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Lin MY, Bonten MJM. The dilemma of assessment bias in infection control research. Clin Infect Dis 2012; 54:1342-7. [PMID: 22337824 DOI: 10.1093/cid/cis016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Infection control studies often rely on infection endpoints to determine whether interventions are effective. However, many infection outcomes, including those defined by standardized surveillance criteria, involve some subjective judgment for determination. Studies that use unblinded ascertainment of subjective infection endpoints are at risk of assessment bias. Unfortunately, infection control studies have not routinely accounted for assessment bias. To ensure validity, infection control studies should incorporate study design elements to control assessment bias, such as blinded assessment or use of objective outcome measures.
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Affiliation(s)
- Michael Y Lin
- Department of Internal Medicine, Section of Infectious Diseases, Rush University Medical Center, Chicago, Illinois 60612, USA.
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102
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Quality improvement interventions to prevent healthcare-associated infections in neonates and children. Curr Opin Pediatr 2012; 24:103-12. [PMID: 22189394 DOI: 10.1097/mop.0b013e32834ebdc3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Healthcare-associated infections cause substantial harm to hospitalized neonates and children. Efforts that prevent these infections are a major focus of current patient safety initiatives. This review focuses on the reports of quality improvement interventions to prevent central line-associated bloodstream infections (CLABSIs) in neonates and children. RECENT FINDINGS Single-center and multicenter collaborative studies have examined the effect of quality improvement interventions to reliably implement central line insertion and maintenance bundles on CLABSI rates in neonatal and pediatric intensive care units. Quality improvement interventions were associated with reductions in CLABSI rates in neonates and children by a half or more, although many of the studies have important methodologic limitations. Studies that utilized improvement science methodologies demonstrated larger improvement effects, but required a sizable investment of institutional support and personnel time. SUMMARY Quality improvement interventions to reduce CLABSI are an important component of patient safety initiatives. Future studies of quality improvement interventions to reduce HAI among hospitalized neonates and children will benefit from further investigation of methods to enhance reliable implementation of evidence-based practices, factors that enable multicenter collaboratives to be more successful, and better understanding of the causes of heterogeneity in the results at different centers.
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Graves N, Barnett AG, Halton K, Crnich C, Cooper B, Beyersmann J, Wolkewitz M, Samore M, Harbarth S. The importance of good data, analysis, and interpretation for showing the economics of reducing healthcare-associated infection. Infect Control Hosp Epidemiol 2012; 32:927-8; author reply 928-30. [PMID: 21828978 DOI: 10.1086/661600] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Miller MR, Niedner MF, Huskins WC, Colantuoni E, Yenokyan G, Moss M, Rice TB, Ridling D, Campbell D, Brilli RJ. Reducing PICU central line-associated bloodstream infections: 3-year results. Pediatrics 2011; 128:e1077-83. [PMID: 22025594 DOI: 10.1542/peds.2010-3675] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To evaluate the long-term impact of pediatric central line care practices in reducing PICU central line-associated bloodstream infection (CLA-BSI) rates and to evaluate the added impact of chlorhexidine scrub and chlorhexidine-impregnated sponges. METHODS A 3-year, multi-institutional, interrupted time-series design (October 2006 to September 2009), with historical control data, was used. A nested, 18-month, nonrandomized, factorial design was used to evaluate 2 additional interventions. Twenty-nine PICUs were included. Two central line care bundles (insertion and maintenance bundles) and 2 additional interventions (chlorhexidine scrub and chlorhexidine-impregnated sponges) were used. CLA-BSI rates (January 2004 to September 2009), insertion and maintenance bundle compliance rates (October 2006 to September 2009), and chlorhexidine scrub and chlorhexidine-impregnated sponge compliance rates (January 2008 to June 2009) were assessed. RESULTS The average aggregate baseline PICU CLA-BSI rate decreased 56% over 36 months from 5.2 CLA-BSIs per 1000 line-days (95% confidence interval [CI]: 4.4-6.2 CLA-BSIs per 1000 line-days) to 2.3 CLA-BSIs per 1000 line-days (95% CI: 1.9-2.9 CLA-BSIs per 1000 line-days) (rate ratio: 0.44 [95% CI: 0.37-0.53]; P < .0001). No statistically significant differences in CLA-BSI rate decreases between PICUs using or not using either of the 2 additional interventions were found. CONCLUSIONS Focused attention on consistent adherence to the use of pediatrics-specific central line insertion and maintenance bundles produced sustained, continually decreasing PICU CLA-BSI rates. Additional use of either chlorhexidine for central line entry scrub or chlorhexidine-impregnated sponges did not produce any statistically significant additional reduction in PICU CLA-BSI rates.
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Affiliation(s)
- Marlene R Miller
- Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA.
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105
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Kelly M, Conway M, Wirth K, Potter-Bynoe G, Billett AL, Sandora TJ. Moving CLABSI prevention beyond the intensive care unit: risk factors in pediatric oncology patients. Infect Control Hosp Epidemiol 2011. [PMID: 22011534 DOI: 10.1086/662376.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVE Central line-associated bloodstream infections (CLABSIs) frequently complicate the use of central venous catheters (CVCs) among pediatric patients with cancer. Our objectives were to describe the microbiology and identify risk factors for hospital-onset CLABSI in this patient population. DESIGN Retrospective case-control study. SETTING Oncology and stem cell transplant units of a freestanding, 396-bed quaternary care pediatric hospital. PARTICIPANTS Case subjects ([Formula: see text]) were patients with a diagnosis of malignancy and/or stem cell transplant recipients with CLABSI occurring during admission. Controls ([Formula: see text]) were identified using risk set sampling of hospitalizations among patients with a CVC, matched on date of admission. METHODS Multivariate conditional logistic regression was used to identify independent predictors of CLABSI. RESULTS The majority of CLABSI isolates were gram-positive bacteria (58%). The most frequently isolated organism was Enterococcus faecium, and 6 of 9 isolates were resistant to vancomycin. In multivariate analyses, independent risk factors for CLABSI included platelet transfusion within the prior week (odds ratio [OR], 10.90 [95% confidence interval (CI), 3.02-39.38]; [Formula: see text]) and CVC placement within the previous month (<1 week vs ≥1 month: OR, 11.71 [95% CI, 1.98-69.20]; [Formula: see text]; ≥1 week and <1 month vs ≥1 month: OR, 7.37 [95% CI, 1.85-29.36]; [Formula: see text]). CONCLUSIONS Adjunctive measures to prevent CLABSI among pediatric oncology patients may be most beneficial in the month following CVC insertion and in patients requiring frequent platelet transfusions. Vancomycin-resistant enterococci may be an emerging cause of CLABSI in hospitalized pediatric oncology patients and are unlikely to be treated by typical empiric antimicrobial regimens.
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Affiliation(s)
- Matthew Kelly
- Department of Medicine, Children's Hospital Boston, Boston, Massachusetts, USA.
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106
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Woeltje KF, McMullen KM, Butler AM, Goris AJ, Doherty JA. Electronic surveillance for healthcare-associated central line-associated bloodstream infections outside the intensive care unit. Infect Control Hosp Epidemiol 2011; 32:1086-90. [PMID: 22011535 DOI: 10.1086/662181] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Manual surveillance for central line-associated bloodstream infections (CLABSIs) by infection prevention practitioners is time-consuming and often limited to intensive care units (ICUs). An automated surveillance system using existing databases with patient-level variables and microbiology data was investigated. METHODS Patients with a positive blood culture in 4 non-ICU wards at Barnes-Jewish Hospital between July 1, 2005, and December 31, 2006, were evaluated. CLABSI determination for these patients was made via 2 sources; a manual chart review and an automated review from electronically available data. Agreement between these 2 sources was used to develop the best-fit electronic algorithm that used a set of rules to identify a CLABSI. Sensitivity, specificity, predictive values, and Pearson's correlation were calculated for the various rule sets, using manual chart review as the reference standard. RESULTS During the study period, 391 positive blood cultures from 331 patients were evaluated. Eighty-five (22%) of these were confirmed to be CLABSI by manual chart review. The best-fit model included presence of a catheter, blood culture positive for known pathogen or blood culture with a common skin contaminant confirmed by a second positive culture and the presence of fever, and no positive cultures with the same organism from another sterile site. The best-performing rule set had an overall sensitivity of 95.2%, specificity of 97.5%, positive predictive value of 90%, and negative predictive value of 99.2% compared with intensive manual surveillance. CONCLUSIONS Although CLABSIs were slightly overpredicted by electronic surveillance compared with manual chart review, the method offers the possibility of performing acceptably good surveillance in areas where resources do not allow for traditional manual surveillance.
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Affiliation(s)
- Keith F Woeltje
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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107
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Kelly M, Conway M, Wirth K, Potter-Bynoe G, Billett AL, Sandora TJ. Moving CLABSI prevention beyond the intensive care unit: risk factors in pediatric oncology patients. Infect Control Hosp Epidemiol 2011; 32:1079-85. [PMID: 22011534 DOI: 10.1086/662376] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVE Central line-associated bloodstream infections (CLABSIs) frequently complicate the use of central venous catheters (CVCs) among pediatric patients with cancer. Our objectives were to describe the microbiology and identify risk factors for hospital-onset CLABSI in this patient population. DESIGN Retrospective case-control study. SETTING Oncology and stem cell transplant units of a freestanding, 396-bed quaternary care pediatric hospital. PARTICIPANTS Case subjects ([Formula: see text]) were patients with a diagnosis of malignancy and/or stem cell transplant recipients with CLABSI occurring during admission. Controls ([Formula: see text]) were identified using risk set sampling of hospitalizations among patients with a CVC, matched on date of admission. METHODS Multivariate conditional logistic regression was used to identify independent predictors of CLABSI. RESULTS The majority of CLABSI isolates were gram-positive bacteria (58%). The most frequently isolated organism was Enterococcus faecium, and 6 of 9 isolates were resistant to vancomycin. In multivariate analyses, independent risk factors for CLABSI included platelet transfusion within the prior week (odds ratio [OR], 10.90 [95% confidence interval (CI), 3.02-39.38]; [Formula: see text]) and CVC placement within the previous month (<1 week vs ≥1 month: OR, 11.71 [95% CI, 1.98-69.20]; [Formula: see text]; ≥1 week and <1 month vs ≥1 month: OR, 7.37 [95% CI, 1.85-29.36]; [Formula: see text]). CONCLUSIONS Adjunctive measures to prevent CLABSI among pediatric oncology patients may be most beneficial in the month following CVC insertion and in patients requiring frequent platelet transfusions. Vancomycin-resistant enterococci may be an emerging cause of CLABSI in hospitalized pediatric oncology patients and are unlikely to be treated by typical empiric antimicrobial regimens.
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Affiliation(s)
- Matthew Kelly
- Department of Medicine, Children's Hospital Boston, Boston, Massachusetts, USA.
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Fraser TG, Gordon SM. CLABSI rates in immunocompromised patients: a valuable patient centered outcome? Clin Infect Dis 2011; 52:1446-50. [PMID: 21628486 DOI: 10.1093/cid/cir200] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The accepted approach to surveillance for hospital-acquired bloodstream infection (HABSI) due to central venous catheters requires use of the National Health and Safety Network (NHSN) definition for catheter-associated bloodstream infection (CLABSI). In this commentary, we discuss our experience with the application of current NHSN surveillance definitions for CLABSI and the impact that public reporting of CLABSI rates in settings with a high prevalence of special populations has on infection prevention (IP) programs. For IP programs to serve the continuous improvement needs of their organizations, surveillance methodologies need to accurately capture the burden of preventable HABSI among immunocompromised individuals with inherent risk for infection. Current NHSN CLABSI definitions lack specificity for complex and heterogeneous patient populations and require modification. Beyond definitions, IP programs must critically assess the value of their current approach to surveillance to assure that patient-centered outcomes are the focus of prevention efforts.
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Affiliation(s)
- Thomas G Fraser
- Department of Infectious Disease, Cleveland Clinic, Cleveland, Ohio, USA.
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Timsit JF, Dubois Y, Minet C, Bonadona A, Lugosi M, Ara-Somohano C, Hamidfar-Roy R, Schwebel C. New materials and devices for preventing catheter-related infections. Ann Intensive Care 2011; 1:34. [PMID: 21906266 PMCID: PMC3170570 DOI: 10.1186/2110-5820-1-34] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 08/18/2011] [Indexed: 11/16/2022] Open
Abstract
Catheters are the leading source of bloodstream infections for patients in the intensive care unit (ICU). Comprehensive unit-based programs have proven to be effective in decreasing catheter-related bloodstream infections (CR-BSIs). ICU rates of CR-BSI higher than 2 per 1,000 catheter-days are no longer acceptable. The locally adapted list of preventive measures should include skin antisepsis with an alcoholic preparation, maximal barrier precautions, a strict catheter maintenance policy, and removal of unnecessary catheters. The development of new technologies capable of further decreasing the now low CR-BSI rate is a major challenge. Recently, new materials that decrease the risk of skin-to-vein bacterial migration, such as new antiseptic dressings, were extensively tested. Antimicrobial-coated catheters can prevent CR-BSI but have a theoretical risk of selecting resistant bacteria. An antimicrobial or antiseptic lock may prevent bacterial migration from the hub to the bloodstream. This review discusses the available knowledge about these new technologies.
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Affiliation(s)
- Jean-François Timsit
- Medical Polyvalent Intensive Care Unit, University Joseph Fourier, Albert Michallon Hospital, BP 217, 38043 Grenoble Cedex 9, France.
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111
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Allard R, Dascal A, Camara B, Létourneau J, Valiquette L. Community-acquired Clostridium difficile-associated diarrhea, Montréal, 2005-2006: frequency estimates and their validity. Infect Control Hosp Epidemiol 2011; 32:1032-4. [PMID: 21931255 DOI: 10.1086/661911] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A retrospective search for community-acquired Clostridium difficile-associated diarrhea in 15 hospitals revealed important discrepancies with numbers for the same period reported in real time to the surveillance system. Several of the observed problems could be solved by implementing case-by-case notification with subsequent investigation by local public health, as for other reportable diseases.
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Affiliation(s)
- Robert Allard
- Public Health Department, Montréal Health and Social Services Agency, Montréal, Québec, Canada.
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112
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Antibiotic use for presumed neonatally acquired infections far exceeds that for central line-associated blood stream infections: an exploratory critique. J Perinatol 2011; 31:514-8. [PMID: 21546938 DOI: 10.1038/jp.2011.39] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess antibiotic use as a complementary neonatal intensive care unit (NICU) infection measure to the central line-associated blood stream infection (CLABSI) rate. STUDY DESIGN Patient days (PDs), line days, antibiotic (AB) use, CLABSI and other proven infections were analyzed in consecutive admissions to two NICUs over 3 and 6 months, respectively, from 1 January 2008 until discharge. An antibiotic course (AC) consisted of one or more uninterrupted antibiotic days (AD), classified as perinatal or neonatal, if started ≤3 d or ≥4 d post birth and as rule-out sepsis or presumed infection (PI) if treated ≤4 d or ≥5d, respectively. Events were expressed per 1000 PD and aggregated by conventional treatment categories and by clinical perception of infection certainty: possible, presumed or proven. RESULT The cohort included 754 patients, 18,345 PD, 6637 line days, 718 AC and 4553 AD. Of total antibiotic use, neonatal use constituted 39.2% of ACs, and 29.0% of ADs, When analyzed per 1000 PD, antibiotic use to treat PIs vs CLABSIs, was either 14 fold (CI 6.6-30) higher for ACs (5.40 vs 0.38/1000 PD, P<0.0001) or 8.8 fold (CI 7.1-11) higher for ADs (48.3 vs 5.5/1000 PD, P<0.0001). CONCLUSION CLABSI rates, present a lower limit of NICU-acquired infections, whereas antibiotic-use measures, about 10-fold higher, may estimate an upper limit of that burden. Antibiotic-use metrics should be evaluated further for their ability to broaden NICU infection assessment and to guide prevention and antibiotic stewardship efforts.
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Cevasco M, Borzecki AM, O'Brien WJ, Chen Q, Shin MH, Itani KM, Rosen AK. Validity of the AHRQ Patient Safety Indicator “Central Venous Catheter-Related Bloodstream Infections”. J Am Coll Surg 2011; 212:984-90. [DOI: 10.1016/j.jamcollsurg.2011.02.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 01/31/2011] [Accepted: 02/01/2011] [Indexed: 10/18/2022]
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Ward MM, Clabaugh G, Evans TC, Herwaldt L. A successful, voluntary, multicomponent statewide effort to reduce health care-associated infections. Am J Med Qual 2011; 27:66-73. [PMID: 21551323 DOI: 10.1177/1062860611405506] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Health care-associated infections (HAIs) increase morbidity, mortality, and hospital costs. Multiple organizations have worked independently to reduce HAIs. Regional collaborative efforts to reduce HAIs have been less common but may be particularly effective. The authors describe a statewide multicomponent approach implemented by the Iowa Healthcare Collaborative (IHC) to reduce HAIs. IHC's initiatives helped providers improve patient care by becoming engaged in specific projects, improving communication, sharing data, and implementing best practices. Other states could use this approach as a model to engage clinicians in patient safety initiatives and thereby accelerate the rate at which clinical care and health care outcomes are improved.
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Fridkin SK, Olmsted RN. Meaningful measure of performance: a foundation built on valid, reproducible findings from surveillance of health care-associated infections. Am J Infect Control 2011; 39:87-90. [PMID: 21356430 DOI: 10.1016/j.ajic.2011.01.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 01/10/2011] [Indexed: 10/18/2022]
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