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Background: Environmental disinfection is essential for reducing spread of healthcare-associated infections (HAIs). Previous studies report conflicting results regarding the effects of ultraviolet (UV) light in reducing infections. This trial evaluated the impact of adding pulsed-xenon UV (PX-UV) to standard terminal cleaning in reducing environmentally implicated HAIs (eiHAIs)., Methods: The Lowering the Acquisition of MDROs with Pulsed-xenon (LAMP) trial was conducted in 2 hospitals (15 inpatient wards) utilizing a cluster-randomized, controlled, double-blinded, interventional crossover trial comparing standard terminal cleaning followed by either PX-UV (intervention arm) or sham (control arm) disinfection. The primary outcome was incidence of eiHAIs from clinical microbiology tests on the fourth day of stay or later or within 3 days after discharge from the study unit. EiHAIs included clinical cultures positive for vancomycin-resistant enterococci, extended-spectrum beta-lactamase-producing Escherichia coli or Klebsiella pneumonia, methicillin-resistant Staphylococcus aureus, and Acinetobacter baumannii, and stool polymerase chain reaction (PCR) positive for Clostridiodes difficile., Results: Between 18 May 2017 and 7 January 2020, 25 732 patients were included, with an incidence of 601 eiHAIs and 180 954 patient-days. There was no difference in the rate of eiHAIs in the intervention and sham arms (3.49 vs 3.17 infections/1000 patient-days, respectively; RR, 1.10; 95% CI, .94-1.29; P = .23). Study results were similar when stratified by eiHAI type, hospital, and unit type., Conclusions: The LAMP study failed to demonstrate an effect of the addition of UV light disinfection following terminal cleaning on reductions in rates of eiHAIs. Further investigations targeting hospital environmental surfaces and the role of no-touch technology to reduce HAIs are needed. Clinical Trials Registration. ClinicalTrials.gov identifier: NCT03349268; R01HS024709., Competing Interests: Potential conflicts of interest. C. J. received funding to their institution from US AHRQ grant/contract R01HS025598 and a US Veterans Affairs Office of Research and Development (ORD) grant, and royalties from the US government (Department of Veterans Affairs) and Xenex. P. E. K. received grant/contracts to their institution from Moderna, Inc, Pfizer, GSK, and Merck; consulting fees from IgY LifeSciences; payments from Merck; and meeting/travel support for attending meetings and/or travel from IgY Lifesciences and Merck. M. J. C. received consulting fees from Xenex. T. C. received consulting fees, payments, or honoraria from Pfizer, Melinta, and Ferring. At the time of the study, S. E. was employed by Xenex. K. S. K. received consulting fees from Merck, Shionogi, AbbVie, Entasis, Qpex, Allecra, Carb-X, VenatoRx, MicuRx, and GSK. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Since the initial publication of A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals in 2008, the prevention of healthcare-associated infections (HAIs) has continued to be a national priority. Progress in healthcare epidemiology, infection prevention, antimicrobial stewardship, and implementation science research has led to improvements in our understanding of effective strategies for HAI prevention. Despite these advances, HAIs continue to affect ∼1 of every 31 hospitalized patients, leading to substantial morbidity, mortality, and excess healthcare expenditures, and persistent gaps remain between what is recommended and what is practiced.The widespread impact of the coronavirus disease 2019 (COVID-19) pandemic on HAI outcomes in acute-care hospitals has further highlighted the essential role of infection prevention programs and the critical importance of prioritizing efforts that can be sustained even in the face of resource requirements from COVID-19 and future infectious diseases crises.The Compendium: 2022 Updates document provides acute-care hospitals with up-to-date, practical expert guidance to assist in prioritizing and implementing HAI prevention efforts. It is the product of a highly collaborative effort led by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Disease Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of organizations and societies with content expertise, including the Centers for Disease Control and Prevention (CDC), the Pediatric Infectious Disease Society (PIDS), the Society for Critical Care Medicine (SCCM), the Society for Hospital Medicine (SHM), the Surgical Infection Society (SIS), and others.

Successful Infection Prevention Programs (IPPs) consist of a multidisciplinary team led by a hospital epidemiologist and managed by infection preventionists. Knowledge of the economics of health care-associated infections (HAIs) and the ability to make a business plan is now essential to the success of programs. Prevention of HAIs is the core function of IPPs with impact on patient outcomes, quality of care, and cost savings for hospitals. This article discusses the structure and responsibilities of an IPP, the regulatory pressures and opportunities that these programs face, and how to build and manage a successful program., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Antibiotic overuse and misuse has contributed to rising rates of multidrug-resistant organisms and Clostridioides difficile. Decreasing antibiotic misuse has become a national public health priority. This review outlines the goals of antimicrobial stewardship, essential members of the program, implementation strategies, approaches to measuring the program's impact, and steps needed to build a program. Highlighted is the alliance between antimicrobial stewardship programs and infection prevention programs in their efforts to improve antibiotic use, improve diagnostic stewardship for C difficile and asymptomatic bacteriuria, and decrease health care-associated infections and the spread of multidrug-resistant organisms., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Antibiotic-resistant organism (ARO) colonization rates in skilled nursing facilities (NFs) are high; hand hygiene is crucial to interrupt transmission. We aimed to determine factors associated with hand hygiene adherence in NFs and to assess rates of ARO acquisition among healthcare personnel (HCP)., Methods: HCP were observed during routine care at 6 NFs. We recorded hand hygiene adherence, glove use, activities, and time in room. HCP hands were cultured before and after patient care; patients and high-touch surfaces were cultured. HCP activities were categorized as high-versus low-risk for self-contamination. Multivariable regression was performed to identify predictors of hand hygiene adherence., Results: We recorded 385 HCP observations and paired them with cultures performed before and after patient care. Hand hygiene adherence occurred in 96 of 352 observations (27.3%) before patient care and 165 of 358 observations (46.1%) after patient care. Gloves were worn in 169 of 376 observations (44.9%). Higher adherence was associated with glove use before patient care (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.44-4.54) and after patient care (OR, 3.11; 95% CI, 1.77-5.48). Compared with nurses, certified nurse assistants had lower hand hygiene adherence (OR, 0.31; 95% CI, 0.15-0.67) before patient care and physical/occupational therapists (OR, 0.22; 95% CI, 0.11-0.44) after patient care. Hand hygiene varied by activity performed and time in the room. HCP hands were contaminated with AROs in 35 of 385 cultures of hands before patient care (0.9%) and 22 of 350 cultures of hands after patient care (6.3%)., Conclusions: Hand hygiene adherence in NFs remain low; it is influenced by job title, type of care activity, and glove use. Hand hygiene programs should incorporate these unique care and staffing factors to reduce ARO transmission.

Background: The impact of healthcare personnel hand contamination in multidrug-resistant organism (MDRO) transmission is important and well studied; however, the role of patient hand contamination needs to be characterized further., Methods: Patients from 2 hospitals in southeast Michigan were recruited within 24 hours of arrival to their room and followed prospectively using microbial surveillance of nares, dominant hand, and 6 high-touch environmental surfaces. Sampling was performed on admission, days 3 and 7, and weekly until discharge. Paired samples of methicillin-resistant Staphylococcus aureus (MRSA) isolated from the patients' hand and room surfaces were evaluated for relatedness using pulsed-field gel electrophoresis and staphylococcal cassette chromosome mec, and Panton-Valentine leukocidin typing., Results: A total of 399 patients (mean age, 60.8 years; 49% male) were enrolled and followed for 710 visits. Fourteen percent (n = 56/399) of patients were colonized with an MDRO at baseline; 10% (40/399) had an MDRO on their hands. Twenty-nine percent of rooms harbored an MDRO. Six percent (14/225 patients with at least 2 visits) newly acquired an MDRO on their hands during their stay. New MDRO acquisition in patients occurred at a rate of 24.6/1000 patient-days, and in rooms at a rate of 58.6/1000 patient-days. Typing demonstrated a high correlation between MRSA on patient hands and room surfaces., Conclusions: Our data suggest that patient hand contamination with MDROs is common and correlates with contamination on high-touch room surfaces. Patient hand hygiene protocols should be considered to reduce transmission of pathogens and healthcare-associated infections., (© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America.)

BACKGROUND Risk adjustment is needed to fairly compare central-line-associated bloodstream infection (CLABSI) rates between hospitals. Until 2017, the Centers for Disease Control and Prevention (CDC) methodology adjusted CLABSI rates only by type of intensive care unit (ICU). The 2017 CDC models also adjust for hospital size and medical school affiliation. We hypothesized that risk adjustment would be improved by including patient demographics and comorbidities from electronically available hospital discharge codes. METHODS Using a cohort design across 22 hospitals, we analyzed data from ICU patients admitted between January 2012 and December 2013. Demographics and International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) discharge codes were obtained for each patient, and CLABSIs were identified by trained infection preventionists. Models adjusting only for ICU type and for ICU type plus patient case mix were built and compared using discrimination and standardized infection ratio (SIR). Hospitals were ranked by SIR for each model to examine and compare the changes in rank. RESULTS Overall, 85,849 ICU patients were analyzed and 162 (0.2%) developed CLABSI. The significant variables added to the ICU model were coagulopathy, paralysis, renal failure, malnutrition, and age. The C statistics were 0.55 (95% CI, 0.51-0.59) for the ICU-type model and 0.64 (95% CI, 0.60-0.69) for the ICU-type plus patient case-mix model. When the hospitals were ranked by adjusted SIRs, 10 hospitals (45%) changed rank when comorbidity was added to the ICU-type model. CONCLUSIONS Our risk-adjustment model for CLABSI using electronically available comorbidities demonstrated better discrimination than did the CDC model. The CDC should strongly consider comorbidity-based risk adjustment to more accurately compare CLABSI rates across hospitals. Infect Control Hosp Epidemiol 2017;38:1019-1024.

Background: Basins used for patient bathing have been shown to be contaminated with multidrug-resistant organisms (MDROs) and have prompted the evaluation of alternatives to soap and water bathing methods., Methods: We conducted a prospective, randomized, open-label interventional crossover study to assess the impact of replacing traditional bath basins with prepackaged washcloths on the incidence of hospital-associated infections (HAIs), MDROs, and secondarily, rates of skin deterioration. Unit-wide use of disposable washcloths over an 8-month period was compared with an 8-month period of standard care using basins., Results: A total of 2,637 patients were included from 2 medical-surgical units at a single tertiary medical center, contributing 16,034 patient days. During the study period, there were a total of 33 unit-acquired infections, the rates of which were not statistically different between study phases (incidence rate ratio, 1.05; 95% confidence interval [CI], 0.50-2.23; P = .88). However, occurrence of skin integrity deterioration was significantly less in the intervention group (odds ratio, 0.44; 95% CI, 0.22-0.88; P = .02)., Conclusions: Although we were unable to demonstrate a significant reduction in HAI or MDRO acquisition, we found a decrease in skin deterioration with the use of disposable washcloths and confirmed earlier findings of MDRO contamination of wash basins., (Copyright © 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

OBJECTIVE To determine which comorbid conditions are considered causally related to central-line associated bloodstream infection (CLABSI) and surgical-site infection (SSI) based on expert consensus. DESIGN Using the Delphi method, we administered an iterative, 2-round survey to 9 infectious disease and infection control experts from the United States. METHODS Based on our selection of components from the Charlson and Elixhauser comorbidity indices, 35 different comorbid conditions were rated from 1 (not at all related) to 5 (strongly related) by each expert separately for CLABSI and SSI, based on perceived relatedness to the outcome. To assign expert consensus on causal relatedness for each comorbid condition, all 3 of the following criteria had to be met at the end of the second round: (1) a majority (>50%) of experts rating the condition at 3 (somewhat related) or higher, (2) interquartile range (IQR)≤1, and (3) standard deviation (SD)≤1. RESULTS From round 1 to round 2, the IQR and SD, respectively, decreased for ratings of 21 of 35 (60%) and 33 of 35 (94%) comorbid conditions for CLABSI, and for 17 of 35 (49%) and 32 of 35 (91%) comorbid conditions for SSI, suggesting improvement in consensus among this group of experts. At the end of round 2, 13 of 35 (37%) and 17 of 35 (49%) comorbid conditions were perceived as causally related to CLABSI and SSI, respectively. CONCLUSIONS Our results have produced a list of comorbid conditions that should be analyzed as risk factors for and further explored for risk adjustment of CLABSI and SSI. Infect Control Hosp Epidemiol 2017;38:449-454.

The Birmingham Hip Resurfacing procedure (BHR) is metal-on-metal resurfacing procedure for hip arthritis. BHR was associated with low risk of surgical site infection (SSI; 0.6%). In addition to antimicrobials, superficial SSIs were treated with incision and drainage, whereas deep incisional or organ-space SSIs required removal of prosthesis. Infect Control Hosp Epidemiol 2016;1-4.

Infection control is the discipline responsible for preventing health care-associated infections (HAIs) and has grown from an anonymous field, to a highly visible, multidisciplinary field of incredible importance. There has been increasing focus on prevention rather than control of HAIs. Infection prevention programs (IPPs) have enormous scope that spans multiple disciplines. Infection control and the prevention and elimination of HAIs can no longer be compartmentalized. This article discusses the structure and responsibilities of an IPP, the regulatory pressures and opportunities that these programs face, and how to build and manage a successful program., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Various transmission routes contribute to spread of carbapenem-resistant Klebsiella pneumoniae (CRKP) in hospitalized patients. Patients with readmissions during which CRKP is again isolated ("CRKP readmission") potentially contribute to transmission of CRKP., Objective: To evaluate CRKP readmissions in the Consortium on Resistance against Carbapenems in K. pneumoniae (CRaCKLe)., Design: Cohort study from December 24, 2011, through July 1, 2013., Setting: Multicenter consortium of acute care hospitals in the Great Lakes region., Patients: All patients who were discharged alive during the study period were included. Each patient was included only once at the time of the first CRKP-positive culture., Methods: All readmissions within 90 days of discharge from the index hospitalization during which CRKP was again found were analyzed. Risk factors for CRKP readmission were evaluated in multivariable models., Results: Fifty-six (20%) of 287 patients who were discharged alive had a CRKP readmission. History of malignancy was associated with CRKP readmission (adjusted odds ratio [adjusted OR], 3.00 [95% CI, 1.32-6.65], P<.01). During the index hospitalization, 160 patients (56%) received antibiotic treatment against CRKP; the choice of regimen was associated with CRKP readmission (P=.02). Receipt of tigecycline-based therapy (adjusted OR, 5.13 [95% CI, 1.72-17.44], using aminoglycoside-based therapy as a reference in those treated with anti-CRKP antibiotics) was associated with CRKP readmission., Conclusion: Hospitalized patients with CRKP-specifically those with a history of malignancy-are at high risk of readmission with recurrent CRKP infection or colonization. Treatment during the index hospitalization with a tigecycline-based regimen increases this risk.

Background: Contact precautions (CPs) are recommended to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission in institutions. Rising doubts about CP effectiveness and recognition of unintended consequences for patients have raised questions about the benefit. The objective of this study was to evaluate the effectiveness and adverse outcomes associated with CPs for prevention of MRSA transmission., Methods: We searched PubMed, Embase, and the Cochrane Library for articles related to effectiveness and adverse outcomes of CPs in patients with MRSA. Criteria for inclusion included the following: articles conducted in the United States, articles performed in an acute care setting, articles that were not a case series or review, and those with standardized collection of data or inclusion of case and control groups. Results were summarized and examined for potential limitations. Recommendations were based on our findings., Results: CPs reduced MRSA transmission in epidemic settings and in instances with high compliance, but a decrease in infection rates was not shown. Unintended consequences of CPs include decreased health care provider (HCP) time spent with patients, low HCP compliance, decreased perceptions of comfort from patients, and greater likelihood of patient complaints and negative psychologic implications., Conclusion: In endemic settings, there are few data to support routine use of CPs to control the spread of MRSA. Education should be performed in hospitals to improve patients' perception of care and understanding of CPs when implemented and HCPs' adherence to good hand hygiene and standard precautions practices., (Published by Elsevier Inc.)

The impact of the 2013 NHSN CAUTI definition on CAUTI rates was analyzed. A total of 107 CAUTI episodes were identified; 60 according to NHSN 2013 definitions only and 47 according to the 2012 and 2013 definitions. Physician-diagnosed "other infections" were more common among patients who had CAUTI only according to NHSN 2013 definitions (P<.001).

Since the publication of "A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals" in 2008, prevention of healthcare-associated infections (HAIs) has become a national priority. Despite improvements, preventable HAIs continue to occur. The 2014 updates to the Compendium were created to provide acute care hospitals with up-to-date, practical, expert guidance to assist in prioritizing and implementing their HAI prevention efforts. They are the product of a highly collaborative effort led by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise, including the Centers for Disease Control and Prevention (CDC), the Institute for Healthcare Improvement (IHI), the Pediatric Infectious Diseases Society (PIDS), the Society for Critical Care Medicine (SCCM), the Society for Hospital Medicine (SHM), and the Surgical Infection Society (SIS).

Since the publication of "A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals" in 2008, prevention of healthcare-associated infections (HAIs) has become a national priority. Despite improvements, preventable HAIs continue to occur. The 2014 updates to the Compendium were created to provide acute care hospitals with up-to-date, practical, expert guidance to assist in prioritizing and implementing their HAI prevention efforts. It is the product of a highly collaborative effort led by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise, including the Centers for Disease Control and Prevention (CDC), the Institute for Healthcare Improvement (IHI), the Pediatric Infectious Diseases Society (PIDS), the Society for Critical Care Medicine (SCCM), the Society for Hospital Medicine (SHM), and the Surgical Infection Society (SIS).

Background: This study aimed to identify risk factors associated with carbapenem-resistant Enterobacteriaceae (CRE) colonization among patients screened with rectal cultures upon admission to a hospital or long-term acute care (LTAC) center and to compare risk factors among patients who were screen positive for CRE at the time of hospital admission with those screen positive prior to LTAC admission., Methods: A retrospective nested matched case-control study was conducted from June 2009 to December 2011. Patients with recent LTAC exposure were screened for CRE carriage at the time of hospital admission, and patients admitted to a regional LTAC facility were screened prior to LTAC admission. Cases were patients with a positive CRE screening culture, and controls (matched in a 3∶1 ratio to cases) were patients with negative screening cultures., Results: Nine hundred five cultures were performed on 679 patients. Forty-eight (7.1%) cases were matched to 144 controls. One hundred fifty-eight patients were screened upon hospital admission and 521 prior to LTAC admission. Independent predictors for CRE colonization included Charlson's score greater than 3 (odds ratio [OR], 4.85 [95% confidence interval (CI), 1.64-14.41]), immunosuppression (OR, 3.92 [95% CI, 1.08-1.28]), presence of indwelling devices (OR, 5.21 [95% CI, 1.09-2.96]), and prior antimicrobial exposures (OR, 3.89 [95% CI, 0.71-21.47]). Risk factors among patients screened upon hospital admission were similar to the entire cohort. Among patients screened prior to LTAC admission, the characteristics of the CRE-colonized and noncolonized patients were similar., Conclusions: These results can be used to identify patients at increased risk for CRE colonization and to help target active surveillance programs in healthcare settings.

Objective: To determine whether increases in contact isolation precautions are associated with decreased adherence to isolation practices among healthcare workers (HCWs)., Design: Prospective cohort study from February 2009 to October 2009., Setting: Eleven teaching hospitals., Participants: HCWs., Methods: One thousand thirteen observations conducted on HCWs. Additional data included the number of persons in isolation, types of HCWs, and hospital-specific contact precaution practices. Main outcome measures included compliance with individual components of contact isolation precautions (hand hygiene before and after patient encounter, donning of gown and glove upon entering a patient room, and doffing upon exiting) and overall compliance (all 5 measures together) during varying burdens of isolation., Results: Compliance with hand hygiene was as follows: prior to donning gowns/gloves, 37.2%; gowning, 74.3%; gloving, 80.1%; doffing of gowns/gloves, 80.1%; after gown/glove removal, 61%. Compliance with all components was 28.9%. As the burden of isolation increased (20% or less to greater than 60%), a decrease in compliance with hand hygiene (43.6%-4.9%) and with all 5 components (31.5%-6.5%) was observed. In multivariable analysis, there was an increase in noncompliance with all 5 components of the contact isolation precautions bundle (odds ratio [OR], 6.6 [95% confidence interval (CI), 1.15-37.44]; P = .03) and in noncompliance with hand hygiene prior to donning gowns and gloves (OR, 10.1 [95% CI, 1.84-55.54]; P = .008) associated with increasing burden of isolation., Conclusions: As the proportion of patients in contact isolation increases, compliance with contact isolation precautions decreases. Placing 40% of patients under contact precautions represents a tipping point for noncompliance with contact isolation precautions measures.

Background: Acinetobacter baumannii infections are common and associated with high mortality and costs. Early identification of asymptomatic carriers can reduce patient-to-patient transmission, but the sensitivity of A baumannii surveillance tools is poor, and thus active surveillance is not routine practice. This study examined whether an active surveillance screening policy can reduce the transmission, mortality, and costs associated with A baumannii., Methods: A simulation model was developed to determine the impact of active screening on patient outcomes. Model parameters included A baumannii prevalence, screening sensitivity and specificity, probability of transmission, progression from colonization to infection, mortality, and cost of screening, contact precautions, and infection. A scenario analysis was performed to evaluate the robustness of the results when varying the sensitivity of the screening test and the prevalence rate of A baumannii., Results: Assuming a screening sensitivity of 55%, active screening reduced A baumannii transmissions, infections, and deaths by 48%. As the screening sensitivity approached 90%, the reduction in transmissions, infections, and deaths reached 78%. For all scenarios tested, active surveillance was cost saving (19%-53% reduction in mean hospital cost per patient) except at a carrier prevalence of ≤2% and screening test sensitivity of ≤55%., Conclusions: In institutions where A baumannii is endemic or during epidemics, implementing a surveillance program is cost-saving and can greatly reduce transmissions and deaths. Methodologies to improve the sensitivity of surveillance testing will help optimize the clinical impact of active screening programs on preventing the spread of A baumannii in health care facilities., (Copyright © 2014 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.)

Objectives: To quantify the effect of nosocomial bloodstream infection (BSI) on older adults, including mortality, length of stay (LOS), and costs attributed to BSI., Design: Retrospective cohort study., Setting: Eight acute care hospitals (7 community hospitals and 1 tertiary university-affiliated facility) belonging to the Duke Infection Control Outreach Network (DICON) from the states of North Carolina and Virginia., Participants: Elderly patients over 65 years of age., Measurements: A multistate, multicenter, matched, retrospective cohort study was conducted from January 1994 through June 2002 in eight hospitals from the Southern-Central United States. Patients aged >65 years with nosocomial BSI were enrolled. Controls without bloodstream infection were matched to cases. Outcomes during the 90-day period following hospital discharge were evaluated to determine the association between BSI and mortality, hospital costs, and LOS., Results: Eight-hundred thirty cases and 830 matched controls were identified, all with a mean age of 74.4 years. Among cases, 81% of BSIs were central line-associated and Staphylococcus aureus was the most common pathogen accounting for 34.6% of infections (2/3 were methicillin resistant). The mortality rate of cases was 49.4%, compared to 33.2% for controls (OR = 2.1, P < .001), LOS was 29.2 days for cases and 20.2 days for controls (P < .001), and hospital charges were $102,276 for cases compared to $69,690 for controls (P < .001). The mean LOS and mean costs attributable to BSI were 10 days and $43,208, respectively., Conclusion: Nosocomial BSI in older adults was significantly associated with increases in 90-day mortality, increased LOS, and increased costs of care. Preventive interventions to eliminate nosocomial BSIs in older adults would likely be cost effective., (© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.)

Objective: To assess the impact of active alerting of positive blood culture data coupled with stewardship intervention on time to appropriate therapy, length of stay, and mortality in patients with gram-negative bacteremia., Design: Quasi-experimental retrospective cohort study in patients with gram-negative bacteremia at the Detroit Medical Center from 2009 to 2011., Setting: Three hospitals (1 community, 2 academic) with active antimicrobial stewardship programs within the Detroit Medical Center., Patients: All patients with monomicrobial gram-negative bacteremia during the study period., Intervention: Active alerting of positive blood culture data coupled with stewardship intervention (2010-2011) compared with patients who received no formalized stewardship intervention (2009)., Results: Active alerting and intervention led to a decreased time to appropriate therapy (8 [interquartile range (IQR), 2-24] vs 14 [IQR, 2-35] hours; P = .014) in patients with gram-negative bacteremia. After controlling for differences between groups, being in the intervention arm was associated with an independent reduction in length of stay (odds ratio [OR], 0.73 [95% confidence interval (CI), 0.62-0.86]), correlating to a median attributable decrease in length of stay of 2.2 days. Additionally, multivariate modeling of patients who were not on appropriate antimicrobial therapy at the time of initial culture positivity showed that patients in the intervention group had a significant reduction in both length of stay (OR, 0.76 [95% CI, 0.66-0.86]) and infection-related mortality (OR, 0.24 [95% CI, 0.08-0.76])., Conclusions: Active alerting coupled with stewardship intervention in patients with gram-negative bacteremia positively impacted time to appropriate therapy, length of stay, and mortality and should be a target of antimicrobial stewardship programs.

Background: Long-term acute care (LTAC) facilities admit patients with complex, advanced disease states. Study aims were to determine the burden posed on hospitals associated with LTAC exposure and analyze the differences between "present on admission" (POA) multidrug-resistant (MDR), gram-negative organisms (GNO) and POA MDR gram-positive organisms (GPO)., Methods: A multicenter retrospective study was conducted in 13 hospitals from southeast Michigan, from September 1, 2008, to August 31, 2009. Cultures obtained in the first 72 hours of hospitalization (ie, POA) of MDR-GPO and MDR-GNO were reviewed. LTAC exposures in the previous 6 months and direct admission from a LTAC were recorded., Results: Overall, 5,297 patients with 7,147 MDR POA cultures were analyzed: 2,619 (36.6%) were MDR-GNO, and 4,528 (63.4%) were MDR-GPO. LTAC exposure in the past 6 months was present in 251 (5.2%) infectious episodes and was significantly more common among POA MDR-GNO than MDR-GPO (158 [8.6%] and 94 [3.1%], respectively, odds ratio, 2.87; P < .001). Recent LTAC exposure was strongly associated with both carbapenem-resistant Enterobacteriaceae (CRE) (31.6% of all CRE cases, P < .001) and Acinetobacter baumannii (14.9% of all A baumannii cases, P < .001)., Conclusion: Nearly 10% of MDR-GNO POA had recent LTAC exposure. Hospital efforts to control the spread of MDR-GNO should focus on collaborations and communications with referring LTACs and interventions targeted towards patients with recent LTAC exposure., (Copyright © 2012 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.)

Increasing numbers of serious hospital/healthcare- or community-acquired infections are caused by resistant (often multi-drug resistant) bacterial pathogens. Because delayed or ineffective initial therapy can have severe negative consequences, patients at risk for these types of infections typically receive initial empiric antibiotic therapy with a broad-spectrum regimen covering the most likely pathogens, based on local surveillance data and risk factors for infection with a resistant microorganism. While improving the likelihood of a successful outcome, use of broad-spectrum, often high-dose, empiric antimicrobial therapy also creates pressure for the selection or development of resistant microorganisms, as well as increasing costs and possibly exposing patients to adverse events or collateral damage such as Clostridium difficile-associated disease. De-escalation is a strategy that attempts to balance the competing aims of providing initial empiric therapy that is appropriate and covers the likely pathogens, and limiting antimicrobial exposure and increased risk for emergence of resistant pathogens. More specifically, the de-escalation strategy involves collection of cultures for later microbiological assessment before initiating broad-spectrum empiric therapy covering the most likely pathogens, with the intention of streamlining or de-escalating to a more narrow-spectrum antimicrobial regimen 2-3 days later if warranted by clinical status and culture results. In some cases, negative culture results and subsequent clinical review may allow for termination of initial empiric therapy. In this manner, de-escalation enables more effective targeting of the causative pathogen(s), elimination of redundant therapy, a decrease in antimicrobial pressure for emergence of resistance, and cost savings. This article examines application of the de-escalation strategy to 3 case patients, one with healthcare-associated pneumonia, another with complicated intra-abdominal infection, and a third with central line-associated bacteremia. Journal of Hospital Medicine 2012;7:S13-S21. © 2012 Society of Hospital Medicine., (Copyright © 2012 Society of Hospital Medicine.)

Objectives: To identify predictors and construct a prediction model for nosocomial bloodstream infection (BSI) in older adults., Design: Retrospective case-control study., Setting: Hospitals belonging to the Duke Infection Control Outreach Network., Participants: Patients age 65 and older with a nosocomial BSI and matched uninfected controls., Measurement: Multiple variables were captured and compared between groups. Independent predictors were identified using conditional logistic regression. A prediction model and score was constructed., Results: Eight hundred thirty cases were compared with 830 controls. Eighty-one percent of nosocomial BSIs were catheter related (CRBSI). Methicillin-resistant Staphylococcus aureus (MRSA) was the most common pathogen isolated (23%). Independent predictors of nosocomial BSI in older adults were male sex, obesity, low McCabe score on admission, presence of a central line at admission, gastrostomy at admission, recent surgery, and urinary incontinence. A prediction model score greater than 11 (total possible score 23) was predictive of infection., Conclusion: MRSA is a common cause of CRBSI in older adults. Male sex, obesity, the presence of a central line, a gastrostomy tube, and urinary incontinence at the time of admission were independent predictors of BSI in hospitalized older adults. The prediction model constructed in this study should be validated prospectively in a different cohort., (© 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.)

Infection control is the discipline responsible for preventing nosocomial infections. There has been an increasing focus on prevention rather than control of hospital-acquired infections. Individuals working in infection control have seen their titles change from infection control practitioner to infection control professional and most recently to infection preventionist (IP), emphasizing their critical role in protecting patients. The responsibilities of IPs span multiple disciplines including medicine, surgery, nursing, occupational health, microbiology, pharmacy, sterilization and disinfection, emergency medicine, and information technology. This article discusses the structure and responsibilities of an infection control program and the regulatory pressures and opportunities the program faces., (Copyright © 2011 Elsevier Inc. All rights reserved.)

The role of suction regulators in nosocomial infections has, to our knowledge, not been studied. A sampling of devices used in hospitals was conducted. Many regulators (173 [37%] of 470) were found to be colonized. A suction circuit model revealed that pathogens can disseminate throughout the circuit (retrograde and antegrade), colonizing an experimental patient stomach.

Background: Hand hygiene noncompliance is a major cause of nosocomial infection. Nosocomial infection cost data exist, but the effect of hand hygiene noncompliance is unknown., Objective: To estimate methicillin-resistant Staphylococcus aureus (MRSA)-related cost of an incident of hand hygiene noncompliance by a healthcare worker during patient care., Design: Two models were created to simulate sequential patient contacts by a hand hygiene-noncompliant healthcare worker. Model 1 involved encounters with patients of unknown MRSA status. Model 2 involved an encounter with an MRSA-colonized patient followed by an encounter with a patient of unknown MRSA status. The probability of new MRSA infection for the second patient was calculated using published data. A simulation of 1 million noncompliant events was performed. Total costs of resulting infections were aggregated and amortized over all events., Setting: Duke University Medical Center, a 750-bed tertiary medical center in Durham, North Carolina., Results: Model 1 was associated with 42 MRSA infections (infection rate, 0.0042%). Mean infection cost was $47,092 (95% confidence interval [CI], $26,040-$68,146); mean cost per noncompliant event was $1.98 (95% CI, $0.91-$3.04). Model 2 was associated with 980 MRSA infections (0.098%). Mean infection cost was $53,598 (95% CI, $50,098-$57,097); mean cost per noncompliant event was $52.53 (95% CI, $47.73-$57.32). A 200-bed hospital incurs $1,779,283 in annual MRSA infection-related expenses attributable to hand hygiene noncompliance. A 1.0% increase in hand hygiene compliance resulted in annual savings of $39,650 to a 200-bed hospital., Conclusions: Hand hygiene noncompliance is associated with significant attributable hospital costs. Minimal improvements in compliance lead to substantial savings.

Background: Surgical site infection (SSI) after coronary artery bypass graft (CABG) surgery is an increasing healthcare problem. Investigators from Australia proposed a new, 3-point scale that assesses SSI risk on the basis of diagnosis of diabetes mellitus and body mass index., Objective: To validate the Australian Clinical Risk Index among patients undergoing CABG surgery in the United States., Design and Setting: Nested case-control study involving patients undergoing CABG surgery at 9 hospitals during 1991-2002., Patients: Case patients were those who developed SSIs after CABG surgery. Control subjects were matched to case patients on the basis of hospital, age, and procedure date., Methods: Odds ratios (ORs) for SSIs were calculated for the comparison of case patients with control subjects for all risk categories determined using the Australian Clinical Risk Index and National Nosocomial Infections Surveillance System (NNIS) risk index. An adjusted area under the curve was used to compare predictive values among risk indices., Results: Four hundred sixty patients were studied, including 269 patients with SSI and 191 control subjects. NNIS risk group 2 was associated with increased rate of SSI (OR, 1.79; 95% confidence interval [CI], 1.19-2.67). No patient had an NNIS risk index of 3. The remaining NNIS categories were not predictive of infection. In contrast, an increase in Australian Clinical Risk Index was associated with an increase in risk of SSI (category 2: OR, 2.39 [95% CI, 1.33-4.29]; category 3: OR, 4.46 [95% CI, 1.83-10.85])., Conclusions: The NNIS risk index predicts the risk of SSI associated with many procedures, but it has limited use in predicting the risk of SSI after CABG surgery. The new Australian Clinical Risk Index stratified patients into discrete groups associated with increased risk of SSI. Data from our study support the use of this new risk index in the US population.

Most evidence-based methods to control the spread of antimicrobial resistance have been developed and applied to the hospital setting. Strategies to control the emergence and spread of antimicrobial resistance in hospitals can be categorized as either infection control or antibiotic stewardship strategies. Infection control is the discipline focused on preventing the spread of infections within the health care setting; antibiotic stewardship can help minimize the emergence of multidrug-resistant organisms by promoting prudent use of antibiotics. This article describes different infection control and antibiotic management strategies that can be used to control antimicrobial resistance in hospital settings.

Background: Despite the high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infection in the hospital, the proportion of patients with MRSA bacteremia who receive appropriate empirical therapy remains suboptimal., Objective: To investigate the proportion of patients with MRSA bloodstream infection (BSI) who received appropriate empirical antibiotic therapy and to identify risk factors associated with receipt of appropriate empirical therapy., Methods: We studied a cohort of patients from 10 hospitals. The primary outcome was the proportion of patients who received appropriate empirical antibiotic therapy for MRSA BSI. Appropriate therapy was defined as receipt of daptomycin, linezolid, quinupristin-dalfopristin, or vancomycin within 1 calendar day after the first blood culture result positive for S. aureus (ie, before antimicrobial susceptibilities were known). Multivariable logistic regression was used to determine variables associated with receipt of appropriate empirical therapy., Results: The study included 562 patients with MRSA BSI. The mean (+/-standard deviation) age of the patients was 64 +/- 16 years, and 288 (51.2%) were male. Only 291 (51.8%) patients received appropriate empirical therapy. Patients were more likely to receive appropriate therapy if they required hemodialysis (odds ratio [OR], 1.36 [95% confidence interval {CI}, 1.00-1.85]), had undergone knee or hip arthroplasty (OR, 3.04 [95% CI, 1.21-7.6]), had a central venous catheter at admission (OR, 1.72 [95% CI, 1.01-2.93]), or had a McCabe score of 1 at admission (OR, 1.83 [95% CI, 1.16-2.83]). Bowel incontinence (OR, 0.41 [95% CI, 0.19-0.92]) and BSIs categorized as primary (OR, 0.41 [95% CI, 0.27-0.63]) were associated with a decreased likelihood of receiving appropriate empirical therapy., Conclusions: Only half of patients with MRSA BSI received appropriate empirical therapy. Factors associated with receiving appropriate empirical antibiotics included the presence of a central venous catheter at admission and a history of joint arthroplasty. Surprisingly, prior MRSA infection was not predictive of receipt of appropriate antimicrobial therapy.

Background: This study examined predictors of in-hospital mortality and time to extubation among patients with acute, severe hospital-acquired pneumonia (HAP) managed in the intensive care unit (ICU)., Methods: Patients with HAP prospectively identified between June 2001 and May 2003 were included in the study if they (1) met the Centers for Disease Control and Prevention's definition for HAP, (2) were treated in the ICU within 1 day of the HAP diagnosis, and (3) required intubation acutely or had a bloodstream infection within 48 hours of the HAP diagnosis., Results: The cohort included 219 patients, 83 of whom died (37.9%). Independent predictors of mortality included cancer (odds ratio [OR] = 4.2; 95% confidence interval [CI] = 1.7 to 10.5), age over 60 years (OR = 2.7; 95% CI = 1.3 to 5.6), APACHE-II score >15 (OR = 2.0; 95% CI = 1.0 to 4.1), and receiving care in the medical ICU (OR = 3.0; 95% CI = 1.1 to 8.2). The following predictors were associated with an increased time to extubation: receipt of vancomycin (1.81-fold increase; P = .001), immunocompromised status (1.92-fold increase; P = .07), and treatment in the surgical or neurosurgical ICU (1.95-fold increase, P = .01; 1.83-fold increase, P = .03)., Conclusion: Vancomycin was associated with increased time to extubation. Alternatives to vancomycin for treating patients with acute, severe HAP should be studied.

Staphylococcus aureus is the leading cause of surgical site infections (SSI) in the United States. In particular, SSI caused by methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a devastating complication, leading to increased mortality rates, increased length of hospitalization, and increased costs. Proven strategies for prevention of SSI caused by S aureus include addressing modifiable risk factors and correct choice and timing of antimicrobial prophylaxis. Other strategies, including decolonization and the use of vancomycin, remain controversial.

We have developed an automated surveillance system to detect bloodstream infection (BSI) occurring after endoscopic retrograde cholangiopancreatography (ERCP). We retrospectively applied this automated surveillance tool to all patients who underwent ERCP at out institution between July 2004 and April 2006 to determine the baseline rates of BSI after ERCP and identify the epidemiology of the pathogens. A total of 2052 ERCPs were performed during the study period; 46 BSIs occurred within 30 days after ERCP (overall rate of post-ERCP BSI, 2.24/100 procedures). The most commonly isolated organisms were Enterobacteriaceae (n = 18; 29%) and enterococci (n = 14; 22%). Because invasive procedures are performed in various outpatient and inpatient settings, novel methods are needed to conduct effective surveillance for infection.

Preventable healthcare-associated infections (HAIs) occur in US hospitals. Preventing these infections is a national priority, with initiatives led by healthcare organizations, professional associations, government and accrediting agencies, legislators, regulators, payers, and consumer advocacy groups. To assist acute care hospitals in focusing and prioritizing efforts to implement evidence-based practices for prevention of HAIs, the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America Standards and Practice Guidelines Committee appointed a task force to create a concise compendium of recommendations for the prevention of common HAIs. This compendium is implementation focused and differs from most previously published guidelines in that it highlights a set of basic HAI prevention strategies plus special approaches for use in locations and/or populations within the hospital when infections are not controlled by use of basic practices, recommends that accountability for implementing infection prevention practices be assigned to specific groups and individuals, and includes proposed performance measures for internal quality improvement efforts.

Objective: To identify risk factors for surgical site infection (SSI) due to methicillin-resistant Staphylococcus aureus (MRSA)., Design: Prospective case-control study., Setting: One tertiary and 6 community-based institutions in the southeastern United States., Methods: We compared patients with SSI due to MRSA with 2 control groups: matched uninfected surgical patients and patients with SSI due to methicillin-susceptible S. aureus (MSSA). Multivariable logistic regression was used to determine variables independently associated with SSI due to MRSA, compared with each control group., Results: During the 5-year study period, 150 case patients with SSI due to MRSA were identified and compared with 231 matched uninfected control patients and 128 control patients with SSI due to MSSA. Two variables were independently associated with SSI due to MRSA in both multivariable regression models: need for assistance with 3 or more activities of daily living (odds ratio [OR] compared with uninfected patients, 3.97 [95% confidence interval {CI}, 2.18-7.25]; OR compared with patients with SSI due to MSSA, 3.88 [95% CI, 1.91-7.87]) and prolonged duration of surgery (OR compared with uninfected patients, 1.98 [95% CI, 1.11-3.55]; OR compared with patients with SSI due to MSSA, 2.33 [95% CI, 1.17-4.62]). Lack of independence (ie, poor functional status) remained associated with an increased risk of SSI due to MRSA after stratifying by age., Conclusions: Poor functional status was highly associated with SSI due to MRSA in adult surgical patients, regardless of age. A patient's level of independence can be easily determined, and this information can be used preoperatively to target preventive interventions.

Introduction: Data regarding the epidemiology, treatment, and outcomes of methicillin-resistant Staphylococcus aureus (MRSA) infections in rural and community hospitals are limited., Methods: This cohort study was conducted at 1 tertiary care hospital and 8 community hospitals in the southeastern United States. Patients with a surgical site infection (SSI) and/or bacteremia due to MRSA were prospectively identified at each study hospital during the period 1994-2003., Results: A total of 129 patients with SSI and 564 patients with bacteremia due to MRSA were identified. Only 57 patients with SSI (44.2%) received antibiotics active against MRSA on the initial date of diagnosis; only 95 (73.6%) received an agent active against MRSA by day 7 after diagnosis of SSI due to MRSA. Ninety-five patients with SSI due to MRSA (73.6%) were readmitted to the hospital within 90 days after their original surgery. The 1-year mortality rate among patients with SSI due to MRSA was 22%. Inadequate therapy was also commonly given to patients with bacteremia: only 216 (38.3%) received antibiotics active against MRSA on the initial day of infection, and only 383 (67.9%) received an agent active against MRSA by day 7 after diagnosis. Approximately one-third of patients with bloodstream infection died during their initial hospitalization. Patients hospitalized in community hospitals were less likely to receive effective antimicrobial therapy on both the day of infection and within 7 days after infection, compared with patients in the tertiary care hospital., Conclusion: Inadequate therapy is commonly administered after diagnosis of SSI and bacteremia due to MRSA in patients in community hospitals.

Objective: To characterize the epidemiology of severe (ie, nonsuperficial) surgical site infection (SSI) in community hospitals., Methods: SSI data were collected prospectively at 26 community hospitals in the southeastern United States. Two analyses were performed: (1) a study of the overall prevalence rates of SSI and the prevalence rates of SSI due to specific pathogens in 2005 at all participating hospitals and (2) a prospective study of consecutive surgical procedures at 9 of the 26 community hospitals from 2000 through 2005., Results: In 2005, a total of 1,010 SSIs occurred after 89,302 procedures (prevalence rate, 1.13 infections per 100 procedures). Methicillin-resistant S. aureus (MRSA) was the pathogen most commonly recovered (from 175 SSIs). Trend data from 2000 through 2005 demonstrated that the prevalence rate of MRSA SSI almost doubled during this period, increasing from 0.12 infections per 100 procedures (95% confidence interval [CI], 0.12-0.13) to 0.23 infections per 100 procedures (95% CI, 0.22-0.24) (P<.0001). In adjusted analysis, MRSA SSI was significantly more prevalent at the end of the study period than at the beginning (prevalence rate ratio, 1.48 [95% CI, 1.36-1.61]; P<.0001)., Conclusions: MRSA was the pathogen that most commonly caused SSI in our network of community hospitals during 2005. The prevalence of MRSA SSI has increased significantly over the past 6 years.

Background: Antibiotic rotation has been proposed as a way to potentially reduce the development of antimicrobial resistant bacteria in intensive care units. We assessed the effect of an antibiotic rotation protocol on the antibiotic susceptibility profiles of three clinically relevant gram-negative microorganisms within our surgical intensive care unit (SICU)., Methods: Our SICU implemented an antibiotic rotation protocol in 2003. Four antibiotics (piperacillin/tazobactam, imipenem/cilastin, ceftazidime, and ciprofloxacin) were rotated as the primary antibiotic used to treat suspected gram-negative infections every month, with the four-drug cycle being repeated every 4 months. Antibiotic susceptibility data for three microorganisms (Pseudomonas aeruginosa, Escherichia coli, and Klebsiella pneumoniae) were collected for the year before (2002) and the year after (2004) the implementation of the rotation protocol. Changes in antimicrobial susceptibility rates were analyzed for the three microorganisms. As a comparison, a similar analysis was conducted for microorganisms isolated from our medical intensive care unit, where no antibiotic rotation protocol was implemented., Results: Implementation of an antibiotic rotation protocol in our SICU resulted in a significant increase in the percentage of P. aeruginosa isolates sensitive to ceftazidime (67% in 2002 vs. 92% in 2004, p = 0.002) and piperacillin/tazobactam (78% in 2002 vs. 92% in 2004, p = 0.043). Isolates from the medical intensive care unit did not demonstrate an increase in antimicrobial susceptibility. In fact, the susceptibility of E. coli to piperacillin/tazobactam decreased during this time period (p = 0.047)., Conclusions: Implementation of an antibiotic rotation protocol in our SICU resulted in overall improvement in the antibiotic susceptibility profile of gram-negative microorganisms relative to our medical intensive care unit, where such a protocol was not used.

Background: After surveillance surveys documented the absence of methicillin-resistant Staphylococcus aureus (MRSA) in our intensive care nursery, an outbreak of MRSA infection occurred there during a 7-month period in 2005., Methods: Control measures included reinforcement of hand hygiene and contact precautions procedures. Active surveillance cultures were obtained on all neonates, including interinstitutional transfers. A cohort unit was dedicated exclusively for neonates with MRSA. Pulsed-field gel electrophoresis was performed on isolates to determine relatedness. We surveyed transferring hospitals to evaluate MRSA activity and surveillance practices in their nurseries., Results: Twenty-five neonates were colonized with MRSA; 9 of these had clinical infections. Isolates from 18 of 21 neonates from this outbreak and 4 neonates from a previous cluster were identical, including 1 isolate obtained upon transfer from another institution. Admission and discharge logs from a 9-month period showed that 127 of 460 admissions (27.6%) were admitted from 34 hospitals, and 247 of 460 (53.7%) were discharged to 32 hospitals. Among 30 transferring hospitals responding to our survey, MRSA activity occurred in 2 of 28 (7%) level 1 nurseries, 4 of 11 (36%) level 2 nurseries and 6 of 10 (60%) level 3 nurseries. Nine of the 30 hospitals (30%) performed some active surveillance., Conclusions: Interinstitutional transfer can play a role in the initiation and propagation of MRSA outbreaks in neonatal nurseries. The burden of MRSA in area nurseries and the rate of transfers affect the potential for interhospital spread of MRSA and may justify changes in policy regarding surveillance for MRSA and communication between hospitals.

Objectives: To estimate the cost of healthcare-associated infections (HAIs) in a network of 28 community hospitals and to compare this sum to the amount budgeted for infection control programs at each institution and for the entire network., Design: We reviewed literature published since 1985 to estimate costs for specific HAIs. Using these estimates, we determined the costs attributable to specific HAIs in a network of 28 hospitals during a 1-year period (January 1 through December 31, 2004). Cost-saving models based on reductions in HAIs were calculated., Setting: Twenty-eight community hospitals in the southeastern region of the United States., Results: The weight-adjusted mean cost estimates for HAIs were $25,072 per episode of ventilator-associated pneumonia, $23,242 per nosocomial blood stream infection, $10,443 per surgical site infection, and $758 per catheter-associated urinary tract infection. The median annual cost of HAIs per hospital was $594,683 (interquartile range [IQR], $299,057-$1,287,499). The total annual cost of HAIs for the 28 hospitals was greater than $26 million. Hospitals budgeted a median of $129,000 (IQR, $92,500-$200,000) for infection control; the median annual cost of HAIs was 4.6 (IQR, 3.4-8.0) times the amount budgeted for infection control. An annual reduction in HAIs of 25% could save each hospital a median of $148,667 (IQR, $74,763-$296,861) and could save the group of hospitals more than $6.5 million., Conclusions: The economic cost of HAIs in our group of 28 study hospitals was enormous. In the modern age of infection control and patient safety, the cost-control ratio will become the key component of successful infection control programs.

Due to the greater in vitro activity of ciprofloxacin than that of levofloxacin against Pseudomonas aeruginosa, the likelihood of isolating a clinical strain of quinolone-resistant (QR) P. aeruginosa might be greater after exposure to levofloxacin than ciprofloxacin. We examined the risk of isolating QR P. aeruginosa in association with prior levofloxacin or ciprofloxacin exposure. A case-case-control study was conducted. Two groups of cases, one with nosocomial QR P. aeruginosa infections and one with nosocomial quinolone-susceptible (QS) P. aeruginosa infections, were compared to a control group of hospitalized patients without P. aeruginosa infections. Bivariable and multivariable analyses were used to determine risk factors for isolation of QR P. aeruginosa and QS P. aeruginosa. One hundred seventeen QR P. aeruginosa and 255 QS P. aeruginosa cases were identified, and 739 controls were selected. Exposures to ciprofloxacin were similar among all three groups (8% for controls, 9.4% for QR P. aeruginosa cases, and 7.5% for QS P. aeruginosa cases; P >/= 0.6). Levofloxacin use was more frequent in the QR P. aeruginosa cases than in the controls (35.9% and 22.1%, respectively; odds ratio [OR] = 2.0; 95% confidence interval [CI] = 1.3 to 3.0) and less frequent in QS P. aeruginosa cases (14.1% of QS P. aeruginosa cases; OR = 0.6; 95% CI = 0.4 to 0.9). In multivariable analysis, levofloxacin, but not ciprofloxacin, was a significant risk factor for isolation of QR P. aeruginosa (OR for levofloxacin = 1.7 [95% CI = 1.0 to 2.9]; OR for ciprofloxacin = 1.2 [95% CI = 0.6 to 2.5]). Levofloxacin was associated with a reduced risk of isolation of QS P. aeruginosa (OR = 0.6; 95% CI = 0.4 to 0.9), whereas ciprofloxacin had no significant effect (OR = 1.0; 95% CI = 0.6 to 1.8). In conclusion, the use of levofloxacin, but not ciprofloxacin, was associated with isolation of QR P. aeruginosa.

Objective: To describe an infection control network (the Duke Infection Control Outreach Network [DICON]) and its impact on nosocomial infection rates in community hospitals., Design: Prospective cohort study of rates of nosocomial infections and exposures of employees to bloodborne pathogens in hospitals during the first 3 years of their affiliation with DICON. Attributable cost and mortality estimates were obtained from published studies.Setting. Twelve community hospitals in North Carolina and Virginia., Results: During the first 3 years of hospital affiliation with DICON, annual rates of nosocomial bloodstream infections at study hospitals decreased by 23% (P = .009). Annual rates of nosocomial infection and colonization due to methicillin-resistant Staphylococcus aureus decreased by 22% (P = .002), and rates of ventilator-associated pneumonia decreased by 40% (P = .001). Rates of exposure of employees to bloodborne pathogens decreased by 18% (P = .003)., Conclusions: The establishment of an infection control network within a group of community hospitals was associated with substantial decreases in nosocomial infection rates. Standard surveillance methods, frequent data analysis and feedback, and interventions based on guidelines and protocols from the Centers for Disease Control and Prevention were the principal strategies used to achieve these reductions. In addition to lessening the adverse clinical outcomes due to nosocomial infections, these reductions substantially decreased the economic burden of infection: the decline in nosocomial bloodstream infections and ventilator-associated pneumonia alone yielded potential savings of 578,307 US dollars to 2,195,954 US dollars per year at the study hospitals.