Biomarker Can Identify Aggressive Form of Bacteria Klebsiella pneumoniae Interview with:

This blood agar plate (BAP) grew colonies of Gram-negative, small rod-shaped and facultatively anaerobic Klebsiella pneumoniae bacteria- CDC image

This blood agar plate (BAP) grew colonies of Gram-negative, small rod-shaped and facultatively anaerobic Klebsiella pneumoniae bacteria- CDC image

Thomas A Russo, MD, CM
The Departments of Medicine, and Microbiology and Immunology
The Witebsky Center for Microbial Pathogenesis
University at Buffalo-State University of New York, and the
Veterans Administration Western New York Healthcare System
Buffalo, New York What is the background for this study? What is Klebsiella pneumoniae?

Response: K. pneumoniae is an important bacterial pathogen that cause a number of different infections. Presently, two pathotypes exist that behave very differently.

Classical K. pneumoniae, which is most common in North America and Europe primarily causes infections in the healthcare setting, usually in patients with co-morbidities. Also, it is becoming increasingly antimicrobial resistant, making treatment challenging.

Hypervirulent K. pneumoniae, which is more common in the Asian Pacific Rim,  can cause infections in otherwise healthy individuals, often causes infection in multiple sites, and these sites are usually not infected by classical K. pneumonia, such as the eye, brain, and aggressive soft-tissue infection (necrotizing fasciitis). Hypervirulent K. pneumonia strains are also becoming antimicrobial resistant, albeit at a slower rate than classical K. pneumoniae at this time.

There are some differences how infections due to these two pathotypes are managed. It would also be ideal to track the prevalence and relative antimicrobial resistance of these two pathotypes, but up until now this could not be reliably done because there was not a validated test that could differentiate them. The goal of this study was to identify biomarkers that could accurately differentiate classical from hypervirulent K. pneumoniae.  Continue reading

Coding Changes Limited Penalty Impact From CMS Hospital-Acquired Conditions Policy Interview with:

Michael S. Calderwood, MD, MPH, FIDSA Regional Hospital Epidemiologist Assistant Professor of Medicine Infectious Disease & International Health

Dr. Calderwood

Michael S. Calderwood, MD, MPH, FIDSA
Regional Hospital Epidemiologist
Assistant Professor of Medicine
Infectious Disease & International Health What is the background for this study?  

Response: Prior work by Lee et al. (N Engl J Med 2012;367:1428–1437) found that the 2008 CMS Hospital-Acquired Conditions (HAC) policy did not impact already declining national rates of central line-associated bloodstream infections (CLABSIs) or catheter-associated urinary tract infections (CAUTIs). We studied why this policy did not have its intended impact by looking at coding practices and the impact of the policy on the diagnosis-related group (DRG) assignment for Medicare hospitalizations. The DRG assignment determines reimbursement for inpatient hospitalizations.

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Perceived Hospital Cleanliness Has Big Impact on Patient Satisfaction Interview with:

Dusty Deringer Vice president of Patient Experience for Crothall Healthcare Compass One Healthcare

Dusty Deringer

Dusty Deringer
Vice president of Patient Experience for Crothall Healthcare
Compass One Healthcare What are the main findings from your new research?

Response: Patients’ perceptions of a hospital’s cleanliness can have a major impact on their overall care and hospital experience. Specifically, the data show correlations between patients’ perceptions of room cleanliness and three important categories: the risk of hospital-acquired infections; a hospital’s score on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and scores on the HCAHPS teamwork indicators.

The findings are important because patients are more likely to recommend a hospital they perceive to be clean. Therefore, it makes cleanliness a target for improvement for all hospitals.

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Antibiotics Encourage Spread of C.diff To Subsequent Patients Who Occupy the Same Bed and Haven’t Received Antibiotics Interview with:

Dr. Daniel E. Freedberg MD M

Dr. Daniel E. Freedberg

Dr. Daniel E. Freedberg MD MS
Division of Digestive and Liver Diseases
Columbia University Medical Center
New York, New York What is the background for this study?

Response: We conducted this study because previous studies indicate that the gastrointestinal microbiome is easily shared between people who co-occupy a given space (such as a hospital room).  We wondered if antibiotics might exert an effect on the local microbial environment.

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ICUs Might Consider Avoiding Tap Water To Limit Pseudomonas Infections from Faucets Interview with:

Dr. Cohen Regev, M.D Head of the infectious diseases and infection control units Sanz Medical Center, Laniado hospital Netanya, Israel

Dr. Cohen Regev

Dr. Cohen Regev, M.D
Head of the infectious diseases and infection control units
Sanz Medical Center, Laniado hospital
Netanya, Israel What is the background for this study?

Response: During 3 months in 2012 we had a number of clinical isolates of Pseudomonas aeruginosa (PA) in our neonatal intensive care unit (NICU) and a high incidence of colonization among ventilated patients in our medical-surgical intensive care unit (MSICU). The origin of PA may be from various environmental sources (‘exogenous’), from the patients’ own microbiome (‘endogenous’), or from both. Since in NICUs the origin is usually exogenous, we investigated the sources of the bacteria, focusing on the faucets of these units, as they were previously incriminated as causes of outbreaks in ICUs.

The study was conducted in Sanz medical center, a 400-bed community hospital located in central Israel. In the NICU we obtained several environmental cultures from faucets using a bacterial swab by rubbing the tip into the distal part of the faucet. Aerators were dismantled from all faucets, cultured from their inner part using a swab and were not repositioned. Contaminated faucets were occasionally replaced or treated with enzymatic fluid and sterilization by Ethylene Oxide. During the intervention and since, neonates were bathed only with warmed sterile water, and tap water was allowed only for hand hygiene practices.

In the MSICU tap water was used only for bathing the patients. All other uses of tap water, such as drinking, moistening and mouth treatments, were allowed using only sterile water. The units’ faucets were sampled on two different days concurrently with surveillance cultures of pharyngeal, sputum and urine from the patients.

Bacteria were identified with VITEK 2 (Biomerieux®) and typing was done by Enterobacterial Repetitive Intergenic Consensus (ERIC) PCR.

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Biofilm Formation Hampers Removal of Dangerous Bacteria from Hospital Surfaces Interview with:
Christine Greene, Ph.D. and Chuanwu Xi, Ph.D.
School of Public Health, Department of Environmental Health Sciences
University of Michigan

Medical Research: What is the background for this study?

Response: Healthcare-associated infections (HAIs) are a serious problem globally.  Acinetobacter baumannii, a gram-negative opportunistic pathogen, was mostly unheard of 10-15 years ago, but is now a clinically significant pathogen in hospitals.  A. baumannii causes a variety of infections ranging from urinary tract infections to bacteremia and patients who are at high risk of A. baumannii infection are those who are critically ill, who have indwelling catheters or patients with long hospital says.  Once infected, the risk of mortality is high – up to 26% for in-hospital patients and as much as 43% for those in the ICU.  The mortality rate is high largely due to the rapid ability for this pathogen to develop antibiotic resistance.  Despite patient isolation, we still see hospital outbreaks because A. baumannii survives very well in the environment and it is resistant to most biocides, detergents, dehydration, and UV radiation.  A. baumannii is also a known biofilm former.  Biofilms serve to protect the microorganism.  In the open environment, biofilms protect from desiccation and other harsh environmental insults such as biocides, thereby promoting persistence in the open environment.  In the human body, biofilms protect against the immune system, provide an additional layer of protection from antibiotics and contribute to reoccurring infections in the patient.

This research characterizes the fitness (desiccation tolerance) trade-offs imposed on A. baumannii isolated from clinical and environmental settings.  This investigation compares isolates of A. baumannii from both environments on the basis of multidrug resistance, biofilms and desiccation tolerance.  We looked to see if either MDR or biofilm formation increased fitness (ability to tolerate desiccation) or impose a fitness cost depending on environmental conditions.

Medical Research: What are the main findings?

Response: We provide evidence of variation in desiccation tolerance between clinical and environmental isolates of similar phenotypes and show a trend of increased desiccation tolerance for high biofilm forming clinical isolates with additional tolerance when the ability to form biofilms is coupled with the multidrug resistance.  By contrast, biofilm formation had a significant impact on desiccation tolerance for environmental isolates.

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Single Use Sharps Recycling Many Reduce C. diff Infections

Dr. Monika Pogorzelska-Maziarz PhD MPH Thomas Jefferson University, Jefferson School of Nursing Philadelphia, PA Interview with:
Dr. Monika Pogorzelska-Maziarz PhD MPH

Thomas Jefferson University, Jefferson School of Nursing
Philadelphia, PA 19107

Medical Research: What is the background for this study? What are the main findings?

Pogorzelska-Maziarz: Sharps disposal containers are ubiquitous in healthcare facilities and there is a growing trend toward hospitals using reusable sharps containers. Several research studies have raised concerns about the potential for sharps containers to become a source of pathogen transmission within the healthcare setting but this issue that has not been systematically studied. This is an important issue given that contamination of the hospital environment has been shown to be an important component of pathogen transmission.

To examine whether the use of reusable versus single use sharps containers was associated with rates of Clostridium difficile, we conducted a cross-sectional study of acute care hospitals. Survey data on the different types of sharps containers used were collected from over 600 hospitals and this data was linked to the Medicare Provider Analysis and Review (MedPAR) dataset, which contains facility characteristics and C. diff infections data. We found that hospitals using single-use containers had significantly lower rates of C. diff versus hospitals using reusable containers after controlling for hospital characteristics such as geographic region, teaching status, ownership type, hospital size and urbanicity. This is an important finding giving the ubiquitous nature of sharps containers in the health care setting, the growing trend toward hospitals using reusable sharps containers and the high burden of C. diff in the hospital setting. Continue reading

Medicare Initiative Reduced Hospital-Acquired Infections

Teresa Waters PhD Professor and Chair, Preventive Medicine University of Tennessee Health Science Center Memphis Interview with:
Teresa Waters PhD

Professor and Chair, Preventive Medicine
University of Tennessee Health Science Center
Memphis TN

Medical Research: What is the background for this study? What are the main findings?

Dr. Waters: On October 1, 2008, Medicare implemented the Hospital-Acquired Conditions (HACs) Initiative, a policy penalizing hospitals for eight complications of hospital care, also known as never events. Under the HACs Initiative, hospitals could no longer justify a higher level Medicare MS-DRG when caring for a patient who developed 1 of the 8 never events. This Initiative was one in a series of CMS payment reforms intended to increase emphasis on value-based purchasing.

We found that Medicare’s nonpayment policy was associated with significant improvements in the time trends for central line associated blood stream infections (CLABSIs) and catheter associated urinary tract infections(CAUTIs). For these outcomes, our data from the National Database of Nursing Quality Indicators showed that introduction of the Medicare policy was associated with an 11% reduction in the rate of change in central line associated blood stream infections and a 10% reduction in the rate of change in CAUTIs. We did not find any relationship between introduction of the policy and significant changes in injurious falls or hospital acquired pressure ulcers (two other important never events covered by the policy). We hypothesized that the Hospital-Acquired Conditions Initiative may have a great effect for conditions where there is strong evidence that better hospital processes yield better outcomes or where processes are more conducive to standardization.

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Hospital Acquired Infections: Still Room for Improvement Interview with:
Shelley S. Magill, M.D., Ph.D.
From the Centers for Disease Control and Prevention
Emory University School of Medicine
Atlanta, Georgia What are the main findings of the study?

Dr. Magill: The results of this survey show that healthcare-associated infections continue to be a threat to patient safety in U.S. acute care hospitals. Among the more than 11,000 patients included in the survey, approximately 4% (or 1 in 25) had at least one healthcare-associated infection at the time of the survey. We used these results to develop national estimates of healthcare-associated infections. We estimated that in 2011, there were approximately 721,800 healthcare-associated infections in U.S. acute care hospitals. The most common types of infections were surgical site infections (SSIs), pneumonias, and gastrointestinal infections.
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Decline in C. Difficile may be due to Decreased Antibiotic Exposure Interview with:
David W. Eyre, B.M., B.Ch.
Nuffield Department of Clinical Medicine
University of Oxford
National Institute for Health Research (NIHR) Oxford Biomedical Research Centre
John Radcliffe Hospital What are the main findings of this study?

Dr. Eyre: All cases of Clostridium difficile in Oxfordshire were studied over 3 years. Isolates were characterized by whole genome sequencing and the data was linked to hospital databases allowing epidemiological relationships between patients at the level of the hospital ward, hospital specialty, and post code to be identified. For comparison, similar information was also available for all other patients with and without diarrhea.  Preliminary work on the genetic diversity of Clostridium difficile within individuals and between individuals within discrete outbreaks allowed reliable interpretation of transmission events using genomic data.

This allowed a complete reconstruction of the pattern of transmission between affected cases in Oxfordshire to be made.

The findings were:
1. Unexpectedly few cases (13%) appear to be acquired from direct ward based contact with other symptomatic cases (these have previously been thought to be the main source of infections, and the focus of prevention efforts). Another 6% were associated with other hospital contact and 3% had plausible community contacts.

2. In 13% of cases potential donors were identified gnomically but no contact, within hospitals or the community, were identified. This suggests that the existence of other modes of transmission of Clostridium difficile.

3. The sources of Clostridium difficile infections were highly genetically diverse, with 45% of cases having a genetically distinct origin – suggesting a diverse reservoir of disease, not previously appreciated

4. During the 3 years of the study the rate of Clostridium difficile in Oxfordshire fell.  Any improvement in infection control techniques would be expected to reduce the incidence of cases caused by within hospital transmission. Surprisingly, similar rates of fall occurred in both in secondary cases (considered to be acquired from hospital associated symptomatic cases) and for primary cases (cases not associated with transmission from symptomatic cases).
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Inexpensive Infection Control Reduces Hospital Mortality and Costs


Thursday, Sept. 8, 2011

CHAPEL HILL, N.C. – At any given time, one of every 20 hospital patients has a hospital-acquired infection, according to the U.S. Department of Health and Human Services.
This leads to an estimated 99,000 deaths in the U.S. each year and up to $33 billion in preventable health care costs.

Now a new study by University of North Carolina at Chapel Hill researchers finds that adopting an inexpensive set of infection control measures could potentially save many thousands of lives and billions of dollars. The study appears in the September 2011 issue of Health Affairs.

“These two initiatives, targeting ventilator associated pneumonias and central line associated bloodstream infections, involved simple steps that lead to dramatic reductions in not only the targeted infections, but also mortality and costs,” said Bradford D. Harris, MD, who led the study while serving as an associate professor of anesthesiology and pediatrics in the UNC School of Medicine. He is now a medical officer at the U.S. Food and Drug Administration in Washington.

The study was conducted in the Pediatric Intensive Care Unit at North Carolina Children’s Hospital, which is one of the five University of North Carolina Hospitals. The study tested three interventions aimed at preventing and reducing hospital acquired infections.

The first intervention was strict enforcement of standard hand hygiene practices on the unit. All health care workers are expected to wash their hands with soap and running water or an alcohol-based rub on entering and leaving a patient’s room, before putting on and after removing gloves, and before and after any task that involves touching potentially contaminated surfaces or body fluids.

The second intervention was implementing a bundle of measures aimed at preventing ventilator-associated pneumonia. Examples included elevating the head of the patient’s bed while the patient is receiving breathing assistance from a ventilator, giving the patient daily breaks from sedation and then — while the patient was unsedated — assessing whether or not the patient is ready to come off the ventilator, and providing daily oral care (teeth brushing, mouth washes, etc.) with a long-lasting antiseptic.

The final intervention was ensuring compliance with guidelines for the use and maintenance of central-line catheters. Examples included using sponges impregnated with an antiseptic, using catheters impregnated with antibiotics whenever possible, and performing two assessments per day of whether patients with central-line catheters still needed them.

Results of the study showed that patients admitted after these interventions were fully implemented got out of the hospital an average of two days earlier, their hospital stay cost about $12,000 less and the number of patient deaths were reduced by two percentage points.

The costs for implementing these measures were modest. Examples include roughly $21 a day for oral care kits and about 60 cents a day for antiseptic patches and hand sanitizers. But adoption of the three interventions collectively could save this single hospital unit an estimated $12 million a year, the study found. If replicated nationwide, these measures potentially could save thousands of lives and billions of dollars each year.

The study concluded that measures such as these have the potential to save both lives and money and will improve the care of all patients.

UNC co-authors of the study are Cherissa Hanson, MD; Claudia Christy, Tina Adams, Andrew Banks and Tina Schade Willis, MD. Matthew Maciejewski, PhD, an associate professor at Duke University School of Medicine who holds adjunct professor appointments at UNC, is also a co-author.