Population and hospital-level COVID-19 measures are associated with increased risk of hospital-onset COVID-19.

A review of hospital-onset COVID-19 cases revealed 8 definite, 106 probable, and 46 possible cases. Correlations between hospital-onset cases and both HCW and inpatient cases were noted in 2021. Rises in community measures were associated with rises in hospital-onset cases. Measures of community COVID-19 activity might predict hospital-onset cases.

A severe acute respiratory coronavirus virus 2 (SARS-CoV-2) nosocomial cluster with inter-facility spread: Lessons learned.

BACKGROUND: Despite infection control guidance, sporadic nosocomial coronavirus disease 2019 (COVID-19) outbreaks occur. We describe a complex severe acute respiratory coronavirus virus 2 (SARS-CoV-2) cluster with interfacility spread during the SARS-CoV-2 δ (delta) pandemic surge in the Midwest. SETTING: This study was conducted in (1) a hematology-oncology ward in a regional academic medical center and (2) a geographically distant acute rehabilitation hospital. METHODS: We conducted contact tracing for each COVID-19 case to identify healthcare exposures within 14 days prior to diagnosis. Liberal testing was performed for asymptomatic carriage for patients and staff. Whole-genome sequencing was conducted for all available clinical isolates from patients and healthcare workers (HCWs) to identify transmission clusters. RESULTS: In the immunosuppressed ward, 19 cases (4 patients, 15 HCWs) shared a genetically related SARS-CoV-2 isolate. Of these 4 patients, 3 died in the hospital or within 1 week of discharge. The suspected index case was a patient with new dyspnea, diagnosed during preprocedure screening. In the rehabilitation hospital, 20 cases (5 patients and 15 HCWs) positive for COVID-19, of whom 2 patients and 3 HCWs had an isolate genetically related to the above cluster. The suspected index case was a patient from the immune suppressed ward whose positive status was not detected at admission to the rehabilitation facility. Our response to this cluster included the following interventions in both settings: restricting visitors, restricting learners, restricting overflow admissions, enforcing strict compliance with escalated PPE, access to on-site free and frequent testing for staff, and testing all patients prior to hospital discharge and transfer to other facilities. CONCLUSIONS: Stringent infection control measures can prevent nosocomial COVID-19 transmission in healthcare facilities with high-risk patients during pandemic surges. These interventions were successful in ending these outbreaks.

A Predictive Model to Identify Complicated Clostridiodes difficile Infection.

Background: Clostridioides difficile infection (CDI) is a leading cause of health care-associated infection and may result in organ dysfunction, colectomy, and death. Published risk scores to predict severe complications from CDI demonstrate poor performance upon external validation. We hypothesized that building and validating a model using geographically and temporally distinct cohorts would more accurately predict risk for complications from CDI. Methods: We conducted a multicenter retrospective cohort study of adults diagnosed with CDI. After randomly partitioning the data into training and validation sets, we developed and compared 3 machine learning algorithms (lasso regression, random forest, stacked ensemble) with 10-fold cross-validation to predict disease-related complications (intensive care unit admission, colectomy, or death attributable to CDI) within 30 days of diagnosis. Model performance was assessed using the area under the receiver operating curve (AUC). Results: A total of 3646 patients with CDI were included, of whom 217 (6%) had complications. All 3 models performed well (AUC, 0.88-0.89). Variables of importance were similar across models, including albumin, bicarbonate, change in creatinine, non-CDI-related intensive care unit admission, and concomitant non-CDI antibiotics. Sensitivity analyses indicated that model performance was robust even when varying derivation cohort inclusion and CDI testing approach. However, race was an important modifier, with models showing worse performance in non-White patients. Conclusions: Using a large heterogeneous population of patients, we developed and validated a prediction model that estimates risk for complications from CDI with good accuracy. Future studies should aim to reduce the disparity in model accuracy between White and non-White patients and to improve performance overall.

Development of a Pharmacist-Led Opt-Out Cessation Treatment Protocol for Combustible Tobacco Smoking Within Inpatient Settings.

Background: Although people who smoke cigarettes are overrepresented among hospital inpatients, few are connected with smoking cessation treatment during their hospitalization. Training, accountability for medication use, and monitoring of all patients position pharmacists well to deliver cessation interventions to all hospitalized patients who smoke. Methods: A large Midwestern University hospital implemented a pharmacist-led smoking cessation intervention. A delegation protocol for hospital pharmacy inpatients who smoked cigarettes gave hospital pharmacists the authority to order nicotine replacement therapy (NRT) during hospitalization and upon discharge, and for referral to the Wisconsin Tobacco Quit Line (WTQL) at discharge. Eligible patients received the smoking cessation intervention unless they actively refused (ie, "opt-out"). The program was pilot tested in phases, with pharmacist feedback between phases, and then implemented hospital-wide. Interviews, surveys, and informal mechanisms identified ways to improve implementation and workflows. Results: Feedback from pharmacists led to changes that improved workflow, training and patient education materials, and enhanced adoption and reach. Refining implementation strategies across pilot phases increased the percentage of eligible smokers offered pharmacist-delivered cessation support from 37% to 76%, prescribed NRT from 2% to 44%, and referred to the WTQL from 3% to 32%. Conclusion: Hospitalizations provide an ideal opportunity for patients to make a tobacco quit attempt, and pharmacists can capitalize on this opportunity by integrating smoking cessation treatment into existing inpatient medication reconciliation workflows. Pharmacist-led implementation strategies developed in this study may be applicable in other inpatient settings.

Documented ß-Lactam Allergy and Risk for Cesarean Surgical Site Infection.

Objective: To examine the relationship between documented ß-lactam allergy and cesarean delivery (CD) surgical site infection (SSI). Study Design. We conducted a retrospective cohort analysis of women who underwent CD at Ben Taub Hospital and Texas Children's Pavilion for Women (Houston, TX) from August 1, 2011, to December 31, 2019. The primary exposure was a documented ß-lactam allergy, and the second exposure of interest was the type of perioperative antibiotic received. The primary outcome was the prevalence of SSI. Maternal characteristics were stratified by the presence or absence of a documented ß-lactam allergy, and significance was evaluated using Pearson's chi-squared test for categorical variables and t-test for continuous variables. A logistic regression model estimated odds of SSI after adjusting for possible confounders. Results: Of the 12,954 women included, 929 (7.2%) had a documented ß-lactam allergy while 12,025 (92.8%) did not. Among the 929 women with a ß-lactam allergy, 495 (53.3%) received non-ß-lactam perioperative prophylaxis. SSI occurred in 38 (4.1%) of women who had a ß-lactam allergy versus 238 (2.0%) who did not (p ≤ 0.001). ß-Lactam allergy was associated with higher odds of SSI compared to no allergy (adjusted odds ratio (aOR) = 1.97; 95%confidence interval (CI) = 1.24-3.14; p = 0.004) after controlling for age, race, ethnicity, insurance status, delivery body mass index (BMI), tobacco use, intra-amniotic infection in labor, duration of membrane rupture, preterm delivery, delivery indication, diabetes, hypertension, group B Streptococcus colonization, and type of perioperative antibiotic received. Conclusion: The presence of a ß-lactam allergy is associated with increased odds of developing a CD SSI after controlling for possible confounders, including the type of perioperative antibiotic received.

External Validation and Comparison of Clostridioides difficile Severity Scoring Systems.

BACKGROUND: Many models have been developed to predict severe outcomes from Clostridioides difficile infection (CDI). These models are usually developed at a single institution and largely are not externally validated. Our aim in this study was to validate previously published risk scores in a multicenter cohort of patients with CDI. METHODS: This was a retrospective study on 4 inpatient cohorts with CDI from 3 distinct sites: the universities of Michigan (2010-2012 and 2016), Chicago (2012), and Wisconsin (2012). The primary composite outcome was admission to an intensive care unit, colectomy, and/or death attributed to CDI within 30 days of positive testing. Both within each cohort and combined across all cohorts, published CDI severity scores were assessed and compared to each other and the Infectious Diseases Society of America (IDSA) guideline definitions of severe and fulminant CDI. RESULTS: A total of 3646 patients were included for analysis. Including the 2 IDSA guideline definitions, 14 scores were assessed. Performance of scores varied within each cohort and in the combined set (mean area under the receiver operator characteristic curve [AuROC], 0.61; range, 0.53-0.66). Only half of the scores had performance at or better than IDSA severe and fulminant definitions (AuROCs of 0.64 and 0.63, respectively). Most of the scoring systems had more false than true positives in the combined set (mean, 81.5%; range, 0%-91.5%). CONCLUSIONS: No published CDI severity score showed stable, good predictive ability for adverse outcomes across multiple cohorts/institutions or in a combined multicenter cohort.

Prevalence of antimicrobial resistance and its clinical implications in Ethiopia: a systematic review.

BACKGROUND: Antimicrobial resistance is one of the major public health challenges in Ethiopia. However, there is no comprehensive summary of existing AMR data in the country. AIM: To determine the prevalence of antimicrobial resistance and its clinical implications in Ethiopia. METHODS: A systematic literature search was performed on the PubMed/Medline database. Original studies on antimicrobial resistance conducted in Ethiopia between 1st January 2009 and 31st July 2019 were included. The outcome measure was the number of isolates resistant to antimicrobial agents in terms of specific pathogens, and disease condition. Data was calculated as total number of resistant isolates relative to the total number of isolates per specific pathogen and medication. RESULTS: A total of 48,021 study participants enrolled from 131 original studies were included resulting in 15,845 isolates tested for antimicrobial resistance. The most common clinical sample sources were urine (28%), ear, nose, and throat discharge collectively (27%), and blood (21%). All the studies were cross-sectional and 83% were conducted in hospital settings. Among Gram-positive bacteria, the reported level of resistance to vancomycin ranged from 8% (Enterococcus species) to 20% (S. aureus). E. coli, K. pneumoniae and P. aeruginosa were the most common Gram-negative pathogens resistant to key antimicrobial agents described in the national standard treatment guideline and were associated with diverse clinical conditions: urinary tract infections, diarrhea, surgical site infections, pneumonia, ocular infections, and middle ear infections. CONCLUSION: Overall, there is a high prevalence of antimicrobial resistance in Ethiopia. Empirical treatment of bacterial infections needs to be guided by up-to-date national guidelines considering local antimicrobial susceptibility patterns. Equipping diagnostic laboratories with culture and drug susceptibility testing facilities, and establishing a strong antimicrobial stewardship program should be high priorities.

Utilizing the SEIPS model to guide hand hygiene interventions at a tertiary hospital in Ethiopia.

We aimed to apply the Systems Engineering Initiative for Patient Safety (SEIPS) model to increase effectiveness and sustainability of the World Health Organization's (WHOs) hand hygiene (HH) guidelines within healthcare systems. Our cross-sectional, mixed-methods study took place at Jimma University Medical Center (JUMC), a tertiary care hospital in Jimma, Ethiopia, between November 2018 and August 2020 and consisted of three phases: baseline assessment, intervention, and follow-up assessment. We conducted questionnaires addressing HH knowledge and attitudes, interviews to identify HH barriers and facilitators within the SEIPS framework, and observations at the WHO's 5 moments of HH amongst healthcare workers (HCWs) at JUMC. We then implemented HH interventions based on WHO guidelines and results from our baseline assessment. Follow-up HH observations were conducted months later during the Covid-19 pandemic. 250 HCWs completed questionnaires with an average knowledge score of 61.4% and attitude scores indicating agreement that HH promotes patient safety. Interview participants cited multiple barriers to HH including shortages and location of HH materials, inadequate training, minimal Infection Prevention Control team presence, and high workload. We found an overall baseline HH compliance rate of 9.4% and a follow-up compliance rate of 72.1%. Drastically higher follow-up compared to baseline compliance rates were likely impacted by our HH interventions and Covid-19. HCWs showed motivation for patient safety despite low HH knowledge. Utilizing the SEIPS model helped identify institution-specific barriers that informed targeted interventions beyond WHO guidelines aimed at increasing effectiveness and sustainability of HH efforts.

Risk Factors and Mortality for Atypical Presentation of COVID-19 Infection in Hospitalized Patients - Lessons From the Early Pandemic.

OBJECTIVE: To assess the clinical epidemiology and outcomes of patients hospitalized with COVID-19 who did not experience fever and cough during the early pandemic. METHODS: Retrospective cohort of all patients admitted during March 13, 2020 through May 13, 2020 with laboratory-confirmed COVID-19 to 3 tertiary-care hospitals. Patient-level data (demographic, clinical manifestations, comorbid illnesses, inpatient treatment) were analyzed. The main outcome variable was atypical presentation, defined as any hospitalized patient with COVID-19 infection who did not experience both fever and cough. We identified risk factors for atypical presentation on univariate and multivariate analyses and assessed 30-day mortality differences via survival analysis. RESULTS: Of 163 patients in the study, 39 (24%) were atypical. On univariate analysis, atypical cases were significantly more likely to be older, reside in a long-term-care facility (LTCF), and have underlying diabetes mellitus, stroke, or cardiac disease; present without dyspnea or myalgia, have lower C-reactive proteins (CRP) and higher beta-natriuretic peptides. They were less likely to receive intensive care unit care or specific COVID-19 treatments (P < .05). The incidence of acute respiratory failure was not significantly different between the groups. On logistic regression, atypical cases were significantly more likely to be LTCF residents (P = 0.003) and have a lower average CRP (P = 0.01). Atypical cases had significantly higher 30-day mortality (hazard ratio 3.4 [95% CI, 1.6 - 7.2], P = 0.002). CONCLUSION: During the first pandemic surge, COVID-19 patients without inflammatory signs and symptoms were more likely to be LTCF residents and had higher mortality. Timely recognition of these atypical presentations may have prevented spread and improved clinical outcomes.

Barriers and facilitators to influenza-like illness absenteeism among healthcare workers in a tertiary-care healthcare system, 2017-2018 influenza season.

OBJECTIVE: Influenza can be introduced and propagated in healthcare settings by healthcare workers (HCWs) working while ill with influenza. However, reasons driving this behavior are unclear. In this study, we examined barriers to and facilitators of absenteeism during the influenza season. DESIGN: Cross-sectional mixed methods study. SETTING: Ambulatory and inpatient settings in a large, tertiary-care healthcare system. METHODS: An anonymous electronic survey was sent to HCWs between June 11 and July 13, 2018, asking participants to self-report influenza-like illness (ie, ILI symptoms of fever, chills, cough, or sore throat) during the 2017-2018 influenza season. We conducted a logistical regression analysis to identify factors associated with absenteeism. RESULTS: Of 14,250 HCWs, 17% responded to the survey. Although 1,180 respondents (51%) reported symptoms of ILI, 575 (43%) did not stay home while ill. The most commonly perceived barriers to ILI absenteeism included being understaffed (odds ratio [OR], 1.78; P = .04), unable to find a replacement for work (OR, 2.26; P = .03), desiring not to use time off (OR, 2.25; P = .003), and paid by the hour or unable to afford being absent (OR, 2.05; P = .02). Common perceived facilitators of absenteeism included support from coworkers and management, clearer policy, better sick days availability, and lower perceived threat of disciplinary action. CONCLUSIONS: Reporting to work with ILI symptoms is common among HCWs. Most barriers and facilitators are related to systems. Addressing system factors, such as policies regarding sick days and sick leave and ensuring adequate backup staffing, is likely to facilitate absenteeism among ill HCWs.

Current practices and evaluation of barriers and facilitators to surgical site infection prevention measures in Jimma, Ethiopia.

Objective: Surgical site infections (SSIs) greatly burden healthcare systems around the world, particularly in low- and middle-income countries. We sought to employ the Systems Engineering Initiative for Patient Safety (SEIPS) model to better characterize SSI prevention practices and factors affecting adherence to prevention guidelines at Jimma University Medical Center (JUMC). Design: Our cross-sectional study consisted of semistructured interviews designed to elicit perceptions of and barriers and facilitators to SSI prevention among surgical staff and observations of current preoperative, perioperative, and postoperative SSI prevention practices in surgical cases. Interviews were recorded, manually transcribed, and thematically coded within the SEIPS framework. Trained observers recorded compliance with the World Health Organization's SSI prevention recommendations. Setting: A tertiary-care hospital in Jimma, Ethiopia. Participants: Surgical nurses, surgeons, and anesthetists at JUMC. Results: Within 16 individual and group interviews, participants cited multiple barriers to SSI prevention including shortages of water and antiseptic materials, lack of clear SSI guidelines and training, minimal Infection Prevention Control (IPC) interaction with surgical staff, and poor SSI tracking. Observations from nineteen surgical cases revealed high compliance with antibiotic prophylaxis (94.7%), hand scrubbing (100%), sterile gloves and instrument use (100%), incision site sterilization (100%), and use of surgical safety checklist (94.7%) but lower compliance with preoperative bathing (26.3%), MRSA screening (0%), and pre- and postoperative glucose (0%, 10.5%) and temperature (57.9%, 47.3%) monitoring. Conclusions: Utilizing the SEIPS model helped identify institution-specific barriers and facilitators that can inform targeted interventions to increase compliance with currently underperformed SSI prevention practices at JUMC.

Neighborhood disadvantage and 30-day readmission risk following Clostridioides difficile infection hospitalization.

BACKGROUND: Clostridioides difficile infection (CDI) is commonly associated with outcomes like recurrence and readmission. The effect of social determinants of health, such as 'neighborhood' socioeconomic disadvantage, on a CDI patient's health outcomes is unclear. Living in a disadvantaged neighborhood could interfere with a CDI patient's ability to follow post-discharge care recommendations and the success probability of these recommendations, thereby increasing risk of readmission. We hypothesized that neighborhood disadvantage was associated with 30-day readmission risk in Medicare patients with CDI. METHODS: In this retrospective cohort study, odds of 30-day readmission for CDI patients are evaluated controlling for patient sociodemographics, comorbidities, and hospital and stay-level variables. The cohort was created from a random 20% national sample of Medicare patients during the first 11 months of 2014. RESULTS: From the cohort of 19,490 patients (39% male; 80% white; 83% 65 years or older), 22% were readmitted within 30 days of an index stay. Unadjusted analyses showed that patients from the most disadvantaged neighborhoods were readmitted at a higher rate than those from less disadvantaged neighborhoods (26% vs. 21% rate: unadjusted OR = 1.32 [1.20, 1.45]). This relationship held in adjusted analyses, in which residence in the most disadvantaged neighborhoods was associated with 16% increased odds of readmission (adjusted OR = 1.16 [1.04, 1.28]). CONCLUSIONS: Residence in disadvantaged neighborhoods poses a significantly increased risk of readmission in CDI patients. Further research should focus on in-depth assessments of this population to better understand the mechanisms underlying these risks and if these findings apply to other infectious diseases.

Barriers and facilitators to standardization of ultrasound use and probe disinfection in the ambulatory setting.

To determine barriers and facilitators to standardization of ultrasound probe disinfection at ambulatory sites, we conducted observations and interviews of staff. Variability was noted in disinfection practices and in the use of protective equipment even for procedures with the potential for the probe to contact sterile tissues. Standardization is needed.

Outcomes of Community and Healthcare-onset Clostridium difficile Infections.

BACKGROUND: Community-onset Clostridium difficile infections (CDI) are increasingly common, but there is little data on outcomes. The purpose of this study is to describe the epidemiology and outcomes of CDI in the Veterans Health Administration (VHA) system and compare these variables between hospital-onset (HCF) and community-onset (CO) cases. METHODS: We conducted a retrospective cohort study that included all patients with a positive test for C. difficile (toxin or toxin genes) within the VHA Corporate Data Warehouse between 2011 and 2014. RESULTS: We identified 19270 episodes of CDI, involving 15972 unique patients; 95% were male, 44% of the cases were HCF, and 42% were CO. Regarding severity, 31% percent of cases were non-severe, 40% were severe, and 21% were fulminant. Exposure to proton pump inhibitors was found in 53% of cases (47% in CO, 62% in HCF). Overall, 40% of patients received antibiotics in the 90 days before CDI (44% in HCF, 36% in CO). Recurrence was 18.2%, and 30-day all-cause mortality was 9.2%. Risk factors for a fulminant case were exposure to clindamycin (odds ratio [OR]: 1.23, P = .01) or proton pump inhibitors (OR: 1.20, P < .001) in the 90 days prior to diagnosis. CONCLUSIONS: CO accounts for a significant proportion of CDI in the VHA system. CO patients are younger and their cases are less severe, but recurrence is more common than in HCF CDI. Therefore CO CDI may account for a considerable reservoir of CDI cases, and prevention efforts should include interventions to reduce CO CDI.

Barriers and Facilitators to Injection Safety in Ambulatory Care Settings.

OBJECTIVEIdentify factors referred to as barriers and facilitators that can prevent or assist safe injection practices in ambulatory care settings to guide quality improvement.DESIGNIn this mixed-methods study, we utilized observations and interviews.SETTINGThis study was conducted at ambulatory clinics at a midwestern academic medical center from May through August 2017. Sites included a variety of clinical settings that performed intramuscular, intradermal, intravenous, or intra-articular injections.PARTICIPANTS AND INTERVENTIONSDirect observations of injections and interviews of ambulatory care staff were conducted. An observation checklist was created, including standards of injection safety from nationally recognized guidelines. Interview questions were developed using the System Engineering Initiative for Patient Safety (SEIPS) model. Interviews were recorded, transcribed, and then coded by 2 investigators.RESULTSIn total, 106 observations and 36 interviews were completed at 21 clinics. Injection safety standards with the lowest adherence included using needleless access devices to prepare injections (33%) and the proper use of multidose vials (<80%). Of 819 coded interview segments, 461 (56.3%) were considered facilitators of safe injection practices. The most commonly identified barriers were patient movement during administration, feeling rushed, and inadequate staffing. The most commonly identified facilitators were availability of supplies, experience in the practice area, and availability of safety needles and prefilled syringes.CONCLUSIONSPerceived barriers and facilitators to infection control elements of injection safety are interconnected with SEIPS elements of persons, organizations, technologies, tasks, and environment. Direct observations demonstrated that knowledge of safety injection standards does not necessarily translate to best practices and may not match self-reported data.Infect Control Hosp Epidemiol 2018;39:841-848.

Wisconsin microbiome study, a cross-sectional investigation of dietary fibre, microbiome composition and antibiotic-resistant organisms: rationale and methods.

INTRODUCTION: Prevention of multidrug-resistant organism (MDRO) infections, such as those caused by methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, fluoroquinolone-resistant Gram-negative bacteria and Clostridium difficile is crucial. Evidence suggests that dietary fibre increases gut microbial diversity, which may help prevent colonisation and subsequent infection by MDROs. The aim of the Winning the War on Antibiotic Resistance (WARRIOR) project is to examine associations of dietary fibre consumption with the composition of the gut microbiota and gut colonisation by MDROs. The secondary purpose of the study is to create a biorepository of multiple body site specimens for future microbiota research. METHODS AND ANALYSIS: The WARRIOR project collects biological specimens, including nasal, oral and skin swabs and saliva and stool samples, along with extensive data on diet and MDRO risk factors, as an ancillary study of the Survey of the Health of Wisconsin (SHOW). The SHOW is a population-based health survey collecting data on several different health determinants and outcomes, as well as objective body measurements and biological specimens. WARRIOR participants include 600 randomly selected Wisconsin residents age 18 and over. Specimens are screened for MDRO colonisation and DNA is extracted for 16S ribosomal RNA-based microbiota sequencing. Data will be analysed to assess the relationship between dietary fibre, the gut microbiota composition and gut MDRO colonisation. ETHICS AND DISSEMINATION: The WARRIOR project is approved by the University of Wisconsin Institutional Review Board. The main results of this study will be published in a peer-reviewed scientific journal.

Cessation-related information, motivation, and behavioral skills in smokers living with HIV.

There is a need for new, targeted smoking cessation interventions for smokers living with HIV. The Information-Motivation-Behavioral Skills (IMB) model has been applied effectively to HIV-related health behaviors and was used in this qualitative study to elicit factors that could lead to the development of innovative and successful cessation interventions for this population. Twenty individuals who smoked from two clinics providing care to people living with HIV participated in open-ended interviews, responding to questions covering the domains of the IMB model, as applied to smokers living with HIV. Participants were enrolled from a larger survey cohort to recruit into groups based on the impact of HIV diagnosis on smoking as well as attempting to enroll a mix of demographics characteristics. Interviews were recorded, transcribed, coded and thematically analyzed using a grounded theory qualitative approach. Interviews continued until thematic saturation was reached. Major themes included: Presence of knowledge deficits regarding HIV-specific health risks of smoking; use of smoking for emotional regulation, where many reported close contacts who smoke and concern with the effect of cessation on their social networks; Use of smoking cessation aids or a telephone-based wellness intervention were acceptable to most. Providing HIV-specific information in cessation advice is of the utmost importance for clinicians caring for smokers living with HIV, as this theme was noted consistently as a potential motivator to quit. Innovative and effective interventions must account for the social aspect of smoking and address other methods of emotional regulation in this population.

Risk factors for infection with multidrug-resistant organisms in Haryana, India.

BACKGROUND: The objective of this study was to investigate risk factors for multidrug-resistant organism (MDRO) infection within patients from a tertiary care hospital in Northern India. This case-control study examined MDRO infection risk factors, including diet, health history, and medical device use. We administered a diet questionnaire to collect data on usual diet and collected data on other risk factors from chart review. All participants were inpatients identified through hospital microbiology reports. A total of 39 MDRO patient cases and 91 controls were included. METHODS: Descriptive statistics, univariate analysis, and multivariate logistic regression were performed to evaluate the association between risk factors and MDRO infection. RESULTS: All cases had gram-negative MDRO infections. Univariate analyses found length of hospital stay, connective tissue disease, hospitalization in the last 12 months, hospitalization of a family member, in-hospital antibiotic use, antibiotic use in the last 12 months, and feeding tube, central venous line, and urinary catheter use to be significantly different between cases and controls. Logistic regression showed a >3-fold increase in the odds of infection with antibiotic use in the last 12 months (odds ratio [OR], 3.30; 95% confidence interval [CI], 1.22-8.91) and urinary catheter use (OR, 3.63; 95% CI, 1.14-11.58). Differences in dietary preferences and fruit, vegetable, and fiber consumption were not significantly associated with infection. CONCLUSIONS: Antibiotic use is a major driver of MDRO infections. Our findings suggest that interventions optimizing antibiotic stewardship and reducing device use should be a priority to prevent MDRO infections.

Challenges to Safe Injection Practices in Ambulatory Care.

Most recent infection outbreaks caused by unsafe injection practices in the United States have occurred in ambulatory settings. We utilized direct observation and a survey to assess injection practices at 31 clinics. Improper vial use was observed at 13 clinics (41.9%). Pharmacy support and healthcare worker education may improve injection practices. Infect Control Hosp Epidemiol 2017;38:614-616.