Top papers in infection prevention and control 2014, as presented by Vicky Fraser and Andreas Voss at ICAAC, Washington, DC

1. 07-­‐09-­‐14
1
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

2. 07-­‐09-­‐14
2
¤ 3.6-­‐year
study
using
WGS-­‐typing
to
study
the
epidemiology
of
CDAD
in
Oxfordshire,
UK
Only
38%
and
54%
of
geneQcally
linked
cases
shared
ward-­‐based
and
hospital-­‐wide
contacts
Eyre
et
al.
NEJM
2013;369:1105-­‐205
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
Data
from
German
naQonal
nosocomial
surveillance
system
(KISS)
Gastmeier
et
al.
JAC
2014;6:1660
Gastmeier
et
al.
JAC
2014;6:1660
BSI
UTI
SSI

3. 07-­‐09-­‐14
3
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
Gastmeier
et
al.
JAC
2014;6:1660
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
MRSA
CC
008
Den
Heijer
et
al.
Lancet
Infect
Dis
2013;13:409-­‐15
Den
Heijer
et
al.
Lancet
Infect
Dis
2013;13:409-­‐15
CC
011
CC
011

4. 07-­‐09-­‐14
4
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)
Jurke
et
al.
Euro
Surveill.
2013;18(36):pii=20579
Jurke
et
al.
Euro
Surveill.
2013;18(36):pii=20579
¤ 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.
Jurke
et
al.
Euro
Surveill.
2013;18(36):pii=20579
¤ 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

5. 07-­‐09-­‐14
5
Fätkenheuer
et
al
Lancet
2014,
published
online
Aug
21st
Fätkenheuer
et
al
Lancet
2014,
published
online
Aug
21st
…
okay,
but
what
did
we
do
in
the
NL
–
screen
&
isolate
and
20%
HH
compliance
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”
Sarah
Zhang
Nature
doi:10.1038/nature.2013.13752
Casey
et
al.
JAMA
2013;
September
16th
(published
online)

6. 07-­‐09-­‐14
6
¤ Proximity
to
swine
manure
applicaQon,
to
crop
fileds,
and
livestock
operaQons
each
was
associated
with
MRSA
and
skin
and
sop-­‐Qssue
infecQon
Could
it
be
that
occupaQonal
hazards
¤ No
MRSA
belonging
to
CC398
(LA-­‐&
lifestyle
are
more
important
MRSA)
than
!?
us?
Casey
et
al.
JAMA
2013;
September
16th
(published
online)
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)
Hetem
et
al.
Emerging
Infect
Dis
2013;19:1797
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

7. 07-­‐09-­‐14
7
creeps … .. back to
Rossi
et
al.
NEJM
2014,370:1524
IN THE MRSA EPIDEMIOLOGY
Hearing CA-MRSA
USA300 & vanco-resistance
in one
strain gives me the
science …
Palerned
Progression
of
Bacterial
PopulaQons
in
the
Premature
Infant
Gut
• 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
La
Rosa
PS,
et
al.
PNAS
Early
EdiQon
2014;
[Epub
ahead
of
print].
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.

8. 07-­‐09-­‐14
8
MulQstate
Point-­‐Prevalence
Survey
of
Health
Care-­‐Associated
InfecQons
12.1%
10.7%
9.3%
9.9%
Organisms
C
diff
S.
aureus
Klebsiella
E.
coli
Magill
SS,
et
al.
N
Engl
J
Med
2014;370:1198-­‐208.
MulQstate
Point-­‐Prevalence
Survey
of
Health
Care-­‐Associated
InfecQons
Different
paQents,
methods,
definiQons
Magill
SS,
et
al.
N
Engl
J
Med
2014;370:1198-­‐208.
MulQstate
Point-­‐Prevalence
Survey
of
Health
Care-­‐Associated
InfecQons
Magill
SS,
et
al.
N
Engl
J
Med
2014;370:1198-­‐208.
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.
ReporQng
SSI
Following
THA
&
TKA
Yokoe
DS,
et
al.
CID
2013;57
(1
Nov):1282-­‐88.

9. 07-­‐09-­‐14
9
• 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.
QuanQfying
Sources
of
Bias
in
NHSN
Haley
VB,
et
al.
ICHE
2014;35(1):1-­‐7.
CDI
Rates
QuanQfying
Sources
of
Bias
in
NHSN
CDI
Rates
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.
• 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
Rohde
JM,
et
al.
JAMA
2014;311(13):1317-­‐26.
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

10. 07-­‐09-­‐14
10
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.
• 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
Nguyen
DB,
et
al.
CID
2013;57(10):1393-­‐1400.
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
• 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
Brennan
BM,
et
al.
ICHE
2014;35(4):342-­‐349.
State
Surveillance
of
CRE
in
Michigan
Brennan
BM,
et
al.
ICHE
2014;35(4):342-­‐349.

11. 07-­‐09-­‐14
11
• 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.
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
Thaden
JT,
et
al.
ICHE
2014;35(8):978-­‐983.
Rising
Rates
of
CRE
in
Community
Hospitals
Thaden
JT,
et
al.
ICHE
2014;35(8):978-­‐983.
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.
Schwaber
MJ
and
Carmeli
Y.
Clin
Infect
Dis
2014;58(5):697-­‐703.

12. 07-­‐09-­‐14
12
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.
Wastewater
Treatment
Plants
Release
Large
Amounts
of
ESBL
E.
coli
into
Environment
• Weekly
samples
x10
wks
from
11
sites,
waste
H2O
network
of
Bréchet
C,
et
al.
CID
2014;58(12):1658-­‐65.
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
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
Kothari
A,
et
al.
CID
2014;59(2):272-­‐278.
⊕
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.

13. 07-­‐09-­‐14
13
Huang
AM,
et
al.
CID
2013;57
(1
Nov):1237-­‐45.
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
Kothari
A,
et
al.
Clin
Infect
Dis
2014;59(2):272-­‐278
… where is
my coffee…
… jawn …
¤
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
Thom
et
al.
Infect
Control
Hosp
Epidemiol
2014;35:1060-­‐62
Thom
et
al.
Infect
Control
Hosp
Epidemiol
2014;35:1060-­‐62

14. 07-­‐09-­‐14
14
¤
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
Thom
et
al.
Infect
Control
Hosp
Epidemiol
2014;35:1060-­‐62
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
¤
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
Freeman
et
al.
AnQmicrobial
Resistance
and
InfecQon
Control
2014,
3:5
Kramer
et
al.
BMC
Infect
Dis
2006;6:130

15. 07-­‐09-­‐14
15
E.
coli
1.5h
to
6
months
Klebsiella
spp.
2.0h
to
>30
months
Kramer
et
al.
BMC
Infect
Dis
2006;6:130
Kampf
et
al.
BMC
Infect
Dis
2014;14:37
¤ Reusable
Qssue
dispensers
with
different
surface
disinfectants
were
randomly
collected
from
healthcare
…
it
faciliis
not
Qes.
about
the
details
of
this
66
dispensers
paper,
but
the
point
¤ “helpful
containing
parts
of
the
disinfectant
that
even
environment”
soluQons
with
surface-­‐may
acbe
Qve
a
source
ingredients
for
infecQwere
ons
collected
in
15
healthcare
faciliQes.
28
dispensers
from
nine
healthcare
faciliQes
were
contaminated
¤ In
none
of
the
hospitals
dispenser
processing
had
been
adequately
performed
Kampf
et
al.
BMC
Infect
Dis
2014;14:37
¤
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

16. 07-­‐09-­‐14
16
¤ 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
By
country
By
type
of
currency
Angelakis
et
al.
Future
Microbiol
2014;9:249
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

17. 07-­‐09-­‐14
17
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?
…
but
the
snow
wasn’t
yellow
…
Kellog
et
al.
Am
J
Infect
Control
2012;40:893
Mermel
LA.
Clin
Infect
2013;56:123-­‐130
Mermel
LA.
Clin
Infect
2013;56:123-­‐130
Mermel
LA.
Clin
Infect
2013;56:123-­‐130

18. 07-­‐09-­‐14
18
hlp://haicontroversies.blogspot.nl
Not
of
the
same
quality,
but
…
… finally
INTERVENTIONS
• 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
Meeker
D,
et
al.
JAMA
Intern
Med
2014;174(3):425-­‐431.

19. 07-­‐09-­‐14
19
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
• 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=.
Viray
MA,
et
al.
ICHE
2014;35(3):243-­‐250.
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.
• 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
Apisarnthanarak
A,
et
al.
AJIC
2014;42:116-­‐121.

20. 07-­‐09-­‐14
20
Apisarnthanarak
A,
et
al.
AJIC
2014;42:116-­‐121.
QUALITY
IMPROVEMENT
• 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
Schmil
S,
et
al.
CID
2014;58
(1
Jan):22-­‐28.
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.
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)
Lopez-­‐Cortes
LE,
et
al.
CID
2013;57
(1
Nov):1225-­‐33.
• 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)
• â14
&
30
day
mortality
OR
0.47
(95%
CI,
0.26
–
0.85)
&
0.56
(95%
CI,
0.34
–
0.93)
HAND
HYGIENE
&
CONTACT
PRECAUTIONS

21. 07-­‐09-­‐14
21
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.
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)
Dhar
S,
et
al.
ICHE
2014;35(3):213-­‐221.
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.

22. 07-­‐09-­‐14
22
Evidence
for
Camel
to
Human
MERS
Transmission
• 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.
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.

23. 07-­‐09-­‐14
23
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.
HarŒord
(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*
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].

24. 07-­‐09-­‐14
24
OTHER
RANDOM
THINGS
Efficacy
of
High-­‐Dose
vs
Std-­‐Dose
Influenza
Vaccine
in
Older
Adults
• 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)
DiazGranados
CA,
et
al.
NEJM
2014;371(7):635-­‐645.
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)
Maltezou
HC,
et
al.
Clin
Infect
Dis
2013;57(11):1520-­‐1526.
• 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.
CID
2014;58(11):1515-­‐1522.
Youngster
I,
et
al.
Clin
Infect
Dis
2014;58(11):1515-­‐1522.
… no worries
– just a few
more minutes

25. 07-­‐09-­‐14
25
¤ “Zero”
infecQons
guaranteed!
Kaier
et
al.
Clin
Microbiol
Infect
2012;18:941
SystemaQc
review
BO-­‐rates
and
understaffing
directly
influence
HAI-­‐rate
Kaier
et
al.
Clin
Microbiol
Infect
2012;18:941
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
Hollis
&
Ahmed
NEJM
2013;369:2474
¤ 2005:
FDA
banned
the
use
of
fluoro-­‐
quinolones
in
poultry
¤ 2012:
FDA
issued
Hollis
&
Ahmed
NEJM
2013;369:2474
nonbinding
guidance
to
farmers
recommending
that
they
avoid
using
anQbioQcs
as
animal
growth
promoters
(banned
in
Europe)
¤ Do
the
same?

26. 07-­‐09-­‐14
26
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
Bernier
et
al.
AnQmicrob
Agents
Chemother
2014;58:71-­‐77
No
explana:on
bejer
understanding
of
an:bio:c
use
by
senior
outpa:ents
is
urgently
needed!
Bernier
et
al.
AnQmicrob
Agents
Chemother
2014;58:71-­‐77
chlorhexidine
alcohol
Povidone-­‐iodine
Maiwald
&
Chan
J
AnQmicrob
Chemother
2014;69:2017
Maiwald
&
Chan
J
AnQmicrob
Chemother
2014;69:2017

27. 07-­‐09-­‐14
27
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

28. 07-­‐09-­‐14
28
¤
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
Steed
et
al.
Am
J
Infect
Control
2014
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
!

29. 07-­‐09-­‐14
29
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
“The
likely
reason
for
the
failure
of
the
surgical
checklist
in
Ontario
is
that
it
was
not
actually
used”
¤ 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
Start
of
a
series
in
ARIC
journal
…
Willemsen
et
al
(provisional
PDF
online,
ARIC
2014

30. 07-­‐09-­‐14
30
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