To describe the results of a survey of members of the Society for Healthcare Epidemiology of America (SHEA) that (1) measured members' perceptions of gaps in the healthcare epidemiology knowledge base and members' priorities for SHEA research goals, (2) assessed whether members would be willing to participate in consortia to address identified gaps in knowledge, and (3) evaluated the need for training for the next generation of investigators in the field of healthcare epidemiology.

Electronic and paper survey of members of SHEA, a professional society formed to advance the science of healthcare epidemiology through research and education.

All society members were invited to participate.

Of 1,289 SHEA members, 593 (46.0%) responded. Respondents identified the following issues as important for the Research Committee of SHEA: setting the scientific agenda for healthcare epidemiology, developing collaborative infrastructure to conduct research, and developing funding mechanisms for research. Respondents ranked multidrug-resistant gram-negative organisms, antimicrobial stewardship, methicillin-resistant Staphylococcus aureus, adherence to effective hand hygiene guidelines, and Clostridium difficile infections as the most important scientific issues facing the field. Respondents ranked inadequate project funding, lack of protected time for research, and inability to obtain a grant, contract, and/or outside funding as the most significant barriers to conducting research. More than 92% of respondents support creating a SHEA research consortium; more than 40% would participate even if no additional funding were available; nearly 90% identified developing research training as a key function for SHEA.

These data provide a road map for the SHEA Research Committee for the next decade.

There are limited data comparing the clinical presentations, comorbidities, and outcomes of patients with infections due to seasonal influenza with patients with infections due to pandemic (H1N1) 2009 influenza.

To compare the epidemiological characteristics and outcomes of pandemic (H1N1) 2009 influenza with those of seasonal influenza.

A cross-sectional study was conducted among patients who received diagnoses during emergency department and inpatient encounters at 2 affiliated academic medical centers in Philadelphia, Pennsylvania. Cases of seasonal influenza during the period November 1, 2005, through June 1, 2008, and cases of pandemic influenza during the period from May 1, 2009, through August 7, 2009, were identified retrospectively.

Forty-nine cases of pandemic influenza and 503 cases of seasonal influenza were identified. Patients with pandemic H1N1 were younger (median age, 29 years) than patients with seasonal influenza (median age, 59 years) (P <.001). More patients with pandemic H1N1 (35 [71%] of 49) were African American, compared with patients with seasonal influenza (267 [53%] of 503; P = .02). Several symptoms were more common among patients with pandemic influenza infections than among patients with seasonal influenza infections: cough (98% vs 83%; P = .007), myalgias (71% vs 46%; P = .001), and pleuritic chest pain (45% vs 15%; P < .001). Pregnancy was the only comorbidity that occurred significantly more often in the pandemic influenza group than in the seasonal influenza group (16% vs 1%; P < .001). There were no significant differences in frequencies of deaths of hospitalized patients, intensive care unit admission, or length of hospitalization between groups.

Other than pregnancy, there were few clinically important differences between infections due to seasonal influenza and those due to pandemic influenza. The greater rate of lower respiratory tract symptoms in pandemic cases might serve to differentiate pandemic influenza from seasonal influenza.

To define the utility of using routine diagnostic methods to detect influenza in older, hospitalized adults.

Descriptive study.

One academic hospital and 1 community hospital during the 2006–2007 and 2007–2008 influenza seasons.

Hospitalized adults 50 years of age or older.

Adults who were 50 years of age or older and hospitalized with symptoms of respiratory illness were enrolled and tested for influenza by use of reverse-transcriptase polymerase chain reaction (RT-PCR). Using RT-PCR as the gold standard, we assessed the performances of rapid antigen tests and conventional influenza culture and the diagnostic use of the clinical definition of influenza-like illness.

Influenza was detected by use of RT-PCR in 26 (11%) of 228 patients enrolled in our study. The sensitivity of the rapid antigen test performed at bedside by research staff members was 19.2% (95% confidence interval, 8.51%–37.9%); the sensitivity of conventional influenza culture was 34.6% (95% confidence interval, 19.4%–53.8%). The ability to detect influenza with both the rapid antigen test and culture was associated with patients with a higher viral load (P = .002 and P = .001, respectively). The ability to diagnose influenza by use of the clinical definition of influenza-like illness had a higher sensitivity (80.8%) but lacked specificity (40.6%).

Because rapid antigen testing and viral culture have poor sensitivity (19.2% and 34.6%, respectively), neither testing method is sufficient to use to determine what type of isolation procedures to implement in a hospital setting.

To identify the determinants of influenza vaccination and the moderators of the intention-behavior relationship among healthcare workers (HCWs).

Prospective survey with 2-month follow-up.

Three university-affiliated public hospitals.

Random sample of 424 HCWs.

The intention of an HCW to get vaccinated against influenza was measured by means of a self-administered questionnaire based on an extended version of the theory of planned behavior. An objective measure of behavior was extracted 2 months later from the vaccination database of the hospitals.

Controlling for past behavior, we found that the determinants of influenza vaccination were intention (odds ratio [OR], 8.32 [95% confidence interval {CI}, 2.82–24.50]), moral norm (OR, 3.01 [95% CI, 1.17–7.76]), anticipated regret (OR, 2.33 [95% CI, 1.23–4.41]), and work status (ie, full time vs part time; OR, 1.99 [95% CI, 1.92–3.29]). Moral norm also interacted with intention as a significant moderator of the intention-behavior relationship (OR, 0.09 [95% CI, 0.03–0.30]). Again, apart from the influence of past behavior, intention to get vaccinated was predicted by use of the following variables: attitude (ß = .32; P < .001), professional norm (β = .18; P < .001), moral norm (β = .18; P < .001), subjective norm (ß = .09; P < .001), and self-efficacy (ß = .08; P < .001). This latter model explained 89% of the variance in HCWs' intentions to get vaccinated against influenza during the next vaccination campaign.

Our study suggests that influenza vaccination among HCWs is mainly a motivational issue. In this regard, it can be suggested to reinforce the idea that getting vaccinated can reduce worry and protect family members.

To develop and validate an algorithm to identify and classify noninvasive infections due to Staphylococcus aureus by using positive clinical culture results and administrative data.

Retrospective cohort study.

Veterans Affairs Maryland Health Care System.

Data were collected retrospectively on all S. aureus clinical culture results from samples obtained from nonsterile body sites during October 1998 through September 2008 and associated administrative claims records. An algorithm was developed to identify noninvasive infections on the basis of a unique S. aureus-positive culture result from a nonsterile site sample with a matching International Classification of Diseases, Ninth Revision (ICD-9-CM), code for infection at time of sampling. Medical records of a subset of cases were reviewed to find the proportion of true noninvasive infections (cases that met the Centers for Disease Control and Prevention National Healthcare Safety Network [NHSN] definition of infection). Positive predictive value (PPV) and negative predictive value (NPV) were calculated for all infections and according to body site of infection.

We identified 4,621 unique S. aureus-positive culture results, of which 2,816 (60.9%) results met our algorithm definition of noninvasive S. aureus infection and 1,805 (39.1%) results lacked a matching ICD-9-CM code. Among 96 cases that met our algorithm criteria for noninvasive S. aureus infection, 76 also met the NHSN criteria (PPV, 79.2% [95% confidence interval, 70.0%–86.1%]). Among 98 cases that failed to meet the algorithm criteria, 80 did not meet the NHSN criteria (NPV, 81.6% [95% confidence interval, 72.8%–88.0%]). The PPV of all culture results was 55.4%. The algorithm was most predictive for skin and soft-tissue infections and bone and joint infections.

When culture-based surveillance methods are used, the addition of administrative ICD-9-CM codes for infection can increase the PPV of true noninvasive S. aureus infection over the use of positive culture results alone.

To determine the epidemiological characteristics of postoperative invasive Staphylococcus aureus infection following 4 types of major surgical procedures.

Retrospective cohort study.

Eleven hospitals (9 community hospitals and 2 tertiary care hospitals) in North Carolina and Virginia.

Adults undergoing orthopedic, neurosurgical, cardiothoracic, and plastic surgical procedures.

We used previously validated, prospectively collected surgical surveillance data for surgical site infection and microbiological data for bloodstream infection. The study period was 2003 through 2006. We defined invasive S. aureus infection as either nonsuperficial incisional surgical site infection or bloodstream infection. Nonparametric bootstrapping was used to generate 95% confidence intervals (CIs). P values were generated using the Pearson x2 test, Student t test, or Wilcoxon rank-sum test, as appropriate.

In total, 81,267 patients underwent 96,455 procedures during the study period. The overall incidence of invasive S. aureus infection was 0.47 infections per 100 procedures (95% CI, 0.43–0.52); 227 (51%) of 446 infections were due to methicillin-resistant S. aureus. Invasive S. aureus infection was more common after cardiothoracic procedures (incidence, 0.79 infections per 100 procedures [95% CI, 0.62–0.97]) than after orthopedic procedures (0.37 infections per 100 procedures [95% CI, 0.32–0.42]), neurosurgical procedures (0.62 infections per 100 procedures [95% CI, 0.53–0.72]), or plastic surgical procedures (0.32 infections per 100 procedures [95% CI, 0.17¬0.47]) (P < .001). Similarly, S. aureus bloodstream infection was most common after cardiothoracic procedures (incidence, 0.57 infections per 100 procedures [95% CI, 0.43–0.72]; P < .001, compared with other procedure types), comprising almost three-quarters of the invasive S. aureus infections after these procedures. The highest rate of surgical site infection was observed after neurosurgical procedures (incidence, 0.50 infections per 100 procedures [95% CI, 0.42–0.59]; P < .001, compared with other procedure types), comprising 80% of invasive S. aureus infections after these procedures.

The frequency and type of postoperative invasive S. aureus infection varied significantly across procedure types. The highest risk procedures, such as cardiothoracic procedures, should be targeted for ongoing preventative interventions.

To assess whether use of oral vancomycin for treatment during an outbreak of Clostridium difficile infection (CDI) was associated with increased rates of colonization with vancomycin-resistant enterococci (VRE)..

A retrospective analysis of hospital databases.

The Jewish General Hospital in Montreal, Quebec, Canada.

We collected data regarding VRE colonization and CDI from November 1, 2000, through September 30, 2007, during which policies of preferential oral metronidazole or vancomycin treatment were implemented to control an outbreak of CDI. Four periods were considered: period 1, the preoutbreak period when metronidazole was used; period 2, the CDI outbreak period when metronidazole was used; period 3, the postoutbreak period when vancomycin was used; and period 4, the postoutbreak period when metronidazole was used.

A total of 2,412 cases of CDI and 425 cases of VRE colonization were identified. The rate of CDI increased significantly during period 2 and decreased to preoutbreak levels during period 3. The rate of VRE also increased during period 2 and decreased during the first 18 months of period 3. A clonal outbreak of cases of VRE (VanA) colonization was observed toward the end of period 3 and into period 4. Excluding the period of the clonal outbreak, there was a strong correlation between the number of cases of CDI and VRE colonization (r = 0.736; P = .001) and a negative association between VRE colonization and vancomycin use (r = —0.765; P = .04).

Increased vancomycin use was not associated with an increase in VRE colonization over a 2-year period. Restriction of vancomycin use during CDI outbreaks because of the fear of increasing VRE colonization may not be warranted.

Multidrug-resistant (MDR) gram-negative bacilli are important nosocomial pathogens.

To determine the incidence of transmission of MDR Acinetobacter baumannii and Pseudomonas aeruginosa from patients to healthcare workers (HCWs) during routine patient care.

Prospective cohort study.

Medical and surgical intensive care units.

We observed HCWs who entered the rooms of patients colonized with MDR A. baumannii or colonized with both MDR A. baumannii and MDR P. aeruginosa. We examined their hands before room entry, their disposable gloves and/or gowns upon completion of patient care, and their hands after removal of gloves and/or gowns and before hand hygiene.

Sixty-five interactions occurred with patients colonized with MDR A. baumannii and 134 with patients colonized with both MDR A. baumannii and MDR P. aeruginosa. Of 199 interactions between HCWs and patients colonized with MDR A. baumannii, 77 (38.7% [95% confidence interval {CI}, 31.9%–45.5%]) resulted in HCW contamination of gloves and/or gowns, and 9 (4.5% [95% CI, 1.6%–7.4%]) resulted in contamination of HCW hands after glove removal before hand hygiene. Of 134 interactions with patients colonized with MDR P. aeruginosa, 11 (8.2% [95% CI, 3.6%–12.9%]) resulted in HCW contamination of gloves and/or gowns, and 1 resulted in HCW contamination of hands. Independent risk factors for contamination with MDR A. baumannii were manipulation of wound dressing (adjusted odds ratio [aQR], 25.9 [95% CI, 3.1–208.8]), manipulation of artificial airway (aOR, 2.1 [95% CI, 1.1–4.0]), time in room longer than 5 minutes (aOR, 4.3 [95% CI, 2.0–9.1]), being a physician or nurse practitioner (aOR, 7.4 [95% CI, 1.6–35.2]), and being a nurse (aOR, 2.3 [95% CI, 1.1–4.8]).

Gowns, gloves, and unwashed hands of HCWs were frequently contaminated with MDR A. baumannii. MDR A. baumannii appears to be more easily transmitted than MDR P. aeruginosa and perhaps more easily transmitted than previously studied methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus. This ease of transmission may help explain the emergence of MDR A. baumannii.

We evaluated the impact of education and an antifungal stewardship program for candidiasis on prescribing practices, antifungal consumption, Candida species infections, and estimated costs at a Thai tertiary care hospital.

A hospital-wide, quasi-experimental study was conducted for 1.5 years before the intervention and 1.5 years after the implementation of an antifungal stewardship program. Inpatient antifungal prescriptions were prospectively observed, and patients' demographic, clinical, and administrative-cost data were collected. Interventions included education, introduction of an antifungal hepatic and/or renal dose adjustment tool, antifungal prescription forms, and prescription-control strategies.

After the intervention, there was a 59% reduction in antifungal prescriptions (from 194 to 80 prescriptions per 1,000 hospitalizations; P < .001). Inappropriate antifungal use decreased (from 71% to 24%; P < .001), a sustained reduction in antifungal use was observed (r = 0.83; P < .001), and fluconazole use decreased (from 242 to 117 defined daily doses per 1,000 patient-days; P < .001). Reductions in the incidence of infection with Candida glabrata (r = 0.69; P < .001) and Candida krusei (r = 0.71; P < .001) were observed, whereas the incidence of infection with Candida albicans (r = —0.81; P < .001) increased. Total cost savings were US$31,615 during the 18-month postintervention period.

Implementation of an antifungal stewardship program was associated with appropriate antifungal drug use, improved resource utilization, and cost savings.

Multidrug-resistant (MDR) Acinetobacter baumannii and Pseudomonas aeruginosa have emerged as the causes of nosocomial infections in critically ill patients.

To characterize the incidence of these MDR bacteria over time in the military healthcare system, comparing isolates recovered from overseas combat casualties with isolates recovered from local military and civilian patients.

Retrospective electronic records review of culture and/or susceptibility testing results of patients admitted to a military level I trauma center in San Antonio, Texas, during the period from January 2001 through December 2008. Multidrug resistance was defined as the first isolated organism resistant to 3 or more classes of antimicrobial agents.

Over time, the percentage of MDR A. baumannii isolates increased from 4% to 55%, whereas the percentage of MDR P. aeruginosa isolates increased from 2% to 8%. Respiratory tract specimens had a higher percentage of MDR A. baumannii isolates (49%), compared with specimens obtained from blood (30%), wound sites (24%), or urine (19%). No difference in the percentages of MDR P. aeruginosa isolates was observed with regard to source of specimen. The percentage of MDR A. baumannii isolates recovered was higher among patients who had been deployed overseas (52%) than among local patients (20%). When isolates recovered from patients in the burn intensive care unit (53% of MDR A. baumannii isolates) were removed from analysis, the percentage of MDR A. baumannii isolates decreased from 38% to 30% while the percentage of MDR P. aeruginosa isolates remained unaffected.

The percentage of MDR A. baumannii isolates increased in this facility among combat casualties and among local patients, which indicates nosocomial transmission; however, there was no significant increase in the percentage of MDR P. aeruginosa isolates. Isolated changes in the MDR pathogens within a facility can occur. Possible interventions to limit the spread of these organisms could include implementing aggressive infection control practices, controlling antibiotic use, and using active culture surveillance.

Use of oral antiseptics decreases the bacterial load in the oral cavity.

To compare the antimicrobial activity of 3 novel oral antiseptics with that of Chlorhexidine, which is considered the “gold standard” of oral hygiene.

Comparative in vitro study.

Four common oral microorganisms (Streptococcus sanguinis, Streptococcus mutans, Candida albicans, and Fusobacterium nucleatum) were tested under standard conditions and at different concentrations, by use of a broth dilution assay and an agar diffusion assay and by calculating the log10 reduction factor (RF). The antimicrobial activity of each antiseptic was assessed by counting the difference in bacterial densities (ie, the log10 number of colony-forming units of bacteria) before and after the disinfection process.

The oral antiseptics containing octenidine (with an RF in the range of 7.1–8.24 CFU/mL) and polyhexamethylene biguanide (with an RF in the range of 7.1–8.24 CFU/mL) demonstrated antimicrobial activity comparable to that of Chlorhexidine (with an RF in the range of 1.03–8.24 CFU/mL), whereas the mouth rinse containing Citroxx (Citroxx Biosciences; with an RF in the range of 0.22–1.36 CFU/mL) showed significantly weaker antimicrobial efficacy. Overall, octenidine and polyhexamethylene biguanide were more active at lower concentrations.

Oral antiseptics containing the antimicrobial agent octenidine or polyhexamethylene biguanide may be considered as potent alternatives to chlorhexidine-based preparations.

Electronic surveillance systems (ESSs) that utilize existing information in databases are more efficient than conventional infection surveillance methods.

To develop an ESS for monitoring bloodstream infections (BSIs) and assess whether data obtained from the ESS were in agreement with data obtained by traditional manual medical-record review.

An ESS was developed by linking data from regional laboratory and hospital administrative databases. Definitions for excluding BSI episodes representing contamination and duplicate episodes were developed and applied. Infections were classified as nosocomial infections, healthcare-associated community-onset infections, or community-acquired infections. For a random sample of episodes, data in the ESS were compared with data obtained by independent medical chart review.

From the records of the 306 patients whose infections were selected for comparative review, the ESS identified 323 episodes of BSI, of which 107 (33%) were classified as healthcare-associated community-onset infections, 108 (33%) were classified as community-acquired infections, 107 (33%) were classified as nosocomial infections, and 1 (0.3%) could not be classified. In comparison, 310 episodes were identified by use of medical chart review, of which 116 (37%) were classified as healthcare-associated community-onset infections, 95 (31%) as community-acquired infections, and 99 (32%) as nosocomial infections. For 302 episodes of BSI, there was concordance between the findings of the ESS and those of traditional manual chart review. Of the additional 21 discordant episodes that were identified by use of the ESS, 17 (81%) were classified as representing isolation of skin contaminants, by use of chart review. Of the additional 8 discordant episodes further identified by use of chart review, most were classified as repeat or polymicrobial episodes of disease. There was an overall 85% agreement between the findings of the ESS and those of chart review (K = 0.78; standard error, K = 0.04) for classification according to location of acquisition.

Our novel ESS allows episodes of BSI to be identified and classified with a high degree of accuracy. This system requires validation in other cohorts and settings.

In 2008, the Medical Officer of Health at Alberta Health Services (Edmonton, Canada) was notified that, in some practice settings, a syringe was used to administer medication through the side port of an intravenous circuit and then the syringe, with residual drug, was used to administer medication to other patients in the same manner. This practice has been implicated in several outbreaks of bloodborne infection in hospital and clinic settings.

A risk assessment model was developed to predict the risk of a patient contracting a bloodborne viral infection from the practice. The risk of transmission was defined as the product of 5 factors: (1) the population prevalence of a specific bloodborne pathogen, (2) the probability of finding a viral bloodborne pathogen in an intravenous circuit, (3) the rate of syringe reuse, (4) the probability of causing disease given a bloodborne pathogen exposure, and (5) the susceptibility of the exposed person.

The risk was modeled first with consistent use of the proximal port of the intravenous circuit. The risk of transmission of hepatitis B virus was approximately 12–53 transmission events per 1,000,000 exposure events for a range of practice probabilities (ie, frequency of the risk practice) from 20% to 80%, respectively. The risk of transmission of hepatitis C virus was approximately 1.0–4.3 transmission events per 1,000,000 exposure events for the same practice probability range, and the risk of transmission of human immunodeficiency virus was approximately 0.03–0.15 transmission events per 1,000,000 exposure events for the same practice probability range. The use of the distal port was associated with a 10-fold decrease in the risk.

Practitioners must practice safe, aseptic injection techniques. The model presented here can be used to estimate the risk of disease transmission in situations where reuse has occurred and can serve as a framework for informing public health action.