Number Of Bloodstream Infections Research Articles

Antimicrobial Stewardship in the Emergency Department Observation Unit: Definition of a New Indicator and Evaluation of Antimicrobial Use and Clinical Outcomes.

We aimed to define a novel indicator for monitoring antimicrobial use specifically in the Emergency Department Observation Unit (EDOU) and to assess the long-term impact of an institutional education-based antimicrobial stewardship program (ASP) on the antimicrobial prescribing pattern and clinical outcomes in this setting. A quasi-experimental interrupted time-series study was performed from 2011 to 2022. An educational ASP was implemented at the EDOU in 2015. To estimate changes in antimicrobial use, we designed an indicator adjusted for patients at risk of antimicrobial prescribing: defined daily doses (DDDs) per 100 patients transferred from the Emergency Department to the Observation Unit (TOs) per quarter. The number of bloodstream infections (BSIs) and the crude all-cause 14-day mortality were assessed as clinical outcomes. Antimicrobial use showed a sustained reduction with a trend change of -1.17 DDD per 100 TO and a relative effect of -45.6% (CI95% -64.5 to -26.7), particularly relevant for meropenem and piperacillin-tazobactam, with relative effects of -80.4% (-115.0 to -45.7) and -67.9% (-93.9 to -41.9), respectively. The incidence density of all BSIs increased significantly during the ASP period, with a relative effect of 123.2% (41.3 to 284.7). The mortality rate remained low and stable throughout the study period, with an absolute effect of -0.7% (-16.0 to 14.7). The regular monitoring of antimicrobial use in the EDOU by using this new quantitative indicator was useful to demonstrate that an institutional education-based ASP successfully achieved a long-term reduction in overall antimicrobial use, with a low and steady BSI mortality rate.

Implementation of a PCR-based strategy to control an outbreak by Serratia marcescens in a Neonatal Intensive Care Unit

ObjectivesTo evaluate the clinical and epidemiological impact of a new molecular surveillance strategy based on qPCR to control an outbreak by Serratia marcescens in a Neonatal Intensive Care Unit (NICU).MethodsWe design a specific qPCR for the detection of S. marcescens in rectal swabs of patients admitted to a NICU. We divided the surveillance study into two periods: (a) the pre-PCR, from the outbreak declaration to the qPCR introduction, and (b) the PCR period, from the introduction of the qPCR until the outbreak was solved. In all cases, S. marcescens isolates were recovered and their clonal relationship was analysed by PFGE. Control measures were implemented during the outbreak. Finally, the number of bloodstream infections (BSI) was investigated in order to evaluate the clinical impact of this molecular strategy.ResultsNineteen patients colonized/infected by S. marcescens were detected in the pre-PCR period (October 2020–April 2021). On the contrary, after the PCR implementation, 16 new patients were detected. The PFGE revealed 24 different pulsotypes belonging to 7 different clonal groups, that were not overlapping at the same time. Regarding the clinical impact, 18 months after the qPCR implementation, no more outbreaks by S. marcescens have been declared in the NICU of our hospital, and only 1 episode of BSI has occurred, compared with 11 BSI episodes declared previously to the outbreak control.ConclusionsThe implementation of this qPCR strategy has proved to be a useful tool to control the nosocomial spread of S. marcescens in the NICU.

Multilocus Sequence Typing of Emerging Azole-Resistant Candida auris Isolates from Critically Ill Patients in a New York City Medical Center

Abstract Candida auris has developed into a slow-moving global pandemic since its emergence in 2009, particularly as a source of nosocomial infection amongst immunocompromised and critically-ill patients. According to CDC data, C. auris emergence has accelerated in the US during the COVID-19 pandemic and has garnered particular attention for its high level of resistance to multiple classes of antifungals. C. auris has been categorized into five genetically diverse clades, each with unique antifungal drug resistance patterns. We have observed a sharp increase in cases identified at our tertiary medical center in New York City over the past three years. In this study, we designed a set of C. auris-specific oligonucleotides to determine the clonality of isolates through Multilocus Sequence Typing (MLST) of four genetic loci known to have a high level of divergence amongst Candida species. From 2020 through 2022 we identified 22 patients with C. auris bloodstream infection at our institution by Matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) and performed MLST on isolates that were available from 19 patients. We assessed four genetic loci: ITS1/ITS2, D1/D2, RPB1 and RPB2; ERG11 was included to assess for mutations associated with fluconazole resistance. We found that the number of blood stream infections increased from 2 cases in 2020 to 12 in 2022. Our MLST results showed that all C. auris isolates from blood and body fluids belong to CDC-defined Clade 1c, which carries the ERG11 gene mutation resulting the amino acid substitution K143R in 14-α-Demethylase associated with fluconazole resistance. These isolates also demonstrated fluconazole resistance by in vitro testing (19/19), amphotericin resistance was present in 44% of isolates with available data (7/16), and all isolates were susceptible to micafungin (19/19). Of 19 patients with blood cultures positive for C. auris, 13 (68%) were in a critical care setting at time of collection, 17 (89%) had been in an ICU during the same admission, and 8 (42%) expired within 3 months of C. auris positivity. MLST is considered a relatively fast and inexpensive method of sequence-based strain typing and has recently been applied to assessing the clonality of C. auris isolates. We show that the use of C. auris-specific oligonucleotides for sequencing, rather than those derived from other Candida species, produces high quality data for MLST, as well as the detection of specific mutations involved in antifungal resistance, such as ERG11. Further assessment is needed by the gold standard in sequence typing, Whole Genome Sequencing (WGS), to confirm our analysis of clonality here. MLST may therefore represent a useful tool in understanding the interrelatedness of invasive C. auris infections in hospitalized patients as well as inform clinical decision-making around infection control and empiric antifungal therapy.

Economic Evaluations of New Antibiotics: The High Potential Value of Reducing Healthcare Transmission Through Decolonization.

Antibiotics designed to decolonize carriers of drug-resistant organisms could offer substantial population health benefits, particularly if they can help avert outbreaks by interrupting person-to-person transmission chains. However, cost effectiveness of an antibiotic is typically evaluated only according to its benefits to recipients, which can be difficult to demonstrate for carriers of an organism that may not pose an immediate health threat to the carrier. We developed a mathematical transmission model to quantify the effects of 2 hypothetical antibiotics targeting carbapenem-resistant Enterobacteriaceae (CRE) among long-term acute care hospital inpatients: one assumed to decrease the death rate of patients with CRE bloodstream infections (BSIs) and the other assumed to decolonize CRE carriers after clinical detection. We quantified the effect of each antibiotic on the number of BSIs and deaths among patients receiving the drug (direct effect) and among all patients (direct and indirect effect) compared to usual care. We applied these results to a cost-effectiveness analysis with effectiveness outcome of life-years gained and assumed costs for antibiotic doses and for CRE BSI. The decolonizing antibiotic, once indirect effects were included, produced increased relative effectiveness and decreased relative costs compared to both usual care and the BSI treatment antibiotic. In fact, in most scenarios, the decolonizing drug was the dominant treatment strategy (ie, less costly and more effective). Antibiotics that decolonize carriers of drug-resistant organisms can be highly cost-effective when considering indirect benefits within populations vulnerable to outbreaks. Public health could benefit from finding ways to incentivize development of decolonizing antibiotics in the US, where drugs with unclear direct benefits to recipients would pose difficulties in achieving FDA approval and financial benefit to the developer.

407. Utilization of Blood Cultures, Risk factors and Outcomes of Bloodstream Infections in Patients Hospitalized with COVID-19

BackgroundDuring the coronavirus disease 2019 (COVID-19) surge, there was a sharp increase of blood cultures (BC) performed at Henry Ford Health System (HFHS). However, the epidemiology and outcomes of bloodstream infections (BSI) in COVID-19 patients (pts) remains undefined. We report the utilization of blood cultures, risk factors and mortality associated with BSI in a large cohort of COVID-19 pts.MethodsA retrospective analysis was performed of all COVID-19 pts that had BC performed during hospitalization at HFHS, a 5-hospital system in southeast Michigan. BSI was defined using NHSN criteria. Demographics, comorbidities, severity of illness, and outcome of pts with and without BSI were compared.ResultsFrom 3/10/2020 to 4/28/2020, 2541 pts were hospitalized with lab-confirmed COVID-19. 1393 (55%) of these pts had BC performed and 80 (5.74%) met criteria for BSI. Of the 84 pathogens identified, Staphylococcus aureus was most common (Figure 1). As compared to 1313 COVID-19 pts without BSI, those with BSI were older (70.1 vs 64.5 years, P = 0.0024). Other factors significantly associated with BSI included chronic kidney disease, higher mSOFA score, ICU stay and mechanical ventilation (all P < 0.0001) (Table 1). Multivariate analysis revealed age (OR, 1.07 CI [1.06–1.08]), ICU stay (OR, 7.91 [CI: 5.75–10.87]) and mSOFA score (OR, 1.29 [CI: 1.13–1.47]) were independent risk factors associated with mortality. BSI was not associated with increased mortality (Table 3). ConclusionAlthough more than half of hospitalized COVID-19 pts had BC done, the number of BSI were low suggesting overutilization of BC. BSI was associated with older age and disease severity. Mortality was not affected by BSI but was primarily driven by age and severity of illness.Disclosures Indira Brar, MD, Gilead (Speaker’s Bureau)janssen (Speaker’s Bureau)ViiV (Speaker’s Bureau) Marcus Zervos, MD, Melinta Therapeutics (Grant/Research Support)

Bacteriological study of blood stream infection (BSI) in ICU patients

Introduction: Blood stream infection is a most common health care associated infection causes significant disease and death worldwide. Patients are admitted to ICUs carry higher risk of nosocomial BSI than those who are admitted in other type of units. Early Identification of causative agents & their antibiotic sensitivity pattern are useful to reduce mortality & improve clinical outcome of the patients. Materials and Methods: A prospective study conducted in tertiary care hospital. During study all the patients monitor for nosocomial blood stream \ infection. Blood sample collected from suspected patient of blood stream infection for detection causative organism & antimicrobial susceptibility pattern. Result: A Total 620 samples were tested out of these 173 (27.90%) were positive growth in culture. Maximum number of blood stream infections were from paediatric ICU (69.62%), followed by Medical ICU (18.35%) and from surgical ICU (12.02%). In present study incidence of length of stay is more after five day of admission in ICU (68.35%). The incidence of blood stream infection due to gram positive organism was (51.28%). Among them Staphylococcus aureus 72 (45.56%) was most common organism. Gram negative organism were quite low (48.73%) among them Klebsiella spp. (16.45%) was most common. The antimicrobial susceptibility pattern of isolated organisms showed high resistance to routinely used antimicrobial agents. Conclusion: The systemic approach by studying the culture of organisms from the foci and blood culture and the antibiotic profile may help the clinician to select appropriate empirical antimicrobial agents. Keywords: Antimicrobial sensitivity, Causative organisms, Intensive care Units, Nosocomial blood stream infection.

2439. The role of positive externalities in economic evaluations of new antibiotics: modeling the impact of reduced transmission in healthcare facilities

BackgroundPositive externalities - beneficial spillover effects enjoyed by individuals who are not the primary consumers of a good - are rarely considered in cost-effectiveness analyses (CEAs) of antimicrobial drugs that could reduce person-to-person transmission of the target pathogen. We developed a compartmental model to simulate the effect of 2 hypothetical antibiotics targeting carbapenem-resistant Enterobacteriaceae (CRE) among hospital inpatients: one that treats bloodstream infections (BSIs) and one that decolonizes carriers. We assessed the contribution of positive externalities to the results of CEAs of these 2 antibiotics in the model.MethodsOur model tracked patients according to CRE carriage, clinical infection, and detection status. Rates of CRE acquisition depended on transmissibility of carriers in different states and were calibrated to data from long-term acute care hospitals. For the BSI treatment scenario we assumed the new drug would decrease the death rate and transmissibility of patients after CRE BSI onset. For the decolonization scenario we assumed the new drug would increase clearance of CRE carriage after clinical detection. For each scenario, we quantified the drug’s effect on the number of BSIs and deaths among patients receiving the drug (direct effect) and among all patients (total effect, i.e., direct plus indirect effect) compared with usual care. For the CEAs, the effectiveness outcome was life-years (LYs) gained and we assumed the new drug cost of $4,000 per dose and cost of a CRE BSI of $24,788.ResultsFor both the BSI treatment and decolonization scenarios, the total effect of introducing the new drug was greater than the direct effect alone, indicating the existence of positive externalities. Relative to usual care, the new drug led to a decrease in incremental cost and an increase in incremental effectiveness (see Figures 1 and 2).ConclusionThe inclusion of positive externalities in CEAs can have important effects on whether these new antibiotics are deemed cost-effective, due to their potential for interrupting chains of transmission. In our model, the inclusion of these effects reduced the incremental cost and increased the incremental effectiveness of these antibiotics. Disclosures All authors: No reported disclosures.

PB1672 REVIEW OF BLOODSTREAM INFECTION IN ADULT PATIENTS OF ACUTE LYMPHOBLASTIC LEUKEMIA TREATED WITH HYPERCVAD – A TERTIARY CENTRE EXPERIENCE

Background:Aside from high relapse rate, the toxicity of HyperCVAD also renders the management of adult patients with acute lymphoblastic leukemia (ALL) challenging. Cycle A of HyperCVAD includes cyclophosphamide, vincristine and doxorubicin while cytarabine and methotrexate are the key components in cycle B.Aims:This study aims to evaluate the bloodstream infection (BSI) of HyperCVAD in ALL patients at Tuen Mun Hospital (TMH).Methods:In this retrospective single centre study from January 2013 to June 2017, 18 de novo ALL patients (7 Philadelphia‐positive, 7 Philadelphia‐negative and 4 T‐lineage) were treated with HyperCVAD +/‐ tyrosine kinase inhibitor (TKI). Anti‐bacterial prophylaxis was not routinely prescribed in our centre. Complete blood count was checked once every two days during chemotherapy and patients would receive granulocyte colony‐stimulating factor (G‐CSF) if there was grade 3 or above neutropenia. Septic workup would be performed when body temperature was ≥ 38 oC. Intravenous piperacillin‐tazobactam or levofloxacin in case of penicillin allergy would be started and intravenous vancomycin would be added in patients with history of methicillin‐resistant Staphylococcus aureus (MRSA) infection. Antibiotics would be adjusted in accordance with culture results and sensitivity profiles. BSI was defined as positive blood culture of a recognized pathogen from a single blood culture or of a common commensal from multiple blood cultures. The primary outcome is the measure of BSIs in incidence density, defined as the number of BSIs per patient‐day. Secondary outcomes include periods of neutropenia in each cycle, organism types and sensitivity profilesResults:The median age of this cohort was 50 years old (21‐67 years old) and 13 (72%) patients were of good past health. Among 88 admissions for HyperCVAD, 31 episodes of BSIs were documented in 16 patients. Three (16.7%) patients had more than one BSI in a single admission. The overall incidence density was 17.9 BSIs per 1,000 patient‐days. The incidence density of BSIs was significantly higher in induction phase (23.8 BSIs per 1,000 patient‐days) and cycle B (Median: 20.6 BSIs per 1,000 patient‐days) when compared with that of cycle A (Median: 5.9 BSIs per 1,000 patient‐days) (p = 0.008). Patients with BSIs were associated with significantly longer duration of neutropenia than those without BSIs (9 days vs. 5 days, p &lt; 0.001). The addition of TKI in Philadelphia‐positive patients did not result in more BSI compared with Philadelphia‐negative or T‐lineage ALL patients (p = 0.294). Gram‐negative bacilli (GNB) accounted for 71% of BSIs and half of the GNB were Escherichia coli. 45.5% of E. coli were extended spectrum beta‐lactamase (ESBL) producing. The remaining 29% of BSIs were caused by gram‐positive cocci (GPC) with Streptococcus mitis as the most common GPC. Majority of cases (61%) did not have an identifiable source of infection. There were three deaths directly related to BSIs.Summary/Conclusion:Bloodstream infection is more common in induction phase and cycle B of HyperCVAD and gram negative bacilli are the main causative agents. Antibacterial prophylaxis can be considered but the emerging drug resistance imposes great challenges. More studies on the effectiveness of antibacterial prophylaxis in the era of multidrug resistant organisms are necessary.

The Changing Epidemiology of Bloodstream Infections and Resistance in Hematopoietic Stem Cell Transplantation Recipients

Objective:Patients receiving hematopoietic stem cell transplantation (HSCT) are exposed to highly immunosuppressive conditions and bloodstream infections (BSIs) are one of the most common major complications within this period. Our aim, in this study, was to evaluate the epidemiology of BSIs in these patients retrospectively.Materials and Methods:The epidemiological properties of 312 patients with HSCT were retrospectively evaluated.Results:A total of 312 patients, followed between 2000 and 2011, who underwent autologous (62%) and allogeneic (38%) HSCT were included in the study. The most common underlying malignancies were multiple myeloma (28%) and Hodgkin lymphoma (21.5%). A total of 142 (45%) patients developed at least 1 episode of BSI and 193 separate pathogens were isolated from the blood cultures. There was a trend of increase in the numbers of BSIs in 2005-2008 and a relative increase in the proportion of gram-positive infections in recent years (2009-2011), and central venous catheter-related BSI was found to be most common source. Coagulase-negative staphylococci (49.2%) and Acinetobacter baumannii (8.8%) were the most common pathogens. Extended-spectrum beta-lactamase-producing strains were 23% and 22% among Escherichia coli and Klebsiella spp. isolates, respectively. Quinolone resistance was detected in 10% of Enterobacteriaceae. Resistance to carbapenems was not detected in Enterobacteriaceae, while it was seen at 11.1% and 23.5% in Pseudomonas and Acinetobacter strains, respectively.Conclusion:A shift was detected from gram-negative bacteria to gram-positive in the etiology over the years and central lines were the most common sources of BSIs.

Impact of Red Blood Cell and Platelet Transfusions in Acute Myeloid Leukemia (AML) Patients Undergoing Remission Induction Chemotherapy

Background: Induction chemotherapy (IC) in Acute Myeloid Leukemia (AML) leads to significant bone marrow suppression. The standard clinical practice to prevent or manage cytopenia related complications, namely anemia or bleeding, has been red blood cell (RBC) and platelet (PLT) transfusion. Accumulating evidence suggests no advantage to patients (pts) managed with liberal transfusion strategies compared to a restrictive approach. However, prior studies excluded patients with bone marrow failure conditions such as AML; hence it remains unclear whether a similar approach can be extrapolated for AML pts. We undertook this study to evaluate the effects of transfusions on treatment outcomes and complications in AML.Methods: Adult pts diagnosed with AML (excluding acute promyelocytic leukemia) at the Cleveland Clinic from 01/2008 - 12/2012 who underwent IC with 7+3 (full dose of cytarabine and anthracycline) and had complete adverse event data were included. Variables including demographics, preexisting comorbidities, AML disease characteristics, organ dysfunction (neurologic, cardiac, pulmonary, renal, hepatic, bleeding and thromboembolic events), infections (bloodstream infection, pneumonia and clostridium difficile associated diarrhea) and treatment response [complete remission (CR), incomplete remission (CRi), persistent disease (PD) and 30-day mortality] were assessed. The outcome of interest was any correlation between the total number of PLT and/or RBC transfusions and (i) organ impairment, (ii) infections, and (iii) treatment outcomes during the induction period. Culture confirmed bloodstream infections included vancomycin resistant enterococcus (VRE), gram-positive bacteria (except VRE), gram-negative bacilli and fungemia. Univariable and multivariable logistic regression models adjusted for potential confounders were performed for each outcome category. Odds ratio (OR) with 95% confidence intervals (CI) are reported.Results: Of 192 pts, 48% (n=93) were female, 85% (n=163) were Caucasian, 54% (n=103) were <60 years, (yrs, range, 19-82), and 17% (n=33) received 2 cycles of induction chemotherapy. Disease characteristics were - de novo AML 89% (n=170) and secondary AML 12% (n=22). Cytogenetic risk groups per CALGB 8461 criteria were - favorable 21% (n=41), intermediate 46% (n=89), unfavorable 24% (n=46), and unknown cytogenetics 8% (n=16). 67% of patients achieved CR (n=128), 15% (n=29) achieved CRi and 14% (n=27) had PD following IC. The median number of RBC and PLT transfusions received during remission induction chemotherapy was 12 RBCs (range 0-49) and 10 PLTs (range 0-62) (figure 1 and 2).In univariable analysis a higher number of RBC and PLT transfusions was associated with an increased risk of bloodstream infections (OR=1.03; CI,1.01-1.05; p=0.001). In multivariable analysis increased number of transfused RBCs and PLTs was associated with lower CR rates (OR=0.94; CI,0.91-0.97; p<0.001) and slightly increased risk for major adverse cardiac events (OR=1.04; CI,1.02-1.07; p=0.002), pulmonary events (OR=1.04; CI,1.02-14.07; p=0.004), neurologic events (OR 1.14; CI,1.07-1.22; p<0.001) and VRE bacteremia (OR=1.04; CI,1.01-1.08; p=0.005). There was no statistically significant association between transfusion and renal dysfunction (OR 1.02; CI,0.99-1.06, p=0.15), liver injury (OR=1.02; CI,1.00-1.05; p=0.067), thromboembolic events (OR=1.02; CI,0.98-1.05; p=0.28), total number of blood stream infections (OR 1.03; CI,1.00-1.05; p=0.019) and 30-day mortality (OR=0.98; CI,0.93-1.03; p=0.56).Conclusion: In multivariable analysis the number of RBC and PLT transfusions during AML IC is associated with a slightly increased risk for cardiac, pulmonary and some infectious complications. Higher numbers of transfusions also appear to be associated with lower CR rates. These data can inform future prospective studies designed to determine the benefits and risks of a restrictive transfusion policy in the AML population. [Display omitted] [Display omitted] DisclosuresSekeres:TetraLogic: Membership on an entity's Board of Directors or advisory committees; Celgene Corporation: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees.

Preventing Central Line Infections with a ‘Quality Nurse’

The number of bloodstream infections from central lines diminished considerably when a unit-based “quality nurse” was assigned to monitor and guide infection control practices.

Mortality and Hospital Stay Associated with Resistant Staphylococcus aureus and Escherichia coli Bacteremia: Estimating the Burden of Antibiotic Resistance in Europe

The relative importance of human diseases is conventionally assessed by cause-specific mortality, morbidity, and economic impact. Current estimates for infections caused by antibiotic-resistant bacteria are not sufficiently supported by quantitative empirical data. This study determined the excess number of deaths, bed-days, and hospital costs associated with blood stream infections (BSIs) caused by methicillin-resistant Staphylococcus aureus (MRSA) and third-generation cephalosporin-resistant Escherichia coli (G3CREC) in 31 countries that participated in the European Antimicrobial Resistance Surveillance System (EARSS). The number of BSIs caused by MRSA and G3CREC was extrapolated from EARSS prevalence data and national health care statistics. Prospective cohort studies, carried out in hospitals participating in EARSS in 2007, provided the parameters for estimating the excess 30-d mortality and hospital stay associated with BSIs caused by either MRSA or G3CREC. Hospital expenditure was derived from a publicly available cost model. Trends established by EARSS were used to determine the trajectories for MRSA and G3CREC prevalence until 2015. In 2007, 27,711 episodes of MRSA BSIs were associated with 5,503 excess deaths and 255,683 excess hospital days in the participating countries, whereas 15,183 episodes of G3CREC BSIs were associated with 2,712 excess deaths and 120,065 extra hospital days. The total costs attributable to excess hospital stays for MRSA and G3CREC BSIs were 44.0 and 18.1 million Euros (63.1 and 29.7 million international dollars), respectively. Based on prevailing trends, the number of BSIs caused by G3CREC is likely to rapidly increase, outnumbering the number of MRSA BSIs in the near future. Excess mortality associated with BSIs caused by MRSA and G3CREC is significant, and the prolongation of hospital stay imposes a considerable burden on health care systems. A foreseeable shift in the burden of antibiotic resistance from Gram-positive to Gram-negative infections will exacerbate this situation and is reason for concern.

Decreasing candidaemia rate in abdominal surgery patients after introduction of fluconazole prophylaxis

Although abdominal surgery is an established risk factor for invasive candidiasis, the precise role of antifungal prophylaxis in these patients is not agreed upon. In 2007, fluconazole was added to the prophylactic antibiotic treatment for patients with gastrointestinal tract perforations or reoperation after colorectal surgery in two university hospitals in Copenhagen. Changes in candidaemia rates associated with this intervention were examined and potential interfering factors evaluated. Rates and clinical characteristics of candidaemias and other blood stream infections (BSIs) in abdominal surgery patients were compared before (1 January 2006 to 30 June 2007) and after the intervention (1 January 2008 to 30 June 2009). The departments’ activity was assessed by number of bed-days, admissions and surgical procedures, and the consumption of antifungals was analysed. The candidaemia rate decreased from 1.5/1000 admissions in the pre-intervention to 0.3/1000 admissions in the post-intervention period (p 0.002). Numbers of BSIs and bed-days remained stable, and numbers of admissions and surgical procedures performed increased during the study period. Fluconazole consumption in the two abdominal surgery departments increased from 4.6 to 12.2 defined daily doses per 100 bed-days (p <0.001), and 3.2 to 5.0 (p 0.01), respectively, but remained unchanged in the intensive care units. We could not detect any increase in fluconazole-resistant strains (14/29 pre- and 2/7 post-intervention, p 0.43). The introduction of fluconazole prophylaxis was followed by a significantly decreased candidaemia rate. However, the observational study design does not allow conclusions regarding causality. No increase in resistance was detected, but follow-up was short and continuing surveillance is needed.

Escherichia coli and Staphylococcus aureus: bad news and good news from the European Antimicrobial Resistance Surveillance Network (EARS-Net, formerly EARSS), 2002 to 2009

Based on data collected by the European Antimicrobial Resistance Surveillance Network (EARS-Net) and the former EARSS, the present study describes the trends in antimicrobial susceptibility patterns and occurrence of invasive infections caused by Escherichia coli and Staphylococcus aureus in the period from 2002 to 2009. Antimicrobial susceptibility results from 198 laboratories in 22 European countries reporting continuously on these two microorganisms during the entire study period were included in the analysis. The number of bloodstream infections caused by E. coli increased remarkably by 71% during the study period, while bloodstream infections caused by S. aureus increased by 34%. At the same time, an alarming increase of antimicrobial resistance in E. coli was observed, whereas for S. aureus the proportion of meticillin resistant isolates decreased. The observed trend suggests an increasing burden of disease caused by E. coli. The reduction in the proportion of meticillin-resistant S. aureus and the lesser increase in S. aureus infections, compared with E. coli, may reflect the success of infection control measures at hospital level in several European countries.

Bloodstream infections: the problem and the challenge

Bloodstream infections (BSI) are an indisputable cause of morbidity and mortality. These infections may originate in the community setting among healthy individuals or among patients actively receiving healthcare as on dialysis, chemotherapy, etc. The largest numbers of BSI, however, are nosocomial. Rates of nosocomial BSI are highest in ICU's but the greatest numbers of cases occur in non-ICU settings. Many are catheter related. Application of simple principles of intravenous catheter placement and maintenance can markedly reduce nosocomial BSI. Although treatment of BSI can be difficult, the greatest challenge is preventing these infections.

Epidemiology of Bloodstream Infections in Patients Receiving Long-term Total Parenteral Nutrition

To describe the epidemiology and microbiologic characteristics of bloodstream infections (BSIs) in patients receiving long-term total parenteral nutrition (TPN). Home TPN therapy has been reported as a risk factor for BSI. However, little knowledge exists regarding the epidemiology of BSIs in this patient group. A descriptive, observational epidemiologic study of patients receiving long-term TPN from January 1981 to July 2005 was performed. Variables analyzed include age, gender, time of follow-up, number of BSIs, microbiologic characteristics, underlying disease necessitating long-term TPN, catheter type, complications related to TPN, and clinical outcome. Forty-seven patients receiving long-term TPN were evaluated. The most frequent indication for long-term TPN was ischemic bowel disease (25.5%). The mean duration of follow-up was 4.5 years. Thirty-eight patients (80.9%) developed 248 BSIs while receiving TPN. More than 1 BSI episode occurred in 78.9% of these patients, and 23.8% of BSI episodes were polymicrobial. The most prevalent pathogen was coagulase negative staphylococci (33.5%). The most frequent complication among patients with BSI was central venous thrombosis (44.7%). Five patients were intravenous drug users. There were 11 deaths among the patients on long-term TPN, 4 of these were related to infection and 4 were related to intravenous drug use. The incidence of BSI is high, and a significant proportion of BSIs in long-term TPN patients are polymicrobial and due to multidrug-resistant bacteria and fungi. Careful management of the infusion line is required and interventions are needed to reduce the risk of catheter-related infections in this population.

Diversification inSalmonellaTyphimurium DT104

Diversification in<i>Salmonella</i>Typhimurium DT104

Clonal Spread of a Vancomycin-Resistant Enterococcus faecium Strain among Bloodstream-Infecting Isolates in Italy

Recent data indicated that the rate of vancomycin resistance in bloodstream-infecting enterococcal isolates in Italy is one of the highest in Europe. The aims of this study were to characterize bloodstream-infecting vancomycin-resistant enterococci (VRE) obtained from various Italian hospitals and to establish whether the isolates were clonally related. During the years 2001 to 2003, a total of 39 VRE isolates were obtained from 19 hospital laboratories in various areas of Italy. Species identification and resistance genotypes of the isolates were obtained by multiplex PCR. Further characterization included antibiotic susceptibility testing, pulsed-field gel electrophoresis (PFGE) of SmaI-digested genomic DNA, detection of virulence genes (esp and hyl), and multilocus sequence typing (MLST) of selected isolates. VRE were identified as 31 Enterococcus faecium (VREfm) isolates and 8 E. faecalis isolates. All but one isolate carried the vanA gene; one VREfm isolate carried the vanB gene. Analysis of the PFGE profiles showed that 28 VREfm isolates shared a similar electrophoretic profile, designed type 1, and were clonally related. All type 1 isolates were resistant to ampicillin, streptomycin, gentamicin, and rifampin and were positive for the esp gene. MLST identified an allelic profile (ST78) comprising purK allele 1, belonging to the C1 clonal lineage, characteristic of human infection and hospital outbreak isolates. The vanB-carrying VREfm isolate, of PFGE type 2, was shown to be a single-locus variant of ST78. Our data indicate that the recent increase in the number of bloodstream infections caused by VRE in Italy is due to the spread of a hospital-adapted, multidrug-resistant VREfm clone belonging to an internationally disseminated lineage.

Kaiser Permanente National Hand Hygiene Program.

Hand hygiene has historically been identified as an important intervention for preventing infection acquired in health care settings. Recently, the advent of waterless, alcohol-based skin degermer and elimination of artificial nails have been recognized as other important interventions for preventing infection. Supplied with this information, the National Infection Control Peer Group convened a KP Hand Hygiene Work Group, which, in August 2001, launched a National Hand Hygiene Program initiative titled "Infection Control: It's In Our Hands" to increase compliance with hand hygiene throughout the Kaiser Permanente (KP) organization. The infection control initiative was designed to include employee and physician education as well as to implement standard hand hygiene products (eg, alcohol degermers), eliminate use of artificial nails, and monitor outcomes. From 2001 through September 2003, the National KP Hand Hygiene Work Group coordinated implementation of the Hand Hygiene initiative throughout the KP organization. To date, outcome monitoring has shown a 26% increase in compliance with hand hygiene as well as a decrease in the number of bloodstream infections and methycillin-resistant Staphylococcus aureus (MRSA) infections. As of May 2003, use of artificial nails had been reduced by 97% nationwide. Endorsement of this Hand Hygiene Program initiative by KP leadership has led to implementation of the initiative at all medical centers throughout the KP organization. Outcome indicators to date suggest that the initiative has been successful; final outcome monitoring will be completed in December 2003.

Nosocomial infections among HIV-positive and HIV-negative patients in a Brazilian infectious diseases unit

Background: Some researchers observed that HIV-infected patients have a higher risk of acquiring nosocomial infections (NI). This study compared the incidence of NI among HIV-positive and HIV-negative inpatients. Methods: Patients from an infectious diseases ward who were classified as positive and negative regarding their HIV status were followed-up for 21 months in a prospective cohort study. Daily surveillance was made with use of Centers for Disease Prevention and Control criteria for NI. Results: NI per 1000 patients-day were 8.16 for HIV-positive patients and 3.94 for HIV-negative patients (P =.01). Central venous catheter (CVC) and urinary catheter utilization was significantly higher among HIV-positive patients than among HIV-negative patients (P <.001). Bloodstream infections (BSI) caused most of the NI, followed by urinary tract infections, vascular infections, and pneumonia. Overall, HIV-positive patients were more likely to have a BSI than were HIV-negative patients (P =.005). When only BSI was analyzed in patients with a CVC, there was no difference in the incidence of BSI between the 2 groups of patients (P =.24). HIV-positive patients were more likely to have an NI caused by Staphylococcus aureus than were HIV-negative patients (P =.04). Other important NI agents in both groups were Acinetobacter baumanii, Klebsiella pneumoniae, Pseudomonas aeruginosa , and coagulase-negative Staphylococcus. Conclusions: In this study the HIV-positive patients were more likely to have NI than were the HIV-negative patients. Overall, HIV-positive patients are at increased risk for an NI caused either by S aureus or a BSI. Although HIV-positive patients had more CVC-days, there was no difference in the number of BSI among both groups, suggesting that the BSI incidence in the HIV-positive group is not exclusively related to the CVC. (Am J Infect Control 2002;30:346-50.)