bluuebunny/crossref_metadata_2025 huggingface dataset:
Diagnostic Stewardship Opportunities for Emergency Department Evaluation of Children with Suspected Urinary Tract Infection
Authors: Wattier Rachel , Singh Prachi , Green-Hopkins Israel , Hersh Adam , Auerbach Andrew , Kaiser Sunitha
Published: September 2024

Background: Among children who start antibiotics for suspected urinary tract infection (UTI) in emergency departments (EDs), 40-60% have negative urine cultures or other results inconsistent with UTI. Practices contributing to excess antibiotic exposure are not well understood. The goal of this study was to understand diagnostic and post-encounter follow-up processes in children who received antibiotics, in order to define targets for intervention. Methods: We identified encounters by children evaluated in two pediatric EDs, over 2 months in the first ED and 9 months in the second ED, to balance different visit volumes. Children 2 months-17 years old were included if they had a urinalysis (UA) and/or urine culture performed, were assigned a primary or secondary diagnosis code for UTI, and initiated antibiotics. Patients were excluded if they received antibiotics prior to the encounter, had prior urologic surgery or device placement, or were immunocompromised or pregnant. Data abstracted by chart review included demographics, documented symptoms, test results, and documented urine culture review and management. Possible UTI symptoms per pediatric criteria included fever, dysuria, urinary frequency, urgency, or hesitancy, suprapubic, abdominal or flank pain, foul smelling urine, or new urinary incontinence. In both EDs, nurses review urine cultures and document changes to treatment plans. Final urine culture results were considered inconsistent with UTI if there was 1) no growth or 2) only mixed growth reported with quantity < 1 00,000 colony forming units/ml. Results: Of 150 eligible children, 146 (97%) had at least one UTI symptom and 146 (97%) had abnormal UA Results: Urine cultures were not performed in 27 (18%) children. Of 123 encounters with urine cultures performed, 71 (58%) had results inconsistent with UTI. Though 67/71 cultures were marked as reviewed, 43/67 (64%) of the patients who could have stopped antibiotics per guideline recommendations did not have documented plans to stop. In those who had documented plans to stop antibiotics, nurses reached 20/23 (87%) caregivers by phone to communicate these recommendations. Conclusion: Many children suspected to have UTI at the time of ED evaluation do not meet criteria for UTI. We found that the most frequent departures from evidence-based practice recommendations were 1) not sending urine cultures, and 2) not stopping antibiotics when culture results did not support the suspected UTI diagnosis. Further investigation should explore barriers and facilitators to these evidence-based practices to develop population- and context-specific diagnostic stewardship strategies.
Impact of Streptococcus pneumoniae Urinary Antigen Testing in a Large Academic Medical Center
Authors: Burton Jensie , Hornback Krutika , Burgoon Rachel , Albakheet Ahmed M
Published: September 2024

Background: The Streptococcal pneumoniae urine antigen (SPUA) test was developed to increase microbiologic diagnosis of pneumonia. Concerns have been raised about the test’s low sensitivity and failure to alter outcomes by de-escalating antibiotics (PMID:31956656). However, the cost-effectiveness and real-world clinical utility of the test remain unclear. Methods: From June 1, 2022 - May 31, 2023, all patients with a SPUA test in the MUSC Health System were identified via Epic SlicerDicer. Those with a positive test underwent chart review. Antibiotics were classified as a “broad” or “targeted” regimen for S. pneumoniae. Targeted regimens included penicillins without beta-lactamase inhibitors, 1st-3rd generation cephalosporins, doxycycline, levofloxacin or moxifloxacin (with or without azithromycin), as well as azithromycin monotherapy. Broad regimens included 4th generation or higher cephalosporins, carbapenems, penicillins with beta-lactamase inhibitors, and vancomycin. Results: In one year, 1,518 patients had a SPUA test ordered. 62 (4%) patients had a positive test. Of those 62 patients, 14 patients were discharged before the test resulted (Table). The average turnaround time for the test was 2.2 days. When comparing antibiotic therapy on the day before the SPUA test resulted to two days after the test resulted, only 7 additional patients were switched to a targeted regimen (Figure). Conclusion: Of 1,518 SPUA tests ordered in a year, most (1,456 or 96%) were negative, with minimal changes to antibiotic therapy based on positive Results: These results are similar to other real-world studies, which showed a positive test prevalence between 4-8% (PMID:30265290) with 15-30% of patients changed to targeted antibiotics following a positive result (PMID:23111919, PMID: 28053969). The SPUA test cost approximately $44,022 (based on $29 test price) but has limited utility in a real-world setting.

Disclosure: Krutika Hornback: Speaker’s Bureau - Cepheid Diagnostics
Survey of VA Laboratory Practices for Carbapenem-resistant Acinetobacter baumannii and Pseudomonas aeruginosa
Authors: Sawyer Aubrey , Ray Cara , Stacey Klutts James , Fitzpatrick Margaret , Suda Katie , Hicks Natalie , Evans Martin , Jones Makoto , Pfeiffer Christopher , Evans Charlesnika
Published: September 2024

Background: Carbapenem-resistant Acinetobacter baumannii (CRAB) and Pseudomonas aeruginosa (CRPA) are drug-resistant pathogens causing high mortality rates with limited treatment options. Understanding the incidence of these organisms and laboratory knowledge of testing protocols is important for controlling their spread in healthcare settings. This project assessed how often Veterans Affairs (VA) healthcare facilities identify CRAB and CRPA and testing practices used. Method: An electronic survey was distributed to 126 VA acute care facilities September-October 2023. The survey focused on CRAB and CRPA incidence, testing and identification, and availability of testing resources. Responses were analyzed by complexity of patients treated at VA facilities (High, Medium, Low) using Fisher’s exact tests. Result: 77 (61.1%) facilities responded, most in urban settings (85.4%). Most respondents were lead or supervisory laboratory technologists (84.2%) from high complexity facilities (69.0%). Few facilities detected CRAB ≥ once/month (4.4%), with most reporting that they have not seen CRAB at their facility (55.0%). CRPA was detected more frequently: 19% of facilities with isolates ≥ once/month, 29.2% a few times per year, and 26.9% reporting had not seen the organism. No differences in CRAB or CRPA incidence was found by facility complexity. Nearly all facilities, regardless of complexity, utilize the recommended methods of MIC or disk diffusion to identify CRAB or CRPA (91.9%) with remaining facilities reporting that testing is done off-site (7.8%). More high complexity facilities perform on-site testing compared to low complexity facilities (32.0% vs 2.7%, p=0.04). 83% of laboratories test for Carbapenemase production, with one-fourth using off-site reference labs. One-fourth of facilities perform additional antibiotic susceptibility testing for CRAB and CRPA isolates, most of which test for susceptibility to combination antibiotics; no differences between complexities were found. Agreement that sufficient laboratory and equipment resources were available was higher in high complexity than in medium complexity facilities (70.7% vs 33.3%, p=0.01), but not low complexity facilities (43.8%). Conclusion: Having timely and accurate testing protocols for CRAB and CRPA are important to quickly control spread and reduce associated mortality. This study shows that most VA protocols follow recommended testing and identification guidelines. Interestingly, there was no difference in CRAB or CRPA incidence for facilities providing higher vs lower complexity of care. While high and low complexity facilities generally reported sufficient resources for CRAB and CRPA evaluation, some medium-complexity labs, who may feel more compelled than low-complexity labs to bring testing in house, reported that additional resources would be required.
UTI Symptomatology and Antibiotic Prescribing among US Veterans Seen in Outpatient Clinics
Authors: Wilson Geneva , Jackson Ravyn , Abdelrahim Sara , Bej Taissa , Jump Robin , Evans Charlesnika
Published: September 2024

Background: Infectious Diseases Society of America guidelines recommend antibiotic prescribing for urinary tract infections (UTIs) when there is a positive culture and signs and symptoms of infection. Despite these guidelines, prescribing for asymptomatic bacteriuria remains prevalent. We conducted a chart review of UTI outpatient encounters to determine the prevalence of antibiotic prescribing as well as patient and provider factors associated with inappropriate prescribing for UTIs. Methods: Patients who were seen at any Department of Veterans Affairs (VA) outpatient clinic with a positive urine culture from 1/1/2019-12/31/2022 were evaluated for inclusion. Exclusion criteria were pregnancy, neutropenia, neurogenic bladder, spinal cord injury/disorder, chronic kidney disease stage III and above, and those undergoing urologic surgical procedures within 7 days. Inappropriate prescribing was defined as an antibiotic prescription given for UTI treatment when no signs or symptoms of infection were recorded during the patient encounter. Chi-square, Fisher’s exact and t-tests were used to evaluate the association between patient and provider characteristics and antibiotic prescribing. Results: Among 341 visits, most patients were male (70%), White (40%), older (mean age of 65.8 ± 15.9 years) and treated at an urban facility (57%). Antibiotics were prescribed for 67% (229/341) of visits. Of the 229 antibiotic courses prescribed, 119 (52%) were appropriate; issued to patients with > = 1 sign or symptom consistent with a urinary tract infection. The most common symptom recorded was dysuria, followed by frequency, urgency, and hematuria (Figure 1). The remaining 110 (48%) antibiotic prescriptions were inappropriate; given to patients without documented UTI-related signs or symptoms. The proportion of inappropriate prescribing was higher among advanced practice practitioners (39/56; 69%) compared to physicians (68/113; 60%; P < 0 .0001). Prescribing of an antibiotic did not differ by gender (p-value=0.3779), race (p-value=0.3972), age (p-value=0.7461) or urban versus rural geography (p-value=0.3647). Discussion: In outpatient clinics, nearly half of antibiotics prescribed to patients with a positive urine culture occurred in the absence of documented of signs or symptoms of a UTI. These results suggest that interventions to improve antibiotic use for UTI-related concerns in the outpatient setting should address UTI-related signs and symptoms as well as asymptomatic bacteriuria. Advanced practice practitioners were more likely to prescribe without documentation of relevant signs or symptoms than physicians. Improving meaningful documentation about the presence or absence of signs and symptoms of a UTI may help reduce inappropriate antibiotic prescriptions in the outpatient setting.

Disclosure: Robin Jump: Research support to my institution from Merck and Pfizer; Advisory boards for Pfizer
Validation and Use of a Measure in Critical Access Hospitals to Reduce Treatment of Asymptomatic Bacteriuria
Authors: Imlay Hannah , Ciarkowski Claire , Kassamali Escobar Zahra , Bryson-Cahn Chloe , Hersh Adam , Martinez-Paz Natalia , Hartlage Whitney , Chan Jeannie , Hardin Hannah , White Andrea , Wu Chaorong , Vaughn Valerie
Published: September 2024

Background: Inappropriate diagnosis and treatment of urinary tract infections (UTI) contributes to antibiotic overuse. The Inappropriate Diagnosis of UTI (ID-UTI) measure—which quantifies the percentage of treated bacteriuria that is asymptomatic (ASB) using a standard definition of UTI—has been validated in acute care hospitals, but not in critical access hospitals (CAHs) where resources differ. Methods: From October 2022-July 2023, ten CAHs participated in a program to reduce ASB treatment, including education, coaching, and hospital feedback using the ID-UTI measure. Our primary aim was to assess performance characteristics of the ID-UTI standard definition and measure in CAHs (Figure 1). Non-physician abstractors from each CAH submitted clinical data (e.g., signs/symptoms) via REDCap for consecutive adult patients who were admitted or discharged from the emergency department and received antibiotics for bacteriuria. The case abstraction goal for each CAH was 5-6 cases/month. To assess feasibility, we evaluated the ability of each CAH to achieve goal case abstractions. To assess validity and reliability of the ID-UTI standard definition, two physicians reviewed 10% of submitted cases using deidentified patient notes and assessed agreement with the standard ID-UTI definition and consensus clinical opinion. Based on submitted data, we provided bi-monthly feedback reports to CAHs including the hospital-level ID-UTI measure to benchmark progress and for peer comparison. We measured monthly change in the ID-UTI measure using a mixed-effects logistic regression model (Figure 1, Figure 2). Results: Among 10 CAHs, 4 (40%) submitted >59 cases over 10 months (goal) while 3 (30%) submitted >35 cases (secondary goal). Physician reviewers assessed 9.5% (58/608) of cases. Utilizing the ID-UTI standard definition, there was high agreement (93%) in ASB vs UTI designation between each physician reviewer and the CAH’s REDCap assessment (Figure 3). Compared to clinical opinion, the ID-UTI standard definition identified 48% (16/33) of ASB cases and 100% (25/25) of UTI cases (Figure 4). Over the program, the percentage of cases treated for UTI that were ASB decreased from 28.4% (range 0-63%) to 18.6% (range, 0-33%; p=0.055) (Figure 5). Conclusions: Case abstraction with use of the ID-UTI measure was feasible and reliable to implement with modifications for CAHs. Data collection by untrained staff was as reliable as physician adjudication. Though the ID-UTI standard definition undercounted ASB cases (low sensitivity), cases reported as ASB were always ASB when adjudicated (high specificity). The program, including performance feedback using the ID-UTI measure, was associated with a trend toward lower treatment of ASB.
Moving Beyond the Reflex: Effect of a Clinical Decision Support Tool on Urine Culture Ordering Practices
Authors: Kim Elizabeth , Kubes Julianne , Ashraf Shanza , Johnson Krystle , Reif Lisa , Garcia Kathryn , Jacob Jesse , Howard-Anderson Jessica
Published: September 2024

Background: Interventions targeting urine culture stewardship can improve diagnostic accuracy for urinary tract infections (UTI) and decrease inappropriate antibiotic treatment of asymptomatic bacteriuria. We aimed to determine if a clinical decision support (CDS) tool which provided guidance on and required documentation of the indications would decrease inappropriately ordered urine cultures in an academic healthcare network that already uses conditional (e.g. reflex) urine testing. Methods: In October 2022, four hospitals within one academic healthcare network transitioned to a new electronic health record (EHR). We developed an embedded CDS tool that provided guidance on ordering either a urinalysis (UA) with reflex to urine culture or a non-reflex urine culture (e.g. for pregnant patients) based on the indication for testing (Figure 1). We compared median monthly UA with reflex culture and non-reflex urine culture order rates pre- (8/2017–9/2022) and post- (10/2022–9/2023) intervention using the Wilcoxon rank-sum test. We used interrupted time-series analyses allowing a one-month time window for the intervention effect to assess changes in monthly UA with reflex culture, non-reflex urine culture, and total urine culture order rates associated with the intervention. Using SAS 9.4, we generated Durbin-Watson statistics to assess for autocorrelation and adjusted for this using a stepwise autoregressive model. Result: The median monthly UA with reflex culture order rates per 1000 patient-days were similar pre- and post- intervention at 36.7 (interquartile range [IQR]: 31.0–39.7) and 35.4 (IQR: 32.8–37.0), respectively (Figure 2). Non-reflex and total urine culture rates per 1000 patient-days decreased from 8.5 (IQR: 8.1–9.1) to 4.9 (IQR: 4.7–5.1) and from 20.0 (IQR: 18.9–20.7) to 14.4 (IQR: 14.0–14.6) post-intervention, respectively. Interrupted time-series analyses revealed that the intervention was associated with a decrease in the monthly non-reflex urine culture by 4.8 cultures/1000 patient-days (p< 0.001) and in the total urine culture monthly order rates by 5.0 cultures/ 1000 patient-days (p < 0 .001) [Figures 3a and b]. The UA with reflex order rate did not significantly change with the intervention (not pictured). Conclusion: In an academic healthcare network that already employed conditional urine testing, the implementation of an EHR-based diagnostic stewardship tool led to additional decreases in both non-reflex and total urine cultures ordered.
Inpatient Hospice Impact on Blood Culture Practices Near the Time of Death, Tertiary Center, Northern California, 2019–2023
Authors: Rodriguez Nava Guillermo , AlGain Sulwan , McIntyre Karen , Miranti Eugenia , Shepard John , Shieh Lisa , Sampson Mindy , Salinas Jorge
Published: September 2024

Introduction: Many central line-associated bloodstream infections are identified in patients nearing the end of life. Stanford Health Care recently introduced the General Inpatient Hospice program. This program offers inpatient hospice care for patients who, due to uncontrolled symptoms, cannot be discharged to a hospice facility or receive home hospice care. We investigated whether this program would impact blood cultures practices near the time of death. Methods: We performed a retrospective cohort study at Stanford Health Care using records of blood culture events from May 2019 to October 2023. We defined a blood culture near-death as those collected within 2 days before the date of death. We performed an interrupted time series linear regression before and after the implementation of the General Inpatient Hospice program on July 1, 2022 to assess blood culture intensity near-death. Blood culture intensity was defined as the proportion of cultures collected near-death in relation to the total number of blood cultures. Additionally, we calculated blood culture positivity rate, which was defined as the proportion of positive blood cultures among all those collected during our study period. Results: Out of 220,269 blood cultures from 24,955 unique patients, a total of 6,147 cultures (9%) were obtained near the time of death. Among these subjects, the median age was 65 years (range 20–102), with 43% identifying as being of White race-ethnicity and 57% as male. Of these cultures, 3044 were positive (49.5%), with Escherichia coli (618, 24%), Klebsiella pneumoniae (341, 13%), and Staphylococcus aureus (166, 10%) being the most common organisms. After the implementation of the General Inpatient Hospice program, the median enrollment was 12 patients (range 3–18) and the median mortality rate was 2.3% (range 2–3%). The blood culture intensity near death decreased by 0.81%, a change that was not statistically significant (95% CI -2.4% to 0.8%, p=.32; Figure 1). Subsequently, the blood culture intensity showed a non-significant increasing trend of 0.05% (95% CI -0.1% to 0.2%, p=0.53). The blood culture positivity rate near the time of death increased by 16% following the intervention, but this increase was not statistically significant (95% CI – 11.8% to 43.3%, p=.26; Figure 2), and it was followed by a non-significant downtrend of 1.9% (95% CI -3.9% to 1.4%, p=.36). Conclusion: We found no significant association between the implementation of an inpatient hospice program and blood culture practices near the time of death, likely due to low patient enrollment.
Reduction in IUSS (Immediate Use Steam Sterilization) Associated with Reduction in Surgical Site Infections
Authors: Jaffe Jennifer , Merz Linda , McMullen Kathleen
Published: September 2024

Background: Immediate use steam sterilization (IUSS) is a potential risk factor for surgical site infection (SSI). During a regulatory survey, it was discovered that IUSS rates for a 767-bed hospital exceeded what had been reported to Infection Prevention (IP) and surgery leaders (estimated at an average of 60 instances per month, with approximately 40 of those in orthopedic cases). A Quality Improvement (QI) project to reduce IUSS was implemented. Methods: The QI project started with the requirement of three signatures for every cycle of IUSS (surgery management, sterilization management, and IP). Additional trays were ordered to provide an ample supply for cases. Surgery personnel were no longer allowed to perform IUSS, and the number of sterilizers available for IUSS was reduced from 8 to 1. The project was fully implemented as of December 2019. To evaluate the impact, SSI rates for hip and knee prothesis were compared using chi square analysis (Epi Info, CDC); before QI project rates were measured from 2017-2019 and after QI project rates were measured for 2020-2022. No other changes were made that were anticipated to impact orthopedic SSI rates. Results: There were no instruments or implants processed by IUSS after December 2019. Prior to the project, there were 9 hip SSI (rate = 0.54 per 100 procedures) and 14 knee SSI (rate = 0.49 per 100 procedures). After the project, hip SSI decreased by 76% (2 SSI, rate = 0.13 per 100 procedures, p = < 0 .05) and knee SSI decreased by 18% (7 SSI, rate = 0.41 per 100 procedures, p=0.67). Conclusion: A multidisciplinary QI project was successful at drastically reducing the use of IUSS, and a correlating statistically significant decrease in hip SSI and clinically significant decrease in knee SSI was seen for 3 years after the project was completed.

Disclosure: Kathleen McMullen: Speaker - 3M
Navigating the Challenges: Construction Lessons in Establishing an Orthopedic Institute in a Sterile Environment
Authors: Mathew Ruby , Shah Mona
Published: September 2024

Background: In order to become a new, state-of-the-art orthopedic institute with additional operating rooms, and a brand new sterile processing department (SPD), construction needed to be done within a sterile environment. Expansion of the operating room (OR) included adding a whole new wing, with smaller construction work within the open and active OR. While construction for a new SPD occurred in the midst of an active and open SPD; unlike the addition of the OR, new SPD construction included heavy demolition and multiple dust generating projects. There were many lessons learned from the built of this brand new institute, which took place in the middle of a pandemic era. Method: Each project involved in the making of the new orthopedic institute required an Infection Control Risk Assessment (ICRA), as well as walkthroughs and team meetings prior to the start of work. Team meetings involved the hospital Infection Preventionist (IP), the construction project manager, and the departments [involved] managers. Requirements, to mitigate dust dispersal into the neighboring sterile environment, were listed in the ICRA. In addition, weekly rounding was conducted by the team to ensure air flow requirements were followed, and there were no accumulation of dust dispersing to the sterile side. Reprocessing was also conducted at sister facilities when existing reprocessing items (sterilizers, instrument washers, cart washers, etc) were shut down; the hospital also went on bypass a few times in order to accommodate patients who emergently needed operating services. Result: By April 2022, after two years of construction, the new orthopedic institute with 12 new operating rooms, new ambulatory surgery units (ASU), new post anesthesia care units (PACU), and a brand new SPD went live. There were more than 100 shutdown notices, over 50 alternative practices in place to continue daily operations while also allowing construction work to continue. Noncompliance to any of the requirements was immediately followed up with an urgent notice to the project manager. Conclusion: Hindsight, heavy construction in a sterile environment is not preferred and it would have been easier to add on a new SPD, similar to how the OR additions were added; instead of building within an actively open sterile environment. Multidisciplinary team meetings conducted at the very beginning of the project would have prevented many shut downs and alternate practices; . It is pertinent that IPs and clinical department managers are involved at the most earliest phases of the construction.
Candida auris in the Healthcare Environment: Prevalence, Anti-Fungal Resistance, and Survival on Porous & Non-Porous Surfaces
Authors: Smith Brandon , Miller Richard
Published: September 2024

Candida auris is an emerging multidrug-resistant pathogenic yeast capable of causing severe illness in the healthcare environment. It spreads easily amongst patient populations, is often resistant to anti-fungal treatments and can survive on surfaces for prolonged periods. In the current study, 85 sites within hospital settings were screened for surface-contaminated Candida species and C. auris. Surface swab samples were transferred to chromogenic agar media designed to isolate and identify Candida species and were incubated at 35°C for 48 hr. Samples were confirmed using molecular techniques designed to specifically target C. auris from other Candida species. Data was compiled to show prevalence of six key Candida species (C. albicans, C. auris, C. glabrata, C. krusei and C. tropicalis). Survivability on surfaces was performed using CDC B11903 C. auris strain. Plastic, metal and fabric surfaces used were purchased from a medical supply store. Once inoculated with 500 CFU/ml in sterile distilled water, the surfaces were kept in a Class II hood with minimal airflow and ambient conditions (21°C, 60% RH) and sampled daily. Results showed 25 of the 85 (29.4%) tested sites were positive for Candida species, with 3 of those sites positive for C. auris. Anti-fungal resistance among the three isolates (tested using concentration gradient test strips) showed notable resistance to fluconazole, but not to amphotericin B nor micafungin. C. auris survivability was dependent upon surface type, with the C. auris test strain surviving for 39 days on three different types of hospital curtains, and ≥10 days on a variety of non-porous plastic or metal surfaces. With demonstrated survivability of C. auris for long periods of time on hospital surfaces, it becomes critical for healthcare facilities to consider C. auris when developing infection prevention programs.
Clinical and Genomic Characteristics of Candida auris in Central Ohio: An Insight into Epidemiological Surveillance
Authors: Kotekal Dhatri , Smith Heather , Carroll Ryan , Ajaka Leama , Liscynesky Christina , Brown Amanda , Murthy Shashanka , Sun Christine , Sovic Michael , Day Shandra , Colburn Nora
Published: September 2024

Background: Candida auris is an emerging threat to hospitalized patients and invasive disease is associated with high mortality. This study describes clinical and microbiological characteristics of nine patients identified with C. auris at Ohio State Wexner Medical Center discovered through active surveillance or clinical investigation and uses whole genome sequencing (WGS) to compare isolates. Methods: In November 2022, an active C. auris surveillance program was implemented to screen patients admitted to high-risk units (intensive care units and progressive care units). Bilateral axilla and groin swabs were obtained upon unit admission and, if positive, were submitted for C. auris polymerase chain reaction (PCR) with culture and sensitivity testing. Patients with a positive screening or clinical isolate from November 2022 to November 2023 underwent chart review for clinical characteristics, microbiologic data, and index admission information. For each isolate, DNA was extracted and WGS was performed. Core single nucleotide polymorphism (SNP) variation identified from the sequence data was used to infer genetic relationships among the isolates. Results: Nine patients were identified between November 2022 and November 2023. The clinical and microbiologic characteristics are summarized in Table 1. All patients were hospitalized at various acute care facilities across the state at least once in the preceding 12 months. C. auris was determined to be present on admission for 6 patients. For 5 of these patients, it was their first interaction with our healthcare system. Three patients were not in contact isolation for >3 days before C. auris was identified. Unit wide point-prevalence screening was completed in these cases and no evidence of transmission was found. WGS showed eight of the nine isolates were related with 28 or less core SNP differences between isolates (Figure 1). One isolate (8) was genetically distinct with >45000 core SNP differences. Five isolates were highly related with a range of 4-15 SNP differences. No temporal or spatial overlap at our institution was identified among these five patients. Conclusions: The active surveillance program identified several patients colonized with C. auris in addition to those found through clinical testing. Multiple risk factors for C. auris were identified with high patient mortality (67%). Majority of the isolates were closely related without association with a known outbreak or epidemiologic link, suggesting a possible diffuse common reservoir. Next steps with surveillance in acute care and long-term care facilities will be critical for early detection to halt transmission of this organism.
Improving Cleaning Validation Utilizing Adenosine Triphosphate Technology
Authors: Siddiqui Mehvish , Garcia Rosemary , Lozano Rosa
Published: September 2024

Background: Thorough cleaning and disinfection of high-touch surface areas in hospital inpatient rooms remain vital parts of effective strategies in reducing hospital-acquired infections (HAIs). Currently, Methodist Specialty & Transplant Hospital (MHST) inconsistently utilizes fluorescent marking for terminal cleaning validation. Without quantitative results, it’s difficult to measure the effectiveness of cleaning. To ensure MHST is maintaining a safe and clean environment for patients & staff, MHST implemented a comprehensive cleaning verification program to include adenosine triphosphate (ATP) technology. We aimed to establish the program with baseline readings, and an overall weekly passing score of 95% for all tested inpatient rooms. Methods: To achieve sustained improvement, we needed to monitor, educate, and have periodic performance feedback to individuals and stakeholders. Key stakeholders (IP, EVS, Operations Leadership, Nursing Leadership representative) were identified, and a weekly meeting was established to discuss the planning and implementation of the ATP program. Some key actions included: standardization of brand of luminometer- device to measure ATP for microbial contamination; establishment of 16 high surface touch points to be tested; partnership with IT to create a database & dashboard for ATP results & data analysis; training of ATP device to all personnel who will be utilizing ATP device; establishment of a threshold for a “pass” clean (relative light unit [RLU] less than or equal to 45). Summary of Results: After baseline testing, the average weekly pass score met goal at 95 percent for all tested rooms. The bedside table located on the 2W floor was the location that failed the most (3 instances). Conclusions: Our program implementation project aimed to improve terminal cleaning validation utilizing ATP technology in inpatient rooms, was successfully implemented. Equipped with quantitative results, the MHST team, was able to verify cleaning quickly and efficiently without any confusion, as it may have been with the previous verification method of fluorescent marking. The partnership between Infection Prevention (IP) & Environmental Services (EVS) was crucial in the implementation of this process improvement- from participating in training together to understanding and sharing ATP pass/fail score data.
Environmental Contamination in Relation to cDHP in Candida auris Patient Rooms as Measured by ATPase
Authors: Moody Julia , Sands Ken , Greene Bonnie , Long Rachel , Dotson Nychie
Published: September 2024

Background: Candida auris (CA) is an urgent threat per Centers for Disease Control and Prevention with rapidly increasing cases across the US. Patient rooms recontaminate with CA within hours after daily cleaning due to skin shedding, persistence on environmental surfaces and resistance to commonly used disinfectants. Continuous dry hydrogen peroxide (cDHP) is a novel environmental technology augmenting daily room disinfection. cDHP reduces CA organism counts based on environmental cultures. Adenosine triphosphatase (ATPase) testing offers rapid results to monitor surface cleanliness. ATPase Testing Protocol: Upon identification of CA, cDHP was activated in the patient’s room. ATPase surface testing was performed in rooms of CA infected inpatients and nearby control rooms of inpatients without CA and thus no cDHP. Group A surfaces near the patient were nurse call handheld devices and/or bed rail. Group B surfaces were horizontal counter and/or computer keyboard, located >3 feet away from the patient. ATPase testing was to occur within one hour of daily room disinfection for CA patient Day0 (day of cDHP activation), Day1, Day7 and Day14 and controls. Daily room disinfection using quaternary disinfectants was replaced with EPA Class P chemicals upon CA identification. Nursing spot disinfects with Class P ready to use disinfectant wipes in all rooms. Results: Testing occurred among 13 CA and 22 control patients in 5 hospitals. In Table 1, pass rates are displayed by cumulative (Day0+1+7+14) test days for surfaces and patient room groups. Analysis applied Pearson’s Chi-squared test with Yates’ continuity correction. Conclusions: Surfaces further from the patient in rooms of CA patients exposed to cDHP had higher ATPase pass rates than controls. Surfaces close to the patient have a high ATPase failure rate, regardless of CA or cDHP. Strategies are needed to ensure disinfection occurs on high touch surfaces near patients. cDHP may have value in supplementing room disinfection. Contributing failure factors include surfaces missed for disinfection, delays in timely testing and known limitations with ATPase methods.
Filtered handheld far-ultraviolet disinfection device in reducing environmental pathogens from high-touch clinical surfaces
Authors: Yaghi Layale , Wilson-Dib Rita , Cantu Sherry , Chatterjee Piyali , Jinadatha Chetan , Chemaly Roy , Spallone Amy
Published: September 2024

Background: Healthcare-acquired infections (HAIs) continue to be a major challenge. In fact, an increased risk of HAIs has been linked to high-touch surfaces contaminated with multidrug-resistant organisms (MDROs), and enhanced environmental disinfection is linked to reduced HAI rates. Recently, more focus has been placed on emerging disinfection technologies, such as UV light-producing portable device that emits light at a wavelength of 222 nm, which has previously demonstrated germicidal capabilities at short contact times. In this study, we aim i) to evaluate the efficacy of a filtered far-UV-C handheld device (FFUHH) to reduce bacterial loads on high-touch surfaces in clinical workrooms in a cancer center, and ii) to isolate, identify and establish a genetic relationship between these environmental clinically significant pathogens and the ones recovered from patients. Methods: Samples were collected weekly on a rotating schedule over a 24-week period from five high-touch items (dictation device, mouse, armchair, desk, and keyboard) in multiple clinical work rooms on hematologic malignancy and stem cell transplant units. Contact plates for colony count and swabs were collected pre- and post-intervention with the FFUHH on standardized adjacent areas respectively for each surface. The swabs were enriched and cultured on selective media to isolate clinically significant pathogens. Whole genome sequencing (WGS) was then performed on environmental pathogens validated by MALDI-TOF as well as clinical samples collected from patients in the same unit around the time of environmental sample collection. Results: A total of 440 plates, 220 pre- and 220 post-interventions, were collected and analyzed. The highest mean colony count pre-treatment was detected from the armchairs and the lowest for the keyboards. The mean reduction of colony forming units (CFUs) ranged between 53% for the keyboard and 83% for the mouse. The reduction was statistically significant across all surfaces with P values < 0.05, except for the keyboard (Figure 1). We isolated many pathogens of the human microbiota identified by MALDI-TOF such as Micrococcus luteus, S. capitis as well as methicillin-resistant S. epidermidis, S. haemolyticus and S. hominis. We also identified several Candida parapsilosis, Pseudomonas stutzeri, one Listeria grayi and one Acinetobacter baumanni. Finally, WSG allowed us to further characterize an environmental multi-drug resistant S. epidermidis ST5 strain associated with patient bacteremia, and ST16 strains detected on surfaces both pre- and post-FFUHH treatment. Conclusion: The FFUHH effectively reduced the microbial burden on high-touch surfaces in clinical workrooms on hematologic malignancy and stem cell units.
Environmental Fungal Contamination Characterization of Three Inpatient Units Utilizing Optimized Detection Methods
Authors: Warren Bobby , Fils-aime Guerbine , Graves Amanda , Barrett Aaron , Steigel Matthew , Smith Becky , Schwartz Ilan , Anderson Deverick
Published: September 2024

Background: Environmental sampling and detection methods for fungi in healthcare settings are not well-established. We previously refined methods for fungal sampling and detection in a controlled laboratory environment and aimed to validate them in a real-world healthcare setting. Methods: We performed a microbiological analysis of air and surfaces in three inpatient units at a tertiary care center. Surface samples were obtained with foam sponges from 3 locations in patient rooms (Patient bedrails, bathroom floor, HVAC export) and 5 locations in units (HVAC exports 3x, clean linen storage, soiled linen storage). Air samples were taken with an active air sampler directly below HVAC exports. Sponges were processed using the stomacher technique. Samples underwent DNA extraction followed by qPCR with FungiQuant primers targeting the 18S rRNA gene. Amplicons from positive samples were sequenced (NextSeq 1000, 300bp PE) and SmartGene databases were used to interpret sequence data. For comparison to culture methods, samples were also plated onto Sabouraud and HardyCHROM Candida + auris medias. Fungal growth underwent DNA extraction, 18S PCR and Sanger sequencing for genus and species identification. Results: A total of 85 samples were obtained, from 15 patient rooms and three units resulting in 61 surface and 24 air samples. Patients in study rooms had a median age of 53, 9 (60%) were male, and no patients had an invasive fungal infection during their hospital encounter. 44 (53%) and 39 (46%) samples were positive for fungi via qPCR and culture, respectively. Of the 44 positive qPCR samples, microbiome analyses identified at least one fungi to the species, genus and family levels in 43 (98%), 28 (64%), 18 (41%) samples, respectively (Table 1). 114 total isolates were identified of which the most common were Mallassezia restricta (30 [26%]), Malassezia globose (29 [25%]), and Pennicillium paradoxum (4 [4%]). 39 genera were identified of which the most common were Mucor (19 [49%]) and Candida (8 [21%]). Of the 39 culture positive samples, 90 total isolates were recovered. The most common species were Paradendryphiella arenariae (19 [21%]), Aspergillus niger (12 [13%]) and Penicillium commune (12 [13%]). Conclusion: These results demonstrate the presence of diverse fungal species in both air and surface samples across inpatient units. Higher sensitivity was noted utilizing qPCR, however, identified genera and species were markedly different between qPCR and culture methods. Larger studies are needed to assess the efficacy of qPCR for fungal detection in the healthcare environment.
Staff Perspectives on Barriers & Facilitators to Meeting Hand Hygiene Goals in a Multicenter Academic Hospital System
Authors: Gibas Kevin , Kinsella Nathan , Stephanie Parente , Diamond Megan , Blanchard Kerry , Mermel Leonard
Published: September 2024

Background: Proper hand hygiene is the most important practice to reduce the transmission of infections in healthcare settings. Despite this, healthcare institutions continue to struggle to achieve and maintain high rates of hand hygiene compliance among healthcare workers with some studies estimating national healthcare worker hand hygiene compliance to be approximately 50%. Methods: We conducted an anonymous one-time survey of our Lifespan Hospital System employees to evaluate barriers and facilitators to performing hand hygiene as well as interventions to improve hand hygiene compliance. The survey was designed with guidance from the Consolidated Framework for Implementation Research and input from Lifespan infection prevention staff. Result: Over four weeks 985 (6%) Lifespan employees completed the survey. Figure 1 shows the aggregate results of the first 4 survey questions which focused on hand hygiene infrastructure at Lifespan, including availability of sanitizer, staff to manage hand hygiene supplies, and educational materials/reminders. One significant finding was >70% of respondents reported that they either did not know if their unit/department has a person assigned to replace/monitor hand hygiene supplies, or if so, who that person is. We also asked employees to rate how effective different interventions would be at improving hand hygiene compliance. Figure 2 shows of five proposed interventions, three were rated as either “moderately effective” or “very effective” by >50% of respondents. These included displaying hand hygiene instructions, making hand hygiene data available to employees, and displaying materials/reminders promoting hand hygiene. There were also 977 free-text responses regarding “barriers or facilitators to proper hand hygiene”. Major barriers identified were a lack of staff to monitor and refill supplies, slow replacement of hand hygiene products, lack of sanitizer dispensers and sinks, inconsistency of sink location and dispenser placement, lack of hand hygiene reminders/educational materials, time constraints, skin irritation from sanitizer, and an inability to have dispensers in behavioral health units. Survey responses led us to enhance the following: educational materials and reminders in work areas; staff education; leadership involvement in hand hygiene initiatives; routine auditing and feedback; conveniently placed sanitizer dispensers and sinks at the point of care; and making hand hygiene compliance data readily available to staff. Conclusion: This survey identifies important barriers and facilitators to achieving high rates of hand hygiene compliance among healthcare workers and provides the basis for interventions aimed at improving hand hygiene compliance in a large multicenter academic hospital system.
Assessing the quality of Hand Hygiene data produced by Alberta Health Services using a time-in-motion study
Authors: Ellison Jennifer , Lu Zhe , Devine Alison , McFerran Blair , Bolton Sandra , Popson Helen , Bush Kathryn
Published: September 2024

Background: Alberta Health Services (AHS) measures hand hygiene compliance through direct observations performed by trained site-based reviewers (SBRs) and facilitated by the Infection Prevention and Control (IPC) program. Within AHS there are >100 acute care facilities, ranging in bed size from four beds to more than 1,000, with catchment populations ranging from one million. A time-in-motion study using trained AHS IPC staff was proposed to validate the completeness and accuracy of data being collected by the SBRs. Methods: The AHS IPC staff performed direct observations at pre-selected facilities across all five zones and four different unit types (emergency, medical, surgical, and intensive care) for four 30-minute periods during weekdays between June and September 2023. An iPad app was used to capture results from all four moments of hand hygiene. The reviewer indicated the day and time of the review and captured as many representative hand hygiene moments and healthcare providers as possible. The distributions of the four moments of hand hygiene, healthcare provider group and overall compliance were compared at the unit type and facility level (tertiary, large urban, regional, pediatric, and small sites) between this time-in-motion study and SBR data collected June-September 2023. Results: The study collected 175 reviews and 4,683 observations from 14 facilities and 48 units. Between June and September 2023, SBRs collected 2,625 reviews and 61,506 observations from these same facility and unit types. Across all facility and unit types, the distribution of the four moments was similar between the study and SBRs. Similar proportions of healthcare providers were also observed. However, the overall hand hygiene compliance collected in the study was approximately 10% lower across all unit types as compared to that collected by the SBRs (study: 63%-84%; SBRs: 75%-92%). Conclusions: In public health surveillance, completeness and accuracy are two characteristics of high-quality data. A time-in-motion study identified that the hand hygiene observations collected by SBRs were complete, as the range of healthcare providers observed, and the distribution of their moments, mirrored that collected in the study. However, the SBRs reported higher compliance than the study participants and the true hand hygiene compliance is likely lower than what is currently being reported. Since this difference was seen consistently across all unit and facility types, trending data over time should still identify areas in need of improvement and may help to suggest causes of the over-reporting.