To investigate coagulase-negative staphylococcus (CONS) causing bacteremia in a neonatal intensive care unit (NICU).

A 14-month retrospective review of 47 infants in the NICU with CONS bacteremia was undertaken to determine CONS glycocalyx production, plasmid pattern, total DNA restriction fragment polymorphism, and clinical risk factors.

The isolates included 32 Staphylococcus epidermidis, six Staphylococcus haemolyticus, four Staphylococcus warneri, four Staphylococcus saprophyticus, and one Staphylococcus hominis. Sixty-five percent of S epidermidis produced glycocalyx; other species did not. Oxacillin resistance (52%) and the antibiograms of the CONS were consistent with other units in the hospital. Five similar CONS plasmid patterns were found among 16 isolates; 31 isolates had unique patterns. Extractions of total DNA from these isolates were digested using HindIII, HaeIII, and BstEII. Those with similar restriction fragment length patterns could not be linked as nosocomially transmitted among infants with bacteremia.

Our observations suggest that multiple strains of CONS infect infants in the NICU who have similar risk factors. Although current infection control practices limit transmission of a pathogen, they do not prevent CONS bacteremias.

Hepatitis C virus (HCV) is a major cause of chronic liver disease worldwide. A patient was recently found to be HCV seropositive during hemodialysis follow-up.

To determine whether nosocomial transmission had occurred and which viral populations were transmitted.

HCV transmission case.

A dialysis unit in a French hospital.

Molecular and epidemiologic investigations were conducted to determine whether 2 cases were related. Risk analysis and auditing procedures were performed to determine the transmission pathway(s).

Sequence analyses of the NS5b region revealed a 5a genotype in the newly infected patient. Epidemiologic investigations suggested that a highly viremic genotype 5a HCV-infected patient who underwent dialysis in the same unit was the source of the infection. Phylogenetic analysis of NS5b and hypervariable region-1 sequences revealed a genetically related virus (>99.9% nucleotide identity). Deep sequencing of hypervariable region-1 indicated that HCV quasispecies were found in the source whereas a single hypervariable region-1 HCV variant was found in the newly infected patient, and that this was identical to the major variant identified in the source patient. Risk analysis and auditing procedures were performed to determine the transmission pathway(s). Nosocomial patient-to-patient transmission via healthcare workers’ hands was the most likely explanation. In our dialysis unit, this unique incident led to the adjustment of infection control policy.

The data support transmission of a unique variant from a source with a high viral load and genetic diversity. This investigation also underlines the need to periodically evaluate prevention and control practices.

Infect. Control Hosp. Epidemiol. 2016;37(2):134–139

To assess whether the implementation of an intensive care unit (ICU) rounding checklist reduces the number of catheter-associated urinary tract infections (CAUTIs).

Retrospective before-and-after study that took place between March 2013 and February 2017.

An academic community hospital 16-bed, mixed surgical, cardiac, medical ICU.

Participants were all patients admitted to the adult mixed ICU and had a diagnosis of CAUTI.

Initiation of an ICU rounding checklist that prompts physicians to address any use of urinary catheters with analysis comparing the preintervention period before roll out of the rounding checklist versus the postintervention periods.

There were 19 CAUTIs and 9,288 urinary catheter days (2.04 CAUTIs per 1,000 catheter days). The catheter utilization ratio increased in the first year after the intervention (0.67 vs 0.60; P = .0079), then decreased in the second year after the intervention (0.53 vs 0.60; P = .0992) and in the third year after the intervention (0.53 vs 0.60; P = .0224). The rate of CAUTI (ie, CAUTI per 1,000 urinary catheter days) decreased from 4.62 before the checklist was implemented to 2.12 in the first year after the intervention (P = .2104). The CAUTI rate was 0.45 in the second year (P = .0275) and 0.96 in the third year (P = .0532).

Our study suggests that utilization of a daily rounding checklist is associated with a decrease in the rates of CAUTI in ICU patients. Incorporating a rounding checklist is feasible in the ICU.

To assess experience, physical infrastructure, and capabilities of high-level isolation units (HLIUs) planning to participate in a 2018 global HLIU workshop hosted by the US National Emerging Special Pathogens Training and Education Center (NETEC).

An electronic survey elicited information on general HLIU organization, operating costs, staffing models, and infection control protocols of select global units.

The survey was distributed to site representatives of 22 HLIUs located in the United States, Europe, and Asia; 19 (86%) responded.

Data were coded and analyzed using descriptive statistics.

The mean annual reported budget for the 19 responding units was US$484,615. Most (89%) had treated a suspected or confirmed case of a high-consequence infectious disease. Reported composition of trained teams included a broad range of clinical and nonclinical roles. The mean number of HLIU beds was 6.37 (median, 4; range, 2–20) for adults and 4.23 (median, 2; range, 1–10) for children; however, capacity was dependent on pathogen.

Responding HLIUs represent some of the most experienced HLIUs in the world. Variation in reported unit infrastructure, capabilities, and procedures demonstrate the variety of HLIU approaches. A number of technical questions unique to HLIUs remain unanswered related to physical design, infection prevention and control procedures, and staffing and training. These key areas represent potential focal points for future evidence and practice guidelines. These data are important considerations for hospitals considering the design and development of HLIUs, and there is a need for continued global HLIU collaboration to define best practices.

In a previous study, we found that unsolicited recommendations to physicians of medically stable patients with pneumonia to suspend parenteral antimicrobials shortened hospital length of stay (LOS) significantly. In this study, we made similar recommendations to physicians treating patients with different indications for parenteral antimicrobials, to examine the effect on LOS.

A nurse-interventionist presented randomly assigned physicians with nonconfrontational suggestions to discontinue parenteral antimicrobials by substituting comparable oral antimicrobials or stopping treatment. Patients were being treated for urinary tract infection, skin infection, or no evident infection. Blinded observers evaluated in-hospital and 30-day postdischarge patient courses. Methodologies were identical to the previous study.

There were 70 physician-patient episodes (49 intervened episodes, 21 control episodes). In 44 episodes (90%), compliant physicians discontinued parenteral antimicrobials. Compared to a median postrandomization LOS of 2.5 days (range, 0 to 40.5) for 21 patients of control physicians, the corresponding LOS for 44 patients of compliant physicians was two days (range, 0 to 8; P= 1.0), and for five patients of noncompliant physicians, five days (range, 3 to 11; P= 0.04).

The combined occurrence of all adverse events detected in this and the previous study was 11% for patients of control physicians, compared to 14% for patients of compliant physicians (P= 0.2), and 19% for patients of noncompliant physicians (P<0.05).

For patients of compliant physicians hospitalized with urinary tract infection, skin and soft tissue infection, or no evident infection, cessation of parenteral antimicrobials did not significantly shorten LOS, due to brief LOS of patients of control physicians. Patients of noncompliant physicians experienced more adverse events and prolonged LOS. The appropriateness of routine continuous use of parenteral antimicrobials in medically stable inpatients is questioned.

To assess the accuracy of provider estimates of ventilator-associated pneumonia (VAP) diagnostic probability in various clinical scenarios.

We conducted a clinical vignette-based survey of intensive care unit (ICU) physicians to evaluate provider estimates of VAP diagnostic probability before and after isolated cardinal VAP clinical changes and VAP diagnostic test results. Responses were used to calculate imputed diagnostic likelihood ratios (LRs), which were compared to evidence-based LRs.

Michigan Medicine University Hospital, a tertiary-care center.

This study included 133 ICU clinical faculty and house staff.

Provider estimates of VAP diagnostic probability were consistently higher than evidence-based diagnostic probabilities. Similarly, imputed LRs from provider-estimated diagnostic probabilities were consistently higher than evidence-based LRs. These differences were most notable for positive bronchoalveolar lavage culture (provider-estimated LR 5.7 vs evidence-based LR 1.4; P < .01), chest radiograph with air bronchogram (provider-estimated LR 6.0 vs evidence-based LR 3.6; P < .01), and isolated purulent endotracheal secretions (provider-estimated LR 1.6 vs evidence-based LR 0.8; P < .01). Attending physicians and infectious disease physicians were more accurate in their LR estimates than trainees (P = .04) and non-ID physicians (P = .03).

Physicians routinely overestimated the diagnostic probability of VAP as well as the positive LRs of isolated cardinal VAP clinical changes and VAP diagnostic test results. Diagnostic stewardship initiatives, including educational outreach and clinical decision support systems, may be useful adjuncts in minimizing VAP overdiagnosis and ICU antibiotic overuse.

To determine the fraction of hospital deaths potentially associated with nosocomial infection (NI).

A matched (1:1) case-control study.

An 800-bed, tertiary-care, teaching hospital.

All patients older than 14 years who were admitted to the hospital between January 1, 1990, and January 1, 1991, were eligible. All 524 consecutive deaths that occurred in the hospital comprised the case group. For each case, a control patient was matched for primary admission diagnosis and admission date.

The proportion of hospital deaths potentially associated with NI was estimated from the population attributable risk (PAR) adjusted for age, gender, service, severity of illness, length of stay, and quality of the medical record.

For stays longer than 48 hours, the PAR for all NIs was estimated to be 21.3% (95% confidence interval [CI95], 16.8%-30.5%). The greatest proportion of deaths potentially associated with NIs was observed in patients with only one infection (PAR, 15.0%; CI96, 10.9%-22.6%) and bacteremia or sepsis (PAR, 7.7%;CI95,4.6%-11.6%).

NIs are associated with a large proportion of intrahospital deaths. This information may help clinicians and healthcare managers to assess the impact of programs for the prevention and control of NIs on intrahospital death.