A survey of infection prevention and animal-assisted activity policies in health care facilities-United States, 2023.

In a survey of 104 US infectious disease specialists, 88% reported working in facilities that allow animal-assisted activities or pet visitation. Variability existed in the species of animals allowed, restricted areas, and veterinary assessments, demonstrating a need to standardize infection prevention approaches across health care facilities to mitigate potential risks.

Variation in North American Infectious Disease Specialists' Practice Regarding Oral and Suppressive Antibiotics for Adult Osteoarticular Infections: Results of an Emerging Infections Network (EIN) Survey.

Background: Osteoarticular infections (OAIs) are commonly treated with prolonged intravenous (IV) antimicrobials. The Oral versus Intravenous Antibiotics for Bone and Joint Infection (OVIVA) trial demonstrated that oral (PO) antibiotics are noninferior to IV antibiotics in the treatment of OAIs. We surveyed infectious disease (ID) physicians about their use of PO antibiotics in the treatment of OAIs. Methods: An Emerging Infection Network survey with 9 questions regarding antibiotic prescribing for the treatment of OAIs was sent to 1475 North American ID physicians. The questions were mostly multiple choice and focused on the use of definitive oral antibiotic therapy (defined as oral switch within 2 weeks of starting antibiotics) and chronic suppressive antibiotic therapy (SAT). Results: Of the 413 physicians who reported treating OAIs, 91% used oral antibiotics at least sometimes and 31% used them as definitive therapy, most often for diabetic foot osteomyelitis and native joint septic arthritis. The oral antibiotics most frequently used for OAIs included trimethoprim-sulfamethoxazole, doxycycline/minocycline, and linezolid for Staphylococcus aureus, amoxicillin/cefadroxil/cephalexin for streptococci, and fluoroquinolones for gram-negative organisms. The most common rationales for not transitioning to oral antibiotics included nonsusceptible pathogens, comorbidities preventing therapeutic drug levels, and concerns about adherence. SAT use was variable but employed by a majority in most cases of periprosthetic joint infection managed with debridement and implant retention. Conclusions: North American ID physicians utilize oral antibiotics and SAT for the management of OAIs, although significant practice variation exists. Respondents voiced a need for updated guidelines.

Infectious Diseases Physician Management of Cryptococcal Meningitis in North America-Is Single High-Dose Liposomal Amphotericin B Being Used?

Background: Several recent randomized trials have been conducted in resource-limited settings for cryptococcal meningitis that have rapidly innovated international guidelines. The 2010 Infectious Diseases Society of America (IDSA) cryptococcal meningitis guideline has not been updated with recent trials. The 2022 AMBITION-cm trial found that a single 10-mg/kg dose of liposomal amphotericin B plus daily flucytosine and fluconazole for 2 weeks was noninferior to 1 week of amphotericin B deoxycholate with flucytosine. It is unknown whether physicians in high-resource settings are using this regimen or more traditional regimens. Methods: We developed an electronic survey in June 2023 to better understand whether physician members of the IDSA Emerging Infections Network (EIN) and Mycoses Study Group Education and Research Consortium (MSG-ERC) had used the AMBITION-cm induction regimen, would use the regimen in hypothetical clinical scenarios, and what perceived barriers to use existed. Results: A total of 242 of 561 (43%) physicians responded to the survey, of whom 205 provided care for persons with cryptococcal meningitis in the last year. Overall, 29 (14%) had used the AMBITION-cm regimen, and 176 (86%) had not. In various hypothetical clinical scenarios, only ∼10% of 209 respondents selected the AMBITION-cm regimen as preferred. Perceived barriers to uptake included the applicability of trials performed in low-resource settings to high-resource settings, that the regimen is not recommended in the 2010 IDSA guidelines, and the applicability to persons without HIV. Conclusions: Most respondents had not used the single-dose liposomal amphotericin B regimen, but the regimen is being used. Further study of this regimen in other patient populations and settings is necessary.

Using a Fitbit-based Walking Game to Improve Physical Activity Among U.S. Veterans.

INTRODUCTION: Physical inactivity, hereafter inactivity, is a serious health problem among U.S. veterans, hereafter veterans. Inactive adults are at risk for adverse cardiac events and premature mortality. Specifically, among veterans, inactivity has been associated with a 23% increase in mortality. In order to increase physical activity among veterans, we developed Veterans Affairs (VA) MapTrek, a mobile-phone-based web app that allows users to take a virtual walk in interesting locations around the world while tracking their progress against that of others like themselves on an interactive map. Steps are counted by a commercially available Fitbit triaxial accelerometer, and users see their progress along a predefined scenic path overlaid on Google Maps. The objective of this study was to determine the effectiveness of VA MapTrek to increase physical activity in a population of veterans at risk for obesity-related morbidity. MATERIALS AND METHODS: We recruited overweight and obese veterans obtaining care at the Iowa City Veterans Affairs Health Center. Half of the veterans were assigned to participate in VA MapTrek. Each week, participants were assigned virtual walking races (Monday through Saturday), which followed a predetermined route that is displayed on Google Maps. The participant's position on the map is automatically updated each time their Fitbit syncs to their phone. In addition, challenges were issued periodically. Veterans in the control group were only given a Fitbit. We regressed daily step counts on the days of the week, the days since the start of the intervention period, whether the user was in the VA MapTrek or Control group, and an interaction between the study group and the days since the start of the intervention period. We included subject-specific random intercepts and subject-specific random slopes. This model was estimated using Bayesian Hamiltonian Monte Carlo using Stan's No-U-Turns sampler. We set vague, uniform priors on all the parameters. RESULTS: We enrolled 276 participants, but only 251 (102 in the control group and 149 in the VA MapTrek group) contributed data during the intervention period. Our analysis suggests an 86.8% likelihood that the VA MapTrek intervention led to a minimum increase of 1,000 daily steps over the 8-week period, compared to the control group. Throughout the 8-week intervention, we project that VA MapTrek participants would have taken an extra 96,627 steps, equivalent to 77.8 additional kilometers (km) (48.3 additional miles), assuming an average of 1,242 steps per km (2,000 steps per mile). CONCLUSIONS: Our study underscores the potential of VA MapTrek as an intervention for promoting walking among veterans who face elevated risks of obesity and cardiac issues. Rural veterans are a high-risk population, and new interventions like VA MapTrek are needed to improve veterans' health.

The Increase in Household Transmission of Pertussis Associated With Diagnostic Delays.

BACKGROUND: Pertussis is a highly contagious respiratory illness that can be especially dangerous to young children. Transmission of pertussis often occurs in household settings and is impacted by the timing of treatment and postexposure chemoprophylaxis. This study analyzes the risk for secondary household transmission and if delays in diagnosing pertussis increased the risk for household transmission. METHODS: We conducted 2 population-based studies using a large nationally representative administrative claims database. The first study utilized a stratified monthly incidence model to compare the incidence of pertussis among enrollees exposed to a family member with pertussis versus those not exposed. The second study was conducted at a household level following the index case of pertussis in each household. We identified diagnostic delays in the initial household case and used a logistic regression model to evaluate if such delays were associated with a greater risk for transmission. RESULTS: The incidence rate ratio of pertussis was 938.99 [95% confidence interval (CI): 880.19-1001.73] among enrollees exposed to a family member with pertussis relative to those not exposed. The odds of secondary household transmission in households where the index case experienced a diagnostic delay was 5.10 (CI: 4.44-5.85) times the odds of transmission when the index case was not delayed. We found that longer delays were associated with a greater risk for secondary household transmission ( P < 0.0001). CONCLUSIONS: There is a high rate of secondary transmission of pertussis in household settings. Diagnostic delays increase the likelihood that pertussis will transmit in the household.

Candida auris screening practices at healthcare facilities in the United States: An Emerging Infections Network survey.

We surveyed members of the Emerging Infections Network about Candida auris screening practices at US healthcare facilities. Only 37% of respondents reported conducting screening; among these, 75% reported detection of at least 1 C. auris case in the last year. Increased screening could improve C. auris detection and prevent spread.

Comparing multiple infection control measures in a nursing home setting: a simulation study.

OBJECTIVE: Compare the effectiveness of multiple mitigation measures designed to protect nursing home residents from infectious disease outbreaks. DESIGN: Agent-based simulation study. SETTING: Simulation environment of a small nursing home. METHODS: We collected temporally detailed and spatially fine-grained location information from nursing home healthcare workers (HCWs) using sensor motes. We used these data to power an agent-based simulation of a COVID-19 outbreak using realistic time-varying estimates of infectivity and diagnostic sensitivity. Under varying community prevalence and transmissibility, we compared the mitigating effects of (i) regular screening and isolation, (ii) inter-resident contact restrictions, (iii) reduced HCW presenteeism, and (iv) modified HCW scheduling. RESULTS: Across all configurations tested, screening every other day and isolating positive cases decreased the attack rate by an average of 27% to 0.501 on average, while contact restrictions decreased the attack rate by an average of 35%, resulting in an attack rate of only 0.240, approximately half that of screening/isolation. Combining both interventions impressively produced an attack rate of only 0.029. Halving the observed presenteeism rate led to an 18% decrease in the attack rate, but if combined with screening every 6 days, the effect of reducing presenteeism was negligible. Altering work schedules had negligible effects on the attack rate. CONCLUSIONS: Universal contact restrictions are highly effective for protecting vulnerable nursing home residents, yet adversely affect physical and mental health. In high transmission and/or high community prevalence situations, restricting inter-resident contact to groups of 4 was effective and made highly effective when paired with weekly testing.

Implementation of contact precautions for multidrug-resistant organisms in the post-COVID-19 pandemic era: An updated national Emerging Infections Network (EIN) survey.

OBJECTIVE: To understand how healthcare facilities employ contact precautions for patients with multidrug-resistant organisms (MDROs) in the post-coronavirus disease 2019 (COVID-19) era and explore changes since 2014. DESIGN: Cross-sectional survey. PARTICIPANTS: Emerging Infections Network (EIN) physicians involved in infection prevention or hospital epidemiology. METHODS: In September 2022, we sent via email an 8-question survey on contact precautions and adjunctive measures to reduce MDRO transmission in inpatient facilities. We also asked about changes since the COVID-19 pandemic. We used descriptive statistics to summarize data and compared results to a similar survey administered in 2014. RESULTS: Of 708 EIN members, 283 (40%) responded to the survey and 201 reported working in infection prevention. A majority of facilities (66% and 69%) routinely use contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) respectively, compared to 93% and 92% in 2014. Nearly all (>90%) use contact precautions for Candida auris, carbapenem-resistant Enterobacterales (CRE), and carbapenem-resistant Acinetobacter baumannii. More variability was reported for carbapenem-resistant Pseudomonas aeruginosa and extended-spectrum ß-lactamase-producing gram-negative organisms. Compared to 2014, fewer hospitals perform active surveillance for MRSA and VRE. Overall, 90% of facilities used chlorhexidine gluconate bathing in all or select inpatients, and 53% used ultraviolet light or hydrogen peroxide vapor disinfection at discharge. Many respondents (44%) reported changes to contact precautions since COVID-19 that remain in place. CONCLUSIONS: Heterogeneity exists in the use of transmission-based precautions and adjunctive infection prevention measures aimed at reducing MDRO transmission. This variation reflects a need for updated and specific guidance, as well as further research on the use of contact precautions in healthcare facilities.

Cystic Fibrosis Carrier States Are Associated With More Severe Cases of Bronchiectasis.

Background: People with cystic fibrosis (CF) are at increased risk for bronchiectasis, and several reports suggest that CF carriers may also be at higher risk for developing bronchiectasis. The purpose of this study was to determine if CF carriers are at risk for more severe courses or complications of bronchiectasis. Methods: Using MarketScan data (2001-2021), we built a cohort consisting of 105 CF carriers with bronchiectasis and 300 083 controls with bronchiectasis but without a CF carrier diagnosis. We evaluated if CF carriers were more likely to be hospitalized for bronchiectasis. In addition, we examined if CF carriers were more likely to be infected with Pseudomonas aeruginosa or nontuberculous mycobacteria (NTM) or to have filled more antibiotic prescriptions. We considered regression models for incident and rate outcomes that controlled for age, sex, smoking status, and comorbidities. Results: The odds of hospitalization were almost 2.4 times higher (95% CI, 1.116-5.255) for CF carriers with bronchiectasis when compared with non-CF carriers with bronchiectasis. The estimated odds of being diagnosed with a Pseudomonas infection for CF carriers vs noncarriers was about 4.2 times higher (95% CI, 2.417-7.551) and 5.4 times higher (95% CI, 3.398-8.804) for being diagnosed with NTM. The rate of distinct antibiotic fill dates was estimated to be 2 times higher for carriers as compared with controls (95% CI, 1.735-2.333), and the rate ratio for the total number of days of antibiotics supplied was estimated as 2.8 (95% CI, 2.290-3.442). Conclusions: CF carriers with bronchiectasis required more hospitalizations and more frequent administration of antibiotics as compared with noncarriers. Given that CF carriers were also more likely to be diagnosed with Pseudomonas and NTM infections, CF carriers with bronchiectasis may have a phenotype more resembling CF-related bronchiectasis than non-CF bronchiectasis.

Association between household opioid prescriptions and risk for overdose among family members not prescribed opioids.

BACKGROUND: Prescription opioids have contributed to the rise in opioid-related overdoses and deaths. The presence of opioids within households may increase the risk of overdose among family members who were not prescribed an opioid themselves. Larger quantities of opioids may further increase risk. OBJECTIVES: To determine the risk of opioid overdose among individuals who were not prescribed an opioid but were exposed to opioids prescribed to other family members in the household, and evaluate the risk in relation to the total morphine milligram equivalents (MMEs) present in the household. METHODS: We conducted a cohort study using a large database of commercial insurance claims from 2001 to 2021. For inclusion in the cohort, we identified individuals not prescribed an opioid in the prior 90 days from households with two or more family members, and determined the total MMEs prescribed to other family members. Individuals were stratified into monthly enrollment strata defined by household opioid exposure and other confounders. A generalized linear model was used to estimate incidence rate ratios (IRRs) for overdose. RESULTS: Overall, the incidence of overdose among enrollees in households where a family member was prescribed an opioid was 1.73 (95% confidence interval [CI]: 1.67-1.78) times greater than households without opioid prescriptions. The risk of overdose increased continuously with the level of potential MMEs in the household from an IRR of 1.23 (95% CI: 1.16-1.32) for 1-100 MMEs to 4.67 (95% CI: 4.18-5.22) for >12,000 MMEs. The risk of overdose associated with household opioid exposure was greatest for ages 1-2 years (IRR: 3.46 [95% CI: 2.98-4.01]) and 3-5 years (IRR: 3.31 [95% CI: 2.75-3.99]). CONCLUSIONS: The presence of opioids in a household significantly increases the risk of overdose among other family members who were not prescribed an opioid. Higher levels of MMEs, either in terms of opioid strength or quantity, were associated with increased levels of risk. Risk estimates may reflect accidental poisonings among younger family members.

Diurnal temperature variation and the implications for diagnosis and infectious disease screening: a population-based study.

OBJECTIVES: Fevers have been used as a marker of disease for hundreds of years and are frequently used for disease screening. However, body temperature varies over the course of a day and across individual characteristics; such variation may limit the detection of febrile episodes complicating the diagnostic process. Our objective was to describe individual variation in diurnal temperature patterns during episodes of febrile activity using millions of recorded temperatures and evaluate the probability of recording a fever by sex and for different age groups. METHODS: We use timestamped deidentified temperature readings from thermometers across the US to construct illness episodes where continuous periods of activity in a single user included a febrile reading. We model the mean temperature recorded and probability of registering a fever across the course of a day using sinusoidal regression models while accounting for user age and sex. We then estimate the probability of recording a fever by time of day for children, working-age adults, and older adults. RESULTS: We find wide variation in body temperatures over the course of a day and across individual characteristics. The diurnal temperature pattern differed between men and women, and average temperatures declined for older age groups. The likelihood of detecting a fever varied widely by the time of day and by an individual's age or sex. CONCLUSIONS: Time of day and demographics should be considered when using body temperatures for diagnostic or screening purposes. Our results demonstrate the importance of follow-up thermometry readings if infectious diseases are suspected.

What do infectious disease specialists think about managing long COVID?

This survey of infectious disease providers on long COVID care revealed a lack of familiarity with existing resources, a sentiment of missing guidelines, and scarcity of dedicated care centers. The low response rate suggests that infectious disease specialists do not consider themselves as the primary providers of long COVID care.

Predicting use of a gait-stabilizing device using a Wii Balance Board.

Gait-stabilizing devices (GSDs) are effective at preventing falls, but people are often reluctant to use them until after experiencing a fall. Inexpensive, convenient, and effective methods for predicting which patients need GSDs could help improve adoption. The purpose of this study was to determine if a Wii Balance Board (WBB) can be used to determine whether or not patients use a GSD. We prospectively recruited participants ages 70-100, some who used GSDs and some who did not. Participants first answered questions from the Modified Vulnerable Elders Survey, and then completed a grip-strength test using a handgrip dynamometer. Finally, they were asked to complete a series of four 30-second balance tests on a WBB in random order: (1) eyes open, feet apart; (2) eyes open, feet together; (3) eyes closed, feet apart; and (4) eyes closed, feet together. The four-test series was repeated a second time in the same random order. The resulting data, represented as 25 features extracted from the questionnaires and the grip test, and data from the eight balance tests, were used to predict a subject's GSD use using generalized functional linear models based on the Bernoulli distribution. 268 participants were consented; 62 were missing data elements and were removed from analysis; 109 were not GSD users and 97 were GSD users. The use of velocity and acceleration information from the WBB improved upon predictions based solely on grip strength, demographic, and survey variables. The WBB is a convenient, inexpensive, and easy-to-use device that can be used to recommend whether or not patients should be using a GSD.

Antifungal Therapeutic Drug Monitoring Practices: Results of an Emerging Infections Network Survey.

In a survey of 523 infectious disease specialists, a moderate to high percentage reported using any antifungal therapeutic drug monitoring (TDM) during itraconazole (72%), posaconazole (72%), and voriconazole (90%) treatment, and a low to moderate percentage reported using any antifungal TDM during prophylaxis (32%, 55%, and 65%, respectively). Long turnaround times for send-out TDM testing and logistical difficulties were frequent barriers.

Comparison of Different Antibiotics and the Risk for Community-Associated Clostridioides difficile Infection: A Case-Control Study.

Background: Antibiotics are the greatest risk factor for Clostridioides difficile infection (CDI). Risk for CDI varies across antibiotic types and classes. Optimal prescribing and stewardship recommendations require comparisons of risk across antibiotics. However, many prior studies rely on aggregated antibiotic categories or are underpowered to detect significant differences across antibiotic types. Using a large database of real-world data, we evaluate community-associated CDI risk across individual antibiotic types. Methods: We conducted a matched case-control study using a large database of insurance claims capturing longitudinal health care encounters and medications. Case patients with community-associated CDI were matched to 5 control patients by age, sex, and enrollment period. Antibiotics prescribed within 30 days before the CDI diagnosis along with other risk factors, including comorbidities, health care exposures, and gastric acid suppression were considered. Conditional logistic regression and a Bayesian analysis were used to compare risk across individual antibiotics. A sensitivity analysis of antibiotic exposure windows between 30 and 180 days was conducted. Results: We identified 159 404 cases and 797 020 controls. Antibiotics with the greatest risk for CDI included clindamycin and later-generation cephalosporins, and those with the lowest risk included minocycline and doxycycline. We were able to differentiate and order individual antibiotics in terms of their relative level of associated risk for CDI. Risk estimates varied considerably with different exposure windows considered. Conclusions: We found wide variation in CDI risk within and between classes of antibiotics. These findings ordering the level of associated risk across antibiotics can help inform tradeoffs in antibiotic prescribing decisions and stewardship efforts.

Harm Reduction: A Missing Piece to the Holistic Care of Patients Who Inject Drugs.

Background: The rise in injection drug use (IDU) has led to an increase in drug-related infections. Harm reduction is an important strategy for preventing infections among people who inject drugs (PWID). We attempted to evaluate the harm reduction counseling that infectious diseases physicians provide to PWID presenting with infections. Methods: An electronic survey was distributed to physician members of the Emerging Infections Network to inquire about practices used when caring for patients with IDU-related infections. Results: In total, 534 ID physicians responded to the survey. Of those, 375 (70%) reported routinely caring for PWID. Most respondents report screening for human immunodeficiency virus (HIV) and viral hepatitis (98%) and discussing the risk of these infections (87%); 63% prescribe immunization against viral hepatitis, and 45% discuss HIV preexposure prophylaxis (PrEP). However, 55% of respondents (n = 205) reported not counseling patients on safer injection strategies. Common reasons for not counseling included limited time and a desire to emphasize antibiotic therapy/medical issues (62%), lack of training (55%), and believing that it would be better addressed by other services (47%). Among respondents who reported counseling PWID, most recommended abstinence from IDU (72%), handwashing and skin cleansing before injection (62%), and safe disposal of needles/drug equipment used before admission (54%). Conclusions: Almost all ID physicians report screening PWID for HIV and viral hepatitis and discussing the risks of these infections. Despite frequently encountering PWID, fewer than half of ID physicians provide safer injection advice. Opportunities exist to standardize harm reduction education, emphasizing safer injection practices in conjunction with other strategies to prevent infections (eg, HIV PrEP or hepatitis A virus/hepatitis B virus vaccination).

Using Thermal Imaging to Track Cellulitis.

Background: Cellulitis is a common soft tissue infection and a major cause of morbidity. The diagnosis is based almost exclusively on clinical history and physical exam. To improve the diagnosis of cellulitis, we used a thermal camera to track how skin temperature of the affected area changed during a hospital stay for patients with cellulitis. Methods: We recruited 120 patients admitted with a diagnosis of cellulitis. Daily thermal images of the affected limb were taken. Temperature intensity and area were analyzed from the images. Highest daily body temperature and antibiotics administered were also collected.We estimated a longitudinal linear mixed-effects model with a random intercept for the affected body area. All observations on a given day were included, and we used an integer time indicator indexed to the initial day (ie, t = 1 for the first day the patient was observed, etc.). We then analyzed the effect of this time trend on both severity (ie, normalized temperature) and scale (ie, area of skin with elevated temperature). Results: We analyzed thermal images from the 41 patients with a confirmed case of cellulitis who had at least 3 days of photos. For each day that the patient was observed, the severity decreased by 1.63 (95% CI, -13.45 to 10.32) units on average, and the scale decreased by 0.63 (95% CI, -1.08 to -0.17) points on average. Also, patients' body temperatures decreased by 0.28°F each day (95% CI, -0.40 to -0.17). Conclusions: Thermal imaging could be used to help diagnose cellulitis and track clinical progress.

A comprehensive framework to estimate the frequency, duration, and risk factors for diagnostic delays using bootstrapping-based simulation methods.

BACKGROUND: The incidence of diagnostic delays is unknown for many diseases and specific healthcare settings. Many existing methods to identify diagnostic delays are resource intensive or difficult to apply to different diseases or settings. Administrative and other real-world data sources may offer the ability to better identify and study diagnostic delays for a range of diseases. METHODS: We propose a comprehensive framework to estimate the frequency of missed diagnostic opportunities for a given disease using real-world longitudinal data sources. We provide a conceptual model of the disease-diagnostic, data-generating process. We then propose a bootstrapping method to estimate measures of the frequency of missed diagnostic opportunities and duration of delays. This approach identifies diagnostic opportunities based on signs and symptoms occurring prior to an initial diagnosis, while accounting for expected patterns of healthcare that may appear as coincidental symptoms. Three different bootstrapping algorithms are described along with estimation procedures to implement the resampling. Finally, we apply our approach to the diseases of tuberculosis, acute myocardial infarction, and stroke to estimate the frequency and duration of diagnostic delays for these diseases. RESULTS: Using the IBM MarketScan Research databases from 2001 to 2017, we identified 2,073 cases of tuberculosis, 359,625 cases of AMI, and 367,768 cases of stroke. Depending on the simulation approach that was used, we estimated that 6.9-8.3% of patients with stroke, 16.0-21.3% of patients with AMI and 63.9-82.3% of patients with tuberculosis experienced a missed diagnostic opportunity. Similarly, we estimated that, on average, diagnostic delays lasted 6.7-7.6 days for stroke, 6.7-8.2 days for AMI, and 34.3-44.5 days for tuberculosis. Estimates for each of these measures was consistent with prior literature; however, specific estimates varied across the different simulation algorithms considered. CONCLUSIONS: Our approach can be easily applied to study diagnostic delays using longitudinal administrative data sources. Moreover, this general approach can be customized to fit a range of diseases to account for specific clinical characteristics of a given disease. We summarize how the choice of simulation algorithm may impact the resulting estimates and provide guidance on the statistical considerations for applying our approach to future studies.