In routine ICU practice, universal decolonization was more effective than targeted decolonization or screening and isolation in reducing rates of MRSA clinical isolates and bloodstream infection from any pathogen. (Funded by the Agency for Healthcare Research and the Centers for Disease Control and Prevention; REDUCE MRSA ClinicalTrials.gov number, NCT00980980).

IMPORTANCE Previous studies suggested that a bundled intervention was associated with lower rates of Staphylococcus aureus surgical site infections (SSIs) among patients having cardiac or orthopedic operations.OBJECTIVE To evaluate whether the implementation of an evidence-based bundle is associated with a lower risk of S aureus SSIs in patients undergoing cardiac operations or hip or knee arthroplasties. DESIGN, SETTING, AND PARTICIPANTS Twenty hospitals in 9 US states participated in this pragmatic study; rates of SSIs were collected for a median of 39 months (range, 39-43) during the preintervention period (March 1, 2009, to intervention) and a median of 21 months (range, 14-22) during the intervention period (from intervention start through March 31, 2014).INTERVENTIONS Patients whose preoperative nares screens were positive for methicillin-resistant S aureus (MRSA) or methicillin-susceptible S aureus (MSSA) were asked to apply mupirocin intranasally twice daily for up to 5 days and to bathe daily with chlorhexidine-gluconate (CHG) for up to 5 days before their operations. MRSA carriers received vancomycin and cefazolin or cefuroxime for perioperative prophylaxis; all others received cefazolin or cefuroxime. Patients who were MRSA-negative and MSSA-negative bathed with CHG the night before and morning of their operations. Patients were treated as MRSA-positive if screening results were unknown. MAIN OUTCOMES AND MEASURESThe primary outcome was complex (deep incisional or organ space) S aureus SSIs. Monthly SSI counts were analyzed using Poisson regression analysis.RESULTS After a 3-month phase-in period, bundle adherence was 83% (39% full adherence; 44% partial adherence). Overall, 101 complex S aureus SSIs occurred after 28 218 operations during the preintervention period and 29 occurred after 14 316 operations during the intervention period (mean rate per 10 000 operations, 36 for preintervention period vs 21 for intervention period, difference, −15 [95% CI, −35 to −2]; rate ratio [RR], 0.58 [95% CI, 0.37 to 0.92]). The rates of complex S aureus SSIs decreased for hip or knee arthroplasties (difference per 10 000 operations, −17 [95% CI, −39 to 0]; RR, 0.48 [95% CI, 0.29 to 0.80]) and for cardiac operations (difference per 10 000 operations, −6 [95% CI, −48 to 8]; RR, 0.86 [95% CI, 0.47 to 1.57]). CONCLUSIONS AND RELEVANCEIn this multicenter study, a bundle comprising S aureus screening, decolonization, and targeted prophylaxis was associated with a modest, statistically significant decrease in complex S aureus SSIs.

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Contributors SSH contributed to study design, study conduct, data analysis, data interpretation and manuscript drafting. RP contributed to study design, study conduct, data interpretation, and manuscript review. KK contributed to study design, data analysis, data interpretation, analytic plan draft, and manuscript review. ES, JM, MH, and RAW contributed to study conduct, data interpretation, and manuscript review. JH, LH, and AG contributed to study conduct, data collection, and manuscript review. KH, LS, REK, JL, MHC, JAJ, and JBP contributed to study conduct and manuscript review. CS, TF, LP, and JS contributed to data collection and manuscript review. MVM contributed to data analysis and manuscript review. TRA contributed to data analysis, data interpretation, and manuscript review.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.Disclosures: Sage Products and Molnlycke contributed antiseptic Chlorhexidine product to this trial. Investigators are also conducting other studies in which contributed antiseptic product is provided to participating hospitals and nursing homes from Stryker (Sage

h Whether targeted or universal decolonization strategies for the control of methicillin-resistant Staphylococcus aureus (MRSA) select for resistance to decolonizing agents is unresolved. The REDUCE-MRSA trial (ClinicalTrials registration no. NCT00980980) provided an opportunity to investigate this question. REDUCE-MRSA was a 3-arm, cluster-randomized trial of either screening and isolation without decolonization, targeted decolonization with chlorhexidine and mupirocin, or universal decolonization without screening to prevent MRSA infection in intensive-care unit (ICU) patients. Isolates from the baseline and intervention periods were collected and tested for susceptibility to chlorhexidine gluconate (CHG) by microtiter dilution; mupirocin susceptibility was tested by Etest. The presence of the qacA or qacB gene was determined by PCR and DNA sequence analysis. A total of 3,173 isolates were analyzed; 2 were nonsusceptible to CHG (MICs, 8 g/ ml), and 5/814 (0.6%) carried qacA or qacB. At baseline, 7.1% of MRSA isolates expressed low-level mupirocin resistance, and 7.5% expressed high-level mupirocin resistance. In a mixed-effects generalized logistic regression model, the odds of mupirocin resistance among clinical MRSA isolates or MRSA isolates acquired in an ICU in intervention versus baseline periods did not differ across arms, although estimates were imprecise due to small numbers. Reduced susceptibility to chlorhexidine and carriage of qacA or qacB were rare among MRSA isolates in the REDUCE-MRSA trial. The odds of mupirocin resistance were no different in the intervention versus baseline periods across arms, but the confidence limits were broad, and the results should be interpreted with caution.

Methicillin-resistant Staphylococcus aureus (MRSA) infections pose a significant challenge to U.S. healthcare facilities, but there has been limited study of initiatives to reduce infection and increase patient safety in community hospitals. To address this need, a multifaceted program for MRSA infection prevention was developed for implementation in 159 acute care facilities. This program featured five distinct tools-active MRSA surveillance of high-risk patients, enhanced barrier precautions, compulsive hand hygiene, disinfection and cleaning, and executive champions and patient empowerment-and was implemented during 1Q-2Q 2007. Postintervention (3Q 2007-2Q 2008), 10.2% of patients with high-risk for infection or complications due to MRSA had nasal colonization. Volume of disposable gown and alcohol-based hand sanitizer use increased substantially following program implementation. Self-reported rates, based on NHSN definitions, of healthcare-associated central line-associated bloodstream infections and ventilator-associated pneumonia due to MRSA decreased 39% (p < .001) and 54% (p < .001), respectively. Infection rates continued to decrease during the follow-up period (1Q-4Q 2009). This sustained improvement demonstrates that reducing healthcare-associated MRSA infections in a large number of diverse facilities is possible and that a "bundled" approach that translates science into clinical and executive performance expectations may aid in overcoming traditional barriers to implementation.

Objectives: Administrative claims data are commonly used for sepsis surveillance, research, and quality improvement. However, variations in diagnosis, documentation, and coding practices for sepsis and organ dysfunction may confound efforts to estimate sepsis rates, compare outcomes, and perform risk adjustment. We evaluated hospital variation in the sensitivity of claims data relative to clinical data from electronic health records and its impact on outcome comparisons. Design, Setting, and Patients: Retrospective cohort study of 4.3 million adult encounters at 193 U.S. hospitals in 2013–2014. Interventions: None. Measurements and Main Results: Sepsis was defined using electronic health record–derived clinical indicators of presumed infection (blood culture draws and antibiotic administrations) and concurrent organ dysfunction (vasopressors, mechanical ventilation, doubling in creatinine, doubling in bilirubin to ≥ 2.0 mg/dL, decrease in platelets to < 100 cells/µL, or lactate ≥ 2.0 mmol/L). We compared claims for sepsis prevalence and mortality rates between both methods. All estimates were reliability adjusted to account for random variation using hierarchical logistic regression modeling. The sensitivity of hospitals’ claims data was low and variable: median 30% (range, 5–54%) for sepsis, 66% (range, 26–84%) for acute kidney injury, 39% (range, 16–60%) for thrombocytopenia, 36% (range, 29–44%) for hepatic injury, and 66% (range, 29–84%) for shock. Correlation between claims and clinical data was moderate for sepsis prevalence (Pearson coefficient, 0.64) and mortality (0.61). Among hospitals in the lowest sepsis mortality quartile by claims, 46% shifted to higher mortality quartiles using clinical data. Using implicit sepsis criteria based on infection and organ dysfunction codes also yielded major differences versus clinical data. Conclusions: Variation in the accuracy of claims data for identifying sepsis and organ dysfunction limits their use for comparing hospitals’ sepsis rates and outcomes. Using objective clinical data may facilitate more meaningful hospital comparisons.

Background. Challenges exist in implementing evidence-based strategies, reaching high compliance, and achieving desired outcomes. The rapid adoption of a publicly available toolkit featuring routine universal decolonization of intensive care unit (ICU) patients may affect catheter-related bloodstream infections.Methods. Implementation of universal decolonization-treatment of all ICU patients with chlorhexidine bathing and nasal mupirocin-used a prerelease version of a publicly available toolkit. Implementation in 136 adult ICUs in 95 acute care hospitals across the United States was supported by planning and deployment tactics coordinated by a central infection prevention team using toolkit resources, along with coaching calls and engagement of key stakeholders. Operational and process measures derived from a common electronic health record system provided real-time feedback about performance. Healthcare-associated central line-associated bloodstream infections (CLABSIs), using National Healthcare Safety Network surveillance definitions and comparing the preimplementation period of January 2011 through December 2012 to the postimplementation period of July 2013 through February 2014, were assessed via a Poisson generalized linear mixed model regression for CLABSI events.Results. Implementation of universal decolonization was completed within 6 months. The estimated rate of CLABSI decreased by 23.5% (95% confidence interval, 9.8%-35.1%; P = .001). There was no evidence of a trend over time in either the pre-or postimplementation period. Adjusting for seasonality and number of beds did not materially affect these results.Conclusions. Dissemination of universal decolonization of ICU patients was accomplished quickly in a large community health system and was associated with declines in CLABSI consistent with published clinical trial findings.