To evaluate the prevalence, epidemiologic features, and molecular characteristics of colonization with community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) among hospitalized dialysis patients and their healthcare workers (HCWs).

Prospective observational clinical and laboratory study of nasal colonization.

A 600-bed urban academic medical center.

One hundred twenty hospitalized dialysis inpatients and 100 HCWs.

Of 120 patients, 40 (33%) were colonized with S. aureus; 26 (65%) of these 40 were colonized with MRSA. Among the 26 MRSA isolates, 10 (38.5%) carried staphylococcal cassette chromosome (SCC) mec type IV (ie, CA-MRSA), and 7 of these 10 carried the genes for the Panton-Valentine leukocidin (PVL) toxin. Patients colonized with healthcare-associated MRSA strains and those colonized with CA-MRSA strains were similar, except for a higher frequency of a history of congestive heart failure among those with healthcare-associated MRSA strains (P = .014). Among 10 patients who presented with or developed an S. aureus infection while hospitalized, 8 were colonized with S. aureus, 7 with MRSA, and 3 with SCCmec type IV strains. Among 100 HCWs, 31 were colonized with S. aureus, including 6 with MRSA; 2 of the MRSA isolates belonged to CA-MRSA strains, and soft-tissue infections were reported in one of the HCWs and in the family member of the other HCW colonized with these strains.

There is a high rate of colonization with MRSA and CA-MRSA among hospitalized dialysis patients and their HCWs. As other studies have found, it appears that individuals are being colonized with both CA-MRSA strains and healthcare-associated MRSA strains.

Oral metronidazole has been recommended for treatment of mild-to-moderate Clostridium difficile–associated disease (CDAD), in part because of concern that use of vancomycin may be more likely to promote colonization and transmission of vancomycin-resistant enterococci (VRE). The objective of our study was to compare the frequency of skin and environmental VRE contamination associated with metronidazole treatment for CDAD with such frequency associated with vancomycin treatment for CDAD.

Prospective, observational study. This study was performed at the Cleveland Veterans Affairs Medical Center (Cleveland, OH). For patients with CDAD who had concurrent VRE colonization, stool, skin, and environmental samples were cultured for VRE before, during, and up to 3 weeks after therapy with metronidazole or vancomycin. The proportions of skin and environmental contamination were compared before and after resolution of diarrhea and during treatment with metronidazole or vancomycin.

Of the 34 patients, 17 were treated with vancomycin and 17 were treated with metronidazole. The proportion of environmental cultures that were positive for VRE was significantly higher during resolution of diarrhea than it was after resolution of diarrhea (38% vs 28%; P = .025), whereas the proportion of skin cultures positive was not different during and after resolution of diarrhea (78% vs 71%; P = .60). There were no differences between patients who received metronidazole and patients who received vancomycin in the proportions of skin culture results (73% vs 77%; P = .80) or environmental culture results (37% vs 32%; P = .359) that were positive for VRE. Eleven patients (32%) had chronic fecal incontinence, and 28 (82%) had incontinence at least once during their CDAD episode.

In VRE-colonized patients with CDAD who experienced frequent fecal incontinence, skin and environmental VRE contamination was common during and after resolution of diarrhea. The frequency of VRE contamination was similar between patients treated with metronidazole and patients treated with vancomycin.

The prevalence of fluoroquinolone (FQ) resistance in Escherichia coli has increased markedly in recent years. Despite the important role of gastrointestinal tract colonization with FQ-resistant E. coli (FQREC), the prevalence of and risk factors for FQREC colonization among the general hospitalized patient population have not been described, to our knowledge. The objective of this study was to identify the prevalence of and risk factors for FQREC colonization among hospitalized patients.

Three-year case-control study. Case patients (ie, all subjects with FQREC colonization) were compared with control patients (ie, all subjects without FQREC colonization).

Two large medical centers within an academic health system.

All patients hospitalized at the 2 study hospitals.

Three annual fecal surveillance surveys were conducted. All patients colonized with FQREC (levofloxacin minimum inhibitory concentration, ≥ 8 μg/mL) were identified.

Of the 774 subjects, 89 (11.5%) were colonized with FQREC. Although there was a significant association between prior FQ use and FQREC colonization on bivariable analysis (odds ratio [OR], 2.02 [95% confidence interval {CI}, 1.14–3.46]; P = .01), there was statistically significant effect modification by year of study (P = .005). In multivariable analyses, after controlling for the hospital and for the duration of hospitalization prior to sampling, the association between FQ use and FQREC colonization was as follows: adjusted OR (aOR), 0.97 (95% CI, 0.29–3.23) in 2002; aOR, 1.41 (95% CI, 0.57–3.50) in 2003; and aOR, 9.87 (95% CI, 3.67–26.55) in 2004.

The association between prior FQ use and FQREC colonization varied significantly by study year, suggesting that the clinical epidemiology of resistant organisms may change over time. Furthermore, in the context of recent work showing significant changes in FQREC prevalence as well as changes in FQ resistance mechanisms (specifically, efflux overexpression) over the same time period, these results suggest a previously unrecognized complexity in the relationship between the clinical and molecular epidemiology of FQ resistance.

Pseudomonas aeruginosa has been increasingly recognized for its ability to cause significant hospital-associated outbreaks, particularly since the emergence of multidrug-resistant strains. Biofilm formation allows the pathogen to persist in environmental reservoirs. Thus, multiple hospital room design elements, including sink placement and design, can impact nosocomial transmission of P. aeruginosa and other pathogens.

From December 2004 through March 2006, 36 patients exposed to the intensive care unit or transplant units of a tertiary care hospital were infected with a multidrug-resistant strain of P. aeruginosa. All phenotypically similar isolates were examined for genetic relatedness by means of pulsed-field gel electrophoresis. Clinical characteristics of the affected patients were collected, and a detailed epidemiological and environmental investigation of potential sources was carried out.

Seventeen of the infected patients died within 3 months; for 12 (71%) of these patients, infection with the outbreak organism contributed to or directly caused death. The source of the outbreak was traced to hand hygiene sink drains, where biofilms containing viable organisms were found. Testing by use of a commercial fluorescent marker demonstrated that when the sink was used for handwashing, drain contents splashed at least 1 meter from the sink. Various attempts were made to disinfect the drains, but it was only when the sinks were renovated to prevent splashing onto surrounding areas that the outbreak was terminated.

This report highlights the importance of biofilms and of sink and patient room design in the propagation of an outbreak and suggests some strategies to reduce the risks associated with hospital sinks.

To investigate a nosocomial outbreak of infection with multidrug-resistant (MDR) Acinetobacter baumannii in the intensive care units at China Medical University Hospital in Taiwan.

Prospective outbreak investigation.

Three intensive care units in a 2,000-bed university hospital in Taichung, Taiwan.

Thirty-eight stable patients in 3 intensive care units, all of whom had undergone an invasive procedure, were enrolled in our study. Ninety-four A. baumannii strains were isolated from the patients or the environment in the 3 intensive care units, during the period from January 1 through December 31, 2006. We characterized A. baumannii isolates by use of repetitive extragenic palindromic–polymerase chain reaction (REP-PCR) and random amplified polymorphic DNA (RAPD) fingerprinting. The clinical characteristics of the source patients and the environment were noted.

All of the clinical isolates were determined to belong to the same epidemic strain of MDR A. baumannii by the use of antimicrobial susceptibility tests, REP-PCR, and RAPD fingerprinting. All patients involved in the infection outbreak had undergone an invasive procedure. The outbreak strain was also isolated from the environment and the equipment in the intensive care units. Moreover, an environmental survey of one of the intensive care units found that both the patients and the environment harbored the same outbreak strain.

The outbreak strain of A. baumannii might have been transmitted among medical staff and administration equipment. Routine and aggressive environmental and equipment disinfection is essential for preventing recurrent outbreaks of nosocomial infection with MDR A. baumannii.

Nosocomial infection (NI) is one of the most serious healthcare issues currently influencing healthcare costs. This study estimates the impact of NI on costs in intensive care units (ICUs).

Prospective surveillance by a retrospective cohort study.

A medical ICU, a surgical ICU, and a mixed medical and surgical ICU in a large tertiary referral medical center.

Surveillance for NIs was conducted for all patients admitted to adult ICUs from 2003 through 2005. Retrospective chart review was conducted for each patient. The generalized linear modeling approach was used to assess the relationship of NIs to the increase in variable costs in individual ICUs and in all ICUs.

A total of 401 NIs occurred in 320 of 2,757 screened patients. The incidence rate was 12.1% in the medical ICU, 14.7% in the surgical ICU, and 16.7% in the mixed medical and surgical ICU (P> .05). All of the mean variable costs were significantly higher for patients with NI than they were for patients without NI, after controlling for covariates. The medical ICU had the greatest increase in mean cost ($13,456, which was 3.52 times [95% confidence interval {CI}, 2.94–4.22 times] the mean cost for patients without NI), followed by the mixed medical and surgical ICU ($6,748, which was 2.74 times [95% CI, 2.33–3.22 times] the mean cost for patients without NI) and the surgical ICU ($5,433, which was 2.46 times [95% CI, 1.99–3.05 times] the mean cost for patients without NI). Mean cost increases according to the site of NI were $6,056 for bloodstream infection (2.36 times [95% CI, 1.97–2.84 times] the mean cost for patients without NI), $4,287 for respiratory tract infection (1.91 times [95% CI, 1.57–2.32 times] the mean cost for patients without NI), $1,955 for urinary tract infection (1.42 times [95% CI, 1.18–1.72 times] the mean cost for patients without NI), and $1,051 for surgical site infection (1.23 times [95% CI, 0.90–1.68 times] the mean cost for patients without NI).

The medical ICU had the lowest rate of NI and the largest excess costs, the surgical ICU had the lowest excess costs, and the mixed medical and surgical ICU had the highest rate of NI. The cost is largely attributable to bloodstream infection and respiratory tract infection.

To identify healthcare worker (HCW) and work-site characteristics associated with HCWs' reported use of recommended respiratory-infection control practices in primary and emergency care settings.

A cross-sectional study using a self-administered questionnaire for HCWs during the summer and fall of 2005.

Primary and emergency care clinics at 5 medical centers in King County, Seattle, Washington.

Nurse professionals who reported receiving training (odds ratio [OR], 2.5 [confidence interval {CI}, 1.1–5.9]; P = .029), instructional feedback from supervisors (OR, 3.0 [CI, 1.5–5.9]; P = .002), and management support for implementing safe work practices had a higher odds of also reporting adherence to recommended respiratory precautions, compared with nurses who did not. Training was the only important determinant for adherence to respiratory precaution measures among medical practitioners (OR, 5.5 [CI, 1.2–25.8]; P = .031). The reported rate of adherence to hand hygiene practices was higher among nurse professionals who were male (OR, 2.2 [CI, 1.0–4.9]; P = .045), had infants, small children, or older adults living at home (OR, 2.2 [CI, 1.2–3.9]; P = .007), reported cleanliness and orderliness of the establishment where they worked (OR, 2.0 [CI, 1.1–3.5]; P = .019), had received respiratory-infection control training (OR, 3.2 [CI, 1.8–6.0]; P<.001), and reported fears about catching a dangerous respiratory infection at work (OR, 2.3 [CI, 1.2–4.5]; P= .011).

A number of HCW and work-site characteristics associated with HCWs' use of recommended respiratory-infection control measures have been identified. These potentially influential characteristics should be considered as targets or guides for further investigation, which should include the evaluation of intervention strategies.

Needlestick injuries are the most common injuries that occur among operation room personnel in the health care service. The risk of infection after a needlestick injury during surgery greatly depends on the quantity of pathogenic germs transferred at the point of injury. The aim of this study was to measure the quantity of blood transferred at the point of a percutaneous injury by using radioactively labeled blood.

This study was conducted to evaluate the risk of infection through blood contact by simulating surgical needlestick injuries ex vivo. The tests were conducted by puncturing single and double latex gloves with diverse sharp devices and objects that were contaminated with Technetium solution–labeled blood.

A mean volume of 0.064 μL of blood was transferred in punctures with the an automatic lancet at a depth of 2.4 mm through 1 layer of latex. When the double-gloving indicator technique was used, a mean volume of only 0.011 μL of blood was transferred (median, 0.007 μL); thus, by wearing 2 pairs of gloves, the transferred volume of blood was reduced by a factor of 5.8.

The results revealed that double gloving leads to a significant reduction in the quantity of blood transferred during needlestick injury.