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Background: The burden of hospital-associated infections (HAIs) and antimicrobial resistance (AMR) in Latin America is high. Improving engagement by healthcare workers (HCWs) in infection prevention and control (IPC) may lead to better patient outcomes; however, little is known about HCW perceptions of IPC in the region. We sought to understand HCW perceptions of IPC processes and practices. Methods: During August–September 2022, HCWs from 30 hospitals with IPC programs in 4 Latin American countries (Panama, Guatemala, Ecuador, and Argentina) were invited to participate in an electronic, voluntary, anonymous survey about their perceptions of IPC at their hospitals. Physicians, nurses, and environmental care (EVC) personnel were prioritized for recruitment. All respondents were asked 18 questions; IPC team members were asked 5 additional questions about specific activities implemented by IPC programs, how data are used, and how IPC could be improved. Answers with 5-point Likert scale responses were categorized into 2 groups (eg, strongly agree or agree vs neutral, disagree, or strongly disagree) for analysis. Results: Of 1,252 HCWs who completed the survey, 181 (14%) were IPC team members, 1,095 (87%) had direct patient contact, and 1,156 (92%) worked >20 hours per week. Figure 1 shows participant characteristics. Most participants (56%) rated their IPC program as very good, 38% rated it as good, and 6% rated it as bad. Physicians were less likely to give a favorable rating. Compliance with prevention bundles and hand hygiene (HH) by colleagues was rated as poor by 28% and 22% of HCWs, respectively; however, only 11% and 5% indicated that their own compliance was poor, respectively. Also, 25% of participants reported not receiving or only occasionally receiving HH compliance data. Similarly, 41% of participants reported not receiving HAI data on a regular basis, and 19% of IPC nurses reported not receiving data despite being responsible for conducting surveillance. Furthermore, 41% of respondents indicated not receiving or only occasionally receiving IPC training or education relevant to their role. When asked about the safety climate, 16% of participants reported not feeling appreciated. In addition, 22% of IPC nurses and 37% of individuals in the “other” category (eg, health technicians and therapists) were more likely to report this. When IPC team members were asked how frequently specific activities were conducted (Fig. 2), several opportunities for improvement were identified, including improving HCW access to HH data and development of strategic plans. Conclusions: Improving HCW access to training on IPC and to data on HAI burden and compliance with HH and prevention bundles should be emphasized in Latin American hospitals.
We evaluated antibiotic use in a private health insurance network in Bolivia with two different healthcare plans. The Health Maintenance Organization plan had 29% lower antibiotic consumption and fewer broad-spectrum antibiotics prescribed than the Preferred Provider Organization. Furthermore, we identified potential targets for future antibiotic stewardship efforts.
We provide an overview of diagnostic stewardship with key concepts that include the diagnostic pathway and the multiple points where interventions can be implemented, strategies for interventions, the importance of multidisciplinary collaboration, and key microbiologic diagnostic tests that should be considered for diagnostic stewardship. The document focuses on microbiologic laboratory testing for adult and pediatric patients and is intended for a target audience of healthcare workers involved in diagnostic stewardship interventions and all workers affected by any step of the diagnostic pathway (ie, ordering, collecting, processing, reporting, and interpreting results of a diagnostic test). This document was developed by the Society for Healthcare Epidemiology of America Diagnostic Stewardship Taskforce.
Implementation of antimicrobial stewardship programs (ASPs) in well-resourced countries has been associated with reductions in antibiotic-resistant infections and improved patient outcomes. Several guidance documents providing recommendations on how to structure antimicrobial stewardship activities at the national and hospital level in resource-limited settings have been published. However, few hospitals in Latin America report having a structure or resources needed for a successful ASP. Given the alarming increases in antimicrobial resistance in Latin America, better understanding of barriers to promote implementation of effective ASPs is urgently needed. We have summarized past and present antimicrobial stewardship activities in Latin American hospitals, and we describe key elements needed in future efforts to strengthen antimicrobial stewardship in the region.
The optimal timing of blood culture (BCx) sets collection has not been evaluated with continuous BCx detection systems. The yield of BCx was similar between short intervals (median, 3 minutes) and longer intervals (median, 16 or 43 minutes) among 5,856 BCx, except for improved polymicrobial bacteremia detection with long-interval BCx.
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 reduce inappropriate antibiotic prescribing for acute respiratory infections (ARIs) by employing peer comparison with behavioral feedback in the emergency department (ED).
A controlled before-and-after study.
The study was conducted in 5 adult EDs at teaching and community hospitals in a health system.
Adults presenting to the ED with a respiratory condition diagnosis code. Hospitalized patients and those with a diagnosis code for a non-respiratory condition for which antibiotics are or may be warranted were excluded.
After a baseline period from January 2016 to March 2018, 3 EDs implemented a feedback intervention with peer comparison between April 2018 and December 2019 for attending physicians. Also, 2 EDs in the health system served as controls. Using interrupted time series analysis, the inappropriate ARI prescribing rate was calculated as the proportion of antibiotic-inappropriate ARI encounters with a prescription. Prescribing rates were also evaluated for all ARIs. Attending physicians at intervention sites received biannual e-mails with their inappropriate prescribing rate and had access to a dashboard that was updated daily showing their performance relative to their peers.
Among 28,544 ARI encounters, the inappropriate prescribing rate remained stable at the control EDs between the 2 periods (23.0% and 23.8%). At the intervention sites, the inappropriate prescribing rate decreased significantly from 22.0% to 15.2%. Between periods, the overall ARI prescribing rate was 38.1% and 40.6% in the control group and 35.9% and 30.6% in the intervention group.
Behavioral feedback with peer comparison can be implemented effectively in the ED to reduce inappropriate prescribing for ARIs.
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.
To evaluate the role of procalcitonin (PCT) results in antibiotic decisions for COVID-19 patients at hospital presentation.
Design, setting, and participants:
Multicenter retrospective observational study of patients ≥18 years hospitalized due to COVID-19 at the Johns Hopkins Health system. Patients who were transferred from another facility with >24 hours stay and patients who died within 48 hours of hospitalization were excluded.
Elevated PCT values were determined based on each hospital’s definition. Antibiotic therapy and PCT results were evaluated for patients with no evidence of bacterial community-acquired pneumonia (bCAP) and patients with confirmed, probable, or possible bCAP. The added value of PCT testing to clinical criteria in detecting bCAP was evaluated using receiving operating curve characteristics (ROC).
Of 962 patients, 611 (64%) received a PCT test. ROC curves for clinical criteria and clinical criteria plus PCT test were similar (at 0.5 ng/mL and 0.25 ng/mL). By bCAP group, median initial PCT values were 0.58 ng/mL (interquartile range [IQR], 0.24–1.14), 0.23 ng/mL (IQR, 0.1–0.63), and 0.15 ng/mL (IQR, 0.09–0.35) for proven/probable, possible, and no bCAP groups, respectively. Among patients without bCAP, an elevated PCT level was associated with 1.8 additional days of CAP therapy (95% CI, 1.01–2.75; P < .01) compared to patients with a negative PCT result after adjusting for potential confounders. Duration of CAP therapy was similar between patients without a PCT test ordered and a low PCT level for no bCAP and possible bCAP groups.
PCT results may be abnormal in COVID-19 patients without bCAP and may result in receipt of unnecessary antibiotics.
In a multicenter cohort of 963 adults hospitalized due to coronavirus disease 2019 (COVID-19), 5% had a proven hospital-acquired infection (HAI) and 21% had a proven, probable, or possible HAI. Risk factors for proven or probable HAIs included intensive care unit admission, dexamethasone use, severe COVID-19, heart failure, and antibiotic exposure upon admission.
Background: In 2018, the Maryland Department of Health, in collaboration with the University of Maryland and Johns Hopkins University, created the Statewide Prevention and Reduction of Clostridioides difficile (SPARC) collaborative to reduce C. difficile as specified in Healthy People 2020. Methods: The SPARC collaborative recruited hospitals contributing most cases to statewide C. difficile standardized infection ratio (SIR), according to data reported to the National Healthcare Safety Network (NHSN). SPARC developed intervention bundles around 4 domains: infection prevention, environmental cleaning, and diagnostic and antimicrobial stewardship. Each facility completed a self-assessment followed by an on-site, day-long, peer-to-peer (P2P) evaluation with 8–12 SPARC subject matter experts (SMEs) representing each domain. The SMEs met with hospital executive leadership and then led 4 domain-based group discussions with relevant hospital team leaders. To identify policy and practice gaps, SMEs visited hospital inpatient units for informal interviews with frontline staff. In a closing session, SPARC SMEs, hospital executives, and team leaders reconvened to discuss preliminary findings. This included review of covert observation data (hand hygiene, personal protective equipment compliance, environmental cleaning) obtained by SPARC team 1–2 weeks prior. Final SPARC P2P written recommendations guided development of customized interventions at each hospital. SPARC provided continuous support (follow up phone calls, educational webinars, technical support, didactic training for antimicrobial stewardship pharmacists) to enhance facility-specific implementation. For every quarter, we categorized C. difficile NHSN data for each Maryland hospital into “SPARC” or “non-SPARC” based on participation status. Using negative binomial mixed models, we analyzed difference-in-difference of pre- and postincidence rate ratios (IRRs) for SPARC and non-SPARC hospitals, which allowed estimation of change attributable to SPARC participation independent of other time-varying factors. Results: Overall, 13 of 48 (27%) hospitals in Maryland participated in the intervention. The baseline SIR for all Maryland hospitals was 0.92, and the post-SPARC SIR was 0.67. The SPARC hospitals had a greater reduction in hospital-onset C. difficile incidence; 8.6 and 4.3 events per 10,000 patient days for baseline and most recent quarter, respectively. For non-SPARC hospitals, these hospital-onset C. difficile incidences were 5.1 preintervention and 4.3 postintervention. We found a statistically significant difference-in-difference between SPARC and non-SPARC hospital C. difficile reduction rates (ratio of IRR, 0.63; 95% CI, 0.44−0.89; P = .01). Conclusions: The Maryland SPARC collaborative, a public health-academic partnership, was associated with a 25% reduction in the Maryland C. difficile SIR. Hospitals participating in SPARC demonstrated significantly reduced C. difficile incidences to match that of high-performing hospitals in Maryland.
Bedside nurses have been recognized as potential antibiotic stewards; however, data on effective ways that nurses can contribute to stewardship activities in acute-care hospitals are scarce. Methods: A nurse-driven urine culture intervention to improve urine culture ordering practices was implemented in a medicine and a neurocritical care unit (NCCU) at The Johns Hopkins Hospital. Bedside nurses implemented an algorithm (Fig. 1) developed by the antibiotic stewardship program (ASP) to review the appropriateness of urine culture and to guide discussions with ordering providers regarding unnecessary urine cultures. Nurses received in-person training by an ASP physician champion on how to use the algorithm and education on the definition and indications for evaluation for asymptomatic bacteriuria and urinary tract infections. The ASP physician periodically visited the units to address concerns and questions. In both units, a nurse champion was identified to serve as liaison between the ASP and bedside nurses, and physician support was obtained before the intervention. The pre- and postintervention periods for the medicine unit were September 2017–August 2018 and September 2018–August 2019, respectively. For the NCCU, these periods were September 2018–February 2019 and March 2019–September 2019, respectively. Trends in urine cultures per 100 patient days (PD) were examined with statistical process charts and compared before and after the intervention using a standard incident ratio (IRR) and Poisson regression. Results: In total, 327 urine cultures were collected in the medicine unit and 293 in the NCCU over the study period. Although the intervention led to a significant 34% reduction in the rate of urine cultures on the medicine unit (from 2.3 to 1.5 cultures/100 PD; IRR, 0.66; 95% CI, 0.50–0.87; P < .01), the number of urine cultures remained without a significant change in the NCCU (from 4.5 to 3.7 cultures/100 PD; IRR, 0.89; 95% CI, 0.65–1.22; P = .48) (Fig. 2). Conclusions: Algorithm-based, nurse-driven review of urine culture indications reduced urine cultures on a medicine unit but not in a neurosciences ICU. Success on the medicine unit may have been driven by highly engaged nurse and physician champions and by patients being able to respond questions about symptoms. The following factors might have impacted results on NCCU: presence of conflicting protocols (eg, panculturing patients every 48 hours per a hypothermia protocol), unit tradition (eg, obtaining cultures to assess treatment response), perception of greater risk benefit in NCCU patients, and unit dynamics (open unit with other primary services placing orders for patients). Unit and team dynamics can affect effective implementation of antimicrobial stewardship interventions by nurses.
Background: Patients with a penicillin/aminopenicillin (PCN) allergy label are more likely to receive non–β-lactam antibiotics and to experience worse clinical outcomes. Given that nurses are often first to interact with patients, we pilot tested a nurse-driven quality improvement initiative to improve PCN allergy documentation and increase β-lactam use. Methods: We conducted a before-and-after study on a labor and delivery unit at The Johns Hopkins Hospital (JHH) from May 2018 to September 2019. Patients aged 18 years with a PCN allergy were included. The intervention included (1) the use of an algorithm developed by the antimicrobial stewardship team to assist nurses in obtaining accurate PCN allergy histories (Fig. 1), (2) identification of a nurse champion to facilitate implementation of the algorithm, and (3) in-person education by a stewardship physician regarding the importance and impact of adequate PCN allergy documentation on clinical outcomes. Readmissions were counted as separate encounters. The primary outcome was improved allergy documentation (either fewer blank documentations, nonspecified rash reactions, drug intolerance documentations (eg, isolated nausea), documentation of signs and symptoms of anaphylaxis not specified as such). The secondary outcome was β-lactam use. Categorical variables were compared using the 2 test and continuous variables were compared with the Student t test. Severe allergic reactions were defined as anaphylaxis, severe skin reactions (eg, Stevens-Johnson syndrome), and organ involvement (eg, hepatitis). Results: Overall, 382 patient admissions were included, 305 in the preintervention (May 2018 to May 2019) and 77 in the postintervention period (June 2019 to September 2019). Mean age and length-of-stay were 30 years and 4 days, respectively, for both periods. The proportion of admitted patients with a PCN allergy label was 8% and 7% for pre- and postintervention periods. Documentation findings in the pre- and postintervention periods respectively were as follows: blank documentation 11% and 12% (P = .89), documentation of specified rashes 0.6% and 1.3% (P = .56), documentation of drug intolerance 11% and 8% (P = .39), documentation of reactions that were indicative of anaphylaxis but not documented specifically as anaphylaxis 8% and 13% (P = .20). Among patients with a documented PCN allergy who received antibiotics, 83 of 177 (47%) and 27 of 43 (63%) received β-lactams (P = .01) in the pre- and postintervention periods, with cefazolin being the antibiotic most commonly used in both periods. Conclusions: Nursing education and an algorithm did not result in significant improvements in PCN allergy documentation in the 3 months after implementation. More data collection is planned to assess the impact of the intervention.
Hospital antibiotic use in Argentina has not been described. We present results of point prevalence surveys on antibiotic use conducted in 109 Argentinian hospitals in November 2018 and submitted to the National Program of Epidemiology and Control of Hospital-Acquired Infections, and we discuss potential areas for improvement.
No standardized surveillance criteria exist for surgical site infection after breast tissue expander (BTE) access. This report provides a framework for defining postaccess BTE infections and identifies contributing factors to infection during the expansion period. Implementing infection prevention guidelines for BTE access may reduce postaccess BTE infections.
Nurses view patient safety as an essential component of their work and have reported a general interest in embracing an antibiotic steward role. However, antibiotic stewardship (AS) functions have not been formally integrated into nursing practice despite nurses’ daily involvement in clinical activities that impact antibiotic decisions (e.g., obtaining specimens for cultures, blood drawing for therapeutic drug monitoring). Recommendations to expand AS programs to include bedside nurses are generating support at a national level, yet a practical guidance on how nurses can be involved in AS activities is lacking. In this review, we provide a framework identifying selected practices where nurses can improve antibiotic prescribing practices through appropriate obtainment of Clostridioides difficile tests, appropriate urine culturing practices, optimal antibiotic administration, accurate and detailed documentation of penicillin allergy histories and through the prompting of antibiotic time outs. We identify reported barriers to engagement of nurses in AS and offer potential solutions that include patient safety principles and quality improvement strategies that can be used to mitigate participation barriers. This review will assist AS leaders interested in advancing the contributions of nurses into their AS programs by discussing education, communication, improvement models, and workflow integration enhancements that strengthen systems to support nurses as valued partners in AS efforts.