Becky A. Miller

Comparison of the Burdens of Hospital-Onset, Healthcare Facility-Associated Clostridium difficile Infection and of Healthcare-Associated Infection due to Methicillin-Resistant Staphylococcus aureus in Community Hospitals

We sought to determine the burden of nosocomial Clostridium difficile infection in comparison to other healthcare-associated infections (HAIs) in community hospitals participating in an infection control network. Our data suggest that C. difficile has replaced MRSA as the most common etiology of HAI in community hospitals in the southeastern United States.

A case-control study of community-associated Clostridium difficile infection: no role for proton pump inhibitors.

BACKGROUND The epidemiology of community-associated Clostridium difficile infection is not well known. We performed a multicenter, case-control study to further describe community-associated C. difficile infection and assess novel risk factors. METHODS We conducted this study at 5 sites from October 2006 through November 2007. Community-associated C. difficile infection included individuals with diarrhea, a positive C. difficile toxin, and no recent (12 weeks) discharge from a health care facility. We selected controls from the same clinics attended by cases. We collected clinical and exposure data at the time of illness and cultured residual stool samples and performed ribotyping. RESULTS Of 1041 adult C. difficile infections, 162 (15.5%) met criteria for community-associated: 66 case and 114 control patients were enrolled. Case patients were relatively young (median 64 years), female (56%), and frequently required hospitalization (38%). Antimicrobials, malignancy, exposure to high-risk persons, and remote health care exposure were independently associated with community-associated C. difficile infection. In 40% of cases, we could not confirm recent antibiotic exposure. Stomach-acid suppressants were not associated with community-associated infection, and 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors appeared protective. Prevalence of the hypervirulent NAP-1/027 strain was infrequent (17%). CONCLUSIONS Community-associated C. difficile infection resulted in a substantial health care burden. Antimicrobials are a significant risk factor for community-associated infection. However, other unique factors also may contribute, including person-to-person transmission, remote health care exposures, and 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors. A role for stomach-acid suppressants in community-associated C. difficile infection is not supported.

Acute Eosinophilic Pneumonia Secondary to Daptomycin: A Report of Three Cases

We describe 3 cases of daptomycin-induced pulmonary toxic effects that are consistent with drug-induced acute eosinophilic pneumonia. Patients presented similarly with dyspnea, cough, hypoxia, and diffuse ground-glass opacities at chest computed tomography. Clinical suspicion for this adverse drug event and cessation of daptomycin until definitive diagnosis can be made is crucial.

The Network Approach for Prevention of Healthcare-Associated Infections: Long-Term Effect of Participation in the Duke Infection Control Outreach Network

OBJECTIVE To describe the rates of several key outcomes and healthcare-associated infections (HAIs) among hospitals that participated in the Duke Infection Control Outreach Network (DICON). DESIGN AND SETTING Prospective, observational cohort study of patients admitted to 24 community hospitals from 2003 through 2009. METHODS The following data were collected and analyzed: incidence of central line-associated bloodstream infections (CLABSIs), ventilator-associated pneumonia (VAP), catheter-associated urinary tract infections (CAUTIs), and HAIs caused by methicillin-resistant Staphylococcus aureus (MRSA); employee exposures to bloodborne pathogens (EBBPs); physician EBBPs; patient-days; central line-days; ventilator-days; and urinary catheter-days. Poisson regression was used to determine whether incidence rates of these HAIs and exposures changed during the first 5 and 7 years of participation in DICON; nonrandom clustering of each outcome was controlled for. Cost saved and lives saved were calculated on the basis of published estimates. RESULTS In total, we analyzed 6.5 million patient-days, 4,783 EBPPs, 2,948 HAIs due to MRSA, and 2,076 device-related infections. Rates of employee EBBPs, HAIs due to MRSA, and device-related infections decreased significantly during the first 5 years of participation in DICON (P< .05 for all models; average decrease was approximately 50%); in contrast, physician EBBPs remained unchanged. In aggregate, 210 CLABSIs, 312 cases of VAP, 332 CAUTIs, 1,042 HAIs due to MRSA, and 1,016 employee EBBPs were prevented. Each hospital saved approximately

Observing and Improving Hand Hygiene Compliance: Implementation and Refinement of an Electronic-Assisted Direct-Observer Hand Hygiene Audit Program

100,000 per year of participation, and collectively the hospitals may have prevented 52-105 deaths from CLABSI or VAP. The 7-year analysis demonstrated that these trends continued with further participation. CONCLUSIONS Hospitals with long-term participation in an infection control network decreased rates of significant HAIs by approximately 50%, decreased costs, and saved lives.

The Impact of Depth of Infection and Postdischarge Surveillance on Rate of Surgical-Site Infections in a Network of Community Hospitals

We implemented a direct-observer hand hygiene audit program that used trained observers, wireless data entry devices, and an intranet portal. We improved the reliability and utility of the data by standardizing audit processes, regularly retraining auditors, developing an audit guidance tool, and reporting weighted composite hand hygiene compliance scores.

Central Line–Associated Infections as Defined by the Centers for Medicare and Medicaid Services’ Hospital-Acquired Condition versus Standard Infection Control Surveillance: Why Hospital Compare Seems Conflicted

OBJECTIVE To describe the epidemiology of surgical-site infections (SSIs) in community hospitals and to explore the impact of depth of SSI, healthcare location at the time of diagnosis, and variations in surveillance practices on the overall rate of SSI. DESIGN Retrospective cohort study. SETTING Thirty-seven community hospitals in the southeastern United States. PATIENTS Consecutive sample of patients undergoing surgical procedures between July 1, 2007, and December 31, 2008. METHODS ANOVA was used to compare rates of SSIs, and the F test was used to compare the distribution of rates of SSIs. Wilcoxon Signed Rank test [corrected] was used to test for differences in performance rankings of hospitals. RESULTS Following 177,706 surgical procedures, 1,919 SSIs were identified (incidence, 1.08 per 100 procedures). Sixty-four percent (1,223 of 1,919) of these were identified as complex SSIs; 87% of the complex SSIs were diagnosed in inpatient settings. The median proportion of superficial-incisional SSIs was 37% (interquartile range, 29.6%-49.5%). Postdischarge SSI surveillance was variable, with 58% of responding hospitals using surgeon letters. As reporting focus was narrowed from all SSIs to complex SSIs (incidence, 0.69 per 100 procedures) and, finally, to complex SSIs diagnosed in the inpatient setting (incidence, 0.51 per 100 procedures), variance in rates changed significantly ([Formula: see text]). Performance ranking of individual hospitals, based on rates of SSIs, differed significantly, depending on the reporting method utilized ([Formula: see text]). CONCLUSIONS Inconsistent reporting methods focused on variable depths of infection and healthcare location at time of diagnosis significantly impact rates of SSI, distribution of rates of SSI, and hospital comparative-performance rankings. We believe that public reporting of SSI rates should be limited to complex SSIs diagnosed in the inpatient setting.

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

OBJECTIVE To evaluate the concordance of case-finding methods for central line-associated infection as defined by Centers for Medicare and Medicaid Services (CMS) hospital-acquired condition (HAC) compared with traditional infection control (IC) methods. SETTING One tertiary care and 2 community hospitals in North Carolina. PATIENTS Adult and pediatric hospitalized patients determined to have central line infection by either case-finding method. METHODS We performed a retrospective comparative analysis of infection detected using HAC versus standard IC central line-associated bloodstream infection surveillance from October 1, 2007, through December 31, 2009. One billing and 2 IC databases were queried and matched to determine the number and concordance of cases identified by each method. Manual review of 25 cases from each discordant category was performed. Sensitivity and positive predictive value (PPV) were calculated using IC as criterion standard. RESULTS A total of 1,505 cases were identified: 844 by International Classification of Diseases, Ninth Revision (ICD-9), and 798 by IC. A total of 204 cases (24%) identified by ICD-9 were deemed not present at hospital admission by coders. Only 112 cases (13%) were concordant. HAC sensitivity was 14% and PPV was 55% compared with IC. Concordance was low regardless of hospital type. Primary reasons for discordance included differences in surveillance and clinical definitions, clinical uncertainty, and poor documentation. CONCLUSIONS The case-finding method used by CMS HAC and the methods used for traditional IC surveillance frequently do not agree. This can lead to conflicting results when these 2 measures are used as hospital quality metrics.

Nontuberculous mycobacterial infection after fractionated CO(2) laser resurfacing.

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 (P = .003). CONCLUSIONS The ability of the antibiogram to predict susceptibility of P. aeruginosa decreases as duration of hospitalization increases.

What the eyes don't see, the heart doesn't grieve over: epidemiology and risk factors for bloodstream infections following cardiac catheterization.

Nontuberculous mycobacteria are increasingly associated with cutaneous infections after cosmetic procedures. Fractionated CO2 resurfacing, a widely used technique for photorejuvenation, has been associated with a more favorable side effect profile than alternative procedures. We describe 2 cases of nontuberculous mycobacterial infection after treatment with a fractionated CO2 laser at a private clinic. Densely distributed erythematous papules and pustules developed within the treated area within 2 weeks of the laser procedure. Diagnosis was confirmed by histologic analysis and culture. Both infections responded to a 4-month course of a multidrug regimen. An environmental investigation of the clinic was performed, but no source of infection was found. The case isolates differed from each other and from isolates obtained from the clinic, suggesting that the infection was acquired by postprocedure exposure. Papules and pustules after fractionated CO2 resurfacing should raise the suspicion of nontuberculous mycobacterial infection.