Active Surveillance and Contact Precautions for Preventing Methicillin-Resistant Staphylococcus aureus Healthcare-Associated Infections During the COVID-19 Pandemic.

BACKGROUND: Statistically significant decreases in methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections (HAIs) occurred in Veterans Affairs (VA) hospitals from 2007 to 2019 using a national policy of active surveillance (AS) for facility admissions and contact precautions for MRSA colonized (CPC) or infected (CPI) patients, but the impact of suspending these measures to free up laboratory resources for testing and conserve personal protective equipment for coronavirus disease 2019 (COVID-19) on MRSA HAI rates is not known. METHODS: From July 2020 to June 2022 all 123 acute care VA hospitals nationwide were given the rolling option to suspend (or re-initiate) any combination of AS, CPC, or CPI each month, and MRSA HAIs in intensive care units (ICUs) and non-ICUs were tracked. RESULTS: There were 917 591 admissions, 5 225 174 patient-days, and 568 MRSA HAIs. The MRSA HAI rate/1000 patient-days in ICUs was 0.20 (95% confidence interval [CI], .15-.26) for facilities practicing "AS + CPC + CPI" compared to 0.65 (95% CI, .41-.98; P < .001) for those not practicing any of these strategies, and in non-ICUs was 0.07 (95% CI, .05-.08) and 0.12 (95% CI, .08-.19; P = .01) for the respective policies. Accounting for monthly COVID-19 facility admissions using a negative binomial regression model did not change the relationships between facility policy and MRSA HAI rates. There was no significant difference in monthly facility urinary catheter-associated infection rates, a non-equivalent dependent variable, in the policy categories in either ICUs or non-ICUs. CONCLUSIONS: Facility removal of MRSA prevention practices was associated with higher rates of MRSA HAIs in ICUs and non-ICUs.

Healthcare-associated infections in Veterans Affairs acute-care and long-term healthcare facilities during the coronavirus disease 2019 (COVID-19) pandemic.

OBJECTIVE: To assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on healthcare-associated infections (HAIs) reported from 128 acute-care and 132 long-term care Veterans Affairs (VA) facilities. METHODS: We compared central-line-associated bloodstream infections (CLABSIs), ventilator-associated events (VAEs), catheter-associated urinary tract infections (CAUTIs), methicillin-resistant Staphylococcus aureus (MRSA), and Clostridioides difficile infections and rates reported from each facility monthly to a centralized database before the pandemic (February 2019 through January 2020) and during the pandemic (July 2020 through June 2021). RESULTS: Nationwide VA COVID-19 admissions peaked in January 2021. Significant increases in the rates of CLABSIs, VAEs, and MRSA all-site HAIs (but not MRSA CLABSIs) were observed during the pandemic in acute-care facilities. There was no significant change in CAUTI rates, and C. difficile rates significantly decreased. There were no significant increases in HAIs in long-term care facilities. CONCLUSIONS: The COVID-19 pandemic had a differential impact on HAIs of various types in VA acute care, with many rates increasing. The decrease in CDI HAIs may be due, in part, to evolving diagnostic testing. The minimal impact of COVID-19 in VA long-term facilities may reflect differences in patient numbers and acuity and early recognition of the impact of the pandemic on nursing home residents leading to increased vigilance and optimization of infection prevention and control practices in that setting. These data support the need for building and sustaining conventional infection prevention and control strategies before and during a pandemic.

Factors That Affect Legionella Positivity in Healthcare Building Water Systems from a Large, National Environmental Surveillance Initiative.

Legionella growth in healthcare building water systems can result in legionellosis, making water management programs (WMPs) important for patient safety. However, knowledge is limited on Legionella prevalence in healthcare buildings. A dataset of quarterly water testing in Veterans Health Administration (VHA) healthcare buildings was used to examine national environmental Legionella prevalence from 2015 to 2018. Bayesian hierarchical logistic regression modeling assessed factors influencing Legionella positivity. The master dataset included 201,146 water samples from 814 buildings at 168 VHA campuses. Overall Legionella positivity over the 4 years decreased from 7.2 to 5.1%, with the odds of a Legionella-positive sample being 0.94 (0.90-0.97) times the odds of a positive sample in the previous quarter for the 16 quarters of the 4 year period. Positivity varied considerably more at the medical center campus level compared to regional levels or to the building level where controls are typically applied. We found higher odds of Legionella detection in older buildings (OR 0.92 [0.86-0.98] for each more recent decade of construction), in taller buildings (OR 1.20 [1.13-1.27] for each additional floor), in hot water samples (O.R. 1.21 [1.16-1.27]), and in samples with lower residual biocide concentrations. This comprehensive healthcare building review showed reduced Legionella detection in the VHA healthcare system over time. Insights into factors associated with Legionella positivity provide information for healthcare systems implementing WMPs and for organizations setting standards and regulations.

Pre-endoscopy coronavirus disease 2019 screening and severe acute respiratory syndrome coronavirus-2 nucleic acid amplification testing in the Veterans Affairs healthcare system: clinical practice patterns, outcomes, and relationship to procedure volume.

BACKGROUND AND AIMS: The coronavirus disease 2019 (COVID-19) pandemic has had profound impacts worldwide, including on the performance of GI endoscopy. We aimed to describe the performance and outcomes of pre-endoscopy COVID-19 symptom and exposure screening and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) nucleic acid amplification testing (NAAT) across the national Veterans Affairs healthcare system and describe the relationship of SARS-CoV-2 NAAT use and resumption of endoscopy services. METHODS: COVID-19 screening and NAAT results from March 2020 to April 2021 were analyzed to determine use, performance characteristics of screening, and association between testing and endoscopic volume trends. RESULTS: Of 220,891 completed endoscopies identified, 115,890 (52.5%) had documented preprocedure COVID-19 symptom and exposure screenings and 154,127 (69.8%) had preprocedure NAAT results within 7 days before scheduled endoscopy. Of 131,894 total canceled endoscopies, 26,475 (20.1%) had screening data and 28,505 (21.6%) had SARS-CoV-2 NAAT results. Overall, positive NAAT results were reported in 1.8% of all individuals tested and in 1.3% of those who screened negative. Among completed and canceled endoscopies, COVID-19 screening had a 34.6% sensitivity (95% confidence interval [CI], 32.4%-36.8%) and 96.4% specificity (95% CI, 96.2%-96.5%) when compared with NAAT. COVID-19 screening had a positive predictive value of 15.0% (95% CI, 14.0%-16.1%) and a negative predictive value of 98.7% (95% CI, 98.7%-98.8%). There was a very weak correlation between monthly testing and monthly endoscopy volume by site (Spearman rank correlation coefficient = .09). CONCLUSIONS: These findings have important implications for decisions about preprocedure testing, especially given breakthrough infections among vaccinated individuals during the SARS-CoV-2 delta and omicron variant surge.

Water Safety and Health Care: Preventing Infections Caused by Opportunistic Premise Plumbing Pathogens.

Health care facility water systems have been associated with the transmission of opportunistic premise plumbing pathogens such as Legionella and nontuberculous mycobacteria. These pathogens can enter a building's water system in low numbers and then proliferate when conditions are conducive to their growth. Patients and residents in health care facilities are often at heightened risk for opportunistic infections, and cases and outbreaks in the literature highlight the importance of routine water management programs and occasions for intervention to prevent additional cases. A multidisciplinary proactive approach to water safety is critical for sustained prevention of health care-associated water-related infections.

Temporal Trends of Candidemia Incidence Rates and Potential Contributions of Infection Control Initiatives Over 18 Years Within the United States Veterans Health Administration System: A Joinpoint Time-Series Analysis.

BACKGROUND: Candidemia is one of the most common causes of nosocomial bloodstream infections, but the impacts of factors affecting its incidence have not been evaluated. METHODS: We analyzed a retrospective cohort of all candidemia patients at 130 acute care hospitals in the Veterans Health Administration (VHA) system from January 2000 through December 2017. Cases were classified as hospital-onset (HO) and non-hospital-onset (NHO). We used Joinpoint regression analysis to assess temporal associations between significant changes in candidemia incidence rates and guidelines or horizontal infection control (IC) interventions. RESULTS: Over 18 years, 17 661 candidemia episodes were identified. Incidence rates of HO cases were increasing until the mid-2000s, followed by a sustained decline, while NHO cases showed a steady decline. The first change in HO candidemia incidence rates (August 2004 [95% confidence interval {CI}, February 2003-April 2005]) was preceded by the publication of catheter-related bloodstream infection (CRBSI) prevention guidelines and the CRBSI surveillance initiation. The second (September 2007 [95% CI, September 2006-June 2009]) had close temporal proximity to the expansion of IC resources within the VHA system. Collectively, these trend changes resulted in a 77.1% reduction in HO candidemia incidence rates since its peak in 2004. CONCLUSIONS: A substantial and sustained systemwide reduction in candidemia incidence rates was observed after the publication of guidelines, VHA initiatives about CRBSI reporting and education on CRBSI prevention, and the systemwide expansion of IC resources.

Healthcare-Associated Legionella Disease: A Multi-Year Assessment of Exposure Settings in a National Healthcare System in the United States.

Healthcare facilities are high-risk environments for Legionella disease (LD), including Legionnaires' disease, but transmission in these settings is often overlooked. We used the LD database at the U.S. Department of Veterans Affairs (VA) national healthcare system to assess the type of healthcare exposure for LD cases. Cases were extracted from the database for 1 September 2012 through 31 July 2019, focusing on cases with an overnight stay at a VA facility during the 10-day exposure window prior to symptom onset. Patient medical charts were reviewed for demographics and types of healthcare setting exposure(s). There were 99 LD cases in the cohort: 31.3% were classified as having definite VA exposure, 37.4% were classified as possible VA with inpatient exposure, and 31.3% were classified as possible VA with both inpatient and outpatient exposure. For definite VA LD cases, 67.7% had some type of exposure in the long-term care setting. While 63% of the 99 cases had exposure in the acute care setting only, both the long-term care and acute care settings contributed substantially to the total number of exposure days. A review of patient movement during the exposure period showed the variable and sometimes extensive use of the VA system, and it provides insights useful for epidemiologic investigations and potential preventive actions.

Health after Legionnaires' disease: A description of hospitalizations up to 5 years after Legionella pneumonia.

BACKGROUND AND OBJECTIVES: Research on Legionnaires' Disease (LD) suggests there may be long-term health complications, but data are limited. This study investigated whether Intensive Care Unit (ICU) admission during LD hospitalization may be associated with adverse health outcomes and characterized subsequent discharge diagnoses in patients with LD up to 5 years post-LD. METHODS: We conducted a retrospective case series study with follow up for 5 years among patients hospitalized at a Department of Veterans Affairs (VA) Medical Center between 2005 and 2010 with LD. Data were collected from medical records on health history, LD severity (including ICU admission), and discharge diagnoses for 5 years post-LD or until death. We used ordinal logistic regression to explore associations between ICU admission and hospitalizations post-LD. Frequency counts were used to determine the most prevalent discharge diagnoses in the 5 years post-LD. RESULTS: For the 292 patients with laboratory-confirmed LD, those admitted to the ICU during LD hospitalization were more likely to have a greater number of hospitalizations within 5 years compared to non-ICU patients (ORHosp 1.92 CI95% 1.25, 2.95). Fifty-five percent (161/292) had ≥ 1 hospitalization within 5 years post-LD. After accounting for pre-existing diagnosis codes in patients with at least one hospitalization in the 2 years prior to LD (n = 77/161 patients, 47.8%), three of the four most frequent new diagnoses in the 5 years post-LD were non-chronic conditions: acute renal failure (n = 22, 28.6%), acute respiratory failure (n = 17, 22.1%) and unspecified pneumonia (n = 15, 19.5%). CONCLUSIONS: Our findings indicate that LD requiring ICU admission is associated with more subsequent hospitalizations, a factor that could contribute to poorer future health for people with severe LD. In addition to chronic conditions prevalent in this study population, we found new diagnoses in the 5-year post-LD period including acute renal failure. With LD incidence increasing, more research is needed to understand conditions and factors that influence long term health after LD.

Effect of testing methods on incidence of Clostridioides difficile infection rates in Veterans' Affairs medical centers.

Clostridioidesdifficile infection rates from 7 facilities that used nucleic acid amplification testing (NAAT) alone for 12 months then switched to NAAT plus toxin enzyme immunoassay (EIA) and reported the latter result for 12 months were compared to 70 facilities that used NAAT alone for all 24 months. There was no significant difference in rates between facility groups over the first 12 months (P = .21, linear regression), but we detected a decrease in rates for the facilities that changed to NAAT+EIA (P < .0001).

Implementation of Legionella Prevention Policy in Health Care Facilities: The United States Veterans Health Administration Experience.

CONTEXT: The Veterans Health Administration requires implementation of Legionella prevention policy in potable water systems at Department of Veterans Affairs (VA) medical facilities across the United States and territories. PROGRAM: The Veterans Health Administration Central Office program offices with expertise in engineering and clinical aspects of Legionella prevention policy have provided joint, structured on-site assistance to VA medical facilities for consultation on policy implementation. Site visits included review of facility documentation and data, discussions with staff, touring of buildings, and development of recommendations. IMPLEMENTATION: Information obtained from on-site consultative assistance provided to VA medical facilities from December 2012 through January 2018 was reviewed to identify engineering and clinical challenges and lessons from implementation of Legionella prevention policy in VA health care buildings. Fifteen consultative site visits were conducted during this period regarding implementation of Legionella prevention and validation of effectiveness. EVALUATION: It was found that implementation of Legionella prevention policy in potable water systems was complex and practices varied for each building. Common implementation challenges included capability of applying engineering controls, water stagnation, and assessment of health care association of Legionella cases. Process challenges included routine verification of actions, methods for assessing environmental validation data, and documentation of requirements. It was found that consistent and data-driven implementation of policy is crucial for an effective program. DISCUSSION: Guidance and standards documents in the community for Legionella prevention in building water systems are often general in nature, but implementation requires specific decisions and routine assessments and modifications to optimize outcomes. This real-world review of challenges and lessons from a large health care system with a detailed primary Legionella prevention policy informs future development of guidance and policy, both within and external to VA, and can provide insight to other health care facilities planning to implement practices for water safety.

Healthcare facility-onset, healthcare facility-associated Clostridioides difficile infection in Veterans with spinal cord injury and disorder.

Objective: To describe the burden and risk of healthcare facility-onset, healthcare facility-associated (HO-HCFA) Clostridioides difficile infection (CDI) in Veterans with spinal cord injury and disorder (SCI/D). Design: Retrospective, longitudinal cohort study from October 1, 2001-September 30, 2010. Setting: Ninety-four acute care Veterans Affairs facilities. Participants: Patients with SCI/D. Outcomes: Incidence rate of HO-HCFA CDI. Methods: Rates of CDI were determined, and crude unadjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were calculated. Multivariable Poisson random-effects regression analyses were used to assess factors independently associated with the rate of CDI. Results: 1,409 cases of HO-HCFA CDI were identified. CDI rates in 2002 were 13.9/10,000 person-days and decreased to 5.5/10,000 person-days by 2010. Multivariable regression analyses found that antibiotic (IRR = 18.79, 95% CI 14.09-25.07) and proton-pump inhibitor (PPI) or H2 blocker use (IRR = 7.71, 95% CI 5.47-10.86) were both independently associated with HO-HCFA CDI. Exposure to both medications demonstrated a synergistic risk (IRR = 37.55, 95% CI 28.39-49.67). Older age, Northeast region, and invasive respiratory procedure in the prior 30 days were also independent risk factors, while longer SCI duration and care at a SCI center were protective. Conclusion: Although decreasing, CDI rates in patients with SCI/D remain high. Targeted antimicrobial stewardship and pharmacy interventions that reduce antibiotic and PPI/H2 blocker use could have profound benefits in decreasing HO-HCFA CDI in this high-risk population.

Methicillin-resistant Staphylococcus aureus Colonization and Pre- and Post-hospital Discharge Infection Risk.

Background: The Department of Veterans Affairs implemented an active surveillance program for methicillin-resistant Staphylococcus aureus (MRSA) in 2007 in which acute care inpatients are tested for MRSA carriage on admission, unit-to-unit transfer, and discharge. Using these data, we followed patients longitudinally to estimate the difference in infection rates for those who were not colonized, those who were colonized on admission (importers), and those who acquired MRSA during their stay. We examined MRSA infections that occurred prior to discharge and at 30, 90, 180, and 365 days after discharge. Methods: We constructed a dataset of 985626 first admissions from January 2008 through December 2015 who had surveillance tests performed for MRSA carriage. We performed multivariable Cox proportional hazards and logistic regression models to examine the relationship between MRSA colonization status and infection. Results: The MRSA infection rate across the predischarge and 180-day postdischarge time period was 5.5% in importers and 7.0% in acquirers without a direct admission to the intensive care unit (ICU) and 11.4% in importers and 11.7% in acquirers who were admitted directly to the ICU. The predischarge hazard ratio for MRSA infection was 29.6 (95% confidence interval [CI], 26.5-32.9) for importers and 28.8 (95% CI, 23.5-35.3) for acquirers compared to those not colonized. Fully 63.9% of all MRSA pre- and postdischarge infections among importers and 61.2% among acquirers occurred within 180 days after discharge. Conclusions: MRSA colonization significantly increases the risk of subsequent MRSA infection. In addition, a substantial proportion of MRSA infections occur after discharge from the hospital.

Achieving balance between implementing effective infection prevention and control practices and maintaining a home-like setting in U.S. Department of Veterans Affairs nursing homes.

Nursing homes present a unique challenge for implementing infection prevention and control practices while striving to maintain a home-like environment. Medical devices such as urinary catheters and central venous catheters have become a part of nursing home care but can predispose residents to associated infections. Because evidence-based prevention bundles were implemented, catheter-associated urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs) were monitored in all U.S. Department of Veterans Affairs (VA) nursing homes, and outcomes were evaluated. Bundle components for CLABSIs focused on insertion technique, site selection, and routine assessment of central line necessity, while the CAUTI bundle focused on insertion technique, appropriate indication, and routine assessment of urinary catheter necessity. From October 2010 through September 2016, VA nursing homes reported nationwide reductions of CAUTIs (51.2%; P < .0001) and CLABSIs (25.0%; P = .0009).

Assessing a National Collaborative Program To Prevent Catheter-Associated Urinary Tract Infection in a Veterans Health Administration Nursing Home Cohort.

OBJECTIVECollaborative programs have helped reduce catheter-associated urinary tract infection (CAUTI) rates in community-based nursing homes. We assessed whether collaborative participation produced similar benefits among Veterans Health Administration (VHA) nursing homes, which are part of an integrated system.SETTINGThis study included 63 VHA nursing homes enrolled in the "AHRQ Safety Program for Long-Term Care," which focused on practices to reduce CAUTI.METHODSChanges in CAUTI rates, catheter utilization, and urine culture orders were assessed from June 2015 through May 2016. Multilevel mixed-effects negative binomial regression was used to derive incidence rate ratios (IRRs) representing changes over the 12-month program period.RESULTSThere was no significant change in CAUTI among VHA sites, with a CAUTI rate of 2.26 per 1,000 catheter days at month 1 and a rate of 3.19 at month 12 (incidence rate ratio [IRR], 0.99; 95% confidence interval [CI], 0.67-1.44). Results were similar for catheter utilization rates, which were 11.02% at month 1 and 11.30% at month 12 (IRR, 1.02; 95% CI, 0.95-1.09). The numbers of urine cultures per 1,000 residents were 5.27 in month 1 and 5.31 in month 12 (IRR, 0.93; 95% CI, 0.82-1.05).CONCLUSIONSNo changes in CAUTI rates, catheter use, or urine culture orders were found during the program period. One potential reason was the relatively low baseline CAUTI rate, as compared with a cohort of community-based nursing homes. This low baseline rate is likely related to the VHA's prior CAUTI prevention efforts. While broad-scale collaborative approaches may be effective in some settings, targeting higher-prevalence safety issues may be warranted at sites already engaged in extensive infection prevention efforts.Infect Control Hosp Epidemiol 2018;820-825.

Evaluating the Effect of a Clostridium difficile Infection Prevention Initiative in Veterans Health Administration Long-Term Care Facilities.

We evaluated rates of clinically confirmed long-term-care facility-onset Clostridium difficile infections from April 2014 through December 2016 in 132 Veterans Affairs facilities after the implementation of a prevention initiative. The quarterly pooled rate decreased 36.1% from the baseline (P<.0009 for trend) by the end of the analysis period. Infect Control Hosp Epidemiol 2018;39:343-345.

Legionnaires Disease Surveillance in US Department of Veterans Affairs Medical Facilities and Assessment of Health Care Facility Association.

Importance: Legionnaires disease (LD) incidence is increasing in the United States. Health care facilities are a high-risk setting for transmission of Legionella bacteria from building water systems to occupants. However, the contribution of LD in health care facilities to national LD rates is not well characterized. Objectives: To determine the burden of LD in US Department of Veterans Affairs (VA) patients and to assess the amount of LD with VA exposure. Design, Setting, and Participants: Retrospective cohort study of reported LD data in VA medical facilities in a national VA LD surveillance system from January 1, 2014, to December 31, 2016. The study population included total veteran enrollees and enrollees who used the VA health care system. Main Outcomes and Measures: The primary outcome was assessment of annual LD rates, categorized by VA and non-VA exposure. Legionnaires disease rates for cases with VA exposure were determined on both population and exposure potential levels. Rates by VA exposure potential were calculated using inpatient bed days of care, long-term care resident days, or outpatient encounters. In addition, types and amounts of LD diagnostic testing were calculated. Case and testing data were analyzed nationally and regionally. Results: There were 491 LD cases in the case report surveillance system from January 1, 2014, to December 31, 2016. Most cases (447 [91%]) had no VA exposure or only outpatient VA exposure. The remaining 44 cases had VA exposure from overnight stays. Total LD rates from January 1, 2014, to December 31, 2016, increased for all VA enrollees (from 1.5 to 2.0 per 100 000 enrollees; P = .04) and for users of VA health care (2.3 to 3.0 per 100 000 enrollees; P = .04). The LD rate for the subset who had no VA exposure also increased (0.90 to 1.47 per 100 000 enrollees; P < .001). In contrast, the LD rate for patients with VA overnight stay decreased on a population level (5.0 to 2.3 per 100 000 enrollees; P < .001) and an exposure level (0.31 to 0.15 per 100 000 enrollees; P < .001). Regionally, the eastern United States had the highest LD rates. The urine antigen test was the most used LD diagnostic method; 49 805 tests were performed in 2015-2016 with 335 positive results (0.67%). Conclusions and Relevance: Data in the VA LD databases showed an increase in overall LD rates over the 3 years, driven by increases in rates of non-VA LD. Inpatient VA-associated LD rates decreased, suggesting that the VA's LD prevention efforts have contributed to improved patient safety.

A Report of the Efforts of the Veterans Health Administration National Antimicrobial Stewardship Initiative.

OBJECTIVE To detail the activities of the Veterans Health Administration (VHA) Antimicrobial Stewardship Initiative and evaluate outcomes of the program. DESIGN Observational analysis. SETTING The VHA is a large integrated healthcare system serving approximately 6 million individuals annually at more than 140 medical facilities. METHODS Utilization of nationally developed resources, proportional distribution of antibiotics, changes in stewardship practices and patient safety measures were reported. In addition, inpatient antimicrobial use was evaluated before and after implementation of national stewardship activities. RESULTS Nationally developed stewardship resources were well utilized, and many stewardship practices significantly increased, including development of written stewardship policies at 92% of facilities by 2015 (P<.05). While the proportional distribution of antibiotics did not change, inpatient antibiotic use significantly decreased after VHA Antimicrobial Stewardship Initiative activities began (P<.0001). A 12% decrease in antibiotic use was noted overall. The VHA has also noted significantly declining use of antimicrobials prescribed for resistant Gram-negative organisms, including carbapenems, as well as declining hospital readmission and mortality rates. Concurrently, the VHA reported decreasing rates of Clostridium difficile infection. CONCLUSIONS The VHA National Antimicrobial Stewardship Initiative includes continuing education, disease-specific guidelines, and development of example policies in addition to other highly utilized resources. While no specific ideal level of antimicrobial utilization has been established, the VHA has shown that improving antimicrobial usage in a large healthcare system may be achieved through national guidance and resources with local implementation of antimicrobial stewardship programs. Infect Control Hosp Epidemiol 2017;38:513-520.

Eight years of decreased methicillin-resistant Staphylococcus aureus health care-associated infections associated with a Veterans Affairs prevention initiative.

BACKGROUND: Declines in methicillin-resistant Staphylococcus aureus (MRSA) health care associated infections (HAIs) were previously reported in Veterans Affairs acute care (2012), spinal cord injury (SCIU) (2011), and long-term-care facilities (LTCFs) (2012). Here we report continuing declines in infection rates in these settings through September 2015. METHODS: Monthly data entered into a national database from 127 acute care facilities, 22 SCIUs, and 133 LTCFs were evaluated for trends using negative binomial regression. RESULTS: There were 23,153,240 intensive care unit (ICU) and non-ICU, and 1,794,234 SCIU patient-days from October 2007-September 2015, and 22,262,605 LTCF resident-days from July 2009-September 2015. Admission nasal swabbing remained >92% in all 3 venues. Admission prevalence changed from 13.2%-13.5% in acute care, from 35.1%-32.0% in SCIUs, and from 23.1%-25.0% in LTCFs during the analysis periods. Monthly HAI rates fell 87.0% in ICUs, 80.1% in non-ICUs, 80.9% in SCIUs, and 49.4% in LTCFs (all P values < .0001 for trend). During September 2015, there were 2 MRSA HAIs reported in ICUs, 20 (with 3 in SCIUs) in non-ICUs, and 31 in LTCFs nationwide. CONCLUSIONS: MRSA HAI rates declined significantly in acute care, SCIUs, and LTCFs over 8 years of the Veterans Affairs MRSA Prevention Initiative.

Healthcare-associated Legionnaires' disease: Limitations of surveillance definitions and importance of epidemiologic investigation.

Healthcare-associated Legionnaires' disease (HCA LD) causes significant morbidity and mortality, with varying guidance on prevention. We describe the evaluation of a case of possible HCA LD and note the pitfalls of relying solely on an epidemiologic definition for association of a case with a facility. Our detailed investigation led to the identification of a new Legionella pneumophila serogroup 1 sequence type, confirmed a healthcare association and helped build the framework for our ongoing preventive efforts. Our experience highlights the role of routine environmental cultures in the assessment of risk for a given facility. As clinicians increasingly rely on urinary antigen testing for the detection of L. pneumophila, our investigation emphasises the importance of clinical cultures in an epidemiologic investigation.