To determine whether the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) laboratory-identified (LabID) event reporting module for Clostridium difficile infection (CDI) is an adequate proxy measure of clinical CDI for public reporting purposes by comparing the 2 surveillance methods.

Validation study.

Thirty New York State acute care hospitals.

Six months of data were collected by 30 facilities using a clinical infection surveillance definition while also submitting the NHSN LabID event for CDI. The data sets were matched and compared to determine whether the assigned clinical case status matched the LabID case status. A subset of mismatches was evaluated further, and reasons for the mismatches were quantified. Infection rates determined using the 2 definitions were compared.

A total of 3,301 CDI cases were reported. Analysis of the original data yielded a 67.3% (2,223/3,301) overall case status match. After review and validation, there was 81.3% (2,683/3,301) agreement. The most common reason for disagreement (54.9%) occurred because the symptom onset was less than 48 hours after admission but the positive specimen was collected on hospital day 4 or later. The NHSN LabID hospital onset rate was 29% higher than the corresponding clinical rate and was generally consistent across all hospitals.

Use of the NHSN LabID event minimizes the burden of surveillance and standardizes the process. With a greater than 80% match between the NHSN LabID event data and the clinical infection surveillance data, the New York State Department of Health made the decision to use the NHSN LabID event CDI data for public reporting purposes.

Prospective, observational, ecological, time series, cross-sectional study examining the association between hand hygiene compliance (HHC) rates and the incidence of hospital-acquired infections.

Acute care hospitals (N = 166) located in the province of Ontario, Canada.

All data were extracted from the Ontario patient safety indicator database (http://www.hqontario.ca/public-reporting/patient-safety). Complete data were available for 166 acute care hospitals from October 1, 2008, to December 31, 2011. The rates of Clostridium difficile infection (CDI) are reported monthly, methicillin-resistant Staphylococcus aureus (MRSA) bacteremia quarterly, and HHC rates yearly. Trends and associations for each indicator were evaluated by ordinary least squares regression (HHC), zero-inflated Poisson regression (MRSA bacteremia), or Poisson regression (CDI). Dependent variables included in the regression analyses were extracted from the same database and included year, healthcare region, and type of hospital (teaching or small or large community).

Compared to those in 2008, reported HHC rates improved every year both before and after environment/patient contact (range, 10.6%–25.3%). Compared to those in 2008, there was no corresponding change in the rates of MRSA bacteremia; however, the rates of CDI decreased in 2009 but were not statistically significantly decreased from baseline in either 2010 or 2011. No consistent association was demonstrated between changes in the rates of HHC and these two healthcare-associated infections (HAIs).

Despite significant improvements in reported rates of HHC among healthcare personnel in Ontario's hospitals, we could not demonstrate a positive ecological impact on rates of these two HAIs.

Stethoscopes are contaminated with pathogenic bacteria and pose a risk for transmission of infections, but few clinicians disinfect their stethoscope after every use. We sought to improve stethoscope disinfection rates among pediatric healthcare providers by providing access to disinfection materials and visual reminders to disinfect stethoscopes.

Prospective intervention study.

Inpatient units and emergency department of a major pediatric hospital.

Physicians and nurses with high anticipated stethoscope use.

Baskets filled with alcohol prep pads and a sticker reminding providers to regularly disinfect stethoscopes were installed outside of patient rooms. Healthcare providers' stethoscope disinfection behaviors were directly observed before and after the intervention. Multivariable logistic regression models were created to identify independent predictors of stethoscope disinfection.

Two hundred twenty-six observations were made in the preintervention period and 261 in the postintervention period (83% were of physicians). Stethoscope disinfection compliance increased significantly from a baseline of 34% to 59% postintervention (P < .001). In adjusted analyses, the postintervention period was associated with improved disinfection among both physicians (odds ratio [OR], 2.3 [95% confidence interval (CI), 1.4-3.5]) and nurses (OR, 14.3 [95% CI, 4.6-44.6]). Additional factors independently associated with disinfection included subspecialty unit (vs general pediatrics; OR, 0.5 [95% CI, 0.3-0.8]) and contact precautions (OR, 2.3 [95% CI, 1.2-4.1]).

Providing stethoscope disinfection supplies and visible reminders outside of patient rooms significantly increased stethoscope disinfection rates among physicians and nurses at a children's hospital. This simple intervention could be replicated at other healthcare facilities. Future research should assess the impact on patient infections.

To identify predictors of community-onset extended-spectrum β-lactamase (ESBL)-producing Escherichia coli infection.

Prospective case-control study.

Acute care hospitals and ambulatory clinics in the Chicago, Illinois, region.

Adults with E. coli clinical isolates cultured in ambulatory settings or within 48 hours of hospital admission.

Cases were patients with ESBL-producing E. coli clinical isolates cultured in ambulatory settings or within 48 hours of admission, and controls were patients with non-ESBL-producing E. coli isolates, matched to cases by specimen, location, and date. Clinical variables were ascertained through interviews and medical record review. Molecular methods were used to identify ESBL types, sequence type ST131, and aac(6′)-Ib-cr.

We enrolled 94 cases and 158 controls. Multivariate risk factors for ESBL-producing E. coli infection included travel to India in the past year (odds ratio [OR], 14.40 [95% confidence interval (CI), 2.92-70.95]), ciprofloxacin use (OR, 3.92 [95% CI, 1.90-8.1]), and age (OR, 1.04 [95% CI, 1.02-1.06]). Case isolates exhibited high prevalence of CTX-M-15 (78%), ST131 (50%), and aac(6′)-Ib-cr (66% of isolates with CTX-M-15).

Providers should be aware of the increased risk of ESBL-producing E. coli infection among returned travelers, especially those from India.

To investigate the distribution of hospital pathogens within general and critical care ward environments and to determine the most significant bacterial reservoirs within each ward type.

Prospective 4-month microbiological survey.

The intensive care unit (ICU) and gastrointestinal (GI) surgical ward of a London teaching hospital.

Sampling was conducted in and around the bed space of 166 different patients (99 in the ICU and 67 in the GI ward).

Conventional agar contact methodology was used to sample 123 predetermined sites twice a week for 17 weeks. Sixty-one surfaces were located within the ICU, and 62 were located within the GI ward. Each surface was located within a theoretical zone of increasing distance from the patient. Aerobic colony counts were determined, and confirmatory testing was conducted on all presumptive pathogens.

Regardless of ward type, surfaces located closest to the patient, specifically those associated with the bed (side rails, bed control, and call button), were the most heavily contaminated. Elsewhere, the type of surfaces contaminated differed with ward type. In the ICU, bacteria were most likely to be on surfaces that were regularly touched by healthcare workers (eg, telephones and computer keyboards). In the GI ward, where the patients were mobile, the highest numbers of bacteria (including potential nosocomial pathogens) were on surfaces that were mainly touched by patients, particularly their toilet and shower facilities.

In terms of cleaning, a hospital should not be considered a single entity. Different ward types should be treated as separate environments, and cleaning protocols should be adjusted accordingly.

To assess the knowledge, attitudes, and practices of infection control among staff in a residential care facility for children and young adults with neurologic and neurodevelopmental conditions.

Self-administered survey.

Residential care facility (facility A).

Facility A staff (N = 200).

We distributed a survey to staff at facility A. We classified staff with direct care responsibilities as clinical (ie, physicians, nurses, and therapists) or nonclinical (ie, habilitation assistants, volunteers, and teachers) and used X2 tests to measure differences between staff agreement to questions.

Of 248 surveys distributed, 200 (81%) were completed; median respondent age was 36 years; 85% were female; and 151 were direct care staff (50 clinical, 101 nonclinical). Among direct care staff respondents, 86% agreed they could identify residents with respiratory symptoms, 70% stayed home from work when ill with respiratory infection, 64% agreed that facility administration encouraged them to stay home when ill with respiratory infection, and 72% reported that ill residents with respiratory infections were separated from well residents. Clinical and nonclinical staff differed in agreement about using waterless hand gel as a substitute for handwashing (96% vs 78%; P = .005) and whether handwashing was done after touching residents (92% vs 75%; P = .04).

Respondents' knowledge, attitudes, and practices regarding infection control could be improved, especially among nonclinical staff. Facilities caring for children and young adults with neurologic and neurodevelopmental conditions should encourage adherence to infection control best practices among all staff having direct contact with residents.

Assessing the impact of 2009 influenza A (H1N1) on healthcare workers (HCWs) is important for pandemic planning.

We retrospectively analyzed employee health records of HCWs at a tertiary care center in New York City with influenza-like illnesses (ILI) and confirmed influenza from March 31, 2009, to February 28, 2010. We evaluated HCWs' clinical presentations during the first and second wave of the pandemic, staff absenteeism, exposures among HCWs, and association between high-risk occupational exposures to respiratory secretions and infection.

During the pandemic, 40% (141/352) of HCWs with ILI tested positive for influenza, representing a 1% attack rate among our 13,066 employees. HCWs with influenza were more likely to have fever, cough, and tachycardia. When compared with the second wave, cases in the first wave were sicker and at higher risk of exposure to patients' respiratory secretions (P = .049). HCWs with ILI- with and without confirmed influenza-missed on average 4.7 and 2.7 work days, respectively (P = .001). Among HCWs asked about working while ill, 65% (153/235) reported they did so (mean, 2 days).

HCWs in the first wave had more severe ILI than those in the second wave and were more likely to be exposed to patients' respiratory secretions. HCWs with ILI often worked while ill. Timely strategies to educate and support HCWs were critical to managing this population during the pandemic.

Describe local changes in the incidence of community-onset and hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) infection and evaluate the impact of MRSA active surveillance on hospital-onset infection.

Observational study using prospectively collected data.

Atlanta Veterans Affairs Medical Center (AVAMC).

All patients seen at the AVAMC over an 8-year period with clinically and microbiologically proven MRSA infection.

All clinical cultures positive for MRSA were prospectively identified, and corresponding clinical data were reviewed. MRSA infections were classified into standard clinical and epidemiologic categories. The Veterans Health Administration implemented the MRSA directive in October 2007, which required active surveillance cultures in acute care settings.

The incidence of community-onset MRSA infection peaked in 2007 at 5.45 MRSA infections per 1,000 veterans and decreased to 3.14 infections per 1,000 veterans in 2011 (P < .001 for trend). Clinical and epidemiologic categories of MRSA infections did not change throughout the study period. The prevalence of nasal MRSA colonization among veterans admitted to AVAMC decreased from 15.8% in 2007 to 11.2% in 2011 (P <.001 for trend). The rate of intensive care unit (ICU)-related hospital-onset MRSA infection decreased from October 2005 through March 2007, before the MRSA directive. Rates of ICU-related hospital-onset MRSA infection remained stable after the implementation of active surveillance cultures. No change was observed in rates of non-ICU-related hospital-onset MRSA infection.

Our study of the AVAMC population over an 8-year period shows a consistent trend of reduction in the incidence of MRSA infection in both the community and healthcare settings. The etiology of this reduction is most likely multifactorial.

Of the 13 US vancomycin-resistant Staphylococcus aureus (VRSA) cases, 8 were identified in southeastern Michigan, primarily in patients with chronic lower-extremity wounds. VRSA infections develop when the vanA gene from vancomycin-resistant enterococcus (VRE) transfers to S. aureus. Incl8-like plasmids in VRE and pSK41-like plasmids in S. aureus appear to be important precursors to this transfer.

Identify the prevalence of VRSA precursor organisms.

Prospective cohort with embedded case-control study.

Southeastern Michigan adults with chronic lower-extremity wounds.

Adults presenting to 3 southeastern Michigan medical centers during the period February 15 through March 4, 2011, with chronic lower-extremity wounds had wound, nares, and perirectal swab specimens cultured for S. aureus and VRE, which were tested for pSK41-like and Incl8-like plasmids by polymerase chain reaction. We interviewed participants and reviewed clinical records. Risk factors for pSK41-positive S. aureus were assessed among all study participants (cohort analysis) and among only S. aureus-colonized participants (case-control analysis).

Of 179 participants with wound cultures, 26% were colonized with methicillin-susceptible S. aureus, 27% were colonized with methicillin-resistant S. aureus, and 4% were colonized with VRE, although only 17% consented to perirectal culture. Six participants (3%) had pSK41-positive S. aureus, and none had Incl8-positive VRE. Having chronic wounds for over 2 years was associated with pSK41-positive S. aureus colonization in both analyses.

Colonization with VRSA precursor organisms was rare. Having long-standing chronic wounds was a risk factor for pSK41-positive S. aureus colonization. Additional investigation into the prevalence of VRSA precursors among a larger cohort of patients is warranted.

Although mandatory vaccination programs have been effective in improving the vaccination rate among healthcare workers, implementing this type of program can be challenging because of varied reasons for vaccine refusal. The purpose of our study is to measure improvement in the influenza vaccination rate from a multifaceted intervention at a Japanese tertiary care center where implementing a mandatory vaccination program is difficult.

Before-and-after trial.

Healthcare workers at a 550-bed, tertiary care, academic medical center in Sapporo, Japan.

We performed a multifaceted intervention including (1) use of a declination form, (2) free vaccination, (3) hospital-wide announcements during the vaccination period, (4) prospective audit and real-time telephone interview for healthcare workers who did not receive the vaccine, (5) medical interview with the hospital executive for noncompliant (no vaccine, no declination form) healthcare workers during the vaccination period, and (6) mandatory submission of a vaccination document if vaccinated outside of the study institution.

With the new multifaceted intervention, the vaccination rate in the 2012-2013 season increased substantially, up to 97%. This rate is similar to that reported in studies with a mandatory vaccination program. Improved vaccination acceptance, particularly among physicians, likely contributed to the overall increase in the vaccination rate reported in the study.

Implementation of comprehensive strategies with strong leadership can lead to substantial improvements in vaccine uptake among healthcare workers even without a mandatory vaccination policy. The concept is especially important for institutions where implementing mandatory vaccination programs is challenging.

Many bloodstream infections (BSIs) occurring in patients with febrile neutropenia following cytotoxic chemotherapy are due to translocation of intestinal microbiota. However, these infections meet the National Healthcare Safety Network (NHSN) definition of central line-associated BSIs (CLABSIs). We sought to determine the differences in the microbiology of NHSN-defined CLABSIs in patients with and without neutropenia and, using these data, to propose a modification of the CLABSI definition.

Retrospective review.

Two large university hospitals over 18 months.

All hospital-acquired BSIs occurring in patients with central venous catheters in place were classified using the NHSN CLABSI definition. Patients with postchemotherapy neutropenia (500 neutrophils/mm3 or lower) at the time of blood culture were considered neutropenic. Pathogens overrepresented in the neutropenic group were identified to inform development of a modified CLABSI definition.

Organisms that were more commonly observed in the neutropenic group compared with the nonneutropenic group included Escherichia coli (22.7% vs 2.5%; P < .001) but not other Enterobacteriaceae, Enterococcus faecium (18.2% vs 6.1%; P = .002), and streptococci (18.2% vs 0%; P < .001). Application of a modified CLABSI definition (removing BSI with enterococci, streptococci, or E. coli) excluded 33 of 66 neutropenic CLABSIs and decreased the CLABSI rate in one study hospital with large transplant and oncology populations from 2.12 to 1.79 cases per 1,000 line-days.

Common gastrointestinal organisms were more common in the neutropenia group, suggesting that many BSIs meeting the NHSN criteria for CLABSI in the setting of neutropenia may represent translocation of gut organisms. These findings support modification of the NHSN CLABSI definition.

TO investigate and describe the relationship between indigenous Australian populations, residential aged care services, and community-onset Staphylococcus aureus bacteremia (SAB) among patients admitted to public hospitals in Queensland, Australia.

Ecological study.

We used administrative healthcare data linked to microbiology results from patients with SAB admitted to Queensland public hospitals from 2005 through 2010 to identify community-onset infections. Data about indigenous Australian population and residential aged care services at the local government area level were obtained from the Queensland Office of Economic and Statistical Research. Associations between community-onset SAB and indigenous Australian population and residential aged care services were calculated using Poisson regression models in a Bayesian framework. Choropleth maps were used to describe the spatial patterns of SAB risk.

We observed a 21% increase in relative risk (RR) of bacteremia with methicillin-susceptible S. aureus (MSSA; RR, 1.21 [95% credible interval, 1.15–1.26]) and a 24% increase in RR with nonmultiresistant methicillin-resistant S. aureus (nmMRSA; RR, 1.24 [95% credible interval, 1.13–1.34]) with a 10% increase in the indigenous Australian population proportion. There was no significant association between RR of SAB and the number of residential aged care services. Areas with the highest RR for nmMRSA and MSSA bacteremia were identified in the northern and western regions of Queensland.

The RR of community-onset SAB varied spatially across Queensland. There was increased RR of community-onset SAB with nmMRSA and MSSA in areas of Queensland with increased indigenous population proportions. Additional research should be undertaken to understand other factors that increase the risk of infection due to this organism.

Contact precautions are a cornerstone of infection prevention but have also been associated with less healthcare worker (HCW) contact and adverse events. We studied how contact precautions modified HCW behavior in 4 acute care facilities.

Prospective cohort study.

Four acute care facilities in the United States performing active surveillance for methicillin-resistant Staphylococcus aureus.

Trained observers performed “secret shopper” monitoring of HCW activities during routine care, using a standardized collection tool and fixed 1-hour observation periods.

A total of 7,743 HCW visits were observed over 1,989 hours. Patients on contact precautions had 36.4% fewer hourly HCW visits than patients not on contact precautions (2.78 vs 4.37 visits per hour; P< .001 ) as well as 17.7% less direct patient contact time with HCWs (13.98 vs 16.98 minutes per hour; P = .02). Patients on contact precautions tended to have fewer visitors (23.6% fewer; P = .08). HCWs were more likely to perform hand hygiene on exiting the room of a patient on contact precautions (63.2% vs 47.4% in rooms of patients not on contact precautions; P< .001).

Contact precautions were found to be associated with activities likely to reduce transmission of resistant pathogens, such as fewer visits and better hand hygiene at exit, while exposing patients on contact precautions to less HCW contact, less visitor contact, and potentially other unintended outcomes.

USA300 methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of skin and soft-tissue infection (SSTI) in military personnel. USA300 MRSA has emerged as an important cause of healthcare-associated bloodstream infection (BSI) in metropolitan centers.

To determine the prevalence, risk factors, and patient outcomes associated with USA300 MRSA BSI in military tertiary medical centers.

Retrospective case-control study.

Patients admitted during the period 2001–2009 with MRSA BSI.

Walter Reed Army Medical Center (Washington, DC) and National Naval Medical Center (Bethesda, MD) tertiary medical centers with 500 inpatient beds combined, which provide care to active duty service members and military beneficiaries.

After identifying patients with MRSA BSI, we collected epidemiological data from electronic medical records and characterized bacterial isolates using pulsed-field gel electrophoresis (PFGE).

A total of 245 MRSA BSI cases were identified, and 151 isolates were available for analysis. Epidemiological characteristics for the 151 patients with available isolates included the following: mean age, 61 years; male sex, 70%; white race, 62%; and combat-wounded service members, 11%. The crude in-hospital mortality rate was 17%. PFGE demonstrated that 30 (20%) of 151 MRSA BSI cases with isolates available for analysis were due to USA300, and 27 (87%) of these 30 cases were healthcare-associated infection. USA300 was associated with a significantly increasing proportion of MRSA BSI when examined over sequential time periods: 2 (4%) of 51 isolates during 2001–2003, 9 (19%) of 47 isolates during 2004–2006, and 19 (36%) of 53 isolates during 2007–2009 (P<.001).

USA300 MRSA is emerging as a cause of healthcare-associated BSI in tertiary military medical centers.

To describe practices for influenza vaccination of healthcare personnel (HCP) with emphasis on correlates of increased vaccination rates.

Survey.

Volunteer sample of hospitals in Louisiana.

All hospitals in Louisiana were invited to participate. A 17-item questionnaire inquired about the hospital type, patients served, characteristics of the vaccination campaign, and the resulting vaccination rate.

Of 254 hospitals, 153 (60%) participated and were included in the 124 responses that were received. Most programs (64%) required that HCP either receive the vaccine or sign a declination form, and the rest were exclusively voluntary (36%); no program made vaccination a condition of employment. The median vaccination rate was 67%, and the vaccination rate was higher among hospitals that were accredited by the Joint Commission; provided acute care; served children, pregnant women, oncology patients, or intensive care unit patients; required a signed declination form; or imposed consequences for unvaccinated HCP (the most common of which was to require that a mask be worn on patient contact). Hospitals that provided free vaccine, made vaccine widely available, advertised the program extensively, required a declination form, and imposed consequences had the highest vaccination rates (median, 86%; range, 81%–91%).

The rate of influenza vaccination of HCP remains low among the hospitals surveyed. Recommended practices may not be enough to reach 90% vaccination rates unless a signed declination requirement and consequences are implemented. Wearing a mask is a strong consequence. Demanding influenza vaccination as a condition of employment was not reported as a practice by the participating hospitals.