[Effect of a long-term quality improvement program on the risk of infection related to peripheral venous catheters]. / Impact d'un programme prolongé d'amélioration continue de la qualité sur le risque infectieux lié aux cathéters veineux périphériques.

INTRODUCTION: Although peripheral venous catheter (PVC) placement is one of the most common invasive procedures used in hospitals, data about the infectious risk associated with it are sparse. Nurses and physicians often underestimate this risk. We describe here a 10-year continuous quality improvement program in a large university hospital. METHODS: The prevention program included: 1/ an observational audit of practices of PVC insertion and maintenance (1996), 2/ two studies of incidence and risk factors for PVC-related infection (1996 and 1999), 3/ 8 annual (1996 to 2006) cross-sectional studies that collected information about duration of PVC placement and other process indicators, 4/ surveillance of nosocomial bacteremia from 2002 through 2006, and 5/ continued education sessions for healthcare workers, based on local surveillance data. RESULTS: Rates of colonization and infection (0.7 cases of bacteremia/1000 PVC days) were similar to data from other studies. PVC that remained in place for more than three days was associated with a higher risk of catheter-related bacteremia in both incidence studies. The annual prevalence studies showed that 15 to 20% of PVCs remained in place for more than three days from 1996 through 2002, but this rate decreased thereafter; it was 6.7% in 2005 and 10.7% in 2006. Practices audits indicated room for improvement in prevention measures. The absolute number of PVC-related bacteremia decreased by more than 50% from 2002 (n=23) to 2006 (n=10). CONCLUSION: This prolonged multifaceted program, including practice audits, continued medical education and monitoring of PVC-related infection, has led to a substantial decrease over time in the infectious risk related to PVC placement.

Epidemiology of multidrug-resistant bacteria in patients with long hospital stays.

OBJECTIVE: To determine rates of colonization with multidrug-resistant (MDR) bacteria (ie, methicillin-resistant Staphylococcus aureus [MRSA], vancomycin-resistant Enterococcus [VRE], extended-spectrum beta -lactamase [ESBL]-producing Enterobacteriaceae, and Acinetobacter baumannii) after prolonged hospitalization and to assess the yield of surveillance cultures and variables associated with colonization with MDR bacteria. DESIGN: Prospective observational cohort study conducted from February 6 to May 26, 2006. METHODS: All patients who spent more than 30 days in our university hospital (Paris, France) were included. Rectal and nasal swab samples obtained during day 30 screening were examined for MRSA, VRE, ESBL-producing Enterobacteriaceae, and A. baumannii. RESULTS: Of 470 eligible patients, 439 had surveillance culture samples available for analysis, including 51 patients (11.6%) with a history of colonization or infection due to 1 or more types of MDR bacteria (MRSA, recovered from 35 patients; ESBL-producing Enterobacteriaceae, from 16 patients; A. baumannii, from 6 patients; and VRE, from 0 patients) and 37 patients (9.5% of the 388 patients not known to have any of the 4 MDR bacteria before day 30 screening) newly identified as colonized by 1 or more MDR bacteria (MRSA, recovered from 20 patients; ESBL-producing Enterobacteriaceae, from 16 patients; A. baumannii, from 1 patient; and VRE, from 0 patients). A total of 87 (19.8%) of 439 patients were identified as colonized or infected with MDR bacteria at day 30. Factors that differed between patients with and without MRSA colonization included age, McCabe score, comorbidity score, receipt of surgery, and receipt of fluoroquinolone treatment. Patients with ESBL-producing Enterobacteriaceae colonization were younger than patients with MRSA colonization. CONCLUSIONS: Differences in the variables associated with MRSA colonization and ESBL-producing Enterobacteriaceae colonization suggest differences in the epidemiology of these 2 organisms. Day 30 screening resulted in a 72.5% increase in the number of patients identified as colonized with at least 1 type of MDR bacteria.

Successful long-term program for controlling methicillin-resistant Staphylococcus aureus in intensive care units.

OBJECTIVE: To evaluate the effectiveness of screening strategy and contact precautions for patients with methicillin-resistant Staphylococcus aureus (MRSA). DESIGN AND SETTING: Prospective observational cohort from 1 February 1995 to 31 December 2001 in three intensive care units (45 beds) in a French teaching hospital. PATIENTS: 8,548 patients admitted to the three ICUs had nasal screening on ICU admission and weekly thereafter. Contact precautions were used in MRSA-positive patients. The following variables were collected: age, gender, severity score, length of stay, workload, and colonization pressure (percentage of patient-days with an MRSA to the number of patient-days in the unit). Alcohol-based handrub solution was introduced in July 2000. We compared the period before this (P1) with that thereafter (P2). RESULTS: Of the 8,548 admitted patients 554 (6.5%) had MRSA at ICU admission, and 456 of the 7,515 (6.1%) exposed patients acquired MRSA. Acquisition incidence decreased from 7.0% in P1 to 2.8% in P2. Independent variables associated with MRSA acquisition were: age (adjusted odds ratio 1.013), severity score (1.047), length of ICU stay (1.015), colonization pressure (1.019), medical ICU (1.58), and P2 (0.49). CONCLUSIONS: MRSA control in these ICUs characterized by a high prevalence of MRSA at admission was achieved via multiple factors, including screening, contact precautions, and use of alcoholic handrub solution. Our results after adjustment of risk factors for MRSA acquisition and the steady improvement in MRSA over several years strengthen these findings. MRSA spreading can be successfully controlled in ICUs with high colonization pressure.