bluuebunny/crossref_metadata_2025 huggingface dataset:
Utilizing Technology to Fill the Ambulatory Care Communicable Disease Practice Gap
Authors: Cook Amy , Delp Kyle , Laughman Jennifer
Published: September 2024

Background: Infection Prevention (IP) practices in ambulatory care are often reactive and many communicable diseases in the community often do not fall onto IP’s radar until the patient becomes ill enough to seek inpatient services. The gap between ambulatory and inpatient care can lead to increased transmission and illness severity. Early identification has substantial impacts on timely implementation of IP mitigation strategies, appropriate handoff upon entry into other care settings, and timely reporting to public health organizations. Current IP processes underutilize electronic health record (EHR) capabilities by relying upon lab driven notifications. This project sought to redesign the IP’s workflows, advancing the health system beyond the acute care setting and into the ambulatory care setting by adding the power of diagnosis codes to close a practice gap. Method: Infection Prevention and Information Technology collaborated to build silent best practice advisories (BPAs) in the EHR that utilized diagnosis codes related to Varicella zoster (VZV) infection charted by ambulatory care providers. These BPAs function by triggering infection statuses that populate the patient chart and include instructions to front line staff on personal protective equipment (PPE) requirements. These BPAs also trigger real-time notifications to the IP team to determine the validity of the infection status and exposure work-up necessity. Chart reviews of diagnosis codes utilized in pre and post intervention timeframes were completed to understand the impact of the silent BPAs. Percentages of patients captured, and Healthcare Worker (HCW) exposure reviews reported were evaluated to demonstrate effectiveness. Plan, Do, Study, Act (PDSA) was utilized to respond to gaps, increase efficiency, and limit erroneous infection statuses. Result: The one-year pre-intervention period revealed 36 total diagnosis codes used for Varicella zoster (VZV) infection; 3% of these infection cases were captured and 4% of eligible cases were reported for HCW exposure review. The one-year post intervention period revealed 40 total diagnosis codes used for VZV infection; 80% of these infection cases were captured and 70% of eligible cases were reported for HCW exposure review. PDSA quality improvement cycles allowed for refinement of the BPA logic that further increased infection cases captured to 100% with 100% of eligible cases reported for HCW exposure review. Conclusion: Utilizing the EHR, the organization appreciated enhanced identification of patients in real-time with VZV infection that allowed for appropriate mitigation strategies to be implemented. This proactive workflow design helps minimize the risk of transmission between ambulatory and acute settings and facilitated HCW exposure reviews.
Diagnosing Pneumonia in the Obese: Are Plain Radiographs Enough?
Authors: Rapose Alwyn
Published: September 2024

Introduction: The obesity pandemic presents numerous challenges in radiography, including patients exceeding the weight limits of imaging equipment, difficulties in palpating anatomical landmarks and inadequate penetration resulting in inaccurate diagnoses and need for repeat imaging resulting in increased radiation exposure. Pneumonia is a common reason for hospitalization, but identifying an infiltrate on the chest radiograph (CXR) in obese patients can be challenging. Conversely, motion artefacts may be misinterpreted as areas of pneumonia resulting in over-diagnosis and consequently the overuse of antibiotics. This study evaluated the diagnostic utility of CXR for identifying pneumonia in obese patients by comparing it with computed tomography (CT scan) performed within 72 hours. We also evaluated the impact on initiation or discontinuation of antibiotics – a very important aspect of antibiotic stewardship. Methods: All patients admitted between July 2020 and 2022 with a diagnosis of pneumonia who underwent both CXR and chest CT scan within a 72-hour window were included. Patients were divided into two groups obese and non-obese based on BMI. The results were evaluated to determine the concordance between the two modalities in diagnosing pneumonia, as well as its influence on antibiotic therapy. Results: A total of 320 patients were included, with a mean age of 65.3 years. 146 (45.6%) were male, and 174 (54.4%) were female. 202 (63.1%) were classified as obese (BMI > 30). CXR was performed as first modality in 313 (97.8%) cases, while 7 (2.2%) underwent CT scan first. In the obese group the overall concordance between the 2 modalities for diagnosing pneumonia was 67.5%. In the non-obese group the concordance was 80.2% (p < 0 .001). Among the obese patients who underwent CXR first, 11 (5%) had antibiotics discontinued after the CT scan results, while the number was 4 (3%) in the non-obese group. Additionally, 3 patients in the obese group had antibiotics initiated after the CT scan. Conclusions: Obesity poses unique challenges to healthcare facilities and imaging equipment. Diagnosing pneumonia in obese patients using CXR alone may result in over-diagnosis. This may lead to unnecessary antibiotic use and delayed diagnosis of alternate disease, or in some cases, missing a pneumonia and under-treatment. A chest CT scan is more sensitive and may be more helpful to identify a pneumonia accurately in these patients and thus facilitate appropriate antibiotic use.
Impact of Discontinuing Contact Precautions for Multidrug-resistant Gram-negative Enterobacteriaceae in a Large Health System
Authors: Karunakaran Sharon , Ludwig Justin , Bridge Christine , Martin Elise , Snyder Graham
Published: September 2024

Background: Contact precautions (CP) to prevent transmission of multidrug-resistant gram-negative (MDRGN) Enterobacteriaceae are recommended, although studies of discontinuation of CP (DcCP) have found no change in healthcare associated infections (HAI) due to extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae. Limited data exists on DcCP for MDRGN in a large health system. Methods: We performed a retrospective observational study analyzing the relationship between use of CP and HAI due to two definitions of MDRGN Enterobacteriaceae: ESBL, and non-susceptibility to ≥3 drug classes (3DC-GNR), with carbapenem resistant Enterobacteriaceae (CRE) serving as control. The study included all inpatient admissions from 2/2017 through 9/2022 at 21 acute care hospitals. Hospitals had latitude to determine CP practices based on local risk assessment, but in 2/2018, system-wide transmission-based precautions guidance was updated to recommend DcCP for MDRGN Enterobacteriaceae and in 12/2019 was updated to clarify DcCP specifically for ESBL and 3DC-GNR while continuing CP for carbapenem-resistant organism carriage. We interviewed infection preventionists to define when CP were used for CRE, ESBL, and 3DC-GNR Enterobacteriaceae. HAI were defined using National Healthcare Safety Network criteria including all HAI categories. We compared the incidence rate of HAI attributable to the two MDRGN types in hospital months with and without use of CP, with HAI due to CRE as a comparison group since all hospitals used CP for CRE throughout the study period. Results: The periods of CP use, by hospital, are shown in Figure 1. Throughout the study period, there were 987 HAI attributed to ESBL Enterobacteriaceae, 579 due to 3DC-GNR Enterobacteriaceae, and 329 due to CRE. Figure 2 shows the unadjusted aggregate rate of HAI for each of the three MRGN types, including among hospitals with and without CP in each month, for ESBL and 3DC-GNR. In months with and without CP, the rate of HAI was 1.482/10,000 and 1.093/10,000 patient days (incidence rate ratio [IRR], 1.356 [95% confidence interval, 1.195-1.540]) for ESBL Enterobacteriaceae. In months with and without CP, the rate of HAI was 1.071/10,000 and 0.493/10,000 patient days (IRR,2.173[95% confidence interval, 1.838-2.569]) for 3DC-GNR Enterobacteriaceae. Conclusion: DcCP was not associated with an increase in HAI due to ESBL and 3DC-GNR Enterobacteriaceae in aggregated facilities that self-selected for DcCP. Facilities that used CP were associated with significantly higher rates of ESBL and 3DC-GNR Enterobacteriaceae, a relationship that did not change as hospitals DcCP for these MDRGN. Further analyses are necessary to assess for a causal relationship.
Antimicrobial bathing of the critically ill for the prevention of healthcare-associated infection at a hospital in California
Authors: Ryan Lilia , Livingston Brooke
Published: September 2024

Background: Patients in the intensive care unit (ICU) have invasive lines increasing their risk for healthcare-associated infections (HAIs). Our objective was to determine if antimicrobial bathing with 2% chlorhexidine gluconate (CHG) compared to the colloidal silver-based antimicrobial product would reduce the incidents of central line–associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI). Methods: We performed a before-and-after study in four adult ICUs at a two-hospital facility in California. Prospective surveillance of CLABSI and CAUTI prevention bundles monitoring was established. The intervention consisted of daily bathing with CHG for all patients in the ICUs. A baseline period of one year was followed by an intervention period of one year. The incidence rates of CLABSIs and CAUTIs were compared between the baseline and intervention periods utilizing a t-test analysis. Results: A total of 10103 patients were included. At Facility A, a mean CLABSI rate of 2.43/1000 central line catheter days (CL) with 2149 patients days (Mean differences 95% CI -0.5–3.1; P>0.0975), during the baseline period followed by 1.11/1000 CL days with 2193 patient days in the intervention period. At Facility B, the mean CLABSI rate of 1.82/1000 CL days with 2976 patient days (Mean differences 95% CI -0.6–2.31; P>0.161) during the baseline period was followed by 1.01/1000 CL days with 2785 patient days in the intervention period. At Facility A, the mean CAUTI rate of 1.37/1000 indwelling catheter days (IUC) with 2149 ICU patient days (Mean difference 95% CI is 0.28–1.97; P 0.2160) was noted in the baseline period, followed by 0.45/1000 IUC days with 2785 in the intervention period. Conclusion: Daily bathing with CHG significantly reduced the incidence of CAUTI at Facility A. It is unclear why Facility A saw a statistically significant reduction in CAUTI, but Facility B did not. The difference in outcomes may be related to hospital size, service lines, supply constraints, and discrepancies in staffing. CHG bathing was not directly associated with a reduced risk of CLABSI at Facility A and B during our limited study, but it was encouraging enough that our organization will continue this intervention to obtain additional data to determine if bathing with CHG will reduce CLABSI and CAUTI.
Impact of Universal Masking by Healthcare Personnel on Non-SARS-CoV-2 Healthcare-Associated Viral Respiratory Infections
Authors: Rosenthal Ayelet , Moore Riley , Fishbein Joseph , Kociolek Larry
Published: September 2024

Background: The impact of universal masking on transmission of endemic respiratory viruses in children’s hospitals is unknown. Our objective was to measure the association between universal masking by healthcare personnel and the incidence of non-SARS-CoV-2 healthcare-associated viral respiratory infections (HA-VRIs) in a free-standing academic pediatric medical center during the COVID-19 pandemic. Methods: In this quasi-experimental study, we measured the incidence rate of non-SARS-CoV-2 HA-VRIs (VRI diagnosed on or after hospital day 3 by one of several molecular assays) during three time periods: prior to the COVID-19 pandemic (pre-intervention: September 2013 - February 2020); during universal masking (intervention: May 2021 - March 2023); and after universal masking was lifted (post-intervention: April 2023 - November 2023). Although universal masking was implemented in late March 2020, we exclude the lockdown period of strict COVID-19-related public health mitigations (i.e., school closures and shelter-in-place advisories) during which community prevalence of non-SARS-CoV-2 respiratory viruses was minimal in our region (March 2020 to April 2021). By negative binomial regression analysis, we compared the level and trend of HA-VRIs between the pre-intervention and intervention periods. Results: Figure 1 illustrates the incidence rate of non-SARS-CoV-2 HA-VRI during the pre-intervention, lockdown, intervention, and post-intervention periods. The aggregate non-SARS-CoV-2 HA-VRI incidence rate during the pre-intervention, intervention, and post-intervention periods was 1.25, 1.84, and 1.96 HA-VRIs per 1000 patient days, respectively. There was no significant difference in the level (p = 0.96) or trend (p = 0.67) of HA-VRI incidence rate between the pre-intervention and intervention periods. Conclusion: Universal masking was not associated with a decrease in the incidence rate of non-SARS-CoV-2 HA-VRIs at our children’s hospital during the COVID-19 pandemic. These findings suggest that universal masking may not be an effective infection prevention measure in children’s hospitals during periods of increased endemic respiratory viral transmission in the community.

Disclosure: Larry Kociolek: Research Support - Merck
Effect measure modification in an RCT of antibiotic prophylaxis in laparoscopic cholecystectomy: A secondary analysis
Authors: Zimba Rebecca
Published: September 2024

Background: Antimicrobial resistance is a growing public health threat. To alleviate selective pressure which leads to the emergence and proliferation of resistance, and to preserve the utility of treatments where they are needed the most, antimicrobial stewardship programs (ASPs) could consider revising surgical antibacterial prophylaxis protocols for low-risk procedures such as laparoscopic cholecystectomy. Methods: Publicly available data was used from a well-powered randomized controlled trial conducted by Matsui and colleagues during 2007-2013 in Japan on the effectiveness of prophylactic antibacterial treatment on reducing post-operative infections following laparoscopic cholecystectomy in low-risk patients. A total of 1037 patients were randomized to receive treatment or no treatment. After randomization, laparoscopic cholecystectomies were converted to open procedures in 28 patients, 14 in each arm, constituting a deviation from the protocol and the administration of additional antibacterial treatment. The original study included both intention-to-treat and per-protocol analyses, finding statistically significant reductions in post-operative infections in the treatment vs no treatment arm (1.2% vs 6.7%, p<0.0001; 1.0% vs 5.9%, p<0.0001, respectively). In the present analysis I assessed the extent to which type of procedure modified the effect of antibacterial prophylaxis on post-operative infection using both additive and multiplicative interaction. Risk and risk differences were estimated using a linear-binomial model and risk ratios were estimated using a log-binomial model. Alpha was set to 0.10. The lowest risk categories for each variable, being assigned to treatment and receiving a laparoscopic procedure, defined the common reference category. Results: A 35 percentage point (pp) increase in the risk of post-op infections relative to the reference category was attributable to the joint effects of omitting prophylaxis and conversion to an open procedure (90% CI 14, 56), compared to a 5 pp increase attributable to omission of prophylaxis (90% CI 3, 7) or a 6 pp increase attributable to conversion to an open procedure (90% CI -5, 18) by themselves. The interaction contrast capturedthis super-additive 24 pp increase in risk (90% CI -1, 47). The relative excess risk due to interaction was 23.81 (90% CI -5.56, 53.19), suggesting a departure from additivity as well. Conclusions: Patients undergoing open cholecystectomies stand to benefit the most from antibacterial prophylaxis compared to patients who have laparoscopic cholecystectomies. ASPs could consider reducing or eliminating surgical prophylaxis in low-risk procedures such as laparoscopic cholecystectomy to alleviate selection pressure for antibacterial resistant organisms and preserve its effectiveness for people undergoing higher risk procedures.
Concordance with Preoperative Intravenous Antibiotics Guidelines and Risk of Surgical Site Infection (SSI)
Authors: Neelakanta Anupama , Davidson Lisa , Fischer Kristin , Kester Shelley , Onsrud Jennifer , Passaretti Katie
Published: September 2024

Background: Administration of antimicrobial prophylaxis close to incision time is recommended as an essential practice to prevent surgical site infections (SSI). Despite guideline recommendations, adherence to preoperative intravenous antibiotic guidelines is variable. We aim to assess perioperative factors associated with guideline concordant (GC), guideline second line (GSL) and non-guideline concordant (NGC) antibiotic choice and timing and impact on odds of SSI. Methods: 3173 patients at 9 hospitals with National Health Safety Network (NHSN) procedure codes for colon surgery and abdominal hysterectomy between January 1, 2023, and October 31, 2023, were identified from the electronic medical record. Data on preoperative intravenous antibiotic choice and timing, history of allergy and methicillin resistant staphylococcus aureus (MRSA) history was collated. SSI were identified using NHSN definitions by trained infection preventionists. SSI identified as present at the time of surgery were excluded. Antibiotic choice and timing were compared to institutional guidelines and patients were categorized as having received GC, GSL or NGC antibiotic choice, and GC or NGC antibiotic timing. Descriptive statistics were used to describe clinical data for patient population and subgroups who received GC, GSL and NGC antibiotics. Univariate logistic regression was performed to assess the association of procedural and clinical factors with the likelihood of an SSI. Results: GC was high overall for both antibiotic choice (94%) and timing (94%). (Table 1) NGC and GSL antibiotic choice were more common in colon surgery, urgent/emergent cases, patients with beta lactam allergies and those with a recent history of MRSA. GSL antibiotic choice was more frequent in inpatients. (Table 2). GC antibiotic timing was more common with GC antibiotic choice (98%) than with NGC (37%) or GSL (51$) antibiotic choice. Odds of SSI were lower in patients who were GC for both antibiotic choice and timing (OR 0.4, p < 0 .001) and increased in patients who received GSL antibiotic choice (OR 5.7 compared to GC, p < 0 .001), underwent urgent/emergent surgeries (OR 4.6, p < 0 .001) or had a history of MRSA in the past year (OR 8.4, p < 0 .001). We found a non-significant trend toward lower infections in patients with GC antibiotic timing (OR 0.5, p 0.08). (Table 3) Conclusion: Combined GC for antibiotic choice and timing was high and associated with lower odds of SSI. NGC and GSL antibiotic choice were associated with patient level factors such as history of MRSA and emergent procedures which may also impact risk of SSI.
Sustainability of Surgical Site Infection (SSI) Prevention Bundle for Pediatric Cardiothoracic Surgery Patients
Authors: Campbell Melissa , Turi Jennifer , English Cheyenne , Collier Sharah , Sistla Vani , Seidelman Jessica , Smith Becky , Lewis Sarah , Kalu Ibukunoluwa
Published: September 2024

Background: Frequent use of delayed sternal closure and prolonged stays in critical care units contribute to surgical site infections among pediatric patients undergoing cardiothoracic (CT) procedures. Bundled interventions to prevent or reduce surgical site infections (SSIs) have shown prior success, but limited data exist on sustainability of these efforts especially during the Coronavirus Disease 2019 (COVID-19) pandemic. Here, we re-examine the SSI rates for pediatric CT procedures after the onset of the pandemic. Methods: In a single academic center providing regional quaternary care, we created a multidisciplinary CT-surgery SSI Prevention workgroup in response to rising CT SSI rates. Bundle elements focused on daily chlorhexidine bathing, environmental cleaning, monthly room changes, linen management, antimicrobial prophylaxis, and sterile techniques for beside and operating room procedures. CDC surveillance definitions were used to identify superficial, deep or organ space SSIs. To assess the bundle’s sustainability, we compared SSI rates during years impacted by the COVID-19 pandemic (2021–2023, period 2) to pre-pandemic rates (2017–2019, period 1). Data from 2020 were excluded to account for bundle implementation, pandemic restrictions, and a minor decrease in surgical volumes. Rates were calculated as surgical site infection cases per 100 procedures. Mean rates across both periods were compared using paired t-tests (Stata/SE version 14.2). Results: Excluding the year 2020, the average SSI rate per 100 CT procedures increased from 1.07 in period 1 to 1.56 in period 2(p=0.55). Concurrently, the average SSI rate per 100 CT procedures with delayed closures increased from 1.49 in period 1 to 1.97 in period 2(p=0.67). Figure 1 shows SSI rates and procedure counts for 2017–2023. Coagulase negative Staphylococci most frequently caused SSIs in period 1 while methicillin-susceptible Staphylococcus aureus (MSSA) was most frequently identified in period 2. During period 2, the estimated compliance with SSI prevention bundle remained stable and reached 95% for pre-operative chlorhexidine baths and use of appropriate antimicrobial prophylaxis. Monthly room changes with dedicated environmental cleaning reached 100% compliance. Conclusion: Despite staffing shortages and resource limitations (e.g., discontinuation of contact isolation for MRSA colonization) during the COVID-19 pandemic, SSI rates for pediatric CT surgeries showed a slight, but non-statistically significant, increase in post-pandemic years as compared to pre-pandemic years. implementation of bundled interventions and improved surveillance methods may have sustainably impacted these SSI rates. Reinforcing bundle adherence as well as identifying additional prevention interventions to incorporate in pre-, intra-, and post-operative periods may improve patient outcomes.
Antimicrobial Use in Belgian Acute Care Hospitals : Results of the 2022 ECDC Point Prevalence Survey
Authors: Catteau Lucy , Latour Katrien , Pearcy Morgan , Catry Boudewijn
Published: September 2024

Background: Point prevalence surveys (PPS) organized by the European Centre for Disease Prevention and Control (ECDC) play a crucial role in assessing healthcare-associated infections (HAIs) and antimicrobial use (AU) in European acute care hospitals. In 2017, a crude prevalence of 28.1% (95% CI 27.3-29.0%) of inpatients receiving at least one antimicrobial was recorded in Belgium (patients ≥65 years: 29.6% (95% CI 28.5-30.7%), < 6 5 years : 26.5% (95%CI 25.3-27.6%)) . Following the challenges posed by the COVID-19 pandemic, the 2022 ECDC-PPS aimed to reassess AU levels. Method: A cross-sectional study was conducted between September and November 2022 in 57 representative acute care Belgian hospital sites (35 mergers), following the ECDC-PPS protocol version 6.0. All patients present in surveyed wards at 8 a.m. on the PPS day and not discharged at that time were included. Infection prevention and control teams collected comprehensive data on hospitals, wards, and AU, including agents and indications. Results: Among the 10,142 included inpatients, 29.3% (95%CI 28.4-30.2) were receiving at least one antimicrobial (patients ≥65 years: 31.1% (95% CI 29.7-32.4%), < 6 5 years : 27.1% (95%CI 25.6-28.6%)). Intensive care units (56.3%), surgical (38.7%), and medical wards (33.1%) demonstrated the highest AU prevalence, while psychiatric wards exhibited the lowest (3.0%). A total of 3,549 antimicrobials were recorded, commonly prescribed for treating community-acquired infections (48.6%) and HAIs (30.3%, including 4.2% of long-term care facility acquired infections), as well as for surgical and medical prophylaxis (12.4 and 6.6%, respectively). Notably, only 22.7% of surgical prophylaxis courses (n=100/440) lasted more than one day. The top three most used antimicrobial agents consisted of amoxicillin in combination with a beta-lactamase inhibitor (J01CR02, 20.0%), cefazolin (J01DB04, 9.8%) and piperacillin in combination with a beta-lactamase inhibitor (J01CR05, 9.6%). The most frequently reported diagnoses for medical antimicrobial treatment were pneumonia (25.7%) and urinary tract infections (17.1%). The reason for AU was available in 80.0% of the medical notes. Conclusion: The 2022 PPS reveals an increased AU prevalence (+1.2%) in Belgian acute care hospitals, especially in patients over 65 years of age (+1.5%). This increase was less pronounced in younger patients (< 6 5y) (+0.6%). Future investigations are crucial to delve into prescription attitudes and modifiable practices, emphasizing the urgent need for robust antimicrobial stewardship programs in these healthcare settings.
Impact of Point Prevalence Surveillance on Transmission of Candida auris Within an Acute Care Health System
Authors: Ivaska Joan , Walker Milena , Jai Claire , Bessel Marjorie
Published: September 2024

Background: Patients infected or colonized with Candida auris can serve as a transmission source for other patients. Screening patients for Candida auris colonization allows facilities to implement infection prevention and control measures and minimize the risk of transmission. The Centers for Disease Control and Prevention (CDC) recommends healthcare facilities perform three types of screening; admission screening in patients with specific risks, close contact screening of patients who overlap a confirmed positive case for 3 or more days or point prevalence surveillance if there is evidence of ongoing transmission within the facility. The CDC further recommends that patients being screened for Candida auris be maintained in transmission-based precautions while awaiting Results: In 2022-2023 there was ongoing transmission of Candida auris occurring in a community served by a large multi-state healthcare system. Close contact and point prevalence surveillance screening for both acute and non-acute healthcare facilities were implemented by the local health jurisdiction. Methods: A composite swab of the bilateral axilla and groin was used to screen close contacts of patients confirmed to be infected or colonized with Candida auris. Close contact was defined as having been on the same unit as the positive patient for 3 or more days while the patient was not in transmission-based precautions. Point prevalence surveillance was performed on all patients currently housed on units where close contact screen-positive patients resided. Potentially exposed patients who had been discharged were not screened. Patients were placed in contact transmission-based precautions until results were received. In 1657 patients in six acute care facilities were identified for Candida auris screening. 161 patients refused or were unable to be screened. Of the 1496 patients screened, 40 screened positive, demonstrating a 2.67% secondary attack rate. Of the 40 screen-positive patients, 5 were identified through point prevalence and 35 through close contact screening. Conclusion: Performing point prevalence surveillance in acute care facilities is operationally challenging and costly with little benefit in the prevention of Candida auris transmission. More robust collection and reporting of screening data is needed to inform surveillance protocols and prevention strategies specific to different healthcare settings. Limitations of this study include the lack of screening completion in discharged patients identified as close contact or point prevalence surveillance eligible. Additionally, some patients had a history of contact with healthcare facilities outside of this healthcare system, with unknown exposure risks or prevention strategies.
Outpatient Antibiotic Consumption Trends in Belgium: A Comparative Analysis of Reimbursement and Sales Data, 2013-2022
Authors: Damian Elena , Bonacini Laura , Kelly Moira , Catry Boudewijn , Catteau Lucy
Published: September 2024

Background: Antimicrobial resistance (AMR) is a global public health concern, necessitating close and timely monitoring of antibiotic consumption (AMC). In Belgium, AMC surveillance traditionally relies on reimbursement data, excluding over-the-counter non-reimbursed or imported products and involving a time lag. This study investigates disparities in AMC between reimbursement data and retail data, providing insights into AMC variations. Additionally this study seeks to critically evaluate the validity and representativeness of the reimbursed data in accurately reflecting the true extent of AMC in the country. Method: Utilizing reimbursement data from the National Institute for Health and Disability Insurance (NIHDI) and retail data (IQVIA Sales data; www.iqvia.com) for systemic antibacterials (ATC Group J01), outpatient consumption was estimated for the period 2013-2022. Volume of antimicrobials was measured in Defined Daily Doses (DDDs - WHO ATC/DDD Index 2023), while population data were extracted from Eurostat. Relative differences (RDs) in DDDs per 1000 inhabitants per day (DID) were computed, and validated through correlation analysis (Pearson’s r) and Bland–Altman plots. Result: J01 antibacterial sales declined from 23.10 DID (2013) to 20.85 (2022). Non-linear decreases, notably during the Covid-19 pandemic (21.54 DID in 2019 to 16.69 in 2020), followed by a rebound to pre-pandemic quantities in 2022 were observed (Figure 1). Reimbursement NIHDI data slightly underestimated IQVIA sales, with RDs ranging from 2% (2013) to 9% (2022). Notable differences, especially in recent years were attributed to quinolone reimbursement criteria changes implemented by law in Belgium in 2018, reducing the reimbursed proportion from 99% (2017) to 35% (2022). ATC-3 level analysis revealed disparities in low-DID groups (J01B, J01E and J01G). Notably, a small proportion of amphenicols (J01B) were reimbursed ( < 1 0%), with a congestion relieving combination product of tiamphenicol (+ N-acetylcysteine; Fluimucil®) frequently bought and remaining unreimbursed. Overall and across ATC3 groups, the correlation between NIDHI and IQVIA estimates was almost perfect across years and the Bland–Altman plots showed high agreement. Conclusion: Reimbursement data are reliable for outpatient AMC monitoring with slightly lower estimates than retail data across most categories. The 2018 quinolone reimbursement criteria change highlights the necessity of incorporating retail data for accurate assessments in this specific category. The synergistic use of reimbursement and retail datasets is crucial for a comprehensive understanding of consumption patterns, supporting effective AMR mitigation strategies in Belgium.
Serratia marcescens Burden in a Neonatal Intensive Care Unit: Colonization Rate, Clinical Infections and Strain Relatedness
Authors: Dabaja Younis Halima , Seguban Angelie , Morillo Andrea , Mazzulli Tony , Lum Ming , Johnstone Jennie
Published: September 2024

Background: Serratia marcescens (S. marcescens) is an environmentally associated organism known for causing healthcare associated infections and outbreaks in neonatal intensive care units (NICUs). The colonization or infection rates in NICU settings remain uncertain. This study aims to evaluate the rate of baseline colonization and clinical infection and relatedness of S. marcescens isolates. Methods: Prospective surveillance of rectal colonization and clinical infection of S. marcescens was conducted on patients admitted to the NICU at Mount Sinai Hospital in Toronto, Ontario, from March 1, 2023, to September 30, 2023. The NICU is a 57 bed unit with all private rooms. Monthly point prevalence assessments by rectal screening were performed, alongside active surveillance for clinical infections associated with S. marcesens. Isolates from screening or clinical samples underwent assessment for relatedness using pulse field gel electrophoresis (PFGE). Results: Over the 7 month study period, 12 different patients (5.4%) were colonized/infected with S. marcescens. Among these, 10 patients (4.5%) were identified through rectal screening (316 rectal swabs were collected from 224 patients) and two patients (0.9%) exhibited positive clinical specimens (urine and endotracheal aspirate) in association with pyelonephritis and ventilator-associated pneumonia, respectively. Of the two clinical cases, one case showed a negative preceding rectal swab and the other detected through a clinical sample before the point prevalence date. The age at which a positive S. marcescens swab or positive clinical specimen was identified ranged from 4 to 66 days (median=18 days, IQR 5-38.8) (Figure 1). Sixty seven infants had repeated screening. Three out of 67 (4.5%) were colonized with S. marcescens, the timing and sequence of positive and negative testing are presented in Figure 2. Females demonstrated a higher positivity rate compared to males [9.1% (9/99) vs 2.4% (3/125), p=0.04, respectively]. PFGE analysis of all 12 (100%) isolates revealed a polyclonal pattern. Most cases were detected from March to May in 9/12 cases (75%). Ten different strains were identified. Notably, two strains demonstrated clusters of two cases each, one during March and the other during May (Figure 3). No mortality was reported among the cases. Conclusions: The study highlights the polyclonal nature of S. marcesens and raises questions about the utility of point prevalence in anticipating clinical cases or patient-to-patient transmission, especially in patients with clinical infection where there were no preceding positive screening tests.
epiXact-ONT: Long-read whole genome sequencing for rapid outbreak detection and comprehensive plasmid transmission analysis
Authors: Briars Emma , Herriott Ian , Brookhart Allison , Hollowell Talia , Billings Nicole , Huntley Miriam , Sater Mohamad
Published: September 2024

Background: Healthcare associated infections (HAIs) are a major contributor to patient morbidity and mortality. HAIs are increasingly important due to the rise of multidrug resistant pathogens which can lead to deadly nosocomial outbreaks. Traditional methods for investigating transmissions are slow, costly and have poor detection resolution. In addition, plasmid transmission which can horizontally transfer critical resistance and virulence genes is not part of routine infection control practice due to lack of comprehensive and cost-effective methods capable of identifying both pathogen and/or plasmid transmission. Here we demonstrate the utility of the Oxford Nanopore Technologies (ONT) platform for whole genome sequencing (WGS) based pathogen and plasmids transmission analysis. Methods: We developed a rapid end-to-end process that includes sample preparation, sequencing optimized for generating long-reads and bioinformatics workflow customized for error-prone ONT data. We use Flye to generate de novo assemblies and a secondary bioinformatics step to identify each circular sequence. Individual circular sequences with an Ori (≥1) are identified. For pathogen clonality analysis we perform a pairwise mapping-based chromosomal sequences comparison eliminating need for an external reference genome. Similarly, individual plasmids are separated and compared pairwise. We annotate both the circularized chromosomal and plasmid sequences for known resistance and virulence genes. Results: We performed ONT (and confirmatory Illumina) sequencing of the genomes of 20 bacterial isolates originating from 5 HAI investigations previously performed at Day Zero Diagnostics using epiXact®, our Illumina-based HAI sequencing and analysis lab service. ONT-based clonality determination had 100% agreement with the Illumina based pipeline. We also found that using the outbreak-specific assembled genomes instead of an external reference increased the SNP-calling resolution in the ONT pipeline. We also identified sets of clonal isolates with both identical plasmids and distinct plasmids; as well as sets of non-clonal isolates with identical plasmids and distinct plasmids. In one subset of 7 multi-species isolates, we identified 2-7 circularized plasmid sequences in each isolate, all harboring known resistance genes. 4 plasmids were found in multiple isolates, with each plasmid appearing in between 2 and 4 distinct isolates. Notably, blaNDM was identified in at least 1 plasmid in each isolate. Conclusion: We demonstrate the utility of ONT for comprehensive HAI investigations, establishing the potential to transform healthcare epidemiology with rapid outbreak determination covering pathogen and plasmid transmission in < 2 4 hours from sample receipt.
Case validation of bloodstream infections with an antibiotic-resistant organism
Authors: Ellison Jennifer , Chow Blanda , Howatt Andrea , Armstrong Logan , Pfister Ted , Lu Zhe , Bush Kathryn
Published: September 2024

Background: Bloodstream infections (BSIs) are an important cause of morbidity and mortality in severely ill patients, contributing to increased length of hospital stay and higher cost of care. Alberta Health Services Infection Prevention and Control (IPC) conducts inpatient surveillance of new episodes of BSIs with methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) or carbapenemase-producing organisms (CPO) in 112 acute care facilities. A case-finding process was undertaken to verify the accuracy of BSI data entry. Methods: All positive MRSA, VRE or CPO blood cultures in 2021 were linked to the Inpatient Discharge Abstract Database (DAD) and the National Ambulatory Care Reporting System (NACRS) to identify new cases during acute care admissions. The results were then compared to surveillance records captured by infection control professionals (ICPs). Cases with unmatched culture date and/or encounter date and cases not identified by ICPs were screened by the study team with final decision made by ICPs. Results were analyzed by ARO and by % increase in number of surveillance records. Results: The laboratory linkage identified 286 new cases. Comparing to surveillance records (n = 248) captured by ICPs, 137 (57.3%) had matching collection dates and encounter dates, 85 (35.6%) had close matches on collection dates and encounter dates, 17 (7.1%) records had either matching collection dates or encounter dates, and 1 (0.4%) record did not have any matches on dates. There were 46 records identified in the laboratory data that were not in the surveillance system and 8 records that were in the surveillance system but not matched to the laboratory data. After review, 22 Surveillance records had data entry errors (1 CPO BSI, 20 MRSA BSI, and 1 VRE BSI), and there were 14 BSI records found to be missing (13 MRSA BSI, 1 VRE BSI). This represents a 6% increase in MRSA BSI and a 3% increase in VRE BSI identified in 2021 and no increase in CPO BSI. Conclusions: A laboratory validation to determine if BSIs with an ARO were missed during routine IPC surveillance identified a small proportion of missed bloodstream infections. The most common reason for the miss was admission through the emergency department with multiple blood cultures collected during a single admission. These results will be shared with the Infection Control program to facilitate correct BSI capture.
An “Epic” Journey to Improve Antimicrobial Stewardship
Authors: Smith Lindsay , Ahern John , Lapin Lisa , Tenney Thyleen
Published: September 2024

Background: Antimicrobial stewardship programs rely heavily on the electronic medical record (EMR) to carry out daily activities, make interventions, optimize patient care, and collect data. In 2019 the University of Vermont Medical Center transitioned from using a third party platform to the Epic (Verona, WI, www.epic.com) Bugsy module for antimicrobial stewardship. Method: We have spent the past 4 years optimizing the Epic foundation to match our institutional antimicrobial prescribing guidelines, susceptibility patterns, and build reports to extract actionable data. Result: During the build process, we readily identified three areas needed for customization: (1) Empiric, definitive, and prophylactic indications of use for all antimicrobials based on our hospital’s internally published books “Guide to Antimicrobial Therapy for Adults” and “Guide to Antimicrobial Therapy for Pediatrics” (figure 1); (2) An on-demand report to capture all patients with new administrations of antimicrobials in the preceding 72 hours, that includes ordering clinician, stop date of therapy, and indication (figure 2); and (3) A unique, custom-built slicer-dicer report to capture high-level data on how each antimicrobial is being prescribed by indication, dose, route of administration, ordering clinician, attending physician, and department (figure 3). Conclusion: We have built a system where we can readily identify patients that are receiving antimicrobials both within and outside of institutional guidelines and know the ordering clinician to contact to provide in-the-moment feedback. We can also collect retrospective data to know which antimicrobial agents were prescribed for all infectious syndromes. These three institutional customizations have provided invaluable information to improve patient care.
Trends and outcomes in community-onset and hospital-onset Staphylococcus bacteremia among hospitals in the United States from 2015 to 2020
Authors: Kobayashi Takaaki , Ai ChinEn , Jung Molly , Salinas Jorge L. , Yu Kalvin C.
Published: September 2024

Background:

We investigated trends in Staphylococcus aureus (staph) bacteremia incidence stratified by methicillin susceptibility (methicillin-susceptible S. aureus [MSSA] vs. methicillin-resistant S. aureus [MRSA]) and onset designation (community-onset [CO] vs. hospital-onset [HO]).

Methods:

We evaluated the microbiological data among adult patients who were admitted to 267 acute-care hospitals during October 1, 2015, to February 28, 2020. Using a subset of data from 41 acute-care hospitals, we conducted a retrospective cohort study to assess patient demographics, characteristics, mortality, length of stay, and costs. We also conducted a case-control study between those with and without staph bacteremia.

Results:

The incidence of MSSA bacteremia significantly increased from 2.43 per 1,000 admissions to 2.87 per 1,000 admissions (estimate=0.0047, P-value=.0006). The incidence of MRSA significantly increased from 2.11 per 1,000 admissions to 2.42 per 1,000 admissions (estimate=0.0126, P-value <.0001). While the incidence of CO MSSA and CO MRSA demonstrated a significant increase (p=0.0023, and p < 0.0001), the incidence of HO MSSA and HO MRSA did not significantly change (p=0.2795 and p < 0.4464). Compared to those without staph bacteremia, mortality, length of stay, and total cost were significantly higher in those with staph bacteremia, regardless of methicillin susceptibility or onset designation.

Conclusion:

The increasing incidence of CO MSSA and MRSA bacteremia might suggest the necessity for dedicated infection control measures and interventions for community members colonized with or at risk of acquiring Staphylococcus aureus.
Association between hospital-onset SARS-CoV-2 and ending universal admission testing and masking at five US hospitals
Authors: Pak Theodore , Kanjilal Sanjat , McKenna Cara , Rhee Chanu , Klompas Michael
Published: September 2024

Background: Many US hospitals have stopped universal masking and testing all patients on admission for SARS-CoV-2. We assessed the association of ending universal masking and admission testing with the incidence of hospital-onset SARS-CoV-2 infections in five Massachusetts hospitals. Method: We conducted a retrospective study of all patients admitted between March 6, 2020 and December 14, 2023 and identified hospital-onset SARS-CoV-2 infections (newly positive SARS-CoV-2 PCR tests >4d after arrival) and community-onset infections (newly positive ≤4d after arrival). We excluded cases if local infection control teams discontinued precautions within 4d (suggesting a false positive or remote/resolved infection). We calculated weekly ratios between hospital-onset and community-onset SARS-CoV-2 cases to account for changes in community SARS-CoV-2 incidence over time. We then performed interrupted time series analysis, looking for changes in the ratio of hospital-onset to community-onset cases across three periods: pre-Omicron period with universal testing and masking in place (March 6, 2020–Dec 16, 2021); Omicron period with universal testing and masking in place (Dec 17, 2021–May 11, 2023); and Omicron period without universal testing and masking (May 12, 2023–Dec 14, 2023). We performed medical record reviews on 100 randomly selected hospital-onset cases after May 12, 2023 to examine if community-onset cases were being misclassified as hospital-onset cases. Result: During the study period, there were 626,908 patient admissions, including 24,980 with community-onset and 1,510 with hospital-onset SARS-CoV-2 infections. The mean weekly ratio of new hospital-onset to community-onset SARS-CoV-2 infections rose from 2.6% before Omicron, to 8.5% (95% CI, 7.0–9.9%) during Omicron, to 17% (95% CI, 15–19%) after universal admission testing and masking ended (Figure 1). There was a significant immediate level change after the pre-Omicron-to-Omicron transition (140% relative increase; 95% CI, 40–240%) and after universal admission testing and masking ended (110% relative increase; 95% CI, 73–150%). On medical record review of 100 randomly selected hospital-onset SARS-CoV-2 cases after universal admission testing had ended, 89% had new symptoms at the time of testing, 80% had PCR cycle thresholds ≤30, 27% had a known COVID-19 exposure, and 97% met at least one of these criteria. In-hospital mortality occurred in 8% of the 100 reviewed cases. Conclusion: Stopping universal masking and admission testing of all hospitalized patients at five Massachusetts hospitals was associated with a significant increase in hospital-onset COVID-19. Nosocomial COVID-19 remains a common complication of hospital care. Preventing nosocomial infections in this vulnerable population remains an important safety goal.

Disclosure: Theodore Pak: Founder/CEO - The East Harlem Software Company, Inc.