Julie Jefferson

Peripheral Venous Catheter-Related Staphylococcus aureus Bacteremia

OBJECTIVE Better understand the incidence, risk factors, and outcomes of peripheral venous catheter (PVC)-related Staphylococcus aureus bacteremia. DESIGN Retrospective study of PVC-related S. aureus bacteremias in adult patients from July 2005 through March 2008. A point-prevalence survey was performed January 9, 2008, on adult inpatients to determine PVC utilization; patients with a PVC served as a cohort to assess risk factors for PVC-related S. aureus bacteremia. SETTING Tertiary care teaching hospital. RESULTS Twenty-four (18 definite and 6 probable) PVC-related S. aureus bacteremias were identified (estimated incidence density, 0.07 per 1,000 catheter-days), with a median duration of catheterization of 3 days (interquartile range, 2-6). Patients with PVC-related S. aureus bacteremia were significantly more likely to have a PVC in the antecubital fossa (odds ratio [OR], 6.5), a PVC placed in the emergency department (OR, 6.0), or a PVC placed at an outside hospital (P = .005), with a longer duration of catheterization (P < .001). These PVCs were significantly less likely to have been inserted in the hand (OR, 0.23) or placed on an inpatient medical unit (OR, 0.17). Mean duration of antibiotic treatment was 19 days (95% confidence interval, 15-23 days); 42% (10/24) of cases encountered complications. We estimate that there may be as many as 10,028 PVC-related S. aureus bacteremias yearly in US adult hospitalized inpatients. CONCLUSION PVC-related S. aureus bacteremia is an underrecognized complication. PVCs inserted in the emergency department or at outside institutions, PVCs placed in the antecubital fossa, and those with prolonged dwell times are associated with such infections.

Impact of Chlorhexidine Bathing on Hospital-Acquired Infections among General Medical Patients

BACKGROUND A paucity of data exists regarding the effectiveness of daily chlorhexidine gluconate (CHG) bathing in non-intensive care unit (ICU) settings. OBJECTIVE To evaluate the effectiveness of daily CHG bathing in a non-ICU setting to reduce methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enteroccocus (VRE) hospital-acquired infections (HAIs), compared with daily bathing with soap and water. DESIGN Quasi-experimental study design; the primary outcome was the composite incidence of MRSA and VRE HAIs. Clostridium difficile HAI incidence was measured as a nonequivalent dependent variable with which to assess potential confounders. SETTING Four general medicine units, with a total of 94 beds, at a 719-bed academic tertiary-care facility in Providence, Rhode Island. PATIENTS A total of 7,102 and 7,699 adult patients were admitted to the medical service in the control and intervention groups, respectively. Patients admitted from January 1 through December 31, 2008, were bathed daily with soap and water (control group), and those admitted from February 1, 2009, through March 31, 2010, were bathed daily with CHG-impregnated cloths (intervention group). RESULTS Daily bathing with CHG was associated with a 64% reduced risk of developing the primary outcome, namely, the composite incidence of MRSA and VRE HAIs (hazard ratio, 0.36 [95% CI, 0.2-0.8]; P = .01). There was no change in the incidence of C. difficile HAIs (P = .6). Colonization with MRSA was associated with an increased risk of developing a MRSA HAI (hazard ratio, 8 [95% CI, 3-19]; P < .001). CONCLUSION Daily CHG bathing was associated with a reduced HAI risk, using a composite endpoint of MRSA and VRE HAIs, in a general medical inpatient population.

Factors Associated with Hand Hygiene Compliance at a Tertiary Care Teaching Hospital

OBJECTIVE To identify factors associated with hand hygiene compliance during a multiyear period of intervention. DESIGN Observational study. SETTING A 719-bed tertiary care teaching hospital. PARTICIPANTS Nursing, physician, technical, and support staff. METHODS Light-duty staff performed hand hygiene observations during the period July 2008-December 2012. Infection control implemented hospital-wide hand hygiene initiatives, including education modules; posters and table tents; feedback to units, medical directors and the executive board; and an increased number of automated alcohol hand hygiene product dispensers. RESULTS There were 161,526 unique observations; overall compliance was 83%. Significant differences in compliance were observed between physician staff (78%) and support staff (69%) compared with nursing staff (84%). Pediatric units (84%) and intensive care units (84%) had higher compliance than did medical (82%) and surgical units (81%). These findings persisted in the controlled multivariate model for noncompliance. Additional factors found to be significant in the model included greater compliance when healthcare workers were leaving patient rooms, when the patient was under contact precautions, and during the evening shift. The overall rate of compliance increased from 60% in the first year of observation to a peak of 96% in the fourth year, and it decreased to 89% in the final year, with significant improvements occurring in each of the 4 professional categories. CONCLUSIONS A multipronged hand hygiene initiative is effective in increasing compliance rates among all categories of hospital workers. We identified a variety of factors associated with increased compliance. Additionally, we note the importance of continuous interventions in maintaining high compliance rates.

Reducing Clostridium difficile Incidence, Colectomies, and Mortality in the Hospital Setting: A Successful Multidisciplinary Approach

BACKGROUND Health care associated Clostridium difficile infections are a major cause of morbidity and mortality in hospitals. In the United States, from 2000 through 2009, discharge diagnoses from hospitals in the United States that included C. difficile increased from 139,000 to 336,600, and the yearly national excess hospital cost associated with hospital-onset C. difficile is estimated to be upwards of

Knowledge and Use of Cumulative Antimicrobial Susceptibility Data at a University Teaching Hospital

1.3 billion. METHODS A hospitalwide, multidisciplinary approach was undertaken at Rhode Island Hospital (Providence), a tertiary care hospital. The hospital plan entailed six interventions: (1) develop a C. difficile hospital infection control plan based on a risk assessment; (2) monitor hospitalwide morbidity and mortality associated with C. difficile infection; (3) improve sensitivity of C. difficile toxin detection in stool specimens using a polymerase chain reaction-based nucleic acid amplification assay; (4) enhance environmental cleaning of patient rooms and equipment; (5) develop a C. difficile infection treatment plan; and (6) conduct other interventions. The incidence of health care-associated C. difficile infection was assessed from January 2006 through the third quarter of 2012; the number of colectomies and mortality associated with C. difficile infection were determined from January 2005 through the third quarter of 2012. RESULTS The incidence of health care-associated C. difficile infection decreased from a peak of 12.2/1,000 discharges during the second quarter of 2006 to 3.6/1,000 discharges during the third quarter of 2012. The yearly mortality in patients with health care-associated C. difficile infection was reduced from a peak of 52 in 2006 to 19 in 2011, with 13 such cases in the first three quarters of 2012. CONCLUSIONS A hospitalwide multidisciplinary approach can reduce health care-associated C. difficile infection morbidity and mortality.

A cluster of community-acquired methicillin-resistant Staphylococcus aureus infections in hospital security guards.

To the Editor—We devised and performed a voluntary, anonymous online survey of the 545 residents and fellows in our housestaff training programs in 2007 to determine whether they were aware of cumulative antimicrobial susceptibility data on our hospital intranet and if this or similar data was used in clinical decision making. Three hundred twenty-six (60%) of 545 house officers completed the survey; 59% were in postgraduate year 1–3, the remainder were in postgraduate year 4–8. The primary patient population cared for by the house officers who responded was adult (54%), pediatric (17%), or both (29%). The largest programs represented were internal medicine (42%), surgery (15%), and pediatrics (14%). Although 74% of house officers responded that they had used general antimicrobial susceptibility data provided in the Sanford Guide, 0%, 3%, 33%, and 64% responded that they always, frequently, occasionally, or never used our hospital’s cumulative (not patient-specific) antimicrobial susceptibility data, respectively. Of those who responded that they occasionally or never used the hospital data, 61% responded that they did not know where to find it, and 14% found it inconvenient to access. When asked if they would use unit-specific antimicrobial susceptibility data (i.e., specified by microorganism and hospital ward) when prescribing antibiotics, 71%, 26%, and 3% responded yes, possibly, or no, respectively. House officers are frequent prescribers of antimicrobial agents, and our survey suggests that they use antimicrobial susceptibility data in decision making. However, at our institution, they use generalized information, which is most easily accessible to them (i.e., the Sanford Guide), rather than hospital-specific data, which are less accessible. The Centers for Disease Control’s 12-Step Program to Prevent Antimicrobial Resistance Among Hospitalized Patients suggests that health care providers use local antibiotic susceptibility data when choosing empirical therapy [1]. The Joint Commission on the Accreditation of Healthcare Organizations recognizes the importance of such data as a quality assurance measure [2]. Nevertheless, the potential impact of local antimicrobial susceptibility data will be constrained unless the information is easily accessible to antibiotic prescribers. Surveys have found variability in analysis and presentation of antimicrobial susceptibility data [3, 4], and recent consensus guidelines have addressed this issue [5]. On the basis of our survey, more attention is needed in health care delivery settings to easily and expeditiously communicate this important information to end users as an integral component of a successful antibiotic stewardship program [6].

Potential Economic Impact of Hospital-Acquired Infections in Uninsured Patients : A Preliminary Investigation

We investigated a cluster of methicillin-resistant Staphylococcus aureus soft-tissue infections in 5 security guards employed in a hospital emergency department. An epidemiologic investigation and molecular subtyping of isolates revealed that the source was a patient and that a community-acquired methicillin-resistant S. aureus strain (USA-300) was transmitted to healthcare workers through physical contact.

Use of failure mode and effect analysis (FMEA) to improve active surveillance for methicillin-resistant Staphylococcus aureus (MRSA) at a university-affiliated medical center

We studied uninsured patients admitted to Rhode Island Hospital from January 1 through June 30, 2005, and from January 1 through June 30, 2006. The mean total hospital charge for an uninsured patient with a hospital-acquired infection was

Operating Room Environmental Cleaning – An Evaluation Using a New Targeting Method

18,487; for those without such an infection, it was

Monitoring hand hygiene compliance in a university-affiliated medical center

4,951 (P < .001). Multivariable linear regression revealed that a hospital-acquired infection accounted for 11.8 excess hospital days (P = .001). Length of stay was the only independent variable associated with total excess hospital charges.