Reduction of nosocomial infection during pediatric intensive care by protective isolation

Association between universal gloving and healthcare-associated infections: A systematic literature review and meta-analysis

Objective:

Healthcare-associated infections (HAIs) are a significant burden on healthcare facilities. Universal gloving is a horizontal intervention to prevent transmission of pathogens that cause HAI. In this meta-analysis, we aimed to identify whether implementation of universal gloving is associated with decreased incidence of HAI in clinical settings.

Methods:

A systematic literature search was conducted to find all relevant publications using search terms for universal gloving and HAIs. Pooled incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were calculated using random effects models. Heterogeneity was evaluated using the Woolf test and the I2 test.

Results:

In total, 8 studies were included. These studies were moderately to substantially heterogeneous (I2 = 59%) and had varied results. Stratified analyses showed a nonsignificant association between universal gloving and incidence of methicillin-resistant Staphylococcus aureus (MRSA; pooled IRR, 0.94; 95% CI, 0.79–1.11) and vancomycin-resistant enterococci (VRE; pooled IRR, 0.94; 95% CI, 0.69–1.28). Studies that implemented universal gloving alone showed a significant association with decreased incidence of HAI (IRR, 0.77; 95% CI, 0.67–0.89), but studies implementing universal gloving as part of intervention bundles showed no significant association with incidence of HAI (IRR, 0.95; 95% CI, 0.86–1.05).

Conclusions:

Universal gloving may be associated with a small protective effect against HAI. Despite limited data, universal gloving may be considered in high-risk settings, such as pediatric intensive care units. Further research should be performed to determine the effects of universal gloving on a broader range of pathogens, including gram-negative pathogens.

Infection Control and the Need for Family-/Child-Centered Care

Patient- and family-centered care (FCC) has become central to the delivery of medical care over the last 20 years and has been shown to improve patient outcomes. Infection control practices have the potential to greatly influence family centeredness and care providers, and hospital personnel must consider the potential impacts of isolation and the use of personal protective equipment (PPE). Approaching infection control with the perspective of FCC requires balancing patient safety and overall patient well-being. In this chapter, authors consider infection control and the benefits of FCC, family and sibling visitation, the use of playrooms, animals in healthcare settings including animal-assisted interventions, the potential adverse effects of infection control practices, and strategies to mitigate these impacts.

Preventing Transmission of Multidrug-Resistant Pathogens in the Intensive Care Unit

Infection control in the intensive care unit (ICU) has seen many advances, including rapid molecular screening tests for resistant organisms and chlorhexidine use in daily baths. Although these developments advance the cause of infection prevention, compliance with some of the basic measures remains elusive. Hand hygiene, antimicrobial stewardship, and reduction in device use remain the low-technology interventions that could have a major impact on nosocomial transmission of antimicrobial-resistant organisms. Although continued research is needed on new and old ways of preventing nosocomial infections, ICU staff must persevere in improving adherence with the measures that are known to be effective.

Contact Precautions More Is Not Necessarily Better

Objective.

To determine whether increases in contact isolation precautions are associated with decreased adherence to isolation practices among healthcare workers (HCWs).

Design.

Prospective cohort study from February 2009 to October 2009.

Setting.

Eleven teaching hospitals.

Participants.

HCWs.

Methods.

One thousand thirteen observations conducted on HCWs. Additional data included the number of persons in isolation, types of HCWs, and hospital-specific contact precaution practices. Main outcome measures included compliance with individual components of contact isolation precautions (hand hygiene before and after patient encounter, donning of gown and glove upon entering a patient room, and doffing upon exiting) and overall compliance (all 5 measures together) during varying burdens of isolation.

Results.

Compliance with hand hygiene was as follows: prior to donning gowns/gloves, 37.2%; gowning, 74.3%; gloving, 80.1%; doffing of gowns/gloves, 80.1%; after gown/glove removal, 61%. Compliance with all components was 28.9%. As the burden of isolation increased (20% or less to greater than 60%), a decrease in compliance with hand hygiene (43.6%—4.9%) and with all 5 components (31.5%—6.5%) was observed. In multivariable analysis, there was an increase in noncompliance with all 5 components of the contact isolation precautions bundle (odds ratio [OR], 6.6 [95% confidence interval (CI), 1.15-37.44];P= .03) and in noncompliance with hand hygiene prior to donning gowns and gloves (OR, 10.1 [95% CI, 1.84—55.54];P= .008) associated with increasing burden of isolation.

Conclusions.

As the proportion of patients in contact isolation increases, compliance with contact isolation precautions decreases. Placing 40% of patients under contact precautions represents a tipping point for noncompliance with contact isolation precautions measures.

Burn Center Barrier Protocols During Dressing Change: A National Survey

Infection control is a critical component of post-burn care with prevention of infection serving as a major cause of decreasing morbidity and mortality. One potential deterrent for infection is barrier protection during dressing changes; however, no evidence-based standard has been established among burn centers. The purpose of this study is to describe the current barrier techniques of American burn centers. A 24-question survey was sent to 121 burn center nurse managers within the United States. The survey was comprised of yes or no questions with comment sections available for further detail. Questions were constructed to gain insight into the variation and commonality that may exist between burn center barrier protocols. Forty-one out of 121 centers (34%) responded. Centers reported the use of head covers, masks, gowns, and gloves during admission of a new burn (71%, 82%, 95%, and 100% respectively); daily dressing changes (64%, 80%, 97%, and 100% respectively); postoperative dressing changes (64%, masks 80%, 97%, and 100% respectively); and dressing changes of a nonburn (66%, 82%, 97%, and 100% respectively). Burn centers reported their use of sterile gloves and gowns during typical burn dressing changes as occurring 20% and 10% of the time, respectively. Estimates for costs of these garments annually ranged from $0 to $250,000. A calculation performed for this study demonstrated that barrier garments used for dressing changes nationwide is approximately $2.43 million. We demonstrated the immense cost, to an institution and nationwide, of barrier garments used solely for dressing changes.

Copper surfaces are associated with significantly lower concentrations of bacteria on selected surfaces within a pediatric intensive care unit

BACKGROUND

Health care-associated infections result in significant patient morbidity and mortality. Although cleaning can remove pathogens present on hospital surfaces, those surfaces may be inadequately cleaned or recontaminated within minutes. Because of copper's inherent and continuous antimicrobial properties, copper surfaces offer a solution to complement cleaning. The objective of this study was to quantitatively assess the bacterial microbial burden coincident with an assessment of the ability of antimicrobial copper to limit the microbial burden associated with 3 surfaces in a pediatric intensive care unit.

METHODS

A pragmatic trial was conducted enrolling 1,012 patients from 2 high acuity care units within a 249-bed tertiary care pediatric hospital over 12 months. The microbial burden was determined from 3 frequently encountered surfaces, regardless of room occupancy, twice monthly, from 16 rooms, 8 outfitted normally and 8 outfitted with antimicrobial copper.

RESULTS

Copper surfaces were found to be equivalently antimicrobial in pediatric settings to activities reported for adult medical intensive care units. The log10 reduction to the microbial burden from antimicrobial copper surfaced bed rails was 1.996 (99%). Surprisingly, introduction of copper objects to 8 study rooms was found to suppress the microbial burden recovered from objects assessed in control rooms by log10 of 1.863 (73%).

CONCLUSION

Copper surfaces warrant serious consideration when contemplating the introduction of no-touch disinfection technologies for reducing burden to limit acquisition of HAIs.

Isolation gowns in health care settings: Laboratory studies, regulations and standards, and potential barriers of gown selection and use

Although they play an important role in infection prevention and control, textile materials and personal protective equipment (PPE) used in health care settings are known to be one of the sources of cross-infection. Gowns are recommended to prevent transmission of infectious diseases in certain settings; however, laboratory and field studies have produced mixed results of their efficacy. PPE used in health care is regulated as either class I (low risk) or class II (intermediate risk) devices in the United States. Many organizations have published guidelines for the use of PPE, including isolation gowns, in health care settings. In addition, the Association for the Advancement of Medical Instrumentation published a guidance document on the selection of gowns and a classification standard on liquid barrier performance for both surgical and isolation gowns. However, there is currently no existing standard specific to isolation gowns that considers not only the barrier resistance but also a wide array of end user desired attributes. As a result, infection preventionists and purchasing agents face several difficulties in the selection process, and end users have limited or no information on the levels of protection provided by isolation gowns. Lack of knowledge about the performance of protective clothing used in health care became more apparent during the 2014 Ebola epidemic. This article reviews laboratory studies, regulations, guidelines and standards pertaining to isolation gowns, characterization problems, and other potential barriers of isolation gown selection and use.

Gloves, gowns and masks for reducing the transmission of meticillin-resistant Staphylococcus aureus (MRSA) in the hospital setting

BACKGROUND

Meticillin-resistant Staphylococcus aureus (MRSA; also known as methicillin-resistant S aureus) is a common hospital-acquired pathogen that increases morbidity, mortality, and healthcare costs. Its control continues to be an unresolved issue in many hospitals worldwide. The evidence base for the effects of the use of gloves, gowns or masks as control measures for MRSA is unclear.

OBJECTIVES

To assess the effectiveness of wearing gloves, a gown or a mask when contact is anticipated with a hospitalised patient colonised or infected with MRSA, or with the patient's immediate environment.

SEARCH METHODS

We searched the Specialised Registers of three Cochrane Groups (Wounds Group on 5 June 2015; Effective Practice and Organisation of Care (EPOC) Group on 9 July 2013; and Infectious Diseases Group on 5 January 2009); CENTRAL (The Cochrane Library 2015, Issue 6); DARE, HTA, NHS EED, and the Methodology Register (The Cochrane Library 2015, Issue 6); MEDLINE and MEDLINE In-Process & Other Non-Indexed Citations (1946 to June week 1 2015); EMBASE (1974 to 4 June 2015); Web of Science (WOS) Core Collection (from inception to 7 June 2015); CINAHL (1982 to 5 June 2015); British Nursing Index (1985 to 6 July 2010); and ProQuest Dissertations & Theses Database (1639 to 11 June 2015). We also searched three trials registers (on 6 June 2015), references list of articles, and conference proceedings. We finally contacted relevant individuals for additional studies.

SELECTION CRITERIA

Studies assessing the effects on MRSA transmission of the use of gloves, gowns or masks by any person in the hospital setting when contact is anticipated with a hospitalised patient colonised or infected with MRSA, or with the patient's immediate environment. We did not assess adverse effects or economic issues associated with these interventions.We considered any comparator to be eligible. With regard to study design, only randomised controlled trials (clustered or not) and the following non-randomised experimental studies were eligible: quasi-randomised controlled trials (clustered or not), non-randomised controlled trials (clustered or not), controlled before-and-after studies, controlled cohort before-after studies, interrupted time series studies (controlled or not), and repeated measures studies. We did not exclude any study on the basis of language or date of publication.

DATA COLLECTION AND ANALYSIS

Two review authors independently decided on eligibility of the studies. Had any study having been included, two review authors would have extracted data (at least for outcome data) and assessed the risk of bias independently. We would have followed the standard methodological procedures suggested by Cochrane and the Cochrane EPOC Group for assessing risk of bias and analysing the data.

MAIN RESULTS

We identified no eligible studies for this review, either completed or ongoing.

AUTHORS' CONCLUSIONS

We found no studies assessing the effects of wearing gloves, gowns or masks for contact with MRSA hospitalised patients, or with their immediate environment, on the transmission of MRSA to patients, hospital staff, patients' caregivers or visitors. This absence of evidence should not be interpreted as evidence of no effect for these interventions. The effects of gloves, gowns and masks in these circumstances have yet to be determined by rigorous experimental studies, such as cluster-randomised trials involving multiple wards or hospitals, or interrupted time series studies.

Reconsidering Contact Precautions for Endemic Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus

BACKGROUND

Whether contact precautions (CP) are required to control the endemic transmission of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) in acute care hospitals is controversial in light of improvements in hand hygiene, MRSA decolonization, environmental cleaning and disinfection, fomite elimination, and chlorhexidine bathing.

OBJECTIVE

To provide a framework for decision making around use of CP for endemic MRSA and VRE based on a summary of evidence related to use of CP, including impact on patients and patient care processes, and current practices in use of CP for MRSA and VRE in US hospitals.

DESIGN

A literature review, a survey of Society for Healthcare Epidemiology of America Research Network members on use of CP, and a detailed examination of the experience of a convenience sample of hospitals not using CP for MRSA or VRE.

PARTICIPANTS

Hospital epidemiologists and infection prevention experts.

RESULTS

No high quality data support or reject use of CP for endemic MRSA or VRE. Our survey found more than 90% of responding hospitals currently use CP for MRSA and VRE, but approximately 60% are interested in using CP in a different manner. More than 30 US hospitals do not use CP for control of endemic MRSA or VRE.

CONCLUSIONS

Higher quality research on the benefits and harms of CP in the control of endemic MRSA and VRE is needed. Until more definitive data are available, the use of CP for endemic MRSA or VRE in acute care hospitals should be guided by local needs and resources.

Infect Control Hosp Epidemiol 2015;36(10):1163–1172

Nosocomial Infection Caused by Antibiotic-Resistant Organisms in the Intensive-Care Unit

Resistance to antimicrobial agents is an evolving process, driven by the selective pressure of heavy antibiotic use in individuals living in close proximity to others. The intensive care unit (ICU), crowded with debilitated patients who are receiving broad-spectrum antibiotics and being cared for by busy physicians, nurses, and technicians, serves as an ideal environment for the emergence of antibiotic resistance. Problem pathogens presently include multiply resistant gram-negative bacilli, methicillin-resistantStaphylococcus aureus, and the recently emerged vancomycin-resistant enterococci. The prevention of antimicrobial resistance in ICUs should focus on recognition via routine unit-based sur veillance, improved compliance with handwashing and barrier precautions, and antibiotic-use policies tailored to individual units within hospitals.

Impact of contact isolation on FIM score change, FIM efficiency score, and length of stay in patients in acute inpatient rehabilitation facility

OBJECTIVES

To explore the impact of contact isolation on the change in functional independence measure (FIM) score, FIM efficiency score, and length of stay.

DESIGN

Retrospective matched case control study.

SETTING

Tertiary care hospital (academic medical center).

PARTICIPANTS

Persons admitted to an acute inpatient rehabilitation facility at a tertiary care hospital from July 2009 through December 2010.

METHODS

Retrospective chart review by obtaining patient data regarding contact isolation status, patient demographics, and rehabilitation diagnosis. Two hundred charts were reviewed, which resulted in identification of 20 patients in contact isolation. These patients subsequently were matched to patients not in contact isolation based on age, rehabilitation diagnosis, and type of insurance. Admission and discharge FIM scores were obtained for these 40 study subjects (20 cases and 20 matched controls).

MAIN OUTCOME MEASUREMENTS

The primary study outcome measurements were change in FIM score (discharge FIM score minus admission FIM score), FIM efficiency score (change in FIM score divided by length of stay), and length of stay.

RESULTS

Compared with patients not in contact isolation, patients in contact isolation showed no statistically significant difference in FIM score change, a lower FIM efficiency score (P = .010), and a 39% longer length of stay (P = .017) when adjusting for confounders.

CONCLUSIONS

This study identifies contact isolation as a likely variable that is associated with increased length of stay and decreased FIM efficiency score in patients in an acute inpatient rehabilitation facility. Further study is needed to identify the role or mechanisms by which contact isolation is involved in these adverse effects so that interventions may be developed to counteract them.

Guidelines for prevention of hospital acquired infections

These guidelines, written for clinicians, contains evidence-based recommendations for the prevention of hospital acquired infections Hospital acquired infections are a major cause of mortality and morbidity and provide challenge to clinicians. Measures of infection control include identifying patients at risk of nosocomial infections, observing hand hygiene, following standard precautions to reduce transmission and strategies to reduce VAP, CR-BSI, CAUTI. Environmental factors and architectural lay out also need to be emphasized upon. Infection prevention in special subsets of patients - burns patients, include identifying sources of organism, identification of organisms, isolation if required, antibiotic prophylaxis to be used selectively, early removal of necrotic tissue, prevention of tetanus, early nutrition and surveillance. Immunodeficient and Transplant recipients are at a higher risk of opportunistic infections. The post tranplant timetable is divided into three time periods for determining risk of infections. Room ventilation, cleaning and decontamination, protective clothing with care regarding food requires special consideration. Monitoring and Surveillance are prioritized depending upon the needs. Designated infection control teams should supervise the process and help in collection and compilation of data. Antibiotic Stewardship Recommendations include constituting a team, close coordination between teams, audit, formulary restriction, de-escalation, optimizing dosing, active use of information technology among other measure. The recommendations in these guidelines are intended to support, and not replace, good clinical judgment. The recommendations are rated by a letter that indicates the strength of the recommendation and a Roman numeral that indicates the quality of evidence supporting the recommendation, so that readers can ascertain how best to apply the recommendations in their practice environments.

Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial

IMPORTANCE

Antibiotic-resistant bacteria are associated with increased patient morbidity and mortality. It is unknown whether wearing gloves and gowns for all patient contact in the intensive care unit (ICU) decreases acquisition of antibiotic-resistant bacteria.

OBJECTIVE

To assess whether wearing gloves and gowns for all patient contact in the ICU decreases acquisition of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) compared with usual care.

DESIGN, SETTING, AND PARTICIPANTS

Cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from January 4, 2012, to October 4, 2012.

INTERVENTIONS

In the intervention ICUs, all health care workers were required to wear gloves and gowns for all patient contact and when entering any patient room.

MAIN OUTCOMES AND MEASURES

The primary outcome was acquisition of MRSA or VRE based on surveillance cultures collected on admission and discharge from the ICU. Secondary outcomes included individual VRE acquisition, MRSA acquisition, frequency of health care worker visits, hand hygiene compliance, health care–associated infections, and adverse events.

RESULTS

From the 26,180 patients included, 92,241 swabs were collected for the primary outcome. Intervention ICUs had a decrease in the primary outcome of MRSA or VRE from 21.35 acquisitions per 1000 patient-days (95% CI, 17.57 to 25.94) in the baseline period to 16.91 acquisitions per 1000 patient-days (95% CI, 14.09 to 20.28) in the study period, whereas control ICUs had a decrease in MRSA or VRE from 19.02 acquisitions per 1000 patient-days (95% CI, 14.20 to 25.49) in the baseline period to 16.29 acquisitions per 1000 patient-days (95% CI, 13.48 to 19.68) in the study period, a difference in changes that was not statistically significant (difference, −1.71 acquisitions per 1000 person-days, 95% CI, −6.15 to 2.73; P = .57). For key secondary outcomes, there was no difference in VRE acquisition with the intervention (difference,  0.89 acquisitions per 1000 person-days; 95% CI, −4.27 to 6.04, P = .70), whereas for MRSA, there were fewer acquisitions with the intervention (difference, −2.98 acquisitions per 1000 person-days; 95% CI, −5.58 to −0.38; P = .046). Universal glove and gown use also decreased health care worker room entry (4.28 vs 5.24 entries per hour, difference, −0.96; 95% CI, −1.71 to −0.21, P = .02), increased room-exit hand hygiene compliance (78.3% vs 62.9%, difference, 15.4%; 95% CI, 8.99% to 21.8%; P = .02) and had no statistically significant effect on rates of adverse events (58.7 events per 1000 patient days vs 74.4 events per 1000 patient days; difference, −15.7; 95% CI, −40.7 to 9.2, P = .24).

CONCLUSIONS AND RELEVANCE

The use of gloves and gowns for all patient contact compared with usual care among patients in medical and surgical ICUs did not result in a difference in the primary outcome of acquisition of MRSA or VRE. Although there was a lower risk of MRSA acquisition alone and no difference in adverse events, these secondary outcomes require replication before reaching definitive conclusions.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT0131821.

Impact of contact isolation for multidrug-resistant organisms on the occurrence of medical errors and adverse events

Contact isolation of infected or colonised hospitalised patients is instrumental to interrupting multidrug-resistant organism (MDRO) cross-transmission. Many studies suggest an increased rate of adverse events associated with isolation. We aimed to compare isolated to non-isolated patients in intensive care units (ICUs) for the occurrence of adverse events and medical errors.

METHODS

We used the large database of the Iatroref III study that included consecutive patients from three ICUs to compare the occurrence of pre-defined medical errors and adverse events among isolated vs. non-isolated patients. A subdistribution hazard regression model with careful adjustment on confounding factors was used to assess the effect of patient isolation on the occurrence of medical errors and adverse events.

RESULTS

Two centres of the Iatroref III study were eligible, an 18-bed and a 10-bed ICU (nurse-to-bed ratio 2.8 and 2.5, respectively), with a total of 1,221 patients. After exclusion of the neutropenic and graft transplant patients, a total of 170 isolated patients were compared to 980 non-isolated patients. Errors in insulin administration and anticoagulant prescription were more frequent in isolated patients. Adverse events such as hypo- or hyperglycaemia, thromboembolic events, haemorrhage, and MDRO ventilator-associated pneumonia (VAP) were also more frequent with isolation. After careful adjustment of confounders, errors in anticoagulant prescription [subdistribution hazard ratio (sHR) = 1.7, p = 0.04], hypoglycaemia (sHR = 1.5, p = 0.01), hyperglycaemia (sHR = 1.5, p = 0.004), and MDRO VAP (sHR = 2.1, p = 0.001) remain more frequent in isolated patients.

CONCLUSION

Contact isolation of ICU patients is associated with an increased rate of some medical errors and adverse events, including non-infectious ones.

Impact of toxigenic Clostridium difficile polymerase chain reaction testing on the clinical microbiology laboratory and inpatient epidemiology

Conversion from Clostridium difficile toxin A/B EIA to tcdB polymerase chain reaction for diagnosis of C. difficile infection (CDI) resulted in significant decreases in laboratory testing volume and largely unchanged C. difficile toxin detection rates. Decreases in healthcare-associated CDI rates (P ≤ 0.05) reflected a clinical practice benefit of this conversion.

Benefits of universal gloving on hospital-acquired infections in acute care pediatric units

BACKGROUND

To prevent transmission, some pediatric units require clinicians to wear gloves for all patient contacts during RSV season. We sought to assess whether a mandatory gloving policy reduced the risk of other health care-acquired infections (HAIs).

METHODS

This retrospective cohort study included all patients admitted to pediatric units of a tertiary care center between 2002 and 2010. Poisson regression models were used to measure the association between mandatory gloving and HAI incidence. Autoregressive models were used to adjust for time correlation.

RESULTS

During the study period, 686 HAIs occurred during 363 782 patient-days. The risk of any HAI was 25% lower during mandatory gloving periods compared with during nongloving periods (relative risk [RR]: 0.75; 95% confidence interval [CI]: 0.69-0.93; P = .01), after adjusting for long-term trends and seasonal effect. Mandatory gloving was associated with lower risks of bloodstream infections (RR: 0.63; 95% CI: 0.49-0.81; P < .001), central line-associated bloodstream infections (RR: 0.61; 95% CI: 0.44-0.84; P = 0.003), and hospital-acquired pneumonia (RR: 0.20; 95% CI: 0.03-1.25; P= 0.09). The reduction was significant in the PICU (RR: 0.63; 95% CI: 0.42-0.93; P = .02), the NICU (RR: 0.62; 95% CI: 0.39-0.98; P = .04), and the Pediatric Bone Marrow Transplant Unit (RR: 0.52; 95% CI: 0.29-0.91, P = .02).

CONCLUSIONS

Universal gloving during RSV season was associated with significantly lower rates of bacteremia and central line-associated bloodstream infections, particularly in the ICUs and the Pediatric Bone Marrow Transplant Unit.

Is patient isolation the single most important measure to prevent the spread of multidrug-resistant pathogens?

Isolation or cohorting of infected patients is an old concept. Its purpose is to prevent the transmission of microorganisms from infected or colonized patients to other patients, hospital visitors, and health care workers, who may subsequently transmit them to other patients or become infected or colonized themselves. Because the process of isolating patients is expensive, time-consuming, often uncomfortable for patients and may impede care, it should be implemented only when necessary. Conversely, failure to isolate a patient with multidrug-resistant microorganisms may lead to adverse outcomes, and may ultimately be expensive when one considers the direct costs of an outbreak investigation and the indirect costs of lost productivity. In this review, we argue that contact precautions are essential to control the spread of epidemic and endemic multidrug-resistant microorganisms, and discuss limitations of some available data.

Patient isolation measures for infants with candida colonization or infection for preventing or reducing transmission of candida in neonatal units

BACKGROUND

Candida is a common nosocomial infection and is associated with increased healthcare costs. In neonates, candida infection is associated with high mortality and morbidity and is transmitted by direct and indirect contact. Patient isolation measures, i.e. single room isolation or cohorting, are usually recommended for infections that spread by contact.

OBJECTIVES

To determine the effect of patient isolation measures (single room isolation and/or cohorting) for infants with candida colonization or infection as an adjunct to routine infection control measures on the transmission of candida to other infants in the neonatal unit.

SEARCH METHODS

Relevant trials in any language were searched in the following databases in July 2011: The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2011), MEDLINE, BIOSIS, EMBASE and CINAHL. Proceedings of the Pediatric Academic Societies (from 1987) and ongoing trials were searched.

SELECTION CRITERIA

Types of studies: Cluster randomized trials (where clusters may be defined by hospital, ward, or other subunits of the hospital).

TYPES OF PARTICIPANTS

Neonatal units caring for infants colonized or infected with Candida. Types of interventions: A policy of patient isolation measures (single room isolation or cohorting of infants with Candida colonization or infection) compared to routine isolation measures.

DATA COLLECTION AND ANALYSIS

The standard methods of the Cochrane Neonatal Review Group (CNRG) were used to identify studies and to assess the methodological quality of eligible cluster-randomized trials. Infection rates and colonization rates were to be expressed as rate ratios for each trial and if appropriate for meta-analysis, the generic inverse variance method in RevMan was to be used.

MAIN RESULTS

No eligible trials were identified.

AUTHORS' CONCLUSIONS

The review found no evidence to either support or refute the use of patient isolation measures (single room isolation or cohorting) in neonates with candida colonization or infection.Despite the evidence for transmission of candida by contact and evidence of cross-infection by health care workers, no standard policy of patient isolation measures beyond routine infection control measures exists in the neonatal unit. There is an urgent need to research the role of patient isolation measures for preventing transmission of candida in the neonatal unit. Well designed trials randomizing clusters of units or hospitals to a type of patient isolation method intervention are needed.

Adverse effects of isolation in hospitalised patients: a systematic review

The use of transmission precautions such as contact isolation in patients known to be colonised or infected with multidrug-resistant organisms is recommended in healthcare institutions. Although essential for infection control, contact isolation has recently been associated with adverse effects in patients. We undertook a systematic review to determine whether contact isolation leads to psychological or physical problems for patients. Studies were included if (1) hospitalised patients were placed under isolation precautions for an underlying medical indication, and (2) any adverse events related to the isolation were evaluated. We found 16 studies that reported data regarding the impact of isolation on patient mental well-being, patient satisfaction, patient safety or time spent by healthcare workers in direct patient care. The majority showed a negative impact on patient mental well-being and behaviour, including higher scores for depression, anxiety and anger among isolated patients. A few studies also found that healthcare workers spent less time with patients in isolation. Patient satisfaction was adversely affected by isolation if patients were kept uninformed of their healthcare. Patient safety was also negatively affected, leading to an eight-fold increase in adverse events related to supportive care failures. We found that contact isolation may negatively impact several dimensions of patient care. Well-validated tools are necessary to investigate these results further. Large studies examining a number of safety indicators to assess the adverse effects of isolation are needed. Patient education may be an important step to mitigate the adverse psychological effects of isolation and is recommended.

Risk factors for healthcare-associated infection in pediatric intensive care units: a systematic review

A systematic review of observational studies on risk factors for healthcare-associated infection in pediatric Intensive Care Units (ICU) was carried out. Studies indexed in MEDLINE, LILACS, Cochrane, BDENF, CAPES databases published in English, French, Spanish or Portuguese between 1987 and 2006 were included and cross references added. Key words for search were 'cross infection' and 'Pediatric Intensive Care Units' with others sub-terms included. 11 studies were selected from 419 originally found: four studies had healthcare-associated infection as the main outcome without a specific site; three articles identified factors associated with lower respiratory tract infection (pneumonia or tracheitis); three articles were concerned with laboratory-confirmed bloodstream infection; and a single retrospective study analyzed urinary tract infection. The production of evidence on risk factors Paediatric ICU has not kept up the same pace of that on adult - there are few studies with adequate design and statistical analysis. The methodological diversity of the studies did not allow for a summarized measurement of risk factors.

Does mixing acute medical admissions with burn patients increase infective complications from paediatric thermal injuries?

In the winter of 2005–2006, the management at our children's hospital elected to admit ‘overspill’ acute medical admissions to the ward used for plastic surgery and burns for logistical reasons. This study was conducted to assess the effects of that change on the incidence of infective complications in thermally-injured patients. Seventy-three patients were studied, 23 in the sample winter and 50 in the two preceding control winters. The data gathered included days on IV fluids and antibiotics, transfer to the Paediatric Intensive Care Unit (PICU), microbiology and a ‘septic signs score’ – based on pyrexia, irritability, diarrhoea/vomiting, wound colonization, bacteraemia. The outcomes studied were: the maximum ‘septic signs score’; patients with a score ≥3; wound colonization; PICU admission; days on antibiotics and IV fluids. A statistically significant increase in patients with septic episodes was demonstrated by an increase in the mean septic signs score (0.66–1.48, P = 0.044) and the number of patients with a score ≥3 (4–22%, P = 0.017). Other analysed variables did not reach statistical significance although the raw data suggested a trend. It was concluded that there is an association between mixing acute medical admissions with thermally-injured patients and an increase in the incidence of infective complications in the latter group.

Rotation of antimicrobial therapy in the intensive care unit: impact on incidence of ventilator-associated pneumonia caused by antibiotic-resistant Gram-negative bacteria

The development of antibiotic resistance is associated with high morbidity and mortality, particularly in the intensive care unit (ICU) setting. We evaluated the effect of an antibiotic rotation programme on the incidence of ventilator-associated pneumonia (VAP) caused by antibiotic-resistant Gram-negative bacteria. We conducted a 2-year before-and-after study at two medical-surgical ICUs at two different tertiary referral hospitals. We included all mechanically ventilated patients admitted for > or =48 h who developed VAP. From 1 January through 31 December 2007, a quarterly rotation of antibiotics (piperacillin/tazobactam, fluoroquinolones, carbapenems and cefepime/ceftazidime) for the empirical treatment of VAP was implemented. We analysed the incidence of VAP and the antibiotic resistance patterns of the responsible pathogens in 2006, before (P1) and, in 2007, after (P2) the introduction of the scheduled rotation programme. Overall, there were 79 VAP episodes in P1 and 44 in P2; the mean incidence of VAP was 20.96 cases per 1,000 days of mechanical ventilation (MV) during P1 and 14.97 in P2, with no significant difference between periods on segmented regression analysis. We observed a non-significant reduction of the number of both the poly-microbial (14 [17.7%] in P1 and 5 [10.6%] in P2 [p = 0.32]) and of the antibiotic-resistant Gram-negative bacteria-related VAP (42 [45.2%] in P1 and 16 [34%] in P2 [p = 0.21]). Conversely, the number of VAP caused by Pseudomonas aeruginosa passed from 8.35 per 1,000 days of MV in P1 to 2.33 per 1,000 days of MV in P2 (p = 0.02). No difference in ICU mortality and crude in-hospital mortality between P1 and P2 was noted. Moreover, no significant change of microbial flora isolated through clinical cultures was observed. We were able to conclude that, despite global microbial flora not being affected by such a programme, antibiotic therapy rotation may reduce the incidence of VAP caused by antibiotic-resistant Gram-negative bacteria in the ICU, such as Pseudomonas aeruginosa. The application of this programme may also improve antibiotic susceptibility. However, further studies are needed to confirm our results.

Rationale and design of the pediatric critical illness stress-induced immune suppression (CRISIS) prevention trial

Despite implementation of CDC recommendations and bundled interventions for preventing catheter-associated blood stream infection, ventilator-associated pneumonia, or urinary catheter-associated infections, nosocomial infections and sepsis remain a significant cause of morbidity and mortality in critically ill children. Recent studies suggest that acquired critical illness stress-induced immune suppression (CRISIS) plays a role in the development of nosocomial infection and sepsis. This condition can be related to inadequate zinc, selenium, and glutamine levels, as well as hypoprolactinemia, leading to stress-induced lymphopenia, a predominant T(H)2 monocyte/macrophage state, and subsequent immune suppression. Prolonged immune dysfunction increases the likelihood of nosocomial infections associated with invasive devices. Although strategies to prevent common complications of critical illness are routinely employed (eg, prophylaxis for gastrointestinal bleeding, thrombophlebitis), no prophylactic strategy is used to prevent stress-induced immune suppression. This is the authors' rationale for the pediatric CRISIS prevention trial (NCT00395161), designed as a randomized, double-blind, controlled clinical investigation to determine if daily enteral supplementation with zinc, selenium, and glutamine as well as parenteral metoclopramide (a dopamine 2 receptor antagonist that reverses hypoprolactinemia) prolongs the time until onset of nosocomial infection or sepsis in critically ill children compared to enteral supplementation with whey protein. If effective, this combined nutritional and pharmacologic approach may lessen the excess morbidity and mortality as well as resource utilization associated with nosocomial infections and sepsis in this population. The authors present the design and analytic plan for the CRISIS prevention trial.

Adverse outcomes associated with Contact Precautions: a review of the literature

BACKGROUND

Contact Precautions (CP) are a standard method for preventing patient-to-patient transmission of multiple drug-resistant organisms (MDROs) in hospital settings. With the ongoing worldwide concern for MDROs including methicillin-resistant Staphylococcus aureus (MRSA) and broadened use of active surveillance programs, an increasing number of patients are being placed on CP. Whereas few would argue that CP are an important tool in infection control, many reports and small studies have observed worse noninfectious outcomes in patients on CP. However, no review of this literature exists.

METHODS

We systematically reviewed the literature describing adverse outcomes associated with CP. We identified 15 studies published between 1989 and 2008 relating to adverse outcomes from CP. Nine were higher quality based on standardized collection of data and/or inclusion of control groups.

RESULTS

Four main adverse outcomes related to CP were identified in this review. These included less patient-health care worker contact, changes in systems of care that produce delays and more noninfectious adverse events, increased symptoms of depression and anxiety, and decreased patient satisfaction with care.

CONCLUSION

Although CP are recommended by the Centers for Disease Control and Prevention as an intervention to control spread of MDROs, our review of the literature demonstrates that this approach has unintended consequences that are potentially deleterious to the patient. Measures to ameliorate these deleterious consequences of CP are urgently needed.

Vancomycin-resistant Enterococcus – A Review From a Singapore Perspective

Introduction: Vancomycin-resistant enterococcus (VRE) can cause serious infections in vulnerable, immunocompromised patients. Materials and Methods: In this article, we summarise current data on epidemiology, detection, treatment and prevention of VRE. Results: VRE was first isolated in Singapore in 1994 and until 2004 was only sporadically encountered in our public hospitals. After 2 outbreaks in 2004 and in 2005, VRE has become established in our healthcare institutions. Multiple studies have shown that VRE spreads mainly via contaminated hands, cloths and portable equipment carried by healthcare workers. Conclusions: Only a comprehensive programme (consisting of active surveillance, isolation of colonised/infected patients, strict adherence to proper infection control practices and anti-microbial stewardship) can limit the spread of these organisms. In addition to monitoring the compliance with traditional infection control measures, new strategies that merit consideration include pre-emptive isolation of patients in high-risk units and molecular techniques for the detection of VRE. Keywords: Antibiotic resistance, Infection control, Outbreaks, Surveillance

Care of children isolated for infection control: a prospective observational cohort study

BACKGROUND

Patients with community-acquired or nosocomial infections are often managed in a hospital with isolation precautions. Given the high prevalence and substantial inconvenience associated with implementation of isolation precautions in pediatric settings, we explored the impact of this intervention on the care provided to children and their families.

OBJECTIVE

The purpose of this work was to compare the quantity and quality of care received by isolated patients relative to nonisolated patients.

PATIENTS AND METHODS

Sixty-five consecutive newly admitted inpatients in private rooms (24 isolated, 41 nonisolated) were recruited from the general pediatric service at the Hospital for Sick Children. Interactions between a medical team with patients and their families were observed. All of the participants were blinded to the study objectives. The medical team was observed during its morning rounds, and data were collected on the quantity and quality of care. Quantity of care was determined by the amount of time that the medical team spent interacting with the patient and parents and the number of organ systems examined by the attending physician during morning rounds. Quality of care was determined by using parental completion of the Pediatric Family Satisfaction Questionnaire.

RESULTS

We found no significant difference in the average amount of time spent interacting with isolated compared with nonisolated patients (516 vs 480 seconds) or the number of organ systems examined in isolated compared with nonisolated patients (3 vs 4). Isolated and nonisolated groups gave high ratings to all of the items pertaining to the facility, doctors, and nurses.

CONCLUSIONS

No large differences in quality or quantity of care were observed between isolated and nonisolated patients in the first 2 days of admission to a pediatric ward.

Patient isolation measures for infants with candida colonization or infection for preventing or reducing transmission of candida in neonatal units

BACKGROUND

Candida is one of the most common nosocomial infections in the intensive care setting worldwide and is associated with increased healthcare costs. In neonates, candida infection is associated with high mortality and morbidity. Candida is transmitted by direct and indirect contact. Routine infection control measures that include standard precautions are routinely employed to prevent spread of nosocomial infections. Patient isolation measures, i.e. single room isolation or cohorting, are usually recommended for infections spread by contact.

OBJECTIVES

To determine the effect of patient isolation measures (single room isolation and/or cohorting) for infants with candida colonization or infection as an adjunct to routine infection control measures on the transmission of candida to other infants in the neonatal unit.

SEARCH STRATEGY

Relevant trials in any language were searched in the following databases in Jan 2007: The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2006), MEDLINE (1966 - Jan 2007) and PREMEDLINE, EMBASE (1980 - Jan 2007), CINAHL (1982 - Jan 2007). Proceedings of the Pediatric Academic Societies (American Pediatric Society, Society for Pediatric Research) and the European Society for Pediatric Research (1987 - Jan 2007) were also searched in Jan 2007. Authors or other experts were contacted for more information on relevant published or unpublished trials. Additional searches were also made in the reference lists of relevant journal articles and in the reviewer's personal files.

SELECTION CRITERIA

Types of studies: Cluster randomized trials (where clusters may be defined by hospital, ward, or other subunits of the hospital).

TYPES OF PARTICIPANTS

Neonatal units caring for infants colonized or infected with candida. Types of interventions: A policy of patient isolation measures (single room isolation or cohorting of infants with candida colonization or infection) compared to routine isolation measures.

DATA COLLECTION AND ANALYSIS

The standard methods of the Cochrane Neonatal Review Group (CNRG) were to be used to identify studies and to assess the methodological quality of eligible trials. The statistical package (RevMan 4.2) provided by the Cochrane Collaboration was to be used. In cluster-randomized trials, if the unit of analysis of the trial was the cluster (not individuals) and analysis took into account the correlation between clusters, the inverse variance method was to be used for meta-analysis. If this was not the case, a narrative synthesis was to be made without meta-analysis. Infection rates and colonization rates were to be expressed as rate ratios for each trial and if appropriate for meta-analysis, the generic inverse variance method in RevMan was to be used.

MAIN RESULTS

No eligible trials were identified.

AUTHORS' CONCLUSIONS

The review found no evidence to either support or refute the use of patient isolation measures (single room isolation or cohorting) in neonates with candida colonization or infection. Despite the evidence for transmission of candida by direct or indirect contact and evidence of cross-infection by health care workers, no standard policy of patient isolation measures beyond routine infection control measures exists in the neonatal unit. There is an urgent need to research the role of patient isolation measures for preventing transmission of candida in the neonatal unit. Cluster randomized trials involving multiple units or hospitals with randomized allocation of one type of patient isolation measure or the other (i.e. single room isolation or cohorting) with careful consideration for determining an appropriate sample size and analysis would be the most appropriate method to research this intervention.

Relationship between immunosuppression and intensive care unit-acquired multidrug-resistant bacteria: a case-control study

OBJECTIVE

To determine the relationship between immunosuppression and intensive care unit (ICU)-acquired multidrug-resistant (MDR) bacteria.

DESIGN

Retrospective case-control study based on prospectively collected data.

SETTING

A 30-bed medical and surgical ICU.

PATIENTS

All patients hospitalized >48 hrs in the ICU were eligible during a 2-yr period.

INTERVENTIONS

Immunosuppression was defined as active solid or hematologic malignancy, leucopenia, or chronic immunosuppressive treatment. MDR bacteria were defined as methicillin-resistant Staphylococcus aureus, ceftazidime- or imipenem-resistant Pseudomonas aeruginosa, Acinetobacter baumannii, Stenotrophomonas maltophilia, and extending spectrum beta-lactamase producing Gram-negative bacilli. MDR bacteria screening (nasal, anal, and axilla swabs and tracheal aspirate in intubated patients) was performed at ICU admission and weekly. Only MDR bacteria isolated >48 hrs after ICU admission were taken into account; duplicates were excluded. Isolation measures were applied in all patients at ICU admission, in patients with MDR bacteria, and in patients with immunosuppression. Immunosuppressed patients (cases) were matched (1:1) with immunocompetent patients (controls) according to all the following criteria: age +/-5 yrs, Simplified Acute Physiology Score II +/-5, duration of ICU stay +/-3 days, and category of admission (medical/surgical). Risk factors for ICU-acquired MDR bacteria were determined using univariate and multivariate analyses.

MEASUREMENTS AND MAIN RESULTS

Of 1,065 eligible patients, nine patients were excluded for absence of MDR bacteria screening at ICU admission. One hundred thirty-three (12%) patients were immunosuppressed, and 128 (96%) of them were successfully matched. Mean time between ICU admission and first ICU-acquired MDR bacteria was 12 +/- 9 days. Incidence of MDR bacteria was significantly higher in cases than in controls (22 vs. 12 MDR bacteria/1000 ICU days, p = .004). However, immunosuppression was not independently associated with ICU-acquired MDR bacteria.Multivariate analysis identified prior antibiotic treatment and antibiotic treatment in the ICU as risk factors for ICU-acquired MDR bacteria (odds ratio [95% confidence interval] = 1.9 [1-3.6], p = .003; 11 [1.4-83], p = .02; respectively).

CONCLUSIONS

Immunosuppression is not independently associated with ICU-acquired MDR bacteria. However, infection control measures used in our ICU may have influenced this result.

Evidence-Based Nursing Practice to Prevent Infection in Hospitalized Neutropenic Patients With Cancer

PURPOSE/OBJECTIVES

To review studies that have assessed the effectiveness of selected nursing interventions used in hospitals to prevent healthcare-associated infections in neutropenic patients with cancer.

DATA SOURCES

Literature review of low microbial diets, protective clothing and environments, personal hygiene, and oral care in English-language articles from PubMed; the Cumulative Index of Nursing and Allied Health Literature; the National Guideline Clearinghouse, 1980-June 2003; and Cochrane Database of Systematic Reviews.

DATA SYNTHESIS

Few studies have demonstrated the effectiveness of low microbial food and water and protective environments and clothing in reducing infections in neutropenic patients with cancer, and hospitals vary in these practices. Skin antisepsis reduces microbial counts, but data regarding the effect on infections are lacking. Many studies were characterized by insufficient sample sizes or use of multiple interventions.

CONCLUSIONS

Major gaps exist in empirical evidence regarding which nursing interventions might be helpful in preventing or controlling healthcare-associated infections in neutropenic patients.

IMPLICATIONS FOR NURSING

Although the evidence base for clinical practices such as a low microbial diet, protective environments and clothing, and special skin antisepsis regimens is weak, some of these practices seem prudent and reasonable. Until further evidence is available, clinicians can use consensus guidelines and should assist in identifying clinical practices that require additional research. Ultimately, interventions with little or no demonstrated efficacy should be examined systematically or abandoned. Additional studies of sufficient sample size regarding nursing practices such as the role of protective environments, room placement, antiseptic bathing, and prevention and treatment of oral complications are indicated. Because of difficulties in randomization and risk stratification, rigorous observational studies often may be an acceptable alternative to clinical trials.

Impact of a methicillin-resistant Staphylococcus aureus active surveillance program on contact precaution utilization in a surgical intensive care unit*

OBJECTIVE

To determine the impact of an active surveillance for methicillin-resistant Staphylococcus aureus (MRSA) on contact precaution utilization, as measured by additional number of contact precaution days attributable to the active surveillance program.

DESIGN

Prospective cohort study.

SETTING

Twenty-four-bed surgical intensive care unit (ICU).

PATIENTS

All patients admitted to the surgical ICU.

INTERVENTIONS

Nasal cultures for MRSA were performed at admission to a surgical ICU for 19 months. Patients admitted>48 hrs also received weekly and discharge nasal cultures.

MEASUREMENTS AND MAIN RESULTS

Clinical data, including start date and initial indication for contact precautions, were prospectively collected. Of 1,893 admissions, 253 (13%) were found to be MRSA-positive during their ICU stay. One hundred forty-six (58%) were identified by nasal culture alone. Compared with the first 10 months of study, the prevalence of MRSA on admission to the ICU during the last 9 months of the study period significantly increased (7.2% vs. 11.4%, p<.001). Acquisition of MRSA by noncolonized patients remained constant between the first 10 months and last 9 months of study (7.0 vs. 5.5 cases per 1000 patient days, p=.29). Two hundred fourteen (6%) of 3461 total contact precaution days in the ICU were attributable to MRSA active surveillance. In sensitivity analyses, the implementation of rapid, same-day results for MRSA active surveillance would increase contact precaution days by 15% compared with no surveillance. If the total number of vancomycin-resistant enterococci patients in the ICU were reduced by 50%, the contact precaution days attributable to active surveillance would increase to 9%.

CONCLUSIONS

MRSA active surveillance increased total contact precaution days in this ICU by 6% yet detected 58% of MRSA cases that would have been otherwise missed. Despite an increasing prevalence of MRSA on admission to the ICU, the acquisition rate has remained constant.

Effectiveness of preemptive barrier precautions in controlling nosocomial colonization and infection by methicillin-resistant Staphylococcus aureus in a burn unit

BACKGROUND

We report the effectiveness of preemptive enhanced barrier precautions in containing a methicillin-resistant Staphylococcus aureus (MRSA) outbreak in a university hospital burn unit and further controlling endemic nosocomial MRSA infection in the unit during the succeeding 27 months.

METHODS

During a 6-month period, 12 patients in a 7-bed burn unit were found to be colonized (7) or infected (5) by MRSA. An epidemiologic study was undertaken.

RESULTS

Seven of the 10 strains of MRSA from patients that were available for DNA typing were clonally identical. Early in the outbreak, a health care worker was found to be a concordant nasal carrier and was successfully decolonized with nasal mupirocin. However, despite stringent compliance with isolation of MRSA-positive patients (targeted precautions), new cases of MRSA colonization or infection continued to occur. The outbreak was rapidly terminated after implementing preemptive barrier precautions with all patients in the unit: a new, clean gown and gloves for any physical contact with the patient or their environment. Although 25% of all nosocomial S aureus isolates in our hospital are resistant to methicillin, the incidence of endemic MRSA colonization and infection in the burn unit has remained very low since implementing barrier precautions unit wide (baseline rate, 2.2 [95% CI: 1.0-4.2] cases per 1000 patient-days; outbreak rate, 7.2 [95% CI: 4.4-11.0] cases per 1000 patient-days; post-outbreak termination endemic rate, 1.1 (95% CI: 0.4-2.3) cases per 1000 patient-days). The rate ratio comparing the outbreak and the baseline period was 3.20 (95% CI: 1.40-7.95, P = .002); the rate ratio comparing the post-outbreak period with the baseline period was 0.48 (95% CI: 0.14-1.53, P = .10), and it has not been necessary to screen personnel for MRSA carriage to prevent nosocomial MRSA infections in this highly vulnerable population.

CONCLUSION

Preemptive barrier precautions were highly effective in controlling the outbreak and, most notably, have also been highly effective in maintaining a very low incidence of nosocomial MRSA infection endemically in the succeeding 27 months of follow-up. Use of clean gloves, with or without a gown, bears consideration for all high-risk hospitalized patients to prevent cross transmission of all multiresistant nosocomial pathogens.

Decreasing ventilator-associated pneumonia in a trauma ICU

BACKGROUND

The incidence of ventilator-associated pneumonia ranges from 10 to 25%, with mortality of 10 to 40%. It prolongs hospital stay and drives up hospital costs. Our Intensive Care Unit (ICU) ventilator-associated pneumonia (VAP) rates were hovering at the National Nosocomial Infection Surveillance (NNIS) 90th percentile (22.3-32.7 infections per 1,000 ventilator days from January 2002 through October 2002) necessitating a performance improvement initiative designed to decrease the incidence of VAP.

METHODS

A ventilator bundle that incorporates the Center for Disease Control (CDC) Guidelines for Prevention of Nosocomial Pneumonia was instituted in June of 2002. In October 2002, an intervention that audited compliance with the ventilator bundle and provided real-time feedback to ICU staff was started. VAP rates were followed using NNIS criteria. Costs were evaluated using hospital TSI data.

RESULTS

VAP did not decrease with institution of the ventilator bundle alone. However, VAP did significantly decrease when the compliance with the ventilator bundle was audited daily and weekly feedback was provided to the caregivers. From November 2002 through June 2003 VAP stayed between 0 and 12.8 per 1,000 ventilator days. The average cost of a VAP was 50,000 dollars.

CONCLUSIONS

Prevention of VAP requires a concerted effort on the part of hospital administration, physicians, and ICU personnel. The program must be evidence-based, maintained, and accepted by ICU personnel. Continued education and feedback are crucial to maintaining a low VAP rate.

Infectious Complications of Cancer Therapy

Advances in the management of cancer, particularly the development of new chemotherapeutic agents, have greatly improved the survival and outcome of patients with hematologic malignancies and solid tumors; overall 5-year survival rates in cancer patients have improved from 39% in the 1960s to 60% in the 1990s.1 However, infection, caused by both the underlying malignancy and cancer chemotherapy, particularly myelosuppressive chemotherapy, remains a persistent challenge.

Isolation of patients in single rooms or cohorts to reduce spread of MRSA in intensive-care units: prospective two-centre study

BACKGROUND

Hospital-acquired infection due to meticillin-resistant Staphylococcus aureus (MRSA) is common within intensive-care units. Single room or cohort isolation of infected or colonised patients is used to reduce spread, but its benefit over and above other contact precautions is not known. We aimed to assess the effectiveness of moving versus not moving infected or colonised patients in intensive-care units to prevent transmission of MRSA.

METHODS

We undertook a prospective 1-year study in the intensive-care units of two teaching hospitals. Admission and weekly screens were used to ascertain the incidence of MRSA colonisation. In the middle 6 months, MRSA-positive patients were not moved to a single room or cohort nursed unless they were carrying other multiresistant or notifiable pathogens. Standard precautions were practised throughout. Hand hygiene was encouraged and compliance audited.

FINDINGS

Patients' characteristics and MRSA acquisition rates were similar in the periods when patients were moved and not moved. The crude (unadjusted) Cox proportional-hazards model showed no evidence of increased transmission during the non-move phase (0.73 [95% CI 0.49-1.10], p=0.94 one-sided). There were no changes in transmission of any particular strain of MRSA nor in handwashing frequency between management phases.

INTERPRETATION

Moving MRSA-positive patients into single rooms or cohorted bays does not reduce crossinfection. Because transfer and isolation of critically ill patients in single rooms carries potential risks, our findings suggest that re-evaluation of isolation policies is required in intensive-care units where MRSA is endemic, and that more effective means of preventing spread of MRSA in such settings need to be found.