To measure support for seasonal influenza vaccination requirements among US healthcare personnel (HCP) and its associations with attitudes regarding influenza and influenza vaccination and self-reported coverage by existing vaccination requirements.

Between lune 1 and June 30, 2010, we surveyed a sample of US HCP (n = 1,664) recruited using an existing probability-based online research panel of participants representing the US general population as a sampling frame.

General community.

Eligible HCP who (1) reported having worked as medical doctors, health technologists, healthcare support staff, or other health practitioners or who (2) reported having worked in hospitals, ambulatory care facilities, long-term care facilities, or other health-related settings.

We analyzed support for seasonal influenza vaccination requirements for HCP using proportion estimation and multivariable probit models.

A total of 57.4% (95% confidence interval, 53.3%–61.5%) of US HCP agreed that HCP should be required to be vaccinated for seasonal influenza. Support for mandatory vaccination was statistically significantly higher among HCP who were subject to employer-based influenza vaccination requirements, who considered influenza to be a serious disease, and who agreed that influenza vaccine was safe and effective.

A majority of HCP support influenza vaccination requirements. Moreover, providing HCP with information about the safety of influenza vaccination and communicating that immunization of HCP is a patient safety issue may be important for generating staff support for influenza vaccination requirements.

Infect Control Hosp Epidemiol 2012;33(3):213-221

To describe a pseudo-outbreak associated with loose bronchoscope biopsy ports caused by inadequate bronchoscope repair practices by third-party vendors and to alert healthcare personnel to assess bronchoscope repair practices.

Outbreak investigation.

A 925-bed tertiary care hospital in Baltimore, Maryland.

Patients who underwent bronchoscopy with certain bronchoscopes after they had been repaired by a third-party vendor.

An epidemiologic investigation was conducted to determine the cause of Pseudomonas putida growth in 4 bronchoalveolar lavage (BAL) specimens within a 3-day period in May 2008. All bronchoscopes were inspected, and cultures were obtained from bronchoscopes and the environment. Bronchoscope cleaning and maintenance practices were reviewed. Microbiologic results from BAL specimens and medical records were reviewed to find additional cases.

All 4 case patients had undergone bronchoscopy with one of 2 bronchoscopes, both of which had loose biopsy ports. Bronchoscope cultures grew P. putida, Pseudomonas aeruginosa, and Stenotrophomonas. The P. putida strains from the bronchoscopes matched those from the patients. Specimens from 12 additional patients who underwent bronchoscopy with these bronchoscopes grew P. putida, P. aeruginosa, or Stenotrophomonas. No patients developed clinical signs or symptoms of infection, but 7 were treated with antibiotics. Investigation revealed that the implicated bronchoscopes had been sent to an external vendor for repair; examination by the manufacturer revealed irregularities in repairs and nonstandard part replacements.

Third-party vendors without access to proprietary information may contribute to mechanical malfunction of medical devices, which can lead to contamination and incomplete disinfection.

Infect Control Hosp Epidemiol 2012;33(3):224-229

To compare heterotrophic plate counts (HPCs) and Legionella species growth from electronic and manual faucet water samples.

Proportions of water samples with growth and colony-forming units were compared using Fisher's exact test and the Wilcoxon rank-sum test, respectively.

Two psychiatric units and 1 medical unit in a 1,000-bed university hospital.

Water samples were collected from 20 newly installed electronic faucets and 20 existing manual faucets in 3 hospital units. Manual faucets were located in rooms adjacent to the electronic faucets and received water from the same source. Water samples were collected between December 15, 2008, and January 29, 2009. Four electronic faucets were dismantled, and faucet components were cultured. Legionella species and HPC cultures were performed using standard methods.

Nearly all electronic faucets (19/20 [95%]) grew Legionella species from at least 1 water sample, compared with less than half (9/20 [45%]) of manual faucets (P = .001). Fifty-four (50%) of 108 electronic faucet water cultures grew Legionella species, compared with 11 (15%) of 75 manual faucet water cultures (P< .001). After chlorine dioxide remediation, 4 (14%) of 28 electronic faucet and 1 (3%) of 30 manual faucet water cultures grew Legionella species (P = .19), and 8 (29%) electronic faucet and 2 (7%) manual faucet cultures had significant HPC growth (P = .04). All 12 (100%) of die internal faucet components from 2 electronic faucets grew Legionella species.

Electronic faucets were more commonly contaminated with Legionella species and other bacteria and were less likely to be disinfected after chlorine dioxide remediation. Electronic faucet components may provide points of concentrated bacterial growth.

Infect Control Hosp Epidemiol 2012;33(3):235-240

Influenza vaccination among nonhospital healthcare workers (HCWs) is imperative, but only limited data are available for factors affecting their compliance.

To examine the factors influencing influenza vaccine compliance among hospital and nonhospital HCWs.

A vaccine compliance questionnaire was administered to HCWs working in myriad healthcare settings in March-June 2011.

Online and paper surveys were used to assess compliance with the 2010/2011, 2009/2010, and H1N1 influenza vaccines and to examine factors that predicted the uptake of the 2010/2011 seasonal influenza vaccine.

In all, 3,188 HCWs completed the survey; half of these (n = 1,719) reported no hospital work time. Compliance rates for all 3 vaccines were significantly higher (P< .001) among hospital versus nonhospital HCWs. In logistic regression stratified by hospital versus nonhospital setting, and when controlling for demographics and past behavior, the determinants of vaccination against the 2010/2011 seasonal influenza among nonhospital-based HCWs included having a mandatory vaccination policy, perceived importance, no fear of vaccine adverse effects, free and on-site access, and perceived susceptibility to influenza. Determinants of hospital-based HCW vaccine compliance included having a mandatory vaccination policy, belief that HCWs should be vaccinated every year, occupational health encouragement, perceived importance of vaccination, on-site access, and no fear of vaccine adverse effects. The strongest predictor of compliance for both worker groups was existence of a mandatory vaccination policy.

The reasons for vaccine uptake among nonhospital-based versus hospital-based HCWs differed. Targeted interventions should be aimed at workers in these settings to increase their vaccine compliance, including implementing a mandatory vaccination policy.

Infect Control Hosp Epidemiol 2012;33(3):243-249

To evaluate the economic impact of ventilator-associated pneumonia (VAP) on length of stay and hospital costs.

Retrospective matched cohort study.

Premier database of hospitals in the United States.

Eligible patients were admitted to intensive care units (ICUs), received mechanical ventilation for ≥2 calendar-days, and were discharged between October 1, 2008, and December 31, 2009.

VAP was defined by International Classification of Diseases, Ninth Revision (ICD-9), code 997.31 and ventilation charges for ≥2 calendar-days. We matched patients with VAP to patients without VAP by propensity score on the basis of demographics, administrative data, and severity of illness. Cost was based on provider perspective and procedural cost accounting methods.

Of 88,689 eligible patients, 2,238 (2.5%) had VAP; the incidence rate was 1.27 per 1,000 ventilation-days. In the matched cohort, patients with VAP (n = 2,144) had longer mean durations of mechanical ventilation (21.8 vs 10.3 days), ICU stay (20.5 vs 11.6 days), and hospitalization (32.6 vs 19.5 days; all P< .0001) than patients without VAP (n = 2,144). Mean hospitalization costs were $99,598 for patients with VAP and $59,770 for patients without VAP (P< .0001), resulting in an absolute difference of $39,828. Patients with VAP had a lower in-hospital mortality rate than patients without VAP (482/2,144 [22.5%] vs 630/2,144 [29.4%]; P<.0001).

Our findings suggest that VAP continues to occur as defined by the new specific ICD-9 code and is associated with a statistically significant resource utilization burden, which underscores the need for cost-effective interventions to minimize the occurrence of this complication.

Infect Control Hosp Epidemiol 2012;33(3):250-256

Systematic review and meta-analysis of randomized controlled trials and quasi-experimental studies to assess the efficacy of daily bathing with chlorhexidine (CHG) for prevention of healthcare-associated bloodstream infections (BSIs).

Medical, surgical, trauma, and combined medical-surgical intensive care units (ICUs) and long-term acute care hospitals.

Inpatients.

Data on patient population, diagnostic criteria for BSIs, form and concentration of topical CHG, incidence of BSIs, and study design were extracted.

One randomized controlled trial and 11 nonrandomized controlled trials reporting a total of 137,392 patient-days met the inclusion criteria; 291 patients in the CHG arm developed a BSI over 67,775 patient-days, compared with 557 patients in the control arm over 69,617 catheter-days. CHG bathing resulted in a reduced incidence of BSIs: the pooled odds ratio using a random-effects model was 0.44 (95% confidence interval, 0.33–0.59; P< .00001). Statistical heterogeneity was moderate, with an I2 of 58%. For the subgroup of studies that examined central line–associated BSIs, the odds ratio was 0.40 (95% confidence interval, 0.27–0.59).

Daily bathing with CHG reduced the incidence of BSIs, including central line-associated BSIs, among patients in the medical ICU. Further studies are recommended to determine the optimal frequency, method of application, and concentration of CHG as well as the comparative effectiveness of this strategy relative to other preventive measures available for reducing BSIs. Future studies should also examine the efficacy of daily CHG bathing in non-ICU populations at risk for BSI.

Infect Control Hosp Epidemiol 2012;33(3):257-267

The impact of antimicrobial scrubs on healthcare worker (HCW) bacterial burden is unknown.

To determine die effectiveness of antimicrobial scrubs on hand and apparel bacterial burden.

Prospective, crossover trial.

Thirty HCWs randomized to study versus control scrubs in an intensive care unit.

Weekly microbiology samples were obtained from scrub abdominal area, cargo pocket, and hands. Mean log colony-forming unit (CFU) counts were calculated. Compliance with hand hygiene practices was measured. Apparel and hand mean log CFU counts were compared.

Adherence measures were 78% (910/1,173) for hand hygiene and 82% (223/273) for scrubs. Culture compliance was 67% (306/460). No differences were observed in bacterial hand burden or in HCWs with unique positive scrub cultures. No difference in vancomycin-resistant enterococci (VRE) and gram-negative rod (GNR) burden was observed. A difference in mean log mediicillin-resistant Staphylococcus aureus (MRSA) CFU count was found between study and control scrubs for leg cargo pocket (mean log CFUs, 11.84 control scrub vs 6.71 study scrub; P = .0002), abdominal area (mean log CFUs, 11.35 control scrub vs 7.54 study scrub; P = .0056), leg cargo pocket at die beginning of shift (mean log CFUs, 11.96 control scrub vs 4.87 study scrub; P = .0028), and abdominal area pocket at die end of shift (mean log CFUs, 12.14 control scrubs vs 8.22 study scrub; P = .0054).

Study scrubs were associated witfi a 4–7 mean log reduction in MRSA burden but not VRE or GNRs. A prospective trial is needed to measure die impact of antimicrobial impregnated apparel on MRSA transmission rates.

Infect Control Hosp Epidemiol 2012;33(3):268-275

To describe the epidemiology of surgical-site infections (SSIs) in community hospitals and to explore the impact of depth of SSI, healthcare location at the time of diagnosis, and variations in surveillance practices on the overall rate of SSI.

Retrospective cohort study.

Thirty-seven community hospitals in the southeastern United States.

Consecutive sample of patients undergoing surgical procedures between July 1, 2007, and December 31, 2008.

ANOVA was used to compare rates of SSIs, and the F test was used to compare the distribution of rates of SSIs. Wilcoxon rank-sum was used to test for differences in performance rankings of hospitals.

Following 177,706 surgical procedures, 1,919 SSIs were identified (incidence, 1.08 per 100 procedures). Sixty-four percent (1,223 of 1,919) of these were identified as complex SSIs; 87% of the complex SSIs were diagnosed in inpatient settings. The median proportion of superficial-incisional SSIs was 37% (interquartile range, 29.6%–49.5%). Postdischarge SSI surveillance was variable, with 58% of responding hospitals using surgeon letters. As reporting focus was narrowed from all SSIs to complex SSIs (incidence, 0.69 per 100 procedures) and, finally, to complex SSIs diagnosed in the inpatient setting (incidence, 0.51 per 100 procedures), variance in rates changed significantly (P = .02). Performance ranking of individual hospitals, based on rates of SSIs, differed significandy, depending on the reporting method utilized (P = .0006).

Inconsistent reporting mediods focused on variable depths of infection and healthcare location at time of diagnosis significandy impact rates of SSI, distribution of rates of SSI, and hospital comparative-performance rankings. We believe that public reporting of SSI rates should be limited to complex SSIs diagnosed in the inpatient setting.

Infect Control Hosp Epidemiol 2012;33(3):276-282

To determine healthcare-associated infection (HAI) prevalence in 9 hospitals in Jacksonville, Florida; to evaluate the performance of proxy indicators for HAIs; and to refine methodology in preparation for a multistate survey.

Point prevalence survey.

Acute care inpatients of any age.

HAIs were defined using National Healthcare Safety Network criteria. In each facility a trained primary team (PT) of infection prevention (IP) staff performed the survey on 1 day, reviewing records and collecting data on a random sample of inpatients. PTs assessed patients with one or more proxy indicators (abnormal white blood cell count, abnormal temperature, or antimicrobial therapy) for the presence of HAIs. An external IP expert team collected data from a subset of patient records reviewed by PTs to assess proxy indicator performance and PT data collection.

Of 851 patients surveyed by PTs, 51 had one or more HAIs (6.0%; 95% confidence interval, 4.5%–7.7%). Surgical site infections (n = 18), urinary tract infections (n = 9), pneumonia (n = 9), and bloodstream infections (n = 8) accounted for 75.8% of 58 HAIs detected by PTs. Staphylococcus aureus was the most common pathogen, causing 9 HAIs (15.5%). Antimicrobial therapy was the most sensitive proxy indicator, identifying 95.5% of patients with HAIs.

HAI prevalence in this pilot was similar to that reported in the 1970s by the Centers for Disease Control and Prevention's Study on the Efficacy of Nosocomial Infection Control. Antimicrobial therapy was a sensitive screening variable with which to identify those patients at higher risk for infection and reduce data collection burden. Additional work is needed on validation and feasibility to extend this methodology to a national scale.

Infect Control Hosp Epidemiol 2012;33(3):283-291