Risk factors and outcomes of infections caused by extremely drug-resistant gram-negative bacilli in patients hospitalized in intensive care units.

BACKGROUND: Extremely drug-resistant gram-negative bacilli (XDR-GNB) increasingly cause health care-associated infections (HAIs) in intensive care units (ICUs). METHODS: A matched case-control (1:2) study was conducted from February 2007 to January 2010 in 16 ICUs. Case and control subjects had HAIs caused by GNB susceptible to ≤1 antibiotic versus ≥2 antibiotics, respectively. Logistic and Cox proportional hazards regression assessed risk factors for HAIs and predictors of mortality, respectively. RESULTS: Overall, 103 case and 195 control subjects were enrolled. An immunocompromised state (odds ratio [OR], 1.55; P = .047) and exposure to amikacin (OR, 13.81; P < .001), levofloxacin (OR, 2.05; P = .005), or trimethoprim-sulfamethoxazole (OR, 3.42; P = .009) were factors associated with XDR-GNB HAIs. Multiple factors in both case and control subjects significantly predicted increased mortality at different time intervals after HAI diagnosis. At 7 days, liver disease (hazard ratio [HR], 5.52), immunocompromised state (HR, 3.41), and bloodstream infection (HR, 2.55) predicted mortality; at 15 days, age (HR, 1.02 per year increase), liver disease (HR, 3.34), and immunocompromised state (HR, 2.03) predicted mortality; and, at 30 days, age (HR, 1.02 per 1-year increase), liver disease (HR, 3.34), immunocompromised state (HR, 2.03), and hospitalization in a medical ICU (HR, 1.85) predicted mortality. CONCLUSION: HAIs caused by XDR-GNB were associated with potentially modifiable factors. Age, liver disease, and immunocompromised state, but not XDR-GNB HAIs, were associated with mortality.

Clinicians' knowledge, attitudes, and practices regarding infections with multidrug-resistant gram-negative bacilli in intensive care units.

OBJECTIVE: To assess how healthcare professionals caring for patients in intensive care units (ICUs) understand and use antimicrobial susceptibility testing (AST) for multidrug-resistant gram-negative bacilli (MDR-GNB). DESIGN: A knowledge, attitude, and practice survey assessed ICU clinicians' knowledge of antimicrobial resistance, confidence interpreting AST results, and beliefs regarding the impact of AST on patient outcomes. SETTING: Sixteen ICUs affiliated with NewYork-Presbyterian Hospital. PARTICIPANTS: Attending physicians and subspecialty residents with primary clinical responsibilities in adult or pediatric ICUs as well as infectious diseases subspecialists and clinical pharmacists. METHODS: Participants completed an anonymous electronic survey. Responses included 4-level Likert scales dichotomized for analysis. Multivariate analyses were performed using generalized estimating equation logistic regression to account for correlation of respondents from the same ICU. RESULTS: The response rate was 51% (178 of 349 eligible participants); of the respondents, 120 (67%) were ICU physicians. Those caring for adult patients were more knowledgeable about antimicrobial activity and were more familiar with MDR-GNB infections. Only 33% and 12% of ICU physicians were familiar with standardized and specialized AST methods, respectively, but more than 95% believed that AST improved patient outcomes. After adjustment for demographic and healthcare provider characteristics, those familiar with treatment of MDR-GNB bloodstream infections, those aware of resistance mechanisms, and those aware of AST methods were more confident that they could interpret AST results and/or request additional in vitro testing. CONCLUSIONS: Our study uncovered knowledge gaps and educational needs that could serve as the foundation for future interventions. Familiarity with MDR-GNB increased overall knowledge, and familiarity with AST increased confidence interpreting the results.

Infection control knowledge, attitudes, and practices among cystic fibrosis patients and their families.

BACKGROUND: In 2003, the Cystic Fibrosis (CF) Foundation in the United States published evidence-based infection control guidelines and distributed these to CF care centers. However, it is unclear how well the guidelines have been disseminated to patients and families, how well patients and families understand the principles of infection control, and what barriers they experience implementing the guidelines. METHODS: We assessed infection control knowledge, attitudes, and practices among CF patients and their families at 17 randomly selected CF centers. Anonymous surveys were completed by CF patients (≥16 years old) or their family members (patients <16 years old). To adjust for similarities of patients within each center, generalized estimating equations regression was used. RESULTS: From January 2007 to May 2009, 1,399 respondents completed surveys of whom 38% were patients and 62% were family members (overall mean age of patients = 14 years). Overall, 65% of respondents were aware of the CF infection control guidelines, but only 30% had discussed them more than once with their CF care team. More than one discussion was associated with increased knowledge of infection control, including routes of pathogen transmission; the importance of avoiding close contact with other CF patients; increased confidence in practicing infection control; and increased belief in the health benefits of infection control. CONCLUSIONS: This study revealed that many CF patients and families are aware of the infection control guidelines, but that few had discussed them more than once with their CF teams. These findings underscore the importance of engaging patients and their families in regular discussions about infection control that address questions and concerns including the potential impact of infection control on health and well-being. Further strategies are needed to overcome barriers to implementing these guidelines.