Fear of Missing Organisms (FOMO): the discordance among broad-spectrum empiric antibiotic therapy, microbiologic results, and definitive antibiotic therapy for diabetic foot infections and lower extremity osteomyelitis.

Objective: Empiric broad-spectrum antibiotic therapy is commonly prescribed for patients hospitalized with diabetic foot infections (DFI) and lower extremity osteomyelitis (OM). The primary objective was to evaluate the concordance between empiric antibiotic therapy, microbiologic results, and definitive antibiotic therapy with a focus on methicillin-resistant Staphylococcus aureus (MRSA) and resistant gram-negative organisms. The secondary objective was to evaluate the negative predictive values (NPV) of select risk factors for MRSA and resistant gram-negative organisms for microbiologic results with these organisms. Design: Retrospective cohort study. Setting: Safety-net health system in Ohio. Patients: Adults hospitalized and receiving antibiotic therapy for DFI or lower extremity OM in 2021. Results: For 259 unique patients, empiric therapies with activity against MRSA and resistant gram-negative organisms were administered to 224 (86.5%) and 217 (83.8%) patients, respectively. Definitive therapies with activity against MRSA and resistant gram-negative organisms were administered to 91 (35%) and 74 (28.6%) patients, respectively. Of 234 patients with microbiologic testing, 29 (12.4%) had positive cultures with MRSA and 41 (17.5%) with resistant gram-negative organisms. The NPVs of risk factors for MRSA and resistant gram-negative organisms for the absence of these organisms in culture were 91% and 85%, respectively. Conclusions: For patients hospitalized with DFI and lower extremity OM, our data suggest opportunities for substantial reductions in empiric therapies with activity against MRSA and resistant gram-negative organisms. The absence of risk factors for these organisms was reasonably good at predicting negative cultures with these organisms.

Natural History of Clostridioides difficile Colonization and Infection Following New Acquisition of Carriage in Healthcare Settings: A Prospective Cohort Study.

BACKGROUND: Limited information is available on the natural history of Clostridioides difficile colonization and infection in patients with new acquisition of C. difficile in healthcare settings. METHODS: In 3 hospitals and affiliated long-term care facilities, we collected serial perirectal cultures from patients with no diarrhea on enrollment to identify new acquisition of toxigenic C. difficile carriage and determined the duration and burden of carriage. Asymptomatic carriage was defined as transient if only 1 culture was positive, with negative cultures before and after, or persistent if 2 or more cultures were positive. Clearance of carriage was defined as 2 consecutive negative perirectal cultures. RESULTS: Of 1432 patients with negative initial cultures and at least 1 follow-up culture, 39 (2.7%) developed C. difficile infection (CDI) without prior detection of carriage and 142 (9.9%) acquired asymptomatic carriage, with 19 (13.4%) subsequently diagnosed with CDI. Of 82 patients analyzed for persistence of carriage, 50 (61.0%) had transient carriage and 32 (39.0%) had persistent carriage, with an estimated median of 77 days to clearance of colonization (range, 14-133 days). Most persistent carriers had a relatively high burden of carriage and maintained the same ribotype over time, whereas most transient carriers had a low burden of carriage detected only using broth enrichment cultures. CONCLUSIONS: In 3 healthcare facilities, 9.9% of patients acquired asymptomatic carriage of toxigenic C. difficile, and 13.4% were subsequently diagnosed with CDI. Most carriers had transient rather than persistent carriage and most patients developing CDI did not have prior detection of carriage.

Real-world evaluation of a two-step testing algorithm for Clostridioides difficile infection.

During the 4 years after implementation of the 2-step Clostridioides difficile infection (CDI) testing algorithm, 70% to 78% of patients with suspected CDI and a positive nucleic acid amplification test but a negative toxin test (NAAT+/TOX-) received CDI treatment. Overall, 73% of NAAT+/TOX- patients were classified as having probable or possible CDI.

SARS in Cars: Carbon Dioxide Levels Provide a Simple Means to Assess Ventilation in Motor Vehicles.

BACKGROUND: Poorly ventilated enclosed spaces pose a risk for airborne transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and other respiratory viruses. Limited information is available on ventilation in motor vehicles under differing driving conditions. METHODS: We conducted carbon dioxide measurements to assess ventilation in motor vehicles under varying driving conditions with 2 to 3 vehicle occupants. During routine driving, carbon dioxide produced by the breathing of vehicle occupants was measured inside 5 cars and a van under a variety of driving conditions with or without the ventilation fan on and with windows open or closed. Carbon dioxide readings above 800 parts per million (ppm) were considered an indicator of suboptimal ventilation. RESULTS: Carbon dioxide levels remained below 800 ppm in all vehicles if the ventilation fan was on and/or the windows were open while parked or during city or highway driving. With the ventilation system set on non-recirculation mode, carbon dioxide levels rose above 800 ppm in all vehicles when the fan was off and the windows were closed while parked and during city driving, and in 2 of the 6 vehicles during highway driving. With the ventilation system set on recirculation mode, carbon dioxide rose above 800 ppm within 10 minutes in all vehicles tested. CONCLUSION: Carbon dioxide measurements could provide a practical and rapid method to assess ventilation in motor vehicles. Simple measures such as opening windows, turning on the fan, and avoiding the recirculation mode greatly improve ventilation.

Improving Timeliness of Antibiotic Administration Using a Provider and Pharmacist Facing Sepsis Early Warning System in the Emergency Department Setting: A Randomized Controlled Quality Improvement Initiative.

OBJECTIVES: Results of pre-post intervention studies of sepsis early warning systems have been mixed, and randomized clinical trials showing efficacy in the emergency department setting are lacking. Additionally, early warning systems can be resource-intensive and may cause unintended consequences such as antibiotic or IV fluid overuse. We assessed the impact of a pharmacist and provider facing sepsis early warning systems on timeliness of antibiotic administration and sepsis-related clinical outcomes in our setting. DESIGN: A randomized, controlled quality improvement initiative. SETTING: The main emergency department of an academic, safety-net healthcare system from August to December 2019. PATIENTS: Adults presenting to the emergency department. INTERVENTION: Patients were randomized to standard sepsis care or standard care augmented by the display of a sepsis early warning system-triggered flag in the electronic health record combined with electronic health record-based emergency department pharmacist notification. MEASUREMENTS AND MAIN RESULTS: The primary process measure was time to antibiotic administration from arrival. A total of 598 patients were included in the study over a 5-month period (285 in the intervention group and 313 in the standard care group). Time to antibiotic administration from emergency department arrival was shorter in the augmented care group than that in the standard care group (median, 2.3 hr [interquartile range, 1.4-4.7 hr] vs 3.0 hr [interquartile range, 1.6-5.5 hr]; p = 0.039). The hierarchical composite clinical outcome measure of days alive and out of hospital at 28 days was greater in the augmented care group than that in the standard care group (median, 24.1 vs 22.5 d; p = 0.011). Rates of fluid resuscitation and antibiotic utilization did not differ. CONCLUSIONS: In this single-center randomized quality improvement initiative, the display of an electronic health record-based sepsis early warning system-triggered flag combined with electronic health record-based pharmacist notification was associated with shorter time to antibiotic administration without an increase in undesirable or potentially harmful clinical interventions.

Microbial bioburden of inpatient and outpatient areas beyond patient hospital rooms.

OBJECTIVE: To investigate the frequency of environmental contamination in hospital areas outside patient rooms and in outpatient healthcare facilities. DESIGN: Culture survey. SETTING: This study was conducted across 4 hospitals, 4 outpatient clinics, and 1 surgery center. METHODS: We conducted 3 point-prevalence culture surveys for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, Clostridioides difficile, Candida spp, and gram-negative bacilli including Enterobacteriaceae, Pseudomonas aeruginosa, Acinetobacter baumanii, and Stenotrophomonas maltophilia in each facility. In hospitals, high-touch surfaces were sampled from radiology, physical therapy, and mobile equipment and in emergency departments, waiting rooms, clinics, and endoscopy facilities. In outpatient facilities, surfaces were sampled in exam rooms including patient and provider areas, patient bathrooms, and waiting rooms and from portable equipment. Fluorescent markers were placed on high-touch surfaces and removal was assessed 1 day later. RESULTS: In the hospitals, 110 (9.4%) of 1,195 sites were positive for 1 or more bacterial pathogens (range, 5.3%-13.7% for the 4 hospitals) and 70 (5.9%) were positive for Candida spp (range, 3.7%-5.9%). In outpatient facilities, 31 of 485 (6.4%) sites were positive for 1 or more bacterial pathogens (range, 2% to 14.4% for the 5 outpatient facilities) and 50 (10.3%) were positive for Candida spp (range, 3.9%-23.3%). Fluorescent markers had been removed from 33% of sites in hospitals (range, 28.4%-39.7%) and 46.3% of sites in outpatient clinics (range, 7.4%-82.8%). CONCLUSIONS: Surfaces in hospitals outside patient rooms and in outpatient facilities are frequently contaminated with healthcare-associated pathogens. Improvements in cleaning and disinfection practices are needed to reduce contamination.

What is the current state of patient education after Clostridioides difficile infection?

In a survey of hospitals and of patients with Clostridioides difficile infection (CDI), we found that most facilities had educational materials or protocols for education of CDI patients. However, approximately half of CDI patients did not recall receiving education during their admission, and knowledge deficits regarding CDI prevention were common.

Efficacy of a stewardship intervention focused on reducing unnecessary use of non-Clostridioides difficile antibiotics in patients with Clostridioides difficile infection.

In a tertiary-care hospital and affiliated long-term care facility, a stewardship intervention focused on patients with Clostridioides difficile infection (CDI) was associated with a significant reduction in unnecessary non-CDI antibiotic therapy. However, there was no significant reduction in total non-CDI therapy or in the frequency of CDI recurrence.

Impact of syndrome-specific antimicrobial stewardship interventions on use of and resistance to fluoroquinolones: An interrupted time series analysis.

BACKGROUND: Fluoroquinolones are often prescribed unnecessarily and are an important risk factor for infection with fluoroquinolone-resistant gram-negative bacilli and Clostridioides difficile. METHODS: We conducted a quasi-experimental study to determine the impact of sequential syndrome-specific stewardship interventions on use of and resistance to fluoroquinolones in a tertiary care hospital. An initial 2-year intervention focused on reducing treatment of asymptomatic bacteriuria and ensuring concordance of urinary tract infection treatment with guidelines. A second 5-year intervention focused on limiting overuse of fluoroquinolones for health care-associated pneumonia in conjunction with a formal stewardship program. The primary outcomes were fluoroquinolone use and changes in use over time analyzed by segmented regression analysis. RESULTS: The asymptomatic bacteriuria and urinary tract infection intervention resulted in a significant reduction in fluoroquinolone use, with a significant change from an increasing to a decreasing rate of use (change in slope of quarterly defined daily doses/1,000 patient days -15.3, P < .01). The health care-associated pneumonia intervention resulted in a continued significant reduction in fluoroquinolone use (rate ratio = 0.68, P < .01). During the interventions, fluoroquinolone susceptibility increased significantly in Pseudomonas aeruginosa, but not in Escherichia coli, Klebsiella spp., or C difficile. CONCLUSIONS: Antimicrobial stewardship interventions focused on specific syndromes may be effective in reducing fluoroquinolone use. In our hospital, reduction in fluoroquinolone use resulted in increased fluoroquinolone susceptibility in P aeruginosa, but not other Enterobacteriaceae or C difficile.

Contamination of Health Care Personnel During Removal of Personal Protective Equipment.

IMPORTANCE: Contamination of the skin and clothing of health care personnel during removal of personal protective equipment (PPE) contributes to dissemination of pathogens and places personnel at risk for infection. OBJECTIVES: To determine the frequency and sites of contamination on the skin and clothing of personnel during PPE removal and to evaluate the effect of an intervention on the frequency of contamination. DESIGN, SETTING, AND PARTICIPANTS: We conducted a point-prevalence study and quasi-experimental intervention from October 28, 2014, through March 31, 2015. Data analysis began November 17, 2014, and ended April 21, 2015. Participants included a convenience sample of health care personnel from 4 Northeast Ohio hospitals who conducted simulations of contaminated PPE removal using fluorescent lotion and a cohort of health care personnel from 7 study units in 1 medical center that participated in a quasi-experimental intervention that included education and practice in removal of contaminated PPE with immediate visual feedback based on fluorescent lotion contamination of skin and clothing. MAIN OUTCOMES AND MEASURES: The primary outcomes were the frequency and sites of contamination on skin and clothing of personnel after removal of contaminated gloves or gowns at baseline vs after the intervention. A secondary end point focused on the correlation between contamination of skin with fluorescent lotion and bacteriophage MS2, a nonpathogenic, nonenveloped virus. RESULTS: Of 435 glove and gown removal simulations, contamination of skin or clothing with fluorescent lotion occurred in 200 (46.0%), with a similar frequency of contamination among the 4 hospitals (range, 42.5%-50.3%). Contamination occurred more frequently during removal of contaminated gloves than gowns (52.9% vs 37.8%, P = .002) and when lapses in technique were observed vs not observed (70.3% vs 30.0%, P < .001). The intervention resulted in a reduction in skin and clothing contamination during glove and gown removal (60.0% before the intervention vs 18.9% after, P < .001) that was sustained after 1 and 3 months (12.0% at both time points, P < .001 compared with before the intervention). During simulations of contaminated glove removal, the frequency of skin contamination was similar with fluorescent lotion and bacteriophage MS2 (58.0% vs 52.0%, P = .45). CONCLUSIONS AND RELEVANCE: Contamination of the skin and clothing of health care personnel occurs frequently during removal of contaminated gloves or gowns. Educational interventions that include practice with immediate visual feedback on skin and clothing contamination can significantly reduce the risk of contamination during removal of PPE.

Overdiagnosis of Urinary Tract Infection and Underdiagnosis of Sexually Transmitted Infection in Adult Women Presenting to an Emergency Department.

Urinary tract infections (UTIs) and sexually transmitted infections (STIs) are commonly diagnosed in emergency departments (EDs). Distinguishing between these syndromes can be challenging because of overlapping symptomatology and because both are associated with abnormalities on urinalysis (UA). We conducted a 2-month observational cohort study to determine the accuracy of clinical diagnoses of UTI and STI in adult women presenting with genitourinary (GU) symptoms or diagnosed with GU infections at an urban academic ED. For all urine specimens, UA, culture, and nucleic acid amplification testing for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis were performed. Of 264 women studied, providers diagnosed 175 (66%) with UTIs, 100 (57%) of whom were treated without performing a urine culture during routine care. Combining routine care and study-performed urine cultures, only 84 (48%) of these women had a positive urine culture. Sixty (23%) of the 264 women studied had one or more positive STI tests, 22 (37%) of whom did not receive treatment for an STI within 7 days of the ED visit. Fourteen (64%) of these 22 women were diagnosed with a UTI instead of an STI. Ninety-two percent of the women studied had an abnormal UA finding (greater-than-trace leukocyte esterase level, positive nitrite test result, or pyuria). The positive and negative predictive values of an abnormal UA finding were 41 and 76%, respectively. In this population, empirical therapy for UTI without urine culture testing and overdiagnosis of UTI were common and associated with unnecessary antibiotic exposure and missed STI diagnoses. Abnormal UA findings were common and not predictive of positive urine cultures.

Evaluation of patients' skin, environmental surfaces, and urinary catheters as sources for transmission of urinary pathogens.

In hospitalized patients with urinary tract infection or asymptomatic bacteriuria, urinary pathogens frequently contaminate skin, high-touch environmental surfaces, and urinary catheters. Contamination is more common in patients with a urinary catheter in place and with gram-positive pathogens. Patients' skin and environmental surfaces may provide an important source for transmission of urinary pathogens.

Effect of a stewardship intervention on adherence to uncomplicated cystitis and pyelonephritis guidelines in an emergency department setting.

OBJECTIVE: To evaluate adherence to uncomplicated urinary tract infections (UTI) guidelines and UTI diagnostic accuracy in an emergency department (ED) setting before and after implementation of an antimicrobial stewardship intervention. METHODS: The intervention included implementation of an electronic UTI order set followed by a 2 month period of audit and feedback. For women age 18-65 with a UTI diagnosis seen in the ED with no structural or functional abnormalities of the urinary system, we evaluated adherence to guidelines, antimicrobial use, and diagnostic accuracy at baseline, after implementation of the order set (period 1), and after audit and feedback (period 2). RESULTS: Adherence to UTI guidelines increased from 44% (baseline) to 68% (period 1) to 82% (period 2) (P≤.015 for each successive period). Prescription of fluoroquinolones for uncomplicated cystitis decreased from 44% (baseline) to 14% (period 1) to 13% (period 2) (P<.001 and P = .7 for each successive period). Unnecessary antibiotic days for the 200 patients evaluated in each period decreased from 250 days to 119 days to 52 days (P<.001 for each successive period). For 40% to 42% of cases diagnosed as UTI by clinicians, the diagnosis was deemed unlikely or rejected with no difference between the baseline and intervention periods. CONCLUSIONS: A stewardship intervention including an electronic order set and audit and feedback was associated with increased adherence to uncomplicated UTI guidelines and reductions in unnecessary antibiotic therapy and fluoroquinolone therapy for cystitis. Many diagnoses were rejected or deemed unlikely, suggesting a need for studies to improve diagnostic accuracy for UTI.

Unnecessary use of fluoroquinolone antibiotics in hospitalized patients.

BACKGROUND: Fluoroquinolones are among the most commonly prescribed antimicrobials and are an important risk factor for colonization and infection with fluoroquinolone-resistant gram-negative bacilli and for Clostridium difficile infection (CDI). In this study, our aim was to determine current patterns of inappropriate fluoroquinolone prescribing among hospitalized patients, and to test the hypothesis that longer than necessary treatment durations account for a significant proportion of unnecessary fluoroquinolone use. METHODS: We conducted a 6-week prospective, observational study to determine the frequency of, reasons for, and adverse effects associated with unnecessary fluoroquinolone use in a tertiary-care academic medical center. For randomly-selected adult inpatients receiving fluoroquinolones, therapy was determined to be necessary or unnecessary based on published guidelines or standard principles of infectious diseases. Adverse effects were determined based on chart review 6 weeks after completion of therapy. RESULTS: Of 1,773 days of fluoroquinolone therapy, 690 (39%) were deemed unnecessary. The most common reasons for unnecessary therapy included administration of antimicrobials for non-infectious or non-bacterial syndromes (292 days-of-therapy) and administration of antimicrobials for longer than necessary durations (234 days-of-therapy). The most common syndrome associated with unnecessary therapy was urinary tract infection or asymptomatic bacteriuria (30% of all unnecessary days-of-therapy). Twenty-seven percent (60/227) of regimens were associated with adverse effects possibly attributable to therapy, including gastrointestinal adverse effects (14% of regimens), colonization by resistant pathogens (8% of regimens), and CDI (4% of regimens). CONCLUSIONS: In our institution, 39% of all days of fluoroquinolone therapy were unnecessary. Interventions that focus on improving adherence with current guidelines for duration of antimicrobial therapy and for management of urinary syndromes could significantly reduce overuse of fluoroquinolones.

Survey of patients' knowledge and opinions regarding the use of indwelling urinary catheters.

In a survey of patients with short-term indwelling urinary catheters, 47% were aware that catheters cause urinary tract infections, 89% believed that catheters were not overused, and 68% preferred catheter placement rather than use of a bedside commode, bedpan, or diaper. Patient education is needed regarding the risks of urinary catheters.