bluuebunny/crossref_metadata_2025 huggingface dataset:
Description of antibiotic stewardship expertise and activities among US public health departments, 2022
Authors: Bizune Destani , Luciano Angelina , Neuhauser Melinda , Hicks Lauri , Kabbani Sarah
Published: September 2023

Background: In 2021, the CDC awarded >$100 million to 62 state, local, and territorial health departments (SLTHDs) to expand antibiotic stewardship expertise and implement antibiotic stewardship activities in different healthcare settings. Our objective was to describe SLTHD antibiotic stewardship personnel and activities to characterize the impact of the funding. Methods: SLTHDs submitted performance measures, including quantitative and qualitative responses, describing personnel supporting antibiotic stewardship activities, types of activities, and healthcare facilities and professionals engaged from January through June 2022. A quantitative analysis of performance measures and qualitative thematic analysis of select narrative responses are reported. Results: Most SLTHDs (58 of 62, 94%) submitted performance measures. Among them, 37 (64%) reported identifying an antibiotic stewardship leader or coleader; most were pharmacists (57%) or physicians (38%) with infectious diseases training (68%) (Table 1). Of the remaining STLHDs, 20 reported barriers to identifying a leader or coleader, including hiring process delays and programmatic barriers (Table 2). SLTHDs reported 254 antibiotic stewardship activities; most reported activities involving multiple activity types (44%). Education and communication (eg, providing stewardship expertise) was the most common single activity (30%), followed by antibiotic use tracking and reporting (13%), assessment of antibiotic stewardship implementation (8%), and action and implementation (eg, audit and feedback letters) (4%). The highest number of activities were implemented in multiple healthcare settings (35%), followed by acute care (21%), outpatient (18%), long-term care (17%), and other (9%) (Fig. 1). SLTHDs reported engaging 4,970 healthcare facilities and 15,194 healthcare professionals in antibiotic stewardship activities across healthcare settings, to date, as part of this funding opportunity (Fig. 2). Conclusions: Antibiotic stewardship funding to SLTHDs allowed for increases in capacity and expanded outreach to implement a variety of antibiotic stewardship activities across multiple healthcare settings. Sustaining STLHD antibiotic stewardship activities can help increase engagement and coordination with healthcare facilities, healthcare professionals, and other partners to optimize antibiotic prescribing and patient safety.

Disclosure: None
Inpatient pediatric antimicrobial use for respiratory infections during the RSV surge
Authors: Hunt Aaron , Burgos Rodrigo , Lora Alfredo Mena
Published: September 2023

Background: In the United States, pneumonia causes >100,000 pediatric hospitalizations annually. On November 4, 2022, the CDC issued a Heath Advisory concerning an upcoming surge of respiratory illnesses including SARS-CoV-2, influenza, and respiratory syncytial virus (RSV). Differentiating between viral and bacterial causes is challenging and can lead to antimicrobial overuse. Currently, tools are being developed to distinguish between viral and bacterial pneumonia. The VALS-DANCE Pneumonia Etiology Predictor (PEP) provides clinical scoring criteria (Fig. 1) to determine probable cause of pneumonia with 93.1% sensitivity for bacterial pneumonia. Scores >11 have a >25% likelihood of having bacterial etiology. Given that antimicrobial exposure increases resistance rates, disrupts natural flora, and increases the risk of side effects, a core goal of researchers is to develop ways to promote stewardship and reduce inappropriate use. We assessed the patterns of use for antimicrobials in pediatric patients admitted with pneumonia at our institution. Methods: This retrospective review included pediatric cases admitted to an urban safety-net community hospital from July 22, 2022, to December 16, 2022. A daily list of all patients receiving antimicrobials was reviewed, and pediatric patients with diagnosis of a respiratory infection were included. Patients with additional indications for antimicrobial therapy, diagnosis of bronchitis, incomplete records, or without complete information were excluded from the scoring criteria. The primary objective was to assess the appropriateness of antimicrobial use for pneumonia, defined as use consistent with PEP scoring recommendations. Results: Of 53 patients reviewed, 37 met inclusion criteria. Of 37 patients, 22 (59.5%) met study criteria for appropriate therapy. The 15 patients (40.5%) who were inappropriate for treatment received an average of 4.67 ± 1.91 days of antibiotics. Of these 15 patients, 11 (73.3%) also had a positive viral test, further increasing the likelihood of a viral etiology. This subgroup had an average antibiotic exposure of 4.27 ± 1.79 days. Documented rationale for therapy included severity of illness (4 of 11), radiograph consolidation (4 of 11), and provider disagreement with radiograph interpretation (3 of 11). Conclusions: Pediatric respiratory infections represent a significant opportunity for antimicrobial stewardship. In this study, as many as 40% of pediatric patients may have received unnecessary antibiotic exposure. Use of the VALS-DANCE criteria may help clinicians identify patients with low likelihood of bacterial infection and reduce antimicrobial use. The national surge of viral infections serves to highlight the vital importance of appropriate diagnostic stewardship.

Disclosure: None
Alarming prevalence of Candida auris among critically ill patients in intensive care units in Dhaka City, Bangladesh
Authors: Chowdhury Fahmida , Hussain Kamal , Khan Sanzida Khan , Ahmed Dilruba , Sen Debashis , Hassan Zakiul , Rahman Mahmudur , Prema Sajeda , Jordan Alex , Lockhart Shawn , Lyman Meghan , Mah-E-Muneer Syeda
Published: September 2023

Background:Candida auris is a multidrug-resistant yeast capable of invasive infection with high mortality and healthcare-associated outbreaks globally. Due to limited labratory capacity, the burden of C. auris is unknown in Bangladesh. We estimated the extent of C. auris colonization and infection among patients in Dhaka city intensive care units. Methods: During August 2021–September 2022 at adult intensive care units (ICUs) and neonatal intensive care units (NICUs) of 1 government and 1 private tertiary-care hospital, we collected skin swabs from all patients and blood samples from sepsis patients on admission, mid-way through, and at the end of ICU or NICU stays. Skin swab and blood with growth in blood-culture bottle were inoculated in CHROMagar, and identification of isolates was confirmed by VITEK-2. Patient characteristics and healthcare history were collected. We performed descriptive analyses, stratifying by specimen and ICU type. Results: Of 740 patients enrolled, 59 (8%) were colonized with C. auris, of whom 2 (0.3%) later developed a bloodstream infection (BSI). Among patients colonized with C. auris, 27 (46%) were identified in the ICU and 32 (54%) were identified from the NICU. The median age was 55 years for C. auris–positive ICU patients and 4 days for those in the NICU. Also, 60% of all C. auris patients were male. Among 366 ICU patients, 15 (4%) were positive on admission and 12 (3%) became colonized during their ICU stay. Among 374 NICU patients, 19 (5%) were colonized on admission and 13 (4%) became colonized during their NICU stay. All units identified C. auris patients on admission and those who acquired it during their ICU or NICU stay, but some differences were observed among hospitals and ICUs (Figure). Among patients colonized on admission to the ICU, 11 (73%) were admitted from another ward, 3 (20%) were admitted from another hospital, and 1 (7%) were admitted from home. Of patients colonized on admission to the NICU, 4 (21%) were admitted from the obstetric ward, 9 (47%) were admitted from another hospital, and 6 (32%) were admitted from home. In addition, 18 patients with C. auris died (12 in the ICU and 6 in the NICU); both patients with C. auris BSIs died. Conclusions: In these Bangladesh hospitals, 8% of ICU or NICU patients were positive for C. auris, including on admission and acquired during their ICU or NICU stay. This high C. auris prevalence emphasizes the need to enhance case detection and strengthen infection prevention and control. Factors contributing to C. auris colonization should be investigated to inform and strengthen prevention and control strategies.

Disclosure: None
Three-day antibiotic duration in patients with pneumonia: A sixty-eight–hospital cohort
Authors: Vaughn Valerie , Petty Lindsay , Ratz David , McLaughlin Elizabeth , Czilok Tawny , Horowitz Jennifer , Malani Anurag , Osterholzer Danielle , Flanders Scott , Gandhi Tejal
Published: September 2023

Background: Since 2019, community-acquired pneumonia (CAP) guidelines have recommended hospitalized patients be treated until clinical “stability and for no less than 5 days.” However, randomized trials have reported that, in patients who stabilize by hospital day 3, very short antibiotic durations (eg, 3 days) are noninferior to longer durations. How these trial results relate to real-world practice is unknown. Methods: Using a 68-hospital cohort study of hospitalized, general-care adults with CAP, we aimed to (1) quantify the percentage of patients who—according to trial criteria—qualify for a 3-day antibiotic duration, (2) quantify the percentage who actually received a 3-day duration, and (3) assess 30-day outcomes. Patients were considered to have CAP if they had a pneumonia discharge diagnosis and met clinical criteria for CAP. Patients with concomitant infections (including COVID-19), admission to intensive care, or severe immunocompromise were not included. Results: Between February 23, 2017, and August 3, 2022, 36,064 patients with CAP were included. Of those, 48.2% (9,826 of 36,064) were excluded due to a condition or organism ineligible for the 3-day treatment (Fig. 1). Of the 18,690 patients remaining, 52.6% (9,826) were unstable on day 3 and thus were ineligible for the 3-day treatment. Therefore, of all 36,064 patients, only 8,864 (24.6%) would be eligible under trial criteria for a 3-day treatment. Notably, 5,493 (55.9%) of 9,826 patients unstable on day 3 would be eligible for 5 days of treatment under national guidelines. In practice, use of 3–4-day treatment was rare, occurring in 599 (6.8%) of 8,864 patients eligible for a 3-day treatment versus 660 (6.7%) of 9,826 patients unstable on day 3 (P = .945). Use of 3–4-day treatment increased over time and comorbidities that could mimic CAP or a negative procalcitonin were more common in patients who received a 3–4-day treatment whereas specific symptoms of CAP were less common (Fig. 2). After adjustments, patients eligible for a 3-day duration who received a 3–4 day treatment versus a ≥5-day treatment had higher 30-day mortality (aOR, 1.87; 95% CI, 1.32–2.64) and readmission (aOR, 1.35; 95% CI, 1.17–1.56). Conclusions: Across 68 hospitals, <25% of patients hospitalized with CAP would be eligible for a 3-day antibiotic treatment. Though increasing over time, there was little use of 3–4-day treatments and, when prescribed, outcomes were worse, potentially due to CAP misdiagnosis. Given the small number of patients eligible for 3-day treatment, and the potential harm with too-short durations, it may be prudent to focus on increasing the use of 5-day treatments.

Disclosures: None
Antibiotic practice and stewardship in the management of neutropenic fever: A survey of US institutions
Authors: Arya Swarn , Wang Xiao , Patel Sonal , Saw Stephen , Decena Mary , Hirsh Rebecca , Pegues David , Ziegler Matthew
Published: September 2023

Background: Neutropenic fever management decisions are complex and result in prolonged duration of broad-spectrum antibiotics. Strategies for antibiotic stewardship in this context have been studied, including de-escalation of antibiotics prior to resolution of neutropenia, with unclear implementation. Here, we present the first survey study to describe real-world neutropenic fever management practices in US healthcare institutions, with particular emphasis on de-escalation strategies after initiation of broad-spectrum antibiotics. Methods: Using REDCap, we conducted a survey of US healthcare institutions through the SHEA Research Network (SRN). Questions pertained to antimicrobial prophylaxis and supportive care in the management of oncology patients and neutropenic fever management (including specific antimicrobial choices and clinical scenarios). Hematologic malignancy hospitalization (2020) and bone-marrow transplantation (2016–2020) volumes were obtained from CMS and Health Resources & Services Administration databases, respectively. Results: Overall, 23 complete responses were recorded (response rate, 35.4%). Collectively, these entities account for ~11.0% of hematologic malignancy hospitalizations and 13.3% bone marrow transplantations nationwide. Of 23 facilities, 19 had institutional guidelines for neutropenic fever management and 18 had institutional guidelines for prophylaxis, with similar definitions for neutropenic fever. Firstline treatment universally utilized antipseudomonal broad-spectrum IV antibiotics (20 of 23 use cephalosporin, 3 of 23 use penicillin agent, and no respondents use carbapenem). Fluoroquinolone prophylaxis was common for leukemia induction patients (18 of 23) but was mixed for bone-marrow transplantation (10 of 23). We observed significant heterogeneity in treatment decisions. For stable neutropenic fever patients with no clinical source of infection identified, 13 of 23 respondents continued IV antibiotics until ANC (absolute neutrophil count) recovery. The remainder had criteria for de-escalation back to prophylaxis prior to this (eg, a fever-free period). Respondents were more willing to de-escalate prior to ANC recovery in patients with identified clinical sources (14 of 23 de-escalations in patients with pneumonia) or microbiological sources (15 of 23 de-escalations in patients with bacteremia) after dedicated treatment courses. In free-text responses, several respondents described opportunities for more systemic de-escalation for antimicrobial stewardship in these scenarios. Conclusions: Our results illustrate the real-world management of neutropenic fever in US hospitals, including initiation of therapy, prophylaxis, and treatment duration. We found significant heterogeneity in de-escalation of empiric antibiotics relative to ANC recovery, highlighting a need for more robust evidence for and adoption of this practice.

Disclosures: None
Development of a multiyear pediatric antibiogram in Georgia identifies antibiotic resistance trends
Authors: Linam Matt , Goldstein Madeleine , Jerris Robert , Gonzalez Mark
Published: September 2023

Background: Antibiograms are used to monitor antibiotic resistance trends and help guide empiric antibiotic treatment. Community pediatricians may not have access to or be comfortable using children’s hospital antibiograms. Creating and disseminating a statewide pediatric antibiogram can help inform antibiotic stewardship efforts.

Objective: To develop a pediatric-specific antibiogram for the state of Georgia. Methods: Annual pediatric antibiograms for the 5 children’s hospitals in Georgia from 2014 through 2021 were collected. All sites complied with the Clinical and Laboratory Standards Institute guidelines for antibiomicrobic breakpoints and antibiogram development. Antibiogram data were combined, and the most common bacteria were selected to incorporate into the statewide antibiogram: Staphylococcus aureus, Streptococcus pneumoniae, Enterococcus faecalis, Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae complex, and Pseudomonas aeruginosa. Antibiogram data were reported as percentage susceptible and total number of isolates. Interhospital susceptibility differences were compared for methicillin-susceptible S. aureus (MSSA), methicillin-resistant S. aureus (MRSA), E. coli, and K. pneumoniae from 2018 through 2021. P < .05 was considered significant. The combined antibiogram data from 2014 through 2021 were used to show antibiotic susceptibility trends over time. Results: The 2021 antibiogram is shown in the Table. For MSSA and MRSA, clindamycin susceptibility was 80% and 85%, respectively. K. pneumoniae susceptibility to amoxicillin-clavulanate was 91%. For E. coli, using urine-specific breakpoints, susceptibility to cefazolin was 89%. A few statistically significant differences in antibiotic susceptibility were detected between hospitals, but most were unlikely to be clinically relevant (all susceptibilities ≥90% or < 80%). A notable exception was trimethoprim-sulfamethoxazole susceptibility for K. pneumoniae, which ranged from 74% to 98% in 2020 and from 74% to 86% in 2021. From 2014 to 2021, the percentage of MRSA decreased from 49% to 34%. Over the 8 years, susceptibility to ceftriaxone for E. coli ranged from 93% to 95% and from 90% to 95% for K. pneumoniae. Susceptibility to meropenem for E. coli and K. pneumoniae ranged from 99% to 100%. Conclusions: Antibiotic susceptibility for pediatric bacterial isolates in Georgia remained stable over time and supported the narrow-spectrum empiric antibiotic treatment recommended in national evidence-based guidelines for skin and soft-tissue infections, community-acquired pneumonia, and uncomplicated urinary tract infections. MRSA rates decreased over time and multidrug-resistant gram-negative bacilli were uncommon and remained stable.

Disclosures: None
Creating an electronic antibiogram using visualization software: Easily updatable and removes the need for yearly manual review
Authors: Dauphin Ashley , McCoy Christopher , Bowden Robert , Lee Matthew , Gold Howard , Chapin Ryan
Published: September 2023

Background: Previously, our hospital manually built a static antibiogram from a surveillance system (VigiLanz) culture report. In 2019, a collaboration between the antimicrobial stewardship team (AST) and the infection control (IC) team set out to leverage data automation to create a dynamic antibiogram. The goal for the antibiogram was the ability to easily distribute and update for hospital staff, with the added ability to perform advanced tracking and surveillance of organism and drug susceptibilities for AST and IC. By having a readily available, accurate, and Clinical and Laboratory Standards Institute (CLSI)–compliant antibiogram, clinicians have the best available data on which to base their empiric antibiotic decisions. Methods: First, assessment of required access to hospital databases and selection of a visualization software (MS Power BI) was performed. Connecting SQL database feeds to Power BI enabled creation of a data model using DAX and M code to comply with the CLSI, generating the first isolate per patient per year. Once a visual antibiogram was created, it was validated against compiled antibiograms using data from the microbiology laboratory middleware (bioMerieux, Observa Integrated Data Management Software). This validation process uncovered some discrepancies between the 2 reference reports due to cascade reporting of susceptibilities. The Observa-derived data were used as the source of truth. The antibiogram prototype was presented to AST/IC members, microbiology laboratory leadership, and other stakeholders to assess functionality. Results: Following feedback and revisions by stakeholders, the new antibiogram was published on a hospital-wide digital platform (Fig. 1). Clinicians may view the antibiogram at any time on desktops from a firewall (or password)–protected intranet. The antibiogram view defaults to the current calendar year and users may interact with the antibiogram rows and columns without disrupting the integrity of the background databases or codes. Each year, simple refreshing of the Power BI antibiogram and changing of the calendar year allows us to easily and accurately update the antibiogram on the hospital-wide digital platform. Conclusions: This interdisciplinary collaboration resulted in a new dynamic, CLSI-compliant antibiogram with improved usability, increased visibility, and straightforward updating. In the future, a mobile version of the antibiogram may further enhance accessibility, bring more useful information to providers, and optimize AST/IC guidelines and education.

Disclosures: None
Impact of early identification of patients meeting testing criteria for Clostridioides difficile on standard infection ratios
Authors: Krier Brad , Gomez-Urena Eric , Schultz Kristin , Brooks Ashley
Published: September 2023

Background:Clostridioides difficile infection (CDI) poses a health burden to patients and a financial burden to hospital systems. Timely identification of CDI patients can reduce the impacts by allowing for prompt treatment and ensuring that proper isolation precautions are in place to prevent spread. It also ensures correct CDI event categorization according to the NHSN. Community-onset (CO) CDI cases are tested on or prior to hospital day 3, and hospital-onset (HO) CDI are tested on or after hospital day 4. The objective of this study was to determine the effectiveness of utilizing an electronic health record (EHR) report to reduce CDI standard infection ratios (SIRs) by identifying potential CDI cases prior to hospital day 4. Methods: From August of 2021 to September 2022, an EHR report was implemented in a 5-hospital healthcare system in the Midwest to identify patients with 3 or more type 6 or 7 stools in a 24-hour period based on Bristol stool chart classification. All inpatients with 3 or more type 6 or 7 stools in 24 hours without an active order for a Clostridioides difficile test were listed. Patients with a laxative in the previous 48 hours, tube feedings without fever or leukocytosis, or a known cause of diarrhea were excluded. The attending provider of the patients meeting criteria were notified with a recommendation to test for C. difficile or provide alternative reason for symptoms. Results: In total, 26 patients were tested for C. difficile using polymerase chain reaction testing. Of those tested, 5 (19.2%) tested positive for C. difficile. There were 13 HO-CDI cases for the healthcare system during this period, for an SIR of 0.351. If the early identified cases were not identified until after hospital day 3, the SIR had the potential to have been 35.6% greater at 0.476. Conclusions: We were able to identify 5 CDI cases prior to hospital day 4 using an early identification report during this 13-month period. Although these cases may have been identified without the use of the EHR report, we were able to obtain a timely CDI diagnosis, potentially limiting the spread of C. difficile and preventing an increase in the CDI SIR by 35.6%. An EHR report to identify patients meeting C. difficile testing criteria may be an effective way to identify CO-CDI prior to HD 4 and thus reduce CDI SIR

Disclosures: None
End-of-life care and hospital-acquired bloodstream infection
Authors: Zarnoski Melanie , Burke Patrick , Gordon Steven , Sitaras Joanne , Fraser Thomas
Published: September 2023

Background: All critically ill patients are at risk for hospital-acquired bloodstream infection (HABSI). At any time, however, there is heterogeneity among patients in the ICU; some patients have the added complexity of end-of-life discussions. We sought to better understand the patients in our medical intensive care unit (MICU) with HABSIs that do and do not meet the NHSN definition for a central-line–associated bloodstream infection (CLABSI) event by evaluating for the presence of a do-not-resuscitate (DNR) order. Methods: The study was conducted at our 66-bed MICU at the Cleveland Clinic Main Campus between January 2021 and September 2022. Surveillance for HABSI to include determination of CLABSI is performed prospectively according to the NSHN definition. The electronic health record was queried for each patient with a HABSI for the presence of a DNR order. DNR orders were categorized as follows: prevalent (DNR orders present at the time of admission to the MICU), incident (orders entered after admission to the MICU), or no DNR (for patients without an order at any time during their MICU stay). For incident orders, time from order to HABSI was recorded. Time to event was calculated as days between ICU admission to HABSI. Results: During the observation period there were 36,477 MICU patient days and 4,815 admissions. There were 112 HABSIs, of which 48 (43%) were CLABSIs. Overall, 65 patients were categorized as incident DNR, 7 were categorized as prevalent DNR, and 40 were categorized as no DNR. For patients with an incident DNR order, 50 HABSIs occurred on the date of or before the order and 15 occurred after the order. In patients in whom HABSI occurred after the incident DNR order, the median number of days between DNR order and HABSI was 11 days (range, 1–69). Discussion: In our MICU, >50% of HABSIs and 60% of CLABSIs occurred in patients with a DNR order incident to their MICU stay. Interventions to prevent hospital-acquired bloodstream infection and the analysis of the events are inextricably linked to issues of end-of-life care for critically ill patients. Further exploration of patient characteristics easily obtainable from the EHR, such as DNR orders, is necessary to inform best practices for prevention and risk adjustment of bloodstream infection rates.

Disclosures: None
Universal COVID-19 screening at hospitals in a large Canadian health region
Authors: Garrod Matthew , Short Katy
Published: September 2023

Background: Hospitals were affected by COVID-19, with significant concern regarding transmission from unidentified cases. Fraser Health, a Canadian regional health authority, implemented universal testing along with screening questions for emergency department (ED) admissions. We sought to determine which factors were associated with SARS-CoV-2–positive test on admission as well as patient outcome, stratified by screening question responses. Methods: This retrospective analysis included patients aged ≥6 years admitted through 12 hospital EDs between November 1, 2020, and June 30, 2022. Admission, laboratory, and screening data were extracted from electronic health records. Patients who had a first SARS-CoV-2 PCR–positive test in the prior 60 days collected within 48 hours of admission were classified as positive. Covariates included age, geographical region, and SARS-CoV-2 variant era. All questions were modeled using multinomial logistic regression, with components informed through crude analysis in R Studio software. Results: There were 88,511 unique eligible admissions, with 7,642 positive tests (8.6%). The positivity rate over the study period ranged from 0.6% to 21.8%, with a mean of 6.5%. Patients meeting screening criteria were 4.7 times (95% CI, 4.43–4.92) as likely to test positive as those who did not. Patients in the SARS-CoV-2 omicron variant era were 3.2 times (95% CI, 2.98–3.47) as likely to test positive as those in the earlier era of the pandemic. Patients later in the pandemic were less likely to be identified by screening questions than those in earlier eras, with patients in the SARS-CoV-2 omicron variant era only 14% (95% CI, 12%–17%) as likely as in the earlier stages of the pandemic to be identified by screening questions. Patients who tested positive were 1.5 (95% CI, 1.37–1.64) times as likely to die as patients who tested negative, whereas patients in later stages of the pandemic were less likely to die overall. Discussion: Patients who tested positive on admission were more likely to meet screening criteria; however, screening missed half of all positive cases. It is not known whether patients who tested positive without meeting screening criteria would have resulted in transmission. Conclusions: Due to changes in COVID-19 epidemiology, Fraser Health has discontinued universal admission screening. Although universal testing increased resource needs, more than half of patients who tested positive during the study period would not have been identified based on screening criteria alone, allowing for implementation of precaution measures to prevent possible transmission. Ultimately, the decision to conduct universal testing must be a balance of the resources required, community prevalence, and patient population.

Disclosures: None
Whether or not the weather matters: A retrospective review assessing the influence of weather on SARS-CoV-2 transmission
Authors: Colaluca Melissa , Harford Sean , Palmer Ann , Wu Ulysses , Wu Kaelin , Kulowski Matthew
Published: September 2023

Background: Since the start of the COVID-19 pandemic, many variables have contributed to surges in cases such as the presence of variants, vaccination status, and comorbid medical conditions. However, other factors can be considered including temperature, precipitation, and periods in large congregations. The spike in SARS-CoV-2 infections during the winter has made it seem plausible that transmission may be affected by meteorological factors. A study by Birukov et al demonstrated that a 1°C increase in temperature was associated with a 3.08% reduction in daily new cases and a 1.19% decrease in daily new deaths. We propose that SARS-CoV-2 transmission will decline more rapidly when either precipitation or temperature is higher; thus, in warmer regions with less precipitation daily cases, hospitalizations and deaths will be lower. Methods: This is a retrospective study of statewide data in Hartford County, Connecticut, collected from May 2020 to June 2022 assessing percent positivity reported in daily case count, hospitalizations for COVID-19, and deaths from COVID-19 collected from the Connecticut Department of Public Health COVID-19 database. Information on weather conditions, including temperature and precipitation, were collected from the National Weather Service pertaining to Hartford County. Trends in variables related to patient outcomes were compared to weather conditions within the county of Hartford. Moreover, certain periods within the various seasons that typically involve large gatherings and public holidays (eg, New Year’s Day, Memorial Day, 4th of July, Labor Day, Thanksgiving, and Christmas Day) were further analyzed. Results: There appears to be an inverse correlation coefficient of −0.422, between confirmed daily cases and mean temperature in Hartford County, indicating that as temperature increases, confirmed cases decrease. This phenomenon is also observed with confirmed daily deaths and mean temperature, with a correlation coefficient of −0.463. Moreover, there is an even more significant relationship between hospitalization cases and mean temperature, with a correlation coefficient of −0.667. Furthermore, the year-end holidays (Christmas Day and New Year’s Day) were associated with a significant spike in confirmed daily cases, hospitalizations, and deaths.

However, the relationship between confirmed daily cases, hospitalized cases, and confirmed deaths against mean precipitation in Hartford County demonstrated no significant relationship, reporting correlation coefficients of −0.042, −0.044, and −0.044, respectively. Conclusions: Our available COVID-19 and weather data show that temperature is inversely correlated with daily cases, hospitalizations, and deaths. However, with regard to precipitation, there was no discernable relationship between the variables.

Disclosures: None
Factors influencing healthcare personnel decision making to work with respiratory symptoms during the COVID-19 pandemic
Authors: Meyer Rachel , Kessler Michael , Shirley Daniel , Stevens Linda , Osman Fauzia , Safdar Nasia
Published: September 2023

Background: Amid the COVID-19 pandemic, healthcare systems were stretched thin, with staffing shortages posing substantial challenges. Limiting spread of COVID-19 among healthcare professionals (HCP) is paramount to preventing exacerbation of such shortages, but strategies are highly dependent on HCP self-screening for symptoms and isolating when present. We examined HCP perceptions of barriers and factors that facilitate staying home when experiencing respiratory symptoms. Methods: At an academic tertiary-care referral center, in inpatient and ambulatory settings, we conducted an anonymous electronic survey between March 11, 2022, and April 12, 2022. Using logistic regression analysis, we analyzed predictors of employees reporting to work with respiratory symptoms using STATA and SAS software. Results: In total, 1,185 individuals including 829 clinical staff and 356 nonclinical staff responded to the survey. When excluding participants who reported working “remotely” (N = 381) and those who reported being unsure of whether they had worked with symptoms (N = 14), the prevalence of working with respiratory symptoms was 63%. There was no significant difference between clinical and nonclinical staff (OR, 1.1; 95% CI, 0.8–1.5; P = .60). Increasing number of years of service was protective against working with symptoms, achieving statistically significance in multivariable analysis after 16 years. Compared to those having worked <1 year, the odds ratios of working with symptoms were 0.32 (95% CI, 0.16–0.65; P = .002), 0.33 (95% CI, 0.15–0.74; P = .007), and 0.32 (95% CI, 0.13–0.79; P = .007) for those working 16–20 years, 21–25 years, and ≥26 years, respectively. More than half of HCP who worked with symptoms identified being understaffed (56.9%), having mild symptoms (55.3%), and sense of responsibility (55.1%) as reasons to work with respiratory symptoms. The following barriers, or reasons to work with symptoms, were more commonly identified as significant by those who worked with symptoms compared to those who did not: being understaffed (OR, 1.87; 95% CI, 1.35–2.58; P ≤ .001), having mild symptoms (OR, 1.96; 95% CI, 1.42–2.71; P < .001), and lack of support from management (OR, 1.84; 95% CI, 1.07–3.18; P = .03). Conclusions: Working with respiratory symptoms is prevalent in clinical and nonclinical HCP. Those with fewer years of work experience appear to be more susceptible to misconceptions and pressures to work despite respiratory symptoms. Messaging should stress support from leadership and the significance of even mild respiratory symptoms and should emphasize responsibility to patients and colleagues to stay home with respiratory symptoms. Strategies to ensure adequate staffing and sick leave may also be high yield.

Disclosures: None
Evaluation of indication in a urinalysis driven reflex urine culture protocol at an academic medical center
Authors: Keintz Mackenzie , Marcelin Jasmine , Rupp Mark , Schooneveld Trevor Van
Published: September 2023

Background: Asymptomatic bacteriuria (ASB) is a widespread problem in hospitalized patients in which only a small subset of patients benefit from treatment. Other patient populations with ASB are harmed by treatment. In 2014, our institution implemented a urinalysis (UA)-driven reflex culture protocol which evaluated patient symptoms, risk factors, and the UA to determine whether bacterial culture was performed (Fig. 1). The goal of this process was to ensure that urine cultures were only performed in those patients who had symptoms of UTI and an abnormal urinalysis while allowing for exceptions in populations where treatment of ASB may be appropriate (ie, pregnancy, aged <3 years, impending urologic surgery, kidney transplant) or where the urinalysis may not be useful in determining whether infection is present (ie, neutropenia). An “other” indication with free-text documentation required was included to allow for unique situations. We evaluated the free-text option to determine whether additional indications were needed and whether data entered were medically appropriate. Methods: This retrospective review at a Midwestern, tertiary-care, academic medical center included inpatient UA with UTI evaluation order sets between July 1, 2020, and June 30, 2022. Descriptive statistics analyzed order-set utilization. Results: In total, 35,469 “urinalysis to reflex culture” order sets were submitted, of which 9,493 resulted in culture. Of these, 839 (8.8%) were ordered with an indication of “other.” “Other” was the most cited indication for special population override contributing to 40% (n = 839 of 2,085) of these indications, followed by kidney or pancreas transplant (29%) and neutropenia (13%). The write-in options fell into 1 of 11 themes (Fig. 2). The 3 most common reasons a urine culture was obtained using the free-text option were nonurologic surgical intervention (n = 223 of 839), immunosuppression not otherwise defined (n = 195 of 839), and symptom presence (n = 146 of 839). Based on current literature, 97% of other indications were inappropriate (n = 816 of 839). If the UTI protocol had been strictly followed, 696 of 839 (83%) cultures ordered with an indication of “other” would not have been obtained, due either to lack of symptoms or, if symptomatic, lack of pyuria. Conclusions: Most cultures obtained by selecting the “other” special population option on the algorithm were obtained in situations in which a urine culture was unnecessary. Removing the “other” indication from the algorithm may improve appropriateness of urine culturing with a possible decrease in CA-UTI and treatment of ASB. Although most write in rationales were inappropriate, adding an additional category for deceased donor-organ evaluation would be reasonable.

Disclosures: None
Characterization of negative health outcomes for dialysis events by vascular access type—Tennessee, 2015–2019
Authors: Suhs Tara , Kurutz Alex , Wilson Christopher
Published: September 2023

Background: The dialysis patient population is at a higher risk for nosocomial infections as well as related negative consequences including hospitalization and death. The CMS and the state of Tennessee mandate reporting of 3 types of dialysis events: positive blood culture, intravenous antimicrobial starts, and pus, redness, or increased swelling at the access site. We explored hospitalization and death outcomes by vascular access types for dialysis events reported to the NHSN for licensed outpatient hemodialysis clinics in Tennessee from 2015 to 2019. Methods: We looked at the frequency of hospitalization and death among those who experienced a dialysis event for 3 types of vascular access: arteriovenous fistula, arteriovenous graft, and tunneled central venous catheter (CVC). Other vascular-access types were excluded due to low usage rates. Odds ratios and confidence intervals were used to quantify the relationship between access type and hospitalization, and access type and death. Pooled analysis was used due to the stable rates of death and hospitalization among access types from 2015 to 2019. Results: From 2015 to 2019, 16,742 dialysis events were reported for the 3 access types: 8,055 dialysis events (48.1%) occurred among those with tunneled CVCs, 7,107 (42.5%) occurred among those with fistulas, and 1,580 (9.4%) occurred among those with grafts. Of the 16,742 dialysis events, 3,420 patients (20.4%) were hospitalized either due or related to their dialysis event; 220 (1.3%) deaths occurred either due to or related to the patient’s dialysis event. The odds of being hospitalized was 1.47 (95% CI, 1.29–1.67) times greater in those with grafts compared to those with fistulas. Patients with tunneled CVCs were 1.30 (95% CI, 1.20–1.41) times greater to be hospitalized compared to those with fistulas. The odds of death was 1.09 (95% CI, 0.9–2.5) times greater in those patient with tunneled CVCs compared to those with fistulas, whereas the odds of death among patients with grafts was 0.73 (95% CI, 0.82–1.43) times the odds of death compared to patients with fistulas. Conclusions: Overall, our findings conclude hemodialysis patients with tunneled CVCs have an increased risk for the negative health outcomes of hospitalization and death when compared to the other access types, supporting previous studies. Additionally, grafts had a higher risk of hospitalization compared to fistulas, but patients with grafts had lower odds of death than those with fistulas. Further investigation is needed to study how the COVID-19 pandemic may have affected the trends of negative health outcomes related to dialysis events.

Disclosures: None
Functional dependence as a contributing factor for patient hand contamination by multidrug-resistant organisms in acute care
Authors: Behunin Trenton , Mantey Julia , Cassone Marco , Mody Lona
Published: September 2023

Background and objectives: Patients with functional disabilities are at higher risk of adverse outcomes, including infections. Although healthcare worker hand contamination has long been recognized as an important source of pathogen acquisition, the role of patient hands has been less clearly defined. We sought to determine whether the presence of functional disabilities is correlated with patient hand contamination by multidrug-resistant organisms (MDROs) and thus a potential target for patient hand hygiene (PHH) interventions. Methods: Case–control study of hand contamination with methicillin-resistant S. aureus, vancomycin-resistant enterococci, and gram-negative bacilli resistant to cephalosporins, fluoroquinolones, and/or carbapenems in 2 acute-care hospitals in southeastern Michigan. Cases (n = 40) and controls (n = 359) were defined as patients with or without hand contamination by MDROs, respectively. We assigned 3 exposure categories based on Katz activities of daily living scores: no functional disabilities (independent, reference group), 1–3 functional disabilities (partially dependent), and 4+ functional disabilities (dependent). We used stepwise logistic regression to identify confounding variables. Logistic regression was then used to establish the relationship between a patient’s functional dependence level and their hand contamination by MDROs. Results: The distribution of hand contamination of each target MDRO by level of patient dependence is shown in the Table. Overall, methicillin-resistant Staphylococcus aureus (MRSA) was the most represented, followed by resistant gram-negatives and vancomycin-resistant enterococci (VRE). Hospital site, sex, and history of MDROs were included in the model based on stepwise regression. The odds ratio (OR) of MRSA hand contamination in the dependent category was 3.19 (95% CI, 1.18–5.54) compared to the independent category, and for any MDRO the OR was 2.77 (95% CI, 1.22–6.32) (Fig. 1). The OR of MRSA hand contamination in the partially dependent category was 1.38 (95% CI, 0.27–7.07) compared to the independent group, and for any MDRO the OR was 0.86 (95% CI, 0.24–3.10) (Fig. 1). Feeding dependence had the highest single association with hand contamination (OR, 3.79, 95% CI, 1.26–11.43), with dressing dependence having the second highest association with hand contamination (OR, 2.82; 95% CI, 1.31–6.05) (Fig. 2). Conclusions: Patients with more functional dependencies were more likely to have MDRO hand contamination. This finding suggests a need for targeted PHH interventions in patients with functional disabilities to help prevent the spread of MDROs in the acute-care setting.

Disclosures: None
Comparison of a standard environmental surface sampling method and a composite approach for select healthcare pathogens
Authors: Chan Monica , Noble-Wang Judith , Rose Laura
Published: September 2023

Background: Hospital surfaces are known to contribute to the spread of healthcare-associated infections (HAIs). Environmental sampling is often performed to locate a reservoir or to evaluate intervention strategies in healthcare facilities. Composite sampling is commonly practiced in other fields of environmental sampling and involves collection of multiple samples combined entirely or partially to form a new sample. We compared a standard CDC surface whole-tool sampling method with a composite sampling approach. Methods:Acinetobacter baumannii (AB), Klebsiella pneumoniae that produce K. pneumoniae carbapenemase (KPC), vancomycin-resistant Enterococcus faecalis (VRE), methicillin-resistant Staphylococcus aureus (MRSA), and Clostridioides difficile spores were suspended in an artificial soil and deposited as 40 µL droplets (~104 CFU total) onto steel coupons of surface areas 323 cm2, 645 cm2, or 1,290 cm2 and dried for 2 hours. The surfaces were sampled with a single pass of a cellulose sponge— either the larger side of the sponge (face) or the smaller side of the sponge (edge)—and the optimal surface area was determined. Recovery from the optimal surface area with a single pass sampling was compared to the recovery using a standard CDC method in which all sides were used (ie, whole-tool method) to sample a standard area (645 cm2). Recovery was determined by culture and total CFU were determined for each optimal surface area. Theoretical composites were constructed using the mean total CFU of optimal surface area; 2×((face) + (edge)). Significance was set at P ≤ .05. Results: Total CFU recovery using the whole-tool method was significantly greater than the single pass sample recovery for MRSA (18,300 vs 16,600 CFU) and VRE (27,600 vs 26,400 CFU) (P < .05). When comparing the theoretical composite method to the standard whole-tool area (625 cm2), the theoretical composite total CFU was significantly greater than the whole-tool method for all organisms. For example, VRE recovery with the standard CDC whole-tool method was 27,600 CFU from 625 cm2, yet a theoretical composite approach recovered 79,800 CFU from an area of 1,290 cm2. Conclusions: Many factors influence recovery when sampling the environment, and composite sampling is a promising approach when sampling large surface areas. Using a theoretical composite of single-pass samples, the potential for improved detection with composite sampling was demonstrated. A composite sampling approach will reduce time and resources for sampling and sample processing, allowing larger surface areas to be investigated which will improve infection control strategies.

Disclosures: None