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Bathing with 4% Chlorhexidine Gluconate (CHG) Reduces Methicillin-Resistant Staphylococcus aureus (MRSA) Soft Tissue Infections for Naval Recruits
Poster Abstracts / American Journal of Infection Control 45 (2017) S16-S93
Outbreak Investigation and Emerging/Reemerging Infectious Diseases Session OI-178 12:30-1:30 p.m. “You’re Rinsing with What?” An Investigation into a Pseudo-Outbreak Within the Bronchoscopy Suite Jennifer Fritz, RN, MSN, CIC, Senior Infection Control Preventionist, Geisinger Health System; Tamara Persing, RN, BSN, MS, CIC, System Administrative Director Infection Prevention Control, Geisinger Health System; Lisa Esolen, MD, FIDSA, System Medical Director Infection Prevention and Control, System Medical Director Occupational Health for Infectious Diseases, Assistant Chief Quality Officer, Geisinger Health System BACKGROUND: Mycobacterium mucogenicum is an organism commonly found in soil and tap water systems. This investigation describes an increase in the incidence of M. mucogenicum in bronchoalveolar lavage (BAL) specimens during routine surveillance. METHODS: Data mining software was utilized to retrospectively identify all cultures positive for M. mucogenicum over a 4-year period. Data was analyzed for type of specimen and location of specimen procurement. Charts were reviewed for clinical presentation and observations of bronchoscopic procedures were conducted. RESULTS: Twenty-one M. mucogenicum cultures were identified over six-months. Of the twenty-one cases, thirteen (62%) were associated with a BAL in the same suite. Chart reviews revealed no incidence of clinical disease consistent with this pathogen. During observations in the effected suite, it was noted that staff prepared lavage solution by placing ice from the unit’s ice machine into a non-sterile pan, then pouring sterile water over the ice. The cold water from this pan was then aspirated for lavaging. When this procedure was changed requiring the sterile water be placed in a sterile bowl then set on top of the ice, no additional cases of M. mucogenicum associated with a BAL were identified over an eight month period. Cultures of the ice from the unit’s machine were negative for M. mucogenicum. CONCLUSIONS: Non-tuberculous Mycobacteria are found in the environment and can be involved with outbreaks and pseudooutbreaks, often relating to hospital water systems.1,2 The practice identified here of mixing non-sterile ice with sterile water for bronchoscopic lavage resulted in a pseudo-outbreak of M. mucogenicum. Subsequent changes to this practice eliminated further positive cultures. Though culturing ice from the machine was not positive, environmental sampling is known to be unreliable. 2 M. mucogenicum can be a water-borne contaminant and increased identification associated with BALs should prompt an evaluation of the lavaging procedures.
Session OI-179 12:30-1:30 p.m. An Investigation of a Cluster of Invasive Fungal Infections in Patients on a Stem Cell Transplant Unit Lauren Ogden, MPH, CIC, Infection Preventionist, Oregon Health & Science University; Carmen Cortes-Ramos, MT(ASCP), SM, CIC, Infectoin Preventionist, Oregon Health Science University; Lynne Strasfeld, MD, Associate Professor, Department of
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Infection Prevention & Control, Division of Infectious Diseases, Oregon Health & Science University; John Townes, MD, Interim Chair Infectious Disease, Medical Director Infection Prevention & Control, Oregon Health & Science University; Keenan Williamson, MPH, Infection Preventionist, Oregon Health & Sciences University; Malinda Burt, BSN, RN, Nurse Manager, Oregon Health & Science University; Jonathan Sebert, RN, Infection Preventionist, Oregon Health and Science University; Kevin Langstaff, BS, Business Data Analyst, Oregon Health and Science University; Yoojin Kim, PhD, Infection Preventionist, OHSU; Molly Hale, MPH, CIC, FAPIC, Manager, Infection Prevention & Control BACKGROUND: Stem cell transplant (SCT) recipients and patients with hematologic malignancy are at risk for invasive fungal infections (IFI). Source of acquisition is difficult to determine, acknowledging the ubiquitous presence of fungal spores in the Pacific Northwest environment. An investigation was conducted to determine the source of an increase in cases of probable and possible (based on clinical and radiographic evidence) IFI on the adult SCT unit of an urban academic medical center. METHODS: A multi-disciplinary team participated in the investigation. The unit was inspected for breaches in conditions appropriate for a protective environment. The air quality in patient rooms, hallways, and near common sinks (with moldy odors) was tested by particulate count and non-viable fungal spore testing. Patients on the unit at the time of the cluster were interviewed regarding exposures. Water leaks, construction/renovation projects and airflow disruption near the unit were reviewed for the prior 2 months. RESULTS: Fungal spore counts for all areas tested in the unit were low (mean 19, range 0-68 spores/m3) compared with outside air (mean 2881, range 1388-4375 spores/m3). The unit had some dust in hallways, but no visible mold. Patients with IFI did not report significantly different exposures from non-IFI patients. No common source exposure was identified and no further cases have been diagnosed within the subsequent month. Area hospitals have also noted an increase in IFIs in a similar timeframe. CONCLUSIONS: Determining if clustered IFI cases are linked to a common source is difficult due to limitations in diagnostic methods, lack of defined incubation period and infectious dose, and poor sensitivity and specificity of environmental sampling methods. Ensuring clean air quality in protected environments is an essential part of preventing IFI in SCT patients. Improved active surveillance methods and standard criteria for determination of healthcare-associated infection are needed to identify healthcare-associated outbreaks of IFIs.
Session OI-180 12:30-1:30 p.m. Bathing with 4% Chlorhexidine Gluconate (CHG) Reduces Methicillin-Resistant Staphylococcus aureus (MRSA) Soft Tissue Infections for Naval Recruits Paula Pintar, MSN, RN, ACNS-BC, CIC, Chief, Organizational Performance ImprovementCaptain James A. Lovell Federal Health Care Center; Jason Loving, Preventive Medicine Techinican, Captain James A. Lovell Federal Health Care Center; Jeremy Garcia, Preventive Medicine Technician, Captain James A. Lovell Federal Health Care Center; Julia Nefczyk, MPH, Environmental Health Officer, Captain James A. Lovell Federal Health Care Center
APIC 44th Annual Educational Conference & International Meeting | Portland, OR | June 14-16, 2017
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Poster Abstracts / American Journal of Infection Control 45 (2017) S16-S93
BACKGROUND: Naval recruits experience a rigorous training schedule to meet service ready expectations during their 8 week boot camp. Delays in meeting and fulfilling boot camp training negatively impacts naval readiness. In 2008 a rise in positive MRSA soft tissue infections was identified, incidence rate of 0.66/1,000 recruits total n = 40,000, thereby reducing the commands ability to complete training on schedule at a cost of $250.00/day/recruit. A literature review was conducted on the application and use of CHG bathing with the majority of studies supporting positive outcomes in reduction of central line and surgical site infections. METHODS: A retrospective study was conducted assessing reduction of MRSA soft tissue infections by incorporating CHG bathing of naval recruits. Setting located in a mid-west naval command station of gender integrated recruits processing approximately 40,000 annually; assignment to a division (80-100 individuals) with average age between 17 to 25 years. Each division is followed through the 8 week boot camp assessing for soft tissue injuries and wounds. During processing week one and on the fifth week recruits are given 4% chlorhexidine gluconate soap for bathing. Instructions are to shower using the product while refraining from applying to mucous membrane areas of the body. RESULTS: Implementation of CHG bathing protocol reduced the number of soft tissue infections (incidence rate 0.09/1000 recruits) related to MRSA by 86% from 2008-2015; resulting in naval command success in graduating recruits on time, reduced sick call rates, lost revenue, and decreased antibiotic use. CONCLUSIONS: This study identified recruits bathing with 4% CHG at two specific intervals reducing MRSA soft tissue infections; lost recruit productivity, antibiotic use, and meeting naval readiness. This process may prove to be beneficial in replicating across all recruit training centers.
Session OI-181 12:30-1:30 p.m. Carbapenem-Resistant Enterobacteriaceae Surveillance to Detect Transmission, Wisconsin Division of Public Health, 2016 Gwen Borlaug, CIC, MPH, Director, HAI Prevention ProgramWisconsin Division of Public Health; Kristin Gundlach, BS, Senior Microbiologist, Wisconsin State Laboratory of Hygiene; Ann Valley, BS, Microbiologist-Advanced, Wisconsin State Laboratory of Hygiene; Christine Muganda, PhD, Communicable Disease Epidemiologist, Wisconsin Division of Public Health; Anna Kocharian, MS, Communicable Diseases Epidemiologist, Wisconsin Division of Public Health BACKGROUND: During 2011, the Wisconsin Division of Public Health (WDPH) mandated hospital-based surveillance for CarbapenemResistant Enterobacteriaceae (CRE) to detect healthcare transmission and mitigate transmission risk. The Wisconsin State Laboratory of Hygiene (WSLH) began laboratory-based surveillance during 2010. METHODS: Hospitals report carbapenem-resistant Klebsiella pneumoniae, K. oxytoca, Escherichia coli and Enterobacter spp. to WDPH using the National Healthcare Safety Network and corresponding protocol. Clinical microbiology laboratories submit carbapenem-non-susceptible isolates to WSLH to detect carbapenemase production. WSLH conducts pulsed-field gel electrophoresis (PFGE) analysis of carbapenemase-positive isolates and notifies WDPH of patients with related (≤3 band differences) isolates. WDPH reviews patient medical records to determine healthcare epidemiologic links, interviews infection preventionists and
conducts facility visits to help reduce future transmission risk. WSLH notified WDPH during September 2016 of three hospital patients with matching K. pneumoniae carbapenemase (KPC)-producing Enterbacter cloacae isolates. WDPH interviewed the facility infection preventionist and the Environmental Services director during an October 2016 onsite visit. Patient histories, isolation practices, staff use of personal protective equipment (PPE), hand hygiene (HH) and environmental services (EVS) protocols were reviewed. RESULTS: Patients A and B were roommates during July 28—August 21, 2016 and were managed by a single sitter to address cognition issues. Patient C was admitted to Patient B’s previous bed location one day after Patient B transferred to Room 1. Patient A was isolated immediately following CRE-positive culture results collected September 4. Patients B and C were identified with CRE after discharge. HH compliance was similar and PPE compliance was lower during July—August compared to other months during 2016. No EVS protocol breaches were noted. CONCLUSIONS: Use of a single sitter to care for two patients in a semi-private room and lower PPE compliance may have contributed to CRE transmission. Statewide CRE surveillance and laboratory analysis is effective in detecting healthcare transmission.
Session OI-182 12:30-1:30 p.m. Case-Control Study Evaluating Risk Factors Associated with a Carbapenem-resistant GramNegative Bacterial Colonization Corrine Bozich, MPH candidate, Masters of Public Health student, Univerity of Pittsburgh; Juliet Ferrelli, MS, MT(ASCP), CIC, FAPIC, Infection Prevention Manager, UPMC Mercy; Rahman Hariri, PhD, MBA, Director of Microbiology, UPMC MercyUniversity of Pittsburgh; Christina Andrzejewski, Pharm D, Antibiotic Stewardship Director, UPMC Mercy; Mohamed Yassin, MD, PhD, Medical Director Infection Control -Hospital Epi, UPMC Mercy—University of Pittsburgh BACKGROUND: Antibiotic resistance is prominent at large medical centers that provide complicated medical care that requires the prolonged use of broad spectrum antibiotics. Multi-drug resistant organisms (MDRO), especially MDR Gram-negative rods (MDRGNR) are a group of bacteria that poses a particular threat, as they cause life-threatening infections with limited options for treatment. Newly emerging organisms such as Carbapenem resistant (CR) bacteria are of particular concern. METHODS: This case-control study was conducted at a large academic medical center. The aim of the study was to evaluate the potential of MDRO surveillance for CR using clinical variables. We included patients with MDR-GNR; cultures of extended spectrum beta-lactamase(ESBL) producing were used as the control, while carbapenem-resistant Enterobactericiae (CRE) and CR non-fermenters (CRNF), i.e. Pseudomonas spp. and Acinetobacter baumannii, were used as cases. Epidemiologic, clinical and utilization data were reviewed and collected. Risk factors for MDRO colonization were reviewed. For data analysis and sample size calculations, SAS 9.4 software was used. RESULTS: A total of 106 patients were included in the study. The mean age and SD were 58 ± 16, 53 ± 16 and 62 ± 19 years for CRE (n = 35), CRNF (n = 26) and ESBL (n = 45) respectively. The patients with CR colonization or infection were more likely to have a chronic wound (P = .0035), have indwelling intravenous or urinary catheters (P = .0017), require mechanical ventilation (P = .0040) and to
APIC 44th Annual Educational Conference & International Meeting | Portland, OR | June 14-16, 2017
Outbreak Investigation and Emerging/Reemerging Infectious Diseases Session OI-178 12:30-1:30 p.m. “You’re Rinsing with What?” An Investigation into a Pseudo-Outbreak Within the Bronchoscopy Suite Jennifer Fritz, RN, MSN, CIC, Senior Infection Control Preventionist, Geisinger Health System; Tamara Persing, RN, BSN, MS, CIC, System Administrative Director Infection Prevention Control, Geisinger Health System; Lisa Esolen, MD, FIDSA, System Medical Director Infection Prevention and Control, System Medical Director Occupational Health for Infectious Diseases, Assistant Chief Quality Officer, Geisinger Health System BACKGROUND: Mycobacterium mucogenicum is an organism commonly found in soil and tap water systems. This investigation describes an increase in the incidence of M. mucogenicum in bronchoalveolar lavage (BAL) specimens during routine surveillance. METHODS: Data mining software was utilized to retrospectively identify all cultures positive for M. mucogenicum over a 4-year period. Data was analyzed for type of specimen and location of specimen procurement. Charts were reviewed for clinical presentation and observations of bronchoscopic procedures were conducted. RESULTS: Twenty-one M. mucogenicum cultures were identified over six-months. Of the twenty-one cases, thirteen (62%) were associated with a BAL in the same suite. Chart reviews revealed no incidence of clinical disease consistent with this pathogen. During observations in the effected suite, it was noted that staff prepared lavage solution by placing ice from the unit’s ice machine into a non-sterile pan, then pouring sterile water over the ice. The cold water from this pan was then aspirated for lavaging. When this procedure was changed requiring the sterile water be placed in a sterile bowl then set on top of the ice, no additional cases of M. mucogenicum associated with a BAL were identified over an eight month period. Cultures of the ice from the unit’s machine were negative for M. mucogenicum. CONCLUSIONS: Non-tuberculous Mycobacteria are found in the environment and can be involved with outbreaks and pseudooutbreaks, often relating to hospital water systems.1,2 The practice identified here of mixing non-sterile ice with sterile water for bronchoscopic lavage resulted in a pseudo-outbreak of M. mucogenicum. Subsequent changes to this practice eliminated further positive cultures. Though culturing ice from the machine was not positive, environmental sampling is known to be unreliable. 2 M. mucogenicum can be a water-borne contaminant and increased identification associated with BALs should prompt an evaluation of the lavaging procedures.
Session OI-179 12:30-1:30 p.m. An Investigation of a Cluster of Invasive Fungal Infections in Patients on a Stem Cell Transplant Unit Lauren Ogden, MPH, CIC, Infection Preventionist, Oregon Health & Science University; Carmen Cortes-Ramos, MT(ASCP), SM, CIC, Infectoin Preventionist, Oregon Health Science University; Lynne Strasfeld, MD, Associate Professor, Department of
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Infection Prevention & Control, Division of Infectious Diseases, Oregon Health & Science University; John Townes, MD, Interim Chair Infectious Disease, Medical Director Infection Prevention & Control, Oregon Health & Science University; Keenan Williamson, MPH, Infection Preventionist, Oregon Health & Sciences University; Malinda Burt, BSN, RN, Nurse Manager, Oregon Health & Science University; Jonathan Sebert, RN, Infection Preventionist, Oregon Health and Science University; Kevin Langstaff, BS, Business Data Analyst, Oregon Health and Science University; Yoojin Kim, PhD, Infection Preventionist, OHSU; Molly Hale, MPH, CIC, FAPIC, Manager, Infection Prevention & Control BACKGROUND: Stem cell transplant (SCT) recipients and patients with hematologic malignancy are at risk for invasive fungal infections (IFI). Source of acquisition is difficult to determine, acknowledging the ubiquitous presence of fungal spores in the Pacific Northwest environment. An investigation was conducted to determine the source of an increase in cases of probable and possible (based on clinical and radiographic evidence) IFI on the adult SCT unit of an urban academic medical center. METHODS: A multi-disciplinary team participated in the investigation. The unit was inspected for breaches in conditions appropriate for a protective environment. The air quality in patient rooms, hallways, and near common sinks (with moldy odors) was tested by particulate count and non-viable fungal spore testing. Patients on the unit at the time of the cluster were interviewed regarding exposures. Water leaks, construction/renovation projects and airflow disruption near the unit were reviewed for the prior 2 months. RESULTS: Fungal spore counts for all areas tested in the unit were low (mean 19, range 0-68 spores/m3) compared with outside air (mean 2881, range 1388-4375 spores/m3). The unit had some dust in hallways, but no visible mold. Patients with IFI did not report significantly different exposures from non-IFI patients. No common source exposure was identified and no further cases have been diagnosed within the subsequent month. Area hospitals have also noted an increase in IFIs in a similar timeframe. CONCLUSIONS: Determining if clustered IFI cases are linked to a common source is difficult due to limitations in diagnostic methods, lack of defined incubation period and infectious dose, and poor sensitivity and specificity of environmental sampling methods. Ensuring clean air quality in protected environments is an essential part of preventing IFI in SCT patients. Improved active surveillance methods and standard criteria for determination of healthcare-associated infection are needed to identify healthcare-associated outbreaks of IFIs.
Session OI-180 12:30-1:30 p.m. Bathing with 4% Chlorhexidine Gluconate (CHG) Reduces Methicillin-Resistant Staphylococcus aureus (MRSA) Soft Tissue Infections for Naval Recruits Paula Pintar, MSN, RN, ACNS-BC, CIC, Chief, Organizational Performance ImprovementCaptain James A. Lovell Federal Health Care Center; Jason Loving, Preventive Medicine Techinican, Captain James A. Lovell Federal Health Care Center; Jeremy Garcia, Preventive Medicine Technician, Captain James A. Lovell Federal Health Care Center; Julia Nefczyk, MPH, Environmental Health Officer, Captain James A. Lovell Federal Health Care Center
APIC 44th Annual Educational Conference & International Meeting | Portland, OR | June 14-16, 2017
S82
Poster Abstracts / American Journal of Infection Control 45 (2017) S16-S93
BACKGROUND: Naval recruits experience a rigorous training schedule to meet service ready expectations during their 8 week boot camp. Delays in meeting and fulfilling boot camp training negatively impacts naval readiness. In 2008 a rise in positive MRSA soft tissue infections was identified, incidence rate of 0.66/1,000 recruits total n = 40,000, thereby reducing the commands ability to complete training on schedule at a cost of $250.00/day/recruit. A literature review was conducted on the application and use of CHG bathing with the majority of studies supporting positive outcomes in reduction of central line and surgical site infections. METHODS: A retrospective study was conducted assessing reduction of MRSA soft tissue infections by incorporating CHG bathing of naval recruits. Setting located in a mid-west naval command station of gender integrated recruits processing approximately 40,000 annually; assignment to a division (80-100 individuals) with average age between 17 to 25 years. Each division is followed through the 8 week boot camp assessing for soft tissue injuries and wounds. During processing week one and on the fifth week recruits are given 4% chlorhexidine gluconate soap for bathing. Instructions are to shower using the product while refraining from applying to mucous membrane areas of the body. RESULTS: Implementation of CHG bathing protocol reduced the number of soft tissue infections (incidence rate 0.09/1000 recruits) related to MRSA by 86% from 2008-2015; resulting in naval command success in graduating recruits on time, reduced sick call rates, lost revenue, and decreased antibiotic use. CONCLUSIONS: This study identified recruits bathing with 4% CHG at two specific intervals reducing MRSA soft tissue infections; lost recruit productivity, antibiotic use, and meeting naval readiness. This process may prove to be beneficial in replicating across all recruit training centers.
Session OI-181 12:30-1:30 p.m. Carbapenem-Resistant Enterobacteriaceae Surveillance to Detect Transmission, Wisconsin Division of Public Health, 2016 Gwen Borlaug, CIC, MPH, Director, HAI Prevention ProgramWisconsin Division of Public Health; Kristin Gundlach, BS, Senior Microbiologist, Wisconsin State Laboratory of Hygiene; Ann Valley, BS, Microbiologist-Advanced, Wisconsin State Laboratory of Hygiene; Christine Muganda, PhD, Communicable Disease Epidemiologist, Wisconsin Division of Public Health; Anna Kocharian, MS, Communicable Diseases Epidemiologist, Wisconsin Division of Public Health BACKGROUND: During 2011, the Wisconsin Division of Public Health (WDPH) mandated hospital-based surveillance for CarbapenemResistant Enterobacteriaceae (CRE) to detect healthcare transmission and mitigate transmission risk. The Wisconsin State Laboratory of Hygiene (WSLH) began laboratory-based surveillance during 2010. METHODS: Hospitals report carbapenem-resistant Klebsiella pneumoniae, K. oxytoca, Escherichia coli and Enterobacter spp. to WDPH using the National Healthcare Safety Network and corresponding protocol. Clinical microbiology laboratories submit carbapenem-non-susceptible isolates to WSLH to detect carbapenemase production. WSLH conducts pulsed-field gel electrophoresis (PFGE) analysis of carbapenemase-positive isolates and notifies WDPH of patients with related (≤3 band differences) isolates. WDPH reviews patient medical records to determine healthcare epidemiologic links, interviews infection preventionists and
conducts facility visits to help reduce future transmission risk. WSLH notified WDPH during September 2016 of three hospital patients with matching K. pneumoniae carbapenemase (KPC)-producing Enterbacter cloacae isolates. WDPH interviewed the facility infection preventionist and the Environmental Services director during an October 2016 onsite visit. Patient histories, isolation practices, staff use of personal protective equipment (PPE), hand hygiene (HH) and environmental services (EVS) protocols were reviewed. RESULTS: Patients A and B were roommates during July 28—August 21, 2016 and were managed by a single sitter to address cognition issues. Patient C was admitted to Patient B’s previous bed location one day after Patient B transferred to Room 1. Patient A was isolated immediately following CRE-positive culture results collected September 4. Patients B and C were identified with CRE after discharge. HH compliance was similar and PPE compliance was lower during July—August compared to other months during 2016. No EVS protocol breaches were noted. CONCLUSIONS: Use of a single sitter to care for two patients in a semi-private room and lower PPE compliance may have contributed to CRE transmission. Statewide CRE surveillance and laboratory analysis is effective in detecting healthcare transmission.
Session OI-182 12:30-1:30 p.m. Case-Control Study Evaluating Risk Factors Associated with a Carbapenem-resistant GramNegative Bacterial Colonization Corrine Bozich, MPH candidate, Masters of Public Health student, Univerity of Pittsburgh; Juliet Ferrelli, MS, MT(ASCP), CIC, FAPIC, Infection Prevention Manager, UPMC Mercy; Rahman Hariri, PhD, MBA, Director of Microbiology, UPMC MercyUniversity of Pittsburgh; Christina Andrzejewski, Pharm D, Antibiotic Stewardship Director, UPMC Mercy; Mohamed Yassin, MD, PhD, Medical Director Infection Control -Hospital Epi, UPMC Mercy—University of Pittsburgh BACKGROUND: Antibiotic resistance is prominent at large medical centers that provide complicated medical care that requires the prolonged use of broad spectrum antibiotics. Multi-drug resistant organisms (MDRO), especially MDR Gram-negative rods (MDRGNR) are a group of bacteria that poses a particular threat, as they cause life-threatening infections with limited options for treatment. Newly emerging organisms such as Carbapenem resistant (CR) bacteria are of particular concern. METHODS: This case-control study was conducted at a large academic medical center. The aim of the study was to evaluate the potential of MDRO surveillance for CR using clinical variables. We included patients with MDR-GNR; cultures of extended spectrum beta-lactamase(ESBL) producing were used as the control, while carbapenem-resistant Enterobactericiae (CRE) and CR non-fermenters (CRNF), i.e. Pseudomonas spp. and Acinetobacter baumannii, were used as cases. Epidemiologic, clinical and utilization data were reviewed and collected. Risk factors for MDRO colonization were reviewed. For data analysis and sample size calculations, SAS 9.4 software was used. RESULTS: A total of 106 patients were included in the study. The mean age and SD were 58 ± 16, 53 ± 16 and 62 ± 19 years for CRE (n = 35), CRNF (n = 26) and ESBL (n = 45) respectively. The patients with CR colonization or infection were more likely to have a chronic wound (P = .0035), have indwelling intravenous or urinary catheters (P = .0017), require mechanical ventilation (P = .0040) and to
APIC 44th Annual Educational Conference & International Meeting | Portland, OR | June 14-16, 2017