bluuebunny/crossref_metadata_2025 huggingface dataset:
Recent Respiratory Tract Infection and Additional Surgeries Increase Risk for Surgical Site Infection in Total Joint Arthroplasty: A Retrospective Analysis of 2255 Patients
Authors: Navalkele Bhagyashri , Krishna Amar , McKelvey George , Perov Samuel , Sood Kunal , Dakallah Youssef , Chopra Teena
Published: October 2017

Background

Surgical site infections (SSI) are one of the most common healthcare-associated infections contributing to high economic burden. Around 658,000 total joint arthroplasties (TJA) are performed annually in the Unites States, estimated 0.9–2.5% develop surgical site infection. Despite following prevention guidelines, SSI continues to occur. The aim of our study was to identify perioperative risk factors for SSI in patients undergoing TJA.

Methods

A retrospective cohort study was performed of patients at the Detroit Medical Center from 2011 to 2015. All adult patients undergoing primary or revision total knee or hip joint arthroplasty were included. Patients were divided into SSI (prosthetic joint infections) and non-SSI group. Baseline characteristics and perioperative variables influencing SSI were assessed. Statistical analysis was performed using SAS software. Continuous variables were compared using Wilcoxon–Rank-sum test and categorical variables using Fischer’s exact test.

Results

Among 2255 included patients, 1203 had knee arthroplasties (53%), 1052 had hip arthroplasties (47%) and SSI occurred in 46 patients (2%). Overall, mean age was 58.81 ± 11 years; 64% were females, 57% were African American, and 41% were smokers. Diabetes did not increase risk for SSI (37% with SSI vs. 26% without SSI; P = 0.09). Administration of general anesthesia, American Society of Anesthesiologists score of ≥2, the presence of hypothermia and hyperglycemia did not statistically increase the risk for SSI. Patients with recent respiratory tract infection in previous 30 days prior to surgery were more likely to develop infection compared with patients without recent infection (20% vs. 6.6%, OR 3.42; 95% confidence interval 1.62–7.22, P = 0.0034). Any additional surgery within 90 days of arthroplasty increased risk for infection (22% vs. 11%, P = 0.03). Among the 46 SSIs, knee surgeries experienced more infections than hip surgeries (67% vs. 33%, P = 0.07).

Conclusion

In this study, recent respiratory tract infection in 30 days prior to surgery and additional surgeries within 90 days after arthroplasty increased risk for SSI. Careful preoperative assessment and sufficient time to postoperative recovery is essential to reduce SSI. Further multicenter studies are needed to validate our findings.

Disclosures

All authors: No reported disclosures.
High-Level Neisseria gonorrhea Resistance Detected in a Newly Implemented Surveillance Program in Kampala, Uganda
Authors: Workneh Meklit , Lamorde Mohammed , Kakooza Francis , Mbabazi Olive , Mugasha Rodney , Walwema Richard , Manabe Yukari , Musinguzi Patrick
Published: October 2017

Background

Neisseria gonorrhea resistance is a growing problem in Uganda with recent data showing increasing ciprofloxacin resistance up to 100% in this population. The WHO Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP) was initiated in Uganda in September 2016 to monitor resistance trends.

Methods

Urethral swabs were collected from men presenting with urethral discharge to the five sentinel clinic sites from September 2016 to March 2017. Samples were transported to a reference laboratory site. Presumptive identification of N. gonorrhea was based on growth of typical appearing colonies on Thayer–Martin in 5% CO2, a positive oxidase test, and observation of Gram-negative, oxidase-positive diplococci in stained smears.

Results

116 samples were received to the reference laboratory site of which 70 (60.3%) had positive growth for Neisseria gonorrhea. Mean age was 28.5 (range 17–60). Fifty-one participants (44%) reported at least one prior episode of gonorrhea and 42 (36%) reported antibiotic use within the previous 60 days. Of those with completed Etest (bioMerieux, Marcy-lÕEtoile, France) resistance profiles, 66 (96%) were ciprofloxacin-resistant or intermediate. One isolate was ceftriaxone-resistant by E-test but susceptible by disk diffusion.

Conclusion

Early results from implementation of a gonorrhea surveillance program in Uganda suggest high levels of resistance to ciprofloxacin (90%) by Etest and penicillin (93%) and tetracyclines (100%) by disk diffusion. Prior studies of gonococcal resistance in Uganda have noted increasing levels of resistance, particularly to ciprofloxacin which until 2010 was the recommended first-line empiric therapy for gonococcal infection in Uganda. Of note, discrepancies were occasionally noted between disk diffusion and Etest results, which requires further investigation. Ongoing surveillance efforts will be crucial to shape clinical guidelines and national policy.

Disclosures

All authors: No reported disclosures.
Extragenital Gonorrhea and Chlamydia Testing Among Women Reporting Extragenital Exposure at an Urban STD Clinic: Is It Worth the Cost?
Authors: Caragol Laura , Voegeli Christopher , Mettenbrink Christie , Wendel Karen , Rietmeijer Cornelis
Published: October 2017

Background

Current guidelines only recommend screening for gonorrhea (GC) and chlamydia (CT) at extragenital sites of exposure in men who have sex with men (MSM). With Medicaid reimbursement for GC/CT nucleic acid amplification testing (NAAT) at approximately $48/test, expanding testing to women requires a value assessment. We report the prevalence of extragenital GC/CT in women with extragenital exposure, determine the proportion of disease missed by urogenital NAAT, and estimate additional cost per infection identified by extragenital testing in women vs MSM.

Methods

We conducted a retrospective analysis of women undergoing extragenital NAAT for GC and CT at Denver Metro Health Clinic. Data were analyzed for all women with extragenital testing from 9/11/2015 to 7/8/2016, and for MSM from 9/3/2013 to 7/8/2016. Statistical Package for the Social Sciences and Excel programs were used for data analysis.

Results

In a total 804 female visits, the mean age was 29 (13–67years); 46% were White non-Hispanic; 37% were Hispanic; and 15% were Black. In women, the prevalence of extragenital GC and CT was 2% (16/804) and 5% (38/804), respectively. The rate of GC infection in women was the same at genital and pharyngeal sites (2%, 16/804) but lower at the rectum (0.25%, 2/804). Female chlamydia rates were 11% genital (85/804), 4% pharyngeal (30/804), and 1.4% rectal (11/804). If only urogenital testing had been performed in women, 27% (6/22) of GC infections and 14% (14/99) of CT infections would have been missed. Overall, isolated extragenital infection accounted for 18% (20/111, 95% CI 12–26%) and 65% (943/1453, 95% CI 62–67%) of the combined GC and CT burden in women and MSM, respectively. On average, 40 women and five MSM were screened with extragenital tests to identify one isolated extragenital infection. Estimated additional Medicaid costs for isolated extragenital infection identified in women was $3,851 and in men was $480 for pharyngeal and rectal testing.

Conclusion

Urogenital screening misses a significant number of extragenital infections in women. However, given the high cost of extragenital screening in women, further work is needed to determine whether screening can be limited to the pharynx or if risk factors can be used to target screening for cost savings.

Disclosures

All authors: No reported disclosures.
Association Between Hospital-Onset Clostridium difficile infection and Admission to a Multi-Bed Room: A Case–control Study
Authors: Vaisman Alon , Jula Michael , Wagner Jessica , Winston Lisa G
Published: October 2017

Background

Few studies have directly examined the link between assignment to a multi-bed vs. single-bed room and the risk for hospital onset C. difficileinfection (HO-CDI). Therefore, in this case–control study, we investigated whether assignment to a single-bed room reduced the risk of HO-CDI in adult inpatients on medical/surgical floors.

Methods

Consecutive cases of HO-CDI, defined as adult patients admitted to San Francisco General Hospital with a new positive C. difficile stool test >72 hours after admission, were identified for the period between January 1, 2010 to December 31, 2015. Patients who first tested positive for C. difficilein the ICU or who had a history of CDI within the last 12 months were excluded. Controls were selected from the general medical/surgical inpatient population using incidence density sampling and matched to cases on the basis of admission unit and length of admission. A multi-bed room was defined as any room with one or more roommates. A multivariate cox proportional hazard model was used to estimate the relationship between room assignment (single vs. multi-bed) and development of HO-CDI. Variables included in the model, on the basis of a directed acyclic graph, were length of admission, HIV infection, and age.

Results

184 cases and 373 controls were identified during the study period. The median ages of cases and controls were 60 years and 56 years, and mean Charlson comorbidity scores were 3.8 and 3.7, respectively. The hazard ratio for the development HO-CDI associated with multi-bed room exposure was 2.32 (P = 0.03) with a 95% CI for the hazard ratio of 1.05 to 5.17.

Conclusion

In this study, assignment of patients to multi-bed rooms on general medical and surgical wards was associated with an increased hazard for the development of HO-CDI. This finding, especially if confirmed in other institutions, could have implications for patient room assignment and hospital design.

Disclosures

All authors: No reported disclosures.
Derivation and Validation of a Clinical Prediction Rule for Complications of Clostridium difficile Infection Using a Multicenter Prospective Cohort
Authors: Chakra Claire Nour Abou , Mcgeer Allison , Labbé Annie-Claude , Simor Andrew E , Gold Wayne , Muller Matthew P , Powis Jeff , Katz Kevin , Cadarette Suzanne , Pépin Jacques , Garneau Julian R , Valiquette Louis
Published: October 2017

Background

Clostridium difficileinfection (CDI) outbreaks were associated with increase in unfavorable outcomes. Identifying and predicting risk of developing complications (cCDI) early in the course of illness could improve clinical decision-making. We developed and validated a prediction rule for cCDI.

Methods

Adult inpatients with confirmed CDI in 10 Canadian hospitals were enrolled and followed for 90 days. Data within 48h of CDI diagnosis were collected: demographics, underlying illnesses, past medical and drug history, clinical signs, blood tests, and strain ribotype. cCDI was defined as one or more of: colonic perforation, toxic megacolon, colectomy, need of vasopressors, ICU admission due to CDI, or if CDI contributed to 30-day death. Predictors’ selection was supported by experts’ opinion suggesting 17 clinical criteria. Cross-validation technique was used (2:1 ratio) and multivariable logistic regression for predictive modeling in the derivation subset. The optimal model was assessed by area under ROC curve (AUC) and prediction error (PE). A predictive score was built by assigning points proportional to adjusted risk estimates.

Results

Among 1380 patients enrolled, 1050 were used for predictive modeling (median age 70 years and one-third infected by ribotype 027 strains). Cases were split into training (n = 700) and validation sets (n = 350). A cCDI occured in 8% and 6.6% respectively. The optimal model with a PE of 5% and an AUC of 0.84 in the validation set included WCC (< 4, 12–19.9, or ≥20 × 109/L), BUN≥11 mmol/L, serum albumin <25 g/L, heart rate > 90/minute, and respiratory rate >20/minute. A predictive score of min 0 and max 13 points was derived. A score ≥7 points was associated with 70% cases of cCDI, showed 68% sensitivity (95% CI, 55–80) in the derivation set and 70% (51–88) in the validation set, a specificity of 73% (69–76) and 76% (72–81) respectively, 17% PPV (9–25), and 97% NPV (95–99) in both sets.

Conclusion

Using a large multicenter prospective cohort and robust modeling approach, we derived a predictive score that included easily available measures at the bedside. The score showed acceptable performance. Further validation is needed on cohorts with different characterstics (non-outbreak setting, higher rate of cCDI). Other approaches such as combination of biomarkers could be more predictive of cCDI.

Disclosures

J. Powis, Merck: Grant Investigator, Research grant; GSK: Grant Investigator, Research grant; Roche: Grant Investigator, Research grant; Synthetic Biologicals: Investigator, Research grant
External validation of clinical scores to predict complications of Clostridium difficile infection
Authors: Beauregard-Paultre Catherine , Chakra Claire Nour Abou , Mcgeer Allison , Labbé Annie-Claude , Simor Andrew E , Gold Wayne , Muller Matthew P , Powis Jeff , Katz Kevin , Cadarette Suzanne , Pépin Jacques , Garneau Julian R , Valiquette Louis
Published: October 2017

Background

Clostridium difficile infection (CDI) is the most common cause of nosocomial diarrhea. About one in 5 patients with CDI (median 18%) develop a complication (cCDI), including mortality. Many predictive scores have been published to identify patients at risk of cCDI but none is currently recommended for clinical use and few were validated. We conducted an external validation study of predictive tools for cCDI.

Methods

Predictive tools were identified through a systematic review. We included those reporting at least an internal validation process. We performed the external validation on a multicenter prospective cohort of 1380 Canadian adults with confirmed CDI. Most cases were elderly (median age 71), had a healthcare facility-associated CDI (90%), and cCDI occurred in 8%. NAP1 strain was found in 52%. The performance of each scoring system was analyzed using individual outcomes. Modifications in predictors were made to match available data in the validation cohort.

Results

We assessed 3 predictive scores and one predictive model. The performance (95% CI) of higher thresholds are shown in the Table. All scores had a low sensitivity and PPV, and moderate specificity and NPV. The model of Shivashankar 2013 (age, WBC> 15, narcotic use, antacids use, creatinine ratio > 1.5) predicted 25% probability of cCDI. All showed similar AUC (0.63–0.67).

Conclusion

The predictive tools included in our study showed moderate performance in a validation cohort with a low rate of cCDI and high proportion of NAP1 strains. Further research is needed to develop an accurate predictive tool to guide clinicians in the management of CDI.

Disclosures

J. Powis, Merck: Grant Investigator, Research grant; GSK: Grant Investigator, Research grant; Roche: Grant Investigator, Research grant; Synthetic Biologicals: Investigator, Research grant
A Nurse-Driven Protocol to Reduce Hospital-Acquired Clostridium difficile Infections
Authors: Nanayakkara Deepa , Mejia Eveline , Nanda Neha
Published: October 2017

Background

Clostridium difficile infection (CDI) is one of the most common healthcare-associated infections. Timely diagnosis is key to reducing associated morbidity and costs. Healthcare-onset (HO) CDI is defined as infection diagnosed 72 hours after hospitalization. Centers for Medicare and Medicaid Services has established benchmarks for HO-CDI for hospitals, which are based on several factors including type of hospital and case mix index. There is a financial penalty if we are above the benchmark. In 2016, 20% of our community-onset C. difficile (CO-CDI) cases were misclassified as HO-CDI. In order to reduce this misclassification, we established a process to assist in early diagnosis.

Methods

We designed and implemented a nurse-driven C. difficile screening protocol to assist in early identification of CO-CDI. Every patient admitted to Keck Hospital (KH) (401 beds) and Norris Comprehensive Cancer Center (35 beds) was screened for diarrhea within the past 24 hours. If diarrhea was present, additional questions were used to capture CO-CDI cases. A nursing order for C. difficile testing was activated for patients who met any of these criteria. Additionally, we used Bristol stool scale (BSS) to standardize stool collection. Only Bristol stool type 7 was accepted by laboratory for processing. Our study period was January 1st through April 30th, 2017 and our baseline period was January 1st through April 30th, 2016.

Results

Screening protocol and BSS were introduced on January 1st, 2017. During the baseline period, a total of 351 orders were placed with 31% within first 3 days of admission. During the study period, a total of 200 orders were placed with 43% within 3 days of admission. Compliance with using the screening tool was nearly 100%. Inter-rater reliability between nurses and lab for identifying the correct BSS was 100%. Baseline misclassification rate was 16%. With the introduction of this screening tool, misclassification decreased to 9%. The HO-CDI rate for the baseline period was 11.5 per 10,000 patient-days and it decreased to 6.27 per 10,000 patient-days in the study period.

Conclusion

We have demonstrated a reduction in HO-CDI rates by establishing a process to assist in early identification of CO-CDI.

Disclosures

All authors: No reported disclosures.
First Environmental Investigation of Toxigenic Clostridium difficile at a Large Hospital in Bangladesh
Authors: Alam M Jahangir , Begum Khurshida , Rashid Tasnuva , Hasan Irtiza , McPherson Jacob , Hossain Feroz , Miranda Julie , Garey Kevin W
Published: October 2017

Background

Toxigenic Clostridium difficile is the most common cause of infectious diarrhea in hospitalized patients in the developed world and an emerging pathogen in developing countries due to increased use of broad-spectrum antibiotics. Although likely ubiquitous worldwide, the prevalence of toxigenic C. difficile spores in the hospital environs of developing countries is poorly understood. The objectives of the study are to isolate and characterize C. difficile from the hospital environs of a large hospitals in Dhaka, Bangladesh.

Methods

As part of our environmental surveillance effort, we collected 330 shoe-bottom swab samples from hospital employees, patients, and visitors inside of a large hospital in Dhaka, Bangladesh. Samples were analyzed for C. difficile using anaerobic enrichment culture and molecular methods. Suspected colonies from cycloserine cefoxitin fructose agar (CCFA) plates were identified by PCR (tcdA, tcdB, cdtA, cdtB and tpi genes) and strain typed using fluorescent PCR ribotyping, and MLVA methods.

Results

A total 149 of 333 (44.7%) shoe-bottom swab samples were culture positive for C. difficile of which 19.8% samples were toxigenic (tcdA and tcdB) C. difficile. A total of 11 distinct ribotypes were identified from 58 toxigenic C. difficile isolates tested. Predominant ribotypes were F053-163 (24.1%), F017 (20.7%), F106 (19.0%), F014-020 (17.2%). Other ribotypes were R001, F005, F010, F018, F054, F216, and FP407. No R027 and R078 C. difficile isolated. A broad MLVA diversity has been seen among the tested strains.

Conclusion

We identified a high prevalence of toxigenic C. difficile with diverse ribotypes from hospital environmental shoe-bottom swabs in Bangladesh. This is the first hospital environmental report of C. difficile from Bangladesh.

Disclosures

All authors: No reported disclosures.
Enhanced Cleaning and Education to Prevent Transmission of Clostridium difficile in Pediatrics
Authors: Aslam Anoshé , Melendez Giselle , Wang Min , Stell Frederic , Kelly Paulette , Killinger James , Dannaoui Aimee , Riedman Scott , Lopez Ruben , Ackerman Jill , Chou Alexander , Wexler Leonard , Smith David , Sanchez Stacy , Robilotti Elizabeth , Kamboj Mini , Eagan Janet
Published: October 2017

Background

Transmission of healthcare-associated Clostridium difficile infection (HA-CDI) has been shown to occur directly or indirectly through a contaminated environment. At a tertiary-care cancer center, HA-CDI rates were higher for pediatric units than for other general oncology units. To address the problem, a multidisciplinary team, including Infection Control, Nursing, and Environmental Services (EVS), was convened and identified refusals and room clutter as barriers to proper cleaning of rooms on the unit.

Aim: The aim of this study seeks to reduce HA-CDI in the inpatient pediatrics setting through environmental and educational interventions.

Methods

In the first phase of the study from February to April 2016, a baseline assessment of prevalent environmental disinfection practices was made among Nursing, EVS, Physicians, and Patient Representatives. Based on this feedback, the following were implemented during Phase 2, from June through October 2016: 1) Unit-wide disinfection with bleach twice a day including common and high traffic areas; 2) Initiation of a “preferred time for cleaning” program to engage families; 3) Enhanced visitor and family education on PPE use; 4) Creation of a communication plan in case of refusal to clean rooms; and 5) Dedicated use of diaper scales.

Results

During the first phase of the study, the following barriers to cleaning were identified: 1) High refusal rate as cleaning was perceived as inconvenient by families due to timing; 2) Common perception among EVS staff that multiple requests for cleaning the room may appear intrusive to the families; 3) Excessive clutter in the room; 4) Lack of education regarding PPE use; and 5) Shared equipment for diapers. To overcome these barriers, several interventions as outlined in methods were implemented. In Phase 2, there were 0 cases of HA-CDI identified in pediatric patients starting in July through October, 2016.

Conclusion

Control of CDI on pediatric units poses unique challenges. Engagement of key stakeholders is essential to identify and meet these challenges and to devise effective strategies that will ultimately lead to reduced hospital-based transmission of CDI.

Disclosures

All authors: No reported disclosures.
Frequently Identified Infection Control Gaps Related to Hand Hygiene in Long-Term Care Facilities
Authors: Tyner Kate , Nailon Regina , Beach Sue , Drake Margaret , Fitzgerald Teresa , Lyden Elizabeth , Rupp Mark E , Schwedhelm Michelle , Tierney Maureen , Ashraf Muhammad Salman
Published: October 2017

Background

Little is known about hand hygiene (HH) policies and practices in long-term care facilities (LTCF). Hence, we decided to study the frequency of HH-related infection control (IC) gaps and the factors associated with it.

Methods

The Nebraska (NE) Infection Control Assessment and Promotion Program (ICAP) in collaboration with NE Department of Health and Human Services conducted in-person surveys and on-site observations to assess infection prevention and control programs (IPCP) in 30 LTCF from 11/2015 to 3/2017. The Centers for Disease Control and Prevention (CDC) Infection Prevention and Control Assessment tool for LTCF was used for on-site interviews and the Centers for Medicare and Medicaid (CMS) Hospital IC Worksheet was used for observations. Gap frequencies were calculated for questions (6 on CDC survey and 8 on CMS worksheet) representing best practice recommendations (BPR). The factors studied for the association with the gaps included LTCF bed size (BS), hospital affiliation (HA), having trained infection preventionists (IP), and weekly hours (WH)/ 100 bed spent by IP on IPCP. Fisher’s exact test and Mann Whitney test were used for statistical analyses.

Results

HH-related IC gap frequencies from on-site interviews are displayed in Figure 1. Only 6 (20%) LTCF reported having all 6 BPR in place and 10 (33%) having 5 BPR. LTCF with fewer gaps (5 to 6 BPR in place) appear more likely to have HA as compared with the LTCF with more gaps but the difference didn’t reach statistical significance (37.5% vs. 7.1%, P = 0.09). When analyzed separately for each gap, it was found that LTCF with HA are more likely to have a policy on preferential use of alcohol based hand rubs than the ones without HA. (85.7%, vs. 26.1% P = 0.008). Several IC gaps were also identified during observations (Figure 2) with one of them being overall HH compliance of <80%. LTCF that have over 90% HH compliance are more likely to have higher median IP WH/100 beds dedicated towards IPCP as compared with the LTCFs with less than 90% compliance (16.4 vs. 4.4, P < 0.05).

Conclusion

Many HH-related IC gaps still exist in LTCF and require mitigation. Mitigation strategies may include encouraging LTCF to collaborate with IP at local acute care hospitals for guidance on IC activities and to increase dedicated IP times towards IPCP in LTCF.

Disclosures

All authors: No reported disclosures.
Impact of Electronic Hand Hygiene Monitoring on Hospital-Acquired Clostridium difficile Infection Rates
Authors: Knepper Bryan , Miller Amber , Ruff Kevin , Van Winks Tina , Zoetewey Julie , Douglas Ivor , Hanley Michael , Young Heather
Published: October 2017

Background

Lower rates of hand hygiene adherence are linked to increased risk of nosocomial transmission of infectious pathogens, thereby increasing morbidity and mortality. Assessing true adherence is difficult using direct observation due to the low number of observations collected, heterogeneous observer training and bias, and the Hawthorne effect. We assessed whether radio frequency identification (RFID) hand hygiene monitoring resulted in changes to our hospital-onset Clostridium difficile (HO-CDI) rates. We also assessed whether electronically measured hand hygiene improved by the end of the intervention period.

Methods

The RFID system was installed in Apr 2016 in 2 medical/surgical units, a progressive care unit, and an intensive-care unit (study group). Registered nurses, certified nursing assistants, and selected physicians wore RFID badges to track hand hygiene adherence. Adherence is defined as washing with soap or alcohol-based hand rub within 1 minute before or after entering or exiting a patient’s room. A second set of rooms (1 ICU, 1 short-stay unit, and 5 medical/surgical units) without the system served as the control group. HO-CDI rates were tracked monthly for each group using NHSN definitions. HO-CDI trends were compared for 15 months before and 12 months after installation of the system using interrupted time series analysis. Average electronic hand hygiene adherence for the first two months and last two months of the intervention period was compared using the Wilcoxon rank-sum test. Other interventions aimed at reducing HO-CDI were consistently applied to both the study and control groups.

Results

One hundred and eighty-six HO-CDI occurred: 73 in the study group and 113 in the control group. In the study group, the trend in HO-CDI rates changed from increasing in the pre-intervention to decreasing in the post-intervention (P = 0.02) (Figure 1). HO-CDI rates in the control group demonstrated no change in trend (P = 0.69) (Figure 2). In the study group, electronically tracked hand hygiene adherence increased from a mean of 46% in Apr-May 2016, to 77% in Feb-Mar 2017 (P < 0.0001).

Conclusion

Electronic RFID hand hygiene systems can have a tangible effect on hospital-acquired infection rates. This result strengthens the argument for using these systems to improve patient safety.

Disclosures

All authors: No reported disclosures.
Improving Hand Hygiene:Anonymously Validated Data Driven Approach Producing Sustainable Culture Change Utilizing “One and Up” Accountability Agents across a Healthcare System- a Cost-effective National Best Practice.
Authors: Ross Jack
Published: October 2017

Background

Inadequate hand hygiene is a major contributor to hospital infections worldwide. Before 2012, in our healthcare system, hand hygiene was monitored by unit managers, nurses, and infection control staff with reported compliance rates of >90%. A five month independent audit by an anonymous observer revealed actual rates of 14–33%. This discordant result was typical of hospitals across the country then and now who have provided intensive education, used peer feedback, and maximized physical hand hygiene supplies. A commitment was made to rigorously improve hand hygiene utilizing validated data, social psychology with disciplinary consequence, and no additional expensive technology.

Methods

Employed dedicated “secret shopper”/anonymous observers were deployed across five hospitals, all units and all shifts, and all job roles to collect valid anonymous hand hygiene observations without local bias. Twice monthly hand hygiene data was shared by hospital, unit, shift, and job role to executive leadership and down to frontline unit staff for daily huddles. Additionally, over 100 “One and Up” Accountability Agents from management ranks were recruited, trained, and performed weekly standardized unit- based hand hygiene obervations openly, giving feedback real-time to non-compliant employess and medical staff; noncompliance was reported to the hospital epidemiologist; and emails on his behalf were sent to the employee’s manager, and the manager’s manager “One and Up”. A four step disciplinary process was begun. The same process was applied to the medical staff.

Results

Over 188, 000 anonymous secret shopper validation observations, and hundreds of thousands of Accountability Agent observations have been performed. Hand hygiene compliance has been >94% for 22 months and ≥97 % for the last 6 months in all five hospitals. No employee or medical staff member advanced beyond the second disciplinary step.

Conclusion

This model represents a national best performance model, with validated and sustained results, accomplished with cultural change and aligned multitier accountability (not technology). It is truly a low cost blueprint for other healthcare systems that seek rapid, honest, and sustained hand hygiene improvement across all job roles, shifts, and different sized hospitals and cultures.

Disclosures

All authors: No reported disclosures.
How Many Patients Who Present to North Central Bronx Hospital with a Sexually Transmitted Disease (Chlamydia, Gonorrhea) Are Tested for HIV?
Authors: Yung Lok
Published: October 2017

Background

To determine whether an individual got infected with either Chlamydia trachomatis, N gonorrhea, or both infected, the HIV test was ordered or not.

Methods

Systematic review and data synthesis of STD and HIV testing results through Quardamed within the 1 month period of November, 2015. Percentage of patients with and without a STD (either Chlamydia trachomatis, N gonorrhea, or both infected) who had HIV test done.

Results

804 patients were tested for gonorrhea or chlamydia by GC probe during November 2015. Thirty-three of 804 (4.1%) individuals were infected with Chlamydia trachomatis. Of those 20 were tested for HIV by rapid oral test. Six of 804 (0.7%) participants who were infected with N gonorrhea had five HIV rapid test done. Two of 804 (0.3%) participants were infected with both diseases and one patient was tested for HIV. Most patients with a confirmed STD were diagnosed in ED (43.4%) followed by OB/GYN (37.3%). Seventy-two percent of patients who were either infected with chlamydia, gonorrhea or both were tested for HIV. In the ED, 48% had an HIV test vs. 80% in OB/GYN (including family planning).

Conclusion

The majority of patients were tested for HIV. More patients were tested in OB/GYN compared with the ED likely because an HIV counselor is readily available during clinic hours. Increase in education and training of health care providers and nurses to become more comfortable in testing patients for HIV may increase the number HIV testing when patients present with STDs.

Disclosures

All authors: No reported disclosures.
Hand hygiene: Knowledge and Practices of Clinical Teachers in Selected Teaching Hospitals in Kenya
Authors: Ndegwa Linus , Nyoni Champion
Published: October 2017

Background

Healthcare-associated infections lead to substantial morbidity and mortality worldwide, and adequate hand hygiene (HH) in the clinical setting is essential for prevention. Clinical teachers are central to the training of healthcare workers (HCW) as they teach and model safe practices in the clinical environment. However, there is limited research on the knowledge and practices of clinical teachers related to HH in teaching hospitals, particularly in African settings. We describe the knowledge and practices of HH amongst clinical teachers in selected teaching hospitals in Kenya.

Methods

Data were collected through self-administered standardized questionnaires with basic demographic, knowledge and practices about HH from clinical teachers employed at two teaching hospitals. Participating clinical teachers were anonymously audited for HH practices using an adapted World Health Organization tool. The audits consisted of 20–30 minutes observations in each ward

Results

Among 57 participants overall, 42 (73.7%) were nurses, 8 (14.0%) clinicians, and 5 (8.8%) therapists. Twenty-one (36.8%) of the participants had knowledge regarding the minimum time needed to practice HH using alcohol based hand rub, 14 (24.6%) knew that hand washing and hand rubbing should be performed in sequence. The combined knowledge score for each individual ranged from 0% to 94.1% with a mean of 50.1% (SD=20.1, Cl 95% 44.7- 55.4%). Hand hygiene compliance significantly varied by clinical instructor’s type; nurses (42.7%) and therapists (38.0%) had the highest adherence and clinicians had the lowest 33.7% (P = 0.0001).

Conclusion

Clinical teachers in this study demonstrated knowledge gaps and poor practices related to HH. Since they serve as role models for future generations of healthcare workers, clinical teachers must recognize the importance of HH in preventing hospital-acquired infections, including when and how HH should be performed while following recommended practices.

Disclosures

All authors: No reported disclosures.
Performance of Zoster Vaccine Live (Zostavax): A Systematic Review of 12 years of Experimental and Observational Evidence
Authors: Dooling Kathleen , Guo Angela , Leung Jessica , Belongia Edward , Harpaz Rafael
Published: October 2017

Background

One in three people in the U.S. will develop herpes zoster during their life. Zoster Vaccine Live (ZVL or Zostavax™), has been licensed in the U.S. since 2006 to prevent herpes zoster. ZVL protection has been shown to wane with time and estimates of effect can be imprecise. We performed a systematic review of the duration of efficacy and effectiveness of ZVL against herpes zoster (HZ).

Methods

We systematically searched PubMed, Embase, Cochrane, and clinicaltrials.gov for vaccine efficacy or effectiveness (VE) studies of ZVL. Two authors independently screened each title and abstract, and potential VE studies were reviewed in-depth. Eligibility criteria included original data on ZVL prevention of HZ in a general population of immunocompetent recipients ≤ 60 years old. Selected articles were abstracted, independently reviewed, and discrepancies adjudicated. We attempted to locate relevant unpublished work and contacted authors for additional data, where necessary. Measures of association were illustrated on a forest plot and converted to VE (1-hazard ratio or risk ratio or odds ratio).

Results

We screened 1302 articles; 17 underwent full text review and 8 met inclusion criteria and were abstracted for this review. Selected studies included 1 phase III randomized controlled trial, 2 quasi experimental and 5 observational studies. One experimental and 5 observational studies estimated VE during the period from vaccination up to 4 years following vaccination; estimates across studies ranged from 33%-55%. Two quasi experimental and 3 observational studies estimated VE for ≥ 4 years following vaccination; estimates ranged from 19%-40%; the median estimate was 24% (Figure). Pooled VE was not calculated due to heterogeneity in length of follow up, age distribution of study subjects, as well as adjustment for factors such as underlying medical conditions.

Conclusion

Most experimental and observational studies estimate VE just above 50% during the 3 years following receipt of ZVL. Beyond 3 years, ZVL protection wanes, with most studies estimating a VE of ≤24% after 4 years. Information on overall efficacy and duration of protection from ZVL will guide policy decisions regarding its use.

Disclosures

E. Belongia, Novavax: Investigator, Research support
Immune Senescence Factors Associated with the Immunogenicity of a Live Attenuated Zoster Vaccine (ZV) in Older Adults
Authors: Weinberg Adriana , Schamder Kenneth , Johnson Michael , Popmihajlov Zoran , Tovar-Salazar Adriana , Caldas Yupanqui , Pang Lei , Cho Alice , Levin Myron
Published: October 2017

Background

ZV confers protection against herpes zoster by increasing the cell-mediated immunity (CMI) to varicella-zoster virus (VZV). ZV immunogenicity and protection decrease with increasing age. We investigated effects of age and immune senescence on ZV immunogenicity.

Methods

399 adults ≥50 years had VZV T-cell helper 1 (Th1) CMI measured by ex vivo VZV-stimulated IL2/IFNg ELISPOT and blood T-cell nonspecific immune senescence by flow cytometric characterization of FOXP3, CD25, IL10, TGFb, PD1, CD28, CD57 and CD31 expression before and at 1, 6 and 52 weeks after ZV. In a subset of 95 vaccinees, VZV-stimulated T cell expression of CD107, Granzyme B, FOXP3, CD25, IL10, TGFb, CD39 and PD1 were also measured. Multivariate regression analysis was used to identify independent effects of age and immune senescence on VZV Th1 CMI (P < 0.025).

Results

IL2+ and IL2+IFNg+ Th1 memory VZV CMI peaked at 6 weeks after ZV and remained elevated at 1 year. Effectors, including VZV-specific IFNg+ Th1, and CD8+CD107+% and CD4+/CD8+Granzyme B+% cytotoxic T lymphocytes (CTL), peaked at 1 week, but only the IFNg+ Th1 effectors remained elevated at 1 year. There was also a transient increase in blood CD8+PD1+% exhausted T cells 1 week after ZV. Independent positive effects on peak memory Th1 VZV CMI included the baseline CMI and negative effects included blood CD4+FOXP3+% T regulatory (Treg) and CD8+PD1+% T exhausted cells. Independent positive effects on peak effector Th1 VZV CMI included baseline CMI and negative effects included blood CD8+CD25+FOXP3+% Treg. Age did not have an independent effect on peak CMI. Independent positive effects on persistent (1 year) memory Th1 included baseline CMI and negative effects included age, blood CD4+FOXP3+% Treg and CD8+PD1+% T exhausted cells. Persistent effector Th1 CMI was negatively affected by age only.

Conclusion

ZV generated VZV-specific Th1 and CTL responses. The early increase of CD8+ exhausted T cells in blood suggested that CTL responses to the vaccine virus may be compromised by immune senescence. The negative of age on VZV Th1 CMI was fully mediated by immune senescence at peak response, but age had a negative effect on CMI persistence that was independent from the markers of immune senescence included in this study.

Disclosures

A. Weinberg, merck: Grant Investigator, Research grant K. Schamder, merck: Grant Investigator, Research grant Z. Popmihajlov, Merck & Co., Inc.: Employee and Shareholder, Salary L. Pang, Merck: Employee and Shareholder, Salary M. Levin, merck: Grant Investigator and Scientific Advisor, Consulting fee and Research grant
A Cost-Effectiveness Analysis of an Adjuvanted Subunit Vaccine for the Prevention of Herpes Zoster and Post-Herpetic Neuralgia
Authors: Carpenter Christopher , Aljassem Annas , Stassinopoulos Jerry , Pisacreta Giovanni , Hutton David
Published: October 2017

Background

Herpes zoster (HZ) develops in up to 50% of unvaccinated individuals who live to 85 years of age, accounting for more than 1 million cases of HZ annually in the United States. A live attenuated vaccine (LAV) for HZ is U.S. FDA approved for persons 50 years or older, though CDC Advisory Committee on Immunization Practices (ACIP) recommendations are only for persons beginning at age 60 years. LAV efficacy at preventing HZ is ~70% for persons 50–59 years of age, with lower efficacy in older adults, and it is efficacious in preventing post-herpetic neuralgia (PHN) beyond the HZ prevention. The efficacy of LAV after vaccination wanes over time. A new adjuvanted HZ subunit vaccine (SUV), administered as a two-dose series, has greater than 95% efficacy against HZ in persons 50–69 years of age. SUV efficacy remains greater than 90% in persons vaccinated at age 70 years and older, including the subgroup older than 80 years of age. Overall efficacy of SUV against PHN approaches 90%. The waning rate of efficacy after SUV vaccination is unknown.

Methods

To estimate the relative cost-effectiveness of SUV, LAV and no vaccination (NV) strategies, a Markov model was developed based on published trials and data on vaccine efficacy persistence, quality of life, resource utilization, costs and disease epidemiology. The perspective was U.S. societal, and the cycle length was one year with a lifelong time horizon. SUV efficacy was estimated for the base case to wane at the same rate as LAV, all persons were assumed to receive both doses of SUV, and the cost of SUV included both doses.

Results

For individuals vaccinated at age 50 years the incremental cost-effectiveness ratio (ICER) for LAV vs. NV was $142,811 per quality-adjusted life-year (QALY); at age 60 years the ICER dropped to $59,482 per QALY. The cost-effectiveness ratio of SUV approached that of LAV when the SUV cost approached $500 for persons vaccinated at age 50 years and when the cost was $400 for those vaccinated at age 60 years. The SUV cost that would result in achieving an ICER target of $100,000 per QALY for SUV vaccination vs. NV at age 50 years was $316; at age 60 years the cost was $638.

Conclusion

Vaccination at age 60 years with SUV was more cost-effective than LAV when SUV cost was ~$450 or less. Vaccination with SUV at age 50 years appeared to be cost-effective if SUV cost was ~$315 or less.

Disclosures

All authors: No reported disclosures.
Vaccination Response to an Ongoing Meningitis Outbreak: Uptake and Attitudes among Men Who Have Sex with Men in Los Angeles, CA
Authors: Holloway Ian , Wu Elizabeth , Gildner Jennifer , Fenimore Vincent , Frew Paula
Published: October 2017

Background

Men who have sex with men (MSM) are at high risk for invasive meningococcal disease (IMD). Following a 2016 IMD outbreak in Southern California, public health officials issued an advisory that urged at-risk adult gay and bisexual men, and all people with HIV, to obtain immunizations. Despite public health efforts to increase MCV4 coverage, uptake and acceptance among MSM remains unknown. Thus, our study sought to: (1) estimate reported MCV4 immunization among MSM in Los Angeles, CA; and (2) document the facilitators and barriers to the newest vaccination recommendation following the recent outbreak.

Methods

From November 2016 through February 2017, we used venue-based sampling to recruit MSM in Los Angeles (N = 513). Eligible participants completed a 30-minute iPad survey that included items on MCV4 status, sexual behavior, vaccination knowledge and behaviors among other factors. Chi-square and independent sample t-tests were used to determine bivariate associations. Statistically significant variables from bivariate analyses were included in a multivariate logistic regression model predicting MCV4 uptake.

Results

Participants were young (M=33, SD=10) and racially/ethnically diverse: White (35.7%), Black/African American (14.6%), Hispanic (36.5%), Asian/Pacific Islander (4.1%), Other (9.2%). Reported MCV4 immunization among MSM (25.4%) and MSM living with HIV (37.7%) was low. Statistically significant correlates of MCV4 uptake in our multivariate model included: younger age (aOR=2.51), prior STI diagnosis (aOR=2.21), believing MCV4 vaccination was important (aOR=3.45), having confidence in the MCV4 vaccine (aOR=5.43), and knowing someone who had received the vaccination (aOR=5.79).

Conclusion

MSM’s perceived health risk, vaccine confidence, and knowledge of someone who received the MCV4 vaccine were important indicators of meningitis immunization in this outbreak context. Provider and public health education efforts may be enhanced by messages that emphasize personal health risks, the safety and efficacy of MCV4, and the importance of meningococcal vaccines for men’s health. Popular opinion leader programs facilitated by someone who had been vaccinated are warranted to enhance MCV4 uptake.

Disclosures

All authors: No reported disclosures.
Factors Associated with Elevated HIV RNA Levels in HIV-Infected Individuals
Authors: Degener Tyler , Allen Sara , Wilson Alicia , Baranoski Amy
Published: October 2017

Background

Virologic suppression is necessary to reduce the risk of complications from HIV infection and to prevent transmission to other individuals. Understanding factors associated with elevated HIV RNA levels in HIV-infected individuals could lead to interventions to improve engagement in care.

Methods

This retrospective, observational study assessed HIV-infected individuals engaged in care in an urban HIV clinic between April 1, 2015 and March 31, 2016. The electronic medical record was reviewed for demographic and HIV-related factors for all individuals with elevated HIV RNA PCR ≥200 copies/mL (EVL) during the study period. Demographic data were compared with individuals with decreased HIV RNA PCR (DVL) <200 copies/mL. Patients with recent HIV diagnosis within 6 months of EVL were excluded due to the possibility of insufficient time to achieve viral suppression after engagement in care. Statistical analysis including Student T-test and Chi Square test was conducted in SPSS, version 24.

Results

There were 519 individuals with EVL with 72 (13.9%) excluded due to recent HIV infection. Of 1,789 patients included in this analysis, 447 (25.0%) had an EVL. The median HIV RNA PCR was 7,240 copies/mL (range 200 to 6,720,990) and median CD4 count was 411 cells/mm3(range 1 to 1,510) in the EVL group. Individuals with EVL were more likely to be younger (mean EVL group age 43.4 years ± S.D. 11.7, range 22–77 vs. 47.5 years ± S.D. 12.4, range 19–84 in DVL group) (P < 0.0001). Individuals with EVL were more likely to be Black (82.1%) (with White 9.2% and Hispanic 8.7%) compared with those with DVL (74.8% Black, 12.4% White, 11.6% Hispanic, 1.6% other) (P = 0.004). The EVL group was 59.3% male, 39.8% female and 0.9% transgender vs. 64.8% male, 34.3% female, and 1.0% transgender in the DVL group. The main risk factors for HIV acquisition were heterosexual sex (46.3% of EVL vs. 43.4% DVL), men who have sex with men (31.8% vs. 36.4%) and injection drug use (14.3% vs. 14.6%). There were no significant differences in gender or risk factors for HIV acquisition between the two groups.

Conclusion

Decreased levels of HIV viremia is a major focus of quality HIV care. Younger age and Black race were associated with elevated HIV RNA levels in individuals engaged in care in a large urban HIV clinic.

Disclosures

All authors: No reported disclosures.