Best Papers in Infection Control

2012-2013
Eli Perencevich, MD MS
Professor of Medicine
University of Iowa, Carver College of Medicine
June 28, 2013
Facts about Iowa City
Original capital of Iowa
Lumositys Smartest Cities 2013
Ranked 478 metro areas
Facts about Iowa City
Original capital of Iowa
Lumositys Smartest Cities 2013
Ranked 478 metro areas
Iowa City 4
th
smartest city
Boston-Cambridge #49
Facts about Iowa City
Original capital of Iowa
Population: 153,000 (metro)
Lumositys Smartest Cities 2013
Ranked 478 metro areas
Iowa City ranked 4
th
smartest
Boston-Cambridge #49
Why?
People From Iowa City
People From Iowa City
People From Iowa City
Topics
Clostridium difficile
MRSA
Surgical Site Infections (SSI)
CLABSI
Universal gloving or contact precautions
Hand Hygiene
MERS-CoV

Andreas Widmer: GNR, VRE, VAP, UTI,
Environmental Cleaning, Chlorhexidine, H7N9
http://haicontroversies.blogspot.com
Topics
Clostridium difficile
MRSA
Surgical Site Infections (SSI)
CLABSI
Universal gloving or contact precautions
Hand Hygiene
MERS-CoV

Fecal Transplants
Duodenal Infusion of Donor Feces for
Recurrent Clostridium difficile
Open-label randomized trial, single center
Population: >18yo, relapsed C. difficile and one
prior course 10 days vanco or metronidazole,
positive stool for toxin
Treatment arms:
Vancomycin PO for 14 days
Vanco PO 14 days + 4L bowel lavage at day 4-5
Vanco PO x 4-5 days, bowel lavage, infusion of
donor feces through a ND tube
Reference: Els van Nood et al. NEJM 2013l 368:407-415 (Jan 31 2013)
Duodenal Infusion of Donor Feces for
Recurrent Clostridium difficile
Reference: Els van
Nood et al. NEJM
2013l 368:407-415
(Jan 31 2013)
13
15
4
3
Reference: Johnston BC et al. Ann Intern Med 2012;157:878-888
Cochrane Review: May 31, 2013
Probiotics and CDAD
Meta-analysis, 1945-2012: 20 RCTs

3818 patients (1974 treated, 1844 controls)

Outcome: positive toxin (A or B) assay

Adverse events lower in treated group:
RR 0.82 (0.65-1.05)
Reference: Johnston BC et al. Ann Intern Med 2012;157:878-888
Cochrane Review: May 31, 2013
Reference: Johnston BC et al. Ann Intern Med 2012;157:878-888
Reference: Johnston BC et al. Ann Intern Med 2012;157:878-888
RR = 0.34
(0.24-0.49)
Reference: Kwok CS et al. Am J Gastroenterol 2012;107:1011-1019
Risk of Clostridium difficile Infection (CDI) With Acid
Suppressing Drugs and Antibiotics: Meta-Analysis
Risk of CDI in proton-pump inhibitor users
versus control or H2-blockers
42 studies (30 case-control, 12 cohort)
313,000 patients
Risk of CDI, OR=1.74 (1.47-2.85) 39 studies
Recurrent CDI, OR=2.51 (1.16-5.44)
H2 blockers protective vs PPI, OR=0.71 (0.53-0.97)
Reference: Kwok CS et al. Am J Gastroenterol 2012;107:1011-1019
PPI+Antibiotics: Number Needed to Harm
Reference: Kwok CS et al. Am J Gastroenterol 2012;107:1011-1019
Patient on antibiotic
28
Switch PPI to H2RA: Number Needed to Prevent CDI
Reference: Kwok CS et al. Am J Gastroenterol 2012;107:1011-1019
PPI to H2 Blocker
69
Should proton pump inhibitors be
added to antimicrobial
stewardship programs as a
restricted drug requiring
infectious disease approval?
Topics
Clostridium difficile
MRSA (VRSA)
Surgical Site Infections (SSI)
CLABSI
Universal gloving or contact precautions
Hand Hygiene
MERS-CoV

MRSA Nasal Carriage in Residents of
Veterans Affairs LTCF
Prospective cohort over 6 months
Three VA long-term care facilities
Nares swab 3 times in 1
st
month, then
monthly
MRSA prevalence = 58%
20% persistant
39% intermittent
41% non-carriers
10% acquired during the 6-month study
Reference: Stone ND et al. Infect Control Hosp Epidemiol. 2012;33(6):551-557
Burden of MRSA
Prior studies excess length of stay (LOS): 3-25 days
Limited by time-dependent bias
Multistate modeling is a potential solution

2009 HUG-wide burden using 4 cohorts:
MRSA-infected patients (C1)
MRSA-free patients (C2)
Sample of non-MRSA matched to MRSA in 2:1 ratio by
age, gender, diagnosis code (C3)
MRSA colonized patients (C4)

Reference: Macedo-Vias M. et al. (Harbarth) J Hosp Infect 2013 Jun;84(2):132-7.
Burden of MRSA infections at a Swiss
University hospital
Reference: Macedo-Vias M. et al. (Harbarth) J Hosp Infect 2013 Jun;84(2):132-7.
Burden of MRSA infections at a Swiss
University hospital
Reference: Macedo-Vias M. et al. (Harbarth) J Hosp Infect 2013 Jun;84(2):132-7.
11.5 days
Impact of Extranasal Testing for MRSA
Legislative mandates require nasal screening
Question: What is the incremental benefit of
extranasal screening?
Methods: Systematic Review
1966 to January 2012
4381 abstracts and 735 articles reviewed
23 included (~39,000 patients)
Reference: McKinnell JA, et al. Infect Control Hosp Epidemiol , 34 (2) (Feb 2013): 161-170
Impact of Extranasal Testing for MRSA
Yield increased (versus nares alone)
33% on ICU admission
37% on hospital admission (high prevalence, >6%)
50% on hospital admission (low prevalence, <6%)
Individual sites vs. nares alone
Oropharynx +21%; Rectum +20%
Wounds +17%; Axilla +7%.
Reference: McKinnell JA, et al. Infect Control Hosp Epidemiol , 34 (2) (Feb 2013): 161-170
Reference: Fowler VG et al. JAMA 309;13: 1368-1378
Editorial: Malani PN. JAMA. 2013;309(13):1408-1409
Benefits of a novel (V710) vaccine targeting S. aureus
infection in cardiothoracic surgery.
8031 patients enrolled
3981: vaccine between 14 and 60 days pre-op
3982: saline placebo.
Primary outcome: S. aureus bacteremia or deep
surgical site infection, 90-days post-op

Data monitoring committee terminated study
Fowler et al.
Primary outcome (deep SSI, bacteremia)
2.6% of vaccinated patients
3.2% of controls, p=0.58.
More adverse events at 14 days in the vaccinated
group (31% vs 22% )

5.5 Times Higher S. aureus mortality in
vaccinated
21% vs 4.2%


Fowler et al.
Reference: Melo-Cristino et al. lancet (Published 21 June 2013)
European VRSA
The case was in a 74yo female in Portugal
Risks: Diabetes on dialysis
She had prior pseudomonal and MRSA foot ulcer rx vanco
May 2013: VRSA detected in pus from a toe amputation
wound
Vancomycin of >256 g/mL and
Teicoplanin MIC of 24g/mL
ST105, SCCmec type II, +mecA and vanA genes (from her VRE).
Resistant to erythromycin, clindamycin, gentamicin, and
ciprofloxacin
Susceptible to co-trimoxazole, tetracycline, tigecycline, linezolid,
daptomycin, quinupristin/dalfopristin, fusidic acid,
cloramphenicol, rifampicin, and mupirocin
Reference: Melo-Cristino et al. lancet (Published 21 June 2013)
Topics
Clostridium difficile
MRSA
Surgical Site Infections (SSI)
CLABSI
Universal gloving or contact precautions
Hand Hygiene
MERS-CoV
Reference: Schweizer M, et al. BMJ 2013;346:f2743 (Published 13 June 2013)
Effectiveness of Bundle Intervention
Assess SSI prevention interventions in
orthopedic and cardiac surgery
Meta-analysis 1995-2011
Included RCTs, QE studies and cohorts
1423 studies review, 39 included
17 nasal decolonization (16 mupirocin and 1 CHG)
15 glycopeptide prophylaxis
7 screening+ nasal decol + vancomycin
Reference: McKinnell JA, et al. Infect Control Hosp Epidemiol , 34 (2) (Feb 2013): 161-170
Bundle:
Screening+Decolonization+Vancomycin
(N=7)
Reference: Schweizer M, et al. BMJ 2013;346:f2743 (Published 13 June 2013)
Reference: Hawn MT et al. JAMA Surgery, March 20, 2013
Timing of Surgical Antibiotic Prophylaxis
and the Risk of Surgical Site Infection (SSI)
Timing is a mandated/reported metric
Aim: Timing impact on SSI
Retrospective cohort 112 VA Hospitals
32,459 non-cardiac cases 2005-2009
Reference: Hawn MT et al. JAMA Surgery, March 20, 2013
Timing of Prophylaxis and SSI
Median time between antibiotic and surgery:
28 minutes (IQR 17-39)

Timing was not significant in any model
Of 16 variables analyzed, timing ranked 15
th


Vancomycin OR 1.75 (1.16-2.65) in
orthopedics

Reference: Hawn MT et al. JAMA Surgery, March 20, 2013
Reference: Merollini KM et al. Am J Infect Control (e-published Feb 2013)
Reference: Merollini KM et al. Am J Infect Control (e-published Feb 2013)
Compared baseline antibiotic prophylaxis
Antibiotic impregnated cement
Laminar air flow operating rooms
Markov model comparing outcomes/costs
Key finding: Use of laminar air operating
rooms combined with routine antibiotic
prophylaxis added AUD $4.59 million cost
increase and 127 QALYs lost

SSI and Total Hips
Topics
Clostridium difficile
MRSA
Surgical Site Infections (SSI)
CLABSI
Universal gloving or contact precautions
Hand Hygiene
MERS-CoV

Counting Central Line Infections
Used Matching Michigan data
Program modeled on Michigan-Keystone
Explored how English hospitals collect/report
ICU-acquired central line infections rates
Used ethnographic methods involving direct
observations in ICUs, interviews with hospital
staff, and documentary analysis
Reference: Dixon-Woods M. Milbank Quarterly. Vol 90, Issue 3 (Sept 2012) 548-591
Counting Central Line Infections
All hospitals given standardized definitions based
on those used by the US CDC
High variability in how data gathered and
interpreted
Gaming played little role in variability
Causes of variability
Challenges in setting up data collection systems
Variable practice in sending blood samples for analysis
Issues deciding the source of infections clinical
judgment
Reference: Dixon-Woods M. Milbank Quarterly. Vol 90, Issue 3 (Sept 2012) 548-591
Unless hospitals are deploying the same
methods to generate the data, using their
reported rates to produce league tables or
impose financial sanctions is probably not
appropriate. Much more needs to be done to
ensure that reported infection rates are
credible, useful, fully integrated with clinical
priorities, and comparable
Mary Dixon-Woods
Estimated annual critical-care CLABSI in US
CMS data used to estimate critical care days
CLABSI rates in ICUs
1990-2004 (NNIS)
2006-2010 (NHSN)
95% confidence intervals using Monte Carlo
simulation
Reference: Wise ME et al, Infect Control Hosp Epidemiol 2013;34(6):547-554
Prevented 104,000 to 198,000 vs 1990 levels
Still 15,000 per year
75% in teaching hospitals, >200 Beds
Topics
Clostridium difficile
MRSA
Surgical Site Infections (SSI)
CLABSI
Universal gloving or contact precautions
Hand Hygiene
MERS-CoV

Exam gloves can keep hands clean if properly worn

Univ. of Iowa mandates gloves in RSV season (pediatrics)
Aim: Determine the impact of gloving on HAI.
Method: QE study with Poisson models (2002-2010)
5 peds units: PICU, NICU, BMT, Heme-Onc & Gen Ward

Universal gloving : 25% reduction in HAI rates, p=0.01
37% reduction in bloodstream infections (RR=0.63,
p<0.01)
39% reductions in CLABSI (RR=0.61, p<0.01)
Universal Gloving
Gloves in PICU, NICU and BMT
Reference: Yin J et al. Pediatrics 2013
RR=0.63

p=0.02
RR=0.62

p=0.04
RR=0.52

p=0.02
RR=1.36

p=0.19
RR=0.86

p=0.61
Topics
Clostridium difficile
MRSA
Surgical Site Infections (SSI)
CLABSI
Universal gloving or contact precautions
Hand Hygiene
MERS-CoV
Predictors of hand hygiene compliance
Predictors not evaluated since ABHR introduced

Monitored 7364 opportunities, 2 years in
Canadian teaching hospital

Level compliance at 45%

Compliance increased after body fluid exposure
(OR=4.7), patient contact (OR=3.9), and glove
use (OR=1.3)
Reference: Lebovic, G. et al. J Hosp Infect 2013 (83): 276-283
Workload not associated with compliance
No significant
association was
found between
compliance and
activity level
(p=0.13)
But compliance
rate very low
Reference: Lebovic, G. et al. J Hosp Infect 2013 (83): 276-283
Reference: Kirkland KB et al. BMJ Qual Saf 2012;21:1019-1026
Hand Hygiene (HH) and HAI
Recent data linking hand hygiene
improvements to lower HAI limited
Multifaceted HH intervention
Leadership at all levels emphasized HH
Measurement and feedback
Hand sanitizer availability
Education, training, marketing campaign
Reference: Kirkland KB et al. BMJ Qual Saf 2012;21:1019-1026
Outcomes and Process
Outcomes:
Hand hygiene compliance rates (before and after
patient or environmental contact)
HAI rates (2006 vs 2009) BSI, SSI, CDI, outpatient
Process:
Number of HH audits
Inventory of hand sanitizers consumed
Number of posters, internal articles
Number of visits by staff to report card website
Monthly Hand Hygiene Compliance
Hand Hygiene and 31% HAI Decline
Reference: Kirkland KB et al. BMJ Qual Saf 2012;21:1019-1026
Hand Hygiene Correlates with HAIs
Reference: Kirkland KB et al. BMJ Qual Saf 2012;21:1019-1026
Topics
Clostridium difficile
MRSA
Surgical Site Infections (SSI)
CLABSI
Universal gloving or contact precautions
Hand Hygiene
MERS-CoV
April 1 May 23: 23 cases (including 2 HCW)
Four hospitals
87% fever, cough, abnormal CXR
65% mortality, 5.2 day incubation, 91% P2P
Reference: Assiri et al. NEJM June 19, 2013
Last paper

Self-controlled risk-interval design
Time after exposure used to construct risk intervals
Required outcome and exposure in period to avoid
selection bias (vaccinated different)
Acted as own controls (confounding)
Risk of Guillain-Barre

Reference: Kwong JC et al. Lancet ID 2013 Published online June 28, 2013

Relative incidence of GBS after influenza vax was
52% higher during the initial 6 weeks (152; 95% CI
117199)
Relative incidence within 6 weeks of an influenza-
coded healthcare encounter was (1581; 95% CI
10282432)
MUCH greater after influenza infection vs. vaccine


Reference: Kwong JC et al. Lancet ID 2013 Published online June 28, 2013

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