10-­‐09-­‐12	  Top	  Ten	  Papers	  in	  Infec4on	  control	                                                            Di...
10-­‐09-­‐12	                  CV	  Opera4ons:	  Day	  Team	  vs.	                 Evening	  Team	  vs.	  Day	  +	  Evenin...
10-­‐09-­‐12	                                                                                                             ...
10-­‐09-­‐12	  You	  wonder	  why	  SSI	  rates	  are	  high?	                                                            ...
10-­‐09-­‐12	                                           Fun	  Facts	  •  Anesthesia	  providers	  in	  OR:	      –  HH	  o...
10-­‐09-­‐12	                                                                                                             ...
10-­‐09-­‐12	               ESBL	  in	  vegetables	                                                            ESBL	  in	 ...
10-­‐09-­‐12	       Pa4ents’	  interpreta4ons	  of	  ‘an4bio4c	                                                           ...
10-­‐09-­‐12	  An4bio4cs	  obtained	  without	  a	  prescrip4on	                    in	  Europe	   Es4mated	  percentage	 ...
10-­‐09-­‐12	   For	  all those,	  who	   are	  under-­‐short	  for	                             	  	                     ...
10-­‐09-­‐12	           Pseudo-­‐outbreak	  Related	  to	  	            Damaged	  Bronchoscopes	  •  Bronchoscopes	  A	  a...
10-­‐09-­‐12	            Eradica4ng	  S.	  aureus	  &	  CA-­‐SSTI	  	                                                     ...
10-­‐09-­‐12	                               Bieber	  Fever	  	  •  Highly	  infec4ous	  	  •  Infec4on	  worsens	  with	  ...
10-­‐09-­‐12	                 Use	  of	  Remote	  Video	  Audi4ng	  and	                                                  ...
10-­‐09-­‐12	  Ra4onale	  for	  HH	  &	  CDI	                                                 When	  bored,	  look	  for	 ...
10-­‐09-­‐12	  New	  ways	  to	  treat	  MSSA/MRSA?	  	                                                           New	  wa...
10-­‐09-­‐12	    Emergence	  of	  mupirocin	  resistance	  in	  CoNS	  	                                            Emerge...
10-­‐09-­‐12	          Epidemic	  Curve	  A.	  xylosoxidans	                                                              ...
10-­‐09-­‐12	                                                                                                             ...
10-­‐09-­‐12	                                                                                                             ...
ICAAC 2012 top papers
ICAAC 2012 top papers
ICAAC 2012 top papers
ICAAC 2012 top papers
ICAAC 2012 top papers
ICAAC 2012 top papers
ICAAC 2012 top papers
ICAAC 2012 top papers
ICAAC 2012 top papers
ICAAC 2012 top papers
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ICAAC 2012 top papers


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Talk by Loreen Herwaldt and Andreas Voss on "Top 10" infection control papers from the last year (2011-2012)

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ICAAC 2012 top papers

  1. 1. 10-­‐09-­‐12  Top  Ten  Papers  in  Infec4on  control   Disclosures •  Grants from: – 3M – AHRQLoreen  Herwaldt                                  Andreas  Voss   Lessons  in  Preparedness   The  London  Olympic   organizers  (LOCOG)  provided   150,000  free  condoms  for   Infection Prevention 10,800  athletes  at  the   Games.  A  Bri4sh  consumer   & goods  group  paid  for  the   exclusive  supply  rights.   Disasters   A  LOCOG  spokeswoman  said   they  were  trying  to  find  out   who  distributed  Kangaroo   condoms  from  an  Australian   compe4tor.         Can  the  Impact  of  Change  of  Surgical   Teams  in  Cardiovascular  Surgery  Be  Operating Room Decorum & Measured  by  Opera4ve  Mortality  or   Surgical Site Infections Morbidity?  A  Propensity  Adjusted   Cohort  Comparison   ML  Brown,  et  al.     Ann  Surg  2011;253:385-­‐392   1  
  2. 2. 10-­‐09-­‐12   CV  Opera4ons:  Day  Team  vs.   Evening  Team  vs.  Day  +  Evening   (Change)  Team  •  Evening  or  Change  vs.  Day:  Significantly   longer  skin  to  skin  4me,  OR  4me,  vent  4me,   ICU  LOS,  hospital  LOS    •  Change  vs.  Evening:  Significantly  longer  skin   to  skin  4me,  OR  4me        ML  Brown,  et  al.  Ann  Surg  2011;253:385-­‐392         The  Impact  of  Preventable   Disrup4on  on  the  Opera4ve  Time   for  Minimally  Invasive  Surgery   L  Al-­‐Hakim   Surg  Endosc  2011;25:3385-­‐3392     L Al-Hakim Surg Endosc 2011;25:3385-3392 General  Surgical  Opera4ve  Dura4on   Is  Associated  with  Increased  Risk-­‐ Adjusted  Infec4ous  Complica4on   Rates  and  Length  of  Hospital  Stay   LD  Procter,  et  al.     J  Am  Coll  Surg  2010;210:60-­‐65     LD Procter, et al. J Am Coll Surg 2010;210:60-65 2  
  3. 3. 10-­‐09-­‐12   Team  Training   •  TeamSTEPPS  training  provided  to  all  OR   staff  over  2  mns  in  2006-­‐2007   •  Ader  9  mns:  team  work  &  communica4on   scores,  SQIP  measures,  pt  sa4sfac4on,  first   Team  Training  Can  Improve   case  on  4me  starts,  morbidity  &  mortality   Opera4ng  Room  Performance   all  improved  significantly   RA  Forse,  et  al.     •  1  year  later:  first  case  on  4me  starts,   morbidity  &  mortality  were  all  worse   Surgery  2011;150:771-­‐778        RA  Forse,  et  al.  Surgery  2011;150:771-­‐778   Now  that’s  teamwork!   Traffic  Flow  in  the  Opera4ng  Room:   An  Explora4ve  and  Descrip4ve  Study   on  Air  Quality  during  Orthopedic   Trauma  Implant  Surgery   AE  Andersson,  et  al.   AJIC  2012,  Jan  28  epublished   CFU  and  OR  Traffic   Reasons  for  Door  Openings  •  For  52/91  (57%)  air  samples,  the  CFU/m3  values     •  177  (33.5%)  =  necessary   >  10  CFU/m3.     –  40    =  expert  consulta4ons   –  137  =  supplies  &  equipment  •  Total  CFU/m3  per  opera4on  &  total  traffic  flow   per  opera4on  (r  =  0.74;  P  =  0.001),  ader   •  184  (35.7%)  =  semi-­‐necessary     controlling  for  procedure  dura4on.     –  76  =  surgical  team  members  entering  or  leaving  •  CFU/m3  and  the  number  of  persons  in  the  OR     –  134  =  breaks   (r  =  0.22;  P  =  0.04)     •  168  (31.8%)  =  unnecessary  •  Traffic  flow,  number  of  persons  present,  &   –  30  =  logis4cs,  like  planning  other  opera4ons   procedure  dura4on  explained  68%  of  the   –  45  =  social   variance  in  total  CFU/m3  (P  =  0.001).   –  93  =  no  detectable  reason        AE  Andersson,  et  al.  AJIC  2012,  Jan  28  epublished        AE  Andersson,  et  al.  AJIC  2012,  Jan  28  epublished   3  
  4. 4. 10-­‐09-­‐12  You  wonder  why  SSI  rates  are  high?   Evalua4ng  an  Evidence-­‐Based   Bundle  for  Preven4ng  Surgical  Site   Infec4on:  A  Randomized  Trial   T  Anthony,  et  al.     Arch  Surg.  2011;146:263-­‐269   Evidence-­‐based  Surgical  Bundle:   Evidence-­‐based  Surgical  Bundle:   Standard  Arm   Extended  Arm     •  Mechanical  bowel  prepara4on  with  oral  an4bio4cs;   •  No  mechanical  bowel  prepara4on;     •  Intraopera4ve  forced  air  warming;   •  Preopera4ve  &  intraopera4ve  warming;     •  Physiologic  concentra4on  of  inspired  oxygen  ader   •  Supplemental  oxygen  during  and  immediately   intuba4on  (target  FiO2  =  30%);   ader  the  opera4on;     •  IV  fluid  given  at  anesthesiologist’s  discre4on;   •  Intraopera4ve  IV  fluid  restric4on;     •  No  wound  edge  protectors;   •  Plas4c  surgical  wound  protector;   •  IV  prophylac4c  Abx  c/w  SCIP:  cefoxi4n  or  ertapenem   T  Anthony,  et  al.  Arch  Surg.  2011;146:263-­‐269   •  IV  prophylac4c  Abx  c/w  SCIP:  cefoxi4n  or   ertapenem   T  Anthony,  et  al.  Arch  Surg.  2011;146:263-­‐269   Evidence-­‐based  Surgical  Bundle   So  much  for  the  bundle!   •  Extended  arm  SSI  =  45%  vs.  Standard  arm  =   24%  (P  =  0.003).     •  Extended  arm:  superficial  incisional  SSIs  =  36%   vs.  Standard  arm  =  19%;  (P  =  0.004).     •  Mul4variable  analysis:  Extended  arm   associated  w/  ↑ SSI  risk  of  2.49-­‐fold  (95%  CI,   1.36-­‐4.56;  P  =  0.003).   T  Anthony,  et  al.  Arch  Surg.  2011;146:263-­‐269   4  
  5. 5. 10-­‐09-­‐12   Fun  Facts  •  Anesthesia  providers  in  OR:   –  HH  opportuni4es:  34-­‐41/hour;  max  54/hour.     –  82%  failure  rate,  range  =  64%-­‐93%  by  provider   group.        C  Biddle  &  J  Shah,  AJIC  2012,  Feb  9  epublished  •  Post-­‐op  abx  for  nonperforated  appendici4s:   –  Did  not  decrease  SSI  rates   –  Were  associated  w/  significantly  ↑  rates  of     C.  difficile,  UTIs,  &  post-­‐op  diarrhea,  &     w/  longer  LOS          BA  Coakley,  et  al.  J  Am  Coll  Surg  2011;213:778-­‐783   Disclaimer  •  As  some  might  know  I  am  a  person  who   excells  in  trying  to  be  “poli4cally  correct”   Green  and  Davison,  BMJ  December  2011   Resistance  to  an4bio4cs   An4bio4c  resistance   5  
  6. 6. 10-­‐09-­‐12   Sales  of  veterinary  an4microbial  agents  in  nine   European  countries  (2005–09)   *  PCU  (animal  popula4on  correc4on  unit)   JAC    Grave  et  al.    JAG    August  2012   JAC    Grave  et  al.    JAG    August  2012   Propor4onal  sales  an4microbial  agents  for  2009    (in  mg  of  ac4ve  ingredient/PCU)   ESBL  in  community  pa4ents   Poster  C02-­‐104   Beyer  guidlines  about  how  to  use  an4bio4cs   Beyer/stricter  regula4ons  about  what  to  use   Ban  certain  an4bio4cs/classes  from  vet-­‐med  ugust  2012   JAC    Grave  et  al.    JAG    A Reuland  et  al.    Clin  Microbiol  Infect.  2012  Jun  11.   ESBL-­‐producing  Enterobacteriaceae  carriage  in     ESBL-­‐producing  Enterobacteriaceae  carriage  in     Dutch  community  pa4ents   Dutch  community  pa8ents  •  AIM:  rate  of  carriage  of  ESBL-­‐producing  Enterobacteriaceae   •  73  of  720  (10.1%)  samples  yielded  ESBL-­‐producing   (ESBL-­‐E)  in  the  community  in  the  Netherlands     organisms,  predominantly  E.  coli.    •  Faecal  samples  from  720  consecu4ve  pa4ents  presen4ng  to   –   No  carbapenemases  were  detected.     their  general  prac44oner   •  Most  frequent  ESBL  was  CTX-­‐M-­‐15  (34/73,  47%).    •  Species  iden4fica4on  and  an4bio4c  suscep4bility  tes4ng   •  CTX-­‐M-­‐15-­‐producing  E.  coli  belonged  to  various  clonal   were  performed  according  to  the  Dutch  na4onal  guidelines.   complexes.  Clonal  complex  ST10  was  predominant.     PCR,  sequencing  and  microarray  were  used  to  characterize   •  In  the  Netherlands,  despite  low  rate  of  an4bio4c   the  genes  encoding  for  ESBL.  Strain  typing  was  performed   consump4on  (in  humans),  resistance  due  to  the  expansion   with  amplified  fragment  length  polymorphism  (AFLP)  and   of  CTX-­‐M  ESBLs,  in  par4cular  CTX-­‐M-­‐15,  is  emerging.     mul4locus  sequence  typing  (MLST).     Reuland  et  al.    Clin  Microbiol  Infect.  2012  Jun  11.   Reuland  et  al.    Clin  Microbiol  Infect.  2012  Jun  11.   6  
  7. 7. 10-­‐09-­‐12   ESBL  in  vegetables   ESBL  in  vegetables  •   Samples of 15 different types of vegetables •  7 samples ESBL positive: 6% obtained from the market, and from organic •  4/15 vegetable types contaminated with ESBL- and conventional stores in Amsterdam positive Enterobacteriaceae•  Vegetables that grow in or on the ground - parsnip - bean sprouts -  radish -  spring onion Reuland  et  al.     Reuland  et  al.     Resistance  in  fish   Resistance  in  fish   …  existence  of  high  levels  of  mobile  genes  conferring   reduced  suscep4bility  to  fluoroquinolones  as  well  as   the  presence  of  ESBL  genes  in  fish     Jiang  et  al.    JAC    July  2012   Jiang  et  al.    JAC    July  2012   …  probably  the  cows  were  wright   Sorry,  no  chicken  either  …   185  confirmed  ESBL  isolates  (43.9%  of  all  samples)   Majority  E.coli  producing  ESBL  types  SHV-­‐12,  CTX-­‐M-­‐1,  and  TEM-­‐52   No  differences  could  be  observed  in  the  prevalence  of  ESBL  producers   between  organic  and  conven4onal  samples.   7  
  8. 8. 10-­‐09-­‐12   Pa4ents’  interpreta4ons  of  ‘an4bio4c   Pa4ents’  interpreta4ons  of  ‘an4bio4c  resistance’     resistance’     •  DESIGN        Mul4  country  (n=9)    qualita4ve  interview   study  (semi-­‐structured)  including  121  adult  pa4ents  who   had  recently  consulted  a  primary  care  clinician  with   symptoms  of  LRTI.   Brookes-­‐Howell  et  al.      J  Gen  Internal  Med  2011;27,766       Brookes-­‐Howell  et  al.      J  Gen  Internal  Med  2011;27,766      Pa4ents’  interpreta4ons  of  ‘an4bio4c  resistance’     •  Most  pa4ents  were  aware  of  the  link   between  an4bio4c  use  and  an4bio4c   resistance.     •  Frequent  misinterpreta4on  of  an4bio4c   resistance  as  a  property  of  the  human   body  rather  than  bacterial  cells     ¤  Emphasize  the  transferability  of  resistance,  and  the  societal   contribu4on  individuals  can  make  through  more  appropriate   an4bio4c  prescribing  and  use  will  help  to  beyer  control  AB-­‐use.   Brookes-­‐Howell  et  al.      J  Gen  Internal  Med  2011;27,766        Morgan  et  al.    LID    2011;11:692   Frequency  of  non-­‐prescrip4on  use  of   An4bio4cs  obtained  without  a   an4bio4cs  in  general  popula4on   prescrip4on  in  Europe        “     …  pooling  data    from  several     countries  might      make  sense  on  a     global  scale,  but  only  gives     a  gross  picture  of  the   frequency  of  non-­‐prescrip>on   use  of  an>bio>cs  …”   Safrany & Monnet  Morgan  et  al.    LID    2011;11:692    Leyer:        Nabil  Safrany  (EC),  Dominique  L  Monnet  (ECDC)            LID    March  2012   8  
  9. 9. 10-­‐09-­‐12  An4bio4cs  obtained  without  a  prescrip4on   in  Europe   Es4mated  percentage  of  systemic  an4bio4cs  sold  at  pharmacies  without  a  prescrip4on    Nabil  Safrany  (EC),  Dominique  L  Monnet  (ECDC)            LID    March  2012   Talon  et  al.  JHI    2011;79:366   Mupirocin resistance is not an inevitable Mupirocin resistance is not an inevitable consequence of mupirocin use consequence of mupirocin use •  Mupirocin  resistance  in  MRSA  in  Besançon   University  Hospital  is  low  with  a  decreasing   consump4on   trend,  from  10%  in  2004  to  3%  in  2009.     •  The  trend  in  resistance  paralleled  mupirocin   high-­‐level   consump4on.     •  The  way  in  which  mupirocin  is  used,  rather   low-­‐level   than  the  volume,  plays  an  important  role  in   the  emergence  of  resistance     Talon  et  al.  JHI    2011;79:366   Talon  et  al.  JHI    2011;79:366   Mupirocin resistance is not an inevitable consequence of mupirocin use •  Comment:     While  I  strongly  support  the  authors’  view:   Low mupirocin resistance as a consequence of cautious mupirocin use “The  way  in  which  mupirocin  is  used  is   important,  …”  I  do  not  fully  understand  their   conclusion  …   Talon  et  al.  JHI    2011;79:366   Talon  et  al.  JHI    2011;79:366   9  
  10. 10. 10-­‐09-­‐12   For  all those,  who   are  under-­‐short  for       (like  me)     their  weight   An8bio8cs                                                                                      No  an8bio8cs   AU  G  U  S  T  2  0  1  2  |  VO  L  4  8  8  |  N  AT  U  R  E  |  6  2  1   S4ll,  the  good  news  …  …  as  opposed  to  rats,  the  fat  monkey  survives  longer  !   Caveat  Emptor:  The  Role  of   Subop4mal  Bronchoscope  Repair   Pseudomonas Among Us Prac4ces  by  a  Third-­‐Party  Vendor  in  a   Pseudo-­‐Outbreak  of  Pseudomonas  in   Bronchoalveolar  Lavage  Specimens   SE  Cosgrove,  et  al.   Infect  Control  Hosp  Epidemiol  2012;33:224-­‐229   10  
  11. 11. 10-­‐09-­‐12   Pseudo-­‐outbreak  Related  to     Damaged  Bronchoscopes  •  Bronchoscopes  A  and  B  grew  P.  pu>da,  P.  aeruginosa,   and  Stenotrophomonas.  •  16/77  (21%)  pts  who  had  bronchs  w/  scope  A  or  B  had   cultures  +  for  >  1  of  these  organisms.  •  No  pa4ents  acquired  infec4ons;  7  were  treated.   Emergence  of  Glutaraldehyde-­‐•  Scopes  A  &  B  were  repaired  by  an  external  vendor.  •  The  manufacturer  found  that  they  had  not  been   Resistant  Pseudomonas  aeruginosa   repaired  properly  &  nonstandard  parts  were  used.     S  Tschudin-­‐Suyer,  et  al.    •  Biopsy  ports  were  easily  loosened  by  hand  &  sludge   Infect  Control  Hosp  Epidemiol   had  accumulated  at  the  port  site.   2011;32:1173-­‐1178   SE  Cosgrove,  et  al.  Infect  Control  Hosp  Epidemiol  2012;33:224-­‐229   Mupirocin, Chlorhexidine, Bleach Bathing, & Staphylococci S  Tschudin-­‐Suyer,  et  al.    Infect  Control  Hosp  Epidemiol  2011;32:1173-­‐1178   Fun  Facts  •  5/92  (5.4%)  Thai  HCW’s  had  grade  1  skin  rxns  to  2%   Effec4veness  of  Measures  to   &  4%  CHG;  2/5  had  derma44s;  1/5  dust  allergy   Eradicate  Staphylococcus  aureus        A  Apisarnthanarak  &  LM  Mundy  CID  2011:53;848-­‐849  •  Meta-­‐analysis  of  16  trials  of  CHG  preop  bathing:  CHG   Carriage  in  Pa4ents  with  Community-­‐ =  7,952  pts;  comparator  groups  =  9,980  pts.     Associated  Skin  &  Sod-­‐Tissue  •  SSI:  6.8%  of  CHG  group  vs.  7.2%  of  comparator   groups;  RR,  0.90;  95%  CI,  0.77-­‐1.05,  P  =  0.19.   Infec4ons:  A  Randomized  Trial        MC  Chlebicki,  et  al.  AJIC  2012,  June  19  epublished   SA  Fritz,  et  al.  •  1/10  surfaces  in  a  university  fitness  center  were   Infect  Control  Hosp  Epidemiol   contaminated  with  MSSA     2011;32:872-­‐880        JD  Markley  et  al.  AJIC  2012,  May  22  epublished           11  
  12. 12. 10-­‐09-­‐12   Eradica4ng  S.  aureus  &  CA-­‐SSTI     Eradica4ng  S.  aureus  &  CA-­‐SSTI    •  Open-­‐label,  randomized  controlled  trial   •  229  par4cipants  followed  4-­‐months  •  Pts  with  recurrent  S.  aureus  CA-­‐SSTIs   •  Eradica4on  rates:  •  Pts  randomized  to  receive:   –  48%  among  controls,     –  Hygiene  educa4on  (control  subjects):   –  56%  in  mupirocin  only  group  (P  =  0.40),   –  Intranasal  2%  mupirocin  ointment  bid  x  5  days   –  54%  mupirocin  &  CHG  group  (P  =  0.51),     –  Intranasal  mupirocin  +  daily  4%  CHG  body  washes     –  71%  mupirocin  and  bleach  group  (P  =  0.02).     x  5  days     –  Intranasal  mupirocin  +  daily  dilute  bleach  water  baths   •  Recurrent  SSTIs:  36%  no  significant  difference   x  5  days   among  groups      SA  Fritz,  et  al.  Infect  Control  Hosp  Epidemiol  2011;32:872-­‐880      SA  Fritz,  et  al.  Infect  Control  Hosp  Epidemiol  2011;32:872-­‐880   Na4onal  MRSA  Rates  Run  Along   Creative Use of with  Fair  Play  of  Na4onal  Football   Modeling Teams:  A  Cross-­‐na4onal  Data   Analysis  of  the  European  Football   Championship,  2008   E  Meyer,  et  al.   Infec4on,  2012  epublished  August  5   Red  &  Yellow  Cards  vs.  MRSA%   A  Mathema4cal  Model  of  Bieber   cards  /  100  min   Fever:  The  most  Infec4ous  Disease   of  Our  Time?     V  Tweedle  &  RJ  Smith   n  =  11   Understanding  the  Dynamics  of  Emerging  &     r  =  0.628   Re-­‐Emerging  Infec4ous  Diseases  Using   p  =  0.038   MRSA  %   Mathema4cal  Models,  2012:  157-­‐177   E.  Meyer,  et  al.  Infec4on,  2012  epublished  August  5     12  
  13. 13. 10-­‐09-­‐12   Bieber  Fever    •  Highly  infec4ous    •  Infec4on  worsens  with  external  media  pressure.  •  Symptoms  include:     –  Time-­‐was4ng,     –  Excessive  purchasing  of  useless  merchandise,   –  Uncontrollable  crying  and/or  screaming.    •  Mathema4cal  model  to  describe  the  spread  of  Bieber   Fever:  persons  can  be:   –  Suscep4ble,     –  Bieber-­‐infected,     V  Tweedle  &  RJ  Smith,  Understanding  the  Dynamics  of  Emerging  &  Re-­‐Emerging     –  Bored  of  Bieber.   Infec4ous  Diseases  Using  Mathema4cal  Models,  2012:  157-­‐177              Hand  Hygiene  -­‐     Hand Hygiene      Down  Under  is  leading   •  HH  compliance  improved  from  43.6%  at   baseline  to  67.8%  (P<0.001).     •  HH  compliance  was  highest  among   nursing  staff  (73.6%)  and  worst  among   medical  staff  (52.3%)   All  moments  are  equal  but  some     are  more  equal    Armelino  et  al.    CID  2012;54:1-­‐7   13  
  14. 14. 10-­‐09-­‐12   Use  of  Remote  Video  Audi4ng  and   Use  of  Remote  Video  Audi4ng  and   Real-­‐4me  Feedback  in  Healthcare   Real-­‐4me  Feedback  in  Healthcare  •  Methods:  The  study  was  conducted  in  an  17-­‐bed  intensive  care   unit  from  June  2008  through  June  2010.  We  placed  cameras   with  views  of  every  sink  and  hand  sani8zer  dispenser  to  record   hand  hygiene  of  HCWs.  Sensors  in  doorways  iden4fied  when  an   individual(s)  entered/exited.  When  video  auditors  observed  a   HCW  performing  hand  hygiene  upon  entering/exi8ng,  they   assigned  a  pass.  •  16-­‐week  period  of  remote  video  audi4ng  without  feedback  and   a  91-­‐week  period  with  feedback  of  data  (con4nuously  displayed   on  electronic  boards  in  the  hallways,  and  summary  reports  for   supervisors).    Armelino  et  al.    CID  2012;54:1-­‐7    Armelino  et  al.    CID  2012;54:1-­‐7   Use  of  Remote  Video  Audi4ng  and   Real-­‐4me  Feedback  in  Healthcare   The Dirty Hand in the Latex Glove •  A  study  of  hand  hygiene  compliance  when   •  During  the  16-­‐week  prefeedback  period,  hand   hygiene  rates  were  less  than  10%     gloves  are  worn.   •  In  the  16-­‐week  pos€eedback  period  it  was  81.6%     •  The  increase  was  maintained  through  75  weeks   at  87.9%   •  Conclusions.  The  data  suggest  that  remote  video   audi4ng  combined  with  feedback  produced  a   significant  and  sustained  improvement  in  hand   dirty e hygiene.   insid  Armelino  et  al.    CID  2012;54:1-­‐7   Fuller  et  al.    ICHE  2011;32:1194  The Dirty Hand in the Latex Glove Finally  ….   •  56  wards  in  15  hospitals  England  &  Wales   •  7578  moments  of  hand  hygiene   •  Glove-­‐use  in  1,983  moments  (26.2%)   •  Rate  of  compliance:   –  With  gloves  41.4%  vs  without  50.0%   –  On  ICU:  47.7%  vs  54.5%   –  Before  contact:  29.7%  vs  40.1%   –  Ader  contact:  47.2%  vs  51.9%   Fuller  et  al.    ICHE  2011;32:1194   14  
  15. 15. 10-­‐09-­‐12  Ra4onale  for  HH  &  CDI   When  bored,  look  for  artwork  …  In  conclusion,  although  soap  and  water  is  superior  to  removing  C.  difficile  spores  from  hands  of  volunteers  compared  to  alcohol-­‐based  hand  hygiene  products,  there  have  been  no  studies  in  acute  care  sePngs  that  have  demonstrated  an  increase  in  CDI  with  alcohol-­‐based  hand  hygiene  products  or  a  decrease  in  CDI  with  soap  and  water.  This  is   Rings  &  long  sleeves  not  part  of  it  in  most  European  countries  why  preferen8al  use  of  soap  and  water  for  hand  hygiene  aRer  caring  for  a  pa8ent  with  CDI  is  not  recommended  in  non-­‐outbreak  sePngs.         MSSA  &  MRSA  &  VRE   Staphylococcus  aureus  CC398   •  Whole-­‐genome  sequence  typing  data  strongly  suggests  that   the  CC398  lineage  originated  in  humans  as  MSSA  and  then   spread  to  livestock   •  Human-­‐associated  isolates  from  the  basal  clades  carried   phages  encoding  human  innate  immune  modulators  that   were  largely  missing  among  the  livestock-­‐associated  isolates     •  CC398  acquired  resistance  to  methicillin  and  tetracycline  ader   the  introduc4on  to  livestock  from  humans     •  Jump  from  humans  to  animals  was  followed  by  a  decreased   capacity  for  human  coloniza8on,  transmission,  and  virulence     Price  et  al.  mBio  3(1):  doi:10.1128/mBio.00305-­‐11     Price  et  al.  mBio  3(1):  doi:10.1128/mBio.00305-­‐11     15  
  16. 16. 10-­‐09-­‐12  New  ways  to  treat  MSSA/MRSA?     New  ways  to  treat  MSSA/MRSA?     •   …  high  doses  of  the  nico4namide  form  of   vitamin  B3  s4mulated  a  specific  gene  (CEBPE),   enhancing  white  blood  cells  ability  to  combat   staph  infec4ons,  including  those  caused  by   MRSA     Kyme  et  al.    J  Clin  Invest    2012  (September)   Kyme  et  al.    J  Clin  Invest    2012  (September)   Reminder:  why  fight  MRSA?   Reminder:  why  fight  MRSA?     •   Receipt  of  nafcillin  or  cefazolin  was  protec4ve   against  mortality  compared  to  vancomycin  even   when  therapy  was  altered  ader  culture  results   iden4fied  MSSA.     •   Convenience  of  vancomycin  dosing  may  not   outweigh  the  poten4al  benefits  of  nafcillin  or   cefazolin  in  the  treatment  of  MSSA  bacteremia.   Schweizer  et  al.    BMC  Infect  Dis    2011,11.279   Schweizer  et  al.    BMC  Infect  Dis    2011,11.279   Emergence  of  mupirocin  resistance  in  CNS     Decoloniza4on   asscociated  with  increased  short-­‐term  use   •  Mupirocin-­‐resistance   –  Low  level  –  muta4on  of  na4ve  chromosomal  ileS  gene   –  High  level  –  plasmid  with  ileS2  (mupA)  gene   •  Presence  of  ileS2-­‐gene  has  been  asscociated  with   resistance  to  clinda,  tetra,  ery,  and  levofloxacin   •  Mup  long  term  use  may  fascilitate  emergence  of   resistance,  short-­‐term  use  (decoloniza4on  pre-­‐ op)  not.   Bathoorn  et  al.    (NL)    JCM    2012;50:2947  (September)   16  
  17. 17. 10-­‐09-­‐12   Emergence  of  mupirocin  resistance  in  CoNS     Emergence  of  mupirocin  resistance  in  CoNS     asscociated  with  increased  short-­‐term  use   asscociated  with  increased  short-­‐term  use  •   Longitudinal  trends  in  high-­‐level  mup-­‐resistants     Resistance   Mup-­‐S   Mup-­‐LL-­‐R   Mup-­‐HL-­‐R    in  STAU  en  CoNS,  prevalence  of  ileS2  genes  in  BSI   (%)   N=192   N=13   N=30   isolates  (2006-­‐2011),  and  mupirocin  use.   oxacillin   66   -­‐-­‐   90     clindamycin   44   69   73  •   Results   ciprofloxacin   40   62   80   –   Annual  use  mup:  3.6  kg  à  13.3  kg   erythromycon   65   85   90   –   median  dura4on  mup-­‐use:  4.3  days     TMP-­‐SMX   40   62   57   –   CoNS  HL  mup-­‐R:      8%  à  22%   tertacycline   23   0   20   –   STAU  HL  mup-­‐R:    only  2  of  363  isolates   Bathoorn  et  al.    (NL)    JCM    2012;50:2947  (September)   Bathoorn  et  al.    (NL)    JCM    2012;50:2947  (September)   Emergence  of  mupirocin  resistance  in  CoNS     asscociated  with  increased  short-­‐term  use  •   Increase  in  hospital  use  of  mup    à     – rapid  increase  high-­‐level  mup-­‐resistance  in  CoNS   and     – resistance  to  other  an4bio4cs.  •   Interes4ng  study  but  s4ll  some  ques4ons:   –  How  many  of  the  CNS  actually  were  from  pa4ents  receiving   mupirocin?       –  Where  CNS  =  contaminats  excluded?     –  Data  on  use  of  an4bio4cs  such  as  cipro,  clinda,  …       Bathoorn  et  al.    (NL)    JCM    2012;50:2947  (September)   Outbreaks Us Inves4ga4on  and  Control  of  an   Outbreak  of  Achromobacter   xylosoxidans  Bacteremia   B  Behrens-­‐Muller,  et  al.   Infect  Control  Hosp  Epidemiol  2012;33:180-­‐184   17  
  18. 18. 10-­‐09-­‐12   Epidemic  Curve  A.  xylosoxidans   Outbreak  of  A.  xylosoxidans   Bacteremia   Bacteremia   •  All  9  pts  w/  A.  xylosoxidans  bacteremia  had  PCA   pumps;    P  <  0.001.     •  Risk  factors  for  A.  xylosoxidans  bacteremia:     –  PCA  pump  used  for  morphine  (OR,  undef;  P  <  .001).     –  PCA  pump  cartridge  with  morphine  started  by  nurse  C   (OR,  46;  95%  CI,  4.0–525.0;  P  <  .001).   •  Nurse  C  resigned.   •  2  staff  members  must  observe  all  PCA  pump   cartridge  handling  &  pharmacy  must  dispose  of   residual  medica4on.      B  Behrens-­‐Muller,  et  al.  Infect  Control  Hosp  Epidemiol  2012;33:180-­‐184   B  Behrens-­‐Muller,  et  al.  Infect  Control  Hosp  Epidemiol  2012;33:180-­‐184   A  Mul4faceted  Interven4on  Strategy   for  Eradica4on  of  a  Hospital-­‐Wide   Outbreak  Caused  by  Carbapenem-­‐ Resistant  Klebsiella  pneumoniae  in   Southern  Israel   A  Borer,  et  al.     Infect  Control  Hosp  Epidemiol   2011;32:1158-­‐1165     5  Key  Elements    •  An  emergency  department  flagging  system,    •  A  cohort  ward,    •  Ac4ve  surveillance  on  high-­‐risk  wards,    •  Cultures  of  the  environment  and  of  staff   members’  hands,    •  A  carbapenem-­‐restric4on  policy.     A.  Borer,  et  al.  Infect  Control  Hosp  Epidemiol  2011;32:1158-­‐1165   A.  Borer,  et  al.  Infect  Control  Hosp  Epidemiol  2011;32:1158-­‐1165   18  
  19. 19. 10-­‐09-­‐12   An  Outbreak  of  Legionnaires  Disease   Associated  with  a  Decora4ve  Water   Wall  Fountain  in  a  Hospital   TE  Haupt,  et  al.   Infect  Control  Hosp  Epidemiol  2012;33:185-­‐191   A.  Borer,  et  al.  Infect  Control  Hosp  Epidemiol  2011;32:1158-­‐1165   Legionnaires’  Disease  &     Legionnaires’  Disease  &     a  Hospital  Water  Wall   a  Hospital  Water  Wall  •  8  people  were  hospitalized  with  Legionnaires’  disease   •  8  people  were  hospitalized  with  Legionnaires’  disease.   from  2/10/2010  to  3/6/2010.   •  3  required  mechanical  ven4la4on.  •  3  required  mechanical  ven4la4on.   •  Hospital  A  was  the  only  reported  common  exposure  •  Median  hospital  LOS:  12  days  (range,  4–21  days).   during  the  10  days  before  illness  onset.    •  4  were  male.   –  3/8  visited  Hospital  A  as  outpa4ents,    •  Ages:  50  to  86  (median,  64)  years.     –  3/8  picked  up  medica4on  at  the  pharmacy,    •  All  8  pa4ents  had  an  underlying  medical  condi4ons   –  1/8  made  a  delivery  to  the  facility,     (DM,  alcoholism,  RA,  or  COPD),  used  immune-­‐ –  1/8  waited  in  the  lobby  during  a  rela4ve’s  outpa4ent  visit.     suppressive  meds,  or  had  other  factors  (smoking).   •  6/8  pa4ents  entered  or  exited  the  facility  through  the  •  All  8  pa4ents  survived.   main  lobby  and  had  passed  the  fountain.        TE  Haupt,  et  al.  Infect  Control  Hosp  Epidemiol  2012;33:185-­‐191        TE  Haupt,  et  al.  Infect  Control  Hosp  Epidemiol  2012;33:185-­‐191     Legionnaires’  Disease  &     a  Hospital  Water  Wall   •  March  13–15:  call  center  staff:   –  Called  ~  4,000  poten4ally  exposed  persons  (3,300   hospital  or  clinic  pa4ents  &  700  pharmacy  customers),   –  Contacted  all  Hospital  A  employees  &  physicians  &  89   volunteers.     •  No  one  had  illness  c/w  Legionnaires’  disease.   •  Review  of  Legionella  urine  an4gen  test  results  Fountain from  4  area  hospitals  iden4fied  1  confirmed  case  Foam material Lp1 CFU/specimen in  a  pa4ent  with  no  Hospital  A  exposure  who  had  53,000 - 1,200,000   been  exposed  to  Legionella  during  foreign  travel.     •  No  known  addi4onal  cases  of  Legionnaires   disease  occurred  ader  the  fountain  shutdown.  TE  Haupt,  et  al.  Infect  Control  Hosp  Epidemiol  2012;33:185-­‐191      TE  Haupt,  et  al.  Infect  Control  Hosp  Epidemiol  2012;33:185-­‐191   19  
  20. 20. 10-­‐09-­‐12   Assessing  Risk  of  Health  Care-­‐ Just  say  “No”  to   acquired  Legionnaires’  Disease  from   Environmental  Sampling:  The  Limits   water  features!   of  Using  a  Strict  Percent  Posi4vity   Approach   JG  Allen,  et  al.     AJIC  2012,  epublished  May  24     Legionella  Water  Culture     Fun  Facts   Posi4vity  Rates  •  Reviewed  31  peer-­‐reviewed  publica4ons  repor4ng   •  Foodborne  GAS  tonsillopharyngi4s  outbreak  at  a  hospital     matched  data.     –  252  persons  affected;  43  were  hospitalized  •  Abstracted  206  data  points,  represen4ng  119  hospitals.     –  Milky  dessert  was  culture  +  for  GAS  (OR,  22.0;  95%  CI  •  30%  posi4vity  metric  had:   11.2-­‐40.9,  P  <  0.001)   –  59%  sensi4vity  =  41%  false-­‐nega4ve  rate   –  1  bakery  employee’s  throat  culture  was  +  for  GAS   –  74%  specificity  =  26%  false-­‐posi4ve  rate   –  Employee  helped  distribute  milky  dessert  •  “These  notable  error  rates  could  have  significant          BM  Ertugrul,  et  al.  Infec4on  2012;40:49–55   implica4ons,  given  that  we  iden4fied  16  peer-­‐reviewed   •  8/11  (73%)  foodborne  listeriosis  outbreaks  in  UK   ar4cles  and  6  government  guidance  documents  that   referenced  the  30%  posi4vity  metric  as  a  risk  assessment   1999-­‐2011  were  associated  w/  sandwiches  obtained  in   tool.”   hospitals.            JG  Allen,  et  al.  AJIC  2012,  epublished  May  24          CL  Liyle,  et  al.  J  Hosp  Infect  2012;82:13-­‐18     •  Food  was  stored  at  inappropriately  warm  temperatures.   If  the  water  doesn’t  get  you,     the  food  will!   Bacterial  Contamina4on  of  an   Automated  Pharmacy  Robot  Used   for  Intravenous  Medica4on   Prepara4on   D  Cluck,  et  al.   Infect  Control  Hosp  Epidemiol  2012;33:517-­‐520   20