To provide an overview of the economic aspects of needlestick and sharps injury (NSI) management among healthcare personnel (HCP) within a Health Technology Assessment project to evaluate the impact of safety-engineered devices on health care

A systematic review of economic analyses related to NSIs was performed in accordance with the PRISMA statement and by searching PubMed and Scopus databases (January 1997–February 2015). Mean costs were stratified by study approach (modeling or data driven) and type of cost (direct or indirect). Costs were evaluated using the CDC operative definition and converted to 2015 International US dollars (Int$).

A total of 14 studies were retrieved: 8 data-driven studies and 6 modeling studies. Among them, 11 studies provided direct and indirect costs and 3 studies provided only direct costs. The median of the means for aggregate (direct + indirect) costs was Int$747 (range, Int$199–Int$1,691). The medians of the means for disaggregated costs were Int$425 (range, Int$48–Int$1,516) for direct costs (9 studies) and Int$322 (range, Int$152–Int$413) for indirect costs (6 studies). When compared with data-driven studies, modeling studies had higher disaggregated and aggregated costs, but data-driven studies showed greater variability. Indirect costs were consistent between studies, mostly referring to lost productivity, while direct costs varied widely within and between studies according to source infectivity, HCP susceptibility, and post-exposure diagnostic and prophylactic protocols. Costs of treating infections were not included, and intangible costs could equal those associated with NSI medical evaluations.

NSIs generate significant direct, indirect, potential, and intangible costs, possibly increasing over time. Economic efforts directed at preventing occupational exposures and infections, including provision of safety-engineered devices, may be offset by the savings from a lower incidence of NSIs.

Infect Control Hosp Epidemiol 2016;37:635–646

Antimicrobial stewardship programs (ASPs) are variably implemented.

To characterize variations of antimicrobial stewardship structure and practices across all inpatient Veterans Affairs facilities in 2012 and correlate key characteristics with antimicrobial usage.

A web-based survey regarding stewardship activities was administered to each facility’s designated contact. Bivariate associations between facility characteristics and inpatient antimicrobial use during 2012 were determined.

Total of 130 Veterans Affairs facilities with inpatient services.

Of 130 responding facilities, 29 (22%) had a formal policy establishing an ASP, and 12 (9%) had an approved ASP business plan. Antimicrobial stewardship teams were present in 49 facilities (38%); 34 teams included a clinical pharmacist with formal infectious diseases (ID) training. Stewardship activities varied across facilities, including development of yearly antibiograms (122 [94%]), formulary restrictions (120 [92%]), stop orders for antimicrobial duration (98 [75%]), and written clinical pathways for specific conditions (96 [74%]). Decreased antimicrobial usage was associated with having at least 1 full-time ID physician (P=.03), an ID fellowship program (P=.003), and a clinical pharmacist with formal ID training (P=.006) as well as frequency of systematic patient-level reviews of antimicrobial use (P=.01) and having a policy to address antimicrobial use in the context of Clostridium difficile infection (P=.01). Stop orders for antimicrobial duration were associated with increased use (P=.03).

ASP-related activities varied considerably. Decreased antibiotic use appeared related to ID presence and certain select practices. Further statistical assessments may help optimize antimicrobial practices.

Infect Control Hosp Epidemiol 2016;37:647–654

To determine the longitudinal changes in viral load of hepatitis B virus (HBV)–infected healthcare workers (HCWs) and its consequences for exclusion of infected HCWs performing exposure-prone procedures, various HBV DNA safety thresholds, and the frequency of monitoring.

Retrospective cohort study June 1, 1996–January 31, 2013.

In the Netherlands, chronically HBV-infected HCWs performing exposure-prone procedures are notified to the Committee for Prevention of Iatrogenic Hepatitis B. Of the 126 notified HCWs, 45 had 2 or more HBV DNA levels determined without antiviral therapy.

A time-to-event analysis for HBV-infected HCWs categorized in various viremia levels surpassing a HBV DNA threshold level of 1×105 copies/mL, above which exposure-prone procedures are not allowed in the Netherlands.

Fluctuations of HBV DNA in follow-up samples ranged from −5.4 to +2.2 log10 copies/mL. A high correlation was seen for each HBV DNA level with the 3 previous levels. In a time-to-event analysis, after 6 months 7.2%, 6.5%, and 14.3% of individuals had surpassed the threshold of 1×105 copies/mL for viral load categories 4.8×103 to 1.5×104; 1.5×104 to 4.0×104; and 4.0×104 to 1.0×105, respectively.

We propose standard retesting every 6 months, with more frequent retesting just below the high threshold value (1×105 copies/mL), and prolonging this standard interval to 1 year after 3 consecutive levels below the threshold in policies with lower safety thresholds (1×103 or 1×104 copies/mL).

Infect Control Hosp Epidemiol 2016;37:655–660

To evaluate the microbiologic effectiveness of the World Health Organization’s 6-step and the Centers for Disease Control and Prevention’s 3-step hand hygiene techniques using alcohol-based handrub.

A parallel group randomized controlled trial.

An acute care inner-city teaching hospital (Glasgow).

Doctors (n=42) and nurses (n=78) undertaking direct patient care.

Random 1:1 allocation of the 6-step (n=60) or the 3-step (n=60) technique.

The 6-step technique was microbiologically more effective at reducing the median log10 bacterial count. The 6-step technique reduced the count from 3.28 CFU/mL (95% CI, 3.11–3.38 CFU/mL) to 2.58 CFU/mL (2.08–2.93 CFU/mL), whereas the 3-step reduced it from 3.08 CFU/mL (2.977–3.27 CFU/mL) to 2.88 CFU/mL (−2.58 to 3.15 CFU/mL) (P=.02). However, the 6-step technique did not increase the total hand coverage area (98.8% vs 99.0%, P=.15) and required 15% (95% CI, 6%-24%) more time (42.50 seconds vs 35.0 seconds, P=.002). Total hand coverage was not related to the reduction in bacterial count.

Two techniques for hand hygiene using alcohol-based handrub are promoted in international guidance, the 6-step by the World Health Organization and 3-step by the Centers for Disease Control and Prevention. The study provides the first evidence in a randomized controlled trial that the 6-step technique is superior, thus these international guidance documents should consider this evidence, as should healthcare organizations using the 3-step technique in practice.

Infect Control Hosp Epidemiol 2016;37:661–666

To evaluate ultraviolet C (UV-C) irradiance, UV-C dosage, and antimicrobial effect achieved by a mobile continuous UV-C device.

Prospective observational study.

We used 6 UV light sensors to determine UV-C irradiance (W/cm2) and UV-C dosage (µWsec/cm2) at various distances from and orientations relative to the UV-C device during 5-minute and 15-minute cycles in an ICU room and a surgical ward room. In both rooms, stainless-steel disks inoculated with methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and Clostridium difficile spores were placed next to sensors, and UV-C dosages and log10 reductions of target organisms achieved during 5-minute and 15-minute cycles were determined. Mean irradiance and dosage readings were compared using ANOVA.

Mean UV-C irradiance was nearly 1.0E-03 W/cm2 in direct sight at a distance of 1.3 m (4 ft) from the device but was 1.12E-05 W/cm2 on a horizontal surface in a shaded area 3.3 m (10 ft) from the device (P<.001). Mean UV-C dosages received by UV-C sensors located at different distances and orientation relative to the device varied significantly during 5-minute cycles and during 15-minute cycles (P<.001). Log10 reductions ranged from >4 to 1–3 for MRSA, >4 to 1–2 for VRE and >4 to 0 log10 for C. difficile spores, depending on the distance from, and orientation relative to, the device with 5-minute and 15-minute cycles.

UV-C irradiance, dosage, and antimicrobial effect received from a mobile UV-C device varied substantially based on location in a room relative to the UV-C device.

Infect Control Hosp Epidemiol 2016;37:667–672

The degree of bacterial contamination of stethoscopes can vary significantly following a physical examination.

To conduct a prospective study to investigate the impact of various environmental and patient characteristics on stethoscope contamination.

Following a standardized examination, the levels of bacterial contamination of 4 regions of the physicians’ hands and 2 sections of the stethoscopes, and the presence of different pathogenic bacteria, were assessed. Predictors of heavy stethoscope contamination were identified through multivariate logistic regression.

In total, 392 surfaces were sampled following examination of 56 patients. The microorganisms most frequently recovered from hands and stethoscopes were Enterococcus spp. (29% and 20%, respectively) and Enterobacteriaceae (16% and 7%, respectively). Staphylococcus aureus (either methicillin susceptible or resistant), extended-spectrum β-lactamase–producing Enterobacteriaceae, and Acinetobacter baumannii were recovered from 4%-9% of the samples from either hands or stethoscopes. There was a correlation between the likelihood of recovering these pathogens from the stethoscopes vs from the physicians’ hands (ρ=0.79; P=.04). The level of patient’s skin contamination was an independent predictor of contamination of the stethoscope diaphragm (adjusted odds ratio [aOR], 1.001; P=.007) and tube (aOR, 1.001; P=.003). Male sex (aOR, 28.24; P=.01) and reception of a bed bath (aOR, 7.52; P=.048) were also independently associated with heavy tube contamination.

Stethoscope contamination following a single physical examination is not negligible and is associated with the level of contamination of the patient’s skin. Prevention of pathogen dissemination is needed.

Infect Control Hosp Epidemiol 2016;37:673–679

To use next-generation sequencing (NGS) analysis to enhance epidemiological information to identify and resolve a Clostridium difficile outbreak and to evaluate its effectiveness beyond the capacity of current standard PCR ribotyping.

NGS analysis was performed as part of prospective surveillance of all detected C. difficile isolates at a university hospital. An outbreak of a novel C. difficile sequence type (ST)-295 was identified in a hospital and a community hostel for homeless adults. Phylogenetic analysis was performed of all ST-295 and closest ST-2 isolates. Epidemiological details were obtained from hospital records and the public health review of the community hostel.

We identified 7 patients with C. difficile ST-295 infections between June 2013 and April 2015. Of these patients, 3 had nosocomial exposure to this infection and 3 had possible hostel exposure. Current Society for Healthcare Epidemiology of America (SHEA)— Infectious Diseases Society of America (IDSA) surveillance definitions (2010) were considered in light of our NGS findings. The initial transmission was not detectable using current criteria, because of 16 weeks between ST-295 exposure and symptoms. We included 3 patients with hostel exposure who met surveillance criteria of hospital-acquired infection due to their hospital admissions.

NGS analysis enhanced epidemiological information and helped identify and resolve an outbreak beyond the capacity of standard PCR ribotyping. In this cluster of cases, NGS was used to identify a hostel as the likely source of community-based C. difficile transmission.

Infect Control Hosp Epidemiol 2016;37:680–684

To define how often methicillin-resistant Staphylococcus aureus (MRSA) is spread from resident to resident in long-term care facilities using whole-genome sequencing

Prospective cohort study

A long-term care facility

Elderly residents in a long-term care facility

Cultures for MRSA were obtained weekly from multiple body sites from residents with known MRSA colonization over 12-week study periods. Simultaneously, cultures to detect MRSA acquisition were obtained weekly from 2 body sites in residents without known MRSA colonization. During the first 12-week cycle on a single unit, we sequenced 8 MRSA isolates per swab for 2 body sites from each of 6 residents. During the second 12-week cycle, we sequenced 30 MRSA isolates from 13 residents with known MRSA colonization and 3 residents who had acquired MRSA colonization.

MRSA isolates from the same swab showed little genetic variation between isolates with the exception of isolates from wounds. The genetic variation of isolates between body sites on an individual was greater than that within a single body site with the exception of 1 sample, which had 2 unrelated strains among the 8 isolates. In the second cycle, 10 of 16 residents colonized with MRSA (63%) shared 1 of 3 closely related strains. Of the 3 residents with newly acquired MRSA, 2 residents harbored isolates that were members of these clusters.

Point prevalence surveys with whole-genome sequencing of MRSA isolates may detect resident-to-resident transmission more accurately than routine surveillance cultures for MRSA in long-term care facilities.

Infect Control Hosp Epidemiol 2016;37:685–691

To evaluate a central line care maintenance bundle to reduce central line–associated bloodstream infection (CLABSI) in non–intensive care unit settings.

Before-after trial with 12-month follow-up period.

A 1,250-bed teaching hospital.

Patients with central lines on 8 general medicine wards. Four wards received the intervention and 4 served as controls.

A multifaceted catheter care maintenance bundle consisting of educational programs for nurses, update of hospital policies, visual aids, a competency assessment, process monitoring, regular progress reports, and consolidation of supplies necessary for catheter maintenance.

Data were collected for 25,542 catheter-days including 43 CLABSI (rate, 1.68 per 1,000 catheter-days) and 4,012 catheter dressing observations. Following the intervention, a 2.5% monthly decrease in the CLABSI incidence density was observed on intervention floors but this was not statistically significant (95% CI, −5.3% to 0.4%). On control floors, there was a smaller but marginally significant decrease in CLABSI incidence during the study (change in monthly rate, −1.1%; 95% CI, −2.1% to −0.1%). Implementation of the bundle was associated with improvement in catheter dressing compliance on intervention wards (78.8% compliance before intervention vs 87.9% during intervention/follow-up; P<.001) but improvement was also observed on control wards (84.9% compliance before intervention vs 90.9% during intervention/follow-up; P=.001).

A multifaceted program to improve catheter care was associated with improvement in catheter dressing care but no change in CLABSI rates. Additional study is needed to determine strategies to prevent CLABSI in non–intensive care unit patients.

Infect Control Hosp Epidemiol 2016;37:692–698

To evaluate hospital administrative data to identify potential surgical site infections (SSIs) following primary elective total hip or knee arthroplasty.

Retrospective cohort study.

All acute care facilities in Alberta, Canada.

Diagnosis and procedure codes for 6 months following total hip or knee arthroplasty were used to identify potential SSI cases. Medical charts of patients with potential SSIs were reviewed by an infection control professional at the acute care facility where the patient was identified with a diagnosis or procedure code. For SSI decision, infection control professionals used the National Healthcare Safety Network SSI definition. The performance of traditional surveillance methods and administrative data–triggered medical chart review was assessed.

Of the 162 patients identified by diagnosis or procedure code, 46 (28%) were confirmed as an SSI by an infection control professional. More SSIs were identified following total hip vs total knee arthroplasty (42% vs16%). Of 46 confirmed SSI cases, 20 (43%) were identified at an acute care facility different than their procedure facility. Administrative data–triggered medical chart review with infection control professional confirmation resulted in a 1.1- to 1.7-fold increase in SSI rate compared with traditional surveillance. SSIs identified by administrative data resulted in sensitivity of 90% and specificity of 99%.

Medical chart review for cases identified through administrative data is an efficient supplemental SSI surveillance strategy. It improves case-finding by increasing SSI identification and making identification consistent across facilities, and in a provincial surveillance network it identifies SSIs presenting at nonprocedure facilities.

Infect Control Hosp Epidemiol 2016;37:699–703