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Hospitals caring for patients with high-consequence pathogens may need to safely manage large volumes of category A waste. Using biological indicators to assess for successful sterilization, autoclave cycle parameters that would inactivate 4 categories of waste were identified and validated utilizing a STERIS Amsco 630LS Steam Sterilizer.
Understanding the cognitive determinants of healthcare worker (HCW) behavior is important for improving the use of infection prevention and control (IPC) practices. Given a patient requiring only standard precautions, we examined the dimensions along which different populations of HCWs cognitively organize patient care tasks (ie, their mental models).
HCWs read a description of a patient and then rated the similarities of 25 patient care tasks from an infection prevention perspective. Using multidimensional scaling, we identified the dimensions (ie, characteristics of tasks) underlying these ratings and the salience of each dimension to HCWs.
Adult inpatient hospitals across an academic hospital network.
In total, 40 HCWs, comprising infection preventionists and nurses from intensive care units, emergency departments, and medical-surgical floors rated the similarity of tasks. To identify the meaning of each dimension, another 6 nurses rated each task in terms of specific characteristics of tasks.
Each HCW population perceived patient care tasks to vary along 3 common dimensions; most salient was the perceived magnitude of infection risk to the patient in a task, followed by the perceived dirtiness and risk of HCW exposure to body fluids, and lastly, the relative importance of a task for preventing versus controlling an infection in a patient.
For a patient requiring only standard precautions, different populations of HCWs have similar mental models of how various patient care tasks relate to IPC. Techniques for eliciting mental models open new avenues for understanding and ultimately modifying the cognitive determinants of IPC behaviors.
Group Name: The Emory COVID-19 Quality and Clinical Research Collaborative
Background: Patients hospitalized with COVID-19 are at risk of secondary infections—10%–33% develop bacterial pneumonia and 2%–6% develop bloodstream infection (BSI). We conducted a retrospective cohort study to identify the prevalence, microbiology, and outcomes of secondary pneumonias and BSIs in patients hospitalized with COVID-19. Methods: Patients aged ≥18 years with a positive SARS-CoV-2 real-time polymerase chain reaction assay admitted to 4 academic hospitals in Atlanta, Georgia, between February 15 and May 16, 2020, were included. We extracted electronic medical record data through June 16, 2020. Microbiology tests were performed according to standard protocols. Possible ventilator-associated pneumonia (PVAP) was defined according to Centers for Disease Control and Prevention (CDC) criteria. We assessed in-hospital mortality, comparing patients with and without infections using the χ2 test. SAS University Edition software was used for data analyses. Results: In total, 774 patients were included (median age, 62 years; 49.7% female; 66.6% black). In total, 335 patients (43.3%) required intensive care unit (ICU) admission, 238 (30.7%) required mechanical ventilation, and 120 (15.5%) died. Among 238 intubated patients, 65 (27.3%) had a positive respiratory culture, including 15 with multiple potential pathogens, for a total of 84 potential pathogens. The most common organisms were Staphylococcus aureus (29 of 84; 34.5%), Pseudomonas aeruginosa (16 of 84; 19.0%), and Klebsiella spp (14 of 84; 16.7%). Mortality did not differ between intubated patients with and without a positive respiratory culture (41.5% vs 35.3%; P = .37). Also, 5 patients (2.1%) had a CDC-defined PVAP (1.7 PVAPs per 1,000 ventilator days); none of them died. Among 536 (69.3%) nonintubated patients, 2 (0.4%) had a positive Legionella urine antigen and 1 had a positive respiratory culture (for S. aureus). Of 774 patients, 36 (4.7%) had BSI, including 5 with polymicrobial BSI (42 isolates total). Most BSIs (24 of 36; 66.7%) had ICU onset. The most common organisms were S. aureus (7 of 42; 16.7%), Candida spp (7 of 42; 16.7%), and coagulase-negative staphylococci (5 of 42; 11.9%); 12 (28.6%) were gram-negative. The most common source was central-line–associated BSI (17 of 36; 47.2%), followed by skin (6 of 36; 16.7%), lungs (5 of 36; 13.9%), and urine (4 of 36; 11.1%). Mortality was 50% in patients with BSI versus 13.8% without (p < 0.0001). Conclusions: In a large cohort of patients hospitalized with COVID-19, secondary infections were rare: 2% bacterial pneumonia and 5% BSI. The risk factors for these infections (intubation and central lines, respectively) and causative pathogens reflect healthcare delivery and not a COVID-19–specific effect. Clinicians should adhere to standard best practices for preventing and empirically treating secondary infections in patients hospitalized with COVID-19.
Background: Antibiotics targeted against Clostridioides difficile bacteria are necessary, but insufficient, to achieve a durable clinical response because they have no effect on C. difficile spores that germinate within a disrupted microbiome. ECOSPOR-III evaluated SER-109, an investigational, biologically derived microbiome therapeutic of purified Firmicute spores for treatment of rCDI. Herein, we present the interim analysis in the ITT population at 8 and 12 weeks. Methods: Adults ≥18 years with rCDI (≥3 episodes in 12 months) were screened at 75 US and CAN sites. CDI was defined as ≥3 unformed stools per day for <48 hours with a positive C. difficile assay. After completion of 10–21 days of vancomycin or fidaxomicin, adults with symptom resolution were randomized 1:1 to SER-109 (4 capsules × 3 days) or matching placebo and stratified by age (≥ or <65 years) and antibiotic received. Primary objectives were safety and efficacy at 8 weeks. Primary efficacy endpoint was rCDI (recurrent toxin+ diarrhea requiring treatment); secondary endpoints included efficacy at 12 weeks after dosing. Results: Overall, 287 participants were screened and 182 were randomized (59.9% female; mean age, 65.5 years). The most common reason for screen failure was a negative C. difficile toxin assay. A significantly lower proportion of SER-109 participants had rCDI after dosing compared to placebo at week 8 (11.1% vs 41.3%, respectively; relative risk [RR], 0.27; 95% confidence interval [CI], 0.15–0.51; p-value <0.001). Efficacy rates were significantly higher with SER-109 vs placebo in both stratified age groups (Figure 1). SER-109 was well-tolerated with a safety profile similar to placebo. The most common treatment-emergent adverse events (TEAEs) were gastrointestinal and were mainly mild to moderate. No serious TEAEs, infections, deaths, or drug discontinuations were deemed related to study drug. Conclusions: SER-109, an oral live microbiome therapeutic, achieved high rates of sustained clinical response with a favorable safety profile. By enriching for Firmicute spores, SER-109 achieves high efficacy while mitigating risk of transmitting infectious agents, beyond donor screening alone. SER-109 represents a major paradigm shift in the clinical management of patients with recurrent CDI. Clinicaltrials.gov Identifier NCT03183128. These data were previously presented as a late breaker at American College of Gastroenterology 2020.
In total, 13 facilities changed C. difficile testing to reflexive testing by enzyme immunoassay (EIA) only after a positive nucleic acid-amplification test (NAAT); the standardized infection ratio (SIR) decreased by 46% (range, −12% to −71% per hospital). Changing testing practice greatly influenced a performance metric without changing C. difficile infection prevention practice.
Background: High-level personal protective equipment (PPE) protects healthcare workers (HCWs) during the care of patients with serious communicable diseases. Doffing body fluid–contaminated PPE presents a risk of self-contamination. A study assessing HCW failure modes and self-contamination with viruses during PPE doffing found that, of all PPE items, the highest number of doffing failure modes and highest self-contamination risk occurred during removal of the 1-layer powered air-purifying respirator (PAPR) hood. Hood type may affect contamination risk; however, no experimental evidence exists comparing hood types. Objective: We quantified and compared the risk of self-contamination with viruses during doffing of a 1e-layer versus a 2-layer PAPR hood. Methods: In this study, 8 HCWs with experience using high-level PPE donned PPE contaminated on 4 prespecified areas with 2 surrogate human viruses, bacteriophage MS2 (a nonenvelope virus) and Φ6 (an enveloped virus). They completed a clinical task then doffed PPE according to a standard protocol. Following doffing, inner gloves, hands, face, and scrubs were sampled for viral contamination using infectivity assays. HCWs performed the entire sequence twice, first with a 1-layer hood with 1 shroud then with a 2-layer hood with 2 shrouds. The Wilcoxon rank-sum test was used to compare viral contamination between the 2 hood types. HCWs were video-recorded to identify failure modes in their doffing process using a failure modes and effects analysis to identify ways that individual actions deviated from optimal behavior. Results: Φ6 transfer to hands, inner gloves, and scrubs were observed for 1 HCW using the 1-layer hood versus scrubs only for 1 HCW using the 2-layer hood. MS2 transfer to hands was observed for 2 HCWs using the 1-layer hood versus none using the 2-layer hood. Inner glove contamination was observed for 6 of 8 HCWs using the 1-layer hood versus 2 of 8 using the 2-layer hood. Conclusions: A significantly higher number of MS2 virus was recovered on the inner gloves of HCWs using the 1-layer versus the 2-layer hood (median difference, 2.27×104; P = .03). In addition, 31 failure modes were identified during removal of the 2-layer hood versus 13 failure modes for the 1-layer hood. The magnitude of self-contamination depends on the type of PAPR hood used. The 2-layer hood resulted in significantly less inner glove contamination than the 1-layer hood. However, more failure modes were identified during the doffing process for the 2-layer hood. In conclusion, the failure modes identified during the use of the 2-layer hood were less likely to result in self-contamination compared to the failure modes identified during use of the 1-layer hood.
Background: US hospitals are required to report C. difficile infections (CDIs) to the NHSN as a performance measure tied to payment penalties for poor scores. Currently, only the charted CDI test results performed last in reflex testing scenarios are reported to the NHSN (CDI events). We describe the reduction in NHSN CDI events from the addition of a reflex toxin enzyme immunoassay (EIA) after a positive nucleic acid amplification test (NAAT) in teaching and nonteaching hospitals, and we estimate the impact on standardized infection ratios (SIR). Methods: Reporting of all CDI test results, by test method, occurred during April 2018–July 2019 to the Georgia Emerging Infections program (funded by the Centers for Disease Control and Prevention), which conducts active population-based surveillance in an 8-county Atlanta area (population, 4 million). Among facilities starting reflex EIA testing, results were aggregated by test method during months of reflex testing to calculate facility-specific reduction in NHSN CDI events (% reduction; 1-[no. EIA+/no. NAAT+]). Differences in percent reduction between facilities by characteristic were compared using the Kruskal-Wallis test. We simulated expected changes in the SIR for a range of reductions, assuming equal effect on both community-onset (CO) and hospital-onset (HO) tests. Each facility’s historical NHSN CDI events prior to reflex testing were used to estimate changes to facility-specific SIRs by reducing values by the corresponding facility’s percent reduction. Results: Overall, 13 acute-care hospitals (bed size, 52–633; ICU bed size, 6–105) started reflex testing during the study period (mean, 7 months, 15,800 admissions, 66,400 patient days), resulting in 550 +NAAT tests reflexing to 180 +EIA tests (pooled mean 58% reduction). Percent reduction varied (mean, 67%; range, 42%–81%) but did not differ between larger (≥217 beds) and smaller hospitals (61 vs 50% reduction; P > .05) or by outsourced versus inhouse testing (65% vs 54% reduction; P > .05). Simulations identified a threshold reduction at which point effect on HO counteract the effects on CO events enough to reduce the SIR; thresholds for nonteaching and teaching were 26% and 32% reduction, respectively (Fig. 1). The estimated reductions in facility-specific SIRs using measured percent reductions on historic NHSN CDI events closely paralleled the simulation, and the mean estimated change in SIR was −46% (range, −12% to −71%) (Fig. 1). Conclusions: Although the magnitude of the effect varied, all 13 facilities experienced dramatic reductions in CDI events reportable to NHSN due to reflex testing; applying these reductions to historical NHSN data illustrates anticipated reductions in their facility-specific SIRs due to this testing change.
Disclosures: Scott Fridkin, consulting fee, vaccine industry (various) (spouse)
Healthcare personnel (HCP) were recruited to provide serum samples, which were tested for antibodies against Ebola or Lassa virus to evaluate for asymptomatic seroconversion.
From 2014 to 2016, 4 patients with Ebola virus disease (EVD) and 1 patient with Lassa fever (LF) were treated in the Serious Communicable Diseases Unit (SCDU) at Emory University Hospital. Strict infection control and clinical biosafety practices were implemented to prevent nosocomial transmission of EVD or LF to HCP.
All personnel who entered the SCDU who were required to measure their temperatures and complete a symptom questionnaire twice daily were eligible.
No employee developed symptomatic EVD or LF. EVD and LF antibody studies were performed on sera samples from 42 HCP. The 6 participants who had received investigational vaccination with a chimpanzee adenovirus type 3 vectored Ebola glycoprotein vaccine had high antibody titers to Ebola glycoprotein, but none had a response to Ebola nucleoprotein or VP40, or a response to LF antigens.
Patients infected with filoviruses and arenaviruses can be managed successfully without causing occupation-related symptomatic or asymptomatic infections. Meticulous attention to infection control and clinical biosafety practices by highly motivated, trained staff is critical to the safe care of patients with an infection from a special pathogen.
To identify ways that the built environment may support or disrupt safe doffing of personal protective equipment (PPE) in biocontainment units (BCU).
We observed interactions between healthcare workers (HCWs) and the built environment during 41 simulated PPE donning and doffing exercises.
The BCUs of 4 Ebola treatment facilities and 1 high-fidelity BCU mockup.
A total of 64 HCWs (41 doffing HCWs and 15 trained observers) participated in this study.
In each facility, we observed how the physical environment influences risky behaviors by the HCW. The environmental design impeded communication between trained observers (TOs) and HCWs because of limited window size or visual obstructions with louvers, which allowed unobserved errors. The size and configuration of the doffing area impacted HCW adherence to protocol, and lack of clear demarcation of zones resulted in HCWs inadvertently leaving the doffing area and stepping back into the contaminated areas. Lack of standard location for items resulted in equipment and supplies frequently shifting positions. Finally, different solutions for maintaining balance while removing shoe covers (ie, chair, hand grips, and step stool) had variable success. We identified the 5 key requirements that doffing areas must achieve to support safe doffing of PPE, and we developed a matrix of proposed design strategies that can be implemented to meet those requirements.
Simple, low-cost environmental design interventions can provide structure to support and improve HCW safety in BCUs. These interventions should be implemented in both current and future BCUs.
To describe current Ebola treatment center (ETC) locations, their capacity to care for Ebola virus disease patients, and infection control infrastructure features.
A 19-question survey was distributed electronically in April 2015. Responses were collected via email by June 2015 and analyzed in an electronic spreadsheet.
The survey was sent to and completed by site representatives of each ETC.
The survey was sent to all 55 ETCs; 47 (85%) responded.
Of the 47 responding ETCs, there are 84 isolation beds available for adults and 91 for children; of these pediatric beds, 35 (38%) are in children’s hospitals. In total, the simultaneous capacity of the 47 reporting ETCs is 121 beds. On the basis of the current US census, there are 0.38 beds per million population. Most ETCs have negative pressure isolation rooms, anterooms, and a process for category A waste sterilization, although only 11 facilities (23%) have the capability to sterilize infectious waste on site.
Facilities developed ETCs on the basis of Centers for Disease Control and Prevention guidance, but specific capabilities are not mandated at this present time. Owing to the complex and costly nature of Ebola virus disease treatment and variability in capabilities from facility to facility, in conjunction with the lack of regulations, nationwide capacity in specialized facilities is limited. Further assessments should determine whether ETCs can adapt to safely manage other highly infectious disease threats.
Infect. Control Hosp. Epidemiol. 2016;37(3):313–318
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