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Background: The FDA issued a "black box" warning regarding risks of fluoroquinolones in 2008 with updates in 2011, 2013, and 2016., Objective: To examine antimicrobial use in hospital-treated UTIs from 2000 to 2020., Design: Cross-sectional study with interrupted time series analysis., Participants: Patient encounters with a diagnosis of UTI from January 2000 to March 2020, excluding diagnoses of renal abscess, chronic cystitis, and infection of the gastrointestinal tract, lungs, or prostate., Main Measures: Monthly use of fluoroquinolone and non-fluoroquinolone antibiotics were assessed. Fluoroquinolone resistance was assessed in available cultures. Interrupted time series analysis examined level and trend changes of antimicrobial use with each FDA label change., Key Results: A total of 9,950,790 patient encounters were included. From July 2008 to March 2020, fluoroquinolone use declined from 61.7% to 11.7%, with similar negative trends observed in inpatients and outpatients, age ≥ 60 and < 60 years, males and females, patients with and without pyelonephritis, and across physician specialties. Ceftriaxone use increased from 26.4% encounters in July 2008 to 63.6% of encounters in March 2020. Among encounters with available culture data, fluoroquinolone resistance declined by 28.9% from 2009 to 2020. On interrupted time series analysis, the July 2008 FDA warning was associated with a trend change (-0.32%, < 0.001) and level change (-5.02%, p < 0.001) in monthly fluoroquinolone use., Conclusions: During this era of "black box" warnings, there was a decline in fluoroquinolone use for hospital-treated UTI with a concomitant decline in fluoroquinolone resistance and rise in ceftriaxone use. Efforts to restrict use of a medication class may lead to compensatory increases in use of a single alternative agent with changes in antimicrobial resistance profiles., (© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: Antimicrobial resistance research in uncomplicated urinary tract infection typically focuses on the main causative pathogen, Escherichia coli; however, little is known about the antimicrobial resistance burden of Klebsiella species, which can also cause uncomplicated urinary tract infections. This retrospective cohort study assessed the prevalence and geographic distribution of antimicrobial resistance among Klebsiella species and antimicrobial resistance trends for K. pneumoniae in the United States (2011-2019)., Methods: K. pneumoniae and K. oxytoca urine isolates (30-day, non-duplicate) among female outpatients (aged ≥ 12 years) with presumed uUTI at 304 centers in the United States were classified by resistance phenotype(s): not susceptible to nitrofurantoin, trimethoprim/sulfamethoxazole, or fluoroquinolone, extended-spectrum β-lactamase-positive/not susceptible; and multidrug-resistant based on ≥ 2 and ≥ 3 resistance phenotypes. Antimicrobial resistance prevalence by census division and age, as well as antimicrobial resistance trends over time for Klebsiella species, were assessed using generalized estimating equations., Results: 270,552 Klebsiella species isolates were evaluated (250,719 K. pneumoniae; 19,833 K. oxytoca). The most frequent resistance phenotypes in 2019 were nitrofurantoin not susceptible (Klebsiella species: 54.0%; K. pneumoniae: 57.3%; K. oxytoca: 15.1%) and trimethoprim/sulfamethoxazole not susceptible (Klebsiella species: 10.4%; K. pneumoniae: 10.6%; K. oxytoca: 8.6%). Extended-spectrum β-lactamase-positive/not susceptible prevalence was 5.4%, 5.3%, and 6.8%, respectively. K. pneumoniae resistance phenotype prevalence varied (p < 0.0001) geographically and by age, and increased over time (except for the nitrofurantoin not susceptible phenotype, which was stable and > 50% throughout)., Conclusions: There is a high antimicrobial resistance prevalence and increasing antimicrobial resistance trends among K. pneumoniae isolates from female outpatients in the United States with presumed uncomplicated urinary tract infection. Awareness of K. pneumoniae antimicrobial resistance helps to optimize empiric uncomplicated urinary tract infection treatment., (© 2024. The Author(s).)

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.

The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases 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 a number of organizations and societies with content expertise.

Background: Carbapenem-resistant Pseudomonas aeruginosa (CRPA) is a global threat, but the distribution and clinical significance of carbapenemases are unclear. The aim of this study was to define characteristics and outcomes of CRPA infections and the global frequency and clinical impact of carbapenemases harboured by CRPA., Methods: We conducted an observational, prospective cohort study of CRPA isolated from bloodstream, respiratory, urine, or wound cultures of patients at 44 hospitals (10 countries) between Dec 1, 2018, and Nov 30, 2019. Clinical data were abstracted from health records and CRPA isolates were whole-genome sequenced. The primary outcome was 30-day mortality from the day the index culture was collected. We compared outcomes of patients with CRPA infections by infection type and across geographic regions and performed an inverse probability weighted analysis to assess the association between carbapenemase production and 30-day mortality., Findings: We enrolled 972 patients (USA n=527, China n=171, south and central America n=127, Middle East n=91, Australia and Singapore n=56), of whom 581 (60%) had CRPA infections. 30-day mortality differed by infection type (bloodstream 21 [30%] of 69, respiratory 69 [19%] of 358, wound nine [14%] of 66, urine six [7%] of 88; p=0·0012) and geographical region (Middle East 15 [29%] of 52, south and central America 20 [27%] of 73, USA 60 [19%] of 308, Australia and Singapore three [11%] of 28, China seven [6%] of 120; p=0·0002). Prevalence of carbapenemase genes among CRPA isolates also varied by region (south and central America 88 [69%] of 127, Australia and Singapore 32 [57%] of 56, China 54 [32%] of 171, Middle East 27 [30%] of 91, USA ten [2%] of 527; p<0·0001). KPC-2 (n=103 [49%]) and VIM-2 (n=75 [36%]) were the most common carbapenemases in 211 carbapenemase-producing isolates. After excluding USA patients, because few US isolates had carbapenemases, patients with carbapenemase-producing CRPA infections had higher 30-day mortality than those with non-carbapenemase-producing CRPA infections in both unadjusted (26 [22%] of 120 vs 19 [12%] of 153; difference 9%, 95% CI 3-16) and adjusted (difference 7%, 95% CI 1-14) analyses., Interpretation: The emergence of different carbapenemases among CRPA isolates in different geographical regions and the increased mortality associated with carbapenemase-producing CRPA infections highlight the therapeutic challenges posed by these organisms., Funding: National Institutes of Health., Competing Interests: Declaration of interests All authors report funding support from the Antibacterial Resistance Leadership Group of the National Institutes of Health (NIH) and the National Institute of Allergy and Infectious Diseases (NIAID; UM1AI104681) during the conduct of this study. Additionally, during the conduct of this study, and outside of the submitted work, the authors report the following disclosures. KSK reports consulting fees paid directly to him by Merck, Shionogi, Qpex, and Micrux. JG-D reports grants and contracts paid to her institution from NIH, BARDA, Janssen Research & Development LLC, Pfizer, BioNTech SE, GCAR, Hoffman La-Roche, I-Mab Bioppharma, Rebiotix, Target Health, LLC OBO Lilly USA, GlaxoSmithKline, Summit Limited, Cidara Therapeutics, Merck Sharp & Dohme, Seres Therapeutics; and Infectious Diseases Society of America Research Committee participation paid to her directly. SSK reports speaker and advisory board payments from Pfizer, Astellas, Novartis, Merck, and Gilead. JMO reports speaker payments from Pfizer, MSD, and Biotoscana; and board participation on the Chair Ethics Committee. SLV-B reports personal fees from Pfizer, Biotoscana, and MSD; meeting support from MSD and Pfizer; and data safety monitoring board participation with MSD and GlaxoSmithKline. PT reports honoraria payments to his institution from Aj Biologics and bioMérieux. GW reports payment to his institution from Allergan for contracted activities. LMA reports grants and contracts paid to her institution from Rainmakers/CDC multisystem inflammatory syndrome in adults with SARS-CoV-2, and Regeneron study co-investigator; consulting and honoraria paid directly to them from Medscape for CME lectures, and Ferring Pharmaceuticals for advisory board participation; and volunteer work as the director of the IDSA Board of Directors. KO reports payments for educational events and presentations from Pfizer, MSD, AstraZeneca, and Farma de Colombia; meeting support from Pfizer, MSD, and Gilead; and expert testimony support from Pfizer, bioMérieux, and MSD. MES reports speaker fees from Pfizer (Argentina); advisory board participation for Wockhardt; consultancy for Basilea; and data safety monitoring board participation with Fulcrum Therapeutics. JMM reports grants from Pfizer, MSD, and bioMérieux, the National Fund for Scientific and Technological Development; and the Agencia Nacional de Investigation y Desarrollo Millennium Science Initiative/Millennium Initiative for Collaborative Research on Bacterial Resistance, Government of Chile. DLP reports grants and contracts paid to his institution from Merck, Pfizer, and Shionogi; consulting and honoraria payments to him by Merck, Shionogi, QPex, Spero Therapeutics, Sumitomo, Pfizer, and bioMérieux; meeting support from Shionogi; and board and committee participation with Symvivo, and AMR action fund. SE reports grants from the NIAID and the NIH and Degruter (Editor in Chief for Statistical Communications in Infectious Diseases); royalties from Taylor & Francis; consulting fees from Genentech, AstraZeneca, Takeda, Microbiotix, Johnson & Johnson, Endologix, ChemoCentryx, Becton Dickinson, Atricure, Roviant, Neovasc, Nobel Pharma, Horizon, International Drug Development Institute, SVB Leerink; payments from Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks; meeting support from the US Food and Drug Administration, the Deming Conference on Applied Statistics, the Clinical Trial Transformation Initiative, the Council for International Organizations of Medical Sciences, the International Chinese Statistical Association Applied Statistics Symposium, and the Antimicrobial Resistance and Stewardship Conference; and board member participation for the NIH, the Breast International Group, the University of Pennsylvania, Duke University, Roche, Pfizer, Takeda, Akouos, Apellis, Teva, Vir, DayOneBio, Alexion, Tracon, Rakuten, AbbVie, Nuvelution, Clover, FHI Clinical, Lung Biotech, SAB Biopharm, Advantagene, the American Statistical Association, the Society for Clinical Trials, and the Frontier Science Foundation. RAB reports grants and contracts, paid to his institution, by VenatoRx, Wockhardt, and Merck; payments made to him by Pfizer to moderate meeting sessions; patents with Case Western Reserve University on the development of boronic acid transition state inhibitors for β-lactamases (WO2022187362A1, US9949995B2, and US20170252326A1); and payment for participation on a data safety monitoring board, safety oversight committee support, and Logistics Associate for DMID-CROMS (contractor) with Technical Resources International. MVV reports contracts, consulting fees, and honoraria payments from Pfizer and MSD; consulting fees from West Quimica Colombia; and honoraria from bioMérieux. RP reports grants from BioFire Diagnostics, ContraFect, and TenNor Therapeutics; is a consultant to Curetis, Specific Technologies, Next Gen Diagnostics, PathoQuest, Selux Diagnostics, 1928 Diagnostics, PhAST, Day Zero Diagnostics, Torus Biosystems, Mammoth Biosciences, and Qvella, for which monies are paid to Mayo Clinic; is a consultant to Netflix and CARB-X; has a patent on Bordetella pertussis and parapertussis PCR issued (US8507201B2), a patent on a device and method for sonication (with royalties paid by Samsung to Mayo Clinic; US7076117B2), and a patent on an anti-biofilm substance issued (US8802414B2); receives an editor's stipend from the Infectious Diseases Society of America; and receives honoraria from the National Board of Medical Examiners, UpToDate, and the Infectious Diseases Board Review Course. CAA reports the grants and contracts paid to his institution from NIH and NIAID, MeMed Diagnostics, Entasis Therapeutics, Merck Pharmaceuticals, and Harris County Public Health; payments to him for UpToDate royalties, reimbursement of meeting attendance, and speaking from Infectious Diseases Society of America, American Society for Microbiology, Society of Hospital Epidemiology of America, European Society for Clinical Microbiology and Infectious Diseases, bioMérieux Foundation, Sociedad Argentina de Infectologia, Sociedad Chilena de Infectologia, Sociedad Colombiana de Infectologia, Panamerican Society for Infectious Diseases, Brazilian Society for Infectious Diseases, reviewer participation as part of the NIH grant Review Study Sections, travel expenses from the Infectious Disease Society of America (IDSA) Board of Directors, and for Editor in Chief for Antimicrobial Agents and Chemotherapy; non-paid participation with WHO Antibacterial Pipeline Advisory Group; and participation on the IDSA Board of Directors. HFC reports participation on a Merck data safety monitoring board for molnupiravir paid directly to him, stock ownership in Moderna and Merck, and a position as expert witness for Lilly and Nexus Pharmaceuticals. VGF reports grants to his institution from the NIH, MedImmune, Allergan, Pfizer, Advanced Liquid Logics, Theravance, Novartis, Merck, Medical Biosurfaces, Locus, Affinergy, ContraFect, Karius, Genentech, Regeneron, Basilea, and Janssen; royalties from UpToDate; personal fees from Novartis, Debiopharm, Genentech, Achaogen, Affinium, Medicines, MedImmune, Bayer, Basilea, Affinergy, Janssen, ContraFect, Regeneron, Destiny, Amphliphi Biosciences, Integrated Biotherapeutics, C3J, Armata, Valanbio, Akagera, Aridis, and Roche; editorial stipend from Infectious Diseases of America; pending patent for a host gene expression signature diagnostic for sepsis (US9850539B2); and stock options with Valanbio and ArcBio. YD reports grants from Entasis, Asahi Kasei Pharma, Shionogi, and Kanto Chemical paid to his institution; consulting fees paid directly to him from Meiji Seika Pharma, Shionogi, Gilead, MSD, Chugai, and bioMérieux; and speaker payments from MSD, Shionogi, AstraZeneca, Teijin Healthcare, Gilead, FujiFilm Toyama Chemical, bioMerieux, HU Frontier, and Eiken Chemical paid to him. DvD reports grants and contracts from the NIH and Merck paid to his institution outside of the published work; and consultancy for Astellas, Merck, Allergan, T2Biosystems, Roche, Achaogen, Neumedicine, Shionogi, Pfizer, Entasis, QPex, Wellspring, and Karius. MJS reports contract payments to his institution from Merck, Allergan, BioFire Diagnostics, Affinity Biosensors, and SNIPRBiome; personal consulting fees from Shionogi; and data and safety monitoring board participation for Spero Therapeutics., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Uncomplicated urinary tract infection (uUTI) is predominantly caused by Escherichia coli, which has increasing antimicrobial resistance (AMR) at the United States (US)-community level. As uUTI is often treated empirically, assessing AMR is challenging, and there are limited contemporary data characterizing period prevalence in the US., Methods: This was a retrospective study of AMR using Becton, Dickinson and Company Insights Research Database (Franklin Lakes, New Jersey, US) data collected 2011-2019. Thirty-day, nonduplicate Escherichia coli urine isolates from US female outpatients (aged ≥12 years) were included. Isolates were evaluated for nonsusceptibility (intermediate/resistant) to trimethoprim-sulfamethoxazole, fluoroquinolones, or nitrofurantoin, and assessed for extended-spectrum β-lactamase production (ESBL+) and for ≥2 or ≥3 drug-resistance phenotypes. Generalized estimating equations were used to model AMR trends over time and by US census region., Results: Among 1 513 882 E. coli isolates, the overall prevalence of isolates nonsusceptible to trimethoprim-sulfamethoxazole, fluoroquinolones, and nitrofurantoin was 25.4%, 21.1%, and 3.8%, respectively. Among the isolates, 6.4% were ESBL+, 14.4% had ≥2 drug-resistance phenotypes, and 3.8% had ≥3. Modeling demonstrated a relative average yearly increase of 7.7% (95% confidence interval [CI], 7.2-8.2%) for ESBL+ isolates and 2.7% (95% CI, 2.2-3.2%) for ≥3 drug-phenotypes (both P < .0001). Modeling also demonstrated significant variation in AMR prevalence between US census regions (P < .001)., Conclusions: Period prevalence of AMR among US outpatient urine-isolated E. coli was high, and for multidrug-resistance phenotypes increased during the study period with significant variation between census regions. Knowledge of regional AMR rates helps inform empiric treatment of community-onset uUTI and highlights the AMR burden to physicians., (© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America.)

Background: Carbapenem-resistant Enterobacterales (CRE) are a global threat. We aimed to describe the clinical and molecular characteristics of Centers for Disease Control and Prevention (CDC)-defined CRE in the USA., Methods: CRACKLE-2 is a prospective, multicentre, cohort study. Patients hospitalised in 49 US hospitals, with clinical cultures positive for CDC-defined CRE between April 30, 2016, and Aug 31, 2017, were included. There was no age exclusion. The primary outcome was desirability of outcome ranking (DOOR) at 30 days after index culture. Clinical data and bacteria were collected, and whole genome sequencing was done. This trial is registered with ClinicalTrials.gov, number NCT03646227., Findings: 1040 patients with unique isolates were included, 449 (43%) with infection and 591 (57%) with colonisation. The CDC-defined CRE admission rate was 57 per 100 000 admissions (95% CI 45-71). Three subsets of CDC-defined CRE were identified: carbapenemase-producing Enterobacterales (618 [59%] of 1040), non-carbapenemase-producing Enterobacterales (194 [19%]), and unconfirmed CRE (228 [22%]; initially reported as CRE, but susceptible to carbapenems in two central laboratories). Klebsiella pneumoniae carbapenemase-producing clonal group 258 K pneumoniae was the most common carbapenemase-producing Enterobacterales. In 449 patients with CDC-defined CRE infections, DOOR outcomes were not significantly different in patients with carbapenemase-producing Enterobacterales, non-carbapenemase-producing Enterobacterales, and unconfirmed CRE. At 30 days 107 (24%, 95% CI 20-28) of these patients had died., Interpretation: Among patients with CDC-defined CRE, similar outcomes were observed among three subgroups, including the novel unconfirmed CRE group. CDC-defined CRE represent diverse bacteria, whose spread might not respond to interventions directed to carbapenemase-producing Enterobacterales., Funding: National Institutes of Health., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: The clinical experience of ceftaroline fosamil (CPT-F) therapy for Gram-positive infective endocarditis is reported from CAPTURE, a retrospective study conducted in the USA., Methods: Data, including patient demographics, medical history, risk factors, microbiological aetiology and clinical outcomes, were collected by review of patient charts between September 2013 and February 2015., Results: Patients (n=55) with Gram-positive endocarditis were treated with CPT-F. The most common risk factors were intravascular devices (43.6%), diabetes mellitus (40.0%) and injection drug use (38.2%). The most commonly isolated pathogens were meticillin-resistant Staphylococcus aureus (MRSA; 80%), meticillin-susceptible S. aureus (MSSA; 7.3%) and coagulase-negative staphylococci (7.3%). CPT-F was given as first-line therapy in 7.3% of patients and as second-line or later therapy in 92.7% of patients, and as monotherapy in 41.8% of patients and as concurrent therapy in 58.2% of patients. Clinical success was observed in 82.6% (19/23) of patients treated with CPT-F as monotherapy. In patients treated with CPT-F as first-line therapy or second-line or later therapy, 75.0% (3/4) and 70.6% (36/51) achieved success, respectively. Clinical success was observed in 77.3% (34/44) of patients with MRSA and 25% (1/4) of patients with MSSA. Two patients discontinued treatment with CPT-F due to an adverse event., Conclusions: CPT-F treatment was associated with a high rate of clinical success in patients with Gram-positive infective endocarditis, including those with risk factors and infections caused by MRSA. A high rate of clinical success was observed in patients treated with CPT-F used as first- line therapy or second-line or later therapy, or as monotherapy or in combination with other antibiotics., (Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.)

The US burden of acute skin infections is substantial. While Staphylococcus aureus and Streptococcus spp. are the most common causes, gram-negative bacteria and mixed infections can occur in some settings. These mixed infections are more likely to result in inappropriate empiric antibiotic therapy. Important challenges remain in diagnosing and treating acute skin 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.

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: The number of ambulatory patients seeking treatment for skin and skin structure infections (SSSI) are increasing. The objective of this study is to determine recent trends in hospital admissions and healthcare resource utilization and identify covariates associated with hospital costs and mortality for hospitalized adult patients with a primary SSSI diagnosis in the United States., Methods: We performed a retrospective cross-sectional analysis (years 2005-2011) of data from the US Healthcare Cost and Utilization Project National Inpatient Sample. Recent trends, patient characteristics, and healthcare resource utilization for patients hospitalized with a primary SSSI diagnosis were evaluated. Descriptive and bivariate analyses were conducted to assess patient and hospital characteristics., Results: A total of 1.8% of hospital admissions for the years 2005 through 2011 were for adult patients with a SSSI primary diagnosis. SSSI-related hospital admissions significantly changed during the study period (P < .001 for trend) ranging from 1.6% (in 2005) to 2.0% (in 2011). Mean hospital length of stay (LOS) decreased from 5.4 days in the year 2005 to 5.0 days in the year 2011 (overall change, P < .001) with no change in hospital costs. Patients with postoperative wound infections had the longest hospital stays (adjusted mean, 5.81 days; 95% confidence interval (CI), 5.80-5.83) and highest total costs (adjusted mean, $9388; 95% CI, $9366-$9410). Year of hospital admission was strongly associated with mortality; infection type, all patient refined diagnosis related group severity of illness level, and LOS were strongly associated with hospital costs., Conclusions: Hospital admissions for adult patients in the United States with a SSSI primary diagnosis continue to increase. Decreasing hospital inpatient LOS and mortality rate may be due to improved early treatment. Future research should focus on identifying alternative treatment processes for patients with SSSI that could shift management from inpatient to outpatient treatment settings.

Infections caused by resistant gram-negative bacteria are becoming increasingly prevalent and now constitute a serious threat to public health worldwide because they are difficult to treat and are associated with high morbidity and mortality rates. In the United States, there has been a steady increase since 2000 in rates of extended-spectrum β-lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, and multidrug-resistant strains of Pseudomonas aeruginosa and Acinetobacter baumannii, particularly among hospitalized patients with intraabdominal infections, urinary tract infections, ventilator-associated pneumonia, and bacteremia. Colonization with resistant gram-negative bacteria is common among residents in long-term care facilities (particularly those residents with an indwelling device), and these facilities are considered important originating sources of such strains for hospitals. Antibiotic resistance is associated with a substantial clinical and economic burden, including increased mortality, greater hospital and antibiotic costs, and longer stays in hospitals and intensive care units. Control of resistant gram-negative infections requires a comprehensive approach, including strategies for risk factor identification, detection and identification of resistant organisms, and implementation of infection-control and prevention strategies. In treating resistant gram-negative infections, a review of surveillance data and hospital-specific antibiograms, including resistance patterns within local institutions, and consideration of patient characteristics are helpful in guiding the choice of empiric therapy. Although only a few agents are available with activity against resistant gram-negative organisms, two recently released β-lactam/β-lactamase inhibitor combinations - ceftolozane/tazobactam and ceftazidime/avibactam - have promising activity against these organisms. In this article, we review the epidemiology, risk factors, and antibiotic resistance mechanisms of gram-negative organisms. In addition, an overview of treatment options for patients with these infections is provided., (© 2015 Pharmacotherapy Publications, Inc.)

Background: Epidemiological characteristics of patients with bloodstream infections (BSI) due to extended-spectrum β-lactamase producing (ESBL) and carbapenem-resistant (CRE) strains are often similar. Mortality rates for CRE BSI are 70%, and mean time to initiation of appropriate therapy is ~5 days. A bedside score was developed to differentiate CRE-BSIs from ESBL-BSIs, in order to help decrease the time to initiation of appropriate therapy for CRE and mortality rates., Findings: Score was developed based of data (2007-2010) abstracted from charts of adult patients from Assaf Harofeh Medical Center (AHMC, Zeriffin, Israel), and validated on a cohort of patients from Detroit Medical Center (DMC, MI, USA). A multivariate model for presence of CRE was generated. A clinical prediction score and ROC curve was derived. 451 patients with ESBL BSIs (285 from AHMC and 166 from DMC) and 74 patients with CRE BSIs (58 from AHMC and 16 from DMC) were included. The prediction score included chemotherapy in the past 3 months (19 points), presence of foreign invasive devices (10 points), no peripheral vascular disease (10 points), reduced consciousness or cognition at time of acute illness (9 points), time in hospital prior to BSI ≥ 3 days (7 points), and age younger than 65 years (6 points). A score of ≥32 to define "high CRE risk" had sensitivity of 59%, specificity of 76%, PPV of 34% and NPV of 90%., Conclusions: The score's 90% NPV implies it could reduce un-necessary (and toxic) empiric use of anti-CRE therapeutics, but this should be studied prospectively and on broader populations in order to test its potential role in reducing mortality.

Background: Both Clostridium [corrected] difficile infection (CDI) rates in hospitals and interest in reducing 30-day readmission rates have increased dramatically in the United States. The objective of this study was to characterize the burden of CDI on 30-day hospital readmissions at a tertiary care health-system., Methods: A patient discharge database was used to identify patients with a CDI diagnosis (ICD-9 code 008.45) during their stay in 2012. Patients were classified as index admissions (CDI discharges) or 30-day readmissions (CDI readmissions). Readmission rates, length of stay (LOS), and time to readmission were assessed among CDI readmissions., Results: Among discharges from the health system (n = 51,353), 615 were diagnosed with CDI (1%). Thirty-day readmissions were more common among CDI discharges (30.1%) than non-CDI discharges (14.4%). Average LOS for CDI readmissions was 5-6 days longer than non-CDI readmissions. Time to readmission was shorter among CDI discharges diagnosed on admission than CDI discharges diagnosed later during their hospital stay (median, 7 days)., Conclusion: Reductions in hospital-onset CDI and readmission of patients with an index CDI can provide tremendous cost savings to hospitals. This calls for better infection control and antibiotic stewardship measures toward CDI management in the hospital and as patients transition to the next level of care., (Copyright © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

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)., (Copyright © 2014 The Society for Healthcare Epidemiology of America. Published by Mosby, Inc. All rights reserved.)

Context: Surgical site infection (SSI) after total hip and knee arthroplasty is a common postoperative complication. We sought to determine readmission rates and costs for total hip and knee arthroplasty complicated by SSI., Design: The Thomson Reuters MarketScan database was searched for patients who underwent knee or hip arthroplasty in 2007. From these data, patients who received a diagnosis of SSI and were readmitted after diagnosis were identified., Setting: A population of 31 to 45 million individuals receiving insurance coverage. Patients who underwent knee or hip arthroplasty who experienced a hospitalization for SSI in the year after surgery were analyzed., Outcome Measures: Total readmission rates and costs per readmission at 30, 60, and 90 days and 1 year after diagnosis of SSI., Results: Of the 76,289 case patients with hip or knee replacement in 2007, 1,026 (1.3%) had a hospitalization for SSI within the year after surgery. Among these patients, 310 (30.2%) were subsequently rehospitalized in the year after initial hospitalization specifically due to SSI-related issues. These rehospitalizations were associated with a mean hospital stay of [Formula: see text] days and a median cost of $20,001 (interquartile range [IQR], $14,057-$30,551). A total of 517 subjects had a subsequent "all-cause" hospitalization during the year after SSI. These rehospitalizations were associated with a mean hospital stay of [Formula: see text] days and a median cost of $19,870 (IQR, $13,913-$29,728)., Conclusions: Readmissions during the year after SSI diagnosis accounted for 1,072 hospital admissions and cost over $25.5 million. These readmissions are costly and might be a future target for decreased reimbursement.

Community-acquired pneumonia (CAP) is a common infectious disease in the United States and the incidence continues to grow as the aging population increases. Overall, in-hospital patient mortality rates have been reported to be as high as 18%. Management of patients with CAP has been challenged by the evolution of resistant pathogens (particularly Streptococcus pneumoniae and Staphylococcus aureus) that have reduced susceptibility to recommended standard antimicrobial agents. Streptococcus pneumoniae continues to be the most frequently identified pathogen in CAP and recently, S. aureus has been found to be the second most often identified pathogen. Data from the SENTRY Antimicrobial Surveillance Program has shown declining susceptibility of pneumococci to penicillin, amoxicillin/clavulanate, and ceftriaxone from 1998 through 2011. In the Assessing Worldwide Resistance Evaluation (AWARE) surveillance program, > 50% of all S. aureus isolates from patient bloodstream infections, skin and skin structure infections, and pneumonia were methicillin-resistant. Stratifying risk factors to identify patients at risk for community-acquired multidrug-resistant pathogens should be considered when selecting therapy. Differences in microbiology and outcomes have been noted in patients presenting from the community with recent exposure to the health care system (eg, nursing home residents, patients with a recent hospital admission). These patients are at an increased risk of an infection caused by a multidrug-resistant pathogen. Understanding a patient's risk for drug-resistant pathogens will allow the physician to choose an appropriate empiric treatment regimen to optimize clinical outcomes.

A case-case-control study was conducted to identify independent risk factors for recovery of Escherichia coli strains producing CTX-M-type extended-spectrum β-lactamases (CTX-M E. coli) within a large Southeastern Michigan medical center. Unique cases with isolation of ESBL-producing E. coli from February 2010 through July 2011 were analyzed by PCR for blaCTX-M, blaTEM, and blaSHV genes. Patients with CTX-M E. coli were compared to patients with E. coli strains not producing CTX-M-type ESBLs (non-CTX-M E. coli) and uninfected controls. Of 575 patients with ESBL-producing E. coli, 491 (85.4%) isolates contained a CTX-M ESBL gene. A total of 319 (84.6%) patients with CTX-M E. coli (282 [74.8%] CTX-M-15 type) were compared to 58 (15.4%) non-CTX-M E. coli patients and to uninfected controls. Independent risk factors for CTX-M E. coli isolation compared to non-CTX-M E. coli included male gender, impaired consciousness, H2 blocker use, immunosuppression, and exposure to penicillins and/or trimethoprim-sulfamethoxazole. Compared to uninfected controls, independent risk factors for isolation of CTX-M E. coli included presence of a urinary catheter, previous urinary tract infection, exposure to oxyimino-cephalosporins, dependent functional status, non-home residence, and multiple comorbid conditions. Within 48 h of admission, community-acquired CTX-M E. coli (n = 51 [16%]) and non-CTX-M E coli (n = 11 [19%]) strains were isolated from patients with no recent health care contacts. CTX-M E. coli strains were more resistant to multiple antibiotics than non-CTX-M E. coli strains. CTX-M-encoding genes, especially bla(CTX-M-15) type, represented the most common ESBL determinants from ESBL-producing E. coli, the majority of which were present upon admission. Septic patients with risk factors for isolation of CTX-M E. coli should be empirically treated with appropriate agents. Regional infection control efforts and judicious antibiotic use are needed to control the spread of these organisms.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of invasive surgical site infection (SSI) in the USA. Antimicrobial prophylaxis for SSI typically includes a cephalosporin. Vancomycin is used to provide MRSA coverage, but the timing of administration is challenging. Linezolid is an attractive agent for SSI prophylaxis, particularly for the prevention of SSI due to MRSA., Methods: We developed a decision-analytic model to evaluate linezolid use for cardiothoracic SSI prophylaxis. A theoretical cohort of 10,000 cardiothoracic surgery patients was followed through 2 stages: (1) occurrence of SSI, and (2) mortality after SSI. All patients were administered cefuroxime, vancomycin, or linezolid between 1 and 180 min prior to surgical incision. SSIs were categorized into 3 pathogen categories: (1) methicillin-susceptible Gram-positive, (2) methicillin-resistant Gram-positive, and (3) other organisms. The most effective strategy resulted in the fewest SSIs. Assumptions for antibiotic effectiveness, impact of administration time, and pathogens were based on the published literature., Results: Compared with cefuroxime, there was a 1% increase in the total number of SSIs in the linezolid group (mean SSI increase = 7), while there was a 12% increase in the vancomycin group (mean SSI increase = 86). Linezolid prophylaxis resulted in fewer SSIs due to methicillin-resistant Gram-positive infections (n = 108) compared with cefuroxime (n = 200, 46% reduction in the linezolid group) and vancomycin (n = 119, 9% reduction in the linezolid group)., Conclusions: This simulation indicates that linezolid may offer benefits for SSI prophylaxis over existing prophylactic agents, particularly for the prevention of SSI due to Gram-positive methicillin-resistant pathogens.

The hospital environment is increasingly recognized as a reservoir for hospital-acquired pathogens. During a 44-month study period, a total of 1,103 basins from 88 hospitals in the United States and Canada were sampled. Overall, 62.2% of the basins (at least 1 basin at each hospital) were contaminated with commonly encountered hospital-acquired pathogens., (Copyright © 2012 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.)

In published studies, cohorts of patients with bacteremia due to vancomycin-resistant Enterococcus (VRE) have predominantly been infected with Enterococcus faecium. Little is known about the epidemiology and outcomes associated with bacteremia due to VR Enterococcus faecalis. A retrospective study of isolates obtained from January 2008 to October 2010 was conducted at Detroit Medical Center (DMC). Unique patients with blood cultures positive for VRE were reviewed. Outcomes were analyzed using logistic regression. During the study period, 105 cases of bacteremia due to VR E. faecalis and 197 cases of bacteremia due to VR E. faecium were identified. The mean age in the study cohort was 61.5 ± 15 years; 162 subjects (53.6%) were male. After controlling for a propensity score, bacteremia due to VR E. faecalis was associated with >2-fold-lower in-hospital mortality than bacteremia due to VR E. faecium. Interestingly, bacteremia due to VR E. faecalis was associated with longer hospital stay after VRE isolation, although total length of stay was similar for groups with VR E. faecalis and VR E. faecium. Bacteremia due to VR E. faecalis was associated with a >2-fold-lower risk for mortality than bacteremia due to VR E. faecium, possibly due to the availability of β-lactam therapeutics for treatment of VR E. faecalis.

Background: Colistin, originally abandoned due to high rates of nephrotoxicity, has been recently reintroduced due to activity against carbapenem-resistant Gram-negative organisms. Recent literature, largely obtained from outside the United States, suggests a lower rate of nephrotoxicity than historically reported., Methods: A retrospective cohort of all patients who received colistin for ≥ 48 hours at the Detroit Medical Center over a 5-year period was performed to determine the rate of colistin-associated nephrotoxicity as defined by the RIFLE criteria., Results: Fifty-four (43%) patients in the cohort developed nephrotoxicity. Patients who experienced nephrotoxicity after colistin administration were in the Risk (13%), Injury (17%), or Failure (13%) categories per RIFLE criteria. Patients who developed nephrotoxicity received significantly higher mean doses than those who did not (5.48 mg/kg per day vs 3.95 mg/kg per day; P < .001), and the toxicity occurred in a dose-dependent fashion. Independent predictors for nephrotoxicity were a colistin dose of ≥ 5.0 mg/kg per day of ideal body weight (odds ratio [OR], 23.41; 95% confidence interval [CI], 5.3-103.55), receipt of concomitant rifampin (OR, 3.81; 95% CI, 1.42-10.2), and coadministration of ≥ 3 concomitant nephrotoxins (OR, 6.80; 95% CI, 1.42-32.49)., Conclusions: In this retrospective cohort, nephrotoxicity (as defined by RIFLE criteria) occurred among 43% of treated patients in a dose-dependent manner. Higher colistin doses, similar to those commonly used in the United States, led to a relatively high rate of nephrotoxicity. These data raise important questions regarding the safe use of colistin in the treatment of multidrug-resistant pathogens.

Background: Previous antibiotic exposure is a risk factor for extended spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae isolation, but the optimal definition of previous antibiotic exposure remains unclear., Methods: This was a retrospective, case-control study comparing 88 patients with ESBL-producing K pneumoniae (cases) and 88 patients with non-ESBL-producing K pneumoniae (controls). Three previous antibiotic exposure definitions were analyzed, including durations of 30, 60, and 90 days prior to organism isolation., Results: The mean cohort age was 63.6 ± 16.9 years, 43% were male, and 86% were black. In bivariate analysis, third-generation cephalosporins and cefepime were associated with ESBL-producing K pneumoniae isolation, and the odds ratios (OR) were significant regardless of previous antibiotic exposure definition. However, for fluoroquinolones and ampicillin/sulbactam, the ORs varied as a function of previous antibiotic exposure definition. In multivariate analysis, third-generation cephalosporin usage was a risk factor for ESBL-producing K pneumoniae isolation, whereas ampicillin/sulbactam usage was protective against these organisms, regardless of the time frame analyzed. Other independent predictors of ESBL-producing K pneumoniae included nursing home residence (OR, 9.30 [95% confidence interval: 3.69-23.43]) and hemodialysis (OR, 13.60 [95% confidence interval: 4.29-43.17])., Conclusion: Prior use of third-generation cephalosporins, nursing home residence, and hemodialysis were independent risk factors for isolation of an ESBL-producing K pneumoniae regardless of the time frame analyzed., (Copyright © 2011 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.)

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.)

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.

Objective: To validate the National Nosocomial Infection Surveillance (NNIS) risk index as a tool to account for differences in case mix when reporting rates of complex surgical site infection (SSI)., Design: Prospective cohort study., Setting: Twenty-four community hospitals in the southeastern United States., Methods: We identified surgical procedures performed between January 1, 2005, and June 30, 2007. The Goodman-Kruskal gamma or G statistic was used to determine the correlation between the NNIS risk index score and the rates of complex SSI (not including superficial incisional SSI). Procedure-specific analyses were performed for SSI after abdominal hysterectomy, cardiothoracic procedures, colon procedures, insertion of a hip prosthesis, insertion of a knee prosthesis, and vascular procedures., Results: A total of 2,257 SSIs were identified during the study period (overall rate, 1.19 SSIs per 100 procedures), of which 1,093 (48.4%) were complex (0.58 complex SSIs per 100 procedures). There were 45 complex SSIs identified following 7,032 abdominal hysterectomies (rate, 0.64 SSIs per 100 procedures); 63 following 5,318 cardiothoracic procedures (1.18 SSIs per 100 procedures); 139 following 5,144 colon procedures (2.70 SSIs per 100 procedures); 63 following 6,639 hip prosthesis insertions (0.94 SSIs per 100 procedures); 73 following 9,658 knee prosthesis insertions (0.76 SSIs per 100 procedures); and 55 following 6,575 vascular procedures (0.84 SSIs per 100 procedures). All 6 procedure-specific rates of complex SSI were significantly correlated with increasing NNIS risk index score (P<.05)., Conclusions: Some experts recommend reporting rates of complex SSI to overcome the widely acknowledged detection bias associated with superficial incisional infection. Furthermore, it is necessary to compensate for case-mix differences in patient populations, to ensure that intrahospital comparisons are meaningful. Our results indicate that the NNIS risk index is a reasonable method for the risk stratification of complex SSIs for several commonly performed procedures.

Objective: To determine if surgical volume affects the risk of surgical site infections (SSI) in community hospitals., Background: The utility of public reporting and the optimal methods to employ when reporting SSI rates remain controversial and contentious issues. Studies examining the association between surgical volume and SSI risk have included few community hospitals and have reported conflicting results., Methods: A prospective study of surgical procedures performed at 18 community hospitals from January 1, 2004 to December 31, 2005, was performed. Hospitals were separated based on average surgical volume per year: small (<1500 procedures), medium (1500 < or = procedures < 4000), and large (> or =4000 procedures). The risk of SSI for each category was determined using multivariable Poisson regression., Results: Prospective surveillance identified 1434 SSIs after 132,111 surgical procedures (prevalence rate = 1.09/100 procedures). In unadjusted analysis, the risk of SSI was almost twice as high at small hospitals [prevalence rate ratio (PRR) = 1.9 (95% CI 1.78-2.05)] and large hospitals [PRR = 1.79 (95% CI 1.70-1.90)] compared with medium hospitals. After adjusting for differences between hospital category and important confounders, the risk of SSI at small hospitals was still 1.5 times higher than medium hospitals [adjusted PRR = 1.49 (95% CI 1.39-1.60)], whereas the risk at large hospitals was substantially decreased compared with medium hospitals [adjusted PRR = 1.29 (95% CI 1.22-1.36)]., Outcomes: The relationship between hospital surgical volume and rates of SSI in community hospitals is important and complex. As public reporting of SSI rates expands, improved methods for risk-adjusting infection rates are needed.

Bloodstream infection (BSI) due to multidrug-resistant Klebsiella is associated with high rates of morbidity and mortality. The aim of this study was to identify predictors of in-hospital mortality among patients with BSI due to ceftazidime-resistant (CAZ-R) Klebsiella pneumoniae at a tertiary care medical center. Patients with CAZ-R K. pneumoniae BSI were identified by our microbiology laboratory between January 1995 and June 2003. Clinical data were collected retrospectively. Logistic regression was used to identify independent predictors of all causes of in-hospital mortality. Of 779 patients with K. pneumoniae BSI, 60 (7.7%) had BSI due to CAZ-R K. pneumoniae; 43 (72%) of these were nosocomial infections. Pulsed-field gel electrophoresis identified a single predominant strain in 17 (28%) patients. The in-hospital mortality rate was 43% (n = 26). Among patients with CAZ-R K. pneumoniae BSI, those who died were similar to survivors with respect to demographic, clinical, and antimicrobial susceptibility characteristics. Only 43 (72%) patients received effective therapy within 5 days of BSI. In bivariable analysis, delay in initiation of effective therapy for >72 h after diagnosis of BSI was associated with death (P = 0.03). Strain genotype was not predictive of outcome. In multivariable analysis, delay in initiation of effective therapy for >72 h after diagnosis of BSI was an independent predictor of death (odds ratio, 3.32; 95% confidence interval, 1.07 to 10.3). Thus, among patients with BSI due to CAZ-R K. pneumoniae, a delay in the initiation of effective therapy of greater than 72 h after BSI was associated with a >3-fold increase in mortality risk.

Background: An increasing number of older persons undergo surgery, but the relationship between increasing age and risk of surgical site infection (SSI) has not been established. The objective of the present study was to determine the relationship between increasing age and risk of SSI., Methods: The present cohort study included patients who underwent surgery between February 1991 and July 2002. Patients >17 years of age were divided randomly into derivation and validation cohorts. The study was conducted at 11 hospitals. SSIs were prospectively identified by use of Centers for Disease Control and Prevention criteria., Results: The study included 144,485 consecutive surgical patients and 1684 SSIs (rate of SSI, 1.2%). There were 72,139 procedures and 873 SSIs in the derivation cohort. Adjusted analyses revealed a significant relationship between age and risk of SSI (P=.006). Risk of SSI increased by 1.1%/year between ages 17 and 65 years (P=.002). At age >/=65 years, risk of SSI decreased by 1.2% for each additional year (P=.008). There were 72,334 procedures and 811 SSIs in the validation cohort. The relationship between age and risk of SSI was similar in the validation cohort., Conclusions: Increasing age independently predicted an increased risk of SSI until age 65 years. At ages >/=65 years, increasing age independently predicted a decreased risk of SSI.

Background: This study evaluated the clinical and economic impact of the emergence of third-generation cephalosporin-resistant Enterobacter species., Methods: Mortality, length of hospitalization, and hospital charges were examined in a cohort that was selected from a group of 477 patients with initial cultures that yielded a third-generation cephalosporin-susceptible Enterobacter species. Case patients (n = 46) had subsequent cultures yielding a third-generation cephalosporin-resistant Enterobacter species. Control patients (n = 113) who did not develop resistance were matched to cases on site of Enterobacter infection and length of hospitalization prior to isolation of the initial susceptible organism. Multivariable analyses were used to adjust for confounding., Results: Twenty-six percent of cases died vs 13% of controls (P =.06). The median total hospital stay for cases was 29.5 days (interquartile range [IQR], 20-60) and 19 days for controls (IQR, 13-27; P<.001). The median hospital charge for cases was $79 323 (IQR, $34 546-$161 384) and for controls was $40 406 (IQR, $18 470-$79 005; P<.001). After adjusting for comorbidities, severity of illness, intensive care unit admission, surgery, transfer from another hospital, sex, and age, emergence of resistance was associated with increased mortality (relative risk, 5.02; P =.01), hospital stay (1.5-fold, P<.001), and hospital charges (1.5-fold, P<.001). Emergence of resistance had a median attributable hospital stay of 9 days and an average attributable hospital charge of $29 379., Conclusions: Emergence of antibiotic resistance in Enterobacter species results in increased mortality, hospital stay, and hospital charges. Minimizing resistance in Enterobacter species should be a priority.