To compare the rate of surgical site infection (SSI) before and after an intervention period in which an optimized policy for antibiotic prophylaxis was implemented. To demonstrate that a more prudent, restrictive policy would not have a detrimental effect on patient outcomes.

Before-after trial with prospective SSI surveillance in the Dutch nosocomial surveillance network (Preventie Ziekenhuisinfecties door Surveillance [PREZIES]), using the criteria of the Centers for Disease Control, including postdischarge surveillance for up to 1 year.

During a preintervention period and a postintervention period (both 6-13 months), 12 Dutch hospitals collected data on antimicrobial prophylaxis and SSI rates. The study was limited to commonly performed surgical procedures in 4 specialties: vascular, intestinal, gynecological and orthopedic surgery. Selected risk factors for analysis were sex, age, American Society of Anesthesiologists classification, wound contamination class, duration of surgery, length of hospital stay before surgery, and urgency of surgery (elective or acute).

A total of 3,621 procedures were included in the study, of which 1,668 were performed before the intervention and 1,953 after. The overall SSI rate decreased from 5.4% to 4.5% (P = .22). Among the procedures included in the study, the largest proportion (55%) were total hip arthroplasty, and the smallest proportion (2%) were replacement of the head of the femur. SSI rates varied from 0% for vaginal hysterectomy to 21.1% for femoropopliteal or femorotibial bypass surgery. Crude and adjusted odds ratios showed that there were no significant changes in procedure-specific SSI rates after the intervention (P>.1).

An optimized and restrictive antibiotic prophylaxis policy had no detrimental effect on the outcome of clean and clean contaminated surgery, as measured by SSI rate.

Institutions such as hospitals, prisons, and long-term care facilities have been identified as focal points for the transmission of emerging infections. Cost-effective control of these infections in large populations requires the identification of optimal subpopulations for targeted infection control interventions. Our objective was to quantify and compare the relative impact that individual institutions or subpopulations have on wider population-level outbreaks of emerging pathogens.

We describe a simple mathematical model to compute the epidemiologic weight (EW) of an institution or subpopulation. The EW represents the rate at which newly infectious individuals exit the institution under consideration.

A hypothetical academic tertiary-care hospital (700 beds, 5-day length of stay [LOS]) and prison (3098 inmates, 27-day LOS).

Individuals entering a hospital in-patient prison ward and nonprisoners entering both medical and surgical intensive-care units and those admitted to the general medical and surgical wards.

The recent example of the community-acquired methicillin-resistant Staphylococcus aureus epidemic is used to illustrate the EW calculation. Hospitals and prisons, which often have vastly dissimilar populations sizes and LOSs and might have differing transmission rates, can have comparable EWs and thus contribute equally to an epidemic in the community.

This method highlights the importance of measuring entrance and exit colonization prevalences for the optimal targeting of prevention measures. The EW not only identified superspreader institutions but also ranks them, enabling public health workers to optimize the allocation of resources to places where they are likely to be of most benefit.

To evaluate the frequency of infections due to community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) strains among our patients with end-stage renal disease.

Prospective observational clinical and laboratory study of patients in 2005. Molecular features of isolates recovered from these patients were compared with those of isolates recovered in 2000 from patients with end-stage renal disease.

A 600-bed urban academic medical center.

Thirty-two patients with end-stage renal disease and MRSA infection at the time of hospitalization from 2005 were evaluated. For comparison, laboratory analysis was performed for 17 MRSA isolates recovered from patients with end-stage renal disease in 2000.

The patients from 2005 were more likely than the patients from 2000 to have infection with strains that carried the staphylococcal cassette chromosome (SCC) mec type IV complex (50% vs 11.8%; relative risk, 4.25 [95% confidence interval, 1.17-25.98]; P = .012) and the Panton-Valentine leukocidin toxin genes (25% vs 0%; P = .038). Eight patients from 2005 were infected with a strain that is identical to MRSA clone USA300 in terms of molecular type and presence of SCCmec type IV and Panton-Valentine leukocidin genes. Among the patients from 2005, those infected with SCCmec type IV strains (ie, CA-MRSA strains) and those infected with SCCmec type II strains (ie, healthcare-associated MRSA [HA-MRSA] strains) were similar with respect to demographic characteristics, risk factors, and outcomes.

We documented an increased proportion of infections with CA-MRSA strains, including clone USA300, among our population of patients undergoing dialysis. Patients infected with CA-MRSA strains and HA-MRSA strains were similar with respect to presenting illness and outcomes.

Most reusable biopsy forceps and all of the currently available single-use biopsy forceps do not have a port that allows fluid flow down the inner tubular shaft of the device. Reusable biopsy forceps are widely used and reprocessed in healthcare facilities, and single-use biopsy forceps are reprocessed either in-house (eg, in Canada and Japan) or by third-party reprocessors (eg, in the United States). The objective of this study was to determine the cleaning efficacy of automated narrow-lumen sonic irrigation cleaning, sonication-only cleaning, and manual cleaning for biopsy forceps.

A simulated-use study was performed by inoculating the inner channel of single-use biopsy forceps with artificial test soil containing both Enterococcus faecalis and Geobacillus stearothermophilus at concentrations of 106 colony-forming units per milliliter. The cleaning methods evaluated were manual cleaning, sonication-only cleaning, and “retroflush” cleaning by an automated narrow-lumen irrigator. Bioburden and organic soil reduction after washing was evaluated. Forceps used in biopsies of patients were also tested to determine the worst-case soiling levels.

Only retroflush irrigation cleaning could effectively remove material from within the shaft portion of the biopsy forceps: it achieved an average reduction of more than 95% in levels of protein, hemoglobin, carbohydrate, and endotoxin. However, even this method of cleaning was not totally effective, as only a 2 log10 reduction in bioburden could be achieved, and there were low residual levels of hemoglobin and carbohydrate.

The data from this evaluation indicate that manual and sonication-only cleaning methods for biopsy forceps were totally ineffective in removing material from within the biopsy forceps. Even the use of retroflush cleaning was not totally effective. These findings suggest that in-hospital reprocessing of biopsy forceps with currently available equipment and cleaning methods is suboptimal.

To determine whether there is an association between the increasing use of alcohol-based hand rubs (ABHRs) and the increased incidence of Clostridium difficile–associated disease (CDAD).

A 500-bed university-affiliated community teaching hospital.

Use of ABHRs during the period 2000-2003 was expressed as the number of liters of ABHR used per 1000 patient-days. The proportion of hand hygiene episodes performed by using an ABHR was determined by periodic observational surveys. CDAD was defined as a physician-ordered stool assay positive for C. difficile toxin A or A/B. The incidence of CDAD was expressed as the number of unique patients who had 1 or more positive CDAD test results per 1,000 patient-days.

During 2000-2003, the use of ABHR increased 10-fold, from 3 to greater than 30 L/1,000 patient-days (P< .001). The proportion of hand hygiene episodes performed using an ABHR increased from 10% to 85% (P< .001). The incidence of CDAD in 2000, 2001, 2002, and 2003 was 1.74, 2.33, 1.14, and 1.18 cases/1,000 patient-days, respectively.

Despite a significant and progressive increase in the use of ABHRs in our facility during a 3-year period, there was no evidence that the incidence of CDAD increased. These findings suggest that factors other than the increased use of ABHRs are responsible for the increasing incidence of CDAD noted since 2000 in other facilities.

To evaluate the effectiveness of a high-level disinfection solution generated inside an endoscope processing system for decontaminating external and internal surfaces of experimentally contaminated heat-sensitive medical devices.

The American Society for Testing and Materials Simulated-Use Test protocol (E1837-02), which incorporates a soil load in each inoculum, was used to evaluate the efficacy of the system when processing 4 common types of endoscopes contaminated separately with 5 types of nosocomial pathogens: Pseudomonas aeruginosa (ATCC 15442), spores of Clostridium difficile (ATCC 9689), a glutaraldehyde-resistant strain of Mycobacterium chelonae, a vancomycin-resistant strain of Enterococcus faecalis, and a methicillin-resistant strain of Staphylococcus aureus. Rinse solution samples from channels and from surfaces of the processed endoscopes were tested for any microbicidal residues.

For all organisms tested, the baseline level of contamination of the endoscopes ranged from 5 log10 to greater than 7 log10 at each external surface site and internal channel. All tests showed reductions in viability of the test organisms to undetectable levels. All rinse solution samples from external and internal sites of the endoscopes proved to be free of any residual microbicidal activity.

The endoscope reprocessor, with its processor-generated high-level disinfection solution, successfully reduced the numbers of selected, clinically relevant pathogens to undetectable levels both in the channels and on the outside surfaces of the 4 representative endoscopes tested in this study.

Computers are ubiquitous in the healthcare setting and have been shown to be contaminated with potentially pathogenic microorganisms. This study was performed to determine the degree of microbial contamination, the efficacy of different disinfectants, and the cosmetic and functional effects of the disinfectants on the computer keyboards.

We assessed the effectiveness of 6 different disinfectants (1 each containing chlorine, alcohol, or phenol and 3 containing quaternary ammonium) against 3 test organisms (oxacillin-resistant Staphylococcus aureus [ORSA], Pseudomonas aeruginosa, and vancomycin-resistant Enterococcus species) inoculated onto study computer keyboards. We also assessed the computer keyboards for functional and cosmetic damage after disinfectant use.

Potential pathogens cultured from more than 50% of the computers included coagulase-negative staphylococci (100% of keyboards), diphtheroids (80%), Micrococcus species (72%), and Bacillus species (64%). Other pathogens cultured included ORSA (4% of keyboards), OSSA (4%), vancomycin-susceptible Enterococcus species (12%), and nonfermentative gram-negative rods (36%). All disinfectants, as well as the sterile water control, were effective at removing or inactivating more than 95% of the test bacteria. No functional or cosmetic damage to the computer keyboards was observed after 300 disinfection cycles.

Our data suggest that microbial contamination of keyboards is prevalent and that keyboards may be successfully decontaminated with disinfectants. Keyboards should be disinfected daily or when visibly soiled or if they become contaminated with blood.

To determine the source of an outbreak of Salmonella javiana infection.

Case-control study.

A total of 101 culture-confirmed cases and 540 epidemiologically linked cases were detected between May 26, 2003, and June 16, 2003, in hospital employees, patients, and visitors. Asymptomatic employees who had eaten in the hospital cafeteria between May 30 and June 4, 2003, and had had no gastroenteritis symptoms after May 1, 2003, were chosen as control subjects.

A 235-bed academic tertiary care children's hospital.

Isolates from 100 of 101 culture-confirmed cases had identical pulsed-field gel electrophoresis patterns. A foodhandler with symptoms of gastroenteritis was the presumed index subject. In multivariate analysis, case subjects were more likely than control subjects to have consumed items from the salad bar (adjusted odds ratio [aOR], 5.3; 95% confidence interval [CI], 2.3-12.1) and to have eaten in the cafeteria on May 28 (aOR, 9.4; 95% CI, 1.8-49.5), May 30 (aOR, 3.6; 95% CI, 1.0-12.7), and/or June 3 (aOR, 4.0; 95% CI, 1.4-11.3).

Foodhandlers who worked while they had symptoms of gastroenteritis likely contributed to the propagation of the outbreak. This large outbreak was rapidly controlled through the use of an incident command center.

To evaluate whether surgical site infection (SSI) rates decrease in surgical departments as a result of performing active SSI surveillance.

Retrospective multiple logistic regression analyses.

A group of 130 surgical departments of German hospitals participating in the Krankenhaus Infektions Surveillance System (KISS).

Data for 19 categories of operative procedures performed between January 1997 and June 2004 were included (119,114 operations). Active SSI surveillance was performed according to National Nosocomial Infections Surveillance system (NNIS) methods and definitions. Departments' SSI rates were calculated individually for each year of surveillance and for each operative procedure category, taking into account when the individual departments had begun their surveillance activities. Multiple logistic regression analyses on a single operation basis were carried out with stepwise variable selection to predict outcomes for patients with SSI. The variables included were as follows: the department's year of participation, NNIS risk index variables, patients' age and sex, and the hospitals' structural characteristics, such as yearly operation frequency, number of beds, and academic status.

For 14 of 19 operative procedure categories analyzed, there was a tendency toward lower SSI rates that was associated with increasing duration of SSI surveillance. In multiple logistic regression analyses of pooled data for all operative procedures, the departments' participation in the surveillance system was a significant independent protective factor. Compared with the surveillance year 1, the SSI risk decreased in year 2 (odds ratio, 0.84; 95% confidence interval, 0.77-0.93) and in year 3 (odds ratio, 0.75; 95% confidence interval, 0.68-0.82), and there was no change in year 4.

The SSI incidence was reduced by one quarter as a result of the surveillance-induced infection control efforts, which indicates the usefulness of a voluntary surveillance system.

To record descriptions of occupational exposures to blood, determine factors predictive of exposure, and identify interventions that might reduce the frequency of exposure.

An analytic, cross-sectional survey.

A total of 601 nurses from surgical wards, operating rooms, and emergency departments.

An anonymous questionnaire developed by the authors on the basis of previously published guidelines was distributed between January and March 2003.

Random, with 18 hospitals selected from 2 urban and rural locations.

Almost half of respondents reported having had at least 1 puncture injury during the preceding year, 1 in 5 had exposure via mucous membranes, and more than half had worked at least once with a recent abrasion or cut on their hands. The number of injuries was independent of age (P = .26), duration of practice (P = .21), and workplace setting (P = .78). The percentage of nurses without percutaneous exposure during the preceding year was significantly higher in the group that received special HIV/AIDS training than in the group that did not (95% confidence interval, 5.8-24.1%; P<.002). The most recent exposure was primarily caused by hollow-bore needles, involved the palm and fingers II-V, was self-inflicted, took place during an elective procedure, and was not reported to the hospital's infection control center by 74% of respondents. The most common reason for not reporting the exposure (38% of cases) was the conviction that the source patient was not infected.

Because of the large number of occupational exposures to blood, especially those due to injuries with hollow-bore needles, nurses should adopt more adequate behavioral strategies to prevent the transmission of blood-borne pathogens. Policies for providing adequate education programs tailored to encourage nurses to report all exposures are urgently required.

To elucidate behavioral determinants of handwashing among nurses.

Statistical modeling using the Theory of Planned Behavior and relevant components to handwashing behavior by nurses that were derived from focus-group discussions and literature review.

The community and 3 tertiary care hospitals.

Children aged 9-10 years, mothers, and nurses.

Responses from 754 nurses were analyzed using backward linear regression for handwashing intention. We reasoned that handwashing results in 2 distinct behavioral practices—inherent handwashing and elective handwashing—with our model explaining 64% and 76%, respectively, of the variance in behavioral intention. Translation of community handwashing behavior to healthcare settings is the predominant driver of all handwashing, both inherent (weighted β = 2.92) and elective (weighted β = 4.1). Intended elective in-hospital handwashing behavior is further significantly predicted by nurses' beliefs in the benefits of the activity (weighted β = 3.12), peer pressure of senior physicians (weighted β = 3.0) and administrators (weighted β = 2.2), and role modeling (weighted β = 3.0) but only to a minimal extent by reduction in effort (weighted β = 1.13). Inherent community behavior (weighted β = 2.92), attitudes (weighted β = 0.84), and peer behavior (weighted β = 1.08) were strongly predictive of inherent handwashing intent.

A small increase in handwashing adherence may be seen after implementing the use of alcoholic hand rubs, to decrease the effort required to wash hands. However, the facilitation of compliance is not simply related to effort but is highly dependent on altering behavioral perceptions. Thus, introduction of hand rub alone without an associated behavioral modification program is unlikely to induce a sustained increase in hand hygiene compliance.

Effective methods to control the emergence of extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella species (ESBL-EK) remain unclear. Variations in the patient populations at different hospitals may influence the effect of antimicrobial formulary interventions.

To examine variations across hospitals in the response to antimicrobial interventions (ie, restriction of ceftazidime and ceftriaxone) designed to curb the spread of ESBL-EK, we conducted a 5-year quasi-experimental study. This study was conducted at 2 hospitals within the same health system: Hospital A is a 625-bed academic medical center, and Hospital B is a 344-bed urban community hospital. All adult patients with a healthcare-acquired clinical culture of ESBL-EK from July 1, 1997 through December 31, 2002 were included.

After the interventions, the use of ceftriaxone decreased by 86% at Hospital A and by 95% at Hospital B, whereas the use of ceftazidime decreased by 95% at Hospital A and by 97% at Hospital B. The prevalence of ESBL-EK at Hospital A decreased by 45% (P< .001), compared with a 22% decrease at Hospital B (P = .36). The following variables were significantly more common among ESBL-EK-infected patients at Hospital B: residence in a long-term care facility (adjusted odds ratio, 3.77 [95% confidence interval, 1.70-8.37]), advanced age (adjusted odds ratio, 1.04 [95% confidence interval, 1.01-1.06]), and presence of a decubitus ulcer (adjusted odds ratio, 4.13 [95% confidence interval, 1.97-8.65]).

The effect of antimicrobial formulary interventions intended to curb emergence of ESBL-EK may differ substantially across institutions, perhaps as a result of differences in patient populations. Variability in the epidemiological profiles of ESBL-EK isolates at different hospitals must be considered when designing interventions to respond to these pathogens.

To investigate the characteristics and origins of methicillin-resistant Staphylococcus aureus (MRSA) strains isolated from neonatal patients admitted to a tertiary care hospital from local and primary care obstetrics clinics.

Molecular typing study.

A 1,278-bed tertiary care hospital (Samsung Medical Center) and 2 primary obstetrics clinics in Seoul, Korea.

The genotypic characteristics of 12 MRSA samples isolated from 11 neonatal patients transferred from 2 primary care obstetrics clinics to a tertiary care hospital were investigated by means of multilocus sequence typing, spa (staphylococcal protein A) typing, and SCCmec typing. Ten MRSA strains isolated from workers and environments in the associated obstetrics clinics were also investigated.

Although the antibiograms of isolates from 2 obstetrics clinics differed, no strain showed multidrug resistance to antimicrobials. Multilocus sequence typing analysis showed that all 22 MRSA isolates analyzed in this study had sequence type 1 (with the allelic profile 1-1-1-1-1-1-1), sequence type 493 (62-1-1-1-1-1-1), or a novel sequence type (25-1-1-1-1-1-1) and that all belonged to a single clonal complex (clonal complex 1). Moreover, they all contained SCCmec type IVA and the identical spa type (UJEBKBP). These genotypic characteristics are similar to those of typical community-associated MRSA strains rather than the hospital-acquired MRSA strains common in Korea.

The findings of this study suggest that community-acquired MRSA strains can spread in primary care clinics and be imported into tertiary care settings.

To describe a nosocomial outbreak of Clostridium difficile–associated disease (CDAD).

A traditional outbreak investigation.

Geriatric department of a tertiary care teaching hospital from March through April 2003.

The outbreak was detected by the C. difficile surveillance program of the infection control unit. CDAD was diagnosed by stool culture and fecal toxin A detection with a qualitative rapid immunoassay. Isolates of C difficile were serotyped and genotyped using pulsed-field gel electrophoresis.

The incidence of CDAD increased from 27 cases per 100,000 patient-days in the 6-month period before the outbreak to 99 cases per 100,000 patient-days during the outbreak. This outbreak involved 21 of 92 patients in 4 geriatric wards, which were located at 2 geographically distinct sites and staffed by the same medical team. The mean age of patients was 83 years (range, 71-100 years). Five (24%) of the 21 patients had community-acquired diarrhea, and secondary hospital transmission resulted in 3 clusters involving 16 patients. Serotyping and genotyping were performed on isolates in stool specimens from 19 different patients; 16 of these isolates were serotype A1, whereas 3 displayed profiles different from the outbreak strain. Management of this outbreak consisted in reinforcement of contact isolation precautions for patients with diarrhea, cohorting of infected patients in the same ward, and promotion of hand hygiene. Relapses occurred in 6 (29%) of 21 patients.

Control of this rapidly developing outbreak of CDAD was obtained with early implementation of cohorting and ward closure and reinforcement of environmental disinfection, hand hygiene, and enteric isolation precautions.

Although adequate knowledge about HIV infection and effective antitransmission measures, such as taking universal precautions in the handling of blood and other body fluids, are important factors in minimizing the risk of HIV transmission in the healthcare setting, little has been reported on the knowledge of nurses with regard to HIV infection and their attitude toward patients with AIDS in Iran. The aim of the present study was to assess these matters.

A questionnaire-based cross-sectional study was conducted from March to April 2003. Included were 1098 nursing staff (registered nurses, registered midwives, and auxiliary nurses) from 8 university teaching hospitals affiliated with the Shiraz University of Medical Sciences.

Registered nurses and midwives had a significantly higher level of knowledge about HIV infection than did auxiliary nurses (χ2 = 16.4; df = 1; P<.001). With regard to the causative agent of AIDS, nurses holding a bachelor of science in nursing or a master of science in nursing (MSN) had a significantly higher level of knowledge than did auxiliary nurses (χ2 = 18.6; df = 1; P<.001). Women more often answered correctly that it is not possible to identify HIV-infected patients by their appearance during the early stages of disease than did men (χ2 = 17.52; df= 1; P<.001). Although 50.7% of respondents had previously cared for patients with AIDS and 54.3% had participated in education programs on AIDS, nearly half stated that they would not want to have to care for patients with AIDS and that, if assigned to care for such a patient, they would ask to be assigned elsewhere.

Our finding that those who scored best on the questionnaire were midwives and single female nurses holding an MSN who had previously cared for HIV-infected patients scored best might indicate that use of selective education campaigns is the most suitable education strategy. The effectiveness of targeted education programs on HIV/AIDS should be repeatedly evaluated in the future.

Urinary tract infections are the leading nosocomial urologic infections and may be a cause of added morbidity and costs, and sometimes sepsis. The aim of this study was to design a predictive score for these complications after prostate surgery.

Multicenter prospective survey.

Eleven French urology centers.

All patients undergoing transurethral resection of prostate (TURP) during a 3-month period.

The overall incidence of postoperative bacteriuria was 25.0% (95% confidence interval, 17.7%-29.5%). Almost all patients (95.7%) received antibiotic prophylaxis. A predictive postoperative bacteriuria score (POBS), with a 6-point scale of 0 to 5, was constructed on the basis of independent risk factors identified in multivariate analysis of a test sample of patients (n = 135) and tested in a validation sample (n = 73). Significantly more infections occurred in patients with a POBS of 2 or higher (87 [8%] vs 48 [50%]; P<.0001). With the test sample, this yielded a sensitivity of 77%, a specificity of 77%, a positive predictive value of 50%, a negative predictive value of 92%, and a global accuracy of 77%.

POBS could be used to distinguish patients at risk of developing infection after TURP. This information might be useful for implementing selective prevention measures or for adjustment for differences in nosocomial infection rates when comparing data between urology centers.

To investigate the potential role of blood pressure (BP) cuffs in the spread of bacterial infections in hospitals.

A comprehensive, prospective study quantitatively and qualitatively evaluating the bacterial contamination on BP cuffs of 203 sphygmomanometers in use in 18 hospital units from January through March 2003.

A university hospital with surgical, medical, and pediatric units.

A level of contamination reaching 100 or more colony-forming units per 25 cm2 was observed on 92 (45%) of inner sides and 46 (23%) of outer sides of 203 cuffs. The highest rates of contamination occurred on the inner side of BP cuffs kept in intensive care units (ICUs) (20 [83%] of 24) or on nurses' trolleys (27 [77%] of 35). None of the 18 BP cuffs presumed to be clean (ie, those that had not been used since the last decontamination procedure) had a high level of contamination. Potentially pathogenic microorganisms were isolated from 27 (13%) of the 203 BP cuffs: 20 of these microorganisms were Staphylococcus aureus, including 9 methicillin-resistant strains. The highest rates of contamination with potentially pathogenic microorganisms were observed on cuffs used in ICUs and those kept on nurses' trolleys. For 4 patients with a personal sphygmomanometer, a genetic link was found between the strains isolated from the BP cuffs and the strains isolated from the patients.

The results of this survey highlight the importance of recognizing BP cuffs as potential vectors of pathogenic bacteria among patients and as a source of reinfection when dedicated to a single patient, emphasizing the urgent need for validated procedures for their use and maintenance.

Education-based interventions can reduce the incidence of catheter-associated bloodstream infection. The generalizability of findings from single-center studies is limited.

To assess the effect of a multicenter intervention to prevent catheter-associated bloodstream infections.

An observational study with a planned intervention.

Twelve intensive care units and 1 bone marrow transplantation unit at 6 academic medical centers.

Patients admitted during the study period.

Updates of written policies, distribution of a 9-page self-study module with accompanying pretest and posttest, didactic lectures, and incorporation into practice of evidence-based guidelines regarding central venous catheter (CVC) insertion and care.

Standard data collection tools and definitions were used to measure the process of care (ie, the proportion of non-tunneled catheters inserted into the femoral vein and the condition of the CVC insertion site dressing for both tunneled and nontunneled catheters) and the incidence of catheter-associated bloodstream infection.

Between the preintervention period and the postintervention period, the percentage of CVCs inserted into the femoral vein decreased from 12.9% to 9.4% (relative ratio, 0.73; 95% confidence interval [CI], 0.61-0.88); the total proportion of catheter insertion site dressings properly dated increased from 26.6% to 34.4% (relative ratio, 1.29; 95% CI, 1.17-1.42), and the overall rate of catheter-associated bloodstream infections decreased from 11.2 to 8.9 infections per 1,000 catheter-days (relative rate, 0.79; 95% CI, 0.67-0.93). The effect of the intervention varied among individual units.

An education-based intervention that uses evidence-based practices can be successfully implemented in a diverse group of medical and surgical units and reduce catheter-associated bloodstream infection rates.

To determine whether feedback on antimicrobial use improves physician compliance with local hospital guidelines on antimicrobial prescribing.

In this time series analysis, in which a historical control period was compared with an intervention period, all orders for antimicrobials (except those for surgical prophylaxis) placed from November 1, 2002, through April 30, 2004, were prospectively evaluated by an antimicrobial management team (AMT) for compliance with local hospital guidelines. During the control period, orders were evaluated to determine compliance with hospital guidelines before and after recommendations by the AMT were provided to physicians. Feedback was given for the second 9-month period in the form of a weekly report to prescribing physicians, a monthly hospital newsletter, and a quarterly report to various hospital committees. During the intervention period, orders were evaluated to determine compliance with hospital guidelines before and after recommendations by the AMT were provided to physicians.

The Veterans Affairs Medical Center, a 110-bed facility, in Louisville, Kentucky.

Internal medicine physicians and general surgeons.

A total of 2,807 antimicrobial courses were evaluated. Compliance with hospital guidelines before AMT recommendations was 70% during the control period and 74% during the intervention period (P = .02). Compliance after AMT recommendations was 90% during the control period and 93% during the intervention period (P ≤ .01).

The use of feedback had a significantly favorable impact on physician compliance with the hospital's guidelines on antimicrobial prescribing. Use of feedback should be added to the list of interventions that promote appropriate antimicrobial use in the hospital setting.

To determine how consistently patients are colonized with methicillin-resistant Staphylococcus aureus (MRSA) at various sites and how many subtypes can be carried simultaneously by a single patient.

A 28-bed Intensive care unit in a tertiary-care referral hospital.

A total of 1,181 patients were screened by culture of swab specimens obtained from the nose, throat, groin, and axilla on admission to the intensive care unit (ICU), twice weekly during their ICU stay, and at discharge.

MRSA was isolated at least once from 224 patients. Of these isolates, 359 were selected from 32 patients to be subtyped using pulsed-field gel electrophoresis. The rate of compliance with collection of swab specimens was 79.9%. The combination of sites colonized varied frequently over time for many patients. Of patients who had swab specimens obtained twice in 1 day, 8.7% had discordant results from the 2 swab sets. No patient had a clinical isolate that was not of an identical subtype to an isolate from an anatomical site that was sampled for screening. Half the patients carried multiple subtypes during their stay, with up to 4 subtypes per patient.

The findings of this study may indicate that these patients have been colonized with MRSA on more than one occasion, possibly because of multiple breaches in infection control procedure. In MRSA-colonized patients, anatomical sites were intermittently colonized and carriage of multiple subtypes was common. These findings indicate that MRSA carriage is not a fixed state but may vary over time.