Control Practices Advisory Committee Guidelines Research Articles

Usage-evaluation study on Vancomycin among hospitalized pediatric patients: Experience from two tertiary care centers of Eastern India

Background: Vancomycin is a highly effective bactericidal antibiotic with excellent efficacy against resistant Gram-positive microorganisms. It is losing its antimicrobial efficacy due to its rampant usage in Food and Drug Administration/Centers for Diseases Control and Prevention as well as off-label clinical uses. To stop its emerging resistance, judicious use of vancomycin following antibiotic stewardship is required. Aims: This study aims to examine the rationality of vancomycin use with respect to its adherence to Hospital Infection Control Practices Advisory Committee guidelines as well as its dosing, duration, adverse effects, and final outcome. Methodology: A retrospective cross-sectional hospital record-based study was conducted at two medical colleges of Eastern India from January 1, 2020, till June 30, 2020, incorporating all admitted newborns and children till 12 years’ age who received vancomycin for any clinical conditions. However, the patients with renal diseases or incomplete history were excluded from the study. Results: A cohort of 388 patients was included of which majority of them (41.2%) were in the age group of 2–12 years and males (56.9%). Sepsis (24.2%) and pneumonia (20.8%) were the most common indications for vancomycin prescription. Overall, appropriate usage of vancomycin was found in 57.2% of patients with maximum appropriate usage which was seen among neonates (64.5%). The areas of inappropriate usage were empirical therapy in febrile neutropenia, surgical prophylaxis, treatment of coagulase-negative Staphylococcal infection, and failure to withdraw vancomycin even after negative culture report for Gram-positive organisms. The final outcome in terms of clinical improvement was seen in 72.4% of patients irrespective of appropriate/inappropriate usage. Conclusion: Monitoring vancomycin usage should be followed in institutional practice to stop the emergence of resistance of vancomycin.

Update to the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Guideline for the Prevention of Surgical Site Infection (2017): A summary, review, and strategies for implementation

Surgical site infections remain a common cause of morbidity, mortality, and increased length of stay and cost amongst hospitalized patients in the United States. This article summarizes the evidence used to inform the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Guideline for the Prevention of Surgical Site Infection (2017), and highlights key updates and new recommendations. We also present specific suggestions for how infection preventionists can play a central role in guideline implementation by translating these recommendations into evidence-based policies and practices in their facility.

Introduction to the Centers for Disease Control and Prevention and Healthcare Infection Control Practices Advisory Committee Guideline for Prevention of Surgical Site Infection: Prosthetic Joint Arthroplasty Section.

Peri-prosthetic joint infection (PJI) is a severe complication of total joint arthroplasty that appears to be increasing as more of these procedures are performed. Numerous risk factors for incisional (superficial and deep) and organ/space (e.g., PJI) surgical site infections (SSIs) have been identified. A better understanding and reversal of modifiable risk factors may lead to a reduction in the incidence of incisional SSI and PJI. The Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recently updated the national Guideline for Prevention of Surgical Site Infection. The updated guideline applies evidence-based methodology, presents recommendations for potential strategies to reduce the risk of SSI, and includes an arthroplasty-specific section. This article serves to introduce the guideline development process and to complement the Prosthetic Joint Arthroplasty section with background information on PJI-specific economic burden, epidemiology, pathogenesis and microbiology, and risk factor information.

Evidence-Based Update to the U.S. Centers for Disease Control and Prevention and Healthcare Infection Control Practices Advisory Committee Guideline for the Prevention of Surgical Site Infection: Developmental Process.

Recommendations in the "Guideline for Prevention of Surgical Site Infection, 1999" were based on experts' selective interpretation of the scientific evidence. Effective 2009, the U.S. Centers for Disease Control and Prevention (CDC) and its Healthcare Infection Control Practices Advisory Committee (HICPAC) updated their guideline development process. This is a narrative summary of the updated process focusing on key changes and challenges specific to the Guideline for Prevention of Surgical Site Infection. The guideline development process now incorporates evidence-based methodology and provides explicit links between the evidence and the recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. There is also participation by professional surgical societies, an updated guideline structure (core and procedure-specific sections), additional planned related manuscripts (introductions to the guideline and research opportunities), and new proposed venues for publication. The new CDC and HICPAC "Guideline for the Prevention of Surgical Site Infection" represents a substantial advancement from recommendations for infection control practices based on expert opinion to evidence-based practices. The new structure is meant to facilitate future updates, in particular, those addressing specialty or procedure-specific surgical site infection prevention questions. Increased presence by the surgical community through the professional surgical societies' engagement in the guideline development process, lead authorship of related manuscripts, and proposed publication in the surgical literature not only increase adherence by the surgical community, but also promote an ongoing collaboration with public health and other partners in a multidisciplinary approach to SSI prevention.

On Contact Precautions: The Good, the Bad, and the Ugly

Affiliations: 1. Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina; 2. Duke Infection Control Outreach Network, Durham, North Carolina; 3. Department of Infectious Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Received December 5, 2013; accepted December 8, 2013; electronically published February 3, 2014. 2014 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2014/3503-0002$15.00. DOI: 10.1086/675295 Contact precautions are designed to reduce opportunities for pathogen transmission by direct and indirect contact with the patient or the patient’s environment. Contact precautions typically include patient placement in a private room, the wearing of gloves and gowns by healthcare personnel while in the room, and proper hand hygiene before room entry and after gloves are removed. Contact precautions have been demonstrated to be effective during outbreaks and, as a result, are widely used as an intensified control measure for multidrug-resistant organisms (MDROs) during outbreak situations. Target pathogens for implementation of contact precautions include methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), C. difficile, and multidrug-resistant gram-negative bacilli. There is no one way to implement contact precautions, however. The Healthcare Infection Control Practices Advisory Committee guideline for management of MDROs in healthcare settings does not specify precisely when to use contact precautions; the appropriate duration of contact precautions for patients who are colonized or infected with an MDRO is undefined; and the definition of an MDRO varies between facilities. Importantly, the use of contact precautions may lead to unintended consequences. Morgan et al identified 4 main adverse outcomes related to contact precautions: less patienthealthcare provider contact, changes in systems of care that produce delays and more noninfectious adverse events, increased symptoms of depression and anxiety, and decreased patient satisfaction with care. Since this review was published in 2009, other reports have confirmed these findings, while additional reports have added to the list of adverse outcomes due to contact precautions, including increased risk of delirium, hypoglycemia, hyperglycemia, and anticoagulant prescribing errors. In this issue, Dhar et al assessed 5 measures of compliance with contact precaution practices in 11 teaching hospitals. These measures included rates of hygiene prior to donning gloves/gowns, gowning, gloving, removal of gloves/gowns, and hand hygiene after gown/glove removal. We believe that readers should draw 2 main conclusions from their analysis. First, compliance with contact precautions was strikingly poor. Overall compliance with all 5 measures was only 28.9% after 1,103 observations. In a multivariate analysis, increasing burden of isolation was associated with (1) an increase in noncompliance with all 5 components of the recommended contact isolation practices and (2) an increase in noncompliance with hand hygiene prior to donning gloves and gowns. That is, not surprisingly, compliance with contact isolation decreased as the burden of isolation increased. Second, there was substantial heterogeneity in the different approaches to contact precautions among the study hospitals. For example, 4 sites required masks in addition to gowns and gloves, 4 sites included infectivity in their local criteria for use of contact precautions, and different hospitals required contact precautions for different organisms (eg, 7 hospitals required contact precautions for MRSA but only 4 for VRE). The multicenter approach and total number of observations are strengths of this study. Other strengths include the use of undercover observers and statistical controls to ensure that results were not driven by individual hospitals. Importantly, these data represent real-world research that confirms most epidemiologists’ fears. The authors acknowledge weaknesses of their study but fail to mention 4 additional problems. First, it is unclear how many observations occurred in the setting of a high (greater than 40%) burden of isolation. Given the wide confidence intervals of the estimate in their model, we presume that few observations occurred when the burden of isolation was high. Second, there was no assessment of interobserver reliability or description of the protocol used by the observers. Lack of such assessment may have biased the observed performance toward higher rates of compliance. Third, observations were excluded if one of the 5 activities were not observed, but it is unclear how many observations were excluded. Finally, overall compliance required

Identifying Antibiotic-Resistant Bacteria in Hospitalized Patients: What Is the Role of Active-Surveillance Cultures?

Antibiotic-resistant bacteria are an important cause of morbidity and mortality among hospitalized patients throughout the world. Controlling the emergence and spread of these organisms in healthcare settings requires multiple strategies, including strict attention to hand hygiene, vigilant disinfection of equipment and the environment, efforts to promote antimicrobial stewardship, and adherence to evidence-based bundles of care practices to prevent infections associated with the use of invasive devices such as central venous catheters and ventilators. Multiple studies have demonstrated that identification of patients who are colonized with organisms such as methicillin-resistant Staphylococcus aureus (MRSA)7 and vancomycin-resistant enterococci (VRE), in conjunction with the use of contact precautions when caring for those who are colonized, can reduce rates of colonization and infection with these bacteria. Active-surveillance cultures (ASCs) for these organisms are currently recommended for hospitalized patients at high risk of carriage. Questions remain, however, regarding which specific populations should be screened, the optimal screening method, and which organisms should be targeted for ASC. In this Q&A, 5 experts with different roles in infection prevention and microbiology [including adult (S.S.H.) and pediatric (A.M.M.) hospital epidemiologists from the US and Europe (S.H.), an infection preventionist (S.A.D.), and a microbiology laboratory director (A.J.M.)] have been asked to comment on several unresolved issues regarding the use of ASC as a strategy to prevent the transmission of multidrug-resistant organisms (MDROs) in hospitals. The 2006 Healthcare Infection Control Practices Advisory Committee guideline for the management of MDROs in healthcare settings notes that the target populations for ASC are not well defined. In what patient populations do ASCs make the most sense, and why are there differences between the “search and destroy” approach used in Europe and what is typically done in the United States? Susan Huang: ASC has been shown to be beneficial in high-risk hospitalized populations where …

Vancomycin-resistant enterococcus outbreak in a pediatric intensive care unit: report of successful interventions for control and prevention

The objective of this study is to retrospectively report the results of interventions for controlling a vancomycin-resistant enterococcus (VRE) outbreak in a tertiary-care pediatric intensive care unit (PICU) of a University Hospital. After identification of the outbreak, interventions were made at the following levels: patient care, microbiological surveillance, and medical and nursing staff training. Data were collected from computer-based databases and from the electronic prescription system. Vancomycin use progressively increased after March 2008, peaking in August 2009. Five cases of VRE infection were identified, with 3 deaths. After the interventions, we noted a significant reduction in vancomycin prescription and use (75% reduction), and the last case of VRE infection was identified 4 months later. The survivors remained colonized until hospital discharge. After interventions there was a transient increase in PICU length-of-stay and mortality. Since then, the use of vancomycin has remained relatively constant and strict, no other cases of VRE infection or colonization have been identified and length-of-stay and mortality returned to baseline. In conclusion, we showed that a bundle intervention aiming at a strict control of vancomycin use and full compliance with the Hospital Infection Control Practices Advisory Committee guidelines, along with contact precautions and hand-hygiene promotion, can be effective in reducing vancomycin use and the emergence and spread of vancomycin-resistant bacteria in a tertiary-care PICU.

Outcome of cefazolin prophylaxis for total knee arthroplasty at an institution with high prevalence of methicillin-resistant Staphylococcus aureus infection

The aim of this study was to evaluate the outcome of cefazolin prophylaxis for total knee arthroplasty (TKA) in a hospital with a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infection. Since July 1, 2006, we have applied a 'care bundle' to TKA to prevent surgical site infection (SSI) without using vancomycin as antimicrobial prophylaxis, in accordance with the 1999 Hospital Infection Control Practices Advisory Committee guidelines. All patients undergoing TKA from July 1, 2006 to September 30, 2009 were enrolled. We reviewed data on SSI collected prospectively as part of routine infection control surveillance. Of 1323 TKAs, an SSI developed in 14 (1.06%) cases, which is comparable to the percentage obtained in other previous reports. When stratified by the National Nosocomial Infection Surveillance risk index, SSI rates were 0.86% (8/926), 1.30% (5/384), and 7.69% (1/13) in risk categories 0, 1, and 2, respectively. Of 14 SSIs, four (29%) were classified as superficial incisional, two (14%) as deep incisional, and eight (57%) as organ-space SSI. Our data suggest that antimicrobial prophylaxis using only cefazolin can maintain low SSI rates if other important infection management measures are employed, even where there is a high prevalence of MRSA infection.

Vancomycin use in a brazilian teaching hospital: comparison with the Hospital Infection Controlpractices Advisory Committee Guidelines (HICPAC)

This study describes vancomycin prescribing patterns in an average complexity hospital and compare the guidelines proposed by the Hospital Infection Control Practices Advisory Committee (HICPAC). The study was conducted in a 256-bed secondary-care hospital. Data were collected of all patients given vancomycin from March 2003 to February 2004, using a standardized chart-extraction form designed. Appropriate and inappropriate use was reviewed according to the Hospital Infection Control Practices Advisory Committee (HICPAC) guidelines on prudent vancomycin use. Out of 118 prescriptions, 95 (80.5%) were considered appropriate. Out of these 95 orders, 77 (81.1%) were administered for empiric treatment of suspected Gram-positive infections, 17 (17.9%) were administered for treatment of proven Gram-positive infections (76.5% identified as Staphyloccocus aureus-like agents) and 1 (1.0%) for beta-lactam allergy. The majority of the patients (96.6%) had recently used an antimicrobial medication (3 months). The mean pre-treatment hospitalization period was 11+/-10 days. Out of the 118 treatments, 67 (56.8%) were for nosocomial infections. The more frequent indications for vancomycin use were pneumonia (48.3%) and primary sepsis (18.6%), accounting for more than 66% of all treatments. No restriction policy was suggested because vancomycin use was considered adequate in the majority of the treatment cases. The broad empiric use of this antimicrobial was greater than expected in the institution and its use should be revised.

Improvement in vancomycin utilization in adults in a Saudi Arabian Medical Center using the Hospital Infection Control Practices Advisory Committee guidelines and simple educational activity

To evaluate vancomycin utilization according to the adapted criteria of the Centers for Disease Control and Prevention (CDC) with a report of the effect of education program on the utilization. We evaluated the utilization of vancomycin over a 3-month period pre- and post-intervention using educational activity. In the pre-intervention period, of the 74 adult patients vancomycin was prescribed for specific treatment in 66% (n=49), empirical therapy in 26% (n=19) and as a prophylaxis in 8% (n=6). Vancomycin utilization was considered appropriate based on the CDC recommendations in 48 (65%) patients. Forty-seven (64%) patients received an appropriate dose regimen based on weight, age and creatinine clearance. Only 31% (n=23) of patients had both peak and trough levels taken around the third dose. In the post-intervention period, vancomycin was used as specific therapy in 41% (n=14) and empirically in 59% (n=20). Compliance with guidelines for empirical use of vancomycin improved from 21% in the pre-intervention phase to 85% after the intervention (P=.0001). In addition, compliance with vancomycin use in specific therapy was 100% compared to 82%. Compliance rate with vancomycin trough level monitoring increased from 35% in the pre-intervention period to 67.7% in the post-intervention period (P=0.0002). In conclusion, in addition to the utilization of CDC based criteria for vancomycin, we had shown that patient's chart review by a clinical pharmacists with a feed back to the physicians when guidelines were not met coupled with and educational efforts are effective methods to decrease inappropriate vancomycin usage.

Assessment of vancomycin use in chronic haemodialysis patients: room for improvement

Vancomycin is frequently prescribed for the management of infections in haemodialysis patients. We evaluated the appropriateness of vancomycin use in our chronic haemodialysis population. Charts of all chronic haemodialysis patients who received vancomycin between 1 March 2003 and 1 March 2004 were retrospectively reviewed. Indication was assessed according to the modified Hospital Infection Control Practices Advisory Committee guidelines for vancomycin prescription. The prescribed dosing regimens were evaluated. A total of 163 courses of vancomycin in 105 patients were assessed. Of all courses, 88% were considered to be initially appropriate, but this decreased to 63% once culture and sensitivity results were available. Use of vancomycin for the management of beta-lactam-sensitive organisms accounted for the majority of inappropriate use. The most common vancomycin-dosing regimen prescribed was 500 mg intravenously at each haemodialysis session (51%); however, considerable variability was observed. Although the initial indication for vancomycin use was generally appropriate, inappropriate continuation of this antibiotic, failure to obtain proper cultures to guide therapy and potentially subtherapeutic dosing regimens were some of the challenges identified. Centres providing chronic haemodialysis should take steps to optimize vancomycin prescription to improve clinical outcomes and reduce the risk of antimicrobial resistance.

An Antibiotic Order Form Intervention Does Not Improve or Reduce Vancomycin Use

To determine whether a paper-based antibiotic ordering system is an effective antibiotic stewardship measure. An antibiotic order form (AOF) was introduced in July 2001 at a pediatric tertiary care hospital. Vancomycin courses prescribed before and after the AOF introduction were retrospectively reviewed based on Hospital Infection Control Practices Advisory Committee guidelines. The impact of the AOF on the appropriateness of vancomycin prescribing was evaluated in univariate and multivariable analyses that adjusted for other factors associated with appropriateness of vancomycin use. The density of vancomycin use after introduction of the AOF was also assessed. Compliance with the AOF was poor (<50%) during the planned study period; therefore an additional 2 months of improved compliance (70-80%) were included. Rates of inappropriate vancomycin use increased during the study periods: 35% before AOF; 39% post-AOF; and 51% during the improved compliance period. On adjusted analysis, vancomycin utilization was significantly more inappropriate after introduction of the AOF. Vancomycin doses per 1000 patient days increased after introduction of the AOF. Inappropriate vancomycin use and vancomycin use overall increased after the introduction of an AOF. An AOF intervention did not have its intended effect of improving and reducing vancomycin use.

Implementing and evaluating a rotating surveillance system and infection control guidelines in 4 intensive care units

Background: In clinical practice, scientific evidence about infection control is often ignored and hygiene rituals are followed. Methods: Within an evidence-based infection control program, a quarterly rotating surveillance program for nosocomial infections was implemented in 4 intensive care units (ICUs) at the Aachen University Hospital, Germany. Results: For the first time, the unit-specific nosocomial infection situation was made clear to the clinical staff by interpretive feedback of the surveillance data. This led to an increased awareness of infection control and a critical review of hygiene practices. After the first surveillance period, the hygiene practices of each ICU were revised and modified. The Centers for Disease Control and Prevention/Hospital Infection Control Practices Advisory Committee guidelines for the prevention of nosocomial infections were adopted and established in tight collaboration with the ward staff. Conclusions: Within the surveillance process, communication and team spirit between infection control and patient care personnel showed a remarkable improvement. Awareness and compliance with hospital hygiene and infection control practices could be raised without directive interaction. (AJIC Am J Infect Control 2001;29:89-93)

Vancomycin Use in a University Medical Center: Comparison with Hospital Infection Control Practices Advisory Committee Guidelines

Vancomycin Use in a University Medical Center: Comparison with Hospital Infection Control Practices Advisory Committee Guidelines

Vancomycin Use in a University Medical Center: Comparison With Hospital Infection Control Practices Advisory Committee Guidelines

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Vancomycin Use in a University Medical Center: Comparison with Hospital Infection Control Practices Advisory Committee Guidelines

Vancomycin Use in a University Medical Center: Comparison with Hospital Infection Control Practices Advisory Committee Guidelines

Vancomycin use in a university medical center: comparison with hospital infection control practices advisory committee guidelines.

To compare actual vancomycin use in a hospital with the guidelines proposed by the Hospital Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention. One-month prospective survey of all patients given vancomycin. Data were collected from patient and laboratory records and discussions with prescribing physicians. Four hundred sixty-one-bed tertiary-care university hospital. Only 35% of the 101 vancomycin orders written during the audit were consistent with HICPAC guidelines. Twenty-eight patients were begun on vancomycin for the treatment of documented infections due to beta-lactam-resistant gram-positive bacteria or because preliminary culture results suggested such bacteria were present. Seven methicillin-resistant Staphylococcus aureus, two ampicillin-resistant enterococci, and 10 coagulase-negative staphylococci were recovered. Vancomycin use was judged inappropriate in 66 patients. The drug was used empirically without obtaining appropriate cultures (44 patients), as surgical prophylaxis (6 patients), for primary treatment of antibiotic-associated colitis (3 patients), for convenience in a hemodialysis patient (1 patient), or for other reasons not recommended by HICPAC (12 patients). Vancomycin use in our teaching center often was inconsistent with HICPAC guidelines. Information from the audit will be useful for designing strategies to improve vancomycin use.