To review the incidence and trends of MRSA during a 12-year (1989-2000) period at a university teaching hospital and the relationship between strain distribution by antibiogram and molecular typing.

Retrospective review of laboratory-based surveillance records on MRSA isolation and characterization of strains by antimicrobial susceptibility and PFGE. A patient episode was counted at the time when MRSA was first isolated.

A 1,350-bed university teaching hospital in Hong Kong.

Those with clinical isolates of MRSA.

During 1989 to 2000, the hospital recorded 1,203,175 deaths and discharges (D&D) and encountered 5,707 patient episodes of new MRSA isolation. The overall incidence of patient episodes of MRSA was 0.47/100 D&D. In 1989, the incidence was 0.81/100 D&D and fell to a low of 0.33/100 D&D in 1995, but then rose to 0.50/100 D&D in 2000. Antibiogram and DNA typing identified 5 major types. PFGE type A constituted 68% (211/312) of isolates and was present throughout the 12-year period. PFGE type B constituted 13% (40/312) of isolates and was only present from 1995 to 2000. These isolates form a distinct clone and had unique antibiotic resistance profiles.

The study showed the establishment of a dominant MRSA clone (PFGE type A group) in the intensive care, medical, and surgical units and the appearance of a new MRSA strain in 1995 (PFGE type B), which partly explained the rise in incidence of MRSA cases and a disproportionate rise in MRSA bacteremia from 1995 to 2000.

To determine the association between state legal mandates for data submission of central line–associated bloodstream infections (CLABSIs) in neonatal intensive care units (NICUs) with process and outcome measures.

Cross-sectional study.

Participants. National sample of level II/III and III NICUs participating in National Healthcare Safety Network (NHSN) surveillance.

State mandates for data submission of CLABSIs in NICUs in place by 2011 were compiled and verified with state healthcare-associated infection coordinators. A web-based survey of infection control departments in October 2011 assessed CLABSI prevention practices, ie, compliance with checklist/bundle components (process measures) in ICUs including NICUs. Corresponding 2011 NHSN NICU CLABSI rates (outcome measures) were used to calculate standardized infection ratios (SIRs). Association between mandates and process and outcome measures was assessed by multivariable logistic regression.

Among 190 study NICUs, 107 (56.3%) were located in states with mandates, with mandates in place >3 years in 52 (49%). More NICUs in states with mandates reported ≥95% compliance to at least 1 CLABSI prevention practice (52.3%–66.4%) than NICUs in states without mandates (28.9%–48.2%). Mandates were predictors of ≥95% compliance with all practices (odds ratio, 2.8; 95% confidence interval, 1.4–6.1). NICUs in states with mandates reported lower mean CLABSI rates in the ≤750-g birth weight group (2.4 vs 5.7 CLABSIs/1,000 central line–days) but not in others. Mandates were not associated with SIR <1.

State mandates for NICU CLABSI data submission were significantly associated with ≥95% compliance with CLABSI prevention practices, which declined with the duration of mandate but not with lower CLABSI rates.

Infect Control Hosp Epidemiol 2014;35(9):1133-1139

To assess clinically relevant outcomes after complete cessation of control measures for vancomycin-resistant enterococci (VRE).

Quasi-experimental ecological study over 3.5 years.

All VRE screening and isolation practices at 4 large academic hospitals in Ontario, Canada, were stopped on July 1, 2012. In total, 618 anonymized abstracted charts of patients with VRE-positive clinical isolates identified between July 1, 2010, and December 31, 2013, were reviewed to determine whether the case was a true VRE infection, a VRE colonization or contaminant, or a true VRE bacteremia. All deaths within 30 days of the last VRE infection were also reviewed to determine whether the death was fully or partially attributable to VRE. All-cause mortality was evaluated over the study period. Generalized estimating equation methods were used to cluster outcome rates within hospitals, and negative binomial models were created for each outcome.

The incidence rate ratio (IRR) for VRE infections was 0.59 and the associated P value was .34. For VRE bacteremias, the IRR was 0.54 and P=.38; for all-cause mortality the IRR was 0.70 and P=.66; and for VRE attributable death, the IRR was 0.35 and P=.49. VRE control measures were not significantly associated with any of the outcomes. Rates of all outcomes appeared to increase during the 18-month period after cessation of VRE control measures, but none reached statistical significance.

Clinically significant VRE outcomes remain rare. Cessation of all control measures for VRE had no significant attributable adverse clinical impact.

Infect Control Hosp Epidemiol 2016;1–7

To characterize handwashing behaviors of children and assess the efficacy of a waiting room-based hand hygiene intervention at improving handwashing ability.

Prospective randomized pilot study.

Emergency department waiting room at a freestanding urban pediatric hospital.

Children (8–18 years) and their parent.

Participants were randomized to glow gel hand washing without hand hygiene education or glow gel hand washing with hand hygiene education. After participants washed with glow gel, “dirty areas” were illuminated using a black light, and hands were scored. A questionnaire about handwashing behavior was administered. All subjects returned 2–4 weeks after intervention to repeat glow gel hand washing and the questionnaire.

Sixty pediatric patients and 57 parents were recruited, with 77% of patients returning for follow up. Patients were 50% male, 58% Latino, 28% African American, and 8% Caucasian. At the initial visit, 91% of children reported hand washing after using the bathroom and 78% reported hand washing before dinner. On the basis of objective scoring, all children improved handwashing ability when compared with the initial visit (P = .02) and were more likely to use warm water at follow up (P = .01). Parents did not significantly improve in handwashing ability (P = .73).

Glow gel hand washing is an effective method to improve children's handwashing ability. This short-term intervention was effective even in the absence of specific hand hygiene education. This intervention could serve as a valuable public health measure to teach hand washing in healthcare settings.

Seasonal variation is a characteristic of many infectious diseases, but relatively little is known about determinants thereof. We studied the impact of place of acquisition and patient characteristics on seasonal variation of bacteremia caused by the 3 most common pathogens.

Seasonal variation analysis.

In 3 Danish health regions (2.3 million total inhabitants), patients with bacteremia were identified from 2000 through 2011 using information from laboratory information systems. Analyses were confined to Escherichia coli, Staphylococcus aureus, and Streptococcus pneumoniae. Additional data were obtained from the Danish National Hospital Registry for the construction of admission histories and calculation of the Charlson comorbidity index (CCI). Bacteremias were categorized as community acquired, healthcare associated (HCA), and hospital acquired. We defined multiple subgroups by combining the following characteristics: species, acquisition, age group, gender, CCI level, and location of infection. Assuming a sinusoidal model, seasonal variation was assessed by the peak-to-trough (PTT) ratio with a 95% confidence interval (CI).

In total, we included 16,006 E. coli, 6,924 S. aureus, and 4,884 S. pneumoniae bacteremia cases. For E. coli, the seasonal variation was highest for community-acquired cases (PTT ratio, 1.24; 95% CI, 1.17–1.32), was diminished for HCA (PTT ratio, 1.14; 95% CI, 1.04–1.25), and was missing for hospital-acquired cases. No seasonal variation was observed for S. aureus. S. pneumoniae showed high seasonal variation, which did not differ according to acquisition (overall PTT ratio, 3.42; 95% CI, 3.10–3.83).

Seasonal variation was mainly related to the species although the place of acquisition was important for E. coli.

Infect Control Hosp Epidemiol 2016;37:946–953

To determine whether central line–associated bloodstream infections (CLABSIs) increase the likelihood of readmission.

Retrospective matched cohort study for the years 2008–2009.

Acute care hospitals.

Medicare recipients. CLABSI and readmission status were determined by linking National Healthcare Safety Network surveillance data to the Centers for Medicare and Medicaid Services’ Medical Provider and Analysis Review in 8 states. Frequency matching was used on International Classification of Diseases, Ninth Revision, Clinical Modification procedure code category and intensive care unit status.

We compared the rate of readmission among patients with and without CLABSI during an index hospitalization. Cox proportional hazard analysis was used to assess rate of readmission (the first hospitalization within 30 days after index discharge). Multivariate models included the following covariates: race, sex, length of index hospitalization stay, central line procedure code, Gagne comorbidity score, and individual chronic conditions.

Of the 8,097 patients, 2,260 were readmitted within 30 days (27.9%). The rate of first readmission was 7.1 events/person-year for CLABSI patients and 4.3 events/person-year for non-CLABSI patients (P<.001). The final model revealed a small but significant increase in the rate of 30-day readmissions for patients with a CLABSI compared with similar non-CLABSI patients. In the first readmission for CLABSI patients, we also observed an increase in diagnostic categories consistent with CLABSI, including septicemia and complications of a device.

Our analysis found a statistically significant association between CLABSI status and readmission, suggesting that CLABSI may have adverse health impact that extends beyond hospital discharge.

Infect Control Hosp Epidemiol 2015;36(8):886–892

Legislative actions and advanced technologies, particularly dissemination of safety-engineered devices, have aided in protecting healthcare personnel from occupational blood and body fluid exposures (BBFE).

To investigate the trends in BBFE among healthcare personnel over 15 years and the impact of safety-engineered devices on the incidence of percutaneous injuries as well as features of injuries associated with these devices.

Retrospective cohort study at University of North Carolina Hospitals, a tertiary care academic facility. Data on BBFE in healthcare personnel were extracted from Occupational Health Service records (2000–2014). Exposures associated with safety-engineered and conventional devices were compared. Generalized linear models were applied to measure the annual incidence rate difference by exposure type over time.

A total of 4,300 BBFE, including 3,318 percutaneous injuries (77%), were reported. The incidence rate for overall BBFE was significantly reduced during 2000–2014 (incidence rate difference, 1.72; P=.0003). The incidence rate for percutaneous injuries was also dramatically reduced during 2001–2006 (incidence rate difference, 1.37; P=.0079) but was less changed during 2006–2014. Percutaneous injuries associated with safety-engineered devices accounted for 27% of all BBFE. BBFE was most commonly due to injecting through skin, placing intravenous catheters, and blood drawing.

Our study revealed significant overall reduction in BBFE and percutaneous injuries likely due in part to the impact of safety-engineered devices but also identified that a considerable proportion of percutaneous injuries is now associated with these devices. Additional prevention strategies are needed to further reduce percutaneous injuries and improve design of safety-engineered devices.

Infect Control Hosp Epidemiol 2016;37:497–504

To investigate suspected pseudo-outbreaks of Mycobacterium tuberculosis (MTB) during August 1994 and July 1995 among patients who did not have clinical findings consistent with tuberculosis.

Retrospective and prospective surveys of all clinical and laboratory data using standard epidemiological tools and DNA fingerprinting.

A university-affiliated community hospital.

Those with positive MTB cultures during periods when we noted that the number of MTB positive cultures greatly outnumbered the usual monthly average (retrospective analysis, 1994) and patients with positive MTB cultures without clinical findings consistent with tuberculosis (prospective survey, 1995).

Epidemiological and molecular studies revealed specimen cross-contamination in the laboratory due to a faulty exhaust hood. Improvement in laboratory ventilation and change of the implicated hood prevented further specimen contamination.

The identification of positive MTB cultures from patients without clinical evidence of tuberculosis should be a signal to suspect laboratory contamination and implement control measures. These should include a thorough epidemiological investigation, DNA fingerprint analysis, and an environmental inspection.

Antibiotic-resistant organism (ARO) colonization rates in skilled nursing facilities (NFs) are high; hand hygiene is crucial to interrupt transmission. We aimed to determine factors associated with hand hygiene adherence in NFs and to assess rates of ARO acquisition among healthcare personnel (HCP).

HCP were observed during routine care at 6 NFs. We recorded hand hygiene adherence, glove use, activities, and time in room. HCP hands were cultured before and after patient care; patients and high-touch surfaces were cultured. HCP activities were categorized as high-versus low-risk for self-contamination. Multivariable regression was performed to identify predictors of hand hygiene adherence.

We recorded 385 HCP observations and paired them with cultures performed before and after patient care. Hand hygiene adherence occurred in 96 of 352 observations (27.3%) before patient care and 165 of 358 observations (46.1%) after patient care. Gloves were worn in 169 of 376 observations (44.9%). Higher adherence was associated with glove use before patient care (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.44–4.54) and after patient care (OR, 3.11; 95% CI, 1.77–5.48). Compared with nurses, certified nurse assistants had lower hand hygiene adherence (OR, 0.31; 95% CI, 0.15–0.67) before patient care and physical/occupational therapists (OR, 0.22; 95% CI, 0.11–0.44) after patient care. Hand hygiene varied by activity performed and time in the room. HCP hands were contaminated with AROs in 35 of 385 cultures of hands before patient care (0.9%) and 22 of 350 cultures of hands after patient care (6.3%).

Hand hygiene adherence in NFs remain low; it is influenced by job title, type of care activity, and glove use. Hand hygiene programs should incorporate these unique care and staffing factors to reduce ARO transmission.

Short-term peripheral venous catheter–related bloodstream infection (PVCR-BSI) rates have not been systematically studied in resource-limited countries, and data on their incidence by number of device days are not available.

Prospective, surveillance study on PVCR-BSI conducted from September 1, 2013, to May 31, 2019, in 727 intensive care units (ICUs), by members of the International Nosocomial Infection Control Consortium (INICC), from 268 hospitals in 141 cities of 42 countries of Africa, the Americas, Eastern Mediterranean, Europe, South East Asia, and Western Pacific regions. For this research, we applied definition and criteria of the CDC NHSN, methodology of the INICC, and software named INICC Surveillance Online System.

We followed 149,609 ICU patients for 731,135 bed days and 743,508 short-term peripheral venous catheter (PVC) days. We identified 1,789 PVCR-BSIs for an overall rate of 2.41 per 1,000 PVC days. Mortality in patients with PVC but without PVCR-BSI was 6.67%, and mortality was 18% in patients with PVC and PVCR-BSI. The length of stay of patients with PVC but without PVCR-BSI was 4.83 days, and the length of stay was 9.85 days in patients with PVC and PVCR-BSI. Among these infections, the microorganism profile showed 58% gram-negative bacteria: Escherichia coli (16%), Klebsiella spp (11%), Pseudomonas aeruginosa (6%), Enterobacter spp (4%), and others (20%) including Serratia marcescens. Staphylococcus aureus were the predominant gram-positive bacteria (12%).

PVCR-BSI rates in INICC ICUs were much higher than rates published from industrialized countries. Infection prevention programs must be implemented to reduce the incidence of PVCR-BSIs in resource-limited countries.

A Canadian health authority implemented a multisectoral intervention designed to control severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission during long-term care facility (LTCF) outbreaks. The primary objective was to evaluate the effectiveness of the intervention 14 days after implementation.

Quasi-experimental, segmented regression analysis.

A series of outbreak measures classified into 4 categories: case and contact management, proactive case detection, rigorous infection control practices and resource prioritization and stewardship.

A mixed-effects segmented Poisson regression model was fitted to the incidence rate of coronavirus disease 2019 (COVID-19), calculated every 2 days, within each facility and case type (staff vs residents). For each facility, the outbreak time period was segmented into an early outbreak period (within 14 days of the intervention) and postintervention period (beyond 14 days following the intervention). Model outputs quantified COVID-19 incidence trend and rate changes between these 2 periods. A secondary model was constructed to identify effect modification by case type.

The significant upward trend in COVID-19 incidence rate during the early outbreak period (rate ratio [RR], 1.07; 95% confidence interval [CI], 1.03–1.11; P < .001) reversed during the postintervention period (RR, 0.73; 95% CI, 0.67–0.80; P < .001). The average trend did not differ by case type during the early outbreak period (P > .05) or the postintervention period (P > .05). However, staff had a 70% larger decrease in the average rate of COVID-19 during the postintervention period than residents (RR, 0.30; 95% CI, 0.10–0.88; P < .05).

Our study provides evidence for the effectiveness of this intervention to reduce the transmission of COVID-19 in LTCFs. This intervention can be adapted and utilized by other jurisdictions to protect the vulnerable individuals in LTCFs.