Are contact precautions "essential" for the prevention of healthcare-associated methicillin-resistant Staphylococcus aureus?

The recently updated SHEA/IDSA/APIC practice recommendations for MRSA prevention in acute care facilities list contact precautions (CP) for patients known to be infected or colonized with MRSA as an "essential practice", meaning that it should be adopted in all acute care facilities. We argue that existing evidence on benefits and harms associated with CP do not justify this recommendation. There are no controlled trials that support broad use of CP for MRSA prevention. Data from hospitals that have discontinued CP for MRSA have found no impact on MRSA acquisition or infection. The burden and harms of CP remain concerning, including the environmental impact of increased gown and glove use. We suggest that CP be included among other "additional approaches" to MRSA prevention that can be implemented under specific circumstances (e.g. outbreaks, evidence of ongoing transmission despite application of essential practices).

Diagnostic stewardship: what impacts antibiotics use?

PURPOSE OF REVIEW: The aim of this study was to review recently published diagnostic stewardship studies of common clinical infectious syndromes and the impact on antibiotic prescribing. RECENT FINDINGS: Diagnostic stewardship can be implemented within healthcare systems and tailored to infectious syndromes, including urinary tract, gastrointestinal, respiratory and bloodstream infections. In urinary syndromes, diagnostic stewardship can decrease unnecessary urine culturing and associated antibiotic prescribing. Diagnostic stewardship of Clostridium difficile testing can decrease antibiotics and test ordering with a reduction in healthcare-associated C. difficile infections. Respiratory syndrome multiplex arrays can decrease time to results and increase detection of clinically relevant pathogens but may not decrease antibiotics use, or worse, could increase over-prescribing if diagnostic stewardship of ordering practices is not exercised. Lastly, blood culturing practices can be improved by clinical decision support to safely decrease collection and broad-spectrum antibiotic use. SUMMARY: Diagnostic stewardship decreases unnecessary antibiotic use in a way that is different from and complementary to antibiotic stewardship. Further studies are needed to quantify the full impact on antibiotic use and resistance. Future considerations should be to institutionalize diagnostic stewardship in patient care activities to leverage integration into systems-based interventions.

Optimal Urine Culture Diagnostic Stewardship Practice-Results from an Expert Modified-Delphi Procedure.

BACKGROUND: Urine cultures are nonspecific and often lead to misdiagnosis of urinary tract infection and unnecessary antibiotics. Diagnostic stewardship is a set of procedures that modifies test ordering, processing, and reporting in order to optimize diagnosis and downstream treatment. In this study, we aimed to develop expert guidance on best practices for urine culture diagnostic stewardship. METHODS: A RAND-modified Delphi approach with a multidisciplinary expert panel was used to ascertain diagnostic stewardship best practices. Clinical questions to guide recommendations were grouped into three thematic areas (ordering, processing, reporting) in practice settings of emergency department, inpatient, ambulatory, and long-term care. Fifteen experts ranked recommendations on a 9-point Likert scale. Recommendations on which the panel did not reach agreement were discussed during a virtual meeting, then a second round of ranking by email was completed. After secondary review of results and panel discussion, a series of guidance statements was developed. RESULTS: One hundred and sixty-five questions were reviewed. The panel reaching agreement on 104, leading to 18 overarching guidance statements. The following strategies were recommended to optimize ordering urine cultures: requiring documentation of symptoms, sending alerts to discourage ordering in the absence of symptoms, and cancelling repeat cultures. For urine culture processing, conditional urine cultures and urine white blood cell count as criteria were supported. For urine culture reporting, appropriate practices included nudges to discourage treatment under specific conditions and selective reporting of antibiotics to guide therapy decisions. CONCLUSIONS: These 18 guidance statements can optimize use of urine cultures for better patient outcomes.

Antibiotic Use and Bacterial Infection among Inpatients in the First Wave of COVID-19: a Retrospective Cohort Study of 64,691 Patients.

Hospitalized patients with SARS-CoV-2 infection (COVID-19) often receive antibiotics for suspected bacterial coinfection. We estimated the incidence of bacterial coinfection and secondary infection in COVID-19 using clinical diagnoses to determine how frequently antibiotics are administered when bacterial infection is absent. We performed a retrospective cohort study of inpatients with COVID-19 present on admission to hospitals in the Premier Healthcare Database between April and June 2020. Bacterial infections were defined using ICD-10-CM diagnosis codes and associated "present on admission" coding. Coinfections were defined by bacterial infection present on admission, while secondary infections were defined by bacterial infection that developed after admission. Coinfection and secondary infection were not mutually exclusive. A total of 18.5% of 64,961 COVID-19 patients (n = 12,040) presented with bacterial infection at admission, 3.8% (n = 2,506) developed secondary infection after admission, and 0.9% (n = 574) had both; 76.3% (n = 49,551) received an antibiotic while hospitalized, including 71% of patients who had no diagnosis of bacterial infection. Secondary bacterial infection occurred in 5.7% of patients receiving steroids in the first 2 days of hospitalization, 9.9% receiving tocilizumab in the first 2 days of hospitalization, and 10.3% of patients receiving both. After adjusting for patient and hospital characteristics, bacterial coinfection (adjusted relative risk [aRR], 1.15; 95% confidence interval [CI], 1.11 to 1.20) and secondary infection (aRR 1.93; 95% CI, 1.82 to 2.04) were both independently associated with increased mortality. Although 1 in 5 inpatients with COVID-19 presents with bacterial infection, secondary infections in the hospital are uncommon. Most inpatients with COVID-19 receive antibiotic therapy, including 71% of those not diagnosed with bacterial infection.

Use of Routine Complete Blood Count Results to Rule Out Anaplasmosis Without the Need for Specific Diagnostic Testing.

BACKGROUND: Anaplasmosis presents with fever, headache, and laboratory abnormalities including leukopenia and thrombocytopenia. Polymerase chain reaction (PCR) is the preferred diagnostic but is overutilized. We determined if routine laboratory tests could exclude anaplasmosis, improving PCR utilization. METHODS: Anaplasma PCR results from a 3-year period, with associated complete blood count (CBC) and liver function test results, were retrospectively reviewed. PCR rejection criteria, based on white blood cell (WBC) and platelet (PLT) counts, were developed and prospectively applied in a mock stewardship program. If rejection criteria were met, a committee mock-refused PCR unless the patient was clinically unstable or immunocompromised. RESULTS: WBC and PLT counts were the most actionable routine tests for excluding anaplasmosis. Retrospective review demonstrated that rejection criteria of WBC ≥11 000 cells/µL or PLT ≥300 000 cells/µL would have led to PCR refusal in 428 of 1685 true-negative cases (25%) and 3 of 66 true-positive cases (5%) involving clinically unstable or immunocompromised patients. In the prospective phase, 155 of 663 PCR requests (23%) met rejection criteria and were reviewed by committee, which endorsed refusal in 110 of 155 cases (71%) and approval in 45 (29%), based on clinical criteria. PCR was negative in all 45 committee-approved cases. Only 1 of 110 mock-refused requests yielded a positive PCR result; this patient was already receiving doxycycline at the time of testing. CONCLUSIONS: A CBC-based stewardship algorithm would reduce unnecessary Anaplasma PCR testing, without missing active cases. Although the prospectively evaluated screening approach involved medical record review, this was unnecessary to prevent errors and could be replaced by a rejection comment specifying clinical situations that might warrant overriding the algorithm.

Detection of Plasmodium Species by High-Resolution Melt Analysis of DNA from Blood Smears Acquired in Southwestern Uganda.

Microscopic diagnosis of malaria using Giemsa-stained blood smears is the standard of care in resource-limited settings. These smears represent a potential source of DNA for PCR testing to confirm Plasmodium infections or for epidemiological studies of archived samples. Therefore, we assessed the use of DNA extracts from stained blood smears for the detection of Plasmodium species using real-time PCR. We extracted DNA from archived blood smears and corresponding red blood cell pellets collected from asymptomatic children in southwestern Uganda in 2010. We then performed real-time PCR followed by high-resolution melting (HRM) to identify Plasmodium species, and we compared our results to those of microscopy. We analyzed a total of 367 blood smears and corresponding red blood cell pellets, including 185 smears (50.4%) that were positive by microscopy. Compared to microscopy, PCR-HRM analysis of smear DNA had a sensitivity of 93.0% (95% confidence interval [CI], 88.2 to 96.2%) and a specificity of 96.7% (95% CI, 93.0 to 98.8%), and PCR-HRM analysis of pellet DNA had a sensitivity of 100.0% (95% CI, 98.0 to 100.0%) and a specificity of 94.0% (95% CI, 89.4 to 96.9%). Identification of positive PCR-HRM results to the species level revealed Plasmodium falciparum (92.0%), Plasmodium ovale (5.6%), and Plasmodium malariae (2.4%). PCR-HRM analysis of DNA extracts from Giemsa-stained thick blood smears or corresponding blood pellets had high sensitivity and specificity for malaria diagnosis, compared to microscopy. Therefore, blood smears can provide an adequate source of DNA for confirmation of Plasmodium species infections and can be used for retrospective genetic studies.

Storage characteristics, nutritive value, and fermentation characteristics of alfalfa packaged in large-round bales and wrapped in stretch film after extended time delays.

The production of baled silage is attractive to producers because it offers advantages over dry hay, particularly by limiting risks associated with wet or unstable weather conditions. Our objectives were to test the effects of delayed wrapping on silage fermentation, storage characteristics, and the nutritive value of baled alfalfa silages. To accomplish this, large-round bales of alfalfa were wrapped in plastic film within 4h of baling (d 0), or after delays of 1, 2, or 3 d. A secondary objective was to evaluate a prototype bale wrap containing an O2-limiting barrier (OB) against an identical polyethylene wrap without the O2 barrier (SUN). Sixty-four 1.19×1.25-m bales of alfalfa were made from 4 field blocks at a mean moisture concentration of 59.1±4.3% with a mean initial wet bale weight of 473±26.4kg. Two bales per field block were assigned to each combination of bale wrap (SUN or OB) and wrapping time (0, 1, 2, or 3 d postbaling), and one bale of each pair was fitted with a thermocouple placed in the geometric center of each bale. All bales were sampled after a 97-d storage period. Internal bale temperatures, recorded at the time bales were wrapped, were greater for all bales with wrapping delays compared with bales wrapped on d 0 (54.9 vs. 34.9°C), and increased to a maximum of 63.9°C after a 3-d delay exhibiting a linear effect of time delay. Total silage fermentation acids (lactic, acetic, propionic, butyric, and isobutyric) were greatest when bales were wrapped on d 0 compared with all bales wrapped with time delays (4.64 vs. 2.26% of DM), and declined with linear and quadratic effects of wrapping delay. Total fermentation acids also were related quadratically to internal bale temperature by regression [y (% of DM)=0.0042x(2) - 0.50x + 17.1; R(2)=0.725]. Similar responses were observed for lactic acid, except that trends were linear, both for orthogonal contrasts evaluating length of wrapping delay, and in regressions on internal bale temperature [y (% of DM)=-0.046x + 3.5; R(2)=0.663]. Butyric acid also was detected, regardless of treatment, but was greatest within bales wrapped on d 0 compared with those with wrapping delays (0.99 vs. 0.38% of DM), and a similar response (0.68 vs. 0.52% of DM) was observed for NH3-N, suggesting that clostridial activity occurred during silage fermentation. Based on these results, silage fermentation characteristics and the nutritive value declined with time delays before wrapping, but responses were exacerbated when delays exceeded 1 d.

Lifestyle and reproductive risk factors associated with anal cancer in women aged over 50 years.

BACKGROUND: Anal cancer incidence increases with age and is higher in women than men. Risk factors in this group other than high-risk human papillomavirus infection are unclear. METHODS: In all, 1.3 million women were recruited in 1996-2001 and followed for incident anal cancer. Cox regression models were used to calculate relative risks (RRs) for anal cancer by various potential risk factors. RESULTS: Five hundred and seventeen incident anal cancers were registered over 13 years of follow-up. The largest RR was associated with a history of cervical intraepithelial neoplasia grade 3 (CIN 3; RR=4.03, 95% CI 2.59-6.28). Other factors associated with significantly increased risks in multivariate analyses were: ever smoking (RR=1.49, 1.24-1.80); previous use of oral contraceptives (RR=1.51, 1.24-1.83); nulliparity (RR=1.61, 1.24-2.07); tubal ligation (RR=1.39, 1.13-1.70) and not living with a partner (RR=1.82, 1.40-2.38). The association with smoking was significantly greater for squamous cell carcinoma than adenocarcinoma of the anus (RR 1.66 vs 0.89, P for heterogeneity=0.04). CONCLUSIONS: History of CIN 3, smoking, past oral contraceptive use, nulliparity, tubal ligation and not living with a partner are risk factors for anal cancer in women. There was a significant increase in risk associated with smoking for squamous cell anal cancers but not adenocarcinomas.

Effects of dairy slurry on silage fermentation characteristics and nutritive value of alfalfa.

Dairy producers frequently ask questions about the risks associated with applying dairy slurry to growing alfalfa (Medicago sativa L.). Our objectives were to determine the effects of applying dairy slurry on the subsequent nutritive value and fermentation characteristics of alfalfa balage. Dairy slurry was applied to 0.17-ha plots of alfalfa; applications were made to the second (HARV1) and third (HARV2) cuttings during June and July of 2012, respectively, at mean rates of 42,400 ± 5271 and 41,700 ± 2397 L/ha, respectively. Application strategies included (1) no slurry, (2) slurry applied directly to stubble immediately after the preceding harvest, (3) slurry applied after 1 wk of post-ensiled regrowth, or (4) slurry applied after 2 wk of regrowth. All harvested forage was packaged in large, rectangular bales that were ensiled as wrapped balage. Yields of DM harvested from HARV1 (2,477 kg/ha) and HARV2 (781 kg/ha) were not affected by slurry application treatment. By May 2013, all silages appeared to be well preserved, with no indication of undesirable odors characteristic of clostridial fermentations. Clostridium tyrobutyricum, which is known to negatively affect cheese production, was not detected in any forage on either a pre- or post-ensiled basis. On a pre-ensiled basis, counts for Clostridium cluster 1 were greater for slurry-applied plots than for those receiving no slurry, and this response was consistent for HARV1 (4.44 vs. 3.29 log10 genomic copies/g) and HARV2 (4.99 vs. 3.88 log10 genomic copies/g). Similar responses were observed on a post-ensiled basis; however, post-ensiled counts also were greater for HARV1 (5.51 vs. 5.17 log10 genomic copies/g) and HARV2 (5.84 vs. 5.28 log10 genomic copies/g) when slurry was applied to regrowth compared with stubble. For HARV2, counts also were greater following a 2-wk application delay compared with a 1-wk delay (6.23 vs. 5.45 log10 genomic copies/g). These results suggest that the risk of clostridial fermentations in alfalfa silages is greater following applications of slurry. Based on pre- and post-ensiled clostridial counts, applications of dairy slurry on stubble are preferred (and less risky) compared with delayed applications on growing alfalfa.

Diagnostic Stewardship for Urine Cultures.

Urinary tract infections are among the most common infectious diagnoses in health care, but most urinary tract infections are diagnosed inappropriately in patients without signs or symptoms of infection. Asymptomatic bacteriuria leads to inappropriate antibiotic prescribing and negative downstream effects, including antimicrobial resistance, health care-associated infections, and adverse drug events. Diagnostic stewardship is the process of modifying the ordering, performing, or reporting of test results to improve clinical care. Diagnostic stewardship impacts the diagnostic pathway to decrease inappropriate detection and treatment of asymptomatic bacteriuria. This article reviews diagnostic stewardship methods and closes with a case study illustrating these principles in practice.

Clinical decision support for gastrointestinal panel testing.

Objective: This study aimed to assess the impact of clinical decision support (CDS) to improve ordering of multiplex gastrointestinal polymerase chain reaction (PCR) testing panel ("GI panel"). Design: Single-center, retrospective, before-after study. Setting: Tertiary care Veteran's Affairs (VA) Medical Center provides inpatient, outpatient, and residential care. Patients: All patients tested with a GI panel between June 22, 2022 and April 20, 2023. Intervention: We designed a CDS questionnaire in the electronic medical record (EMR) to guide appropriate ordering of the GI panel. A "soft stop" reminder at the point of ordering prompted providers to confirm five appropriateness criteria: 1) documented diarrhea, 2) no recent receipt of laxatives, 3) C. difficile is not the leading suspected cause of diarrhea, 4) time period since a prior test is >14 days or prior positive test is >4 weeks and 5) duration of hospitalization <72 hours. The CDS was implemented in November 2022. Results: Compared to the pre-implementation period (n = 136), fewer tests were performed post-implementation (n = 92) with an IRR of 0.61 (p = 0.003). Inappropriate ordering based on laxative use or undocumented diarrhea decreased (IRR 0.37, p = 0.012 and IRR 0.25, p = 0.08, respectively). However, overall inappropriate ordering and outcome measures did not significantly differ before and after the intervention. Conclusions: Implementation of CDS in the EMR decreased testing and inappropriate ordering based on use of laxatives or undocumented diarrhea. However, inappropriate ordering of tests overall remained high post-intervention, signaling the need for continued diagnostic stewardship efforts.

Storage characteristics, nutritive value, energy content, and in vivo digestibility of moist, large rectangular bales of alfalfa-orchardgrass hay treated with a propionic acid-based preservative.

Unstable weather, poor drying conditions, and unpredictable rainfall events often place valuable hay crops at risk. Recent research with large round bales composed of alfalfa (Medicago sativa L.) and orchardgrass (Dactylis glomerata L.) has shown that these large-bale packages are particularly sensitive to spontaneous heating and dry matter (DM) losses, as well as other undesirable changes with respect to forage fiber, protein, and energy density. Various formulations of organic acids have been marketed as preservatives, normally for use on hays that are not desiccated adequately in the field to facilitate safe bale storage. Our objectives for this study were to (1) evaluate the efficacy of applying a commercial (buffered) propionic acid-based preservative at 3 rates (0, 0.6, and 1.0% of wet-bale weight) to hays baled at 3 moisture concentrations (19.6, 23.8, and 27.4%) on the subsequent storage characteristics and poststorage nutritive value of alfalfa-orchardgrass forages packaged in large rectangular (285-kg) bales, and then (2) evaluate the in vivo digestibility of these hays in growing lambs. Over a 73-d storage period, the preservative was effective at limiting spontaneous heating in these hays, and a clear effect of application rate was observed for the wettest (27.4%) bales. For drier hays, both acid-application rates (1.0 and 0.6%) yielded comparable reductions in heating degree days >30°C relative to untreated controls. Reductions in spontaneous heating could not be associated with improved recovery of forage DM after storage. In this study, most changes in nutritive value during storage were related to measures of spontaneous heating in simple linear regression relationships; this suggests that the modest advantages in nutritive value resulting from acid treatment were largely associated with perturbations of normal heating patterns during bale storage. Although somewhat erratic, apparent digestibilities of both DM (Y=-0.0080x + 55.6; R(2)=0.45) and organic matter (Y=-0.0085x + 55.5; R(2)=0.53) evaluated in growing lambs were also directly related to heating degree days in simple linear relationships. Based on these data, applying propionic acid-based preservatives to large rectangular bales is likely to provide good insurance against spontaneous heating during storage, as well as modest benefits with respect to nutritive value and digestibility.

Grain boundary character distribution of nanocrystalline Cu thin films using stereological analysis of transmission electron microscope orientation maps.

Stereological analysis has been coupled with transmission electron microscope (TEM) orientation mapping to investigate the grain boundary character distribution in nanocrystalline copper thin films. The use of the nanosized (<5 nm) beam in the TEM for collecting spot diffraction patterns renders an order of magnitude improvement in spatial resolution compared to the analysis of electron backscatter diffraction patterns in the scanning electron microscope. Electron beam precession is used to reduce dynamical effects and increase the reliability of orientation solutions. The misorientation distribution function shows a strong misorientation texture with a peak at 60°/[111], corresponding to the Σ3 misorientation. The grain boundary plane distribution shows {111} as the most frequently occurring plane, indicating a significant population of coherent twin boundaries. This study demonstrates the use of nanoscale orientation mapping in the TEM to quantify the five-parameter grain boundary distribution in nanocrystalline materials.

What did nursing home residents think about COVID-19 prevention practices in the era of vaccination and treatment?

We surveyed 57 nursing home residents to assess the subjective impact of COVID-19 prevention practices. Residents were mostly accepting of testing and symptom screening; however, many would like more choices. Sixty-nine percent want to have some say in when or where to mask. Most (87%) residents want to return to group activities. Residents on long-stay units (58%) are more likely than residents on short-stay units (27%) to accept additional risk of COVID-19 transmission to increase their quality of life.

#Coronavirus on TikTok: user engagement with misinformation as a potential threat to public health behavior.

Coronavirus disease (COVID)-related misinformation is prevalent online, including on social media. The purpose of this study was to explore factors associated with user engagement with COVID-related misinformation on the social media platform, TikTok. A sample of TikTok videos associated with the hashtag #coronavirus was downloaded on September 20, 2020. Misinformation was evaluated on a scale (low, medium, and high) using a codebook developed by experts in infectious diseases. Multivariable modeling was used to evaluate factors associated with number of views and presence of user comments indicating intention to change behavior. One hundred and sixty-six TikTok videos were identified and reviewed. Moderate misinformation was present in 36 (22%) videos viewed a median of 6.8 million times (interquartile range [IQR] 3.6-16 million), and high-level misinformation was present in 11 (7%) videos viewed a median of 9.4 million times (IQR 5.1-18 million). After controlling for characteristics and content, videos containing moderate misinformation were less likely to generate a user response indicating intended behavior change. By contrast, videos containing high-level misinformation were less likely to be viewed but demonstrated a nonsignificant trend towards higher engagement among viewers. COVID-related misinformation is less frequently viewed on TikTok but more likely to engage viewers. Public health authorities can combat misinformation on social media by posting informative content of their own.