Disinfection of central venous access device needleless connectors: A human factors analysis.

OBJECTIVE: Evidence-based central-line-associated bloodstream infection (CLABSI) prevention guidelines recommend the use of an antiseptic scrub to disinfect needleless connectors before device access. Guideline noncompliance may render disinfection ineffective. The goal of this study was to observe needleless-connector disinfection practices and to identify perceived facilitators and barriers to best practices of needleless-connector access. METHODS: A human factors mixed-methods study involving nursing focus groups of perceived barriers and facilitators and clinical observations of compliance with instructions and protocols for use of 3.15% chlorhexidine gluconate/70% isopropyl alcohol (CHG/IPA) and 70% isopropyl alcohol (IPA) antisepsis products for central venous access device (CVAD) needleless-connector disinfection was conducted in intensive care units (ICUs) at 2 academic medical centers. RESULTS: Access to the antiseptic product and lesser workload were identified as best-practice facilitators. Barriers were the time required per needleless-connector access and knowledge deficits. Of the 48 observed access events, 77% resulted in needleless-connector disinfection. The observed mean needleless-connector scrubbing times when using IPA were substantially below the recommended time. Drying time after product use was negligible. CONCLUSIONS: Lack of access to the disinfection product, emergency situations, and high workload were barriers to needleless-connector disinfection. Observed scrubbing and drying times were shorter than recommended, especially for IPA wipes. These needleless-connector disinfection deficits may increase the risk of CLABSI. Ongoing education and periodic competency evaluation of needleless-connector disinfection, improvement of supply management, and staffing workload are required to imbed and sustain best practices. Further study involving a larger sample size in diverse patient populations is warranted.

Outbreak of necrotizing enterocolitis caused by norovirus in a neonatal intensive care unit.

OBJECTIVES: To investigate an outbreak of necrotizing enterocolitis (NEC) in a neonatal intensive care unit (NICU) and to identify the etiology, describe illness risk factors, and develop control measures. STUDY DESIGN: A retrospective case-control study was performed including newborns with NEC and newborns without NEC, examining demographic factors and exposures to medications, staff members, and procedures before illness. Stool samples from affected newborns were collected and tested for bacteria, parasites, and viruses. RESULTS: We confirmed a NEC outbreak in the NICU in January 1998 with 8 cases, including 2 deaths, clustered in time and space. Norovirus-like particles were identified in all available stools from cases; norovirus (NoV) was confirmed with reverse transcriptase polymerase chain reaction in 4 of 6 samples. NEC cases were younger, had lower Apgar scores, and received antibiotics longer than 25 control subjects. Three NICU health care personnel had more contact with cases than control subjects; 1 staff member recalled having gastroenteritis symptoms around the time of the outbreak. CONCLUSIONS: This report associates NoV with NEC. NoV appeared to precipitate NEC in predisposed infants. Spatial clustering and epidemiologic links between cases and a health care worker with gastroenteritis suggests that NoV should be investigated among the etiologies of NEC outbreaks and that interventions targeted to interruption of NoV transmission should be considered.

Observational trial of antibiotic-coated central venous catheters in critically ill pediatric patients.

BACKGROUND: Catheter-associated bloodstream infections (CABSI) are among the most common and serious adverse events experienced by critically ill children. Randomized trials have demonstrated that the use of central venous catheters (CVC) coated with antiseptic solutions reduces rates of CABSI in adult patients; however, their efficacy in children has not been evaluated. OBJECTIVE: To compare the incidence of CABSI, rate of complications, and microbiology of infection in critically ill children treated with antibiotic-coated or noncoated CVC (NC-CVC). METHODS: A prospective observational trial was conducted in the pediatric intensive care unit (PICU) during a 13-month period. A minocycline-rifampin-coated CVC (MR-CVC) or NC-CVC was placed by PICU physicians who nonpreferentially selected CVC type. RESULTS: We studied the outcomes associated with the first CVC placed in 225 patients, including 69 MR-CVC and 156 NC-CVC. Patients who received MR-CVC, as compared with NC-CVC, were similar in gender, age, and severity of illness at time of PICU admission. The incidence density of CABSI did not vary by catheter type [MR-CVC: 7.53 per 1000 catheter-days (95% confidence interval 2.05-19.17); NC-CVC: 8.64 CABSI per 1000 catheter-days (95% confidence interval 3.74-16.96)]. However, the median time to infection in children with MR-CVC was 3-fold longer than in children with NC-CVC [18 versus 5 days (P = 0.053)]. No difference was seen in the incidence of complications, including thrombosis and catheter site reaction, between MR- and NC-CVC. No significant difference was observed in the types of organisms recovered from patients with MR- and NC-CVC. CONCLUSIONS: The use of MR-CVC significantly delayed the onset of CABSI in PICU patients. Larger, randomized trials are needed to better define potential differences in the incidence of CABSI, rate of complications, and microbiology of infection among pediatric patients treated with antiseptic-coated CVC and NC-CVC.

Risk adjustment for surgical site infection after median sternotomy in children.

OBJECTIVE: To determine whether the National Nosocomial Infections Surveillance (NNIS) System risk index adequately stratified a population of pediatric patients undergoing cardiac surgery according to the risk of developing surgical site infection (SSI). DESIGN: A retrospective, case-control study. SETTING: An urban tertiary care children's hospital. PATIENTS: Patients who had a median sternotomy performed between January 1, 1995, and December 31, 2003, were eligible for inclusion in the study. For all case patients, medical records were reviewed to verify that all patients met the case definition for SSI. Control subjects were chosen randomly from among all patients who underwent median sternotomy during the study period who did not develop SSI. RESULTS: Thirty-eight patients with SSI and 172 patients without SSI were included. One hundred six patients (50%) were male. The median patient age was 4 months. The sensitivity of the NNIS risk index with cutoff scores of 0 to 1 and 2 to 3 was 20%. The distribution of patients with SSI for an NNIS risk index score of 0 was 0%; for a score of 1, 80%; for a score of 2, 20%; and for a score of 3, 0%. The distribution of patients without SSI for a scores of 0 was 4%; for a score of 1, 87%; for a score of 2, 9%; and for a score of 3, 0%. The area under the receiver-operating characteristic curve (AUC) of the original NNIS risk index was 0.57. The modified risk indices did not perform significantly better, with an AUC range of 0.58 to 0.73. CONCLUSIONS: The NNIS risk index did not adequately stratify pediatric patients undergoing median sternotomy according to their risk of developing an SSI. Various modifications to the risk index yielded only slightly higher AUC values.

Administrative data fail to accurately identify cases of healthcare-associated infection.

OBJECTIVE: Some policy makers have embraced public reporting of healthcare-associated infections (HAIs) as a strategy for improving patient safety and reducing healthcare costs. We compared the accuracy of 2 methods of identifying cases of HAI: review of administrative data and targeted active surveillance. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional prospective study was performed during a 9-month period in 2004 at the Children's Hospital of Philadelphia, a 418-bed academic pediatric hospital. "True HAI" cases were defined as those that met the definitions of the National Nosocomial Infections Surveillance System and that were detected by a trained infection control professional on review of the medical record. We examined the sensitivity and the positive and negative predictive values of identifying HAI cases by review of administrative data and by targeted active surveillance. RESULTS: We found similar sensitivities for identification of HAI cases by review of administrative data (61%) and by targeted active surveillance (76%). However, the positive predictive value of identifying HAI cases by review of administrative data was poor (20%), whereas that of targeted active surveillance was 100%. CONCLUSIONS: The positive predictive value of identifying HAI cases by targeted active surveillance is very high. Additional investigation is needed to define the optimal detection method for institutions that provide HAI data for comparative analysis.

Delayed recognition of a pseudo-outbreak of Mycobacterium terrae.

Pseudo-outbreaks of mycobacteria are difficult to recognize because of long incubation periods for growth and species identification. We report our experience with one clinical microbiology laboratory that isolated a species of nontuberculous mycobacteria from 14 patient specimens. These specimens came from 12 patients at 2 hospitals over a 6-day period and included 6 different fluids or tissues. Because of the delay between mycobacterial specimen submission and growth in culture, the outbreak was not noted until more than a month later. Initial species determination by a reference laboratory indicated that these isolates were Mycobacterium fortuitum. One patient received treatment for presumed M fortuitum brain infection, and it was not effective in changing her clinical course. The isolates were sent to the Centers for Disease Control and Prevention (CDC) for identification and typing by pulsed-field gel electrophoresis. The CDC determined that the isolates were an identical strain of M terrae, thus confirming a pseudo-outbreak. Combining pseudo-outbreak isolates with those correctly identified initially as M terrae during the 6-day period in question, there were 22 samples from 20 patients with M terrae. Since the pseudo-outbreak, the number of cultures of M terrae in the clinical laboratory has returned to baseline levels without any specific intervention.

A national outbreak of Ralstonia mannitolilytica associated with use of a contaminated oxygen-delivery device among pediatric patients.

OBJECTIVES: In August 2005, the Centers for Disease Control and Prevention was notified of a Ralstonia species outbreak among pediatric patients receiving supplemental oxygen therapy with the Vapotherm 2000i (Vapotherm, Inc, Stevensville, MD). The Vapotherm 2000i is a reusable medical device that was used in >900 hospitals in the United States in 2005. Ralstonia are waterborne bacilli that have been implicated in hospital-acquired infections. We initiated an investigation to determine the source of the outbreak and implement infection control and prevention measures. PATIENTS AND METHODS: We performed a case-control study at 1 hospital and conducted national case findings to obtain clinical and environmental samples for laboratory analysis. Case-patients had health care-acquired Ralstonia colonization or infection. Isolates were compared by using pulsed-field gel electrophoresis. We tested manufacturer-recommended disinfection protocols for the Vapotherm 2000i under simulated-use conditions. RESULTS: Case-patients at the hospital (n = 5) were more likely to have received Vapotherm therapy than controls. Nationally, Ralstonia mannitolilytica was confirmed in 38 patients (aged 5 days to 7 years); 35 (92%) of the patients were exposed to the Vapotherm 2000i before recovery of the organism. Pulsed-field gel electrophoresis showed related R. mannitolilytica strains from isolates sent from 18 hospitals in 12 states. A Vapotherm machine reprocessed with a protocol proposed by the manufacturer grew Ralstonia spp after 7 days of simulated use. In December 2005, Vapotherm recalled the 2000i. CONCLUSIONS: Our findings suggest intrinsic contamination of Vapotherm devices with Ralstonia spp. New medical devices may provide therapy equivalent to current devices yet pose novel reprocessing challenges.