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PubMed1998

Biofilms, infectious agents, and dental unit waterlines: a review.

Aquatic biofilms, which are widespread not only in nature but also in medical and dental devices, can be the source of serious nosocomial infections. In these hardy microbial communities, pathogens like nontuberculous mycobacteria, Pseudomonas aeruginosa, Legionella pneumophila, and other bacteria not only survive but proliferate and lie in wait for susceptible hosts. Not only are these organisms intrinsically resistant to high temperatures and biocides, but the biofilms they inhabit enhance their resistance. This should be of concern to infection control practitioners. The bacterial colonization of dental unit waterlines can be used as a model to investigate the problem of waterborne biofilms in health care settings.

Bacterial Infections↗

PubMed1997

Guidelines for prevention of nosocomial pneumonia. Centers for Disease Control and Prevention.

This document updates and replaces CDC's previously published "Guideline for Prevention of Nosocomial Pneumonia" (Infect Control 1982;3:327-33, Respir Care 1983;28:221-32, and Am J Infect Control 1983;11:230-44). This revised guideline is designed to reduce the incidence of nosocomial pneumonia and is intended for use by personnel who are responsible for surveillance and control of infections in acute-care hospitals; the information may not be applicable in long-term-care facilities because of the unique characteristics of such settings. This revised guideline addresses common problems encountered by infection-control practitioners regarding the prevention and control of nosocomial pneumonia in U.S. hospitals. Sections on the prevention of bacterial pneumonia in mechanically ventilated and/or critically ill patients, care of respiratory-therapy devices, prevention of cross-contamination, and prevention of viral lower respiratory tract infections (e.g., respiratory syncytial virus [RSV] and influenza infections) have been expanded and updated. New sections on Legionnaires disease and pneumonia caused by Aspergillus sp. have been included. Lower respiratory tract infection caused by Mycobacterium tuberculosis is not addressed in this document. Part I, "An Overview of the Prevention of Nosocomial Pneumonia, 1994, provides the background information for the consensus recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC) in Part II, Recommendations for Prevention of Nosocomial Pneumonia." Pneumonia is the second most common nosocomial infection in the United States and is associated with substantial morbidity and mortality. Most patients who have nosocomial pneumonia are infants, young children, and persons > 65 years of age; persons who have severe underlying disease, immunosuppression, depressed sensorium, and/or cardiopulmonary disease and persons who have had thoracoabdominal surgery. Although patients receiving mechanically assisted ventilation do not represent a major proportion of patients who have nosocomial pneumonia, they are at highest risk for acquiring the infection. Most bacterial nosocomial pneumonias occur by aspiration of bacteria colonizing the oropharynx or upper gastrointestinal tract of the patient. Because intubation and mechanical ventilation alter first-line patient defenses, they greatly increase the risk for nosocomial bacterial pneumonia. Pneumonias caused by Legionella sp., Aspergillus sp., and influenza virus are often caused by inhalation of contaminated aerosols. RSV infection usually occurs after viral inoculation of the conjunctivae or nasal mucosa by contaminated hands. Traditional preventive measures for nosocomial pneumonia include decreasing aspiration by the patient, preventing cross-contamination or colonization via hands of personnel, appropriate disinfection or sterilization of respiratory-therapy devices, use of available vaccines to protect against particular infections, and education of hospital staff and patients. New measures being investigated involve reducing oropharyngeal and gastric colonization by pathogenic microorganisms.

Aspergillosis↗

PubMed1991

Infection control: the premier quality assessment program in United States hospitals.

The three decennial international meetings of the Centers for Disease Control have reaffirmed the national health priority for prevention of nosocomial infections. Moreover, the past 20 years have seen the institutionalization of the infection control practitioner and hospital epidemiologist. The epidemiologic activities of these two groups have included access to medical care, identification of risk factors, and both prevention and control of adverse nosocomial events. As such, they represent experience with issues commonly referred to as quality of care. It is argued that infection control not only is now but has been from its inception the premier quality assessment program in the United States. Moreover, it is the only activity in quality assessment that has been shown to be efficacious.

Cross Infection↗

PubMed2004

Direct costs of multidrug-resistant Acinetobacter baumannii in the burn unit of a public teaching hospital.

We conducted a case-control study to determine the attributable direct costs of multidrug-resistant Acinetobacter baumannii (MDRAB) in the burn unit of a public teaching hospital. The mean total hospital cost of patients who acquired MDRAB was 98,575 dollars higher than that of control patients who had identical burn severity of illness indices ( P <.01). These data should help infection control practitioners and others determine the cost-effectiveness of specific interventions designed to control this emerging nosocomial pathogen.

Acinetobacter Infections↗

PubMedDate not supplied

Universal precautions: improving the knowledge of trained nurses.

Universal precautions relate to the management of blood-borne viruses such as human immunodeficiency virus (HIV) and hepatitis B and C. Advice on the transmission of blood-borne viruses and the precautionary measures used to reduce or eliminate cross-infection have been addressed by national and professional bodies. There is a significant amount of research which assesses trained nurses' knowledge of universal precautions and includes understanding of the transmission routes of blood-borne viruses and the measures required to prevent cross-infection. However, the majority of the literature indicates an incomplete knowledge among trained nurses of the principles and application of universal precautions. The ability of the trained nurse to fulfil his/her role as health educator, teacher and therefore effective infection control practitioner is questioned by the literature. This article discusses the role of education in improving the knowledge of trained nurses and considers the implementation of in-service training and preregistration education.

Body Fluids↗

PubMed1999

Characterization and proposed nomenclature of epidemic strains of methicillin-resistant Staphylococcus aureus in Canada.

We hope that standardized nomenclature for identifying epidemic MRSA strains prevalent in Canadian hospitals will be helpful to physicians and infection control practitioners attempting to understand and control the spread of the organism in health-care facilities. It is anticipated that as MRSA continues to evolve in Canadian health-care facilities other strains may be recognized as "epidemic"; as these strains become better characterized they may be added to those designated above. Laboratory physicians and infection control personnel are invited to submit strains that may warrant characterization and designation as a Canadian epidemic strain to the Laboratory Centre for Disease Control, Health Canada, Winnipeg, Manitoba.

Canada↗

PubMed1989

Sporadic bacteremia complicating central venous catheter use in a community hospital: a model to predict frequency and aid in decision-making for initiation of investigation.

Sporadic bacteremia complicating single-lumen central venous catheter (CVC) use was prospectively recorded in a community hospital in 1981 and 1982. Sixty-four of 1258 (5.1%) patients had definite bacteremia. A nested case-control study was then undertaken to identify predictive risk factors. Fifteen statistically significant factors found in the 1981 cohort were tested in the 1982 cohort, and four remained significant for both years. Univariate and multiple logistic regression analysis on both years' findings, separately and together, identified two independently associated factors: diagnosed respiratory colonization/infection (p less than 0.0001) and serum albumin level (p less than 0.001). Based on these factors, an equation was developed to express the probability of bacteremia. Solving this equation provides an infection control practitioner with an expected rate of bacteremia that complicates CVC use and provides an aid for decision-making for investigation in the absence of clusters.

Catheterization, Central Venous↗

PubMed1999

A decade of prevalence surveys in a tertiary-care center: trends in nosocomial infection rates, device utilization, and patient acuity.

OBJECTIVE: To evaluate the usefulness of repeated prevalence surveys to determine trends in the rates of nosocomial infections and to detect changes in risk factors (e.g., use of invasive devices) associated with nosocomial infections. PATIENTS AND METHODS: Ten annual prevalence surveys were conducted by trained infection control practitioners between 1985 and 1995 for acute-care patients on the medical, surgical, pediatric, and obstetric-gynecologic services at a 900-bed, tertiary-care, teaching hospital with 750 acute-care beds. The same methods of chart review and concurrent reporting from nursing, the microbiology and clinical laboratory, and the pharmacy were used each year to collect data on the prevalence of nosocomial infections, invasive-device utilization, and abnormal laboratory indicators. Although data were collected on a single day, a period-prevalence study approach was used, because charts were reviewed for any infection data occurring within the 7 days prior to the survey. RESULTS: The hospital census for acute care patients, as measured by the prevalence surveys, declined sharply over the 10 years, from 673 to 575 patients (P = .02). However, the medical service census increased from 150 to 188 patients (P = .01). During the same period, there was a significant decrease in the mean length of stay, from 7.3 to 6.0 days (P = .01), and a concomitant increase in the mean diagnosis related-group case-mix index, from 1.03 to 1.24 (P = .001). Overall, nosocomial infection rates remained unchanged over the study period (mean of 9.85 infections per 100 patients), but rates of nosocomial bloodstream infection increased from 0.0% in 1985 to 2.3% in 1995 (P = .05). Nosocomial infection rates were significantly higher on the medical and surgical services than on other services (P<.001). Utilization rates increased significantly for Foley catheters (9.0% to 16.0%, P = .002) and ventilators (5.0% to 8.0%, P = .05). CONCLUSIONS: Despite apparent increases in the severity of illness of our patients, overall rates of nosocomial infection remained stable during a decade of study. Rates of nosocomial bloodstream infection increased, in parallel with National Nosocomial Infection Surveillance System data. We found repeated prevalence surveys to be useful in following trends and rates of infection, device utilization, and abnormal laboratory values among patients at our institution. Such methodologies can be valuable and low-cost components of a comprehensive infection surveillance, prevention, and control program and other potential quality-improvement initiatives, because they enable better annual planning of departmental strategies to meet hospital needs.

Adolescent↗

PubMed1988

Surgical complications related to insertion of penile prostheses with emphasis on infection and cost.

We initiated a prospective study of penile prosthesis implant surgery to evaluate risk factors for infection and other complications. Twenty-one patients admitted for surgery or related complications were evaluated over a seven-month period. The two types of penile prostheses implanted were (1) inflatable and (2) semi-rigid. Nine of 21 patients (43%) developed postoperative complications. Although cephapirin and gentamicin were given prophylactically, four of nine patients had four wound infections and one case of pneumonia. One case of Bacteroides fragilis bacteremia was due to stool incontinency during surgery. In two of the wound infections, removal and reinsertion of the prosthesis was necessary. Other complications included hypotension during surgery, prosthesis malfunction and malposition, and urethral tears. There were no significant associations between infection and age, length of surgery, or type of prosthesis used. These complications contributed to prolonged hospital stay and readmission (87 extra days for the infected patients at a cost of $44,000). Antibiotic costs to treat the infections totaled $1,900. Prospective evaluation by infection control practitioners of various elective surgeries can be useful in quantitating the complication rate and targeting patients at risk, with the goal of minimizing hospital costs.

Cephapirin↗

PubMed1994

Latex allergies: a new infection control issue.

The incidence of latex allergies has been increasing steadily in health care workers over the past few years. It is now thought to be somewhere between 6 and 14%. It has been suggested that this is directly attributable to the increased use of latex gloves by health care workers. Infection control practitioners (ICPs) have responsibilities not only to the patient population but also to the staff. Compliance with universal precautions cannot be expected if the allergy issue isn't dealt with. Education and screening are the first tools of prevention. In cases where it is too late for prevention, guidelines must be provided for allergic patients and staff, and nonlatex equipment must be made accessible as necessary. In order to do this, ICPs must be knowledgeable about products containing latex and the available alternatives. The issue of airborne particles and allergic staff remains somewhat controversial but the idea of maintaining a latex-free environment in extreme circumstances must at least be considered. This is an infection control issue and ICPs can make a difference.

Gloves, Protective↗

PubMed2001

Screening for methicillin-resistant Staphylococcus aureus in the endemic hospital: what have we learned?

Control of methicillin-resistant Staphylococcus aureus (MRSA) still generates controversy among infection control practitioners. Opponents claim that once MRSA becomes endemic in an institution, control efforts are no longer justified. This review examines the usefulness, feasibility and cost-effectiveness of control programmes in acute-care hospitals where eradication of MRSA has either failed or has never been attempted; hence, the pathogen has become endemic. High endemicity is associated with increased hospital-acquired infection rates, increased use of glycopeptides and subsequent risk of emergence of antibiotic-resistant Gram-positive bacteria, and additional healthcare costs. Thus, MRSA control has many advantages. Indeed, in many institutions the actual benefit of containment efforts was manifested through the resultant decrease in the incidence of hospital-acquired MRSA infections. Successful programmes are based on an early identification of the MRSA reservoir and prompt implementation of contact precautions. The most efficacious strategy to detect occult MRSA carriage is via the screening of high-risk patients on admission to the hospital which has proven to be cost-effective in varied acute-care endemic settings.

Acute Disease↗

PubMed1990

Methicillin-resistant Staphylococcus aureus: a descriptive analysis on veterans.

Concern over complications of a potentially large outbreak of methicillin-resistant Staphylococcus aureus (MRSA) prompted intensive monitoring and establishment of effective communication lines between infection control practitioners, nurses, physicians, and microbiology personnel. From October, 1986, through September, 1987, 77 patients at the Veterans Administration Medical Center in Oklahoma City had MRSA. Charts were available for review on 63 of these patients. When those with charts available were reviewed, 41 patients had nosocomial (NC) and 22 had community-acquired (CA) MRSA. Of the 41 NC patients, 34 were infected (of which 17 died during hospitalization) and 7 colonized (3 died). Of the 22 CA patients, 15 were infected (4 died) and 7 colonized (2 died). Length of stay was NC-infected, mean 51.8 days; NC-colonized, 38.9 days; CA-infected, 14.9 days; and CA-colonized, 16.1 days. This study shows the importance of NC MRSA, especially as it relates to hospital costs and care of many extended stay patients.

Aged↗

PubMed1994

Application of cost-effectiveness methodology to the consideration of needlestick-prevention technology.

Data from the study of needlestick-prevention devices in 10 New York State hospitals enabled application of cost-effectiveness analysis techniques for determining relative benefits of various safety interventions. This article introduces to infection control practitioners several economic concepts related to cost-effectiveness methodology and provides two examples of how they may be applied for decision-making purposes. A critical aspect of the analysis described is the determination of a base cost of needlestick injury. By applying decision analysis to experience-based data aggregated from participating institutions, base expected cost of needlestick injury was determined to be $363.

Cost-Benefit Analysis↗

PubMed2004

Preliminary assessment of an automated surveillance system for infection control.

BACKGROUND AND OBJECTIVE: Rapid identification and investigation of potential outbreaks is key to limiting transmission in the healthcare setting. Manual review of laboratory results remains a cumbersome, time-consuming task for infection control practitioners (ICPs). Computer-automated techniques have shown promise for improving the efficiency and accuracy of surveillance. We examined the use of automated control charts, provided by an automated surveillance system, for detection of potential outbreaks. SETTING: A 656-bed academic medical center. METHODS: We retrospectively reviewed 13 months (November 2001 through November 2002) of laboratory-patient data, comparing an automated surveillance application with standard infection control practices. We evaluated positive predictive value, sensitivity, and time required to investigate the alerts. An ICP created 75 control charts. A standardized case investigation form was developed to evaluate each alert for the likelihood of nosocomial transmission based on temporal and spatial overlap and culture results. RESULTS: The 75 control charts were created in 75 minutes and 18 alerts fired above the 3-sigma level. These were independently reviewed by an ICP and associate hospital epidemiologist. The review process required an average of 20 minutes per alert and the kappa score between the reviewers was 0.82. Eleven of the 18 alerts were determined to be potential outbreaks, yielding a positive predictive value of 0.61. Routine surveillance identified 5 of these 11 alerts during this time period. CONCLUSION: Automated surveillance with user-definable control charts for cluster identification was more sensitive than routine methods and is capable of operating with high specificity and positive predictive value in a time-efficient manner.

Cross Infection↗

PubMed1997

Sentinel system for nosocomial infections in The Netherlands: a pilot study.

OBJECTIVE: To determine the feasibility of standardized surveillance of nosocomial infections (NI) in The Netherlands, using local data on patients with NI collected by infection control practitioners (ICPs) and denominator data on all patients under surveillance obtained from the Dutch National Medical Registry (LMR). DESIGN: A prospective, multicenter study. SETTING: Eight hospitals in the Utrecht region, and the National Institute of Public Health and the Environment. PATIENTS: ICPs traced NI in gynecological and orthopedic patients for 9 to 16 months. Denominator data on all patients under surveillance were obtained from the LMR. RESULTS: Data from 8,922 patients were collected; the ICPs registered 470 patients with 526 NI. Overall, the NI incidence was 5.9 per 100 patients, or 6.3 per 1,000 patient days. Urinary tract infections (UTI) were most frequent (3.3%), followed by surgical-wound infections (SWI; 2.0%) and bloodborne infections (0.12%). The incidence of both SWI and UTI differed markedly between hospitals, only partially on account of differences in patient mix (age, type of operations), antibiotic prophylaxis, and intensity of tracing methods for NI. Delay in the availability of denominator data hampered the timely feedback of incidence figures. CONCLUSIONS: Surveillance of NI in a network of sentinel hospitals offered valuable information on the occurrence of NI and on factors influencing the incidence of NI. It revealed situations in which both NI surveillance and infection control methods in individual hospitals should be improved. Obtaining denominator data on all patients from electronically registered patient discharge data greatly reduces the workload of ICPs and enables surveillance on all types of NI (all body sites and all pathogens). For timely feedback, numerator and denominator data within hospitals must be linked.

Adult↗

PubMed2004

A comparison of competing methods for the detection of surgical-site infections in patients undergoing total arthroplasty of the knee, partial and total arthroplasty of hip and femoral or similar vascular bypass.

Recent research suggests that the retrospective review of the International Classification of Disease (ICD-9-CM) codes assigned to a patient episode will identify a similar number of healthcare-acquired surgical-site infections as compared with prospective surveillance by infection control practitioners (ICP). We tested this finding by replicating the methods for 380 surgical procedures. The sensitivity and specificity of the ICP undertaking prospective surveillance was 80% and 100%, and the sensitivity and specificity of the review of ICD-10-AM codes was 60% and 98.9%. Based on these results we do not support retrospective review of ICD-10-AM codes in preference prospective surveillance for SSI.

Arthroplasty, Replacement, Hip↗

PubMed2005

[Consumption of hand-hygiene products in health establishments in the west of France].

OBJECTIVES: The study had for aim to investigate hand hygiene product use in French hospitals between 2000 and 2003. DESIGN: A questionnaire was sent in 2002 and 2 more in 2003 and 2004 (for 2000 to 2003) requiring data on type of hospital, number of beds, staff members, admissions and patient-day, litres of mild soap, antiseptic soap and alcohol-based rub used and price per litre. Indices were calculated accordingly. RESULTS: 574 hospitals answered over the 4 year period (average 143 per year) representing an average of 50 000 beds/year, 80 000 full-time staff positions, 1.2 million admissions and 16 millions patient-days. The median consumption of mild soap was 3.8 l per bed, 2.7 l per staff member, 2.4 l per 100 admissions, and 10.6 ml per patient-day. The median consumption of antiseptic soap was 1 l per bed, 0.8 l per staff member, 4.8 l per 100 admissions, and 3.2 ml per patient-day. The median consumption of alcohol-based rub (HAS) was 0.3 l per bed, 0.3 l per staff-member, 1.5 l per admission, and 0.9 l per patient-day. Between 2000 and 2003, HAS use significantly increased from 69 to 88% (a relative increase of 31%) and the median consumption increased from 0.5 ml to 1.5 ml per patient-day. 370 fully completed grids gave a number of 7 opportunities per patient-day with less than 1 for HAS. CONCLUSION: The best indicator for an infection control practitioners is the quantity of alcohol-based solution in ml/patient-day and HAS per patient-day is the reference.

Alcohols↗

PubMed2001

Infection control considerations during construction activities: land excavation and demolition.

Because current trends in hospital restructuring in North America, amalgamations and mergers, and the aging of health care facilities, the need to restructure physical buildings has become greater. Hospital construction carries with it risks to patients. One key concern is the risk of aspergillosis associated with hospital construction. Infection control practitioners must consider some key factors when addressing land excavation and building demolition, which differ in some ways from construction that occurs within a health care facility. The key factors to consider are project concept, risk assessment of patients, procedures and environment, air quality, routes of entry and egress, soil management, conducting inspections, contingency planning, housekeeping, and lines of cooperation and communication with various stakeholders. Considering these areas will help ensure that health care facility personnel and the workers have exercised diligence in patient care.

Aspergillus↗