Implementing and validating a home-infusion central-line-associated bloodstream infection surveillance definition

OBJECTIVE

Central-line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy is necessary to track efforts to reduce infections, but a standardized, validated, and feasible definition is lacking. We tested the validity of a home-infusion CLABSI surveillance definition and the feasibility and acceptability of its implementation.

DESIGN

Mixed-methods study including validation of CLABSI cases and semistructured interviews with staff applying these approaches.

SETTING

This study was conducted in 5 large home-infusion agencies in a CLABSI prevention collaborative across 14 states and the District of Columbia.

PARTICIPANTS

Staff performing home-infusion CLABSI surveillance.

METHODS

From May 2021 to May 2022, agencies implemented a home-infusion CLABSI surveillance definition, using 3 approaches to secondary bloodstream infections (BSIs): National Healthcare Safety Program (NHSN) criteria, modified NHSN criteria (only applying the 4 most common NHSN-defined secondary BSIs), and all home-infusion-onset bacteremia (HiOB). Data on all positive blood cultures were sent to an infection preventionist for validation. Surveillance staff underwent semistructured interviews focused on their perceptions of the definition 1 and 3-4 months after implementation.

RESULTS

Interrater reliability scores overall ranged from κ = 0.65 for the modified NHSN criteria to κ = 0.68 for the NHSN criteria to κ = 0.72 for the HiOB criteria. For the NHSN criteria, the agency-determined rate was 0.21 per 1,000 central-line (CL) days, and the validator-determined rate was 0.20 per 1,000 CL days. Overall, implementing a standardized definition was thought to be a positive change that would be generalizable and feasible though time-consuming and labor intensive.

CONCLUSIONS

The home-infusion CLABSI surveillance definition was valid and feasible to implement.

Healthcare personnel interactive pathogen exposure response system

Exposure investigations are labor intensive and vulnerable to recall bias. We developed an algorithm to identify healthcare personnel (HCP) interactions from the electronic health record (EHR), and we evaluated its accuracy against conventional exposure investigations. The EHR algorithm identified every known transmission and used ranking to produce a manageable contact list.

The need to expand the infection prevention workforce in home infusion therapy

Infection prevention and surveillance training approaches for home infusion therapy have not been well defined. We interviewed home infusion staff who perform surveillance activities about barriers to and facilitators for central line-associated bloodstream infection (CLABSI) surveillance and identified barriers to training in CLABSI surveillance. Our findings show a lack of formal surveillance training for staff. This gap can be addressed by adapting existing training resources to the home infusion setting.

Controlling the chaos: Information management in home-infusion central-line-associated bloodstream infection (CLABSI) surveillance

Objectives

Access to patient information may affect how home-infusion surveillance staff identify central-line-associated bloodstream infections (CLABSIs). We characterized information hazards in home-infusion CLABSI surveillance and identified possible strategies to mitigate information hazards.

Design

Qualitative study using semistructured interviews.

Setting and participants

The study included 21 clinical staff members involved in CLABSI surveillance at 5 large home-infusion agencies covering 13 states and the District of Columbia. Methods: Interviews were conducted by 1 researcher. Transcripts were coded by 2 researchers; consensus was reached by discussion.

Results

Data revealed the following barriers: information overload, information underload, information scatter, information conflict, and erroneous information. Respondents identified 5 strategies to mitigate information chaos: (1) engage information technology in developing reports; (2) develop streamlined processes for acquiring and sharing data among staff; (3) enable staff access to hospital electronic health records; (4) use a single, validated, home-infusion CLABSI surveillance definition; and (5) develop relationships between home-infusion surveillance staff and inpatient healthcare workers.

Conclusions

Information chaos occurs in home-infusion CLABSI surveillance and may affect the development of accurate CLABSI rates in home-infusion therapy. Implementing strategies to minimize information chaos will enhance intra- and interteam collaborations in addition to improving patient-related outcomes.

Differential Role of Type 2 Diabetes as a Risk Factor for Tuberculosis in the Elderly versus Younger Adults

The elderly are understudied despite their high risk of tuberculosis (TB). We sought to identify factors underlying the lack of an association between TB and type 2 diabetes (T2D) in the elderly, but not adults. We conducted a case-control study in elderly (≥65 years old; ELD) vs. younger adults (young/middle-aged adults (18-44/45-64 years old; YA|MAA) stratified by TB and T2D, using a research study population (n = 1160) and TB surveillance data (n = 8783). In the research study population the adjusted odds ratio (AOR) of TB in T2D was highest in young adults (AOR 6.48) but waned with age becoming non-significant in the elderly. Findings were validated using TB surveillance data. T2D in the elderly (vs. T2D in younger individuals) was characterized by better glucose control (e.g., lower hyperglycemia or HbA1c), lower insulin resistance, more sulphonylureas use, and features of less inflammation (e.g., lower obesity, neutrophils, platelets, anti-inflammatory use). We posit that differences underlying glucose dysregulation and inflammation in elderly vs. younger adults with T2D, contribute to their differential association with TB. Studies in the elderly provide valuable insights into TB-T2D pathogenesis, e.g., here we identified insulin resistance as a novel candidate mechanism by which T2D may increase active TB risk.

2053. The Need to Expand the Infection Prevention Workforce in Home Infusion Therapy

Background

Infection preventionists who perform surveillance for central line-associated bloodstream infections (CLABSIs) in hospitals receive training in application of rigorous surveillance definitions. However, in the home infusion setting where CLABSIs also occur, the approach for training and methods to perform surveillance has not been well defined.

Objective

In this qualitative study, we sought to characterize how home infusion surveillance staff are trained in CLABSI surveillance and to identify barriers to CLABSI surveillance in the home infusion setting.

Methods

We interviewed 21 surveillance staff members of five non-profit home infusion agencies covering portions of thirteen states and Washington, DC across the Mid-Atlantic, Northeast, and Midwest. Interview questions were developed using the Systems Engineering in Patient Safety (SEIPS) 2.0 framework. Data were analyzed both inductively and deductively by two team members. These interviews are part of a larger study, some of whose findings have been previously discussed in prior publications. Data specific to training home infusion surveillance staff in CLABSI surveillance are presented (Table 1).

Results

Many of the CLABSI surveillance staff had received no formal training in CLABSI surveillance. Instead, many either learned on the job (often from predecessors who also had not been formally trained), drew from previous clinical experience, perused online resources, or attended conferences. A lack of (1) resources for learning, (2) formal training offered by their agencies, and (3) awareness of professional development resources were identified as barriers to CLABSI surveillance training in the home infusion setting.

Conclusion

Our findings indicate a current lack of formal training in CLABSI surveillance for staff performing CLABSI surveillance in home infusion therapy. The home infusion surveillance workforce can be strengthened by providing home infusion-specific standardized training, perhaps through adaptations of resources used for training surveillance staff in other settings.

Disclosures

Sara E. Cosgrove, MD, Basilea: Member of Infection Adjudication Committee.

434. Healthcare Personnel Interactive Pathogen Exposure Response System

Background

Infectious disease exposure investigations in the hospital are labor-intensive for the infection prevention and control (IPC) team and vulnerable to healthcare personnel (HCP) recall bias. We developed an electronic health record (EHR) algorithm to identify and rank patient-HCP interactions based on the likelihood and intensity of exposure.

Methods

We compared conventional and EHR-based findings from seven exposure investigations conducted between November 1, 2020 and February 1, 2022 at The Johns Hopkins Hospital (JHH), a 1095 bed academic tertiary center in Baltimore, MD. Conventional exposure investigations were conducted for hospitalized patients who tested positive for SARS-CoV-2 while not in COVID-19 isolation precautions. IPC contacted department managers to identify and report potentially exposed HCPs to occupational health. The EHR-based method identified HCP-patient interactions based on clinical data such as documentation in the flowsheet, medication administration, etc. A score was calculated for each HCP based on the estimated duration and intensity of the contact. Genomic sequencing of available samples was performed to investigate transmission events.

Results

Overall, the EHR-based system identified 75% (59/79) of the HCPs identified by conventional exposure investigations and 100% of those who document in the EHR. In contrast, it was unable to identify any potentially exposed individuals who do not document in the EHR (Table 1). All patient-HCP COVID-19 transmissions identified by conventional investigation and confirmed through genomic sequencing were identified by the EHR-based system, and all had high-intensity scores (i.e., top quartile of the list of exposed individuals). Table 1.Comparison of Conventional and EHR Based COVID-19 Exposure Investigations

Conclusion

We found clinical EHR data was highly sensitive and specific in identifying potentially exposed HCPs compared with conventional exposure investigations. The inability to detect interactions with support staff or others who do not document in the EHR was a limitation and suggests that EHR data can augment but not replace conventional exposure investigations. The system’s speed, ease, and lower resource requirements make it a promising tool to more efficiently complete exposure investigations in healthcare settings.

Disclosures

Sara E. Cosgrove, MD, Basilea: Member of Infection Adjudication Committee.

A task analysis of central line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy

BACKGROUND

Barriers for home infusion therapy central line associated bloodstream infection (CLABSI) surveillance have not been elucidated and are needed to identify how to support home infusion CLABSI surveillance. We aimed to (1) perform a goal-directed task analysis of home infusion CLABSI surveillance, and (2) describe barriers to, facilitators for, and suggested strategies for successful home infusion CLABSI surveillance.

METHODS

We conducted semi-structured interviews with team members involved in CLABSI surveillance at 5 large home infusion agencies to explore work systems used by members of the agency for home infusion CLABSI surveillance. We analyzed the transcribed interviews qualitatively for themes.

RESULTS

Twenty-one interviews revealed 8 steps for performing CLABSI surveillance in home infusion therapy. Major barriers identified included the need for training of the surveillance staff, lack of a standardized definition, inadequate information technology support, struggles communicating with hospitals, inadequate time, and insufficient clinician engagement and leadership support.

DISCUSSION

Staff performing home infusion CLABSI surveillance need health system resources, particularly leadership and front-line engagement, access to data, information technology support, training, dedicated time, and reports to perform tasks.

CONCLUSIONS

Building home infusion CLABSI surveillance programs will require support from home infusion leadership.

Evaluating Immunity to SARS-CoV-2 in Nursing Home Residents using Saliva IgG

BACKGROUND

SARS-CoV-2 circulating variants coupled with waning immunity pose a significant threat to the long-term care (LTC) population. Our objective was to measure salivary IgG antibodies in residents and staff of a LTC facility to 1) evaluate IgG response in saliva post-natural infection and vaccination and 2) assess its feasibility to describe the seroprevalence over time.

METHODS

We performed salivary IgG sampling of all residents and staff who agreed to testing in a 150-bed skilled nursing facility during three seroprevalence surveys between October 2020 and February 2021. The facility had SARS-CoV-2 outbreaks in May 2020 and November 2020, when 45 of 138 and 37 of 125 residents were infected, respectively; they offered two Federal vaccine clinics in January 2021. We evaluated quantitative IgG in saliva to the Nucleocapsid (N), Spike (S), and Receptor binding domain (RBD) Antigens of SARS-CoV-2 over time post-infection and post-vaccination.

RESULTS

124 residents and 28 staff underwent saliva serologic testing on one or more survey visits. Over three surveys, the SARS-CoV-2 seroprevalence at the facility was 49%, 64%, and 81%, respectively. IgG to S, RBD, and N Antigens all increased post infection. Post vaccination, the infection naïve group did not have a detectable N IgG level, and N IgG levels for the previously infected did not increase post vaccination (p < 0.001). Fully vaccinated subjects with prior COVID-19 infection had significantly higher RBD and S IgG responses compared with those who were infection-naïve prior to vaccination (p < 0.001 for both).

CONCLUSIONS

Positive SARS-COV-2 IgG in saliva was concordant with prior infection (Anti N, S, RBD) and vaccination (Anti S, RBD) and remained above positivity threshold for up to 9 months from infection. Salivary sampling is a non-invasive method of tracking immunity and differentiating between prior infection and vaccination to inform need for boosters in LTC residents and staff. This article is protected by copyright. All rights reserved.

The case for wearable proximity devices to inform physical distancing among healthcare workers

Objective

Despite the importance of physical distancing in reducing SARS-CoV-2 transmission, this practice is challenging in healthcare. We piloted use of wearable proximity beacons among healthcare workers (HCWs) in an inpatient unit to highlight considerations for future use of trackable technologies in healthcare settings.

Materials and Methods

We performed a feasibility pilot study in a non-COVID adult medical unit from September 28 to October 28, 2020. HCWs wore wearable proximity beacons, and interactions defined as <6 feet for ≥5 s were recorded. Validation was performed using direct observations.

Results

A total of 6172 close proximity interactions were recorded, and with the removal of 2033 false-positive interactions, 4139 remained. The highest proportion of interactions occurred between 7:00 Am–9:00 Am. Direct observations of HCWs substantiated these findings.

Discussion

This pilot study showed that wearable beacons can be used to monitor and quantify HCW interactions in inpatient settings.

Conclusion

Technology can be used to track HCW physical distancing.

Physical distancing, or social distancing, is important in preventing COVID-19. It is hard for healthcare workers (HCWs) to physically distance at work. We tested a device (proximity beacon) that HCWs could wear to measure their distance from each other among HCWs on a medical unit. The device measured any time HCWs were within 6 feet of each other for at least 5 s. We watched HCWs who were close to each other. The devices and our observations showed that 7:00 Am—9:00 Am was the highest risk time for not physically distancing. This study shows that wearable devices can be a tool to monitor HCWs physical distancing on a hospital unit.

Does This Patient Need Blood Cultures? A Scoping Review of Indications for Blood Cultures in Adult Nonneutropenic Inpatients

Guidance regarding indications for initial or follow-up blood cultures is limited. We conducted a scoping review of articles published between January 2004 and June 2019 that reported the yield of blood cultures and/or their impact in the clinical management of fever and common infectious syndromes in nonneutropenic adult inpatients. A total of 2893 articles were screened; 50 were included. Based on the reported incidence of bacteremia, syndromes were categorized into low, moderate, and high pretest probability of bacteremia. Routine blood cultures are recommended in syndromes with a high likelihood of bacteremia (eg, endovascular infections) and those with moderate likelihood when cultures from the primary source of infection are unavailable or when prompt initiation of antibiotics is needed prior to obtaining primary source cultures. In syndromes where blood cultures are low-yield, blood cultures can be considered for patients at risk of adverse events if a bacteremia is missed (eg, patient with pacemaker and severe purulent cellulitis). If a patient has adequate source control and risk factors or concern for endovascular infection are not present, most streptococci or Enterobacterales bacteremias do not require routine follow-up blood cultures.

Prevalence of Co-infection at the Time of Hospital Admission in COVID-19 Patients, A Multicenter Study

BACKGROUND

Bacterial infections may complicate viral pneumonias. Recent reports suggest that bacterial co-infection at time of presentation is uncommon in coronavirus disease 2019 (COVID-19); however, estimates were based on microbiology tests alone. We sought to develop and apply consensus definitions, incorporating clinical criteria to better understand the rate of co-infections and antibiotic use in COVID-19.

METHODS

A total of 1016 adult patients admitted to 5 hospitals in the Johns Hopkins Health System between March 1, 2020, and May 31, 2020, with COVID-19 were evaluated. Adjudication of co-infection using definitions developed by a multidisciplinary team for this study was performed. Both respiratory and common nonrespiratory co-infections were assessed. The definition of bacterial community-acquired pneumonia (bCAP) included proven (clinical, laboratory, and radiographic criteria plus microbiologic diagnosis), probable (clinical, laboratory, and radiographic criteria without microbiologic diagnosis), and possible (not all clinical, laboratory, and radiographic criteria met) categories. Clinical characteristics and antimicrobial use were assessed in the context of the consensus definitions.

RESULTS

Bacterial respiratory co-infections were infrequent (1.2%); 1 patient had proven bCAP, and 11 (1.1%) had probable bCAP. Two patients (0.2%) had viral respiratory co-infections. Although 69% of patients received antibiotics for pneumonia, the majority were stopped within 48 hours in patients with possible or no evidence of bCAP. The most common nonrespiratory infection was urinary tract infection (present in 3% of the cohort).

CONCLUSIONS

Using multidisciplinary consensus definitions, proven or probable bCAP was uncommon in adults hospitalized due to COVID-19, as were other nonrespiratory bacterial infections. Empiric antibiotic use was high, highlighting the need to enhance antibiotic stewardship in the treatment of viral pneumonias.

Diabetes screen during tuberculosis contact investigations highlights opportunity for new diabetes diagnosis and reveals metabolic differences between ethnic groups

Type 2 diabetes (T2D) is a prevalent risk factor for tuberculosis (TB), but most studies on TB-T2D have focused on TB patients, been limited to one community, and shown a variable impact of T2D on TB risk or treatment outcomes. We conducted a cross-sectional assessment of sociodemographic and metabolic factors in adult TB contacts with T2D (versus no T2D), from the Texas-Mexico border to study Hispanics, and in Cape Town to study South African Coloured ethnicities. The prevalence of T2D was 30.2% in Texas-Mexico and 17.4% in South Africa, with new diagnosis in 34.4% and 43.9%, respectively. Contacts with T2D differed between ethnicities, with higher smoking, hormonal contraceptive use and cholesterol levels in South Africa, and higher obesity in Texas-Mexico (p < 0.05). PCA analysis revealed striking differences between ethnicities in the relationships between factors defining T2D and dyslipidemias. Our findings suggest that screening for new T2D in adult TB contacts is effective to identify new T2D patients at risk for TB. Furthermore, studies aimed at predicting individual TB risk in T2D patients, should take into account the heterogeneity in dyslipidemias that are likely to modify the estimates of TB risk or adverse treatment outcomes that are generally attributed to T2D alone.