Bloodstream infections among patients receiving therapeutic plasma exchanges in the intensive care unit: a 10 year multicentric study.

BACKGROUND: Therapeutic plasma exchanges (TPE), which affect the humoral response, are often performed in combination with immunosuppressive drugs. For this reason, TPE may be associated with an increased susceptibility to infections. We aimed to describe blood stream infection (BSI) incidence in ICU patients treated with TPE and to identify associated risk factors. METHODS: We retrospectively included patients that had received at least one session of TPE in the ICU of one of the 4 participating centers (all in Paris, France) between January 1st 2010 and December 31th 2019. Patients presenting with a BSI during ICU stay were compared to patients without such an infection. Risk factors for BSI were identified by a multivariate logistic regression model. RESULTS: Over 10 years in the 4 ICUs, 387 patients were included, with a median of 5 [2-7] TPE sessions per patient. Most frequent indications for TPE were thrombotic microangiopathy (47%), central nervous system inflammatory disorders (11%), hyperviscosity syndrome (11%) and ANCA associated vasculitis (8.5%). Thirty-one patients (8%) presented with a BSI during their ICU stay, a median of 7 [3-11] days after start of TPE. In a multivariate logistic regression model, diabetes (OR 3.32 [1.21-8.32]) and total number of TPE sessions (OR 1.14 [1.08-1.20]) were independent risk factors for BSI. There was no difference between TPE catheter infection related BSI (n = 11 (35%)) and other sources of BSI (n = 20 (65%)) regarding catheter insertion site (p = 0.458) or rate of TPE catheter related deep vein thrombosis (p = 0.601). ICU course was severe in patients presenting with BSI when compared to patients without BSI, with higher need for mechanical ventilation (45% vs 18%, p = 0.001), renal replacement therapy (42% vs 20%, p = 0.011), vasopressors (32% vs 12%, p = 0.004) and a higher mortality (19% vs 5%, p = 0.010). CONCLUSION: Blood stream infections are frequent in patients receiving TPE in the ICU, and are associated with a severe ICU course. Vigilant monitoring is crucial particularly for patients receiving a high number of TPE sessions.

Health care-associated Clostridioides difficile infection: Learning the perspectives of health care workers to build successful strategies.

BACKGROUND: Clostridioides difficile (C difficile) is one of the most common health care-associated infections that negatively impact patient care and health care costs. This study takes a unique approach to C difficile infection (CDI) control by investigating key prevention obstacles through the perspectives of Stanford health care (SHC) frontline health care personnel. METHODS: An anonymous qualitative survey was distributed at SHC, focusing on knowledge and practice of CDI prevention guidelines, as well as education, communication, and perspectives regarding CDI at SHC. RESULTS: 112 survey responses were analyzed. Our findings unveiled gaps in personnel's knowledge of C difficile diagnostic guidelines and revealed a need for targeted communication and guideline-focused education. Health care staff shared preferences and recommendations, with the majority recommending enhanced communication of guidelines and information as a strategy for reducing CDI rates. The findings were then used to design and propose internal recommendations for SHC to mitigate the gaps found. DISCUSSION: Many guidelines and improvement strategies are based on strong scientific and medical foundations; however, it is important to ask whether these guidelines are effectively translated into practice. Frontline health care workers hold empirical perspectives that could be key in infection control. CONCLUSIONS: Our findings emphasize the importance of including frontline health care personnel in infection prevention decision-making processes and the strategies presented here can be applied to mitigating infections in different health care settings.

Retrospective matched cohort study of incidence rates and excess length of hospital stay owing to pressure injuries in an Asian setting.

Background: Little is known about stage 1 and 2 pressure injuries that are health care-acquired. We report incidence rates of health care-acquired stage 1 and stage 2 pressure injuries, and, estimate the excess length of stay using four competing analytic methods. We discuss the merits of the different approaches. Methods: We calculated monthly incidence rates for stage 1 and 2 health care-acquired pressure injuries occurring in a large Singapore acute care hospital. To estimate excess stay, we conducted unadjusted comparisons with a control cohort, performed linear regression and then generalized linear regression with a gamma distribution. Finally, we fitted a simple state-based model. The design for the cost attribution work was a retrospective matched cohort study. Results: Incidence rates in 2016 were 0.553% (95% confidence interval [CI] 0.55, 0.557) and 0.469% (95% CI 0.466, 0.472) in 2017. For data censored at 60 days' maximum stay, the unadjusted comparisons showed the highest excess stay at 17.68 (16.43-18.93) days and multi-state models showed the lowest at 1.22 (0.19, 2.23) days. Conclusions: Poor-quality methods for attribution of excess length of stay to pressure injury generate inflated estimates that could mislead decision makers. The findings from the multi-state model, which is an appropriate method, are plausible and illustrate the likely bed-days saved from lowering the risk of these events. Stage 1 and 2 pressure injuries are common and increase costs by prolonging the length of stay. There will be economic value investing in prevention. Using biased estimates of excess length of stay will overstate the potential value of prevention.

A New Performance Metric to Estimate the Risk of Exposure to Infection in a Health Care Setting: Descriptive Study.

BACKGROUND: Despite several measures to monitor and improve hand hygiene (HH) in health care settings, health care-acquired infections (HAIs) remain prevalent. The measures used to calculate HH performance are not able to fully benefit from the high-resolution data collected using electronic monitoring systems. OBJECTIVE: This study proposes a novel parameter for quantifying the HAI exposure risk of individual patients by considering temporal and spatial features of health care workers' HH adherence. METHODS: Patient exposure risk is calculated as a function of the number of consecutive missed HH opportunities, the number of unique rooms visited by the health care professional, and the time duration that the health care professional spends inside and outside the patient's room without performing HH. The patient exposure risk is compared to the entrance compliance rate (ECR) defined as the ratio of the number of HH actions performed at a room entrance to the total number of entrances into the room. The compliance rate is conventionally used to measure HH performance. The ECR and the patient exposure risk are analyzed using the data collected from an inpatient nursing unit for 12 weeks. RESULTS: The analysis of data collected from 59 nurses and more than 25,600 records at a musculoskeletal rehabilitation unit at the Toronto Rehabilitation Institute, KITE, showed that there is no strong linear relation between the ECR and patient exposure risk (r=0.7, P<.001). Since the ECR is calculated based on the number of missed HH actions upon room entrance, this parameter is already included in the patient exposure risk. Therefore, there might be scenarios that these 2 parameters are correlated; however, in several cases, the ECR contrasted with the reported patient exposure risk. Generally, the patients in rooms with a significantly high ECR can be potentially exposed to a considerable risk of infection. By contrast, small ECRs do not necessarily result in a high patient exposure risk. The results clearly explained the important role of the factors incorporated in patient exposure risk for quantifying the risk of infection for the patients. CONCLUSIONS: Patient exposure risk might provide a more reliable estimation of the risk of developing HAIs compared to ECR by considering both the temporal and spatial aspects of HH records.

Droplet precautions on-site (DroPS) during the influenza season 2018/2019: a possible alternative to single room isolation for respiratory viral infections.

BACKGROUND: The guideline-driven and widely implemented single room isolation strategy for respiratory viral infections (RVI) such as influenza or respiratory syncytial virus (RSV) can lead to a shortage of available hospital beds. We discuss our experience with the introduction of droplet precautions on-site (DroPS) as a possible alternative. METHODS: During the 2018/19 influenza season we introduced DroPS on several wards of a single tertiary care center, while other wards maintained the traditional single room isolation strategy. On a daily basis, we evaluated patients for the development of respiratory symptoms and screened those with a clinical diagnosis of hospital-acquired respiratory viral infection (HARVI) for influenza/RSV by molecular rapid test. If negative, it was followed by a multiplex respiratory virus PCR. We report the concept of DroPS, the feasibility of the strategy and the rate of microbiologically confirmed HARVI with influenza or RSV infection on the DroPS wards compared to wards using the traditional single room isolation strategy. RESULTS: We evaluated all hospitalised patients at risk for a HARVI, 741 (72%) on the DroPS wards and 293 (28%) on the regular wards. The hospital-acquired infection rate with influenza or RSV was 2/741 (0.3%; 1× influenza A, 1× RSV) on the DroPS wards and 2/293 (0.7%; 2× influenza A) on the regular wards. CONCLUSIONS: Droplet precautions on-site (DroPS) may be a simple and potentially resource-saving alternative to the standard single room isolation strategy for respiratory viral infections. Further studies in a larger clinical context are needed to document its safety.

How dirty are the pens in health-care environment? An easily overlooked detail of hand hygiene.

Pens, common in hospitals, may be a potential vehicle for cross-infection. In this study, the number of pathogens on different pens and the positive rates of several common multi-drug-resistant bacteria were calculated and compared according to the nature of use and material. In addition, the effect of pens on bacterial transmission was explored through simulation experiments. High levels of bacteria were found on pens and the simulations demonstrated transmission of bacteria.

Health Care-Acquired Viral Respiratory Diseases.

Health care-acquired viral respiratory infections are common and cause increased patient morbidity and mortality. Although the threat of viral respiratory infection has been underscored by the coronavirus disease 2019 (COVID-19) pandemic, respiratory viruses have a significant impact in health care settings even under normal circumstances. Studies report decreased nosocomial transmission when aggressive infection control measures are implemented, with more success noted when using a multicomponent approach. Influenza vaccination of health care personnel furthers decrease rates of transmission; thus, mandatory vaccination is becoming more common. This article discusses the epidemiology, transmission, and control of health care-associated respiratory viral infections.

Infection Prevention in the Era of COVID-19: 2021 Basic Procedure Review.

Infection prevention and control practices represent a vital behavioral skill set, especially in the era of COVID-19. Standard precautions, correct use of personal protective equipment, proper hand hygiene, and appropriate cleaning and disinfecting are necessary to prevent health-care-acquired infections in care facilities.

Psychological characteristics are associated with healthcare worker adherence to infection control practices.

BACKGROUND: Most bloodstream infections related to vascular catheters can be avoided if evidence-based practices are applied during insertion and maintenance. In practice, adherence by health care workers (HCWs) is unsatisfactory and is the main current challenge. The objective of this study is to investigate associations between adherence to infection control practices and performance in psychological tests. METHODS: We conducted a prospective observational study in 4 intensive care units involving HCWs. Physicians were observed for adherence to hand hygiene (HH). Nurses were observed during central venous catheter dressing and handling. HCWs were then evaluated psychologically. RESULTS: There were 7,572 observations of 248 HCWs. Adherence to different steps of central venous catheter manipulation ranged widely: from 13% for HH before procedure to 95% regarding the use of gloves. Adherence to HH ranged from 14% before to 99% after dressing. For physicians, HH ranged from 10% before touching patients to 98% after touching body fluids, and adherence was associated with age, self-esteem, and aggression. For nurses, adherence was positively associated with deference, and negatively associated with nurturance. CONCLUSIONS: Psychosocial variables affect the quality of care that HCWs provide. The next step would be to define what type of psychological interventions could be effective.

Light-guided nudging and data-driven performance feedback improve hand hygiene compliance among nurses and doctors.

BACKGROUND: Evidence-based practices to increase hand hygiene compliance (HHC) among health care workers are warranted. We aimed to investigate the effect of a multimodal strategy on HHC. METHODS: During this 14-month prospective, observational study, an automated monitoring system was implemented in a 29-bed surgical ward. Hand hygiene opportunities and alcohol-based hand rubbing events were measured in patient and working rooms (medication, utility, storerooms, toilets). We compared baseline HHC of health care workers across periods with light-guided nudging from sensors on dispensers and data-driven performance feedback (multimodal strategy) using the Student's t test. RESULTS: The doctors (n = 10) significantly increased their HHC in patient rooms (16% vs 42%, P< .0001) and working rooms (24% vs 78%, P= .0006) when using the multimodal strategy. The nurses (n = 26) also increased their HHC significantly from baseline in both patient rooms (27% vs 43%, P = .0005) and working rooms (39% vs 64%, P< .0001). The nurses (n = 9), who subsequently received individual performance feedback, further increased HHC, compared with the period when they received group performance feedback (patient rooms: 43% vs 55%, P< .0001 and working rooms: 64% vs 80%, P< .0001). CONCLUSIONS: HHC of doctors and nurses can be significantly improved with light-guided nudging and data-driven performance feedback using an automated hand hygiene system.

Health Care-associated infections studies project: An American Journal of Infection Control and National Healthcare Safety Network data quality collaboration case study.

This National Healthcare Safety Network (NHSN) surveillance case study is part of a case-study series in the American Journal of Infection Control (AJIC). These cases reflect some of the complex patient scenarios Infection preventionists have encountered in their daily surveillance of health care-associated infections using NHSN definitions. Objectives have been previously published.

Nosocomial Infections: A History of Hospital-Acquired Infections.

In the United States, healthcare acquired infections (HAIs) or nosocomial infections are the sixth leading cause of death. This article reviews the history, prevalence, economic costs, morbidity and mortality, and risk factors associated with HAIs. Types of infections described include bacterial, fungal, viral, and multidrug resistant infections that contribute to the most common causes of HAIs, which include catheter- associated urinary tract infections, hospital-acquired pneumonias, bloodstream infections, and surgical site infections. Most nosocomial infections are preventable and monitoring and prevention strategies are described.

Impact of Chlorhexidine Bathing on Antimicrobial Utilization in Surgical Intensive Care Unit.

BACKGROUND: This secondary analysis compared antimicrobial utilization among surgical intensive care unit patients randomized to every other day chlorhexidine bathing (chlorhexidine) versus daily soap and water bathing (soap-and-water) using data from the CHlorhexidine Gluconate BATHing trial. MATERIALS AND METHODS: Antimicrobial utilization was quantified using defined daily dose (DDD)/100 patient-days and agent-days/100 patient-days for systemic antimicrobials. Antivirals (except oseltamivir), antiparasitics, and prophylaxis agents were excluded. The 2018 anatomic therapeutic chemical/DDD index was used to calculate DDD. Agent-days were calculated as the sum of calendar days where antimicrobials were administered. Patient-days were defined as time patients were at risk for health care-acquired infections plus up to 14 d. Primary analyses were conducted using linear regression adjusted for baseline Acute Physiology and Chronic Health Evaluation II scores. RESULTS: Of 325 CHlorhexidine Gluconate BATHing trial patients, 312 (157 in soap-and-water and 155 in chlorhexidine) were included. The median (interquartile range) of total antimicrobial DDD/100 patient-days was 135.4 (75.2-231.8) for soap-and-water and 129.9 (49.2-215.3) for chlorhexidine. The median (interquartile range) of total antimicrobial agent-days/100 patient-days was 155.6 (83.3-243.2) for soap-and-water and 146.7 (66.7-217.4) for chlorhexidine. After adjusting for Acute Physiology and Chronic Health Evaluation II scores, chlorhexidine bathing was associated with a nonsignificant reduction in total antimicrobial DDD/100 patient-days (-3.9; 95% confidence interval, -33.9 to 26.1; P = 0.80) and total antimicrobial agent-days/100 patient-days (-10.3; 95% confidence interval, -34.7 to 14.1; P = 0.41). CONCLUSIONS: Compared with daily soap and water bathing, every other day chlorhexidine bathing did not significantly reduce total antimicrobial utilization in surgical intensive care unit patients.

Eosinopenia and Binary Toxin Increase Mortality in Hospitalized Patients With Clostridioides difficile Infection.

BACKGROUND: Patients with Clostridioides difficile infection (CDI) with either eosinopenia or infected with a binary toxin strain have increased likelihood of mortality. However, the relationship between binary toxin and eosinopenia to synergistically increase mortality has not been studied in humans. We hypothesized that patients with CDI due to binary toxin strains and concomitant peripheral eosinopenia would have a higher likelihood of inpatient mortality. METHODS: This multicenter, retrospective cohort study included adult patients with CDI of known ribotypes stratified by eosinopenia, defined as an absence of eosinophils in the peripheral blood (Houston cohort). The primary outcome was inpatient mortality. Results were supported by a separate national cohort of veterans with CDI (Veterans' cohort). RESULTS: In the Houston cohort, a total of 688 patients from 13 institutions in 6 cities were included. Of these, 132 (19%) had an eosinophil count of 0.0 cells/µL (0.0 cells*109/L) and 109 (16%) were infected with a binary toxin strain. After adjusting for covariates, the combination of eosinopenia and infection with a binary toxin strain was an independent predictor of inpatient mortality (odds ratio [OR], 7.8; 95% confidence interval [CI], 1.9-33.2; P = .005). In the separate Veterans' cohort (n = 790), this combination was also a significant predictor of inpatient mortality (OR, 6.1; 95% CI, 1.5-23.9; P = .009). CONCLUSIONS: In conclusion, the combination of eosinopenia and CDI due to a binary toxin strain was correlated with increased mortality in hospitalized patients from 2 independent cohorts. Prospective studies should further study this important subset of patients at the time of CDI diagnosis.

Clinical experiences with a new system for automated hand hygiene monitoring: A prospective observational study.

BACKGROUND: Hand hygiene compliance (HHC) among health care workers remains suboptimal, and good monitoring systems are lacking. We aimed to evaluate HHC using an automated monitoring system. METHODS: A prospective, observational study was conducted at 2 Danish university hospitals employing a new monitoring system (Sani nudge). Sensors were located on alcohol-based sanitizers, health care worker name tags, and patient beds measuring hand hygiene opportunities and sanitations. RESULTS: In total, 42 nurses were included with an average HHC of 52% and 36% in hospitals A and B, respectively. HHC was lowest in patient rooms (hospital A: 45%; hospital B: 29%) and highest in staff toilets (hospital A: 72%; hospital B: 91%). Nurses sanitized after patient contact more often than before, and sanitizers located closest to room exits and in hallways were used most frequently. There was no association found between HHC level and the number of beds in patient rooms. The HHC level of each nurse was consistent over time, and showed a positive correlation between the number of sanitations and HHC levels (hospital A: r = 0.69; hospital B: r = 0.58). CONCLUSIONS: The Sani nudge system can be used to monitor HHC at individual and group levels, which increases the understanding of compliance behavior.

Secondary measures of hand hygiene performance in health care available with continuous electronic monitoring of individuals.

BACKGROUND: Hand hygiene (HH) compliance in health care is usually measured against versions of the World Health Organization's "Your 5 Moments" guidelines using direct observation. Such techniques result in small samples that are influenced by the presence of an observer. This study demonstrates that continuous electronic monitoring of individuals can overcome these limitations. METHODS: An electronic real-time prompting system collected HH data on a musculoskeletal rehabilitation unit for 12 weeks between October 2016 and October 2017. Aggregate and professional group scores and the distributions of individuals' performance within groups were analyzed. Soiled utility room exits were monitored and compared with performance at patient rooms. Duration of patient room visits and the number of consecutive missed opportunities were calculated. RESULTS: Overall, 76,130 patient room and 1,448 soiled utility room HH opportunities were recorded from 98 health care professionals. Aggregate unit performance for patient and soiled utility rooms were both 67%, although individual compliance varied greatly. The number of hand wash events that occurred while inside patient rooms increased with longer visits, whereas HH performance at patient room exit decreased. Eighty-three percent of missed HH opportunities occurred as part of a series of missed events, not in isolation. CONCLUSIONS: Continuous collection of HH data that includes temporal, spatial, and personnel details provides information on actual HH practices, whereas direct observation or dispenser counts show only aggregate trends.

The Mortality Burden of Multidrug-resistant Pathogens in India: A Retrospective, Observational Study.

BACKGROUND: The threat posed by antibiotic resistance is of increasing concern in low- and middle-income countries (LMICs) as their rates of antibiotic use increase. However, an understanding of the burden of resistance is lacking in LMICs, particularly for multidrug-resistant (MDR) pathogens. METHODS: We conducted a retrospective, 10-hospital study of the relationship between MDR pathogens and mortality in India. Patient-level antimicrobial susceptibility test (AST) results for Enterococcus spp., Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp. were analyzed for their association with patient mortality outcomes. RESULTS: We analyzed data on 5103 AST results from 10 hospitals. The overall mortality rate of patients was 13.1% (n = 581), and there was a significant relationship between MDR and mortality. Infections with MDR and extensively drug resistant (XDR) E. coli, XDR K. pneumoniae, and MDR A. baumannii were associated with 2-3 times higher mortality. Mortality due to methicillin-resistant S. aureus (MRSA) was significantly higher than susceptible strains when the MRSA isolate was resistant to aminoglycosides. CONCLUSIONS: This is one of the largest studies undertaken in an LMIC to measure the burden of antibiotic resistance. We found that MDR bacterial infections pose a significant risk to patients. While consistent with prior studies, the variations in drug resistance and associated mortality outcomes by pathogen are different from those observed in high-income countries and provide a baseline for studies in other LMICs. Future research should aim to elucidate the burden of resistance and the differential transmission mechanisms that drive this public health crisis.

Impact of the 2012 Medicaid Health Care-Acquired Conditions Policy on Catheter-Associated Urinary Tract Infection and Vascular Catheter-Associated Infection Billing Rates.

In July 2012, the Centers for Medicare & Medicaid Services ceased hospital Medicaid reimbursements for certain health care-acquired conditions. Using billing data from 2008-2014, we found no impact of this policy on rates of 2 targeted conditions, vascular catheter-associated infections and catheter-associated urinary tract infections, among Medicaid or non-Medicaid patients.

Effect of electronic real-time prompting on hand hygiene behaviors in health care workers.

BACKGROUND: Poor hand hygiene by health care workers is a major cause of nosocomial infections. This research evaluated the ability of an electronic monitoring system with real-time prompting capability to change hand hygiene behaviors. METHODS: Handwashing activity was measured by counting dispenser activations on a single nursing unit before, during, and after installation of the system. The effect of changing the prompt duration on hand hygiene performance was determined by a cluster-randomized trial on 3 nursing units with 1 acting as control. Sustainability of performance and participation was observed on 4 nursing units over a year. All staff were eligible to participate. RESULTS: Between June 2015 and December 2016, a total of 459,376 hand hygiene opportunities and 330,740 handwashing events from 511 staff members were recorded. Dispenser activation counts were significantly influenced by use of the system (χ2[3] = 75.76; P < .0001). Hand hygiene performance dropped from 62.61% to 24.94% (odds ratio, 0.36; 95% confidence interval, 0.34-0.38) when the prompting feature was removed. Staff participation had a negative trajectory of -0.72% (P < .001), whereas change in average performance was -0.18% (P < .001) per week for the year. CONCLUSIONS: Use of electronic monitoring with real-time prompts of 20 seconds' duration nearly doubles handwashing activity and causes handwashing to occur sooner after entering a patient room. These improvements are sustainable over a year.

Impact of the International Nosocomial Infection Control Consortium's multidimensional approach on rates of ventilator-associated pneumonia in 14 intensive care units in 11 hospitals of 5 cities within Argentina.

BACKGROUND: To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach (IMA) on ventilator-associated pneumonia (VAP) rates in 11 hospitals within 5 cities of Argentina from January 2014-April 2017. METHODS: A multicenter, prospective, before-after surveillance study was conducted through the use of International Nosocomial Infection Control Consortium Surveillance Online System. During baseline, we performed outcome surveillance of VAP applying the definitions of the Centers for Disease Control andPrevention's National Healthcare Safety Network. During intervention, we implemented the IMA, which included a bundle of infection prevention practice interventions, education, outcome surveillance, process surveillance, feedback on VAP rates and consequences, and performance feedback of process surveillance. Bivariate and multivariate regression analyses were performed using a logistic regression model to estimate the effect of the intervention. RESULTS: We recorded 3,940 patients admitted to 14 intensive care units. At baseline, there were 19.9 VAPs per 1,000 mechanical ventilator (MV)-days-with 2,920 MV-days and 58 VAPs, which was reduced during intervention to 9.4 VAPs per 1,000 MV-days-with 9,261 MV-days and 103 VAPs. This accounted for a 52% rate reduction (incidence density rate, 0.48; 95% confidence interval, 0.3-0.7; P .001). CONCLUSIONS: Implementing the IMA was associated with significant reductions in VAP rates in intensive care units within Argentina.