Assessing the Impact of 2-Step Clostridioides difficile Testing at the Healthcare Facility Level.

BACKGROUND: Two-step testing for Clostridioides difficile infection (CDI) aims to improve diagnostic specificity but may also influence reported epidemiology and patterns of treatment. Some providers fear that 2-step testing may result in adverse outcomes if C. difficile is underdiagnosed. METHODS: Our primary objective was to assess the impact of 2-step testing on reported incidence of hospital-onset CDI (HO-CDI). As secondary objectives, we assessed the impact of 2-step testing on C. difficile-specific antibiotic use and colectomy rates as proxies for harm from underdiagnosis or delayed treatment. This longitudinal cohort study included 2 657 324 patient-days across 8 regional hospitals from July 2017 through March 2022. Impact of 2-step testing was assessed by time series analysis with generalized estimating equation regression models. RESULTS: Two-step testing was associated with a level decrease in HO-CDI incidence (incidence rate ratio, 0.53 [95% confidence interval {CI}, .48-.60]; P < .001), a similar level decrease in utilization rates for oral vancomycin and fidaxomicin (utilization rate ratio, 0.63 [95% CI, .58-.70]; P < .001), and no significant level (rate ratio, 1.16 [95% CI, .93-1.43]; P = .18) or trend (rate ratio, 0.85 [95% CI, .52-1.39]; P = .51) change in emergent colectomy rates. CONCLUSIONS: Two-step testing is associated with decreased reported incidence of HO-CDI, likely by improving diagnostic specificity. The parallel decrease in C. difficile-specific antibiotic use offers indirect reassurance against underdiagnosis of C. difficile infections still requiring treatment by clinician assessment. Similarly, the absence of any significant change in colectomy rates offers indirect reassurance against any rise in fulminant C. difficile requiring surgical management.

Evaluation of a Virtual Training to Enhance Public Health Capacity for COVID-19 Infection Prevention and Control in Nursing Homes.

CONTEXT: Between April 2020 and May 2021, the Centers for Disease Control and Prevention (CDC) awarded more than $40 billion to health departments nationwide for COVID-19 prevention and response activities. One of the identified priorities for this investment was improving infection prevention and control (IPC) in nursing homes. PROGRAM: CDC developed a virtual course to train new and less experienced public health staff in core healthcare IPC principles and in the application of CDC COVID-19 healthcare IPC guidance for nursing homes. IMPLEMENTATION: From October 2020 to August 2021, the CDC led training sessions for 12 cohorts of public health staff using pretraining reading materials, case-based scenarios, didactic presentations, peer-learning opportunities, and subject matter expert-led discussions. Multiple electronic assessments were distributed to learners over time to measure changes in self-reported knowledge and confidence and to collect feedback on the course. Participating public health programs were also assessed to measure overall course impact. EVALUATION: Among 182 enrolled learners, 94% completed the training. Most learners were infection preventionists (42%) or epidemiologists (38%), had less than 1 year of experience in their health department role (75%), and had less than 1 year of subject matter experience (54%). After training, learners reported increased knowledge and confidence in applying the CDC COVID-19 healthcare IPC guidance for nursing homes (≥81%) with the greatest increase in performing COVID-19 IPC consultations and assessments (87%). The majority of participating programs agreed that the course provided an overall benefit (88%) and reduced training burden (72%). DISCUSSION: The CDC's virtual course was effective in increasing public health capacity for COVID-19 healthcare IPC in nursing homes and provides a possible model to increase IPC capacity for other infectious diseases and other healthcare settings. Future virtual healthcare IPC courses could be enhanced by tailoring materials to health department needs, reinforcing training through applied learning experiences, and supporting mechanisms to retain trained staff.

Expert Consensus on Metrics to Assess the Impact of Patient-Level Antimicrobial Stewardship Interventions in Acute-Care Settings.

Antimicrobial stewardship programs (ASPs) positively impact patient care, but metrics to assess ASP impact are poorly defined. We used a modified Delphi approach to select relevant metrics for assessing patient-level interventions in acute-care settings for the purposes of internal program decision making. An expert panel rated 90 candidate metrics on a 9-point Likert scale for association with 4 criteria: improved antimicrobial prescribing, improved patient care, utility in targeting stewardship efforts, and feasibility in hospitals with electronic health records. Experts further refined, added, or removed metrics during structured teleconferences and re-rated the retained metrics. Six metrics were rated >6 in all criteria: 2 measures of Clostridium difficile incidence, incidence of drug-resistant pathogens, days of therapy over admissions, days of therapy over patient days, and redundant therapy events. Fourteen metrics rated >6 in all criteria except feasibility were identified as targets for future development.

Intervention to reduce transmission of resistant bacteria in intensive care.

BACKGROUND: Intensive care units (ICUs) are high-risk settings for the transmission of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE). METHODS: In a cluster-randomized trial, we evaluated the effect of surveillance for MRSA and VRE colonization and of the expanded use of barrier precautions (intervention) as compared with existing practice (control) on the incidence of MRSA or VRE colonization or infection in adult ICUs. Surveillance cultures were obtained from patients in all participating ICUs; the results were reported only to ICUs assigned to the intervention. In intervention ICUs, patients who were colonized or infected with MRSA or VRE were assigned to care with contact precautions; all the other patients were assigned to care with universal gloving until their discharge or until surveillance cultures obtained at admission were reported to be negative. RESULTS: During a 6-month intervention period, there were 5434 admissions to 10 intervention ICUs, and 3705 admissions to 8 control ICUs. Patients who were colonized or infected with MRSA or VRE were assigned to barrier precautions more frequently in intervention ICUs than in control ICUs (a median of 92% of ICU days with either contact precautions or universal gloving [51% with contact precautions and 43% with universal gloving] in intervention ICUs vs. a median of 38% of ICU days with contact precautions in control ICUs, P<0.001). In intervention ICUs, health care providers used clean gloves, gowns, and hand hygiene less frequently than required for contacts with patients assigned to barrier precautions; when contact precautions were specified, gloves were used for a median of 82% of contacts, gowns for 77% of contacts, and hand hygiene after 69% of contacts, and when universal gloving was specified, gloves were used for a median of 72% of contacts and hand hygiene after 62% of contacts. The mean (±SE) ICU-level incidence of events of colonization or infection with MRSA or VRE per 1000 patient-days at risk, adjusted for baseline incidence, did not differ significantly between the intervention and control ICUs (40.4±3.3 and 35.6±3.7 in the two groups, respectively; P=0.35). CONCLUSIONS: The intervention was not effective in reducing the transmission of MRSA or VRE, although the use of barrier precautions by providers was less than what was required. (Funded by the National Institute of Allergy and Infectious Diseases and others; STAR*ICU ClinicalTrials.gov number, NCT00100386.).

Infection control and bloodstream infection prevention: the perspective of patients receiving hemodialysis.

Patients on hemodialysis, particularly those dialyzed through central lines, are at risk of acquiring bloodstream infections. Strategies to prevent bloodstream infections in patients on dialysis include educating patients about infection prevention, although patients' perspectives on this topic are not known. During focus groups conducted to explore these issues, patients reported that education on infection prevention should begin early in the process of dialysis, and that patients should be actively engaged as partners in infection prevention.

Physician perceptions of barriers to infection prevention and control in labor and delivery.

OBJECTIVE: To learn about the perceptions of healthcare personnel (HCP) on the barriers they encounter when performing infection prevention and control (IPC) practices in labor and delivery to help inform future IPC resources tailored to this setting. DESIGN: Qualitative focus groups. SETTING: Labor and delivery units in acute-care settings. PARTICIPANTS: A convenience sample of labor and delivery HCP attending the Infectious Diseases Society for Obstetrics and Gynecology 2022 Annual Meeting. METHODS: Two focus groups, each lasting 45 minutes, were conducted by a team from the Centers for Disease Control and Prevention. A standardized script facilitated discussion around performing IPC practices during labor and delivery. Coding was performed by 3 reviewers using an immersion-crystallization technique. RESULTS: In total, 18 conference attendees participated in the focus groups: 67% obstetrician-gynecologists, 17% infectious disease physicians, 11% medical students, and 6% an obstetric anesthesiologist. Participants described the difficulty of consistently performing IPC practices in this setting because they often respond to emergencies, are an entry point to the hospital, and frequently encounter bodily fluids. They also described that IPC training and education is not specific to labor and delivery, and personal protective equipment is difficult to locate when needed. Participants observed a lack of standardization of IPC protocols in their setting and felt that healthcare for women and pregnant people is not prioritized on a larger scale and within their hospitals. CONCLUSIONS: This study identified barriers to consistently implementing IPC practices in the labor and delivery setting. These barriers should be addressed through targeted interventions and the development of obstetric-specific IPC resources.

CDC's Hospital-Onset Clostridioides difficile Prevention Framework in a Regional Hospital Network.

Importance: Despite modest reductions in the incidence of hospital-onset Clostridioides difficile infection (HO-CDI), CDI remains a leading cause of health care-associated infection. As no single intervention has proven highly effective on its own, a multifaceted approach to controlling HO-CDI is needed. Objective: To assess the effectiveness of the Centers for Disease Control and Prevention's Strategies to Prevent Clostridioides difficile Infection in Acute Care Facilities Framework (hereafter, the Framework) in reducing HO-CDI incidence. Design, Setting, and Participants: This quality improvement study was performed within the Duke Infection Control Outreach Network from July 1, 2019, through March 31, 2022. In all, 20 hospitals in the network participated in an implementation study of the Framework recommendations, and 26 hospitals did not participate and served as controls. The Framework has 39 discrete intervention categories organized into 5 focal areas for CDI prevention: (1) isolation and contact precautions, (2) CDI confirmation, (3) environmental cleaning, (4) infrastructure development, and (5) antimicrobial stewardship engagement. Exposures: Monthly teleconferences supporting Framework implementation for the participating hospitals. Main Outcomes and Measures: Primary outcomes were HO-CDI incidence trends at participating hospitals compared with controls and postintervention HO-CDI incidence at intervention sites compared with rates during the 24 months before the intervention. Results: The study sample included a total of 2184 HO-CDI cases and 7 269 429 patient-days. In the intervention cohort of 20 participating hospitals, there were 1403 HO-CDI cases and 3 513 755 patient-days, with a median (IQR) HO-CDI incidence of 2.8 (2.0-4.3) cases per 10 000 patient-days. The first analysis included an additional 3 755 674 patient-days and 781 HO-CDI cases among the 26 controls, with a median (IQR) HO-CDI incidence of 1.1 (0.7-2.7) case per 10 000 patient-days. The second analysis included an additional 2 538 874 patient-days and 1751 HO-CDI cases, with a median (IQR) HO-CDI incidence of 5.9 (2.7-8.9) cases per 10 000 patient-days, from participating hospitals 24 months before the intervention. In the first analysis, intervention sites had a steeper decline in HO-CDI incidence over time relative to controls (yearly incidence rate ratio [IRR], 0.79 [95% CI, 0.67-0.94]; P = .01), but the decline was not temporally associated with study participation. In the second analysis, HO-CDI incidence was declining in participating hospitals before the intervention, and the rate of decline did not change during the intervention. The degree to which hospitals implemented the Framework was associated with steeper declines in HO-CDI incidence (yearly IRR, 0.95 [95% CI, 0.90-0.99]; P = .03). Conclusions and Relevance: In this quality improvement study of a regional hospital network, implementation of the Framework was not temporally associated with declining HO-CDI incidence. Further study of the effectiveness of multimodal prevention measures for controlling HO-CDI is warranted.

Survey Design: To Ask or Not to Ask? That is the Question...

Surveys are one of the most frequent modes of observation and measurement. Survey research can be exploratory, descriptive, and/or explanatory. Modes of survey administration vary and include face-to-face, telephone, mail, and Internet. There are numerous considerations that that must be taken into account when designing and conducting a survey. Deciding what information is needed and why is important when developing questions for a survey; it is essential to define the purpose of the survey and to be as specific as possible in terms of the data to be collected. Response rate varies by target audience and is influenced by a number of factors such as incentives, survey length, and perceived burden. From question development to survey construction, the goal is to minimize measurement error with systematic planning and execution.

Burnout and staff turnover among certified nursing assistants working in acute care hospitals during the COVID-19 pandemic.

INTRODUCTION: Healthcare worker burnout is a growing problem in the United States which affects healthcare workers themselves, as well as the healthcare system as a whole. The goal of this qualitative assessment was to understand factors that may lead to healthcare worker burnout and turnover through focus groups with Certified Nursing Assistants who worked in acute care hospitals during the COVID-19 pandemic. METHODS: Eight focus group discussions lasting approximately 30 minutes each were held remotely from October 2022-January 2023 with current and former Certified Nursing Assistants who worked during the COVID-19 pandemic in acute care hospitals. Participants were recruited through various sources such as social media and outreach through professional organizations. The focus groups utilized open-ended prompts including topics such as challenges experienced during the pandemic, what could have improved their experiences working during the pandemic, and motivations for continuing or leaving their career in healthcare. The focus groups were coded using an immersion-crystallization technique and summarized using NVivo and Microsoft Excel. Participant demographic information was summarized overall and by current work status. RESULTS: The focus groups included 58 Certified Nursing Assistants; 33 (57%) were current Certified Nursing Assistants and 25 (43%) were Certified Nursing Assistants who no longer work in healthcare. Throughout the focus groups, five convergent themes emerged, including staffing challenges, respect and recognition for Certified Nursing Assistants, the physical and mental toll of the job, facility leadership support, and pay and incentives. CONCLUSIONS: Focus group discussions with Certified Nursing Assistants identified factors at individual and organizational levels that might contribute to burnout and staff turnover in healthcare settings. Suggestions from participants on improving their experiences included ensuring staff know they are valued, being included in conversations with leadership, and improving access to mental health resources.

Making a C-DIFFerence: Implementation of a prevention collaborative to reduce hospital-onset Clostridioides difficile infection rates.

Objective: To assist hospitals in reducing Clostridioides difficile infections (CDI), the Centers for Disease Control and Prevention (CDC) implemented a collaborative using the CDC CDI prevention strategies and the Targeted Assessment for Prevention (TAP) Strategy as foundational frameworks. Setting: Acute-care hospitals. Methods: We invited 400 hospitals with the highest cumulative attributable differences (CADs) to the 12-month collaborative, with monthly webinars, coaching calls, and deployment of the CDC CDI TAP facility assessments. Infection prevention barriers, gaps identified, and interventions implemented were qualitatively coded by categorizing them to respective CDI prevention strategies. Standardized infection ratios (SIRs) were reviewed to measure outcomes. Results: Overall, 76 hospitals participated, most often reporting CDI testing as their greatest barrier to achieving reduction (61%). In total, 5,673 TAP assessments were collected across 46 (61%) hospitals. Most hospitals (98%) identified at least 1 gap related to testing and at least 1 gap related to infrastructure to support prevention. Among 14 follow-up hospitals, 64% implemented interventions related to infrastructure to support prevention (eg, establishing champions, reviewing individual CDIs) and 86% implemented testing interventions (eg, 2-step testing, testing algorithms). The SIR decrease between the pre-collaborative and post-collaborative periods was significant among participants (16.7%; P < .001) but less than that among nonparticipants (25.1%; P < .001). Conclusions: This article describes gaps identified and interventions implemented during a comprehensive CDI prevention collaborative in targeted hospitals, highlighting potential future areas of focus for CDI prevention efforts as well as reported challenges and barriers to prevention of one of the most common healthcare-associated infections affecting hospitals and patients nationwide.

Gaps in infection prevention practices for catheter-associated urinary tract infections and central line-associated bloodstream infections as identified by the Targeted Assessment for Prevention Strategy.

BACKGROUND: Catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI) represent a substantial portion of health care-associated infections (HAIs) reported in the United States. The Targeted Assessment for Prevention Strategy is a quality improvement framework to reduce health care-associated infections. Data from the Targeted Assessment for Prevention Facility Assessments were used to determine common infection prevention gaps for CAUTI and CLABSI. METHODS: Data from 2,044 CAUTI and 1,680 CLABSI assessments were included in the analysis. Items were defined as potential gaps if ≥33% respondents answered Unknown, ≥33% No, or ≥50% No or Unknown or Never, Rarely, Sometimes, or Unknown to questions pertaining to those areas. Review of response frequencies and stratification by respondent role were performed to highlight opportunities for improvement. RESULTS: Across CAUTI and CLABSI assessments, lack of physician champions (<35% Yes) and nurse champions (<55% Yes), along with lack of awareness of competency assessments, audits, and feedback were reported. Lack of practices to facilitate timely removal of urinary catheters were identified for CAUTI and issues with select device insertion practices, such as maintaining aseptic technique, were perceived as areas for improvement for CLABSI. CONCLUSIONS: These data suggest common gaps in critical components of infection prevention and control programs. The identification of these gaps has the potential to inform targeted CAUTI and CLABSI prevention efforts.

A modified Delphi approach to develop a trial protocol for antibiotic de-escalation in patients with suspected sepsis.

Background: Early administration of antibiotics in sepsis is associated with improved patient outcomes, but safe and generalizable approaches to de-escalate or discontinue antibiotics after suspected sepsis events are unknown. Methods: We used a modified Delphi approach to identify safety criteria for an opt-out protocol to guide de-escalation or discontinuation of antibiotic therapy after 72 hours in non-ICU patients with suspected sepsis. An expert panel with expertise in antimicrobial stewardship and hospital epidemiology rated 48 unique criteria across 3 electronic survey rating tools. Criteria were rated primarily based on their impact on patient safety and feasibility for extraction from electronic health record review. The 48 unique criteria were rated by anonymous electronic survey tools, and the results were fed back to the expert panel participants. Consensus was achieved to either retain or remove each criterion. Results: After 3 rounds, 22 unique criteria remained as part of the opt-out safety checklist. These criteria included high-risk comorbidities, signs of severe illness, lack of cultures during sepsis work-up or antibiotic use prior to blood cultures, or ongoing signs and symptoms of infection. Conclusions: The modified Delphi approach is a useful method to achieve expert-level consensus in the absence of evidence suifficient to provide validated guidance. The Delphi approach allowed for flexibility in development of an opt-out trial protocol for sepsis antibiotic de-escalation. The utility of this protocol should be evaluated in a randomized controlled trial.

A qualitative assessment of factors affecting nursing home caregiving staff experiences during the COVID-19 pandemic.

BACKGROUND: A large portion of COVID-19 cases and deaths in the United States have occurred in nursing homes; however, current literature including the frontline perspective of staff working in nursing homes is limited. The objective of this qualitative assessment was to better understand what individual and facility level factors may have contributed to the impact of COVID-19 on Certified Nursing Assistants (CNAs) and Environmental Services (EVS) staff working in nursing homes. METHODS: Based on a simple random sample from the National Healthcare Safety Network (NHSN), 7,520 facilities were emailed invitations requesting one CNA and/or one EVS staff member for participation in a voluntary focus group over Zoom. Facility characteristics were obtained via NHSN and publicly available sources; participant demographics were collected via SurveyMonkey during registration and polling during focus groups. Qualitative information was coded using NVIVO and Excel. RESULTS: Throughout April 2021, 23 focus groups including 110 participants from 84 facilities were conducted homogenous by participant role. Staffing problems were a recurring theme reported. Participants often cited the toll the pandemic took on their emotional well-being, describing increased stress, responsibilities, and time needed to complete their jobs. The lack of consistent and systematic guidance resulting in frequently changing infection prevention protocols was also reported across focus groups. CONCLUSIONS: Addressing concerns of low wages and lack of financial incentives may have the potential to attract and retain employees to help alleviate nursing home staff shortages. Additionally, access to mental health resources could help nursing home staff cope with the emotional burden of the COVID-19 pandemic. These frontline staff members provided invaluable insight and should be included in improvement efforts to support nursing homes recovering from the impact of COVID-19 as well as future pandemic planning.

Prevention of community-associated methicillin-resistant Staphylococcus aureus infection among Asian/Pacific Islanders: a qualitative assessment.

BACKGROUND: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has been increasingly reported over the past decade, including in Asian/Pacific Islanders (A/PIs). METHODS: We conducted ethnographic interviews in O'ahu and Kaua'i, Hawai'i, with 10 Asian/Pacific Islanders identified as having a history of CA-MRSA infections. RESULTS: Most (7/10) thought skin infections were not a new problem in Hawai'i. Most (8/9) attempted to self-treat the infection prior to seeking medical care with a range of home remedies and store- bought solutions. Most respondents did not initially comprehend the severity of their infection and only sought medical treatment after concern from family, unbearable pain, and/or other symptoms of illness. CONCLUSION: Clinicians should be aware of the reportedly frequent use of home remedies by this population, as it may potentially contribute to interactions when treatments are combined. If clinicians and public health professionals do not address perceptions and misperceptions of how MRSA is acquired, it will be very difficult to prevent infection, and may also delay individuals from seeking treatment.

Implementation of the Targeted Assessment for Prevention Strategy in a healthcare system to reduce Clostridioides difficile infection rates.

BACKGROUND: Prevention of Clostridioides difficile infection (CDI) is a national priority and may be facilitated by deployment of the Targeted Assessment for Prevention (TAP) Strategy, a quality improvement framework providing a focused approach to infection prevention. This article describes the process and outcomes of TAP Strategy implementation for CDI prevention in a healthcare system. METHODS: Hospital A was identified based on CDI surveillance data indicating an excess burden of infections above the national goal; hospitals B and C participated as part of systemwide deployment. TAP facility assessments were administered to staff to identify infection control gaps and inform CDI prevention interventions. Retrospective analysis was performed using negative-binomial, interrupted time series (ITS) regression to assess overall effect of targeted CDI prevention efforts. Analysis included hospital-onset, laboratory-identified C. difficile event data for 18 months before and after implementation of the TAP facility assessments. RESULTS: The systemwide monthly CDI rate significantly decreased at the intervention (ß2, -44%; P = .017), and the postintervention CDI rate trend showed a sustained decrease (ß1 + ß3; -12% per month; P = .008). At an individual hospital level, the CDI rate trend significantly decreased in the postintervention period at hospital A only (ß1 + ß3, -26% per month; P = .003). CONCLUSIONS: This project demonstrates TAP Strategy implementation in a healthcare system, yielding significant decrease in the laboratory-identified C. difficile rate trend in the postintervention period at the system level and in hospital A. This project highlights the potential benefit of directing prevention efforts to facilities with the highest burden of excess infections to more efficiently reduce CDI rates.

A national survey of testing and management of asymptomatic carriage of C. difficile.

A nationwide survey indicated that screening for asymptomatic carriers of C. difficile is an uncommon practice in US healthcare settings. Better understanding of the role of asymptomatic carriage in C. difficile transmission, and of the measures available to reduce that risk, are needed to inform best practices regarding the management of carriers.

Hand hygiene practices after brief encounters with patients: an important opportunity for prevention.

OBJECTIVE: To identify characteristics of encounters between healthcare workers (HCWs) and patients that correlated with hand hygiene adherence among HCWs. DESIGN: Observational study. SETTING: Intensive care unit in a Veterans Affairs hospital. PARTICIPANTS: HCWs. RESULTS: There were 767 patient encounters observed (48.6% involved nurses, 20.6% involved physicians, and 30.8% involved other HCWs); 39.8% of encounters involved patients placed under contact precautions. HCW contact with either the patient or surfaces in the patient's environment occurred during all encounters; direct patient contact occurred during 439 encounters (57.4%), and contact with environmental surfaces occurred during 710 encounters (92.6%). The median duration of encounters was 2 minutes (range, <1 to 51 minutes); 33.6% of encounters lasted 1 minute or less, with no significant occupation-associated differences in the median duration of encounters. Adherence with hand hygiene practices was correlated with the duration of the encounter, with overall adherences of 30.0% after encounters of < or =1 minute, 43.4% after encounters of >1 to < or =2 minutes, 51.1% after encounters of >3 to < or =5 minutes, and 64.9% after encounters of >5 minutes (P<.001 by the chi (2) for trend). In multivariate analyses, longer encounter duration, contact precautions status, patient contact, and nursing occupation were independently associated with adherence to hand hygiene recommendations. CONCLUSIONS: In this study, adherence to hand hygiene practices was lowest after brief patient encounters (i.e., < 2 minutes). Brief encounters accounted for a substantial proportion of all observed encounters, and opportunities for hand contamination occurred during all brief encounters. Therefore, improving adherence after brief encounters may have an important overall impact on the transmission of healthcare-associated pathogens and may deserve special emphasis in the design of programs to promote adherence to hand hygiene practices.

Impact of different methods of feedback to clinicians after postprescription antimicrobial review based on the Centers For Disease Control and Prevention's 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults.

OBJECTIVES: To evaluate (1) the framework of the 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults that is part of the Centers for Disease Control and Prevention (CDC) Campaign to Prevent Antimicrobial Resistance in Healthcare Settings, with regard to steps addressing antimicrobial use; and (2) methods of feedback to clinicians regarding antimicrobial use after postprescription review. DESIGN: Prospective intervention to identify and modify inappropriate antimicrobial therapy. SETTING: A 1,000-bed, tertiary care teaching hospital. PATIENTS: Inpatients in selected medicine and surgery units receiving broad-spectrum antimicrobials for 48-72 hours. INTERVENTIONS: We created a computer-based clinical-event detection system that automatically identified inpatients taking broad-spectrum and "reserve" antimicrobials for 48-72 hours. Although prior approval was required for initial administration of broad-spectrum and reserve antimicrobials, once approval was obtained, therapy with the antimicrobials could be continued indefinitely at the discretion of the treating clinician. Therapy that was ongoing at 48-72 hours was reviewed by an infectious diseases pharmacist or physician, and when indicated feedback was provided to clinicians to modify or discontinue therapy. Feedback was provided via a direct telephone call, a note on the front of the medical record, or text message sent to the clinician's pager. The acceptance rate of feedback was recorded and recommendations were categorized according to the 12 steps recommended by the CDC. RESULTS: Interventions were recommended for 334 (30%) of 1,104 courses of antimicrobial therapy reviewed. A total of 87% of interventions fit into one of the CDC's 12 steps of prevention: 39% into step 3 ("target the pathogen"), 1% into step 4 ("access experts"), 3% into steps 7 and 8 ("treat infection, not colonization or contamination"), 18% into step 9 ("say ;no' to vancomycin"), and 26% into step 10 ("stop treatment when no infection"). The rate of compliance with recommendations to improve antimicrobial use was 72%. No differences in compliance were seen with the different methods of feedback. CONCLUSIONS: Nearly one-third of antimicrobial courses did not follow the CDC's recommended 12 steps for prevention of antimicrobial resistance. Clinicians demonstrated high compliance with following suggestions made after postprescription review, suggesting that it is a useful approach to decreasing and improving antimicrobial use among inpatients.

Infectious diseases physicians' preferences for continuing medical education on antimicrobial resistance and other general topics.

A 19-item survey instrument was designed and mailed by the Infectious Diseases Society of America to its membership to determine the media preferred by infectious diseases physicians for continuing medical education on general topics and on antimicrobial resistance. The objective of the survey was to offer the developers of educational programs knowledge on which to base more-effective ways to deliver educational materials to physicians in this specialty.

Incidence of pediatric and neonatal intensive care unit-acquired infections.

OBJECTIVE: To compare the cumulative incidence of infections acquired in the pediatric intensive care unit (PICU) and neonatal intensive care unit (NICU). DESIGN: Estimation of the cumulative incidence of infections with data obtained from the Pediatric Prevention Network (PPN) point-prevalence survey and observed rates from the National Nosocomial Infections Surveillance (NNIS) system. SETTING: Ten hospitals participated in both the PPN survey and NNIS system. PARTICIPANTS: All patients present on the PPN survey dates (August 4, 1999, or February 1, 2000) in the NICUs or PICUs of the PPN hospitals were included in the survey. Point prevalences for PICU-acquired and for NICU-acquired infections at these hospitals were calculated from the survey data. The cumulative incidence rates were estimated from the point prevalence rates using a standard formula and a standard method for calculating the time to recovery (ie, on the basis of the assumption that discontinuance of antimicrobial therapy indicates recovery from infection); alternate methods to judge the time to recovery from infection were also explored. RESULTS: The average cumulative incidence of intensive care unit-acquired infection for NICUs and PICUs combined (all units), as measured by NNIS, was 14.1 cases per 100 patients; in comparison, the prevalence was 14.06 cases for 100 patients (median difference, -0.95 cases per 100 patients; 95% confidence interval, -4.6 to 5.0 cases per 100 patients), and the estimated cumulative incidence using the standard method of calculating the time to recovery was 13.8 cases per 100 patients (median difference, -1.5 cases per 100 patients; 95% confidence interval, -9.1 to 2.9 cases per 100 patients). Estimates of cumulative incidence using alternate methods for calculation of time to recovery did not perform as well (range, 4.9-100.9 cases per 100 patients). The average incidence density for all units, as measured by the NNIS system, was 6.8 cases per 1,000 patient-days, and the estimate of incidence density using the standard method of calculating the time to recovery was 3.6 cases per 1,000 patient-days (median difference, 4.3 cases per 1,000 patient-days; 95% confidence interval, 0.9 to 9.2 cases per 1,000 patient-days). Estimated incidence densities using alternate methods for determining recovery time correlated closely with observed incidence densities. CONCLUSIONS: In this patient population, the simple point prevalence provided the best estimate of cumulative incidence, followed by use of a standard formula and a standard method of calculating the time to recovery. Estimation of incidence density using alternate methods performed well. The standard formula and method may provide an even better estimate of cumulative incidence than does simple prevalence in general populations.