To compare outcomes between patients discharged on intravenous (IV) versus oral (PO) antibiotics for the treatment of orthopedic infections, after creation of an IV-to-PO guideline, at a single academic medical center in the United States.

This was a retrospective, propensity score matched, cohort study of adult patients hospitalized for orthopedic infections from September 30, 2020, to April 30, 2022. Patients discharged on PO antibiotics were matched to patients discharged on IV antibiotics. The primary outcome was one-year treatment failure following discharge. Secondary outcomes were incidence of 60-day treatment failure, adverse drug events (ADE), readmissions, infectious disease clinic “no-show” rates, and emergency department (ED) encounters.

Ninety PO-treated patients were matched to 90 IV-treated patients. Baseline characteristics were similar in the two groups after matching. There was no significant difference in the proportions of patients on PO versus IV antibiotics experiencing treatment failure at one year (26% vs 31%, P = .47). There were no significant differences for any secondary outcomes: treatment failure within 60 days (13% vs 14%, P = 1.00), ADE (13% vs 11%, P = .82), unplanned readmission (17% vs 21%, P = .57), or ED encounters (9% vs 18%, P = .54). Survival analyses identified no significant differences in time-to-event between PO and IV treatment for any of the outcomes assessed.

There were no appreciable differences in outcomes between patients discharged on PO compared to IV regimens. Antimicrobial stewardship interventions to increase prescribing of PO antibiotics for the treatment of orthopedic infections should be encouraged.

Inpatient behavioral health units (BHUs) had unique challenges in implementing interventions to mitigate coronavirus disease 2019 (COVID-19) transmission, in part due to socialization in BHU settings. The objective of this study was to identify the transmission routes and the efficacy of the mitigation strategies employed during a COVID-19 outbreak in an inpatient BHU during the Omicron surge from December 2021 to January 2022.

An outbreak investigation was performed after identifying 2 COVID-19-positive BHU inpatients on December 16 and 20, 2021. Mitigation measures involved weekly point prevalence testing for all inpatients, healthcare workers (HCWs), and staff, followed by infection prevention mitigation measures and molecular surveillance. Whole-genome sequencing on a subset of COVID-19-positive individuals was performed to identify the outbreak source. Finally, an outbreak control sustainability plan was formulated for future BHU outbreak resurgences.

We identified 35 HCWs and 8 inpatients who tested positive in the BHU between December 16, 2021, and January 17, 2022. We generated severe acute respiratory coronavirus virus 2 (SARS-CoV-2) genomes from 15 HCWs and all inpatients. Phylogenetic analyses revealed 3 distinct but genetically related clusters: (1) an HCW and inpatient outbreak likely initiated by staff, (2) an HCW and inpatient outbreak likely initiated by an inpatient visitor, and (3) an HCW-only cluster initiated by staff.

Distinct transmission clusters are consistent with multiple, independent SARS-CoV-2 introductions with further inpatient transmission occurring in communal settings. The implemented outbreak control plan comprised of enhanced personal protective equipment requirements, limited socialization, and molecular surveillance likely minimized disruptions to patient care as a model for future pandemics.

Prescribing of antibiotics for viral upper respiratory infections (URIs) remains a pressing public health problem. We sought to reduce inappropriate prescribing of antibiotics for URIs in Mayo Clinic Arizona.

Single-center, quasi-experimental, and retrospective cohort study

Emergency medicine and all primary care departments

The interventions included sharing baseline prescribing data, education, resources, and quarterly peer comparison reports. Encounters with diagnostic codes for respiratory infections commonly caused by viruses were categorized as Tier 3 (ie, never appropriate to prescribe antibiotics). Our goal was to reduce inappropriate prescribing for Tier 3 encounters by 22% in 2022.

Department education was completed by June 2022. The annual antibiotic prescribing rate for Tier 3 encounters was reduced by 29%, from a baseline rate of 23.6% in 2021 to 16.4% in 2022 (P < .001). The posteducation prescribing rate was 13.1%. Repeat respiratory-related healthcare contact within 14 days of Tier 3 encounters did not differ between patients prescribed and not prescribed an antibiotic in all of 2022 (4.7% antibiotic vs 4.2% no antibiotic, P = .595) or during the posteducation period (3.7% vs 4.6%, P = .604).

A multi-faceted intervention, which included baseline education, syndrome-specific order panels, resources for symptomatic management, and peer comparison reports, resulted in significant reduction of inappropriate antibiotic prescribing for URIs.

Carbapenem-resistant organisms (CROs) are an urgent health threat. Since 2017, Alameda County Health Public Health Department (ACPHD) mandates reporting of carbapenem-resistant Enterobacterales (CRE) and encourages voluntary reporting of non-CRE CROs including carbapenem-resistant Acinetobacter baumannii (CRAB) and carbapenem-resistant Pseudomonas aeruginosa (CRPA). Surveillance data from ACPHD were analyzed to describe the epidemiology of CROs and target public health interventions.

Healthcare facilities in Alameda County reported CRO cases and submitted isolates to ACPHD to characterize carbapenemase genes; deaths were identified via the California Electronic Death Registration System. CRO cases with isolates resistant to one or more carbapenems were analyzed from surveillance data from July 2019 to June 2021.

Four hundred and forty-two cases of CROs were reported to Alameda County from 408 patients. The county case rate for CROs was 29 cases per 100,000 population, and cases significantly increased over the 2-year period. CRPA was most commonly reported (157 cases, 36%), and cases of CRAB increased 1.83-fold. One-hundred eighty-six (42%) cases were identified among residents of long-term care facilities; 152 (37%) patients had died by January 2022. One hundred and seven (24%) cases produced carbapenemases.

The high burden of CROs in Alameda County highlights the need for continued partnership on reporting, testing, and infection prevention to limit the spread of resistant organisms. A large proportion of cases were identified in vulnerable long-term care residents, and CRAB was an emerging CRO among this population. Screening for CROs and surveillance at the local level are important to understand epidemiology and implement public health interventions.

Many available facepiece filtering respirators contain ferromagnetic components, which may cause significant problems in the magnetic resonance imaging (MRI) environment. We conducted a randomized crossover trial to assess the effectiveness, usability, and comfort of 3 types of respirators, judged to be “conditionally MRI safe” with an aluminum nosepiece (Halyard 46727 duckbill-type respirators and Care Essentials MSK-002 bifold cup-type respirators) or “MRI safe” completely metal free (Eagle AG2200 semirigid cup-type respirators).

We recruited 120 participants to undergo a quantitative fit test (QNFT) on each of the 3 respirators in a randomized order. Participants then completed a usability and comfort assessment of each respirator.

There were significant differences in the QNFT pass rates (51% for Halyard 46727, 73% for Care Essentials MSK-002, and 86% for Eagle AG2200, P < .001). The first-time fit test pass rate and overall fit factor were significantly higher for Eagle AG2200 compared with the other 2 respirators. Eagle AG2200 scored the lowest ratings in the ease of use and overall comfort. There were no significant differences in other modalities, including the seal rating, breathability, firmness, and overall assessment.

Our study supports the utility of the Eagle AG2200 and Care Essentials MSK-002 respirators for healthcare professionals working in an MRI environment, based on their high QNFT pass rates and reasonably good overall usability and comfort scores. Eagle AG2200 is unique because of its metal-free construction. However, its comparatively lower usability and comfort ratings raise questions about practicality, which may be improved by greater user training.

Many factors have been associated with the risk of toxigenic C. difficile diarrhea (TCdD). This study derived and internally validated a multivariate model for estimating the risk of TCdD in patients with diarrhea using readily available clinical factors.

A random sample of 3,050 symptomatic emergency department or hospitalized patients undergoing testing for toxigenic C. difficile at a single teaching hospital between 2014 and 2018 was created. Unformed stool samples positive for both glutamate dehydrogenase antigen by enzyme immunoassay and tcdB gene by polymerase chain reaction were classified as TCdD positive. The TCdD Model was created using logistic regression and was modified to the TCdD Risk Score to facilitate its use.

8.1% of patients were TCdD positive. TCdD risk increased with abdominal pain (adjusted odds ratio 1.3; 95% CI, 1.0–1.8), previous C. difficile diarrhea (2.5, 1.1–6.1), and prior antibiotic exposure, especially when sampled in the emergency department (4.2, 2.5–7.0) versus the hospital (1.7, 1.3–2.3). TCdD risk also increased when testing occurred earlier during the hospitalization encounter, when age and white cell count increased concurrently, and with decreased eosinophil count. In internal validation, the TCdD Model had moderate discrimination (optimism-corrected C-statistic 0.65, 0.62–0.68) and good calibration (optimism-corrected Integrated Calibration Index [ICI] 0.017, 0.001–0.022). Performance decreased slightly for the TCdD Risk Score (C-statistic 0.63, 0.62–0.63; ICI 0.038, 0.004–0.038).

TCdD risk can be predicted using readily available clinical risk factors with modest accuracy.

A beta-lactam antibiotics (BLA) allergy label is common, resulting in disadvantageous outcomes due to the usage of second-line antimicrobial agents. Noncontrolled case-series analyses report low rates of hypersensitivity reactions, following intentional/non-intentional BLA challenges among labeled inpatients. The study aims were to explore predictors and outcomes associated with hypersensitivity reactions following BLA challenge among BLA-allergic labeled inpatients.

Retrospective cohort study (2019–2020) of adult (≥18 years) inpatients (Shamir Medical Center, Israel), labeled as allergic to ≥1 BLA, who received ≥1 dose/s of BLA during their stay. Independent predictors to develop allergic reactions and the independent associations of allergic reactions with clinical outcomes were queried by logistic and Cox regressions.

Of 9,670 inpatients (14,088 hospitalizations), 3,570 (37%) were labeled as allergic to ≥1 BLA. Of those, 1,171 (33%) patients received ≥1 BLA. The majority were women (67%), and the mean age was 69.3 ± 19.4 years. Only 30 patients (2.6%) developed a reaction, all mild. Independent predictors to develop an allergic reaction were documented reactions in the past, atopic background, antihistamines administration prior to the BLA challenge, and high risk for cross-reactivity, based on the BLA side chains, between the labeled and the challenged agents. Reaction upon the BLA challenge was not independently associated with any worse outcome.

Despite the commonality of allergy labeling, and the commonality of BLA administration to labeled inpatients, hypersensitivity reactions were mild and rare. Interventional stewardship strategies for active BLA de-labeling among low-risk patients should be promoted, to improve patients’ and institutional health and fiscal outcomes.

Post-transplant infections remain a leading cause of morbidity and mortality in solid organ transplant recipients (SOTRs) and local standardized antimicrobial treatment guidelines may contribute to improved clinical outcomes. Our study assessed the rate of therapeutic compliance with local standard guidelines in the treatment of common infections in SOTR, and their associated outcomes.

Consecutive adult SOTRs admitted to the transplant floor from January–September 2020 and were treated for an infectious syndrome were followed until discharge or for 30 days following the date of diagnosis, whichever was shorter. Data was extracted from electronic medical records. Guideline compliance was characterized as either appropriate, effective but unnecessary, undertreatment, or inappropriate.

Nine hundred and thirty-six SOTR were admitted to the transplant ward, of which 328 patients (35%) received treatment for infectious syndromes. Guidelines were applicable to 252 patients, constituting 275 syndromes: 86 pneumonias; 82 urinary tract infections; 40 intra-abdominal infections; 38 bloodstream infections; and 29 C. difficile infections. 200/246 (81%) of infectious syndromes received appropriate or effective but unnecessary empiric treatment. In addition, appropriate tailoring of antimicrobials resulted in a significant difference in 30-day all-cause mortality (adjusted OR of 0.07, 95% CI 0.01–0.38; P = .002). Lastly, we found that guideline-compliant empiric therapy was found to prevent the development of multi-drug resistance in a time-dependent analysis (adjusted HR of 0.21, 95% CI 0.08–0.52; P = .001).

Our data show that adherence to locally developed guidelines was associated with reduced mortality and resistant-organism development in our cohort of SOTR.

This study aimed to investigate the prevalence and practices of antibiotic use in intensive care units (ICUs) in Nepal and to identify potential areas for implementing antimicrobial stewardship programs.

A point prevalence survey was conducted to characterize and quantify the antimicrobial utilization in level III ICUs of Nepal.

Data on antibiotic prescription rates, reasons for prescribing antibiotics, and prescribing practices were collected and analyzed. The prevalence of antimicrobial resistance was also assessed.

The antibiotic prescribing rate was found to be very high, with 92.85% of patients in ICU on antibiotics. Prolonged surgical prophylaxis was the most common reason for prescribing antibiotics. Empirical therapy accounted for 67.5% of all antibiotic prescriptions. Prescribing practices were poor, with low adherence to guidelines and best practices. Broad-spectrum antibiotics were commonly used even for surgical prophylaxis or community-acquired infections. High resistance was observed against commonly used antibiotics.

The study underscores the urgent need for effective antimicrobial stewardship programs in ICUs of Nepal. Implementing robust stewardship programs could help optimize antibiotic utilization, improve patient outcomes, and combat the global threat of antimicrobial resistance. The findings serve as a stepping stone toward understanding and improving antibiotic prescribing practices in ICUs of Nepal.

Central line-associated bloodstream infections (CLABSIs) harm children. Insertion and maintenance bundles have significantly reduced CLABSIs, but infections still occur. The objective was to develop bedside infection prevention (IP) rounds and evaluate their impact on CLABSI rates.

This quality improvement project was initiated sequentially in the neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU) of a large academic children’s hospital. IP rounds, interdisciplinary discussions led by the hospital epidemiologist and unit nursing leader with the bedside nurse, occurred weekly for patients with central lines. Discussions included strategies to optimize line maintenance and identify and mitigate patient-specific infection risks. Concerns and recommendations were communicated with the clinician. CLABSIs were identified by prospective surveillance using standard definitions. The change in CLABSIs over time was analyzed using days-between-events charts (g chart).

IP rounds included 3,832 patients in the NICU and 1,322 patients in the PICU. Opportunities were identified to reduce line access and protect the dressing from contamination. The average days between CLABSIs in the NICU increased from 41 days to 54 days after IP rounds began. The longest time between CLABSIs was 362 days. In the PICU, the average days between CLABSIs increased from 53 to 91 days. The longest time between CLABSIs was 398 days.

IP rounds reduced CLABSIs in the NICU and PICU by reinforcing best practices, encouraging proactive strategies, and fostering communication between members of the healthcare team.