To determine the extent to which evidence-based practices for the prevention of central venous catheter (CVC)-associated bloodstream infections are incorporated into the policies and practices of academic intensive care units (ICUs) in the United States and to determine variations in the policies on CVC insertion, use, and care.

A 9-page written survey of practices and policies for nontunneled CVC insertion and care.

ICUs in 10 academic tertiary-care hospitals.

ICU medical directors and nurse managers.

Twenty-five ICUs were surveyed (1-6 ICUs per hospital). In 80% of the units, 5 separate groups of clinicians inserted 24%-50% of all nontunneled CVCs. In 56% of the units, placement of more than two-thirds of nontunneled CVCs was performed in a single location in the hospital. Twenty units (80%) had written policies for CVC insertion. Twenty-eight percent of units had a policy requiring maximal sterile-barrier precautions when CVCs were placed, and 52% of the units had formal educational programs with regard to CVC insertion. Eighty percent of the units had a policy requiring staff to perform hand hygiene before inserting CVCs, but only 36% and 60% of the units required hand hygiene before accessing a CVC and treating the exit site, respectively.

ICU policy regarding the insertion and care of CVCs varies considerably from hospital to hospital. ICUs may be able to improve patient outcome if evidence-based guidelines for CVC insertion and care are implemented.

Bloodstream infection (BSI) rates are used as comparative clinical performance indicators; however, variations in definitions and data-collection approaches make it difficult to compare and interpret rates. To determine the extent to which variation in indicator specifications affected infection rates and hospital performance rankings, we compared absolute rates and relative rankings of hospitals across 5 BSI indicators.

Multicenter observational study. BSI rate specifications varied by data source (clinical data, administrative data, or both), scope (hospital wide or intensive care unit specific), and inclusion/exclusion criteria. As appropriate, hospital-specific infection rates and rankings were calculated by processing data from each site according to 2-5 different specifications.

A total of 28 hospitals participating in the EPIC study.

Hospitals submitted deidentified information about all patients with BSIs from January through September 1999.

Median BSI rates for 2 indicators based on intensive care unit surveillance data ranged from 2.23 to 2.91 BSIs per 1000 central-line days. In contrast, median rates for indicators based on administrative data varied from 0.046 to 7.03 BSIs per 100 patients. Hospital-specific rates and rankings varied substantially as different specifications were applied; the rates of 8 of 10 hospitals were both greater than and less than the mean. Correlations of hospital rankings among indicator pairs were generally low (rs = 0-0.45), except when both indicators were based on intensive care unit surveillance (rs = 0.83).

Although BSI rates seem to be a logical indicator of clinical performance, the use of various indicator specifications can produce remarkably different judgments of absolute and relative performance for a given hospital. Recent national initiatives continue to mix methods for specifying BSI rates; this practice is likely to limit the usefulness of such information for comparing and improving performance.

Needleless valve connectors for vascular catheters are widely used throughout the United States because they reduce the risk of biohazardous injuries from needlesticks and exposure to bloodborne pathogens, such as human immunodeficiency virus and hepatitis C virus. Patients with long-term central venous catheters are at significant risk of acquiring catheter-related bloodstream infections caused by microbes that gain access through the connection between the administration set and the catheter or an injection port. Most healthcare practitioners wipe the membranous septum of the needleless connector or the injection port with 70% alcohol before accessing it. We report a simulation study of the efficacy of conventional alcohol disinfection before access, compared with that of a novel antiseptic-barrier cap that, when threaded onto a needleless luer-activated valved connector, allows a chlorhexidine-impregnated sponge to come into continuous contact with the membranous surface; after removal of the cap, there is no need to disinfect the surface with alcohol before accessing it.

One hundred five commercial, needleless luer-activated valved connectors, each accessible by a blunt male-connector luer-lock attachment, were purchased from 3 manufacturers and were tested. The membranous septum of each test device was first heavily contaminated with ~105 colony-forming units of Enterococcus faecalis and then was allowed to dry for 24 hours. Fifteen of the contaminated devices were not disinfected (positive controls), 30 were conventionally disinfected with a commercial 70% alcohol pledget, and 60 had the antiseptic cap threaded onto the connector and then removed after 10 minutes. The test connectors were then accessed with a sterile syringe containing nutrient broth media, which was injected, captured on the downstream side of the intraluminal fluid pathway, and cultured quantitatively.

All 15 control connectors (100%) showed massive transmission of microorganisms across the membranous septum (4,500-10,000 colony-forming units). Of the 30 connectors accessed after conventional disinfection with 70% alcohol, 20 (67%) showed transmission of microorganisms (442-25,000 colony-forming units). In contrast, of the 60 connectors cultured after application of the novel antiseptic cap, only 1 (1.6%) showed any transmission of microorganisms (P<.001).

The findings of this study show that, if the membranous septum of a needleless luer-activated connector is heavily contaminated, conventional disinfection with 70% alcohol does not reliably prevent entry of microorganisms. In contrast, the antiseptic-barrier cap provided a high level of protection, even in the presence of very heavy contamination. This novel technology deserves to be studied in a clinical trial.

To compare risk factors, clinical features, and outcomes in patients with Enterococcus avium, Enterococcus casseliflavus, Enterococcus durans, Enterococcus gallinarum, and Enterococcus mundtii bacteremia (cases) with those in patients with Enterococcus faecalis bacteremia (controls).

A retrospective case-control study.

A 725-bed, university-affiliated, academic medical center.

The clinical microbiology database at Northwestern Memorial Hospital from January 1994 to May 2003 was searched to identify cases; each case was matched to one control on the basis of date of admission.

Thirty-three cases were identified and matched with 33 controls. The mean duration of hospital stay was longer (29.7 vs 17.2 days; P = .03) and the mean time to acquisition of bacteremia was greater (16.5 vs 6.3 days; P = .003) for cases than controls. Cases were more likely to have underlying hematologic malignancies (P < .001), to have been treated with corticosteroids (P = .02), and to be neutropenic (P = .003). Controls were more likely to have an indwelling bladder catheter (P = .01), and cases were more likely to have the gastrointestinal tract as a source of infection (P = .007) and to have concurrent cholangitis (P = .002). There were no differences in severity of illness or in mortality rates.

Compared with patients with E. faecalis bacteremia, patients with non-E. faecalis, non-Enterococcus faecium enterococcal bacteremia were more likely to have a hematologic malignancy, prior treatment with corticosteroids, neutropenia, and cholangitis; longer duration of hospital stay was also identified as a clinical feature. However, non-E. faecalis, non-E. faecium species are not associated with any differences in mortality.

Groin wound infection (GWI) after femoral artery catheterization is unusual. However, several reports of GWI associated with the use of a Perclose device appear in the surgical literature.

A case-control study.

We pooled 23 cases and 83 controls from a university hospital and a community medical center.

A case was defined as a patient who developed a GWI after a femoral artery catheterization. At the university hospital, 3 controls were randomly selected from the at-risk population and matched to each case by time of procedure only (within 2 weeks). At the community medical center, 4 controls were selected and matched to each case by time of procedure (within 2 weeks), sex, and age (within 5 years).

We considered several covariates, including age, sex, body mass index, medical conditions, Perclose use, hematoma formation, and antithrombotic therapy. In a multivariate model, only hematoma formation (odds ratio, 68.8; 95% confidence interval, 12.1-391.4) and glycoprotein IIb/IIIa platelet inhibitor therapy (odds ratio, 6.1; 95% confidence interval, 1.1-33.6) were statistically significant predictors of GWI; Perclose use (odds ratio, 0.9; 95% confidence interval, 0.2-3.7) was not a statistically significant predictor of GWI. However, most of the hematomas (15/17) formed after procedures during which a Perclose device was used.

Perclose use did not have any additional effect on GWI risk beyond the effect that hematoma formation had.

To evaluate the efficacy of silicone-based, silver ion–impregnated urinary catheters in the prevention of nosocomial urinary tract infections (NUTIs).

Prospective, crossover study to compare the efficacy of a silicone-based, hydrogel-coated, silver-impregnated Foley catheter with that of a silicone-based, hydrogel-coated catheter in the prevention of NUTIs.

Adult medical and surgical wards of a university teaching hospital.

A total of 3,036 patients with catheters were evaluated; 1,165 (38%) of the catheters were silver impregnated, and 1,871 (62%) were not silver impregnated. Study groups were not identical; there were more men, a shorter duration of catheterization, and fewer urine cultures per 1,000 catheter-days in the silver catheter group. The rate of NUTIs per 1,000 Foley-days was 14.29 in the silver catheter group, compared with 16.15 in the nonsilver catheter group (incidence rate ratio, 0.88; 95% confidence interval, 0.70-1.11; P = .29). The median length of catheterization prior to the onset of a urinary tract infection (ie, exposure time) was 4 days for each group. There were no differences in the recovery of gram-positive, gram-negative, or fungal organisms in NUTIs. In a multivariate survival analysis, no factors, including silver catheters, were protective against NUTI.

Unlike previous trials of latex-based, silver ion–impregnated Foley catheters, we found that silicone-based, silver-impregnated Foley catheters were not effective in preventing NUTIs; however, this study was affected by differences in the study groups. Prospective trials remain important in assessing the efficacy and cost-effectiveness of new silver-coated products.

To assess the degree of fungal contamination in hospital environments and to evaluate the ability of air conditioning systems to reduce such contamination.

We monitored airborne microbial concentrations in various environments in 10 hospitals equipped with air conditioning. Sampling was performed with a portable Surface Air System impactor with replicate organism detection and counting plates containing a fungus-selective medium. The total fungal concentration was determined 72-120 hours after sampling. The genera most involved in infection were identified by macroscopic and microscopic observation.

The mean concentration of airborne fungi in the set of environments examined was 19 ± 19 colony-forming units (cfu) per cubic meter. Analysis of the fungal concentration in the different types of environments revealed different levels of contamination: the lowest mean values (12 ± 14 cfu/m3) were recorded in operating theaters, and the highest (45 ± 37 cfu/m3) were recorded in kitchens. Analyses revealed statistically significant differences between median values for the various environments. The fungal genus most commonly encountered was Penicillium, which, in kitchens, displayed the highest mean airborne concentration (8 ± 2.4 cfu/m3). The percentage (35%) of Aspergillus documented in the wards was higher than that in any of the other environments monitored.

The fungal concentrations recorded in the present study are comparable to those recorded in other studies conducted in hospital environments and are considerably lower than those seen in other indoor environments that are not air conditioned. These findings demonstrate the effectiveness of air-handling systems in reducing fungal contamination.

Although adequate knowledge about HIV infection and effective antitransmission measures, such as taking universal precautions in the handling of blood and other body fluids, are important factors in minimizing the risk of HIV transmission in the healthcare setting, little has been reported on the knowledge of nurses with regard to HIV infection and their attitude toward patients with AIDS in Iran. The aim of the present study was to assess these matters.

A questionnaire-based cross-sectional study was conducted from March to April 2003. Included were 1098 nursing staff (registered nurses, registered midwives, and auxiliary nurses) from 8 university teaching hospitals affiliated with the Shiraz University of Medical Sciences.

Registered nurses and midwives had a significantly higher level of knowledge about HIV infection than did auxiliary nurses (χ2 = 16.4; df = 1; P<.001). With regard to the causative agent of AIDS, nurses holding a bachelor of science in nursing or a master of science in nursing (MSN) had a significantly higher level of knowledge than did auxiliary nurses (χ2 = 18.6; df = 1; P<.001). Women more often answered correctly that it is not possible to identify HIV-infected patients by their appearance during the early stages of disease than did men (χ2 = 17.52; df= 1; P<.001). Although 50.7% of respondents had previously cared for patients with AIDS and 54.3% had participated in education programs on AIDS, nearly half stated that they would not want to have to care for patients with AIDS and that, if assigned to care for such a patient, they would ask to be assigned elsewhere.

Our finding that those who scored best on the questionnaire were midwives and single female nurses holding an MSN who had previously cared for HIV-infected patients scored best might indicate that use of selective education campaigns is the most suitable education strategy. The effectiveness of targeted education programs on HIV/AIDS should be repeatedly evaluated in the future.

To establish the occurrence, distribution, and secular time trend of nosocomial infections (NIs) in a surgical intensive care unit (ICU).

Follow-up study in a teaching hospital in Spain.

In May 1995 we established an nosocomial infection surveillance system in our surgical ICU. We collected information daily for all patients who were in the ICU for at least 48 hours (546 patients from 1996 through 2000). We used the Centers for Disease Control and Prevention definitions and criteria for infections. Monthly, we determined the site-specific incidence densities of NIs, the rates of medical device use, and the Poisson probability distribution, which determined whether the case count equalled the number of expected cases (the mean number of cases during the previous year, with extreme values excluded). We compared yearly and monthly infection rates by Poisson regression, using site-specific NIs as a dependent variable and year and month as dummy variables. We tested annual trends with an alternative Poisson regression model fitting a single linear trend.

The average rate of catheter-associated urinary tract infections was 8.4 per 1000 catheter-days; that of ventilator-associated pneumonia, 21 per 1000 ventilator-days; and that of central line–associated bloodstream infections, 30 per 1000 central line–days. The rate of urinary tract infections did not change over the study period, but there was a trend toward decreases in the rates of central line–associated bloodstream infections and ventilator-associated pneumonia.

An NI surveillance and control program contributed to a progressive decrease in NI rates.

To evaluate the impact of an infection control program in an intensive care unit (ICU).

Prospective before-after study. Two 6-month study periods were compared; between these periods, an infection control program based on isolation was implemented.

Polyvalent ICU of Montpellier Teaching Hospital.

Any patient who was hospitalized in the ICU for >48 hours and was discharged during 1 of the 2 periods.

The main patient-related variables were sex, age at admission, type of patient (surgical, medical, or trauma), Simplified Acute Physiology Score II, length of ICU stay, need for intubation, duration of exposure to invasive devices, onset of nosocomial infection and pathogens responsible, and death. We compared the 2 study periods with respect to the incidence of 4 nosocomial infections (pneumonia, urinary tract infection, bacteremia, and catheter-associated infection), the frequency of infection with the main multidrug-resistant pathogens, and patient survival.

Patients in periods 1 and 2 were similar with regard to sex, age, physiology score, and exposure to invasive devices. The rates of infection with multidrug-resistant pathogens were significandy lower during period 2 than during period 1 (infection rate: 28.1% of patients in period 1 and 9.6% of patients in period 2 [P = .01]; pneumonia rate: 32.6% of patients in period 1 and 4.2% of patients in period 2 [P = .008]). The mortality rate among patients with nosocomial pneumonia was 38.2% in period 1 and 4.3% in period 2 (P = .009).

After implementation of an infection control program, the rate of infection with multidrug-resistant pathogens decreased, as did the mortality rate among patients with nosocomial pneumonia.