Sharps with engineered sharps injury protections (SESIPs) have been found to reduce risk of sharps injuries (Sis). We examined trends in SI rates among employees of acute care hospitals in Massachusetts, including the impact of SESIPs on SI trends during 2002-2007.

Prospective surveillance.

Seventy-six acute care hospitals licensed by the Massachusetts Department of Public Health.

Employees of acute care hospitals who reported Sis to their employers.

Data on Sis in acute care hospitals collected by the Massachusetts Sharps Injury Surveillance System were used to examine trends in SI rates over time by occupation, hospital size, and device. Negative binomial regression was used to assess trends.

During 2002-2007, 16,158 Sis among employees of 76 acute care hospitals were reported to the surveillance system. The annual SI rate decreased by 22%, with an annual decline of 4.7% (P < .001). Rates declined significantly among nurses (—7.2% per year; P < .001) but not among physicians (—0.9% per year; P = .553). SI rates associated with winged steel needles and hypodermic needles and syringes also declined significantly as the proportion of injuries involving devices with sharps injury prevention features increased during the same time period.

SI rates involving devices for which SESIPs are widely available and appear to be increasingly used have declined. The continued use of devices lacking SI protections for which SESIPs are available needs to be addressed. The extent to which injuries involving SESIPs are due to flaws in design or lack of experience and training must be examined.

To investigate potential sources of gram-negative multidrug-resistant organisms (MDROs) in a deployed US military healthcare facility.

Active surveillance.

Swab sampling of patients, hospital personnel, and environmental surfaces was performed before the opening of a new medical treatment facility in Iraq and then serially for the next 6 months. Multidrug resistant isolates were genotypically characterized using pulsed-field gel electrophoresis (PFGE). Univariate and multivariate analysis were performed to evaluate associations between patient characteristics and MDRO carriage.

Deployed US military medical facility.

A total of 1,348 samples were obtained, yielding 654 isolates, 42 of which were MDROs. One hundred fifty-eight patients were sampled; swabs from 18 patients yielded 29 MDR isolates. Host nation patients comprised 89% of patients with MDROs and 37% of patients without MDROs (P < .001 ). Host nation patient status was also significantly associated with MDRO carriage in multivariate logistic regression analysis (adjusted odds ratio, 2.9; confidence interval, 1.3-6.3; P = .009). Bacteria with PFGE patterns matching those recovered from host nation patients were later isolated from environmental surfaces including recovery room patient monitors and the trauma bay floor.

At this facility, MDRO isolation was predominantly obtained from newly admitted host nation patients,,which may reflect baseline colonization with MDROs in the community. Patient MDRO carriage was linked to subsequent environmental contamination. These findings support intensive infection control efforts in forward deployed facilities.

Recent outbreaks of Clostridium difficile infection (CDI) have been difficult to control, and data indicate that the importance of different sources of transmission may have changed. Our objectives were to evaluate the contributions of asymptomatic and symptomatic C. difficile carriers to new colonizations and to determine the most important epidemiological factors influencing C. difficile transmission.

Retrospective cohort study of all patients admitted to medical wards at a large tertiary care hospital in the United States in the calendar year 2008.

Data from six medical wards and published literature were used to develop a compartmental model of C. difficile transmission. Patients could be in one of five transition states in the model: resistant to colonization (R), susceptible to colonization (S), asymptomatically colonized without protection against CDI (C-), asymptomatically colonized with protection against CDI (C+), and diseased (ie, with CDI; D).

The contributions of C-, C+, and D patients to new colonizations were similar. The simulated basic reproduction number ranged from 0.55 to 1.99, with a median of 1.04. These values suggest that transmission within the ward alone from patients with CDI cannot sustain new C. difficile colonizations and therefore that the admission of colonized patients plays an important role in sustaining transmission in the ward. The epidemiological parameters that ranked as the most influential were the proportion of admitted C- patients and the transmission coefficient for asymptomatic carriers.

Our study underscores the need to further evaluate the role of asymptomatically colonized patients in C. difficile transmission in healthcare settings.

Since hospitals in a region often share patients, an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) infection in one hospital could affect other hospitals.

Using extensive data collected from Orange County (OC), California, we developed a detailed agent-based model to represent patient movement among all OC hospitals. Experiments simulated MRSA outbreaks in various wards, institutions, and regions. Sensitivity analysis varied lengths of stay, intraward transmission coefficients (β), MRSA loss rate, probability of patient transfer or readmission, and time to readmission.

Each simulated outbreak eventually affected all of the hospitals in the network, with effects depending on the outbreak size and location. Increasing MRSA prevalence at a single hospital (from 5% to 15%) resulted in a 2.9% average increase in relative prevalence at all other hospitals (ranging from no effect to 46.4%). Single-hospital intensive care unit outbreaks (modeled increase from 5% to 15%) caused a 1.4% average relative increase in all other OC hospitals (ranging from no effect to 12.7%).

MRSA outbreaks may rarely be confined to a single hospital but instead may affect all of the hospitals in a region. This suggests that prevention and control strategies and policies should account for the interconnectedness of health care facilities.

In August 2007, Illinois passed legislation mandating methicillin-resistant Staphylococcus aureus (MRSA) admission screening for intensive care unit patients. We assessed hospital staff perceptions of the implementation of this law.

Mixed-methods evaluation using structured focus groups and questionnaires.

Eight Chicago-area hospitals.

Three strata of staff (leadership, midlevel, and frontline) at each hospital.

All participants completed a questionnaire and participated in a focus group. Focus group transcripts were thematically coded and analyzed. The proportion of staff agreeing with statements about MRSA and the legislation was compared across staff types.

Overall, 126 hospital staff participated in 23 focus groups. Fifty-six percent of participants agreed that the legislation had a positive effect at their facility; frontline staff were more likely to agree than midlevel and leadership staff (P < .01). Perceived benefits of the legislation included increased awareness of MRSA among staff and better knowledge of the epidemiology of MRSA colonization. Perceived negative consequences included the psychosocial effect of screening and contact precautions on patients and increased use of resources. Most participants (59%) would choose to continue the activities associated with the legislation but advised facilities in states considering similar legislation to educate staff and patients about MRSA screening and to draft clear implementation plans.

Staff from Chicago-area hospitals perceived that mandatory MRSA screening legislation resulted in some benefits but highlighted implementation challenges. States considering similar initiatives might minimize these challenges by optimizing messaging to patients and healthcare staff, drafting implementation plans, and developing program evaluation strategies.

Better understand the incidence, risk factors, and outcomes of peripheral venous catheter (PVC)-related Staphylococcus aureus bacteremia.

Retrospective study of PVC-related S. aureus bacteremias in adult patients from July 2005 through March 2008. A point-prevalence survey was performed January 9, 2008, on adult inpatients to determine PVC utilization; patients with a PVC served as a cohort to assess risk factors for PVC-related S. aureus bacteremia.

Tertiary care teaching hospital.

Twenty-four (18 definite and 6 probable) PVC-related S. aureus bacteremias were identified (estimated incidence density, 0.07 per 1,000 catheter-days), with a median duration of catheterization of 3 days (interquartile range, 2-6). Patients with PVC-related S. aureus bacteremia were significantly more likely to have a PVC in the antecubital fossa (odds ratio [OR], 6.5), a PVC placed in the emergency department (OR, 6.0), or a PVC placed at an outside hospital (P = .005), with a longer duration of catheterization (P < .001). These PVCs were significantly less likely to have been inserted in the hand (OR, 0.23) or placed on an inpatient medical unit (OR, 0.17). Mean duration of antibiotic treatment was 19 days (95% confidence interval, 15-23 days); 42% (10/24) of cases encountered complications. We estimate that there may be as many as 10,028 PVC-related S. aureus bacteremias yearly in US adult hospitalized inpatients.

PVC-related S. aureus bacteremia is an underrecognized complication. PVCs inserted in the emergency department or at outside institutions, PVCs placed in the antecubital fossa, and those with prolonged dwell times are associated with such infections.

To evaluate the impact of ertapenem use in Pseudomonas aeruginosa carbapenem resistance, taking into account the volume of antimicrobial consumption, the consumption by the entire hospital of alcohol-based antiseptic hand rub, and the density rate of invasive practices.

Before-and-after trial.

A tertiary care university hospital in southern Brazil.

Ertapenem was first added to the hospital formulary in June 2006, and it was excluded in February 2009. We evaluated Pseudomonas aeruginosa resistance rates through 3 study periods: period 1, before ertapenem use (17 months); period 2, during ertapenem use (33 months); and period 3, after exclusion of ertapenem (15 months).

After introduction of ertapenem, there was a significant decrease in median consumption of imipenem or meropenem, from 2.6 to 2.2 defined daily doses (DDDs) per 100 patient-days (level change from 0.04 to -1.08; P < .01), and an increase in the use of these medications after ertapenem exclusion, from 2.2 to 3.3 DDDs per 100 patient-days (level change from -0.14 to 0.91; P < .01), by segmented regression analysis. There was no difference in the incidence density of carbapenem-resistant P. aeruginosa infection related to ertapenem use throughout the study periods. However, by multiple regression analysis, the reduction in the rate of carbapenem-resistant P. aeruginosa infection correlated significantly with the increase in the volume of alcohol used as hand sanitizer, which was from 660.7 mL per 100 patient-days in period 1 to 2,955.1 mL per 100 patient-days in period 3 (P = .04). Ertapenem use did not impact the rate of carbapenem-resistant P. aeruginosa infection.

Use of alcohol-based hand gel, rather than ertapenem, was associated with a reduction in the rates of carbapenem-resistant P. aeruginosa infection. Measures to reduce resistance must include factors other than just antimicrobial stewardship programs alone.

To evaluate the effect of oral hygiene with 0.12% Chlorhexidine gluconate on the incidence of nosocomial pneumonia and ventilator-associated pneumonia (VAP) in children undergoing cardiac surgery.

Prospective, randomized, double-blind, placebo-controlled trial.

Pediatric intensive care unit (PICU) at a tertiary care hospital.

One hundred sixty children undergoing surgery for congenital heart disease, randomized into 2 groups: Chlorhexidine (n = 87) and control (n = 73).

Oral hygiene with 0.12% Chlorhexidine gluconate or placebo preoperatively and twice a day postoperatively until PICU discharge or death.

Patients in experimental and control groups had similar ages (median, 12.2 vs 10.8 months; P = .72) and risk adjustment for congenital heart surgery 1 score distribution (66% in category 1 or 2 in both groups; P = .17). The incidence of nosocomial pneumonia was 29.8% versus 24.6% (P = .46) and the incidence of VAP was 18.3% versus 15% (P = .57) in the Chlorhexidine and the control group, respectively. There was no difference in intubation time (P = .34), need for reintubation (P = .37), time interval between hospitalization and nosocomial pneumonia diagnosis (P = .63), time interval between surgery and nosocomial pneumonia diagnosis (P = .10), and time on antibiotics (P = .77) and vasoactive drugs (P = .16) between groups. Median length of PICU stay (3 vs 4 days; P = .53), median length of hospital stay (12 vs 11 days; P = .67), and 28-day mortality (5.7% vs 6.8%; P = .77) were also similar in the Chlorhexidine and the control group.

Oral hygiene with 0.12% Chlorhexidine gluconate did not reduce the incidence of nosocomial pneumonia and VAP in children undergoing cardiac surgery.

ClinicalTrials.gov identifier: NCT00829842.

To use clinical vignettes to understand antimicrobial prescribing practices in neonatal intensive care units (NICUs).

Vignette-based survey.

Four tertiary care NICUs.

Antibiotic prescribers in NICUs.

Clinicians from 4 tertiary care NICUs completed an anonymous survey containing 12 vignettes that described empiric, targeted, or prophylactic antibiotic use. Responses were compared with Centers for Disease Control and Prevention guidelines for appropriate use.

Overall, 161 (59% of 271 eligible respondents) completed the survey, 37% of whom had worked in NICUs for 7 or more years. Respondents were more likely to appropriately identify use of targeted therapy for methicillin-susceptible Staphylococcus aureus, that is, use of oxacillin rather than vancomycin, than for Escherichia coli, that is, use of first-generation rather than third-generation cephalosporin, (P < .01). Increased experience significantly predicted appropriate prescribing (P = .02 ). The proportion of respondents choosing appropriate duration of postsurgical prophylaxis (P < .01) and treatment for necrotizing enterocolitis differed by study site (P = .03).

The survey provides insight into antibiotic prescribing practices and informs the development of future antibiotic stewardship interventions for NICUs.