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Background: Prevention of hospital-onset bacteremia (HOB) in all settings is a healthcare priority. The CDC is developing a neonatal-specific HOB quality metric, but the epidemiology of neonatal HOB is poorly understood. Our objective was to validate a prior single-center finding that HOB risk varies by birthweight and postnatal age in a multicenter cohort. Methods: We performed a multicenter, retrospective cohort study of neonates admitted to 4 neonatal intensive care units (NICUs) for ≥4 days between July 1, 2016, and July 1, 2021. HOB was defined as a positive blood culture for bacteria or fungi on day ≥4 of admission. The first HOB event in the hospitalization was counted per neonate. Repeat HOB events during a neonate’s admission were excluded. Poisson regression models with robust variance estimates were used to estimate the incidence rate (IR) of HOB, expressed as HOB events per 1,000 patient days and IR ratios (IRRs), within strata defined by CDC birthweight categories and 4-week postnatal age intervals, adjusting for central venous catheter (CVC) presence at time of HOB and study site. Results: The analysis included 9,267 neonates, contributing 191,295 patient days and 470 HOB events, with an unadjusted IR of 2.46 per 1,000 patient days (Table 1). Of 477 infants born ≤750 g, 153 (30.1%) had a HOB with an IR of 13.3 (95% CI, 10.5–16.0) events per 1,000 patient days in the first 4 weeks after birth (Fig. 1). After adjusting for CVC presence and study site, infants ≤750 g had a higher HOB rate in the first 4 weeks of life (IRR, 7.45; 95% CI, 3.81–14.56) compared to infants ≥2,500 g. After 8 weeks of life, there was no difference in HOB rate in the 2 groups (IRR, 0.8, 95% CI, 0.3–2.7). Conclusions: Neonates born ≤750 g were at highest risk for HOB within the first 4 weeks after birth; however, risk for HOB was not consistent over time. Postnatal age should be considered in a neonatal HOB quality metric.
Background: Respiratory cultures are commonly obtained from patients with suspicion for ventilator-associated infections (VAIs). In the absence of specimen ordering and collection guidelines, management practices may differ. We characterized current respiratory culture collection practices and perceptions and identified potential barriers to changing practices among a national collaborative of pediatric intensive care units (PICUs). Methods: We conducted an electronic survey of PICU physicians, advanced practice providers (APPs), respiratory therapists (RTs), and nurses at 16 US academic pediatric hospitals across the United States. Positive Likert-scale responses (eg, “agree” and “strongly agree”) were grouped. To account for varying hospital representation, we analyzed the results as the median proportion of participants with that response across the hospitals. Results: After excluding incomplete responses, 568 (44%) of 1,301 invited participants responded (range, 16–107 per site); the median hospital response rate was 60% (range, 17%–83%). Roles included physicians (35%), APPs (10%), RTs (24%), and nurses (31%). Moreover, 44% of the participating units cared for cardiac surgery patients. Across hospitals, specimens are often collected by RTs, followed by nurses, typically via inline endotracheal aspirate for either endotracheal tubes or tracheostomies. Saline lavage is a common practice, but only 4% reported a standardized approach. Examining the likeliness to obtain cultures for different clinical symptoms, the widest variation in responses were for fever and inflammatory markers without respiratory symptoms (median proportion, 68%; IQR, 54%–79%), isolated change in secretion characteristics (67%; IQR, 54%–78%), isolated increased secretions (55%; IQR, 40%–65%), isolated inflammatory markers (49%; IQR, 38%–57%) or isolated fever (49%; IQR, 38%–61%). Overall, 75% (IQR, 70%–86%) of reported respiratory cultures were likely to be obtained as a “pan culture.” Most respondents (median proportion, 69%) felt confident about the indications to obtain cultures, but 60% felt that clinicians had a low threshold, and 84% reported clinical practice variation. Barriers to change included reluctance to change (70%), opinion of consultants (64%), and fear of missing a diagnosis of VAI (62%). Respondents agreed that they would find clinical decision support (CDS) tools helpful (79%). In addition, 83% expected that they would follow CDS, and 82% thought that CDS would help align ICU and/or consulting teams. Conclusions: Among 16 participating hospitals, we detected a lack of standardized respiratory-culture specimen collection and ordering practices. Most respondents agreed that CDS tools would be helpful. Diagnostic stewardship of respiratory cultures using CDS must account for potential reluctance to change and needs to address stakeholder perspectives, including fear of missing infections.
Hospitalized neonates are at high risk for hospital-associated bloodstream infections (HA-BSI) and require locally contextualized interventions to prevent HA-BSI.
The Preventing Infections in Neonates (PIN) collaborative aimed to reach a 50% decrease in neonatal HA-BSI rates for a 27-bed Level IV neonatal intensive care unit (NICU). Using quality improvement (QI) methodologies, a multidisciplinary cross-cultural collaborative implemented phased and bundled interventions from July 2017 to September 2019. Descriptive statistics and statistical process control charts were used to analyze infection rates.
There were 916 admissions, 19,812 patient-days, and 4264 central line days in the NICU during the project period. Monthly baseline preintervention HA-BSI median rate was 3.95/1000 patient-days and decreased to 1.73/1000 patient-days (56% change) during the bundled interventions. Quarterly HA-BSI rates also decreased from the preintervention median of 4.5/1000 patient-days to 3.3/1000 patient-days during the intervention period (IRR 0.73; 95%CI 0.39, 1.36). Staff were highly compliant with hand hygiene and environmental cleaning. Through project efforts, compliance with bundle elements increased from 25% at baseline to a peak of 97% for central line (CL) insertion checklists and from 13% to a peak of 56% for CL maintenance checklists.
Unit-based bundled interventions can reduce neonatal HA-BSI in limited resource settings. Future studies can assess similar practices in other units and the impact of the pandemic on interventions to reduce HA-BSIs.
Previously published guidelines have provided comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing efforts to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection. This document updates the “Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission and Infection in Acute Care Hospitals” published in 2014.1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
In total, 50 healthcare facilities completed a survey in 2021 to characterize changes in infection prevention and control and antibiotic stewardship practices. Notable findings include sustained surveillance for multidrug-resistant organisms but decreased use of human resource-intensive interventions compared to previous surveys in 2013 and 2018 conducted prior to the COVID-19 pandemic.
The epidemiology of community-onset Staphylococcus aureus infections is evolving. We performed a multihospital, retrospective study of pediatric community-onset S. aureus susceptibilities between 2015 and 2020. Oxacillin and clindamycin susceptibility remained lower at 67% and 75%, respectively. Tetracycline and trimethoprim-sulfamethoxazole susceptibility remained high at >90%. Oxacillin susceptibility was highest in invasive infections.
In a large healthcare worker cohort, we quantified the association between behaviors and risk of coronavirus disease 2019 (COVID-19) during different pandemic phases, adjusting for prior infection and vaccination. Individual characteristics, including personal concerns, were associated with these behaviors. Public health messaging should target high-risk populations and behaviors as the pandemic evolves.
Background: Little is known about the impact of healthcare-associated respiratory syncytial virus (HA-RSV) in hospitalized children. To address this gap, we assessed the epidemiology and clinical impact associated with HA-RSV in a multiseason, multicenter study. Methods: During respiratory viral seasons 2016–2017, 2017–2018, and 2018–2019, we retrospectively identified HA-RSV cases in hospitalized children 72 hours after admission or within 48 hours of discharge in readmitted patients. Due to reduced availability of testing for non–SARS-CoV-2 viruses during the first year of the COVID-19 pandemic, the 2019–2020 season was excluded. We initiated prospective HA-RSV surveillance during the 2020–2021 season and continued surveillance through November 2021 due to the unusual interseasonal RSV community outbreak. We determined demographic and clinical characteristics of HA-RSV cases and explored possible outcomes associated with RSV including transfer to the pediatric ICU and escalation of respiratory support from day −2 to day +4 (day 0 was the day of RSV detection). We explored the timeframe of day −2 to day +4 because events during this timeframe could be attributed to RSV infection. Respiratory support escalation was defined as change from room air to supplemental oxygen, increase in fraction of inspired oxzygen (FiO2) on same respiratory support modality, or change from noninvasive to invasive support. Results: Were identified 86 HA-RSV cases: 20 (23.3%) from 2016–2017, 26 (30.2%) from 2017–2018, 34 (39.5%) from 2018–2019, and 6 (7%) from October 2020–November 2021. HA-RSV was diagnosed a median of 14 days (IQR, 8–45) after admission. Moreover, 29 (33.7%), 31 (36.0%), and 26 (30.2%) cases were aged 60 months during these, respective seasons. Also, 33 (38.4%) had >3 comorbid conditions, most commonly gastrointestinal (n = 33, 38.4%), respiratory (n = 28, 32.6%), and/or congenital–genetic disorders (n = 28, 32.6%). However, 9 (10.5%) had no comorbid conditions. From day −2 to day +4, 15 children (17.4%) were transferred to the PICU and 38 (49.3%) of 77 evaluable cases required respiratory support escalation, most commonly supplemental oxygen delivered by nasal cannula (n = 15, 19.5%). Furthermore, 11 patients (14.3%) required invasive support. Conclusions: HA-RSV was associated with use of healthcare resources, including the need for respiratory support escalation and/or transfer to intensive care. From October 2020 to November 2021, lower numbers of HA-RSV were observed. The reasons for this are unknown, but potentially occurred in parallel to markedly reduced RSV in the community and may have resulted from visitor restrictions, which included no siblings and/or universal masking by hospital staff and visitors.
Funding: Funding for this research was provided by Merck Sharp & Dohme, a subsidiary of Merck & Co.
Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmissions among healthcare workers and hospitalized patients are challenging to confirm. Investigation of infected persons often reveals multiple potential risk factors for viral acquisition. We combined exposure investigation with genomic analysis confirming 2 hospital-based clusters. Prolonged close contact with unmasked, unrecognized infectious, individuals was a common risk.
To assess preventability of hospital-onset bacteremia and fungemia (HOB), we developed and evaluated a structured rating guide accounting for intrinsic patient and extrinsic healthcare-related risks.
HOB preventability rating guide was compared against a reference standard expert panel.
A 10-member panel of clinical experts was assembled as the standard of preventability assessment, and 2 physician reviewers applied the rating guide for comparison.
The expert panel independently rated 82 hypothetical HOB scenarios using a 6-point Likert scale collapsed into 3 categories: preventable, uncertain, or not preventable. Consensus was defined as concurrence on the same category among ≥70% experts. Scenarios without consensus were deliberated and followed by a second round of rating.
Two reviewers independently applied the rating guide to adjudicate the same 82 scenarios in 2 rounds, with interim revisions. Interrater reliability was evaluated using the κ (kappa) statistic.
Expert panel consensus criteria were met for 52 scenarios (63%) after 2 rounds.
After 2 rounds, guide-based rating matched expert panel consensus in 40 of 52 (77%) and 39 of 52 (75%) cases for reviewers 1 and 2, respectively. Agreement rates between the 2 reviewers were 84% overall (κ, 0.76; 95% confidence interval [CI], 0.64–0.88]) and 87% (κ, 0.79; 95% CI, 0.65–0.94) for the 52 scenarios with expert consensus.
Preventability ratings of HOB scenarios by 2 reviewers using a rating guide matched expert consensus in most cases with moderately high interreviewer reliability. Although diversity of expert opinions and uncertainty of preventability merit further exploration, this is a step toward standardized assessment of HOB preventability.
We analyzed the efficacy, cost, and cost-effectiveness of predictive decision-support systems based on surveillance interventions to reduce the spread of carbapenem-resistant Enterobacteriaceae (CRE).
We developed a computational model that included patient movement between acute-care hospitals (ACHs), long-term care facilities (LTCFs), and communities to simulate the transmission and epidemiology of CRE. A comparative cost-effectiveness analysis was conducted on several surveillance strategies to detect asymptomatic CRE colonization, which included screening in ICUs at select or all hospitals, a statewide registry, or a combination of hospital screening and a statewide registry.
We investigated 51 ACHs, 222 LTCFs, and skilled nursing facilities, and 464 ZIP codes in the state of Maryland.
Patients or participants:
The model was informed using 2013–2016 patient-mix data from the Maryland Health Services Cost Review Commission. This model included all patients that were admitted to an ACH.
On average, the implementation of a statewide CRE registry reduced annual CRE infections by 6.3% (18.8 cases). Policies of screening in select or all ICUs without a statewide registry had no significant impact on the incidence of CRE infections. Predictive algorithms, which identified any high-risk patient, reduced colonization incidence by an average of 1.2% (3.7 cases) without a registry and 7.0% (20.9 cases) with a registry. Implementation of the registry was estimated to save $572,000 statewide in averted infections per year.
Although hospital-level surveillance provided minimal reductions in CRE infections, regional coordination with a statewide registry of CRE patients reduced infections and was cost-effective.
We analyzed the impact of a 7-day recurring asymptomatic SARS-CoV-2 testing protocol for all patients hospitalized at a large academic center. Overall, 40 new cases were identified, and 1 of 3 occurred after 14 days of hospitalization. Recurring testing can identify unrecognized infections, especially during periods of elevated community transmission.
Background: Blood cultures are fundamental in the diagnosis and treatment of sepsis. Culture practices vary widely, and overuse can lead to false-positive results and unnecessary antibiotics. Our objective was to describe the implementation of a multisite quality improvement collaborative to reduce unnecessary blood cultures in pediatric intensive care unit (PICU) patients, and its 18-month impact on blood culture rates and safety metrics. Methods: In 2018, 14 PICUs joined the Blood Culture Improvement Guidelines and Diagnostic Stewardship for Antibiotic Reduction in Critically Ill Children (Bright STAR) Collaborative, designed to understand and improve blood culture practices in critically ill children. Guided by a centralized multidisciplinary study team, sites first reviewed existing evidence for safe reduction of unnecessary blood cultures and assessed local practices and barriers to change. Subsequently, local champions developed and implemented clinical decision-support tools informed by local patient needs to guide new blood-culture practices. The coordinating study team facilitated regular evaluations and discussions of project progress through monthly phone calls, site visits if requested by sites or the study team, and collaborative-wide teleconferences. The study team collected monthly blood culture rates and monitored for possible delays in obtaining blood cultures using a standardized review process as a safety balancing metric. We compared 24 months of baseline data to 18 months of postimplementation using a Poisson regression model accounting for the site-specific patient days and correlation of culture use within a site over time. Results: Across the 14 sites, before implementation, 41,768 blood cultures were collected over 259,701 PICU patient days. The mean preimplementation site-specific blood culture rate was 15.7 cultures per 100 patient days (rate range, 9.6–48.2 cultures per 100 patient days). After implementation, 22,397 blood cultures were collected over 208,171 PICU patient days. The mean postimplementation rate was 10.4 cultures per 100 patient days (rate range, 4.7–28.3 cultures per 100 patient days), which was 33.6% lower than the preimplementation (relative rate 0.66; 95% CI, 0.65–0.68 p <0.01). In 18 months post-implementation, sites reviewed 793 positive blood cultures, and identified only one suspected delay in culture collection possibly attributable to the site’s blood culture reduction program. Conclusions: Multidisciplinary quality improvement teams safely facilitated a 33.6% average reduction in blood culture use in critically ill children at 14 hospitals. Future collaborative work will determine the impact of blood culture diagnostic stewardship on antibiotic use and other important patient safety outcomes.
ABSTRACT IMPACT: Optimizing the use of endotracheal aspirate cultures (EACs) has the potential to improve the care of complex mechanically ventilated children by improving testing practices and avoiding unnecessary antibiotic treatment for false-positive results. OBJECTIVES/GOALS: An electronic survey has previously been employed to characterize the practices and attitudes around blood cultures among critically ill children. The objective of this work was to develop and pilot a new survey as a tool to understand practices and attitudes that could inform quality improvement initiatives to optimize EAC practices. METHODS/STUDY POPULATION: Informed by prior experience of diagnostic stewardship of EAC in other settings and using a similar structure to the blood culture practice survey, we developed an electronic self-administered survey sent to respiratory therapists, advanced practice providers, and physicians at the Johns Hopkins All Children’s pediatric intensive care unit. RESULTS/ANTICIPATED RESULTS: A total of 27 of 87 clinicians (37%) responded to the survey (22 respiratory therapists, 9 attending physicians and 1 advanced practice provider). Responses indicated samples are typically collected by respiratory therapists via in-line (endotracheal) or open suctioning (tracheostomy). Most respondents did not feel EACs could lead to unintended negative consequences (71%), agreed practices vary between people (89%), and felt an algorithm would help align the clinical team (79%). Most respondents agreed some clinicians may be reluctant to change practice (82%) and may not change practice due to concern for missing diagnosis of ventilator-associated pneumonia or tracheitis (78%). Surveillance cultures were not used in this unit and there were no prior EAC diagnostic stewardship efforts. DISCUSSION/SIGNIFICANCE OF FINDINGS: This survey captured practices, perceptions and barriers to changes that will inform the implementation of quality improvement initiatives to optimize EAC use in this unit. Future studies can consider utilizing an electronic survey to describe practice variation, clinician believes and attitudes about EAC testing in ventilated patients.
This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.
To develop a pediatric research agenda focused on pediatric healthcare-associated infections and antimicrobial stewardship topics that will yield the highest impact on child health.
The study included 26 geographically diverse adult and pediatric infectious diseases clinicians with expertise in healthcare-associated infection prevention and/or antimicrobial stewardship (topic identification and ranking of priorities), as well as members of the Division of Healthcare Quality and Promotion at the Centers for Disease Control and Prevention (topic identification).
Using a modified Delphi approach, expert recommendations were generated through an iterative process for identifying pediatric research priorities in healthcare associated infection prevention and antimicrobial stewardship. The multistep, 7-month process included a literature review, interactive teleconferences, web-based surveys, and 2 in-person meetings.
A final list of 12 high-priority research topics were generated in the 2 domains. High-priority healthcare-associated infection topics included judicious testing for Clostridioides difficile infection, chlorhexidine (CHG) bathing, measuring and preventing hospital-onset bloodstream infection rates, surgical site infection prevention, surveillance and prevention of multidrug resistant gram-negative rod infections. Antimicrobial stewardship topics included β-lactam allergy de-labeling, judicious use of perioperative antibiotics, intravenous to oral conversion of antimicrobial therapy, developing a patient-level “harm index” for antibiotic exposure, and benchmarking and or peer comparison of antibiotic use for common inpatient conditions.
We identified 6 healthcare-associated infection topics and 6 antimicrobial stewardship topics as potentially high-impact targets for pediatric research.
To evaluate the effect of 70% isopropyl alcohol–impregnated central venous catheter caps on ambulatory central-line–associated bloodstream infections (CLABSIs) in pediatric hematology-oncology patients.
This study was a 24-month, cluster-randomized, 2 period, crossover clinical trial.
The study was conducted in 15 pediatric healthcare institutions, including 16 pediatric hematology-oncology clinics.
All patients with an external central line followed at 1 of the 16 hematology-oncology clinics.
Usual ambulatory central-line care per each institution using 70% isopropyl alcohol–impregnated caps at home compared to usual ambulatory central-line care in each institution without using 70% isopropyl alcohol–impregnated caps.
Of the 16 participating clinics, 15 clinics completed both assignment periods. As assigned, there was no reduction in CLABSI incidence in clinics using 70% isopropyl alcohol–impregnated caps (1.23 per 1,000 days) compared with standard practices (1.38 per 1,000 days; adjusted incidence rate ratio [aIRR], 0.83; 95% CI, 0.63–1.11). In the per-protocol population, there was a reduction in positive blood culture incidence in clinics using 70% isopropyl alcohol-impregnated caps (1.51 per 1,000 days) compared with standard practices (1.88 per 1,000 days; aIRR, 0.72; 95% CI, 0.52–0.99). No adverse events were reported.
Isopropyl alcohol–impregnated central-line caps did not lead to a statistically significant reduction in CLABSI rates in ambulatory hematology-oncology patients. In the per-protocol analysis, there was a statistically significant decrease in positive blood cultures. Larger trials are needed to elucidate the impact of 70% isopropyl alcohol–impregnated caps in the ambulatory setting.