To evaluate the usability and effectiveness of a computerized clinical decision support (CDS) intervention aimed at reducing the duration of urinary tract catheterizations.

Retrospective cohort study.

Academic healthcare system.

All adult patients admitted from March 2009 through May 2012.

A CDS intervention was integrated into a commercial electronic health record. Providers were prompted at order entry to specify the indication for urinary catheter insertion. On the basis of the indication chosen, providers were alerted to reassess the need for the urinary catheter if it was not removed within the recommended time. Three time periods were examined: baseline, after implementation of the first intervention (stock reminder), and after a second iteration (homegrown reminder). The primary endpoint was the usability of the intervention as measured by the proportion of reminders through which providers submitted a remove urinary catheter order. Secondary endpoints were the urinary catheter utilization ratio and the rate of hospital-acquired catheter-associated urinary tract infections (CAUTIs).

The first intervention displayed limited usability, with 2% of reminders resulting in a remove order. Usability improved to 15% with the revised reminder. The catheter utilization ratio declined over the 3 time periods (0.22, 0.20, and 0.19, respectively; P < .001), as did CAUTIs per 1,000 patient-days (0.84, 0.70, and 0.51, respectively; P < .001).

A urinary catheter removal reminder system was successfully integrated within a healthcare system’s electronic health record. The usability of the reminder was highly dependent on its user interface, with a homegrown version of the reminder resulting in higher impact than a stock reminder.

Infect Control Hosp Epidemiol 2014;35(9):1147-1155

Extensively drug resistant (XDR) Acinetobacter baumannii infections are increasing. Knowledge of risk factors can help to prevent these infections.

We designed a 1: 1: 1 case-case-control study to identify risk factors for XDR A. baumannii bacteremia in Singapore and Thailand. Case group 1 was defined as having infection due to XDR A. baumannii, and case group 2 was defined as having infection due to non-XDR A. baumannii. The control group comprised patients with blood cultures obtained to determine possible infection.

There were 93 patients in each group. Pitt bacteremia score (adjusted odds ratio [aOR], 2.570 [95% confidence interval (CI), 1.528–4.322]), central venous catheters (CVCs; aOR, 12.644 [95% CI, 2.143–74.620]), use of carbapenems (aOR, 54.391 [95% CI, 3.869–764.674]), and piperacillin-tazobactam (aOR, 55.035 [95% CI, 4.803–630.613]) were independently associated with XDR A. baumannii bacteremia. In case group 2, Pitt bacteremia score (aOR, 1.667 [95% CI, 1.265–2.196]) and third-generation cephalosporins (aOR, 2.965 [95% CI, 1.224–7.182]) were independently associated with non-XDR A. baumannii bacteremia. Concurrent infections (aOR, 3.527 [95% CI, 1.479–8.411]), cancer (aOR, 3.172 [95% CI, 1.135–8.865]), and respiratory source (aOR, 2.690 [95% CI, 1.160–6.239]) were associated with an increased risk of 30-day mortality. Survivors received more active empirical therapy (16.7% vs 9.6%; P = .157), had fewer cases of XDR bacteremia (45.8% vs 52.6%; P = .452), and received higher median definitive polymyxin B doses (840,000 units vs 700,000 units; P = .339)

Use of CVC and broad spectrum antibiotics were unique risk factors of XDR A. baumannii bacteremia. Effective antimicrobial stewardship together with use of a CVC bundle may reduce the incidence of these infections. Risk factors of acquisition and mortality may help identify patients for early initiation of polymyxin B therapy.

To determine whether hand hygiene adherence is influenced by peer effects and, specifically, whether the presence and proximity of other healthcare workers has a positive effect on hand hygiene adherence

An observational study using a sensor network.

A 20-bed medical intensive care unit at a large university hospital.

Hospital staff assigned to the medical intensive care unit.

We deployed a custom-built, automated, hand hygiene monitoring system that can (1) detect whether a healthcare worker has practiced hand hygiene on entering and exiting a patient’s room and (2) estimate the location of other healthcare workers with respect to each healthcare worker exiting or entering a room.

We identified a total of 47,694 in-room and out-of-room hand hygiene opportunities during the 10-day study period. When a worker was alone (no recent healthcare worker contacts), the observed adherence rate was 20.85% (95% confidence interval [CI], 19.78%–21.92%). In contrast, when other healthcare workers were present, observed adherence was 27.90% (95% CI, 27.48%–28.33%). This absolute increase was statistically significant (P < .01). We also found that adherence increased with the number of nearby healthcare workers but at a decreasing rate. These results were consistent at different times of day, for different measures of social context, and after controlling for possible confounding factors.

The presence and proximity of other healthcare workers is associated with higher hand hygiene rates. Furthermore, our results also indicate that rates increase as the social environment becomes more crowded, but with diminishing marginal returns.

Infect Control Hosp Epidemiol 2014;35(10):1277–1285

With growing demands to track and publicly report and compare infection rates, efforts to utilize automated surveillance systems are increasing. We developed and validated a simple algorithm for identifying patients with clinical methicillin-resistant Staphylococcus aureus (MRSA) infection using microbiologic and antimicrobial variables. We also estimated resource savings.

Patients who had a culture positive for MRSA at any of 5 acute care Veterans Affairs hospitals were eligible. Clinical infection was defined on the basis of manual chart review. The electronic algorithm defined clinical MRSA infection as a positive non-sterile-site culture with receipt of MRSA-active antibiotics during the 5 days prior to or after the culture.

In total, 246 unique non-sterile-site cultures were included, of which 168 represented infection. The sensitivity (43.4%–95.8%) and specificity (34.6%–84.6%) of the electronic algorithm varied depending on the combination of antimicrobials included. On multivariable analysis, predictors of algorithm failure were outpatient status (odds ratio, 0.23 [95% confidence interval, 0.10–0.56]) and respiratory culture (odds ratio, 0.29 [95% confidence interval, 0.13–0.65]). The median cost was $2.43 per chart given 4.6 minutes of review time per chart.

Our simple electronic algorithm for detecting clinical MRSA infections has excellent sensitivity and good specificity. Implementation of this electronic system may streamline and standardize surveillance and reporting efforts.

Infect Control Hosp Epidemiol 2014;35(6):692–698

We evaluated the spread of multidrug-resistant Enterobacteriaceae in 38 nursing homes (NHs) in the Centre region of France.

We conducted a multicenter prevalence study and evaluated extended-spectrum β-lactamase- and carbapenemase-producing Enterobacteriaceae (ESBLE and CPE, respectively) colonization of 1,155 residents. The colonizing isolates were studied by randomly amplified polymorphic DNA typing. We observed hygiene practices and studied the contamination of the environment in 8 NHs.

A total of 114 residents were ESBLE carriers (9.9%); none were CPE carriers. A total of 82.6% of the ESBLE were Escherichia coli. ESBLE colonization was associated with poor health status (P = .002), malignancy (P = .006), urinary incontinence (P = .007), fecal incontinence (P = .002), previous hospitalization (P = .033), and carbapenem treatment (P = .040). The clonal relationship between isolates within NHs suggested resident-to-resident ESBLE transmission in 15 NHs. ESBLE isolates were recovered from 6 of 232 bedrooms studied. A total of 1,533 observations revealed low rates of conformity for hand hygiene (25.7%), the use of gloves (45.9%) and protective clothing (13.3%), and waste management (46.7%). Conformity rates correlated inversely with ESBLE carriage rates.

In most of the participating NHs, improved application of standard precautions during incontinence care is needed, and greater efforts to clean the environment of residents are required.

Exposure of healthcare personnel to bloodborne pathogens (BBPs) can be prevented in part by using safety-engineered sharp devices (SESDs) and other safe practices, such as double gloving. In some instances, however, safer devices and practices cannot be utilized because of procedural factors or the lack of a manufactured safety device for the specific clinical use. In these situations, a standardized system to examine requests for waiver from expected practices is necessary

Before-after program analysis.

Large academic medical center.

Vanderbilt University Medical Center developed a formalized system for an improved waiver process, including an online submission and tracking site, and standards surrounding implementation of core safe practices. The program’s impact on sharp device injuries and utilization of double gloving and blunt sutures was examined.

Following implementation of the enhanced program, there was an increase in the amount of undergloves and blunt sutures purchased for surgical procedures, suggesting larger utilization of these practices. The rate of sharp device injuries of all at-risk employees decreased from 2.32% to 2.12%, but this decline was not statistically significant (P = .14). The proportion of reported injuries that were deemed preventable significantly decreased from 72.7% (386/531) before implementation to 63.9% (334/523; P = .002) after implementation of the enhanced program.

An enhanced BBP protection program was successful at providing guidance to increase safe practices and at improving the management of SESD waiver requests and was associated with a reduction in preventable sharp device injuries.

Antibiograms have effectively improved antibiotic prescribing in acute-care settings; however, their effectiveness in skilled nursing facilities (SNFs) is currently unknown.

To develop SNF-specific antibiograms and identify opportunities to improve antibiotic prescribing.

Cross-sectional and pretest-posttest study among residents of 3 Maryland SNFs.

Antibiograms were created using clinical culture data from a 6-month period in each SNF. We also used admission clinical culture data from the acute care facility primarily associated with each SNF for transferred residents. We manually collected all data from medical charts, and antibiograms were created using WHONET software. We then used a pretest-posttest study to evaluate the effectiveness of an antibiogram on changing antibiotic prescribing practices in a single SNF. Appropriate empirical antibiotic therapy was defined as an empirical antibiotic choice that sufficiently covered the infecting organism, considering antibiotic susceptibilities.

We reviewed 839 patient charts from SNF and acute care facilities. During the initial assessment period, 85% of initial antibiotic use in the SNFs was empirical, and thus only 15% of initial antibiotics were based on culture results. Fluoroquinolones were the most frequently used empirical antibiotics, accounting for 54.5% of initial prescribing instances. Among patients with available culture data, only 35% of empirical antibiotic prescribing was determined to be appropriate. In the single SNF in which we evaluated antibiogram effectiveness, prevalence of appropriate antibiotic prescribing increased from 32% to 45% after antibiogram implementation; however, this was not statistically significant (P = .32).

Implementation of antibiograms may be effective in improving empirical antibiotic prescribing in SNFs.

To review and describe device utilization and central line-associated bloodstream (CLABSI) events among patients in a non-intensive care unit (ICU) setting and to examine the morbidity and mortality associated with these events.

One-year descriptive review.

A single tertiary center with a 1,200-bed hospital and 209 adult ICU beds.

Hospitalized patients identified as having a CLABSI event attributed to a non-ICU setting.

The cohort was identified from a prospective infection prevention database. Charts and administrative data sets were reviewed to further characterize the patients. Device utilization ratios (DURs) and CLABSI rates were calculated using National Health and Safety Network (NHSN) CLABSI definitions. Need for ICU stay and crude mortality rates were recorded.

A total of 136 patients with 156 CLABSIs were identified, of whom 78 (57%) were being treated for a hematological malignancy (HM). The overall DUR was 0.27. A tunneled line was in place for 118 (76%) of the CLABSI events, and a peripherally inserted central catheter was in place for 32 (21%) of the CLABSI events. The non-ICU CLABSI rate was significantly higher than the concurrent ICU rate (2.1 CLABSIs per 1,000 catheter-days vs 1.5 CLABSIs per 1,000 catheter-days; P = .02). Hospital mortality was 23% in the affected group and was significantly higher in patients with HM.

CLABSI rates over a 1-year period were higher in patients outside the ICU at our hospital and were associated with significant mortality.

To find the source of tuberculin skin test conversions among 38 hospital employees on 1 floor during routine testing January–February 2010.

Record review of patients at a private hospital during September-December 2009 and interviews with hospital employees. Names of patients from the state tuberculosis (TB) registry were cross-referenced with hospital records for admissions. Mycobacterium tuberculosis genotype results in the county and adjacent counties were examined, and contacts were evaluated for TB infection and disease.

One of the 38 employees, a nurse, was diagnosed with pulmonary TB with a matching M. tuberculosis genotype and drug resistance pattern (isoniazid monoresistant) to those of a county jail inmate also recently diagnosed with pulmonary TB. The nurse had no known contact with that inmate; however, another inmate in his 20's from the same jail had been hospitalized under that nurse's care in October 2009. That young man died, and a postmortem examination result subsequently confirmed TB, which had not been suspected. Exposure to this man with undiagnosed TB could explain the transmission: 87 (27%) of the 318 hospital-based contacts without previous positive tuberculin skin test results were infected, and 9 contacts had active TB.

This investigation demonstrated M. tuberculosis transmission in a hospital due to a missed diagnosis and nonadherence to national TB infection control guidelines. Routine TB screening of employees allowed early detection of this missed TB diagnosis, facilitating prompt evaluation of contacts. Healthcare providers should suspect TB in symptomatic persons and adhere to TB control policies.

Ventilator-associated pneumonia (VAP) is among the most lethal of all healthcare-associated infections. Guidelines summarize interventions to prevent VAP, but translating recommendations into practice is an art unto itself.

Summarize strategies to enhance adoption of VAP prevention interventions.

We conducted a systematic literature review of articles in the MEDLINE database published between 2002 and 2012. We selected articles on the basis of specific inclusion criteria. We used structured forms to abstract implementation strategies and inserted them into the “engage, educate, execute, and evaluate” framework.

Twenty-seven articles met our inclusion criteria. Engagement strategies included multidisciplinary teamwork, involvement of local champions, and networking among peers. Educational strategies included training sessions and developing succinct summaries of the evidence. Execution strategies included standardization of care processes and building redundancies into routine care. Evaluation strategies included measuring performance and providing feedback to staff.

We summarized and organized practical implementation strategies in a framework to enhance adoption of recommended evidence-based practices. We believe this work fills an important void in most clinical practice guidelines, and broad use of these strategies may expedite VAP reduction efforts.

To develop a candidate definition for central line–associated bloodstream infection (CLABSI) in neonates with presumed mucosal barrier injury due to gastrointestinal (MBI-GI) conditions and to evaluate epidemiology and microbiology of MBI-GI CLABSI in infants

Multicenter retrospective cohort study.

Neonatal intensive care units from 14 US children’s hospitals and pediatric facilities.

A multidisciplinary focus group developed a candidate MBI-GI CLABSI definition based on presence of an MBI-GI condition, parenteral nutrition (PN) exposure, and an eligible enteric organism. CLABSI surveillance data from participating hospitals were supplemented by chart review to identify MBI-GI conditions and PN exposure.

During 2009–2012, 410 CLABSIs occurred in 376 infants. MBI-GI conditions and PN exposure occurred in 149 (40%) and 324 (86%) of these 376 neonates, respectively. The distribution of pathogens was similar among neonates with versus without MBI-GI conditions and PN exposure. Fifty-nine (16%) of the 376 initial CLABSI episodes met the candidate MBI-GI CLABSI definition. Subsequent versus initial CLABSIs were more likely to be caused by an enteric organism (22 of 34 [65%] vs 151 of 376 [40%]; P = .009) and to meet the candidate MBI-GI CLABSI definition (19 of 34 [56%] vs 59 of 376 [16%]; P < .01).

While MBI-GI conditions and PN exposure were common, only 16% of initial CLABSIs met the candidate definition of MBI-GI CLABSI. The high proportion of MBI-GI CLABSIs among subsequent infections suggests that infants with MBI-GI CLABSI should be a population targeted for further surveillance and interventional research.

Infect Control Hosp Epidemiol 2014;35(11):1391–1399

This study aimed to monitor the microbiological effect of cleaning near-patient sites over a 48-hour period with a novel disinfectant, electrolyzed water.

One ward dedicated to acute care of the elderly population in a district general hospital in Scotland.

Lockers, left and right cotsides, and overbed tables in 30 bed spaces were screened for aerobic colony count (ACC), methicillin-susceptible Staphylococcus aureus (MSSA), and methicillin-resistant S. aureus (MRSA) before cleaning with electrolyzed water. Sites were rescreened at varying intervals from 1 to 48 hours after cleaning. Microbial growth was quantified as colony-forming units (CFUs) per square centimeter and presence or absence of MSSA and MRSA at each site. The study was repeated 3 times at monthly intervals.

There was an early and significant reduction in average ACC (360 sampled sites) from a before-cleaning level of 4.3 to 1.65 CFU/cm2 at 1 hour after disinfectant cleaning (P <.0001). Average counts then increased to 3.53 CFU/cm2 at 24 hours and 3.68 CFU/cm2 at 48 hours. Total MSSA/MRSA (34 isolates) decreased by 71% at 4 hours after cleaning but then increased to 155% (53 isolates) of precleaning levels at 24 hours.

Cleaning with electrolyzed water reduced ACC and staphylococci on surfaces beside patients. ACC remained below precleaning levels at 48 hours, but MSSA/MRSA counts exceeded original levels at 24 hours after cleaning. Although disinfectant cleaning quickly reduces bioburden, additional investigation is required to clarify the reasons for rebound contamination of pathogens at near-patient sites.

Infect Control Hosp Epidemiol 2014;35(12):1505–1510

Hand hygiene and environmental cleaning are essential infection prevention strategies, but the relative impact of each is unknown. This information is important in assessing resource allocation.

We developed an agent-based model of patient-to-patient transmission—via the hands of transiently colonized healthcare workers and incompletely terminally cleaned rooms—in a 20-patient intensive care unit. Nurses and physicians were modeled and had distinct hand hygiene compliance levels on entry and exit to patient rooms. We simulated the transmission of Acinetobacter baumannii, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococci for 1 year using data from the literature and observed data to inform model input parameters.

We simulated 175 parameter-based scenarios and compared the effects of hand hygiene and environmental cleaning on rates of multidrug-resistant organism acquisition. For all organisms, increases in hand hygiene compliance outperformed equal increases in thoroughness of terminal cleaning. From baseline, a 2∶1 improvement in terminal cleaning compared with hand hygiene was required to match an equal reduction in acquisition rates (eg, a 20% improvement in terminal cleaning was required to match the reduction in acquisition due to a 10% improvement in hand hygiene compliance).

Hand hygiene should remain a priority for infection control programs, but environmental cleaning can have significant benefit for hospitals or individual hospital units that have either high hand hygiene compliance levels or low terminal cleaning thoroughness.

Infect Control Hosp Epidemiol 2014;35(9):1156-1162

To investigate an outbreak of New Delhi metallo-β-lactamase (NDM)–producing carbapenem-resistant Enterobacteriaceae (CRE) and determine interventions to interrupt transmission.

Epidemiologic investigation of an outbreak of NDM-producing CRE among patients at a Colorado acute care hospital.

Case patients had NDM-producing CRE isolated from clinical or rectal surveillance cultures (SCs) collected during the period January 1, 2012, through October 20, 2012. Case patients were identified through microbiology records and 6 rounds of SCs in hospital units where they had resided. CRE isolates were tested by real-time polymerase chain reaction for blaNDM. Medical records were reviewed for epidemiologic links; relatedness of isolates was evaluated by pulsed-field gel electrophoresis (PFGE) and whole genome sequencing (WGS). Infection control (IC) was assessed through staff interviews and direct observations.

Two patients were initially identified with NDM-producing CRE during July–August 2012. A third case patient, admitted in May, was identified through microbiology records review. SC identified 5 additional case patients. Patients had resided in 11 different units before identification. All isolates were highly related by PFGE. WGS suggested 3 clusters of CRE. Combining WGS with epidemiology identified 4 units as likely transmission sites. NDM-producing CRE positivity in certain patients was not explained by direct epidemiologic overlap, which suggests that undetected colonized patients were involved in transmission.

A 4-month outbreak of NDM-producing CRE occurred at a single hospital, highlighting the risk for spread of these organisms. Combined WGS and epidemiologic data suggested transmission primarily occurred on 4 units. Timely SC, combined with targeted IC measures, were likely responsible for controlling transmission.

Antimicrobial stewardship programs (ASPs) are a mechanism to ensure the appropriate use of antimicrobials. The extent to which ASPs are formally implemented in freestanding children's hospitals is unknown. The objective of this study was to determine the prevalence and characteristics of ASPs in freestanding children's hospitals.

We conducted an electronic survey of 42 freestanding children's hospitals that are members of the Children's Hospital Association to determine the presence and characteristics of their ASPs. For hospitals without an ASP, we determined whether stewardship strategies were in place and whether there were barriers to implementing a formal ASP.

We received responses from 38 (91%) of 42. Among responding institutions, 16 (38%) had a formal ASP, and 15 (36%) were in the process of implementing a program. Most ASPs (13 [81%] of 16) were started after 2007. The median number of full-time equivalents dedicated to ASPs was 0.63 (range, 0.1–1.8). The most common antimicrobials monitored by ASPs were linezolid, vancomycin, and carbapenems. Many hospitals without a formal ASP were performing stewardship activities, including elements of prospective audit and feedback (9 [41%] of 22), formulary restriction (9 [41%] of 22), and use of clinical guidelines (17 [77%] of 22). Antimicrobial outcomes were more likely to be monitored by hospitals with ASPs (100% vs 68%; P = .01), although only 1 program provided support for a data analyst.

Most freestanding children's hospitals have implemented or are developing an ASP. These programs differ in structure and function, and more data are needed to identify program characteristics that have the greatest impact.

Healthcare workers experience occupational risk of infection and may transmit infections to patients. Vaccination provides an efficient means of protecting workers and patients, but uptake may be low. We sought to identify factors influencing vaccine acceptance by healthcare workers in order to obtain insights leading to more effective vaccination programs in this population.

Systematic review and meta-analysis.

We searched Medline, Embase, and CINAHL databases to identify studies published up to May 2012. Factors influencing vaccination acceptance were devised a priori. Random-effects meta-analysis was performed to generate summary estimates of effect. Heterogeneity and publication bias were explored using statistical tools.

Thirty-seven studies evaluating a variety of vaccines (against influenza, pertussis, smallpox, anthrax, and hepatitis B) were included. Homogeneous effects on vaccine acceptance were identified with desire for self-protection (odds ratio [OR], 3.42 [95% confidence interval (CI), 2.42–4.82]) and desire to protect family and friends (OR, 3.28 [95% CI, 1.10–9.75]). Concern that vaccine transmits the illness it was meant to prevent decreased acceptance (OR, 0.42 [95% CI, 0.30–0.58]). Differences in physician and nurse acceptance of immunization were seen between Asian and non-Asian studies.

Consideration of self-protection (rather than absolute disease risk or protection of patients) appears the strongest and most consistent driver of healthcare workers’ decisions to accept vaccination, though other factors may also be impactful, and reasons for between-study divergence in effects is an important area for future research. This finding has important implications for the design of programs to enhance healthcare worker vaccine uptake.

Infect Control Hosp Epidemiol 2014;35(6):699–708

To examine the cost-effectiveness of pre- and postexposure approaches for ensuring hepatitis B protection among previously vaccinated healthcare personnel (HCP).

A decision-analytic model was developed for alternative strategies of ensuring hepatitis B protection under assumptions of 68% and 95% long-term protection after a primary vaccination series. Costs and quality-adjusted life years (QALYs) lost from infections were estimated, and incremental cost-effectiveness ratios (ICERs) were calculated relative to a no intervention alternative over 10 years of intervention. Separate analyses were performed for trainees and nontrainees, using the healthcare system perspective. Trainees face higher risk of exposure and likely received primary vaccination as infants.

General healthcare settings.

Trainee and nontrainee HCP.

Preexposure testing for antibody to hepatitis B surface antigen followed by additional vaccination for HCP without protective antibody levels; postexposure evaluation and management for HCP reporting blood or body fluid exposures

The preexposure strategy prevents more infections and has higher costs than the postexposure strategy or no intervention. For trainees, 10-year preexposure evaluation ICERs are $832,875 and $144,457 per QALY for 95% and 68% long-term vaccine protection, respectively. Trainee 10-year postexposure evaluation ICERs are $1,146,660 and $191,579 per QALY under the 95% and 68% long-term protection assumptions, respectively. For nontrainees, 10-year ICERs are $745,739 and $1,129,286 per QALY for the preexposure and postexposure evaluation strategies, respectively.

ICERs may inform decision makers as they decide whether the added cost of the preexposure strategy provides sufficient value in preventing infections.