Evaluation of hospital-onset bacteraemia and fungaemia in the USA as a potential healthcare quality measure: a cross-sectional study.

BACKGROUND: Hospital-onset bacteraemia and fungaemia (HOB) is being explored as a surveillance and quality metric. The objectives of the current study were to determine sources and preventability of HOB in hospitalised patients in the USA and to identify factors associated with perceived preventability. METHODS: We conducted a cross-sectional study of HOB events at 10 academic and three community hospitals using structured chart review. HOB was defined as a blood culture on or after hospital day 4 with growth of one or more bacterial or fungal organisms. HOB events were stratified by commensal and non-commensal organisms. Medical resident physicians, infectious disease fellows or infection preventionists reviewed charts to determine HOB source, and infectious disease physicians with training in infection prevention/hospital epidemiology rated preventability from 1 to 6 (1=definitely preventable to 6=definitely not preventable) using a structured guide. Ratings of 1-3 were collectively considered 'potentially preventable' and 4-6 'potentially not preventable'. RESULTS: Among 1789 HOB events with non-commensal organisms, gastrointestinal (including neutropenic translocation) (35%) and endovascular (32%) were the most common sources. Overall, 636/1789 (36%) non-commensal and 238/320 (74%) commensal HOB events were rated potentially preventable. In logistic regression analysis among non-commensal HOB events, events attributed to intravascular catheter-related infection, indwelling urinary catheter-related infection and surgical site infection had higher odds of being rated preventable while events with neutropenia, immunosuppression, gastrointestinal sources, polymicrobial cultures and previous positive blood culture in the same admission had lower odds of being rated preventable, compared with events without those attributes. Of 636 potentially preventable non-commensal HOB events, 47% were endovascular in origin, followed by gastrointestinal, respiratory and urinary sources; approximately 40% of those events would not be captured through existing healthcare-associated infection surveillance. DISCUSSION: Factors identified as associated with higher or lower preventability should be used to guide inclusion, exclusion and risk adjustment for an HOB-related quality metric.

New Vibrio cholerae sequences from Eastern and Southern Africa alter our understanding of regional cholera transmission.

Despite ongoing containment and vaccination efforts, cholera remains prevalent in many countries in sub-Saharan Africa. Part of the difficulty in containing cholera comes from our lack of understanding of how it circulates throughout the region. To better characterize regional transmission, we generated and analyzed 118 Vibrio cholerae genomes collected between 2007-2019 from five different countries in Southern and Eastern Africa. We showed that V. cholerae sequencing can be successful from a variety of sample types and filled in spatial and temporal gaps in our understanding of circulating lineages, including providing some of the first sequences from the 2018-2019 outbreaks in Uganda, Kenya, Tanzania, Zambia, and Malawi. Our results present a complex picture of cholera transmission in the region, with multiple lineages found to be co-circulating within several countries. We also find evidence that previously identified sporadic cases may be from larger, undersampled outbreaks, highlighting the need for careful examination of sampling biases and underscoring the need for continued and expanded cholera surveillance across the African continent.

Medical education during the COVID-19 pandemic: a reflection on the JHUSOM experience.

BACKGROUND: We sought to understand the relative risk of COVID-19 infection and identify risk factors for infection to identify targets for mitigation among medical students. METHODS: An observational cohort study of Johns Hopkins School of Medicine students was conducted from June 2020 to July 2021. Blood samples were collected and tested at three visits to assess for antibodies against SARS-CoV-2. Additionally, a questionnaire was administered at each visit to collect demographic information and assess potential social and behavioral risk factors. RESULTS: 264 students enrolled in the study, and 38 participants completed all study requirements by study end. Roughly 6% of the first- and second-year classes had a reported positive COVID-19 test compared to 5% of third- and fourth-year students. By visit 3, 92% of medical students had detectable antibodies against COVID-19 compared to 4% during the study enrollment period. From study enrollment to visit 3, there was a 10-fold increase in the percentage of students reporting attending large social gatherings and dining in restaurants. CONCLUSIONS: Overall, few COVID-19 cases were found among medical students, even those on clinical rotations. As the study progressed, students reported engaging in higher-risk social behaviors in conjunction with increasing vaccination rates among students.

Association of Nirmatrelvir/Ritonavir Treatment and COVID-19-Neutralizing Antibody Titers in a Longitudinal Health Care Worker Cohort.

Nirmatrelvir/ritonavir (NMV/r) is used for the treatment of coronavirus disease 2019 (COVID-19) infection. However, rebound COVID-19 infections can occur after taking NMV/r. We examined neutralizing antibodies to the severe acute respiratory syndrome coronavirus 2 spike protein before and after infection in people who did and did not take NMV/r to determine if NMV/r impedes the humoral immune response.

Diagnostic stewardship to improve patient outcomes and healthcare-associated infection (HAI) metrics.

Diagnostic stewardship seeks to improve ordering, collection, performance, and reporting of tests. Test results play an important role in reportable HAIs. The inclusion of HAIs in public reporting and pay for performance programs has highlighted the value of diagnostic stewardship as part of infection prevention initiatives. Inappropriate testing should be discouraged, and approaches that seek to alter testing solely to impact a reportable metric should be avoided. HAI definitions should be further adapted to new testing technologies, with focus on actionable and clinically relevant test results that will improve patient care.

A Survey of PICU Clinician Practices and Perceptions regarding Respiratory Cultures in the Evaluation of Ventilator-Associated Infections in the BrighT STAR Collaborative.

OBJECTIVES: To characterize respiratory culture practices for mechanically ventilated patients, and to identify drivers of culture use and potential barriers to changing practices across PICUs. DESIGN: Cross-sectional survey conducted May 2021-January 2022. SETTING: Sixteen academic pediatric hospitals across the United States participating in the BrighT STAR Collaborative. SUBJECTS: Pediatric critical care medicine physicians, advanced practice providers, respiratory therapists, and nurses. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We summarized the proportion of positive responses for each question within a hospital and calculated the median proportion and IQR across hospitals. We correlated responses with culture rates and compared responses by role. Sixteen invited institutions participated (100%). Five hundred sixty-eight of 1,301 (44%) e-mailed individuals completed the survey (median hospital response rate 60%). Saline lavage was common, but no PICUs had a standardized approach. There was the highest variability in perceived likelihood (median, IQR) to obtain cultures for isolated fever (49%, 38-61%), isolated laboratory changes (49%, 38-57%), fever and laboratory changes without respiratory symptoms (68%, 54-79%), isolated change in secretion characteristics (67%, 54-78%), and isolated increased secretions (55%, 40-65%). Respiratory cultures were likely to be obtained as a "pan culture" (75%, 70-86%). There was a significant correlation between higher culture rates and likelihood to obtain cultures for isolated fever, persistent fever, isolated hypotension, fever, and laboratory changes without respiratory symptoms, and "pan cultures." Respondents across hospitals would find clinical decision support (CDS) helpful (79%) and thought that CDS would help align ICU and/or consulting teams (82%). Anticipated barriers to change included reluctance to change (70%), opinion of consultants (64%), and concern for missing a diagnosis of ventilator-associated infections (62%). CONCLUSIONS: Respiratory culture collection and ordering practices were inconsistent, revealing opportunities for diagnostic stewardship. CDS would be generally well received; however, anticipated conceptual and psychologic barriers to change must be considered.

Microbiome dysbiosis: a modifiable state and target to prevent Staphylococcus aureus infections and other diseases in neonates.

Bacterial infections present a significant threat to neonates. Increasingly, studies demonstrate associations between human diseases and the microbiota, the communities of microorganisms on or in the body. A "healthy" microbiota with a great diversity and balance of microorganisms can resist harmful pathogens and protect against infections, whereas a microbiota suffering from dysbiosis, can predispose to pathogen colonization and subsequent infection. For decades, strategies such as bacterial interference, decolonization, prebiotics, and probiotics have been tested to reduce Staphylococcus aureus disease and other infections in neonates. More recently, microbiota transplant has emerged as a strategy to broadly correct dysbiosis, promote colonization resistance, and prevent infections. This paper discusses the benefits of a healthy neonate's microbiota, exposures that alter the microbiota, associations of dysbiosis and neonatal disease, strategies to prevent dysbiosis, such as microbiota transplantation, and presents a framework of microbiome manipulation to reduce Staphylococcus aureus (S. aureus) and other infections in neonates.

Three doses of COVID-19 mRNA vaccine induce class-switched antibody responses in inflammatory arthritis patients on immunomodulatory therapies.

Patients with inflammatory arthritis (IA) are at increased risk of severe COVID-19 due to medication-induced immunosuppression that impairs host defenses. The aim of this study was to assess antibody and B cell responses to COVID-19 mRNA vaccination in IA patients receiving immunomodulatory therapies. Adults with IA were enrolled through the Johns Hopkins Arthritis Center and compared with healthy controls (HC). Paired plasma and peripheral blood mononuclear cell (PBMC) samples were collected prior to and 30 days or 6 months following the first two doses of mRNA vaccines (D2; HC=77 and IA=31 patients), or 30 days following a third dose of mRNA vaccines (D3; HC=11 and IA=96 patients). Neutralizing antibody titers, total binding antibody titers, and B cell responses to vaccine and Omicron variants were analyzed. Anti-Spike (S) IgG and S-specific B cells developed appropriately in most IA patients following D3, with reduced responses to Omicron variants, and negligible effects of medication type or drug withholding. Neutralizing antibody responses were lower compared to healthy controls after both D2 and D3, with a small number of individuals demonstrating persistently undetectable neutralizing antibody levels. Most IA patients respond as well to mRNA COVID-19 vaccines as immunocompetent individuals by the third dose, with no evidence of improved responses following medication withholding. These data suggest that IA-associated immune impairment may not hinder immunity to COVID-19 mRNA vaccines in most individuals.

Strategies to reduce hospital-associated bloodstream infections in a limited resource setting: Preventing Infections in Neonates (PIN) collaborative.

Background: Hospitalized neonates are at high risk for hospital-associated bloodstream infections (HA-BSI) and require locally contextualized interventions to prevent HA-BSI. Methods: The Preventing Infections in Neonates (PIN) collaborative aimed to reach a 50% decrease in neonatal HA-BSI rates for a 27-bed Level IV neonatal intensive care unit (NICU). Using quality improvement (QI) methodologies, a multidisciplinary cross-cultural collaborative implemented phased and bundled interventions from July 2017 to September 2019. Descriptive statistics and statistical process control charts were used to analyze infection rates. Results: There were 916 admissions, 19,812 patient-days, and 4264 central line days in the NICU during the project period. Monthly baseline preintervention HA-BSI median rate was 3.95/1000 patient-days and decreased to 1.73/1000 patient-days (56% change) during the bundled interventions. Quarterly HA-BSI rates also decreased from the preintervention median of 4.5/1000 patient-days to 3.3/1000 patient-days during the intervention period (IRR 0.73; 95%CI 0.39, 1.36). Staff were highly compliant with hand hygiene and environmental cleaning. Through project efforts, compliance with bundle elements increased from 25% at baseline to a peak of 97% for central line (CL) insertion checklists and from 13% to a peak of 56% for CL maintenance checklists. Conclusions: Unit-based bundled interventions can reduce neonatal HA-BSI in limited resource settings. Future studies can assess similar practices in other units and the impact of the pandemic on interventions to reduce HA-BSIs.

Medical Education during the COVID-19 Pandemic: A Reflection on the JHUSOM Experience.

Background: We sought to understand the relative risk of COVID-19 infection and identify risk factors for infection to identify targets for mitigation among medical students. Methods: An observational cohort study of Johns Hopkins School of Medicine students was conducted from June 2020 to July 2021. Blood samples were collected and tested at three visits to assess for the presence of antibodies against SARS-CoV-2. Additionally, a questionnaire was administered at each visit to collect demographic information and assess potential social and behavioral risk factors. Results: 264 students enrolled in the study, and 38 participants completed all study requirements by study end. Roughly 6% of the first- and second-year classes had a reported positive COVID-19 test compared to 5% of third- and fourth-year students. By visit 3, 92% of medical students had detectable antibodies against COVID-19 compared to 4% during the study enrollment period. From study enrollment to visit 3, there was a 10-fold increase in the percentage of students reporting attending large social gatherings and dining in restaurants. Conclusions: Overall, few COVID-19 cases were found among medical students, even those on clinical rotations. As the study progressed, students reported engaging in higher-risk social behaviors in conjunction with increasing vaccination rates among students.

Sustainability of the Bright STAR Diagnostic Stewardship Program to Reduce Blood Culture Rates Among Critically Ill Children.

This quality improvement study evaluates whether pediatric intensive care units sustained reduced blood culture rates after participation in the Bright STAR collaborative from 2017 to 2020.

Maternal Colonization Versus Nosocomial Transmission as the Source of Drug-Resistant Bloodstream Infection in an Indian Neonatal Intensive Care Unit: A Prospective Cohort Study.

BACKGROUND: Drug-resistant gram-negative (GN) pathogens are a common cause of neonatal sepsis in low- and middle-income countries. Identifying GN transmission patterns is vital to inform preventive efforts. METHODS: We conducted a prospective cohort study, 12 October 2018 to 31 October 2019 to describe the association of maternal and environmental GN colonization with bloodstream infection (BSI) among neonates admitted to a neonatal intensive care unit (NICU) in Western India. We assessed rectal and vaginal colonization in pregnant women presenting for delivery and colonization in neonates and the environment using culture-based methods. We also collected data on BSI for all NICU patients, including neonates born to unenrolled mothers. Organism identification, antibiotic susceptibility testing, and next-generation sequencing (NGS) were performed to compare BSI and related colonization isolates. RESULTS: Among 952 enrolled women who delivered, 257 neonates required NICU admission, and 24 (9.3%) developed BSI. Among mothers of neonates with GN BSI (n = 21), 10 (47.7%) had rectal, 5 (23.8%) had vaginal, and 10 (47.7%) had no colonization with resistant GN organisms. No maternal isolates matched the species and resistance pattern of associated neonatal BSI isolates. Thirty GN BSI were observed among neonates born to unenrolled mothers. Among 37 of 51 BSI with available NGS data, 21 (57%) showed a single nucleotide polymorphism distance of ≤5 to another BSI isolate. CONCLUSIONS: Prospective assessment of maternal GN colonization did not demonstrate linkage to neonatal BSI. Organism-relatedness among neonates with BSI suggests nosocomial spread, highlighting the importance of NICU infection prevention and control practices to reduce GN BSI.

Application of Participatory Ergonomics to the Dissemination of a Quality Improvement Program for Optimizing Blood Culture Use.

BACKGROUND: Blood cultures are overused in pediatric ICUs (PICUs), which may lead to unnecessary antibiotic use and antibiotic resistance. Using a participatory ergonomics (PE) approach, the authors disseminated a quality improvement (QI) program for optimizing blood culture use in PICUs to a national 14-hospital collaborative. The objective of this study was to evaluate the dissemination process and its impact on blood culture reduction. METHODS: The PE approach emphasized three key principles (stakeholder participation, application of human factors and ergonomics knowledge and tools, and cross-site collaboration) with a six-step dissemination process. Data on interactions between sites and the coordinating team and site experiences with the dissemination process were collected using site diaries and semiannual surveys with local QI teams, respectively, and correlated with the site-specific change in blood culture rates. RESULTS: Overall, participating sites were able to successfully implement the program and reduced their blood culture rates from 149.4 blood cultures per 1,000 patient-days/month before implementation to 100.5 blood cultures per 1,000 patient-days/month after implementation, corresponding to a 32.7% relative reduction (p < 0.001). Variations in the dissemination process, as well as in local interventions and implementation strategies, were observed across sites. Site-specific changes in blood culture rates were weakly negatively correlated with the number of preintervention interactions with the coordinating team (p = 0.057) but not correlated with their experiences with the six domains of the dissemination process or their interventions. CONCLUSIONS: The authors applied a PE approach to disseminate a QI program for optimizing PICU blood culture use to a multisite collaborative. Working with local stakeholders, participating sites tailored their interventions and implementation processes and achieved the goal of reducing blood culture use.

Comparison of Administrative Database-Derived and Hospital-Derived Data for Monitoring Blood Culture Use in the Pediatric Intensive Care Unit.

BACKGROUND: Optimizing blood culture practices requires monitoring of culture use. Collecting culture data from electronic medical records can be resource intensive. Our objective was to determine whether administrative data could serve as a data source to measure blood culture use in pediatric intensive care units (PICUs). METHODS: Using data from a national diagnostic stewardship collaborative to reduce blood culture use in PICUs, we compared the monthly number of blood cultures and patient-days collected from sites (site-derived) and the Pediatric Health Information System (PHIS, administrative-derived), an administrative data warehouse, for 11 participating sites. The collaborative's reduction in blood culture use was compared using administrative-derived and site-derived data. RESULTS: Across all sites and months, the median of the monthly relative blood culture rate (ratio of administrative- to site-derived data) was 0.96 (Q1: 0.77, Q3: 1.24). The administrative-derived data produced an estimate of blood culture reduction over time that was attenuated toward the null compared with site-derived data. CONCLUSIONS: Administrative data on blood culture use from the PHIS database correlates unpredictably with hospital-derived PICU data. The limitations of administrative billing data should be carefully considered before use for ICU-specific data.

SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute-care hospitals: 2022 Update.

Previously published guidelines have provided comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing efforts to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection. This document updates the "Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission and Infection in Acute Care Hospitals" published in 2014.1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Healthcare-Associated Respiratory Syncytial Virus in Children's Hospitals.

BACKGROUND: Outbreaks of healthcare-associated respiratory syncytial virus (HA-RSV) infections in children are well described, but less is known about sporadic HA-RSV infections. We assessed the epidemiology and clinical outcomes associated with sporadic HA-RSV infections. METHODS: We retrospectively identified hospitalized children ≤18 years old with HA-RSV infections in six children's hospitals in the United States during the respiratory viral seasons October-April in 2016-2017, 2017-2018, and 2018-2019 and prospectively from October 2020 through November 2021. We evaluated outcomes temporally associated with HA-RSV infections including escalation of respiratory support, transfer to the pediatric intensive care unit (PICU), and in-hospital mortality. We assessed demographic characteristics and comorbid conditions associated with escalation of respiratory support. RESULTS: We identified 122 children (median age 16.0 months [IQR 6, 60 months]) with HA-RSV. The median onset of HA-RSV infections was hospital day 14 (IQR 7, 34 days). Overall, 78 (63.9%) children had two or more comorbid conditions; cardiovascular, gastrointestinal, neurologic/neuromuscular, respiratory, and premature/ neonatal comorbidities were most common. Fifty-five (45.1%) children required escalation of respiratory support and 18 (14.8%) were transferred to the PICU. Five (4.1%) died during hospitalization. In the multivariable analysis, respiratory comorbidities (aOR: 3.36 [CI95 1.41, 8.01]) were associated with increased odds of escalation of respiratory support. CONCLUSIONS: HA-RSV infections cause preventable morbidity and increase healthcare resource utilization. Further study of effective mitigation strategies for HA-respiratory viral infections should be prioritized; this priority is further supported by the impact of the COVID-19 pandemic on seasonal viral infections.