Jeanmarie Mayer

Clinical Findings and Demographic Factors Associated With ICU Admission in Utah Due to Novel 2009 Influenza A(H1N1) Infection

BACKGROUNDnNovel 2009 influenza A(H1N1) infection has significantly affected ICUs. We sought to characterize our regions clinical findings and demographic associations with ICU admission due to novel A(H1N1).nnnMETHODSnWe conducted an observational study from May 19, 2009, to June 30, 2009, of descriptive clinical course, inpatient mortality, financial data, and demographic characteristics of an ICU cohort. A case-control study was used to compare the ICU cohort to Salt Lake County residents.nnnRESULTSnThe ICU cohort of 47 influenza patients had a median age of 34 years, Acute Physiology and Chronic Health Evaluation II score of 21, and BMI of 35 kg/m2. Mortality was 17% (8/47). All eight deaths occurred among the 64% of patients (n = 30) with ARDS, 26 (87%) of whom also developed multiorgan failure. Compared with the Salt Lake County population, patients with novel A(H1N1) were more likely to be obese (22% vs 74%; P < .001), medically uninsured (14% vs 45%; P < .001), and Hispanic (13% vs 23%; P < .01) or Pacific Islander (1% vs 26%; P < .001). Observed ICU admissions were 15-fold greater than expected for those with BMI > or = 40 kg/m2 (standardized morbidity ratio 15.8, 95% CI, 8.3-23.4) and 1.5-fold greater than expected among those with BMI of 30 to 39 kg/m(2) for age-adjusted and sex-adjusted rates for Salt Lake County.nnnCONCLUSIONSnSevere ARDS with multiorgan dysfunction in the absence of bacterial infection was a common clinical presentation. In this cohort, young nonwhites without medical insurance were disproportionately likely to require ICU care. Obese patients were particularly susceptible to critical illness due to novel A(H1N1) infection.

Multicenter Study of Clostridium difficile Infection Rates from 2000 to 2006

OBJECTIVEnTo compare incidence rates of Clostridium difficile infection (CDI) during a 6-year period among 5 geographically diverse academic medical centers across the United States by use of recommended standardized surveillance definitions of CDI that incorporate recent information on healthcare facility (HCF) exposure.nnnMETHODSnData on C. difficile toxin assay results and dates of hospital admission and discharge were collected from electronic databases. Chart review was performed for patients with a positive C. difficile toxin assay result who were identified within 48 hours after hospital admission to determine whether they had any HCF exposure during the 90 days prior to their hospital admission. CDI cases, defined as any inpatient with a stool toxin assay positive for C. difficile, were categorized into 5 surveillance definitions based on recent HCF exposure. Annual CDI rates were calculated and evaluated by use of the chi(2) test for trend and the chi(2) summary test.nnnRESULTSnDuring the study period, there were significant increases in the overall incidence rates of HCF-onset, HCF-associated CDI (from 7.0 to 8.5 cases per 10,000 patient-days; P < .001); community-onset, HCF-associated CDI attributed to a study hospital (from 1.1 to 1.3 cases per 10,000 patient-days; P = .003); and community-onset, HCF-associated CDI not attributed to a study hospital (from 0.8 to 1.5 cases per 1,000 admissions overall; P < .001). For each surveillance definition of CDI, there were significant differences in the total incidence rate between HCFs.nnnCONCLUSIONSnThe increasing incidence rates of CDI over time and across healthcare institutions and the correlation of CDI incidence in different surveillance categories suggest that CDI may be a regional problem and not isolated to a single HCF within a community.

Multicenter study of surveillance for hospital-onset Clostridium difficile infection by the use of ICD-9-CM diagnosis codes.

OBJECTIVEnTo compare incidence of hospital-onset Clostridium difficile infection (CDI) measured by the use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) discharge diagnosis codes with rates measured by the use of electronically available C. difficile toxin assay results.nnnMETHODSnCases of hospital-onset CDI were identified at 5 US hospitals during the period from July 2000 through June 2006 with the use of 2 surveillance definitions: positive toxin assay results (gold standard) and secondary ICD-9-CM discharge diagnosis codes for CDI. The chi(2) test was used to compare incidence, linear regression models were used to analyze trends, and the test of equality was used to compare slopes.nnnRESULTSnOf 8,670 cases of hospital-onset CDI, 38% were identified by the use of both toxin assay results and the ICD-9-CM code, 16% by the use of toxin assay results alone, and 45% by the use of the ICD-9-CM code alone. Nearly half (47%) of cases of CDI identified by the use of a secondary diagnosis code alone were community-onset CDI according to the results of the toxin assay. The rate of hospital-onset CDI found by use of ICD-9-CM codes was significantly higher than the rate found by use of toxin assay results overall (P < .001), as well as individually at 3 of the 5 hospitals (P < .001 for all). The agreement between toxin assay results and the presence of a secondary ICD-9-CM diagnosis code for CDI was moderate, with an overall kappa value of 0.509 and hospital-specific kappa values of 0.489-0.570. Overall, the annual increase in CDI incidence was significantly greater for rates determined by the use of ICD-9-CM codes than for rates determined by the use of toxin assay results (P = .006).nnnCONCLUSIONSnAlthough the ICD-9-CM code for CDI seems to be adequate for measuring the overall CDI burden, use of the ICD-9-CM discharge diagnosis code for CDI, without present-on-admission code assignment, is not an acceptable surrogate for surveillance for hospital-onset CDI.

Dissemination and sustainability of a hospital-wide hand hygiene program emphasizing positive reinforcement.

OBJECTIVEnTo increase and sustain hospital-wide compliance with hand hygiene through a long-term ongoing multidimensional improvement program emphasizing behavioral factors.nnnDESIGNnQuasi-experimental short study (August 2000-November 2001) and descriptive time series (April 2003-December 2006).nnnSETTINGnA 450-bed teaching tertiary-care hospital.nnnINTERVENTIONSnAn initial intervention bundle was introduced in pilot locations that addressed cognitive behavioral factors, which included access to alcohol sanitizer, education, and ongoing audit and feedback. The bundle was subsequently disseminated hospital-wide, along with a novel approach focused on behavior modification through positive reinforcement and annually changing incentives.nnnRESULTSnA total of 36,123 hand hygiene opportunities involving all categories of healthcare workers from 12 inpatient units were observed from October 2000 to October 2006. The rate of compliance with hand hygiene significantly improved after the intervention in 2 cohorts over the first year (from 40% to 64% of opportunities and from 34% to 49% of opportunities;P <.001, compared with the control group). Mean compliance rates ranged from 19% to 41% of 4174 opportunities (at baseline), increased to the highest levels of 73%-84% of 6,420 opportunities 2 years after hospital-wide dissemination, and remained improved at 59%-81% of 4,990 opportunities during year 6 of the program.nnnCONCLUSIONnThis interventional cohort study used a behavioral change approach and is one of the earliest and largest institution-wide programs promoting alcohol sanitizer from the United States that has shown significant and sustained improvements in hand hygiene compliance. This creative campaign used ongoing frequent audit and feedback with novel use of immediate positive reinforcement at an acceptable cost to the institution.

Agreement in Classifying Bloodstream Infections Among Multiple Reviewers Conducting Surveillance

BACKGROUNDnMandatory reporting of healthcare-associated infections (HAIs) is increasing. Evidence for agreement among different reviewers applying HAI surveillance criteria is limited. We aim to characterize agreement among infection preventionists (IPs) conducting surveillance for central line-associated bloodstream infection (CLABSI) with each other and as compared with simplified laboratory-based definitions.nnnMETHODSnAbstracted electronic health records were assembled from inpatients with positive blood cultures at a tertiary-care Veterans Affairs (VA) hospital over a 5-year period. Identical patient records were made available to VA IPs from different facilities to report on CLABSI using their usual surveillance methods. Positive blood cultures were also evaluated using laboratory-based definitions. Standard indices of interrater agreement, expressed as a κ statistic, were computed between IPs, and between IPs and simplified laboratory-based methods.nnnRESULTSnOverall, 114 patient records were reviewed by 18 IPs, the majority of whom specified they followed National Healthcare Safety Network criteria. The overall agreement among IPs by κ statistic was 0.42 (standard error [SE], 0.06). IPs had better agreement with a simple laboratory-based definition with an average κ of 0.55 (SE, 0.05). The proportion of patient records that 18 IPs reported with CLABSI ranged from 14% to 39% (overall mean, 28% with a coefficient of variation of 25%). When simple laboratory-based methods were applied to different sets of patient records, classification was more consistent with CLABSI assigned in a proportion ranging from 36% to 42% (overall mean, 39%).nnnCONCLUSIONSnReliability of IP-conducted surveillance to identify HAI may not be ideal for public reporting goals of interhospital comparisons.

Healthcare Personnel Attire in Non-Operating-Room Settings

Healthcare personnel (HCP) attire is an aspect of the medical profession steeped in culture and tradition. The role of attire in cross-transmission remains poorly established, and until more definitive information exists priority should be placed on evidence-based measures to prevent healthcare-associated infections (HAIs). This article aims to provide general guidance to the medical community regarding HCP attire outside the operating room. In addition to the initial guidance statement, the article has 3 major components: (1) a review and interpretation of the medical literature regarding (a) perceptions of HCP attire (from both HCP and patients) and (b) evidence for contamination of attire and its potential contribution to cross-transmission; (2) a review of hospital policies related to HCP attire, as submitted by members of the Society for Healthcare Epidemiology of America (SHEA) Guidelines Committee; and (3) a survey of SHEA and SHEA Research Network members that assessed both institutional HCP attire policies and perceptions of HCP attire in the cross-transmission of pathogens. Recommendations for HCP attire should attempt to balance professional appearance, comfort, and practicality with the potential role of apparel in the cross-transmission of pathogens. Although the optimal choice of HCP attire for inpatient care remains undefined, we provide recommendations on the use of white coats, neckties, footwear, the bare-below-the-elbows strategy, and laundering. Institutions considering these optional measures should introduce them with a well-organized communication and education effort directed at both HCP and patients. Appropriately designed studies are needed to better define the relationship between HCP attire and HAIs.

Description of outbreaks of health-care-associated infections related to compounding pharmacies, 2000-12.

PURPOSEnOutbreaks of health-care-associated infections related to compounding pharmacies from 2000 through 2012 are described.nnnMETHODSnPubMed and the websites for the Centers for Disease Control and Prevention and the Food and Drug Administration were searched to identify infectious outbreaks associated with compounding pharmacies outside the hospital setting between January 2000 and November 2012.nnnRESULTSnBetween January 2000 and before the 2012 fungal meningitis outbreak, 11 outbreaks were identified, involving 207 infected patients and 17 deaths after exposure to contaminated compounded drugs. The 2012 meningitis outbreak had a similar mortality rate but increased these totals almost fivefold. Half of the outbreaks involved patients in more than one state. Three outbreaks involved ophthalmic drugs. The remaining outbreaks involved corticosteroids, heparin flush solutions, cardioplegia solution, i.v. magnesium sulfate, total parenteral nutrition, and fentanyl. The outbreaks were caused by pathogens commonly associated with health-care-associated infections, common skin commensals, and organisms that rarely cause infection. Morbidity was substantial, including vision loss. Half the outbreaks resulted in recall of all sterile drugs from the pharmacy due to systemic problems with sterile procedures.nnnCONCLUSIONnBefore the nationwide 2012 fungal meningitis outbreak, drugs produced by compounding pharmacies were associated with 11 other smaller, but equally serious, outbreaks that occurred sporadically over the past 12 years. Lapses in sterile compounding procedures led to contamination of compounded drugs, exposure to patients, and a threat to public health in these outbreaks. Recognition and subsequent public health investigation were usually triggered by the occurrence of illness among multiple patients in a single health care setting.

Multicenter study of the impact of community-onset Clostridium difficile infection on surveillance for C. difficile infection

OBJECTIVEnTo evaluate the impact of cases of community-onset, healthcare facility (HCF)-associated Clostridium difficile infection (CDI) on the incidence and outbreak detection of CDI.nnnDESIGNnA retrospective multicenter cohort study.nnnSETTINGnFive university-affiliated, acute care HCFs in the United States.nnnMETHODSnWe collected data (including results of C. difficile toxin assays of stool samples) on all of the adult patients admitted to the 5 hospitals during the period from July 1, 2000, through June 30, 2006. CDI cases were classified as HCF-onset if they were diagnosed more than 48 hours after admission or as community-onset, HCF-associated if they were diagnosed within 48 hours after admission and if the patient had recently been discharged from the HCF. Four surveillance definitions were compared: cases of HCF-onset CDI only (hereafter referred to as HCF-onset CDI) and cases of HCF-onset and community-onset, HCF-associated CDI diagnosed within 30, 60, and 90 days after the last discharge from the study hospital (hereafter referred to as 30-day, 60-day, and 90-day CDI, respectively). Monthly CDI rates were compared. Control charts were used to identify potential CDI outbreaks.nnnRESULTSnThe rate of 30-day CDI was significantly higher than the rate of HCF-onset CDI at 2 HCFs (P < .01). The rates of 30-day CDI were not statistically significantly different from the rates of 60-day or 90-day CDI at any HCF. The correlations between each HCFs monthly rates of HCF-onset CDI and 30-day CDI were almost perfect (rho range, 0.94-0.99; P < .001). Overall, 12 time points had a CDI rate that was more than 3 standard deviations above the mean, including 11 time points identified using the definition for HCF-onset CDI and 9 time points identified using the definition for 30-day CDI, with discordant results at 4 time points ((kappa = 0.794; P < .001).nnnCONCLUSIONSnTracking cases of both community-onset and HCF-onset, HCF-associated CDI captures significantly more CDI cases, but surveillance of HCF-onset, HCF-associated CDI alone is sufficient to detect an outbreak.

Utility of a Commercial PCR Assay and a Clinical Prediction Rule for Detection of Toxigenic Clostridium difficile in Asymptomatic Carriers

ABSTRACT A commercial PCR assay of perirectal swab specimens detected 17 (68%) of 25 asymptomatic carriers of toxigenic Clostridium difficile, including 93% with skin and/or environmental contamination. A clinical prediction rule, followed by PCR screening, could be used to identify carriers at high risk of C. difficile shedding.

Importation, Antibiotics, and Clostridium difficile Infection in Veteran Long-Term Care: A Multilevel Case–Control Study

Context Variation in Clostridium difficile incidence among long-term care facilities is not well-understood. Contribution This study compared regional Veterans Health Administration long-term care facilities. There was wide variation in C difficile incidence that was largely explained by differences in overall use of antibiotics and the importation of C difficile from acute care settings, rather than individual patient factors, such as age, number of comorbidities, and antibiotic use. Implication Approaches that focus on infection control and institutional antibiotic stewardship may be most beneficial for reducing C difficile incidence in long-term care facilities. Clostridium difficile infection is a diarrheal disease that is associated with antibiotic and health care exposures. It has the highest prevalence, morbidity, and mortality of any health careassociated infection (1, 2). Risk factors have been extensively studied and include age, comorbidity burden, abdominal surgery, feeding tube use, and exposure to antibiotics and antacids (3). Almost all antibiotic classes are believed to increase risk; however, the risk is greatest for antibiotics with activity against gut flora but none against C difficile, including cephalosporins, fluoroquinolones, and clindamycin (4, 5). Antacids, especially proton-pump inhibitors, are believed to increase risk by reducing stomach acidity, thereby allowing increased numbers of viable C difficile to reach the gut. Although clinical risk factors have been extensively studied, the environmental and facility-level exposures that may drive C difficile transmission have not. What is known is that C difficile is transmitted by the fecaloral route, and patients with symptomatic disease or asymptomatic colonization have high bacterial loads in their stool and shed infectious spores into their environs for extended periods (6, 7). Exposure of patients to ward-level disease pressure, measured as the daily number of infectious patients with recent C difficile present in the same ward, predicts increased risk for infection (8). In addition to disease pressure, antibiotic use in wards has been shown to increase the risk for infection together with individual-level antibiotic exposure (9). This independent effect of ward antibiotic use may be due to the higher likelihood of asymptomatic C difficile colonization and shedding among patients with recent antibiotic exposure (7), which creates a greater environmental C difficile burden. Long-term care facilities provide services to residents requiring assistance with activities of daily living in a residential setting, skilled nursing, spinal cord injury care, and rehabilitation. In long-term care, antimicrobial use is generally high, with the point prevalence around 8%; of this, 25% to 75% may be inappropriate (10). To our knowledge, the effect of antimicrobial use on C difficile incidence in long-term care has never been explored. Further, long-term care residents have frequent contact with acute care facilities; therefore, importation of hospital-onset C difficile infection may be an important risk factor for infection in long-term care facilities (11). Models incorporating both individual- and facility-level risk factors can be used to distinguish risk factors that affect individual susceptibility to disease from those that that may be associated with the degree of environmental contamination and that may proxy spore ingestion (12). The objective of this study was to obtain a comprehensive picture of the individual and regional factors that drive C difficile infection risk across Veterans Health Administration (VHA) long-term care facilities, with an interest in the role of importation of persons with acute careonset C difficile infection and regional rates of antibiotic use. Methods Ethics Statement Study approval was obtained from the Research Ethics Board of the Veterans Affairs Salt Lake City Health Care System. The Board waived the need for consent because there was no contact with residents, and anonymity was assured. Study Design We conducted a retrospective study of VHA long-term care residents across 111 health care regions from 1 January 2006 through 31 December 2012. In the VHA, health care regions act as local health care systems and usually provide both acute and long-term care services. In most of these regions, long-term care services were delivered at a single facility (n= 89), although care was distributed across 2 or more locations (n= 22) in some regions. All long-term care facilities provide 24-hour nursing care, and some also provide psychiatric, spinal cord injury, or hospice care. This retrospective study used a multilevel, longitudinal, nested casecontrol design. To accurately estimate resident risk, a multilevel model that incorporated both resident-level risk factors (characteristics of specific at-risk persons) and regional risk factors (measures of the prevalence of residents who were likely to shed C difficile spores) was used. To allow short-term pharmaceutical exposures to be measured in an appropriate retrospective window, the analysis data set was broken down into a longitudinal resident-day format. Because the resultant data set was extensive, a nested casecontrol design was used. Population Residents were considered at risk for onset of C difficile infection in a long-term care facility if they resided in an inpatient VHA long-term care facility for 3 or more of the previous 28 days and did not have a positive C difficile test result in the prior 8 weeks. Health care regions, and eligible residents within them, were included in the risk set if there were at least 6 years of data in which long-term and acute care censuses were greater than an average of 10 eligible, at-risk persons per day for each month of the given year. Regions without acute care facilities were excluded because imported cases of C difficile infection from non-VHA acute care facilities were not captured and would have led to an underestimate of C difficile importation in those regions. Definition of Cases and Controls Residents were considered cases on the date of a positive C difficile toxin test result 3 days or more after long-term care admission and at least 8 weeks from a previous positive result (13). Positive results were identified from VHA microbiology data using natural language processing (14). Eligible controls were resident-days that did not meet the case definition and could include resident-days from persons who later became cases. A 1%, unmatched, simple random sample of eligible controls was selected for analysis. Resident Risk Factors The 7 resident risk factors assessed were age, sex, number of days of acute care hospitalization within the previous 4 weeks, number of comorbid conditions, and 3 pharmaceutical exposures. The value of each time-varying parameter was assessed for each day. For comorbidities, acute and long-term care facility discharge diagnosis codes (International Classification of Diseases, Ninth Revision, Clinical Modification) were used to assess the presence of 14 comorbid conditions in the preceding year as per the Charlson comorbidity index (15, 16). For a given resident, the total number of comorbid conditions was summed. The following 3 pharmaceutical exposure variables were assessed, each in a 4-week retrospective window: proton-pump inhibitors; any antibiotic except C difficile treatment agents (metronidazole, oral vancomycin, and fidaxomicin); and an antibiotic risk index with 4 mutually exclusive risk levels consisting of high (receipt of cephalosporins, fluoroquinolones, or clindamycin), medium (receipt of penicillins, macrolides, or sulfonamides but no high-risk agents), low (receipt of tetracyclines), or no antibiotic receipt or receipt of C difficile treatment agents only. This antibiotic risk index was based on a similar index developed in an independent cohort study (17). Pharmaceutical exposure information was drawn from administration data of the VHA electronic medical record and included all courses given during inpatient care in VHA acute or long-term care facilities. Community exposures were not considered. In addition to the 7 resident risk factors, a control variable for the duration of follow-up time, defined as the total number of days a given resident stayed in a VHA acute or long-term care facility within the past 28 days, was measured and categorized into deciles. Health Care Regional Risk Factors The 5 regional risk factors measured were average resident age, average resident comorbidities, proton-pump inhibitor use, antibiotic use, and importation of cases of acute care C difficile infection. These factors were measured from the full resident population of the regions because residents who were not at risk (that is, those recently admitted with a recent positive C difficile test result) were just as likely if not more likely to transmit C difficile. Proton-pump inhibitor use and antibiotic use (excluding the C difficile treatment agents previously mentioned) were measured as days with therapy per 1000 resident-days. Exposure on a given day contributed 1 unit to the numerator, regardless of the number of specific agents, dosage, or number of doses administered on that day. Importation of cases of acute care C difficile infection was measured as the prevalence of residents in the region who were infected with C difficile at an acute care facility in the previous 8 weeks per 10000 resident-days. Acute careonset C difficile infection was defined as a patient with a positive C difficile toxin test result 3 or more days after admission to an acute care facility. Statistical Analysis The incidence of C difficile across the VHA, and within each region, was measured using the weighted mean. In all statistical analyses, sampling weights of 1 for cases and 100 for controls corresponded to the inverse of the probability of selection, allowing analyses to produce unbiased estimates of