Alcohol-based hand rubs (ABHRs) are an effective means of decreasing the transmission of bacterial pathogens. Alcohol is not effective against Clostridium difficile spores. We examined the retention of C. difficile spores on the hands of volunteers after ABHR use and the subsequent transfer of these spores through physical contact.

Nontoxigenic C. difficile spores were spread on the bare palms of 10 volunteers. Use of 3 ABHRs and chlorhexidine soap-and-water washing were compared with plain water rubbing alone for removal of C. difficile spores. Palmar cultures were performed before and after hand decontamination by means of a plate stamping method. Transferability of C. difficile after application of ABHR was tested by having each volunteer shake hands with an uninoculated volunteer.

Plain water rubbing reduced palmar culture counts by a mean (± standard deviation [SD]) of 1.57 ± 0.11 log10 colony-forming units (CFU) per cm2, and this value was set as the zero point for the other products. Compared with water washing, chlorhexidine soap washing reduced spore counts by a mean ( ± SD) of 0.89 ± 0.34 log10 CFU per cm2; among the ABHRs, Isagel accounted for a reduction of 0.11 ± 0.20 log10 CFU per cm2 (P = .005), Endure for a reduction of 0.37 ± 0.42 log10 CFU per cm2 (P = .010), and Purell for a reduction of 0.14 ± 0.33 log10 CFU per cm2 (P = .005). There were no statistically significant differences between the reductions achieved by the ABHRs; only Endure had a reduction statistically different from that for water control rubbing (P = .040). After ABHR use, handshaking transferred a mean of 30% of the residual C. difficile spores to the hands of recipients.

Hand washing with soap and water is significantly more effective at removing C. difficile spores from the hands of volunteers than are ABHRs. Residual spores are readily transferred by a handshake after use of ABHR.

To determine the prevalence of asymptomatic carriage of Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) among healthcare professionals (HCPs) who experience varying degrees of exposure to ambulatory patients and to genetically characterize isolates.

This single-center, cross-sectional study enrolled 256 staff from the intensive care units, emergency department, and prehospital services of an urban tertiary care university hospital in 2008. Occupational histories and nasal samples for S. aureus cultures were obtained. S. aureus isolates were genetically characterized with the use of spa typing and screened for mecA. MRSA isolates underwent further characterization.

S. aureus was isolated from 112 of 256 (43.8%) HCPs, including 30 of 52 (57.7%) paramedics, 51 of 124 (41.1%) nurses, 11 of 28 (39.3%) clerical workers, and 20 of 52 (38.5%) physicians. MRSA was isolated from 17 (6.6%) HCPs, including 1 (1.9%) paramedic, 13 (10.5%) nurses, 1 (3.6%) clerical worker, and 2 (3.8%) physicians. Among S. aureus isolates, 15.2% were MRSA. MRSA prevalence was 9.6% (12/125) in emergency department workers, 5.1% (4/79) in intensive care unit workers, and 1.9% (1/52) in emergency medical services workers. Compared with paramedics, who had the lowest prevalence of methicillin resistance among S. aureus isolates (1 of 30 [3.3%] isolates), nurses, who had the highest prevalence (13 of 51 [25.4%] isolates), had an odds ratio of 9.92 (95% confidence interval, 1.32-435.86; P = .02) for methicillin resistance. Analysis of 15 MRSA isolates revealed 7 USA100 strains, 6 USA300 strains, 1 USA800 strain, and 1 EMRSA-15 strain. All USA300 strains were isolated from emergency department personnel.

The observed prevalence of S. aureus and MRSA colonization among HCPs exceeds previously reported prevalences in the general population. The proportion of community-associated MRSA among all MRSA in this colonized HCP cohort reflects the distribution of the USA300 community-associated strain observed increasingly among US hospitalized patients.

Staphylococcus aureus is an important cause of infection in intensive care unit (ICU) patients. Colonization with methicillin-resistant S. aureus (MRSA) is a risk factor for subsequent S. aureus infection. However, MRSA-colonized patients may have more comorbidities than methicillin-susceptible S. aureus (MSSA)-colonized or noncolonized patients and therefore may be more susceptible to infection on that basis.

To determine whether MRSA-colonized patients who are admitted to medical and surgical ICUs are more likely to develop any S. aureus infection in the ICU, compared with patients colonized with MSSA or not colonized with S. aureus, independent of predisposing patient risk factors.

Prospective cohort study.

A 24-bed surgical ICU and a 19-bed medical ICU of a 1,252-bed, academic hospital.

A total of 9,523 patients for whom nasal swab samples were cultured for S. aureus at ICU admission during the period from December 2002 through August 2007.

Patients in the ICU for more than 48 hours were examined for an ICU-acquired S. aureus infection, defined as development of S. aureus infection more than 48 hours after ICU admission.

S. aureus colonization was present at admission for 1,433 (27.8%) of 5,161 patients (674 [47.0%] with MRSA and 759 [53.0%] with MSSA). An ICU-acquired S. aureus infection developed in 113 (2.19%) patients, of whom 75 (66.4%) had an infection due to MRSA. Risk factors associated with an ICU-acquired S. aureus infection included MRSA colonization at admission (adjusted hazard ratio, 4.70 [95% confidence interval, 3.07-7.21]) and MSSA colonization at admission (adjusted hazard ratio, 2.47 [95% confidence interval, 1.52-4.01]).

ICU patients colonized with S. aureus were at greater risk of developing a S. aureus infection in the ICU. Even after adjusting for patient-specific risk factors, MRSA-colonized patients were more likely to develop S. aureus infection, compared with MSSA-colonized or noncolonized patients.

To better understand the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection in different patient populations, to perform quantitative analysis of MRSA in nasal cultures, and to characterize strains using molecular fingerprinting.

Prospective, multicenter study.

Eleven different inpatient and outpatient healthcare facilities.

MRSA-positive inpatients identified in an active surveillance program; inpatients and outpatients receiving hemodialysis; inpatients and outpatients with human immunodeficiency virus (HIV) infection; patients requiring cardiac surgery; and elderly patients requiring long-term care.

Nasal swab samples were obtained from January 23, 2006, through July 27, 2007; MRSA strains were quantified and characterized by molecular fingerprinting.

A total of 444 nares swab specimens yielded MRSA (geometric mean quantity, 794 CFU per swab; range, 3-15,000,000 CFU per swab). MRSA prevalence was 20% for elderly residents of long-term care facilities (25 of 125 residents), 16% for HIV-infected outpatients (78 of 494 outpatients), 15% for outpatients receiving hemodialysis (31 of 208 outpatients), 14% for inpatients receiving hemodialysis (86 of 623 inpatients), 3% for HIV-infected inpatients (5 of 161 inpatients), and 3% for inpatients requiring cardiac surgery (6 of 199 inpatients). The highest geometric mean quantity of MRSA was for inpatients requiring cardiac surgery (11,500 CFU per swab). An association was found between HIV infection and colonization with the USA300 or USA500 strain of MRSA (P ≤ .001). The Brazilian clone was found for the first time in the United States. Pulsed-field gel electrophoresis patterns for 11 isolates were not compatible with known USA types or clones.

Nasal swab specimens positive for MRSA had a geometric mean quantity of 794 CFU per swab, with great diversity in the quantity of MRSA at this anatomic site. Outpatient populations at high risk for MRSA carriage were elderly residents of long-term care facilities, HIV-infected outpatients, and outpatients receiving hemodialysis.

Methicillin-resistant Staphylococcus aureus (MRSA) transmission and infections are a continuing problem in hospitals. Although some have recommended universal surveillance for MRSA at hospital admission to identify and to isolate MRSA-colonized patients, there is a need for formal economic studies to determine the cost-effectiveness of such a strategy.

We developed a stochastic computer simulation model to determine the potential economic impact of performing MRSA surveillance (ie, single culture of an anterior nares specimen) for all hospital admissions at different MRSA prevalences and basic reproductive rate thresholds from the societal and third party-payor perspectives. Patients with positive surveillance culture results were placed under isolation precautions to prevent transmission by way of respiratory droplets. MRSA-colonized patients who were not isolated could transmit MRSA to other hospital patients.

The performance of universal MRSA surveillance was cost-effective (defined as an incremental cost-effectiveness ratio of less than $50,000 per quality-adjusted life-year) when the basic reproductive rate was 0.25 or greater and the prevalence was 1% or greater. In fact, surveillance was the dominant strategy when the basic reproductive rate was 1.5 or greater and the prevalence was 15% or greater, the basic reproductive rate was 2.0 or greater and the prevalence was 10% or greater, and the basic reproductive rate was 2.5 or greater and the prevalence was 5% or greater.

Universal MRSA surveillance of adults at hospital admission appears to be cost-effective at a wide range of prevalence and basic reproductive rate values. Individual hospitals and healthcare systems could compare their prevailing conditions (eg, the prevalence of MRSA colonization and MRSA transmission dynamics) with the benchmarks in our model to help determine their optimal local strategies.

Active surveillance to detect patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) is increasingly practiced in healthcare settings. However, inpatients may already become sources of transmission before appropriate precautions are implemented.

To examine the frequency of MRSA contamination of commonly touched skin and environmental surfaces before patient carriage status became known.

We conducted a 6-week prospective study of patients who were identified by use of polymerase chain reaction (PCR) at hospital admission as having nasal MRSA colonization. Skin and environmental contamination was assessed within hours of completion of PCR screening.

There were 116 patients identified by PCR screening as having nasal MRSA colonization during the period from mid-April to May 2008, of whom 83 (72%) were enrolled in our study. Overall, MRSA was detected on the skin of 38 (51%) of 74 patients and in the environment of 37 (45%) of 83 patients Of 83 environmental culture samples, 63 (76%) were obtained within 7 hours after PSR results became available, and 73 (88%) were obtained before wards were notified of PCR Results. Of the 83 MRSA-colonized patients, 15 (18%) had contaminated their environment 25 hours after admission, and 29 (35%) had contaminated their environment 33 hours after admission. Thirty-two (39%) of the 83 patients had roommates, 13 (41%) of whom contaminated their environment. The median interval from admission to PCR result was 20 hours, and the median interval from PCR result to notification was 23 hours. An increased quantity of MRSA cultured from a nasal sample was significantly associated with contamination.

Before any contact precautions can be implemented, newly identified MRSA carriers frequently have contaminated their environment with MRSA and have contamination of commonly examined skin sites. In hospitals that perform active surveillance, strategies are needed to minimize delays in screening or to preemptively identify patients at high risk for disseminating MRSA.

To determine whether the molecular epidemiological characteristics of methicillin-resistant Staphylococcus aureus (MRSA) had changed in a level III neonatal intensive care unit (NICU).

Retrospective review of medical records.

Level III NICU of a university-affiliated children's hospital in New York, New York.

Case patients were neonates hospitalized in the NICU who were colonized or infected with MRSA.

Rates of colonization and infection with MRSA during the period from 2000 through 2008 were assessed. Staphylococcal chromosomal cassette (SCC) mecA analysis and genotyping for S. aureus encoding protein A (spa) were performed on representative MRSA isolates from each clonal pulsed-field gel electrophoresis pattern.

Endemic MRSA infection and colonization occurred throughout the study period, which was punctuated by 4 epidemiologic investigations during outbreak periods. During the study period, 93 neonates were infected and 167 were colonized with MRSA. Surveillance cultures were performed for 1,336 neonates during outbreak investigations, and 115 (8.6%) neonates had MRSA-positive culture results. During 2001-2004, healthcare-associated MRSA clones, carrying SCC mec type II, predominated. From 2005 on, most MRSA clones were community-associated MRSA with SCC mec type IV, and in 2007, USA300 emerged as the principal clone.

Molecular analysis demonstrated a shift from healthcare-associated MRSA (2001-2004) to community-associated MRSA (2005-2008).

The recent emergence of carbapenem resistance among Enterobacteriaceae is a major threat for hospitalized patients, and effective strategies are needed.

To assess the effect of an intensified intervention, which included active surveillance, on the incidence of infection with carbapenem-resistant Klebsiella pneumoniae.

Sheba Medical Center, a 1,600-bed tertiary care teaching hospital in Tel Hashomer, Israel.

Quasi-experimental study.

The medical records of all the patients who acquired a carbapenem-resistant K. pneumoniae infection during 2006 were reviewed. An intensified intervention was initiated in May 2007. In addition to contact precautions, active surveillance was initiated in high-risk units. The incidence of clinical carbapenem-resistant K. pneumoniae infection over time was measured, and interrupted time-series analysis was performed.

The incidence of clinical carbapenem-resistant K. pneumoniae infection increased 6.42-fold from the first quarter of 2006 up to the initiation of the intervention. In 2006, of the 120 patients whose clinical microbiologic culture results were positive for carbapenem-resistant K. pneumoniae, 67 (56%) developed a nosocomial infection. During the intervention period, the rate of carbapenem-resistant K. pneumoniae rectal colonization was 9%. Of the 390 patients with carbapenem-resistant K. pneumoniae colonization or infection, 204 (52%) were identified by screening cultures. There were a total of 12,391 days of contact precautions, and of these, 4,713 (38%) were added as a result of active surveillance. After initiation of infection control measures, we observed a significant decrease in the incidence of carbapenem-resistant K. pneumoniae infection.

The use of active surveillance and contact precautions, as part of a multifactorial intervention, may be an effective strategy to decrease rates of nosocomial transmission of carbapenem-resistant K. pneumoniae colonization or infection.

To evaluate whether hospital-acquired catheter-associated urinary tract infections (CA-UTIs) are accurately documented in discharge records with the use of International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes so that nonpayment is triggered, as mandated by the Centers for Medicare and Medicaid Services (CMS) Hospital-Acquired Conditions Initiative.

We conducted a retrospective medical record review of 80 randomly selected adult discharges from May 2006 through September 2007 from the University of Michigan Health System (UMHS) with secondary-diagnosis urinary tract infections (UTIs). One physician-abstractor reviewed each record to categorize UTIs as catheter associated and/or hospital acquired; these results (considered “gold standard”) were compared with diagnosis codes assigned by hospital coders. Annual use of the catheter association code (996.64) by UMHS coders was compared with state and US rates by using Healthcare Cost and Utilization Project data.

Patient mean age was 58 years; 56 (70%) were women; median length of hospital stay was 6 days; 50 patients (62%) used urinary catheters during hospitalization. Hospital coders had listed 20 secondary-diagnosis UTIs (25%) as hospital acquired, whereas physician-abstractors indicated that 37 (46%) were hospital acquired. Hospital coders had identified no CA-UTIs (code 996.64 was never used), whereas physician-abstractors identified 36 CA-UTIs (45%; 28 hospital acquired and 8 present on admission). Catheter use often was evident only from nursing notes, which, unlike physician notes, cannot be used by coders to assign discharge codes. State and US annual rates of 996.64 coding (~1% of secondary-diagnosis UTIs) were similar to those at UMHS.

Hospital coders rarely use the catheter association code needed to identify CA-UTI among secondary-diagnosis UTIs. Coders often listed a UTI as present on admission, although the medical record indicated that it was hospital acquired. Because coding of hospital-acquired CA-UTI seems to be fraught with error, nonpayment according to CMS policy may not reliably occur.

To evaluate the feasibility of using an electronic hand hygiene surveillance and feedback monitoring device.

A 2-phase pilot study included initial direct observation of hand hygiene practices as part of routine hospital quality assurance (phase I) and subsequent monitoring using an electronic hand hygiene surveillance device (phase II).

A 700-bed tertiary care teaching hospital.

Phase I included a convenience sample of healthcare workers. Phase II included 7 medical interns and 7 registered nurses recruited through email and at work-related meetings.

During phase I, healthcare workers were directly observed at patient room entry and exit during the period April through November 2008. During phase II, hand hygiene data were gathered through indirect observation using the electronic device during a 4-week period in August 2009. Twenty patient rooms were fitted with electronic trigger devices that signaled a reader unit worn by participants when they entered the room, and 70 dispensers for liquid soap or hand sanitizer were fitted with triggers that signaled the reader unit when the dispenser was used. The accuracy of the devices was checked by the principal investigator, who manually recorded his room entries and exits and dispenser use while wearing a reader unit.

During phase I, hand hygiene occurred before room entry for 95 (25.1%) and after room exit for 149 (39.4%) of 378 directly observed patient room visits, for a cumulative composite compliance rate of 32.3%. Among the 378 room visits, 347 (91.8%) involved contact with the patient and/or environment. During phase II, electronic monitoring revealed a cumulative composite compliance rate of 25.5%. The electronic device captured 61 (98%) of 62 manually recorded room entries and 133 (95%) of 140 manually recorded dispensing events.

The electronic hand hygiene surveillance device seems to be a practical method for routinely monitoring hand hygiene compliance in healthcare workers.