1215. Variation in Hand Hygiene Improvement After Implementation of an Electronic Hand Hygiene System During the COVID-19 Pandemic

Background

Electronic hand hygiene (HH) monitoring systems have many potential advantages but there are limited data on wide-scale implementation of these systems. Table

Quantification of Occupational and Community Risk Factors for SARS-CoV-2 Seropositivity Among Health Care Workers in a Large U.S. Health Care System

BACKGROUND

Identifying occupational risk factors for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among health care workers (HCWs) can improve HCW and patient safety.

OBJECTIVE

To quantify demographic, occupational, and community risk factors for SARS-CoV-2 seropositivity among HCWs in a large health care system.

DESIGN

A logistic regression model was fitted to data from a cross-sectional survey conducted in April to June 2020, linking risk factors for occupational and community exposure to coronavirus disease 2019 (COVID-19) with SARS-CoV-2 seropositivity.

SETTING

A large academic health care system in the Atlanta, Georgia, metropolitan area.

PARTICIPANTS

Employees and medical staff members elected to participate in SARS-CoV-2 serology testing offered to all HCWs as part of a quality initiative and completed a survey on exposure to COVID-19 and use of personal protective equipment.

MEASUREMENTS

Demographic risk factors for COVID-19, residential ZIP code incidence of COVID-19, occupational exposure to HCWs or patients who tested positive on polymerase chain reaction test, and use of personal protective equipment as potential risk factors for infection. The outcome was SARS-CoV-2 seropositivity.

RESULTS

Adjusted SARS-CoV-2 seropositivity was estimated to be 3.8% (95% CI, 3.4% to 4.3%) (positive, n = 582) among the 10 275 HCWs (35% of the Emory Healthcare workforce) who participated in the survey. Community contact with a person known or suspected to have COVID-19 (adjusted odds ratio [aOR], 1.9 [CI, 1.4 to 2.6]; 77 positive persons [10.3%]) and community COVID-19 incidence (aOR, 1.5 [CI, 1.0 to 2.2]) increased the odds of infection. Black individuals were at high risk (aOR, 2.1 [CI, 1.7 to 2.6]; 238 positive persons [8.3%]).

LIMITATIONS

Participation rates were modest and key workplace exposures, including job and infection prevention practices, changed rapidly in the early phases of the pandemic.

CONCLUSION

Demographic and community risk factors, including contact with a COVID-19-positive person and Black race, are more strongly associated with SARS-CoV-2 seropositivity among HCWs than is exposure in the workplace.

PRIMARY FUNDING SOURCE

Emory COVID-19 Response Collaborative.

Risk Factors Associated With SARS-CoV-2 Seropositivity Among US Health Care Personnel

IMPORTANCE

Risks for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among health care personnel (HCP) are unclear.

OBJECTIVE

To evaluate the risk factors associated with SARS-CoV-2 seropositivity among HCP with the a priori hypothesis that community exposure but not health care exposure was associated with seropositivity.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted among volunteer HCP at 4 large health care systems in 3 US states. Sites shared deidentified data sets, including previously collected serology results, questionnaire results on community and workplace exposures at the time of serology, and 3-digit residential zip code prefix of HCP. Site-specific responses were mapped to a common metadata set. Residential weekly coronavirus disease 2019 (COVID-19) cumulative incidence was calculated from state-based COVID-19 case and census data.

EXPOSURES

Model variables included demographic (age, race, sex, ethnicity), community (known COVID-19 contact, COVID-19 cumulative incidence by 3-digit zip code prefix), and health care (workplace, job role, COVID-19 patient contact) factors.

MAIN OUTCOME AND MEASURES

The main outcome was SARS-CoV-2 seropositivity. Risk factors for seropositivity were estimated using a mixed-effects logistic regression model with a random intercept to account for clustering by site.

RESULTS

Among 24 749 HCP, most were younger than 50 years (17 233 [69.6%]), were women (19 361 [78.2%]), were White individuals (15 157 [61.2%]), and reported workplace contact with patients with COVID-19 (12 413 [50.2%]). Many HCP worked in the inpatient setting (8893 [35.9%]) and were nurses (7830 [31.6%]). Cumulative incidence of COVID-19 per 10 000 in the community up to 1 week prior to serology testing ranged from 8.2 to 275.6; 20 072 HCP (81.1%) reported no COVID-19 contact in the community. Seropositivity was 4.4% (95% CI, 4.1%-4.6%; 1080 HCP) overall. In multivariable analysis, community COVID-19 contact and community COVID-19 cumulative incidence were associated with seropositivity (community contact: adjusted odds ratio [aOR], 3.5; 95% CI, 2.9-4.1; community cumulative incidence: aOR, 1.8; 95% CI, 1.3-2.6). No assessed workplace factors were associated with seropositivity, including nurse job role (aOR, 1.1; 95% CI, 0.9-1.3), working in the emergency department (aOR, 1.0; 95% CI, 0.8-1.3), or workplace contact with patients with COVID-19 (aOR, 1.1; 95% CI, 0.9-1.3).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of US HCP in 3 states, community exposures were associated with seropositivity to SARS-CoV-2, but workplace factors, including workplace role, environment, or contact with patients with known COVID-19, were not. These findings provide reassurance that current infection prevention practices in diverse health care settings are effective in preventing transmission of SARS-CoV-2 from patients to HCP.

484. The Impact of SARS-CoV-2 on Reproduction Rates of Seasonal Influenza and RSV

Background

The COVID-19 pandemic caused by SARS-CoV-2 has precipitated a global health crisis. In an effort to decrease person-to-person transmission, societal-level non-pharmacologic interventions (NPIs) to maintain social distancing have been enacted. As SARS-CoV-2 shares similar routes of transmission with other respiratory viruses, implementation of these NPIs may have decreased transmission for multiple viral pathogens. We compared influenza and respiratory syncytial (RSV) rates in prior seasons to rates during the 2019 - 2020 season at two large academic centers in Atlanta and Boston.

Methods

The clinical records were queried for adults with respiratory virus testing conducted at the Emory Healthcare system and associated clinics in Atlanta and the Mass General Brigham (MGB) Healthcare System in Boston. Total cases for influenza A and B, RSV and SARS-CoV-2 were analyzed for each week of the past 5 seasons (07/01/2015-05/30/2020) for the Atlanta and Boston sites. Systematic changes in viral infection rates were calculated using viral reproduction rates, R(t), between consecutive weeks. R(t) is the ratio of the number of positive cases in one week to the number of positive cases in the previous week. We used statistical bootstrapping to determine whether R(t) for influenza and RSV were lower in 2019–2020 following the introduction of SARS-CoV-2. Analyses were conducted using R (v 4.0.0).

Absolute respiratory virus activity by season, Boston (panel A) v. Atlanta (panel B)

Results

For the 2019–2020 Atlanta season, R(t) < 1 (which reflects steady decline in infection rates) occurred at week 28 for influenza A, week 33 for influenza B, and week 35 for RSV, which corresponded with the increase of SARS-Cov-2 cases. The R(t) of these viruses stayed at or near 1 during weeks 33–35 in prior seasons, and R(t) was greater than 1 up to week 47. Data from MGB sites showed similar trends with a sudden decline in R(t) to < 1 at the start of the SARS-CoV-2 pandemic.

Conclusion

We note decreased transmission of influenza and RSV during a time window where widespread movement restrictions and social distancing were imposed to control COVID-19. This trend was most pronounced for influenza A in Atlanta and influenza B in Boston. These data suggest that NPIs can have important effects across multiple pathogens.

Disclosures

Kraft Colleen, MD, MSc, Rebiotix (Advisor or Review Panel member)

Quantification of occupational and community risk factors for SARS-CoV-2 seropositivity among healthcare workers in a large U.S. healthcare system

BACKGROUND

Quantifying occupational risk factors for SARS-CoV-2 infection among healthcare workers can inform efforts to improve healthcare worker and patient safety and reduce transmission. This study aimed to quantify demographic, occupational, and community risk factors for SARS-CoV-2 seropositivity among healthcare workers in a large metropolitan healthcare system.

METHODS

We analyzed data from a cross-sectional survey conducted from April through June of 2020 linking risk factors for occupational and community exposure to COVID-19 with SARS-CoV-2 seropositivity. A multivariable logistic regression model was fit to quantify risk factors for infection. Participants were employees and medical staff members who elected to participate in SARS-CoV-2 serology testing offered to all healthcare workers as part of a quality initiative, and who completed a survey on exposure to COVID-19 and use of personal protective equipment. Exposures of interest included known demographic risk factors for COVID-19, residential zip code incidence of COVID-19, occupational exposure to PCR test-positive healthcare workers or patients, and use of personal protective equipment. The primary outcome of interest was SARS-CoV-2 seropositivity.

RESULTS

SARS-CoV-2 seropositivity was estimated to be 5.7% (95% CI: 5.2%-6.1%) among 10,275 healthcare workers. Community contact with a person known or suspected to have COVID-19 (aOR=1.9, 95% CI:1.4-2.5) and zip code level COVID-19 incidence (aOR: 1.4, 95% CI: 1.0-2.0) increased the odds of infection. Black individuals were at high risk (aOR=2.0, 95% CI:1.6-2.4). Overall, occupational risk factors accounted for 27% (95% CI: 25%-30%) of the risk among healthcare workers and included contact with a PCR test-positive healthcare worker (aOR=1.2, 95% CI:1.0-1.6).

CONCLUSIONS

Community risk factors, including contact with a COVID-19 positive individual and residential COVID-19 incidence, are more strongly associated with SARS-CoV-2 seropositivity among healthcare workers than exposure in the workplace.

Low-dose whole-lung radiation for COVID-19 pneumonia: Planned day 7 interim analysis of a registered clinical trial

BACKGROUND

Individuals of advanced age with comorbidities face a higher risk of death from coronavirus disease 2019 (COVID-19), especially once they are ventilator-dependent. Respiratory decline in patients with COVID-19 is precipitated by a lung-mediated aberrant immune cytokine storm. Low-dose lung radiation was used to treat pneumonia in the pre-antibiotic era. Radiation immunomodulatory effects may improve outcomes for select patients with COVID-19.

METHODS

A single-institution trial evaluating the safety and efficacy of single-fraction, low-dose whole-lung radiation for patients with COVID-19 pneumonia is being performed for the first time. This report describes outcomes of a planned day 7 interim analysis. Eligible patients were hospitalized, had radiographic consolidation, required supplemental oxygen, and were clinically deteriorating.

RESULTS

Of 9 patients screened, 5 were treated with whole-lung radiation on April 24 until April 28 2020, and they were followed for a minimum of 7 days. The median age was 90 years (range, 64-94 years), and 4 were nursing home residents with multiple comorbidities. Within 24 hours of radiation, 3 patients (60%) were weaned from supplemental oxygen to ambient air, 4 (80%) exhibited radiographic improvement, and the median Glasgow Coma Scale score improved from 10 to 14. A fourth patient (80% overall recovery) was weaned from oxygen at hour 96. The mean time to clinical recovery was 35 hours. There were no acute toxicities.

CONCLUSIONS

In a pilot trial of 5 oxygen-dependent elderly patients with COVID-19 pneumonia, low-dose whole-lung radiation led to rapid improvements in clinical status, encephalopathy, and radiographic consolidation without acute toxicity. Low-dose whole-lung radiation appears to be safe, shows early promise of efficacy, and warrants further study.

LAY SUMMARY

Researchers at Emory University report preliminary safety outcomes for patients treated with low-dose lung irradiation for coronavirus disease 2019 (COVID-19) pneumonia. Five residents of nursing or group homes were hospitalized after testing positive for COVID-19. Each had pneumonia visible on a chest x-ray, required supplemental oxygen, and experienced a clinical decline in mental status or in work of breathing or a prolonged or escalating supplemental oxygen requirement. A single treatment of low-dose (1.5-Gy) radiation to both lungs was delivered over the course of 10 to 15 minutes. There was no acute toxicity attributable to radiation therapy. Within 24 hours, 4 patients had rapidly improved breathing, and they recovered to room air at an average of 1.5 days (range, 3-96 hours). Three were discharged at a mean time of 12 days, and 1 was preparing for discharge. Blood tests and repeat imaging confirm that low-dose whole-lung radiation treatment appears safe for COVID-19 pneumonia. Further trials are warranted.

Obstetricians on the Coronavirus Disease 2019 (COVID-19) Front Lines and the Confusing World of Personal Protective Equipment

As health care systems struggle to maintain adequate supplies of personal protective equipment, there is confusion and anxiety among obstetricians and others about how to best protect themselves, their coworkers, and their patients. Although use of personal protective equipment is a critical strategy to protect health care personnel from coronavirus disease 2019 (COVID-19), other strategies also need to be implemented on labor and delivery units to reduce the risk of health care-associated transmission, including screening of all pregnant women who present for care (case identification), placing a mask on and rapidly isolating ill pregnant women, and minimizing the number of personnel who enter the room of an ill patient (physical distancing). Although the mechanism of transmission of COVID-19 is not known with certainty, current evidence suggests that COVID-19 is transmitted primarily through respiratory droplets. Therefore, strict adherence to hand hygiene and consistent use of recommended personal protective equipment are cornerstones for reducing transmission. In addition, it is critical that health care professionals receive training on and practice correct donning (putting on) and doffing (removing) of personal protective equipment and avoid touching their faces as well as their facial protection to minimize self-contamination.

Comparison of Rates of Central Line-Associated Bloodstream Infections in Patients With 1 vs 2 Central Venous Catheters

IMPORTANCE

National Healthcare Safety Network methods for central line-associated bloodstream infection (CLABSI) surveillance do not account for potential additive risk for CLABSI associated with use of 2 central venous catheters (CVCs) at the same time (concurrent CVCs); facilities that serve patients requiring high acuity care with medically indicated concurrent CVC use likely disproportionally incur Centers for Medicare & Medicaid Services payment penalties for higher CLABSI rates.

OBJECTIVE

To quantify the risk for CLABSI associated with concurrent use of a second CVC.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included adult patients with 2 or more days with a CVC at 4 geographically separated general acute care hospitals in the Atlanta, Georgia, area that varied in size from 110 to 580 beds, from January 1, 2012, to December 31, 2017. Variables included clinical conditions, central line-days, and concurrent CVC use. Patients were propensity score-matched for likelihood of concurrence (limited to 2 CVCs), and conditional logistic regression modeling was performed to estimate the risk of CLABSI associated with concurrence. Episodes of CVC were categorized as low or high risk and single vs concurrent use to evaluate time to CLABSI with Cox proportional hazards regression models. Data were analyzed from January to June 2019.

EXPOSURES

Two CVCs present at the same time.

MAIN OUTCOMES AND MEASURES

Hospitalizations in which a patient developed a CLABSI, allowing estimation of patient risk for CLABSI and daily hazard for a CVC episode ending in CLABSI.

RESULTS

Among a total of 50 254 patients (median [interquartile range] age, 59 [45-69] years; 26 661 [53.1%] women), 64 575 CVCs were used and 647 CLABSIs were recorded. Concurrent CVC use was recorded in 6877 patients (13.7%); the most frequent indications for concurrent CVC use were nutrition (554 patients [14.1%]) or hemodialysis (1706 patients [43.4%]). In the propensity score-matched cohort, 74 of 3932 patients with concurrent CVC use (1.9%) developed CLABSI, compared with 81 of 7864 patients with single CVC use (1.0%). Having 2 CVCs for longer than two-thirds of a patient's CVC use duration was associated with increased likelihood of developing a CLABSI, adjusting for central line-days and comorbidities (adjusted risk ratio, 1.62; 95% CI, 1.10-2.33; P = .001). In survival analysis adjusting for sex, receipt of chemotherapy or total parenteral nutrition, and facility, compared with a single CVC, the daily hazard for 2 low-risk CVCs was 1.78 (95% CI, 1.35-2.34; P < .001), while the daily hazard for 1 low-risk and 1 high-risk CVC was 1.80 (95% CI, 1.42-2.28; P < .001), and the daily hazard for 2 high-risk CVCs was 1.78 (95% CI, 1.14-2.77; P = .01).

CONCLUSIONS AND RELEVANCE

These findings suggest that concurrent CVC use is associated with nearly 2-fold the risk of CLABSI compared with use of a single low-risk CVC. Performance metrics for CLABSI should change to account for variations of this intrinsic patient risk among facilities to reduce biased comparisons and resultant penalties applied to facilities that are caring for more patients with medically indicated concurrent CVC use.

Knowledge, Attitudes, and Behaviors Regarding Piperacillin-Tazobactam Prescribing Practices: Results From a Multicenter Study

We investigated knowledge, attitudes, and behaviors of prescribers concerning piperacillin-tazobactam use at 4 Emory University-affiliated hospitals. Discussions during focus groups indicated that the participants' perceived knowledge of clinical criteria for appropriate piperacillin-tazobactam use was inadequate. Retrospective review of medical records identified inappropriate practices. These findings have influenced ongoing interventions aimed at optimizing piperacillin-tazobactam use.

High Risk of Prosthetic Valve Endocarditis and Death After Valve Replacement Operations in Dialysis Patients

BACKGROUND

Despite a high burden of dialysis access-related bloodstream infections and an increasing incidence of endocarditis, few data are available addressing the risk of prosthetic valve endocarditis (PVE) in the dialysis population. We sought to assess the risk of PVE and death after valve replacement operations in patients receiving long-term dialysis.

METHODS

A matched retrospective cohort study was conducted comprising patients admitted for valve replacement operations at two university hospitals. Patients without dialysis were matched 1:1 with dialysis patients by valve(s) replaced, year of operation, and presence of active endocarditis as the indication for valve replacement. Patient characteristics were compared using χ(2) and t tests. The development of PVE was defined by use of the modified Duke criteria and analyzed with Cox proportional hazards regression.

RESULTS

Two hundred seventy-eight patients were included, with 139 in either cohort. The PVE risk per year of follow-up was 0.14 in the dialysis cohort and 0.03 in the nondialysis cohort. Dialysis remained a risk factor (adjusted hazard ratio 5.61 [95% confidence interval, 2.17 to 14.5], p = 0.0004) after age and race were controlled for. The 5-year survival rate was lower after valve replacement operation in the dialysis group (25.4%) than in the nondialysis group (75.9%, p < 0.001).

CONCLUSIONS

The risk of PVE and death after valve replacement operations in dialysis patients is substantial and significantly higher than in patients without dialysis. These findings highlight the importance of a careful preoperative risk-benefit assessment and underscore the need to prevent hemodialysis-related bloodstream infections.

Ebola or Not? Evaluating the Ill Traveler From Ebola-Affected Countries in West Africa

Most ill travelers returning from Ebola-affected countries have not had Ebola. However, institutions and public health departments need to be prepared. We present our experience triaging, evaluating and managing 25 ill returned travelers from these countries.

Background. The 2014–2015 Ebola epidemic in West Africa had global impact beyond the primarily affected countries of Guinea, Liberia, and Sierra Leone. Other countries, including the United States, encountered numerous patients who arrived from highly affected countries with fever or other signs or symptoms consistent with Ebola virus disease (EVD).

Methods. We describe our experience evaluating 25 travelers who met the US Centers for Disease Control and Prevention case definition for a person under investigation (PUI) for EVD from July 20, 2014 to January 28, 2015. All patients were triaged and evaluated under the guidance of institutional protocols to the emergency department, outpatient tropical medicine clinic, or Emory's Ebola treatment unit. Strict attention to infection control and early involvement of public health authorities guided the safe evaluation of these patients.

Results. None were diagnosed with EVD. Respiratory illnesses were common, and 8 (32%) PUI were confirmed to have influenza. Four patients (16%) were diagnosed with potentially life-threatening infections or conditions, including 3 with Plasmodium falciparum malaria and 1 with diabetic ketoacidosis.

Conclusions. In addition to preparing for potential patients with EVD, Ebola assessment centers should consider other life-threatening conditions requiring urgent treatment, and travelers to affected countries should be strongly advised to seek pretravel counseling. Furthermore, attention to infection control in all aspects of PUI evaluation is paramount and has presented unique challenges. Lessons learned from our evaluation of potential patients with EVD can help inform preparations for future outbreaks of highly pathogenic communicable diseases.

Temporary Central Venous Catheter Utilization Patterns in a Large Tertiary Care Center Tracking the “Idle Central Venous Catheter”

Objectives.

Although central venous catheter (CVC) dwell time is a major risk factor for catheter-related bloodstream infections (CR-BSIs), few studies reveal how often CVCs are retained when not needed (“idle”). We describe use patterns for temporary CVCs, including peripherally inserted central catheters (PICCs), on non-ICU wards.

Design.

A retrospective observational study.

Setting.

A 579-bed acute care, academic tertiary care facility.

Methods.

A retrospective observational study of a random sample of patients on hospital wards who have a temporary, nonimplanted CVC, with a focus on on daily ward CVC justification. A uniform definition of idle CVC-days was used.

Results.

We analyzed 89 patients with 146 CVCs (56% of which were PICCs); of 1,433 ward CVC-days, 361 (25.2%) were idle. At least 1 idle day was observed for 63% of patients. Patients had a mean of 4.1 idle days and a mean of 3.4 days with both a CVC and a peripheral intravenous catheter (PIV). After adjusting for ward length of stay, mean CVC dwell time was 14.4 days for patients with PICCs versus 9.0 days for patients with non-PICC temporary CVCs (other CVCs; P< .001). Patients with a PICC had 5.4 days in which they also had a PIV, compared with 10 days in other CVC patients (P< .001). Patients with PICCs had more days in which the only justification for the CVC was intravenous administration of antimicrobial agents (8.5 vs 1.6 days; P = .0013).

Conclusions.

Significant proportions of ward CVC-days were unjustified. Reducing “idle CVC-days” and facilitating the appropriate use of PIVs may reduce CVC-days and CR-BSI risk.

Infect Control Hosp Epidemiol 2012;33(1):50-57

Electronic Documentation of Central Venous Catheter—Days: Validation Is Essential

Background.

Measurement of central line-associated bloodstream infection (CLABSI) rates outside of intensive care units is challenged by the difficulty in reliably determining central venous catheter (CVC) use. The National Healthcare Safety Network (NHSN) allows for use of electronic data for determination of CVC-days, but validation of electronic data has not been studied systematically.

Objective.

To design and validate a process to reliably measure CVC-days outside of the intensive care units that leverages electronic documentation.

Methods.

Thirty-four inpatient wards at 2 academic hospitals using a common electronic platform for nursing documentation were studied. Electronic queries were created to capture patient and CVC information, and tools and processes for tracking and reporting errors in documentation were developed. Strategies to validate electronic data included comparisons with manual CVC-day determinations and automated data validation using customized tools. Interventions included redesign of documentation interface, real-time audit with feedback of errors, and education. The primary outcome was patient-level total error rate in electronic CVC-day measurement compared with manually counted CVC-days.

Results.

At baseline, there were a mean (± standard deviation) of 0.32 ± 0.25 electronic CVC-day errors (omission and commission errors summed and counted equally) per manually counted CVC-day. After several process improvement cycles over 7 months, the error rate decreased to &lt;0.05 errors per CVC-day and remained at or below this level for 2 years.

Conclusions.

Baseline electronic CVC-day counts had a high error rate. Stepwise interventions reduced errors to consistently low levels. Validation of electronic calculation of CVC-days is essential to ensure accuracy, particularly if these data will be used for interinstitutional comparison.

Use of a Mandatory Declination Form in a Program for Influenza Vaccination of Healthcare Workers

Objective.

To evaluate the utility and impact of using a declination form in the context of an influenza immunization program for healthcare workers.

Methods.

A combined form for documentation of vaccination consent, medical contraindication(s) for vaccination, or vaccination declination was used during the 2006-2007 influenza season in a healthcare system employing approximately 9,200 nonphysician employees in 3 hospitals; a skilled nursing care facility; a large, multisite, faculty-practice plan; and an administrative building. Responses were entered into a database that contained files from human resources departments, which allowed correlation with job category and work location.

Results.

The overall levels of influenza vaccination coverage of employees increased from 43% (3,892 of 9,050) during the 2005-2006 season to 66.5% (6,123 of 9,214) during the 2006-2007 season. Of 9,214 employees, 1,898 (20.6%) signed the declination statement. Among the occupation groups, nurses had the lowest rate of declining vaccination (13.2% [393 of 2,970]; P < .0001), followed by pharmacy personnel (18.1% [40 of 221]), ancillary personnel with frequent patient contact (21.9% [169 of 771), and all others (24.7% [1,296 of 5,252]). Among the employees who declined vaccination, nurses were the least likely to select the reasons “afraid of needles” (3.8% [15 of 393], vs. 9.1% [137 of 1,505] for all other groups; P < .001) and “fear of getting influenza from the vaccine” (13.5% [53 of 393], vs. 20.5% [309 of 1,505]; P = .002). Seven pregnant nurses had been advised by their obstetricians to avoid vaccination. When declination of influenza vaccination was analyzed by age, 16% of personnel (797 of 4,980) 50 years of age and older declined to be vaccinated, compared with 26% of personnel (1,101 of 4,234) younger than 50 years of age {P < .0001).

Conclusions.

Implementing use of the declination form during the 2006-2007 influenza season was one of several measures that led to a 55% increase in the acceptance of influenza vaccination by healthcare workers in our healthcare system. Although we cannot determine to what degree use of the declination form contributed to the increased rate of vaccination, use of this form helped the vaccination program assess the reasons for declination and will help to focus future vaccination campaigns.

The Role of the Hospital Environment in Preventing Healthcare-Associated Infections Caused by Pathogens Transmitted through the Air

OBJECTIVE:

To assess and synthesize available evidence in the infection control and healthcare design literature on strategies using the built environment to reduce the transmission of pathogens in the air that cause healthcare-associated infections (HAIs).

BACKGROUND:

Air can serve as a route for transmission of important HAI pathogens, including Mycobacterium tuberculosis and influenza, and may play a role for others typically transmitted by contact, including Staphylococcus aureus and Clostridium difficile.

TOPICAL HEADINGS:

Four primary interventions can be used interrupt the transmission of pathogens in air: ventilation, filtration, decontamination, and isolation. Many studies demonstrate that unidirectional airflows, when combined with very clean air and frequent air changes, reduce bacterial counts in the air, though mostly focused on the operating room. A high-efficiency particulate air filter removes almost all particles from the air and is used in protective environments such as the operating room, but little evidence supports its broader application. Ultraviolet germicidal radiation can augment the performance of heating, ventilation, and air conditioning systems. Isolation with negative pressure ventilation prevents spread of airborne pathogens such as tuberculosis.

CONCLUSIONS:

Current evidence is limited by the complexity of the interactions between pathogens and potential hosts, and in the methods used to assess impact of these strategies. Because the factors that affect transmission of the pathogens are complex and transcend disciplines, a collaborative approach among the key stakeholders in healthcare facility design should be actively pursued from planning to completion of construction and in rigorous research to best determine how design can reduce HAIs.

The Role of Water in the Transmission of Healthcare-Associated Infections: Opportunities for Intervention through the Environment

OBJECTIVE:

To assess and synthesize available evidence in the infection control and healthcare design literature on strategies using the built environment to reduce the transmission of pathogens in water that cause healthcare-associated infections (HAIs).

BACKGROUND:

Water can serve as a reservoir or source for pathogens, which can lead to the transmission of healthcare-associated infections (HAIs). Water systems harboring pathogens, such as Legionella and Pseudomonas spp., can also foster the growth of persistent biofilms, presenting a great health risk.

TOPICAL HEADINGS:

Strategies for interrupting the chain of transmission through the built environment can be proactive or reactive, and include three primary approaches: safe plumbing practices (maintaining optimal water temperature and pressure; eliminating dead ends), decontamination of water sources (inactivating or killing pathogens to prevent contamination), and selecting appropriate design elements (fixtures and materials that minimize the potential for contamination).

CONCLUSIONS:

Current evidence clearly identifying the environment's role in the chain of infection is limited by the variance in surveillance strategies and in the methods used to assess impact of these strategies. In order to optimize the built environment to serve as a tool for mitigating infection risk from waterborne pathogens—from selecting appropriate water features to maintaining the water system—multidisciplinary collaboration and planning is essential.

The Role of Facility Design in Preventing the Transmission of Healthcare-Associated Infections: Background and Conceptual Framework

OBJECTIVE:

To describe the conceptual framework and methodology used to conduct a comprehensive literature review of current evidence evaluating the role of the built environment in the transmission of healthcare-associated infections.

BACKGROUND:

A multidisciplinary approach to evaluating a vast and diverse dataset requires a conceptual framework to create a common understanding for interpretation. This common understanding is accomplished through the application of a “chain of transmission” model depicting temporal and physical paths of pathogens that cause healthcare-associated infections. The chain of transmission interventions model argues that infection can potentially be reduced by interrupting any of several links in the chain.

TOPICAL HEADINGS:

The key pathogens impacted by the built environment are identified. The chain of transmission and the conceptual framework are described. Opportunities for intervention through the built environment are presented, which in turn guide the subsequent methodology used to conduct the systematic literature review.

CONCLUSIONS:

The chain of transmission interventions model is a multidisciplinary conceptualization of the interaction between pathogens and the built environment, and this model facilitated a systematic literature review of a very large amount of data.

The Role of the Hospital Environment in the Prevention of Healthcare-Associated Infections by Contact Transmission

OBJECTIVE:

This article describes the role of the hospital environment in the spread of pathogens by direct and indirect contact. In addition, the prevention of transmission through interventions involving the built environment is discussed.

BACKGROUND:

The hospital environment can become contaminated with pathogenic microorganisms, some of which can persist for long periods of time. Although contamination is common, the contribution of the hospital environment to the development of healthcare-associated infections remains unclear. In part spurred by the development of newer technologies to enhance environmental cleaning or to prevent contamination, research into the role of the environment in causing healthcare-associated infections has accelerated.

TOPICAL HEADINGS:

A review of the recent literature finds an increasing body of evidence implicating contaminated surfaces in patient care areas in the transmission of pathogens and the development of infections. Single-patient rooms and optimally placed alcohol hand rub dispensers and other design features can mitigate infection risk. Enhanced environmental cleaning including touchless technologies and self-cleaning surfaces can reduce environmental contamination and may prevent infections.

CONCLUSIONS:

The hospital environment contributes to transmission of pathogens in hospitals and to the development of healthcare-associated infections. Newer technologies to prevent environmental contamination or to enhance cleaning are promising although additional studies with the endpoints of reduction of infections are needed before the role of these technologies is known.

The Role of Facility Design in Preventing Healthcare-Associated Infection: Interventions, Conclusions, and Research Needs

OBJECTIVE:

To summarize the findings and provide recommendations based on the multidisciplinary literature review and industry scan, focusing on the links between the built environment and healthcare-associated infections. To propose a research agenda in order to increase informed design decisions and advance the evidence base.

BACKGROUND:

The HAI-Design project explores the research linking a range of design interventions to healthcare-associated infection. The multidisciplinary team evaluated over 3,800 articles and conducted interviews with a range of stakeholders including CEOs, architects, designers, physicians and other healthcare experts, the results of which are featured in this special Supplement as topical papers.

TOPICAL HEADINGS:

The four topical papers describing the role of the built environment in the acquisition of healthcare-associated infections are summarized. The evidence evaluating the strategies for intervention through the built environment is analyzed, and a research agenda is proposed.

CONCLUSIONS:

While the evidence base supporting the efficacy of strategies and technologies continues to grow, there are currently few data that demonstrate a reduction in infection rates. The need for multidisciplinary collaboration and increased efforts to standardize the evaluation of environmental studies are essential to overcome the many challenges and improve the reliability of data

Distribution of pathogens in central line-associated bloodstream infections among patients with and without neutropenia following chemotherapy: evidence for a proposed modification to the current surveillance definition

OBJECTIVE

Many bloodstream infections (BSIs) occurring in patients with febrile neutropenia following cytotoxic chemotherapy are due to translocation of intestinal microbiota. However, these infections meet the National Healthcare Safety Network (NHSN) definition of central line-associated BSIs (CLABSIs). We sought to determine the differences in the microbiology of NHSN-defined CLABSIs in patients with and without neutropenia and, using these data, to propose a modification of the CLABSI definition.

DESIGN

Retrospective review.

SETTING

Two large university hospitals over 18 months.

METHODS

All hospital-acquired BSIs occurring in patients with central venous catheters in place were classified using the NHSN CLABSI definition. Patients with postchemotherapy neutropenia (500 neutrophils/mm(3) or lower) at the time of blood culture were considered neutropenic. Pathogens overrepresented in the neutropenic group were identified to inform development of a modified CLABSI definition.

RESULTS

Organisms that were more commonly observed in the neutropenic group compared with the nonneutropenic group included Escherichia coli (22.7% vs 2.5%; P < .001) but not other Enterobacteriaceae, Enterococcus faecium (18.2% vs 6.1%; P = .002), and streptococci (18.2% vs 0%; P < .001). Application of a modified CLABSI definition (removing BSI with enterococci, streptococci, or E. coli) excluded 33 of 66 neutropenic CLABSIs and decreased the CLABSI rate in one study hospital with large transplant and oncology populations from 2.12 to 1.79 cases per 1,000 line-days.

CONCLUSIONS

Common gastrointestinal organisms were more common in the neutropenia group, suggesting that many BSIs meeting the NHSN criteria for CLABSI in the setting of neutropenia may represent translocation of gut organisms. These findings support modification of the NHSN CLABSI definition.

History of SHEA-Sponsored Research: Time to Pass the Torch

Since its inception, the Society for Healthcare Epidemiology of America (SHEA) has promoted research into prevention of adverse events in hospitals. In 1995, SHEA made this mission concrete by initiating a collaborative research project with the Joint Commission on the Accreditation of Health Care Organization (now known as the Joint Commission). In the early 1990s, the Joint Commission was implementing its “Agenda for Change” and associated Indicator Monitoring System. At the time, there were numerous competing measurement systems that used different definitions, all aimed at measuring the quality of patient care, and many had indicators measuring the incidence of hospital-acquired infections. Some of these indicators used administrative data, such as International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, to measure adverse events.

A population-based investigation of invasive vancomycin-resistant Enterococcus infection in metropolitan Atlanta, Georgia, and predictors of mortality

BACKGROUND

Vancomycin-resistant Enterococcus organisms (VRE) have emerged as common nosocomial pathogens, but few population-based data are available on the impact of invasive VRE infections.

METHODS

We assessed the incidence of invasive VRE infections and predictors of mortality among patients identified during prospective, population-based surveillance performed in the metropolitan statistical area (MSA) of Atlanta, Georgia.

RESULTS

From July 1997 through June 2000, a total of 192 patients who resided in the Atlanta MSA developed an invasive VRE infection, for a rate of 1.57 cases per 100,000 person-years. The incidence of invasive VRE disease significantly increased from 0.91 cases per 100,000 person-years during the first year of the study to 1.73 cases per 100,000 person-years during the third year of the study (P<.001). Rates of invasive VRE infection were significantly higher among African American patients than white patients (2.59 vs 0.70 cases per 100,000 person-years; P<.001). Blood was the most common sterile site from which VRE was recovered (161 [83%] of 193 isolates), followed by deep surgical sites (17 [9%]), peritoneal fluid (10 [5%]), pleural fluid (3 [2%]), and cerebrospinal fluid (1 [0.5%]). In multivariate analysis, a Charlson comorbidity index of 5 or greater, previous receipt of antibiotic therapy, having 2 or more sets of blood cultures positive for VRE, and receipt of central parenteral nutrition were independent predictors of mortality, whereas receipt of an antibiotic with in vitro activity against the VRE isolate was associated with a decreased risk of mortality. Molecular typing revealed 38 different pulsed-field gel electrophoresis patterns, but the 2 most common pulsed-field gel electrophoresis types were found at 3 Emory University-affiliated hospitals.

CONCLUSIONS

The incidence of invasive VRE infection significantly increased in the Atlanta MSA during the 3-year study period, with significant racial disparities detected. Receipt of an antimicrobial agent with in vitro activity against VRE was associated with a lower mortality rate. Molecular typing results demonstrated polyclonal emergence of VRE in Atlanta.

Subdural empyema and other suppurative complications of paranasal sinusitis

Suppurative intracranial infection, including meningitis, intracranial abscess, subdural empyema, epidural abscess, cavernous sinus thrombosis, and thrombosis of other dural sinuses, are uncommon sequelae of paranasal sinusitis. A high index of suspicion is necessary to identify these serious complications. We present a patient with subdural empyema in whom the diagnosis was delayed, followed by a discussion of suppurative complications of sinusitis. The case shows the rapid progression of subdural empyema, which represents a true neurosurgical emergency requiring prompt diagnosis and management.

Liver-infiltrating lymphocytes in chronic human hepatitis C virus infection display an exhausted phenotype with high levels of PD-1 and low levels of CD127 expression

The majority of people infected with hepatitis C virus (HCV) fail to generate or maintain a T-cell response effective for viral clearance. Evidence from murine chronic viral infections shows that expression of the coinhibitory molecule PD-1 predicts CD8+ antiviral T-cell exhaustion and may contribute to inadequate pathogen control. To investigate whether human CD8+ T cells express PD-1 and demonstrate a dysfunctional phenotype during chronic HCV infection, peripheral and intrahepatic HCV-specific CD8+ T cells were examined. We found that in chronic HCV infection, peripheral HCV-specific T cells express high levels of PD-1 and that blockade of the PD-1/PD-L1 interaction led to an enhanced proliferative capacity. Importantly, intrahepatic HCV-specific T cells, in contrast to those in the periphery, express not only high levels of PD-1 but also decreased interleukin-7 receptor alpha (CD127), an exhausted phenotype that was HCV antigen specific and compartmentalized to the liver, the site of viral replication.

Phase II, randomized, double-blind, multicenter study comparing the safety and pharmacokinetics of tefibazumab to placebo for treatment of Staphylococcus aureus bacteremia

Tefibazumab (Aurexis), a humanized monoclonal antibody that binds to the surface-expressed adhesion protein clumping factor A, is under development as adjunctive therapy for serious Staphylococcus aureus infections. Sixty patients with documented S. aureus bacteremia (SAB) were randomized and received either tefibazumab at 20 mg/kg of body weight as a single infusion or a placebo in addition to an antibiotic(s). The primary objective of the study was determining safety and pharmacokinetics. An additional objective was to assess activity by a composite clinical end point (CCE). Baseline characteristics were evenly matched between groups. Seventy percent of infections were healthcare associated, and 57% had an SAB-related complication at baseline. There were no differences between the treatment groups in overall adverse clinical events or alterations in laboratory values. Two patients developed serious adverse events that were at least possibly related to tefibazumab; one hypersensitivity reaction was considered definitely related. The tefibazumab plasma half-life was 18 days. Mean plasma levels were <100 microg/ml by day 14. A CCE occurred in six patients (four placebo and two tefibazumab patients) and included five deaths (four placebo and one tefibazumab patient). Progression in the severity of sepsis occurred in four placebo and no tefibazumab patients. Tefibazumab was well tolerated, with a safety profile similar to those of other monoclonal antibodies. Additional trials are warranted to address the dosing range and efficacy of tefibazumab.

Antibiotic resistance in long-term acute care hospitals: the perfect storm

OBJECTIVE

To examine bacterial antibiotic resistance and antibiotic use patterns in long-term acute care hospitals (LTACHs) and to evaluate effects of antibiotic use and other hospital-level variables on the prevalence of antibiotic resistance.

DESIGN

Multihospital ecologic study.

METHODS

Antibiograms, antibiotic purchasing data, and demographic variables from 2002 and 2003 were obtained from 45 LTACHs. Multivariable regression models were constructed, controlling for other hospital-level variables, to evaluate the effects of antibiotic use on resistance for selected pathogens. Results of active surveillance in 2003 at one LTACH were available.

RESULTS

Among LTACHs, median prevalences of resistance for several antimicrobial-organism pairs were greater than the 90th percentile value for National Nosocomial Infections Surveillance system (NNIS) medical intensive care units (ICUs). The median prevalence of methicillin resistance among Staphylococcus aureus isolates was 84%. More than 60% of patients in one LTACH were infected or colonized with methicillin-resistant S. aureus and/or vancomycin-resistant Enterococcus at the time of admission. Antibiotic consumption in LTACHs was comparable to consumption in NNIS medical ICUs. In multivariable logistic regression modeling, the only significant association between antibiotic use and the prevalence of antibiotic resistance was for carbapenems and imipenem resistance among Pseudomonas aeruginosa isolates (odds ratio, 11.88 [95% confidence interval, 1.42-99.13]; P=.02).

CONCLUSIONS

The prevalence of antibiotic resistance among bacteria recovered from patients in LTACHs is extremely high. Although antibiotic use in LTACHs likely contributes to resistance prevalence for some antimicrobial-organism pairs, for the majority of such pairs, other variables, such as prior colonization with and horizontal transmission of antimicrobial-resistant pathogens, may be more important determinants. Further research on antibiotic resistance in LTACHs is needed, particularly with respect to determining optimal infection control practices in this environment.

Sparse 2-D array design for real time rectilinear volumetric imaging

Several sparse 2-D arrays for real time rectilinear volumetric imaging were investigated. All arrays consisted of 128x128=16,384 elements with lambda spacing operating at 5 MHz. Because of system limitations, not all of the elements could be used. From each array, 256 elements were used as transmitters, and 256 elements were used as receivers. These arrays were compared by computer simulation using Field II. For each array, beamplots for the on-axis case and an illustrative off-axis case were obtained. For the off-axis case, the effects of receive mode dynamic focusing were studied to maintain the beam perpendicular to the transducer face. Main lobe widths, side lobe heights, clutter floor levels, and pulse-echo sensitivities were quantified for each array. The sparse arrays, including a vernier periodic array, a random array, and a Mills cross array, were compared with a fully sampled array that served as the "gold standard". The Mills cross design showed the best overall performance under the current system constraints.

Changes in endogenous TPO levels during mobilization chemotherapy are predictive of CD34+ megakaryocyte progenitor yield and identify patients at risk of delayed platelet engraftment post-PBPC transplant

Patients with delayed platelet recovery post-PBPC transplant (PBPCT) are a high-risk group for thrombocytopenic bleeding and platelet transfusion dependence. Total CD34+ cell dosage has been proposed as the most important factor influencing the rate of platelet recovery. To achieve the shortest time to platelet engraftment, a minimum leukapheresis target of 10x10(6) CD34+ cells/kg was established for 30 patients. Of the 29 evaluable patients, 62% had rapid (group I: time to platelets >20x10(9)/l < or =10 days and 50x10(9)/l < or =14 days) platelet recoveries while 38% had delayed (group II: 20x10(9)/l >10 days and 50x10(9)/l >14 days) recoveries. Groups I and II were compared for: (1) pretreatment variables; (2) mobilizing capability of CD34+ cells and subsets including megakaryocyte (Mk) progenitors; (3) infused dose of these cells at transplant; (4) changes in endogenous levels of Mpl ligand (or TPO) during mobilization and myeloablative chemotherapy. Group II patients received significantly more platelet transfusions (6 vs. 2.1, P = 0.002) post-PBPCT, had a higher proportion of patients with a prior history of BM disease (64% vs. 6%, P = 0.001), and showed a reduced ability to mobilize differentiated (CD34+/38+, CD34+/DR+) and Mk progenitors (CD34+/42a+, CD34+/61+). Only the number of Mk progenitors reinfused at transplant was significantly different between the groups (group II vs. group I: CD34+/42a+ = 1.02 vs. 2.56x10(6)/kg, P = 0.013; CD34+/61+ = 1.12 vs. 2.70x10(6)/kg, P = 0.015). The ability to mobilize Mk progenitors correlated with percentage changes in endogenous levels of TPO from baseline to platelet nadir during mobilization chemotherapy (CD34+/42a+: r = 0.684, P = 0.007; CD34+/61+: r = 0.684, P = 0.007), with group II patients experiencing lower percentage changes. An inverse trend but no correlation was observed between serial TPO levels and platelet counts. TPO levels remained elevated in group II patients throughout a prolonged period of thrombocytopenia (median days to 50x10(9)/l = 25 vs. 11 for group I), indicating that delayed engraftment was not due to a deficiency of TPO but to a lack of Mk progenitor target cells. Our results show that the number of reinfused Mk progenitors is a better predictor of platelet engraftment than total CD34+ cell dosage. Small changes in endogenous TPO levels during mobilization predict for low Mk progenitor yields.

Indinavir crystalluria: identification of patients at increased risk of developing nephrotoxicity

OBJECTIVE

To determine whether the protease inhibitor indinavir sulfate, which is extremely insoluble at physiologic pH levels and which is known to be associated with nephrolithiasis, is associated with crystalluria at a usual therapeutic dose.

METHODS

Freshly voided urine from 27 male human immunodeficiency virus patients being treated with indinavir at a dose of 800 mg, tid, in an outpatient setting and from 20 healthy subjects undergoing routine physical examination was subjected to dipstick urinalysis and microscopic examination of urinary sediments.

RESULTS

Three (11%) of 27 patients treated with indinavir developed highly characteristic crystalluria during the course of therapy. No such crystals were observed in the urine of the 20 healthy subjects.

CONCLUSION

Indinavir crystalluria was identified in asymptomatic patients treated with usual therapeutic doses of the drug. Screening urines of patients taking indinavir may be useful in identifying patients at risk for developing nephrotoxicity.

Exogenous Neisseria meningitidis endophthalmitis

PURPOSE

To report a case of Neisseria meningitidis endophthalmitis in association with a leaking filtering bleb and to consider antibiotic prophylaxis of those people with whom the patient had contact.

METHOD

We treated an 81-year-old man who had a chronic, leaking filtering bleb and who developed exogenous N meningitidis endophthalmitis.

RESULT

N meningitidis endophthalmitis was controlled with antibiotic therapy. Antibiotic prophylaxis for those with whom the patient had contact was not recommended.

CONCLUSION

In this case, the N meningitidis strain was not considered invasive because the bacteria apparently entered the eye through a leaky filtering bleb and not through the bloodstream. Recovery of noninvasive N meningitidis does not require prophylaxis for patient contacts. In cases of endogenous or idiopathic N meningitidis endophthalmitis, antibiotic prophylaxis of close patient contacts may be warranted.

Nosocomial and community-acquired Staphylococcus aureus bacteremias from 1980 to 1993: impact of intravascular devices and methicillin resistance

The rate of nosocomial bacteremia due to Staphylococcus aureus has increased over the past decade, but trends in community-acquired S. aureus bacteremia are less certain. This hospital-based observational study compares nosocomial and community-acquired S. aureus bacteremias during 1980-1983 and 1990-1993. The rate of nosocomial S. aureus bacteremia increased from 0.75 to 2.80 cases per 1,000 discharges, while the rate of community-acquired S. aureus bacteremia increased from 0.84 to 2.43 cases per 1,000 discharges. The number of nosocomial device-related bacteremias increased eightfold; 56% of S. aureus bacteremias were associated with devices during 1990-1993. Intravascular devices were associated with no community-acquired S. aureus bacteremias during 1980-1983 but with 22% during 1990-1993. Methicillin-resistant S. aureus (MRSA) seldom caused bacteremia during 1980-1983. From 1990 to 1993, MRSA caused 32% and 18.5% of nosocomial and community-acquired S. aureus bacteremias, respectively. The rates of both community-acquired and nosocomial S. aureus bacteremias have increased significantly since 1980. In addition to their role in nosocomial infections, MRSA and intravascular device-related S. aureus bacteremias are emerging problems in the nonhospital setting.

Osteomyelitis of the sternum caused by Apophysomyces elegans

Apophysomyces elegans, a member of the family Mucoraceae, was found to infect the chest wall and sternum of an immunocompetent man following minor trauma. As in previous cases, amphotericin B therapy alone was inadequate. Extensive surgical debridement was required in order to eradicate the infection.

Culture isolation of Acanthamoeba species and leptomyxid amebas from patients with amebic meningoencephalitis, including two patients with AIDS

Acanthamoeba species and leptomyxid organisms are free-living amebas that cause meningoencephalitis, primarily in immunocompromised patients. We report the isolation and culture of Acanthamoeba species and leptomyxid amebas from four patients with fatal amebic meningoencephalitis. Acanthamoeba species were cultured from brain abscess specimens from three immunocompromised patients (including two patients with AIDS). In the case of the fourth patient, who had no identifiable immunodeficiency, leptomyxid amebas were cultured from a specimen from a subcutaneous nodule and were identified in amebic granulomas in brain tissue by the indirect immunofluorescence test. Persons with advanced infection due to the human immunodeficiency virus may be at increased risk for amebic meningoencephalitis, but the diagnosis should be considered in the differential diagnosis of any immunocompromised patient with cerebral abscesses.

Suppurative cervical lymphadenitis after Yersinia enterocolitica bacteremia

Yersinia enterocolitica is increasingly recognized as a pathogen causing diverse complications. We have reported the case of a man with fever, abdominal tenderness, and Y enterocolitica bacteremia. After antibiotic therapy, his condition improved initially, but later, suppurative cervical lymphadenitis developed. This suggests that the hematogenous spread of Y enterocolitica to a distal lymphatic focus of infection is a possible complication of Y enterocolitica bacteremia.