Contact precautions as a barrier to hand hygiene: The Plan-Do-Study-Act (PDSA) framework to improve compliance with gloved hand hygiene.

In an identified quality improvement effort, nurses were observed regarding their workflow while in contact precaution rooms. Multiple opportunities for hand hygiene were missed while nurses were in gloves, predominantly while moving between "dirty" and "clean" tasks. An education initiative afterward did not show improvement in hand hygiene rates.

Maintaining prevention focus: the impact of an interdisciplinary taskforce on CAUTI rates during an EMR transition.

We employed an interrupted time series analysis to assess the impact of changing electronic medical records, concurrent with a Catheter-Associated Urinary Tract Infection (CAUTI) Taskforce, on CAUTI rates. We found that rates increased in most ICUs before returning to baseline. These findings suggest that a multi-faceted approach may reduce CAUTI rates.

Impairment of health-related quality of life among people with type 2 diabetes and advanced liver fibrosis.

People with type 2 diabetes mellitus (T2DM) show a high prevalence of steatotic liver disease (SLD), and especially metabolic dysfunction-associated steatotic liver disease (MASLD), with liver fibrosis. Their health-related quality of life (HRQL) is affected by multiple in part overlapping factors and aggravated by metabolic and liver-related comorbidities, including liver fibrosis stage. The aim of this study was to investigate the effect size of advanced fibrosis (AF) on the HRQL in people with T2DM. A total of 149 individuals with T2DM treated at a primary care provider within the German disease management program (DMP) were included in the final analysis. Vibration-controlled transient elastography (VCTE) was used to non-invasively detect steatosis and AF. The EQ-5D-3L questionnaire was used to assess the HRQL. Uni- and multivariable linear regression models were used to identify independent predictors of impaired HRQL. The majority was male (63.1%), and the median age was 67 years (IQR 59; 71). In the entire cohort, the prevalence of MASLD and AF was 70.7% and 19.5%, respectively. People with T2DM and AF had an overall lower HRQL in comparison to those without AF (p < 0.001). Obesity (ß: - 0.247; 95% CI - 0.419, - 0.077) and AF (ß: - 0.222; 95% CI - 0.383, - 0.051) remained independent predictors of a poor HRQL. In turn, T2DM-related comorbidities were not predictive of an impaired HRQL. Obesity and AF negatively affect the HRQL in patients with SLD and T2DM in primary care. Awareness of liver health and specific interventions may improve patient-reported and liver-related outcomes in people with T2DM.

Obesity and harmful alcohol consumption are predictors for advanced liver disease in the disease management program for type 2 diabetes.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a major risk factor for advanced liver disease. The aim of this prospective cohort study was to assess the prevalence and associated risk factors of liver fibrosis and cirrhosis in primary care centers participating in the diabetes disease management program (DMP) in Germany. METHODS: A total of 175 participants with the diagnosis of T2DM were enrolled in two primary care centers. Steatotic liver disease (SLD; hepatic steatosis, ≥275 dB/m), fibrosis (≥8 kPa), and cirrhosis (≥15 kPa) were assessed non-invasively using vibration-controlled transient elastography. Multivariable logistic regression analysis was performed to identify clinical predictors of fibrosis and cirrhosis. The AUDIT questionnaire was used to screen for alcohol consumption, and a score ≥8 was considered harmful alcohol consumption. RESULTS: The majority of participants were male (62%), and the median age was 66 years (interquartile range 59; 71). The median body mass index was 31.1 kg/m2 , with 58.9% of the participants being obese. Harmful alcohol consumption was prevalent in 8.0% and 20.0% of the entire cohort and in those with cirrhosis, respectively. The prevalence of SLD, fibrosis, and cirrhosis was 77.1%, 42.3%, and 12.0%, respectively. In multivariable logistic regression analysis, obesity, and harmful alcohol consumption were associated with the highest odds of fibrosis (odds ratio [OR] 5.198, 95% confidence interval [CI] 2.269-11.908) and cirrhosis (OR 5.615, 95% CI 1.274-24.756), respectively. CONCLUSION: The prevalence of fibrosis and cirrhosis in patients seen in the diabetes DMP in Germany is high. Obesity and harmful alcohol consumption increase the risk of fibrosis and cirrhosis in people with T2DM. Screening for advanced liver disease and associated risk factors within the DMP program may reduce the liver disease burden in this high-risk population.

Candida auris in the burn unit: a prolonged biphasic outbreak.

Candida auris is an emerging pathogen responsible for healthcare-associated infections and outbreaks. This organism has a high tolerance to both high temperatures and high salinity. We describe our experience with a C. auris outbreak in an 8-bed inpatient burn unit at an academic medical center.

A randomized trial comparing the intraoperative durability of double-gloving with Biogel® surgical gloves to 3 comparators.

Objective: To determine and compare the intraoperative durability of 4 major surgical glove brands. Design Setting and Participants: This study is a randomized open-label clinical trial in which surgical gloves from 4 manufacturers are randomized to 5 surgical subspecialty study groups: (1) orthopedic surgery, (2) neurosurgery, (3) colorectal surgery, (4) trauma or acute general surgery, and (5) cardiac and plastic surgeries. The study was divided into 10 periods, with a cross-over design, and was conducted at a tertiary care academic medical center. Participants were licensed and certified physicians, physicians-in-training, scrub nurses, or technicians working within the sterile field. Interventions: Participants from each study group were randomly assigned to 1 of 4 surgical glove manufacturer types and subsequently rotated through the other 3 glove brands such that each participant acted as their own control in the sequential cross-over design. Main Outcomes and Measures: The primary outcome was to determine and compare the intraoperative failure rate of Biogel® Sterile Surgical undergloves against sterile surgical undergloves from 3 other manufacturers, both as a combined competitor group and individually. Results: There were no differences between brands with respect to the primary outcome of underglove intraoperative failures. Brand 1 wearers were slightly more likely to detect glove failures when they occurred. Conclusion: The durability of surgical gloves intraoperatively is similar across 4 major glove manufacturers. Detection of intraoperative failures is infrequent, though specific glove characteristics may promote enhanced detection. Recognition of glove perforations intraoperatively is important in the maintenance of a maximally sterile field. Trial Registration: ClinicalTrials.gov Identifier: NCT03344354.

Electronic hand hygiene monitoring systems: Not worth the costs.

Electronic hand hygiene monitoring systems allow the collection of large volumes of data. However, significant resources are required to validate and maintain these systems. Additionally, data are lacking on the correlation with clinically important outcomes. Direct observation of hand hygiene remains the gold standard for monitoring hand hygiene compliance.

Staphylococcal decolonization to prevent surgical site infection: Is there a role in colorectal surgery?

Objective: We implemented a preoperative staphylococcal decolonization protocol for colorectal surgeries if efforts to further reduce surgical site infections (SSIs). Design: Retrospective observational study. Setting: Tertiary-care, academic medical center. Patients: Adult patients who underwent colorectal surgery, as defined by National Healthcare Safety Network (NHSN), between July 2015 and June 2020. Emergent cases were excluded. Methods: Simple and multivariable logistic regression were performed to evaluate the relationship between decolonization and subsequent SSI. Other predictive variables included age, sex, body mass index, procedure duration, American Society of Anesthesiology (ASA) score, diabetes, smoking, and surgical oncology service. Results: In total, 1,683 patients underwent nonemergent NHSN-defined colorectal surgery, and 33.7% underwent the staphylococcal decolonization protocol. SSI occurred in 92 (5.5%); 53 were organ-space infections and 39 were superficial wound infections. We detected no difference in overall SSIs between those decolonized and not decolonized (P = .17). However, superficial wound infections were reduced in the group that received decolonization versus those that did not: 7 (1.2%) of 568 versus 32 (2.9%) of 1,115 (P = .04). Conclusions: Staphylococcal decolonization may prevent a subset of SSIs in patients undergoing colorectal surgery.

Predictors of in-hospital mortality in a cohort of people living with HIV (PLHIV) admitted to an academic medical intensive care unit from 2009 to 2014: A retrospective cohort study.

Outcomes for critically ill people living with human immunodeficiency virus (PLHIV) have changed with the use of antiretroviral therapy (ART). To identify these outcomes and correlates of mortality in a contemporary critically ill cohort in an urban academic medical center in Baltimore, a city with a high burden of HIV, we conducted a retrospective cohort study of individuals admitted to a medical intensive care unit (MICU) at a tertiary care center between 2009 and 2014. PLHIV who were at least 18 years of age with an index MICU admission of ≥24 hours during the 5-year study period were included in this analysis. Data were obtained for participants from the time of MICU admission until hospital discharge and up to 180 days after MICU admission. Logistic regression was used to identify independent predictors of hospital mortality. Between June 2009 and June 2014, 318 PLHIV admitted to the MICU met inclusion criteria. Eighty-six percent of the patients were non-Hispanic Blacks. Poorly controlled HIV was very common with 70.2% of patients having a CD4 cell count <200 cells/mm3 within 3 months prior to admission and only 34% of patients having an undetectable HIV viral load. Hospital mortality for the cohort was 17%. In a univariate model, mortality did not differ by demographic variables, CD4 cell count, HIV viral load, or ART use. Regression analysis adjusted by relevant covariates revealed that MICU patients admitted from the hospital ward were 6.4 times more likely to die in hospital than those admitted from emergency department. Other positive predictors were a diagnosis of end-stage liver disease, cardiac arrest, ventilator-dependent respiratory failure, vasopressor requirement, non-Hodgkin lymphoma, and symptomatic cytomegalovirus disease. In conclusion, in this critically ill cohort with HIV infection, most predictors of mortality were not directly related to HIV and were similar to those for the general population.

Changes in nursing team composition and risk of device-associated infection in intensive care units.

The relationship between nursing staffing levels and healthcare-associated infections (HAIs) has been explored previously with conflicting results. This study uses daily shift records from 2 intensive care units (ICUs) to evaluate whether nuanced changes in nursing team composition impacts subsequent risk for device associated HAIs. Staffing deficiencies may be associated with periods of risk prior to central line-associated bloodstream infection in the ICU.

Short-term effectiveness of COVID-19 vaccines in immunocompromised patients: A systematic literature review and meta-analysis.

OBJECTIVES: We aimed to assess the short-term effectiveness of COVID-19 vaccines among immunocompromised patients to prevent laboratory-confirmed symptomatic COVID-19 infection. METHODS: Systematic review and meta-analysis. We calculated the pooled diagnostic odds ratio [DOR] (95% CI) for COVID-19 infection between immunocompromised patients and healthy people or those with stable chronic medical conditions. VE was estimated as 100% x (1-DOR). We also investigated the rates of developing anti-SARS-CoV-2 spike protein IgG between the 2 groups. RESULTS: Twenty studies evaluating COVID-19 vaccine response, and four studies evaluating VE were included in the meta-analysis. The pooled DOR for symptomatic COVID-19 infection in immunocompromised patients was 0.296 (95% CI: 0.108-0.811) with an estimated VE of 70.4% (95% CI: 18.9%- 89.2%). When stratified by diagnosis, IgG antibody levels were much higher in the control group compared to immunocompromised patients with solid organ transplant (pOR 232.3; 95% Cl: 66.98-806.03), malignant diseases (pOR 42.0, 95% Cl: 11.68-151.03), and inflammatory rheumatic diseases (pOR 19.06; 95% Cl: 5.00-72.62). CONCLUSIONS: We found COVID-19 mRNA vaccines were effective against symptomatic COVID-19 among the immunocompromised patients but had lower VE compared to the controls. Further research is needed to understand the discordance between antibody production and protection against symptomatic COVID-19 infection.

The coronavirus disease 2019 (COVID-19) delta wave: Refocusing effort and remaining resilient in the face of evolving infection prevention and antimicrobial stewardship challenges.

Challenges for infection prevention and antimicrobial stewardship programs have arisen with the fourth wave of the coronavirus disease 2019 (COVID-19) pandemic, fueled by the delta variant. These challenges include breakthrough infections in vaccinated individuals, decisions to re-escalate infection prevention measures, critical medication shortages, and provider burnout. Various strategies are needed to meet these challenges.

Variation in practice for preoperative antibiotic prophylaxis: a survey from an academic tertiary referral center in the United States.

BACKGROUND: Antibiotic surgical prophylaxis is a core strategy for prevention of surgical site infections (SSI). Despite best practice guidelines and known efficacy of antibiotic prophylaxis in decreasing SSI risk, there is often wide variation in its use. This study was designed to determine the individual perspectives of perioperative providers at an academic tertiary referral center regarding their knowledge of preoperative antibiotic choice, dosing, and timing. METHODS: A prospective survey was conducted amongst surgical and anesthesia team members involved in preoperative antibiotic decision making. The survey addressed ten key principles relating to preoperative antibiotic use, including antibiotic choice, timing and rate of infusion, and dosing. The survey was distributed among orthopaedic surgeons, residents, and anesthesia providers at their respective monthly service line meetings between August 2017 to June 2019. The data was stored and analyzed in a Microsoft Excel worksheet. RESULTS: A total of 73 providers completed the survey. Twenty-two (30 %) of the providers agreed and 47 (64 %) disagreed that both vancomycin and cefazolin are equally effective for antibiotic prophylaxis. As for antibiotic choice in patients with penicillin allergies, 37 (51 %) agreed with vancomycin, 21 (29 %) agreed with clindamycin, and 15 (21 %) disagreed with both alternatives. When providers were surveyed regarding the appropriateness of standard versus weight adjusted dosing, 67 (92 %) agreed that vancomycin should be weight adjusted and 63 (86 %) agreed that cefazolin should be weight adjusted. CONCLUSIONS: There is no clear consensus amongst providers for which antibiotic to administer for antibiotic prophylaxis despite existing guidelines. Discrepancy also exists between orthopaedic surgery and anesthesia providers in regards to appropriate antibiotic choice for patients with reported penicillin allergies. Institutions should implement evidence-based protocols for preoperative antibiotic prophylaxis and continue to prospectively monitor compliance in order to identify any inconsistencies that could result in inappropriate antibiotic prophylaxis for patients.

Infection Prevention and Antimicrobial Stewardship Program Collaboration During the COVID-19 Pandemic: a Window of Opportunity.

PURPOSE OF REVIEW: We describe the similarities between antimicrobial stewardship programs (ASPs) and infection prevention programs (IPPs), and we discuss how these similarities lend themselves to synergy between programs. We also discuss how the COVID-19 pandemic has generated further opportunities for future collaborations that could benefit both programs. RECENT FINDINGS: The COVID-19 pandemic has created new needs, such as real-time data and access to personnel important to both programs, such as information technologists and infectious diseases specialists. It has also increased concerns about rising rates of antimicrobial resistance and healthcare-associated infections, both of which overlap significantly and are key focus areas for both ASPs and IPPs. These emergent issues have highlighted the need for enhanced program infrastructure and new team models. The shift towards telecommunication and telework has facilitated the creation of enhanced infrastructures for collaboration on activities ranging from data access and reporting to providing telehealth services to remote hospitals. These enhanced infrastructures can be leveraged in future collaborative efforts between ASPs and IPPs. SUMMARY: Collaboration between IPPs and ASPs can mitigate setbacks experienced by health systems during the current pandemic, enhance the performance of both programs in the post-pandemic era and increase their preparedness for future pandemic threats. As health systems plan for the post-pandemic era, they should invest in opportunities for synergy between ASPs and IPPs highlighted during the pandemic.

Prevention of Clostridioides difficile in hospitals: A position paper of the International Society for Infectious Diseases.

Clostridioides difficile infection is an increasing presence worldwide. Prevention is multipronged, reflecting a complex and evolving epidemiology. Multiple guidelines exist regarding the prevention of C. difficile infection in healthcare settings; however, existing guidelines do not address C. difficile in low- and middle-income countries (LMIC). Nevertheless, the prevalence of C. difficile in LMIC likely parallels, if not exceeds, that of high-income countries, and LMIC may experience additional challenges in C. difficile diagnosis and control. A panel of experts was convened by the International Society for Infectious Diseases (ISID) to review the current state of C. difficile infections globally and make evidence-based recommendations for infection prevention that are broadly applicable.

The impact of coronavirus disease 2019 (COVID-19) on provider use of electronic hand hygiene monitoring technology.

The use of an electronic hand hygiene monitoring system (EHHMS) decreased due to the coronavirus disease 2019 (COVID-19) pandemic. We analyzed dispenser use, hand hygiene (HH) badge use, and HH compliance to determine the effect of COVID-19 on EHHMS use and HH compliance. HH product shortages and other pandemic-induced challenges influenced EHHMS use.

Effect of ultraviolet-C light disinfection at terminal patient discharge on hospital-acquired infections in bone marrow transplant and oncology units.

We employed an interrupted time series analysis to assess the impact of ultraviolet-C light disinfection at terminal discharge in an oncology unit and a bone marrow transplant unit on the incidence of hospital-acquired infections. The deployment of ultraviolet-C light disinfection was associated with a significant decrease in the rate of Clostridioides difficile infections and a significant decrease in the rate of central line-associated blood stream infections in the bone marrow transplant unit.

Antimicrobial Stewardship at the Core of COVID-19 Response Efforts: Implications for Sustaining and Building Programs.

We describe traditional antimicrobial stewardship program (ASP) activities with a discussion of how these activities can be refocused in the setting of the COVID-19 pandemic. Additionally, we discuss possible adverse consequences of ASP attention diversion on COVID-19 response efforts and overall implications for future pandemic planning. We also discuss ASP in collaboration with other groups within health systems and how COVID-19 may affect these relationships long term. Despite the paucity of literature on Antimicrobial Stewardship and COVID-19, the potential contributions of ASPs during a pandemic are numerous. ASPs can develop strategies to identify patients with COVID-19-like-illness; this is particularly useful when these patients are missed at the time of health system entry. ASPs can also play a critical role in the management of potential drug shortages, developing local treatment guidelines, optimizing the use of antibiotics, and in the diagnostic stewardship of COVID-19 testing, among other roles. Importantly, it is often difficult to ascertain whether critically ill patients who are hospitalized with COVID-19 have concurrent or secondary bacterial infections-ASPs are ideally situated to help optimize antimicrobial use for these patients via a variety of mechanisms. ASPs are uniquely positioned to aid in pandemic response planning and relief efforts. ASPs are already integrated into health systems and play a key role in optimizing antimicrobial prescribing. As ASPs assist in COVID-19 response, understanding the role of ASPs in pandemic relief efforts may mitigate damage from future outbreaks.

Chasing the rate: An interrupted time series analysis of interventions targeting reported hospital onset Clostridioides difficile, 2013-2018.

OBJECTIVE: To assess the impact of major interventions targeting infection control and diagnostic stewardship in efforts to decrease Clostridioides difficile hospital onset rates over a 6-year period. DESIGN: Interrupted time series. SETTING: The study was conducted in an 865-bed academic medical center. METHODS: Monthly hospital-onset C. difficile infection (HO-CDI) rates from January 2013 through January 2019 were analyzed around 5 major interventions: (1) a 2-step cleaning process in which an initial quaternary ammonium product was followed with 10% bleach for daily and terminal cleaning of rooms of patients who have tested positive for C. difficile (February 2014), (2) UV-C device for all terminal cleaning of rooms of C. difficile patients (August 2015), (3) "contact plus" isolation precautions (June 2016), (4) sporicidal peroxyacetic acid and hydrogen peroxide cleaning in all patient areas (June 2017), (5) electronic medical record (EMR) decision support tool to facilitate appropriate C. difficile test ordering (March 2018). RESULTS: Environmental cleaning interventions and enhanced "contact plus" isolation did not impact HO-CDI rates. Diagnostic stewardship via EMR decision support decreased the HO-CDI rate by 6.7 per 10,000 patient days (P = .0079). When adjusting rates for test volume, the EMR decision support significance was reduced to a difference of 5.1 case reductions per 10,000 patient days (P = .0470). CONCLUSION: Multiple aggressively implemented infection control interventions targeting CDI demonstrated a disappointing impact on endemic CDI rates over 6 years. This study adds to existing data that outside of an outbreak situation, traditional infection control guidance for CDI prevention has little impact on endemic rates.

Nurse survey, knowledge gaps and the creation of an environmental hygiene protocol for patient transport and removing linen from patient rooms.

General guidance for personal protective equipment (PPE) is provided by the Occupational Safety and Health Administration and the United States Centers for Disease Control and Prevention. Previous research of PPE demonstrates the ability of gloves to harbor infectious pathogens. We surveyed health care workers to investigate current PPE practices during linen removal from patient rooms and during patient transport. The results suggest a possible risk for cross-contamination of the environment from overuse of gloves.