Linda Graviss

Risk factors for infections with multidrug‐resistant Pseudomonas aeruginosa in patients with cancer

Pseudomonas aeruginosa is responsible for a wide range of infections. In immunocompromised patients with cancer, the emergence of multidrug resistant P. aeruginosa may have grave consequences.

Clinical experience with minocycline and rifampin-impregnated central venous catheters in bone marrow transplantation recipients: efficacy and low risk of developing staphylococcal resistance.

In this retrospective evaluation of the 4-year clinical use of minocycline and rifampin-impregnated catheters in bone marrow transplantation (BMT) patients, we report low risk of development of staphylococcal resistance to the antibiotics coating the catheters and efficacy in preventing primary staphylococcal bloodstream infections.

Impact of Surveillance for Vancomycin-Resistant Enterococci on Controlling a Bloodstream Outbreak among Patients with Hematologic Malignancy

OBJECTIVE To determine the impact of stool surveillance cultures of critically ill patients on controlling vancomycin-resistant enterococci (VRE) outbreak bacteremia. DESIGN Stool surveillance cultures were performed on patients who had hematologic malignancy or were critically ill at the time of hospital admission to identify those colonized with VRE. Hence, contact isolation was initiated. SETTING A tertiary-care cancer center with a high prevalence of VRE. PARTICIPANTS All patients with hematologic malignancy who were admitted to the hospital as well as all of those admitted to the intensive care unit were eligible. RESULTS Active stool surveillance cultures performed between 1997 and 2001 decreased the incidence density of VRE bacteremias eightfold while vancomycin use remained constant. In fiscal year (FY) 1997 and FY 1998, there were five and three VRE outbreak bacteremias, respectively. The outbreak clones were responsible for infection in 69% of those patients with VRE bacteremia. However, the stool surveillance program resulted in the complete control of VRE bacteremia by FY 1999 until the end of the study. CONCLUSION Despite the steady use of vancomycin, the active surveillance program among high-risk patients with hematologic malignancy and those who were critically ill resulted in the complete control of VRE outbreak bacteremia at our institution.

Association of increased influenza vaccination in health care workers with a reduction in nosocomial influenza infections in cancer patients

BACKGROUND Vaccination of health care workers (HCWs) remains a key strategy to reduce the burden of influenza infections in cancer patients. METHODS In this 8-year study, we evaluated the effect of a multifaceted approach, including a mandatory influenza vaccination program, on HCW vaccination rates and its effect on nosocomial influenza infections in cancer patients. RESULTS The influenza vaccination rate of all employees significantly increased from 56% (8,762/15,693) in 2006-2007 to 94% (17,927/19,114) in 2013-2014 (P < .0001). The 2009 mandatory participation program increased HCW vaccination rates in the targeted groups (P < .0001), and the addition of an institutional policy in 2012 requiring influenza vaccination or surgical mask use with each patient contact further increased vaccination rates by 10%-18% for all groups in 1 year. The proportion of nosocomial influenza infections significantly decreased (P = .045) during the study period and was significantly associated with increased HCW vaccination rates in the nursing staff (P = .043) and in personnel working in high-risk areas (P = .0497). CONCLUSIONS Multifaceted influenza vaccination programs supported by institutional policy effectively increased HCW vaccination rates. Increased HCW vaccination rates were associated with a reduction in the proportion of nosocomial influenza infections in immunocompromised cancer patients.

Healthcare-associated outbreaks due to Mucorales and other uncommon fungi

Healthcare‐associated outbreaks of fungal infections, especially with uncommon and emerging fungi, have become more frequent in the past decade.

The role of interventional molecular epidemiology in controlling clonal clusters of multidrug resistant Pseudomonas aeruginosa in critically ill cancer patients.

BACKGROUND Pseudomonas aeruginosa is one of the leading causes of hospital-acquired infections in intensive care units (ICUs). The objective was to evaluate the impact of molecular identification of clonal multidrug-resistant (MDR) P aeruginosa strains and the implementation of infection control measures. METHODS One hundred seventy-seven strains from ICU patients infected or colonized with MDR P aeruginosa from May 2001 to April 2006 were collected. In vitro susceptibility to 16 antibiotics was done. Pulsed-field gel electrophoresis was performed to identify clonal strains. Nosocomial outbreak was defined as the presence of > or =3 MDR P aeruginosa over < or =3 consecutive months. RESULTS During the 5 years of the study, 25 infected and 14 colonized patients with a clonal strain of MDR P aeruginosa were distributed among 5 episodic clusters. These strains were only susceptible to ceftazidime and colistin. Molecular biology identification, diligent monitoring, and multidisciplinary infection control interventions were implemented to suppress this clonal strain after each cluster. Even more, after the last outbreak (June-August 2005), the infection control measures were able to reduce the MDR P aeruginosa to zero during the last 8 months of this study. CONCLUSION Interventional molecular epidemiology combined with early identification, monitoring, and implementation of multidisciplinary infection control measures can control temporarily the transmission of MDR P aeruginosa infection in ICUs.

The role of molecular methods in the prevention of nosocomial methicillin-resistant Staphylococcus aureus clusters in cancer patients

In 2002, an increased incidence of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) in our institution triggered a conventional investigation that failed to identify a common source. Molecular typing of the 70 nosocomial MRSA isolates obtained identified a predominant health care-associated clone A in the first trimester. Aggressive infection control measures led to a significant decrease in the number of isolates per 10,000 hospital days between the first trimester and the last 2 trimesters of 2003 (6.4 vs 3.8; P = .04). This was attributed to a decrease in clone A: SCCmec II, USA100, PVL gene-negative (2.3 per 10.000 patient-days vs 0.1 per 10,000 patient-days; P = .004). However, in 2003, 23% of the nosocomial isolates were SCCmec IV, USA300, PVL gene-positive. At that time, molecular methods allowed the detection and prevention of a nosocomial MRSA outbreak caused by a health care-associated clone; however, the community strains (SCCmec IV) have become a frequent cause of nosocomial infection in our institution.

What Is the Real Rate of Surgical Site Infection

PURPOSE Surgical site infections (SSIs) are associated with patient morbidity and increased health care costs. Although several national organizations including the University HealthSystem Consortium (UHC), the National Surgical Quality Improvement Program (NSQIP), and the National Healthcare Safety Network (NHSN) monitor SSI, there is no standard reporting methodology. METHODS We queried the UHC, NSQIP, and NHSN databases from July 2012 to June 2014 for SSI after gynecologic surgery at our institution. Each organization uses different definitions and inclusion and exclusion criteria for SSI. The rate of SSI was also obtained from chart review from April 1 to June 30, 2014. SSI was classified as superficial, deep, or organ space infection. The rates reported by the agencies were compared with the rates obtained by chart review using Fishers exact test. RESULTS Overall SSI rates for the databases were as follows: UHC, 1.5%; NSQIP, 8.8%; and NHSN, 2.8% (P < .001). The individual databases had wide variation in the rate of deep infection (UHC, 0.7%; NSQIP, 4.7%; NHSN, 1.3%; P < .001) and organ space infection (UHC, 0.4%; NSQIP, 4.4%; NHSN, 1.4%; P < .001). In agreement with the variation in reporting methodology, only 19 cases (24.4%) were included in more than one database and only one case was included in all three databases (1.3%). CONCLUSION There is discordance among national reporting agencies tracking SSI. Adopting standardized metrics across agencies could improve consistency and accuracy in assessing SSI rates.

Unit-Based Staff Hand Hygiene (HH) Monitors To Improve Compliance in a Comprehensive Cancer Center

ISSUE: Both the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) patient safety goal and the Centers for Disease Control and Preventions (CDC) guidelines recommend monitoring of hand hygiene adherence and providing feedback to patient care staff. In order to advance patient safety and HH compliance, a three-pronged approach was implemented to enhance HH education, observation and measurement of HH compliance. PROJECT: Three components were implemented to improve compliance with HH practices: Education Component (Phase I) Development and implementation of a mandatory computer-based learning module on hand hygiene for all patient care staff that included HHs “Top Ten List” based on CDCs Guideline for Hand Hygiene in Health-Care Settings, 2002 Focused and targeted educational program for fellows, residents and mid-level providers including staff in invasive procedural areas Special educational HH program in Spanish for spanish-speaking staff Training of unit-based HH observers (100) using the Train-the-Trainer model Focus on HH compliance during Patient Safety Week Campaign in March 2005 Evaluation Component (Phase II) Three HH observational periods for assessment of HH compliance by trained HH monitors and infection control practitioners in all patient care areas Monthly self-assessment in patient care area units and diagnostic areas Communication and Feedback of Results Component (Phase III) Communication to staff, managers and administration regarding HH violations and compliance rates Prompt follow-up with re-education in patient care areas where HH violations rates were lower than expected. RESULTS: In Phase I, 100% of patient care staff complied with HH computer-based training. A total of 100 unit-based HH observers were trained using the Train-the-Trainer approach with education on HH basics, use of HH tool and feedback to colleagues and peers. In Phases II and III, observational periods with assessment of HH compliance were implemented by the trained HH observer of each clinical area. Data from observation periods, demonstrated an incremental improvement in HH practices with an initial baseline of 79% and an average of 91% in subsequent periods. LESSONS LEARNED: A coordinated systems approach that includes patient care staff, physicians, committees and administration is essential when initiating a process change. Providing education and feedback to staff and physicians will improve compliance. Identification of areas where additional education and feedback on HH is required and will also improve compliance.

What is the real rate of surgical-site infection?

171 Background: Surgical site infections (SSI) are associated with patient morbidity and increased healthcare costs. Although several national organizations monitor SSI including the University Health System Consortium (UHC), National Surgical Quality Improvement Program (NSQIP), National Healthcare Safety Network (NHSN) and Agency for Healthcare Research and Quality (AHRQ), there is no standard reporting methodology. We compared SSI rates from these databases to our own chart review. METHODS We queried the UHC, NSQIP, NHSN and AHRQ databases from 7/2012-6/2014 for SSI following gynecologic surgery at our institution. UHC and AHRQ rely on ICD-9 coding while NSQIP and NHSN employ trained reviewers. Each organization uses different definitions, inclusion and exclusion criteria for SSI. NSQIP reviews 13-17% of cases at our institution while the other agencies include all cases. The rate of SSI was also obtained from chart review for 5/1/2014-6/30/2014 with SSI defined as an infection of the surgical incision or organ space requiring antibiotics. SSI was classified as superficial, deep or organ space (OS). The rates reported by the agencies were compared to the rate obtained by chart review using Fishers exact test. RESULTS The combined UHC/NSQIP/NHSN/AHRQ SSI rate was 5.1% (78/1,540) while the rate found by chart review was 12% (20/166) (p = 0.001). Overall SSI rates for the databases were: UHC 1.6%, NSQIP 8.8%, NHSN 2.9% and AHRQ < 1%. The combined database reported fewer superficial SSI compared to investigator chart review but did not differ significantly when reporting deep and OS: superficial 1.6% v 7.8% (p < 0.001), deep 2.1% v 1.2% (p = 0.57) and OS 2.9% v 3.6% (p = 0.26). The individual databases had wide variation in rate of superficial (UHC 0.7% NSQIP 1.2% NHSN 0.5% AHRQ 0%), deep (UHC 0.7% NSQIP 4.7% NHSN 1.3% AHRQ 0%) and OSI (UHC 0.03% NSQIP 4.4% NHSN 1.4% AHRQ < 1%). Only 19 cases (24.4%) were included in > 1 database. Only one case was included in three databases (1.3%) and no cases were included in all four. CONCLUSIONS There is discordance among national reporting agencies tracking SSI and all agencies reported a different rate of SSI compared to chart review. Adopting standardized metrics across agencies could improve consistency and accuracy in assessing SSI rates.