bluuebunny/crossref_metadata_2025_split huggingface dataset:
Changes in Regional Hospital-Identified Clostridioides difficile Infection, 2015–2018
Authors: Dantes Raymund , Edwards Jonathan , Li Qunna 
Published: November 2020

Background: Regional changes in United States C. difficile infection (CDI) are not well understood but important for targeting prevention strategies. Methods: Community-onset (CO) CDI was defined as positive C. difficile stool tests collected on or before hospital day 3 (where admission was day 1), reported by acute-care hospitals to the CDC NHSN over 3 years: year 1, July 1, 2015–June 30, 2016; year 2, July 1, 2016–June 30, 2017; year 3, July 1, 2017–June 30, 2018. Healthcare facility-onset CDI (HO-CDI) was similarly defined but with stool collection after hospital day 3. Hospital referral regions (HRRs) were defined by the Dartmouth Atlas of Health Care, and they represent 306 healthcare markets. Standardized infection ratios (SIRs) were calculated using separate multivariable models for (1) CO-CDI events in an emergency department/observation unit (ED/Obs), (2) CO-CDI events among inpatients, and (3) HO-CDI, accounting for facility-level factors, They resulted in ratios of observed to predicted infections, similar to established methods. SIRs were pooled within each facility to create a hospital-identified SIR by summing observed and predicted events for CO-CDI events in both testing locations and HO-CDI events, then pooled by HRR by summing all facility observed and predicted events within the region. Data from facilities not within an HRR were excluded. Results: Total CO-CDI (ED/Obs and inpatient) and HO-CDI events decreased, even as the number of reporting facilities slightly increased over the 3-year period (Fig. 1). Among 306 HRRs in year 3, the median number of hospitals was 10 (IQR, 6–17), with a median of 526 (IQR, 272–1,002) hospital-identified CDI events per HRR. Variables significantly associated with CDI incident rate and included in SIR models 1–3 included C. difficile test type, hospital type, teaching affiliation, hospital bed size, and presence of an ED/Obs unit. Intensive care unit capacity was included in models 2 and 3, and the ratio of hospital admissions to emergency department encounters in model 1. Pooled mean HRR hospital-identified C. difficile SIRs decreased each year (0.972, 0.914, and 0.838), and decreases also varied by HRR (Fig. 2). Conclusions: National decreases in a combined hospital-identified C. difficile SIR are widespread but may be more aggregated in particular regions. Although SIR adjustments were limited to facility-level factors, aggregation of CDI SIR by HRR may be useful for infection preventionists and public health authorities to further understand regional CDI patterns.Funding: NoneDisclosures: None
Characteristics of Candida auris Patients at a Tertiary-Care Hospital, 2017–2019, Nairobi, Kenya
Authors: Ombajo Loice , Correia Malcolm , Kanyua Alice , Bore Cheptoo , Juma Phoebe , Muthui Edith , Osoro-Mbui Joan , Bancroft Elizabeth , R Jackson Brendan , Toda Mitsuru 
Published: November 2020

Background:Candida auris is of global concern due to its increasing frequency in intensive care units (ICUs), reported resistance to antifungal agents, propensity to cause outbreaks, and persistence in clinical environments. We investigated an increase in C. auris cases in an ICU in Kenya to determine the source of transmission and to control the spread of the disease. Methods: To identify cases, we reviewed laboratory records of patients with blood cultures yielding C. auris and organisms for which it is commonly misidentified by Vitek 2 v 8.01 software (ie, C. haemulonii, C. duobushaemulonii and C. famata) during January 2018–May 2019. We retrospectively reviewed medical charts of C. auris patients to extract information on demographics, underlying conditions, hospital procedures, treatments, and outcomes. We also enhanced infection control efforts by implementing contact precautions, equipment, and environmental disinfection, and hand hygiene training and compliance observations. Results: We identified 32 C. auris patients (Fig. 1). Median patient age was 55 years (IQR, 43–65), and 57% were male. Length of hospitalization before C. auris isolation was 30 days (IQR, 14–36). All had been admitted to the ICU. The most common reasons for admission were sepsis (50%), pneumonia (34%), surgery (25%), and stroke or other neurologic diagnosis (25%). Underlying comorbidities included hypertension (38%), diabetes mellitus (25%), and malignancy (29%). Two patients had HIV. Moreover, 61% of cultures yielded multidrug-resistant bacteria. Also, 33% of the patients had been admitted to this hospital in the preceding 3 months; 21% had been admitted to a hospital outside of Kenya; and 10% had been admitted to another hospital in Kenya in the previous year. Almost all (97%) had a central venous catheter, 45% had an acute dialysis catheter, 66% had an endotracheal tube, and 34% had a tracheostomy, with 69% receiving mechanical ventilation before C. auris isolation. Most (94%) had urinary catheters, 84% had nasogastric tubes, 91% had received total parenteral nutrition, and 75% had received blood products. All patients received broad-spectrum antibiotics and 49% received an antifungal before C. auris isolation. All-cause in-hospital mortality was 64% for the 28 patients whose outcomes were available. Following implementation of a hand hygiene campaign and improved equipment and environmental disinfection, no further cases were identified. Conclusions: We identified C. auris bloodstream infections associated with high all-cause mortality in a Kenyan hospital ICU. All patients had treatments and procedures suggesting severe underlying illness. Enhanced infection control contained the outbreak.Funding: NoneDisclosures: None
CHG Skin Application in Non-ICU Patients with Central Venous Catheters: Impact on CLABSI, MRSA Bacteremia, and LabID Rates
Authors: Dombecki Carey , Sweeney Jennifer , White Jackie , Valyko Amanda , Stillwell Terri , Mills John , Washer Laraine 
Published: November 2020

Background: Prevention of central-line–associated bloodstream infections (CLABSIs) and methicillin-resistant Staphylococcus aureus (MRSA) infections requires a multifaceted approach including strategies to decrease cutaneous bacterial colonization. Prior studies have shown benefit from chlorhexidine-gluconate (CHG) skin application on CLABSI and MRSA infection rates in intensive care units (ICUs); however, the use of CHG in the non-ICU population has not been well studied. Methods: We performed a quasi-experimental before-and-after study to evaluate the use of daily 2% CHG wipes in non-ICU patients at a 1,000 bed acute-care teaching hospital beginning in November 2017. The study population included adult and pediatric patients with central venous catheters on non-ICU units, excluding patients on the following units: stem cell transplant and hematologic malignancy (these units had already established use of CHG skin application as a standard prior to the intervention), labor and delivery, and psychiatry. CHG was applied according to the manufacturer’s instruction by nurses or nurse aides and random monthly auditing of compliance was performed. NHSN CLABSI, hospital-onset MRSA bacteremia, and hospital-onset MRSA LabID rates were compared for the period 24 months before the intervention (November 1, 2015, through October 31, 2017) to the 24-month period after the intervention (November 1, 2017, through October 31, 2019) using a paired t test. Notably, the health system also discontinued the use of contact precautions for patients with MRSA (excluding MRSA from open, draining wounds) 11 months prior to onset of this intervention. Results: The CLABSI rate decreased by 26% from 0.594 events per 1,000 central-line days (n = 50) before the intervention to 0.438 events per 1,000 central-line days (n = 38) after the intervention (P = 0.19). The number of CLABSIs with gram-positive organisms also decreased by 29%. MRSA LabID rates decreased by 37% from 0.301 events per 1,000 patient days (n = 119) to 0.189 events per 1,000 patient days (n = 75) (P = 0.01). MRSA bacteremia rates decreased by 79% from 0.058 events per 1,000 patient days (n = 23) to 0.012 events per 1,000 patient days (n = 5) (P < 0.01). Compliance with the intervention was 83% (n = 225). Conclusions: Daily CHG skin application in non-ICU patients with central venous catheters is an effective strategy to prevent CLABSIs and MRSA infections. We observed a decrease in MRSA LabID and bacteremia rates despite discontinuation of contact precautions. These findings suggest that a horizontal prevention approach of daily CHG skin application may be an effective alternative to contact isolation to interrupt transmission of MRSA in hospitalized patients outside the ICU setting.Funding: NoneDisclosures: None
Clostridium difficile Infection Prevention Bundle Implementation
Authors: Ling Moi Lin , Jin Pinhong , Tan Kwee Yuen 
Published: November 2020

Background: The optimal prevention of healthcare onset Clostridium difficile infection (CDI) has been a challenging one in an acute tertiary-care hospital with limited number of single rooms. Asymptomatic patients with CDI are nursed in open wards but tagged with a green sticker to alert staff of their status. This signal prompts cleaning staff to use 5,000 ppm sodium hypochlorite to clean environmental surfaces in the multibed room and to continue with modified contact precautions. Methods: We conducted a survey on infection prevention measures used in the management of CDI patients over 2 weeks among senior nurse managers, clinicians, and registered nurses in 38 inpatient wards. We categorized the survey results into 4 types of practices: established practices, nonestablished practices (easy implementation), nonestablished practices (lack of resources), and nonestablished practices (staff resistance). We then identified barriers to determine reasons for resistance to nonestablished practices before the implementation of the CDI bundle in May 2019. The bundle comprised the following components: contact precautions, antimicrobial stewardship, isolation of CDI patient with diarrhea in single room, environment, and equipment hygiene. Following the survey, we enhanced the signage for CDI patients to be more obvious. Monthly, we monitored the incidence of HO-Clostridium difficile to assess effectiveness of implementation measures. Results: Nonestablished practices (easy implementation) included uncertainty of diarrhea definition and the recommended environmental hygiene disinfectant, lack of understanding of the importance of complying to personal protective equipment (PPE), and inconsistency in conveying CDI status. Among nonestablished practices (lack of resources), shortage of isolation beds for CDI patients with diarrhea and unavailability of electronic alert system for CDI patients within the institution are the major issues faced by clinical staff. Unavailability of CDI indicator stickers, contact precaution posters, and sporicidal wipes were noted in 6 medical and surgical wards. Nonestablished practices (staff resistance) were related to the time taken to don full PPE and reluctance to arrange for an isolation bed due to increased workload and unavailability of isolation beds. A shift was noted in the control chart for HO-Clostridium difficile after the implementation of the CDI bundle in May 2019. Conclusions: The categorization of practices into established and nonestablished practices can help to identify barriers that may interfere with successful implementation of an infection prevention bundle.Funding: NoneDisclosures: None
Cohorting KPC+ Klebsiella pneumoniae (KPC-Kp)–Positive Patients—A Genomic Exposé of Cross-Colonization Hazards
Authors: Hawken Shawn , Hayden Mary , Lolans Karen , Yelin Rachel , Weinstein Robert , Lin Michael , Snitkin Evan 
Published: November 2020

Background: Long-term acute-care hospitals (LTACHs) are disproportionately burdened by multidrug-resistant organisms (MDROs) like KPC-Kp. Although cohorting KPC-Kp+ patients into rooms with other carriers can be an outbreak-control strategy and may protect negative patients from colonization, it is unclear whether cohorted patients are at unintended increased risk of cross colonization with additional KPC-Kp strains. Methods: Cohorting KPC-Kp+ patients at admission into rooms with other positive patients was part of a bundled intervention that reduced transmission in a high-prevalence LTACH. Rectal surveillance culturing for KPC-Kp was performed at the start of the study, upon admission, and biweekly thereafter, capturing 94% of patients. We evaluated whole-genome sequencing (WGS) evidence of acquisition of distinct KPC-Kp strains in a convenience sample of patients positive for KPC-Kp at study start or admission to identify plausible secondary KPC-Kp acquisitions. Results: WGS multilocus sequence type (MLST) strain variability was observed among the 452 isolates from the 254 patients colonized by KPC-Kp (Fig. 1). Among the 32 patients who were positive at the beginning of the study or admission and had a secondary isolate collected at a later date (median, 89 days apart, range, 2–310 days), 17 (53%) had secondary isolates differing by MLST from their admission isolate. Although 60% of the KPC-Kp in the study was ST258, there was substantial genomic variation within ST258 isolates from the same patient (range, 0–102 genetic variants), suggesting multiple acquisitions of distinct ST258 isolates. Among the 17 patients who imported ST258 and had ST258 isolated again later, 11 (65%) carried secondary isolates genetically closer to isolates from other importing patients than to their own ST258 (Fig. 2). Examination of spatiotemporal exposures among patients with evidence of multiple acquisitions revealed that 11 (65%) patients with multiple MLSTs shared a room with a patient who was colonized with an isolate matching the secondary MLST, and 6 (35%) patients who carried multiple distinct ST258 isolates shared a room with a patient who imported these closely related isolates prior to secondary acquisition. Conclusions: Half of patients who imported KPC-Kp and had multiple isolates available had genomically supported secondary acquisitions linked to roommates who carried the acquired strains. Although cohorting is intended to protect negative patients from acquiring MDROs, this practice may promote multiple strain acquisitions by colonized patients in the cohort, potentially prolonging the period of MDRO carriage and increasing time at risk of infection. Our findings add to the debate about single-patient rooms, which may be preferred to cohorts to minimize potential harms by reducing MDRO transmission.Funding: NoneDisclosures: None
Collaborative Approach to Developing Infection Prevention Control Recommendations at a Tertiary-Care Pediatric Hospital
Authors: Lee Bonita , Durand Joan , Jones Helen , Gartner Nicole , Driscoll Jennifer , Watson Cheryl , Chandran Uma , Sivarajan Veena , Pereira Nichole , Clonfero Maria , Degroot Jaylene , Childs Michelle 
Published: November 2020

Background: Stollery Children’s Hospital (SCH) is a tertiary-care pediatric hospital with a complex infrastructure: 3 NICUs located at 3 different hospitals, and all of the pediatric inpatient beds, PICU, PCICU, and a medical-surgical NICU at the main SCH site shared buildings with an academic adult hospital. We describe a collaborative process used to develop standardized SCH Infection Prevention and Control (IPC) recommendations. Methods: The SCH IPC formed a working group with Patient and Family-Centered Care (PFCC) and family representatives in 2014 to enhance the engagement of families in regards to IPC issues and initiatives. The working group identified inconsistent messages provided to families when a child was admitted as a patient requiring additional precautions (PRAP). The working group then developed a framework of key questions to be answered for family care providers of PRAP. The working group held several consultative meetings with frontline staff followed by a review of published guidelines and consultations with other pediatric hospitals about contentious issues. A consensus meeting with all key stakeholders was held to finalize IPC recommendations. Results: The key contentious issues included (1) whether personal protective equipment is required for family care providers who stay overnight with PRAP and (2) whether family care providers of PRAP are allowed to access nutrition centers on clinical units and family lounges in PCICU–PICU–NICU that were stocked with free hot meals for the families. No directly applicable recommendation was available IPC guidelines on these issues. Discussions of these topics were directed by PFCC at family councils of various clinical programs with efforts to seek opinions from more family representatives. Expert opinions and current practice were also obtained from Canadian hospitals through emails and from US hospitals through SHEA Open Forum by ICP. A final consensus meeting revisiting all available information was held, and a new Stollery IPC guideline was created with families as partners sharing the IPC vision of minimizing transmission risk at SCH. Conclusions: A consultative engagement and consensus process was successful in the development of IPC recommendations for family care providers for PRAP for implementation at a tertiary-care pediatric hospital with a complex infrastructure. The next step is to develop family-friendly educational and resource materials with clear and concise messages.Funding: NoneDisclosures: None
Comparison of Bacterial Contamination in a Children’s Outpatient Clinic: General Medicine Versus Pulmonary Units
Authors: Levine David , Spratt Henry , Hanks June , Woods Charles , Joel Ledbetter , Gentner Kevin , Brunton Lindsey 
Published: November 2020

Background: The bacteria that inhabit outpatient healthcare facilities influence patient outcomes and recovery, although the diversity and quantity of these bacterial communities is largely unknown. Whether differences in bacterial presence exist in individual medical specialty units of an outpatient clinic is also largely unknown. The purpose of this study was to compare bacterial species found in the general medicine and pulmonary units of an outpatient children’s clinic associated with a teaching hospital. Methods: In total, 6 locations (4 floor sites, counters, air ducts) were sampled in 3 rooms in the pulmonary (PUL) unit and 3 rooms in the general medicine (GM) unit on 13 days over a 6-month period. Sterile double transport swabs were utilized, transported on ice to a microbiology lab, and used to inoculate Hardy Diagnostics Cdiff Banana Broth (for Clostridium difficile), CHROM MRSA agar (for methicillin-resistant Staphylococcus aureus [MRSA]), eosin methylene blue (Levine-type, for Lac&plus; gram negatives [GN]), and Pseudomonas isolation agar (for Pseudomonas spp and P. aeruginosa [PS and PSA]). Media were incubated for 48 hours at 37&deg;C and were scored for bacterial presence based on colonial observation. Results: The presence of bacteria isolated from GM and PUL units differed by species and location. Based on the percentage of positive swabs, the presence of GN was widespread in both units (Fig&nbsp;1). Additionally, bacterial presence was greatest on the floors (GN ranged from 72% to 85% on floors in the 2 units), whereas counters had fewer positive swabs (GN ranged from 23% to 38% on counters), and swabs from return air ducts rarely led to bacterial growth. The 1 case in which swabs from the PUL unit resulted in higher levels of bacterial growth than for the GM unit was for PSA (GM, 8%; PUL, 13%). C. difficile detection was the same on both units (ie, 35% of floor samples showed contamination). Conclusions: The levels of environmental bacterial presence observed for these clinic units differed in some cases by unit and ranged from not detectable to very high levels. Detection of C. difficile on 35% of floor samples in both units could be problematic. Additionally, for the PUL unit, contamination of 13% of floor samples by PSA should raise concerns because many patients in this clinic have cystic fibrosis (CF). Although many CF patients are colonized by PSA, others may potentially contract an infection by this pathogen from the clinical environment. This observation supports current infection control recommendations for CF patients in outpatient settings.Funding: NoneDisclosures: None
Comparison of Metrics Used to Track CLABSIs and CAUTIs Across a Regional Network
Authors: Advani Sonali , Smith Becky , Seidelman Jessica , Turner Nicholas , Hostler Christopher , Anderson Deverick John , Lewis Sarah 
Published: November 2020

Background: The standardized infection ratio (SIR) is the nationally adopted metric used to track and compare catheter-associated urinary tract infections (CAUTIs) and central-line– associated bloodstream infections (CLABSIs). Despite its widespread use, the SIR may not be suitable for all settings and may not capture all catheter harm. Our objective was to look at the correlation between SIR and device use for CAUTIs and CLABSIs across community hospitals in a regional network. Methods: We compared SIR and SUR (standardized utilization ratio) for CAUTIs and CLABSIs across 43 hospitals in the Duke Infection Control Outreach Network (DICON) using a scatter plot and calculated an R2 value. Hospitals were stratified into large (>70,000 patient days), medium (30,000–70,000 patient days), and small hospitals (<30,000 patient days) based on DICON’s benchmarking for community hospitals. Results: We reviewed 24 small, 11 medium, and 8 large hospitals within DICON. Scatter plots for comparison of SIRs and SURs for CLABSIs and CAUTIs across our network hospitals are shown in Figs. 1 and 2. We detected a weak positive overall correlation between SIR and SUR for CLABSIs (0.33; R2 = 0.11), but no correlation between SIR and SUR for CAUTIs (−0.07; R2 = 0.00). Of 15 hospitals with SUR >1, 7 reported SIR <1 for CLABSIs, whereas 10 of 13 hospitals with SUR >1 reported SIR <1 for CAUTIs. Smaller hospitals showed a better correlation for CLABSI SIR and SUR (0.37) compared to medium and large hospitals (0.19 and 0.22, respectively). Conversely, smaller hospitals showed no correlation between CAUTI SIR and SUR, whereas medium and larger hospitals showed a negative correlation (−0.31 and −0.39, respectively). Conclusions: Our data reveal a weak positive correlation between SIR and SUR for CLABSIs, suggesting that central line use impacts CLABSI SIR to some extent. However, we detected no correlation between SIR and SUR for CAUTIs in smaller hospitals and a negative correlation for medium and large hospitals. Some hospitals with low CAUTI SIRs might actually have higher device use, and vice versa. Therefore, the SIR alone does not adequately reflect preventable harm related to urinary catheters. Public reporting of SIR may incentivize hospitals to focus more on urine culture stewardship rather than reducing device utilization.Funding: NoneDisclosures: None