Lisa Saiman

Surgical Site Infection Following Spinal Instrumentation for Scoliosis: A Multicenter Analysis of Rates, Risk Factors, and Pathogens

BACKGROUNDnSurgical site infection following correction of pediatric scoliosis is well described. However, we are aware of no recent multicenter study describing the rates of surgical site infection, and associated pathogens, among patients with different etiologies for scoliosis.nnnMETHODSnA multicenter, retrospective review of surgical site infections among pediatric patients undergoing spinal instrumentation to correct scoliosis was performed at three childrens hospitals in the United States. Study subjects included all patients undergoing posterior spinal instrumentation from January 2006 to December 2008. Surgical site infections were defined according to the Centers for Disease Control and Preventions National Healthcare Safety Network case definition, with infections occurring within one year after surgery.nnnRESULTSnFollowing the analysis of 1347 procedures performed in 946 patients, surgical site infection rates varied among procedures performed in patients with different scoliosis etiologies. Procedures performed in patients with neuromuscular scoliosis had the highest surgical site infection rates (9.2%), followed by those performed in patients with syndromic scoliosis (8.8%), those performed in patients with other scoliosis (8.4%), those performed in patients with congenital scoliosis (3.9%), and those performed in patients with idiopathic scoliosis (2.6%). Surgical site infection rates varied among procedures in patients undergoing primary spinal arthrodesis based on etiology, ranging from 1.2% (95% confidence interval, 0.1% to 1.3%) in patients with idiopathic scoliosis to 13.1% (95% confidence interval, 8.4% to 17.8%) in patients with neuromuscular scoliosis. Surgical site infection rates following primary and revision procedures were similar among patients with different etiologies. In distraction-based growing constructs, rates were significantly lower for lengthening procedures than for revision procedures (p = 0.012). Multivariate analysis demonstrated that non-idiopathic scoliosis and extension of instrumentation to the pelvis were risk factors for surgical site infections. The three most common pathogens were Staphylococcus aureus (25.0% [95% confidence interval, 17.8% to 32.2%]), coagulase-negative staphylococci (17.1% [95% confidence interval, 10.9% to 23.3%]), and Pseudomonas aeruginosa (10.7% [95% confidence interval, 5.6% to 15.8%]). Overall, 46.5% (95% confidence interval, 35.5% to 57.5%) of surgical site infections contained at least one gram-negative organism; 97.0% (95% confidence interval, 90.8% to 100.0%) of these infections were in patients with non-idiopathic scoliosis.nnnCONCLUSIONSnSurgical site infection rates were significantly higher following procedures in patients with non-idiopathic scoliosis (p < 0.001). Lengthening procedures had the lowest rate of surgical site infection among patients with early onset scoliosis who had undergone instrumentation with growing constructs. Gram-negative pathogens were common and were most common following procedures in patients with non-idiopathic scoliosis. These findings suggest a role for targeted perioperative antibiotic prophylaxis to prevent surgical site infection following pediatric scoliosis instrumentation procedures.

Changing Epidemiology of the Respiratory Bacteriology of Patients With Cystic Fibrosis

BACKGROUNDnMonitoring potential changes in the epidemiology of cystic fibrosis (CF) pathogens furthers our understanding of the potential impact of interventions.nnnMETHODSnWe performed a retrospective analysis using data reported to the Cystic Fibrosis Foundation Patient Registry (CFFPR) from 2006 to 2012 to determine the annual percent changes in the prevalence and incidence of selected CF pathogens. Pathogens included Pseudomonas aeruginosa, methicillin-susceptible Staphylococcus aureus (MSSA), methicillin-resistant S aureus (MRSA), Haemophilus influenzae, Burkholderia cepacia complex, Stenotrophomonas maltophilia, and Achromobacter xylosoxidans. Changes in nontuberculous mycobacteria (NTM) prevalence were assessed from 2010 to 2012, when the CFFPR collected NTM species.nnnRESULTSnIn 2012, the pathogens of highest prevalence and incidence were MSSA and P aeruginosa, followed by MRSA. The prevalence of A xylosoxidans and B cepacia complex were relatively low. From 2006 to 2012, the annual percent change in overall (as well as in most age strata) prevalence and incidence significantly decreased for P aeruginosa and B cepacia complex, but significantly increased for MRSA. From 2010 to 2012, the annual percent change in overall prevalence of NTM and Mycobaterium avium complex increased.nnnCONCLUSIONSnThe epidemiology of CF pathogens continues to change. The causes of these observations are most likely multifactorial and include improvements in clinical care and infection prevention and control. Data from this study will be useful to evaluate the impact of new therapies on CF microbiology.

Hospital-Acquired Infections in the NICU: Epidemiology for the New Millennium

Nosocomial infections are an important cause of morbidity and mortality in the preterm neonate. Extrinsic and intrinsic risk factors make the preterm neonate particularly susceptible to infection. This review focuses on two major pathogens that cause nosocomial infection, Candida and methicillin-resistant Staphylococcus aureus. The difficult diagnosis of meningitis in the neonate also is discussed.

The epidemiology of methicillin-susceptible and methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit, 2000―2007

Objective:To assess the epidemiology of methicillin-susceptible Staphylococcus aureus (MSSA) and methicillin-resistant S. aureus (MRSA) infections in a neonatal intensive care unit (NICU).Study Design:A retrospective chart review was conducted from 2000–2007; demographic and clinical characteristics of infected infants and crude mortality were assessed.Results:During the study period, there were 123 infections caused by MSSA and 49 infections caused by MRSA. Although the types of infections caused by MSSA and MRSA were similar, infants with MRSA infections were younger at clinical presentation than infants with MSSA infections (P=0.03). The overall rate of S. aureus infections was approximately 15–30 per 1000 patient-admissions. The rate of bacteremia and skin and soft tissue infections remained stable over time. Among extremely low birth weight infants (birth weight <1000u2009g), 4.8 and 1.8% developed an infection caused by MSSA or MRSA, respectively. Infections occurred in a bimodal distribution of birth weight; 53% of infections occurred in extremely low birth weight infants and 27% occurred among term infants birth weight ⩾2500u2009g, many of whom underwent surgical procedures.Conclusions:MSSA and MRSA remain significant pathogens in the NICU, particularly for extremely premature infants and term infants undergoing surgery. Further work should investigate infection control strategies that effectively target the highest risk groups and determine if vertical transmission of MRSA is responsible for the younger age at presentation of infection.

Cell phone intervention to improve adherence: Cystic fibrosis care team, patient, and parent perspectives

Treatment regimens for patients with cystic fibrosis (CF) are time‐consuming and complex, resulting in consistently low adherence rates. To date, few studies have evaluated innovative technologies to improve adherence in this population. Current infection control guidelines for patients with CF seek to minimize patient‐to‐patient transmission of potential pathogens. Thus, interventions must avoid face‐to‐face contact and be delivered individually, limiting opportunities for peer support. This study aimed to develop and assess a web‐enabled cell phone, CFFONE™, designed to provide CF information and social support to improve adherence in adolescents with CF.

Changes in the Molecular Epidemiological Characteristics of Methicillin‐Resistant Staphylococcus aureus in a Neonatal Intensive Care Unit

OBJECTIVEnTo determine whether the molecular epidemiological characteristics of methicillin-resistant Staphylococcus aureus (MRSA) had changed in a level III neonatal intensive care unit (NICU).nnnDESIGNnRetrospective review of medical records.nnnSETTINGnLevel III NICU of a university-affiliated childrens hospital in New York, New York.nnnPATIENTSnCase patients were neonates hospitalized in the NICU who were colonized or infected with MRSA.nnnMETHODSnRates of colonization and infection with MRSA during the period from 2000 through 2008 were assessed. Staphylococcal chromosomal cassette (SCC) mecA analysis and genotyping for S. aureus encoding protein A (spa) were performed on representative MRSA isolates from each clonal pulsed-field gel electrophoresis pattern.nnnRESULTSnEndemic MRSA infection and colonization occurred throughout the study period, which was punctuated by 4 epidemiologic investigations during outbreak periods. During the study period, 93 neonates were infected and 167 were colonized with MRSA. Surveillance cultures were performed for 1,336 neonates during outbreak investigations, and 115 (8.6%) neonates had MRSA-positive culture results. During 2001-2004, healthcare-associated MRSA clones, carrying SCC mec type II, predominated. From 2005 on, most MRSA clones were community-associated MRSA with SCC mec type IV, and in 2007, USA300 emerged as the principal clone.nnnCONCLUSIONSnMolecular analysis demonstrated a shift from healthcare-associated MRSA (2001-2004) to community-associated MRSA (2005-2008).

Catheter Dwell Time and CLABSIs in Neonates With PICCs: A Multicenter Cohort Study

OBJECTIVE: To determine whether the daily risk of central line–associated bloodstream infections (CLABSIs) increases over the dwell time of peripherally inserted central catheters (PICCs) in high-risk neonates. METHODS: Multicenter retrospective cohort including NICU patients with a PICC inserted between January 2005 and June 2010. We calculated incidence rates and used Poisson regression models to assess the risk of developing CLABSI as a function of PICC dwell time. RESULTS: A total of 4797 PICCs placed in 3967 neonates were included; 149 CLABSIs occurred over 89u2009946 catheter-days (incidence rate 1.66 per 1000 catheter-days). In unadjusted analysis, PICCs with a dwell time of 8 to 13 days, 14 to 22 days, and ≥23 days each had an increased risk of infection compared with PICCs in place for ≤7 days (P < .05). In adjusted analysis, the average predicted daily risk of CLABSIs after PICC insertion increased during the first 2 weeks after PICC insertion and remained elevated for the dwell time of the catheter. There was an increased risk of CLABSIs in neonates with concurrent PICCs (adjusted incidence rate ratio 2.04, 1.12–3.71). The incidence of Gram-negative CLABSIs was greater in PICCs with dwell times >50 days (incidence rate ratio 5.26, 2.40–10.66). CONCLUSIONS: The risk of CLABSIs increased during the 2 weeks after PICC insertion and then remained elevated until PICC removal. Clinicians should review PICC necessity daily, optimize catheter maintenance practices, and investigate novel CLABSI prevention strategies in PICCs with prolonged dwell times.

Antimicrobial resistance among isolates causing invasive pneumococcal disease before and after licensure of heptavalent conjugate pneumococcal vaccine.

Background The impact of the pneumococcal conjugate vaccine (PCV-7) on antibiotic resistance among pneumococcal strains causing invasive pneumococcal disease (IPD) has varied in different locales in the United States. We assessed trends in IPD including trends for IPD caused by penicillin non-susceptible strains before and after licensure of PCV-7 and the impact of the 2008 susceptibility breakpoints for penicillin on the epidemiology of resistance. Methodology/Principal Findings We performed a retrospective review of IPD cases at Morgan Stanley Childrens Hospital of NewYork-Presbyterian, Columbia University Medical Center. Subjects were ≤18 years of age with Streptococcus pneumoniae isolated from sterile body sites from January 1995–December 2006. The rate of IPD from 1995–1999 versus 2002–2006 significantly decreased from 4.1 (CI95 3.4, 4.8) to 1.7 (CI95 1.3, 2.2) per 1,000 admissions. Using the breakpoints in place during the study period, the proportion of penicillin non-susceptible strains increased from 27% to 49% in the pre- vs. post-PCV-7 era, respectively (pu200a=u200a0.001), although the rate of IPD caused by non-susceptible strains did not change from 1995–1999 (1.1 per 1,000 admissions, CI95 0.8, 1.5) when compared with 2002–2006 (0.8 per 1,000 admissions, CI95 0.6, 1.2). In the multivariate logistic regression model controlling for the effects of age, strains causing IPD in the post-PCV-7 era were significantly more likely to be penicillin non-susceptible compared with strains in the pre-PCV-7 era (OR 2.46, CI95 1.37, 4.40). However, using the 2008 breakpoints for penicillin, only 8% of strains were non-susceptible in the post-PCV-7 era. Conclusions/Significance To date, there are few reports that document an increase in the relative proportion of penicillin non-susceptible strains of pneumococci causing IPD following the introduction of PCV-7. Active surveillance of pneumococcal serotypes and antibiotic resistance using the new penicillin breakpoints is imperative to assess potential changes in the epidemiology of IPD.

Implementation and Impact of an Automated Group Monitoring and Feedback System to Promote Hand Hygiene Among Health Care Personnel

BACKGROUNDnDespite substantial evidence to support the effectiveness of hand hygiene for preventing health care-associated infections, hand hygiene practice is often inadequate. Hand hygiene product dispensers that can electronically capture hand hygiene events have the potential to improve hand hygiene performance. A study on an automated group monitoring and feedback system was implemented from January 2012 through March 2013 at a 140-bed community hospital.nnnMETHODSnAn electronic system that monitors the use of sanitizer and soap but does not identify individual health care personnel was used to calculate hand hygiene events per patient-hour for each of eight inpatient units and hand hygiene events per patient-visit for the six outpatient units. Hand hygiene was monitored but feedback was not provided during a six-month baseline period and three-month rollout period. During the rollout, focus groups were conducted to determine preferences for feedback frequency and format. During the six-month intervention period, graphical reports were e-mailed monthly to all managers and administrators, and focus groups were repeated.nnnRESULTSnAfter the feedback began, hand hygiene increased on average by 0.17 events/patient-hour in inpatient units (interquartile range = 0.14, p = .008). In outpatient units, hand hygiene performance did not change significantly. A variety of challenges were encountered, including obtaining accurate census and staffing data, engendering confidence in the system, disseminating information in the reports, and using the data to drive improvement.nnnCONCLUSIONSnFeedback via an automated system was associated with improved hand hygiene performance in the short-term.

Current capabilities and capacity of Ebola treatment centers in the United States

OBJECTIVEnTo describe current Ebola treatment center (ETC) locations, their capacity to care for Ebola virus disease patients, and infection control infrastructure features.nnnDESIGNnA 19-question survey was distributed electronically in April 2015. Responses were collected via email by June 2015 and analyzed in an electronic spreadsheet.nnnSETTINGnThe survey was sent to and completed by site representatives of each ETC.nnnPARTICIPANTSnThe survey was sent to all 55 ETCs; 47 (85%) responded.nnnRESULTSnOf the 47 responding ETCs, there are 84 isolation beds available for adults and 91 for children; of these pediatric beds, 35 (38%) are in childrens hospitals. In total, the simultaneous capacity of the 47 reporting ETCs is 121 beds. On the basis of the current US census, there are 0.38 beds per million population. Most ETCs have negative pressure isolation rooms, anterooms, and a process for category A waste sterilization, although only 11 facilities (23%) have the capability to sterilize infectious waste on site.nnnCONCLUSIONSnFacilities developed ETCs on the basis of Centers for Disease Control and Prevention guidance, but specific capabilities are not mandated at this present time. Owing to the complex and costly nature of Ebola virus disease treatment and variability in capabilities from facility to facility, in conjunction with the lack of regulations, nationwide capacity in specialized facilities is limited. Further assessments should determine whether ETCs can adapt to safely manage other highly infectious disease threats.