Linda Greene

Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their surgical site infection (SSI) prevention efforts. This document updates “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals,” published in 2008. 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.

Developing a new, national approach to surveillance for ventilator-associated events*.

Objective:To develop and implement an objective, reliable approach to surveillance for ventilator-associated events in adult patients. Design:The Centers for Disease Control and Prevention (CDC) convened a Ventilator-Associated Pneumonia (VAP) Surveillance Definition Working Group in September 2011. Working Group members included representatives of stakeholder societies and organizations and federal partners. Main results:The Working Group finalized a three-tier, adult surveillance definition algorithm for ventilator-associated events. The algorithm uses objective, readily available data elements and can identify a broad range of conditions and complications occurring in mechanically ventilated adult patients, including but not limited to VAP. The first tier definition, ventilator-associated condition (VAC), identifies patients with a period of sustained respiratory deterioration following a sustained period of stability or improvement on the ventilator, defined by changes in the daily minimum fraction of inspired oxygen or positive end-expiratory pressure. The second tier definition, infection-related ventilator-associated complication (IVAC), requires that patients with VAC also have an abnormal temperature or white blood cell count, and be started on a new antimicrobial agent. The third tier definitions, possible and probable VAP, require that patients with IVAC also have laboratory and/or microbiological evidence of respiratory infection. Conclusions:Ventilator-associated events surveillance was implemented in January 2013 in the CDC’s National Healthcare Safety Network. Modifications to improve surveillance may be made as additional data become available and users gain experience with the new definitions.

Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates “Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals,” published in 2008. 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.

Reappraisal of Routine Oral Care With Chlorhexidine Gluconate for Patients Receiving Mechanical Ventilation: Systematic Review and Meta-Analysis

IMPORTANCE Regular oral care with chlorhexidine gluconate is standard of care for patients receiving mechanical ventilation in most hospitals. This policy is predicated on meta-analyses suggesting decreased risk of ventilator-associated pneumonia, but these meta-analyses may be misleading because of lack of distinction between cardiac surgery and non-cardiac surgery studies, conflation of open-label vs double-blind investigations, and insufficient emphasis on patient-centered outcomes such as duration of mechanical ventilation, length of stay, and mortality. OBJECTIVE To evaluate the impact of routine oral care with chlorhexidine on patient-centered outcomes in patients receiving mechanical ventilation. DATA SOURCES PubMed, Embase, CINAHL, and Web of Science from inception until July 2013 without limits on date or language. STUDY SELECTION Randomized clinical trials comparing chlorhexidine vs placebo in adults receiving mechanical ventilation. Of 171 unique citations, 16 studies including 3630 patients met inclusion criteria. DATA EXTRACTION AND SYNTHESIS Eligible trials were independently identified, evaluated for risk of bias, and extracted by 2 investigators. Differences were resolved by consensus. We stratified studies into cardiac surgery vs non-cardiac surgery and open-label vs double-blind investigations. Eligible studies were pooled using random-effects meta-analysis. MAIN OUTCOMES AND MEASURES Ventilator-associated pneumonia, mortality, duration of mechanical ventilation, intensive care unit and hospital length of stay, antibiotic prescribing. RESULTS There were fewer lower respiratory tract infections in cardiac surgery patients randomized to chlorhexidine (relative risk [RR], 0.56 [95% CI, 0.41-0.77]) but no significant difference in ventilator-associated pneumonia risk in double-blind studies of non-cardiac surgery patients (RR, 0.88 [95% CI, 0.66-1.16]). There was no significant mortality difference between chlorhexidine and placebo in cardiac surgery studies (RR, 0.88 [95% CI, 0.25-2.14]) and nonsignificantly increased mortality in non-cardiac surgery studies (RR, 1.13 [95% CI, 0.99-1.29]). There were no significant differences in mean duration of mechanical ventilation or intensive care length of stay. Data on hospital length of stay and antibiotic prescribing were limited. CONCLUSIONS AND RELEVANCE Routine oral care with chlorhexidine prevents nosocomial pneumonia in cardiac surgery patients but may not decrease ventilator-associated pneumonia risk in non-cardiac surgery patients. Chlorhexidine use does not affect patient-centered outcomes in either population. Policies encouraging routine oral care with chlorhexidine for non-cardiac surgery patients merit reevaluation.

Sustained reduction in methicillin-resistant Staphylococcus aureus wound infections after cardiothoracic surgery.

BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) wound infections after cardiac surgery have increased in recent years and carry significant morbidity and mortality. In our hospital, MRSA accounted for 56% of postoperative infections. METHODS Postoperative wound infection rates were compared for the 3 years before (baseline period) and after (intervention period) introduction of a comprehensive MRSA intervention program. The intervention included preoperative screening for MRSA colonization, administration of intravenous vancomycin prophylaxis for identified carriers, administration of intranasal mupirocin calcium ointment to all patients regardless of colonization status for 5 days beginning the day before surgery, and application of mupirocin to chest tube sites at the time of removal. RESULTS Postoperative MRSA wound infections decreased by 93% (32 infections per 2767 cases in the baseline period vs 2 infections per 2496 cases in the intervention period; relative risk, 0.069; P < .001). Overall wound infection rates decreased from 2.1% to 0.8% (59 infections per 2769 cases vs 20 infections per 2496 cases; P < .001). During the intervention period, there was no change in the number of MRSA infections after noncardiac surgery. CONCLUSION This MRSA intervention program, in which all patients receive intranasal mupirocin and patients colonized with MRSA receive vancomycin prophylaxis, has resulted in a near-complete and sustained elimination of MRSA wound infections after cardiac surgery.

Preventing catheter-associated urinary tract infections: An executive summary of the Association for Professionals in Infection Control and Epidemiology, Inc, Elimination Guide

The Association for Professionals in Infection Control and Epidemiology (APIC) began publishing their series of Elimination Guides in 2007. Since then, 9 Elimination Guides have been developed that cover a range of important infection prevention issues, including the prevention of catheter-related bloodstream infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections (CAUTIs), as well as mediastinitis surgical site surveillance. Multidrug-resistant organisms, including methicillin-resistant Staphylococcus aureus, Clostridium difficile, and multidrug-resistant Acinetobacter baumannii, also have been the focus of APIC Elimination Guides. The content of each of these Elimination Guides will be summarized in a series of upcoming Brief Reports published in The Journal. This article provides an executive summary of the APIC Elimination Guide for CAUTIs. Infection preventionists are encouraged to obtain the original, full-length APIC Elimination Guide for more thorough coverage of CAUTI prevention.

Guide to the elimination of orthopedic surgery surgical site infections: An executive summary of the Association for Professionals in Infection Control and Epidemiology elimination guide

This article is an executive summary of the APIC Guide to the Elimination of Orthopedic Surgical Site Infections. Infection preventionists, care providers, and perioperative personnel are encouraged to obtain the original, full length APIC Elimination Guide for more thorough coverage on strategies to prevent surgical site infections in orthopedic surgery.

Developing a new, national approach to surveillance for ventilator-associated events: Executive summary

Shelley S Magill MD PhD, Michael Klompas MD MPH, Robert Balk MD, Suzanne M Burns RN ACNP MSN RRT, Clifford S Deutschman MS MD, Daniel Diekema MD, Scott Fridkin MD, Linda Greene RN MPS, Alice Guh MD MPH, David Gutterman MD, Beth Hammer RN MSN ANP-BC, David Henderson MD, Dean R Hess PhD RRT, Nicholas S Hill MD, Teresa Horan MPH, Marin Kollef MD, Mitchell Levy MD, Edward Septimus MD, Carole VanAntwerpen RN BSN, Don Wright MD MPH, and Pamela Lipsett MD MHPE

Preventing ventilator-associated pneumonia: An executive summary of the Association for Professionals in Infection Control and Epidemiology, Inc, Elimination Guide

This article is an executive summary of the Association for Professionals in Infection Control and Epidemiology, Inc, Elimination Guide for ventilator-associated pneumonia. Infection preventionists are encouraged to obtain the original, full-length Association for Professionals in Infection Control and Epidemiology, Inc, Elimination Guide for more thorough coverage of ventilator-associated pneumonia prevention.

Developing a new, national approach to surveillance for ventilator-associated events: executive summary.

This article is an executive summary of a report from the Centers for Disease Control and Prevention Ventilator-Associated Pneumonia Surveillance Definition Working Group, entitled “Developing a new, national approach to surveillance for ventilator-associated events” and published in Critical Care Medicine . The full report provides a comprehensive description of the Working Group process and outcome. In September 2011, the Centers for Disease Control and Prevention (CDC) convened a Ventilator-Associated Pneumonia (VAP) Surveillance Definition Working Group to organize a formal process for leaders and experts of key stakeholder organizations to discuss the challenges of VAP surveillance definitions and to propose new approaches to VAP surveillance in adult patients (Table 1).