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Pediatric antimicrobial stewardship programs (ASPs) improve antibiotic use for hospitalized children. Prescriber surveys indicate acceptance of ASPs, but data on infectious diseases (ID) physician opinions of ASPs are lacking. We conducted a survey of pediatric ID physicians, ASP and non-ASP, and their perceptions of ASP practices and outcomes.
We performed a survey of adult infectious diseases (ID) physicians to explore unintended consequences of antimicrobial stewardship programs (ASP). ID physicians worried about disagreement with colleagues, provider autonomy, and remote recommendations. Non-ASP ID physicians expressed more concern regarding ASPs focus on costs, provider efficiency, and unintended consequences of ASP guidance.
Although a growing number of healthcare facilities are implementing healthcare personnel (HCP) coronavirus disease 2019 (COVID-19) vaccination requirements, vaccine exemption request management as a part of such programs is not well described.
Infectious disease (ID) physician members of the Emerging Infections Network with infection prevention or hospital epidemiology responsibilities.
Eligible persons were sent a web-based survey focused on hospital plans and practices around exemption allowances from HCP COVID-19 vaccine requirements.
Of the 695 ID physicians surveyed, 263 (38%) responded. Overall, 160 respondent institutions (92%) allowed medical exemptions, whereas 132 (76%) allowed religious exemptions. In contrast, only 14% (n = 24) allowed deeply held personal belief exemptions. The types of medical exemptions allowed varied considerably across facilities, with allergic reactions to the vaccine or its components accepted by 145 facilities (84%). For selected scenarios commonly used as the basis for religious and deeply held personal belief exemption requests, 144 institutions (83%) would not approve exemptions focused on concerns regarding right of consent or violations of freedom of personal choice, and 140 institutions (81%) would not approve exemptions focused on introducing foreign substances into one’s body or the sanctity of the body. Most respondents noted plans for additional infection prevention interventions for HCP who received an exemption for COVID-19 vaccination.
Although many respondent institutions allowed exemptions from HCP COVID-19 vaccination requirements, the types of exemptions allowed and how the exemption programs were structured varied widely.
We surveyed infectious disease specialists about early coronavirus disease 2019 (COVID-19) vaccination preparedness. Almost all responding institutions rated their facility’s preparedness plan as either excellent or adequate. Vaccine hesitancy and concern about adverse reactions were the most commonly anticipated barriers to COVID-19 vaccination. Only 60% believed that COVID-19 vaccination should be mandatory.
Presenteeism, or working while ill, by healthcare personnel (HCP) experiencing influenza-like illness (ILI) puts patients and coworkers at risk. However, hospital policies and practices may not consistently facilitate HCP staying home when ill.
Objective and methods:
We conducted a mixed-methods survey in March 2018 of Emerging Infections Network infectious diseases physicians, describing institutional experiences with and policies for HCP working with ILI.
Of 715 physicians, 367 (51%) responded. Of 367, 135 (37%) were unaware of institutional policies. Of the remaining 232 respondents, 206 (89%) reported institutional policies regarding work restrictions for HCP with influenza or ILI, but only 145 (63%) said these were communicated at least annually. More than half of respondents (124, 53%) reported that adherence to work restrictions was not monitored or enforced. Work restrictions were most often not perceived to be enforced for physicians-in-training and attending physicians. Nearly all (223, 96%) reported that their facility tracked laboratory-confirmed influenza (LCI) in patients; 85 (37%) reported tracking ILI. For employees, 109 (47%) reported tracking of LCI and 53 (23%) reported tracking ILI. For independent physicians, not employed by the facility, 30 (13%) reported tracking LCI and 11 (5%) ILI.
More than one-third of respondents were unaware of whether their institutions had policies to prevent HCP with ILI from working; among those with knowledge of institutional policies, dissemination, monitoring, and enforcement of these policies was highly variable. Improving communication about work-restriction policies, as well as monitoring and enforcement, may help prevent the spread of infections from HCP to patients.
A nationwide survey indicated that screening for asymptomatic carriers of C. difficile is an uncommon practice in US healthcare settings. Better understanding of the role of asymptomatic carriage in C. difficile transmission, and of the measures available to reduce that risk, are needed to inform best practices regarding the management of carriers.
To characterize healthcare provider diagnostic testing practices for identifying Clostridioides (Clostridium) difficile infection (CDI) and asymptomatic carriage in children.
An 11-question survey was sent by e-mail or facsimile to all pediatric infectious diseases (PID) members of the Infectious Diseases Society of America’s Emerging Infections Network (EIN).
Among 345 eligible respondents who had ever responded to an EIN survey, 196 (57%) responded; 162 of these (83%) were aware of their institutional policies for CDI testing and management. Also, 159 (98%) respondents knew their institution’s C. difficile testing method: 99 (62%) utilize NAAT without toxin testing and 60 (38%) utilize toxin testing, either as a single test or a multistep algorithm. Of 153 respondents, 10 (7%) reported that formed stools were tested for C. difficile at their institution, and 76 of 151 (50%) reported that their institution does not restrict C. difficile testing in infants and young children. The frequency of symptom- and age-based testing restrictions did not vary between institutions utilizing NAAT alone compared to those utilizing toxin testing for C. difficile diagnosis. Of 143 respondents, 26 (16%) permit testing of neonatal intensive care unit patients and 12 of 26 (46%) treat CDI with antibiotics in this patient population.
These data suggest that there are opportunities to improve CDI diagnostic stewardship practices in children, including among hospitals using NAATs alone for CDI diagnosis in children.
To delineate the timing of, indications for, and assessment of visitor restriction policies and practices (VRPP) in pediatric facilities.
An electronic survey to characterize VRPP in pediatric healthcare facilities.
The Infectious Diseases Society of America Emerging Infections Network surveyed 334 pediatric infectious disease consultants via an electronic link. Descriptive analyses were performed.
A total of 170 eligible respondents completed a survey between 12 July and August 15, 2016, for a 51% response rate. Of the 104 respondents (61%) familiar with their VRPP, 92 (88%) had VRPP in all inpatient units. The respondents reported age-based VRPP (74%) symptom-based VRPP (97%), and outbreak-specific VRPP (75%). Symptom-based VRPP were reported to be seasonal by 24% of respondents and to be implemented year-round according to 70% of respondents. According to the respondents, communication of VRPP to families occurred at admission (87%) and through signage in care areas (64%), while communication of VRPP to staff occurred by email (77%), by meetings (55%), and by signage in staff-only areas (49%). Respondents reported that enforcement of VRPP was the responsibility of nursing (80%), registration clerks (58%), unit clerks (53%), the infection prevention team (31%), or clinicians 16 (16%). They also reported that the effectiveness of VRPP was assessed through active surveillance of hospital acquired respiratory infections (62%), through active surveillance of healthcare worker exposures (28%) and through patient/family satisfaction assessments (29%).
Visitor restriction policies and practices vary in scope, implementation, enforcement, and physician awareness in pediatric facilities. A prospective multisite evaluation of outcomes would facilitate the adoption of uniform guidance.
Studies have suggested that contact precautions (CP) for methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus may have risks that outweigh the benefits. These risks, coupled with more widespread use of horizontal interventions such as daily bathing with chlorhexidine gluconate, have brought into question the value of routine CP for these organisms.
To assess the state of utilization of CP as well as adjunctive measures to reduce the risk of transmission in US hospitals.
Total of 751 physician members of the Emerging Infections Network.
An 8-question electronic survey distributed by email.
A total of 426/751 (57%) responded to the survey; 337/364 (93%) of respondents use routine CP for methicillin-resistant S. aureus and 335/364 (92%) use routine CP for vancomycin-resistant enterococcus. The most widely used trigger for initiation of CP for both pathogens was positive clinical culture. Practices for discontinuation of isolation varied widely. We found that 325/354 (92%) perform routine chlorhexidine gluconate bathing and 236/353 (67%) perform S. aureus decolonization with mupirocin for 1 or more subsets of inpatients, and 82/356 (23%) reported using either hydrogen peroxide vapor or ultraviolet-C room disinfection at discharge. Free text responses noted frustration and variation in the application, practice, and process for initiation and discontinuation of CP.
Use of CP for methicillin-resistant S. aureus and vancomycin-resistant enterococcus remains commonplace, although horizontal interventions such as chlorhexidine gluconate bathing are increasingly used. The heterogeneity of practices and policies was striking. Evidence-based guidelines regarding CP and horizontal interventions are needed.
Diagnosis and treatment of vascular infections is complex and depends on a variety of factors, including the location of the infected tissue, the microbiology of the infection, and patient-specific factors, such as anatomy and immune status. Purulent or suppurative thrombophlebitis is inflammation of a peripheral or central venous wall because of the presence of microorganisms. Endarteritis (or infective arteritis) and mycotic aneurysms are infections of the arterial walls; arterial aneurysms or pseudoaneurysms are usually present because endarteritis may be difficult to diagnose unless an aneurysm is present. The term mycotic aneurysm is a misnomer that refers to any arterial aneurysm of infectious cause, fungal or bacterial, and may also include secondary infections of pre-existing aneurysms or pseudoaneurysms. Vascular graft infections present an even wider spectrum of disease that depends on the type and location of the graft. Management of infections located on vascular prostheses is further complicated by the fact that prosthesis excision can jeopardize a patient's life and organ function, and alternative grafting techniques, including ex situ bypass, autologous reconstruction, and a variety of other graft materials, must be considered. Finally, endovascular repair of aneurysms has resulted in a variety of infectious complications of endovascular stents, stent-grafts, and other intra-arterial devices.
Pathogenesis and diagnosis
Septic thrombophlebitis is characterized by inflammation with suppuration of the vein wall. The various anatomic sites of this serious condition determine the clinical significance and manifestations. Superficial suppurative thrombophlebitis is most often a complication of indwelling intravenous catheters or intravenous substance use. Suppurative thrombophlebitis due to intravenous catheters occurs more commonly with plastic than with steel cannulas. Irritation of the vein wall and subsequent development of purulent thrombophlebitis occurs more often with polyethylene catheters than with Teflon or Silastic catheters and is higher in lower extremity cannulation. Central vein thrombosis is a relatively common complication of central venous catheterization, occurring in as many as one-third of patients in some autopsy and clinical series. Peripherally inserted central venous catheters are also associated with increased risk of symptomatic thrombosis. Suppurative thrombophlebitis of the thoracic central veins results from the bacterial or fungal contamination (sepsis) of these often asymptomatic thrombi. The second major type of septic thrombophlebitis occurs by invasion from adjacent primary nonvascular infections and includes Lemierre's syndrome (internal jugular vein septic thrombophlebitis) as well as other entities discussed elsewhere. Lemierre's syndrome, although rare, usually follows an oropharyngeal infection and occurs most often in previously healthy patients aged 16 to 25 years.
To identify current outpatient parenteral antibiotic therapy practice patterns and complications.
We administered an 11-question survey to adult infectious disease physicians participating in the Emerging Infections Network (EIN), a Centers for Disease Control and Prevention–sponsored sentinel event surveillance network in North America. The survey was distributed electronically or via facsimile in November and December 2012. Respondent demographic characteristics were obtained from EIN enrollment data.
Overall, 555 (44.6%) of EIN members responded to the survey, with 450 (81%) indicating that they treated 1 or more patients with outpatient parenteral antimicrobial therapy (OPAT) during an average month. Infectious diseases consultation was reported to be required for a patient to be discharged with OPAT by 99 respondents (22%). Inpatient (282 [63%] of 449) and outpatient (232 [52%] of 449) infectious diseases physicians were frequently identified as being responsible for monitoring laboratory results. Only 26% (118 of 448) had dedicated OPAT teams at their clinical site. Few infectious diseases physicians have systems to track errors, adverse events, or “near misses” associated with OPAT (97 [22%] of 449). OPAT-associated complications were perceived to be rare. Among respondents, 80% reported line occlusion or clotting as the most common complication (occurring in 6% of patients or more), followed by nephrotoxicity and rash (each reported by 61%). Weekly laboratory monitoring of patients who received vancomycin was reported by 77% of respondents (343 of 445), whereas 19% of respondents (84 of 445) reported twice weekly laboratory monitoring for these patients.
Although use of OPAT is common, there is significant variation in practice patterns. More uniform OPAT practices may enhance patient safety.
Carbapenem-resistant Enterobacteriaceae (CRE) infections are increasing and are associated with considerable morbidity and mortality. Members of the Emerging Infections Network treating CRE encountered difficulties in obtaining laboratory results and struggled with limited treatment options. In addition, many treated patients experienced an alarming degree of drug toxicity from CRE therapies.
The diagnosis of central line-associated bloodstream infections (CLABSIs) is often controversial, and existing guidelines differ in important ways.
To determine both the range of practices involved in obtaining blood culture samples and how central line-associated infections are diagnosed and to obtain members' opinions regarding the process of designating bloodstream infections as publicly reportable CLABSIs.
Electronic and paper 11-question survey of infectious-diseases physician members of the Infectious Diseases Society of America Emerging Infections Network (IDSA EIN).
All 1,364 IDSA EIN members were invited to participate.
692 (51%) members responded; 52% of respondents with adult practices reported that more than half of the blood culture samples for intensive care unit (ICU) patients with central lines were drawn through existing lines. A sizable majority of respondents used time to positivity, differential time to positivity when paired blood cultures are used, and quantitative culture of catheter tips when diagnosing CLABSI or determining the source of that bacteremia. When determining whether a bacteremia met the reportable CLABSI definition, a majority used a decision method that involved clinical judgment.
Our survey documents a strong preference for drawing 1 set of blood culture samples from a peripheral line and 1 from the central line when evaluating fever in an ICU patient, as recommended by IDSA guidelines and in contrast to current Centers for Disease Control and Prevention recommendations. Our data show substantial variability when infectious-diseases physicians were asked to determine whether bloodstream infections were primary bacteremias, and therefore subject to public reporting by National Healthcare Safety Network guidelines, or secondary bacteremias, which are not reportable.
To describe the prevalence and characteristics of antimicrobial stewardship programs (ASPs) in hospitals across the United States and to describe financial support provided for these programs.
Electronic and paper 14-question survey of infectious diseases physician members of the Infectious Diseases Society of America Emerging Infections Network (IDSA EIN).
All 1,044 IDSA EIN members who care for adult patients were invited to participate.
Five hundred twenty-two (50%) members responded. Seventy-three percent of respondents reported that their institutions had or were planning an ASP, compared with 50% reporting the same thing in an EIN survey 10 years before. A shift was noted from formulary restriction alone to use of a set of tailored strategies designed to provide information and feedback to prescribers, particularly in community hospitals. Lack of funding and lack of personnel were reported as major barriers to implementing a program. Fifty-two percent of respondents with an ASP reported that infectious diseases physicians do not receive direct compensation for their participation in the ASP, compared with 18% 10 years ago.
The percentage of institutions reporting ASPs has increased over the last decade, although small community hospitals were least likely to have these programs. In addition, ASP strategies have shifted dramatically. Lack of funding remains a key barrier for ASPs, and administrators need additional cost savings data in order to support ASPs. Interestingly, while guidelines and editorials regard compensated participation by an infectious diseases physician in these programs as critical, we found that more than half of the respondents reported no direct compensation for ASP activities.
A minority of infectious diseases consultants currently work in healthcare institutions requiring influenza vaccination for healthcare workers, and in approximately half of these institutions, the healthcare workers who refuse vaccination do not face substantial consequences for their refusal. Although true mandatory policies are not common, a majority of infectious diseases consultants support such policies.
We surveyed infectious diseases physicians to determine their practice patterns with regard to both antimicrobial lock prophylaxis and antimicrobial lock therapy. Antimicrobial lock prophylaxis is relatively uncommon; only 19% of infectious diseases physicians reported using it at least once. Although antimicrobial lock therapy is more commonly used, we found a significant variation in practice patterns.
To describe the prevalence, characteristics, and barriers to implementation of antimicrobial stewardship programs (ASPs) in pediatrics.
Design and Participants.
In December 2008, we surveyed the pediatric members of the Emerging Infections Network, a network of infectious diseases consultants located throughout North America. Participants responded regarding whether their hospital had or planned to develop an ASP, its characteristics, barriers to improvement or implementation, and perceptions about antimicrobial resistance.
Of 246 pediatric infectious disease consultants surveyed, 147 (60%) responded. Forty-five respondents (33%) reported having an ASP, and 25 (18%) were planning a program. The percentage of respondents from freestanding children's hospitals who were planning ASPs was higher than the percentage of respondents from other settings who were planning ASPs (P = .04). Most existing programs were developed before 2000 and had a limited number of full-time equivalent staff, and few programs used a prospective audit-and-feedback structure. Many programs were not monitoring important end points associated with ASPs, including cost and number of antibiotic-days. The major barriers to implementation of an ASP were lack of resources, including funding, time, and personnel, noted by more than 50% of respondents. Regardless of the presence of an ASP, respondents perceived antibiotic resistance as a more significant problem nationally than at their local hospital (P < .001).
The prevalence of ASPs in pediatrics is limited, and opportunities exist to improve current programs.
The use of declination statements was associated with a mean increase of 11.6% in influenza vaccination rates among healthcare workers at 22 hospitals. In most hospitals, there were no negative consequences for healthcare workers who refused to sign the forms, and most policies were implemented along with other interventions designed to increase vaccination rates.