CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting

Mortality attributable to hospital-acquired infections among surgical patients

We performed a multicenter prospective matched cohort study to evaluate the mortality attributable to hospital-acquired infections among 12,791 patients admitted to surgical departments. We were able to match 731 patients with 1 or more hospital-acquired infections (ie, case patients) with 731 patients without a hospital-acquired infection (ie, control patients) at a 1:1 ratio. Of the 731 case patients, 42 (5.7%) died; of the 731 control patients, 23 (3.1%) died--a significant difference of 2.6%.

Multistate outbreak of Pseudomonas fluorescens bloodstream infection after exposure to contaminated heparinized saline flush prepared by a compounding pharmacy

BACKGROUND

Pharmaceutical compounding, the manipulation of ingredients to create a customized medication, is a widespread practice. In January 2005, the Centers for Disease Control and Prevention was notified of 4 cases of Pseudomonas fluorescens bacteremia that were traced to contaminated heparinized saline intravenous flush syringes prepared as a compounded medical product.

PATIENTS AND METHODS

We reviewed medical records of symptomatic patients with P. fluorescens-positive cultures of blood specimens or sections of explanted catheters, reviewed the production process of syringes, performed syringe cultures, compared isolates by pulsed-field gel electrophoresis (PFGE), and examined catheters by scanning electron microscopy.

RESULTS

We identified 80 patients in 6 states with P. fluorescens-positive cultures during December 2004-March 2006. Sixty-four patients (80%) had received a diagnosis of cancer. Seventy-four (99%) of 75 patients for whom information about catheter type was available had long-term indwelling catheters. Thirty-three (41%) of 80 cases were diagnosed 84-421 days after the patient's last potential exposure to a contaminated flush (delayed-onset cases). Compared with patients with early infection onset, more patients with delayed infection onset had venous ports (100% versus 50%; P <.001). By PFGE, clinical isolates from 50 (98%) of 51 patients were related to isolates cultured from unopened syringes. Scanning electron microscopy of explanted catheters revealed biofilms containing organisms morphologically consistent with P. fluorescens.

CONCLUSION

This outbreak underscores important challenges in ensuring the safety of compounded pharmaceuticals and demonstrates the potential for substantially delayed infections after exposures to contaminated infusates. Exposures to compounded products should be considered when investigating outbreaks. Patients exposed to contaminated infusates require careful follow-up, because infections can occur long after exposure.

Device-associated nosocomial infections in limited-resources countries: findings of the International Nosocomial Infection Control Consortium (INICC)

NEED

The rates of health care-associated infections (HAIs) and bacterial resistance in developing countries are 3 to 5 times higher than international standards. HAIs increase length of stay (10 days), costs (US $5000 to US $12,000), and mortality (by a factor of 2 to 3).

ORGANIZATION

The International Nosocomial Infection Control Consortium (INICC), founded in 1998, is the only source of aggregated international data on the epidemiology of device-associated infections (DAIs). Its advisory board includes 12 representatives from developed countries, who help guide INICC's activities, and 8 country coordinators. The INICC network has about 5400 active researchers in 98 intensive care units (ICUs) in 18 countries on 4 continents that conduct infection control research and surveillance using standardized DAI surveillance definitions and methodologies.

SURVEILLANCE

Participating hospitals use the Centers for Disease Control and Prevention (CDC) surveillance method and DAI definitions. Unlike the CDC, the INICC collects data from patients with and without DAI and matches patients to evaluate risk factors, attributable mortality, length of stay, and costs and conducts process surveillance to measure and improve compliance with infection control guidelines.

RESULTS

INICC's surveillance at 98 ICUs in 18 limited resources countries on 4 continents for 10 years has significantly improved infection control guidelines compliance and reduced DAI rates and mortality rates. After 11 years of implementing process surveillance intervention in 77 ICUs of 34 cities of 14 countries, including observation of 88,661 opportunities for hand hygiene, education, performance monitoring, feedback, and peer support from high-level hospital administrators, hand-hygiene compliance among ICU healthcare workers increased from 35.1% to 60.7% (RR 1.73, P < 0.01). In 78 ICUs of 37 cities of 13 countries, by implementing outcome and process surveillance interventions, INICC reduced central line associated bloodstream infection (CLAB) rates from 16.1 to 10.1 CLABs per 1000 CL days (RR: 0.63, P < 0.01), ventilator associated pneumonia (VAP) from 22.5 to 18.6 VAPs per1000 device days (RR: 0.83, P < 0.01), and catheter associated urinary tract infections (CAUTI) rates from 8.2 to 6.9 CAUTIs per 1000 device days (RR: 0.85, P = 0.02).

CONCLUSION

Implementation of INICC outcome and process surveillance, education, monitoring and performance feedback methodologies increases compliance with hand hygiene and other infection-control interventions and reduces rates of DAIs.

The International Nosocomial Infection Control Consortium (INICC): goals and objectives, description of surveillance methods, and operational activities

We have shown that intensive care units (ICUs) in countries with limited resources have rates of device-associated health care-associated infection (HAI), including central line-related bloodstream infection (CLAB), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infection (CAUTI), 3 to 5 times higher than rates reported from North American, Western European, and Australian ICUs. The International Nosocomial Infection Control Consortium (INICC) is an international ongoing collaborative HAI control program with a surveillance system based on that of the US National Healthcare Safety Network. The INICC was founded 10 years ago to promote evidence-based infection control in hospitals in limited-resource countries and in hospitals of developed countries without sufficient experience in HAI surveillance and control, through the analysis and feedback of surveillance data collected voluntarily by the member hospitals. It developed from a handful of South American hospitals in 1998 to a dynamic network of 98 ICUs in 18 countries, and is the only source of aggregate standardized international data on HAI epidemiology. Herein we report the criteria and mechanisms for gaining membership in INICC; the training of personnel in INICC hospitals; the INICC protocol for outcome surveillance of CLABs, VAPs, and CAUTIs in ICUs, microorganism profiles, bacterial resistance, antibiotic use, extra length of stay, extra costs, extra mortality, and risk factor analysis, and for process surveillance, including compliance rates for hand hygiene, vascular catheter care, urinary catheter care, and measures for prevention of VAP; and the use of surveillance data feedback as a powerful weapon for control of HAIs. The INICC will continue to evolve in its quest to find more effective and efficient ways to assess patient risk and improve patient safety in hospitals.

Countrywide molecular survey of methicillin-resistant Staphylococcus aureus strains in Poland

The present investigation was undertaken to assess the proportion of methicillin-resistant Staphylococcus aureus (MRSA) strains among hospital-acquired isolates and to determine the clones of MRSA currently circulating in Poland by using a number of molecular techniques. Between January and May 2005, methicillin resistance was investigated among a total of 915 S. aureus isolates collected from 39 hospitals. A total of 208 (22.7%) isolates were positive for the mecA gene by PCR. The molecular characterization of MRSA isolates was carried out by the multiple-locus variable-number tandem repeat fingerprinting, pulsed-field gel electrophoresis, multilocus sequence typing, and staphylococcal chromosomal cassette mec (SCCmec) typing methods. The Hungarian (PFGE B; ST239, SCCmec type III [ST239-III]), Iberian (ST247-I), and Berlin (ST45-IV) clones were predominant, representing approximately 52.9, 11.5, and 10.0% of the MRSA isolates, respectively. A decline in the proportion of earlier MRSA clones, such as ST5-IV (a Pediatric clone), ST80-IV) (a Mediterranean clone), ST239-III (a Polish and Brazilian clone), and ST30-IV (a southwest Pacific clone) was observed. Additionally, the emergence of an MRSA clone with SCCmec type V, possibly representing a community-acquired strain, was observed in two hospitals during this study.

Bloodstream infections due to extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae: risk factors for mortality and treatment outcome, with special emphasis on antimicrobial therapy

This study was conducted to evaluate risk factors for mortality and treatment outcome of bloodstream infections due to extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae (ESBL-EK). ESBL production in stored K. pneumoniae and E. coli blood isolates from Jan 1998 to Dec 2002 was phenotypically determined according to NCCLS guidelines and/or the double-disk synergy test. A total of 133 patients with ESBL-EK bacteremia, including 66 patients with ESBL-producing K. pneumoniae and 67 with ESBL-producing E. coli, were enrolled. The overall 30-day mortality rate was 25.6% (34 of 133). Independent risk factors for mortality were severe sepsis, peritonitis, neutropenia, increasing Acute Physiology and Chronic Health Evaluation II score, and administration of broad-spectrum cephalosporin as definitive antimicrobial therapy (P < 0.05 for each of these risk factors). In 117 of the 133 patients, excluding 16 patients who died within 3 days after blood culture sample acquisition, the 30-day mortality rates according to definitive antibiotics were as follows: carbapenem, 12.9% (8 of 62); ciprofloxacin, 10.3% (3 of 29); and others, such as cephalosporin or an aminoglycoside, 26.9% (7 of 26). When patients who received appropriate definitive antibiotics, such as carbapenem or ciprofloxacin, were evaluated, mortality in patients receiving inappropriate empirical antimicrobial therapy was found not to be significantly higher than mortality in those receiving appropriate empirical antimicrobial therapy (18.9 versus 15.5%; P = 0.666). Carbapenem and ciprofloxacin were the most effective antibiotics in antimicrobial therapy for ESBL-EK bacteremia. A delay in appropriate definitive antimicrobial therapy was not associated with higher mortality if antimicrobial therapy was adjusted appropriately according to the susceptibility results. Our data suggest that more prudent use of carbapenem as empirical antibiotic may be reasonable.