The medical needs of the approximately 1 million persons residing in assisted living facilities (ALFs) continually become more demanding. Moreover, the number of ALF residents is expected to double by 2030. ALFs are not subject to federal oversight; state regulations that govern ALF infection control are variable. In 2005, two outbreaks of acute hepatitis B virus (HBV) infection in ALFs in Virginia were associated with sharing fingerstick devices used in blood glucose monitoring.

To characterize infection control practices, determine compliance with guidelines, and identify educational and policy needs in ALFs in Virginia.

Following the outbreaks of HBV infection, educational packets were sent to ALFs in Virginia to inform them of infection control guidelines and recommendations regarding glucose monitoring. A follow-up survey consisting of on-site interviews was conducted in a random sample of ALFs. Differences among infection control practices, according to the size and ownership of the ALFs, were assessed.

Fifty of 155 ALFs in central Virginia were surveyed. Of the 45 ALFs that had used fingerstick devices, 7 (16%) had shared these devices (without cleaning) between residents. Sharing practices for glucose monitoring equipment did not differ by facility size or ownership. Of all 50 ALFs, 17 (34%) did not offer employees HBV vaccine. HBV vaccine was less frequently offered at ALFs that had fewer than 50 residents, compared with ALFs with at least 50 residents (P < .01), and HBV vaccine was less frequently offered at ALFs that were individually owned, compared with those that were not individually owned (P = .02).

Despite outreach and long-standing recommendations, approximately 1 in 6 facilities shared fingerstick devices, and more than one-third of ALFs surveyed were considered noncompliant with federal guidelines (Occupational Safety and Health Administration Bloodborne Pathogens Standard). Public health and licensing agencies should work with ALFs to implement infection control measures and prevent disease transmission.

We compared a whole-blood interferon-γ release assay (QuantiFERON-TB Gold In-Tube test, hereafter “QFT-in tube test”) with a tuberculin skin test (TST) to determine which test more accurately identified latent Mycobacterium tuberculosis infection in healthcare staff.

A total of 481 hospital staff members were recruited from 5 hospitals in Melbourne, Australia. They provided information about demographic variables and tuberculosis (TB) risk factors (ie, birth or travel in a country with a high prevalence of TB, working in an occupation likely to involve contact with M. tuberculosis or individuals with TB, or being a household contact of an individual with a proven case of pulmonary TB). The QFT-in tube test and the TST were administered in accordance with standardized protocols. Concordance between the test results and positive risk factors was analyzed using the к statistic, the McNemar test, and logistic regression.

A total of 358 participants had both a TST result and a QFT-in tube test result available for comparison. There were fewer positive QFT-in tube test results than positive TST results (6.7% vs. 33.0%; P < .001). Agreement between the tests was poor (71%; к = 0.16). A positive QFT-in tube test result was associated with birth in a country with a high prevalence of TB, the number of years an individual had lived in a country with a high prevalence of TB (ie, the effect of each additional year, treated as a continuous variable), and high-risk occupational contact. A positive TST result was associated with older age, receipt of bacille Calmette-Guérin (BCG) vaccination, and working in an occupation that involved patient contact. Receipt of BCG vaccination was most strongly associated with discordant results in instances in which the TST result was positive and the QFT-in tube test result was negative.

In a population of healthcare staff with a low prevalence of TB and a significant rate of BCG vaccination, a positive QFT-in tube test result was associated with the presence of known risk factors for TB exposure, whereas a positive TST result was more strongly associated with a prior history of BCG vaccination.

To determine the impact of known observers on hand hygiene performance in inpatient care units with differing baseline levels of hand hygiene compliance.

Observational study.

Three inpatient care units, selected on the basis of past hand hygiene performance, in a hospital where hand hygiene observation and feedback are routine.

Three infection control practitioners (ICPs) and a student intern observed hospital staff.

Beginning in late 2005, the 3 ICPs, who were well known to the hospital staff, performed frequent, regular observations of hand hygiene in all 3 inpatient care units of the hospital, as part of routine surveillance. During the study period (January-May 2007), a student intern who was unknown to the hospital staff also performed observations of hand hygiene in the 3 inpatient care units. The rates of hand hygiene compliance observed by the 3 ICPs were compared with those observed by the student intern.

The 3 ICPs observed 332 opportunities for hand hygiene during 15 observation periods, and the student intern observed 355 opportunities during 19 observation periods. The overall rate of hand hygiene compliance observed by the ICPs was 65% (ie, in 215 of the 332 opportunities, the performance of proper hand hygiene by hospital staff was observed), and the overall rate of hand hygiene compliance observed by the student intern was 58% (ie, in 207 of the 355 opportunities, the performance of proper hand hygiene by hospital staff was observed) (P = .1). Both the ICPs and the student intern were able to distinguish between inpatient care units with a high rate of hand hygiene compliance (hereafter referred to as high-performing units) and those with a low rate (hereafter referred to as low-performing units). However, in the 2 high-performing units, the ICPs observed significantly higher compliance rates than did the student intern, whereas in the low-performing unit, both the ICPs and the student intern measured similarly low rates of hand hygiene compliance.

Recognized observers are associated with higher rates of hand hygiene compliance, even in a healthcare setting where such observations have become routine. This effect (ie, the Hawthorne effect) is more pronounced in high-performing units and insignificant in low-performing units. The use of unrecognized observers may be important for verifying high performance but is probably unnecessary for documenting poor performance. Moreover, the Hawthorne effect may be a useful tool for sustaining and improving hand hygiene compliance.

The presence of methicillin-resistant Staphylococcus aureus (MRSA) and glycopeptide-intermediate S. aureus (GISA) in hospitals poses a significant challenge to hospital infection control teams. The use of disinfectants for both surface and hand cleaning is an essential part of the infection control measures.

To evaluate the effectiveness of common hospital hand disinfectants against MRSA, GISA, and heterogeneous GISA (hGISA).

For methicillin-susceptible S. aureus (MSSA), MRSA, GISA, and hGISA, the levels of susceptibility to hand disinfectants and their active ingredients were determined. Suspension tests were performed on commercial handwashing products.

Minimum inhibitory concentrations (MICs) of 2-propanol, Chlorhexidine, and hexachlorophene were similar for all phenotypes. The MICs of cetrimide and triclosan were higher for the MRSA, GISA, and hGISA strains than for the MSSA strain. The MICs for the chlorhexidine-containing agents Hibisol and Hibiscrub (AstraZeneca) and for the propanol-containing agent Sterillium (Medline) were 1-2-fold lower for the MSSA strains than for the MRSA, GISA, and hGISA strains. Suspension tests showed that the GISA and hGISA strains were less susceptible to the triclosan-containing agent Aquasept (SSL) than were the MRSA and MSSA strains, with resistance increasing with glycopeptide resistance. Products containing Betadine (Purdue) were more effective against the GISA and hGISA strains than against the MRSA and MSSA strains, especially after the strain was exposed to the product for 30 seconds.

Using the EN 1040 standard criteria for the performance of disinfectants, we determined that all agents, except 50% Aquasept for hGISA and 0.33% hexachlorophene for GISA, performed effectively. However, the GISA and hGISA strains were less susceptible to triclosan-containing products, compared with the MRSA stains, but were more susceptible to products containing Betadine.

To describe the epidemiology of bloodstream infection caused by USA300 strains of methicillin-resistant Staphylococcus aureus (MRSA), which are traditionally associated with cases of community-acquired infection, in the healthcare setting.

Retrospective cohort study.

Three academically affiliated hospitals in Denver, Colorado.

Review of cases of S. aureus bloodstream infection during the period from 2003 through 2007. Polymerase chain reaction was used to identify MRSA USA300 isolates.

A total of 330 cases of MRSA bloodstream infection occurred during the study period, of which 286 (87%) were healthcare-associated. The rates of methicillin resistance among the S. aureus isolates recovered did not vary during the study period and were similar among the 3 hospitals. However, the percentages of cases of healthcare-associated MRSA bloodstream infection due to USA300 strains varied substantially among the 3 hospitals: 62%, 19%, and 36% (P < .001) for community-onset cases and 33%, 3%, and 33% (P = .005) for hospital-onset cases, in hospitals A, B, and C, respectively. In addition, the number of cases of healthcare-associated MRSA bloodstream infection caused by USA300 strains increased during the study period at 2 of the 3 hospitals. At each hospital, USA300 strains were most common among cases of community-associated infection and were least common among cases of hospital-onset infection. Admission to hospital A (a safety-net hospital), injection drug use, and human immunodeficiency virus infection were independent risk factors for healthcare-associated MRSA bloodstream infection due to USA300 strains.

The prevalence of USA300 strains among cases of healthcare-associated MRSA bloodstream infection varied dramatically among geographically clustered hospitals. USA300 strains are replacing traditional healthcare-related strains of MRSA in some healthcare settings. Our data suggest that the prevalence of USA300 strains in the community is the dominant factor affecting the prevalence of this strain type in the healthcare setting.

To assess the impact of an institution-wide infection control education program on the rate of transmission of methicillin-resistant Staphylococcus aureus (MRSA).

Before-and-after study.

A 472-bed, urban, university-affiliated hospital.

During the period March-May 2004, all hospital staff completed a mandatory infection control education program, including the receipt of hospital-specific MRSA data and case-based practice with additional precautions.

The rate of nosocomial MRSA acquisition was calculated as the number of cases of nosocomial MRSA acquisition per 100 days that a person with MRSA colonization or infection detected at admission is present in the hospital (“admission MRSA” exposure-days) for 3 time periods: June 2002-February 2003 (before the Toronto outbreak of severe acute respiratory syndrome [SARS]), June 2003-February 2004 (after the outbreak of SARS), and June 2004-February 2005 (after education). A case of nosocomial acquisition of MRSA colonization or infection represented a patient first identified as colonized or infected more than 72 hours after admission or at admission after a previous hospitalization.

The rate of nosocomial acquisition of MRSA colonization or infection was 8.8 cases per 100 admission MRSA exposure-days for the period before SARS, 3.8 cases per 100 admission MRSA exposure-days for the period after SARS (P < .001 for before SARS vs after SARS), and 1.9 cases per 100 admission MRSA exposure-days for the period after education (P = .02 for after education vs before education). The volume of alcohol-based handrub purchased was apparently stable, with 4,010 L during fiscal year 2003-2004 (April 2003-March 2004) compared with 3,780 L during fiscal year 2004—2005. The observed rate of compliance with hand washing did not change significantly (40.9% during education vs 44.2% after education; P = .23). The total number of patients screened for MRSA colonization was not different in the 3 periods.

The rate of nosocomial acquisition of MRSA colonization or infection decreased after SARS and was further reduced in association with a hospital-wide education program.

TO describe what is, to our knowledge, the first nosocomial outbreak of infection with pan–drug-resistant (including colistin-resistant) Acinetobacter baumannii, to determine the risk factors associated with these types of infections, and to determine their clinical impact.

Nested case-control cohort study and a clinical-microbiological study.

A 1,521-bed tertiary care university hospital in Seville, Spain.

Case patients were inpatients who had a pan-drug-resistant A. baumannii isolate recovered from a clinical or surveillance sample obtained at least 48 hours after admission to an intensive care unit (ICU) during the time of the epidemic outbreak. Control patients were patients who were admitted to any of the “boxes” (ie, rooms that partition off a distinct area for a patient's bed and the equipment needed to care for the patient) of an ICU for at least 48 hours during the time of the epidemic outbreak.

All the clinical isolates had similar antibiotic susceptibility patterns (ie, they were resistant to all the antibiotics tested, including Colistin), and, on the basis of repetitive extragenic palindromic-polymerase chain reaction, it was determined that all of them were of the same clone. The previous use of quinolones and glycopeptides and an ICU stay were associated with the acquisition of infection or colonization with pan-drug-resistant A. baumannii. To control this outbreak, we implemented the following multicomponent intervention program: the performance of environmental decontamination of the ICUs involved, an environmental survey, a revision of cleaning protocols, active surveillance for colonization with pan-drug-resistant A. baumannii, educational programs for the staff, and the display of posters that illustrate contact isolation measures and antimicrobial use recommendations.

We were not able to identify the common source for these cases of infection, but the adopted measures have proven to be effective at controlling the outbreak.

To review the effect of interventions, including a complete restriction in the use of fluoroquinolones (FQs), used to control an outbreak of hospital-onset Clostridium difficile infection (HO-CDI) caused primarily by the epidemic North American pulsed-field gel electrophoresis type 1 strain.

Retrospective cohort and case-control study of all episodes of HO-CDI both before and after 2 interventions.

Community hospital; January 1, 2005, through March 31, 2007.

Complete, 5-month, facility-wide restriction of fluoroquinolone use, during which a change in the environmental-services contractor occurred.

During a 27-month period, 319 episodes of HO-CDI occurred. The hospital-wide mean defined daily doses of antimicrobials decreased 22% after restricting FQ use, primarily because of a 66% decrease in the use of FQs. The interventions were also associated with a significant change in the HO-CDI incidence trends and with an absolute decrease of 22% in HO-CDI cases caused by the epidemic strain (from 66% before the intervention period to 44% during and after the intervention period; P = .02). Univariate analysis revealed that case patients with HO-CDI due to the epidemic strain were more likely than control patients, who did not have diarrhea, to receive a FQ, whereas case patients with HO-CDI due to a nonepidemic strain were not. However, FQ use was not significantly associated with HO-CDI in multivariable analysis.

An outbreak of epidemic-strain HO-CDI was controlled at a community hospital after an overall decrease in antimicrobial use, primarily because of a restriction of FQ use and a change in environmental-services contractors. The restriction of FQ use may be useful as an adjunct control measure in a healthcare facilities during outbreaks of epidemic-strain HO-CDI.