The purpose of this document is to highlight practical recommendations to assist acute-care hospitals in prioritization and implementation of strategies to prevent healthcare-associated infections through hand hygiene. This document updates the Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals through Hand Hygiene, published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the Association for Professionals in Infection Control and Epidemiology, the American Hospital Association, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

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Objective Obstructive eustachian tube dysfunction (OETD) affects up to 5% of adults; however, available treatment strategies have limitations. It was previously reported that balloon dilation of the eustachian tube (BDET) with the eustachian tube balloon catheter + medical management (MM) results in a significantly higher proportion of subjects with normalized tympanograms versus MM alone at 6- and 24-week follow-up. The current analysis extends these initial findings by investigating the durability of BDET + MM treatment outcomes through 52 weeks. Study Design Prospective cohort follow-up study from the treatment group in a previously reported multicenter randomized controlled trial. Setting Twenty-one investigational sites across the United States. Subjects and Methods Here we report on secondary and exploratory endpoints for patients with OETD who previously failed MM and were randomized to the BDET + MM cohort. Analyses of tympanogram outcomes are reported by ear, unless specified otherwise, as a more accurate measure of durability of the procedure over time. Results Among subjects randomized to BDET + MM, the overall number with normalized tympanograms and ETDQ-7 scores (Eustachian Tube Dysfunction Questionnaire-7) remained comparable to those reported at 6- versus 52-week follow-up: tympanograms, 73 of 143 (51.0%) versus 71 of 128 (55.5%); ETDQ-7, 79 of 142 (55.6%) versus 71 of 124 (57.3%). The overall number of ears with normalized tympanograms also remained comparable, with 117 of 204 (57%) versus 119 of 187 (63.6%). Conclusions The present study suggests that the beneficial effects of BDET + MM on tympanogram normalization and symptoms of subjects with refractory OETD demonstrate significant durability that is clinically relevant through 52 weeks.

Objectives/HypothesisTo assess balloon dilation of the Eustachian tube with Eustachian tube balloon catheter in conjunction with medical management as treatment for Eustachian tube dilatory dysfunction.Study DesignIn this prospective, multicenter, randomized, controlled trial, we assigned, in a 2:1 ratio, patients age 22 years and older with Eustachian tube dilatory dysfunction refractory to medical therapy to undergo balloon dilation of the Eustachian tube with balloon catheter in conjunction with medical management or medical management alone.MethodsThe primary endpoint was normalization of tympanogram at 6 weeks. Additional endpoints were normalization of Eustachian Tube Dysfunction Questionaire‐7 symptom scores, positive Valsalva maneuver, mucosal inflammation, and safety.ResultsPrimary efficacy results demonstrated superiority of balloon dilation of the Eustachian tube with balloon catheter + medical management compared to medical management alone. Tympanogram normalization at 6‐week follow‐up was observed in 51.8% (72/139) of investigational patients versus 13.9% (10/72) of controls (P < .0001). Tympanogram normalization in the treatment group was 62.2% after 24 weeks. Normalization of Eustachian Tube Dysfunction Questionaire‐7 Symptom scores at 6‐week follow‐up was observed in 56.2% (77/137) of investigational patients versus 8.5% (6/71) controls (P < .001). The investigational group also demonstrated substantial improvement in both mucosal inflammation and Valsalva maneuver at 6‐week follow‐up compared to controls. No device‐ or procedure‐related serious adverse events were reported for those who underwent balloon dilation of the Eustachian tube.ConclusionsThis study demonstrated superiority of balloon dilation of the Eustachian tube with balloon catheter + medical management compared to medical management alone to treat Eustachian tube dilatory dysfunction in adults.Level of Evidence1b. Laryngoscope, 128:1200–1206, 2018

Reports of health care--associated viral hepatitis transmission have been increasing in the United States. Transmission due to poor infection control practices during myocardial perfusion imaging (MPI) has not previously been reported. The aim of this study was to identify the source of incident hepatitis C virus (HCV) infection in a patient without identified risk factors who had undergone MPI 6 weeks before diagnosis. Practices at the cardiology clinic and nuclear pharmacy were evaluated, and HCV testing was performed in patients with shared potential exposures. Clinical and epidemiologic information was obtained for patients with HCV infection, and molecular testing was performed to assess viral relatedness. Evidence of HCV transmission among patients who had undergone MPI at the cardiology clinic on 2 separate dates was found, involving 2 potential source patients and a total of 5 newly infected patients. Molecular testing identified a high degree of genetic homology among viruses from patients with common procedure dates. The nuclear medicine technologist routinely drew up flush from multidose vials of saline solution using the same needle and syringe that had been used to administer radiopharmaceutical doses. Multipatient use of vials was not observed, but a review of purchasing invoices and interviews with staff members suggested that this had occurred. No evidence of transmission via contamination of radiopharmaceuticals at the nuclear pharmacy was found. In conclusion, transmission of HCV occurred because of unsafe injection practices during MPI. Cardiologists should carefully review their infection control practices and the practices of other staff members involved with these procedures.

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Although patients colonized or infected with methicillin-resistant Staphylococcus aureus have been placed on contact isolation for many years, more recent guidelines recommend enhanced control measures, such as routine active surveillance. We report here the results of a survey of 70 hospitals in North Carolina with regard to current management issues surrounding methicillin-resistant S. aureus.

ISSUE: The university-based program, SPICE, was initiated in 1980 in North Carolina (NC) to assist community hospitals in managing tuberculosis (TB) patients in their facility as specialized TB facilities were being phased out. The program began to focus on infection control as needs of hospitals changed. SPICE is based at the University of North Carolina School of Medicine, Infectious Disease Division. PROJECT: In 1982 the program offered infection control support and services for the 169 NC hospitals, added long-term care facilities in 1988, and added home health and hospice in 1989. The services provided include telephone consultation, onsite outbreak investigations with ability to perform molecular epidemiology, education (training courses and seminars), and research. SPICE staff consists of an infection control professional, a PhD specialized in environmental/infection control, a physician specialized in infectious diseases/infection control, a public health epidemiologist, and an educational coordinator. RESULTS: With little increase in funding and staff, SPICE continued to increase its services to healthcare facilities as shown in the following table (incomplete data 1981-85)Tabled 1Summary of SPICE ServicesConsultsCoursesAttendeesWorkshopsOutbreaks1986-95549132938184421996-2005619944229817430 Open table in a new tab In the past 10 years 2.5 times as many participants were trained in infection control courses as in the previous decade. LESSONS LEARNED: As responsibilities increased for infection control professionals (ICPs), education and consultation provided by SPICE expanded. Among the additional SPICE interventions were the following: in 1997 development and publication of a State-approved guideline for the management of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) in extended care facilities; in 1999 publication of three charts to aid in the management of bioterrorism entitled Bioterrorism Agents I, Bioterrorism Agents II, and Chemical Terrorism Agents; in 2003 in response to the Severe Acute Respiratory Syndrome (SARS) outbreak, creation of a SARS policy for NC acute-care facilities; in 2005, in response to outbreaks in NC, publication of recommendations for cleaning and disinfection of glucometers; in 2005 a state-sponsored algorithm for the management and treatment of community-associated MRSA. For the past ten years SPICE has provided infection control resources electronically with over 800 subscribers to the newsletter "Report of the Month." A comprehensive website provides multiple guidelines, recent PowerPoint lectures and links to other key websites such as CDC, SHEA, APIC. SPICE has continued to respond to the expanding role of ICPs in NC. We believe this unique Statewide program provides substantial benefit to the infection control community and their preparedness for new and emerging diseases including pandemics.

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Objective: The objective of this study was to compare short-and long-term hearing outcomes for patients undergoing primary laser stapedotomy minus prosthesis (STAMP) versus conventional laser stapedotomy.Study Design: We conducted a retrospective case review of 167 consecutive patients from 1993 to 2002.Setting: Otology/neurotology tertiary referral center.Patients: We studied those with clinical otosclerosis without previous otologic surgery.Interventions: Patients with otosclerosis confined to the fissula ante fenestram underwent STAMP. Patients with more extensive otosclerosis or anatomic contraindications to STAMP underwent standard laser stapedotomy.Main Outcome Measures: Pure-tone audiometry was performed before surgery, postoperatively, and on routine followup examination.Results: Of the 183 ears in 167 patients, 128 (67.1%) underwent laser stapedotomy and 55 (32.98%) underwent STAMP. The STAMP mean air-bone gap (ABG) closed from a preoperative value of 22 dB (standard deviation [SD], 10 dB) to 6 dB (SD, 7 dB) on average follow up of 778 days. In 128 laser stapedotomy patients with an average follow up of 747 days, the preoperative mean ABG closed from 27 dB (SD, 10 dB) to 8 dB (SD, 7 dB). There was a trend toward improvement in high-frequency air conduction thresholds after STAMP versus worsening of high-frequency thresholds in the conventional stapedotomy group. There was a statistically significant improvement in most recent postoperative high-frequency (60008000 Hz) air conduction thresholds in the STAMP patients compared with patients who underwent conventional laser stapedotomy.Conclusion: Laser STAMP, when used for isolated anterior footplate otosclerosis, provides excellent high-frequency hearing, yields lasting results similar to conventional laser stapedotomy, and has a low incidence of refixation necessitating revision surgery.

Hypothesis The osseointegrative capacity of medical-grade bone cement can be used to improve fixation and prevent displacement of an ossicular prosthesis in a guinea pig model. Background Successful ossiculoplasty requires a firm connection between the vibrating tympanic membrane and the inner ear. In patients requiring revision ossiculoplasty, half of failures are due to prosthesis displacement. Bone cements have been used as prosthetic material in craniofacial surgery, and their adhesive and osseointegrative properties make them ideal for use in ossicular reconstruction. Methods Twenty-four adult male guinea pigs underwent a postauricular surgical approach for access to the middle ear. Hydroxyapatite and Dahllite cements were used in an alternating fashion to fix ossicular bone. Four animals were killed immediately to demonstrate mechanical bonding of the ossicles at the time of application. Nineteen animals were killed 8 weeks postoperatively to assess bonding capacity and histologic inflammation. Results Both cements mechanically bonded the ossicles at the time of application, but Dahllite cement set faster in the moist environment of the middle ear space. Histologic examination showed bonding of the ossicles with both cements, with little evidence of inflammation or foreign body reaction. Conclusions Hydroxyapatite and Dahllite bone cements showed evidence of osseointegration with ossicular bone in the guinea pig model. Further studies are under way to determine the osseointegrative capacity of Dahllite cement between the guinea pig malleus and a partial prosthesis, and any ototoxic effects with use in the middle ear.

Purpose of review To examine the indications and applications of inner ear perfusion in the treatment of common otologic diseases, including Meniere disease, sudden sensorineural hearing loss, and autoimmune inner ear disease. Recent findings The number of surgical procedures, including vestibular neurectomy, labyrinthectomy, and endolymphatic sac surgery, decreased during the 1990s. Intratympanic gentamicin therapy has become the most frequently performed invasive procedure for treatment of Meniere disease. Reports on successful control of vertigo in patients with Meniere disease have ranged from 71.4 to 100%. There is a correlation between the degree of vestibular ablation in transtympanic gentamicin, the control of vertigo, and the risk of hearing loss. Patients with less than 75% ice-reduced vestibular response had a statistically lower risk of hearing loss, but they had a higher rate of persistent vertigo than patients with 100% reduced vestibular response. One hundred percent reduced vestibular response may not be indicative of complete vestibular ablation and may not be necessary for control of vertigo symptoms. In preliminary studies, inner ear perfusion of methylprednisolone in patients with severe, profound sudden sensorineural hearing loss who fail to respond to standard treatment is beneficial, with improvement in hearing thresholds of 16 to 25 dB and dramatic improvement in speech discrimination scores. No immunosuppressive medication has been found effective in suppressing inner ear inflammatory infiltrates or reducing hearing loss in an animal model. Summary Transtympanic chemical perfusion of the inner ear is safe, inexpensive, and easily performed by an otologic surgeon. With inner ear perfusion, high inner ear concentrations of medication can be achieved, and systemic side effects are minimized.

In order to discern trends in surgical procedures used to treat Ménière's disease in the United States during the 1990s, we mailed a questionnaire to 700 members of the American Otological Society and the American Neurotology Society. These physicians were asked about the frequency, results, and complications of surgical procedures for Ménière's disease that they had performed between Jan. 1, 1990, and Dec. 31, 1999. Questionnaires were returned by 137 surgeons (19.6%). Their responses indicated that the number of vestibular neurectomies, labyrinthectomies, and endolymphatic sac surgeries all decreased during 1999. Meanwhile, the use of office-administered intratympanic gentamicin therapy increased rapidly throughout the entire 10-year period, and by 1999 it had become the most frequently used invasive treatment for Ménière's disease. Surgeons now seem to reserve inpatient procedures for cases where intratympanic gentamicin fails to control vertigo.

Background: Three patients with identical strains of M tuberculosis (TB) underwent bronchoscopy on the same day at hospital A. Methods: We reviewed each patient’s clinical history, hospital A’s infection control practices for bronchoscopies, and specimen and isolate handling at each of 3 laboratories involved. We searched for possible community links between patients. Restriction fragment length polymorphism was performed on TB isolates. Results: The first patient who underwent bronchoscopy had biopsy-confirmed granulomatous pulmonary TB. A sputum sample collected from the third patient 6 weeks after the bronchoscopy produced an isolate with an identical restriction fragment length polymorphism pattern to isolates collected during the bronchoscopies. No evidence existed for community transmission or laboratory contamination; the only common link was the bronchoscopy. Different bronchoscopes were used for each patient. Hospital ventilation and wall-suctioning were functioning well. Respiratory technicians reported sometimes reusing the nozzles of atomizers on more than one patient. A possible mechanism for transmission was contamination from the first patient of the atomizer if it was used to apply lidocaine to the pharynx and nasal passages of other patients. Conclusions: A contaminated atomizer may have caused TB transmission during bronchoscopy. Hospital A changed to single-use atomizers after this investigation. (AJIC Am J Infect Control 2001;29:1-6)

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