Katherine Ellingson

Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Sustained Reduction in the Clinical Incidence of Methicillin- Resistant Staphylococcus aureus Colonization or Infection Associated with a Multifaceted Infection Control Intervention

OBJECTIVE To assess the impact and sustainability of a multifaceted intervention to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission implemented in 3 chronologically overlapping phases at 1 hospital. DESIGN Interrupted time-series analyses. SETTING A Veterans Affairs hospital in the northeastern United States. PATIENTS AND PARTICIPANTS Individuals admitted to acute care units from October 1, 1999, through September 30, 2008. To calculate the monthly clinical incidence of MRSA colonization or infection, the number of MRSA-positive cultures obtained from a clinical site more than 48 hours after admission among patients with no MRSA-positive clinical cultures during the previous year was divided by patient-days at risk. Secondary outcomes included clinical incidence of methicillin-sensitive S. aureus colonization or infection and incidence of MRSA bloodstream infections. INTERVENTIONS The intervention--implemented in a surgical ward beginning October 2001, in a surgical intensive care unit beginning October 2003, and in all acute care units beginning July 2005--included systems and behavior change strategies to increase adherence to infection control precautions (eg, hand hygiene and active surveillance culturing for MRSA). RESULTS Hospital-wide, the clinical incidence of MRSA colonization or infection decreased after initiation of the intervention in 2001, compared with the period before intervention (P = .002), and decreased by 61% (P < .001) in the 7-year postintervention period. In the postintervention period, the hospital-wide incidence of MRSA bloodstream infection decreased by 50% (P = .02), and the proportion of S. aureus isolates that were methicillin resistant decreased by 30% (P < .001). CONCLUSIONS Sustained decreases in hospital-wide clinical incidence of MRSA colonization or infection, incidence of MRSA bloodstream infection, and proportion of S. aureus isolates resistant to methicillin followed implementation of a multifaceted prevention program at one Veterans Affairs hospital. Findings suggest that interventions designed to prevent transmission can impact endemic antimicrobial resistance problems.

Estimated Risk of Human Immunodeficiency Virus and Hepatitis C Virus Infection among Potential Organ Donors from 17 Organ Procurement Organizations in the United States

To prevent unintentional transmission of bloodborne pathogens through organ transplantation, organ procurement organizations (OPOs) screen potential donors by serologic testing to identify human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection. Newly acquired infection, however, may be undetectable by serologic testing. Our objective was to estimate the incidence of undetected infection among potential organ donors and to assess the significance of risk reductions conferred by nucleic acid testing (NAT) versus serology alone. We calculated prevalence of HIV and HCV—stratified by OPO risk designation—in 13 667 potential organ donors managed by 17 OPOs from 1/1/2004 to 7/1/2008. We calculated incidence of undetected infection using the incidence‐window period approach. The prevalence of HIV was 0.10% for normal risk potential donors and 0.50% for high risk potential donors; HCV prevalence was 3.45% and 18.20%, respectively. For HIV, the estimated incidence of undetected infection by serologic screening was 1 in 50 000 for normal risk potential donors and 1 in 11 000 for high risk potential donors; for HCV, undetected incidence by serologic screening was 1 in 5000 and 1 in 1000, respectively. Projected estimates of undetected infection with NAT screening versus serology alone suggest that NAT screening could significantly reduce the rate of undetected HCV for all donor risk strata.

Male-to-Female Sexual Transmission of Zika Virus—United States, January–April 2016

We report on 9 cases of male-to-female sexual transmission of Zika virus in the United States occurring January–April 2016. This report summarizes new information about both timing of exposure and symptoms of sexually transmitted Zika virus disease, and results of semen testing for Zika virus from 2 male travelers.

Vascular access hemorrhages contribute to deaths among hemodialysis patients

In 2007 the Maryland Medical Examiner noted a potential cluster of fatal vascular access hemorrhages among hemodialysis patients, many of whom died outside of a health-care setting. To examine the epidemiology of fatal vascular access hemorrhages, we conducted a retrospective case review in District of Columbia, Maryland, and Virginia from January 2000 to July 2007 and a case-control study. Records from the Medical Examiner and Centers for Medicare and Medicaid Services were reviewed, from which 88 patients were identified as fatal vascular access hemorrhage cases. To assess risk factors, a subset of 20 cases from Maryland was compared to 38 controls randomly selected among hemodialysis patients who died from non-vascular access hemorrhage causes at the same Maryland facilities. Of the 88 confirmed cases, 55% hemorrhaged from arteriovenous grafts, 24% from arteriovenous fistulas, and 21% from central venous catheters. Of 82 case-patients with known location of hemorrhage, 78% occurred at home or in a nursing home. In the case-control analysis, statistically significant risk factors included the presence of an arteriovenous graft, access-related complications within 6 months of death, and hypertension; presence of a central venous catheter was significantly protective. Psychosocial factors and anticoagulant medications were not significant risk factors. Effective strategies to control vascular access hemorrhage in the home and further delineation of warning signs are needed.

Continued decline in blood collection and transfusion in the United States-2015

In 2011 and 2013, the National Blood Collection and Utilization Survey (NBCUS) revealed declines in blood collection and transfusion in the United States. The objective of this study was to describe blood services in 2015.

Evaluation of International Classification of Diseases, Ninth Revision, Clinical Modification Codes for Reporting Methicillin-Resistant Staphylococcus aureus Infections at a Hospital in Illinois

BACKGROUND States, including Illinois, have passed legislation mandating the use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for reporting healthcare-associated infections, such as methicillin-resistant Staphylococcus aureus (MRSA). OBJECTIVE To evaluate the sensitivity of ICD-9-CM code combinations for detection of MRSA infection and to understand implications for reporting. METHODS We reviewed discharge and microbiology databases from July through August of 2005, 2006, and 2007 for ICD-9-CM codes or microbiology results suggesting MRSA infection at a tertiary care hospital near Chicago, Illinois. Medical records were reviewed to confirm MRSA infection. Time from admission to first positive MRSA culture result was evaluated to identify hospital-onset MRSA (HO-MRSA) infections. The sensitivity of MRSA code combinations for detecting confirmed MRSA infections was calculated using all codes present in the discharge record (up to 15); the effect of reviewing only 9 diagnosis codes, the number reported to the Centers for Medicare and Medicaid Services, was also evaluated. The sensitivity of the combination of diagnosis codes for detection of HO-MRSA infections was compared with that for community-onset MRSA (CO-MRSA) infections. RESULTS We identified 571 potential MRSA infections with the use of screening criteria; 403 (71%) were confirmed MRSA infections, of which 61 (15%) were classified as HO-MRSA. The sensitivity of MRSA code combinations was 59% for all confirmed MRSA infections when 15 diagnoses were reviewed compared with 31% if only 9 diagnoses were reviewed (P < .001). The sensitivity of code combinations was 33% for HO-MRSA infections compared with 62% for CO-MRSA infections (P < .001). CONCLUSIONS Limiting analysis to 9 diagnosis codes resulted in low sensitivity. Furthermore, code combinations were better at revealing CO-MRSA infections than HO-MRSA infections. These limitations could compromise the validity of ICD-9-CM codes for interfacility comparisons and for reporting of healthcare-associated MRSA infections.

National Estimates of Central Line–Associated Bloodstream Infections in Critical Care Patients

UNLABELLED OBJECTIVE. Recent studies have demonstrated that central line-associated bloodstream infections (CLABSIs) are preventable through implementation of evidence-based prevention practices. Hospitals have reported CLABSI data to the Centers for Disease Control and Prevention (CDC) since the 1970s, providing an opportunity to characterize the national impact of CLABSIs over time. Our objective was to describe changes in the annual number of CLABSIs in critical care patients in the United States. DESIGN  Monte Carlo simulation. Setting. U.S. acute care hospitals. PATIENTS  Nonneonatal critical care patients. METHODS  We obtained administrative data on patient-days for nearly all US hospitals and applied CLABSI rates from the National Nosocomial Infections Surveillance and the National Healthcare Safety Network systems to estimate the annual number of CLABSIs in critical care patients nationally during the period 1990-2010 and the number of CLABSIs prevented since 1990. RESULTS  We estimated that there were between 462,000 and 636,000 CLABSIs in nonneonatal critical care patients in the United States during 1990-2010. CLABSI rate reductions led to between 104,000 and 198,000 fewer CLABSIs than would have occurred if rates had remained unchanged since 1990. There were 15,000 hospital-onset CLABSIs in nonneonatal critical care patients in 2010; 70% occurred in medium and large teaching hospitals. CONCLUSIONS  Substantial progress has been made in reducing the occurrence of CLABSIs in U.S. critical care patients over the past 2 decades. The concentration of critical care CLABSIs in medium and large teaching hospitals suggests that a targeted approach may be warranted to continue achieving reductions in critical care CLABSIs nationally.

Onchocerciasis: a potential risk factor for glaucoma

Background: Onchocerciasis is a microfilarial disease that causes ocular disease and blindness. Previous evidence of an association between onchocerciasis and glaucoma has been mixed. This study aims to further investigate the association between onchocerciasis and glaucoma. Methods: All subjects were patients at the Bishop John Ackon Christian Eye Centre in Ghana, west Africa, undergoing either trabeculectomy for advanced glaucoma or extracapsular extraction for cataracts, who also had a skin snip biopsy for onchocerciasis. A cross sectional case-control study was performed to assess the difference in onchocerciasis prevalence between the two study groups. Results: The prevalence of onchocerciasis was 10.6% in those with glaucoma compared with 2.6% in those with cataracts (OR, 4.45 (95% CI 1.48 to 13.43)). The mean age in the glaucoma group was significantly younger than in the cataract group (59 and 65, respectively). The groups were not significantly different with respect to sex or region of residence. In models adjusted for age, region, and sex, subjects with glaucoma had over three times the odds of testing positive for onchocerciasis (OR, 3.50 (95% CI 1.10 to 11.18)). Conclusions: This study has shown a positive association between subclinical onchocerciasis and glaucoma. This finding emphasises the importance of eradication of onchocerciasis from west Africa.

Cost projections for implementation of safety interventions to prevent transfusion-transmitted Zika virus infection in the United States

In August 2016, the Food and Drug Administration advised US blood centers to screen all whole blood and apheresis donations for Zika virus (ZIKV) with an individual‐donor nucleic acid test (ID‐NAT) or to use approved pathogen reduction technology (PRT). The cost of implementing this guidance nationally has not been assessed.