Since the publication of "A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals" in 2008, prevention of healthcare-associated infections (HAIs) has become a national priority. Despite improvements, preventable HAIs continue to occur. The 2014 updates to the Compendium were created to provide acute care hospitals with up-to-date, practical, expert guidance to assist in prioritizing and implementing their HAI prevention efforts. They are the product of a highly collaborative effort led by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise, including the Centers for Disease Control and Prevention (CDC), the Institute for Healthcare Improvement (IHI), the Pediatric Infectious Diseases Society (PIDS), the Society for Critical Care Medicine (SCCM), the Society for Hospital Medicine (SHM), and the Surgical Infection Society (SIS).
Background.Coronary artery bypass graft (CABG) and primary arthroplasty surgical site infection (SSI) rates are declining slower than other healthcare-associated infection rates. We examined antimicrobial prophylaxis (AMP) regimens used for these operations and compared their spectrum of activity against reported SSI pathogens.Methods.Pathogen distributions of CABG and hip/knee arthroplasty complex SSIs (deep and organ/space) reported to the National Healthcare Safety Network (NHSN) from 2006 through 2009 and AMP regimens (same procedures and time period) reported to the Surgical Care Improvement Project (SCIP) were analyzed. Regimens were categorized as standard (cefazolin or cefuroxime),β-lactam allergy (vancomycin or clindamycin with or without an aminoglycoside), and extended spectrum (vancomycin and/or an aminoglycoside with cefazolin or cefuroxime). AMP activity of each regimen was predicted on the basis of pathogen susceptibility reports and published spectra of antimicrobial activity.Results.There were 6,263 CABG and arthroplasty complex SSIs reported (680,489 procedures; 880 NHSN hospitals). Among 6,574 pathogens reported, methicillin-sensitiveStaphylococcus aureus(23%), methicillin-resistantS. aureus(18%), coagulase-negative staphylococci (17%), andEnterococcusspecies (7%) were most common. AMP regimens for 2,435,703 CABG and arthroplasty procedures from 3,330 SCIP hospitals were analyzed. The proportion of pathogens predictably susceptible to standard (used in 75% of procedures),β-lactam (12%), and extended-spectrum (8%) regimens was 41%–45%, 47%–96%, and 81%—96%, respectively.Conclusion.Standard AMP, used in three-quarters of CABG and primary arthroplasty procedures, has inadequate activity against more than half of SSI pathogens reported. Alternative strategies may be needed to prevent SSIs caused by pathogens resistant to standard AMP regimens.
The technology of intravenous catheter access ports has evolved from open ports covered by removable caps to more-sophisticated, closed versions containing mechanical valves. We report a significant increase in catheter-related bloodstream infections after the introduction of a new needle-free positive-pressure mechanical valve intravenous access port at our institution.
Objective.To determine the prevalence of the vaccine-preventable diseases caused by varicella, measles, rubella, and hepatitis A and B viruses in a multinational healthcare workforce.Design.Prospective cohort study.Setting.A 750-bed tertiary care center located in Riyadh, Saudi Arabia.Methods.In compliance with hospital policy, newly recruited healthcare workers (HCWs) were enrolled in the study from September 2001 to March 2005. Serum samples were collected from all HCWs during the initial hiring process and tested for IgG antibodies against each of the 5 viral agents. Nonimmune HCWs were subsequently vaccinated at the earliest opportunity.Results.A total of 4,006 newly hired (international and local) employees were included in the study. All underwent serologic testing for IgG antibodies against varicella, measles, rubella, hepatitis A, and hepatitis B viruses. Of the total, 63% were female and 37% were male. Middle Eastern employees comprised 47% of the total, followed by employees from the Far East (35%), the West (10%), and Africa (8%). Forty-two percent were nurses, 27% were in administration, 18% were medical technicians, and 13% were physicians. Among the 4,006 newly hired HCWs, 14% had negative IgG antibody test results for varicella virus, 13% for measles virus, 10% for rubella virus, 33% for hepatitis A virus, and 43% for hepatitis B virus. More women than men were susceptible to hepatitis A (40% vs. 24%; P< .001), whereas more men were susceptible to hepatitis B (55% vs. 35%; P< .001). Varicella susceptibility was more common among HCWs from the Far East (19%), whereas susceptibility to measles, rubella, hepatitis A, and hepatitis B was highest among HCWs from the Middle East. Both relative youth and male sex were associated with lack of antibodies against hepatitis B virus and rubella virus. In contrast, female sex and younger age were associated with lack of antibodies against hepatitis A virus (P< .001).Conclusion.Seroprevalence surveys of vaccine-preventable diseases among HCWs, although labor intensive, are invaluable in caring for a multinational workforce.
Agrobacterium isolates from intravenous catheters of three hospitalized patients were initially identified as A. tumefaciens, but inability to produce 3-ketolactose revealed that two of them were A. vitis. However, rDNA analysis correlated all of the isolates to A. tumefaciens. Pulsed-field gel electrophoresis analysis ascertained the nosocomial transmission of the infection.
OBJECTIVE:To investigate the clinical features and the epidemiology of Acinetobacter baumannii in Spanish hospitals. DESIGN:Prospective multicenter cohort study. SETTING:Twenty-seven general hospitals and one paraplegic center in Spain. METHODS:All cases of A. baumannii colonization or infection detected by clinical samples during November 2000 were included. Isolates were identified using phenotypic and genotypic methods. The molecular relatedness of the isolates was assessed by pulsed-field gel electrophoresis. RESULTS:Twenty-five (89%) of the hospitals had 221 cases (pooled rate in general hospitals, 0.39 case per 1,000 patient-days; range, 0 to 1.17). The rate was highest in intensive care units (ICUs). Only 3 cases were pediatric. The mean age of the patients in the general hospitals was 63 years; 69% had a chronic underlying disease and 80% had previously received antimicrobial treatment. Fifty-three percent of the patients had an infection (respiratory tract, 51%; surgical site, 16%; and urinary tract, 11%). Crude mortality was higher in infected than in colonized patients (27% vs 10%; relative risk, 1.56; 95% confidence interval, 1.2 to 2.0; P = .003). Molecular analysis disclosed 79 different clones. In most hospitals, a predominant epidemic clone coexisted with other sporadic clones. Imipenem resistance was present in 39% of the hospitals. CONCLUSIONS:A. baumannii was present in most participating Spanish hospitals (particularly in ICUs) with different rates among them. The organisms mainly affected predisposed patients; half of them were only colonized. Epidemic and sporadic clones coexisted in many centers.
Abstract Objectives: To identify risk factors for the respiratory acquisition of extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae among patients admitted to a neurosurgical intensive care unit (NSICU) and to modify them without changing general infection control measures. Design: Nested case-control and intervention study. Setting: A 1,200-bed, tertiary-care teaching hospital with a 17-bed NSICU. Methods: Sputa of all patients admitted to the NSICU were cultured weekly during the study. From October 2002 through February 2003, 29 case-patients from whose sputum ESBL-producing K. pneumoniae was isolated were detected and 59 controls-patients were randomly selected among patients without any positive isolate of ESBL-producing K. pneumoniae. After analyzing the risk factors, we intervened to modify them and compared the acquisition rate of ESBL-producing K. pneumoniae before (October 2002 to February 2003) and after (April to August 2003) the intervention. Results: Multivariate analysis showed that prior exposure to third-generation cephalosporins (TGCs) (OR, 6.0; CI95, 1.9 to 18.6; P= .002) was an independent risk factor of ESBL-producing K. pneumoniae acquisition. The neurosurgical team was notified of the result, and the infectious diseases specialist visited the NSICU three times a week to regulate TGC use during the intervention period. Patients admitted before the intervention were older than patients admitted after. The respiratory acquisition of ESBL-producing K. pneumoniae per 1,000 patient-days (13.5 [CI95, 8.9 to 18.1] vs 2.7 [CI95, 0.9 to 4.6]) and the antimicrobial use density of TGCs (38.2 ± 5.0 vs 17.3 ± 2.6; P < .001) decreased significantly after the intervention. Conclusion: Prior exposure to TGCs was an independent risk factor for the respiratory acquisition of ESBL-producing K. pneumoniae, and less use of TGCs was associated with a decrease in acquisition.
BACKGROUND: Nosocomial infections due to medical devices are of increasing concern to infection control practitioners. Attempts to prevent such infections have included surveillance cultures of endoscopes and bronchoscopes. In July 2002, the infectious disease consultation service was asked to see three patients with sepsis due to multidrug-resistant Pseudomonas aeruginosa after endoscopic retrograde cholangiopancreatography (ERCP).OBJECTIVE: To describe an outbreak of multidrug-resistant P aeruginosa sepsis after ERCP at an institution that performs routine surveillance cultures of endoscopes.DESIGN: A traditional outbreak investigation supplemented by pulsed-field gel electrophoresis (PFGE) was undertaken, including a case-control analysis based on the hypothesis that all infected individuals had their ERCP performed with the same endoscope.SETTING: A tertiary-care academic medical center.RESULTS: The case-control analysis confirmed the hypothesis that undergoing ERCP with the implicated endoscope was associated with a culture positive for Pseudomonas (P = .01). The available strains were identical by PFGE. This outbreak occurred despite a negative surveillance culture of the implicated endoscope 1 month earlier.CONCLUSIONS: Infectious morbidity can occur after endoscopy despite negative surveillance cultures. The practice of routine endoscope cultures does not prevent device-related infectious morbidity
OBJECTIVE:To evaluate the usefulness of screening cultures in the control of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae in intensive care units (ICUs).DESIGN:A 4-year retrospective study.SETTING:Two adult ICUs of a university-affiliated public hospital in France.RESULTS:A total of 7,777 specimens were analyzed and 28 (0.97%) of 2,883 screened patients had a positive result on a screening test, among the 3,678 admitted patients. Thirteen of these 28 patients were only carriers; 4 were carriers and then were colonized or infected 2, 2, 3, and 8 days later, respectively; and 11 were colonized or infected before a screening test was positive. Cluster analysis showed that the occurrence of ESBL-producing Enterobacteriaceae cross-transmission within both ICUs was limited to 9 cases. Thus, most cases (19 of 28) were probably imported. Surveillance cultures failed to detect 9 of the 19 cases.CONCLUSION:The low prevalence of ESBL-producing Enterobacteriaceae carriers on admission (0.45%) and the relative ineffectiveness of our screening test to detect imported cases suggest that systematic detection of ESBL-producing Enterobacteriaceae in ICU patients is not cost-effective and that the use of clinical cultures may be sufficient to control ESBL-producing Enterobacteriaceae in non-epidemic situations.
Abstract Objective: To describe the epidemiology of endemic multidrug-resistant Pseudomonas aeruginosa colonizations and infections in critically ill patients. Design: Prospective study on bacterial strain typing and retrospective cohort study of charts of patients in the intensive care unit (ICU). Patients: Fifty-three patients with P. aeruginosa isolated from clinical cultures in 2001 were selected, divided into those with P. aeruginosa in vitro resistant to at least two classes of antibiotics (multidrug-resistant, n = 18) and those susceptible to all or resistant to only one antibiotic (susceptible, n = 35). Results: Risk factors for multidrug-resistant P. aeruginosa included maxillary sinusitis, long-dwelling central venous catheters, prolonged use of certain antibiotics, a high lung injury score, and prolonged mechanical ventilation and duration of stay. The frequency of colonization (approximately 50%) versus infection (ie, ventilator-associated pneumonia) did not differ between the groups. On amplified fragment-length polymorphism analysis, 64% of the multidrug-resistant strains had been potentially transmitted via cross-colonization and 36% had probably originated endogenously. ICU mortality was 22% in the multidrug-resistant group and 23% in the susceptible group, although the duration of mechanical ventilation was longer in the former. Conclusions: Patients with sinusitis who stayed in the ICU longer, were ventilated longer because of acute lung injury, received antibiotics for longer durations, and had long-dwelling central venous catheters ran an elevated risk of acquiring multidrug-resistant P. aeruginosa. These patients did not have a higher mortality than patients with susceptible P. aeruginosa. Prevention of the emergence of multidrug-resistant strains requires changes in infection control measures and antibiotic policies in our ICU.
OBJECTIVE:To evaluate three different DNA techniques for typing nonfermentative gram-negative bacilli isolated from Latin American hospitals.DESIGN:One hundred twenty-six nonfermentative gram-negative bacilli were typed.PARTICIPANTS:Pseudomonas aeruginosa (n = 64) and Acinetobacter baumannii (n = 42) samples were obtained from blood cultures of patients admitted to 10 medical centers in Latin America during 1998 and Stenotrophomonas maltophilia (n = 20) samples were obtained from patients admitted to the Hospital São Paulo between 1999 and 2001.METHODS:All samples were typed using automated ribotyping, PFGE, and ERIC-PCR. The discriminatory power for each technique was calculated using Hunter's generalized formula.RESULTS:All strains could be typed by automated ribotyping and ERIC-PCR, but two strains (1.6%) were not typeable by PFGE. All three techniques showed 100% reproducibility. The time to obtain the results was shorter for automated ribotyping and ERIC-PCR compared with PFGE. Likewise, the costs for ERIC-PCR and PFGE were lower than those for automated ribotyping. The interpretation of results was more complicated and more difficult with ERIC-PCR than with both PFGE and automated ribotyping. All techniques presented excellent discriminatory power for P. aeruginosa (0.98). PFGE presented the highest discriminatory power (0.94) for A. baumannii, and both PFGE and ERIC-PCR showed higher discriminatory power (0.90 for both) than automated ribotyping (0.82) for S. maltophilia.CONCLUSIONS:PFGE showed the highest discriminatory power for typing these nonfermentative gram-negative bacilli. However, automated ribotyping and ERIC-PCR can provide results in a shorter time period with similar discriminatory power.
OBJECTIVE: To evaluate intrahospital and interhospital clonal dissemination of extended-spectrum beta-lactamase (ESBL)-producing strains of Klebsiella pneumoniae.SETTING: Eight tertiary-care university hospitals and 16 regional hospitals in Taiwan.METHODS: Two hundred eleven confirmed ESBL-producing isolates of K pneumoniae were collected from January 1998 to June 2000. The isolates were characterized by various typing methods, including antibiogram (9 antimicrobial agents), computer-based ribotyping, pulsed-field gel electrophoresis (PFGE), and isoelectric focusing of beta-lactamase.RESULTS: Ribotyping identified 70 distinct ribogroups among 200 isolates evaluated. Forty-three of these ribogroups were unique. Eleven ribogroups, comprising 115 isolates, were detected in more than one hospital (interhospital dissemination), whereas 16 groups (42 isolates) were detected in more than one patient within a hospital (intrahospital dissemination). The combination of ribotyping and PFGE identified two large epidemic clones, which were called 691.5/PFGE-G and 595.7/PFGE-A. These epidemic clones were detected mainly in the hospitals located in the northern and central regions of Taiwan. However, variation of the profiles of antibiograms and isoelectric focusing was apparent within each clone. In addition, isolates with the same isoelectric focusing profile (isoelectric points 7.9, 8.2, and 8.4) and antibiogram (resistance to 9 compounds evaluated) were present among different molecular-typed clones.CONCLUSIONS: Our results showed that clonal dissemination (both interhospital and intrahospital dissemination) is occurring in several regions of Taiwan. Rapid computer-based ribotyping associated with PFGE demonstrated multiple epidemic clones of ESBL-producing K pneumoniae in Taiwan. The combination of phenotypic and molecular methods has proved useful to characterize these epidemic clones.
AbstractObjective:To examine and quantify the temporal trends of nosocomial multidrug-resistant, gram-negative bacilli.Design:A 9-year surveillance study was conducted. Multidrug resistance was defined as resistance to 3 or more antimicrobial classes.Setting:Tertiary-care institution.Results:From 1994 to 2002, multidrug-resistant, gram-negative bacilli increased from 1% to 16% for multidrug-resistant Pseudomonas aeruginosa, 4% to 13% for multidrug-resistant Enterobacter species, 0.5% to 17% for multidrug-resistant Klebsiella species, 0% to 9% for multidrug-resistant Proteus species, and 0.2% to 4% for multidrug-resistant Escherichia coli (P ≤ .05). The most common pattern of multidrug resistance was co-resistance to quinolones, third-generation cephalosporins, and aminoglycosides.Conclusion:The rapid rise of multidrug-resistant, gram-negative bacilli may warrant infection control programs to include these pathogens in strategies aimed at limiting the emergence and spread of antimicrobial-resistant pathogens.
OBJECTIVES:To investigate environmental contamination by extended-spectrum beta-lactamase-producing Enterobacteriaceae and to perform a comparative molecular analysis of clinical and environmental strains.SETTING:A 17-bed cardiac surgery intensive care unit of a 480-bed university teaching hospital.METHODS:Following an outbreak of extended-spectrum beta-lactamase-producing Enterobacteriaceae, an environmental survey revealed extensive contamination of the environment (particularly faucets, sink drains, and the joints of the countertops) by extended-spectrum beta-lactamase-producing Enterobacteriaceae. Environmental strains were compared with clinical strains by pulsed-field gel electrophoresis and randomly amplified polymorphic DNA.RESULTS:A total of 62 environmental strains belonging to 4 species of extended-spectrum beta-lactamase-producing Enterobacteriaceae were analyzed and compared with 43 clinical strains obtained from 34 patients. Comparative molecular analysis revealed 4 identical or closely related patterns (3 from Klebsiella oxytoca and 1 from Enterobacter cloacae) between environmental and clinical strains.CONCLUSIONS:Moist surfaces may serve as sources of multiply resistant Enterobacteriaceae in the intensive care unit. Identification and disinfection of such sources may therefore be helpful in prevention and control of outbreaks.
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This issue of Infection Control and Hospital Epidemiology contains multiple articles focusing on the clinical and public health implications of infections by extended-spectrum beta-lactamase (ESBL)–producing Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter baumannii and their resistance profiles to commonly prescribed antimicrobials. The first five articles in this issue1-5 add to a growing body of literature that substantiates the following: (1) as in North America, gramnegative pathogens are important causes of hospitalacquired infections in Europe and Asia; (2) antimicrobial resistance among gram-negative pathogens is a global problem; (3) the pathogens encountered in healthcare institutions in North America, Europe, and Asia are, for the most part, similar; (4) the risk factors (eg, device use or antimicrobial overprescribing) associated with hospitalacquired infections and antimicrobial resistance are universal; (5) surveillance activities are important for the characterization and control of gram-negative, healthcareassociated infections in Europe and Asia and require appropriate integration of epidemiologic, microbiologic, and clinical data; and (6) the microbiology laboratory is important in the characterization and control of healthcare-associated infections and antimicrobial resistance. In the first article in this issue of Infection Control and Hospital Epidemiology, Yu et al. used a combination of phenotypic and molecular typing methods to demonstrate clonal dissemination of ESBL-producing Klebsiella pneumoniae in 24 hospitals located in several regions of Taiwan.1 Using a combination of ribotyping and pulsed-field gel electrophoresis (PFGE), they identified two epidemic clones in hospitals located in the northern and central regions of the country. Within each clone, however, there were variations in the antibiogram and isoelectric focusing profiles of isolates. Their findings suggest significant intrahospital and interhospital clonal transmission of ESBL-producing K. pneumoniae and confirm the ubiquity of this resistant pathogen in major teaching hospitals in all regions of Taiwan. They provide evidence that interinstitutional transmission of ESBL-producing K. pneumoniae parallels the movement of mobile patient populations. Previously, Monnet et al. used molecular typing to demonstrate interhospital transmission of ESBL-producing Klebsiella species in one region of the United States, and concluded that physical proximity of hospitals might facilitate interhospital transmission of ESBL-producing K. pneumoniae.6 More recently, the results of a case–control study at a district teaching hospital in Taiwan identified ceftazidime use as an independent risk factor associated with acquisition of ESBL-producing K. pneumoniae.7 The findings of Yu et al. are consistent with those of a 2004 report of nationwide surveillance data on antimicrobial resistance among gram-negative pathogens in 21 Taiwanese medical centers—gramnegative bacterial resistance is prevalent in medical centers and regional hospitals throughout Taiwan.8 In the second article in this issue of Infection Control and Hospital Epidemiology, Rodriguez-Bano et al. report the results of a multicenter study conducted to characterize the clinical features and molecular epidemiology of A. baumannii infections in 28 hospitals in Spain that together served a catchment area containing approximately 25% of the Spanish population.2 During November 2000, every new patient with A. baumannii infection or colonization was included in the study: all isolates were typed first using phenotypic methods and then using genotyping with PFGE. Twenty-five (89%) of the 28 participating hospitals
We describe intrinsic contamination with Klebsiella pneumoniae occurring during the manufacture of germicidal hand soap, labeled as containing 2% chlorhexidine, used throughout a 350-bed community medical center. A 3-year retrospective study failed to find evidence of increased incidence of clinical isolates of this strain.
OBJECTIVES:To evaluate the emergence of resistance of Pseudomonas aeruginosa and Acinetobacter species to imipenem, ciprofloxacin, or both after the use of these drugs and to compare resistant with susceptible isolates by molecular typing.DESIGN:Cohort study.SETTING:Burn intensive care unit (ICU) with 4 beds in a tertiary-care university hospital.METHODS:During 16 months, surveillance cultures were performed for all patients admitted to the ICU. Demographic information was obtained for each patient. Molecular typing was done by pulsed-field gel electrophoresis using restriction enzymes for 71 isolates of P. aeruginosa and Acinetobacter species.RESULTS:Thirty-four patients were admitted and 22 were colonized by susceptible P. aeruginosa or Acinetobacter species before they used the antimicrobials. Nine (41%) of these patients had a resistant isolate after antimicrobial use: 5 had used imipenem alone, 1 had used ciprofloxacin, and 3 had used both drugs. The interval between isolation of the susceptible and resistant isolates ranged from 4 to 25 days, but was 10 or more days for 6 patients. Molecular typing revealed that susceptible and resistant isolates from each patient were different and that although there were no predominant clones among susceptible isolates, there was a predominant clone among resistant isolates of P. aeruginosa and of Acinetobacter.CONCLUSIONS:Resistance was not due to the acquisition of resistance mechanisms by a previously susceptible strain, but rather to cross-transmission. Although various measures involving antimicrobial use have received great attention, it would seem that practices to prevent cross-transmission are more important in controlling resistance.
An abstract is not available for this content so a preview has been provided. As you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
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