Lowering the Acquisition of Multi-drug Resistant Organism (MDROs) with Pulsed-xenon (LAMP) Study: a cluster randomized controlled, double-blinded, interventional crossover trial.

BACKGROUND: Environmental disinfection is essential for reducing spread of healthcare associated infections (HAIs). Previous studies report conflicting results regarding the effects of ultraviolet light (UV) in reducing infections. This trial evaluated the impact of adding pulsed xenon UV (PX-UV) to standard terminal cleaning in reducing environmentally-implicated HAIs (eiHAIs). METHODS: The LAMP trial was conducted in 2 hospitals (15 inpatient wards) utilizing a cluster randomized controlled, double-blinded, interventional crossover trial comparing standard terminal cleaning followed by either pulsed xenon ultraviolet (PX-UV) disinfection (intervention arm) or sham disinfection (control arm). The primary outcome was incidence of eiHAIs from clinical microbiology tests on the 4th day of stay or later or within 3 days after discharge from the study unit. EiHAIs included clinical cultures positive for vancomycin-resistant enterococci (VRE), extended spectrum beta-lactamase-producing Escherichia coli or Klebsiella pneumonia, methicillin-resistant Staphylococcus aureus (MRSA), and Acinetobacter baumannii, and stool PCR positive for Clostridiodes difficile. FINDINGS: Between May 18, 2017 to Jan 7, 2020, 25,732 patients were included, with an incidence of 601 eiHAI and 180,954 patient days. There was no difference in the rate of eiHAIs in the intervention and sham arms (3.49 vs 3.17 infections/1000 patient days respectively, RR 1.10 CI (0.94, 1.29, p= 0.23)). Study results were similar when stratified by eiHAI type, hospital, and unit type. CONCLUSION: The LAMP study failed to demonstrate an effect of the addition of UV light disinfection following terminal cleaning on reductions in rates of eiHAIs. Further investigations targeting hospital environmental surfaces and the role of no touch technology to reduce HAIs are needed.

Case of Extensively Drug-Resistant Shigella sonnei Infection, United States.

We report extensively drug-resistant (XDR) Shigella sonnei infection in an immunocompromised patient in Texas, USA. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry failed to identify XDR Shigella, but whole-genome sequencing accurately characterized the strain. First-line antimicrobials are not effective against emerging XDR Shigella. Fosfomycin, carbapenems, and tigecycline are potential alternatives.

Using a handheld UV device for disinfection in the patient care environment: A descriptive qualitative study.

Frontline nurses play a critical role in the prevention of healthcare-acquired infections (HAIs) through daily practices of hand hygiene and decontamination of surfaces. Despite these practices, environmental contamination and HAIs persist. Emerging use of UV light at wavelengths safe for human exposure provides additional strategies for disinfecting the patient care environment. The purpose of this qualitative study is to explore frontline nursing feedback regarding a novel handheld UV device prototype. A convenience sample of nurses were invited to participate in facilitated individual or small group discussions led by one member of the research team. Thematic analysis of discussion transcripts was completed by two members of the research team. Sixteen registered nurses participated. Four themes found in the study were time considerations, complexity, safety (patient and nurse), and characteristics of technology to improve patient care. Findings suggest that while nursing staff are willing to use technology, it must be considered valuable to patient care and should not hinder the provision of care. Inclusion of inputs from nursing staff for development of technology identifies potential barriers to acceptance and use in the practice environment.

Reactive High-Valent Iron Intermediates in Enhancing Treatment of Water by Ferrate.

Efforts are being made to tune the reactivity of the tetraoxy anion of iron in the +6 oxidation state (FeVIO42-), commonly called ferrate, to further enhance its applications in various environmental fields. This review critically examines the strategies to generate highly reactive high-valent iron intermediates, FeVO43- (FeV) and FeIVO44- or FeIVO32- (FeIV) species, from FeVIO42-, for the treatment of polluted water with greater efficiency. Approaches to produce FeV and FeIV species from FeVIO42- include additions of acid (e.g., HCl), metal ions (e.g., Fe(III)), and reductants (R). Details on applying various inorganic reductants (R) to generate FeV and FeIV from FeVIO42- via initial single electron-transfer (SET) and oxygen-atom transfer (OAT) to oxidize recalcitrant pollutants are presented. The common constituents of urine (e.g., carbonate, ammonia, and creatinine) and different solids (e.g., silica and hydrochar) were found to accelerate the oxidation of pharmaceuticals by FeVIO42-, with potential mechanisms provided. The challenges of providing direct evidence of the formation of FeV/FeIV species are discussed. Kinetic modeling and density functional theory (DFT) calculations provide opportunities to distinguish between the two intermediates (i.e., FeIV and FeV) in order to enhance oxidation reactions utilizing FeVIO42-. Further mechanistic elucidation of activated ferrate systems is vital to achieve high efficiency in oxidizing emerging pollutants in various aqueous streams.

Factors That Affect Legionella Positivity in Healthcare Building Water Systems from a Large, National Environmental Surveillance Initiative.

Legionella growth in healthcare building water systems can result in legionellosis, making water management programs (WMPs) important for patient safety. However, knowledge is limited on Legionella prevalence in healthcare buildings. A dataset of quarterly water testing in Veterans Health Administration (VHA) healthcare buildings was used to examine national environmental Legionella prevalence from 2015 to 2018. Bayesian hierarchical logistic regression modeling assessed factors influencing Legionella positivity. The master dataset included 201,146 water samples from 814 buildings at 168 VHA campuses. Overall Legionella positivity over the 4 years decreased from 7.2 to 5.1%, with the odds of a Legionella-positive sample being 0.94 (0.90-0.97) times the odds of a positive sample in the previous quarter for the 16 quarters of the 4 year period. Positivity varied considerably more at the medical center campus level compared to regional levels or to the building level where controls are typically applied. We found higher odds of Legionella detection in older buildings (OR 0.92 [0.86-0.98] for each more recent decade of construction), in taller buildings (OR 1.20 [1.13-1.27] for each additional floor), in hot water samples (O.R. 1.21 [1.16-1.27]), and in samples with lower residual biocide concentrations. This comprehensive healthcare building review showed reduced Legionella detection in the VHA healthcare system over time. Insights into factors associated with Legionella positivity provide information for healthcare systems implementing WMPs and for organizations setting standards and regulations.

The viral phoenix: enhanced infectivity and immunity evasion of SARS-CoV-2 variants.

SARS-CoV-2 pandemic continues with emergence of new variants of concerns. These variants are fueling the third and fourth waves of pandemic across many nations. Here we describe the new emerging variants of SARS-CoV-2 and why they have enhanced infectivity and possess the ability to evade immunity.

Frontline Nurse Feedback During the Development of a System to Track Cleaning of Portable Medical Equipment.

As part of the development and testing of an innovative technology for tracking disinfection of portable medical equipment, end-user feedback was obtained during an initial trial on two acute care hospital units. The disinfection tracking device was installed on the computers-on-wheels and vital signs machines. Each device had the capability of detecting a cleaning event, reporting the event to an online database, and displaying the time since last cleaning event on a visual display. End-user feedback regarding functionality, usefulness of information provided, and impact on workflow was obtained by survey and facilitated group discussions. Seventeen frontline nurses completed the anonymous survey, and 22 participated in the facilitated group discussions. End users found the system functionally easy to use and the information about time since last cleaning useful and reported minimum disruption of workflow. Functionality of the system was confirmed by consistency between recorded and self-reported cleaning patterns. Managers found the data on cleaning of portable medical equipment helpful in validating compliance with hospital equipment cleaning policy. Frontline staff expressed appreciation for technology that helps them and improves outcomes but also discussed concerns about the potential for technology that creates extra work and disruption in the busy frontline nursing care delivery environment. Nurses were appreciative of opportunities to provide feedback and input into efforts to develop and introduce technology. Recorded cleaning events coincided with self-reported equipment cleaning patterns and illustrated that the device efficiently collects information deemed useful by the end user.

Asynchronous Testing of 2 Specimen-Diversion Devices to Reduce Blood Culture Contamination: A Single-Site Product Supply Quality Improvement Project.

OBJECTIVE: Blood culture contamination above the national threshold has been a consistent clinical issue in the ED setting. Two commercially available devices were examined that divert an initial small volume of the specimen before the collection of blood culture to reduce skin contamination. METHODS: Prospectively, 2 different blood culture-diversion devices were made available in the unit supplies to ED clinicians at a single site during 2 different periods of time as a follow-up strategy to an ongoing quality improvement project. Blood samples were collected in the emergency department over a period of 16 months. A retrospective record review study was conducted comparing the use of the 2 specimen-diversion devices with no device (control group) for blood culture contamination rates. The main outcome of monthly blood culture contamination per device was tested using a Bayesian Poisson multilevel regression model. RESULTS: A total of 4030 blood samples were collected and analyzed from November 2017 to February 2019. The model estimated that the mean incidence of contaminated blood draws in the device A group was 0.29 (0.14-0.55) times the incidence of contaminated draws in the control group. The mean incidence of contaminated blood draws in the device B group was 0.23 (0.13-0.37) times the incidence of contaminated draws in the control group, suggesting that initial-diversion methods reduced blood culture contamination. CONCLUSION: Initial specimen-diversion devices supplement present standard phlebotomy protocols to bring down the blood culture contamination rate.

Classical and alternative disinfection strategies to control the COVID-19 virus in healthcare facilities: a review.

The coronavirus disease COVID-19 has spread throughout the world and has been declared as a pandemic by the World Health Organization on March 11th, 2020. The COVID-19 is caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). One possible mode of virus transmission is through surfaces in the healthcare settings. This paper reviews currently used disinfection strategies to control SARS-CoV-2 at the healthcare facilities. Chemical disinfectants include hypochlorite, peroxymonosulfate, alcohols, quaternary ammonium compounds, and hydrogen peroxide. Advanced strategies include no-touch techniques such as engineered antimicrobial surfaces and automated room disinfection systems using hydrogen peroxide vapor or ultraviolet light.

Current understanding of the surface contamination and contact transmission of SARS-CoV-2 in healthcare settings.

The novel coronavirus disease (COVID-19) has rapidly spread across the world and was subsequently declared as a pandemic in 2020. To overcome this public health challenge, comprehensive understanding of the disease transmission is urgently needed. Recent evidences suggest that the most common route of transmission for SARS-CoV-2 is likely via droplet, aerosol, or direct contact in a person-to-person encounter, although the possibility of transmission via fomites from surfaces cannot be ruled out entirely. Environmental contamination in COVID-19 patient rooms is widely observed due to viral shedding from both asymptomatic and symptomatic patients, and SARS-CoV-2 can survive on hospital surfaces for extended periods. Sequence of contact events can spread the virus from one surface to the other in a hospital setting. Here, we review the studies related to viral shedding by COVID-19 patients that can contaminate surfaces and survival of SARS-CoV-2 on different types of surfaces commonly found in healthcare settings, as well as evaluating the importance of surface to person transmission characteristics. Based on recent evidences from the literature, decontamination of hospital surfaces should constitute an important part of the infection control and prevention of COVID-19.

Are Many Patients Diagnosed With Healthcare-associated Clostridioides difficile Infections Colonized With the Infecting Strain on Admission?

In a cohort of 480 patients admitted to an acute care hospital, 68 (14%) had positive perirectal cultures for toxigenic Clostridioides difficile on admission. Of the 11 patients (2%) diagnosed with healthcare-associated C. difficile infections, 3 (27%) had genetically related admission and infection isolates, based on whole-genome sequencing.

Increased HCV Screening Yields Discordant Gains in Diagnoses Among Urban and Rural Veteran Populations in Texas: Results of a Statewide Quality Improvement Initiative.

BACKGROUND: Chronic hepatitis C virus (HCV) infection is a significant health burden among military veterans. Our goals were to increase monthly HCV screenings, diagnoses, and sustained virologic responses (SVR) among 88,652 unscreened birth cohort Veterans in Texas. METHODS: The interventions were enabled within six of the eight healthcare systems (HCSs) that compose Veteran's Integrated Service Network 17. The remaining two HCSs served as controls. The HCSs were separated into two groups: urban and rural; each composed of a control and three interventional HCSs. Decision support programming was embedded within the Computerized Patient Record System that prompted HCV screening among previously unscreened birth cohort patients. Clinical process design and educational efforts were enacted to enhance treatment capacity. RESULTS: Monthly screenings increased 4.89 times (p < 0.001) and 2.97 times (p < 0.001) during the postinterventional period relative to control for urban and rural HCSs, respectively. For urban HCSs, diagnoses increased 1.58 (p < 0.001) times more than the control group during the postinterventional period, but there was no difference in number of diagnoses in the rural HCSs (p = 0.86). Monthly SVR increased 2.69 times more than the control group during the postinterventional period (p < 0.001). CONCLUSION: Decision support improved HCV screening among birth cohort patients in both urban and rural HCSs. Increased screening boosted the monthly number of diagnoses in the urban HCSs, but not in the rural HCSs; which rebuts the utility of birth cohort screening among rurally residing veterans. These interventions significantly improved the rate of SVR achievement relative to control.

Accelerated Oxidation of Organic Contaminants by Ferrate(VI): The Overlooked Role of Reducing Additives.

This paper presents an accelerated ferrate(VI) (FeVIO42-, FeVI) oxidation of contaminants in 30 s by adding one-electron and two-electron transfer reductants (R(1) and R(2)). An addition of R(2) (e.g., NH2OH, AsIII, SeIV, PIII, and NO2-, and S2O32-) results in FeIV initially, while FeV is generated with the addition of R(1) (e.g., SO32-). R(2) additives, except S2O32-, show the enhanced oxidation of 20-40% of target contaminant, trimethoprim (TMP). Comparatively, enhanced oxidation of TMP was up to 100% with the addition of R(1) to FeVI. Interestingly, addition of S2O32- (i.e., R(2)) also achieves the enhanced oxidation to 100%. Removal efficiency of TMP depends on the molar ratio ([R(1)]:[FeVI] or [R(2)]:[FeVI]). Most of the reductants have the highest removal at molar ratio of ∼0.125. A FeVI-S2O32- system also oxidizes rapidly a wide range of organic contaminants (pharmaceuticals, pesticides, artificial sweetener, and X-ray contrast media) in water and real water matrices. FeV and FeIV as the oxidative species in the FeVI-S2O32--contaminant system are elucidated by determining removal of contaminants in oxygenated and deoxygenated water, applying probing agent, and identifying oxidized products of TMP and sulfadimethoxine (SDM) by FeVI-S2O32- systems. Significantly, elimination of SO2 from sulfonamide (i.e., SDM) is observed for the first time.

Interaction of healthcare worker hands and portable medical equipment: a sequence analysis to show potential transmission opportunities.

BACKGROUND: While research has demonstrated the importance of a clean health care environment, there is a lack of research on the role portable medical equipment (PME) play in the transmission cycle of healthcare-acquired infections (HAIs). This study investigated the patterns and sequence of contact events among health care workers, patients, surfaces, and medical equipment in a hospital environment. METHODS: Research staff observed patient care events over six different 24 h periods on six different hospital units. Each encounter was recorded as a sequence of events and analyzed using sequence analysis and visually represented by network plots. In addition, a point prevalence microbial sample was taken from the computer on wheels (COW). RESULTS: The most touched items during patient care was the individual patient (850), bedrail (375), bed-surface (302), and bed side Table (223). Three of the top ten most common subsequences included touching PME and the patient: computer on wheels ➔ patient (62 of 274 total sequences, 22.6%, contained this sequence), patient ➔ COW (20.4%), and patient ➔ IV pump (16.1%). The network plots revealed large interconnectedness among objects in the room, the patient, PME, and the healthcare worker. CONCLUSIONS: Our results demonstrated that PME such as COW and IV pump were two of the most highly-touched items during patient care. Even with proper hand sanitization and personal protective equipment, this sequence analysis reveals the potential for contamination from the patient and environment, to a vector such as portable medical equipment, and ultimately to another patient in the hospital.

Evaluation of a pulsed-xenon ultraviolet room disinfection device for impact on contamination levels of methicillin-resistant Staphylococcus aureus.

BACKGROUND: Healthcare-acquired infections with methicillin-resistant Staphylococcus aureus (MRSA) are a significant cause of increased mortality, morbidity and additional health care costs in United States. Surface decontamination technologies that utilize pulsed xenon ultraviolet light (PPX-UV) may be effective at reducing microbial burden. The purpose of this study was to compare standard manual room-cleaning to PPX-UV disinfection technology for MRSA and bacterial heterotrophic plate counts (HPC) on high-touch surfaces in patient rooms. METHODS: Rooms vacated by patients that had a MRSA-positive polymerase chain reaction or culture during the current hospitalization and at least a 2-day stay were studied. 20 rooms were then treated according to one of two protocols: standard manual cleaning or PPX-UV. This study evaluated the reduction of MRSA and HPC taken from five high-touch surfaces in rooms vacated by MRSA-positive patients, as a function of cleaning by standard manual methods vs a PPX-UV area disinfection device. RESULTS: Colony counts in 20 rooms (10 per arm) prior to cleaning varied by cleaning protocol: for HPC, manual (mean = 255, median = 278, q1-q3 132-304) vs PPX-UV (mean = 449, median = 365, q1-q3 332-530), and for MRSA, manual (mean = 127; median = 28.5; q1-q3 8-143) vs PPX-UV (mean = 108; median = 123; q1-q3 14-183). PPX-UV was superior to manual cleaning for MRSA (adjusted incident rate ratio [IRR] = 7; 95% CI <1-41) and for HPC (IRR = 13; 95% CI 4-48). CONCLUSION: PPX-UV technology appears to be superior to manual cleaning alone for MRSA and HPC. Incorporating 15 minutes of PPX-UV exposure time to current hospital room cleaning practice can improve the overall cleanliness of patient rooms with respect to selected micro-organisms.

Risk of Hepatitis B Reactivation in Patients Receiving Ibrutinib: The National Veterans Affairs Cohort.

Background: Ibrutinib has been a first-line treatment for chronic lymphocytic leukemia since 2014. Case reports of hepatitis B virus (HBV) reactivation after ibrutinib initiation have been presented. The association between the risk of HBV reactivation and ibrutinib initiation remains unclear. This nationwide study aimed to estimate the incidence of HBV reactivation after ibrutinib initiation. Method: This study included patients who received ibrutinib between 1 February 2014 and 31 October 2019. Possible reactivations were searched by (1) changes in HBV surface antigen or HBV DNA from no data or negative status to positive after ibrutinib initiation, (2) alanine aminotransferase levels that were at least 3 times the baseline value after ibrutinib initiation, and (3) new antiviral prescriptions against HBV after ibrutinib initiation. Individual chart reviews were conducted to identify HBV reactivation attributed to ibrutinib. The cumulative incidence of HBV reactivation was calculated. Results: A total 4130 patients were eligible during the study period. Of these, patients with negative HBV core antibody (anti-HBcAb; n = 1670) and patients who were taking antivirals against HBV (n = 60) were excluded. There were 2219 patients without anti-HBcAb testing results. Among the remaining 181 patients with positive anti-HBcAb, 7 HBV reactivations were directly attributable to ibrutinib treatment after chart review, for a 3.9% cumulative incidence. Conclusions: Our study revealed a low cumulative incidence of HBV reactivation after ibrutinib initiation among patients with previous anti-HBcAb positivity, indicating a moderate risk of HBV reactivation.

Evolution of a Distinct SARS-CoV-2 Lineage Identified during an Investigation of a Hospital Outbreak.

The SARS-CoV-2 virus steadily evolves, and numerous antigenically distinct variants have emerged over the past three years. Tracking the evolution of the virus would help us understand the process that generates the diverse variants and predict the future evolutionary trajectory of SARS-CoV-2. Here, we report the evolutionary trajectory of a unique Omicron lineage identified during an outbreak investigation that occurred in a residence unit in the healthcare system. The new lineage had four distinct non-synonymous and two distinct synonymous mutations apart from its parental lineage. Since this lineage of virus was exclusively found during the outbreak, we were able to track the detailed evolutionary history of the entire lineage along the transmission path. Furthermore, we estimated the evolutionary rate of the SARS-CoV-2 Omicron variant from the analysis of the evolution of the lineage. This new Omicron sub-lineage acquired 3 mutations in a 12-day period, and the evolutionary rate was estimated as 3.05 × 10-3 subs/site/year. This study provides more insight into an ever-evolving virus.