bluuebunny/crossref_metadata_2025 huggingface dataset:
Measuring Implementation of Antibiotic Stewardship in Critical Access Hospitals Using the NHSN Annual Facility Survey
Authors: Vargas Natalia , Brinkman Sarah , Grangaard Laura
Published: November 2020

Background:
Critical access hospitals (CAHs) serving rural communities have numerous limitations regarding resources, infrastructure, and staffing to support antibiotic stewardship programs (ASPs) and related quality improvement activities. The Federal Office of Rural Health Policy (FORHP) established the Medicare Beneficiary Quality Improvement Project (MBQIP) to provide CAHs with specialized technical assistance in quality improvement data collection and reporting to drive improvements in the quality of care and to reduce barriers to establishing ASPs. In 2016, FORHP developed an antibiotic stewardship process measure in partnership with the CDC to assess progress on implementing ASPs and to optimize hospital quality improvement practices related to antibiotic use. This is the first measure to be successfully implemented and reported at a national level to improve the judicious use of antibiotics in hospitals. Methods: A process measure was developed to assess adherence to the 7 core elements of a successful hospital ASP (ie, leadership, accountability, drug expertise, action, tracking, reporting, and education), as defined by CDC guidelines. Implementation was accomplished through CAH participation in the NHSN Annual Facility Survey (AFS). Responses were analyzed to assess fidelity to each core element, to identify trends, and to benchmark measure reporting among 1,350 CAHs across the United States. Responses were mapped to 7 core element categories, and the total number of positive responses were matched to each core element for a specific survey year to track progress. Overall, the measure assessed progress in meeting all 7 core elements, as well as program robustness in the number of actions implemented and the amount of data tracked and reported at each hospital. NHSN reports were generated to tailor technical assistance activities and to assist hospitals with measure uptake and reporting. Results: CAH participation in the NHSN significantly increased from 2014 to 2018 (83% response rate). From 2014 through 2018, reporting of the new antibiotic stewardship measure consistently increased. CAHs that met all core elements increased from 18% (2014) to 73% (2018). Performance-based benchmarks enabled hospital comparisons and the establishment of reporting goals. Conclusions: This study highlights viable approaches to measuring antibiotic stewardship at a national level to drive improvements in care at hospitals of any size. The implementation of the antibiotic stewardship measure across CAHs demonstrates the impact of federal programs like MBQIP for hospitals that are building capacity for quality improvement. For the first time, CAHs were able to measure and compare their implementation of ASPs to other hospitals at the state and national level.

Funding: None

Disclosures: None
Accuracy of Infection Control Surveillance in Identifying Genomically Confirmed Cross Transmission Clusters
Authors: Hansen Kyle , Ellison Richard T. , Ward Doyle V. , Holler Devon J. , Ashworth Judy L. , Fortunato-Habib Mary M. , Carmona Juan J. , Gross Brian D.
Published: November 2020

Background: Infection prevention surveillance for cross transmission is often performed by manual review of microbiologic culture results to identify geotemporally related clusters. However, the sensitivity and specificity of this approach remains uncertain. Whole-genome sequencing (WGS) analysis can help provide a gold-standard for identifying cross-transmission events. Objective: We employed a published WGS program, the Philips IntelliSpace Epidemiology platform, to compare accuracy of two surveillance methods: (i.) a virtual infection practitioner (VIP) with perfect recall and automated analysis of antibiotic susceptibility testing (AST), sample collection timing, and patient location data and (ii) a novel clinical matching (CM) algorithm that provides cluster suggestions based on a nuanced weighted analysis of AST data, timing of sample collection, and shared location stays between patients. Methods: WGS was performed routinely on inpatient and emergency department isolates of Enterobacter cloacae, Enterococcus faecium, Klebsiella pneumoniae, and Pseudomonas aeruginosa at an academic medical center. Single-nucleotide variants (SNVs) were compared within core genome regions on a per-species basis to determine cross-transmission clusters. Moreover, one unique strain per patient was included within each analysis, and duplicates were excluded from the final results. Results: Between May 2018 and April 2019, clinical data from 121 patients were paired with WGS data from 28 E. cloacae, 21 E. faecium, 61 K. pneumoniae, and 46 P. aeruginosa isolates. Previously published SNV relatedness thresholds were applied to define genomically related isolates. Mapping of genomic relatedness defined clusters as follows: 4 patients in 2 E. faecium clusters and 2 patients in 1 P. aeruginosa cluster. The VIP method identified 12 potential clusters involving 28 patients, all of which were “pseudoclusters.” Importantly, the CM method identified 7 clusters consisting of 27 patients, which included 1 true E. faecium cluster of 2 patients with genomically related isolates. Conclusions: In light of the WGS data, all of the potential clusters identified by the VIP were pseudoclusters, lacking sufficient genomic relatedness. In contrast, the CM method showed increased sensitivity and specificity: it decreased the percentage of pseudoclusters by 14% and it identified a related genomic cluster of E. faecium. These findings suggest that integrating clinical data analytics and WGS is likely to benefit institutions in limiting expenditure of resources on pseudoclusters. Therefore, WGS combined with more sophisticated surveillance approaches, over standard methods as modeled by the VIP, are needed to better identify and address true cross-transmission events.

Funding: This study was supported by Philips Healthcare.

Disclosures: None
Comparative Antimicrobial Efficacy of Current Alcohol-Based Hand Rubs: Formulation, Dose, and Test Methods All Matter
Authors: Arbogast James , Parker Albert , Jarvis William , Macinga David
Published: November 2020

Background: Alcohol-based hand rubs (ABHRs) are the primary form of hand hygiene in healthcare settings globally. Many developed countries, and most US hospitals utilize wall-mounted ABHR dispensers throughout the facility. The adoption of automated touch-free dispensers is increasing. However, data on the efficacy of ABHRs when used at dispensed amounts are limited. The evidence is strong, showing that formulation matters (not just alcohol concentration) and that agent volume impacts efficacy. Objective: We evaluated the efficacy of ABHR foams on human hands using 2 controlled test methods at variable volumes (ie, typical doses and realistic volumes that healthcare personnel could use in patient care practice). Methods: We tested 8 commercially available ABHR products, the WHO hand-rub formulation, (P1–P9) and a nonantibacterial foam handwash control (P10) on human participants at 2 different application frequencies (“1 application” and “10 applications”) using 2 different ASTM test methods (E1174 and E2755). Studies using ASTM-E1174 evaluated 3 different application volumes (0.7 mL, 1.1 mL, and 2.0 mL) of the 10 products, each tested on 12–13 subjects. Studies using ASTM-E2755 evaluated a single 1.1 mL volume for the 9 ABHR products (P1–P9), each on 2–12 subjects. A linear mixed-effects model was fit separately to log reductions with random effects for subject and date, and a fixed effect for product. Results: Four different foam formulations (P1–P4) consistently outperformed all other formulations by the E1174 method, especially with increasing volumes and after 10 product applications (Fig. 1). When tested with E2755, all formulations performed similarly, with only P1 and P2 differentiating after 10 applications (Fig. 2). ABHR efficacy consistently increased with larger application volumes, whereas the handwash control (P10) achieved a similar efficacy (∼2 log reduction) at all volumes. Efficacy for some ABHR formulations increased, whereas others decreased with repeated applications. Alcohol concentration did not correlate with log reduction. Conclusions: Formulation and the product application volume affect the antimicrobial efficacy of ABHR; therefore, those data should be critically assessed by healthcare personnel assessing ABHR product performance. Test methods matter: when E1174 was used, greater differentiation between formulations was observed. This may be due to the larger contamination volume and greater soil load used in E1174.

Funding: GOJO Industries, Inc., provided Funding: for this study.

Disclosures: James W. Arbogast and David R. Macinga report salary from GOJO Industries.
Using Machine Learning to Detect Hospital-Specific Risk Factors of Surgical Site Infections
Authors: Kozák Jakub , Vraná Lenka , Vavřinová Petra
Published: November 2020

Background:
Identification of healthcare-associated infections (HAIs) is just a first step in the surveillance of HAIs. The other part is the analysis and interpretation of collected data, which should help to set up effective preventive measures targeted where they are needed the most. General risk factors of HAIs are mostly well known, but how do the environment and processes of each hospital affect risks of HAI? Can advanced methods of data analytics reveal hidden hospital-specific risk factors of surgical site infections (SSIs)? Methods: We analyzed data from electronic health records stored in the clinical information system of Hospital Jihlava, Czech Republic, with 650 beds and 7,500 surgeries performed annually. For each inpatient stay with a surgical procedure, we automatically observed almost 1,500 features that could lead to a higher incidence of SSIs. These features consist of patient demographic data, information from structured data (eg, patient diagnoses, departments, specific rooms, operating theaters, surgeons and other hospital staff participating in the surgery), and information extracted from clinical notes using natural language processing (eg, procedures, invasive devices, and comorbidities). We used a model based on survival analysis to reveal the risk factors that can increase the probability of SSI during the inpatient stay or outpatient care after discharge. Results: We automatically evaluated risk factors weekly for 4 months (July 2019–October 2019). We detected 16 distinct significant risk factors during this period—between 2 and 6 active risk factors each week. For example, patients visiting a specific department were up to 5 times more likely to develop an HAI than the rest of the patients (P < .001). Some of the risk factors revealed were significant only within a short time, and some of them occurred perpetually. When a feature became significant, it was considered an early warning of a problem that should be addressed by the infection prevention and control team. Trends in risk factors coefficients can also help in assessing the performance of the launched preventive measures. Conclusions: Advanced data analytics can effectively uncover hospital-specific risk factors affecting surgical site infections. Such systems can automatically deliver results that can be further explored and used as a basis for targeted preventive measures.

Funding: Datlowe provided support for this study.

Disclosures: Jakub Kozák reports salary from and ownership of Datlowe.
A Descriptive Analysis of Outpatient Antimicrobial Use for Urinary Tract Infections in Virginia
Authors: Mazdeyasna Hasti , Bernard Shaina , Kang Le , Godbout Emily , Lee Kimberly , Pakyz Amy , Noda Andrew , Kim Jihye , Markley John Daniel , Doll Michelle Elizabeth , Bearman Gonzalo , Stevens Michael
Published: November 2020

Background: Data regarding outpatient antibiotic prescribing for urinary tract infections (UTIs) are limited, and they have never been formally summarized in Virginia. Objective: We describe outpatient antibiotic prescribing trends for UTIs based on gender, age, geographic region, insurance payer and International Classification of Disease, Tenth Revision (ICD-10) codes in Virginia. Methods: We used the Virginia All-Payer Claims Database (APCD), administered by Virginia Health Information (VHI), which holds data for Medicare, Medicaid, and private insurance. The study cohort included Virginia residents who had a primary diagnosis of UTI, had an antibiotic claim 0–3 days after the date of the diagnosis and who were seen in an outpatient facility in Virginia between January 1, 2016, and December 31, 2016. A diagnosis of UTI was categorized as cystitis, urethritis or pyelonephritis and was defined using the following ICD-10 codes: N30.0, N30.00, N30.01, N30.9, N30.90, N30.91, N39.0, N34.1, N34.2, and N10. The following antibiotics were prescribed: aminoglycosides, sulfamethoxazole/trimethoprim (TMP-SMX), cephalosporins, fluoroquinolones, macrolides, penicillins, tetracyclines, or nitrofurantoin. Patients were categorized based on gender, age, location, insurance payer and UTI type. We used χ2 and Cochran-Mantel-Haenszel testing. Analyses were performed in SAS version 9.4 software (SAS Institute, Cary, NC). Results: In total, 15,580 patients were included in this study. Prescriptions for antibiotics by drug class differed significantly by gender (P < .0001), age (P < .0001), geographic region (P < .0001), insurance payer (P < .0001), and UTI type (P < .0001). Cephalosporins were prescribed more often to women (32.48%, 4,173 of 12,846) than to men (26.26%, 718 of 2,734), and fluoroquinolones were prescribed more often to men (53.88%, 1,473 of 2,734) than to women (47.91%, 6,155 of 12,846). Although cephalosporins were prescribed most frequently (42.58%, 557 of 1,308) in northern Virginia, fluoroquinolones were prescribed the most in eastern Virginia (50.76%, 1677 of 3,304). Patients with commercial health insurance, Medicaid, and Medicare were prescribed fluoroquinolones (39.31%, 1,149 of 2,923), cephalosporins (56.33%, 1,326 of 2,354), and fluoroquinolones (57.36%, 5,910 of 10,303) most frequently, respectively. Conclusions: Antibiotic prescribing trends for UTIs varied by gender, age, geographic region, payer status and UTI type in the state of Virginia. These data will inform future statewide antimicrobial stewardship efforts.

Funding: None

Disclosures: Michelle Doll reports a research grant from Molnlycke Healthcare.
Evaluation of the Performance and Resource Needs of a Construction Infection Prevention and Control Program
Authors: Devine Eric , Fullerton Jessica , Rebelo Carly , Zebarth Karl , Oxley Alexandra , Hota Susy
Published: November 2020

Background:
The University Health Network (UHN) is a multisite, academic health sciences center in Toronto, Canada, with 1,300 inpatient beds and ∼126,000 emergency department visits annually. Clinical services include a transplant program, cancer center, dialysis units, and rehabilitation sites. Currently, ∼0.83 km2 (>9 million ft2) of UHN real estate, ∼200 construction, renovation and maintenance projects are underway. The UHN Construction Infection Control Program (CICP) was created in 2012 and has expanded to include 3.5 FTEs to meet the needs of infection prevention oversight during these activities. We describe the performance indicators for the UHN CICP between May 2016 and December 2018 that have informed productivity and resource needs. Methods: Since 2016, construction infection preventionists (CIPs) have prospectively collected data on the frequency of activities reflecting CIP productivity and core job functions: number of meetings (attended and missed), site inspections, responses to breaches in control measures, education hours delivered, urgent requests, and after-hours work. Annual activity rates (frequency of activity divided by CIP months) were analyzed for trends, accounting for additions in CICP personnel over time. Results: Human resources and activities performed in the CICP from 2016 to 2018 are outlined in Table 1. As CICP human resources increased, the number of initiatives supported by the CICP team rose. Activity rates for attended meetings, inspections and hours of education provided increased with higher CIP resources, suggesting an improvement in individual productivity of each CIP (Fig. 1). Concurrently, the rate of missed meetings declined and after-hour requests and breach responses remained stable. Conclusions: An appropriately staffed CICP for the volume and risk level of organization-wide construction, renovation, and maintenance activities is crucial to infection prevention. We developed performance indicators based upon key functions of CIPs to evaluate the productivity of our team and ensure we had adequate human resources to maintain patient safety through our evolving needs.

Funding: None

Disclosures: Susy Hota reports contract research for Finch Therapeutics.
Racial Differences in Incidence of Staphylococcus aureus Joint Infections in Metropolitan Atlanta, 2016–2018
Authors: Overton Rahsaan , Sefton Samantha , Thomas Stepy , Fridkin Scott , Webster Andrew , Ray Susan
Published: November 2020

Background:Staphylococcus aureus is the leading cause of joint infections. These infections may arise in native or prosthetic joints. Previous analysis of population-based surveillance has documented racial differences in incidence of invasive S. aureus bloodstream infections. We hypothesized that racial differences in incidence would not persist among of S. aureus joint infections. Methods: We utilized data from the Georgia Emerging Infections Program (GA EIP), which conducts CDC-funded active, population-based surveillance for iSA within the 8-county area of Atlanta. Cases were defined as residents of the surveillance area with S. aureus isolated during 2016–2018 from joint fluid or tissue, and cultures within a 30-day period after the initial culture date were considered a single case. Age- and race-specific incidence were calculated using US census data; incidence rate ratios (RR) and adjusted rate ratios (aRR) were calculated using the Mantel-Hanzel method. Results: Between 2016 and 2018, 500 iSA joint infections were identified (iMRSA, 28.2% and iMSSA, 71.8%): 34.4% occurred in black patients and 65.6% occurred in white patients. Also, 90 cases (18%) had a bloodstream infection (BSI) within 30 days of the joint infection. Incidence of iSA joint infections dropped 22% from 9.4 per 100,000 in 2016 to 7.5 per 100,000 in 2018 (RR, 0.79; 95% CI, 0.7–0.9). Adjusting for year, incidence was 40% lower among blacks than whites (RR, 0.6,; 95% CI, 0.5–0.7); this finding was attributed to blacks having 60% lower incidence of iMSSA joint infections compared to whites (aRR, 0.4; 95% CI, 0.3–0.5) but similar MRSA incidence (aRR, 1.2; 95% CI, 0.8–1.6). The highest incidence was observed among whites aged >65 years with iMSSA infections (30.2 per 100,000) (Fig. 1). Among cases with a full chart review (n = 138), surgery in the prior 90 days was uncommon (n = 42, 30.4%), and a preceding major orthopedic procedure was even more rare (n = 13, 9.4%). Antecedent therapeutic injections and arthroscopic procedures are under investigation. Conclusions: Unlike S. aureus bacteremia, where previous analysis demonstrates higher incidences among blacks predominantly due to MRSA, our data demonstrate that the incidence of S. aureus joint infections is higher in whites, predominantly due to MSSA. Investigations in differential practices regarding orthopedic illness and injury should be pursued.

Funding: None

Disclosures: Scott Fridkin reports that his spouse receives consulting fees from the vaccine industry.
Road to Increasing AMR: A Study on Antibiotics Prescribing Pattern
Authors: Fofanah Bobson Derrick , Conteh Christiana , Weiss Jamine
Published: November 2020

Background: Infectious diseases and the rapid emergence of multidrug-resistant pathogens continue to pose a threat to global health. The development of antimicrobial-resistant organisms is an alarming issue caused by inappropriate use of antibiotic agents. It is estimated that death from antimicrobial resistant pathogens could increase >10-fold to ~10 million deaths annually by 2050 if action is not taken. “It is essential to have reliable data on how medicines are used in order to identify areas to develop targeted interventions” (WHO 2011). Investigating antimicrobial use in hospitals is the first step in evaluating the underlying causes of AMR. In Sierra Leone, no other study related to antibiotic prescribing patterns in hospital setting has been undertaken. Objective: To investigate antibiotic prescription patterns using the WHO hospital antimicrobial use indicator tool at the Kingharman Hospital for 1 month. Methods: Data were collected from patient charts for 1 month, January 1–31, 2019. A data extraction tool was used to capture information on patient demographics, diagnosis, and antibiotics prescription details regarding dosage, duration, and frequency of administration. The tool adopted 6 selected indicators from the WHO antimicrobial use manual to measure the extent of antibiotic use in hospital and performance among prescribers. Results: Of the 189 charts reviewed, 175 included antibiotic prescriptions. The percentage of prescriptions involving antibiotics was 92.5%. The average number of drugs prescribed was 2, with an average duration of 5.2 days. Moreover, 50.5% of antibiotics prescribed were generic, and 96.6% were from the Ministry of Health and Sanitation Essential Medicine List (EML). The most commonly used antibiotics were ciprofloxacin (38.8%), followed by ceftriaxone (23.0%), amoxicillin (16.8%), metronidazole (8.5%), and others(12.7%). Typhoid accounted for 34.8% of broad-spectrum antibiotics, UTI accounted for 17.7%, malaria accounted for 12.5%, 25.5% were unspecified, and 9.5% were for unclear diagnoses. Typically, combinations of fluroquinolones and cephalosporins were used to treat typhoid and UTIs. Conclusions: This cross-sectional study represents a broad picture of antibiotic prescribing patterns at the King Harman Hospital. There was no strict adherence to the WHO recommended prescribing guidelines. These findings also indicate the degree of irrational and inappropriate prescribing of broad-spectrum antibiotics. This study highlights the need for a comprehensive assessment of antimicrobial use to gain a better understanding of national antibiotic use and to guide interventions to reducing AMR.

Funding: None

Disclosures: None

If I am discussing specific healthcare products or services, I will use generic names to extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company.

Disagree

Christiana Kallon
The Design and Implementation of an IPC Certificate Course: Experiences From Sierra Leone
Authors: Weiss Jamine , Kolwaite Amy , Lyman Meghan , Kassa Getachew , Rabkin Miriam , Maruta Anna , Murrman Marita , Benya Hassan , Conteh Christiana
Published: November 2020

Background: Trained infection prevention and control (IPC) practitioners are critical to reducing healthcare-associated infections (HAI) and improving patient safety. Despite having HAI rates 3 times higher than high-income countries, many low- and middle-income countries (LMICs) lack trained IPC professionals. During the 2014–2016 Ebola outbreak in West Africa, the Sierra Leone Ministry of Health and Sanitation (MoHS) recognized this need and appointed and trained IPC focal persons at all district hospitals. Following the outbreak, MoHS requested assistance from the US CDC to develop and implement a comprehensive IPC training program for IPC specialists. Methods: The CDC, alongside its partners, convened a multidisciplinary team to develop an IPC certificate course. ICAP led the curriculum development process using a “backwards design” approach, starting with development of competencies and learning objectives, then designing an evaluation framework and learning strategies, and finally, identifying course content. The curriculum was based on existing resources, primarily designed for high-income countries, which were adapted to the Sierra Leone context and aligned with national IPC policies and guidelines. Additionally, an IPC steering committee, led by MoHS, was established to provide national leadership and oversight and make country-level decisions regarding accreditation and career pathways for IPC specialists. Results: The course includes three 2-week workshops over 6 months consisting of classroom didactics and hands-on activities. Topics include standard and transmission-based precautions, microbiology, laboratory, HAI, quality improvement, leadership, and scientific writing. Between sessions, participants conduct IPC activities at their work site and share results during subsequent workshops. Participants receive electronic tablets, which contain course content, assessment tools, and references, to upload their work into a cloud-based storage system for facilitators to provide feedback. They also receive in-person mentorship and connect with peers through a group messaging platform to share lessons learned. Participants’ knowledge and skills are assessed using a before-and-after test and observing them perform IPC practices using standardized checklists. The first cohort of 25 participants will complete the course in November 2019. Conclusions: The IPC certificate course is the first comprehensive, competency-based IPC training in Sierra Leone. Successes, challenges, sustainability, and lessons learned remain to be determined; however, based on similar models, the course has the potential to significantly improve IPC in Sierra Leone. Additionally, it is a model that can be replicated in other resource-limited settings.

Funding: None

Disclosure:None
Use of a Multidisciplinary Incident Command System in Response to Measles Outbreak in Maryland
Authors: McIlquham Taylor , Sick-Samuels Anna , Billman Carrie , Andonian Jennifer , Dudley Melissa , Husain Amyna , Maloney Robert , Oruc Cagla , Brown Mary , Maragakis Lisa , Milstone Aaron Michael
Published: November 2020

Background: Measles is a highly contagious virus that reemerged in 2019 with the highest number of reported cases in the United States since 1992. Beginning in March 2019, The Johns Hopkins Hospital (JHH) responded to an influx of patients with concern for measles as a result of outbreaks in Maryland and the surrounding states. We report the JHH Department of Infection Control and Hospital Epidemiology (HEIC) response to this measles outbreak using a multidisciplinary measles incident command system (ICS). Methods: The JHH HEIC and the Johns Hopkins Office of Emergency Management established the HEIC Clinical Incident Command Center and coordinated a multipronged response to the measles outbreak with partners from occupational health services, microbiology, the adult and pediatric emergency departments, marketing and communication and local and state public health departments. The multidisciplinary structure rapidly developed, approved, and disseminated tools to improve the ability of frontline providers to quickly identify, isolate, and determine testing needs for patients suspected to have measles infection and reduce the risk of secondary transmission. The tools included a triage algorithm, visitor signage, staff and patient vaccination guidance and clinics, and standard operating procedures for measles evaluation and testing. The triage algorithms were developed for phone or in-person and assessed measles exposure history, immune status, and symptoms, and provided guidance regarding isolation and the need for testing. The algorithms were distributed to frontline providers in clinics and emergency rooms across the Johns Hopkins Health System. The incident command team also distributed resources to community providers to reduce patient influx to JHH and staged an outdoor measles evaluation and testing site in the event of a case influx that would exceed emergency department resources. Results: From March 2019 through June 2019, 37 patients presented with symptoms or concern for measles. Using the ICS tools and algorithms, JHH rapidly identified, isolated, and tested 11 patients with high suspicion for measles, 4 of whom were confirmed positive. Of the other 26 patients not tested, none developed measles infection. Exposures were minimized, and there were no secondary measles transmissions among patients. Conclusions: Using the ICS and development of tools and resources to prevent measles transmission, including a patient triage algorithm, the JHH team successfully identified, isolated, and evaluated patients with high suspicion for measles while minimizing exposures and secondary transmission. These strategies may be useful to other institutions and locales in the event of an emerging or reemerging infectious disease outbreak.

Funding: None

Disclosures: Aaron Milstone reports consulting for Becton Dickinson.
Validation of Administrative Codes for Identification of Staphylococcus aureus Infections Among Electronic Health Data
Authors: Rose Ashley , Gokhale Runa , See Isaac , Baggs James , Slayton Rachel , Fridkin Scott , Hatfield Kelly
Published: November 2020

Background: Epidemiological studies have utilized administrative discharge diagnosis codes to identify methicillin-resistant and methicillin-sensitive Staphylococcus aureus (MRSA and MSSA) infections and trends, despite debate regarding the accuracy of utilizing codes for this purpose. We assessed the sensitivity and positive predictive value (PPV) of MRSA- and MSSA-specific diagnosis codes, trends, characteristics, and outcomes of S. aureus hospitalizations by method of identification. Methods: Clinical micro biology results and discharge data from geographically diverse US hospitals participating in the Premier Healthcare Database from 2012–2017 were used to identify monthly rates of MRSA and MSSA. Positive MRSA or MSSA clinical cultures and/or a MRSA- or MSSA-specific International Classification of Diseases, Ninth/Tenth Revision, Clinical Modification (ICD-9/10 CM) diagnosis codes from adult inpatients (aged ≥18 years) were included as S. aureus hospitalizations. Septicemia was defined as a positive blood culture or a MRSA or MSSA septicemia code. Sensitivity and PPV for codes were calculated for hospitalizations where admission status was not listed as transfer; true infection was considered a positive clinical culture. Negative binominal regression models measured trends in rates of MRSA and MSSA per 1,000 hospital discharges. Results: We identified 168,634 MRSA and 148,776 MSSA hospitalizations in 256 hospitals; 17% of MRSA and 21% of MSSA were septicemia. Less than half of all S. aureus hospitalizations (49% MRSA, 46% MSSA) and S. aureus septicemia hospitalizations (37% MRSA, 38% MSSA) had both a positive culture and diagnosis code (Fig. 1). Sensitivity of MRSA codes in identifying positive cultures was 61% overall and 56% for septicemia, PPV was 62% overall and 53% for septicemia. MSSA codes had a sensitivity of 49% in identifying MSSA cultures and 52% for MSSA septicemia; PPV was 69% overall and 62% for septicemia. Despite low sensitivity, MRSA trends are similar for cultures and codes, and MSSA trends are divergent (Fig. 2). For hospitalizations with septicemia, mortality was highest among those with a blood culture only (31.3%) compared to hospitalizations with both a septicemia code and blood culture (16.6%), and septicemia code only (14.7%). Conclusions: ICD diagnosis code sensitivity and PPV for identifying infections were consistently poor in recent years. Less than half of hospitalizations have concordant microbiology laboratory results and diagnosis codes. Rates and trend estimates for MSSA differ by method of identification. Using diagnosis codes to identify S. aureus infections may not be appropriate for descriptive epidemiology or assessing trends due to significant misclassification.

Funding: None

Disclosures: Scott Fridkin reports that his spouse receives consulting fees from the vaccine industry.
VRE Screening and Isolation: One Size Does Not Fit All
Authors: Vaisman Alon , Mistry Smit , Zanchettin Sarah , Hota Susy
Published: November 2020

Background: The need for screening and isolation for patients colonized with vancomycin-resistant Enterococcus (VRE) remains controversial. In this study, we examined the effects of discontinuation and reinstatement of these practices on VRE infection and colonization incidence within a multisite, tertiary-care hospital center, including its effects on specific at-risk groups. Methods: We retrospective analyzed VRE clinical isolate, infection, and bacteremia incidence rates at our hospital (1) prior to discontinuation of universal screening and isolation (January 2010–June 2012), (2) during discontinuation (July 2012–April 2017), and (3) after reinstatement of screening and isolation in high-risk wards (intensive care and multiple-organ transplant units, June 2017–April 2019). Monthly incidence rates were calculated for each of 3 sites at our tertiary-care hospital: site A, which includes the transplant program, site B, an adult cancer hospital, and site C, which includes orthopedic and neurology programs. To understand the differential effect of screening and isolation on various risk groups, incidence rates were also calculated for individual programs within our hospital, including medicine, surgery, intensive care, oncology, and transplant programs. Results: During the period of study, 3,167 cases of VRE isolates were identified. Patient colonizations of VRE across the institution increased throughout the study period, with the monthly number of newly colonized patients increasing from 10.4 in the first period of study to 20.6 in the last period. The overall VRE clinical isolate, infection, and bacteremia incidence rates did not increase following the cessation of VRE screening and isolation precautions; however, a significant increase was seen among the patients at site B (Fig. 1, infection rates). Furthermore, there was a significant decrease in VRE clinical isolate, infection, and bacteremia incidence following the reinstatement of screening in the ICU and transplant programs at site A, but no effect was seen in the other programs (Fig. 2, infection rates). Conclusions: The risk associated with discontinuing VRE screening and isolation measures appears depend on the subgroup of patients within a hospital environment. Furthermore, risk-based or unit-based VRE screening and isolation appears to be effective at controlling VRE incidence, even after measures had previously been discontinued. Additional study of other inpatient settings is warranted to determine the effects of screening and isolation for VRE on other patient subgroups.

Funding: None

Disclosures: Susy Hota reports contract research for Finch Therapeutics.
Competency of Infection Preventionists in Japan
Authors: Misao Hanako , Kawakami Kazumi
Published: November 2020

Backgrounds: In the United States, the Association for Professionals in Infection Control and Epidemiology (APIC) announced a competency model for infection preventionists (IP) in 2011. On the other hand, IPs in Japan must develop their career by themselves because there are no guidelines of career development for Japanese IPs. In recent years, infectious diseases and infection control issues have become more global. Objective: Aiming for international collaboration among IPs, the purpose of this study were to clarify the actual competencies of IPs in Japan and the United States and to compare the competencies of both. We report on the competencies of IPs in Japan. Methods: Semistructured interviews were conducted with 67 certified nurses in infection control (CNIC) who responded to the translated version of the APIC Competency Model Assessment Tool. From the qualitative descriptive analysis of interview verbatim records, we extracted the behavioral characteristics and completed the questionnaire “Survey of Competency for Infection Preventionist,” which consisted of 130 items. A survey form was created using Survey Monkey. We sent e-mails to ask anonymous survey collaboration, including the URL of the survey form, to 2,284 CNIC and CNS in infection control professionals. The research was approved by the research ethics committee at the facility to which the researcher belongs (Juntendo University, approval no. 30–49). Results: The number of responses was 648 and the response rate was 28.4%. The mean years of experience as nurses of 648 respondents was 24.7 (SD, 6.9), and >60% belonged to general hospitals. The scores of mean and standard deviation of each category were as follows: “Clarification of infectious disease process” (mean, 79.1; SD, 13.2); “HAI surveillance and epidemiological survey” (mean, 49.3; SD, 12.3); “Prevention and control of transmission of infectious microorganisms” (mean, 93.8; SD, 17.3); “Management and communication” (mean, 128.5; SD, 23.7); “Education and Research” (mean, 56.8; SD, 11.0); “Employee and occupational health” (mean, 40.6; SD, 9.6); and the total score of all categories (mean, 449.4; SD, 74.4). Based on years of experience as infection preventionists, we divided them into 3 groups: beginners, competent, and experts. As the career level increased, each category score for competency increased (ANOVA, P < .001). However, the mean scores of competency did not reach 70% of the total score for the following categories: “Prevention and control of transmission of infectious microorganisms.” “Education and research,” and “Employee and occupational health.” Conclusions: The competencies that need to be strengthened for the career development of Japanese IPs have been clarified.

Funding: This study was supported by JSPS KAKENHI.

Disclosures: None
Developing a Competency Model for Nurses Certified in Infection Control in Japan
Authors: Kawakami Kazumi , Misao Hanako
Published: November 2020

Background: In July 2019, 2,793 nurses were registered as certified nurse in infection control (CNIC) at the Japanese Nursing Association (JNA). Most CNICs work as full-time infection preventionists (IPs) in hospitals. However, a competency model for CNICs has not been developed in Japan yet. Therefore, we developed a competency model for CNICs. Methods: We conducted a 2-phase explanatory sequential mixed-methods study between November 2013 and October 2019. The participants were 1,711 CNICs listed on the JNA website. Phase 1 was a cross-sectional study using self-administered questionnaires that included 10 competency domains based on the Association for Professionals in Infection Control and Epidemiology Competency Assessment Tool. Considering years of experience as an IP and full-time position, participants’ career stages were novice, competent, proficient, and expert. The CNICs who answered the questionnaire were included in the interview during phase 2, which was a descriptive qualitative study. Specifically, 10–30 participants were selected from each career stage. Semi-structured individual interviews were conducted, and verbatim transcripts were analyzed qualitatively. The knowledge, skills, and abilities of CNICs were extracted at each career stage. This study was approved by the Research Ethics Committee of Juntendo University (approval no. 25-27). Results: During phase 1, 1,711 CNICs were invited to participate: 975 returned the questionnaire (57% response rate) and 969 (99.3%) responses were valid and used in the analysis. Only 257 participants agreed to attend the interviews. In phase 2, interviews were conducted with 67 CNICs: 30 novice, 20 competent, 13 proficient, and 4 expert. The mean years of experience as a nurse and CNIC were 22.2 (SD, 7.0) and 5.3 (SD, 3.1), respectively. As the career stage advanced, the contents and range of infection prevention role and activities in the hospital or community expanded across competency domains. In clarification of infection process, one of the crucial competencies, the novice needed to consult reference material about the infectious disease each time due to lack of knowledge. Although the competent CNICs understood the frequent occurrence of infectious disease, they needed the specialist’s advice. However, the proficient and expert CNICs could interpret information independently, and importantly, expert CNICs could distinguish between what they know and do not know. Conclusions: Using an explanatory sequential mixed-methods approach, we developed a competency model for CNICs that may encourage CNICs to develop their expertise and that is useful in assessing the qualities or abilities of CNICs. In the future, this model can be used to develop systematic educational programs for CNICs.

Funding: This study was supported by JSPS KAKENHI.

Disclosures: None
Effectiveness of Dry Hydrogen Peroxide on Reducing Environmental Microbial Bioburden Risk in a Pediatric Intensive Care Unit
Authors: Melgar Mario , Ramirez Marylin , Matheu Laura , Gomez Miguel , Ferrolino Jose Amadeo
Published: November 2020

Background: Environmental contamination is a known risk factor for healthcare-associated infection acquisition. Transmission of pathogens from the environment can occur from indirect or direct patient contact with the environment or via healthcare workers’ hands. Dry hydrogen peroxide (DHP) has been shown to reduce microbial contamination in the hospital setting. This novel technology allows safe delivery of hydrogen peroxide in an occupied space, using ambient air and humidity to help create DHP. This study describes the implementation of DHP as an adjunct to routine environmental cleaning and disinfection, with the goal of reducing air and surface microbial bioburden in the intensive care unit (ICU) of a pediatric oncology hospital in Guatemala. Methods: A prospective IRB-approved study was conducted. Two rooms served as controls and 2 rooms served as intervention DHP sites. Air and surface cultures (5 high-touch, 2 low-touch) and adenosine triphosphate (ATP) swabs were collected from study areas for 1 week prior to deployment of the portable DHP units and at various time points for 1 month during the intervention phase. Air samples were collected using settling plates. The level of microbial burden was measured using colony-forming units (CFU) and ATP levels. A comparison between groups was carried out using Poisson regression analyses for CFU counts and linear regression analyses for log-transformed ATP levels. Results: In total, 280 surface cultures and ATP surface swabs were collected and analyzed. The overall mean microbial burden was significantly reduced in the intervention group compared to the control group (mean, 5.50 vs 11.77; P ≤ .0001). Reductions in microbial CFU were observed across all sampling sites in the intervention group. ATP readings in both control and intervention group showed passing levels of surface cleanliness. ATP was measured in terms of relative light units (RLU). A reduction in the mean RLU levels was also noted in the intervention group compared to the control group (172.08 vs 225.83; P ≤ .006). A reduction in aerobic CFU was seen as well in the air samples in the intervention group but was not statistically significant (P = .139). The ICU census was full, and services were not affected. Conclusions: DHP was effective in reducing surface and air microbial bioburden in an occupied space. Further studies of the impact of DHP decontamination on incidence of nosocomial infections should be performed.

Funding: This study was supported by Synexis.

Disclosures: None
Evaluation of a Continuous Decontamination Technology in an Intensive Care Unit
Authors: BSN Tami Inman , Chansolme David
Published: November 2020

Background: The scientific literature increasingly indicates the need for the development of continuous disinfection to address the persistent contamination and recontamination that occurs in the patient rooms despite routine cleaning and disinfection. Methods: To determine a baseline microbial burden level on patient room surfaces in the intensive care unit (ICU) of a large urban hospital, 50 locations were swabbed for total colony-forming units (CFU) and the prevalence of methicillin-resistant Staphylococcus aureus (MRSA). Once the baseline in ICU patient rooms was established, 5 novel decontamination devices were installed in the HVAC ducts near these patient rooms. The devices provide a continuous low-level application of oxidizing molecules, predominately hydrogen peroxide. These molecules exit the duct and circulate in the patient room through normal convection, landing on all surfaces. After activation, environmental sampling was conducted every 4 weeks for 4 months. The effect from continuous low levels of oxidizing molecules on the intrinsic microbial burden and the prevalence of MRSA were analyzed. In addition to external laboratory reports, the facility tracked healthcare-associated infections (HAIs) in the unit. HAI data were averaged by month and were compared to the preactivation average in the same unit. Results: The preactivation average microbial burden found on the 50 locations were 179,000 CFU per 100 in2. The prevalence of MRSA was 71% with an average of 81 CFU per 100 in2. After activation of the devices, levels of microbial burden, prevalence of MRSA, and average monthly HAI rates were all significantly lower on average: 95% reduction in average microbial burden (8,206 CFU per 100 in2); 81% reduction in the prevalence of MRSA (13% vs 71%); 54% reduction in the average of healthcare-onset HAIs. All data were obtained from the averages of sampling data for 4 weeks during the 4-month trial period. Conclusions: The continuous application of low levels of oxidizing molecules throughout the patient rooms of an ICU demonstrated 3 outcomes: reduced overall surface microbial burden, lowered the incidence of MRSA, and significantly decreased the monthly average HAI rate. Please note, the ICU ran other infection prevention interventions at this time, including standard cleaning, as well as and their standard disinfecting techniques.

Funding: This study was supported by the CASPR Group.

Disclosures: None
Impact of Antimicrobial Stewardship Programs in Latin American Adult Intensive Care Units: PROA-LATAM Project
Authors: Quirós Rodolfo , Angeleri Patricia , Zurita Jeannete , Aleman Washington , Carneiro Marcelo , Guerra Silvia , Medina Julio , Luquerna Ximena Castañda , Guerra Alexander , Vega Silvio , Cuéllar Luis , Munita Jose , Maki Gina , Prentiss Tyler , Escobar Elvio , Foianini Ángel , Zervos Marcus , Bardossy Ana
Published: November 2020

Background: Antimicrobial stewardship programs (ASPs) are useful in improving clinical outcomes in a cost-effective way and in reducing antimicrobial resistance. Objective: We sought to determine the impact of ASP in adult medical-surgical intensive care units (MS-ICUs). Methods: A multicenter study, in 77 MS-ICUs of 9 Latin-American countries, was conducted along 12 months (July 2018–June 2019). A self-assessment survey using a tool based on CDC recommendations (0–100 scale) was performed at the beginning, after 6 months, and at the end of the study. The impact of ASP was evaluated monthly using the following indicators: antimicrobial consumption (defined daily doses [DDD] per 100 patient days), appropriateness of antimicrobial prescriptions (percentage of total prescriptions), crude mortality rate (events per 100 discharges), and hospital-acquired multidrug-resistant microorganisms (MDRs) and Clostridioides difficile infections (CDI events per 1,000 patient days). These indicators were compared between MS-ICUs that reached the 75th percentile and those that maintained the 25th percentile at the final self-assessment. Results: Of all indicators evaluated, only surgical prophylaxis ≤24 hours, vancomycin therapeutic monitoring, and aminoglycosides (1 dose per day) did not show significant differences between MS-ICUs at the 75th percentile and the 25th percentile. CDI events were significantly higher at the 75th percentile MS-ICUs, probably related to better detection of C. difficile (Table 1). Conclusions: This study confirmed that MS-ICUs with more comprehensive ASPs had significantly better indicators.

Funding: Proprietary Organization: MERCK

Disclosures: None