Victor O. Popoola

Methicillin-Resistant Staphylococcus aureus Transmission and Infections in a Neonatal Intensive Care Unit despite Active Surveillance Cultures and Decolonization: Challenges for Infection Prevention

OBJECTIVE To characterize the epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) transmission and infections in a level IIIC neonatal intensive care unit (NICU) and identify barriers to MRSA control. SETTING AND DESIGN Retrospective cohort study in a university-affiliated NICU with an MRSA control program including weekly nares cultures of all neonates and admission nares cultures for neonates transferred from other hospitals or admitted from home. METHODS Medical records were reviewed to identify neonates with NICU-acquired MRSA colonization or infection between April 2007 and December 2011. Compliance with hand hygiene and an MRSA decolonization protocol were monitored. Relatedness of MRSA strains were assessed using pulsed-field gel electrophoresis (PFGE). RESULTS Of 3,536 neonates, 74 (2.0%) had a culture grow MRSA, including 62 neonates with NICU-acquired MRSA. Nineteen of 74 neonates (26%) had an MRSA infection, including 8 who became infected before they were identified as MRSA colonized, and 11 of 66 colonized neonates (17%) developed a subsequent infection. Of the 37 neonates that underwent decolonization, 6 (16%) developed a subsequent infection, and 7 of 14 (50%) that remained in the NICU for 21 days or more became recolonized with MRSA. Using PFGE, there were 14 different strain types identified, with USA300 being the most common (31%). CONCLUSIONS Current strategies to prevent infections-including active identification and decolonization of MRSA-colonized neonates-are inadequate because infants develop infections before being identified as colonized or after attempted decolonization. Future prevention efforts would benefit from improving detection of MRSA colonization, optimizing decolonization regimens, and identifying and interrupting reservoirs of transmission.

Impact of Colonization Pressure and Strain Type on Methicillin-Resistant Staphylococcus aureus Transmission in Children

We studied the transmissibility of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) and healthcare-associated methicillin-resistant S. aureus (HA-MRSA) strains and the association of MRSA colonization pressure and MRSA transmission in critically ill children. Importantly, we found that in hospitalized children MRSA colonization pressure above 10% increases the risk of MRSA transmission 3-fold, and CA-MRSA and HA-MRSA strains have similar transmission dynamics.

Active Surveillance Cultures and Decolonization to Reduce Staphylococcus aureus Infections in the Neonatal Intensive Care Unit

BACKGROUND Staphylococcus aureus is a common cause of healthcare-associated infections in neonates. OBJECTIVE To examine the impact of methicillin-susceptible S. aureus (MSSA) decolonization on the incidence of MSSA infection and to measure the prevalence of mupirocin resistance. METHODS We retrospectively identified neonates admitted to a tertiary care neonatal intensive care unit (NICU) from April 1, 2011, through September 30, 2014. We compared rates of MSSA-positive cultures and infections before and after implementation of an active surveillance culture and decolonization intervention for MSSA-colonized neonates. We used 2 measurements to identify the primary outcome, NICU-attributable MSSA: (1) any culture sent during routine clinical care that grew MSSA and (2) any culture that grew MSSA and met criteria of the National Healthcare Safety Networks healthcare-associated infection surveillance definitions. S. aureus isolates were tested for mupirocin susceptibility. We estimated incidence rate ratios using interrupted time-series models. RESULTS Before and after the intervention, 1,523 neonates (29,220 patient-days) and 1,195 neonates (22,045 patient-days) were admitted to the NICU, respectively. There was an immediate reduction in the mean quarterly incidence rate of NICU-attributable MSSA-positive clinical cultures of 64% (incidence rate ratio, 0.36 [95% CI, 0.19-0.70]) after implementation of the intervention, and MSSA-positive culture rates continued to decrease by 21% per quarter (incidence rate ratio, 0.79 [95% CI, 0.74-0.84]). MSSA infections also decreased by 73% immediately following the intervention implementation (incidence rate ratio, 0.27 [95% CI, 0.10-0.79]). No mupirocin resistance was detected. CONCLUSION Active surveillance cultures and decolonization may be effective in decreasing S. aureus infections in NICUs.

Patient Preferences for Receiving Education on Venous Thromboembolism Prevention – A Survey of Stakeholder Organizations

Importance Venous thromboembolism (VTE) is a major cause of morbidity and mortality among hospitalized patients and is largely preventable. Strategies to decrease the burden of VTE have focused on improving clinicians’ prescribing of prophylaxis with relatively less emphasis on patient education. Objective To develop a patient-centered approach to education of patients and their families on VTE: including importance, risk factors, and benefit/harm of VTE prophylaxis in hospital settings. Design, Setting and Participants The objective of this study was to develop a patient-centered approach to education of patients and their families on VTE: including importance, risk factors, and benefit/harm of VTE prophylaxis in hospital settings. We implemented a three-phase, web-based survey (SurveyMonkey) between March 2014 and September 2014 and analyzed survey data using descriptive statistics. Four hundred twenty one members of several national stakeholder organizations and a single local patient and family advisory board were invited to participate via email. We assessed participants’ preferences for VTE education topics and methods of delivery. Participants wanted to learn about VTE symptoms, risk factors, prevention, and complications in a context that emphasized harm. Although participants were willing to learn using a variety of methods, most preferred to receive education in the context of a doctor-patient encounter. The next most common preferences were for video and paper educational materials. Conclusions Patients want to learn about the harm associated with VTE through a variety of methods. Efforts to improve VTE prophylaxis and decrease preventable harm from VTE should target the entire continuum of care and a variety of stakeholders including patients and their families.

The Johns Hopkins Venous Thromboembolism Collaborative: Multidisciplinary team approach to achieve perfect prophylaxis.

Venous thromboembolism (VTE) is an important cause of preventable harm in hospitalized patients. The critical steps in delivery of optimal VTE prevention care include (1) assessment of VTE and bleeding risk for each patient, (2) prescription of risk-appropriate VTE prophylaxis, (3) administration of risk-appropriate VTE prophylaxis in a patient-centered manner, and (4) continuously monitoring outcomes to identify new opportunities for learning and performance improvement. To ensure that every hospitalized patient receives VTE prophylaxis consistent with their individual risk level and personal care preferences, we organized a multidisciplinary task force, the Johns Hopkins VTE Collaborative. To achieve the goal of perfect prophylaxis for every patient, we developed evidence-based, specialty-specific computerized clinical decision support VTE prophylaxis order sets that assist providers in ordering risk-appropriate VTE prevention. We developed novel strategies to improve provider VTE prevention ordering practices including face-to-face performance reviews, pay for performance, and provider VTE scorecards. When we discovered that prescription of risk-appropriate VTE prophylaxis does not ensure its administration, our multidisciplinary research team conducted in-depth surveys of patients, nurses, and physicians to design a multidisciplinary patient-centered educational intervention to eliminate missed doses of pharmacologic VTE prophylaxis that has been funded by the Patient Centered Outcomes Research Institute. We expect that the studies currently underway will bring us closer to the goal of perfect VTE prevention care for every patient. Our learning journey to eliminate harm from VTE can be applied to other types of harm. Journal of Hospital Medicine 2016;11:S8-S14.

Peripherally Inserted Central Venous Catheter Complications in Children Receiving Outpatient Parenteral Antibiotic Therapy (OPAT).

OBJECTIVE To identify the frequency of and risk factors associated with complications necessitating removal of the peripherally inserted central catheters (PICCs) in patients receiving outpatient parenteral antibiotic therapy (OPAT) and to determine the appropriateness of OPAT in children with OPAT-related complications. METHODS A retrospective cohort of children who had a PICC inserted at the Johns Hopkins Childrens Center between January 1, 2003, and December 31, 2013, and were discharged from the hospital on OPAT was assembled. RESULTS A total of 1,465 PICCs were used to provide antibiotic therapy for 955 children after hospital discharge. Among these, 117 PICCs (8%) required removal due to a complication (4.6 of 1,000 catheter days). Children discharged to a long-term care facility were at increased risk of adverse PICC events (incidence risk ratio [IRR], 3.32; 95% confidence interval [CI], 1.79-6.17). For children receiving OPAT, age of the child (adjusted IRR [aIRR], 0.95; 95% CI, 0.92-0.98), noncentral PICC tip location (aIRR, 2.82; 95% CI, 1.66-4.82), and public insurance (aIRR, 1.63; 95% CI, 1.10-2.40) were associated with adverse PICC events. In addition, 34 patients (32%) with adverse events may not have required intravenous antibiotics at the time of hospital discharge. CONCLUSIONS Of children discharged with PICCs on OPAT during the study period, 8% developed a complication necessitating PICC removal. Children discharged to a long-term care facility had an increased rate of complication compared with children who were discharged home. With improved education regarding appropriate duration of antibiotic therapy and situations in which early conversion to enteral therapy should be considered, PICC-related complications may have been avoided in 32% of children. Infect.

Low Prevalence of Mupirocin Resistance Among Hospital-Acquired Methicillin-Resistant Staphylococcus aureus Isolates in a Neonatal Intensive Care Unit with an Active Surveillance Cultures and Decolonization Program

How to cite this article: Nuntra Suwantarat, Karen C. Carroll, Tsigereda Tekle, Tracy Ross, Victor O. Popoola and Aaron M. Milstone (2015). Low Prevalence of Mupirocin Resistance Among Hospital-Acquired Methicillin-Resistant Staphylococcus aureus Isolates in a Neonatal Intensive Care Unit with an Active Surveillance Cultures and Decolonization Program. Infection Control & Hospital Epidemiology, 36, pp 232-234 doi:10.1017/ice.2014.17

Prevalence of graduated compression stocking–associated pressure injuries in surgical intensive care units

Purpose This study aimed to determine the prevalence of static graduated compression stocking (sGCS)‐associated pressure injury among patients in surgical intensive care units (ICUs). Methods We retrospectively reviewed data from wound care rounds between April 2011 and June 2012 at 3 surgical ICUs at an urban, tertiary care hospital. Patients with sGCS‐associated pressure injury were identified and descriptive analysis was performed on their demographic, perioperative, and postoperative characteristics. Results We examined 1787 individual patients during 2391 patient encounters. A total of 129 (7.2%) of patients developed pressure injuries. Forty patients (2.2%) developed sGCS‐associated pressure injury. Static GCS–associated pressure injury accounted for 31% (40/129) of all pressure injuries and 74% (40/54) of all medical device–related pressure injury. Eighteen (45%) and 6 (15%) developed stage 1 and 2 pressure injury, respectively, and 16 (40%) developed deep tissue injuries. The mean age of our patients was 64.7 years, about half (47.5%) were male, and their mean Acute Physiology and Chronic Health Evaluation II score was 18.8. Many had comorbid conditions, including obesity (44.5%) and diabetes (42.5%), and required mechanical ventilation (45%). Conclusions Pressure injuries are a notable complication of sGCS in surgical ICU patients. Appropriate measures are required to help avoid this potentially preventable harm. HighlightsGraduated compression stockings (GCS) and other forms of mechanic prophylaxis may be used alone or in combination with pharmacologic venous thromboembolism prophylaxis in surgical intensive care patients. This study aimed to determine the prevalence of and risk factors for GCS‐associated pressure ulcers among patients in surgical intensive care units.We report the prevalence of GCS‐associated pressure ulcer which was 2.2% among a cohort of intensive care surgical patients in an urban, teaching tertiary care hospital. Many of the patients who developed GCS‐associated pressure ulcer were obese (44.5%) and diabetic (42.5%) and with a history of cigarette smoking (44.1%).Most of these patients required extensive postoperative critical care, which included mechanical ventilation (45%) and vasopressor agents for more than 48 hours. At the time of ulcer diagnosis, 28.2% patients were moderately to heavily sedated. The median number of days from the maximum cumulative net fluid balance to ulcer diagnosis was 2 days, an indication that fluid balance might play a role in GCS‐associated pressure ulcer.We also discuss various approaches/strategies to help prevent GCS‐associated pressure ulcer in critically ill surgical patients which includes appropriate fitting of GCS and daily surveillance for excessive tissue compression. We conclude by emphasizing the need to reexamine our approach to mechanical prophylaxis against venous thromboembolism, especially in critically ill patients in which the harms may outweigh the benefits.

Treating Parents to Reduce NICU Transmission of Staphylococcus aureus (TREAT PARENTS) trial: protocol of a multisite randomised, double-blind, placebo-controlled trial

Introduction More than 33 000 healthcare-associated infections occur in neonatal intensive care units (NICUs) each year in the USA. Parents, rather than healthcare workers, may be a reservoir from which neonates acquire Staphylococcus aureus (S. aureus) colonisation in the NICU. This study looks to measure the effect of treating parents with short course intranasal mupirocin and topical chlorhexidine antisepsis on acquisition of S. aureus colonisation and infection in neonates. Methods and analysis The TREAT PARENTS trial (Treating Parents to Reduce Neonatal Transmission of S. aureus) is a multicentre randomised, masked, placebo-controlled trial. Shortly after a neonate is admitted to the NICU, parents will be tested for S. aureus colonisation. If either parent screens positive for S. aureus, then both parents as a pair will be enrolled and randomised to one of the two possible masked treatment arms. Arm 1 will include assignment to intranasal 2% mupirocin plus topical antisepsis with chlorhexidine gluconate impregnated cloths for 5 days. Arm 2 will include assignment to placebo ointment and placebo cloths for skin antisepsis for 5 days. The primary outcome will be neonatal acquisition of an S. aureus strain that is concordant to the parental baseline S. aureus strain as determined by periodic surveillance cultures or a culture collected during routine clinical care that grows S. aureus. Secondary outcomes will include neonatal acquisition of S. aureus, neonatal S. aureus infection, eradication of S. aureus colonisation in parents, natural history of S. aureus colonisation in parents receiving placebo, adverse reactions to treatment, feasibility of intervention, and attitudes and behaviour in consented parents. Four hundred neonate-parent pairs will be enrolled. Ethics and dissemination The study was approved by Johns Hopkins University IRB in June 2014 (IRB number 00092982). Protocol V.7 was approved in November 2014. Findings will be published in peer-reviewed journals. Trial registration number NCT02223520.

Risk Factors for Persistent Methicillin-Resistant Staphylococcus aureus Colonization in Children with Multiple Intensive Care Unit Admissions

We studied methicillin-resistant Staphylococcus aureus (MRSA)-colonized children with multiple intensive care unit (ICU) admissions to assess the persistence of MRSA colonization. Our data found that children with more than 1 year between ICU admissions had a higher prevalence of MRSA colonization than the overall ICU population, which supports empirical contact precautions for children with previous MRSA colonization.