Diane G. Dumigan

Lack of association between the increased incidence of Clostridium difficile-associated disease and the increasing use of alcohol-based hand rubs

OBJECTIVE To determine whether there is an association between the increasing use of alcohol-based hand rubs (ABHRs) and the increased incidence of Clostridium difficile-associated disease (CDAD). SETTING A 500-bed university-affiliated community teaching hospital. METHODS Use of ABHRs during the period 2000-2003 was expressed as the number of liters of ABHR used per 1000 patient-days. The proportion of hand hygiene episodes performed by using an ABHR was determined by periodic observational surveys. CDAD was defined as a physician-ordered stool assay positive for C. difficile toxin A or A/B. The incidence of CDAD was expressed as the number of unique patients who had 1 or more positive CDAD test results per 1,000 patient-days. RESULTS During 2000-2003, the use of ABHR increased 10-fold, from 3 to greater than 30 L/1,000 patient-days (P<.001). The proportion of hand hygiene episodes performed using an ABHR increased from 10% to 85% (P<.001). The incidence of CDAD in 2000, 2001, 2002, and 2003 was 1.74, 2.33, 1.14, and 1.18 cases/1,000 patient-days, respectively. CONCLUSION Despite a significant and progressive increase in the use of ABHRs in our facility during a 3-year period, there was no evidence that the incidence of CDAD increased. These findings suggest that factors other than the increased use of ABHRs are responsible for the increasing incidence of CDAD noted since 2000 in other facilities.

Do Infection Control Measures Work for Methicillin-Resistant Staphylococcus aureus?

OBJECTIVE To review evidence regarding the effectiveness of control measures in reducing transmission of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals. DESIGN Literature review and surveillance cultures of hospitalized patients at high risk for MRSA colonization or infection. SETTING A 500-bed, university-affiliated, community teaching hospital. RESULTS The percentage of nosocomial S. aureus infections caused by MRSA increased significantly between 1982 and 2002, despite the use of various isolation and barrier precaution policies. The apparent ineffectiveness of control measures may be due to several factors including the failure to identify patients colonized with MRSA. For example, cultures of stool specimens submitted for Clostridium difficile toxin assays at one hospital found that 12% of patients had MRSA in their stool, and 41% of patients with unrecognized colonization were cared for without using barrier precautions. Other factors include the use of barrier precaution strategies that do not account for multiple reservoirs of MRSA, poor adherence of healthcare workers (HCWs) to recommended barrier precautions and handwashing, failure to identify and treat HCWs responsible for transmitting MRSA, and importation of MRSA by patients admitted from other facilities. Control programs that include active surveillance cultures (ASCs) of high-risk patients and use of barrier precautions have reduced MRSA prevalence rates and have been cost-effective. Using a staged approach to implementing ASCs can minimize logistic problems. CONCLUSION MRSA control programs are effective if they include ASCs of high-risk patients, use of barrier precautions when caring for colonized or infected patients, hand hygiene, and treating HCWs implicated in MRSA transmission.

Comparison of Fluorescent Marker Systems with 2 Quantitative Methods of Assessing Terminal Cleaning Practices

OBJECTIVE To compare fluorescent markers with aerobic colony counts (ACCs) and an adenosine triphosphate (ATP) bioluminescence assay system for assessing terminal cleaning practices. DESIGN A prospective observational survey. SETTING A 500-bed university-affiliated community teaching hospital. METHODS In a convenience sample of 100 hospital rooms, 5 high-touch surfaces were marked with fluorescent markers before terminal cleaning and checked after cleaning to see whether the marker had been entirely or partially removed. ACC and ATP readings were performed on the same surfaces before and after terminal cleaning. RESULTS Overall, 378 (76%) of 500 surfaces were classified as having been cleaned according to fluorescent markers, compared with 384 (77%) according to ACC criteria and 225 (45%) according to ATP criteria. Of 382 surfaces classified as not clean according to ATP criteria before terminal cleaning, those with the marker removed were significantly more likely than those with the marker partially removed to be classified as clean according to ATP criteria (P = .003). CONCLUSIONS Fluorescent markers are useful in determining how frequently high-touch surfaces are wiped during terminal cleaning. However, contaminated surfaces classified as clean according to fluorescent marker criteria after terminal cleaning were significantly less likely to be classified as clean according to ACC and ATP assays.

Surveillance of hemodialysis-associated primary bloodstream infections: the experience of ten hospital-based centers.

OBJECTIVE To determine baseline rates of primary bloodstream infection (BSI) among a large pool of patients receiving hemodialysis using standardized surveillance tools and methodology. DESIGN Prospective, descriptive analysis of primary BSI rates. SETTING Ten hospital-based hemodialysis centers in Connecticut. PATIENTS All patients receiving long-term hemodialysis in the participating facilities. RESULTS A total of 158 BSIs occurred during 142,525 dialysis sessions within a 12-month study period. Of the BSIs, 15.2% occurred in patients with fistula or graft access and 84.8% in patients with central venous catheter access (P < .001). Rates per 100 patient-years in centers ranged from 0 to 30.8, with a mean of 16.6. Rates per 1,000 dialysis sessions ranged from 0 to 2.1, with a mean of 1.1. Coagulase-negative staphylococci and Staphylococcus aureus (including methicillin-resistant S. aureus) accounted for 61% and Klebsiella or Enterobacter species for 14.6% of infections. Of the patients, 63.3% received vancomycin, 24.7% received cefazolin, and 41.7% received aminoglycosides. Rates declined in the second 6 months of the study from 1.4 to 0.8 infections per 1,000 dialysis sessions (P < .001). CONCLUSIONS Primary BSI rates varied widely among participating centers and declined during the study period. BSIs were strongly associated with central venous catheter access. Further studies are needed to determine the reasons for variance in rates between centers and among various types of hemodialysis access.

Cleanliness of portable medical equipment disinfected by nursing staff

Increased attention has been focused on disinfection by housekeepers, but few data are available on disinfection of equipment by nurses. We used adenosine triphosphate bioluminescence assays and aerobic cultures to assess the cleanliness of portable medical equipment disinfected by nurses between each patient use. We found that the equipment was not being disinfected as per protocol and that education and feedback to nursing are warranted to improve disinfection of medical equipment.

Discontinuation of Contact Precautions for Patients No Longer Colonized with Methicillin‐Resistant Staphylococcus aureus

To reduce the number of patients with known methicillin-resistant Staphylococcus aureus (MRSA) colonization who are repeatedly placed in isolation on hospital readmission, we screened patients who had no positive results for MRSA culture in the previous 6 months. Twenty-one (21%) of 98 patients were no longer colonized and were removed from contact precautions.

Using Technology and Tenacity to Improve Influenza Vaccination Rates in a Community Teaching Hospital

Diane G. Dumigan, RN, BSN, CIC, Infection Preventionist; Lisa Tyler, Executive Assistant, Department of Nursing; Lizette Cortes, Executive Assistant, Human Resources; Mary Kuncas, RN, BSN, MS, VP Patient Services; Elizabeth Conrad, MS, VP Human Resources; Andrea Santerre, RN, MS, Manager, Occupational Health; Richard Meskill, IT Specialist, Information Services; Michelle Whitbread, MT, MPH, Timothea Cooper, RN, BSN, CIC, Cynthia Kohan, MT, MS, CIC, Infection Preventionist; Dan Sullivan, MS, Labor Relations, Human Resources; Tom Mendillo, BS, HEM, Director, Safety; John M. Boyce, MD, Chief, Section of Infectious Diseases; Hospital of Saint Raphael, New Haven, CT