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Background: In March–April 2021, 23 patients at a 906-bed hospital in Delaware had surgical implantation of a bone graft product contaminated with Mycobacterium tuberculosis; 17 patients were rehospitalized for surgical site infections and 6 developed pulmonary tuberculosis. In May 2021, we investigated this tuberculosis outbreak and conducted a large, multidisciplinary, contact investigation among healthcare personnel (HCP) and patients potentially exposed over an extended period in multiple departments. Methods: Exposed HCP were those identified by their managers as present, without the use of airborne precautions, in operating rooms (ORs) during index spine surgeries or subsequent procedures, the postanesthesia care unit (PACU) when patients had draining wounds, inpatient rooms when wound care was performed, and the sterile processing department (SPD) on the days repeated surgeries were performed. We created and assigned an online education module and symptom screening questionnaire to exposed HCP. Employee health services (EHS) instituted a dedicated phlebotomy station to provide interferon-γ release assay (IGRA) testing for HCP at ≥8 weeks after last known exposure. EHS managed all exposed HCP, including nonemployees (eg, private surgeons) via automated e-mail reminders, which were escalated through supervisory chains as needed until follow-up completion. The infection prevention team notified exposed patients, defined as those who shared semiprivate rooms with case patients with transmissible tuberculosis. The Delaware Division of Public Health performed IGRA testing. Results: There were 506 exposed HCP in ORs (n = 100), the PACU (n = 87), inpatient units (n = 140), the SPD (n = 54), and other locations (n = 122); 83% were employed by the health system. Surgical masks and eye protection were routinely used during patient care. All exposed HCP completed screening by December 17, 2021. Furthermore, 2 HCP had positive IGRAs without symptoms or chest radiograph abnormalities, indicating latent tuberculosis infection, but after further review of records and interviews, we discovered that they had previously tested positive and had been treated for latent tuberculosis infection. In addition, 5 exposed patients tested negative and 2 remain pending. Conclusions: This large investigation demonstrated the need for a systematic process that encompassed all exposed HCP including nonemployees and incorporated administrative controls to ensure complete follow-up. We did not identify any conversions related to this outbreak despite high burden of disease in case patients and multiple exposures to contaminated bone-graft material and infectious bodily fluids without respirator use. Transmission risk was likely reduced by baseline surgical mask use and rapid institution of airborne precautions after outbreak recognition.
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).
The supply of N95 respirators has been severely strained by the coronavirus disease 2019 (COVID-19) pandemic. We used quantitative fit-testing to evaluate 16 participants and 45 respirators through up to 4 rounds of ultraviolet decontamination and clinical reuse. The mean fit-test failure rate was 29.7%, and the probability of failure increased through N95 reuse.
SHEA endorses adhering to the recommendations by the CDC and ACIP for immunizations of all children and adults. All persons providing clinical care should be familiar with these recommendations and should routinely assess immunization compliance of their patients and strongly recommend all routine immunizations to patients. All healthcare personnel (HCP) should be immunized against vaccine-preventable diseases as recommended by the CDC/ACIP (unless immunity is demonstrated by another recommended method). SHEA endorses the policy that immunization should be a condition of employment or functioning (students, contract workers, volunteers, etc) at a healthcare facility. Only recognized medical contraindications should be accepted for not receiving recommended immunizations.
To assess the utility of an automated, statistically-based outbreak detection system to identify clusters of hospital-acquired microorganisms.
Multicenter retrospective cohort study.
The study included 43 hospitals using a common infection prevention surveillance system.
A space–time permutation scan statistic was applied to hospital microbiology, admission, discharge, and transfer data to identify clustering of microorganisms within hospital locations and services. Infection preventionists were asked to rate the importance of each cluster. A convenience sample of 10 hospitals also provided information about clusters previously identified through their usual surveillance methods.
We identified 230 clusters in 43 hospitals involving Gram-positive and -negative bacteria and fungi. Half of the clusters progressed after initial detection, suggesting that early detection could trigger interventions to curtail further spread. Infection preventionists reported that they would have wanted to be alerted about 81% of these clusters. Factors associated with clusters judged to be moderately or highly concerning included high statistical significance, large size, and clusters involving Clostridioides difficile or multidrug-resistant organisms. Based on comparison data provided by the convenience sample of hospitals, only 9 (18%) of 51 clusters detected by usual surveillance met statistical significance, and of the 70 clusters not previously detected, 58 (83%) involved organisms not routinely targeted by the hospitals’ surveillance programs. All infection prevention programs felt that an automated outbreak detection tool would improve their ability to detect outbreaks and streamline their work.
Automated, statistically-based outbreak detection can increase the consistency, scope, and comprehensiveness of detecting hospital-associated transmission.
Quality measures are increasingly reported by hospitals to the Centers for Medicare and Medicaid Services (CMS), yet there may be tradeoffs in performance between infection control (IC) and other quality measures. Hospitals that performed best on IC measures did not perform well on most CMS non–IC quality measures.
To examine self-reported practices and policies to reduce infection and transmission of multidrug-resistant organisms (MDRO) in healthcare settings outside the United States.
International members of the Society for Healthcare Epidemiology of America (SHEA) Research Network.
Electronic survey of infection control and prevention practices, capabilities, and barriers outside the United States and Canada. Participants were stratified according to their country’s economic development status as defined by the World Bank as low-income, lower-middle-income, upper-middle-income, and high-income.
A total of 76 respondents (33%) of 229 SHEA members outside the United States and Canada completed the survey questionnaire, representing 30 countries. Forty (53%) were high-, 33 (43%) were middle-, and 1 (1%) was a low-income country. Country data were missing for 2 respondents (3%). Of the 76 respondents, 64 (84%) reported having a formal or informal antibiotic stewardship program at their institution. High-income countries were more likely than middle-income countries to have existing MDRO policies (39/64 [61%] vs 25/64 [39%], P=.003) and to place patients with MDRO in contact precautions (40/72 [56%] vs 31/72 [44%], P=.05). Major barriers to preventing MDRO transmission included constrained resources (infrastructure, supplies, and trained staff) and challenges in changing provider behavior.
In this survey, a substantial proportion of institutions reported encountering barriers to implementing key MDRO prevention strategies. Interventions to address capacity building internationally are urgently needed. Data on the infection prevention practices of low income countries are needed.
Occupancy has been associated with risk for healthcare-associated infections, yet its definition varies widely. Occupancy can be modeled as a function of census, acuity of the patient care unit, staffing ratio, or some combination. This article discusses the appropriate parameterization of these measures and how to interpret their impact.
Administrative and surveillance data are used frequently in healthcare epidemiology and antimicrobial stewardship (HE&AS) research because of their wide availability and efficiency. However, data quality issues exist, requiring careful consideration and potential validation of data. This methods paper presents key considerations for using administrative and surveillance data in HE&AS, including types of data available and potential use, data limitations, and the importance of validation. After discussing these issues, we review examples of HE&AS research using administrative data with a focus on scenarios when their use may be advantageous. A checklist is provided to help aid study development in HE&AS using administrative data.
Timely identification of outbreaks of hospital-associated infections is needed to implement control measures and minimize impact. Survey results from 33 hospitals indicated that most hospitals lacked a formal cluster definition and all targeted a very limited group of prespecified pathogens. Standardized, statistically based outbreak detection could greatly improve current practice.
Infect. Control Hosp. Epidemiol. 2016;37(4):466–468
Hospital Ebola preparation is underway in the United States and other countries; however, the best approach and resources involved are unknown.
To examine costs and challenges associated with hospital Ebola preparation by means of a survey of Society for Healthcare Epidemiology of America (SHEA) members.
Electronic survey of infection prevention experts.
A total of 257 members completed the survey (221 US, 36 international) representing institutions in 41 US states, the District of Columbia, and 18 countries. The 221 US respondents represented 158 (43.1%) of 367 major medical centers that have SHEA members and included 21 (60%) of 35 institutions recently defined by the US Centers for Disease Control and Prevention as Ebola virus disease treatment centers. From October 13 through October 19, 2014, Ebola consumed 80% of hospital epidemiology time and only 30% of routine infection prevention activities were completed. Routine care was delayed in 27% of hospitals evaluating patients for Ebola.
Convenience sample of SHEA members with a moderate response rate.
Hospital Ebola preparations required extraordinary resources, which were diverted from routine infection prevention activities. Patients being evaluated for Ebola faced delays and potential limitations in management of other diseases that are more common in travelers returning from West Africa.
Achieving high healthcare personnel (HCP) influenza vaccination rates has typically required mandating vaccination, which is often challenging to implement. Our objective was to achieve >90% employee influenza vaccination without a mandate.
Prospective quality improvement initiative
SETTING AND PARTICIPANTS
All employees of a 2-hospital, 1,100-bed, community-based academic healthcare system.
The multimodal HCP vaccination campaign consisted of a mandatory declination policy, mask-wearing for non-vaccinated HCP, highly visible “I’m vaccinated” hanging badges, improved vaccination tracking, weekly compliance reports to managers and vice presidents, disciplinary measures for noncompliant HCP, vaccination stations at facility entrances, and inclusion of a target employee vaccination rate (>75%) metric in the annual employee bonus program. The campaign was implemented in the 2011–2012 influenza season and continued throughout the 2012–2013 through 2014–2015 influenza seasons. Employee compliance, vaccination, exemption and declination rates were calculated and compared with those of the seasons prior to the intervention.
Compared with vaccination rates of 57%–72% in the 3 years preceding the intervention, employee influenza vaccination increased to 92% in year 1 and 93% in years 2–4 (P<.001). The proportion of employees declaring medical/religious exemptions or declining vaccination decreased during the 4 years of the program (respectively, 1.2% to 0.5%, P<.001; 4.4% to 3.8%, P=.001).
An integrated multimodal approach incorporating peer pressure, accountability, and financial incentives was associated with increased employee vaccination rate from ≤72% to ≥92%, which has been sustained for 4 influenza seasons. Such programs may provide a model for behavioral change within healthcare organizations.
To determine whether gowning and gloving for all patient care reduces contamination of healthcare worker (HCW) clothing, compared to usual practice.
Five study sites were recruited from intensive care units (ICUs) randomized to the intervention arm of the Benefits of Universal Gown and Glove (BUGG) study.
All HCWs performing direct patient care in the study ICUs were eligible to participate.
Surveys were performed first during the BUGG intervention study period (July–September 2012) with universal gowning/gloving and again after BUGG study conclusion (October–December 2012), with resumption of usual care. During each phase, HCW clothing was sampled at the beginning and near the end of each shift. Cultures were performed using broth enrichment followed by selective media. Acquisition was defined as having a negative clothing culture for samples taken at the beginning of a shift and positive clothing culture at for samples taken at the end of the shift.
A total of 348 HCWs participated (21–92 per site), including 179 (51%) during the universal gowning/gloving phase. Overall, 51 (15%) HCWs acquired commonly pathogenic bacteria on their clothing: 13 (7.1%) HCWs acquired bacteria during universal gowning/gloving, and 38 (23%) HCWs acquired bacteria during usual care (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.2–0.6). Pathogens identified included S. aureus (25 species, including 7 methicillin-resistant S. aureus [MRSA]), Enterococcus spp. (25, including 1 vancomycin-resistant Enterococcus [VRE]), Pseudomonas spp. (4), Acinetobacter spp. (4), and Klebsiella (2).
Nearly 25% of HCWs practicing usual care (gowning and gloving only for patients with known resistant bacteria) contaminate their clothing during their shift. This contamination was reduced by 70% by gowning and gloving for all patient interactions.
This white paper identifies knowledge gaps and new challenges in healthcare epidemiology research, assesses the progress made toward addressing research priorities, provides the Society for Healthcare Epidemiology of America (SHEA) Research Committee's recommendations for high-priority research topics, and proposes a road map for making progress toward these goals. It updates the 2010 SHEA Research Committee document, “Charting the Course for the Future of Science in Healthcare Epidemiology: Results of a Survey of the Membership of SHEA,” which called for a national approach to healthcare-associated infections (HAIs) and a prioritized research agenda. This paper highlights recent studies that have advanced our understanding of HAIs, the establishment of the SHEA Research Network as a collaborative infrastructure to address research questions, prevention initiatives at state and national levels, changes in reporting and payment requirements, and new patterns in antimicrobial resistance.
To assess definitions, experience, and infection control practices for multidrug-resistant gram-negative bacteria (MDR-GNB), including Enterobacteriaceae, Acinetobacter, and Pseudomonas species, in acute care hospitals.
US and international members of the Society for Healthcare Epidemiology of America (SHEA) Research Network.
Online survey that included definitions, infection control procedures, and microbiology capability related to MDR-GNB and other MDR bacteria.
From November 2012 through February 2013, 66 of 170 SHEA Research Network members responded (39% response rate), representing 26 states and 15 countries. More than 80% of facilities reported experience with each MDR-GNB isolate, and 78% had encountered GNB resistant to all antibiotics except colistin (62% Acinetobacter, 59% Pseudomonas, and 52% Enterobacteriaceae species). Participants varied regarding their definitions of “multidrug resistant,” with 14 unique definitions for Acinetobacter, 18 for Pseudomonas, and 22 for Enterobacteriaceae species. Substantial variation also existed in isolation practices. Although isolation was commonly used for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and carbapenem-resistant Enterobacteriaceae (CRE), approximately 20% of facilities did not isolate for MDR Pseudomonas or Acinetobacter. The majority of those that isolated MDR organisms also removed isolation using a wide variety of criteria.
Facilities vary significantly in their approach to preventing MDR-GNB transmission. Although practices for MRSA and VRE are relatively standardized, emerging pathogens CRE and other MDR-GNB have highly varied definitions and management. This confusion makes communication difficult, and varied use of isolation may contribute to emergence of these organisms. Public health agencies need to promote standard definitions and management to enable broader initiatives to limit emergence of MDR-GNB.
We calculated rates of ventilator-associated pneumonia (VAP) by using surveillance data, clinical data, and coding data. Compared with the VAP rates calculated on the basis of surveillance data, the VAP rates calculated on the basis of coding data were significantly overestimated in 4 of 5 intensive, care units. Efforts to improve coding and clinical documentation will address much but not all of this discrepancy between surveillance and administrative data.
To determine whether total and antianaerobic antibiotic exposure increases the risk of room contamination among vancomycin-resistant enterococci (VRE)–colonized patients.
Design And Setting.
A 14-month study in 2 intensive care units at an academic tertiary care hospital in Boston, Massachusetts.
All patients who acquired VRE or were VRE-colonized on admission and who had environmental cultures performed.
We performed weekly environmental cultures (2 sites per room) and considered a room to be contaminated if there was a VRE-positive environmental culture during the patient's stay. We determined risk factors for room contamination by use of the Cox proportional hazards model.
Of 142 VRE-colonized patients, 35 (25%) had an associated VRE-positive environmental culture. Patients who contaminated their rooms were more likely to have diarrhea than those who did not contaminate their rooms (23 [66%] of 35 vs 41 [38%] of 107; P = .005) and more likely to have received antibiotics while VRE colonized (33 [94%] of 35 vs 86 [80%] of 107; P = .02). There was no significant difference in room contamination rates between patients exposed to antianaerobic regimens and patients exposed to nonantianaerobic regimens or between patients with and patients without diarrhea, but patients without any antibiotic exposure were unlikely to contaminate their rooms. Diarrhea and antibiotic use were strongly confounded; although two-thirds of room contamination occurred in rooms of patients with diarrhea, nearly all of these patients received antibiotics. In multivariable analysis, higher mean colonization pressure in the ICU increased the risk of room contamination (adjusted hazard ratio per 10% increase, 1.44 [95% confidence interval, 1.04–2.04]), whereas no antibiotic use during VRE colonization was protective (adjusted hazard ratio, 0.21 [95% confidence interval, 0.05–0.89]).
Room contamination with VRE was associated with increased mean colonization pressure in the ICU and diarrhea in the VRE-colonized patient, whereas no use of any antibiotics during VRE colonization was protective.
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