Category Archives: Nosocomial Infections

What is the risk for transmitting infection by healthcare providers using a stethoscope as he or she moves from patient to patient?

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Bottom line:  Stethoscopes, mostly the earpieces, are a reservoir for bacteria, but there is no evidence directly addressing any association between use of stethoscopes on multiple patients and transmission of the bacteria found on the stethoscope

Halcomb E, et al. Role of MRSA reservoirs in the acute care setting. JBI Library of Systematic Reviews. 2008; 6(16): 633-685.
Identified one observational study of the eartips of stethoscopes dedicated to patients on contact precaution for MRSA.  13 of 78 (17%) eartips examined had potentially pathogenic bacteria on them, but none of the bacteria were the same as the infectious agents in the patients.

Other similar studies were identifed in a PubMed search.   Only the Brook (1997) paper below describes an actual infection (in a nurse) traced to an earpiece of a stethoscope.  The other studies show that most common organisms identified on stethoscopes (mostly earpieces) is S. aureas.

Gopinath KG, et al. Pagers and stethoscopes as vehicles of potential nosocomial pathogens in a tertiary care hospital in a developing country.  Trop Doct. 2011 Jan;41(1):43-5.  PMID: 21109607

Youngster I, et al. The stethoscope as a vector of infectious diseases in the paediatric division.  Acta Paediatr. 2008 Sep;97(9):1253-5.   PMID:18554272

Bernard L, et al.  Bacterial contamination of hospital physicians’ stethoscopes.  Infect Control Hosp Epidemiol. 1999 Sep;20(9):626-8.  PMID:10501265

Brook I.  Bacterial flora of stethoscopes’ earpieces and otitis externa.  Ann Otol Rhinol Laryngol. 1997 Sep;106(9):751-2.  PMID:9302906

Smith MA, et al.  Contaminated stethoscopes revisited.  Arch Intern Med. 1996 Jan 8;156(1):82-4.  PMID:8526701

Wright IM, et al.  Stethoscope contamination in the neonatal intensive care unit.  J Hosp Infect. 1995 Jan;29(1):65-8.  PMID:7738341

Search strategy:
Consulted and evidence summary source:  Searched Joanna Briggs Institute for “stethoscope and infection” – Identified a systematic review, which cited a paper on stethoscopes dedicated to MRSA-infected patients as as reservoirs.
Looked up that reference in PubMed and identified terms for a focused PubMed search:
(“Stethoscopes/microbiology”[MAJR] OR “Equipment contamination”[MAJR]) AND (nosocomial OR “hospital-acquired infection”)

Used QUOSA to identify articles from this set that discuss stethoscopes.

What are the latest recommendations for prevention of C. difficile?

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Dynamed references Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).  Infect Control & Hosp Epidemiology. 2010; 31(5): 421-455.
Recommendations for prevention of infection during a hospital outbreak include (definitions of ratings are in Table 1, p. 434):
•    Healthcare workers and visitors must use gloves (A-I) and gowns (B-III) on entry to a room of a patient with CDI.
•    Emphasize compliance with the practice of hand hygiene (A-II).
•    In a setting in which there is an outbreak or an increased CDI rate, instruct visitors and healthcare workers to wash hands with soap (or antimicrobial soap) and water after caring for or contacting patients with CDI (B-III).
•    Accommodate patients with CDI in a private room with contact precautions (B-III).   If single rooms are not available, cohort patients, providing a dedicated commode for each patient (C-III).
•    Maintain contact precautions for the duration of diarrhea (C-III).
•    Routine identification of asymptomatic carriers (patients or healthcare workers) for infection control purposesis not recommended (A-III) and treatment of such identified patients is not effective (B-I).
•    Identification and removal of environmental sources of C. difficile, including replacement of electronic rectal thermometers with disposables, can reduce the incidence of CDI (B-II).
•    Use chlorine-containing cleaning agents or other sporicidal agents to address environmental contamination in areas associated with increased rates of CDI (B-II).
•    Routine environmental screening for C. difficile is not recommended (C-III).

Reviewed JKN 4/14

What is the prevalence of C. difficile infection in hospitals in the United States?

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DynaMed references CDC report on prevalence of C. diff. diagnoses in hospital discharges
Emerg Infect Dis. 2006 Mar;12(3):409-15.
Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003.  McDonald LC, et al.
Study of annual rate of hospital discharges with listed diagnosis of C. difficile-associated diarrhea in National Hospital Discharge Survey.  31 per 100,000 population in 1996; increasing from 2000 to 2003 reaching 61 per 100,000 population in 2003

Emerg Infect Dis. 2008 Jun;14(6):929-31.
Increase in adult Clostridium difficile-related hospitalizations and case-fatality rate, United States, 2000-2005.  Zilberberg MD, et al.
Reports incidence of C. difficile diagnosis in hospital discharge.  Table displays incidence by age group

Reviewed JKN 4/14

What are the outcomes and care issues for patients undergoing intra-aortic balloon pump through the subclavian artery?

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PubMed
intra-aortic balloon pump AND (axillary OR axillo-subclavian OR subclavian)
Includes several papers describing results in small series of patients undergoing this procedure. Outcomes reported include survival to intended endpoint of the bridge, mortality, device-related infections, bleeding, etc.  You can add terms for specific outcomes and/or specific patient populations to the search to focus your results.

AACN Procedure Manual for Critical Care, 6th ed., provides details on the procedure, equipment, outcomes, etc. It references this case report/review, which is included in the PubMed search above.
Heart Lung Circ. 2006 Apr;15(2):148-50.
Intraaortic balloon pump insertion through the subclavian artery. Subclavian artery insertion of IABP.  Marcu CB, Donohue TJ, Ferneini A, Ghantous AE

Note: The AACN Manual is available in print at the EUH Branch Library.

SEARCH METHODS
The results above were achieved by a search of DynaMed, Joanna Briggs, AACN Procedure Manual for Critical Care, and PubMed using combinations of these concepts:
intra-aortic balloon pump
axillary OR axillo-subclavian OR subclavian
clinical trials
complications OR outcomes

Neither DynaMed nor Joanna Briggs JBI had specifics on this method of the intraaortic balloon pump.

Reviewed by John Nemeth 4/14

What are guidelines for prevention of healthcare associated infections in children?

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A search of CINAHL and PubMed for the concepts of healthcare associated children and pediatrics included the following studies on prevention of infections.

Sandora, Thomas Prevention of healthcare-associated infections in children: new strategies and success stories.
Current opinion in infectious diseases 2010 vol:23 iss:4 pg:300 -305

Rosenthal, Victor Central line-associated bloodstream infections in limited-resource countries: a review of the literature. Clinical infectious diseases 2009 vol:49 iss:12 pg:1899 -1907

McGoldrick, Mary Preventing central line-associated bloodstream infections and the Joint Commission’s Home Care National Patient Safety Goals. Home healthcare nurse 2009 vol:27 iss:4 pg:220 -8

Doshi, Rupali, Healthcare-associated Infections: epidemiology, prevention, and therapy.
The Mount Sinai journal of medicine, New York 2009 vol:76 iss:1 pg:84 -94

Rosenthal, Victor The International Nosocomial Infection Control Consortium (INICC): goals and objectives, description of surveillance methods, and operational activities. American journal of infection control 2008 vol:36 iss:9 pg:e1 -12

Zingg, Walter Central venous catheter-associated infections. Bailliere’s best practice & research. Clinical anaesthesiology 2008 vol:22 iss:3 pg:407 -421

Kanouff, Alan Prevention of nosocomial infections in the intensive care unit. Critical care nursing quarterly 2008 vol:31 iss:4 pg:302 -308

Kline, Andrea Pediatric catheter-related bloodstream infections: latest strategies to decrease risk. AACN clinical issues 2005 vol:16 iss:2 pg:185 -98

Chapman, Rachel Candida infections in the neonate. Current opinion in pediatrics 2003 vol:15 iss:1 pg:97 -102

Eggimann, P Overview of catheter-related infections with special emphasis on prevention based on educational programs. Clinical microbiology and infection 2002 vol:8 iss:5 pg:295 -309

Karlowsky, J A Candidemia in a Canadian tertiary care hospital from 1976 to 1996. Diagnostic microbiology and infectious disease 1997 vol:29 iss:1 pg:5 -9

What are guidelines for best practice with hemodialysis catheters?

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These guidelines were found in the National Guideline Clearinghouse. To read relevant sections, search the text for hemodialysis.

Mermel LA, et al. “Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America.” Clinical Infectious Diseases 49.1 (2009):1-45.

O’Grady NP, et al. “Guidelines for the prevention of intravascular catheter-related infections.” 2011.

Searches within PubMed located these CNE articles.

McAfee, Nancy, et al. “A continuous quality improvement project to decrease hemodialysis catheter infections in pediatric patients: use of a closed luer-lock access cap.” Nephrology Nursing Journal 37.5 (2010):541-4.

Dutka, Paula, and HelenBrickel. “A practical review of the kidney dialysis outcomes quality initiative (KDOQI) guidelines for hemodialysis catheters and their potential impact on patient care.” Nephrology Nursing Journal 37.5 (2010):531-5.

Dinwiddie, Lesley C, and CynthiaBhola. “Hemodialysis catheter care: current recommendations for nursing practice in North America.” Nephrology Nursing Journal 37.5 (2010):507-20, 528.

Reviewed and updated 5/6/2014 ldt

Can a MRSA bundle prevent healthcare-associated MRSA infections in the ICU?

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Bottom line:  Use of a bundle decreased infection rates of healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) at Veterans Affairs (VA) hospitals.

Summary: Jain R, et al. Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.  N Engl J Med. 2011 Apr 14;364(15):1419-30.

The study compared rates of healthcare-acquired MRSA infections at VA units before (October 2005 – March 2007) and after (October 2007 – June 2010) implementation of a care bundle that included universal nasal surveillance for MRSA, contact precautions for patients colonized or infected with MRSA, promotion of hand hygiene, and a change in the workplace culture that made infection control the responsibility of every staff member who had contact with patients. During the period there was a total of  8,318,675 patient days. Rates of MRSA infections in ICU units were reduced by 62% while the rates at units other than ICUs were reduced by 45% during the same period.

Huskins WC, et al. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med. 2011 Apr 14;364(15):1407-18.

This study of 18 ICU units looked at infection rates of MRSA and vancomycin-resistant enterococcus (VRE) in adult ICUs. Units were randomized to receive an intervention (n=10)  of increased surveillance and expanded barriers or to remain the same as a control (n=8). Intervention group patients were assigned to contact precautions based on history of MRSA or VRE in the past 12 months or results of nasal and perianal swabs. Patients in control units had swabs, but contact precautions were instituted based on hospital procedures and were blinded to the swab results. As Figure 3 summarizes, there was no significant difference in change of infection rates between the two groups. Authors concluded that the intervention was unable to reduce the transmission of MRSA and VRE. The surveillance cultures identified a significant subgroup of colonized patients who would not have been recognized otherwise, but the healthcare providers who participated in the study failed to use clean gowns and gloves and perform hand hygiene as often as was required by the intervention.

Two studies of antibiotic care bundles for MRSA in ICUs can be found here.

Reviewed and updated 4/11/2014 ldt