To evaluate two different methods of measuring catheter-associated urinary tract infection (CAUTI) rates in the setting of a quality improvement initiative aimed at reducing device utilization.

Comparison of CAUTI measurements in the context of a before-after trial of acute care adult admissions to a multicentered healthcare system.

CAUTIs were identified with an automated surveillance system, and device-days were measured through an electronic health record. Traditional surveillance measures of CAUTI rates per 1,000 device-days (R1) were compared with CAUTI rates per 10,000 patient-days (R2) before (T1) and after (T2) an intervention aimed at reducing catheter utilization.

The device-utilization ratio declined from 0.36 to 0.28 between T1 and T2 (P< .001), while infection rates were significantly lower when measured by R2 (28.2 vs 23.2, P = .02). When measured by R1, however, infection rates trended upward by 6% (7.79 vs. 8.28, P = .47), and at the nursing unit level, reduction in device utilization was significantly associated with increases in infection rate.

The widely accepted practice of using device-days as a method of risk adjustment to calculate device-associated infection rates may mask the impact of a successful quality improvement program and reward programs not actively engaged in reducing device usage.

Asymptomatic bacteriuria/candidiuria (ASB) and culture-negative pyuria (CNP) are common and often result in inappropriate antibiotic use. We aimed to evaluate whether a standardized educational memorandum could reduce antimicrobial utilization for ASB/CNP.

Quasi-experimental study with a control group, from a convenience sample of inpatients with abnormal urinalysis or urine culture results in a Veterans Affairs hospital.

An educational memorandum outlining guidelines for diagnosis and treatment of ASB was placed in the chart of patients with ASB/CNP who were receiving antimicrobials.

The records of patients meeting inclusion criteria were abstracted for demographics, comorbidities, antimicrobials, and symptoms suggestive of possible urinary tract infection (UTI). Patients were categorized as having ASB, CNP, or UTI. The number of antimicrobial-days attributed to ASB/CNP was compared between the control group and the intervention group.

Charts of 301 patients with abnormal urine results were reviewed. Thirty of 117 (26%) patients in the control group received antimicrobials for ASB/CNP for an average of 6.3 days. In the intervention group, 24 of 92 (26%) patients received antimicrobials for ASB/CNP for an average of 2.2 days (t-test: P<.001). Adverse events from antimicrobials for ASB/CNP occurred in 3 of the 30 (10%) patients in the control group. There were no adverse events from untreated ASB/CNP in the intervention group.

ASB and CNP resulted in antimicrobial exposure in more than one-quarter of our study patients. Placing a standardized memorandum in the electronic record was associated with a 65% relative reduction in antimicrobial-days for ASB and CNP.

Expanding hospitalized patients' risk stratification for Clostridium difficile infection (CDI) is important for improving patient safety. We applied definitions for hospital-onset (HO) and community-onset (CO) CDI to electronic data from 85 hospitals between January 2007 and June 2008 to identify factors associated with higher HO CDI rates.

Nonrecurrent CDI cases were identified among adult (≥18-year-old) inpatients by a positive C. difficile toxin assay result more than 8 weeks after any previous positive result. Case categories included HO, CO-hospital associated (CO-HA), CO-indeterminate hospital association (CO-IN), and CO–non–hospital associated (CO-NHA). C. difficile testing intensity (CDTI) was defined as the total number of C. difficile tests performed, normalized to the number of patients with at least 1 C. difficile toxin test recorded. We calculated both the incidence density and the prevalence of CDI where appropriate. We fitted a multivariable Poisson model to identify factors associated with higher HO CDI rates.

Among 1,351,156 unique patients with 2,022,213 admissions, 9,803 cases of CDI were identified; of these, 50.6% were HO, 17.4% were CO-HA, 9.0% were CO-IN, and 23.0% were CO-NHA. The incidence density of HO was 6.3 per 10,000 patient-days. The prevalence of CO CDI on admission was, per 10,000 admissions, 8.4 for CO-HA, 4.4 for CO-IN, and 11.1 for CO-NHA. Factors associated (P< .0001) with higher HO CDI rates included older age, higher CO-NHA prevalence on admission, and increased CDTI.

Electronic health information can be leveraged to risk-stratify HO CDI rates by patient age and CO-NHA prevalence on admission. Hospitals should optimize diagnostic testing to improve patient care and measured CDI rates.

Controversy exists over whether Clostridium difficile infection (CDI) commonly occurs in long-term care facility residents who have not been recently transferred from an acute care hospital.

To assess the incidence and outcome of CDI in a long-term care facility.

Retrospective cohort study in a 262-bed long-term care Veterans Affairs facility in Pittsburgh, Pennsylvania, for the period January 2004 through June 2010. CDI was identified by positive stool C. difficile toxin assay and acute diarrhea. Patients were categorized as hospital-associated CDI (HACDI) or long-term care facility–associated CDI (LACDI) and followed for 6 months.

The annual rate of CDI varied between 0.11 and 0.23 per 1,000 resident-days for HACDI patients and between 0.04 and 0.28 per 1,000 resident-days for LACDI patients. We identified 162 patients, 96 patients (59.3%) with HACDI and 66 patients (40.7%) with LACDI. Median age was 74 and 77 years, respectively, for HACDI and LACDI (P = .055) patients. There were more patients with at least 1 relapse of CDI during 6 months of follow up in LACDI patients (32/66, 48.5%) than in HACDI patients (28/96, 29.2%; P = .009). Logistic regression showed that ages of at least 75 years (odds ratio [OR], 2.33; 95% confidence interval [CI], 1.07–5.07; P = .033), more than 2 transfers to an acute care hospital (OR, 7.88; 95% CI, 1.88–32.95; P = .005), and LACDI (OR, 3.15; 95% CI, 1.41–7.05; P = .005) were associated with relapse of CDI.

Forty percent of CDI cases were acquired within the long-term care facility, indicating a substantial degree of transmission. Optimal strategies to prevent CDI in the long-term care facility are needed.

To characterize handwashing behaviors of children and assess the efficacy of a waiting room-based hand hygiene intervention at improving handwashing ability.

Prospective randomized pilot study.

Emergency department waiting room at a freestanding urban pediatric hospital.

Children (8–18 years) and their parent.

Participants were randomized to glow gel hand washing without hand hygiene education or glow gel hand washing with hand hygiene education. After participants washed with glow gel, “dirty areas” were illuminated using a black light, and hands were scored. A questionnaire about handwashing behavior was administered. All subjects returned 2–4 weeks after intervention to repeat glow gel hand washing and the questionnaire.

Sixty pediatric patients and 57 parents were recruited, with 77% of patients returning for follow up. Patients were 50% male, 58% Latino, 28% African American, and 8% Caucasian. At the initial visit, 91% of children reported hand washing after using the bathroom and 78% reported hand washing before dinner. On the basis of objective scoring, all children improved handwashing ability when compared with the initial visit (P = .02) and were more likely to use warm water at follow up (P = .01). Parents did not significantly improve in handwashing ability (P = .73).

Glow gel hand washing is an effective method to improve children's handwashing ability. This short-term intervention was effective even in the absence of specific hand hygiene education. This intervention could serve as a valuable public health measure to teach hand washing in healthcare settings.

To study the frequency of isolation of Acinetobacter baumannii complex (ABC) and methicillin-resistant Staphylococcus aureus (MRSA) from surfaces of rooms newly vacated by patients with multidrug-resistant (MDR) ABC following various rounds of routine terminal cleaning and disinfection (C/D) with bleach or 1 round of C/D followed by hydrogen peroxide vapor (HPV) treatment.

A 900-bed tertiary care hospital.

ABC and MRSA cultures were obtained from hospital rooms including 312 rooms (mean, 18.3 sites/room) following 4 rounds of C/D, 37 rooms (mean, 20 sites/room) following 1 round of C/D before and after HPV treatment, and 134 rooms (mean, 20 sites/room) following 1 round of C/D and HPV treatment.

Following 4 rounds of C/D, 83 (26.6%) rooms had 1 or more culture-positive sites; 102 (1.8%) sites in 51 (16.4%) rooms grew ABC, and 108 (1.9%) sites in 44 (14.1%) rooms grew MRSA. The addition of HPV treatment to 1 round of C/D resulted in a significant drop in ABC- and MRSA-positive room sites (odds ratio, 0 [95% confidence interval, 0–0.8]; P = .04 for both organisms). Following 1 round of C/D and HPV treatment, 6 (4.5%) rooms were culture-positive for ABC, MRSA, or both.

Routine terminal C/D of hospital rooms vacated by MDRABC-positive patients may be associated with a significant number of ABC- or MRSA-positive room surfaces even when up to 4 rounds of C/D are performed. The addition of HPV treatment to 1 round of C/D appears effective in reducing the number of persistently contaminated room sites in this setting.

To describe the implementation of an institution-wide, multiple-step intervention to curtail the epidemic spread of carbapenem-resistant Klebsiella pneumoniae (CRKP).

Consecutive intervention analyses.

All patients admitted to a 775-bed tertiary care medical center in Jerusalem, Israel, from 2006 through 2010.

The effects of 4 interventions were assessed: (1) a policy of isolation for patients colonized or infected with CRKP in single rooms, which was started in March 2006; (2) cohorting of CRKP patients with dedicated nursing staff and screening of patients neighboring a patient newly identified as a carrier of CRKP, which was started in March 2007; (3) weekly active surveillance of intensive care unit patients, which was started during August 2008; and (4) selective surveillance of patients admitted to the emergency department, which was started in March 2009. Interrupted regression analysis and change-point analysis were used to assess the effect of each intervention on the CRKP epidemic.

Patient isolation alone failed to control the spread of CRKP, with incidence increasing to a peak of 30 new cases per 1,000 hospital beds per month. Institution of patient cohorting led to a steep decline in the incidence of CRKP acquisition (P< .001). Introduction of active surveillance interventions was followed by a decrease in the incidence of CRKP-positive clinical cultures but an increase in the incidence of CRKP-positive screening cultures. The mean prevalence of CRKP positivity for the period after cohorting began showed a statistically significant change from the mean prevalence in the preceding period (P< .001).

The cohorting of patients with dedicated staff, combined with implementation of focused active surveillance, effectively terminated the epidemic spread of CRKP. Cohorting reduced cross-infection within the hospital, and active surveillance allowed for earlier detection of carrier status. Both interventions should be considered in attempts to contain a hospital epidemic.

Coagulase-negative staphylococci (CoNS) are the most commonly isolated pathogens in the neonatal intensive care unit (NICU). CoNS infections are associated with increased morbidity, including neurodevelopmental impairment.

To describe the epidemiology of CoNS infections in the NICU. To determine mortality among infants with definite, probable, or possible CoNS infections.

We performed a retrospective cohort study of all blood, urine, and cerebrospinal fluid cultures from samples obtained from infants aged <121 postnatal days.

A total of 248 NICUs managed by the Pediatrix Medical Group from 1997 to 2009.

We identified 16,629 infants with 17,624 episodes of CoNS infection: 1,734 (10%) definite, 3,093 (17%) probable, and 12,797 (73%) possible infections. Infants with a lower gestational age and birth weight had a higher incidence of CoNS infection. When controlling for gestational age, birth weight, and 5-minute Apgar score, we found that infants with definite, probable, or possible CoNS infection had lower mortality (odds ratio [OR], 0.74 [95% confidence interval {CI}: 0.61, 0.89], 0.68 [95% CI, 0.59, 0.79], and 0.69 [95% CI, 0.63, 0.76], respectively) compared with infants who had negative culture results (P<.001). No significant difference in overall mortality was found in infants who had definite CoNS infection compared with those who had probable or possible CoNS infection (OR, 0.93 [95% CI, 0.75, 1.16] and 0.85 [95% CI, 0.70, 1.03], respectively).

CoNS infection was strongly related to lower gestational age and birth weight. Infants with clinical sepsis and culture-positive CoNS infection had lower mortality rates than infants with clinical sepsis and negative blood culture results. No difference in mortality between infants with a diagnosis of definite, probable, or possible CoNS infection was observed.