Staphylococcus aureus carriage among healthcare workers (HCWs) is a concern in hospital settings, where it may provide a reservoir for later infections in both patients and staff. Earlier studies have shown that the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) carriage in HCWs is highly variable, depending notably on location, hospital department type, MRSA prevalence among patients, and type of contacts with patients. However, MRSA incidence in HCWs and its occupational determinants have seldom been studied.

A prospective, observational cohort study was conducted between May and October 2009 in a French rehabilitation center hospital. HCWs and patients were screened weekly for S. aureus nasal carriage. Methicillin-susceptible S. aureus and MRSA prevalence and incidence were estimated and factors associated with MRSA acquisition were identified using generalized estimating equation regression methods.

Among 343 HCWs included in the analysis, the average prevalence was 27% (95% CI, 24%–29%) for methicillin-susceptible S. aureus and 10% (8%–11%) for MRSA. We observed 129 MRSA colonization events. According to the multivariable analysis, high MRSA prevalence level among patients and HCW occupation were significantly associated with MRSA acquisition in HCWs, with assistant nurses being more at risk than nurses (odds ratio, 2.2; 95% CI, 1.4–3.6).

Our findings may help further our understanding of the transmission dynamics of MRSA carriage acquisition in HCWs, suggesting that it is notably driven by carriage among patients and by the type of contact with patients.

Infect Control Hosp Epidemiol 2015;36(7):767–776

We examined the usefulness of a simple method to account for incomplete postdischarge follow-up during surveillance of surgical site infection (SSI) by use of the National Nosocomial Infections Surveillance (NNIS) system's risk index.

Retrospective cohort study that used data prospectively collected from 1993 through 2006.

Five private, nonuniversity healthcare facilities in Belo Horizonte, Brazil.

Consecutive patients undergoing the following NNIS operative procedures: 20,981 operations on the genitourinary system, 11,930 abdominal hysterectomies, 7,696 herniorraphies, 6,002 cholecystectomies, and 6,892 laparotomies.

For each operative procedure category, 2 SSI risk models were specified. First, a model based on the NNIS system's risk index variables was specified (hereafter referred to as the NNIS-based model). Second, a modified model (hereafter referred to as the modified NNIS-based model), which was also based on the NNIS system's risk index, was specified with a postdischarge surveillance indicator, which was assigned the value of 1 if the patient could be reached during follow-up and a value of 0 if the patient could not be reached. A formal comparison of the capabilities of the 2 models to assess the risk of SSI was conducted using measures of calibration (by use of the Pearson goodness-of-fit test) and discrimination (by use of receiver operating characteristic curves). Goodman-Kruskal correlations (G) were also calculated.

The rate of incomplete postdischarge follow-up varied between 29.8% for abdominal hysterectomies and 50.5% for cholecystectomies. The modified NNIS-based model for laparotomy did not show any significant benefit over the NNIS-based model in any measure. For all other operative procedures, the modified NNIS-based model showed a significantly improved discriminatory ability and higher G statistics, compared with the NNIS-based model, with no significant impairment in calibration, except if used to assess the risk of SSI after operations on the genitourinary system or after a cholecystectomy.

Compared with the NNIS-based model, the modified NNIS-based model added potentially useful clinical information regarding most of the operative procedures. Further work is warranted to evaluate this method for accounting for incomplete postdischarge follow-up during surveillance of SSI.

To explore the prevalence and drivers of hospital-level variability in antibiotic utilization among hematopoietic cell transplant (HCT) recipients to inform antimicrobial stewardship initiatives.

Retrospective cohort study using data merged from the Pediatric Health Information System and the Center for International Blood and Marrow Transplant Research.

The study included 27 transplant centers in freestanding children’s hospitals.

The primary outcome was days of broad-spectrum antibiotic use in the interval from day of HCT through neutrophil engraftment. Hospital antibiotic utilization rates were reported as days of therapy (DOTs) per 1,000 neutropenic days. Negative binomial regression was used to estimate hospital utilization rates, adjusting for patient covariates including demographics, transplant characteristics, and severity of illness. To better quantify the magnitude of hospital variation and to explore hospital-level drivers in addition to patient-level drivers of variation, mixed-effects negative binomial models were also constructed.

Adjusted hospital rates of antipseudomonal antibiotic use varied from 436 to 1121 DOTs per 1,000 neutropenic days, and rates of broad-spectrum, gram-positive antibiotic use varied from 153 to 728 DOTs per 1,000 neutropenic days. We detected variability by hospital in choice of antipseudomonal agent (ie, cephalosporins, penicillins, and carbapenems), but gram-positive coverage was primarily driven by vancomycin use. Considerable center-level variability remained even after controlling for additional hospital-level factors. Antibiotic use was not strongly associated with days of significant illness or mortality.

Among a homogenous population of children undergoing HCT for acute leukemia, both the quantity and spectrum of antibiotic exposure in the immediate posttransplant period varied widely. Antimicrobial stewardship initiatives can apply these data to optimize the use of antibiotics in transplant patients.

Infect Control Hosp Epidemiol 2018;797–805

To identify comorbid conditions associated with surgical site infection (SSI) among patients undergoing renal transplantation and improve existing risk adjustment methodology used by the Centers for Disease Control and Prevention National Healthcare Safety Network (NHSN).

Patients (≥18 years) who underwent renal transplantation at University of Maryland Medical Center January 1, 2010-December 31, 2011.

Trained infection preventionists reviewed medical records to identify surgical site infections that developed within 30 days after transplantation, using NHSN criteria. Patient demographic characteristics and risk factors for surgical site infections were identified through a central data repository. International Statistical Classification of Disease, Ninth Revision, Clinical Modification codes were used to analyze individual component comorbid conditions and calculate the Charlson and Elixhauser comorbidity indices. These indices were compared with the current NHSN risk adjustment methodology.

A total of 441 patients were included in the final cohort. In bivariate analysis, the Charlson components of cerebrovascular disease, peripheral vascular disease, and rheumatologic disorders and Elixhauser components of obesity, rheumatoid arthritis, and weight loss were significantly associated with the outcome. A model utilizing the variables from the NHSN methodology had a c-statistic of 0.56 (95% CI, 0.48–0.63), whereas a model that also included comorbidities from the Charlson and Elixhauser indices had a c-statistic of 0.65 (95% CI, 0.58–0.73). The model with all 3 risk adjustment scores performed best and was statistically different from the NHSN model alone, demonstrated by improvement in the c statistic (0.65 vs 0.56).

Risk adjustment models should incorporate electronically available comorbid conditions.

Infect Control Hosp Epidemiol 2016;1–6

To describe the characteristics of and trends in nosocomial infection among human immunodeficiency virus (HIV)-infected patients.

Multicenter prospective cohort study.

HIV-infected patients were enrolled at time of first inpatient admission at five Veterans' Administration Medical Centers (VAMCs).

As of March 1995, 2,541 patients with 6,625 inpatient admissions had been monitored in the five VAMCs. A total of 530 nosocomial infections were detected using standard Centers for Disease Control and Prevention definitions. Overall distribution by infection site was 31% for primary bloodstream infections (BSIs), 28% for urinary tract infections, 15% for pneumonia, and 26% for all other sites. Of BSIs, 63% were central line-associated bloodstream infections (CLABs). The rate of CLABs per 1,000 central line days was 6.5 (range, 2.3-8.3) for all patients from participating hospitals, similar to the median CLAB rate of 6.0 for patients in medical intensive-care units (ICUs) of National Nosocomial Infections Surveillance (NNIS) System hospitals from January 1990 through September 1994. For ICU-specific CLABs, the rate from hospitals reporting at least one ICU CLAB was 12.7 (range, 12.1-13.1), comparable to the 90th percentile of NNIS hospital medical ICUs (13.1). Staphylococcus aureus, associated with 35% of BSIs, was the most common nosocomial BSI pathogen. Our data demonstrated the following: 13 (10%) of 134 patients with CD4 counts ≥200 cells/mm3 had a CLAB, compared with 61 (6%) of 1,011 patients with CD4 counts <200 cells/mm3, P=.08; the per-day risk of CLABs did not change with increased duration of catheterization (P=.4); and the per-day risk of a temporary (ie, short-term) CLAB was greater than that of a permanent CLAB (P<.001).

The data suggest that HIV-infected patients were at higher risk of acquiring a BSI than were patients in the NNIS population; patients with CD4 counts ≥200 cell/mm3 and temporary central lines were at increased risk for BSI, perhaps reflecting widespread prophylaxis with trimethoprim-sulfamethoxazole among patients with CD4 counts <200 cells/mm3; and, in contrast to most studies, S aureus, not coagulase-negative Staphylococcus, was the most common BSI pathogen.

To examine the policies and practices in hospitals within the state of Victoria, Australia, with respect to vaccination of staff against hepatitis B infection.

A written self-administered questionnaire to be completed by the infection control officer (or designated officer for hepatitis B vaccination) within each hospital.

Public (teaching and nonteaching) and private hospitals, including metropolitan and rural institutions in Victoria.

A random sample of 30% of Victorian hospitals were asked to participate in the survey. Of 78 eligible institutions, 69 (88%) completed and returned questionnaires.

There was no consistent hepatitis B prevention policy in place across Victoria. Of the 69 responding hospitals, 63 (91%) offered hepatitis B vaccination to staff, and 58 (84%) of these also paid all costs of vaccination. Of the 63 hospitals offering vaccination to staff, 39 offered vaccination to all staff, 23 offered vaccination based on job title, and one offered vaccination based on anticipated exposure. In many institutions, postexposure protocols were recalled more readily than preexposure vaccination guidelines. Numerous respondents indicated a need for clear guidelines on policy and clarification on practical matters of management, such as acceptable immune levels, management of nonresponders to the primary series, and the need for, and timing of, booster doses of vaccine. Eleven (18%) of the 63 hospitals offering hepatitis B vaccination to staff undertook routine prevaccination screening, a practice not generally regarded as cost-effective in Australia. Fifty-five of these hospitals (91%) also undertook postvaccination screening.

It is evident from this study that a considerable number of potentially susceptible healthcare personnel in Victorian hospitals remain unprotected against hepatitis B infection. A more reliable and consistent approach to preexposure hepatitis B vaccination is recommended

To identify risk factors for pediatric Candida central line-associated bloodstream infections (CLABSIs).

Retrospective case-control study.

Freestanding tertiary care children's hospital.

Patients with Candida CLABSI from January 31, 2000, through December 31, 2010, compared with age- and year-matched controls.

Demographics, comorbidities, presence of indwelling foreign bodies, exposure to antibiotics or corticosteroids, total parenteral nutrition (TPN) or blood transfusions, complications, and outcome were evaluated. Bivariate and then logistic regression were used to compare temporal trends and risk factors.

A total of 160 Candida CLABSI patients (median age, 1.96 years) were compared with 457 controls. Those with Candida CLABSIs were more likely to have intestinal failure (adjusted odds ratio [aOR], 6.777 [95% confidence interval (CI), 2.315–19.839]; P < .001), to have a gastrostomy tube in place (aOR, 4.156 [95% CI, 2.317–7.456]; P < .001), and to receive TPN (aOR, 3.897 [95% CI, 2.403–6.319]; P < .001) or blood transfusions (aOR, 2.990 [95% CI, 1.841–4.856]; P < .001), and they had a 3-fold increase in mortality (aOR, 3.543 [95% CI, 1.501–8.364]; P = .004). Candida albicans was most common, but non-albicans strains resistant to amphotericin (C. lusitaniae) and fluconazole (C. glabrata and C. krusei) were also found.

Those patients with intestinal failure, gastrostomy tube presence, and/or receipt of TPN and blood transfusions are at increased risk for development of Candida CLABSI.

To determine the prevalence of infections and antibiotic use at a community hospital in 1990 and to compare the results with those from previous surveys in 1971, 1979, and 1984.

Point prevalence survey.

Community teaching hospital.

All hospitalized patients, excluding those on the nursery, psychiatry, and short-stay wards.

Medical records were reviewed and a pertinent physical examination was performed on each patient.

Overall, 46 (20.1%) of 229 patients had infection in 1990. Community-acquired and hospital-acquired infections were present in 26 (11.4%) and 24 (10.5%) of the patients, respectively. The most common site of community-acquired infection was the deep abdomen in 8 (25.8%) of 32 sites, while hospital-acquired infection most frequently involved the lower respiratory tract in 8 (25.0%) of 32 sites. Antimicrobial agents were being administered to 88 (38.4%) of the patients. Cephalosporins (particularly newer, broad-spectrum agents) were the most frequently used antibiotics, comprising 53 (45.3%) of the 117 total antimicrobial prescriptions. seven (18.4%) of the 38 antibiotics used for surgical prophylaxis were given for more than 48 hours. Trend analysis revealed no significant changes in the proportions of patients with community-acquired, hospital-acquired, or total infection over the last 20 years (p=.18, p=.12, and p=.O7, respectively). While the overall use of antibiotics increased p<.ool), the administration of prophylactic perioperative antibiotics for greater than 48 hours decreased p=.009).

Despite major shifts in factors associated with an increased risk of infection, the overall prevalences of hospital-acquired and community-acquired infections remained remarkably constant during the last 20 years. Although total antibiotic use increased, the duration of surgical prophylaxis decreased and the pattern of use of therapeutic antibiotics also changed with increased use of broad-spectrum agents