Jane D. Siegel

Guidelines for the prevention of intravascular catheter-related infections.

BACKGROUND Although many catheter-related bloodstream infections (CRBSIs) are preventable, measures to reduce these infections are not uniformly implemented. OBJECTIVE To update an existing evidenced-based guideline that promotes strategies to prevent CRBSIs. DATA SOURCES The MEDLINE database, conference proceedings, and bibliographies of review articles and book chapters were searched for relevant articles. STUDIES INCLUDED Laboratory-based studies, controlled clinical trials, prospective interventional trials, and epidemiologic investigations. OUTCOME MEASURES Reduction in CRBSI, catheter colonization, or catheter-related infection. SYNTHESIS The recommended preventive strategies with the strongest supportive evidence are education and training of healthcare providers who insert and maintain catheters; maximal sterile barrier precautions during central venous catheter insertion; use of a 2% chlorhexidine preparation for skin antisepsis; no routine replacement of central venous catheters for prevention of infection; and use of antiseptic/antibiotic-impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (ie, education and training, maximal sterile barrier precautions, and 2% chlorhexidine for skin antisepsis). CONCLUSION Successful implementation of these evidence-based interventions can reduce the risk for serious catheter-related infection.

INFECTION CONTROL RECOMMENDATIONS FOR PATIENTS WITH CYSTIC FIBROSIS: MICROBIOLOGY, IMPORTANT PATHOGENS, AND INFECTION CONTROL PRACTICES TO PREVENT PATIENT-TO-PATIENT TRANSMISSION

Infection Control Recommendations for Patients With Cystic Fibrosis: Microbiology, Important Pathogens, and Infection Control Practices to Prevent Patient-to-Patient Transmission updates, expands, and replaces the consensus statement, Microbiology and Infectious Disease in Cystic Fibrosis published in 1994. This consensus document presents background data and evidence-based recommendations for practices that are intended to decrease the risk of transmission of respiratory pathogens among CF patients from contaminated respiratory therapy equipment or the contaminated environment and thereby reduce the burden of respiratory illness. Included are recommendations applicable in the acute care hospital, ambulatory, home care, and selected non-healthcare settings. The target audience includes all healthcare workers who provide care to CF patients. Antimicrobial management is beyond the scope of this document.

Infection Control in Cystic Fibrosis

SUMMARY Over the past 20 years there has been a greater interest in infection control in cystic fibrosis (CF) as patient-to-patient transmission of pathogens has been increasingly demonstrated in this unique patient population. The CF Foundation sponsored a consensus conference to craft recommendations for infection control practices for CF care providers. This review provides a summary of the literature addressing infection control in CF. Burkholderia cepacia complex, Pseudomonas aeruginosa, and Staphylococcus aureus have all been shown to spread between patients with CF. Standard precautions, transmission-based precautions including contact and droplet precautions, appropriate hand hygiene for health care workers, patients, and their families, and care of respiratory tract equipment to prevent the transmission of infectious agents serve as the foundations of infection control and prevent the acquisition of potential pathogens by patients with CF. The respiratory secretions of all CF patients potentially harbor clinically and epidemiologically important microorganisms, even if they have not yet been detected in cultures from the respiratory tract. CF patients should be educated to contain their secretions and maintain a distance of >3 ft from other CF patients to avoid the transmission of potential pathogens, even if culture results are unavailable or negative. To prevent the acquisition of pathogens from respiratory therapy equipment used in health care settings as well as in the home, such equipment should be cleaned and disinfected. It will be critical to measure the dissemination, implementation, and potential impact of these guidelines to monitor changes in practice and reduction in infections.

Infection Prevention and Control Guideline for Cystic Fibrosis: 2013 Update

The 2013 Infection Prevention and Control (IP&C) Guideline for Cystic Fibrosis (CF) was commissioned by the CF Foundation as an update of the 2003 Infection Control Guideline for CF. During the past decade, new knowledge and new challenges provided the following rationale to develop updated IP&C strategies for this unique population: 1. The need to integrate relevant recommendations from evidence-based guidelines published since 2003 into IP&C practices for CF . These included guidelines from the Centers for Disease Control and Prevention (CDC)/Healthcare Infection Control Practices Advisory Committee (HICPAC), the World Health Organization (WHO), and key professional societies, including the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA). During the past decade, new evidence has led to a renewed emphasis on source containment of potential pathogens and the role played by the contaminated healthcare environment in the transmission of infectious agents. Furthermore, an increased understanding of the importance of the application of implementation science, monitoring adherence, and feedback principles has been shown to increase the effectiveness of IP&C guideline recommendations. 2. Experience with emerging pathogens in the non-CF population has expanded our understanding of droplet transmission of respiratory pathogens and can inform IP&C strategies for CF . These pathogens include severe acute respiratory syndrome coronavirus and the 2009 influenza A H1N1. Lessons learned about preventing transmission of methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant gram-negative pathogens in non-CF patient populations also can inform IP&C strategies for CF.

Prevention of invasive group A streptococcal disease among household contacts of case patients and among postpartum and postsurgical patients: Recommendations from the centers for disease control and prevention

The Centers for Disease Control and Prevention hosted a workshop to formulate recommendations for the control of invasive group A streptococcal (GAS) disease among household contacts of persons with invasive GAS infections and for responding to postpartum and postsurgical invasive GAS infections. Experts reviewed data on the risk of subsequent invasive GAS infection among household contacts of case patients, the effectiveness of chemoprophylactic regimens for eradicating GAS carriage, and the epidemiology of postpartum and postsurgical GAS infection clusters. For household contacts of index patients, routine screening for and chemoprophylaxis against GAS are not recommended. Providers and public health officials may choose to offer chemoprophylaxis to household contacts who are at an increased risk of sporadic disease or mortality due to GAS. One nosocomial postpartum or postsurgical invasive GAS infection should prompt enhanced surveillance and isolate storage, whereas > or =2 cases caused by the same strain should prompt an epidemiological investigation that includes the culture of specimens from epidemiologically linked health care workers.

Influenza Vaccination of Healthcare Workers and Vaccine Allocation for Healthcare Workers During Vaccine Shortages

Influenza causes substantial morbidity and mortality annually, particularly in high-risk groups such as the elderly, young children, immunosuppressed individuals, and individuals with chronic illnesses. Healthcare-associated transmission of influenza contributes to this burden but is often under-recognized except in the setting of large outbreaks. The Centers for Disease Control and Prevention has recommended annual influenza vaccination for healthcare workers (HCWs) with direct patient contact since 1984 and for all HCWs since 1993. The rationale for these recommendations is to reduce the chance that HCWs serve as vectors for healthcare-associated influenza due to their close contact with high-risk patients and to enhance both HCW and patient safety. Despite these recommendations as well as the effectiveness of interventions designed to increase HCW vaccination rates, the percentage of HCWs vaccinated annually remains unacceptably low. Ironically, at the same time that campaigns have sought to increase HCW vaccination rates, vaccine shortages, such as the shortage during the 2004-2005 influenza season, present challenges regarding allocation of available vaccine supplies to both patients and HCWs. This two-part document outlines the position of the Society for Healthcare Epidemiology of America on influenza vaccination for HCWs and provides guidance for the allocation of influenza vaccine to HCWs during a vaccine shortage based on influenza transmission routes and the essential need for a practical and adaptive strategy for allocation. These recommendations apply to all types of healthcare facilities, including acute care hospitals, long-term-care facilities, and ambulatory care settings.

Single-dose penicillin prophylaxis against neonatal group B streptococcal infections. A controlled trial in 18,738 newborn infants.

Neonatal Group B streptococcal infections may not respond to antimicrobial therapy and have been associated with case fatality rates of 50 per cent or greater. We evaluated the effect on colonization and disease rates of a single intramuscular dose of aqueous penicillin G given at birth in a prospectively controlled study of 18,738 neonates during a 25-month period. The colonization rate in the mothers was 26.6 per cent, with 50 per cent concordance in the untreated infants and 12.2 per cent in the penicillin-treated infants (P < 0.001). There was a significant decrease in the incidence of disease caused by all penicillin-susceptible organisms in the penicillin group (0.64 vs. 2.26 cases per thousand live births, P = 0.005). Disease caused by penicillin-resistant pathogens was increased in the penicillin-treated group during the first year of the study but was unaffected during the second year. Routine administration of parenteral penicillin at birth cannot be recommended until the effect on the incidence of disease caused by penicillin-resistant pathogens is fully defined.

Preventing Transmission of Multidrug-Resistant Bacteria in Health Care Settings: A Tale of Two Guidelines

Two guidelines for the control of multidrug-resistant organisms in health care facilities have appeared during the past 3 years--one from the Society for Healthcare Epidemiology of America and one, in draft form, from the Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention. These guidelines reflect universal concern in the infection-control community about todays unprecedented levels of activity of multidrug-resistant organisms and about inadequate or inconsistent application of potentially effective control measures. The 2 guidelines provide detailed reviews of pertinent issues and evidence-based, rated recommendations, which overlap considerably. Recommendations regarding indications for active surveillance cultures and the extent of their use constitute the major divergence. Although implementation of comprehensive control plans for multidrug-resistant organisms advocated by both guidelines will require health care facilities to confront difficult programmatic issues, aggressive and widespread adoption of control measures for multidrug-resistant organisms is urgently needed.

Complex Molecular Epidemiology of Methicillin-Resistant Staphylococcus aureus Isolates From Children With Cystic Fibrosis in the Era of Epidemic Community-Associated Methicillin-Resistant S aureus

BACKGROUND Limited data exist about the molecular types of methicillin-resistant Staphylococcus aureus (MRSA) strains found in children with cystic fibrosis (CF). We sought to characterize MRSA strains from these patients and compare them with MRSA strains from non-CF pediatric patients. METHODS All MRSA isolates were collected prospectively at Childrens Medical Center in Dallas, TX, and the University of Chicago Comer Childrens Hospital in 2004 to 2005. All CF MRSA isolates underwent susceptibility testing, multilocus sequence typing, Panton-Valentine leukocidin gene detection (pvl+), and staphylococcal chromosome cassette mec (SCCmec) typing. RESULTS A total of 22 of 34 MRSA isolates (64.7%) from patients with CF belonged to clonal complex (CC) 5 and contained SCCmec II, so-called health-care associated MRSA (HA-MRSA) strains. Nine of 34 MRSA strains (26.5%) were CC 8, and contained SCCmec IV, so-called community-associated MRSA (CA-MRSA) strains. The CA-MRSA strains tended to be isolated from newly colonized CF patients. In contrast, CC8 isolates predominated among the non-CF patients (294 of 331 patients; 88.8%). MRSA isolates from children with CF were more likely to be resistant to clindamycin (65% vs 19%, respectively) and ciprofloxacin (62% vs 17%, respectively) compared with strains from non-CF patients (p < 0.001). There was no difference in the rate of pvl+ isolate recovery from children with CF undergoing a surveillance culture (7 of 23 children) compared with those with pulmonary exacerbation (3 of 11 children; p = 1.0). CONCLUSIONS Both CA-MRSA (CC8) isolates and HA-MRSA (CC5) isolates populate the respiratory tracts of children with CF. HA-MRSA isolates predominated, but CA-MRSA strains predominated among CF patients with newly acquired MRSA strains and among the non-CF patients. The presence of CA-MRSA strains in children with CF was not associated with exacerbation or necrotizing pneumonia.

Prevention of early-onset group b streptococcal disease: Another look at single-dose penicillin at birth

Objective To determine the effect of single-dose penicillin given at birth on the rate of early-onset group B streptococcal (GBS) invasive disease in an inner-city population. Methods Laboratory-based surveillance of GBS disease from 1972–1994 at Parkland Memorial Hospital and Childrens Medical Center in Dallas, Texas, was reviewed retrospectively. All infants born at Parkland Memorial Hospital from January 1, 1972 to December 31, 1994, or a total of 259,049 live births, were included. Early-onset (within 3 days) GBS disease rates were compared for each of five observation groups to determine the efficacy of a single dose of aqueous penicillin G (50,000 U for infants weighing 2000 g or more and 25,000 U for those weighing less than 2000 g) administered intramuscularly within 1 hour of delivery for prevention of GBS disease. Results The rates of early-onset GBS disease were compared in five observation groups: A) pre-study, January 1, 1972 to December 3, 1977—no GBS prophylaxis; B) prospective, controlled intervention study, December 4, 1977 to May 31, 1981, including infants who received a single dose of penicillin at birth (group B1) and those who did not (group B2); C) universal penicillin prophylaxis, June 1, 1981 to October 31, 1986; and D) no routine penicillin prophylaxis, November 1, 1986 to December 31, 1994. The incidence of early-onset GBS disease in the penicillin groups (B1, C) was significantly lower than that in the untreated groups (A, B2, D): 0.25 and 0.63 per 1000 versus 1.59, 1.19, and 1.95 per 1000, respectively (P ≤ .03). The incidence of late-onset GBS disease was unaffected by penicillin prophylaxis, and there was no increase in the incidence of disease caused by penicillin-resistant pathogens or associated mortality in penicillin-treated infants: 2.2 and 2.1 per 1000 versus 1.6 and 3.3 per 1000 for disease; 1.0 and 0.5 per 1000 versus 0.4 and 0.3 per 1000 for deaths. Conclusion Universal administration of single-dose pencillin at birth is a safe and effective intervention for the prevention of early-onset GBS disease.