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.

Aligning Patient Safety and Stewardship: A Harm Reduction Strategy for Children.

Purpose of review: Review important patient safety and stewardship concepts and use clinical examples to describe how they align to improve patient outcomes and reduce harm for children. Recent findings: Current evidence indicates that healthcare overuse is substantial. Unnecessary care leads to avoidable adverse events, anxiety and distress, and financial toxicity. Increases in antimicrobial resistance, venous thromboembolism, radiation exposure, and healthcare costs are examples of patient harm associated with a lack of stewardship. Studies indicate that many tools can increase standardization of care, improve resource utilization, and enhance safety culture to better align safety and stewardship. Summary: The principles of stewardship and parsimonious care can improve patient safety for children.

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.

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.

Management of the COVID-19-Infected Psychiatric Inpatients: Unique Infection Prevention Considerations and Evolving Strategies.

REASON FOR REVIEW: The COVID-19 pandemic has affected the way healthcare services are provided and created challenges to the delivery of behavioral health in the inpatient setting. Here, we present our front-line experience of infection prevention for the psychiatric patient in the COVID era. RECENT FINDINGS: There are unique challenges surrounding COVID-19 precautions within inpatient psychiatric settings. The challenges presented to psychiatric care by COVID-19 begin in the emergency department and follow the patient through the continuum of care once admitted to the facility. Unit infrastructure, patient population, treatment modalities, staffing considerations, and discharge planning are distinct instances where COVID-19 protocols that are well-suited for other hospital settings necessitate revision for psychiatric settings. SUMMARY: The purpose of this communication is to add to the current body of shared experience of infection prevention for the psychiatric patient in the COVID-19 era.

The common gamma-chain cytokines IL-2, IL-7, IL-15, and IL-21 induce the expression of programmed death-1 and its ligands.

The programmed death (PD)-1 molecule and its ligands (PD-L1 and PD-L2), negative regulatory members of the B7 family, play an important role in peripheral tolerance. Previous studies have demonstrated that PD-1 is up-regulated on T cells following TCR-mediated activation; however, little is known regarding PD-1 and Ag-independent, cytokine-induced T cell activation. The common gamma-chain (gamma c) cytokines IL-2, IL-7, IL-15, and IL-21, which play an important role in peripheral T cell expansion and survival, were found to up-regulate PD-1 and, with the exception of IL-21, PD-L1 on purified T cells in vitro. This effect was most prominent on memory T cells. Furthermore, these cytokines induced, indirectly, the expression of PD-L1 and PD-L2 on monocytes/macrophages in PBMC. The in vivo correlate of these observations was confirmed on PBMC isolated from HIV-infected individuals receiving IL-2 immunotherapy. Exposure of gamma c cytokine pretreated T cells to PD-1 ligand-IgG had no effect on STAT5 activation, T cell proliferation, or survival driven by gamma c cytokines. However, PD-1 ligand-IgG dramatically inhibited anti-CD3/CD28-driven proliferation and Lck activation. Furthermore, following restimulation with anti-CD3/CD28, cytokine secretion by both gamma c cytokine and anti-CD3/CD28 pretreated T cells was suppressed. These data suggest that gamma c cytokine-induced PD-1 does not interfere with cytokine-driven peripheral T cell expansion/survival, but may act to suppress certain effector functions of cytokine-stimulated cells upon TCR engagement, thereby minimizing immune-mediated damage to the host.

Levofloxacin for Antibacterial Prophylaxis in Pediatric Patients With Acute Myeloid Leukemia or Undergoing Hematopoietic Stem Cell Transplantation.

OBJECTIVE: This study aimed to evaluate the use of levofloxacin for the prevention of bacterial infections in pediatric patients with acute myeloid leukemia or those undergoing hematopoietic stem cell transplantation. METHODS: This study was a single-center, retrospective review designed to assess the frequency of bacteremia with levofloxacin prophylaxis compared with historical controls that used other, clinician-directed antibacterial prophylaxis. The primary outcome of the study was microbiologically documented bacteremia. Secondary outcomes included febrile neutropenia, clinically documented infection, duration of neutropenia, treatment antibiotic exposure days, Clostridioides difficile infection, and infection-related mortality. RESULTS: Of the 60 patients included, 24 patients with 32 hospital admissions received levofloxacin and 36 patients with 48 hospital admissions received clinician-directed prophylaxis. There was no difference found in the frequency of bacteremia between levofloxacin and clinician-directed prophylaxis (15.6% vs 10.4%, p = 0.49). There was no difference in the incidence of febrile neutropenia, clinically documented infection, treatment antibiotic exposure days, or 30-day infection-related mortality between the 2 groups. The levofloxacin group had a longer mean duration of neutropenia compared with clinician-directed prophylaxis (26.8 days vs 16.4 days, p = 0.01). CONCLUSIONS: There was no difference in bacteremia between levofloxacin prophylaxis and clinician-directed prophylaxis in pediatric patients with acute myeloid leukemia or those undergoing hematopoietic stem cell transplantation. Levofloxacin prophylaxis is an appropriate alternative for the prevention of serious bacterial infections in this patient population, although further studies are needed to confirm these results.

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.

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.

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.

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.

Stopping the routine use of contact precautions for management of MRSA and VRE at three academic medical centers: An interrupted time series analysis.

BACKGROUND: Contact precautions (CP) are a widely adopted strategy to prevent cross-transmission of organisms, commonly methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Some hospitals have discontinued CP for patients with MRSA or VRE; however, the impact on hospital-acquired infection rates (HAI) has not been assessed systematically. METHODS: Retrospective multicenter interrupted time series between 2002 and 2017 at three academic hospitals. Participating hospitals discontinued CP for patients with contained body fluids who were colonized or infected with MRSA or VRE. The primary intervention was stopping the use of CP. Secondary interventions were horizontal infection prevention strategies. The primary outcomes were rates of central line-associated bloodstream infections, catheter-associated urinary tract infections, mediastinal surgical site infection, and ventilator-associated pneumonia due to MRSA, VRE, or any organism using Centers for Disease Control and Prevention National Healthcare Safety Network surveillance definitions. RESULTS: Central line-associated bloodstream infections, catheter-associated urinary tract infections, mediastinal surgical site infection, and ventilator-associated pneumonia rates trended down at each institution. There were no statistically significant increases in these infections associated with discontinuing CP. Individual horizontal infection prevention strategies variably impacted HAI outcomes. CONCLUSIONS: Stopping the routine use of CP for patients with contained body fluids who are colonized or infected with MRSA or VRE did not result in increased HAIs. Bundled horizontal infection prevention strategies resulted in sustained HAI reductions.

Clostridioides difficile nurse driven protocol: A cautionary tale.

In a 12-month study, a nurse driven protocol was implemented at a tertiary academic medical center. The purpose of the nurse driven protocol was to identify community-onset Clostridioides difficile infections, expeditiously isolate patients with presumed C difficile diarrheal illness, and prevent transmission while simultaneously decreasing the incidence of hospital-onset C difficile. The overall adherence to fidelity of the protocol was poor and failed to have a significant impact on infection rates.

The learning hospital: From theory to practice in a hospital infection prevention program.

The learning hospital is distinguished by ceaseless evolution of erudition, enhancement, and implementation of clinical best practices. We describe a model for the learning hospital within the framework of a hospital infection prevention program and argue that a critical assessment of safety practices is possible without significant grant funding. We reviewed 121 peer-reviewed manuscripts published by the VCU Hospital Infection Prevention Program over 16 years. Publications included quasi-experimental studies, observational studies, surveys, interrupted time series analyses, and editorials. We summarized the articles based on their infection prevention focus, and we provide a brief summary of the findings. We also summarized the involvement of nonfaculty learners in these manuscripts as well as the contributions of grant funding. Despite the absence of significant grant funding, infection prevention programs can critically assess safety strategies under the learning hospital framework by leveraging a diverse collaboration of motivated nonfaculty learners. This model is a valuable adjunct to traditional grant-funded efforts in infection prevention science and is part of a successful horizontal infection control program.

Bare below the elbows in an academic medical center.

We investigated the compliance of health care personnel with a voluntary, institution-wide bare below the elbows (BBE) approach to inpatient care at an academic medical center. BBE compliance increased significantly across all provider types over a 2-year period. The overall compliance with BBE by health care personnel nearly doubled from 2016-2017, increasing significantly from 40% to 84%.

Central line-associated bloodstream infections and completion of the central line insertion checklist: A descriptive analysis comparing a dedicated procedure team to other providers.

A primary strategy of central line-associated bloodstream infection (CLABSI) prevention is standardized, aseptic insertion of central lines. We compared hospital-wide CLABSI rate pre- and post-implementation of a dedicated procedure team as well as central line checklist completion and patient-specific variables between the procedure team and other providers. No significant differences were found. Further CLABSI prevention should focus on central line maintenance.

Impact of discontinuation of contact precautions on central-line associated bloodstream infections in an academic children's hospital.

We investigated the impact of discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus infected or colonized patients on central-line associated bloodstream infection rates at an academic children's hospital. Discontinuation of contact precautions with a bundled horizontal infection prevention platform resulted in no adverse impact on CLABSI rates.

Urine test stewardship for catheterized patients in the critical care setting: Provider perceptions and impact of electronic order set interventions.

We implemented an electronic medical record (EMR) decision support tool for ordering urine cultures per evidence-based guidelines. Following the EMR change, we found a significant increase in proportion of cultures ordered for catheterized intensive care unit (ICU) patients meeting guidelines. We surveyed providers and found poor understanding of urine culture guidelines for catheterized ICU patients. EMR-based interventions and educational opportunities have potential to improve urine culture guideline adherence and reduce unnecessary testing and antibiotic use.

You get back what you give: Decreased hospital infections with improvement in CHG bathing, a mathematical modeling and cost analysis.

BACKGROUND: Multiple studies have shown that bathing with chlorhexidine gluconate (CHG) wipes reduces hospital-acquired infections (HAIs). We employed a mathematical model to assess the impact of CHG patient bathing on central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and hospital-onset Clostridium difficile (C diff) infections and the associated costs. METHODS: Using a Markov chain, we examined the effect of CHG bathing compliance on HAI outcomes and the associated costs. Using estimates from 2 different studies on CHG bathing effectiveness for CLABSI, CAUTI, and C diff, the number of HAIs per year were estimated along with associated costs. The simulations were conducted, assuming CHG bathing at varying compliance rates. RESULTS: At 32% reduction in HAI incidence, increasing CHG bathing compliance from 60% to 90% results in 20 averted infections and $815,301.75 saved cost. CONCLUSIONS: As CHG bathing compliance increases, yearly HAIs decrease, and the overall cost associated with the HAIs also decreases.

Pediatric Antimicrobial Stewardship: State of the Art.

PURPOSE OF REVIEW: We aim to systematically review the literature on the effectiveness of pediatric antimicrobial stewardship programs (ASPs) and antimicrobial stewardship (AS) strategies in the United States (US) inpatient setting. Furthermore, we review current gaps and challenges for unique pediatric populations and those in ambulatory settings. RECENT FINDINGS: Misuse and overuse of antimicrobials have been identified as key factors for antimicrobial resistance (AR). Multiple professional organizations support the implementation of hospital-based ASPs to decrease antimicrobial consumption, improve patient outcomes, and reduce healthcare costs. There is limited data on the effectiveness of inpatient pediatric ASPs and AS strategies in unique populations. Furthermore, there is a paucity of evidence on ASPs in ambulatory settings. This review contributes to the growing body of evidence that supports the use of pediatric ASPs to optimize antimicrobial therapy in the inpatient setting as well as in unique patient populations and ambulatory settings. Active stewardship is critical and antimicrobial consumption is a key outcome metric for programs.