Building the future of ID: A call to action for quality improvement research and measurement.

Quality is central to value-based care and measurement is essential for assessing performance and understanding improvement over time. Both value-based care and methods for quality measurement are evolving. Infectious Diseases has been less engaged than other specialties in quality measure development, and Infectious Diseases providers must seize the opportunity to engage with quality measure development and research. Antimicrobial stewardship programs are an ideal starting point for Infectious Diseases-related quality measure development; antimicrobial stewardship program interventions and best practices are Infectious Diseases-specific, measurable, and impactful, yet grossly undercompensated. Herein, we provide a scheme for prioritizing research focused on development of Infectious Diseases-specific quality measures. Maturation of quality measurement research in Infectious Diseases, beginning with an initial focus on stewardship-related conditions then expanding to non-stewardship topics, will allow Infectious Diseases to take control of its future in value-based care, and promote the growth of Infectious Diseases through greater recognition of its value.

Hand hygiene behavior change: a review and pilot study of an automated hand hygiene reminder system implementation in a public hospital.

Objective: To review and study implementation of an automated hand hygiene reminder system (AHHRS). Design: Prospective, nonrandomized, before-after quality improvement pilot study conducted over 6 months. Setting: Medical-surgical unit (MSU) and medical intensive care unit (MICU) at a public hospital in New York City. Participants: There were 2,642 healthcare worker observations in the direct observation (DO) period versus 265,505 in the AHHRS period, excluding AHHRS observations collected during the 1-month crossover period when simultaneous DO occurred. Intervention: We compared hand hygiene adherence (HHA) measured by DO prior to the pilot and after AHHRS implementation. We compared changes in HHA and potential cross-contamination events (CCEs) (room exit and subsequent entry without HHA) from baseline for each biweekly period during the pilot. Results: Engagement, education/training, data transparency, and optimization period resulted in successful implementation and adoption of the AHHRS. Observations were greater utilizing AHHRS than DO (265,505 vs 2,642, P < .01). Due to the expected Hawthorne effect, HHA was significantly less for AHHRS than DO in MSU (90.99% vs 97.21%, P < .01) and MICU (91.21% vs 98.65%, P < .01). HHA significantly improved from 86.47% to 89.68% in MSU (P < .001) and 85.93% to 91.24% in the MICU (P < .001) from the first biweekly period of AHHRS utilization to the last. CCE decreased from 73.42% to 65.11% in the MSU and significantly decreased from 81.22% to 53.19% in the MICU (P < .05). Conclusions: We describe how an AHHRS approach was successfully implemented at our facility. With ongoing feedback and system optimization, AHHRS improved HHA and reduced CCE over time.

COVID-19 Complications in a Newly Diagnosed HIV Patient: A Case of Multiple Herpesvirus Reactivation and HLH Post-ART Initiation.

BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) and Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) can trigger profound immune activation and systemic inflammation, leading to severe, often fatal, conditions. Simultaneously, HIV-infected patients, prone to immune dysregulation, face an increased risk of severe complications from SARS-CoV-2. The optimal timeline for initiating antiretroviral therapy (ART) in patients with severe SARS-CoV-2 and HIV co-infection, especially concerning the risk of HLH, remains uncertain. CASE REPORT We detail the case of a 47-year-old male with previously undiagnosed HIV who, following ART initiation, developed HLH amid SARS-CoV-2 co-infection. The patient also had biopsy-proven Kaposi Sarcoma with immunoreactivity to Human Herpesvirus 8 (HHV-8), detectable peripheral blood Epstein Barr virus (EBV) DNA PCR and Cytomegalovirus (CMV) DNA PCR, and suspected Pneumocystis jirovecii pneumonia. We believe these conditions contributed to the development of HLH. This case represents a unique report of multiple herpesviruses reactivation, acquired HLH during COVID-19 in a patient with previously undiagnosed HIV. Despite receiving ART, steroids, and appropriate antimicrobial therapy, the patient's condition did not improve. CONCLUSIONS Further research is required to understand immune dysregulation, including HLH, in patients with HIV and SARS-CoV-2 co-infection. The effects of ART initiation on treatment-naïve patients with potential concurrent opportunistic infections and/or herpesvirus reactivation warrant deeper examination to formulate clinical guidelines.

Choosing wisely initiative for reducing urine cultures for asymptomatic bacteriuria and catheter-associated asymptomatic bacteriuria in an 11-hospital safety net system.

BACKGROUND: Treatment of asymptomatic bacteriuria (ASB) is common. Overtreatment of ASB leads to harm, including adverse effects from antibiotics, antibiotic resistance, and increased length of stay. METHODS: This quality improvement initiative targeted inappropriate urine cultures across 11 hospitals in a safety-net setting. A mandatory prompt for appropriate indications for urine culture orders and a best practice advisory (BPA) for urine culture on patients with urinary catheters were created. Urine culture ordering was compared pre-intervention (6/2020 to 10/2021) to post-intervention (12/2021 to 8/2022). Catheter associated urinary tract infections (CAUTI) was compared pre- and post-intervention. Variation in urine culture ordering and CAUTI rates in hospitals were assessed. RESULTS: Inpatient urine cultures decreased by 20.9% (p<0.001). Inpatient urine cultures on patients with urinary catheters decreased by 21.6% (p<0.001). CAUTI rates remained unchanged post-intervention. High variation in urine culture ordering and CAUTI rates was seen among hospitals. CONCLUSIONS: This initiative successfully decreased urine cultures in a large, safety-net system. Further study is needed in assessing variation among hospitals.

Nudging to select single-lumen over multiple-lumen peripherally inserted central catheters (PICCs) in a large safety net system.

BACKGROUND: Peripherally inserted central catheters (PICCs) are increasingly used for vascular access in inpatient settings. Compared to multilumen PICCs, single-lumen PICCs carry a lower rate of complications, including central-line-associated bloodstream infection and thrombosis. Despite this, multilumen PICCs are still overused. METHODS: This quality improvement initiative was implemented across 11 hospitals at New York City Health + Hospitals safety net system. The electronic health record (EHR) interventional radiology or vascular access team consultation orders were modified to allow for lumen choice, with default selection to a single-lumen PICC. RESULTS: Average single-lumen PICC utilization increased by 25.5%, from 44.4% to 69.9% (P < .001). CLABSI rates had a nonsignificant reduction by 26.7% from 2.44 to 1.79 infections per month (P = .255). Among provider types in the postintervention period, single-lumen PICC utilization ranged from 67.7% for advanced practice providers to 82.4%-94.6% for physicians. Among provider specialties, utilization ranged from 31.8% for neurology to 97.7% for orthopedics. Additionally, there was large variation in pre- and postintervention differences in utilization by hospital. CONCLUSIONS: We successfully increased single-lumen PICC utilization across all 11 safety net hospitals. This expands on previous work on improving single-lumen PICC use and use of default nudges in large, resource-limited settings. Further study is needed to examine variation among provider types, specialties, and hospitals.

Bacterial and fungal coinfections in COVID-19 patients hospitalized during the New York City pandemic surge.

We observed bacterial or fungal coinfections in COVID-19 patients admitted between March 1 and April 18, 2020 (152 of 4,267, 3.6%). Among these patients, mortality was 57%; 74% were intubated; 51% with bacteremia had central venous catheters. Time to culture positivity was 6-7 days, and 79% had received prior antibiotics. Metallo-ß-lactamase-producing E. cloacae coinfections occurred in 5 patients.

Analysis of catheter utilization, central line associated bloodstream infections, and costs associated with an inpatient critical care-driven vascular access model.

BACKGROUND: Central line-associated bloodstream infections (CLABSI) carry serious risks for patients and financial consequences for hospitals. Avoiding unnecessary temporary central venous catheters (CVC) can reduce CLABSI. Critical Care Medicine (CCM) is often consulted to insert CVC when alternatives are unavailable. We aim to describe clinical and financial implications of a CCM-driven vascular access model. METHODS: In this retrospective, observational cohort study, all CLABSI and a sample of CCM consults for CVC insertion on adult medical-surgical inpatient units were reviewed in 2019. Assessment of CVC appropriateness and financial analysis of labor, reimbursement, and attributable CLABSI cost was conducted. RESULTS: Of 554 CCM consult requests, 75 (13.5%) were for CVC and 36 (48.0%) resulted in CVC insertion; 6 (16.7%) CVC were avoidable. Three CLABSI occurred in avoidable CVC with estimated annual attributable cost of $165,099. Estimated annual CCM consultant cost for CVC was $78,094 generating $110,733 in reimbursement. Overall estimated annual loss was $132,460. DISCUSSION: Reliance on CCM for intravenous access resulted in avoidable CVC, CLABSI, inefficient physician effort, and financial losses; nurse-driven vascular access models offer potential cost savings and risk reduction. CONCLUSIONS: CCM-driven vascular access models may not be cost-effective; alternatives should be considered for utilization reduction, CLABSI prevention, and financial viability.

The damage response framework and infection prevention: From concept to bedside.

Hospital-acquired infections remain a common cause of morbidity and mortality despite advances in infection prevention through use of bundles, environmental cleaning, antimicrobial stewardship, and other best practices. Current prevention strategies and further hospital-acquired infection reduction are limited by lack of recognition of the role that host-microbe interactions play in susceptibility and by the inability to analyze multiple risk factors in real time to accurately predict the likelihood of a hospital-acquired infection before it occurs and to inform medical decision making. Herein, we examine the value of incorporating the damage-response framework and host attributes that determine susceptibility to infectious diseases known by the acronym MISTEACHING (ie, microbiome, immunity, sex, temperature, environment, age, chance, history, inoculum, nutrition, genetics) into infection prevention strategies using machine learning to drive decision support and patient-specific interventions.

Early Infectious Disease Consultation Is Associated With Lower Mortality in Patients With Severe Sepsis or Septic Shock Who Complete the 3-Hour Sepsis Treatment Bundle.

OBJECTIVE: Severe sepsis and septic shock (SS/SS) treatment bundles reduce mortality, and early infectious diseases (ID) consultation also improves patient outcomes. We retrospectively examined whether early ID consultation further improves outcomes in Emergency Department (ED) patients with SS/SS who complete the sepsis bundle. METHOD: We included 248 adult ED patients with SS/SS who completed the 3-hour bundle. Patients with ID consultation within 12 hours of ED triage (n = 111; early ID) were compared with patients who received standard care (n = 137) for in-hospital mortality, 30-day readmission, length of hospital stay (LOS), and antibiotic management. A competing risk survival analysis model compared risks of in-hospital mortality and discharge alive between groups. RESULTS: In-hospital mortality was lower in the early ID group unadjusted (24.3% vs 38.0%, P = .02) and adjusted for covariates (odds ratio, 0.47; 95% confidence interval (CI), 0.25-0.89; P = .02). There was no significant difference in 30-day readmission (22.6% vs 23.5%, P = .89) or median LOS (10.2 vs 12.1 days, P = .15) among patients who survived. A trend toward shorter time to antibiotic de-escalation in the early ID group (log-rank test P = .07) was observed. Early ID consultation was protective of in-hospital mortality (adjusted subdistribution hazard ratio (asHR), 0.60; 95% CI 0.36-1.00, P = .0497) and predictive of discharge alive (asHR 1.58, 95% CI, 1.11-2.23; P-value .01) after adjustment. CONCLUSIONS: Among patients receiving the SS/SS bundle, early ID consultation was associated with a 40% risk reduction for in-hospital mortality. The impact of team-based care and de-escalation on SS/SS outcomes warrants further study.

Gonococcal breast abscess.

A 32-year-old nonlactational women with a nipple piercing and previous oral-to-breast contact presented with findings consistent with mastitis and abscess, however, the patient failed multiple courses of empiric antimicrobials. Needle aspiration was performed and the culture was positive for N. gonorrhoeae. She was successfully treated with intravenous ceftriaxone and transitioned to oral ciprofloxacin once susceptibilities were known. N. gonorrhoeae is an uncommon cause of nonlactational mastitis and abscess. A few cases have been reported in the context of sexual contact and nipple piercings. In an era of increasing antimicrobial resistance and with the risk of disseminated gonococcal infection, a high index of suspicion should be maintained within this clinical context.

Rapid Diagnostic Testing of Hospitalized Malawian Children Reveals Opportunities for Improved HIV Diagnosis and Treatment.

Recent World Health Organization (WHO) guidelines recommend antiretroviral therapy (ART) for all HIV-infected people; previously CD4+ T lymphocyte quantification (CD4 count) or clinical staging determined eligibility for children ≥ 5 years old in low- and middle-income countries. We examined positive predictive value (PPV) of a rapid diagnostic test (RDT) algorithm and ART eligibility for hospitalized children with newly diagnosed HIV infection. We enrolled 363 hospitalized Malawian children age 2 months to 16 years with two serial positive HIV RDT from 2013 to 2015. Children aged ≤ 18 months whose nucleic acid testing was negative or unavailable were later excluded from the analysis (N = 16). If RNA PCR was undetectable, human immunodeficiency virus (HIV) enzyme immunoassay (EIA) and western blot (WB) were performed. Those with negative or discordant EIA and WB were considered HIV negative and excluded from further analysis (N = 6). ART eligibility was assessed using age, CD4 count, and clinical HIV stage. Among 150 patients with HIV RNA PCR results, 15 had undetectable HIV RNA. Of those, EIA and WB were positive in nine patients and negative or discordant in six patients. PPV of serial RDT was 90% versus RNA PCR alone and 96% versus combined RNA PCR, EIA, and WB. Of all patients aged ≥ 5 years, 8.9% were ineligible for ART under previous WHO guidelines. Improved HIV testing algorithms are needed for accurate diagnosis of HIV infection in children as prevalence of pediatric HIV declines. Universal treatment will significantly increase the numbers of older children who qualify for ART.

Bundle in the Bronx: Impact of a Transition-of-Care Outpatient Parenteral Antibiotic Therapy Bundle on All-Cause 30-Day Hospital Readmissions.

BACKGROUND: A streamlined transition from inpatient to outpatient care can decrease 30-day readmissions. Outpatient parenteral antibiotic therapy (OPAT) programs have not reduced readmissions; an OPAT bundle has been suggested to improve outcomes. We implemented a transition-of-care (TOC) OPAT bundle and assessed the effects on all-cause, 30-day hospital readmission. METHODS: Retrospectively, patients receiving postdischarge intravenous antibiotics were evaluated before and after implementation of a TOC-OPAT program in Bronx, New York, between July, 2015 and February, 2016. Pearson's χ2 test was used to compare 30-day readmissions between groups, and logistic regression was used to adjust for covariates. Time from discharge to readmission was analyzed to assess readmission risk, using log-rank test to compare survival curves and Cox proportional hazards model to adjust for covariates. Secondary outcomes, 30-day emergency department (ED) visits, and mortality were analyzed similarly. RESULTS: Compared with previous standard care (n = 184), the TOC-OPAT group (n = 146) had significantly lower 30-day readmissions before (13.0% vs 26.1%, P < .01) and after adjustment for covariates (odds ratio [OR] = 0.51; 95% confidence interval [CI], 0.27-0.94; P = .03). In time-dependent analyses, TOC-OPAT patients were at significantly lower risk for readmission (log-rank test, P < .01; hazard ratio = 0.56; 95% CI, 0.32-0.97; P = .04). Propensity-matched sensitivity analysis showed lower readmissions in the TOC-OPAT group (13.6% vs 24.6%, P = .04), which was attenuated after adjustment (OR = 0.51; 95% CI, 0.25-1.05; P = .07). Mortality and ED visits were similar in both groups. CONCLUSIONS: Our TOC-OPAT patients had reduced 30-day readmissions compared with the previous standard of care. An effective TOC-OPAT bundle can successfully improve patient outcomes in an economically disadvantaged area.

Developing Interactive Antimicrobial Stewardship and Infection Prevention Curricula for Diverse Learners: A Tailored Approach.

BACKGROUND: To impart principles of antimicrobial stewardship (AS) and infection prevention and control (IPC), we developed a curriculum tailored to the diverse aptitudes of learners at our medical center. METHODS: We integrated case-based modules, group learning activities, smartphone applications (apps), decision support tools, and prescription audit and feedback into curricula of the medical school, medicine residency program, infectious diseases (ID) fellowship program, and hospital medicine program operations. Interventions were implemented in 2012-2016 using a quasi-experimental before-and-after study design, and this was assessed using pre- and postintervention surveys or audit of antibiotic prescriptions. RESULTS: Over 180 medical students participated in the AS and IPC seminars. After smartphone app introduction, 69% reported using the app as their preferred source of antibiotic information. Approximately 70% of students felt comfortable prescribing antibiotics for a known infection compared with 40% at baseline (P = .02), and approximately 83% were able to identify the appropriate personal protective equipment for specific scenarios. Approximately 99% agreed that they have a role in promoting patient safety and preventing healthcare-associated infections as medical students. At 20 months, appropriateness of trainee antibiotic prescriptions increased by 20% (P < .01). Almost all ID fellows indicated that the AS and IPC seminar was a vital training supplement. Uptake of internist antibiotic recommendations using AS decision support tools was approximately 70%. CONCLUSIONS: All 5 interventions addressed learning objectives and knowledge gaps and are applicable across a range of environments. Evaluating long-term impact of our curriculum is the focus of future study.

Fatal Pediatric Cerebral Malaria Is Associated with Intravascular Monocytes and Platelets That Are Increased with HIV Coinfection.

Cerebral malaria (CM) is a major contributor to malaria deaths, but its pathophysiology is not well understood. While sequestration of parasitized erythrocytes is thought to be critical, the roles of inflammation and coagulation are controversial. In a large series of Malawian children hospitalized with CM, HIV coinfection was more prevalent than in pediatric population estimates (15% versus 2%, P < 0.0001, chi-square test), with higher mortality than that seen in HIV-uninfected children (23% versus 17%, P = 0.0178, chi-square test). HIV-infected (HIV(+)) children with autopsy-confirmed CM were older than HIV-uninfected children (median age, 99 months versus 32 months, P = 0.0007, Mann-Whitney U test) and appeared to lack severe immunosuppression. Because HIV infection is associated with dysregulated inflammation and platelet activation, we performed immunohistochemistry analysis for monocytes, platelets, and neutrophils in brain tissue from HIV(+) and HIV-uninfected children with fatal CM. Children with autopsy-confirmed CM had significantly (>9 times) more accumulations of intravascular monocytes and platelets, but not neutrophils, than did children with nonmalarial causes of coma. The monocyte and platelet accumulations were significantly (>2-fold) greater in HIV(+) children than in HIV-uninfected children with autopsy-confirmed CM. Our findings indicate that HIV is a risk factor for CM and for death from CM, independent of traditional measures of HIV disease severity. Brain histopathology supports the hypotheses that inflammation and coagulation contribute to the pathogenesis of pediatric CM and that immune dysregulation in HIV(+) children exacerbates the pathological features associated with CM. IMPORTANCE : There are nearly 1 million malaria deaths yearly, primarily in sub-Saharan African children. Cerebral malaria (CM), marked by coma and sequestered malaria parasites in brain blood vessels, causes half of these deaths, although the mechanisms causing coma and death are uncertain. Sub-Saharan Africa has a high HIV prevalence, with 3 million HIV-infected (HIV(+)) children, but the effects of HIV on CM pathogenesis and mortality are unknown. In a study of pediatric CM in Malawi, HIV prevalence was high and CM-attributed mortality was higher in HIV(+) than in HIV-uninfected children. Brain pathology in children with fatal CM was notable not only for sequestered malaria parasites but also for intravascular accumulations of monocytes and platelets that were more severe in HIV(+) children. Our findings raise the possibility that HIV(+) children at risk for malaria may benefit from targeted malaria prophylaxis and that adjunctive treatments targeting inflammation and/or coagulation may improve CM outcomes.