To evaluate (1) the framework of the 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults that is part of the Centers for Disease Control and Prevention (CDC) Campaign to Prevent Antimicrobial Resistance in Healthcare Settings, with regard to steps addressing antimicrobial use; and (2) methods of feedback to clinicians regarding antimicrobial use after postprescription review.

Prospective intervention to identify and modify inappropriate antimicrobial therapy.

A 1,000-bed, tertiary care teaching hospital.

Inpatients in selected medicine and surgery units receiving broad-spectrum antimicrobials for 48-72 hours.

We created a computer-based clinical-event detection system that automatically identified inpatients taking broad-spectrum and “reserve” antimicrobials for 48-72 hours. Although prior approval was required for initial administration of broad-spectrum and reserve antimicrobials, once approval was obtained, therapy with the antimicrobials could be continued indefinitely at the discretion of the treating clinician. Therapy that was ongoing at 48-72 hours was reviewed by an infectious diseases pharmacist or physician, and when indicated feedback was provided to clinicians to modify or discontinue therapy. Feedback was provided via a direct telephone call, a note on the front of the medical record, or text message sent to the clinician's pager. The acceptance rate of feedback was recorded and recommendations were categorized according to the 12 steps recommended by the CDC.

Interventions were recommended for 334 (30%) of 1,104 courses of antimicrobial therapy reviewed. A total of 87% of interventions fit into one of the CDC's 12 steps of prevention: 39% into step 3 (“target the pathogen”), 1% into step 4 (“access experts”), 3% into steps 7 and 8 (“treat infection, not colonization or contamination”), 18% into step 9 (“say ‘no’ to vancomycin”), and 26% into step 10 (“stop treatment when no infection”). The rate of compliance with recommendations to improve antimicrobial use was 72%. No differences in compliance were seen with the different methods of feedback.

Nearly one-third of antimicrobial courses did not follow the CDC's recommended 12 steps for prevention of antimicrobial resistance. Clinicians demonstrated high compliance with following suggestions made after postprescription review, suggesting that it is a useful approach to decreasing and improving antimicrobial use among inpatients.

Many studies have investigated the association between prior antibiotic use and antibiotic resistance. However, methods used in past studies to describe the extent of prior antibiotic use (eg, use of the 2 categories exposure versus no exposure and measurement of duration of exposure) have not been reviewed. The impact of the use of different methods for quantifying the use of antibiotics is unknown. The objectives of this study were to characterize past approaches to describing the extent of antibiotic use and to identify the impact of the use of different methods on associations between use of specific antibiotics and infection with an antibiotic-resistant-organism.

We conducted a systematic review of studies that investigated risk factors for extended-spectrum β-lactamase (ESBL)-producing Escherichia coli and Klebsiella species to identify variability in past approaches to describing the extent of antibiotic use. We then reanalyzed a data set from a prior study of risk factors for infection with ESBL-producing E. coli and Klebsiella species. We developed 2 separate multivariable models: 1 in which prior antibiotic use was described as a categorical variable (eg, exposure or no exposure) and 1 in which antibiotic use was described as a continuous variable (eg, measured in antibiotic-days). These models were compared qualitatively.

Large academic medical center.

The 25 articles included in the systematic review revealed a variety of methods used to describe the extent of prior antibiotic exposure. Only 1 study justified its approach. Results from the 2 multivariable models that used different methodologic approaches differed substantially. Specifically, use of third-generation cephalosporins was a risk factor for infection with ESBL-producing E. coli and Klebsiella species when antibiotic use was described as a continuous variable but not when antibiotic use was described as a categorical variable.

There has been no consistent method for assessing the extent of prior antibiotic exposure. The use of different methods may substantially alter the identified antimicrobial risk factors, which has important implications for the resultant interventions regarding antimicrobial use.

To evaluate factors related to a gradual rise in sternal surgical site infection (SSI) rates.

Retrospective cohort study.

A 608-bed, tertiary care teaching hospital.

All patients who underwent coronary artery bypass graft (CABG) from January 2000 through September 2004.

Of 3,578 patients who underwent CABG, 144 (4%) had sternal SSI. There was an increase in infection rate, with a marked reduction in the number of operations per year. The percentage of patients with peripheral vascular disease increased from 12% to 24.3% (P < .001), and the percentage with congestive heart failure increased from 17% to 22% (P < .001). Between 2002 and 2004, the mean duration of surgery increased from 233 to 290 minutes (P < .001), the percentage of patients with a National Nosocomial Infections Surveillance System (NNIS) risk index of 2 increased from 14.3% to 38% (P < .001), and the percentage of patients with a postoperative stay in the intensive care unit of greater than 72 hours increased from 29% to 40.6% (P < .001). Multivariate analysis showed diabetes mellitus, peripheral vascular disease, obesity, duration of surgery, and postoperative stay in the intensive care unit of greater than 72 hours to be independently associated with infection.

An increase in infection in the CABG population not associated with an outbreak may be a reflection of a change in the severity of illness. Preoperative, intraoperative, and postoperative markers for increased infection risk may be used, in addition to the NNIS risk index, to assess the patient population risk.

We describe the investigation of a tuberculosis (TB) exposure in which a neonatal intensive care unit (NICU) respiratory therapist was the index patient, as well as the rationale by which exposed infants were managed and possible explanations for the lack of transmission to these patients.

Description of an exposure investigation.

Academic, level IV NICU of a tertiary care children's hospital.

Contacts of a respiratory therapist with pulmonary TB disease, including household members, healthcare coworkers, and infant patients.

In addition to 5 household contacts, 248 healthcare coworkers and 180 infant patients were identified as possibly exposed during the 24 days that the index patient worked between December 3, 2004, and January 30, 2005. Tuberculin skin tests (TSTs) were performed for 233 of the 235 contacts with the greatest degree of exposure (household and coworker contacts) who had a previously documented negative TST result or whose TST status was unknown prior to the investigation. No cases of latent tuberculosis infection or TB disease were identified. Because of characteristics of the index case, the exposure duration and setting, the infants' small lung volumes, and lack of evidence of transmission to higher-risk contacts, infants were not clinically evaluated or empirically treated for TB disease. Surveillance for subsequent illness was carried out by primary healthcare providers and parents. No TB disease or unexplained illness in these infants was reported in the 20 months following the exposure.

After limited hospital exposure to a healthcare worker with pulmonary TB disease who is not highly contagious, neonates can be safely managed without specific evaluation for TB disease or empirical treatment.

To quantify the value of performing active surveillance cultures for detection of methicillin-resistant Staphylococcus aureus (MRSA) on intensive care unit (ICU) discharge.

Prospective cohort study.

Medical ICU (MICU) and surgical ICU (SICU) of a tertiary care hospital.

We analyzed data on adult patients who were admitted to the MICU or SICU between January 17, 2001, and December 31, 2004. All participants had a length of ICU stay of at least 48 hours and had surveillance cultures of anterior nares specimens performed on ICU admission and discharge. Patients who had MRSA-positive clinical cultures in the ICU were excluded.

Of 2,918 eligible patients, 178 (6%) were colonized with MRSA on ICU admission, and 65 (2%) acquired MRSA in the ICU and were identified by results of discharge surveillance cultures. Patients with MRSA colonization confirmed by results of discharge cultures spent 853 days in non-ICU wards after ICU discharge, which represented 27% of the total number of MRSA colonization-days during hospitalization in non-ICU wards for patients discharged from the ICU.

Surveillance cultures of nares specimens collected at ICU discharge identified a large percentage of MRSA-colonized patients who would not have been identified on the basis of results of clinical cultures or admission surveillance cultures alone. Furthermore, these patients were responsible for a large percentage of the total number of MRSA colonization-days during hospitalization in non-ICU wards for patients discharged from the ICU.

To determine the prevalence and molecular epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) strains among residents in residential care homes for the elderly in Hong Kong.

Cross-sectional and descriptive study.

A total of 949 residents in 13 residential care homes for elderly persons in Hong Kong in January 2005.

MRSA colonization was assessed by culture of swab specimens from anterior nares and active skin lesions. Characteristics of residents were obtained by a standard questionnaire. All MRSA isolates were analyzed by polymerase chain reaction for their staphylococcal cassette chromosome (SCC) mec content and were typed by pulsed-field gel electrophoresis (PFGE) and multilocus sequencing.

MRSA colonization was detected in 27 residents (2.8%). No MRSA was found in 2 facilities. The rate of MRSA carriage in the other 11 facilities ranged from 1.9% to 4.2%. In univariate analysis, functional immobility (odds ratio [OR], 1.4), history of hospital admission (OR, 2.3), and the use of nebulized medication (OR, 5.4) were significantly associated with MRSA colonization. The isolates had 11 unique antibiograms, with 14 isolates susceptible to all but 1 or 2 of the non-β-lactam antimicrobial agents tested. The isolates exhibited SCCmec types I (1 isolate), II (2 isolates), III (1 isolate), IV/IVA (10 isolates), and V (13 isolates). No isolates had the Panton-Valentine leukocidin genes. PFGE analysis clustered all except 1 isolate into 7 PFGE types, designated HKU10 to HKU70. Between 1 and 4 unique PFGE types were found in the individual residential care facilities.

This study documented the emergence of SCCmec types IV and V among genetically diverse MRSA strains in residential care homes for elderly persons in Hong Kong.

Investigation of a program to eradicate amebiasis using consecutive intensive mass screenings followed by medication in a large institute for adults with mental retardation in Taiwan.

Prospective cohort study, with 3 years of follow-up.

A large, 450-bed institution for adults with mental retardation located in southern Taiwan.

All 443 adults with mental retardation in the institution, who have various motor and/or mental handicaps, were included in this study.

A total of 7 consecutive intensive mass screenings for amebiasis for all residents (performed in March, August and November 2001, March and August 2002, January 2003, and May 2004). Infected patients were treated using the standard protocol of the Center for Disease Control of Taiwan.

Enzyme immunoassay testing was used for the amebiasis screening, with the rapid detection of the specific antigen for Entamoeba histolytica in human fecal specimens confirmed by microscopic examination. The serial prevalence and cumulative incidence were then calculated. The prevalence of amebic infection declined in serial screenings, but new infections and reinfections were detected in 5 of 6 follow-up screenings. The prevalence was 10.8% at the beginning of the program and then gradually reduced, falling to 6.3%, 3.6%, 2.7%, 3.4%, and 2.2%. Finally, no more positive cases were identified in the last screening (May 2004). The cumulative incidence rate stabilized at around 40% by the fifth screening. Of the 179 infected patients, 120 had primary infections, with 59 cases of multiple amebic infections.

Active surveillance with intensive mass screening is an effective method of identifying asymptomatic and latent cases of amebiasis in areas where it is endemic, such as an institution for adults with mental retardation.

To determine whether introduction of a needleless mechanical valve device (NMVD) at a long-term acute care hospital was associated with an increased frequency of catheter-related bloodstream infection (BSI).

For patients with a central venous catheter in place, the catheter-related BSI rate during the 24-month period before introduction of the NMVD, a period in which a needleless split-septum device (NSSD) was being used (hereafter, the NSSD period), was compared with the catheter-related BSI rate during the 24-month period after introduction of the NMVD (hereafter, the NMVD period). The microbiological characteristics of catheter-related BSIs during each period were also compared. Comparisons and calculations of relative risks (RRs) with 95% confidence intervals (CIs) were performed using χ2 analysis.

Eighty-six catheter-related BSIs (3.86 infections per 1,000 catheter-days) occurred during the study period. The rate of catheter-related BSI during the NMVD period was significantly higher than that during the NSSD period (5.95 vs 1.79 infections per 1,000 catheter-days; RR, 3.32 [95% CI, 2.88–3.83]; P < .001). A significantly greater percentage of catheter-related BSIs during the NMVD period were caused by gram-negative organisms, compared with the percentage recorded during the NSSD period (39.5% vs 8%; P = .007). Among catheter-related BSIs due to gram-positive organisms, the percentage caused by enterococci was significantly greater during the NMVD period, compared with the NSSD period (54.8% vs 13.6%; P = .004). The catheter-related BSI rate remained high during the NMVD period despite several educational sessions regarding proper use of the NMVD.

An increased catheter-related BSI rate was temporally associated with use of a NMVD at the study hospital, despite several educational sessions regarding proper NMVD use. The current design of the NMVD may be unsafe for use in certain patient populations.

Intravascular catheters are indispensable tools in modern medical therapy. In spite of their great benefits, however, the widespread use of catheters leads to several complications, including infections that cause significant morbidity, mortality, and economic losses for hospitalized patients.

This study was conducted at Farabi Hospital, a 495-bed facility at Karadeniz Technical University Medical School in Trabzon, Turkey, and involved 3 separate periods: preeducation, education, and posteducation. Patients with intravascular catheters were monitored daily, as were the results of their physical examinations. The information acquired was recorded in a questionnaire.

During the preeducation period (October 2003 through March 2004), 405 intravascular catheters inserted into 241 patients were observed for 5,445 catheter-days. Seventy-one cases of intravascular catheter-related infection (CRI) were identified, giving a CRI rate of 13.04 infections per 1,000 catheter-days. The catheter-related bloodstream infection (CRBSI) rate was 8.3 infections per 1,000 catheter-days, and the exit-site infection (ESI) rate was 3.5 infections per 1,000 catheter-days. During the posteducation period (June through November 2004), 365 intravascular catheters inserted into 193 patients were observed for 5,940 catheter-days. Forty-five cases of CRI were identified, giving a rate of 7.6 infections per 1,000 catheter-days. The CRBSI rate was 4.7 infections per 1,000 catheter-days, and the ESI rate was 2.2 infections per 1,000 catheter-days. When findings from the 2 periods were compared, it was determined that education reduced CRI incidence by 41.7%.

CRI can be prevented when hospital personnel are well informed about these infections. We compared the knowledge levels of the relevant personnel in our hospital before and after theoretical and practical training and identified a significant increase in knowledge after training (P < .0001 ). Parallel to this, although still below ideal levels, we identified a significant improvement in the incidence of CRI during the posteducation period (P = .004). The rate was low for the first 3 months of this period but increased 2.08 times after the third month. In conclusion, regular training for the residents in charge of inserting intravascular catheters and the nurses and interns who maintain the catheters is highly effective in reducing the rate of CRI in large teaching hospitals.

To assess adverse events associated with antiretroviral regimens for human immunodeficiency virus (HIV) postexposure prophylaxis (PEP), with a particular focus on the treatment combination of zidovudine, lamivudine, and tenofovir (ZDV-3TC-TDF).

Retrospective chart review for individuals who received HIV PEP for occupational and nonoccupational exposure, and multivariate analyses to identify risk factors for noncompletion of PEP and adverse events associated with PEP.

University of Rochester Health Service Occupational Health Program and University of Rochester AIDS Center.

Healthcare workers who received HIV PEP for occupational exposure from January 1, 1999, to December 31, 2004, and individuals who received HIV PEP for nonoccupational exposure from January 1, 2002, to December 31, 2004.

We found increased rates of nausea among subjects who received treatment with ZDV-3TC-TDF and subjects who received treatment with zidovudine, lamivudine, and indinavir (ZDV-3TC-IDV). Analyses showed that female sex was a risk factor for nausea. Compared with subjects who received treatment with ZDV-3TC-TDF, subjects who received treatment with ZDV-3TC-IDV were less likely to not complete the HIV PEP for occupational exposure.

Preventive treatment of adverse events may be necessary to ensure completion of HIV PEP.

Persons who receive live attenuated vaccine may occasionally transmit the vaccine strain to others. The risk of such transmission is a concern, especially for persons who provide care to immunocompromised patients (ie, family and healthcare workers [HCWs]). Since the Advisory Committee on Immunization Practices released guidelines 10 years ago, several new live attenuated products have been introduced, and additional information on older vaccines has become available. To better define the risk of transmission associated with live vaccines, we reviewed the currently available literature.

A review of the medical literature revealed no major risk of transmission associated with any live attenuated vaccine. A theoretical risk continues to exist for the live attenuated intranasal influenza vaccine and the smallpox vaccine.

The available data support routine vaccination with live attenuated vaccines for all household contacts of immunocompromised patients and for HCWs caring for such Patients. The benefit for immunocompromised patients of providing herd immunity against this group of potentially devastating pathogens outweighs the risk, if any, of secondary transmission.

To assess the impact of outbreaks of Bordetella pertussis infection on a tertiary care medical system.

Retrospective study.

Academic tertiary care medical center and affiliated ambulatory care settings.

All patients and healthcare workers (HCWs) who were in close contact with patients with laboratory-confirmed cases of B. pertussis infection from October 1, 2003, through September 30, 2004.

Direct and indirect medical center costs were determined, including low and high estimates of time expended in the evaluation and management of exposed patients and HCWs during outbreak investigations of laboratory-confirmed cases of B. pertussis infection.

During this period, 20 primary and 3 secondary laboratory-confirmed cases of B. pertussis infection occurred, with 2 primary pertussis cases and 1 secondary case occurring in HCWs. Outbreak investigations prompted screening of 353 medical center employees. Probable or definitive exposure was identified for 296 HCWs, and 287 subsequently received treatment or prophylaxis for B. pertussis infection. Direct medical center costs for treatment and prophylaxis were $13,416 and costs for personnel time were $19,500-$31,190. Indirect medical center costs for time lost from work were $51,300-$52,300. The total cost of these investigations was estimated to be $85,066-$98,456.

Frequent B. pertussis exposures had a major impact on our facility. Given the impact of exposures on healthcare institutions, routine vaccination for HCWs may be beneficial.

To investigate the impact of antimicrobial resistance on clinical and economic outcomes among hospitalized patients with multidrug-resistant (MDR) Acinetobacter baumannii bacteremia.

A retrospective, matched-cohort study.

A tertiary care university teaching hospital

A matched case-control (1:1) study was conducted to compare the differences in clinical and economic outcomes of patients with MDR A. baumannii bacteremia and patients with non-MDR A. baumannii bacteremia. Case patients were matched to control patients on the basis of sex, age, severity of underlying and acute illness, and length of hospital stay before onset of bacteremia.

Forty-six (95.8%) of 48 cases with MDR A. baumannii bacteremia were eligible for the study and matched with appropriate controls. The sepsis-related mortality rate was 34.8% among cases and 13.0% among controls, for an attributable mortality rate of 21.8% (adjusted odds ratio, 4.1 [95% confidence interval, 1.1-15.7]; P = .036). After the onset of bacteremia, cases and controls had a significantly different length of hospital stay (54.2 vs 34.1 days; P = .006), hospitalization cost (US$9,349 vs US$4,865; P = .001 ), and antibiotic therapy cost (US$2,257 vs US$1,610; P = .014). Thus, bacteremia due to MDR A. baumannii resulted in 13.4 days of additional hospitalization and US$3,758 of additional costs, compared with bacteremia due to non-MDR A. baumannii.

Patients with MDR A. baumannii bacteremia had a higher mortality rate and incurred greater medical costs than patients with non-MDR A. baumannii bacteremia.