1. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
1
Video
from
ICPIC
2013
(available
on
YouTube)
InfecEon
control
talks
are
generally
rated
as
“therapeuEc”
for
HCWs
with
sleeping
disorders.
Disclaimer
As
a
non-­‐naEve
(Dutch/German)
English
speaker
some
of
the
things
I
say
may
sound
“harsher”
than
meant
to
…
hUp://www.slideshare.net/iPrevent/voss-­‐icaac-­‐online
hUp://actu.epfl.ch/news/slowing-­‐the-­‐aging-­‐process-­‐only-­‐with-­‐anEbioEcs/
Propionibacterium
Eur
Spine
J
2013
Apr
22(4):
689
+
690
+
697

2. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
2
Conclusions
The
addiEon
of
anEbioEcs
to
therapeuEc
regimens
for
uncomplicated
severe
acute
malnutriEon
was
associated
with
a
significant
improvement
in
recovery
and
mortality
rates.
Trehan
et
al.
N
Engl
J
Med
2013;368:5
Kluytmans
et
al.
CID
2013;56:478
¤ One
hundred
forty-­‐five
ESBL-­‐EC
isolates
from
retail
chicken
meat,
human
rectal
carriers,
and
blood
cultures
were
analyzed
using
mulElocus
sequence
typing,
phylotyping,
ESBL
genes,
plasmid
replicons,
virulence
genes,
amplified
fragment
length
polymorphism
(AFLP),
and
pulsed-­‐field
gel
electrophoresis
(PFGE).
RESULTS:
¤ Three
source
groups
overlapped
substanEally
when
their
geneEc
composiEon
was
compared.
¤ A
predicEon
model
based
on
the
combined
data
classified
40%
of
the
human
isolates
as
chicken
meat
isolates.
CONCLUSIONS:
¤ We
found
significant
geneEc
similariEes
among
ESBL-­‐EC
isolates
from
chicken
meat
and
humans
…
Chicken
meat
is
a
likely
contributor
to
the
recent
emergence
of
ESBL-­‐
EC
in
human
infecEons
in
the
study
region.
Kluytmans
et
al.
CID
2013;56:478
Kluytmans
et
al.
CID
2013;56:478
Kluytmans
et
al.
CID
2013;56:478
Kluytmans
et
al.
CID
2013;56:478
¤
Carbepeneames
in
the
food-­‐chain?

3. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
3
Collignon
P
et
al.
EID
Augustus
2013
Es9ma9on
based
on
dutch
data!
¤ EsEmate
for
NL
²
21
addiEonal
death,
²
908
hospital
bed-­‐days
¤ EsEmate
for
Europe
²
1,518
addiEonal
death,
²
67,236
hospital
bed-­‐days
¤ The
ongoing
use
of
3GC
in
mass
therapy
and
prophylaxis
should
be
urgently
examined
and
stopped,
parEcularly
in
poultry,
not
only
in
Europe,
but
worldwide!
Collignon
P
et
al.
EID
Augustus
2013
Ammerlaan
et
al.
CID
2012;54:1342
¤ Increased
nosocomial
BSI
rates
due
to
ARB
occur
in
addiEon
to
infecEons
caused
by
ASB,
increasing
the
total
burden
of
disease.
Ammerlaan
et
al.
CID
2012;54:1342
“… for to everyone who has, more shall be given,
and he will have an abundance’
hUp://www.slideshare.net/iPrevent/voss-­‐icaac-­‐online
¤ Whole
genome
mapping
creates
high-­‐resoluEon,
ordered
whole
genome
restricEon
maps
¤ Access
WGM
for
(LA-­‐)MRSA
Bosch
et
al
PLOSone
8(6):
e66493

4. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
4
¤ Whole
genome
mapping
produced
highly
reproducible
results
¤ Provided
a
much
higher
discriminatory
power
than
spa-­‐typing,
PFGE,
or
MLVA
¤ Whole
genome
mapping
can
provide
a
comparison
with
other
maps
Bosch
et
al
PLOSone
8(6):
e66493
¤ Samples
from
71
ambulances
from
34
different
Chicago-­‐area
municipaliEes
¤ At
least
one
S.
aureus
sample
was
found
in
69%
of
ambulances
tested
à
12%
MRSA.
James
V.
Rago
et
al.
Am
J
Infect
Control,
April
20122
Na9onal
MRSA
Rates
Run
Along
with
Fair
Play
of
Na9onal
Football
Teams:
A
Cross-­‐naEonal
Data
Analysis
of
the
European
Football
Championship,
2008
E.
Meyer
et
al.
InfecEon
2012
epublished
August
5
r
=
0.628
p
=
0.038
cards
/
100
min
MRSA
%
E.
Meyer
et
al.
InfecEon
2012
epublished
August
5
Copper a day -
Keeps MRSA away
Noyce
et
al.
J
Hosp
Infect
2006;63:289-­‐297
¤
Repeat
of
study
in
The
Netherlands
woud
not
be
possible
…

5. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
5
Edmond
&
Wenzel
New
Engl
J
Med
May
2013
Editorial:
Huang
et
al.
Targeted
versus
universal
decolonizaEon
to
prevent
ICU
infecEon.
N
Engl
J
Med
2013.
DOI:
10.1056/NEJMoa1207290.
¤ Ver9cal
infec9on-­‐preven9on
strategy.
² VerEcal
intervenEons
are
designed
to
reduce
colonizaEon
or
infecEon
due
to
a
specific
pathogen
by
detecEon
and
isolaEon
,
they
typically
have
high
resource
uElizaEon,
and
costs
² The
philosophical
underpinning
is
one
of
excepEonalism:
some
pathogens
are
more
important
than
others
and
merit
special
control
measures.
¤ Horizontal
strategy
² is
populaEon-­‐based,
is
applied
universally,
and
uses
intervenEons
effecEve
in
controlling
all
pathogens
transmiUed
by
means
of
the
same
mechanism.
² Includes
hand
hygiene,
chlorhexidine
bathing,
and
care
bundles,
and
they
oqen
require
modificaEon
of
the
behavior
of
HCWs
Edmond
&
Wenzel
New
Engl
J
Med
May
2013
O’Brien
AM
et
al.
(2012)
PLoS
ONE
7(1):e30092
Largest
sampling
of
raw
meat
products
for
MRSA
contaminaEon
to
date
in
the
U.S.
¤ 395
pork
samples
were
collected
from
a
total
of
36
stores
in
Iowa,
Minnesota,
and
New
Jersey.
¤ S.
aureus
was
isolated
from
256
samples
(64.8%)
S.aureus
MRSA
Conven9onal
67.3%
95%
CI
61.7%–72.6%
6.3%
95%
CI
3.9%—9.7%
An9bio9c-­‐free
56.8%
95%
CI
46.3%–67.0%
7.4%
95%
CI
3.0%–14.6%
convenEonal
alternaEve
convenEonal
O’Brien
AM
et
al.
(2012)
PLoS
ONE
7(1):e30092
van
Rijn
et
al.
PLoS
ONE
8(6):
e65594
¤ Regular
consumpEon
of
poultry
(OR
2.40;
95%
CI
1.08–5.33)
¤ CaUle
density
per
municipality
(OR
1.30;
95%
CI
1.00–1.70)
¤ Sharing
of
scuba
diving
equipment
(OR
2.93
5%
CI
1.19–7.21)
¤ CA-­‐MRSA
carriage
was
not
related
to
being
of
foreign
origin.
van
Rijn
et
al.
PLoS
ONE
8(6):
e65594

6. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
6
Top
Infec9on
Preven9on
Papers
2012
–
2013
Victoria
J.
Fraser,
MD
Adolphus
Busch
Professor
and
Chairman
of
Medicine
Washington
University
School
of
Medicine
St.
Louis,
Missouri
Disclosures
¤ Consultant:
BaUelle
¤ Research
Funding:
² CDC
Epicenters
Program
² NIH
K24
Mid
Career
Award
² NIH
CTSA
Research
&
EducaEon
Director
² NIH
KM1
CER
Career
Development
Program
² AHRQ
R24
CER
Infrastructure
Grant
² BJH
FoundaEon
¤ Husband
VP
@
Express
Scripts,
3
kids

7. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
7
Surveillance
and
Epidemiology
are
S9ll
Key
NNIS
à
NHSN
&
CLABSI
Surveillance:
BACKGROUND
&
METHODS
¤ #
ICUs
reporEng
á
from
144
(1990)
to
794
(2010)
¤ ICU
days
á
236,000
(1990)
to
11.4m
(2010)
¤ ProporEon
of
Large
teaching
hospitals
â
from
57%
(1990)
to
24%
(2010)
¤ 34%
(CI
31.3-­‐36.6%)
–
55%
(CI
53.4-­‐57%)
fewer
CLABSI
in
2009
vs
2001
¤ CriEcal
care
days
obtained,
CLABSI
rates
NNIS/NHSN,
applied
adjusted
CLABSI
rates
to
criEcal
care
days
¤ 3
scenarios:
1)
no
adjustment,
2)
NNIS
CLABSI
rates
2004-­‐2006
to
1990-­‐2004
(surveillance
arEfact),
3)
â
NNIS
rates
by
1/2
of
scenario
2:
Monte
Carlo
simulaEons,
adult
pts.
¤ Account
for
Δ
definiEons,
hospital
type,
Δ
to
NHSN
Wise
ME
et
al.
Infect
Control
Hosp
Epidemiol.
2013;34:547-­‐554
Na9onal
Es9mates
of
CLABSIs
in
Cri9cal
Care
Pa9ents
Wise
ME
et
al.
Infect
Control
Hosp
Epidemiol.
2013;34:547-­‐554
Figure
3.
Hospital-­‐onset
CLABSI
rates
(cases
per
1,000
ICU
pt
days
)
adjusted
for
CLABSI
definiEon
change,
surveillance
parEcipaEon
changes,
and
system
transiEon,
excluding
neonates,
U.S.,
1990–2010
Wise
ME
et
al.
Infect
Control
Hosp
Epidemiol.
2013;34:547-­‐554

8. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
8
Incidence
Trends
in
Pathogen-­‐Specific
CLABSI
in
U.S.
ICUs,
1990–2010
Fagan
RP
et
al.
Infect
Control
Hosp
Epidemiol.
2013;34:893-­‐899
¤ Methods
–
AcEve
ICU
surveillance,
CDC
NNIS
1990-­‐2004
&
NHSN
2006-­‐2010
¤ Results
² 60%
â
in
ICU
CLABSIs
over
the
past
decade
² Incidence
of
HO-­‐MRSA
BSI
â
11%/year
2005-­‐2008
² EsEmated
18,000
CLABSI/year
since
2006
² Since
2006
² S.
aureus
-­‐18.3%
(CI,
-­‐20.8
to
-­‐15.8%)
annual
â
² GNR
-­‐16.4%
(CI,
-­‐18
to
-­‐14.7%)
annual
â
² Enterococci
-­‐17.8%
(CI,
-­‐19
to
-­‐16.1%)
annual
â
² Candida
-­‐13.5%
(CI,
-­‐15.4
to
-­‐11.5%)
annual
â
² No
Δ
in
pediatric
ICU
for
S.
aureus
Risk
of
Acquiring
ESBL
Klebsiella
&
E.
coli
From
Prior
Room
Occupants
in
the
ICU
Ajao
AO
et
al.
Infect
Control
Hosp
Epidemiol.
2013;34:453-­‐458
¤ Methods
² MICU
–
SICU
pts
of
U
of
MD
9/2001
–
6/30/2009,
² Perianal
cultures
(LOTS)
¤ Results
² 267/7651
(3%)
pts
acquired
ESBL
GNR
in
ICU
² 32/267
(12%)
in
room
¯ˉ 𝑐
prior
ESBL⊕
pt
² Prior
room
not
significantly
associated
² AOR
1.39
(CI
0.94-­‐2.08)
² 6/32
(18%)
had
similar
PFGE
strain
to
prior
occupant
Ajao
AO
et
al.
Infect
Control
Hosp
Epidemiol.
2013;34:453-­‐458
Discon9nua9on
of
CP
for
MRSA:
A
RCT
Comparing
Passive
&
Ac9ve
Screening
With
Culture
&
PCR
Shenoy
ES
et
al.
Clin
Infect
Dis.
2013;57:176-­‐184
¤ RCT
@
MGH,
MRSA
prevalence
8%
(Hx
on
admission)
¤ No
rouEne
CHG
bathing
or
decolonizaEon
protocol
¤ Pts
MRSA
Hx
>
90
days;
12/2010
–
9/2011,
could
enroll
on
anEbioEcs
(but
not
D/C
CP);
admission
alert
ID
pts
¤ NonintervenEon
=
usual
care;
HO
orders
3
MRSA
nasal
Cx,
24
hrs
apart;
OFF
anEbioEcs,
1°
team
not
noEfied
of
enrollment
¤ IntervenEon
=
Cx
and
PCR
x3,
24
hrs
apart
(Cepheid)

9. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
9
Discon9nua9on
of
CP
for
MRSA:
A
RCT
Comparing
Passive
&
Ac9ve
Screening
With
Cx
&
PCR
Shenoy
ES
et
al.
Clin
Infect
Dis.
2013;57:176-­‐184
¤ 634
eligible;
457
included
(198
control,
259
intervenEon)
¤ 62/198
(31%)
controls
screened
(1/2
on
ICUs
acEve
screening);
259/259
(100%)
intervenEon
screened
¤ 19/198
(9.6%)
controls;
&
191/259
(73.7%)
intervenEon
completed
screening
¤ SensiEvity=
90.9%,
95.5%,
100%
(1st,
2nd,
3rd
swab)
¤ CP
stopped
4x
more
in
intervenEon
(CI,
2.3-­‐7.1)
¤ ~
½
off
anEbioEcs
at
screen;
~
both
arms
NS
Discon9nua9on
of
CP
for
MRSA:
A
RCT
Comparing
Passive
and
Ac9ve
Screening
With
Cx
and
PCR
Shenoy
ES
et
al.
Clin
Infect
Dis.
2013;57:176-­‐184
¤ First
PCR
vs
3
Cx
=
sensiEvity
93.9%
(95%
CI,
85.4-­‐97.6%),
specificity
92%
(95%
CI,
85.9-­‐95.6%),
PPV
86.1%
(95%
CI,
75.9-­‐93.1%)
and
NPV
96.6%
(95%
CI,
91.6-­‐99.1%)
¤ Passive
Cx,
AcEve
Cx,
PCR,
CP
D/C
rates
(6.6,
26.6
and
63.8%)
and
â
CP
days
104,
418
and
1841
¤
(55%
â
CP
days)
¤ Annualized
savings
$86,950,
$349,472,
$1,539,180
¤ No
difference
if
pts
on
anEbioEcs
So
Much
Pain
Over
So
Many
Regula9ons:
Has
it
Made
a
Meaningful
Difference?
Payment
&
Repor9ng
Policies
&
HAI
Impact
¤ 10/2008
CMS
eliminates
payment
for
HAC
(CVC
BSI
one
example)
¤ 1/2011
CMS
requires
all
hospitals
parEcipaEng
in
IPPS
to
report
CVC
BSI
to
CDC
NHSN
¤ 32
states
&
Washington
DC
mandate
CVC
BSI
reporEng
¤ Oregon
ICU
study;
external
validaEons
&
adjudicaEon
á
publicly
reported
rates
27%
¤ “ReacEve
measure”
–
measure
that
modifies
phenomenon
under
study
&
changes
thing
being
measured
¤ “Shame
&
financial
penalty”
incents
â
sensiEvity
¤ 2
studies
of
CMS
nonpayment
policy
found
NO
measurable
impact
on
CVC
BSI
or
other
HAI
rates
&
no
difference
in
CVC
BSIs
in
hospitals
in
voluntary
or
mandatory
reporEng
states
Krein
SL
et
al.
JGIM.
2012;27(7):773-­‐779.
Lee
GM
et
al.
NEJM.
2012;367(15):1428-­‐1437.
Dixon-­‐Woods
&
Perencevich
ICHE.
2013;34(6):555-­‐557.
Effect
of
Nonpayment
for
Preventable
Infec9ons
in
U.S.
Hospitals
¤ NHSN
Data
2006
–
2011,
CLABSI
and
CAUTI
vs
VAP
¤ Quasi-­‐exp,
interrupted
Eme
series,
398
hospitals
¤ â
secular
trends
for
CLABSI,
CAUTI
&
VAP
LONG
BEFORE
POLICY
IMPLEMENTED
¤ No
change
in
rates
post
vs
pre
CLABSI
(IRR
1,
p=.97),
CAUTI
(IRR
1.03,
p=0.08),
VAP
(IRR
0.99,
p
=
.52)
¤ No
difference
in
mandatory
reporEng
states,
or
by
volume,
size,
type
ownership,
teaching
hospital
Lee
GM
et
al.
NEJM.
2012;367:1428-­‐1437

10. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
10
Effect
of
Nonpayment
for
Preventable
Infec9ons
in
U.S.
Hospitals
Lee
GM
et
al.
NEJM.
2012;367:1428-­‐1437
Figure
1.
Incidence
Rates
of
Infec9ons
Reported
by
Hospital
Units
between
January
2006
and
March
2011.
The
dashed
line
in
all
three
panels
indicates
the
Eming
of
implementaEon
of
the
Centers
for
Medicare
and
Medicaid
Services
policy,
in
October
2008.
Effect
of
Nonpayment
for
Hospital-­‐Acquired,
Catheter-­‐Associated
Urinary
Tract
Infec9on
¤ Retro
Before-­‐
Aqer,
HCUP
inpt
data
from
MI;
2007
&
2009
¤ Non-­‐CAUTI
² 5.2
–
17.1%
(mean
10%,
CI
9.5
–
10.5%)
2007
² 5
–
20%
(mean
10.3%,
CI
9.8
–
10.9%)
2009
¤ CAUTI
² 0
–
1.1%
(mean
0.09%,
CI
0.06
–
0.12%)
2007
² 0
–
0.95%
(mean
0.14%,
CI
0.11
–
0.17%)
2009
¤ 2009,
2.6%
(CI
1.6
–
3.6%)
HA
UTIs
coded
as
CAUTI
¤ Nonpayment
for
CAUTI
only
â
payment
(0.003%)
HospitalizaEons
Meddings
JA
et
al.
Ann
Intern
Med.
2012;157:305-­‐312
Effect
of
Nonpayment
for
Hospital-­‐Acquired,
Catheter-­‐Associated
Urinary
Tract
Infec9on
Meddings
JA
et
al.
Ann
Intern
Med.
2012;157:305-­‐312
â
Rates
of
hospital-­‐acquired
non-­‐CAUTIs
and
CAUTIs
in
2009
and
change
in
rates
from
2007
to
2009.
A
hospital's
rate
of
diagnosis
was
calculated
as
the
percentage
of
each
hospital's
discharges
of
adults
with
the
indicated
diagnosis.
CAUTI
=
catheter-­‐associated
urinary
tract
infec9on.
Figure
Legend:
ON
MY
HANDS
hUp://www.slideshare.net/iPrevent/voss-­‐icaac-­‐online

11. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
11
Scheithauer
et
al.
BMC
InfecEous
Diseases
2013,
13:367
¤ 378
paEent
cases
were
evaluated
with
5674
opportuniEes
for
hand
rubs
(HR)
and
1664
HR
performed.
¤ Compliance
increased
from
21%
to
29%,
and
finally
45%
¤ IntervenEons
were
aimed
at
increasing
compliance
as
well
as
reducing
the
number
of
HR
needed
by
improving
workflow
prac9ces.
Scheithauer
et
al.
BMC
InfecEous
Diseases
2013,
13:367
For
individual
paEent
care,
the
number
of
HH
moments
significantly
decreased
from
22
to
13
for
non-­‐surgical
and
from
13
to
7
for
surgical
paEents
(both
p<0.001)
Scheithauer
et
al.
BMC
InfecEous
Diseases
2013,
13:367
¤
EvaluaEng
and
improving
the
workflow
is
an
important
(and
oqen
forgoUen)
intervenEon
to
improve
HH
compliance
in
our
“overloaded”
HCWs!
Kirkland
et
a.
BMJ
Qual
Saf
2012;21:1019–1026
¤ IntervenEons
² (1)
leadership/accountability;
(2)
measurement/
feedback;
(3)
hand
saniEser
availability;
(4)
educaEon/
training;
(5)
markeEng/communicaEon
¤ Results
² HH
compliance
increased
significantly
from
41%
to
87%
(p<0.01),
and
improved
further
to
91%
(p<0.01)
the
following
year.
² Nurses
achieved
higher
HH
compliance
(93%)
than
physicians
(78%).
² There
was
a
significant,
sustained
decline
in
the
HAI-­‐
rate
from
4.8
to
3.3
(p<0.01)
per
1000
inpaEent
days.
Kirkland
et
a.
BMJ
Qual
Saf
2012;21:1019–1026

12. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
12
Nothing
new,
but
s9ll
nice
to
see
that
HH
works
..
Kirkland
et
a.
BMJ
Qual
Saf
2012;21:1019–1026
Allegranzi
et
al.
Lancet
Infect
Dis
2013,
August
23rd
Works
gloabbly,
too..
¤ Overall
compliance
increased
from
51·∙0%
before
the
intervenEon
to
67·∙2%
aqer.
¤ Compliance
was
independently
associated
with
gross
naEonal
income
per
head,
with
a
greater
effect
of
the
intervenEon
in
low-­‐
income
and
middle-­‐income
countries
(OR
4·∙67).
Stone
et
al.
BMJ
2012;344:e3005
¤ InvesEgate
the
associaEon
between
infec9ons
and
procurement
¤ 187
acute
trusts
in
England
and
Wales
¤ Combined
procurement
of
soap
and
alcohol
hand
rub
tripled
from
21.8
to
59.8
mL
per
paEent
bed
day
¤ Rates
fell
for
MRSA
bacteraemia
(1.88
to
0.91
cases
per
10
000
bed
days)
and
C.
difficile
infecEon
(16.75
to
9.49
cases).
MSSA
bacteraemia
rates
did
not
fall.
Stone
et
al.
BMJ
2012;344:e3005
Aqer
roll-­‐out
increase
in
soap
>
alcohol
Stone
et
al.
BMJ
2012;344:e3005
¤ Increased
procurement
of
soap
was
independently
associated
with
reduced
C.
difficile
infecEon
¤ Increased
procurement
of
alcohol
hand
rub
was
independently
associated
with
reduced
MRSA
bacteraemia
(delayed
effect)
Stone
et
al.
BMJ
2012;344:e3005

13. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
13
¤ Q:
Why
is
the
overall
compliance
(for
both
groups)
decreasing
over
Eme?
¤ A:
² wearing
off
of
the
novelty
of
cleanyourhands
as
other
quality
iniEaEves
were
introduced
² performance
of
the
ward
co-­‐ordinators
had
not
been
monitored
and
no
retraining
offered
hUp://www.aricjournal.com/supplements/2/S1
¤
1600
stock-­‐photos
were
evaluated.
¤
Most
common
mistakes
were
with
regard
to
HCWs
white
coats
and
uniforms
¤
Of
the
photos
²
displaying
doctors
89%
were
incorrect
²
displaying
nurses
31%
were
incorrect
Spierings
et
al.
P141,
hUp://www.aricjournal.com/supplements/2/S1
Spierings
et
al.
P141,
hUp://www.aricjournal.com/supplements/2/S1
Conclusion
² The
results
seem
to
reflect
the
real
world
with
only
40%
of
stock
photos
displaying
correct
behavior
and
doctors
shown
as
being
worse
than
nurses.
² It
seems
that
the
stereotype
image
of
a
doctor
does
not
agree
with
the
current
hand
hygiene
guidelines.
² If
we
aim
for
higher
compliance
rates
with
IC
measures,
we
need
to
change
the
social
image
of
HCWs
John
A.
Bergh

14. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
14
¤
TV/adverEsing
is
expressly
directed
at
ge‚ng
us
to
do
something
that
is
in
the
best
interests
of
the
adverEser,
but
not
necessarily
our
own.
¤ Elementary
school
children
see
an
average
of
15
TV
food
ads
per
day
² 98%
of
these
ads
promote
products
high
in
fat
and
sugar).
¤ Children
exposed
to
food
ads
during
a
cartoon
ate
significantly
more
of
the
snack
food
in
front
of
them
(45%
more!)
We
need
ads
with
“correctly
behaving”
HCWs
on
TV
Makary
JAMA,
April
17,
2013—Vol
309,
No.
15
1591
Same
system
being
used
to
evaluate
OR
Eme-­‐out,
compliance
with
isolaEon
measures,
…
The
Wallstreet
Journal
12
December
2012
Gustafson
et
al.
Mayo
Clin
Proc
2000;75:705-­‐8
Sheldon
Cooper,
The
Big
Bang
Theory

15. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
15
BACKGROUND:
¤ Minimal
research
has
been
published
evaluaEng
the
effecEveness
of
hand
hygiene
delivery
systems
(ie,
rubs,
foams,
or
wipes)
at
removing
viruses
from
hands.
METHODS:
¤ Hands
of
30
volunteers
were
inoculated
with
H1N1
and
randomized
to
treatment
with
foam,
gel,
or
hand
wipe
applied
to
half
of
each
volunteer's
finger
pads.
RESULTS:
¤ Treatments
with
all
products
resulted
in
a
significant
reducEon
in
viral
Eters
(>3
logs)
at
their
respecEve
exposure
Emes
that
were
staEsEcally
comparable.
Larson
et
al.
Am
J
Infect
Control
2012;40:806
Cleanliness
is
Next
to
Godliness
Effect
of
Daily
Chlorhexidine
Bathing
on
Hospital-­‐Acquired
Infec9ons
Climo
MW
et
al.
NEJM.
2013;368:533-­‐42
¤ MulEcenter,
cluster-­‐randomized
nonblinded
crossover
trial
¤ Daily
bathing
CHG-­‐impregnated
washcloths
¤ 9
ICU’s
&
BMT’s
in
6
hospitals
(7,727
pts),
no-­‐rinse
2%
CHG
cloths
vs
non-­‐anEmicrobial
cloths
x
6
mos
¤ IR
of
MDRO
&
HA-­‐BSI
compared
Poisson
regression
¤ MDRO
acquisiEon
5.6/1000
pt
days
vs
6.6/1000
pt
days
(p
=
0.03);
23%
lower
CHG
¤ HA-­‐BSI
4.78/1000
pt
days
vs
6.60/1000
pt
days
(p
=
0.007);
28%
lower
CHG
Effect
of
Daily
CHG
Bathing
on
HAIs
Caveats
¤ Study
interrupted
by
recall
of
CHG
cloths
due
to
Burkholderia
cepacia
contaminaEon
¤ AcEve
surveillance
for
MRSA
&
VRE;
isolates
submiUed
for
CHG
resistance
¤ No
Δ
in
MRSA
acquisiEon
¤ â
rates
fungal
CA-­‐BSI
¤ Emergence
of
high
level
CHG
resistance
not
seen,
low
toxicity
Climo
MW
et
al.
NEJM.
2013;368:533-­‐42

16. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
16
Effect
of
Daily
CHG
Bathing
on
HAIs
Climo
MW
et
al.
NEJM.
2013;368:533-­‐42
Figure
2.
Rates
of
Primary
Bloodstream
Infec9ons
According
to
the
Type
of
Hospital
Unit.
Incidence
rates
of
hospital-­‐acquired
primary
bloodstream
infecEons
are
shown
among
units
using
daily
bathing
with
either
chlorhexidine-­‐
impregnated
washcloths
or
nonanEmicrobial
washcloths
(control).
BMT
denotes
bone
marrow
transplantaEon
unit,
MICU
medical
intensive
care
unit,
and
SICU
surgical
intensive
care
unit.
Effect
of
Hospital-­‐Wide
Chlorhexidine
Pa9ent
Bathing
on
Healthcare-­‐Associated
Infec9ons
¤ Hibiclens
4%
CHG
¤ Monitored
CLABSI,
CAUTI,
VAP,
VRE,
MRSA,
CDI
¤ “Horizontal”
infecEon
prevenEon
¤ Ease
of
use,
broad
spectrum,
prolonged
residual
effect
Rupp
ME
et
al.
ICHE.
2012;33(11):1094-­‐1100
Effect
of
Hospital-­‐Wide
Chlorhexidine
Pa9ent
Bathing
on
Healthcare-­‐Associated
Infec9ons
¤ Quasi-­‐experimental,
staged,
dose-­‐escalaEon
x19
mos
¯ˉ𝑐
4
mo
washout,
3
cohorts
(2008-­‐2010)
¤ Academic
center,
NE,
all
pts
except
infants/neonates
¤ CHG
basin
baths
3x/week
or
daily
¤ Adherence
ICU
(90%)
vs
(57.7%)
non-­‐ICU
p
=
<
.001
¤ C
diff
â
all
cohorts
0.71
(95%
CI,
0.57-­‐0.89;
p
=
.003)
3x/wk
&
.041
(95%
CI,
0.29-­‐0.59;
p
=
.001)
daily
CHG
¤ Washout
1.85
(95%
CI,
1.38-­‐2.53;
p
=
<
.001)
Rupp
ME
et
al.
ICHE.
2012;33(11):1094-­‐1100
Effect
of
Hospital-­‐Wide
Chlorhexidine
Pa9ent
Bathing
on
Healthcare-­‐Associated
Infec9ons
Rupp
ME
et
al.
ICHE.
2012;33(11):1094-­‐1100
Figure
1.
Effect
of
chlorhexidine
gluconate
(CHG)
bathing
on
Clostridium
difficile
infecEon.
Trends
in
incidence
of
C.
difficile
infecEon
are
shown
for
the
3
cohorts
of
paEents
over
the
course
of
the
study.
The
long-­‐dashed
line
depicts
the
3-­‐days-­‐per-­‐week
bathing
period.
The
solid
line
starEng
aqer
the
3-­‐days-­‐per-­‐week
bathing
period
in
each
cohort
depicts
the
every-­‐day
CHG
bathing
period.
The
short-­‐dashed
line
indicates
the
washout
period.
pt
d,
paEent-­‐days.

17. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
17
The
Efficacy
of
Daily
Bathing
with
Chlorhexidine
for
Reducing
HAI
BSIs:
A
Meta-­‐analysis
¤ Similar
efficacy
cloth
or
liquid
¤ Wipes:
OR=
0.41
[95%
CI,
0.25-­‐0.65],
¤ All
others:
OR=0.47
[95%
CI,
0.31-­‐0.69])
¤ Similar
sensiEvity
CLABSI
(OR
0.40
[95%
CI,
0.27-­‐0.59]),
¤ All
BSI
(OR
0.46
[95%
CI,
0.31-­‐0.69])
¤ Greatest
evidence
in
MICUs,
single
SICU
no
benefit,
no
benefit
GNR,
Heterogeneous
studies
O’Horo
JC
et
al.
ICHE.
2012;33(3):257-­‐267
O’Horo
JC
et
al.
Infect
Control
Hosp
Epidemiol.
2012;33(3):257-­‐267
Figure
3.
Risk
of
healthcare-­‐associated
bloodstream
infecEon
(BSI)
with
chlorhexidine
(CHG)
bathing
and
comparator,
using
paEent-­‐days
in
the
analysis.
“Events”
refers
to
the
study
end
point
of
central
line–associated
BSI
or
BSI,
as
defined
in
Table
1.
Studies
using
a
CHG-­‐impregnated
cloth
are
listed
in
the
lower
subgroup
(1.2.2);
all
other
studies
are
listed
on
top
(1.2.1).
CI,
confidence
interval;
M-­‐H,
Mantel-­‐Haenszel.
Scary
Hospital
Outbreaks
Hospital
Outbreak
of
MERS
Coronavirus
¤ WHO
reported
iniEal
2
cases
9/2012
MERS-­‐CoV
¤ Saudi
Arabia,
Qatar,
Jordan,
UK,
Germany,
France,
Tunisia
and
Italy
¤ Novel
lineage
C
–
MERS-­‐CoV
¤ 4/1/2013
–
5/23/13
=
23
confirmed
&
11
probable,
single
monophyleEc
clade
cases
in
the
eastern
province
of
Saudi
Arabia
Assiri
A
et
al.
NEJM.
2013;369:407-­‐16
Hospital
Outbreak
of
MERS
Coronavirus
¤ Median
age
56,
most
male
¤ Signs/symptoms:
fever
87%,
cough
89%,
vomiEng
or
diarrhea
35%
¤ Onset
² ICU:
median
5
days
(1
–
10
d)
² MV:
median
7
days
(3
–
11
d)
² Death:
median
11
days
(5
–
27
d)
Assiri
A
et
al.
NEJM.
2013;369:407-­‐16

18. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
18
Hospital
Outbreak
of
MERS
Coronavirus
¤ Survival
3/4
(75%)
acEve
surveillance
vs
3/19
(16%)
clinically
idenEfied
(p
=
0.04)
¤ IncubaEon
5.2
d
(95%
CI,
1.9
-­‐
14.7
d)
¤ Person-­‐to-­‐person
transmission
in
HD
units,
ICUs,
inpt
units
in
3
faciliEes,
21/23
cases,
5
family
members,
2
HCWs
¤ CP
&
droplet
precauEons,
surveillance
&
IC
criEcal
Assiri
A
et
al.
NEJM.
2013;369:407-­‐16
Hospital
Outbreak
of
Middle
East
Respiratory
Syndrome
Coronavirus
Assiri
A
et
al.
NEJM.
2013;369:407-­‐16
Figure
1
Epidemiologic
Plot
of
Confirmed
and
Probable
Cases
of
MERS-­‐CoV
InfecEon
in
Saudi
Arabia,
April
1–May
23,
2013.
All
confirmed
and
probable
cases
are
shown,
according
to
the
locaEon
of
the
most
probable
transmission.
One
of
the
five
family
contacts
(PaEent
M)
who
is
included
as
having
been
exposed
in
Hospital
A
was
also
exposed
through
caring
for
the
paEent
at
home
and
may
have
acquired
the
infecEon
either
in
the
hospital
or
in
the
community.
Hospital
Outbreak
of
Middle
East
Respiratory
Syndrome
Coronavirus
Assiri
A
et
al.
NEJM.
2013;369:407-­‐16
Figure
2
Transmission
Map
of
Outbreak
of
MERS-­‐CoV
InfecEon.
All
confirmed
cases
and
the
two
probable
cases
linked
to
transmission
events
are
shown.
PutaEve
transmissions
are
indicated,
as
well
as
the
date
of
onset
of
illness
and
the
se‚ngs.
The
leUers
within
the
symbols
are
the
paEent
idenEfiers
(see
Fig.
S2
in
the
Supplementary
Appendix).
Innova9ve
Interven9ons
to
Reduce
HAIs
Beyond
the
bundle
–
journey
of
a
ter9ary
care
MICU
to
zero
CLABSIs
¤ ObservaEonal
cohort,
25
bed
MICU,
1/2008
–
12/2011
¤ MulEdisciplinary
team;
bundle,
inserEon
checklist,
demonstraEon
of
competencies
for
line
maintenance
&
access,
daily
CL
necessity
checklist,
quality
rounds,
surveillance
&
feedback
¤ Molecular
epi,
environmental
Cx
&
cleaning,
â
VRE
contaminants
¤ CHG
bathing;
RCA
of
all
CLABSI
¤ IntervenEons
to
â
contaminants
needed
to
get
to
zero
Exline
MC
et
al.
CriEcal
Care.
2013;17:R41

19. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
19
Beyond
the
bundle
–
journey
of
a
ter9ary
care
MICU
to
zero
CLABSI
Exline
MC
et
al.
CriEcal
Care.
2013;17:R41
Figure
1.
Central
line-­‐associated
bloodstream
infecEons,
compliance
with
central
line
inserEon
and
dressing
maintenance
during
the
study
period.
NHSN,
NaEonal
Health
Safety
Network.
Targeted
versus
Universal
Decoloniza9on
to
Prevent
ICU
Infec9on
¤ PragmaEc
cluster
RCT:
1. MRSA
screening
&
isolate
MRSA
+
2. Targeted
decolonizaEon
(screening,
isolaEon
&
decolonizaEon
of
MRSA
carriers)
3. Universal
decolonizaEon
(no
screening,
decolonize
all)
¤ 43
hospitals,
74
ICUs,
74,256
pts
randomized
¤ (BIG,
Just
amazing
to
implement)
Huang
SS
et
al.
NEJM.
2013;368:2255-­‐2265
Targeted
versus
Universal
Decoloniza9on
to
Prevent
ICU
Infec9on
¤ 12
mo
baseline
1/1/09
–
12/31/09;
phase-­‐in
1/1/10
–
4/7/10,
18
mo
intervenEon
4/8/10
–
9/30/11
¤ Primary
outcomes:
ICU
aUributable
MRSA
⊕
Cx,
¤ 2°
outcome:
ICU
aUributable
MRSA
BSI
&
all
BSI
¤ Designed
80%
power
to
detect
40%
â
in
MRSA
BSI
rate
in
grp
2,
&
60%
â
grp
3;
ITT
Huang
SS
et
al.
NEJM.
2013;368:2255-­‐2265
Targeted
versus
Universal
Decoloniza9on
to
Prevent
ICU
Infec9on
¤ Grp
1:
<
1.0%
got
mupirocin
or
CHG
¤ Grp
2:
90.8%
(56-­‐100%)
MRSA
carriers
got
mupirocin
&
88.8%
(54-­‐98.4%)
got
CHG
¤ Grp
3:
86.1%
(41-­‐99.1%)
got
mupirocin
&
80.8%
(53.1-­‐98.6%)
got
CHG
(highest
baseline
BSI
rate,
BMT,
Tx)
¤ Grps
similar
@
baseline;
7
adverse
rash
events
Huang
SS
et
al.
NEJM.
2013;368:2255-­‐2265
Targeted
versus
Universal
Decoloniza9on
to
Prevent
ICU
Infec9on
Huang
SS
et
al.
NEJM.
2013;368:2255-­‐2265

20. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
20
Targeted
versus
Universal
Decoloniza9on
to
Prevent
ICU
Infec9on
¤ Universal
decolonizaEon
most
effecEve
â
MRSA
clinical
Cx
37%
&
all
BSI
44%
¤ Strengths:
sample
size,
diverse
se‚ngs,
usual
pracEce,
real
world
¤ Need
to
decolonize
181
pts
to
prevent
1
+
MRSA
Cx
&
decolonize
54
to
prevent
1
BSI
¤ Why
did
it
work
this
way?
¤ 1)
started
on
Day
1
no
delay,
2)
â
environmental
burden,
3)
â
skin
colonizaEon
Huang
SS
et
al.
NEJM.
2013;368:2255-­‐2265
hUp://www.slideshare.net/iPrevent/voss-­‐icaac-­‐online
Leverstein-­‐van
Hall
et
al.
Lancet
Infect
Dis
2011;10:830
Emerging
InfecEous
Diseases
•
www.cdc.gov/eid
•
Vol.
19,
No.
8,
August
2013
Emerging
InfecEous
Diseases
•
www.cdc.gov/eid
•
Vol.
19,
No.
8,
August
2013
Where
do
I
need
to
go
…

21. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
21
slide
from
Sunita
Paltansing
Central
A
&
Carabians:
25%
South
America:
6%
North
Afria:
40%
Middle
Afria:
30%
South
Afria:
12%
Middle
East:
13%
Central
Asia:
30%
South-­‐east
Asia:
34%
East
Asia
(China):
67%
South-­‐Asia
(India):
72%
Overall:
31%
ESBL+
aqer
travel
Emerging
InfecEous
Diseases
•
www.cdc.gov/eid
•
Vol.
19,
No.
8,
August
2013
¤
Although
26
parEcipants
had
posiEve
results
for
ESBL-­‐E
6
months
aqer
travel,
they
were
not
all
posiEve
for
the
same
enterobacterial
strain
that
was
idenEfied
immediately
aqer
travel.
²
15
of
26
(57%)
different
¤ What
does
that
mean
with
regard
to
isolaEon/
(de-­‐)flagging
of
paEents?
AE
Andersson,
et
al.
AJIC
2012,
Jan
28
epublished
¤
High
levels
of
CFU
correlated
with
total
traffic
flow
per
operaEon
and
the
number
of
persons
in
the
OR
¤
Traffic
flow,
number
of
persons
present,
&
procedure
duraEon
explained
68%
of
the
variance
in
total
CFU
AE
Andersson,
et
al.
AJIC
2012,
Jan
28
epublished
¤ 177
(33.5%)
=
necessary
²
40
=
expert
consultaEons
²
137
=
supplies
&
equipment
¤ 184
(35.7%)
=
semi-­‐necessary
²
76
=
surgical
team
members
entering
or
leaving
²
134
=
breaks
¤ 168
(31.8%)
=
unnecessary
²
30
=
logisEcs,
like
planning
other
operaEons
/
²
45
=
social
²
93
=
no
detectable
reason
AE
Andersson,
et
al.
AJIC
2012,
Jan
28
epublished

22. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
22
¤ 77
(13.8%)
=
necessary
²
40
=
expert
consultaEons
²
37
=
supplies
&
equipment
¤ 76
(13.6%)
=
semi-­‐necessary
²
76
=
surgical
team
members
entering
or
leaving
¤ 402
(72.4%)
=
unnecessary
²
134
break
,
100
supplies
&
equipment
²
30
=
logisEcs,
like
planning
other
operaEons
/
²
45
=
social
²
93
=
no
detectable
reason
AE
Andersson,
et
al.
AJIC
2012,
Jan
28
epublished
¤ OperaEng-­‐suit
aqer
4-­‐8h
the
worst
¤ No
clothing
–
(no)
shedding
Hill
et
al.
Lancet
,
November
9,
1974
“Naked
below
the
elbow”
really
works
Merollini
et
al.
AJIC
2013
in
press
Methods
¤ Baseline
use
of
anEbioEc
prophylaxis
(AP)
was
compared
with
no
anEbioEc
prophylaxis
(no
AP),
anEbioEc-­‐impregnated
cement
(AP
+
ABC),
and
laminar
air
operaEng
rooms
(AP
+
LOR).
¤ A
Markov
model
was
used
to
simulate
long-­‐term
health
and
cost
outcomes
of
a
hypotheEcal
cohort
of
30,000
total
hip
arthroplasty
paEents.
Merollini
et
al.
AJIC
2013
in
press
Conclusion
¤ PrevenEng
deep
SSI
with
anEbioEc
prophylaxis
and
anEbioEc-­‐impregnated
cement
has
shown
to
improve
health
outcomes
among
hospitalized
paEents,
save
lives,
and
enhance
resource
allocaEon.
¤ Based
on
this
evidence,
the
use
of
laminar
air
opera9ng
rooms
is
not
recommended.
Merollini
et
al.
AJIC
2013
in
press

23. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
23
Gastmeier
et
al.
.
J
Hosp
Infect
2012;81:73-­‐78
Conclusions:
It
would
be
a
waste
of
resources
to
establish
new
operaEng
rooms
with
LAF,
and
quesEonable
as
to
whether
LAF
systems
in
exisEng
operaEng
rooms
should
be
replaced
by
convenEonal
venElaEon
systems
Bischoff
et
al.
J
Infect
Dis
2013
Jan
30
Bischoff
et
al.
J
Infect
Dis
2013
Jan
30
¤
Subjects
with
influenza-­‐like
symptoms
¤
QuanEtaEve
impact
air
samples
¤
43%
of
subjects
emiUed
influenza-­‐virus
²
19%
super-­‐spreaders
(32x
more
than
others)
¤
Emission
>50%
of
human
infecEous
dose
at
1,
3,
and
6
feet
distance
C.
Makison
Booth
et
al.
J
Hosp
Infect
2013
Methods
A
dummy
test
head
aUached
to
a
breathing
simulator
was
used
to
test
the
performance
of
surgical
masks
against
a
viral
challenge.
…
C.
Makison
Booth
et
al.
J
Hosp
Infect
2013
Findings
Live
influenza
virus
was
measurable
from
the
air
behind
all
surgical
masks
tested.
A
surgical
mask
will
reduce
exposure
to
aerosolised
influenza
virus;
reducEons
ranged
from
1.1-­‐
to
55-­‐fold
(average
6-­‐fold),
depending
on
the
design
of
the
mask.
C.
Makison
Booth
et
al.
J
Hosp
Infect
2013

24. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
24
Conclusion
The
results
show
limitaEons
of
surgical
masks
in
this
context,
although
they
are
to
some
extent
protecEve.
C.
Makison
Booth
et
al.
J
Hosp
Infect
2013
Might
there
be
a
difference
if
the
mask
is
molded
or
not?
Gedik
et
al.
AnEmicrobial
Resistance
Infect
Control
2013;2:22
Bacterial
ContaminaEon
of
an
Automated
Pharmacy
Robot
Used
for
Intravenous
MedicaEon
PreparaEon
Cluck
et
al.
ICHE
2012;33:517-­‐520
no need for humans to cause outbreaks
3
isolates
from
the
robot
and
3/6
isolates
from
lidocaine
dispensed
by
the
robot
had
idenEcal
B.
cereus
isolates.
Cluck
et
al.
ICHE
2012;33:517-­‐520

25. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
25
TO
ERR
IS
HUMAN,
but
to
really
foul
things
up
you
need
a
robot
TO
ERR
IS
HUMAN,
to
blame
it
on
someone
else
shows
management
potenEal
Cluck
et
al.
ICHE
2012;33:517-­‐520
Policing
One-­‐track
mind
Guidelines
Guidelines
Guidelines
Guidelines
More
guidelines
IC
needs
to
be
to-­‐the-­‐point
hUp://www.slideshare.net/iPrevent/voss-­‐icaac-­‐online

26. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
26
¤ Clinical
MRSA
isolates
from
30/31
Orange
Co.,
CA
hospitals
² 10/08
–
4/10,
ER
excluded,
100/hospitals
or
12
mo,
+
up
to
20
blood
isolates/mo
¤ spa
type
t008
=
CA-­‐MRSA,
sample
got
MLST
&
PFGE
¤ 46%
isolated
spa
t008
(CA-­‐MRSA)
(range
14%-­‐81%),
next
most
common
t002
(15%),
t242
(21%)
¤ spa
t008
was
USA300
by
PFGE
¤ Of
CA-­‐MRSA,
66%
wounds,
14%
respiratory,
9%
other,
8%
blood,
3%
urine,
also
37%
of
HO-­‐MRSA
Murphy
CR
et
al.
ICHE.
2013;34:581-­‐587
Murphy
CR
et
al.
Infect
Control
Hosp
Epidemiol.
2013;34:581-­‐587
Figure
1.
Percentage
of
all
isolates
that
were
community-­‐associated
methicillin-­‐resistant
Staphylococcus
aureus
(CA-­‐MRSA;
gray)
and
percentage
of
isolates
that
were
CA-­‐MRSA
and
associated
with
hospital-­‐onset
infecEon
(black),
by
hospital.
Hospitals
that
collected
fewer
than
50
isolates
are
marked
with
a
star;
fewer
than
20
isolates
were
collected
from
hospitals
3,
4,
6,
7,
and
30.
¤ 6
PA
hospitals,
clinical
research
data
2007-­‐08
(MedMined/MediQual)
¤ ⊕
toxin
>
48
hrs
¯ˉ 𝑝
admit,
>
8
weeks
¯ˉ 𝑝 previous
⊕
¤ 1:3
matching
¯ˉ 𝑐
non-­‐cases,
HO-­‐CDI
had
higher
mortality
(11.8%
vs
7.3%,
p<.05),
longer
LOS
(median
interquarEle
range
12
days
(9-­‐21)
vs
11
days
(11.059-­‐38.429)
p<0.01),
higher
cost
(median
interquarEle
$20,804
($11,059-­‐
$38,429)
vs
$16,634
($9,413-­‐$30,319)
p<.01)
¤ AUributable
effect
HO-­‐CDI
4.5%
mortality
(95%
CI
0.2-­‐8.7%
p<.05),
2.3
days
(95%
CI
0.9-­‐3.8
p<.01),
$6,117
($1,659-­‐$10,574
p<.01)
Tabak
TP
et
al.
ICHE.
2013;34:588-­‐596
¤ NaEonal
burden
esEmates
based
on
2009
HO-­‐CDI
data
¤ 216,000
acute
care
discharges
¯ˉ 𝑐
CDI
(HO-­‐CDI
~
65%)
² 140,000
HO-­‐CDI
discharges
2009
(Epicenters)
¤ 300,000
á
hospital
days,
>
$850m
á
costs,
>
$6,000
deaths/year
¤ Strengths:
90%
matching
propensity
scores
¤ Limits:
retrospecEve,
generalizable,
toxin
tests
Tabak
TP
et
al.
ICHE.
2013;34:588-­‐596

27. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
27
Tabak
TP
et
al.
Infect
Control
Hosp
Epidemiol.
2013;34:588-­‐596
Figure
1.
A,
Mortality
rate
among
Clostridium
difficile
infecEon
(CDI)
cases
versus
noncases
before
and
aqer
matching.
B,
Mortality
or
postdischarge
care
rate
among
CDI
cases
versus
noncases
before
and
aqer
matching.
C,
Average
length
of
stay
among
CDI
cases
versus
noncases
before
and
aqer
matching.
D,
Cost
per
case
among
CDI
cases
versus
noncases
before
and
aqer
matching.
¤ Kyne:
Cost
$3,669,
LOS
3.6
days,
no
á
mortality
@
3
or
12
mo
(only
infected
pts,
HO-­‐CDI).
¤ CID
2002;34:346-­‐353.
¤ Dubberke:
Cost
$2,454-­‐$7,179/case
(LR
vs
propensity-­‐matched
prs)
at
end
of
admit
or
180
days,
LOS
2.8
days,
readmission
19.3%,
death
5.7%
(nonsurgical
pts,
all
CDI).
¤ ICHE
2009;30:57-­‐66,
Emerg
Infect
Dis
2008;14:1031-­‐1038,
¤ CID
2008;46:497-­‐504.
¤ O’Brien:
Cost
$13,675,
LOS
2.95
days
(MA
hosp
admin
data,
20
discharge
dx
only,
not
1°.
¤ ICHE
2007;28:1219-­‐1227.
¤ Miller:
Endemic
mortality
1-­‐2%,
epidemic
mortality
7-­‐17%.
¤ CID
2010;50:194-­‐201.
Tabak
TP
et
al.
ICHE.
2013;34:588-­‐596
Shepard
J
et
al.
JAMA
Surg.
doi:10.1001/jamasurg.2013.2246
¤ Methods
–
RetrospecEve,
4
JH
hospitals,
record
review
collect
APR-­‐DRG
by
ICP;
2007-­‐2010
¤ Results
² SSI
$7,493
vs
$7,924
(p=.99)
Cost
² 10.56
d
vs
5.64
d
(p<.001)
LOS
² 51.94
vs
8.19/100
(p<.001)
Readmissions
Shepard
J
et
al.
JAMA
Surg.
doi:10.1001/jamasurg.2013.2246
Shepard
J
et
al.
JAMA
Surg.
doi:10.1001/jamasurg.2013.2246

28. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
28
Shepard
J
et
al.
JAMA
Surg.
doi:10.1001/jamasurg.2013.2246
Shepard
J
et
al.
JAMA
Surg.
doi:10.1001/jamasurg.2013.2246
Figure
1.
Mean
Daily
Total
Charges
for
a
Pa9ent
vs
the
Length
of
Stay
for
the
Pa9ent
¤ JHH
Pilot
Study
20
pts
VRE
&
other
MDROs,
cultured
5
pairs
of
“sterile
supplies”
from
room
@
discharge;
&
H2O2
vapor
¤ 7/100
supplies
VRE⊕,
4/20
rooms
(20%),
H2O2,
none
H2O2
(p=.014)
¤ 9/100
supplies
MDRO⊕
,
6/20
rooms
(30%),
H2O2,
none
H2O2
(p=.003)
¤ 50%
recovered
organisms
DID
NOT
match
pt
isolate
¤ ~
Direct
annual
cost
discarded
supplies
$387,055
¤ Can
disinfect
supplies
in
rooms
undergoing
H2O2
vapor
disinfecEon
OUer
JA
et
al.
ICHE.
2013;34:472-­‐478
OUer
JA
et
al.
ICHE.
2013;34:472-­‐478
BeUer
Methods
to
Clean
&
Disinfect
the
Environment

29. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
29
¤ Metallic
Cu⧺
intrinsic
broad
spectrum
anEmicrobial
acEvity
¤ In
vitro
Cu⧺
surfaces
â
bacterial
concentraEons
7
logs
in
2
hrs
¤ MUSC,
MSKCC
&
Ralph
Johnson
VA
¤ 8
Cu⧺,
8
std
rooms,
650
admissions
6/2010
–
7/2011
¤ Cu
⧺
bed
rails,
overbed
tables,
IV
poles,
arm
chairs,
call
buUon,
mouse,
computer
palm
rest,
bezel
touch
screen
monitor
¤ Weekly
cultures
Salgado
CD
et
al.
Infect
Control
Hosp
Epidemiol.
2013;34:479-­‐486
¤ Bivariate
analysis:
á
APACHE
II
score
assoc
á
HAI
&
colonizaEon
(p=.011)
¤ Bivariate:
infecEon
on
admission;
HAI
16.6
vs
5.7
p=.
047
non-­‐Cu⧺
vs
Cu⧺
¤ MV
analysis:
APACHE
II
score
(p=.011)
and
Cu⧺
(p=.
027)
¤ Significant
associaEon
env
bioburden
&
HAI
¤ Bioburden
17%
vs
50%
(0.76
log
â
p<.0001)
Cu⧺
¤ Foot-­‐board
bioburden
similar
(2,786
vs
2,388
CFU/
100cm2)
No
Cu⧺
Salgado
CD
et
al.
ICHE.
2013;34:479-­‐486
¤ 53.4%
of
pts
in
Cu⧺
rooms
had
at
least
1
object
removed
(non-­‐study
bed)
¤ 13.4%
non
Cu⧺
rooms
exposed
to
Cu⧺
chair
¤ Caveats,
cleaning,
tarnishing,
impact
on
different
organisms,
environments,
cost
benefit
Salgado
CD
et
al.
ICHE.
2013;34:479-­‐486
Salgado
CD
et
al.
Infect
Control
Hosp
Epidemiol.
2013;34:479-­‐486
Salgado
CD
et
al.
Infect
Control
Hosp
Epidemiol.
2013;34:479-­‐486
Figure
2.
QuarEle
distribuEon
of
healthcare-­‐acquired
infecEons
(HAIs)
straEfied
by
microbial
burden
measured
in
the
intensive
care
unit
(ICU)
room
during
the
paEent’s
stay.
There
was
a
significant
associaEon
between
burden
and
HAI
risk
(
),
with
89%
of
HAIs
occurring
among
paEents
cared
for
in
a
room
with
a
burden
of
more
than
500
colony-­‐forming
units
(CFUs)/100
cm2.

30. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
30
Anderson
DJ
et
al.
ICHE
Epidemiol.
2013;34:466-­‐471
¤ Methods
² Env
cultures
for
VRE,
C.
diff,
Acinetobacter
before
and
aqer
UV
Rx
² 2
hospitals,
39
rooms
of
pts
colonized
¯ˉ 𝑐
VRE,
C.
diff,
Acinetobacter
(Tru-­‐D
SmartUVC;
Lumalier)
¤ Results
–
UV-­‐C
² Any
organism
(1.07
log10
â
p<.0001)
² Target
pathogen
(1.35
log10
â
p<.0001)
² VRE
(1.68
log10
â
p<.0001)
² C.
diff
(1.16
log10
â
p<.0001)
² Acinetobacter
(1.71
log10
â
p=.25)
Anderson
DJ
et
al.
ICHE.
2013;34:466-­‐471
Figure
1.
Change
in
proporEon
of
posiEve
plates
for
target
organisms
before
and
aqer
use
of
an
automated
ultraviolet-­‐C
emiUer.
Sitzlar
B
et
al.
ICHE.
2013;34:459-­‐465
¤ Methods
² 3
sequenEal
intervenEons
² Fluorescent
markers
to
monitor
&
feedback
on
cleaning
² Automated
UV
adjuncEve
disinfecEon
² Enhanced
disinfecEon,
dedicated
team,
supervision
&
clearance
² Cleveland
VA,
21
months
Sitzlar
B
et
al.
ICHE.
2013;34:459-­‐465
¤ Results
² Fluorescent
marker
improved
cleaning
thoroughness
(47-­‐81%,
p<.0001)
² ⊕
Cx
â
14%
(p=.024),
48%
(p<.001),
89%
(p=.006),
(intervenEons
1,
2
&
3)
² Baseline
67%
CDI
rooms
had
⊕ Cx
aqer
disinfecEon
vs
57%,
35%
&
7%
(intervenEons
1,
2
&
3)
² 35%
of
CDI
rooms
had
⊕ Cx
¯ˉ 𝑝
UV
treatment
² Daily
disinfecEon,
dedicated
team
(Clorox
Germicidal
Wipes)
&
cleaning/supervision
of
cleaning
ATP
bioluminescence
(CleanTrace;
3M)

31. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
31
Sitzlar
B
et
al.
Infect
Control
Hosp
Epidemiol.
2013;34:459-­‐465
Figure
1.
Effect
of
sequenEal
environmental
cleaning
and
disinfecEon
intervenEons
on
thoroughness
of
cleaning
(determined
on
the
basis
of
fluorescent
marker
removal)
and
on
disinfecEon
of
Clostridium
difficile
infecEon
(CDI)
rooms
(determined
on
the
basis
of
environmental
cultures
for
C.
difficile).
IntervenEon
1
(January
1,
2011,
through
February
28,
2012;
14
months)
involved
educaEon
in
combinaEon
with
monitoring
of
fluorescent
marker
removal
from
high-­‐touch
surfaces
with
feedback
to
housekeepers;
intervenEon
2
(March
1,
2012,
through
June
30,
2012;
4
months)
included
addiEon
of
an
automated
ultraviolet
radiaEon
device
for
disinfecEon
of
CDI
rooms;
intervenEon
3
(July
1,
2012,
through
September
30,
2012;
3
months)
included
enhanced
standard
cleaning
through
formaEon
of
a
3-­‐person
dedicated
daily
disinfecEon
team
for
high-­‐touch
surfaces
in
CDI
rooms
and
implementaEon
of
a
process
requiring
that
terminally
cleaned
CDI
rooms
be
“cleared”
for
the
next
paEent
by
environmental
services
supervisors
and/or
infecEon
control
staff.
Each
intervenEon
was
divided
into
3
Eme
periods,
which
are
indicated
by
separate
bars.
Sitzlar
B
et
al.
ICHE.
2013;34:459-­‐465
Figure
2.
Improvement
in
thoroughness
of
cleaning
of
high-­‐touch
surfaces
with
the
fluorescent
marker
intervenEon.
Abbo
LM
et
al.
Clin
Infect
Dis.
2013;57:631-­‐638
¤ Methods
–
Cross-­‐secEonal
mulEcenter
electronic
survey
of
4th
year
med
students’
knowledge,
a‚tudes
&
percepEons
re:
anEmicrobial
use
&
resistance,
quanEty
&
quality
of
educaEon
on
AB
Rx;
Miami,
JH,
U
WA
¤ Results
–
317/519
(60%)
responded;
57%
♀,
mean
age
27,
all
had
anEmicrobial
stewardship
programs
Abbo
LM
et
al.
Clin
Infect
Dis.
2013;57:631-­‐638
Medical
Students’
Percep9ons
and
Knowledge
About
An9microbial
Stewardship:
How
Are
We
Educa9ng
Our
Future
Prescribers?
¤ Differences
in
educaEonal
resources
used,
perceived
preparedness
&
knowledge
¤ 90%
wanted
more
knowledge
&
educaEon,
mean
correct
knowledge
51%,
only
15%
had
done
ID
¤ Those
who
did
ID
ranked
quality
of
AB
educaEon
higher
(3.93
vs
3.44,
p=.0003),
no
difference
in
knowledge
scores
¤ Only
1/3
reported
“adequate”
fundamental
knowledge
of
anEmicrobial
prescribing
Abbo
LM
et
al.
Clin
Infect
Dis.
2013;57:631-­‐638
“Everyone
Else
is
Worse
Than
Me/Us”
¤ Students
perceived
anEbioEc
overuse
more
naEonally
than
at
their
hospital
¤ Residents
&
Sr
MDs
agree
“other
doctors”
overprescribe
anEmicrobials
compared
to
“themselves”;
anEbioEcs
overused
“naEonally”
compared
to
“their
own
pracEce”
Arch
Intern
Med
2002;162:2210-­‐2216
Arch
Intern
Med
2004;164:1662-­‐1668
ICHE
2011;32:714-­‐718
ICHE
2006;27:1274-­‐1277

32. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
32
Abbo
LM
et
al.
Clin
Infect
Dis.
2013;57:631-­‐638
Abbo
LM
et
al.
Clin
Infect
Dis.
2013;57:631-­‐638
Abbo
LM
et
al.
Clin
Infect
Dis.
2013;57:631-­‐638
Abbo
LM
et
al.
Clin
Infect
Dis.
2013;57:631-­‐638

33. Top
papers
ICAAC
2013
September
13th,
2013
Fraser
&
Voss
33
Bacterial
Infec9on
as
a
Likely
Cause
of
Adverse
Reac9ons
to
Polyacrylamide
Hydrogel
Fillers
in
Cosme9c
Surgery
Christensen
L
et
al.
Clin
Infect
Dis.
2013;56:1438-­‐1444
¤ Widespread
and
á
use
of
gel
fillers
for
cosmeEcs
¤ á
long-­‐lasEng
adverse
reacEons
(FDA
reports
tripled
2008-­‐2011;
457
to
1309)
¤ Hyaluronic
acid
hydrogels,
longer-­‐lasEng
collagen,
RXN
rates
4.5%
-­‐
18.6%
¤ $22.5
billion
filler
market;
incidence
of
gel
injecEons
not
registered;
#
and
brands
of
gel
syringes
used
not
public
Bacterial
Infec9on
as
a
Likely
Cause
of
Adverse
Reac9ons
to
Polyacrylamide
Hydrogel
Fillers
in
Cosme9c
Surgery
Christensen
L
et
al.
Clin
Infect
Dis.
2013;56:1438-­‐1444
¤ RXNS
=
lumps,
nodules,
swelling
granulomas
¤ EEology
unclear;
Rx
=
anE-­‐inflammatory
agents,
steroids,
anEbioEcs
¤ MulEcenter
case-­‐control
study;
59
paEents,
28
controls,
biopsy
&
cytology,
Cx,
16S
rRNA,
Gram
stain,
FISH
Bacterial
Infec9on
as
a
Likely
Cause
of
Adverse
Reac9ons
to
Polyacrylamide
Hydrogel
Fillers
in
Cosme9c
Surgery
Christensen
L
et
al.
Clin
Infect
Dis.
2013;56:1438-­‐1444
¤ Bacteria
in
98%
cases,
(S
epi,
Propionibacterium)
up
to
5
years
aqer
injecEon,
none
in
controls
¤ Long-­‐term
infecEons
likely
due
to
biofilms
¤ Sterile
technique
and
adequate
skin
prep
mandatory
?
Explore
anEbioEc
prophylaxis
???
(Please
don’t)
Grade
2
(A
and
B)
and
grade
3
(C
and
D)
reac9ons
in
biopsies
from
lip
and
hand
9ssue
seen
ater
3
weeks
and
1
year,
respec9vely.
Christensen
L
et
al.
Clin
Infect
Dis.
2013;56:1438-­‐1444
©
The
Author
2013.
Published
by
Oxford
University
Press
on
behalf
of
the
InfecEous
Diseases
Society
of
America.
All
rights
reserved.
For
Permissions,
please
e-­‐mail:
journals.permissions@oup.com.
Three-­‐dimensional
confocal
laser
scanning
microscopy
(CSLM)
of
a
biopsy
from
a
grade
3
reac9on
following
gel
injec9on
into
the
cheek
2
years
previously.
Christensen
L
et
al.
Clin
Infect
Dis.
2013;56:1438-­‐1444
©
The
Author
2013.
Published
by
Oxford
University
Press
on
behalf
of
the
InfecEous
Diseases
Society
of
America.
All
rights
reserved.
For
Permissions,
please
e-­‐mail:
journals.permissions@oup.com.
¤ Acknowledgements:
¤ Andreas
Voss
for
pu‚ng
up
with
me
¤ Washington
University
ID
Faculty
&
Fellows
¤ BJC
&
BJH
InfecEon
PrevenEon
Specialists
¤ CDC,
AHRQ,
HHS,
CMS,
NIH
and
Industry
for
funding
these
great
studies
¤ The
InvesEgaEve
Teams
who
did
this
research