To evaluate hospital administrative data to identify potential surgical site infections (SSIs) following primary elective total hip or knee arthroplasty.

Retrospective cohort study.

All acute care facilities in Alberta, Canada.

Diagnosis and procedure codes for 6 months following total hip or knee arthroplasty were used to identify potential SSI cases. Medical charts of patients with potential SSIs were reviewed by an infection control professional at the acute care facility where the patient was identified with a diagnosis or procedure code. For SSI decision, infection control professionals used the National Healthcare Safety Network SSI definition. The performance of traditional surveillance methods and administrative data–triggered medical chart review was assessed.

Of the 162 patients identified by diagnosis or procedure code, 46 (28%) were confirmed as an SSI by an infection control professional. More SSIs were identified following total hip vs total knee arthroplasty (42% vs16%). Of 46 confirmed SSI cases, 20 (43%) were identified at an acute care facility different than their procedure facility. Administrative data–triggered medical chart review with infection control professional confirmation resulted in a 1.1- to 1.7-fold increase in SSI rate compared with traditional surveillance. SSIs identified by administrative data resulted in sensitivity of 90% and specificity of 99%.

Medical chart review for cases identified through administrative data is an efficient supplemental SSI surveillance strategy. It improves case-finding by increasing SSI identification and making identification consistent across facilities, and in a provincial surveillance network it identifies SSIs presenting at nonprocedure facilities.

Infect Control Hosp Epidemiol 2016;37:699–703

To estimate the costs of 3 MRSA transmission prevention scenarios compared with standard precautions in community-based nursing homes.

Cost analysis of data collected from a prospective, observational study.

Care activity data from 401 residents from 13 nursing homes in 2 states.

Cost components included the quantities of gowns and gloves, time to don and doff gown and gloves, and unit costs. Unit costs were combined with information regarding the type and frequency of care provided over a 28-day observation period. For each scenario, the estimated costs associated with each type of care were summed across all residents to calculate an average cost and standard deviation for the full sample and for subgroups.

The average cost for standard precautions was $100 (standard deviation [SD], $77) per resident over a 28-day period. If gown and glove use for high-risk care was restricted to those with MRSA colonization or chronic skin breakdown, average costs increased to $137 (SD, $120) and $125 (SD, $109), respectively. If gowns and gloves were used for high-risk care for all residents in addition to standard precautions, the average cost per resident increased substantially to $223 (SD, $127).

The use of gowns and gloves for high-risk activities with all residents increased the estimated cost by 123% compared with standard precautions. This increase was ameliorated if specific subsets (eg, those with MRSA colonization or chronic skin breakdown) were targeted for gown and glove use for high-risk activities.

Infect Control Hosp Epidemiol 2016;37:962–966

To assess antimicrobial utilization before and after a change in urine culture ordering practice in adult intensive care units (ICUs) whereby urine cultures were only performed when pyuria was detected.

Quasi-experimental study

A 700-bed academic medical center

Patients admitted to any adult ICU

Aggregate data for all adult ICUs were obtained for population-level antimicrobial use (days of therapy [DOT]), urine cultures performed, and bacteriuria, all measured per 1,000 patient days before the intervention (January–December 2012) and after the intervention (January–December 2013). These data were compared using interrupted time series negative binomial regression. Randomly selected patient charts from the population of adult ICU patients with orders for urine culture in the presence of indwelling or recently removed urinary catheters were reviewed for demographic, clinical, and antimicrobial use characteristics, and pre- and post-intervention data were compared.

Statistically significant reductions were observed in aggregate monthly rates of urine cultures performed and bacteriuria detected but not in DOT. At the patient level, compared with the pre-intervention group (n=250), in the post-intervention group (n=250), fewer patients started a new antimicrobial therapy based on urine culture results (23% vs 41%, P=.002), but no difference in the mean total DOT was observed.

A change in urine-culture ordering practice was associated with a decrease in the percentage of patients starting a new antimicrobial therapy based on the index urine-culture order but not in total duration of antimicrobial use in adult ICUs. Other drivers of antimicrobial use in ICU patients need to be evaluated by antimicrobial stewardship teams.

Infect. Control Hosp. Epidemiol. 2016;37(4):448–454

To determine the effect of graft choice (allograft, bone-patellar tendon-bone autograft, or hamstring autograft) on deep tissue infections following anterior cruciate ligament (ACL) reconstructions.

Retrospective cohort study.

Patients from 6 US health plans who underwent ACL reconstruction from January 1, 2000, through December 31, 2008.

We identified ACL reconstructions and potential postoperative infections using claims data. A hierarchical stratified sampling strategy was used to identify patients for medical record review to confirm ACL reconstructions and to determine allograft vs autograft tissue implanted, clinical characteristics, and infection status. We estimated infection rates overall and by graft type. We used logistic regression to assess the association between infections and patients’ demographic characteristics, comorbidities, and choice of graft.

On review of 1,452 medical records, we found 55 deep wound infections. With correction for sampling weights, infection rates varied by graft type: 0.5% (95% CI, 0.3%-0.8%) with allografts, 0.6% (0.1%–1.5%) with bone-patellar tendon-bone autografts, and 2.5% (1.9%–3.1%) with hamstring autograft. After adjusting for potential confounders, we found an increased infection risk with hamstring autografts compared with allografts (odds ratio, 5.9; 95% CI, 2.8–12.8). However, there was no difference in infection risk among bone-patellar tendon-bone autografts vs allografts (odds ratio, 1.2; 95% CI, 0.3–4.8).

The overall risk for deep wound infections following ACL reconstruction is low but it does vary by graft type. Infection risk was highest in hamstring autograft recipients compared with allograft recipients and bone-patellar tendon-bone autograft recipients.

Infect Control Hosp Epidemiol 2016;37:827–833

To use a unique multicomponent administrative data set assembled at a large academic teaching hospital to examine the risk of percutaneous blood and body fluid (BBF) exposures occurring in operating rooms.

A 10-year retrospective cohort design.

A single large academic teaching hospital.

All surgical procedures (n=333,073) performed in 2001–2010 as well as 2,113 reported BBF exposures were analyzed.

Crude exposure rates were calculated; Poisson regression was used to analyze risk factors and account for procedure duration. BBF exposures involving suture needles were examined separately from those involving other device types to examine possible differences in risk factors.

The overall rate of reported BBF exposures was 6.3 per 1,000 surgical procedures (2.9 per 1,000 surgical hours). BBF exposure rates increased with estimated patient blood loss (17.7 exposures per 1,000 procedures with 501–1,000 cc blood loss and 26.4 exposures per 1,000 procedures with >1,000 cc blood loss), number of personnel working in the surgical field during the procedure (34.4 exposures per 1,000 procedures having ≥15 personnel ever in the field), and procedure duration (14.3 exposures per 1,000 procedures lasting 4 to <6 hours, 27.1 exposures per 1,000 procedures lasting ≥6 hours). Regression results showed associations were generally stronger for suture needle–related exposures.

Results largely support other studies found in the literature. However, additional research should investigate differences in risk factors for BBF exposures associated with suture needles and those associated with all other device types.

Infect. Control Hosp. Epidemiol. 2015;37(1):80–87

Carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-CRE) are extremely drug-resistant pathogens. Screening of contacts of newly identified CP-CRE patients is an important step to limit further transmission. We aimed to determine the risk factors for CP-CRE acquisition among patients exposed to a CP-CRE index patient.

A matched case-control study was performed in a tertiary care hospital in Israel. The study population was comprised of patients who underwent rectal screening for CP-CRE following close contact with a newly identified CP-CRE index patient. Cases were defined as positive tests for CP-CRE. For each case patient, 2 matched controls were randomly selected from the pool of contacts who tested negative for CP-CRE following exposure to the same index case. Bivariate and multivariate analyses were conducted using conditional logistic regression.

In total, 53 positive contacts were identified in 40 unique investigations (896 tests performed on 735 contacts) between October 6, 2008, and June 7, 2012. blaKPC was the only carbapenemase identified. In multivariate analysis, risk factors for CP-CRE acquisition among contacts were (1) contact with an index patient for ≥3 days (odds ratio [OR], 9.8; 95% confidence interval [CI], 2.0–48.9), (2) mechanical ventilation (OR, 4.1; 95% CI, 1.4–11.9), and (3) carriage or infection with another multidrug-resistant organism (MDRO; OR, 2.6; 95% CI, 1.0–7.1). Among patients who received antibiotics, cephalosporins were associated with a lower risk of acquisition.

Patient characteristics (ventilation and carriage of another MDRO) as well as duration of contact are risk factors for CP-CRE acquisition among contacts. The role of cephalosporins requires further study.

Infect Control Hosp Epidemiol 2016;1–7

Hospitalized influenza patients are often treated with antibiotics empirically while awaiting final diagnosis. The goal of this study was to describe the inappropriate continuation of antibiotics for influenza respiratory tract infections (RTIs).

We retrospectively studied adults admitted to our institution over 2 respiratory flu seasons with positive influenza RTIs. Inappropriate antibiotic duration (IAD) was defined as antibiotic use for >24 hours after a positive influenza test in patients presenting with <72 hours of RTI symptoms and with no other indications of bacterial infection.

During the study period, 322 patients included in this study were admitted for influenza RTI. Respiratory cultures were ordered for 50 of these patients (15.5%) and 71 patients (22%) had a positive chest x-ray, but antibiotics were prescribed to 211 patients (65.5%) on admission. Antibiotics were inappropriately continued in 73 patients (34.5%). Patients receiving IAD had a longer length of stay (LOS) (median, 6 days; range, 4–9 days) compared with those whose antibiotics were discontinued appropriately (median, 5 days; range, 3–8 days) and those who were not treated with antibiotics (median, 4 days; range, 3–6 days; P<.001). However, mortality was similar among these 3 groups: 3 patients (4.1%) from the IAD cohort died; 6 patients (4.3%) from the group with an appropriate antibiotic duration died; and 2 patients [1.8%] from the group given no antibiotics died (P=.510). The 30-day readmission rates were similar as well: 9 patients (12.3%) from the IAD group were readmitted within 30 days; 21 patients (15.2%) from the group with appropriate antibiotic duration were readmitted; and 11 patients (9.9%) from the group given no antibiotics were readmitted (P=.455). Total hospital costs were greater in patients treated with IAD ($10,645; range, $6,485–$18,035) compared with the group treated with appropriate antibiotic duration ($7,479; range, $4,866–$12,922) and the group given no antibiotics $5,961 (range, $4,711–$9,575). Thus, the hospital experienced a median loss in net hospital revenue of $2,076 per IAD patient compared with a patient for which antibiotic duration was appropriate.

The majority of patients with influenza RTI received antibiotics on admission, and 34.5% were inappropriately continued on antibiotics without evidence of bacterial infection, which led to increased LOS, loss of net revenue, and no improvement in outcome. Thus, stewardship initiatives aimed at this population are warranted.

Infect Control Hosp Epidemiol 2016;37:583–589

Surgical site infections (SSIs) are common hospital-acquired infections. Tracking SSIs is important to monitor their incidence, and this process requires primary data collection. In this study, we derived and validated a method using health administrative data to predict the probability that a person who had surgery would develop an SSI within 30 days.

All patients enrolled in the National Surgical Quality Improvement Program (NSQIP) from 2 sites were linked to population-based administrative datasets in Ontario, Canada. We derived a multivariate model, stratified by surgical specialty, to determine the independent association of SSI status with patient and hospitalization covariates as well as physician claim codes. This SSI risk model was validated in 2 cohorts.

The derivation cohort included 5,359 patients with a 30-day SSI incidence of 6.0% (n=118). The SSI risk model predicted the probability that a person had an SSI based on 7 covariates: index hospitalization diagnostic score; physician claims score; emergency visit diagnostic score; operation duration; surgical service; and potential SSI codes. More than 90% of patients had predicted SSI risks lower than 10%. In the derivation group, model discrimination and calibration was excellent (C statistic, 0.912; Hosmer-Lemeshow [H-L] statistic, P=.47). In the 2 validation groups, performance decreased slightly (C statistics, 0.853 and 0.812; H-L statistics, 26.4 [P=.0009] and 8.0 [P=.42]), but low-risk patients were accurately identified.

Health administrative data can effectively identify postoperative patients with a very low risk of surgical site infection within 30 days of their procedure. Records of higher-risk patients can be reviewed to confirm SSI status.

Infect. Control Hosp. Epidemiol. 2016;37(4):455–465

To evaluate a computer-assisted point-prevalence survey (CAPPS) for hospital-acquired infections (HAIs).

Validation cohort.

A 754-bed teaching hospital in the Netherlands.

For the internal validation of a CAPPS for HAIs, 2,526 patients were included. All patient records were retrospectively reviewed in depth by 2 infection control practitioners (ICPs) to determine which patients had suffered an HAI. Preventie van Ziekenhuisinfecties door Surveillance (PREZIES) criteria were used. Following this internal validation, 13 consecutive CAPPS were performed in a prospective study from January to March 2013 to determine weekly, monthly, and quarterly HAI point prevalence. Finally, a CAPPS was externally validated by PREZIES (Rijksinstituut voor Volksgezondheid en Milieu [RIVM], Bilthoven, Netherlands). In all evaluations, discrepancies were resolved by consensus.

In our series of CAPPS, 83% of the patients were automatically excluded from detailed review by the ICP. The sensitivity of the method was 91%. The time spent per hospital-wide CAPPS was ~3 hours. External validation showed a negative predictive value of 99.1% for CAPPS.

CAPPS proved to be a sensitive, accurate, and efficient method to determine serial weekly point-prevalence HAI rates in our hospital.

Infect Control Hosp Epidemiol 2016;1–6

To improve hand hygiene (HH) compliance among physicians and nurses in a rural hospital in sub-Saharan Africa (SSA) using the World Health Organization’s (WHO’s) Guidelines on Hand Hygiene in Health Care.

This study was a quasi-experimental design divided into 4 phases: (1) preparation of materials and acquisition of the hospital administration’s support, (2) baseline evaluation, (3) intervention, and (4) follow-up evaluation.

A 160-bed, non-referral hospital in Gitwe, Rwanda

A total of 12 physicians and 54 nurses participated in this study.

The intervention consisted of introducing locally produced alcohol-based hand rub (ABHR); educating healthcare workers (HCWs) on proper HH practice; providing pocket-sized ABHR bottles for HCWs; placing HH reminders in the workplace; and surveying HCWs at surrounding health centers regarding HH compliance barriers. Hand hygiene infrastructure, compliance, and knowledge were assessed among physicians and nurses using baseline observations and a follow-up evaluation survey.

Overall, HH compliance improved from 34.1% at baseline to 68.9% post intervention (P<.001), and HH knowledge was significantly enhanced (P<.001). The 3 departments included in this study had only 1 sink for 29 patient rooms, and 100% of HH opportunities used ABHR. Hand hygiene compliance was significantly higher among physicians than nurses both before and after the intervention. All measures of HH compliance improved except for “after body fluid exposure,” which was 51.7% before intervention and 52.8% after intervention (P>.05).

Hand hygiene campaigns using WHO methods in SSA have been implemented exclusively in large, referral hospitals. This study shows that an HH program using the WHO tools successfully improved HH in a low-income, rural hospital in SSA.

Infect Control Hosp Epidemiol 2016;37:834–839