bluuebunny/crossref_metadata_2025 huggingface dataset:
Observational Bias Within Hospital-Wide Hand Hygiene Program
Authors: Marques Amy , Tucker Robert , Klompas Michael
Published: November 2020

Background:
Hand hygiene (HH) is critical to prevent hospital-acquired infections. Running a successful HH program requires valid and accurate HH data to monitor the status and progress of HH improvement efforts. HH data are frequently subject to variable forms of bias, for which considerations must be made to enhance the validity of HH data. Objective: We assessed the extent to which observers may be prone to report more favorable HH rates when observing healthcare workers from the same professional group versus members of other job categories. Methods: We analyzed HH data from 48,543 electronically collected observations conducted by frontline healthcare workers in a 793-bed acute-care hospital from January 1, 2019, through July 31, 2019. All auditors received training on HH observations and proper use of the data collection application. Compliance data were sorted into peer versus nonpeer observations by profession. We compared HH compliance rates for members of each professional group when monitoring peers versus nonpeers. We further stratified results by ancillary professions (central transport, unit associates, food services, pharmacy, phlebotomy, rehabilitation services, and respiratory therapy) versus nonancillary professions (doctors, nurses, physician assistants, patient care assistants). Results: Of 12,488 ancillary observations, 7,184 (57.5%) were peer observations and 36,055 were nonancillary observations, of which 15,942 (44.2%) were peer observations. The percentage of peer-to-peer observations versus nonpeer observations varied by profession, ranging from 96% of central transport workers and 91% of environmental services observations to 21% of patient care assistants and 34% of physician’s assistants. Average compliance rates for peer versus nonpeer observations in ancillary groups were 98% (95% CI, 98.7%–99.2%) versus 83% (95% CI, 82.5%–84.5%). Average compliance rates nonancillary groups were 92% (95% CI, 92.0%–92.8%) for peers versus 88% (95% CI, 87.8%–88.7%) for nonpeers (Table 1). Conclusions: We documented a propensity for some categories of healthcare workers to record discrepant rates of HH compliance when observing members of the same peer group versus others. This effect was more pronounced amongst ancillary versus nonancillary services. This study adds to the literature of potential sources of bias in HH monitoring programs. Operational changes in HH program data collection may be warranted to try to mitigate these biases such as increasing the frequency of validation exercises conducted by nonaffiliated observers, weighting peer versus nonpeer observations differently, or switching to automated electronic monitoring systems.

Funding: None

Disclosures: None
Occupational Health Hazards Among Medical Waste Handlers in Ahmadu Bello University Teaching Hospital Zaria Northwest Nigeria
Authors: Onoja-Alexander Mary , Zakari Usman , Alexander Onoja , Umar Ahmad , Ajumoka Emmanuel , Igboanusi Chinedu John-Cemillus , Aliyu Alhaji
Published: November 2020

Background: Occupational injuries are important public health issues, especially among healthcare workers. The medical waste handler is at risk of hazards posed by medical waste as well as from the environment. The aim of the study was to determine occupational hazards that hospital waste handlers in Ahmadu Bello University Teaching Hospital, Zaria, were exposed to and to assess their knowledge and practice of safety measures. Methods: A cross-sectional descriptive study was conducted among 79 medical waste handlers in Ahmadu Bello University Zaria using a multistage sampling technique. Data were collected using structured self-administered and interviewer administered questionnaire and analyzed using SPSS version 20 software with significance set at P < .05. Results: More than half of the respondents (56.4%) were men, and most (70.3%) had <5 years work experience. Most of the respondents (60.8%) had had an injury in the previous 6 months. The most common injuries were falling on a slippery floor (48.1%), contact/irritant dermatitis (40.5%), and 34.2% from stress. Only 45.6% received treatment following injury at the work place. Most respondents (75.9%) were aware of safety devices, and more than half (51.9%) received their information from special safety training. More than half of the respondents (51.1%) had poor knowledge of use of safety devices, and 60% had special training in occupational safety. Most respondents (89.9%) used heavy-duty rubber hand gloves, but only 5.1% used aprons. Also, 82.3% of respondents used these devices regularly at work, and more than half of respondents (62%) had been immunized against hepatitis. Also, 65.8% practiced universal precautions. Occupational injury was higher among those aged 15–19 years (occupational injury rate, 75%) compared to those aged 34–39 years (occupational injury rate, 16%). A positive association was detected between gender and injury in the last 6 months; injury was more common among men (43%) than among women (15%). Conclusions: Among respondents, there was a high level of injury and poor knowledge of the use of protective devices. Regular use of protective measures was not commensurate with the reported level of awareness. Concerted efforts are needed to ensure the safety of the medical waste handlers in his work place.

Funding: None

Disclosures: None
Octenidine Body Wash and Nasal Gel Reduces MRSA Bacteremia
Authors: Ang Brenda , Chow Angela
Published: November 2020

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is highly prevalent in Singapore hospitals. The Ministry of Health (MOH) has set a reduction of MRSA bacteremia as a key performance indicator for publicly funded hospitals, resulting in the adoption of various strategies to achieve this goal. Decolonization regimens have been implemented in different institutions with variable outcomes. In Tan Tock Seng hospital (TTSH), octenidine was chosen instead of chlorhexidine for its gentler action on the skin, and nasal octenidine was chosen instead of mupirocin (which has a high resistance rate) for nasal decolonization. Methods: All patients admitted to TTSH are screened for MRSA on admission. Patients who are either colonized or infected with MRSA are either placed in isolation rooms (when available) or are placed in cohorts in MRSA wards. The Department of Infection Prevention and Control (IPC) keeps a database of all patients with positive cultures for MRSA, including bacteremia. We used this database to implement and evaluate targeted strategies in such MRSA wards. In January 2018 we began a pilot project in 1 ward, whereby all patients had intranasal octenidine gel applied twice a day for 5 days, as well as daily octenisan baths throughout their stay in the ward. The outcome of interest was MRSA bacteremia occurring ≥3 days after admission. This quasi-experimental before-and-after study was conducted from January 2016 to September 2019 with January 2018 excluded as a washout month. Results: In total, 44 observational months (24 months before the intervention 20 months after the intervention) and 4,309 patients were included. In the preintervention period, 12 bacteremia cases occurred among 2,333 patients (0.5%); in the postintervention period, 4 MRSA bacteremia cases occurred in 1,976 patients (0.2%): RR, 0.49 (95% CI, 0.13–1.22), 1-sided P = .07. The rate of MRSA bacteremia was halved, but it did not reach statistical significance due to the small number of cases overall. The products were well tolerated by patients and staff who applied them to nonambulant patients. Conclusions: Octenidine baths and nasal gel reduced risk of MRSA bacteremia in a cohort of MRSA-positive patients, and this strategy may be preferable to the universal use of antiseptic baths.

Funding: None

Disclosures: None
Operating Room Nurses’ Knowledge of Surgical Site Infection Prevention Measures
Authors: Oliveira Adriana
Published: November 2020

Background:
Surgical site infection (SSI) stands out among healthcare-related infections as one of the most important globally due to its associated morbidity and mortality. However, it is well known that the transoperative period is recognized as one of the most critical moments for the prevention of SSI. Objective: We evaluated the knowledge of the operating room (OR) nurse coordinators regarding SSI prevention measures. Methods: We conducted a cross-sectional study in 30 large hospitals in the state of Minas Gerais, Brazil, from February 2018 to April 2019. Data were collected through interviews with OR nurse coordinators. Results: Administration time of prophylactic antibiotic administered between 30 and 60 minutes prior to surgery was reported by 84% of the professionals and the suspension of this agent in the first 24 hours was reported by 47.8%. Preoperative hair removal within the operating room was mentioned by 60% of respondents and 36.7% mentioned using a razor. The Safe Surgery program of the WHO was unknown to 6.7% of nurses. Among those who knew about it, 20.8% stated that there was no surgical site demarcation. Presentation of the surgical team occurred before the beginning of the procedure in only 53.3% of the institutions. Patient surveillance for SSI was reported by 93.3% of respondents, but the criteria adopted for the diagnosis of SSI were unknown, even though SSI rates were given for 90% of services, predominantly via meetings (53.5%). Conclusions: The knowledge of nurses related to the prevention of SSI was not satisfactory, pointing to the need for immediate efforts in education and awareness programs. Such programs may facilitate changes in practice through the recognition of surgical patient risk by these professionals, thus leading to better planning and practice during the trans-operative period.

Funding: None

Disclosures: None
Optimizing Sentinel Surveillance to Target Containment of Emerging Multidrug-Resistant Organisms in Regional Networks
Authors: Paul Prabasaj , Slayton Rachel , Kallen Alexander , Walters Maroya , Jernigan John
Published: November 2020

Background: Successful containment of regional outbreaks of emerging multidrug-resistant organisms (MDROs) relies on early outbreak detection. However, deploying regional containment is resource intensive; understanding the distribution of different types of outbreaks might aid in further classifying types of responses. Objective: We used a stochastic model of disease transmission in a region where healthcare facilities are linked by patient sharing to explore optimal strategies for early outbreak detection. Methods: We simulated the introduction and spread of Candida auris in a region using a lumped-parameter stochastic adaptation of a previously described deterministic model (Clin Infect Dis 2019 Mar 28. doi:10.1093/cid/ciz248). Stochasticity was incorporated to capture early-stage behavior of outbreaks with greater accuracy than was possible with a deterministic model. The model includes the real patient sharing network among healthcare facilities in an exemplary US state, using hospital claims data and the minimum data set from the CMS for 2015. Disease progression rates for C. auris were estimated from surveillance data and the literature. Each simulated outbreak was initiated with an importation to a Dartmouth Atlas of Health Care hospital referral region. To estimate the potential burden, we quantified the “facility-time” period during which infectious patients presented a risk of subsequent transmission within each healthcare facility. Results: Of the 28,000 simulated outbreaks initiated with an importation to the community, 2,534 resulted in patients entering the healthcare facility network. Among those, 2,480 (98%) initiated a short outbreak that died out or quickly attenuated within 2 years without additional intervention. In the simulations, if containment responses were initiated for each of those short outbreaks, facility time at risk decreased by only 3%. If containment responses were initiated for the 54 (2%) outbreaks lasting 2 years or longer, facility time at risk decreased by 79%. Sentinel surveillance through point-prevalence surveys (PPSs) at the 23 skilled-nursing facilities caring for ventilated patients (vSNF) in the network detected 50 (93%) of the 54 longer outbreaks (median, 235 days to detection). Quarterly PPSs at the 23 largest acute-care hospitals (ie, most discharges) detected 48 longer outbreaks (89%), but the time to detection was longer (median, 716 days to detection). Quarterly PPSs also identified 76 short-term outbreaks (in comparison to only 14 via vSNF PPS) that self-terminated without intervention. Conclusions: A vSNF-based sentinel surveillance system likely provides better information for guiding regional intervention for the containment of emerging MDROs than a similarly sized acute-care hospital–based system.

Funding: None

Disclosures: None
Outbreaks of Healthcare-Associated Infections in Sao Paulo State, Brazil: Results From a Statewide Monitoring System
Authors: de Jesus Marçal Heloisa , Madalosso Geraldine , Assis Denise , Padoveze Maria Clara
Published: November 2020

Background:
Outbreaks of healthcare-associated infections (HAI) are relevant causes of morbidity and mortality. Healthcare-authorities should monitor them to allow prompt interventions, identify tendencies along the time, and develop large scale strategies to avoid new cases and clusters. According to the Brazilian legislation, any outbreak should be reported to health authorities. Sao Paulo State Health Department (Brazil) has a system in place since 2011 to monitor HAI outbreaks. This study aims at describing the 3.5 last year’s results of surveillance system for monitoring HAI outbreaks. Methods:Study design: Quantitative descriptive study. Source of information: Database from HAI outbreak reports, Division of Hospital Infection at Sao Paulo State Health Department. Reports were filled out online by professionals from healthcare settings or regional health authorities according to predefined criteria. Interventions were put in place by the health authorities based on the analysis of each situation in a timely manner. Variables analyzed: Number of reports, local, infection site, type of care unit, causative microorganisms, number of cases, and number of deaths. Results: The number of reports have been stable for 3 years: 2016 (n = 34, 34.7%), 2017 (n = 28, 28.6%), 2018 (n = 25, 25.5%) and the first semester of 2019 (n = 11, 11.2%). These reports encompassed 712 confirmed cases and 123 deaths. The reports were mainly about infection outbreaks; 6 reports were about colonization of multidrug-resistant microorganisms. The bloodstream was the most frequent infection site in the HAI outbreak reports (n = 37, 37.7%), followed by respiratory tract (n = 25, 25.5%), urinary tract (n = 10, 10.2%), and surgical wound (n = 9, 9.2%). HAI outbreaks happened more frequently in intensive care units, including neonatal, pediatric, and adult ICUs (n = 38, 38.8%), followed by clinical and general wards (n = 20, 20.4%), hemodialysis (n = 6, 6.1%), and surgical wards (n = 5, 5.1%). Among reported outbreaks, 62.2% occurred in the capital and the metropolitan region of São Paulo. Microorganisms causing the HAI outbreaks reports were mainly carbapenem resistant, both Klebsiella pneumoniae (n = 28, 28.5%) and Acinetobacter baumannii (n = 12, 12.2%), but carbapenem-susceptible Pseudomonas aeruginosa (n = 7, 7.1%) was also reported. Conclusions: HAI outbreaks reported to health authorities in Sao Paulo may represent only a minute percentage of the total outbreaks, most of which are still not being reported, despite the normative. However, the available data emphasize the importance of developing strategies for intensive care units and hemodialysis units that focus on reducing bloodstream infections caused by multidrug-resistant gram-negative organisms.

Funding: None

Disclosures: None
Outpatient Fluoroquinolone Medication Use Evaluation at an Academic Veterans Affairs Medical Center
Authors: Markley John Daniel , Vaughan Leroy , Stevens Michael , Hitchcock Matthew
Published: November 2020

Background: Fluoroquinolones (FQs) are one of the most commonly prescribed antibiotic classes in the United States. In recent years, their widespread use has come under heightened scrutiny due potential adverse drug reactions including risks of mental health side effects, serious blood sugar disturbances, and Food and Drug Administration (FDA) black-box warnings for tendinopathy, aortic aneurysm, and dissection. These warnings prompted the Department of Veterans Affairs Pharmacy Benefits Management Service to perform a nationwide FQ utilization review, which identified our facility for potential overuse of FQs in the outpatient setting: 82.2 prescriptions per 1,000 unique patients compared to an average of 48 prescriptions per 1,000 unique patients across all VHA facilities. We then embarked on a FQ medication use evaluation (MUE). Objective: To determine appropriateness of FQ prescribing practices in the outpatient setting. Methods: The study setting was a 399-bed tertiary-care Veterans Hospital with >250 affiliated outpatient clinics in Richmond, Virginia. A retrospective chart review was conducted on a convenience sample of consecutive patients prescribed an FQ from each quarter between April 1, 2018, and March 31, 2019. Chart review included patient demographics, location, FQ used, dose, indication, appropriateness, prescriber, and documentation of patient counseling on FDA black box warnings. Appropriate treatment was defined by national and local antimicrobial therapy guidelines. Results: In total, 265 patients were included the study. Among them, 233 patients (88%) were men and the mean age was 68 years. Overall, 127 patients (48%) were prescribed FQs inappropriately. Primary care clinics and the emergency department (ED) had the highest frequency of inappropriate FQ prescriptions (Fig. 1). Moreover, 92 patients (35%) were prescribed FQs for surgical prophylaxis prior to urological procedures. FQs were most commonly inappropriately prescribed for urinary tract infection (UTI, n =74, 84%) and upper respiratory tract infection (URI, n=27, 84%) (Fig. 2). Documented counseling on FDA black box warnings occurred in 82 cases (31%). Conclusions: In our MUE, outpatient prescribing of FQs was inappropriate nearly 50% of the time. The most commonly documented indications for FQs determined to be inappropriate included UTI and URI. Inappropriate prescriptions most commonly originated from primary care and the emergency department. Urology had the highest volume of FQ prescriptions, which were mostly appropriate surgical prophylaxis based on indication (though an alternative agent would be preferred based on local resistance rates). Documentation of patient counseling for FDA black-box warnings on FQs was uncommon.

Funding: None

Disclosures: None
Healthcare Professionals Perception of Mobile Phone Usage and Hand Hygiene Adhesion in Intensive Care Units
Authors: Sanchez Evelyn , Perdigão-Neto Lauro , dos Santos Sânia Alves , Rizek Camila , Gomez Maria Renata , Martins Roberta , de Oliveira Gaspar , Guimaraes Thais , Boszczowski Icaro , Rossi Flavia , Freire Maristela , Levin Anna , Costa Silvia Figueiredo , Farrel Marina
Published: November 2020

Background: The introduction of new technologies into the medical field has the duality of improvement and concerns about correct usage and cleaning. Mobile phones are used by healthcare professionals (HCPs) in the work place, and there is not an official policy about their use in health environment. Methods: We asked 60 intensive care unit (ICU) HCPs from 2 units (the burn unit and the internal medicine unit) to participate in an electronic survey about mobile phone usage and hand hygiene compliance; we also cultured the hands and mobile phones of the participants. Unfortunately, 13 HCPs did not participate. Susceptibility testing of the strains was conducted, as well as molecular testing. Results: Overall, 47 HCPs responded to the inquiry: 19% were nurses (9 of 47), 19% were resident physicians (9 of 47), 17% were nursery technicians (8 of 47), 17% were physiotherapists (8 of 47), 13% were cleaning staff (6 of 47), 11% were consultants (5 of 47), and 4% were technicians (2 of 47). Moreover, 26 of 47 participants (55%) were woman and 21 (45%) were men. From all HCP categories, 39 of 47 respondents (83%) reported that they had optimal hand hygiene compliance. However, 92% of respondents had a colonized hand and 90% had a colonized mobile phone. Also, 44 of 47 HCPs (94%) reported that the took their personal mobile phone into the workplace; 40 (85%) reported that they used it during the work day and 35 (74%) reported that they cleaned it. However, 8 HCPs (26%) reported that they had never cleaned the device. All of the HCPs understood that mobile phones can harbor bacteria, and 27 of 47 HCPs (57.45%) indicated that they use 70% alcohol to clean their mobile phones. In contrast, the first choice for hand hygiene was water and soap in 51% of HCPs (24 of 47). Also, 3 HCPs did not have any colonization in the hand culture but had healthcare-associated infection (HAI) pathogens in the mobile phone culture. Conclusions: A policy regarding mobile phone usage in the healthcare setting should be in place, and cleaning of electronic devices in hospitals should be standardized.

Funding: None

Disclosures: None

Funding: None

Disclosures: None
Peripherally Inserted Central Catheters Present on Admission and the Risk of Central-Line–Associated Bloodstream Infection
Authors: Burke Patrick , Nickoli Elise , Sitaras Joanne , Mullins Wanda , Dandache Patricia
Published: November 2020

Background: Patients presenting to hospitals often arrive with peripherally inserted central catheters (PICC) in place upon admission. The admitting facility may not be familiar with that device’s history and the unknown risk for bloodstream infection associated with it often prompts requests for device replacement. A blanket approach to “change all lines” must be balanced with the potential for patient discomfort and insertion-related complications. To better inform our approach to prevention, we determined the incidence of central-line–associated bloodstream infection (CLABSI) in adult patients presenting to hospitals in our health system with a PICC present on admission (POA), relative to those who have a PICC placed after admission (PAA). Methods: This retrospective cohort study included all adult hospital encounters at 11 Cleveland Clinic acute-care hospitals lasting > 2 days in 2018 with electronic medical record nursing care flowsheet documentation of a PICC during the stay. Patients whose admission diagnosis was related to intravascular catheter infection, children aged <18 years, and observation unit encounters were excluded. Patients were categorized as having a PICC POA if a nurse selected that option on a PICC flowsheet, otherwise the patient was categorized has having a PICC PAA. Surveillance for CLABSI was performed in all inpatient locations at all hospitals according to the NHSN protocol. Patients with ≥1 CLABSI were matched to encounters by name and date of admission. Repeat infections occurring to the same patient were excluded. Results: Of the 8,827 eligible hospital encounters, 1,799 (20%) involved a PICC POA and 7,028 (80%) had PICCs PAA. Across 11 hospitals, the median proportion of PICC-associated encounters with a device POA was 15% (range, 8%–25%). Moreover, 23 of the 112 CLABSIs (21%) in our cohort occurred in patients with a PICC POA and 89 (79%) occurred in patients with a PICC PAA (Table 1). The overall relative risk of CLABSI, whether the PICC was placed before or after admission, was 1.00 (95% CI, 0.64–1.60). Conclusions: Patients with a PICC present on admission to our hospitals were no more likely to experience a CLABSI than patients who had a PICC placed after admission. Replacing vascular catheters that are POA may not reduce the risk of CLABSI. With up to 25% of PICC-associated encounters having the device POA, universal device replacement at admission would involve hundreds of patients per year at our multihospital health system.

Funding: None

Disclosures: None
Postintravitreal Injection Endophthalmitis: An Infection Control Investigation and Case–Control Analysis of Risk Factors
Authors: Halsey James , Tischendorf Jessica , Anderson Laura , Pop-Vicas Aurora , Osman Fauzia , Safdar Nasia
Published: November 2020

Background: Intravitreal injection of vascular endothelial growth factor inhibitors with or without steroids is a well-established, effective therapy for several ocular disorders. The expected rate of complications from these injections is low, with meta-analyses reporting 5–6 occurrences of infectious endophthalmitis per 10,000 injections. Through October 2019, our health system observed 8 cases of endophthalmitis among 7,693 injections (10.4 per 10,000 injections), compared to 1 case in 2018. This unusually high rate prompted an infection control investigation and a case control study to examine risk factors for the development of postintravitreal injection endophthalmitis. Methods: Infection control providers performed direct observation of several ophthalmologists performing intravitreal injections on 3 separate occasions to determine points of intervention to prevent infection. To define risk factors for postintravitreal injection endophthalmitis, we conducted a retrospective case-control study of the 8 affected patients. Four control patients were selected per case, matched by clinic location, drug injected, and date of injection (total subjects, N = 40). We extracted patient-level risk factors from medical records; documentation was not sufficient to compare procedure-level factors. We conducted unadjusted univariate Poisson regression and Mantel–Cox method rate ratios to identify significant risk predictors of endophthalmitis. Results: Direct observation yielded variable practice in use of masks, gloves, sterile lid speculum, and the duration of povidone-iodine contact on the ocular surface prior to injection. The location of alcohol hand gel relative to the procedure field was suboptimal. Due to patient volume, there were significant delays between procedure and patient prep and injection time. The mean age was 76 years among cases and 74.1 years among controls; 35% of patients were men. Age-related macular degeneration was the most common indication for injection (55%). Only 10% of injections were bilateral. Although not statistically significant, patients with coronary artery disease had a higher rate of infection than those without coronary artery disease (165.3 vs 16.3 per 10,000 person years; IRR = 3.0; 95% CI, 0.60–14.8; P = .18); current smokers were also at higher risk (86.9 per 10,000; IRR, 3.2; 95% CI, 0.33–30.4; P = .32). Conclusions: Coronary artery disease and smoking were risk factors for the development of postintravitreal injection endophthalmitis in a 2019 cluster of cases in our organization. We are continuing to work with our ophthalmologists to optimize infection prevention in the injection environment, including strict use of gloves, appropriate use of povidone-iodine, and routinely wearing a mask and encouraging a no-talking policy during injections.

Funding: None

Disclosures: None
Prevalence, Distribution, and Antibiotic Susceptibilities of Nosocomial Infections at a Tertiary Hospital in Port Harcourt, Nigeria
Authors: Stanley Catherine Nonyelum , Ekada Inimuvie
Published: November 2020

Background: Previously, many infections could be treated effectively based on the clinician’s past clinical experience. The development of resistance to essentially all of the antimicrobial agents currently in use in clinical practice has made this scenario more of the exception than the norm. Selecting an appropriate antimicrobial agent has become increasingly more challenging; the clinician has to navigate through the variety of available agents in the face of increasing antimicrobial resistance. The diagnostic laboratory now plays very important role in clinical practice. To ensure safe and effective empirical treatment, a surveillance study of the susceptibility pattern of common pathogens and appropriate use of antibiotics is imperative. Objective: We report on the prevalence, distribution, and antibiotic susceptibility patterns of nosocomial pathogens isolated at the University of Port Harcourt Teaching Hospital (UPTH) and the effectiveness of the antibiotics commonly prescribed at the hospital in treating these infections. Methods: A retrospective cross-sectional study of specimens received at the microbiology laboratory was conducted over a 6-month period, from October 2015 to March 2016, using urine, blood, and semen specimens. In total, 5,160 samples received and analyzed at the laboratory within the study period were assessed. Results: Of the 5,160 specimens analyzed, 881(17.07%) were positive for bacteria: 691(78.43%) from urine, 86 (9.76%) from blood, and 104 (11. 81%) from semen. Escherichia coli (35.74%), Klebsiella pneumoniae (52.33%), and Staphylococcus aureus (65.4%) were the most frequently isolated pathogens from urine, blood, and semen, respectively. Widespread multidrug resistance was observed among the organisms. Klebsiella pneumoniae, S. aureus, and E. coli isolated from urine were resistant to amoxicillin/clavulanate, cefuroxime, ceftazidime, ciprofloxacin, ampicillin, gentamycin, and ceftriaxone. A review of the pattern of prescribing antibiotics revealed that in the emergency unit, ceftriaxone (34.09%) and metronidazole (30.09%) were most frequently prescribed, whereas in the general outpatient department, metronidazole (19.09%), amoxicillin (16.61%), amoxicillin/clavulanate (9.39%), and ofloxacin (9.39%) were often prescribed. S. aureus was susceptible to only ceftriaxone, whereas K. pneumoniae and E. coli were susceptible only to ofloxacin. Conclusions: Most of the isolated pathogens were not susceptible to the frequently prescribed antibiotics. Empirical prescribing of antibiotics without current epidemiological data of pathogens in the hospital can only further exacerbate the problem of antimicrobial resistance. The need for periodic epidemiological surveillance and rational use of antibiotics anchored on a good antibiotic stewardship program is therefore strongly recommended.

Funding: None

Disclosures: None
Reduced Length of Stay Using Clinical Decision Support Tool (ASAP) for Empiric Antibiotic Selection
Authors: Acree Mary , Singh Kamaljit , Ravichandran Urmila , Grant Jennifer , Fleming Gary , Hadsell Bryce , Shah Nirav
Published: November 2020

Background: Empiric antibiotic selection is challenging and requires knowledge of the local antibiogram, national guidelines and patient-specific factors, such as drug allergy and recent antibiotic exposure. Clinical decision support for empiric antibiotic selection has the potential to improve adherence to guidelines and improve patient outcomes. Methods: At NorthShore University HealthSystem, a 4-hospital, 789 bed system, an automated point-of-care decision support tool referred to as Antimicrobial Stewardship Assistance Program (ASAP) was created for empiric antibiotic selection for 4 infectious syndromes: pneumonia, skin and soft-tissue infections, urinary tract infection, and intra-abdominal infection. The tool input data from the electronic health record, which can be modified by any user. Using an algorithm created with electronic health record data, antibiogram data, and national guidelines, the tool produces an antibiotic recommendation that can be ordered via a link to order entry. If the tool identifies a patient with a high likelihood for a multidrug-resistant infection, a consultation by an infectious diseases specialist is recommended. Utilization of the tool and associated outcomes were evaluated from July 2018 to May 2019. Results: The ASAP tool was executed by 140 unique, noninfectious diseases providers 790 times. The tool was utilized most often for pneumonia (194 tool uses), followed by urinary tract infection (166 tool uses). The most common provider type to use the tool was an internal medicine hospitalist. The tool increased adherence to the recommended antibiotic regimen for each condition. Antibiotic appropriateness was assessed by an infectious diseases physician. Antibiotics were considered appropriate when they were similar to the antibiotic regimen recommended by the ASAP. Inappropriate antibiotics were classified as broad or narrow. When antibiotic coverage was appropriate, hospital length of stay was statistically significantly shorter (4.8 days vs 6.8 days for broad antibiotics vs 7.4 days for narrow antibiotics; P < .01). No significant differences were identified in mortality or readmission. Conclusions: A clinical decision support tool in the electronic health record can improve adherence to recommended empiric antibiotic therapy. Use of appropriate antibiotics recommended by such a tool can reduce hospital length of stay.

Funding: None

Disclosures: None
Wine Making and the Politics of Identity in Alsace, 1918–1939
Authors: Carrol Alison
Published: November 2020

This article examines the politics of wine making in Alsace in the two decades after the region returned to French rule in 1918. During these years Alsatian wine makers worked to transform their wines to meet the tastes of French drinkers, following five decades of producing wine for German consumption. As wine makers grappled with the question of how to secure the future of their industry, Alsatian wine became emblematic of the most contentious aspects of Alsace's reintegration into France. The introduction of new laws on viticulture raised the question of what was French about wine, the wine industry's woes symbolised the difficulties of Alsace's economic reintegration and wine became an emblem for often fierce wrangling over identity and belonging in the recovered region. This article traces this process and argues that while wine became a symbol of the complications of reintegration, its importance in understandings of French national culture equally allowed it to offer a solution to the problems that return to France caused for Alsace's wine industry in the interwar years. In this way, this case study of the politics of wine making in Alsace is suggestive of wine's broader power as a symbol of national belonging.
Substantive Divergence: The Meaning of Public Opinion on Government Spending in Red and Blue
Authors: Krimmel Katherine , Rader Kelly
Published: November 2020

We examine the substantive meaning of public opinion on government spending using open-ended data from an original survey. Belying the conventional wisdom on this subject, we find that public opinion on government spending is not reducible to views on social welfare programs. While most people do have specific associations with spending, in the aggregate, public associations span a wide range of government functions. Balance does not necessarily mean harmony, however. We find strong evidence of what we callsubstantive divergencealong party lines in this area—when they think about spending, Republicans and Democrats envision different bundles of goods and services, on average. This is true even for opposing partisans with the same overall assessment of spending (e.g., those who say government spends too much). These findings bring fiscal conflict into sharper relief and also have broader implications for the conceptualization and measurement of differences across parties, as well as other political cleavages.
Malaria Exposure in Ann Township, Myanmar, as a Function of Land Cover and Land Use: Combining Satellite Earth Observations and Field Surveys
Authors: Hoffman‐Hall Amanda , Puett Robin , Silva Julie A. , Chen Dong , Baer Allison , Han Kay Thwe , Han Zay Yar , Thi Aung , Htay Thura , Thein Zaw Win , Aung Poe Poe , Plowe Christopher V. , Nyunt Myaing Myaing , Loboda Tatiana V.
Published: November 2020

Despite progress toward malaria elimination in the Greater Mekong Subregion, challenges remain owing to the emergence of drug resistance and the persistence of focal transmission reservoirs. Malaria transmission foci in Myanmar are heterogeneous and complex, and many remaining infections are clinically silent, rendering them invisible to routine monitoring. The goal of this research is to define criteria for easy‐to‐implement methodologies, not reliant on routine monitoring, that can increase the efficiency of targeted malaria elimination strategies. Studies have shown relationships between malaria risk and land cover and land use (LCLU), which can be mapped using remote sensing methodologies. Here we aim to explain malaria risk as a function of LCLU for five rural villages in Myanmar's Rakhine State. Malaria prevalence and incidence data were analyzed through logistic regression with a land use survey of ~1,000 participants and a 30‐m land cover map. Malaria prevalence per village ranged from 5% to 20% with the overwhelming majority of cases being subclinical. Villages with high forest cover were associated with increased risk of malaria, even for villagers who did not report visits to forests. Villagers living near croplands experienced decreased malaria risk unless they were directly engaged in farm work. Finally, land cover change (specifically, natural forest loss) appeared to be a substantial contributor to malaria risk in the region, although this was not confirmed through sensitivity analyses. Overall, this study demonstrates that remotely sensed data contextualized with field survey data can be used to inform critical targeting strategies in support of malaria elimination.
Hybrid gold/DNA nanowire circuit with sub-10 nm nanostructure arrays
Authors: Choi Jong Seob , Park Hye Bin , Tsui Jonathan H. , Hong Byungyou , Kim Deok-Ho , Kim Hyung Jin
Published: November 2020

We report on a simple and efficient method for the selective positioning of Au/DNA hybrid nanocircuits using a sequential combination of electron-beam lithography (EBL), plasma ashing, and a molecular patterning process. The nanostructures produced by the EBL and ashing process could be uniformly formed over a 12.6 in2 substrate with sub-10 nm patterning with good pattern fidelity. In addition, DNA molecules were immobilized on the selectively nanopatterned regions by alternating surface coating procedures of 3-(aminopropyl)triethoxysilane (APS) and diamond like carbon (DLC), followed by deposition of DNA molecules into a well-defined single DNA nanowire. These single DNA nanowires were used not only for fabricating Au/DNA hybrid nanowires by the conjugation of Au nanoparticles with DNA, but also for the formation of Au/DNA hybrid nanocircuits. These nanocircuits prepared from Au/DNA hybrid nanowires demonstrate conductivities of up to 4.3 × 105 S/m in stable electrical performance. This selective and precise positioning method capable of controlling the size of nanostructures may find application in making sub-10 nm DNA wires and metal/DNA hybrid nanocircuits.
Microneedle-based skin patch for blood-free rapid diagnostic testing
Authors: Jiang Xue , Lillehoj Peter B.
Published: November 2020

Rapid diagnostic tests are one of the most commonly used tests to detect and screen for infectious diseases in the developing world. While these tests are simple, inexpensive, and readily available, they rely on finger-prick blood sampling, which requires trained medical personnel, poses risks of infection, and can complicate cooperation in young children, asymptomatic individuals, and communities with blood taboos. Here, we report a novel microneedle-based skin patch for the rapid detection of protein biomarkers in dermal interstitial fluid. Sample collection is facilitated by a hydrophilic hollow microneedle array that autonomously extracts and transports interstitial fluid to an antibody-based lateral flow test strip via surface tension for colorimetric antigen detection. We employ a simple gold enhancement treatment to enhance the detection sensitivity of this colloidal gold-based lateral flow assay and elucidate the underlying mechanism of this enhancement mechanism through experimental investigation. For proof-of-concept, this device was used to detect Plasmodium falciparum histidine-rich protein 2, a biomarker for malaria infection, which could be detected at concentrations as low as 8 ng/mL. Each test can be completed in <20 min and requires no equipment. To the best of our knowledge, this work is the first demonstration of a microneedle-based lateral flow assay for rapid protein detection in dermal interstitial fluid. In addition to its simplicity, minimally invasive nature, and low cost, this diagnostic device can be readily adapted to detect other protein biomarkers in interstitial fluid, making it a promising tool for point-of-care testing.
Cognitive deficits and white matter abnormalities in never-treated first-episode schizophrenia
Authors: Yang Mi , Gao Shan , Zhang Xiangyang
Published: November 2020

Cognitive impairment is viewed as a core symptom of schizophrenia (SCZ), but its pathophysiological mechanism remains unclear. White matter (WM) disruption is considered to be a central abnormality that may contribute to cognitive impairment in SCZ patients. However, few studies have addressed the association between cognition and WM integrity in never-treated first-episode (NTFE) patients with SCZ. In this study, we used the MATRICS Consensus Cognitive Battery (MCCB) to evaluate cognitive function in NTFE patients (n = 39) and healthy controls (n = 30), and associated it with whole-brain fractional anisotropy (FA) values obtained via voxel-based diffusion tensor imaging. We found that FA was lower in five brain areas of SCZ patients, including the cingulate gyrus, internal capsule, corpus callosum, cerebellum, and brainstem. Compared with the healthy control group, the MCCB’s total score and 8 out of 10 subscores were significantly lower in NTFE patients (allp < 0.001). Moreover, in patients but not healthy controls, the performance in the Trail Making Test was negatively correlated with the FA value in the left cingulate. Our findings provide evidence that WM disconnection is involved in some cognitive impairment in the early course of SCZ.
The role of emotion regulation as a mediator between early life stress and posttraumatic stress disorder, depression and anxiety in Syrian refugees
Authors: Demir Zaynab , Böge Kerem , Fan Yan , Hartling Corinna , Harb Mazen R. , Hahn Eric , Seybold Joachim , Bajbouj Malek
Published: November 2020

Early life stress is an important factor in later psychopathology, including symptoms of posttraumatic stress disorder (PTSD), depression, and anxiety. The purpose of the present study was to investigate the effect of early life stress on psychiatric symptoms within a sample of Syrian refugees. In this model, the use of cognitive emotion regulation strategies was assessed as a potential mediator of the relationship between early life stress and current symptoms of PTSD, depression, and anxiety. Bootstrap analyses were generated to test the indirect effect of emotion regulation (Cognitive Emotion Regulation Questionnaire) on the relationship between early life stress (Childhood Trauma Questionnaire), PTSD (Harvard Trauma Questionnaire), depressive (PHQ-9) and anxiety (GAD-7) symptoms in eighty-nine Syrian refugees resided in Germany (n = 49) and Jordan (n = 40). The indirect effect of maladaptive strategies was significant between early life stress and psychopathology, whereas the mediation effect of adaptive strategies was not significant. The findings provide an evidence that emotional dysregulation is an underlying factor affecting psychological symptoms in refugees with adverse childhood experiences. These results suggest targeting cognitive emotion regulation in prospective prevention and treatment strategies.
Emotional face processing across neurodevelopmental disorders: a dynamic faces study in children with autism spectrum disorder, attention deficit hyperactivity disorder and obsessive-compulsive disorder
Authors: Vandewouw Marlee M. , Choi EunJung , Hammill Christopher , Arnold Paul , Schachar Russell , Lerch Jason P. , Anagnostou Evdokia , Taylor Margot J.
Published: November 2020

Autism spectrum disorder (ASD) is classically associated with poor face processing skills, yet evidence suggests that those with obsessive-compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD) also have difficulties understanding emotions. We determined the neural underpinnings of dynamic emotional face processing across these three clinical paediatric groups, including developmental trajectories, compared with typically developing (TD) controls. We studied 279 children, 5–19 years of age but 57 were excluded due to excessive motion in fMRI, leaving 222: 87 ASD, 44 ADHD, 42 OCD and 49 TD. Groups were sex- and age-matched. Dynamic faces (happy, angry) and dynamic flowers were presented in 18 pseudo-randomized blocks while fMRI data were collected with a 3T MRI. Group-by-age interactions and group difference contrasts were analysed for the faces vs. flowers and between happy and angry faces. TD children demonstrated different activity patterns across the four contrasts; these patterns were more limited and distinct for the NDDs. Processing happy and angry faces compared to flowers yielded similar activation in occipital regions in the NDDs compared to TDs. Processing happy compared to angry faces showed an age by group interaction in the superior frontal gyrus, increasing with age for ASD and OCD, decreasing for TDs. Children with ASD, ADHD and OCD differentiated less between dynamic faces and dynamic flowers, with most of the effects seen in the occipital and temporal regions, suggesting that emotional difficulties shared in NDDs may be partly attributed to shared atypical visual information processing.
Nimodipine improves cortical efficiency during working memory in healthy subjects
Authors: Zink Caroline F. , Giegerich Mellissa , Prettyman Greer E. , Carta Kayla E. , van Ginkel Marcus , O’Rourke Molly P. , Singh Eesha , Fuchs Edward J. , Hendrix Craig W. , Zimmerman Eric , Breakey Jennifer , Marzinke Mark A. , Hummert Pamela , Pillai Jay J. , Weinberger Daniel R. , Bigos Kristin L.
Published: November 2020

The L-type calcium channel gene, CACNA1C, is a validated risk gene for schizophrenia and the target of calcium channel blockers. Carriers of the risk-associated genotype (rs1006737 A allele) have increased frontal cortical activity during working memory and higher CACNA1C mRNA expression in the prefrontal cortex. The aim of this study was to determine how the brain-penetrant calcium channel blocker, nimodipine, changes brain activity during working memory and other cognitive and emotional processes. We conducted a double-blind randomized cross-over pharmacoMRI study of a single 60 mg dose of oral nimodipine solution and matching placebo in healthy men, prospectively genotyped for rs1006737. With performance unchanged, nimodipine significantly decreased frontal cortical activity by 39.1% and parietal cortical activity by 42.8% during the N-back task (2-back > 0-back contrast; PFWE < 0.05; n = 28). Higher peripheral nimodipine concentrations were correlated with a greater decrease in activation in the frontal cortex. Carriers of the risk-associated allele, A (n = 14), had a greater decrease in frontal cortical activation during working memory compared to non-risk allele carriers. No differences in brain activation were found between nimodipine and placebo for other tasks. Future studies should be conducted to test if the decreased cortical brain activity after nimodipine is associated with improved working memory performance in patients with schizophrenia, particularly those who carry the risk-associated genotype. Furthermore, changes in cortical activity during working memory may be a useful biomarker in future trials of L-type calcium channel blockers.