William Greendyke

Clostridium Difficile Infection in Acute Care Hospitals: Systematic Review and Best Practices for Prevention

OBJECTIVE Prevention of Clostridium difficile infection (CDI) in acute-care hospitals is a priority for hospitals and clinicians. We performed a qualitative systematic review to update the evidence on interventions to prevent CDI published since 2009. DESIGN We searched Ovid, MEDLINE, EMBASE, The Cochrane Library, CINAHL, the ISI Web of Knowledge, and grey literature databases from January 1, 2009 to August 1, 2015. SETTING We included studies performed in acute-care hospitals. PATIENTS OR PARTICIPANTS We included studies conducted on hospitalized patients that investigated the impact of specific interventions on CDI rates. INTERVENTIONS We used the QI-Minimum Quality Criteria Set (QI-MQCS) to assess the quality of included studies. Interventions were grouped thematically: environmental disinfection, antimicrobial stewardship, hand hygiene, chlorhexidine bathing, probiotics, bundled approaches, and others. A meta-analysis was performed when possible. RESULTS Of 3,236 articles screened, 261 met the criteria for full-text review and 46 studies were ultimately included. The average quality rating was 82% according to the QI-MQCS. The most effective interventions, resulting in a 45% to 85% reduction in CDI, included daily to twice daily disinfection of high-touch surfaces (including bed rails) and terminal cleaning of patient rooms with chlorine-based products. Bundled interventions and antimicrobial stewardship showed promise for reducing CDI rates. Chlorhexidine bathing and intensified hand-hygiene practices were not effective for reducing CDI rates. CONCLUSIONS Daily and terminal cleaning of patient rooms using chlorine-based products were most effective in reducing CDI rates in hospitals. Further studies are needed to identify the components of bundled interventions that reduce CDI rates. Infect Control Hosp Epidemiol 2017;38:476-482.

Outbreak of Rapidly Growing Nontuberculous Mycobacteria Among Patients Undergoing Cosmetic Surgery in the Dominican Republic.

Rapidly growing nontuberculous mycobacteria (RG-NTM), which can contaminate inadequately sterilized medical instruments, have been known to cause serious postsurgical skin and soft tissue infections that often are characterized by a prolonged incubation period and a disfiguring clinical course. Historically, these infections have been associated with surgical procedures performed outside the United States. The Centers for Disease Control and Prevention recently reported an outbreak of RG-NTM infections among women who underwent cosmetic surgery in the Dominican Republic. Because of the large Dominican American community in upper Manhattan, we have recently observed a number of these cases at NewYork-Presbyterian Hospital/Columbia University Medical Center. We highlight the case of a 55-year-old woman who developed a postsurgical RG-NTM infection after bilateral breast reduction in the Dominican Republic; she experienced progressive deformity of her left breast until the causative pathogen was identified 20 months after her initial surgery. To assist in the timely diagnosis and treatment of these infections, we aim to promote greater awareness among physicians who are likely to encounter such patients. We present the pathologic findings of a review of 7 cases of RG-NTM infections seen at NewYork-Presbyterian Hospital/Columbia University Medical Center and discuss the diagnostic and therapeutic challenges associated with these infections, such as prolonged incubation periods, the need for acid-fast stains and mycobacterial cultures, and the combination of surgical therapy and lengthy antibiotic courses that are often required for treatment.

Infectious Complications and Vaccinations in the Posttransplant Population

Infections remain a major cause of mortality and morbidity after both kidney and liver transplantation, and internists increasingly play a major role in diagnosing and treating these infections. Because of immunosuppression, solid organ transplant recipients do not often demonstrate classic signs and symptoms of infection and have a broader variety of common and opportunistic infections, many of which are generally more difficult to diagnose and treat. Although these patients have many risk factors for infection, a major determinant is the time after transplant as it relates to levels of immunosuppression, healing, and hospital or environmental exposures.

Exploring the Role of the Bedside Nurse in Antimicrobial Stewardship: Survey Results From Five Acute-Care Hospitals

occurrences were related to management and were therefore not reported as dispenser defects. In a cross-sectional survey-based study, Kohan et al described a defect rate of 2% (4 of 166) in mechanical HHDs after having been in use for 16 months; the authors concluded that mechanical HHDs, even from the same manufacturer, may differ considerably in their design and may not function similarly. Although well-functioning HHD systems may be seen as a basis for adequate hand hygiene compliance and careful evaluation of newly introduced products is important to guarantee cost-effective allocation of financial resources in healthcare institutions, defect rates of touchless HHDs have not been reported in the literature previously. Our study has 2 main limitations. First, we investigated defect rates of touchless and mechanical HHDs from a single manufacturer, which may limit the generalizability of the study results. Second, the definite cause of device or pump malfunctions could not be determined. In conclusion, we observed a significantly higher defect rate among touchless HHDs than among mechanical HHDs. The ease of use of touchless HHDs for visitors should be balanced with the additional resources required for maintenance. Mechanical HHDs may be better suited for healthcare workers due to their high reliability, low maintenance requirements, and battery-free function. An evaluation of touchless HHDs from other manufacturers is warranted.

Comparing the Bioburden Measured by Adenosine Triphosphate (ATP) Luminescence Technology to Contact Plate–Based Microbiologic Sampling to Assess the Cleanliness of the Patient Care Environment

The correlation between ATP concentration and bacterial burden in the patient care environment was assessed. These findings suggest that a correlation exists between ATP concentration and bacterial burden, and they generally support ATP technology manufacturer-recommended cutoff values. Despite relatively modest discriminative ability, this technology may serve as a useful proxy for cleanliness.Infect Control Hosp Epidemiol 2018;39:622-624.

Genomic Surveillance Reveals Diversity of Multidrug-Resistant Organism Colonization and Infection: A Prospective Cohort Study in Liver Transplant Recipients

Background Multidrug-resistant organisms (MDROs) are an important cause of morbidity and mortality after solid organ transplantation. We aimed to characterize MDRO colonization dynamics and infection in liver transplant (LT) recipients through innovative use of active surveillance and whole-genome sequencing (WGS). Methods We prospectively enrolled consecutive adult patients undergoing LT from March 2014 to March 2016. Fecal samples were collected at multiple timepoints from time of enrollment to 12 months posttransplant. Samples were screened for carbapenem-resistant Enterobacteriaceae (CRE), Enterobacteriaceae resistant to third-generation cephalosporins (Ceph-RE), and vancomycin-resistant enterococci. We performed WGS of CRE and selected Ceph-RE isolates. We also collected clinical data including demographics, transplant characteristics, and infection data. Results We collected 998 stool samples and 119 rectal swabs from 128 patients. MDRO colonization was detected in 86 (67%) patients at least once and was significantly associated with subsequent MDRO infection (0 vs 19.8%, P = .002). Child-Turcotte-Pugh score at LT and duration of post-LT hospitalization were independent predictors of both MDRO colonization and infection. Temporal dynamics differed between MDROs with respect to onset of colonization, clearance, and infections. We detected an unexpected diversity of CRE colonizing isolates and previously unrecognized transmission that spanned Ceph-RE and CRE phenotypes, as well as a cluster of mcr-1-producing isolates. Conclusions Active surveillance and WGS showed that MDRO colonization is a highly dynamic and complex process after LT. Understanding that complexity is crucial for informing decisions regarding MDRO infection control, use of therapeutic decolonization, and empiric treatment regimens.

Infection Prevention and Control Education for Environmental Services Workers (ESW): “Cleaner is Safer – ESW on the Front-line of Infection Prevention”

Abstract Background Studies suggest that improving environmental cleaning and disinfection reduces pathogen transmission and prevents healthcare-associated infections (HAIs). We designed and administered an educational program for hospital ESW based on findings from a 2015 knowledge, attitudes, and practices survey. Methods An interactive 5-part educational program was given to front-line ESW at 5 acute care hospitals from 7/16 to 3/17 using principles of adult learning theory. Audience response system (ARS), videos, demonstrations, role-playing, and graphics were used to illustrate concepts and emphasize the rationale for HAI prevention strategies. Topics included HAIs, hand hygiene, isolation precautions, personal protective equipment, daily and discharge cleaning, and strategies to overcome common challenges and barriers. Evaluation included ARS questions, written evaluations, and assessment of daily cleaning before and after education using the 3M™ Clean-Trace™ Hygiene Management System. Clean surfaces were those with <250 relative light units detected. Chi-square tests were performed, where appropriate. Results On average, 357 (range: 303-391) ESW attended each of the 5 program components. Most participants rated the presentations as ‘excellent’ or ‘very good’ (93%) and agreed they were useful (95%). After the program, participants indicated they were more comfortable donning/doffing PPE (91%), performing hand hygiene (96%), and better understood the importance of disinfecting high-touch surfaces (96%). The frequency of effective cleaning of high-touch surfaces in occupied patient rooms significantly improved following education (Table). Conclusion A novel educational program, designed using adult learning theory, that addressed ESW’s self-identified challenges was well-received and appears to have resulted in learning, behavior change, and improved daily cleaning. Future research will assess program sustainability and long-term impact on hospital cleanliness and patient outcomes. Surface Percentage of surfaces identified as clean (%) Pre-intervention Post-intervention Absolute % change Toilet seat 85 88 3 Toilet flush 60 82 22 Overbed table 29 87 58* Bed rail 8 50 42* Call box 5 65 60* Visitor chair 0 59 59* *P < 0.05. Disclosures All authors: No reported disclosures.

Knowledge, Attitudes, and Practices Regarding Antimicrobial Stewardship Among Antimicrobial Prescribers at Five Acute Care Hospitals

 The survey results will be used to develop and implement clinical AS interventions at NYP. Future research efforts will focus on the identification of changes in antimicrobial prescribing practices and clinical outcomes associated with enhanced AS educational initiatives and increased postprescription review and feedback resources. CONCLUSION Contact Information: Elizabeth Salsgiver, MPH Weill Cornell Medical College Phone: 802-598-6065 Email: ELS7021@med.cornell.edu