To control an outbreak of Shewanella algae and S. putrefaciens infections by identifying the risk factors for infection and transmission.

Matched case-control study.

A university-affiliated tertiary acute care hospital in Seoul, Republic of Korea, with approximately 1,600 beds.

From June 20, 2003, to January 16, 2004, a total of 31 case patients with Shewanella colonization or infection and 62 control patients were enrolled in the study.

Requirement to use single-use measuring cups and standard precautions (including hand washing before and after patient care and use of gloves).

S. algae or S. putrefaciens was isolated from blood, for 9 (29.0%) of 31 patients who acquired one of the organisms; from bile, for 8 (25.8%), and from ascitic fluid, for 8 (25.8%). The attack rate of this outbreak was 5.8% (31 patients infected or colonized, of 534 potentially exposed on ward A) and the pathogenicity of the two species together was 77.4% (24 patients infected, of 31 who acquired the pathogens). The estimated incubation period for Shewanella acquisition was 3–49 days. Using logistic analysis, we identified the following risk factors: presence of external drainage catheters in the hepatobiliary system (odds ratio [OR], 20; P < .001), presence of hepatobiliary disease (OR, 6.4; P < .001), admission to the emergency department of the hospital (OR, 2.9; P = .039), wound classification of “contaminated” or “dirty or infected” (OR, 16.5; P = .012), an American Society of Anesthesiologists score of 3 or higher (OR, 8.0; P = .006), duration of stay in ward A (OR, 1.1; P < .001), and, for women, an age of 60–69 years (OR, 13.3; P = .028). A Shewanella isolate was recovered from the surface of a shared measuring cup, and 12 isolates of S. algae showed the same pulsed-field gel electrophoresis pattern.

This Shewanella outbreak had a single-source origin and spread by contact transmission via a contaminated measuring cup. Shewanella species are emerging as potentially serious human pathogens in hospitals and could be included in hospital infection surveillance systems.

Several medical devices used during hemodynamic procedures, particularly angiographic diagnostic and therapeutic cardiac catheters, are manufactured for single use only. However, reprocessing and reuse of these devices has been reported, to determine the frequency of reuse and reprocessing of single-use medical devices used during hemodynamic procedures in Brazil and to evaluate how reprocessing is performed.

National survey, conducted from December 1999 to July 2001.

Most of the institutions affiliated with the Brazilian Society of Hemodynamic and Interventional Cardiology were surveyed by use of a questionnaire sent in the mail.

The questionnaire response rate was 50% (119 of 240 institutions). Of the 119 institutions that responded, 116 (97%) reported reuse of single-use devices used during hemodynamic procedures, and only 26 (22%) reported use of a standardized reprocessing protocol. Cleaning, flushing, rinsing, drying, sterilizing and packaging methods varied greatly and were mostly inadequate. Criteria for discarding reused devices varied widely. Of the 119 institutions that responded, 80 (67%) reported having a surveillance system for adverse events associated with the reuse of medical devices, although most of these institutions did not routinely review the data, and only 38 (32%) described a training program for the personnel who reprocessed single-use devices.

The reuse of single-use devices used during hemodynamic procedures was very frequent in hospitals in Brazil. Basic guidance on how to reuse and reprocess single-use medical devices is urgently needed, because, despite the lack of studies to support reusing and reprocessing single-use medical devices, such devices are necessary in limited-resource areas in which these practices are current.

Previous studies from developed countries reported that nosocomial bloodstream infection (BSI) in neonatal care units (NCUs) increases length of stay and costs. However, no such information is available for Algerian NCUs.

To evaluate the influence of BSI in neonates on additional charges and length of hospital stay.

Prospective, nested case-control study.

The 47-bed NCU of the University Hospital of Blida, Algeria.

A total of 83 neonates with BSIs (case patients) and 166 neonates without BSIs (control patients), admitted to the NCU during the study period (April 2004 through December 2007), were matched for sex, birth weight, length of NCU stay, and year of hospital admission. Each patient's length of stay in the NCU was obtained prospectively on daily rounds. The estimated cost of each NCU-day was provided by the hospital's finance department. The cost of antibiotics prescribed was provided by the hospital's pharmacy department.

The mean additional length of NCU stay for case patients, compared with control patients, was 9.2 days (24.3 vs 15.1 days). The mean additional cost of antibiotics was $546. The mean cumulative additional cost was $1,315.

This study highlights the effect of BSI on extra costs for NCU patients, especially costs due to prolongation of hospital stay and increased antibiotic use, and suggests that NCUs in Algeria have a financial interest in reducing the rate of BSI.

To evaluate the knowledge of healthcare students after four curricula on infection control and to identify sources of information.

Cross-sectional study.

Four healthcare schools at Rouen University (Rouen, France).

Medical students, nursing students, assistant radiologist students, and physiotherapist students taking public health courses.

To measure students' knowledge of infection control and their sources of information, 6 multiple-choice questions were asked about 3 specific areas: standard precautions, hand hygiene, and nosocomial infection. Each questionnaire section had 10 possible points, for an overall perfect score of 30. The sources of information for these 3 areas were also recorded: self-learning, practice training in wards, formal training in wards, and teaching during the curriculum. A logistic regression analysis was performed to identify factors associated with acceptable level of knowledge.

Three hundred fifty students (107 medical students, 78 nursing students, 71 physiotherapist students, and 94 assistant radiologist students) were included in the study. The mean overall score (±SD) was 21.5 ± 2.84. Nursing students had a better mean overall score (23.2 ± 2.35) than did physiotherapist students (21.9 ± 2.36), medical students (21.1 ± 2.35), and assistant radiologist students (20.5 ± 3.04; P < .001). The mean scores (±SD) for the component sections of the questionnaire were 8.5 ±1.4 for standard precautions, 7.4 ± 1.26 for hand hygiene, and 5.7 ± 1.55 for nosocomial infections (P < .001). The main source of information was material taught during the curriculum. Results of multivariate analysis indicate that the probability of attaining acceptable knowledge in each area was smaller for medical students and assistant radiologist students than for nursing students.

The overall score for infection control indicated that instruction was effective; however, knowledge levels were different by area (the best scores were results of tests of standard precautions) and curriculum (nursing students achieved the best overall score). Ward training for daily infection control practice (ie, bedside instructions training and course work) could be improved for healthcare students.

A number of recent studies of antimicrobial resistance have focused on the role of antimicrobial-resistant pathogens that colonize the gastrointestinal tract. However, participation rates have been low in studies that involve fecal sampling. Attitudes toward such studies among potential study participants have not been assessed.

We conducted a cross-sectional survey, enrolling 3 groups of inpatients from a large academic center. Group 1 consisted of patients who had previously participated in a cohort study of fluoroquinolone-resistant Escherichia coli, which involved the collection of perirectal swab samples. Group 2 consisted of patients who had previously refused to participate in the study of fluoroquinolone-resistant E. coli. Group 3 consisted of patients who had never been asked to participate in the study of the fluoroquinolone-resistant E. coli. The survey assessed patients' attitudes and beliefs regarding medical research and their willingness to consent to collection of a perirectal swab sample. Response options were recorded on a 5-point Likert scale. The Fisher exact test was used to compare dichotomized responses across study groups.

A total of 90 patients were surveyed: there were 29 in group 1 and in group 2 and 32 in group 3. Of 90 patients, 31 (35%) believed researchers might run additional tests on collected samples without informing the patient, whereas 25 (27%) believed persons other than the research team might gain access to study results. The belief that a person could get sicker as a result of a having a perirectal swab sample collected was significantly more common among patients who had previously refused to participate in the fluoroquinolone-resistant E. coli study.

This study highlights important beliefs and attitudes that are associated with the likelihood of participating in studies of antimicrobial resistance. Explicitly addressing these concerns with eligible patients is critical to optimize participation in future studies.

To evaluate an intervention to prevent falls at a hospital.

A quasi-experimental intervention with historical and contemporaneous control groups.

Nursing staff and patients in the medicine service (comprising 2 intervention floors and 2 control floors) at an academic hospital.

Nursing staff were educated regarding fall prevention during the period from April through December 2005. Data on implemented prevention strategies were collected on control and intervention floors. Mean monthly fall rates were compared over time and between intervention and control floors, using repeated-measures analysis of variance.

Postintervention fall knowledge test scores for the nursing staff were greater than preintervention test scores (mean postintervention test score, 91%; mean preintervention test score, 72%; P < .001). Use of prevention strategies was greater on intervention floors than it was on control floors, including patient education via pamphlets (46% vs 15%; P < .001), use of toileting schedules (36% vs 25%; P = .016), and discussion of high-risk medications (51% vs 30%; P < .001). The mean fall rate for the first 5 months of the intervention was 43% less than that for the 9-month preintervention period for intervention floors (3.81 falls per 1,000 patient-days vs 6.64 falls per 1,000 patient-days; P = .043). Comparisons of mean rates for the overall 9-month intervention period versus the 9-month preintervention period showed a 23% difference in the fall rate for intervention floors, but this did not reach statistical significance (5.09 falls per 1,000 patient-days vs 6.64 falls per 1,000 patient-days; P = .182).

The nursing staffs knowledge and use of prevention strategies increased. Fall rates decreased for 5 months after the educational intervention, but the reduction was not sustained.

To evaluate the assumption that resistance rates in intensive care units (ICUs) are markedly influenced by cross-transmission events in addition to high rates of antimicrobial usage.

This was a prospective ICU- and laboratory-based surveillance study involving 35 German ICUs from 1999 through 2004. A total of 585 ciprofloxacin- or imipenem-resistant isolates of Pseudomonas aeruginosa were investigated together with resistance rate and unit-based antimicrobial usage density. Antimicrobial use was reported in terms of defined daily doses per 1,000 patient-days. All the strains were assigned to ICU-based genotypes. Genodiversity was calculated as the numbers of indistinguishable ICU-based genotypes found per isolates tested. Reduced ICU-based genodiversity was taken as an indirect measure of frequently occurring cross-transmission events.

The genodiversity of ciprofloxacin- and imipenem-resistant P. aeruginosa isolates was significantly lower (P ≤ .05, by Fisher exact test) in ICUs with high resistance rate and low antimicrobial usage density (genodiversity, 0.50 and 0.50, respectively) than in ICUs that featured low resistance rate in the presence of high antimicrobial usage density (genodiversity, 0.90 and 0.95, respectively). In ICUs with low genodiversity, there was a greater rise in resistance rate with increasing antimicrobial usage density, compared with that in ICUs with high diversity.

This study on resistant P. aeruginosa isolates supports the assumption that high resistance rate in the presence of low antimicrobial usage density results from more-frequent cross-transmission events. A greater rise in resistance rate with increasing antimicrobial usage density in ICUs with low genodiversity indicates that resistance rate in ICUs might be markedly determined by cross-transmission events other than antimicrobial usage.

To estimate the consequences of failure of initial antibiotic therapy for patients with complicated skin and skin-structure infections.

Retrospective cohort study.

Large US multihospital database.

We identified a total of 47,219 patients (age 18 years or older) who were admitted to the hospital for complicated skin and skin-structure infections from April 1, 2003, through March 31, 2004, and who received intravenous antibiotics during the first 2 hospital-days (ie, initial antibiotic therapy). Failure of therapy was defined as drainage, debridement, or receipt of other intravenous antibiotics at any subsequent time (except for changes to narrower-spectrum agents or any therapy change immediately before discharge). Predictors of failure of antibiotic therapy and mortality were examined using multivariate logistic regression. Analysis of covariance was used to estimate the impact of treatment failure on duration of intravenous antibiotic therapy, length of stay, and total inpatient charges.

For 10,782 admitted patients (22.8%), there was evidence of failure of initial antibiotic therapy. In multivariate analyses, treatment failure was associated with receipt of vasoactive medications during the first 2 hospital-days (odds ratio [OR], 1.66 [95% confidence interval {CI}, 1.19-2.31]), initiation of antibiotic therapy in the intensive care unit (OR, 1.53 [95% CI, 1.28-1.84]), and the patient's Charlson comorbidity index (OR per 1-point increase, 1.06 [95% CI, 1.04-1.08]); treatment failure was also was associated with a 3-fold increase in mortality (OR, 2.91 [95% CI, 2.34-3.62]). Compared with patients for whom initial treatment was successful, patients who experienced treatment failure received intravenous antibiotic therapy for a mean of 5.7 additional days, were hospitalized for a mean of 5.4 additional days, and incurred a mean of $5,285 (in 2003 dollars) in additional inpatient charges (all P <.01).

Failure of initial antibiotic therapy in the treatment of complicated skin and skin-structure infections is associated with significantly worse clinical and economic outcomes.

Thailand is one of 22 countries designated by the World Health Organization as “high burden” with regard to tuberculosis. Preventing nosocomial tuberculosis transmission remains an important, unmet need. We investigated the adequacy of current practices to evaluate hospitalized patients for tuberculosis, which is critical in preventing delayed diagnosis and nosocomial tuberculosis transmission.

Thailand conducts active, population-based surveillance for pneumonia in 2 rural provinces. Case report forms are completed for all persons who are hospitalized and meet a case definition of having clinical pneumonia. We analyzed how frequently patients had an adequate diagnostic evaluation for infectious pulmonary tuberculosis, in accordance with national guidelines. We conducted multivariate analyses to determine patient and health-system factors associated with an inadequate diagnostic evaluation for tuberculosis and with tuberculosis disease.

Of 8,853 cases of clinical pneumonia between September 2003 and March 2006,73% were in patients not adequately evaluated for tuberculosis. Acid-fast bacilli (AFB)–positive tuberculosis was diagnosed in 188 cases, which was 2% of all pneumonia cases and 12% of pneumonia cases in patients adequately evaluated for tuberculosis. Diagnostic evaluations for tuberculosis were less commonly performed among those who were younger than 25 years of age, were female, and lacked cough, sputum production, hemoptysis, and dyspnea. Among patients adequately evaluated, a clinical syndrome of no cough, no hemoptysis, and normal chest radiography findings had a 95% negative predictive value.

The prevalence of AFB-positive, pulmonary tuberculosis was high among adults hospitalized with clinical pneumonia in Thailand. Most patients were not adequately evaluated for tuberculosis. Efforts are needed to improve identification and diagnosis of infectious tuberculosis cases in hospitalized patients.

To estimate the risk of bloodstream infection associated with catheter dwell time in infants.

Retrospective study.

Duke University Medical Center neonatal intensive care unit, an academic, level 3 nursery in Durham, North Carolina.

A case of catheter-associated bloodstream infection was defined as one that occurred in an infant whose culture-positive blood sample was collected more than 24 hours after catheter insertion or within 72 hours after catheter removal. We used multivariable logistic regression to control for the catheter's position and dwell time as well as the infant's sex, gestational age, age at time of catheter insertion, birth weight, and weight at time of catheter insertion.

We identified 135 cases of catheter-associated bloodstream infection. The mean catheter dwell time was 12.2 days (range, 0–113 days), and the mean time to bloodstream infection was 10.8 days (range, 1–57 days). An increase in catheter dwell time was associated with a lower risk of bloodstream infection (odds ratio, 0.975 [95% confidence interval, 0.954–0.996]; P = .02).

increased risk of catheter-associated bloodstream infection was observed with increased catheter dwell time. This may have been due to the infant's improved nutrition, decreased need for other invasive devices, and maturing skin and immune system as catheter dwell time increased.