To assess the rate of and the risk factors for the detection of methicillin-resistant S. aureus (MRSA) and vancomycin-resistant enterococci (VRE) on the protective gowns and gloves of healthcare workers (HCWs).

We observed the interactions between HCWs and patients during routine clinical activities in a 29-bed medical intensive care unit at the University of Maryland Medical Center, an urban tertiary care academic hospital. Samples for culture were obtained from HCWs' hands prior to their entering a patient's room, from HCWs' disposable gowns and gloves after they completed patient care activities, and from HCWs' hands immediately after they removed their protective gowns and gloves.

Of 137 HCWs caring for patients colonized or infected with MRSA and/or VRE, 24 (17.5%; 95% confidence interval, 11.6%–24.4%) acquired the organism on their gloves, gown, or both. HCW contact with the endotracheal tube or tracheostomy site of a patient (P < .05), HCW contact with the head and/or neck of a patient (P < .05), and HCW presence in the room of a patient with a percutaneous endoscopic gastrostomy and/or jejunostomy tube (P < .05) were associated with an increased risk of acquiring these organisms.

The gloves and gowns of HCWs frequently become contaminated with MRSA and VRE during the routine care of patients, and particularly during care of the patient's respiratory tract and any associated indwelling devices. As part of a larger infection control strategy, including high-compliance hand disinfection, they likely provide a useful barrier to transmitting antibiotic-resistant organisms among patients in an inpatient setting.

To evaluate the adequacy of discharge room cleaning and the impact of a cleaning intervention on the presence of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) on environmental surfaces in intensive care unit (ICU) rooms.

Prospective environmental study.

Convenience sample of ICU rooms in an academic hospital.

The intervention consisted of (1) a change from the use of pour bottles to bucket immersion for applying disinfectant to cleaning cloths, (2) an educational campaign, and (3) feedback regarding adequacy of discharge cleaning. Cleaning of 15 surfaces was evaluated by inspecting for removal of a preapplied mark, visible only with an ultraviolet lamp (“black light”). Six surfaces were cultured for MRSA or VRE contamination. Outcomes of mark removal and culture positivity were evaluated by X2 testing and generalized linear mixed models, clustering by room.

The black-light mark was removed from 44% of surfaces at baseline, compared with 71 % during the intervention (P < .001). The intervention increased the likelihood of removal of black-light marks after discharge cleaning (odds ratio, 4.4; P < .001), controlling for ICU type (medical vs surgical) and type of surface. The intervention reduced the likelihood of an environmental culture positive for MRSA or VRE (proportion of cultures positive, 45% at baseline vs 27% during the intervention; adjusted odds ratio, 0.4; P = .02). Broad, flat surfaces were more likely to be cleaned than were doorknobs and sink or toilet handles.

Increasing the volume of disinfectant applied to environmental surfaces, providing education for Environmental Services staff, and instituting feedback with a black-light marker improved cleaning and reduced the frequency of MRSA and VRE contamination.

To identify risk factors for acquisition of methicillin-resistant Staphylococcus aureus (MRSA) in patients exposed to an MRSA-colonized roommate.

Retrospective cohort study.

A 472-bed acute-care teaching hospital in Toronto, Canada.

Inpatients who shared a room between 1996 and 2004 with a patient who had unrecognized MRSA colonization.

Exposed roommates were identified from infection-control logs and from results of screening for MRSA in the microbiology database. Completed follow-up was defined as completion of at least 2 sets of screening cultures (swab samples from the nares, the rectum, and skin lesions), with at least 1 set of samples obtained 7–10 days after the last exposure. Chart reviews were performed to compare those who did and did not become colonized with MRSA.

Of 326 roommates, 198 (61.7%) had completed follow-up, and 25 (12.6%) acquired MRSA by day 7–10 after exposure was recognized, all with strains indistinguishable by pulsed-field gel electrophoresis from those of their roommate. Two (2%) of 101 patients were not colonized at day 7–10 but, with subsequent testing, were identified as being colonized with the same strain as their roommate (one at day 16 and one at day 18 after exposure). A history of alcohol abuse (odds ratio [OR], 9.8 [95% confidence limits {CLs}, 1.8, 53]), exposure to a patient with nosocomially acquired MRSA (OR, 20 [95% CLs, 2.4,171]), increasing care dependency (OR per activity of daily living, 1.7 [95% CLs, 1.1, 2.7]), and having received levofloxacin (OR, 3.6 [95% CLs, 1.1,12]) were associated with MRSA acquisition.

Roommates of patients with MRSA are at significant risk for becoming colonized. Further study is needed of the impact of hospital antimicrobial formulary decisions on the risk of acquisition of MRSA.

Use of active surveillance cultures for methicillin-resistant Staphylococcus aureus (MRSA) for all patients admitted to the intensive care unit has been shown to reduce nosocomial transmission. However, the cost-effectiveness and the utility of implementing use of active surveillance cultures nationwide remain controversial. We sought to develop an artificial neural network (ANN) model that would predict the likelihood of MRSA colonization.

Two acute care hospitals, one in Pittsburgh (hospital A) and one in Kaohsiung, Taiwan (hospital B).

Nasal cultures were performed for all patients admitted to the hospitals. A total of 46 potential risk factors in hospital A and 86 potential risk factors in hospital B associated with MRSA colonization were assessed. Culture results were obtained; 75% of the data were used for training our ANN model, and the remaining 25% were used for validating our ANN model. The culture results were the “gold standard” for determining the accuracy of the model predictions.

The ANN model predictions were accurate 95.2% of the time for hospital A (sensitivity, 94.3%; specificity, 96.0%) and 94.2% of the time for hospital B (sensitivity, 96.6%; specificity, 91.8%), integrating all potential risk factors into the model. Only 17 potential risk factors were needed for the hospital A ANN model (accuracy, 90.9%; sensitivity, 98.5%; specificity, 83.4%), and only 20 potential risk factors were needed for the hospital B ANN model (accuracy, 90.5%; sensitivity, 96.6%; specificity, 84.3%), if the minimal risk factor method was used. Cross-validation analysis showed an average accuracy of 85.6% (sensitivity, 91.3%; specificity, 80.0%).

Our ANN model can be used to predict with an accuracy of more than 90% which patients carry MRSA. The false-negative rates were significantly lower than the false-positive rates in the ANN predictions, which can serve as a safety buffer in case of patient misclassification.

To investigate whether there is a correlation between the rates of antimicrobial drug consumption in hospital departments and the prevalence of antimicrobial resistance among clinically important bacteria recovered in the hospital.

Retrospective study.

Tertiary care hospital in Greece.

Data on antimicrobial consumption (from January 2001 through December 2004) were expressed as defined daily doses per 100 bed-days. The prevalence of antimicrobial resistance among isolates of Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, and Enterococcusfaecium recovered during the same time period were calculated by the microbiology department. We then performed the following analyses: (1) a comparison of the consumption rates for different antimicrobial groups in individual hospital departments, (2) a comparison of the prevalence of resistance to different antimicrobials, and (3) a correlation analysis of antimicrobial consumption rates and the prevalence of antimicrobial resistance.

The rates of antimicrobial consumption and the prevalence of resistance varied substantially among the hospital's departments. The annual rate of consumption for carbapenems correlated with the rate of consumption for glycopeptides and third-generation cephalosporins (P < .05). Among P. aeruginosa isolates, the prevalence of imipenem resistance correlated with the prevalence of resistance to amikacin, ciprofloxacin, and ceftazidime (P < .05). The rate of carbapenem consumption correlated with the prevalence of imipenem resistance among P. aeruginosa and A. baumannii isolates (P < .05). The rate of aminoglycoside consumption correlated with the prevalence of amikacin resistance among P. aeruginosa, K. pneumoniae, and E. coli isolates (P < .05). However, the rate of consumption for fluoroquinolones and glycopeptides had no correlation with the prevalence of ciprofloxacin resistance among gram-negative bacteria or vancomycin resistance among E. faecium isolates.

These data are suggestive of a differential relationship between antimicrobial consumption and the prevalence of antimicrobial resistance among various species and for various antimicrobial agents. These findings may help to optimize antimicrobial prescription policies in the hospital, especially in departments that have both high rates of antimicrobial consumption and a high prevalence of antimicrobial resistance.

To quantify the economic burden of in-hospital surgical site infections (SSIs) at a European university hospital.

Matched case-control study nested in a prospective observational cohort study.

Basel University Hospital in Switzerland, where an average of 28,000 surgical procedures are performed per year.

All in-hospital occurrences of SSI associated with surgeries performed between January 1, 2000, and December 31, 2001, by the visceral, vascular, and traumatology divisions at Basel University Hospital were prospectively recorded. Each case patient was matched to a control patient by age, procedure code, and National Nosocomial Infection Surveillance System risk index. The case-control pairs were analyzed for differences in cost of hospital care and in provision of specialized care.

A total of 6,283 procedures were performed:187 SSIs were detected in inpatients, 168 of whom were successfully matched with a control patient. For case patients, the mean additional hospital cost was SwF19,638 (95% confidence interval [CI], SwF8,492–SwF30,784); the mean additional postoperative length of hospital stay was 16.8 days (95% CI, 13–20.6 days); and the mean additional in-hospital duration of antibiotic therapy was 7.4 days (95% CI, 5.1–9.6 days). Differences were primarily attributable to organ space SSIs (n = 76).

Ina European university hospital setting, SSIs are costly and constitute a heavy and potentially preventable burden on both patients and healthcare providers.

To study the incidence of sepsis in the Valencian Community (Spain) during a period of 10 years (1995–2004).

We downloaded data on discharge diagnoses of septicemia in all 26 public hospitals in the Valencian Community during the 10-year study period, as well as the additional discharge diagnoses of each patient.

We identified 33,767 cases of sepsis during the study period. The age-standardized incidence rates among men increased from 64.11 (95% confidence interval [CI], 60.37–67.85) cases per 100,000 population in 1995 to 114.02 (95% CI, 109.02–118.50) cases per 100,000 population in 2004 (P < .001), and those among women increased from 45.08 (95% CI, 42.01–48.15) cases per 100,000 population in 1995 to 83.62 (95% CI, 79.85–87.39) cases per 100,000 population in 2004 (P < .001). Gram-negative bacteria were the most frequently involved microorganisms (in 21.4% of cases), and there was a significant increase in the number of sepsis cases caused by these organisms from 1999 onward. The mortality rate was approximately 42.5% among patients hospitalized for sepsis, and mortality was associated with organ failure. In addition, mortality was associated with the microorganism responsible not being known, with infection due to fungi, and with polymicrobial sepsis.

The rates of hospitalization both for sepsis overall and for severe sepsis in the Valencian Community (Spain) are lower than those in other countries but are increasing, by 5% each year. The increase in the number of cases in which gram-negative bacteria are the cause of sepsis is notable.

To implement a system for monitoring of rare events based on statistical process control charts.

Statistical process control plotting by g chart of clinical microbiology laboratory data.

Primary and secondary care Norwegian hospital with a 9-bed intensive care unit.

During the winter of 2001–2002 in Norway, there was a national monoclonal nosocomial outbreak of Pseudomonas aeruginosa infection mainly affecting patients in intensive care units. In the present work, we demonstrate how the use of SPC at one of the affected hospitals would have detected this outbreak several weeks before the alert from the Norwegian National Public Health Institute (NIPH). By plotting the monthly incidence rate of P. aeruginosa infection (with a c chart), we found that the hospital would have been alerted in February, by plotting the number of days between events (with a g chart), we found that the hospital would have detected a process already out of control in early January 2002. Not until 9 weeks later (ie, mid-March) did the NIPH declare the P. aeruginosa outbreak to be national, and a commercially produced mouth swab contaminated during the manufacturing process was found to be the source.

The plotting of rare events, such as an outbreak of nosocomial infection, with a g chart may be used for early detection of a process out of control.

To evaluate the knowledge of healthcare students after four curricula on infection control and to identify sources of information.

Cross-sectional study.

Four healthcare schools at Rouen University (Rouen, France).

Medical students, nursing students, assistant radiologist students, and physiotherapist students taking public health courses.

To measure students' knowledge of infection control and their sources of information, 6 multiple-choice questions were asked about 3 specific areas: standard precautions, hand hygiene, and nosocomial infection. Each questionnaire section had 10 possible points, for an overall perfect score of 30. The sources of information for these 3 areas were also recorded: self-learning, practice training in wards, formal training in wards, and teaching during the curriculum. A logistic regression analysis was performed to identify factors associated with acceptable level of knowledge.

Three hundred fifty students (107 medical students, 78 nursing students, 71 physiotherapist students, and 94 assistant radiologist students) were included in the study. The mean overall score (±SD) was 21.5 ± 2.84. Nursing students had a better mean overall score (23.2 ± 2.35) than did physiotherapist students (21.9 ± 2.36), medical students (21.1 ± 2.35), and assistant radiologist students (20.5 ± 3.04; P < .001). The mean scores (±SD) for the component sections of the questionnaire were 8.5 ±1.4 for standard precautions, 7.4 ± 1.26 for hand hygiene, and 5.7 ± 1.55 for nosocomial infections (P < .001). The main source of information was material taught during the curriculum. Results of multivariate analysis indicate that the probability of attaining acceptable knowledge in each area was smaller for medical students and assistant radiologist students than for nursing students.

The overall score for infection control indicated that instruction was effective; however, knowledge levels were different by area (the best scores were results of tests of standard precautions) and curriculum (nursing students achieved the best overall score). Ward training for daily infection control practice (ie, bedside instructions training and course work) could be improved for healthcare students.

Thailand is one of 22 countries designated by the World Health Organization as “high burden” with regard to tuberculosis. Preventing nosocomial tuberculosis transmission remains an important, unmet need. We investigated the adequacy of current practices to evaluate hospitalized patients for tuberculosis, which is critical in preventing delayed diagnosis and nosocomial tuberculosis transmission.

Thailand conducts active, population-based surveillance for pneumonia in 2 rural provinces. Case report forms are completed for all persons who are hospitalized and meet a case definition of having clinical pneumonia. We analyzed how frequently patients had an adequate diagnostic evaluation for infectious pulmonary tuberculosis, in accordance with national guidelines. We conducted multivariate analyses to determine patient and health-system factors associated with an inadequate diagnostic evaluation for tuberculosis and with tuberculosis disease.

Of 8,853 cases of clinical pneumonia between September 2003 and March 2006,73% were in patients not adequately evaluated for tuberculosis. Acid-fast bacilli (AFB)–positive tuberculosis was diagnosed in 188 cases, which was 2% of all pneumonia cases and 12% of pneumonia cases in patients adequately evaluated for tuberculosis. Diagnostic evaluations for tuberculosis were less commonly performed among those who were younger than 25 years of age, were female, and lacked cough, sputum production, hemoptysis, and dyspnea. Among patients adequately evaluated, a clinical syndrome of no cough, no hemoptysis, and normal chest radiography findings had a 95% negative predictive value.

The prevalence of AFB-positive, pulmonary tuberculosis was high among adults hospitalized with clinical pneumonia in Thailand. Most patients were not adequately evaluated for tuberculosis. Efforts are needed to improve identification and diagnosis of infectious tuberculosis cases in hospitalized patients.