Despite the increasing rates of carbapenem-resistant Acinetobacter baumannii (CRAB) carriage among hospitalized patients in endemic settings, the role of active surveillance cultures and cohorting is still debated. We sought to determine the long-term effect of a multifaceted infection-control intervention on the incidence of CRAB in an endemic setting.

A prospective, quasi-experimental study was performed at a 670-bed, acute-care hospital. The study consisted of 4 phases. In phase I, basic infection control measures were used. In phase II, CRAB carriers were cohorted in a single ward with dedicated nursing and enhanced environmental cleaning. In phase III large-scale screening in high-risk units was implemented. Phase IV comprised a 15-month follow-up period.

During the baseline period, the mean incidence rate (IDR) of CRAB was 44 per 100,000 patient days (95% CI, 37.7–54.1). No significant decrease was observed during phase II (IDR, 40.8 per 100,000 patient days; 95% CI, 30.0–56.7; P = .97). During phase III, despite high compliance with control measures, ongoing transmission in several wards was observed and the mean IDR was 53.9 per 100,000 patient days (95% CI, 40.5–72.2; P = .55). In phase IV, following the implementation of large-scale screening, a significant decrease in the mean IDR was observed (25.8 per 100,000 patient days; 95% CI, 19.9–33.5; P = .03). An overall reduction of CRAB rate was observed between phase I and phase IV (rate ratio, 0.6; 95% CI, 0.4–0.9; P < .001).

The comprehensive intervention that included intensified control measures with routine active screening cultures was effective in reducing the incidence of CRAB in an endemic hospital setting.

Whole-genome sequencing (WGS) is increasingly used to characterize hospital outbreaks of carbapenemase-producing Enterobacterales (CPE). However, access to WGS is variable and testing is often centralized, leading to delays in reporting of results.

We describe the utility of a local sequencing service to promptly respond to facility needs over an 8-year period.

The study was conducted at Royal Prince Alfred Hospital in Sydney, Australia. All CPE isolated from patient (screening and clinical) and environmental samples from 2015 onward underwent prospective WGS. Results were notified to the infection control unit in real time. When outbreaks were identified, WGS reports were also provided to senior clinicians and the hospital executive administration. Enhanced infection control interventions were refined based on the genomic data.

In total, 141 CPE isolates were detected from 123 patients and 5 environmental samples. We identified 9 outbreaks, 4 of which occurred in high-risk wards (intensive care unit and/or solid-organ transplant ward). The largest outbreak involved Enterobacterales containing an NDM gene. WGS detected unexpected links among patients, which led to further investigation of epidemiological data that uncovered the outpatient setting and contaminated equipment as reservoirs for ongoing transmission. Targeted interventions as part of outbreak management halted further transmission.

WGS has transitioned from an emerging technology to an integral part of local CPE control strategies. Our results show the value of embedding this technology in routine surveillance, with timely reports generated in clinically relevant timeframes to inform and optimize local control measures for greatest impact.

Vancomycin is often initiated in hospitalized patients; however, it may be unnecessary or continued for longer durations than needed. Oversight of all vancomycin orders may not be feasible with widespread prescribing and strategies to enlist other clinicians to serve as stewards of vancomycin use are needed. We implemented 2 sequential interventions: a protocol in which the pharmacist orders MRSA nasal swab followed by a protocol requiring approval from pharmacists to continue vancomycin for >72 hours.

In this single-center, retrospective, quasi-experimental study, we evaluated vancomycin use after implementation of a pharmacy-driven MRSA nasal-swab ordering protocol and a vancomycin 72-hour restriction protocol. The primary outcome was the change in the standardized antibiotic administration ratio (SAAR) for antibacterial agents for resistant gram-positive infections. We also evaluated the impact on antibiotic utilization.

Following the MRSA swab protocol, the SAAR decreased from 1.26 to 1.13 (P < .001; 95% confidence interval [CI], 1.16–1.25). After the 72-hour approval process, the SAAR was 0.96 (P < .001; 95% CI, 1.0–1.12). Vancomycin utilization decreased from 138.9 to 125.3 days of therapy per 1,000 patient days following the MRSA swab protocol (P < .001) and to 112.7 (P < .001) following the 72-hour approval protocol. Interrupted time-series analysis identified a similar rate of decline in utilization following the 2 interventions (−0.3 and −0.5; P = .16). Both interventions combined resulted in a significant reduction (−1.5; P < .001).

Implementation of a pharmacist-driven MRSA nasal-swab ordering protocol, followed by a 72-hour approval protocol, was associated with a significant reduction in the SAAR for antibiotics used in the treatment of resistant gram-positive infections and a reduction in vancomycin utilization. Leveraging the oversight of primary service clinical pharmacists through these protocols proved to be an effective strategy.

Incidence and risk factors for recurrent Clostridioides difficile infection (rCDI) are well established in adults, though data are lacking in pediatrics. We aimed to determine incidence of and risk factors for rCDI in pediatrics.

This retrospective cohort study of pediatric patients was conducted at 3 tertiary-care hospitals in Canada with laboratory-confirmed CDI between April 1, 2012, and March 31, 2017. rCDI was defined as an episode of CDI occurring 8 weeks or less from diagnostic test date of the primary episode. We used logistic regression to determine and quantify risk factors significantly associated with rCDI.

In total, 286 patients were included in this study. The incidence proportion for rCDI was 12.9%. Among hospitalized patients, the incidence rate was estimated at 2.6 cases of rCDI per 1,000 hospital days at risk (95% confidence interval [CI], 1.7–3.9). Immunocompromised patients had higher incidence of rCDI (17.5%; P = .03) and higher odds of developing rCDI independently of antibiotic treatment given for the primary episode (odds ratio [OR], 2.31; 95% CI, 1.12–5.09). Treatment with vancomycin monotherapy did not show statistically significant protection from rCDI, independently of immunocompromised status (OR, 0.33; 95% CI, 0.05–1.15]).

The identification of increased risk of rCDI in immunocompromised pediatric patients warrants further research into alternative therapies, prophylaxis, and prevention strategies to prevent recurrent disease burden within these groups. Treatment of the initial episode with vancomycin did not show statistically significant protection from rCDI.

To explore infection preventionists’ perceptions of hospital leadership support for infection prevention and control programs during the coronavirus disease 2019 (COVID-19) pandemic and relationships with individual perceptions of burnout, psychological safety, and safety climate.

Cross-sectional survey, administered April through December 2021.

Random sample of non-federal acute-care hospitals in the United States.

Lead infection preventionists.

We received responses from 415 of 881 infection preventionists, representing a response rate of 47%. Among respondents, 64% reported very good to excellent hospital leadership support for their infection prevention and control program. However, 49% reported feeling burned out from their work. Also, ∼30% responded positively for all 7 psychological safety questions and were deemed to have “high psychological safety,” and 76% responded positively to the 2 safety climate questions and were deemed to have a “high safety climate.” Our results indicate an association between strong hospital leadership support and lower burnout (IRR, 0.61; 95% CI, 0.50–0.74), higher perceptions of psychological safety (IRR, 3.20; 95% CI, 2.00–5.10), and a corresponding 1.2 increase in safety climate on an ascending Likert scale from 1 to 10 (β, 1.21; 95% CI, 0.93–1.49).

Our national survey provides evidence that hospital leadership support may have helped infection preventionists avoid burnout and increase perceptions of psychological safety and safety climate during the COVID-19 pandemic. These findings aid in identifying factors that promote the well-being of infection preventionists and enhance the quality and safety of patient care.

We evaluated the adequacy of microbiological tests in patients withholding or withdrawing life-sustaining treatment (WLST) at the end stage of life.

The study was conducted at 2 tertiary-care referral hospitals in Daegu, Republic of Korea.

Retrospective cross-sectional study.

Demographic findings, clinical and epidemiological characteristics, statistics of microbiological tests, and microbial species isolated from patients within 2 weeks before death were collected in 2 tertiary-care referral hospitals from January to December 2018. We also reviewed the antimicrobial treatment that was given within 3 days of microbiological testing in patients on WLST.

Of the 1,187 hospitalized patients included, 905 patients (76.2%) had WLST. The number of tests per 1,000 patient days was higher after WLST than before WLST (242.0 vs 202.4). Among the category of microbiological tests, blood cultures were performed most frequently, and their numbers per 1,000 patient days before and after WLST were 95.9 and 99.0, respectively. The positive rates of blood culture before and after WLST were 17.2% and 18.0%, respectively. Candida spp. were the most common microbiological species in sputum (17.4%) and urine (48.2%), and Acinetobacter spp. were the most common in blood culture (17.3%). After WLST determination, 70.5% of microbiological tests did not lead to a change in antibiotic use.

Many unnecessary microbiological tests are being performed in patients with WLST within 2 weeks of death. Microbiological testing should be performed carefully and in accordance with the patient’s treatment goals.

National validation of claims-based surveillance for surgical-site infections (SSIs) following colon surgery and abdominal hysterectomy.

Retrospective cohort study.

US hospitals selected for data validation by Centers for Medicare & Medicaid Services (CMS).

The study included 550 hospitals performing colon surgery and 458 hospitals performing abdominal hysterectomy in federal fiscal year 2013.

We requested 1,200 medical records from hospitals selected for validation as part of the CMS Hospital Inpatient Quality Reporting program. For colon surgery, we sampled 60% with a billing code suggestive of SSI during their index admission and/or readmission within 30 days and 40% who were readmitted without one of these codes. For abdominal hysterectomy, we included all patients with an SSI code during their index admission, all patients readmitted within 30 days, and a sample of those with a prolonged surgical admission (length of stay > 7 days). We calculated sensitivity and positive predictive value for the different groups.

We identified 142 colon-surgery SSIs (46 superficial SSIs and 96 deep and organ-space SSIs) and 127 abdominal-hysterectomy SSIs (58 superficial SSIs and 69 deep and organ-space SSIs). Extrapolating to the full CMS data validation cohort, we estimated an SSI rate of 8.3% for colon surgery and 3.0% for abdominal hysterectomy. Our colon-surgery surveillance codes identified 93% of SSIs, with 1 SSI identified for every 2.6 patients reviewed. Our abdominal-hysterectomy surveillance codes identified 73% of SSIs, with 1 SSI identified for every 1.6 patients reviewed.

Using claims to target record review for SSI validation performed well in a national sample.

To systematically review the methodology, performance, and generalizability of diagnostic models for predicting the risk of healthcare-facility–onset (HO) Clostridioides difficile infection (CDI) in adult hospital inpatients (aged ≥18 years).

CDI is the most common cause of healthcare-associated diarrhea. Prediction models that identify inpatients at risk of HO-CDI have been published; however, the quality and utility of these models remain uncertain.

Two independent reviewers evaluated articles describing the development and/or validation of multivariable HO-CDI diagnostic models in an inpatient setting. All publication dates, languages, and study designs were considered. Model details (eg, sample size and source, outcome, and performance) were extracted from the selected studies based on the CHARMS checklist. The risk of bias was further assessed using PROBAST.

Of the 3,030 records evaluated, 11 were eligible for final analysis, which described 12 diagnostic models. Most studies clearly identified the predictors and outcomes but did not report how missing data were handled. The most frequent predictors across all models were advanced age, receipt of high-risk antibiotics, history of hospitalization, and history of CDI. All studies reported the area under the receiver operating characteristic curve (AUROC) as a measure of discriminatory ability. However, only 3 studies reported the model calibration results, and only 2 studies were externally validated. All of the studies had a high risk of bias.

The studies varied in their ability to predict the risk of HO-CDI. Future models will benefit from the validation on a prospective external cohort to maximize external validity.