How effective are monthly departmental tracer surveys? A five-year retrospective study of 138 surveys in 96 departments

BACKGROUND

Repeat departmental-wide surveys are commonly employed for infection-control. There remains debate concerning their cost-effectiveness.

AIM OF THE STUDY

To measure the impact of repeat departmental-wide surveys in major in-patient departments (IPD) and ambulatory facilities (AF) in a tertiary care hospital.

DESIGN

Retrospective study of 138 surveys conducted in 96 departments over a five-year period.

METHODS

Two itemized questionnaires were designed to assess the most frequently inadequately-adhered-to infection control measures: one for IPD (with 21 items), the other for AF (with 17 items).

RESULTS

A total of 72 surveys were conducted in 49 IPDs, of which 39 (54%) were repeat surveys, and 66 surveys in 47 AFs, of which 33 (50%) were repeat surveys. The baseline rate of adherence/department was 71%±14 for the IPD, with an increase from the first to the last survey to 82%±13 (p=0.037). In 15/21 measured infection control items, adherence improved. Adherence to infection control items was lower at baseline in the AFs than in the IPDs (63±27), with an increase to 76±20 (NS). Although adherence improved for nine items, it deteriorated in another eight, producing an overall statistically unchanged outcome.

CONCLUSION

Repeat whole-department surveys contribute moderately to increased adherence to infection control guidelines. Ambulatory facilities demonstrate lower rates of adherence to infection control guidelines and are less receptive to educational measures.

Descriptive epidemiology of central line-associated bloodstream infections at an academic medical center in Iowa, 2019-2022

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) increased nationally during the COVID-19 pandemic. We described CLABSIs at our institution during 2019 to 2022.

METHODS

This retrospective observational study examined CLABSIs among adult inpatients at an 866-bed teaching hospital in the Midwest. CLABSI incidence was trended over time and compared to monthly COVID-19 admissions. Manual chart review was performed to obtain patient demographics, catheter-associated variables, pathogens, and clinical outcomes.

RESULTS

We identified 178 CLABSIs. The CLABSI incidence (cases per 1,000 line days) tripled in October 2020 as COVID-19 admissions increased. CLABSIs in 2020 were more frequently caused by coagulase-negative staphylococci and more frequently occurred in the intensive care units 7+ days after central line insertion. The CLABSI incidence normalized in early 2021 and did not increase during subsequent COVID-19 surges. Throughout 2019 to 2022, about half of the nontunneled central venous catheters involved in CLABSI were placed emergently. One-quarter of CLABSIs involved multiple central lines. Chlorhexidine skin treatment adherence was limited by patient refusal.

CONCLUSIONS

The increase in CLABSIs in late 2020 during a surge in COVID-19 admissions was likely related to central line maintenance but has resolved. Characterizing CLABSI cases can provide insight into adherence to guideline-recommended prevention practices and identify areas for improvement at individual institutions.

Clostridioides difficile infection in neurosurgical patients in a national centre over 10 years: less common but associated with longer hospital stays

BACKGROUND

Clostridioides difficile infection (CDI) is a leading cause of healthcare-associated (HA) diarrhoea, contributing to patient morbidity and prolonged length-of-stay (LOS). We retrospectively assessed CDI over a decade in a national neurosurgical centre, with a multi-disciplinary approach to CDI surveillance and antimicrobial stewardship, by comparing CDI patients with other patient groups.

METHODS

Data on CDI in neurosurgical inpatients between January 2012 and December 2021 were collated. Disease-specific variables were compared to other inpatients with CDI. Rates per 10,000 bed days used were calculated. Patient-specific differences were compared with neurosurgical patients without CDI. CDI rates by patient group were explored using odds ratio (OR) and χ2 analyses. Negative binomial regression was used to investigate CDI rates over time.

RESULTS

Of 50 neurosurgical patients with CDI, all were HA; the average age was 53 years (standard deviation (SD) 16.3 years), 49 were first-episode CDI, and three had severe CDI. The majority (76.7%) had received recent antimicrobials. Compared with non-neurosurgical CDI patients, neurosurgical CDI rates differed significantly (1.9 versus 3.6 per 10,000 bed days used, p < 0.05), neurosurgical patients were younger (p ≤ 0.01), C. difficile testing was more likely to be requested by neurosurgeons (OR 2.4; p ≤ 0.01), and the proportion of severe CDI was higher (6% versus 2%, OR 3.0, p = 0.07, confidence interval (CI) 0.54 to 11.3). Within the neurosurgical cohort, CDI patients had an average LOS four times that of other patients (CI 15.2 to 35.1; p < 0.01) and were older (53.5 versus 47.8 years, CI 0.1 to 11 years; p < 0.05). Only one CDI outbreak was linked to neurosurgical patients.

CONCLUSION

CDI in neurosurgery patients differed from the wider hospital, with greater awareness of CDI testing. Longer LOS impacted bed utilisation with limited capacity. Robust surveillance supports proactive antimicrobial stewardship programmes in this vulnerable population.

Multi-site implementation of whole genome sequencing for hospital infection control: A prospective genomic epidemiological analysis

BACKGROUND

Current microbiological methods lack the resolution to accurately identify multidrug-resistant organism (MDRO) transmission, however, whole genome sequencing can identify highly-related patient isolates providing opportunities for precision infection control interventions. We investigated the feasibility and potential impact of a prospective multi-centre genomics workflow for hospital infection control.

METHODS

We conducted a prospective genomics implementation study across eight Australian hospitals over 15 months (2017,2018), collecting all clinical and screening isolates from inpatients with vanA VRE, MRSA, ESBL Escherichia coli (ESBL-Ec), or ESBL Klebsiella pneumoniae (ESBL-Kp). Genomic and epidemiologic data were integrated to assess MDRO transmission.

FINDINGS

In total, 2275 isolates were included from 1970 patients, predominantly ESBL-Ec (40·8%) followed by MRSA (35·6%), vanA VRE (15·2%), and ESBL-Kp (8·3%).Overall, hospital and genomic epidemiology showed 607 patients (30·8%) acquired their MDRO in hospital, including the majority of vanA VRE (266 patients, 86·4%), with lower proportions of ESBL-Ec (186 patients, 23·0%), ESBL-Kp (42 patients, 26·3%), and MRSA (113 patients, 16·3%). Complex patient movements meant the majority of MDRO transmissions would remain undetected without genomic data.The genomics implementation had major impacts, identifying unexpected MDRO transmissions prompting new infection control interventions, and contributing to vanA VRE becoming a notifiable condition. We identified barriers to implementation and recommend strategies for mitigation.

INTERPRETATION

Implementation of a multi-centre genomics-informed infection control workflow is feasible and identifies many unrecognised MDRO transmissions. This provides critical opportunities for interventions to improve patient safety in hospitals.

FUNDING

Melbourne Genomics Health Alliance (supported by State Government of Victoria, Australia), and National Health and Medical Research Council (Australia).

Impact of antimicrobial stewardship programs on antibiotic consumption and antimicrobial resistance in four Colombian healthcare institutions

BACKGROUND

Antimicrobial stewardship programs (ASPs) have become a fundamental pillar in optimizing antimicrobial usage, improving patient care, and reducing antimicrobial resistance (AMR). Herein we evaluated the impact of an ASP on antimicrobial consumption and AMR in Colombia.

METHODS

We designed a retrospective observational study and measured trends in antibiotic consumption and AMR before and after the implementation of an ASP using interrupted time series analysis over a 4-year period (24 months before and 24 months after ASP implementation).

RESULTS

ASPs were implemented according to the available resources in each of the institutions. Before ASP implementation, there was a trend toward an increase in the antibiotic consumption of all measured antimicrobials selected. Afterward, an overall decrease in antibiotic consumption was observed. The use of ertapenem and meropenem decreased in hospital wards, while a decrease in the use of ceftriaxone, cefepime, piperacillin/tazobactam, meropenem, and vancomycin was observed in intensive care units. After ASP implementation, the trend toward an increase of oxacillin-resistant Staphylococcus aureus, ceftriaxone-resistant Escherichia coli, and meropenem-resistant Pseudomonas aeruginosa was reversed.

CONCLUSIONS

In our study, we showed that ASPs are a key strategy in tackling the emerging threat of AMR and have a positive impact on antibiotic consumption and resistance.

Impact of COVID-19 on an infection prevention and control program, Iowa 2020-2021

Background

The COVID-19 pandemic has affected infection prevention and control (IPC) programs worldwide. We evaluated the impact of COVID-19 on the University of Iowa Hospitals & Clinics IPC program by measuring the volume of calls to the program, changes in healthcare-associated infection rates, and team member perceptions.

Methods

We retrieved the IPC call log and healthcare-associated infection trends for 2018-2020. We defined 2 periods: pre-COVID-19 (2018-2019) and COVID-19 (January-December 2020). We also conducted one-on-one interviews and focus group interviews with members of the IPC program and describe changes in their working conditions during the COVID-19 period.

Results

A total of 6,564 calls were recorded during 2018-2020. The pre-COVID-19 period had a median of 71 calls and/or month (range: 50-119). During the COVID-19 period, the median call volume increased to 368/month (range: 149-829), and most calls were related to isolation precautions (50%). During the COVID-19 period, the central line-associated bloodstream infection incidence increased significantly. Infection preventionists reported that the ambiguity and conflicting guidance during the pandemic were major challenges.

Conclusions

Our IPC program experienced a 500% increase in consultation requests. Planning for future bio-emergencies should include creative strategies to increase response capacity within IPC programs.

Risk factors for nosocomial SARS-CoV-2 infections in patients: results from a retrospective matched case-control study in a tertiary care university center

BACKGROUND

Factors contributing to the spread of SARS-CoV-2 outside the acute care hospital setting have been described in detail. However, data concerning risk factors for nosocomial SARS-CoV-2 infections in hospitalized patients remain scarce. To close this research gap and inform targeted measures for the prevention of nosocomial SARS-CoV-2 infections, we analyzed nosocomial SARS-CoV-2 cases in our hospital during a defined time period.

METHODS

Data on nosocomial SARS-CoV-2 infections in hospitalized patients that occurred between May 2020 and January 2021 at Charité university hospital in Berlin, Germany, were retrospectively gathered. A SARS-CoV-2 infection was considered nosocomial if the patient was admitted with a negative SARS-CoV-2 reverse transcription polymerase chain reaction test and subsequently tested positive on day five or later. As the incubation period of SARS-CoV-2 can be longer than five days, we defined a subgroup of "definite" nosocomial SARS-CoV-2 cases, with a negative test on admission and a positive test after day 10, for which we conducted a matched case-control study with a one to one ratio of cases and controls. We employed a multivariable logistic regression model to identify factors significantly increasing the likelihood of nosocomial SARS-CoV-2 infections.

RESULTS

A total of 170 patients with a nosocomial SARS-CoV-2 infection were identified. The majority of nosocomial SARS-CoV-2 patients (n = 157, 92%) had been treated at wards that reported an outbreak of nosocomial SARS-CoV-2 cases during their stay or up to 14 days later. For 76 patients with definite nosocomial SARS-CoV-2 infections, controls for the case-control study were matched. For this subgroup, the multivariable logistic regression analysis revealed documented contact to SARS-CoV-2 cases (odds ratio: 23.4 (95% confidence interval: 4.6-117.7)) and presence at a ward that experienced a SARS-CoV-2 outbreak (odds ratio: 15.9 (95% confidence interval: 2.5-100.8)) to be the principal risk factors for nosocomial SARS-CoV-2 infection.

CONCLUSIONS

With known contact to SARS-CoV-2 cases and outbreak association revealed as the primary risk factors, our findings confirm known causes of SARS-CoV-2 infections and demonstrate that these also apply to the acute care hospital setting. This underscores the importance of rapidly identifying exposed patients and taking adequate preventive measures.

Implementation of an automated cluster alert system into the routine work of infection control and hospital epidemiology: experiences from a tertiary care university hospital

Background

Early detection of clusters of pathogens is crucial for infection prevention and control (IPC) in hospitals. Conventional manual cluster detection is usually restricted to certain areas of the hospital and multidrug resistant organisms. Automation can increase the comprehensiveness of cluster surveillance without depleting human resources. We aimed to describe the application of an automated cluster alert system (CLAR) in the routine IPC work in a hospital. Additionally, we aimed to provide information on the clusters detected and their properties.

Methods

CLAR was continuously utilized during the year 2019 at Charité university hospital. CLAR analyzed microbiological and patient-related data to calculate a pathogen-baseline for every ward. Daily, this baseline was compared to data of the previous 14 days. If the baseline was exceeded, a cluster alert was generated and sent to the IPC team. From July 2019 onwards, alerts were systematically categorized as relevant or non-relevant at the discretion of the IPC physician in charge.

Results

In one year, CLAR detected 1,714 clusters. The median number of isolates per cluster was two. The most common cluster pathogens were Enterococcus faecium (n = 326, 19 %), Escherichia coli (n = 274, 16 %) and Enterococcus faecalis (n = 250, 15 %). The majority of clusters (n = 1,360, 79 %) comprised of susceptible organisms. For 906 alerts relevance assessment was performed, with 317 (35 %) alerts being classified as relevant.

Conclusions

CLAR demonstrated the capability of detecting small clusters and clusters of susceptible organisms. Future improvements must aim to reduce the number of non-relevant alerts without impeding detection of relevant clusters. Digital solutions to IPC represent a considerable potential for improved patient care. Systems such as CLAR could be adapted to other hospitals and healthcare settings, and thereby serve as a means to fulfill these potentials.

Strategies for Effective Infection Prevention Programs: Structures, Processes, and Funding

Successful Infection Prevention Programs (IPPs) consist of a multidisciplinary team led by a hospital epidemiologist and managed by infection preventionists. Knowledge of the economics of health care-associated infections (HAIs) and the ability to make a business plan is now essential to the success of programs. Prevention of HAIs is the core function of IPPs with impact on patient outcomes, quality of care, and cost savings for hospitals. This article discusses the structure and responsibilities of an IPP, the regulatory pressures and opportunities that these programs face, and how to build and manage a successful program.

The Clean Care Contest: promoting hand hygiene among healthcare and medical students

INTRODUCTION

Despite continuing efforts, compliance rates and knowledge of best practices in hand hygiene remain disappointing. Recognizing that conventional educational tools seem out of touch with young people and that the med and messages contents need refreshing, the Italian Study Group of Hospital Hygiene of the Italian Society of Hygiene, Preventive Medicine and Public Health devised a novel approach to promote the creation of innovative educational tools for improving knowledge of, and compliance with, hand hygiene rules among healthcare and medical students.

METHODS

A contest in creating educational material on hand hygiene practices involved university students of nursing and medicine, and of other healthcare degrees. Students from the universities of the GISIO network were invited to create educational material (e.g., videos, posters, presentations, leaflets, and screensavers) to be presented by May 5th 2019 during the World Hand Hygiene Day / Save Lives: Clean Your Hands Global Annual Initiative of the World Health Organization). A local and a national winners were awarded.

RESULTS

Three different local and national contests were performed during 2016, 2017 and 2018. During the three-year period, more than 270 educational tools have been developed: 130 (48%) were judged useful for hand hygiene promotion campaigns. The most frequent projects participating in the contests were videos (39%), posters (29%), leaflets (14%), and others (18%) submitted by more than 1,500 students of nursing (40%), medicine (31%), dentistry (7%), and of other healthcare courses in 14 universities. Products were evaluated by a local committee and, subsequently, local winners represented their University in a national contest.

CONCLUSIONS

The contest provided a framework for the creation of innovative and potentially effective educational tools via an engaging approach that leveraged student creativity. Given the need to improve compliance rates, this study suggests that new ways can be advantageously explored to teach hand hygiene procedures and increase awareness of the importance of their consistent use among healthcare and medical students.

Incidence and impact of hospital-acquired pneumonia: a Portuguese nationwide four-year study

This article presents the incidence of hospital-acquired pneumonia (HAP) in Portugal during a four-year period (2014-2017). Data were retrieved from the 100 Portuguese hospital diagnosis discharge database for adult patients and included gender, age, chronic comorbidities, mortality and hospital length of stay. There were 28,632 episodes of HAP, an incidence of 0.95 per 100 admissions. HAP patients had both a prolonged hospital length of stay (mean 26.4 days) and high mortality (33.6%). Most episodes occurred in patients aged ≥65 years and in males (76.1% and 61.7%, respectively). Invasive ventilation was required in 18.8%.

Clinical characteristics, outcomes and prognosticators in adult patients hospitalized with COVID-19

BACKGROUND

COVID-19 is a novel disease caused by SARS-CoV-2.

METHODS

We conducted a retrospective evaluation of patients admitted with COVID-19 to one site in March 2020. Patients were stratified into 3 groups: survivors who did not receive mechanical ventilation (MV), survivors who received MV, and those who received MV and died during hospitalization.

RESULTS

There were 140 hospitalizations; 22 deaths (mortality rate 15.7%), 83 (59%) survived and did not receive MV, 35 (25%) received MV and survived; 18 (12.9%) received MV and died. Thee mean age of each group was 57.8, 55.8 and 72.7 years, respectively (P = .0001). Of those who received MV and died, 61% were male (P = .01). More than half the patients (n = 90, 64%) were African American. First measured d-dimer >575.5 ng/mL, procalcitonin > 0.24 ng/mL, lactate dehydrogenase >445.6 units/L, and brain natriuretic peptide (BNP) >104.75 pg/mL had odds ratios of 10.5, 5, 4.5 and 2.9, respectively for MV (P < .05 for all). Peak BNP >167.5 pg/mL had an odds ratio of 6.7 for inpatient mortality when mechanically ventilated (P = .02).

CONCLUSIONS

Age and gender may impact outcomes in COVID-19. D-dimer, procalcitonin, lactate dehydrogenase and BNP may serve as early indicators of disease trajectory.

Simultaneous detection and ribotyping of Clostridioides difficile, and toxin gene detection directly on fecal samples

Background

Clostridioides difficile is the most common cause of nosocomial diarrhea. Ribotyping of cultured strains by a PCR-based test is used to study potential transmission between patients. We aimed to develop a rapid test that can be applied directly on fecal samples for simultaneous detection and ribotyping of C. difficile, as well as detection of toxin genes.

Methods

We developed a highly specific and sensitive primer set for simultaneous detection and ribotyping of C. difficile directly on total fecal DNA. Toxin genes were detected with primers adapted from Persson et al. (Clin Microbiol Infect 14(11):1057–1064). Our study set comprised 130 fecal samples: 65 samples with positive qPCR for C. difficile toxin A/B genes and 65 C. difficile qPCR negative samples. PCR products were analyzed by capillary gel electrophoresis.

Results

Ribosomal DNA fragment peak profiles and toxin genes were detected in all 65 C. difficile positive fecal samples and in none of the 65 C. difficile negative samples. The 65 samples were assigned to 27 ribotypes by the Dutch reference laboratory. Our peak profiles corresponded to these ribotypes, except for two samples. During a C. difficile outbreak, patients were correctly allocated to the outbreak-cluster based on the results of direct fecal ribotyping, before C. difficile isolates were cultured and conventionally typed.

Conclusion

C. difficile ribotyping directly on fecal DNA is feasible, with sensitivity and specificity comparable to that of diagnostic toxin gene qPCR and with ribotype assignment similar to that obtained by conventional typing on DNA from cultured isolates. This supports simultaneous diagnosis and typing to recognize an outbreak.

Bacterial but no SARS-CoV-2 contamination after terminal disinfection of tertiary care intensive care units treating COVID-19 patients

Background

In intensive care units (ICUs) treating patients with Coronavirus disease 2019 (COVID-19) invasive ventilation poses a high risk for aerosol and droplet formation. Surface contamination of severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) or bacteria can result in nosocomial transmission.

Methods

Two tertiary care COVID-19 intensive care units treating 53 patients for 870 patient days were sampled after terminal cleaning and preparation for regular use to treat non-COVID-19 patients.

Results

A total of 176 swabs were sampled of defined locations covering both ICUs. No SARS-CoV-2 ribonucleic acid (RNA) was detected. Gram-negative bacterial contamination was mainly linked to sinks and siphons. Skin flora was isolated from most swabbed areas and Enterococcus faecium was detected on two keyboards.

Conclusions

After basic cleaning with standard disinfection measures no remaining SARS-CoV-2 RNA was detected. Bacterial contamination was low and mainly localised in sinks and siphons.

Water management program implementation in California hospitals following the Centers for Medicare and Medicaid Services requirement

Health care facilities receiving Centers for Medicare and Medicaid Services reimbursement were required to implement water management programs (WMP) in 2017. Among 263 (66%) California hospitals responding to questions in the National Healthcare Safety Network Annual Survey, approximately 92% reported having a WMP in 2018; 76% routinely monitored for Legionella in their water systems. High levels of WMP implementation are likely the result of Centers for Medicare and Medicaid Services regulatory requirements and widespread promulgation of CDC WMP recommendations.

Excess mortality due to pandrug-resistant Acinetobacter baumannii infections in hospitalized patients

BACKGROUND

Pandrug-resistant Acinetobacter baumannii (PDRAB) is increasingly being reported as a nosocomial pathogen worldwide, but determining its clinical impact is challenging.

AIM

To assess the spectrum of excess mortality attributable to PDRAB infection in acute care settings.

METHODS

This four-year cohort study was conducted in a tertiary-care referral hospital in Greece to estimate excess in-hospital mortality due to PDRAB infection by comparing patients infected to those colonized with PDRAB by means of competing risks survival analysis.

FINDINGS

The study cohort comprised 91 patients (median age: 67 years; 77% men). For most patients, PDRAB was first isolated in the intensive care unit (ICU) (N = 51; 57%) or following ICU discharge (N = 26; 29%). Overall in-hospital mortality was 68% (95% confidence interval (CI): 57.5-77.5%). PDRAB-infected patients (N = 62; 68%) and PDRAB-colonized patients (N = 29; 32%) had similar baseline characteristics, but the absolute excess risk of 30-day mortality in infected patients compared to colonized patients was 34% (95% CI: 14-54%). Multivariable competing risks regression showed that PDRAB infection significantly increased the daily hazard of 30-day in-hospital death (cause-specific hazard ratio (csHR): 3.10; 95% CI: 1.33-7.21) while simultaneously decreasing the daily rate of discharge (csHR: 0.24; 95% CI: 0.08-0.74), thereby leading to longer hospitalization. Stronger effects were observed for bloodstream infections.

CONCLUSION

New effective antimicrobials would be expected to prevent mortality in one of every three patients treated for PDRAB infection and reduce their length of hospitalization. However, available therapeutic options remain extremely limited and emphasis on preventing healthcare-associated transmission of PDRAB is ever more important.

Impact of maternal death reviews at a rural hospital in Zambia: a mixed methods study

Background

Maternal mortality in sub-Saharan Africa remains high despite programmatic efforts to improve maternal health. In 2007, the Zambian Ministry of Health mandated facility-based maternal death review (MDR) programs in line with World Health Organization recommendations. We assessed the impact of an [MDR program] at a district-level hospital in rural Zambia.

Methods

We conducted a mixed methods convergent study using hospital data on maternal mortality and audit reports of 106 maternal deaths from 2007 to 2011. To evaluate the overall impact of MDR on maternal mortality, we compared baseline (2007) to late (2010–11) post-intervention inpatient maternal mortality indicators. MDR committee reports were coded and dominant themes were extracted in a qualitative analysis. We assessed potential risk factors for maternal mortality in a before-and-after design comparing the periods 2008–09 and 2010–11.

Results

In-hospital maternal mortality declined from 23 per thousand live births in 2007 to 8 per thousand in 2010–11 (P < 0.01). Maternal case fatality for puerperal sepsis and uterine rupture decreased significantly from 63 and 32% in 2007 to 10 and 9% in 2010–11 (P < 0.01). No significant reduction was seen in case fatality due to postpartum hemorrhage. Qualitative analysis of risk factors for maternal mortality revealed four core themes: standards of practice, health systems, accessibility, and patient factors. Specific risk factors included delayed referral, missed diagnoses, intra-hospital delays in care, low medication inventory, and medical error. We found no statistically significant differences in the prevalence of risk factors between the before-and-after periods.

Conclusions

Implementation of MDR was accompanied by a significant decrease in maternal mortality with reductions in maternal death from puerperal sepsis and uterine rupture, but not postpartum hemorrhage. Qualitative analysis of audit reports identified several modifiable risk factors within four core areas. Comparisons of potential explanatory factors did not show any differences over time. These results imply that MDR offers a means for hospitals to curtail maternal deaths, except deaths due to postpartum hemorrhage, suggesting additional interventions are needed. Documentation of MDR meetings provides an instrument to guide further quality improvements.

Effectiveness and cost-effectiveness of a Clostridium difficile vaccine candidate in a hospital setting

Toxoid vaccines against Clostridium difficile infections (CDI) appear promising in reducing the risk of developing toxin-mediated symptoms. We sought to evaluate the effectiveness and cost-effectiveness of a vaccine candidate in a hospital setting. We developed an agent-based simulation model of nosocomial CDI in a 300-bed hospital. Targeting high-risk patients for vaccination, we estimated the reduction of symptomatic CDI. Using the net reduction of CDI-associated isolation days, we evaluated the vaccine's cost-effectiveness from a healthcare provider perspective over a 2-year period with an average monthly incidence of 5 cases per 10,000 patient-days pre-vaccination. Assuming a vaccine efficacy in the range 60-90%, vaccinating 40% of high-risk patients pre-admission reduced symptomatic CDI by 16.6% (95% CI: 15.2, 17.9). When the vaccine coverage increased to 80%, the reduction of symptomatic CDI was 34.6% (95% CI: 33.7, 35.9). For a willingness to pay (WTP) of CDN$1000 (corresponding to the average costs of case isolation per day), vaccine was cost-effective for vaccination costs per individual (VCPI) up to CDN$111 in the scenario of 40% vaccine coverage. With the same WTP, vaccine was cost-effective for VCPI up to CDN$121 when the vaccine coverage increased to 80%. A significant portion (~80%) of hospital colonization is caused by environmental transmission of C. difficile, which markedly reduced the effectiveness of vaccine below its assumed efficacy. However, due to the number of CDI-associated isolation days averted, vaccination of high-risk patients can be cost-effective depending on the WTP and the VCPI.

Clostridium difficile intervention timelines for diagnosis, isolation, and treatment

BACKGROUND

Developing timelines of nosocomial Clostridium difficile infection (CDI) is critical to improving control and preventive measures. The objective of this study was to provide data-driven estimates of CDI timelines of diagnosis, isolation, and treatment in a hospital setting.

METHODS

We obtained data for all CDI inpatients with symptoms onset occurring between January 1, 2013, and December 30, 2017, from St Joseph's Healthcare in Hamilton, Canada. We analyzed full empirical distributions of timelines associated with the diagnosis, isolation, and treatment of CDI.

RESULTS

A total of 683 inpatients with CDI symptoms were recorded, of which 243 cases were identified as health care-associated infection (HAI). The mean time intervals between the onset of CDI symptoms after admission and the release of laboratory results were 1.2 days and 1.9 days for the HAI and community-associated infection (CAI) patient groups, respectively. The mean time intervals from symptoms onset to the start of isolation were 1.5 days and 2.6 days for the corresponding patient groups. The initiation of treatment within 2 days of symptoms onset reduced the duration of first isolation (P value < .0001); however, the type of initial antibiotic used for CDI treatment was not associated with the duration of isolation.

CONCLUSIONS

Estimated timelines did not differ (P values > .6) between HAI and CAI patient groups with symptoms onset after admission. These estimates are useful for evaluating the effectiveness of CDI interventions.

Bare below the elbows in an academic medical center

We investigated the compliance of health care personnel with a voluntary, institution-wide bare below the elbows (BBE) approach to inpatient care at an academic medical center. BBE compliance increased significantly across all provider types over a 2-year period. The overall compliance with BBE by health care personnel nearly doubled from 2016-2017, increasing significantly from 40% to 84%.

Risk factors for ventilator-associated events: A prospective cohort study

BACKGROUND

In January 2013, the Centers for Disease Control and Prevention released new surveillance definitions for ventilator-associated event (VAE) to replace ventilator-associated pneumonia (VAP) in adult patients. VAEs are associated with prolonged mechanical ventilation and hospital death, but little is known about their risk factors and how best to prevent them.

METHODS

We compared VAE cases with non-VAE cases with regard to demographics, comorbidities, sedative exposures, opioids exposures, paralytic exposures, routes of nutrition, blood products, gastric retention, and fluid balance. Patients mechanically ventilated for ≥4 days between January 1, 2017, and December 31, 2017, in 2 adult intensive care units of a tertiary care teaching hospital in China were included.

RESULTS

On multivariable logistic regression, significant risk factors for VAEs were positive daily fluid balances of ≥ 50 mL between day of intubation and the fourth day of mechanical ventilation (relative risk [RR], 8.39; 95% confidence interval [CI], 2.99-23.50), sedative administered between the first day and the fourth day of invasive mechanical ventilation (RR, 15.69; 95% CI, 1.62-152.06), and daily gastric retention of ≥200 mL between day of intubation and the fourth day of mechanical ventilation (RR, 9.27; 95% CI, 1.89-45.47).

CONCLUSIONS

Positive daily fluid balances of ≥50 mL, sedatives administered, and gastric retention of ≥200 mL are risk factors for VAEs. Intervention studies are needed to determine if targeting these risk factors can lower VAE rates.

Nosocomial outbreak of influenza A H3N2 in an inpatient oncology unit related to health care workers presenting to work while ill

Objective

To describe an outbreak of influenza A in an oncology unit, highlighting infection control methods implemented, and examining reasons health care workers (HCWs) present to work with influenza-like illness (ILI).

Methods

Confirmed cases were defined by the presence of ILI and a positive nasopharyngeal polymerase chain reaction swab for influenza A H3. Probable cases were defined as exposed HCWs with ILI who were unavailable for polymerase chain reaction testing. Infection prevention measures included closing the ward for new admissions, oseltamivir prophylaxis for all exposed groups, and dismissal from work of HCWs with ILI until resolution of symptoms. An anonymous survey of the cases in our HCWs was conducted to better elucidate reasons behind presenteeism.

Results

Over the course of 8 days (November 16, 2017, to November 22, 2017), influenza was diagnosed in 7 of 10 inpatients on the oncology ward, 16 HCWs (14 confirmed, 2 probable), and 2 visitors. The suspected index case was an HCW. Of the surveyed HCWs, 64% presented to work despite feeling ill (ie, presenteeism). The most common reason was “sense of duty as a health care worker.”

Conclusions

This nosocomial outbreak of influenza highlights the challenges of protecting inpatients from viral respiratory tract infections. HCWs and patient visitors with ILI should avoid work or visiting until resolution of peak respiratory symptoms and adhere to strict respiratory etiquette.

Hospital Infection Prevention: How Much Can We Prevent and How Hard Should We Try?

PURPOSE OF REVIEW

To summarize the extent to which hospital-acquired infections (HAIs) are preventable and to assess expectations, challenges, and barriers to improve patient outcomes.

RECENT FINDINGS

HAIs cause significant morbidity and mortality. Getting to zero HAIs is a commonly stated goal yet leads to unrealistic expectations. The extent to which all HAIs can be prevented remains debatable and is subject to multiple considerations and barriers. Current infection prevention science is inexact and evolving. Evidence-based infection prevention practices are often incompletely implemented and at times controversial. Highly sensitive surveillance results in overdiagnosis, calling into question the real incidence of HAIs. Perceived reductions in HAIs by gaming the system lead to false conclusions about preventability and may cause harm. Successful HAI reduction programs require executive oversight yet keeping hospital leaders engaged in infection prevention is a challenge given competing priorities. Medicine is not a physical science with precisely defined laws; thus, infection prevention interventions are subject to variable outcomes. Perhaps up to 55-70% of HAIs are potentially preventable. This is subject to a law of diminishing returns as the preventable proportion of HAIs may reduce over time with improvements in patient safety. As the principle tenet of medicine is first do no harm, infection prevention programs should relentlessly pursue reliable, sustainable, and practical strategies for heightened patient safety.

Predictors of Clostridium difficile infection and predictive impact of probiotic use in a diverse hospital-wide cohort

BACKGROUND

Hospital-based predictive models for Clostridium difficile infection (CDI) may aid with surveillance efforts.

METHODS

A retrospective cohort of adult hospitalized patients who were tested for CDI between May 1, 2011, and August 31, 2016, was formed. Proposed clinical and sociodemographic predictors of CDI were evaluated using multivariable predictive logistic regression modeling.

RESULTS

In a cohort of 5,209 patients, including 1,092 CDI cases, emergency department location (adjusted odds ratio [aOR], 1.91; 95% confidence interval [CI], 1.51, 2.41; compared with an intensive care unit reference category, which had the lowest observed odds in the study) and prior exposure to a statin (aOR, 1.26, 95% CI, 1.06, 1.51), probiotic (aOR, 1.39; 95% CI, 1.08, 1.80), or high-risk antibiotic (aOR, 1.54; 95% CI, 1.29, 1.84), such as a cephalosporin, a quinolone, or clindamycin, were independent predictors of CDI. Probiotic use did not appear to attenuate the odds of CDI in patients exposed to high-risk antibiotics, but moderate-risk antibiotics appeared to significantly attenuate the odds of CDI in patients who received probiotics.

CONCLUSIONS

Emergency department location, high-risk antibiotics, probiotics, and statins were independently predictive of CDI. Further exploration of the relationship between probiotics and CDI, especially in diverse patient populations, is warranted.

How to: molecular investigation of a hospital outbreak

BACKGROUND

Studying hospital outbreaks by using molecular tools, i.e. synthesizing the molecular epidemiology data to its appropriate clinical-epidemiologic context, is crucial in order to identify infection source, infer transmission dynamics, appropriately allocate prevention resources and implement control measures. Whole-genome sequencing (WGS) of pathogens has become the reference standard, as it is becoming more accessible and affordable. Consequently, sequencing of the full pathogen genome via WGS and major progress in fit-for-purpose genomic data analysis tools and interpretation is revolutionizing the field of outbreak investigations in hospitals. Metagenomics is an additional evolving field that might become commonly used in the future for outbreak investigations. Nevertheless, practitioners are frequently limited in terms of WGS or metagenomics, especially for local outbreak analyses, as a result of costs or logistical considerations, reduced or lack of locally available resources and/or expertise. As a result, traditional approaches, including pulsed-field gel electrophoresis, repetitive-element palindromic PCR and multilocus sequence typing, along with other typing methods, are still widely used.

AIMS

To provide practitioners with evidenced-based action plans for usage of the various typing techniques in order to investigate the molecular epidemiology of nosocomial outbreaks, of clinically significant pathogens in acute-care hospitals.

SOURCES

PubMed search with relevant keywords along with personal collection of relevant publications.

CONTENT

Representative case scenarios and critical review of the relevant scientific literature.

IMPLICATIONS

The review provides practical action plans to manage molecular epidemiologic investigations of outbreaks caused by clinically significant nosocomial pathogens, while prioritizing the use and timely integration of the various methodologies.

The Role of the Hospital Epidemiologist in Antibiotic Stewardship

Antibiotic stewardship programs (ASPs) play a crucial role in controlling the emergence of resistant organisms, reducing rates of Clostridium difficile infections and associated hospital length of stay, promoting judicious use of antibiotics, and minimizing associated adverse events. There is a significant overlap between the goals of infection control programs and ASPs, and both programs can benefit from a synergistic relationship. Hospital epidemiologists can support these programs by providing leadership support, sharing surveillance data, bridging gaps between ASPs and departments such as microbiology, integrating educational programs with ASPs, sharing outbreak alerts, and assisting with the development of treatment algorithms.

Impact of infection prevention and control training on health facilities during the Ebola virus disease outbreak in Guinea

Background

In 2014–2016, West Africa faced the most deadly Ebola Virus Disease (EVD) outbreak in history. A key strategy to overcome this outbreak was continual staff training in Infection Prevention and Control (IPC), with a focus on Ebola. This research aimed to evaluate the impact of IPC training and the quality of IPC performance in health care facilities of one municipality of Conakry, Guinea.

Methods

This study was conducted in February 2016. All health facilities within Ratoma municipality, Conakry, Guinea, were evaluated based on IPC performance standards developed by the Guinean Ministry of Health. The IPC performance of healthcare facilities was categorised into high or low IPC scores based on the median IPC score of the sample. The Mantel-Haenzsel method and logistic regression were used for statistical analysis.

Results

Twenty-five percent of health centres had one IPC-trained worker, 53% had at least two IPC-trained workers, and 22% of health centres had no IPC-trained workers. An IPC score above median was positively associated with the number of trained staff; health centres with two or more IPC-trained workers were eight times as likely to have an IPC score above median, while those with one IPC-trained worker were four times as likely, compared to centres with no trained workers. Health centres that implemented IPC cascade training to untrained medical staff were five times as likely to have an IPC score above median.

Conclusions

This research highlights the importance of training healthcare staff in IPC and organising regular cascade trainings. IPC strategies implemented during the outbreak should continue to be reinforced for the better health of patients and medical staff, and be considered a key factor in any outbreak response.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5444-3) contains supplementary material, which is available to authorized users.

Carbapenem-resistant Enterobacteriaceae in patients admitted to the emergency department: prevalence, risk factors, and acquisition rate

BACKGROUND

Carbapenem-resistant Enterobacteriaceae (CRE) have been reported worldwide and are associated with high mortality rates. Intestinal colonization acts as a reservoir and fosters exchange of resistance mechanisms.

AIM

To investigate the prevalence of patients harbouring CRE on hospital admission, risk factors associated, and the acquisition rate within the emergency department (ED).

METHODS

This was a cross-sectional survey with 676 patients consecutively admitted to the ED study during the months of May to July 2016. A questionnaire was performed and rectal swabs were collected from patients on admission, for culture and for multiplex real-time polymerase chain reaction (PCR). If the patient was hospitalized for more than one week in the ED, samples were taken again to determine the acquisition rate of CRE.

FINDINGS

Forty-six patients were colonized; all positive PCR were Klebsiella pneumoniae carbapenemase. The acquisition rate was 18%. Previous exposure to healthcare in the last year, liver disease, and use of antibiotics in the last month were risk factors for colonization. Six patients with no previous exposure to healthcare were CRE-colonized on admission, suggesting transmission of CRE within the community.

CONCLUSION

Screening of high-risk patients on admission to the ED is a strategy to early identify CRE carriage and may contribute to control CRE dissemination.

Estimating the impact post randomization changes in staff behavior in infection prevention trials: a mathematical modeling approach

BACKGROUND

Randomized controlled trials (RCTs) of behavior-based interventions are particularly vulnerable to post-randomization changes between study arms. We assess the impact of such a change in a large, multicenter study of universal contact precautions to prevent infection transmission in intensive care units.

METHODS

We construct a stochastic mathematical model of methicillin-resistant Staphylococcus aureus (MRSA) acquisition in a simulated 18-bed intensive care unit (ICU). Using parameters from a recent study of contact precautions that reported a post-randomization change in contact rates, with fewer visits observed in the treatment arm, we explore the impact of several possible interpretations of this change on MRSA acquisition rates.

RESULTS

Scenarios where contact precautions resulted in less patient visitation resulted in a mean decrease in MRSA acquisition rate of 37%, accounting for much of the effect reported in the trial.

CONCLUSIONS

Behavior changes that impact the contact rate have the potential to drastically alter the results of RCTs in infection control settings. Careful monitoring for these changes, and an assessment of which changes will likely have the greatest impact on the study before the study begins are both recommended.

Building a Successful Infection Prevention Program: Key Components, Processes, and Economics

Infection control is the discipline responsible for preventing health care-associated infections (HAIs) and has grown from an anonymous field, to a highly visible, multidisciplinary field of incredible importance. There has been increasing focus on prevention rather than control of HAIs. Infection prevention programs (IPPs) have enormous scope that spans multiple disciplines. Infection control and the prevention and elimination of HAIs can no longer be compartmentalized. This article discusses the structure and responsibilities of an IPP, the regulatory pressures and opportunities that these programs face, and how to build and manage a successful program.

Infection Prevention in the Hospital from Past to Present: Evolving Roles and Shifting Priorities

Hospital epidemiologists are vital components of integrated health centers. This central place in the healthcare landscape has rapidly evolved over a half century. Early hospital epidemiologists possessed a visionary focus on patient safety many decades prior to the quality revolution of the 1990s. A systematic and scientific approach to infection prevention has facilitated the evolution of hospital epidemiology, along with advances in technology, and increasing public attention to infectious complications in the hospital. Currently, the growing expansion of tasks and moving regulatory targets strain existing resources. These challenges threaten to limit the effectiveness of some infection-prevention activities, while also providing important opportunities for improving care. It will be increasingly important to advocate for appropriate resources to address a diverse set of changing infection prevention priorities.

Persistence of a major endemic clone of oxacillin-resistant Staphylococcus lugdunensis sequence type 6 at a tertiary medical centre in northern Taiwan

OBJECTIVES

The aim of this study was to investigate the molecular epidemiology and clinical characteristics of a major clone of oxacillin-resistant Staphylococcus lugdunensis in a tertiary hospital.

METHODS

All S. lugdunensis isolated from sterile sites between June 2003 and May 2013 were collected for analysis. Pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST) were performed to study their genetic relationships.

RESULTS

A total of 118 S. lugdunensis isolates were analysed by PFGE. Three major PFGE pulsotypes were found: A, H, and L. Most of the pulsotype A isolates were oxacillin-resistant, and SCCmec type V and type VT. Isolates from another major clonal group that consisted primarily of pulsotype L were oxacillin-resistant and SCCmec type II. These 14 SCCmec type II S. lugdunensis isolates demonstrated high PFGE similarity and were obtained in the study hospital over a period of 40 months. Three of these 14 patients had clinically significant bacteraemia, and all three cases were in the intensive care unit. Further MLST analysis of the isolates identified an endemic S. lugdunensis strain of sequence type 6, clonal complex 1.

CONCLUSIONS

This study identified a major endemic clone of S. lugdunensis that is oxacillin-resistant, SCCmec type II, ST6, and capable of long-term persistence in the hospital. Continuous infection control surveillance and monitoring of S. lugdunensis should be considered in endemic areas.