The COVID-19 has had major direct (e.g., deaths) and indirect (e.g., social inequities) effects in the United States. While the public health response to the epidemic featured some important successes (e.g., universal masking ,and rapid development and approval of vaccines and therapeutics), there were systemic failures (e.g., inadequate public health infrastructure) that overshadowed these successes. Key deficiency in the U.S. response were shortages of personal protective equipment (PPE) and supply chain deficiencies. Recommendations are provided for mitigating supply shortages and supply chain failures in healthcare settings in future pandemics. Some key recommendations for preventing shortages of essential components of infection control and prevention include increasing the stockpile of PPE in the U.S. National Strategic Stockpile, increased transparency of the Stockpile, invoking the Defense Production Act at an early stage, and rapid review and authorization by FDA/EPA/OSHA of non-U.S. approved products. Recommendations are also provided for mitigating shortages of diagnostic testing, medications and medical equipment.

Throughout the COVID-19 pandemic, many areas in the United States experienced healthcare personnel (HCP) shortages tied to a variety of factors. Infection prevention programs, in particular, faced increasing workload demands with little opportunity to delegate tasks to others without specific infectious diseases or infection control expertise. Shortages of clinicians providing inpatient care to critically ill patients during the early phase of the pandemic were multifactorial, largely attributed to increasing demands on hospitals to provide care to patients hospitalized with COVID-19 and furloughs.1 HCP shortages and challenges during later surges, including the Omicron variant-associated surges, were largely attributed to HCP infections and associated work restrictions during isolation periods and the need to care for family members, particularly children, with COVID-19. Additionally, the detrimental physical and mental health impact of COVID-19 on HCP has led to attrition, which further exacerbates shortages.2 Demands increased in post-acute and long-term care (PALTC) settings, which already faced critical staffing challenges difficulty with recruitment, and high rates of turnover. Although individual healthcare organizations and state and federal governments have taken actions to mitigate recurring shortages, additional work and innovation are needed to develop longer-term solutions to improve healthcare workforce resiliency. The critical role of those with specialized training in infection prevention, including healthcare epidemiologists, was well-demonstrated in pandemic preparedness and response. The COVID-19 pandemic underscored the need to support growth in these fields.3 This commentary outlines the need to develop the US healthcare workforce in preparation for future pandemics.

Throughout history, pandemics and their aftereffects have spurred society to make substantial improvements in healthcare. After the Black Death in 14th century Europe, changes were made to elevate standards of care and nutrition that resulted in improved life expectancy.1 The 1918 influenza pandemic spurred a movement that emphasized public health surveillance and detection of future outbreaks and eventually led to the creation of the World Health Organization Global Influenza Surveillance Network.2 In the present, the COVID-19 pandemic exposed many of the pre-existing problems within the US healthcare system, which included (1) a lack of capacity to manage a large influx of contagious patients while simultaneously maintaining routine and emergency care to non-COVID patients; (2) a “just in time” supply network that led to shortages and competition among hospitals, nursing homes, and other care sites for essential supplies; and (3) longstanding inequities in the distribution of healthcare and the healthcare workforce. The decades-long shift from domestic manufacturing to a reliance on global supply chains has compounded ongoing gaps in preparedness for supplies such as personal protective equipment and ventilators. Inequities in racial and socioeconomic outcomes highlighted during the pandemic have accelerated the call to focus on diversity, equity, and inclusion (DEI) within our communities. The pandemic accelerated cooperation between government entities and the healthcare system, resulting in swift implementation of mitigation measures, new therapies and vaccinations at unprecedented speeds, despite our fragmented healthcare delivery system and political divisions. Still, widespread misinformation or disinformation and political divisions contributed to eroded trust in the public health system and prevented an even uptake of mitigation measures, vaccines and therapeutics, impeding our ability to contain the spread of the virus in this country.3 Ultimately, the lessons of COVID-19 illustrate the need to better prepare for the next pandemic. Rising microbial resistance, emerging and re-emerging pathogens, increased globalization, an aging population, and climate change are all factors that increase the likelihood of another pandemic.4

The Society for Healthcare Epidemiology in America (SHEA) strongly supports modernization of data collection processes and the creation of publicly available data repositories that include a wide variety of data elements and mechanisms for securely storing both cleaned and uncleaned data sets that can be curated as clinical and research needs arise. These elements can be used for clinical research and quality monitoring and to evaluate the impacts of different policies on different outcomes. Achieving these goals will require dedicated, sustained and long-term funding to support data science teams and the creation of central data repositories that include data sets that can be “linked” via a variety of different mechanisms and also data sets that include institutional and state and local policies and procedures. A team-based approach to data science is strongly encouraged and supported to achieve the goal of a sustainable, adaptable national shared data resource.

Clostridioides difficile infection (CDI) is associated with substantial morbidity and mortality. This study described outcomes associated with mandatory infectious diseases (ID) consultation in hospitalized patients with CDI. ID consultation was associated with increased appropriate concomitant antibiotic use, however longer courses of concomitant antibiotics were administered.

Since the initial publication of A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals in 2008, the prevention of healthcare-associated infections (HAIs) has continued to be a national priority. Progress in healthcare epidemiology, infection prevention, antimicrobial stewardship, and implementation science research has led to improvements in our understanding of effective strategies for HAI prevention. Despite these advances, HAIs continue to affect ∼1 of every 31 hospitalized patients,1 leading to substantial morbidity, mortality, and excess healthcare expenditures,1 and persistent gaps remain between what is recommended and what is practiced.

The widespread impact of the coronavirus disease 2019 (COVID-19) pandemic on HAI outcomes2 in acute-care hospitals has further highlighted the essential role of infection prevention programs and the critical importance of prioritizing efforts that can be sustained even in the face of resource requirements from COVID-19 and future infectious diseases crises.3

The Compendium: 2022 Updates document provides acute-care hospitals with up-to-date, practical expert guidance to assist in prioritizing and implementing HAI prevention efforts. It is the product of a highly collaborative effort led by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Disease 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 organizations and societies with content expertise, including the Centers for Disease Control and Prevention (CDC), the Pediatric Infectious Disease Society (PIDS), the Society for Critical Care Medicine (SCCM), the Society for Hospital Medicine (SHM), the Surgical Infection Society (SIS), and others.

Background: Antibiotic overuse and the resulting patient outcomes span all hospitals. However, although antibiotic stewardship can improve antibiotic use, effective stewardship programs require expertise and an infrastructure that are not present in all hospitals. Rural hospitals have less access to resources, infectious disease expertise, and participation in academic research. Thus, we compared antibiotic overuse at discharge between rural and nonrural hospitals for patients diagnosed with community-associated pneumonia (CAP) or urinary tract infection (UTI)—the 2 most common hospital infections. Methods: To determine whether antibiotic overuse at discharge was higher among rural versus nonrural hospitals, we analyzed data from a 41-hospital prospective cohort of patients treated for CAP or UTI between July 1, 2017, and July 30, 2019, in Michigan. Antibiotic overuse was defined as treatment that was unnecessary (ie, patient did not have an infection), excessive (ie, duration >4 days for CAP), or included suboptimal fluoroquinolone use (ie, safer alternative available). Overuse was determined based on patient risk factors, symptoms, allergies, diagnostic results, and time to stability. Hospital rurality was defined using the Rural–Urban Continuum Codes (RUCC) score. We defined rural as a score ≥4 and very rural as a score of 7–9. We used t tests to compare the mean percentage of patients with antibiotic overuse at discharge between nonrural and rural (and very rural) hospitals. Results: Across 41 hospitals, we included 23,449 patients with CAP or UTI. There were 5 rural (and 3 very rural) hospitals with 2,039 (and 1,082) patients. Antibiotic overuse at discharge was present in 43.1% of patient cases in nonrural hospitals, 52.5% in rural hospitals (P = .04 vs nonrural) and 58.1% in very rural hospitals (P = .007 vs nonrural). Compared to nonrural hospitals, the mean percentage of cases with antibiotic overuse at discharge in rural hospitals was 9.4% higher (15.1% higher in very rural hospitals). Results were similar in a subgroup analysis of only patients with UTI (47.0% in rural vs 37.5% in nonrural, mean difference, 9.5%; P = .03) but were not statistically significant in patients with CAP (53.8% vs 48.0%, respectively; mean difference, 5.8%; P = 0.23). Conclusions: In this retrospective study, rural hospitals—especially very rural hospitals, had higher rates of antibiotic overuse at discharge than nonrural hospitals. Our findings suggest that antibiotic stewardship interventions tailored toward the unique differences in infrastructure, resources, and needs of rural hospitals are essential to community health.

Disclosures: None

Background: Since 2019, community-acquired pneumonia (CAP) guidelines have recommended hospitalized patients be treated until clinical “stability and for no less than 5 days.” However, randomized trials have reported that, in patients who stabilize by hospital day 3, very short antibiotic durations (eg, 3 days) are noninferior to longer durations. How these trial results relate to real-world practice is unknown. Methods: Using a 68-hospital cohort study of hospitalized, general-care adults with CAP, we aimed to (1) quantify the percentage of patients who—according to trial criteria—qualify for a 3-day antibiotic duration, (2) quantify the percentage who actually received a 3-day duration, and (3) assess 30-day outcomes. Patients were considered to have CAP if they had a pneumonia discharge diagnosis and met clinical criteria for CAP. Patients with concomitant infections (including COVID-19), admission to intensive care, or severe immunocompromise were not included. Results: Between February 23, 2017, and August 3, 2022, 36,064 patients with CAP were included. Of those, 48.2% (9,826 of 36,064) were excluded due to a condition or organism ineligible for the 3-day treatment (Fig. 1). Of the 18,690 patients remaining, 52.6% (9,826) were unstable on day 3 and thus were ineligible for the 3-day treatment. Therefore, of all 36,064 patients, only 8,864 (24.6%) would be eligible under trial criteria for a 3-day treatment. Notably, 5,493 (55.9%) of 9,826 patients unstable on day 3 would be eligible for 5 days of treatment under national guidelines. In practice, use of 3–4-day treatment was rare, occurring in 599 (6.8%) of 8,864 patients eligible for a 3-day treatment versus 660 (6.7%) of 9,826 patients unstable on day 3 (P = .945). Use of 3–4-day treatment increased over time and comorbidities that could mimic CAP or a negative procalcitonin were more common in patients who received a 3–4-day treatment whereas specific symptoms of CAP were less common (Fig. 2). After adjustments, patients eligible for a 3-day duration who received a 3–4 day treatment versus a ≥5-day treatment had higher 30-day mortality (aOR, 1.87; 95% CI, 1.32–2.64) and readmission (aOR, 1.35; 95% CI, 1.17–1.56). Conclusions: Across 68 hospitals, <25% of patients hospitalized with CAP would be eligible for a 3-day antibiotic treatment. Though increasing over time, there was little use of 3–4-day treatments and, when prescribed, outcomes were worse, potentially due to CAP misdiagnosis. Given the small number of patients eligible for 3-day treatment, and the potential harm with too-short durations, it may be prudent to focus on increasing the use of 5-day treatments.

Disclosures: None

Background: IDSA guidelines recommend withholding treatment in patients with asymptomatic bacteriuria in the absence of systemic signs of infection. However, some patients with bacteriuria may not be able to express symptoms either due to presence of indwelling catheter, underlying complicated urologic anatomy, dementia, or altered mental status (AMS). Clinicians frequently treat bacteriuria in this population with antimicrobial therapy due to concern for sepsis. To determine treatment need, we aimed to review prevalence and risk factors for bacteremic urinary tract infection (UTI) in a cohort of hospitalized inpatients without definitive signs and symptoms of a UTI. Methods: This retrospective cohort study of inpatients with a positive urine culture who presented without definitive signs or symptoms of a UTI was conducted between July 1, 2017, and June 30, 2022, in 68 academic and community hospitals (Michigan Hospital Medicine Safety Consortium). Signs and symptoms were obtained from medical record review 3 days before and after urine-culture collection. Bacteremic UTI was defined as any positive blood culture growing at least 1 organism matching the urine culture. Risk factors for bacteremic UTI were assessed using multivariable logistic regression models with results expressed as odds ratios (ORs) for dichotomous variables and relative risks (RRs) for continuous variables. Results: Of 11,793 patients meeting study criteria, 73.6% were female with a median age of 78.2 years. Overall, 41.8% had AMS, 33.8% had dementia, 15.6% had an indwelling urinary catheter, and 54.6% had complicated urologic history (eg, urologic surgery). Of these, 166 patients (1.4%) developed bacteremic UTI. On adjusted analysis, male sex, hypotension, heart rate >90, urinary retention, fatigue, log of serum leukocytosis [1 log increase in serum WBC = 2.718 × serum white blood cell count (WBC)], and pyuria with >25 WBC per high-powered field (WBC/hpf) on urinalysis were associated with bacteremic UTI (Table). Older age, presence of an indwelling catheter, complicated urologic history, functional decline, AMS, dementia, and change in urine were not associated with higher odds for bacteremic UTI (Table). Of patients with AMS and no definitive signs or symptoms of a UTI, only 89 (1.8%) of 4,932 developed a bacteremic UTI. Conclusions: Bacteremic UTI is relatively rare in hospitalized inpatients presenting with bacteriuria without symptoms of UTI. Predictors of bacteremic UTI included male sex, hypotension, tachycardia, urinary retention, fatigue, serum leukocytosis, and higher levels of pyuria (>25 WBC/hpf) on urinalysis. Our findings provide stewards a framework to risk stratify inpatients of older age who present with positive urine cultures but without (or are unable to express) signs or symptoms of UTI.

Disclosures: None

Background: Inappropriate broad-spectrum antibiotic use targeting methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa can result in increased adverse events, antibiotic resistance, and Clostridioides difficile infection. In 2019, revised ATS/IDSA community-acquired pneumonia (CAP) guidelines removed healthcare-associated pneumonia (HCAP) as a clinical entity and modified patient factors warranting empiric broad-spectrum antibiotic (BSA) use. As a result, most patients hospitalized with CAP should receive empiric antibiotics targeting standard CAP pathogens. Based on revised guidelines, we evaluated predictors and outcomes associated with inappropriate BSA use among hospitalized patients with CAP. Methods: Between November 2019 and July 2022, trained abstractors collected data on non-ICU adult medical patients admitted with CAP at 67 Michigan hospitals who received either an inappropriate empiric BSA on hospital day 1 or 2 or a standard CAP regimen. Inappropriate empiric BSA use was defined as use of an anti-MRSA or anti-pseudomonal antibiotic in a patient eligible for standard CAP coverage per IDSA guidelines. Patients with immune compromise, moderate or severe chronic obstructive pulmonary disease (COPD), pulmonary complication, or guideline-concordant treatment with BSA were excluded. Data collected included comorbidities, antibiotic use and hospitalizations in the preceding 90 days, cultures in the preceding year, signs or symptoms of pneumonia, hospital characteristics, and 30-day postdischarge patient outcomes. Data were collected through chart review and patient phone calls. Predictors of inappropriate empiric BSA were evaluated using logistic general estimating equation (GEE) models, accounting for hospital-level clustering. We assessed the effect of inappropriate empiric BSA (vs standard CAP therapy) on 30-day patient outcomes using logistic GEE models controlling for predictors associated with the outcome and probability of treatment. Results: Of 8,286 included patients with CAP, 2,215 (26.7%) were empirically treated with inappropriate BSA. The median BSA treatment was 3 days (IQR, 2.5). After adjustments, factors associated with inappropriate empiric BSA treatment included hospitalization or treatment with high-risk antibiotics in preceding 90 days, transfer from a postacute care facility, hemodialysis, support with ≥3 L supplemental oxygen, severe sepsis, leukocytosis, and higher pneumonia severity index (Fig. 1). After adjustments, patients with inappropriate empiric BSA treatment had higher readmissions 30 days after discharge, more transfers to the intensive care unit, more antibiotic-associated adverse events, and longer hospitalizations (Fig. 2). Conclusions: Patients hospitalized with CAP often received inappropriate BSA as empiric coverage, and this inappropriate antibiotic selection was associated with worse patient outcomes. To improve patient outcomes, stewardship efforts should focus on reducing inappropriate BSA use in patients hospitalized for CAP with historic HCAP risk factors or severe CAP without other guideline-directed indications for BSA.

Financial support. H.M.S. initiative is underwritten by Blue Cross and Blue Shield of Michigan.

Disclosures: None

A pseudo-outbreak of bronchoscopy-associated Mycobacterium chelonae and M. mucogenicum was traced to contaminated ice machine water and ice. A nonsterile ice bath was used to cool uncapped, sterile, saline syringes used to slow procedural bleeding. Joining the growing evidence of bronchoscopy pseudo-outbreaks, our investigation describes several lessons for future prevention.

Testing of asymptomatic patients for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) (ie, “asymptomatic screening) to attempt to reduce the risk of nosocomial transmission has been extensive and resource intensive, and such testing is of unclear benefit when added to other layers of infection prevention mitigation controls. In addition, the logistic challenges and costs related to screening program implementation, data noting the lack of substantial aerosol generation with elective controlled intubation, extubation, and other procedures, and the adverse patient and facility consequences of asymptomatic screening call into question the utility of this infection prevention intervention. Consequently, the Society for Healthcare Epidemiology of America (SHEA) recommends against routine universal use of asymptomatic screening for SARS-CoV-2 in healthcare facilities. Specifically, preprocedure asymptomatic screening is unlikely to provide incremental benefit in preventing SARS-CoV-2 transmission in the procedural and perioperative environment when other infection prevention strategies are in place, and it should not be considered a requirement for all patients. Admission screening may be beneficial during times of increased virus transmission in some settings where other layers of controls are limited (eg, behavioral health, congregate care, or shared patient rooms), but widespread routine use of admission asymptomatic screening is not recommended over strengthening other infection prevention controls. In this commentary, we outline the challenges surrounding the use of asymptomatic screening, including logistics and costs of implementing a screening program, and adverse patient and facility consequences. We review data pertaining to the lack of substantial aerosol generation during elective controlled intubation, extubation, and other procedures, and we provide guidance for when asymptomatic screening for SARS-CoV-2 may be considered in a limited scope.

Background: As of January 2022, more than 57 million cases of COVID-19 have been reported in the United States. Three primary COVID-19 vaccines are widely available: Pfizer (BNT162b2), Moderna (mRNA-1273), and Johnson & Johnson’s-Janssen (JNJ-78436735). The vaccines are effective but do not prevent all infections. We investigated trends in type of vaccine receipt, demographic characteristics, and disease outcomes in COVID-19 breakthrough infections among hospitalized patients. Methods: A breakthrough case is defined as the detection of SARS-CoV-2 ≥14 days after completion of all doses of an FDA-authorized COVID-19 vaccine. An electronic medical record report in EPIC EHR software identified 85 fully vaccinated patients with a documented positive SARS-CoV-2 result between February and September 2021 at 2 hospitals in southeastern Michigan. Demographic information and hospitalization characteristics, including length of stay and oxygen requirements, were collected from the report. Patients were classified into disease severity categories: nonsevere, severe, or critical. A case was considered severe if the patient’s oxygen saturation level (SpO2) was ≤94% on room air or if the patient required supplemental oxygen. Illness was considered critical if the patient developed respiratory failure, including mechanical ventilation or extracorporeal membrane oxygenation. All other cases were classified as nonsevere. Cycle threshold (Ct) values, the number of PCR cycles required to reach a threshold of SARS-CoV-2 genomic material, were collected from the hospital microbiology lab. Results: We identified 85 breakthrough infections (Fig. 1). The average patient age was 69.9±15.7 years, and 44 (51.8%) were female. Severe disease was most common (n = 73, 85.9%) followed by nonsevere disease (n = 7, 8.24%), and 9 patients (10.6%) in this cohort died. Most patients received either the Moderna (n = 35, 41.2%) or Pfizer (n = 38, 44.7%) vaccines. Pfizer vaccine receipt was most common among patients with severe illness (n = 33 of 73, 45.2%), and Moderna vaccine receipt was most common among patients with critical illness (n = 4 of 5, 80.0%). Average time from last vaccination to positive test was longest among Moderna vaccine recipients (181.9±43.1 days) and shortest among J&J vaccine recipients (91.0±61.1 days). The average Ct value was 23.8±7.5 and ranged from 13.0 to 41.3. There were no appreciable differences in the average Ct value by vaccine manufacturer. Conclusions: Breakthrough infections among hospitalized patients were uncommon, but incidence increased with time after vaccine receipt in all vaccines. Further study is needed to examine differences and severity in breakthrough infections by vaccine type and in individuals who completed booster vaccines.

Funding: None

Disclosures: None

Background:Clostridioides difficile infection (CDI) is a major source of morbidity and mortality. Even after recovery, recurrent CDI (rCDI) occurs frequently, and concomitant antibiotic use for treatment of a concurrent non–C. difficile infection is a major risk factor. Treatment with fidaxomicin versus vancomycin is associated with similar rate of cure and lower recurrence risk. However, the comparative efficacy of these 2 agents remains unclear in those receiving concomitant antibiotics. Methods: We conducted a randomized, controlled, open-label trial at the University of Michigan and St. Joseph Mercy hospitals in Ann Arbor, Michigan. Patients provided written informed consent at enrollment. We included all hospitalized patients aged ≥18 years with a positive test for toxigenic C. difficile, >3 unformed stools per 24 hours, and ≥1 qualifying concomitant antibiotic with a planned treatment of an infection for ≥5 days after enrollment. We excluded patients with complicated CDI, allergy to vancomycin–fidaxomicin, planned adjunctive CDI treatments, CDI treatment for >24 hours prior to enrollment, concomitant laxative use, current or planned colostomy or ileostomy, and/or planned long-term (>12 weeks) concomitant antibiotic use. Clinical cure was defined as resolution of diarrhea for 2 consecutive days maintained until the end of therapy and for 2 days afterward. rCDI was defined as recurrent diarrhea with positive testing within 30 days of initial treatment. Patients were randomized (stratified by ICU status) to fidaxomicin 200 mg twice daily or vancomycin 125 mg orally 4 times daily for 10 days. If concomitant antibiotic treatment continued >10 days, the study drug continued until the concomitant antibiotic ended. Bivariable statistics included t tests and χ2 tests. Results: After screening 5,101 patients for eligibility (May 2017–May 2021), 144 were included and randomized (Fig. 1). Study characteristics and outcomes are noted in Table 1. Baseline characteristics were similar between groups. Most patients were aged <65 years, were on a proton-pump inhibitor (PPI), and were not in the ICU. The mean duration of concomitant antibiotic was 18.4 days. In the intention-to-treat population, clinical cure (73% vs 62.9%; P =.195), and rCDI (3.3% vs 4.0%; P >.99) were similar for fidaxomicin and vancomycin, respectively. Conclusions: In this study of patients with CDI receiving a concomitant antibiotic, a numerically higher proportion were cured with fidaxomicin versus vancomycin, but this result did not reach statistical significance. Overall recurrence was lower than anticipated in both arms compared to previous studies in which duration of CDI treatment was not extended during concomitant antibiotic treatment. Future studies are needed to ascertain whether clinical cure is higher with fidaxomicin than vancomycin during concomitant antibiotic exposure, and whether extending the duration of CDI treatment reduces recurrence.

Funding: Merck & Co.

Disclosures: None

This consensus statement by the Society for Healthcare Epidemiology of America (SHEA) and the Society for Post-Acute and Long-Term Care Medicine (AMDA), the Association for Professionals in Epidemiology and Infection Control (APIC), the HIV Medicine Association (HIVMA), the Infectious Diseases Society of America (IDSA), the Pediatric Infectious Diseases Society (PIDS), and the Society of Infectious Diseases Pharmacists (SIDP) recommends that coronavirus disease 2019 (COVID-19) vaccination should be a condition of employment for all healthcare personnel in facilities in the United States. Exemptions from this policy apply to those with medical contraindications to all COVID-19 vaccines available in the United States and other exemptions as specified by federal or state law. The consensus statement also supports COVID-19 vaccination of nonemployees functioning at a healthcare facility (eg, students, contract workers, volunteers, etc).