To compare a hydrogen peroxide dry-mist system and a 0.5% hypochlorite solution with respect to their ability to disinfect Clostridium difficile-contaminated surfaces in vitro and in situ.

Prospective, randomized, before-after trial.

Two French hospitals affected by C. difficile.

In situ efficacy of disinfectants was assessed in rooms that had housed patients with C. difficile infection. A prospective study was performed at 2 hospitals that involved randomization of disinfection processes. When a patient with C. difficile infection was discharged, environmental contamination in the patient's room was evaluated before and after disinfection. Environmental surfaces were sampled for C. difficile by use of moistened swabs; swab samples were cultured on selective plates and in broth. Both disinfectants were tested in vitro with a spore-carrier test; in this test, 2 types of material, vinyl polychloride (representative of the room's floor) and laminate (representative of the room's furniture), were experimentally contaminated with spores from 3 C. difficile strains, including the epidemic clone ribotype 027-North American pulsed-field gel electrophoresis type 1.

There were 748 surface samples collected (360 from rooms treated with hydrogen peroxide and 388 from rooms treated with hypochlorite). Before disinfection, 46 (24%) of 194 samples obtained in the rooms randomized to hypochlorite treatment and 34 (19%) of 180 samples obtained in the rooms randomized to hydrogen peroxide treatment showed environmental contamination. After disinfection, 23 (12%) of 194 samples from hypochlorite-treated rooms and 4 (2%) of 180 samples from hydrogen peroxide treated rooms showed environmental contamination, a decrease in contamination of 50% after hypochlorite decontamination and 91% after hydrogen peroxide decontamination (P < .005). The in vitro activity of 0.5% hypochlorite was time dependent. The mean (±SD) reduction in initial log10 bacterial count was 4.32 ± 0.35 log10 colony-forming units after 10 minutes of exposure to hypochlorite and 4.18 ± 0.8 logl0 colony-forming units after 1 cycle of hydrogen peroxide decontamination.

In situ experiments indicate that the hydrogen peroxide dry-mist disinfection system is significantly more effective than 0.5% sodium hypochlorite solution at eradicating С difficile spores and might represent a new alternative for disinfecting the rooms of patients with C. difficile infection.

The medical needs of the approximately 1 million persons residing in assisted living facilities (ALFs) continually become more demanding. Moreover, the number of ALF residents is expected to double by 2030. ALFs are not subject to federal oversight; state regulations that govern ALF infection control are variable. In 2005, two outbreaks of acute hepatitis B virus (HBV) infection in ALFs in Virginia were associated with sharing fingerstick devices used in blood glucose monitoring.

To characterize infection control practices, determine compliance with guidelines, and identify educational and policy needs in ALFs in Virginia.

Following the outbreaks of HBV infection, educational packets were sent to ALFs in Virginia to inform them of infection control guidelines and recommendations regarding glucose monitoring. A follow-up survey consisting of on-site interviews was conducted in a random sample of ALFs. Differences among infection control practices, according to the size and ownership of the ALFs, were assessed.

Fifty of 155 ALFs in central Virginia were surveyed. Of the 45 ALFs that had used fingerstick devices, 7 (16%) had shared these devices (without cleaning) between residents. Sharing practices for glucose monitoring equipment did not differ by facility size or ownership. Of all 50 ALFs, 17 (34%) did not offer employees HBV vaccine. HBV vaccine was less frequently offered at ALFs that had fewer than 50 residents, compared with ALFs with at least 50 residents (P < .01), and HBV vaccine was less frequently offered at ALFs that were individually owned, compared with those that were not individually owned (P = .02).

Despite outreach and long-standing recommendations, approximately 1 in 6 facilities shared fingerstick devices, and more than one-third of ALFs surveyed were considered noncompliant with federal guidelines (Occupational Safety and Health Administration Bloodborne Pathogens Standard). Public health and licensing agencies should work with ALFs to implement infection control measures and prevent disease transmission.

The anterior nares are the most sensitive single site for detecting methicillin-resistant Staphylococcus aureus (MRSA) colonization. Colonization patterns of USA300 MRSA colonization are unknown.

To assess whether residents of extended care facilities who are colonized with USA300 MRSA have different nares or skin colonization findings, compared with residents who are colonized with non-USA300 MRSA strains.

The study population included residents of 5 extended care units in 3 separate facilities who had a recent history of MRSA colonization. Specimens were obtained weekly for surveillance cultures from the anterior nares, perineum, axilla, and skin breakdown (if present) for 3 weeks. MRSA isolates were categorized as USA300 MRSA or non-USA300 MRSA.

Of the 193 residents who tested positive for MRSA, 165 were colonized in the anterior nares, and 119 were colonized on their skin. Eighty-four percent of USA300 MRSA-colonized residents had anterior nares colonization, compared with 86% of residents colonized with non-USA300 MRSA (P = .80). Sixty-six percent of USA300 MRSA–colonized residents were colonized on the skin, compared with 59% of residents colonized with non-USA300 MRSA (P = .30).

Colonization patterns of USA300 MRSA and non-USA300 MRSA are similar in residents of extended care facilities. Anterior nares cultures will detect most—but not all—people who are colonized with MRSA, regardless of whether it is USA300 or non-USA300 MRSA.

The use of sterile gloves is part of general aseptic procedure, which aims to prevent surgical team members from transmitting infectious agents to patients during procedures performed in an operating room. In addition, surgical gloves also protect team members against patient-transmitted infectious agents. Adequate protection, however, requires that the glove material remain intact. The risk of perforations in surgical gloves is thought to correlate with the duration of wear, yet very few prospective studies have addressed this issue.

We prospectively collected 898 consecutive pairs of used surgical gloves over a 9-month period in a single institution. After surgical team members wore the gloves during surgical procedures, the gloves were examined for microperforations using the watertight test described in European Norm 455, part 1. The gloves were analyzed as a pair; if 1 glove had a perforation, the pair was considered to be perforated. In addition, we evaluated the use of a hand cream that contained a suspension of cornstarch and ethanol to determine its potential influence on the rate of microperforation.

Wearing gloves for 90 minutes or less resulted in microperforations in 46 (15.4%) of 299 pairs of gloves, whereas wearing gloves for 91-150 minutes resulted in perforation of 54 (18.1%) of 299 pairs, and 71 of (23.7%) of 300 pairs were perforated when the duration of wear was longer than 150 minutes (P = .05). Subgroup analysis revealed no significant difference in the rates of microperforation for surgeons (56 [23.0%] of 244 pairs of gloves perforated), first assistants (43 [19.0%] of 226 pairs perforated), and surgical nurses (53 [20.5%] of 259 pairs perforated). Of 171 microperforations, 114 (66.7%) were found on the left hand glove (ie, the glove on subjects' nondominant hand), predominantly on the left index finger (55 [32.3%]). The use of the hand cream had no influence on the rate of microperforation.

Because of the increase in the rate of microperforation over time, it is recommended that surgeons, first assistants, and surgical nurses directly assisting in the operating field change gloves after 90 minutes of surgery.

To evaluate the effect of bathing patients with 2% chlorhexidine on the rates of central vascular catheter (CVC)–associated bloodstream infection (BSI) at a long-term acute care hospital (LTACH).

Quasi-experimental study.

A 70-bed LTACH in the greater Chicago area.

All consecutive patients admitted to the LTACH during the period from February 2006 to February 2008.

For patients at the LTACH, daily 2% chlorhexidine baths were instituted during the period from September 2006 until May 2007 (ie, the intervention period). A preintervention period (in which patients were given daily soap-and-water baths) and a postintervention period (in which patients were given daily nonmedicated baths and weekly 2% chlorhexidine baths) were also observed. The rates of CVC-associated BSI and ventilator-associated pneumonia were analyzed for the intervention period and for the pre- and postintervention periods.

The rates of CVC-associated BSI were 9.5, 3.8, and 6.4 cases per 1,000 CVC-days during the preintervention, intervention, and postintervention periods, respectively. By the end of the intervention period, there was a net reduction of 99% in the CVC-associated BSI rate. No changes were seen in the rates of ventilator-associated pneumonia during the preintervention and intervention periods.

Daily chlorhexidine baths appeared to be an effective intervention to reduce rates of CVC-associated BSI in an LTACH.

Infection-control interventions are needed to minimize transmission of influenza-like illness (ILI) and other infections in settings where children are in close proximity.

A 240-children Thai kindergarten.

Three-year, quasi-experimental study was conducted to assess the association between the use of a bundle of 4 infection control interventions and the incidence of ILI, diarrheal illnesses, and hand-foot-mouth infections among preschool children. The numbers of incident infections were calculated for the preintervention year (period 1), the immediate postintervention year (period 2), and the sustained postintervention year (period 3).

The monthly incidence of ILI in period 1 (mean, 124 episodes per month) was 25.8 cases per 1,000 child-days; in period 2, it was 10.1 cases per 1,000 child-days (a reduction of 60.8%; P = .008); and in period 3, it was 8.2 cases per 1,000 child-days (a further reduction of 19%; P = .002). The monthly incidence of diarrheal illnesses in period 1 was 14 cases per 1,000 child-days; in period 2, it was 4 cases per 1,000 child-days (P = .01); and in period 3, it was 3 cases per 1,000 child-days (P = .007). The yearly incidence of hand-foot-mouth infection in period 1 was 10 cases per 1,000 child-days; in period 2, it was 1 case per 1,000 child-days (P = .01); and in period 3, it was 0.5 cases per 1,000 child-days per year (P = .007).

Use of the infection control intervention bundle was associated with reduced incidence of ILI at the Thai preschool.

To identify risk factors associated with surgical site infection (SSI) after pediatric posterior spinal fusion procedure by examining characteristics related to the patient, the surgical procedure, and tissue hypoxia.

Retrospective case-control study nested in a hospital cohort study.

A 475-bed, tertiary care children's hospital.

All patients who underwent a spinal fusion procedure during the period from January 1995 through December 2006 were included. SSI cases were identified by means of prospective surveillance using National Nosocomial Infection Surveillance system definitions. Forty-four case patients who underwent a posterior spinal fusion procedure and developed an SSI were identified and evaluated. Each case patient was matched (on the basis of date of surgery, ± 3 months) to 3 control patients who underwent a posterior spinal fusion procedure but did not develop an SSI. Risk factors for SSI were evaluated by univariate analysis and multivariable conditional logistic regression. Odds ratios (ORs), with 95% confidence intervals (CIs) and P values, were calculated.

From 1995 to 2006, the mean annual rate of SSI after posterior spinal fusion procedure was 4.4% (range, 1.1%—6.7%). Significant risk factors associated with SSI in the univariate analysis included the following: a body mass index (BMI) greater than the 95th percentile (OR, 3.5 [95% CI, 1.5–8.3]); antibiotic prophylaxis with clindamycin, compared with other antibiotics (OR, 3.5 [95% CI, 1.2 10.0]); inappropriately low dose of antibiotic (OR, 2.6 [95% CI, 1.0–6.6]); and a longer duration of hypothermia (ie, a core body temperature of less than 35.5°C) during surgery (OR, 0.4 [95% CI, 0.2–0.9]). An American Society of Anesthesiologists (ASA) score of greater than 2, obesity (ie, a BMI greater than the 95th percentile), antibiotic prophylaxis with clindamycin, and hypothermia were statistically significant in the multivariable model.

An ASA score greater than 2, obesity, and antibiotic prophylaxis with clindamycin were independent risk factors for SSI. Hypothermia during surgery appears to provide protection against SSI in this patient population.

Multidisciplinary antimicrobial utilization teams (AUTs) have been proposed as a mechanism for improving antimicrobial use, but data on their efficacy remain limited.

To determine the impact of an AUT on antimicrobial use at a teaching hospital.

Randomized controlled intervention trial.

A 953-bed, public, university-affiliated, urban teaching hospital.

Patients who were given selected antimicrobial agents (piperacillin-tazobactam, levofloxacin, or vancomycin) by internal medicine ward teams.

Twelve internal medicine teams were randomly assigned monthly: 6 teams to an intervention group (academic detailing by the AUT) and 6 teams to a control group that was given indication-based guidelines for prescription of broad-spectrum antimicrobials (standard of care), during a 10-month study period.

Proportion of appropriate empirical, definitive (therapeutic), and end (overall) antimicrobial usage.

A total of 784 new prescriptions of piperacillin-tazobactam, levofloxacin, and vancomycin were reviewed. The proportion of antimicrobial prescriptions written by the intervention teams that was considered to be appropriate was significantly higher than the proportion of antimicrobial prescriptions written by the control teams that was considered to be appropriate: 82% versus 73% for empirical (risk ratio [RR], 1.14; 95% confidence interval [CI], 1.04-1.24), 82% versus 43% for definitive (RR, 1.89; 95% CI, 1.53-2.33), and 94% versus 70% for end antimicrobial usage (RR, 1.34; 95% CI, 1.25-1.43). In multivariate analysis, teams that received feedback from the AUT alone (adjusted RR, 1.37; 95% CI, 1.27-1.48) or from both the AUT and the infectious diseases consultation service (adjusted RR, 2.28; 95% CI, 1.64-3.19) were significantiy more likely to prescribe end antimicrobial usage appropriately, compared with control teams.

A multidisciplinary AUT that provides feedback to prescribing physicians was an effective method in improving antimicrobial use.

ClinicalTrials.gov identifier: NCT00552838.

To determine whether Staphylococcus aureus isolates from the nares of patients on a burn trauma unit were related to isolates colonizing or infecting other body sites.

Active surveillance for S. aureus, a case-control study, and pulsed-field gel electrophoresis of S. aureus isolates.

A burn trauma unit of a Midwestern university teaching hospital.

Patients admitted from February 1, 2002, through March 30, 2007, who had S. aureus isolated either from a nasal culture and from another body site (case patients) or from a nasal culture alone (control subjects).

Nineteen patients met the case patient definition and had paired isolates from the nares and an additional site available for typing. Of the 19 case patients, 8 had infections, 7 of which were caused by methicillin-resistant S. aureus (5 USA100 strain and 2 USA300 strain). A total length of stay of more than 3 weeks (odds ratio [OR], 8.75 [95% confidence interval {CI}, 2.2–34.6]; P = .002), residence in a long-term care facility (OR, 9.4 [95% CI, 2.1–42.5]; P = .004), and diabetes (OR, 3.2 [95% CI, 1.0–10.0]; P = .05) were associated with the isolation of S. aureus from the nares and other sites. Seventeen case patients (89.5%) had closely related isolates obtained from culture of samples from the nares and from other sites.

Prolonged length of stay, diabetes, or residing in a long-term care facility increased the risk of having S. aureus at sites other than the nares. S. aureus isolates from other body sites usually were closely related to nasal isolates. Most case patients had colonized or infected wounds that could be a source of S. aureus for other patients.

We evaluated the usefulness of topical decolonization therapy for reducing the risk of methicillin-resistant Staphylococcus aureus (MRSA) infection among MRSA-colonized inpatients.

Retrospective cohort study.

Three hospitals with universal surveillance for MRSA; at their physician's discretion, colonized patients could be treated with a 5-day course of nasal mupirocin calcium 2%, twice daily, plus Chlorhexidine gluconate 4% every second day.

MRSA carriers were later retested for colonization (407 subjects; study 1) or followed up for development of MRSA infection (933 subjects; study 2). Multivariable methods were used to determine the impact of decolonization therapy on the risks of sustained colonization (in study 1) and MRSA infection (in study 2).

Independent risk factors for sustained colonization included residence in a long-term care facility (odds ratio [OR], 1.8 [95% confidence interval {CI}, 1.1–3.2]) and a pressure ulcer (OR, 2.3 195% CI, 1.2–4.4]). Mupirocin at any dose decreased this risk, particularly during the 30-60-day period after therapy; mupirocin resistance increased this risk (OR, 4.1 [95% CI, 1.6–10.7]). Over a median follow-up duration of 269 days, 69 (7.4%) of 933 patients developed infection. Independent risk factors for infection were length of stay (hazard ratio [HR], 1.2 per 5 additional days [95% CI, 1.0–1.4]), chronic lung disease (HR, 1.7 [95% CI, 1.0–2.8]), and receipt of non-MRSA-active systemic antimicrobial agents (HR, 1.8 [95% CI, 1.1–3.1]). Receipt of mupirocin did not affect the risk of infection, although there was a trend toward delayed infection among patients receiving mupirocin (median time to infection, 50 vs 15.5 days; P = .06).

Mupirocin-based decolonization therapy temporarily reduced the risk of continued colonization but did not decrease the risk of subsequent infection.

To study the acquisition and cross-transmission of Staphylococcus aureus in different intensive care units (ICUs).

We performed a multicenter cohort study. Six ICUs in 6 countries participated. During a 3-month period at each ICU, all patients had nasal and perineal swab specimens obtained at ICU admission and during their stay. All S. aureus isolates that were collected were genotyped by spa typing and multilocus variable-number tandem-repeat analysis typing for cross-transmission analysis. A total of 629 patients were admitted to ICUs, and 224 of these patients were found to be colonized with S. aureus at least once during ICU stay (22% were found to be colonized with methicillin-resistant S. aureus [MRSA]). A total of 316 patients who had test results negative for S. aureus at ICU admission and had at least 1 follow-up swab sample obtained for culture were eligible for acquisition analysis.

A total of 45 patients acquired S. aureus during ICU stay (31 acquired methicillin-susceptible S. aureus [MSSA], and 14 acquired MRSA). Several factors that were believed to affect the rate of acquisition of S. aureus were analyzed in univariate and multivariate analyses, including the amount of hand disinfectant used, colonization pressure, number of beds per nurse, antibiotic use, length of stay, and ICU setting (private room versus open ICU treatment). Greater colonization pressure and a greater number of beds per nurse correlated with a higher rate of acquisition for both MSSA and MRSA. The type of ICU setting was related to MRSA acquisition only, and the amount of hand disinfectant used was related to MSSA acquisition only. In 18 (40%) of the cases of S. aureus acquisition, cross-transmission from another patient was possible.

Colonization pressure, the number of beds per nurse, and the treatment of all patients in private rooms correlated with the number of S. aureus acquisitions on an ICU. The amount of hand disinfectant used was correlated with the number of cases of MSSA acquisition but not with the number of cases of MRSA acquisition. The number of cases of patient-to-patient cross-transmission was comparable for MSSA and MRSA.

Although many studies have examined nosocomial bloodstream infection (BSI), US national estimates of incidence and case-fatality rates have seldom been reported.

The purposes of this study were to generate US national estimates of the incidence and severity of nosocomial BSI and to identify risk factors for nosocomial BSI among adults hospitalized in the United States on the basis of a national probability sample.

This cross-sectional study used the US Nationwide Inpatient Sample for the year 2003 to estimate the incidence and case-fatality rate associated with nosocomial BSI in the total US population. Cases of nosocomial BSI were defined by using 1 or more International Classification of Diseases, 9th Revision, Clinical Modification codes in the secondary field(s) that corresponded to BSIs that occurred at least 48 hours after admission. The comparison group consisted of all patients without BSI codes in their NIS records. Weighted data were used to generate US national estimates of nosocomial BSIs. Logistic regression was used to identify independent risk factors for nosocomial BSI.

The US national estimated incidence of nosocomial BSI was 21.6 cases per 1,000 admissions, while the estimated case-fatality rate was 20.6%. Seven of the 10 leading causes of hospital admissions associated with nosocomial BSI were infection related. We estimate that 541,081 patients would have acquired a nosocomial BSI in 2003, and of these, 111,427 would have died. The final multivariate model consisted of the following risk factors: central venous catheter use (odds ratio [OR], 4.76), other infections (OR, 4.61), receipt of mechanical ventilation (OR, 4.97), trauma (OR, 1.98), hemodialysis (OR, 4.83), and malnutrition (OR, 2.50). The total maximum rescaled R2 was 0.22.

The Nationwide Inpatient Sample was useful for estimating national incidence and case-fatality rates, as well as examining independent predictors of nosocomial BSI.

To characterize the epidemiology and microbiology of ventilator-associated pneumonia (VAP) in a long-term acute care hospital (LTACH).

Retrospective study of prospectively identified cases of VAP.

Single-center, 207-bed LTACH with the capacity to house 42 patients requiring mechanical ventilation, evaluated from April 1, 2006, through January 31, 2008.

Data on the occurrence of VAP were collected prospectively as part of routine infection surveillance at Radius Specialty Hospital. After March 2006, Radius Specialty Hospital implemented a bundle of interventions for the prevention of VAP (hereafter referred to as the VAP-bundle approach). A case of VAP was defined as a patient who required mechanical ventilation at Radius Specialty Hospital for at least 48 hours before any symptoms of pneumonia appeared and who met the Centers for Disease Control and Prevention criteria for VAP. Sputum samples were collected from a tracheal aspirate if there was clinical suspicion of VAP, and these samples were semi-quantitatively cultured.

During the 22-month study period, 23 cases of VAP involving 19 patients were associated with 157 LTACH admissions (infection rate, 14.6%), corresponding to a rate of 1.67 cases per 1,000 ventilator-days, which is a 56% reduction from the VAP rate of 3.8 cases per 1,000 ventilator-days reported before the implementation of the VAP-bundle approach (P<.001). Microbiological data were available for 21 (91%) of 23 cases of VAP. Cases of VAP in the LTACH were frequently polymicrobial (mean number ± SD, 1.78 ± 1.0 pathogens per case of VAP), and 20 (95%) of 21 cases of VAP had at least 1 pathogen (Pseudomonas species, Acinetobacter species, gram-negative bacilli resistant to more than 3 antibiotics, or methicillin-resistant Staphylococcus aureus) cultured from a sputum sample. LTACH patients with VAP were more likely to have a neurological reason for ventilator dependence, compared with LTACH patients without VAP (69.6% of cases of VAP vs 39% of cases of respiratory failure; P = .014). In addition, patients with VAP had a longer length of LTACH stay, compared with patients without VAP (median length of stay, 131 days vs 39 days; P = .002). In 6 (26%) of 23 cases of VAP, the patient was eventually weaned from use of mechanical ventilation. Of the 19 patients with VAP, 1 (5%) did not survive the LTACH stay.

The VAP rate in the LTACH is lower than the VAP rate reported in acute care hospitals. Cases of VAP in the LTACH were frequently polymicrobial and were associated with multidrug-resistant pathogens and increased length of stay. The guidelines from the Centers for Disease Control and Prevention that are aimed at reducing cases of VAP appear to be effective if applied in the LTACH setting.

To evaluate the prevalence, epidemiologic features, and molecular characteristics of colonization with community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) among hospitalized dialysis patients and their healthcare workers (HCWs).

Prospective observational clinical and laboratory study of nasal colonization.

A 600-bed urban academic medical center.

One hundred twenty hospitalized dialysis inpatients and 100 HCWs.

Of 120 patients, 40 (33%) were colonized with S. aureus; 26 (65%) of these 40 were colonized with MRSA. Among the 26 MRSA isolates, 10 (38.5%) carried staphylococcal cassette chromosome (SCC) mec type IV (ie, CA-MRSA), and 7 of these 10 carried the genes for the Panton-Valentine leukocidin (PVL) toxin. Patients colonized with healthcare-associated MRSA strains and those colonized with CA-MRSA strains were similar, except for a higher frequency of a history of congestive heart failure among those with healthcare-associated MRSA strains (P = .014). Among 10 patients who presented with or developed an S. aureus infection while hospitalized, 8 were colonized with S. aureus, 7 with MRSA, and 3 with SCCmec type IV strains. Among 100 HCWs, 31 were colonized with S. aureus, including 6 with MRSA; 2 of the MRSA isolates belonged to CA-MRSA strains, and soft-tissue infections were reported in one of the HCWs and in the family member of the other HCW colonized with these strains.

There is a high rate of colonization with MRSA and CA-MRSA among hospitalized dialysis patients and their HCWs. As other studies have found, it appears that individuals are being colonized with both CA-MRSA strains and healthcare-associated MRSA strains.

To evaluate common hand hygiene methods for efficacy in removing Clostridium difficik.

Randomized crossover comparison among 10 volunteers with hands experimentally contaminated by nontoxigenic C. difficile.

Interventions included warm water with plain soap, cold water with plain soap, warm water with antibacterial soap, antiseptic hand wipes, alcohol-based handrub, and a control involving no Intervention. All interventions were evaluated for mean reduction in colony-forming units (CFUs) under 2 contamination protocols: “whole hand” and “palmar surface.” Results were analyzed according to a Bayesian approach, by using hierarchical models adjusted for multiple observations.

Under the whole-hand protocol, the greatest adjusted mean reductions were achieved by warm water with plain soap (2.14 log10 CFU/mL [95% credible interval (Cri), 1.74-2.54 log10 CFU/mL]), cold water with plain soap (1.88 log10 CFU/mL [95% Cri, 1.48-2.28 log10 CFU/mL), and warm water with antibacterial soap (1.51 log10 CFU/mL [95% Cri, 1.12-1.91 logu, CFU/mL]), followed by antiseptic hand wipes (0.57 log10 CFU/mL [95% Cri, 0.17-0.96 log10 CFU/mL]). Alcohol-based handrub (0.06 log10 CFU/mL [95% CrI, -0.34 to 0.45 log10 CFU/mL]) was equivalent to no Intervention. Under the palmar surface protocol, warm water with plain soap, cold water with plain soap, and warm water with antibacterial soap again yielded the greatest mean reductions, followed by antiseptic hand wipes (26.6, 26.6, 26.6, and 21.9 CFUs per plate, respectively), when compared with alcohol-based handrub. Hypothenar (odds ratio, 10.98 [95% Cri, 1.96-37.65]) and thenar (odds ratio, 6.99 [95% Cri, 1.25-23.41]) surfaces were more likely than fingertips to remain heavily contaminated after handwashing.

Handwashing with soap and water showed the greatest efficacy in removing C. difficile and should be performed preferentially over the use of alcohol-based handrubs when contact with C. difficile is suspected or likely.

Although influenza vaccination of healthcare workers reduces influenza-like illness and overall mortality among patients, national rates of vaccination for healthcare providers are unacceptably low. We report the implementation of a new mandatory vaccination policy by means of a streamlined electronic enrollment and vaccination tracking system at the National Institutes of Health (NIH) Clinical Center.

To evaluate the outcome of a new mandatory staff influenza vaccination program.

A new hospital policy endorsed by all the component NIH institutes and the Clinical Center departments mandated that employees who have patient contact either be vaccinated annually against influenza or sign a declination specifying the reason(s) for refusal. Those who fail to comply would be required to appear before the Medical Executive Committee to explain their rationale. We collected in a database the names of all physician and nonphysician staff who had patient contact. When a staff member either was vaccinated or declined vaccination, a simple system of badge scanning and bar-coded data entry captured essential data. The database was continuously updated, and it provided a list of noncompliant employees with whom to follow up.

By February 12, 2009, all 2,754 identified patient-care employees either were vaccinated or formally declined vaccination. Among those, 2,424 (88%) were vaccinated either at the NIH or elsewhere, 36 (1.3%) reported medical contraindications, and 294 (10.7%) declined vaccination for other reasons. Among the 294 employees without medical contraindications who declined, the most frequent reason given for declination was concern about side effects.

Implementation of a novel vaccination tracking process and a hospital policy requiring influenza vaccination or declination yielded dramatic improvement in healthcare worker vaccination rates and likely will result in increased patient safety in our hospital.