bluuebunny/crossref_metadata_2025_split huggingface dataset:
Reductions in Positive Clostridioides difficile Events Reportable to NHSN With Adoption of Reflex EIA Testing in 13 Atlanta Hospitals
Authors: Goodenough Dana , Sefton Samantha , Smith Elizabeth , Kraft Colleen , Varkey Jay , Fridkin Scott 
Published: November 2020

Background: US hospitals are required to report C. difficile infections (CDIs) to the NHSN as a performance measure tied to payment penalties for poor scores. Currently, only the charted CDI test results performed last in reflex testing scenarios are reported to the NHSN (CDI events). We describe the reduction in NHSN CDI events from the addition of a reflex toxin enzyme immunoassay (EIA) after a positive nucleic acid amplification test (NAAT) in teaching and nonteaching hospitals, and we estimate the impact on standardized infection ratios (SIR). Methods: Reporting of all CDI test results, by test method, occurred during April 2018–July 2019 to the Georgia Emerging Infections program (funded by the Centers for Disease Control and Prevention), which conducts active population-based surveillance in an 8-county Atlanta area (population, 4 million). Among facilities starting reflex EIA testing, results were aggregated by test method during months of reflex testing to calculate facility-specific reduction in NHSN CDI events (% reduction; 1-[no. EIA+/no. NAAT+]). Differences in percent reduction between facilities by characteristic were compared using the Kruskal-Wallis test. We simulated expected changes in the SIR for a range of reductions, assuming equal effect on both community-onset (CO) and hospital-onset (HO) tests. Each facility’s historical NHSN CDI events prior to reflex testing were used to estimate changes to facility-specific SIRs by reducing values by the corresponding facility’s percent reduction. Results: Overall, 13 acute-care hospitals (bed size, 52–633; ICU bed size, 6–105) started reflex testing during the study period (mean, 7 months, 15,800 admissions, 66,400 patient days), resulting in 550 +NAAT tests reflexing to 180 +EIA tests (pooled mean 58% reduction). Percent reduction varied (mean, 67%; range, 42%–81%) but did not differ between larger (≥217 beds) and smaller hospitals (61 vs 50% reduction; P > .05) or by outsourced versus inhouse testing (65% vs 54% reduction; P > .05). Simulations identified a threshold reduction at which point effect on HO counteract the effects on CO events enough to reduce the SIR; thresholds for nonteaching and teaching were 26% and 32% reduction, respectively (Fig. 1). The estimated reductions in facility-specific SIRs using measured percent reductions on historic NHSN CDI events closely paralleled the simulation, and the mean estimated change in SIR was −46% (range, −12% to −71%) (Fig. 1). Conclusions: Although the magnitude of the effect varied, all 13 facilities experienced dramatic reductions in CDI events reportable to NHSN due to reflex testing; applying these reductions to historical NHSN data illustrates anticipated reductions in their facility-specific SIRs due to this testing change.Funding: NoneDisclosures: Scott Fridkin, consulting fee, vaccine industry (various) (spouse)
Enhancing Influenza Vaccination of Hospital Workers from 30% to 80% Through Application of Behavior Change Theories
Authors: Lingaas Egil , Sandness Ylva , Raastad Ragnhild 
Published: November 2020

Background: Historically, influenza vaccination coverage among Norwegian healthcare workers has been low. In 2014–2015 and 2015–2016 the national averages were 9% and 12%, respectively, Although the Fig.s for Oslo University Hospital were higher (30% in 2015–2016), we were still far from the goal of 75% set by the WHO. The same year, <10% of employees at Vestre Viken Hospital Trust were vaccinated. Before the 2016–2017 influenza season, we therefore launched a campaign using methods based on behavior change theories and social marketing to enhance vaccination coverage. Methods: In May–June 2016 a questionnaire was sent by e-mail to all employees at Oslo University Hospital (n = ~25,000) and Vestre Viken Hospital Trust (n = 9,000). The questionnaire was structured according to the theory of planned behavior, asking questions related to attitude, subjective norms, and perceived control. The respondents were asked to grade each answer from 1 to 5, and we could then calculate a score for each question based on the proportion (%) of respondents across the 5 grades. Thus a score between 0 and 500 was possible. We then selected the questions with the highest and lowest scores for intervention, and applied stages of change principles and social marketing for implementation. In May–June 2017, the same questionnaire was sent to all employees and the procedure was repeated before the 2017–2018 influenza season. Finally, for the third time, the procedure was repeated before the 2019–2020 season. This time some additional questions were added, about which sources the employees were using for information on influenza vaccination. Results: In 2017–2018 vaccination coverage increased from 30% to 54%. The year after we reached 73%, and at the time of abstract submission (November 12, 2019) we have passed 80% for the 2019–2020 season, still with more vaccines to be given. Among Norwegian healthcare workers, attitudes and perceived control seemed to have a stronger impact on behavior (vaccination) than subjective norms. Conclusions: We were able to significantly increase voluntary influenza vaccination, reaching the WHO goal of at least 75%, by the application of behavior change theories and social marketing.Funding: NoneDisclosure: Egil Lingaas, Salary - 3M Healthcare
Epidemiology and Clinical Outcomes Associated With Extensively Drug-Resistant (XDR) Acinetobacter in US Veterans’ Affairs Health Care
Authors: Fitzpatrick Margaret , Suda Katie , Poggensee Linda , Vivo Amanda , Gutkowski Marissa , Wilson Geneva , Evans Charlesnika 
Published: November 2020

Background: Infections caused by Acinetobacter spp are often healthcare acquired, difficult to treat, and associated with high mortality. Extensively drug-resistant (XDR) Acinetobacter are nonsusceptible to at least 1 agent in all but 2 or fewer antimicrobial classes. Epidemiologic and outcome data for XDR Acinetobacter are limited and have largely been reported outside the United States. This national cohort study describes epidemiology, clinical characteristics, and outcomes for patients with XDR Acinetobacter in VA health care. Methods: This was a retrospective cohort study including microbiology and clinical data from all patients hospitalized between 2012 and 2018 at any VA medical center who had cultures that grew XDR Acinetobacter spp. Performance and reporting of bacterial speciation and antibiotic susceptibility testing were performed by each VA laboratory according to their protocol. Descriptive statistics were used to summarize data. Results: Of 11,541 unique patients with 15,358 cultures that grew Acinetobacter spp during the study period, 410 (3.6%) patients had 670 (4.4%) cultures that grew XDR Acinetobacter. Mean age was 68 years (SD, 12.2 years) and the median Charlson comorbidity index was 3 (IQR, 1–5). The greatest proportion of isolates were from the respiratory tract (n = 235, 35%) followed by urine (n = 184, 28%). The South had the greatest proportion of patients with XDR Acinetobacter (n = 162, 40%); almost all patients were seen at urban VA medical centers (n = 406, 99%). Most patients (n = 335, 82%) had had antibiotic exposure in the prior 90 days, most commonly vancomycin (n = 238, 65%) and third- or fourth-generation cephalosporins (n = 155, 38%). Most patients (n = 334, 81%) also had a hospital or long-term care admission in the prior 90 days. Fig. 1 shows antibiotic susceptibilities of XDR Acinetobacter isolates; polymyxins, tigecycline, and minocycline demonstrated the highest susceptibility. In-hospital mortality occurred in 90 patients (22%), 30-day mortality in 97 patients (24%), and 1-year mortality in 198 patients (48%). Of 93 patients, 23% were readmitted to the hospital within 90 days. Conclusions: Providers should maintain a heightened suspicion for infection with XDR Acinetobacter spp in older patients seen at urban medical centers who have had recent healthcare and antibiotic exposures, particularly if they have respiratory or urinary tract infections. Isolation of XDR Acinetobacter is associated with high in-hospital and 30-day mortality. New antibiotics targeting MDR gram-negative bacteria generally lack activity against Acinetobacter, leaving polymyxins, tigecycline, and minocycline as the only limited treatment options. Therefore, novel antibiotics for XDR Acinetobacter are urgently needed.Funding: NoneDisclosures: None
No Device, No Problem? Healthcare-Associated Bloodstream and Urinary Tract Infections in a Children’s Hospital
Authors: Gornick Wendi , Huff Beth , Singh Jasjit 
Published: November 2020

Background: Central-line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) definitions continue to be refined to ensure accuracy. As facilities decrease CLABSI and CAUTI, and as midline catheters become more widely utilized, we sought to understand our non–central-line bloodstream infections (NCLBSI) and non–catheter-associated urinary tract infections (NCAUTI). Total healthcare-associated bloodstream infections (HABSIs) and urinary tract infections (HAUTIs) may provide more objective measures. Methods: The CHOC Children’s Hospital is a 334-bed quaternary-care hospital in Orange, California, with 146 intensive care unit (ICU) beds. We retrospectively reviewed all HABSIs (CLABSIs + NCLBSIs) and HAUTIs (CAUTIs + NCAUTIs) from July 1, 2016, to June 30, 2019, for demographic and microbiologic data. Both HABSI and HAUTI were defined as healthcare-associated infection when the date of event occurs on or after the third calendar day of admission. CLABSI and CAUTI were both defined using CDC-NHSN criteria. Mucosal barrier injury laboratory-confirmed bloodstream infections were excluded. Results: In a 3-year period, there were 100 HABSIs, of which 26 (26%) were NCLBSIs. The mean age for HABSI was 81 months. Enteric gram-negative infections (42%) and Staphylococcus aureus (35%) were the most common etiology for NCLBSI. The most common etiologies for CLABSI were coagulase-negative staphylococci (23%), Staphylococcus aureus (22%), and enteric gram-negatives (22%). Pseudomonas aeruginosa accounted for 16% of CLABSIs, but no NCLBSIs (Fig. 1). There was 1 midline catheter NCLBSI. There were 49 HAUTIs, of which 39 (80%) were NCAUTIs. One asymptomatic bacteremic urinary tract infection was included with the CAUTIs. The mean age for HAUTI was 55 months. The most common etiology of CAUTI was Pseudomonas aeruginosa (50%), whereas for NCAUTI the most common etiology was enteric gram-negative organisms (69%) (Fig. 2). In total, 11 HAUTIs (22%) resulted in secondary sepsis. Most HABSIs and HAUTIs occurred in the ICU setting. There were 6 deaths (6%) among HABSI patients and 3 deaths (8%) among HAUTI patients within 2 weeks of infection (Fig. 3). Conclusions: A preponderance of HABSIs were CLABSIs, but most HAUTIs were NCAUTIs. Although patient demographic and microbiologic differences exist in CLABSIs and NCLBSIs as well as CAUTIs and NCAUTIs, S. aureus and P. aeruginosa are important pathogens, particularly in device-associated infections. Trending total numbers of HABSIs and HAUTIs may be less subjective and may avert the shifting of categories seen with increased use of midline catheters. In addition, non–device-associated infections are potential causes of morbidity and mortality.Funding: NoneDisclosures: None
Risk of Hospital-Onset C. difficile Infection Increases With Prior Inpatient and Outpatient Visits
Authors: Miller Aaron , Segre Alberto , Sewell Daniel , Pemmaraju Sriram , Polgreen Philip 
Published: November 2020

Background:Clostridioides difficile is a leading cause of healthcare-associated infections, and greater healthcare exposure is a primary risk factor for Clostridioides difficile infection (CDI). Longer hospital stays and greater CDI pressure, both at the hospital level and the level, have been linked to greater risk. In addition, symptoms associated with healthcare-associated CDI often do not present until a patient has been discharged. Our study objective was to estimate the extent to which exposure to different types of healthcare settings (eg, prior hospitalization, emergency department [ED], outpatient or long-term care) increase risk for hospital-onset CDI. Methods: We conducted a case-control study using the Truven Marketscan Commerical Claims and Medicare Supplemental databases from 2001 to 2017. Case patients were selected as all inpatient visits with a secondary diagnosis of CDI and no previous CDI diagnosis in the prior 90 days. Controls were selected from all inpatient admissions without any CDI diagnosis during the current admission or prior 90 days. A logistic regression model was used to estimate risk associated with prior healthcare exposure. Indicators were created for prior exposure to different healthcare settings: separate indicators were used to indicate transfer, exposure to that setting in the prior 1–30 days, 31–60 days and 61–90 days. Separate indicators were created for prior hospitalization, ED, outpatient clinic, nursing home or long-term care facilities (LTCFs), psychiatric or substance-abuse facility or other outpatient facility. We also included an indicator for prior exposure to a family member with CDI and prior outpatient antibiotics. Results: Estimates for selected variables (odds ratios) are presented in Table 1. Prior hospitalization, ED visits, outpatient clinics, nursing home and LTCFs were all associated with increased risk of secondary diagnosed CDI. Prior hospitalization and nursing home/LTCF conveyed the greatest risk. In addition, a ‘dose-–response’ relationship occurred for each of these exposure settings, with exposure nearest the admission date having the largest risk. Prior exposure to psychiatric , substance abuse, or other outpatient facilities were not risk factors for CDI. Having a family member with prior CDI and both low-risk and high-risk outpatient antibiotics were associated with increased risk. These factors also exhibited a ‘dose–response’ pattern. Conclusions: Exposure to various healthcare settings significantly increased risk for secondary CDI. Prior healthcare exposures occurring nearest to the point of admission conveyed the greatest risk. These results suggest that many hospital-associated CDI cases attributed to a current hospital stay may actually be acquired from prior healthcare settings.Funding: CDC Modeling Infectious Diseases (MInD) in Healthcare NetworkDisclosures: None
A Bundled Approach to Reduce Delayed Testing and Hospital-Acquired Cases of Clostridioides difficile Infection
Authors: Chirca Ioana , Sun Alan , Albrecht Adrienne Wright , Henry Kelly 
Published: November 2020

Background:Clostridioides difficile is a leading cause of nosocomial infectious diarrhea in developed countries, and it has a significant economic impact throughout the world. Early detection of the pathogen and its toxins is critical because early treatment significantly reduces infection-related morbidity, mortality, and medical cost. Surveillance of healthcare-associated infections (HAIs) is conducted using the NHSN standardized infection ratio (SIR). This metric allows comparison of a facility’s observed infection rate to a national benchmark. The SIR can be elevated due to both a lack of institutional criteria for stool submission and the use of highly sensitive but poorly specific testing as a standalone test for diagnosis. The SIR can be artificially elevated by inclusion of C difficile carriers rather than infected patients due to inappropriate testing and overly sensitive methods. We aimed to determine the impact of an institutional nursing-driven protocol for stool submission as well as 2-step testing on the SIR. Methods: Starting from the fourth quarter of 2018, we instituted a nursing protocol for initiation of C. difficile testing. If the patient had ≥3 soft, loose, or liquid stools in 24 hours within the first 3 days of admission, they were placed on contact precautions and an unformed stool sample was submitted for C. difficile nucleic acid amplification testing (NAAT). A positive result prompted further evaluation with a stool enzyme immunoassay toxin test for confirmation of active infection. From hospital day 4 onward, stricter criteria were implemented for testing for C. difficile infection. Data were extrapolated for calculation of a quarterly SIR. This value was then compared to retrospective SIR data from the first quarter of 2016 to the third quarter of 2018. Results: The quarterly total of hospital-onset C. difficile infections from the first quarter of 2016 to the third quarter of 2018 ranged from 24 to 39 incidents per quarter. After implementing the nursing-driven protocol and 2-step testing, the quarterly total of hospital onset C. difficile infections decreased to 5–6 per quarter. The SIR prior to initiation ranged from 0.66 to 1.37 and decreased to 0.306–0.386 after the nursing-driven protocol and 2-step testing were implemented. Conclusions: Implementation of both an institutional nursing-driven protocol for stool submission and a 2-step testing protocol reduced the number of quarterly hospital-onset C. difficile events as well as our facility’s quarterly SIR to below the national standard.Funding: NoneDisclosures: Ioana Chirca, University Hospital
A Successful Bundled Intervention to Reduce Hospital-Acquired Pneumonia: Sustainability Still an Issue
Authors: Ben Mirian Dal , Perdiz Rafael , Amarante Gustavo , Colombari Heloise , Ramos Cintia , Viveiros Libanês Viviane , Barbosa Sandra , Oliveira Maura 
Published: November 2020

Background: Hospital-acquired pneumonia (HAP) is one of the most common healthcare-associated infections (HAIs). Interventions based on the identification of patients at risk for aspiration with subsequent application of multidisciplinary measures, such as speech therapy follow-up, head elevation, oral hygiene, and patient and family education can be effective in reducing the incidence of HAP. In 2016, the step-down unit of our institution experienced an increase in the incidence of HAP with 21 cases. A root-cause analysis showed that most of them were related to comorbidities that increased aspiration risk. We conducted an study to decrease the incidence of HAP through a multidisciplinary bundled intervention. Methods: We conducted a quasi-experimental study in a 45-bed step-down unit from January 2016 to June 2019. In January 2017, we conducted an educational intervention with all the unit team, reinforcing practices of bed head elevation and oral hygiene. In June 2018, we observed inconsistencies in practice and conducted a second intervention with another round of educational training and a bundled intervention consisting of the following elements: identification of patients at risk for aspiration at admission by a speech therapy evaluation, bed-head elevation, oral hygiene, feeding guidance individualized to each patient by a nutritionist and a speech therapist, patient and family education with a printed material, signaling of aspiration risk in a care plan board within the room and development of a sialorrhea treatment protocol. HAP surveillance was conducted in accordance to CDC definitions and was reported as number of HAP cases per 1,000 patient days. Results: Our first intervention decreased the incidence of HAP in the first semester of 2017 from 1.03 to 0.29 (graph) but was not sustained. The incidence started to increase in the second semester of 2017 and reached a high incidence of 1.87 HAP per 1,000 patient days in the first semester of 2018. The second bundled intervention succeeded in decreasing HAP incidence to 0.57 in the second semester of 2018 and 0.23 in the first semester of 2019. Conclusions: An educational intervention combined with a bundled intervention focused on strategies to reduce the risk of aspiration succeeded in decreasing the incidence of HAP in a step-down unit. However, the sustainability of improvements remains challenging.Funding: NoneDisclosures: None
A Survey of Antibiotic-Resistant Microorganisms in Hospital Sink Drains
Authors: Franco Lauren , Ganim Christine , Tanner Windy 
Published: November 2020

Background: Handwashing sinks in healthcare environments are reservoirs for healthcare pathogens and antibiotic-resistant microorganisms (ARO). We investigated the distribution of HCP and ARO within and among handwashing sinks in healthcare settings. To do this, we determined the differences in the number of ARO between samples within a sink (biofilm vs planktonic samples), between sink types (healthcare worker [HCW] vs patient room sinks), and between hospitals in the same city. Methods: Tap water, sink surface, drain cover, tail pipe, p-trap water and p-trap samples were collected from 2 patient room sinks and 2 HCW sinks over 11 months in 2 acute-care hospitals. Suspected pathogens were isolated from selective media (Pseudosel, Chromagar KPC, and MacConkey with 2 mg/L cefotaxime) and identified via MALDI-ToF. Isolates confirmed to be healthcare pathogens were characterized via disk diffusion to determine their antibiotic susceptibility according to CLSI guidelines. Isolates not susceptible to carbapenems (meropenem or ertapenem) were tested further via the modified carbapenem inactivation method to detect carbapenemase production. Results:Pseudomonas aeruginosa and Enterobacteriaceae (Enterobacter spp, Klebsiella spp, and Citrobacter spp) were the most frequently isolated pathogens. Among these isolates (195 P. aeruginosa and 42 Enterobacteriaceae isolates), 28.5% of P. aeruginosa and 85.7% of Enterobacteriaceae were nonsusceptible to 1 or more of the antibiotics tested. Of the isolates that were nonsusceptible to a carbapenem (46 of 237; 19%), none displayed phenotypic carbapenemase production. Other mechanisms of resistance have not been confirmed. There was no significant difference in the percentage of nonsusceptible HCP isolated from biofilm samples (from p-trap and tail pipe) compared to planktonic (p-trap water) samples (P > .05 for P. aeruginosa and Enterobacteriaceae). A greater percentage of resistant or intermediate isolates was recovered from patient room sinks than from HCW sinks (P < .05) for both P. aeruginosa and Enterobacteriaceae isolates (76.4 vs 32.9% for Enterobacteriaceae, 25.6 vs 0.3% for P. aeruginosa). We detected no significant difference in percentage of nonsusceptible isolates between the 2 hospitals sampled (P > .05). Conclusions: This survey of healthcare sinks supports previous work citing that they are reservoirs for HCP and ARO. This work further examines the distribution of HCP and ARO within and among sinks in these environments. Our findings thus far in the 2 hospitals studied reveal a higher percentage of ARO in patient sinks than in HCW sinks. This finding may suggest a higher input of ARO from patient use or greater selective pressure in patient room sinks.Disclosures: NoneFunding: Lauren Franco, Centers for Disease Control and Prevention