Lisa Sturm

Measurement of Foot Traffic in the Operating Room: Implications for Infection Control

Surgical site infections cause significant morbidity and mortality in the postoperative period. Opening of the operating room door disrupts its filtered atmosphere, increasing contamination above the wound. We conducted a study of traffic in the operating room as a risk for infections. This is an observational study of recorded behaviors in the operating room. Data collected included number of people entering/exiting, the role of these individuals, and the cause for the event. A total of 3071 door openings were recorded in 28 cases. Traffic varied from 19 to 50 events per hour across specialties. The preincision period represented 30% to 50% of all events. Information requests accounted for the majority of events. Door openings increase in direct proportion to case length, but have an exponential relationship with the number of persons in the operating room. There is a high rate of traffic across all specialties, compromising the sterile environment of the operating room. (Am J Med Qual. 2009;24:45-52)

Does bronchoalveolar lavage enhance our ability to treat ventilator-associated pneumonia in a trauma-burn intensive care unit?

BACKGROUND Recent literature supports the notion that bronchoalveolar lavage (BAL) in ventilated trauma patients may improve our ability to diagnose and treat ventilator-associated pneumonia (VAP). We hypothesized that BAL would decrease the number of cases of VAP diagnosed and impact our antibiotic use and ventilator days. METHODS Prospective data on all infectious complications were collected for patients admitted to the trauma-burn service for the year 2001. All VAPs between January 1, 2001, through June 30, 2001, were diagnosed without BAL (No BAL group) using clinical signs of fever, sputum production, leukocytosis, chest radiographs, and sputum culture. After July 1, 2001, VAP was diagnosed with the use of BAL. RESULTS There were 37 cases of VAP in the No BAL group (11%) and 29 cases of VAP (8%) in the BAL group. There were no statistical differences in Injury Severity Score, hospital length of stay, ventilator days, or mortality between the two groups. The time to initial treatment of VAP was shorter for the BAL group, but did not reach significance. The number of patients who had their VAP pathogens correctly treated with empiric antibiotics was also the same between the two groups. There was no difference in the rate of recurrent pneumonias. The antibiotic costs and respiratory therapy/ventilator costs were not statistically different between the groups for trauma patients, although antibiotic costs were higher for burn patients. CONCLUSION The routine use of BAL to diagnose VAP in our mixed trauma-burn population did not impact on clinical outcomes or antibiotic use. Our results do not justify the additional costs and potential risks of BAL for all patients. The means of VAP diagnosis may not be as important as choosing the appropriate antibiotics for common VAP organisms in any given intensive care unit.

Definitional Change in NHSN CAUTI Was Associated with an Increase in CLABSI Events: Evaluation of a Large Health System

BACKGROUND The National Healthcare Safety Network (NHSN) catheter-associated urinary tract infection (CAUTI) definition was revised as of January 2015 to exclude funguria and lower bacteriuria levels. We evaluated the effect of the CAUTI definition change on NHSN-defined central-line-associated bloodstream infection (CLABSI) outcomes. METHODS We compared CAUTI and CLABSI NHSN-defined outcomes for calendar years 2014 and 2015 in the adult intensive care units (ICUs) of a single large health system. Changes in the event rates, the associated organisms, and the standardized infection ratio (SIR) were evaluated. RESULTS The study included 137 adult ICUs from 65 hospitals. The CAUTI SIR dropped from 1.04 in 2014 to 0.58 in 2015 (-44.2%), while the CLABSI SIR increased from 0.36 in 2014 to 0.47 in 2015 (+30.6%). CAUTI rates dropped 44.8% from 2.09 to 1.15 events per 1,000 device days (P<.001). Gram-positive-associated CAUTI rates dropped 36.7% from 0.34 to 0.22 per 1,000 device days (P=.007). CLABSI rates increased 27.1% from 0.71 to 0.90 per 1,000 device days (P=.027). Candida-associated CLABSI increased by 91.1% from 0.104 to 0.198 per 1,000 device days (P=.012), and Enterococcus-associated CLABSI increased by 121.6% from 0.071 to 0.16 per 1,000 device days (P=.008). CONCLUSIONS The revised CAUTI definition led to a large reduction in CAUTI rates and, in turn, an increase in candidemia and enterococcemia cases classified as CLABSI events. These findings have important implications on the perceived successes or failures to eliminate both infections. Infect Control Hosp Epidemiol 2017;38:685-689.

Implementation of Weight-Based Antimicrobial Dosing for Surgical Site Infection Prophylaxis

Surgical site infections (SSIs) increase morbidity, mortality, and health care costs. Morbid obesity has been identified as an independent risk factor; it has been demonstrated that higher doses of antimicrobials are warranted to achieve adequate tissue concentrations. In 2008, the University of Michigan Health System (UMHS) implemented weight-based dosing such that patients with a documented weight of ≥80 kg would receive a larger initial dose of antibiotic for surgical prophylaxis. This process included a pharmacy dose optimization program provided by an operating room pharmacy where pharmacists could automatically increase the dose based on weight if the initial order was noncompliant with institutional guidelines. The objectives of the study were to assess rates of compliance with the guidelines prior to and after implementation. This study was a retrospective evaluation of SSI prophylaxis dosing in obese patients prior to (April through June 2008) and after (September through November 2008) implementation of a dose optimization program. After implementation, there was a 29.7% increase in weight-based antibiotic surgical prophylaxis; pharmacy intervention accounted for 15% of the change. The implementation of a dose optimization program could prove to be cost-effective by ensuring patients receive the correct weight-based antibiotic and by perhaps reducing the incidence of SSIs.

Hospital-Onset Staphylococcus aureus Bacteremia Is A Better Measure Than MRSA Bacteremia for Assessing Infection Prevention: Evaluation of 50 US Hospitals

Of 500 hospital-onset Staphylococcus aureus bacteremia events (58% methicillin-susceptible S. aureus [MSSA]; 42% methicillin-resistant S. aureus [MRSA]), we found no significant differences in S. aureus bacteremia rates between medium-sized and large hospitals. However, the proportion of S. aureus bacteremia caused by MSSA was greater in medium-sized hospitals and did not correlate with MRSA bacteremia. Infect Control Hosp Epidemiol 2018;39:476-478.

Introducing Hospital Onset Bloodstream Infection (HOBSI) as a Tool to Evaluate Infection Prevention: Assessment of 51 US Hospitals

Abstract Background Currently, publicly reported infections include a few types of events, and do not provide a comprehensive picture on overall infection prevention practices. Hospital onset bloodstream infection (HOBSI), regardless of source, reflects invasive infection from an at risk patient population in inpatient healthcare settings. Methods Using one infection prevention surveillance system, we identified all positives blood cultures for 5 organisms commonly associated with healthcare infections (Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Candida species) over the 12 months of 2016, across 51 acute care hospitals. Each HOBSI was counted once per patient and was classified based on the NHSN definition. Validation was performed comparing individual site laboratory microbiology data to the surveillance system report. Results A total of 1,053 HOBSI events occurred over 2,797,568 patient-days at an aggregate rate of 3.76 per 10,000 patient-days. Small (<100 beds) hospitals had very low event rates. There were significant differences between medium (100–300 beds) size and large (>300 beds) hospitals, specifically candidemia and Gram-negative bacteremia (table). S. Aureus and Candida species represented 57% of all HOBSIs. Facility and system events were trended monthly over time based on individual and all organisms combined and provided an objective assessment of invasive infections over time (figure). Conclusion Automated reporting of HOBSI for common organisms associated with invasive disease provides an objective method to evaluate infection prevention in medium and large hospitals and potentially benchmarking based on hospital characteristics in the future. Disclosures All authors: No reported disclosures.