bluuebunny/crossref_metadata_2025_split huggingface dataset:
Increased Isolation of Pathogens After Resin-Containing Blood Culture Bottle Implementation
Authors: Yen Christina , Feeser Baevin , King Aleah , Mehrotra Preeti , Wright Sharon 
Published: November 2020

Background: Resin-containing blood culture bottles (RBB) are used to increase the isolation of microorganisms by binding antimicrobials in sampled blood. Since RBB implementation in April 2018, our infection preventionists noted an increase in positive blood cultures on routine surveillance. Objective: To describe the change in bacterial isolation post-RBB implementation. Methods: All positive blood culture sets drawn in adult inpatient units or the emergency room between October 2017 and September 2018 and their associated organisms were obtained from the hospital laboratory database. Then, regardless of central-line placement or “present on admission” designation, the 2019 NHSN surveillance definitions for laboratory-confirmed bloodstream infection (LCBI-1 and LCBI-2) were applied to categorize all positive cultures as “common commensals” (CCs) or pathogens. A univariate analysis was performed using the Mantel-Haenszel χ2 test (OpenEpi version 3.01). Results: Although the number of monthly blood cultures drawn remained effectively stable before and after implementation (pre-RBB median, 3,512.5; post-RBB median, 3,626), the rate ratio of positive cultures increased by 1.36 times: pre-RBB median, 127 sets per month and post-RBB median, 172.5 sets per month (χ2 = 5.785; P = .008). The rate ratio of pathogen-containing cultures increased by 1.40 times (pre-RBB median, 98 sets per month and post-RBB median, 137.5 sets per month; χ&sup2; = 5.615; P = .009) with only a 1.24 increase in CCs (pre-RBB median, 29 and post-RBB median, 36; χ&sup2; = 0.553; P = .229) (Fig. 1). Conclusions: After RBB implementation, the monthly incidence rate of pathogen-containing sets increased. Additionally, the increase in these sets as well as of overall positive blood cultures was statistically significant. Current literature on RBBs does not suggest preferential increased isolation of pathogens. Further study is needed to determine whether our findings are related to blood-culturing practices or the RBBs themselves.Funding: NoneDisclosures: None
Increased Return Clinic Visits for Adults with Group A Streptococcal Pharyngitis Treated with a Macrolide
Authors: Rovelsky Suzette , Pontefract Benjamin , Nevers McKenna , Hersh Adam , Samore Matthew , Madaras-Kelly Karl 
Published: November 2020

Background: A multicenter audit-and-feedback intervention was conducted to improve management of acute respiratory infections (ARIs) including group A streptococcal (GAS) pharyngitis within 6 VA medical Centers (VAMCs). A relative reduction (24.8%) in azithromycin prescribing after the intervention was observed. Within these facilities during 2015–2018, 2,266 cases of GAS occurred, and susceptibility to erythromycin ranged from 55% to 70%. We evaluated whether prescribing a macrolide for GAS pharyngitis was associated with an increase in outpatient return visits. Methods: A cohort of ambulatory adults treated for GAS pharyngitis (years 2014–2019) at 6 VAMCs was created. Demographic, diagnostic, treatment, and revisit data were extracted from the Corporate Data Warehouse. GAS pharyngitis was defined by an acute pharyngitis diagnostic code combined with a GAS-positive rapid strep test or throat culture ≤3 days of index date. Antibiotic prescriptions were included if filled ≤3 days of index date and were classified as first line (penicillin/amoxicillin), second line (cephalexin/clindamycin), macrolides (azithromycin, clarithromycin, erythromycin), or other (remaining antibiotics). A return visit was defined as a new visit to primary care, urgent care, or the emergency department with a diagnostic code for an ARI ≤30 days from the index visit. Logistic regression was used to adjust for nonantibiotic covariates and to compare treatments. Results are reported as odds ratio (OR ± 95% CI; P value). Results: Of 12,666 patients with a diagnostic code for acute pharyngitis, 2,923 (23.1%) had GAS testing performed. Of those, 582 (19.9%) were GAS-positive and 460 (15.7%) received antibiotics. The mean age was 39.0 years (±SD, 11.7) and 73.7% were male. Antibiotics included penicillins for 363 patients (78.9%), cephalosporins for 21 (4.6%), clindamycin for 32 (7.0%), macrolides for 47 (10.2%), and other for 17 (3.9%). Penicillin allergy was documented in 48 patients (10.5%), and these patients received cephalosporins (18.8%), clindamycin (35.4%), macrolides (41.7%), and other antibiotics (4.2%). Return visits occurred in 47 cases (10.4%). Limited chart review indicated that 6 of 10 macrolide recipients (60.0%) with return visits had recurrence or unresolved symptoms. After adjustment for calendar month and facility, odds of a return visit for treatment with a macrolide relative to penicillins was 2.79 (OR, 1.19; 95% CI, ±6.56; P = .02). The audit-feedback intervention was not associated with ARI-related return visits (OR, 0.53; 95% CI, 0.26–1.06; P = .07). Conclusions: Return visit rates were higher for GAS pharyngitis patients treated with a macrolide than for those treated with penicillins. Macrolides were the most commonly prescribed non-penicillin therapy irrespective of penicillin allergy. Further work is necessary to determine the reason for the increase in return visits.Funding: NoneDisclosures: None
Influenza With an Infiltrate: Investigating the New Community-Acquired Pneumonia Guidelines
Authors: Barner Amanda , Bruno-Murtha Lou Ann 
Published: November 2020

Background: The Infectious Diseases Society of America released updated community-acquired pneumonia (CAP) guidelines in October 2019. One of the recommendations, with a low quality of supporting evidence, is the standard administration of antibiotics in adult patients with influenza and radiographic evidence of pneumonia. Procalcitonin (PCT) is not endorsed as a strategy to withhold antibiotic therapy, but it could be used to de-escalate appropriate patients after 48–72 hours. Radiographic findings are not indicative of the etiology of pneumonia. Prescribing antibiotics for all influenza-positive patients with an infiltrate has significant implications for stewardship. Therefore, we reviewed hospitalized, influenza-positive patients at our institution during the 2018–2019 season, and we sought to assess the impact of an abnormal chest x-ray (CXR) and PCT on antibiotic prescribing and outcomes. Methods: We conducted a retrospective chart review of all influenza-positive admissions at 2 urban, community-based, teaching hospitals. Demographic data, vaccination status, PCT levels, CXR findings, and treatment regimens were reviewed. The primary outcome was the difference in receipt of antibiotics between patients with a negative (<0.25 ng/mL) and positive PCT. Secondary outcomes included the impact of CXR result on antibiotic prescribing, duration, 30-day readmission, and 90-day mortality. Results: We reviewed the medical records of 117 patients; 43 (36.7%) received antibiotics. The vaccination rate was 36.7%. Also, 11% of patients required intensive care unit (ICU) admission and 84% received antibiotics. Moreover, 109 patients had a CXR: 61 (55.9%) were negative, 29 (26.6%) indeterminate, and 19 (17.4%) positive per radiologist interpretation. Patients with a positive PCT (OR, 12.7; 95% CI, 3.43–60.98; P < .0007) and an abnormal CXR (OR, 7.4; 95% CI, 2.9–20.1; P = .000003) were more likely to receive antibiotics. There was no significant difference in 30-day readmission (11.6% vs 13.5%; OR, 0.89; 95% CI, 0.21–3.08; P = 1) and 90-day mortality (11.6% vs 5.4%; OR, 2.37; 95% CI, 0.48–12.75; P = .28) between those that received antibiotics and those that did not, respectively. Furthermore, 30 patients (62.5%) with an abnormal CXR received antibiotics and 21 (43.7%) had negative PCT. There was no difference in 30-day readmission or 90-day mortality between those that did and did not receive antibiotics. Conclusions: Utilization of PCT allowed selective prescribing of antibiotics without impacting readmission or mortality. Antibiotics should be initiated for critically ill patients and based on clinical judgement, rather than for all influenza-positive patients with CXR abnormalities.Funding: NoneDisclosures: None
Interrater Reliability: Item Analysis to Develop Valid Questions for Case-Study Scenarios
Authors: Holmes Kelly , Moinuddin Mishga , Steinfeld Sandi 
Published: November 2020

Background: Development of an interrater reliability (IRR) process for healthcare-associated infection surveillance is a valuable learning tool for infection preventionists (IPs) and increases accuracy and consistency in applying National Healthcare Safety Network (NHSN) definitions (1-3). Case studies from numerous resources were distributed to infection preventionists of varying experience levels (4-6). Item analysis, including item difficulty index and item discrimination index, was applied to individual test questions to determine the validity of the case scenarios at measuring individual mastery of the NHSN surveillance definitions (7-8). Methods: Beginning in 2016, a mandatory internal IRR program was developed and distributed to infection preventionists (IPs) of varying experience level. Each year through 2019, a test containing 30–34 case studies was developed with multiple-choice questions. Case studies were analyzed using 2 statistical methods to determine item difficulty and validity of written scenarios. P values for each test question were calculated using the item difficulty index formula, with harder questions resulting in values closer to 0.0. Point biserial correlation was applied to each question to determine highly discriminating questions, measured in a range from −1.0 and 1.0. Results: Between 2016 and 2019, 124 questions were developed and 145 respondents participated in the mandatory IRR program. The overall test difficulty was 0.70 (range, 0.64–0.74). Moreover, 17 questions (14%) were determined to have high “excellent” discrimination, 41 questions (33%) were determined to have “good” discrimination, 57 questions (46%) were determined to have “poor” discrimination, and 9 questions (7%) were found to have negative discrimination values. Conclusions: IRR testing identifies educational opportunities for IPs responsible for the correct application of NHSN surveillance definitions. Valid test scenarios are foundational components of IRR tests. Case scenarios that are determined to have a high discrimination index should be used to develop future test questions to better assess mastery of application of surveillance definitions to clinical cases.Funding: NoneDisclosures: None
Investigation of Pansusceptible Pseudomonas aeruginosa Meningitis Cases in Patients With External Ventricular Devices
Authors: Kim Yoojin , Cortes-Ramos Carmen , Nix Chad Douglas , Ogden Lauren , Hale Molly , Townes John 
Published: November 2020

Background: During a 2-month period at an academic medical system, 4 cases of pansusceptible P. aeruginosa (PsA) meningitis were identified among neuroscience intensive care unit (NSICU) patients with an external ventricular device (EVD). Methods: We reviewed microbiology data for the previous 2 years to determine background PsA rates and to identify additional cases of PsA meningitis. A case was defined as the isolation of PsA from a CSF specimen. We convened a multidisciplinary group of stakeholders to review medical records of case patients and to conduct a series of observational rounds. Scalp swab specimens were collected from NSICU patients to detect possible skin colonization. Pulsed-field gel electrophoresis (PFGE) analyses were performed on PsA isolates from the 4 case patients and 5 patients with PsA isolates from other body sites. Results: There was no hospital-wide increase in PsA incidence, and no patient without an EVD had PsA cultured from CSF. Infections occurred, on average, 10 days (range, 6–15 days) after EVD insertion. Cases were geographically dispersed in the NSICU and did not share common staff. None of the PsA isolates were genetically related and all scalp cultures were negative. Observations included multiple opportunities for contact with water sources: sinks in proximity to the head of the bed, storage of supplies next to sinks, reuse of bath basins, and use of dilute peroxide to clean surgical wounds. Multiuse shampoos, conditioners and lotions, not approved for hospital use, were found on the unit. Furthermore, 3 of 4 patients received cefazolin >24 hours after 6 of their 7 neurosurgeries for an average of 4.7 days (range, 0.8–4 days). Care practices were changed to mitigate contact between EVD sites and environmental water sources, and extended cefazolin surgical prophylaxis was discontinued. EVD practices were revised, and clinical teams had their competency confirmed. No additional cases have been identified in the 16 months following these interventions. Conclusions: This cluster of EVD infections was likely caused by patient care practices that resulted in independent introductions of PsA from multiple nonsterile or contaminated water sources. Antibiotic selection of PsA by extended use of cefazolin perioperative prophylaxis may have also contributed. EVD care practices should be designed to limit contact between and EVD insertion sites and nonsterile water sources or potentially contaminated care supplies. To substantiate performance improvement efforts and ensure interinstitutional comparability, a practical, standardized EVD-associated infection surveillance definition is needed.Funding: NoneDisclosures: None
Knowledge of Adverse Events Following Immunization Reporting Tool and System Among Primary Healthcare Workers in Jigawa State
Authors: Umar Ahmad , Sufiyan Muawiyyah , Tukur Dahiru , Onoja-Alexander Mary , Amadu Lawal , Bashir Sulieman 
Published: November 2020

Background: Adverse events following immunization (AEFI) surveillance largely depends on the ability of the healthcare worker (HCW) to timely detect and report cases using the correct reporting tools through an appropriate system. AEFI surveillance is carried out regularly during both routine immunization services and supplemental immunization activities in the state. Objective: We assessed knowledge of adverse events following immunization reporting tools and system among primary HCWs in Jigawa state, northwestern Nigeria. Method: A descriptive cross-sectional design was used for this study. A multistage sampling technique was used to select 290 HCWs that had spent at least 6 months in immunization units of primary healthcare centers of Jigawa state. Data were collected using pretested self-administered structured questionnaire with open and closed ended questions and were analyzed using IBM SPSS version 20 software. All statistical tests were 2-tailed with P < .05 as the statistical significance level. Results: Most of the primary HCWs (93.2%) had AEFI reporting forms in their health facilities, and 68.9% said that the AEFI reporting form could be obtained from a focal or contact person in the health facility. Up to 96.4% of the primary HCWs were aware of how to report AEFI. Also, ~76.6% of primary HCWs knew the correct AEFI reporting flow, but only 15.8% knew that only serious AEFIs are reported. Furthermore, ~78.8% and 19.4% of HCWs mentioned telephone and filling forms as some of the appropriate methods of AEFI notification, respectively. Conclusions: Most primary HCWs had reporting forms in their health facilities and were aware of how to report an AEFI. Most of the respondents knew the correct AEFI reporting flow. The state in collaboration with local government authorities should provide quality training on AEFI reporting and reporting system.Funding: NoneDisclosures: None
KPC-Producing Enterobacter cloacae Transfer Through Pipework Between Hospital Sink Waste Traps in a Laboratory Model System
Authors: Aranega Bou Paz , Ellaby Nicholas , Ellington Matthew , Moore Ginny 
Published: November 2020

Background: Carbapenemase-producing Enterobacterales (CPE) have become an increasingly common cause of hospital-acquired infections while their reservoirs within the clinical setting remain poorly understood. Outbreaks have been linked to hospital sinks, which have been shown to harbor and, under certain conditions, disperse CPE to surrounding surfaces. Hospital and laboratory studies have proposed that Gram-negative organisms, including CPE, can migrate through plumbing biofilms, leading to widespread contamination of the drainage system. Methods: To assess the prevalence of CPE in hospital sinks, drain swabs and waste trap water samples were taken from 10 sinks in 10 hospitals. Hospitals were in different regions of England; 4 had reported recent cases of CPE infection. To investigate spread and dispersal of CPE, waste traps from a single hospital were installed in a laboratory model sink system. Built to simulate a clinical setting, the model incorporated 12 sinks, 6 of which were connected through a common waste pipe. All 12 taps were automatically flushed. Drainage was automatically controlled. Nutrients were provided daily to maintain the bacterial populations, which were regularly sampled to monitor their composition. At 3 weeks after installation, the waste traps were subjected to a drainage backflow event. Waste trap water populations continued to be monitored, and when transfer between sinks was suspected, isolates were characterized and compared using whole-genome sequencing. Results: Between January and June 2019, 200 samples were taken from 103 sinks. In total, 24 (23%) sinks (in 8 hospitals) harbored CRE; of which 10 (in 5 hospitals) harbored at least 1 CPE. Immediately after a backflow event in the laboratory model system, 2 KPC-producing E. cloacae were recovered from a waste trap in which CPE had not been previously detected. The isolates were identified as ST501 and ST31 and were genetically indistinguishable from those colonizing sinks elsewhere in the system. Following intersink transfer, KPC-producing E. cloacae ST501 successfully integrated into the microbiome of the recipient sink and was detected in the waste trap water at least 6 months after the backflow event. At 2 and 3 months after the backflow, other intersink transfers involving Escherichia coli and KPC-producing E. cloacae were also observed. Conclusions: Sink waste traps and drains are a reservoir for CPE in hospitals. Once established, CPE contamination might not be confined to a single sink and could spread through wastewater plumbing. Hospitals frequently report drainage problems, which could cause or facilitate CPE transfer between sinks and could lead to long-term establishment.Funding: NoneDisclosures: None
Laboratory Testing, Diagnostic Coding, and Treatment for Electronic Identification of Clostridioides difficile Infection
Authors: Stevens Vanessa , Benin Andrea , Dantes Raymund , Khader Karim , Nugent Sean , Lewis Julia , Adam Terrence , Zhang Rui , Fu Steven , Jones Makoto , Pollock Daniel , Waisbren Steven 
Published: November 2020

Background: Accurate identification of Clostridioides difficile infections (CDIs) from electronic data sources is important for surveillance. We evaluated how frequently laboratory findings were supported by diagnostic coding and treatment data in the electronic health record. Methods: We analyzed a retrospective cohort of patients in the Veterans’ Affairs Health System from 2006 through 2016. A CDI event was defined as a positive laboratory test for C. difficile toxin or toxin genes in the inpatient, outpatient, or long-term care setting with no prior positive test in the preceding 14 days. Events were classified as incident (no CDI in the prior 56 days), or recurrent (CDI in the prior 56 days) and were evaluated for evidence of clinical diagnosis based on International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) and ICD-10-CM codes and at least 1 dose of an anti-CDI agent (intravenous or oral metronidazole, fidaxomicin, or oral vancomycin). We further assessed the possibility of treatment without testing by quantifying positive laboratory tests and diagnostic codes among inpatients receiving an anti-CDI agent. A course of anti-CDI therapy was defined as continuous treatment with the same drug. Results: Among 119,063 incident and recurrent CDI events, 70,114 (58.9%) had a diagnosis code and 15,850 (13.3%) had no accompanying treatment. The proportion of patients with ICD codes was highest among patients treated with fidaxomicin (82.6% of 906) or oral vancomycin (74.3% of 30,777) and was lower among patients receiving metronidazole (63.3% of 103,231) and those without treatment (29.9% of 15,850). The proportion of events with ICD codes and treatment was similar between incident and recurrent episodes. During the study period, there were ~470,000 inpatient courses of metronidazole, fidaxomicin, and oral vancomycin. Table 1 shows the presence of ICD codes and positive laboratory tests by anti-CDI agents. Among 51,100 courses of oral vancomycin, 51% had an ICD code and 44% had a positive test for C. difficile within 7 days of treatment initiation. Among 1,013 courses of fidaxomicin, 79% had an ICD code and 56% had a positive laboratory test. Conclusions: In this large cohort, there was evidence of substantial CDI treatment without confirmatory C. difficile testing and, to a lesser extent, some positive tests without accompanying treatment or coding. A combination of data sources may be needed to more accurately identify CDI from electronic health records for surveillance purposes.Funding: NoneDisclosures: None