scholarly journals A Multicenter Study of Clostridium difficile Infection—Related Colectomy, 2000—2006

2012 ◽  
Vol 33 (5) ◽  
pp. 470-476 ◽  
Author(s):  
Amelia M. Kasper ◽  
Humaa A. Nyazee ◽  
Deborah S. Yokoe ◽  
Jeanmarie Mayer ◽  
Julie E. Mangino ◽  
...  
Keyword(s):  
Clostridium Difficile ◽  
Tertiary Care ◽  
Healthcare Facility ◽  
The United States ◽  
Healthcare Facilities ◽  
Tertiary Care Centers ◽  
Design And Methods ◽  
Study Hospital ◽  
Community Onset ◽  
Over Time

Objective.To assess Clostridium difficile infection (CDI)-related colectomy rates by CDI surveillance definitions and over time at multiple healthcare facilities.Setting.Five university-affiliated acute care hospitals in the United States.Design and Methods.Cases of CDI and patients who underwent colectomy from July 2000 through June 2006 were identified from 5 US tertiary care centers. Monthly CDI-related colectomy rates were calculated as the number of CDI-related colectomies per 1,000 CDI cases, and cases were categorized according to recommended surveillance definitions. Logistic regression was performed to evaluate risk factors for CDI-related colectomy.Results.In total, 8,569 cases of CDI were identified, and 75 patients underwent CDI-related colectomy. The overall colectomy rate was 8.7 per 1,000 CDI cases. The CDI-related colectomy rate ranged from 0 to 23 per 1,000 CDI episodes across hospitals. The colectomy rate for healthcare-facility-onset CDI was 4.3 per 1,000 CDI cases, and that for community-onset CDI was 16.5 per 1,000 CDI cases (P < .05). There were significantly more CDI-related colectomies at hospitals B and C (P < .05).Conclusions.The overall CDI-related colectomy rate was low, and there was no significant change in the CDI-related colectomy rate over time. Onset of disease outside the study hospital was an independent risk factor for colectomy.

scholarly journals Multicenter Study of Clostridium difficile Infection Rates from 2000 to 2006

2010 ◽  
Vol 31 (10) ◽  
pp. 1030-1037 ◽  
Author(s):  
Erik R. Dubberke ◽  
Anne M. Butler ◽  
Deborah S. Yokoe ◽  
Jeanmarie Mayer ◽  
Bala Hota ◽  
...  
Keyword(s):  
Clostridium Difficile ◽  
Hospital Admission ◽  
Healthcare Facility ◽  
The United States ◽  
Incidence Rates ◽  
Regional Problem ◽  
Toxin Assay ◽  
Definition Of ◽  
Study Hospital ◽  
Community Onset

Objective.To compare incidence rates of Clostridium difficile infection (CDI) during a 6-year period among 5 geographically diverse academic medical centers across the United States by use of recommended standardized surveillance definitions of CDI that incorporate recent information on healthcare facility (HCF) exposure.Methods.Data on C. difficile toxin assay results and dates of hospital admission and discharge were collected from electronic databases. Chart review was performed for patients with a positive C. difficile toxin assay result who were identified within 48 hours after hospital admission to determine whether they had any HCF exposure during the 90 days prior to their hospital admission. CDI cases, defined as any inpatient with a stool toxin assay positive for C. difficile, were categorized into 5 surveillance definitions based on recent HCF exposure. Annual CDI rates were calculated and evaluated by use of the χ2 test for trend and the χ2 summary test.Results.During the study period, there were significant increases in the overall incidence rates of HCF-onset, HCF-associated CDI (from 7.0 to 8.5 cases per 10,000 patient-days; P < .001); community-onset, HCF-associated CDI attributed to a study hospital (from 1.1 to 1.3 cases per 10,000 patient-days; P = .003); and community-onset, HCF-associated CDI not attributed to a study hospital (from 0.8 to 1.5 cases per 1,000 admissions overall; P < .001). For each surveillance definition of CDI, there were significant differences in the total incidence rate between HCFs.Conclusions.The increasing incidence rates of CDI over time and across healthcare institutions and the correlation of CDI incidence in different surveillance categories suggest that CDI may be a regional problem and not isolated to a single HCF within a community.

scholarly journals Multicenter Study of the Impact of Community-Onset Clostridium difficile Infection on Surveillance for C. difficile Infection

2009 ◽  
Vol 30 (6) ◽  
pp. 518-525 ◽  
Author(s):  
Erik R. Dubberke ◽  
Anne M. Butler ◽  
Bala Hota ◽  
Yosef M. Khan ◽  
Julie E. Mangino ◽  
...  
Keyword(s):  
Clostridium Difficile ◽  
Control Charts ◽  
Healthcare Facility ◽  
The United States ◽  
Outbreak Detection ◽  
Multicenter Cohort Study ◽  
Time Points ◽  
Stool Samples ◽  
The Impact ◽  
Community Onset

Objective.To evaluate the impact of cases of community-onset, healthcare facility (HCF)-associated Clostridium difficile infection (CDI) on the incidence and outbreak detection of CDI.Design.A retrospective multicenter cohort study.Setting.Five university-affiliated, acute care HCFs in the United States.Methods.We collected data (including results of C. difficile toxin assays of stool samples) on all of the adult patients admitted to the 5 hospitals during the period from July I, 2000, through June 30, 2006. CDI cases were classified as HCF-onset if they were diagnosed more than 48 hours after admission or as community-onset, HCF-associated if they were diagnosed within 48 hours after admission and if the patient had recently been discharged from the HCF. Four surveillance definitions were compared: cases of HCF-onset CDI only (hereafter referred to as HCF-onset CDI) and cases of HCF-onset and community-onset, HCF-associated CDI diagnosed within 30, 60, and 90 days after the last discharge from the study hospital (hereafter referred to as 30-day, 60-day, and 90-day CDI, respectively). Monthly CDI rates were compared. Control charts were used to identify potential CDI outbreaks.Results.The rate of 30-day CDI was significantly higher than the rate of HCF-onset CDI at 2 HCFs (P < .01 ). The rates of 30-day CDI were not statistically significantly different from the rates of 60-day or 90-day CDI at any HCF. The correlations between each HCF's monthly rates of HCF-onset CDI and 30-day CDI were almost perfect (ρ range, 0.94-0.99; P < .001). Overall, 12 time points had a CDI rate that was more than 3 standard deviations above the mean, including 11 time points identified using the definition for HCF-onset CDI and 9 time points identified using the definition for 30-day CDI, with discordant results at 4 time points (k = 0.794; P < .001).Conclusions.Tracking cases of both community-onset and HCF-onset, HCF-associated CDI captures significantly more CDI cases, but surveillance of HCF-onset, HCF-associated CDI alone is sufficient to detect an outbreak.

scholarly journals Varying Rates of Clostridium Difficile-Associated Diarrhea at Prevention Epicenter Hospitals

2005 ◽  
Vol 26 (8) ◽  
pp. 676-679 ◽  
Author(s):  
SeJean Sohn ◽  
Michael Climo ◽  
Daniel Diekema ◽  
Victoria Fraser ◽  
Loreen Herwaldt ◽  
...  
Keyword(s):  
Clostridium Difficile ◽  
Hospital Admissions ◽  
Tertiary Care ◽  
The United States ◽  
Case Definition ◽  
Specific Information ◽  
Case Definitions ◽  
Data Set ◽  
Tertiary Care Centers ◽  
Healthcare Associated

AbstractBackground:Clostridium difficile-associated diarrhea (CDAD) causes substantial healthcare-associated morbidity. Unlike other common healthcare-associated pathogens, little comparative information is available about CDAD rates in hospitalized patients.Objectives:To determine CDAD rates per 10,000 patient-days and per 1,000 hospital admissions at 7 geographically diverse tertiary-care centers from 2000 to 2003, and to survey participating centers on methods of CDAD surveillance and case definition.Methods:Each center provided specific information for the study period, including case numbers, patient-days, and hospital characteristics. Case definitions and laboratory diagnoses of healthcare-associated CDAD were determined by each institution. Within institutions, case definitions remained consistent during the study period.Results:Overall, mean annual case rates of CDAD were 12.1 per 10,000 patient-days (range, 3.1 to 25.1) and 7.4 per 1,000 hospital admissions (range, 3.1 to 13.1). No significant increases were observed in CDAD case rates during the 4-year interval, either at individual centers or in the Prevention Epicenter hospitals as a whole. Prevention Epicenter hospitals differed in their CDAD case definitions. Different case definitions used by the hospitals applied to a fixed data set resulted in a 30% difference in rates. No associations were identified between diagnostic test or case definition used and the relative rate of CDAD at a specific medical center.Conclusions:Rates of CDAD vary widely at tertiary-care centers across the United States. No significant increases in case rates were identified. The varying clinical and laboratory approaches to diagnosis complicated comparisons between hospitals. To facilitate benchmarking and comparisons between institutions, we recommend development of a more standardized case definition.

scholarly journals A Multi-Pronged Approach to Control Healthcare Facility-Onset Clostridium difficile Infection in a Tertiary Care Community Hospital

2017 ◽  
Vol 4 (suppl_1) ◽  
pp. S405-S405
Author(s):  
Raymond Chinn ◽  
Jennifer Wyatt ◽  
Pam Wells ◽  
Tracy Fox ◽  
Jacqueline Daley ◽  
...  
Keyword(s):  
Clostridium Difficile ◽  
Clostridium Difficile Infection ◽  
Infection Prevention ◽  
Community Hospital ◽  
Tertiary Care ◽  
Healthcare Facility ◽  
P Value ◽  
Intervention Period ◽  
Care Community ◽  
Community Onset

Abstract Background Clostridium difficile infection (CDI) contributes to significant increases in healthcare-associated morbidity and mortality. Multiple strategies have been promulgated to accurately diagnose and to control healthcare facility-onset (HO) CDI. Sharp Memorial Hospital is a 438-bed tertiary care community hospital. In 2014, the standardized infection ratio (SIR) CDI was 1.406 (2006–2008 baseline) with a p value of 0.0005. We report the results of a multi-disciplinary approach that has reduced our HO-CDI SIR. The National Healthcare Safety Network definitions and methodologies were used throughout the study. Methods Various multi-disciplinary interventions were implemented over a 12 month period from April 2015 through March 2016 that included enhanced administrative support and the creation of a multi-disciplinary CDI Steering Committee (Figure 1). A Lean Six Sigma approach was launched that included a two-day rapid process improvement (RPI) workshop in July 2015 with participation of an interdisciplinary team of frontline staff, leaders from the 2 units with high CDIs, Infection Prevention, and Environmental Services. Subsequently, lessons learned from the RPI were disseminated throughout the hospital. The laboratory and information technology staff and the antimicrobial stewardship program also contributed. Results Compared with the intervention period, the post intervention period (April 2016 through March 2017) documented a significant increase in the number of samples submitted for CDI testing ≤ 3 days after admission and a significant decrease in the number of samples submitted &gt; 3 days after admission. There were significant decreases in the HO-CDI SIR from 0.947 to 0.676 (p value 0.0485) and in quinolone days of therapy from 265 to 246 (p value 0.0001). Conclusion We have demonstrated a significant decrease in our HO-CDI using a multi-pronged approach that highlighted a return and reinforcement of back to basics infection prevention. High HO-CDI SIR in previous years might indicate missed community-onset, community-onset healthcare facility-associated cases. We did not employ other technologies such as the hands-free disinfection devices. Sustainability remains a future challenge. Disclosures All authors: No reported disclosures.

scholarly journals 124. Six-year Longitudinal Analysis of an Inpatient Infectious Diseases Telemedicine Service at a Community Hospital

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S191-S192
Author(s):  
Nupur Gupta ◽  
Adit B Sanghvi ◽  
John Mellors ◽  
Rima Abdel-Massih
Keyword(s):  
Infectious Disease ◽  
Tertiary Care ◽  
Medical Officer ◽  
Rural Hospital ◽  
Hospital Length Of Stay ◽  
Observation Study ◽  
Patient Acuity ◽  
Telemedicine Service ◽  
Tertiary Care Centers ◽  
Over Time

Abstract Background Telemedicine (TM) has emerged as a viable solution to extend infectious disease (ID) expertise to communities without access to this specialty.1 TM allows clinicians in rural settings to connect with specialists at distant sites and provide the best care for their patients, often eliminating the need for hospital transfers. Here, we describe the experience from one of the longest standing inpatient Tele-ID consult services using live audio-video (AV) visits with the assistance of a telepresenter. Methods Longitudinal data were collected from a 126-bed rural hospital in Pennsylvania that had no access to ID consultation before 2014. Live AV consults during business hours began in 2014 and telephonic physician to physician consults were made available 24/7. All ID consult data were extracted from the hospital electronic health record between 2014 to 2019. Key outcomes assessed included the number of consult encounters, total hospital length of stay (LOS), discharges to home, transfer to tertiary care centers, and readmission rates at 30 days. Results Most consulted patients were Caucasians, and females with an average age of 64.7 years (Table 1). The number of unique consult encounters increased annually from 111 in 2014 to 469 in 2019 (Table 1). The Charlson Comorbidity Score and Elixhauser Comorbidity Index also increased each year beginning in 2016 (Table 1). By contrast, LOS decreased each year as did the 30-day readmission rate (Table 2). Most patients were not transferred (average 89.4% over 6 years) to tertiary care centers and more than half were discharged to home each year (Table 2). Conclusion This longitudinal 6-year observation study of an inpatient TM ID service at a rural hospital showed remarkable annual growth in consult encounters (total growth &gt;400%). Despite increasing patient acuity, overall hospital LOS decreased over time (10.2 to 8.2 days). Patient transfers to tertiary care centers remained low (average 10.5% over 6 years) as did 30-day readmissions (average 16.3% over 6 years). The majority of patients were discharged to home (average 61.3% over 6 years). These findings show that a rural inpatient TM ID consult service can expand over time and is an effective alternative for hospitals without access to ID expertise. Disclosures John Mellors, MD, Abound Bio (Shareholder)Accelevir Diagnostics (Consultant)Co-Crystal Pharmaceuticals (Shareholder)Gilead (Consultant, Grant/Research Support)Merck (Consultant) Rima Abdel-Massih, MD, Infectious Disease Connect (Shareholder, Other Financial or Material Support, Chief Medical Officer)

Driving Restrictions and Early Arrhythmias in Patients Receiving a Secondary Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD-II study)

Circulation ◽  
2021 ◽  
Author(s):  
Christian Steinberg ◽  
Nicolas Dognin ◽  
Amit Sodhi ◽  
Catherine Champagne ◽  
John A. Staples ◽  
...  
Keyword(s):  
Secondary Prevention ◽  
Incidence Rate ◽  
Cardiac Event ◽  
Tertiary Care ◽  
Industrialized Countries ◽  
Cardioverter Defibrillator ◽  
Driving Restrictions ◽  
Tertiary Care Centers ◽  
First 90 Days ◽  
Over Time

Background: Regulatory authorities of most industrialized countries recommend 6-months of private driving restriction after implantation of a secondary prevention ICD. These driving restrictions result in significant inconvenience and social implications. The purpose of this study was to assess the incidence rate of appropriate device therapies in contemporary recipients of a secondary prevention ICD. Methods: A retrospective study at three Canadian tertiary care centers enrolling consecutive patients with new secondary prevention ICD implants between 2016-2020. Results: 721 patients were followed for a median of 760 days (324, 1190). The risk of recurrent ventricular arrhythmia was highest during the first three months after device insertion (34.4%), and decreased over time (10.6% between 3−6 months, 11.7% between 6-12 months). The corresponding incidence rate per 100 patient-days was 0.48 (95% CI 0.35-0.64) at 90 days, 0.28 (95% CI 0.18−0.48) at 180 days and 0.20 (95% CI 0.13−0.31) between 181-365 days after ICD insertion (p<0.001). The cumulative incidence of arrhythmic syncope resulting in sudden cardiac incapacitation was 1.8% within the first 90 days and subsequently dropped to 0.4% between 91-180 days (p<0.001) after ICD insertion. Conclusions: The incidence rate of appropriate therapies resulting in sudden cardiac incapacitation in contemporary recipients of a secondary prevention ICD is much lower than previously reported, and significantly declines after the first three months. Lowering driving restrictions to three months after the index cardiac event seems safe and revision of existing guidelines recommending should be considered in countries still adhering to a 6-months period. Existing restrictions for private driving after implantation of a secondary prevention ICD should be reconsidered.

Recommendations for Surveillance of Clostridium difficile–Associated Disease

2007 ◽  
Vol 28 (2) ◽  
pp. 140-145 ◽  
Author(s):  
L. Clifford McDonald ◽  
Bruno Coignard ◽  
Erik Dubberke ◽  
Xiaoyan Song ◽  
Teresa Horan ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Clostridium Difficile ◽  
Pseudomembranous Colitis ◽  
Ad Hoc ◽  
Toxic Megacolon ◽  
Healthcare Facility ◽  
Case Patient ◽  
Healthcare Settings ◽  
Community Onset ◽  
Laboratory Assay

Background.The epidemiology of Clostridium difficile-associated disease (CDAD) is changing, with evidence of increased incidence and severity. However, the understanding of the magnitude of and reasons for this change is currently hampered by the lack of standardized surveillance methods.Objective and Methods.An ad hoc C. difficile surveillance working group was formed to develop interim surveillance definitions and recommendations based on existing literature and expert opinion that can help to improve CDAD surveillance and prevention efforts.Definitions and Recommendations.A CDAD case patient was defined as a patient with symptoms of diarrhea or toxic megacolon combined with a positive result of a laboratory assay and/or endoscopic or histopathologic evidence of pseudomembranous colitis. Recurrent CDAD was defined as repeated episodes within 8 weeks of each other. Severe CDAD was defined by CDAD-associated admission to an intensive care unit, colectomy, or death within 30 days after onset. Case patients were categorized by the setting in which C. difficile was likely acquired, to account for recent evidence that suggests that healthcare facility-associated CDAD may have its onset in the community up to 4 weeks after discharge. Tracking of healthcare facility–onset, healthcare facility–associated CDAD is the minimum surveillance required for healthcare settings; tracking of community–onset, healthcare facility–associated CDAD should be performed only in conjunction with tracking of healthcare facility–onset, healthcare facility–associated CDAD. Community–associated CDAD was defined by symptom onset more than 12 weeks after the last discharge from a healthcare facility. Rates of both healthcare facility–onset, healthcare facility–associated CDAD and community–onset, healthcare facility–associated CDAD should be expressed as case patients per 10,000 patient–days; rates of community-associated CDAD should be expressed as case patients per 100,000 person-years.

scholarly journals 2351. Rate and Consequences of Missed Clostridioides (Clostridium) difficile Infection Diagnosis from Non-disclosure of Clostridioides difficile Multiplex PCR Results. Two-Hospital Experience

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S809-S809
Author(s):  
Ioannis Zacharioudakis ◽  
Fainareti Zervou ◽  
Michael Phillips ◽  
Maria E Aguero-Rosenfeld
Keyword(s):  
New York ◽  
Clostridium Difficile ◽  
The United States ◽  
Adverse Outcomes ◽  
Adult Patients ◽  
Unknown Etiology ◽  
Clostridioides Difficile ◽  
Appropriate Therapy ◽  
Traditional Risk Factors ◽  
Community Onset

Abstract Background It is common practice among microbiology laboratories in the United States to blind the BioFire FilmArray GI Panel results for Clostridioides (Clostridium) difficile (C. difficile) in fear of over-diagnosis of C. difficile infection (CDI). Methods We conducted a retrospective cohort study in 2 tertiary academic centers in New York to examine the rate of missed CDI diagnosis and the associated adverse outcomes from blinding the BioFire FilmArray GI Panel results for C. difficile. Of note, in one of the two included hospitals the list of daily positives is reviewed by an Infectious Diseases attending to determine whether cases have been tested for CDI and if not if they meet criteria for CDI. Adult patients with FilmArray GI Panel positive for C. difficile on admission to the hospital who lacked dedicated testing for C. difficile were included in the analysis and were stratified as possible, probable and definite cases of missed CDI diagnosis. Results Among the 144 adult patients with a FilmArray GI Panel test positive for C. difficile within 48 hours of hospital admission, 18 did not have a concurrent dedicated C. difficile testing. Eight patients were categorized as possible cases of missed CDI diagnosis, 5 as probable and 4 as definite, for a total of 17 cases of at least possibly missed CDI diagnosis. One case was considered to represent C. difficile colonization rather than infection for a rate of 6.9% of CDI over-diagnosis based on the FilmArray GI Panel results. Missed CDI diagnoses were associated with a delay in initiation of appropriate therapy, admission to the intensive care unit, hospital re-admission, colorectal surgery and death/discharge to hospice. Five out of 17 cases of missed CDI diagnosis (29.4%) lacked traditional risk factors for CDI. Conclusion In conclusion, the practice of concealing FilmArray GI Panel results for C. difficile may lead to a higher rate of missed CDI diagnosis than over-diagnosis and might need to be re-considered at least in patients with community-onset colitis of unknown etiology on presentation to the hospital. Disclosures All authors: No reported disclosures.

66 The Effect of Transfer on Outcomes in Burns

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S43-S43
Author(s):  
Elizabeth Bruenderman ◽  
Selena The ◽  
Nathan Bodily ◽  
Matthew Bozeman
Keyword(s):  
Tertiary Care ◽  
Total Body Surface Area ◽  
The United States ◽  
Infectious Complications ◽  
Burn Care ◽  
Burn Center ◽  
Total Body ◽  
Tertiary Care Centers ◽  
Inhalation Burn ◽  
Time From Injury

Abstract Introduction Burn care in the United States takes place primarily in tertiary care centers with specialty-focused burn capabilities. Patients are often initially transported to centers without burn capabilities, requiring subsequent transfer to a higher level of care. This study aims to evaluate the effect of this treatment delay on outcomes. Methods Under IRB approval, adult burn patients meeting American Burn Association (ABA) criteria for transfer at a single burn center were retrospectively identified. Cohorts were divided into patients who were initially taken to a non-burn center and subsequently transferred versus patients taken immediately to a burn center. Outcomes between the groups were compared. Results A total of 122 patients were identified, 61 in each cohort. There was no difference between the transfer and direct admit cohorts with respect to median age (52 vs. 46, p = 0.45), percent total body surface area burn (10% vs. 10%, p = 0.08), concomitant injury (0 vs. 4, p = 0.12), or intubation prior to admission (5 vs. 7, p = 0.76). Transfer patients experienced a longer median time from injury to burn center admission than directly admitted patients (1 vs. 8 hours, p &lt; 0.01). Directly admitted patients were more likely to have inhalation burn (18 vs. 4, p &lt; 0.01), require intubation after admission (10 vs. 2, p = 0.03), require an emergent procedure (18 vs. 5, p &lt; 0.01), and develop infectious complications (14 vs. 5, p = 0.04). However, there was no difference between transfers and direct admits in ventilator days (9 vs. 3 days, p = 0.37), number of operations (0 vs. 0, p = 0.16), length of stay (3 vs. 3 days, p = 0.44), or mortality (6 vs. 3, p = 0.50). Conclusions This study suggests that significantly injured, hemodynamically unstable patients were more likely to be immediately identified and taken directly to a burn center. Patients who otherwise met ABA criteria for transfer were not affected by short delays in transfer to definitive burn care. Applicability of Research to Practice Initial triage and evaluation of hemodynamically stable patients at non-burn centers does not negatively impact outcomes in patients who meet ABA criteria for transfer to a burn center.

Increasing Prevalence of Methicillin-Resistant Staphylococcus aureus in the United States

1990 ◽  
Vol 11 (12) ◽  
pp. 639-642 ◽  
Author(s):  
John M. Boyce
Keyword(s):  
United States ◽  
Staphylococcus Aureus ◽  
Methicillin Resistant Staphylococcus Aureus ◽  
Tertiary Care ◽  
The United States ◽  
University Hospitals ◽  
Methicillin Resistant ◽  
Large Numbers ◽  
Tertiary Care Centers ◽  
Community Teaching

AbstractIn the period 1975 to 1981, methicillin-resistant Staphylococcus aureus (MRSA) emerged as an important nosocomial pathogen in tertiary care centers in the United States. To determine if the prevalence of this organism has continued to increase, a questionnaire was sent to hospital epidemiologists in 360 acute care hospitals. A total of 256 (71%) of the 360 individuals responded. Overall, 97% (246/256) of responding hospitals reported having patients with MRSA in the period 1987 through 1989. Respondents in 217 hospitals provided estimates of the number of cases seen in 1987, 1988 and 1989. The percentage of respondents reporting one or more patients with MRSA increased from 88% in 1987 to 96.3% in 1989 (p = .0008). The percent of respondents reporting large numbers (≥50) of cases per year increased from 18% in 1987 to 32% in 1989 (p = .0006). Increasing frequency of large outbreaks was observed in community, community-teaching, federal, municipal and university hospitals.

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