bluuebunny/crossref_metadata_2025_split huggingface dataset:
Diagonal Interventions in Infection Prevention: Successful Collaboratives to Decrease CLABSI at a VA Health Care System
Authors: Steele Amy S. , Carlson Abigail , Drummond Shay L. 
Published: November 2020

Background: Vertical interventions in public health are disease focused, whereas horizontal interventions are systems based. The new concept of “diagonal interventions” merging these 2 approaches is also applicable to infection prevention (IP). During fiscal year (FY) 2016, our facility identified 14 central-line–associated blood stream infections (CLABSIs), resulting in a rate of 1.44 cases per 1,000 catheter days, twice that of FY2015 (0.75 cases per 1,000 catheter days). Methods: Focusing on a horizontal “systems building” approach, the IP team used previously developed informal relationships to mobilize a formal multidisciplinary team comprised of IP, nursing educators, the intravenous therapy team, and frontline staff. Initially charged with implementation of disinfecting caps for needleless connectors, the IP team capitalized on this multidisciplinary resource to launch a multifaceted communication and education campaign supporting CLABSI-specific interventions. For vertical interventions, an IP risk assessment revealed variations in care and maintenance of central lines and the need for staff education. A literature search was conducted to identify evidence-based strategies for reducing CLABSIs, leading to the development of a nursing-led bundle of the following elements: (1) education on CDC hand hygiene guidelines, (2) central-line competency validation and assessment for nurses on hire and annually, (3) standardized processes across all wards for central-line dressing changes (“timed on Tuesdays”), and (4) a pilot program for disinfecting caps on 3 inpatient wards. The IP team identified CLABSIs using standard NHSN definitions. Catheter days were obtained on each inpatient ward. Unit-specific rates were calculated per 1,000 catheter days. Mann-Kendall Test was used to assess rate trends over time, whereas the Fisher exact test was used for rate comparisons. A P < .05 was considered significant. Results: CLABSI rates decreased from 1.44 in FY2016 to 0.12 in FY2019 (Kendall τ = −0.5; P < .001) (Fig. 1). During the 3-month pilot phase of disinfecting caps, no CLABSIs were identified on 3 intervention wards versus 3 CLABSIs on control wards (rate, 0 vs 2.57; P = .27) and 1 CLABSI in the 3-month baseline period prior to the intervention (0 vs 0.40; P > .99). Disinfecting caps were expanded house-wide beginning in FY2018. The multidisciplinary team evolved into a sustained collaborative (“Scrub Club”) meeting biweekly. They have now broadened their focus to quality improvement initiatives for multiple healthcare-associated infections (HAIs). Conclusions: The IP team has traditionally utilized vertical models of intervention. The use of “diagonal” models that incorporate horizontal health systems strengthening can transform multidisciplinary partnerships into long-term collaboratives essential for sustained reduction of HAIs.Funding: NoneDisclosures: None
Does Blood on “Dirty” Instruments Interfere With the Effectiveness of Sterilization Technologies?
Authors: Rutala William , Gergen Maria , Weber David Jay 
Published: November 2020

Background: Surgical instruments that enter sterile tissue should be sterile because microbial contamination could result in disease transmission. Despite careful surgical instrument reprocessing, surgeons and other healthcare personnel (HCP) describe cases in which surgical instruments have been contaminated with organic material (eg, blood). Although most of these cases are observed before the instrument reaches the patient, in some cases the contaminated instrument contaminates the sterile field, or rarely, the patient. In this study, we evaluated the robustness of sterilization technologies when spores and bacteria mixed with blood were placed on dirty (uncleaned) instruments. Methods: Dirty surgical instruments were inoculated with 1.5105 to 4.1107 spores or vegetative bacteria (MRSA, VRE or Mycobacterium terrae) in the presence or absence of blood. The spores used were most resistant to the sterilization process tested (eg, Geobacillus stearothermophilus for steam and HPGP and Bacillus atrophaeus for ETO). Once the inoculum dried, the instruments were placed in a peel pouch and sterilized by steam sterilization, ethylene oxide (ETO), or hydrogen peroxide gas plasma (HPGP). These experiments are not representative of practice or manufacturer’s recommendations because cleaning must always precede sterilization. Results: Steam sterilization killed all the G. stearothermophilus spores and M. terrae when inoculated onto dirty instruments in the presence or absence of blood (Table 1). ETO failed to inactivate all test spores (B. atrophaeus) when inoculated onto dirty instruments (60% failure) and dirty instruments with blood (90% failure). ETO did kill the vegetative bacteria (MRSA, VRE) under the same 2 test conditions (ie, dirty instruments with and without blood). The failure rates for HPGP for G. stearothermophilus spores and MRSA were 60% and 40%, respectively, when mixed with blood on a dirty instrument. Conclusions:This investigation demonstrated that steam sterilization is the most robust sterilization process and is effective even when instruments were not cleaned and the test organisms (G. stearothermophilus spores and MRSA) were mixed with blood. The low-temperature sterilization technologies tested (ie, ETO, HPGP) failed to inactivate the test spores but ETO did kill the test bacteria (ie, MRSA, VRE). These findings should assist HCP to assess the risk of infection to patients when potentially contaminated surgical instruments enter the sterile field or are unintentionally used on patients during surgery. Our data also demonstrate the importance of thorough cleaning prior to sterilization.Funding: NoneDisclosures: Dr. Rutala was a consultant to ASP (Advanced Sterilization Products)
Effectiveness of an Alcohol-Based Nasal Antiseptic in Reducing MRSA Bacteremia in an Adult Intensive Care Population
Authors: Reeves Lauren , Barton Lisa , Nash Michelle , Williams Jennifer , Guimera Don , Simmons Bryan , Hysmith Nicholas , Morton Jackie 
Published: November 2020

Background: Hospitalized patients are at an increased risk of invasive infection with Staphylococcus aureus when colonized with the bacteria on admission. Rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia are directly correlated with overall patient acuity, placing patients in intensive care areas at greatest risk. Universal decolonization with nasal antibiotic ointments has been shown to reduce the incidence of invasive MRSA in critically ill patients; however, debate remains regarding the long-term efficacy of this strategy and the possibility of developing antimicrobial resistance. An alcohol-based nasal antimicrobial may be an effective alternative. This study evaluated the effectiveness of a twice daily alcohol-based product in reducing the rate of MRSA bacteremia in an academic tertiary-care adult intensive care setting. Methods: Our study was an observational design with retrospective and prospective cohorts each consisting of 61 critical care beds. The baseline incidence of MRSA bacteremia was determined from a 7-month period preceding the implementation of the nasal antimicrobial. At implementation, each admission received an electronic order for an alcohol-based nasal antiseptic that was applied twice daily during the intensive care stay. The primary outcome was the incidence of MRSA bacteremia in each group. MRSA bacteremia was defined by the CDC NHSN criteria after review by an infection prevention nurse. The 2 test was used to compare the rates between the 2 groups, and P < .005 was considered significant. Results: The study periods contained similar patient days, with 12,475 in the retrospective group and 12,733 in the prospective group. The rate of MRSA bacteremia in the retrospective cohort was 0.2404 compared to 0 in the prospective cohort. This rate change was statistically significant, with P < .0001. Conclusions: The alcohol-based nasal antiseptic was effective in reducing healthcare-onset MRSA bacteremia in this intensive care population. This approach may be a safe and effective alternative to nasal antibiotic ointment that avoids antibiotic resistance risks.Funding: NoneDisclosures: None
Effectiveness of Antimicrobial Filter Placement in ICU Taps to Prevent the Occurrence of HAIs by Pseudomonas aeruginosa (12-Months)
Authors: Chico-Sánchez Pablo , Canovas-Javega Sandra , Jimenez-Sepulveda Natali J. , Leutscher-Vasen Edith , Villanueva-Ruiz Cesar O. , Benito-Miralles Carmen M. , Hernandez-Maldonado Maria , Lameiras-Azevedo Ana S. , Sanchez-Paya Jose 
Published: November 2020

Background:Pseudomonas aeruginosa, is the third etiologic agent of healthcare associated infections, and the most frequent pathogen in ventilator-associated pneumonia (VAP). In critical care units is associated with high mortality, long hospital stay, and high healthcare-associated costs. We evaluated the effectiveness of filter placement in the water taps in critical care units to prevent the occurrence of healthcare-associated infections (HAIa) by Pseudomonas aeruginosa. Methods: This experimental study was both cross-over and open-label in nature. We included patients admitted for >24 hours in critical care units over 24 months. The study was divided into 4 periods of 6 months each. We divided the study into 2 groups: patients in units with filters and patients in units without filters. We compared the incidence density of P. aeruginosa HAIs (number of cases divided by the number of person days) according the ECDC definition of case criteria between the groups. The 2 test was used, and the magnitude of the association was calculated as a rate ratio with a 95% confidence interval, adjusted using a Poisson regression model. Results: Overall, 1,132 patients were included in the study: 595 in units with water tap filters and 537 in units without water tap filters. HAI incidence among patients in units with water tap filters was 5.3 per 1,000 person days stay; without water tap filters, HAI incidence was 4.7 per 1,000 person days stay (HR, 0.94; 95% CI, 0.47–1.90). Conclusions: The preliminary results of this study indicate a a lower incidence of P. aeruginosa HAIs in units with filters placed in water taps than in units without filters.Disclosures: NoneFunding: None
Evaluation of a Disease State Stewardship Intervention for Urinary Tract Infections at an Academic Medical Center
Authors: Xhemali Xhilda , Forster Derek , Clemons Bryant , Cotner Sarah , VanHoose Jeremy , Burgess Donna , Burgess David , Myint Thein , Maskey Mitu Karki , Wallace Katie 
Published: November 2020

Background: Urinary tract infections (UTIs) are often misdiagnosed and mismanaged. Disease state stewardship initiatives targeting UTIs through the development of institutional guidelines and real-time prospective audit and feedback (PAAF) on provider management may have a significant impact on the overuse of antimicrobials. Objective: Our study evaluated the effectiveness of a UTI focused disease state stewardship intervention by assessing institutional guideline adherence before and after implementation. Methods: This retrospective quasi-experimental study was conducted at a tertiary-care academic medical center. Patients >18 years of age receiving antimicrobials for a UTI were included. A previously performed retrospective review of UTI management from September-November 2017 was used as the baseline. The UTI management guideline was implemented in July 2018, and service lines were educated. A PAAF initiative began in June 2019, whereby the antimicrobial stewardship team performed daily reviews of patients receiving antimicrobials for UTIs. Data was collected on their management, and providers were contacted in real time with recommendations based on the institutional guideline. Patients reviewed June–October 2019 were included in the postimplementation analysis. Patients were excluded if they were pregnant, underwent a urological procedure with risk of mucosal bleeding, or were an outside hospital transfer already on UTI therapy. The primary outcome of this study was to evaluate guideline adherence before and after the implementation of PAAF for the management of UTIs. Results: In total, 198 patients in the preintervention group and 246 in the PAAF group were included. The emergency department was the primary ordering service of urinalyses (60.1% vs 66.1%; P = .2287) in both periods and altered mental status as the main indication for testing (35.2% vs 31.3%; P = .5465). Treatment of asymptomatic bacteriuria and pyuria decreased significantly between the 2 periods: 74.8% versus 36.2% (P = .0001). Appropriate ordering of urinalyses (33.8% vs 68.3%; P = .0001) and urine cultures (29.3% vs 61.0%; P = .0001) also improved in the PAAF group. Recommendations made during PAAF included therapy discontinuation (66.7%), antimicrobial therapy change (15.5%), or duration modification (15.5%), and 59.5% of first interventions were accepted. Overall guideline compliance significantly improved from 13.1% in the preintervention period to 26.1% in the PAAF period (P = .0011). Conclusions: A UTI disease state intervention was associated with significant reductions in the treatment of asymptomatic presentations as well as an improvement in overall guideline adherence. We believe that this approach represents a powerful stewardship strategy for decreasing unnecessary antimicrobial usage.Funding: NoneDisclosures: None
Evaluation of Initial Outcomes of an Antimicrobial Stewardship Program in a Nonprofit Hospital in Brazil
Authors: Junior Adelino Freire , Fagundes Fernando , Neto Mozar Castro , Barbosa Carine , Alves Thais 
Published: November 2020

Background: One of the main global public health challenges is the fight against microbial resistance, according to the World Health Organization. Inadequate use of antimicrobials is considered one of the main factors related to the phenomenon and is quite common in the hospital environment. Managing the use of antimicrobials in hospitals has become a necessity and has shown positive results in many ways, such as maximizing the effects of pharmacotherapy, preventing the emergence of resistant microorganisms, and reducing healthcare costs. Methods: The prescriptions for patients admitted to a 380-bed nonprofit private hospital in Belo Horizonte, Brazil were monitored from January 1, 2019, to August 31, 2019, with a monthly average of 251 patients followed by the antimicrobial stewardship (AMS) team (1 infectious diseases doctor and 2 clinical pharmacists). Patients selected for follow-up and intervention were those submitted to intravenous, intramuscular, and/or oral antibiotic therapy with the following antimicrobial agents: piperacillin/tazobactam, carbapenem, polymyxin B, tigecycline, vancomycin, teicoplanin, daptomycin, third- and fourth-generation cephalosporins, quinolone, and aminoglycosides. Patients on prophylactic or antimicrobial treatment not mentioned above were excluded from surveillance. Interventions were dose adjustments, drug adjustment by culture results, intravenous to oral treatment switch, and discontinuation of therapy. Results: There were 318 interventions, and 64.82% of the interventions performed by the AMS team were accepted by prescribers. The interventions provided a total savings of BR$ 119,706 (~US$30,000) in direct antimicrobial spending. Correlating the interventions with the defined daily dose (DDD) measurement and comparing data from the same period in 2018, we detected a reductions in the consumption of several antimicrobials: ceftriaxone (25.6%), ciprofloxacin (45.7%), meropenem (34%), piperacillin/tazobactam (12.7%), teicoplanin (18.8%), vancomycin (20.6%), cefepime (23.9%) and polymyxin B (26%). We also detected reductions in days of therapy (DOT) for most of these drugs, such as polymyxin B, with an average reduction of 2 DOT. Conclusions: Reducing antimicrobial use is one of the key strategies for avoiding unnecessary exposure and selective pressure leading to the emergence of resistant microorganisms. The measured data point to a favorable trend in the rational use of antimicrobials in our institution with simple interventions. The results presented were used to reaffirm the importance of the AMS team in our institution. More data on length of stay, indirect costs, reduction of side effects, mortality, and occurrence of microbial resistance should be made.Funding: NoneDisclosures: None
Evaluation of Novel “No-Touch” Technologies for Decontamination of Toys in Pediatric Healthcare Settings
Authors: Haydar Hanan , Kumar Jessica , Cadnum Jennifer , Hoyen Claudia , Donskey Curtis 
Published: November 2020

Background: Toys in playrooms are often shared among patients in pediatric healthcare settings; they can present a risk for transmission of bacterial and viral pathogens. Effective cleaning and disinfection of toys using disinfectant wipes is labor intensive and difficult due to irregular surfaces. Methods: We conducted a point-prevalence culture survey to determine the frequency of contamination of in-use toys and high-touch surfaces in playrooms in a pediatric healthcare facility with methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Clostridioides difficile. Using a variety of toys inoculated with pathogens, we evaluated efficacy and ease-of-use of 3 novel “no-touch” technologies: (1) an electrostatic sprayer, (2) a small ultraviolet-C (UV-C) box (18.9 × 9.9 × 1.8 inches) for smaller toys, and (3) a high-level disinfection cabinet using ultrasonic submicron droplets of peracetic acid and hydrogen peroxide. Test pathogens included C. difficile, MRSA, and Candida auris. Results: Of 135 items cultured in playrooms, 6 (4.4%) were contaminated with MRSA, 1 (0.7%) was contaminated with VRE, and none were contaminated with C. difficile. Each of the technologies reduced all pathogens by >4 log10 CFU on all types of toys tested (plastic, soft rubber, and tablet). The electrostatic sprayer was considered the easiest to use by all users because large numbers of toys could be processed much more quickly (ie, spray for 20 seconds and allow to air dry) than with disinfectant wipes. The disinfection cabinet required 21 minutes for cycle completion, whereas the decontamination cycle for the UV box was only 30–90 seconds but with limited capacity to hold toys. Conclusions: Three “no-touch” technologies were effective for disinfection of toys contaminated with healthcare-associated pathogens. The electrostatic spray application of disinfectant was considered the easiest to use for rapid decontamination of toys.Funding: NoneDisclosures: None
Evaluation of Patient Risk Factors for Carbapenemase-Producing Organism Colonization
Authors: Stover Carolyn , Chan Allison , Vallabhaneni Snigdha , Brown Allison , Keaton Amelia , Shugart Alicia , Dotson Nychie , Arenas Sebastian , Kainer Marion , Walters Maroya 
Published: November 2020

Background: Carbapenemase-producing organisms (CPOs) are a growing antibiotic resistance threat. Colonization screening can be used to identify asymptomatically colonized individuals for implementation of transmission-based precautions. Identifying high-risk patients and settings to prioritize screening recommendations can preserve facility resources. To inform screening recommendations, we analyzed CPO admission screens and screening conducted on point-prevalence surveys (PPSs) performed through the Antibiotic Resistance Laboratory Network’s Southeast Regional Laboratory (SE AR Lab Network). Methods: During 2017–2019, the SE AR Lab Network collected data via a REDCap survey for a subset of CPO screens on a limited set of easily determined patient risk factors. Rectal swabs were collected and tested with the Cepheid Carba-R. Specimens collected within 2 days of admission were classified as admission screening and the remainder were classified as PPS. Index cases were excluded from analyses. Odd ratios (ORs) and 95% confidence intervals were calculated, and a value of 0.1 was used for cells with a value of zero. Results: In total, 520 screens were conducted, which included 366 admission screens at 2 facilities and 154 screens from 27 PPSs at 8 facilities. CPOs were detected in 14 (2.7%) screens, including in 10 (2.7%) admission screens and in 4 (2.6%) contacts during PPSs; carbapenemases detected were Klebsiella pneumoniae carbapenemase (KPC) (n = 12), New Delhi Metallo-β-lactamase (NDM) (n = 1) and Verona Integron-Encoded Metallo-β-lactamase (VIM) (n = 1). One long-term acute care hospital (LTACH) performed universal admission screening, which accounted for 96% of admission screens and all 10 CPOs detected by admission screening. Mechanical ventilation (OR, 5.0; 95% CI, 1.4–18.0) and the presence of a tracheostomy (OR, 5.4; 95% CI, 1.5–19.4) were associated with a positive admission screen. Moreover, 8 facilities conducted PPSs: 4 acute care hospitals, 2 long-term acute care hospitals, and 2 nursing homes. CPO prevalence in long-term acute care hospitals was 4.8% (2 of 42), 2.4% (1 of 41) in acute care hospitals, and 1.5% (1 of 69) in nursing homes. Requiring assistance with bathing (OR, 4.8; 95% CI, 1.6–8.0) and stool incontinence (OR, 16.6; 95% CI, 13.4–19.8) were associated with a positive screen on PPSs. All 7 roommates of known cases tested negative for CPO colonization. Conclusions: Findings suggest that patients with certain easily assessed characteristics, such as mechanical ventilation, tracheostomy, or stool incontinence or who require bathing assistance, may be associated with CPO positivity during screening. Further data collection and analysis of such risk factors may provide insight for the development of more targeted admission and contact screening strategies.Funding: NoneDisclosures: None