To determine the 180-day cumulative incidence of culture-confirmed Staphylococcus aureus infections after elective pediatric surgeries.

Retrospective cohort study utilizing the Premier Healthcare database (PHD).

Inpatient and hospital-based outpatient elective surgical discharges.

Pediatric patients <18 years who underwent surgery during elective admissions between July 1, 2010, and June 30, 2015, at any of 181 PHD hospitals reporting microbiology results.

In total, 74 surgical categories were defined using ICD-9-CM and CPT procedure codes. Microbiology results and ICD-9-CM diagnosis codes defined S. aureus infection types: bloodstream infection (BSI), surgical site infection (SSI), and other types (urinary tract, respiratory, and all other). Cumulative postsurgical infection incidence was calculated as the number of infections divided by the number of discharges with qualifying elective surgeries.

Among 11,874 inpatient surgical discharges, 180-day S. aureus infection incidence was 1.79% overall (1.00% SSI, 0.35% BSI, 0.45% other). Incidence was highest among children <2 years of age (2.76%) and lowest for those 10–17 years (1.49%). Among 50,698 outpatient surgical discharges, incidence was 0.36% overall (0.23% SSI, 0.05% BSI, 0.08% others); it was highest among children <2 years of age (0.57%) and lowest for those aged 10–17 years (0.30%). MRSA incidence was significantly higher after inpatient surgeries (0.68%) than after outpatient surgeries (0.14%; P < .0001). Overall, the median days to S. aureus infection was longer after outpatient surgery than after inpatient surgery (39 vs. 31 days; P = .0116).

These findings illustrate the burden of postoperative S. aureus infections in the pediatric population, particularly among young children. These results underscore the need for continued infection prevention efforts and longer-term surveillance after surgery.

Healthcare-associated infections (HAIs) remain a major challenge. Various strategies have been tried to prevent or control HAIs. Positive deviance, a strategy that has been used in the last decade, is based on the observation that a few at-risk individuals follow uncommon, useful practices and that, consequently, they experience better outcomes than their peers who share similar risks. We performed a systematic literature review to measure the impact of positive deviance in controlling HAIs.

A systematic search strategy was used to search PubMed, CINAHL, Scopus, and Embase through May 2020 for studies evaluating positive deviance as a single intervention or as part of an initiative to prevent or control healthcare-associated infections. The risk of bias was evaluated using the Downs and Black score.

Of 542 articles potentially eligible for review, 14 articles were included for further analysis. All studies were observational, quasi-experimental (before-and-after intervention) studies. Hand hygiene was the outcome in 8 studies (57%), and an improvement was observed in association with implementation of positive deviance as a single intervention in all of them. Overall HAI rates were measured in 5 studies (36%), and positive deviance was associated with an observed reduction in 4 (80%) of them. Methicillin-resistant Staphylococcus aureus infections were evaluated in 5 studies (36%), and positive deviance containing bundles were successful in all of them.

Positive deviance may be an effective strategy to improve hand hygiene and control HAIs. Further studies are needed to confirm this effect.

Temporal overlap of the Atlantic hurricane season and seasonal influenza vaccine rollout has the potential to result in delays or disruptions of vaccination campaigns. We documented seasonal influenza vaccination behavior over a 5-year period and explored associations between flooding following Hurricane Harvey and timing and uptake of vaccines, as well as how the impacts of Hurricane Harvey on vaccination vary by race, wealth, and rurality.

Retrospective cohort analysis.

Texas counties affected by Hurricane Harvey.

Active users of the Veterans’ Health Administration in 2017.

We used geocoded residential address data to assess flood exposure status following Hurricane Harvey. Days to receipt of seasonal influenza vaccines were calculated for each year from 2014 to 2019. Proportional hazards models were used to determine how likelihood of vaccination varied according to flood status as well as the race, wealth, and rural–urban residence of patients.

The year of Hurricane Harvey was associated with a median delay of 2 weeks to vaccination and lower overall vaccination than in prior years. Residential status in flooded areas was associated with lower hazards of influenza vaccination in all years. White patients had higher proportional hazards of influenza vaccination than non-White patients, though this attenuated to 6.39% (hazard ratio [HR], 1.0639; 95% confidence interval [CI], 1.034–1.095) in the hurricane. year.

Receipt of seasonal influenza vaccination following regional exposure to the effects of Hurricane Harvey was delayed among US veterans. White, non–low-income, and rural patients had higher likelihood of vaccination in all years of the study, but these gaps narrowed during the hurricane year.

To assess current resources, interventions, and obstacles of pediatric outpatient antimicrobial stewardship programs (ASP).

Cross-sectional study.

Institutions from the Sharing Antimicrobial Reports for Pediatric Stewardship OutPatient collaborative (SHARPS-OP).

Antimicrobial stewardship leaders from the above institutions.

An investigator-developed survey was deployed online in September 2020 to antimicrobial stewardship leaders in SHARPS-OP institutions. The survey was divided into 4 sections: (1) basic information, (2) status of pediatric outpatient ASP in the institutions including financial support, (3) outpatient ASP interventions undertaken by the institutions, and (4) needs and SHARPS-OP collaborative goals.

Of 56 invited institutions, 45 participated, achieving an 80% response rate. Only 5 sites (11%) had allocated financial support for an outpatient ASP, compared to 42 (95.6%) for their inpatient ASP. The most widely used outpatient ASP interventions included antimicrobial guidance (57.8%), education (46.7%), and quality improvement projects (37.8%). Time was identified as the biggest barrier to expanding outpatient ASPs (91.1%), followed by financial support (53.3%), development of meaningful reports (51.1%), and administrative support (44.4%). Important goals of the collaborative included seeking learning opportunities and developing clear metrics for pediatric outpatient ASP benchmarking. Program needs included securing operational support (35.8%) and strengthening data analysis (31.6%).

Very few pediatric institutions with robust inpatient ASPs have devoted time and financial support to advance outpatient efforts. To promote appropriate antibiotic prescribing in the outpatient arena, time and resource funding by administrative leaders are necessary to develop a robust, sustainable stewardship infrastructure.

Inpatient surgical site infections (SSIs) cause morbidity in children. The SSI rate among pediatric ambulatory surgery patients is less clear. To fill this gap, we conducted a multiple-institution, retrospective epidemiologic study to identify incidence, risk factors, and outcomes.

We identified patients aged <22 years with ambulatory visits between October 2010 and September 2015 via electronic queries at 3 medical centers. We performed sample chart reviews to confirm ambulatory surgery and adjudicate SSIs. Weighted Poisson incidence rates were calculated. Separately, we used case–control methodology using multivariate backward logistical regression to assess risk-factor association with SSI.

In total, 65,056 patients were identified by queries, and we performed complete chart reviews for 13,795 patients; we identified 45 SSIs following ambulatory surgery. The weighted SSI incidence following pediatric ambulatory surgery was 2.00 SSI per 1,000 ambulatory surgeries (95% confidence interval [CI], 1.37–3.00). Integumentary surgeries had the highest weighted SSI incidence, 3.24 per 1,000 ambulatory surgeries (95% CI, 0.32–12). The following variables carried significantly increased odds of infection: clean contaminated or contaminated wound class compared to clean (odds ratio [OR], 9.8; 95% CI, 2.0–48), other insurance type compared to private (OR, 4.0; 95% CI, 1.6–9.8), and surgery on weekend day compared to weekday (OR, 30; 95% CI, 2.9–315). Of the 45 instances of SSI following pediatric ambulatory surgery, 40% of patients were admitted to the hospital and 36% required a new operative procedure or bedside incision and drainage.

Our findings suggest that morbidity is associated with SSI following ambulatory surgery in children, and we also identified possible targets for intervention.

Overuse of antibiotics in the emergency department (ED) for uncomplicated acute respiratory tract infections (uARTIs) is a public health issue that needs to be addressed. We aimed to identify factors associated with antibiotic use for uARTIs in adults presenting at the ED.

We searched Medline, Embase, PsycINFO and the Cochrane Library for articles published from 1 January 2005 to 30 June 2017 using a predetermined search strategy. Titles and abstracts of English articles on antibiotic prescription and inappropriate antibiotic use for adult ARTI at EDs were assessed, followed by full article review, by 2 authors.

Emergency departments.

Adults aged 18 years and older.

Of the 2,591 articles retrieved, 12 articles met the inclusion criteria and 11 studies were conducted in the United States. Patients with normal C-reactive protein levels and positive influenza tests were less likely to receive antibiotic treatment. Nonclinical factors associated with antibiotic use were longer waiting time and perceived patient desire for antibiotics. Patients attended by internal medicine physicians comanaged by house staff or who visited an ED which provided education to healthcare providers on antibiotics use were less likely to receive antibiotics.

English-language articles that fulfilled the selection criteria outside the United States were limited. Factors associated with antibiotics use are multifaceted. Education of healthcare providers presents an opportunity to improve antibiotic use.

Despite the numerous advantages of central venous catheters (CVCs), they have been associated with a variety of complications. Surveillance for mechanical complications of CVCs is not routine, so the true incidence and impact of this adverse patient outcome remains unclear.

Prospectively collected CVC data on mechanical complications were reviewed from a centralized database for all in-hospital patient days at our tertiary-care hospital from January 2001 to June 2016 in patients aged <19 years. Patient demographics, CVC characteristics, and rates of mechanical complications per 1,000 days of catheter use were described.

In total, 8,747 CVCs were placed in 5,743 patients during the study period, which captured 780,448 catheter days. The overall mechanical complication rate was 6.1 per 1,000 catheter days (95% confidence interval [CI], 5.9–6.3). The highest complication rates were in nontunneled lines; this was consistent throughout the 15-year study period. Also, 521 CVCs (∼6%) were removed due to mechanical complications before therapy termination. Catheters with tip location in the superior vena cava or right atrium had the fewest complications.

Mechanical complications of CVCs are a common and significant event in the pediatric population. We propose that CVC-associated mechanical complications become a routinely reported patient safety outcome.

Effective infection prevention and control (IPC) measures are key for protecting patients from nosocomial infections and require knowledge of transmission mechanisms in different settings. We performed a detailed outbreak analysis of the transmission and outcome of coronavirus disease 2019 (COVID-19) in a geriatric ward by combining whole-genome sequencing (WGS) with epidemiological data.

Retrospective cohort study.

Tertiary-care hospital.

Patients and healthcare workers (HCWs) from the ward with a nasopharyngeal sample (NPS) positive for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) RNA during the outbreak period.

Patient data regarding clinical characteristics, exposure and outcome were collected retrospectively from medical records. Stored NPSs from 32 patients and 15 HCWs were selected for WGS and phylogenetic analysis.

The median patient age was 84 years and 17 (53%) of 32 were male. Also, 14 patients (44%) died within 30 days of sampling. Viral loads were significantly higher among the deceased. WGS was successful in 28 (88%) of 32 patient samples and 14 (93%) of 15 HCW samples. Moreover, 3 separate viral clades were identified: 1 clade and 2 subclades among both patient and HCW samples. Integrated epidemiological and genetic analyses revealed 6 probable transmission events between patients and supported hospital-acquired COVID-19 among 25 of 32 patients.

WGS provided an insight into the outbreak dynamics and true extent of nosocomial COVID-19. The extensive transmission between patients and HCWs indicated that current IPC measures were insufficient. We recommend increased use of WGS in outbreak investigations to identify otherwise unknown transmission links and to evaluate IPC measures.

To describe the epidemiology of patients with nonintestinal carbapenem-resistant Enterobacterales (CRE) colonization and to compare clinical outcomes of these patients to those with CRE infection.

A secondary analysis of Consortium on Resistance Against Carbapenems in Klebsiella and other Enterobacteriaceae 2 (CRACKLE-2), a prospective observational cohort.

A total of 49 US short-term acute-care hospitals.

Patients hospitalized with CRE isolated from clinical cultures, April, 30, 2016, through August 31, 2017.

We described characteristics of patients in CRACKLE-2 with nonintestinal CRE colonization and assessed the impact of site of colonization on clinical outcomes. We then compared outcomes of patients defined as having nonintestinal CRE colonization to all those defined as having infection. The primary outcome was a desirability of outcome ranking (DOOR) at 30 days. Secondary outcomes were 30-day mortality and 90-day readmission.

Of 547 patients with nonintestinal CRE colonization, 275 (50%) were from the urinary tract, 201 (37%) were from the respiratory tract, and 71 (13%) were from a wound. Patients with urinary tract colonization were more likely to have a more desirable clinical outcome at 30 days than those with respiratory tract colonization, with a DOOR probability of better outcome of 61% (95% confidence interval [CI], 53%–71%). When compared to 255 patients with CRE infection, patients with CRE colonization had a similar overall clinical outcome, as well as 30-day mortality and 90-day readmission rates when analyzed in aggregate or by culture site. Sensitivity analyses demonstrated similar results using different definitions of infection.

Patients with nonintestinal CRE colonization had outcomes similar to those with CRE infection. Clinical outcomes may be influenced more by culture site than classification as “colonized” or “infected.”

Performance characteristics of SARS-CoV-2 nucleic acid detection assays are understudied within contexts of low pre-test probability, including screening asymptomatic persons without epidemiological links to confirmed cases, or asymptomatic surveillance testing. SARS-CoV-2 detection without symptoms may represent presymptomatic or asymptomatic infection, resolved infection with persistent RNA shedding, or a false-positive test. This study assessed the positive predictive value of SARS-CoV-2 real-time reverse transcription polymerase chain reaction (rRT-PCR) assays by retesting positive specimens from 5 pre-test probability groups ranging from high to low with an alternate assay.

In total, 122 rRT-PCR positive specimens collected from unique patients between March and July 2020 were retested using a laboratory-developed nested RT-PCR assay targeting the RNA-dependent RNA polymerase (RdRp) gene followed by Sanger sequencing.

Significantly fewer (15.6%) positive results in the lowest pre-test probability group (facilities with institution-wide screening having ≤3 positive asymptomatic cases) were reproduced with the nested RdRp gene RT-PCR assay than in each of the 4 groups with higher pre-test probability (individual group range, 50.0%–85.0%).

Large-scale SARS-CoV-2 screening testing initiatives among low pre-test probability populations should be evaluated thoroughly prior to implementation given the risk of false-positive results and consequent potential for harm at the individual and population level.

To investigate the feasibility of using an ultraviolet light-emitting diode (UV LED) robot for the terminal decontamination of coronavirus disease 2019 (COVID-19) patient rooms.

We assessed the presence of viral RNA in samples from environmental surfaces before and after UV LED irradiation in COVID-19 patient rooms after patient discharge.

We analyzed 216 environmental samples from 17 rooms: 2 from airborne infection isolation rooms (AIIRs) in the intensive care unit (ICU) and 15 from isolation rooms in the community treatment center (CTC). Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA was detected in 40 (18.5%) of 216 samples after patient discharge: 12 (33.3%) of 36 samples from AIIRs in the ICU, and 28 (15.6%) of 180 samples from isolation rooms in the CTC. In 1 AIIR, all samples were PCR negative after UV LED irradiation. In the CTC rooms, 14 (8.6%) of the 163 samples were PCR positive after UV LED irradiation. However, viable virus was not recovered from the culture of any of the PCR-positive samples.

Although no viable virus was recovered, SARS-CoV-2 RNA was detected on various environmental surfaces. The use of a UV LED disinfection robot was effective in spacious areas such as an ICU, but its effects varied in small spaces like CTC rooms. These findings suggest that the UV LED robot may need enough space to disinfect rooms without recontamination by machine wheels or insufficient disinfection by shadowing.

To identify the impact of universal masking on COVID-19 incidence and putative SARS-CoV-2 transmissions events among children’s hospital healthcare workers (HCWs).

Quasi-experimental study.

Single academic free-standing children’s hospital.

We performed whole-genome sequencing of SARS-CoV-2- PCR-positive samples collected from HCWs 3 weeks before and 6 weeks after implementing a universal masking policy. Phylogenetic analyses were performed to identify clusters of clonally related SARS-CoV-2 indicative of putative transmission events. We measured COVID-19 incidence, SARS-CoV-2 test positivity rates, and frequency of putative transmission events before and after the masking policy was implemented.

HCW COVID-19 incidence and test positivity declined from 14.3 to 4.3 cases per week, and from 18.4% to 9.0%, respectively. Putative transmission events were only identified prior to universal masking.

A universal masking policy was associated with reductions in HCW COVID-19 infections and occupational acquisition of SARS-CoV-2.