Infections following cardiovascular implantable electronic device (CIED) procedures, including pacemaker and implantable cardioverter–defibrillators, are devastating and costly. Preimplantation prophylactic antimicrobials are effective for reducing postprocedural infections. However, routine postprocedural antimicrobials are not associated with improved outcomes, and they may be harmful. Thus, we sought to characterize antimicrobial use patterns following CIED procedures.

All patients who underwent CIED procedures from October 1, 2007 to September 30, 2013 and had procedural information entered into the VA Clinical Assessment Reporting and Tracking (CART) software program were included in this study. All antibiotic prescriptions lasting more than 24 hours following device implantation or revision were identified using pharmacy databases, and postprocedural antibiotic use lasting more than 24 hours was characterized.

In total, 3,712 CIED procedures were performed at 34 VA facilities on 3,570 patients with a mean age of 71.7 years (standard deviation [SD], 11.1 years), 98.4% of whom were male. Postprocedural antibiotics >24 hours were prescribed following 1,579 of 3,712 CIED procedures (42.5%). The median duration of therapy was 5 days (interquartile range [IQR], 3–7 days). The most commonly prescribed antibiotic was cephalexin (1,152 of 1,579; 72.9%), followed by doxycycline (118 of 1,579; 7.47%) and ciprofloxacin (93 of 1,579; 5.9%). Vancomycin was used in 73 of 1,579 prescriptions (4.62%). Among the highest quartile of procedural volume, prescribing practices varied considerably, ranging from 3.2% to 77.6%.

Nearly 1 in 2 patients received prolonged postprocedural antimicrobial therapy following CIED procedures, and the rate of postprocedural antimicrobial therapy use varied considerably by facility. Given the lack of demonstrated benefit of routine prolonged antimicrobial therapy following CIED procedures, antimicrobial use following cardiac device interventions may be a potential target for quality improvement programs and antimicrobial stewardship.

Infect Control Hosp Epidemiol 2016;37:1005–1011

To estimate the cost-effectiveness of safety-engineered devices (SEDs) relative to non-SEDs for winged steel needles, intravenous catheter stylets, suture needles, and insulin pen needles.

Decision analysis modeling.

Hypothetical cohort of healthcare workers who utilized needle devices.

We developed a decision-analytic model to estimate and compare the life-cycle costs and benefits for SED and non-SED needle devices. For this cost-effectiveness analysis, we quantified the total direct medical cost per needlestick injury, number of needlestick injuries avoided, and incremental cost-effectiveness ratio. Sensitivity analyses were performed to examine the robustness of the base-case analysis.

In the base-case analysis, we calculated the incremental cost-effectiveness ratios of SED winged steel needles, intravenous catheter stylets, suture needles, and insulin pen needles to be $2,633, $13,943, $1,792, and $1,269 per needlestick injury avoided, respectively. Sensitivity analyses showed that the calculated incremental cost-effectiveness ratio values for using SEDs did not fall below zero even after adjusting the values of each parameter.

The use of SED needle devices would not produce cost savings for hospitals. Government intervention may be needed to systematically protect healthcare workers in Japan from the risk of bloodborne pathogen infections.

Infect Control Hosp Epidemiol 2016;37:1012–1021

To identify issues during donning and doffing of personal protective equipment (PPE) for infectious diseases and to inform PPE procurement criteria and design.

A mixed methods approach was used. Usability testing assessed the appropriateness, potential for errors, and ease of use of various combinations of PPE. A qualitative constructivist approach was used to analyze participant feedback.

Four academic health sciences centers: 2 adult hospitals, 1 trauma center, and 1 pediatric hospital, in Toronto, Canada.

Participants (n=82) were representative of the potential users of PPE within Western healthcare institutions.

None of the tested combinations provided a complete solution for PPE. Environmental factors, such as anteroom layout, and the design of protocols and instructional material were also found to impact safety. The study identified the need to design PPE as a complete system, rather than mixing and matching components.

Healthcare institutions are encouraged to use human factors methods to identify risk and failure points with the usage of their selected PPE, and to modify on the basis of iterative evaluations with representative end users. Manufacturers of PPE should consider usability when designing the next generation of PPE.

Infect Control Hosp Epidemiol 2016;37:1022–1028

To compare central line use and central line–associated bloodstream infection in newborn infants before and after the introduction of a central line infection prevention bundle in order to determine the effectiveness of the bundle and to identify areas for further improvement.

Retrospective cohort analysis of prospectively collected data.

Level 5 neonatal intensive care unit in Sydney, Australia.

Newborn infants admitted to the Royal Prince Alfred Hospital Neonatal Intensive Care Unit who had a central venous catheter (CVC) inserted.

Data regarding clinical characteristics, CVC use, and infection were collected before and after the introduction of a bundle of interventions. The bundles encompassed (1) insertion of CVC, (2) maintenance of CVC, (3) an education program, and (4) ongoing surveillance and feedback.

Baseline and intervention groups were comparable in clinical characteristics. The number of CVCs inserted was reduced in the intervention group (central line utilization rate, 0.16 vs 0.2, P<.0001). Overall CVC dwell time was reduced, resulting from significant reduction in peripherally inserted CVC dwell time (6 days [95% CI, 5.0–11.8 days] vs 7.3 days [4.0–10.4 days], P=.0004). Central line–associated bloodstream infections were significantly reduced, predominantly secondary to decreased peripherally inserted CVC–related bloodstream infections (1.2/1,000 central line–days vs 11.5/1,000 central line–days, P<.0001).

This central line infection bundle was effective in reducing CVC use, dwell time, and central line–associated bloodstream infections.

Infect Control Hosp Epidemiol 2016;37:1029–1036

Measuring processes of care performance rates is an invaluable tool for quality improvement; however, collecting daily process measure data is time-consuming and burdensome.

To evaluate the accuracy of sampling strategies to estimate monthly compliance rates with ventilator-associated pneumonia prevention measures.

A total of 37 intensive care units affiliated with 29 hospitals participating in a 2-state 35-month ventilator-associated pneumonia prevention collaborative. Analysis was limited to 325 unit-months with complete data entry rates.

We calculated unit-month level actual and sample monthly compliance rates for 6 ventilator-associated pneumonia prevention measures, using 4 sampling strategies: sample 1 day per month, sample 1 day per week, sample 7 consecutive days per month, and sample 7 consecutive days per month plus additional consecutive days as necessary to obtain at least 30 ventilator-days for that month whenever possible. We compared sample versus actual rates using paired t test and χ2 test.

Mean sampling accuracy ranged 84%–97% for 1 day per month, 91%–98% for 1 day per week, 92%–98% for 7 consecutive days per month, and 96%–99% for 7 consecutive days with at least 30 days per month if possible. The most accurate sampling strategy was to sample 7 consecutive days with at least 30 ventilator-days per month if possible. With this strategy, sample rates were within 10% of actual rates in 88%–99% of unit-months and within 5% of actual rates in 74%–97% of unit-months.

Sampling process measures intermittently rather than continually can yield accurate estimates of process measure performance rates.

Infect Control Hosp Epidemiol 2016;37:1037–1043

Inappropriate treatment of asymptomatic bacteriuria (ASB) in the hospital setting is common. We sought to evaluate the treatment rate of ASB at the 3 hospitals and assess the impact of a hospitalist-focused improvement intervention.

Prospective, interventional trial.

Two community hospitals and a tertiary-care academic center.

Adult patients with a positive urine culture admitted to hospitalist services were included in this study. Exclusions included pregnancy, intensive care unit admission, history of a major urinary procedure, and actively being treated for a urinary tract infection (UTI) at the time of admission or >48 hours prior to urine collection.

An educational intervention using a pocket card was implemented at all sites followed by a pharmacist-based intervention at the academic center. Medical records of the first 50 eligible patients at each site were reviewed at baseline and after each intervention for signs and symptoms of UTI, microbiological results, antimicrobials used, and duration of treatment for positive urine cultures. Diagnosis of ASB was determined through adjudication by 2 hospitalists and 2 infectious diseases physicians.

Treatment rates of ASB decreased (23.5%; P=.001) after the educational intervention. Reductions in treatment rates for ASB differed by site and were greatest in patients without classic signs and symptoms of UTI (34.1%; P<.001) or urinary catheters (31.2%; P<.001). The pharmacist-based intervention was most effective at reducing ASB treatment rates in catheterized patients.

A hospitalist-focused educational intervention significantly reduced ASB treatment rates. The impact varied across sites and by patient characteristics, suggesting that a tailored approach may be useful.

Infect Control Hosp Epidemiol 2016;37:1044–1051

Healthcare workers (HCWs) lack familiarity with evidence-based guidelines for the prevention of healthcare-associated infections (HAIs). There is good evidence that effective educational interventions help to facilitate guideline implementation, so we investigated whether e-learning could enhance HCW knowledge of HAI prevention guidelines.

We developed an electronic course (e-course) and tested its usability and content validity. An international sample of voluntary learners submitted to a pretest (T0) that determined their baseline knowledge of guidelines, and they subsequently studied the e-course. Immediately after studying the course, posttest 1 (T1) assessed the immediate learning effect. After 3 months, during which participants had no access to the course, a second posttest (T2) evaluated the residual learning effect.

A total of 3,587 HCWs representing 79 nationalities enrolled: 2,590 HCWs (72%) completed T0; 1,410 HCWs (39%) completed T1; and 1,011 HCWs (28%) completed T2. The median study time was 193 minutes (interquartile range [IQR], 96–306 minutes)

The median scores were 52% (IQR, 44%–62%) for T0, 80% (IQR, 68%–88%) for T1, and 74% (IQR, 64%–84%) for T2. The immediate learning effect (T0 vs T1) was +24% (IQR, 12%–34%; P<.001), and a residual effect (T0 vs T2) of +18% (IQR 8–28) remained (P<.001). A 200-minute study time was associated with a maximum immediate learning effect (28%). A study time >300 minutes yielded the greatest residual effect (24%).

Moderate time invested in e-learning yielded significant immediate and residual learning effects. Decision makers could consider promoting e-learning as a supporting tool in HAI prevention.

Infect Control Hosp Epidemiol 2016;37:1052–1059

To characterize the epidemiology of bloodstream infections in Switzerland, comparing selected pathogens in community and university hospitals.

Observational, retrospective, multicenter laboratory surveillance study.

Data on bloodstream infections from 2008 through 2014 were obtained from the Swiss infection surveillance system, which is part of the Swiss Centre for Antibiotic Resistance (ANRESIS). We compared pathogen prevalences across 26 acute care hospitals. A subanalysis for community-acquired and hospital-acquired bloodstream infections in community and university hospitals was performed.

A total of 42,802 bloodstream infection episodes were analyzed. The most common etiologies were Escherichia coli (28.3%), Staphylococcus aureus (12.4%), and polymicrobial bloodstream infections (11.4%). The proportion of E. coli increased from 27.5% in 2008 to 29.6% in 2014 (P = .04). E. coli and S. aureus were more commonly reported in community than university hospitals (34.3% vs 22.7%, P<.001 and 13.9% vs 11.1%, P<.001, respectively). Fifty percent of episodes were community-acquired, with E. coli again being more common in community hospitals (41.0% vs 32.4%, P<.001). The proportion of E. coli in community-acquired bloodstream infections increased in community hospitals only. Community-acquired polymicrobial infections (9.9% vs 5.6%, P<.001) and community-acquired coagulase-negative staphylococci (6.7% vs 3.4%, P<0.001) were more prevalent in university hospitals.

The role of E. coli as predominant pathogen in bloodstream infections has become more pronounced. There are distinct patterns in community and university hospitals, potentially influencing empirical antibiotic treatment.

Infect Control Hosp Epidemiol 2016;37:1060–1067

High-quality cost estimates for hospital-acquired Clostridium difficile infection (CDI) are vital evidence for healthcare policy and decision-making.

To evaluate the costs attributable to hospital-acquired CDI from the healthcare payer perspective.

We conducted a population-based propensity-score matched cohort study of incident hospitalized subjects diagnosed with CDI (those with the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada code A04.7) from January 1, 2003, through December 31, 2010, in Ontario, Canada. Infected subjects were matched to uninfected subjects (those without the code A04.7) on age, sex, comorbidities, geography, and other variables, and followed up through December 31, 2011. We stratified results by elective and nonelective admissions. The main study outcomes were up-to-3-year costs, which were evaluated in 2014 Canadian dollars.

We identified 28,308 infected subjects (mean annual incidence, 27.9 per 100,000 population, 3.3 per 1,000 admissions), with a mean age of 71.5 years (range, 0–107 years), 54.0% female, and 8.0% elective admissions. For elective admission subjects, cumulative mean attributable 1-, 2-, and 3-year costs adjusted for survival (undiscounted) were $32,151 (95% CI, $28,192–$36,005), $34,843 ($29,298–$40,027), and $37,171 ($30,364–$43,415), respectively. For nonelective admission subjects, the corresponding costs were $21,909 ($21,221–$22,609), $26,074 ($25,180–$27,014), and $29,944 ($28,873–$31,086), respectively.

Hospital-acquired CDI is associated with substantial healthcare costs. To the best of our knowledge, this study is the first CDI costing study to present longitudinal costs. New strategies may be warranted to mitigate this costly infectious disease.

Infect Control Hosp Epidemiol 2016;37:1068–1078

To conduct a full economic evaluation assessing the costs and consequences related to probiotic use for the primary prevention of Clostridium difficile–associated diarrhea (CDAD).

Cost-effectiveness analysis using decision analytic modeling.

A cost-effectiveness analysis was used to evaluate the risk of CDAD and the costs of receiving oral probiotics versus not over a time horizon of 30 days. The target population modeled was all adult inpatients receiving any therapeutic course of antibiotics from a publicly funded healthcare system perspective. Effectiveness estimates were based on a recent systematic review of probiotics for the primary prevention of CDAD. Additional estimates came from local data and the literature. Sensitivity analyses were conducted to assess how plausible changes in variables impacted the results.

Treatment with oral probiotics led to direct costs of CDN $24 per course of treatment per patient. On average, patients treated with oral probiotics had a lower overall cost compared with usual care (CDN $327 vs $845). The risk of CDAD was reduced from 5.5% in those not receiving oral probiotics to 2% in those receiving oral probiotics. These results were robust to plausible variation in all estimates.

Oral probiotics as a preventive strategy for CDAD resulted in a lower risk of CDAD as well as cost-savings. The cost-savings may be greater in other healthcare systems that experience a higher incidence and cost associated with CDAD.

Infect Control Hosp Epidemiol 2016;37:1079–1086

Polymerase chain reaction (PCR) assays based on the detection of the toxin B gene are replacing enzyme-linked immunosorbent assay (ELISA)–based toxin production detection or cell cytotoxicity assay in most laboratories.

To determine the proportion of pediatric patients diagnosed withClostridium difficile infection by PCR who would have also been diagnosed by ELISA and to compare the clinical characteristics of PCR+/ELISA+ vs PCR+/ELISA− patients.

Using the microbiology laboratory information system, stool samples positive for C. difficile by PCR between October 2010 and July 2014 were identified. Using frozen stool specimens, an ELISA for toxin A and B was performed. A retrospective medical chart review was conducted to obtain demographic and clinical data. Duplicate samples were excluded.

A total of 136 PCR-positive samples underwent ELISA testing: 54 (40%) were positive for toxin A or B. The mean (SD) age of the entire cohort was 8.5 (6.2) years. There was no difference in age, gender, clinical manifestation, previous medical problems, and management between patients positive or negative by ELISA. However, patients positive by ELISA were more likely to have had a recent exposure to antibiotics (67.9% vs 50%; crude odds ratio, 2.1 [95% CI, 1.03–4.28]).

In our pediatric population, 60% of patients with C. difficile diagnosed by PCR had no toxin detectable by ELISA. ELISA-negative patients were less likely to have received an antibiotic recently compared with ELISA-positive patients. These results highlight the need to standardize laboratory criteria for the diagnosis of C. difficile infections in children.

Infect Control Hosp Epidemiol 2016;37:1087–1093