On-demand, hospital-based, severe acute respiratory coronavirus virus 2 (SARS-CoV-2) genomic epidemiology to support nosocomial outbreak investigations: A prospective molecular epidemiology study.

Objectives: We evaluated the added value of infection control-guided, on demand, and locally performed severe acute respiratory coronavirus virus 2 (SARS-CoV-2) genomic sequencing to support outbreak investigation and control in acute-care settings. Design and setting: This 18-month prospective molecular epidemiology study was conducted at a tertiary-care hospital in Montreal, Canada. When nosocomial transmission was suspected by local infection control, viral genomic sequencing was performed locally for all putative outbreak cases. Molecular and conventional epidemiology data were correlated on a just-in-time basis to improve understanding of coronavirus disease 2019 (COVID-19) transmission and reinforce or adapt control measures. Results: Between April 2020 and October 2021, 6 outbreaks including 59 nosocomial infections (per the epidemiological definition) were investigated. Genomic data supported 7 distinct transmission clusters involving 6 patients and 26 healthcare workers. We identified multiple distinct modes of transmission, which led to reinforcement and adaptation of infection control measures. Molecular epidemiology data also refuted (n = 14) suspected transmission events in favor of community acquired but institutionally clustered cases. Conclusion: SARS-CoV-2 genomic sequencing can refute or strengthen transmission hypotheses from conventional nosocomial epidemiological investigations, and guide implementation of setting-specific control strategies. Our study represents a template for prospective, on site, outbreak-focused SARS-CoV-2 sequencing. This approach may become increasingly relevant in a COVID-19 endemic state where systematic sequencing within centralized surveillance programs is not available. Trial registration: clinicaltrials.gov identifier: NCT05411562.

Diabetic foot infections: how to investigate more efficiently? A retrospective study in a quaternary university center.

BACKGROUND: Diabetic foot infections are frequent and associated with substantial morbidity and substantial cost to the healthcare system. Up to 34% of diabetic patients will develop an ulcer potentially leading to osteomyelitis. Imaging plays a crucial role in the diagnostic process. Imaging modalities to investigate the diabetic foot infection are many and imaging prescription habits remain heterogeneous across physicians. We aimed to improve the appropriateness of imaging examination requested, and performed, for diabetic foot osteomyelitis and we aimed to reduce the overall imaging-related cost. METHODS: Local committee was created to develop an algorithm for suspected diabetic foot osteomyelitis. Best practices were defined by the local algorithm. The algorithm was shared with our physicians. Pre- and post-intervention analysis was conducted retrospectively. All adult diabetic patients with suspected foot osteomyelitis were included. Adherence to best practices was measured. Statistical analysis with Chi-Square and two tailed unpaired t-test was performed. RESULTS: Pre-intervention cohort had 223 patients (mean age: 63; 168 men). Adherence to best practice was 43%. Scintigraphy (48%) preferred over MRI (44%) and performed simultaneously in 15 patients. Post-intervention cohort had 73 patients (mean age: 66; 62 men). Adherence to best practice was 78%, improved by 35% (p < 0.001). MRI (51%) preferred over scintigraphy (23%) and performed simultaneously in three patients. Scintigraphy examinations decreased by 25% (p < 0.001). MRI examinations increased by 7% (p = 0.32). Hospital imaging related fees decreased by 22% per patient (p = 0.002). CONCLUSION: Interval improvement in adequate adherence while reducing unnecessary examinations for patients and decreasing costs for the healthcare system was observed.

Assessment of antimicrobial prescribing practice, knowledge, and culture in three teaching hospitals.

BACKGROUND: Antimicrobial resistance (AR) is one of the most critical threats to global health. One of its root causes, misuse of antibiotics, can stem from prescribers' preconceived ideas, differing attitudes, and lack of knowledge. Canadian data on this subject are scarce. This study aimed to understand the culture and knowledge of antimicrobial prescribing to optimize strategies targeting prescribers in the local antimicrobial stewardship program (ASP). METHODS: An anonymous online survey was developed and distributed to antimicrobials prescribers at three acute-care teaching hospitals. The questionnaire surveyed perception of AR and ASPs. RESULTS: A total of 440 respondents completed the entire survey. All agreed that AR is a significant challenge in Canada. The vast majority (86%) of respondents believed that AR is a significant problem at their working hospital. However, only 36% of respondents believed that antibiotics are misused locally. Most (92%) agreed that ASPs can decrease AR. Several knowledge gaps were identified through clinical questions. For example, respondents failed to identify treatment indications for asymptomatic bacteriuria 15% of the time and 59% chose an unnecessarily broad antibiotic when presented a microbiology report with susceptibility results associated with a common clinical syndrome. Prescribers' self-reported confidence did not correlate with their knowledge score. CONCLUSIONS: Respondents recognized AR as a critical issue but awareness and knowledge on antibiotic misuse were lacking. As shown in previous studies, respondents see the threat of AR in a more theoretical way. This study provided a better understanding of antimicrobial prescribing practices and ways to optimize them within three teaching hospitals in Montréal. Barriers to optimal antimicrobial prescribing were identified and strategies for improving the effectiveness of the ASP will be developed accordingly.

HISTORIQUE: La résistance antimicrobienne (RA) est l'une des plus graves menaces qui pèsent sur la santé mondiale. L'une de ses causes profondes, le mésusage des antibiotiques, peut découler des idées préconçues, des divergences d'attitudes et du manque de connaissances des prescripteurs. Les données canadiennes sur le sujet sont rares. La présente étude visait à comprendre la culture et les connaissances sur la prescription d'antimicrobiens pour optimiser les stratégies auprès des prescripteurs dans le cadre du programme de gestion des antimicrobiens (PGA) local. MÉTHODOLOGIE: des chercheurs ont préparé un sondage anonyme en ligne et l'ont diffusé auprès des prescripteurs d'antimicrobiens de trois hôpitaux universitaires de soins aigus. Ils ont ainsi sondé la perception de la RA et du PGA. RÉSULTATS: Au total, 440 répondants ont rempli la totalité du sondage. Tous ont indiqué que la RA est un problème important au Canada. La grande majorité des répondants (86 %) étaient d'avis que la RA est un grave problème à l'hôpital où ils travaillent. Cependant, seulement 36 % d'entre eux pensaient que les antibiotiques étaient mal utilisés dans leur localité. La plupart (92 %) convenaient que le PGA peut réduire la RA. Les questions cliniques ont permis de relever plusieurs lacunes. Par exemple, dans 15 % des cas, les répondants n'étaient pas en mesure de déterminer les indications thérapeutiques de la bactériurie asymptomatique, 59 % ont choisi inutilement un antibiotique à large spectre après avoir parcouru un rapport de microbiologie dont les résultats de susceptibilité étaient associés à un syndrome clinique courant. La confiance que déclaraient les prescripteurs n'était pas corrélée avec leurs connaissances. CONCLUSIONS: Les répondants convenaient que la RA était un problème important, mais ne possédaient pas les connaissances nécessaires sur le mésusage des antibiotiques. Comme l'ont démontré des études antérieures, ils perçoivent la menace de la RA sous un angle plutôt théorique. La présente étude a permis de mieux comprendre les pratiques de prescription d'antibiotiques et de relever des moyens de les optimiser dans trois hôpitaux universitaires de Montréal. Les chercheurs ont relevé les obstacles à la prescription optimale d'antimicrobiens et mettront au point des stratégies pour améliorer l'efficacité du PGA en conséquence.

Clinical Evaluation of In-House-Produced 3D-Printed Nasopharyngeal Swabs for COVID-19 Testing.

3D-printed alternatives to standard flocked swabs were rapidly developed to provide a response to the unprecedented and sudden need for an exponentially growing amount of diagnostic tools to fight the COVID-19 pandemic. In light of the anticipated shortage, a hospital-based 3D-printing platform was implemented in our institution for the production of swabs for nasopharyngeal and oropharyngeal sampling based on the freely available, open-source design provided to the community by University of South Florida's Health Radiology and Northwell Health System teams as a replacement for locally used commercial swabs. Validation of our 3D-printed swabs was performed with a head-to-head diagnostic accuracy study of the 3D-printed "Northwell model" with the cobas PCR Media® swab sample kit. We observed an excellent concordance (total agreement 96.8%, Kappa 0.936) in results obtained with the 3D-printed and flocked swabs, indicating that the in-house 3D-printed swab could be used reliably in the context of a shortage of flocked swabs. To our knowledge, this is the first study to report on autonomous hospital-based production and clinical validation of 3D-printed swabs.

Antimicrobial Stewardship: How the Microbiology Laboratory Can Right the Ship.

Antimicrobial stewardship is a bundle of integrated interventions employed to optimize the use of antimicrobials in health care settings. While infectious-disease-trained physicians, with clinical pharmacists, are considered the main leaders of antimicrobial stewardship programs, clinical microbiologists can play a key role in these programs. This review is intended to provide a comprehensive discussion of the different components of antimicrobial stewardship in which microbiology laboratories and clinical microbiologists can make significant contributions, including cumulative antimicrobial susceptibility reports, enhanced culture and susceptibility reports, guidance in the preanalytic phase, rapid diagnostic test availability, provider education, and alert and surveillance systems. In reviewing this material, we emphasize how the rapid, and especially the recent, evolution of clinical microbiology has reinforced the importance of clinical microbiologists' collaboration with antimicrobial stewardship programs.