National Healthcare Safety Network (NHSN) report: data summary for 2006 through 2008, issued December 2009

Successful strategies for high participation in three regional healthcare surveys: an observational study

BACKGROUND

Regional healthcare facility surveys to quantitatively assess nosocomial infection rates are important for confirming standardized data collection and assessing health outcomes in the era of mandatory reporting. This is particularly important for the assessment of infection control policies and healthcare associated infection rates among hospitals. However, the success of such surveys depends upon high participation and representativeness of respondents.

METHODS

This descriptive paper provides methodologies that may have contributed to high participation in a series of administrative, infection control, and microbiology laboratory surveys of all 31 hospitals in a large southern California county. We also report 85% (N = 72) countywide participation in an administrative survey among nursing homes in this same area.

RESULTS

Using in-person recruitment, 48% of hospitals and nursing homes were recruited within one quarter, with 75% recruited within three quarters.

CONCLUSIONS

Potentially useful strategies for successful recruitment included in-person recruitment, partnership with the local public health department, assurance of anonymity when presenting survey results, and provision of staff labor for the completion of detailed survey tables on the rates of healthcare associated pathogens. Data collection assistance was provided for three-fourths of surveys. High compliance quantitative regional surveys require substantial recruitment time and study staff support for high participation.

Risk factors for surgical site infections following spinal fusion procedures: a case-control study

BACKGROUND

Spinal fusion procedures are associated with a significant rate of surgical site infection (SSI) (1%-12%). The goal of this study was to identify modifiable risk factors for spinal fusion SSIs at a large tertiary care center.

METHODS

A retrospective, case-control (1:3 ratio) analysis of SSIs following posterior spine fusion procedures was performed over a 1-year period. Clinical and surgical data were collected through electronic database and chart review. Variables were evaluated by univariate analysis and multivariable logistic regression.

RESULTS

In total, 57 deep SSIs were identified out of 1587 procedures (3.6%). Infections were diagnosed a mean of 13.5 ± 8 days postprocedure. Staphylococcus aureus was the predominant pathogen (63%); 1/3 of these isolates were methicillin resistant. Significant patient risk factors for infection by univariate analysis included ASA score >2 and male gender. Among surgical variables, infected cases had significantly higher proportions of staged procedures and thoracic level surgeries and had a greater number of vertebrae fused. Notably, infected fusion procedures had a longer duration of closed suction drains than controls (5.1 ± 2 days vs 3.4 ± 1 day, respectively; P < .001). Drain duration (unit odds ratio [OR], 1.6 per day drain present; 95% confidence interval [CI], 1.3-1.9), body mass index (OR, 1.1; 95% CI, 1.0-1.1), and male gender (OR, 2.7; 95% CI, 1.4-5.6) were significant risk factors in the multivariate analysis.

CONCLUSIONS

Prolonged duration of closed suction drains is a strong independent risk factor for SSI following instrumented spinal fusion procedures. Therefore, removing drains as early as possible may lower infection rates.

[Quality indicators in an intensive care unit: a two-year healthcare-associated infection surveillance program]

OBJECTIVE

To estimate quality healthcare indicators in an intensive care unit (ICU).

METHODS

A prospective observational study was conducted on all patients referred to the medical ICU of Ramón y Cajal hospital (Madrid) for more than 48 hours, from January 1 2008 to December 31 2009.

RESULTS

A total of 503 patients were included, of whom 7.4% developed a healthcare-associated infection (HAI) attributable to their stay in the ICU. The median length of stay was 5 days. A ventilator-associated pneumonia (VAP) was observed in 1.9% of patients, with a VAP rate of 3.8 per 1,000 ventilator-days. A catheter-associated urinary tract infection (CAUTI) was found in 3.6% of the patients, with a CAUTI rate of 4.5 per 1,000 catheter-days. The cumulative incidence of central line-associated bloodstream infection (CLABSI) was 1.8%, with a CLABSI rate of 2.2 per 1,000 central line-days.

CONCLUSIONS

Our results are similar to those of other studies using the same methodology. An HAI surveillance system is a key factor for implementing a healthcare quality improvement system. The obtained indicators allow intra-comparison over time and with other similar hospitals, the monitoring of infection control measures, and thus an effective improvement in healthcare quality and patient safety.

Impact of obesity on surgical site infection in colon and rectal surgery

Obesity affects over 30% of the United States population. Over the past 10 years, there has been increased recognition of the prevalence of obesity and its contribution to worse outcomes among medical and surgical patients. In particular, obesity has been validated as a risk factor for surgical site infection (SSI) among patients undergoing major abdominal surgery with some reports demonstrating an increased risk of SSI as high as sixty percent (60%) among obese patients. For patients undergoing elective colon and rectal surgery, a higher incidence of SSI (up to 45%) has been reported in comparison to outcomes of other surgical procedures. Obesity, as well as numerous other variables, have been implicated as a potential source for this increased incidence. Although the pathophysiology of obesity-related SSI has been suggested (decreased wound oxygen tension, impaired tissue antibiotic penetration, altered immune function, etc.), the true effect of obesity has not been clearly described. The purpose of this review is to examine the growing epidemic of obesity and its specific impact on SSI for both general and colorectal surgical patients. The proposed mechanisms for why obesity increases the risk of SSI will be briefly discussed, as well.

Ventilator-associated pneumonia as a model for approaching cost-effectiveness and infection prevention in the ICU

PURPOSE OF REVIEW

Nosocomial infection is a major cause of morbidity and mortality. In the ICU, ventilator-associated pneumonia (VAP) represents the most prevalent and visible hospital-acquired infection (HAI). Although some evidence-based strategies reduce the incidence of VAP, despite a recent policy drive toward zero VAP rates, no evidence supports feasibility of VAP eradication. Furthermore, in the era of resource constraints, cost-effectiveness of various strategies is critical to consider.

RECENT FINDINGS

Recent approaches to VAP prevention conglomerate single maneuvers into bundles. Although the cost-effectiveness of some VAP-preventive interventions, such as continuous subglottic suctioning and silver-coated endotracheal tube, has been evaluated singly, less is known about the investments needed to implement the recommended bundled approaches in the context of their ability to prevent VAP and such important downstream implications as the use of antibiotics and other hospital resources. A well designed model from Australia examining the cost-effectiveness of a catheter-related blood stream infection bundle can serve as robust scaffolding for building a credible value proposition for the VAP bundles.

SUMMARY

Cost-effectiveness of VAP prevention bundles is not known. This is a critical piece of information, particularly as it relates to such important downstream outcomes of VAP prevention as the use of antibiotics and hospital length of stay. Understanding the incremental cost-effectiveness of VAP bundles can help prioritize efforts to minimize the associated morbidity.

Reducing PICU central line-associated bloodstream infections: 3-year results

OBJECTIVES

To evaluate the long-term impact of pediatric central line care practices in reducing PICU central line-associated bloodstream infection (CLA-BSI) rates and to evaluate the added impact of chlorhexidine scrub and chlorhexidine-impregnated sponges.

METHODS

A 3-year, multi-institutional, interrupted time-series design (October 2006 to September 2009), with historical control data, was used. A nested, 18-month, nonrandomized, factorial design was used to evaluate 2 additional interventions. Twenty-nine PICUs were included. Two central line care bundles (insertion and maintenance bundles) and 2 additional interventions (chlorhexidine scrub and chlorhexidine-impregnated sponges) were used. CLA-BSI rates (January 2004 to September 2009), insertion and maintenance bundle compliance rates (October 2006 to September 2009), and chlorhexidine scrub and chlorhexidine-impregnated sponge compliance rates (January 2008 to June 2009) were assessed.

RESULTS

The average aggregate baseline PICU CLA-BSI rate decreased 56% over 36 months from 5.2 CLA-BSIs per 1000 line-days (95% confidence interval [CI]: 4.4-6.2 CLA-BSIs per 1000 line-days) to 2.3 CLA-BSIs per 1000 line-days (95% CI: 1.9-2.9 CLA-BSIs per 1000 line-days) (rate ratio: 0.44 [95% CI: 0.37-0.53]; P < .0001). No statistically significant differences in CLA-BSI rate decreases between PICUs using or not using either of the 2 additional interventions were found.

CONCLUSIONS

Focused attention on consistent adherence to the use of pediatrics-specific central line insertion and maintenance bundles produced sustained, continually decreasing PICU CLA-BSI rates. Additional use of either chlorhexidine for central line entry scrub or chlorhexidine-impregnated sponges did not produce any statistically significant additional reduction in PICU CLA-BSI rates.

Hospital-wide reduction in central line-associated bloodstream infections: a tale of two small community hospitals

Despite increasing awareness of central line-associated bloodstream infections (CLABSIs) in general wards, published strategies come from intensive care units (ICUs) of large tertiary care centers. After implementing a central line insertion checklist, two community hospitals experienced an 86% reduction in CLABSI rates in ICUs and a 57% reduction in non-ICU settings over 36 months.

Moving CLABSI prevention beyond the intensive care unit: risk factors in pediatric oncology patients

BACKGROUND AND OBJECTIVE

Central line-associated bloodstream infections (CLABSIs) frequently complicate the use of central venous catheters (CVCs) among pediatric patients with cancer. Our objectives were to describe the microbiology and identify risk factors for hospital-onset CLABSI in this patient population.

DESIGN

Retrospective case-control study.

SETTING

Oncology and stem cell transplant units of a freestanding, 396-bed quaternary care pediatric hospital.

PARTICIPANTS

Case subjects ([Formula: see text]) were patients with a diagnosis of malignancy and/or stem cell transplant recipients with CLABSI occurring during admission. Controls ([Formula: see text]) were identified using risk set sampling of hospitalizations among patients with a CVC, matched on date of admission.

METHODS

Multivariate conditional logistic regression was used to identify independent predictors of CLABSI.

RESULTS

The majority of CLABSI isolates were gram-positive bacteria (58%). The most frequently isolated organism was Enterococcus faecium, and 6 of 9 isolates were resistant to vancomycin. In multivariate analyses, independent risk factors for CLABSI included platelet transfusion within the prior week (odds ratio [OR], 10.90 [95% confidence interval (CI), 3.02-39.38]; [Formula: see text]) and CVC placement within the previous month (<1 week vs ≥1 month: OR, 11.71 [95% CI, 1.98-69.20]; [Formula: see text]; ≥1 week and <1 month vs ≥1 month: OR, 7.37 [95% CI, 1.85-29.36]; [Formula: see text]).

CONCLUSIONS

Adjunctive measures to prevent CLABSI among pediatric oncology patients may be most beneficial in the month following CVC insertion and in patients requiring frequent platelet transfusions. Vancomycin-resistant enterococci may be an emerging cause of CLABSI in hospitalized pediatric oncology patients and are unlikely to be treated by typical empiric antimicrobial regimens.

Outcome of cefazolin prophylaxis for total knee arthroplasty at an institution with high prevalence of methicillin-resistant Staphylococcus aureus infection

OBJECTIVES

The aim of this study was to evaluate the outcome of cefazolin prophylaxis for total knee arthroplasty (TKA) in a hospital with a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infection.

METHODS

Since July 1, 2006, we have applied a 'care bundle' to TKA to prevent surgical site infection (SSI) without using vancomycin as antimicrobial prophylaxis, in accordance with the 1999 Hospital Infection Control Practices Advisory Committee guidelines. All patients undergoing TKA from July 1, 2006 to September 30, 2009 were enrolled. We reviewed data on SSI collected prospectively as part of routine infection control surveillance.

RESULTS

Of 1323 TKAs, an SSI developed in 14 (1.06%) cases, which is comparable to the percentage obtained in other previous reports. When stratified by the National Nosocomial Infection Surveillance risk index, SSI rates were 0.86% (8/926), 1.30% (5/384), and 7.69% (1/13) in risk categories 0, 1, and 2, respectively. Of 14 SSIs, four (29%) were classified as superficial incisional, two (14%) as deep incisional, and eight (57%) as organ-space SSI.

CONCLUSIONS

Our data suggest that antimicrobial prophylaxis using only cefazolin can maintain low SSI rates if other important infection management measures are employed, even where there is a high prevalence of MRSA infection.

Epidemiology of central line-associated bloodstream infections in the pediatric intensive care unit

OBJECTIVE

Describe central line-associated bloodstream infection (CLA-BSI) epidemiology in pediatric intensive care units (PICUs).

DESIGN

Descriptive study (29 PICUs); cohort study (18 PICUs).

SETTING

PICUs in a national improvement collaborative.

PATIENTS/PARTICIPANTS

Patients admitted October 2006 to December 2007 with 1 or more central lines.

METHODS

CLA-BSIs were prospectively identified using the National Healthcare Safety Network definition and then readjudicated using the revised 2008 definition. Risk factors for CLA-BSI were examined using age-adjusted, time-varying Cox proportional hazards models.

RESULTS

In the descriptive study, the CLA-BSI incidence was 3.1/1,000 central line-days; readjudication with the revised definition resulted in a 17% decrease. In the cohort study, the readjudicated incidence was 2.0/1,000 central line-days. Ninety-nine percent of patients were CLA-BSI-free through day 7, after which the daily risk of CLA-BSI doubled to 0.27% per day. Compared with patients with respiratory diagnoses (most prevalent category), CLA-BSI risk was higher in patients with gastrointestinal diagnoses (hazard ratio [HR], 2.7 [95% confidence interval {CI}, 1.43-5.16]; P < .002 ) and oncologic diagnoses (HR, 2.6 [CI, 1.06-6.45]; P = .037). Among all patients, including those with more than 1 central line, CLA-BSI risk was lower among patients with a central line inserted in the jugular vein (HR, 0.43 [CI, 0.30-0.95]; [P < .03).

CONCLUSIONS

The 2008 CLA-BSI definition change decreased the measured incidence. The daily CLA-BSI risk was very low in patients during the first 7 days of catheterization but doubled thereafter. The risk of CLA-BSI was lower in patients with lines inserted in the jugular vein and higher in patients with gastrointestinal and oncologic diagnoses. These patients are target populations for additional study and intervention.

Benchmarking risk-adjusted adult antibacterial drug use in 70 US academic medical center hospitals

BACKGROUND

Antimicrobial stewardship programs are advised to measure and risk-adjust antimicrobial use to facilitate interhospital comparisons, a process called benchmarking. The purpose of this investigation was to evaluate a new benchmarking strategy for antibacterials.

METHODS

Hospital-wide adult antibacterial drug use in 2009 was measured as days of therapy (DOT) and length of therapy (LOT) from billing records in 70 US academic medical centers (AMCs). Patients were assigned to 1 of 35 clinical service lines (CSL) based on their Medicare Severity Diagnosis Related Group. Expected (E) use was determined by indirect standardization and compared with observed (O) use.

RESULTS

Of 1,791 ,180 discharged adults, 63.7% received antibacterial drugs; the range by CSL was 14.3% (psychiatry) to 99.7% (lung transplant). Mean ± SD hospital-wide use was 839 ± 106 DOTs (range, 594-1109) and 536 ± 53.0 LOT (range, 427-684) per 1000 patient-days. The ventilator support CSL had the most DOT per discharge, 39.4 ± 9.4 days; the LOT was 21.5 ± 4.5 days. The hospital-wide O/E ratio range was 0.7-1.45; in 5 AMCs the ratio exceeded the 90% confidence interval (CI) and was below the 90% CI in 6. Variability in use was explained by the proportion of treated patients within each CSL and mean LOT and DOT per discharge.

CONCLUSIONS

Adult antibacterial drug use was benchmarked to expected use adjusted for patient mix, and outlier hospitals were identified. Differences between expected and observed use reflect usage patterns that were benchmarked and are targets for evaluation and intervention.

[Multicentre study of infection incidence in knee prosthesis]

OBJECTIVE

To determine the incidence of surgical site infection in knee prosthesis surgical procedure for a follow-up period of one year in twelve hospitals in Madrid region.

MATERIAL AND METHOD

A prospective study was carried out from January to December 2009 using a national surveillance system called Indicadores Clínicos de Mejora Continua de Calidad. Primary and revision knee joint replacements in patients operated on in the previous year were included. Criteria used to define surgical site infection and patient risk index categories were those established by the Centers for Disease Control and Prevention and National Nosocomial Infections Surveillance. The incidence rates were worked out crude and adjusted by hazard ratio.

RESULTS

2,088 knee prosthesis procedures were analyzed. The overall incidence of surgical site infection was 2.1%. Sixty-five percent of the infections were organ/space. Sixty percent of the infections were identified in the early postoperative period. Of all surgical site infections, 41.9% were microbiologically confirmed. Antibiotic prophylaxis was implemented correctly in 63.3% of the cases. The most important cause of inappropriate prophylaxis was an unsuitable duration in 85.7% of the cases. The presurgical preparation was carried out correctly in 50.3% of surgical operations. The incidence of knee arthroplasty infection was twice as high as in the National Healthcare Safety Network and similar to national rates.

DISCUSSION

In this study, the incidence of infection was within the range of infection rates in other published European studies. Surveillance and control strategies of health care for associated infections allow us to assess trends and the impact of preventive measures.

Effectiveness of a hand hygiene promotion strategy using alcohol-based handrub in 6 intensive care units in Colombia

BACKGROUND

Hand hygiene is an effective strategy for the prevention of health care-associated infection (HAI). We investigated the effect of a hand hygiene promotion strategy introducing alcohol-based handrub (AHBR) on the incidence of HAI in a university hospital in Colombia.

METHODS

A Prospective cohort study was performed in 6 intensive care units from January 2001 to December 2005. HAI were identified using standard US Centers for Disease Control and Prevention definitions. Alcohol-based handrub dispensers were installed between February and June 2002.

RESULTS

Total ABHR consumption was 5,794 L (mean, 28.9 L per 1,000 patient-days) and significantly increased over time (+9.2% per year; P < .001). Of 14,516 patients cumulating 166,498 patient-days, 2,398 (16.5%) acquired a total of 3,490 HAI episodes (20.9 per 1,000 patient-days). Incidence densities for central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia, and urinary tract infections were 7.7, 10.6, and 3.6 episodes per 1,000 device-days, respectively. A significant decrease was observed for CLABSI (-12.7% per year; P < .001) with low nurse-to-patient ratio independently associated with infection (odds ratio, 1.11; 95% confidence interval: 1.07-1.16; P < .001).

CONCLUSION

Improved hand hygiene measured by increased ABHR consumption resulted in CLABSI reduction. Low nurse-to-patient ratio is independently associated with HAI in an upper-middle income country.

Socioeconomic impact on device-associated infections in limited-resource neonatal intensive care units: findings of the INICC

PURPOSE

To evaluate the impact of country socioeconomic status and hospital type on device-associated healthcare-associated infections (DA-HAIs) in neonatal intensive care units (NICUs).

METHODS

Data were collected on DA-HAIs from September 2003 to February 2010 on 13,251 patients in 30 NICUs in 15 countries. DA-HAIs were defined using criteria formulated by the Centers for Disease Control and Prevention. Country socioeconomic status was defined using World Bank criteria.

RESULTS

Central-line-associated bloodstream infection (CLA-BSI) rates in NICU patients were significantly lower in private than academic hospitals (10.8 vs. 14.3 CLA-BSI per 1,000 catheter-days; p < 0.03), but not different in public and academic hospitals (14.6 vs. 14.3 CLA-BSI per 1,000 catheter-days; p = 0.86). NICU patient CLA-BSI rates were significantly higher in low-income countries than in lower-middle-income countries or upper-middle-income countries [37.0 vs. 11.9 (p < 0.02) vs. 17.6 (p < 0.05) CLA-BSIs per 1,000 catheter-days, respectively]. Ventilator-associated-pneumonia (VAP) rates in NICU patients were significantly higher in academic hospitals than in private or public hospitals [13.2 vs. 2.4 (p < 0.001) vs. 4.9 (p < 0.001) VAPs per 1,000 ventilator days, respectively]. Lower-middle-income countries had significantly higher VAP rates than low-income countries (11.8 vs. 3.8 per 1,000 ventilator-days; p < 0.001), but VAP rates were not different in low-income countries and upper-middle-income countries (3.8 vs. 6.7 per 1,000 ventilator-days; p = 0.57). When examined by hospital type, overall crude mortality for NICU patients without DA-HAIs was significantly higher in academic and public hospitals than in private hospitals (5.8 vs. 12.5%; p < 0.001). In contrast, NICU patient mortality among those with DA-HAIs was not different regardless of hospital type or country socioeconomic level.

CONCLUSIONS

Hospital type and country socioeconomic level influence DA-HAI rates and overall mortality in developing countries.

Economic impact of use of chlorhexidine-impregnated sponge dressing for prevention of central line-associated infections in the United States

BACKGROUND

The economic impact of adding chlorhexidine gluconate (CHG)-impregnated sponge dressing to standard care (ie, chg-impregnated sponge dressing + skin preparation and transparent film dressing vs skin preparation and transparent film dressing) for the prevention of central-line infections was evaluated.

METHODS

Clinical and economic data were obtained from peer-reviewed published studies to populate the decision model. The efficacy of reducing catheter-related bloodstream infection (CR-BSI) incidence with CHG-impregnated sponge dressing came from 2 recent randomized controlled trials. One-way and two-way sensitivity analyses were performed on key clinical and economic parameters.

RESULTS

Based on model calculations, a hypothetical 400-bed hospital inserting 3,078 central venous catheters (CVCs) per year is expected to avoid an average of 35 CR-BSIs, 145 local infections, and 281 intensive care unit days annually with the systematic use of CHG-impregnated sponge dressing. Potential hospital net cost savings (mainly because of reduced CR-BSIs with use of the dressing) would be $895,000 annually. Results were robust across a range of values in sensitivity analyses.

CONCLUSION

CHG-impregnated sponge dressing is a cost-effective CR-BSI prevention treatment option for patients requiring CVCs. The importance of these results should be considered in the context of federal government and insurance company policies that no longer permit enhanced reimbursement for CR-BSI.

Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: epidemiologic and economic consequences

BACKGROUND

Central venous lines (CVLs) are used extensively in intensive care units (ICUs) but can sometimes lead to catheter-related blood stream infections (CRBSIs). This study evaluated a "CVL bundle" to see whether the CRBSI rate would decrease, analyze any changes in the flora of CRBSIs, and project any decrease in health care costs.

METHODS

The CVL bundle was implemented on all patients admitted to the ICU starting January 2008. Data from CRBSI rates from 2006 and 2007 were pooled to compare the intervention. A Poisson analysis generated a relative risk reduction. Determination of costs were made by taking the excess length of stay multiplied by other costs (supplies, medications, cost of replacement of CVL) at our institution.

RESULTS

Overall infection rates decreased with an improvement in CRBSIs in all ICUs that participated. Although the proportion of gram-negative organisms did not change significantly, there was a decrease in the proportion of gram-positive infections (P = .05) and an increase in fungal infections (P = .04). The total excess cost per organism was determined by the following: total excess cost = excess length of stay + replacement of CVL + drug administration + antibiotic cost. The weighted excess cost took the total excess cost times a correction factor based on organism frequency. The total excess cost of any given CRBSI is approximately $32,254.

CONCLUSION

Preventing CRBSIs can improve patient care while reducing hospital stays, costs, and possible mortality. CVL bundles are fairly easy to perform with reproducible results.

Electronic surveillance for healthcare-associated central line-associated bloodstream infections outside the intensive care unit

BACKGROUND

Manual surveillance for central line-associated bloodstream infections (CLABSIs) by infection prevention practitioners is time-consuming and often limited to intensive care units (ICUs). An automated surveillance system using existing databases with patient-level variables and microbiology data was investigated.

METHODS

Patients with a positive blood culture in 4 non-ICU wards at Barnes-Jewish Hospital between July 1, 2005, and December 31, 2006, were evaluated. CLABSI determination for these patients was made via 2 sources; a manual chart review and an automated review from electronically available data. Agreement between these 2 sources was used to develop the best-fit electronic algorithm that used a set of rules to identify a CLABSI. Sensitivity, specificity, predictive values, and Pearson's correlation were calculated for the various rule sets, using manual chart review as the reference standard.

RESULTS

During the study period, 391 positive blood cultures from 331 patients were evaluated. Eighty-five (22%) of these were confirmed to be CLABSI by manual chart review. The best-fit model included presence of a catheter, blood culture positive for known pathogen or blood culture with a common skin contaminant confirmed by a second positive culture and the presence of fever, and no positive cultures with the same organism from another sterile site. The best-performing rule set had an overall sensitivity of 95.2%, specificity of 97.5%, positive predictive value of 90%, and negative predictive value of 99.2% compared with intensive manual surveillance.

CONCLUSIONS

Although CLABSIs were slightly overpredicted by electronic surveillance compared with manual chart review, the method offers the possibility of performing acceptably good surveillance in areas where resources do not allow for traditional manual surveillance.

Incidence and risk factors for health care-associated pneumonia in a pediatric intensive care unit

OBJECTIVES

To determine the incidence and risk factors for health care-associated pneumonia in a pediatric intensive care unit.

DESIGN

Prospective cohort study.

SETTING

Pediatric intensive care unit with 16 medical and surgical beds in a tertiary teaching hospital in Recife, northeast Brazil.

PATIENTS

Patients aged <18 yrs were consecutively enrolled between January 2005 and June 2006 into a cohort set to investigate health care-associated infections. Newborns and patients admitted for surveillance and those staying for <24 hrs were excluded. Patients were followed up daily throughout the stay and until 48 hrs after discharge from the unit.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

This report focuses on health care-associated pneumonia, defined as pneumonia that occurs >48 hrs after admission but that was not incubating at the time of admission, as the primary outcome. Intrinsic and extrinsic variables were prospectively recorded into a standardized form. Statistical analyses, including multivariable logistic regression, were performed in Stata version 9.1. There were 765 eligible admissions. Health care-associated pneumonia occurred in 51 (6.7%) patients with an incidence density of 13.1 episodes/1,000 patient-days. There were 366 (47.8%) patients on mechanical ventilation, of whom 39 (10.7%) presented with ventilator-associated pneumonia with an incidence density of 27.1/1,000 days on ventilation. Longer stay on ventilation (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.01-1.08), use of gastric tube (OR, 2.88; 95% CI, 1.41-5.87), and of sedatives/analgesics (OR, 2.45; 95% CI, 1.27-4.72) were identified as independent risk factors for healthcare-associated pneumonia.

CONCLUSION

Identification of independent predictors of health care-associated pneumonia may inform preventive measures. Strategies to optimize use of sedatives/analgesics, reduce the use of gastric tubes, and reduce the time on ventilation should be considered for inclusion in future intervention studies.

Moving CLABSI prevention beyond the intensive care unit: risk factors in pediatric oncology patients

BACKGROUND AND OBJECTIVE

Central line-associated bloodstream infections (CLABSIs) frequently complicate the use of central venous catheters (CVCs) among pediatric patients with cancer. Our objectives were to describe the microbiology and identify risk factors for hospital-onset CLABSI in this patient population.

DESIGN

Retrospective case-control study.

SETTING

Oncology and stem cell transplant units of a freestanding, 396-bed quaternary care pediatric hospital.

PARTICIPANTS

Case subjects ([Formula: see text]) were patients with a diagnosis of malignancy and/or stem cell transplant recipients with CLABSI occurring during admission. Controls ([Formula: see text]) were identified using risk set sampling of hospitalizations among patients with a CVC, matched on date of admission.

METHODS

Multivariate conditional logistic regression was used to identify independent predictors of CLABSI.

RESULTS

The majority of CLABSI isolates were gram-positive bacteria (58%). The most frequently isolated organism was Enterococcus faecium, and 6 of 9 isolates were resistant to vancomycin. In multivariate analyses, independent risk factors for CLABSI included platelet transfusion within the prior week (odds ratio [OR], 10.90 [95% confidence interval (CI), 3.02-39.38]; [Formula: see text]) and CVC placement within the previous month (<1 week vs ≥1 month: OR, 11.71 [95% CI, 1.98-69.20]; [Formula: see text]; ≥1 week and <1 month vs ≥1 month: OR, 7.37 [95% CI, 1.85-29.36]; [Formula: see text]).

CONCLUSIONS

Adjunctive measures to prevent CLABSI among pediatric oncology patients may be most beneficial in the month following CVC insertion and in patients requiring frequent platelet transfusions. Vancomycin-resistant enterococci may be an emerging cause of CLABSI in hospitalized pediatric oncology patients and are unlikely to be treated by typical empiric antimicrobial regimens.

The quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths a year--and aim to do even better

A decade ago the Institute of Medicine estimated that 44,000-98,000 preventable deaths occur each year in US hospitals. The leaders of Ascension Health-one of the nation's largest health care delivery networks, with sixty-nine hospitals in twenty states and the District of Columbia-dedicated themselves to preventing equivalent numbers of deaths in their system. In 2003 they set a goal of reducing preventable deaths by 900 each year by 2008. By fiscal year 2010 Ascension Health had reduced preventable deaths by more than 1,500 people annually and, by some calculations, by more than 5,000 people annually, compared to 2004. Ascension Health had also achieved important improvements in preventing birth trauma and reducing rates of pressure ulcers and hospital-acquired infections. The health care system could achieve even greater results by adopting the safety principles used in high-reliability entities such as the nuclear power industry. The adoption of such principles can lead to impressive improvements in health care quality.

Device-associated infections rates in adult, pediatric, and neonatal intensive care units of hospitals in the Philippines: International Nosocomial Infection Control Consortium (INICC) findings

BACKGROUND

This study investigated the rate of device-associated health care-associated infection (DA-HAI), microbiological profiles, bacterial resistance, length of stay (LOS), and mortality rate in 9 intensive care units (ICUs) of 3 hospital members of the International Nosocomial Infection Control Consortium (INICC) in the Philippines.

METHODS

This was an open-label, prospective cohort, active DA-HAI surveillance study of adult, pediatric, and newborn patients admitted to 9 tertiary care ICUs in the Philippines between January 2005 and December 2009, implementing methodology developed by the INICC. Data collection was performed in the participating ICUs, and data were uploaded and analyzed at the INICC headquarters using proprietary software. DA-HAI rates were registered based on definitions promulgated by the Centers for Disease Control and Prevention's National Healthcare Safety Network.

RESULTS

Over a 5-year period, 4952 patients hospitalized in ICUs for a total of 40,733 days acquired 199 DA-HAIs, for an overall rate of 4.9 infections per 1,000 ICU-days. Ventilator-associated pneumonia posed the greatest risk (16.7 per 1,000 ventilator-days in the adult ICUs, 12.8 per 1,000 ventilator-days in the pediatric ICU, and 0.44 per 1,000 ventilator-days in the neonatal ICUs), followed by central line-associated bloodstream infections (4.6 per 1,000 catheter-days in the adult ICUs, 8.23 per 1,000 ventilator-days in the pediatric ICU, and 9.6 per 1,000 ventilator-days in the neonatal ICUs) and catheter-associated urinary tract infections (4.2 per 1,000 catheter-days in the adult ICUs and 0.0 in the pediatric ICU).

CONCLUSION

DA-HAIs pose far greater threats to patient safety in Philippine ICUs than in US ICUs. The establishment of active infection control programs that involve infection surveillance and implement guidelines for prevention can improve patient safety and should become a priority.

Association of surgeon with surgical site infection after liver transplantation

Surgical site infection (SSI) after liver transplantation has been associated with increased risk of allograft loss and death. Identification of modifiable risk factors for these infections is imperative. To our knowledge, intraoperative practices associated with transplant surgeons have not been assessed as a risk factor. A retrospective cohort study of risk factors for SSI after 1036 first liver transplantations completed by seven surgeons at a single center between 2003 and 2008 was undertaken. Cox proportional hazards models were used to evaluate the association between surgeons and SSIs. SSIs were identified in 166 of 1036 patients (16%). Single variable analysis showed strong evidence of an association between surgeon and SSI (p = 0.0007); the estimated cumulative incidence of SSI ranged from 7% to 24%. This result was consistent in multivariable analysis adjusting for potentially confounding variables (p = 0.002). The occurrence of organ-space or deep SSI varied significantly among surgeons in both single variable analysis (p = 0.005) and multivariable analysis (p = 0.006). These findings provide evidence that differences in the surgical practices of individual surgeons are associated with risk for SSI after liver transplantation. Identification of specific surgical practices associated with risk of SSI is warranted.

[Urinary tract colonization and infection in critically ill patients]

Urinary tract infections (UTIs) account for 20-50% of all hospital-acquired infections occurring in the intensive care unit (ICU). In some reports UTI was found to be more frequent than hospital-acquired pneumonia and intravascular device bacteremia, with a greater incidence in developing countries. The risk factors associated with the appearance of UTI include the severity of illness at the time of admission to the ICU, female status, prolonged urinary catheterization or a longer ICU stay and poor urinary catheter management - mainly disconnection of the closed system. about the present study offers data on the epidemiology of UTI in the ICU, the identified risk factors, etiology, diagnosis, impact upon morbidity and mortality, and the measures to prevent its appearance.

Automated detection of external ventricular and lumbar drain-related meningitis using laboratory and microbiology results and medication data

Objective

Monitoring of healthcare-associated infection rates is important for infection control and hospital benchmarking. However, manual surveillance is time-consuming and susceptible to error. The aim was, therefore, to develop a prediction model to retrospectively detect drain-related meningitis (DRM), a frequently occurring nosocomial infection, using routinely collected data from a clinical data warehouse.

Methods

As part of the hospital infection control program, all patients receiving an external ventricular (EVD) or lumbar drain (ELD) (2004 to 2009; n = 742) had been evaluated for the development of DRM through chart review and standardized diagnostic criteria by infection control staff; this was the reference standard. Children, patients dying <24 hours after drain insertion or with <1 day follow-up and patients with infection at the time of insertion or multiple simultaneous drains were excluded. Logistic regression was used to develop a model predicting the occurrence of DRM. Missing data were imputed using multiple imputation. Bootstrapping was applied to increase generalizability.

Results

537 patients remained after application of exclusion criteria, of which 82 developed DRM (13.5/1000 days at risk). The automated model to detect DRM included the number of drains placed, drain type, blood leukocyte count, C-reactive protein, cerebrospinal fluid leukocyte count and culture result, number of antibiotics started during admission, and empiric antibiotic therapy. Discriminatory power of this model was excellent (area under the ROC curve 0.97). The model achieved 98.8% sensitivity (95% CI 88.0% to 99.9%) and specificity of 87.9% (84.6% to 90.8%). Positive and negative predictive values were 56.9% (50.8% to 67.9%) and 99.9% (98.6% to 99.9%), respectively. Predicted yearly infection rates concurred with observed infection rates.

Conclusion

A prediction model based on multi-source data stored in a clinical data warehouse could accurately quantify rates of DRM. Automated detection using this statistical approach is feasible and could be applied to other nosocomial infections.

Integrated Multilevel Surveillance of the World's Infecting Microbes and Their Resistance to Antimicrobial Agents

Microbial surveillance systems have varied in their source of support; type of laboratory reporting (patient care or reference); inclusiveness of reports filed; extent of microbial typing; whether single hospital, multihospital, or multicountry; proportion of total medical centers participating; and types, levels, integration across levels, and automation of analyses performed. These surveillance systems variably support the diagnosis and treatment of patients, local or regional infection control, local or national policies and guidelines, laboratory capacity building, sentinel surveillance, and patient safety. Overall, however, only a small fraction of available data are under any surveillance, and very few data are fully integrated and analyzed. Advancing informatics and genomics can make microbial surveillance far more efficient and effective at preventing infections and improving their outcomes. The world's microbiology laboratories should upload their reports each day to programs that detect events, trends, and epidemics in communities, hospitals, countries, and the world.

Device-associated infection rates and extra length of stay in an intensive care unit of a university hospital in Wroclaw, Poland: International Nosocomial Infection Control Consortium's (INICC) findings

PURPOSE

The aim of this study was to determine device-associated health care-associated infections (DA-HAI) rates, microbiologic profile, bacterial resistance, and length of stay in one intensive care unit (ICU) of a hospital member of the International Nosocomial Infection Control Consortium (INICC) in Poland.

MATERIALS AND METHODS

A prospective DA-HAI surveillance study was conducted on an adult ICU from January 2007 to May 2010. Data were collected by implementing the methodology developed by INICC and applying the definitions of DA-HAI provided by the National Healthcare Safety Network at the US Centers for Disease Control and Prevention.

RESULTS

A total of 847 patients hospitalized for 9386 days acquired 206 DA-HAIs, an overall rate of 24.3% (95% confidence interval [CI], 21.5-27.4), and 21.9 (95% CI, 19.0-25.1) DA-HAIs per 1000 ICU-days. Central line-associated bloodstream infection rate was 4.01 (95% CI, 2.8-5.6) per 1000 catheter-days, ventilator-associated pneumonia rate was 18.2 (95% CI, 15.5-21.6) per 1000 ventilator-days, and catheter-associated urinary tract infection rate was 4.8 (95% CI, 3.5-6.5) per 1000 catheter-days. Length of stay was 6.9 days for those patients without DA-HAI, 10.0 days for those with central line-associated bloodstream infection, 15.5 days for those with ventilator-associated pneumonia, and 15.0 for those with catheter-associated urinary tract infection.

CONCLUSIONS

Most DA-HAI rates are lower in Poland than in INICC, but higher than in the National Healthcare Safety Network, expressing the feasibility of lowering infection rates and increasing patient safety.

Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired catheter-associated urinary tract infections in intensive care units

Catheter-associated urinary tract infections account for 40% of all health care-associated infections. An evidence-based, nurse-driven daily checklist for initiation and continuance of urinary catheters was implemented in 5 adult intensive care units. Measures of compliance, provider satisfaction, and clinical outcomes were recorded. Compliance with the checklist was 50 to 100%: catheter-associated urinary tract infections decreased from 2.88 to 1.46 per 1000 catheter days and catheter days decreased in 2 intensive care units.

Chlorhexidine antisepsis significantly reduces the incidence of sepsis and septicemia during parenteral nutrition in surgical infants

BACKGROUND/PURPOSE

After a change in national policy, central venous catheter (CVC) antisepsis with chlorhexidine was introduced in our hospital. Our aim was to evaluate whether this change reduced the rate of infection seen during parenteral nutrition (PN) in infants requiring gastrointestinal surgery.

METHODS

Two groups of consecutive infants were compared: control, 98 infants who had CVC antisepsis with 70% isopropanol alone, and chlorhexidine, 112 infants who had CVC antisepsis with 2% chlorhexidine in 70% isopropanol. Incidence rates of sepsis (blood cultures taken) and septicemia (blood cultures positive) were compared by Poisson regression.

RESULTS

Seventy-one percent of infants experienced clinically suspected sepsis. The incidence of septicemia was 32%. The incidence rate ratio for sepsis was 0.72 (95% confidence interval, 0.61-0.84) for the chlorhexidine group vs control (P < .0005). The incidence rate ratio for septicemia was 0.49 (95% confidence interval, 0.36-0.67; P < .0005); that is, over a given period of PN, patients had half the rate of positive blood cultures after the introduction of chlorhexidine antisepsis compared with before.

CONCLUSION

(1) The incidence of sepsis and septicemia among surgical infants on PN for gastrointestinal anomalies is high. (2) Chlorhexidine CVC antisepsis has significantly reduced this incidence, and we advocate its use in this group of patients.