Vancomycin-resistant enterococci (VRE) are a major cause of nosocomial infection. We sought to compare vancomycin-resistant (VR) Enterococcus faecalis bacteremia and VR Enterococcus faecium bacteremia in cancer patients with respect to risk factors, clinical presentation, microbiological characteristics, antimicrobial therapy, and outcomes.

We identified 210 cancer patients with VRE bacteremia who had been treated between January 1996 and December 2004; 16 of these 210 had VR E. faecalis bacteremia and were matched with 32 patients with VR E. faecium bacteremia and 32 control patients. A retrospective review of medical records was conducted.

Logistic regression analysis showed that, compared with VR E. faecalis bacteremia, VR E. faecium bacteremia was associated with a worse clinical response to therapy (odds ratio [OR], 0.3 [95% confidence interval (CI), 0.07-0.98]; P = .046) and a higher overall mortality rate (OR, 8.3 [95% CI, 1.9-35.3]; P = .004), but the VRE-related mortality rate did not show a statistically significant difference (OR, 6.8 [95% CI, 0.7-61.8]; P = .09). Compared with control patients, patients with VR E. faecalis bacteremia were more likely to have received an aminoglycoside in the 30 days before the onset of bacteremia (OR, 5.8 [95% CI, 1.2-27.6]; P = .03), whereas patients with VR E. faecium bacteremia were more likely to have received a carbapenem in the 30 days before the onset of bacteremia (OR, 11.7 [95% CI, 3.6-38.6]; P<.001). In a multivariate model that compared patients with VR E. faecium bacteremia and control patients, predictors of mortality included acute renal failure on presentation (OR, 15.1 [95% CI, 2.3-99.2]; P = .004) and VR E. faecium bacteremia (OR, 11 [95% CI, 2.7-45.1]; P<.001). No difference in outcomes was found between patients with VR E. faecalis bacteremia and control patients.

VR E. faecium bacteremia in cancer patients was associated with a poorer outcome than was VR E. faecalis bacteremia. Recent receipt of carbapenem therapy was an independent risk factor for VR E. faecium bacteremia, and recent receipt of aminoglycoside therapy was independent risk factor for E. faecalis bacteremia.

To compare the ability of 2 types of dressings to contain vaccinia virus after smallpox vaccination.

Prospective, nonrandomized trial.

The smallpox vaccination clinic in a medium-sized military hospital.

Ninety-seven active-duty military members who received smallpox vaccination in accordance with US Department of Defense and Centers for Disease Control and Prevention guidelines.

The first 40 participants enrolled were instructed to cover their vaccination sites with a semipermeable membrane placed over a separate gauze pad, and the subsequent 57 participants were given a semipermeable membrane bonded to an absorbent pad. Swab samples of the external surface of the dressing were collected 7 and 21 days after vaccination. Real-time quantitative polymerase chain reaction was used to detect vaccinia DNA in the samples.

The rate of vaccinia DNA detection was significantly higher for samples obtained from vaccinees who were using the separate gauze and semipermeable membrane, compared with the vacinees who were using the gauze-impregnated semipermeable membrane (22% vs 2.2%; P = .008; odds ratio, 12.3 [95% confidence interval, 1.4-567.4]).

A gauze-impregnated semipermeable membrane more effectively reduced viral passage to the external surface of the dressing than did a semipermeable membrane placed over a separate gauze pad. Routine use of such dressings following smallpox vaccination might reduce the incidence of autoinoculation and secondary transmission.

To determine whether the National Nosocomial Infections Surveillance (NNIS) System risk index adequately stratified a population of pediatric patients undergoing cardiac surgery according to the risk of developing surgical site infection (SSI).

A retrospective, case-control study.

An urban tertiary care children's hospital.

Patients who had a median sternotomy performed between January 1,1995, and December 31, 2003, were eligible for inclusion in the study. For all case patients, medical records were reviewed to verify that all patients met the case definition for SSI. Control subjects were chosen randomly from among all patients who underwent median sternotomy during the study period who did not develop SSI.

Thirty-eight patients with SSI and 172 patients without SSI were included. One hundred six patients (50%) were male. The median patient age was 4 months. The sensitivity of the NNIS risk index with cutoff scores of 0 to 1 and 2 to 3 was 20%. The distribution of patients with SSI for an NNIS risk index score of 0 was 0%; for a score of 1, 80%; for a score of 2, 20%; and for a score of 3, 0%. The distribution of patients without SSI for a scores of 0 was 4%; for a score of 1, 87%; for a score of 2, 9%; and for a score of 3, 0%. The area under the receiver-operating characteristic curve (AUC) of the original NNIS risk index was 0.57. The modified risk indices did not perform significantly better, with an AUC range of 0.58 to 0.73.

The NNIS risk index did not adequately stratify pediatric patients undergoing median sternotomy according to their risk of developing an SSI. Various modifications to the risk index yielded only slightly higher AUC values.

To determine risk factors for acquisition of multidrug-resistant (MDR) Acinetobacter baumannii infection during an outbreak, to describe the clinical manifestations of infection, and to ascertain the cost of infection.

Case-control study.

Surgical intensive care unit in a 400-bed urban teaching hospital and level 1 trauma center.

Case patients received a diagnosis of infection due to A. baumannii isolates with a unique pattern of drug resistance (ie, susceptible to imipenem, variably susceptible to aminoglycosides, and resistant to all other antibiotics) between December 1, 2004, and August 31, 2005. Case patients were matched 1 : 1 with concurrently hospitalized control patients. Isolates' genetic relatedness was established by pulsed-field gel electrophoresis.

Sixty-seven patients met the inclusion criteria. Case and control patients were similar with respect to age, duration of hospitalization, and Charlson comorbidity score. MDR A. baumannii infections included ventilator-associated pneumonia (in 56.7% of patients), bacteremia (in 25.4%), postoperative wound infections (in 25.4%), central venous catheter-associated infections (in 20.9%), and urinary tract infections (in 10.4%). Conditional multiple logistic regression was used to determine statistically significant risk factors on the basis of results from the bivariate analyses. The duration of hospitalization and healthcare charges were modeled by multiple linear regression. Significant risk factors included higher Acute Physiology and Chronic Health Evaluation II score (odds ratio [OR], 1.1 per point increase; P = .06), duration of intubation (OR, 1.4 per day intubated; P<.01), exposure to bronchoscopy (OR, 22.7; P = .03), presence of chronic pulmonary disease (OR, 77.7; P = .02), receipt of fluconazole (OR, 73.3; P<.01), and receipt of levofloxacin (OR, 11.5; P = .02). Case patients had a mean of $60,913 in attributable excess patient charges and a mean of 13 excess hospital days.

Infection control measures included the following: limitations on the performance of pulsatile lavage wound debridement, the removal of items with upholstered surfaces, and the implementation of contact isolation for patients with suspected MDR A. baumannii infection.

This large outbreak of infection due to clonal MDR A. baumannii caused significant morbidity and expense. Aerosolization of MDR A. baumannii during pulsatile lavage debridement of infected wounds and during the management of respiratory secretions from colonized and infected patients may promote widespread environmental contamination. Multifaceted infection control interventions were associated with a decrease in the number of MDR A. baumannii isolates recovered from patients.

To identify patients with a diagnosis of Clostridium difficile–associated disease (CDAD) in the ambulatory care setting and determine the relationship of symptom onset and diagnosis to prior hospitalization and exposure to antimicrobials.

Single-center, retrospective study.

Medical records were reviewed for outpatients and hospitalized patients with a stool assay positive for C. difficile toxin A from January 1998 through March 2005. Patients with recurrent CDAD or residing in an extended-care facility were excluded. CDAD in patients who had been hospitalized in the 100 days prior to diagnosis was considered potentially hospital-associated.

Of the 84 patients who met the inclusion criteria, 75 (89%) received a diagnosis 1-60 days after hospital discharge (median, 12 days), and 71 (85%) received a diagnosis within 30 days after discharge. Of the 69 patients whose records contained information regarding time of symptom onset, 62 (90%) developed diarrhea within 30 days of a previous hospital discharge, including 7 patients with symptom onset prior to discharge and 9 with onset on the day of discharge. The median time from symptom onset to diagnosis was 6 days. Of 84 patients, 77 (92%) had received antimicrobials during a prior hospitalization, but 55 (65%) received antimicrobials both as inpatients and as outpatients.

If all cases of CDAD diagnosed within 100 days of hospital discharge were assumed to be hospital-associated, 71 (85%) of 84 patients with CDAD were identified within 30 days, and 75 (89%) of 84 were identified by day 60. Continued outpatient antimicrobial exposure confounds determination of whether late-onset cases are community- or hospital-associated.

Preventing hospital falls and injuries requires knowledge of fall and injury circumstances. Our objectives were to determine whether reported fall circumstances differ among hospitals and to identify predictors of fall-related injury.

Retrospective cohort study. Adverse event data on falls were compared according to hospital characteristics. Logistic regression was used to determine adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for risk factors for fall-related injury.

Nine hospitals in a Midwestern healthcare system.

Inpatients who fell during 2001-2003.

The 9 hospitals reported 8,974 falls that occurred in patient care areas, involving 7,082 patients; 7,082 falls were included in our analysis. Assisted falls (which accounted for 13.3% of falls in the academic hospital and 9.8% of falls in the nonacademic hospitals; P <.001) and serious fall-related injuries (which accounted for 3.7% of fall-related injuries in the academic hospital and 2.2% of fall-related injuries in the nonacademic hospitals; P <.001) differed by hospital type. In multivariate analysis for the academic hospital, increased age (aOR, 1.006 [95% CI, 1.000-1.012]), falls in locations other than patient rooms (aOR, 1.53 [95% CI, 1.03-2.27]), and unassisted falls (aOR, 1.70 [95% CI, 1.23-2.36]) were associated with increased injury risk. Altered mental status was associated with a decreased injury risk (aOR, 0.72 [95% CI, 0.58-0.89]). In multivariate analysis for the nonacademic hospitals, increased age (aOR, 1.007 [95% CI, 1.002-1.013]), falls in the bathroom (aOR, 1.46 [95% CI, 1.06-2.01]), and unassisted falls (aOR, 1.83 [95% CI, 1.37-2.43]) were associated with injury. Female sex (aOR, 0.83 [95% CI, 0.71-0.97]) was associated with a decreased risk of injury.

Some fall characteristics differed by hospital type. Further research is necessary to determine whether differences reflect true differences or merely differences in reporting practices. Fall prevention programs should target falls involving older patients, unassisted falls, and falls that occur in the patient's bathroom and in patient care areas outside of the patient's room to reduce injuries.

Disinfection and sterilization are critical components of infection control. Unfortunately, breaches of disinfection and sterilization guidelines are not uncommon.

To describe a method for evaluating a potential breach of guidelines for high-level disinfection and sterilization of medical devices.

The appropriate scientific literature was reviewed to determine the frequency of failures of compliance. A risk assessment model was constructed.

A 14-step protocol was constructed to aid infection control professionals in the evaluation of potential disinfection and sterilization failures. In addition, a model is presented for aiding in determining how patients should be notified of the potential adverse event. Sample statements and letters are provided for communicating with the public and individual patients.

Use of a protocol can guide an institution in managing potential disinfection and sterilization failures.

In July 1999, a rare strain of multidrug-resistant Salmonella enterica serovar Senftenberg was isolated from the sputum of a trauma patient. Over a 6-year period (1999-2005) in northeast Florida, this Salmonella serovar spread to 66 other patients in 16 different healthcare facilities as a result of frequent transfers of patients among institutions. To our knowledge, this is the first outbreak of healthcare-associated infection and colonization with a fluoroquinolone-resistant strain of S. Senftenberg in the United States.

To investigate an outbreak of infection and colonization with an unusual strain of S. Senftenberg and assist with infection control measures.

A case series, outbreak investigation, and microbiological study of all samples positive for S. Senftenberg on culture.

Cases of S. Senftenberg infection and colonization occurred in hospitals and long-term care facilities in 2 counties in northeast Florida.

The affected patients were mostly elderly persons with multiple medical conditions. They were frequently transferred between healthcare facilities. This Salmonella serovar was capable of long-term colonization of chronically ill patients. All S. Senftenberg isolates tested shared a similar pulsed-field gel electrophoresis (PFGE) pattern.

A prolonged outbreak of infection and colonization with multidrug-resistant S. Senftenberg was identified in several healthcare facilities throughout the Jacksonville, Florida, area and became established when infection control measures failed. The bacterial agent was capable of long-term colonization in chronically ill patients. Because the dispersal pattern of this strain suggested a breakdown of infection control practices, a multipronged intervention approach was undertaken that included intense education of personnel in the different institutions, interinstitutional cooperation, and transfer paperwork notification.

To analyze the risk factors for surgical site infection (SSI) complicating coronary artery bypass graft (CABG) surgery and to create an alternative SSI risk score based on the results of multivariate analysis.

A prospective cohort study involving inpatient and laboratory-based surveillance of patients who underwent CABG surgery over a 27-month period from January 1, 2003 through March 31, 2005. Data were obtained from 6 acute care hospitals in Victoria, Australia, that contributed surveillance data for SSI complicating CABG surgery to the Victorian Hospital Acquired Infection Surveillance System Coordinating Centre and the Australasian Society of Cardiac and Thoracic Surgeons, also in Victoria.

A total of 4,633 (93%) of the 4,987 patients who underwent CABG surgery during this period were matched in the 2 systems databases. There were 286 SSIs and 62 deep or organ space sternal SSIs (deep or organ space sternal SSI rate, 1.33%). Univariate analysis revealed that diabetes mellitus, body mass index (BMI) greater than 35, and receipt of blood transfusion were risk factors for all types of SSI complicating CABG surgery. Six multivariate analysis models were created to examine either preoperative factors alone or preoperative factors combined with operative factors. All models revealed diabetes and BMI of 30 or greater as risk factors for SSI complicating CABG surgery. A new preoperative scoring system was devised to predict sternal SSI, which assigned 1 point for diabetes, 1 point for BMI of 30 or greater but less than 35, and 2 points for BMI of 35 or greater. Each point in the scoring system represented approximately a doubling of risk of SSI. The new scoring system performed better than the National Nosocomial Infections Surveillance System (NNIS) risk index at predicting SSI.

A new weighted scoring system based on preoperative risk factors was created to predict sternal SSI risk following CABG surgery. The new scoring system outperformed the NNIS risk index. Future studies are needed to validate this scoring system.

No information is available about the financial impact of central venous catheter (CVC)-associated bloodstream infection (BSI) in Mexico.

To calculate the costs associated with BSI in intensive care units (ICUs) in Mexico City.

An 18-month (June 2002 through November 2003), prospective, nested case-control study of patients with and patients without BSI.

Adult ICUs in 3 hospitals in Mexico City.

A total of 55 patients with BSI (case patients) and 55 patients without BSI (control patients) were compared with respect to hospital, type of ICU, year of hospital admission, length of ICU stay, sex, age, and mean severity of illness score. Information about the length of ICU stay was obtained prospectively during daily rounds. The daily cost of ICU stay was provided by the finance department of each hospital. The cost of antibiotics prescribed for BSI was provided by the hospitals' pharmacy departments.

For case patients, the mean extra length of stay was 6.1 days, the mean extra cost of antibiotics was $598, the mean extra hospital cost was $11,591, and the attributable extra mortality was 20%.

In this study, the duration of ICU stay for patients with central venous catheter-associated BSI was significantly longer than that for control patients, resulting in increased healthcare costs and a higher attributable mortality. These conclusions support the need to implement preventive measures for hospitalized patients with central venous catheters in Mexico.

To determine the attributable mortality and outcome of nosocomial Acinetobacter bacteremia.

Matched, retrospective cohort study.

Large, university-based, tertiary care center.

Of 219 patients with nosocomial Acinetobacter bacteremia identified by prospective surveillance during a 3-year period, 52 met the criteria for the study and were matched to a control patient by age, sex, primary and secondary diagnosis, operative procedures, and date of admission.

A 100% success rate was achieved in the proportion of case patients and control patients matched for the compared criteria, except for major operative procedures (88%) and the presence of an important secondary underlying disease (54.5%). Twenty-nine (55.7%) of the case patients died, compared with 10 (19.2%) of the control patients (P < .001). The attributable mortality was 36.5% (95% CI, 27%-46%) and the risk ratio for death was 2.9 (95% CI, 1.58-5.32). In a multivariate survival analysis, older age, mechanical ventilation, renal failure, and Acinetobacter bacteremia (hazard ratio [HR], 4.41; 95% confidence interval [CI], 1.97-9.87; P < .001) were found to be independent predictors of mortality. There was a trend for a longer median duration of hospitalization among case patients, compared with control patients (11.5 vs. 6.5 days; P = .06). Three isolates were resistant to all but 1 antibiotic tested (colistin), and 45 isolates (86.5%) were resistant to 4 or more different antibiotic classes.

When adjusted for risk-exposure time and severity of disease at admission, nosocomial Acinetobacter bacteremia is associated with mortality in excess of that caused by the underlying diseases alone.

To determine the prevalence and molecular epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) strains among residents in residential care homes for the elderly in Hong Kong.

Cross-sectional and descriptive study.

A total of 949 residents in 13 residential care homes for elderly persons in Hong Kong in January 2005.

MRSA colonization was assessed by culture of swab specimens from anterior nares and active skin lesions. Characteristics of residents were obtained by a standard questionnaire. All MRSA isolates were analyzed by polymerase chain reaction for their staphylococcal cassette chromosome (SCC) mec content and were typed by pulsed-field gel electrophoresis (PFGE) and multilocus sequencing.

MRSA colonization was detected in 27 residents (2.8%). No MRSA was found in 2 facilities. The rate of MRSA carriage in the other 11 facilities ranged from 1.9% to 4.2%. In univariate analysis, functional immobility (odds ratio [OR], 1.4), history of hospital admission (OR, 2.3), and the use of nebulized medication (OR, 5.4) were significantly associated with MRSA colonization. The isolates had 11 unique antibiograms, with 14 isolates susceptible to all but 1 or 2 of the non-β-lactam antimicrobial agents tested. The isolates exhibited SCCmec types I (1 isolate), II (2 isolates), III (1 isolate), IV/IVA (10 isolates), and V (13 isolates). No isolates had the Panton-Valentine leukocidin genes. PFGE analysis clustered all except 1 isolate into 7 PFGE types, designated HKU10 to HKU70. Between 1 and 4 unique PFGE types were found in the individual residential care facilities.

This study documented the emergence of SCCmec types IV and V among genetically diverse MRSA strains in residential care homes for elderly persons in Hong Kong.

To describe how continuous validation of data on surgical site infection (SSI) is being performed in the Dutch National Nosocomial Infection Surveillance System (Preventie Ziekenhuisinfecties door Surveillance [PREZIES]), to assess the quality and accuracy of the PREZIES data, and to present the corresponding outcomes of the assessment.

Mandatory, 1-day on-site validation visit to participating hospitals every 3 years. The process of surveillance, including the quality of the method of data collection, is validated by means of a structured interview. The use of SSI criteria is validated by review of medical records, with the judgment of the validation team as the criterion standard.

Hospitals participating in PREZIES.

During 1999-2004, the validation team visited 40 hospitals and reviewed 859 medical charts. There was no deviation between reports of SSI by infection control professionals and findings by the PREZIES validation team at 30 hospitals and 1 deviation in each of 10 hospitals; the positive predictive value was 0.97, and the negative predictive value was 0.99. The validation team often gave advice to the hospital, aimed at perfecting the process of surveillance. On 2 occasions, data were removed from the PREZIES database after the validation visit revealed deviations from the SSI surveillance protocol that could have resulted in nonrepresentative SSI rate data.

PREZIES is confident that the assembled Dutch SSI surveillance data are reliable and robust and are sufficiently accurate to be used as a reference for interhospital comparison. PREZIES will continue performing on-site validation visits, to improve the process of surveillance and ensure the reliability of the surveillance data.

To determine risk factors for neonatal methicillin-resistant Staphylococcus aureus (MRSA) skin and soft-tissue infection in a well-infant nursery.

Case-control studies.

A well-infant nursery in a nonteaching, community hospital.

Case infants were newborns in the nursery who were born in the period November 2003 through June 2004 and had onset of MRSA skin and soft-tissue infection within 21 days after discharge from the nursery. Site inspections were conducted. Control infants were randomly selected male infants in the nursery during the outbreak periods. MRSA isolates were characterized with pulsed-field gel electrophoresis.

Eleven case infants were identified in 2 outbreaks: outbreak 1 occurred from November 18 through December 24, 2003, and outbreak 2 occurred from May 26 through June 5, 2004. All were full-term male infants with pustular-vesicular lesions in the groin. Inspection revealed uncovered circumcision equipment, multiple-dose lidocaine vials, and inadequate hand hygiene practices. In outbreak 1, case infants (n = 6) had a significantly higher mean length of stay than control infants (3.7 vs 2.5 days; P = .01). In outbreak 2, case infants (n = 5) were more likely to have been circumcised in the nursery (OR, undefined [95% CI, 1.7 to undefined]) and to have received lidocaine injections (OR, undefined [95% CI, 2.6 to undefined]). Controlling for length of stay, case infants were more likely to have been circumcised in the nursery (OR, 12.2 [95% CI, 1.5 to undefined]). Pulsed-field gel electrophoresis showed that 7 available isolates were indistinguishable from a community-associated MRSA strain (USA300-0114).

Newborns in well-infant nurseries are at risk for nosocomial infection with community-associated MRSA strains. Reducing length of stay, improving circumcision and hand hygiene practices, and eliminating use of multiple-dose lidocaine vials should decrease transmission of community-associated MRSA strains in nurseries.

Femoral neck fracture is the most frequent orthopedic emergency among elderly persons. Despite a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) carriage in this population, no multicenter study of antibiotic prophylaxis practices and the rate and microbiological characteristics of surgical site infection (SSI) has been performed in France.

Retrospective, multicenter cohort study.

Twenty-two university and community hospitals in France.

Each center provided data on 25 consecutive patients who underwent surgery for femoral neck fracture during the first quarter of 2005. Demographic, clinical, and follow-up characteristics were recorded, and most patients had a follow-up office visit or were involved in a telephone survey 1 year after surgery.

These 22 centers provided data on 541 patients, 396 (73%) of whom were followed up 1 year after surgery. Of 504 (93%) patients for whom antibiotic prophylaxis was recorded, 433 (86%) received a cephalosporin. Twenty-two patients had an SSI, for a rate of 5.6% (95% confidence interval, 3.7-8.0). SSI was reported for 15 (6.9%) of patients who had a prosthesis placed and for 7 (3.9%) who underwent osteosynthesis (P = .27). SSI was diagnosed a median of 30 days after surgery (interquartile range, 21-41 days); 7 (32%) of these SSIs were superficial infections, and 15 (68%) were deep or organ-space infections. MRSA caused 7 SSIs (32%), Pseudomonas aeruginosa caused 5 (23%), other staphylococci caused 4 (18%), and other bacteria caused 2 (9%); the etiologic pathogen was unknown in 4 cases (18%). Reoperation was performed for 14 patients with deep or organ-space SSI, including 6 of 7 patients with MRSA SSI. The mortality rate 1 year after surgery was 20% overall but 50% among patients with SSI. In univariate analysis, only the National Nosocomial Infections Surveillance System risk index score was significantly associated with SSI (P = .006).

SSI after surgery for femoral neck fracture is severe, and MRSA is the most frequently encountered etiologic pathogen. A large, multicenter prospective trial is necessary to determine whether the use of antibiotic prophylaxis effective against MRSA would decrease the SSI rate in this population.

Clostridium difficile is a major cause of infectious diarrhea in hospitalized patients. Between August 2003 and January 2004, we experienced an increase in the incidence of C. difficile–associated disease. We describe the investigation into and management of the outbreak in this article.

A total of 73 consecutive patients with nosocomial C. difficile–associated diarrhea were identified. C. difficile isolates were characterized using toxin-specific enzyme immunoassays, a tissue-culture fibroblast cytotoxicity assay, polymerase chain reaction (PCR), and antimicrobial susceptibility tests. Rates of recurrence and of C. difficile colitis were recorded. Changes in antibiotic use and infection control policies were documented.

The incidence of C. difficile–associated diarrhea peaked at 21 cases per 1,000 patient admissions. Of the C. difficile isolates recovered, 85 (95%) were identical toxin A–negative and toxin B-positive strains, corresponding to toxinotype VIII and PCR ribotype 017. All clonal isolates were resistant to multiple antibiotics, including ofloxacin, ciprofloxacin, levofloxacin, moxifloxacin, and gatifloxacin (minimum inhibitory concentrations [MICs] of greater than 32 μg/mL) and erythromycin, clarithromycin, and clindamycin (MICs of greater than 256 μg/mL). Recurrent C. difficile–associated disease occurred in 26 (36%) of the patients. At least 10 (14%) of the patients developed C. difficile colitis. Additional infection control measures introduced included the use of ward memos, a hand-hygiene awareness campaign, increased environmental cleaning, attention to prescribing practices for antibiotics, increased awareness of diarrheal illness, and early isolation of affected patients. Total use of fluoroquinolones did not change throughout the study period. Despite persistence of this toxin-variant strain, the incidence of C. difficile–associated disease in our institution decreased to fewer than 5 cases per 1,000 admissions.

We report on the emergence of a fluoroquinolone- and clindamycin-resistant, toxin A–negative, and toxin B–positive strain of C. difficile associated with an outbreak of C. difficile–associated disease in our institution during a 6-month period. We found that careful attention to improvement of infection control interventions was the most important means of controlling this nosocomial pathogen.

To compare healthcare workers' skin tolerance for and acceptance of 3 alcohol-based hand rub formulations.

Double-blind, randomized, crossover clinical trial.

Intensive care unit in a university hospital.

Thirty-eight healthcare workers (HCWs).

A total of 3 alcohol-based hand rub formulations (hereafter, formulations A, B, and C) were used in random order for 3-5 consecutive working days during regular nursing shifts. Formulations A and B contained the same emollient, and formulations B and C contained the same alcohol at the same concentration. Use of each test formulation was separated by a “washout” period of at least 2 days. A visual assessment of skin integrity by a blinded observer using a standard 6-item scale was conducted before and after the use of each formulation. Univariate and multivariate analyses were used for the assessment of risk factors for skin alteration, and product acceptability was assessed by use of a customized questionnaire after the use of each formulation.

Thirty-eight HCWs used each of 3 formulations for a median of 3 days (range, 3-5 days). The mean amount of product used daily (±SD) was 54.9 ± 23.5 mL (median, 50.9 mL). Both subjective and objective evaluation of skin conditions after use showed lower HCW tolerance for product C. Male sex (odds ratio [OR], 3.17 [95% confidence interval {CI}, 1.1-8.8]), fair or very fair skin (OR, 3.01 [95% CI, 1.1-7.9]), skin alteration before hand rub use (OR, 3.73 [95% CI, 1.7-8.1]), and use of formulation C (OR, 8.79 [95% CI, 2.7-28.4]) were independently associated with skin alteration.

This protocol permits a fast-track comparison of HCWs' skin tolerance for different alcohol-based hand rub formulations that are used in healthcare settings. The emollient in formulation C may account for its inferior performance.

To examine the association between working conditions and needlestick injury among registered nurses. We also describe needle use and needlestick injuries according to nursing position, workplace, and specialty.

Three-wave longitudinal survey conducted between November 2002 and April 2004.

A probability sample of 2,624 actively licensed registered nurses from 2 states in the United States. Follow-up rates for waves 2 and 3 were 85% and 86%, respectively. Respondents who had worked as a nurse during the past year (n = 2,273) prior to wave 1 were included in this analysis.

Of the nurses, 15.6% reported a history of needlestick injury in the year before wave 1, and the cumulative incidence by wave 3 was 16.3%. The estimated number of needles used per day was significantly related to the odds of sustaining a needlestick injury. Hours worked per day, weekends worked per month, working other than day shifts, and working 13 or more hours per day at least once a week were each significantly associated with needlestick injuries. A factor combining these variables was significantly associated with needlestick injuries even after adjustment for job demands, although this association was somewhat explained by physical job demands.

Despite advances in protecting workers from needlestick injuries, extended work schedules and their concomitant physical demands are still contributing to the occurrence of injuries and illnesses to nurses. Such working conditions, if modified, could lead to further reductions in needlestick injuries.

To determine the prevalence, risk factors, and outcomes of nosocomial infection due to antimicrobial resistant bacteria in patients treated in the pediatric intensive care unit (PICU).

Nested case-cohort study. Patient data were collected prospectively, and antimicrobial susceptibility data were abstracted retrospectively.

A large pediatric teaching hospital.

All PICU patients admitted from September 1, 1999, to September 1, 2001, unless they died within 24 hours after PICU admission, were 18 years old or older, or were neonatal intensive care unit patients receiving extracorporeal membrane oxygenation.

A total of 135 patients with more than 1 nosocomial bacterial infection were analyzed; 52% were male, 75% were white, the mean Pediatric Risk of Mortality score was 10.5, and the mean age was 3.5 years. Of these patients, 37 (27%) had nosocomial infections due to antibiotic-resistant organisms. In univariate analysis, transplantation (odds ratio [OR], 2.83 [95% confidence interval (CI), 1.05-7.66]) and preexisting lung disease (OR, 2.63 [95% CI, 1.18-5.88]) were associated with nosocomial infections due to antibiotic-resistant organisms. Age, Pediatric Risk of Mortality score at admission, length of hospital stay before infection, and other underlying conditions were not associated with infections due to antibiotic-resistant organisms. Patients infected with antibiotic-resistant organisms had greater mean PICU lengths of stay after infection, compared with patients infected with antibiotic-susceptible organisms (22.9 vs 12.8 days; P = .004), and higher crude mortality rates (OR, 2.40 [95% CI, 1.03-5.61]).

Identifiable risk factors exist for nosocomial infections due to antibiotic-resistant organisms. In univariate analysis, infections due to antibiotic-resistant bacteria are associated with increased length of stay in the PICU after onset of infection and increased mortality.

Prior-approval antimicrobial stewardship programs (ASPs) improve patient outcomes and decrease antimicrobial resistance. These benefits would be limited if physicians circumvented ASP efforts. We evaluated whether prescribers wait until after the prior-approval period to order restricted antimicrobial therapy that is in conflict with guidelines or unnecessary.

A cross-sectional study design and a retrospective cohort study design.

A tertiary care, academic medical center with a prior-approval ASP that was active between 8 AM and 10 PM.

We evaluated whether there was an increase in the proportion of orders for antimicrobial therapy that involve restricted (vs nonrestricted) antimicrobials during the first hour that the ASP is inactive (ie, the first hour that prior approval is not required), compared with the remainder of the day. We also evaluated whether restricted antimicrobial therapy ordered during this first hour is less likely to be continued when the ASP becomes active the next day, compared with that ordered during the preceding hour.

A greater proportion of the antimicrobial therapy orders placed between 10:00 PM and 10:59 PM were for restricted agents, compared with orders placed during other periods (57.0% vs 49.9%; P = .02). Surgical patients for whom antimicrobial therapy orders were placed between 10:00 PM and 10:59 PM were less likely to have that antimicrobial therapy continued, compared with patients whose therapy was ordered between 9:00 PM and 9:59 PM (60.0% vs 98.1%; P <.001). Nonsurgical patients whose therapy orders were placed between 10:00PM and 10:59 PM were also less likely to have the ordered antimicrobial therapy continued, compared with patients whose therapy was ordered between 9:00 PM and 9:59 PM (70.8% vs 84.2%; P = .01).

Physicians avoid having to obtain prior approval for therapy involving restricted antimicrobials by waiting until restrictions are no longer active to place orders. Compared with restricted antimicrobial therapy ordered when the ASP is active, these courses of therapy are less often continued by the ASP, suggesting that they are more likely to be in conflict with guidelines or unnecessary.