Nosocomial Cases Research Articles

Short-term effect of antibiotic control policy on the usage patterns and cost of antimicrobials, mortality, nosocomial infection rates and antibacterial resistance

In 2003 Turkish government released a new budget application instruction for regulating the usage of parenteral antibiotics inside and outside of the hospitals. In this study it was aimed to evaluate the effect of this instruction on the overall usage of restricted antibiotics, their cost, overall mortality, bacterial resistance patterns and nosocomial infection rates in intensive care units (ICUs) of our setting for March-October 2002 and March-October 2003 periods. Overall daily defined dose/1000 patients/day of restricted drugs decreased, whereas unrestricted drugs increased significantly after the instruction. The cost of all analysed drugs in 2003 period was 540,303USD (-19.6%) less than 2002 period. Nosocomial infection rates in ICUs decreased significantly (p<0.05). When all microbiologically confirmed nosocomial bacteremia cases during the study period were analysed, amoxycilline/clavulanate, ciprofloxacin, cefuroxime, cefotaxime, piperacilline/tazobactam resistance and ESBL rate in Klebsiella pneumoniae decreased significantly (p<0.05). Amikacin resistance in Escherichia coli and Acinetobacter baumannii increased significantly (p<0.05). Antibiotic control is one of the most important and significant ways to save money, and to prevent antibacterial resistance.

Fifteen-Year Study of the Changing Epidemiology of Methicillin-Resistant Staphylococcus aureus

Purpose The study’s purpose was to elucidate the evolutionary, microbiologic, and clinical characteristics of methicillin-resistant Staphylococcus aureus (MRSA) infections. Methods MRSA cases from military medical facilities in San Diego, from 1990 to 2004, were evaluated and categorized as community-acquired or nosocomial. Sequence type, staphylococcal chromosomal cassette gene type, and Panton-Valentine leukocidin gene status were determined for a subset of isolates. Results Over the 15-year period, 1888 cases of MRSA were identified; 65% were community acquired. The incidence (155 infections/100 000 person-year in 2004) and household-associated cases rapidly increased since 2002. Among persons with community-acquired MRSA, 16% were hospitalized and only 17% were initially given an effective antibiotic. Community-acquired MRSA cases compared with nosocomial MRSA cases were more often soft-tissue and less often urinary, lung, or bloodstream infections ( P < .001). Patients with community-acquired MRSA were younger (22 vs 64 years, P < .001) and less likely to have concurrent medical conditions (9% vs 98%, P < .001). Clindamycin resistance increased among community-acquired MRSA isolates during 2003 and 2004 compared with previous years (79% vs 13%, P < .001). Genetically, nosocomial MRSA isolates were significantly different than those acquired in the community. Although community-acquired MRSA isolates were initially diverse by 2004, one strain (staphylococcal chromosomal cassette type IV, sequence type 8, Panton-Valentine leukocidin gene positive) became the predominant isolate. Conclusions Community-acquired and intrafamilial MRSA infections have increased rapidly since 2002. Our 15 years of surveillance revealed the emergence of distinct community-acquired MRSA strains that were genetically unrelated to nosocomial MRSA isolates from the same community.

Épidémiologie des fongémies dans les hôpitaux français non universitaires en 2004 : enquête multicentrique ColBVH

Introduction The aim of our study was to determinate the frequency of candidemia, the species encountered and their susceptibility to antifungal agents in French hospitals in 2004. Methods A prospective survey of septicaemia, including candidaemia was conducted among 193 non teaching French hospitals during October 2004. All bloodstream infections were reported and the bloodstream isolates sent to two coordinating centers. Species identification and susceptibility were performed by biologists as usual, and further confirmed by use of alternative methods, including Minimal Inhibitory Concentration (MIC) determination. Results The survey was effective in 93 hospitals, where 2013 bloodstream infections were noticed, including 46 candidaemia (2,3%). Candida sp. Is the 7th pathogen responsible for bloodstream infection, without concern of the origin of the infection. Candidaemia was hospitally acquired in 80,4% of cases ( N = 37/46). Candidaemia represents 0,7% ( N = 9/1211) of community-acquired bloodstream infections but 4,5% ( N = 37/802) of nosocomial cases, placing Candida sp. at the 5th row of frequency in this last group. No mistakes were noticed during identification, but two strains were not named. After confirmation of identification, species are distributed as follows: 23 C. albicans (50%), 13 C. glabrata (28,3%), 5 C. tropicalis (10,9%), 3 C. parapsilosis (6,5%), 1 C. krusei (2,2%), and 1 C. kefyr (2,2%). The overall susceptibility is 97,7% for amphotericin B, 93,2% for 5-fluorocytosin, 88,6% for fluconazole, 70,5% for itraconazole, 95,5% for voriconzole and 100% of strains haved very low MIC for caspofungin. Concerning the two main species isolated, 95,5% of C. albicans strains remain susceptible to fluconazole, but only 69% of C. glabrata strains. Two strains, 1 C. albicans and 1 C. glabrata exhibit cross resistance to azoles. The majority of amphotericin, fluconazole, and itraconazole decreased susceptibility strains are found into C. glabrata strains, but susceptibility to 5-fluorocytosin and very low MCI to caspofungin remained in this species. Conclusion Our survey allowed us to get data from French non-teaching hospitals in 2004 about frequency of candidaemia among septicaemia. Candida species distribution and in vitro susceptibility patterns of the strains isolated. Candidaemia is not a rare event, specially when septicaemia is nosocomially acquired. C. albicans is the main species isolated and remains highly in vitro susceptible to antifungals. One important feature is the frequency of C. glabrata in our survey. Considering its decreased susceptibility to azoles, this finding confirms the need for rapid identification of yeast isolated from bloodstream samples, and antifungal susceptibility testing each time it is available.

Multihospital surveillance of nosocomial methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococcus, and Clostridium difficile: Analysis of a 4-year data-sharing project, 1999-2002

This study sought to establish a benchmark of resistant organism rates among a cohort of regional hospitals. The Centers for Disease Control and Prevention (CDC) definitions were used to standardize the methodology for obtaining rates per 1000 patient days of nosocomial infection and colonization with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE), and nosocomial infection with Clostridium difficile (CDIF). Only newly acquired nosocomial cases were counted. Data were reported as individual hospital control charts and as cohorted aggregate data. VHA East Coast Infection Control Professionals from 32 hospitals in New Jersey and Pennsylvania were involved. Benchmarks were established with pooled mean rates for each cohort. During the observational period, a statistically significant downward trend was observed for VRE and MRSA (P = .02 and .0007, respectively), and an upward trend was observed for CDIF (P = .0256). Benchmarks were established to compare nosocomial MRSA, VRE, and CDIF rates. Although significant changes in rates were observed, no attempt was made to establish a causal relationship between infection control practices and observed rates. However, a secondary gain was achieved through sharing best practices.

“Real Time” Syndromic Surveillance for ED Patients with Community Respiratory Virus (CRV) at a University Medical Center

ISSUE: During CRV season, pts requiring hospital care can impact our bed capacity and our ability to provide services to all pts. PROJECT: <b>1. Syndromic surveillance:</b> ICP reviewed ED logs daily, recording total number of ED pts seen and number of pts with CRV symptoms. <b>2. Recommended Rapid Testing:</b> for RSV, Influenza (A and B), and viral culture for pts being admitted with CRV symptoms. <b>3. Respiratory Hygiene/Empiric Precautions:</b> At ED entrance Volunteer observes patients/visitors for Flu Like Illnesses (FLI) asks them to put on a mask. ED Staff discharge pts not requiring admission asap. Pts for admission with a positive rapid test, admit to private room or in with another confirmed case of like illness. Pts with CRV symptoms and a negative rapid test remain on precautions/private room until CRV is excluded by culture. <b>4. Special High Census Provision:</b> is activated if 5 or more ED pts are waiting for admission. <b>5. Dissemination of Information:</b> Weekly graphs on IC Web Site. RESULTS: From Dec04 - Mar 05, there were 39,947 ED pt visits, average 333 and range [180 to 399] per day, of those 7,463 pts had FLI. average was 62 range was [31 to 135]. ED pt volume increased several times but didn't necessitate special high census provisions. Specimens for direct influenza testing (QFLU) and respiratory virus cultures (RVC) were submitted for 158 pts from 12/1/04 to 3/1/05. 146 RVC were done. 161 QFLU were done. Influenza A was diagnosed in 39 pts, 12 by QFLU and 27 by RVC after negative QFLU. Influenza B was diagnosed in 4 pts, one by QFLU and 3 by RVC after negative QFLU. RSV was diagnosed in 9 pts by RSV direct assay followed by positive culture. RSV was diagnosed in 15 pts by culture. Sensitivity of QFLU was disappointing, only 13 of 43 pts with influenza were detected by the direct test (30% sensitivity). The sensitivity of the RSV direct assay was better 9 of 15 pts with positive culture for RSV were positive by the RSV direct assay. There were no nosocomial cases resulting from pts admitted directly from the ED, but 4 immunosuppressed inpatients developed nosocomial Influenza and 1 nosocomial RSV. LESSONS LEARNED: Real time CRV data helped manage pt flow during periods of high census. Rapid assays had variable sensitivity and specificity, limiting their utility in bed management. Daily screening for FLI and work restriction of sick employees/visitors is needed to prevent nosocomial CRV transmission to immunosuppressed inpatients.

Prospective 3-Year Surveillance for Nosocomial and EnvironmentalLegionella pneumophila: Implications for Infection Control

To perform a 3-year, prospective surveillance program for legionnaires disease (LD) in a large university hospital in Rome, and to assess the usefulness of the hospital water monitoring program in predicting the risk of nosocomial LD. Samples from patients with new cases of nosocomial pneumonia were sent for legionella laboratory investigations. Meanwhile, water samples for bacteriological analysis were collected every 6 months from high- and medium-risk hospital wards (10 in total). Legionella pneumophila isolates collected were serotyped and analyzed by pulsed-field gel electrophoresis. From June 2001 through May 2004, the pneumonia surveillance identified one case of nosocomial LD among 43 cases of nosocomial pneumonia (2.3%). Environmental investigations detected L. pneumophila in 12 (18.7%) of the 64 water samples, of which 50% belonged to serogroup 1. The L. pneumophila count and the percentage of positive locations never exceeded 10(2) colony-forming units/L and 20%, respectively, except when the LD nosocomial case occurred (positive water samples, 40%; L. pneumophila count, <10(2) colony-forming units/L). Genotyping showed 3 prevalent clones of L. pneumophila in the water distribution network, of which one persisted over the 3 years. One clone contained 3 different L. pneumophila serogroups (2, 4, and 6). The low incidence of nosocomial cases of LD appears to be associated with a low percentage (<20%) of positive water samples per semester and with a low contamination level (<10(2) colony-forming units/L). An infection control system for nosocomial LD should, therefore, be based on both environmental and clinical surveillance, together with the appropriate maintenance of the hospital water distribution system.

A Practical Application of Practice-Based Learning: Development of an Algorithm for Empiric Antibiotic Coverage in Ventilator-Associated Pneumonia

Development of practice-based learning (PBL) is one of the core competencies required for resident education by the Accreditation Council for Graduate Medical Education, and specialty organizations including the American College of Surgeons have formed task forces to understand and disseminate information on this important concept. However, translating this concept into daily practice may be difficult. Our goal was to describe the successful application of PBL to patient care improvement with development of an algorithm for the empiric therapy of ventilator-associated pneumonia (VAP). The algorithm development occurred in two phases. In phase 1, the microbiology and timing of VAP as diagnosed by bronchoalveolar lavage was reviewed over a 2-year period to allow for recognition of patterns of infection. In phase 2, based on these data, an algorithm for empiric antibiotic coverage that would ensure that the large majority of patients with VAP received adequate initial empiric therapy was developed and put into practice. The period of algorithm use was then examined to determine rate of adequate coverage and outcome. : In Phase 1, from January 1, 2000 to December 31 2001, 110 patients were diagnosed with VAP. Analysis of microbiology revealed a sharp increase in the recovery of nosocomial pathogens on postinjury day 7 (19% < day 7 versus 47% > or = day 7, p = 0.003). Adequate initial antibiotic coverage was seen in 74%. In Phase 2, an algorithm employing ampicillin- sulbactam for coverage of community- acquired pathogens before day 7 and cefipime for nosocomial coverage > or =day 7 was then employed from January 1, 2002 to December 31, 2003. Evaluation of 186 VAP cases during this interval revealed a similar distribution of nosocomial cases (13% < day 7 versus 64% > or = day 7, p < 0.0001). Empiric antibiotic therapy was adequate in 82% of cases <day 7 and 85% of cases > or =day 7: overall accuracy improved to 83% (p = 0.05). Mortality from phase 1 to phase 2 trended toward a decrease (21% versus 13%, p = 0.1). Application of the concept of PBL allowed for identification of local patterns of infection and development of an institution specific treatment algorithm that resulted in >80% adequate initial empiric coverage for VAP with a trend toward decreased mortality. PBL allows for alteration in practice based on local patterns and outcomes and has the potential to improve patient care.

Cas de coqueluche parmi le personnel d'un service de maternité : gestion d'une alerte sanitaire

Pertussis is a highly contagious acute respiratory tract infection, with a poor prognosis in non-vaccinated new-borns. Objectives The authors had for aim to investigate an epidemic of 5 pertussis cases among health care workers (HCW) in our maternity ward with potential exposure of new-borns and to evaluate HCW compliance and experience gain. Methods A retrospective study was made using a questionnaire with HCW on preventive measures taken (antibiotic prophylaxis with erythromycin and wearing a mask). Results Two hundred and thirty-eight patients were warned of a potential pertussis contamination. No nosocomial case was detected among patients or their new borns. Ten proved or probable cases were identified among 101 HCW having answered ( N = 101/210, 48%). Sixty percent of HCW people followed the antibiotic treatment and 85% wore a mask among whom 46% adequately. Non-compliance factors were mainly related to adverse effects (41%), delayed information (41%), and false vaccine protection (22%). Crisis communication was felt as unsatisfactory for 72% of HCW and recommendations not adapted for 39% of the staff. Conclusion This survey points out the difficulty of managing a pertussis alert in a medical ward.

Economics of Rotavirus Gastroenteritis and Vaccination in Europe

Rotavirus is a major cause of gastroenteritis in children throughout Europe and the world. In addition to causing morbidity and mortality in children, rotavirus gastroenteritis (RVGE) creates a major economic burden on health care systems and families in Europe. The costs of hospital admissions for RVGE and nosocomial infections generate significant medical treatment costs throughout the region. Less information is available on the costs associated with less severe episodes and the costs borne by families, including lost time from work. The availability of rotavirus vaccines presents an effective opportunity to prevent RVGE and these associated economic costs, as well as providing protection to each child and hence benefiting the child's family. The adoption of rotavirus vaccine by health authorities in Europe will require a comparison of the costs and benefits. Economic evaluations that compare the costs of vaccination to the economic benefits of rotavirus vaccination will provide an estimate of its financial impact on health care systems and society. However, to provide a complete picture, economic evaluations of rotavirus vaccines will need to account for both the reduced costs and the reduced morbidity from prevented RVGE. Cost-effectiveness analyses based on quality-adjusted life years (QALYs) provide a systematic approach for assessing vaccination as a health investment, comparing the incremental costs associated with rotavirus vaccination and the reduced morbidity and mortality. QALYs provide a standardized approach for quantifying and comparing reductions in health-related quality of life and premature mortality. Although methodologic limitations exist in applying the QALY approach to childhood vaccines, their use in cost effectiveness analyses allows decision makers to consider the full health benefits of rotavirus and other vaccines.

Epidemiological Survey of Human Metapneumovirus Infection in a Large Pediatric Tertiary Care Center

The human metapneumovirus (hMPV) was recently identified and linked to acute respiratory tract infections (ARTI). To assess the clinical importance of this virus in infants and children, we developed a rapid and efficient reverse transcription-PCR-based screening method for a large volume of samples and tested retrospectively a collection of 1,132 respiratory specimens submitted over a full year period to the virology laboratory of a large tertiary care pediatric center in Montreal, Canada. A total of 41 samples from 37 patients were positive by this method. During the winter months of 2001, up to 8% of specimens submitted for respiratory virus testing were hMPV positive. Sequencing data of the hMPV M gene revealed that two genogroups of the virus, each of which can be divided into two subgroups, cocirculated during this time period. A case-controlled study was conducted to compare the symptoms associated with hMPV infection with those involving other etiologic agents causing ARTI. Symptoms most frequently observed in hMPV-positive patients were cough, wheezing, and dyspnea, although the symptomatology could differ substantially from patient to patient. No distinct symptom profile could be associated with hMPV. Three nosocomial cases of hMPV infection were identified. Together, our data suggest that hMPV is a significant cause of symptomatic respiratory tract infections in infants and children. The incidence of the disease and the morbidity associated with the infection justify adding hMPV to the list of common respiratory viruses routinely screened for by clinical laboratories.

Prognosis in Patients With Pneumonia and Chronic Obstructive Pulmonary Disease

To study the incidence, severity, and mortality rates of pneumonia in a cohort of chronic obstructive pulmonary disease (COPD) patients monitored over 3 years. A total of 596 patients diagnosed with COPD according to spirometric criteria were included in the study. The variables assessed were mortality and severity according to the Pneumonia Severity Index (PSI) for community-acquired pneumonia (CAP). Of the 596 patients included in the study, 75 (12.6%) developed at least 1 episode of pneumonia during the 3 years of the study. The overall incidence of pneumonia was 55.1 per 1000 person-years. There were 88 episodes in 75 patients. COPD severity, evaluated based on percentage of predicted FEV1, was mild in 9 patients, moderate in 24, and severe in 42. Seventy-six (86.3%) episodes were CAP and 12 (13.6%) were acquired in hospital. Fourteen CAP cases corresponded to PSI group V, 28 to group IV, 20 to group III, and 14 to groups I and II. Overall mortality was 12.5% (11/88). The mortality rate was 41.7% (5/12) for nosocomial cases and 7.8% (6/76) for CAP cases (OR, 6.67; 95% confidence interval, 1.65-26.93). Assessing CAP mortality by level of severity, we found that the mortality rate was 35.7% (5/14) for group V and 3.5% (1/28) for group IV. No deaths occurred among patients in the other severity groups. The incidence of pneumonia in COPD patients is high. More than half the cases of CAP (55.2%) in our COPD patients were classified in PSI risk groups IV and V.

Hospital-wide prospective mandatory surveillance of invasive aspergillosis in a French teaching hospital (2000–2002)

A multidisciplinary working group devoted to epidemiological surveillance of invasive aspergillosis (IA) was created in January 2000 in Grenoble University Hospital. This article presents the results of a three-year IA surveillance. The multidisciplinary working group surveyed all hospitalized patients, and the mycology laboratory detected most suspected IA cases. Cases were reviewed monthly by the Aspergillosis Committee, and were classified according to international consensus criteria. Possible nosocomial acquisition was determined. Among the 490 alerts, 74 IA cases were observed: six proven cases (8%), 36 (49%) probable cases and 32 (43%) possible cases. The incidence was 4.4 (95% CI 3.4-5.4) IA/100 000 patient-days. Among the proven and probable IA cases, we observed 10 nosocomial cases and six cases of undetermined origin. No cases were noted in the protected rooms in the haematology unit. Only one cluster of cases (three nosocomial cases) was detected in the haematology unit. Forty-three percent of cases (N=32) were hospitalized in the haematology unit, and all other cases were hospitalized elsewhere. This three-year survey found a high rate of non-nosocomial IA cases and a high frequency of IA cases hospitalized in units other than haematology. Thus, this study shows the importance of IA surveillance in haematology units and all high-risk units.

Legionnaire's disease: a nosocomial outbreak in Turkey

Six nosocomial cases of Legionella pneumophila occurred over a two-week period, with one further case being diagnosed retrospectively after 30 days. Strains isolated from the hospital water system were clonally related to a single sputum isolate. A sero-epidemiological investigation into legionella exposure amongst staff and inpatients was undertaken at the eight-year-old Inonu University Medical Centre in Turkey, which has 600 beds and central air conditioning. There is no disinfection programme for the hospital water system. A total of 500 serum samples (400 hospital staff and 100 inpatients) were screened for antibody to L. pneumophila by enzyme-linked immunosorbent assay (ELISA). Seroreactive cases were confirmed by a four-fold antibody rise in ELISA, a high indirect immunofluorescent assay (IFA) antibody titre or a positive urinary antigen test. ELISA showed that 24 (6%) of the 400 hospital staff and seven (7%) of the 100 inpatients had antibody titres higher than the cut-off value. ELISA-seroreactive cases were followed for two to four weeks. Of these subjects, seven (three patients and four staff) showed a four-fold rise in antibody titre by ELISA, six (three patients and three staff) had a high IFA titre, three patients with pneumonia had a positive urinary antigen test, and one of these patients also had a positive sputum culture. In addition, 22 water distribution systems were screened for the presence of L. pneumophila by culture. L. pneumophila was isolated from 15 sites. Pulsed-field gel electrophoresis typing indicated that all strains isolated from water systems were identical and clonally related to the strain isolated from sputum. Superheating and flushing of water systems were undertaken with legionella being re-isolated from four sites. Repeated superheating and flushing eliminated legionella completely. This study demonstrated that rapid detection of L. pneumophila and adequate superheating and flushing of water systems are effective for elimination and reduction of spread of this organism.

VanB-VanC1Enterococcus gallinarum, Italy

To the Editor: We report detecting a vanB determinant in Enterococcus gallinarum in poultry in Italy. High-level vanA-mediated glycopeptide resistance has been described for E. gallinarum and E. casseliflavus (1–4), and vanB-mediated vancomycin resistance has been frequently described for E. faecalis and E. faecium. However, vanB-mediated resistance in isolates of E. gallinarum has been described only in sporadic nosocomial cases of infection or colonization (5,6). In January 2005, a study of contamination by foodborne organisms in slaughtered broiler carcasses was conducted in Sicily. To detect glycopeptide-resistant enterococci (GRE), each carcass was placed in a bag with 100 mL sterile buffered peptone water and shaken vigorously for 60 sec. After overnight incubation at 37°C, 0.5 mL rinsate was added in duplicate to 5 mL ethyl violet azide broth (Oxoid, Basingstoke, United Kingdom) with 4 mg/L vancomycin. Broth cultures were further incubated at 37°C for 48 h, and 0.1 mL aliquots were spread onto duplicate plates of VRE (commercial denomination product, Oxoid) agar. A vancomycin-resistant isolate of E. gallinarum was identified in a carcass from a broiler farm in eastern Sicily. The biochemical tests of API 20 Strep (bioMerieux, Marcy l'Etoile, France) and motility test at 30°C were used to characterize the isolate at the species level. The MICs of vancomycin and teicoplanin were 64 μg/mL and 1 μg/mL, respectively. The isolate was subjected to a multiplex polymerase chain reaction followed by an endonuclease cleavage of amplicons by MspI (Invitrogen, Carlsbad, CA, USA) as previously described (7) to detect van gene determinants; this process demonstrated a simultaneous presence of vanC1 and vanB determinants. E. gallinarum and the other motile enterococci are thought to infrequently cause infection. However, the recent involvement of vanC1-vanA E. gallinarum in person-to-person spread in a long-term-care facility (8) and in an intensive care unit (2), along with identification of vanC1-vanB isolates in some patients treated with prolonged courses of glycopeptides (5,6), suggests reassessment of their possible pathogenic role. For the first time, 1 isolate of E. gallinarum has been found harboring the vanB gene in poultry. Our findings confirm that E. gallinarum can capture the genetic determinants of high-level glycopeptide resistance, probably under selective pressure conditions that do not permit survival of a host organism with constitutive low-level resistance (3). Previous studies have demonstrated that E. gallinarum can transfer these determinants to E. faecium by conjugation (2). The role of food animals as reservoirs of GRE and the causes of their persistently high prevalence in poultry carcasses in some European countries are being investigated (9). Moreover, the public health risk associated with consumer exposure to GRE when handling raw animal foods is poorly understood. In Europe, the food chain is thought to be the major source of GRE since avoparcin was used as a food additive for animals until the European Union ban in 1997. Previous studies in Italy showed that avoparcin withdrawal successfully reduced GRE contamination of poultry meat products (10). However, our finding, 7 years after the European Union ban, highlights that resistance genotypes in motile enterococci should be closely monitored (11).

Nosocomial Endocarditis in a Tertiary Hospital: An Increasing Trend in Native Valve Cases

Introduction Changes in the etiology, epidemiology, and outcome of infective endocarditis (IE) have been observed in recent years. Newer invasive therapeutic interventions have increased the risk of bacteremia and nosocomial endocarditis in the population at risk. A retrospective analysis of hospital-acquired IE cases was performed in a tertiary hospital during 1985 to 1999 Material and methods Cases included were those classified as “probable” or “definite” by the IE diagnostic criteria of Durack. Nosocomial acquisition was considered if diagnosis was made > 72 h after hospital admission and there was no evidence that IE was present at the time of admission. Patients receiving a diagnosis within 60 days of a previous hospital admission were also classified as nosocomial, when a risk procedure for bacteremia was performed, or when any predisposing factor for IE was present during hospitalization. Early prosthetic valve endocarditis (PVE) cases (< 1 year) were excluded from the analysis. Clinical characteristics, etiology, predisposing cardiac condition, source of infection, and outcome were analyzed. Results were compared with those obtained in community-acquired cases Results Of 493 cases of IE diagnosed over 15 years, 38 were considered to be hospital acquired. Twenty-eight cases were native valve endocarditis (NVE) in non-IV drug user patients, and 10 cases were late PVE. Overall, the most frequent microorganisms involved were staphylococci (58%). The main sources of infection were intravascular procedures or catheter-related infections (55%). When nosocomial NVE cases were compared with community-acquired cases, mortality was greater (29% vs 9.7%) in hospital-acquired endocarditis. Analysis of time trends showed an increased rate of nosocomial cases in NVE throughout the years of the study Conclusions In NVE, the number of cases that are hospital acquired has been increasing during the last 15 years. These cases are frequently associated with invasive intravascular procedures or IV catheter-related infections. Most patients have a previous valvulopathy that predisposes to IE. The spectrum of microorganisms involved is different from the community-acquired cases. Also, the outcome of endocarditis is worse in nosocomial NVE patients Changes in the etiology, epidemiology, and outcome of infective endocarditis (IE) have been observed in recent years. Newer invasive therapeutic interventions have increased the risk of bacteremia and nosocomial endocarditis in the population at risk. A retrospective analysis of hospital-acquired IE cases was performed in a tertiary hospital during 1985 to 1999 Cases included were those classified as “probable” or “definite” by the IE diagnostic criteria of Durack. Nosocomial acquisition was considered if diagnosis was made > 72 h after hospital admission and there was no evidence that IE was present at the time of admission. Patients receiving a diagnosis within 60 days of a previous hospital admission were also classified as nosocomial, when a risk procedure for bacteremia was performed, or when any predisposing factor for IE was present during hospitalization. Early prosthetic valve endocarditis (PVE) cases (< 1 year) were excluded from the analysis. Clinical characteristics, etiology, predisposing cardiac condition, source of infection, and outcome were analyzed. Results were compared with those obtained in community-acquired cases Of 493 cases of IE diagnosed over 15 years, 38 were considered to be hospital acquired. Twenty-eight cases were native valve endocarditis (NVE) in non-IV drug user patients, and 10 cases were late PVE. Overall, the most frequent microorganisms involved were staphylococci (58%). The main sources of infection were intravascular procedures or catheter-related infections (55%). When nosocomial NVE cases were compared with community-acquired cases, mortality was greater (29% vs 9.7%) in hospital-acquired endocarditis. Analysis of time trends showed an increased rate of nosocomial cases in NVE throughout the years of the study In NVE, the number of cases that are hospital acquired has been increasing during the last 15 years. These cases are frequently associated with invasive intravascular procedures or IV catheter-related infections. Most patients have a previous valvulopathy that predisposes to IE. The spectrum of microorganisms involved is different from the community-acquired cases. Also, the outcome of endocarditis is worse in nosocomial NVE patients

Economic impact of community-acquired and nosocomial lower respiratory tract infections in young children in Germany

Data on the economic burden of lower respiratory tract infections (LRTI) in young children are lacking in Germany. The objective of the cost-of-illness study was to estimate the economic impact of community-acquired LRTI and nosocomial LRTI as well as of infections due to respiratory syncytial virus (RSV), parainfluenza viruses (PIV) and influenza viruses (IV). The economic analysis is part of the PRIDE study, a prospective, multi-centre, population-based epidemiological study on the impact of LRTI in children aged 0 to 36 months in Germany. The analysis includes children with community-acquired infections (1329 cases treated as outpatients, 2039 cases treated as inpatients) and nosocomial infections (90 cases). Medical services consumed were generated by chart abstraction and parental expenses data by telephone interviews within four weeks after physician visit or hospitalisation. Costs were evaluated from following perspectives: third party payer, parent and society. Total costs for outpatient treatment are Euro 123 per LRTI case. Stratified by virus type, total costs per case are Euro 163 (RSV), Euro 100 (PIV) and Euro 223 (IV). Total costs per hospitalised LRTI case amount to Euro 2579. Stratified by virus type, total costs per case are Euro 2772 (RSV), Euro 2374 (PIV) and Euro 2597 (IV). Total costs per nosocomial case are Euro 2814. Economic burden due to LRTI is Euro 213 million annually. It is concluded that treatment of LRTI in children up to age three causes a considerable economic burden in Germany. Presented results are the first data describing the economic burden of LRTI in young children assessed by means of the incidence data for Germany. This cost-of-illness study provides basic data for further decision-making, focusing on the economic assessment of preventive strategies for RSV, PIV and IV infections.

Hospital-Acquired Invasive Group A Streptococcal Infections in Ontario, Canada, 1992-2000

A significant proportion of invasive group A streptococcal infections are hospital acquired. No large, prospective studies have characterized this subgroup of cases and evaluated the risk of transmission in hospitals. We conducted prospective, population-based surveillance of invasive group A streptococcal infections in Ontario, Canada, from 1992 to 2000. Epidemiologic and microbiologic investigations were conducted to identify cross-transmission. We identified 291 hospital-acquired cases (12.4%) among 2351 cases of invasive group A streptococcal disease. Hospital-acquired invasive group A streptococcal infections are heterogeneous, including surgical site (96 cases), postpartum (86 cases), and nonsurgical, nonobstetrical infections (109 cases). Surgical site infections affected 1 of 100,000 surgical procedures and involved all organ systems. Postpartum infections occurred at a rate of 0.7 cases per 10,000 live births and exhibited an excellent prognosis. Nonsurgical, nonobstetrical infections encompassed a broad range of infectious syndromes (case-fatality rate, 37%). Nine percent of cases were associated with in-hospital transmission. Transmission occurred from 3 of 142 patients with community-acquired cases of necrotizing fasciitis requiring intensive care unit (ICU) admission, compared with 1 of 367 patients with community-acquired cases without necrotizing fasciitis admitted to the ICU and 1 of 1551 patients with other cases (P<.001). Fifteen outbreaks were identified; 9 (60%) involved only 2 cases. Hospital staff were infected in 1 of 15 outbreaks, but colonized staff were identified in 6 (60%) of 10 investigations in which staff were screened. Presentation of hospital-associated invasive group A streptococcal infections is diverse. Cross-transmission is common; illness occurs in patients but rarely in staff. Isolation of new cases of necrotizing fasciitis and intervention after a single nosocomial case may also prevent transmission.

Community pertussis outbreak: Systems and processes to maximize efficiency

ISSUE: Our community experienced an increase in cases of Bordetella pertussis between June 24 and September 20, 2004. Increased demand for treatment, prophylaxis, and education caused stress on the healthcare system. Communication, tools, and processes were developed or modified to maximize efficiency and effectiveness. PROJECT: Controls were implemented throughout the system with emphasis on outpatient areas, visitors, pediatrics, obstetrics, and neonatal intensive care. Communication between public health, infection control, employee health, pharmacy, and providers was critical for managing the influx of ill, exposed, and worried well. Very early into the outbreak, treatment and prophylaxis algorithms were distributed to providers. Later, a liaison role was created to facilitate communication between case finders and providers. The treatment protocol was revised based on new knowledge regarding erythromycin drug interactions. Ill employees were furloughed for 5 days. A database efficiently organized case and contact information. All outbreak management tools were ready and available in an “outbreak toolbox” file. RESULTS: Masks were worn during 35% of encounters with 43 pertussis-positive patients. Thirty-one employees were exposed during patient care, 25 ill employees were furloughed, and 5 ill employees exposed 147 patients. There were no hospitalizations or nosocomial cases. Employee referrals and prescription costs totaled over $14,000. LESSONS LEARNED: Based on our experience, we would recommend the following: 1) Form a multidisciplinary coordination team early in the outbreak. 2) Have all outbreak tools (i.e., screening, prophylaxis, and education tools) in a central location and ready to use. 3) Provide treatment and prophylaxis algorithms and information to providers on a timely basis. 4) Utilize a pharmacy to distribute prophylaxis and evaluate drug interactions. 5) Implement respiratory hygiene/cough etiquette to minimize transmission of respiratory pathogens. 6) Implement droplet precautions (mask) when examining or collecting respiratory specimens from undiagnosed, coughing patients. 7) Identify ill employees and expedite employee test results. 8) Regularly meet with local public health officials. 9) Exposed patients should be contacted only by trained health professionals. 10) Inform and educate departments exposed to ill co-workers. 11) Utilize a computer database to manage cases and contacts. 12) Facilitate communication between public health officials.

Reduction of nosocomial acquisition of methicillin-resistant Staphylococcus aureus (MRSA) in a community hospital through adherence to standard precautions

BACKGROUND/OBJECTIVES: The number of patients culture-positive for methicillin-resistant Staphylococcus aureus (MRSA) at a 235-bed community acute care hospital had been slowly increasing since data were first collected. According to policy, MRSA-positive patients were placed in contact precautions. In 2002 the infection control committee changed this policy as it appeared to have little or no effect on the incidence of nosocomial spread but had a negative impact on patient care. The new policy eliminated use of contact precautions; instead only standard precautions would be followed on MRSA patients. The Centers for Disease Control and Prevention (CDC) state that standard precautions “should control the spread of MRSA in most instances” but that “if MRSA is judged by the hospital's infection control program to be of special clinical or epidemiologic significance, then contact precautions should be considered.” Prior to the policy change, there was an average of 10 nosocomial cases of MRSA/month (1.61/1000 patient days). Following the elimination of contact precautions, the incidence of nosocomial MRSA decreased and has sustained. The average number of nosocomial cases of MRSA 2 years later was METHODS: Prior to implementing the policy, the infection control practitioner (ICP) met with medical staff committees to discuss the proposed change and its rationale, to educate physicians, and to gain their support. There was mixed support, but ultimately the policy change was accepted. The ICP implemented an educational program for all staff focusing on three things: MRSA and its transmission; the prevalence of MRSA at the facility and incidence of nosocomial spread; and the fundamentals of standard precautions, emphasizing the importance of strict adherence with all patients. Educational efforts focused on a paradigm shift whereby prevention of transmission through standard precautions rather than reliance on patient isolation was emphasized. RESULTS: Nosocomial MRSA significantly decreased following discontinuation of contact precautions. The rate went from 9.67 cases/mo to 4.33 cases/mo. Patient care was positively impacted. CONCLUSIONS: Educational interventions which focused on adherence to standard precautions resulted in improved quality of patient care and decreased nosocomial MRSA. Education of staff proved to be far more important in decreasing nosocomial spread than did initiating contact precautions.

The CDC's campaign to prevent antimicrobial resistance offers structure, strategy, and authority to a hospital's efforts to battle an increase in resistant organisms

ISSUE: This is a 547-bed urban teaching hospital with 26,000 annual discharges. In the fall of 1999, the incidence of community-acquired methicillin-resistant <i>Staphylococcus aureus</i> (CA-MRSA) MRSA doubled; a year later, the incidence of nosocomial cases (N-MRSA) also doubled. By the end of 2002, the incidence of CA-MRSA had quadrupled and N-MRSA had tripled over the pre-2000 baseline. PROJECT: In August 2002, the infection control committee commissioned a task force (TF) to address this trend. Its primary goal was to implement the CDC Campaign to Prevent Antimicrobial Resistance. The first priority was to gain recognition and support from hospital leadership, then to aim advertising efforts at the entire hospital community. The TF was organized into four working groups (WGs). Each WG initiated at least one project. Project champions were chosen to lead each effort. The Prevent Infection (PI) WG sought to improve the number of inpatients immunized against influenza. In 2002-2003 only 95 inpatients were immunized. Diagnose and Treat (DT) chose to construct a standardized pathway for treatment of community-acquired pneumonia (CAP). No standard approach for management of CAP existed in 2002. Use Antibiotics Wisely (UAW) focused its efforts on establishing an antibiotic management team (AMT). In 2002, antibiotic oversight consisted of a specialized pharmacist and a restricted formulary requiring approval from an infectious disease (ID) fellow. Prevent Transmission (PT) implemented the CDC 2002 Guideline for Hand Hygiene in Health Care Settings. In 2002, poor hand hygiene practices were observed in many areas of the hospital. RESULTS: PI's campaign facilitated an increased influenza immunization of high-risk inpatients to >700 a year. DT involved multidisciplinary stakeholders to develop a CAP care path that was implemented in July 2004. Endpoints are tracked, and use of the pathway has increased. UAW established an AMT composed of an ID physician and a pharmacological doctor. Antimicrobial usage was reduced by 7%, and costs were reduced by 15% over the previous fiscal year. PT instituted an intense campaign to improve hand hygiene, which resulted in steady improvement. Since 2002, incidence of N-MRSA has decreased, while incidence of CA-MRSA has doubled. LESSONS LEARNED: Reduction of antibiotic-resistant organisms requires three components: support from leadership, effective project champions, and a marketing strategy to reach the entire workforce. The CDC's Campaign to Reduce Antimicrobial Resistance offers a vehicle and a strategy to reach these objectives.