Top Papers 2014

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Andreas Voss, MD,PhD Victoria J. Fraser, MD Radboud University Medical Centre Washington University School of Medicine Nijmegen, Netherlands St. Louis, Missouri

Lets get started !

¤ Central concept of efforts to prevent C. difficile: “Symptoma3c pa3ents in hospitals are the major source of transmission”

¤  Are we missing sources? ² … novel routes of disseminaQon not addressed by current control strategies

²  … cases acquired outside the hospital ² … important sources of transmission?

² AsymptomaQc carriers of toxin-‐producing strains of C. difficile outnumber infected paQents !

² InfecQons were as frequently linked to asymptomaQc carriers as to symptomaQc paQents (30% and 29%, respecQvely)

Dubberke ICHE 2008;29:Suppl 1:S81-‐S92, Loo NEJM 2011;365:1693, Curry CID 2013

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¤ 3.6-‐year study using WGS-‐typing to study the epidemiology of CDAD in Oxfordshire, UK

Eyre et al. NEJM 2013;369:1105-‐205

Only 38% and 54% of geneQcally linked cases shared ward-‐based and hospital-‐wide contacts

five diarrhea pa3ents, one line up, a coincidence

Donskey CJ. NEJM 2013;369:1263-‐4

SymptomaQc CDAD-‐paQents no longer the main source of C. difficile in hospitals ? ¤  Generalizability? Study done in a non-‐outbreak segng with good infecQon control measures ²  isolaQon of suspected paQents ²  daily (audited) hypo-‐chloride disinfecQon

¤  DetecQon methods? How good was the detecQon in symptomaQc paQents (test sensiQvity)

¤ Point of acquisiQon not examined. No cultures on admission.

Donskey CJ. NEJM 2013;369:1263-‐4 Gastmeier et al. JAC 2014;6:1660

Gastmeier et al. JAC 2014;6:1660

Data from German naQonal nosocomial surveillance system (KISS)


SSI

UTI

BSI

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The high overall VRE proporQon in Germany is mainly due to the situaQon in four states (Rhine-‐Westphalia, Hesse, Thuringia and Saxony ). There is an urgent need to analyse the

epidemiology of VRE in detail to develop appropriate infecQon control strategies

Den Heijer et al. Lancet Infect Dis 2013;13:409-‐15

¤  About 20 family doctors per country ¤  Countries: Austria, Belgium, CroaQa, France, Hungary,

Spain, Sweden, the Netherlands, UK (2010/11)

¤  Nasal swabs from 200 paQents, aged 4 years or older (or ≥18 years in the UK), who visited their pracQce for a non-‐infecQous disorder.

¤ Exclusion: paQents who had anQmicrobials or who had been admiled to hospital in the previous 3 months, who were immunocompromised (eg those with diabetes mellitus) and nursing home residents

Den Heijer et al. Lancet Infect Dis 2013;13:409-‐15 Den Heijer et al. Lancet Infect Dis 2013;13:409-‐15

Den Heijer et al. Lancet Infect Dis 2013;13:409-‐15 Den Heijer et al. Lancet Infect Dis 2013;13:409-‐15

MRSA

CC 008

CC 011

CC 011

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Jurke et al. Euro Surveill. 2013;18(36):pii=20579

¤ In 2007, all hospitals started to systemaQcally screen defined paQents associated with any one of the known risk factors, prior to or upon admission to a hospital.

¤ From 2007 to 2011, the MRSA admission incidence (0.51 vs 1.09 MRSA cases/100 paQents admiled), the MRSA incidence density (0.87 vs 1.54 MRSA cases/1,000 paQent days) as well as the mean daily MRSA-‐burden (1.30 vs 1.82 MRSA-‐in-‐hospital days/100 paQent days) increased significantly (p<0.0001)



¤ IniQally, more MRSA carriers are found when more paQents are screened. ² This may make some hospitals reluctant to establish such a screening policy due to increasing and costly efforts to isolate paQents in single rooms.

¤ However, only aper few years, the nosocomial MRSA burden decreases, which finally may encourage the hospitals to accept this burden of prevenQon.


¤  Guidance outlines a more focused, cost-‐effecQve approach to MRSA screening.

¤  RecommendaQon for Trusts to move to focussed screening programmes has been designed to promote a more efficient and effecQve method for idenQfying and managing high risk MRSA posiQve paQents.

¤  Focussed screening should be adopted in line with local risk assessments to ensure that Trusts concentrate on reducing negaQve paQent outcomes for their own populaQons.

Change the MRSA screening policy from mandatory universal screening to focused screening

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Fätkenheuer et al Lancet 2014, published online Aug 21st Fätkenheuer et al Lancet 2014, published online Aug 21st

Fätkenheuer et al Lancet 2014, published online Aug 21st

Hand hygiene +++ Screening ? Isolation Decolonization +

“the strategy of screening and isola:on cannot be regarded as a gold standard

to prevent the spread of MRSA”

… okay, but what did we do in the NL –

screen & isolate and 20% HH compliance

Sarah Zhang Nature doi:10.1038/nature.2013.13752 Casey et al. JAMA 2013; September 16th (published online)

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¤ Proximity to swine manure applicaQon, to crop fileds, and livestock operaQons each was associated with MRSA and skin and sop-‐Qssue infecQon

¤ No MRSA belonging to CC398 (LA-‐MRSA) !?

Could it be that occupaQonal hazards & lifestyle are more important than us?

Casey et al. JAMA 2013; September 16th (published online) Hetem et al. Emerging Infect Dis 2013;19:1797

Hetem et al. Emerging Infect Dis 2013;19:1797

Transmissibility of LA-‐MRSA is (sQll) 4.4 Qmes lower than that of other MRSA

(not associated with livestock)

Bourigault et al. PLOS Current Outbreaks, March 7, 2014

IN THE MRSA EPIDEMIOLOGY

¤  sequence type (ST) 8 community-‐associated geneQc lineage, SCCmec type IVa, spa type t292 related to MRSA lineage USA300

Rossi et al. NEJM 2014,370:1524

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Rossi et al. NEJM 2014,370:1524

IN THE MRSA EPIDEMIOLOGY

Hearing CA-MRSA USA300 & vanco-resistance in one

strain gives me the creeps … .. back to

science …

Palerned Progression of Bacterial PopulaQons in the Premature Infant Gut

La Rosa PS, et al. PNAS Early EdiQon 2014; [Epub ahead of print].

•  ProspecQve stool 58 premies, 922 specimens, SLCH NICU, 16S rNA pyrosequencing,

•  Microbiota → Bacilli, Gammaproteobacteria to Clostridia (abrupt Δes)

•  33-‐36 wks postconceptual, 3-‐12 wks life = well colonized by anaerobes

•  AnQbioQcs, birth type, diet & age influence pace -‐not sequence

Palerned Progression of Bacterial PopulaQons in the Premature Infant Gut

La Rosa PS, et al. PNAS Early EdiQon 2014; [Epub ahead of print].

Sepsis from the Gut

•  Methods: ProspecQve stool, premies with sepsis, Culture & genome sequencing

•  Results: 11 babies with late onset BSI; 7 had stool with GBS, S. marcescens or E. coli which matched BSI, 4/96 overlap non-‐sepsis babies colonized with matching GBS or S. marcescens

•  Impact: Highlights “microclusters”, study stool surveillance, DecolonizaQon and á hygiene?

Carl MA, et al. CID 2014;58 (1 May): 1211-‐18.

MulQstate Point-‐Prevalence Survey of Health Care-‐Associated InfecQons

•  Methods – NHSN definiQons, 1 day surveys of 183 hospitals

•  Results –  HAI in 4% (452/11,282) (95% CI, 3.7%-‐ 4.4%) – Pneumonia (21.8%), SSI (21.8%), GI (17.1%) – Device-‐associated (25.6%), CAUTI; CLABSI, VAP – ~648,000 pts with 721,800 HAIs in 2011

Magill SS, et al. N Engl J Med 2014;370:1198-‐208.

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12.1%

10.7%9.9%

9.3%

Organisms

C diff

S. aureus

Klebsiella

E. coli



Different paQents, methods, definiQons




BSI in Community Hospitals in 21st Century

•  9 comm hospitals, SE US, 2003-‐2006, 1,470 pts •  56% COHA, 29% CABSI, 15% HOHA •  23% MDRO, SA (28%), E. coli (24%), CNS (10%) •  38% inappropriate AB (33% med, range 21 – 71%) •  MV predictors of inappropriate AB: hospital (p<0.001), assistance ≥3 ADLs (p=0.005), Charlson score (p=0.05), COHA (p=0.01), HOHA (p=0.02)

Anderson DJ, et al. PLoS ONE 2014;9(3):e91713.

•  Retro cohort in CA; 1 THA/TKA, 2006 – 2009; ICD-‐9-‐CM codes, within 365 days of surgery

•  THA SSI (2.3%), TKA SSI (2.0%) •  17% missed by opera:ve hospital surveillance alone •  ProporQon SSI detected at nonop hospital (0-‐100%) •  Including SSIs at nonop hospitals improved rankings for 6%

THA & 61% TKA •  90 day surveillance detected 81% THA & 74% TKA SSI

Yokoe DS, et al. CID 2013;57 (1 Nov):1282-‐88. Yokoe DS, et al. CID 2013;57 (1 Nov):1282-‐88.

ReporQng SSI Following THA & TKA

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•  80,461 invasive MRSA (95% CI, 69,515 – 93,414) •  48,353 HACO (95% CI, 40,195 – 58,642) •  14,156 HO MRSA (95% CI, 10,096 – 20,440) •  16,560 CA-‐MRSA(95% CI, 12,806 – 21,811) •  Since 2005, Na:onal es:mated incidence

! in HACO by 27.7%, ! in HO by 54.2%, ! In CA-‐MRSA by only 5%

Dantes R, et al. JAMA Intern Med 2013;173(21):1970-‐78.

QuanQfying Sources of Bias in NHSN CDI Rates

•  Sensi:vity analysis, 124 NY hospitals, 2010 •  NY NHSN CDI reports compared to DC billing records •  Corrected for inaccurate repor:ng, OSH lab results, excluding pt days not @ risk, adjus:ng for pt age

•  Including pt days “not at risk” in denominator ↓ HO CDI rate 43%, 8% misclassifica:on

•  Age adjustment (7% misclassifica:on) & repor:ng errors (6% misclassifica:on)

Haley VB, et al. ICHE 2014;35(1):1-‐7.





Development & ValidaQon of Recurrent C diff. Risk-‐PredicQon Model

•  Retro cohort, large urban AMC, 2003 – 2009, all adults with inpt CDI

•  10% (425/4196) pts → recurrent CDI •  CO-‐HA, ≥ 2 prior hospitalizaQons in past 60 days, new gasQc acid suppression, FQ & high risk AB use at onset & age predicted recurrence (C stat 0.643) discriminaQon; calibraQon (Brier score .089), NPV 90% or >

•  ICU stay protecQve

Zilberberg MD, et al. J Hosp Medicine 2014;9:418-‐423. Rohde JM, et al. JAMA 2014;311(13):1317-‐26.

•  21 RCTs 8,735 pts; 18 (7,593) used for meta-‐analysis

•  Pooled risk of all serious infecQons: restricQve vs liberal group 11.8% (95% CI, 7 – 16.7%) vs 16.9% (95% CI, 8.9 – 25.4%)

•  Risk RaQo RR = 0.82 (95% CI, 0.72 -‐ 0.95)

•  RestricQve NNT to prevent serious infecQon 38 (95% CI, 24 – 122)

•  RR 0.80 (95% CI, 0.70 – 0.97) NNT 20 (95% CI, 12 – 133) even with leukocyte reducQon

•  RR 0.70 (95% CI, 0.54 – 0.91) Ortho, RR 0.51 (95% CI, 0.28 – 0.95) Sepsis

•  No difference for cardiac, criQcally ill, UGI bleed, LBWT infants

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MDRO •  Hospital analyses of MRSA admit prevalence, acquisiQon rates & incident nosocomial clinical culture (INCC)

•  112 VAs 2007 – 2010 aper MRSA bundle, GL mixed models •  MRSA admit prev 11.4%, acquis 5.2/1,000 pt days at risk •  10% ↑ in ave admit prev assoc with 9.7% ↑ wkly

acquisiQon rates (p<.001), 9.8% ↑ wkly INCC rates (p<.001) •  ↓ acquisiQon → ↓ importaQon → ↓ acquisiQon •  ↓ INCC in pts with neg admit → ↓ transmission → ↓

infecQon

Jones M, et al. CID 2014;58 (1 Jan):32-‐39.

Nguyen DB, et al. CID 2013;57(10):1393-‐1400.

•  15,700 invasive MRSA infecQons in US dialysis pts in 2010 Pop data 9 US metro areas 2005 – 2011, USRDS

•  7,489 infecQons 85.7% HACO, 93.2% BSI •  Incidence ↓ 6.5 to 4.2/100 dialysis pts (annual ↓7.3%),

↓ 6.7 % HACO, 10.5% HO •  60.4% dialyzed through CVC; Fistula First IniQaQve ↓ CVC use

in HD from 27.8% in 2009 to 18.8% in 2011

Invasive MRSA in Chronic Dialysis in US 2005 – 2011

Nguyen DB, et al. CID 2013;57(10):1393-‐1400.

Statewide Surveillance of CRE in Michigan

Brennan BM, et al. ICHE 2014;35(4):342-‐349.

•  9/2012 – 2/2013, 21 faciliQes (17 ACH, 4 LTAC);102/957,220, IR 1.07/10,000 pt days

•  89 KP, 13 E coli; 61% urine cultures •  35% HO, 65% CO; 75% of CO had HC exposure in past 90 days

•  CVD, ESRD, DM most common comorbidiQes •  Surgery in 90 days, recent infecQon, MDRO colonizaQon, AB exp -‐esp 3rd or 4th gen CS

State Surveillance of CRE in Michigan

Brennan BM, et al. ICHE 2014;35(4):342-‐349.

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•  Chicago 1 day pt prev survey; 24/25 short-‐stay ACH ICU , 7/7 LTACHs

•  Rectal, inguinal, urine sites à Enterobacteriaceae blaKPC •  30.4% LTACH pts colonized with KPC (119/391) •  3.3% ACH pts colonized with KPC (30/910); prev raQo 9.2%;

(95% CI, 6.3-‐13.5) •  LTACH prev range (10-‐54%); 100% ⊕ vs 15/24 ACH (0-‐29%) •  LTACH type, mech vent & LOS = independent risk factors

Lin MY, et al. CID 2013;57 (1 Nov):1246-‐52. Thaden JT, et al. ICHE 2014;35(8):978-‐983.

Rising Rates of CRE in Community Hospitals

•  CRE evaluated from 25 com hospitals ‘08 – 12; 305 CRE isolates & 16 hospitals, 59% symptomaQc

•  KP (91%), HCA (94%), CRE detecQon rate ↑ 5x (0.26 to 1.4/100,000 pt days), IRR= 5.3 (95% CI, 1.22 – 22.7) p=0.01

•  Only 5 hospitals adopted lower CRE break pts (4.1 vs 0.5/100,000 pt days, p<.001) IRR, 8.1 (95% CI, 2.7 – 24.6) before & aper Δ

•  DetecQon rate (3.3 vs 1.1/100,000, p=.01) in hospitals with lower break pt

Rising Rates of CRE in Community Hospitals

Thaden JT, et al. ICHE 2014;35(8):978-‐983. Schwaber MJ and Carmeli Y. Clin Infect Dis 2014;58(5):697-‐703.

Ongoing NaQonal IntervenQon to Contain CRE

•  2006 Israel outbreak CRE, KP ST-‐258 (from US in 2005) •  3/2007 new acquisiQon 55/100,000 pt days (clinical Cx) •  Crude mortality 44-‐70%, BSI mortality 50% •  MOH ACH guidelines: 1) all CRE → isolaQon or “carrier” cohorts, physical separaQon; 2) dedicated staff for carriers – leveled off but ongoing spread

•  >YR1, acQve surveillance for high risk (ward contacts, new cases, OSH Tx, wards with hi CRE prevalence)

•  LTCF – PACH surveillance then LTCF guidelines •  Lab guidelines for CPE detecQon & D/C isolaQon

Schwaber MJ and Carmeli Y. Clin Infect Dis 2014;58(5):697-‐703. Schwaber MJ and Carmeli Y. Clin Infect Dis 2014;58(5):697-‐703.

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Schwaber MJ and Carmeli Y. CID 2014;58(5):697-‐703.

•  Cross-‐secQonal study, HUG, Switzerland •  Cultured food & food handlers, PCR & sequencing blaCTX-‐M, blaSHV,

blaTEM genes, MLST •  92% raw chicken ESBL-‐PE⊕; 86% of hospital & 100% of community •  No egg, beef, rabbit or cooked chicken ESBL-‐PE⊕

•  No an:bio:c residues, 6.5% HUG food handlers ESBL-‐PE⊕ carriers •  Chicken common blaCTX-‐M1, blaCTX-‐M2; blaCTX-‐M14, blaCTX-‐M15, mostly

human •  Good news → minimal risk to food handers, hospital staff, pa:ents •  Hospital food bejer in Europe than US ☺ •  AB free period prior to animal slaughter in EU vs US hospital pts

where no one dies without 5 an:bio:cs ☺

Stewardson AJ, et al. ICHE 2014;35(4):375-‐383.

Bréchet C, et al. CID 2014;58(12):1658-‐65.

Wastewater Treatment Plants Release Large Amounts of ESBL E. coli into Environment

•  Weekly samples x10 wks from 11 sites, waste H2O network of Besanҫon City, France

•  Total E. coli & ESBL E. coli determined for each sample •  PFGE, MLST, blaESBL genes by sequencing •  EC load > in urban vs hosp waste H2O (7.5x105 vs 3.5x105 CFU /ml) •  ESBL E coli recovered from almost all samples (0.3% of total EC in

untreated H2O upstream) •  ESBL E coli higher in hospital waste H2O vs community (27x103 vs

0.8x103 CFU /ml) •  WWTP eliminated 98% of E. coli & 94% ESBL EC •  WWTP “enriched” ESBL E coli, >600 billion ESBL EC released into

river daily; ferQlizer sludge ~ 2.6x105 ESBL EC/gram

NEW TECHNOLOGIES

Kothari A, et al. CID 2014;59(2):272-‐278.

Emerging Technologies for Rapid IdenQficaQon of Bloodstream Pathogens

•  Timing & appropriateness of anQbioQc Rx influences outcome •  7.6% ↓ survival/Hour aper hypotension unQl effecQve Rx •  5x ↑ mortality for inappropriate anQbioQcs in 6% of sepQc shock •  Broad spectrum AB Rx iniQally •  Pathogen ID from ⊕ blood Cx •  PepQde nucleic acid fluorescent in situ hybridizaQon molecular

strains (PNA-‐FISH) •  PNA-‐FISH, differenQate SA & CoNS, E. faecalis & E. species E. coli,

KP, PA & Candida, TAT=90”, sensiQviQes & specificity 96-‐100% •  Quick FISH (AdvanDx) 2013, TAT=20”

•  Quasi-‐exp before-‐ aper of MALDI-‐TOF with AST, Uof MI

•  245 intervenQon & 256 pre-‐intervenQon pts •  MALDI-‐TOF with AST = â organism ID Qme (84 vs 55.9 Hrs, p < .001), â Qme to effecQve AB (90.3 vs 47.3 hrs, p < .001)

•  Mortality (20.3% vs 14.5%), LOS ICU (14.9 vs 8.3 d), recurrent BSI (5.9 vs 2.0%) MALDI-‐TOF (univariate)

•  Accept AST rec trend â mortality OR 0.55 (p = 0.75)

Huang AM, et al. CID 2013;57 (1 Nov):1237-‐45.

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Huang AM, et al. CID 2013;57 (1 Nov):1237-‐45.

Kothari A, et al. Clin Infect Dis 2014;59(2):272-‐278

MALDI-‐TOF Cost EffecQveness & Impact

•  MALDI-‐TOF with ASP ↓ Qme to adjust AB by 46 Hrs in BSI, ↓ LOS ICU 1.2 days , ↓ LOS 1.8, ↓ cost $19,547

•  Gram (-‐) BSI, 42% improvement in Rx with MALDI-‐TOF

•  501 pts BSI & Fungemia, ASP & MALDI-‐TOF ↓ Qme to effecQve AB by 9.7 Hrs & Qme to opQmal Rx by 43 hrs, ↓ ICU LOS 6.6 days, ↓ mortality 20.3 to 12.7%

Perez KK, et al. Arch Pathol Lab Med 2013;137:1247-‐54 Huang AM, et al. Clin Infec Dis 2013;57:1237-‐45

Clerc O, et al. Clin Infect Dis 2013;56:1101-‐7

… where is my coffee…

… jawn …

Thom et al. Infect Control Hosp Epidemiol 2014;35:1060-‐62 Thom et al. Infect Control Hosp Epidemiol 2014;35:1060-‐62

¤  MSDS Poly spray (silicone quaternary amine)

¤  8 surfaces

²  sink, call bulon, bedside table, monitor, telephone, supply cart, door handle, floor

¤  Results:

² No significant effect on environmental contaminaQon

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Thom et al. Infect Control Hosp Epidemiol 2014;35:1060-‐62

¤  Problem adherence?

¤  Love the concept of changing the surface

¤  Studies with copper, silver silica, Biosafe HM 4100 (polymer) embedded in polyurethane, light-‐acQvated anQmicrobials, … have worked before

Freeman et al. AnQmicrob Resistance Infect Control 2014;3:5

¤  We systemaQcally sampled 8 surfaces in the rooms and bathrooms of adult paQents colonized or infected with ESBL-‐EC or ESBL-‐KP throughout their hospital stay.

¤  Environmental contaminaQon was defined as recovery of an ESBL-‐producing organism matching the source paQent’s isolate

Freeman et al. AnQmicrobial Resistance and InfecQon Control 2014, 3:5

¤ 



Rooms of paQents with ESBL-‐KP have substanQally higher contaminaQon rates than those with ESBL-‐EC. This finding may help explain the apparently higher transmissibility of ESBL-‐KP in the hospital segng

Kramer et al. BMC Infect Dis 2006;6:130

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Kramer et al. BMC Infect Dis 2006;6:130

E. coli 1.5h to 6 months Klebsiella spp. 2.0h to >30 months

Kampf et al. BMC Infect Dis 2014;14:37

Kampf et al. BMC Infect Dis 2014;14:37

¤ Reusable Qssue dispensers with different surface disinfectants were randomly collected from healthcare faciliQes.

¤ 66 dispensers containing disinfectant soluQons with surface-‐acQve ingredients were collected in 15 healthcare faciliQes. 28 dispensers from nine healthcare faciliQes were contaminated

¤ In none of the hospitals dispenser processing had been adequately performed

… it is not about the details of this paper, but the point that even

“helpful parts of the environment” may be a source for infecQons

¤  NIH program to encourage handwashing in hospitals and day care centers

¤  Program promotes a symbolic teddy bear (T. Bear) with slogans/reminders to pracQce HH.

¤  Stuffed T. Bear was dispensed to the hospitalized child.

¤  Could T. Bear serve as a "fomite”?

Hughes et al. Infect Control. 1986 Oct;7(10):495-‐500

¤ ProspecQve study of 39 sterilized T. Bears, one week aper use: ² S.aureus, K.pneumoniae, P.aeruginosa, E.coli, Candida spp, Cryptococcus, Aspergillus and others.

² Although the T. Bear handwashing campaign should not be discredited, the promoQonal toy may pose an unnecessary expense and hazard and should not be used in hospitals.

Hughes et al. Infect Control. 1986 Oct;7(10):495-‐500 hlp://www.dailymail.co.uk/femail/arQcle-‐2019527/Will-‐dishwasher-‐food-‐poisoning.html#ixzz3A00xnnOQ

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¤ Three weeks ago, I arranged for a scienQst to take swabs from ten sites around my home ...

¤ According to his report, I’ve got E.coli in the dishwasher, toxic fungus on the bath mat and goodness knows what festering in the toy box. As for the baby’s car seat, you don’t even want to go there...

hlp://www.dailymail.co.uk/femail/arQcle-‐2019527/Will-‐dishwasher-‐food-‐poisoning.html#ixzz3A00xnnOQ

Angelakis et al. Future Microbiol 2014;9:249 Angelakis et al. Future Microbiol 2014;9:249

By country By type of currency

Angelakis et al. Future Microbiol 2014;9:249

… and I always thought that it gets

contaminated during use …

Angelakis et al. Future Microbiol 2014;9:249

… and I always thought that it gets

contaminated during use …

Only 46% of the HCWs washed their hands Aper “visiQng” the toilets

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Kellog et al. Am J Infect Control 2012;40:893

¤ 1/3 of the hikers has fecal contaminaQon on their hands

¤ The quesQon is: Who’s fecal flora is it?

Kellog et al. Am J Infect Control 2012;40:893

… but the snow wasn’t yellow …

Mermel LA. Clin Infect 2013;56:123-‐130 Mermel LA. Clin Infect 2013;56:123-‐130

Mermel LA. Clin Infect 2013;56:123-‐130

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hlp://haicontroversies.blogspot.nl

Not of the same quality, but …

… finally

INTERVENTIONS

Meeker D, et al. JAMA Intern Med 2014;174(3):425-‐431.

•  Poster-‐sized commitment lelers in exam rooms x12 wks in cold & flu season, 14 clinicians, 5 clinics

•  Posters = photographs, signatures, commitment to avoid inappropriate AB prescribing for acute URI

•  Inappropriate RX 42.8% & 43.5% intervenQon & control baseline vs 33.7% & 52.7% with intervenQon (10% ↓)

•  Commitment lelers 19.7% ↓ in inapprop RX (p=0.02)

•  ~ NaQonal impact ↓ 2.6m unnecessary Scripts, & save $70.4m/yr

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Enriched Enteral NutriQon DID NOT ↓ InfecQons in Mechanically VenQlated PaQents

•  DB RCT, 301 pts in 14 ICUs, MV & tube feeds 22 hrs, Hi-‐protein enteral nutriQon with immune modulaQng nutrients (152) vs std Hi-‐protein enteral nutriQon (149)

•  No difference in infecQons, 53% vs 52% •  Higher mortality with enriched nutriQon, 54% vs 35%

vanZanten ARH, et al. JAMA 2014;312(5):514-‐524.

NaQonal IntervenQon to Prevent Spread of CRE in Israel PACH

•  ProspecQve cohort intervenQonal study •  13 Israeli PACHs, MulQfaceted intervenQon 2008 – 2011

1)  Periodic on-‐site assessment of IC policies & resources (16 pt score)

2)  Assessment of CRE risk factors 3)  NaQonal guidelines for CRE control in PACHs, acQve

surveillance & CP for CRE carriers 4)  Cross-‐secQonal rectal carriage surveys

•  IC score ↑ from 6.8 – 14 (p<.001) •  Carriage ↓ from 12.1% to 7.9% (p=.008) •  Overall carrier prevalence ↓ from 16.8% to 12.5% (p=.013)

Ben-‐David D, et al. ICHE 2014;35(7):802-‐809.

Ben-‐David D, et al. ICHE 2014;35(7):802-‐809.

Daily CHG Bathing & SA PrevenQon

Viray MA, et al. ICHE 2014;35(3):243-‐250.

•  MICU & SICU; BJH 1250 beds, Qme-‐series methods •  CHG in SICU 20.68% ↓ MRSA acquisiQon (12.64 vs

10.03/1,000 pt days) β -‐2.62 (95 CI -‐5.19 to -‐0.04, p=.046)

•  No Δ in MICU (No CHG) (10.97 vs 11.3/1,000 pt days β -‐11.10 (95% CI -‐37.40 to 15.19, p=.40)

•  20.77% ↓ in all SA in SICU (2002-‐2007) 19.73/1,000 vs 15.63/1,000 pt days (95% CI -‐7.25 to 0.95, p=.012)

•  ICU-‐acquired MRSA ↓ by 41% in SICU (1.96 vs 1.15/1,000 pt days, p=.001)

•  Strengths: Qme-‐series methods, control unit, accounted for secular trends in colonizaQon pressure, pt mix

Figure 1. Unadjusted rates of methicillin-‐resistant Staphylococcus aureus (MRSA) acquisiQon per 1,000 paQent-‐days at risk for the intervenQon care unit.

Viray MA, et al. ICHE 2014;35(3):243-‐250. Apisarnthanarak A, et al. AJIC 2014;42:116-‐121.

•  ADV Source Control (CHG bathing & QID CHG oral care) & thorough Env cleaning for XDR A. baumanni, Thai MICU

•  3 phases; 12 mo base; CP, Act Surv, cohorQng XDR A. baumanni, BID Env detergent cleaning & ASP

•  P2: Bleach cleaning + ADV source control •  P3: 2 mo flood closure; same as P2 except no bleach

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Apisarnthanarak A, et al. AJIC 2014;42:116-‐121.

QUALITY IMPROVEMENT

Schmil S, et al. CID 2014;58 (1 Jan):22-‐28.

•  Methods: CMS Admin Data, 2008-‐2009, 11 infec:ons –  Cohorts with and without ID, propensity score matched, demographics, comorbidi:es, hospital type

–  Regression modes ID vs non-‐ID & early vs late ID consult •  Results: ID ↓readmissions OR 0.96 (95% CI .93 -‐ .99)

– ↓LOS 3.7% (95% CI -‐5.5% to -‐1.9%) –  ID – no difference in charges or payments –  Early ID consult had ↓ 30 day mortality, readmission, hospital & ICU LOS, & charges & payments than late ID consult

PosiQve Impact of ID Consults •  SAB: 9 matched prs – excess cost per life saved $18,000 •  Pts seen by ID longer course anQbioQcs (Lundberg) •  Mandatory ID consult for SAB ↑ use of echo (P<.04), detecQon

of BE (P<.04), adherence to EBM (P<.04) (Jenkins) •  2 Yr prospecQve study SAB 56% ↓ in 28 day mortality with ID

consult (P=.022) •  6 yr cohort study, ID ↓ mortality OR 0.6 (CI .4 – 1.0) •  600 SAB cases, ID ↓ 7 day, 30 day & 1 yr mortality (P<.0001)

(effecQve iniQal Rx)

Lundberg J, et al. Clin Perform Qual Health Care 1998;6:9-‐11. Honda H, et al. Am J Med 2010;123:631-‐7. Rieg S, et al. J InfecQon 2009;59:232-‐9. Robinson JO, et al. Eur J Clin Microbiol Infect Dis 2012;31:2421-‐8. Lahey T, et al. Medicine 2009;88:263. Jenkins TC, et al. Clin Infect Dis 2008;46:1000-‐8.

Lopez-‐Cortes LE, et al. CID 2013;57 (1 Nov):1225-‐33.

Impact of an Evidence-‐Based Bundle in the Quality Management and Outcome of SAB

•  SystemaQc review, quasi-‐exp intervenQon, 12 Spanish hospitals, 6 structured wrilen recommendaQons (EBM)

•  á Adherence to f/u blood Cx OR 2.83 (95% CI, 1.78 – 4.49)

•  á Early source control OR 4.56 (95% CI, 2.12 – 9.79)

•  á Early cloxacillin for MSSA OR 1.79 (95% CI, 1.15 – 2.78)

•  á Appropriate duraQon of Rx OR 2.13 (95% CI, 1.24 – 3.64)

•  â14 & 30 day mortality OR 0.47 (95% CI, 0.26 – 0.85) & 0.56 (95% CI, 0.34 – 0.93)

HAND HYGIENE & CONTACT PRECAUTIONS

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Accuracy of RFID Badge to Monitor HH

•  Comparison of direct observaQon with RFID data, 2 hospitals

•  1,554 HH events, accuracy high in simulaQon (88.5%), low in real life (52.4)%, p<0.01

•  Accuracy for detecQng HCW movement in & out of rooms (100%) simulaQon vs 54.3% in & 49.5% out in real life (p<0.01)

Pineles LL, et al. AJIC 2014;42(2):144-‐147.

Fig 2 RFID hand hygiene system accuracy in simulated validation phase versus real-life clinical practice.

Pineles LL, et al. AJIC 2014;42(2):144-‐147.

Fig 3 RFID badge detection system used in a hospital unit with fields detecting HCP in a pt room (blue) and when using a HH dispenser (yellow). Multiple sample HCPs are depicted with a badge in place...

Pineles LL, et al. AJIC 2014;42(2):144-‐147. Dhar S, et al. ICHE 2014;35(3):213-‐221.

Contact PrecauQons: More is Not Necessarily Beler

•  Prosp cohort, 2/2009 – 10/2009, 11 teaching hospitals •  Compliance HH before gowns/gloves 37.2%, gowns 74.3%,

gloves 80%, doffing gowns/gloves 80%, HH aper gloves 61% •  Compliance all components 28.9% •  ↑ burden of isolaQon (≤20% to >60%) ↓ HH compliance

(43.6% -‐ 4.9%) & all 5 components(31.5% -‐ 6.5%) •  MV analysis ↑ noncompliance all 5 bundle OR = 6.6 (95%

CI, 1.15 – 37.49) (p=.03) & HH before gloves •  OR = 10.1 (95% CI, 1.84 – 55.54) (p=.008) •  HH compliance ↓ by team leader vs alone (26.3% vs 38.7%,

p<.05)

ZOONOSIS •  43-‐yo Saudi man, 8 days fever,

rhinorrhea, cough, malaise, ↑ SOB •  Owned 9 camels; visited them daily

unQl 3 days before admission •  4 camels sick – rhinorrhea •  Pt applied nasal medicine to camel 7

days before his illness •  Pt’s nasal swabs + for MERS-‐CoV

upE, ORF1a, ORF1b on RT-‐PCR •  MERS CoV cultured from pt & camel,

idenQcal full genome sequencing •  Pt’s AB Qter ↑ from 0 to 1:280

Azhar EI, et al. NEJM 2014;370(26):2499-‐2505.

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•  EgypQan tomb bat (Taphozous perforatus) in Saudi Arabia, RNA

•  Cross-‐reacQng MERS-‐CoV anQbodies in dromedary camels in Oman, Canary Islands & Egypt

•  MERS Co-‐V RNA → RT-‐PCR, parQal genome sequencing of viral RNA in 3/4 nasal samples of 14 camels & 2 pts nasal swabs in Qatar

Haagmans BL, et al. Lancet Infect Dis 2014;14:140-‐5.

Memish ZA, et al. Emerg Infect Dis 2013;19:1819-‐23.

Evidence for Camel to Human MERS Transmission

Azhar EI, et al. NEJM 2014;370(26):2499-‐2505.

Bridget & Kuehn JAMA 2014;13 Aug. doi:10.1001/jama.2014.9916

OUTBREAKS

Hajj Pilgrimage & AcquisiQon, Spread of Respiratory InfecQons

•  >2 million parQcipate annually •  RetrospecQve cohort study 129 French

residents •  Pretravel nose & throat Cx, quesQonnaire 2013

& pre-‐return tesQng Flu A, Flu B, Flu C, Flu (H1N1), adenovirus, metapneumovirus, paraflu, RSV, rhinovirus, S. pneumo, N. meningiQdis, B. pertussis, & M. pneumoniae

•  21.5% pre & 38.8% post Hajj viruses+ (p=.003) •  1/3 acquired virus in Saudi Arabia (rhino 14%,

corona 12.4%, flu (H3N2) 6.2%) No MERS •  50% pre & 62% post Hajj acquired S. pneumo •  Flu vaccine & HH ↓ prevalence of resp

infecQons

Benkouiten S, et al. Emerg Infect Dis 2014;20(11); ahead of print hlp://dx.doi.org/10.3201/eid2011.140600.

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Transplant-‐Associated LCMV InfecQon •  LCMV – lymphocyQc choriomeningiQs virus endemic in

rodents (mice = fatal meningiQs, hamsters = asymptomaQc) •  Humans = mild-‐moderate flu-‐like illness or asepQc

meningiQs with few sequelae •  4 ill organ recipients in Iowa, donor 49yo ♂ unresponsive

post HA & vomiQng, ICH •  Tx recipients fever, abd pain, diarrhea, SOB, AMS •  LCMVC RT-‐PCR from blood & liver in 2 sickest pts & aorQc

Qssue from donor •  3/4 recipients got LCMVC IgM (not cornea recipient) •  Rx = ↓ immunosuppression with PO or IV ribavirin & IgG •  5 clusters reported post Tx

Hocevar SN, et al. Ann Intern Med 2014;160(4):213-‐220. Schafer IJ, et al. CDC MMWR 2014;63(Mar 21):249.

MulQstate Outbreak of Salmonella InfecQons Linked to Organic Sprouted Chia Powder

•  8/2014; 25 cases, Salmonella Newport (20), S. Har�ord (7), S. Oranienburg (4) from 16 states

•  3 hospitalized, no deaths, ages 1 – 81yrs, median 45, 65% female

•  Recall: Navitas Naturals & Omega Blend Sprouted Smoothie Mix & Williams-‐Sonoma Omega 3 Smoothie Mixer

•  Pulse Net – Pan sensiQve

hlp://www.cdc.gov/salmonella/newport-‐05-‐14/

hjp://www.cdc.gov/salmonella/newport-‐05-‐14/

Persons infected with the outbreak strains of Salmonella Newport, Harnord, or Oranienburg, by state*

hjp://www.cdc.gov/salmonella/newport-‐05-‐14/

MulQstate Outbreak of Salmonella Cotham & Kisarawe Linked to Pet Bearded Dragon

•  150 persons, 35 states since 2012, 57%, <5 yrs of age, 43% hospitalized, 8% resistant to cerriaxone

•  Don’t let children or immunosuppressed adults handle rep:les or amphibians

•  Don’t keep in day care, schools for kids <5 or those who act <5, don’t keep in kitchen

•  Don’t touch your mouth arer handling rep:les/amphibians •  Don’t let them loose in house, don’t bathe them in kitchen sink, bathroom sink or bathtub

hlp://www.cdc.gov/salmonella/cotham-‐04-‐14/

Outbreak of SM BSI in Pts with TPN from Compounding Pharmacy

•  19 pts with S marcescens, 9 died, alack rate 35%

•  Compounding pharmacy; filter sterilizing AA soluQon, using nonsterile AA due to naQonal shortage

•  Breaches in mixing, filtraQon & sterility tesQng

•  S marcescens from pharmacy H20 faucet, mixing container & AA powder, idenQcal to cases

Gupta N, et al. CID 2014;24 Apr [Epub ahead of print]. Gupta N, et al. CID 2014;24 Apr [Epub ahead of print].

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OTHER RANDOM THINGS

•  Phase IIIb-‐IV mulQcenter, RCT DB ; IIV3-‐HD (60 μg hemaggluQnin) vs std trivalent IIV3-‐SD (15 μg per strain) in pts ≥65 yrs, 2011-‐12 & 2012-‐13 N hemisphere season

•  31,989 pts, 126 centers, US & Canada •  ITT 228 (1.4%) IIV3-‐HD vs 301 (1.9%) IIVS-‐SD lab confirmed FLU

•  RelaQve efficacy 24.2% (95% CI, 9.7 – 36.5) •  HAI Qters & seroprotecQon rates ≥1:40 sig higher in IIV3-‐HD •  Serious AE 8.3% IIV3-‐HD vs 9.0% RR 0.92 (95% CI, 0.85 – 0.99)

Efficacy of High-‐Dose vs Std-‐Dose Influenza Vaccine in Older Adults

DiazGranados CA, et al. NEJM 2014;371(7):635-‐645.

Maltezou HC, et al. Clin Infect Dis 2013;57(11):1520-‐1526.

Impact of Postpartum Influenza Vaccine

•  3 hospitals 2012-‐2013, flu vaccine offered to moms & household members in Athens; moms contacted every 2 weeks re: fever, symptoms, HC use, anQbioQcs

•  553 moms, 573 babies •  Vaccine 841/1844 (45.6%) household contacts •  41.9% siblings → 49% moms vaccinated •  PP vaccine ↓ 37.7% ILI, ↓ 41.8% HC seeking,

↓ 45% AB •  MV analysis = mom vaccine vs siblings (NS)

Youngster I, et al. CID 2014;58(11):1515-‐1522.

•  Healthy vol donors, screened, frozen fecal suspension •  Relapsing CDI pts got frozen FMT by NG or colonoscopy,

20 pts, 10 each arm •  Median 4 relapses (range 2-‐16 prior to study) •  14 (70%) resolved p FMT (8/10 colonoscopy, 6/10 NG) •  5 retreated, 4 cured, overall cure 90% •  Daily stools ↓ from 7 (IQR 5-‐10) to 2 (IQR 1-‐2) •  Self-‐ranked health score ↑ 4 (IQR 2-‐6) to 8 (IQR 5-‐9)

Youngster I, et al. Clin Infect Dis 2014;58(11):1515-‐1522.

… no worries – just a few

more minutes

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¤ “Zero” infecQons guaranteed!

Kaier et al. Clin Microbiol Infect 2012;18:941

Kaier et al. Clin Microbiol Infect 2012;18:941

SystemaQc review BO-‐rates and

understaffing

directly influence

HAI-‐rate

No pa:ent = no harm

Hollis & Ahmed NEJM 2013;369:2474


¤  Approximately 80% of anQbioQcs in the United States are consumed in agriculture and aquaculture

¤ Non–pharmaceuQcal-‐grade anQbioQcs are typically priced at approximately $25 per kilogram


¤ 2005: FDA banned the use of fluoro-‐quinolones in poultry

¤ 2012: FDA issued nonbinding guidance to farmers recommending that they avoid using anQbioQcs as animal growth promoters (banned in Europe)

¤ Do the same?

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Bernieret al. AAC 2014;58:71-‐77

Weekly anQbioQc consumpQon per 1,000 inhabitants (solid) and flu-‐like syndrome incidence (dojed)

Bernier et al. AnQmicrob Agents Chemother 2014;58:71-‐77

The numbers of weekly anQbioQc prescripQons per 1,000 inhabitants during campaign periods decreased unQl winter 2006 to 2007 (30% [95% confidence interval {CI},36.3

to23.8%]; P<0.001) and then stabilized except for individuals>60 years of age


No explana:on

bejer understanding of an:bio:c use by senior outpa:ents is urgently

needed!


Maiwald & Chan J AnQmicrob Chemother 2014;69:2017 Maiwald & Chan J AnQmicrob Chemother 2014;69:2017

chlorhexidine

alcohol

Povidone-‐iodine

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Charehbili Surg Infect 2014;15:DOI: 10.1089/sur.2012.185

¤  Single center, non-‐randomized, non-‐blinded, retrospecQve study

¤  2010 and prior: 1% iodine in 70% alcohol

¤  2011 and aper a preparaQon of 0.5% chlorhexidine in 70% alcohol

¤  SSI according to naQonal surveillance definiQon

¤  Protocol for prevenQng SSI did not differ during the two years in which the study was conducted (?)

Charehbili Surg Infect 2014;15:DOI: 10.1089/sur.2012.185

Charehbili et al. Surg Infect 2014;15:DOI: 10.1089/sur.2012.185 Steed et al. Am J Infect Control 2014

Steed et al. Am J Infect Control 2014 Steed et al. Am J Infect Control 2014

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Steed et al. Am J Infect Control 2014

¤  Very effecQve in reducing the bacterial load, but …

¤  … 2 hours aper last applicaQon: what is the bacterial load in the next morning?

¤  … no informaQon about effect aper mulQple day use (load reducQon?, side effects?)

¤  … no informaQon on the percentage of HCWs that became MRSA-‐free

Bryce et al. J Hosp Infect 2014; doi: 10.1016/j.jhin.2014.06.017. [Epub ahead of print]

Leape NEJM 2014; 370:1063-‐64 Leape NEJM 2014; 370:1063-‐64

… only this one isn’t funny !

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Urbach et al. NEJM 2014; 370:1029-‐38

¤  InformaQon on the use of surgical safety checklists from 130 of 133 hospitals

¤  200,000 surgical procedures

¤  Inclusion of 3 months before the introducQon of a surgical checklist, and one starQng 3 months aper the introducQon of the checklist

Urbach et al. NEJM 2014; 370:1029-‐38

Urbach et al. NEJM 2014; 370:1029-‐38

¤  It is not the act of Qcking off a checklist that reduces complicaQons, but performance of the acQons it calls for

¤  Implement the behavioral change ² demonstrate the need for change, engage leadership, provide training

in teamwork, make HCW accountable

¤  Provide local teams with direcQon, coaching, training, data management, opportunity to learn from others

¤  “Gaming” ¤  Full implementaQon needs Qme

Leape NEJM 2014; 370:1063-‐64

“The likely reason for the failure of the surgical checklist in Ontario is that it was not actually used”

Start of a series in ARIC journal …

Willemsen et al (provisional PDF online, ARIC 2014

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A.  Local guidelines not available B.  Shortcomings in constraints C.  HAIs D.  Use of medical devices E.  Environmental contaminaQon F.  AnQmicrobial use G.  ESBL carriage

Willemsen et al (provisional PDF online, ARIC 2014 Willemsen et al (provisional PDF online) ARIC 2014

LongQn et al. Mayo Clin Proc 2014;89:291-‐299

Top Papers 2014

Health & Medicine

Transcript of Top Papers 2014