Risk factors for colonization with extended-spectrum cephalosporin-resistant and carbapenem-resistant Enterobacterales among hospitalized patients in Guatemala: An Antibiotic Resistance in Communities and Hospitals (ARCH) study.

Objectives: The spread of extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) and carbapenem-resistant Enterobacterales (CRE) has resulted in increased morbidity, mortality, and health care costs worldwide. To identify the factors associated with ESCrE and CRE colonization within hospitals, we enrolled hospitalized patients at a regional hospital located in Guatemala. Methods: Stool samples were collected from randomly selected patients using a cross-sectional study design (March-September, 2021), and samples were tested for the presence of ESCrE and CRE. Hospital-based and household variables were examined for associations with ESCrE and CRE colonization using lasso regression models, clustered by ward (n = 21). Results: A total of 641 patients were enrolled, of whom complete data sets were available for 593. Colonization with ESCrE (72.3%, n = 429/593) was negatively associated with carbapenem administration (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.11-0.42) and positively associated with ceftriaxone administration (OR 1.61, 95% CI 1.02-2.53), as was reported hospital admission within 30 days of the current hospitalization (OR 2.84, 95% CI 1.19-6.80). Colonization with CRE (34.6%, n = 205 of 593) was associated with carbapenem administration (OR 2.62, 95% CI 1.39-4.97), reported previous hospital admission within 30 days of current hospitalization (OR 2.58, 95% CI 1.17-5.72), hospitalization in wards with more patients (OR 1.05, 95% CI 1.02-1.08), hospitalization for ≥4 days (OR 3.07, 95% CI 1.72-5.46), and intubation (OR 2.51, 95% CI 1.13-5.59). No household-based variables were associated with ESCrE or CRE colonization in hospitalized patients. Conclusion: The hospital-based risk factors identified in this study are similar to what has been reported for risk of health care-associated infections, consistent with colonization being driven by hospital settings rather than community factors. This also suggests that colonization with ESCrE and CRE could be a useful metric to evaluate the efficacy of infection and prevention control programs in clinics and hospitals.

Legionnaires' disease in transportation, construction and other occupations in 39 US jurisdictions, 2014-2016.

BACKGROUND: Certain workers are at increased risk for acquiring Legionnaires' disease compared with other workers. This study aims to identify occupations at increased risk for acquiring Legionnaires' disease. METHODS: Using data from the US Centers for Disease Control and Prevention's Supplemental Legionnaires' Disease Surveillance System, this study identified Legionnaires' disease confirmed patients ≥16 years of age in 39 states with reported symptom onset during 2014-2016. Age-adjusted and sex-adjusted incidence rate ratios (IRR) stratified by occupation group were calculated by comparing Legionnaires' disease patients in an occupation group (eg, transportation) to those in all other occupation groups (eg, non-transportation). RESULTS: A total of 2553 patients had a known occupation group. The two occupations with the highest burden were transportation (N=287; IRR=2.11) and construction (N=269; IRR=1.82). Truck drivers comprised the majority (69.7%) of the transportation occupation group and construction labourers comprised almost half (49%) of the construction occupation group. The healthcare support occupation had the highest IRR (N=75; IRR=2.16). CONCLUSION: Transportation and construction workers, who are generally not covered by guidance related to building water systems, have increased risk of Legionnaires' disease compared with other workers. One hypothesised risk factor for truck drivers is the use of non-genuine windshield cleaner in their vehicles. A simple intervention is to use genuine windshield cleaner with bactericidal properties (ie, includes isopropanol/methanol) which can reduce the risk of Legionella growth and transmission. To improve surveillance of Legionnaires' disease and identification of similar exposures, the authors encourage the collection of occupation and industry information for all patients with Legionnaires' disease.

Chemical Composition of Electronic Vaping Products from School Grounds in California.

INTRODUCTION: The use of electronic vaping products (EVPs) containing nicotine, marijuana, and/or other substances remains prominent among youth; with EVPs containing nicotine being the most commonly used tobacco product among youth since 2014. However, a detailed understanding of the chemical composition of these products is limited. METHODS: During February 25th-March 15th, 2019, a total of 576 EVPs, including 233 e-cigarette devices (with 43 disposable vape pens) and 343 e-liquid cartridges/pods/bottled e-liquids, were found or confiscated from a convenience sample of 16 public high schools in California. Liquids inside 251 vape pens and cartridges/pods/bottled e-liquids were analyzed using a gas chromatography/mass spectrometry (GC/MS). For comparison, new JUUL pods, the most commonly used e-cigarette among youth during 2018-2019, with different flavorings and nicotine content were purchased and analyzed. RESULTS: For e-cigarette cartridges/pods/bottled e-liquids, nicotine was detected in 204 of 208 (98.1%) samples. Propylene glycol (PG) and vegetable glycerin (VG) were dominant solvents in nicotine-containing EVPs. Among 43 disposable vape pen devices, cannabinoids such as tetrahydrocannabinol (THC) or cannabidiol (CBD) were identified in 39 of 43 (90.1%) samples, of which 3 contained both nicotine and THC. Differences in chemical compositions were observed between confiscated or collected JUULs and purchased JUULs. Measured nicotine was inconsistent with labels on some confiscated or collected bottled e-liquids. CONCLUSIONS: EVPs from 16 participating schools were found to widely contain substances with known adverse health effects among youth, including nicotine and cannabinoids. There was inconsistency between labeled and measured nicotine on the products from schools. IMPLICATIONS: This study measured the main chemical compositions of EVPs found at 16 California public high schools. Continued efforts are warranted, including at the school-level, to educate, prevent and reduce youth use of EVPs.

Using Colonization to Understand the Burden of Antimicrobial Resistance Across Low- and Middle-Income Countries.

Understanding the burden of antibiotic resistance globally is hindered by incomplete surveillance, particularly across low-resource settings. The Antibiotic Resistance in Communities and Hospitals (ARCH) consortium encompasses sites across 6 resource-limited settings and is intended to address these gaps. Supported by the Centers for Disease Control and Prevention, the ARCH studies seek to characterize the burden of antibiotic resistance by examining colonization prevalence at the community and hospital level and to evaluate for risk factors that are associated with colonization. In this supplement, 7 articles present results from these initial studies. Though future studies identifying and evaluating prevention strategies will be critical to mitigate spreading resistance and its impact on populations, the findings from these studies address important questions surrounding the epidemiology of antibiotic resistance.

Colonization With Antibiotic-Resistant Bacteria in a Hospital and Associated Communities in Guatemala: An Antibiotic Resistance in Communities and Hospitals (ARCH) Study.

BACKGROUND: We estimated the prevalence of colonization with extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) and carbapenem-resistant Enterobacterales (CRE) from a hospital and associated communities in western Guatemala. METHODS: Randomly selected infants, children, and adults (<1, 1-17, and ≥18 years, respectively) were enrolled from the hospital (n = 641) during the coronavirus disease 2019 (COVID-19) pandemic, March to September 2021. Community participants were enrolled using a 3-stage cluster design between November 2019 and March 2020 (phase 1, n = 381) and between July 2020 and May 2021 (phase 2, with COVID-19 pandemic restrictions, n = 538). Stool samples were streaked onto selective chromogenic agar, and a Vitek 2 instrument was used to verify ESCrE or CRE classification. Prevalence estimates were weighted to account for sampling design. RESULTS: The prevalence of colonization with ESCrE and CRE was higher among hospital patients compared to community participants (ESCrE: 67% vs 46%, P < .01; CRE: 37% vs 1%, P < .01). Hospital ESCrE colonization was higher for adults (72%) compared with children (65%) and infants (60%) (P < .05). Colonization was higher for adults (50%) than children (40%) in the community (P < .05). There was no difference in ESCrE colonization between phase 1 and 2 (45% and 47%, respectively, P > .05), although reported use of antibiotics among households declined (23% and 7%, respectively, P < .001). CONCLUSIONS: While hospitals remain foci for ESCrE and CRE colonization, consistent with the need for infection control programs, community prevalence of ESCrE in this study was high, potentially adding to colonization pressure and transmission in healthcare settings. Better understanding of transmission dynamics and age-related factors is needed.

Assessment of School Staff Knowledge and Perceptions of Student E-cigarette Use and Resource Needs, and E-cigarettes Confiscated at 12 North Carolina High Schools - 2019.

BACKGROUND: E-cigarettes are the most commonly used tobacco product among US youth and are regularly used on school grounds. We assessed school staff's awareness of students' e-cigarette use, response by schools, and resources needed to address use, and examined e-cigarettes confiscated by school staff in North Carolina to guide prevention and identify needed resources. METHODS: In May 2019, staff from a random sample of 25 of 451 North Carolina public and charter high schools were invited to complete an online survey and semistructured interview; 12 schools consented to ≥ 1 component (survey, N = 514; interviews, N = 35). Staff knowledge and perceptions of students' e-cigarette use and school tobacco policies were assessed, including school efforts to address e-cigarette use. E-cigarette products confiscated by nine schools from students during the 2018-2019 school year were collected. LIMITATIONS: Only 12 public high schools participated, and these schools might not be representative of all North Carolina high schools. Quantitative surveys were not collected from all staff at participating schools; however, the response rate was 62% and included different staff positions and both urban and rural schools. Finally, e-cigarette products collected by schools might not be representative of all devices used by students. RESULTS: Among surveyed staff, 33% observed students using e-cigarettes on school grounds; 86% believed e-cigarette use somewhat or largely contributes to learning disruptions. Overall, 94% of respondents knew their school's policy prohibits student e-cigarette use on school grounds, and 57% were not confident their school has resources to help students quit. From 35 interviews, themes included concern that schools' tobacco-free policies do not deter use and additional resources are needed to address e-cigarette use in schools. Of 336 collected devices, there were different e-cigarette types and most (65%) e-liquid bottles were flavored. CONCLUSION: Efforts are warranted to incorporate evidence-based curricula; educate staff, parents, and youth regarding health risks of e-cigarette use; and help youth quit e-cigarettes.

Infection Prevention and Control Initiatives to Prevent Healthcare-Associated Transmission of SARS-CoV-2, East Africa.

The coronavirus disease pandemic has highlighted the need to establish and maintain strong infection prevention and control (IPC) practices, not only to prevent healthcare-associated transmission of SARS-CoV-2 to healthcare workers and patients but also to prevent disruptions of essential healthcare services. In East Africa, where basic IPC capacity in healthcare facilities is limited, the US Centers for Disease Control and Prevention (CDC) supported rapid IPC capacity building in healthcare facilities in 4 target countries: Tanzania, Ethiopia, Kenya, and Uganda. CDC supported IPC capacity-building initiatives at the healthcare facility and national levels according to each country's specific needs, priorities, available resources, and existing IPC capacity and systems. In addition, CDC established a multicountry learning network to strengthen hospital level IPC, with an emphasis on peer-to-peer learning. We present an overview of the key strategies used to strengthen IPC in these countries and lessons learned from implementation.

Absence of SARS-CoV-2 infections among patients with end-stage renal disease following facility-wide testing in four outpatient hemodialysis facilities.

Facility-wide testing performed at 4 outpatient hemodialysis facilities in the absence of an outbreak or escalating community incidence did not identify new SARS-CoV-2 infections and illustrated key logistical considerations essential to successful implementation of SARS-CoV-2 screening. Facilities could consider prioritizing facility-wide SARS-CoV-2 testing during suspicion of an outbreak in the facility or escalating community spread without robust infection control strategies in place. Being prepared to address operational considerations will enhance implementation of facility-wide testing in the outpatient dialysis setting.

Chemical Composition of JUUL Pods Collected From Students in California High Schools.

PURPOSE: To examine the chemical composition of JUUL pods collected from a convenience sample of 16 high schools in California to identify possible consumer modification or counterfeit use. METHODS: Using Gas Chromatography-Mass Spectrometry, we quantitatively analyzed the nicotine, propylene glycol (PG), and vegetable glycerin (VG) in JUUL pods (n = 26) collected from California high schools and compared results to commercial 3% (n = 15) and 5% (n = 24) JUUL pods purchased online. RESULTS: Most of the collected JUUL pods (24/26 pods) had a nicotine concentration (43.3 mg/ml, 95% PI: 21.5-65.1) outside the prediction intervals (PI) of the 3% (33.5 mg/ml, 95% PI: 31.8-35.2) and 5% (55.0 mg/ml, 95% PI: 51.5-58.3) commercial JUUL pods. Most (73%) collected JUUL pods had VG concentrations (583.5 mg/ml, PI: 428.9-738.1) lower than the 3% (722.2 mg/ml, PI: 643.0-801.4) and 5% (710.5 mg/ml, PI: 653.1-767.8) commercial JUUL pods. CONCLUSIONS: Used JUUL products collected from high school students or found on school grounds were not chemically consistent with the manufacturer's stated formulations.

Coronavirus Disease 2019 (COVID-19) in Americans Aboard the Diamond Princess Cruise Ship.

BACKGROUND: The Diamond Princess cruise ship was the site of a large outbreak of coronavirus disease 2019 (COVID-19). Of 437 Americans and their travel companions on the ship, 114 (26%) tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). METHODS: We interviewed 229 American passengers and crew after disembarkation following a ship-based quarantine to identify risk factors for infection and characterize transmission onboard the ship. RESULTS: The attack rate for passengers in single-person cabins or without infected cabinmates was 18% (58/329), compared with 63% (27/43) for those sharing a cabin with an asymptomatic infected cabinmate, and 81% (25/31) for those with a symptomatic infected cabinmate. Whole genome sequences from specimens from passengers who shared cabins clustered together. Of 66 SARS-CoV-2-positive American travelers with complete symptom information, 14 (21%) were asymptomatic while on the ship. Among SARS-CoV-2-positive Americans, 10 (9%) required intensive care, of whom 7 were ≥70 years. CONCLUSIONS: Our findings highlight the high risk of SARS-CoV-2 transmission on cruise ships. High rates of SARS-CoV-2 positivity in cabinmates of individuals with asymptomatic infections suggest that triage by symptom status in shared quarters is insufficient to halt transmission. A high rate of intensive care unit admission among older individuals complicates the prospect of future cruise travel during the pandemic, given typical cruise passenger demographics. The magnitude and severe outcomes of this outbreak were major factors contributing to the Centers for Disease Control and Prevention's decision to halt cruise ship travel in US waters in March 2020.

Clinical Course of SARS-CoV-2 Infection in Adults with ESKD Receiving Outpatient Hemodialysis.

Background: Patients with ESKD on maintenance dialysis receive dialysis in common spaces with other patients and have a higher risk of severe SARS-CoV-2 infections. They may have persistently or intermittently positive SARS-CoV-2 RT-PCR tests after infection. We describe the clinical course of SARS-CoV-2 infection and the serologic response in a convenience sample of patients with ESKD to understand the duration of infectivity. Methods: From August to November 2020, we enrolled patients on maintenance dialysis with SARS-CoV-2 infections from outpatient dialysis facilities in Atlanta, Georgia. We followed participants for approximately 42 days. We assessed COVID-19 symptoms and collected specimens. Oropharyngeal (OP), anterior nasal (AN), and saliva (SA) specimens were tested for the presence of SARS-CoV-2 RNA, using RT-PCR, and sent for viral culture. Serology, including neutralizing antibodies, was measured in blood specimens. Results: Fifteen participants, with a median age of 58 (range, 37‒77) years, were enrolled. Median duration of RT-PCR positivity from diagnosis was 18 days (interquartile range [IQR], 8‒24 days). Ten participants had at least one, for a total of 41, positive RT-PCR specimens ≥10 days after symptoms onset. Of these 41 specimens, 21 underwent viral culture; one (5%) was positive 14 days after symptom onset. Thirteen participants developed SARS-CoV-2-specific antibodies, 11 of which included neutralizing antibodies. RT-PCRs remained positive after seroconversion in eight participants and after detection of neutralizing antibodies in four participants; however, all of these samples were culture negative. Conclusions: Patients with ESKD on maintenance dialysis remained persistently and intermittently SARS-CoV-2-RT-PCR positive. However, of the 15 participants, only one had infectious virus, on day 14 after symptom onset. Most participants mounted an antibody response, including neutralizing antibodies. Participants continued having RT-PCR-positive results in the presence of SARS-CoV-2-specific antibodies, but without replication-competent virus detected.

Laboratory-Acquired Dengue Virus Infection, United States, 2018.

Investigation of a dengue case in a laboratory worker in North Carolina, USA, revealed that the case-patient prepared high-titer dengue virus stocks soon before illness onset. Improper doffing of gloves with an open finger wound likely resulted in cutaneous exposure. This case reinforces recommendations for enhanced precautions when working with high-titer dengue virus.

Public Health Responses to COVID-19 Outbreaks on Cruise Ships - Worldwide, February-March 2020.

An estimated 30 million passengers are transported on 272 cruise ships worldwide each year* (1). Cruise ships bring diverse populations into proximity for many days, facilitating transmission of respiratory illness (2). SARS-CoV-2, the virus that causes coronavirus disease (COVID-19) was first identified in Wuhan, China, in December 2019 and has since spread worldwide to at least 187 countries and territories. Widespread COVID-19 transmission on cruise ships has been reported as well (3). Passengers on certain cruise ship voyages might be aged ≥65 years, which places them at greater risk for severe consequences of SARS-CoV-2 infection (4). During February-March 2020, COVID-19 outbreaks associated with three cruise ship voyages have caused more than 800 laboratory-confirmed cases among passengers and crew, including 10 deaths. Transmission occurred across multiple voyages of several ships. This report describes public health responses to COVID-19 outbreaks on these ships. COVID-19 on cruise ships poses a risk for rapid spread of disease, causing outbreaks in a vulnerable population, and aggressive efforts are required to contain spread. All persons should defer all cruise travel worldwide during the COVID-19 pandemic.

Perceived impact of state-mandated reporting on infection prevention and control departments.

BACKGROUND: Currently, most US states have adopted legislation requiring hospitals to submit health care-associated infection (HAI) data. We evaluated the perceived impact of state HAI laws on infection prevention and control (IPC) departments. METHODS: A web-based survey of a national sample of all non-veteran hospitals enrolled in the National Healthcare Safety Network was conducted in fall 2011. Variations in IPC department resources and characteristics in states with and without laws were compared by use of χ², Mann-Whitney (Wilcoxon), and Student t tests. Multinomial logistic regression was used to identify increases or decreases, versus no change, in perceived resources, time, influence, and visibility of the IPC department in states with and without HAI laws. RESULTS: Overall, 1,036 IPC departments provided complete data (30% response rate); 755 (73%) were located in states with laws. Respondents in states with reporting laws were more likely to report less time for routine IPC activities (odds ratio, 1.61; 95% confidence interval, 1.12-2.31) and less visibility of the IPC department (odds ratio, 1.70; 95% confidence interval, 1.12-2.58) than respondents in states without laws, after controlling for geographic region, setting, and the presence of a hospital epidemiologist. CONCLUSIONS: Respondents in states with laws reported negative effects on their IPC department, beyond what was required by federal mandates. Further research should examine resources necessary to comply with state HAI laws and evaluate unintended consequences of state HAI laws.

Nursing Home Infection Control Program Characteristics, CMS Citations, and Implementation of Antibiotic Stewardship Policies: A National Study.

Recently, the Centers for Medicare & Medicaid Services (CMS) final rule required that nursing homes (NHs) develop an infection control program that includes an antibiotic stewardship component and employs a trained infection preventionist (IP). The objectives of this study were to provide a baseline assessment of (1) NH facility and infection control program characteristics associated with having an infection control deficiency citation and (2) associations between IP training and the presence of antibiotic stewardship policies, controlling for NH characteristics. A cross-sectional survey of 2514 randomly sampled US NHs was conducted to assess IP training, staff turnover, and infection control program characteristics (ie, frequency of infection control committee meetings and the presence of 7 antibiotic stewardship policies). Responses were linked to concurrent Certification and Survey Provider Enhanced Reporting data, which contain information about NH facility characteristics and citations. Descriptive statistics and multivariable regression analyses were conducted to account for NH characteristics. Surveys were received from 990 NHs; 922 had complete data. One-third of NHs in this sample received an infection control deficiency citation. The NHs that received deficiency citations were more likely to have committees that met weekly/monthly versus quarterly ( P < .01). The IPs in 39% of facilities had received specialized training. Less than 3% of trained IPs were certified in infection control. The NHs with trained IPs were more likely to have 5 of the 7 components of antibiotic stewardship in place (all P < .05). The IP training, although infrequent, was associated with the presence of antibiotic stewardship policies. Receiving an infection control citation was associated with more frequent infection control committee meetings. Training and support of IPs is needed to ensure infection control and antibiotic stewardship in NHs. As the CMS rule becomes implemented, more research is warranted. There is a need for increase in trained IPs in US NHs. These data can be used to evaluate the effectiveness of the CMS final rule on infection management processes in US NHs.

Implementation of Electronic Health Records in US Nursing Homes.

While electronic health records have emerged as promising tools to help improve quality of care, nursing homes have lagged behind in implementation. This study assessed electronic health records implementation, associated facility characteristics, and potential impact on quality indicators in nursing homes. Using national Centers for Medicare & Medicaid Services and survey data for nursing homes, a cross-sectional analysis was conducted to identify variations between nursing homes that had and had not implemented electronic health records. A difference-in-differences analysis was used to estimate the longitudinal effect of electronic health records on commonly used quality indicators. Data from 927 nursing homes were examined, 49.1% of which had implemented electronic health records. Nursing homes with electronic health records were more likely to be nonprofit/government owned (P = .04) and had a lower percentage of Medicaid residents (P = .02) and higher certified nursing assistant and registered nurse staffing levels (P = .002 and .02, respectively). Difference-in-differences analysis showed greater quality improvements after implementation for five long-stay and two short-stay quality measures (P = .001 and .01, respectively) compared with those who did not implement electronic health records. Implementation rates in nursing homes are low compared with other settings, and better-resourced facilities are more likely to have implemented electronic health records. Consistent with other settings, electronic health records implementation improves quality in nursing homes, but further research is needed to better understand the mechanism for improvement and how it can best be supported.

Influence of staff infection control training on infection-related quality measures in US nursing homes.

Health care-associated infections are a leading cause of morbidity and mortality in US nursing home residents. Ongoing training of nursing home staff is vital to the implementation of infection prevention and control processes. Our aim was to describe associations between methods, frequency, and timing of staff infection prevention and control training and infection-related quality measures. In this national survey of nursing homes, timing of staff infection prevention and control training was associated with reduced indwelling urinary catheter use.

Infection Trends in US Nursing Homes, 2006-2013.

OBJECTIVES: The objectives of this study were to estimate trends in the prevalence of infections in nursing home (NH) residents using 2006-2013 Minimum Data Set (MDS) data, estimate the number of all infections in 2013, and evaluate differences in trends between MDS versions 2.0 and 3.0. DESIGN: Retrospective study. SETTING: NHs in the United States. PARTICIPANTS: All NH residents with a quarterly or annual MDS assessment in 2006-2013 (n = 30,366,807 assessments). MEASUREMENTS: MDS 2.0 and 3.0 quarterly and annual assessment data (2006-2013) from over 15,000 NHs were used to estimate the 7-day prevalence of multidrug-resistant organism (MDRO) infection, pneumonia, septicemia, viral hepatitis, and wound infection and 30-day prevalence of urinary tract infection (UTI). Admission assessments were excluded. Annual infection counts were estimated using 2013 data. Changes in the prevalence of reported infections over time and differences in trends between MDS 2.0 and 3.0 were examined using tests of linear trends. RESULTS: In 2013, there were an estimated 1.13 to 2.68 million infections in NH residents. UTI and pneumonia were the most commonly reported infections in every quarter, ranging from 5.6% to 8.1% and 1.4% to 2.5%, respectively. Prevalence of all infections increased in 2006-2010 (P values < .01). In 2011-2013, prevalence of UTI, MDRO, and wound infections decreased and viral hepatitis increased (P values < .0001). Between MDS 2.0 and 3.0, the prevalence of UTI, MDRO, and wound infections decreased and the prevalence of viral hepatitis increased (P values < .0001). CONCLUSION: Infections are a major and persistent problem in NHs. Although MDS data are useful for identifying trends in infection prevalence, revisions in definitions need to be accounted for when evaluating trends over time. Additional research is needed to identify factors that contribute to changes in infection prevalence.