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Background: Approaches to the prescription behavior of broad-spectrum antibiotics, including preauthorization and prospective audit and feedback (PAF), are a focus of antimicrobial stewardship (ASP). However, preprescription behavior, such as blood-culture collection before empiric prescription, is understudied and merits more attention given its influence on the usage of broad-spectrum antibiotics. At the University of Tokyo Hospital, carbapenems are subject to PAF, which has resulted in a compensatory increase in piperacillin-tazobactam use. To evaluate the inherent preprescription behavior associated with a broad-spectrum antibiotic, we investigated the initial blood-culture collection practices upon hospitalization in patients who were continued on empiric piperacillin-tazobactam. Methods: A retrospective observational study was conducted at the University of Tokyo Hospital, a tertiary-care hospital in Tokyo, Japan. Patients who were administered piperacillin-tazobactam on the day of hospitalization between April 2016 and December 2017 were included. Patients aged <=18 years and/or patients who discontinued piperacillin-tazobactam within two days were excluded. Only 1 admission per patient was kept for analysis. The medical records of 250 randomly selected patients were reviewed to obtain data on demographics, blood-culture collection, severity, specialties, and risk factors for multidrug-resistant organisms. A multivariable logistic regression analysis was used to identify factors associated with blood-culture collection. Results: In total, 960 discrete patients fulfilled the study criteria. Of the randomly selected 250 patients, blood cultures were collected from 162 patients (64.8%), and microbial growth was observed in 30 cases (18.5%). Enterobacterales and anaerobes accounted for 73.3% of the microbial population. Gastroenterologists (94, 37.6%) and general surgeons (52, 20.8%) were the most common prescribers. Hepatobiliary (83, 33.2%), respiratory (58, 23.2%), and intra-abdominal infections (IAI; 34, 13.6%) were the major suspected diagnoses. Blood-culture collection was associated with the use of immunosuppressive agents (OR, 3.48; 95% CI, 1.49–8.99), intrabdominal infection (OR, 0.28; 95% CI, 0.12–0.67), systemic inflammatory response syndrome criteria ≥ 2 (OR, 4.50; 95% CI, 2.25–9.42), and surgical specialty (OR, 0.33; 95% CI, 0.18–0.60). Conclusions: More than one-third of patients requiring hospitalization and empiric piperacillin-tazobactam did not undergo blood-culture collection. The finding that blood cultures were less likely to be obtained in patients with suspected IAI requiring hospitalization and by surgical specialties raises a concern regarding suboptimal evaluation. Further assessment of the appropriateness of blood-culture collection in the setting of broad-spectrum antibiotic prescription and tailored promotion of blood-culture collection to surgical specialties may be warranted.
Disclosures: S.K.: The author (during graduate school (PhD) was involved in antiviral research relevant to a neglected tropical disease and favipiravir. During this graduate school research, favipiravir was provided by FUJIFILM Toyama Chemical Co. Ltd
To assess the effectiveness of a targeted intervention using a collaborative approach, added to a comprehensive educational intervention, to facilitate the appropriate use of oral third-generation cephalosporins (3GCs).
The University of Tokyo Hospital, a tertiary-care teaching hospital.
Approximately 2,000,000 outpatients and 80,000 inpatients at the hospital between April 2017 and March 2020.
The targeted intervention using the collaborative approach was implemented in the departments with the highest use of oral 3GCs (ophthalmology and dermatology departments). Interrupted time-series analysis was applied to assess the change in days of therapy (DOT) of oral 3GCs between the preintervention period (April 2017–April 2019) and the postintervention period (May 2019–March 2020) for both inpatients and outpatients.
After the introduction of the targeted intervention with oral 3GCs, a significant immediate reduction of 13.48 DOT per 1,000 patient days was detected in inpatients (P < .001). However, no significant change in slope was observed before and after the intervention (−0.02 DOT per 1,000 patient days per month; P = .94). Although a temporary increase was observed after the targeted intervention in outpatients, the slope significantly decreased (−0.69 DOT per 1,000 outpatient visits per month; P = .044). No differences were observed in the use of other oral antibiotics after the intervention.
The targeted intervention contributed to a reduction in DOT of oral 3GCs in both inpatients and outpatients. Targeted interventions using a collaborative approach might be helpful in further decreasing the inappropriate use of antibiotics.
The coronavirus disease 2019 (COVID-19) pandemic has influenced current infection control practices in the healthcare setting. We surveyed 74 hospitals in Japan regarding changes in their infection control practices or policies between 2020 and the present. We found that the current hospital infection control practices for COVID-19 are adequate.
Background: The genus Roseomonas, containing pink-pigmented glucose nonfermentative bacteria, has been associated with various primary and nosocomial human infections; however, to our knowledge, its nosocomial transmission has never been reported in the literature. Here, we report a nosocomial cluster of Roseomonas mucosa bacteremia. Methods: Two cases of R. mucosa bacteremia in 2018 are described. Clinical and epidemiological investigations were undertaken. Environmental surfaces prone to water contamination in the patient wards were sampled and cultured. The sampled surfaces included sinks, faucets, toilets, sewage, showerheads, refrigerators, exhaust vents, and washing machines. The 2 clinical isolates and all environmental isolates that showed growth of pink colonies were identified using matrix-assisted laser desorption/ionization time of flight mass spectrometry and 16S rRNA gene sequencing. Pulse-field gel electrophoresis (PFGE) was performed and fingerprinting software was used to analyze the DNA restriction patterns and determine their similarity. Results: Two patients who developed R. mucosa bacteremia had received care from the same treatment team. The patients were on different wards but had overlapping hospital stays. In addition to the treatment team, no other shared exposure was identified. Moreover, 126 environmental surfaces were sampled, of which 7 samples grew pink colonies. The 9 isolates from the patients and the environmental samples were examined using 16S rRNA gene sequencing. Overall, 7 isolates, including isolates from both patients, were identified as R. mucosa, and the other 2 isolates were identified as Roseomonas gilardii subsp. rosea (Fig. 1). With 80% similarity as a cutoff, PFGE analysis revealed that the R. mucosa isolates from 2 patients’ blood cultures and 3 environmental isolates (a washing machine in the ward, a sink in the shared washroom, and a sink in the patient room) belonged to the same clone (Fig. 2). Conclusions: The hospital water environment was contaminated with R. mucosa, and the same clone caused bacteremia in 2 separate patients, suggesting nosocomial transmission of R. mucosa possibly linked to contaminated water, environment, and/or patient care.
We assessed the impact of personal protective equipment (PPE) doffing errors on healthcare worker (HCW) contamination with multidrug-resistant organisms (MDROs).
Prospective, observational study.
The study was conducted at 4 adult ICUs at 1 tertiary-care teaching hospital.
HCWs who cared for patients on contact precautions for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci, or multidrug-resistant gram-negative bacilli were enrolled. Samples were collected from standardized areas of patient body, garb sites, and high-touch environmental surfaces in patient rooms. HCW hands, gloves, PPE, and equipment were sampled before and after patient interaction. Research personnel observed PPE doffing and coded errors based on CDC guidelines.
We enrolled 125 HCWs; most were nurses (66.4%) or physicians (19.2%). During the study, 95 patients were on contact precautions for MRSA. Among 5,093 cultured sites (HCW, patient, environment), 652 (14.7%) yielded the target MDRO. Moreover, 45 HCWs (36%) were contaminated with the target MDRO after patient interactions, including 4 (3.2%) on hands and 38 (30.4%) on PPE. Overall, 49 HCWs (39.2%) made multiple doffing errors and were more likely to have contaminated clothes following a patient interaction (risk ratio [RR], 4.69; P = .04). All 4 HCWs with hand contamination made doffing errors. The risk of hand contamination was higher when gloves were removed before gowns during PPE doffing (RR, 11.76; P = .025).
When caring for patients on CP for MDROs, HCWs appear to have differential risk for hand contamination based on their method of doffing PPE. An intervention as simple as reinforcing the preferred order of doffing may reduce HCW contamination with MDROs.
Bathing intensive care unit (ICU) patients with 2% chlorhexidine gluconate (CHG)–impregnated cloths decreases the risk of healthcare-associated bacteremia and multidrug-resistant organism transmission. Hospitals employ different methods of CHG bathing, and few studies have evaluated whether those methods yield comparable results.
To determine whether 3 different CHG skin cleansing methods yield similar residual CHG concentrations and bacterial densities on skin.
Prospective, randomized 2-center study with blinded assessment.
PARTICIPANTS AND SETTING
Healthcare personnel in surgical ICUs at 2 tertiary-care teaching hospitals in Chicago, Illinois, and Boston, Massachusetts, from July 2015 to January 2016.
Cleansing skin of one forearm with no-rinse 2% CHG-impregnated polyester cloth (method A) versus 4% CHG liquid cleansing with rinsing on the contralateral arm, applied with either non–antiseptic-impregnated cellulose/polyester cloth (method B) or cotton washcloth dampened with sterile water (method C).
In total, 63 participants (126 forearms) received method A on 1 forearm (n=63). On the contralateral forearm, 33 participants received method B and 30 participants received method C. Immediately and 6 hours after cleansing, method A yielded the highest residual CHG concentrations (2500 µg/mL and 1250 µg/mL, respectively) and lowest bacterial densities compared to methods B or C (P<.001).
In healthy volunteers, cleansing with 2% CHG-impregnated cloths yielded higher residual CHG concentrations and lower bacterial densities than cleansing with 4% CHG liquid applied with either of 2 different cloth types and followed by rinsing. The relevance of these differences to clinical outcomes remains to be determined.
To identify modifiable risk factors for acquisition of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae (KPC) colonization among long-term acute-care hospital (LTACH) patients.
Multicenter, matched case-control study.
Four LTACHs in Chicago, Illinois.
Each case patient included in this study had a KPC-negative rectal surveillance culture on admission followed by a KPC-positive surveillance culture later in the hospital stay. Each matched control patient had a KPC-negative rectal surveillance culture on admission and no KPC isolated during the hospital stay.
From June 2012 to June 2013, 2,575 patients were admitted to 4 LTACHs; 217 of 2,144 KPC-negative patients (10.1%) acquired KPC. In total, 100 of these patients were selected at random and matched to 100 controls by LTACH facility, admission date, and censored length of stay. Acquisitions occurred a median of 16.5 days after admission. On multivariate analysis, we found that exposure to higher colonization pressure (OR, 1.02; 95% CI, 1.01–1.04; P=.002), exposure to a carbapenem (OR, 2.25; 95% CI, 1.06–4.77; P=.04), and higher Charlson comorbidity index (OR, 1.14; 95% CI, 1.01–1.29; P=.04) were independent risk factors for KPC acquisition; the odds of KPC acquisition increased by 2% for each 1% increase in colonization pressure.
Higher colonization pressure, exposure to carbapenems, and a higher Charlson comorbidity index independently increased the odds of KPC acquisition among LTACH patients. Reducing colonization pressure (through separation of KPC-positive patients from KPC-negative patients using strict cohorts or private rooms) and reducing carbapenem exposure may prevent KPC cross transmission in this high-risk patient population.
Infect Control Hosp Epidemiol 2017;38:670–677
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