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Infection Control and Hospital Epidemiology 02/2013; 34(2):117-8. · 3.67 Impact Factor
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Nimalie D Stone,
Muhammad S Ashraf,
Jennifer Calder,
Christopher J Crnich,
Kent Crossley,
Paul J Drinka, Carolyn V Gould,
Manisha Juthani-Mehta,
Ebbing Lautenbach,
Mark Loeb, [......],
Preeti N Malani,
Lona Mody,
Joseph M Mylotte,
Lindsay E Nicolle,
Mary-Claire Roghmann,
Steven J Schweon,
Andrew E Simor,
Philip W Smith,
Kurt B Stevenson,
Suzanne F Bradley
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ABSTRACT: (See the commentary by Moro, on pages 978-980 .) Infection surveillance definitions for long-term care facilities (ie, the McGeer Criteria) have not been updated since 1991. An expert consensus panel modified these definitions on the basis of a structured review of the literature. Significant changes were made to the criteria defining urinary tract and respiratory tract infections. New definitions were added for norovirus gastroenteritis and Clostridum difficile infections.
Infection Control and Hospital Epidemiology 10/2012; 33(10):965-77. · 3.67 Impact Factor
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Amit S Chitnis,
Pam S Caruthers,
Agam K Rao,
Joanne Lamb,
Robert Lurvey,
Valery Beau De Rochars,
Brandon Kitchel,
Margarita Cancio,
Thomas J Török,
Alice Y Guh, Carolyn V Gould,
Matthew E Wise
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ABSTRACT: Objective. To describe a Klebsiella pneumoniae carbapenemase (KPC)-producing carbapenem-resistant Enterobacteriaceae (CRE) outbreak and interventions to prevent transmission. Design, setting, and patients. Epidemiologic investigation of a CRE outbreak among patients at a long-term acute care hospital (LTACH). Methods. Microbiology records at LTACH A from March 2009 through February 2011 were reviewed to identify CRE transmission cases and cases admitted with CRE. CRE bacteremia episodes were identified during March 2009-July 2011. Biweekly CRE prevalence surveys were conducted during July 2010-July 2011, and interventions to prevent transmission were implemented, including education and auditing of staff and isolation and cohorting of CRE patients with dedicated nursing staff and shared medical equipment. Trends were evaluated using weighted linear or Poisson regression. CRE transmission cases were included in a case-control study to evaluate risk factors for acquisition. A real-time polymerase chain reaction assay was used to detect the bla(KPC) gene, and pulsed-field gel electrophoresis was performed to assess the genetic relatedness of isolates. Results. Ninety-nine CRE transmission cases, 16 admission cases (from 7 acute care hospitals), and 29 CRE bacteremia episodes were identified. Significant reductions were observed in CRE prevalence (49% vs 8%), percentage of patients screened with newly detected CRE (44% vs 0%), and CRE bacteremia episodes (2.5 vs 0.0 per 1,000 patient-days). Cases were more likely to have received β-lactams, have diabetes, and require mechanical ventilation. All tested isolates were KPC-producing K. pneumoniae, and nearly all isolates were genetically related. Conclusion. CRE transmission can be reduced in LTACHs through surveillance testing and targeted interventions. Sustainable reductions within and across healthcare facilities may require a regional public health approach.
Infection Control and Hospital Epidemiology 10/2012; 33(10):984-92. · 3.67 Impact Factor
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ABSTRACT: Objective. To evaluate national data on healthcare-associated infections (HAIs), device utilization, and antimicrobial resistance in long-term acute care hospitals (LTACHs). Design and setting. Comparison of data from LTACHs and from medical and medical-surgical intensive care units (ICUs) in short-stay acute care hospitals reporting to the National Healthcare Safety Network (NHSN) during 2010. Methods. Rates of central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and ventilator-associated pneumonia (VAP) as well as device utilization ratios were calculated. For each HAI, pathogen profiles and antimicrobial resistance prevalence were evaluated. Comparisons were made using Poisson regression and the Mood median and χ(2) tests. Results. In 2010, 104 LTACHs reported CLABSIs and 57 reported CAUTIs and VAP to the NHSN. Median CLABSI rates in LTACHs (1.25 events per 1,000 device-days reported; range, 0.0-5.96) were comparable to rates in major teaching ICUs and were higher than those in other ICUs. CAUTI rates in LTACHs (median, 2.61; range, 0.0-9.92) were higher and VAP rates (median, 0.0; range, 0.0-3.29) were generally lower than those in ICUs. Central line utilization in LTACHs was higher than that in ICUs, whereas urinary catheter and ventilator utilization was lower. Methicillin resistance among Staphylococcus aureus CLABSIs (83%) and vancomycin resistance among Enterococcus faecalis CAUTIs (44%) were higher in LTACHs than in ICUs. Multidrug resistance among Pseudomonas aeruginosa CAUTIs (25%) was higher in LTACHs than in most ICUs. Conclusions. CLABSIs and CAUTIs associated with multidrug-resistant organisms present a challenge in LTACHs. Continued HAI surveillance with pathogen-level data can guide prevention efforts in LTACHs.
Infection Control and Hospital Epidemiology 10/2012; 33(10):993-1000. · 3.67 Impact Factor
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ABSTRACT: The dramatic changes in the epidemiology of Clostridium difficile infection (CDI) during recent years, with increases in incidence and severity of disease in several countries, have made CDI a global public health challenge. Increases in CDI incidence have been largely attributed to the emergence of a previously rare and more virulent strain, BI/NAP1/027. Increased toxin production and high-level resistance to fluoroquinolones have made this strain a very successful pathogen in healthcare settings. In addition, populations previously thought to be at low risk are now being identified as having severe CDI. Recent genetic analysis suggests that C. difficile has a highly fluid genome with multiple mechanisms to modify its content and functionality, which can make C. difficile adaptable to environmental changes and potentially lead to the emergence of more virulent strains. In the face of these changes in the epidemiology and microbiology of CDI, surveillance systems are necessary to monitor trends and inform public health actions.
Clinical Infectious Diseases 08/2012; 55 Suppl 2:S65-70. · 9.15 Impact Factor
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ABSTRACT: Seven organ/space surgical site infections (SSIs) that occurred after arthroscopic procedures and were due to Pseudomonas aeruginosa of indistinguishable pulsed-field gel electrophoresis (PFGE) patterns occurred at hospital X in Texas from April 22, 2009, through May 7, 2009.
To determine the source of the outbreak and prevent future infections.
Infection control observations and a case-control study.
Laboratory records were reviewed for case finding. A case-control study was conducted. A case patient was defined as someone who underwent knee or shoulder arthroscopy at hospital X during the outbreak period and subsequently developed organ/space SSI due to P. aeruginosa. Cultures of environmental and surgical equipment samples were performed, and selected isolates were analyzed by PFGE. Surgical instrument reprocessing practices were reviewed, and surgical instrument lumens were inspected with a borescope after reprocessing to assess cleanliness.
The case-control study did not identify any significant patient-related or operator-related risk factors. P. aeruginosa grew from 62 of 388 environmental samples. An isolate from the gross decontamination sink had a PFGE pattern that was indistinguishable from that of the case patient isolates. All surgical instrument cultures showed no growth. Endoscopic evaluation of reprocessed arthroscopic equipment revealed retained tissue in the lumen of both the inflow/outflow cannulae and arthroscopic shaver handpiece. No additional cases occurred after changes in instrument reprocessing protocols were implemented. After this outbreak, the US Food and Drug Administration released a safety alert about the concern regarding retained tissue within arthroscopic shavers.
These SSIs were likely related to surgical instrument contamination with P. aeruginosa during instrument reprocessing. Retained tissue in inflow/outflow cannulae and shaver handpieces could have allowed bacteria to survive sterilization procedures.
Infection Control and Hospital Epidemiology 12/2011; 32(12):1179-86. · 3.67 Impact Factor
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ABSTRACT: Over the past 2 decades, multiple interventions have been developed to prevent catheter-associated urinary tract infections (CAUTIs). The CAUTI prevention guidelines of the Healthcare Infection Control Practices Advisory Committee were recently revised.
To examine changes in rates of CAUTI events in adult intensive care units (ICUs) in the United States from 1990 through 2007.
Data were reported to the Centers for Disease Control and Prevention (CDC) through the National Nosocomial Infections Surveillance System from 1990 through 2004 and the National Healthcare Safety Network from 2006 through 2007. Infection preventionists in participating hospitals used standard methods to identify all CAUTI events (categorized as symptomatic urinary tract infection [SUTI] or asymptomatic bacteriuria [ASB]) and urinary catheter-days (UC-days) in months selected for surveillance. Data from all facilities were aggregated to calculate pooled mean annual SUTI and ASB rates (in events per 1,000 UC-days) by ICU type. Poisson regression was used to estimate percent changes in rates over time.
Overall, 36,282 SUTIs and 22,973 ASB episodes were reported from 367 facilities representing 1,223 adult ICUs, including combined medical/surgical (505), medical (212), surgical (224), coronary (173), and cardiothoracic (109) ICUs. All ICU types experienced significant declines of 19%-67% in SUTI rates and 29%-72% in ASB rates from 1990 through 2007. Between 2000 and 2007, significant reductions in SUTI rates occurred in all ICU types except cardiothoracic ICUs.
Since 1990, CAUTI rates have declined significantly in all major adult ICU types in facilities reporting to the CDC. Further efforts are needed to assess prevention strategies that might have led to these decreases and to implement new CAUTI prevention guidelines.
Infection Control and Hospital Epidemiology 08/2011; 32(8):748-56. · 3.67 Impact Factor
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Infection Control and Hospital Epidemiology 08/2011; 32(8):822-3. · 3.67 Impact Factor
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Infection Control and Hospital Epidemiology 08/2010; 31(8):870-2. · 3.67 Impact Factor
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Infection Control and Hospital Epidemiology 02/2010; 31(4):319-26. · 3.67 Impact Factor
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Robert P Gaynes, Carolyn V Gould,
Jonathan Edwards,
Theresa L Antoine,
Henry M Blumberg,
Kathryn Desilva,
Mark King,
Alice Kraman,
Jan Pack,
Bruce Ribner,
Ulrich Seybold,
James Steinberg,
John A Jernigan
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ABSTRACT: We examined interventions to optimize piperacillin-tazobactam use at 4 hospitals. Interventions for rotating house staff did not affect use. We could target empiric therapy in only 35% of cases. Because prescribing practices seemed to be institution specific, interventions should address attitudes of local prescribers. Interventions should target empiric therapy and ordering of appropriate cultures.
Infection Control and Hospital Epidemiology 07/2009; 30(8):794-6. · 3.67 Impact Factor
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David B Blossom,
Alexander J Kallen,
Priti R Patel,
Alexis Elward,
Luke Robinson,
Ganpan Gao,
Robert Langer,
Kiran M Perkins,
Jennifer L Jaeger,
Katie M Kurkjian, [......],
Takashi Kei Kishimoto,
Zachary Shriver,
Ann W McMahon,
K Frank Austen,
Steven Kozlowski,
Arjun Srinivasan,
George Turabelidze, Carolyn V Gould,
Matthew J Arduino,
Ram Sasisekharan
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ABSTRACT: In January 2008, the Centers for Disease Control and Prevention began a nationwide investigation of severe adverse reactions that were first detected in a single hemodialysis facility. Preliminary findings suggested that heparin was a possible cause of the reactions.
Information on clinical manifestations and on exposure was collected for patients who had signs and symptoms that were consistent with an allergic-type reaction after November 1, 2007. Twenty-one dialysis facilities that reported reactions and 23 facilities that reported no reactions were included in a case-control study to identify facility-level risk factors. Unopened heparin vials from facilities that reported reactions were tested for contaminants.
A total of 152 adverse reactions associated with heparin were identified in 113 patients from 13 states from November 19, 2007, through January 31, 2008. The use of heparin manufactured by Baxter Healthcare was the factor most strongly associated with reactions (present in 100.0% of case facilities vs. 4.3% of control facilities, P<0.001). Vials of heparin manufactured by Baxter from facilities that reported reactions contained a contaminant identified as oversulfated chondroitin sulfate (OSCS). Adverse reactions to the OSCS-contaminated heparin were often characterized by hypotension, nausea, and shortness of breath occurring within 30 minutes after administration. Of 130 reactions for which information on the heparin lot was available, 128 (98.5%) occurred in a facility that had OSCS-contaminated heparin on the premises. Of 54 reactions for which the lot number of administered heparin was known, 52 (96.3%) occurred after the administration of OSCS-contaminated heparin.
Heparin contaminated with OSCS was epidemiologically linked to adverse reactions in this nationwide outbreak. The reported clinical features of many of the cases further support the conclusion that contamination of heparin with OSCS was the cause of the outbreak.
New England Journal of Medicine 01/2009; 359(25):2674-84. · 53.30 Impact Factor
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ABSTRACT: In recent years, the incidence and severity of Clostridium difficile-associated disease (CDAD) have increased dramatically. Beginning in 2000, widespread regional outbreaks associated with a previously uncommon hypervirulent strain of C. difficile have occurred in North America and Europe. Most likely because of increased toxin production as well as other virulence factors, this epidemic strain has caused more severe and refractory disease leading to complications, including intensive care unit admission, colectomies, and death. Worldwide increasing use of fluoroquinolones and cephalosporins has likely contributed to the proliferation of this epidemic strain, which is highly resistant to both. The elderly have been disproportionately affected by CDAD, but C. difficile has also recently emerged in populations previously considered to be at low risk, including healthy outpatients and peripartum women, although it is unknown if these cases are related to the epidemic strain. Nevertheless, transmission within hospitals is the major source of C. difficile acquisition, and previous or concurrent antimicrobial use is almost universal among cases. Applying current evidence-based strategies for management and prevention is critically important, and clinicians should maintain an awareness of the changing epidemiology of CDAD and take measures to reduce the risk of disease in patients.
Critical care (London, England) 02/2008; 12(1):203. · 4.61 Impact Factor
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11/2007: pages 52 - 70; , ISBN: 9780470988336
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ABSTRACT: The occurrence of mutator phenotypes among laboratory-generated and clinical levofloxacin-resistant strains of Streptococcus pneumoniae was determined using fluctuation analysis. The in vitro selection for levofloxacin-resistant mutants of strain D39, each with point mutations in both gyrA and parC or parE, was not associated with a significant change in the mutation rate. Two of eight clinical isolates resistant to levofloxacin (MIC, >8 microg/ml) had estimated mutation rates of 1.2 x 10(-7) and 9.4 x 10(-8) mutations per cell division, indicating potential mutator phenotypes, compared to strain D39, which had an estimated mutation rate of 1.4 x 10(-8) mutations per cell division. The levofloxacin-resistant isolates with the highest mutation rates showed evidence of dysfunctional mismatch repair and contained missense mutations in mut genes at otherwise highly conserved sites. The association of hypermutability in levofloxacin-resistant S. pneumoniae clinical isolates with mutations in DNA mismatch repair genes provides further evidence that mismatch repair mutants may have a selective advantage in the setting of antibiotic pressure, facilitating the development of further antibiotic resistance.
Antimicrobial Agents and Chemotherapy 09/2007; 51(9):3225-9. · 4.84 Impact Factor
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Theresa L Antoine,
Amy B Curtis,
Henry M Blumberg,
Kathryn Desilva,
Mesfin Fransua, Carolyn V Gould,
Mark King,
Alice A Kraman,
Jan Pack,
Bruce Ribner,
Ulrich Seybold,
James P Steinberg,
Jane B Wells,
Ronda L Sinkowitz-Cochran,
Denise Cardo,
John A Jernigan,
Robert P Gaynes
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ABSTRACT: We investigated knowledge, attitudes, and behaviors of prescribers concerning piperacillin-tazobactam use at 4 Emory University-affiliated hospitals. Discussions during focus groups indicated that the participants' perceived knowledge of clinical criteria for appropriate piperacillin-tazobactam use was inadequate. Retrospective review of medical records identified inappropriate practices. These findings have influenced ongoing interventions aimed at optimizing piperacillin-tazobactam use.
Infection Control and Hospital Epidemiology 12/2006; 27(11):1274-7. · 3.67 Impact Factor
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ABSTRACT: To examine bacterial antibiotic resistance and antibiotic use patterns in long-term acute care hospitals (LTACHs) and to evaluate effects of antibiotic use and other hospital-level variables on the prevalence of antibiotic resistance.
Multihospital ecologic study.
Antibiograms, antibiotic purchasing data, and demographic variables from 2002 and 2003 were obtained from 45 LTACHs. Multivariable regression models were constructed, controlling for other hospital-level variables, to evaluate the effects of antibiotic use on resistance for selected pathogens. Results of active surveillance in 2003 at one LTACH were available.
Among LTACHs, median prevalences of resistance for several antimicrobial-organism pairs were greater than the 90th percentile value for National Nosocomial Infections Surveillance system (NNIS) medical intensive care units (ICUs). The median prevalence of methicillin resistance among Staphylococcus aureus isolates was 84%. More than 60% of patients in one LTACH were infected or colonized with methicillin-resistant S. aureus and/or vancomycin-resistant Enterococcus at the time of admission. Antibiotic consumption in LTACHs was comparable to consumption in NNIS medical ICUs. In multivariable logistic regression modeling, the only significant association between antibiotic use and the prevalence of antibiotic resistance was for carbapenems and imipenem resistance among Pseudomonas aeruginosa isolates (odds ratio, 11.88 [95% confidence interval, 1.42-99.13]; P=.02).
The prevalence of antibiotic resistance among bacteria recovered from patients in LTACHs is extremely high. Although antibiotic use in LTACHs likely contributes to resistance prevalence for some antimicrobial-organism pairs, for the majority of such pairs, other variables, such as prior colonization with and horizontal transmission of antimicrobial-resistant pathogens, may be more important determinants. Further research on antibiotic resistance in LTACHs is needed, particularly with respect to determining optimal infection control practices in this environment.
Infection Control and Hospital Epidemiology 10/2006; 27(9):920-5. · 3.67 Impact Factor
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ABSTRACT: The prevalence of vancomycin-resistant enterococci (VRE) has increased markedly during the past decade. Few data exist regarding the epidemiology of resistance of VRE to chloramphenicol, one of the few therapeutic options.
Survey and case-control study.
A 725-bed, tertiary-care academic medical center and a 344-bed urban community hospital.
Hospitalized patients with blood cultures demonstrating VRE.
We examined the trends in the prevalence of chloramphenicol resistance in VRE blood isolates at our institution from 1991 through 2002 and conducted a case-control study to identify risk factors for chloramphenicol resistance among these isolates.
From 1991 through 2002, the annual prevalence of chloramphenicol-resistant VRE increased from 0% to 12% (P < .001, chi-square test for trend). Twenty-two case-patients with chloramphenicol-resistant VRE bloodstream isolates were compared with 79 randomly selected control-patients with chloramphenicol-susceptible VRE. Independent risk factors for chloramphenicol-resistant VRE were prior chloramphenicol use (odds ratio [OR], 10.9; 95% confidence interval [CI95], 1.72-68.91; P = .01) and prior fluoroquinolone use (OR, 4.74; CI95, 1.15-19.42; P = .03). Chloramphenicol-resistant VRE isolates were more likely to be susceptible to beta-lactams and resistant to tetracycline than were chloramphenicol-susceptible VRE isolates.
Significant increases in the prevalence of chloramphenicol-resistant VRE may limit the future utility of chloramphenicol in the treatment of VRE infections, and close monitoring of susceptibility trends should continue. The association between fluoroquinolone use and chloramphenicol-resistant VRE, reflecting possible co-selection of resistance, suggests that recent dramatic increases in fluoroquinolone use may have broader implications than previously recognized.
Infection Control and Hospital Epidemiology 02/2004; 25(2):138-45. · 3.67 Impact Factor
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ABSTRACT: Therapeutic options for vancomycin-resistant enterococcal (VRE) bloodstream infections are extremely limited. Chloramphenicol is effective when VRE isolates are susceptible to this agent. However, longitudinal trends in chloramphenicol-resistant VRE (CR-VRE) are unknown. The possible association between CR-VRE and antibiotic use has not been studied. We analyzed the antimicrobial susceptibility profiles of all VRE blood isolates from 1991-2000 at our institution. We performed a correlational study to examine the relationship between annual hospital-wide use of specific antibiotics and antibiotic classes and CR-VRE prevalence. During the 10-year study period, the prevalence of CR-VRE increased from 0 to 11% ( P< 0.001, trend). CR-VRE prevalence was correlated only with chloramphenicol use (P=0.05 ) and quinolone use (P= 0.01 ). If these trends continue, dependence on newer, more expensive agents will increase. The correlation between both chloramphenicol use and quinolone use and the prevalence of CR-VRE suggests that efforts to preserve the utility of chloramphenicol in VRE infections may depend on optimizing the use of these agents.
International Journal of Antimicrobial Agents 02/2004; 23(2):200-3. · 4.13 Impact Factor
