Ana C. Bardossy

Vancomycin-Resistant Enterococci: Epidemiology, Infection Prevention, and Control.

Vancomycin-resistant enterococci (VRE) infections have acquired prominence as a leading cause of health care-associated infections. Understanding VRE epidemiology, transmission modes in health care settings, risk factors for colonization, and infection is essential to prevention and control of VRE infections. Infection control strategies are pivotal in management of VRE infections and should be based on patient characteristics, hospital needs, and available resources. Hand hygiene is basic to decrease acquisition of VRE. The effectiveness of surveillance and contact precautions is variable and controversial in endemic settings, but important during VRE outbreak investigations and control. Environmental cleaning, chlorhexidine bathing, and antimicrobial stewardship are vital in VRE prevention and control.

Preventing Hospital-acquired Infections in Low-income and Middle-income Countries: Impact, Gaps, and Opportunities

In low-income and middle-income countries (LMIC) health care-associated infections (HAIs) are a serious concern. Many factors contribute to the impact in LMIC, including lack of infrastructure, inconsistent surveillance, deficiency in trained personnel and infection control programs, and poverty- related factors. In LMIC the risk of HAIs may be up to 25% of hospitalized patients. Building infection control capacity in LMIC is possible where strategies are tailored to the specific needs of LMIC. Strategies must start with simple, cost-effective measures then expand to include more complicated measures. Goals for short-term, medium-term, and long-term actions should be planned and resources prioritized.

Evaluation of contact precautions for methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus

HighlightsThere remain limited data on the use of contact precautions (CPs) and its effect on hospital‐acquired infections (HAIs) of resistant organisms, including methicillin‐resistant Staphylococcus aureus (MRSA) and vancomycin‐resistant Enterococcus (VRE).Our study demonstrates the effect of discontinuing CPs for MRSA and VRE on HAI rates.Discontinuing CPs did not adversely affect the endemic MRSA and VRE HAI rates in our institution. Background: There are limited controlled data demonstrating contact precautions (CPs) prevent methicillin‐resistant Staphylococcus aureus (MRSA) and vancomycin‐resistant Enterococcus (VRE) infections in endemic settings. We evaluated changes in hospital‐acquired MRSA and VRE infections after discontinuing CPs for these organisms. Methods: This is a retrospective study done at an 800‐bed teaching hospital in urban Detroit. CPs for MRSA and VRE were discontinued hospital‐wide in 2013. Data on MRSA and VRE catheter‐associated urinary tract infections (CAUTIs), ventilator‐associated pneumonia (VAP), central line–associated bloodstream infections (CLABSIs), surgical site infections (SSIs), and hospital‐acquired MRSA bacteremia (HA‐MRSAB) rates were compared before and after CPs discontinuation. Results: There were 36,907 and 40,439 patients hospitalized during the two 12‐month periods: CPs and no CPs. Infection rates in the CPs and no‐CPs periods were as follows: (1) MRSA infections: VAP, 0.13 versus 0.11 (P = .84); CLABSI, 0.11 versus 0.19 (P = .45); SSI, 0 versus 0.14 (P = .50); and CAUTI, 0.025 versus 0.033 (P = .84); (2) VRE infections: CAUTI, 0.27 versus 0.13 (P = .19) and CLABSI, 0.29 versus 0.3 (P = .94); and (3) HA‐MRSAB rates: 0.14 versus 0.11 (P = .55), respectively. Conclusions: Discontinuation of CPs did not adversely impact endemic MRSA and VRE infection rates.

Risk Factors for 30-Day Mortality in Patients with Methicillin-Resistant Staphylococcus aureus Bloodstream Infections

OBJECTIVES Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections (BSI) are a major health care problem accounting for a large percentage of nosocomial infections. The aim of this study was to identify risk factors associated with 30-day mortality in patients with MRSA BSI. METHODS This was a retrospective study performed in Southeast Michigan. Over a 9- year period, a total of 1,168 patients were identified with MRSA BSI. Patient demographics and clinical data were retrieved and evaluated using electronic medical health records. RESULTS 30-day mortality during the 9-year study period was 16%. Significant risk factors for 30-day mortality were age, cancer, heart disease, neurologic disease, nursing home residence and Charlson score >3 with Odds Ratio (OR) of 1.03 (CI 1.02-1.04), 2.29 (CI 1.40-3.75), 1.78 (CI 1.20-2.63), 1.65 (CI 1.08-2.25), 1.66 (CI 1.02 - 2.70) and 1.86 (CI 1.18 - 2.95) correspondingly. Diabetes mellitus, peripheral vascular disease (PVD), and readmission were protective factors for 30-day mortality with OR of 0.53 (CI 0.36-0.78), 0.46 (CI 0.26-0.84) and 0.13 (CI0.05 - 0.32) respectively. CONCLUSIONS Our study identified significant risk factors for 30-day mortality in patients with MRSA BSI. Interestingly, diabetes mellitus, PVD and readmission were protective effects on 30-day mortality. There was no statistically significant variability in 30-day mortality over the 9-year study period.

Impact and Limitations of the 2015 National Health and Safety Network Case Definition on Catheter-Associated Urinary Tract Infection Rates

Application of the new 2015 NHSN definition of catheter-associated urinary tract infection (CAUTI) in intensive care units reduced CAUTI rates by ~50%, primarily due to exclusion of candiduria. This significant reduction in CAUTI rates resulting from the changes in the definition must be considered when evaluating effectiveness of CAUTI prevention programs. Infect Control Hosp Epidemiol 2017;38:239-241.

The Role of Environmental Contamination in the Transmission of Nosocomial Pathogens and Healthcare-Associated Infections

Purpose of ReviewThe aim of this review is to highlight the role of environmental contamination in healthcare-associated infections (HAIs) and to discuss the most commonly implicated nosocomial pathogens.Recent FindingsRecent studies suggest that environmental contamination plays a significant role in HAIs and in the unrecognized transmission of nosocomial pathogens during outbreaks, as well as ongoing sporadic transmission. Several pathogens can persist in the environment for extended periods and serve as vehicles of transmission and dissemination in the hospital setting. Cross-transmission of these pathogens can occur via hands of healthcare workers, who become contaminated directly from patient contact or indirectly by touching contaminated environmental surfaces. Less commonly, a patient could become colonized by direct contact with a contaminated environmental surface.SummaryThis review describes the role of environmental contamination in HAIs and provides context for reinforcing the importance of hand hygiene and environmental decontamination for the prevention and control of HAIs.

Culturing practices and the care of the urinary catheter in reducing NHSN-defined catheter-associated urinary tract infections: The tale of two teaching hospitals

We compared interventions to improve urinary catheter care and urine culturing in adult intensive care units of 2 teaching hospitals. Compared to hospital A, hospital B had lower catheter utilization, more compliance with appropriate indications and maintenance, but higher urine culture use and more positive urine cultures per 1,000 patient days.

Multidrug-resistant microorganisms colonizing lower extremity wounds in patients in a tertiary care hospital, Lima, Peru

Multidrug-resistant organism (MDRO) infections cause high morbidity and mortality, and high costs to patients and hospitals. The study aims were to determine the frequency of MDRO colonization and associated factors in patients with lower-extremity wounds with colonization. A cross-sectional study was designed during November 2015 to July 2016 in a tertiary care hospital in Lima, Peru. A wound swab was obtained for culture and susceptibility testing. MDRO colonization was defined if the culture grew with methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and/or extended spectrum beta-lactamase (ESBL) microorganisms. The frequency of MDRO wound colonization was 26.8% among the 97 patients enrolled. The most frequent MDRO obtained was ESBL-producing Escherichia coli, which was significantly more frequent in chronic wounds versus acute wounds (17.2% versus 0%, P < 0.05). Infection control measures should be implemented when patients with chronic lower-extremity wounds are admitted.

High vancomycin serum trough is not associated with reduction of mortality in methicillin-resistant Staphylococcus aureus bloodstream infections

The current Infectious Diseases Society of America (IDSA) and the American Society of Health-System Pharmacists (ASHP) guidelines recommend a vancomycin serum trough concentration of 15 to 20 mg/L in patients with methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI). The objective of this study was to evaluate the mortality difference in MRSA BSI pre and post hospital-wide implementation of higher serum trough concentration per IDSA/ ASHP guidelines. This was a retrospective cohort study performed in an integrated hospital health system (2238 beds) in Southeast Michigan. We evaluated 1173 consecutive individual patients with MRSA BSI over a 9-year period. The vancomycin minimum inhibitory concentrations (MICs) were determined by Etest method for all isolates. Attainment of vancomycin serum trough concentration per IDSA/ASHP guidelines was implemented in January 2010 by clinical pharmacist as part of the antimicrobial stewardship program. During the study period, the mean vancomycin MIC was 1.57 ± 0.26 mg/L, the percentage of MRSA isolates with vancomycin MIC ≥ 2 mg/L was 17.5%, and the 30-day all-cause mortality was 16.5%. There was no difference in mortality during the 9-year period (p=0.193). There was no change in all-cause mortality for MRSA BSI after the hospital-wide implementation of higher vancomycin dose and serum trough concentration per IDSA/ ASHP guidelines. Prospective multicenter, controlled studies evaluating optimal dosing strategies for vancomycin are warranted. Correspondence to: Marcus J. Zervos, Division Head, Infectious Diseases, Henry Ford Health System, Professor of Medicine, Wayne State University School of Medicine, Detroit, MI 48202, USA, Tel: +1-313-916-2573; Fax: +1-313-9162993; E-mail: mzervos1@hfhs.org

Risk factors associated with vancomycin-resistant enterococcus (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) co-infection

A retrospective case control study evaluated risk factors for co-infection with methicillin resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). Over an 8-year period, 111 patients with MRSA and VRE were identified as cases and 1077 patients with MRSA alone were controls. The variables collected were age, gender, previous antibiotic administration, bacterium strain type and underlying comorbidities. Independent risk factors of co-infection were exposure to vancomycin (OR=3.70), quinolones (OR=3.09) and cephalosporins (OR=2.03) up to 3 months before bacterial isolation, neurologic disease (OR=2.22), gastrointestinal disease (OR=1.95), respiratory disease (OR=2.00) renal disease (OR=1.67), diabetes (OR=1.83) and dialysis (OR=1.92). The results of the study will have important implications for control interventions. Correspondence to: Katherine Reyes, Henry Ford Health System, Division of Infectious Diseases, 2799 West Grand Blvd CFP3, Henry Ford Health System, Detroit, MI, 48202, USA, Tel: 313-916-2573; E-mail: kreyes1@hfhs.org