To describe the epidemiologic features of an outbreak of an acute respiratory tract infection (ARI) caused by β-lactamase-negative ampicillin-resistant (BLNAR) nontypeable Haemophilus influenzae (NTHi) in an acute-care ward.

Cross-sectional case-control study.

An acute-care ward (ward A) in a general hospital of Kochi in western Japan.

Patients who shared a room with an index patient and all staff in ward A were screened and followed from July 1 to August 31, 2015. Sputum or throat swab samples were collected from participants and tested by culture and polymerase chain reaction (PCR). The association between detected pathogens and ARI development among all participants was examined. A case-control study was conducted to identify risk factors for disease.

In total, 78 participants, including the index patient, were enrolled. Of all participants, 27 (34.6%) developed mild respiratory symptoms during a 3-week period: 24 were diagnosed as upper respiratory tract infections, and 3 were diagnosed as lower respiratory tract infections. The presence of BLNAR NTHi was confirmed in 13 participants, and multilocus sequence typing demonstrated that these isolates belonged to sequence type 159. All isolates showed identical pulsed-field gel electrophoresis patterns. The presence of BLNAR NTHi was strongly associated with ARI development, whereas viruses were not associated with the disease. Multivariate analyses demonstrated that a history of contact with the index patient was independently associated with ARI caused by BLNAR NTHi.

BLNAR NTHi has the potential to cause upper respiratory tract infections among adults and to spread rapidly in hospital settings.

Infect Control Hosp Epidemiol 2018;39:652–659

Clostridium difficile spores play an important role in transmission and can survive in the environment for several months. Optimal methods for measuring environmental C. difficile are unknown. We sought to determine whether increased sample surface area improved detection of C. difficile from environmental samples.

Samples were collected from 12 patient rooms in a tertiary-care hospital in Toronto, Canada.

Samples represented small surface-area and large surface-area floor and bedrail pairs from single-bed rooms of patients with low (without prior antibiotics), medium (with prior antibiotics), and high (C. difficile infected) shedding risk. Presence of C. difficile in samples was measured using quantitative polymerase chain reaction (qPCR) with targets on the 16S rRNA and toxin B genes and using enrichment culture.

Of the 48 samples, 64·6% were positive by 16S qPCR (geometric mean, 13·8 spores); 39·6% were positive by toxin B qPCR (geometric mean, 1·9 spores); and 43·8% were positive by enrichment culture. By 16S qPCR, each 10-fold increase in sample surface area yielded 6·6 times (95% CI, 3·2–13) more spores. Floor surfaces yielded 27 times (95% CI, 4·9–181) more spores than bedrails, and rooms of C. difficile–positive patients yielded 11 times (95% CI, 0·55–164) more spores than those of patients without prior antibiotics. Toxin B qPCR and enrichment culture returned analogous findings.

Clostridium difficile spores were identified in most floor and bedrail samples, and increased surface area improved detection. Future research aiming to understand the role of environmental C. difficile in transmission should prefer samples with large surface areas.

To evaluate the impact of universal contact precautions (UCP) on rates of multidrug-resistant organisms (MDROs) in intensive care units (ICUs) over 9 years

Retrospective, nonrandomized observational study

An 800-bed adult academic medical center in New York City

All patients admitted to 6 ICUs, 3 of which instituted UCP in 2007

Using a comparative effectiveness approach, we studied the longitudinal impact of UCP on MDRO incidence density rates, including methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and carbapenem-resistant Klebsiella pneumoniae. Data were extracted from a clinical research database for 2006–2014. Monthly MDRO rates were compared between the baseline period and the UCP period, utilizing time series analyses based on generalized linear models. The same models were also used to compare MDRO rates in the 3 UCP units to 3 ICUs without UCPs.

Overall, MDRO rates decreased over time, but there was no significant decrease in the trend (slope) during the UCP period compared to the baseline period for any of the 3 intervention units. Furthermore, there was no significant difference between UCP units (6.6% decrease in MDRO rates per year) and non-UCP units (6.0% decrease per year; P=.840).

The results of this 9-year study suggest that decreases in MDROs, including multidrug-resistant gram-negative bacilli, were more likely due to hospital-wide improvements in infection prevention during this period and that UCP had no detectable additional impact.

Infect Control Hosp Epidemiol 2018;39:534–540

The healthcare environment is recognized as a source for healthcare-acquired infection. Because cleaning practices are often erratic and always intermittent, we hypothesize that continuously antimicrobial surfaces offer superior control of surface bioburden.

To evaluate the impact of a photocatalytic antimicrobial coating at near-patient, high-touch sites in a hospital ward.

The study took place in 2 acute-care wards in a large acute-care hospital.

A titanium dioxide-based photocatalytic coating was sprayed onto 6 surfaces in a 4-bed bay in a ward and compared under normal illumination against the same surfaces in an untreated ward: right and left bed rails, bed control, bedside locker, overbed table, and bed footboard. Using standardized methods, the overall microbial burden and presence of an indicator pathogen (Staphylococcus aureus) were assessed biweekly for 12 weeks.

Treated surfaces demonstrated significantly lower microbial burden than control sites, and the difference increased between treated and untreated surfaces during the study. Hygiene failures (>2.5 colony-forming units [CFU]/cm2) increased 2.6% per day for control surfaces (odds ratio [OR], 1.026; 95% confidence interval [CI], 1.009–1.043; P=.003) but declined 2.5% per day for treated surfaces (OR, 0.95; 95% CI, 0.925–0.977; P<.001). We detected no significant difference between coated and control surfaces regarding S. aureus contamination.

Photocatalytic coatings reduced the bioburden of high-risk surfaces in the healthcare environment. Treated surfaces became steadily cleaner, while untreated surfaces accumulated bioburden. This evaluation encourages a larger-scale investigation to ascertain whether the observed environmental amelioration has an effect on healthcare-acquired infection.

Infect Control Hosp Epidemiol 2018;39:398–404

Extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBL-E) are emerging worldwide. Contact precautions are recommended for known ESBL-E carriers to control the spread of ESBL-E within hospitals.

This study quantified the acquisition of ESBL-E rectal carriage among patients in Dutch hospitals, given the application of contact precautions.

Data were used from 2 cluster-randomized studies on isolation strategies for ESBL-E: (1) the SoM study, performed in 14 Dutch hospitals from 2011 through 2014 and (2) the R-GNOSIS study, for which data were limited to those collected in a Dutch hospital in 2014. Perianal cultures were obtained, either during ward-based prevalence surveys (SoM), or at admission and twice weekly thereafter (R-GNOSIS). In both studies, contact precautions were applied to all known ESBL-E carriers. Estimates for acquisition of ESBL-E were based on the results of admission and discharge cultures from patients hospitalized for more than 2 days (both studies) and a Markov chain Monte Carlo (MCMC) model, applied to all patients hospitalized (R-GNOSIS).

The absolute risk of acquisition of ESBL-E rectal carriage ranged from 2.4% to 2.9% with an ESBL-E acquisition rate of 2.8 to 3.8 acquisitions per 1,000 patient days. In addition, 28% of acquisitions were attributable to patient-dependent transmission, and the per-admission reproduction number was 0.06.

The low ESBL-E acquisition rate in this study demonstrates that it is possible to control the nosocomial transmission of ESBL in a low-endemic, non-ICU setting where Escherichia coli is the most prevalent ESBL-E and standard and contact precautions are applied for known ESBL-E carriers.

Nederlands Trialregister, NTR2799, http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2799; ISRCTN Registry, ISRCTN57648070, http://www.isrctn.com/ISRCTN57648070

Infect Control Hosp Epidemiol 2018;39:32–39

To evaluate the impact of discontinuing routine contact precautions (CP) for endemic methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) on hospital adverse events.

Retrospective, nonrandomized, observational, quasi-experimental study.

Academic medical center with single-occupancy rooms.

Inpatients.

We compared hospital reportable adverse events 1 year before and 1 year after discontinuation of routine CP for endemic MRSA and VRE (preintervention and postintervention periods, respectively). Throughout the preintervention period, daily chlorhexidine gluconate bathing was expanded to nearly all inpatients. Chart reviews were performed to identify which patients and events were associated with CP for MRSA/VRE in the preintervention period as well as the patients that would have met prior criteria for MRSA/VRE CP but were not isolated in the postintervention period. Adverse events during the 2 periods were compared using segmented and mixed-effects Poisson regression models.

There were 24,732 admissions in the preintervention period and 25,536 in the postintervention period. Noninfectious adverse events (ie, postoperative respiratory failure, hemorrhage/hematoma, thrombosis, wound dehiscence, pressure ulcers, and falls or trauma) decreased by 19% (12.3 to 10.0 per 1,000 admissions, P=.022) from the preintervention to the postintervention period. There was no significant difference in the rate of infectious adverse events after CP discontinuation (20.7 to 19.4 per 1,000 admissions, P=.33). Patients with MRSA/VRE showed the largest reduction in noninfectious adverse events after CP discontinuation, with a 72% reduction (21.4 to 6.08 per 1,000 MRSA/VRE admissions; P<.001).

After discontinuing routine CP for endemic MRSA/VRE, the rate of noninfectious adverse events declined, especially in patients who no longer required isolation. This suggests that elimination of CP may substantially reduce noninfectious adverse events.

Infect Control Hosp Epidemiol 2018;788–796

To evaluate the incidence of surgical site infection (SSI) in a cohort of pancreas transplant recipients and assess predisposing risk factors for SSI

Retrospective cohort study

Single transplant center in Canada

Patients who underwent any simultaneous pancreas and kidney (SPK) or pancreas after kidney (PAK) transplant procedures between January 2000 and December 2015

In this retrospective cohort evaluation of SPK or PAK recipients, we assessed the incidence of SSI and risk factors associated with superficial, deep, and organ/space SSI. Multivariate logistic regression was used to identify independent risk factors for SSI in SPK and PAK recipients.

In total, 445 adult transplant recipients were enrolled. The median age of these patients was 51 years (range, 19–71 years), and 64.9% were men. SSIs were documented in 108 patients (24.3%). Organ/space SSIs predominated (59 patients, 54.6%), followed by superficial SSIs (47 patients, 43.5%) and deep SSIs (3 patients, 2.8%). Factors predictive of SSIs in the multivariate analysis were cold pancreas ischemic time (odds ratio [OR], 1.002; P=.019) and SPK transplant (compared to PAK transplant recipients; OR, 2.38; P=.038). Patients with SSIs developed graft loss more frequently (OR, 16.99; P<.001).

Organ/space SSIs remain a serious and common complication after SPK and PAK. Prolonged cold ischemic time and SPK transplant were the risk factors predictive of SSIs. Appropriate perioperative prophylaxis in high-risk patients targeting the potential pathogens producing SSIs in kidney and/or pancreas transplant recipients and a reduction in cold ischemia may prove beneficial in reducing these SSIs.

Carbapenemase-producing Enterobacteriaceae (CPE) outbreaks are mostly attributed to patient-to-patient transmission via healthcare workers.

We describe successful containment of a prolonged OXA-48–producing S. marcescens outbreak after recognizing the sink traps as the source of transmission.

The Sheba Medical Center intensive care unit (ICU), contains 16 single-bed, semi-closed rooms. Active CPE surveillance includes twice-weekly rectal screening of all patients. A case was defined as a patient detected with OXA-48 CPE >72 hours after admission. A root-cause analysis was used to investigate the outbreak. All samples were inoculated on chrom-agar CRE, and carbapenemase genes were detected using commercial molecular Xpert-Carba-R. Environmental and patient S. marcescens isolates were characterized using PFGE.

From January 2016 to May 2017, 32 OXA-48 CPE cases were detected, and 81% of these were S. marcescens. A single clone was the cause of all but the first 2 cases. The common factor in all cases was the use of relatively large amounts of tap water. The outbreak clone was detected in 2 sink outlets and 16 sink traps. In addition to routine strict infection control measures, measures taken to contain the outbreak included (1) various sink decontamination efforts, which eliminated the bacteria from the sink drains only temporarily and (2) educational intervention that engaged the ICU team and lead to high adherence to ‘sink-contamination prevention guidelines.’ No additional cases were detected for 12 months.

Despite persistence of the outbreak clones in the environmental reservoir for 1 year, the outbreak was rapidly and successfully contained. Addressing sink traps as hidden reservoirs played a major role in the intervention.

Bathing intensive care unit (ICU) patients with 2% chlorhexidine gluconate (CHG)–impregnated cloths decreases the risk of healthcare-associated bacteremia and multidrug-resistant organism transmission. Hospitals employ different methods of CHG bathing, and few studies have evaluated whether those methods yield comparable results.

To determine whether 3 different CHG skin cleansing methods yield similar residual CHG concentrations and bacterial densities on skin.

Prospective, randomized 2-center study with blinded assessment.

Healthcare personnel in surgical ICUs at 2 tertiary-care teaching hospitals in Chicago, Illinois, and Boston, Massachusetts, from July 2015 to January 2016.

Cleansing skin of one forearm with no-rinse 2% CHG-impregnated polyester cloth (method A) versus 4% CHG liquid cleansing with rinsing on the contralateral arm, applied with either non–antiseptic-impregnated cellulose/polyester cloth (method B) or cotton washcloth dampened with sterile water (method C).

In total, 63 participants (126 forearms) received method A on 1 forearm (n=63). On the contralateral forearm, 33 participants received method B and 30 participants received method C. Immediately and 6 hours after cleansing, method A yielded the highest residual CHG concentrations (2500 µg/mL and 1250 µg/mL, respectively) and lowest bacterial densities compared to methods B or C (P<.001).

In healthy volunteers, cleansing with 2% CHG-impregnated cloths yielded higher residual CHG concentrations and lower bacterial densities than cleansing with 4% CHG liquid applied with either of 2 different cloth types and followed by rinsing. The relevance of these differences to clinical outcomes remains to be determined.

Infect Control Hosp Epidemiol 2018;39:405–411

To determine the efficacy in eradicating Staphylococcus aureus (SA) carriage of a 5-day preoperative decolonization bundle compared to 2 disinfectant soap showers, with both regimens self-administered at home.

Open label, single-center, randomized clinical trial.

Ambulatory orthopedic, urologic, neurologic, colorectal, cardiovascular, and general surgery clinics at a tertiary-care referral center in the United States.

Patients at the University of Minnesota Medical Center planning to have elective surgery and not on antibiotics.

Consenting participants were screened for SA colonization using nasal, throat, axillary, and perianal swab cultures. Carriers of SA were randomized, stratified by methicillin resistance status, to a decolonization bundle group (5 days of nasal mupirocin, chlorhexidine gluconate [CHG] bathing, and CHG mouthwash) or control group (2 preoperative showers with antiseptic soap). Colonization status was reassessed preoperatively. The primary endpoint was absence of SA at all 4 screened body sites.

Of 427 participants screened between August 31, 2011, and August 9, 2016, 127 participants (29.7%) were SA carriers. Of these, 121 were randomized and 110 were eligible for efficacy analysis (57 decolonization bundle group, 53 control group). Overall, 90% of evaluable participants had methicillin-susceptible SA strains. Eradication of SA at all body sites was achieved for 41 of 57 participants (71.9%) in the decolonization bundle group and for 13 of 53 participants (24.5%) in the control group, a difference of 47.4% (95% confidence interval [CI], 29.1%–65.7%; P<.0001).

An outpatient preoperative antiseptic decolonization bundle aimed at 4 body sites was significantly more effective in eradicating SA than the usual disinfectant showers (ie, the control).

ClinicalTrials.gov identifier: NCT02182115

To describe an outbreak of multidrug-resistant Pseudomonas aeruginosa in which the hospital waste-pipe system was the likely source of contamination and to report the bundle of measures that facilitated the long-term control of the outbreak.

Outbreak investigation.

The hematology unit of a tertiary-care referral center.

Patients who were colonized or infected with P. aeruginosa belonging to the clonal outbreak.

Patients admitted to our 15-bed stem-cell transplantation hematology unit were screened for P. aeruginosa carriage. Pseudomonas aeruginosa isolates were also obtained from diagnostic samples. We assessed the microbiological contamination of P-traps, water and toilets for 42 months. Extended-spectrum β-lactamases (ESBLs) and metallo-β-lactamases (MBLs) were screened and identified by polymerase chain reaction (PCR) and sequencing. Molecular typing of ESBL- or MBL-producing isolates was carried out using pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST).

From 2009 to 2013, a biclonal outbreak of IMP-19–producing ST235 (11 cases) and IMP-29–producing ST111 (10 cases) of P. aeruginosa occurred. The environmental investigation strongly suggested that P-traps were the reservoirs for the outbreak strains. A bundle of infection control measures, including engineering interventions on water outlets and disinfection of P-traps, controlled the outbreak.

We report a prolonged outbreak of IMP-producing high-risk clones of P. aeruginosa, for which P-traps seems to play a major role in cross-transmission. It appears essential to implement proactive measures to limit the bacterial load in water fittings of high-risk units.

Infect Control Hosp Epidemiol 2018;39:164–169

To explore the prevalence and drivers of hospital-level variability in antibiotic utilization among hematopoietic cell transplant (HCT) recipients to inform antimicrobial stewardship initiatives.

Retrospective cohort study using data merged from the Pediatric Health Information System and the Center for International Blood and Marrow Transplant Research.

The study included 27 transplant centers in freestanding children’s hospitals.

The primary outcome was days of broad-spectrum antibiotic use in the interval from day of HCT through neutrophil engraftment. Hospital antibiotic utilization rates were reported as days of therapy (DOTs) per 1,000 neutropenic days. Negative binomial regression was used to estimate hospital utilization rates, adjusting for patient covariates including demographics, transplant characteristics, and severity of illness. To better quantify the magnitude of hospital variation and to explore hospital-level drivers in addition to patient-level drivers of variation, mixed-effects negative binomial models were also constructed.

Adjusted hospital rates of antipseudomonal antibiotic use varied from 436 to 1121 DOTs per 1,000 neutropenic days, and rates of broad-spectrum, gram-positive antibiotic use varied from 153 to 728 DOTs per 1,000 neutropenic days. We detected variability by hospital in choice of antipseudomonal agent (ie, cephalosporins, penicillins, and carbapenems), but gram-positive coverage was primarily driven by vancomycin use. Considerable center-level variability remained even after controlling for additional hospital-level factors. Antibiotic use was not strongly associated with days of significant illness or mortality.

Among a homogenous population of children undergoing HCT for acute leukemia, both the quantity and spectrum of antibiotic exposure in the immediate posttransplant period varied widely. Antimicrobial stewardship initiatives can apply these data to optimize the use of antibiotics in transplant patients.

Infect Control Hosp Epidemiol 2018;797–805

To quantify the association between having a prior bed occupant or roommate with a positive blood, respiratory, urine, or wound culture and subsequent infection with the same organism.

Case-control study.

The study included 4 hospitals within an academically affiliated network in New York City, including a community hospital (221 beds), a pediatric acute-care hospital (283 beds), an adult tertiary-/quaternary-care hospital (647 beds), and a pediatric and adult tertiary-/quaternary-care hospital (914 beds).

All 761,426 inpatients discharged from 2006 to 2012 were eligible. Cases included all patients who developed a healthcare-associated infection (HAI) with Staphylococcus aureus, Acinetobacter baumannii, Streptococcus pneumoniae, Pseudomonas aeruginosa, Klebsiella pneumoniae, Enterococcus faecalis, or Enterococcus faecium. Controls were uninfected patients matched by fiscal quarter, hospital, and length of stay. For each bed occupied during the 3–5-day period prior to infection, microbiology results for assigned roommates and the patient who occupied the bed immediately prior to the case were collected. For controls, the day of infection of the matched case served as the reference point.

In total, 10,289 HAIs were identified. In a multivariable analysis controlling for both exposures and patient characteristics, the odds of cases having been exposed to a prior bed occupant with the same organism were 5.83 times that of controls (95% confidence interval [CI], 3.62–9.39), and the odds of cases having been exposed to a roommate with the same organism were 4.82 times that of controls (95% CI, 3.67–6.34).

Infected or colonized roommates and prior occupants do pose a risk, which may warrant enhanced terminal and intermittent cleaning measures.

Infect Control Hosp Epidemiol 2018;39:541–546

To compare the epidemiology, clinical characteristics, and mortality of patients with bloodstream infections (BSI) caused by extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (ESBL-EC) versus ESBL-producing Klebsiella pneumoniae (ESBL-KP) and to examine the differences in clinical characteristics and outcome between BSIs caused by isolates with CTX-M versus other ESBL genotypes

As part of the INCREMENT project, 33 tertiary hospitals in 12 countries retrospectively collected data on adult patients diagnosed with ESBL-EC BSI or ESBL-KP BSI between 2004 and 2013. Risk factors for ESBL-EC versus ESBL-KP BSI and for 30-day mortality were examined by bivariate analysis followed by multivariable logistic regression.

The study included 909 patients: 687 with ESBL-EC BSI and 222 with ESBL-KP BSI. ESBL genotype by polymerase chain reaction amplification of 286 isolates was available. ESBL-KP BSI was associated with intensive care unit admission, cardiovascular and neurological comorbidities, length of stay to bacteremia >14 days from admission, and a nonurinary source. Overall, 30-day mortality was significantly higher in patients with ESBL-KP BSI than ESBL-EC BSI (33.7% vs 17.4%; odds ratio, 1.64; P=.016). CTX-M was the most prevalent ESBL subtype identified (218 of 286 polymerase chain reaction-tested isolates, 76%). No differences in clinical characteristics or in mortality between CTX-M and non–CTX-M ESBLs were detected.

Clinical characteristics and risk of mortality differ significantly between ESBL-EC and ESBL-KP BSI. Therefore, all ESBL-producing Enterobacteriaceae should not be considered a homogeneous group. No differences in outcomes between genotypes were detected.

ClinicalTrials.gov. Identifier: NCT01764490.

Infect Control Hosp Epidemiol 2018;39:660–667

Due to concerns over increasing fluoroquinolone (FQ) resistance among gram-negative organisms, our stewardship program implemented a preauthorization use policy. The goal of this study was to assess the relationship between hospital FQ use and antibiotic resistance.

Retrospective cohort.

Large academic medical center.

We performed a retrospective analysis of FQ susceptibility of hospital isolates for 5 common gram-negative bacteria: Acinetobacter spp., Enterobacter cloacae, Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Primary endpoint was the change of FQ susceptibility. A Poisson regression model was used to calculate the rate of change between the preintervention period (1998–2005) and the postimplementation period (2006–2016).

Large rates of decline of FQ susceptibility began in 1998, particularly among P. aeruginosa, Acinetobacter spp., and E. cloacae. Our FQ restriction policy improved FQ use from 173 days of therapy (DOT) per 1,000 patient days to <60 DOT per 1,000 patient days. Fluoroquinolone susceptibility increased for Acinetobacter spp. (rate ratio [RR], 1.038; 95% confidence interval [CI], 1.005–1.072), E. cloacae (RR, 1.028; 95% CI, 1.013–1.044), and P. aeruginosa (RR, 1.013; 95% CI, 1.006–1.020). No significant change in susceptibility was detected for K. pneumoniae (RR, 1.002; 95% CI, 0.996–1.008), and the susceptibility for E. coli continued to decline, although the decline was not as steep (RR, 0.981; 95% CI, 0.975–0.987).

A stewardship-driven FQ restriction program stopped overall declining FQ susceptibility rates for all species except E. coli. For 3 species (ie, Acinetobacter spp, E. cloacae, and P. aeruginosa), susceptibility rates improved after implementation, and this improvement has been sustained over a 10-year period.

A significant portion of patients with Clostridium difficile infections (CDI) experience recurrence, and there is little consensus on its treatment. With the availability of newer agents for CDI and the added burdens of recurrent disease, a cost-effectiveness analysis may provide insight on the most efficient use of resources.

A decision-tree analysis was created to compare the cost-effectiveness of 3 possible treatments for patients with first CDI recurrence: oral vancomycin, fidaxomicin, or bezlotoxumab plus vancomycin. The model was performed from a payer’s perspective with direct cost inputs and a timeline of 1 year. A systematic review of literature was performed to identify clinical, utility, and cost data. Quality-adjusted life years (QALY) and incremental cost-effectiveness ratios were calculated. The willingness-to-pay (WTP) threshold was set at $100,000 per QALY gained. The robustness of the model was tested using one-way sensitivity analyses and probabilistic sensitivity analysis.

Vancomycin had the lowest cost ($15,692) and was associated with a QALY gain of 0.8019 years. Bezlotoxumab plus vancomycin was a dominated strategy. Fidaxomicin led to a higher QALY compared to vancomycin, at an incremental cost of $500,975 per QALY gained. Based on our WTP threshold, vancomycin alone was the most cost-effective regimen for treating the first recurrence of CDI. Sensitivity analyses demonstrated the model’s robustness.

Vancomycin alone appears to be the most cost-effective regimen for the treatment of first recurrence of CDI. Fidaxomicin alone led to the highest QALY gained, but at a cost beyond what is considered cost-effective.

We evaluated the utility of vancomycin-resistant Enterococcus (VRE) surveillance by varying 2 parameters: admission versus weekly surveillance and perirectal swabbing versus stool sampling.

Prospective, patient-level surveillance program of incident VRE colonization.

Liver transplant surgical intensive care unit (SICU) of a tertiary-care referral medical center with a high prevalence of VRE.

All patients admitted to the SICU from June to August 2015.

We conducted a point-prevalence estimate followed by admission and weekly surveillance by perirectal swabbing and/or stool sampling. Incident colonization was defined as a negative screen followed by positive surveillance. VRE was detected by culture on Remel Spectra VRE chromogenic agar. Microbiologically-confirmed VRE bloodstream infections (BSIs) were tracked for 2 months. Statistical analyses were calculated using the McNemar test, the Fisher exact test, the t test, and the χ2 test.

In total, 91 patients underwent VRE surveillance testing. The point prevalence of VRE colonization was 60.9%; VRE prevalence on admission was 30.1%. Weekly surveillance identified an additional 7 of 28 patients (25.0%) with incident colonization. VRE BSIs were more common in VRE-colonized patients than in noncolonized patients (8 of 43 vs 2 of 48; P=.028). In a direct comparison, perirectal swabs were more sensitive than stool samples in detecting VRE (64 of 67 vs 56 of 67; P=.023). Compliance with perirectal swabbing was 89% (201 of 226) compared to 56% (127 of 226) for stool collection (P≤0.001).

We recommend weekly VRE surveillance over admission-only screening in high-burden units such as liver transplant SICUs. Perirectal swabs had greater collection compliance and sensitivity than stool samples, making them the preferred methodology. Further work may have implications for antimicrobial stewardship and infection control.

To compare bacterial contamination of military-approved uniforms and hospital-provided scrubs donned by nursing staff in an inpatient setting.

Randomized experimental crossover study.

Large academic military medical center.

Inpatient units were randomized to predetermine the order of uniform sampling. Participants included nursing staff who provided direct patient care across 7 eligible inpatient units. Sampling of 6 designated sites on the uniform was completed on arrival to work, at ~4 hours into their shift, and at the 8-hour time point, for a total of 18 samples. Sampling of each participant occurred on 2 separate occasions, once in a military-approved uniform, and once in hospital-provided scrubs. After 24 hours of incubation, a colony-counting machine was used to calculate the total colony-forming units (CFU) of the sample.

Across all time points, military-approved uniforms demonstrated a 2-fold bacterial increase at the abdominal site and 3-fold increases at the sleeve cuff and waist pocket regions compared to the same regions on hospital-provided scrubs.

Nurses should be aware that bacteria are present at much higher levels on their personal military uniforms compared to hospital-provided scrubs. Additional research is needed to determine whether these findings are a function of wear, laundering, or environmental factors. Nurses should adhere to daily uniform washing to reduce bacterial load and minimize risk of nosocomial infections to the patients they care for.

To elicit expert consensus on the likelihood of infectious outcomes (patient colonization or infection) following a broad range of infectious risk moments (IRMs) from observations in acute care.

Expert consensus study using modified Delphi technique.

Panel of 40 international experts including nurses, physicians and microbiologists specialized in infectious diseases and infection prevention and control (IPC).

The modified Delphi process consisted of 3 online survey rounds, with feedback of mean ratings and expert comments between rounds. The Delphi survey comprised 52 care scenarios representing observed IRMs organized into 6 sections: hands, gloves, medical devices, mobile objects, invasive procedures, and additional moments. For each scenario, experts indicated the likelihood of both patient colonization and infection on a scale from 0 to 5 (high). Expert ratings were plotted against frequencies of IRMs observed during actual patient care resulting in a risk index.

Following 3 rounds, consensus was achieved for 92 of 104 items (88.5%). The mean ratings across all scenarios for likelihood of colonization and infection were 2.68 and 2.02, respectively. The likelihood of colonization was rated higher than infection for 48 of 52 scenarios. Ratings were significantly higher for colonization (P=.001) and infection (P<.0005) when the scenario involved transfer of pathogens to critical patient sites.

The design of effective IPC strategies requires the selection of behaviors according to their impact on patient outcomes. The IRM index reported here provides a basis for standardizing and prioritizing targets for quality improvement initiatives, training, and future research in acute health care.

Infect Control Hosp Epidemiol 2018;39:280–289

Among nosocomial bloodstream infections caused by enterococcal species, Ireland has the highest proportion caused by vancomycin-resistant enterococci (VRE) in Europe at 45.8%. The contribution of the near-patient environment to VRE transmission outside of outbreaks was investigated.

A prospective observational study was conducted during 7 sampling periods.

Recovery of VRE isolates by swabbing the near-patient environment and patients in the intensive care unit (ICU) was conducted to identify reservoirs, clinical and molecular epidemiological associations, and the success of active surveillance cultures (ASCs).

Of 289 sampling occasions involving 157 patients and their bed spaces, VRE isolates were recovered from patient bed spaces, clinical samples, or both on 114 of 289 sampling occasions (39.4%). The patient and their bed space were positive for VRE on 34 of 114 VRE-associated sampling occasions (29.8%). Of 1,647 environment samples, 107 sites (6.5%) were VRE positive, with significantly greater VRE recovery from isolation rooms than from the open-plan area (9.1% vs 4.1%; P < .0001). The most frequently VRE-contaminated sites were the drip stand, bed control panel, and chart holders, which together accounted for 61% of contaminated sites. The use of ASCs resulted in a 172% increase in identification of VRE-colonized patients. Molecular typing revealed 2 environmental clusters, 1 cluster involving 3 patients and generally greater heterogeneity of patient isolates compared to environmental isolates.

Even outside of outbreaks, near-patient ICU environmental contamination with VRE is common. Better infection control policies that limit environmental transmission of VRE in the ICU and that are supported by molecular epidemiological studies, in real time, are needed.

Infect Control Hosp Epidemiol 2018;39:40–45