Contact Tracing and Exposure Investigation in Response to the First Case of Monkeypox Virus Infection in the United States During the 2022 Global Monkeypox Outbreak.

BACKGROUND: In May 2022, the first case of monkeypox virus (MPXV) infection in the United States in the current global outbreak was identified. As part of the public health and health care facility response, a contact tracing and exposure investigation was done. OBJECTIVE: To describe the contact tracing, exposure identification, risk stratification, administration of postexposure prophylaxis (PEP), and exposure period monitoring for contacts of the index patient, including evaluation of persons who developed symptoms possibly consistent with MPXV infection. DESIGN: Contact tracing and exposure investigation. SETTING: Multiple health care facilities and community settings in Massachusetts. PARTICIPANTS: Persons identified as contacts of the index patient. INTERVENTION: Contact notification, risk stratification, and symptom monitoring; PEP administration in a subset of contacts. MEASUREMENTS: Epidemiologic and clinical data collected through standard surveillance procedures at each facility and then aggregated and analyzed. RESULTS: There were 37 community and 129 health care contacts identified, with 4 at high risk, 49 at intermediate risk, and 113 at low or uncertain risk. Fifteen health care contacts developed symptoms during the monitoring period. Three met criteria for MPXV testing, with negative results. Two community contacts developed symptoms. Neither met criteria for MPXV testing, and neither showed disease progression consistent with monkeypox. Among 4 persons with high-risk exposures offered PEP, 3 elected to receive PEP. Among 10 HCP with intermediate-risk exposures for which PEP was offered as part of informed clinical decision making, 2 elected to receive PEP. No transmissions were identified at the conclusion of the 21-day monitoring period, despite the delay in recognition of monkeypox in the index patient. LIMITATION: Descriptions of exposures are subject to recall bias, which affects risk stratification. CONCLUSION: In a contact tracing investigation involving 166 community and health care contacts of a patient with monkeypox, no secondary cases were identified. PRIMARY FUNDING SOURCE: None.

The Limited Utility of Ranking Hospitals Based on Their Colon Surgery Infection Rates.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) use colon surgical site infection (SSI) rates to rank hospitals and apply financial penalties. The CMS' risk-adjustment model omits potentially impactful variables that might disadvantage hospitals with complex surgical populations. METHODS: We analyzed adult patients who underwent colon surgery within facilities associated with HCA Healthcare from 2014 to 2016. SSIs were identified from National Health Safety Network (NHSN) reporting. We trained and validated 3 SSI prediction models, using (1) current CMS model variables, including hospital-specific random effects (HCA-adapted CMS model); (2) demographics and claims-based comorbidities (expanded-claims model); and (3) demographics, claims-based comorbidities, and NHSN variables (claims-plus-electronic health record [EHR] model). Discrimination, calibration, and resulting rankings were compared among all models and the current CMS model with published coefficient values. RESULTS: We identified 39 468 colon surgeries in 149 hospitals, resulting in 1216 (3.1%) SSIs. Compared to the HCA-adapted CMS model, the expanded-claims model had similar performance (c-statistic, 0.65 vs 0.67, respectively), while the claims-plus-EHR model was more accurate (c-statistic, 0.70; 95% confidence interval, .67-.73; P = .004). The sampling variation, due to the low surgical volume and small number of infections, contributed 74% of the total variation in observed SSI rates between hospitals. When CMS model rankings were compared to those from the expanded-claims and claims-plus-EHR models, 18 (15%) and 26 (22%) hospitals changed quartiles, respectively, and 10 (8.3%) and 12 (10%) hospitals changed into or out of the lowest-performing quartile, respectively. CONCLUSIONS: An expanded set of variables improved colon SSI risk predictions and quartile assignments, but low procedure volumes and SSI events remain a barrier to effectively comparing hospitals.

Evolving Insights Into the Epidemiology and Control of Clostridium difficile in Hospitals.

Typing studies suggest that most cases of hospital-onset Clostridium difficile infection (CDI) are unrelated to other cases of active disease in the hospital. New cases may instead be due to transmissions from asymptomatic carriers or progression of latent C. difficile present on admission to active infection. Direct exposure to antibiotics remains the primary risk factor for CDI but ward-level antibiotic use, antibiotic exposure of the prior room occupant, and C. difficile status of the prior room occupant increase risk for C. difficile acquisition while antibiotic exposure, gastric acid suppression, and immunosuppression increase risk for progression to infection. These insights suggest possible new approaches to prevent CDI, including screening to identify and isolate carriers, universal gloving, greater use of sporicidal cleaning methods, enhancing antibiotic and possibly proton pump inhibitor stewardship, and prescribing prophylactic vancomycin and/or probiotics to colonized patients to prevent progression from colonization to infection. We review current evidence and questions related to these interventions.

Subglottic Secretion Drainage and Objective Outcomes: A Systematic Review and Meta-Analysis.

OBJECTIVE: Current guidelines recommend endotracheal tubes with subglottic secretion drainage to prevent ventilator-associated pneumonia. Subglottic secretion drainage is associated with fewer ventilator-associated pneumonia diagnoses, but it is unclear to what extent this reflects fewer invasive pneumonias versus fewer false-positive diagnoses due to less secretions and/or less microbial colonization of the oropharynx. We, therefore, undertook a systematic review and meta-analysis of the impact of subglottic secretion drainage on duration of mechanical ventilation, ICU and hospital length of stay, ventilator-associated events, mortality, antibiotic utilization, stridor, and reintubations to better understand the net benefits and limitations of this intervention. DATA SOURCES: We searched Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica Database, and PubMed from inception through February 22, 2015, without language restrictions. STUDY SELECTION: Randomized controlled trials comparing subglottic secretion drainage versus no subglottic secretion drainage in adult patients on mechanical ventilation. DATA EXTRACTION: Eligible trials were abstracted and assessed for risk of bias by two reviewers. DATA SYNTHESIS: We identified 17 eligible trials with a total of 3,369 patients. Subglottic secretion drainage was associated with lower ventilator-associated pneumonia rates (risk ratio, 0.58; 95% CI, 0.51-0.67; I2 = 0%), but there were no significant differences between groups in duration of mechanical ventilation (weighted mean difference, -0.16 d; 95% CI, -0.64 to 0.33; I2 = 0%), ICU length of stay (weighted mean difference, +0.17 d; 95% CI, -0.62 to 0.95; I2 = 0%), hospital length of stay (weighted mean difference, -0.57 d; 95% CI, -2.44 to 1.30; I2 = 0%), ventilator-associated events (risk ratio, 0.97; 95% CI, 0.65-1.43), or mortality (risk ratio, 0.93; 95% CI, 0.84-1.03; I2 = 0%). Two studies observed significantly less antibiotic use with subglottic secretion drainage whereas a third did not. There were no significant differences between groups in stridor or reintubations. CONCLUSIONS: Subglottic secretion drainage is associated with lower ventilator-associated pneumonia rates but does not clearly decrease duration of mechanical ventilation, length of stay, ventilator-associated events, mortality, or antibiotic usage. Further data are required to demonstrate the benefits of subglottic secretion drainage.

A Medical Resident-Pharmacist Collaboration Improves the Rate of Medication Reconciliation Verification at Discharge.

BACKGROUND: At the Hospital of the University of Pennsylvania (Philadelphia), it is standard practice to perform medication reconciliation at patient discharge. Although pharmacists historically were available to assist resident physicians in the discharge medication reconciliation process, the process was never standardized. An internal review showed a 60%-70% rate of pharmacist review of discharge medication lists, potentially enabling medication errors to go unnoticed during transitions of care. In response, a medical resident- and pharmacist-led collaboration was designed, and a pre-post-intervention study was conducted to assess its effectiveness. METHODS: A new work flow was established in which house staff notified pharmacists when a preliminary discharge medication list was ready for reconciliation and provided access for pharmacists to correct medication errors in the electronic discharge document with physician approval. Length of stay, average time of day of patient discharge, and readmission data were compared in the pre- and post-intervention periods. RESULTS: There were 981 discharges in the preintervention period and 1,207 in the postintervention period. The rate of pharmacist reconciliation increased from 64.0% to 82.4% after the intervention (p<.0001). The average number of errors identified and corrected by pharmacists decreased from 0.979 to 0.862 per discharge (p<.0001). There was no significant change in readmission rates or time of discharge after the intervention. CONCLUSIONS: Redesigning the discharge medication reconciliation process in a teaching hospital to include a review of medical resident discharge medication lists by pharmacists provided more opportunities for discharge medication error identification and correction.

The Bristol stool scale and its relationship to Clostridium difficile infection.

The Bristol stool form scale classifies the relative density of stool samples. In a prospective cohort study, we investigated the associations between stool density, C. difficile assay positivity, hospital-onset C. difficile infection, complications, and severity of C. difficile. We describe associations between the Bristol score, assay positivity, and clinical C. difficile infection.

Combined laparoscopic and open colon surgery rankings fail to accurately rank hospitals by surgical-site infection rate.

OBJECTIVE: To compare strategies for hospital ranking based on colon surgical-site infection (SSI) rate by combining all colon procedures versus stratifying by surgical approach (ie, laparoscopic vs open). DESIGN: Retrospective cohort study. METHODS: We identified SSIs among Medicare beneficiaries undergoing colon surgery from 2009 through 2013 using previously validated methods. We created a risk prediction model for SSI using age, sex, race, comorbidities, surgical approach (laparoscopy vs open), and concomitant colon and noncolon procedures. Adjusted SSI rates were used to rank hospitals. Subanalyses were performed for common colon procedures and procedure types for which there were both open and laparoscopic procedures. We generated ranks using only open and only laparoscopic procedures, overall and for each subanalysis. Rankings were compared using a Spearman correlation coefficient. RESULTS: In total, 694,813 colon procedures were identified among 508,135 Medicare beneficiaries. The overall SSI rate was 7.6%. The laparoscopic approach was associated with lower SSI risk (OR, 0.5; 95% CI, 0.4-0.5), and higher SSI risk was associated with concomitant abdominal surgeries (OR, 1.4; 95% CI, 1.4-1.5) and higher Elixhauser score (OR, 1.1; 95% CI, 1.0-1.1). Hospital rankings for laparascopic procedures were poorly correlated with rankings for open procedures (r = 0.23). CONCLUSIONS: Hospital rankings based on total colon procedures fail to account for differences in SSI risk from laparoscopic vs open procedures. Stratifying rankings by surgical approach yields a more equitable comparison of surgical performance.

The impact of surgical volume on hospital ranking using the standardized infection ratio.

The Centers for Medicare and Medicaid Services require hospitals to report on quality metrics which are used to financially penalize those that perform in the lowest quartile. Surgical site infections (SSIs) are a critical component of the quality metrics that target healthcare-associated infections. However, the accuracy of such hospital profiling is highly affected by small surgical volumes which lead to a large amount of uncertainty in estimating standardized hospital-specific infection rates. Currently, hospitals with less than one expected SSI are excluded from rankings, but the effectiveness of this exclusion criterion is unknown. Tools that can quantify the classification accuracy and can determine the minimal surgical volume required for a desired level of accuracy are lacking. We investigate the effect of surgical volume on the accuracy of identifying poorly performing hospitals based on the standardized infection ratio and develop simulation-based algorithms for quantifying the classification accuracy. We apply our proposed method to data from HCA Healthcare (2014-2016) on SSIs in colon surgery patients. We estimate that for a procedure like colon surgery with an overall SSI rate of 3%, to rank hospitals in the HCA colon SSI dataset, hospitals that perform less than 200 procedures have a greater than 10% chance of being incorrectly assigned to the worst performing quartile. Minimum surgical volumes and predicted events criteria are required to make evaluating hospitals reliable, and these criteria vary by overall prevalence and between-hospital variability.

The Use of Bronchoscopy During the Coronavirus Disease 2019 Pandemic: CHEST/AABIP Guideline and Expert Panel Report.

BACKGROUND: The coronavirus disease 2019 (COVID-19) has swept the globe and is causing significant morbidity and mortality. Given that the virus is transmitted via droplets, open airway procedures such as bronchoscopy pose a significant risk to health-care workers (HCWs). The goal of this guideline was to examine the current evidence on the role of bronchoscopy during the COVID-19 pandemic and the optimal protection of patients and HCWs. STUDY DESIGN AND METHODS: A group of approved panelists developed key clinical questions by using the Population, Intervention, Comparator, and Outcome (PICO) format that addressed specific topics on bronchoscopy related to COVID-19 infection and transmission. MEDLINE (via PubMed) was systematically searched for relevant literature and references were screened for inclusion. Validated evaluation tools were used to assess the quality of studies and to grade the level of evidence to support each recommendation. When evidence did not exist, suggestions were developed based on consensus using the modified Delphi process. RESULTS: The systematic review and critical analysis of the literature based on six PICO questions resulted in six statements: one evidence-based graded recommendation and 5 ungraded consensus-based statements. INTERPRETATION: The evidence on the role of bronchoscopy during the COVID-19 pandemic is sparse. To maximize protection of patients and HCWs, bronchoscopy should be used sparingly in the evaluation and management of patients with suspected or confirmed COVID-19 infections. In an area where community transmission of COVID-19 infection is present, bronchoscopy should be deferred for nonurgent indications, and if necessary to perform, HCWs should wear personal protective equipment while performing the procedure even on asymptomatic patients.

Association of Open Approach vs Laparoscopic Approach With Risk of Surgical Site Infection After Colon Surgery.

Importance: Colon surgery is associated with a high rate of surgical site infection (SSI), and there is an urgent need for strategies to reduce infection rates. Objective: To assess whether laparoscopic colon surgery is associated with a lower surgical site infection rate than open-approach laparoscopy, especially in patients with medically complex conditions. Design, Setting, and Participants: This cohort study used previously validated diagnosis and procedure codes from Medicare beneficiaries who underwent colon surgery from January 1, 2009, to November 30, 2013. Analyses were performed from August 1 to December 31, 2018. Main Outcomes and Measures: Outcome measures were SSI events, medical comorbidities, and laparoscopic or open approach procedures. Results: A total of 229 726 patients (mean [SD] age, 74.3 [9.4] years; 128 499 [55.9%] female) underwent colon procedures. There were 105 144 laparoscopic procedures and 124 582 open procedures. The overall mean SSI rate was 6.2%, varying by surgical procedure from 5.8% to 7.6%. Among the full study population, adjusted model results showed a significant association of laparoscopy with lower odds of SSI (odds ratio, 0.43; 95% CI, 0.41-0.46; P < .001). When stratified by surgical approach, the mean SSI rates were 4.1% (procedure-specific range, 3.9%-5.1%) for the laparoscopic approach and 7.9% (procedure-specific range, 7.4%-10.2%) for the open approach. When stratified by Elixhauser score groups, the mean SSI rates were 6.2% (procedure-specific range, 3.2%-8.7%) for group 1 (0-1 comorbidity), 5.5% (procedure-specific range, 3.6%-11.1%) for group 2 (2 comorbidities), and 6.6% (procedure-specific range, 4.6%-10.6%) for group 3 (3-13 comorbidities). An interaction was also observed between laparoscopic approach and Elixhauser groups, with increased odds of SSI among patients who had 3 to 13 comorbidities present at the time of the procedure (odds ratio, 1.21; 95% CI, 1.11-1.32) compared with patient groups with fewer comorbidities. The population attributable fraction of SSIs for use of the open approach was 34.2%. A total of 2317 of 3882 hospitals (59.7%) performed few (0%-10%) or most (>50%) procedures laparoscopically. Conclusions and Relevance: Policy changes that promote surgical education and resources for laparoscopy, especially at low-adoption hospitals, may be associated with reduced colon SSI rates. Support of the development of innovative educational policies may help achieve improvement in patient outcomes and decreased health care use in colon surgery.

Oral vancomycin prophylaxis during systemic antibiotic exposure to prevent Clostridiodes difficile infection relapses.

OBJECTIVE: To determine whether oral vancomycin prophylaxis accompanying systemic antibiotics reduces the risk of relapse in patients with history of Clostridioides difficile infection (CDI). DESIGN: Retrospective cohort study. PATIENTS: Adult inpatients with a history of CDI who received systemic antibiotics in either of 2 hospitals between January 2009 and June 2015. METHODS: We compared relapse rates in patients who started oral vancomycin concurrently with systemic antibiotics (exposed group) versus those who did not. We assessed for CDI relapse by toxin or nucleic acid testing at 90 days. We used inverse probability weighting and machine learning to adjust for confounders, to estimate propensity for treatment, and to calculate odds ratios for CDI relapse. We performed secondary analyses limited to toxin-positive relapses, patients with 1 versus >1 prior CDI episodes, and patients who received oral vancomycin on each antibiotic day. RESULTS: CDI relapse occurred within 90 days in 19 of 193 exposed patients (9.8%) versus 53 of 567 unexposed patients (9.4%; unadjusted odds ratio [OR], 1.06; 95% confidence interval [CI], 0.60-1.81; adjusted OR, 0.63; 95% CI, 0.35-1.14). CDI relapses at 90 days were less frequent in exposed patients with only 1 prior episode of CDI (OR, 0.42; 95% CI, 0.19-0.93) but not in those with >1 prior episode (OR, 1.19; 95% CI, 0.42-3.33). Our findings were consistent with a lack of benefit of oral vancomycin when restricting results to toxin-positive relapses and to patients who received vancomycin each antibiotic day. CONCLUSIONS: Prophylactic oral vancomycin was not consistently associated with reduced risk of CDI relapse among hospitalized patients receiving systemic antibiotics. However, patients with only 1 prior CDI episode may benefit.

The Relationship Between Sedatives, Sedative Strategy, and Healthcare-Associated Infection: A Systematic Review.

BACKGROUND Healthcare-associated infections (HAIs) cause significant morbidity in critically ill patients. An underappreciated but potentially modifiable risk factor for infection is sedation strategy. Recent trials suggest that choice of sedative agent, depth of sedation, and sedative management can influence HAI risk in mechanically ventilated patients. OBJECTIVE To better characterize the relationships between sedation strategies and infection. METHODS Systematic literature review. RESULTS We found 500 articles and accepted 70 for review. The 3 most common sedatives for mechanically ventilated patients (benzodiazepines, propofol, and dexmedetomidine) have different pharmacologic and immunomodulatory effects that may impact infection risk. Clinical data are limited but retrospective observational series have found associations between sedative use and pneumonia whereas prospective studies of sedative interruptions have reported possible decreases in bloodstream infections, pneumonia, and ventilator-associated events. CONCLUSION Infection rates appear to be highest with benzodiazepines, intermediate with propofol, and lowest with dexmedetomidine. More data are needed but studies thus far suggest that a better understanding of sedation practices and infection risk may help hospital epidemiologists and critical care practitioners find new ways to mitigate infection risk in critically ill patients. Infect Control Hosp Epidemiol 2016;1-9.

Catheter salvage in home infusion patients with central line-associated bloodstream infection.

In a retrospective study of home infusion patients with central line-associated bloodstream infection, use of a central venous port, cancer diagnosis, and absence of systemic inflammatory response syndrome were associated with use of catheter salvage. Relapse of infection was uncommon.