ESCMID guidelines for the management of the infection control measures to reduce transmission of multidrug-resistant Gram-negative bacteria in hospitalized patients.

Healthcare-associated infections due to multidrug-resistant Gram-negative bacteria (MDR-GNB) are a leading cause of morbidity and mortality worldwide. These evidence-based guidelines have been produced after a systematic review of published studies on infection prevention and control interventions aimed at reducing the transmission of MDR-GNB. The recommendations are stratified by type of infection prevention and control intervention and species of MDR-GNB and are presented in the form of 'basic' practices, recommended for all acute care facilities, and 'additional special approaches' to be considered when there is still clinical and/or epidemiological and/or molecular evidence of ongoing transmission, despite the application of the basic measures. The level of evidence for and strength of each recommendation, were defined according to the GRADE approach.

Epidemiology of and surveillance for postpartum infections.

We screened automated ambulatory medical records, hospital and emergency room claims, and pharmacy records of 2,826 health maintenance organization (HMO) members who gave birth over a 30-month period. Full-text ambulatory records were reviewed for the 30-day postpartum period to confirm infection status for a weighted sample of cases. The overall postpartum infection rate was 6.0%, with rates of 7.4% following cesarean section and 5.5% following vaginal delivery. Rehospitalization; cesarean delivery; antistaphylococcal antibiotics; diagnosis codes for mastitis, endometritis, and wound infection; and ambulatory blood or wound cultures were important predictors of infection. Use of automated information routinely collected by HMOs and insurers allows efficient identification of postpartum infections not detected by conventional surveillance.

Management of urethritis in health maintenance organization members receiving care at a multispecialty group practice in Massachusetts.

BACKGROUND: Cost containment has led to a concern that health maintenance organization-insured patients presenting with complaints of urethritis may be treated without being tested. GOAL: To determine the proportion of men presenting with symptoms of urethritis who are tested for Chlamydia trachomatis and Neisseria gonorrhoeae. STUDY DESIGN: Reviews were performed on 196 randomly selected patient records with an outpatient visit and a diagnostic code consistent with urethritis between 1995 and 1997. Data were collected on demographics, diagnostic testing, and treatment. RESULTS: Diagnostic testing for C trachomatis and N gonorrhoeae was performed, respectively, in 92.3% and 83.2% of the men presenting at an initial visit with complaints of urethritis. Altogether, 98.2% of the patients who met the Centers for Disease Control criteria for documenting urethritis were tested for C trachomatis and N gonorrhoeae. CONCLUSION: Diagnostic testing for C trachomatis and N gonorrhoeae is nearly universal in this multispecialty group practice setting, facilitating surveillance and public health efforts.

Automated methods for surveillance of surgical site infections.

Automated data, especially from pharmacy and administrative claims, are available for much of the U.S. population and might substantially improve both inpatient and postdischarge surveillance for surgical site infections complicating selected procedures, while reducing the resources required. Potential improvements include better sensitivity, less susceptibility to interobserver variation, more uniform availability of data, more precise estimates of infection rates, and better adjustment for patients' coexisting illness.

Using automated pharmacy records to assess the management of tuberculosis.

We used automated pharmacy dispensing data to characterize tuberculosis (TB) management for 45 health maintenance organization (HMO) members. Pharmacy records distinguished patients treated in HMOs from those treated elsewhere. For cases treated in HMOs, they provided useful information about appropriateness of prescribed regimens and adherence to therapy.

Supplementing tuberculosis surveillance with automated data from health maintenance organizations.

Data collected by health maintenance organizations (HMOs), which provide care for an increasing number of persons with tuberculosis (TB), may be used to complement traditional TB surveillance. We evaluated the ability of HMO-based surveillance to contribute to overall TB reporting through the use of routinely collected automated data for approximately 350,000 HMO members. During approximately 1.5 million person-years, 45 incident cases were identified in either HMO or public health department records. Eight (18%) confirmed cases had not been identified by the public health department. The most useful screening criterion (sensitivity of 89% and predictive value positive of 30%) was dispensing of two or more TB drugs. Pharmacy dispensing information routinely collected by many HMOs appears to be a useful adjunct to traditional TB surveillance, particularly for identifying cases without positive microbiologic results that may be missed by traditional public health surveillance methods.

Reducing vancomycin use utilizing a computer guideline: results of a randomized controlled trial.

BACKGROUND: Vancomycin-resistant enterococci represent an increasingly important cause of nosocomial infections. Minimizing vancomycin use represents a key strategy in preventing the spread of these infections. OBJECTIVE: To determine whether a structured ordering intervention using computerized physician order entry that requires use of a guideline could reduce intravenous vancomycin use. DESIGN: Randomized controlled trial assessing frequency and duration of vancomycin therapy by physicians. PARTICIPANTS AND SETTING: Three hundred ninety-six physicians and 1,798 patients in a tertiary-care teaching hospital. INTERVENTION: Computer screen displaying, at the time of physician order entry, an adaptation of the Centers for Disease Control and Prevention guidelines for appropriate vancomycin use. MAIN OUTCOME MEASURES: The frequency of initiation and renewal of vancomycin therapy as well the duration of therapy prescribed on a per prescriber basis. RESULTS: Compared with the control group, intervention physicians wrote 32 percent fewer orders (11.3 versus 16.7 orders per physician; P = 0.04) and had 28 percent fewer patients for whom they either initiated or renewed an order for vancomycin (7.4 versus 10.3 orders per physician; P = 0.02). In addition, the duration of vancomycin therapy attributable to physicians in the intervention group was 36 percent lower than the duration of therapy prescribed by control physicians (26.5 versus 41.2 days; P = 0.05). Analysis of pharmacy data confirmed a decrease in the overall hospital use of intravenous vancomycin during the study period. CONCLUSION: Implementation of a computerized guideline using physician order entry decreased vancomycin use. Computerized guidelines represent a promising tool for changing prescribing practices.

Simplified surveillance for nosocomial bloodstream infections.

OBJECTIVE: To compare a surveillance definition of noso comial bloodstream infections requiring only microbiology data to the Centers for Disease Control and Prevention's (CDC) current definition. SETTING: Six teaching hospitals. METHODS: We classified a representative sample of 73 positive blood cultures from six hospitals growing common skin contaminant isolates using a definition for bacteremia requiring only microbiology data and the CDC definition for primary bloodstream infection (National Nosocomial Infections Surveillance [NNIS] System review method). The classifications assigned during routine prospective surveillance also were noted, and the time required to classify isolates by the two methods was compared. RESULTS: Among 65 blood cultures growing common skin contaminant isolates obtained from adults, the agreement rate between the microbiology data method and the NNIS review method was 91%. Agreement was significantly poorer for the eight blood cultures growing common skin contaminant isolates obtained from pediatric patients. The microbiology data method requires approximately 20 minutes less time per isolate than does routine surveillance. CONCLUSIONS: A definition based on microbiology data alone yields the same result as the CDC's definition in the large majority of instances. It is more resource-efficient than the CDC's current definition.

Use of antibiotic exposure to detect postoperative infections.

OBJECTIVE: To assess the utility of postoperative antibiotic exposure as an indicator of postoperative infection after coronary artery bypass graft surgery. DESIGN: We determined an optimal antibiotic exposure threshold by creating receiver operating characteristic curves. SETTING: Tertiary healthcare institution (United States); national sample (Israel). PATIENTS: 5,887 patients undergoing coronary artery bypass graft surgery. RESULTS: Postoperative antibiotic exposure with at least 9 days between the first and last dates of antibiotic administration, excluding the first postoperative day, had a sensitivity of 95% (261/276) and specificity of 85% (3,944/4,628) for identifying surgical-site infection, using as a gold standard surgical-site infections identified by conventional prospective surveillance or extrapolated from review of a sample of medical records. In contrast, using the same gold standard for surgical-site infections, the sensitivity of routine prospective surveillance alone was only 60%. The predictive value positive of the defined antibiotic exposure was 28% (261/945) for surgical-site infection and 60% (563/945) for any nosocomial infection. In the Israeli cohort, the sensitivity was 87% (74/85) and the specificity was 82% (735/898). CONCLUSION: Antibiotic exposure of sufficient duration and timing was more sensitive than conventional methods in detecting nosocomial infection and required substantially less effort to collect. Although the predictive value positive for surgical-site infection was only moderate, the majority of individuals identified this way had a nosocomial infection.

Epidemiology of a dominant clonal strain of vancomycin-resistant Enterococcus faecium at separate hospitals in Boston, Massachusetts.

In 1996, the dominant (43%) strain of vancomycin-resistant enterococci (VRE; type A) at Massachusetts General Hospital was identified at Brigham and Women's Hospital (BWH). To characterize the epidemiology of infection with type A isolates of VRE at BWH, we collected demographic and clinical data for all patients from whom VRE were isolated from a clinical specimen through September 1996. The first clinical isolates from all BWH patients from whom VRE were isolated were typed by pulsed-field gel electrophoresis of SmaI digests of chromosomal DNA. Among patients hospitalized after the first patient at BWH infected with a type A isolate of VRE was identified, exposures were compared between patients who acquired type A isolates of VRE and those who acquired other types of VRE. Isolates from 99 patients identified to have acquired VRE were most commonly from blood (n = 27), urine (n = 19), or wounds (n = 19). Three months after the index patient arrived at BWH and at a time when > or =12 types of strains of VRE were present, type A isolates of VRE became dominant; 39 of 75 (52%) of the study cohort had acquired type A isolates of VRE. We found no association between the acquisition of type A isolates of VRE and transfer from another institution or temporal overlap by service, ward, or floor with patients known to have acquired type A isolates of VRE. By multivariate analysis, only residence in the medical intensive care unit (adjusted odds ratio [OR], 3.2; 95% confidence interval [CI], 1.4 to 107) and the receipt of two or more antibiotics per patient-day (adjusted OR, 12.2; 95% CI, 1.2 to 9.0) were associated with the acquisition of strain A. This strain of VRE, dominant at two Boston hospitals, was associated with intensity of antibiotic exposures (i.e., two or more antibiotics per patient-day). We hypothesize that this strain may have unidentified properties providing a mechanism favoring its spread and dominance over other extant isolates, and further studies are needed to define these properties.

Surveillance for surgical site infections: the uses of antibiotic exposure.

Conventional methods of surveillance for surgical site infections are resource intensive, thus creating an incentive to develop simpler alternatives. Antibiotic exposure may serve as a satisfactory marker for a physician's belief that infection is present and, therefore, may be a more efficient, and perhaps more accurate, measure than identification of an explicit diagnosis in the medical record. Surveillance strategies that use antibiotic exposure may provide resource-efficient adjuncts for surveillance of surgical site infections or be used in selected circumstances as substitutes for conventional surveillance methods.