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OBJECTIVE. Healthcare-acquired infections (HAIs) cause substantial patient morbidity and mortality. Items in the environment harbor microorganisms that may contribute to HAIs. Reduction in surface bioburden may be an effective strategy to reduce HAIs. The inherent biocidal properties of copper surfaces offer a theoretical advantage to conventional cleaning, as the effect is continuous rather than episodic. We sought to determine whether placement of copper alloy-surfaced objects in an intensive care unit (ICU) reduced the risk of HAI. DESIGN. Intention-to-treat randomized control trial between July 12, 2010, and June 14, 2011. SETTINg. The ICUs of 3 hospitals. PATIENTS. Patients presenting for admission to the ICU. METHODS. Patients were randomly placed in available rooms with or without copper alloy surfaces, and the rates of incident HAI and/or colonization with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) in each type of room were compared. RESULTS. The rate of HAI and/or MRSA or VRE colonization in ICU rooms with copper alloy surfaces was significantly lower than that in standard ICU rooms (0.071 vs 0.123; P = .020). For HAI only, the rate was reduced from 0.081 to 0.034 (P = .013). CONCLUSIONs. Patients cared for in ICU rooms with copper alloy surfaces had a significantly lower rate of incident HAI and/or colonization with MRSA or VRE than did patients treated in standard rooms. Additional studies are needed to determine the clinical effect of copper alloy surfaces in additional patient populations and settings.

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The contribution of environmental surface contamination with pathogenic organisms to the development of health care-associated infections (HAI) has not been well defined. The microbial burden (MB) associated with commonly touched surfaces in intensive care units (ICUs) was determined by sampling six objects in 16 rooms in ICUs in three hospitals over 43 months. At month 23, copper-alloy surfaces, with inherent antimicrobial properties, were installed onto six monitored objects in 8 of 16 rooms, and the effect that this application had on the intrinsic MB present on the six objects was assessed. Census continued in rooms with and without copper for an additional 21 months. In concert with routine infection control practices, the average MB found for the six objects assessed in the clinical environment during the preintervention phase was 28 times higher (6,985 CFU/100 cm(2); n = 3,977 objects sampled) than levels proposed as benign immediately after terminal cleaning (<250 CFU/100 cm(2)). During the intervention phase, the MB was found to be significantly lower for both the control and copper-surfaced objects. Copper was found to cause a significant (83%) reduction in the average MB found on the objects (465 CFU/100 cm(2); n = 2714 objects) compared to the controls (2,674 CFU/100 cm(2); n = 2,831 objects [P < 0.0001]). The introduction of copper surfaces to objects formerly covered with plastic, wood, stainless steel, and other materials found in the patient care environment significantly reduced the overall MB on a continuous basis, thereby providing a potentially safer environment for hospital patients, health care workers (HCWs), and visitors.

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Successful treatment of many musculoskeletal infections often requires an extended course of outpatient antimicrobial therapy, much of which is administered parenterally outside the hospital under the guidance of an infectious disease specialist. Delivery of outpatient parenteral antimicrobial therapy (OPAT) may occur in physicians' offices, ambulatory infusion centers, or hospital clinics but most frequently is done in patients' homes, often by the patients themselves. In this article, we outline the essential elements of outpatient antimicrobial therapy for musculoskeletal infections with particular emphasis on OPAT, including patient selection and evaluation; antimicrobial administration, including the route, duration, and complications of central venous access; and clinical and laboratory monitoring of antimicrobial therapy. We believe that primary care physicians, orthopedists, and infectious disease specialists caring for patients with musculoskeletal infections should become familiar with the use of, indications for, and complications of OPAT.

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UNLABELLED: Limited data are available regarding the risk factors and outcome of polymicrobial prosthetic joint infection (PJIs) when compared with monomicrobial PJI. Between January 1998 and November 2006, we retrospectively identified 34 of 174 prosthetic joint infections (19%) were polymicrobial. The 2-year cumulative probability of success of treating polymicrobial and monomicrobial PJIs was 63.8% and 72.8%, respectively. Twenty-six percent, 38%, and 29% of PJIs were treated with two-stage exchange, débridement and retention, or resection arthroplasty, respectively, and the 2-year survival rate free of treatment failure in each group was 77.7% (95% confidence interval, 42.8%-94.2%), 52.7% (95% confidence interval, 28.4%-75.9%), and 64.2% (95% confidence interval, 28.7%-88.9%). Methicillin-resistant Staphylococcus aureus (26.4% versus 7.1%) and anaerobes (11.7% versus 2.8%) were more common in polymicrobial PJIs. Polymicrobial PJIs occurred in patients with a soft tissue defect/dehiscence (23.5% versus 2.8%), drainage (79.4% versus 39.2%), or prior local irradiation (8.8% versus 0.71%). We found the following factors associated with polymicrobial prosthetic joint infections: the presence of a soft tissue defect/wound dehiscence (odds ratio, 5.9), drainage (odds ratio, 5.0), and age 65 years or older (odds ratio, 2.8). LEVEL OF EVIDENCE: Level III, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

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We determined the effect of methicillin resistance on the outcome of patients with Staphylococcus aureus prosthetic joint infections. From January 1995 to December 2004, 33% of 137 episodes of prosthetic joint infections were the result of S. aureus (in monomicrobial or polymicrobial cultures). Thirty-three (24%) episodes among 31 patients were the result of methicillin-susceptible S. aureus and 12 (9%) episodes among 12 patients were the result of methicillin-resistant S. aureus. Overall treatment failure rate was 38%. Patients with methicillin-susceptible S. aureus or methicillin-resistant S. aureus prosthetic joint infections did not differ in age, gender, comorbidities, joint age, prior surgical procedures performed on the affected joint, number of postsurgical medical complications, or duration of intravenous antimicrobial therapy. Patients with methicillin-resistant S. aureus prosthetic joint infection had longer hospital durations (median, 15 versus 10 days). Methicillin-resistant S. aureus in periprosthetic tissue culture resulted in a higher risk of treatment failure (hazard ratio, 9.2; 95% confidence interval, 2.40-35.46) than methicillin-susceptible S. aureus when controlling for joint location (total knee arthroplasty versus total hip arthroplasty [hazard ratio, 5.8; 95% confidence interval, 1.52-22.19]) and removal of hardware (hazard ratio, 0.24; 95% confidence interval, 0.077-0.75). Efforts should be made to prevent methicillin-resistant S. aureus infections of joint arthroplasties and develop new treatment modalities.

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OBJECTIVE: To determine whether introduction of a needleless mechanical valve device (NMVD) at a long-term acute care hospital was associated with an increased frequency of catheter-related bloodstream infection (BSI). DESIGN: For patients with a central venous catheter in place, the catheter-related BSI rate during the 24-month period before introduction of the NMVD, a period in which a needleless split-septum device (NSSD) was being used (hereafter, the NSSD period), was compared with the catheter-related BSI rate during the 24-month period after introduction of the NMVD (hereafter, the NMVD period). The microbiological characteristics of catheter-related BSIs during each period were also compared. Comparisons and calculations of relative risks (RRs) with 95% confidence intervals (CIs) were performed using chi (2) analysis. RESULTS: Eighty-six catheter-related BSIs (3.86 infections per 1,000 catheter-days) occurred during the study period. The rate of catheter-related BSI during the NMVD period was significantly higher than that during the NSSD period (5.95 vs 1.79 infections per 1,000 catheter-days; RR, 3.32 [95% CI, 2.88-3.83]; P<.001). A significantly greater percentage of catheter-related BSIs during the NMVD period were caused by gram-negative organisms, compared with the percentage recorded during the NSSD period (39.5% vs 8%; P=.007). Among catheter-related BSIs due to gram-positive organisms, the percentage caused by enterococci was significantly greater during the NMVD period, compared with the NSSD period (54.8% vs 13.6%; P=.004). The catheter-related BSI rate remained high during the NMVD period despite several educational sessions regarding proper use of the NMVD. CONCLUSIONS: An increased catheter-related BSI rate was temporally associated with use of a NMVD at the study hospital, despite several educational sessions regarding proper NMVD use. The current design of the NMVD may be unsafe for use in certain patient populations.

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