National Nosocomial Infections Surveillance System Research Articles

Return to the fundamentals: Implementing best practice reduces cardiac bypass surgical site infection rates

BACKGROUND/OBJECTIVES: Surgical site infections (SSIs) are associated with increased morbidity and mortality and prolonged hospital stay. Risk for SSIs is associated with breaks from best practice recommendations promulgated by the Centers for Disease Control and Prevention (CDC) and endorsed by many other surgery-associated organizations. In 2002, routine SSI rates for coronary artery bypass grafts (CABGs) were over the National Nosocomial Infections Surveillance System (NNIS) 90th percentile. Rates for donor graft sites (leg) and the sternums were both too high. Cultures obtained from the former site grew largely gram-negative rods or were polymicrobial, and those from the latter site grew gram-positive organisms. METHODS: This 1000-bed tertiary-care hospital in Baltimore, Maryland, does approximately 600 CABGs each year. Best practices, including education of nurses, physician assistants, and surgeons, were implemented over a 2-year period to increase awareness of the data supporting these practices and compliance. Interventions included use of 2% chlorhexidine showers for patients the evening prior to and morning of CABG to reduce their bacterial burden. The pre-surgical skin prep in the operating room was changed to an alcohol/betadine combination for prepping. A water-free surgical hand scrub, as well as additional cleaning of the patient's groin area prior to individual leg skin prep, were instituted as well. Prophylactic antimicrobial choice and the timing were optimized and the use of flash sterilization decreased. RESULTS: The SSI rates for CABG procedures went from a high of 12.16 infections/100 cases in the first quarter of 2003 to a low of 5.15 infections/100 cases in the third quarter of 2004. This represents a 58% decrease in SSI for CABG in a period of approximately 18 months and translates into a minimum cost savings of $153,799. CONCLUSIONS: Interventions to prevent SSIs take a long time and a great deal of work and must be endorsed by many people. Implementation of the best practices within the cardiac surgery department resulted in a significant decrease in SSI (p = 0.02) and cost savings of $153,799. Continual reinforcement of best practices is needed to maintain a safe patient environment.

Perceptions of organizational climate by intensive care unit (ICU) nurses: Preliminary results from the ICU Working Conditions Study

OBJECTIVES: Due to the complexity of patients' illnesses and reportedly difficult working conditions, ICUs are potentially dangerous places for both patients and nurses. Organizational climate (OC) is frequently identified as an important working condition factor related to nurse retention and safety outcomes. The specific aims of this study include examining the relationships between nurse working conditions and patient and employee safety outcomes and identifying predictors (i.e., staffing ratios, nurses' income, workload, and setting characteristics) that influence the OC perceived by nurses. METHODS: Because healthcare-associated infections are a major patient safety outcome, hospitals were invited to participate through the Association of Professionals in Infection Control and Epidemiology, Inc., (APIC) electronic list and the National Nosocomial Infections Surveillance System (NNIS). Administrative data on nurse working conditions and employee safety were collected. In addition, patient-level data came from Medicare files and infection surveillance reports. ICU nurses were surveyed to understand their perceptions of OC. RESULTS: Infection control professionals from 68 hospitals in 26 states enrolled 110 ICUs. Surveys were obtained from 2323 ICU nurses (mean response rate=41%/ICU). The average nurse respondent was 39.5 years old (SD=9.4), had 15.6 years (SD=9.2) experience in healthcare, and had worked in their current position for 8.0 years (SD=7.5). Overall, 17% (n=391) of the nurses indicated they intended to leave their positions in the coming year. Because not every hospital provided all requested data, this multivariable analysis of predictors that influenced OC perceived by ICU nurses consisted of data from 27 ICUs from 17 hospitals. After controlling for staffing ratios, nurses' income and workload had significant independent positive effects on OC, as did NNIS affiliation. Hospital teaching status had a significant negative effect on OC (all p values <0.05). CONCLUSIONS: These findings may help hospitals to design and implement strategies aimed at improving the OC in their setting, which may ultimately result in improved patient and employee outcomes. While market solutions (e.g., wage increases) may help, they are not the only solutions. Ensuring appropriate nurse workloads may improve the OC. Multivariate analyses relating OC to safety outcomes are being conducted and should further inform these issues.

A multidisciplinary approach towards the reduction of ventilator-associated pneumonia (VAP)

ISSUE: VAP is the second most frequent healthcare-acquired infection and contributes to significant morbidity and mortality, with an added cost of up to $40,000 per patient. Multiple studies have been published that show significant reduction in VAP rates with a multidisciplinary team approach targeted on risk-reduction strategies. Infection control (IC) surveillance for April-June 2004 (Q2) showed high VAP rates in the 25-bed medical-surgical intensive care unit (ICU), 19-bed neuro-critical care unit (NCCU), and 16-bed coronary care unit (CCU), as compared to the National Nosocomial Infection Surveillance System (NNIS) used for benchmarking at our 478-bed acute care level II trauma facility. PROJECT: As part of a multidisciplinary taskforce, IC worked collaboratively with the critical care committee and the respiratory therapy (RT) department toward implementation of a ventilator bundle. This included a comprehensive oral care protocol (OCP) along with other evidence-based practices, including elevation of the head of the bed to >30 degrees, daily sedation holiday, and daily assessment of readiness to extubate. In September 2004, RT assumed responsibility for performing 2-hourly OCP using a dilute hydrogen peroxide solution, oropharyngeal suctioning every 6 hours, and sharing responsibility for brushing every 12 hours with nursing. Steps were taken to ensure bedside availability of the OCP kit. A comprehensive education campaign was undertaken to disseminate the practice recommendations and to emphasize hand hygiene, adherence to contact precautions, and proper disinfection measures. Compliance was assessed and reinforced during daily multidisciplinary rounds by the nurse managers and random rounds by IC, with frequent feedback to nursing and medical staffs. RESULTS: Our performance improvement initiatives resulted in significant reduction in VAP rates, from 21/1523 ventilator days in Q2 to 3/1734 ventilator days for October-December 2004 (Q4), a decrease of 26% (range 18-100%; p < 0.05). From Q2 to Q4, the unit-specific VAP rates per 1000 ventilator days decreased from 13.18 to 2.36 for ICU, from 17.24 to 0.0 for CCU, and from 12.01 to 2.96 for NCCU (p < 0.001 for all three units), all well below the 2003 NNIS benchmark (p < 0.001). LESSONS LEARNED: Implementation of a collaborative effort led to a significant VAP rate reduction in our three adult critical care units, especially after RT assumed ownership for implementation of the OCP.

Implementation and establishment of nationwide surgical site infections surveillance in Japan

ISSUE: There used to be no database against which hospitals can compare their surveillance data for surgical site infections (SSIs). In 1998, the Japanese Nosocomial Infections Surveillance (JNIS) system was established by adopting the U.S. National Nosocomial Infection Surveillance System (NNIS). Its aim was to create the database of SSIs in Japan through surveillance. PROJECT: Hospitals that were willing to submit data were invited to participate in this project. Data collection began in 1999. Data were submitted via e-mail, using Excel™ spreadsheets. Feedback was given about once a year by paper reports to each hospital. RESULTS: The number of participating hospitals increased from eight in 1999 to about 80 by the end of 2004. A total 20,948 cases were surveyed from November 1998 through December 2003. The primary operative procedure was abdominal surgery because the persons responsible for surveillance are mainly gastrointestinal surgeons. Unlike in the United States, in Japan there are insufficient numbers of certified infection control practitioners, and surgeons are interested in performing surveillance on their own. Risk stratification is a necessary factor comparing hospital data against data in the JNIS system. We used the NISS SSI risk index system and it suited our data. On other hand, we modified system by dividing large bowel operation (COLO) into two different categories (COLN for colon, and REC for rectum) because many Japanese surgeons think that the risk of SSIs is lower for colon surgery than for rectal surgery due to differences in anatomy and the complexity of the operations. The overall SSI rates in COLN and REC procedures were 14.8% and 17.3%, respectively. Even though the difference was not statistically significant (p=0.12, chi square test), it seemed to support the surgeons' perceptions. Also, the SSI rate for esophageal operations, which we separated, was 21.6% (19/43) and much higher than that of OGIT category (5.2%), where it is included in the NNIS system. Feedback data included SSI rates by procedure and by other factors such as age, gender, and SSI rate-stratified NISS risk index. Questionnaires sent out in 2003 showed overall satisfaction among participating hospitals. LESSONS LEARNED: A nationwide SSI surveillance system was implemented in Japan, and we were able to create a national reference data in the past 5 years.

Device-associated nosocomial infection rates in intensive care units in an Italian hospital

OBJECTIVES: To measure the incidence of device-associated nosocomial infections (NI) in intensive care units (ICUs). To measure days of extra length of stay (ELOS). METHODS: We performed a prospective NI surveillance study in three ICUs of one private hospital in Milan, Italy. NIs were identified using the Centers for Disease Control and Prevention's National Nosocomial Infections Surveillance System (NNIS) definitions. We calculated ELOS by subtracting nosocomial average length of stay (ALOS) of patients with and without NI. RESULTS: From November 2003 to March 2004 (5 months), we enrolled 273 patients, 1151 bed days (BD), 1512 central vascular catheter (CVC) days, 673 mechanical ventilator (MV) days, and 1107 urinary catheter (UC) days. The overall NI rate was 9.9% (27/273) and 23.5 (27/1512) per 1000 BD. The most common site of NI was MV-associated pneumonia (40.7%, or 11/27), and CVC-associated laboratory-confirmed bloodstream infection and clinical sepsis (LCBI and CSEP) (40.7%, or 11/27), followed by UC-associated urinary tract infection (UTI) (18.5%, or 5/27). Pneumonia rate was 16.3 (11/673) per 1000 MV days. The ALOS with pneumonia was 16.7; the ALOS without NI was 2.7 with 14.0 days of ELOS. BSI rate was 7.3 (11/1512) per 1000 CVC days. The ALOS with bloodstream infection (BSI) was 18.8, representing 16.0 days of ELOS. UTI rate was 4.5 (5/1107) per 1000 UC days. The ALOS with UTI was 14.0, representing 11.3 days of ELOS. CONCLUSION: Our infection control program must continue to be aimed at invasive device-associated nosocomial infections. A patient with BSI increases ALOS by 16 days; 14 days for UTIs, and 11.3 days increase for pneumonia.

Blue Ribbon Abstract Award: Standardization of the central venous catheter insertion process reduces catheter-associated bloodstream infections in a university hospital medical intensive care unit

ISSUE: Use of central venous catheters (CVC) has been associated with increased incidence of bloodstream infections (BSIs). We set out to decrease the rate of CVC-associated BSI (CVC-BSI) by implementing a multifaceted intervention that included provider education, a standardized insertion checklist, and real-time performance feedback. PROJECT: Our institution defines CVC-BSI using National Nosocomial Infections Surveillance (NNIS) system criteria. During the year prior to the intervention (October 2001 to September 2002), our 14-bed medical intensive care unit (MICU) had a CVC-BSI rate of 7.6/1000 central line days. Based upon published guidelines, a multidisciplinary team developed a mandatory online tutorial and examination for medical and nursing staff. At each CVC insertion or guidewire exchange, the bedside nurse completed a standardized checklist that identified evidence-based insertion behaviors. The checklists were scanned into a computerized database, allowing rapid data entry. Real-time performance feedback reports were generated, and the MICU staff and physicians were provided unit specific data at the start of each month and 3 weeks later to allow resident physicians, who rotate monthly, to review their data and adjust their practice as needed. This collaborative intervention was designed to be educational and not punitive in nature. RESULTS: Following implementation in October 2002, the intervention has been used for 701 CVC insertions. The CVC-BSI rate for lines impacted by this study decreased to a 2004 rate of 1.9/1000 central line days. There have been two periods of greater than 200 days each between CVC-BSI. Positive feedback from this intervention has led to its acceptance and continued use for more than 2 years. MICU is proud of the low BSI rate and works to maintain it. LESSONS LEARNED: Using a standardized intervention aimed at CVC insertion reduces CVC-BSI rates. Development of a successful program requires cooperation and buy-in from physicians as well as nursing staff to effect change. Use of a standardized form provides data for process improvement as well as documentation for the medical record. The observation checklist is available in the electronic medical record. Due to the continued success in the MICU, we started implementing the intervention in all critical care areas in 2004.

Surveillance of selected bowel surgeries for surgical site infection (SSI) rates in-hospital plus post-discharge

BACKGROUND: This health center is a 750-bed tertiary-care community hospital. Surveillance data from October 2002 through September 2004 on selected bowel surgeries were analyzed to determine SSI rates in-hospital plus post-discharge. METHODS: The automated infection control expert (AICE) program was interfaced with the operating room's computer program to generate a record on each selected surgical patient. To collect SSI data, the infection control practitioner (ICP) reviewed culture and sensitivity reports, emergency and urgent care visits, re-admissions, consult notes, antibiotic prescribing, and patient charts. Quarterly reports of patient lists were sent by the ICP via intra-hospital computer, e-mail, or letter to the responsible surgeon for post-discharge SSI feedback. Each patient's record was completed with the remaining data, including any 30-day post-op SSI information, and entered into AICE. The ICP collected data by incorporating a PDA (personal digital assistant) and uploading into AICE. RESULTS: There were 596 selected bowel surgeries that included abdominal perineal resections (29), bowel resections lithotomy (203), bowel resections supine (272), Hartmann procedures (43), and laparoscopic colon resections (49). The SSI rate for in-hospital plus post-discharge from October 2002 through September 2003 was 69/272 (25%) and from October 2003 through September 2004, was 69/324 (21%). The ICD-9 codes listed for the National Nosocomial Infection Surveillance (NNIS) system report for colon surgeries are extensive which limits study comparison. There were 88/596 (15%) SSIs detected in-hospital and 50/596 (8%) SSIs detected post-discharge. Compliance with post-discharge surveillance by surgeons was 73% (8/11). CONCLUSIONS: The in-hospital plus post-discharge surveillance is a more accurate reflection of SSI rates. Comparing SSI rates to consecutive years of data and not to NNIS were determined. A process for consistent pre-operative antibiotic prophylaxis was initiated in the second year. Opportunities to initiate further strategies to improve SSI rates, e.g., shaving, skin preparation and traffic flow in the operating room, are underdiscussion.

Increased Risk of Mortality with MRSA vs. MSSA

In Germany, a nosocomial infection surveillance network similar to the CDC’s National Nosocomial Infections Surveillance System was established in

Surgical-Site Infection After Cardiac Surgery: Incidence, Microbiology, and risk Factors

To identify risk factors associated with surgical-site infection according to the depth of infection, the cardiac procedure, and the National Nosocomial Infections Surveillance System risk index. Prospective survey conducted during a 12-month period. A 48-bed cardiac surgical department in a teaching hospital. Patients admitted for cardiac surgery between February 2002 and January 2003. Surgical-site infections were diagnosed in 3% of the patients (38 of 1,268). Of the 38 surgical-site infections, 20 were superficial incisional infections and 18 were mediastinitis for incidence rates of 1.6% and 1.4%, respectively. Cultures were positive in 28 cases and the most commonly isolated pathogen was Staphylococcus. A National Nosocomial Infections Surveillance System risk index score of 2 or greater was associated with a risk of surgical-site infection (relative risk, 2.4; P < .004). Heart transplantation, mechanical circulatory assistance, coronary artery bypass graft with the use of internal mammary artery, and reoperation for cardiac tamponade or pericard effusion were independent risk factors associated with surgical-site infection. Data surveillance using incidence rates stratified by cardiac procedure and type of infection is relevant to improving infection control efforts. Risk factors in patients who developed superficial infection were different from those in patients who developed mediastinitis. Coronary artery bypass graft using internal mammary artery was associated with a high risk of surgical-site infection, and independent factors such as reoperation for cardiac tamponade or pericard effusion increased the risk of infection.

Rates of Surgical-Site Infection: An International Comparison

To quantify the occurrence of surgical-site infections (SSIs) in an Italian region and to estimate the proportion of potentially avoidable infections through benchmarking comparison. Prospective study during 1 month based on a convenience sample of surgical patients admitted to 31 public hospitals. All of the patients undergoing an intervention included among the 44 operative procedures of the National Nosocomial Infections Surveillance (NNIS) System were enrolled. Ninety-five percent of the patients were actively observed after discharge for up to 30 days for all of the operations and for up to 1 year for operations involving implantation. Among the 6,167 operative procedures studied, 290 infections were recorded (4.7 per 100 procedures), 206 (71%) of which were SSIs (3.3 per 100 procedures; 95% confidence interval, 2.9-3.9). One hundred thirty-five SSIs (65.5%) were superficial infections, 53 (25.7%) were deep infections, and 12 (5.8%) were organ-space infections; in 6 cases (2.9%), the type of SSI was not recorded. The frequency of SSIs observed in this study was significantly higher for several procedures than that expected when the NNIS System rates (standardized infection ratio [SIR] ranging from 1.77 to 6.42) or the Hungarian rates (SIR ranging from 1.28 to 3.04) were applied to the study population. The high intensity of postdischarge surveillance can in part explain the differences observed. To allow for meaningful benchmarking comparison, in addition to intrinsic patient risk, data on the intensity of postdischarge surveillance should be included in published reports.

Surgical Site Infections after Pediatric Intracranial Surgery for Craniofacial Malformations: Frequency and Risk Factors

Surgical site infections (SSIs) after pediatric intracranial surgery for craniofacial malformations are relatively common and potentially serious nosocomial infections. Despite this, few studies have been published on this topic. We performed a retrospective study to determine the incidence of and factors associated with SSIs after intracranial surgery for craniofacial malformations at a single multidisciplinary craniofacial center during a 6-year period. Retrospective chart review was performed on 254 patients who underwent 281 intracranial procedures during a 6-year period. Patients with SSIs (cases) were compared with those without SSIs (controls). National Nosocomial Infection Surveillance System criteria were used to identify cases of SSI. SSIs occurred in 9 (3.2%) of 281 intracranial procedures that took place during the study period. Factors associated with an SSI included a complicated diagnosis comprising a diagnosis of syndromic craniosynostosis, frontonasal dysplasia, or oblique facial cleft (odds ratio [OR], 13.0; 95% confidence interval [CI], 2.6-64.4); duration of surgery longer than 426 minutes (OR, 12.1; 95% CI, 2.4-59.9); closure of skin under tension (OR, 12.5; 95% CI, 3.0-52.6); use of bovine pericardium (OR and 95% CI undefined); more than four surgeons present during surgery (OR, 6.3; 95% CI, 1.2-32); pediatric intensive care unit stay longer than 2 days (OR, 10.8; 95% CI, 2.2-53.3); and use of a ventilator after surgery (OR, 4.8; 95% CI, 1.2-18.6). In this study, the presence of a complicated diagnosis and a number of other factors were associated with an SSI after pediatric intracranial surgery for craniofacial malformations. We speculate that a complicated diagnosis may be a marker for other factors that contribute to the risk of an SSI. Future studies investigating SSIs after intracranial surgery should consider these factors.

Standardized Infection Surveillance in Long-Term Care Interfacility Comparisons From a Regional Cohort of Facilities

To measure infection rates in a regional cohort of long-term-care facilities (LTCFs) using standard surveillance methods and to analyze different methods for interfacility comparisons. Seventeen LTCFs in Idaho. Prospective, active surveillance for LTCF-acquired infections using standard definitions and case-finding methods was conducted from July 2001 to June 2002. All surveillance data were combined and individual facility performance was compared with the aggregate employing a variety of statistical and graphic methods. The surveillance data set consisted of 472,019 resident-days of care with 1717 total infections for a pooled mean rate of 3.64 infections per 1000 resident-days. Specific infections included respiratory (828; rate, 1.75), skin and soft tissue (520; rate, 1.10), urinary tract (282; rate, 0.60), gastrointestinal (77; rate, 0.16), unexplained febrile illnesses (6; rate, 0.01), and bloodstream (4; rate, 0.01). Initially, methods adopted from the National Nosocomial Infections Surveillance System were used comparing individual rates with pooled means and percentiles of distribution. A more sensitive method appeared to be detecting statistically significant deviations (based on chi-square analysis) of the individual facility rates from the aggregate of all other facilities. One promising method employed statistical process control charts (U charts) adjusted to compare individual rates with aggregate monthly rates, providing simultaneous visual and statistical comparisons. Small multiples graphs were useful in providing images valid for rapid concurrent comparison of all facilities. Interfacility comparisons have been demonstrated to be valuable for hospital infection control programs, but have not been studied extensively in LTCFs.

Double, Double, Toil and Trouble Infections Still Spreading in Long-Term–Care Facilities

The rapid shift in the delivery of healthcare from acute care settings to chronic care settings has continued unabated.1 Provision of care to an increasingly frail and elderly population in long-term–care facilities (LTCFs) is, not unexpectedly, associated with infection. In hospitals, guidelines and processes for detection, diagnosis, treatment, and control of infections have evolved during approximately the past 40 years. In contrast, infection control research in LTCFs began in the 1980s, conducted by investigators from a few institutions based primarily in North America.2 In 2005, basic questions remain regarding the prevalence of infection and the most effective means of diagnosis and treatment. In addition, it is difficult to judge the efficacy, or lack thereof, of infection control measures used in LTCFs. The Society for Healthcare Epidemiology of America (SHEA) and the Association for Professionals in Infection Control and Epidemiology (APIC) have called for active surveillance for collection and review of infection control data in LTCFs analogous to that done in hospitals.3,4 Unfortunately, no specific processes have been defined and widely varying infection rates generated by different methods in individual LTCFs have made interfacility comparisons difficult. In this issue of Infection Control and Hospital Epidemiology, Stevenson et al. propose a standardized surveillance program that was prospectively validated in 17 regional skilled nursing facilities.5 Infection control professionals experienced in infection surveillance were trained to use uniform infection definitions, based on the McGeer criteria, data collection, and reporting methods.6 Surveillance data were compiled from ward rounds and review of records, temperature charts, antibiotic orders, laboratory data, culture data, and radiographic studies. Residents’ functional status, diagnoses, and treatments were obtained from the Minimum Data Set.7 Data were adjusted for acuity using resource utilization groups, version III (RUG-III), case-mix indices.8 Of submitted reports, 93.9% were correctly identified as infection, and the authors found less variability in infection rates between facilities with this process. Infection rates and threshold data for each month could be generated for each facility to account for the seasonal variability of some infections. In addition, individual facility data could be compared against aggregate data for all facilities per month or by percentiles in a manner used by the National Nosocomial Infections Surveillance (NNIS) System.9 Using these data as a benchmark, the authors propose that LTCFs would be able to compare their infection rates with those in other facilities. Such data would assist in determining whether infection control strategies require re-evaluation or greater resource allocation. Ultimately, the authors hope that a network of LTCFs could enter their own data into a central repository similar to the NNIS System. The Centers for Medicare & Medicaid Services has been considered using such data for public performance reporting, and the Department of Veterans Affairs is considering using its nationwide computerized patient database to begin to address the prevalence of infection and antibiotic resistance in its LTCFs. This is an important study in that the clinically based McGeer criteria are validated as effective and accurate in the detection of infection when used by facilities with personnel experienced in infection detection. However, even with highly trained infection control personnel, more than

Risk factors for surgical site infections in a free-standing outpatient setting

More information about risk factors for surgical site infections in outpatient settings is necessary for creation of surveillance systems in this field. The aim of this study was to determine the incidence of surgical site infections (SSI) in an outpatient setting and to investigate whether the risk index of the National Nosocomial Infections Surveillance (NNIS) System is appropriate for outpatient settings. A retrospective cohort design was used to investigate SSI following all hernia repairs and varicose veins operations over a 9-year period in a freestanding outpatient setting. The exposure variables studied were age, sex, and American Society of Anesthesiologists (ASA) score of the patient; duration of operation; performing surgeon's name; type of operation; type of anesthesia; and follow-up period. An univariable and a multivariable analysis were performed to determine risk factors for SSI. A total of 1095 operations were performed: 714 on varicose veins and 381 on hernia repairs. The median follow-up period was 43 days. The crude SSI rate was 1.2% (varicose veins operations, 1.5%; hernia repair operations, 0.5%). According to the results of the logistic regression model, only 1 factor remained significant: Patients with spinal anesthesia were 11 times as likely to develop a SSI as patients with any other type of anesthesia (95% CI, 2.15-200.5). The NNIS risk index was not suitable for assessing SSI rates in this outpatient setting and for these specific procedures.

Efficacy of current agents used in the treatment of Gram-positive infections and the consequences of resistance

The proportion of pathogens causing hospital-onset infections that are resistant to antimicrobial agents continues to increase worldwide. Inadequate antimicrobial therapy is an important factor in the emergence of resistance and is associated with increased mortality. In the USA in 2000, the National Nosocomial Infections Surveillance system reported that >50% of Staphylococcus aureus isolates collected from intensive care units were resistant to methicillin (MRSA). The emergence of community-acquired MRSA is a new concern. MRSA are associated with adverse clinical outcomes and increased hospital costs. The increasing prevalence of MRSA contributes to the use of glycopeptides; however, isolates with intermediate and full resistance to vancomycin and teicoplanin are now being reported. Newer agents, such as the oxazolidinone linezolid, are effective in the treatment of serious Gram-positive infections; however, linezolid-resistant isolates of Enterococcus faecium, Enterococcus faecalis and S. aureus have been reported. Therefore, there is an unmet clinical need for new agents with activity against Gram-positive pathogens. Daptomycin, a lipopeptide with a novel mode of action, was recently approved for the treatment of skin and soft tissue infections in the USA. The two case studies presented herein detail experience with the use of daptomycin in the USA.

Surgical site infection surveillance after open gastrectomy and risk factors for surgical site infection

Surgical site infection (SSI) surveillance was examined in gastric cancer patients who had undergone an open gastrectomy between 1997 and 2003 at Keio University Hospital in Tokyo, Japan. National Nosocomial Infections Surveillance (NNIS) reports and several studies have discussed SSI risk factors, but only open gastrectomy was analyzed by regression analysis. The purpose of this study was to examine these issues by performing a regression analysis for the prediction of SSI. SSI was defined by the surgical patient component according to the NNIS system (1999) produced by the Centers for Disease Control and Prevention. Patients undergoing an open gastrectomy were followed up and monitored for SSIs. Risk factors for SSI, after all factors were considered, were studied using single and multivariate analysis. The study enrolled 984 patients who had undergoing an open gastrectomy. Using multivariate and logistic regression analysis, the duration of the operation was identified as a [corrected] risk factor for SSI at open gastrectomy. Although numerous potential risk factors in surgical patients were examined, the duration of the operation was the only significant risk factor for SSIs after open gastrectomy.

Infections de site opératoire chez les patientes césarisées : bilan de 5 années de surveillance

To determine the incidence of surgical site infections and to identify risk factors for infections. A prospective study of surgical site infections (SSI) after cesarean section was carried out from September 1997 to September 1998 (pilot study) and from January 2000 to August 2003, using the methodology of the American National Nosocomial Infection Surveillance System. Follow up of women was performed by midwives until discharge and during the post-natal visit. Suspected surgical site infections were confirmed by surgeons and infection control practitioners. The microbiological file of each patient was edited 30 days after cesarean section. Risk factors were analyzed using a logistic regression model. During the pilot study, infection rate was estimated at 3.2%. At multivariate analysis, factors independently associated with an increased risk of SSI were ASA score > 1, performance of cesarean section in a room not dedicated to this activity, and use of an open urine drainage system. During the following years (2000-2003), infection rates progressively decreased to reach 1.9% in 2003. Infections included superficial wound infections (involving skin and subcutaneous tissue) (47%), deep wound infections (involving deep and soft tissue (fascia and muscle) (20%) and organ/space infections (i.e. endometritis, pelvic abscess) (33%). Infections occurred after patient discharge in 47.5% of cases and diagnosis was based only on clinical findings in 30% of cases. Infected patients were hospitalized longer (median: 6 days) than non infected patients. Prospective surveillance of SSI led to better awareness of infectious problems among health care workers, to identification of risk factors and evaluation of health procedures. Surveillance contributed to a decrease in nosocomial infections.

Ventilator-associated pneumonia in a pediatric intensive care unit in Saudi Arabia: a 30-month prospective surveillance.

To describe the rate, risk factors, and outcome of ventilator-associated pneumonia (VAP) in pediatric patients. This prospective surveillance study of VAP among all patients receiving mechanical ventilation for 48 hours or more admitted to a pediatric intensive care unit (PICU) in Saudi Arabia from May 2000 to November 2002 used National Nosocomial Infections Surveillance (NNIS) System definitions. Three hundred sixty-one eligible patients were enrolled. Most were Saudi with a mean age of 28.6 months. Thirty-seven developed VAP. The mean VAP rate was 8.87 per 1,000 ventilation-days with a ventilation utilization rate of 47%. The mean duration of mechanical ventilation was 21 days for VAP patients and 10 days for non-VAP patients. The mean PICU stay was 34 days for VAP patients and 15 days for non-VAP patients. Among VAP patients, Pseudomonas aeruginosa was the most common organism, followed by Staphylococcus aureus. Other gram-negative organisms were also encountered. There was no significant difference between VAP and non-VAP patients regarding mortality rate. Witnessed aspiration, reintubation, prior antibiotic therapy, continuous enteral feeding, and bronchoscopy were associated with VAP. On multiple logistic regression analysis, only prior antibiotic therapy, continuous enteral feeding, and bronchoscopy were independent predictors of VAP. The mean VAP rate in this hospital was higher than that reported by NNIS System surveillance of PICUs. This study has established a benchmark for future studies of VAP in the pediatric intensive care population in Saudi Arabia. Additional studies from the region are necessary for comparison and development of preventive measures.

Prevention of central venous catheter-related bloodstream infections using non-technologic strategies.

To evaluate the incidence of nosocomial bacteremias related to the use of non-impregnated central venous catheters (CVCs) when only non-technologic strategies were used to prevent them. This was a prospective study of infectious complications of CVCs placed in intensive care unit (ICU) patients from April 1997 to December 2001. The medical-surgical ICU of a tertiary-care, university-affiliated hospital in Argentina. We studied all patients admitted to the ICU using non-impregnated CVCs. Maximal sterile barrier precautions (ie, use of cap, mask, sterile gown, sterile gloves, and large sterile drape), strict handwashing, preparation of the patients' skin with antiseptic solutions, insertion and management of catheters by trained personnel, and continuing quality improvement programs aimed at appropriate insertion and maintenance of catheters were employed. During the study period, 2,525 patients were admitted to the ICU. Eight hundred sixty-eight patients had 1,037 CVCs inserted. The number of CVC-related bloodstream infections (BSIs), acquired in the ICU, was 2.7 per 1,000 CVC-days (13 nosocomial CVC-related BSIs during 4,770 days of CVC use). Microorganisms isolated included methicillin-susceptible Staphylococcus aureus (n = 6), methicillin-resistant S. aureus (n = 2), coagulase-negative methicillin-resistant Staphylococcus (n = 2), Escherichia coli (n = 1), Klebsiella pneumoniae (n = 1), and Enterobacter cloacae (n = 1). A low rate of catheter-related BSI was achieved without antimicrobial-impregnated catheters. The incidence of CVC-associated bacteremias corresponded to the 10th to 20th percentile range of the National Nosocomial Infections Surveillance System hospitals for the same type of ICU.

Prevention of Central Venous Catheter–Related Bloodstream Infections Using Non-Technologic Strategies

AbstractObjective:To evaluate the incidence of nosocomial bacteremias related to the use of non-impregnated central venous catheters (CVCs) when only non-technologic strategies were used to prevent them.Design:This was a prospective study of infectious complications of CVCs placed in intensive care unit (ICU) patients from April 1997 to December 2001.Setting:The medical–surgical ICU of a tertiary-care, university-affiliated hospital in Argentina.Methods:We studied all patients admitted to the ICU using non-impregnated CVCs. Maximal sterile barrier precautions (ie, use of cap, mask, sterile gown, sterile gloves, and large sterile drape), strict handwashing, preparation of the patients' skin with antiseptic solutions, insertion and management of catheters by trained personnel, and continuing quality improvement programs aimed at appropriate insertion and maintenance of catheters were employed.Results:During the study period, 2,525 patients were admitted to the ICU. Eight hundred sixty-eight patients had 1,037 CVCs inserted. The number of CVC-related bloodstream infections (BSIs), acquired in the ICU, was 2.7 per 1,000 CVC-days (13 nosocomial CVC-related BSIs during 4,770 days of CVC use). Microorganisms isolated included methicillin-susceptible Staphylococcus aureus (n = 6), methicillin-resistant S. aureus (n = 2), coagulase-negative methicillin-resistant Staphylococcus (n = 2), Escherichia coli (n = 1), Klebsiella pneumoniae (n = 1), and Enterobacter cloacae (n = 1).Conclusions:A low rate of catheter-related BSI was achieved without antimicrobial-impregnated catheters. The incidence of CVC-associated bacteremias corresponded to the 10th to 20th percentile range of the National Nosocomial Infections Surveillance System hospitals for the same type of ICU.