bluuebunny/crossref_metadata_2025_split huggingface dataset:
Implementation of a Low-Cost Method to Reduce Bacterial Load in Patient-Room Sink Drains
Authors: Bédard Emilie , Benoit Marie-Ève , Bourdin Thibault , Charron Dominique , DeLisle Gaëlle , Daraiche Stéphane , Gravel Sophie , Robert Etienne , Constant Philippe , Déziel Eric , Quach Caroline , Prévost Michèle 
Published: November 2021

Background: Sink drains can act as breeding grounds for multidrug-resistant (MDR) bacteria, leading to outbreaks. Drains provide a protected humid environment where nutrient-rich substances are available. Recent and growing installation of water and energy conservation devices have led to increased frequency of drain blockage due to biofilm accumulation. Ineffective drainage may lead to backflow and accumulation of water in the sink during use, increasing the risk of contaminated aerosols formation or direct contamination of surrounding material and equipment. Cleaning and disinfection procedures of sink drains need to be improved to prevent amplification and dispersion of MDR bacteria. The objective of this study was to investigate alternatives to reduce the biofilm and risk of contamination through aerosols. Methods: Sink drains from patient rooms were randomly selected in the neonatal intensive care unit of a 450-bed pediatric hospital. We tested 4 approaches: (1) new drain; (2) self-disinfecting heating-vibration drain; (3) chemical disinfection with 20 ppm chlorine for 30 minutes; and (4) thermal disinfection with > 90°C water for 30 minutes. A special device was used during disinfection to increase the disinfectant contact time with the biofilm. Treatments were conducted weekly, with prior sampling of drain water. Other drains were also sampled weekly, including a control drain with no intervention. Bacterial loads were evaluated using flow cytometry and heterotrophic plate counts. The drains were made of stainless steel, a heat-conductive material. Results: Preliminary results show that chlorine disinfection had a small impact (<1 log) on culturable bacteria at 48 hours after disinfection but not after a week or repeated weekly disinfection. Thermal disinfection using boiling water is promising, showing an important decrease of 4 log in culturable cells after 48 hours and a concentration still 100× lower 1 week after the disinfection. Repeated weekly thermal disinfection maintained lower culturable levels in the drain. No culturable cells were detected in water from the self-disinfecting drain 2 months after installation, whereas the new drain became fully colonized to concentrations similar to those of drains prior to interventions during the same period. Conclusions: Thermal disinfection of drains is a promising alternative to chlorine. This solution is interesting because it is nontoxic and easy to perform, requiring a small volume of hot water. The rapid recolonization of the new drain suggests that replacing contaminated drains is not a sustainable solution and would need to be paired with a thermal disinfection program to maintain low culturable cells.Funding: NoDisclosures: None
How Does Antimicrobial Resistance Increase Medical Costs in Community-Acquired Acute Pyelonephritis?
Authors: Kim Bongyoung , Cheong Taul , Ahn Jungmo 
Published: November 2021

Background: The proportion of antimicrobial-resistant Enterobacterales that are causative pathogens for community-acquired acute pyelonephritis (CA-APN) has been increasing. We examined the effect of antimicrobial resistance on medical costs in CA-APN. Methods: A single-center retrospective cohort study was conducted at a tertiary-care hospital in Korea between January 2018 to December 2019. All hospitalized patients aged ≥19 years who were diagnosed with CA-APN were recruited, and those with Enterobacterales as a causative pathogen were included. Comparisons between CA-APN caused by extended-spectrum β-lactamase (ESBL)–producing pathogens (ESBL+ group) and those by non–ESBL-producing organisms (ESBL– group) as well as CA-APN caused by ciprofloxacin-resistant pathogens (CIP-R group) and those by ciprofloxacin-sensitive pathogens (CIP-S group) were performed. Log-linear regression was performed to determine the risk factors for medical costs. Results: In total, 241 patients were included in this study. Of these, 75 (31.1%) had an ESBL-producing pathogen and 87 (36.1%) had a ciprofloxacin-resistant pathogen. The overall medical costs were significantly higher in the ESBL+ group compared with the ESBL− group (US$3,730.18 vs US$3,119.32) P <0.001) as well as in CIP-R group compared with CIP-S group (3,730.18 USD vs. 3,119.32 USD, P =0.005). In addition, length of stay was longer in ESBL+ group compared with ESBL-group (11 vs. 8 days, P <0.001) as well as in CIP-R group compared with CIP-S group (11 vs. 8 days, P <0.001). There were no significant difference in the proportion of clinical failure between ESBL+ and ESBL- groups; CIP-R and CIP-S groups. Based on the log-linear regression model, the costs associated with ESBL-producing Enterobacterales as the causative pathogen would be, on average, 27% higher or US$1,211 higher than its counterpart (P = .026). By the same token, a patient who is a year older would incur US$23 higher cost (P = .040). Having any structural problem in urinary tract would incur US$1,231 higher cost (P = .015). A unit increase in Pitt score would incur US$767 USD higher cost (P < 0.001) higher cost, all other things constant. Conclusions: Medical costs for hospitalized patients with CA-APN are increased by the existence of ESBL-producing Enterobacterales but not by the existence of ciprofloxacin-resistant Enterobacterales.Funding: NoDisclosures: None
Periprocedural Testing and Antimicrobial Prophylaxis for Ureteral Stent Removal: An Opportunity for Antimicrobial Stewardship
Authors: Kotekal Dhatri , Hecker Michelle , Lengu Irma , Son Andrea 
Published: November 2021

Background: The American Urologic Association’s 2019 Best Practices Statement highlights the importance of procedural and host factors in optimizing antimicrobial prophylaxis for urologic procedures. For ureteral stent removal, a procedure considered low risk, the recommendation for prophylaxis is uncertain and is dependent primarily on patient factors. We examined periprocedural practices and outcomes for both low-risk and intermediate- to high-risk patients undergoing this procedure in a county hospital. Methods: A retrospective cohort study was performed on all patients who underwent stent removal from January to December 2019. Patients were classified as being low risk if they met the following criteria: age 48 hours within the previous 30 days, absence of external urinary catheters, no intermittent catheterization, absence of prosthetic cardiac valves, not pregnant, and not immunocompromised. All other patients were classified as intermediate to high risk. We assessed periprocedural urine testing, antimicrobial prophylaxis, and clinical outcomes. Results: Of 158 unique patients, 84 (53%) were classified as low risk. As shown in Table 1, preprocedural urine cultures were performed in 55% of low-risk versus 69% of intermediate- to high-risk patients. For the patients for whom urine cultures were performed, cultures were positive in 22% of low-risk versus 55% of intermediate- to high-risk patients (p < .0001). All patients received antimicrobial prophylaxis, most often a single dose after the procedure. None of the low risk patients had a positive urine culture or hospitalization within 30 days post procedure. Conclusions: Overall, 53% of patients undergoing stent removal were considered low-risk hosts, yet 100% of patients received antimicrobial prophylaxis. Future studies are needed to evaluate interventions to reduce unnecessary antimicrobial prophylaxis and standardize preprocedural testing in low-risk patients undergoing stent removal.Funding: NoDisclosures: None
Successful Treatment of Invasive MRSA Infections in Children Using Area Under the Vancomycin Concentration-Time Curve Divided by the Minimum Inhibitory Concentration (AUC/MIC) to Measure Vancomycin Exposure
Authors: Chiang Leslie , Pong Alice , Bradley John , Anderson Paige , Murray William 
Published: November 2021

Background: Vancomycin is the treatment of choice for invasive methicillin-resistant Staphylococcus aureus (MRSA) infections. Previous guidelines issued by the Infectious Diseases Society of America (IDSA) recommended targeting vancomycin serum trough concentrations of 15–20 mg/L; however, troughs <15 mg/L are also associated with increased odds of renal toxicity. To minimize toxicity, recently updated ASHP/IDSA/PIDS vancomycin dosing guidelines recommend the use of an area under the vancomycin concentration-time curve divided by the minimum inhibitory concentration (AUC/MIC) pharmacodynamic index to measure vancomycin exposure, with an AUC/MIC ratio >400 correlating with clinical efficacy. However, data on vancomycin therapeutic drug monitoring (TDM) in children are limited. Our institutional practice since January 2009 has been to use AUC/MIC, rather than serum trough concentrations, to guide vancomycin dosing. In this study, we describe clinical outcomes in vancomycin-treated children with invasive MRSA infections using this dosing method. Methods: We performed a retrospective chart review of children hospitalized with invasive MRSA infections between 2006 and 2019 at Rady Children’s Hospital in San Diego, California. Clinical, microbiologic, and pharmacologic data including the site of MRSA infection, clinical failure or cure, occurrence of acute kidney injury (AKI), vancomycin MIC, vancomycin AUC, and serum trough concentrations were collected. Results: In total, 61 invasive MRSA cases were reviewed: 20 were admitted January 2016 through December 2008, and 41 were admitted January 2009 through June 2019 (Figure 1). Most patients did not have medical comorbidities. The most common types of infections were primary bacteremia (34%) and osteomyelitis (32%). Of 61 children, 50 (82%) had positive clinical outcomes regardless of vancomycin dosing method. Of 20 patients, 8 (40%) admitted prior to January 2009 developed AKI, compared with 5 (12%) of 41 patients admitted after January 2009. Conclusions: In our retrospective review, most patients had clinically successful outcomes regardless of which dosing strategy was used. We found higher rates of renal toxicity in patients who were admitted prior to 2009, with TDM based on measuring peak and trough concentrations, compared with those using AUC/MIC for TDM. Our findings suggest that AUC/MIC TDM for invasive MRSA infections may be associated with lower rates of renal toxicity.Funding: NoDisclosures: None
Identification of Potentially Unnecessary Micafungin Use Patterns: Opportunities for Antifungal Stewardship Interventions
Authors: Concha Miguel Chavez , Hsueh Kevin , Durkin Michael , Spec Andrej 
Published: November 2021

Background: Echinocandins are used as first-line therapy for suspected and confirmed Candida spp, and its indiscriminate use may drive selection for echinocandin resistance. We evaluated patterns of use of micafungin to identify opportunities for antifungal stewardship. Methods: We identified all micafungin completed orders and microbiological test result data from July 2018 to November 2020 among hospitalized patients in Barnes-Jewish Hospital. Continuous micafungin courses with <48 hours of interruption were considered independent courses. We evaluated micafungin use in 3 scenarios in which its use may be unnecessary: (1) patients with blood cultures negative for Candida spp, (2) patients with recovery of yeast or Candida spp from tracheal aspirates, and (3) patients with recovery of yeast or Candida spp from urine cultures. We only included micafungin courses if they were initiated within 5 days of blood culture collection or up to 4 days after tracheal or urine culture collection to account for incubation and decision to initiate treatment. Results: We found 3,381 micafungin courses in 3,287 admissions. Of these, 2,532 courses had blood culture collection around micafungin initiation and were included in the first analysis: 1,879 (74%) were negative, 149 (6%) had Candida spp isolated in the blood, and 504 (20%) had positive blood cultures for other organisms. Micafungin was given for a median duration of 3 days (IQR, 2–7) to those with negative blood cultures and for 3 days (IQR, 1–5) to those with positive blood cultures without candidemia (p < 0.001), and prolonged durations of more than 5 days was seen in 768/1879 (41%) and 143/504 (28%) of courses, respectively (p <0.001). A total of 487 micafungin courses were initiated after tracheal aspirate culture collection. Those with yeast isolated (n = 100, 21%) received similar micafungin duration compared to those that had no yeast isolated [3 (2-7 IQR) vs. 3 (2-7) days, respectively; p = 0.56). Finally, a total of 844 micafungin courses started after urine culture collection. A total of 49 (6%) had yeast isolated from the urine and treatment duration was similar to those that did not [3 (1-6 IQR) vs. 3 (2-6) days, respectively; p = 0.87). Conclusions: Echinocandin treatment courses did not differ when a yeast was identified from a tracheal isolate or urine specimen. However, a substantial proportion of treatment courses were prolonged in those with negative Candida spp in the blood, suggesting opportunities for antifungal stewardship interventions.Funding: NoDisclosures: None
Veteran Satisfaction for Upper Respiratory-Tract Infection (URI) Visits Is Not Associated with Antibiotic Receipt But Is Associated with Antibiotic Expectation
Authors: Owens Staub Milner , Pellegrino Rachael , Johnson Morgan , Gettler Erin , Roumie Christianne , Dittus Robert , Hulgan Todd 
Published: November 2021

Background: Antibiotics are not recommended but are often prescribed for upper respiratory-tract infections (URIs). Prescribers cite patient expectation as a driver of inappropriate antibiotic prescribing; prior literature has demonstrated higher satisfaction scores in patients who receive antibiotics compared to those who do not. We assessed whether veteran satisfaction at URI visits was associated with antibiotic receipt or with reported expectation for antibiotics. Methods: We surveyed veterans with documented URI encounters in the Veterans’ Affairs Tennessee Valley Healthcare System between January 1, 2018, and December 31, 2019. Patients not evaluated in person, with documented dementia, or who died prior to the study start date were excluded. Veterans were asked to recall their URI visit and to complete the Patient Safety Questionnaire (PSQ)-18 (Rand Corporation) and questions assessing antibiotic expectations. The PSQ-18, an 18-item survey that assesses patient satisfaction, uses a 5-point Likert scale (ie, strongly disagree, disagree, uncertain, agree, strongly agree), yielding a composite score of 18–90. Higher scores represent more satisfaction with care. Demographic and visit-specific information were extracted via chart review. We used multivariable linear regression to assess differences in composite PSQ-18 satisfaction scores between those who did and did not receive an antibiotic, adjusted for patient and visit characteristics, and to assess differences in satisfaction scores for those who did and did not report expecting antibiotics, adjusted for antibiotic receipt. Results: We identified 1,435 patients seen for URI at 17 sites. After exclusions, 1,343 veterans were eligible for chart abstraction. After excluding 42 responders who responded after study close or returned blank surveys, the final analytic cohort included 432 (32.2%) of 1,343 responders; 225 (52.1%) received an antibiotic and 207 (47.9%) did not. Mean total satisfaction for veterans who received an antibiotic was 67.8 (SD, ±9.4) compared to 66.7 (SD, ±9.7) for those who did not (Figure 1). Increased total satisfaction was not significantly associated with antibiotic receipt (0.65; 95% CI, −2.0 to 3.3). Most veterans (72.0%) disagreed that visit satisfaction depended on antibiotic receipt. However, only 30.8% reported that they would not expect an antibiotic for URI visits. A significant reduction in total satisfaction (−4.1; 95% CI, −6.3 to −1.9) was associated with expecting compared to not expecting an antibiotic. Conclusions: Our findings suggest that prescribing an antibiotic is not associated with increased veteran satisfaction for URI visits but is associated with expecting an antibiotic. Future work will evaluate methods to change veteran antibiotic expectations.Funding: NoDisclosures: None
Chronic Antibiotic Suppression for Nonstaphylococcal Prosthetic Joint Infections Treated with Debridement or Implant Retention
Authors: Sekar Poorani , Nair Rajeshwari , Beck Brice , Alexander Bruce , Miell Kelly , Tande Aaron , Dukes Kimberly , Friberg Julia , Schweizer Marin , Pugely Andrew 
Published: November 2021

Background: Early postoperative and acute prosthetic joint infection (PJI) may be managed with debridement, antibiotics, and implant retention (DAIR). Among patients with nonstaphylococcal PJI, an initial 4–6-week course of intravenous or highly bioavailable oral antibiotics is recommended in the Infectious Diseases Society of America (IDSA) guidelines, with disagreement among committee members on the need for subsequent chronic oral antimicrobial suppression (CAS). We aimed to characterize patients with nonstaphylococcal PJI who received CAS and to compare them to those who did not receive CAS. Methods: This retrospective cohort study included patients admitted to Veterans’ Affairs (VA) hospitals from 2003 to 2017 who had a PJI caused by nonstaphylococcal bacteria, underwent DAIR, and received 4–6 weeks of antimicrobial treatment. PJI was defined by Musculoskeletal Infection Society (MSIS) 2011 criteria. CAS was defined as at least 6 months of oral antibiotics following initial treatment of the PJI. Patients were followed for 5 years after debridement. We used χ2 tests and t tests were used to compare patients who received CAS with those who did not receive CAS. Results: Overall, 561 patients had a nonstaphylococcal PJI treated with DAIR, and 80.6% of patients received CAS. The most common organisms causing PJI were streptococci. We detected no significant differences between patients who received CAS and those who did not receive CAS, except that modified Acute Physiology and Chronic Health Evaluation (mAPACHE) scores were higher among patients who did not receive CAS (Table 1). Conclusion: Patients not on CAS were more severely ill (by mAPACHE) than those on CAS. Otherwise, the 2 groups were not different. This finding was contrary to our hypothesis that patients with multiple comorbidities or higher mAPACHE scores would be more likely to get CAS. A future analysis will be conducted to assess treatment failure in both groups. We hope to find a specific cohort who may benefit from CAS and hope to deimplement CAS in others who may not benefit from it.Funding: NoDisclosures: None
COVID-19 and Ventilator-Associated Event Discordance
Authors: Cawcutt Kelly , Rupp Mark , Musil Lauren 
Published: November 2021

Background: The COVID-19 pandemic has challenged healthcare facilities since its discovery in late 2019. Notably, the subsequent COVID-19 pandemic has led to an increase in healthcare-acquired infections such as ventilator associated events (VAEs). Many hospitals in the United States perform surveillance for the NHSN for VAEs by monitoring mechanically ventilated patients for metrics that are generally considered to be objective and preventable and that lead to poor patient outcomes. The VAE definition is met in a stepwise manner. Initially, a ventilator-associated condition (VAC) is met when there an increase in ventilator requirements after a period of stability or improvement. An IVAC is then met when there is evidence of an infectious process such as leukocytosis or fever and a new antimicrobial agent is started. Finally, possible ventilator-associated pneumonia (PVAP) is met when there is evidence of microbial growth or viral detection. Since the beginning of the COVID-19 pandemic, our hospital has seen an increase in VAEs, which is, perhaps, not unexpected during a respiratory illness pandemic. However, the NSHN definitions of VAE, and PVAP in particular, do not account for the novelty and nuances of COVID-19. Methods: We performed a chart review of 144 patients who had a VAE reported to the NHSN between March 1 and December 31, 2020. Results: Of the 144 patients with a VAE reported to NHSN, 39 were SARS-CoV-2 positive. Of the 39 patients, 4 patients (10.25%) met the NHSN PVAP definition due to a positive SARS-CoV-2 PCR that was collected in the prolonged viral shedding period of their illness (< 90 days). One of the four patients also had a bacterial infection in addition to their subsequent positive COVID-19 result. All these patients were admitted to the hospital with a COVID-19 diagnosis and their initial PCR swab was performed upon admission. Conclusions: We believe that the PVAP definition was inappropriately triggered by patients who were decompensating on the ventilator due to a novel respiratory virus that was present on admission. Early in the pandemic, frequent swabbing of these patients was performed to try and understand the duration of viral shedding and to determine when it would be safe to transfer patients from isolation after prolonged hospitalization. The NSHN definition should take into consideration the prolonged viral shedding period of COVID-19 and natural history of the illness, and subsequent COVID-19 testing within 90 days of an initial positive should not require classification as a hospital-acquired PVAP.Funding: NoDisclosures: None
‘Dazed and Confused!’ Context and Social Disconnect in the Time of Pandemic
Authors: Piguet Olivier 
Published: November 2021

AbstractHumans are social animals. Our sense of identity and ‘self’ is defined in part by the roles we perform in the social groups to which we belong. This article discusses some of the variables that contribute to our sense of self, including language, place of origin, education and shared social norms. It also outlines some of the general mechanisms that underpin our various social networks. In its final part, this article reviews the impact of social isolation, such as that happened during the COVID pandemic, on these social mechanisms and the resulted disruption of psychological wellbeing in individuals diagnosed with dementia.
A versatile organisation: Mapping the military's core roles in a changing security environment
Authors: Wilén Nina , Strömbom Lisa 
Published: November 2021

AbstractWhat roles are military institutions expected to play in today's rapidly changing security environment? How are they supposed to interact with the society they are tasked to protect? These questions have been posed by classical military sociologists as well as by a newer generation of scholars. Yet so far, a comprehensive mapping of the military's potential roles in contemporary society is missing. In this article we contribute to an update of this debate by providing a categorisation of the different roles and tasks that the military institution plays in current industrialised democratic states. We identify three core roles, each divided into subroles, by drawing on an extensive reading of 70 National White Papers and Security Strategies from 37 OECD member states: (collective) defence, collective security, and aid to the nation. We analyse how these roles and tasks influence recent configurations in civil-military relations. This study thereby contributes with: (1) a useful illustration of the military's shifting roles and tasks in contemporary society; (2) increased understandings of how the different roles impact civil-military relations and related to this; and (3) a practical starting point for further analyses of the military organisation's internal challenges related to its, at times, contradictory roles.