A Multifaceted Approach to Reduction of Catheter-Associated Urinary Tract Infections in the Intensive Care Unit With an Emphasis on "Stewardship of Culturing".

BACKGROUND Catheter-associated urinary tract infections (CAUTIs) are among the most common hospital-acquired infections (HAIs). Reducing CAUTI rates has become a major focus of attention due to increasing public health concerns and reimbursement implications. OBJECTIVE To implement and describe a multifaceted intervention to decrease CAUTIs in our ICUs with an emphasis on indications for obtaining a urine culture. METHODS A project team composed of all critical care disciplines was assembled to address an institutional goal of decreasing CAUTIs. Interventions implemented between year 1 and year 2 included protocols recommended by the Centers for Disease Control and Prevention for placement, maintenance, and removal of catheters. Leaders from all critical care disciplines agreed to align routine culturing practice with American College of Critical Care Medicine (ACCCM) and Infectious Disease Society of America (IDSA) guidelines for evaluating a fever in a critically ill patient. Surveillance data for CAUTI and hospital-acquired bloodstream infection (HABSI) were recorded prospectively according to National Healthcare Safety Network (NHSN) protocols. Device utilization ratios (DURs), rates of CAUTI, HABSI, and urine cultures were calculated and compared. RESULTS The CAUTI rate decreased from 3.0 per 1,000 catheter days in 2013 to 1.9 in 2014. The DUR was 0.7 in 2013 and 0.68 in 2014. The HABSI rates per 1,000 patient days decreased from 2.8 in 2013 to 2.4 in 2014. CONCLUSIONS Effectively reducing ICU CAUTI rates requires a multifaceted and collaborative approach; stewardship of culturing was a key and safe component of our successful reduction efforts. Infect Control Hosp Epidemiol 2017;38:186-188.

Durable improvement in hand hygiene compliance following implementation of an automated observation system with visual feedback.

Automated observations systems for monitoring hand hygiene facilitate more measurements than feasible with direct observation and may enhance performance. We report that an automated observation system with immediate feedback was associated with a rapid and durable improvement in hand hygiene compliance.

Hospital-acquired Staphylococcus aureus primary bloodstream infection: A comparison of events that do and do not meet the central line-associated bloodstream infection definition.

BACKGROUND: This study was done to describe the incidence and outcomes of primary hospital-acquired bloodstream infection (HABSI) secondary to Staphylococcus aureus (SA) that did and did not meet the National Healthcare Safety Network's (NHSN's) definition for central line-associated bloodstream infection (CLABSI). METHODS: Consecutive hospitalized patients during a 48-month study period with an SA HABSI were categorized according to those who did and did not meet the NHSN's definitions for CLABSI and non-CLABSI. Primary outcomes were mortality at 30 days and 1 year. Secondary outcomes were the incidence of complicated bacteremia and the need for operative intervention secondary to the HABSI event. RESULTS: A total of 122 episodes of primary SA HABSIs were identified: 78 (64%) were CLABSIs, and 44 (36%) were non-CLABSIs. Overall 30-day and 1-year mortality in the cohort was 21.3% and 38.5%, respectively, and did not differ significantly between the 2 groups. Complicated SA HABSI was significantly more common in the non-CLABSI group (15.9% [n = 7] vs 0% [n = 0], P ≤ .001). CONCLUSIONS: Primary SA HABSI was associated with significant 30-day and 1-year mortality. Complications from SA non-CLABSI requiring surgical intervention were significantly more common than in those with a CLABSI event. Our findings affirm the significance of non-device-related hospital-acquired infections.

The impact of multidrug resistance on outcomes in ventilator-associated pneumonia.

Multidrug-resistant (MDR) organisms in ventilator-associated pneumonia were found in 49 of 107 patients and were associated with home antibiotics, pre-ventilator-associated pneumonia hospital stay, and health care exposure. Overall, MDR organisms were associated with increased mortality (P = .006). On multivariate analysis, MDR status was modulated by organism class. In nonfermenting gram-negative rods, no association between MDR and mortality was found, but, in all other organisms, MDR was associated with increased mortality risk (hazard ratio, 6.15; 95% confidence interval: 1.80-21.05, P = .004).

The descriptive epidemiology of central line-associated bloodstream infection among patients in non-intensive care unit settings.

OBJECTIVE: To review and describe device utilization and central line-associated bloodstream (CLABSI) events among patients in a non-intensive care unit (ICU) setting and to examine the morbidity and mortality associated with these events. DESIGN: One-year descriptive review. SETTING: A single tertiary center with a 1,200-bed hospital and 209 adult ICU beds. PATIENTS: Hospitalized patients identified as having a CLABSI event attributed to a non-ICU setting. METHODS: The cohort was identified from a prospective infection prevention database. Charts and administrative data sets were reviewed to further characterize the patients. Device utilization ratios (DURs) and CLABSI rates were calculated using National Health and Safety Network (NHSN) CLABSI definitions. Need for ICU stay and crude mortality rates were recorded. RESULTS: A total of 136 patients with 156 CLABSIs were identified, of whom 78 (57%) were being treated for a hematological malignancy (HM). The overall DUR was 0.27. A tunneled line was in place for 118 (76%) of the CLABSI events, and a peripherally inserted central catheter was in place for 32 (21%) of the CLABSI events. The non-ICU CLABSI rate was significantly higher than the concurrent ICU rate (2.1 CLABSIs per 1,000 catheter-days vs 1.5 CLABSIs per 1,000 catheter-days; [Formula: see text]). Hospital mortality was 23% in the affected group and was significantly higher in patients with HM. CONCLUSIONS: CLABSI rates over a 1-year period were higher in patients outside the ICU at our hospital and were associated with significant mortality.

Development of a modified surveillance definition of central line-associated bloodstream infections for patients with hematologic malignancies.

OBJECTIVE: To develop a modified surveillance definition of central line-associated bloodstream infection (mCLABSI) specific for our population of patients with hematologic malignancies to better support ongoing improvement efforts at our hospital. DESIGN: Retrospective cohort study. PATIENTS: Hematologic malignancies population in a 1,200-bed tertiary care hospital on a 22-bed bone marrow transplant (BMT) unit and a 22-bed leukemia unit. METHODS: An mCLABSI definition was developed, and pathogens and rates were compared against those determined using the National Healthcare Safety Network (NHSN) definition. RESULTS: By the NHSN definition the CLABSI rate on the BMT unit was 6.0 per 1,000 central line-days, and by the mCLABSI definition the rate was 2.0 per 1,000 line-days ([Formula: see text]). On the leukemia unit, the NHSN CLABSI rate was 14.4 per 1,000 line-days, and the mCLABSI rate was 8.2 per 1,000 line-days ([Formula: see text]). The top 3 CLABSI pathogens by the NHSN definition were Enterococcus species, Klebsiella species, and Escherichia coli. The top 3 CLABSI pathogens by the mCLABSI definition were coagulase-negative Staphylococcus (CONS), Pseudomonas aeruginosa, and Staphylococcus aureus. The difference in the incidence of CONS as a cause of CLABSI under the 2 definitions was statistically significant ([Formula: see text]). CONCLUSIONS: A modified surveillance definition of CLABSI was associated with an increase in the identification of staphylococci as the cause of CLABSIs, as opposed to enteric pathogens, and a decrease in CLABSI rates.

Decrease in Staphylococcus aureus colonization and hospital-acquired infection in a medical intensive care unit after institution of an active surveillance and decolonization program.

OBJECTIVE: To evaluate the effects of an active surveillance program for Staphylococcus aureus linked to a decolonization protocol on the incidence of healthcare-associated infection and new nasal colonization due to S. aureus. DESIGN: Retrospective quasi-experimental study. SETTING: An 18-bed medical intensive care unit at a tertiary care center in Cleveland, Ohio. METHODS: From January 1, 2006, through December 31, 2007, all patients in the medical intensive care unit were screened for S. aureus nasal carriage at admission and weekly thereafter. During the preintervention period, January 1 through September 30, 2006, only surveillance occurred. During the intervention period, January 1 through December 31, 2007, S. aureus carriers received mupirocin intranasally. Beginning in February 2007, carriers also received chlorhexidine gluconate baths. RESULTS: During the preintervention period, 604 (73.7%) of 819 patients were screened for S. aureus nasal carriage, yielding 248 prevalent carriers (30.3%). During the intervention period, 752 (78.3%) of 960 patients were screened, yielding 276 carriers (28.8%). The incidence of S. aureus carriage decreased from 25 cases in 3,982 patient-days (6.28 cases per 1,000 patient-days) before intervention to 18 cases in 5,415 patient-days (3.32 cases per 1,000 patient-days) (P=.04; relative risk [RR], 0.53 [95% confidence interval {CI}, 0.28-0.97]) and from 9.57 to 4.77 cases per 1,000 at-risk patient-days (P=.02; RR, 0.50 [95% CI, 0.27-0.91]). The incidence of S. aureus hospital-acquired bloodstream infection during the 2 periods was 2.01 and 1.11 cases per 1,000 patient-days, respectively (P=.28). The incidence of S. aureus ventilator-associated pneumonia decreased from 1.51 to 0.18 cases per 1,000 patient-days (P=.03; RR, 0.12 [95% CI, 0.01-0.83]). The total incidence of S. aureus hospital-acquired infection decreased from 3.52 to 1.29 cases per 1,000 patient-days (P=.03; RR, 0.37 [95% CI, 0.14-0.90]). CONCLUSIONS: Active surveillance for S. aureus nasal carriage combined with decolonization was associated with a decreased incidence of S. aureus colonization and hospital-acquired infection.

Necessary but not sufficient: a comparison of surveillance definitions of Clostridium difficile-associated diarrhea.

In this article, we describe our comparison of the Cleveland Clinic surveillance definition of Clostridium difficile-associated diarrhea and the definition mandated by the Ohio Department of Health. We found the definitions to be concordant only 71% of the time; the Ohio Department of Health definition identified 278 of the 391 cases identified by the Cleveland Clinic definition. Surveillance definitions mandated by the Ohio Department of Health overrepresented the number of cases attributable to nosocomial transmission at our institution.

Predictors of long-term mortality in patients with ventilator-associated pneumonia.

PURPOSE: To determine the long-term outcome of ventilator-associated pneumonia (VAP) and identify factors associated with increased mortality. METHODS: We retrospectively studied 671 patients with VAP admitted to an intensive care unit between 1994 and 2000. We determined long-term and out-of-hospital mortality for these patients. RESULTS: The in-hospital mortality was 42.3%; 19.8% of patients had concomitant bacteremia, the mortality was 59.7% versus 38.0% for those without bacteremia (P <.001). The factors associated with increased hospital mortality by univariable analysis were: diagnosis on admission, the need of vasopressors during the stay in the intensive care unit, not undergoing a tracheostomy, the absence of fever, the presence of concomitant bacteremia, and renal failure or the need for dialysis. Patients transferred from an outside hospital and patients with normal serum bicarbonate, serum total bilirubin <2 mg/dL, and platelets >120x4> 10(3)/microL had a lower in-hospital mortality. All of these factors except bilirubin level, platelet count, transfer from outside hospital, and serum bicarbonate remained significant on multivariable analysis. The estimated mortality at 1, 3 and 5 years is 25.9% (95% confidence interval [CI], 20.2-30.1%), 33.6% (95% CI, 27.4-39.2%) and 44.7% (95% CI, 38.1-50.6%), respectively. CONCLUSIONS: VAP is associated with a high rate of hospital and long-term mortality. The presence of bacteremia is associated with a high mortality. The 5-year estimated mortality of the survivors is less than 50%.

Weekly versus daily changes of in-line suction catheters: impact on rates of ventilator-associated pneumonia and associated costs.

BACKGROUND: An earlier randomized, controlled trial showed that weekly or as-needed (as opposed to daily) changes of in-line suction catheters were associated with substantial cost savings, without a higher rate of ventilator-associated pneumonia (VAP). To examine the impact of decreasing the frequency of in-line suction catheter changes in our medical intensive care unit, we conducted an observational study, comparing the catheter costs and frequency of VAP during (1) a control period, during which in-line suction catheters were changed daily, and (2) a treatment period, during which the catheters were changed every 7 days or sooner if needed, for mechanical failure or soilage. METHODS: All adult patients admitted to our 18-bed medical intensive care unit were evaluated for the 3-month interval 1 year prior to the practice change (May through July 1998) and for the 3 months after implementing the new policy (May through July 1999). To avoid bias related to usual seasonal variation in VAP frequency, we also determined (via medical records) the VAP rate during May through July 1997. The occurrence of VAP was ascertained by an infection control practitioner, using criteria established by the Centers for Disease Control and applied in a standard fashion. The VAP rate was calculated as the mean number of VAPs per 100 ventilator-days for each 3-month interval. Use of ventilators, humidifiers, and non-heated-wire, disposable circuits was uniform during the study, as were policies regarding humidity, temperature settings, and frequency of routine ventilator circuit changes. RESULTS: During the control period 146 patients accounted for 1,075 ventilator-days and there were 2 VAPs (0.19 VAPs per 100 ventilator-days). During the treatment period 143 patients accounted for 1,167 ventilator-days and there were no VAPs. The mean +/- SD duration of in-line suction catheter use during the treatment period was 3.8 +/- 0.8 days, and 51% of the patients had the same catheter in place for > 3 days (range 4-9 days). The actual cost of catheters used during the treatment period was lower than during the control period ($1,330 vs $6,026), predicting annual catheter cost savings of $18,782. CONCLUSIONS: We conclude that (1) a policy of weekly (vs daily) change of in-line suction catheter is associated with substantial cost savings, with no significant increase in the frequency of VAP, and (2) to the extent that these findings confirm the results of prior studies they support a policy of changing in-line suction catheters weekly rather than daily.

The role of preoperative antibiotic prophylaxis in cosmetic surgery.

An estimated 2.7 million cosmetic procedures were performed in the United States in 1998, yet the role of preoperative antibiotic prophylaxis for cosmetic surgery is not clearly defined. Routine antibiotic prophylaxis for cosmetic procedures was discontinued by the senior author at the authors' institution in an effort to reduce use and cost in June of 1999. Subsequently, a cluster of four Staphylococcus aureus postoperative surgical site infections were identified. A case-control study to identify risk factors for surgical site infections in these patients was performed. All patients who underwent cosmetic surgical procedures by the senior author during June of 1999 and did not develop a surgical site infection were selected as control patients. Four case patients and 12 control patients were included in the study. The significant risk factors associated with surgical site infections were the mean duration of procedure (5 hours versus 2 hours; p = 0.02), general anesthesia (p = 0.004), and placement of a Blake drain (p = 0.004). No common source of infection was identified by review and observation of surgical technique. Pulse-field gel analysis of the S. aureus isolates from the four case patients and the nares of surgical personnel revealed no common strain. After the reinstitution of preoperative antibiotic prophylaxis with cefazolin for procedures anticipated to last 3 hours or longer, no additional surgical site infections were identified through December of 1999 (four of 29 versus none of 104; p = 0.002). It was concluded that targeted antibiotic prophylaxis for cosmetic surgery with cefazolin may be useful in reducing surgical site infections attributable to S. aureus.