Countywide Variation in Infection Prevention Definitions and Policies for Hospital-Associated Multi-Drug Resistant Organisms (MDROs) and C. difficile

Background: Understanding differences in how hospitals define, report, and respond to hospital-associated MDROs is important for inter-facility comparisons. 

Objective: To conduct a countywide survey of hospitals in Orange County (OC), CA to assess MDRO and C. difficile burden for differences in definitions, practices, and policies.

Methods: We surveyed infection prevention programs at acute care hospitals in OC.  The survey consisted of 40 questions about infection control definitions and policies, and 18 data tables measuring the monthly burden of hospital-associated MDROs and C difficile for a recent 12-month period (2007-2008).

Results:   Of 32 acute care hospitals in OC, 27 (84%) completed survey question data and 19 (59%) completed data tables. Of the 27 hospitals, the median number of annual admissions was 8,778 (range, 108-33,001).  Six were long term acute care hospitals. 

Countywide, there were 3 common definitions of “hospital-associated”.  33% of hospitals used a 48 hour definition, 30% used a >3 calendar day definition, and 33% used a >4 calendar day definition.  1 hospital used a definition that included tracking C. difficile within 3 months of admission.  For ward attribution, 63% and 33% of hospitals used ward location 2 and 3 calendar days prior to a culture, respectively.

89%, 78% and 78% of hospitals considered MRSA, C. difficile, and MDR Acinetobacter to be the most concerning pathogens, respectively. All hospitals tracked MRSA, C. difficile, and VRE, and 63% used an electronic tracking system, mainly for MRSA.  Incidence for these pathogens (Table 1) varied widely.

Nearly all hospitals (96%) required gown and gloves when entering MRSA+ patient rooms, regardless of patient contact.  For MRSA patients, 52% required staff to wear masks if sputum cultures were MRSA+.  Contact precautions were less common for patients with MDR Acinetobacter (89%), ESBL gram-negatives (85%), and MDR Pseudomonas (67%).  Respectively, 93%, 74%, and 74% of hospitals had policies regarding the discontinuation of contact isolation for MRSA, VRE, and C. difficile.   

Special cleaning for contact precautions rooms was common.  11% used a different disinfectant and 74% replaced curtains. Most (74%) used bleach for cleaning C.difficile patient rooms routinely and on discharge.

Conclusions:  Substantial variation among countywide infection prevention programs exists.  Importantly, there were multiple definitions of “nosocomial”, which may have large effects on self-reported MDRO and C. difficile rates. Differences also existed on how to attribute nosocomial cases to a specific ward. Nearly all hospitals considered MRSA and C. difficile pressing concerns and several had specialized cleaning procedures.  These data suggest that guidance and confirmation of standardized surveillance definitions, and methods of tracking and cleaning are still needed.