To characterize the presence and magnitude of viruses in the air and on surfaces in the rooms of hospitalized patients with respiratory viral infections, and to explore the association between care activities and viral contamination.

Prospective observational study.

Acute-care academic hospital.

In total, 52 adult patients with a positive respiratory viral infection test within 3 days of observation participated. Healthcare workers (HCWs) were recruited in staff meetings and at the time of patient care, and 23 wore personal air-sampling devices.

Viruses were measured in the air at a fixed location and in the personal breathing zone of HCWs. Predetermined environmental surfaces were sampled using premoistened Copan swabs at the beginning and at the end of the 3-hour observation period. Preamplification and quantitative real-time PCR methods were used to quantify viral pathogens.

Overall, 43% of stationary and 22% of personal air samples were positive for virus. Positive stationary air samples were associated with ≥5 HCW encounters during the observation period (odds ratio [OR], 5.3; 95% confidence interval [CI], 1.2–37.8). Viruses were frequently detected on all of the surfaces sampled. Virus concentrations on the IV pole hanger and telephone were positively correlated with the number of contacts made by HCWs on those surfaces. The distributions of influenza, rhinoviruses, and other viruses in the environment were similar.

Healthcare workers are at risk of contracting respiratory virus infections when delivering routine care for patients infected with the viruses, and they are at risk of disseminating virus because they touch virus-contaminated fomites.

To determine whether HCP were at higher risk than adults working in nonhealthcare roles (non-HCP).

Prospective cohort study.

Acute-care hospitals and other businesses in Toronto, Ontario, Canada.

Adults aged 18–69 years were enrolled for 1 or more of the 2010/2011, 2011/2012, and 2012/2013 influenza seasons. Swabs collected during acute respiratory illnesses were tested for influenza and pre- and postseason blood samples were tested for influenza-specific immune response.

The adjusted odds of influenza were similar for HCP and non-HCP (odds ratio [OR], 1.29; 95% confidence interval [CI], 0.63–2.63). Older adults and those vaccinated against influenza had lower odds, and those who shared their workspace and who used corrective eyewear had higher odds of influenza.

HCP and other working adults are at similar risk of influenza infection.

To assess the effect of peer-identified change agents (PICAs) compared to management-selected change agents (MSCAs) on hand hygiene behavior in acute care.

Randomized-controlled study.

Two internal medicine wards of a public, university-affiliated, tertiary-care hospital in Malaysia.

We randomly allocated 2 wards to hand hygiene promotion delivered either by PICAs (study arm 1) or by MSCAs (study arm 2). The primary outcome was hand hygiene compliance using direct observation by validated auditors. Secondary outcomes were hand hygiene knowledge and observations from ward tours.

Mean hand hygiene compliance in study arm 1 and study arm 2 improved from 48% (95% confidence interval [CI], 44%–53%) and 50% (95% CI, 44%–55%) in the preintervention period to 66% (63%–69%) and 65% (60%–69%) in the intervention period, respectively. We detected no statistically significant difference in hand hygiene improvement between the 2 study arms. Knowledge scores on hand hygiene in study arm 1 and study arm 2 improved from 60% and 63% to 98% and 93%, respectively. Staff in study arm 1 improved hand hygiene because they did not want to disappoint the efforts taken by the PICAs. Staff in study arm 2 felt pressured by the MSCAs to comply with hand hygiene to obtain good overall performance appraisals.

Although the attitude of PICAs and MSCAs in terms of leadership, mode of action and perception of their task by staff were very different, or even opposed, both PICAs and MSCAs effectively changed behavior of staff toward improved hand hygiene to comparable levels.

Sink drainage systems are not amenable to standard methods of cleaning and disinfection. Disinfectants applied as a foam might enhance efficacy of drain decontamination due to greater persistence and increased penetration into sites harboring microorganisms.

To examine the efficacy and persistence of foam-based products in reducing sink drain colonization with gram-negative bacilli.

During a 5-month period, different methods for sink drain disinfection in patient rooms were evaluated in a hospital and its affiliated long-term care facility. We compared the efficacy of a single treatment with 4 different foam products in reducing the burden of gram-negative bacilli in the sink drain to a depth of 2.4 cm (1 inch) below the strainer. For the most effective product, the effectiveness of foam versus liquid-pouring applications, and the effectiveness of repeated foam treatments were evaluated.

A foam product containing 3.13% hydrogen peroxide and 0.05% peracetic acid was significantly more effective than the other 3 foam products. In comparison to pouring the hydrogen peroxide and peracetic acid disinfectant, the foam application resulted in significantly reduced recovery of gram-negative bacilli on days 1, 2, and 3 after treatment with a return to baseline by day 7. With repeated treatments every 3 days, a progressive decrease in the bacterial load recovered from sink drains was achieved.

An easy-to-use foaming application of a hydrogen peroxide- and peracetic acid-based disinfectant suppressed sink-drain colonization for at least 3 days. Intermittent application of the foaming disinfectant could potentially reduce the risk for dissemination of pathogens from sink drains.

The epidemiology of ESBL-producing Enterobacteriaceae (ESBL-PE) has been extensively studied in hospitals, but data on community transmission are scarce. We investigated ESBL-PE cocarriage and acquisition in households using a systematic literature review.

We conducted a systematic literature search to retrieve cross-sectional or cohort studies published between 1990 and 2018 evaluating cocarriage proportions and/or acquisition rates of ESBL-PE among household members, without language restriction. We excluded studies focusing on animal-to-human transmission or conducted in nonhousehold settings. The main outcomes were ESBL-PE cocarriage proportions and acquisition rates, stratified according to phenotypic or genotypic assessment of strain relatedness. Cocarriage proportions of clonally related ESBL-PE were transformed using the double-arcsine method and were pooled using a random-effects model. Potential biases were assessed manually.

We included 13 studies. Among 863 household members of ESBL-PE positive index cases, prevalence of ESBL-PE cocarriage ranged from 8% to 37%. Overall, 12% (95% confidence interval [CI], 8%–16%) of subjects had a clonally related strain. Those proportions were higher for Klebsiella pneumoniae (20%–25%) than for Escherichia coli (10%–20%). Acquisition rates of clonally related ESBL-PE among 180 initially ESBL-PE–free household members of a previously identified carrier ranged between 1.56 and 2.03 events per 1,000 person weeks of follow-up. We identified multiple sources of bias and high heterogeneity (I2, 70%) between studies.

ESBL-PE household cocarriage is frequent, suggesting intrafamilial acquisition. Further research is needed to evaluate the risk and control of ESBL-PE household transmission.

Prevention of Clostridioides difficile infection (CDI) is a national priority and may be facilitated by deployment of the Targeted Assessment for Prevention (TAP) Strategy, a quality improvement framework providing a focused approach to infection prevention. This article describes the process and outcomes of TAP Strategy implementation for CDI prevention in a healthcare system.

Hospital A was identified based on CDI surveillance data indicating an excess burden of infections above the national goal; hospitals B and C participated as part of systemwide deployment. TAP facility assessments were administered to staff to identify infection control gaps and inform CDI prevention interventions. Retrospective analysis was performed using negative-binomial, interrupted time series (ITS) regression to assess overall effect of targeted CDI prevention efforts. Analysis included hospital-onset, laboratory-identified C. difficile event data for 18 months before and after implementation of the TAP facility assessments.

The systemwide monthly CDI rate significantly decreased at the intervention (β2, −44%; P = .017), and the postintervention CDI rate trend showed a sustained decrease (β1 + β3; −12% per month; P = .008). At an individual hospital level, the CDI rate trend significantly decreased in the postintervention period at hospital A only (β1 + β3, −26% per month; P = .003).

This project demonstrates TAP Strategy implementation in a healthcare system, yielding significant decrease in the laboratory-identified C. difficile rate trend in the postintervention period at the system level and in hospital A. This project highlights the potential benefit of directing prevention efforts to facilities with the highest burden of excess infections to more efficiently reduce CDI rates.

A guideline for the prevention of Clostridioides difficile infection (CDI) in 127 Veterans Health Administration acute-care facilities was implemented in July 2012. Beginning in 2015, a targeted assessment for prevention strategy was used to evaluate facilities for hospital-onset healthcare-facility–associated CDIs to focus prevention efforts where they might have the most impact in reaching a reduction goal of 30% nationwide.

We calculated standardized infection ratios (SIRs) and cumulative attributable differences (CADs) using a national data baseline. Facilities were ranked by CAD, and those with the 10 highest CAD values were targeted for periodic conference calls or a site visit from January 2016–September 2019.

The hospital-onset healthcare-facility–associated CDI rate in the 10 facilities with the highest CADs declined 56% during the process improvement period, compared to a 44% decline in the 117 nonintervention facilities (P = .03).

Process improvement interventions targeting facilities ranked by CAD values may be an efficient strategy for decreasing CDI rates in a large healthcare system.

The reported incidence of Clostridoides difficile infection (CDI) has increased in recent years, partly due to broadening adoption of nucleic acid amplification tests (NAATs) replacing enzyme immunoassay (EIA) methods. Our aim was to quantify the impact of this switch on reported CDI rates using a large, multihospital, empirical dataset.

We analyzed 9 years of retrospective CDI data (2009–2017) from 47 hospitals in the southeastern United States; 37 hospitals switched to NAAT during this period, including 24 with sufficient pre- and post-switch data for statistical analyses. Poisson regression was used to quantify the NAAT-over-EIA incidence rate ratio (IRR) at hospital and network levels while controlling for longitudinal trends, the proportion of intensive care unit patient days, changes in surveillance methodology, and previously detected infection cluster periods. We additionally used change-point detection methods to identify shifts in the mean and/or slope of hospital-level CDI rates, and we compared results to recorded switch dates.

For hospitals that transitioned to NAAT, average unadjusted CDI rates increased substantially after the test switch from 10.9 to 23.9 per 10,000 patient days. Individual hospital IRRs ranged from 0.75 to 5.47, with a network-wide IRR of 1.75 (95% confidence interval, 1.62–1.89). Reported CDI rates significantly changed 1.6 months on average after switching to NAAT testing (standard deviation, 1.9 months).

Hospitals that switched from EIA to NAAT testing experienced an average postswitch increase of 75% in reported CDI rates after adjusting for other factors, and this increase was often gradual or delayed.

To describe pathogen distribution and rates for central-line–associated bloodstream infections (CLABSIs) from different acute-care locations during 2011–2017 to inform prevention efforts.

CLABSI data from the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) were analyzed. Percentages and pooled mean incidence density rates were calculated for a variety of pathogens and stratified by acute-care location groups (adult intensive care units [ICUs], pediatric ICUs [PICUs], adult wards, pediatric wards, and oncology wards).

From 2011 to 2017, 136,264 CLABSIs were reported to the NHSN by adult and pediatric acute-care locations; adult ICUs and wards reported the most CLABSIs: 59,461 (44%) and 40,763 (30%), respectively. In 2017, the most common pathogens were Candida spp/yeast in adult ICUs (27%) and Enterobacteriaceae in adult wards, pediatric wards, oncology wards, and PICUs (23%–31%). Most pathogen-specific CLABSI rates decreased over time, excepting Candida spp/yeast in adult ICUs and Enterobacteriaceae in oncology wards, which increased, and Staphylococcus aureus rates in pediatric locations, which did not change.

The pathogens associated with CLABSIs differ across acute-care location groups. Learning how pathogen-targeted prevention efforts could augment current prevention strategies, such as strategies aimed at preventing Candida spp/yeast and Enterobacteriaceae CLABSIs, might further reduce national rates.

To characterize nontuberculous mycobacteria (NTM) associated with case clusters at 3 medical facilities.

Retrospective cohort study using molecular typing of patient and water isolates.

Veterans Affairs Medical Centers (VAMCs).

Isolation and identification of NTM from clinical and water samples using culture, MALDI-TOF, and gene population sequencing to determine species and genetic relatedness. Clinical data were abstracted from electronic health records.

An identical strain of Mycobacterium conceptionense was isolated from 41 patients at VA Medical Centers (VAMCs A, B, and D), and from VAMC A’s ICU ice machine. Isolates were initially identified as other NTM species within the M. fortuitum clade. Sequencing analyses revealed that they were identical M. conceptionense strains. Overall, 7 patients (17%) met the criteria for pulmonary or nonpulmonary infection with NTM, and 13 of 41 (32%) were treated with effective antimicrobials regardless of infection or colonization status. Separately, a M. mucogenicum patient strain from VAMC A matched a strain isolated from a VAMC B ICU ice machine. VAMC C, in a different state, had a 4-patient cluster with Mycobacterium porcinum. Strains were identical to those isolated from sink-water samples at this facility.

NTM from hospital water systems are found in hospitalized patients, often during workup for other infections, making attribution of NTM infection problematic. Variable NTM identification methods and changing taxonomy create challenges for epidemiologic investigation and linkage to environmental sources.

To identify patient and provider characteristics associated with high-volume antibiotic prescribing for children in Tennessee, a state with high antibiotic utilization.

Cross-sectional, retrospective analysis of pediatric (aged <20 years) outpatient antibiotic prescriptions in Tennessee using the 2016 IQVIA Xponent (formerly QuintilesIMS) database.

Patient and provider characteristics, including county of prescription fill, rural versus urban county classification, patient age group, provider type (nurse practitioner, physician assistant, physician, or dentist), physician specialty, and physician years of practice were analyzed.

Tennessee providers wrote 1,940,011 pediatric outpatient antibiotic prescriptions yielding an antibiotic prescribing rate of 1,165 per 1,000 population, 50% higher than the national pediatric antibiotic prescribing rate. Mean antibiotic prescribing rates varied greatly by county (range, 39–2,482 prescriptions per 1,000 population). Physicians wrote the greatest number of antibiotic prescriptions (1,043,030 prescriptions, 54%) of which 56% were written by general pediatricians. Pediatricians graduating from medical school prior to 2000 were significantly more likely than those graduating after 2000 to be high antibiotic prescribers. Overall, 360 providers (1.7% of the 21,798 total providers in this dataset) were responsible for nearly 25% of both overall and broad-spectrum antibiotic prescriptions; 20% of these providers practiced in a single county.

Fewer than 2% of providers account for 25% of pediatric antibiotic prescriptions. High antibiotic prescribing for children in Tennessee is associated with specific patient and provider characteristics that can be used to design stewardship interventions targeted to the highest prescribing providers in specific counties and specialties.

To estimate the attributable mortality, length of stay (LOS), and healthcare cost of pediatric and neonatal healthcare-acquired bloodstream infections (HA-BSIs).

A systematic review and meta-analysis.

A systematic search (January 2000–September 2018) was conducted in PubMed, Cochrane, and CINAHL databases. Reference lists of selected articles were screened to identify additional studies. Case–control or cohort studies were eligible for inclusion when full text was available in English and data for at least 1 of the following criteria were provided: attributable or excess LOS, healthcare cost, or mortality rate due to HA-BSI. Study quality was evaluated using the Critical Appraisal Skills Programme Tool (CASP). Study selection and quality assessment were conducted by 2 independent researchers, and a third researcher was consulted to resolve any disagreements. Fixed- or random-effect models, as appropriate, were used to synthesize data. Heterogeneity and publication bias were evaluated.

In total, 21 studies were included in the systematic review and 13 studies were included in the meta-analysis. Attributable mean LOS ranged between 4 and 27.8 days; healthcare cost ranged between $1,642.16 and $160,804 (2019 USD) per patient with HA-BSI; and mortality rate ranged between 1.43% and 24%. The pooled mean attributable hospital LOS was 16.91 days (95% confidence interval [CI], 13.70–20.11) and the pooled attributable mortality rate was 8% (95% CI, 6–9). A meta-analysis was not conducted for cost due to lack of eligible studies.

Pediatric HA-BSIs have a significant impact on mortality, LOS, and healthcare cost, further highlighting the need for implementation of HA-BSI prevention strategies.