Objective: Neonates usually acquire Group B streptococcal infection vertically from the maternal birth canal during delivery. In January 2010, a Group B streptococcal outbreak investigation was conducted in response to an increased number of clinical specimens from our neonatal intensive care unit. Methods: Microbiology laboratory records were reviewed to identify Group B streptococcal from specimens originating from the neonatal intensive care unit during December 2009 and January 2010. Patients from whom these specimens were collected were identified and their charts reviewed. Environmental samples to screen for Group B streptococcal were collected from the unit, clinical and environmental isolates were compared by pulsed field gel electrophoresis. Point prevalence screening was conducted twice before declaring the outbreak over. Results: Pulsed field gel electrophoresis patterns of three clinical strains from six patients were indistinguishable. One environmental strain was isolated from one of the patients monitor, and had identical pulsed field gel electrophoresis pattern to that of the three clinical strains. Infection control measures were implemented in the neonatal intensive care unit and follow-up point prevalence screening identified no new cases. Conclusions: Although poor infection control practice has been implicated in previous reports of nosocomial outbreaks of Group B streptococcal infection in neonatal intensive care units, our finding provides unique evidence that the environment can act as a reservoir of Group B streptococcal and play a key role in nosocomial transmission.

BACKGROUND:Hospital environmental service workers (ESWs) play an important role in interrupting the chain of infection because the environment is a reservoir for nosocomial pathogens. Improving ESWs' knowledge through education has been shown to improve ESW cleaning, but the behavioral determinants of their work have not been studied. Understanding and targeting ESWs' attitudes and beliefs may inform strategies to improve environmental cleaning. METHODS:With the theory of planned behavior as framework, we used questionnaires and focus groups to examine intensive care unit ESWs' attitudes, beliefs [behavioral, normative, and control], and control) and intent about their job. Baseline quantitative microbial cultures of high-touch services were performed before and after cleaning. After an educational intervention addressing their attitudes, beliefs, and general infection control knowledge, attitudes, beliefs, and microbial contamination were reassessed. RESULTS:Beliefs were uniformly strong (4.5/5-5/5), and normative beliefs correlated best with intent to clean (R(2) = 0.3). Themes elicited from the focus groups included "me versus them," lack of appreciation, pride in work, and "if it were me." The rate of environmental contamination was significantly improved after the intervention (P = .0074 vs P = .0023, respectively); the measured relationship among attitudes, beliefs, and intent was not significantly changed. CONCLUSION:ESWs' attitudes and beliefs about their job may impact their intent to clean and in turn the effectiveness of their efforts. Understanding and addressing these attitudes and beliefs can be used to inform strategies for sustained improvement of environmental cleaning.

Surveillance, a method used in epidemiology to study the incidence, distribution and control of disease, is an important means of gathering and analyzing information that can be used as needed to effect change. Surveillance has been an important component of the Blueprint for Patient Safety at the Hospital for Sick Children to identify potential and existing vulnerabilities and failures and put measures in place to avoid and mitigate any harm. Reviewing internal reports and actively seeking vulnerabilities has allowed us to make important changes to improve patient safety at the hospital. In this article, we review four internal surveillance strategies that have been particularly successful in driving change - safety reports, morbidity and mortality reviews, patient safety walkarounds and shoe leather infection control rounds - and discuss the successes and challenges we have experienced.

BACKGROUND The present study describes a vancomycin-resistant enterococci (VRE) outbreak investigation and a case-control study to identify risk factors for VRE acquisition in a tertiary care pediatric hospital. OBJECTIVE To report an outbreak investigation and a case-control study to identify risk factors for VRE colonization or infection in hospitalized children. METHODS Screening for VRE cases was performed by culture or polymerase chain reaction. A case-control study of VRE-colonized patients was undertaken. Environmental screening was performed using standard culture and susceptibility methods, with pulsed-field gel electrophoresis to determine relationships between VRE isolates. Statistical analysis was performed using SAS version 9.0 (SAS Institute Inc, USA). RESULTS Thirty-four VRE-positive cases were identified on 10 wards between February 28, 2005, and May 27, 2005. Pulsed-field gel electrophoresis analysis confirmed a single outbreak strain that was also isolated from a video game found on one affected ward. Multivariate analysis identified cephalosporin use as the major risk factor for VRE colonization. CONCLUSIONS In the present study outbreak, VRE colonization was significantly associated with cephalosporin use. Because shared recreational items and environmental surfaces may be colonized by VRE, they warrant particular attention in housekeeping protocols, particularly in pediatric institutions.

Background: Although isolation precautions are an important aspect of hospital infection control, current rates of isolation in a pediatric hospital and rates of compliance with established precautions are unknown. We therefore initiated hospital-wide point prevalence studies to determine unit-specific rates of patient isolation and compliance with proper isolation requirements focusing on communication of isolation status and availability of personal protective equipment. In this report, we present data from the first 14 months of the study.Methods: This was a prospective observational study. Twice monthly, between January 2004 and February 2005, infection control professionals reviewed the types and appropriateness of isolation of all hospitalized patients, except for those on the psychiatry unit.Results: Seventeen percent of patients in the hospital during the study period were isolated, most frequently for community-acquired infections. Droplet isolation precautions were the most common form of isolation. overall, only 74.6% of patients were isolated appropriately. The solid organ transplantation, hematology/oncology, and bone marrow transplantation units were those with the highest rates of inappropriate isolation.Conclusion: At our hospital, community-acquired infections, in particular respiratory infections, were the most common reasons for patient isolation. Monitoring of the appropriateness of isolation precautions offers the opportunity to reduce health care-related transmission of infection and identify specific target areas for improvement.

OBJECTIVE:To determine whether contaminated ultrasound gel is the source of intermittent outbreaks of nosocomial infection due to Burkholderia cepacia complex in patients without cystic fibrosis since 1992.DESIGN:A prospective clinical and in vitro study of all in-use bottles of ultrasound gel, as well as a retrospective analysis of archived bacterial strains, were performed. Handling of gel for clinical purposes throughout the hospital was evaluated. Gel and archived clinical isolates of B. cepacia complex were speciated to genomovar level and characterized by pulsed-field gel electrophoresis, and the pulsed-field gel electrophoresis patterns were compared.SETTING:The Hospital for Sick Children, a 300-bed, tertiary care, pediatric academic health sciences center in Toronto, Canada.PATIENTS:All patients without cystic fibrosis from whom B. cepacia complex was recovered at the Hospital for Sick Children since 1992.RESULTS:No standardized protocol for storage or handling of ultrasound gel was found. Gel from 39% of bottles grew either B. cepacia (genomovar I) or Burkholderia stabilis (genomovar IV). These isolates had pulsed-field gel electrophoresis patterns identical to 2 of the 7 clinical pulsed-field gel electrophoresis types that are responsible for 88% of clinical isolates.CONCLUSIONS:Contaminated ultrasound gel contributed to nosocomial infection due to B. cepacia complex in this institution over the course of 10 years. Suggested guidelines for the handling of ultrasound gel are provided.

BACKGROUND:Enteral feeding tubes have been associated with outbreaks of antimicrobial-resistant organisms, but the pathogenesis of this association has not been investigated. We hypothesized that the enteral feed administration sets become colonized externally by microbes grown from the enteral tube hub, and therefore serve as a reservoir of organisms that can be crosstransmitted.METHODS:We conducted a prospective observational cohort pilot study, obtaining bacterial cultures from the external enteral feed administration set and from the hub of nasogastric, gastric, or gastrojejunal tubes in children receiving enteral feeding while hospitalized in a tertiary care pediatric hospital.RESULTS:Thirty-six of 37 hubs cultured had bacterial growth. Twenty-nine of 36 administration sets (78%) sampled had at least 1 microbe isolated that was also cultured from the hub. No significant risk factors for colonization were identified.CONCLUSIONS:Enteral feed administration sets are frequently colonized by organisms in the enteral tube hub. These sets can serve as a reservoir of organisms that can be crosstransmitted between patients. Adherence to Standard Precautions is critical when handling enteral feeding apparatuses.

OBJECTIVE:To define nosocomial urinary tract infection (NUTI) rates in a pediatric intensive care unit, and determine whether practice recommendations have been sustained after 10 yrs.DESIGN:Retrospective, descriptive observational study followed by point prevalence audits of duration of urinary tract catheterization.SETTING:A 32-bed pediatric intensive care unit in a multidisciplinary, 300-bed, university-affiliated tertiary care hospital.SUBJECTS:The retrospective review included patients admitted to the pediatric intensive care unit between December 1997 and July 1999 who developed a NUTI. The audits of duration of urinary tract catheterization were performed in December 2001.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:The primary outcome measure was the development of NUTI. Out of 2,832 consecutive admissions, 25 patients developed 27 episodes of NUTI (rate, 0.95/100 admissions). Previous surgery for congenital heart disease was the primary risk factor for NUTI. All 18 patients for whom the duration of catheterization was available had been catheterized for at least 3 days. Gram-negative bacilli and yeast accounted for 82% of NUTI pathogens. Twenty percent of bacterial pathogens were antibiotic resistant. Audits of the duration of urinary tract catheterization done on five separate occasions revealed that the mean duration of catheterization ranged from 3.5 to 4.7 days, with a peak absolute value of 16 days.CONCLUSIONS:NUTIs in children in our pediatric intensive care unit were associated with previous cardiovascular surgery and with urinary tract catheterization of at least 3 days. The need for careful fluid monitoring by catheterization must be balanced against the increased risk of catheter-related urinary tract infection. Removal of urinary catheters at the earliest opportunity will prevent many infections. Ongoing education or innovative strategies will be required to sustain optimal practice.

Awareness is growing of the role of pertussis infection among adolescents and adults, and of the possibility of nosocomial transmission. However, pertussis remains difficult to diagnose. We report a case of nosocomially acquired pertussis in a healthcare worker, diagnosed by polymerase chain reaction. The high sensitivity and rapid turnaround time for this test is useful to confirm the diagnosis when advising a healthcare worker to refrain from working.