Joan N. Hebden

Multidrug-resistant Acinetobacter Infection Mortality Rate and Length of Hospitalization

Acinetobacter infections have increased and gained attention because of the organism’s prolonged environmental survival and propensity to develop antimicrobial drug resistance. The effect of multidrug-resistant (MDR) Acinetobacter infection on clinical outcomes has not been reported. A retrospective, matched cohort investigation was performed at 2 Baltimore hospitals to examine outcomes of patients with MDR Acinetobacter infection compared with patients with susceptible Acinetobacter infections and patients without Acinetobacter infections. Multivariable analysis controlling for severity of illness and underlying disease identified an independent association between patients with MDR Acinetobacter infection (n = 96) and increased hospital and intensive care unit length of stay compared with 91 patients with susceptible Acinetobacter infection (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.2–5.2 and OR 2.1, 95% CI 1.0–4.3] respectively) and 89 uninfected patients (OR 2.5, 95% CI 1.2–5.4 and OR 4.2, 95% CI 1.5–11.6] respectively). Increased hospitalization associated with MDR Acinetobacter infection emphasizes the need for infection control strategies to prevent cross-transmission in healthcare settings.

Risk Factors for Colonization with Extended-Spectrum β-Lactamase–producing Bacteria and Intensive Care Unit Admission

Coexisting conditions and previous antimicrobial drug exposure predict colonization.

Systems ambiguity and guideline compliance: a qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare-associated infections

Background: Consistent compliance with evidence-based guidelines is challenging yet critical to patient safety. We conducted a qualitative study to explore the underlying causes for non-compliance with evidence-based guidelines aimed at preventing four types of healthcare-associated infections in the surgical intensive care unit (SICU) setting. Methods: Twenty semistructured interviews were conducted with attending physicians (3), residents (2), nurses (6), quality improvement coordinators (3), infection control practitioners (2), respiratory therapists (2) and pharmacists (2) in two SICUs. Using a grounded theory approach, we performed thematic analyses of the interviews. Results: The concept of systems ambiguity to explain non-compliance with evidence-based guidelines emerged from the data. Ambiguities hindering consistent compliance were related to tasks, responsibilities, methods, expectations and exceptions. Strategies reported to reduce ambiguity included clarification of expectations from care providers with respect to guideline compliance through education, use of visual cues to indicate the status of patients with respect to a particular guideline, development of tools that provide an overview of information critical for guideline compliance, use of standardised orders, clarification of roles of care providers and use of decision-support tools. Conclusions: The concept of systems ambiguity is useful to understand causes of non-compliance with evidence-based guidelines aimed at reducing healthcare-associated infections. Multi-faceted interventions are needed to reduce different ambiguity types, hence to improve guideline compliance.

Prevalence of methicillin-resistant Staphylococcus aureus and Acinetobacter baumannii in a long-term acute care facility

BACKGROUND Patients in long-term acute care (LTAC) facilities often have many known risk factors for acquisition of antibiotic-resistant bacteria. However, the prevalence of resistance in these facilities has not been well described. METHODS We performed a single-day, point-prevalence study of a 180-bed, university-affiliated LTAC facility in Baltimore to assess the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and Acinetobacter baumannii in the anterior nares, perirectal area, sputum, and wounds. RESULTS Among the 147 patients evaluated, we found a high prevalence of colonization by both MRSA (28%) and A baumannii (30%). Of the A baumannii isolates, 90% were susceptible to imipenem and 92% were susceptible to ampicillin-sulbactam. No isolates were resistant to both imipenem and ampicillin-sulbactam. CONCLUSION The high prevalence of resistance found in this study supports the need for increased surveillance of patients in the LTAC environment. The fact that these patients are often frequently transferred to tertiary care facilities also supports the need for coordination and collaboration among facilities within the same health care system and the broader geographic area.

Video-based training increases sterile-technique compliance during central venous catheter insertion.

Objective:To evaluate the effect of an online training course containing video clips of central venous catheter insertions on compliance with sterile practice. Design:Prospective randomized controlled study. Setting:Admitting area of a university-based high-volume trauma center. Subjects:Surgical and emergency medicine residents rotating through the trauma services. Interventions:An online training course on recommended sterile practices during central venous catheter insertion was developed. The course contained short video clips from actual patient care demonstrating common noncompliant behaviors and breaks regarding recommended sterile practices. A 4-month study with a counterbalanced design compared residents trained by the video-based online training course (video group) with those trained with a paper version of the course (paper group). Residents who inserted central venous catheters but received neither the paper nor video training were used as a control group. Consecutive central venous catheter insertions from 12 noon to 12 midnight except Sundays were video recorded. Measurements and Main Results:Sterile-practice compliance was judged through video review by two surgeons blinded to the training status of the residents. Fifty residents inserted 73 elective central venous catheters (19, 31, and 23 by the video, paper, and control group operators, respectively) into 68 patients. Overall compliance with proper operator preparation, skin preparation, and draping was 49% (36 of 73 procedures). The training had no effect on selection of site and skin preparation agent. The video group was significantly more likely than the other two groups to fully comply with sterile practices (74% vs. 33%; odds ratio, 6.1; 95% confidence interval, 2.0–22.0). Even after we controlled for the number of years in residency training, specialty, number of central venous catheters inserted, and central venous catheter site chosen, the video group was more likely to comply with recommended sterile practices (p = .003). Conclusions:An online training course, with short video clips of actual patient care demonstrating noncompliant behaviors, improved sterile-practice compliance for central venous catheter insertion. Paper handouts with equivalent content did not improve compliance.

An episodic outbreak of genetically related Burkholderia cepacia among non-cystic fibrosis patients at a university hospital

OBJECTIVE To investigate an outbreak of Burkholderia cepacia. DESIGN Observational study and chart review. PATIENTS Adult non-cystic fibrosis (CF) patients. SETTING Intensive care units (ICUs) at a university-affiliated teaching hospital. METHODS As part of the epidemiological investigation, we conducted a chart review and collected environmental samples. A review of work schedules of healthcare workers also was performed. We used B. cepacia selective agar for preliminary screening for all isolates, which subsequently were confirmed as members of the B. cepacia complex by polyphasic analysis employing conventional biochemical reactions and genus- and species-specific polymerase chain reaction assays. Pulsed-field gel electrophoresis, randomly amplified polymorphic DNA typing, and automated ribotyping were used to genotype the isolates. As part of the intervention, contact isolation precautions were initiated for all patients identified as having had a culture positive for B. cepacia. RESULTS Between September 1997 and September 1999, B. cepacia was isolated from 31 adult patients without CF in ICUs at a university-affiliated teaching hospital. Based on geographic clustering and genotypic analysis, three distinct clusters were observed involving 20 patients. Isolates from 17 of these patients were available for testing and were found to be of the same strain (outbreak strain). Further taxonomic analysis indicated that the outbreak strain was B. cepacia complex genomovar III. Twelve (71%) of the 17 patients were judged to be infected, and 5 (29%) were colonized with this strain. Six of 200 environmental cultures from multiple sources in the hospitals ICUs yielded B. cepacia. Two of these isolates, both recovered from rooms of colonized patients, were the same genotype as the outbreak strain recovered from patients. CONCLUSION Despite an extensive investigation, the source of the B. cepacia clone involved in this outbreak remains unknown. The spatial and temporal pattern of cases suggests that cross-transmission of a genetically related strain contributed to clustering among patients. The initiation of contact isolation may have limited the extent of this transmission. Additional studies are needed to elucidate better the epidemiology of nosocomial B. cepacia infection among non-CF adult patients.

Factors Associated with Increased Healthcare Worker Influenza Vaccination Rates: Results from a National Survey of University Hospitals and Medical Centers

OBJECTIVE To ascertain which components of healthcare worker (HCW) influenza vaccination programs are associated with higher vaccination rates. DESIGN Survey. SETTING University-affiliated hospitals. METHODS Participating hospitals were surveyed with regard to their institutional HCW influenza vaccination program for the 2007-2008 influenza season. Topics assessed included vaccination adherence and availability, use of declination statements, education methods, accountability, and data reporting. Factors associated with higher vaccination rates were ascertained. RESULTS Fifty hospitals representing 368,696 HCWs participated in the project. The median vaccination rate was 55.0% (range, 25.6%-80.6%); however, the types of HCWs targeted by vaccination programs varied. Programs with the following components had significantly higher vaccination rates: weekend provision of vaccine (58.8% in those with this feature vs 43.9% in those without; P = .01), train-the-trainer programs (59.5% vs 46.5%; P = .005), report of vaccination rates to administrators (57.2% vs 48.1%; P = .04) or to the board of trustees (63.9% vs 53.4%; P = .01), a letter sent to employees emphasizing the importance of vaccination (59.3% vs 47%; P = .01), and any form of visible leadership support (57.9% vs 36.9%; P = .01). Vaccination rates were not significantly different between facilities that did and those that did not require a signed declination form for HCWs who refused vaccination (56.9% vs 55.1%; P = .68), although the precise content of such statements varied. CONCLUSIONS Vaccination programs that emphasized accountability to the highest levels of the organization, provided weekend access to vaccination, and used train-the-trainer programs had higher vaccination coverage. Of concern, the types of HCWs targeted by vaccination programs differed, and uniform definitions will be essential in the event of public reporting of vaccination rates.

Preliminary assessment of an automated surveillance system for infection control.

BACKGROUND AND OBJECTIVE Rapid identification and investigation of potential outbreaks is key to limiting transmission in the healthcare setting. Manual review of laboratory results remains a cumbersome, time-consuming task for infection control practitioners (ICPs). Computer-automated techniques have shown promise for improving the efficiency and accuracy of surveillance. We examined the use of automated control charts, provided by an automated surveillance system, for detection of potential outbreaks. SETTING A 656-bed academic medical center. METHODS We retrospectively reviewed 13 months (November 2001 through November 2002) of laboratory-patient data, comparing an automated surveillance application with standard infection control practices. We evaluated positive predictive value, sensitivity, and time required to investigate the alerts. An ICP created 75 control charts. A standardized case investigation form was developed to evaluate each alert for the likelihood of nosocomial transmission based on temporal and spatial overlap and culture results. RESULTS The 75 control charts were created in 75 minutes and 18 alerts fired above the 3-sigma level. These were independently reviewed by an ICP and associate hospital epidemiologist. The review process required an average of 20 minutes per alert and the kappa score between the reviewers was 0.82. Eleven of the 18 alerts were determined to be potential outbreaks, yielding a positive predictive value of 0.61. Routine surveillance identified 5 of these 11 alerts during this time period. CONCLUSION Automated surveillance with user-definable control charts for cluster identification was more sensitive than routine methods and is capable of operating with high specificity and positive predictive value in a time-efficient manner.

Targeted Surveillance of Methicillin-Resistant Staphylococcus aureus and Its Potential Use To Guide Empiric Antibiotic Therapy

ABSTRACT The present study aimed to determine the frequency of methicillin-resistant Staphylococcus aureus (MRSA)-positive clinical culture among hospitalized adults in different risk categories of a targeted MRSA active surveillance screening program and to assess the utility of screening in guiding empiric antibiotic therapy. We completed a prospective cohort study in which all adults admitted to non-intensive-care-unit locations who had no history of MRSA colonization or infection received targeted screening for MRSA colonization upon hospital admission. Anterior nares swab specimens were obtained from all high-risk patients, defined as those who self-reported admission to a health care facility within the previous 12 months or who had an active skin infection on admission. Data were analyzed for the subcohort of patients in whom an infection was suspected, determined by (i) receipt of antibiotics within 48 h of admission and/or (ii) the result of culture of a sample for clinical analysis (clinical culture) obtained within 48 h of admission. Overall, 29,978 patients were screened and 12,080 patients had suspected infections. A total of 46.4% were deemed to be at high risk on the basis of the definition presented above, and 11.1% of these were MRSA screening positive (colonized). Among the screening-positive patients, 23.8% had a sample positive for MRSA by clinical culture. Only 2.4% of patients deemed to be at high risk but found to be screening negative had a sample positive for MRSA by clinical culture, and 1.6% of patients deemed to be at low risk had a sample positive for MRSA by clinical culture. The risk of MRSA infection was far higher in those who were deemed to be at high risk and who were surveillance culture positive. Targeted MRSA active surveillance may be beneficial in guiding empiric anti-MRSA therapy.

Value of performing active surveillance cultures on intensive care unit discharge for detection of methicillin-resistant Staphylococcus aureus.

OBJECTIVE To quantify the value of performing active surveillance cultures for detection of methicillin-resistant Staphylococcus aureus (MRSA) on intensive care unit (ICU) discharge. DESIGN Prospective cohort study. SETTING Medical ICU (MICU) and surgical ICU (SICU) of a tertiary care hospital. PARTICIPANTS We analyzed data on adult patients who were admitted to the MICU or SICU between January 17, 2001, and December 31, 2004. All participants had a length of ICU stay of at least 48 hours and had surveillance cultures of anterior nares specimens performed on ICU admission and discharge. Patients who had MRSA-positive clinical cultures in the ICU were excluded. RESULTS Of 2,918 eligible patients, 178 (6%) were colonized with MRSA on ICU admission, and 65 (2%) acquired MRSA in the ICU and were identified by results of discharge surveillance cultures. Patients with MRSA colonization confirmed by results of discharge cultures spent 853 days in non-ICU wards after ICU discharge, which represented 27% of the total number of MRSA colonization-days during hospitalization in non-ICU wards for patients discharged from the ICU. CONCLUSIONS Surveillance cultures of nares specimens collected at ICU discharge identified a large percentage of MRSA-colonized patients who would not have been identified on the basis of results of clinical cultures or admission surveillance cultures alone. Furthermore, these patients were responsible for a large percentage of the total number of MRSA colonization-days during hospitalization in non-ICU wards for patients discharged from the ICU.