Acinetobacter baumannii is an emerging gram-negative pathogen that can cause healthcare-acquired infections among patients. Treatment is complicated for cases of healthcare-acquired infection with A. baumannii resistant to imipenem.

To elucidate the risk factors for imipenem-resistant A. baumannii (IRAB) infection or colonization and to identify the effect of resistance on clinical and economic outcomes.

We analyzed data from 2 medical centers of the University of Pennsylvania. Longitudinal trends in the prevalence of IRAB clinical isolates were characterized during the period from 1989 through 2004. For A. baumannii isolates obtained from 2001 through 2006, a case-control study was conducted to investigate the association between prior carbapenem use and IRAB infection or colonization, and a cohort study was performed to identify the effect of IRAB infection or colonization on mortality, length of stay after culture, and hospital cost after culture.

From 1989 through 2004, the annual prevalence of IRAB isolates ranged from 0% to 21%. During the period from 2001 through 2006, there were 386 unique patients with A. baumannii isolates, and 89 (23.1%) had IRAB isolates. Prior carbapenem use was independently associated with IRAB infection or colonization (adjusted odds ratio, 3.04 [95% confidence interval, 1.07–8.65]). There was a borderline significant association between IRAB infection or colonization and mortality, although this association was limited to isolates recovered from blood samples (adjusted odds ratio, 5.30 [95% confidence interval, 0.81–34.59]). Compared with patients with imipenem-susceptible A. baumannii infection or colonization, patients with IRAB infection or colonization had a longer hospital stay after culture (median, 21 vs 16 days; P = .07) and greater hospital charges after culture (mean, $334,516 vs $276,059; P = .03). After controlling for patient location in an intensive care unit, transfer from another facility, and length of hospital stay before culture, there was no longer an independent association between IRAB infection or colonization and higher cost after culture and length of stay after positive culture result.

Many A. baumannii isolates exhibit imipenem resistance, which is strongly associated with prior use of carbapenems. Given the high mortality rate associated with A. baumannii infection or colonization, interventions to curb further emergence of cases of IRAB infection and strategies to optimize therapy are needed.

The risk of latent tuberculosis (LTBI) in healthcare workers (HCWs) is high. Until recently, the tuberculin skin test (TST) was the only diagnostic test available for Mycobacterium tuberculosis infection. A new enzyme-linked immunosorbent assay test, the QuantiFERON-TB Gold (QFT-G) test, was recommended by the US Centers for Disease Control and Prevention as an alternative test for the diagnosis of LTBI in HCWs. The purpose of our study was to compare the TST and the QFT-G test in Spanish HCWs in order to improve procedures for the detection of LTBI.

A cross-sectional study with blinded comparison of TST and QFT-G test results was carried out among 134 HCWs at an 800-bed Spanish university hospital. The level of interferon-7 production stimulated by the QFT-G test was measured. A concentration of at least 0.35 IU/mL was considered a positive result. An induration of at least 5 mm in non-BCG-vaccinated or at least 15 mm in BCG-vaccinated HCWs for the TST was considered positive.

Of the 134 HCWs included (mean age, 33.4 years; 101 [75.4%] women; 47 [35.1%] BCG vaccinated), the LTBI prevalence diagnosed with any test was 11.2% (95% confidence interval, 6.6%-18.1%), with the TST was 8.96%, and with the QFT-G test was 5.97% (nonsignificant differences). The QFT-G test value was higher in subjects with TST induration of at least 15 mm than in subjects with TST induration of less than 15 mm (P < .001). Overall agreement between the results of the two tests was found in 94% of HCWs (K = 0.56), but agreement was only 59% in HCWs who had a positive result for both tests. Disagreement was present in the results found for 5% of HCWs.

Few studies have compared both tests in populations with high M. tuberculosis exposure but low BCG vaccination prevalence. Agreement between both tests is high, especially among negative Results. Studies are needed to clarify the reasons for disagreement and to establish the best TST and QFT-G test cutoff point.

During fall 2005, personal stockpiling of oseltamivir for use during an outbreak of H5N1 influenza virus infection was widely reported. The present study aimed to identify indications for oseltamivir prescriptions to determine whether oseltamivir that was not intended for seasonal influenza was inappropriately consumed and to compare persons who were likely to have stockpiled oseltamivir and those who did not with respect to their knowledge, understanding, concerns, and expectations regarding avian influenza.

Survey to evaluate usage patterns for oseltamivir and assess views about avian influenza.

A total of 109 outpatients who received a prescription for oseltamivir between September 1, 2005, and December 31, 2005, and 825 matched control subjects.

Of 109 prescriptions, 36 (33.0%) were prescribed for patients with appropriate indications. Sixty-eight (62.4%) of 109 patients identified as having received oseltamivir and 440 (53.3%) of 825 individuals identified as not having received it responded to the questionnaire. Only 2 prescription recipients whose oseltamivir was not intended for immediate consumption reported that they had consumed the oseltamivir. Persons who probably intended to stockpile oseltamivir were older and more often white than those unlikely to stockpile it. They also reported greater worry about avian influenza and more often expected avian influenza to spread to the United States than those unlikely to stockpile, but there were no significant differences in responses to other questionnaire items.

A large proportion of the oseltamivir prescriptions written in fall 2005 were probably intended for personal stockpiling. Similarities in participants' responses to questionnaire items suggest that educational campaigns may not be an effective method to curtail stockpiling of antimicrobial medications during an infectious threat. Promoting appropriate prescribing practices among providers may be a better means by which to minimize personal stockpiling.

To review the effect of interventions, including a complete restriction in the use of fluoroquinolones (FQs), used to control an outbreak of hospital-onset Clostridium difficile infection (HO-CDI) caused primarily by the epidemic North American pulsed-field gel electrophoresis type 1 strain.

Retrospective cohort and case-control study of all episodes of HO-CDI both before and after 2 interventions.

Community hospital; January 1, 2005, through March 31, 2007.

Complete, 5-month, facility-wide restriction of fluoroquinolone use, during which a change in the environmental-services contractor occurred.

During a 27-month period, 319 episodes of HO-CDI occurred. The hospital-wide mean defined daily doses of antimicrobials decreased 22% after restricting FQ use, primarily because of a 66% decrease in the use of FQs. The interventions were also associated with a significant change in the HO-CDI incidence trends and with an absolute decrease of 22% in HO-CDI cases caused by the epidemic strain (from 66% before the intervention period to 44% during and after the intervention period; P = .02). Univariate analysis revealed that case patients with HO-CDI due to the epidemic strain were more likely than control patients, who did not have diarrhea, to receive a FQ, whereas case patients with HO-CDI due to a nonepidemic strain were not. However, FQ use was not significantly associated with HO-CDI in multivariable analysis.

An outbreak of epidemic-strain HO-CDI was controlled at a community hospital after an overall decrease in antimicrobial use, primarily because of a restriction of FQ use and a change in environmental-services contractors. The restriction of FQ use may be useful as an adjunct control measure in a healthcare facilities during outbreaks of epidemic-strain HO-CDI.

Few data are available on methicillin-resistant Staphylococcus aureus (MRSA) colonization in day care. We performed a study in a medical university child care center to study the epidemiology of MRSA in this population.

Survey.

A child care center on the campus of a university medical center.

One hundred four children who attended the child care center and 32 employees gave samples that were cultured for MRSA. Seventeen household members of the children and employee found to be colonized with MRSA also gave samples that were cultured. Parents and employees completed questionnaires about demographic characteristics, medical conditions and treatments, and possible exposure risks outside the child care center. In addition, 195 environmental samples were taken from sites at the childcare center. Isolates were analyzed for relatedness by use of molecular typing, and statistical analysis was performed.

The prevalence of MRSA in the children was 6.7%. One employee (3.1%) was colonized with MRSA. Cultures of samples given by 6 of 17 (35.3%) family members of these children and the employee yielded MRSA. MRSA was recovered from 4 of 195 environmental samples. Molecular typing revealed that many of the MRSA isolates were indistinguishable, and 18 of the 21 isolates were community-associated MRSA. Multivariable analysis revealed that receipt of macrolide antibiotics (P = .002; odds ratio, 39.6 [95% confidence interval, 3.4—651.4]) and receipt of asthma medications (P = .024; odds ratio, 26.9 [95% confidence interval, 1.5-500.7]) were related to MRSA colonization.

There was a low prevalence of MRSA colonization in children and employees in the child care center but a higher prevalence of colonization in their families. Molecular typing showed that transmission of MRSA likely occurred in the child care center. The use of macrolide antibiotics and asthma medications may increase the risk of MRSA colonization in this population.

To validate the National Nosocomial Infections Surveillance system risk index through administrative data to predict surgical site infections.

Retrospective cohort study.

Population-based analysis in Ontario, Canada.

All elderly patients who underwent elective surgery from April 1, 1992, through March 31, 2006 (n = 469,349).

Data on procedural and patient outcomes were gathered from linked population-wide hospital discharge records and physician claims. The 75th percentile of surgical duration was estimated through anesthesiologist billing fees recorded in 15-minute increments; the American Society of Anesthesiology score of at least 3 out of 5 was estimated by diagnostic codes for severe systemic illness; and all surgeries were classified as clean or clean-contaminated because of their elective nature (thus, the maximum score on the modified index was 2).

A total of 147,216 surgeries (31%) had a score of 0;246,592 (53%) had a score of 1; and 75,541 (16%) had a score of 2 on the modified index. The 30-day risk of surgical site infection increased with each increment in the modified index (score of 0, 5.4%; score of 1, 8.0%; score of 2, 14.3%; P < .001). The association was evident for surgical site infection diagnosed during the index admission (score of 0, 2.0%; score of 1, 3.7%; score of 2, 8.9%; P < .001), as well as that associated with reoperation or death (score of 0, 0.04%; score of 1, 0.23%; score of 2, 0.73%; P < .001). The modified index predicted increases in surgical site infection risk within each of 11 surgical subgroups. In accord with past research, the modified index had modest discrimination (C statistic, 0.59), and the majority of surgical site infections (72%) occurred within lower risk strata.

The modified index predicts surgical site infection in population-based analyses and is associated with incremental increases in risk.

To examine the impact of different acellular pertussis booster vaccination strategies on the probability of a nosocomial pertussis outbreak occurring and the distribution of outbreak sizes observed for each intervention strategy.

Neonatal intensive care unit.

We developed a stochastic, agent-based simulation model to examine the impact of booster vaccination strategies for pertussis on health care-related transmission.

Our results demonstrate that healthcare worker booster vaccination decreases the probability of secondary transmission from 49% (base case, no boosting) to 2% (if 95% of healthcare workers are boosted) and decreases final outbreak size. Boosting family caregivers did not have a clinically significant impact on nosocomial disease transmission.

The provision of booster vaccine to healthcare workers in the neonatal intensive care unit substantially reduces the risk of hospital-centered pertussis outbreaks in a manner that enhances the health of hospitalized children. A formal health economic analysis of this finding is currently under way. Policies to protect patient safety in pediatric facilities should include compliance with the United States Advisory Committee on Immunization Practices, which recommends provision of pertussis booster vaccination to healthcare workers.

To provide a novel way to predict the likelihood that antibiotic therapy will result in prompt, adequate therapy on the basis of local microbiological data.

Prospective study conducted at 3 medical intensive care units at the Viennese General Hospital, a tertiary care medical university teaching hospital in Vienna, Austria.

One hundred one patients who received mechanical ventilation and who met the criteria for having ventilator-associated pneumonia.

Fiberoptic bronchoscopic examination was performed, and bronchoalveolar samples were collected. Samples were analyzed immediately by a single technician. Minimum inhibitory concentrations were determined for imipenem, cephalosporins (cefepime and cefpirome), ciprofloxacin, and piperacillin-tazobactam, and drug resistance rates were calculated. These drug resistance rates were translated into the likelihood of inadequate therapy (LIT; the frequency of inadequately treated patients per antibiotic and drug-resistant strain), cumulative LIT (the cumulative frequency of inadequately treated patients), and syndrome-specific LIT.

Amongthe 101 bronchoalveolar samples, culture yielded significant (at least 1 × 104 colony-forming units per raL) polymicrobial findings for 34 and significant monomicrobial findings for 31; 36 culture results were negative. Of the isolates from patients with ventilator-associated pneumonia who had monomicrobial culture findings, 33% were gram-positive bacteria and 20% were gram-negative bacteria. LIT suggested that 1 of 2 patients was treated inadequately for Pseudomonas aeruginosa infection. The LIT for patients with ventilator-associated pneumonia revealed that the rank order of antibiotics for appropriate therapy was (1) imipenem, (2) cephalosporins, (3) ciprofloxacin, and (4) piperacillin-tazobactam. These calculations were based solely on microbiological data.

The novel ratio LIT may help clinicians use microbiological data on drug resistance to predict which antimicrobial agents will provide adequate therapy. In daily practice, this new approach may be helpful for choosing adequate antimicrobial therapy.

To evaluate the usefulness of an adenosine triphosphate (ATP) bioluminescence assay for assessing the efficacy of daily hospital cleaning practices.

A 2-phase prospective intervention study.

A university-affiliated community teaching hospital.

During phase I of our study, 5 high-touch surfaces in 20 patient rooms were sampled before and after daily cleaning. Moistened swabs were used to sample these surfaces and were then plated onto routine and selective media, and aerobic colony counts were determined after 48 hours of incubation. Specialized ATP swabs were used to sample the same high-touch surfaces in the 20 patient rooms and were then placed in luminometers, and the amount of ATP present was expressed as relative light units. During phase II of our study, after in-service housekeeper educational sessions were given, the housekeepers were told in advance when ATP readings would be taken before and after cleaning.

During phase I, the colony counts revealed that the 5 high-touch surfaces were often not cleaned adequately. After cleaning, 24 (24%) of the 100 surface samples were still contaminated with methicillin-resistant Staphylococcus aureus, and 16 (16%) of the 100 surface samples still yielded vancomycin-resistant enterococci. ATP readings (expressed as relative light units) revealed that only bathroom grab bars and toilet seats were significantly cleaner after daily cleaning than before. During phase II, a total of 1,013 ATP readings were obtained before and after daily cleaning in 105 rooms. The median relative light unit was significantly lower (ie, surfaces were cleaner) after cleaning than before cleaning for all 5 high-touch surfaces.

Suboptimal cleaning practices were documented by determining aerobic colony counts and by use of an ATP bioluminescence assay. ATP readings provided quantitative evidence of improved cleanliness of high-touch surfaces after the implementation of an intervention program.

Needlestick injuries are the most common injuries that occur among operation room personnel in the health care service. The risk of infection after a needlestick injury during surgery greatly depends on the quantity of pathogenic germs transferred at the point of injury. The aim of this study was to measure the quantity of blood transferred at the point of a percutaneous injury by using radioactively labeled blood.

This study was conducted to evaluate the risk of infection through blood contact by simulating surgical needlestick injuries ex vivo. The tests were conducted by puncturing single and double latex gloves with diverse sharp devices and objects that were contaminated with Technetium solution–labeled blood.

A mean volume of 0.064 μL of blood was transferred in punctures with the an automatic lancet at a depth of 2.4 mm through 1 layer of latex. When the double-gloving indicator technique was used, a mean volume of only 0.011 μL of blood was transferred (median, 0.007 μL); thus, by wearing 2 pairs of gloves, the transferred volume of blood was reduced by a factor of 5.8.

The results revealed that double gloving leads to a significant reduction in the quantity of blood transferred during needlestick injury.

The aim of this study was to determine potential risk factors for mortality in patients with nosocomial Stenotrophomonas maltophilia pneumonia.

A retrospective, single-center, observational study.

A 2400-bed tertiary teaching hospital in southern Taiwan.

This retrospective study evaluated patients (age, at least 18 years) with nosocomial pneumonia (S. maltophilia isolated from respiratory culture) who were seen at Kaohsiung Chang Gung Memorial Hospital over a 3-year period. A total of 406 patients (64% male, mean age ± standard deviation, 69.6 ± 14.93 years; mean duration of hospital stay ± standard deviation, 57.5 ± 39.47 days) were included.

Most index isolates (53.9%) were from the first sample cultured. Polymicrobial isolates were cultured from samples from 177 (43.6%) of the 406 study patients. The most common copathogen was Pseudomonas aeruginosa (53.11% of isolates). The all-cause hospital mortality rate was 42.6% (173 deaths among 406 patients). Survivors had a shorter time from admission to a positive index culture result than did nonsurvivors (26.1 vs 31.7 days; P = .04). Mortality was significantly higher among patients with malignancy (adjusted odds ratio [AOR], 2.48; 95% confidence interval [CI], 1.52–4.07; P < .001 ), renal disease (AOR, 2.6; 95% CI, 1.51–4.47; P = .001), intensive care unit stay (AOR, 1.72; 95% CI, 1.1–2.7; P = .018), and inadequate initial empirical antibiotic therapy (AOR, 2.17; 95% CI, 1.4–3.38; P = .001).

S. maltophilia pneumonia is associated with a high mortality rate and is commonly associated with concomitant polymicrobial colonization or infection. Underlying comorbidities and inadequate initial empirical antibiotic therapy substantially account for increased mortality rates.

The sterility assurance level of 10−6 is an established standard that defines the quality of sterile products. The aim of the present study was to develop a method that correlated the results from microbial-barrier testing of flexible sterile barrier systems with the estimated microbial challenge that the package encounters during storage and transport.

The effectiveness of microbial-barrier packaging was determined by the use of an exposure chamber test with 20 periodic atmospheric pressure changes of 50 and 70 hPa. Flexible peel pouches were used as sterile barrier systems. The logarithmic reduction value of a sterile barrier system was calculated on the basis of the experimental results and compared with the logarithmic reduction value required for the microbial challenges to maintain sterility during transport and storage.

For pouches made of paper and plastic-film material, a logarithmic reduction value of 5.4 was obtained on the basis of 30 of 99 plates becoming nonsterile after being exposed to a 50 hPa difference in periodic atmospheric pressure changes. For pouches made of paper and plastic-film material, a logarithmic reduction value of 5.2 was obtained on the basis of 48 of 100 plates becoming nonsterile after being exposed to a 70 hPa difference in atmospheric pressure. For pouches made of nonwoven and plastic-film material, logarithmic reduction values of 6.38 (ie, 3 of 99 plates became nonsterile after being exposed to a 50 hPa pressure difference) and 6.07 (ie, 3 of the 99 plates became nonsterile after being exposed to a 70 hPa pressure difference) were obtained. Calculating an expected microbial challenge during transport and storage that requires barrier properties corresponding to a logarithmic reduction value of 5.83 and taking the sterility assurance level into account, we found that only the nonwoven pouches fulfilled the European standard EN 556-1.

Using the data obtained in a microbial exposure test with a specified flow rate of a bacterial aerosol, we found that the effectiveness of the sterile barrier system against the actual microbial challenge can be examined and evaluated at the sterility assurance level of 10−6.

To investigate whether the reduction effect due to participation in a nosocomial infection surveillance system for laboratory-confirmed central venous catheter (CVC)-associated primary bloodstream infection (BSI), ventilator-associated pneumonia (VAP), and surgical site infection (SSI) is reproducible for different time periods, independent of confounding factors that might occur during a specific time period.

Data from the German national nosocomial infection surveillance system from the period January 1997 through June 2008 were used. CVC-associated BSI data and SSI data were analyzed for 3 starting periods, and VAP data were analyzed for 2 starting periods. Monthly infection rates were calculated for the following 36 months, and relative risks comparing the first and third surveillance years of each period were calculated.

A total of 2,399 CVC-associated BSI cases from 267 intensive care units, 3,637 VAP cases from 150 intensive care units, and 829 SSIs following 3 different procedures from 113 departments were analyzed. A significant reduction in VAP was shown for both starting periods investigated (overall relative risk [RR], 0.80 [95% CI, 0.74-0.86]). A significant reduction in CVC-associated BSI was demonstrated for 2 of 3 starting periods (overall RR, 0.83 [95% CI, 0.75-0.91]). A significant reduction in SSI was found for 2 starting periods for knee prosthesis insertion (overall RR, 0.56 [95% CI, 0.38-0.82]), for all of the 3 starting periods for cesarean delivery (overall RR, 0.75 [95% CI, 0.61-0.93]), and for none of the 3 starting periods for endoscopically performed cholecystectomy (overall RR, 0.89 [95% CI, 0.62-1.27]).

The surveillance effect, manifest as a significant reduction of nosocomial infection rates between the first and third years of participation in a surveillance system, was observed independently from the calendar year in which the surveillance activities started.

To describe the epidemiology and control of 2 separate outbreaks of pertussis at a large tertiary care center and the resource consumption associated with these outbreaks.

Descriptive study.

The Mayo Clinic in Rochester, Minnesota, a tertiary care center catering to both referral patients and patients from the community.

We reviewed routine and enhanced surveillance data collected by infection prevention and control practitioners during the outbreaks. Pertussis was diagnosed either on the basis of a nasopharyngeal specimen positive for Bordetella pertussis by use of polymerase chain reaction (PCR) or on the basis of a compatible clinical syndrome along with an epidemiologic link to PCR-confirmed cases.

Two pertussis outbreaks, the first community based and the second hospital based (ie, due to transmission among healthcare personnel), occurred during the period from October 2004 through October 2005. In the first outbreak from November 2004 through March 2005, there were 109 cases diagnosed; 105 (96%) of these cases were diagnosed on the basis of a nasopharyngeal specimen positive for B. pertussis by use of PCR. Adolescents 10-19 years of age were most affected (77 cases [71%]). Only 13 cases (12%) occurred among healthcare personnel; however, many healthcare personnel required postexposure prophylaxis. A second outbreak of 122 cases occurred during the period from July through October 2005; of these 122 cases, 96 (79%) were diagnosed on the basis of a nasopharyngeal specimen positive for B. pertussis by use of PCR, and 64 (52%) involved healthcare personnel. There were many instances of transmission among healthcare personnel and from patients to healthcare personnel, but no documented transmission from healthcare personnel to Patients. The outbreaks were controlled by aggressive case finding, treatment of those infected, prophylaxis of all healthcare personnel and patients who had contact with both probable and confirmed cases, implementation of educational efforts, and compliance with respiratory etiquette. Vaccination of healthcare personnel against pertussis began in October 2005.

Pertussis remains a public health problem. Outbreaks in healthcare facilities consume the resources of those facilities in terms of personnel, testing, treatment of cases, and prophylaxis of those individuals who were in contact with those cases. Adult vaccination may reduce the disease burden.

Because of an increase in the rate of surgical site infections (SSIs) following spinal procedures at the study hospital, we conducted a study to determine risk factors associated with the development of a SSI.

Case-control study.

A community hospital in Houston, Texas, with more than 500 beds.

Fifty-five case patients who developed SSI after spinal surgery and 179 control patients who did not develop SSI after spinal surgery.

We examined patient- and hospital-associated risk factors for SSI by using existing data on patients who underwent spinal operations at the study hospital between December 2003 and August 2005. Multivariable analysis was conducted using logistic regression to determine significant risk factors associated with SSI.

The presence of comorbidities (odds ratio [OR], 3.15 [95% confidence interval (CI), 1.20-8.26]) and surgical duration greater than the population median of 100 minutes (OR, 2.48 [95% CI, 1.12-5.49]) were identified as independent risk factors for SSI. The use of only povidone-iodine for preoperative skin antisepsis was found to be protective (OR, 0.16 [95% CI, 0.06-0.45]). Specific operating room, hospital staff involved in the procedures, workers' compensation status, method of hair removal, smoking status, or incontinence were not statistically significant.

The presence of comorbidities and increased surgical duration are risks for postoperative infection. The use of only povidone-iodine was found to decrease the risk of infection.

Observational surveys of hand hygiene compliance are time consuming. Measuring the use of a hand hygiene product is a less time-consuming method of monitoring the frequency of hand hygiene performance.

To evaluate the usefulness of electronic devices for monitoring alcohol-based hand rub use.

Prospective observational trial.

A university-affiliated teaching hospital.

Prototypes of an electronic device designed to record each time a dispenser is used (hereafter referred to as a hand hygiene event) were placed in alcohol-based hand rub dispensers on the general medical ward and in the surgical intensive care unit. Data were downloaded wirelessly to a data logger and then uploaded to a dedicated Web site for analysis. Alcohol-based hand rub dispensers were located in patient rooms and in corridors.

During a 6-month trial, 105,462 hand hygiene events occurred in the surgical intensive care unit, and 44,845 events occurred on the general medical ward. The dispensers located in patient rooms accounted for 47% of the hand hygiene events performed in the surgical intensive care unit but for only 36% of events on the general medical ward (P<.001). The dispensers most often used were located in corridors. Hand hygiene events were most common on Tuesdays, Wednesdays, and Thursdays, between 7:00 AM and 11:00 AM.

The use of these electronic devices provided an efficient and accurate method of monitoring the frequency of alcohol-based hand rub performance on the general medical ward and in the surgical intensive care unit, and yielded more detailed information on usage patterns than did expressing use as liters per 1,000 patient-days. The wireless downloading of data from dispensers required a limited amount of time, and the dedicated Web site facilitated data analysis. Such devices should prove useful in monitoring the impact of various interventions on the frequency of hand hygiene performance.