Preparation of Patients for Central Venous Catheter Care in the Home: Perspectives From Health Care Personnel.

Patients managing central venous catheters (CVCs) outside of hospitals need training in CVC care. Using 3 focus groups, the study identified themes in how health care personnel (HCP) prepare patients and their caregivers for CVC care at home. Four major themes and 25 nested subthemes were identified: (1) providing the right amount of education at the right time, (2) tailoring education to patient needs, (3) developing patient education tools, and (4) managing differences in recommendations to patients. HCPs in the study ensured patients and caregivers learn what they need to know when they need to know it, using appropriate patient education tools. Patients and caregivers are largely responsible for CVC care and central line-associated bloodstream infection prevention outside of acute care hospitals and long-term care settings, and HCP take seriously their obligation to provide them with appropriate education and tools to best enhance their ability to keep themselves safe.

Discordant performance of mpox serological assays.

BACKGROUND: Since July 23, 2022, global mpox cases reached 92,546, with over 31,000 in the United States. Asymptomatic carriage is a critical mechanism influencing the global dissemination of mpox. Seroprevalence studies are crucial for determining the epidemic's true burden, but uncertainties persist in serologic assay performance and how smallpox vaccination may influence assay interpretation. OBJECTIVES: Our study aimed to assess the performance of several diagnostic assays among mpox-positive, vaccinated, and pre-outbreak negative control samples. This investigation sought to enhance our understanding and management of future mpox outbreaks. STUDY DESIGN: Serum samples from 10 mpox-positive, five vaccinated uninfected, and 137 pre-outbreak controls were obtained for serological testing. The mpox-positive samples were obtained around 100 days post symptom onset, and vaccinated patients were sampled approximately 90 days post-vaccination. Multiple diagnostic assays were employed, including four commercial ELISAs (Abbexa, RayBioTech, FineTest, ProteoGenix) and a multiplex assay (MesoScale Diagnostics (MSD)) measuring five mpox and five smallpox antigens. RESULTS: Three commercial ELISA kits had low specificity (<50 %). The Proteogenix ELISA targeting the E8L antigen had a 94 % sensitivity and 87 % specificity. The E8L antigen on the MSD assay exhibited the greatest distinction between exposure groups, with 98 % sensitivity and 93 % specificity. CONCLUSIONS: None of the assays could distinguish between mpox-positive and vaccinated samples. The MSD assay targeting the MPXV E8L antigen demonstrated the greatest differentiation between mpox-positive and pre-outbreak negative samples. Our findings underscore the imperative to identify sensitive and specific assays to monitor population-level mpox exposure and infection.

Characterizing Patients Presenting on Hospital Admission With Central Line-Associated Bloodstream Infections: A Multicenter Study.

BACKGROUND: There are no systematic measures of central line-associated bloodstream infections (CLABSIs) in patients maintaining central venous catheters (CVCs) outside acute care hospitals. To clarify the burden of CLABSIs in these patients, we characterized patients with CLABSI present on hospital admission (POA). METHODS: Retrospective cross-sectional analysis of patients with CLABSI-POA in 3 health systems covering 11 hospitals across Maryland, Washington DC, and Missouri from November 2020 to October 2021. CLABSI-POA was defined using an adaptation of the acute care CLABSI definition. Patient demographics, clinical characteristics, and outcomes were collected via record review. Cox proportional hazard analysis was used to assess factors associated with the all-cause mortality rate within 30 days. RESULTS: A total of 461 patients were identified as having CLABSI-POA. CVCs were most commonly maintained in home infusion therapy (32.8%) or oncology clinics (31.2%). Enterobacterales were the most common etiologic agent (29.2%). Recurrent CLABSIs occurred in a quarter of patients (25%). Eleven percent of patients died during the hospital admission. Among patients with CLABSI-POA, mortality risk increased with age (hazard ratio vs age <20 years by age group: 20-44 years, 11.2 [95% confidence interval, 1.46-86.22]; 45-64 years, 20.88 [2.84-153.58]; ≥65 years, 22.50 [2.98-169.93]) and lack of insurance (2.46 [1.08-5.59]), and it decreased with CVC removal (0.57 [.39-.84]). CONCLUSIONS: CLABSI-POA is associated with significant in-hospital mortality risk. Surveillance is required to understand the burden of CLABSI in the community to identify targets for CLABSI prevention initiatives outside acute care settings.

Orthopoxvirus-Specific T-Cell Responses in Convalescent Mpox Patients.

Orthopoxvirus-specific T-cell responses were analyzed in 10 patients who had recovered from Mpox including 7 people with human immunodeficiency virus (PWH). Eight participants had detectable virus-specific T-cell responses, including a PWH who was not on antiretroviral therapy and a PWH on immunosuppressive therapy. These 2 participants had robust polyfunctional CD4+ T-cell responses to peptides from the 121L vaccinia virus (VACV) protein. T-cells from 4 of 5 HLA-A2-positive participants targeted at least 1 previously described HLA-A2-restricted VACV epitope, including an epitope targeted in 2 participants. These results advance our understanding of immunity in convalescent Mpox patients.

A Bundle of the Top 10 OPAT Publications in 2022.

Outpatient parenteral antimicrobial therapy (OPAT) has become more common in clinical settings. Correspondingly, OPAT-related publications have also increased; the objective of this article was to summarize clinically meaningful OPAT-related publications in 2022. Seventy-five articles were initially identified, with 54 being scored. The top 20 OPAT articles published in 2022 were reviewed by a group of multidisciplinary OPAT clinicians. This article provides a summary of the "top 10" OPAT publications of 2022.

Controlling the chaos: Information management in home-infusion central-line-associated bloodstream infection (CLABSI) surveillance.

Objectives: Access to patient information may affect how home-infusion surveillance staff identify central-line-associated bloodstream infections (CLABSIs). We characterized information hazards in home-infusion CLABSI surveillance and identified possible strategies to mitigate information hazards. Design: Qualitative study using semistructured interviews. Setting and participants: The study included 21 clinical staff members involved in CLABSI surveillance at 5 large home-infusion agencies covering 13 states and the District of Columbia. Methods: Interviews were conducted by 1 researcher. Transcripts were coded by 2 researchers; consensus was reached by discussion. Results: Data revealed the following barriers: information overload, information underload, information scatter, information conflict, and erroneous information. Respondents identified 5 strategies to mitigate information chaos: (1) engage information technology in developing reports; (2) develop streamlined processes for acquiring and sharing data among staff; (3) enable staff access to hospital electronic health records; (4) use a single, validated, home-infusion CLABSI surveillance definition; and (5) develop relationships between home-infusion surveillance staff and inpatient healthcare workers. Conclusions: Information chaos occurs in home-infusion CLABSI surveillance and may affect the development of accurate CLABSI rates in home-infusion therapy. Implementing strategies to minimize information chaos will enhance intra- and interteam collaborations in addition to improving patient-related outcomes.

Implementing and validating a home-infusion central-line-associated bloodstream infection surveillance definition.

OBJECTIVE: Central-line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy is necessary to track efforts to reduce infections, but a standardized, validated, and feasible definition is lacking. We tested the validity of a home-infusion CLABSI surveillance definition and the feasibility and acceptability of its implementation. DESIGN: Mixed-methods study including validation of CLABSI cases and semistructured interviews with staff applying these approaches. SETTING: This study was conducted in 5 large home-infusion agencies in a CLABSI prevention collaborative across 14 states and the District of Columbia. PARTICIPANTS: Staff performing home-infusion CLABSI surveillance. METHODS: From May 2021 to May 2022, agencies implemented a home-infusion CLABSI surveillance definition, using 3 approaches to secondary bloodstream infections (BSIs): National Healthcare Safety Program (NHSN) criteria, modified NHSN criteria (only applying the 4 most common NHSN-defined secondary BSIs), and all home-infusion-onset bacteremia (HiOB). Data on all positive blood cultures were sent to an infection preventionist for validation. Surveillance staff underwent semistructured interviews focused on their perceptions of the definition 1 and 3-4 months after implementation. RESULTS: Interrater reliability scores overall ranged from κ = 0.65 for the modified NHSN criteria to κ = 0.68 for the NHSN criteria to κ = 0.72 for the HiOB criteria. For the NHSN criteria, the agency-determined rate was 0.21 per 1,000 central-line (CL) days, and the validator-determined rate was 0.20 per 1,000 CL days. Overall, implementing a standardized definition was thought to be a positive change that would be generalizable and feasible though time-consuming and labor intensive. CONCLUSIONS: The home-infusion CLABSI surveillance definition was valid and feasible to implement.

Infection prevention and antibiotic stewardship program needs and practices in 2021: A survey of the Society for Healthcare Epidemiology of America Research Network.

In total, 50 healthcare facilities completed a survey in 2021 to characterize changes in infection prevention and control and antibiotic stewardship practices. Notable findings include sustained surveillance for multidrug-resistant organisms but decreased use of human resource-intensive interventions compared to previous surveys in 2013 and 2018 conducted prior to the COVID-19 pandemic.

The need to expand the infection prevention workforce in home infusion therapy.

Infection prevention and surveillance training approaches for home infusion therapy have not been well defined. We interviewed home infusion staff who perform surveillance activities about barriers to and facilitators for central line-associated bloodstream infection (CLABSI) surveillance and identified barriers to training in CLABSI surveillance. Our findings show a lack of formal surveillance training for staff. This gap can be addressed by adapting existing training resources to the home infusion setting.

Duration of antibiotics through care transitions: A quality improvement initiative.

Antibiotic resistance is increasing worldwide and can be largely attributed to excess antibiotic use. At our institution, 75% of patients were prescribed excess antibiotic days and total duration of therapy was appropriate in only 24.5% of cases per the reviewers. Choice of antibiotic was appropriate in 70.4% of cases.

A framework for implementing antibiotic stewardship in ambulatory care: Lessons learned from the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use.

Antibiotic overuse is common in ambulatory care settings, underscoring the importance of outpatient antibiotic stewardship to ensure safe and effective antibiotic prescription. In response to this need, the Agency for Healthcare Research and Quality (AHRQ) developed the AHRQ Safety Program for Improving Antibiotic Use in Ambulatory Care. The Safety Program successfully assisted 389 outpatient practices across the United States to establish ambulatory antibiotic stewardship. Herein, we have used lessons learned from the AHRQ Safety Program to describe a step-by-step framework to assist practices with establishing antibiotic stewardship in the outpatient setting. Steps include obtaining support from practice leadership; establishing an antibiotic stewardship team; garnering support from practice members; determining how to access antibiotic prescribing data; building communication skills around antibiotic use in the practice; implementing educational content around an infectious syndrome; monitoring antibiotic prescription data; and implementing a sustainability plan.

Assessment of Changes in Visits and Antibiotic Prescribing During the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use and the COVID-19 Pandemic.

Importance: The Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use aimed to improve antibiotic prescribing in ambulatory care practices by engaging clinicians and staff to incorporate antibiotic stewardship into practice culture, communication, and decision-making. Little is known about implementation of antibiotic stewardship in ambulatory care practices. Objective: To examine changes in visits and antibiotic prescribing during the AHRQ Safety Program. Design, Setting, and Participants: This cohort study evaluated a quality improvement intervention in ambulatory care throughout the US in 389 ambulatory care practices from December 1, 2019, to November 30, 2020. Exposures: The AHRQ Safety Program used webinars, audio presentations, educational tools, and office hours to engage stewardship leaders and clinical staff to address attitudes and cultures that challenge judicious antibiotic prescribing and incorporate best practices for the management of common infections. Main Outcomes and Measures: The primary outcome of the Safety Program was antibiotic prescriptions per 100 acute respiratory infection (ARI) visits. Data on total visits and ARI visits were also collected. The number of visits and prescribing rates from baseline (September 1, 2019) to completion of the program (November 30, 2020) were compared. Results: Of 467 practices enrolled, 389 (83%) completed the Safety Program; of these, 292 (75%) submitted complete data with 6 590 485 visits to 5483 clinicians. Participants included 82 (28%) primary care practices, 103 (35%) urgent care practices, 34 (12%) federally supported practices, 39 (13%) pediatric urgent care practices, 21 (7%) pediatric-only practices, and 14 (5%) other practice types. Visits per practice per month decreased from a mean of 1624 (95% CI, 1317-1931) at baseline to a nadir of 906 (95% CI, 702-1111) early in the COVID-19 pandemic (April 2020), and were 1797 (95% CI, 1510-2084) at the end of the program. Total antibiotic prescribing decreased from 18.2% of visits at baseline to 9.5% at completion of the program (-8.7%; 95% CI, -9.9% to -7.6%). Acute respiratory infection visits per practice per month decreased from baseline (n = 321) to a nadir of 76 early in the pandemic (May 2020) and gradually increased through completion of the program (n = 239). Antibiotic prescribing for ARIs decreased from 39.2% at baseline to 24.7% at completion of the program (-14.5%; 95% CI, -16.8% to -12.2%). Conclusions and Relevance: In this study of US ambulatory practices that participated in the AHRQ Safety Program, significant reductions in the rates of overall and ARI-related antibiotic prescribing were noted, despite normalization of clinic visits by completion of the program. The forthcoming AHRQ Safety Program content may have utility in ambulatory practices across the US.

Implementing a Toolkit to Improve the Education of Patients on Home-Based Outpatient Parenteral Antimicrobial Therapy (OPAT).

BACKGROUND: Patients discharged to the home on home-based outpatient parenteral antimicrobial therapy (OPAT) perform their own infusions and catheter care; thus, they require high-quality training to improve safety and the likelihood of treatment success. This article describes the study team's experience piloting an educational toolkit for patients on home-based OPAT. METHODS: An OPAT toolkit was developed to address barriers such as unclear communication channels, rushed instruction, safe bathing with an intravenous (IV) catheter, and lack of standardized instructions. The research team evaluated the toolkit through interviews with home infusion nurses implementing the intervention, surveys of 20 patients who received the intervention, and five observations of the home infusion nurses delivering the intervention to patients and caregivers. RESULTS: Of surveyed patients, 90.0% were comfortable infusing medications at the time of discharge, and 80.0% with bathing with the IV catheter. While all practiced on equipment, 75.0% used the videos and the paper checklists. Almost all (95.0%) were satisfied with their training, and all were satisfied with managing their IV catheters at home. The videos were considered very helpful, particularly as reference. Overall, nurses adjusted training to patient characteristics and modified the toolkit over time. Shorter instruction forms were more helpful than longer instruction forms. CONCLUSION: Developing a toolkit to improve the education of patients on home-based OPAT has the potential to improve the safety of and experience with home-based OPAT.

A Bundle of the Top 10 OPAT Publications in 2021.

As outpatient parenteral antimicrobial therapy (OPAT) becomes more common, it may be difficult to stay current with recent related publications. A group of multidisciplinary OPAT clinicians reviewed and ranked all OPAT publications published in 2021. This article provides a high-level summary of the OPAT manuscripts that were voted the "top 10" publications of 2021.

A task analysis of central line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy.

BACKGROUND: Barriers for home infusion therapy central line associated bloodstream infection (CLABSI) surveillance have not been elucidated and are needed to identify how to support home infusion CLABSI surveillance. We aimed to (1) perform a goal-directed task analysis of home infusion CLABSI surveillance, and (2) describe barriers to, facilitators for, and suggested strategies for successful home infusion CLABSI surveillance. METHODS: We conducted semi-structured interviews with team members involved in CLABSI surveillance at 5 large home infusion agencies to explore work systems used by members of the agency for home infusion CLABSI surveillance. We analyzed the transcribed interviews qualitatively for themes. RESULTS: Twenty-one interviews revealed 8 steps for performing CLABSI surveillance in home infusion therapy. Major barriers identified included the need for training of the surveillance staff, lack of a standardized definition, inadequate information technology support, struggles communicating with hospitals, inadequate time, and insufficient clinician engagement and leadership support. DISCUSSION: Staff performing home infusion CLABSI surveillance need health system resources, particularly leadership and front-line engagement, access to data, information technology support, training, dedicated time, and reports to perform tasks. CONCLUSIONS: Building home infusion CLABSI surveillance programs will require support from home infusion leadership.

The Voice of the Patient: Patient Roles in Antibiotic Management at the Hospital-to-Home Transition.

OBJECTIVE: Our objective was to characterize tasks required for patient-performed antibiotic medication management (MM) at the hospital-to-home transition, as well as barriers to and strategies for patient-led antibiotic MM. Our overall goal was to understand patients' role in managing antibiotics at the hospital-to-home transition. METHODS: We performed a qualitative study including semistructured interviews with health care workers and contextual inquiry with patients discharged home on oral antibiotics. The setting was one academic medical center and one community hospital. Participants included 37 health care workers and 16 patients. We coded interview transcripts and notes from contextual inquiry and developed themes. RESULTS: We identified 6 themes involving barriers or strategies for antibiotic MM. We identified dissonance between participant descriptions of the ease of antibiotic MM at the hospital-to-home transition and their experience of barriers. Similarly, patients did not always recognize when they were experiencing side effects. Lack of access to follow-up care led to unnecessarily long antibiotic courses. Instructions about completing antibiotics were not routinely provided. However, patients typically did not question the need for the prescribed antibiotic. CONCLUSIONS: There are many opportunities to improve patient-led antibiotic MM at the hospital-to-home transition. Mismatches between patient perceptions and patient experiences around antibiotic MM at the hospital-to-home transition provide opportunities for health system improvement.