Although catheter-associated urinary tract infection (CAUTI) and catheter-associated asymptomatic bacteriuria (CAABU) are clinically distinct conditions, most literature describing the risks of bacteriuria does not distinguish between them. We studied the relationship between catheter-associated bacteriuria and bacteremia from a urinary source in CAUTI relative to that in CAABU. Second, we investigated whether the presence or absence of urinary symptoms in catheterized patients with bacteriuria was associated with bacteremia from any source or mortality. Finally, we explored the effect of antimicrobial treatment of bacteriuria on subsequent bacteremia from any source and mortality.

We performed a retrospective cohort study with 30 days of follow-up after an initial positive urine culture. CAUTI and CAABU were defined by Infectious Diseases Society of America guidelines.

A large tertiary care facility.

All inpatients with a urinary catheter (external or indwelling) and a positive urine culture between October 2010 and June 2011.

We captured 444 episodes of catheter-associated bacteriuria in 308 patients; 128 (41.6%) patients had CAUTI, and 180 (58.4%) had CAABU. Three episodes of bacteriuria were followed by bacteremia from a urinary source (0.7%). CAUTI, rather than CAABU, was associated with bacteremia from any source, but neither CAUTI nor CAABU predicted subsequent mortality. Use of antimicrobial agents to treat bacteriuria was not associated with either bacteremia from any source or mortality.

Bacteremia from a urinary source was infrequent, and there was no evidence of an association of mortality with symptomatic versus asymptomatic bacteriuria in this population. Antibiotic treatment of bacteriuria did not affect outcomes.

Peripherally inserted central catheter (PICC) tip malposition is potentially associated with complications, and postplacement adjustment of PICCs is widely performed. We sought to characterize the association between central line-associated bloodstream infection (CLABSI) or venous thrombus (VT) and PICC adjustment.

Retrospective cohort study.

University of Michigan Health System, a large referral hospital.

Patients who had PICCs placed between February 2007 and August 2007.

The primary outcomes were development of CLABSI within 14 days or VT within 60 days of postplacement PICC adjustment, identified by review of patient electronic medical records.

There were 57 CLABSIs (2.69/1,000 PICC-days) and 47 VTs (1.23/1,000 PICC-days); 609 individuals had 1, 134 had 2, and 33 had 3 or more adjustments. One adjustment was protective against CLABSI (P = .04), whereas 2 or 3 or more adjustments had no association with CLABSI (P = .58 and .47, respectively). One, 2, and 3 or more adjustments had no association with VT formation (P = .59, .85, and .78, respectively). Immunosuppression (P< .01), power-injectable PICCs (P = .05), and 3 PICC lumens compared with 1 lumen (P = .02) were associated with CLABSI. Power-injectable PICCs were also associated with increased VT formation (P = .03).

Immunosuppression and 3 PICC lumens were associated with increased risk of CLABSI. Power-injectable PICCs were associated with increased risk of CLABSI and VT formation. Postplacement adjustment of PICCs was not associated with increased risk of CLABSI or VT. Infect Control Hosp Epidemiol 2013;34(8):785-792

Develop a clinical decision support tool comprised of an electronic medical record alert and antimicrobial stewardship navigator to facilitate antimicrobial stewardship.

We analyzed alerts targeting antimicrobial de-escalation to assess the effectiveness of the navigator as a stewardship tool. The alert provides antimicrobial recommendations, then directs providers to the navigator, which includes order management, relevant patient information, evidence-based clinical information, and bidirectional communication capability.

Academic, tertiary care medical center with an electronic medical record.

Alerts containing stewardship recommendations and immediate access to the navigator were created.

Antibiotic use and response data were collected 1 day before stewardship recommendation via the best practice alert (BPA) tool and 1 day after the BPA tool response. A total of 1,285 stewardship BPAs were created. Two hundred and forty-four (18.9%) of the BPAs were created and acted upon within 72 hours for the purpose of de-escalation: 169 (69%) were accepted, 30 (12%) were accepted with modification, and 45 (18%) were rejected. Statistically significant decreases in total antibiotic use as well as in use of broad-spectrum (anti-methicillin-resistant Staphylococcus aureus and anti-pseudomonal) agents occurred when accepted recommendations were compared with rejected recommendations.

We describe the successful development of a clinical decision support tool to perform prospective audit and feedback comprised of an alert and navigator system featuring evidence-based recommendations and clinical and educational information. We demonstrate that this tool improves antibiotic use through our example of de-escalation.

This project was registered at ClinicalTrials.gov (NCT01573195).

The World Health Organization (WHO) has published “Guidelines on Hand Hygiene in Health Care” recommending 2 hand rub formulations based on 80% vol/vol ethanol or 75% vol/vol isopropanol for local production in healthcare settings where commercial products are not available or are too expensive. Previous investigations have shown that neither formulation meets the efficacy requirements of European norm (EN) 12791, which is the most stringent available norm for surgical hand rub preparations. Even when modified with approximately 5% higher alcohol content, the formulations proved to be inferior to the reference of the norm when measured after 3 hours.

Because the high glycerol content of the formulations was suspected to negatively influence their efficacy, additional investigations were performed with varying glycerol content.

Modified formulations with higher alcohol concentration (mass instead of volume percentage) and lower glycerol concentration (0.725% instead of 1.45%) or without the addition of glycerol were evaluated for their conformity with the efficacy requirements of EN 12791, which demands noninferiority in comparison with a reference hand antisepsis procedure immediately and 3 hours after treatment on volunteers’ hands.

Randomized Latin-square design.

Microbiology laboratory of the Medical University of Vienna, Vienna, Austria.

Twenty-five healthy volunteers.

Reducing the concentration of glycerol or omitting it completely rendered both WHO formulations noninferior to the reference, both immediately and 3 hours after surgical hand antisepsis.

Both WHO-recommended formulations meet the efficacy requirements of EN 12791 by increasing their alcohol concentrations by 5%, prolonging their application to 5 minutes and reducing the glycerol concentration to 0.725%.

The Centers for Medicare and Medicaid Services' (CMS's) Hospital Inpatient Quality Reporting program includes the initial selection of antibiotics for adult community-acquired pneumonia (CAP) patients as a performance measure. A multidisciplinary team denned opportunities for improving performance in appropriate antibiotic use among CAP patients. The team consisted of personnel from the emergency department (ED), the antimicrobial stewardship program (infectious disease, pharmacy), and performance improvement.

Quasi-experimental before-after study.

A large, urban, multicampus academic medical center.

Interventions included an algorithm for ED providers identifying appropriate antibiotic selections, development of a CAP kit consisting of appropriate antibiotics and dosing regimens bundled with the treatment algorithm, and preloading an automated ED medication dispensing and management system. A quality improvement methodology (“plan, do, check, act”) was used to pilot stewardship interventions at one ED campus and later at a second ED campus.

In the pilot ED, appropriate antibiotic selection for CAP improved from 54.9% before the intervention in 2008 to 93.4% after the intervention in 2011 (P< .001). Subsequently, in the second ED appropriate antibiotic regimens for CAP improved from 64.6% before the intervention in 2008 to 91.3% after the intervention in 2011 (P = .004). The rates of another CMS measure, antibiotic administration within 6 hours, were not statistically different before and after the interventions. In an interrupted time series logistic regression analysis, the intervention was found to be significantly associated with the improved prescribing (P< .001).

The combination of interdisciplinary teamwork, antibiotic stewardship, education, and information technology is associated with replicable and sustained prescribing improvements.

Peripherally inserted central catheters (PICCs) are associated with central line-associated bloodstream infection (CLABSI). The magnitude of this risk relative to central venous catheters (CVCs) is unknown.

To compare risk of CLABSI between PICCs and CVCs.

MEDLINE, CinAHL, Scopus, EmBASE, and Cochrane CENTRAL were searched. Full-text studies comparing the risk of CLABSI between PICCs and CVCs were included. Studies involving adults 18 years of age or older who underwent insertion of a PICC or a CVC and reported CLABSI were included in our analysis. Studies were evaluated using the Downs and Black scale for risk of bias. Random effects meta-analyses were used to generate summary estimates of CLABSI risk in patients with PICCs versus CVCs.

Of 1,185 studies identified, 23 studies involving 57,250 patients met eligibility criteria. Twenty of 23 eligible studies reported the total number of CLABSI episodes in patients with PICCs and CVCs. Pooled meta-analyses of these studies revealed that PICCs were associated with a lower risk of CLABSI than were CVCs (relative risk [RR], 0.62; 95% confidence interval [CI], 0.40-0.94). Statistical heterogeneity prompted subgroup analysis, which demonstrated that CLABSI reduction was greatest in outpatients (RR [95% CI], 0.22 [0.18-0.27]) compared with hospitalized patients who received PICCs (RR [95% CI], 0.73 [0.54-0.98]). Thirteen of the included 23 studies reported CLABSI per catheter-day. Within these studies, PICC-related CLABSI occurred as frequently as CLABSI from CVCs (incidence rate ratio [95% CI], 0.91 [0.46-1.79]).

Only 1 randomized trial met inclusion criteria. CLABSI definition and infection prevention strategies were variably reported. Few studies reported infections by catheter-days.

Although PICCs are associated with a lower risk of CLABSI than CVCs in outpatients, hospitalized patients may be just as likely to experience CLABSI with PICCs as with CVCs. Consideration of risks and benefits before PICC use in inpatient settings is warranted.

Little is known about whether those performing healthcare-associated infection (HAI) surveillance vary in their interpretations of HAI definitions developed by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN). Our primary objective was to characterize variations in these interpretations using clinical vignettes. We also describe predictors of variation in responses.

Cross-sectional study.

United States.

A sample of US-based members of the Society for Healthcare Epidemiology of America (SHEA) Research Network.

Respondents assessed whether each of 6 clinical vignettes met criteria for an NHSN-defined HAI. Individual- and institutional-level data were also gathered.

Surveys were distributed to 143 SHEA Research Network members from 126 hospitals. In total, 113 responses were obtained, representing at least 61 unique hospitals (30 respondents did not identify a hospital); 79.2% (84 of 106 nonmissing responses) were infection preventionists, and 79.4% (81 of 102 nonmissing responses) worked at academic hospitals. Among the 6 vignettes, the proportion of respondents correctly characterizing the vignettes was as low as 27.3%. Combining all 6 vignettes, the mean percentage of correct responses was 61.1% (95% confidence interval, 57.7%–63.8%). Percentage of correct responses was associated with presence of a clinical background (ie, nursing or physician degrees) but not with hospital size or infection prevention and control department characteristics.

Substantial heterogeneity exists in the application of HAI definitions in this survey of infection preventionists and hospital epidemiologists. Our data suggest a need to better clarify these definitions, especially when comparing HAI rates across institutions.

To determine the effectiveness of an automated ultraviolet-C (UV-C) emitter against vancomycin-resistant enterococci (VRE), Clostridium difficile, and Acinetobacter spp. in patient rooms.

Prospective cohort study.

Two tertiary care hospitals.

Convenience sample of 39 patient rooms from which a patient infected or colonized with 1 of the 3 targeted pathogens had been discharged.

Environmental sites were cultured before and after use of an automated UV-C-emitting device in targeted rooms but before standard terminal room disinfection by environmental services.

In total, 142 samples were obtained from 27 rooms of patients who were colonized or infected with VRE, 77 samples were obtained from 10 rooms of patients with C. difficile infection, and 10 samples were obtained from 2 rooms of patients with infections due to Acinetobacter. Use of an automated UV-C-emitting device led to a significant decrease in the total number of colony-forming units (CFUs) of any type of organism (1.07 log10 reduction; P < .0001), CFUs of target pathogens (1.35 log10 reduction; P < .0001), VRE CFUs (1.68 log10 reduction; P < .0001), and C. difficile CFUs (1.16 log10 reduction; P < .0001). CFUs of Acinetobacter also decreased (1.71 log10 reduction), but the trend was not statistically significant P = .25). CFUs were reduced at all 9 of the environmental sites tested. Reductions similarly occurred in direct and indirect line of sight.

Our data confirm that automated UV-C-emitting devices can decrease the bioburden of important pathogens in real-world settings such as hospital rooms.

An emergent strain (ribotype 027) of Clostridium difficile infection (CDI) has been implicated in epidemics worldwide. Organizational factors such as bed occupancy have been associated with an increased incidence of CDI; however, the data are sparse, and the association has not been widely demonstrated. We investigated the association of bed occupancy and CDI within a large hospital organization in the United Kingdom.

To establish whether bed occupancy rates are a significant risk factor for CDI in the general ward setting.

A retrospective cohort study was carried out on data from 2006 to 2008. Univariate and multivariate Cox regression modeling was used to examine the strength and significance of the associations. Variables included patient characteristics, antibiotic policy exposure, case mix, and bed occupancy rates.

A total of 1,589 cases of hospital-acquired CDI were diagnosed (1.7% of admissions), with an overall infection rate of 2.16 per 1,000 patient-days. Median bed occupancy was 93.3% (interquartile range, 83.3%–100%) Univariate and multivariate analyses showed positive and statistically significant associations. In the adjusted model, patients on wards with occupancy rates of 80%–89.9% had rates of CDI that were 56% higher (hazard ratio, 1.56 [95% confidence interval, 1.18–2.04]; P<.001) compared with baseline (0%–69.9% occupancy). CDI rates were 55% higher for patients on wards with maximal bed occupancy (100%).

There is strong evidence of an association between high bed occupancy and CDI. Without effective interventions at high levels of bed occupancy, the economic benefits sought from reducing bed numbers may be negated by the increased risk of CDI.

To determine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Clostridium difficile infection (CDI) in Canadian hospitals.

National point prevalence survey in November 2010.

Canadian acute care hospitals with at least 50 beds.

Adult inpatients colonized or infected with MRSA or VRE or with CDI.

The prevalence (per 100 inpatients) of MRSA, VRE, and CDI was determined. Associations between prevalence and institutional characteristics and infection control policies were evaluated.

One hundred seventy-six hospitals (65% of those eligible) participated. The median (range) prevalence rates for MRSA and VRE colonization or infection and CDI were 4.2% (0%–22.1%), 0.5% (0%–13.1%), and 0.9% (0%–8.6%), respectively. Median MRSA and VRE infection rates were low (0.3% and 0%, respectively). MRSA, VRE, and CDI were thought to have been healthcare associated in 79%, 96%, and 84% of cases, respectively. In multivariable analysis, routine use of a private room for colonized/infected patients was associated with lower median MRSA infection rate (prevalence ratio [PR], 0.44 [95% confidence interval (CI), 0.22–0.88]) and VRE prevalence (PR, 0.26 [95% CI, 0.12–0.57]). Lower VRE rates were also associated with enhanced environmental cleaning (PR, 0.52 [95% CI, 0.36–0.75]). Higher bed occupancy rates were associated with higher rates of CDI (PR, 1.02 [95% CI, 1.01–1.03]).

These data provide the first national prevalence estimates for MRSA, VRE, and CDI in Canadian hospitals. Certain infection prevention and control policies were found to be associated with prevalence and deserve further investigation.

To describe characteristics of Clostridium difficile infection (CDI) and markers of severe CDI among patients with hematologic malignancies.

Case-control study.

Tertiary care teaching hospital.

Inpatients with hematologic malignancies and CDI were age and time matched with 2 control inpatients without hematologic malignancies. Chart reviews were performed, and C. difficile isolates were strain typed.

Case patients (n = 41) and control patients (n = 82) patients were different in respect to receipt of immunosuppressive agents within 2 months (92.7% vs 25.6%; P < .0001); neutropenia within 2 months (75.6% vs 3.7%; P < .0001) and mean (± standard deviation) white blood cell (WBC) count at diagnosis (4.9 ± 14.1 vs 11.8 ± 6.8 × 103 cells/mL; P = .0002); baseline mean creatinine level (0.89 ± 0.1 vs 1.6 ± 2.4 mg/dL; P = .003), mean creatinine level at diagnosis (0.83 ± 0.4 vs 1.85 ± 1.9 mg/dL; P = .004), and creatinine increases of 1.5 times over baseline (2.4% vs 15.1%; P = .02). Immunosuppressive agents and creatinine level remained significant in multivariable analysis (P = .03 for both variables). Severity correlated with mortality when measured by alternate severity criteria but not when measured by the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America criteria, which are based solely on WBC count and creatinine elevation. The prevalence of the epidemic BI/NAP1/027 strain was similar in both groups.

Patients with hematologic malignancies had lower creatinine levels at the time of CDI diagnosis compared with control patients. WBC counts also tended to be lower in case patients. CDI severity criteria based on WBC count and creatinine level may not be applicable to patients with hematologic malignancies.

Individually packaged sterile supply items may become contaminated and act as vectors for nosocomial transmission of multidrug-resistant organisms (MDROs). Thus, many hospitals have a policy to dispose of these unused, packaged supply items at patient discharge from the hospital, which has considerable cost implications. We evaluated the frequency of contamination of these items, the efficacy of hydrogen peroxide vapor (HPV) in disinfecting them, and costs associated with discarded supplies.

Before-after study.

A pilot study was performed in the rooms of 20 patients known to be colonized or infected with vancomycin-resistant enterococci (VRE), and a follow-up study was performed in an additional 20 rooms of patients under precautions for various MDROs in 6 high-risk units. Five pairs of supply items were selected. One item of each pair was sampled without exposure to HPV, and the other was sampled after HPV exposure. The cost of discarded supplies was calculated by examining stock lists of supplies stored on the study units.

Seven (7%) of 100 items were contaminated with VRE in the pilot study, and 9 (9%) of 100 items were contaminated with MDROs in the follow-up study. None of the items were contaminated after exposure to HPV (P < .02 in both the pilot and the follow-up study). The annual cost of supplies discarded at patient hospital discharge was $387,055. This figure does not include the cost of waste disposal and is therefore likely to be an underestimation of the financial burden.

HPV effectively disinfected the packaging of supply items, which could generate considerable financial and environmental benefits.

The primary objective of this study was to validate a novel method of assessing hand hygiene compliance using ultrasound transmitters in patient zones and staff tagged with receivers. The secondary objective was to assess the impact of audio reminders and quantified individual feedback.

An observational comparison against manual assessment followed by assessment using an open-label randomized control method.

Patient zones were established in 3 wards of 2 large teaching hospitals, including 88 general and 18 intensive care unit ward beds.

Consented regular ward nursing, medical, and allied health staff.

Concordance between 40 hours of manual observation using trained hand hygiene auditors and automated measures of opportunities and compliance. Subsequent measured interventions were reminder beeps and written individual feedback.

When compared with manual observations, ultrasound monitoring underestimated percentage compliances by a nonsignificant mean (95% confidence interval [CI]) difference of 5.2% (−20.1% to 9.8%; P = .491). After the intervention, adjusted multivariate analysis showed mean (95% CI) overall compliance in the intervention arm was 6.8% (2.5%−11.1%; P = .002) higher than in the control arm. Results stratified by compliance at entry and exit showed that the effect of intervention was stronger for compliance at exit than at entry.

Our automated measure of hand hygiene compliance is valid when compared with the traditional gold standard of manual observations. As an interventional tool, ultrasound-based automated hand hygiene audits have significant benefit that can be built upon with enhancements and find increasing acceptance with time.

To determine prevalence, predictors, and outcomes of infection due to Escherichia coli sequence type ST131.

Retrospective cohort.

All healthcare settings in Olmsted County, Minnesota (eg, community hospital, tertiary care center, long-term care facilities, and ambulatory clinics).

Ambulatory and hospitalized children and adults with extraintestinal E. coli isolates.

We analyzed 299 consecutive, nonduplicate extraintestinal E. coli isolates submitted to Olmsted County laboratories in February and March 2011. ST131 was identified using single-nucleotide polymorphism polymerase chain reaction and further evaluated through pulsed-field gel electrophoresis. Associated clinical data were abstracted through medical record review.

Most isolates were from urine specimens (90%), outpatients (68%), and community-associated infections (61%). ST131 accounted for 27% of isolates overall and for a larger proportion of those isolates resistant to fluoroquinolones (81%), trimethoprim-sulfamethoxazole (42%), gentamicin (79%), and ceftriaxone (50%). The prevalence of ST131 increased with age (accounting for 5% of isolates from those 11–20 years of age, 26% of isolates from those 51–60 years of age, and 50% of isolates from those 91–100 years of age). ST131 accounted for a greater proportion of healthcare-associated isolates (49%) than community-associated isolates (15%) and for fully 76% of E. coli isolates from long-term care facility (LTCF) residents. Multivariable predictors of ST131 carriage included older age, LTCF residence, previous urinary tract infection, high-complexity infection, and previous use of fluoroquinolones, macrolides, and extended-spectrum cephalosporins. With multivariable adjustment, ST131-associated infection outcomes included receipt of more than 1 antibiotic (odds ratio [OR], 2.54 [95% confidence interval (CI), 1.25–5.17]) and persistent or recurrent symptoms (OR, 2.53 [95% CI, 1.08–5.96]). Two globally predominant ST131 pulsotypes accounted for 45% of STB 1 isolates.

ST131isa dominant, antimicrobial-resistant clonal group associated with healthcare settings, elderly hosts, and persistent or recurrent symptoms.

To determine the association between contact precautions and depression or anxiety as well as feelings of anger, sadness, worry, happiness, or confusion.

Prospective frequency-matched cohort study.

The University of Maryland Medical Center, a 662-bed tertiary care hospital in Baltimore, Maryland.

A total of 1,876 medical and surgical patients over the age of 18 years were approached; 528 patients were enrolled from January through November 2010, and 296 patients, frequency matched by hospital unit, completed follow-up on hospital day 3.

The primary outcome was Hospital Anxiety and Depression Scale (HADS) scores on hospital day 3, controlling for baseline HADS scores. Secondary moods were measured with visual analog mood scale diaries. Patients under contact precautions had baseline symptoms of depression 1.3 points higher (P < .01) and anxiety 0.8 points higher (P = .08) at hospital admission using HADS. Exposure to contact precautions was not associated with increased depression (P = .42) or anxiety (P = .25) on hospital day 3. On hospital day 3, patients under contact precautions were no more likely than unexposed patients to be angry (20% vs 20%; P = .99), sad (33% vs 38%; P = .45), worried (51% vs 46%; P = .41), happy (58% vs 67%; P = .14), or confused (23% vs 24%; P = .95).

Patients under contact precautions have more symptoms of depression and anxiety at hospital admission but do not appear to be more likely to develop depression, anxiety, or negative moods while under contact precautions. The use of contact precautions should not be restricted by the belief that contact precautions will produce more depression or anxiety.

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 evaluate an internet-based preapproval antimicrobial stewardship program for sustained reduction in antimicrobial prescribing and resulting cost savings.

Retrospective cohort study and cost analysis.

Review of all doses and charges of antimicrobials dispensed to patients over 6 years (July 1, 2005–June 30, 2011) at a tertiary care pediatric hospital.

Restricted antimicrobials account for 26% of total doses but 81% of total antimicrobial charges. Winter months (November–February) and the oncology and infant and toddler units were associated with the highest antimicrobial charges. Five restricted drugs accounted for the majority (54%) of charges but only 6% of doses. With an average approval rate of 91.5% (95% confidence interval [CI], 91.1%–91.9%), the preapproval antibiotic stewardship program saved $103,787 (95% CI, $98,583–$109,172) per year, or $14,156 (95% CI, $13,446–$14,890) per 1,000 patient-days.

A preapproval antimicrobial stewardship program effectively reduces the number of doses and subsequent charges due to restricted antimicrobials years after implementation. Hospitals with reduced resources for implementing postprescription review may benefit from a preapproval antimicrobial stewardship program. Targeting specific units, drugs, and seasons may optimize preapproval programs for additional cost savings.

To describe the frequency of use of all types of urinary catheters, including but not limited to indwelling catheters, as well as positive cultures associated with the various types. We also determined the accuracy of catheter-days reporting at our institution.

Prospective, observational trial based on patient-level review of the electronic medical record. Chart review was compared with standard methods of catheter surveillance and reporting by infection control personnel.

Ten internal medicine and 5 long-term care wards in 2 tertiary care Veterans Affairs hospitals in Texas from July 2010 through June 2011.

The study included 7,866 inpatients.

Measurements included patient bed-days; days of use of indwelling, external, suprapubic, and intermittent urinary catheters; number of urine cultures obtained and culture results; and infection control reports of indwelling catheter-days.

We observed 7,866 inpatients with 128,267 bed-days on acute medicine and extended care wards during the study. A urinary catheter was used on 36.9% of the total bed-days observed. Acute medicine wards collected more urine cultures per 1,000 bed-days than did the extended care wards (75.9 and 10.4 cultures per 1,000 bed-days, respectively; P < .0001 ). Catheter-days were divided among indwelling-catheter-days (47.8%), external-catheter-days (48.4%), and other (intermittent- and suprapubic-catheter-days, 3.8%). External catheters contributed to 376 (37.3%) of the 1,009 catheter-associated positive urine cultures. Urinary-catheter-days reported to the infection control department missed 20.1% of the actual days of indwelling catheter use, whereas 12.0% of their reported catheter-days were false.

Urinary catheter use was extremely common. External catheters accounted for a large portion of catheter-associated bacteriuria, and standard practices for tracking urinary-catheter-days were unreliable.

ClinicalTrials.gov identifier: NCT01052545.

To assess the ability of Medicare claims to identify US hospitals with high rates of surgical site infection (SSI) after hip arthroplasty.

Retrospective cohort study.

Acute care US hospitals.

Fee-for-service Medicare patients 65 years of age and older who underwent hip arthroplasty in US hospitals from 2005 through 2007.

Hospital rankings were derived from claims codes suggestive of SSI, adjusted for age, sex, and comorbidities, while using generalized linear mixed models to account for hospital volume. Medical records were obtained for validation of infection on a random sample of patients from hospitals ranked in the best and worst deciles of performance. We then calculated the risk-adjusted odds of developing a chart-confirmed SSI after hip arthroplasty in hospitals ranked by claims into worst- versus best-performing deciles.

Among 524,892 eligible Medicare patients who underwent hip arthroplasty at 3,296 US hospitals, a patient who underwent surgery in a hospital ranked in the worst-performing decile based on claims-based evidence of SSI had 2.9-fold higher odds of developing a chart-confirmed SSI relative to a patient with the same age, sex, and comorbidities in a hospital ranked in the best-performing decile (95% confidence interval, 2.2-3.7).

Medicare claims successfully distinguished between hospitals with high and low SSI rates following hip arthroplasty. These claims can identify potential outlier hospitals that merit further evaluation. This strategy can also be used to validate the completeness of public reporting of SSI.