bluuebunny/crossref_metadata_2025_split huggingface dataset:
CDIFFerently: A Bundled Approach to Clostridium difficile Reduction
Authors: Deming Sarah 
Published: November 2020

Background: Since 2015 the rate of healthcare facility-onset Clostridium difficile infections (HO CDI) at Faxton-St Luke’s Healthcare (FSLH) has remained higher than both New York state and federal benchmarks, despite the use of traditional prevention efforts. Methods: We used the define-measure-analyze-improve-control (DMAIC) process improvement model to better understand the reasons that our rates remained high and to develop a comprehensive reduction strategy.•Define: High HO CDI rates. NHSN SIR consistently above 1.0•Measure•Diagnostic stewardship. Are patients being tested appropriately?•Antibiotic stewardship: Do prescribing practices follow best-practice recommendations?•Environmental cleanliness: Are staff following standard and transmission based precautions? How effective are current cleaning practices? What is being done to limit contamination of the environment of care?•Perform a gap analysis of CDI prevention strategies at FSLH vs current best practice recommendations, emerging strategies in scientific literature and successful approaches at other health-care facilities.•Analyze•Staff do not have a clear understanding of symptoms and risk factors of CDI and often initiate testing inappropriately.•Overuse of broad spectrum antimicrobial agents. No antibiotic time outs. Limited Pharmacy staff available for auditing and feedback regarding prescribing practices.•UV disinfection system under-utilized. Shared patient care equipment not cleaned between uses. Delay in implementation of contact precautions. Lack of opportunities for patient hand hygiene.•Improve•Algorithms for screening and testing built into Electronic Medical Record Orders for testing coupled with orders for contact precautions•Align antimicrobial prescribing with best practice•Audit and reward compliance with UV light utilization, environmental cleaning Reduce shared patient care equipment, replace with disposable items•Provide products for patient hand hygiene•Implement marketing campaign to tie elements together•Control•Audit compliance with testing and isolation policies•Laboratory rejection of formed stools•Audit cleaning processes with adenosine triphosphate (ATP) monitor•Track ultraviolet light usageFunding: NoneDisclosures: None
Effect of Removing Contact Precautions for Multidrug-Resistant Organisms on Hospital Infections in a Pediatric Health System
Authors: Linam Matthew , Hoskins Dorian , Jaggi Preeti , Gonzalez Mark , Watson Renee , Shane Andi 
Published: November 2020

Background: Discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) have failed to show an increase in associated transmission or infections in adult healthcare settings. Pediatric experience is limited. Objective: We evaluated the impact of discontinuing contact precautions for MRSA, VRE, and extended-spectrum β-lactamase–producing gram-negative bacilli (ESBLs) on device-associated healthcare-associated infections (HAIs). Methods: In October 2018, contact precautions were discontinued for children with MRSA, VRE, and ESBLs in a large, tertiary-care pediatric healthcare system comprising 2 hospitals and 620 beds. Coincident interventions that potentially reduced HAIs included blood culture diagnostic stewardship (June 2018), a hand hygiene education initiative (July 2018), a handshake antibiotic stewardship program (December 2018) and multidisciplinary infection prevention rounding in the intensive care units (November 2018). Compliance with hand hygiene and HAI prevention bundles were monitored. Device-associated HAIs were identified using standard definitions. Annotated run charts were used to track the impact of interventions on changes in device-associated HAIs over time. Results: Average hand hygiene compliance was 91%. Compliance with HAI prevention bundles was 81% for ventilator-associated pneumonias, 90% for catheter-associated urinary tract infections, and 97% for central-line–associated bloodstream infections. Overall, device-associated HAIs decreased from 6.04 per 10,000 patient days to 3.25 per 10,000 patient days after October 2018 (Fig. 1). Prior to October 2018, MRSA, VRE and ESBLs accounted for 10% of device-associated HAIs. This rate decreased to 5% after October 2018. The decrease in HAIs was likely related to interventions such as infection prevention rounds and handshake stewardship. Conclusions: Discontinuation of contact precautions for children with MRSA, VRE, and ESBLs were not associated with increased device-associated HAIs, and such discontinuation is likely safe in the setting of robust infection prevention and antibiotic stewardship programs.Funding: NoneDisclosures: None
Evaluation of Antibiotic Prophylaxis and Postsurgery Antibiotics for Urological Surgeries at an Academic Medical Center
Authors: Drwiega Emily , Rab Saira , Kandiah Sheetal , Kriengkauykiat Jane , Wong Jordan 
Published: November 2020

Objective: The purpose of this study was to evaluate antibiotic use in patients undergoing urological procedures. Methodology: This single-center, IRB-approved, retrospective, observational study was conducted at Grady Health System. Patients were included if they underwent their first inpatient urologic procedure between April 1, 2016, and April 1, 2018. Patients were excluded if they were <18 years old, pregnant, or a prisoner. The primary outcome was percentage of overall adherence to our institutional guidelines for surgical prophylaxis as a composite of antibiotic selection, dose, preoperative timing, and postoperative duration. Secondary outcomes include individual components of the composite outcome, nephrotoxicity, Clostridium difficile infection, and discharge antibiotic prescriptions. Descriptive statistics were used. Results: Of the 100 patients evaluated, 11% achieved adherence with the primary outcome. Of the 89 patients who did not achieve composite outcome, only 8 selected the appropriate perioperative antibiotic. Overall, 30% were dosed appropriately, 47% were administered at the appropriate time with respect to time of incision, and 46% received perioperative antibiotics for no more than 24 hours. Also, 19 patients did not receive perioperative antibiotics. Overall, 14 different perioperative antibiotic regimens were utilized, despite institutional guidelines recommending 1 of 3 options. All 9 patients who developed nephrotoxicity received noncompliant perioperative prophylaxis. No patient developed Clostridium difficile infection within 30 days of surgery. Moreover, 58 patients were discharged with a prescription for at least 1 antibiotic. Conclusions: Most perioperative antibiotic prophylaxes for genitourinary surgeries are not compliant with institution guideline recommendations. Despite having institutional guidelines, there was a large variety in the antibiotic regimens that patients received. All of the patients identified as having an evaluated antibiotic-related adverse effect did not receive appropriate perioperative antibiotic prophylaxis. More than half of the patients received a prescription at discharge for at least 1 antibiotic.Funding: NoneDisclosures: None
Financial and Labor Benefits of the Individual TB Risk Assessment Model for Annual TB Screening
Authors: Sims Kristin , Stienecker Roger 
Published: November 2020

Background:
Since 1991, US tuberculosis (TB) rates have declined, including among health care personnel (HCP). Non–US born persons accounted for approximately two-thirds of cases. Serial TB testing has limitations in populations at low risk; it is expensive and labor intensive. Method: We moved a large hospital system from facility-level risk stratification to an individual risk model to guide TB screening based on Tuberculosis Screening, Testing, and Treatment of US Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019. This process included individual TB risk assessment, symptom evaluation, TB testing for M. tuberculosis infection (by either IGRA or TST) for HCP without documented evidence of prior LTBI or TB disease, with an additional workup for TB disease for HCP with positive test results or symptoms compatible with TB disease. In addition, employees with specific job codes deemed high risk were required to undergo TB screening. Result: In 2018, this hospital system of ~10,000 employees screened 7,556 HCP for TB at a cost of $348,625. In 2019, the cost of the T Spot test increased from $45 to $100 and the cost of screening 5,754 HCP through October 31, 2019, was $543,057. In 2020, it is anticipated that 755 HCP will be screened, saving the hospital an estimated minimum of $467,557. The labor burden associated with employee health personnel will fall from ~629.66 hours to 62.91 hours. The labor burden associated with pulling HCPs from the bedside to be screened will be reduced from 629.66 hours to 62.91 hours as well. Conclusion: Adoption of the individual risk assessment model for TB screening based on Tuberculosis Screening, Testing, and Treatment of US Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019 will greatly reduce financial and labor burdens in healthcare settings when implemented.Funding: NoneDisclosures: None
First Candida auris Outbreak Experience in a Tertiary-Care General Hospital in Qatar, 2019
Authors: Visan Feah , Ansari Naser Al , Wali Walid Al , Zakaria Almunzer , Hasanat Omar Al , Castro Jenalyn , Hudaib Ghada , Ummer Ubaid , Ajmi Jameela Al , Asuncion Mildred , Shaukat Adila , Hamed Manal 
Published: November 2020

Background:Candida auris is an invasive, multidrug-resistant pathogen that can cause outbreaks in hospitals. The mode of transmission is through contaminated hospital items such as fomites and staff interventions. The outbreak of Candida auris affecting 13 patients at the medical intensive care unit (MICU) and medical inpatient unit, either in the form of infection or colonization, is the first documented C. auris outbreak in the Qatar. Methods: The first case was identified in November 2018 in a patient colonized in the respiratory tract. Candida auris biweekly tests were conducted. The second to fourth cases were confirmed in the MICU admitted in the same room (room 2). The fifth case was identified incidentally and was not part of the screening in another ward (6 North Medical Inpatient Unit), and 4 weeks later, Candida auris was isolated from the urine and throat of a patient on this ward. The realization that case 5 was an index case changed the direction of the outbreak investigation, and expanded screening was started among the medical inpatients. When the IPC team identified cases 6–11 and 13, all had possible epidemiological links with case 5. Results: Our root-cause analysis suggests that the index case came from another general hospital. However, because no screening protocol has been established for Candida auris, interventions have not been in place to effectively prevent and control this organism. A strong collaborative outbreak team worked to end this outbreak using the following evidence-based IPC interventions: (1) patient screening and decolonization; (2) environmental screening; (3) enhanced environmental disinfection using peracetic acid wipes, 1% chlorine, and hydrogen peroxide vapor disinfection; (4) prophylactic contact precautions; (5) enhanced hand hygiene with bare below elbows protocol; and (6) a no white gown policy. Conclusions: The outbreak of Candida auris was declared to have nbeen terminated on August 22, 2019. Despite the long period involved in this outbreak, we succeeded in ending it through the concerted efforts of a multidisciplinary team utilizing the latest scientific evidence.Funding: NoneDisclosures: None
Friend or Foe: Perceptions of Infectious Disease Specialists as Stewards and Social Determinants of Antimicrobial Prescribing
Authors: Constantinescu Cora , Furr Caitlyn Cook , Vayalumkal Joseph , Conly John , Gilfoyle Elaine , Kassam Aliya 
Published: November 2020

Background: Inappropriate prescribing behavior can be associated with higher rates of antibiotic resistance, calling for detailed studies on how physicians make prescribing decisions. We conducted a mixed-methods study to investigate physician antibiotic prescribing behavior in a 141-bed pediatric hospital. Methods: We applied a mixed-methods research design. The quantitative phase was conducted over a 6-month period to identify cases of inappropriate prescribing. The qualitative phase comprised 22 qualitative interviews with clinical teaching units (CTU) and pediatric intensive care unit (PICU) team members (physicians and pharmacists). Two coders analyzed the data deductively using the theoretical domain framework (TDF), as well as the social determinants of antimicrobial prescribing (SDAP). Results: In 52.9% of the 36 identified cases in the CTU and 31.4% of the 37 cases in the PICU, an infectious diseases (ID) consultation occurred. Compliance rates with ID recommendations were 79% and 91% in the CTU and PICU, respectively. The CTU and PICU expressed appreciation for ID involvement when ID supported their de-escalation choices in complex cases and in cases in which less commonly known antibiotics were used. However, the ID service involvement was perceived as detrimental to antimicrobial prescribing decisions for CTU and PICU across 3 of the 4 SDAP domains (Fig. 1, qualitative research quotes). Relationship between clinicians: CTU physicians and pharmacists perceived ID involvement as negatively impacting the relationship of the team. Antimicrobial decisions were automatically defaulted to ID, whereas pharmacy involvement was disregarded and the decisions were delayed. Risk, fear, and emotion: These were experienced across all respondents’ groups that identified ID specialists’ egos and personalities as contrary to open collaborative discussion on antimicrobial decisions. (Mis)perception of the problem: ID physicians were identified as more conservative in their antimicrobial choices, leading to prolonged duration of treatment, broader choices, and longer hospitalizations. The CTU and pharmacy respondents felt that ID recommendations were inconsistent among physicians and deviated from guidelines with little justification. Conclusions: Although CTU and PICU teams tend to comply with ID prescribing recommendations and ID involvement with complicated cases, pharmacists, CTU physicians, and PICU physicians perceived ID consultations to negatively affect collaborative efforts for stewardship. These findings offer novel insights into how an ID service can improve its role to positively affect appropriate prescribing. CTU and PICU respondents called for a supportive and trusting relationship with the ID service as a major driver for behavioral change and enhanced stewardship.Funding: NoneDisclosures: None
Highly Local Clostridioides difficile Infection (CDI) Pressure as Risk Factors for CDI
Authors: Riaz Talal , Khan Nabeel , Polgreen Philip , Segre Alberto , Sewell Daniel , Pemmaraju Sriram 
Published: November 2020

Background.
Colonization pressure at the unit level is known to be a risk factor for Clostridioides difficile infections in hospitals. Because C. difficile colonization is not routinely detected in clinical practice, only patients identified as having C. difficile infection (CDI) are included in these pressure calculations. We used data from the University of Iowa Hospitals and Clinics (UIHC) to determine whether highly local CDI pressure, due to patients in nearby rooms, is more strongly correlated with CDI than unit-level CDI pressure. Methods: We designed a base logistic regression model using variables known to be risk factors for CDI: age, antibiotic/gastric acid suppressor use, low albumin, prior hospitalization, comorbidities. To the base model, we add 2 measures, mean colonization pressure (MCP) and sum colonization pressure (SCP) of CDI at the unit level to obtain new models. To the base model, we also added CDI colonization pressure by considering CDI cases at different distance thresholds from the focal patient. Distances between patient rooms were extracted from hospital floor plans. Results: Adding unit-level CDI colonization pressures to the base model improved performance. However, adding CDI colonization pressures due to roommates and due to patients at different distances improved the model much more (Table 1). The top (resp. bottom) row shows in-sample (resp. out-of-sample) C-statistics for the base model, the base model with unit-level MCP, the base model with roommate MCP, and the base model with MCP from patients are different distances added as separate features. C-statistics for the base model and the base model with unit CDI pressure (SCP and MCP) are compared in Fig. 1 with C-statistics from the base model with CDI pressure from patients at distances D = 0, 1, 2, 3, 4, 5, 10, 15, 20 hops (1 hop = 5–6 meters). Conclusions: Our results support the hypothesis that unit CDI colonization pressure is a risk factor for CDI. However, by incorporating spatially granular notions of distances between patients in our analysis, we were able to demonstrate that the true source of CDI pressure at the UIHC is almost exclusively attributable to roommates and patients in adjacent rooms.Funding: NoneDisclosures: None
Impact of Leadership Walk-Arounds and Feedback from Senior Management to Reduce CLABSI Rates
Authors: Warrier Anup , Bernadit Soumya 
Published: November 2020

Background:
Aster Medcity is a 400-bed tertiary-care hospital in India. Over the years, the CLABSI rates have been within the INICC benchmarks but much above the CDC benchmarks. Is it possible to achieve the CDC/NHSN benchmarks without using engineered vascular access devices? How can we implement the available evidence in using feedback as an effective way to improve practices? Methods: In this prospective interventional trial, we compared the CLABSI rates at baseline over the previous 6 months (January 2019 to June 2019) with the CLABSI rates over the following 3 months (July –September 2019) with introduction of a new feedback structure. This feedback was delivered in the following ways. (1) Leadership walk-arounds consisted of the CEO, CNO, and CMS visiting each unit that reported a CLABSI as soon as it was reported (instead of the month end when cumulative reports become available) to discuss what went wrong and what could be corrected with the local unit teams. (2) The CEO had a 1-to-1 discussion with the nursing leadership regarding the monthly CLABSI rates with clear goal setting for the nursing teams. (3) Daily feedback on the practices as reviewed in the observational audits by the infection control team (ie, infection control nurses) was provided to the ICU teams through the ICO and CMS to the individual practitioners (both nurses and doctors). Results: Metrics were collected for both the process measures as well as outcome measures. The CLABSI outcome measure dropped from a mean of 4 per 1,000 CVC days before the intervention to a mean of 1 per 1,000 CVC days after the intervention, both calculated for a 6-month period. The compliance to hand hygiene as per the WHO 5 Moments improved from a mean of 79% to 86%, and the compliance to safe injection practices improved from 76% to 95%. Noncompliant HCWs observed via the daily feedback system dropped from 16–20 HCWs per week at the start of the intervention to 5–6 HCWs per week by the end of 6 months. The environmental cleaning scores (using glow-gel scores with the CDC environmental cleaning tool) remained at an average of 85%. Conclusions: Feedback is the backbone of most of the interventions of quality and infection control teams of healthcare organizations. Increased frequency and feedback from senior management can overcome inertia in improving practices on the ground level. This method could be more cost-effective at reducing CLABSIs than engineered devices.Funding: NoneDisclosures: None
Implementation of Two-Step Clostridioides difficile Testing Algorithm and Management of Possible Carriers
Authors: Markley J. Daniel , Tassone Daniel , Christian Melanie , Vaughan Leroy , Stevens Michael P. , Hitchcock Matthew M. , Hill Emily 
Published: November 2020

Background: Updated IDSA-SHEA guidelines recommend different diagnostic approaches to C. difficile depending on whether There are pre-agreed institutional criteria for patient stool submission. If stool submission criteria are in place, nucleic acid amplification testing (NAAT) alone may be used. If not, a multistep algorithm is suggested, incorporating various combinations of toxin enzyme immunoassay (EIA), glutamate dehydrogenase (GDH), and NAAT, with discordant results adjudicated by NAAT. At our institution, we developed a multistep algorithm leading with NAAT with reflex to EIA for toxin testing if NAAT is positive. This algorithm resulted in a significant proportion of patients with discordant results (NAAT positive and toxin EIA negative) that some experts have categorized as possible carriers or C. difficile colonized. In this study, we describe the impact of a multistep algorithm on hospital-onset, community-onset, and healthcare-facility–associated C. difficile infection (HO-CDI, CO-CDI, and HFA-CDI, respectively) rates and the management of possible carriers. Methods: The study setting was a 399-bed, tertiary-care VA Medical Center in Richmond, Virginia. A retrospective chart review was conducted. The multistep C. difficile testing algorithm was implemented June 4, 2019 (Fig. 1). C. difficile testing results and possible carriers were reviewed for the 5 months before and 4 months after implementation (January 2019 to September 2019). Results: In total, 587 NAATs were performed in the inpatient and outpatient setting (mean, 58.7 per month). Overall, 123 NAATs (21%) were positive: 59 in the preintervention period and 63 in the postintervention period. In the postintervention period, 23 positive NAATs (26%) had a positive toxin EIA. Based on LabID events, the mean rate of HO+CO+HCFA CDI cases per 10,000 bed days of care (BDOC) decreased significantly from 9.49 in the preintervention period to 1.15 in the postintervention period (P = .019) (Fig. 2). Also, 9 of the possible carriers (22%) were treated for CDI based on high clinical suspicion, and 6 of the possible carriers (14%) had a previous history of CDI. Of these, 5 (83%) were treated for CDI. In addition, 1 patient (2%) converted from possible carrier to positive toxin EIA within 14 days. The infectious diseases team was consulted for 11 possible carriers (27%). Conclusions: Implementation of a 2-step C difficile algorithm leading with NAAT was associated with a lower rate of HO+CO+HCFA CDI per 10,000 BDOC. A considerable proportion (22%) of possible carriers were treated for CDI but did not count as LabID events. Only 2% of the possible carriers in our study converted to a positive toxin EIA.Funding: NoneDisclosures: None