Multidisciplinary antimicrobial utilization teams (AUTs) have been proposed as a mechanism for improving antimicrobial use, but data on their efficacy remain limited.

To determine the impact of an AUT on antimicrobial use at a teaching hospital.

Randomized controlled intervention trial.

A 953-bed, public, university-affiliated, urban teaching hospital.

Patients who were given selected antimicrobial agents (piperacillin-tazobactam, levofloxacin, or vancomycin) by internal medicine ward teams.

Twelve internal medicine teams were randomly assigned monthly: 6 teams to an intervention group (academic detailing by the AUT) and 6 teams to a control group that was given indication-based guidelines for prescription of broad-spectrum antimicrobials (standard of care), during a 10-month study period.

Proportion of appropriate empirical, definitive (therapeutic), and end (overall) antimicrobial usage.

A total of 784 new prescriptions of piperacillin-tazobactam, levofloxacin, and vancomycin were reviewed. The proportion of antimicrobial prescriptions written by the intervention teams that was considered to be appropriate was significantly higher than the proportion of antimicrobial prescriptions written by the control teams that was considered to be appropriate: 82% versus 73% for empirical (risk ratio [RR], 1.14; 95% confidence interval [CI], 1.04-1.24), 82% versus 43% for definitive (RR, 1.89; 95% CI, 1.53-2.33), and 94% versus 70% for end antimicrobial usage (RR, 1.34; 95% CI, 1.25-1.43). In multivariate analysis, teams that received feedback from the AUT alone (adjusted RR, 1.37; 95% CI, 1.27-1.48) or from both the AUT and the infectious diseases consultation service (adjusted RR, 2.28; 95% CI, 1.64-3.19) were significantiy more likely to prescribe end antimicrobial usage appropriately, compared with control teams.

A multidisciplinary AUT that provides feedback to prescribing physicians was an effective method in improving antimicrobial use.

ClinicalTrials.gov identifier: NCT00552838.

To evaluate common hand hygiene methods for efficacy in removing Clostridium difficik.

Randomized crossover comparison among 10 volunteers with hands experimentally contaminated by nontoxigenic C. difficile.

Interventions included warm water with plain soap, cold water with plain soap, warm water with antibacterial soap, antiseptic hand wipes, alcohol-based handrub, and a control involving no Intervention. All interventions were evaluated for mean reduction in colony-forming units (CFUs) under 2 contamination protocols: “whole hand” and “palmar surface.” Results were analyzed according to a Bayesian approach, by using hierarchical models adjusted for multiple observations.

Under the whole-hand protocol, the greatest adjusted mean reductions were achieved by warm water with plain soap (2.14 log10 CFU/mL [95% credible interval (Cri), 1.74-2.54 log10 CFU/mL]), cold water with plain soap (1.88 log10 CFU/mL [95% Cri, 1.48-2.28 log10 CFU/mL), and warm water with antibacterial soap (1.51 log10 CFU/mL [95% Cri, 1.12-1.91 logu, CFU/mL]), followed by antiseptic hand wipes (0.57 log10 CFU/mL [95% Cri, 0.17-0.96 log10 CFU/mL]). Alcohol-based handrub (0.06 log10 CFU/mL [95% CrI, -0.34 to 0.45 log10 CFU/mL]) was equivalent to no Intervention. Under the palmar surface protocol, warm water with plain soap, cold water with plain soap, and warm water with antibacterial soap again yielded the greatest mean reductions, followed by antiseptic hand wipes (26.6, 26.6, 26.6, and 21.9 CFUs per plate, respectively), when compared with alcohol-based handrub. Hypothenar (odds ratio, 10.98 [95% Cri, 1.96-37.65]) and thenar (odds ratio, 6.99 [95% Cri, 1.25-23.41]) surfaces were more likely than fingertips to remain heavily contaminated after handwashing.

Handwashing with soap and water showed the greatest efficacy in removing C. difficile and should be performed preferentially over the use of alcohol-based handrubs when contact with C. difficile is suspected or likely.

TO apply interim surveillance definitions of Clostridium difficile infection (CDI) cases to 1 year of data from the provincewide surveillance system of Manitoba, Canada, to determine the epidemiology of CDI incident cases in a population.

CDI cases were categorized with interim surveillance definitions developed by an ad hoc C. difficile surveillance working group. Incident cases recorded in the provincial CDI database between July 2005 and June 2006 were linked to the provincial hospitalization and nursing home databases and analyzed.

One thousand six incident cases were identified over 1 year. Five hundred fifteen (51%) cases were associated with and began in a healthcare facility (HCF), whereas 275 (27%) were associated with and began in the community. An additional 131 (13%) cases were HCF associated but began in the community, while 85 (8%) were of indeterminate origin. Cases of HCF-associated CDI occurred in patients who were older than did cases of community-associated CDI (P < .0001). The provincial rate of community-onset cases was 23.4 per 100,000 person-years, and rates varied among geographic areas. HCF-associated CDI rates among the 10 largest hospitals varied from 0.5 to 8.4 per 10,000 patient-days. The time to CDI onset after hospital admission indicated that 25% of nosocomial cases began by the 8th day, and 50% began by the 17th day.

Although the majority of CDI cases were associated with exposure to a HCF, 40% of incident CDI began in the community. Populations with HCF- and community-associated CDI demonstrated significantly different age distributions. The wide variation of rates among HCFs requires explanation. The high percentage of incident cases in the community warrants increased study.

To evaluate the effectiveness of the oral application of a 0.12% solution of Chlorhexidine for prevention of respiratory tract infections among intensive care unit (ICU) patients.

The study design was a double-blind, randomized, placebo-controlled trial.

The study was performed in an ICU in a tertiary care hospital at a public university.

Study participants comprised 194 patients admitted to the ICU with a prospective length of stay greater than 48 hours, randomized into 2 groups: those who received Chlorhexidine (n = 98) and those who received a placebo (n = 96).

Oral rinses with Chlorhexidine or a placebo were performed 3 times a day throughout the duration of the patient's stay in the ICU. Clinical data were collected prospectively.

Both groups displayed similar baseline clinical features. The overall incidence of respiratory tract infections (RR, 1.0 [95% confidence interval [CI], 0.63-1.60]) and the rates of ventilator-associated pneumonia per 1,000 ventilator-days were similar in both experimental and control groups (22.6 vs 22.3; P = .95). Respiratory tract infection-free survival time (7.8 vs 6.9 days; P = .61), duration of mechanical ventilation (11.1 vs 11.0 days; P = .61), and length of stay (9.7 vs 10.4 days; P = .67) did not differ between the Chlorhexidine and placebo groups. However, patients in the Chlorhexidine group exhibited a larger interval between ICU admission and onset of the first respiratory tract infection (11.3 vs 7.6 days; P = .05). The chances of surviving the ICU stay were similar (RR, 1.08 [95% CI, 0.72-1.63]).

Oral application of a 0.12% solution of Chlorhexidine does not prevent respiratory tract infections among ICU patients, although it may retard their onset.

Controlled studies that took place in medical intensive care units (MICUs) have demonstrated that bathing patients with Chlorhexidine gluconate (CHG) can reduce skin colonization with potential pathogens and can lessen the risk of central venous catheter (CVC)-associated bloodstream infection (BSI).

TO examine, without oversight of practice by research study staff, the effectiveness or real-world effect of patient cleansing with CHG on rates of CVC-associated BSI.

In the fall of 2005, the MICU at Rush University Medical Center discontinued bathing patients daily with soap and water and substituted skin cleansing with no-rinse, 2% CHG-impregnated cloths. This change was a clinical management decision without research input.

A 21-bed MICU at Rush University Medical Center.

Patients hospitalized in the MICU during the period from September 2004 through October 2006.

In a pre-post study design, we gathered data from administrative and laboratory databases, infection control practitioner logs, and patient medical charts to compare rates of CVC-associated BSI and blood culture contamination between the baseline soap-and-water bathing period (September 2004-October 2005) and the CHG bathing period (November 2005-October 2006). Rates of secondary BSI, Clostridium difficile infection (CDI), ventilator-associated pneumonia (VAP), and urinary tract infection (UTI) served as control variables that were not expected to be affected by CHG bathing.

Bathing with CHG was associated with a statistically significant decrease in the rate of CVC-associated BSI (from 5.31 to 0.69 cases per 1,000 CVC-days; P = .006) and in the rate of blood culture contamination (from 6.99 to 4.1 cases per 1,000 patient-days; P = .04). Rates of secondary BSI, CDI, VAP, and UTI did not change significantly.

In our analysis of real-world practice, daily bathing of MICU patients with CHG was effective at reducing rates of CVC-associated BSI and blood culture contamination. Controlled studies are needed to determine whether these beneficial effects extend outside the MICU.

To compare the effects of different skin preparation solutions on surgical-site infection rates.

Three skin preparations were compared by means of a sequential implementation Design. Each agent was adopted as the preferred modality for a 6-month period for all general surgery cases. Period 1 used a povidone-iodine scrub-paint combination (Betadine) with an isopropyl alcohol application between these steps, period 2 used 2% Chlorhexidine and 70% isopropyl alcohol (ChloraPrep), and period 3 used iodine povacrylex in isopropyl alcohol (DuraPrep). Surgical-site infections were tracked for 30 days as part of ongoing data collection for the National Surgical Quality Improvement Project initiative. The primary outcome was the overall rate of surgical-site infection by 6-month period performed in an intent-to-treat manner.

Single large academic medical center.

All adult general surgery patients.

The study comprised 3,209 operations. The lowest infection rate was seen in period 3, with iodine povacrylex in isopropyl alcohol as the preferred preparation method (3.9%, compared with 6.4% for period 1 and 7.1% for period 2; P = .002). In subgroup analysis, no difference in outcomes was seen between patients prepared with povidone-iodine scrub-paint and those prepared with iodine povacrylex in isopropyl alcohol, but patients in both these groups had significantly lower surgical-site infection rates, compared with rates for patients prepared with 2% Chlorhexidine and 70% isopropyl alcohol (4.8% vs 8.2%; P = .001).

Skin preparation solution is an important factor in the prevention of surgical-site infections. Iodophor-based compounds may be superior to Chlorhexidine for this purpose in general surgery patients.

To determine the attributable (direct) mortality and morbidity caused by carbapenem-resistant Klebsiella pneumoniae bacteremia.

A matched retrospective, historical cohort design, using a stepwise procedure to stringendy match the best control subjects to the best case subjects.

A 1,000-bed tertiary-care university teaching hospital.

Case subjects were defined as adult patients with carbapenem-resistant K. pneumoniae bacteremia during the period from October 2005 through October 2008. Control subjects were defined as patients who were very similar to case subjects except that they did not have bacteremia.

Matching potential control subjects to case subjects was performed at a 1:1 ratio using a computerized record system. The criteria used included same hospitalization period, similar Charlson comorbidity index, same underlying disease, same age within 10 years, and same sex. Demographic and clinical characteristics were collected from medical records.

During the study period, 319 patients developed an infection due to carbapenem-resistant K. pneumoniae. Of these 319 patients, 39 (12.2%) developed a bloodstream infection, for an overall rate of 0.59 episodes of carbapenem-resistant K. pneumoniae bacteremia per 10,000 patient-days. We excluded 7 patients from our study, leaving a total of 32 case subjects in our cohort. Case subjects were significandy more likely than control subjects (n = 32) to require care in an intensive care unit (12 case subjects [37.5%] vs 3 control subjects [9.4%]), ventilator support (17 case subjects [53.1%] vs 8 control subjects [25%]), and use of a central venous catheter (19 case subjects [59.4%] vs 9 control subjects [28.1%]). For case subjects, the crude mortality rate was 71.9% (ie, 23 of the 32 case subjects died); for control subjects, the crude mortality rate was 21.9% (ie, 7 of the 32 control subjects died) (P < .001. For case subjects, the attributable mortality was 50% (95% confidence interval [CI], 15.3%-98.6%). A mortality risk ratio of 3.3 (95% CI, 2.9-28.5) was found for case subjects with carbapenem-resistant K. pneumoniae bacteremia.

Patients with carbapenem-resistant K. pneumoniae require more intensive and invasive care. We have shown that the crude and attributable mortality rates associated with carbapenem-resistant K. pneumoniae bacteremia were striking.

TO evaluate the effectiveness of a rigorous search and destroy policy for controlling methicillin-resistant Staphylococcus aureus (MRSA) infection or colonization.

Hospital-based observational follow-up study.

Erasmus University Medical Center Rotterdam, a 1,200-bed tertiary care center in Rotterdam, the Netherlands.

Outbreak control was accomplished by the use of active surveillance cultures for persons at risk, by the preemptive isolation of patients at risk, and by the strict isolation of known MRSA carriers and the eradication of MRSA carriage. For unexpected cases of MRSA colonization or infection, patients placed in strict isolation or contact isolation and healthcare workers (HCWs) were screened. We collected data from 2000–2004.

During the 5-year study period, 51,907 MRSA screening cultures were performed for 21,598 persons at risk (8,403 patients and 13,195 HCWs). By screening, it was determined that 123 (1.5%) of 8,403 patients and 31 (0.2%) of 13,195 HCWs were MRSA carriers. From the performance of clinical cultures, it was determined that 54 additional patients were MRSA carriers, resulting in a total of 177 patients carrying MRSA. Of the 177 patients carrying MRSA, 144 (81%) were primary patients, and 33 (19%) secondary Patients. The average number of nosocomial transmissions was 6.7 per year. The cumulative incidence of MRSA colonization among this group of patients was 0.10 cases per 100 admissions. Of 156 cases of MRSA colonization, 44 (28%) were acquired in a foreign healthcare institution, and 45 (29%) were acquired in other Dutch hospitals, 22 (47%) of which were acquired in a single hospital in our region. There were 16 cases (10%) that occurred in a nursing home and another 16 cases (10%) that fulfilled our definition of community-acquired MRSA colonization; there were 4 cases (3%) categorized as “other” and 31 cases (20%) for which the source of MRSA acquisition remained unknown. The basic reproduction rate was 10-fold less for patients isolated on admission, compared with those who were not. During the 5-year study period, 5 episodes of MRSA bacteremia occurred in which 4 patients died, an incidence rate of 0.28 cases of infection per 100,000 patient-days per year.

Our results show that, during a rigorous search and destroy policy, a low incidence of MRSA in our medical center was continuously observed and that this policy most likely contributed to a very low nosocomial transmission rate.

Few data are available on methicillin-resistant Staphylococcus aureus (MRSA) colonization in day care. We performed a study in a medical university child care center to study the epidemiology of MRSA in this population.

Survey.

A child care center on the campus of a university medical center.

One hundred four children who attended the child care center and 32 employees gave samples that were cultured for MRSA. Seventeen household members of the children and employee found to be colonized with MRSA also gave samples that were cultured. Parents and employees completed questionnaires about demographic characteristics, medical conditions and treatments, and possible exposure risks outside the child care center. In addition, 195 environmental samples were taken from sites at the childcare center. Isolates were analyzed for relatedness by use of molecular typing, and statistical analysis was performed.

The prevalence of MRSA in the children was 6.7%. One employee (3.1%) was colonized with MRSA. Cultures of samples given by 6 of 17 (35.3%) family members of these children and the employee yielded MRSA. MRSA was recovered from 4 of 195 environmental samples. Molecular typing revealed that many of the MRSA isolates were indistinguishable, and 18 of the 21 isolates were community-associated MRSA. Multivariable analysis revealed that receipt of macrolide antibiotics (P = .002; odds ratio, 39.6 [95% confidence interval, 3.4—651.4]) and receipt of asthma medications (P = .024; odds ratio, 26.9 [95% confidence interval, 1.5-500.7]) were related to MRSA colonization.

There was a low prevalence of MRSA colonization in children and employees in the child care center but a higher prevalence of colonization in their families. Molecular typing showed that transmission of MRSA likely occurred in the child care center. The use of macrolide antibiotics and asthma medications may increase the risk of MRSA colonization in this population.

To investigate whether the reduction effect due to participation in a nosocomial infection surveillance system for laboratory-confirmed central venous catheter (CVC)-associated primary bloodstream infection (BSI), ventilator-associated pneumonia (VAP), and surgical site infection (SSI) is reproducible for different time periods, independent of confounding factors that might occur during a specific time period.

Data from the German national nosocomial infection surveillance system from the period January 1997 through June 2008 were used. CVC-associated BSI data and SSI data were analyzed for 3 starting periods, and VAP data were analyzed for 2 starting periods. Monthly infection rates were calculated for the following 36 months, and relative risks comparing the first and third surveillance years of each period were calculated.

A total of 2,399 CVC-associated BSI cases from 267 intensive care units, 3,637 VAP cases from 150 intensive care units, and 829 SSIs following 3 different procedures from 113 departments were analyzed. A significant reduction in VAP was shown for both starting periods investigated (overall relative risk [RR], 0.80 [95% CI, 0.74-0.86]). A significant reduction in CVC-associated BSI was demonstrated for 2 of 3 starting periods (overall RR, 0.83 [95% CI, 0.75-0.91]). A significant reduction in SSI was found for 2 starting periods for knee prosthesis insertion (overall RR, 0.56 [95% CI, 0.38-0.82]), for all of the 3 starting periods for cesarean delivery (overall RR, 0.75 [95% CI, 0.61-0.93]), and for none of the 3 starting periods for endoscopically performed cholecystectomy (overall RR, 0.89 [95% CI, 0.62-1.27]).

The surveillance effect, manifest as a significant reduction of nosocomial infection rates between the first and third years of participation in a surveillance system, was observed independently from the calendar year in which the surveillance activities started.

Hepatitis C virus (HCV) transmission occurs in 0.2%-10% of people after accidental needlestick exposures. However, postexposure prophylaxis is not currently recommended. We sought to determine the safety, tolerability, and acceptance of postexposure prophylaxis with peginterferon alfa-2b in healthcare workers (HCWs) exposed to blood from HCV-infected patients.

Open-label pilot trial of peginterferon alfa-2b for HCV postexposure prophylaxis.

TWO academic tertiary-referral centers.

HCWs exposed to blood from HCV-infected patients were informed of the availability of postexposure prophylaxis. Persons who elected postexposure prophylaxis were given weekly doses of peginterferon alfa-2b for 4 weeks.

Among 2,702 HCWs identified with potential exposures to bloodborne pathogens, 213 (7.9%) were exposed to an HCV antibody-positive source. Of 51 HCWs who enrolled in the study, 44 (86%) elected to undergo postexposure prophylaxis (treated group). Seven subjects elected not to undergo postexposure prophylaxis (untreated group). No cases of HCV transmission were observed in either the treated or untreated group, and no cases occurred in the remaining 162 HCWs who did not enroll in this study. No serious adverse events related to a peginterferon alfa-2b regimen were recorded, but minor adverse events were frequent.

In this pilot study, there was a lower than expected frequency of HCV transmission after accidental occupational exposure. Although peginterferon alfa-2b was safe, because of the lack of HCV transmission in either the treated or untreated groups there is little evidence to support routine postexposure prophylaxis against HCV in HCWs.

Medical and nursing students (hereafter referred to as “healthcare students”) are at risk of contracting and transmitting infectious diseases in a hospital Setting. The aim of our study was to evaluate the vaccination history of healthcare students and their serologic immunity against vaccine-preventable diseases.

Prospective cohort study.

A tertiary care children's hospital in Athens, Greece, which is affiliated with the University of Athens.

Healthcare students were recruited during April through November 2007. The information obtained from these students during personal interviews included demographics and whether there was a history of varicella, measles, mumps, rubella, and/or hepatitis A or B virus infection. Vaccination history and documentation of disease were abstracted from available medical records. Serum antibodies against the above-mentioned viral agents were determined by use of an enzyme-linked immunosorbent assay. Seronegative students and those with immunization gaps were referred to local vaccination clinics, and compliance was assessed 3 months later.

A total of 187 healthcare students were recruited, 131 (70.1%) of whom provided complete documentation of vaccination history. Adequate immunity against diphtheria and tetanus was documented for 55 (37.2%) and 73 (49.3%) of the 148 participants, respectively, whereas age-appropriate vaccination against pertussis, diphtheria, tetanus, and poliomyelitis was noted for 138 (93.2%), 147 (99.3%), 147 (99.3%), and 147 (99.3%) healthcare students, respectively. Of 185 healthcare students, 171 (92.4%) were immune to varicella. Of 182 healthcare students, 179 (98.4%) were immune to measles, 163 (89.6%) were immune to mumps, and 176 (96.7%) were immune to rubella. Of 179 healthcare students, 151 (84.4%) were immune to hepatitis B virus. Of 178 healthcare students, 26 (14.6%) were immune to hepatitis A virus. Antibodies (10 IU/L or higher) to hepatitis B surface antigen were detected for 151 (84.4%) of 179 healthcare students, and antibodies (10 IU/L or higher) to hepatitis A virus were detected for 26 (14.6%) of 178 healthcare students. Fewer than 30% of participants were in full compliance with recommended vaccinations.

We have determined that there is a certain proportion of healthcare students who are susceptible to certain vaccine-preventable diseases. The development of an appropriate vaccination strategy is required to decrease the risk of transmission in a hospital setting.