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Assess healthcare workers’ (HCW) attitudes toward universal masking, and gowns and gloves used as part of transmission-based precautions.
Design:
Cross-sectional survey.
Setting:
Academic, tertiary care medical center in Baltimore, Maryland.
Participants:
HCW who work in patient care areas and have contact with patients.
Methods:
In May 2023, a 15-question web-based survey was distributed by the hospital’s communications team via email. The survey contained questions to assess HCW perceptions of universal masking policies prior to the availability of COVID-19 vaccines and at the time of the survey, and the use of gowns and gloves for transmission-based precautions. Descriptive statistics were used to summarize data. Differences in agreement with universal masking over time, level of agreement with gown and glove policies, and with all PPE types across respondent characteristics were assessed.
Results:
257 eligible respondents completed the survey. Nurses and patient care technicians (43%) and providers (17%) were the most commonly reported roles. Agreement with universal mask use decreased from 84% early in the pandemic to 55% at the time of the survey. 70% and 72% of HCW agreed masks protect themselves and others, respectively. 63% expressed any level of annoyance with mask wearing, the most often due to communication challenges or physical discomfort. 75% agreed with gown use for antibiotic-resistant bacteria compared with 90% for glove use.
Conclusions:
The majority of HCW agree with the use of PPE to prevent pathogen transmission in the healthcare setting. Agreement with universal mask use for patient care shifted during the COVID-19 pandemic.
COVID-19 changed the epidemiology of community-acquired respiratory viruses. We explored patterns of respiratory viral testing to understand which tests are most clinically useful in the postpandemic era.
Methods:
We conducted a retrospective observational study of discharge data from PINC-AI (formerly Premier), a large administrative database. Use of multiplex nucleic acid amplification respiratory panels in acute care, including small (2–5 targets), medium (6–11), and large panels (>11), were compared between the early pandemic (03/2020–10/2020), late pandemic (11/2020–4/2021), and prepandemic respiratory season (11/2019 - 02/2020) using ANOVA.
Results:
A median of 160.5 facilities contributed testing data per quarter (IQR 155.5–169.5). Prepandemic, facilities averaged 103 respiratory panels monthly (sd 138), including 79 large (sd 126), 7 medium (sd 31), and 16 small panels (sd 73). Relative to prepandemic, utilization decreased during the early pandemic (62 panels monthly/facility; sd 112) but returned to the prepandemic baseline by the late pandemic (107 panels monthly/facility; sd 211). Relative to prepandemic, late pandemic testing involved more small panel use (58 monthly/facility, sd 156) and less large panel use (47 monthly/facility, sd 116). Comparisons among periods demonstrated significant differences in overall testing (P < 0.0001), large panel use (P < 0.0001), and small panel use (P < 0.0001).
Conclusions:
Postpandemic, clinical use of respiratory panel testing shifted from predominantly large panels to predominantly small panels. Factors driving this change may include resource availability, costs, and the clinical utility of targeting important pathogenic viruses instead of testing “for everything.”
“All or none” approaches to the use of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) both fail to recognize that transmission risk varies. This qualitative study assessed healthcare personnel perspectives regarding the feasibility of a risk-tailored approach to use contact precautions for MRSA more strategically in the acute care setting.
Identifying long-term care facility (LTCF)-exposed inpatients is important for infection control research and practice, but ascertaining LTCF exposure is challenging. Across a large validation study, electronic health record data fields identified 76% of LTCF-exposed patients compared to manual chart review.
Transient acquisition of methicillin-resistant Staphylococcus aureus (MRSA) on healthcare personnel (HCP) gloves and gowns following patient care has been examined. However, the potential for transmission to the subsequent patient has not been studied. We explored the frequency of MRSA transmission from patient to HCP, and then in separate encounters from contaminated HCP gloves and gowns to a subsequent simulated patient as well as the factors associated with these 2 transmission pathways.
Methods:
We conducted a prospective cohort study with 2 parts. In objective 1, we studied MRSA transmission from random MRSA-positive patients to HCP gloves and gowns after specific routine patient care activities. In objective 2, we simulated subsequent transmission from random HCP gloves and gowns without hand hygiene to the next patient using a manikin proxy.
Results:
For the first objective, among 98 MRSA-positive patients with 333 randomly selected individual patient–HCP interactions, HCP gloves or gowns were contaminated in 54 interactions (16.2%). In a multivariable analysis, performing endotracheal tube care had the greatest odds of glove or gown contamination (OR, 4.06; 95% CI, 1.3–12.6 relative to physical examination). For the second objective, after 147 simulated HCP–patient interactions, the subsequent transmission of MRSA to the manikin proxy occurred 15 times (10.2%).
Conclusion:
After caring for a patient with MRSA, contamination of HCP gloves and gown and transmission to subsequent patients following HCP-patient interactions occurs frequently if contact precautions are not used. Proper infection control practices, including the use of gloves and gown, can prevent this potential subsequent transmission.
The gold standard for hand hygiene (HH) while wearing gloves requires removing gloves, performing HH, and donning new gloves between WHO moments. The novel strategy of applying alcohol-based hand rub (ABHR) directly to gloved hands might be effective and efficient.
Design:
A mixed-method, multicenter, 3-arm, randomized trial.
Setting:
Adult and pediatric medical-surgical, intermediate, and intensive care units at 4 hospitals.
Participants:
Healthcare personnel (HCP).
Interventions:
HCP were randomized to 3 groups: ABHR applied directly to gloved hands, the current standard, or usual care.
Methods:
Gloved hands were sampled via direct imprint. Gold-standard and usual-care arms were compared with the ABHR intervention.
Results:
Bacteria were identified on gloved hands after 432 (67.4%) of 641 observations in the gold-standard arm versus 548 (82.8%) of 662 observations in the intervention arm (P < .01). HH required a mean of 14 seconds in the intervention and a mean of 28.7 seconds in the gold-standard arm (P < .01). Bacteria were identified on gloved hands after 133 (98.5%) of 135 observations in the usual-care arm versus 173 (76.6%) of 226 observations in the intervention arm (P < .01). Of 331 gloves tested 6 (1.8%) were found to have microperforations; all were identified in the intervention arm [6 (2.9%) of 205].
Conclusions:
Compared with usual care, contamination of gloved hands was significantly reduced by applying ABHR directly to gloved hands but statistically higher than the gold standard. Given time savings and microbiological benefit over usual care and lack of feasibility of adhering to the gold standard, the Centers for Disease Control and Prevention and the World Health Organization should consider advising HCP to decontaminate gloved hands with ABHR when HH moments arise during single-patient encounters.
Misdiagnosis of bacterial pneumonia increases risk of exposure to inappropriate antibiotics and adverse events. We developed a diagnosis calculator (https://calculator.testingwisely.com) to inform clinical diagnosis of community-acquired bacterial pneumonia using objective indicators, including incidence of disease, risk factors, and sensitivity and specificity of diagnostic tests, that were identified through literature review.
To evaluate the efficacy of a new continuously active disinfectant (CAD) to decrease bioburden on high-touch environmental surfaces compared to a standard disinfectant in the intensive care unit.
Design:
A single-blind randomized controlled trial with 1:1 allocation.
Setting:
Medical intensive care unit (MICU) at an urban tertiary-care hospital.
Participants:
Adult patients admitted to the MICU and on contact precautions.
Intervention:
A new CAD wipe used for daily cleaning.
Methods:
Samples were collected from 5 high-touch environmental surfaces before cleaning and at 1, 4, and 24 hours after cleaning. The primary outcome was the mean bioburden 24 hours after cleaning. The secondary outcome was the detection of any epidemiologically important pathogen (EIP) 24 hours after cleaning.
Results:
In total, 843 environmental samples were collected from 43 unique patient rooms. At 24 hours, the mean bioburden recovered from the patient rooms cleaned with the new CAD wipe (intervention) was 52 CFU/mL, and the mean bioburden was 92 CFU/mL in the rooms cleaned the standard disinfectant (control). After log transformation for multivariable analysis, the mean difference in bioburden between the intervention and control arm was −0.59 (95% CI, −1.45 to 0.27). The odds of EIP detection were 14% lower in the rooms cleaned with the CAD wipe (OR, 0.86; 95% CI, 0.31–2.32).
Conclusions:
The bacterial bioburden and odds of detection of EIPs were not statistically different in rooms cleaned with the CAD compared to the standard disinfectant after 24 hours. Although CAD technology appears promising in vitro, larger studies may be warranted to evaluate efficacy in clinical settings.
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.
Known concentrations of Staphylococcus aureus and Candida auris were applied on gloves and gowns then sampled with E-swabs and BBL liquid Amies swabs. The mean numbers of colony-forming units per milliliter (CFU/mL) obtained from culture of the 2 swab types were not different, suggesting that either can be used for recovery of these two pathogens from personal protective equipment.
Multiplex polymerase chain reaction (PCR) respiratory panels are rapid, highly sensitive tests for viral and bacterial pathogens that cause respiratory infections. In this study, we (1) described best practices in the implementation of respiratory panels based on expert perspectives and (2) identified tools for diagnostic stewardship to enhance the usefulness of testing.
Methods:
We conducted a survey of the Society for Healthcare Epidemiology of America Research Network to explore current and future approaches to diagnostic stewardship of multiplex PCR respiratory panels.
Results:
In total, 41 sites completed the survey (response rate, 50%). Multiplex PCR respiratory panels were perceived as supporting accurate diagnoses at 35 sites (85%), supporting more efficient patient care at 33 sites (80%), and improving patient outcomes at 23 sites (56%). Thirteen sites (32%) reported that testing may support diagnosis or patient care without improving patient outcomes. Furthermore, 24 sites (58%) had implemented diagnostic stewardship, with a median of 3 interventions (interquartile range, 1–4) per site. The interventions most frequently reported as effective were structured order sets to guide test ordering (4 sites), restrictions on test ordering based on clinician or patient characteristics (3 sites), and structured communication of results (2 sites). Education was reported as “helpful” but with limitations (3 sites).
Conclusions:
Many hospital epidemiologists and experts in infectious diseases perceive multiplex PCR respiratory panels as useful tests that can improve diagnosis, patient care, and patient outcomes. However, institutions frequently employ diagnostic stewardship to enhance the usefulness of testing, including most commonly clinical decision support to guide test ordering.
In total, 50 healthcare facilities completed a survey in 2021 to characterize changes in infection prevention and control and antibiotic stewardship practices. Notable findings include sustained surveillance for multidrug-resistant organisms but decreased use of human resource-intensive interventions compared to previous surveys in 2013 and 2018 conducted prior to the COVID-19 pandemic.
Hospital readmission is unsettling to patients and caregivers, costly to the healthcare system, and may leave patients at additional risk for hospital-acquired infections and other complications. We evaluated the association between comorbidities present during index coronavirus disease 2019 (COVID-19) hospitalization and the risk of 30-day readmission.
Design, setting, and participants:
We used the Premier Healthcare database to perform a retrospective cohort study of COVID-19 hospitalized patients discharged between April 2020 and March 2021 who were followed for 30 days after discharge to capture readmission to the same hospital.
Results:
Among the 331,136 unique patients in the index cohort, 36,827 (11.1%) had at least 1 all-cause readmission within 30 days. Of the readmitted patients, 11,382 (3.4%) were readmitted with COVID-19 as the primary diagnosis. In the multivariable model adjusted for demographics, hospital characteristics, coexisting comorbidities, and COVID-19 severity, each additional comorbidity category was associated with an 18% increase in the odds of all-cause readmission (adjusted odds ratio [aOR], 1.18; 95% confidence interval [CI], 1.17–1.19) and a 10% increase in the odds of readmission with COVID-19 as the primary readmission diagnosis (aOR, 1.10; 95% CI, 1.09–1.11). Lymphoma (aOR, 1.86; 95% CI, 1.58–2.19), renal failure (aOR, 1.32; 95% CI, 1.25–1.40), and chronic lung disease (aOR, 1.29; 95% CI, 1.24–1.34) were most associated with readmission for COVID-19.
Conclusions:
Readmission within 30 days was common among COVID-19 survivors. A better understanding of comorbidities associated with readmission will aid hospital care teams in improving postdischarge care. Additionally, it will assist hospital epidemiologists and quality administrators in planning resources, allocating staff, and managing bed-flow issues to improve patient care and safety.
Methicillin-resistant Staphylococcus aureus (MRSA) is a significant nosocomial pathogen in the ICU. MRSA contamination of healthcare personnel (HCP) gloves and gowns after providing care to patients with MRSA occurs at a rate of 14%–16% in the ICU setting. Little is known about whether the MRSA isolates identified on HCP gown and gloves following patient care activities are the same as MRSA isolates identified as colonizing or infecting the patient.
Methods:
From a multisite cohort of 388 independent patient MRSA isolates and their corresponding HCP gown and glove isolates, we selected 91 isolates pairs using a probability to proportion size (PPS) sampling method. To determine whether the patient and HCP gown or gloves isolates were genetically similar, we used 5 comparative genomic typing methods: phylogenetic analysis, spa typing, multilocus sequence typing (MLST), large-scale BLAST score ratio (LSBSR), and single-nucleotide variant (SNV) analysis.
Results:
We identified that 56 (61.5%) of isolate pairs were genetically similar at least by 4 of the methods. Comparably, the spa typing and the LSBSR analyses revealed that >75% of the examined isolate pairs were concordant, with the thresholds established for each analysis.
Conclusions:
Many of the patient MRSA isolates were genetically similar to those on the HCP gown or gloves following a patient care activity. This finding indicates that the patient is often the primary source of the MRSA isolates transmitted to the HCP, which can potentially be spread to other patients or hospital settings through HCP vectors. These results have important implications because they provide additional evidence for hospitals considering ending the use of contact precautions (gloves and gowns) for MRSA patients.
To evaluate the impact of a standardized, process-validated intervention utilizing daily hospital-wide patient-zone sporicidal disinfectant cleaning on incidence density of healthcare-onset Clostridioides difficile infection (HO-CDI) standardized infection ratios (SIRs).
Design:
Multi-site, quasi-experimental study, with control hospitals and a nonequivalent dependent variable.
Setting:
The study was conducted across 8 acute-care hospitals in 6 states with stable endemic HO-CDI SIRs.
Methods:
Following an 18-month preintervention control period, each site implemented a program of daily hospital-wide sporicidal disinfectant patient zone cleaning. After a wash-in period, thoroughness of disinfection cleaning (TDC) was monitored prospectively and optimized with performance feedback utilizing a previously validated process improvement program. Mean HO-CDI SIRs were calculated by quarter for the pre- and postintervention periods for both the intervention and control hospitals. We used a difference-in-differences analysis to estimate the change in the average HO-CDI SIR and HO-CAUTI SIR for the pre- and postintervention periods.
Results:
Following the wash-in period, the TDC improved steadily for all sites and by 18 months was 93.6% for the group. The mean HO-CDI SIRs decreased from 1.03 to 0.6 (95% CI, 0.13–0.75; P = .009). In the adjusted difference-in-differences analysis in comparison to controls, there was a 0.55 reduction (95% CI, −0.77 to −0.32) in HO-CDI (P < .001) or a 50% relative decrease from baseline.
Conclusions:
This study represents the first multiple-site, quasi-experimental study with control hospitals and a nonequivalent dependent variable to evaluate a 4-component intervention on HO-CDI. Following ongoing improvement in cleaning thoroughness, there was a sustained 50% decrease in HO-CDI SIRs compared to controls.
To assess preventability of hospital-onset bacteremia and fungemia (HOB), we developed and evaluated a structured rating guide accounting for intrinsic patient and extrinsic healthcare-related risks.
Design:
HOB preventability rating guide was compared against a reference standard expert panel.
Participants:
A 10-member panel of clinical experts was assembled as the standard of preventability assessment, and 2 physician reviewers applied the rating guide for comparison.
Methods:
The expert panel independently rated 82 hypothetical HOB scenarios using a 6-point Likert scale collapsed into 3 categories: preventable, uncertain, or not preventable. Consensus was defined as concurrence on the same category among ≥70% experts. Scenarios without consensus were deliberated and followed by a second round of rating.
Two reviewers independently applied the rating guide to adjudicate the same 82 scenarios in 2 rounds, with interim revisions. Interrater reliability was evaluated using the κ (kappa) statistic.
Results:
Expert panel consensus criteria were met for 52 scenarios (63%) after 2 rounds.
After 2 rounds, guide-based rating matched expert panel consensus in 40 of 52 (77%) and 39 of 52 (75%) cases for reviewers 1 and 2, respectively. Agreement rates between the 2 reviewers were 84% overall (κ, 0.76; 95% confidence interval [CI], 0.64–0.88]) and 87% (κ, 0.79; 95% CI, 0.65–0.94) for the 52 scenarios with expert consensus.
Conclusions:
Preventability ratings of HOB scenarios by 2 reviewers using a rating guide matched expert consensus in most cases with moderately high interreviewer reliability. Although diversity of expert opinions and uncertainty of preventability merit further exploration, this is a step toward standardized assessment of HOB preventability.
Evidence supporting collection of follow-up blood cultures for Gram-negative bacteremia is mixed. We sought to understand why providers order follow-up blood cultures when managing P. aeruginosa bacteremia and whether follow-up blood cultures in this context are associated with short- and long-term survival.
Methods:
We conducted a retrospective cohort study of adult inpatients with P. aeruginosa bacteremia at the University of Maryland Medical Center in 2015–2020. Kaplan-Meier survival curves and Cox regression with time-varying covariates were used to evaluate the association between follow-up blood cultures and time to mortality within 30 days of first positive blood culture. Provider justifications for follow-up blood cultures were identified through chart review.
Results:
Of 159 eligible patients, 127 (80%) had follow-up blood cultures, including 9 (7%) that were positive for P. aeruginosa and 10 (8%) that were positive for other organisms. Follow-up blood cultures were typically collected “to ensure clearance” or “to guide antibiotic therapy.” Overall, 30-day mortality was 25.2%. After risk adjustment for patient characteristics, follow-up blood cultures were associated with a nonsignificant reduction in mortality risk (hazard ratio, 0.43; 95% confidence interval, 1.08; P = .071). In exploratory analyses, the potential mortality reduction from follow-up blood cultures was driven by their use in patients with Pitt bacteremia scores >0.
Conclusions:
Follow-up blood cultures are commonly collected for P. aeruginosa bacteremia but infrequently identify persistent bacteremia. Targeted use of follow-up blood cultures based on severity of illness may reduce unnecessary culturing.