bluuebunny/crossref_metadata_2025_split huggingface dataset:
Universal Masking to Prevent Nosocomial Respiratory Viral Infections in Malignant Hematology Inpatient Units
Authors: Arulsundaram Vishnuka , Houston Kelsey , Vicencio Elisa , Rebelo Carly , Vaisman Alon , Hota Susy 
Published: November 2020

Background: Patients with hematologic malignancies are at increased risk for respiratory virus infections (RVIs) and may experience prolonged asymptomatic viral shedding contributing to transmission. In response to 2 extensive RVI outbreaks in our adult cancer center, a universal masking policy was implemented whereby inpatients on malignant hematology units and their visitors were required to wear procedure masks whenever they were walking outside their rooms. Visitors were required to mask when inside patient rooms. Staff were not included in the policy. Here, we describe the impact of universal masking on the incidence of nosocomial RVI in malignant hematology patients. Methods: In this before-and-after study, we examined the effects of universal masking in malignant hematology units of a 170-bed adult cancer hospital in Toronto, Canada, between January 1, 2015, and September 30, 2019. Nosocomial RVI incidence, RVI outbreak descriptions, and hand hygiene compliance rates were collected from hospital infection control databases. Mask utilization was extracted from hospital purchasing records. Staff influenza vaccination rates were obtained from occupational health records. RVI incidence rates before and after the intervention were compared using Wilcoxon rank-sum test. Results: The preimplementation phase ran from January 1, 2015, to February 28, 2017, and the postimplementation phase spanned March 1, 2017, to September 30, 2019. Monthly mask utilization on malignant hematology units increased by 105% after implementing the universal masking policy. Nosocomial RVI incidence decreased significantly after implementing the universal masking policy, and the number of cases involved in RVI outbreaks also decreased (Table 1). There was a 14% increase in nasopharyngeal swab orders after implementation. Staff influenza vaccination rates, hand hygiene compliance and infection control policies remained stable throughout the study. Conclusions: A reduction in the incidence of nosocomial RVI and number of RVI cases in outbreaks was observed after implementing the universal masking policy. Although we were unable to directly measure compliance with the intervention, increased mask utilization after the intervention implied adherence to the policy. Our experience suggests that universal masking in malignant hematology inpatients may be an effective RVI prevention strategy. Further rigorous study is warranted.Funding: NoneDisclosures: Susy Hota reports contract research for Finch Therapeutics.
Use of a Beta-Lactam Graded Challenge Process at an Academic Medical Center
Authors: Watkins Andrew , Amaya Lee , Wolfe Macey , Schoen John , Stohs Erica , May Sara , Rupp Mark , Schooneveld Trevor Craig Van , Alexander Bryan , Bergman Scott 
Published: November 2020

Background: A penicillin allergy guidance document containing an algorithm for challenging penicillin allergic patients with β-lactams was developed by the antimicrobial stewardship program (ASP). As part of this algorithm, a “graded challenge” order set was created containing antimicrobial orders and safety medications along with monitoring instructions. The process is designed to challenge patients at low risk of reaction with infusions of 1% of the target dose, then 10%, and finally the full dose, each 30 minutes apart. We evaluated outcomes from the order set. Methods: Orders of the graded challenge over 17 months (March 2018 through July 2019) were reviewed retrospectively. Data were collected on ordering and outcomes of the challenges and allergy documentation. Use was evaluated based on ASP-recommended indications: history of IgE-mediated or unknown reaction plus (1) no previous β-lactam tolerance and the reaction occurred >10 years ago, or (2) previous β-lactam tolerance, now requiring a different β-lactam for treatment. Only administered challenges were included and descriptive statistics were utilized. Results: Of 67 orders, 57 graded challenges were administered to 56 patients. The most common allergies were penicillins (87.7%) and cephalosporins (38.6%), with the most common reactions being unknown (41.7%) or hives (22%). The most common antibiotics challenged were ceftriaxone (43.9%), cefepime (21.1%), and cefazolin (5.3%). Antibiotics given prior to challenge included vancomycin (48.2%), fluoroquinolones (35.7%), carbapenems (21.4%), aztreonam (19.6%), and clindamycin (12.5%). The median duration of challenged antibiotic was 6 days. The infectious diseases service was consulted on 59.6% of challenges and 75.4% of challenges were administered in non-ICU settings. There was 1 reaction (1.8%) involving a rash with the second infusion, which was treated with oral diphenhydramine and had no lasting effects. Based on indications, 80.7% of challenges were aligned with ASP guidance criteria. The most common use outside of these criteria was in patients without IgE-mediated reactions (10.5%). Most of these had minor rashes and could have received a full dose of a cephalosporin. Allergy information was updated in the electronic health record after 91.2% of challenges. Conclusions: We demonstrated the utility of a graded challenge process at our academic medical center. It was well tolerated, ordered frequently by noninfectious diseases clinicians, administered primarily in non-ICU settings, and regularly resulted in updated allergy information in the medical record. With many patients initially receiving broad-spectrum antibiotics with high costs or increased rates of adverse effects, graded challenges can potentially prevent the use of suboptimal therapies with minimal time and resource investment.Funding: NoneDisclosures: Scott Bergman reports a research grant from Merck.
Use of Next-Generation Sequencing to Rule Out Cluster of Pseudomonas aeruginosa in a Cardiac Critical Care Unit
Authors: Neilsen Chad , Rose Rebecca , Nolan David , McCarter Yvette Simone , Rollini Fabiana , Lamers Susanna , Sands Michael Lee , Hoadley Thuyvi 
Published: November 2020

Background: In spring of 2019, 2 positive sputum cases of Pseudomonas aeruginosa in the cardiac critical care unit (CCU) were reported to the UFHJ infection prevention (IP) department. The initial 2 cases, detected within 3 days of each other, were followed shortly by a third case. Epidemiological evidence was initially consistent with a hospital-acquired infection (HAI): 2 of the 3 patients roomed next to each other, and all 3 patients were ventilated, 2 of whom shared the same respiratory therapist. However, no other changes in routine or equipment were noted. The samples were cultured and processed using Illumina NGS technology, generating 1–2 million short (ie, 250-bp) reads across the P. aeruginosa genome. As an additional positive control, 8 P. aeruginosa NGS data sets, previously shown to be from a single outbreak in a UK facility, were included. Reads were mapped back to a reference sequence, and single-nucleotide polymorphisms (SNPs) between each sample and the reference were extracted. Genetic distances (ie, the number of unshared SNPs) between all UFHJ and UK samples were calculated. Genetic linkage was determined using hierarchical clustering, based on a commonly used threshold of 40 SNPs. All UFHJ patient samples were separated by >18,000 SNPs, indicating genetically distinct samples from separate sources. In contrast, UK samples were separated from each other by <16 SNPs, consistent with genetic linkage and a single outbreak. Furthermore, the UFHJ samples were separated from the UK samples by >17,000 SNPs, indicating a lack of geographical distinction of the UFHJ samples (Fig. 1). These results demonstrated that while the initial epidemiological evidence pointed towards a single HAI, the high-precision and relatively inexpensive (<US$1500) NGS analysis conclusively demonstrated that all 3 CCU P. aeruginosa cases derived from separate origins. The hospital avoided costly and invasive infection prevention interventions in an attempt to track down a single nonexistent source on the CCU, and no further cases were found. This finding supports the conclusion reached from the NGS that this represented a pseudo-outbreak. Furthermore, these genomes serve as an ongoing record of P. aeruginosa infection, providing even higher resolution for future cases. Our study supports the use of NGS technology to develop rational and data-driven strategies. Furthermore, the ability of NGS to discriminate between single-source and multiple-source outbreaks can prevent inaccurate classification and reporting of HAIs, avoiding unnecessary costs and damage to hospital reputations.Funding: NoneDisclosures: Susanna L. Lamers reports salary from BioInfoExperts and contract research for the NIH, the University of California - San Francisco, and UMASS Medical School.
Utilizing Behavioral Science to Improve Antibiotic Prescribing in Rural Urgent Care Settings
Authors: Cummings Patricia , Alajajian Rita , May Larissa , Grant Russel , Greer Hailey , Dezfuli Massoud 
Published: November 2020

Background: The rate of inappropriate antibiotic prescribing for acute respiratory tract infections (ARTIs) is 45% among urgent care centers across the United States. To contribute to the US National Action Plan for Combating Antibiotic-Resistant Bacteria, which aims to decrease rates of inappropriate prescribing, we implemented 2 behavioral nudges using the evidence-based MITIGATE tool kit from urgent-care settings, at 3 high-volume, rural, urgent-care centers. Methods: An interrupted time series (ITS) analysis was conducted comparing a preintervention phase during the 2017–2018 influenza season (October through March) to the intervention phase during the 2018–2019 influenza season. We compared the rate of inappropriate or non–guideline-concordant antibiotic prescribing for ARTIs across 3 urgent-care locations. The 2 intervention behavioral nudges were (1) staff and patient education and (2) peer comparison. Provider education included presentations at staff meetings and grand rounds, and patient education print materials were distributed to the 3 locations coupled with news media and social media. We utilized the CDC “Be Antibiotics Aware” campaign materials, with our hospital’s logo added, and posted them in patient rooms and waiting areas. For the peer comparison behavioral intervention, providers were sent individual feedback e-mails with their prescribing data during the intervention period and a blinded ranking e-mail in which they were ranked in comparison to their peers. In the blinded ranking email, providers were placed into categories of “low prescribers,” those with a ≤23% inappropriate antibiotic prescribing rate based on the US National Action Plan for Combating Antibiotic-Resistance Bacteria 2020 goal, or “high prescribers,” those with a rate greater than the national average (45%) of inappropriate antibiotic prescribing for ARTI. Results: Our results show that fewer inappropriate antibiotic prescriptions were written during the intervention period (58.8%) than during the preintervention period (73.0%), resulting in a 14.5% absolute decrease in rates of inappropriate prescribing among urgent-care locations over a 6-month period (Fig. 1). The largest percentage decline in rates was seen in the month of April (−35.8%) when compared to April of the previous year. The ITS analysis revealed that the rate of inappropriate prescribing was statistically significantly different during the preintervention period compared to the intervention period (95% CI, −4.59 to −0.59; P = .0142). Conclusions: Using interventions outlined in the MITIGATE tool kit, we were able to reduce inappropriate antibiotic prescribing for ARTI in 3 rural, urgent-care locations.Funding: NoneDisclosures: Larissa May repo, Speaking honoraria-Cepheid Research grants-Roche Consultant-BioRad Advisory Board-Qvella Consultant-Nabriva
When Legionnaires’ Disease Isn’t: Case Presentation and Implications of the Council of State and Territorial Epidemiologists (CSTE) Changes to Case Definitions
Authors: Stout Janet E. , Malani Anurag 
Published: November 2020

Background: Most cases of Legionnaires’ disease are diagnosed by the urinary antigen test (UAT). Single cases of suspected healthcare-acquired Legionnaires’ disease are often investigated by local and state health departments. Such investigations can result in disruptive and expensive interventions. We report a case of a urine-antigen–positive patient whose clinical presentation was inconsistent with Legionnaires’ disease. Within the same year, an employee at this hospital was diagnosed with presumed community-acquired Legionnaires’ disease; however, the case was considered by the health department to be healthcare acquired. The occurrence of 2 cases, as determined by the health department, fulfilled the definition for an outbreak investigation and triggered water restrictions and extensive testing of the environment and patients for Legionella. The cases and the implications of these actions are reviewed in the context of new information about false-positive urinary-antigen tests and changes to the outbreak case definitions for Legionnaires’ disease by the Council of State and Territorial Epidemiologists (CTSE). This includes “probable” cases that have no positive diagnostic tests.Funding: NoneDisclosures: Janet E. Stout reports salary from the Special Pathogens Laboratory and is an owner.
Patients Discharged From Hospitals Without a Clostridioides difficile Infection Increase the Risk of CDI in Family Members
Authors: Miller Aaron , Segre Alberto , Sewell Daniel , Pemmaraju Sriram , Polgreen Philip 
Published: November 2020

Background:Clostridioides difficile infections (CDIs) present and are transmitted in both community and healthcare settings. Patients who become colonized or infected during hospitalization may be discharged into the community. Asymptomatic spread and/or community-based transmission have also been posited as alternative sources for healthcare-onset CDI cases. The objective of our study was to determine whether individuals are at greater risk for developing a CDI if they have a family member that spent time hospitalized in the prior 90 days, even if the hospitalized family member had no prior diagnosis of CDI. Methods: We conducted a retrospective cohort study using the Truven Marketscan database from 2001 through 2017; both commercial claims and Medicare supplemental data were included. We categorized enrollees by age, sex, month, year, exposure to a family member with CDI, hospitalization, or high- or low-risk antibiotic use in the prior 90 days. We then subdivided these groups based on the total amount of time that other family members spent hospitalized in the prior 90 days: ≤4 days, 5–10, 11–20, 21–30, 41–50 or >50 days. Within each subgroup, we computed the incidence of CDI. We then used a stratified regression model (log-linear quasi-Poisson) to estimate the incidence of CDI in each enrollment bin. Finally, we repeated our analysis using all CDI cases, CDI cases with no prior CDI in the family, and cases without prior hospitalization. Results: Over the 17-year study period, >5.1 billion enrollment months were represented in our dataset. We identified 224,818 cases of CDI, 223,744 cases without prior CDI in a family member and 164,650 CDI cases where the case patient had no prior hospitalization. Table 1 depicts the estimated risk (incident rate ratios) associated with the amount of time that other family members spent hospitalized in the prior 90 days. There is a very clear dose–response curve, and the relative risk for CDI increase as the amount of time other family members spent hospitalized increased. Other risk factors included prior hospitalization, low- and high-risk antibiotics, age, female sex and exposure to a family member with CDI. Conclusions: Having a family member who has been hospitalized in the prior 90 days significantly increases the risk for CDI, even if the family member did not have CDI. The total amount of time other family members spent in the hospital is positively associated with the level of risk.Funding: CDC Modeling Infectious Diseases (MInD) in Healthcare NetworkDisclosures: None
Bloodstream Infections with Typical Probiotic Organisms
Authors: Gore Sara , Tucker Kendall 
Published: November 2020

Background: Probiotics are protective against Clostridioides difficile infection and antibiotic-associated diarrhea, and they may decrease risk of infections following complex abdominal surgeries. Infectious risks associated with probiotic use are not well described in the literature. We describe probiotic use among patients with bloodstream infections (BSIs) due to organisms typically found in probiotics. Methods: Patients with positive blood cultures with Lactobacillus spp, Saccharomyces spp, and Bifidobacterium spp at our large academic hospital from October 2016 through October 2019 were identified using Theradoc, a clinical surveillance tool. Clinical data and orders for probiotics, including probiotic capsules, probiotic yogurt, and kefir, were extracted from the electronic medical record. Cases were considered distinct if the cultures were collected 7 or more days apart. True infections were defined as positive cultures which were treated with antimicrobials and had provider documentation outlining clinical relevance of culture data. Results: Among 26 distinct episodes of BSI, 16 (62%) were considered true infections. The remaining 10 cases were interpreted as contaminants or of unclear significance. Of the 16 cases representing true infection in 14 patients, 6 (38%) had received probiotics in the hospital in the preceding month. Among these patients, 5 had Lactobacillus bacteremia and had received Lactobacillus capsules, probiotic yogurt, and/or kefir. One patient had Saccharomyces fungemia following receipt of probiotic yogurt and kefir. All 6 patients with BSI possibly related to probiotic use had an antecedent gastrointestinal procedure or surgery within a month of the BSI, and 2 had intra-abdominal abscesses from which the same organism was cultured. Of the 16 true BSIs, 9 occurred in immunocompromised hosts, but antecedent probiotic use was confirmed in only 1 of these cases. Two episodes caused by different organisms occurred within the same month; all other episodes were >60 days apart. Conclusions: In our retrospective review of BSIs with organisms typically found in probiotics over a 3-year period at a large academic hospital, more than one-third of those with clinically relevant BSIs had antecedent probiotic use within the hospital. All patients with infections possibly related to probiotic use had recent gastrointestinal procedures or surgery, raising concern for probiotic use following interventions that increase the risk for gastrointestinal tract leakage or translocation. Further research is necessary to assess the risk of bloodstream infection in postoperative patients treated with probiotics.Funding: NoneDisclosures: None
Bright STAR Collaborative Consensus Guidelines for Blood Culture Use in Critically Ill Children
Authors: Woods-Hill Charlotte , Koontz Danielle , Voskertchian Annie , Miller Marlene , Fackler James , Shea Judy , Milstone Aaron Michael 
Published: November 2020

Background: Blood cultures are essential diagnostic tools used to identify bloodstream infections and to guide antimicrobial therapy. However, collecting cultures without clear indications or that do not inform management can lead to false-positive results and unnecessary use of antibiotics. Blood culture practices vary significantly in critically ill children. Our objective was to create a consensus guideline focusing on when to safely avoid blood cultures in pediatric intensive care unit (PICU) patients. Methods: A panel of multidisciplinary experts, many participating in the Blood Culture Improvement Guidelines and Diagnostic Stewardship for Antibiotic Reduction in Critically Ill Children (Bright STAR) Collaborative, engaged in a 2-part modified Delphi process. Round 1 consisted of a preparatory literature summary and an electronic survey sent to subject matter experts (SMEs). In the survey, SMEs rated a series of recommendations about when to avoid blood cultures on a 5-point Likert scale, 1 being the lowest score and 5 being the highest score. Consensus was achieved for each recommendation if 75% of respondents chose a score of 4 or 5, and these were included in the final guideline. Any recommendations that did not meet these a priori criteria for consensus were set aside for discussion during the in-person expert panel review (round 2). An outside expert in consensus methodology facilitated round 2. After a review of the survey results and comments from round 1 and group discussion, the SMEs voted on these recommendations in real time. Voting was blinded. Participants included Bright STAR site leads, national content experts, and representatives from relevant national societies. Results: We received 29 completed surveys from 34 invited participants for an 85% response rate. Of the 27 round 1 recommendations, 18 met predetermined criteria for consensus. Round 2 included 26 in-person voting participants who (1) discussed and modified the 9 recommendations that had not met round 1 consensus, and (2) modified for clarity or condensed from multiple into single recommendations the 18 recommendations that had met the round 1 consensus. The final document contains 19 recommendations that provide guidance on how to safely improve blood culture use in PICU patients (Table 1). Also, 8 recommendations discussed did not reach consensus for inclusion. Conclusions: Using a modified Delphi process, we created consensus recommendations on when to avoid blood cultures and prevent overuse in critically ill children. These guidelines are a critical step in disseminating diagnostic stewardship and reducing unnecessary testing on a wider scale.Funding: Agency for Healthcare Research and Quality, R18 HS025642-01, 9/2017 – 9/2020 (Aaron Milstone, PI)Disclosures: None