Unit Based Champions Infection Prevention eBug Bytes

1. Unit Based ChampionsInfection PreventioneBug Bytes August 2012

2. Infections After C-Section Reduced By Administering Antibiotics During Surgery • The previous practice of waiting to give antibiotics until after the surgical delivery of the baby evolved out of concern that these drugs might hide signs of blood infection in the newborn. But other recent studies have shown that giving antibiotics in the hour before surgery both reduced the risk of infection in the mother and had no effect on the health of the infant. Researchers tracked C-section deliveries and associated surgical site infections at Barnes-Jewish Hospital between January 2003-December 2010. Based on reduced infection rates following other types of surgeries, the hospital changed its policy to administering antibiotics before C-section surgery in January 2004. The American College of Obstetricians and Gynecologists recommended the same change in practice in 2011. In 2003, the year before the policy changed, the infection rate oscillated around nine or 10 infections per 100 cesarean deliveries. A downward trend in the infection rate began after the policy switch and by 2010, the rate was about two infections per 100 cesarean sections. On average, the researchers calculated about five fewer infections per 100 surgeries due to changing the timing of the antibiotics. Over the entire eight-year period, the researchers observed 303 infections following 8,668 cesarean deliveries. • Kittur ND, McMullen KM, Russo AJ, Ruhl L, Kay HH, Warren DK. Long-term effect of infection prevention practices and case mix on cesarean surgical site infections. Obstetrics & Gynecology. August 2012

3. Researchers Identify Levels of Bacterial Contamination on Hospital Beds • Hospital beds on a bariatric surgery ward were randomized to either receive or not receive a launderable cover (Trinity Guardion). Bacterial counts on the surface of the mattress, the bed deck, and the launderable cover were then collected using Petrifilm Aerobic Count Plates at three time periods (before patient use, after discharge, and after terminal cleaning). Standard hospital linen was used in all rooms. • The launderable cover (n=28) was significantly cleaner prior to patient use than were the cleaned mattresses (n=38) (1.1 CFU/30cm2 vs. 7.7 CFU/30cm2; p=0.0189). The mattresses without launderable covers became significantly contaminated during use (7.7CFU/30cm2 on admission vs. 79.1 CFU/30cm2 after discharge; p<0.001). • The mattresses with launderable covers did not become contaminated (3.0 CFU/30cm2 on admission vs. 2.5 CFU/30cm2 at discharge; p=0.703). After terminal cleaning, the mattress surface contamination decreased to 12.8 CFU/30cm2 (median 3 CFU/30cm2; SD 7.8), but the bed deck was more contaminated (6.7 CFU/30cm2 after discharge compared to 30.9 CFU/30cm2 after terminal cleaning; p=0.031). • EA, Allen S, Gray L and Kaufman C. A randomized trial to evaluate a launderable bed protection system for hospital beds. Antimicrobial Resistance and Infection Control. 2012, 1:27 doi:10.1186/2047-2994-1-27

4. Nurse Staffing, Burnout Linked to Hospital Infections – Part I Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing analyzed data previously collected by the Pennsylvania Health Care Cost Containment Council, the American Hospital Association Annual Survey, and a 2006 survey of more than 7,000 registered nurses from 161 hospitals in Pennsylvania to study the effect of nurse staffing and burnout on catheter-associated urinary tract infections (CAUTI) and surgical site infections (SSI), two of the most common HAIs. Job-related burnout was determined by analyzing the emotional exhaustion subscale from the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) that was obtained from nurse survey responses. The MBI-HSS filters 22 items on job-related attitudes into emotional exhaustion, depersonalization, and personal accomplishment, identifying emotional exhaustion as the key component to burnout syndrome. More than one-third of survey respondents got an emotional exhaustion score of 27 or greater, the MBI-HSS definition for healthcare personnel burnout.

5. Nurse Staffing, Burnout Linked to Hospital Infections – Part II • Comparing CAUTI rates with nurses’ patient loads (5.7 patients on average), the researchers found that for each additional patient assigned to a nurse, there was roughly one additional infection per 1,000 patients (or 1,351 additional infections per year, calculated across the survey population). Additionally, each 10 percent increase in a hospital’s high-burnout nurses corresponded with nearly one additional CAUTI and two additional SSIs per 1,000 patients annually (average rate of CAUTIs across hospitals was 9 per 1,000 patients; for SSIs it was 5 per 1,000 patients). • Using the per-patient average costs associated with CAUTIs ($749 to $832 each) and SSIs ($11,087 to $29,443 each), the researchers estimate that if nurse burnout rates could be reduced to 10 percent from an average of 30 percent, Pennsylvania hospitals could prevent an estimated 4,160 infections annually with an associated savings of $41 million. • Reference: Jeannie P. Cimiotti, APIC August 2012

6. Expensive Hospital Readmissions Linked to HAIs • New research finds a strong link between healthcare-associated infections (HAIs) and patient readmission after an initial hospital stay. The findings, published in the June 2012 issue of Infection Control and Hospital Epidemiology, suggest that reducing such infections could help reduce readmissions, considered to be a major driver of unnecessary healthcare spending and increased patient morbidity and mortality. • 136,513 patients admitted to the University of Maryland Medical Center over eight years (2001-2008) were studied for readmissions within one year after discharge, as well as the number of patients with positive cultures for one of three major HAIs: (MRSA), (VRE), or (C. difficile) more than 48 hours after admission, considered a proxy for an HAI. • 4,737 patients with positive clinical cultures for MRSA, VRE or C. difficile after more than 48 hours following hospital admission. These patients were 40 percent more likely to readmitted to the hospital within a year and 60 percent more likely to be readmitted within 30 days than patients with negative or no clinical cultures. • Reference: Carley B. Emerson, Lindsay M. Eyzaguirre, Jennifer S. Albrecht, Angela C. Comer, Anthony D. Harris, Jon P. Furuno. Healthcare-Associated Infection and Hospital Readmission. Infection Control and Hospital Epidemiology 33:6. June 2012

7. Klebsiella Cases Tied to Handwashing Sinks – Part I • An outbreak of class A extended-spectrum β-lactamase–producing K. oxytoca occurred at a 472-bed, acute tertiary-care facility in Toronto. • Klebsiella oxytoca is an opportunistic pathogen that causes primarily hospital-acquired infections, most often involving immunocompromised patients or those requiring intensive care. Reported outbreaks have most frequently involved environmental sources. K. oxytoca, like other Enterobacteriaceae, may acquire extended-spectrum β-lactamases (ESBL) and carbapenemases; outbreaks of multidrug-resistant K. oxytoca infection pose an increasing risk to hospitalized patients. • From October 2006 through March 2011, a total of 66 patients acquired K. oxytoca with one of two related pulsed-field gel electrophoresis patterns. Isolates were considered hospital acquired if the first specimen (clinical culture or rectal swab) yielding resistant K. oxytoca was obtained >3 days after the admission date or if the specimen was obtained <3 days after admission in a patient who had been hospitalized at the outbreak hospital within the previous three months. Patients were characterized as infected or colonized.

8. Klebsiella Cases Tied to Handwashing Sinks – Part II • New cases continued to occur despite reinforcement of infection control practices, prevalence screening, and contact precautions for colonized/infected patients. Cultures from handwashing sinks in the intensive care unit yielded K. oxytoca with identical pulsed-field gel electrophoresis patterns to cultures from the clinical cases. No infections occurred after implementation of sink cleaning three times daily, as well as sink drain modifications, and an antimicrobial stewardship program. In contrast, a cluster of four patients infected with K. oxytoca in a geographically distant medical ward without contaminated sinks was contained with implementation of active screening and contact precautions. • The researchers emphasize that sinks should be considered potential reservoirs for clusters of infection caused by K. oxytoca. • Reference: Lowe C, Willey B, et al. Outbreak of Extended-Spectrum β-Lactamase–producing Klebsiella oxytoca Infections Associated with Contaminated Handwashing Sinks. Vol. 18, No. 8. Emerg Infect Dis. August 2012.

9. MRSA infections double in 5 years at academic hospitals • According to a recent report published in the August issue of Infection Control and Hospital Epidemiology, infections caused by methicillin-resistant Staphylococcus aureus (MRSA) doubled at academic medical centers nationwide in five years. University of Chicago Medicine and University Health System Consortium (UHC) researchers estimated that hospital admissions for MRSA infections increased from about 21 out of every 1,000 patients hospitalized in 2003 to about 42 out of every 1,000 in 2008, or almost 1 in 20 inpatients. • The new findings counter a recent Centers for Disease Control and Prevention (CDC) study that found MRSA cases in hospitals were declining. The CDC study looked only at cases of invasive MRSA, which are infections found in the blood, spinal fluid or deep tissue. It excluded infections of the skin, which the UHC study includes. The study utilized the UHC database, which includes data from 90 percent of all not-for-profit academic medical centers in the U.S. However, like many such databases, the UHC data are based on billing codes hospitals submit to insurance companies, which often underestimate MRSA cases. • Source: August issue of Infection Control and Hospital Epidemiology,

10. CDC reports cases 18-29 of H3N2v virusinfection; continues to recommend interim precautions when interacting with pigs • This week CDC reports 12 additional human infections with influenza A (H3N2) variant virus in 3 states: Hawaii (1 case), Ohio (10 cases) and Indiana (1 case). The H3N2v virus contains the M gene from the human influenza A (H1N1)pdm09 (2009 H1N1) virus, as have the previous 17 cases detected since July 2011. All of this week's reported cases occurred in people who had direct or indirect contact with swine prior to their illness. • The 10 cases in Ohio were associated with attendance at a fair where reportedly ill swine were present. The H3N2v case reported by Indiana also occurred in a person who attended a fair where swine were present. CDC continues to recommend preventive actions people can take to make their fair experience a safe and healthy one. • Most human illness with H3N2v virus infection has resulted in signs and symptoms of influenza (fever, cough, runny nose, sore throat, muscle aches); 3 hospitalizations have occurred. All of the people hospitalized had high risk conditions. All H3N2v virus cases have recovered fully.

11. Man pours bleach in dialysis machines • When a kidney dialysis center accused a worker of asking patients for painkillers, authorities said he became so enraged he sneaked back into the clinic and poured bleach into dialysis machines. Workers at the Fresenius Medical Care clinic in West Columbia, SC, discovered the contaminated water before anyone was hurt. A month long investigation led deputies to Donald Foster III, who has been charged with attempted murder and second-degree burglary. Foster was suspended from his job as an equipment technician and patient care technician on July 2, but he came back less than a week later and tainted the water • Foster poured bleach into tanks that hold the purified water used to filter waste from the bodies of 20 patients, hoping the deaths from his sabotage would bankrupt the firm, police said. • Pure water is so critical to the dialysis process that workers check the tanks several times a day, including before any patients are hooked up to the machines