[Show abstract][Hide abstract] ABSTRACT: Reports of bloodstream infections caused by methicillin-resistant
among chronic hemodialysis patients to 2 Centers for Disease Control and Prevention surveillance systems (National Healthcare Safety Network Dialysis Event and Emerging Infections Program) were compared to evaluate completeness of reporting. Many methicillin-resistant
bloodstream infections identified in hospitals were not reported to National Healthcare Safety Network Dialysis Event.
Infect. Control Hosp. Epidemiol.
Full-text · Article · Nov 2015 · Infection Control and Hospital Epidemiology
[Show abstract][Hide abstract] ABSTRACT: Background:
Antibiotic use in long-term care facilities (LTCF) is high and often inappropriate. Antimicrobial stewardship programs (ASP) improve patient safety, reduce healthcare costs and may impact rates of antibiotic resistance; however ASP guidance focuses on hospitals. Antibiotic treatment of asymptomatic bacteriuria is common in LTCF. We began a pilot program with a LTCF to assess baseline knowledge and practice to implement an ASP.
Staff prescribers (physicians and nurse practitioners) and nurse managers in a 340 bed LTCF were surveyed to assess knowledge and beliefs about antibiotic use and urinary tract infection (UTI) management. Survey questions were Likert-scaled 1 to 5, with 5 indicating strong agreement. Available data sources were: Pharmacy Antibiotic Report, Infection Log and Daily Nursing Report. Prescribing data from December 2012 – February 2013 were reviewed.
All (4/4) staff prescribers and 79% (20/24) nurse managers completed surveys. All prescribers and 50% of nurse managers believed antibiotic use leads to family perception of high-quality care. Notably, 50% of prescribers and 50% of nurse managers believed that antibiotics were almost always appropriate for residents with new confusion and history of UTI with indwelling catheter, and 50% prescribers and 39% nurse managers without an indwelling catheter. From December 2012 – February 2013, 79 antibiotic courses were dispensed: 26 (33%) had no stated indication and 12 (15%) were for UTI. Of the 12 prescriptions for UTI, 7 (58%) had no documentation of UTI on the Infection Log or Daily Nursing Report.
Antibiotic use in this LTCF was high (1 of every 4-5 residents); documentation of clinical indication for antibiotic was often missing or inconsistent between data sources. Surveying prescribers and nurse managers uncovered a bias towards prescribing antibiotics and a lack of understanding of UTI management. A pre-program assessment provided the framework for an ASP by identifying available data sources, highlighting documentation incompleteness, establishing an antibiotic utilization baseline, and identifying educational needs for bacteriuria management.
[Show abstract][Hide abstract] ABSTRACT: Background: Healthcare worker (HCW) diversion of narcotics has been associated with bloodborne pathogen transmission. Minnesota Department of Health (MDH) was contacted by a hospital regarding a cluster of 4 patients with Ochrobactrum anthropi (OA) bacteremia on a surgical unit.
Methods: MDH initiated an epidemiological investigation of patients with bacteremia from Oct. 2010–March 2011. Pulsed-field gel electrophoresis (PFGE) was performed on isolates from positive cultures of blood and medication solution.
Results: 25 surgical unit patients had bacteremia; 10 were polymicrobial. Organisms identified included Klebsiella oxytoca (KO; n=21), OA (n=8), Stenotrophomonas maltophilia (SM; n=2), and 5 other organisms (n=9). All patients had acute symptoms prompting blood culture [24 (96%) fever, 15 (60%) tachycardia, 15 (60%) increased pain, 12 (48%) confusion/agitation]. Within 48 hours following blood culture, 6 (24%) were transferred to intensive care, 3 (12%) had emergent surgery, and 1 (4%) died. Average monthly bacteremia rates on the surgical unit for SM, OA, and KO per 1,000 patient-days were 0, 0, and 0, in Oct. 2009–March 2010 compared to 0.4, 1.1, and 3.2 per 1,000 patient-days in Oct. 2010–March 2011, respectively.
All patients received IV narcotics prior to symptom onset. Narcotic bags collected from patients grew KO (n=4) and SM (n=2). KO bacteremia isolates were indistinguishable by PFGE from isolates from narcotic IV bags in use by the same patients; 1 SM bacteremia isolate was indistinguishable from 2 narcotic bag SM isolates. Cultures of unopened narcotic vials were negative. In March 2011, a HCW admitted to diversion and replacement of narcotic with saline. OA isolates recovered from an opened saline bottle in the HCW’s office were closely related by PFGE to bacteremia OA isolates. The HCW tested negative for HIV, HBV and HCV.
Conclusion: Narcotic diversion and replacement with saline by a HCW was associated with Gram-negative bacteremias resulting in significant patient harm. Infection surveillance should include review of all bacteremias and prompt investigation of unusual organisms or patterns. Facilities must also ensure compliance with regulatory requirements for monitoring narcotic access and administration.
[Show abstract][Hide abstract] ABSTRACT: The screening method, which employs readily available data, is an inexpensive and quick means of estimating vaccine effectiveness (VE). We compared estimates of effectiveness of heptavalent pneumococcal conjugate vaccine (PCV7) against invasive pneumococcal disease (IPD) using the screening and case-control methods. Cases were children aged 19-35 months with pneumococcus isolated from normally sterile sites residing in Active Bacterial Core surveillance areas in the United States. Case-control VE was estimated for 2001-2004 by comparing the odds of vaccination among cases and community controls. Screening-method VE for 2001-2009 was estimated by comparing the proportion of cases vaccinated to National Immunization Survey-derived coverage among the general population. To evaluate the plausibility of screening-method VE findings, we estimated attack rates among vaccinated and unvaccinated persons. We identified 1,154 children with IPD. Annual population PCV7 coverage with ≥1 dose increased from 38% to 97%. Case-control VE for ≥1 dose was estimated as 75% against all-serotype IPD (annual range: 35-83%) and 91% for PCV7-type IPD (annual range: 65-100%). By the screening method, the overall VE was 86% for ≥1 dose (annual range: -240-70%) against all-serotype IPD and 94% (annual range: 62-97%) against PCV7-type IPD. As cases of PCV7-type IPD declined during 2001-2005, estimated attack rates for all-serotype IPD among vaccinated and unvaccinated individuals became less consistent than what would be expected with the estimated effectiveness of PCV7. The screening method yields estimates of VE that are highly dependent on the time period during which it is used and the choice of outcome. The method should be used cautiously to evaluate VE of PCVs.
[Show abstract][Hide abstract] ABSTRACT: Circulating strains of Staphylococcus aureus (SA) have changed in the last 30 years including the emergence of community-associated methicillin-resistant SA (MRSA). A report suggested staphylococcal toxic shock syndrome (TSS) was increasing over 2000-2003. The last population-based assessment of TSS was 1986.
Population-based active surveillance for TSS meeting the CDC definition using ICD-9 codes was conducted in the Minneapolis-St. Paul area (population 2,642,056) from 2000-2006. Medical records of potential cases were reviewed for case criteria, antimicrobial susceptibility, risk factors, and outcome. Superantigen PCR testing and PFGE were performed on available isolates from probable and confirmed cases.
Of 7,491 hospitalizations that received one of the ICD-9 study codes, 61 TSS cases (33 menstrual, 28 non-menstrual) were identified. The average annual incidence per 100,000 of all, menstrual, and non-menstrual TSS was 0.52 (95% CI, 0.32-0.77), 0.69 (0.39-1.16), and 0.32 (0.12-0.67), respectively. Women 13-24 years had the highest incidence at 1.41 (0.63-2.61). No increase in incidence was observed from 2000-2006. MRSA was isolated in 1 menstrual and 3 non-menstrual cases (7% of TSS cases); 1 isolate was USA400. The superantigen gene tst-1 was identified in 20 (80%) of isolates and was more common in menstrual compared to non-menstrual isolates (89% vs. 50%, p = 0.07). Superantigen genes sea, seb and sec were found more frequently among non-menstrual compared to menstrual isolates [100% vs 25% (p = 0.4), 60% vs 0% (p<0.01), and 25% vs 13% (p = 0.5), respectively].
TSS incidence remained stable across our surveillance period of 2000-2006 and compared to past population-based estimates in the 1980s. MRSA accounted for a small percentage of TSS cases. tst-1 continues to be the superantigen associated with the majority of menstrual cases. The CDC case definition identifies the most severe cases and has been consistently used but likely results in a substantial underestimation of the total TSS disease burden.
[Show abstract][Hide abstract] ABSTRACT: Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a community pathogen. Community-associated (CA) MRSA infections have occurred among multiple members of a household. We describe the incidence of and risk factors for MRSA colonization among household contacts of children with CA-MRSA infections.
MRSA-infected children <18 years of age who lacked established healthcare-associated MRSA risk factors were identified through surveillance at 12 Minnesota hospital laboratories. Nasal swab specimens and information on medical history and hygiene behaviors were collected from case-patients and enrolled household contacts during home visits. S. aureus isolates obtained from nasal cultures were screened for oxacillin resistance.
In all, 236 households consisting of 236 case-patients and 712 household contacts were enrolled. Home visits were conducted on an average of 69 days after the onset of symptom in case-patients (range: 16-178 days). Twenty-nine (13%) case-patients and 82 (12%) household contacts had MRSA nasal colonization. Nasal MRSA colonization in ≥ 1 household contact occurred in 58 (25%) households. Household contacts who assisted the case-patient to bathe or who shared balms/ointments/lotion with the case-patient were more likely to be colonized (P < 0.01, P < 0.05), whereas those who reported using antibacterial versus nonantibacterial soap for hand washing were less likely to be colonized (P < 0.05) with MRSA clonally related to the case-patient infection isolate.
Only 13% of case-patients had MRSA nasal colonization on an average of 69 days after their initial MRSA infection. CA-MRSA colonization may be short-lived or may occur at non-nasal sites. One quarter of households had at least one household contact colonized with MRSA. Modifiable behaviors, such as sharing personal items, may contribute to transmission.
No preview · Article · May 2011 · The Pediatric Infectious Disease Journal
[Show abstract][Hide abstract] ABSTRACT: The objective of this study is to determine the costs per hospital admission of screening intensive care unit patients for methicillin-resistant Staphylococcus aureus (MRSA) and isolating those who are colonized.
Data on the costs of the intervention come from the Minneapolis Veterans Affairs Medical Center, a 279-bed teaching hospital and outpatient facility. A microcosting approach is used to determine the intervention costs for 3 different laboratory testing protocols. The costs of caring for MRSA-infected patients come from the experience of 241 Minneapolis Veterans Affairs Medical Center patients with MRSA infections in 2004 through 2006. The effectiveness of the intervention comes from the extant literature. To capture the effect of screening on reducing transmission of MRSA to other patients and its effect on costs, a Markov simulation model was employed.
The intervention was cost saving compared with no intervention for all 3 laboratory processes evaluated and for all of the 1-way sensitivity analyses considered.
Because of the high cost of caring for a MRSA patient, interventions that reduce the spread of infections-such as screening intensive care unit patients upon admission studied here-are likely to pay for themselves.
Preview · Article · Feb 2011 · American journal of infection control
[Show abstract][Hide abstract] ABSTRACT: To determine differences in healthcare costs between cases of methicillin-susceptible Staphylococcus aureus (MSSA) infection and methicillin-resistant S. aureus (MRSA) infection in adults.
Retrospective study of all cases of S. aureus infection.
Department of Veterans Affairs hospital and associated clinics.
There were 390 patients with MSSA infections and 335 patients with MRSA infections.
We used medical records, accounting systems, and interviews to identify services rendered and costs for Minneapolis Veterans Affairs Medical Center patients with S. aureus infection with onset during the period from January 1, 2004, through June 30, 2006. We used regression analysis to adjust for patient characteristics.
Median 6-month unadjusted costs for patients infected with MRSA were $34,657, compared with $15,923 for patients infected with MSSA. Patients with MRSA infection had more comorbidities than patients with MSSA infection (mean Charlson index 4.3 vs 3.2; P < .001). For patients with Charlson indices of 3 or less, mean adjusted 6-month costs derived from multivariate analysis were $51,252 (95% CI, $46,041-$56,464) for MRSA infection and $30,158 (95% CI, $27,092-$33,225) for MSSA infection. For patients with Charlson indices of 4 or more, mean adjusted costs were $84,436 (95% CI, $79,843-$89,029) for MRSA infection and $59,245 (95% CI, $56,016-$62,473) for MSSA infection. Patients with MRSA infection were also more likely to die than were patients with MSSA infection (23.6% vs 11.5%; P < .001). MRSA infection was more likely to involve the lungs, bloodstream, and urinary tract, while MSSA infection was more likely to involve bones or joints; eyes, ears, nose, or throat; surgical sites; and skin or soft tissue (P < .001).
Resistance to methicillin in S. aureus was independently associated with increased costs. Effective antimicrobial stewardship and infection prevention programs are needed to prevent these costly infections.
Preview · Article · Feb 2010 · Infection Control and Hospital Epidemiology
[Show abstract][Hide abstract] ABSTRACT: We compared passive surveillance and International Classification of Diseases, 9th Revision, codes for completeness of staphylococcal toxic shock syndrome (TSS) surveillance in the Minneapolis-St. Paul area, Minnesota, USA. TSS-specific codes identified 55% of cases compared with 30% by passive surveillance and were more sensitive (p = 0.0005, McNemar chi2 12.25).
Preview · Article · Jun 2009 · Emerging Infectious Diseases
[Show abstract][Hide abstract] ABSTRACT: Background: Although the incidence of staphylococcal toxic shock syndrome (STSS) decreased significantly from 1980-1986, toxin producing community-associated methicillin-resistant Staphylococcus aureus (CAMRSA) has emerged and has been linked to STSS. Recent data suggest the numbers of STSS cases are increasing. Methods: To determine the incidence and clinical characteristics of STSS, population based active surveillance for STSS among all 24 hospitals in the seven-county Minneapolis-St. Paul area (population 2,642,056) was conducted. ICD-9 codes from all hospital discharges between January 1, 2000-December 31, 2003 were utilized for case finding and charts were reviewed for STSS CDC surveillance definition. Results: 7,414 hospitalizations received one of six ICD-9 study codes; 1,691 hospitalizations were reviewed. Forty-three STSS cases (23 menstrual, 20 nonmenstrual) were identified. Three cases had MRSA isolated (9% of culture positive cases); two had antimicrobial susceptibility profiles consistent with CAMRSA and one was confirmed as USA 400. Averaged over 2000-2003, the yearly incidence per 100,000 persons was 0.52 (95% Confidence Interval [CI] 0.32-0.77) for all STSS, 1.41 (95% CI 0.63-2.61) for menstrual STSS ages 13-24 years, 0.43 (95% CI, 0.19-0.82) for menstrual STSS ages 25-54 years, and 0.32 (95% CI 0.12-0.67) for nonmenstrual STSS. From 2000-2003, the incidence of menstrual STSS increased significantly among 13-24 year-olds (from <0.1 to 2.3, P=.02) and decreased significantly among 25-54 year-olds (from 1.0 to 0.2, P=.01). Only 1 (5%) nonmenstrual case and 9 (39%) menstrual cases were reported to the Minnesota Department of Health. Conclusions: From 2000-2003, the incidence of menstrual STSS appears to be increasing among ages 13-24 years and decreasing among ages 25-54 years. These changes suggest evolving risk factors affecting menstrual STSS incidence, but CAMRSA does not appear to be a factor in this change. Under the current STSS surveillance system, there is substantial underreporting.