcare workers in 56 medical or care of the elderly wards and intensive care units in 15 hospitals across England and Wales. Methods.?We observed hand hygiene and glove usage (7,578 moments for hand hygiene) during 249 one-hour sessions. Observers also recorded whether gloves were or were not worn for individual contacts. Results.?Gloves were used in 1,983 (26.2%) of the 7,578 moments for hand hygiene and in 551 (16.7%) of 3,292 low-risk contacts; gloves were not used in 141 (21.1%) of 669 high-risk contacts. The rate of hand hygiene compliance with glove use was 41.4% (415 of 1,002 moments), and the rate without glove use was 50.0% (1,344 of 2,686 moments). After adjusting for ward, healthcare worker type, contact risk level, and whether the hand hygiene opportunity occurred before or after a patient contact, glove use was strongly associated with lower levels of hand hygiene (adjusted odds ratio, 0.65 [95% confidence interval, 0.54-0.79]; [Formula: see text]). Conclusion.?The rate of glove usage is lower than previously reported. Gloves are often worn when not indicated and vice versa. The rate of compliance with hand hygiene was significantly lower when gloves were worn. Hand hygiene campaigns should consider placing greater emphasis on the World Health Organization indications for gloving and associated hand hygiene. Trial registration.?National Research Register N0256159318.

PMID: 22080658 [PubMed - in process]