bluuebunny/crossref_metadata_2025_split huggingface dataset:
Improving Appropriate Testing for Clostridium difficile Infection: Update on Sustainability of a Quality Improvement Project
Authors: Bula-Rudas Fernando , Chatterjee Archana , Lopez Santiago 
Published: November 2020

Background: Children aged <1 year are usually colonized with Clostridium difficile: colonization rates range between 30% and 70%. In children, other infectious causes of diarrhea are more common than C. difficile. Molecular testing for C. difficile yields very high sensitivity. Clinical judgement is required for testing children with suspected infectious diarrhea. Inappropriate C. difficile testing may lead to antibiotic overuse. Methods: Initially, for the years 2016–2018, we collected data for positive C. difficile nucleic acid amplification tests (NAATs) at Sanford Children’s Hospital. In 2017, a physician-driven protocol was implemented to replace the current nurse-driven protocol for testing. We implemented national guidelines for testing and treatment in pediatric patients. Microbiology lab was given autonomy to use Bristol stool criteria to process stool samples for C. difficile. Formed stools were rejected for testing for C. difficile. The result was suppressed in patients aged <1 year. We presented the available data at the SHEA spring conference in 2020. We collected new data until June of 2019 to measure the sustainability of the intervention. Results: In 2016, there were 78 C. difficile tests: 17 were positive and 11 were categorized as an HAI. From January 1 to June 30, 2017, there were 26 C. difficile tests: 8 were positive and 3 were categorized as an HAI. Furthermore, 16 C. difficile tests were obtained from July 7 to December 31, 2017: 4 were positive and 1 categorized as an HAI. In 2018, there were 18 tests and 2 were positive; 1 was categorized as an HAI. In 2019, there were 16 tests and 2 were positive; 1 of these was categorized as an HAI. Conclusions: Implementing 2 interventions (removal of a nurse-driven protocol and microbiology lab autonomy for rejecting formed stool samples) for improving C. difficile testing accomplished a reduction of >80% in the number of tests obtained. Overall, there was a sustained reduction in the number of positive tests and HAIs in the years 2018 and 2019. The 2 interventions have been sustainable over time.Funding: NoneDisclosures: None
Improving Confirmatory Testing for the Antimicrobial Resistance Surveillance Network in Ethiopia
Authors: Wadhwa Ashutosh , Parsons Michele , Beyene Degefu , Assefa Dawit , Alebachew Gebrie , Hazim Carmen , Westercamp Matthew , Kanter Theresa , Thomas Elizabeth , Dinku Surafel Fentaw , Hailu Kibra , Mohamed Aynalem , Mitiku Mequanit , Omondi Michael , Gallagher Kathleen , Berhanu Amare , Halpin Alison , Bollinger Susan 
Published: November 2020

Background: In July 2017, the Ethiopian Public Health Institute (EPHI) launched an antimicrobial resistance (AMR) surveillance network at 4 sentinel laboratories. The National Clinical Bacteriology and Mycology Laboratory (NRL) at EPHI performs monthly confirmatory testing on a subset of isolates submitted by these sites. We assessed the existing confirmatory testing program to identify gaps and develop solutions, including a monitoring and evaluation (M&E) system. Methods: We assembled a technical working group (TWG) of key stakeholders. Laboratory site visits included workflow observation, process mapping, document review, and technologist interviews. Proposed solutions to observed gaps were drafted in formats consistent with their intended application. Feedback from the TWG was incorporated into final drafts. Available AMR network staff members were trained remotely, and they will train remaining staff. Results: Table 1 describes major gaps and solutions identified. Conclusions: Confirmatory testing provides a mechanism to evaluate laboratory testing proficiency, target improvements, and estimate surveillance data quality, yet standardized methods were lacking. Our efforts highlight key components of confirmatory testing programs and provide a model for use in laboratories with similar needs.Funding: NoneDisclosures: None
Inactivation of Candida auris and Candida albicans by Ultraviolet-C
Authors: Rutala William , Kanamori Hajime , Gergen Maria , Sickbert-Bennett Emily , Weber David Jay 
Published: November 2020

Background:Candida auris is an emerging fungal pathogen that is often resistant to major classes of antifungal drugs. It is considered a serious global health threat because it has caused severe infections with frequent mortality in over a dozen countries. C. auris can survive on healthcare environmental surfaces for at least 7 days, and it causes outbreaks in healthcare facilities. C. auris has an environmental route of transmission. Thus, infection prevention strategies, such as surface disinfection and room decontamination technologies (eg, ultraviolet [UV-C] light), will be essential to controlling transmission. Unfortunately, data are limited regarding the activity of UV-C to inactivate this pathogen. In this study, a UV-C device was evaluated for its antimicrobial activity against C. auris and C. albicans. Methods: We tested the antifungal activity of a single UV-C device using the vegetative bacteria cycle, which delivers a reflected dose of 12,000 µW/cm2. This testing was performed using Formica sheets (7.6 × 7.6 cm; 3 × 3 inches). The carriers were inoculated with C. auris or C. albicans and placed horizontal on the surface or vertical (ie, perpendicular) to the vertical UV-C lamp and at a distance from 1. 2 m (~4 ft) to 2.4 m (~8 ft). Results: Direct UV-C, with or without FCS (log10 reduction 4.57 and 4.45, respectively), exhibited a higher log10 reduction than indirect UV-C for C. auris (log10 reduction 2.41 and 1.96, respectively), which was statistically significant (Fig. 1 and Table 1). For C. albicans, although direct UV-C had a higher log10 reduction (log10 reduction with and without FCS, 5.26 and 5.07, respectively) compared to indirect exposure (log10 reduction with and without FCS, 3.96 and 3.56, respectively), this difference was not statistically significant. The vertical UV had statistically higher log10 reductions than horizontal UV against C. auris and C. albicans with FCS and without FCS. For example, for C. auris with FCS the log10 reduction for vertical surfaces was 4.92 (95% CI 3.79, 6.04) and for horizontal surfaces the log10 reduction was 2.87 (95% CI, 2.36–3.38). Conclusions:C. auris can be inactivated on environmental surfaces by UV-C as long as factors that affect inactivation are optimized (eg, exposure time). These data and other published UV-C data should be used in developing cycle parameters that prevent contaminated surfaces from being a source of acquisition by staff or patients of this globally emerging pathogen.Funding: NoneDisclosures: None
India Antimicrobial Stewardship and Resistance (INTEREST): A Needs Assessment Survey
Authors: Shah Aditya , OHoro John , Shah Varun , Dutt Taru , Shah Sanjiv , Kashyap Rahul 
Published: November 2020

Background: The emergence and spread of antimicrobial resistance is a major problem in India with significant knowledge on whether this is a systems–based, prescriber and patient characteristic based or diagnostic technologies–based issue. Methods: An electronic survey was sent to select distribution list of intensive care units (ICU) and hospital inpatient (medicine ward) providers from India. Survey questions included antimicrobial clinical practice data, access to electronic medical records, microbiological diagnostic techniques, and access to microbiology data. The survey focused on antimicrobial prescription trends and their association with diagnostic techniques. Results: There were 90 responses from 18 states in 65 ZIP codes. They had median of 187.5 beds (IQR, 40–470). Representative responders had a median age of 40 years (IQR, 31–53). Among the responders, 73 (81%) were men. Of the 90 responses, 48 providers (52%) practiced solely in ICUs (medical and surgical) and 40 providers (45%) practiced solely on the medical ward or floor, with the rest practicing in other units. In total, 31 centers (34%) reported full access to electronic medical records, and 53 centers (59%) had access to wi-fi or Internet. Interestingly, 27 centers (30%) needed to use personal provider phone data for Internet access. Only 26 centers (29%) had electronic microbiological data. Also, 63 respondents (70%) agreed to de-escalation behavior after receiving microbiological data. In addition, 55 respondents (61%) agreed that patients have easy access to outpatient antibiotics without an appropriate prescription, over the counter. Furthermore, 58 responders (64%) said that antibiotic resistance was a major problem at their center, and 61 responders (68%) were familiar with antimicrobial stewardship programs. Among the centers, 69 (77%) had no access to formal infectious disease programs at their center. Only 27 centers (30%) had a formal Clostridium difficile–associated infection reporting and control program. Only 28 centers (31%) had a formal occupational health program. Conclusions: In a large-scale, semistructured, online survey, most issues related to easy availability of antibiotics and lack of “electronization” of medical and microbiological records. It was reassuring that most providers expressed knowledge of the existing antimicrobial stewardship program.Funding: NoneDisclosures: None
Inequities and Barriers to Routine Immunization Coverage in Urban and Rural Areas of Sindh, Pakistan
Authors: Masood Tariq , Guriro Subhash , Mehraj Jaishri 
Published: November 2020

Background: Child mortality has remained a major challenge in developing countries. Annually, many children <5 years of age die prematurely due to vaccine-preventable diseases. In South Asia, Pakistan has struggled to achieve global standards of vaccination. Objective: Therefore, we sought to determine barriers to vaccination coverage among children aged 12–23 months and inequities in rural and urban settings of the Sindh province of Pakistan. Methods: We conducted a cross-sectional study in the rural and urban settings of the Sindh province of Pakistan. A 30-cluster household survey was conducted following the WHO guidelines, and 300 children were recruited from each study setting: Lyari, Karachi (urban area) and Umerkot (rural area). Information on the pretested questionnaire was obtained from consenting parents of the children in the study area. The multivariable logistic regression model was used to identify the determinants of vaccination. Results: In total, 600 children from both urban and rural settings were included in the analysis. The mean age was 17.70 months (SD, 3.46), and 50.2% children in the study were boys. Overall, 62.8% children were vaccinated in both settings. Moreover, ~80.3% children were fully vaccinated in the urban part compared with 45.3% in the rural part. The dropout rates for BCG and measles 1 were 17% and 29% in urban and rural areas, respectively. The dropout rates for Penta 1 to Penta 3 were 7% in Lyari and 38% in Umerkot. The penta 1–measles 1 dropout rates were 15% in Lyari and 37% in Umerkot. In multivariable analysis, parental knowledge about vaccination (OR, 9.77; 95% CI, 1.76–54.28), access to a vaccination center (OR, 2.51; 95% CI, 1.19–5.26) and mother’s tetanus vaccination: 1 dose (aOR, 4.27; 95% CI, 1.84–9.93) and 2 doses (OR, 12.43; 95% CI, 7.71–20.04) were associated with vaccination. Conclusions: We identified inequities in vaccination status among the populations of rural and urban areas of Pakistan. Vaccination coverage was higher in an urban setting than in a rural setting of Sindh province. Parental knowledge about vaccination, access to a vaccination center, and mother’s tetanus vaccination status were the major factors of low vaccination coverage among these children.Funding: NoneDisclosures: None
Insertion Site Inflammation Is Associated with Central-Line–Associated Bloodstream Infection
Authors: Salinas Jorge , Clore Gosia , Kukla Mary , AlZunitan Mohammed , Abosi Oluchi , Puig-Asensio Mireia , Marra Alexandre , Diekema Daniel , Edmond Michael 
Published: November 2020

Background: Central lines (CL) are widely used in the inpatient setting and central-line–associated bloodstream infection (CLABSI) is a serious complication of CL use. Because CL insertion site inflammation (ISI) may precede the onset of CLABSI, we aimed to define ISI, to determine whether ISI was associated with CLABSI, and to develop an automated surveillance system for ISI. Methods: We extracted electronic medical records (EMRs) of adult patients hospitalized at the University of Iowa Hospitals & Clinics during January 2015–December 2018. Nurses routinely document CL insertion-site characteristics in specifically designed flow sheets in the EMR. An ISI was counted every time ≥1 of the following signs were documented during CL assessments: edema, erythema, induration, tenderness, or drainage. A 1:2 case-control investigation was performed by matching nonmucosal barrier injury (non-MBI) CLABSI patients (cases) to patients without a CLABSI diagnosis (controls). We matched for age (±10 years), sex, date (±30 days), inpatient unit, central-line days, and central-line type (temporary vs permanent). The main exposure of interest was having an ISI on or before CLABSI onset. CLABSIs were determined using CDC NHSN definitions. We then created a metric: ISI days (defined as the number of days with ≥1 ISI documented) and plotted ISI incidence (ISI days per central-line days) to quantify the burden of ISIs and to determine whether ISI and non-MBI CLABSI incidences were collinear. An automated surveillance system for ISI was created using structured query language queries to the EMR data repository and Tableau software. Results: During 2015–2018, we detected 194 CLABSI cases that were matched to 338 controls. CLABSI patients had greater odds of having an ISI (OR, 2.3; 95% CI, 1.3–4.0). Over the study period, ISI incidence decreased from ~80 to ~50 ISI days per 1,000 CL days. Non-MBI CLABSI rates also decreased from ~1.5 to ~1.0 CLABSIs per 1,000 CL days. Conclusions: ISI incidence is associated with non-MBI CLABSI incidence. Because ISI incidence is higher than CLABSI incidence, surveillance for ISI could be a more sensitive indicator for monitoring the impact of CLABSI prevention practices. Automated surveillance for novel process metrics is a promising infection prevention tool.Funding: NoneDisclosures: None
Investigation and Containment of New Delhi Metallo-β-Lactamase (NDM)–Producing Carbapenem-Resistant Enterobacteriaceae (CRE) in a Hospital Intensive Care Unit
Authors: Sperling Karoline , Priddy Amy , Suntharam Nila , Karlen Adam 
Published: November 2020

Background: With increasing medical tourism and international healthcare, emerging multidrug resistant organisms (MDROs) or “superbugs” are becoming more prevalent. These MDROs are unique because they are resistant to antibiotics and can carry special resistance mechanisms. In April 2019, our hospital was notified that a superbug, New Delhi Metallo-β-lactamase(NDM)–producing carbapenem-resistant Enterobacteriaceae (CRE), was identified in a patient who had been transferred to another hospital after being at our hospital for 3 weeks. Our facility had a CRE admission screening protocol in place since 2013, but this patient did not meet the criteria to be screened on admission. Methods: The infection prevention (IP) team consulted with the Minnesota Department of Health (MDH) and gathered stakeholders to discuss containment strategies using the updated 2019 CDC Interim Guidance for Public Health Response to Contain Novel or Targeted Multidrug-resistant Organisms (MDROs) to determine whether transmission to other patients had occurred. NDM CRE was classified under tier 2 organisms, meaning those primarily associated with healthcare settings and not commonly identified in the region, and we used this framework to conduct an investigation. A point-prevalence study was done in an intensive care unit that consisted of rectal screening of 7 patients for both CRE and Candida auris, another emerging MDRO. These swabs were sent to the Antibiotic Resistance Laboratory Network (ARLN) Central Regional Lab at MDH for testing. An on-site infection control risk assessment was done by the MDH Infection Control Assessment and Response (ICAR) team. Results: All 7 patients were negative for both CRE and C. auris, and no further screening was done. During the investigation, it was discovered that the patient had had elective ambulatory surgery outside the United States in March 2019. The ICAR team assessment provided overall positive feedback to the nursing unit about isolation procedures, cleaning products, and hand hygiene product accessibility. Opportunities included set-up of soiled utility room and updating our process to the 2019 MDH recommendation to screen patients for CRE and C. auris on admission who have been hospitalized, had outpatient surgery, or hemodialysis outside the United States in the previous year. Conclusions: Point-prevalence study results showed no transmission of CRE and highlighted the importance of standard precautions. This event supports the MDH recommendation to screen for CRE any patients who have been hospitalized, had outpatient surgery, or had hemodialysis outside the United States in the previous year.Funding: NoneDisclosures: None
Investigation of a Prolonged Group A Streptococcus Outbreak Among Residents and Outpatients Receiving Wound Care at a Long-Term Care Facility (LTCF)
Authors: Cilwick Alana , Burdorf April , Bamberg Wendy , Czaja Christopher , Burakoff Alexis , Brousseau Geoffrey , Johnston Helen 
Published: November 2020

Background: In February 2019, the Colorado Department of Public Health and Environment (CDPHE) identified a cluster of 3 invasive group A Streptococcus (GAS) infections in residents receiving wound care in a long-term care facility (LTCF). An investigation revealed a larger outbreak that extended to nonresidents receiving outpatient wound care at the LTCF. Methods: A case was defined as a positive culture for GAS emm type 82 from an individual with exposure to the LTCF between January and June 2019. Cases were categorized as clinical (symptoms of GAS disease or GAS isolated from a wound or sterile site) or carriage (no symptoms). Carriers were identified via samples collected from throat and skin lesions. Screening occurred in 2 rounds and included residents of affected units followed by screening of all wound-care staff and residents facility-wide. Available isolates were sent for emm type testing and whole-genome sequencing (WGS) at the CDC. CDPHE staff performed infection control observations. Results: We identified 14 cases: 8 clinical and 6 carriage (from 5 residents and 1 staff member). Two patients with invasive GAS died. Of 8 patients with clinical GAS, 6 resided in the facility on or 1 day prior to symptom onset; 2 were not residents but received outpatient therapy at the LTCF. All 8 patients with clinical GAS (100%) and 3 carriers had received wound care. The staff member with emm 82 carriage had provided wound care and occupational therapy to the affected residents and the 2 outpatients. Two additional cases were detected with onset dates following staff member decolonization. Moreover, 13 of the 14 emm 82 isolates were found to be identical by WGS. Infection control observations identified lapses in staff wound care and hand hygiene practices in the residential and outpatient settings of the facility. Conclusions: This investigation details a large GAS outbreak in an LTCF associated with asymptomatic carriage in residents and staff that included patients who had only received care in the outpatient portion of the facility. The outbreak was halted following decolonization of a staff member and improvements in infection control, including in the outpatient setting. Outpatient services, particularly wound care, provided by LTCFs should be considered when investigating LTCF-related GAS cases and outbreaks.Funding: NoneDisclosures: None
Is Hospital-Onset Bloodstream Infection (HOBSI) a Useful Measure to Evaluate Infection Prevention Progress?
Authors: Sturm Lisa , Service Network , Bufalino Angelo , Huang Ren-huai , Sharma Mamta , Erlinger Thomas , Fakih Mohamad 
Published: November 2020

Background: Acute-care hospitals in the United States are required to submit 6 healthcare-associated infection (HAI) metrics to the CMS for reporting and performance purposes prior to payment. We examined the association between HAI rate trends and hospital-onset bloodstream infection (HO-BSI) rate trends across a large, multihospital health system. Methods: HO-BSI events were identified across 52 hospitals attributable to Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, or Candida spp using the NHSN Lab ID event definition of ≥day 4 of admission. We compared the performance from January 2016 to March 2019 for HO-BSI and the 6 NHSN-defined HAIs: central-line–associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), Clostridioides difficile, methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, abdominal hysterectomy surgical site infections (SSIs), and colon SSI. We calculated 2 “infection composite scores” to account for the 6 HAIs based on all observed or predicted events (score 1) and an average of the 6 HAI standardized infection ratios (SIRs; score 2). We normalized both measures to 1 for a 12-months rolling baseline. We evaluated the HO-BSI rate change over time and compared it to the change in the infection score over the same period. We compared the change in the 12-month rolling rates of the 2 HAI scores and the HO-BSI rate. Results: During the 39-month period, 3,288 HO-BSI events occurred over 9,775,118 patient days. The source of HO-BSI events included S. aureus (33.5%), P. aeruginosa (10.2%), E. coli (19.7%), K. pneumoniae (13.8%), and Candida spp (22.8%). HO-BSI event rates decreased by 17.3% from 12-month rolling baseline to last 12 months (3.70 vs 3.06 per 10,000 patient days). Similarly, 7,648 HAI events were observed, with the source of events being Clostridioides difficile (57.0%), CAUTI (15.1%), CLABSI (12.8%), MRSA (7.0%), colon SSI (6.4%), and abdominal hysterectomy SSI (1.7%). The 2 HAI scores and the HO-BSI rate all showed a notable decrease from the 2016 baseline period (Fig. 1). The reductions in the HAI scores were both strongly correlated with the reduction in the HO-BSI rate, with the HAI score 1 having a stronger correlation (r = 0.949; P < .001) than was observed for HAI score 2 (r = 0.867; P < .001). Conclusions: Utilization of a HO-BSI measure may prove useful as a correlated but distinct marker of infection prevention improvement or trends. HO-BSI could be useful as an objective electronically obtainable measure to assist in the evaluation of performance within and across facilities.Funding: NoneDisclosures: None