Vancomycin-resistant Enterococcus (VRE) bloodstream infections (BSIs) are associated with increased morbidity and mortality.

To determine the hospital costs and length of stay attributable to VRE BSI and vancomycin-sensitive Enterococcus (VSE) BSI and the independent effect of vancomycin resistance on hospital costs.

A retrospective cohort study was conducted of 21,154 nonsurgical patients admitted to an academic medical center during the period from 2002 through 2003. Using administrative data, attributable hospital costs (adjusted for inflation to 2007 US dollars) and length of stay were estimated with multivariate generalized least-squares (GLS) models and propensity score-matched pairs.

The cohort included 94 patients with VRE BSI and 182 patients with VSE BSI. After adjustment for demographics, comorbidities, procedures, nonenterococcal BSI, and early mortality, the costs attributable to VRE BSI were $4,479 (95% confidence interval [CI], $3,500-$5,732) in the standard GLS model and $4,036 (95% CI, $3,170-$5,140) in the propensity score-weighted GLS model, and the costs attributable to VSE BSI were $2,250 (95% CI, $l,758-$2,880) in the standard GLS model and $2,023 (95% CI, $1,588-$2,575) in the propensity score-weighted GLS model. The median values of the difference in costs between matched pairs were $9,949 (95% CI, $1,579-$24,693) for VRE BSI and $5,282 (95% CI, $2,042-$8,043) for VSE BSI. The costs attributable to vancomycin resistance were $1,713 (95% CI, $1,338-$2,192) in the standard GLS model and $1,546 (95% CI, $1,214-$1,968) in the propensity score-weighted GLS model. Depending on the statistical method used, attributable length of stay estimates ranged from 2.2 to 3.5 days for patients with VRE BSI and from 1.1 to 2.2 days for patients with VSE BSI.

VRE BSI and VSE BSI were independently associated with increased hospital costs and increased length of stay. Vancomycin resistance was associated with increased costs.

To assess healthcare workers' attitudes and concerns regarding seasonal and pandemic influenza vaccines in order to improve vaccination campaign communications.

Cross-sectional survey.

All 6 health authorities in British Columbia, Canada.

An anonymous, self-administered online survey was conducted from August 30 through September 30, 2009. Question topics included demographic characteristics, factors influencing acceptance of seasonal influenza vaccine, factors influencing intentions to accept pandemic H1N1 influenza vaccine, and knowledge and concerns regarding the effect of the influenza pandemic.

All 96,217 British Columbia healthcare workers were eligible to participate.

A volunteer sample of 4,046 healthcare workers returned the survey; 3,563 (88%) were women, 58% were under 50 years old (mean age ± standard deviation, 45.3 ± 10.9 years), 3,152 of 4,023 (79%) had 5 or more years of experience in their profession, 1,853 of 4,023 (46%) were nurses, and 2,833 (70%) had been vaccinated against seasonal influenza the previous year. Two thousand eight hundred (69%) respondents reported intending to receive the pandemic H1N1 vaccine. The most important predictor of this intention was having received the seasonal vaccine the previous year (odds ratio [OR], 6.25 [95% confidence interval {CI}, 5.39-7.26]). Worry about making loved ones ill was the only attitude associated with intention to receive the pandemic H1N1 vaccine (adjusted OR, 1.38 [95% CI, 1.27-1.50]). Concerns with vaccine safety (adjusted OR, 0.31 [95% CI, 0.25-0.39]) and belief “that H1N1 is not severe enough” (adjusted OR, 0.29 [95% CI, 0.26-0.32]) were independently associated with the intention to reject the pandemic H1N1 vaccine.

Vaccination campaigns for pandemic H1N1 vaccine should use messages that emphasize the risk of illness among younger people and the opportunity to protect loved ones by getting the vaccine and should address concerns about the safety and effectiveness of the vaccine.

To assess the feasibility and effectiveness of the World Health Organization hand hygiene improvement strategy in a low-income African country.

A before-and-after study from December 2006 through June 2008, with a 6-month baseline evaluation period and a follow-up period of 8 months from the beginning of the intervention.

University Hospital, Bamako, Mali.

TWO hundred twenty-four healthcare workers.

The intervention consisted of introducing a locally produced, alcohol-based handrub; monitoring hand hygiene compliance; providing performance feedback; educating staff; posting reminders in the workplace; and promoting an institutional safety climate according to the World Health Organization multimodal hand hygiene improvement strategy. Hand hygiene infrastructure, compliance, healthcare workers' knowledge and perceptions, and handrub consumption were evaluated at baseline and at follow-up.

Severe deficiencies in the infrastructure for hand hygiene were identified before the intervention. Local handrub production and quality control proved to be feasible, affordable, and satisfactory. At follow-up, handrubbing was the quasi-exclusive hand hygiene technique (93.3%). Compliance increased from 8.0% at baseline to 21.8% at follow-up (P < .001). Improvement was observed across all professional categories and medical specialities and was independently associated with the intervention (odds ratio, 2.50; 95% confidence interval, 1.8-3.5). Knowledge enhanced significantly (P < .05), and perception surveys showed a high appreciation of each strategy component by staff.

Multimodal hand hygiene promotion is feasible and effective in a low-income country. Access to handrub was critical for its success. These findings motivated the government of Mali to expand the intervention nationwide. This experience represents a significant advancement for patient safety in developing countries.

To describe vaporized hydrogen peroxide (VHP) as an adjuvant in the control of multidrug-resistant (MDR) Acinetobacter baumannii infection in a long-term acute care hospital (LTACH) and to describe the risk factors for acquisition of MDR A. baumannii infection in the LTACH population.

Outbreak investigation, case-control study, and before-after intervention trial.

A 54-bed LTACH affiliated with a tertiary care center in northeastern Ohio.

Investigation of outbreak with clinical and environmental cultures, antimicrobial susceptibility testing, polymerase chain reaction assay of repetitive chromosomal elements to type strains, and case-control study; and intervention consisting of comprehensive infection control measures and VHP environmental decontamination.

Thirteen patients infected or colonized with MDR A. baumannii were identified from January 2008 through June 2008. By susceptibility testing, 10 (77%) of the 13 isolates were carbapenem-resistant. MDR A. baumannii was found in wound samples, blood, sputum, and urine. Wounds were identified as a risk factor for MDR A. baumannii colonization. Ventilator-associated pneumonia was the most common clinical syndrome caused by the pathogen, and the associated mortality was 14% (2 of the 13 case patients died). MDR A. baumannii was found in 8 of 93 environmental samples, including patient rooms and a wound care cart; environmental and clinical cultures were genetically related. Environmental cultures were negative immediately after VHP decontamination and both 24 hours and 1 week after VHP decontamination. Nosocomial acquisition of the pathogen in the LTACH ceased after VHP Intervention. When patients colonized with MDR A. baumannii reoccupied rooms, environmental contamination recurred.

Environmental decontamination using VHP combined with comprehensive infection control measures interrupted nosocomial transmission of MDR A. baumannii in an LTACH. The application of this novel approach to halt the transmission of MDR A. baumannii warrants further investigation.

To determine the effect of a bundle of infection control interventions on the horizontal transmission of Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae during an outbreak.

Quasi-experimental study.

Long-term acute care hospital.

On July 23,2008, a bundled intervention was implemented: daily 2% Chlorhexidine gluconate baths for patients, enhanced environmental cleaning, surveillance cultures at admission, serial point prevalence surveillance (PPS), isolation precautions, and training of personnel. Baseline PPS was performed before the intervention was implemented. Any gram-negative rod isolate suspected of KPC production underwent a modified Hodge test and, if results were positive, confirmatory polymerase chain reaction testing. Clinical cases were defined to occur for patients whose samples yielded KPC-positive gram-negative rods in clinical cultures.

Baseline PPS performed on June 17, 2008, showed a prevalence of colonization with KPC-producing isolates of 21% (8 of 39 patients screened). After implementation of the intervention, monthly PPS was performed 5 times, which showed prevalences of colonization with KPC-producing isolates of 12%, 5%, 3%, 0%, and 0% (P < .001). From January 1, 2008, until the intervention, 8 KPC-positive clinical cases—suspected to be due to horizontal transmission—were detected. From implementation of the intervention through December 31, 2008, only 2 KPC-positive clinical cases, both in August 2008, were detected. From January 1 through December 31, 2008, 8 patients were detected as carriers of KPC-producing isolates at admission to the institution, 4 patients before and 4 patients after the intervention.

A bundled intervention was successful in preventing horizontal spread of KPC-producing gram-negative rods in a long-term acute care hospital, despite ongoing admission of patients colonized with KPC producers.

Patients undergoing orthopedic surgery are susceptible to methicillin-resistant Staphylococcus aureus (MRSA) infections, which can result in increased morbidity, hospital lengths of stay, and medical costs. We sought to estimate the economic value of routine preoperative MRSA screening and decolonization of orthopedic surgery patients.

A stochastic decision-analytic computer simulation model was used to evaluate the economic value of implementing this strategy (compared with no preoperative screening or decolonization) among orthopedic surgery patients from both the third-party payer and hospital perspectives. Sensitivity analyses explored the effects of varying MRSA colonization prevalence, the cost of screening and decolonization, and the probability of decolonization success.

Preoperative MRSA screening and decolonization was strongly cost-effective (incremental cost-effectiveness ratio less than $6,000 per quality-adjusted life year) from the third-party payer perspective even when MRSA prevalence was as low as 1%, decolonization success was as low as 25%, and decolonization costs were as high as $300 per patient. In most scenarios this strategy was economically dominant (ie, less costly and more effective than no screening). From the hospital perspective, preoperative MRSA screening and decolonization was the economically dominant strategy for all scenarios explored.

Routine preoperative screening and decolonization of orthopedic surgery patients may under many circumstances save hospitals and third-party payers money while providing health benefits.

To better understand the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection in different patient populations, to perform quantitative analysis of MRSA in nasal cultures, and to characterize strains using molecular fingerprinting.

Prospective, multicenter study.

Eleven different inpatient and outpatient healthcare facilities.

MRSA-positive inpatients identified in an active surveillance program; inpatients and outpatients receiving hemodialysis; inpatients and outpatients with human immunodeficiency virus (HIV) infection; patients requiring cardiac surgery; and elderly patients requiring long-term care.

Nasal swab samples were obtained from January 23, 2006, through July 27, 2007; MRSA strains were quantified and characterized by molecular fingerprinting.

A total of 444 nares swab specimens yielded MRSA (geometric mean quantity, 794 CFU per swab; range, 3-15,000,000 CFU per swab). MRSA prevalence was 20% for elderly residents of long-term care facilities (25 of 125 residents), 16% for HIV-infected outpatients (78 of 494 outpatients), 15% for outpatients receiving hemodialysis (31 of 208 outpatients), 14% for inpatients receiving hemodialysis (86 of 623 inpatients), 3% for HIV-infected inpatients (5 of 161 inpatients), and 3% for inpatients requiring cardiac surgery (6 of 199 inpatients). The highest geometric mean quantity of MRSA was for inpatients requiring cardiac surgery (11,500 CFU per swab). An association was found between HIV infection and colonization with the USA300 or USA500 strain of MRSA (P ≤ .001). The Brazilian clone was found for the first time in the United States. Pulsed-field gel electrophoresis patterns for 11 isolates were not compatible with known USA types or clones.

Nasal swab specimens positive for MRSA had a geometric mean quantity of 794 CFU per swab, with great diversity in the quantity of MRSA at this anatomic site. Outpatient populations at high risk for MRSA carriage were elderly residents of long-term care facilities, HIV-infected outpatients, and outpatients receiving hemodialysis.

Methicillin-resistant Staphylococcus aureus (MRSA) is an emerging concern in infectious disease practice. Although MRSA infections occur in a wide variety of anatomic sites, the majority of studies considering the risk factors for methicillin resistance among S. aureus infections have focused on MRSA bacteremia.

To describe risk factors associated with methicillin resistance among S. aureus infections at different anatomic sites.

We collected information on the demographic and clinical characteristics of patients examined at the Atlanta Veterans Affairs Medical Center with S. aureus infections during the period from June 2007 through May 2008. We used multivariate logistic regression to describe factors significantly associated with methicillin resistance.

There were 568 cases of S. aureus infection among 528 patients. We identified 352 cases (62%) of MRSA infection and 216 cases (38%) of methicillin-sensitive S. aureus infection. The adjusted odds of methicillin resistance were higher among infections that occurred among patients who had a prior history of MRSA infection (odds ratio [OR], 3.9 [95% confidence interval {CI}, 2.3–6.4]) or resided in a long-term care facility during the past 12 months (OR, 2.0 [95% CI, 1.0-4.0]) but were lower for infections that occurred among patients who had undergone a biopsy procedure during the past 12 months (OR, 0.7 [95% CI, 0.6-0.9]). Most cases of infection were community-onset infections (523 [92%] of 568 cases), and about one-half (278 [49%]) were not healthcare associated.

Compared with previous studies of methicillin resistance among patients with S. aureus bacteremia, we found similar factors to be associated with methicillin resistance among S. aureus isolates recovered from more diverse anatomic sites of infection. Of note, nearly one-half of our cases of MRSA infection were not healthcare associated.

To determine the epidemiological characteristics of postoperative invasive Staphylococcus aureus infection following 4 types of major surgical procedures.

Retrospective cohort study.

Eleven hospitals (9 community hospitals and 2 tertiary care hospitals) in North Carolina and Virginia.

Adults undergoing orthopedic, neurosurgical, cardiothoracic, and plastic surgical procedures.

We used previously validated, prospectively collected surgical surveillance data for surgical site infection and microbiological data for bloodstream infection. The study period was 2003 through 2006. We defined invasive S. aureus infection as either nonsuperficial incisional surgical site infection or bloodstream infection. Nonparametric bootstrapping was used to generate 95% confidence intervals (CIs). P values were generated using the Pearson x2 test, Student t test, or Wilcoxon rank-sum test, as appropriate.

In total, 81,267 patients underwent 96,455 procedures during the study period. The overall incidence of invasive S. aureus infection was 0.47 infections per 100 procedures (95% CI, 0.43–0.52); 227 (51%) of 446 infections were due to methicillin-resistant S. aureus. Invasive S. aureus infection was more common after cardiothoracic procedures (incidence, 0.79 infections per 100 procedures [95% CI, 0.62–0.97]) than after orthopedic procedures (0.37 infections per 100 procedures [95% CI, 0.32–0.42]), neurosurgical procedures (0.62 infections per 100 procedures [95% CI, 0.53–0.72]), or plastic surgical procedures (0.32 infections per 100 procedures [95% CI, 0.17¬0.47]) (P < .001). Similarly, S. aureus bloodstream infection was most common after cardiothoracic procedures (incidence, 0.57 infections per 100 procedures [95% CI, 0.43–0.72]; P < .001, compared with other procedure types), comprising almost three-quarters of the invasive S. aureus infections after these procedures. The highest rate of surgical site infection was observed after neurosurgical procedures (incidence, 0.50 infections per 100 procedures [95% CI, 0.42–0.59]; P < .001, compared with other procedure types), comprising 80% of invasive S. aureus infections after these procedures.

The frequency and type of postoperative invasive S. aureus infection varied significantly across procedure types. The highest risk procedures, such as cardiothoracic procedures, should be targeted for ongoing preventative interventions.

Ertapenem exposure has been reported to select for cross-resistance to other carbapenems in Pseudomonas aeruginosa in vitro. Single-center investigations report conflicting results. We evaluated ertapenem use and antipseudomonal carbapenem susceptibility for 6 years spanning the time of ertapenem adoption at each of 25 US hospitals.

Retrospective primary and secondary data analysis.

Use density ratios for imipenem and meropenem (collectively, “other carbapenems”) and ertapenem were derived from data in a commercial database on the total number of grams used in the 3 years before and the 3 years after adoption of ertapenem at each hospital. A general linear model using repeated measures analysis of variance was used to explore associations between the 6-year change in antipseudomonal carbapenem susceptibility rates (determined from hospital antibiograms) and ertapenem use in each year, while controlling for other carbapenem use.

Ertapenem use increased once adopted. With regard to the postadoption period, the median use density ratio for year 4 was 4.1 (interquartile range [IQR], 1.7-5.2), for year 5 was 6.0 (IQR, 2.7-8.5), and for year 6 was 6.5 (IQR, 4.0-11.6). The median use density ratio for other carbapenem use for year 1 was 8.7 (IQR, 5.7-13.5), and by year 6 it had increased to 19.3 (IQR, 9.6-26.2). Change in mean antipseudomonal carbapenem susceptibility across time (85% in year 1 to 82% in year 6) was not significant (P = .22). Change in 6-year antipseudomonal carbapenem susceptibility was not associated with ertapenem use in any year while controlling for other carbapenem use (P > .20 for all years of ertapenem use).

Although significant change in P. aeruginosa susceptibility to antipseudomonal carbapenems was not detected during this multicenter study, which to our knowledge is the most extensive assessment to date of this important drug use-susceptibility relationship, continued evaluation of the relationship is prudent.

Carbapenem resistance among Enterobacteriaceae is of concern because of increasing prevalence and limited therapeutic options. Limited research has been focused on understanding ertapenem resistance as a more sensitive marker for resistance to other carbapenems. We sought to determine risk factors for acquisition of ertapenem-resistant, meropenem-susceptible, or intermediate Enterobacteriaceae and to assess associated patient outcomes.

Retrospective case-control study among adult hospitalized inpatients.

A 902-bed quaternary care urban hospital.

Sixty-two cases of ertapenem-resistant Enterobacteriaceae were identified from March 14, 2006, through October 31, 2007, and 62 unmatched control patients were randomly selected from other inpatients with cultures positive for ertapenem-susceptible Enterobacteriaceae. Thirty-seven (60%) of case patient isolates were Enterobacter cloacae, 20 (32%) were Klebsiella pneumoniae, and 5 (8%) were other species of Enterobacteriaceae. Risk factors for ertapenem-resistant Enterobacteriaceae infection included intensive care unit stay (odds ratio [OR], 4.6 [95% confidence interval {CI}, 2.0–10.3]), vancomycin-resistant Enterococcus colonization (OR, 7.1 [95% CI, 2.4–21.4]), prior central venous catheter use (OR, 10.0 [95% CI, 3.0–33.1]), prior receipt of mechanical ventilation (OR, 5.8 [95% CI, 2.1–16.2]), exposure to any antibiotic during the 30 days prior to a positive culture result (OR, 18.5 [95% CI, 4.9–69.9]), use of a β-lactam during the 30 days prior to a positive culture result (OR, 6.9 [95% CI, 3.0–16.0], and use of a carbapenem during the 30 days prior to a positive culture result (OR, 18.2 [95% CI, 2.6–130.0]). For the 62 case patients, 30-day outcomes from the time of positive culture result were 24 discharges (39%), 10 deaths (16%), and 28 continued hospitalizations (44%). The final end point of the hospitalization was discharge for 44 patients (71%) and death for 18 patients (29%).

Ertapenem-resistant Enterobacteriaceae are important nosocomial pathogens. Multiple mechanisms of resistance maybe in operation. Additional study of ertapenem resistance is needed.

To compare incidence of hospital-onset Clostridium difficile infection (CDI) measured by the use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) discharge diagnosis codes with rates measured by the use of electronically available C. difficile toxin assay results.

Cases of hospital-onset CDI were identified at 5 US hospitals during the period from July 2000 through June 2006 with the use of 2 surveillance definitions: positive toxin assay results (gold standard) and secondary ICD-9-CM discharge diagnosis codes for CDI. The x2 test was used to compare incidence, linear regression models were used to analyze trends, and the test of equality was used to compare slopes.

Of 8,670 cases of hospital-onset CDI, 38% were identified by the use of both toxin assay results and the ICD-9-CM code, 16% by the use of toxin assay results alone, and 45% by the use of the ICD-9-CM code alone. Nearly half (47%) of cases of CDI identified by the use of a secondary diagnosis code alone were community-onset CDI according to the results of the toxin assay. The rate of hospital-onset CDI found by use of ICD-9-CM codes was significantly higher than the rate found by use of toxin assay results overall (P<.001), as well as individually at 3 of the 5 hospitals (P<.001 for all). The agreement between toxin assay results and the presence of a secondary ICD-9-CM diagnosis code for CDI was moderate, with an overall k value of 0.509 and hospital-specific k values of 0.489–0.570. Overall, the annual increase in CDI incidence was significantly greater for rates determined by the use of ICD-9-CM codes than for rates determined by the use of toxin assay results (P = .006).

Although the ICD-9-CM code for CDI seems to be adequate for measuring the overall CDI burden, use of the ICD-9-CM discharge diagnosis code for CDI, without present-on-admission code assignment, is not an acceptable surrogate for surveillance for hospital-onset CDI.

To present the evaluation of a large-scale quantitative respirator-fit testing program.

Concurrent questionnaire survey of fit testers and test subjects.

Ambulatory care, home nursing care, and acute care hospitals across South Australia.

Quantitative facial-fit testing was performed with TSI PortaCount instruments for healthcare workers (HCWs) who wore 5 different models of a disposable P2 (N95-equivalent) respirator. The questionnaire included questions about the HCWs age, sex, race, occupational category, main area of work, smoking status, facial characteristics, prior training and experience in use of respiratory masks, and number of attempts to obtain a respirator fit.

A total of 6,160 HCWs were successfully fitted during the period from January through July 2007. Of the 4,472 HCWs who responded to the questionnaire and were successfully fitted, 3,707 (82.9%) were successfully fitted with the first tested respirator, 551 (12.3%) required testing with a second model, and 214 (4.8%) required 3 or more tests. We noted an increased pass rate on the first attempt over time. Asians (excluding those from South and Central Asia) had the highest failure rate (16.3% [45 of 276 Asian HCWs were unsuccessfully fitted]), and whites had the lowest (9.8% [426 of 4,338 white HCWs]). Race was highly correlated with facial shape. Among occupational groups, doctors had the highest failure rate (13.4% [81 of 604 doctors]), but they also had the highest proportion of Asians. Prior education and/or training in respirator use were not associated with a higher pass rate.

Certain facial characteristics were associated with higher or lower pass rates with regard to fit testing, and fit testers were able to select a suitable respirator on the basis of a visual assessment in the majority of cases. For the fit tester, training and experience were important factors; however, for the HCW being fitted, prior experience in respirator use was not an important factor.

To determine the effectiveness of a UV-C-emitting device to eliminate clinically important nosocomial pathogens in a contaminated hospital room.

This study was carried out in a standard but empty hospital room (phase 1) and in a room previously occupied by a patient with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) infection (phase 2) in an acute care tertiary hospital in North Carolina from January 21 through September 21, 2009. During phase 1, 8 × 8 cm Formica sheets contaminated with approximately 104-105 organisms of MRSA, VRE, multidrug-resistant (MDR) Acinetobacter baumannii, or Clostridium difficile spores were placed in a hospital room, both in direct line of sight of the UV-C device and behind objects. After timed exposure, the presence of the microbes was assessed. During phase 2, specific sites in rooms that had housed patients with MRSA or VRE infection were sampled before and after UV-C irradiation. After timed exposure, the presence of MRSA and VRE and total colony counts were assessed.

In our test room, the effectiveness of UV-C radiation in reducing the counts of vegetative bacteria on surfaces was more than 99.9% within 15 minutes, and the reduction in C. difficile spores was 99.8% within 50 minutes. In rooms occupied by patients with MRSA, UV-C irradiation of approximately 15 minutes duration resulted in a decrease in total CFUs per plate (mean, 384 CFUs vs 19 CFUs; P < .001), in the number of samples positive for MRSA (81 [20.3%] of 400 plates vs 2 [0.5%] of 400 plates; P < .001 ), and in MRSA counts per MRSA-positive plate (mean, 37 CFUs vs 2 CFUs; P < .001).

This UV-C device was effective in eliminating vegetative bacteria on contaminated surfaces both in the line of sight and behind objects within approximately 15 minutes and in eliminating C. difficile spores within 50 minutes.

To determine the incidence and describe the changing epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection in Canadian hospitals from 1995–2007.

Forty-eight hospitals participating in the Canadian Nosocomial Infection Surveillance Program.

Prospective, laboratory-based surveillance for incident cases of MRSA colonization or infection among hospitalized patients.

Clinical and epidemiologic data were obtained by review of hospital records. Standard criteria were used to determine whether MRSA colonization or infection was present and whether the MRSA strain was healthcare associated or community associated. A representative subset of isolates was characterized by use of pulsed-field gel electrophoresis and staphylococcal cassette chromosome (SCC) mec typing.

From 1995 to 2007, a total of 37,169 hospitalized patients were newly identified as either infected or colonized with MRSA, and the overall incidence of both MRSA colonization and MRSA infection increased from 0.65 to 11.04 cases per 10,000 patient-days (P < .001). Of these 37,169 patients, 11,828 (32%) had an MRSA infection, and infection rate increased from 0.36 to 3.43 cases per 10,000 patient-days. The proportion of community-associated MRSA strains increased from 6% to 23% (P < .001). The most common genotype (47% of isolates) was CMRSA-2 (USA100/800); in 2007, CMRSA-10 (USA300) was the second most common strain (27% of isolates), associated with SCCmec type IV. Patients with CMRSA-10 were predominantly from western Canada and were more likely to be children (odds ratio [OR], 10.0 [95% confidence interval {CI}, 7.4–13.4]) and to have infection (OR, 2.3 [95% CI, 1.9–2.7]), especially skin and/or soft tissue infection (OR, 5.9 [95% CI, 5.0–6.9]).

The overall incidence of both MRSA colonization and MRSA infection increased 17-fold in Canadian hospitals from 1995 to 2007. There has also been a dramatic increase in cases of community-associated MRSA infection due to the CMRSA-10 (USA300) clone. Continued surveillance is needed to monitor the ongoing evolution of MRSA colonization or infection in Canada and globally.

Show how detailed incubation period estimates can be used to identify and investigate potential healthcare-associated infections and dangerous diseases.

We used the incubation period of 9 respiratory viruses to derive decision rules for distinguishing between community- and hospital-acquired infection. We developed a method, implemented in a simple spreadsheet, that can be used to investigate the exposure history of an individual patient and more specifically to identify the probable time and location of infection. Illustrative examples are used to explain and evaluate this technique.

If the risks of hospital and community infection are equal, 95% of patients who develop symptoms of adenovirus infection within 5 days of hospital admission will have been infected in the community, as will 95% of patients who develop symptoms within 3 days for human-coronavirus infection, 2.5 days for severe acute respiratory syndrome, 1 day for influenza A, 0.5 day for influenza B, 12 days for measles, 2 days for parainfluenza, 4 days for respiratory syncytial virus infection, and 1.5 days for rhinovirus infection. Sources of infection suggested by analysis of the symptom onset times of individual patients are consistent with those from detailed investigations.

This work shows how a detailed understanding of the incubation period can be an effective tool for identifying the source of infection, ultimately ensuring patient safety.

Determining risk factors for acquisition of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals is important for defining infection-control measures that may lead to fewer hospital-acquired infections.

To determine patient-associated risk factors for acquisition of MRSA in a tertiary care hospital with the goal of identifying modifiable risk factors.

A retrospective matched case-control study was performed. Case patients who acquired MRSA during hospitalization and 2 matched control patients were selected among inpatients admitted to target units during the period from 2001 through 2008. The odds of exposure to potential risk factors were compared between case patients and control patients, using matched univariate conditional logistic regression. A single multivariate conditional logistic regression model identifying independent patient-specific risk factors was generated.

A total of 451 case patients and 866 control patients were analyzed. Factors positively associated with MRSA acquisition were as follows: target unit stay before index culture; primary diagnosis of respiratory disease, digestive tract disease, injury or trauma, or other diagnosis compared with cardiocirculatory disease; peripheral vascular disease; mechanical ventilation with pneumonia; ventricular shunting or ventriculostomy; and ciprofloxacin use. Factors associated with decreased risk were receipt of a solid-organ transplant and use of penicillins, cephalosporins, rifamycins, daptomycin or linezolid, and proton pump inhibitors.

Among the factors associated with increased risk, few are modifiable. Patients with at-risk conditions could be targeted for intensive surveillance to detect acquisition sooner. The association of MRSA acquisition with target unit exposure argues for rigorous application of hand hygiene, appropriate barriers, environmental control, and strict aseptic technique for all procedures performed on such Patients. Our findings support focusing efforts to prevent MRSA transmission and restriction of ciprofloxacin use.

To compare the efficacy of universal gloving with emollient-impregnated gloves with standard contact precautions for the control of multidrug-resistant organisms (MDROs) and to measure the effect on healthcare workers' (HCWs') hand skin health.

Prospective before-after trial.

An 18-bed surgical intensive care unit.

During phase 1 (September 2007 through March 2008) standard contact precautions were used. During phase 2 (March 2008 through September 2008) universal gloving with emollient-impregnated gloves was used, and no contact precautions. Patients were screened for vancomycin-resistant Enterococcus (VRE) and methicillin-resistant Staphylococcus aureus (MRSA). HCW hand hygiene compliance and hand skin health and microbial contamination were assessed. The incidences of device-associated infection and Clostridium difficile infection (CDI) were determined.

The rate of compliance with contact precautions (phase 1) was 67%, and the rate of compliance with universal gloving (phase 2) was 78% (P = .01). Hand hygiene compliance was higher during phase 2 than during phase 1 (before patient care, 40% vs 35% of encounters; P = .001; after patient care, 63% vs 51% of encounters; P < .001). No difference was observed in MDRO acquisition. During phases 1 and 2, incidences of device-related infections, in number of infections per 1,000 device-days, were, respectively, 3.7 and 2.6 for bloodstream infection (P = .10), 8.9 and 7.8 for urinary tract infection (P = .10), and 1.0 and 1.1 for ventilator-associated pneumonia (P = .09). The CDI incidence in phase 1 and in phase 2 was, respectively, 2.0 and 1.4 cases per 1,000 patient-days (P = .53). During phase 1, 29% of HCW hand cultures were MRSA positive, compared with 13% during phase 2 (P = .17); during phase 1, 2% of hand cultures were VRE positive, compared with 0 during phase 2 (P = .16). Hand skin health improved during phase 2.

Compared with contact precautions, universal gloving with emollient-impregnated gloves was associated with improved hand hygiene compliance and skin health. No statistically significant change in the rates of device-associated infection, CDI, or patient MDRO acquisition was observed. Universal gloving may be an alternative to contact precautions.