To identify risk factors for methicillin-susceptible (MSSA) and methicillin-resistant S. aureus (MRSA) nasal carriage and surgical site infection (SSI) among patients undergoing fracture fixation procedures who were included in a quality improvement protocol involving screening patients for S. aureus nasal carriage and treating carriers with intranasal mupirocin and chlorhexidine bathing.

Retrospective cohort study.

Level 1 trauma center.

1,254 adults who underwent operative fixation of 1,298 extremity or pelvis fractures between 8/1/2014 – 7/31/2017.

We calculated rates of S. aureus nasal carriage and SSI. We used multivariable stepwise logistic regression and selected the final models based on Akaike information criterion.

Of the 1,040 screened first procedures, 262 (25.19%) were performed on S. aureus nasal carriers: 211 (20.29%) on MSSA carriers and 51 (4.90%) on MRSA carriers. Long-term care facility residence (odds ratio [OR] 3.38; 95% confidence interval [CI] 1.17–9.76) was associated with MRSA nasal carriage. After adjusting for statistically and clinically significant variables, MRSA carriage was significantly associated with any SSI (OR 4.58; 95% CI 1.63–12.88), S. aureus SSI (OR 10.11; 95% CI 3.25–31.42), and MRSA SSI (OR 27.25; 95% CI 5.33–139.24), whereas MSSA carriage was not. Among S. aureus carriers, any chlorhexidine use was documented for 232 (88.55%), and any intranasal mupirocin was documented for 85 (40.28%) MSSA carriers and 33 (64.71%) MRSA carriers.

MRSA carriage was associated with a significant risk of SSI after operative fracture fixation. Many carriers did not undergo decolonization, suggesting that a simplified decolonization protocol is needed.

Many preoperative urine cultures are of low value and may even lead to patient harms. This study sought to understand practices around ordering preoperative urine cultures and prescribing antibiotic treatment.

Open-ended, semi-structured qualitative interviews

5 Veterans Affairs hospitals.

Interviews with 14 surgeons (9 surgeons, 5 surgical leaders), 7 infectious disease physicians, 8 surgical advanced practice providers (APPs), 1 surgical nurse manager, 3 infectious disease pharmacists, 1 hospitalist, and 1 lab manager.

We interviewed participants using a qualitative semi-structured interview guide. Collected data was coded inductively and with the Dual Process Model (DPM) using MAXQDA software. Data in the “Testing Decision-Making” code was further reviewed using the concept of perceived risk as a sensitizing concept.

We identified themes relating to surgeons’ concerns about de-implementing preoperative urine cultures to detect asymptomatic bacteriuria (ASB) in patients undergoing non-urological procedures: (1) anxiety and uncertainty surrounding missing infection signs spanned surgical specialties, (2) there were perceived risks of negative consequences associated with omitting urine cultures and treatment prior to specific procedure sites and types, and additionally, (3) participants suggested potential routes for adjusting these perceived risks to facilitate de-implementation acceptance. Notably, participants suggested that leadership support and peer engagement could help improve surgeon buy-in.

Concerns about perceived risks sometimes outweigh the evidence against routine preoperative urine cultures to detect ASB. Evidence from trusted peers may improve openness to de-implementing preoperative urine cultures.

A substantial proportion of patients undergoing hemodialysis carry Staphylococcus aureus in their noses, and carriers are at increased risk of S. aureus bloodstream infections. Our pragmatic clinical trial implemented nasal povidone-iodine (PVI) decolonization for the prevention of bloodstream infections in the novel setting of hemodialysis units.

We aimed to identify pragmatic strategies for implementing PVI decolonization among patients in outpatient hemodialysis units.

Qualitative descriptive study.

Outpatient hemodialysis units affiliated with five US academic medical centers. Units varied in size, patient demographics, and geographic location.

Sixty-six interviewees including nurses, hemodialysis technicians, research coordinators, and other personnel.

We conducted interviews with personnel affiliated with all five academic medical centers and conducted thematic analysis of transcripts.

Hemodialysis units had varied success with patient recruitment, but interviewees reported that patients and healthcare personnel (HCP) found PVI decolonization acceptable and feasible. Leadership support, HCP engagement, and tailored patient-focused tools or strategies facilitated patient engagement and PVI implementation. Interviewees reported both patients and HCP sometimes underestimated patients’ infection risks and experienced infection-prevention fatigue. Other HCP barriers included limited staffing and poor staff engagement. Patient barriers included high health burdens, language barriers, memory issues, and lack of social support.

Our qualitative study suggests that PVI decolonization would be acceptable to patients and clinical personnel, and implementation is feasible for outpatient hemodialysis units. Hemodialysis units could facilitate implementation by engaging unit leaders, patients and personnel, and developing education for patients about their infection risk.

Surgical-site infections (SSIs) can be catastrophic. Bundles of evidence-based practices can reduce SSIs but can be difficult to implement and sustain.

We sought to understand the implementation of SSI prevention bundles in 6 US hospitals.

Qualitative study.

We conducted in-depth semistructured interviews with personnel involved in bundle implementation and conducted a thematic analysis of the transcripts.

The study was conducted in 6 US hospitals: 2 academic tertiary-care hospitals, 3 academic-affiliated community hospitals, 1 unaffiliated community hospital.

In total, 30 hospital personnel participated. Participants included surgeons, laboratory directors, clinical personnel, and infection preventionists.

Bundle complexity impeded implementation. Other barriers varied across services, even within the same hospital. Multiple strategies were needed, and successful strategies in one service did not always apply in other areas. However, early and sustained interprofessional collaboration facilitated implementation.

The evidence-based SSI bundle is complicated and can be difficult to implement. One implementation process probably will not work for all settings. Multiple strategies were needed to overcome contextual and implementation barriers that varied by setting and implementation climate. Appropriate adaptations for specific settings and populations may improve bundle adoption, fidelity, acceptability, and sustainability.

Although multiple studies revealed high vaccine effectiveness of coronavirus disease 2019 (COVID-19) vaccines within 3 months after the completion of vaccines, long-term vaccine effectiveness has not been well established, especially after the δ (delta) variant became prominent. We performed a systematic literature review and meta-analysis of long-term vaccine effectiveness.

We searched PubMed, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science from December 2019 to November 15, 2021, for studies evaluating the long-term vaccine effectiveness against laboratory-confirmed COVID-19 or COVID-19 hospitalization among individuals who received 2 doses of Pfizer/BioNTech, Moderna, or AstraZeneca vaccines, or 1 dose of the Janssen vaccine. Long-term was defined as >5 months after the last dose. We calculated the pooled diagnostic odds ratio (DOR) with 95% confidence interval for COVID-19 between vaccinated and unvaccinated individuals. Vaccine effectiveness was estimated as 100% × (1 − DOR).

In total, 16 studies including 17,939,172 individuals evaluated long-term vaccine effectiveness and were included in the meta-analysis. The pooled DOR for COVID-19 was 0.158 (95% CI: 0.157-0.160) with an estimated vaccine effectiveness of 84.2% (95% CI, 84.0- 84.3%). Estimated vaccine effectiveness against COVID-19 hospitalization was 88.7% (95% CI, 55.8%–97.1%). Vaccine effectiveness against COVID-19 during the δ variant period was 61.2% (95% CI, 59.0%–63.3%).

COVID-19 vaccines are effective in preventing COVID-19 and COVID-19 hospitalization across a long-term period for the circulating variants during the study period. More observational studies are needed to evaluate the vaccine effectiveness of third dose of a COVID-19 vaccine, the vaccine effectiveness of mixing COVID-19 vaccines, COVID-19 breakthrough infection, and vaccine effectiveness against newly emerging variants.

Ceftazidime/avibactam (C/A), ceftolozane/tazobactam (C/T), imipenem/relebactam (I/R), and meropenem/vaborbactam (M/V) combine either a cephalosporin (C/T and C/A) or a carbapenem antibiotic (M/V and I/R) with a β-lactamase inhibitor. They are used to treat carbapenem-resistant Enterobacterales (CRE) and/or multidrug-resistant Pseudomonas aeruginosa (MDRPA).

We compared the pooled clinical success of these medications to older therapies.

PubMed and EMBASE were searched from January 1, 2012, through September 2, 2020, for C/A, C/T, I/R, and M/V studies. The main outcome was clinical success, which was assessed using random-effects models. Stratified analyses were conducted for study drug, sample size, quality, infection source, study design, and multidrug-resistant gram-negative organism (MDRGNO) population. Microbiological success and 28- and 30-day mortality were assessed as secondary outcomes. Heterogeneity was determined using I2 values.

Overall, 25 articles met the inclusion criteria; 8 observational studies and 17 randomized control trials. We detected no difference in clinical success comparing new combination antibiotics with standard therapies for all included organisms (pooled OR, 1.21; 95% CI, 0.96–1.51). We detected a moderate level of heterogeneity among the included studies I2 = 56%. Studies that focused on patients with CRE or MDRPA infections demonstrated a strong association between treatment with new combination antibiotics and clinical success (pooled OR, 2.20; 95% CI, 1.60–3.57).

C/T, C/A, I/R, and M/V are not inferior to standard therapies for treating various complicated infections, but they may have greater clinical success for treating MDRPA and CRE infections. More studies that evaluate the use of these antibiotics for drug-resistant infections are needed to determine their effectiveness.

Healthcare workers (HCWs) are at risk of COVID-19 due to high levels of SARS-CoV-2 exposure. Thus, effective vaccines are needed. We performed a systematic literature review and meta-analysis on COVID-19 short-term vaccine effectiveness among HCWs.

We searched PubMed, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science from December 2019 to June 11, 2021, for studies evaluating vaccine effectiveness against symptomatic COVID-19 among HCWs. To meta-analyze the extracted data, we calculated the pooled diagnostic odds ratio (DOR) for COVID-19 between vaccinated and unvaccinated HCWs. Vaccine effectiveness was estimated as 100% × (1 − DOR). We also performed a stratified analysis for vaccine effectiveness by vaccination status: 1 dose and 2 doses of the vaccine.

We included 13 studies, including 173,742 HCWs evaluated for vaccine effectiveness in the meta-analysis. The vast majority (99.9%) of HCWs were vaccinated with the Pfizer/BioNTech COVID-19 mRNA vaccine. The pooled DOR for symptomatic COVID-19 among vaccinated HCWs was 0.072 (95% confidence interval [CI], 0.028–0.184) with an estimated vaccine effectiveness of 92.8% (95% CI, 81.6%–97.2%). In stratified analyses, the estimated vaccine effectiveness against symptomatic COVID-19 among HCWs who had received 1 dose of vaccine was 82.1% (95% CI, 46.1%–94.1%) and the vaccine effectiveness among HCWs who had received 2 doses was 93.5% (95% CI, 82.5%–97.6%).

The COVID-19 mRNA vaccines are highly effective against symptomatic COVID-19, even with 1 dose. More observational studies are needed to evaluate the vaccine effectiveness of other COVID-19 vaccines, COVID-19 breakthrough after vaccination, and vaccine efficacy against new variants.

To evaluate the frequency of antibiotic prescribing for common infections via telemedicine compared to face-to-face visits.

Systematic literature review and meta-analysis.

We searched PubMed, CINAHL, Embase (Elsevier platform) and Cochrane CENTRAL to identify studies comparing frequency of antibiotic prescribing via telemedicine and face-to-face visits without restrictions by publish dates or language used. We conducted meta-analyses of 5 infections: sinusitis, pharyngitis, otitis media, upper respiratory infection (URI) and urinary tract infection (UTI). Random-effect models were used to obtain pooled odds ratios (ORs). Heterogeneity was evaluated with I2 estimation and the Cochran Q statistic test.

Among 3,106 studies screened, 23 studies (1 randomized control study, 22 observational studies) were included in the systematic literature review. Most of the studies (21 of 23) were conducted in the United States. Studies were substantially heterogenous, but stratified analyses revealed that providers prescribed antibiotics more frequently via telemedicine for otitis media (pooled odds ratio [OR], 1.26; 95% confidence interval [CI], 1.04–1.52; I2 = 31%) and pharyngitis (pooled OR, 1.16; 95% CI, 1.01–1.33; I2 = 0%). We detected no significant difference in the frequencies of antibiotic prescribing for sinusitis (pooled OR, 0.86; 95% CI, 0.70–1.06; I2 = 91%), URI (pooled OR, 1.18; 95% CI, 0.59–2.39; I2 = 100%), or UTI (pooled OR, 2.57; 95% CI, 0.88–7.46; I2 = 91%).

Telemedicine visits for otitis media and pharyngitis were associated with higher rates of antibiotic prescribing. The interpretation of these findings requires caution due to substantial heterogeneity among available studies. Large-scale, well-designed studies with comprehensive assessment of antibiotic prescribing for common outpatient infections comparing telemedicine and face-to-face visits are needed to validate our findings.

Studying phenotypic and genetic characteristics of age at onset (AAO) and polarity at onset (PAO) in bipolar disorder can provide new insights into disease pathology and facilitate the development of screening tools.

To examine the genetic architecture of AAO and PAO and their association with bipolar disorder disease characteristics.

Genome-wide association studies (GWASs) and polygenic score (PGS) analyses of AAO (n = 12 977) and PAO (n = 6773) were conducted in patients with bipolar disorder from 34 cohorts and a replication sample (n = 2237). The association of onset with disease characteristics was investigated in two of these cohorts.

Earlier AAO was associated with a higher probability of psychotic symptoms, suicidality, lower educational attainment, not living together and fewer episodes. Depressive onset correlated with suicidality and manic onset correlated with delusions and manic episodes. Systematic differences in AAO between cohorts and continents of origin were observed. This was also reflected in single-nucleotide variant-based heritability estimates, with higher heritabilities for stricter onset definitions. Increased PGS for autism spectrum disorder (β = −0.34 years, s.e. = 0.08), major depression (β = −0.34 years, s.e. = 0.08), schizophrenia (β = −0.39 years, s.e. = 0.08), and educational attainment (β = −0.31 years, s.e. = 0.08) were associated with an earlier AAO. The AAO GWAS identified one significant locus, but this finding did not replicate. Neither GWAS nor PGS analyses yielded significant associations with PAO.

AAO and PAO are associated with indicators of bipolar disorder severity. Individuals with an earlier onset show an increased polygenic liability for a broad spectrum of psychiatric traits. Systematic differences in AAO across cohorts, continents and phenotype definitions introduce significant heterogeneity, affecting analyses.