BACKGROUND Results of previous single center observational studies suggest that daily bathing of patients with chlorhexidine may prevent hospital-acquired bloodstream infections (HABSIs) and acquisition of multidrug-resistant organisms (MDROs). METHODS We conducted a multicenter, cluster randomized, non-blinded crossover trial to evaluate the effect of daily bathing with chlorhexidine impregnated washcloths on the acquisition of MDROs and incidence of HABSIs. Nine intensive care and bone marrow transplant units in 6 hospitals were randomly assigned to bathe patients with either 2% no-rinse chlorhexidine-impregnated or non-antimicrobial washcloths for a six-month period, exchanged for the alternate product during the subsequent six months. The incidence rates of acquisition of MDRO and HABSI rates were compared between the two time periods by Poisson regression analysis. RESULTS A total of 7735 patients were enrolled during the study. The overall MDRO acquisition rate was 21% lower when chlorhexidine bathing was used (5.10 cases per 1000 patient days) than when non-antimicrobial washcloths were used (6.60 cases per 1000 patient days, p=0.028). The overall HABSI rate was 31% lower when chlorhexidine was used (4.45 cases per 1000 patient days) than when non-antimicrobial cloths were used (6.60 cases per 1000 patient days, p=0.007) No serious skin reactions were noted in either study period. CONCLUSIONS Daily bathing with chlorhexidine-impregnated washcloths significantly reduced the risk of acquiring MDROs and developing HABSI.

We conclude that daily chlorhexidine bathing among ICU patients may reduce the acquisition of MRSA and VRE. The approach is simple to implement and inexpensive and may be an important adjunctive intervention to barrier precautions to reduce acquisition of VRE and MRSA and the subsequent development of healthcare-associated BSI.

The transcriptomes of vancomycin intermediate-resistance Staphylococcus aureus (VISA) clinical isolates HIP5827 and Mu50 (MIC ‫؍‬ 8 g/ml) were compared to those of highly vancomycin-resistant S. aureus (VRSA; MIC ‫؍‬ 32 g/ml) passage derivatives by microarray. There were 35 genes with increased transcription and 16 genes with decreased transcription in common between the two VRSAs compared to those of their VISA parents. Of the 35 genes with increased transcription, 15 involved purine biosynthesis or transport, and the regulator (purR) of the major purine biosynthetic operon (purE-purD) was mutant. We hypothesize that increased energy (ATP) is required to generate the thicker cell walls that characterize resistant mutants.Vancomycin is the treatment of choice for serious infections caused by oxacillin-resistant Staphylococcus aureus, and some isolates are reported that are susceptible only to this antibiotic (8, 12). Oxacillin-resistant S. aureus isolates with reduced susceptibility to vancomycin (vancomycin intermediate-resistance S. aureus [VISA] isolates; the vancomycin MIC increases from 1 to 8 g/ml) have been recovered from patients receiving prolonged courses of vancomycin (1-3). A number of abnormalities have been noted among VISA isolates, including reduced rate of growth, decreased cell wall cross-linking (6, 16), increased cell wall thickness (4, 10), decreased autolysis (17), changes in penicillin binding proteins (6, 9, 15), and alterations in glutamate amidation of the peptidoglycan stem peptide (5). No unifying molecular hypothesis has been proposed that explains the VISA phenotype, but the current hypothesis is that the thickened, poorly cross-linked cell wall provides more peripheral targets for vancomycin, trapping the antibiotic before it can reach its site of lethal action at the cell membrane (17). It is also assumed that because of the long clinical vancomycin exposure times required to generate resistance, multiple genes and, probably, multiple metabolic pathways have been altered.We sought to assess genomic changes in gene transcription (the transcriptome) by DNA microarray and took a number of approaches different from those taken by others in trying to understand genomic changes associated with the VISA phenotype. First, we used clinical VISA isolates as parents rather than vancomycin-susceptible laboratory strains. There is evidence that there is something unique about VISA isolates that allows them to become resistant to vancomycin more easily than other S. aureus isolates (13). Second, we sought to amplify the phenotype by continued exposure of VISA isolates to vancomycin in vitro, further increasing the vancomycin MIC. We hypothesized that in this way, we would create isogenic strain sets that exaggerate the changes present in clinical VISA isolates. Third, we compared stable mutants of VISA strains for which vancomycin MICs were increased and we did not grow strains in the presence of the antibiotic, removing any direct effect of the antibiotic on transcription.Generation of mutant...

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Hospital formulary restriction of clindamycin is an effective way to decrease the number of infections due to C. difficile. It can also lead to a return in clindamycin susceptibility among isolates and can effect cost savings to the hospital.

"Prevalence of the use of central venous access devices within and outside of the intensive care unit: Results of a survey among hospitals in the prevention epicenter program of the Centers for Disease Control and Prevention." Infection Control and Hospital Epidemiology.24,12. 942-945. (2003).

Legislation aimed at controlling antimicrobial-resistant pathogens through the use of active surveillance cultures to screen hospitalized patients has been introduced in at least 2 US states. In response to the proposed legislation, the Society for Healthcare Epidemiology of America (SHEA) and the Association for Professionals in Infection Control and Epidemiology, Inc., (APIC) have developed this joint position statement. Both organizations are dedicated to combating health care-associated infections with a wide array of methods, including the use of active surveillance cultures in appropriate circumstances. This position statement reviews the proposed legislation and the rationale for use of active surveillance cultures, examines the scientific evidence supporting the use of this strategy, and discusses a number of unresolved issues surrounding legislation mandating use of active surveillance cultures. The following 5 consensus points are offered. (1) Although reducing the burden of antimicrobial-resistant pathogens, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), is of preeminent importance, the APIC and the SHEA do not support legislation to mandate use of active surveillance cultures to screen for MRSA, VRE, or other antimicrobial-resistant pathogens. (2) The SHEA and the APIC support the continued development, validation, and application of efficacious and cost-effective strategies for the prevention of infections caused by MRSA, VRE, and other antimicrobial-resistant and antimicrobial-susceptible pathogens. (3) The APIC and the SHEA welcome efforts by health care consumers, together with private, local, state, and federal policy makers, to focus attention on and formulate solutions for the growing problem of antimicrobial resistance and health care-associated infections. (4) The SHEA and the APIC support ongoing additional research to determine and optimize the appropriateness, utility, feasibility, and cost-effectiveness of using active surveillance cultures to screen both lower-risk and high-risk populations. (5) The APIC and the SHEA support stronger collaboration between state and local public health authorities and institutional infection prevention and control experts.

We conclude that the selective use of intranasal mupirocin and daily chlorhexidine bathing for patients colonized with MRSA reduced the incidence of MRSA colonization and infection and contributed to reductions identified by active-surveillance cultures. This finding suggests that additional strategies to reduce the incidence of MRSA infection and colonization--beyond expanded surveillance--may be needed.