Survey of infection control practices in hemodialysis units: preventing vascular access-associated bloodstream infections.

OBJECTIVE: Despite surveillance, the Quebec Healthcare-Associated Infections Surveillance Program saw no improvement in vascular access-associated bloodstream infections in hemodialysis (HD). We aimed to determine the infection control measures recommended and implemented in Quebec's HD units, compliance of local protocols to infection control practice guidelines, and reasons behind the low prevalence of arteriovenous fistulas. METHODS: An online survey was elaborated on the basis of the Centers for Disease Control and Prevention (CDC) and National Kidney Foundation Kidney Disease Outcomes Quality Initiative guidelines. The questionnaire was validated (construct, content, face validity, and reliability) and sent to all HD units in Quebec (n = 40). Results were analyzed using descriptive statistics, linear regression, and Poisson regression. RESULTS: Thirty-seven (93%) of 40 HD units participated. Thirty (94%) of the 32 centers where central catheters are inserted have written insertion protocols. Compliance with practice guidelines is good, except for full-body draping during catheter insertion (79%) and ointment use at insertion site (3%). Prevention measures for catheter maintenance are in accordance with guidelines, except for skin disinfection with at least 0.5% chlorhexidine and 70% alcohol (67% compliance) and regular antiseptic ointment use at the insertion site (3%). Before fistula cannulation, skin preparation is suboptimal; forearm hygiene is performed in only 61% of cases. Several factors explain the low rate of fistulas, including patient preference (69%) and lack of surgical resources (39%; P = .01). CONCLUSIONS: Improvement in standardization of care according to practice guidelines is necessary. Fistula rate could be increased by improving access to surgical resources and patient education. Strategies are now being elaborated to address these findings.

A survey of preventive measures used and their impact on central line-associated bloodstream infections (CLABSI) in intensive care units (SPIN-BACC).

BACKGROUND: The Quebec central line-associated bloodstream infections (CLABSI) in intensive care units (ICUs) Surveillance Program saw a decrease in CLABSI rates in most ICUs. Given the surveillance trends observed in recent years, we aimed to determine what preventive measures have been implemented, if compliance to measures was monitored and its impact on CLABSI incidence rates. METHODS: All hospitals participating in the Quebec healthcare-associated infections surveillance program (SPIN-BACC - n = 48) received a 77-question survey about preventive measures implemented and monitored in their ICU. The questionnaire was validated for construct, content, face validity, and reliability. We used Poisson regression to measure the association between compliance monitoring to preventive measures and CLABSI rates. RESULTS: Forty-two (88%) eligible hospitals completed the survey. Two components from the maximum barrier precautions were used less optimally: cap (88%) and full sterile body drape (71%). Preventive measures reported included daily review of catheter need (79%) and evaluation of insertion site for the presence of inflammation (90%). Two hospitals rewired lines even if an infection was suspected or documented.In adult ICUs, there was a statistically significant greater decrease in CLABSI rates in ICUs that monitored compliance to preventive insertion measures, after adjusting for teaching status and the number of hospital beds (p = 0.036). CONCLUSIONS: Hospitals participating to the SPIN-BACC program follow recommendations for CLABSI prevention, but only a minority locally monitor their application. Compliance monitoring of preventive measures for catheter insertion was associated with a decrease in CLABSI incidence rates.

Central line-associated bloodstream infection in neonatal intensive care units.

OBJECTIVE: Describe the epidemiology of central line-associated bloodstream infections (CLABSIs) in neonatal intensive care units (NICUs) participating in a standardized and mandatory CLABSI surveillance program. DESIGN: Retrospective cohort. Setting. We included patients admitted (April 2007-March 2011) to 7 level II/III NICUs who developed a CLABSI (as defined by the National Healthcare Safety Network). METHODS: CLABSIs/1,000 central line-days and device utilization ratio were calculated; χ(2) test, Student t test, Kruskal-Wallis, and Poisson regression were used. RESULTS: Overall, 191 patients had 202 CLABSI episodes for a pooled mean rate of 4.0 CLABSIs/1,000 central line-days and a device utilization ratio of 0.20. Annual pooled mean CLABSI rates increased from 3.6 in 2007-2008 to 5.1 CLABSIs/1,000 central line-days in 2010-2011 (P - .01). The all-cause 30-day case fatality proportion was 8.9% (n = 17) and occurred a median of 8 days after CLABSI. Coagulase-negative Staphylococcus was identified in 112 (50.5%) cases. Staphylococcus aureus was identified in 22 cases, and 3 (13.6%) were resistant to methicillin. An underlying intra-abdominal pathology was found in 20% (40/202) of CLABSI cases, 50% of which were reported in the last year of study. When adjusted for mean birth weight, annual CLABSI incidence rates were independently associated with the proportion of intra-abdominal pathology (P = .007) and the proportion of pulmonary pathology (P = .016) reported. CONCLUSION: The increase in CLABSI rates in Quebec NICUs seems to be associated with an increased proportion of cases with underlying intra-abdominal and pulmonary pathologies, which needs further investigation.

Healthcare-associated bloodstream infections secondary to a urinary focus: the Québec provincial surveillance results.

OBJECTIVE: Urinary tract infections (UTIs) are an important source of secondary healthcare-associated bloodstream infections (BSIs), where a potential for prevention exists. This study describes the epidemiology of BSIs secondary to a urinary source (U-BSIs) in the province of Québec and predictors of mortality. DESIGN: Dynamic cohort of 9,377,830 patient-days followed through a provincial voluntary surveillance program targeting all episodes of healthcare-associated BSIs occurring in acute care hospitals. SETTING: Sixty-one hospitals in Québec, followed between April 1, 2007, and March 31, 2010. PARTICIPANTS: Patients admitted to participating hospitals for 48 hours or longer. METHODS: Descriptive statistics were used to summarize characteristics of U-BSIs and microorganisms involved. Wilcoxon and χ(2) tests were used to compare U-BSI episodes with other BSIs. Negative binomial regression was used to identify hospital characteristics associated with higher rates. We explored determinants of mortality using logistic regression. RESULTS: Of the 7,217 reported BSIs, 1,510 were U-BSIs (21%), with an annual rate of 1.4 U-BSIs per 10,000 patient-days. A urinary device was used in 71% of U-BSI episodes. Identified institutional risk factors were average length of stay, teaching status, and hospital size. Increasing hospital size was influential only in nonteaching hospitals. Age, nonhematogenous neoplasia, Staphylococcus aureus, and Foley catheters were associated with mortality at 30 days. CONCLUSION: U-BSI characteristics suggest that urinary catheters may remain in patients for ease of care or because practitioners forget to remove them. Ongoing surveillance will enable hospitals to monitor trends in U-BSIs and impacts of process surveillance that will be implemented shortly.

Epidemiology of central line-associated bloodstream infections in Quebec intensive care units: a 6-year review.

BACKGROUND: The burden of central line-associated bloodstream infections (CLABSI) in Canadian intensive care units (ICUs) is not well established. The present study aimed to describe CLABSI epidemiology in Quebec ICUs during 2003-2009. METHODS: The study population was a retrospective dynamic cohort of 58 ICUs that participated in the Surveillance Provinciale des Infections Nosocomiales program during 2003-2009. We calculated annual CLABSI incidence rates (IRs), central venous catheter (CVC) utilization ratios, and case-fatality proportions, and described the pathogens involved. We analyzed data using descriptive statistics and standardized incidence ratios. RESULTS: A total of 891 CLABSIs were identified during 446,137 CVC-days. In 2003-2009, CLABSI IRs were 1.67 CLABSI/1,000 CVC-days in adult ICUs, 2.20 CLABSIs/1,000 CVC-days in pediatric ICUs, and 4.40 CLABSIs/1,000 CVC-days in neonatal ICUs. Since 2007, CLABSI IRs in adult, pediatric and neonatal ICUs have decreased by 11%, 50%, and 18%, respectively. Pediatric ICUs had the highest CVC utilization ratio (median, 0.61; interquartile range, 0.57-0.66). Coagulase-negative staphylococci caused 53% of the CLABSIs. The proportion of methicillin-resistant Staphylococcus aureus declined from 70% to <40% after 2006. CONCLUSIONS: CLABSIs result in a considerable burden of illness in Quebec ICUs. However, CLABSI IRs have decreased since 2007, and the proportion of methicillin-resistant S aureus has remained <40% since 2006. Continuous surveillance is essential to determine whether these changes are sustainable.

Surveillance Provinciale des Infections Nosocomiales (SPIN) Program: implementation of a mandatory surveillance program for central line-associated bloodstream infections.

BACKGROUND: In 2003, the Surveillance Provinciale des Infections Nosocomiales (SPIN) program was launched to gather data on incidence rates of central line-associated bloodstream infections (CLABSIs) in intensive care units (ICUs) in the Province of Quebec. To improve the generalizability of SPIN benchmarks, in 2007 participation in SPIN became mandatory for all ICUs with ≥10 beds. OBJECTIVE: To describe the implementation process, surveillance methods, and overall results of the SPIN program between 2003 and 2009. METHODS: SPIN surveillance methods are based on the National Healthcare Safety Network. Participation is open to all Quebec ICUs and as of January 2007 is mandatory for all units with ≥10 beds. Data include CLABSI incidence rates for 2003-2009 and the epidemiology of CLABSI cases. RESULTS: Mandatory participation in the SPIN program increased the number of ICUs by 100% (from 30 to 60 units). For 2003-2009, the overall CLABSI incidence rates were 1.67 CLABSIs/1,000 catheter-days for adult ICUs, 2.24 CLABSIs/1,000 catheter-days for pediatric ICUs, and 4.40 CLABSIs/1,000 catheter-days for neonatal ICUs. The patients with CLABSI were predominately female (60%), mean patient age was 44 ± 32 years, and 64% of the patients had a regular central venous line in place. CONCLUSION: The implementation of mandatory participation was essential to increase the generalizability of SPIN CLABSI incidence rates, which also improved the quality of these data for use as provincial benchmarks.

The impact of smoking on adherence to treatment for latent tuberculosis infection.

BACKGROUND: Studies have shown an association between smoking and tuberculosis (TB) infection, disease and TB-related mortality. We hypothesized that smokers with latent tuberculosis infection (LTBI) are less likely to comply with their LTBI treatment regimen, thus increasing their risk of developing active disease. We thus documented the impact of smoking on adherence to LTBI treatment. METHOD: Between 1998 and 2000, a convenience sample of patients undergoing treatment for LTBI completed a questionnaire on smoking status. Level of adherence to LTBI treatment was tested for associations with socio-demographic profile, and smoking status RESULTS: 320 patients were recruited, and 302 (94%) completed the questionnaire. Smoking prevalence was 21%. 72% of patients were adherent to LTBI treatment. Women (OR = 2.0; 95% CI: 1.2-3.3) and non-smokers (OR = 1.8; 95% CI: 1.0-3.3) were associated with adherence to LTBI treatment. Only gender was found as an independent predictor of adherence after adjusting for age and smoking status (OR = 1.9; 95% CI: 1.06-3.3). CONCLUSION: Males and smokers need to have extra supervision to ensure compliance with LTBI treatment.

Incidence of serious side effects from first-line antituberculosis drugs among patients treated for active tuberculosis.

Major adverse reactions to antituberculosis drugs can cause significant morbidity, and compromise treatment regimens for tuberculosis (TB). Among patients treated for active TB we estimated the incidence, and risk factors, of major side effects from first-line anti-TB drugs. Side effects, resulting in modification or discontinuation of therapy, or hospitalization, were attributed on the basis of resolution after withdrawal, and/or recurrence with rechallenge. Among 430 patients treated between 1990 and 1999, the incidence of all major adverse effects was 1.48 per 100 person-months of exposure (95% confidence interval [95% CI], 1.31 to 1.61) for pyrazinamide, compared with 0.49 (95% CI, 0.42 to 0.55) for isoniazid, 0.43 (95% CI, 0.37 to 0.49) for rifampin, and 0.07 (95% CI, 0.04 to 0.10) for ethambutol. Occurrence of any major side effect was associated with female sex (adjusted hazard ratio, 2.5; 95% CI, 1.3 to 4.7), age over 60 years (adjusted hazard ratio, 2.9; 95% CI, 1.3 to 6.3), birthplace in Asia (adjusted hazard ratio, 2.5; 95% CI, 1.3 to 5.0), and human immunodeficiency virus-positive status (adjusted hazard ratio, 3.8; 95% CI, 1.05 to 13.4). Pyrazinamide-associated adverse events were associated with age over 60 years (adjusted hazard ratio, 2.6; 95% CI, 1.01 to 6.6) and birthplace in Asia (adjusted hazard ratio, 3.4; 95% CI, 1.4 to 8.3), whereas rifampin-associated adverse events were associated with age over 60 years (adjusted hazard ratio, 3.9; 95% CI, 1.02 to 14.9) and human immunodeficiency virus-positive status (adjusted hazard ratio, 8.0; 95% CI, 1.5 to 43). The incidence of pyrazinamide-induced hepatotoxicity and rash during treatment for active TB was substantially higher than with the other first-line anti-TB drugs, and higher than previously recognized.