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In a survey of infection prevention programs, leaders reported frequent clinical and infection prevention practice modifications to avoid coronavirus disease 2019 (COVID-19) exposure that exceeded national guidance. Future pandemic responses should emphasize balanced approaches to precautions, prioritize educational campaigns to manage safety concerns, and generate an evidence-base that can guide appropriate infection prevention practices.
Background: Appropriate testing of blood procalcitonin (PCT) can potentially inform antibiotic de-escalation in patients with severe infections. When used along with observed clinical improvements, PCT testing can support antimicrobial stewardship. However, this testing must be used optimally to ensure that it is actionable, cost-effective, and provides patient benefit. Although this test is widely used, little is known about the appropriateness of this testing in select populations. Methods: In this retrospective review, we evaluated PCT monitoring patterns and appropriateness of use and relationship to antibiotic days of therapy in a system of community hospitals. We evaluated the use of PCT testing in patients with known confounders, namely pregnancy, chronic kidney disease, or neutropenia, which we classified as “inappropriate use” because these conditions can affect the interpretation of PCT results. We also evaluated the relationship between PCT testing and antibiotic days of therapy for patients with sepsis, pneumonia, or lower respiratory tract infections. Results: In a 1-year period, ∼206,302 PCT tests were performed at 146 facilities, an average of ∼1,413 per facility per year. Approximately 27.7% of these tests were given to patients who were pregnant or had a confounding comorbidity such as chronic kidney disease or neutropenia. Of these “inappropriate” tests, >90% were given to patients with chronic kidney disease. Older patients (aged 60–80 years, n = 93,021) were more likely to receive a PCT test while also having a confounding comorbidities; 24% of older patients with a PCT test also had chronic kidney disease. Of all patients with a PCT test and chronic kidney disease, ∼76% were also diagnosed with either sepsis, pneumonia, or lower respiratory tract infections. Conclusions: Confounding conditions can affect PCT levels independently of infection. Additionally, some clinicians use PCT tests as probes for other physiological maladies. This analysis demonstrated that there is opportunity for education about the appropriate use of this test, how to interpret results in the presence of confounding conditions, and how to transform PCT test results into actions that facilitate antimicrobial stewardship and better patient care.
To design better antimicrobial stewardship programs, detailed data on the primary drivers and patterns of antibiotic use are needed.
To characterize the indications for antibiotic therapy, agents used, duration, combinations, and microbiological justification in 6 acute-care US facilities with varied location, size, and type of antimicrobial stewardship programs.
DESIGN, PARTICIPANTS, AND SETTING
Retrospective medical chart review was performed on a random cross-sectional sample of 1,200 adult inpatients, hospitalized (>24 hrs) in 6 hospitals, and receiving at least 1 antibiotic dose on 4 index dates chosen at equal intervals through a 1-year study period (October 1, 2009–September 30, 2010).
Infectious disease specialists recorded patient demographic characteristics, comorbidities, microbiological and radiological testing, and agents used, dose, duration, and indication for antibiotic prescriptions.
On the index dates 4,119 (60.5%) of 6,812 inpatients were receiving antibiotics. The random sample of 1,200 case patients was receiving 2,527 antibiotics (average: 2.1 per patient); 540 (21.4%) were prophylactic and 1,987 (78.6%) were therapeutic, of which 372 (18.7%) were pathogen-directed at start. Of the 1,615 empirical starts, 382 (23.7%) were subsequently pathogen-directed and 1,231 (76.2%) remained empirical. Use was primarily for respiratory (27.6% of prescriptions) followed by gastrointestinal (13.1%) infections. Fluoroquinolones, vancomycin, and antipseudomonal penicillins together accounted for 47.1% of therapy-days.
Use of broad-spectrum empirical therapy was prevalent in 6 US acute care facilities and in most instances was not subsequently pathogen directed. Fluoroquinolones, vancomycin, and antipseudomonal penicillins were the most frequently used antibiotics, particularly for respiratory indications.
To estimate and compare the impact on healthcare costs of 3 alternative strategies for reducing bloodstream infections in the intensive care unit (ICU): methicillin-resistant Staphylococcus aureus (MRSA) nares screening and isolation, targeted decolonization (ie, screening, isolation, and decolonization of MRSA carriers or infections), and universal decolonization (ie, no screening and decolonization of all ICU patients).
Cost analysis using decision modeling.
We developed a decision-analysis model to estimate the health care costs of targeted decolonization and universal decolonization strategies compared with a strategy of MRSA nares screening and isolation. Effectiveness estimates were derived from a recent randomized trial of the 3 strategies, and cost estimates were derived from the literature.
In the base case, universal decolonization was the dominant strategy and was estimated to have both lower intervention costs and lower total ICU costs than either screening and isolation or targeted decolonization. Compared with screening and isolation, universal decolonization was estimated to save $171,000 and prevent 9 additional bloodstream infections for every 1,000 ICU admissions. The dominance of universal decolonization persisted under a wide range of cost and effectiveness assumptions.
A strategy of universal decolonization for patients admitted to the ICU would both reduce bloodstream infections and likely reduce healthcare costs compared with strategies of MRSA nares screening and isolation or screening and isolation coupled with targeted decolonization.
To determine rates of blood culture contamination comparing 3 strategies to prevent intensive care unit (ICU) infections: screening and isolation, targeted decolonization, and universal decolonization.
Pragmatic cluster-randomized trial.
Forty-three hospitals with 74 ICUs; 42 of 43 were community hospitals.
Patients admitted to adult ICUs from July 1, 2009, to September 30, 2011.
After a 6-month baseline period, hospitals were randomly assigned to 1 of 3 strategies, with all participating adult ICUs in a given hospital assigned to the same strategy. Arm 1 implemented methicillin-resistant Staphylococcus aureus (MRSA) nares screening and isolation, arm 2 targeted decolonization (screening, isolation, and decolonization of MRSA carriers), and arm 3 conducted no screening but universal decolonization of all patients with mupirocin and chlorhexidine (CHG) bathing. Blood culture contamination rates in the intervention period were compared to the baseline period across all 3 arms.
During the 6-month baseline period, 7,926 blood cultures were collected from 3,399 unique patients: 1,099 sets in arm 1, 928 in arm 2, and 1,372 in arm 3. During the 18-month intervention period, 22,761 blood cultures were collected from 9,878 unique patients: 3,055 sets in arm 1, 3,213 in arm 2, and 3,610 in arm 3. Among all individual draws, for arms 1,2, and 3, the contamination rates were 4.1%, 3.9%, and 3.8% for the baseline period and 3.3%, 3.2%, and 2.4% for the intervention period, respectively. When we evaluated sets of blood cultures rather than individual draws, the contamination rate in arm 1 (screening and isolation) was 9.8% (N = 108 sets) in the baseline period and 7.5% (N = 228) in the intervention period. For arm 2 (targeted decolonization), the baseline rate was 8.4% (N = 78) compared to 7.5% (N = 241) in the intervention period. Arm 3 (universal decolonization) had the greatest decrease in contamination rate, with a decrease from 8.7% (N = 119) contaminated blood cultures during the baseline period to 5.1% (N = 184) during the intervention period. Logistic regression models demonstrated a significant difference across the arms when comparing the reduction in contamination between baseline and intervention periods in both unadjusted (P = .02) and adjusted (P = .02) analyses. Arm 3 resulted in the greatest reduction in blood culture contamination rates, with an unadjusted odds ratio (OR) of 0.56 (95% confidence interval [CI], 0.044-0.71) and an adjusted OR of 0.55 (95% CI, 0.43-0.71).
In this large cluster-randomized trial, we demonstrated that universal decolonization with CHG bathing resulted in a significant reduction in blood culture contamination.
Since the publication of “A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals” in 2008, prevention of healthcare-associated infections (HAIs) has become a national priority. Despite improvements, preventable HAIs continue to occur. The 2014 updates to the Compendium were created to provide acute care hospitals with up-to-date, practical, expert guidance to assist in prioritizing and implementing their HAI prevention efforts. They are the product of a highly collaborative effort led by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise, including the Centers for Disease Control and Prevention(CDC), the Institute for Healthcare Improvement (IHI), the Pediatric Infectious Diseases Society (PIDS), the Society for Critical Care Medicine (SCCM), the Society for Hospital Medicine (SHM), and the Surgical Infection Society (SIS).
Preventing healthcare-associated infections (HAIs) is a national priority. Although substantial progress has been achieved, considerable deficiencies remain in our ability to efficiently and effectively translate existing knowledge about HAI prevention into reliable, sustainable, widespread practice. “A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014 Updates” is the product of a highly collaborative endeavor designed to support hospitals’ efforts to implement and sustain HAI prevention strategies.
Since the publication of “A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals” in 2008, prevention of healthcare-associated infections (HAIs) has become a national priority. Despite improvements, preventable HAIs continue to occur. The 2014 updates to the Compendium were created to provide acute care hospitals with up-to-date, practical, expert guidance to assist in prioritizing and implementing their HAI prevention efforts. They are the product of a highly collaborative effort led by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise, including the Centers for Disease Control and Prevention (CDC), the Institute for Healthcare Improvement (IHI), the Pediatric Infectious Diseases Society (PIDS), the Society for Critical Care Medicine (SCCM), the Society for Hospital Medicine (SHM), and the Surgical Infection Society (SIS).
Preventing healthcare-associated infections (HAIs) is a national priority. Although substantial progress has been achieved, considerable deficiencies remain in our ability to efficiently and effectively translate existing knowledge about HAI prevention into reliable, sustainable, widespread practice. “A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014 Updates” is the product of a highly collaborative endeavor designed to support hospitals' efforts to implement and sustain HAI prevention strategies.
This article is an executive summary of a report from the Centers for Disease Control and Prevention Ventilator-Associated Pneumonia Surveillance Definition Working Group, entitled “Developing a new, national approach to surveillance for ventilator-associated events” and published in Critical Care Medicine. The full report provides a comprehensive description of the Working Group process and outcome.
In September 2011, the Centers for Disease Control and Prevention (CDC) convened a Ventilator-Associated Pneumonia (VAP) Surveillance Definition Working Group to organize a formal process for leaders and experts of key stakeholder organizations to discuss the challenges of VAP surveillance definitions and to propose new approaches to VAP surveillance in adult patients (Table 1).
Because of the live viral backbone of live attenuated influenza vaccine (LAIV), questions have arisen regarding infection control precautions and restrictions surrounding its use in healthcare personnel (HCP). This document provides guidance from the Society for Healthcare Epidemiology of America regarding use of LAIV in HCP and the infection control precautions that are recommended with its use in this population.
Misuse and overuse of antimicrobials, primarily involving therapeutic agents used to treat infection in humans, is considered one of the world's most pressing public health problems. Not only does such inappropriate use diminish the therapeutic benefit of essential medications, it also facilitates the development and spread of multidrug-resistant organisms (MDROs). Antimicrobial resistance and the rise in MDROs globally are associated with increased morbidity and mortality, cross-transmission within and between healthcare settings, and increased consumption of limited patient-care resources. Despite elevated awareness, publication of guidelines on antimicrobial stewardship, and several initiatives, the proportion of resistant strains causing both health care- and community-associated infections continues to increase and the number of new antimicrobials continues to decline.
This document serves as an update and companion piece to the 2005 Society for Healthcare Epidemiology of America (SHEA) Position Paper entitled “Influenza Vaccination of Healthcare Workers and Vaccine Allocation for Healthcare Workers During Vaccine Shortages.” In large part, the discussion about the rationale for influenza vaccination of healthcare personnel (HCP), the strategies designed to improve influenza vaccination rates in this population, and the recommendations made in the 2005 paper still stand. This position paper notes new evidence released since publication of the 2005 paper and strengthens SHEA's position on the importance of influenza vaccination of HCP. This document does not discuss vaccine allocation during times of vaccine shortage, because the 2005 SHEA Position Paper still serves as the Society's official statement on that issue.
A minority of infectious diseases consultants currently work in healthcare institutions requiring influenza vaccination for healthcare workers, and in approximately half of these institutions, the healthcare workers who refuse vaccination do not face substantial consequences for their refusal. Although true mandatory policies are not common, a majority of infectious diseases consultants support such policies.
The use of declination statements was associated with a mean increase of 11.6% in influenza vaccination rates among healthcare workers at 22 hospitals. In most hospitals, there were no negative consequences for healthcare workers who refused to sign the forms, and most policies were implemented along with other interventions designed to increase vaccination rates.
VHA Mountain States conducted a survey and analysis of infection control (IC) staffing resources, organizational structures, and clinical processes related to reducing the incidence of healthcare-associated infections (HAIs) in community healthcare facilities.
Member participation was solicited for 2 study components. The first was a survey of demographic characteristics regarding the type and size of the facility and the structure and functions of IC departments. The second was an observational study of infection prevention practices related to general hand hygiene (GHH), ventilator-associated pneumonia (VAP), catheter-related bloodstream infection (CRBSI), and catheter-related urinary tract infection (CRUTI).
A total of 31 not-for-profit community healthcare facilities submitted data; the number of beds in participating centers ranged from less than 50 beds (1 facility) to more than 500 beds (7 facilities). IC department staffing ranged from 0.3 to 5.0 full-time equivalents. There was a positive correlation between average daily census and IC staffing (r = .879; P<.001). Observational studies revealed that compliance with the use of alcohol-based hand rubs (77%) was significantly better than compliance with the use of soap and water (64%; P<.001). Seven (30%) of 23 organizations observed 90% or better compliance with VAP process measures; 7 of 27 (26%) observed 90% or better compliance with guidelines for preventing CRBSI; and 14 (56%) demonstrated proper placement of urinary drainage bags at least 90% of the time.
There was variation in IC department structure and processes among the participating organizations. Infection prevention practices were inconsistent. These findings emphasize the need for more-effective implementation of current evidence-based recommendations for preventing HAIs and reducing the risk of harm to patients.