More than 10% of patients admitted to intensive care units (ICUs) experience a severe, healthcare-associated infection, such as ventilator-associated pneumonia (VAP) or bloodstream infection (BSI). What could be a public health target for prevention is hotly debated, because properly adjusting for intrinsic risk factors in the patient population is difficult. We aimed to estimate the proportion of ICU-acquired VAP and BSI cases that are amenable to prevention in routine conditions.

We analyzed routine data collected prospectively according to the European standard protocol for patient-based surveillance of healthcare-acquired infections in ICUs. We computed the number of infections to be expected if, after adjustment for case mix, the infection incidence in ICUs with higher infection rates could be reduced to that of the top-tenth-percentile-ranked ICU. Computations came from model-based simulation of individual patient profiles over time in the ICU. The preventable proportion was computed as the number of observed cases minus the number of expected cases divided by the number of observed cases.

Data for 78,222 patients admitted for more than 2 days to 525 ICUs in 6 European countries from 2005 to 2008 were available for analysis. We calculated that 52% of VAP and 69% of BSI was preventable.

Our pragmatic, if highly conservative, estimates quantify the potential for prevention of VAP and BSI in routine conditions, assuming that variation in infection incidence between ICUs can be eliminated with improved quality of care, apart from variation attributable to differential case mix.

The Centers for Disease Control and Prevention implemented new surveillance definitions for ventilator-associated events (VAEs) in January 2013. We describe the epidemiology, attributable morbidity, and attributable mortality of VAEs.

Retrospective cohort study.

Academic tertiary care center.

All patients initiated on mechanical ventilation between January 1, 2006, and December 31, 2011.

We calculated and compared VAE hazard ratios, antibiotic exposures, microbiology, attributable morbidity, and attributable mortality for all VAE tiers.

Among 20,356 episodes of mechanical ventilation, there were 1,141 (5.6%) ventilator-associated condition (VAC) events, 431 (2.1%) infection-related ventilator-associated complications (IVACs), 139 (0.7%) possible pneumonias, and 127 (0.6%) probable pneumonias. VAC hazard rates were highest in medical, surgical, and thoracic units and lowest in cardiac and neuroscience units. The median number of days to VAC onset was 6 (interquartile range, 4–11). The proportion of IVACs to VACs ranged from 29% in medical units to 42% in surgical units. Patients with probable pneumonia were more likely to be prescribed nafcillin, ceftazidime, and fluroquinolones compared with patients with possible pneumonia or IVAC-alone. The most frequendy isolated organisms were Staphylococcus aureus (29%), Pseudomonas aeruginosa (14%), and Enterobacter species (7.9%). Compared with matched controls, VAEs were associated with more days to extubation (relative rate, 3.12 [95% confidence interval (CI), 2.96–3.29]), more days to hospital discharge (relative rate, 1.46 [95% CI, 1.37–1.55]), and higher hospital mortality risk (odds ratio, 1.98 [95% CI, 1.60–2.44]).

VAEs are common and morbid. Prevention strategies targeting VAEs are needed.

To analyze trends in the incidence and pathogen distribution of healthcare-associated bloodstream infections (HABSIs) over a 20-year period (1992–2011).

Historical cohort study.

Thirty-two-bed neonatal intensive care unit (NICU) in a tertiary referral hospital.

Neonates with HABSIs defined according to the criteria of the National Institute of Child Health and Development (NICHD).

A hospital-based ongoing surveillance program was used to identify HABSI cases in neonates. A distinction between definite or possible HABSI was made according to the NICHD criteria. Incidence, incidence densities (HABSIs per 1,000 hospital-days and HABSIs per 1,000 total parenteral nutrition–days), and case fatality rate were calculated. Logistic regression analysis was used to find time trends. Four periods of 5 years were considered when executing variance analysis.

In total, 682 episodes of HABSIs occurred on 9,934 admissions (6.9%). The median total incidence density rate was 3.1 (interquartile range, 2.2–3.9). A significant increasing time trend in incidence density was observed for the period 1995–2011 (P < .003). A significant decrease in the case fatality rate was found in the last 5-year period (P < .001). No neonate died following possible HABSIs, whereas the case fatality rate among neonates with definite HABSIs was 9.7%. Most HABSIs were caused by coagulase-negative staphylococci (n = 414 [60.7%]). A significant increase in Staphylococcus aureus HABSI was observed in the last 10-year period (P < .001).

An increase in incidence density rate occurred, while the case fatality rate dropped. Better perinatal care could be responsible for the latter. A decrease in days before infection and a high incidence of coagulase-negative Staphylococcus HABSIs indicate the need for vigorous application of evidence-based prevention initiatives, in particular for catheter care.

Prevalence of multidrug-resistant (MDR) gram-negative (GN) bacteria is increasing globally and is complicated by patient movement between acute and long-term care facilities (LTCFs). In Asia, the contribution of LTCFs as a source of MDR GN infections is poorly described. We aimed to define the association between residence in LTCFs and MDR GN bloodstream infections (BSIs).

Secondary analysis of data from an observational cohort.

Two tertiary referral hospitals in Singapore, including the 1,400-bed Tan Tock Seng Hospital and the 1,600-bed Singapore General Hospital.

Adult patients with healthcare-onset (HCO) or hospital-onset (HO) GN BSI.

Patients were identified from hospital databases using standard definitions. Risk factors for both MDR GN HCO and HO BSI were analyzed using a multivariable logistic regression model.

A total of 675 episodes of GN BSI occurred over a 31-month period. Residence in a LTCF was an independent risk factor for developing MDR GN BSI (odds ratio [OR], 5.1 [95% confidence interval (CI), 2.2–11.9]; P < .01) when antibiotics were not used within the preceding 30 days. This risk persisted beyond the first 48 hours of hospitalization (OR, 3.4 [95% CI, 1.3–9.0]; P = .01). Previous culture growing an MDR organism (OR, 1.8 [95% CI, 1.3–2.7]; P < .01), previous antibiotic use (OR, 1.8 [95% CI, 1.2–2.6]; P < .01), and intensive care unit stay (OR, 2.2 [95% CI, 1.2–3.9]; P = .01), increased the risk of MDR GN BSI.

Residence in a LTCF is an independent risk factor for MDR GN BSI. Attempts to contain MDR GN bacteria in large Asian cities, where the proportion of the population that is elderly is projected to increase, should include infection prevention strategies that engage LTCFs.

To test the hypothesis that methicillin-susceptible Staphylococcus aureus (MSSA) carriage may protect against nosocomial methicillin-resistant S. aureus (MRSA) acquisition by competing for colonization of the anterior nares.

Prospective cohort and nested case-control study.

Swiss university hospital.

All adult patients admitted to 14 wards of the general medicine division between April 1 and October 31, 2007.

Patients were screened for MRSA and MSSA carriage at admission to and discharge from the division. Associations between nosocomial MRSA acquisition and MSSA colonization at admission and other confounders were analyzed by univariable and multivariable analysis.

Of 898 patients included, 183 (20%) were treated with antibiotics. Nosocomial MRSA acquisition occurred in 70 (8%) of the patients (case patients); 828 (92%) of the patients (control subjects) were free of MRSA colonization at discharge. MSSA carriage at admission was 20% and 21% for case patients and control subjects, respectively. After adjustment by multivariate logistic regression, no association was observed between MSSA colonization at admission and nosocomial MRSA acquisition (adjusted odds ratio [aOR], 1.2 [95% confidence interval (CI), 0.6–2.3]). By contrast, 4 independent predictors of nosocomial MRSA acquisition were identified: older age (aOR per 1-year increment, 1.05 [95% CI, 1.02–1.08]); increased length of stay (aOR per 1-day increment, 1.05 [95% CI, 1.02–1.09]); increased nursing workload index (aOR per 1-point increment, 1.02 [95% CI, 1.01–1.04]); and previous treatment with macrolides (aOR, 5.6 [95% CI, 1.8–17.7]).

Endogenous MSSA colonization does not appear to protect against nosocomial MRSA acquisition in a population of medical patients without frequent antibiotic exposure.

To find the source of tuberculin skin test conversions among 38 hospital employees on 1 floor during routine testing January–February 2010.

Record review of patients at a private hospital during September-December 2009 and interviews with hospital employees. Names of patients from the state tuberculosis (TB) registry were cross-referenced with hospital records for admissions. Mycobacterium tuberculosis genotype results in the county and adjacent counties were examined, and contacts were evaluated for TB infection and disease.

One of the 38 employees, a nurse, was diagnosed with pulmonary TB with a matching M. tuberculosis genotype and drug resistance pattern (isoniazid monoresistant) to those of a county jail inmate also recently diagnosed with pulmonary TB. The nurse had no known contact with that inmate; however, another inmate in his 20's from the same jail had been hospitalized under that nurse's care in October 2009. That young man died, and a postmortem examination result subsequently confirmed TB, which had not been suspected. Exposure to this man with undiagnosed TB could explain the transmission: 87 (27%) of the 318 hospital-based contacts without previous positive tuberculin skin test results were infected, and 9 contacts had active TB.

This investigation demonstrated M. tuberculosis transmission in a hospital due to a missed diagnosis and nonadherence to national TB infection control guidelines. Routine TB screening of employees allowed early detection of this missed TB diagnosis, facilitating prompt evaluation of contacts. Healthcare providers should suspect TB in symptomatic persons and adhere to TB control policies.

Compare the severity of illnesses associated with influenza and noninfluenza acute respiratory illness (ARI) in healthcare personnel (HCP).

Prospective observational cohort.

HCP at 2 healthcare organizations with direct patient contact were enrolled prior to the 2010–2011 influenza season.

HCP who were fewer than 8 days from the start of fever/feverishness/chills and cough were eligible for real-time reverse-transcription polymerase chain reaction influenza virus testing of respiratory specimen. Illness severity was assessed by the sum of self-rated severity (0, absent; 3, severe) of 12 illness symptoms, subjective health (0, best health; 9, worst health), activities of daily living impairment (0, able to perform; 9, unable to perform), missed work, and duration of illness.

Of 1,701 HCP enrolled, 267 were tested for influenza, and 58 (22%) of these tested positive. Influenza compared with noninfluenza illnesses was associated with higher summed 12-symptom severity score (mean [standard deviation], 17.9 [5.4] vs 14.6 [4.8]; P < .001), worse subjective health (4.5 [1.8] vs 4.0 [1.8]; P < .05), greater impairment of activities of daily living (4.9 [2.5] vs 3.8 [2.5]; P < .01), and more missed work (12.1 [10.5] vs 7.8 [10.5] hours; P < .01). Differences in symptom severity, activities of daily living, and missed work remained significant after adjusting for illness and participant characteristics.

Influenza had a greater negative impact on HCP than noninfluenza ARIs, indicated by higher symptom severity scores, less ability to perform activities of daily living, and more missed work. These results highlight the importance of efforts to prevent influenza infection in HCP.

To perform detailed psychometric testing of the compliance with standard precautions scale (CSPS) in measuring compliance with standard precautions of clinical nurses and to conduct cross-cultural pilot testing and assess the relevance of the CSPS on an international platform.

A cross-sectional and correlational design with repeated measures.

Nursing students from a local registered nurse training university, nurses from different hospitals in Hong Kong, and experts in an international conference.

The psychometric properties of the CSPS were evaluated via internal consistency, 2-week and 3-month test-retest reliability, concurrent validation, and construct validation. The cross-cultural pilot testing and relevance check was examined by experts on infection control from various developed and developing regions.

Among 453 participants, 193 were nursing students, 165 were enrolled nurses, and 95 were registered nurses. The results showed that the CSPS had satisfactory reliability (Cronbach α = 0.73; intraclass correlation coefficient, 0.79 for 2-week test-retest and 0.74 for 3-month test-retest) and validity (optimum correlation with criterion measure; r = 0.76, P < .001; satisfactory results on known-group method and hypothesis testing). A total of 19 experts from 16 countries assured that most of the CSPS findings were relevant and globally applicable.

The CSPS demonstrated satisfactory results on the basis of the standard international criteria on psychometric testing, which ascertained the reliability and validity of this instrument in measuring the compliance of clinical nurses with standard precautions. The cross-cultural pilot testing further reinforced the instrument's relevance and applicability in most developed and developing regions.

Develop and implement an effective program for hazard analysis and control of waterborne pathogens at a multicampus hospital with clinics.

A longitudinal study. Several-year study including analysis of results from monitoring and tests of 26 building water systems.

Outpatient and inpatient healthcare facilities network.

The hazard analysis and critical control point (HACCP) process was used to develop a water management program (WMP) for the hospital campuses. The HACCP method systematically addressed 3 questions: (1) What are the potential waterborne hazards in the building water systems of these facilities? (2) How are the hazards being controlled? (3) How do we know that the hazards have been controlled? Microbiological and chemical tests of building water samples were used to validate the performance of the WMP; disease surveillance data further validated effective hazard control.

Hazard analysis showed that waterborne pathogens were generally in good control and that the water quality was good in all facilities. The hospital network has had several legionellosis cases that were identified as presumptive hospital acquired, but none was confirmed or substantiated by water testing in follow-up investigations. Building water system studies unrelated to these cases showed that pressure tanks and electronic automatic faucets required additional hazard control.

Application of the HACCP process for long-term building water systems management was practical and effective. The need for critical control point management of temperature, flow, and oxidant (chlorine) residual concentration was emphasized. The process resulted in discovery of water system components requiring additional hazard control.

To assess the effect of adenosine triphosphate (ATP) device measurement of hospital room cleaning and feedback of pooled results to environmental service workers (EVS) to improve cleaning efficacy.

Nonrandomized controlled trial conducted over 20 months.

Three hospitals of varying size.

EVS workers, randomly selected on the basis of convenience sample of rooms.

Environmental cleanliness composite scores were combined with layered educational interventions and used to provide feedback to EVS workers on specific hospital units. Trends in cleaning efficacy were observed after the interventions.

Cleaning efficacy improved significantly with each intervention (P < .01) and decreased during the washout period.

The ATP detection device combined with educational feedback for EVS workers resulted in significant improvement in cleaning efficacy of the hospital room environment.