Search

Objective Surgical site infections (SSIs) are a serious and costly post-op complication. Generating SSI rates often requires labor-intensive methods, but increasing numbers of publications reported SSI rates using administrative data. Methods Index laminectomy and spinal fusion procedures were identified using Canadian Classification of Health Interventions (CCI) procedure codes for inpatients and outpatients in the province of Alberta, Canada between 2008 and 2015. SSIs occurring in the year postsurgery were identified using the International Classification of Diseases, 10th Revision, Canada (ICD-10-CA) diagnosis and CCI procedure codes indicative of post-op infection. Rates of SSIs and case characteristics were reported. Results Over the 8-year study period, 21,222 index spinal procedures were identified of which 12,027 (56.7%) were laminectomy procedures, with 322 SSIs identified, an SSI rate of 2.7 per 100 procedures. Of the 9,195 (43.3%) fusion procedures, 298 were identified as an SSI, an SSI rate of 3.2 per 100 procedures. This study found SSI rates increased from 2008 and 2015, and rates were the highest in the 0-18 year age group. Conclusions The rates reported in this study were similar to published SSI rates using traditional surveillance methods, suggesting administrative data may be a viable method for reporting SSI rates following spinal procedures. Further work is needed to validate SSIs identified using administrative data by comparing to traditional surveillance.

In a population-based, five-year retrospective cohort study of 5304 adult patients with hospital-acquired Clostridioides difficile infection across Alberta (N=101 hospitals), 30-day all-cause and attributable mortality were 12.2% and 4.5%, respectively. Patients >75 years of age had the highest odds of attributable mortality (odds ratio (OR) 9.34, 95% confidence interval (CI) 2.92-29.83) and largest difference in mean length of stay (11.7 days, 95% CI 8.2-15.2). A novel finding was that elevated white blood cell count at admission was associated with reduced attributable mortality (OR 0.67, 95% CI 0.50-0.90) which deserves further study. Advancing age was incrementally and significantly associated with all outcomes.

Background and objectives:The landscape of antimicrobial resistance (AMR) surveillance is changing rapidly. The primary objective of this study was to assess the benefit of linking population-based infection prevention and control surveillance data on methicillin-resistant Staphylococcus aureus (MRSA) to hospital discharge abstract data (DAD). We assessed the value of this novel data linkage for the characterization of hospital-acquired (HA) and community-acquired MRSA (CA-MRSA) cases.Methods:Incident inpatient MRSA surveillance data for all adults (≥18 years) from 4 acute-care facilities in Calgary, Alberta, between April 1, 2011, and March 31, 2017, were linked to DAD. Personal health number (PHN) and gender were used to identify specific individuals, and specimen collection time-points were used to identify specific hospitalization records. A third common variable on admission date between these databases was used to validate the linkage process. Descriptive statistics were used to characterize HA-MRSA and CA-MRSA cases identified through the linkage process.Results:A total of 2,430 surveillance records (94.6%) were successfully linked to the correct hospitalization period. By linking surveillance and administrative data, we were able to identify key differences between patients with HA- and CA-MRSA. These differences are consistent with previously reported findings in the literature. Data linkage to DAD may be a novel tool to enhance and augment the details of base surveillance data.Conclusion and recommendations:This is the first Canadian study linking a frontline healthcare-associated infection AMR surveillance database to an administrative population database. This work represents an important methodological step toward complementing traditional AMR surveillance data practices. Data linkage to other data types, such as primary care, emergency, social, and biological data, may be the basis of achieving more precise data focused around AMR.

Objective:To determine the attributable cost and length of stay of hospital-acquired Clostridioides difficile infection (HA-CDI) from the healthcare payer perspective using linked clinical, administrative, and microcosting data.Design:A retrospective, population-based, propensity-score–matched cohort study.Setting:Acute-care facilities in Alberta, Canada.Patients:Admitted adult (≥18 years) patients with incident HA-CDI and without CDI between April 1, 2012, and March 31, 2016.Methods:Incident cases of HA-CDI were identified using a clinical surveillance definition. Cases were matched to noncases of CDI (those without a positive C. difficile test or without clinical CDI) on propensity score and exposure time. The outcomes were attributable costs and length of stay of the hospitalization where the CDI was identified. Costs were expressed in 2018 Canadian dollars.Results:Of the 2,916 HA-CDI cases at facilities with microcosting data available, 98.4% were matched to 13,024 noncases of CDI. The total adjusted cost among HA-CDI cases was 27% greater than noncases of CDI (ratio, 1.27; 95% confidence interval [CI], 1.21–1.33). The mean attributable cost was $18,386 (CAD 2018; USD $14,190; 95% CI, $14,312–$22,460; USD $11,046-$17,334). The adjusted length of stay among HA-CDI cases was 13% greater than for noncases of CDI (ratio, 1.13; 95% CI, 1.07–1.19), which corresponds to an extra 5.6 days (95% CI, 3.10–8.06) in length of hospital stay per HA-CDI case.Conclusions:In this population-based, propensity score matched analysis using microcosting data, HA-CDI was associated with substantial attributable cost.

Background Clostridioides difficile infection (CDI) is one of the most common health care–associated infections. This study assessed the validity of a laboratory-based surveillance method as compared with a traditional, clinical surveillance method to identify hospital-acquired CDIs. Methods Retrospective analysis of positive C difficile laboratory records between April 2015 and March 2017 were compared with a clinical dataset of positive inpatient C difficile cases for all acute care facilities in Alberta, Canada. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated using STATA/IC 13.0. Results The laboratory surveillance method had a sensitivity of 96.6% (95% confidence interval [CI], 95.7%-97.3%) and a specificity of 65.7% (95% CI, 63.6%-67.8%); positive predictive value and negative predictive value were 74.3% (95% CI, 73.2%-75.5%) and 94.9% (95% CI, 93.7%-95.9%), respectively. Discussion To date, the breadth of research on alternate CDI surveillance systems has focused on the use of International Statistical Classification of Diseases and Related Health Problems 9th and 10th Revision coding mechanisms. Our results expand on the published literature, as a laboratory approach may provide more timely information, with a smaller amount of misclassified cases. Conclusions Using a laboratory surveillance method to capture hospital-acquired CDI cases is highly sensitive but not overly specific. Changes to improve the specificity of this method are provided.

Background While decolonization of Staphylococcus aureus reduces surgical site infection (SSI) rates following hip and knee arthroplasty, its cost-effectiveness is uncertain. We sought to examine the cost-effectiveness of a decolonization protocol for Staphylococcus aureus prior to hip and knee replacement in Alberta compared to standard care – no decolonization. Methods Decision analytic models and a probabilistic sensitivity analysis were used for a cost-effectiveness analysis, with the effectiveness of decolonization based on a large published pre- and post- intervention trial. The primary outcomes of the models were infections prevented and health care costs. We modelled the cost-effectiveness of decolonization in a hypothetical cohort of adult patients undergoing hip and knee replacement in Alberta, Canada. Information on the incidence of complex surgical site infections (SSIs), as well as the cost of care for patients with and without SSIs was taken from a provincial infection control database, and health administrative data. Results Use of the decolonization bundle was cost saving compared to usual care ($153/person), and resulted in 16 complex Staphylococcus aureus SSIs annually as opposed to 32 (with approximately 8000 hip or knee arthroplasties performed). The probabilistic sensitivity analysis demonstrated that the majority (84%) of the time the decolonization bundle was cost saving. The model was robust to one-way sensitivity analyses conducted within plausible ranges. There were small upfront costs associated with using a decolonization protocol, however, this model demonstrated cost savings over one year. In a Markov model that considered the impact of a decolonization bundle over a lifetime as it pertained to the need for subsequent joint replacements and patient quality of life, the bundle still resulted in cost savings ($161/person). Conclusions Decolonization for Staphylococcus aureus prior to hip and knee replacements resulted in cost savings and fewer SSIs, and should be considered prior to these procedures.

Chikungunya, a mosquito-borne viral, acute febrile illness (AFI) is associated with polyarthralgia and polyarthritis. Differentiation from other AFI is difficult due to the non-specific presentation and limited availability of diagnostics. This 3-year study identified independent clinical predictors by day post-illness onset (DPO) at presentation and age-group that distinguish chikungunya cases from two groups: other AFI and dengue. Specimens collected from participants with fever ≤7 days were tested for chikungunya, dengue viruses 1–4, and 20 other pathogens. Of 8,996 participants, 18.2% had chikungunya, and 10.8% had dengue. Chikungunya cases were more likely than other groups to be older, report a chronic condition, and present, Author summary Chikungunya is an acute febrile illness (AFI), caused by the chikungunya virus (CHIKV), that is transmitted by mosquitoes. Patients with chikungunya exhibit joint, muscle, or bone pain, and may also have skin rash, red eyes (conjunctiva), and red swollen joints (arthritis). Up to 20% of cases develop long lasting arthritis, fatigue or psychiatric conditions. We used data from our prospective study to identify signs and symptoms that predict chikungunya. We enrolled 8,996 AFI patients and tested for CHIKV, dengue viruses 1–4 (DENV 1–4), and other pathogens. A pathogen was detected in 55% of participants; 18.2% had CHIKV and 10.8% had DENV 1–4 infections. This study compared the clinical presentation of chikungunya with that of all other AFI and dengue alone. Regardless of timing of presentation, significant predictors of chikungunya were joint pain, muscle, bone or back pain, and red conjunctiva when compared to other AFI, and arthritis, joint pain, skin rash, any bleeding, and irritability, when dengue was the comparator group. Chikungunya patients were less likely than AFI and dengue patients to have low platelets, signs of poor circulation, diarrhea, headache, and cough. By enrolling febrile patients at presentation, we identified unbiased predictors of chikungunya. These findings can assist physicians to clinically diagnose chikungunya and initiate proper patient management.

BACKGROUNDHip and knee arthroplasty infections are associated with considerable healthcare costs. The merits of reducing the postoperative surveillance period from 1 year to 90 days have been debated.OBJECTIVESTo report the first pan-Canadian hip and knee periprosthetic joint infection (PJI) rates and to describe the implications of a shorter (90-day) postoperative surveillance period.METHODSProspective surveillance for infection following hip and knee arthroplasty was conducted by hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP) using standard surveillance definitions.RESULTSOverall hip and knee PJI rates were 1.64 and 1.52 per 100 procedures, respectively. Deep incisional and organ-space hip and knee PJI rates were 0.96 and 0.71, respectively. In total, 93% of hip PJIs and 92% of knee PJIs were identified within 90 days, with a median time to detection of 21 days. However, 11%–16% of deep incisional and organ-space infections were not detected within 90 days. This rate was reduced to 3%–4% at 180 days post procedure. Anaerobic and polymicrobial infections had the shortest median time from procedure to detection (17 and 18 days, respectively) compared with infections due to other microorganisms, including Staphylococcus aureus.CONCLUSIONSPJI rates were similar to those reported elsewhere, although differences in national surveillance systems limit direct comparisons. Our results suggest that a postoperative surveillance period of 90 days will detect the majority of PJIs; however, up to 16% of deep incisional and organ-space infections may be missed. Extending the surveillance period to 180 days could allow for a better estimate of disease burden.Infect Control Hosp Epidemiol 2017;38:147–153

OBJECTIVETo evaluate hospital administrative data to identify potential surgical site infections (SSIs) following primary elective total hip or knee arthroplasty.DESIGNRetrospective cohort study.SETTINGAll acute care facilities in Alberta, Canada.METHODSDiagnosis and procedure codes for 6 months following total hip or knee arthroplasty were used to identify potential SSI cases. Medical charts of patients with potential SSIs were reviewed by an infection control professional at the acute care facility where the patient was identified with a diagnosis or procedure code. For SSI decision, infection control professionals used the National Healthcare Safety Network SSI definition. The performance of traditional surveillance methods and administrative data–triggered medical chart review was assessed.RESULTSOf the 162 patients identified by diagnosis or procedure code, 46 (28%) were confirmed as an SSI by an infection control professional. More SSIs were identified following total hip vs total knee arthroplasty (42% vs16%). Of 46 confirmed SSI cases, 20 (43%) were identified at an acute care facility different than their procedure facility. Administrative data–triggered medical chart review with infection control professional confirmation resulted in a 1.1- to 1.7-fold increase in SSI rate compared with traditional surveillance. SSIs identified by administrative data resulted in sensitivity of 90% and specificity of 99%.CONCLUSIONMedical chart review for cases identified through administrative data is an efficient supplemental SSI surveillance strategy. It improves case-finding by increasing SSI identification and making identification consistent across facilities, and in a provincial surveillance network it identifies SSIs presenting at nonprocedure facilities.Infect Control Hosp Epidemiol 2016;37:699–703

SUMMARYPatients with methicillin-resistant Staphylococcus aureus (MRSA) clones, which were traditionally seen in the community setting (USA400/CMRSA7 and USA300/CMRSA10), are often identified as hospital-acquired (HA) infections using Infection Prevention and Control (IPC) surveillance definitions. This study examined the demographics and healthcare risk factors of patients with HA-MRSA to help understand if community MRSA clones are from a source internal or external to the hospital setting. Despite USA300/CMRSA10 being the predominant clone in Alberta, hospital clones (USA100/CMRSA2) still dominated in the acute care setting. In the Alberta hospitalized population, patients with USA400/CMRSA7 and USA300/CMRSA10 clones were significantly younger, had fewer comorbidities, and a greater proportion had none or ambulatory care-only healthcare exposure. These findings suggest that there are two distinct populations of HA-MRSA patients, and the patients with USA400/CMRSA7 and USA300/CMRSA10 clones identified in hospital more greatly resemble patients affected by those clones in the community. It is possible that epidemiological assessment overidentifies HA acquisition of MRSA in patients unscreened for MRSA on admission to acute care.

ObjectiveNearly 800,000 primary hip and knee arthroplasty procedures are performed annually in North America. Approximately 1% of these are complicated by a complex surgical site infection (SSI), leading to very high healthcare costs. However, population-based studies to properly estimate the economic burden are lacking. We aimed to address this knowledge gap.DesignEconomic burden study.MethodsUsing administrative health and clinical databases, we created a cohort of all patients in Alberta, Canada, who received a primary hip or knee arthroplasty between April 1, 2012, and March 31, 2015. All patients who developed a complex SSI postoperatively were identified through a provincial infection prevention and control database. A combination of corporate microcosting data and gross costing methods were used to determine total mean 12- and 24-month costs, enabling comparison of costs between the infected and noninfected patients.ResultsMean 12-month total costs were significantly greater in patients who developed a complex SSI compared to those who did not (CAD$95,321 [US$68,150] vs CAD$19,893 [US$14,223];P< .001). The magnitude of the cost difference persisted even after controlling for underlying patient factors. The most commonly identified causative pathogen (38%) wasStaphylococcus aureus(95% MSSA).ConclusionsComplex SSIs following hip and knee arthroplasty lead to high healthcare costs, which are expected to rise as the yearly number of surgeries increases. Using our costing estimates, the cost-effectiveness of different strategies to prevent SSIs should be investigated.

Background Nocardia species are thin, aerobic, filamentous, gram-positive bacilli that are ubiquitous in soil worldwide. Nocardia infections are divided into three main categories: pulmonary nocardiosis, disseminated nocardiosis, and cutaneous nocardiosis. Methods We present a case of cerebral nocardiosis in an immunocompetent patient caused by Nocardia beijingensis (NB). Results A 60-year-old Caucasian lady from Florida with type 2 diabetes mellitus, hypertension, hyperlipidemia, presented to the emergency room with complaints of altered mentation. Per husband, she was having episodes of emesis and diarrhea 3 days prior to admission that resolved however, her mentation significantly deteriorated to where she was unable to perform simple chores around the house. Pertinently she had resection of lung mass 2 months prior to admission which found to be benign. Vital sign at admission was stable and on examination, the patient was alert and oriented, however, lethargic appearing. Neurological examination was pertinent for expressive aphasia; however, cranial nerves II-XII were grossly intact. The patient was also found to have a 3 cm by 4 cm, tender, cystic lesion on the left-sided occipital scalp. The remainder of the physical examination was unremarkable. Admission laboratories were remarkable for leukocytosis and hyperglycemia. MRI of the brain was completed that showed multiple areas of vasogenic edema and multiple nodules with the largest being 1.8 cm suggestive of abscesses. She was started empirically on vancomycin, ceftriaxone, metronidazole, and ampicillin. Cerebral spinal fluid showed neutrophilic pleocytosis, low glucose, and high protein. Initial cultures including CSF were negative. Left-sided occipital scalp lesion was excised and sent for pathology and culture. Initial cultures showed gram-positive bacilli, so antibiotics were de-escalated to sulfamethoxazole/trimethoprim and ceftriaxone. Repeat imaging showed improving abscess, and final cultures resulted in NB. Conclusion NB is believed to have originated in Southeast Asia. NB has been associated mainly with infections in immunocompromised. In the United States, the two only other cases of NB described in immunocompetent hosts were interestingly from Florida as well. Disclosures All authors: No reported disclosures.

Background The rates of antimicrobial-resistant organisms (ARO) continue to increase for both hospitalized and community patients. Few resources have been allocated to reduce the spread of resistance on global, national and local levels, in part because the broader economic impact of antimicrobial resistance (i.e. the externality) is not fully considered when determining how much to invest to prevent AROs, including strategies to contain antimicrobial resistance, such as antimicrobial stewardship programs. To determine how best to measure and incorporate the impact of externalities associated with the antimicrobial resistance when making resource allocation decisions aimed to reduce antimicrobial resistance within healthcare facilities, we reviewed the literature to identify publications which 1) described the externalities of antimicrobial resistance, 2) described approaches to quantifying the externalities associated with antimicrobial resistance or 3) described macro-level policy options to consider the impact of externalities. Medline was reviewed to identify published studies up to September 2016. Main body An externality is a cost or a benefit associated with one person’s activity that impacts others who did not choose to incur that cost or benefit. We did not identify a well-accepted method of accurately quantifying the externality associated with antimicrobial resistance. We did identify three main methods that have gained popularity to try to take into account the externalities of antimicrobial resistance, including regulation, charges or taxes on the use of antimicrobials, and the right to trade permits or licenses for antimicrobial use. To our knowledge, regulating use of antimicrobials is the only strategy currently being used by health care systems to reduce antimicrobial use, and thereby reduce AROs. To justify expenditures on programs that reduce AROs (i.e. to formally incorporate the impact of the negative externality of antimicrobial resistance associated with antimicrobial use), we propose an alternative approach that quantifies the externalities of antimicrobial use, combining the attributable cost of AROs with time-series analyses showing the relationship between antimicrobial utilization and incidence of AROs. Conclusion Based on the findings of this review, we propose a methodology that healthcare organizations can use to incorporate the impact of negative externalities when making resource allocation decisions on strategies to reduce AROs. Electronic supplementary material The online version of this article (doi:10.1186/s13756-017-0211-2) contains supplementary material, which is available to authorized users.

Several factors related to the hospital environment may affect the spread of hospital-acquired infections including ward design characteristics such as the number and location of handwashing stations and washrooms, and the number of beds per room. However, opportunities to study the effects of these factors are rare. The authors of this study conducted an analysis of the number of hospital-acquired infections in an older, ‘historic design’ hospital ward compared with a recently built ‘new design’ ward., BACKGROUND: Renovation of a general medical ward provided an opportunity to study health care facility design as a factor for preventing hospital-acquired infections. OBJECTIVE: To determine whether a hospital ward designed with predominantly single rooms was associated with lower event rates of hospital-acquired infection and colonization. METHODS: A prospective controlled trial with patient allocation incorporating randomness was designed with outcomes on multiple ‘historic design’ wards (mainly four-bed rooms with shared bathrooms) compared with outcomes on a newly renovated ‘new design’ ward (predominantly single rooms with private bathrooms). RESULTS: Using Poisson regression analysis and adjusting for time at risk, there were no differences (P=0.18) in the primary outcome (2.96 versus 1.85 events/1000 patient-days, respectively). After adjustment for age, sex, Charlson score, admitted from care facility, previous hospitalization within six months, isolation requirement and the duration on antibiotics, the incidence rate ratio was 1.44 (95% CI 0.71 to 2.94) for the new design versus the historic design wards. A restricted analysis on the numbers of events occurring in single-bed versus multibed wings within the new design ward revealed an event incidence density of 1.89 versus 3.47 events/1000 patient-days, respectively (P=0.18), and an incidence rate ratio of 0.54 (95% CI 0.15 to 1.30). CONCLUSIONS: No difference in the incidence density of hospital-acquired infections or colonizations was observed for medical patients admitted to a new design ward versus historic design wards. A restricted analysis of events occurring in single-bed versus multibed wings suggests that ward design warrants further study.

Background More than 99% of poliovirus infections are non-paralytic and therefore, not detected by acute flaccid paralysis (AFP) surveillance. Environmental surveillance (ES) can detect circulating polioviruses from sewage without relying on clinical presentation. With extensive ES and continued circulation of polioviruses, Pakistan presents a unique opportunity to quantify the impact of ES as a supplement to AFP surveillance on overall completeness and timeliness of poliovirus detection. Methods Genetic, geographic and temporal data were obtained for all wild poliovirus (WPV) isolates detected in Pakistan from January 2011 through December 2013. We used viral genetics to assess gaps in AFP surveillance and ES as measured by detection of ‘orphan viruses’ (≥1.5% different in VP1 capsid nucleotide sequence). We compared preceding detection of closely related circulating isolates (≥99% identity) detected by AFP surveillance or ES to determine which surveillance system first detected circulation before the presentation of each polio case. Findings A total of 1,127 WPV isolates were detected by AFP surveillance and ES in Pakistan from 2011–2013. AFP surveillance and ES combined exhibited fewer gaps (i.e., % orphan viruses) in detection than AFP surveillance alone (3.3% vs. 7.7%, respectively). ES detected circulation before AFP surveillance in nearly 60% of polio cases (200 of 346). For polio cases reported from provinces conducting ES, ES detected circulation nearly four months sooner on average (117.6 days) than did AFP surveillance. Interpretation Our findings suggest ES in Pakistan is providing earlier, more sensitive detection of wild polioviruses than AFP surveillance alone. Overall, targeted ES through strategic selection of sites has important implications in the eradication endgame strategy.

Background Healthcare acquired infections (HAI) are an important public health problem in developed countries, but comprehensive data on trends over time are lacking. Prevalence surveys have been used as a surrogate for incidence studies and can be readily repeated. Methods The Canadian Nosocomial Infection Surveillance Program conducted prevalence surveys in 2002 and 2009 in a large network of major Canadian acute care hospitals. NHSN definitions of HAI were used. Use of isolation precautions on the survey day was documented. Results In 2009, 9,953 acute care inpatients were surveyed; 1,234 infections (124/1000) were found, compared to 111/1000 in 2002, (p

Background. Electronic surveillance systems (ESSs) that utilize existing information in databases are more efficient than conventional infection surveillance methods. The objective was to assess an ESS for bloodstream infections (BSIs) in the Calgary Zone for its agreement with traditional medical record review.Methods. The ESS was developed by linking related data from regional laboratory and hospital administrative databases and using set definitions for excluding contaminants and duplicate isolates. Infections were classified as hospital-acquired (HA), healthcare-associated community-onset (HCA), or community-acquired (CA). A random sample of patients from the ESS was then compared with independent medical record review.Results. Among the 308 patients selected for comparative review, the ESS identified 318 episodes of BSI of which 130 (40.9%) were CA, 98 (30.8%) were HCA, and 90 (28.3%) were HA. Medical record review identified 313 episodes of which 136 (43.4%) were CA, 97 (30.9%) were HCA, and 80 (25.6%) were HA. Episodes of BSI were concordant in 304 (97%) cases. Overall, there was 85.5% agreement between ESS and medical record review for the classification of where BSIs were acquired (kappa = 0.78, 95% Confidence Interval: 0.75–0.80).Conclusion. This novel ESS identified and classified BSIs with a high degree of accuracy. This system requires additional linkages with other related databases.

In 2003, a survey examining infection control and antimicrobial restriction policies and practices for preventing the emergence and transmission of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), and extended spectrum beta-lactamase (ESBL) was performed within Canadian teaching hospitals as part of the Canadian Nosocomial Infection Surveillance Program. Twenty-eight of 29 questionnaires were returned. The majority of facilities conducted admission screening for MRSA (96.4%) and VRE (89.3%) but only 1 site screened for ESBL/AmpC. Rates of MRSA, VRE, and ESBL remain low in Canada. It is believed that these lower rates may be due to intense admission screening protocols and stringent infection control policies for antimicrobial-resistant organisms (AROs) within Canadian institutions. Few (MRSA: 14.8%; VRE: 12.0%) recorded the number of patients screened. Regular prevalence surveys were done for MRSA (21.4%), VRE (35.7%), and ESBL/AmpC (3.8%). Pre-emptive precautions were applied for MRSA by 60.7% and for VRE by 75.0% of facilities. All facilities flagged patients previously identified with MRSA and VRE but only 46.2% flagged ESBL and 15.4% flagged AmpC patients. Barrier precautions varied by ARO and patient-care setting. In the inpatient non-ICU setting, more than 90% wore gowns and gloves for MRSA and VRE but only 50% for ESBL; and 57.1% wore masks for MRSA. Attempts to decolonize MRSA patients had been made by 82.1%, largely in order to place them in another facility. Policies restricting antimicrobial prescribing were reported by 21 facilities (75.0%). Further studies examining hospital infection control policies and corresponding rates of ARO infections would help in identifying and refining best practice guidelines within Canadian institutions.

The Canadian Nosocomial Infection Surveillance Program has been performing surveillance of antibiotic-resistant organisms in Canada since 1994. The authors of this study compared two point-prevalence surveys of antimicrobial use that were conducted in hospitals that were participating in the program in 2002 and 2009. The authors compared the use of antimicrobials between these two surveys. The changes in antimicrobial use over time are presented, in addition to potential reasons for and consequences of these changes., BACKGROUND: Increasing antimicrobial resistance has been identified as an important global health threat. Antimicrobial use is a major driver of resistance, especially in the hospital sector. Understanding the extent and type of antimicrobial use in Canadian hospitals will aid in developing national antimicrobial stewardship priorities. METHODS: In 2002 and 2009, as part of one-day prevalence surveys to quantify hospital-acquired infections in Canadian Nosocomial Infection Surveillance Program hospitals, data were collected on the use of systemic antimicrobial agents in all patients in participating hospitals. Specific agents in use (other than antiviral and antiparasitic agents) on the survey day and patient demographic information were collected. RESULTS: In 2002, 2460 of 6747 patients (36.5%) in 28 hospitals were receiving antimicrobial therapy. In 2009, 3989 of 9953 (40.1%) patients in 44 hospitals were receiving antimicrobial therapy (P1 agent, from 12.0% of patients in 2002 to 37.7% in 2009. CONCLUSION: From 2002 to 2009, the prevalence of antimicrobial agent use in Canadian Nosocomial Infection Surveillance Program hospitals significantly increased; additionally, increased use of broad-spectrum agents and a marked increase in simultaneous use of multiple agents were observed.

Background Annual influenza vaccination is recommended for health care workers in both the United States and Canada. Estimations of vaccine coverage are commonly used to evaluate these vaccination programs. Purpose We identify, discuss, and illustrate challenges including definitions of health care worker (HCW), selection of indicators, and data sources in the estimation of staff influenza vaccination coverage rates. Methods To illustrate the impact of the factors we discuss, we created a database of a simulated pool of HCWs that included varying proportions of permanent, casual, and contract staff under differing scenarios of staff turnover and differing probabilities of individuals being vaccinated. The Excel 97 random number generator (Microsoft) was used to randomly allocate the HCW to different strata under differing staff turnover rates and to designate individuals as being vaccinated. Results The nature of the staff targeted in the program policy has a large impact on the estimations of vaccine coverage. Different indicators provide data that might be useful for different purposes. The counts in the numerator and denominator of a period prevalence may be useful for estimation of the total workload required of the vaccination program. An incidence density might be useful as an indicator of the efficiency of the program in “capturing” staff for vaccination. The indicator that may be easiest is the point prevalence. Conclusion Program evaluators must think carefully when planning to estimate staff vaccination coverage to avoid invalid comparisons of estimates over time and place. State or province-wide targets for health care worker (HCW) vaccination may be meaningless unless appropriate criteria for the calculation of influenza vaccination rates are developed and specified.

Background: Nosocomial infections and antibiotic-resistant pathogens cause significant morbidity, mortality, and economic costs. The infection surveillance and control resources and activities in Canadian acute care hospitals had not been assessed in 20 years. Methods: In 2000, surveys were mailed to infection control programs in all Canadian hospitals with more than 80 acute care beds. The survey was modeled after the US Study on the Efficacy of Nosocomial Infection Control instrument, with new items dealing with resistant pathogens and computerization. Surveillance and control indices were calculated. Results: One hundred seventy-two of 238 (72.3%) hospitals responded. In 42.1% of hospitals, there was fewer than 1 infection control practitioner per 250 beds. Just 60% of infection control programs had physicians or doctoral professionals with infection control training who provided services. The median surveillance index was 65.6/100, and the median control index was 60.5/100. Surgical site infection rates were reported to individual surgeons in only 36.8% of hospitals. Conclusions: There were deficits in the identified components of effective infection control programs. Greater investment in resources is needed to meet recommended standards and thereby reduce morbidity, mortality, and expense associated with nosocomial infections and antibiotic-resistant pathogens. (Am J Infect Control 2003;31:266-73.)

Identifying etiologies of acute febrile illnesses (AFI) is challenging due to non-specific presentation and limited availability of diagnostics. Prospective AFI studies provide a methodology to describe the syndrome by age and etiology, findings that can be used to develop case definitions and multiplexed diagnostics to optimize management. We conducted a 3-year prospective AFI study in Puerto Rico. Patients with fever ≤7 days were offered enrollment, and clinical data and specimens were collected at enrollment and upon discharge or follow-up. Blood and oro-nasopharyngeal specimens were tested by RT-PCR and immunodiagnostic methods for infection with dengue viruses (DENV) 1–4, chikungunya virus (CHIKV), influenza A and B viruses (FLU A/B), 12 other respiratory viruses (ORV), enterovirus, Leptospira spp., and Burkholderia pseudomallei. Clinical presentation and laboratory findings of participants infected with DENV were compared to those infected with CHIKV, FLU A/B, and ORV. Clinical predictors of laboratory-positive dengue compared to all other AFI etiologies were determined by age and day post-illness onset (DPO) at presentation. Of 8,996 participants enrolled from May 7, 2012 through May 6, 2015, more than half (54.8%, 4,930) had a pathogen detected. Pathogens most frequently detected were CHIKV (1,635, 18.2%), FLU A/B (1,074, 11.9%), DENV 1–4 (970, 10.8%), and ORV (904, 10.3%). Participants with DENV infection presented later and a higher proportion were hospitalized than those with other diagnoses (46.7% versus 27.3% with ORV, 18.8% with FLU A/B, and 11.2% with CHIKV). Predictors of dengue in participants presenting, Author summary We conducted a prospective study of acute febrile illness (AFI) in Puerto Rico to better understand the etiology of AFI among all age groups in the tropics. Such findings could assist clinicians to identify disease-specific characteristics, which can then be used to initiate proper patient management. We enrolled 8,996 AFI patients and tested them for dengue viruses 1–4 (DENV 1–4) and 21 other pathogens. A pathogen was detected in 55% of patients, most frequently chikungunya virus (CHIKV, 18%), influenza A or B virus (FLU A/B, 12%), DENV 1–4 (11%), or another respiratory virus (ORV, 10%). Participants with dengue presented later after symptom onset and were hospitalized more often (47%) than patients with another etiology of AFI (27% with ORV, 19% with FLU A/B, and 11% with CHIKV). Predictors of patients with dengue differed by timing of presentation but included eye pain, nausea, and low white blood cell or platelet counts; negative predictors included symptoms of respiratory illness. By enrolling febrile patients at clinical presentation, we identified unbiased predictors of patients with dengue as compared to other common AFI. Findings can be used to diagnose dengue patients to provide early and appropriate clinical management.

Objective.To compare the immunogenicity of hepatitis B vaccine administered via intradermal (ID) versus intramuscular (IM) route.Methods:Subjects chose either to specify the route of immunization or to undergo random allocation to vaccination by the ID (0.15 mL) or the IM (1.0 mL) route. Yeast-derived recombinant hepatitis B vaccine was given at 0, 30, and 180 days. Hepatitis B surface antibody (HBsAb) and hepatitis B core antibody (HBcAb) were measured by microparticle enzyme immunoassay.Results:763 subjects were enrolled. Baseline screening identified 65 subjects (8%) who were positive for HBsAb or HBcAb. Vaccination was completed by 590 (85%) of 698 enrollees (370 ID, 220 IM). Seroconversion rates (geometric mean titers [GMT]>0 IU/mL HBsAb) for those vaccinated ID were 99% and 96% for screening at 9 months and 1 year post-vaccination, respectively; subjects vaccinated intramuscularly had similar rates of 95% and 96%. Seropositivity rates (GMT ≥ 10 IU/mL HBsAb) showed a similar pattern, with 95%, 92%, and 73% at 9 months and 1 and 2 years, respectively, for those vaccinated ID, and 94%, 93%, and 81% for those having IM vaccination. GMT for HBsAb was significantly higher for individuals vaccinated IM than for those vaccinated ID (PConclusions:Higher-dose ID vaccination (3 vs 1 μg per injection) uses one sixth of the dose required for standard IM vaccination. It is a cost-effective way to vaccinate populations against hepatitis B virus, but the long-term efficacy of the ID route must still be investigated.

Emergence of plasmids harbouring bla(NDM-1) is a major public health concern due to their association with multidrug resistance and their potential mobility.PCR was used to detect bla(NDM-1) from clinical isolates of Providencia rettgeri (PR) and Klebsiella pneumoniae (KP). Antimicrobial susceptibilities were determined using Vitek 2. The complete DNA sequence of two bla(NDM-1) plasmids (pPrY2001 and pKp11-42) was obtained using a 454-Genome Sequencer FLX. Contig assembly and gap closures were confirmed by PCR-based sequencing. Comparative analysis was done using BLASTn and BLASTp algorithms.Both clinical isolates were resistant to all β-lactams, carbapenems, aminoglycosides, ciprofloxacin and trimethoprim/sulfamethoxazole, and susceptible to tigecycline. Plasmid pPrY2001 (113 295 bp) was isolated from PR. It did not show significant homology to any known plasmid backbone and contained a truncated repA and novel repB. Two bla(NDM-1)-harbouring plasmids from Acinetobacter lwoffii (JQ001791 and JQ060896) shared 100% similarity to a 15 kb region that contained bla(NDM-1). pPrY2001 also contained a type II toxin/antitoxin system. pKp11-42 (146 695 bp) was isolated from KP. It contained multiple repA genes. The plasmid backbone had the highest homology to the IncFIIk plasmid type (51% coverage, 100% nucleotide identity). The bla(NDM-1) region was unique in that it was flanked upstream by IS3000 and downstream by a novel transposon designated Tn6229. pKp11-42 also contained a number of mutagenesis and plasmid stability proteins.pPrY2001 differed from all known plasmids due to its novel backbone and repB. pKp11-42 was similar to IncFIIk plasmids and contained a number of genes that aid in plasmid persistence.

A retrospective cohort study was conducted to determine the incidence of post-caesarean infections in a Canadian community teaching hospital using computer algorithms designed for the diagnosis of nosocomial infections. Inferential chart review was done on 1335 women delivered by lower-segment caesarean section (793 primary and 542 secondary) at the Calgary General Hospital between January 1985 and April 1988. The overall infection rates were 42.1 and 46.1% for women delivered by primary and secondary caesarean section, respectively. Incisional surgical wound infection accounted for the largest proportion of post-caesarean infections found. Women delivered by primary caesarean section had significantly higher rates of endometritis, deep surgical wound infection and bacteraemia than those delivered by secondary section. All types of post-caesarean infection, except asymptomatic bacteriuria, caused the duration of the post-partum hospital stay to be significantly increased.

Background Health care-associated infections (HAIs) cause considerable morbidity and mortality to hospitalized patients. The objective of this point prevalence study was to assess the burden of HAIs in the Canadian pediatric population, updating results reported from a similar study conducted in 2002. Methods A point prevalence survey of pediatric inpatients was conducted in February 2009 in 30 pediatric or combined adult/pediatric hospitals. Data pertaining to one 24-hour period were collected, including information on HAIs, microorganisms isolated, antimicrobials prescribed, and use of additional (transmission based) precautions. The following prevalent infections were included: pneumonia, urinary tract infection, bloodstream infection, surgical site infection, viral respiratory infection, Clostridium difficile infection, viral gastroenteritis, and necrotizing enterocolitis. Results One hundred eighteen patients had 1 or more HAI, corresponding to a prevalence of 8.7% (n = 118 of 1353, 95% confidence interval: 7.2-10.2). Six patients had 2 infections. Bloodstream infections were the most frequent infection in neonates (3.0%), infants (3.1%), and children (3.5%). Among all patients surveyed, 16.3% were on additional precautions, and 40.1% were on antimicrobial agents, whereas 40.7% of patients with a HAI were on additional precautions, and 89.0% were on antimicrobial agents. Conclusion Overall prevalence of HAI in 2009 has remained similar to the prevalence reported from 2002. The unchanged prevalence of these infections nonetheless warrants continued vigilance on their prevention and control.

Objective:Multipatient use and prolonged use of prefilled disposable oxygen humidifier bottles (Aquapak 301, Respiratory Care, Inc., Arlington Heights, IL) were evaluated by performing microbiologic monitoring and a cost analysis on bottles used for varying numbers of patients and lengths of time.Methods:Humidifiers were hung for a maximum of one month. Monitoring was conducted in 6 different nursing areas. Quantitative cultures were done for aerobes and Legionella. Reusable humidifier bottles also were monitored.Results:Cultures were obtained from 1,311 disposable and 60 reusable humidifiers. No significant bacterial contamination was detected in the prefilled disposable oxygen humidifier units. Ten percent of the reusable bottles were contaminated by organisms associated with skin flora.Conclusions:Multipatient use and increased duration of use of disposable humidifiers result in cost savings without increasing patient risk. Restricted multipatient use of prefilled disposable oxygen humidifier bottles for a period of one month is a safe and cost-efficient practice.

Background The Canadian Nosocomial Infection Surveillance Program (CNISP) has conducted surveillance for incident cases of methicillin-resistant Staphylococcus aureus (MRSA) in sentinel hospitals since 1995. In 2007, a reliability audit of the 2005 data was conducted. Methods In 2005, 5,652 cases were submitted to the CNISP from 43 hospitals. A proportional sample of submitted forms (up to 25) from each site were randomly selected. Stratified random sampling was used to obtain the comparison data. The original data were compared with the reabstracted data for congruence on 7 preselected variables. Results Reabstracted data were received from 30 out of 43 hospitals (70%), providing 443 of the 598 case forms requested (74%). Of these, 397 (90%) had matching case identification numbers. Overall, the percentage of discordant responses was 7.0%, ranging from 3.5% for sex and up to 23.7% for less well-defined variables (eg, where MRSA was acquired). Conclusion Our findings suggest that, in general, the 2005 MRSA data are reliable. However to improve reliability a data quality framework with quality assurance practices, including ongoing auditing should be integrated into the CNISP’s surveillance programs. Providing training to data collectors and standard definitions with practical examples may help to improve data quality, especially for those variables that require clinical judgment.

Background Molecular diagnostic tests to detect enterovirus in clinical specimens usually target highly conserved sites in the 5′-non-translated region, allowing detection of all members of the genus. The sequences in the 5′-NTR do not correlate with serotype, but PCR and sequencing of the VP1 region can be used for typing; this system has largely replaced traditional antigenic typing. Objective To investigate the relative performance of two common enterovirus assays. Study design We compared the relative sensitivities of Taqman® real-time RT-PCR (rRT-PCR) and a VP1 semi-nested PCR (RT-snPCR) assay in which sequencing the VP1 amplicon also provides typing information. Results There was 89% concordance between the two methods among the 371 clinical specimens tested (74 positive in both assays and 257 negative in both assays). Twenty-seven rRT-PCR-negative/VP1-positive specimens were confirmed positive by sequencing; 13 specimens were rRT-PCR-positive/VP1-negative. Conclusions The results suggest that either assay can produce satisfactory results, but that using both assays in parallel should provide the highest sensitivity for clinical diagnostic testing.

Objectives: To examine the spatial patterning of the individuals with gonorrhea or chlamydia infection in the Calgary Health Region (CHR) to target prevention and control activities. Methods: A Geographic Information System was used to map the prevalence rates of gonorrhea and chlamydia infection in the CHR to 2001 Census Tracts in the CHR. Data from the 2001 Canadian Census were used to describe the socioeconomic status (SES) of these areas. Results: Low SES indicators correlated with each other (low median household income, lower education, single mothers) as did high SES indicators (married, owning a dwelling, high median income, university education). A correlation was detected between areas of low SES and areas of high prevalence rates for gonorrhea and for chlamydia. These areas clustered primarily downtown and in the northeast part of the city. Conclusions: Nodes and corridors of activity in Calgary were detected in correlation studies of the 2001 Census variables used. The core (high prevalence) areas should be the areas targeted for sexually transmitted infection prevention and control. This can be done at the community level through measures such as more sexually transmitted infection clinics operating with longer hours in areas identified from this mapping. HISTORICALLY, GONORRHEA HAS been a nationally notifiable sexually transmitted infection (STI) in Canada since 1924. However, genital chlamydia infection is a more recently recognized disease: The Public Health Agency of Canada began national surveillance in 1990.1 Since treatment for gonorrhea is not effective against chlamydia, many people treated for gonorrhea had a concomitant, silent chlamydia infection that remained untreated.2 Canadian guidelines now recommend additional treatment for chlamydia when the presence of gonorrhea is suspected; however, chlamydia remains a ubiquitous disease.3 In the Calgary Health Region (CHR), gonorrhea and chlamydia diagnoses increased after years of decline. Gonorrhea infections decreased from 51.2 to 15.5 per 100,000 between 1990 and 1995, and then increased to 19.75 per 100,000 in 2001. Chlamydia infections decreased from 309.7 to 177.4 per 100,000 between 1990 and 1997 and subsequently increased to 200.84 per 100,000

Background Low rates of staff influenza vaccine coverage occur in many health care facilities. Many programs do not offer vaccination to physicians or to volunteers, and some programs do not measure coverage or do so only for a subset of staff. The use of theory in planning and evaluation may prevent these problems and lead to more effective programs. Method We discuss the use of theory in the planning and evaluation of health programs and demonstrate how it can be used for the evaluation and planning of a hospital or nursing home influenza control program. Results The application of theory required explicit statement of the goals of the program and examination of the assumptions underlying potential program activities. This indicated that staff should probably be considered as employees, volunteers, physicians, and contractors of the facility. It also directed attention to evidence–based strategies for increasing vaccination rates. Conclusion The application of a program planning model to a problem of institutional influenza prevention may prevent planners from excluding important target populations and failing to monitor the important indicators of program success.

Background Places where people meet sex partners may play an important role in the propagation of sexually transmitted infections. Social network analysis (SNA) has the potential to quantify the role that places of social aggregation play in syphilis transmission based on a relational approach. The primary objective of this study was to explore the use of SNA as both an epidemiological and methodological tool to determine the relative importance of sex partner meeting venues to the transmission of syphilis, in a sustained infectious syphilis outbreak. Methods In a network survey study, we identified and enrolled 52 cases and named contacts of infectious syphilis among individuals, aged 18−75 years at a Sexually Transmitted Disease clinic in Alberta Canada, during routine public health measures of infectious disease control between April and August, 2009. In addition to standard contact tracing information, participants were asked to list all venues attended in the last 6 months where sexual partnering may have occurred. We constructed a sexual affiliation network by linking together persons infected with syphilis, and their named sexual contacts, to sex partner meeting venues. By transposing the sexual affiliation matrix and applying matrix multiplication we created two separate networks; a network of persons connected by venues and a dual network of venues connected by persons. Hierarchal clustering was performed to model patterns of individual patronage of venues, and network algebraic measures of centrality and permutation statistical methods were used to determine what type of venue connected the most individuals infected with syphilis. Results 77% of participants reported meeting a sex partner at a social venue in the last 6 months. We identified a densely connected sexual affiliation network of 94 men who have sex with men (MSM), comprised of 18 cases of infectious syphilis and 76 named sexual contacts connected by 21 venues. In the network of sex partner meeting venues, Internet venues had higher degree centrality than non-internet venues (p Conclusions To our knowledge, this is the first study to use SNA of a sexual affiliation network to quantify the importance of places in an outbreak of infectious syphilis. Network analysis allowed identification of three key venues that connected individuals who were infected with syphilis. These venues could provide public health officials with an epidemiologic target for primary and secondary prevention strategies to prevent further dissemination of disease.

Background: The purpose of this study was to determine the efficiency of a joint infection control/occupational health program for the follow-up of accidental blood or bloody body fluid exposures in health care workers. Methods: A comprehensive staff follow-up program for all blood exposures with known patient sources was initiated in 1989, consisting of patient follow-up by the Infection Control Department (risk assessment for hepatitis B virus [HBV] and HIV infection and obtaining of consent for HIV testing) and staff follow-up by the Occupational Health Department. In 1992 a mailed survey was conducted to examine exposure follow-up policies and responsibilities in large teaching hospitals across Canada. Results: A total of 924 exposures with known patient sources were reported betwee January 1989 and December 1993. HIV and HBV screening was obtained for 67.9% and 87.6% of patients assessed as at low risk and 82.3% and 92.2% of thos assessed as at high risk for infection, respectively. Two previously unknown HIV-seropositive patients were identified, one of whom had been classified as at low risk (one of 530 [0.19%] patients at low risk who underwent screening]. Primary reasons for screening being missed were patient discharge (46.3%) or communications problems (18.0%). The requirement for informed written consent before HIV screening accounted for the difference in completed HIV and BV screens. Results if the hospital survey indicated tat 40.8% of Canadian hospitals follow up all patients who are involved in blood exposures; however, most hospitals still rely on the physician to obtain consent (87.6%). Conclusions: Use of ICPs to screen patients involved in staff blood exposures during regular hours may be the most efficient method of follow-up, particularly if supplemented by a backup team of health professionals on nights and weekends. Although screening all patients for HBV/HIV may detect patients with undisclosed high-risk behaviors, institutions must decide whether the practice is cost-effective in areas of low prevalence.

Objective:To review experience with methicillin-resistant Staphylococcus aureus (MRSA) in tertiary acute-care teaching hospitals on the Canadian prairies.Design:Retrospective review for a 36-month period, 1990 through 1992.Setting:Five tertiary acute-care teaching hospitals in three Canadian prairie provinces.Methods:MRSA isolates and susceptibility were identified through the clinical microbiology laboratory at each institution. For each patient, data collected included duration of institutional residence prior to isolation, patient ethnic background, age, sex, and antimicrobial susceptibility. Epidemiologic typing of strains used restriction fragment length polymorphism analysis by pulsed-field gel electrophoresis.Results:Two hundred fifty-nine MRSA isolates were identified in 135 patients during the 36 months, with substantial institutional variation in number of isolates. No consistent increase in yearly numbers of isolates was apparent. Patients usually had MRSA identified at admission (62%); only one of five centers had the majority of isolates acquired nosocomially. Patients with MRSA present at admission were more frequently of aboriginal (First Nations) ethnicity (62% compared with 14% of nosocomial; Pinterprovincial or inter-institutional identity of strains.Conclusions:MRSA isolated in patients in tertiary care institutions in these three Canadian provinces usually is acquired prior to admission. A disproportionate number of isolates are identified in aboriginal Canadians. Epidemiologic typing was consistent with a polyclonal origin of MRSA in this geographic area.