To describe a Klebsiella pneumoniae carbapenemase (KPC)–producing carbapenem-resistant Enterobacteriaceae (CRE) outbreak and interventions to prevent transmission.

Epidemiologic investigation of a CRE outbreak among patients at a long-term acute care hospital (LTACH).

Microbiology records at LTACH A from March 2009 through February 2011 were reviewed to identify CRE transmission cases and cases admitted with CRE. CRE bacteremia episodes were identified during March 2009–July 2011. Biweekly CRE prevalence surveys were conducted during July 2010–July 2011, and interventions to prevent transmission were implemented, including education and auditin? of staff and isolation and cohorting of CRE patients with dedicated nursing staff and shared medical equipment. Trends were evaluated using weighted linear or Poisson regression. CRE transmission cases were included in a case-control study to evaluate risk factors for acquisition. A real-time polymerase chain reaction assay was used to detect the blaKPC gene, and pulsed-field gel electrophoresis was performed to assess the genetic relatedness of isolates.

Ninety-nine CRE transmission cases, 16 admission cases (from 7 acute care hospitals), and 29 CRE bacteremia episodes were identified. Significant reductions were observed in CRE prevalence (49% vs 8%), percentage of patients screened with newly detected CRE (44% vs 0%), and CRE bacteremia episodes (2.5 vs 0.0 per 1,000 patient-days). Cases were more likely to have received β-lactams, have diabetes, and require mechanical ventilation. All tested isolates were KPC-producing K. pneumoniae, and nearly all isolates were genetically related.

CRE transmission can be reduced in LTACHs through surveillance testing and targeted interventions. Sustainable reductions within and across healthcare facilities may require a regional public health approach.

Infect Control Hosp Epidemiol 2012;33(10):984-992

To evaluate national data on healthcare-associated infections (HAIs), device utilization, and antimicrobial resistance in long-term acute care hospitals (LTACHs).

Comparison of data from LTACHs and from medical and medical-surgical intensive care units (ICUs) in short-stay acute care hospitals reporting to the National Healthcare Safety Network (NHSN) during 2010.

Rates of central line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and ventilator-associated pneumonia (VAP) as well as device utilization ratios were calculated. For each HAI, pathogen profiles and antimicrobial resistance prevalence were evaluated. Comparisons were made using Poisson regression and the Mood median and x2 tests.

In 2010, 104 LTACHs reported CLABSIs and 57 reported CAUTIs and VAP to the NHSN. Median CLABSI rates in LTACHs (1.25 events per 1,000 device-days reported; range, 0.0-5.96) were comparable to rates in major teaching ICUs and were higher than those in other ICUs. CAUTI rates in LTACHs (median, 2.61; range, 0.0-9.92) were higher and VAP rates (median, 0.0; range, 0.0-3.29) were generally lower than those in ICUs. Central line utilization in LTACHs was higher than that in ICUs, whereas urinary catheter and ventilator utilization was lower. Methicillin resistance among Staphylococcus aureus CLABSIs (83%) and vancomycin resistance among Enterococcus faecalis CAUTIs (44%) were higher in LTACHs than in ICUs. Multidrug resistance among Pseudomonas aeruginosa CAUTIs (25%) was higher in LTACHs than in most ICUs.

CLABSIs and CAUTIs associated with multidrug-resistant organisms present a challenge in LTACHs. Continued HAI surveillance with pathogen-level data can guide prevention efforts in LTACHs.

Infect Control Hosp Epidemiol 2012;33(10):993-1000

Bloodstream infection (BSI) secondary to nosocomial urinary tract infection is associated with substantial morbidity, mortality, and additional financial costs. Our objective was to identify predictors of nosocomial urinary tract-related BSI.

Matched case-control study.

Midwestern tertiary care hospital.

Cases n = 298) were patients with a positive urine culture obtained more than 48 hours after admission and a blood culture obtained within 14 days of the urine culture that grew the same organism. Controls (n = 667), selected by incidence density sampling, included patients with a positive urine culture who were at risk for BSI but did not develop one.

Conditional logistic regression and classification and regression tree analyses.

The most frequently isolated microorganisms that spread from the urinary tract to the bloodstream were Enterococcus species. Independent risk factors included neutropenia (odds ratio [OR], 10.99; 95% confidence interval [CI], 5.78-20.88), renal disease (OR, 2.96; 95% CI, 1.98-4.41), and male sex (OR, 2.18; 95% CI, 1.52-3.12). The probability of developing a urinary tract-related BSI among neutropenic patients was 70%. Receipt of immunosuppressants (OR, 1.53; 95% CI, 1.04-2.25), insulin (OR, 4.82; 95% CI, 2.52-9.21), and antibacterials (OR, 0.66; 95% CI, 0.44-0.97) also significantly altered risk.

The heightened risk of urinary tract-related BSI associated with several comorbid conditions suggests that the management of nosocomial bacteriuria may benefit from tailoring to certain patient subgroups. Consideration of time-dependent risk factors, such as medications, may also help guide clinical decisions in reducing BSI.

Infect Control Hosp Epidemiol 2012;33(10):1001-1007

To collect data about personal protective equipment (PPE) management and to provide indications for improving PPE policies in Europe.

Descriptive, cross-sectional survey.

Data were collected in 48 isolation facilities in 16 European countries nominated by National Health Authorities for the management of highly infectious diseases (HIDs).

Data were collected through standardized checklists at on-site visits during February-November 2009. Indications for adequate PPE policies were developed on the basis of a literature review, partners' expert opinions, and the collected data.

All facilities have procedures for the selection of PPE in case of HID, and 44 have procedures for the removal of PPE. In 40 facilities, different levels of PPE are used according to a risk assessment process, and in 8 facilities, high-level PPE (eg, positive-pressure complete suits or Trexler units) is always used. A fit test is performed at 25 of the 40 facilities at which it is applicable, a seal check is recommended at 25, and both procedures are used at 17. Strategies for promoting and monitoring the correct use of PPE are available at 42 facilities. In case of a sudden increase in demand, 44 facilities have procedures for rapid supply of PPE, whereas 14 facilities have procedures for decontamination and reuse of some PPE.

Most isolation facilities devote an acceptable level of attention to PPE selection and removal, strategies for the promotion of the correct use of PPE, and ensuring adequate supplies of PPE. Fit test and seal check procedures are still not widely practiced. Moreover, policies vary widely between and within European countries, and the development of common practice procedures is advisable.

Infect Control Hosp Epidemiol 2012;33(10):1008-1016

Healthcare providers and other employees, especially those who do not work in a hospital, may not easily find help after the occurrence of a blood exposure accident. In 2006, a national call center was established in the Netherlands to fill this gap.

All occupational blood exposure accidents reported to the 24-hours-per-day, 7-days-per-week call center from 2007, 2008, and 2009 were analyzed retrospectively for incidence rates, risk assessment, handling, and preventive measures taken.

A total of 2,927 accidents were reported. The highest incidence rates were reported for private clinics and hospitals (68.5 and 54.3 accidents per 1,000 person-years, respectively). Dental practices started reporting incidents frequently after the arrangement of a collective financial agreement with the call center. Employees of ambulance services, midwife practices, and private clinics reported mostly high-risk accidents, whereas penitentiaries frequently reported low-risk accidents. Employees in mental healthcare facilities, private clinics, and midwife practices reported accidents relatively late. The extent of hepatitis B vaccination in mental healthcare facilities, penitentiaries, occupational health services, and cleaning services was low (<70%).

The national call center successfully organized the national registration and handling of blood exposure accidents. The risk of blood exposure accidents could be estimated on the basis of this information for several occupational branches. Targeted preventive measures for healthcare providers and other employees at risk can next be developed.

Infect Control Hosp Epidemiol 2012;33(10):1017-1023

To examine potential clinical outcomes and cost of active methicillin-resistant Staphylococcus aureus (MRSA) surveillance with and without decolonization in neonatal intensive care units (NICUs) from the perspective of healthcare providers in Hong Kong.

Decision analysis modeling.

NICU.

Hypothetical cohort of patients admitted to an NICU.

We designed a decision tree to simulate potential outcomes of active MRSA surveillance with and without decolonization in patients admitted to an NICU. Outcome measures included total direct medical cost per patient, MRSA infection rate, and MRSA-associated mortality rate. Model inputs were derived from the literature. Sensitivity analyses evaluated the impact of uncertainty in all model variables.

In the base-case analysis, active surveillance plus decolonization showed a lower expected MRSA infection rate (0.911% vs 1.759%), MRSA-associated mortality rate (0.223% vs 0.431%), and total cost per patient (USD 47,294 vs USD 48,031) compared with active surveillance alone. Sensitivity analyses showed that active surveillance plus decolonization cost less and had lower event rates if the incidence risk ratio of acquiring MRSA infections in carriers after decolonization was less than 0.997. In 10,000 Monte Carlo simulations, active surveillance plus decolonization was significantly less costly than active surveillance alone 99.9% of the time, and both the MRSA infection rate and the MRSA-associated mortality rate were significantly lower 99.9% of the time.

Active surveillance plus decolonization for patients admitted to NICUs appears to be cost saving and effective in reducing the MRSA infection rate and the MRSA-associated mortality rate if addition of decolonization to active surveillance reduces the risk of MRSA infection.

Infect Control Hosp Epidemiol 2012;33(10):1024-1030

To describe the epidemiology and healthcare costs of Clostridium difficile infection (CDI) identified in the outpatient setting.

Population-based, retrospective cohort study.

Kaiser Permanente Colorado and Kaiser Permanente Northwest members between June 1, 2005, and September 30, 2008.

We identified persons with incident CDI and classified CDI by whether it was identified in the outpatient or inpatient healthcare setting. We collected information about baseline variables and follow-up healthcare utilization, costs, and outcomes among patients with CDI. We compared characteristics of patients with CDI identified in the outpatient versus inpatient setting.

We identified 3,067 incident CDIs; 56% were identified in the outpatient setting. Few strong, independent predictors of diagnostic setting were identified, although a previous stay in a nonacute healthcare institution (odds ratio [OR], 1.45 [95% confidence interval (CI), 1.13-1.86]) was statistically associated with outpatient-identified CDI, as was age from 50 to 59 years (OR, 1.64 [95% CI, 1.18-2.29]), 60 to 69 years (OR, 1.37 [95% CI, 1.03-1.82]), and 70 to 79 years (OR, 1.36 [95% CI, 1.06-1.74]), when compared with persons aged 80-89 years.

We found that more than one-half of incident CDIs in this population were identified in the outpatient setting. Patients with outpatient-identified CDI were younger with fewer comorbidities, although they frequently had previous exposure to healthcare. These data suggest that practitioners should be aware of CDI and obtain appropriate diagnostic testing on outpatients with CDI symptoms.

Infect Control Hosp Epidemiol 2012;33(10):1031-1038